аЯрЁБс>ўџ ;=ўџџџ:џџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџьЅС%` №Пі(bjbjNрNр 0.,Š,Šб џџџџџџЄ2222222FЊ Њ Њ Њ $Ю FЛьі і і і і і і і ђ є є є є є є $Їh^]2і і і і і 22і і u† † † і 2і 2і ђ † і ђ † † 22† і ъ а™.%pkЩЊ † о ‹0Л† m ^m† m2† Xі і † і і і і і | і і і Лі і і і FFFdЊ FFFЊ FFF222222џџџџ Exhibit H In accordance with N.J.A.C. 11:20-3.1(e) each carriers shall file this Identification of Standard Plans no later than July 1, 2009 and an amended Identification of Standard Plans within 60 days of any change in the plans being offered by the carrier. Identification of Standard Plans 1. INFORMATION ABOUT THE CARRIER AND RESPONDENT Carrier Name:__________________________________________________________________ NAIC #:____________________ Respondent Information: Name: _______________________________Title: ____________________________________ Address:______________________________________________________________________ ______________________________________________________________________________ Telephone: __________________FAX: ________________Email address: _________________ Is Carrier a Federally Qualified HMO? ______________ If yes, attach evidence. 2. INFORMATION ABOUT THE FILING Date of Filing: _____________________ If the filing is being made after a change in the plans offered to individual consumers: Date plan change(s) made: _________________________ Date of withdrawal pursuant to NJAC 11:20-18, if applicable: ______________________ Date of conversion pursuant to NJAC 11:20-24.7, if applicable: __________________________ 3. IDENTIFICATION OF PLANS BEING OFFERED Place a check next to each standard plan being offered. Ё% Plan A/50 (Must be offered unless carrier is Federally Qualified HMO) Delivery System (Check all that apply) Ё% Indemnity Ё% PPO Ё% POS Deductible Options (Check all that apply) Ё% $2,500 (must offer) Ё% $1,000 Ё% $5,000 Ё% $10,000 Ё% amount to qualify as a HDHP Copayment Options (Check all that apply) Ё% $15 Ё% $30 Ё% $40 Ё% $50 Ё% Plan B Delivery System (Check all that apply) Ё% Indemnity Ё% PPO Ё% POS Deductible Options (Check all that apply) Ё% $2,500 (must offer) Ё% $1,000 Ё% $5,000 Ё% $10,000 Ё% amount to qualify as a HDHP Copayment Options (Check all that apply) Ё% $15 Ё% $30 Ё% $40 Ё% $50 Ё% Plan C Delivery System (Check all that apply) Delivery System (Check all that apply  3AL‘  ' ( ) Y U p q ‘ W p ˜ ђ ѓ є і   U Žтф  њѕњёэёэёњсеёњёбЭбХСбСбСЙБЙБб­Ђš‘‹€zododh“zЈhЛfRCJ$aJ$h“zЈhЛfRCJaJ hУeйaJhG~0hЛfRCJaJ hЛfRaJhЛfRhЛfRaJhЛfRCJ(aJ(hЛfRhЛfRCJ(aJ(hЛfRhУeйhЦ&ф5hУeйhУeй5hЦ&фhЦ&фhЦ&ф5hўA‘hУeйh ih3v5CJ$aJ$h ih i5CJ$aJ$hпNчh i hпNч5 h i5'   ( ) Y Ц о / ~ Э p q ‘ З  D ˜ ђ ѓ  V іёящяриииииигириииииищЮЮgd igdўA‘dhgd i dh@&gd('|@&gd('|gd i $@&a$gd('|і(§р8TЊцњJЂњОPdД \ Д x!Ю! ""n"Ц"#т#8&t&њњњњњњѕѕѕѕѕѕѕѕѕѕѕѕѕѕѕѕѕѕѕѕѕѕgd“zЈgd i (*Ž’”ЦШорRTЌЎКМШЪжицшъьіњLNtv’”ќў02HJz|$&24@BPRT^bfД   . ѕъѕпѕъѕъѕдЩдЩѕЩдЩдЩдЩдЩСЖС­ЇЩдЩдЩдЩдЩдЩдЩдЩдЩдЩдЩдЩЖС­ЇЁЇЩŸЩдЩU h{6aJ h“zЈaJhЛfRh“zЈaJhЛfRh“zЈCJ(aJ(h“zЈCJ(aJ(h“zЈh“zЈCJaJh“zЈh“zЈCJ$aJ$h“zЈhУeйCJaJh“zЈhЛfRCJ$aJ$h“zЈhЛfRCJaJ>) Ё% Indemnity Ё% PPO Ё% POS Deductible Options (Check all that apply) Ё% $2,500 (must offer) Ё% $1,000 Ё% $5,000 Ё% $10,000 Ё% amount to qualify as a HDHP Copayment Options (Check all that apply) Ё% $15 Ё% $30 Ё% $40 Ё% $50 Ё% Plan D Delivery System (Check all that apply) Ё% Indemnity Ё% PPO Ё% POS Deductible Options (Check all that apply) Ё% $2,500 (must offer) Ё% $1,000 Ё% $5,000 Ё% $10,000 Ё% amount to qualify as a HDHP Copayment Opti. 0 L N Ж И ъ ь !!4!6!а!в!о!р!ь!ю!њ!ќ! " """""p"r"˜"š"Ж"И" #"#T#V#l#n#ž# #$&:&<&H&J&V&X&d&f&t&v&x&‚&Œ&ф&ѕъѕъѕъѕъѕъѕъѕъѕъѕъѕъпзЮШТъѕъѕъѕъѕъѕъѕъѕъРъѕъѕъѕъѕъЕ­Єž“h“zЈhG~0CJaJ hG~0aJhЛfRhG~0aJhG~0CJ(aJ(hЛfRhG~0CJ(aJ(U h{6aJ h“zЈaJhЛfRh“zЈaJh“zЈCJ(aJ(hЛfRh“zЈCJ(aJ(h“zЈh“zЈCJaJh“zЈh“zЈCJ$aJ$7ons (Check all that apply) Ё% $15 Ё% $30 Ё% $40 Ё% $50 Ё% Plan HMO Copayment Options (Check all that apply) Ё% $15 Ё% $30 (must offer) Ё% $40 Ё% $50 Deductible and Coinsurance (list the combinations below.) ____________________________________________ ____________________________________________ Referral (Check all that apply) Ё% Required Ё% Not Required t&Œ&т&:'А'f(Њ(і(њњњњњњѕgd igdG~0ф&ц&ђ&є&'''*',':'А'f(Њ(Ќ(Ў(А(Ш(Ь(Ю(а(№(є(і(ѕъѕътѕъѕъзбзЭѕътъѕътъЩh“zЈhG~0 hG~0aJhG~0hG~0CJaJhG~0CJaJh“zЈhG~0CJaJh“zЈhG~0CJ$aJ$.:p iАа/ Ар=!А "А # $ %ААаАа а†œ<@ёџ< NormalCJ_HmH sH tH DAђџЁD Default Paragraph FontViѓџГV  Table Normal :V і4ж4ж laі (kєџС(No List 4B@ђ4 i Body Text$a$VY@V ('| Document Map-D MЦ џ€CJOJQJ^Jб .џџџџ ()YЦо/~Э pq‘ЗD˜ђѓVžЦђ€ЋЩгћ'SЕрў0X„А = [ e  Й х G r  œ Ч ѓ . ‰ Ћ г 0€€˜0€˜0€0€€˜0€0€€˜0€)˜0€)˜0€)˜0€)˜0€)˜0€)˜0€)˜0€)0€€˜0€q˜0€q˜0€q˜0€q˜0€q˜0€q0€€˜0€ѓ˜0€ѓ˜0€ѓ˜0€ѓ˜0€ѓ˜0€ѓ˜0€ѓ˜0€ѓ˜0€ѓ˜0€ѓ˜@0€ѓ˜@0€ѓ˜@0€ѓ˜@0€ѓ˜@0€ѓ˜0€ѓ˜0€ѓ˜0€ѓ˜@0€ѓ˜@0€ѓ˜@0€ѓ˜@0€ѓ˜@0€ѓ˜0€ѓ˜0€ѓ˜@0€ѓ˜@0€ѓ˜@0€ѓ˜@0€ѓ˜@0€ѓ˜0€ѓ˜0€ѓ˜0€ѓ˜0€ѓ˜0€ѓ˜0€ѓ˜0€ѓ . ф&і( t&і( і( г (eg68TYў"*‹•ЏД3=W_РЪфщšДМ ' A F Х Я щ ё R \ v { Ї Б Ы а Š • г 3333333333333333333333 3AL‘''Upœ Њ Ћ а г г хй/ i3vG~0{6ЛfRwQTАix('|KўA‘“zЈУeй рЦ&фпNчѓг 9]Ї0џ@€,§WXVVVVV V б p@pppp p"p&џџUnknownџџџџџџџџџџџџG‡z €џTimes New Roman5€Symbol3& ‡z €џArial5& ‡za€џTahoma"ёˆ№аh1ћЬf1ћЬfУ У  №ЅРДД€24Ы Ы 2ƒQ№ппHP)№џ?фџџџџџџџџџџџџџџџџџџџџџ i2џџExhibit Ellen DeRosabimckeeўџр…ŸђљOhЋ‘+'Гй0t˜ЈДЬифє  0 < HT\dlфExhibitEllen DeRosaNormalbimckee2Microsoft Office Word@FУ#@ЮЈpkЩ@ЮЈpkЩУ ўџеЭеœ.“—+,љЎ0є hp€ˆ˜  ЈАИ Р дфNJDOBIЫ ' Exhibit Title ўџџџўџџџ!"#$%&'()ўџџџ+,-./01ўџџџ3456789ўџџџ§џџџ<ўџџџўџџџўџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџRoot Entryџџџџџџџџ РFРT3%pkЩ>€Data џџџџџџџџџџџџ1Tableџџџџ mWordDocumentџџџџ0.SummaryInformation(џџџџџџџџџџџџ*DocumentSummaryInformation8џџџџџџџџ2CompObjџџџџџџџџџџџџqџџџџџџџџџџџџўџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџўџ џџџџ РFMicrosoft Office Word Document MSWordDocWord.Document.8є9Вq