ORDER No. 28454 TO EMPLOY DON GRAY TO EVALUATE EMPLOYEE HEALTH INSURANCE BIDS On this the 15'}' day of December, 2003 upon motion made by Commissioner Williams, Seconded by Commissioner Baldwin the Court unanimously approved a vote 3-0-0 To employ Mr. Don Gray out of Professional Services at a cost not to exceed $5,000, and have him report back to this Court with his evaluation of the proposals and any recommendations he may have, and that he be authorized to submit late numbers from any or all of the offers as to their best and final offers. Barbara Nemec Derr County Treasurer December 15,2003 Subject: Agenda: Acceptance, rejection or other appropriate action on Employee Health Insurance Bids (County Judge) County Judge and County Commissioners: Exhibit 1: Declination letters -Wallace & Associates Exhibit 2: Dental Proposals -Wallace & Associates Exhibit 3: AFLAC Insurance -Wallace & Associates Exhibit 4: Benefit Planners (Medical} -Wallace & Associates *Plan not being considered per recommendation from Wallace & Associates Exhibit 5: Group Administrators (Medical) -Wallace & Associates *Plan not being considered per recommendation from Wallace & Associates Exhibit 6: Mutual of Omaha (Medical) -Wallace & Associates *Concern: efficiency of enrollment due to lack of local office representative Points Of Interest: Banking & Funding: Clarification regarding the issuance of the benefit payment referred to as "Customer's Name" -clarify "Customer's Name." Questionnaire: Select Risk. Exhibit 7: County Choice (Medical) -Brian Finley, Finley & Associates, Rhonda Taylor, Taylor Insurance Points of Interest: Proposal rate are based on the following: * Enrollment to occur by 12/10/03. * Offer guaranteed until 12/1'/3. * Retirees pay the same as active employees, regardless of age. • Decisions made less than 30 days prior to your anniversary date may result in a delay in implementation of benefits. Exhibit 8: GreenTree Administrators -Brian Finley, Finley & Associates Points of Interest: Five employees requiring claim details: ~' Exhibit 9: Employee Benefit Administrators -Brian Finley, Finley & Associates, Ray Rothwell Exhibit lo: Broker Questionnaire: Brian Finley, Finley & Associates, Wallace & Associates Table of Contents I. Mutual of Omaha: a. Rate Proposal b. Drug Prescription Fees c. Funding Levels IL County Choice: a. Rate Proposal b. Funding Levels III. GreenTree Administrators a. Rate Proposals b. Drug Prescription Fees c. Funding Levels IV. Employee Benefits a. Rate Proposal b. Drug Prescription Fees V. Returned Questionnaires a. Brian Finley & Associates b. Wallace & associates Proposals Retrieved a. Advanced Insurance b. Brian Finley & Associates c. Keith Langley d. MetLife Insurance e. Ray Rothwell f. TAC g. Taylor Insurance h. Sherlock Insurance Agency i. Wallace & Associates Returned Proposals a. Brian Finley & Associates b. Ray Rothwell c. Taylor Insurance d. Wallace & Associates Bid Packages Picked-up (October 31, 2003, 8:00 a.m.) RFP's Returned (December O1, 2003, 9:00 a.m.) Open Health Insurance bids and refer for review and evaluation (December 04, 2003, 1:00 p.m.) Consider and discuss acceptance, rejection or other appropriate action on Employee Health Insurance Bids (December 15, 2003, 9:00 a.m.) Don Gray 512/261-0900 Austin, Texas $125.00/hr .36 per mile 2-3 days(approx) Mutual of Omaha Kerr County Plan A Employee Emp loyee+ Family ASO Fee $ 24.30 $ 24.30 PPO Fee $ 2.95 $ 2.95 UR Fee $ 2.40 $ 2.40 Cobra/HIPAA $ 0.80 $ 0.80 Total Admin Fee's $ 30.45 $ 30.45 Annual costs $ 66,502.80 $ 14,981.40 $ 81,484.20 Aggregate fee $ 6.25 $ 6.25 40k ISL $ 44.42 $ 113.42 Total Stop loss $ 50.67 $ 119.67 Annual costs $ 110,663.28 $ 58,877.64 $ 169,540.92 Aggregate Attachm $ 331.46 $ 732.75 Annual costs $ 723,908.64 $ 360,513.00 $ 1,084,421.64 head count 182 41 223 Maximum Liability $ 412.58 $ 882.87 $ 1,335,446.76 Renewal Rates $ 324.13 $ 549.73 Annual costs $ 707,899.92 $ 270,467.16 $ 978,367.08 ~!' PsP~ t-e~/ ~ y (j(J/j~~~fJ-CP ~ /~S~~cI~9T-PS ~e~ v ~ n., ~ ~]~C ~iiyz Mutual of Omaha Kerr County Plan B Employee Empl oyee+ Family ASO Fee $ 24.30 $ 24.30 PPO Fee $ 2.95 $ 2.95 UR Fee $ 2.40 $ 2.40 Cobra/HIPAA $ 0.80 $ 0.80 Total Admin Fee's $ 30.45 $ 30.45 Annual costs $ 10,231.20 $ 4,750.20 $ 14,981.40 Aggregate fee $ 6.25 $ 6.25 40k ISL $ 44.42 $ 113.42 Total Stop loss $ 50.67 $ 119.67 Annual costs $ 17,025.12 $ 18,668.52 $ 35,693.64 Aggregate Attachm $ 272.47 $ 600.26 Annual costs $ 91,549.92 $ 93,640.56 $ 185,190.48 head count 28 13 41 Maximum Liability $ 353.59 $ 750.38 $ 235,865.52 Renewal Rates $ 324.13 $ 549.73 Annual costs $ 108,907.68 $ 85,757.88 $ 194,665.56 Mutual of Omaha Kerr County Plan C Employee Employee+ Family ASO Fee $ 24.30 $ 24.30 PPO Fee $ 2.95 $ 2.95 UR Fee $ 2.40 $ 2.40 Cobra/HIPAA $ 0.80 $ 0.80 Total Admin Fee's $ 30.45 $ 30.45 Annual costs $ 4,019.40 $ 1,827.00 $ 5,846.40 Aggregate fee $ 6.25 $ 6.25 40k ISL $ 44.42 $ 113.42 Total Stop loss $ 50.67 $ 119.67 Annual costs $ 6,688.44 $ 7,180.20 $ 13,868.64 Aggregate Attachm $ 245.31 $ 539.70 Annual costs $ 32,380.92 $ 32,382.00 $ 64,762.92 head count 11 5 16 Maximum Liability $ 326.43 $ 689.82 $ 84,477.96 Renewal Rates $ 324.13 $ 549.73 Annual costs $ 42,785.16 $ 32,983.80 $ 75,768.96 Plan Summary -Prescription Drugs Class(es) 01,02 Covered Services In-Network Out-of-Network Retail (up to a 30.day supply per prescription) Plan pays 100% after: Plan pays: • Generic Drugs • $10 copay • SO% coinsurance • Brand Name Drugs on Formulary • $20 wpay • SO% coinsurance • Brand Name Drugs not on Formulary • $3S wpay • SO% coinsurance Mail Order (up to a 100.day supply per prescription) Plan pays 100% after: Plan pays: • Generic Drugs • $20 wpay • No Benefit • Brand Name Drugs on Formulary • $40 copay • No Benefit • Brand Name Drugs not on Formulary • $70 copay • No Bencfit Other: • Oral contraceptives are included as covered drugs. • This plan has a voluntary generic program- This means that you and your physician may choose brand name drugs that have generic equivalents without penalty. • A formulary is a list of preferred medications that have been clinically reviewed by the Plan. To find out if a medication is on the formulary, call Express Scripts, Inc. at 800-889-0375. • A prescription drug claim form maybe used to claim reimbursement until you receive your prescription drug identification card. These forms can also be used ifout-of-network benefits apply to your plan. Mutual of Omaha 23 3621 Plan Summary -Prescription Drugs Class(es) 03,04 Covered Services In-Network Out-of-Network Retail (up to a 30-day supply per prescription} Plan pays 100% after: Plan pays: • Generic Drugs • $10 copay • SO% coinsurance • Brand Name Drugs on Formulary • $30 copay • SO% coinsurance • Brand Name Drugs not on Formulary • $4S copay • SO% coinsurance Mail Order (up to a 100-day supply per prescription) Plan pays 100% after: Plan pays: • Generic Drugs • $20 copay • No Benefit • Brand Name Drugs on Formulazy + $60 cupay • No Benefit • Brand Name Drugs not on Formulary • $90 copay • No Benefit Other: • Oral contraceptives are included as covered drugs. • This plan has a voluntary generic program. This means that you and your physician may choose brand name drugs that have generic equivalents without penalty. • A formulary is a list of preferred medications that have been clinically reviewed by the Plan. To find out if a medication is on the formulary, call Express Scripts, Inc. at 800-889-0375. • A prescription drug claim form may be used to claim reimbursement until you receive your prescription drug identification card. These forms can also be used ifout-of-network benefits apply to your plan. Mutual of Omaha 24 3621 Plan Summary -Prescription Drugs Class(es) 05,06 Covered Services In-Network Out-of-Network Retail (up to a 30-day supply per prescription) Plan pays 100% after: Plan pays: • Generic Drugs • $ i 0 copay • 50% coinsurance • Brand Name Drugs on Formulary • $30 c;opay • 50% coinsurance • Brand Name Drugs not on Formulary • $45 copay • 50% coinsurance Mail Order (up to a 100-day supply per prescription) Plan pays 100% after: Plan pays: • Generic Drugs • $20 copay • No Beneftt • Brand Name Drugs on Formulary • $60 copay • No Benefit • Brand Name Drugs not on Formulary • $90 copay • No Benefit Other: • Oral contraceptives are included as covered drugs. • This plan has a voluntary generic program. This means that you and your physician may choose brand name drugs that have generic equivalents without penalty. • A formulary is a list of preferred medications that have been clinically reviewed by the Plan. To find out if a medication is on the formulary, call Express Scripts, lnc. at 800-889-0375. • A prescription drug claim form maybe used to claim reimbursement until you receive your prescription drug identification card. These forms can also be used ifout-of-network benefits apply to your plan. Mutual of Omaha 25 3621 Rate Summary -Stop Loss CIaSS All Eligible Employees Description Stop Loss Specific Rates ~ Annual Total Aggregate Rates Annual Total We are proposing Specific and Aggregate stop loss coverage. Monthly Monthly Annual Unit #ees Rate Premium Premium Employee 221 $44.42 $9,816.82 $117,801.84 Employee and One or 59 $113.42 $6,691.78 $80,301.36 More De endents $198,103.20 Monthly Monthly Annual Unit #ees Rate Premium Premium Employee With or 280 $6.25 $1,750.00 $21,000.00 Without De endents $21,000.00 *Stop Loss Rates include a 10.00% of premium commission. Aggregate Deductible Factors Plan A Plan B Plan C Minimum Unit #ees Monthly Monthly Annual Factors Aggregate Deductible Deductible Employee 182 $331.46 $60,325.72 $723,908.64 Employee and One or 41 $732.75 $30,042.75 $360,513.00 More D endents Flan A $90,368.47 $1,084,421.b4 Employee Only 28 $272.47 $7,629.16 $91,549.92 Employee and One or 13 $600.26 $7,803.38 $93,640.56 More D endents Plan B $15,432.54 $185,190.48 Employee Only 11 $245.31 $2,698.41 $32,380.92 Employee and One or 5 $539.70 $2,698.50 $32,382.00 More D endents Plan C $5,396.91 $64,762.92 Combined Total $111,197.92 $1,334,375.04 * The Minimum Monthly Deductible will be based on the greater of (a) the first month's actual exposure counts multiplied by the aggregate factors, or (b) the minimum monthly deductible shown above. Mutual of Omaha 51 8700 ... ~. ~ ~" '° R CQUNTY RQPaSAL FQR KER GRQUP HEALTH P Ch to c 300 $459.57 $629.97 Employee Only ee Child $827.22 $g65.09 Empl°y mployee & Children $1,332.75 E loyee & Spouse e & Family Emp $20 -^ loye __- $2501500 visit Go-Pay Office 90!70 peductible t Network 1nlOu Co_lnsurance °I0 $150013500 InlOut NetwGer Maximum uran $75 Co-lns InlOut Network Emergency Room $5120 35 n G ra d pptto~-~ ou-' Rx card wilJe e $10p deductible for Y Gho ec 100 $409.02 $569.02 $736.23 $858.93 $1,186.15 825 $750!1000 80!60 $3000!0000 $100 $5 Choosing th the following are based on h 01101105. Proposal rates 4 throng from 0110110 effective b 12110103. -ble employees. only. Rates ccur Y ° of elig empl°yee rate Enrollment to ° ent of 100 /° ° of the ~~ * inimum enrollm tion of 100 I° A m er contribu p minimum emplountij12I1103. over the rate. of age. uaranteed fees are 2°~O regardless date ~,* Offer g inlstration loyees, ,._ ~. EOBRA A ay the same a ~ 30 days prior to your anniversary ~.w_,__ ~ Retirees p de less `narnplementation of benefits. w~,~- pecisions maa delay ;..._~~ ., .__.rv_ may result in JANUARY ~' 200` Ch cto a 1200 $386 A4 $541.04 $884.87 $810.68 $1,119.51 `°$30 $1000!4000 80160 $300016000 $100 $512p135 ho~ce- 1 ~ n of Counties .~'~ar ASSQCIdtLO eeBeaeFitsPool ~Iealtl~ +°~-Emp~Oy 11126103 TAC HEBP (New Groups} Expected paid claims -medical (a) prr~ ' Expected paid claims - Rx ~" 7 TOTAL EXPECTED PAID CLAIMS ADMINISTRATION CHARGE (b) STOPLOSS PREMIUM $50,000 per Participant 125 % Aggregate MONTHLY FIXED COST CLAIM LIABILITY FACTOR pry MONTHLY COST FOR ~"7 ADMINISTRATION, STOP LOSS AND PAID CLAIMS Kerr County A50 and Stoploss HEALTH Rx 5/20/35 Choice 300 Choice 1200 AD = 1/1/04 Composite Composite ANNUAL' 200 65 265 $261.03 $236.09 $810,622 $92.02 $84.27 $286,579 $353.05 $320.36 $1,097,201 $46.18 $46.16 $43.98 $43.98 $9.49 $9.49 $99.65 $99.65 $441.31 $400.45 $500.10 $50,873 For the contract period $540.96 HEBP's ACCOUNT MINIMUM BALANCE: Recommended Funding Amounts $513.43 $474.97 $146,852 "" $139,856 $30,178 $316,887 $1,371,501 "' $1,688,386 $1,627,441 Recommentled funding amounts should fund expected paid claims (EPC), administration. stoploss charges and estimated reserves; if claims exceed EPC, the Employer will be requiretl to make additional funds oval able up to the Maximum Claim Liability. ' This annual projection is based on the current enrollment, the actual results wdl differ. " If the specific (individual) stoploss limit is changed, the stoploss premium and Liability Factors will be adjusted. "' This annual aggregate amount is based on the current enrollment; in no event, will HEBP's Claim Liability be less than $1,302,926 TERMINATION Run-Off Administration $0.00 $o Run-Off Liability Factor $342.58 $313 74 $269,328 TOTAL $269,328 Upon termination, the run-off factors above wit be multiplied times the total of all memberships actually exposed during each of the three months immediately preceding contract termination and the result will he the obligation of the Employer; the TOTAL above is based on the current enrollment. (The Run-OH Administration amount is due and payable whether or not BCBST processes the run-off claims.) f~ In addition to the Self Funded Trust underv/riting contingencies, the following will apply: The rates above are effective for twelve months contingent upon: 1) an effective date np later than 1-Ot-04 2) the Employer paying 100 % of the employee only cost for all lines of coverage !i 3) a minimum enrollment of 265 employees with 21 % carrying dependent coverage 4) a monthly enrollment of no fewer than 240 employees 5) no additional taxes being imposed and no increase in existing taxes 6) The maximum medical and prescription drug claims for each participant that will apply to the aggregate stoploss is $50,000. 7) Prescription drug claims are not subject to the specifc stoploss insurance. 8) The aggregate stoploss insurance shall apply to the medical antl prescription drug claims subject to the levels identiFled above. 9) Health aggregate stoploss is based on a 12/12 policy. ~p,~ 10) BCBSTX is not the administrator of the prescription drug program. l~ (a) Required to fund bank account for medical only claims. Choice 300/1200 with $50k SSL ~____ Expected paid claims -medical (a) Expected paid claims - Rx TOTAL EXPECTED PAID CLAIMS ADMINISTRATION CHARGE (b) STOPLOSS PREMIUM ^, ~ $100,000 per Participant !~7 125% Aggregate MONTHLY FIXED COST CLAIM LIABILITY FACTOR w MONTHLY COST FOR ADMINISTRATION, STOP LOSS AND PAID CLAIMS Kerr County ASO and stoploss HEALTH Rx 5/20/35 Choke 300 Choice 1200 AD = 1/1/ab Composite Composite ANNUAL' 200 65 265 $278.26 $253.32 $865,414 $92.02 $84.2 $286,579 $370.28 $337 59 $1,151,992 $46.18 $46.16 $146,852 "<' $26.75 $2675 $85,065 $9.49 $949 $30,178 $82.42 $82.42 $262,096 $462.85 $421.99 $1,439,990 "` $545.27 $50441 $1,702,086 HEBP's ACCOUNT MINIMUM BALANCE: $50,873 For the contract period Recommended Funding Amounts $513.43 $474.97 $t,fi27,441 Recommended funding amounts should fund expected paid claims (EPC), administration, stoploss charges and estimated reserves; if claims exceed EPC, the Employer will be required to make additional funds available up to the Maximum Claim Liability 'This annual projection is based on the current enrollment; the actual results will differ. " 1f the specific (individual) stoploss limit is changed, the stoploss premium and Liabtlily Factors will be adjusted. "' This annual aggregate amount is based on the current enrollment; m no event, will HEBP's Claim Liability be less than $1,367,991 TERMINATION Run-Off Administration $0.00 $0 Run-Off Liability Factor $342.5a $313'4 $269,328 TOTAL $269,328 ri Upon termination, the run-off factors above will he multiplied times the total cf all memberships actually exposed during each of the three months immetliately preceding contract termination and the result will be the obligaHOn of the Emp4oyer, the TOTAL above is based on the current enrollment. (The Run-Off Administration amount is due and payable whether or not BCBST processes the run-off claims. ) In addition to the Self Funded Trust underwriting contingencies, the following will apply: The rates above are effective for twelve months contingent upon. 1) an effective date no later than 1-Ot-04 2) the Employer paying 100 % of the employee only cost for all fines of coverage 3) a minimum enrollment of 265 employees with 21 % carrying dependent coverage 4) a monthly enrollment of no fewer than 24C employees 5) no additional taxes being imposed and no increase in existing taxes 6) The maximum medical and prescription drug claims for each participant that will apply to the aggregate slopfoss is $100,000. 7) Prescription drug claims are not subject to the specific stoploss insurance. 8) The aggregate stoploss insurance shall apply to the medical and prescription drug claims subject to the levels idenLfied above. 9) Health aggregate stoploss Is based on a 12/12 policy. 10) BCBSTX is not the administrator of the prescription drug program. (a) Requiretl to fund bank account far medical only claims. Choice 300/1200 with $100k SSL i e proscription DrnK partictpatinB pdvancePCS ~_ loss cnantmuml SO ~ W ' px’gprogram estop vailab5e o[ Prescribed DA Px~exiptioo of appfY20 c°insuranc enetic is a' (coPaYs Wrll n S}5 copaY when no 8 Deductible Sip copaY when no Senepe i5 available or prescribe UA~v grand Name a ar actual cost rlon-Ptefened Lesscr at 55 eaP' Y grand Name 1 name drugs when "Dispense as Generic b'arrd a~the d{fJzrence ro Purchase aired is P ` (us the brand name etzeting ~ itt be req ruS• P Members [s not indicated nd brand name d Written" (DANA the 8cneru a ~ bztween the cost of to 90_da} supPiY S40 CopaY ail Service r r ~~_- . ~ $40 CopaY - Nnn-ptefetcedBrandNanje g10 CoPa dame With the Tcaas Band h a master contract CS ihroug Dntgs are not admrnistered by Genetic vanceP trop Benefits are pi°vrdee Ben fits Pool. Pfescrip of Go D ea Health and gmploy ~3ote'. yrescriP Associatio B1ueShield of Texas, mac' B1ueGross ~- Specific Deductible: $ 40,000 $ 50,000 $ 60,000 Claim Basis: 12/12 12/12 12112 Monthly Rates: ee: $ 36.26 $ 29.72 $ 25.35 family: $ 93.89 $ 78.03 $ 67.32 Monthly Premium: $ 13,502 $ 11,131 $ 9,540 Annual Premium: $ 162,022 $ 133,572 $ 114,482 A RE AT OVERAGE OFFER 1 OFFER 2 OFFER 3 Covered Benefits: Medical/Rx Medical/Rx Medical/Rx Claim Basis: 12/12 12/12 12/12 Monthy Rate: Super Composite Rate $ 3.12 $ 3.15 $ 3.20 Monthly Premium: $ 864 $ 873 $ 886 Annual Premium: $ 10,371 $ 10,471 $ 10,637 Monthly Attachment Factors: ee $ 267.35 $ 273.03 $ 276.82 family $ 637.57 $ 651.34 $ 660.63 Monthly Attachment Point: $ 96,269 $ 98,328 $ 99,708 Annual Attachment Point: $ 1,155,230 $ 1,179,935 $ 1,196,493 M AR F STS OFFER 1 OFFER 2 OFFER 3 FlXED COSTS Monthly Specific Premium: $ 13,502 $ 11,131 $ 9,540 Monthly Aggregate Premium: $ 864 $ 873 $ 886 Total Fixed Monthly Premium: $ 14,366 $ 12,004 $ 10,427 VARIABLE COSTS Monthly Attachment Point: $ 96,269 $ 98,328 $ 99,708 TOTAL COSTS Expected Monthly Costs: $ 91,381 $ 90,666 $ 90,193 Expected Annual Costs: $ 1,096,577 $ 1,087,991 $ 1,082,313 Maximum Monthly Costs: $ 110,635 $ 110,332 $ 110,134 Maximum Annual Costs: $ 1,327,623 $ 1,323,978 $ 1,321,611 SeeGfk Axo!m~odation: $.50 (per eelmo)" A98re9a~ACeommadatlon: $1.50 (per ee/mo)•• "Fees are not InCltided M rates Kerr County Effective Date: 1!1!2004 (The quote expires on the effective date.) Commission Level: o G~roe are based on : ee: 217 family: 60 PRESCR1p"1 tON DRUG BENEFIT PLANE&C .... PLAN B ~ C ..$45.00 I .......... Yharnracy Option ................. Co-Payment, per Prescription .................. ~ ................. ........... ...... . ~ ~ ~ $30.60 ...$10.00 .. Multiple Source Brand ........... ......... ~ ....................... : "' ................ ••, .,.,,,. Single Source Brand.....•~•••~ ••' . Generic Drugs ................ $54.00 90 Day) .............................. . ............. Nisi Order t ' tion r Prescnp $35.00 ...... . .. Co-payment, pe Source Brand........... • ................. l . $15.00 .. .. e .......... Multip le Source Brand ......................... Sing ............... . .......... .................... Generic Drugs .............. N . PLANT BENEFTT D TISSUE TRANS HUMAN ORGAN AN . •...,.. .$zso,ooo ................... .. .. .......so°° ............. . ....................................... .... ......... Maximttni .. . ... .......... ......70°~° ..... . Lifetime nce m network .................. .......................... 80% .. Plan A ...... co-insura .......... Plan A co-insurance out of net’TOP L08Zi COVEAAiiES MiCLUGE: A0Y3REGATE STOP L06S COVERAGES UfCLUDE: Iuleda! Mew ftX I188~EQ. LNE3 EE: Z77 J4S$tI01tED LIVES E~ 277 277 60 DEP. 60 60 OPTtQN 1 omuCTIBLE: X008 aPeaFtic atop Los3 - ACCIJNIWATIONPERIOD: Inarfred n t?JPsld In tz MQNTtB.Y ANNt1Al MONTHLY RATE6: ~ ~ C~ ~.j 536.91 544.10 St2:870.07 1154.440.84 A~06RBGATE ATOP 1085 AICCUMUUITIDN PERIOD; kKtafef! M 121Psfd it-12 l-G<4R8GY1,TE DED: ssli MQNFHLY ATTENT w-i~ FAICTORS JWNUAL ftAT~ MONTHLY ANNUAL - ~ ~ DEQU~TtBi.E ~ ~ ~ ~3 - ~.y6 ' 5392.;1 i1.313.80f,9/ 32.2 12.71 tTSit.~ 58,M86_Gd OPT10N 2 - oapucnBl.~ iS/~.063 iPE~ BTEfh 8083 ACCUMUIJ1TiON PERIOD: Incu~ed In t?JF~aid 1+1.12 MoIiTHLY M1Nwu. IIAONTHLY RIlTES: ~; ~ ~ S~iI - 1'!0:25 f36a4 610,547.66 1126.$71.80 1KiGREG1~TE 8TOt* ROa6 ACCUNWI.IUTION f~RIOD: k~srod in 1?A'eid in 12 AGC#tECiATE DED: 2911 M6MFfLY ATrlrCNMENT AGGREGATE FACYORS MINLtAI RATE IYIOM'FILY ANNUAL €~ ~ 6-~°.:~ ~€ ~ ffi~I SCI 1351.84 Swf~J6 i1.40t,4Sb.76 52.27 52.ti 5781.39 38.e8s_sa PL~A3E SEE NE7~CF PAG]:' FUR MdRE OP"1'IONS STOP LOSS QUOTATION CONTINUED PACIFIC UFE 8- ANNUITY COMPANY Stop Loos PrndtlCts Ullder1v11ttatf ny Pedac Ute Insure-ioe Compin QPT'!4N 9 - orsoucTteLF: saaoao jiPEGFtC 8TQP LOSE ACGUMt~J1T1ON Pi:RIOE?: itgtredirrl?/Pdgln 12 MONTHLY RATES: ~ ~ MO~NT~HLY AN~~N~ iC~5.6~ 33D:63 38.9©7.31_ Syt17,247,72 M~GRfQATE BTaP LO>!8 Atx;t1MULATNDN PizR10[3: kfCURed !n 12fPeid in 12 At3C~REcATE DEb: .2546 AAONTHLYATTACHMENT At:~QRt_GAYE ~ , FACTORS ANNtJA,k RATS iMONTJiLY AtWdUAL EE IMP ~GTIRlE ~E P.EcP ~._I COST 8339.~ti 1405.59 S7A20,489.58 12.27 22.71 5791.39 59,49B~.t3d PLEASE SEE NEXT PAGE FOR ALL QUOTATION CONTIIVGF~+ICITS Kerr County Fidelity Security Stop Loss: $40,000 Contract: 12/12 Current PPO Benefits Plan A Specific Premium Aggregate Funding Subtotal Medical Administration Utilzation Management COBRAMIPAA PPO Total Admn. Related Monthly Fixed Cost Claims Factors Monthly Maximum Monthly Fixed Monthly Clavns Monthly Total Monthly Billing fee: $25.00 1 ~~ l ~ ., \ ~ w 164 13 14 11 Emp Emp/Child(ren) Emp/Spouse Emp/Family $52.67 $122.15 $122.15 $122.15 6.90 6.90 6.90 6.90 $59.57 $129.05 $129.05 $129.05 $14.00 $14.00 $14 00 $14.00 $1.95 $1.95 $1.95 $1.95 $0.50 $0.50 $0.50 $0.50 3.00 $3.00 3.00 X3.00 $19.45 $19.45 $19.45 $19.45 $79.02 $148.50 $148 50 $148.50 $48P'r•10 $~~8.4G $4rW00 K~3D~$+39'01 $4Ba-b2- $656-86 $7950 $851 $18,602.28 $89,204.09 Annual Fixed Annual Claims $223,227.36 g1,D38:q+t~pg ~S ~~~'~~ y r $107,806.37 Annual Total $i'P93;6PB44 Effected Claims $802,836.75 if r "G' _ `' Z .... ~~ 5 O . j !~ ~ r ~~ ~ Kerr County ~ Fidelity Security Stop Loss: $40,000 Contract: 12112 I i Current PPO Benefits Plan B I~ '~ Specific Premium 1~ Aggregate Funding 11 Subtotal ~" Medical Administration ~~ Utilzation Management COBRA/HIPAA PPO Total Admn. Related ~7 Monthly Fixed Cost Claims Factors Monthly Maximum Monthly Fixed Monthly Claims Monthly Total MoMhty Billing fee: $25.D0 30 7 7 3 Emp Emp/Child(ren) Emp/Spouse Emp/Family $52.67 $122.15 $122.15 $122.15 6.90 6.90 $6.90 6.90 $59 57 $129.05 $129.05 $129 05 $14.00 $14.00 $14.00 $14 00 $195 $195 $1.95 $1.95 $0.50 $0.50 $0 50 $0.50 3.00 3.00 3.00 3.00 $19 45 $19.45 $19 45 $19.45 $79.02 $148.50 $148.50 $148.50 $79'00 $365 $452'60 $saSeD $35802 $s1s-5o $stjo~5o $eQSSo ~~s~.~i~ y-~,.~~, ~r s~.yo ~ a ~r.e~ $4,895.10 $15,724.00 Annual Fixed Annual Claims $59,741.20 $1,98'689V0 ~s~,C/~~ ~~G $20,619.10 Annual Total $2!9.42!x'20 ~~~ ~ FlI ~. ~~ E~eded Claims $141,516.00 Kerr County Fidelity Security Stop Loss: $40,000 Contract: 12!12 Current PPO Benefits Plan C 11 2 2 1 Emp Emp/Child(ren) Emp/Spouse Emp/Family Specific Premium $52.67 $122.15 $122.15 $122.15 Aggregate Funding 6.90 6.90 6.90 $6.90 Subtotal $59.57 $129 05 $129.05 $129 O5 Medical Administration $14 00 $14 00 $14 00 $14 00 Utilzation Management $1.95 $1.95 $1.95 $1.95 COBRAlHIPAA $0.50 $0.50 $0.50 $0.50 PPO 3.00 3.00 3.00 3.00 Total Admn. Related $19.45 $19.45 $19.45 $19 45 Monthly Fixed Cost $79.02 $148.50 $148.50 $148.50 Claims Factors $2#8'50 $3~'S Pit ~ ~~~ L~3,~`' $40f~0 $,SDG-iS ~~~, ~' ~US~,c~a Monthly Maximum $?,~32 y>4~5~~ry ~55~0~ ~~~ $65~.r2~ Z ~ 2~N.~ 1' t ~ c Monthly Fixed $isv 72 Annual Fixed $t9,340sa Monthly Claims $4,677.75 Annual Claims $6fr, Y3~S.~0 {~ (` ~/~ f[ (~ ` Monthly Total $6,289 47 Annual Total yF5~3.g4 t ~ ~ V~ //~ y ~ ` ~ , ~y~ G' ~ Monthly Billing fee: $25.00 Expected Claims $42,099.75 1(~-'T ~`7 KERR COUNTY SCHEDULE OF BENEFITS EFF DATE 01/01/02 SELF FUNDED IN NETWORK NON-NETWORK TYPE OF SERVICE PROVIDERS PROVIDERS Calendar Year BeneSt Plan A Plan B Plan C Plan A Plan B Plan C Calendar year deductible Family Maximum Unit - 3 Persons $9.00 $750 $1,200 $800 $1500 $2,000 Last 3 month carry-over $1,200 $2,250 $3,600 $2,400 $4,500 $6,000 Coinsurance Maximum $2,000 $3,000 $4,000 $4,000 $5,000 $8,000 Family Maximum Uiut - 3 Person $6,000 $9,000 $12,000 $12,000 $15,000 $24,000 Total Out of Pocket Maximum $2,400 $3,750 $5,200 $4,800 $6,500 $10,000 Family Maximum Unit - 3 Person $7,200 $11,250 $15,600 14,400 $19,500 $30,000 Lifetime Maximum Per Person $1,000,000 CO-INSURANCE CO-INSURANCE BENEFITS DED PPO NON-PPO LII~IITATIONS Physician Office Visit excludes x-ray, lab and Waived $10 co-pay Plan A $20 co-pay Plan A surgery done at the time of (For Kerrville the office visit Co-Pay Providers Only) Waived $20 co-pay Plan B $30 co-pay Plan B will only apply to CPT codes 99201-99215 & Waived $30 co-pay Plan C $40 co-pay Plan C 99241-99245 Physician Office Visit excludes x-ray, lab and Waived $20 co-pay Plan A $20 co-pay Plan A surgery done at the time of (For Outside Kerrville the office visit. Co-Pay Providers Only) Waived $20 co=pay Plan B $30 co-pay Plan B will only apply to CPT codes 99201-99215 & Waived $20 co-pay Plan C $40 co-pay Plan C 99241-99245 PLAN PLAN PLAN PLAN PLAN PLAN OTHER BENF.hTTS DED A B C A B C LII1~iITATIONS Physician Inpatient Applies 90% 80% 80% 70% 60% 60% Physician Surgery Applies 90% 80% 80% 70% 60% 60% *For Inpatient Anesthesiology Applies 90% 80% 80% 70% 60% 60% *For Inpatient Allergy testing, serum & injections Applies 90% 80% 80% 70% 60% 60% X-ray, Radiologist Applies 90% 80% 80% 70% 60% 60% Lab, Pathologist Applies 70% 70% 70% 70% 60% 60% Preferred Lab - LabOne Waived i00% 100% 100% N/A N/A N/A After $300 max per accident subject to the Accidental Injuries Waived 100% 100% 100% N/A N/A N/A ded stud co-insurance