Medical Benefits - Munetrix - Login€¦ · labsIX-Rays Speech Therapy Outpatient Physical &...

..........~~

OISCLAIMER: This document is a sum mary of certain plan features. It should not be interpreted as a complete compari son of the products represented. Beaverton Rural Schools

All Employees

Assumed Effective Date: 7/1/2016 Option 1 Option 2 Option 3 Option 4

Plan

r-BCBSM SBI'PO $500.2mc; $10/$40/$80 Rx ($1,500 £CM)

-

BC8SM 5B PPO HSA $1!JOG.mc; $10/$40/$80 Rx-- Priority Health POS $500-0%; $20 OV; $10/$40/$80 Rx Priority Health POS HSA $1300-0%; $10/$40/$80 Rx

Rate Period Purchased Plan Features Deductible Annual Deductible - 1P Annual Deductible - 2P/FF Additional Cost After Deductible Employee Coinsurance after Deductible

Coinsurance Max - 1P

Coinsurance Max - 2P/FF Out of Pocket Maxlmum

Max ded, coinsurance, copays - 1P

Max ded, coinsurance, copays - 2P/FF Copayments Office Visit/Specialist Urgent Care/ER Chiropractic Limit/Copay Rx Copay Total Monthly Costs One Person (lP) Two Person (2P) Family (FF) Total Annual Premium Combined Current Uves Combined Annual Premium

Single (annual amounts) Taxes and Fees

Total Plan Cost

PA 152 Hard Cap

Amount Over/Under Hard Cap

7/1/2016-6/30/2017 In Network

$500 $1,000

20%

$1,500

$3,000

$6,350

$12,700

$20/$20 $20/$150

12/$20 $ 10/$40/$80 Rx

Census Rates 16 $536.67 16 $1,277.50 46 $1,595.00 78 $1,228,760

Included in total plan cost

$6,440.07

$6,142.11

$297.96

7/1/2016-6/30/2017 In Network

$1,300 $2,600

0%

$950

$1,900

$2,250

$4,500

0% after Ded. 0% after Oed.

12/0% after Ded . $10/$40/$80 Rx after Ded.

Census Rates 16 $471.41 16 $1.120.89 46 $1,399.24 78 $1,078,100


$5,656.94

$6,142.11

-$485.17

7/1/2016-6/30/2017 In Network

$500 $1,000

0%

$0

$0

$6,850

$13,700

$20/$35 $75/$150

50/$20 (combined with PT and OT) $10/$40/$80 Rx

Census Rates 16 $536.08 16 $1,195.06 46 $1,484.99 78 $1,152,093


$6,432.96

$6,142.11

$290.85

7/1/2016-6/30/2017 In Network

$1.300 $2,600

0%

$1,000

$2,000

$2,300

$4,600

0% after Ded. 0% after Ded .

50/0% after Ded. (combined with PT and OT] $10/540/$80 Rx after Ded .

Census Rates 16 $451.04 16 $1 ,004.00 46 $1,247.29 78 $967,872


$5,412.48

$6,142.11

-$729.63

Two Person (annual amounts) Taxes and Fees

Total Plan Cost

PA 152 Hard Cap



$15,330.00

$12,845.04

$2,484.96


$13,450.67

$12,845.04

$605.63


$14,340.72

$12,845.04

$1,495.68


$12,048.00

$12,845.04

-$797.04

Family (annual amounts) Taxes and Fees

Total Plan Cost

PA 152 Hard Cap



$19,139_97

$16,751 .23

-$2, 3~ _

-


$16,790.83

$16,751 .23

$39.60

Included In total plan cost

$17,819.88

$16,751.23

$1,068.65


$14,967.48

$16,751.23

-$1,783.75 -

BCBSM: 'BCBSM rates include certain federal taxes and fees established by the Affordable Care Act as well as certain State ta xes and assessments. The figures are estimates and may change for future billings. 'BCBSM quoted rates do not include commissions paid to SET SEG. Fees for SET SEG services are addressed in a separate agreement. BCBSM rates may change based on final BCBSM underwriting guidelines, actual group enrollment and participation .

Priori ty Health:

' Priority Health rates, fees and/or claims projections include "Michigan cla ims tax", PPACA fees and assessments, or similar fees or taxes that may be imposed by the Federal Government or the State of Michigan.

'Priority Health plans include an additional 20 chiropractic visits, totalling 50, combined with PT and OT.

'BCBSM and Priority Health rates include enrollment and billing service fee .

Printed On 512512016

Annual Deductible

Annual Out-of-Pocket

Preventive Care Services

Office Visits Urgent Care

Hospital Emergency Room

labsIX-Rays

Speech Therapy

Outpatient Physical & Occupational Therapy

Chiropractic Care

Prescription Drugs Contraceptives

$500/$1,000

$1,500/$3,000 includes ded/rx

100%

Office Visits $20 co-pay Specialist $20 co-pay

Urgent Care $25 co-pay

$50 co-pay Co-pay waived if admitted or accidental injury

100% after deductible

100% - prenatal/postnatal

100% after deductible physical/occIspeech therapy

combined 60 visits

$20 co-pay 38 visit maxlyr

$10 - generic $40 - formulary

$40 - nonformulary mail order/90 day retail 2x

$5,000/$10,000 employee $500/$1,000

$6,850/$13,700 includes ded/rx

100%

Office ViSits $20 co-pay Specialist $35 co-pay


ER $50 co-pay




$20 co-pay max 30 visits

$20 co-pay max 30 combined visits for outpatient/occupational and chiropractic


$40 - nonformulary $40 - Preferred Specialty

$40 - Non-preferred Specialty mail order/90 day retail 2x

$5,000/$10,000 employee $500/$1,000

$6,8501$13,700 includes ded/coin/rx

100%



ER $50 co-pay



100% Covered






$1,300/$2,600 employee $500/$1,000

$2,300/$4,600 incl udes ded/rx

100%






100% after deductible max 30 visits

100% after deductible max 30 combined visits for outpatient/occupational and chiropractic

After Deductible: $10 - generic

$40 - formulary $40 - nonformulary

$40 - Preferred Specialty $40 - Non-preferred Specialty

mail order/90 day retail 2x

$500/$1,000

$6,850/$13,700 includes dedllrx

100%



ER $50 co-pay

100% Covered


100% Covered






+

n/a

$956,164.44

n/a

$1,109,152.80

$136;080.00

$965,339.04 $884,625.36

$100;800.00

$966,128.76 $1,050,908.40

**Rates could change based on final enrollment**

***MESSA Premium includes Admin and Support Staffs Renewal***

.. :.. .. ... .. .. Beaverton Rural Schools ~ Renewal Date: July I, 2016 .Coldbrook

.--===t: ,~ ,~ ~ ~ ~ ~ ~ ~ ~ ..iiiiIiIJ:

Teachers INSURANCE GROUP w:

(All Combined)

Medical Benefits

Messa - ABC Plan Messa - ABC Plan Priority Health* POS HSA In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

Current RenewaJ Option 1 Deductible

Individual $1,300 $2,600 $1,300 $2,600 $1,300 $2,600 Family $2,600 $5,200 $2,600 $5,200 $2,600 $5,200

Annual Out of Pocket Maximum Includes Deductible, Coinsurance &. Copays

Individual $2,300 $4,500 $2,300 $4,500 $2,300 $4,600 Family $4,600 $9,000 $4,600 $9,000 $4,600 $9,200

Coinsurance 100% 80% 100% 80% 100% 80% PCP Office Visits 100% after ded 80% after ded 100% after ded 80% after ded 100% after ded 80% after ded Specialist Office Visits 100% after ded 80% after ded 100% after ded 80% after ded 100% after ded 80% after ded Urgent Care Visits 100% after ded 80% after ded 100% after ded 80% after ded 100% after ded 80% after ded Diagnostic Imaging 100% after ded 80% after ded 100% after ded 80% after ded 100% after ded 80% after ded Emergency Room 100% after ded 80% after ded 100% after ded 80% after ded 1000/0 after ded Inpatient Hospital 100% after ded 80% after ded 100% after ded 80% after ded 100% after ded 80% after ded Diagnostic X-Ray fLab 100% after ded 80% after ded 100% after ded 80% after ded 100% after ded 80% after ded Chiropractic Spinal Manipulation 100% after ded 80% after ded 100% after ded 80% after ded 100% after ded 80% after ded Preventive Care 100%' Not Covered 100% Not Covered 100% 800/0 after ded Prescription Drugs Generic $10 after ded

Copay + 25% $10 after ded

Copay + 25% $10 after ded

Not Covered Brand - Preferred $40 after ded $40 after ded $40 after ded Brand - Non-Preferred $40 after ded $40 after ded $40 after ded

Rates Single 0 $442.28 $510.34 $449.15

Double 0 $993.25 $1,146.39 $1,009.11

Family 4 Monthly Premium

Monthly Taxes & Fees

$1,235.68

$4,942.72 $115.12

$1,426.25

$5,705.00 $115.12

$1,255.46

$5,021.84 $115.12

.f

Monthly Premium including Taxes &. Fees $5,057.84 $5,820.12 $5,136.96 Total Annual Premium $60,694.08 $69,841.44 $61,643.52

% Change from Current 15.07% 1.56% Notes: *Priority Health Rx includes an open formulary and does not require step therapy

In accordance with Treasury Circular 230 Disclosure, this document is not intended to be used & cannot be used for: I) avoiding Federal tax-related penalties, or II) promoting, marketing or recommending anything that is tax-related.

Thp rntpo; rtrp o;ubipct to final enrol1ment. This is not a auarantee ofbenefits or rates and should not be relied upon as such.

~~ MESSA. Quote Summary Exclusively for Requested: 05/16/2016 Good health. Good business. Great schools. Beaverton Rural Schools Quote Request 10: 221262

1475 Kendale Boulevard, PO Box 2560 Quote Effective 07/01/2016 MESSA Field Rep: Jacqueline Mast

East Lansing, MI 48826-2560

900.292.4910

Quoted Group(s): 295H-Admlnistrators

Description Current - 295H NON-PAK

Medical: MESSA Choices IN Deductible: $5001$1000 OON Deductible: $10001$2000 OV/UC/ER Copay: $201$25/$50 RX Drug Co pay: SaverRx Riders Included: None

Medical: MESSA ABC Plan 1 IN Deductible: $1300/$2600 OON Deductible: $26001$5200 OV/UC/ER Copay: NIA RX Drug Copay: ABCRx Riders Included: None

Rate

578.42

1,299.57

1,616.87

520.72 1,169.76

1,455.33

Census Used

Single: 0

2-Person: 2

Family: 3

Quote 10334597 Rate

PAKA MESSA Choices 534.65 $1000/$2000 1,201.09 $20001$4000 1,494.32 $201$251$50 SaverRx None

Quote 10 334598 PAKA MESSA Choices $1000/$2000 $2000/$4000 $201$251$50 SaverRx None

Rate

534.65 1,201.09 1,494.32

Dental: Not Included in Benefit Package Single: 0 36.31 36.31 Class I: 2-Person: 2 100% 71.87 100% 71.87 Class II: Family: 3 100% 134.26 100% 134.26 Class III: 100% 100% Annual Max: $1,000 S1,000 Class IV: 90% 90% Lifetime Max: $2,500 $2,500 Riders Included: 2 Cleanings 2 Cleanings

Vision: Not Included in Benefit Package Single: 0

2-Person: 2

Family: 3

VSP2 5.13 11.03 16.59

VSP2S 5.76 12.38 18.64

Life Ins: Not Included in Benefit Package 5 $100,000 $100,000 Volume: 500,000 500,000 Rate/$1,000: 0.12 0.12 Composite:

AD&D Ins: Not Included in Benefit Package 5

12.00 $100,000 $100,000

12.00

Volume: 500,000 500,000 Rate/$1,OOO: 0.03 0.03 Composite: Dep Life Ins: Not Included in Benefit Package

Volume:

Rate/$1,000: Composite:

3.00 Not Included in Benefit Package


LTD: Not Included in Benefit Package Waiting Period:

Alcohol/Drug:

Mental/Nervous: SS Offset:

COLA: Volume:

Ratel$100: Composite:

5 60% Max $4,500 120 CDMF 2 Year Limitation 2 Year Limitation Primary

No 30,826

0.47 28.98

60% Max $4,500 120 CDMF 2 Year Limitation 2 Year Limitation Primary No

30,826 0.47

28.98 Total Monthly Rate Per Member - Single $620.07 $620.70 Total Monthly Rate Per Member - 2 Person $1,327.97 $1,329.32 Total Monthly Rate Per Member - Family $1,689.15 $1 ,691.20

The above rates are based on the information provided. Material changes in the composition ofthe group such as number ofenrollees, definable group, eligibility requirements or plans offered may affect the final rates. These rates do not include the Michigan Claims Tax Assessment, State Premium Tax or ACA Federal Taxes/Fees.

Page




800.292.4910

I Quoted Group(s): 295H-Administrators

I Descriptio'n Current - 295H Rate Census Used Quote ID 334597 Rate Quote ID 334598 Rate

Medical: Not Included in Benefit Package

IN Deductible:

OON Deductible:

I OV/UC/ER Copay: RX Drug Copay:

Riders Included:

Dental: Nbt h,c1uded in Benefit Package Single: 0

PAKB Not Included in Benefit Package

36.31


36.31 Class I: 2-Person: 0 100% 71.87 100% 71.87 Class II: Family: 0 100% 134.26 100% 134.26 Class III: 100% 100% Annual Max: $1,000 $1,000 Class IV: 90% 90% Lifetime Max: $2,500 $2,500 Riders Included:


2-Person: 0

Family: 0

2 Cleanings

VSP2 5.13 11.03

16.59

2 Cleanings

VSP2S 5.76 12.38 18.64

Life Ins: Not Included in Benefit Package 0 $100,000 $100,000 Volume: 0 0 Rate/$1,OOO: 0.12 0.12 Composite:

AD&D Ins: Not Included in Benefit Package 0

12.00

$100,000 12.00

$100,000 Volume: 0 0 Rate/$1,OOO: 0.03 0.03 Composite: 3.00 3.00 Dep Life Ins: Not Included in Benefit Package

Volume:

Rate/$1,OOO:

Composite:

Not Included in Benefit Package Not Included in Benefit Package


Alcohol/Drug:

Mental/Nervous:

SS Offset:

COLA:

Volume:

Ratel$100:

Composite:

0 60% Max $4,500 120 CDMF

2 Year Limitation 2 Year Limitation Primary

No

0 0.47

28.98

60% Max $4,500 120 CDMF 2 Year Limitation

2 Year Limitation Primary

No 0

0.47

28.98 Total Monthly Rate Per Member - Single $85.42 $86.05 Total Monthly Rate Per Member - 2 Person $126.88 $128.23 Total Monthly Rate Per Member - Family $194.83 $196.88

rhe above rates are based on the information provided. Material changes in the composition ofthe group such as number ofenrollees, definable group, eligibility requirements Jr plans offered may affect thefinal rates. These rates do not include the Michigan Claims Tax Assessment, State Premium Tax or ACA Federal Taxes/Fees.

Page 2

f~ MESSA. Quote Summary Exclusively for Requested: 05/16/2016

Good. health.-Good business. Great-schools. --Beaverton -Rural·-Schools --- Quote RequestlD: 221262



800.292.4910

I Quoted Group(s): 295H-Adminlstrators

Description Current - 295H Rate


IN Deductible:

OON Deductible:

Ov/UC/ER Copay:

RX Drug Copay:

Riders Included:

Census Used

Single: 0

2-Person: 0

Family: 0

Quote 10 334597 Rate Quote 10 334598

PAKC PAKC

MESSA ABC Plan 1 510.34 MESSA ABC Plan 1 $13001$2600 1,146.39 $13001$2600 $26001$5200 1,426.25 $2600/$5200 NIA NIA ABCRx ABC Rx None None

Rate

510.34 1,146.39 1,426.25

1 Dental: Not Included in Benefit Package

Class I:

Class II:

Class III:

Annual Max:

Class IV:

Lifetime Max:

Riders Included:

Single: 0

2-Person: 0

Family: 0

36.31 100% 71.87 100% 100% 134.26 100% 100% 100% $1,000 $1,000 90% 90% $2,500 $2,500 2 Cleanings 2 Cleanings

36.31 71.87

134.26


2-Person: 0

Family: 0

VSP2 5.13 VSP2S 11.03 16.59

5.76 12.38 18.64

Life Ins: Not Included in Benefit Package

Volume:

Rate/$1,000:

Composite:

AD&D Ins: Not Included in Benefit Package

Volume:

Rate/$1,OOO:

Composite:

Dep Life Ins: Not Included in Benefit Package

Volume:

Rate/$1,OOO:

Composite:

LTD: Not Included in Benefit Package

Waiting Period:

Alcohol/Drug:

Mental/Nervous:

SS Offset:

COLA:

Volume:

Rate/$100:

Composite:

0

0

0

Total Monthly Rate Per Member - Single

Total Monthly Rate Per Member - 2 Person

Total Monthly Rate Per Member Family

$100,000 $100,000 0

0.12 12.00

$100,000 $100,000 0

0.03 3.00

°0.12 12.00

0 0.03 3.00


60% Max $4,500 120CDMF 2 Year Limitation 2 Year Limitation Primary No

° 0.47 28.98

60% Max $4,500 120 CDMF 2 Year Limitation 2 Year Limitation Primary No

0 0.47

28.98 $595.76

$1,273.27

$1,621.08

$596.39

$1,274.62

$1,623.13

"he above rates are based on the information provided. Material changes in the composition ofthe group such as number ofenrollees, dejinable group, eligibility requirements 'r plans ofJered may afJectthejinal rates. These rates do not include the Michigan Claims Tax Assessment, State Premium Tax or ACA Federal Taxes/Fees.

Page 3

~... MESSA. Quote Summary Exclusively for Requested: 05/16/2016 Good health. Good business. Great schools. Beaverton Rural Schools Quote Request ID: 221264

1475 Kendale Boulevard, PO Box 2560 Quote Effective 07101/2016 MESSA Field Rep: Jacqueline Mast


800.292.4910

, Quoted Group(s): NEW-Central Office Stafff

! Description Current - NEW Rate Census Used Quote ID 334538 Rate Quote ID 334539 Rate

I

IMedical: Single: 1

PAKA MESSA Choices 534.65

PAKA MESSA Choices 534.65

IN Deductible: 2-Person: 3 $10001$2000 1,201.09 $10001$2000 1,201.09

l OON Deductible: Family: 0 $20001$4000 1,494.32 $20001$4000 1,494.32 I OV/UC/ER Copay: $201$251$50 $201$251$50

: RX Drug Copay: SaverRx SaverRx

Riders Included: None None

Dental: Single: 1 41.92 41.92 , Class I: 2-Person: 3 100% 82.23 100% 82.23 , Class II: Family: 0 100% 145.08 100% 145.08 ! Class III: 100% 100%

I Annual Max: $1,000 $1,000

Class IV: 90% 90%

Lifetime Max: $2,500 $2,500

I Riders Included: 2 Cleanings 2 Cleanings ,

Vision: Single: 1 VSP2 5.13 VSP2S 5.76 2-Person: 3 11.03 12.38

I Family: 0 16.59 18.64 t

Life Ins: 4 $100,000 $100,000

Volume: 400,000 400,000

Rate/$1,000: 0.12 0.12

I Composite: 12.00 12.00 I AD&D Ins: 4 $100,000 $100,000

Volume: 400,000 400,000

Rate/$1,000: 0.03 0.03

Composite: 3.00 3.00 Dep Life Ins: Not Included in Benefit Package Not Included in Benefit Package Volume:


LTD: Not Included in Benefit Package Not Included in Benefit Package Waiting Period:

Alcohol/Drug: Mental/Nervous: SS Offset:

COLA:

Volume:

Rate/$100:

Total Monthly Rate Per Member - Single $596.70 $597.33 Total Monthly Rate Per Member - 2 Person $1,309.35 $1,310.70 Total Monthly Rate Per Member - Family $1,670.99 $1,673.04

The above rates are based on the inJormation provided. Material changes in the composition ojthe group such as number ojenrollees, definable group, eligibility requirements orplans aJfored may ajJectthe final rates. These rates do not include the Michigan Claims Tax Assessment, State Premium Tax or ACA Federal Taxes/Fees.

Page

~~ MESSA. Quote Summary Exclusively for Requested: 05/16/2016 Good health. Good business. Great schools. Beaverton Rural Schools Quote Request ID: 221264



800.292.4910

Quoted Group(s): NEW-Central Office Stafff

Description Current - NEW

Medical:

IN Deductible:

OON Deductible:

OV/UC/ER Copay:

RX Drug Copay:

Riders Included:

Rate Census Used Quote 10 334538 Rate


Quote 10 334539 Rate


Dental: Single: 0 41.92 41.92 Class I: 2-Person: 0 100% 82.23 100% 82.23 Class II: Family: 0 100% 145.08 100% 145.08 Class I": 100% 100% Annual Max: $1,000 $1,000 Class IV: 90% 90% Lifetime Max: $2,500 $2,500 Riders Included:

Vision:

Life Ins:

Single: 0

2-Person: 0

Family: 0

0

2 Cleanings

VSP2 5.13 11.03 16.59

$100,000

2 Cleanings

VSP2S 5.76 12.38 18.64

$100,000 Volume: 0 0 Rate/$1,OOO: 0.12 0.12 Composite:

AD&D Ins:

Volume:


0

12.00 $100,000

0 0.03 3.00

12.00 $100,000

0 0.03 3.00

Dep Life Ins:

Volume:



LTD:

Waiting Period:

Alcohol/Drug:

Menial/Nervous:

SS Offset:

COLA:

Volume:

Rate1$100:


Total Monthly Rate Per Member - Single $62.05 $62.68

Total Monthly Rate Per Member - 2 Person $108.26 $109.61 Total Monthly Rate Per Member - Family $176.67 $178.72

The above rates are based on the information provided. Material changes in the composition ofthe group such as number ofenrollees, definable group, eligibility requirements 'Jr plans ofJered may afJectthefinal rates. These rates do not include the Michigan Claims Tax Assessment, State Premium Tax or ACA Federal TaxeslFees.

Page 2

~~ MESSA. Quote Summary Exclusively for Requested: 05/16/2016 Good health. Good business. Great schools. Beaverton Rural Schools Quote Request ID: 221263

1475 Kendale Boulevard. PO Box 2560 Quote Effective 07/01/2016 MESSA Field Rep: Jacqueline Mast

East Lansing. M148826-2560

800.292.4910

. Quoted Group(s): NEW-Full-Time BESPA

Description Current -.NEW Rate Census Used Quote ID 334496 Rate

PAKA

Quote ID 334497 Rate

PAKA

Medical: Single: 1 MESSA Choices 534.65 MESSA Choices 534.65 IN Deductible: 2-Person: 0 $10001$2000 1,201.09 $10001$2000 1,201.09 OON Deductible:

OV/UC/ER Copay: RX Drug Co pay: Riders Included:

Family: 1 $20001$4000 1,494.32 $201$251$50 SaverRx None

$20001$4000 1,494.32 $201$251$50 SaverRx None

Dental: Single: 0 38.46 38.46 Class I: 2-Person: 1 100% 75.83 100% 75.83 Class II: Family: 1 100% 138.39 100% 138.39 Class III: 100% 100% Annual Max: $1,000 $1,000 Class IV: 90% 90% Lifetime Max: $2,500 $2,500 Riders Included:

Vision: Single: 0

2-Person: 1

Family: 1

2 Cleanings

VSP2 5.13 11.03 16.59

2 Cleanings

VSP2S 5.76 12.38 18.64

Life Ins: 2 $5,000 $5,000 Volume: 10,000 10,000 Rate/$1.000: 0.12 0.12 Composite: 0.60 0.60 AD&D Ins: 2 $5,000 $5,000 Volume: 10,000 10,000 Rate/$1,OOO: 0.03 0.03 Composite: 0.15 0.15 Dep Life Ins: Volume:

Rate/$1.000: Composite: LTD: Waiting Period:

Alcohol/Drug: Mental/Nervous:

SS Offset:

COLA: Volume:

Rate/$100:

Not Included in Benefit Package




Total Monthly Rate Per Member - Single $578.99 $579.62 Total Monthly Rate Per Member - 2 Person $1.288.70 $1.290.05 Total Monthly Rate Per Member - Family $1,650.05 $1,652.10

fhe above rates are based on the infonnation provided. Material changes in the composition ofthe group such as number ofenrollees. definable group. eligibility requirements Jr plans offered may affect the final rates. These rates do not include the Michigan Claims Tax Assessment, State Premium Tax or ACA Federal Taxes/Fees.

Page 1

~.J MESSA. Quote Summary Exclusively for Requested: 05/16/2016 Good health. Good business. Great schools. Beaverton Rural Schools Quote Request 10: 221263



800292.4910

Quoted Group(s): NEW-Full-Time BESPA

Description Current - NEW Rate Census Used Quote 10334496 Rate Quote 10 334497 Rate

Medical:

IN Deductible:

OON Deductible:

OV/UC/ER Capay:

RX Drug Copay:

Riders Included:

PAKB


PAKB


Dental: Single: 2 44.13 44.13 Class I: 2-Person: 7 100% 86.31 100% 86.31 Class II: Family: 3 100% 149.35 100% 149.35 Class Ill: 100% 100% Annual Max: $1,000 $1,000 Class IV: 90% 90% Lifetime Max: $2,500 $2,500 Riders Included: 2 Cleanings 2 Cleanings

Vision: Single: 2

2-Person: 7

Family: 3

VSP2 5.13 11.03 16.59

VSP2S 5.76 12.38 18.64

Life Ins: 12 $5,000 $5,000 Volume: 60,000 60,000 Rate/$1,000: 0.12 0.12 Composite: 0.60 0.60 AD&D Ins: 12 $5,000 $5,000 Volume: 60,000 60,000 Rate/$1,000: 0.03 0.03 Composite:

Dep Life Ins:

Volume:




LTD:

Waiting Period:

Alcohol/Drug:

Mental/Nervous:

SS Offset:

COLA:

Volume:

Rate/$100:


Total Monthly Rate Per Member - Single $50.01 $50.64 Total Monthly Rate Per Member - 2 Person $98.09 $99.44

Total Monthly Rate Per Member - Family $166.69 $168.74

rhe above rates are based on the infonnation provided. Material changes in the composition ofthe group such as number ofenrollees, definable group, eligibility requirements Ir plans offered may affect the final rates. These rates do not include the Michigan Claims Tax Assessment, State Premium Tax or ACA Federal Taxes/Fees.

Page 2

~~ MESSA. Quote Summary Exclusively for Requested: 05/16/2016

Good health. Good business. Great schools. Beaverton Rural Schools Quote Request ID: 221261



600.292.4910

Quoted Group(s): NEW-Part-Time BESPA

Description Current - NEW Rate Census Used Quote ID 334495 Rate

NON-PAK


IN Deductible: OON Deductible:

OV/UC/ER Copay: RX Drug Copay: Riders Included:

Dental: Single: 1 31.57 Class I: 2-Person: 7 80% 61.16 Class II: Family: 9 80% 98.91 Class Iii: 80% Annual Max: $1,000 Class IV: Lifetime Max: $ 0 Riders Included:

Vision: Single: 1

2 Cleanings

VSP2 5.13 2-Person: 7 11.03 Family: 9 16.59

Life Ins: Not Included in Benefit Package Volume:

Rate/$1,000:

AD&D Ins: Not Included in Benefit Package Volume:

Rate/$1,000:

Dep Life Ins: Not Included in Benefit Package Volume: Rate/$1,000:


Alcohol/Drug: Mental/Nervous:

SS Offset: COLA: Volume: Rate/$100:

rhe above rates are based on the information provided. Material changes in the composition ofthe group such as number ofenrollees, definable group, eligibility requirements Ir plans ofJered may afJectthefinal rates. These rates do not include the Michigan Claims Tax Assessment, State Premium Tax or ACA Federal Taxes/Fees.

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Irnrn~u'\I ....A.".......,." ....1' for Requested: 05/1612016 Good health. Good business. Great schools. Quote Request ID: 221260

1475 Kendale Boulevard. PO Box 2560 Quote Effective 07/01/2016 MESSA Field Rep: Jacqueline Mast East Lansing. MI 48826-2560 800.292.4910

Description Current - 295B Rate Census Used Quote 10 334470 Rate PAKA

Medical: MESSA Choices IN Deductible: $500/$1000 OON Deductible: $1000/$2000 OV/UC/ER Copay: $20/$25/$50 RX Drug Copay: Saver Rx Riders Included: None

566.B8 1.273.61 1.584.56

Single: 10 2-Person: 11 Family: 37

PAKA MESSA Choices 534.65 $10001$2000 1,201.09

$20001$4000 1,494.32 $201$251$50 SaverRx None

Dental: Class BO% Class II: BO% Class III: 80% Annual Max: $1,000 Class IV: Lifetime Max: $0 Riders Included: 2Cleanings

27.74 54.65 93.04


27.74 80% 54.65 80% 93.04 BO% $1.000

$0 2 Cleanings

Vision: VSP2 5.13 11.03 16.59


VSP2 5.13 11.03 16.59

Life Ins: $40.000 5B $40,000 Volume: 2.320,000 Rate/$1,OOO: 0.11 Composite: 4.40 4.40 AD&D Ins: $40,000 58 $40.000 Volume: 2,320,000 Ratel$1.000: 0.03 Composite: 1.20 Dep Life Ins: Not Included in Benefit Package Volume: Ratel$1.000: Composite: LTD: Not Included in Benefit Package Waiting Period: Alcohol/Drug: MentallNervous: SS Offset: COLA: Volume: Ratel$100:



Total Monthly Rate Per Member - Single $605.35 $573.12 Total Monthly Rate Per Member - 2 Person $1.344.89 $1.272.37 Tolal Monthly Rate Per Member - Family $1,699.79 $1.609.55

fhe above rates are based on the information provided. Material changes in the composition ofthe group such as number ofenrollees, definable group. eligibility requirements Jr plans offered may affecllhefinal rales. These rales do not include the Michigan Claims Tax Assessment, Siale Premium Tax or ACA Federal Taxes/Fees.

Page 1

I




800.292.4910

Quoted Group(s): 295B·Teacher

Description Current - 2958 Rate Census Used Quote 10 334470 Rate

PAKB PAKB

Medical: Not Included in Benefit Package Not Included in Benefit Package IN Deductible:

OON Deductible:

OV/UC/ER Copay: RX Drug Copay: Riders Included:

Dental: 28.06 Single: 0 28.06 Class I: 80% 52.98 2-Person: 1 80% 52.98 Class II: 80% 86.44 80% 86.44 Class III: 80%

Family: 2 80%

Annual Max: $1,000 $1,000 Class IV:

Lifetime Max: $0 $0 Riders Included: 2 Cleanings 2 Cleanings

Vision: VSP2 5.13 VSP2 5.13Single: 0 11.03 11.032-Person: 1

16.5916.59 Family: 2

Life Ins: $40,000 3 $40,000 Volume: 120,000 Rate/$1,000: 0.11 Composite: 4.40 4.40 AD&D Ins: $40,000 $40,000 Volume:

3 120,000

0.03

Composite: 1.20

Rate/$1,000: 1.20

Dep Life Ins: Not Included in Benefit Package Not Included in Benefit Package Volume: Rate/$1,000: Com~osite:

LTD: Not Included in Benefit Package Not Included in Benefit Package Waiting Period:

Alcohol/Drug:

Mental/Nervous:

SS Offset: COLA:

Volume:

Rate/$100:

Total Monthly Rate Per Member - Single $38.79 $38.79

Total Monthly Rate Per Member - 2 Person $69.61 $69.61 Total Monthly Rate Per Member - Family $108.63 $108.63

rile above rates are based on the information provided. Material changes in the composition ofthe group such as number ofenrollees, definable group, eligibility requirements wplalls offered may affect the final rates. These rates do not include the Michigan Claims Tax Assessment, Siale Premium Tax or ACA Federal Taxes/Fees.

Page 2

Quote Summary Exclusively for Requested: 05/16/2016 Good health. Good business. Great schools. Beaverton Rural Schools Quote Request ID: 221260



BOO.292.4910

~-' MESSA.

Quoted Group(s): 2958-Tea-cher

Description Current - 2'958

PAKC

Rate Census Used Quote ID 334470 Rate

PAKC

Medical: MESSA ABC Plan 1 510.34 Single: 0 MESSA ABC Plan 1 510.34

IN Deductible: $13001$2600 1,146.39 2-Person: 0 $13001$2600 1,146.39

OON Deductible: $26001$5200 OV/UC/ER Copay: N/A RX Drug Copay: ABCRx

Riders Included: None

Dental: Class I: 80% Class II: 80% Class III: 80% Annual Max: $1,000

Class IV:

Lifetime Max: $0

Riders Included: 2 Cleanings

1,426.25

27.74 54.65 93.04

Family: 4

Sin'gle: 0

2-Person: 0 Family: 4

$26001$5200 1,426.25

N/A ABCRx

None

27.74 80% 54.65 80% 93.04

80%

$1,000

$0

2 Cleanings

Vision: VSP2 5.13 11.03 16.59


VSP2 5.13 11.03

16.59

Life Ins: $40,000 4 $40,000 Volume: 160,000 Ratel$1,000: 0.11 Composite: 4.40 4.40 AD&D Ins: $40,000 Volume:

Ratel$1,000: Composite: 1.20

4 $40,000 160,000

0.03 1.20

Dep Life Ins: Not Included in Benefit Package Volume:

Rate/$1,000: Composite: LTD: Not Included in Benefit Package

Waiting Period:

Alcohol/Drug:

Mental/Nervous:

SS Offset:

COLA: Volume: Ratel$100:



Total Monthly Rate Per Member - Single $548.81 $548.81 Total Monthly Rate Per Member - 2 Person $1,217.67 $1,217.67 Total Monthly Rate Per Member - Family $1,541.48 $1,541.48

rhe above rates are based on the infonnation provided. Material changes in the composition ofthe group such as number ofenrollees. definable group. eligibility requirements Jr plans offered may affect the final rates. These rates do not include the Michigan Claims Tax Assessment. State Premium Tax or ACA Federal Taxes/Fees.

Page 3

~-' MESSA. Quote Summary Exclusively for Requested: OS/23/2016 Good health. Good business. Great schools. Beaverton Rural Schools Quote Request ID: 221353

1475 Kendale Boulevard, PO Box 2560 Quote Effective 07/01/2016 MESSA Field Rep: Jacqueline Mast East Lansing, MI 48826-2560

BOO.292.4910

Quoted Group(s): NEW-ACA Eligible Employees

Description Current - NEW Rate Census Used Quote ID 334599 Rate

NON-PAK Medical: Single: 4 MESSA Choices 545.53 IN Deductible: 2-Person: 0 $1000/$2000 1,225.57 OON Deductible:

OV/UC/ER Co pay:

RX Drug Co pay:

Riders Included:

Family: 0 $2000/$4000 1,524.79 $20/$25/$50

SaverRx None

Dental: Class I:

Class II:

Class III: Annual Max:

Class IV: Lifetime Max:

Riders Included:


Vision: Not Included in Benefit Package

Life Ins:

Volume:

Rate/$1,000:


AD&D Ins:

Volume:

Rate/$1,000:


Dep Life Ins: Volume:

Rate/$1,000:


LTD:

Waiting Period:

Alcohol/Drug:

Mental/Nervous:

SS Offset: COLA: Volume:

Rate/$100:


fhe above rates are based on the information provided. Material changes in the composition ofthe group such as number ofenrollees, definable group, eligibility requirements Ir plans offered may affect the final rates. These rates do not include the Michigan Claims Tax Assessment, State Premium Tax or ACA Federal Taxes/Fees.

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