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City of La Porte
<br />Net Employer Cost and Budget Exhibit - Medical, Rx
<br />2021 Plan Year
<br />ABCD = A+B+CEFGHIJ = E+F+G+H+IKLM = K+LNO = J+M+NP = J+MQR = Q-P
<br />1
<br />ENROLLMENTCLAIMS DATAFIXED COSTEMPLOYER NET COSTBUDGET DATA
<br />23
<br />MonthPPOAHF 1000AHF 1500TotalPPOAHF 1000AHF 1500Stop LossAHF FundTotalAdminStop LossTotalEE ContribsNet CostTotal CostBudgetSurplus
<br />2021-0115494159 407$215,000$51,802$52,105$0$15,329$334,237$12,633$55,136$67,770($54,627)$347,380$402,007$577,945$175,938
<br />2021-0215393163 409$289,568$82,263$72,667$0$33,577$478,074$12,695$55,407$68,103($54,795)$491,382$546,177$599,044$52,868
<br />2021-03
<br />2021-04
<br />2021-05
<br />2021-06
<br />2021-07
<br />2021-08
<br />2021-09
<br />2021-10
<br />2021-11
<br />2021-12
<br />Total307187322816$504,568$134,065$124,772$0$48,906$812,311$25,329$110,544$135,872($109,422)$838,762$948,183$1,176,989$228,806
<br />Avg/PEPM 15494161 408$1,643.54$716.92$387.49$0.00$96.08$995.48$31.04$135.47$166.51($134.10)$1,027.89$1,161.99$1,442.39$280.40
<br />BUDGET AND CONTRIBUTION DATAYear to Date SummaryTotalPEPM
<br />PPO Plan EEEESpEEChFam Total Net Paid Claims$812,311$995.48
<br />2021 Maximum Claims$1,827.86Total Fixed Costs$135,872$166.51
<br />Employee Contributions$55.22$276.28$255.20$315.42 Subtotal - Total Costs$948,183$1,161.99
<br />Employer Contributions$850.83$1,717.02$1,375.65$2,312.12 Total Cost as % of Budget81%
<br />Premium Equivalents$906.05$1,993.30$1,630.85$2,627.54Employee Contributions($109,422)($134.10)
<br />Fixed Costs - Admin$31.04$31.04$31.04$31.04 Total - Net Employer Costs$838,762$1,027.89
<br />Fixed Costs - Stop Loss$135.47$135.47$135.47$135.47
<br />AHF 1000 Plan EEEESpEEChFam
<br />2021 Maximum Claims$1,827.86
<br />Employee Contributions$22.71$184.17$168.77$222.06
<br />Employer Contributions$628.20$1,247.84$1,002.88$1,665.58
<br />AHF 1500
<br />Rx, 26%
<br />Med, 74%
<br />Premium Equivalents$650.91$1,432.01$1,171.65$1,887.64
<br />Fixed Costs - Admin$31.04$31.04$31.04$31.04
<br />Fixed Costs - Stop Loss$135.47$135.47$135.47$135.47
<br />AHF 1500 Plan EEEESpEEChFam AHF 1000
<br />Med, 69%Rx, 31%
<br />2021 Maximum Claims$1,827.86
<br />Employee Contributions$14.65$105.00$95.25$120.68
<br />Employer Contributions$616.62$1,283.80$1,041.04$1,710.01
<br />PPO
<br />Med, 74%Rx, 26%
<br />Premium Equivalents$631.27$1,388.80$1,136.29$1,830.69
<br />Fixed Costs - Admin$31.04$31.04$31.04$31.04
<br />0%10%20%30%40%50%60%70%80%90%100%
<br />Fixed Costs - Stop Loss$135.47$135.47$135.47$135.47
<br />ASO and Stop Loss Detail
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<br /> Due to carrier enrollment reporting, figures such as Contributions and Budget may vary slightly.
<br />Administration
<br />2
<br />AdministratorAetna; RxBenefits
<br /> Employee Contributions represent an estimate based on the monthly headcounts multiplied by the monthly employee Non-Tobacco contributions, not the actual
<br />NetworkAetna; CVS employee contributions collected by City of La Porte.
<br />3
<br /> Budget represents the monthly headcounts multiplied by the 2021 AHF & PPO fully-insured equivalent rates.
<br />Stop Loss
<br />CarrierVistaUW / SABS
<br />Specific Stop Loss Deductible$165,000
<br />Contract24/12
<br />CoverageMedical / Rx
<br />Aggregate Stop LossMedical / Rx
<br />1
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