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City of La Porte <br />Stop Loss Exhibit <br />2021 Plan Year <br />ABCD = A+B+CEFGH = E+F+GIJ = H+IKLM = J/K <br />ENROLLMENTCLAIMS DATAAGGREGATE ACCUMULATION <br />Attachment <br />SpecificAggregate % of Expected <br />1 <br />MonthPPOAHF 1000AHF 1500TotalPPOAHF 1000AHF 1500Total Stop LossClaimsPoint Claims% of Maximum Claims <br />2021-0115494159 407$215,000$51,802$52,105$318,908$0$318,908$743,93954%43% <br />2021-0215393163 409$289,568$82,263$72,667$444,497$0$444,497$747,59574%59% <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$763,405$0$763,405$1,491,534 <br />64%51% <br />Avg/PEPM 15494161 408$1,643.54$716.92$387.49$935.55$0.00$935.55$1,827.86 <br />Claim Factors <br />$1,600,000 <br />PPO Plan EEEESpEEChFam <br />$1,827.86 <br />2021 Maximum Claims <br />$1,400,000 <br />AHF 1000 Plan EEEESpEEChFam <br />$1,827.86 <br />2021 Maximum Claims$1,200,000 <br />AHF 1500 Plan EEEESpEEChFam <br />$1,000,000 <br />$1,827.86 <br />2021 Maximum Claims <br />$800,000 <br />ASO and Stop Loss Detail <br />$600,000 <br />Administration <br />Aetna, RxBenefits <br />Administrator <br />$400,000 <br />Aetna, CVS <br />Network <br />$200,000 <br />Stop Loss <br />VistaUW / SABS <br />Carrier <br />$0 <br />$165,000 2021-012021-02 <br />Specific Stop Loss Deductible <br />24/12 <br />Contract <br />Medical / Rx <br />Coverage <br />Aggregate Claims YTDAttachment Pt YTD <br />Medical / Rx <br />Aggregate Stop Loss <br />1 <br /> Attachment Point represents an estimate based on the monthly headcounts multiplied by the monthly maximum claims factor. <br />2 <br /> <br />