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CityofLaPorte <br />StopLossExhibit <br />2017PlanYear <br />ABCD=A+B+CEFGH=E+F+GIJ=H+IKLM=J/K <br />ENROLLMENTCLAIMSDATAAGGREGATEACCUMULATION <br />Attachment <br />SpecificAggregate%ofExpected%ofMaximum <br />1 <br />MonthPPOAHF1000AHF1500TotalPPOAHF1000AHF1500TotalStopLossClaimsPointClaimsClaims <br />20170119915251 402$326,572$127,724$21,013$475,309$0$475,309$628,09695%76% <br />20170219815252 402$321,747$122,737$17,919$462,404$0$462,404$630,44392%73% <br />201703 <br />201704 <br />201705 <br />201706 <br />201707 <br />201708 <br />201709 <br />201710 <br />201711 <br />201712 <br />Total397304103804$648,318$250,462$38,933$937,713$0$937,713$1,258,54093%75% <br />Avg/PEPM 19915252 402$1,633.04$823.89$377.99$1,166.31$0.00$1,166.31$1,565.35 <br />ClaimFactors <br />PPOPlan EEEESpEEChFam <br />$1,400,000 <br />2017MaximumClaims$809.30$1,982.78$1,982.78$1,982.78 <br />$1,200,000 <br />AHF1000Plan EEEESpEEChFam <br />2017MaximumClaims$809.30$1,982.78$1,982.78$1,982.78$1,000,000 <br />AHF1500Plan EEEESpEEChFam <br />$800,000 <br />2017MaximumClaims$809.30$1,982.78$1,982.78$1,982.78 <br />$600,000 <br />ASOandStopLossDetail <br />$400,000 <br />Administration <br />$200,000 <br />AdministratorAetna <br />NetworkAetna <br />$0 <br />StopLoss <br />201701201702 <br />CarrierSABenefits/PartnerRE <br />SpecificStopLossDeductible$165,000 <br />AggregateClaimsYTDAttachmentPtYTD <br />Contract24/12 <br />CoverageMedical/Rx <br />AggregateStopLossMedical/Rx <br />1 <br />AttachmentPointrepresentsanestimatebasedonthemonthlyheadcountsmultipliedbythemonthlymaximumclaimsfactor. <br />2 <br /> <br />