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<br />Attachment A Schedule <br /> <br />Cass County Personnel <br /> <br />Contract Period: January 1,2006 through December 31,2006 <br /> <br />Paid Claims Basis <br /> <br />Stop-Loss insurance coverages are based on Plan Benefits incurred in the period January 1, 1984 through <br />December 31,2006 and paid during the Contract Period. Individual Stop-Loss Attachment Point is $65,000 per <br />Member and the Aggregate Stop-Loss Attachment is 120% of expected Plan Benefits paid during the Contract <br />Period. <br /> <br />1. Expected monthly enrollment levels: <br /> <br />Single: <br />Single Plus Dependent: <br />Family: <br /> <br />SC 100 8-03 <br />151 Contracts <br />74 Contracts <br />110 Contracts <br /> <br />SC 100 CCA 8-03 <br />1 Contracts <br />o Contracts <br />1 Contracts <br /> <br />DSC 225 <br />152 Contracts <br /> <br />185 Contracts <br /> <br />2. Aggregate Stop-Loss Attachment Point per Subscriber: (x 12 for Contract Period) <br /> <br />Single: $308.87 $319.06 <br />Single Plus Dependent: 543.61 561.55 <br />Family: 803.06 829.56 <br /> <br />$39.00 <br /> <br />101.72 <br /> <br />3. Aggregate Stop-Loss Attachment Point, maximum administrative fees (net of BlueCard fees and compensation) <br />and conversion coverage costs per Contract Period based on the figures shown in Section 1 and 2 above. <br /> <br />Aggregate Stop-Loss Attachment Point: <br />Maximum administrative fees and conversion coverage costs: <br /> <br />$2,413,175 <br />$166,509 (6.9% of Claims) <br /> <br />4. Monthly premium for stop-loss coverage (aggregate and individual): <br /> <br />Single: $32.68 <br />Single Plus Dependent: 57.52 <br />Family: 84.98 <br /> <br />$32.68 <br />57.52 <br />84.98 <br /> <br />5. Summary of estimated Maximum Contract Period Cost at enrollment levels in Section 1 above: <br /> <br />Aggregate Stop-Loss Attachment Point: <br />Maximum administrative fees and conversion coverage costs: <br />Stop-Loss coverage premium: <br /> <br />$2,413,175 <br />166,509 <br />223,879 <br /> <br />$2,803,563 <br /> <br />Total Maximum Cost: <br /> <br />In addition to the total maximum cost, applicable BlueCard fees and compensation will apply. <br /> <br />The parties have caused this Agreement to be executed by their respective authorized officers. <br /> <br />CASS COUNTY PERSONNEL <br />Box 2806 <br />Fargo, North Dakota 58102 <br /> <br />BLUE CROSS BLUE SHIELD <br />OF NORTH DAKOTA <br />4510 13th Avenue S <br />Fargo, North Dakota 58 21-0001 <br /> <br />By: <br /> <br />By: <br /> <br /> <br />ice President, Ac uarial <br />and Membership Services <br /> <br />II/If J()";- <br />. <br /> <br />Title: <br /> <br />Title: <br /> <br />Date: <br /> <br />Date: <br /> <br />Group Numbers: 1 0033 <br />