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Attachment A Schedule <br /> <br />Cass County Personnel <br /> <br />Contract Pedod: January 1, 2004 through December 31, 2004 <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, 2004 and paid dudng 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 /> SC 100 8-03 SC 100 OOA 8.03 <br />Single: 141 Contracts 0 Contracts <br />Single Plus Dependent: 63 Contracts 0 Contracts <br />Family:. 112 Contracts 1 Contracts <br /> <br />Aggregate Stop-Loss Attachment Point per Subscriber: (x 12 for Contract Period) <br /> <br /> Single: $276.81 <br /> Single Plus Dependent: 459.56 <br /> Family: 728.77 <br /> <br />$285.85 <br /> 474.57 <br /> 752.58 <br /> <br />3. Aggregate Stop-Loss Attachment Point, maximum administrative fees (net of BlueCard fees and compensation) <br /> and conversion coverage costs per Contract Pedod 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 />$1,804,288 <br /> $124,496 (6.9% of Claims) <br /> <br />Monthly premium for stop-loss coverage (aggregate and individual): <br /> <br /> Single: $27.84 <br /> Single Plus Dependent: 48.92 <br /> Family: 72.16 <br /> <br />$27.84 <br /> 48.92 <br /> 72.16 <br /> <br />5. Summary of estimated Maximum Contract Pedod Cost at enrollment levels in Section I above: <br /> <br />Aggregate Stop-Loss Attachment Point: <br />Maximum administrative fees and conversion coverage costs: <br />Stop-Loss coverage premium: <br /> <br />$1,804,288 <br /> 124,496 <br /> 181,938 <br /> <br />Total Maximum Cost: $2,110,720 <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 />By: <br />Title: Title: <br />Date: Date: <br /> <br />BLUE CROSS BLUE SHIELD <br />OF NORTH DAKOTA <br />4510 13th Avenue SW <br />Fargo, North Dakota 58121~0001 <br /> <br /> ~ Vi~ce'President, Actuarial <br /> "--'~nd Membership Services <br /> <br />Group Numbers: 10033 <br /> <br /> <br />
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