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<br />Attachment A Schedule <br /> <br />Cass County Personnel <br /> <br />Contract Period: ,January 1, 2007 through December 31, 2007 <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, 2007 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 />165 Contracts <br />74 Contracts <br />109 Contracts <br /> <br />SC 100 DDA 8-03 <br />1 Contracts <br />o Contracts <br />1 Contracts <br /> <br />DSC 225 <br />196 Contracts <br /> <br />111 Contracts <br /> <br />2. <br /> <br />Aggregate Stop-Loss Attachment Point per Subscriber: (x 12 for Contract Period) <br /> <br />Single: $348.50 <br />Single Plus Dependent: 613.36 <br />Family: 906.09 <br /> <br />$360.00 <br />633.60 <br />935.99 <br /> <br />$44.00 <br /> <br />114.75 <br /> <br />oJ <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 />$2,691,746 <br />$185,730 (6.9% of Claims) <br /> <br />4. Monthly premium for stop-loss coverage (aggregate and individual): <br /> <br />Single: <br />Single Plus Dependent: <br />Family: <br /> <br />$37.26 <br />65.58 <br />96.88 <br /> <br />$37.26 <br />65.58 <br />96.88 <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 />$2,691,746 <br />185,730 <br />260,339 <br /> <br />$3,137,815 <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 58121-0001 <br /> <br />Bv. <br />.f . <br /> <br />By: <br /> <br />Title: Cha,~( rY'/1.n) GtsJ CoL/;Oty CO(\'\"J"I1IS~',D)l <br /> <br />Title: <br /> <br />Vice President, Actuarial <br />and Membership Services <br /> <br />Date: <br />RX: Creditable <br />Group Numbers: 10033 <br /> <br />Date: <br />