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Paid Basis Attachment A Schedule Cass County Government Contract Period: January 1, 2009 through December 31, 2009 Stop-Loss coverages are based on Paid Benefits incurred in the period January 1, 1984 through December 31, 2009 and paid during the Contract Period. Individual Stop-Loss Attachment Point is $65,000 per Member and the Aggregate Stop-Loss Attachment is 120% of expected Paid Benefits paid during the Contract Period. 1. Expected monthly enrollment levels: Single: Single Plus Dependent: Family: SC 1008-07 164 Contracts 70 Contracts 116 Contracts SC 100 CCA 8-07 2 Contracts o Contracts o Contracts DSC 225 188 Contracts 115 Contracts 2. Aggregate Stop-Loss Attachment Point per Subscriber (x 12 for Contract Period): Single: Single Plus Dependent: Family: $391.75 689.47 1,018.54 $404.67 712.22 1,052.15 $52.80 137.70 3. Aggregate Stop-Loss Attachment Point, maximum administrative fees (net of BlueCard@ fees and compensation) and conversion coverage costs per Contract Period based on the figures shown in 1 and 2 above: Aggregate Stop-Loss Attachment Point: Maximum administrative fees and conversion coverage costs: $3,086,781 $182,120 (5.9% of claims expense) 4. Monthly premium for stop-loss coverage (aggregate and individual): Single: Single Plus Dependent: Family: $54.96 96.74 142.92 $54.96 96.74 142.92 5. Summary of estimated maximum Contract Period costs at enrollment levels in 1 above: Aggregate Stop-Loss Attachment Point: Maximum administrative fees and conversion coverage costs: Stop-Loss insurance premium: $3,086,781 182,120 389,687 $3,658,588 Total maximum Cost: In addition to the total maximum cost, applicable BlueCard@ fees and compensation will apply. The parties have caused this Agreement to be executed by their respective authorized officers. By: BLUE CROSS BLUE SHIELD OF NORTH DAKOTA 4510 13th Avenue S Fargo, North Dakota 58121-0001 ~w....."!1 v' 1~~ Bradley W. Bartle VP Actuarial and Membership Services CASS COUNTY GOVERNMENT PO Box 2806 Fargo, North Dakota 58108 By: Title: thcU (mtln I ~rf (1Un1lj G7mm; )l~ IOn Title: Date: II, lP-JObf RX: Deemed Creditable Group Numbers: 10033 Date: g- (1-'" De Dental products and/or administrative services are offered independently by The Dental Service Corporation of North Dakota (DSC). These are not Blue Cross Blue Shield products and/or administrative services. DSC is solely responsible for their products and/or administrative services.