CITY OF NASHUA
Group Name: ¥
Firm ID: 344217 Ant hem
Effective: 07/01/16 agi ea
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REFER TO SUMMARY OF BENEFITS ereeney oy os meron areee ate Br
Benefit: ABN260PY Medicat $20 OV, $250/500 Ded 100% Coin $100 ER :
Drug $5/15/35 RETAIL; $5/30/70 MAIL; UNLIMITED:
BNE182PN Medical $20 OV, $250/500 Ded 100% Coin $100 ER
Drug $5/15/35 RETAIL; $5/30/70 MAIL; UNLIMITED
CGHSA16001 Medical $2000 IN & CON 2XAF 100% IN 70/30% CON Coin INN QOP $2060/4000; QON GOP $4n0N/8000
Drug Ded/Coins
Specific NIA Aggregate: NIA Contract Terms: 24/12 (PAID)
Current State * Current
Administration Assessments Counts
ABN260PY
Individual $48.25 $0.02 535
Couple $48.25 $0.05 2
Parent/Child $48.25 $0.05 144
Family $48.25 $0.07 671
BNE182PN
Individuat $48.25 $0.02 64
Couple $48.25 $0.05 30
Parent/Child $48.25 $0.05 2
Family $48.25 $0.06 28
CGHSA16001
Individual $48.25 $0.03 53
Couple $48.25 $0.05 36
Parent/Child $48.25 $0.05 19
Family $48.25 $0.07 126
[Annual Totals $1,113,417 $4,112 1923 |
l PEPM $48.25 $0.05 1923
[ PMPM $20.03 $0.02 4832 |
Renewal State * Current
Administration** Assessments Counts
ABN260PY
Individual $49.40 $2.21 535
Couple $49.40 $4.42 342
Parent/Child $49.40 $4.42 414
Family $48.40 $5.97 571
BNE182PN
Individual $49.40 $2.04 64
Couple $48.40 $4.08 30
Parent/Child $49.40 $4.08 2
Family $49.40 $5.91 28
CGHSA16001
Individual $48.40 £2.39 59
Couple $49.40 $4.79 36
Parent/Child $49.40 $4.79 19
Family $49.40 $6.46 126
[Annual Totals $1,140,037 $98,742 1923 |
[ PEPM $49.40 $4.28 i923
PMPM $20.51 $1.78 4632 I
[Percent 24% |
Advance Deposit
$560,953 Group's current balance on 7/1/2616 will be applied to satisfy this deposit.
* Actual Assessments for the Vaccine Program are assessed on child covered lives (<19 yrs residing in NH) and will appear on the monthly medical ASO bill. The rate is currently $9.95 and is subject to change.
* ASO admin fees will be billed on a PEPM basis. Anthem ASO Administration fee assumes Rx Rebate sharing (with CON) at 100%.
¥ CON agrees to a three year contract, Anthem will guarantee that the Anthem Administration fee increase for years 2 and 3 will be limited to a max/year of 2.5%.
*“The benefits reflected in this quotation have been adjusted to comply with changes required by the Affordable Care Act beginning in 2014.
PEPM
Commissions Admin Fee $ 55,843.92 $2.42
StopLoss $ - $0.00
Total Commissions $ 55,843.92 $2.42
estimated membership while final commissions are based on actual membership.
The above commissions may vary from final commissions because they are based on
Anthem does not include any standard commissions in administrative retention paid by group.
This quote carrles commissions requested by the Producer of Record as follows:
LB
| have read and agreed to the terms and conditions as outlined in the ASO Pricing Assumptions.
Total # of eligible employees:
City of Nashua_D Multi 051016.xlsm
Blended Aligned ASO Rate Sheet
05/10/2016
