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2. Health InsuranceCity of Kalispell Pos! Office Box 1997Kalispell. Mot:gana 59903-19W - Telephone �406)758-7700 Fax Date: Auoust 23, 2003 TO. Mayor and City Council 1=roin: Amy Robertson, Finance Director Frank Ciarn, er, Interinn City Manager RE: IIcalth Insurance Please find attached information provided by MMWA and the League of Cities for the proposed group health insurance progrann. Included is IW1MIA's cover letter which. spells out their time frames for commitment. Documents included are the 1) Memorandum of Intent to Participate, a 2) rate schedule for all the Cities and a 3) Comparison of Medical Benefits Program sheet. Note: The rate schedule rates shown for Kalispell do not include the additional premium of S55 per month to cover the run out of claims from our self insured fund.. The rates shown are the amounts sent to Blue Cross each month. Not provided but available is the Program Agreement, a rather lengthy document of tens and definitions which we will provide on .!Monday. ...A Proven Reputation for August 13, 2004 City of Kalispell City Clerk Theresa White P.O. Box 1997 Kalispell, MT 59903 Re: MMIA Employee Benefits Programs Program Implementation Dear City Clerk Theresa White: The MMIA and the League of Cities and Towns have been working since last fall to develop an employee benefits program. At a meeting of the MMIA Employee Benefits Committee held on August 3, 2004, the Committee adopted rates and benefits for the self -insured Medical, Dental and Vision programs. The Employee Benefits Program will begin providing coverage on October 1, 2004, provided the minimum initial enrollment is met. Please note that the rates provided herein are based on our meeting the minimum threshold and are subject to change if that threshold is not met. This letter and enclosures will introduce you and the City of Kalispellto the Employee Benefits Programs soon to be available through the MMIA, and explain the process of enrolling your employees in these programs. The City of Kalispell is not required to participate in all of the benefit programs in order to participate in any single program. The term "program" refers to the Medical program, Dental program and Vision program. Each program is offered independent of one another. The City of Kalispell may participate in all, only one, or a couple of the benefit programs. The term "plan" refers to the various plans of benefits within each of the benefit programs. For example, under the Medical program there are six different plans of benefits -- Advantage Plan, CMM Plan, Health First Plan, Blue Saver, Security Plan and the Choice Plan. The Medical and Dental programs' rates included in the attachments are for all cities and towns currently participating in the MLCT Group Purchase Pool and the cities of Whitefish, Livingston, Havre, Laurel and Kalispell. The rates are equal to the July 1, 2004 Blue Cross Blue Shield of Montana (BCBSMT) renewal rates less 2.7%. All other cities and towns are eligible to participate in any one of the six plans of benefits identified above. The rate will be determined based on the benefit plan selected and the applicable BCBSMT rate level less 2.7%. The BCBSMT rate level establishes the rates based on the average age of the city or town as a group. The MMIA's new self -insured Employee Benefits Program's eligibility will be administered through an electronic eligibility system. This system should dramatically reduce the amount of staff time currently required of your staff for eligibility administration and premium accounting. In order to ensure a smooth transition of your employee's coverage, the MMIA set August 31, 2004 as the deadline for receipt of your notification of intent to participate. We realize that scheduled Council meeting dates and/or employee relations may make this deadline impossible to meet; therefore, you may request an extension. Simply notify the MMIA of your need for an extension and indicate the date that you expect to provide the necessary documentation to initiate participation on October 1, 2004. The last date for notification to participate in the initial Program is September 17, 2004. 7400 Shoreline Drive • Suite 3 - Stockton, CA 95215 (209) 957-3185 • Fax (209) 957-205= Toll Free: (800) 232-3185 • legacyconsult.corr CA License OA91324 • NV License 34581 • AZ License 9536S Page 2 August 13, 2004 If the City of Kalispell does not currently offer employee benefits, the City of Kalispellmust comply with the Montana statue Sec 2-18-702, MCA governing group insurance for public employees and officers. This code requires a two-thirds -vote of respective, -officers -and__emp.loyees._.to_.approve _ commitment -of participation in an Employee Benefits Program. Language from Sec 2-18-702, MCA is provided below for your easy reference. 2-18-702. Group insurance for public employees and officers. (1) (a) Except as provided in subsection (1)(c), all counties, cities, towns, school districts, and the board of regents shelf upon approval by two-thirds vote of their respective officers and employees enter into group hospitalization, medical, health, including long- term disability, accident, or group fife insurance contracts or plans for the benefit of their officers and employees and their dependents. The laws prohibiting discrimination on the basis of marital status in Title 49 do not prohibit bona fide group insurance plans from providing greater or additional contributions for insurance benefits to employees with dependents than to employees without dependents or with fewer dependents. Enclosed in this packet you will find the following materials: Each of the following three Legal Documents must be executed and forwarded to. the MMIA to initiate participation in the MMIA's Employee Benefits Programs, 1. Memorandum Of Intent To Participate In MMIA Employee Benefits Program; 2. Resolution Authorizing Participation In The Montana Municipal Insurance Authority Employee Benefits Program And Authorizing The Execution Of The Memorandum Of Intent To Participate In Such Program And Such Other Documents As May Be Necessary To Effectuate Participation In Such Employee Benefits Program; and 3. Employee Benefits Program Agreement. For coverage to become effective October 1, 2004, please fax_ the executed Menrnramduttt Q Intent To Participate In MMIA Emnlnyee Benefits FrMrom to the MMIA at (41W 449-7440 by August 31, 2004. If you miss this deadline, you may still participate by requesting an extension on the notification deadline. Simply notify the MMIA in writing of your need for an extension and indicate the date that you expect to provide the necessary documentation to initiate participation on October 1, 2004.. PROC AM Rii NPFTT RFTF.RFNC V CHI FTC Reference sheets detailing the Medical plans of benefits are included for your easy reference. As soon as we receive information from BCBSMT on the Dental and Vision benefits, we will provide a similar document detailing those plans. Medical & Rx Program Premium &Benefit Suitrmary The enclosed summary comparison provides basic benefit information and premium rates. The premiums shown reflect the July 1, 2004 rates and the reduced rate under the MMIA Employee Benefits Program. Please let us know immediately if any information on this summary comparison relative to the City of Kalispell is incorrect. You will see that the information pertaining to the prescription drag benefit is incomplete. We have not been successful in securing this information from BCBSMT. We would appreciate your providing us with any information you may have that details the City of Kalispell's current prescription drug benefit. ENROLLMENT AND CHANGE FORM A sample of the Enrollment and Change Form has been included for your information and files. An adequate supply of these forms will be sent to you for employees to complete upon our receipt of the City of Kalispell's executed Memorandum Of Intent To Participate In MMIA Employee Benefits Program. Page 3 August 13, 2004 REGIONAL TRAINING SCHEDULE We realize. that- _there will be many questions by the City of Kalispell's Human Resource Department relative to enrollment, coverage and processing monthly eligibility and premium payments, In order to provide the necessary gaining, the MMIA with the assistance of its consulting agency Legacy Enterprises will be holding Regional Training Sessions. The dates, times and locations of those training sessions will be provided as soon as all of the cities and towns participating on October 1, 2004 have been determined. However, we expect that these sessions will be scheduled in late September or early October. Should you not be able to attend any of the sessions, Legacy Enterprises will also be available to provide individual assistance upon request. Once again, we encourage you to notify us as quickly as possible, but not later than August 31, 2004, of the City of Kalispell's intent to participate in the new MMIA's Employee Benefits Program so that we can expedite your employees' enrollment and coverage. We are confident that the City of Kalispell will recognize both direct premium cost savings and indirect savings in the administration of the benefits plans through its participation in the new MMIA's Employee Benefits Program. Please advise, should you have any questions or if we can be of any assistance. I can be reached by calling the MMIA office at (800) 635-3089 or Legacy Enterprises at 1-800-232-3185, or by e-mail bworthinoon�iao.mmia.net or charless Ie ac consult.com. Two members of the Legacy staff have been designated to assist in implementation of the MMIA's new Employee Benefits Program, Kathy Delucchi and Christi Musick. If you are not able to reach Bob or Charlynn at any time, please contact them by calling 1-800-232-3185 or by their respective e-mail addresses kdelucchiplegac_yconsult.com and clmusick Ie ac consult.com Si h 1 less President & CEO cc: Alec Hansen, Montana League of Cities and Towns Bob Worthington, Montana Municipal Insurance Authority Enclosures MEMORANDUM OF INTENT TO PARTICIPATE IN MMIA EMPLOYEE BENEFITS PROGRAM WHEREAS, the MONTANA MUNICIPAL INSURANCE AUTHORITY (MMAA) has _undertaken_ steps to create and --organize a group -self=insurance hospitalization, medical, health, including long-term disability, accident or group life insurance Employee Benefits Program ("Employee Benefits Program') for the benefit of the Members of the MMIA and their respective public officials, employees and their families and dependents who are eligible for participation in such Employee Benefits Program; and, WHEREAS, the undersigned city or town which is a member of the MMIA has previously expressed an interest in participating in such Employee Benefits Program; and WHEREAS, in order to make the continuing commitments of manpower, finances and as a condition for entering into contracts with third party service providers and others to effectuate the commencement of the Employee Benefits Program on October 1, 2004, it is necessary that the MMIA have a commitment from a minimum number of cities and towns to participate in such Employee Benefits Program to ensure the initial viability of such Employee Benefits Program; and WHEREAS, the undersigned city and town is ready, willing and able to make a commitment to participation in the Employee Benefits Program as of the effective date of the Employee Benefits Program for an initial period of sixty (60) months from the effective date; Now, THEREFORE, the MMIA and undersigned city or town agree as follows: The undersigned city or town, by action of its governing council, does hereby commit to participate in the Employee Benefits Program which the MMIA shall establish for an initial period of no less than sixty (60) months from the effective date of the Employee Benefits Program, provided, however, that for each city or town which participates in the Program commencing with the Effective Date of the Employee Benefits Program, as defined below, the initial period of participation shall be for a period ending June 30, 2009. Provided further that any city or town which enters the Employee Benefits Program after the Effective Date shall be required to participate in the Employee Benefits Program for a period of sixty (60) months from their first date of participation or until the end of the Policy Year during which the sixtieth month occurs, whichever is longer. 2. The MMIA hereby commits that it will establish, organize, and make operational the Employee Benefits Program within the time frame stated Memorandum of Intent to Participate/2167.100.0001 hereinafter upon receipt of a duly executed Memorandum of Commitment to Participate in the Employee Benefits Program ("Commitment Memo") from members of the MMIA which desire to participate in the Employee Benefits Program (the "Members") and whose employees, retirees, or dependents in the -aggregate -include a -sufficient number _of Employee Benefits Program beneficiaries such that the consulting actuary retained to assist in the creation of the Employee Benefits Program will advise that there is sufficient participation to permit rates to be charged which will be actuarially sound and consistent with the objective of the Employee Benefits Program to fully fund the Employee Benefits Program. It is the intent of the Employee Benefits Program to establish rates which represent a 2.7% reduction in the premiums currently paid by participants in the Montana League of Cities and Towns pooled program ("MLCT Pooled Program"). The reduction provided for herein shall be applicable for the initial nine (9) month period after the commencement of the Employee Benefits Program or until June 30, 2005, whichever is sooner, ("Initial Period") and such reduction shall be determined as follows: (i) For those cities and towns which are participants in the MLCT Pooled Program on the day immediately preceding the commencement of the Employee Benefits Program, during such Initial Period the health and welfare plans provided under the Employee Benefits Program shall be identical to the health and welfare plans provided to participants in the MLCT Pooled Proerarn durinLy the month immediately prior to the commencement of the Initial Period. - (ii) For those cities and towns which elect to participate in the Employee Benefits Program during the Initial Period which were not participants in the MLCT Pooled Program during the month immediately prior to their participation in the Employee Benefits Program, unless the MMIA and such city or town shall otherwise agree, during the Initial Period the city or town which desires to participate in the Employee Benefits Program shall select one of the existing plans offered by the MLCT Pooled Program which shall, to the maximum extent possible, mirror the benefits provided by each such city or town to its officers, employees or retirees during the month immediately preceding such city or town's participation in the Employee Benefits Program. The MMIA shall calculate the premium to be paid by each such city or town based on the rating tables then in effect for Members of the Employee Benefits Program, which rating tables shall reflect the 2.7% reduction in rates made available to members of the MLCT Pooled Program as described hereinabove. MemorAndurn of Intent to Participate/2167.100.0001 (iii) The MMIA reserves the right in its sole discretion to permit any city or town which was not a member of the MLCT Pooled Program but which had during the month preceding the commencement of. the Initial Period a health and welfare plan which had been separately rated by an actuary and was administered by Blue Cross and Blue Shield of Montana to continue such plan as one of the plans administered through the Employee Benefits Program for the Initial Period at a premium rate which is 2.7% less than the premium rate the city or town paid during the month immediately preceding its entry into the Employee Benefits Program. The undersigned city or town hereby acknowledges that after the Initial Period the MMIA may modify or substitute another plan or plans which shall then be selected by the participating cities and towns. 3. Unless the MMIA and a city or town shall otherwise make arrangements for the execution of a Commitment Memo by the city or town at a later time, executed commitment memos are due on or before September 1, 2004. 4. Provided that the MMIA receives the required minimum number of duly executed Commitment Memos so that by August 31, 2004 the consulting actuary may advise the MMIA that the conditions set forth in paragraph 2 hereinabove have been met, and subject further to the terms and conditions concerning the health services provided to each Member during the initial Period as described in paragraph 2 hereinabove, the MMIA will establish a Employee Benefits Program which will provide health services as may be set forth in the Participant Agreement, which services may also include, as may be appropriate and as may be provided in the discretion of the Authority, dental, vision, disability and/or life insurance, on such terms and conditions as the Board of Directors of the Authority may in their sole discretion determine is in the best interests of the Members, effective October 1, 2004 ("Effective Date"). In the event that the MMIA does not receive the requisite representations from the consulting actuary on or before August 31, 2004, the MMIA reserves the right to delay the Effective Date until the beginning of the calendar quarter immediately following such time as the minimum numbers of Commitment Memos are received by the MMIA. Provided, however, that if the minimum numbers of Commitment Memos are not received so that the consulting actuary may make the requisite representations by December 31, 2004, the MMIA shall have no further obligation to any city or town to organize or implement such Employee Benefits Program. MemorAndum of Intent to Participate/2167.100,0001 5. The MMIA Board of Directors shall no later than the Effective Date, or the delayed Effective Date if the requisite representations are not made by the consulting actuary by August 31, 2004 as provided in paragraph 3 hereinabove, appoint a Committee ("Employee Benefits Program Committee') of no fewer than seven (7) and no more than (15) members to oversee the operations of the Employee Benefits Program. The Employee Benefits Program Committee members shall be representatives of cities and towns which are Members of the MMIA but need not be members or participants in the Employee Benefits Program. A majority of the members of the Employee Benefits Program Committee shall be members of the Board of Directors of the MMIA as provided by the terms of the MMIA's Interlocal Agreement and Bylaws. The Employee Benefits Program Committee shall report to the Board of Directors of the MMIA and shall be given such discretion and authority to operate and bind the Employee Benefits Program as shall be set forth in a Resolution of the Board of Directors of the MMIA creating such Employee Benefits Program Committee. 6. Any city or town wishing to become a participant in the Employee Benefits Program at its inception shall be required to agree to a commitment to remain in the Employee Benefits Program for a period of at least sixty (60) months from the Effective Date or delayed Effective Date, as may be appropriate. Any city or town which enters the Employee Benefits Program after the date of its inception shall also be required to agree to a commitment to remain in the Employee Benefits Program for a period of at least sixty (60) months from the date of the commencement of Coverage in the Employee Benefits Program. 7. The undersigned city or town hereby acknowledges and agrees that prior to the Effective Date of the commencement of the Employee Benefits Program it shall pay in advance three (3) months' premium due under the Employee Benefits Program. It is further acknowledged and agreed that after making such advance payment of premium, the premium for the fourth and each succeeding month shall be due monthly at the beginning of each calendar month as provided in the Employee Benefits Program Agreement. 8. The MMIA and the undersigned city or town acknowledge and agree that the Employee Benefits Program is designed to provide health and welfare benefits to both active and retired employees and dependents of each Member to the extent such Member currently provides health and welfare benefits to both active and retired employees. Memor4ndum of Intent to Participate/2167.100.0001 9. The MMIA in consultation with the Employee Benefits Program Committee shall establish premiums for the Employee Benefits Program. Rates for each category of employee or retiree will be determined by the MMIA based upon advice from consultants and/or a consulting benefits actuary and insurance carvers. Rates may vary depending upon -factors including, but not limited to, demographic characteristics, loss experience of each participating city or town, loss experience of all participating cities and towns, and the differences, if any, in benefits provided in individual plans offered. 10. Participants in the Employee Benefits Program will remit monthly premiums based upon rates established for each category of employee and the census of covered employees, dependents and retirees. i t . Benefits provided to the beneficiaries of the Health Plan shall be as set forth in the Participation Agreement or other coverage document provided to each participating city or town and as otherwise agreed upon between the participating city or town and its recognized employee organizations as applicable. 12. The MMIA shall issue each city or town which is a participant in the Employee Benefits Program a Participation Agreement outlining the coverage provided, including terms and conditions of coverage, on or about the Effective Date or delayed Effective Date, as appropriate, of the Employee Benefits Program. 13. The undersigned city or town acknowledges and agrees that the Health Plan shall be fully funded by any or all of the following: pooling risk; purchasing individual stop loss coverage to protect the pool from large claims; and purchasing aggregate stop loss coverage. 14. The undersigned city or town further acknowledges and agrees that in furtherance of the intent to fully fund the Employee Benefits Program for each year of its operation, the MMIA shall calculate premiums which reflect and further the intent of the Employee Benefits Program to be fully funded. 15. The undersigned city or town further acknowledges and agrees that, notwithstanding the intent of the MMIA to fully fund the Employee Benefits Program for each year of its operation, in the event that the Employee Benefits Program should not be adequately funded for any reason, pro-rata assessments to the participants in the Employee Benefits Program may be utilized to ensure the approved funding level for applicable policy. Memorandum of Intent to Participate/2167.100.0001 16. The undersigned city or town shall maintain staff to act as liaison with the Employee Benefits Program administrators. 17 - _This Memorandum - may be executed in several -counterparts, each of which shall be an original, all of which shall constitute but one and the same instrument. 18. This Memorandum of Commitment represents the commitment of the undersigned city or town to participate in the Employee Benefits Program and shall not be rescinded unless (a) the Employee Benefits Program is not implemented by the Effective Date or delayed Effective Date, as may be appropriate, or (b) the material terms and conditions of the Employee Benefits Program as set forth in this Memorandum of Commitment are altered or deleted as of the Effective Date or delayed Effective Date of the Employee Benefits Program. Dated this day of , 2004. MONTANA MUNICIPAL INSURANCE AUTHORITY Its: CITY OR TOWN OF: Its: MemorSndum of Intent to Participatei2167.100.0001 MMIA Employee Benefits Program Benefits & Premium Rates - October 1, 2004 Self-Jnsured Medical Benefits Monthly Premium Rates Monthly Premium Rates BCBSMT MLCT Pool MMIA Employee Benefits Program Effective: July 1, 2004 1 Effective: October 1, 2004* Child Child Baker, City of 340,60 681.21 596,06 596.06 936.86 331.40 662.82 579.97 '.. 579.97 ': 911.37 Belgrade, City of 254.22 508.43 444.88 444.88 699,10 247 3fi 94 4.70 432.87 32,87 "` 680;22 Bridger, Town of 379.74 759.50 664,46 _. 664.46 1,D44.31 _ ... 369.49 738.99 646.52 646,52 1,016.11 Broadus, Town of PENDING BCBSMT PREMIUM RATE INFORMATION Cascade, Town of 254,22 508.43 444.88 444.86 699.10 _ .. 247.36 .._ _36 494.70 _ _ ... 432.87 432.87 880,22 Q Chester, Town of 211,84 423.67 370.71 370.71 582.55 206.12 412.23 360.70 360,70 '', 566,82 Choteau, City of 281.56 563.12 492.73 492.73 774.28 273.96 547.92 479.43 ; 479.43 : 753,37 e Circle, Town of 310,71 621.41 433.62 433.62 854.44 302.32 604.63 421.91 421.91 831,37 e Clyde Park, Town of 281.56 563.12 492.73 492.73 774.28 273.96 547,92 479.43 479.43 753.37 o Columbus, Town of 211.84 423.67 3.70,71 370,71 582,56 206.12 412.2.3 360.70 360.70 '', 566,82 „ Cut Bank, City of 353.07 706.15 617,78 617.78 970,95 343.54 687.08 601.10 601.10 944.73 Denton, Town of 202.72 405.43 354.75 354.75 .557.47 197.25 394.48 345.17 345.17 542,42 Dillon City of 282.46 56492 494.31 494.31 776 77 274.83 549.67 480 96 480.96 755.80 Dodson, Town of PENDING BCBSMT PREMIUM RATE iNt"ORMATION Drummond, Town of 353.07 - 706,15 617.78 :... ....... 617.78 . _. 970,95 343.54 687.08 601 10 601.10 944,73 _ a East Helena City of 353.07 706.15 617.78 - 617.78 979.95 343.54 1 687.08 601A0 601.10 944,73 „ Eureka, Town of - 310.71 621.41 433.62 433.62 854,44 302.32 604.63 421,91 421.91 831.37 .. _. ..... s Fairview, Town of 310,71 621 Al 433.62 433.62 854 44 302.32 604.63 _ 421.91 ......_ I 421 91 -.. $31.37 - P Flaxville, Town of PENDING BCBSMT PREMIUM RATE INFORMATION x Forsyth, City of 340.60 j 681.21 596.06 596.06 936.66 331,40 662.82 579,97 579.97 911.37 1: Fort Benton, City of - .. 255.45 510.91 447.05 447.D5 - 7D2.5fl 248.55 497.12 . .... 434.98 434.98 - 683.53 _ - Fort Peck, Town of 254.22 508.43 444.88 444.88 699.10 247.36 494.70 432.87 432.87 ', 680.22 . Hamilton, City of 392.00 547.00 540.00 540,00 829.W 381.42 632.23 525,42 - $25 42 806,62 :. Havre, City of 346.20 699.60 926.20 336.$5 680.71 0.00 0.00 901.19 Harlowton, City of 310.71 621 Al 433.62 433.62 854.44 _ _ 302,32 604.63 421.91 421.91 __... 831.37 o Hingham, Town of PENDING ........ ........ BCBSMT PREMIUM RATE INFORMATION .. - ...... ............ Jordan, Town of _ _ PENDING BCBSMT PREMIUM RATE INFORMATION _ -. - - d Kaiis eIt City of P Y _ 408.39 859.47 714 69 ---.. 714Z911..... 997 91 ._ ... 397 37 836.27„ 1 695 39 -. 695 39 970.97 Laurel, City of 397.74 876.21 632.44 632.44 1,012.00 387.00 852.55 615.36 'i, 615,36 984.68 Lewistown, City of 342.13 - 684,29 598 74 598.74 940.90 _ _ ... 332.89 665.81 ..... 582.57 582.57 915.50 Lima, Town of PENDING BCBSMT PREMIUM RATE INFORMATION Livingston, City of 318.02 636.04 636.04 636.04. 874,56 309.43 618.87 618.87 618.87 850.95 Miles City, City of 337 6fi 614.56 702.DD '', 702.00 965 23 328.54 597.97 683.05 683.05 939.17 MLCT Staff �.,, ., ,� -._.san 337,38 7n 674.76 ��n nQ 480.30 Gnu ns 48D,30 sn7 n� 927.80 Inc �n n 328.27 hfl� 07 656.54 ce1 a� 46733 Sao oa 467.33 nn� �c 902.75 77c no as rvun,n Moore, Town of ., T 428.22 .4u 856.43 v 749,37 749.37 - 1 1,177.59 416.66 w.«« 833.31 -.«« 729.14 729.14 -- 1 145.80 37 Nashua Town of 254.22 508.43 444.88 4441 699 1D 247.36 494.70 432.87 432.87 680,22 a Opheim, Town of PENDING BCBSMT PREMIUM RATE INFORMATION g Plains, Town of 282.46 564.92 494 31 - 494.31 _._-. 776.77 274.63 549.67 480.96 480.96 755.80 a Pientywood, City of _ - 329.25 658.50 ... 576.19 _.. 576.19 - 905.44 _ 320 36 640.72 560 63 560.63 ` $80.99 - Po' lar, COYYof __.. - 323 80 - 647.60 566,65 _ 566.65 ... _ 890.45 3'15.06 630.11 - 551.35 551.35 866,41 - Roundup, City of 254.22 508,43 444.88 444.88 699.10 247.36 494.70 432.87 432.87 680.22 Saco, Town of -... PENDING BCBSMT PREMIUM _ RATE INFORMATION - Scobay, City of 316.41 632.83 553.73 553.73 870.1. 307.87 615.74 538,78 538.78 846.66 « Shelby, City 237.06 474.11 414,86 l 414.86 &51.91 _ 230.66 461.31 _ .. .... 403.66 403,66 634,31 Sidney, City of 274A$ 548.91 48030 480.30 754.76 267.04 534.09 467.33 1 461.33 734.38 Stanford, Town of 337.38 674.76 480.30 480.30 927.80 328.27 656.54 46T.33 467.33 902.75 Superior, Town of 289 74 579.48 507.05 507.05 796.79 281.92 563.83 49336 493.36 775.28 Terry, Town of 282.46 564,92 494.31 494.31 776.77 274.83 549.67 480.96 480.96 755,$0 .......... ...... Thompson Falls, City of 310.71 621.41 433,62 433.62 854.44 302.32 604.63 421.91 421,91 831.37 Three Forks, City of 310,71 621.41 433 62 433.62 854.44 302.32 604.63 421,91 421.91 831.37 52 Townsend, City at -_,..,,,...__310.71 _.__ 621.41 _ . 433 62 j 433.62 854.44 302 32 ........ 604.63 421.91 421 91- 831.37 - West Yellowstone, Town of 353.07 70615 617.78 617.78 970,95 343.64 687.08 601,10 601.10 94433 Whitefish, City of - 316.99 578.09 562.99 562,99 820.40 303.43 562.48 547.79 ... 547,79 798,25 - Wolf Point, City of 379.74 759.50 664.46 _ 664.46 1,044.31 369.49 738.99 646.52 646.52 , 1,016.11 "Oct 1, 2004 rates are based on Jul 1, 2004 effective monthly premium rates less 2, 7% reflected above and are subject to change if data is not current, MMIA Medical Benefit Pmrn€um8 -- October 1, 2004 Montana Municipal Insurance Authority — Employee Benefits Program Comparison of Medical Benefits Calendar Year Deductible(s) Annual Out -of -Pocket Maximum Lifetime_ Maximum Inpatient Hospital Room, Board & Support Services (prior authorization required) Ambulatory Surgery Center Emergency Room Accident Benefit Surgeon & Anesthetist Office Visits Physician Services C_hildren's Preventative Care Routine Exam Employee& Spouse Diagnostic X-Ray &_Lab Durable Medical Equipment Ambulance Home Health Care (prior authorization required) Chiropractic Services Infertility Services Psychiatric & Substance Abuse Inpatient Hospital tnpatient/©utpatient Professional $100 - $200 $1,000 - $2,000' $500 - $1,000' $1,000 - $2,000' $1 100 - $2,200 $1,000 - $2,000 $2,000 - $4,000 $3,000 - $6,000 $5,000,000 $5,000,000 $5,000,000 $5,000,000 89% 70% 60% 50°/ 80% 70% 60°/n 50% --- ------------- � 80% 70% - 60% 50% _._ -- 100% to $300 -- —— 100% to $300 ----------- 100% to $300 then, 80% then, 70% 60% then, 50% 80% 70% 60% 50% --- 80% 70% �— - 60% -- 50% 80%, 70% 60% 50% 80% 70% 60% 50% 80% 70% 60% 50% 80% 70% 60% 50% 80%70°/ . ._.... 60% 50% - 80% 70% 60% T 50% 80% - 180 visits 70% - 180 visits 60% -- 180 visits 50% - 180 visits 80% - 10 visits' 70% - 10 visits' 60% - 10 visits' 50% - 10 visits' $100 for x-rays m... Y $100 for x-rays y $100 for x-rays - $100 for x-rays i �60% � 80°1° � 3Od'ays 70% �,30 days � 30 days l, 50%- 30�days 80% ^' 12 visits � 70% - 12 visits j 60% ^' 12 visits � 50% ^' 12 visits Retail Brand Formulary Rx Co -pay $12 $12 $12 Retail Non Formulary Brand Co -pay $22 $22 $22 Drugs for treatment of infertility ' No deducible for Proessional Provider services and out of state physician services. z This benefit is paid at 100% to $500 of primary care services received from a BCBSMT Participating Provider. 3 Additional visits are available with an approved treatment plan. $12 $22 $4,000 - aa nnn - 100% i 100% to 0 100% 100°/ to $500' — - 100% to $50b2 100% to $50b2 100% to $5002 - - 1001/0 100% to $5002 100 % to $500' t00% 100°/ - 180 visits Not covered lVV%o"C1 80% - 12 visits 100% 100% Prepared by Legacy Bnterpr1ses Insurance Services, Inc.