Res No 096-21-15716RESOLUTION NO. 096-21 -1571 6
A Resolution authorizing the City Manager to purchase dental and vision insurance
benefits from Humana for full-time employees and participating retirees for the 2021-2022
Fiscal Year.
WHEREAS, the City, through its Agent of Record, Brown and Brown of Florida, solicited more than
three quotes, compared the insurance rates, dental and vision plan design, provider network, as well as the
City's previous claims experience/ratio; and
WHEREAS, City staff recommend the selection of Humana for the provision of dental and vision
insurance benefits for all full-time employees and participating retirees; and
WHEREAS, the premium shall be charged to departmental line items in their respective account
number.
NOW THEREFORE, BE IT RESOLVED BY THE MAYOR AND CITY COMMISSIONERS OF
THE CITY OF SOUTH MIAMI, FLORIDA:
Section 1. The foregoing recitals are hereby ratified and confirmed as being true and they are
incorporated into this resolution by reference as if set forth in full herein.
Section 2. The Commission hereby authorized the City Manager to execute the dental and vision
insurance renewal policy with Humana for the City of South Miami full time employees and participating
retirees for the 2021-2022.
Section 3. Corrections. Conforming language or technical scrivener -type corrections may be made by
the City Attorney for any conforming amendments to be incorporated into the final resolution for signature.
Section 4. Severability. If any section clause, sentence, or phrase of this resolution is for any reason
held invalid or unconstitutional by a court of competent jurisdiction, the holding shall not affect the validity of
the remaining portions of this resolution.
Section 5. Effective Date. This resolution shall become effective immediately upon adoption.
PASSED AND ADOPTED this 17a' day of Au ust, 2021.
ATTEST: APPROVED: <<
CITY 13LERK JdAYOR
READ AND APPROVED AS TO FORM,
LANGUAGE. LEGALITY AND
I_1
COMMISSION VOTE: 5-0
Mayor Philips: Yea
Commissioner Corey: Yea
Commissioner Harris: Yea
Commissioner Liebman: Yea
Commissioner Gil: Yea
Agenda item No:7.
City Commission Agenda item Report
Meeting Date: August 17, 2021
Submitted by: Samantha Fraga-Lopez
Submitting Department: Human Resources
Item Type: Resolution
Agenda Section:
Subject:
A Resolution authorizing the City Manager to purchase dental and vision insurance benefits from Humana for
full-time employees and participating retirees for Fiscal Year 2021-2022. 3/5 (City Manager)
Suggested Action:
Attachments:
Memo Vision and Dental 21-22.docx
Reso Dental and Vision 21-22.doc
21-22 Vision Comparison.pdf
21-22 Dental Comparison.pdf
CITY OF SOUTH MIAMI
South Miami OFFICE OF THE CITY MANAGER
THE CITY OF PLEASANT LIVING INTER -OFFICE MEMORANDUM
TO: The Honorable Mayor & Members of the City Commission
FROM: Shari Kamali, City Manager
VIA: Samantha Fraga-Lopez, Assistant City Manager
DATE: August 17, 2021
SUBJECT: A Resolution authorizing the City Manager to purchase dental and vision
insurance benefits from Humana for full-time employees and participating
retirees for Fiscal Year 2021-2022.
BACKGROUND: The City's benefits consultant, Brown and Brown of Florida, Inc., solicited
quotes from Humana, MetLife, Aetna, Cigna, Florida Blue, and Guardian
for the employee's dental and vision insurance coverages for South Miami
full-time employees and retirees for the 2021— 2022 Fiscal Year. Humana,
the City's current dental and vision insurance carrier's renewal rate
represented a 0% increase from last year's rate for the DHMO dental plan
offered by the City. The dental PPO, which can be elected at the
employees' expense, was quoted at a $3.31 monthly increase. The City
currently contributes $8.49 per eligible employee, per month, toward
dental insurance coverage and vision is voluntarily paid by the employee.
Humana's vision plan is on a two (2) year rate guarantee, therefore there
is no increase for FY 21-22. The Humana plans provide the best coverage
including rates, and co -pays. The renewal is appropriately funded in the
proposed budget for Fiscal Year 2021-2022.
RECOMMENDATION: Based upon the proposals received, Brown and Brown and City Staff
recommend the City renew with the current Humana carrier for dental and
vision insurances.
AMOUNT: The estimated total annual premiums cost for dental benefits paid by the
City is about $12,300 based on today's full-time personnel.
ACCOUNT: Premium charges for the health will be charged to the designated
departmental budget line items as proposed in the Fiscal Year 2021-2022
budget.
ATTACHMENTS: Proposed resolution
Comparison Vision
Comparison Dental
2
October 2021 Vision Comparison for City of South Miami
Fcarrier
Network Provider
Network Status
Eye Care Wellness
Eye Exam
Frequency
Lenses
Single Vision
Bifocals
Trifocal
Frequency
Frames
Selected Frames
Frequency
Contacts
Medically Necessary
Elective Contacts
Contribution Type
Part ici ation Requirements
Rate Guarantee
Employee
Employee + Spouse
Employee + Child
Family
Monthly Total
Annual Total
% Change in Total Annual Premium
$ Change in Monthly Premium by Plan
$ Change in Total Annual Premium
51
12
14
E eMed
In -Network OON
$0 Copay up to $30
Every 12 Months
Reimbursement
$0 Copay up to $25
$0 Copay up to $40
$0 Copay up to $60
Every 12 Months
Reimbursement
$200 allowance + up to $100
20 /o discount over
Every 24 Months
Reimbursement
100% up to $210
$200 allowance up to $160
Voluntary
Expires 9/30/2022
$7.13
$14.26
$15.27
$23.01
$909.60
$10,915.20
51
12
14
In -Network OON
$0 Copay up to $45
Every 12 Months
Reimbursement
$0 Copay up to $30
$0 Copay up to $50
$0 Copay up to $_65
Every 12 Months
Reimbursement
$ 200 allowance + up to $70
20 /° discount over
Every 24 Months
Reimbursement
100% up to $210
$200 allowance up to $105
Contributory
68%
24 Months
$9.12
$18.25
$19.54
$29.44
$1,163.76
$13,965.12
27.94%
$254.16
$3,049.92
Declined to Quote
Rates shown are based on census data provided. Final rates are subject to underwriting and actual enrollment. This comparison is for
r ii�ur��ra
illustrative purposes only. The full policy and certificate of coverage will supersede any and all materials provided herein. Page t of 5
October 2021 Vision Comparison for City of South Miami
Network Provider
Network Status
Eye Care Wellness
Eye Exam
Frequency
Lenses
Single Vision
Bifocals
Trifocal
Frequency
Frames
Selected Frames
Frequency
Contacts
Medically Necessary
Elective Contacts
Contribution Type
Participation Requirements
Rate Guarantee
Employee
Employee + Spouse
Employee + Child
Family
Monthly Total
Annual Total
% Change in Total Annual Premium
$ Change in Monthly Premium by Plan
$ Chan a in Total Annual Premium
51
12
14
E eMed
In -Network OON
$0 Copay up to $30
Every 12 Months
Reimbursement
$0 Copay up to $25
$0 Copay up to $40
$0 Copay up to $60
Every 12 Months
Reimbursement
$2000 allowance + up to $100
20 /o discount over
Every 24 Months
Reimbursement
100% up to $210
$200 allowance up to $160
Voluntary
Expires 9/30/2022
$7.13
$14.26
$15.27
$23.01
$909.60
$10,915.20
l
Not Quoted
Florida
Not Quoted
Rates shown are based on census data provided. Final rates are subject to underwriting and actual enrollment. This comparison is for
illustrative purposes only. The full policy and certificate of coverage will supersede any and all materials provided herein. Page 2 of 5
October 2021 Vision Comparison for City of South Miami
Network Provider
Network Status
Eye Care Wellness
Eye Exam
Frequency
Lenses
Single Vision
Bifocals
Trifocal
Frequency
Frames
Selected Frames
Frequency
Contacts
Medically Necessary
Elective Contacts
Contribution Type
Partici ation Requirements
Rate Guarantee
Employee
Employee + Spouse
Employee + Child
Family
Monthly Total
Annual Total
% Change in Total Annual Premium
$ Change in Monthly Premium by Plan
$ Change in Total Annual Premium
51
14
EyeMed
In -Network OON
$0 Copay up to $30
Every 12 Months
Reimbursement
$0 Copay up to $25
$0 Copay up to $40
$0 Copay up to $60
Every 12 Months
Reimbursement
$ 200 allowance + up to $100
20 /o discount over
Every 24 Months
Reimbursement
100% up to $210
$200 allowance up to $160
Voluntary
Expires 9/30/2022
$7.13
$14.26
$15.27
$23.01
$909.60
$10,915.20
Guardian
Not Quoted
Declined to Quote
Rates shown are based on census data provided. Final rates are subject to underwriting and actual enrollment. This comparison is for
In
illustrative purposes only. The full policy and certificate of coverage wip supersede any and all materials provided herein. Page 3 of 5
October 2021 Vision Comparison for City of South Miami
Network Provider
Network Status
Eye Care Wellness
Eye Exam
Frequency
Lenses
Single Vision
Bifocals
Trifocal
Frequency
Frames
Selected Frames
Frequency
Contacts
Medically Necessary
Elective Contacts
Contribution Type
Participation Requirements
Rate Guarantee
Employee
Employee + Spouse
Employee + Child
Family
Monthly Total
Annual Total
% Change In Total Annual Premium
$ Change in Monthly Premium by Plan
$ Change In Total Annual Premium
51
12
14
EyeMed
In -Network OON
$0 Copay up to $30
Every 12 Months
Reimbursement
$0 Copay up to $25
$0 Copay up to $40
$0 Copay j up to $60
Every 12 Months
Reimbursement
$200 allowance + up to $100
20 /o discount over
Every 24 Months
Reimbursement
100% up to $210
$200 allowance up to $160
Voluntary
Expires 9/30/2022
$7.13
$14.26
$15.27
$23.01
$909.60
$10,915.20
Mutual of Omaha
Declined to Quote
Standard
Declined to Quote
IM
Rates shown are based on census data provided. Final rates are subject to underwriting and actual enrollment. This comparison is for
r c�aaa rwtira
illustrative purposes only. The futl policy and certificate of coverage will supersede any and all materials provided herein. page 4 of 5
October 2021 Vision Comparison for City of South Miami
Network Provider
Network Status
Eye Care Wellness
Eye Exam
Frequency
Lenses
Single Vision
Bifocals
Trifocal
Frequency
Frames
Selected Frames
Frequency
Contacts
Medically Necessary
Elective Contacts
Contribution Type
Participation Requirements
Rate Guarantee
Employee
Employee + Spouse
Employee + Child
Family
Monthly Total
Annual Total
Change in Total Annual Premium
$ Change in Monthly Premium by Plan
$ Change in Total Annual Premium
51
12
14
EyeMed
In -Network OON
$0 Copay up to $30
Every 12 Months
Reimbursement
$0 Copay up to $25
$0 Copay up to $40
$0 Copay up to $60
Every 12 Months
Reimbursement
$2000 allowance + up to $100
20 /o discount over
Every 24 Months
Reimbursement
100 % up to $210
$200 allowance up to $160
Voluntary
Expires 9/3012022
$7.13
$14.26
$15.27
$23.01
$909.60
$10,915.20
UnitedHealthcare
Rates shown are based on census data provided. Final rates are subject to underwriting and actual enrollment. This comparison is for
W illustrative purposes only. The full policy and certificate of coverage will supersede any and all materiels provided herein. Page 5 of 9
October 2021 Dental Comparison for City of South Miami
Plan Name
Provider Acess
Benefit Description
Preventive (Class 1)
Basic (Class II)
Major Class III
Maximum Annual Benefit
Deductible (IndividuallFamily)
Deductible Waived - Class I
Orthodontia (coverage/lifetime max
Reimbursement Schedule
Benefits
Routine Exams - 9430
Teeth Cleaning - 1110
Full Mouth/Panoramic X-rays - 0330
Simple Extractions - 7111
Root Canal (Endodontics) - 3330
Perio. Scaling/Root Planning - 4341
Full or Partial Dentures - 5110
Crowns - 6752
Employer Contribution
Minimum Participation Requirement
Waiting Period Major Services
Rate Guarantee
Employee
Employee + Spouse
Employee + Children)
Family
Monthly Premium By Product
Total Monthly Premium
Total Annual Premium
% Change in Monthly Premium by Plan
$ Change in Monthly Premium by Plan
$ Change in Total Monthly Premium
% Change in Total Annual Premium
$ Change in Total Annual Premium
37
6
5
2
Humana
Humana
DMO HD205 OR
PPO
In Network Only
In -Network
Out of Network
n/a
100%
100%
n/a
80%
80%
n/a
50%
50%
Unlimited
Unlimited
Unlimited
n/a
$50/$150
$50/$150
n/a
Yes
Yes
$2,650 Child & Adult
$1,000 Child Only
$1,000 Child Only
Fee Schedule
Fee Schedule
MAC
No Charge
100%
100%
No Charge
100%
100%
No Charge
100%
100%
No Charge
80%
80%
$250
80%
80%
$55 per quad
80%
80%
$375
50%
50%
$270
50%
50%
Contributory
Contributory
None
None
Expires 9/30/21
Expires 9/30/21
Current
Current
$8.49
34
$33.39
$16.98
3
$69.70
$19.11
4
$78.55
$30.74
8
$123.23
$573.04 $2,644.40
$3,217.44
$38,609.28
37
6
5
2
Humana
Humana
DMO HD205 OR
PPO
In Network Only
-Network
Out of Network
-In
n/a
100%
100%
n/a
80%
80%
n/a
50%
50%
Unlimited
Unlimited
Unlimited
n/a
$50/$150
$50/$150
n/a
Yes
Yes
$2,650 Child & Adult
$1,000 Child Only
$1,000 Child Only
Fee Schedule
Fee Schedule
MAC
No Charge
100%
100%
No Charge
100%
100%
No Charge
100%
100%
No Charge
80%
80%
$250
80%
80%
$55 per quad
80%
80%
$375
50%
50%
$270
50%
50%
Contributory
Contributory
None
None
12 Months
Renewal
12 Months
Renewal
$8.49
34
$36.70
$16.98
3
$76.60
$19.11
4
$86.33
$30.74
8
$135.43
$573.04 $2,906.36
$3,479.40
$41,752.80
0.0%
9.9%
$0.00
$261.96
$261.96
8.1 %
$ 3,143.52
0
Information shown is based on census data provided. For illustrative purposes only. The cer ificale of coverage, final rates, and final enrollment wll supersede any and all materials provided herein. Page 1 10
October 2021 Dental Comparison for City of South Miami
Plan Name
Provider Acess
Benefit Description
Preventive (Class I)
Basic (Class II)
Major Class III
Maximum Annual Benefit
Deductible (individual/Family)
Deductible Waived - Class I
Orthodontia (coverage/lifetime max
Reimbursement Schedule
Benefits
Routine Exams - 9430
Teeth Cleaning - 1110
Full Mouth/Panoramic X-rays - 0330
Simple Extractions - 7111
Root Canal (Endodontics) - 3330
Perio. Scaling/Root Planning - 4341
Full or Partial Dentures - 5110
Crowns - 6752
Employer Contribution
Minimum Participation Requirement
Waiting Period Major Services
Rate Guarantee
Employee
Employee + Spouse
Employee + Child(ren)
Family
Monthly Premium By Product
Total Monthly Premium
Total Annual Premium
% Change in Monthly Premium by Plan
$ Change in Monthly Premium by Plan
$ Change in Total Monthly Premium
% Change In Total Annual Premium
$ Change in Total Annual Premium
37
6
5
2
Humana
DMO HD205 OR
Humana
PPO
In Network Only
In -Network
Out of Network
n/a
100%
100%
n/a
80%
80%
n/a
50%
50%
Unlimited
Unlimited
Unlimited
n/a
$50/$150
$50/$150
n/a
Yes
Yes
$2,650 Child & Adult
$1,000 Child Only
$1,000 Child Only
Fee Schedule
Fee Schedule
MAC
No Charge
100%
100%
No Charge
100%
100%
No Charge
100%
100%
No Charge
80%
80%
$250
80%
60%
$55 per quad
80%
80%
$375
50%
50%
$270
50%
50%
Contributory
Contributory
None
None
Expires 9/30/21
Current
Expires 9/30/21
Current
$8.49
34
$33.39
$16.98
3
$69.70
$19.11
4
$78.55
$30.74
8
$123.23
$573.04 $2,644.40
$3,217.44
$38,609.28
37
6
5
2
DMO MET290
PPO
In Network Only
In -Network
Out of Network
n/a
100%
100%
n/a
80%
80%
n/a
50%
50%
Unlimited
$5.000
$5,000
n/a
$50/$150
$50/$150
n/a
Yes
Yes
$2,680 Child & Adult
$1,000 Child Only
$1,000 Child Only
Fee Schedule
Fee Schedule
MAC
No Charge
100%
100%
$5
100%
100%
No Charge
100%
100%
$5
80%
80%
$265
80%
80%
$50 per quad
80%
80%
$440
50%
50%
$290
50%
50%
Contributory
Contributory
10 enrolled
5 enrolled
None
12 Months
12 Months
$11.76
34
$34.43
$20.58
3
$71.88
$24.69
4
$81.00
$34.68
8
$127.07
$751.41 $2,726.82
$3,478.23
$41,738.76
31.1 %
3.1 %
$178.37
$82.42
$260.79
8.1 %
$3,129.48
Information shown is based on census data provided. For illustrative purposes only. The cerlificate of coverage, final rates, and final enrollment wll supersede any and all materials provided herein. Page 2 11
October 2021 Dental Comparison for City of South Miami
Carrier
Plan Name
Provider Acess
Benefit Description
Preventive (Class 1)
Basic (Class 11)
Major Class III
Maximum Annual Benefit
Deductible (Individual/Family)
Deductible Waived - Class I
Orthodontia (coverage/lifetime max
Reimbursement Schedule
Benefits
Routine Exams - 9430
Teeth Cleaning - 1110
Full Mouth/Panoramic X-rays - 0330
Simple Extractions - 7111
Root Canal (Endodontics) - 3330
Perio. Scaling/Root Planning - 4341
Full or Partial Dentures - 5110
Crowns - 6752
Employer Contribution
Minimum Participation Re uirement
Waiting Period Major Services
Rate Guarantee
Employee
Employee + Spouse
Employee + Child(ren)
Family
Monthly Premium By Product
Total Monthly Premium
Total Annual Premium
% Change in Monthly Premium by Plan
$ Change in Monthly Premium by Plan
$ Change in Total Monthly Premium
% Change In Total Annual Premium
$ Change in Total Annual Premium
37
6
5
2
Humana
Humana
DMO HD205 OR
PPO
In Network Only
In -Network
Out of Network
n/a
100%
100%
n/a
80%
80%
n/a
50%
50%
Unlimited
Unlimited
Unlimited
n/a
$50/$150
$50/$150
n/a
Yes
Yes
$2,650 Child & Adult
$1,000 Child Only
$1,000 Child Only
Fee Schedule
Fee Schedule
MAC
No Charge
100%
100%
No Charge
100%
100%
No Charge
100%
100%
No Charge
80%
80%
$250
80%
80%
$55 per quad
80%
80%
$375
50%
50%
$270
50%
50%
Contributory
Contributory
None
None
Ex ires 9/30/21
Expires 9/30/21
Current
Current
$8.49
34
$33.39
$16.98
3
$69.70
$19.11
4
$78.55
$30.74
8
$123.23
$573.04 $2,644.40
$3,217.44 _
$38,609.28
Cigna
0
Information shown is based on census data provided. For illustrative purposes only. The certificate of coverage, final rates, and final enrollment wit supersede any and all materials provided herein. Page 312
October 2021 Dental Comparison for City of South Miami
Plan Name
Provider Acess
Benefit Description
Preventive (Class 1)
Basic (Class II)
Major Class III
Maximum Annual Benefit
Deductible (Individual/Family)
Deductible Waived - Class I
Orthodontia covers ellifetime max
Reimbursement Schedule
Benefits
Routine Exams - 9430
Teeth Cleaning - 1110
Full Mouth/Panoramic X-rays - 0330
Simple Extractions - 7111
Root Canal (Endodontics) - 3330
Perio. Scaling/Root Planning - 4341
Full or Partial Dentures - 5110
Crowns - 6752
Employer Contribution
Minimum Participation Requirement
Waiting Period Major Services
Rate Guarantee
Employee
Employee + Spouse
Employee + Child(ren)
Family
Monthly Premium By Product
Total Monthly Premium
Total Annual Premium
% Change in Monthly Premium by Plan
$ Change in Monthly Premium by Plan
$ Change in Total Monthly Premium
% Change in Total Annual Premium
$ Change in Total Annual Premium
37
6
5
2
Humana
DMO HD205 OR
Humana
PPO
In Network Only
In -Network
Out of Network
n/a
100%
100%
n/a
80%
80%
n/a
50%
50%
Unlimited
Unlimited
Unlimited
n/a
$50/$150
$50/$150
n/a
Yes
Yes
$2,650 Child & Adult
$1,000 Child Only
$1,000 Child Only
Fee Schedule
Fee Schedule
MAC
No Charge
100%
100%
No Charge
100%
100%
No Charge
100%
100%
No Charge
80%
80%
$250
80%
80%
$55 per quad
80%
80%
$375
50%
50%
$270
50%
50%
Contributory
Contributory
None
None
Expires 9/30/21
Expires 9/30/21
Current
Current
$8.49
34
$33.39
$16.98
3
$69.70
$19.11
4
$78.55
$30.74
8
$123.23
$573.04 $2,644.40
$3,217.44
$38,609.28
Florida Blue
MM
Guardian
VINIA
Information shown is based on census data provided. For illustrative purposes only. The cortifikato of coverage, final rates, and final enrollment wll supersede any and all materials provided herein. Page 4 13
October 2021 Dental Comparison for City of South Miami
Carrier
Plan Name
Provider Acess
Benefit Description
Preventive (Class 1)
Basic (Class II)
Major Class III
Maximum Annual Benefit
Deductible (Individual/Family)
Deductible Waived - Class I
Orthodontia (coverage/lifetime max
Reimbursement Schedule
Benefits
Routine Exams - 9430
Teeth Cleaning -1110
Full Mouth/Panoramic X-rays - 0330
Simple Extractions - 7111
Root Canal (Endodontics) - 3330
Perio. Scaling/Root Planning - 4341
Full or Partial Dentures - 5110
Crowns - 6752
Employer Contribution
Minimum Participation Requirement
Waiting Period Major Services
Rate Guarantee
Employee 37
Employee + Spouse 6
Employee + Child(ren) 5
Family 2
Monthly Premium By Product
Total Monthly Premium
Total Annual Premium
% Change in Monthly Premium by Plan
$ Change in Monthly Premium by Plan
$ Change in Total Monthly Premium
% Change in Total Annual Premium
$ Change in Total Annual Premium
Humana
Humana
DMO HD205 OR
PPO
In Network Only
In -Network
Out of Network
n/a
100%
100%
n/a
80%
80%
n/a
50%
50%
Unlimited
Unlimited
Unlimited
n/a
$50/$150
$50/$150
n/a
Yes
Yes
$2,650 Child & Adult
$1,000 Child Only
$1,000 Child Only
Fee Schedule
Fee Schedule
MAC
No Charge
100%
100%
No Charge
100%
100%
No Charge
100%
100%
No Charge
80%
80%
$250
80%
80%
$55 per quad
80%
80%
$375
50%
50%
$270
50%
50%
Contributory
Contributory
None
None
Expires 9/30/21
Expires 9/30/21
Current
Current
$8.49
34
$33.39
$16.98
3
$69.70
$19.11
4
$78.55
$30.74
8
$123.23
$573.04 $2,644.40
$3,217.44
$38,609.28
Mutual of Omaha
Declined Quote
0
Information shown is based on census data provided. For illustrative purposes only. The certificate of coverage, final rates, and final enrollment wll supersede any and all materials provided herein. Page 514
October 2021 Dental Comparison for City of South Miami
Carrier
Plan Name
Provider Acess
Benefit Description
Preventive (Class 1)
Basic (Class II)
Major Class III
Maximum Annual Benefit
Deductible (Individual/Family)
Deductible Waived - Class I
Orthodontia (coverage/lifetime max
Reimbursement Schedule
Benefits
Routine Exams - 9430
Teeth Cleaning - 1110
Full Mouth/Panoramic X-rays - 0330
Simple Extractions - 7111
Root Canal (Endodontics) - 3330
Perio. Scaling/Root Planning - 4341
Full or Partial Dentures - 5110
Crowns - 6752
Employer Contribution
Minimum Participation Requirement
Waiting Period Major Services
Rate Guarantee
Employee
Employee + Spouse
Employee + Child(ren)
Family
Monthly Premium By Product
Total Monthly Premium
Total Annual Premium
% Change in Monthly Premium by Plan
$ Change in Monthly Premium by Plan
$ Change in Total Monthly Premium
% Change in Total Annual Premium
$ Change in Total Annual Premium
37
6
5
2
Humana
Humana
DMO HD205 OR
PPO
In Network Only
In -Network
Out of Network
n/a
100%
100%
n/a
80%
80%
n/a
50%
50%
Unlimited
Unlimited
Unlimited
n/a
$50/$150
$50/$150
n/a
Yes
Yes
$2,650 Child & Adult
$1,000 Child Only
$1,000 Child Only
Fee Schedule
Fee Schedule
MAC
No Charge
100%
100%
No Charge
100%
100%
No Charge
100%
100%
No Charge
80%
80%
$250
80%
80%
$55 per quad
80%
80%
$375
50%
50%
$270
50%
50%
Contributory
Contributory
None
None
Expires 9/30/21
Expires 9/30/21
Current
Current
$8.49
34
$33.39
$16.98
3
$69.70
$19.11
4
$78.55
$30.74
8
$123.23
$573.04 $2,644.40
$3,217.44
$38,609.28
Standard
Declined
UnitedHealthcare
0
Information shown is based on census data provided. For illustrative purposes only. The certifrcato of coverage, final rates, and final enrollment wit supersede any and all materials provided herein. Page 615