FY 2016-2017 GROUP INSURANCE PREMIUM RATES EFFECTIVE

State Total: Employee State: Total Employee: State Employee: State Leave/LO: COBRA [HAEX] State Health Plan PPO Employee Only $ 62.74 $ 250.94 $ 313.6...
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CIVIL SERVICE COMMISSION EMPLOYEE BENEFITS DIVISION

FY 2016-2017 GROUP INSURANCE PREMIUM RATES EFFECTIVE OCTOBER 9, 2016 For NERE & Bargaining Units: AFSCME, MCO, MSEA, UAW, SEIU Local 517M, Judicial Branch, and Non-Represented (Z60-Z89) PLAN NAME/CODE [HAEX] State Health Plan PPO

Employee or Spouse with Medicare (State Pays 100%)

[H2F0] Catastrophic Health Plan 2

[H3ZN] Decline Health Ins. [H4ZN] "Opt Out" Health 3 [VBW0] State Vision Plan

[V3ZN] Decline Vision Ins. [DBEX] State Dental Plan

Option Employee Only Employee & Spouse Employee & Child (ren) Full Family Employee Only Employee & Spouse Employee & Child (ren) Full Family

Employee $ 62.74 $ 125.48 $ 110.42 $ 173.16 $ $ $ $ -

BIWEEKLY State $ 250.94 $ 501.91 $ 441.68 $ 692.63 $ 250.94 $ 501.91 $ 441.68 $ 692.63

$ $ $ $ $ $ $ $

Employee Only Employee & Spouse Employee & Child (ren) Full Family (n/a)

$ $ $ $

$ $ $ $

$ $ $ $

(n/a) Employee Only Employee & Spouse Employee & Child (ren) Full Family (n/a) Employee Only Employee & Spouse Employee & Child (ren) Full Family

(n/a) (n/a)

$ $ $ $ $ $ $ $

(n/a) 1.05 1.91 2.32 3.18

15.81 31.62 31.62 31.62 (n/a)

$ $ $ $

(n/a) 2.38 4.19 5.12 6.93 (n/a) 19.87 36.26 44.16 60.49

$ $ $ $

Total 313.68 627.39 552.10 865.79 250.94 501.91 441.68 692.63

Employee $ 1,631.14 $ 3,262.40 $ 2,870.90 $ 4,502.10 $ $ $ $ -

$ $ $ $ $ $ $ $

15.81 31.62 31.62 31.62 (n/a)

$ $ $ $

$ $ $ $

$ $ $ $

(n/a) 2.38 4.19 5.12 6.93 (n/a) 20.92 38.17 46.48 63.67

$ $ $ $

(n/a) (n/a)

$ $ $ $ $ $ $ $

(n/a) 27.19 49.62 60.43 82.77

ANNUAL State 6,524.54 13,049.61 11,483.59 18,008.40 6,524.54 13,049.61 11,483.59 18,008.40 411.06 822.12 822.12 822.12 (n/a)

$ $ $ $

(n/a) 61.97 108.88 132.99 180.23 (n/a) 516.53 942.74 1,148.10 1,572.63

$ $ $ $

$ $ $ $ $ $ $ $ $ $ $ $

Total 8,155.68 16,312.01 14,354.49 22,510.50 6,524.54 13,049.61 11,483.59 18,008.40 411.06 822.12 822.12 822.12 (n/a)

$ $ $ $

(n/a) 61.97 108.88 132.99 180.23 (n/a) 543.72 992.36 1,208.53 1,655.40

$ $ $ $

BIWEEKLY - PART TIME 1 Employee State $ 156.84 $ 156.84 $ 313.69 $ 313.69 $ 276.05 $ 276.05 $ 432.89 $ 432.89 $ $ $ $ $ $ $ $ -

ANNUAL - PART TIME 1 Employee State $ 4,077.84 $ 4,077.84 $ 8,156.00 $ 8,156.01 $ 7,177.24 $ 7,177.25 $ 11,255.25 $ 11,255.25 $ $ $ $ $ $ $ $ -

MONTHLY Leave/LO COBRA $ 679.64 $ 693.23 $ 1,359.33 $ 1,386.52 $ 1,196.21 $ 1,220.13 $ 1,875.88 $ 1,913.39 $ 543.71 $ 554.59 $ 1,087.47 $ 1,109.22 $ 956.97 $ 976.11 $ 1,500.70 $ 1,530.71

$ $ $ $

$ $ $ $

$ $ $ $

-

$ $ $ $

(n/a) (n/a)

7.91 15.81 15.81 15.81 (n/a)

$ $ $ $

1.19 2.09 2.56 3.47

$ $ $ $

$ $ $ $

(n/a) 10.46 19.08 23.24 31.83

$ $ $ $

(n/a) 1.19 2.09 2.56 3.47 (n/a) 10.46 19.08 23.24 31.83

-

$ $ $ $

(n/a)

$ $ $ $

(n/a) 30.98 54.44 66.49 90.11 (n/a) 271.86 496.18 604.26 827.70

$ $ $ $

205.53 411.06 411.06 411.06 (n/a)

$ $ $ $

(n/a) 30.99 54.44 66.50 90.12 (n/a) 271.86 496.18 604.27 827.70

$ $ $ $

34.26 68.51 68.51 68.51 (n/a)

$ $ $ $

34.94 69.88 69.88 69.88 (n/a)

$ $ $ $

(n/a) 5.16 9.07 11.08 15.02 (n/a) 45.31 82.70 100.71 137.95

$ $ $ $

(n/a) 5.27 9.26 11.30 15.32 (n/a) 46.22 84.35 102.73 140.71

$ $ $ $

$ $ $ $

[DP00] Preventive Dental Plan

Employee Only Employee & Spouse Employee & Child (ren) Full Family

$ $ $ $

-

$ $ $ $

2.99 5.21 5.21 7.42

$ $ $ $

2.99 5.21 5.21 7.42

$ $ $ $

-

$ $ $ $

77.74 135.46 135.46 192.92

$ $ $ $

77.74 135.46 135.46 192.92

$ $ $ $

1.50 2.61 2.61 3.71

$ $ $ $

1.50 2.61 2.61 3.71

$ $ $ $

38.87 67.73 67.73 96.46

$ $ $ $

38.87 67.73 67.73 96.46

$ $ $ $

6.48 11.29 11.29 16.08

$ $ $ $

6.61 11.51 11.51 16.40

[DMEX] Midwestern Dental (DMO)

Employee Only Employee & Spouse Employee & Child (ren) Full Family

$ $ $ $

-

$ $ $ $

16.79 16.79 16.79 16.79

$ $ $ $

16.79 16.79 16.79 16.79

$ $ $ $

-

$ $ $ $

436.44 436.44 436.44 436.44

$ $ $ $

436.44 436.44 436.44 436.44

$ $ $ $

8.39 8.39 8.39 8.39

$ $ $ $

8.39 8.39 8.39 8.39

$ $ $ $

218.22 218.22 218.22 218.22

$ $ $ $

218.22 218.22 218.22 218.22

$ $ $ $

36.37 36.37 36.37 36.37

$ $ $ $

37.10 37.10 37.10 37.10

[D3ZN] Decline Dental Ins. [D4ZN] "Opt Out" Dental 4 Employee Life [LUEX/LREX] Employee Life Only (Fire/Crash Rescue Officers--51-01 only) [DL01] Dependent Life Options

(n/a)

(n/a)

(n/a)

(n/a)

(n/a)

(n/a)

(n/a)

(n/a)

(n/a)

(n/a)

(n/a)

(n/a)

(n/a)

(n/a)

(n/a)

(n/a)

(n/a)

(n/a)

(n/a)

(n/a)

(n/a)

(n/a)

(n/a)

(n/a)

Employee Only $

Employee Only Sp $ 1,500 &/or Ch $ 1,000 Sp $ 5,000 &/or Ch $ 2,500 Sp $10,000 &/or Ch $ 5,000 Sp $25,000 &/or Ch $10,000 Child(ren) Only $10,000 Sp $50,000 &/or Ch $15,000 Sp $0 &/or Ch $15,000

$ $ $ $ $ $ $ $

-

0.20 0.60 1.20 4.00 0.75 5.26 1.13

24¢/$1,000

24¢/$1,000

$

-

$6.24/$1,000

$6.24/$1,000

$

26¢/$1,000 $ $ $ $ $ $ $ -

26¢/$1,000 $ 0.20 $ 0.60 $ 1.20 $ 4.00 $ 0.75 $ 5.26 $ 1.13

$ $ $ $ $ $ $ $

-

$6.76/$1,000 $ $ $ $ $ $ $ -

$6.76/$1,000 $ 5.20 $ 15.60 $ 31.20 $ 104.00 $ 19.50 $ 136.76 $ 29.38

$ $ $ $ $ $ $ $

5.20 15.60 31.20 104.00 19.50 136.76 29.38

Page 1 of 2

-

0.20 0.60 1.20 4.00 0.75 5.26 1.13

$

-

$

$ $ $ $ $ $ $ $

-

$ $ $ $ $ $ $ $

(n/a) (n/a)

-

24¢/$1,000

52¢/$1,000

$

-

5.20 15.60 31.20 104.00 19.50 136.76 29.38

26¢/$1,000 $ $ $ $ $ $ $ -

56¢/$1,000 $ 0.43 $ 1.30 $ 2.60 $ 8.67 $ 1.63 $ 11.40 $ 2.45

$ $ $ $ $ $ $ $

-

-

CIVIL SERVICE COMMISSION EMPLOYEE BENEFITS DIVISION

FY 2016-2017 GROUP INSURANCE PREMIUM RATES EFFECTIVE OCTOBER 9, 2016 For NERE & Bargaining Units: AFSCME, MCO, MSEA, UAW, SEIU Local 517M, Judicial Branch, and Non-Represented (Z60-Z89) PLAN NAME/CODE [HBCN] Blue Care Network

[HI00] Health Alliance Plan

[HMCL] McLaren Health Plan

[HMEX] Physicians Health Plan

[HPRI] Priority Health Plan

Option Employee Only Employee & Spouse Employee & Child (ren) Full Family Employee Only Employee & Spouse Employee & Child (ren) Full Family Employee Only Employee & Spouse Employee & Child (ren) Full Family Employee Only Employee & Spouse Employee & Child (ren) Full Family Employee Only Employee & Spouse Employee & Child (ren) Full Family

BIWEEKLY State

Employee $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

41.45 82.90 72.95 114.40 40.76 81.87 72.01 113.12 35.70 71.40 62.81 98.52 44.22 88.45 77.83 122.06 58.55 117.07 103.03 161.56

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

234.89 469.78 413.40 648.29 230.98 463.95 408.03 641.00 202.30 404.61 355.95 558.29 250.60 501.20 441.06 691.66 250.94 501.91 441.68 692.63

Total $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

276.34 552.68 486.35 762.69 271.74 545.82 480.04 754.12 238.00 476.01 418.76 656.81 294.82 589.65 518.89 813.72 309.49 618.98 544.71 854.19

ANNUAL State

Employee $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

1,077.71 2,155.45 1,896.79 2,974.52 1,059.79 2,128.70 1,872.14 2,941.06 928.21 1,856.45 1,633.18 2,561.56 1,149.82 2,299.64 2,023.67 3,173.49 1,522.18 3,043.83 2,678.69 4,200.60

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

1

6,107.05 12,214.19 10,748.45 16,855.60 6,005.45 12,062.62 10,608.82 16,665.98 5,259.83 10,519.87 9,254.66 14,515.52 6,515.66 13,031.32 11,467.45 17,983.11 6,524.54 13,049.61 11,483.59 18,008.40

BIWEEKLY - PART TIME 1 Employee State

Total $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

7,184.76 14,369.64 12,645.24 19,830.12 7,065.24 14,191.32 12,480.96 19,607.04 6,188.04 12,376.32 10,887.84 17,077.08 7,665.48 15,330.96 13,491.12 21,156.60 8,046.72 16,093.44 14,162.28 22,209.00

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

138.17 276.34 243.18 381.35 135.87 272.91 240.02 377.06 119.00 238.01 209.38 328.41 147.41 294.83 259.44 406.86 154.74 309.49 272.35 427.10

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

138.17 276.34 243.18 381.35 135.87 272.91 240.02 377.06 119.00 238.01 209.38 328.41 147.41 294.83 259.44 406.86 154.74 309.49 272.35 427.10

ANNUAL - PART TIME 1 Employee State $ 3,592.38 $ 7,184.82 $ 6,322.62 $ 9,915.06 $ 3,532.62 $ 7,095.66 $ 6,240.48 $ 9,803.52 $ 3,094.02 $ 6,188.16 $ 5,443.92 $ 8,538.54 $ 3,832.74 $ 7,665.48 $ 6,745.56 $ 10,578.30 $ 4,023.36 $ 8,046.72 $ 7,081.14 $ 11,104.50

Part-time employees hired on or after 1/1/2000 whose regular work schedule is 40 hours or less per biweekly pay period. Part-time employees hired on or before 12/30/1999 pay the full-time rate. Employees in the Catastrophic Health Plan will receive a $50 rebate with each paycheck beginning the first pay period after effective date of coverage. 3 Employees who opt out of Health coverage (because they have "primary" coverage through a non-State employee or non-State retired spouse) will receive a rebate identical to the Catastrophic Health Plan. 4 Employees who opt out of dental coverage (because they have “primary” coverage through a non-State employee or non-State retired spouse) will receive a rebate identical to the Preventive Dental Plan. 2

Page 2 of 2

$ 3,592.38 $ 7,184.82 $ 6,322.62 $ 9,915.06 $ 3,532.62 $ 7,095.66 $ 6,240.48 $ 9,803.52 $ 3,094.02 $ 6,188.16 $ 5,443.92 $ 8,538.54 $ 3,832.74 $ 7,665.48 $ 6,745.56 $ 10,578.30 $ 4,023.36 $ 8,046.72 $ 7,081.14 $ 11,104.50

MONTHLY Leave/LO COBRA $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

598.73 1,197.47 1,053.77 1,652.51 588.77 1,182.61 1,040.08 1,633.92 515.67 1,031.36 907.32 1,423.09 638.79 1,277.58 1,124.26 1,763.05 670.56 1,341.12 1,180.19 1,850.75

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

610.71 1,221.42 1,074.85 1,685.56 600.55 1,206.26 1,060.88 1,666.60 525.98 1,051.99 925.47 1,451.55 651.57 1,303.13 1,146.75 1,798.31 683.97 1,367.94 1,203.79 1,887.77