ORDER N0.28927
EMPLOYEE HEALTH BENEFITS PROGRAM AND AWARD OF BID.
Came to be heard this the 1st day of December 2004 with a motion made by
Commissioner Nicholson seconded by Commissioner Letz. The Court unanimously
approved by vote of 4-0-0 to award the employee health benefits program to Mutual of
Omaha in accordance with their proposal.
r~ .. , -.. - ,:. .. .
~iM..~i~~NAii~W ~ fii
Assume Farii(f E7cduct;bla is (2)q
Deductibles Assume NorrPPO is (2~
$0	$250 I	1.40?/0
~
$0	$500	4.900
$0 ~	$1,000 ~	9.1:0%
$0	$1,500	13,30%
$0	$2,000 '	..16:80%
$0 ~	$2,500	19.60%
$0 ~	$3,000	22.40%
Coinsurance		
100% PPO / 80'6 Non-PPO	90°do PPO 170% Noy-PPO	7.00%
100°~ PPO 180°~f, Non-PPO	80°~6 PPO 160% Nor>-PPO	12.60°i6
100% PPO / 80°i6 Non-PPO	70°~6 PPO / 50% NorrPPO	17.50°r6
100% PPO / 80°6 Non-PPO	50°~ PPO / 50% Non-PPO	2520%
90% PPO 1 TO°i6 Non-PPO	80°6 PPO / 60% Non-PPO	5.60%
90°~ PPO / 70°i6 Non-PPO	70°r6 PPO 150% Non-PPO	11.90°r6
! 90% PPO ! 70°i6 Non-PPO	50°~fo PPO / 50°~b Non-PPO	20.30°~
80% PPO / 60% Non-PPO	70°~6 PPO / 50% Non-PPO	6.30%
80% PPO 160°~ Non-PPO	50°~G PPO ! 50°~ Non-PPO	15.40°~
70% PPO / 50°/6 Non-PPO	50°~6 PPO 150°~ Non-PPO	9.80%
Out-of-Pocket 1 Assume iJeductible is not included in the out-of-pocket 8 Family is (?J~
3 Assume Non-PPO is (2)C)
1.40%
4.20%
9.10%
9.10°i6
9.80°r6
10.50%
14.00%
14.00%
2.10%
7.70%
7.70°~
7.70%
8.40%
11.90%
New Plan
2,500	3,000	1.00%
2 500	4,000	4.20°r6
2,$00	5 000	4:70%
3000	4,000	1.40%
3,000	5 000	1.00°i6
at
OfftC YSit Assume Lab & X is included, excludes Cat-scan's, MRrs and outpatient sugery	
Co-Pay $10	$15	1.00%
$10	$20	1.00°~
$i 0	$25	1.00°i6
$10	$30	1.00°/b
$10	$35	1.00%
$10	$40	1.00°~b
$15	$20	1.00%
$15	$25	1.00°i6
$15	$30	1.00%
$15	$35	1.00°h
$15	$40	1.00%
$20	$25	1.00%
$20	$30	1.00%
$20	$35	1.00%
$20	$40	1.00%
		
		
		
		
		
$35	$40	1.00%
$10, $20, $30 $35, or $40	Eliminate Co-pay, appy ded 8 Co-ins.	1.00%
$25	$30	1.00%
$25	$35	1.00%
$25	$40	1.00%
$30	$35	1.00%
$30	$40	1.00%
j Coinsurance			
	100% PPO ! 80°6 Non-PPO	90°6 PPO ! 70°i6 Non-PPO	TAO%
	100% PPO ! 80% Non-PPO	8096 PPO / 60°i6 Non-PPO	12.60%
	100% PPO / 80°i6 Non-PPO	70°~ PPO / 50°r6 Non-PPO	17.50°~
	100°~ PPO / 80°i6 Non-PPO	50°~6 PPO / 50°~ Non-PPO	2520%
			
	90°~ PPO / TO°.6 Non-PPO	80% PPO / 60% Non-PPO	5.60%
	90°~ PPO / 7D% Non-PPO	70°~ PPO ! 50% Non-PPO	11.90%
	90% PPO / 70% Non-PPO	50°~ PPO / 50°~ Non-PPO	20.30°~
			
	80% PPO / 60% Non-PPO	70% PPO / 50% Non-PPO	6.30°/a
	80% PPO / 60°/b Non-PPO	50°~6 PPO / 50°i6 Non-PPO	15.40°~6
			
	70% PPO / 50°~ Non-PPO 50°~6 PPO 150% Non-PPO 9.80%
,+ .. ~ ..
~~~mss~~~~~mw: ss~~ ~~a
Assume Family ~'`ecfuctible is (2~
Plan Design	Culrnen# Plan	New Plan	°~G 1~~Q
Out-of-Pocket Corrt'd $i 000	$1,540	:~°fa
$1000	$2 000	4~i~00~o
$1000	$2,500	5.60°i6
$1,000	$3 000	6;3~k%o
$1000	$4,000	x:80°!0
$1,000	$5,000	9:8:4°/a
$1500	$2,000	~.OO°~ .
$1,500	$2,500	1,00%
$1500	$3,000	1.40°i6
$1,500	$4,000	4.90%
$1,500	$5,000-	4:90%°
z o00	2,5ao	1.OO°~
2 000	3,000	1::40°~b
2,000	4 000	4,90a/o
2 000	5,000	4:~0°~6
		
		
		
		
		
4 000	5,000	1.00%
Faml at	Fami at 3	1.00°i5
Non-PPO at	N©n-PPO at 3X	1.00°~
Offic VSit Assume Lab & X-ray is included, excludes Cat-scan's, MRI's and outpatient sugary	
Co-Pay $10	$15	1.00°~
$10	$20	1.00°k
$i0	$25	1.00°fo
$10	$30	1.00°i6
$10	$35	1.00%
$10	$40	1.00%
$15	$20	1.00%
$15	$25	1.00%
$15	$30	1.00%
$15	$35	1.00%
$15	$40	1.00°r6
$20	$25	1.00%
$20	$30	1.00%
$20	$35	1.00°i6
$20	$40	1.00°i6
		
		
		
		
		
$35	$40	1.00%
$10, $20, $30 $35, or $40	Eliminate Co- , apply dad 8 Co-ins.	1.00%
2,500	3,000	1..00%
2 500	4,000	4.20°i6
2 500	5,000	4:20~i6
3,000	4,000	1.00%
3,000	5 000	1.00°~b
$25	$30	1.00%
$25	$35	1.00%
S25	$40	1.00%
$30	$35	1.00°r6
$30	$40	1.00%
Coinsuil ance			
	100% PPO / .80°16 Non-PPO	90°e6 PPO 170%o Non-PPO	7.00%
	100% PPO / 80°,6 Non-PPO	80•i6 PPO ! 60°~ Non-PPO	12.60°i6
	100% PPO / 80°i6 Non-PPO	70% PPO / 50 ib Non-PPO	17.50°!0
	100% PPO / 80% Non-PPO	50°i6 PPO / 50°~ Non-PPO	2520%
			
	90°i6 PPO f 70% Non-PPO	80°x6 PPO / 60°r6 Non-PPO	5,60°~
	90% PPO / 70°~b Non-PPO	70°~6 PPO / 50% Non-PPO	11.90%
	90% PPO / 70°~ Non-PPO	50°~f° PPO / 50°r6 Non-PPO	20.30°r6
			
	80% PPO / 60% Non-PPO	70°~ PPO / 50% Non-PPO	6.30%
	80% PPO / 60°r6 Non-PPO	50°~ PPO / 50°~ Non-PPO	15.40%
			
	70°x6 PPO ! 50% Non-PPO 50°~6 PPO 150% Non-PPO 9.80%
. =_~
Assume Fatuity Deductible is ~(2JQ
Plan Design	Current -Plan	New Plain	°~:ssitse-
Out-of-Pocket CoM'd $1000	$1,500	;4:9..4P.
$1000	$2 000	4:00~'~ ,
$1,000	$2 500	~J;~°/6
$1000	$3,000	.:6;30%:
$1000	.$4,000	9<80°~
$1,000	$5,000	9.80°k
$1500	$2,000	1.00°l0 .
$1,500	$2 500	1,00°fo
$1500	$3,000	i.40°i6
$1,500	$4,000	4:90°k
$t,500	$5,000	4.90%
2,000	2,580	i .00%
2 000	3,000	1:.40°~6
2,000	4 000	4,90a/o
2,000	5,000	4:90°i6
		
		
		
		
		
4,000	5 000	1.00%
Faml at	Fami at 3	1.00°/b
Non-PPO at	Non-PPO at 3X	1.00%
OffIC V~SIt Assume Lab 8 X-ray is included, excludes Cat-scan's, MRI's and outpatient sugary	
Co-Pay $10	$15	1.00%
$10	$20	1.00%
$10	$25	1.00°/Fo
$10	$30	1.00%
$10	$35	1.00°r6
$10	$40	1.00%
$15	$20	1.00%
$15	$25	1.00°i6
$15	$30	1,00%
$15	$35	1.00°k
$15	$40	1.00%
$20	$25	1.00%
$20	$30	1.00%
$20	$35	1.00%
$20	$40	1.00%
		
		
		
		
		
$35	$40	1.00%
$10, $20, $30 $35, Of $40	Eliminate Co-pay, apply clad 8 Co-ins.	1.00%
2,500	3,000	.1.00%
2500	4,000	4.20?/0
2,500	5 000	4:20°i6
3 000	4,000	1.00%
3,000	5 000	1.00%
$25	$30	1.00%
$25	$35	1.00°r6
$25	$40	1.00°i6
$30	$35	1.00%
$30	$40	1.00%
Coinsurance			
	100% PPO / 80°,6 Non-PPO	90°6 PPO / 70°/n Nor~PPO	7.00°~
	100% PPO / 80°d° Non-PPO	80'i6 PPO / 60°~ NotrPPO	12.60°r6
	i 00% PPO ! 80°i6 Non-PPO	70°r6 PPO / 50% Non-PPO	17.50%0
	100% PPO 180% NorrPPO	50% PPO / 50°i6 NOn-PPO	2520%
			
	90% PPO 170°r6 Non-PPO	80% PPO / 60% Non-PPO	5.60%
	90% PPO 170°i6 Non-PPO	70% PPO / 50% Non-PPO	11.90%
	90% PPO / 70°i6 Non-PPO	50°~b PPO / 5016 Non-PPO	20.30°ib
			
	80% PPO / 60°i6 Non-PPO	70°~ PPO / 50°~ Non-PPO	6.30%
	80% PPO / 60°ib Non-PPO	50°~fo PPO / 50% Non-PPO	15.40°~
			
	70% PPO / 50% Non-PPO 50°~ PPO / 50% Non-PPO 9.80%
Assume Fatuity Deductible is (2X}
New Pien
4.90°i6
2,500	3,000	1.00%
2,500	4,000	4.20°i6
2,300	5,000	4:20°~
3 000	4,000	1.Q0%
3,000	5,000	1.00°/b
Offic v5it Assume Lab & X is included, excludes Cat-scan's, MRI's and outpatient sugery	
CaPay $10	$15	1.00°6
$i 0	$20	1.00°i6
$10	$25	1.00%
$i 0	$30	1.00%
$10	$35	1.00°ib
$10	$40	1.00%
$15	$20	1.00%
$15	$25	1.00%
$15	$30	1.00%
$15	$35	1.00%
$15	$40	1.00°ib
$20	$25	1.00%
$20	$30	1.00%
$20	$35	1.00%
$20	$40	1.00%
		
		
		
		
		
$35	$40	1.00%
$10, $20, $30 $35, or $40	Eliminate Co- , apply ded 8 Co-ins.	1.00%
$25	$30	1.00%
$25	$35	1.00°i6
$25	$40	1.00°r6
$30	$35	1.00%
$30	$40	1.00%
Coinsurance			
	100% PPO 180°~6 Non-PPO	90°6 PPO 170°i6 Non-PPO	T.00%
	100% PPO ! 80°.6 Non-PPO	80'.b PPO / 60°i6 Non-PPO	12.60%
	100% PPO ! 80% Non-PPO	7a°i6 PPO 150% Non-PPO	17.50%
	100°~ PPO ! 80°~ Non-PPO	50°r6 PPO 150°~ Non-PPO	2520%
			
	90°~ PPO 170°k Non-PPO	80% PPO / 60°~ Non-PPO	5.60%
	90°~ PPO 170°i6 Non-PPO	70°~6 PPO 150% Non-PPO	11.90%
	90% PPO ! 70°~b Non-PPO	50°r6 PPO 150°~ Non-PPO	20.30°rb
			
	80% PPO ! 60°~ Non-PPO	70% PPO / 50°~ Non-PPO	6.30°~
	80% PPO 160% Non-PPO	50% PPO ! 50°~f° Non-PPO	15.40%
			
	70% PPO 150°~ Non-PPO 50°i6 PPO 150% Non-PPO 9.80%
~i~farl ~I~l+~/n~t'+i~~ ~l~ ~~~~~M11~ ~Ili~~fit~i~e'f'w~~.!
Assume Family l~rluctibk3 fs (2X)
Plan Design	Curnen# Ptan	New Plan	°~4_ .E~telpe-.
Out-of-Pocket Con!'d $1,0~	$1,5Q0	~;9Q°e6
$1400	$2 000	4:rJt1%
$1,400	$2 500	5,~°b
$1,OD0	$3,0~	6;3D~o
$1,000	$4,000	x:80% .
$1,000	$5,000	9.80%
$1500	$2,000	1.t}000i6 .
$1,500	$2 500	1 AQ%`i
$1,540	$3,000	1.40°r6
$1,504	$4,000	4.90%
$1,540	$5,000	4,90%°
2,000	2,500	1.00%
2 000	3,000	1.:40°ib
2,000	4 000	4,90ai6
2,040	5,000	~:~lo°~
		
		
		
		
		
4,400	5 000	1.00%
Famt at	Fami at 3	1.00°ib
Non-PPO at	Non-PPO at 3X	1.00°~
OffIC VSit Assume Lab & X 'ts included, excludes Cat-scan's, MRI's and outpatient sugery	
Co-Pay $10	$15	1.00°i6
$10	$20	1.00%
$i 0	$25	1.00%
$10	$30	1.00°i6
$10	$35	1.00°i6
$10	$40	1.00%
$15	$20	1.00°i6
$15	$25	1.00%
$15	$30	1.00%
$15	$35	1.00%
$15	$40	1.00°i6
$20	$25	1.00%
$20	$30	1.00%
$20	$35	1.b0%
$20	$40	1 AO°r6
		
		
		
		
		
$35	$40	1.00%
$10, $20, $34 $35, or $40	Eliminate Co-pay, apply ded & Co-ins.	1.00%
2,500	3,000	1.00%
2,500	4,000	420°i6
2,500	5 000	4:20°i6
3,000	4,000	1.OD%
3,000	5,000	1.00°~6
$25	$30	1.00%
$25	$35	1.00%
$25	$40	1.00°i6
$30	$35	1.00°r6
$30	$40	1.00%
Coinsurance			
	100% PPO / 8t)% Non-PPO	90°6 PPO / 70% Non-PPO	T.00°i6
	100% PPO / 80°i6 Non-PPO	80°~ PPO / 60% Non-PPO	12.60°~
	100% PPO ! 80% Non-PPO	70°i6 PPO 150% Non-PPO	17.50°!0
	100°~ PPO 180% Non-PPO	50°~ PPO 150°k Non-PPO	2520%
			
	90% PPO ! 70% Non-PPO	80°i6 PPO J 60% Non-PPO	5,60%
	90% PPO / 70°i6 Non-PPO	70°i6 PPO 150% Non-PPO	11.90%
	90% PPO / 70°~6 Non-PPO	50°~fo PPO / 5096 Non-PPO	20.30%
			
	80% PPO / 60°~ Non-PPO	70°~ PPO ! 50°r6 Non-PPO	6.30°~
	80% PPO 160°/b Non-PPO	50°~6 PPO / 50% Non-PPO	15.40%
			
	70% PPO / 50°r6 Non-PPO 50°do PPO / 50% Non-PPO 9.80%
Assume Famiry Deductible Is (2Xj
Plan Design Current Plan	New Plan	°%.E~~e
Out-of-Pocket Cont'd $i 000	$15Q0	~ 4:9Q°~_ .
$1000	$2,000	4~Q°b
$1 000	$2 500	5.60%
$1000	$3,000	$;30~b .
$1,000	.$4.000	- 9:80%
$1,000	$5,000	9.80°!0
$1500	$2,000	1.~0%
$1,500	$2,500	1.00Q,6
$1 500	$3,000	1.40°ib
$1,500	$4 000	4.90°i6
$1,500	$5 000	4:90°ib
2,000	2,500	1..00%
2 000	3,000	1:.4©°i6
2,000	4,000	4;90ai6
2,000	5,000	4.90°r6
		
		
		
		
		
4,000	5 000	1.00%
Famt at	Fami at 3	1.00°i6
Non-PPO at	Non-PPO at 3X	1.00°~
OffiC ViiSlt Assume Lab & X-ray is included, excludes Cat-scan's, MRrs and outpatient sugery	
Co-Pay $10	$15	1.00°i6
$10	$20	1.00%
$10	$25	1.00%
$10	$30	1.04°i6
$10 -	$35	1.00°i6
$10	$40	1.00°i6
$15	$20	1.00%
$15	$25	1.00%
$15	$30	1.00%
$15	$35	1.00°h
$15	$40	1.00%
$20	$25	1.00%
$20	$30	1.00%
$20	$35	1.00%
$20	$40	1.00%
		
		
		
		
		
$35	$40	1.00%
$10, $20, $30 $35, or $40	Eliminate Co- ,apply ded 8 Co-ins.	1.00%
2,500	3,000	1.00%
2500	4,000	420%
2,500	5 000	4:20°i6
3 000	4,000	1.00%
3,000	5 000	1.00%
$25	$30	1.00%
$25	$35	1.00%
$25	$40	1.00%
$30	$35	1.00°r6
$30	$40	1.00%
._ z ~~ . .
Assume Fatuity Deducb'ble is (2)C)
DeductiblF~s Assume Non-PPO is (2)q
$0	$250	1.40%
$o	$500	4.9a°~
$o	$1,OOO	9.1~°l0
$0	$1,500	13,30%
$(3	$2,000	16.$0°i6
$0	$2,500	1$.60%
$0	$3,000	22.40%
Coinsurance			
	100°~ PPO /80°,6 Non-PPO	90°6 PPO 170% Non-PPO	7A0%
	100% PPO / 80% Non-PPO	80.6 PPO / 60% Non-PPO	12.60°~6
	100% PPO / 80°~ Non-PPO	70°i6 PPO / 50% Noo-PPO	17.50°~b
	100°~ PPO 180% Non-PPO	50°i6 PPO / 50°r6 Non-PPO	2520%
			
	90% PPO / 70°~ Non-PPO	80°6 PPO / 60% Non-PPO	5.60%
	90% PPO 170°~6 Non-PPO	70% PPO / 50% Non-PPO	11.90°6
	90°i6 PPO ! 70°i6 Non-PPO	50% PPO / 50°ib Non-PPO	20.30°i6
			
	80% PPO / 60% Non-PPO	70% PPO / 50% Non-PPO	6.30°~b
	80% PPO / 60% Non-PPO	50°~ PPO / 50% Non-PPO	15.40°~
			
	70% PPO / 50% Non-PPO 50°~6 PPO 150°i6 Non-PPO 9.80%
Pian Design	Current Plan	New Plan	,°~.f~e
Out-of-Pocket Cont'd $i 000	$1,500	_ , :~a°
$1 000	00	~.9E11°~6
$1 000	$2.500	5:~0'i6
$1 000	$3,000	8;3E3~6
$1000	.$4,000	x:80% .
$1,000	$5,000	'9'.80%
$1 500	$2 000	1.~0°l0 ,
$1,500	$2,500	1,00°i6
$1.500	$3,000	1.40°i6
$1,300	$4,000	4:90%
$1,500	$5,000	4:90%°
2,000	2 500	1.00%
2 000	3,000	1:4©°i6
2,000	4,000	4.90%
2,000	5,080	4:00°i6
		
		
		
		
		
4,000	5,000	1.00°i6
Faml at	Fami at 3	t.00°/b
Non-PPO at	Non-PPO at 3X	1.00°~
OffiC ViSlt Assume Lab & X is included, excludes Cat scan's, Mgrs and outpatient sugery	
Co-Pay $10	$15	1.00°~6
$10	$20	1.00%
$10	$25	1.00%
$10	$30	1.00%
$10	$35	1.00°i6
$10	$40	1.00°~
$15	$20	1.00%
$15	$25	1.00%
$15	$30	1.00%
$15	$35	1.00%
$15	$40	1.00%
$20	$25	1.00%
$20	$30	1.00%
$20	$35	1.00°i6
$20	$40	1.00%
		
		
		
		
		
$35	$40	1.00%
$10, $20, $30 $35, or $40	Eliminate Co-pay, appy ded 8 Co-ins.	1.00%
2,500	3,000	.1.00%
2,500	4,000	4.211"i6
2,500	5,000	4:20°i6
3 000	4,000	1.00%
3,000	5 008	1.00°i6
$25	$30	1.00%
$25	$35	1.00%
$25	$40	1.00°~
$30	$35	1.00%
$30	$40	1.00%
Coinsurance		
' 100°~ PPO ! 80°~6 Non-PPO	90°~ PPO / 70°ib Non-PPO	T.00°i6
100°ib PPO 180°~6 NorrPPO	80% PPO / 60% Non-PPO	12.G0°~6
~+ 100°~ PPO 180% Non-PPO	70°i6 PPO / 5096 Non-PPO	17.50°,r6
100% PPO / 80% Non-PPO	50°~ PPO / 50°~ Non-PPO	2520°rb
'. 90% PPO J 7i)°r6 Non-PPO	80°6 PPO / 60°~ Non-PPO	5,60%
90°~ PPO / 70°i6 Non-PPO	70°~6 PPO / 50°k Non-PPO	11.90°r6
90% PPO / 70% Non-PPO	50°~ PPO / 50°r6 Non-PPO	20.30°r6
! 80% PPO / 60% Non-PPO	70°/O PPO / 50°~ Non-PPO	6.30°~
I I 80% PPO / 60°~ Non-PPO	50D~b PPO / 50°~ NorrPPO	15.40%
70% PPO / 50% Non-PPO	50°~ PPO / 50% Non-PPO	9.80%
Assume Deductible is not included in the out-of-pocket 8 Family is (2JC)
Assume Non-PPO is (2~
9.10°~
9.10°~
7.70%
7.70°i6
_.. ~.
~~
Assume Family Deductible is (2)C)
New Plan
2,500	3,000	i.00%
2500	4,000	4.20%
2 500	5,000	4:20%
3 000	4,000	1.00%
3,000	5 000	1.00°~b
a
at
OtfiC YSit Assume Lab 8 X-ray is included, excludes Cat-scan's, MRYs and outpatient sugery	
Co-Pay $10	$15	1.0.0°ib
$10	$20	1.00%
$i0	$25	1.00%
$10	$30	1.Q0°~
$10	$35	1.00°~6
$10	$40	1.00%
$15	$20	1.00°i6
$15	$25	1.00%
$15	$30	1.00%
$15	$35	1.00%
$15	$40	1.00%
$20	$25	1.00%
$20	$30	1.00°i6
$20	$35	1.00%
$20	$40	1.00%
		
		
		
		
		
$35	$40	1.00%
$10, $20, $30 $35, or $40	Eliminate Co-pay, apply ded 8 Co-ins.	1.00%
$25	$30	1.00%
$25	$35	1.00°r6
$25	$40	1.00°i6
$30	$35	1.00°r6
$30	$40	1.00%
Coinsurance			
	100% PPO / 80°6 Non-PPO	90°6 PPO / 70°ib Not~PPO	7.00°i6
	100°i6 PPO / 80°~6 Non-PPO	80% PPO / 60°~ Non-PPO	12.60%
	100°~ PPO / 80°i6 Non-PPO	70°i6 PPO / 50% NotrPPO	17.50%
	100% PPO / 80°~b Non-PPO	50°~ PPO / 50% Non-PPO	2520%
			
	90% PPO 170% Noire-PPO	80°1b PPO / 60% Non-PPO	5.60%
	90% PPO / 70°i6 Non-PPO	70°i6 PPO 150°k Non-PPO	11.90%
	90% PPO / 70% Non-PPO	50°~6 PPO / 50% Non-PPO	20.30°~6
			
i	80% PPO / 60% Non-PPO	70% PPO / 50°~ Non-PPO	6.30°~6
	80% PPO / 60°~ Non-PPO	50°i6 PPO 150°r6 Non-PPO	15.40°k
			
1	70°i6 PPO / 50°16 Non-PPO 50°~6 PPO / 50% Non-PPO 9.80%
Assume Deductible is not included in the out-0f-pocket 8 Family is (2~
Assume Non-PPO is (2)q
$0	$500	1.40%
$0	$1,000	4.20%
$0	$1,500	9.10%
$0	$2 000	9.10°i6
$0	$2,500	9.80%
$0	$3,000	10.50%
$0	$4,000	14.00°~
$0	$5,000	14.00%
		
$500	$1 000	2.10°~
$500	$1,500	7.70%
$500	$2,000	7.70°~
$500	$2 500	7.70%
$500	$3,000	8.40%
$500	$4,000	11.90°k
~HN~:,..~:..:.E.~
Assume Family Deductible is (ZX)
Plan Design Current Plan	New Plan	% se-
Out-of-Pocket Corrt'd $1 000	$1,5p0	,x;90°~'i`
$1 000	$2,000	~:°~°
$i 000	$2,500	5.~°
$1,000	$3,000	8,3Q',/o .
$1000	$4,000	x:80°~
$1,000	$5,000	9:€~0°10
$1500	$2 000	1.00% .
$1,500	$2,500	1,00°~
$1 500	$3 000	1.40°ib
$1,500	$4,000	4:90°i6
$1,500	$5 000	4:90"~6
2 000	2 500	1.:00%
2 000	3,000	1.4©°i6
2,800	4 000	4.90°i6
2,800	5,000	4.90°i6
		
		
		
		
		
4,800	5 000	1.00°i6
Fami at	Fami at 3	t.00°/b
Non-PPO at	Non-PPO at 3	1.00°~
Off"IC Visit Assume Lab & X is included, excludes Cat-scan's, MRrs and outpatient suge	
Co-Pay $10	$15	1.08°ib
$10	$20	t .00%
$f0	$25	t.00%
$10	$30	1.00°r6
$10 -	$35	t.00%
$10	$40	1.00°i6
$15	$20	1.00%
$15	$25	1.00%
$15	$30	1.00%
$15	$35	1.00%
$15	$40	1.00°r6
$20	$25	1.00%
$20	$30	1.00%
$20	$35	1.00°i6
$20	$40	1 AO%
		
		
		
		
		
$35	$40	1.00%
$10, $20, $30 $35, or $40	Eliminate Co-pay, appry ded 8 Co-ins.	1.00%
2,500	3,000	.1.00%
2 500	4,000	4.20%°
2,500	5,000	4:20°i6
3 000	4,000	1.00%
3,000	5 000	1.00%
$25	$30	1.00%
$25	$35	1.00%
$25	$40	1.00%
$30	$35	1.00°~
$30	$40	1.00%
Gary R. Looney, REBC
110 E Crockett
San Antonio, Texas 78205
Phone: (210) 712-2161 Fax: (210) 727-~iNG
FINAL RECOMMENDATION REPORT
Date :12/1 /2004
TO :Kerr County Commissioners Court
From :Gary Looney REBC
RE : RFP Analysis -Medical and Life Insurance Plans
Dear Sirs:
1 have completed my review of the proposals submitted to Kerr County for Third Party
Administrative Services, Medical Aggregate and Specific Stop Loss Insurance and Group Term
Life Insurance. There were two objectives of the bid request. The first objective was to examine
the cost of the current plan of benefits in relationship to the proposals received and the renewal
offered by the current carrier to determine if the current plan was cost effective. The second
objective was to determine if the current plan of benefits should be changed. If the plan were to
be changed, what plan of benefits would be offered to employees and what would the cost
differential be to the County. Contingent with the two objectives, it was also necessary to
examine the services of the current Third Party Administrator.
Current:
A summary of the current plan of benefits offered to employees is included under
Tab 1. The benefit plan offered to employees and paid for by Kerr County is plan A. Plan A is
selected by 63% of your employees with 29% in Plan B and 8% in Plan C. Currently the County
pays 100% of the employee cost for Plan A with premium credit offered to employees who select
Plans B or C.
A bid summary sheet assuming the current plan of benefits as described is included under
Tab 2.
The current stop loss contract is a 12/12 contract. For a Gaim to be eligible to be paid the claim
must be incurred and paid within a 12 month period. The proposals I have illustrated are 15/12
contracts. Claims incurred in the last 3 months of the plan year will be included in the specific
and aggregate contracts for reimbursement for 12 months of the next plan year.
Optional Plans:
I have included an Optional Plan utilizing a Health Reimbursement Arrangement for your
employees. The plan design is intended to closely match Plan A.
These are a few of the primary differences in the new plan design:
1. The deductible has been increased from $400 to $1,000.
2. The Physician Office Co-pay has been increased to $30.00
3. The Maximum Out-of-Pocket cost has increased from $2,400 to $3,000.
4. The $300 supplemental Accident benefit is removed
5. Physician office Co-pays include x-ray, lab, and in office surgery performed in
physicians office. Lab services performed by an in network Lab are not subject to
deductible.
December 1, 2004 FINAL RECOMMENDATION REPORT Page 2 of 2
6. A Health Reimbursement Arrangement is added to provide each covered
employee and covered dependent a $ 600 per year reimbursement for medical
expenses eligible to be paid under the medical plan. The reimbursement
arrangement will allow reimbursements for eligible deductible expenses,
coinsurance expenses, and other out of pocket expenses eligible for benefit under
the plan. It does not include reimbursement for co-payments made at the doctors'
office or for co-payments made for prescription drugs.
7. The year end carry over for unused deductibles is eliminated.
A "Sample Plan" benefit summary is included under Tab 3.
The pricing model for the Optional plan is included under Tab 4. The projected plan costs are
estimated based on the proposals submitted.
A "Sample" lower priced optional plan is shown under Tab 5. The lesser benefit plan would be
made available to employees who wish to have a lower premium cost. This option has
substantially reduced benefits. The premium cost is shown under Tab 4. Since the County is
funding the plan with greater benefits a credit is generated for those who wish to participate in
the lesser benefit plan. I do not recommend the lesser benefit plan to be provided as the County
sponsored plan.
The life insurance benefits are at a very low level for each employee ($10,000). I recommend an
increase in the basic life insurance coverage paid by the County. The current rate and bid results
are shown on the spreadsheet under Tab 6.
As a result of a rate decrease for the life insurance plan, it is possible to increase each employee
to $20,000 of life insurance with a net result of an increase in premium of approximately $4,000
per year.
It is my recommendation:
1. That the County change the medical plan design and adopt a Health Reimbursement
Arrangement. The intent of the plan design is to provide additional benefit to those
employees who are prudent in the utilization of the medical benefit plan.
2. That the County provide an optional plan for those employees who wish to have a plan
with lesser benefits at a reduced cost.
3. That the County increase the basic Life and Accidental Death and Dismemberment
policy to $20,000 per active employee.
4. That the County select Mutual of Omaha as the carrier for 2005.
sincerely appreciate your confidence in our efforts to provide you and your employees with the
very best in employee benefits.
~G ~~--,~
Gary R Looney REBc
Risk Management Consultant

IOrRR COUNTY
SCHEDULE OF BENEFITS
SELF FUNDED	IIV NEITVORK	NON-NETWORK
TYPE OF SERVICE	PROVIDERS	PROVIDERS
Calendar Year Benefit	Plan A	Plan B	flan C	Ptah A	Plan B	Plan C
Calendar year deductible						
Family Maximum Unit - 3 Persons	$400	$750	$1,200	$800	$1500	52,000
Last 3 month carry-0ver	$1,200	52,250	$3,600	$2,400	84,500	$6,000
Coinsurance Maximum	$2,000	$3,000	$4,000	$4,000	85,000	88,000
Family Maximum Unit - 3 Person	$6,000	$9,000	'512,000	$12,000	$15,000	$24,000
Total Out of Pocket Maximum	$2,400	$3,750	$5,200	$4,800	$6,500	$10,000
Family Maximum Unit - 3 Person	$7,200	$ 11,250	'515,600	14,400	$19,500	$30,000
Lifetime Maaaimuaa Per Person	;1,000,000
		CO-INSURANCE	CO-INSLTItANCE	
BEIVEFIT5	DED	PPO	l!ION PPO	LIMITATIONS
Physician Office Visit				excludes x-ray, lab and
	Waived	$10 co-pay Plan A	820 co-pay Plan A	surgery done at the time oC
(For Kerrville				the office visit. Co-Pay
Providers Only)	Waived	$20 co-pay Plan B	$30 co-pay Plan B	will only apply to CPT
				codes 99201-992 i5 8c
	Waived	$30 co-pay Plan C	$40 ca-pay Plan C	99241-99245
				excludes x-ray, lal~ and
Physician Once Vsit	tNaived	$2fl co-pay Pia„ A	$20 co-pay Plan A	surgery done at the time of
				the ofTicc visit. Co-Pay
(For Outside•#;errville	Waived	$20,co-pay Plari B•• •	$30 co-pay Plan•B	will on1Y apply to CPT
Providers Only)				codes 99201-99215 &
•	Waived	$30 co-pay Plan C	$40 co-pay Plan C	99241-99245
		PLAN	PLAN	PLAN	PLAN	PLAN	PLAN	
OTHER BENEFITS	DED	A	B	C	A	B	C	IIMTTATION5
Physician Inpatient	Applies	90°/n	$0%	80%	70%	60%	60%	
Physician Surgery	Applies	90%	80%	80%	70%	60%	60%	*For Inpatient
Anesthesiology	Applies	90%	80%	80%	70%	60%	60%	*For Inpatient
Allergy testing, scrum &								
injections	Appiics	90%	80%	$0%	70%	60%	60%	
X-ray, Radiologist	Applies	90%	80%	80%	70%	60%	60%	
l,ab, Pathologist	Applies	70°/0	70%	70%	70%	60°/o	GO%	
1'ref~rrcd l..ab - Lal~One	~~~aived	L00°~o	100°io	i00°'o	!~/.~	N/A	N/A	
								After x300 max per
								accident subject to the
Accidental Cnjuries	Waived	100%	100%	100%	N/A	N/A	N/A	ded aad co-insurance
Kerr County flan Uocument January 1, 2003 5
	CO-INSURANCE	CO-IIVSUItANCE	
	rPO	IvoN.PPo	
		PLAN	PLAN	PLAN	PLAN	PLAN	PLAN	
BENEFITS	DED	A	B	C	A	B	C	LIMITATIONS
								Services do not include
Outpatient Services	Appliu	90%	80%	80°/.	70%	60%	60%	outpatient surgery
								All services related to the
								outpatient surgical
								procedure to include
								Anesthesia, Lab/Path, xray,
Outpatient Surgery	waived	90%	80%	80%	70%	60%	60%	etc.
								Lifetime max for all levels
Home Health Care Services	Applies	90%	80%	80%	70%	60%	60%	$10,000
								Limited to Facility's
								semiprivate room rate with
								7 days of the s 3 day
Skilled Nursing Facility	Applies	90%	80%	80%	70%	60%	60%	hospital stay
								life time max for all levels
Hospice Care	Applies	90%	80%	80%	70%	60%	60%	$20,000
Spinal Manipulation								$1,500 calendar year max
Chiropractic	Applies	90%	80%	80%	70%	60%	60%	for all levels
								$1,500 calendar year max
Physical Therapy	Applies	90%	80%	80%	70%	60%	60%	for all levels
'								Medical necessity must be
Speech Therapy	Applies	90%	80%	80%	70%	60%	60%	documented for all levels
								For emergency transport
Ambulance Services	Applies	90%	80%	80%	70°10	60%	60%	to a covered fatality
								If New Born not added in
Routine New Born Care								first 31 days coverage will
{Inpatient Nursery)	Waived	90%	80%	80%	70%	60%	60%	terminate
								If New Born not added in
New Born Cart {Sick Baby)								first 31 days coverage will
(Inpatient Nursery}	Applies	90%	80%	80%	70%	60%	60%	tctininatc
Maternity Benefits								
Initial otlice visit	Applies							
Delivery related fges	Applies							Dependent Daughters arc
Other OB related fees	Applies	90%	80%	80°10	70%	60%	60%	not covered
Preventive Care								Services include but not
Calendar Ycar Max of								limited to, Office visits,
8200 (Adult, Well Baby,								pap smear, mammogram,
Well Chitd)								prostate screening,
(Does not include physicals								Routine GYN exams,
for tamp, school, pre-								routine x-ray/lab,
employment, and school								immunizations, flu shots,
slx~nsorcd sports activity)								routine eye and hearing
	Waived	100%	100%	!00%	N/A	N/A	N/A	exams.
6 Kcrr County Ptan Documcm ,f anuary 1, 2003
	CO-INSURANCE	CO-ZNSCTItANCE	
	i1'PO	NON~PO	

BENEFITS	
DED	PZ.AN
A	PLAN
B	PLAN
C	PLAN
A	PLAN
B	PLAN
C	
LIMITATIONS
Durable Medical								Requires doctor's
Equipment	Applies	90%	80%	80%	70%	60%	60%	prescription
Hospital Inpatient								Per-certification is required
ASP room & board limit	Applies	90%	80%	80%	70°10	60%	60%	$500 penalty if none
Emergenry Room &								Treatment for a medical
Physician	Applies	90%	80%	80%	70%	60%	60%	emergenry
Mental Disorders								
inpatient - 7 days per	Applies	50%	50%	50%	50%	50%	50%	
calendar year max								Co-insurance for Inpatient
								or Outpatient does not
Outpatient - 20 visits per								apply towards the out-of
calendar year max	Applies	50%	50%	50%	50%	50%	50%	pocket maximum
		See Definition of "Serious
		Mental Illness in the Plan
Serious Mental Illness	same ss any other illness	Document
Substance Abuse							
Inpatient - 7 days per							
calendar year max	Applies	50%	50%	50% 50%	50%	50%	Co-insurance for Inpatient
							or Outpatient dots not
Outpatient - 20 visits per							apply towards the out-of-
calendar year max	Applies	50%	50%	50% 50%	50%	50%	pocket maximum
							Removal of partial or fully
Dental Oral Surgtry	Waived	90%	80%	80% N/A	N/A	N/A	impacted teeth
All other Professional							See details under
Services	Applies	90%	80%	80% 70°/a	60%	60%	"Covered Expenses"
PRESCRIPTION DRUG BENEFIT
PLAN A
Pharmacy option
Co-payment, per Prescription •
Multiplcsourcc Brand .................................................................. 835.00
Single Source Brand ................................................... ............. 520.00
Generic Drugs ........................................................................ f 5.00
Mail Order (90 Day)
Co-payment, per Prescription
A{uitiplcsourcc Brand .................................................................. S40.00
Single Source Br<tnd ................................................................... 525.00
Generic Drugs ........................................................................ S10.00
Kerr County Plan nceumenl January 1, 2003
PRESCRIPTION DRUG BI~.NEFIT
PIfAN B & C
PLAN B AND C
Pharmacy Optioa
Co-payment, per Prescription
Multiple source Brand ................................................................. ;45.00
Single Source Brand ..........................:................ ..............
......... 7130.00
Generic Drugs ........................................................................ =10.00
Maul Order (90 Day)
Co-payment, per Prescription
Multiptesource Brand .................................................................. 850.00
Single Source Brand ................................................................... =35.00
Generic Drugs ........................................................................ 215.00
HUMAN ORGAN AND TISSUE TRANSPLANT BENEFIT
lifcdmc maximum ..... ................................................................... 3250,000
Plan A co-insurance in network ............................................................................. 90%
Plan A co-insurance out of network ............................................_............................. 70%
Plan B StB co-insurance in net„'ork ......................................................................... 80%
Plan B & C co-insurance out of network ................................ . . .................................... 60%
Maximum payable for:
Transportation, Lodging, and Mca1s ............................................................... 810,000
Maximum per day for lodging and meals ...... . .................................................... 8 200
Pre-Authorization $eguired for Transplant Evaluation -Expenses incurred in connection a~th the evaluation of a Covcrcd
Participant for an~• human organ or tissue transplant will be covered, but onl~• after referral to and pre-authorization through Employee
Benefit Administrators, Inc.(EBA), the TPA Contract Administrator has occurred. The Covered Participant or his physician should
contact EBA, Inc. for pre-authorization of an evaluation for transplant prior to the: referral to a transplant physician. EBA will assign
Interlink Health Services as the case manager to work with the Covered Participant closely through out the transplant process.
Pre-Authorizattion Requirement for TransalaatProcedure-Expenses incurred in connection with any organ or tissue transplant
listed in this provision will be covered subject to referral to and pre-authorization by the Plan Administrator's authorized review specialist,
Interlink Health Services. Transplant coverage is offered under this plan through a preferred provider networkofspatialized professionals
and facilities. Coverage is also provided for Transplant services obtained outside of the preferred network at a reduced benefit Icvel.
As soon as reasonably possible, but in no event more than ten (] 0) days after a Covered Member's attending physician has indicated that
the Covered Member is a potential candidate for a transplant, the Covered IVlember or his Physician should contact the Plan
Administrator for referral to the net„•orl:'s medical revic~r specialist for evaluation :tnd pre-authorization. A comprehensive treatment
plan must be developed for this plan's medical review, and must include such inforr.~ation as diagnosis, the nature of the transplant, the
setting of the procedure, (i.e, name and address of the hospital), any secondary rriedical complications, a five yea prognosis, two (2)
qualified opinions confirming the need for the procedure, as wee as a description and the estimated cost of the proposed treatment. (One
or both confirming Physician's statements may also be required. The Covered Member may provide a comprehensive treatment Man
indcpcndenl of the preft:rrcd provider network, but this will (~c subject to medical al~aropriateness review and may result in non-network
i~cnefil coverage.
H t~Ccrr C:~~umy flan Ih~c~uncau ,January I, 2003
All potential transplant cases wil[ be assessed for their appropriateness for Large Case Management.
Covered Traast-lant Expettuses
The term "covered acpensu"with respect to transplanu includes the reasonable and customary expenses for services and supplies which
are covered under this plan (or which arc spedfically identified as covered Duty under this provision) and which are medically necessary
and appropriate to the Transplant.
(A) Charges incurred in the evaluation, screening, and candidacy determination process.
(B) Gitatgcs incurred for organ transplantation.
(C) Charges for organ procurement, including donor expenses not covered under the donor's.plan of benefiu.
• Coverage for organ procurement from anon-living donor will be provided for costs involved in removing,
preserving and transporting the organ.
• Charges for organ procurement for a living donor will be provided for the cost involved in screening the
potential donor, transporting the donor to and from the site of'the transplant, as well as for medical expenses
associated with removal of the donated organ and the medical services provided to the donor in the interim
and for follow up care.
)f the transplant procedure is a bone marrow transplant, coverage will be provided for the cost involved in the
removal of the patient's bone marrow (autologous) or donated marrow (allogcncic). Coverage wil! also be
provided for search charges to identify and unrelated match, treatment and storage costs of the marrow, to
the time of reinfusion. (I'he harvesting of the marrow need not be performed within the transplant benefit
period)
(D) Charges incurred for follow up care, 'tncluding immuno-supptrssant therapy.
(E) Charges for transportation to and from the site of the covered organ transplant procedure for the recipient and one
• other individuals. In addition, all reasonable and necessary lodging and meal expenses incurred during the transplant
brnefit period will be covered up to a maximum of $10,000.00 per transplant period.
Re-transolaatatdoa
Re-transplantation will be covered up to two re-transplants, for a total of three transplants per person, per lifetime. Each transplant and
re-transplant will have a new benefit period and a new maximum lifetime benefit.
DEFINITIONS
Covered Traasnlaat Procedures-Covered Transplant Procedures are any of the following adul t or pediatric human organ and tissue
transplant procedures determined to be Medically Necessary:
Heart Lung Simultaneous Heart/Luung Bone Marrow
liver Kidney Simultaneous Pancreas/Kidney
Transplant NetworkProviders- Transplant Network Providers arc those Hospitals and Physicians that arc under contract with the
Plan to provide Transplant Services. Benefits Paid are enhanced when the Covered Partidpant uses Transplant l~rctworlt Pro~~ders.
Non Transplant Network Providers- Non-Transplant Network Providers are those Hospitals and Physicians that arc not under
contrau with the Plan to provide Transplant Services and have been approved by lnterlink Services. Transplant Services that have been
approved for anon-transplant faulity or by anon-transplant provider will be eligible for benefits under this plan at a reduced rate.
Transplant Services- Transplant Services means any services directly related to a Covered Transplant Procedure including, but not
limited to, inpatient and outpatient Hospital services, physician services for diagnosis, treatment and surgery for a Covered Transplant
Procedure, diagnostic services, and procurement of an organ or tissue, including services provided to a living donor of an organ or tissue
for procurement of an organ or tissue. Transplant Services also includes but is not limited to, durable medical equipment rental outside
of the hospital, prescription drugs including immunosuppressives; surgical suppiic•s and dressings, and home health care.
BENEFITS PAID
Transplant Network Provider- Covered expenses will be reimbursed at the stated co-insurance rates listrd abo~~r fur Tr;uispi:uu
Services provided through a Transplant Network Provider with respect to the type of Covered Transpi.~utt Procedure performed. 100°.'0
of reasonable and necessary transportation, lodging, and meal costs for the Covered Participant and one significant other arc covered for
travel re{aced to the initial evaluation prior to transplant, and subscyucnt admissic•n for a Covered Transplant Procedure performed by
a Transplant Network Provider. If the recipient is a minor, transportation cosu for two companions may be covered.
Kerr County Plan Document January 1, 2!103
iV/ 11./ VY 11. VV ywiv ww. ./vvV v[iaav N va.a a.. .u ~r -
Non-TransplantNetworkProvider-90%ofcoveredchargcs (subjectto reasonable andcustomary) forTransplantServices provided
through aNon-Transplant Network Provider with respect to the type of Covered Transplar-t Procedure performed that have been
approved by Intcrlink Health Services. 60% otcovered charges (subject to reasonable and customary} for Transplant Services provided
through a Non•Transplant Network Provider not approved by Interlink Health Services. Transportation, lodging, and meal costs for
travel related to the initial evaluation, ongoing evaluatioru prior to transplant and subsequent admission for a Covered Transplant
Procedure performed by aNon-Transplant Network Provider arc not covered under this Plan.
MAII'-IIMZJMS
Transportation. Lodging. and Meals-;10,000.00 for ail travel, lodging, and meals related to Transplant Services performed by
a Transplant Network Provider. $200.00 per day maximum for lodging and meals. Itemized receipts in a form satisfactory to the TPA
Contract Administrator must be submitted by the Covered Participant when claims are filtd for reimbursement.
Organ and/or Tissue Procurement- The payments for procurement expenses for a donor organ are covered at i 00% when the
Covered Transplant Procedure is performed by a Transplant Network Provider. H•~wever, the payments for procurement expenses for
bone marrow associated with allogeneic bone marrow transplant may not exceed $10,000.00.
The payment for procurement expenses for a donor organ or tissue when the Covered Transplant Procedure is performed by a Transplant
Network Provider orNon-Transplant Network Provider arc covered at l00% but may not exceed the following Maximums, per Covered
Procedure:
Lung ;10,000.00 Heart/Lung ;10,000.00
Heart !!10,000.00 Kidnry/Pancreas ;10,000.00
Liver ;10,000.00 AllogeneicBMT ;10,000.00
Maximum for all Transplant Services-The total dollar amount to be paid to or on behalf of Covered Participant for alt Transplant
Services including the Covered Transplant Procedure shall be included in and subject to the Plan Benefit Maximum. The maximums
shown for Transportation, Lodging, Meals, and Procurement are excluded in this maximum.
Special Rules for Oman Transplants- The Covered Participant must have been covered under the Plan for at least six (6)
consecutive months immediately prior to the date of transplant. Covered Participants who are Newborns need not meet this requirement.
The six (6}month waiting period is waived when any organ transplant for a Covered Participant is the direct result of a covered accident
Exclusions
There arc no bcn~ts for
(A.). services and supplies of any provrder located outside the United Stories of America, except for procurement services
(subject to the amounts shown in the Maximum section).
(B.1 services and supplies which are eligible to be repaid under any private or public research fund, whether or not such funding was
app!"red for or received.
(C.) implant of an artificial or mechanical heart or part thereof, this does_ not i_ncl_t_rd_e_ reQlacernent of a heart valve.
(D.} services for non-human organ transplants.
(E.) all other exclusions, limitations or conditions set forth in this Plan shall apF•ly to Transplant Services unless otherwise provided
in this Transplant Services section.
OUT-OF-POCKET MAXIMUM
The Plan will pay the prescribed coinsurance on covered medical expenses for each covered Participant's bills until the out-of-pocket
maximum has been ruched as outlined in the Schedule of Benefits, including the calendar year deductible. Covered expctrses incurred
for the rest of the calendar year will be payable at 100%. The office visit co-pav will still apply after the co-insurance Las
been met.
PRE-EXISTING CONDITIONS MAXIMUM
Replacement of Coverage .......................................................... Pre-Existing limitation is waived
'~cw Hire -Maximum payable ............ . ......................................................... S 1000.00
l.atc Enrollces ................................................................................... S 0.00
WAITING PERIOD
"fhe first f IsQ day of th<• month following the completion of the F.mploycc's 30 day wailing period. The waiting period wit! not apply to
an cmployrc cuvcred on the original effcctiva date of this flan.
I fl Derr County Plan Docmnent fanuary t, 2003
/'° ~
PUBLIC PARTICIPATION FORM ~ ~~
FOR
KERB COUNTY COMMISSIONERS' COURT
Instructions: Fill out all appropriate blanks. Please print or write legibly. Present to the County
Clerk prior to the time that the A/genda Item (or Items) you wish to address are discussed.
Name: ~ ~-l~- ('e' `~ /'~Ejf1-" (-'
Address: ~ O O ~ ~ . ©~"~C C-~-'
Telephone:
Place of Employment: ~C-C u t2 ~ (~ ~ ~~~ ~~~~
Employment Telephone: O 3 ~ -33 ~ - 3 ~O
Do you represent any particular group or organization? Yes ~ No ^
If you represent a group or organization, please state the name, address and telephone number of
such group or organization. ;~
~e c ~ r~ ~ ~ "`I ~c~s~ (first-n! ( ~
to ~ o /v . D uaE-c <
~~-~2 s~~ l (?~
Which agenda Item (or Items) do you wish to address?
I,~
In general, are you for or against such Agenda Item (or Items)? For ^ Against ^
Signature
NOTE: This Public Participation Form must be presented to the County Clerk prior to the
time the agenda item(s) are discussed.
Once you reach the podium, please state your name and who/what you represent clearly
for the court reporter to accurately record who you are.
~(J °~
/L~
PUBLIC PARTICIPATION FORM
FOR
KERR COUNTY COMMISSIONERS' COURT
Instructions: Fill out all appropriate blanks. Please print or write legibly. Present to the County
Clerk prior to the time that the Agenda Item (or Items) you wish to address are discussed.
Name: i ~cu"T~o~v~
Address: ~zc~ ~y~ F ~__ ~ ~,~ . i ~ 7~S ~0
Telephone: ~5 30 77`1/ .? S
Place of Employment: (11.c bin ~ ~ ~ ('u s~
Employment Telephone: ~ 30 77y 2 ~ S S~
Do you represent any particular group or organization? Yes ~ No ^
If you represent a group or organization, please state the name, address and telephone number of
such group or organization.
,gcn K r ~4s"1
PO. QaK yo~v
L~ l ~ a~ %~ 7~S k Sl /- ~/o !a
Which agenda Item (or Items) do you wish to address? /, Z.
In general, are you for or against such Agenda Item (or Items)? For ^ Against ^
Signature
NOTE: This Public Participation Form must be presented to the County Clerk prior to the
time the agenda item{s) are discussed.
Once you reach the podium, please state your name and who/what you represent clearly
for the court reporter to accurately record who you are.
I ~~~~r /~~~ L1P
Insurance Since 1935
...an Assurex Gtobat Partner
Kerr County
December 1, 2004
Prepared by:
Gary R. Looney, REBC
Catto & Catto Benefits Group, LLP
This Proposal describes the insurance benefits in an easily understood manner. They do not create or confer any
rights. The exact terms of the plan are outlined in the detailed provisions of the policies issued by the insurance
carriers. The following was prepared for the purpose of outline presentation only.
Gary R. Looney, REBC
110 E Crockett
,._, San Antonio, Texas 78205
Phone: (210) 222-2161 Fax: (210) 227-5006
FINAL RECOMMENDATION REPORT
Date :12/1 /2004
TO :Kerr County Commissioners Court
From :Gary Looney REBC
RE : RFP Analysis -Medical and Life Insurance Plans
Dear Sirs:
I have completed my review of the proposals submitted to Kerr County for Third Party
Administrative Services, Medical Aggregate and Specific Stop Loss Insurance and Group Term
Life Insurance. There were two objectives of the bid request. The first objective was to examine
the cost of the current plan of benefits in relationship to the proposals received and the renewal
offered by the current carrier to determine if the current plan was cost effective. The second
objective was to determine if the current plan of benefits should be changed. If the plan were to
be changed, what plan of benefits would be offered to employees and what would the cost
differential be to the County. Contingent with the two objectives, it was also necessary to
examine the services of the current Third Party Administrator.
Current:
A summary of the current plan of benefits offered to employees is included under
Tab 1. The benefit plan offered to employees and paid for by Kerr County is plan A. Plan A is
selected by 63% of your employees with 29% in Plan B and 8% in Plan C. Currently the County
pays 100% of the employee cost for Plan A with premium credit offered to employees who select
Plans B or C.
A bid summary sheet assuming the current plan of benefits as described is included under
Tab 2.
The current stop loss contract is a 12/12 contract. For a claim to be eligible to be paid the claim
must be incurred and paid within a 12 month period. The proposals I have illustrated are 15/12
contracts. Claims incurred in the last 3 months of the plan year will be included in the specific
and aggregate contracts for reimbursement for 12 months of the next plan year.
Optional Plans:
I have included an Optional Plan utilizing a Health Reimbursement Arrangement for your
employees. The plan design is intended to closely match Plan A.
These are a few of the primary differences in the new plan design:
1. The deductible has been increased from $400 to $1,000.
2. The Physician Office Co-pay has been increased to $30.00
3. The Maximum Out-of-Pocket cost has increased from $2,400 to $3,000.
4. The $300 supplemental Accident benefit is removed
5. Physician office Co-pays include x-ray, lab, and in office surgery performed in
physicians office. Lab services performed by an in network Lab are not subject to
deductible.
December 1, 2004 FINAL RECOMMENDATION REPORT Page 2 of 2
.._, 6. A Health Reimbursement Arrangement is added to provide each covered
employee and covered dependent a $ 600 per year reimbursement for medical
expenses eligible to be paid under the medical plan. The reimbursement
arrangement will allow reimbursements for eligible deductible expenses,
coinsurance expenses, and other out of pocket expenses eligible for benefit under
the plan. It does not include reimbursement for co-payments made at the doctors'
office orfor co-payments made for prescription drugs.
7. The year end carry over for unused deductibles is eliminated.
A GSample Plan" benefit summary is included under Tab 3.
The pricing model for the Optional plan is included under Tab 4. The projected plan costs are
estimated based on the proposals submitted.
A "Sample" lower priced optional plan is shown under Tab 5. The lesser benefit plan would be
made available to employees who wish to have a lower premium cost. This option has
substantially reduced benefits. The premium cost is shown under Tab 4. Since the County is
funding the plan with greater benefits a credit is generated for those who wish to participate in
the lesser benefit plan. I do not recommend the lesser benefit plan to be provided as the County
sponsored plan.
The life insurance benefits are at a very low level for each employee ($10,000). I recommend an
increase in the basic life insurance coverage paid by the County. The current rate and bid results
are shown on the spreadsheet under Tab 6.
"~ As a result of a rate decrease for the life insurance plan, it is possible to increase each employee
to $20,000 of life insurance with a net result of an increase in premium of approximately $4,000
per year.
It is my recommendation:
1. That the County change the medical plan design and adopt a Health Reimbursement
Arrangement. The intent of the plan design is to provide additional benefit to those
employees who are prudent in the utilization of the medical benefit plan.
2. That the County provide an optional plan for those employees who wish to have a plan
with lesser benefits at a reduced cost.
3. That the County increase the basic Life and Accidental Death and Dismemberment
policy to $20,000 per active employee.
4. That the County select Mutual of Omaha as the carrier for 2005.
I sincerely appreciate your confidence in our efforts to provide you and your employees with the
very best in employee benefits.
----~
~~
Gary R Looney REBC
Risk Management Consultant
~~
~ .~ ~
~Kll~ CO vat s ~
SCHEDULE OF BENEFITS
SELF FUNDED	IN NETWORK	NON-NETWORK
TYPE OF SERVICE	PROVIDERS	PROVIDERS
Calendar Year BeneSt	Plan A	Plan B	F']an C	Plan A	Plan B	Plan C
Calendar year deductible						
Family Maximum Unit - 3 Persons	$400	8750	$1,200	5800	$1500	$2
000
Last 3 month carry-over	51,200	$2,250	$3,600	$2,400	$4,500	,
$6,000
Coinsurance Maximum	$2,000	$3,000	$4,000	$4,000	85,000	88,000
Family Maximum Unit - 3 Person	$6,000	$9,000	512,000	$12,000	$15,000	$24,000
Total Out of pocket Maximum	$2,400	$3,750	$5,200	$4,800	$6,500	$10,000
Family Maximum Unit - 3 Person	$7,200	$11,250	'515,600	14,400	819,500	$30,000
Lifetime Maximnaa Per Person	$1,000,000
		CO-INSURANCE	CO-INSURANCE	
BENEFITS	DED	PPO	]vON PPO	LIMITATIONS
Physician Office Visit				excludes x-ray, lab and
	Waived	$10 co-pay Plan A	$20 co-pay Plan A	surgery done at the time of
{For Kerrville				the aflice visit. Ca-pay
Providers Only)	Waived	$20 co-pay Plan B	$30 co-pay Plan B	will only apply to CPT
				codes 99201-992 i5 8:
	Waived	$30 co-pay Plan C	$40 co-pay Plan C	99241-99245
				excludes x-ra~~, !ab and
Physicivt Office Visit	Waived	$20 co-pay Plata A	$20 co-pay Plan A	surgery done al thr timr of

~				the office visit. Co-Pay
(For Outside
$errville	Waived	$20.co-pay Plan B~' •	$30 co-pay Plan•B	will only apply to CPT
Providers Oaiy)				codes 99201-992 i 5 &
'	Waived	$30 co-pay Plan C	$40 co-pay Plan C	99241-99245
		PLAN	PLAN	PLAN	PLAN	PLAN	PLAN	
OTHER BENEFITS	DED	A	B	C	A	B	C	LII4IITATIONS
Physician Inpatient	Applies	90%	$0%	L'0%	70%	60%	60%	
Physician Surgery	Applies	90%	80%	$0%	70%	60%	60%	*For Inpatient
Anesthesiology	Applies	90%	80%	80%	70%	fi0%	60%	*For Inpatient
Allergy testing, serum &								
injections	Applies	90%	80%	80%	70%	60%	60%	
l-ray, Radiologist	Applies	90%	80%	$0%	70%	60%	60%	
C.ab, pathologist	Applies	70°'0	70%	70%	70%	60%	60%	
Preferred L•tb - L-tbOne	1~~aived	100°~0	l00°io	100°'°	!\'/.A	N/A	N/A	
								After $300 tmauc per
								accident subject to the
:accidental Injuries	Waived	100%	100%	100%	N/A	N/A	N/A	ded and co-insaraace
Kerr County E'lao Document January 1, 2003 5
	CO-INSURANCE	CO-INSURANCE	
	PPO	l'~ON-PPO	
		PLAN	PLAN	PLAN	PLAN	PLAN	PLAN	
BENEFITS	DED	A	B	C	A	B	C	LIMITATIONS
								Services do not include
Outpatient Services	Applies	90%	80%	80%	70%	60%	60%	outpatient surgery
								All services related to the
								outpatient surgical
								procedure to include
								Anesthesia,Lab/Path, xray,
Outpatient Surgery	waived	90%	80%	80%	70%	60%	60%	etc.
								Lifetime max for all levels
Home Health Care Services	Applies	90%	80%	80%	70%	60%	60%	$10,000
								Limited to facility's
								semiprivate room rate with
								7 days of the a 3 day
Skilled Nursing Facility	Applies	90%	80%	80%	70%	60%	60%	hospital stay
								Life time max for all levels
Hospice Care -	Applies	90%	80%	80%	70%	60%	60%	$20,000
Spinal Manipulation								$1,500 calendar year max
Chiropractic	Applies	90%	80%	80%	70%	60%	60%	for all levels
								$1,500 calendar year max
Physical Therapy	Applies	90%	80%	80%	70%	60%	60%	for all levels
								Medical necessity must be
Speech Therapy	Applies	90%	80%	80%	70%	60%	60%	documented for all levels
								For emergency transport
Ambulance Services	Applies	90%	80%	80%	70%	60%	60%	to a covered facility
								If Ntw Barn not added in
Routine New Born Care								first 31 days coverage will
(Inpatient Nursery)	Waived	90%	80%	80%	70%	60%	60%	terminate
								If New Born not added in
New Born Care {Sick Baby}								first 31 days coverage will
(Inpatient Nursery)	Applies	90%	80%	80%	70%	60%	60%	terminate
Maternity Benefits								
Initial office visit	Applies							
Delivery related foes	Applies							Dependent Daughters are
Other OB related fees	Applies	90%	80%	SO%	70%	60%	60%	not covered
Preventive Care								Services include but not
Calendar Year Max of								limited to, Office visits,
$200 {Adult, Well Baby,								pap smear, mammogram,
Well Child)								prostate screening,
(Does not include physicals								Routine GYN exams,
far camp, school, pre-								routine x-ray/lab,
employment, and school								immunizations, flu shots,
slx~nsored sports activity)								routine eye and hearing
	Waived	l0U"/°	100%	100%	N/A	N/A	N/A	exams.
ICcrr County Plan Documc,ii January 1, 2003
	CO-INSURANCE	COINSURANCE	
	PPO	NON PPO	
		PLAN	PLAN	PLAN	PLAN	PLAN	PLAN	
BENEFITS	DED	A	8	C	A	B	C	LIIVl1TATIONS
Durable Medical								Requires doctor's
Equipment	Applies	90%	80%	80%	70%	60%	60°!o	prescription
Hospital Inpatient								Per-r~rtification is required
ASP room & board limit	Applies	90%	80%	80%	70%	60°/0	60%	S50D penalty if none
Emergency Room &								Treatment for a medical
Physician	Applies	90%	80%	80%	70%	60%	60%	emergenry
Mental Disorders								
Inpatient - 7 days per	Applies	50%	50%	50%	50%	50°1°	50%	
calendar year max								Co-insurance for Inpatient
								or Outpatient dots not
Outpatient - 20 visits per								apply towards the out-0f--
calcndar year max	Applies	50%	50%	50%	50°/o	SO%	50%	pocket maximum
		See DeFnition of "Serious
		Mental Dlness in the Plan
Serioas Mental Illness	wine as any other illness	Document
Substance Abuse							
Inpatient - 7 days per							
calendar year max	Applies	50%	50%	50% 50%	50%	50%	Co-insurance for Inpatient
							or Outpatient does not
Outpatient - 20 visits per							apply towards the out-of-
calendar year max	Applies	50%	50%	50% 50%	50%	50%	pocket maximum
							Removal of partial or fully
Dental Oral Surgery	Waived	90%	80%	80% N/A	N/A	N/A	impacted teeth
Alt other Professional							See details under
Services	Applies	90%	80%	80% 70%	60%	60%	"Covered Expenses"
PRESCRIPTION DRUG BENEFIT
. PLAN A
Pharmacy Option
Co-payment, per Prescription
Multiple source Brand .................................................................. 835.00
Single Source Brand ................................................... ............. 820.00
Generic Drugs ........................................................................ 8 5.00
Mail Order (90 Day)
Co-payment, per Prescription
11Iultiplesource Brand .................................................................. 840.00
Singh Saurccl3r~ind ................................................................... 525.00
Generic Drugs ........................................................................ S10.00
Kerr County Plan Document ,January 1, 2003 7

Non-Transplant Network Provider- 90% ofcoveredcharges (subject to reasonable and customary) for Transplant Services provided
through aNon-Transplant Nciwork Provider with respect to the type of Covered Transplant Procedure performed that have been
approved by Interlink Health Services. 60% of covered chazges (subj ect to reasonable and customary) for Transplant Services provided
--- through aNon-Transplant Network Provider not approved by Interlink Health 5etvices, Transportation, lodging, and mea3 costs for
travel related to the initial evaluation, ongoing evaluations prior to transplant and subsequent admission for a Covered Transplant
Procedure performed by a Non Transplant Network Provider are not covered under this Plan,
AdA.I~IMUMS
Transportation. Lodgine, and Meals- $10,000.00 for all travel, lodging, and meals related to Transplant Services performed by
a Transplant Network Provider. $200.00 per day maximum for lodging and meals. Itemized receipts in a form satisfactory to the TPA
Contract Administrator must be submitted by the Covered Participant when claims are filed for reimbursement.
Organ and/or Tisane Procurement- The payments for procurement expenses for a donor organ are covered at i 00% when the
Covered Transplant Procedure is performed by a Transplant Network Provider. H~~wever, the payments for procurement expenses for
bone marrow associated with allogeneic bone mazrow transplant may not exceed $10,000.00.
The payment for procurement expenses for a donor organ or tissue when the Covered Transplant Procedure is performed by a Transplant
Network Provider orNon-Transplant Network Provider are covered at 100% but may not exceed the following Maximums, per Covered
Procedure:
Lung $10,000.00 Heart/Lung $ L O,OOOAO
Heart $10,000.00 Kidney/Pancreas $10,000.00
Liver $10,000.00 Allogeneic BMT $10,000.00
Maximum for aII TransplaatServices-The total dollar amount to be paid to or on bthaif of Covered Participant for all Transplant
Services including the Covered Transplant Procedure shall be included in and subject to the Plan Benefit Maximum. The maximums
shown for Transportation, Lodging, Meals, and Procurement are excluded in this maximum.
Special Rules for Organ Transplants- The Covered Participant must have been covered under the Plan for at least six {6}
,..., consecutive months immediately prior to the date of transplant. Covered Participant; who are Newborns need not meet this requirement.
The six (6}month waiting period is waived when any organ transplant foca Covered Participant is the direct result ofa covered accident
Exclusions
There arc no benefits for:
(A.). services and supplies of any provider located outside the United States of America, except for procurement services
(subject to the amounts shown in the Maximum section}.
(B.1 services and supplies which are eligible to be repaid under any private or public research fund, whether or not such Funding was
applied for or received.
(G} implant of an artificial or mechanical heart or part thereof, this does notsnelude replacement of a heart valve.
(D.} services for non-human organ transplants.
(E.) all other exclusions, limitations or conditions set forth in this Plan shall apply to Transplant Services unless otherwise provided
in this Transplant Services section.
OUT.OF POCKET MAXIMUM
The Plan will pay the prescribed coinsurance on covered medical expenses for each covered Participant's bills until the out-of-pocket
maximum has been reached as outlined in the Schedule of Benefits, including the ct~lendar yeaz deductible. Covered expenses incurred
For the rest of the calendar year will be payable at 1 OQ%. The office visit co-u;ay will still apply after the co-insurance has
been met.
PRE-EXISTING CONDITIONS MAXIMUM
Replacement of Coverage .......................................................... Pre-Existing limitation is waived
New Hire-Maximum payable ...................................................................... $ 1000.00
Late Enrollees ................................................................................... S 0.00
WAITING PERIOD
"17~e first (]st} day of tht• month following the completiori ofthe Employee's 30 day waiting period. "f'hc waiting period will not apply to
""' an employer covered on the original clTcctivc date of this plan.
1 ~ I~trr County flan Docwncnt January (, 2063
PRESCRYPTION DRUG BI~NEFIT
PI.ANB&C
PLAN B AND C
Pharmacy Option
Co-payment, per Prescription
Multiple source Brand .................................................................. $45.00
Single Source Brand ................................................................... $30.00
Generic Drugs ........................................................................ 110.00
Mai[ Order (90 Day}
Co-payment, per Prescription
Multiplesource Brand .................................................................. 850.00
Single Source Brand ................................................................._. 135.00
Generic Drugs ........................................................................ $15.00
HUMAN ORGAN AND TISSUE TRANSPLANT BENEFIT
lifetime maximum .................................................................................. $250,000
Plan A co-insurance in network ............................................................. ................ 90%
Plan A co-insurance out of network .......................................................................... 70%
Plan B & B co-insurance in network ....................................,.................................... 80%
Plan B & C co-insurance out of network ...................................................................... 60%
Maximum payable for:
Transportation, Lodging, and Meals ............................................................... 810,000
Maximum per day for lodging and meals ............................................ . .............. 8 200
Pre-Authorization Required for Transalant Evaluation -Expenses incuned in connection ti7th the evaluation of a Covered
Participant for am' human organ or tissue transplant will be covered, but onl}• after referral to and pre-authorization through Employee
Benefit Administrators, Inc.(EBA), the TPA Contract Administrator has occurred. The Covered Participant or his physician should
contact EBA, Inc. for pre-authorization of an evaluation for transplant prior to the: referral to a transplant physician. EBA will assign
Interiink Health Services as the case manager to work with the Covered Participant closely through out the transplant process.
Pre~Authorization Requirement for TransplantProcedure-Expenses incurred in connection with any organ or tissue transplant
Listed in this provision will be covered subject to referral to and pre-authorization by the Plan Administrator's authorized review specialist,
Interlink Health Services. Transplant coverage is offered under this plan through a preferred provider networkofspecialized professionals
and facilities. Coverage is also provided for Transplant services obtained outside of the preferred network at a reduced benefit level.
As soon as reasonably possible, but in no event more than ten (10} days after a Covered Member's attending physician has indicated that
the Covered Member is a potential candidate for a transplant, the Covered N[ember or his Physician should contact the Plan
Administrator for referral to the net.+•orl:'s medical revie~+~ specialist Fos evaluation :tnd pre-authorization. A comprehensive treatment
plan must be developed for this plan's medical review, and must include such infon::tation as diagnosis, the nature of the transplant, the
setting of the procedure, (i.e. name and address of the hospital), any secondary rrtedical complications, a five yea prognosis, two {2)
qualified opinions conftming the need for the procedure, as wee as a description and the estimated cost of the proposed treatment. ~{One
or both confirming Physician's statements may also be required. The Covered Meirher may provide a comprehensive treatment plan
independent of the l~rcfc:rrcd provider network, but this will Ise subject to medical ali~ropriateness review and may result in non-network
.._.
benefit coverage.
g !{err ~dlU1NV plan Ducaiment ,}aaiiary 1, 2003
All potential transplant cases will be assessed for their appropriateness for Large Case Management.
Covered Transplant Expenses
The term "covered expenses" with respect to transplants includes the reasonable and customary expenses forservices and supplies which
are covered under this plan (or which are specifically identified as covered only under this provision) and which are medically necessary
and appropriate to the Transplant.
(A) Charges incurred in the evaluation, screening, and candidacy determination process.
(B) Charges incurred for organ transplantation.
(C) Charges for organ procurement, including donor expenses not covered under the donor's plan of benefits.
• Coverage for organ procurement from anon-living donor will be provided for costs involved in removing,
preserving and transporting the organ.
• Charges for organ procurement for a living donor will be provided for the cost involved in screening the
potential donor, transporting the donor to and From the site ofthe transplant, as well as for medical expenses
associated with removal of the donated organ and the medical services provided to the donor in the interim
and for follow up cart.
• If the transplant procedure is a bone marrow transplant, coverage will be provided for the cost involved in the
removal of the patient's bone marrow (autologous) or donated marrow (allogeneic)_ Coverage will also be
provided for search chazges to identify and unrelated match, treatment and storage costs of the marrow, to
the time of reinfusion. (The harvesting of the marrow need not be performed within the transplant benefit
period)
(D) Charges incurred for follow up care, including immuno-suppressant therapy.
(E) Charges for transportation to and from the site of the covered organ transplant procedure for the recipient and one
other individuals. In addition, all reasonable and necessary lodging and meal expenses incurred during the transplant
benef t period will be covered up to a maximum of 810,000.00 leer transplant period.
Re-transpiantadon
Re-transplantation will be covered up to two re-transplants, for a total of three transplants per person, per lifetime. Each transplant and
re-transplant will have a new benefit period and a new maximum lifetime benefit.
DEF[NITIONS -
Covered TranBplantProcedures-Covered Transplant Procedures are any of the following adult or pediatric human organ and tissue
transplant procedures determined to be Medically Necessary:
Heart lung Simultaneous Heart/Utng Bone Marrow
liver Kidney Simultaneous Pancreas/Kidney
Transplant Network Providers- Transplant Network Providers are those Hospitals and Physicians that arc under contract with the
Plan to provide Transplant Services. Benefits Paid are enhanced when the Covered Participant uses Transplant Netwod: Providers.
Non=Transplant Network Prnviders- Non-Transplant Network Providers are those Hospitals and Physicians that are not under
contract with the Plan to provide Transplant Services and have been approved by Interiink Services. Transplant Sen~ices that have been
approved for anon-transplant facility or by anon-transplant provider will be eligible for benefits under this plan at a reduced rate.
Transplant Services- Transplant Services means any services directly related to a Covered Transplant Procedure including, but not
limited to, inpatient and outpatient Hospital services, physician services Eor diagne~sis, treatment and surgery for a Covcrcd Transplant
Procedure, diagnostic services, and procurement of an organ or tissue, including se rvices provided to a living donor of an organ or tissue
for procurement of an organ or tissue. Transplant Scrvices also includes but is not limited to, durable medical equipment rental outside
of the hospital, prescription drugs including immunosuppressives; surgical supplies and dressings, and home health care.
BENEFITS PAID
Transplant Network Provider- Covered expenses will be reimbursed at Q~e stated co-insurance rates listed aborr for Tr;uispiacu
Scrvices provided through a Transplant Network Provider with respect to the type of Covered Transplant Procedure performed. 100°.'0
of reasonable and necessary transportation, lodging, and meal costs for the Covered Participant and ale significant other are covered for
travel related to the initial evaluation prior to transplant, and subsequent admission for a Covered Transplant Procedure performed by
a Transplant Network Provider. If the recipient is a minor, transportation costs for two companions may be covered.
^` Kerr County Plan Document January 1, 213
County of Kerr
Bid Spread Sheet
TPA 13nat Wea Group 8 Pennon Admin. EBA MtAW of Orneha
BeneM Planners
		Optlon S	Opton 2	
Reinsurma Carrier	Groat Wed HeaBtlare	S ba	Art~eriean United Life Ins Co	tkdfed Or Omaha
Sdup Fee •:	WaNed	S 2,800	Nana	
Retxwal Fee			Nana	
Run-WRun-Om: Adminisuadon Fee Charged by EBA(?)		10%	570.00 per daim	
Estimated rem out damn IiabifilTy	S 745,000	S 745,000	S 145,000	S 745,000
Specific Lifetinse Maximran ReimMrnanart	S 1,000,000	S 1,000,000	S 7,000,000	S 960,000
Aggregate Plan veer Annua Maxunum Rreimbunemem	s 7,ooo,ow	$ t,o6o,ooD	$ 1,ooD,aao	$ 1,000,030
PPO Network	TTC	GPA Healltsrriad	TTC	TfC
	125%canidor	125%cortida	125%arddor	125%conidor
• Nore. These sea are one dme annual and are not included /n rorols below.				
STOP-LOSS BASIS				
Number of Employees: Plan 1	265	265	265	165
Number of Spousal Units				
Number of Dependent Units: m Children				
Number of Family Units				
Number of Employees: Plan 2	hduded'n above oouM			
Number of Spouse Unity	Quote k band an blended rates			
Number of Dependent Urllta: m Children				
Number of Family Units				
Number of Employee: Plan 3	lnduded in above InuM			
Number of Spouse Units	OuoOs is based on blersied rate			
Number of Dependent Unbs: or Children				
Number of Family Unite				
Spedfic Deductibk:	3 40,000	S 40,000	S 40,000	S 40,000
Specific Comrod:	15M2	12/15	1972	1512
Specific Coouatt Includes	Medial 8 Wt	Medical 8 Ra	Meded	Medkk:sll 8 Rx
Aggregate Contract:	1972	72.!75	1912	7512
Maximum Aggregate Run hr				226,750
A Contract Includes	Medical 8 Fbt	Medical 8 Rx	Medal 8 Wt	Medal 8 Rx
MONTHLY FIXED COSTS				
Specific Premium				
Composite:	S 6213	S 710.48	S 74.55	S 43.78
Aggregate Prgnium				
Composite:	S 8.95	S 9.75	S 5.56	S 4.31
Monthly Cap	Na	S	S	
Admioiarationl aR fee per unit per month)				
Claims Cod Per Employe : Composite rote	S 79.45	S 16.50	S 12.50	$ 79.90
Utilisation Review	$	S 2.00	$ 1.85	S 2.40
Disease Management Option 1	S 3.25		S 7.00	S 1.91
Dixase Marugemeot Option 2	rJa	Isla		
Disease Management Option 3	Na	tJa	S 3.00	
PPO Network Axes Fces	induded	S 5.50	S 3.00	S 2.49
				
PPO Network: Out of Area N network fee	induded		Nane	Na
Rx Program Fees	bid		Nan	N
Web Based Acaas	Ytduded		.15 PEPM 0	Yes
COBRA	included	S 2.25	S 0.20	S 0.50
H1PAA	irlduded		S 0.20	S 0.30
Positive Pay Banking System	iriduded		t>la	
Tote! Per	$ 19.45	S 26.25	$ 77.75	S 27.50
AGGREGATE FACTORS				
Composim:	$ 594.83	S 577.29	$ 554.04	S 452.64
Momlily:	$ 157,630	S 148,940	S 146,827	S 119,950
Annua:	S 1,897,559	$ 7,787,282	S 1,761,847	S 1,439,395
TOTAL ANNUAL COSTS				
Speific Stop Loss Premium	S 197,573	S 351,326	S 237,069	S 739,220
Aggregate Stop Loss Premium	S 26,461	S 31,005	S 17,744	$ 13,706
Administration -COBRA FIB'AA (Broker)	S 61,851	S 59,625	S 41,022	$ 65,826
UR, PPG, Rx	Irxiuded'n Pdnirliatratlon	S 23,850	S 15,423	$ 15,550
Disease Managerrcnt	S 10,335		S 9,540	S 6,074
				
ToW Feed	S 296,220	S 465,806	S 311,258	S 234,302
Expected Claims Cost ezduding Fixed Coat:	$ 1,416,670	S 1,340,462	S 1,321,385	S 1,079,546
Maximum Clauns Costs excluding Fixed Cost:	S 1,891,559	S 1,767,282	S 1,761,847	S 1,439,395
Expee%ed Clauro Cost including Fixed Coat:	S 1,716,890	S 1,806,268	S 1,632,644	S 1,313,849
Maximum Claims Costs includin Fixed Cost	S 2,189,780	S 2,253,089	S 2,073,706	$ 1,673,698
				
				


Notre:	Pass Through cod far pdrdirp, ID
cards, enrolment rnsetlrpe 5250
day for BPI eee	
Plan Bcaklefe ae Dane Ihrouph
cost		
				
County of Kerr wttn HRn
Bid Spread Sheet
TPA EBA Mutual of Omahs
	Plan Chanpea	
Reinsurance Carver	American United Life Ins Co	United Of Omaha
Setup Fee •:	None	Initial Deposit RequYed
Renewal Fee	None	
Run-In/Run-Out: Administration Fee Charged by EBA(?)	510.00 per deim	
Estimated run out claim liabililty	5 145,000	5 145,000
Specific Lifetime Maximum Reimbursement	S 1,OOO,OOD	S 960,000
Aggregate Plan Year Annual Maximum Rreimbursement	5 1,000,000	5 1,000,000
PPO Network	TTC	TTC
	125% Condor	125% corridor
• Note: These fees are one rime annual and are nor included in totals be%w.		
STOP-LOSS BASIS		
Number of Employees: Plan 1	265	265
Number of Spousal Units		
Number of Dependent Units: or Children		
Number of Family Units		
Number of Employees. Plan 2		
Number of Spousal Units		
Number of Dependent Units: or Children		
Number of Family Units		
Number of Employees: Plan 3		
Number of Spousal Units		
Number of Dependent Units: or Children		
Numbu of Family Units		
Specific Deductible:	S 40,000	S 40,000
Specific Contract:	15112	15112
Specific Contract Includes	Medical	Medical S Rx
Aggregate Contract:	15112	15/12
Maximum Aggregate Run In		226,750
Aggregate Contract Includes	Medical 6 Rx	Medical b Rx
MONTHLY FDtED COSTS		
Specific Premium		
Composite:	S 68.05	5 43.78
Aggregate Premium		
Composite:	S 5.58	S 4.31
Monthly Cap		
Admiuiatratioo(sll fee per unit per month)		
Claims Cost Per Employee :Composite rate	S 12.50	S 19.90
Utilization Review	S 1.85	5 2.40
Disease Management Option 1	5 1.00	S 1.91
Disease Management Option 2		
Disease Management Option 3	S 3.00	
PPO Network Access Fees	5 3.00	5 2.49
		
PPO Network: Out of Area in network Fee	None	Na
Rx Program Fees	Non	N
Web Based Access	.15 PEPM (Optionaq	Yes
COBRA	S 0.20	S 0.50
IiIPAA	S 0.20	S 0.30
Positive Pay Banking System	Na	
Total Per Em Joyce:	S 17.75	5 27.50
AGGREGATE FACTORS		
Composite:	S 520.00	S 439.53
Monthly:	S 137,800	S 116,175
Annual:	S 1,653,600	S 1,397,705
TOTAL ANNUAL COSTS		
Specific Stop Loss Premium	5 216,399	5 139,220
Aggregate Stop Loss Premium	5 17,744	S 13,706
Administration - COBRA HIPAA (Broker)	5 41,022	5 65,826
UR, PPO, Rx	S 15,423	S 15,550
Disease Management	S 9,540	S 6,074
		
Total Fixed	S 290,588	S 234,302
Expected Claims Cost excluding Fixed Cost:	5 1,240,200	5 1,048,279
Maximum Claims Costs excluding Fixed Cost:	S 1,653,600	S 1,397,705
Expected Claims Cost including Fixed Cost:	S 1,530,788	S 1,282,581
Maximum Claims Costs including Fixed Cost:	5 1,944,188	5 1,632,008
		
		

Noes;	
Does not indude 5200,000 estimated HRA reimbursement	Does not indude 5200,000 estimated
HRA reimbursement
	Does Not IncNde Disease Mgmnt	
SAMPLE
SCHEDULE OF BENEFITS
Major Medical Benefits for Covered Persons
..-_
Benefit Levels for services rendered in the geographical area serviced by the Preferred Provider
Organization (PPO):
The "PPO Benefit" level applies to services rendered by a Partiapating Provider in the designated PPO Network;
the "Non-PPO Benefrt" level applies to services rendered by providers other than Partiapating Providers (Non-
Network). In addition, the "PPO Benefr" level applies to the following situations:
1. If a Partiapating Provider refers a Covered Person to a facility which is not a Partiapating Provider because
no appropriate Partiapating Provider facility is available;
2. If a Partiapating Provider refers a Covered Person to a Physiaan who is not a Partiapating Provider because
there is no appropriate specialist available among Partiapating Providers; and
3. If a Medical Emergency or initial treatment of an Acadental Injury requires services of a Non-partiapating
Provider.
PPO Benefit Non-PPO Benefit
Lifetime Major Medical Maximum Benefit
Per Covered Person $1,000,000 $1,000,000
Health Reimbursement Arrangement
See Separate Contract for Specifics
In General -Each covered employee and dependent will receive an annual credit of $ 600 to be used to
offset co-insurance, deductible, and other non reimbursed expenses eligible for benefit under this plan.
Unused amounts will be carried forward. The maximum accumulation will be equal to the maximum out
of pocket expense under the plan for in network expenses.
Calendar Year Deductible
(No Last Quarter Deductible Carryover)
,,,._ Per Covered Person $ 1000 $3000
Family Limit* $ 3000 $ 9000
Benefit Percentage	90% of $20,000	70°/. of $20,000
(Unless otherwise noted)	100%thereafter	100%thereafter
Annual Out-of-Pocket Maximum		
(In addition to Deductible and Co-pays)		
Per Covered Person	$ 2,000	$ 6,000
Family Limit*	$ 4,000	$12,000
Inpatient Hospital Services	90 % after	70% after
(All related charges)	Deductible	Deductible
Pre-notification required		
Room and Board Limit	Semi-Private	Average Semi-Private
Intensive Care Limit	Negotiated PPO	Usual and Customary
	Fee Schedule	
Hospital Emergency Room	90% after	90% after
Medical Emergency	Deductible	Deductible
(See Medical Emergency definition in plan document, Page --)	
Hospital Emergency Room	90% after Z 75 Co-pay	90% after $ 75 Co-pay
Non-Medical Emergency	Deductible Applies	Deductible Applies
(See Medical Emergency definition in plan document, Page ---)	
Pre Admission Testing	100%	100%
„_,_ (Within 10 days of Hospital Confinement)	Deductible Waived	Deductible Waived
NOTE: The Calendar Year Deductible and Annual Out-of-Pocket Maximum are determined by in network PPO
Covered Charges. Upon reaching the Annual Out-of-Pocket Maximum, Covered Medical F~cpenses
are payable at 100% for the remainder of the Calendar Year. The Lifetime and Calendar Year
Maximum Benefits are PPO Covered Charges. Non-PPO out of pocket maximums are determined
separately.
"Applies collectively to all Covered Persons in the same family.
SCHEDULE OF BENEFITS (Cont'd)
PPO Benefit
Accidental Injury	90% after
'~ Deductible NOT waived	Deductible
Ambulance Service	90% after
	Deductible
Minor Emergency Medical Clinic	$ 75 Co-pay
	Then 90% after
	Deductible
Outpatient SurgerylAmbulatory	90% after
Surgical Center	Deductible
(All related charges)	
Outpatient Hospital Lab/X-ray	90% after
(All related charges)	Deductible
Outpatient Independent Lab/X-ray	90% after
(All related charges)	Deductible
Physician Services	
Office Visit	100% after
(Includes examination, treatment, in office surgery,	$30 Co-pay*
lab, x-ray, chemotherapy/radiation therapy,	
tests and supplies provided and billed by	
Physician at the time of the office visit, except	
-~ infusion therapy and physical therapy.	
In-Office Services	100%
(Without Office Visit billed)	Deductible Waived
*If charges are less than $30, Co-pay is actual charge.
Allergy Testing 100% after
$30 Co-pay*
Allergy Serum and Injections 100%
Deductible Waived
Second Surgical Opinion
Voluntary Second Surgical Opinion 100%
Deductible Waived
Maximum benefd payable per occurrence 5100
All Other Physician Services 90% after
Deductible
Non-PPO Benefit
70% after
Deductible
70% after
Deductible
$ 75 Co-pay
Then 70% after Deductible
for non emergency care
70°k after
Deductible
70% after
Deductible
70% after
Deductible
70°/.after
Deductible
70% after
Deductible
70% after
Deductible
70% after
Deductible
100%
Deductible Waived
5100
70% after
Deductible
SCHEDULE OF BENEFITS (Cont'd.)
PPO Benefit
Maternity 90% after
(Empbyees 8~ Covered Dependents) Deductible
(Including prenatal, delivery and postnatal care)
Office Visit Co-pay does not apply
Alternative Birthing Center 100%
Deductible Waived
Routine Newborn Care 90% after
Inpatient Hospital nursery charges and Deductible
pediatric care.
Payable under covered mother's claim.
Baby must be added as a Dependent within
thirty (30) days of birth to be eligible for this benefit
Maximum Number of Days 5
Dialysis/lnfusion Therapy 90% after
Deductible
Wig following Chemotherapy/Radiation Therapy
Lifetime Maximum
Maximum Benefit
Physical Therapy
Occupational Therapy
Speech Therapy
Restorative on the same basis as an Illness
Maximum Lifetime Benefd
for Down Syndrome
Durable Medical Equipment (DMEu
Medical Supplies
Orthotics
Chiropractic Expense Benefits
Calendar Year Maximum Benefit
(Includes X-rays)
Office Visit Co-pay does not apply
Chiropractic Benefits do not apply
to Annual Out-of-Pocket Maximum.
1
5125
90% after
Deductible
90% after
Deductible
90% after
Deductible
65,000
90% after
Deductible
90% after
Deductible
90% after
Deductible
X5,000
Non-PPO Benefit
70% after
Deductible
70% after
Deductible
70% after
Deductible
5
70% after
Deductible
1
X125
70% after
Deductible
70% after
Deductible
70% after
Deductible
X5,000
70°/. after
Deductible
70% after
Deductible
70% after
Deductible
;5,000
SCHEDULE OF BENEFITS (Cont'd.)
	PPO Benefit	Non-PPO Benefit
Long Term Care*		
Rehabilitation Faality	90%after	70%after
Pre-certification required	Deductible	Deductible
Skilled Nursing Faality	90%after	70%after
Pre-certification required	Deductible	Deductible
Maximum Benefr per confinement	180 Days	180 Days
Lifetime Maximum	365 Days	365 Days
Home Health Care	90%after	70% after
	Deductible	Deductible
Lifetime Maximum Benefd	;20,000	;10,000
Hospice	90°~ after	70%after
Pre-certification required	Deductible	Deductible
Lifetime Maximum Benefit	;10,000	;5,000
Private Duty Nursing	90%after	70%after
	Deductible	Deductible
Lifetime Maximum Benefd	;10,000	;10,000
*Prior authorization from the Utilization Review Co	mpany is required for all Long Term Care. The Plan's internal
Lifetime and Calendar Year Maximum Benefrts for	Long Term Care may be waived if Medical Case Management
or the Utilization Review Company directs the treatment.	
Organ and Tissue Transplants	90°/. after	70%after
Non-experimental transplants only	Deductible	Deductible
(See plan document for Coverage of Organ and		
Tissue Transplants)		
Donor Expenses*	90°/. after	70%after
Deductible Deductible
Maximum Donor Beneftt ;5,000 ;5,000
Payable under recipient's claim.
* Note: Donor Expenses do not apply to the Annual Out-Of-Pocket Maximum.
Mental & Nervous Conditions, Chemical
Dependency, Drug and Substance Abuse
Inpatient and Psychiatric	90%after	70%after
Day Treatment Facility	Deductible	Deductible
Inpatient Maximum Number of Days per		
Calendar Year	30	30
Psychiatric Day Treatment Faality		
Maximum Number of Days per Calendar Year	60	60
Office Visit	90% after	70%after
Office Visit Co-pay does not apply	Deductible	Deductible
SCHEDULE OF BENEFITS (Cont'd.)
PPO Benefit Non-PPO Benefit
,-.
Maximum Benefd Payable per Visit ;100 X100
Mental 8~ Nervous Conditions; Chemical Limited to 3 Series of
Dependency; Drug and Substance Abuse Treatment Treatments per Lifetime*
Mental & Nervous Conditions; Chemical
Dependency; Drug and Substance Abuse Benefits
do not apply to Annual Out-of-Pocket Maximum.
" A series of treatments is a planned, structured, organized program which may indude inpatient or outpatient
treatment and is complete when the covered individual is discharged on medical advice from inpatient care,
day treatment, or outpatient treatment without lapse in treatment or when a person fails to materially comply
with the treatment program for a period of thirty (30) days. A separate series of treatments commences when
a period of six (6) months has lapsed since last occurrence.
TemporomandibularJomt Syndrome (TMJ)	90% after	70% after
	Deductible	Deductible
Lifetime Maximum Benefit	X2,500	;2,500
Sleep Disorders	90% after	70% after
Covered on the same basis as any Illness	Deductible	Deductible
Preventive and Wellness Care Benefits
This benefd is payable for Covered Procedures
incurred as part of a Preventive and Wellness
Care Program and is not payable fortreatment
of a diagnosed Illness or Injury. Services must
be identified and billed as routine or part of a
routine physical exam.
Covered Wellness Procedures:
1. Annual Routine Physical Exam (induding lab,
x-ray and other medical screening procedures)
2. Annual Pap Smear/Gynecological Exam
3. Annual Mammography (routine) -age thirty-five (35) and older
4. Annual PSA test (routine)
1. Well-Baby Care/Well-Child Care
(other than Routine Newborn)
6. Routine Immunizations
Maximum Wellness Benefit Per Calendar Year
Per Covered Person	$500	j;500
Preventive and Wellness Expenses in		
excess of Calendar Year Maximum Benefit	Not covered	Not covered
Office Visit for Covered Wellness Procedures	100% after	70%
	j;30 Co-pay	
All Other Covered Medical F~cpenses, not	90% after	70% after
listed in the Schedule of Benefits (subject	Deductible	Deductible
to Plan Maximums and Limitations), are		
payable at applicable Benefit Percentage		
after satisfying the Calendar Year Deductible.		
OUT-0F-AREA BENEFIT
The "Out-of--Area" Benefd applies to Covered Charges for a Covered Person living or traveling outside of the
geographical zip code area serviced by the Preferred Provider Organization (PPO).
	Out-of--Area Benefit
Calendar Year Deductible	
Per Covered Person	;500
Family Limit*	;1,000
Benefit Percentage	80%
(unless otherwise noted)	
Benefit PercentagelAnnual Stop Loss Maximum	80% of;10,000
(unless otherwise noted)	100% thereafter
Annual Out-of-Pocket Maximum	
(In Addfion to Deductible)	
Per Covered Person	;2,000
Family Limit"`	;6,000
Physician Office Visit	80% after Deductible
Accidental Injury	80% after Deductible
Deductible Waived first 90 days	
Hospital Emergency Room	90% after Deductible
Medical Emergency	
Hospital Emergency Room	90% after;50 Co-pay
Non-Medical Emergency	Deductible Applies
Routine Newborn Care 80% after Deductible
Mental & Nervous Conditions, Chemical
Dependency, Drug and Substance Abuse
Inpatierrt/OutpatientTreatrnent Facility 80% after Deductible
Office Visit 80% after Deductible
(see page 10 for Benefrts)
Chiropractic Cana 80% after Deductible
(see page 9 for Benefits)
Preventive and Wellness Care 80% after Deductible
Calendar Year Maximum Wellness Benefit ;500
(see page 11 for Covered Procedures)
Out-of-Area Covered Expenses are listed in
The Plan's Schedule of Benefits and are subject to
all Plan Maximums and Limitations as previously
outlined in the Schedule of Benefits.
*Applies collectively to all Covered Persons in the same family.
NOTE: The Calendar Year Deductible, Annual Out-of-Pocket Maximum, Calendar Year Maximum Benefit and
Lifetime Maximum Benefd are combined for PPO, Non-PPO and Out-of-Area Covered Charges.
PRESCRIPTION DRUG PLAN
Prescription Card Service
Supply Limit
Generic Drugs
Brand Name Drugs
Brand Name Drugs not on formulary
Mail Order Service
Supply Limit
Generic Drugs
Brand Name Drugs
Brand Name Drugs not on formulary
30 days
100% after; 5 Co-pay
100% after; 3S Co-pay
100% after; 50 Co-pay
100 days
100% after;15 Co-pay
100% after; 70 Co-pay
100% after;100 Co-pay
If the Pharmacy charge is less than the Generic or Brand Co-pay, then the actual charge will become the Co-pay.
Generic and Brand Name Co-payments apply separately to each prescription and refill and do not apply to the
Calendar Year Deductible or Annual Out-of-Pocket Maximum. To be covered, prescription drugs must be:
1. Purchased from a partiapating licensed pharmacist; and
2. Dispensed to the Covered Person for whom they are prescribed.
Definitions
Brand Name Drugs
Trademark drugs or substances marketed by the original manufacturer whose patent rights are still in effect.
Generic Drugs
Drugs or Substances which:
1. Are not trademark drugs or substances;
2. Are legally substituted for trademark drugs or substances; and
3. Are legally prescribed by a Qualified Prescriber.
Prescription Drugs
1. Drugs or medicines which are prescribed by a Qualified Prescriber for the treatment of Illness, injury,
or pregnancy;
2. Injectable insulin;
3. Oral contraceptives; and
4. Prenatal vitamins.
Qualified Prescriber
A licensed Physiaan, Dentist, or other health care Practitioner who may, in the legal scope of his/ her
practice, prescribe drugs or medicnes.
Drug Utilization Review
The Plan includes a Drug Utilization Review program which is automatically administered by the pharmacist
through a nationwide computer network that verifies the eligibility of each Covered Person's card and protects the
Covered Person from conflicting prescriptions which might prove harmful if taken at the same time. This program
also guards against duplication of medications and incorrect dosage levels.
Prescriation Drus~ Plan - Drus~s Covered
1. Legend drugs (drugs requiring a prescription by federal law). See F~cdusion list below for exceptions.
2. Insulin on prescription.
3. Disposable insulin needles/syringes and other necessary diabetic supplies on prescription.
4. Tretinoin, all dosage forms (e.g. Retin-A), for individuals to the age of twerrty-six (26) years.
5. Compounded medication of which at least one ingredient is a prescription legend drug.
6. Any other drug which under the applicable state law may only be dispensed upon the written prescription of a
Physiaan or other lawful prescriber.
7. Legend oral contraceptives.
8. Prenatal vitamins.
9. ADD (Attention Defeat Disorder~ADHD (Attention Defeat Hyperactivity Disorder) drags.
10. Drugs prescribed for impotence/sexual dysfunction.
11. Imitrex, pill and injectable.
Prescription Drus~ Plan -Exclusions
1. Interferon Beta -1 B (Betaseron)
2. Prescription vitamins except prenatal.
3. Contraceptive patches.
4. Stadol.
5. Injectable form of legend drugs.
6. Corrtraceptive devices.
7. Anorectics (any drug used for the purpose of weight loss).
8. Growth hormones.
9. Immunization agents, biological sera, blood or blood plasma.
10. Infertility medications.
11. Levonorgestrel (Norplant).
12. Drugs for the treatment of alopecia (baldness).
13. Non-legend drugs otherthanthose listed above.
14. Smoking deterrent medications or any other smoking cessation aids, all dosage forms.
15. Tretinoin, all dosage forms (e.g. Retin-A), for individualstwenty-six (26) years of age or older.
16. Therapeutic devices or appliances, inducting needles, syringes, support garments and other non-medical
substances, regardless of intended use, except those listed above.
17. Charges for the administration or injection of any drug.
18. Prescriptions which a Covered Person is entitled to receive without charge from any Worker's Compensation
laws.
19. Drugs labeled "Caution-limited by federal law to investigational use," or experimental drugs, even though a
charge is made to the individual.
20. Medication which is to be taken by or administered to an individual, in whole or in part, while he/she is a
patient in a licensed Hospital, rest home, sanitarium, extended care fadlity, convalescent Hospital, nursing
home or similar institution which operates on its premises, or allows to be operated on its premises, a faality
for dispensing pharmaceutical.
21. Any prescription refilled in excess of the number specified by the Physiaan, or any refill dispensed after
one year from the Physiaan's original order.
NOTE: Drugs excluded from the Prescription Drug Plan, such as injectables, which are determined to be
Covered Charges under Major Medical Expense Benefits, are subject to the Calendar Year
Deductible and payable at 75°/a Prescription drugs covered under the Prescription Drug Plan are
not subject to the Pre-existing Condition Exclusion Limitation of the Plan.
Prescription Drugs purchased outside of the Prescription Drug Plan will not be eligible for
benefits under the Plan.
SAMPLE
SCHEDULE OF BENEFITS
Major Medical Benefits for Covered Persons
Benefit Levels for services rendered in the geographical area serviced by the Preferred Provider
Organization (PPO):
The "PPO Benefit" level applies to services rendered by a Partiapating Provider in the designated PPO Network;
the "Non-PPO Benefid" level applies to services rendered by providers other than Participating Providers (Non-
Network). In addition, the "PPO Benefid" level applies to the following situations:
1. tf a Particpating Provider refers a Covered Person to a faality which is rat a Partiapating Provider because
no appropriate Particpating Provider facility is available;
2. If a Partiapating Provider refers a Covered Person to a Physiaan who is not a Partiapating Provider because
there is no appropriate speaalist available among Participating Providers; and
3. If a Medical Emergency or infial treatment of an Acadental Injury requires services of a Non-partiapating
Provider.
PPO Benefit Non-PPO Benefit
Lifetime Major Medical Maximum Benefit
Per Covered Person	;1,000,000	$1,000,000
Health Reimbursement Arrangement	Not Applicable	
Calendar Year Deductible		
(No Last Quarter Deductible Carryover}		
Per Covered Person	$ 1,500	$ 4,000
Family Limit*	$ 4,000	$ 12,000
Benefit Percentage	80% of $20,000	80% of 620,000
(Unless otherwise noted)	100%thereafter	100•/.thereafter
Annual Out-of-Pocket Maximum		
(In addition to Deductible and Co-pays)		
Per Covered Person	6 4,500	612,000
Family Limit*	6 9,000	638,000
Inpatient Hospital Services	80 % after	80% after
(All related changes)	Deductible	Deductible
Pre-notification required		
Room and Board Limit	Semi-Private	Average Semi-Private
Intensive Care Limit	Negotiated PPO	Usual and Customary
	Fee Schedule	
Hospital Emergency Room	80% after	80% after
Medical Emergency	Deductible	Deductible
(See Medical Emergency definition in plan document, Page --)
Hospital Emergency Room 80% after 6100 Co-pay 80% after 6100 Co-pay
Non-Medical Emergency Deductible Applies Deductible Applies
(See Medical Emergency definition in plan document, Page --)
Pre Admission Testing 100% 100°/.
(Within 10 days of Hospital Confinement) Deductible Waived Deductible Waived
NOTE: The Calendar Year Deductible and Annual Out-of-Pocket Maximum are determined by in network PPO
Covered Charges. Upon reaching the Annual Out-of-Pocket Maximum, Covered Medical Expenses
are payable at 100% for the remainder of the Calendar Year. The Lifetime and Calendar Year
Maximum Benefids are PPO Covered Charges. Non-PPO out of pocket maximums are determined
separately.
"Applies collectively to all Covered Persons in the same family.
Accidental Injury
Deductible NOT waived
Ambulance Service
Minor Emergency Medical Clinic
(All related charges)
SCHEDULE OF BENEFITS (Cont'd)
PPO Benefit
80%after
Deductible
80%after
Deductible
$ 100 Co-pay
Then 80%after
Deductible
Outpatient Surgery/Ambulatory 80%after
Surgical Center Deductible
Non-PPO Benefit
60% after
Deductible
60%after
Deductible
$ 100 Co-pay
Then 60%after Deductible
for non emergency care
60%after
Deductible
Outpatient Hospital Lab/X-ray	80% after	60%after
(All related charges)	Deductible	Deductible
Outpatient Independent LabIX-ray	80%after	60°~ after
(All related charges)	Deductible	Deductible
Physician Services		
Office Visit	100% after	60%after
(Includes examination, treatment, in office surgery,	$ 40 Co-pay*	Deductible
lab. x-ray, chernotherapy!radiationthevapy,		
tests and supplies provided and billed by		
Physician at the time of the office visit, except		
infusion therapy and physical therapy.		
In-Office Services	100%	60°/.after
(Without Office Visit billed)	Deductible Waived	Deductible
*If charges are less than $60, Co-pay is actual charge.
Allergy Testing 100% after 60% after
$60 Co-pay* Deductible
Allergy Serum and Injections 100°~ 60%after
Deductible Waived Deductible
Second Surgical Opinion
Voluntary Second Surgical Opinion 100% 100%
Deductible Waived Deductible Waived
Maximum benefrt payable per occurrence $100 $100
All Other Physician Services 80%after 60%after
Deductible Deductible
SCHEDULE OF BENEFITS (Cont'd.)
PPO Benefit
Maternity 80% after
(Employees & Covered Dependerrts) Deductible
(Inducting prenatal, delivery and postnatal care)
Office Visit Co-pay does not apply
Alternative Birthing Center 100%
Deductible Waived
Routine Newborn Care 80% after
Inpatient Hospital nursery charges and Deductible
pediatric care.
Payable under covered mother's daim.
Baby must be added as a Dependent within
thirty (30) days of birth to be eligible for this benefit
Maximum Number of Days 5
Dialysisllnfusion Therapy 80% after
Deductible
Wig following Chemotherapy/Radiation Therapy
Lifetime Maximum
Maximum Benefit
Physical Therapy
Occupational Therapy
Speech Therapy
Restorative on the same basis as an Illness
Maximum Lifetime Benefrt
for Down Syndrome
Durable Medical Equipment (DMEu
Medical Supplies
Orthotics
Chiropractic Expense Benefits
Calendar Year Maximum Benefit
(Indudes X-rays)
Office Visit Co-pay does not apply
Chiropractic Benefrs do not apply
to Annual Out-of-Pocket Maximum.
1
X125
80% after
Deductible
80% after
Deductible
80% after
Deductible
X5,000
80% after
Deductible
80% after
Deductible
80% after
Deductible
x5,000
Non-PPO Benefit
60% after
Deductible
60% after
Deductible
60% after
Deductible
5
60% after
Deductible
1
x125
60% after
Deductible
60% after
Deductible
60% after
Deductible
X5,000
60% after
Deductible
60% after
Deductible
60% after
Deductible
'5,000
SCHEDULE OF BENEFITS {Cont'd.~
	PPO Benefit	Non-PPO Benefit
Long Term Care*		
Rehabilitation Faality	80% after	60% after
Pre-certification required	Deductible	Deductible
Skilled Nursing Faality	80% after	60% after
Pre-certification required	Deductible	Deductible
Maximum Benefit per confinement	180 Days	180 Days
Lifetime Maximum	365 Days	365 Days
Home Health Care	80% after	60% after
	Deductible	Deductible
Lifetime Maximum Benefit	;20,000	;10,000
Hospice	80% after	60% after
Pre-certification required	Deductible	Deductible
Lifetime Maximum Benefrt	;10,000	;5,000
Private Duty Nursing	80% after	60% after
	Deductible	Deductible
Lifetime Maximum Benefrt	;10,000	;10,000
*Prior authorization from the utilization Review Company is required for all Long Term Care. The Plan's internal
Lifetime and Calerxiar Year Maximum Benefits for Long Term Care may be waived if Medical Case Management
or the Utilization Review Company directs the treatment.	
Organ and Tissue Transplants	80°/. after	60% after
Non-experimental transplants only	Deductible	Deductible
• (See plan document for Coverage of Organ and		
Tissue Transplants)		
Donor Expenses*	80% after	60°/.after
	Deductible	Deductible
Maximum Donor Benefit	;5,000	;5,000
Payable under recipient's Gaim.		
* Note: Donor Expenses do not apply to the Annual	Out-Of-Packet Maximum.	
Mental 8~ Nervous Conditions, Chemical		
Dependency, Drug and Substance Abuse		
Inpatient and Psychiatric	80% after	60°/. after
Day Treatment Faality	Deductible	Deductible
Inpatient Maximum Number of Days per		
Calendar Year	30	30
Psychiatric Day Treatment Facility		
Maximum Number of Days per Calendar Year	60	60
Office Visit	80°/. after	60% after
Office Visit Co-pay does not apply	Deductible	Deductible
SCHEDULE OF BENEFITS (Cont'd.)
PPO Benefit Non-PPO Benefit
Maximum Benefit Payable per Visit X100 x100
Mental 8~ Nervous Conditions; Chemical Limited to 3 Series of
Dependency; Drug and Substance Abuse Treatment Treatments per Lifetime*
Mental 8~ Nervous Conditions; Chemical
Dependency; Drug and Substance Abuse Benefits
do not apply to Annual Out-of-Pocket Maximum.
* A series of treatments is a planned, structured, organized program which may include inpatient or outpatient
treatment and is complete when the covered individual is discharged on medical advice from inpatient care,
day treatment, or outpatient treatment without lapse in treatment or when a person fails to materially comply
with the treatment program for a period of thirty (30) days. A separate series of treatments commences when
a period of six (6) months has lapsed since last occurrence.
TemporomandibularJcint Syndrome (TMJ)
Lifetime Maximum Benefr
80% after
Deductible
);2,500
60% after
Deductible
);2,500
Sleep Disorders
Covered on the same basis as any Illness
Preventive and Wellness Care Benefits
This benefit is payable for Covered Procedures
incurred as part of a Preventive and Wellness
Care Program and is not payable fortreatment
of a diagnosed Illness or Injury. Services must
be identified and billed as routine or part of a
routine physical exam.
80% after
Deductible
Covered Wellness Procedures:
1. Annual Routine Physical Exam (including lab,
x-ray and other medical screening procedures)
2. Annual Pap Smear/Gynecological Exam
3. Annual Mammography (routine) -age thirty-five (35) and older
4. Annual PSA test (routine)
1. Well-Baby CarelVVell-Child Care
(other than Routine Newborn)
6. Routine Immunizations
Maximum Wellness Benefr Per Calendar Year
Per Covered Person X500
Preventive and Wellness Expenses in
excess of Calendar Year Maximum Benefd Not covered
Office Visit for Covered Wellness Procedures 100% after
S 40 Co-pay
All Other Covered Medical F~cpenses, not 80% after
listed in the Schedule of Benefits (subject Deductible
to Plan Maximums and Limitations), are
payable at applicable Benefit Percentage
after satisfying the Calendar Year Deductible.
60% after
Deductible
)6500
Not covered
60%
60% after
Deductible
OUT-0F-AREA BENEFIT
The "Out-0f--Area" Benefd applies to Covered Charges for a Covered Person living or traveling outside of the
geographical zip code area serviced by the Preferred Provider Organization (PPO).
	Out-of--Area Benefit
Calendar Year Deductible	
Per Covered Person	;1,500
Family Limit''	; 3000
Benefit Percentage	80%
(unless otherwise noted)	
Benefit Percentage/Annual Stop Loss Maximum	80% of;20,000
(unless otherwise noted)	100°/.thereafter
Annual Out-of-Pocket Maximum	
(In Addition to Deductible)	
Per Covered Person	; 4,500
Family Limit'	; 9,000
Physician Office Visit	80% after Deductible
Accidental Injury	80% after Deductible
Deductible Waived first 80 days	
Hospital Emergency Room	80% after Deductible
Medical Emergency	
Hospital Emergency Room	80% after;10000-pay
Non-Medical Emergency	Deductible Applies
Routine Newborn Care 80% after Deductible
Mental 8< Nervous Conditions, Chemical
Dependency, Drug and Substance Abuse
Inpatient/Outpatierrt Treatment Faality	80% after Deductible
Office Visit	80% after Deductible
(see Plan Document for Benefds)	
Chiropractic Care	80% after Deductible
(see Plan Document for Benefits)	
Preventive and Wellness Care	80% after Deductible
Calendar Year Maximum Wellness Benefit	;500
(see Plan Document for Covered Procedures)	
Out-of-Area Covered Expenses are listed in	
The Plan's Schedule of Benefrts and are subject to	
all Plan Maximums and Limitations as previously	
outlined in the Schedule of Benefits.	
*Applies collectively to all Covered Persons in the same family.
NOTE: The Calendar Year Deductible, Annual Out-of-Pocket Maximum, Calendar Year Maximum Benefd and
Lifetime Maximum Benefd are combined for PPO, Non-PPO and Out-of-Area Covered Charges.
PRESCRIPTION DRUG PLAN
Prescription Card Service
Supply Limit
Generic Drugs
Brand Name Drugs
Brand Name Drugs not on formulary
Mail Order Service
Supply Limit
Generic Drugs
Brand Name Drugs
Brand Name Drugs not on formulary
30 days
100% after;15 Co-pay
100% after ~ 45 Co-pay
100% after; 60 Co-pay
100 days
100°~ after ~ 30 Co-pay
100% after ~ 90 Co-pay
100% after ~ 120 Co-pay
If the Pharmacy charge is less than the Generic or Brand Co-pay, then the actual charge will become the Co-pay.
Generic and Brand Name Co-payments apply separately to each prescription and refill and do not apply to the
Calendar Year Deductible or Annual Out-of-Pocket Maximum. To be covered, prescription drugs must be:
1. Purchased from a partidpating licensed pharmaast; and
2. Dispensed to the Covered Person for whom they are prescribed.
Definitions
Brand Name Drugs
Trademark drugs or substances marketed by the original manufacturer whose patent rights are still in effect.
Generic Drugs
Drugs or Substances which:
1. Are not trademark drugs or substances;
2. Are legally substituted for trademark drugs or substances; and
3. Are legally prescribed by a Qualified Prescriber.
Prescription Drugs
1. Drugs or medicines which are prescribed by a Qualified Prescriber for the treatment of Illness, injury,
or pregnancy;
2. Injectable insulin;
3. Oral contraceptives; and
4. Prenatal vitamins.
Qualified Prescriber
A licensed Physiaan, Dentist, or other health care Practitioner who may, in the legal scope of his/ her
practice, prescribe drugs or medicines.
Drus~ Utilization Review
-~ The Plan indudes a Drug Utilization Review program which is automatically administered by the pharmaast
through a nationwide computer network that verifies the eligibility of each Covered Person's card and protects the
Covered Person from conflicting prescriptions which might prove ham~ful if taken at the same time. This program
also guards against duplication of medications and incorrect dosage levels.
Prescription Drum Plan - Druos Covered
1. Legend drugs (drugs requiring a prescription by federal law). See Exclusion list below for exceptions.
2. Insulin on prescription.
3. Disposable insulin needleslsyringes and other necessary diabetic supplies on prescription.
4. Tretinoin, all dosage forms (e.g. Retin-A), for individuals to the age of twenty-six (26) years.
5. Compounded medication of which at least one ingredient is a prescription legend drug.
6. Any other drug which under the applicable state law may only be dispensed upon the written prescription of a
Physiaan or other lawful prescriber.
7. Legend oral contraceptives.
8. Prenatal vitamins.
9. ADD (Attention Defeat Disorder~ADHD (Attention Defeat Hyperactivity Disorder) drugs.
10. Drugs prescribed for impotence/sexual dysfunction.
11. Imitrex, pill and injectable.
Prescription Drusr Plan -Exclusions
1. Interferon Beta -1 B (Betaseron)
2. Prescription vitamins except prenatal.
3. Contraceptive patches.
4. Stadol.
5. Injectable form of legend drugs.
6. Contraceptive devices.
7. Anorectics (any drug used for the purpose of weigh loss).
8. Growth hormones.
9. Immunization agerrts, biological sera, blood or blood plasma.
10. Infertility medications.
11. Levonorgestrel (Norplant).
12. Drugs forthe treatment of alopeaa (baldness).
13. Non-legend drugs otherthanthose listed above.
14. Smoking deterrent medications or any other smoking cessation aids, all dosage forms.
15. Tretinoin, all dosage forms (e.g. Retin-A), for individualstwenty-six (26) years of age or older.
16. Therapeutic devices or appliances, including needles, syringes, support garments and other non-medical
substances, regardless of intended use, except those listed above.
17. Charges for the administration or injection of any drug.
18. Prescriptions which a Covered Person is entitled to receive without charge from any Worker's Compensation
laws.
19. Drugs labeled "Caution-limited by federal law to investigational use,° or experimental drugs, even though a
charge is made to the individual.
20. Medication which is to be taken by or administered to an individual, in whole or in part, while he/she is a
patient in a licensed Hospital, rest home, sanitarium, extended care faality, cornalescent Hospital, nursing
home or similar institution which operates on its premises, or allows to be operated on its premises, a faality
for dispensing pharmaceutical.
21. Any prescription refilled in excess of the number specified by the Physiaan, or any refill dispensed after
one year from the Physiaan's original order.
NOTE: Drugs excluded from the Prescription Drug Plan, such as injectables, which are determined to be
Covered Charges under Major Medical Expense Benefits, are subject to the Calendar Year
Deductible and payable at 75%. Prescription drugs covered under the Prescription Drug Plan are
not subject to the Pre-existing Condition Exclusion Limitation of the Plan.
Prescription Drugs purchased outside of the Prescription Drug Plan will not be eligible for
benefits under the Plan.
Kerr ~oun~Y
Group Term ~'rfe Insuranoa
Agerd
Volume t 000
Basic life Insurance ratelS ,
RatelSt,000 ermonth
Basic AD~psurance Premium P
Total Life mium per month
Total AD&D Pre Premium
Total Annall ADD Prem~m
Tetal Premnrm
5 2,590~0p0
Rat Reduron
~ actions based °n Ongrnal Face Amt
Red
Conversion Privilege
Accelerated Death genetrt
Retirees Covered
pisability Waiver QP ~~m
Travel Assistance
Porlabil'dY
GaN R ~.ooneY° ~eac
110 E Croc-cett 78205
San Antonio2 6exa~ 12101 ~~-~
P~,121D1 ~-
~fayetie l:da
Mr, Finley
Bene51 Planners Mat a+ of Omaha ~ff Wa~Ce t
ING Mr. WaNaca
Mr. Fnley
2 years
2 years g5
~~ ~ age 70
60°k ~ a9e
70°k (t4 age 75 Yes
Yes Yes
2 Years B5
35% ~ a9e
55°~ ~ a9 a 75
70°!° (~ g
Yes
Yes
No
Yas
No Yas
Yes No
Kansas Gity Life M ~Wa ~a~~
Mr. Wallace
gtandard Life Ins
Mr. Wallace
2 years 35°t° ~ a9e 65
rs 35°A ~ age 70 35~ ~ age 75 65°k @ ag 15
35°h ~ aag~e 7U 55°k ~ a~ 75 35°b @a9e
25°b ~ Yes
15°ia ~ a9e 75 70~ ~
Yes ~~~ Miniumum No Yes
Yes No Yes yes
No Yes Yes Yes
Yes
TABLE OF CONTENTS
Introduction
• Mutual of Omaha
Group Life Insurance
Basic Life
• Product Overview
• Plan Summary-Basic Life
Additional Features-Basic AD&D
• Eligibility
Section #
1
2
Customer Services & Claims Processing s
• Claims Processing
• Quality Assurance
• Customer Service Overview
Cost Summary/Funding
• Class Description/Rate Summary
• Rating Criteria -General
• Additional Rating Criteria
4
Mutual of Omaha
D000
Mutual of Omaha
People Meeting Employee Benefit Needs
Mutual of Omaha has a 60-year tradition of providing quality insurance products that fulfill employee
benefit needs for businesses nationwide. Employers may choose from our broad portfolio of products and
services to develop an employee benefit package meeting their specific needs and budget requirements.
Our people are dedicated to serving you with innovative, cost-effective products and superior, personalized
service.
We welcome the opportunity to introduce you to Mutual of Omaha's products and services. Please
remember, as amulti-product carrier, Mutual of Omaha can simplify your benefit administration
requirements as the single-source provider of your employee benefits program.
BYOQd AYYQy We offer you the convenience and efficiency of buying from one source.
Mutual of Omaha's portfolio of group products includes:
of Products
• Term Life -Basic, Supplemental & Voluntary
[~ SBrVlC6S Options include.•
- AD&D
- Dependent Life
• Dental - PPO & Indemnity
Options include:
- Comprehensive or preventive benefits
- Adult and child orthodontia
- Scheduled or UcP~C plans
• Medical - PPO, Indemnity, POS & HMO
Options include:
- Vision
- Prescription Drugs
"' - Flexible Spending Accounts (FSA)
- Consumer Driven Health Plans (CDHP) available for PPO/Indemnity only
• Disability -Short Term & Long Term (STD & LTD)
Options include:
- Coordinated STD & LTD claims management
- "Back to work" programs
• Employee Assistance Program (EAP)
• Worksite Marketing -Voluntary products with complete enrollment services.
Options include:
- Life -Universal & Term
- AD&D
- Dental - PPD & Indemnity
- Criticallllness
- Disability -Short Term & Long Term
Retirement Plans
Options include:
- 401 (k)
- Defined Benefit Plans
- Group Annuities
- Separate Accounts
- Guaranteed Investment Contracts (GICs)
Mutual of Omaha
t 1003
Mutual of Omaha continues
People Meeting Employee Benefit Needs
Sales & With sales and service offices nationwide, Mutual of Omaha responds
Service qurckly to your benefit questions and service needs.
Leadership ~
Experience
Financial
Strength c&
Security
Mutual of Omaha Group Benefit Services is one of the leading providers and
administrators of group plans in America.
• Annual group revenues of approximately $2.5 billion
• Group benefits paid each working day total nearly $5.9 million
• Currently administer over 12,300 plans
• Assets exceed $15.4 billion
• Policyholder surplus of $1.65 billion
Group Benefit Services is backed by the financial strength of Mutual of
Omaha Insurance Company and United of Omaha Life Insurance Company.
Both consistently earn high ratings from national financial ratings agencies,
illustrating our financial stability and sound operating performance.
A.M. Best Company, Inc.	A (Excellent)	February, 2003
(for overall financial strength and	Third highest of 15	
abili to meet contractual obli ations		
Moody's Investors Service	Aa3 (Excellent)	August, 2002
(for long-term financial performance,	Fourth highest of 21	
including improving operational trends,		
excellent asset quality and investment		
mans ement, and stron ca italization		
Standard & Poor's	AA- (Very Strong)	September, 2003
(for financial ability to meet the	Fourth highest of 18	
obligations of our insurance policies		
and their terms		
Mutual of Omaha
1003
Product Overview -Basic Life and AD&D
Providing the Protection You Expect
Class(es) OI Alternate 1
Mutual of Omaha is pleased to present this proposal designed to meet your Group Life Insurance needs.
When comparing our product, service and cost, we believe you'll find our Basic Life offers great value.
COVeYage(S) This information applies to:
• Basic Life and AD&D
Accelerated For qualified persons with a terminal illness we pay:
Death Benefit A sum equal to 50% of the basic life insurance benefit
• Up to a maximum of $100,000
This amount is subtracted from the principal sum prior to payment of a death
benefit.
Grief and Beneficiaries will receive information that will help them cope with the loss
of a loved one. This brochure discusses difficult issues like feelings or how
Healing to help a grieving child. We will provide this to all beneficiaries who receive
an interest free checking account, as outlined above.
Layoff/Leave Life insurance will be continued to the end of the month following the
individual's layoff or leave of absence approved by the employer.
of Absence
Conversions Individuals covered under this plan, who cease to be eligible for coverage,
may convert to an individual policy. The conversion policy:
• Does not require evidence of good health
• May contain limitations
• Must be applied for within 31 days of becoming ineligible
• Can be any of our individual life insurance policies offered, except term
insurance, up to the terminated amount of coverage
Mutual of Omaha
2100
Plan Summary -Basic Life and AD&D
Class(es) 01 Alternate 1
Employee -
Basic Life (flag
Guarantee
Issue
Age Reductl'ons
Waiver of
Premium
Accelerated
Death Benefit
Employee -
Basic AD&D
Amount of Basic Life Insurance:
class ol: $lo,ooo
• In the event of death, the Basic Life Insurance benefit will equal the
amount of Basic Life Insurance after any age reductions minus any
accelerated death benefits previously paid under this plan.
Basic Life: All amounts of Life Insurance are Guarantee Issue. No
evidence of insurability will be required because of the
Amount of Life Insurance.
At A¢e
65
70
75
80
85
90
Benefits reduce to:
65%
45%
30%
20%
15%
10%
Benefits terminate at retirement.
Life insurance continues for totally disabled employees without payment of
premium if:
• Disability begins while the employee is insured by us
• Disability begins prior to age 60 and terminates at age 65
• Proof of disability is given to us, prior to the end of the Disability
Elimination Period (first 9 months of disability)
• Proof of continued disability is verified periodically, according to the
terms of the contract
Amount of Accelerated Death Benefit: 50% of the amount of Life Insurance
in force, but not to exceed $100,000.
The Accidental Death & Dismemberment (AD&D) Principal Sum amount is:
• Equal to the amount of Basic Life Insurance excludes retired covered
persons.
This proposal does not illustrate state-mandated benefits. They will be included in your plan as required.
Mutual of Omaha
4 3110
Plan Summary -Basic Life and AD&D
continued
.-. Class(es) Ol Alternate 1
ADc~D The AD&D benefit is paid if an employee is injured as a result of an accident,
and that injury is independent of sickness and all other causes. We will pay
the benefit shown in the Table indicated below (according to the following
losses):
AD&D Benefit
Schedule
Loss	Benefit
Life	Principal Sum
Both Hands	
Both Feet	
Entire Sight of Both Eyes	
One Hand and One Foot	
One Hand and Entire Sight of One Eye	
One Foot and Entire Sight of One Eye	
Speech and Hearing (both ears)	
Entire Sight of One Eye	One-half Principal Sum
Speech or Hearing (both ears)	
One Hand or One Foot	
Loss of Thumb & Index Finger of same	One-fourth Principal Sum
Hand	
AD&D we will not pay for any loss which:
• results from intentionally self-inflicted injury or sickness, suicide or
ExClllSlO1ZS attempted suicide
^' • results from participation in a riot or in the commission of a felony
• results from an act of declared or undeclared war or armed aggression
• is incurred while the covered person is on active duty or training in the
Armed Forces, National Guard or Reserves of any state or country and
for which any governmental body or its agencies are liable
• is caused by intentional, self-infliction of carbon monoxide poisoning
emanating from a motor vehicle
• is caused by the covered person while intoxicated or under the influence
of any controlled drug
• results in injuries the covered person receives while riding in any aircraft
engaged in racing, endurance tests, or acrobatic or stunt flying
For a complete list of exclusions, please contact your representative.
This proposal does not illustrate state-mandated benefits. They will be included in your plan as required.
Mutual of Omaha
3110
Eligibility -Basic Life and AD&D
Class(es) 01 Alternate 1
Who is Eligible?
Employees All active, permanent full-time persons may be covered. We require a
minimum number of 30 hours per work week.
When Coverage Begins
Current Coverage for most employees insured under the current plan of life
insurance begins on the effective date of the plan.
Employees
Exceptions are shown in this table.
New Hires
Evidence of
Good Health
Policy Issuance
Employees who are:	Coverage begins...
Confined	when confinement ends.
• in a hospital	
• in an institution	
• in a care facility	
• at home	
not at work due to injury or sickness	when the employee returns to work.
a late applicant	when we approve the application.
Coverage for employees hired after the effective date of the plan will be
effective either on:
• First day following the completion of any qualifying period
• First of the month following the completion of any qualifying period
Evidence of good health is required if
• Enrollment is received after 31 days of becoming eligible
• You apply for reinstatement of coverage after the policy has lapsed
We provide the following for your group:
• Master document for the plan sponsor
• Administrative supplies
• Benefits document for employees
Mutual of Omaha
6 2000
Claims Processing -Life and AD&D
Timely, Accurate and Cost-Effective
Mutual of Omaha's group life claim processing and customer services consistently meets or exceeds
industry standards for timeliness and accuracy. These services are greatly appreciated at a difficult time
when employees and beneficiaries need it the most.
Service we set high standards for processing claims right the first time. These
standards assure you of accurate and efficient claims processing with every
Warranty claim submission.
Measurements we measure:
• Payment Accuracy
• Time Service
Payment Payment accuracy measures if the benefit amount and beneficiary was paid
correctly. Our payment accuracy standard is 98%.
Accuracy
Time Service Time Service measures indicate speed of handling a claim.
Our claims processing standard is:
^ 95% within 5 business days
• 100% within 10 business days
Customer-	Mutual of Omaha has alleviated the notification burden that employers and
	the disabled employees must initiate to waive premium. Customers who
centric Life	have both Long-Term Disability and non-contributory Basic Term Life
Waiver	coverages receive seamless transition of information between the LTD
	claims area to the Life claims area. This allows our Life claims area to
Notification	initiate the Waiver of Premium process with the customer directly.
Process	
Quallty we have set high standards:
Assurance To process your claims right the fast time
• To assure you we are consistently accurate and efficient
• All claims are reviewed by a supervisor
• All claims over $100,000 are reviewed by an Officer
• Perform quality reviews
Mutual of Omaha
7000
Quality Assurance
Monitoring the Performance of Our Services
"~ Our Medical Management Quality Assurance staff provides ongoing evaluation of all our services.
Goals we reach and continually improve upon the following goals:
• Monitoring member and provider satisfaction
• Initiation of staff development programs
• Communication of results to internal committees and departments
Guidelines Guidelines enable us to monitor appropriateness in areas such as:
• Time service requirements
• Policies and procedures
S`atlSfaCtzOn Member and Provider satisfaction is monitored through annual surveys.
Training we monitor our staffs training and re-training needs through:
• Survey responses
• Quality assurance review
• National accreditation requirements
Communication we have a corporate quality committee that utilizes results to assure quality
improvements are made.
Mutual of Omaha
g 5002
Quality Assurance continued
Our Claims Quality Assurance staff provides ongoing evaluation of claim processing.
Review Quality Assurance Reviews affirm and measure our commitments. The
types of reviews we use are:
Types
• Pre-disposition
• Post-disposition
• Systems
• Audits
Pre Deposition The unit claims supervisor conducts this review and includes:
• 100% review for all new examiners
• Claims which exceed a specified dollar limit for all examiners
POSt DISpOSItl~OfZ P°st-disposition review includes:
• 2% of each examiners daily production
• 1 % of each analyst's and specialist's daily production
• At least one claim per week for each supervisor, manager and customer
service representative
• Random review of electronic claims each week
• Case-specific and focused re-audits as needed
System Senior Quality Assurance Specialists compare system data to:
• Policy language
• Legislative mandates
Audits we perform:
• Daily quality reviews of selected claims
• Annual operational reviews to monitor office performance and identify
potential process improvements.
Mutual of Omaha
9 5002
Customer Service Overview -Life and AD&D
Providing Service You Expect
Class(es) 01 Alternate 1
Each client has requirements that are specific to their own organization. Our dedicated service team works
with you to meet your requirements.
Services You can count on us to:
• Be accessible
• Document your calls
• Respond accurately and promptly
• Provide trained personnel
• Dedicate a team to your account
Toll-Free we provide atoll-free customer service line. It is available from 8:00 a.m
to 4:30 p.m. (CST). 1 (800) 775-8805.
Line If more information is needed to answer an inquiry, we call back within 24
hours.
Dedicated we dedicate a service team with on-line access to your account. This
approach provides:
Team
• Person to person customer service and claim analyst
• Familiarity and knowledge of your plan
• Accurate and consistent responses
Mutual of Omaha
l0 5100
Rate Summary -Life and AD&D
Alternate 1
.._. CIaSS Class O1:A11 eligible employees
Description
Fully Insured we are proposing afully-insured program for:
Rates Life Class(es) O1
• AD&D Class(es) O1
Life
AD&D

Unit	
Lives	Monthly
Rate	
Volume	Monthly
Total	Annual
Total
Per $1000	260	$.20	2,520,500	$ 504.10	$6,049.20
Per $1000	260	$.02	2,520,500	$ 50.41	$ 604.92
Mutual of Omaha
11 8100
Rating Criteria -General
We have made some assumptions in the preparation of this quote. Changes in these assumptions may
impact the rates or fees. These assumptions apply to all coverages quoted unless otherwise noted.
Effective Date Our proposal assumes an effective date no later than 01/01/2005.
Acceptance This proposal is contingent upon Home Office review and acceptance of the
completed application for coverage. We recommend you do not cancel or
drop existing coverage until you receive notification of our acceptance.
.State Our proposal assumes the situs state is Texas.
SIC We have assumed the applicable Standard Industry Code (SIC) for this
group is 9111.
Expiration This proposal expires 01/01/2005.
Limitations This proposal is subject to our standard product terms, limitations, and
exclusions. Please refer to a sample booklet or contract for these details. A
sample standard booklet or contract is available upon request.
Proposal Our quote is based on our standard product and services. We reserve the
right to re-rate or withdraw our proposal prior to the effective date if any of
COnlhtl011S the following changes:
• SIC code
• Employer contributions
• Information regarding disabled or COBRA participants
• For cases that are experience rated - -risk increases based on review of
current carrier's claims experience including open or pended claims
• Demographics (age, gender, occupation, earnings, location and size)
• Plan participation -increase/decrease of 10% or more lives
• Laws, regulations and judicial and administrative orders and decisions
affecting:
- benefits
- cost of administration
- cost of health care services
• Proposed effective date
• Benefits or eligibility
• Premium tax
Mutual of Omaha
12 8000
Rating Criteria -General continued
Change in - After the effective date, we reserve the right to change rates or fees on
or after the date there is a change in any of these factors resulting from
Rates/Fees or relating to:
• Any modification or amendment of the plan or our administrative
duties
• An increase or decrease of 10% or more lives in the number of
participants enrolled
• An increase in premium tax, guarantee or uninsured fund
assessment or other governmental charge based upon or related to
premium
• A merger or consolidation, or an acquisition or divestiture (through
stock, assets or exchange) of all or part of a business enterprise
affecting the customer's employee population
• The enactment, issuance, amendment, or enforcement of any law,
regulation, judicial or administrative order or decision, including,
without limitation, any law allowing competing health care
providers to bargain collectively with health plans, insurance
carriers or health maintenance organizations
- In addition to the right to change rates or fees in accordance with the
preceding paragraph, we may change rates or fees any time after the
most recent Rate Guarantee Date, provided the Company has given at
least 30 days advance written notice of the rate or fee increase.
Booklets This proposal includes charges for booklet printing in our standard format.
Claim Claim processing is handled by:
Processing United of Omaha Life Insurance Company
Mutual of Omaha
13 8000
Additional Rating Criteria -Life and AD&D
Class(es) 01 Alternate 1
We have made some assumptions in the preparation of this quote. Changes in these assumptions
may impact the rates or fees. These additional assumptions apply to Basic Life and AD&D.
Standard This proposal requires use of our standard system-compatible benefits and
contract provisions.
Contract
• Applicable Federal and State mandates are added at issuance
• A sample standard contract, certificate booklet and/or subscription
agreement documents are available upon request
Underwriting This quote assumes the underwriting company for Life and AD&D will be
United of Omaha Life Insurance Company.
Company
Rate Guarantee Basic Life and AD&D rates are guaranteed for 24 months.
Funding Our quote assumes this coverage is Fully-Insured. This coverage is not
eligible for refunds.
Section 125 The Certificate will not include complete information regarding the election
changes which may be permissible under the employer's Internal Revenue
Code Section 125 cafeteria plan. The employer is responsible for
establishing and maintaining a written cafeteria plan document and
communicating the terms of the plan, including permitted elected changes,
to their plan participants. The employer should consult their own legal
counsel regarding these issues
~' llgllllllty Employees --We require employees to work a minimum of 30 hours per
work week in order to be eligible.
Requirement
Parh'cipah'on
Assumptions -Employee
Coverage	Minimum Participation	Eligible	Covered	Plan Sponsor
Contribution
Basic Life & AD&D	100%	260	260	100%
Mutual of Omaha
14 8101
Pra~ct ~3verv~ew -Consumer-Driven ~ieaith Plan
Empowering People to Take Personal Responsibility for Their Health Care
Health care benefit costs are increasing annually at a double-digit pace, causing employers difficulty in
offering benefits necessary to attract and retain the best workforce possible. Mutual of Omaha's
Consumer-Driven Health Plan combines high-quality benefits with features designed to engage employees
in becoming active consumers of their own health care.
The Consumer-Driven Health Plan has web-based tools that help employees make better consumer
decisions. Included is access to information on: choosing plan options that fit their lifestyle and budget;
provider quality information; status of claims; health and wellness education; and access to personal health
reimbursement account activity.
What is the Mutual of Omaha's Consumer-Driven Health Plan is apatient-directed
health plan that encourages employees to participate more in the cost of
Consumer- their health care, become more involved in their personal health care
Driven Health decisions and come to a higher appreciation of their benefits.
Plan ? The plan includes three components:
• Group health coverage
• A Health Reimbursement Account (HRA)
• Web-based tools
Ben of tS t0 Increased employee satisfaction with health benefits.
• Plan design flexibility allows employers to tailor benefit plans to their
Employers needs.
• Employees see true costs of their health care rather than being insulated
..-. through flat dollar copays.
• Analysis shows that employees incepted to choose health care services
wisely contribute to lower plan utilization without sacrificing their
health.
• To reduce the potential for adverse selection, we can assist in selecting
appropriate plan options and price tags.
• If the employer replaces their current plans with our Consumer-Driven
Health Plan, all employees will be in one risk pool that may translate
into more control in curbing health care costs.
• Our Total Care Management programs help manage the care of the
small percentage of employees with the highest percentage of claims.
• Provides an innovative and attractive benefit package for recruiting and
retaining good employees.
Mutual of Omaha
7 3810
P't'~~~~: ~~~t~~'i~W - Consumer-Driven Heaitil Pian
continued
'~' Empowering People to Take Personal Responsibility for Their Health Care
Benefits to The freedom to choose from a menu of benefit options rather than
being limited to one pre-determined benefits package.
Employees More control over how health care dollars are spent- they appreciate
the opportunity to spend their health care dollars their way.
• Satisfaction of becoming more personally involved with health care
choices and decisions.
• Preventive/Routine benefits generally are payable at 100% (up to a
predetermined amount), encouraging employees to receive routine care
and stay healthy.
• Unused HRA funds rollover to future years, building savings for future
covered health care expenses when needed (while covered under the
Plan)-
• Consumer-friendly web support tools and information that help
members make effective and informed benefit decisions.
• The freedom to see any provider, but also the benefit of lower out-of-
pocket expenses by using preferred providers.
• Plan option may realize lower employee premium contributions than
the current plan.
Mutual of Omaha
3810
Pr~c~uet €~w~r~i~w -Consumer-Driven Health Plan
continued
Empowering People to Take Personal Responsibility for Their Health Care
Group Health Mutual of Omaha's Consumer-Driven Health Plan provides:
• Health coverage for expenses that exceed the plan's deductible.
Coverage A plan deductible that is generally a high value (e.g., $1,000 - $5,000).
• A wide range of deductible, coinsurance and out-of-pocket limits.
• Preventive/routine services that can be paid at 100% (up to a
predetermined maximum).
• A separate prescription drug plan deductible, coinsurance and out-of-
pocketlimit that
- better supports people with chronic conditions
- while still involving them in the cost of the prescriptions.
Health The IIRA is:
• Offered in conjunction with the high deductible health coverage plan
Reimbursement option.
Account (HRA) Funded by the employer with apre-determined amount.
• Used by an employee to cover out-of-pocket medical expenses.
• Set up so leftover funds roll over from year-to-year as an incentive to
employees to use their funds prudently.
Flexible
Spending
Account (FSA)
In addition to the H1ZA, our Consumer-Driven Health Plan can also offer a
traditional Flexible Spending Account (FSA) option for an additional cost.
Initial Set-Up Fee:
Communication Material:
$500
$1.55 per eligible employee, as
requested annually
FSA Fee: $3.75 per participating employee per
month (no commission)
$4.20 per participating employee per
month (with commission)
Debit Card Fee (optional): $1.50 per participating employee per month
Web-Based	~ addition to printed communication materials, Mutual of Omaha's
	Consumer-Driven Health Plan offers several web-based tools to assist the
TOOLS -	employee in making a plan option decision and manage the use of health
Pre-enrollment	care expenditures. Included are:
	• An overview of the Consumer-Driven Health Plan, including how the
	HRA works.
	• Sample claim examples to compare against your employee's claim
	experience.
	• A worksheet to assist employees in determining which plan option (if
	applicable) would best meet their needs.
	• Plan summary information detailing covered services for your
	company's plan options.
	• Online provider directory.
	• Access to health and wellness information, including a health risk
	assessment.
	Mutual of Omaha
	9 3810
Product overview -Consumer-Driven Health Plan
continued
Empowering People to Take Personal Responsibility for Their Health Care
• Provider quality of care (through Healthgrades link).
• Glossary of commonly used terms.
• Frequently Asked Questions about health care coverage.
Web-Based After enrolling in the Consumer-Driven Health Plan plan, the employee
will be able to:
Tools -
Post-enrollment Access the same information available during pre-enrollment (as
described above).
• Check medical claims status through online inquiry.
• Access their HRA account balances and activity.
• Print forms (e.g., full-time student, other insurance).
• Access prescription drug information and a list of drug formularies.
Value Added Our product offering includes a full array of value-added services that all
medical products benefit from:
Services A nation-wide network of preferred providers in more than 300
metropolitan areas.
• Total Care Management, which integrates all components of health
coverage to improve quality of care and help keep costs down with
medical management, cost management and pharmacy intervention
processes that seek the highest quality health care for the most sensible
use of health care dollar. Programs included:
/ Healthy Pregnancy
/ Utilization Management
/ Case Management
/ Disease Management
/ Medical Specialty Network
/ National Ancillary Network
QIItI~OnS We also offer the option to purchase additional services for your
employees:
• Web enrollment
• Nurse triage services
• Debit card option for point-of-service payment of out-of-pocket
expenses from the plan member's HRA account
• Employee Assistance Program
• Behavioral Health Management
Mutual of Omaha
l0 3810
Pr®duet overview -Consumer-Driven Health Plan
The Health Reimbursement Account
The Health Reimbursement Account (HRA) is offered in conjunction with a high deductible medical plan
and is funded by the employer.
Sales/Service ~' experienced, professional staff can assist you with:
Team Administration
• Communications
• Enrollment meetings
• Compliance with laws affecting HRAs
Track A dedicated staff, certified in Flexible Compensation Instruction and
members in Employers Council on Flexible Compensation (ECFC), is
Record assigned to your HRA account. They bring with them a track record
demonstrating:
• Quick turnaround of reimbursement checks
• Accuracy in administrative services
• Experience in administering similar programs since 1986
Service The key features of our HRA services are:
Features	Employee communication packets
•	Prompt claims reimbursement
~"" •	Automated medical claim interface
•	Debit card option
•	Toll free customer service line
•	Web site self-service
•	Automated information line
•	Administration manual
•	Prototype plan document and summary plan description
•	Employer and employee reporting
•	Data protection
Mutual of Omaha
11 3820
Pr~t~uct overview -Consumer-Driven Health Plan
continued
The Health Reimbursement Account
Employee four employees receive a communication packet that helps them understand
the HRA program. The packet includes:
Communicah'on
• An introduction letter explaining the program
• A brochure summarizing how the plan works
• An enrollment form
• An envelope
Prompt Claims Claims are processed daily with a five workday average turnaround from
receipt of request to claim payment. Checks/Explanation ofBenefits
Reimbursement (EOBs):
• Are mailed directly to the employee's homes.
• Can be direct deposited to employee's bank account.
Automated An automated claim interface process is in place to pass eligible medical
plan expenses (i.e., deductibles, copays, coinsurance) to the HRA system for
Claim Interface automatic processing and payment. This reduces the employee's manual
filing for reimbursement of eligible out-of-pocket expenses from the medical
plan.
Debit Card The debit card option automates the process of paying for eligible expenses
at point of service. The debit card:
Option Is loaded with the employee's annual election for each account.
• Enables employees to use the debit card only at eligible reimbursement
account locations wherever MasterCard is accepted -such as a
pharmacy.
• . , Allows approved expenses to be automatically deducted from the
employees account.
• Reduces paperwork and administrative hassles for the employee.
Toll Free Line we provide a toll free line for employees to call for claims inquiries.
Benefit counselors can assist employees from 8:00 a.m. to 6:00 p.m. ET
(Monday through Friday, except holidays).
Web site Employees have access to their HRA 24 hours a day, 7 days a week. The
website offers:
• Secure access to account information, including balance and claim
history.
• Submission of questions or address changes on line.
• Claim forms and other documents for downloading and printing.
Mutual of Omaha
12 3820
Pl'4dtIC~ ~verv~e~v -Consumer-Driven Health Plan
continued
The Health Reimbursement Account
Automated ~ automated telephone system provides employees with instant access to
their current account information 24 hours a day, 7 days a week, including:
Information
Line Total claims and payments
• Account balances
Administratl'on ~' administration manual gives the plan sponsor information on:
Manual Enrollment processes and use of forms
• Reports
• Claims processing
Plan Document we provide a prototype plan document upon your request. The plan sponsor
is responsible for having their legal counsel customize the plan document.
Reports we deliver a full array of standard reports to meet your needs and the needs
of your employees.
Data Protection Maximum protection of data is provided through full daily backups.
Mutual of Omaha
13 3820
Proc~~ct ®verview -Consumer-Driven Health Plan
continued
The Health Reimbursement Account
How the HRA Works
Prior to the The Plan Sponsor determines the HRA amount to be funded for each
employee electing the high deductible medical plan in conjunction with the
Plan Year xxA.
The Plan Sponsor prefunds our bank account with 4% of estimated annual
paid claims. If a debit card option is selected, the plan sponsor will also be
required to prefund an amount equivalent to 4% of the cumulative plan
elections for a prefunding total of 8%.
Reimbursement `~ automated claim interface process is in place to pass eligible medical
plan expenses (i.e., deductibles, copays, coinsurance) to the HRA system for
Requests automatic processing and payment. This reduces the employee's manual
filing for reimbursement of eligible out-of-pocket expenses from the medical
plan.
To receive payment from the HRA account, employees can manually
submit:
• Proof of their expense
• A completed reimbursement request form
Minimum ~' nLn'-"'um reimbursement amount of $25 is recommended. Expenses must
reach the minimum amount before they can be reimbursed.
Reimbursement
Time Service Reimbursement requests are processed daily and reimbursed within five
workdays of receipt of the request.
Mutual of Omaha
14 3820
Product Overview -Consumer-Driven Health Plan
continued
The Health Reimbursement Account
Employer Reports
Type of Reports Our reports assist you in completing Part III Schedule A, Form 5500.
Employer reports include:
• Activity Summary report
• Check History report
• Detail report
• Year-End Report
Reports are available electronically via File Transfer Protocol (FTP), a-mail
or in hard copy format.
ACtI~V~ty We provide a quarterly activity summary report for the plan sponsor. This
report summarizes:
Summary
Report Year-to-date account information at the company level.
• employer risk based on annual elections, contributions, reimbursements
and balances.
Check History A fax or a-mail is sent every week detailing:
Report Checks issued
• A request for authorization for a funds transfer to cover the amount of
checks issued
A monthly check register is also provided to the plan sponsor.
Detail Report The detail report is distributed quarterly. This report includes year-to-date:
• account status for each employee
• claims paid
• account balances
Year End A year-end report is provided following the close of the plan year via a final:
Report Activity Summary Report
• Detail Report
Mutual of Omaha
15 3820
Product ~VerVieW -Consumer-Driven I-~eaith Pian
continued
The Health Reimbursement Account
Employee Reports
Type of Reports your employees are informed regarding their xRA account through the
following reports:
• Checks and EOB
• Detailed account statement
Check/EOB Checks/EOBs are mailed to the employee's home (unless a direct deposit
option is elected). Each check issued includes an EOB indicating:
• Year-to-date payment
• Remaining account balance
EOBs can be provided via mail or a-mail.
Detailed ~ account statement is sent via mail or a-mail to employees following the
third quarter as a reminder of their remaining balance. ,
Account
Statement
Mutual of Omaha
16 3820
Product Overview -Consumer-Driven Health Plan
continued
The Health Reimbursement Account
How Administrative Responsibilities are Shared
Duf., We are responsible for:
Responsibilities Processing and paying eligible expense reimbursements weekly.
• Requesting funds be transferred from the plan sponsor's bank account to
cover the amount of reimbursement checks issued (e.g., automatic debit
against the plan sponsor's account).
• Faxing a weekly check history to you for bank account reconciliation.
• Providing standard reports.
• Providing a detailed Administration Manual.
• Assisting you with enrollment meetings on a fee for service basis.
• Providing a prototype plan document and summary plan description,
upon request.
Employer You are responsible for:
Responsibilitl'es Making plan provision decisions, including the HRA amount to be
funded and eligible expenses.
• Completing the preliminary application and service agreement.
• Customizing the plan document and summary plan description.
• Prefunding our bank account with 4% of estimated annual paid claims
(If a debit card option is selected, the plan sponsor will also be required
to prefund an amount equivalent to 4% of the cumulative plan elections
for a prefunding total of 8%).
• Authorizing ACH transfers out of your bank account to cover
reimbursement checks.
• Notifying us of any additions, terminations or changes.
Banking we need the following information on your bank account:
Informah'on Name and address ofbank
• Account number
• Transit number
Mutual of Omaha
17 3820
Product Overview -Consumer-Driven Health Plan
continued
The Health Reimbursement Account
Implementation Schedule
Planning and Thorough planning and preparation prior to the effective date assures
successful plan operation. Our experience and implementation process:
Preparah'on
• Identifies each step of implementation
• Assigns tasks to responsible persons
• Ensures requirements are met or exceeded
Time Table we recommend using the following implementation milestones prior to the
effective date:
60 days 60 days before the effective date you:
• Make decisions on plan provisions by completing
our case detail brief document
• Distribute enrollment packets
• Begin open enrollment period
• Hold group employee meetings
35 days	35 days before the effective date you:
	• Close the open enrollment
	• Review enrollment forms
30 days	30 days before the effective date you:
	• Submit enrollment data to us
20 days	20 days before the effective date we:
• Have enrollment data on the system
• Send administrative materials to you
5-10 days 5-10 days before the effective date you:
• Distribute reimbursement request forms to employees
• Provide web site information to employees
Mutual of Omaha
18 3820