HomeMy WebLinkAboutJanuary 2004 •
CITY OF OAK PARK HEIGHTS
C1157
January 1 , 2004
• South Central Region of the City, County, and Other Governmental Agency Service
Cooperative
January 1, 2004 Renewal
TABLE OF CONTENTS
1) Renewal Rates
2) Projected Renewal Year Claims and Renewal Development Summaries
3) Combined Experience Reports for Periods 1, 2, and 3
4) High Case Report
5) Component Summary Report
6) Utilization Graph
7) Population Distribution Graph
• 8) Age Distribution Graph
9) Claims Distribution Report
10) Benefit Descriptions
11) Miscellaneous
•
• January 1, 2004 Renewal Increase
for
CITY OF OAK PARK HEIGHTS
CI157
Increase:
2003 Rate 12.1% 2004 Rate
DOUBLE GOLD
S $405.56 $454.50
F $1,115.26 $1,250.00
•
• South Central CCOGA January 1,2004 Renewal
CO •
O
-C O
O N CO O CO O CO 0 r ti O LO
•C O r O EA EA °_ �t C D N ° cr N
) N r N N N CO co O _� CO <- c.6
0 4 N EA EA N N N CO CN EA co
U , EA N EA EA ER EA '-
N• MO a
'5 O
Cll (o
n N
X •,-
W O C
r 0)
O X
N
O
-co O
O N N- Q) 4 co 4 O L)
•i r- <- V' O CO EA CO - CO
° M
�N CO O N N N N M Cv)CO N d EA N CO CO
(I) '- CO `-' N N N Lf) N
U , ,�_ CO EA _ 64 EA
Cq) N EA EA EA EA
• O
C
N O
0- N
X
N W O
EM
▪ O
O O
U O N N CO CO O CO 1,.... ..
CO ° O CO
C r ) O 1- O co EA A °
L O CO !_ N- p C N O M- �3
CD N • N '
I EA IC)
EA l[)
EA I- N
EA EA EA
>-- 2
• C O
vo 7 Q O
N
X
...
W O _
9
O 0 C C
O O C C C
Ii '
W <- Q Q d
O o 0 0
N LO CT CO
CD
ca f c6 cO ----\
L c) L C
°- EEE
N
L N N L L�
Q. a n a
Zr 2
(C CO o Q
in- o 0 0 0
E r r t- E
CLS CC) co C6
(C 0 .0 .0 . 0
-o�' c 0 0 C, m
o 0 m E 2 2 2 E }
to °) U M N U 3
= a) @ co N o 0 CO c`a E
cn �, a)
C9 �_ m O O O c a E
LTi co_ L a) N cv N O N
=• CCf C.) co N E U w CO O 7 - C� 2 )
3 O N O r N co O L CL as 0 11 d O c>6 d Q Q U v co, O co Er E d C CV
O �' W (n > to p N O a
d' a W U p o 0 o v 4 m co
O i E i _ J _ O o) co cn LL
o N O O c6 RS ,C cB O0. 2 cn O a) N O•
r W a >- d 0 h U) F- 0 CL S' a N
>- O U co
i, C N
O O c- N CO V LC) CO N.: O C)) . 7 LC)
I
1 �•■ N
r
V COO if r °c ° M
Q C O• O CO O N N O r
r d CO CO CF CO r '[t <- - d
N N u7 N CO CO
W ER ER e- ER �•- r
• ER 69 ER 3
W aa)
C
a)
M
'p r M r C7
M aco, r
co
co c O
N O O co
'C 7 O O N co' O)
V 69 69 r ER O CO
'41; Q ER ER ER
U)
a)
(o
C ` O C
N d N
L.
= E U
0 co
2 o
T
c0
a-
u)
r OJ r O O C`7
L71 0 E iS ; O 8 1� Cp
V E r l(J In O E � CO �+ 2
CC as CO
LL. FR Efl ER Ffl LL') .0 CD
E CO M , coo U �.
M It)) co co co co o c
CO ER 6N9 d O N `7 ti O O M M j
�" N CO O Cf)tI CO QQ
V N N � ERA It) �— ,0 0
ER ER ER I 0 0
CD 0
�
ILI C
E U
o
a)
E c
N
C
U
CD Z
Q 1 C N
r1� L E..i 113 2 Q ° C CI_ cn
0) c E E a E E
C m Es cc E a) 2 co ‘.."'‘ a o
y p v a �, E
�/ O m CO a) m t c 0_
co a) CO CO m 3 O v v) m
w m m >' 0 o c aoi @ t E
r= 'm
m a3) a) 3 O O ns ° c o �� c`o
aci aci c C7 a °) 0 c
O � a) uJ m co m
J E a m
N N 'O u) m = N a 0 N a) 7
aU) aUi v E O 0 ` ° 00 U a) o a
O O N C9 0 0 C d a)
'0 U 0 O W .0 C
s. a a ` co Cl) J i V Q O O
0 'O -p a C C E U U m O a) ; N 'O E
V '0 a) a) V A O •@ a) C 0 0 _V a) in C r S'
t m m t m 0 U ° m 0 Z u- a) 'ET) ° �� = v)
3 3 a3i o m CO a@i m r ° �� p 7, a)
x m 0 o CO- E u) 0) o E E CO � CO M CO E °, Q N m
W a) 0 0 0 V E C o o •@ a3i L `F.° uN) c C U �'V C
_ N N N U .E, "O O 0 C V 0 0 (0 d V) V W C CC6 5 a) a) co •C -O J n• I 'a a) ' - C
3N- rN" N O L a d N •� > d C in a—) 0 cO `� 0 .a)
M 01 N r N (. a 0 o) a a E .D C 0 0 c`6 ,-• Q a) a) co
dd N O O O = >>O o o U O Q a. co F- �S Q. , N N N 0 U > o o D O V U C G N
Q C �+ O O Q 0 .a U 'O a) F0 0 C N O. N
O N — r r a) O` -O c0 L
LL O a) 7 L n Op a) 0 cn
N 0 a)co
N C "O 0 a) C 0 O
O� o d 2 0 d H- z 0 M `O °o
LL + N
0 co. r N c7 7 6f) CO N- O 6) r s Cp
N-
• C co
N
O N
W
co
p to
to
a) o
z -
To
-0 3
o a)
N a c
U I M N U G
U 2 -0 7
u) O c
0> co d
O
U
O O O O O O N D) 7 t) co M U Cl) p
) ui
— o o O O O O CD h W N r--.. to O o . co
c
E d ca0 0 0 0 0 0 O C') O tf) O a a = O_
64 Efl s 64 . 0) CD CD 0) N O r = E O L CC)
d 69 64 69 69 64 69 N y 0 E
._ -° •'
'c � c ° a)
CD 7 0 CO a)
C1 U U
a X O > CD
0 0 0 0 0 0 CD co V N- to U d t6 C
1.-... 64EA t!964 Eta 64 V CD to N 0 C n . N C "a ton
0
N LO CO t-- ) M
N.-----.. E C M CO O , to N O U
U N
co 69 < t E uER to a> a co v� E c L O a a)
0 p N
a CD _0 a 0 `°
Q N 0. U N , c
Q a a E o O
CO
ID '� a n
\ L
d. P N � 609 � � �� � U m O V co d U 7
•� N O CO M V r7 CD C6 r N
CD to 64 N 64 64 FD 64 N T o) C6
U L a w oT m c c
C a 0 c .3 _E
o aN E C
O m E- o
— N c
)
L a) N 0 0 0 0 0 0 0 CD CD M CM E N N .0 N N U 0
U E 6 i9 A 69 69 L
0 'O - U .
S 0 CD r In V D o CD x > 2
O W' tooNrinCD n of
CZ 64 ER ti Q C N CD.
Q a o 69- E» U =
5 .] U
C
�`E c o >,>7 o CD E p �o .
.0 p c a)
o_w c -O
C N w 0 0 0 0 0 0 f` N N N N N L Cp E m
C \ TA, EFT EA fR ER EFT V C7 CO CO CO OD N U O
O N- 0 0 o co cD co co m .- m 9 'a..)>- w g
0 CD CD to o o o 7 U O -o co
N e f fl i0i» » i� fl 64 ED ma 6 m
N co N> U J
-V
U U U a E. ..=1
cu co
c r E N U U C o 3 C
p 76 ' 01 0 C U
o
p i000000 � n in �c a �° ._ E
a,o m a)N a) co a) O) j\ S U N d U N
S E U O E 0 Cn
C) a L• U N CCD
o _w O O U
0 0 0 0 0 0 M M N N N N V C) O CO U CO p Ca
O Ca O N N N N N N C d U >. a)
H "0 U !n U 2 O 0
C
U_ C!) [1 O
C N Z
0 7 m L - LO CD
0 > U 0 . j E U
to c m O N m _
To c 2
t"` >, Cn 0 0 0 0 0 0 N N N N N N N is N O E O O
V - 0 ,- <- N- c CD Em N V >,
o O C U f0 fa U .0
C6 E _� w aa)i O U 0 U Jo a) -o
LL C
Cr) 0) (6 p f0 U N U N
F- U . ._ .0 o c c `m c
= o > c -o y o 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 O m d C� 7 Q N N
_ U
LLI Ca as o_ U @ C
O as
a)
2 N C N Q w >, , C a) N E 0
Y is to 0 c a CD `m C y m `)
E a) t o o m - CD Q o 2
d = Q d � 000000t- .- 0000 �-y @ � in d
S d J E CJ m L °) _ to
Y U c co a) `o ° a H E
Q 0 in c co E .0 c a) > c
o W ° C m °) H ° a
LL o C U 0 U W (i) a V c o
D ato 00000000000 _N ■ 73 a aa)i Cj m 0
› p - C 0 0 0 0 0 0 0 0 0 0 0 CN D
E c3 C N N N N N N N \ N N N N C > > , N ) a) 'Co"
,- o4 . O O d n U o - = 14 0000f 0 d a r Z c
1
• N
N N co
R e-
lf)
O N c-
R
CD D to
Z -
-0 Ca
O N
` c
C m U CC CO
wPc o N
R O E v3 U) a)
d N d C
> D. r. -a o
m E 0_
-O C
Cn CO c
R
I U N
N O N r h CD CO O) LO CO N- N CO O >, U) co U
R a CO N 0 R CO r r LO CD h M N (D O c CO C
N N. LC) N CD N LU d V CD O V . . 7 O
E.d O N O N LO r N LC) N_ CO CD O _ E O a).m
11) co M N ;n 0
a 6.3 f!9 Cfl ff3 C!3 Ef3 to CA 69 69 H3 C�9 69 (0 N Cn O E
>. oO co
'C f) C CU
N 0 CO CD m
0. .) CUB
'n X O > CO
7 N. CD M N. CD M CO N M N r N ` a) N CO C
N �' CO LC) •d• CO CO LO CO ,- CO CO .L-. N C a to
CO V co N r R U) N- M r M r O C R
^ E tO CD CC] CD LO r a LC) N. CD CA aO CV O U .. a) N
C`') N CA H3 V3 V36969 EA E9 V3 N > CO (0
L Q Q to v3 E9 c a C)•O
O
C2- C\I 63 -o u> R � =
\ 0. a)
o
d Q a a E 0
C�\ N y CD tO co O In N O M C cm m L) a >
O 2 m U c O.
a) E
..:t' 'O
C co M M CD O O r N. n O) O N- M C 1 CU
3
rtJ Q •- . LO CD N O C) co V' N- 1"- CD CO LC) CO
O 0 CD N N iN M r M CO M CO @ R U .0
0 a y � � F» rcflEa � �cfl�vuv o >,c O as c
•0) n m 3 R
•C•-+ , o
r
0 U > o O O CO L' N CU Nc
' N >, N 0
W CU U) C) V C) CO CO LO CO LO 1-. O N d '
S X � N D m LCN O O N (D to N LO O NCI)O . r c- LC) M CO O O LC) r co b c) b Cu ..N- C > y
> - R N CO ti O O N r o N CD o CO O E E@
CII O L 7 E Eft ea 69 r N Cf3 r N CO 1- C 0 a) o.S W Q O. W U Ef3 E3 E3 fA 63 Ef3 Ef3 O
j J .t C)
O a) o D3
O Z)
>+ N E C 3 as
.� p CD
ac 14 ow a) E—N d C
N N N N N N V C V V' 'V 7 V O L '-n., C C
\ E co O O CO V C V' V 'Cl' 'r V V C CO N 'O — N O R
O O CO CD CO CO 0 0 0 0 0 0 0 0 O }
U CO CO LO LO tO LO to LO l!') lI) LO C!7 m N -� Cl)
NH3 V3 63 6.3 V Ef3 63 69 69 ER E9 V3 c- (U O) C-O U m
N f6 Cn'� N U
N— t O .c y 0 m
1 O U U 0_ O
I a) CV E a> 2 a) c o >• c
C Q CO Cn .0 Cn f0 O C E
Q N c- O) O) Cr) O) O) O) C) O h 'O �O - U O .0 O E
.� N LO LC) LC) LO V V C' V V C LU C) C N a) a m E
E \ S O) C N f1 O-N
E co• L O E X C O in CD
w -o b O
_ a, Ca E u, w
Q N N N N N N N N N N N N N C' co 0
CO N as.0 CO
�� R N N N N N N N N N N N N CD • a C • O.7° a) > 0)
0 ` N N . L O >-
C
,O N U O d O
C 'O C N'> 0) d C (1)
O O . CO O O CO
ti V o > U- -c,€ > E m ° N 3 °c n c o
r _ � E 0 C9 T a N N N N r r r r r r r r CO
U R U n.O d
y 1 E m
CO r ° c m `.ao m
U. S. ,,, a) " a .0 r
Cl) � @ C CN a• 7 w
F U v o O _
a s o o R o a c -
O >,L0 0 0 0 0 0 o o o o o C o c
lc
ccs o 0= 0 C i c c 5 u> ZS
m it o. a) c o W n
I d
N Q a) >, m > aci n. E p
E C >+ U
Cr E N U _o o) a) D' o > m n. C
< C) E .c'5 -o w d O
. 0. J U O O O O r r r r r r r r N U ~w :� c a) C C LO
(L/ U _C N N Vp O� -OOH T ID
Q Q to C N E C a .O co CO
O c) W U O '� F Cl d
LL 0 Ct 0 U Cn .O a) .c
W M
• N it d N N N N N N N N N N N N ' 5 N C C 5 a) p
• r Q- L = 000000000000 y O N -O -O CU W O N
C '- 0 0 0 0 0 0 0 0 0 0 CD 0 E O
U C C N N N N N N N N N N N N +R„ N.- C > > > N O) Cl) M
r 0 0 N M In (D C) O O d U 2 `O co N a) a) C,
U o z � � 00000000o r i- Q n 0. d z m n
0 y i N
76 E
CO
LO
O N CO
fa EA
a) a O
z
o a)
c
a d y a) c Q
fr
111 a C N CO U a a)
ca .O E N q
a> a)
o
Cn > a 7
C .O
as a)
oo a) a)
goT m o y rnvi
aca <>••,. c COC
E2Nv C• T a = a).4
Tames N n f ° .cm
co f» <fl EA m y o f
T = >. LO y
•C 'a' c
co c a7 (a 41
0. U �.
-O X O CO
N cN N- LC) M L.. CO C O
_ V co co a)j C c y co
,�� CO O E9 N 0 •> CO W a)
S.. O o E�3 -- y a) a U a
p O -a ) °'
C\1 = ti a —
C Cl) y
1 L c
CO
6 > m c Q
in 2
W O •� ; (T M N O iii Y N
Oy R N a) >' O)Ca
U acne, o 0) C =
an c
N 0O E v _ � a>
O U
.L - y m N w O co
= C6 N > y
X > a' ,� C) co a E 0 CC
(� y0 L ['7 - Q C a) II
_C)W Q a W U EA EA b4 0 •
>+ 0 E
= oT co
-
— O -°c co a) c C E
O ° , _-a
C - ccv — - a) a :F. co oC
C E CO 0) N - C a)
oN coi co LO N o) �} a0
CV 69 En Eft a) C O'O U CO
cc cc O .0 a) L N O N m
o .>.. a > d 00_c
CO E y N a) C O 5. C
C
O N y Ca O C f
O � vvo rn a 0 �° -° E a)
N c> m c a) n na)
E U � O E o - m Cn
0 O a> U X c Ca
oN a
N y
E
@ � .,- o o m a' a o
o N N 7 - C • a.D a) > EL
a
U CZ C O
o aa) C '00-� m L '� a) W .m
E E
L-
EO 1..1 C
co o y Oi y m 3 N C 0 p
T y r N a1 a CZ O y a E o r C
o – U 1- 1.- N C CO E o y a T
.E 2 � 0 C > . c c Q 'C)
C N a .
0. C E o Q) U U O E- t
CO o m o m y �. n w
F- o a a) o = zm
= a > c =E m
y c O a)_ C a)
CD U c) c) O O oz O O Q c y U
fl d C co o.p a) = N
6' = N Q ) T CO f > o N E o
Y cp CO N O a) o =p 16 co 2 a)a co U
Q Q) C V E Z a (a Q) Q. O 2
Ill Q. C Q N .�y.. O co m a) L E y C T d
CL) J U (.� m N L Q) C
Ce
Q U N i 1'] i- i : esi
d O om .
U_ 0 C U 0 U W U) ~"E.
Q ° -_= co
O m
N C) Cv .+ -o O Q O Q O
7z-; .c o o _o C a a m W O `
O V O C O O R ' O O O >. 'CO- 0) a) N
U o Z C.) H 0 c d a CL >- Z U in
-4-
(Nt
U)
co
, 0 a
TO
a)
c
a)
Ct
Cl) Cl) L
0 o
0 0 0
TO TO To
I— H H
T N co
O O CD
CD CD O
-1-0 N N N
L N N N
OT T 0
Q 1 N
r N CO CD
N O O O
• N N N
L1_ T T T
CD O O O
L � _ •
CO c c c
U 2 E_ _E 2 E
a) .(f) ate) .2 ate) .
CY)
i _c ,_ .c L .c
c a) c a) c a)
U - P
L e) s- 4) L Cl)
N- 0
Lr) O U O U - U
U 00 00 CO 00 CO
U) C� r.. d' .,.. N .a-.
i E _E E
CD U CB (� CB
L!1 '6 D U D U
D i 'D i D L
a) -0 a) .Q a) -0
x E X E X E
U) E U) E U) E
E O E O E O O
Q a) ca C ca c c�
O Ct U " U " U " 2
LL o m a) a) ccv'
• �_ E 45 E E' E a)
a) a) m
U Fes- H H `o
0
N
M
N
En
• 0 v r p
;,
-4-, _
0 En b .„.•
r-•
bUA al p rn N •a.
,-' •+-' C�, +' J s.
U ¢ •- • +-, 4■ -0 r1;
U
U
0 cC 0 >' 0 ^" CA
Y ' > CID z 0
•� 0
0 N O CZ -- U z. C UCd C �- r" � U a) O ,-,
. O Q C ,
?p ''-' � aj U
Cl)
▪ . ° = - , fY CC
. N O r �
- U • U C) ., A .-. r. r.ct
4- n V - N a, p (-,1 U O •
, . D H - a c- d=, U cd a, p y
Ch rte" •c: U pp p_ n�'
ail • rn U `d .' C U O U C U .. •I ..,,N C C.)
a7 O•., 'b • U •O O" ' 0 ? a � u -� U O
� O
14 -C U M �. a) N ',Li U •-, •4-
U w a
- 'C7
O ;..0
CC ct p+ �-
U O
bcN O n U •
O b0 t)0 (I) -" O cp.74 d b v ' -d.'
U • O•� O O j � i n
U 01) O 0 � r, 0 C.4--.1 .p O, .0 O 0 --'
O .' ccl
a `n i . cd U i. Sy D p v'
VD n U U >,
"
CI? p c U cc
yO � O •7, .
= U •'" :. a) A 4 O • > ..O
r.
is S�, U = b N N N "d 0
3 > �
\/l Ct ▪ to
p al U U c n_ p C
0.. c 'd p bo
:
U U ~ w, N ,._•-+ V �Q, L Ct +' A-4 O H
ter.
N O S " d
;i a)
SI U v "d „v O C , --, O• •- p N
O .4 :� • by Ct rn N c l
r-
,O eC 0 d U
hl) r 0 'O c - O v p U U U C U r. cH y
• ) c b. O 0 O b15 •� .� O rn ' r U
r: CJD
c ? c 4--. Ca) :r 'd cd 0 c+-, 4 r.' O U ., ct t t
U a) .4-4 n g=-1 O ca a) •• • ,--0 U N r-4
Ct
r �' a)CC a) y r p
U cd U - U . = O .'4 `c '�
p
.' Ec U a w r-, O r' . p 0 U O
c . p ; m r' . o •.. bA U Off .,41.1 0
+ C p . .-i y a)N N
0. -r- O i.., U O 'G U O CZ
✓ O U
cC c, I2
Co) (i)
0 s. cn
a) r U
C.)
.� cC r
r cC O ct O .N. 0 0
--
- O O b0
.--• •
r
s-' U N ,� V) r - ter, ter-,cn
p cn .. U
bUA ,.„ cd a) �" p n
U 4. Lt Q O r n,, O•
N i .-� p .ter-, .�'.
C.) O -r>
�,' r .
r •', r •O cC N
c c0 r i sm., p
.. .d U y N .�
. "O
,- ct r r N Q.
'N 4 -1-,
cd 1,
'" _
i
O r >, V)Ct CCI c O, JIO
-,
U � � Nc . _
czt'S O On- ccs a .0 ,-0 ›• O r
U
- 0 sue-, a) 0 u) O
_ s~
U
bA p M C) . + Q
.O � a) • "CS .,b %=1. O p_
cz
p r o 0 O U
0
o
'" U ct N v] 78
ti ' CI)• 0 r
; a);.
_
�by O r' N O co r.
cG N r: C
U E-' O
r c A -U
N . . O O E U
• b. O 'O CS a O • '- 0 ' ) bA U
.
.O cd •S" -� .r.
40 ^ C) ( O O —
r U . O
U 0 .., U c.) ct v)
r., cd ;.
r U U U
O bp •b O C •.-.
o. U o. r� - R, rr , r U
) o> r. ,r-, N O0 0 (q
� n cd R'N _N V
O .. a) O-
•N ,
5 '0 C a)
t. r � a' te r,N " p ^ .. N ct b u
U•U 0 T 0 n r U'G N � O = a) d O O 0.
cl) " r r
a� cd U � G) 1
p v
o
G ) "p -co - - C .,b O •
—
;
. cd U i •0; c a
0 .te� ° O .7.; . N N N N Q at
r V ' r
-•. cid
.^. '� up
.. r L/D E" •r cC E O'' .5 4* H vU Rs'
0
N
N to co
a@ °\o 0 0 o `m o 0
N>- O N o o a) O o 0 0
y O M O (�! >._ m O C O
> to >
U N I� CO M U • ,- co O V i N a3
o a c d
co CD co to COD. O N O N CD LO to V p N
M O 03 CD O co CO LO V .e co ,- co CD iX
2 EA r T r' N d M N cci O� N 2 ch co co 7 O
d H> ER ER 69 d 64 69 EA EH EH n. 69 EA 64 ER ER
To
a) HO a) as a)
E >. .N E :2- h M E >, y E E- H co E >, .N '--
0 O -00 .> 0 IUA 0 O a > N UUi 0 0 '00 > a Cl)v)
N Cv
N a a a a a 'i • a s 0 0 a> 3 a s a a a En
'i co O O 0 O CO ,- Q. N n co to Q O CV CV N L() N
Q. U E» Ef) rn co ° o) co co r- r, U ,- <- v m co
6 EA ffl C.) CO LO Hi 69 Q N Efl EH
z
ER
s 69
.c 0 a)
'C a
0 0
O a w Z
.0 .P._'C -p .O 0 C '0 S] co
• a o o m 0 2 Q. N c m o a @ m a) E
O 0 E d c o N E aE o o E o
MS o o E N s o o E w o o E
0 co p ni a) — a a) O N o a a> co C N a) a-• CL a)
C .= a N a> Cl) 0. N ;= a U) N O_ N = O. N 0 U a
E N _N a O- U L Q a Q) U L 5 ..) a a U N
cu U
• '0 a) m U = -o ca N 0 U 0 '0 Cl) 0 U
CO C O i 0 co a •> v) co C co a > co h E C Cl) O > N V)
4-. Q O O CO co tf) ) Q co N N Q) LO) 0 Q O O V V CO
0 O O C� O) _ 4) 4 V to O) O) C- CO O)
N I co m m ,- r I
co M
t
N• LO 0
M N
U R o 0 0 0 0 0 0 0 0 o C 0 0 0 0 0
UO q r 7 0 00 T0 3 m Co r•) N oi
CO C O co O cc; O = N co ri M -4 c a) -. O N
F- E N v N E E
_ > > >
— o CO 0 CO o CO
W ; i 'L
1 CU CD CD
co
r to rn v, o u
LO 0 CO m d
rn
C �) O
Q in in iti p
O L L o L
TO C 75 C
LL O C CO O O C C O O 2 C .O
O o y a N '
o . Q 2 c 0 .N a
r)
N a 2 -0 n_0 CO o n ` cn
_ 2 n N E 2 o 0 E E.
a)
U 0 a d c O a Q 5 O a ci cv
2 co
•
•
N
N
CI) f0 0 0 0 o Ol m o 0 '6.-‘,'.
f")
c a7 O O O O c›..Q16-
)
O O O 64'-
,--
U > o o °o o U > o a° 0
LI
o d `. c d f c- <-
a)
c
oO o o O a)
do o O o g co 2' °o °o, o °o, X
g E» °cn c; c;°e3 d o9 64 ° Z °4 64 o 9
a a E4 a
a
U O a) m a) m
sat E > m p E >, .5 H an E >, •- Z
p m -o > a) p m '00 > op m -mo •> a
O N a`> a`) a`> N
I
co
U CO 69 64 CD
0)
0 O 0
0
O -
C -
O m :t)....
a
m a m
CO
m m m 0N
o 0 u) 2 E c o n E
o v)
IC E 0 O '0 0 V. - o L `
0," m Y D 0 5 n p @ Q nl
L 41. O O N a)
_ n . p N n N
= a o p N ._ a N a U)
N D y a a U L 5 - - U y a O. .8 a)a m a) E N m m N �= CD m o 0 o ' 43)i o o m Cll co a > vC/) ' 0 m - > CO c -o >
Q O O O CO
L Q O O O O-
O O O O M O O O O O 0 C N 0
4.a)O o O O
Q
E U N o U) N o
ui
O a> va 64 64 I o O c o v w c� n �, e» e9 e9
U cn
I m E v CO rn <6 v C E v
I— m m es e» E4 v as m v ii -o n- Q d 1D= ta m a m
0_
0) O 0)W i
Y a a) a a) 4 a)
_ To 3 a 3 7a 3
o
a.Y c ° a a ~ m w 2
In a> O m d
Q 0 -. m .. m Vi m N
O CC _ 5 . E s E o
LL 0 c c 0 = 0 0 m °-
O o C a) q O O O C N O o O
C C _ -N _ N
} O N a) m N 41 N a) m a) N o m 0 a) O
S1 co D. U O '@ a d U d (a O- w U N
U O d a) 0 Q a 0 d d NI
•
•
(NJ
N N 119
0 0 0 0 o e Q O -4.,.. o C9
(0} O O 00 CO CO} O O \ \°
. o o .0 o o
p
0 O O C 0 o O N N
o a o
d ca
0
c
C
CD N
O 0o ,-In In 2 o CD CO CO 2
U
O
_ o _ _ co
0 i 0 o _0 0
E >, •N Z M E > w E F- c E >, .N E F-
MO m -00 > N O m -o > (On o N "00 > Cl)
O N N N N N N Ili 'C-13 N N N N N
cNi 01
n n a n i 0 n n 0. n n n n n en
rn O O O Q. : 22 : Q O O O O O V U 69 69 Ea 2 Q U e o O ° w w a w w a
cu a CO a m
41,- 0 m a Ct. cco a
flfl n m EI
en O L O CU CZ O i6 O .N N Q N _ rz N
• W N N @ E >. > .Q N N L To E Cl)
� U -0• < O O C.) . O O O co 0 Q O CO co N
o o _.:CD 0 0 0 0 o CI 0 0 0 0
CD te
C a+ cti N •■•
a C � 0
� � N N N
Z U p O O O C� O O m O O O O O
O fn E!i V> CO oO _ EH fA t�
U _ C• E 69 E9 C E O O c E 2 2
�- ' CO 7 69 cfl co
a a "C)
a
2 c2 0 0 0
W "a i 'i
I 0 0 0
_ _ o
EC — `o @
Q p N 0 N o n
a. I.- F-' I I- c N 1- c 2
0
N Q a) ti Vi
O Ct .n n U o O_ ❑z ° U a a o o = E c
O d 2 N c O a 2 N
2
•
•
N
N N
L. CC)
cp• >- o t-- 0 t� o o CO 0 0 0 0 CO
t > u) dj O oo • L > M M W M O d•
O CD T N CO n h 0 • O 0
0 N N N CO N- 0 - r m C 0 N (6
3
a)
c
0
eC
2 N N- u) CO 0) CO 2 { N- CO R N CO n CO O CO M CC)
4. (n O N U) CA d O N CO CO d N CT O 0) OD CD•g d c�i .t It) v 2 co cc) rn r Ili ° c. 0o ,i b N cci
N in � 64 co N 69 69 N Ffl co to N co
0- Ev cf3 Ci) CA n- EiJ F» EA ffl d Eft Eft eft cA
CO C')
C) O O
O O O
N N N o
�° i o Z. o
Q H Q. I- Q. F-
Q N (S) (0 CO C) OD Q N N CO O (() V M ¢ Q) V T N- CO 6)
4. U CO oo N N in ^L d .V CO V CO N N .L d •U h CO CO Li)
-C 5 to M ss 69 t» b) E» N c» E va cA Ve
t o `a o cn ° w o U n o c
O O U
U
v IC •L b a cis m a
as a) c c
c N O M O p O
N :N .) N .N n Ni 7.-,.7.N �
RS M ui = ti Q °) ri o of o v .Q c)i o cc) r ui
E w �U) o 0 � D
. C �
`-+ N -Q n- U C a w
c —
= N 1 Q 0 Q 0 Q
C 4• M CV e-
o 0 �
O O O
O O O
cL 5 _co
C O O O in CE C co co co W C6 C N O N LO CO CO o N O .- O v V <- (U co to (1) CO V O = (D O CO 7 N 0) CO
V c=a T N Cn M N > O m u) Ef3 in N ? C() N O
}- 2 va ifl �r 'CO
CO ci s 69 _ ' co f» e3 ds NN
= a a fr9 69
CD iii o o 0
W 'r.: 'i -,...
= a a. a.
Y
w — o To To
Q Ct o o o
d 3 n F- ti I- oo
Y c °) in ° a
O i iri v 9.
s r °•
c .N ' (o o C £ In m `0 c Cl) CD o•w c m J v m C
-'
O M Q - c m 2
O L > < 5 Q T o. co @ 1›' N o Q) a, CO O
JD o a) 2 L n U p) cc 2 45 n 0 U) LL O a) N
•,-- _
O cn x U 0 O (7 x U o a> O co x O O N
..N.ii..
49..t
'I-
N
•
CO
a
To
c a)
a� c
"'T. N
a N
t
M
O O O
N O x c
O N
# c N CD
h s a ca CO C f"1
G II
0
0
N ++
T L
O f
-`
NillicE N
h
L Vi
0 —
IX
°' o O 3
A
A+ O. � i C1
W
a)
U5 Q> CD
. U N
CU
` y O
Li C•1
X te
W it
C
cu cis
To
� o o is
as
p N v o
N ° m
2 cu
c
a)
� o
o "'
5
I.-- 0
I G
_°c r c H
,. o0 r... O IL To
C) 20
�- o m a_
o
4 ,-
o ,
So
Li- O co
O N o°
r' N
iii
I-- O rj
---
N
0 o
x
,410 ,....._ ,._....... .•
a)
0
a
` 3
L
, 0
A,g a)
To
2
?cF
a)
u_
a)
N-
Lo
O
_ o
a
0-a O °
d 2
!— C, a)
.0 -0 .0
n
m
Q ° H ac
— N o 0
t— � O
Q C � O
CO Co >N -CI
u_ —° 4
o r.)_- un
E— W
U
x
— >
w o
°-, 4-,
w
a)
a)
>,
;r Q
e E
w,
m
2
I a)
^i
c6 O
E -
O
—10
. I I
0 0 0 e e 0 0 e-
0 O O O • O O O O
N- CO Li, -cP c) N N-
_ ! 3 ;s Y V r GO
goiA up
L
R
r
LI,
s 0' '` !
g . akE € Z :. 3f € s '
y% , x � g p ,ct
WtEP6''OVON4gPggttgigigRIAPPINgONIg5gPPiAPOrt*PMK• v)
M
[,^- .
,)UY _
e— 0
U
'^ = omPwmevgwweoPPg.t, M
0 ',:)1 3
,=,n a o
Y
II
N 0 Jt
cD 0
Q O N 0
• O , o 0
Q
N
o
I— .c ifIgai,:i0004:10::"0::.:1P.Mg:PgginFOltiggitAKOORRAN:gg.ORPRIRMI:A§ ,.._
WA >a.,u<x.f,,....Ag x i a.. ams,,,,6. t X .w:.=mg ,Ln& .
11111111111111
lipiggptp40,rply •;r
.........................
.
r
J
I �
G
i
0 0 0 0 0 0 0 0
in O in C) LO Cr) In C)
0, C) N N ,- S
a
N
CI)
co
0
0 ,
N
C
N
rY
y N co
o a o 0 C 0 0 0 0 0 0 0 o a o 0 0 0 0 0 0 0 0 0 o a o 0 0 0 o v o 0 0 0
r- CO rro o o 00CD 0 CO CO OD CO rnrn000 NCIIC 002s) 000o
C N- 4 CO N O 6 0 0 6 0 C O CE) O) r co r r 0 0 O C w O C) r r O r CD O CD CD
C)• Z CO C) rL N U E CO r
i L
M CL p
M • ~ M ~ 0 ~
O 0 N
0
N N 'i
• Q
< y M N M x 0 0 0 0 0 0 Q Q N I 0) M Cn r N r r 0 0 0 N .0 y N N- r r O r 0 0 0 O N
Cj N r IL) e C V CD ID GI L p = d 00I
O ) 0 3 2 U O ■) 0
O OL
L —
,J
O TS ;a a
ttl
-RS
w o. C.
n/ m o 0 0 _ M o _ H o 0 0 0
I.L p ,- 0 0 ' 0 0 0 0 0 0 0 o i o 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
O m r-- M 0 0 0 0 0 0 O E r M CD O r CC) O O O T O E N r N O O to O O O O
M 0) O O 0 0 0 0 0 0 W C- CD M V Q) CD M O O D O C0 M co to r 0 C- 0 0 0 0
•
0 U U M M N O V U .-- r r r N N U V N N r M
0 07 .�. O 0) .5. L 0l ....
N a � cL a � a) 0F0
E
m
i+ L V •
cn CI m m ❑
LL
❑ ,
Ch C C o0 (D 0 0 0 0 0 0 0 CD C r 0 Ln M (P M O o 0 M T C M N r O O M O O o 0 CD
O N Cf) EA3 Ef)E!9 69 69 64 C') . O o N N h M n Ef)Ef3 69 0� CO 6) O o EA M V3 Efl 69 69 h-
E/r.. CY co CO N O co 0) O CO N CO N CO CO r O N `- O 1` r- co M
- O W N W o N (P O CD CD M O N N O N N N LID CA N
O 64 63 69 64 N O 64 r E9 N r N N N r 64 V4 CC)
,CU N d Eft O a 69 EA ER 69 v> d 64 64 64 ER ER
V Lc)
N
o fC C
O ftS C
C O CO
H
to
I -,
C7 'C
iu •. O
_ _O • o 'i
•L 0 0 0 0 0 0 0 0 0 0 0 0
W a) CD 0 0 0 0 0 0 0 0 •a, 0 0 0 0 0 0 0 0 0 n' 0 0 0 0 0 0 0 0 0 2
dCC O O O O O O O O O W O O O O o 0 0 0 0 W O o 0 0 0 0 0 0 0 W
o CD
W i NI " N CC) N CO COD h 0 J a O O O rte- 117 CI)O in > o■ CCJ 0 0 C1') Cn O r--Is)
Q c C0 p� ER 64 64 69 64 64 64 64 64 G L' N N 64 N M 6 I� J w 69 N ER N 6 C!) h - J
C4 ER E»Efl EA 64 ER 64 EFl Q l0 6. ff. 6. fH Ef3 E. 6. EA Q
D o r r r r p o i o `� ~O o R O I-
C)
tl d a' moo 000000o F CM 64000000000 I-- C X 64000000000 j--
O O o Lo 0 0 0 0 0 0 0 O Cf) 0 0 0 0 0 Co 0 O CD C) 0 0 0 0 0 CD
O N It)O I) CI C) O Cn N n O u5 U) Cn O C) N C)ci to iti CI) O A
>- N fl 64 64_
r N CO Cn 69 EA 64 r r N M CC) N- H9 64 64 N M It)
1-- 6464 CA 6964 EA ER 64 EA EA ER H9 69 69 Cfl 6,:)-64E9
U =
a.
a
M
0
co
co
co
co
N
U7
•
•
N
M
0
To
a)
a)
a)
cc
ul
C
O
n
U
co
N
a)
5
a)
a
0
U
W
L
0 O
_
U
C (a
O
co IF
a)
O
N
. -o O a)
$- a) Z m
V a)
CA cc A
CD 73 ai
EL
o 0 7 U m o
E O C C
X 3 O N _c
y,,, t0 Q C O U
C Y to a) a) o
a.
o a>,._ m .o
O U- c U Y
■ o f6 3
Z U °) u
O _
>, -a E
U) c U E _ Z
r' o) t ui o
>,
U O L U a) m
U
O
ii >
}-• 69 O O m 0) C a)
V cu
2 0 ° w Q m 0 U
0 - o o Q a) _> c
lL Q Q o ic, ° a'rn ai m o
I Z Z ° Q 3 Q >- 5 a)
a)
Y 0
0
Qf1 t6 a) a) n
3 a)
❑ n Y
0 2 o
O CC C0 U o CZ m ° o a a,
O G J 5 w 0 a) 0 n at))CO
t"' 'a U U Q) c+)
O a) v O i O Q) i U N
co c0 c)
L N
H 0
2004 Group Renewal Bulletin
Small Group
Service Cooperative
Blue Cross
Effective with January 2004 renewals, Small Group Service Cooperative groups will be
required to select a standard Small Group product offered by Blue Cross or a Common
Benefit plan as designated by your regional Service Cooperative. Upon each renewal
thereafter, you will be required to change your benefits as designated by Blue Cross,
Service Cooperative and/or State and Federal legislation. Please contact your agent or
sales representative if you have any questions regarding these changes. Thank you for
renewing your Plan. We appreciate your business.
Legislative Changes
Mandate to Cover Hearing Aids for Children-This mandate requires insurers to
cover hearing aids for children 18 and younger who have a hearing loss due to a
congenital malformation of the ears not correctable by other covered procedures.
Coverage is limited to one hearing aid per ear every three years.
Benefit Changes
Irk
Redesign of Comprehensive Major Medical with Deductible Plan-The $200
deductible plan(Plan 116) is being closed due to low sales volume. If you are
currently in this plan, you will need to select another plan. In addition, a new
deductible plan(Plan 123) is available featuring a$2,000/person-$4,000 family
deductible. The new deductible option was created due to market demand.
Change in Medical Out-of-Pocket Maximum-The medical out-of-pocket
maximums are being changed as follows:
Plan# In Network Extended/Out-of-Network
4 $2,500/person $5,000/person
113 $1,100/person-$5,000/family $2,500/person
114 $1,300/person-$5,000/family $2,500/person
118 $1,500/person-$5,000/family $2,500/person
120 $1,800/person-$5,000/family $2,700/person
122 $2,250/person-$5,000/family $2,700/person
123 $2,500/person-$5,000/family $3,000/person
128 $2,300/person-$7,000/family $2,500/person
130 $2,750/person-$7,000/family $3,000/person
124 $3,000/person-$7,000/family $4,500/person
126 no change $4,500/person
Page 1 of 2
FINAL 8/27/03
2004 Blue Cross Small (rroun Service Coonerative
A
Change in Prescription Drug Out-of-Pocket Maximum—The drug out-of-pocket
maximums are being increased on Plan 4 from $300/person to $500/person, and on
Plans 113, 114, 118, 120 and 122 from $500/person- $750/family to $500/person-
$1,000/family.
Prescription Drug Dispensing Limitation—The dispensing limitation for
prescription drugs is being changed from a 34-day supply to a 31-day supply. This
change applies to all plans except Plan 1.
Dispensing Limitation for Oral Contraceptives Changing—Your plan has allowed
for members to purchase 3 cycles of oral contraceptives for 1 copay. This is being
changed so members will now pay 3 copays for 3 cycles of oral contraceptives.
Members may continue to purchase a 3-month supply at one time to avoid
inconvenience. This change applies to all plans except Plan 1.
Network Change—The BlueChoice network is being eliminated, therefore, your plan
will be changed to the Blue Cross(Aware)network. The BlueChoice network was
initially designed as a smaller, more cost effective network for our clients. Over the
years,the Blue Cross (Aware)network and BlueChoice network have melded together
to the point that BlueChoice no longer offers a distinct savings advantage. This
change will simplify claims processing and reduce service-related issues for members.
Members can be assured that their providers are included in the Blue Cross (Aware)
network, as this is our largest, broadest network available.
Select Providers—Your plan will continue to utilize Select Providers for chiropractic
care and behavioral health care services as it continues to provide a savings advantage.
Previously,physical therapy and occupational therapy(PT/OT) services and home
infusion therapy have used Select Providers. Since a Select Provider network no
longer exists for PT/OT care or home infusion therapy members should use Blue Cross
(Aware)providers for the highest level of benefits.
Major Organ and Bone Marrow Transplant Coverage Change—The Blue Cross
Association has a national transplant network called Blue Quality Centers for
Transplant(BQCT). Benefits will be based on one of the following: 1) If a member
uses a BQCT Center, your plan will pay 100%of the transplant payment allowance.
2) If a center is not in the BQCT, but is a participating transplant provider with the
local par Plan, benefits will be provided at the same level of coverage as"out-of-
network"hospital inpatient care. 3) For centers that are not in the BQCT or a
participating transplant provider with the local par Plan, there would be no coverage.
MSA Blue Changes
Deductible and Out-of-Pocket Increases—An attractive feature of the MSA Blue
product is that the range for deductibles and out-of-pockets increases annually based
on the Consumer Price Index (CPI)to keep pace with inflation. The Department of
Labor generally issues the new ranges in December of the prior year. Please talk to
your agent or sales representative for more information.
Page 2 of 2
FINAL 8/27/03
2004 Blue Cross Small Grout)Service Coonerative