HomeMy WebLinkAboutJanuary 2005 •
CITY OF OAK PARK HEIGHTS
CI157
January 1 , 2005
South Central Region of the City, County, and Other Governmental Agency Service
Cooperative
January 1, 2005 Renewal
TABLE O F C ONTENTS
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) VEBA Alternates
11) Miscellaneous
•
• January 1, 2005 Increase
for
CITY OF OAK PARK HEIGHTS
01157
Increase:
2004 Rate 0.0% 2005 Rate
DOUBLE GOLD- PLAN#1
S $454.50 $454.50
F $1,250.00 $1,250.00
•
• South Central City, County and Other Governmental Agency Service Cooperative
0 '0 CD
0
O N N N- N O N O O O O tf)
.L O CD O of O O N 69 N ° C*) O C*) .;,,,,.=, C) O)
O N O N C'7 CO CO LO r' If) CX) CO
0. N CO 64 64 r T O C'7 C'7 `_
o 0 r ,- r r r 64
0 ■ 69 64 64 64 _64
Q1 0 Q
8 O To
X r N
W co c
co =
co
O
-C O
O N co r C) V co '- \° M C3) 0) L
•C • O O CO tt e- O) 64 0) ° O 00 O7 ° N-
CO CO LO N N *� CA LO p 1.0 T Q N CC' 63 O r O L) CO
Q r N-
r 64 T N C+) N
t.) 1 T CD 64 T 64 64
- O
b- cp
Q
X e-
V) W _0
•Ri ON N
O
0 C:2 -0 C--)
O N CD N N V C) C'") ti r CO
"zt N-
1..„, O •- ' O Lc) O O N 64 N of O (C) ° I-
r CO N 64 (NI O CJ) f3) m N LC) CO CO
N O C'') OJ CO- r' C'') 1- 0)
a1 r N C, r E!-T T--
M CO N 64
U i t In r r 69
C N 64 69 hT 69
C O
CO '7 Si co
N
0 `� x
a W O
O O C C C a)
N cp 2 2 .o
co
o c n c co
7:3 c c c
c c c -°
Q) N Q Q Q >
0 0
It0 0 c Q o c c r _c a)
E E E a)
CT) L
Q CL Q ^
LL C
0 0 0 2 co
d' r- N - w Cl)
Cn CO CO 0) V) a)
E O O O E a
o
'F'D "Ft S W f6 f4 O
N- 0 to to U) 0 D.
in -o _c _c 0)
• ' a) c C c CO c
v 5 0 E 2 2 2 _E >- a
C C [D CO �t N-- .E O U
a) C U c*) N U r.
F- cn E ti a) N Ch V' C cv U)
= a) (n cn cn O O O Cti to a C
_
0 0) C Cb O co O N �' p E ,
W Cn O ca c -o
= U E U C ' r o o °) ni )
Y `° o) a N a v) ° 3 C) a
= 3 °) o m E _ U N M v a) a) m e
u > (� C9 O O O O N r OL -� Cl
o• E cn a a) a U o C U o 0 0 0 W
O w -i a) O cn
LL CO > > '- m a) m n as p^ .- co a) O
`� Oi O� a) L - O O O O a` C
cm '0 °
} a a >- a 0 F- in I- U
F- o co C
N.-- o « T O U O r N C) ' U) O CYJ ) T :
Lo
0,
Co
0) CO CO Co CO A- co
° U V - Lf) N- C*) r o ° �t
co C (V (Ni d Q) (b Co O ,-
✓ d CO CO M. (vj O
N N M N CO N N 0
i � r N
X 3
W (v
c
(v
ar
>' "O CO CO (9 CD N O ^
CD C ' CO O V N CO_ °
CR Cr) CA
f� N-- r- 6) t` r r
N N CO N 64 Ea N
L- Q 64 64 69
U
N
cv
C `O C
N CD E
C.1 L.
C E U
U 0
2 o L
T
Co
a
0
N N- N tt) C(J Cr) �)
Cn - r O CO r O CA CO
Y• U E 0 O r c- (T a)
(a Ca C`') (a L O 00 EF} Lf) CU
C a)
CO
E CO LC) O C
r r a U co
U) N- CO7 N CA N
C) r C'') r C
CO 64 t- 64 N CO N C
EA EA 69 a) d C) "7 (� In tin r • C
C CO LO CO CO CO O
C U
U N V CO V> O U
C 0 E
i
ii
C.) a. 0 CD
0_
i O. c
CU ,� aL 2 a
Cr (n E -
C.) ac) E E 0 � "E a E
C m @ •E .a) m a E
C) O ° ° m •) c -°
a) U E 0
ft OJ c` c`5 0 m t c 0. a
in 0 V O U (n
N O T >, a) .
W Co CO A _, O C CU m Ca a)
m a) a) 3 0 f0 O C CO c) N
• c c a) (0 w �, a a) U -o •.
O () a) C w - m (n CO N a) C
U E2
0) 17 u, m 0 C (O O •� N N "O V
(n a) a) U _ 0 O a) O U °) _ a a)
r co a a ° ° a] N J L C O w L
- in a C U Q o
C.- -p N N -o >. OC '@ a) C ) 0 V a) in C N ° E•• Cll L L O 0 C (U C O O E C
C). O) L (O 0 U `' (a 0 Z lL p) •�
N a Q)
cn • 3 3 'm a) o E) �a c m co •i•
i 0) c, _c ° m
I--
= ci CO 3 o E E @ m .� U E > N
(7 aa)) o0 oO ov a E c ° o •(0 3 P (� (n C U @ C
111 �- N N O •m -o •p •p U C 0 W N O a) •O 0
C4 3 3 •0 .p L a ._(1)a 0 w C '> a ' -0 ro m
(U
C 1 CT a s ot O E o ° < Cl) a) CO .LC-• �-•
Q c aci o co' o a 7n) co m c0 _) 4 n_ (r L'- �o E E o E) c 2
Q I.L' a) N N N i_ C d to 0 O Q (v .f7 U 7 f C C U m co a co
r r Q
O O a) 7 - a) — -0 N (0 co U a) O
co U
_
O N •p C v p CD d c- c. C (O
co)- r a 2 0 Cl_ t— Z 0 C CC N
o o °
r U. o
0 O N C) [ Lf) CO i� cc; O) a N
C')
OD
• m
m m
0 E
o Cp
co
co
,--
m a
z- °
-6 3 C)
'O 0 N d C a. C)d .. D O d
CC
ca O E • C E
d rn C.
d " -co o
7--
w d n
co C) ' c
> C a)
0
U N N
_ E r O C) CO CO 0 ti O) CO N N N u) p >� CO CT N
d a c'7 O C7 CD N O Et C`•) n O CO t- co O c co C•
N n O CD r lf) CO c N OD c (D >' O. 7 a
T d O N O r c (D O T r Ch O = E O co co
u) C) CO O 0 0 L c
a C�4 69 64 64 69 64 69 64 64 64 69 64 64 C fn o E
6 h
C >. 0 a)
C d
Co c Co CO
p X O >+ CC
w r- N- O C•) u) r- u) CD CD . CD C) p) co C
C r r-- r CD u) O � r CO CD r- OD c v; C 'D COi,
m ca c r rn c Q) m r-- LO CO O ■ C) C Co
^ E u) CO u') u) u) f` o_'+ c CD u) w CD n O O d N `)
N 69 69 64 64 64 64 r 64 64 64 r r co
i O a 64 64 �4 m C) a o
d
O CC O C N h a N co
1 d u
(t7 a > Ta a
d y O c N CO O CO N r� CO CO N u) V a) E
�' •a , co C`) C'') CD ti O r u) CD Cn u) CD C C. d C
O > c O r O Cp <Y N u) (`7 OJ CO co
• O 69 (N 69 69 Efl 69 64 r CO 69 64 64 u) d Co" >, o) co
0 a CO 64 s9 (v o C c
CD 0 E U v ° m
O d m o O
� N a a) N c
d o, r` r CO m r CO O N a co rn co co a)- a`) -o
0 0_ -0 .- =
d O r c N N CO c N u) u) N c'7 O :• O - C 'O d
S r r N 0) N Cf) c O u) N O) t+ N C CO d > h
X > a1 C N Cb r n r- O r CD O O r Ni co- CC C. C)) E o co
W O` W .0 EA 69 64 K _) ; N 69 64 LI N- n C= a _d a
C. 0 64 d O 0 Y °)
o ID m a
_� CV 2 Cco o >,
O `) C m� • E
-C O _c °W C -a
1:f CV co N N N N c c c c c c c Et O J r t C E Co
C \ E co (6 2 C) C' Q c Et Q C c Et CO (ll ' CU O
r O CD C7 Cfl CD 0 0 0 0 0 0 0 0 O .0
C') c) Cri C) u) Cr) u'i C) L6 C-) in Cri ari Lt) c7 '� Co -p°' -o ,,
r - cn
N = H4 V4 (i4 69 Ca 64 64 64 64 63 ER e» CO Or N En
d° U m
64 co •> a) U
75 r` L v N O m
ID
N E N N d C O >
C O •n ") Co o c ac)
JD O w 0 0 0 0 0@ CJ) O N- a co o m 8 '-- - ° E 2
CV m to �r) �n to c v c 'C) LI) co c
ca 0 c . a - d
r- E U O a
E o Q
r n O Q m
o V Cn O d C CO -O
U T 2 s -o F5 - oo c
a E 'C, w
Tv La N N N N N N N N N N N N 'C C jj O CTS /U C O CO
G N N N N N N N N N N N N CD C 2 a d •> co
O ro _ N a• ro N d > L O } C
O 0 C n)- CI) Q C N d O
N O _ � E
P.-
uy c 2• 5 m 3- C C
o
O T m 'U a to-o 2 O d>, La N N N N r r r r r r r r 0 5 > c
O (C co )
°▪ C m g O E to co 0 C > C n , Cn
d
C N C 0 O o O N CC -O L
LL 0 E v, do - m E .0 0)
V) o CC o b y • d y `
!- U o o c o ca
Z O O T _ c _•-• p
0 "W o0000ooO0000 O c o`' . 8= E2 Q 'N' m •
W m i cC n W- °.0 d c
= a N Q m > m > I w E c
is co n o m 1 a m m L a o co CC _� U 01 d o Co "-' TC d
0.. C < d W 0 0 0 0 � r r r CO ° • E- - E o to C) >'0 d
cu
J ° r r r r CJ iT C) O c
CC U _ r
0 <O �� 0 y 0 N c 0 > m o C o N
O W r 'm fA C d _
OO R U O V W v) C C c
(` y N N N N N N N N N N N N :"' '° N d C co C) O
c- y 0 0 0 0 0 0 0 0 0 0 0 0 y O C -a -a O W 0
O U 000000000000 _ 2 'o .
O C N N NN ` N ` N N N N N Co `C•' > > • CO d 1-
U o - � , 000000000 ° rte FO- 0 = a [i Co }. Z u m
• m 1..f
a> , N O
R C a,
Yr
Z c5• -, 69 0
O Ta
C
'a N o C a °
• d L=
L11 a d 69 E a E
° E 0 Q1
'
• Q d t> a
la a
C
l0
00 a)
d
'7 N r O) ;2) N CD CD '''.-4 O r a j, to a)y
a m C M O CD a) C O N N O C CO C
(D O CD r� r C C•i N N r- >' 0. a O
E * 7 CD (N Ca N- CO r O CD O) a) a) - O c
>,a_ cc C') to N 64 N 3 E O L 2
CO H9 E9 Ca 69 64 69 64 69 ,ee 69 69 C Ql O E
T C >. O N
a c m °
m a m
CL x °D
O x ) >' m
O N- N CD F) CC) r C') CO N F) CO ° a, CO C
O VD a) a) O N F) N- a) r CD - ,, C -0 N
O r Cr) V CD O O) LC r 0 CD CD N a) C O
' E N- ti C r- N 'V' CD ,- tC) Ca `,) C O O 0 N a
— 69 69 69 69 69 69 64 69 •` CO CO
L d 69 69 (A b9 b9 0 ° -.C) O"O
CD C
O Q -O M a -C M
Q N ° -
(n
Q) c) ° a E a
z > CO c a
LL �. a U) a) CN- 0CCaCVLOCOr, r,- o a 2 c� ° E
r c o ,N al V N r CC r` Q a a) a
U � 0 0 0 0 � to to r co c° c N c� CO m s N
O co N- Co in N CD r N (C) N r CO C N O ° O O 69 69 U 6`°� fA Ef3 69 69 E9 fA 69 64 >,
>,
c c
= 0) n Cl) C 3 CO
U O E co v -° a)
L m
` O 0
a) es OD W N N a) C') O) CD F) CO r U) O a) m 'n a, ° O
•.0. .a d r co •a- r C Cf) C) ro O) r r- m O •� C 'a
is O r� v r co to co C) r� o m cD C ° - a) > CO
X > °) a`s c o 0 0 tri rn T CD O cfl (N e CO a a E ° CO
W � w X69 69 69 CV Q c ° C
Q a v 69 64 s9 69 64 64 ° 5 •_= Y °
69 ▪ a .0
CD V
-C p a ° C[ a, E
a aL z @ E C= N CO o- N C7 ') *) C7• E (N (N (N (N N M C^> Ci CD O a) 7D 0 @
°
O 0 OD o rn CD CD CD CD O O O O u) C a v Cut o C t C - ` r ` N- o ° a o C °N
e9 CO CO m'5 a)U
r U L ° O m
U ` O
I 5 V CC
a) co E --a2 C p h m o c• m� O U O L ° °E
- 1_ O Cn co D 1:0 a) C O) C) 0) O O O O a) -0 � 0
•- 0- 7 ' C f (C C C D ° C E N y- ( o) C n a)
O aa)) U .0 O E X C ti co
0 CO 0 Cn a a) a -°0 U
m � rCC° o m C 3 o CO ° CO
N N N N N N N N N N N N c C as a1 > °
o ` N a CD N Q) , >O L O >- C
_ i7 C O C `a d N O
O ° a -O CO - °L 'O O
t` o > ° 0 � - > E
L V C Cl) o N m 3 CO c o 0
>.w N N N N O CM -0 a ° Cn E O d C
U " r o o 5 0 E ° ca
m m
R Cn C ° 0 („) % °°C co N 'O L
co LL CO Co '- 3 U ID C L Cl)
H U °) ° c a o
z a s > ° C a@ ro o
C7 C o o o o o 0 0 0 0 0 0 0 o c 2 °= C a) < C ,
° a CO c c U
W m R Ci a ac @ o ° o E
E ° a C
c
CV E
°R
fn Cl) )C) .O 3 E m ° a C>, @ a 5 oQ a) L ° $ E ° ° ,
2
C C Q a) U) orna) rnoo00oa) F m F- 0)
` c a• N J V U r NJ
E_ r r r r 0 °• E 'tv a) O N
2 Q � C > C N
Q U � @ O O
o W C r•- ry E Wo O U u CO o 0 . •a O
N a' V M M M ch m c0 c') co c') c•) M = 70 a, a`� c C m a) c)
. � 00000000000o y r d -o ° W .-6--- Q N
>- p ,-• - 0 0 0 0 0 0 0 0 0 0 c) 0 C E
F- — 0 a C N N N N N N N N N N N N A w- a > > >, CO CA CD C-
r• U O r N M e? C1) co h- N CA O r r O fD V 2 2 CO a) ° a)
I V p Z ry 0 0 0 0 0 0 0 0 0 r H 0 = a CL a >- Z U) CJ
• ��
d = <1- a
CD CO
'° E r
z -
o 3
o a)
_
Ts m N a) C o- o
7 .o CO 0 O N CY
W a) 6 > c F
@ o E a) a =
>- d ", a) o
y lo-
u) a) o
0
r
o co N
r L O 7 N >O . a C
U
m a 0 c m C
E2O r a o o
> a — E OU �L CU
a s c, O E d
�
, _ N
'o c
63 7 0 O O
O. U N 3
"O x O >'
U
O � _
= . N. LC L O
C N no
^ N = cD ELC� cn O U a) of
S.._ O n. �' a) a`) a "-°
o CD v --
m
^^L ^^\,, C CC a
a) N E N
O a O =°
Cr Dorn o d a ° co m U a _a
c° E
a) O p > r a) O
co> c 0 .0 b9 cs d9
a to ` °
= m
o E oz) o
L p a) E U
L m N =U
O
0 co} �
.•-•
o ca m = CC 2 fl Cr F o
CZ - � � a n.
W
a" W U 3 a) =
,
Y
0 -a
, E CO O
>
C ,3 o� O n m o -
.� O a m aa =w C o
,; CV � ` om rn E rn m m c m
O O a o a =
CV = rnm co o
G N f» e» a
a o .0 ,_ CO a,
c 7 um
O .. a) L aa) o a'm
■ c - a •2 a 0.c
0 ° a a >. 0 3
C p M m o c a,
O co E
o 0 0 0 ° o o .- E a)
N a) n LCD o o Q a o _ _
a C a a d
0 E U L O E U
U x C
U U N ti
s a oN
C T
U N N C a N > a co 7
N C O
o H '0 Q N ., 0 a, p
o a > m s c ° u m a 7 a
U o > ,, ° E m o , mm m 3 = 0
U N o'
E co > - -- c N 9
W
ci 2 E cn o 0 U 0 a) CO 0 LC
U) `o 'co 3o ma) h 2
U U N
C
I a 3 L T p
O
C) >. ✓) O O O C L @ -
C Q O N ro C L Q m a= U
v L. c0 (9 a
CL L-
N E CZ N a) o' E
O
3 �_ U .a o ° o > m a
Q d L-o -O a O cai,L
d -J S U U . N ,- S C a)
N• E
oW
cot cv
O
O a O
U b o 0 o w 0 o =0 o a w m c*
o
r m o o m
tot 0 0 o
U co ? EMoo i- ❑ 0 a s a r z 0 -La
0)
00
v• a
63
a)
a)
CC
c) co co
L L
co co co
-o o 0
0 0 0
ca ca To
O
I-- I- I—o _
N co d"
O O O
O O O
'L.-. C N N
0 7-- r O
0 1 1 1 CD
CD CD O
• (')/ N N N
t1_
LII
2E 2E 2E
0) — F.., ,— ...-5
I U -0 0 '0 U -0
= CD C Cl) C a)
— -0 — -0
L a) L Q) L a)
ti .O U O U C)
LC)
Q QX) c N 00
f
UO -� O .�. O .4-,
CO CB CO
O .c O O
+-' - .■-. N
I E E 1
O ._ _ C9
W I _ v . c) a 3
5... i3 '�a) a) a) a) L a� a)
CD
X X X
( E C E co
Y C E p E 0 E p
O U a) U a) U a) 2
S. L L
a) a) a)
la-• o a) � a) CN
HUH• N O
O
N
R----
_
C-6
3 v, i
co. 0 -0
o_ O '•• O ^rte O r.O •
.U, vp r •.1 C.,w .r
O
O o.-. cG >'
y r r Uj
e) Z U U
r U r, :� N v O C) .
.N.' U •—Z — b 0 ^? U
Q .-.
G '- U r v 'G .r v; o
t . y r ..,
0) .- -0 O ,r. v
v
.. v 4• 7 0 e-• v r
y O r V
C
te ,
i r C3 -. U.
W v C6 p ca C. F 3
.- O v
:-.4 G• .o 0 c_ Co r-• 0.) v r U :.
U .= o o ter ^. p �_+
r v 1
v r� • r^ cv O p �? 7 O p
• N U r i•r U CZ ci, j, U v •-..CZ 0
d 4-. y �" r 0
f.-,-.4 y d O O u
N a
CZ C+. C.) U
e. U I-('' '• b c.UG O
0 1•■•I
C 7 ,= D v >, � O r •o ca
v U U r U O
CZ
.'[r N CO CO v cil bA U �O ^� O up o
O v O N V p :, p
r .� - - CO - Cr:, U -.
O U r v ct v, -, r v' r
am
I., cn r c) UU 0 O O 0 U .,
o O � C, O M
R.
r U . p . O U C.
., U 0 U - : o::,p=s : . G s O —
C.) ,....,c.) .0 ,....v) — r N v 'C - O N c O • U
O c3 - -o - U 7 y 7z) �O p0 "-' r* V `"'7 N
v U U - cc- U r, •- O e) U
. v O =" N —
. p .. ro 0, y 0 6) CO cv, = -p N ^' U .^�
0
LPL U .. O. U �' co
U �; U o ^� U r ct c vO _r
CG r ^ O
.], a) cC C O bA p v ". 0 0
O v U 'r O a� y U
c". . by rr cu r i U >> i.r.
O p v Jr — e:
c p , ai'O p ✓i— ^
v, O 1 O J O v
-O c ) O 3 X
C.)r v O c v v,
v t-. c O '7p 4. 0 r v U
r c
o
ct - C
0 w :.. n O C cr, O. H G 0) - N CC 0 . Cr) vp r''' CF.(
O r G O ,. Ct L) rU, G
H .. H 3 0. U 4° C.
•
•
5 C)ep
o, o v) .*
r
M O r O N U
CO - r cn U
cr)
t1.0 U Q
U " cG
U
.--, ^ ' y tt
CO U
U
c
•
C C p vi n c ,
cd .d co U
tip VD U 4. _ p = .= .1
e� O 'C bUA •n •r 510 n
r
N U yy U .0 N
CO O n
;? v '7 U r
p r-- N
o H U r cG
Pk) ^i U O U y
C) r
r .1 O N
• _, O U = U
U
U
CO
v
va ct r C p `a p r
� �. 4� 'cn OJ
UO O N O 0) +-+
r H U r O U
O u
Cu O ,� "7 U C
O •� 'O n
up v CO
M U '" U O r
C.) 41 p b-0•c� V,
r Q U r u i ^ U
v 'G O" O U r
L. w, " c3 O U
U r N cd .'". '_> v)
O —
VD n y U a� co D CL) p _~ �. Q O ? , U v
w ••co v
v U 4 U. y G co O
u co U O UO
r
cil -
- O v . ., ti 'i7 'O —' a
O= U •,..., - ' •-. _
M ,_.• Cu.- C. "' : .-' _
. r
r p y v O p O a
0 OD --' ..c.
O U d
r • U u� c J U
.4*, r. v
l • U p j
„ Co CO O
b N
U U•
O
■ ? '� V
i �
, ^ H ., r G H r. • H r
•
CD
CS)
CO
o o
m o 0 `m
O r'J CO M Q C O ° o o
L > O N r Lri Oj L r M ° O 4
U .r ro
�••) Q7 r v
N R
e a a)
co _ c
N O O 0 N
2 O N c7 O 2 ..-- O c N N 2 co c h CO C)
cr
e9 V- d3 U r- C) N E9 �3 tag
To
EL
N p N f0 O To
_�? a �. .� U p r v Q O
2- >. •N E '� E >. ° F- a E >, .N L F-
el- v cc N co N N N G) ` d N N N d O CO N G) Q)NI cs4
a n a a a i 0 a s n a a a s a a a
co co co O C) N •rt c u') .- C) Q O CC n c r N
Q 0 ee es Lo c co Q O r h cD 0 c co n N-
Q c e3 c» 0 cn to /:9.... Q O N C!) e3
EA .� N N ff3 = lf) N e3
Z 69 69 69
t o) 0 0
O o
cu ; C)b a . -a a) D a
0 C co
- m m y E C N m a ti ccc
N
O C j O C p N O C N p O > > E N
p N N - - a N O N G) C O .N O -• a °'
p ._ n y ' CC a 'N = a a) co a N C. co a
= N C a C. U a N 5 Q a d CC L = Q C. V d try
4-0 ¢ o C N In O V j in co V Q c o c*) In
O o o C) �l 0) C) N r r
N Cl N N r r 0 co co
O N-
U-) °o °C o
Q r- (NI N N
O {y A O O O O � O O o o O D O O O p
/� O O N W to to r m > c`') in r r•
V V) C O O o7 N lf) = N N -4 O N = r=r -T co
c c 7 co
E c 7 co
G (`J
• >
CD o d o a o a_
W i i
I a ) 44
Y
CC• ca
CL o m r-
o N rn cc 2
Y c cn o Q) d
Q Q) N— = (n 7 —N =
O 0 s 0 N N C cD C = N r C W
C
LL L) 0 - C O O C C •O O cC O
O O a) • ° , ° c
p ` - n - o
>- N a _ @ N 3 a) m m CC a ti v o
F- n @ a a
ro. CC `
2 n a `
U f O a `a O C. C. O a
•
•
La
a)
co
�' o o °'
Cm o 0 0 0 cam) r
o O O o
CO
O O O O u > to O O N Ci
U O o V v
d . o 3
a)
C
o ° oo ° CO 0 o 0 0 m o CO 2 V) 0 ,=o ° ° ° c o o c d o o c-> m g d3 69
g te be vs e3 2 be r » sv ce
d d
To
U O N To-
=
E >, E er E T -- .E. N v E >, .N
N
oO co • > N O a) •O �> N 0 co 'O > N
N N a) N N N N N U) - 'Co d N
n n a n L a s a a Nr a a a a
i o 0 0 0 0 0_ o - a o 0 4 0 0 r
Q V EA Efl ffl (A Q V (n T- 69 69 Q V W (O M O
Q N N 69 b9 69
o
o 0
a. o w
Q) a a a -o `- ;0 -P
co C
4 N C -,D 4 C c 4 y c L
�- O O O iE CO O N O C O O 7 O C
t} f9 � -, c-, m "' L =--- N NO co r N
LL o .^� m o `n� a p _IV n
- a a = n m N = a a) m m
N - .N. a a O i D � 4- a U L 5 n a
CO co D a m N 0 a m N a� = m N a`)
V J C a) 'O '> N C aD 'O 5 N C C (0 V > N
O O O U
Q N N r O
O l o o a o w ° ° p o a o 0
N N CV CN
o O ti cn O en o o
0 0
0- c.c o N C..) Ni (f)
co
O V • m 63 C M 0
69 0 69 c"i N CO C O N ON ON (%+
CO a) N r: O S U m CO •
U co • > V CO E N N C r [[)
0 , E� 69 10 - N (A E9 Efl 0
0_
0 a co a co a ti
o O o m 0 a)
W .
Y co a a) a a)
m
_ To 3 m 3 To 3
< (O O
Y 3 p a) O
a
CL r A N o �- F
z
0 N N
C-
C
Q 0 .. m To m co
O CC L )) L E C- N
- LI_ C � C o c d C C a
N
O o 2 d P O o _ C p O N _O O
C _
N d a) N 6
N C r C N N C O
N .� 0 0 . Q U U a - n a) 0
9 N ` N
V - a 0 d a n O a a o C 9 . T
0 a a
0
•
C)
CD
0
CD
@� ° ° o o my ° ° c c
L o
• L o 0
Uy o o ° ° U � o o cD CC;
a>
c
2 0 °o °o, o g o °o Z o0 0 h- rr-- Cr
a o
d c» °may 6°s °+fr Q 69 69 6 a 69•
•°9 ss 69
U O N _ d
-E > __N .E p E >. Z F- v E > .N > I-
Q o
cC a > W co co 'O .7)> rn o co to > y
co Zr) UJ N N N N N N N N N N N N
C. s a a •i co a s a a a a a a
> i o s9 °9 6 co °� Q U °9 69- °cam nog Q t� °9 °9 °4 C
U z o 0
Q
Q) ro m a _ m D '0 o
Ca CL. O @ @ O N c0 CC Q1 O CO M C)
O O C O m -.. E 0 O V O E
ivrt
t O O O - 00 O (NI O O
'V- N L - N O @ L a) o @ _c — a)
V co .N a) a co N N Ci O N N a
o — a a� w N = a N = °• t, 8 u)
E Cl•E C _1b a C. v . rn a a C) a a v
CO E N C) E N d • co
() ,C c m co > v c m > v c m > v
w-+ V za < . o ° o ci d o 0 o v- c.) < co 0 o N
C ,� 0 0 0 0 0 0 0 0 o O o 0 0 0
0
— `r N
p tB ) o co° o
Cl Q) N N N
p U j 0 °(,3 °� o69- o ° °� o o co m c» °d o 0
05 69 C H d > e» —
• - b
2 C2
0 0 0
w °' 01 °'
a
m o ° m °3
<• co O w O y O fn
Q. C ~ O ~ O 2
Y C ° LC) - 1.0 - a
N O w N Ti
O _C a L .a n N
ca N
L1.. to o c 0 o U co o c U
O o cc) c _ o c 0 c
N a) ry N U @ y U a N U o
_ m
@ m 9 - a m . Cl a o CNI
n ` n a `U O a p a 2 a> - O a
•
•
I)
C)
CO
m ° e e o 0 0 o m ° -- f
m )- to C 0- .- Q 0 (D o CO c o �„�
U ..- r` a) v v U a) r; O Q ca v r
j
.. CL N Q c a C CY N
2 O) co CO O) t` O M N Cn P- it) Q CO co 0 co C
EL CD CO Cn .- CO CO a Cf> CD O ,- CD d
M m cc; o f 2 t7i a ri rte. - - e- c7 N CO
CL ` 'f' es a 6 s `s cv a 63 v>
v o 0
0 0 0
O N N
N
T i O i C
a.Q FC 0. F- Q
Q
Q • O r r co co O O U Cb N co R N
Q c) r` r Q r) N -0 d U N r) M c) .0 d co C r) N I`
to EA 69 64 Efl N69 EH » y 69 63 CA 69 L ? O n ( O h O 63 O
O 0 69
Q p U L. U L. U
a.Q -
to .- a
if: U co 4 C
•L
p C O s p � O O
0 [L N O C6
N Cn O an d
O N - N N _o N N _0 •
E —co P-
.'N E N ' r) a) E N- CD C- N. E O CO O L0
Ni ri Ni •C • D 2 Ni e- r) r co .0 D r) O C7 O V
ca
Cl) O p 2 8 p = 8 y , a`,
.).+ . E .d co E U C fL
.y ti Q p ¢ 0 Q
C)
p p r` o 0 0
Q. L N N N
a U i
Q co' C (7) N CD C) n
N U) CO LO P O r) C co r) — I!) f N. co r 1!) C (0 CD
0 r) If) .7 V N O) = a) (0 CO 00 C O f`
C7 ,- CO O , 1-- t- V C) N s- CO CO CO U n > 69 ffl it; • >. CA N Cf N c,5 C j O Q) I.0 V-
,_ O)
-._ r» e» E s ea vs 69 69 .- c 6 u
d r a a ss ss
U 0 0 0 0
W
I iti 4
El. CL
Y
CC To m ti
3 o F- m r- 2
Y o n a)a) d
Q N N N N a)
O C .0 r
N C o n CO O C U N CD O C N (D O
LL Lo O N C \ U O N y 1 V
ns
0 c N U O O Q (9 > C 2 ` co> Q Q
O Q >, ° O` a F a ti a m m a o
H -) o) p L O U T [Y 0 N 9 U 22 2 8 N
� _S
•
C018
°
0
To
3
0 0 3
a.)
a Et
oH<: r .
O
o f'
mo
2 co
v
c
m
y_ o
O a� w
W N O C
C
.c!, a M
.Q xi,
W u
L
as as
O °' o
N
;J mo -Co
_
C ca
o
N -moo
ch CZ
CD ° c
o d
n
TO
c
0
No
a,
Lo
N--- a'z'
U o � �
a ; -.. U
c .:,,,,,,J,,,..:.....-,,, ,.8 4— ue
O
co
EL
Et N
cn
N Q w o O 0 N• u- o N c0 o r
U o
I ,
, .
. , , i ,_
e ,.....,„.„,...,.,.:,„„,„,„..,,,,.......,„....,..„.....,„......,.....,...........,.,.....,.......,..,..„ ....,.......,. .. ......,.. ...................„,..,.............„..„...., ,,,.. .. ,. .. ,
AI:;:tatainging:ggi.tiadgelegifieneggingn,g:::INgagf...;x.M.A.m.n:006.:Mainftharf:g0.,..q10::::EN:415:* co o C
....
,.........,,,,,,,,,„„,„
;:1.11.1iNSSMONAM:giiagEggefatiNNURRANERgliggaggaRRigitgiNSASSE:gagegii:Weingh -Z-.5 a
a)
0
j 2
1 -0
E^ m
a)
I
a)
L
1 _
N. I i I N
a)
in MOW Q
U o
Cr) a) CD .
1-- 7,6 0
2 a)
0 as °� o u)
W C = LL o
CO
1 0 a> r
-
C'_ O 4 Q O a)
EL Q I
Q O .0
CD =
O O >'
I
0
N I
• F- I
. _
U
Q)
a 0
I
1 W
a)
I T
• O
W
I
CD
I
i i I
I °-' >,
o
I � a
• I I ) w
I
I
•
o` o 0 0
0 0 0 0 - 0 0 0 0
N- cfl "r c) CV
1
0 f41;•:g<'.., :''''''''',4,*:,.-:,'",•:,••'.4,,,i..•.:,..e..:,,,,,,'':,.: .e/-
r .
I �
f
F .
t ? n "Cr
L
3 Cr
•
I1
'y "'s x�i+ b.,z,„ r r E, , �. -g,.E"3�gZ R'z �r'4W-,'
3 R 5,X;L i aYY D' `P.M R
',a,m..h�,.xL.. �.,✓. 1.au�7 n.,_l,�, nL 1 �YT �g �'e �' ��Y
T-
..— Q
. " a'b CO
I— Q %� .yew d
= 0 n ¢ =
CI. . .-. N 0
�_ (D
O
O -
n.
N
4.
m•
= o o
S T
Q '
i
O c
f 3 'R �� �l}' r ' z Fx �z3` s�� i e ah rjy V. z +,b� + Q ,,,3. � J A:44.oes.. 1n ` ,.4i E�£ fi Z
pP � . i � r
et
t
1 j _
I I 1
C
a D
• i I i
1
o0 0 ."8"-' c o 0 0 0
co t.0 co tp O t.0 O O
V CO CO N N ,-- ..r.-
C)
b
C
Li
0 -Fs
C
Cr
u) N N
p .0 o 0 0 o c o 0 --,,,j, .....9, o p o o c o 0 0 o c o o p „Q 0 '6 0 0 0 0 0 0 '6 0
0000000000 o to o O) 0 0 0 O O O n o h o, 0 0? 0) 0 0 0
C y co 0 0 C7 0 0 0 0 o O C y C) M N to N N O O O O C p) r- t•') r. e- M r a- O O O
U `C U 2 N r U Lr tf) N
a f9 a IT, a .--
0 0 o
f- N. F- O F--
O p N
N N C—
L : ■
< C., - CO N 0 0 0 0 0 0 0 0 O Q d �) N C) C) r r 0 0 0 0 r L y O co C r N r r O O O N
.B - V- It) O C N r- u7 • .B C Cn r in•
O 7
o a) U . (j) U °)O U
= c O 2 i
O O0
s
o "CS T3 R
rcS Cl.) RS CL
p„ n.
/
I,L, 4.. N o 0 0 0 0 0 0 0 0 o c o 0 0 0 0 0 0 0 0 0 U) o 0 0 0 0 0 0 0 0 0
O - r C)) O O O o 0 0 0 o O E N N- CO o CO to O O 0 0 N O G N N a- CD (D r N O o 0
_ _A r O O O 0 0 0 0 O O C..) _ CO CO N CO r C O O O O O .- rp t` *" C co co O o 0
O U r` N O U U r (� r N U V r r r N
O to O m .�. L tv .5
N d ` c_ d d �o
a)
_ L - E
l4 r 0)
++ i U cu
Q CD d C
Li-(I) CO O O o 0 0 0 0 0 0 c') Q r t- N O) O N C n O co co co O "' O h C`) C') N N C`) 0 0 0 O
_ r- co 69 C9 69 69 69 69 69 69 to r - to o Cn co m C7 69 69 69 49 (D N '- o) c CO u) to r� E9 69 CA C
P `C'r d O N C") Cu O CD r CD CT CT N CO F to .- O) C") V- CO C*) o
O O CD O CD f:N V7 O G O O N tci r W N t�
C ^ N d 69 O a ��6949 E9 E9 N d �49 69 469 69 '-
0 u) N
co
U co =
O t4 O
= O C4
H CE '�
w ZS O
= O_
Y .a) 0 0 0 0 0 0 - 'O 0 0 0 0 0 0 0 0 0 0 0 CD 0 0 0 0 0 0 0 00: y 0000 o 00 o 0CC �- OOO O O O O O O CC
<r m (1. CC Oo00000w oa0000000Ly) 000000000w
CL 3 _o-tt) OOtritnttioL')> CL o-'t?46Ttri tri otri> 0)-`t?ooTtr) u)oui>
O d N N co to r O J L m r N In N Ch to n J i W r N Ln N Ch t) r` J
Q a f9 t7, f9 E9 69 CA EA f9 69 69 Q m or fA.9 69 69 69 64 69 69 69 O Q W CS 49 69(A 64 69 69 69 69 O Q
O Q' O Mi O r r r O C . ■ , a7 0 i Ks F-
CY �cc0oo00cc 0 0 CC f9oo o o 000000 CM 69000000000 F-
LL• o 0 L o 000ao otn0000 000 otno000000
O r N lt) O Lt)to tfi C7 tf) N Lti O tt) lt) t[)C7 tti N tt) O tti to tti O t!)
›- cv fPi C9 b9 a-- r N co co N- 69 69 69 r r N C) to n- 69 69 EA r r N co to r--
)- ._ 69 64 64 Efl E9 69 69 69 E9 64 64 69 69 69 69 69 69 69
U
n
• a
M
N
C
O
O
N
n
in
• o LC)
CD r
'Cr CV CO
• O
7 ;t 64 69
to
64
O O
Q O o co O
on O co co N-
O� 6464
O O
O o tfi O
m O Ni 4
LJ O co CV CO
> b9 • It 64 64
O O
O to
Q p
ul c0 co co
O O
LC) O
Q m b-s O
O co co N sO> 64�O7
O O
Q O o f') to O
CO L N tf> c+7
LL1 N9 a a) N
64 64
N
o
O
m N V
O
C) CN CO
Q > co 't 64
O
U CD 2 0
� � E Qo tno
• i U N w co 0 co O co CV Lo
N N.
C/) O
Q >
t9 N CO
N > O O OC
U m T c N LC
CO CO
> Eq O 64 64
O
U
O a m LL
C.) �
U)
Z
0
W
S
a
0
LL
• a (0 0
C� Z U
2
N- N
2• 4t LC) La
U U
as BlueCross BlueShield
t76) V BluePius
of Minnesota Small Employer Survey
• Independent licensees of the Blue Cross and Blue Shield Association
Date
Group Number
Group Name
The purpose of this survey is to determine if your business is currently in compliance with the Minnesota
Small Employer Health Benefit Act. This law requires that we check an employer's status each year at
their renewal. Please answer the questions listed below and follow the instructions at the bottom. If you
have any questions,please call your agent or Blue Cross market representative.
Yes No
❑ ❑ 1. Is the headquarters of your business located in Minnesota?
❑ ❑ 2. Are all employees paid wages under your company's Federal Tax ID number?
❑ ❑ 3. Is Blue Cross Blue Shield of Minnesota or Blue Plus your company's only health
care plan?
❑ ❑ 4. Our records indicate that your company is not a member of a controlled group. Is
this correct? (If you are unsure, consult your accountant.)
❑ ❑ 5. Did you employ an average of no less than 2 (including owners and partners)nor
41) more than 50 employees (excluding owners and partners) during the previous
calendar year? Please note, an employee is defined as an individual working at
least 20 hours or more per week, and excludes COBRA, seasonal, leased,
temporary, and independent contract employees.
Cl ❑ 6. Do at least 75%of the employees that your company has defined as eligible for
coverage participate in this plan? Please note, to determine your participation
level, do not include employees that have waived coverage due to coverage under
another group health plan, MCHA, medical assistance (MA), General Assistance
Medical Care, or Medicare Plans A and B.
❑ ❑ 7. Do you contribute at least 50% of each employee's (single coverage only) monthly
health insurance cost?
If you answered YES to all the questions,you need to take no further action. The payment of your
premium constitutes no change in your employer status.
If you answered NO to any of the questions, please fax the completed survey to (651) 662-1068 or mail it
to:
Blue Cross Blue Shield of Minnesota
Small Group Underwriting, Route 3-40
PO Box 64560
St. Paul,Minnesota 55164-0560
All other questions about this renewal should be referred to your agent or Blue Cross market
, 0representative.
compliance A 10/07/02
Blue Cross and Blue Shield of Minnesota
• 2005 Group Renewal Bulletin
Small Group
Service Cooperative
Blue Cross •
Effective with January 2005 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 and Annual Reminders
The following describes the benefit changes as a result of State legislation.
• Cleft Lip and Palate Mandate Changed—This mandate increases the age limit for a dependent child to
receive services for cleft lip and palate that are scheduled or initiated prior to the child turning age 19. The
statute previously required treatment up to age 18.
• Scalp Hair Prostheses Changed-This mandate was effective August 1, 1987 mandating coverage for scalp
hair prostheses worn for hair loss due to Alopecia Areata. The benefit was up to $350 per calendar year and
expenses were not subject to a deductible. With the change the expenses are now subject to deductible.
• Routine Cancer Screening Changed -This mandate has been expanded to include coverage for CA125 tests
for women at risk for ovarian cancer.
• Annual Notification to Employees and Dependents who are Minnesota Comprehensive Health
Association (MCHA)Enrollees-Minnesota law requires employers to notify their employees who are covered
by MCHA of their right to enroll in the group plan on the renewal date. The employee can choose to join the
group plan or stay with MCHA. Please notify your employees and dependents with MCHA coverage about this
option. If they want to apply, ask them to complete a health history application and mail the completed
application to your agent or sales representative immediately. Blue Cross will review the applications and
reserve the right to adjust your group rates. The applicant's coverage will be effective on your renewal date.
Benefit Changes
The following describes the benefit changes made by Blue Cross. These changes represent our commitment to
remaining competitive in both cost and plan design.
• Change to Comprehensive Major Medical with Deductible Plans—The benefit level for office visits is
changing from 80%coverage to 100%coverage after a $25 office visit copay. Lab and x-ray services occurring
during the visit will be paid at 100%.
• Closing of Basic Blue Plans—As a result of low enrollment in Basic Blue plans 124, 126, 128, 130 and the
increased interest in our consumer directed products(Health Reimbursement Accounts(HRAs) and Health
Savings Accounts(HSAs) we have decided to close Basic Blue.
S Renaming the Options Blue for Small Groups product- We are now using Options Blue as the name for all
consumer directed products. With this change,we are renaming the Options Blue for Small Groups product to
as
Blue Cross and Blue Shield of Minnesota is an independent licensee of the Blue Cross and Blue Shield Association qQQ
L253P 1(4'OG1
Options Blue-High Deductible Health Plan(HDHP) compatible with HRAs. Plan numbers are 161, 163 and
165.
• Closing of MSA Blue Plans and introduction of Options Blue 1I -High Deductible Health Plan (HDHP)
compatible with HSAs-We are closing the MSA Blue Plans to make way for our new HSA products, Options
Blue- High Deductible Health Plan (HDHP) compatible with HSAs. The new product is very similar to MSA
Blue but takes advantage of recent changes in the law that allow for lower deductible options and first-dollar
preventive care coverage. The plan numbers are 140- 151.
• Prescription drug copay changing—The current drug copay of$14 is changing to a 20%coinsurance
with a minimum of$10 and a maximum of$30 per prescription. If the cost of the prescription is less
than $10,the member pays the cost of the drug. Drugs purchased through mail order will require a
copay of$40 per prescription. This change does not apply to Plans 1, 23, 24, 161, 163, 165, 170, 172,
174, 176, 178 or 180.
• Limitations now applying to PT/OT/ST services-Physical, occupational and speech therapy services
will be limited to a combined maximum benefit of$500 per person per calendar year when services are
received from a nonparticipating provider.
•
Plan Name Savings Single Family
Plan #1 (Aware Gold No Copay) 0.0% $454.50 $1,250.00
Plan#4 (Aware Gold With Copay) 10.7% $406.00 $1,117.00
Plan #6 (Preferred Gold Full w/Copay) 8.9% $414.00 $1,138.50
Plan#8 (Preferred Gold Limited 90/10) 17.3% $376.00 $1,034.00
Plan #27 (Preferred Gold Limited 80/20) 19.9% $364.00 $1,001.00
Plan #30 (Preferred Gold $300 Ded.) 24.0% $345.50 $949.50
Plan#31 (Preferred Gold $500 Ded.) 25.8% $337.50 $928.00
Plan #32 (Preferred Gold $1000 Ded.) 29.4% $320.50 $882.00
Plan #33 (Preferred Gold $2000 Ded.) 32.7% $306.00 $841.50
Plan#113 (CMM $15 Copay) 15.9% $382.00 $1,051.50
Plan #114 (CMM $25 Copay) 17.5% $375.00 $1,031.50
Plan #118 (CMM $300 Ded.) 20.7% $360.50 $991.00
Plan#120 (CMM $500 Ded.) 22.6% $351.50 $967.00
Plan#122 (CMM $1000 Ded.) 26.5% $334.00 $919.00
Plan #123 (CMM $2000 Ded.) 29.9% $318.50 $876.50
Plan #161 ($1000 Ded. HRA) 31.9% $309.50 $851.50
Plan#163 ($1500 Ded. HRA) 36.3% $289.50 $797.00
Plan #165 ($2500 Ded. HRA) 43.0% $259.00 $712.50
Plan#170 ($1100 Ded. 80% HSA) 32.8% $305.00 $839.50
Plan #172 ($1800 Ded. 80% HSA) 40.4% $270.50 $744.50
Plan #174 ($2600 Ded. 80% HSA) 46.8% $241.50 $664.50
Plan#176 ($1100 Ded. 100% HSA) 25.3% $339.50 $933.50
Plan #178 ($1800 Ded. 100% HSA) 33.0% $304.50 $837.00
Plan #180 ($2600 Ded. 100% HSA) 40.0% $272.50 $750.00
Please contact me with any questions that you may have. Thanks!
David D. Smith
Underwriting
(651) 662-4147
• ® BlueCross BlueShield Group Leader
ooa BluePlus• of Minnesota
Inkmdent Names o•e Um Om and IIw. Assoelailaa
od
Bulletin,
Bulletin G5A-04 April 2004
Blue Cross and Blue Shield of Minnesota and Blue Plus
Pharmacy Solutions Introduces New Mail Order Pharmacy
Your health plan includes a mail-order prescription drug program administered by Caremark called Gold
Net by Mail. With this benefit, your members can receive their long-term or maintenance medications
(typically 90 days) through the mail. Starting June 1, 2004, Gold Net by Mail will be replaced by
PrimeMail Pharmacy, a program administered by Prime Therapeutics.At that time,we will discontinue
our relationship with Caremark for mail order prescriptions.
Why the change?
Prime Therapeutics, our pharmacy benefits manager recently completed construction of a world-class
mail order pharmacy in Dallas,Texas.We believe PrimeMail will offer members safe and quality
medications, timely home delivery, improved customer service and cost savings.
We are communicating with members.
To ensure a smooth transition for your employees to PrimeMail Pharmacy, members will receive a
PrimeMail introductory packet.The packet will be mailed the week of April 19,2004 and will include:
• Member Guide to learn about this benefit
•Pharmacy Form to order long-term medications
•Prescription Checklist to review order before sending
• Return envelope to mail orders to PrimeMail Pharmacy
Savings s for employers and your employees.
Currently, only a small percentage of your employees are utilizing their mail-order benefit. This is
unfortunate because a mail-order pharmacy offers significant cost-savings opportunities for members.
PrimeMail offers competitive discounts on brand-name prescription drugs and considerable savings on
generics. In addition, many patients will be able to receive a three-month supply of their medication for
the cost of just two copayments. Plus, PrimeMail is a service your employees will appreciate because it
affords quality medication, convenience,privacy and safety.
Help us get the word out.
To help build awareness and encourage use of PrimeMail, we've prepared a series of employer
announcements, newsletter articles and posters that you can share with your employees. Contact your
sales representative for PrimeMail promotional reminders and additional PrimeMail packets to distribute
to new employees.
Blue Cross and Blue Shield of Minnesota and Blue Plus strive to provide you with the best possible
benefits and services. We're confident you and your employees will find PrimeMail to be a safe,
convenient and cost-effective way to order your long-term prescriptions.
Thank you for your attention to this important change.
Blue Cross and Blue Shield of Minnesota and Blue Plus•P.O. Box 64560•St. Paul, MN 55164-0560
® BlueCross Blueshieki Group Leader
,769 BluePlus
of Minnesota
Wgwdrt keme.1 W Mr 4w w Mw fMM/MW Wr
•
Bulletin G1A-04 February 2004
New Policy for Blue Cross and Blue Shield of Minnesota
Conversion/Transfer from Group Coverage to Individual
Medicare Supplement/Select Coverage
Effective March I,2004,if Medicare-eligible members covered under employer group contracts
want to change their coverage to an individual Medicare Supplement/Select product with
prescription drug coverage (Senior GoldsM drug rider or the Extended Basic contract),a health
history application must first be completed and approved.
If prescription drug coverage is not included in the Medicare Supplement/Select product,those
members may simply complete an Open Enrollment application in order to transfer from group
coverage to an individual Medicare Supplement/Select product.
Members wishing to transfer from a group product to an individual Medicare Supplement/
Select plan must apply within 63 days of the loss of group coverage.
Please Note: State and Federal law allows members applying l ' within six months of their
Medicare Part B effective open-enrollment date to enroll in any Medicare Supplement/Select
product with no health questions asked.