Item C28BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: October 15, 2003 Division: Management Services
Bulk Item: Yes X No
Department: Group Insurance
AGENDA ITEM WORDING: Approval to complete the application for voluntary dental and
vision benefits with American General effective January 1, 2004.
ITEM BACKGROUND: BOCC approved the administrations recommendation on April 17,
2003 to make dental and vision benefits available to employees through a third party at a savings
of $920,000.00 to the Group Insurance Program.
PREVIOUS RELEVANT BOCC ACTION: BOCC directed on April 17, 2003 that a request for
proposals be done for a fully -insured voluntary dental and vision benefits.
CONTRACT/AGREEMENT CHANGES: Rates are guaranteed for 2 years.
STAFF RECOMMENDATIONS: Approval
TOTAL COST: $869,950.00
COST TO COUNTY: None
BUDGETED: Yes
SOURCE OF FUNDS:
No
REVENUE PRODUCING: Yes No AMOUNT PER MONTH Year
APPROVED BY: County Atty OMB/Purchasing Risk Management J'�i----
DIVISION DIRECTOR APPROVAL:--t
Sheila A. Barker
DOCUMENTATION: Included To Follow X Not Required
DISPOSITION: AGENDA ITEM
Revised 1/03
1111 No. Westshore Blvd., Suite 208
Tampa, FL 33607-4711 Telephone: 813-287-1040 Facsimile: 813-287-1041 Interisk
E-mail: IsinteriskQaol.com
Corporation
Memorandum
To: Maria Fernandez/Monroe County Benefits
From: Interisk Corporation/Lawton Swan
Date: October 2, 2003
Re: Dental and Vision Proposal Review
The County received and reviewed thirteen separate proposals for dental benefits and four
proposals for vision benefits. Based on the County's initial review, the two top proposers
(CompBenefits and Amercian General) were forwarded to Interisk Corporation for a more
detailed analysis. Those proposals have been reviewed and the following comments are
provided for your consideration.
The CompBenefits and American General proposals are considered similar in benefits provided
and the proposed rates are reasonable in today's fully insured market place.
Dental Benefit
Both the CompBenefits Insurance Company and American General proposals provide
indemnity benefits. Members can utilize any dentist as needed in the Monroe County
area. CompBenefits offers a two tiered rating structure while American General offers a
four tiered rating structure. The four -tiered rating structure allows employees more
flexibility to fit their individual needs and should result in lower overall cost to
employees. American General also has offered a lower rating system for their preferred
provider organization (PPO). They are willing to utilize those rates for the dental benefit
plan even though they do not currently have an active dental network in the County.
Their out -of -network benefits are comparable to the County's current dental plan and in
some cases are better. Both proposals provide a two-year rate guarantee.
The American General enjoys a favorable rating from the A. M. Best Company, the
leading insurance rating organization. CompBenefits Insurance Company is not
currently rated by the A. M. Best Company. Their financial statements submitted with
their proposal were reviewed and do not display as much capital and surplus as the
American General proposal. We believe the stronger and ultimately less cost proposal is
the one from American General and recommend it for selection for January 1, 2004.
Vision Benefit
Both CompBenefits and American General proposed vision benefits. We believe the
benefits under each are acceptable. CompBenefits' proposes a dual rate structure.
However, their Combo Option was eliminated from consideration because it requires
100% participation, which would be difficult for the County to achieve. Their Section
125 Option rates are higher than American General's.
October 2, 2003
Since the CompBenefits Combo Option was eliminated from consideration, the
American General proposal offers lower rates. It is recommended that the American
General proposal be accepted for the January 1, 2004 — 2005 term.
We believe that using one source for both the dental and vision benefits will result in better
coordination and lower costs.
K
October 2, 2003
Dental Rates
CompBenefits
American General
PPO Option
Indemnity Option
Employee 32.48/month
Employee 25.98/mo
33.65/month
Employee + Family 96.54/month
Emp+Spouse 50.35/mo
65.22/month
Emp+Children 54.33/mo
70.38/month
Emp+Fam 78.70/mo
101.94/month
Vision Rates
CompBenefits
American General
Combo Plan
(mandatory 100%)
See.125 Plan
(voluntary)
(voluntary)
Employee 3.69/mo
Employee 5.92/mo
Employee 4.70/mo
Emp + one 7.39/mo
Emp + one 11.82/m
Emp+Spouse 9.10/mo
Emp+ faro 12.38/m
Emp+fam 19.80/m
Emp+Faro 15.10/mo
AmERICAN The United States Life Insurance Company in the City of New York
GENERAL Member of American International Group, Inc.
(Called United States Life)
MASTER APPLICATION FOR EMPLOYEE BENEFITS
United States Life's group underwriting rules will be used to determine whether the applicant, if accepted, will participate in
a Multiple Employer Trust, or will be issued a -group policy.
IMPORTANT NOTICE
Any person who knowingly and with intent to injure, defraud or deceive any insurer files an application or statement of
claim containing any false, incomplete or misleading information, is guilty of a felony in the third degree.
APPLICANT DATA:
1. Full name of Applicant (Company): S
2. Group Contact Name: c�
3. Street Address: �IiC7G S1 W-,LNTQA --Jupii,
City: .z�I l Wes Stater Zip: Telephone: (CS)_ aQa— QSZLIA
Mailing Address (if different): Fax: ("- `')S) ool ` �USoi
City: Stater Zip:
Email Address: SIC Code:
4. Applicant is a: ❑ Proprietorship ❑ Partnership ❑ Corporation ❑ Union
Ether (Explain): GLj_\.tr�' CoW Lk*__ -KM
5. Nature of Business: e,i5ik2L_k4 _,f—Z-
6. Are the employees of any affiliated or subsidiary companies or any other locations to be covered? ❑ Yes Ca<O
If yes, give details below. If more space is needed, attach a separate sheet. # of Full -Time
Name of Company Nature of Business Full Address Employees
7. Have you ever been insured for group insurance with United States Life? ❑ Yes o
If yes, give details below.
Group policy number(s)
Date Insurance Ended Effective Date (if still insured) _
8. Is coverage applied for in this application replacing other employer sponsored group insurance? es ❑ No
If yes please complete information below and attach a copy of the present carrier's last bill, the insurance
certificate, and the group policy (if applicable).
Group Carrier's Name and Proposed
Group Voluntary Effective Date Termination Date
Life ' ❑ Life ' ❑
Dental Dental ❑ A; aer,zk
STD ❑ STD ❑ '
LTD ❑ LTD ❑
' including annuities
9. Are there other Group Life Insurance plans (including annuities) in force which you are not replacing or currently
applying for with another carrier? ❑ Yes ['-]-I�o If yes, please indicate the highest benefit amount of each plan.
Will any coverages selected be part of a Flexible Benefit Program under section 125? 94s ❑ No If Yes, please
list coverages below and the percentage of the employees contribution that is paid with pre-tax dollars.
❑ Life and AD&D % ❑ Dental/Vision �% ElDisability %
NOTE: The applicant may be required to furnish proof that duplication of coverage does not exist. If the application is approved based on the
representation that existing insurance will be terminated, insurance under the United States Life plan may not take effect until the day after the
existing insurance is terminated.
HOME OFFICE USE ONLY Group Number: Division Number:
G-24077 (FL) Page 1
00305101-1186 R08/02.
EMPLOYEE ELIGIBILITY
A FULL-TIME EMPLOYEE is one who:
• works at least 30 hours (20 hours for Voluntary Life only) per week, or?-5 hours per week (requires underwriting
approval)
• works the Applicant's regular work schedule; and
• performs his/her job for full pay; and
• works at the Applicant's place of business.
10. Do you want to exclude any classes of full-time employees from coverage? ❑ Yes P; / If yes, list each class by
salary, job title, union membership, or other condition pertaining to employment:
Total # of excluded employees
PARTICIPATION DATA
A WAITING PERIOD is a period of time that an employee must work on a full-time basis in an eligible class before
becoming eligible for coverage. PRESENT EMPLOYEES means employees who are at work on a full-time basis on
the effective date. /
11. Waiting period: Present Employees L�' months OR ❑ First of the month following months'
Future Employees &,i �4�f_S months OR ❑ First of the month following months'
*Only option available for Voluntary Coverages. Available on Group coverages with the 1st of the month effective date only.
12. a. Number of Full -Time Employees (Include employees not to be covered and those being continued)
12. b. Number of Full-time Employees waiving all coverages .......................... ��...............................................
13. Do you employ 20 or more employees? (Include part-time, union, etc.) t?Yes ❑ No
CONTRIBUTION DATA/PREMIUM ELECTION
14. Will the employees be required to contribute toward the cost of the insurance? es ❑ No
(For Voluntary Plans, employees pay all of the cost.)
If yes, indicate the percentage of the cost of each coverage the employer will pay.
Note: If the employer pays the entire cost for the employees, then 100% of the eligible employees must be covered.
Coverage
Life/AD&D
Dep Life
EE Dental*
Dep Dental*
EE Vision*
Dep Vision*
STD
LTD
Integrated DI
Employer %
115.
The employer must contribute a minimum of 35% of the total dental and vision premiums
a. Premiums will be paid: ❑ Annually ❑ Semi-annually ❑ QuarterWlyL'_ onthly
15. b. Have you elected to pay your premiums using electronic transfer? ❑Yes
EMPLOYEE/DEPENDENT DATA
16. Are there any employees who, in the las,_J2 months, have been out of work due to injury or sickness for at least 5
consecutive working days? ❑ Yes o If yes, give details below. If more space is needed, attach a separate
sheet, signed and dated by the Applicant. Note: This question does not need to be answered for Life and AD&D
groups with more than 50 employees insured, Dental coverages, or for Disability coverages with ten (10) or
more employees insured.
Date
Disability
Began
Current Amount
Of Group Life
Insurance in Force
Describe Nature of Injury/Sickness
Date Return To
Full -Time Work
G-24077(FL)
REQUESTED EFFECTIVE DATE
I request that the coverage(s) chosen take effect on:
❑ the date the application is approved in writing by United States Life; or
��AIJIJA(1 1{If the application is approved in writing by United States Life, this will be the Effective Date, which may not
be changed. (A first of the month effective date must be requested for Voluntary plans).
For all plans except Voluntary, premiums will be due as of the effective date. The premium for the first month of coverage must be included.
APPLICANT'S DECLARATION
1. 1 verify that all employees applying for coverage listed on the census form are actively at work and working at least 30 hours
per week, unless another minimum work requirement was authorized by The United States Life Insurance Company, and all
employees meet the eligibility requirements as listed on the application.
2. 1 verify that the United States Life Insurance Company's benefit plan(s) have been offered to all employees. Completed
waivers are attached for those employees and dependents electing not to participate in the plan(s). Note: Changes in the
Census data, may affect previously quoted rates.
3. To the best of my knowledge and belief, all statements and answers given in this application are true and complete.
4. The agent(s) appointed for this application is (are): AILj0 hL\U20 :
5. 1 understand and agree that:
• no agent may change or waive any of the provisions of this application or of any plan of insurance;
• any change or waiver may be made only by an officer of United States Life; and
• this application will be accepted or declined partly on the basis of the statements and answers given in this application.
• If the insurance contract compromises a part of an employee benefit plan, the United States Life Insurance Company is
granted sole discretionary authority to determine eligibility, make all factual determinations and to construe all terms of the
policy. The United States Life Insurance Company has no responsibility or control with respect to any other benefit which
may be provided beyond this contract or any other plan of benefits.
DATE PRINT NAME OF OFFICER, PARTNER, PROPRIETOR
WITNESS SIGNATURE OF OFFICER, PARTNER, PROPRIETOR
Note: If there are any modifications to the statements and answers given in this application (i.e. crossed -out, whited -out erased information), the applicant must
attest to the modification(s) by giving a complete signature in the margin of each page which includes a modification. Applicant Beneficiary Forms, Dependent
Information Forms, or Refusal of Coverage Forms must be completed for coverage if applicable.
PRODUCING AGENT'S DECLARATION/DATA
Please Print PRODUCING AGENT
To the best of my/our knowledge and belief, all the statements and answers given in this application are true and complete.
(Please check one of the following)
❑ To the best of my/our knowledge and belief, the insurance applied for does not replace any existing insurance.
❑ The insurance applied for will replace the following coverage (provide plan names, effective dates, and proposed termination
dates):
Signature Date City and State Where Signed
Producer # Tax ID # /SS # % Commissions split with other agents
Name As Licensed License #
Mailing Address
City/State/Zip
Phone Fax E-Mail
'Please
Print GENERALAGENT
General Agent # Name TAX ID # / SS #
Phone Fax E-Mail
HOME OFFICE USE ONLY
Policy No. Premium Deposit $ Underwriter
Mode Coverages
Group Contact Producer GA
G-24077 (FL) Page 3
00305101-1186 R08/02
AMERICAN
GENERAL
The United States Life Insurance Company in the City of New York
Member of American International Group, Inc.
(Called United States Life)
PARTICIPATION AGREEMENT
Full Name of Applicant (Company):
I understand that Application G-24077(FL) may be an application to participate in a Multiple Employer Trust, as
determined by the underwriting rules of United States Life. If it is, then this Participation Agreement applies.
The Trust Agreement establishes the group insurance fund. A copy of the Trust Agreement will be provided to
me if I request it in writing. I agree to be bound by the terms of the Trust Agreement.
DATE
WITNESS
PRINT NAME OF OFFICER, PARTNER, OR PROPRIETOR
SIGNATURE OF OFFICER, PARTNER, OR PROPRIETOR
HOME OFFICE USE ONLY Group Number: Division Number:
G-24077 (FL) - PARTICIPATION AGREEMENT
00305101-1188A R08%0,2
U)
Z
O
LL
O
U
Z
g
a
J
H
Z
W
0
�rn
ca
Ln —
O
_
N O N t
8
p
V
o
C N
N
fl N
�=?
TZ
,ZQ
O
$
O
CC)
O
Ln
p
O aJ
u'f � O
l0
O�UO
�
O
X
W
c
O=
Z
c� 7
LU
a
G7
O
Z
r
p Vo7S
O
O
L
ca
•p
O
N a> a) N
a L
cN-
N
a)
0
{.i
N m t
0
N
�
000
lOf1
N
r
CLJ a)
Z
p
0 0
Z 4.
IL
w
W
CL M p>
`}
C
VUl
V
�,
G
Z
>�
�-0
0 o2S
L a)
L E r a�
Q
Z
a M
N Q
N
p
p
O
R p Of
O
o� 01 O C
a
N t'
U O
N
a+
Q
X
O
r
00
lf] E J_.�
Ln p E
t 4 i_+
cn Ln Z o
O
W
N
3
O� C N 3
v
a G
te�
27O
opo
cax
'n0
�
�
=
o'
V
Z LL
C,
41
N
r
r00
C)
ara)
�a-O
'�
n O O
O Qp
V
Z �'
v :3
0—
> rn
O O ra)ln
o
pp
p
�p\tnQ
C)
O@
p
O 41 O
00
�
C
Lnt+ p S
W
I-N
O +,
cn
N
X
W
O Q
LL
Z
u 7
m
OZ
>
a�
O
W
IL
C.
ova
LnQ
N n o
g
25
a
o
o o
V
Z O
0 +-� O
T-
OT"
00
Ln
� O
N 04�
of
X
W
0= Q
G
W
Z
Z
V O
LL
Ln
L CraD
O
v)
NQ m
Ln
7
Ipl
O
R
O
o C C)F
O�U
4O
N
v>
X
00
Ln
off= ON
ZN'"'
W
�>
OZ
V
r
1�
0
O N —
'O
L N
C
Z F.
Z
N a (C
$
oe
o O N
a W
C
+' O
vNi
t�i�
X
00
Ln
to t,, '0 O
Z
N Z 4,
W
0
V
W
a)I.-
Z
O@
Ln O
L
L C
D O N
Z
pS
O
a
O O U
N
N
$
000
Ln
Ul) O
{d
LL
W
N Q
O� Q
(y
Q
N
U p
C
H
E
W
c�
Z
a)
m
LU Z
A
_
_
m05
m
m
L
V
O
p
� L
Z
>
p co
Ln
v+ m
O En
ca
v�'i
m
0Lm
Q
0
V
aL
m
O V
N
■
=
m>
_
r
��-
k
B
§0
k
*
*
*
*/M/
k00
G
R
G7\
\
0
_
0
0=■=
§
o
G
OD—u
-1
a
z
z
■§
r
=
>
I�
§
�kk
8
E
§(�
f
+
*
*0�/
§§
o
amU
�
e
_Em
/
G
R
Ln2Ee
§
$t2
G
G�/
0/k
z
a
\
u
0)
o�//�
k
/ k m
§
E
2 j
*
a
$
$\ 2 r o e
�u
e
=m
G
B
moo_
Gt�kk�
ktt
3
/e
z
-
=u
0wotz
§§
kkkE
§
E
2
a
$
R
$®=coe
0
w cn
7)
/
S
B
Bƒa73
o ■
■
0220�
u<
z §
2
o 0o
0
k
§�§
00
E6G3
\
r
k
cn
UD
0 �
22roe
Ln
■
®
3
Ln C.4
§
z
\E£&S
=u
§
2
P
GBgo
=
0woLL
�0
L
\
j
0
0
�
�k�§k\
2
\kk0
ITZ�
0CU—
�u
u«
k
k
�
§
cj>R
§
E
$
a
k
$co
* / § _
2
%
G
2
\
\
Ln
@4
��k\
m0
�
o�
om
m
>
/
\
.
60
/
§
0
o
■
k
k
0
0
Cl04
/ 0 �
§
@
m
�2�
�22\
>.
■
q
®
D
x
LU
04�
om
z
m
tu
go
■
In
/
k
\2�
k
/\k
k
/
\§
/2�2
§
G
e&.
� 2
LL
20�§
LU
o�
0m
%§
k
E
U.
\
LU
a)
LU
k
■
e
k
t
0
_
\
j
m2
#2
I
c =
2
_
2
= £
z
gV
gG
§�
2�
o
u
a) n&—
0.g
m
mg
32
2@
t2
0§
7
/
a
C0
Z
O
U)
Q
d
2
O
U
Z
a
Q
F-
Z
W
0
a
N
O Q)
.a
g
3'
R
O
N O p
°o a c`v
mo
to 'A
g
o
p
0
u
o rno a�
S V
a
Ln -W O
U),O S
VNi
N
O
i_ °
N Oo V
Z
U
X
W
Z
Y
`ra'
$
g
�
�
'C O a)
�=atcv
�1
�
cn O, _
G m U
N
Lr)
'
o
W
0
Ln
0 O
lLn E_ >
ON
Z O
N
r
V)�
'0 o 0
m
u
3
W
4' —E
gL
in
LA
g
o
a�°)
oaa)a�LO�
°
p
in
�cc
�o0
°�
o
Ln
t -0OFZN
Ic
� O
?
°a) OfC
la.
Z
U
X
U
4f
H
W
>
LL
m Q
g
o
OLn
'0p�
o
o
0 c cu
c
IL Z
o
a 0
p
0
in
O oho
v°i
F3
VZ
Ln 4-1 O
V) 0 4-)
v>
cn
O
00
a 'a a) O
p N- p) >
Z
X
a U A
W
Y
p 2 O=
d
O
F 00
Vf F 3
c-r v+—
N U C_
>
o
'O
�
Z�
N
o
O
A
O
ZOW
v>
4+
x
�n
M
X
a Z
N� acv
Cl m V
Z
W
W
OW
0
W
4V
W CG
N
()
a)
a)
V
W LL 0 Z o
p
Z N
g
>O
a�
a)
a
a°
7
a a
OU
N
Z
a
O
Z
w
u
u
u
W
W
LL
J
F
C be
f
Ln a) O
a`>
C
>W a
L O O 1y
O o
o co
0
N' L
p
O
O
: L
p
o°Lr)°
N i
��CNQtOw
Ln
L
o
°0�
v
yH 0
� O
v
-
!0
O � O �O
O
Z
>
:E
Q
Zz
u
C Z_
w ==
p N p
C
0 C C 7
19
LL V o
_
N a
g
O O
R
O
a0Z
o �O
6
C4
Ln
�g
co
Ln a��N
a Z
v> p°
<n
<n
>
O a)- o
z
°
��a
U
J
tA
Cu U_
Z F
O a)
L
OO .00�vi
z
Q
G~
v,
a
@M
Op
OC
O
Op CO
�
Q
°
UW
OV
O
V)
try
a)
N
OD
l
H'O>O
UWC
O C m
Z
ZU
Z
O 1
a]
cl
O o
a
7
E
H
u a)
Z
@
W
N
X
L
m
V
(C
E0
L
m
N C-
Z > v�i
—
Ln
U LA
L_
O M
to
O
0
O
O
J..1
�O
14
u a`U
'IA :Q
mU
[Q
gc)
t! f�
pU
M
U)
11J
2
_D
2
W
}
J
2
1-
Z
O
2
CO lA M
OI M M I�
N NN N
Nc
PZT
j M
ON
cf
V>
CMN O M
C,
F
M In O e-
M w I, O
N
0) N
W
`
N N N
N
L C
W
�
0
C
Z
—
>. �
a
N rn
n 00 N
z
Z M
Lri T-: r�
a a
N
W a
O >
c
Z a
N
m co n
— I-
c- M lA
o^
a O
O
M O
E
O O
va
M
N N N
�a
aa
acNi
O >
� c
C
N
N
O O
(D lA
w M
>
N N
C
W
�
a
G
v
o
CR c
c
M
to co
c (L)
E
u
Z
>
N
�
c p
r,
E ED
c
W
In co
I-.
Co N
7
Z
W
N N
J
U.
I� ll� CO
4,
W
O
N LO oo
O
z
a
N N N
Lo
m
a
M
O
C�O
W
LL
L Q >.
E
W
0
Z
M N N
N
O
W
N
W
O
C
O Of
LL
z
H N d
J
7 7 � C
5 N
H
N eq N
us Z
N (N
0 J
ao
96
o-
M d)
Z
W
W u N }
— J
J i2
D Q
W
Nu
U
I.-Z
Z— Z N Z
O Q ca Q ca Q
W W W W W W
W W W W W W
000 0 00
J J J J J J
a a a a a a
LU LU ui LU L
W W W W W W
O
rn
co
a
U)
W
c�
G
W
w
a
J
Z
CO
G
N �
�
F400-tclzg
N IN CD
p N Cl
w
E
i = O4-1
O t
a
0 U 0)
U O 0 ca a
d'
Ln
N LD
0)
H
N N
C O
Z
W
W
O
R
m E
O
7 Q 0)
a
p1 > E
y O C t'
�EO.�'
M
I� O
a
Ln
Ln
N
41 (D
�0 0 5
Q
n
N
�
c °o
a
L- N
c 'v,
Q, N T
C))0R Q?
LL
C 0 —
3 U N?
cWc
i 0
W
�.
M
N N_
N
a
v�i
z
c a m a)
1.01 rn
CO c
N LLnn Cl T-
J
r
n r
�
z
z
N
E_ 3 0
W
7 O o O
O
a
z
Q
_
.
Ln
M C , Y
_
0)
00 (n
Lr°3+i°w)
u
M Li
N
M 00 00
N N
10
C ) 0
0
p)
CL
r
L.
IL
C 0) N
W O
c E Q a
Q Q
(D Ln
w"W U E
c
a W
M a)
C •O w
F•
pj W
M Lri
m co
N N
v m a) N
O Q E
Q W
0
m a) m
a
OL •O � LM
0)
? C
N
O 0 0) O m
0
= R LL a W •�
Ln
c Ln E V)
N Q PA LMD Cl
Z
W
W o }
0 J
Q
J
oe
a anivo¢
W
0 + 0
N
I-.z
Z Z z
0 <ca < ca <
W W W W W W
W W W W W W
000000
J J J J J J
a a a a a a
� LU LU LU
W W W W W W
J
Q
H
Z
w
0
v
(D
O)
N
a
z
0
U)
Q
a
0
U
z
g
Z
0
C
a
Y
eg.
V1
Vf
V1
V1
m
Q
G
L
OoWaui
C
@Ce
C
C
CD
N UU
;
CE
OQZ
O E
E
E
—
F
C{B
OYO
U.
N
�N-
NNN
(D
>O 7
w
a)
CL
Z d
~
O
O O O CD CD
co co
In
0 0
W
LO
O
N W
N N (n W
N W
N lz
U C
4-J
L
4-J
�
J
0
LLIx
O o
E
E
E
Q E
O o
rn oCN
N
(M
O LU
Z
v, B i
1
�
Q
Ln 27
O
i O
N
N CL
N W
N N N W
N W
N W
Q 'O
x O
i,
Y
1+
O O �
4-E
C
C
0 C
F, C
\
,On
z3
E
E+
EoE
N4-
F
W
N
N
r
C CN�
O N>
$
N
Q �>
N
O O
' CO 4J
U
>
Ln
N
S>
S S S S>
� >
V- >
>
O O
T- W
T- � c- r W
V) '6 W
N W
Q
U— U
y1
L {n
N1
LA
\p
LL OC
C
O C
C
U C
N
cn
E
E
E
E
b
E
rn o o C
N
N
Q
N
CL O W
Z
'tn �
S
Q
pO1
f0
O
n N
Cf >
co CD In N w
:T w CO e- >
In N
R >
O a)a)O
>
>
�
N W
N (n N U) W
N W
N W
Q 'd
O
r
of
Vf
N
H
Q
N
w
ate.+
Y
Y
L
N
O
W
2
O
E
O
E+
O O
EQE
Ora
Cl)�'
zo
Q
W
N
r
N
C
Q N
C
Q N
U
p
o
U
Z
�O
OU �M
@ OU
s>
sass>V�>�>
>N
r W
r r r W
N 'iS W
N W
Q
Q
N
Ln
to
to
4
LL OL
C
j C
C
C
i, -a
Fo E
O
o
a
E
U
E
E
E
O W CL CL
N
75 0CE
� w N
'N
v
N
v
N
o)
Lcv
o) N
Z O
LL
.fl iL.+
S
a)O
O
N
J
U)M
(n a)
>
N W
M O O a)O
N (O , >
N U) (n (n W
.:T>
N W
� >
N W
O
IZ
F
LL
W N
p
U N
fC ,
^
w�' •�'LA
a E
C
C
�C
-
C>
o ao
�' E
0m
O�ca
o Z°vc
V —
—E
—E
a�E
E
w�Q�
E
OWE
U N
LU a
4- C
r
N
N
°'
C Y
E E .
O_
mtan)
O' R
CLm>
a)
:2 w
m>
O N
c>
O O
T->
��
E
Owe
7
L1 W
CL W
N W
N W
0 L C
U O w
N
N
U
Z LOUce
i-+
=
Cl Ln
m a
O
'� O
O
N 'L
E O
OWL
LL a
O
n E
N E
E
" E
V
N N
W N
d N
N
'O
y
fl 27
O
O Z
O
O 2
O
O a)
Ln
In a)
M w
In CD
W
C7
W
N W
N W
N W
N
H
LL
�
fn
F-
Qx
N
W
W
m
W
N
H
Y
W
LU
LL
o
g
000 o
/%KLnk
§ E
E E
§
§/E
.[35
o E
C4 z m
CDS R
2
§
»
®
a) E
�E
.33'
5. o E
C-4zm�
a
w /
me C-- 0 ®
G
t°,G232h
2
m =E t u f 25 2/
g
§
§ 2 2 --IM4T
■
_
o—cuc��_�m
@a£s°®=—a
§
k\$G�0 0C;4D
~a§m/
LeuaE
q 7GLn
//
/
e
m
u
\@
§
° E
2
kE2
§
04
� LU
t
Im
kƒz$
§
Lnu0LL
+ + + +
wLULUuiLU
LUuiuuLULU
00000
aa�a�
■uiuiu�
ui ui ui ui�
AMERICAN
GENERAL
National PPO Dental Coverage
Coinsurance
Services In Out*
Deductible
And
Preventive 100% 100%
$0 In network, $50 Out of Network
Basic 90% 80%
$50
Deductible
Major 60% 50%
$50
Ortho 50%
$0
Maximums
$2,000 Calendar Year Non-Ortho Maximum
$1,500 Lifetime Ortho Maximum
Miscellaneous
Endo, Perio, and Oral Surgery covered as Basic services.
*Payment at 80a' percentile.
Ortho benefit covers dependent children only.
Waiting Periods Applicable to late entrants only.
Six months for Basic services.
Twelve Months for Major services.
Twenty -Four Months for Ortho services.
No Loss — No Gain Continuity of coverage. will be provided for all employees as of the effective date of
coverage. No individuals will lose coverage solely based on the change in carriers.
Dental Provisions ➢ AIG National Network dentists must be used for In network reimbursement.
➢ Child(ren)'s coverage terminates at age 19; or 25 if full-time student
➢ TMJ coverage is excluded..
Rate Summary
National PPO Dental
2 year
Employee Only
$25.98
Employee & Spouse
$50.35
Employee & Child(ren)
$54.33
Full Family
$78.70
SPEC T
ILIA/\
A UnitedHealth Group Company
SPECTERA VISION PROGRAM
Benefits
Network,
Out-of-Network2
Eye Examination
100%
up to $40.00
Spectacle Lenses
Single Vision
100%
up to $40.00
Bifocal
100%
up to $60.00
Trifocal
100%
up to $80.00
Lenticular
100%
up to $80.00
Frames o
100%3
up to $45.00
Elective Contact Lenses4
Covered -in -full contacts 100% up to $105
All other elective contacts up to $105 up to $105
Necessary Contact Lensess 100% up to $210.00
Network Benefits — Exam and materials copays and patient options are paid to the network provider by the plan participant.
Out -of -Network Benefits — The plan participant pays full fee to the provider and Spectera reimburses the participant for services rendered up to
maximum allowance. There are no copays or deductibles.
Frame Benefit - Over 60% of all frames on the market today are covered -in -full by Spectera's frame benefit (after applicable copay). With
Spectera's frame benefit, all frames with a $50 wholesale cost or less are covered -in -full at private practice providers. For any frame with a
wholesale cost greater than $50 at private practice providers, the participant only pays the difference between the wholesale cost of the frame
and the $50 allowance. Plan participants receive a minimum $120 frame allowance for frames purchased at retail chain providers.
Contact lenses are provided in lieu of spectacle lenses and frames. Spectera's contact lens benefit covers in -full (after applicable copay) the
fitting/evaluation fees, contacts (disposable contacts/up to 4 boxes, depending on prescription), and up to 2 follow-up visits. A $105 allowance
is applied toward the fitting/evaluation fees and purchase of contact lenses outside of Spectera's covered -in -full contacts (materials copay does
not apply). Toric, gas permeable, and bifocal contacts are all examples of contacts that are outside of our covered -in -full selection.
Necessary contact lenses are determined at the provider's discretion for one or more of the following conditions: Following cataract surgery; To
correct extreme vision problems that cannot be corrected with spectacle lenses; With certain conditions of anisometropia; With certain
conditions of keratoconus.
2004-25
SPECILV\
�
A UnitedHealth Group Company
spectera, Inc. administers prepaid vision care underwritten by American General Life Insurance Company
Monroe County Government
SERVICE FREQUENCY
EXAM 12 MONTHS
LENSES 12 MONTHS
FRAMES 24 MONTHS
FULLY INSURED
100% VOLUNTARY
OPTION 1 - 12/12/24
$4.70 Employee
$ 15 Copay-Exam $9.10 Employee + Spouse
$ 30 Copay-Materials $9.50 Employee + Child(ren)
$1 5.10 Employee + Family
January 1, 2004