Attachment to Comptroller's Memorandum 2000-24 - Rate Charts A-N MSA TABLES 7/1/2000 TO 6/30/2001 RATES

Attachment to Comptroller's Memorandum 2000-24 - Rate Charts A-N

MSA TABLES
7/1/2000 TO 6/30/2001 RATES
  TABLE EMPLOYEE TABLE STATE
  NO. DEDUCTION NO. PORTION
Chart A (PAIRED D/OEs 7J/7H PRE-TAX) (SORT CODE 00001)
Blue Cross State Preferred (PAIRED D/OEs 7G/7H POST-TAX) (SORT CODE 00001)
  26 PAY BI-WEEKLY  
INDIVIDUAL 010 24.34 011 132.97
SUBSCRIBER + ONE 012 82.49 013 263.59
FAMILY 014 97.97 015 326.76
FLES 018 54.66 019 212.76
  24 PAY SEMI-MONTHLY  
INDIVIDUAL 216 26.37 217 144.05
SUBSCRIBER + ONE 218 89.36 219 285.56
FAMILY 220 106.13 221 353.99
FLES 224 59.22 225 230.49
         
CHART B (PAIRED D/OEs 5P/54 PRE-TAX) (SORT CODE 00159)
Blue Cross Dental w/A&C (PAIRED D/OEs 42/54 POST-TAX) (SORT CODE 00159)
  26 PAY BI-WEEKLY  
INDIVIDUAL 176 0 177 10.38
FAMILY 178 6.4 179 25.32
FLES 180 3.29 181 18.05
  24 PAY SEMI-MONTHLY  
INDIVIDUAL 382 0 383 11.25
FAMILY 384 6.94 385 27.43
FLES 386 3.56 387 19.56
         
CHART C (PAIRED D/OEs 5P/54 PRE-TAX) (SORT CODE 00159)
Blue Cross Dental w/A,B,&C (PAIRED D/OEs 42/54 POST-TAX) (SORT CODE 00159)
  26 PAY BI-WEEKLY  
INDIVIDUAL 042 2.77 043 10.38
FAMILY 044 11.57 045 25.32
FLES 174 5.69 175 18.05
  24 PAY SEMI-MONTHLY  
INDIVIDUAL 248 3 246 11.25
FAMILY 247 12.53 251 27.43
FLES 380 6.15 381 19.56
         
CHART D (PAIRED D/OEs 6R/6P PRE-TAX) (SORT CODE 00079)
BlueCare POE (PAIRED D/OEs 6N/6P POST-TAX) (SORT CODE 00079)
  26 PAY BI-WEEKLY  
INDIVIDUAL 046 0.48 047 104.45
SUBSCRIBER + ONE 048 23.2 049 207.63
FAMILY 050 32.86 051 250.43
FLES 052 13.54 053 164.83
  24 PAY SEMI-MONTHLY  
INDIVIDUAL 252 0.52 253 113.15
SUBSCRIBER + ONE 254 25.13 255 224.94
FAMILY 256 35.6 257 271.3
FLES 258 14.67 259 178.56
         
CHART E (PAIRED D/OEs 7U/7S PRE-TAX) (SORT CODE 00077)
BlueCare Point of Service (PAIRED D/OEs 7R/7S POST-TAX) (SORT CODE 00077)
  26 PAY BI-WEEKLY  
INDIVIDUAL 082 6.75 083 103.82
SUBSCRIBER + ONE 084 38.02 085 205.23
FAMILY 086 44.88 087 253.66
FLES 088 16.84 089 171.13
  24 PAY SEMI-MONTHLY  
INDIVIDUAL 288 7.31 289 112.48
SUBSCRIBER + ONE 290 41.19 291 222.34
FAMILY 292 48.62 293 274.8
FLES 294 18.25 295 185.39
         
CHART F (PAIRED D/OEs 6L/6J PRE-TAX) (SORT CODE 00006)
ConnectiCare (PAIRED D/OEs 6I/6J POST-TAX) (SORT CODE 00006)
  26 PAY BI-WEEKLY  
INDIVIDUAL 763 - 764 87.05
SUBSCRIBER + ONE 765 13.75 766 177.76
FAMILY 767 19.99 768 215.05
FLES 769 8.23 770 139.76
  24 PAY SEMI-MONTHLY  
INDIVIDUAL 771 - 772 94.31
SUBSCRIBER + ONE 773 14.90 774 192.57
FAMILY 775 21.66 776 232.97
FLES 777 8.92 778 151.40
         
CHART G (PAIRED D/OEs 6W/6U PRE-TAX) (SORT CODE 00259)
P.H.S Charter HMO (PAIRED D/OEs 6T/6U POST-TAX) (SORT CODE 00259)
  26 PAY BI-WEEKLY  
INDIVIDUAL 116 0.15 117 99.28
SUBSCRIBER + ONE 118 21.98 119 196.78
FAMILY 120 31.14 121 237.33
FLES 122 12.83 123 156.2
  24 PAY SEMI-MONTHLY  
INDIVIDUAL 260 0.165 261 107.55
SUBSCRIBER + ONE 262 23.815 263 213.17
FAMILY 264 33.735 265 257.1
FLES 272 13.9 273 169.22
         
CHART H (PAIRED D/OEs 5R/5K PRE-TAX) (SORT CODE 00185)
CIGNA Dental Health (PAIRED D/OEs 5J/5K POST-TAX) (SORT CODE 00185)
  26 PAY BI-WEEKLY  
INDIVIDUAL 140 0.00 141 7.08
SUBSCRIBER + ONE 142 2.55 143 13.03
FAMILY 144 3.61 145 15.51
FLES 146 1.49 147 10.55
  24 PAY SEMI-MONTHLY  
INDIVIDUAL 276 0.00 277 7.67
SUBSCRIBER + ONE 278 2.76 279 14.12
FAMILY 280 3.91 281 16.80
FLES 282 1.61 283 11.43
         
CHART I (PAIRED D/OEs 7P/7M PRE-TAX) (SORT CODE 00001)
Blue Cross Out of Area Plan (PAIRED D/OEs 7L/7M POST-TAX) (SORT CODE 00001)
  26 PAY BI-WEEKLY  
INDIVIDUAL 134 6.75 135 146.7
SUBSCRIBER + ONE 124 38.02 125 299.56
FAMILY 136 44.88 137 369.43
FLES 138 16.84 139 244.02
  24 PAY SEMI-MONTHLY  
INDIVIDUAL 344 7.31 345 158.93
SUBSCRIBER + ONE 340 41.19 341 324.53
FAMILY 346 48.62 347 400.22
FLES 348 18.25 349 264.35
         
CHART J (PAIRED D/OEs 5A/5C PRE-TAX) (SORT CODE 00078)
BlueCare POE Plus (PAIRED D/OEs 5B/5C POST-TAX) (SORT CODE 00078)
  26 PAY BI-WEEKLY  
INDIVIDUAL 266 0.00 267 100.20
SUBSCRIBER + ONE 268 18.46 269 201.98
FAMILY 270 25.38 271 245.16
FLES 274 10.45 275 159.89
  24 PAY SEMI-MONTHLY  
INDIVIDUAL 284 0.00 285 108.55
SUBSCRIBER + ONE 286 20.00 287 218.81
FAMILY 296 27.50 297 265.59
FLES 298 11.32 299 173.22
         
CHART K (PAIRED D/OEs 5F/5L PRE-TAX) (SORT CODE 00261)
PHS CHARTER POS (PAIRED D/OEs 5G/5L POST-TAX) (SORT CODE 00261)
  26 PAY BI-WEEKLY  
INDIVIDUAL 327 6.24 328 96.05
SUBSCRIBER + ONE 329 35.18 330 189.87
FAMILY 350 41.52 351 234.66
FLES 352 15.58 353 158.32
  24 PAY SEMI-MONTHLY  
INDIVIDUAL 354 6.76 355 104.05
SUBSCRIBER + ONE 356 38.11 357 205.69
FAMILY 358 44.98 359 254.22
FLES 360 16.88 361 171.51
         
CHART L (PAIRED D/OEs 5Q/5T PRE-TAX) (SORT CODE 00260)
PHS PASSPORT HMO (PAIRED D/OEs 5S/5T POST-TAX) (SORT CODE 00260)
  26 PAY BI-WEEKLY  
INDIVIDUAL 397 0.00 398 97.44
SUBSCRIBER + ONE 399 18.46 400 195.91
FAMILY 401 25.38 402 237.70
FLES 403 10.45 404 155.20
  24 PAY SEMI-MONTHLY  
INDIVIDUAL 405 0.00 406 105.56
SUBSCRIBER + ONE 407 20.00 408 212.23
FAMILY 409 27.50 410 257.51
FLES 411 11.32 412 168.13
         
CHART M (PAIRED D/OEs 50/53 PRE-TAX) (SORT CODE 00003)
MEDSPAN POS (PAIRED D/OEs 51/53 POST-TAX) (SORT CODE 00003)
  26 PAY BI-WEEKLY  
INDIVIDUAL 440 6.36 441 97.95
SUBSCRIBER + ONE 442 35.88 443 193.62
FAMILY 444 42.34 445 239.31
FLES 446 15.89 447 161.45
  24 PAY SEMI-MONTHLY  
INDIVIDUAL 448 6.90 449 106.11
SUBSCRIBER + ONE 472 38.87 473 209.75
FAMILY 474 45.87 475 259.26
FLES 476 17.22 477 174.90
         
CHART N (PAIRED D/OEs 6D/6F PRE-TAX) (SORT CODE 00004)
MEDSPAN POE (PAIRED D/OEs 6E/6F POST-TAX) (SORT CODE 00004)
  26 PAY BI-WEEKLY  
INDIVIDUAL 524 0.00 525 93.84
SUBSCRIBER + ONE 526 20.75 527 185.71
FAMILY 528 29.39 529 223.99
FLES 530 12.11 531 147.43
  24 PAY SEMI-MONTHLY  
INDIVIDUAL 541 0.00 542 101.67
SUBSCRIBER + ONE 543 22.48 544 201.18
FAMILY 545 31.84 547 242.66
FLES 548 13.12 549 159.71

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