State of Connecticut Office of the State Comptroller MEMORANDUM NO. 99-23 Attachment 1
MSA TABLES
7/1/99 TO 6/30/2000 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)
27 PAY BI-WEEKLY
INDIVIDUAL 010 23.44 011 128.04
SUBSCRIBER + ONE 012 79.43 013 253.83
FAMILY 014 94.34 015 314.66
FLES 018 52.64 019 204.88
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)
27 PAY BI-WEEKLY
INDIVIDUAL 176 0.00 177 10.00
FAMILY 178 6.16 179 24.39
FLES 180 3.16 181 17.39
24 PAY SEMI-MONTHLY
INDIVIDUAL 382 0.00 383 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)
27 PAY BI-WEEKLY
INDIVIDUAL 042 2.66 043 10.00
FAMILY 044 11.13 045 24.39
FLES 174 5.47 175 17.39
24 PAY SEMI-MONTHLY
INDIVIDUAL 248 3.00 246 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)
27 PAY BI-WEEKLY
INDIVIDUAL 046 0.46 047 100.58
SUBSCRIBER + ONE 048 22.34 049 199.94
FAMILY 050 31.64 051 241.16
FLES 052 13.04 053 158.72
24 PAY SEMI-MONTHLY
INDIVIDUAL 252 0.52 253 113.15
SUBSCRIBER + ONE 254 25.13 255 224.94
FAMILY 256 35.60 257 271.30
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)
27 PAY BI-WEEKLY
INDIVIDUAL 082 6.50 083 99.98
SUBSCRIBER + ONE 084 36.61 085 197.63
FAMILY 086 43.22 087 244.26
FLES 088 16.22 089 164.79
24 PAY SEMI-MONTHLY
INDIVIDUAL 288 7.31 289 112.48
SUBSCRIBER + ONE 290 41.19 291 222.34
FAMILY 292 48.62 293 274.80
FLES 294 18.25 295 185.39
CHART F (PAIRED D/OEs 6L/6J PRE-TAX) (SORT CODE 00006)
Kaiser Foundation Health (PAIRED D/OEs 6I/6J POST-TAX)(SORT CODE 00006)
27 PAY BI-WEEKLY
INDIVIDUAL 126 0.00 127 83.83
SUBSCRIBER + ONE 128 6.62 129 177.80
FAMILY 130 9.63 131 216.71
FLES 132 3.97 133 138.55
24 PAY SEMI-MONTHLY
INDIVIDUAL 332 0.00 333 94.31
SUBSCRIBER + ONE 334 7.45 335 200.02
FAMILY 336 10.83 337 243.80
FLES 338 4.46 339 155.86
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)
27 PAY BI-WEEKLY
INDIVIDUAL 116 0.15 117 95.60
SUBSCRIBER + ONE 118 21.17 119 189.49
FAMILY 120 29.99 121 228.53
FLES 122 12.36 123 150.41
24 PAY SEMI-MONTHLY
INDIVIDUAL 260 6.76 261 104.05
SUBSCRIBER + ONE 262 38.11 263 205.69
FAMILY 264 44.98 265 254.22
FLES 272 16.88 273 171.51
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)
27 PAY BI-WEEKLY
INDIVIDUAL 140 0.00 141 6.82
SUBSCRIBER + ONE 142 2.45 143 12.55
FAMILY 144 3.48 145 14.93
FLES 146 1.43 147 10.16
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)
27 PAY BI-WEEKLY
INDIVIDUAL 134 6.50 135 141.26
SUBSCRIBER + ONE 124 36.61 125 288.47
FAMILY 136 43.22 137 355.74
FLES 138 16.22 139 234.98
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 000078)
BlueCare POE Plus (PAIRED D/OEs 5B/5C POST-TAX)(SORT CODE 000078)
27 PAY BI-WEEKLY
INDIVIDUAL 266 0.00 267 96.49
SUBSCRIBER + ONE 268 17.78 269 194.50
FAMILY 270 24.44 271 236.08
FLES 274 10.06 275 153.97
24 PAY SEMI-MONTHLY
INDIVIDUAL 474 45.87 475 259.26
SUBSCRIBER + ONE 476 17.22 477 174.90
FAMILY 541 0.00 542 101.67
FLES 543 22.48 544 201.18
CHART K (PAIRED D/OEs 5F/5L PRE-TAX)(SORT CODE 000261)
PHS CHARTER POS (PAIRED D/OEs 5G/5L POST-TAX)(SORT CODE 000261)
27 PAY BI-WEEKLY
INDIVIDUAL 327 6.01 328 92.49
SUBSCRIBER + ONE 329 33.88 330 182.83
FAMILY 350 39.98 351 225.98
FLES 352 15.00 353 152.46
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 000260)
PHS PASSPORT HMO (PAIRED D/OEs 5S/5T POST-TAX)(SORT CODE 000260)
27 PAY BI-WEEKLY
INDIVIDUAL 397 0.00 398 93.83
SUBSCRIBER + ONE 399 17.78 400 188.65
FAMILY 401 24.44 402 228.9
FLES 403 10.06 104 149.45
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)
27 PAY BI-WEEKLY
INDIVIDUAL 440 6.13 441 94.32
SUBSCRIBER + ONE 442 34.55 443 186.45
FAMILY 444 40.77 445 230.45
FLES 446 15.30 447 155.47
24 PAY SEMI-MONTHLY
INDIVIDUAL 448 6.90 449 106.12
SUBSCRIBER + ONE 472 38.90 473 209.76
FAMILY 474 45.90 475 259.26
FLES 476 17.20 477 174.90
CHART N (PAIRED D/OEs 6D/6F PRE-TAX) (SORT CODE 00004)
MEDSPAN POE (PAIRED D/OEs 6E/6F POST-TAX) (SORT CODE 00004)
27 PAY BI-WEEKLY
INDIVIDUAL 524 0.00 525 90.37
SUBSCRIBER + ONE 526 19.98 527 178.83
FAMILY 528 28.30 529 215.70
FLES 530 11.66 531 141.97
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
CHART O (PAIRED D/OEs 47/71 PRE-TAX) (SORT CODE 00005)
MEDSPAN POE-G (PAIRED D/OEs 48/71 POST-TAX) (SORT CODE 00005)
27 PAY BI-WEEKLY
INDIVIDUAL 670 0.00 671 0.00
SUBSCRIBER + ONE 672 0.00 673 0.00
FAMILY 674 0.00 675 0.00
FLES 676 0.00 677 0.00
24 PAY SEMI-MONTHLY
INDIVIDUAL 678 0.00 679 0.00
SUBSCRIBER + ONE 680 0.00 681 0.00
FAMILY 682 0.00 683 0.00
FLES 684 0.00 685 0.00
CHART P (PAIRED D/OEs 6L/6J PRE-TAX) (SORT CODE 00006)
KAISER NEW ENROLLEES (PAIRED D/OEs 6I/6J POST-TAX) (SORT CODE 00006)
27 PAY BI-WEEKLY
INDIVIDUAL 763 0.00 764 83.83
SUBSCRIBER + ONE 765 13.24 766 171.18
FAMILY 767 19.25 768 207.08
FLES 769 7.93 770 134.58
24 PAY SEMI-MONTHLY
INDIVIDUAL 771 0.00 772 94.31
SUBSCRIBER + ONE 773 14.90 774 192.57
FAMILY 776 232.98 776 232.98
FLES 778 151.40 778 151.40

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