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Medical Rates Insurance Cigna HMO High Plan w/Standard (DHMO) Dental Plan City provides stipend to each employee for health insurance. Employees may opt-out of health insurance by providing proof of alternate coverage. City pays 100% of the cost for employee coverage for dental DHMO plan and the vision plan and 50% of the cost for dependent coverage for dental DHMO plan and the vision plan. Dental and vision insurance are mandatory for employees. RATES EMPLOYEE EMPLOYEE + EMPLOYEE + CHILD(REN) SPOUSE $465.26 $861.94 $1,014.31 $13.43 $30.21 $26.86 $5.68 $10.76 $11.32

$1,279.74 $48.61 $16.68

EMPLOYEE

EMPLOYEE + CHILD(REN)

EMPLOYEE + SPOUSE

FAMILY

$650.00

$750.00

$750.00

$750.00

$500.00

$465.26

$861.94

$1,014.31

$1,279.74

$-

$-

$8.39

$6.72

$17.59

$-

$-

$2.54

$2.82

$5.50

$-

$465.26

$872.87

$1,023.85

$1,302.83

$-

$184.74

$(122.87)

$(273.85)

$(552.83)

$500.00

FICA / Medicare Tax (7.65%)

$14.13

0

0

0

$38.25

Monthly Balance (Subtotal less FICA/Medicare Tax)

170.61

122.87

273.85

552.83

461.75

85.30

61.44

136.92

276.42

230.88

RATES PER MONTH Health Insurance Dental Insurance Vision Insurance

Monthly City Insurance Stipend to Employee Monthly Cost Health Insurance Monthly Cost Dental Insurance Monthly Cost Vision Insurance Total Monthly Cost of Insurance

FAMILY

OPTED OUT

Monthly Subtotal (insurance stipend less insurance cost)

Pay Period Balance (Cost or Allowance to Employee) **Based on 24 paychecks

*Note: Amounts in BLUE represent monies paid to employee; Amounts in RED represent monies paid by employee. **Pay period balance is based on 24 paychecks; therefore employees will have two paychecks with NO insurance deductions. 11


hmo-high-w-standard-dental-pdf