| Company Name | Acme Manufacturing |
| Simplicity Group Number |
E04000075 |
| Plan Year |
January 1, 2024 to
December 31, 2024 |
| Simplicity Plan Option |
HSA Option A:
$1,000 single deductible
$2,000 family deductible |
| PPO Network |
Ultima |
Specific Stop Loss
Attachment Point |
$100,000 |
| Specific Stop Loss Carrier |
HCC Benefits |
| Aggregate Attachment Point |
$400,000 |
| Aggregate Stop Loss Carrier |
HCC Benefits |
| Contract Type |
15/12 |
|
| Type |
Rate |
Current Monthly
Enrollment |
Monthly Funding |
Total
Members |
| Employee |
$243.94 |
10 |
$2439.40 |
10 |
Employee/
Child |
$403.83 |
6 |
$2,422.98 |
15 |
Employee/
Spouse |
$506.45 |
10 |
$5,064.50 |
20 |
| Family |
$631.57 |
32 |
$20,210.24 |
159 |
| Total |
|
58 |
$30,137.12 |
204 |
| Claim Type |
Amount |
| Medical |
$345,251 |
| Dental |
$17,346 |
| Vision |
$8,623 |
| Rx |
$54,657 |
| Paid Claims |
$425,878 |
|
