State of Connecticut

Attachment to: 
Comptroller's Memorandum 2001-29 
Rate Charts A-N
April 30, 2001

MSA TABLES
7/1/2001 TO 6/30/2002 RATES
 
TABLE
NO.
EMPLOYEE
DEDUCTION
TABLE
NO.
STATE
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 27.96 011 152.78
SUBSCRIBER + ONE 012 94.76 013 302.87
FAMILY 014 112.53 015 375.48
FLES 018 62.81 019 244.45
  24 PAY SEMI-MONTHLY
INDIVIDUAL 216 30.29 217 165.52
SUBSCRIBER + ONE 218 102.66 219 328.11
FAMILY 220 121.91 221 406.76
FLES 224 68.04 225 264.83
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 0.00 177 11.53
FAMILY 178 7.11 179 28.11
FLES 180 3.65 181 20.04
  24 PAY SEMI-MONTHLY
INDIVIDUAL 382 0.00 383 12.49
FAMILY 384 7.70 385 30.45
FLES 386 3.95 387 21.71
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 3.06 043 11.53
FAMILY 044 12.83 045 28.11
FLES 174 6.31 175 20.04
  24 PAY SEMI-MONTHLY
INDIVIDUAL 248 3.32 246 12.49
FAMILY 247 13.90 251 30.45
FLES 380 6.83 381 21.71
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 1.42 047 119.14
SUBSCRIBER + ONE 048 26.65 049 238.58
FAMILY 050 37.76 051 287.75
FLES 052 15.55 053 189.40
  24 PAY SEMI-MONTHLY
INDIVIDUAL 252 1.54 253 129.07
SUBSCRIBER + ONE 254 28.88 255 258.45
FAMILY 256 40.91 257 311.72
FLES 258 16.85 259 205.18
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 7.75 083 119.3
SUBSCRIBER + ONE 084 43.68 085 235.82
FAMILY 086 51.56 087 291.47
FLES 088 19.35 089 196.63
  24 PAY SEMI-MONTHLY
INDIVIDUAL 288 8.40 289 129.24
SUBSCRIBER + ONE 290 47.33 291 255.47
FAMILY 292 55.86 293 315.75
FLES 294 20.97 295 213.01
CHART F (PAIRED D/OEs 6L/6J PRE-TAX) (SORT CODE 00006)
ConnectiCare HMO Personal Care (PAIRED D/OEs 6I/6J POST-TAX) (SORT CODE 00006)
26 PAY BI-WEEKLY
 
INDIVIDUAL 763 - 764 103.76
SUBSCRIBER + ONE 765 19.11 766 209.16
FAMILY 767 26.28 768 253.87
FLES 769 10.81 770 165.58
  24 PAY SEMI-MONTHLY
INDIVIDUAL 771 - 772 112.41
SUBSCRIBER + ONE 773 20.70 774 226.59
FAMILY 775 28.47 776 275.02
FLES 777 11.72 778 179.37
CHART G (PAIRED D/OEs 6W/6U PRE-TAX) (SORT CODE 00259)
Health Net Charter HMO (PAIRED D/OEs 6T/6U POST-TAX) (SORT CODE 00259)
26 PAY BI-WEEKLY
 
INDIVIDUAL 116 1.85 117 125.92
SUBSCRIBER + ONE 118 28.25 119 252.85
FAMILY 120 40.02 121 304.97
FLES 122 16.49 123 200.72
  24 PAY SEMI-MONTHLY
INDIVIDUAL 260 2.01 261 136.41
SUBSCRIBER + ONE 262 30.605 263 273.91
FAMILY 264 43.36 265 330.37
FLES 272 17.86 273 217.46
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 7.36
SUBSCRIBER + ONE 142 2.65 143 13.55
FAMILY 144 3.76 145 16.12
FLES 146 1.55 147 10.97
  24 PAY SEMI-MONTHLY
INDIVIDUAL 276 0.00 277 7.98
SUBSCRIBER + ONE 278 2.87 279 14.68
FAMILY 280 4.07 281 17.47
FLES 282 1.67 283 11.89
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 7.75 135 168.56
SUBSCRIBER + ONE 124 43.68 125 344.21
FAMILY 136 51.56 137 424.48
FLES 138 19.35 139 280.38
  24 PAY SEMI-MONTHLY
INDIVIDUAL 344 8.40 345 182.61
SUBSCRIBER + ONE 340 47.33 341 372.88
FAMILY 346 55.86 347 459.85
FLES 348 20.97 349 303.74
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 0.00 267 115.13
SUBSCRIBER + ONE 268 21.20 269 232.09
FAMILY 270 29.16 271 281.69
FLES 274 12.00 275 183.72
  24 PAY SEMI-MONTHLY
INDIVIDUAL 284 0.00 285 124.73
SUBSCRIBER + ONE 286 22.97 287 251.43
FAMILY 296 31.59 297 305.17
FLES 298 13.00 299 199.04
CHART K (PAIRED D/OEs 5F/5L PRE-TAX) (SORT CODE 00261)
Health Net CHARTER POS (PAIRED D/OEs 5G/5L POST-TAX) (SORT CODE 00261)
26 PAY BI-WEEKLY
 
INDIVIDUAL 327 8.02 328 123.42
SUBSCRIBER + ONE 329 45.19 330 243.97
FAMILY 350 53.34 351 301.54
FLES 352 20.02 353 203.42
  24 PAY SEMI-MONTHLY
INDIVIDUAL 354 8.69 355 133.70
SUBSCRIBER + ONE 356 48.96 357 264.30
FAMILY 358 57.79 359 326.66
FLES 360 21.69 361 220.38
CHART L (PAIRED D/OEs 5Q/5T PRE-TAX) (SORT CODE 00260)
Health Net PASSPORT HMO (PAIRED D/OEs 5S/5T POST-TAX) (SORT CODE 00260)
26 PAY BI-WEEKLY
 
INDIVIDUAL 397 0.00 398 125.21
SUBSCRIBER + ONE 399 23.05 400 252.40
FAMILY 401 31.71 402 306.35
FLES 403 13.05 404 199.80
  24 PAY SEMI-MONTHLY
INDIVIDUAL 405 0.00 406 135.64
SUBSCRIBER + ONE 407 24.98 408 273.43
FAMILY 409 34.35 410 331.88
FLES 411 14.14 412 216.45
CHART M (PAIRED D/OEs 8N/8L PRE-TAX) (SORT CODE 00052)
CTCARE POS OPEN ACCESS (PAIRED D/OEs 8K/8L POST-TAX) (SORT CODE 00052)
26 PAY BI-WEEKLY
 
INDIVIDUAL 440 7.56 441 116.41
SUBSCRIBER + ONE 442 42.63 443 230.11
FAMILY 444 50.31 445 284.42
FLES 446 18.88 447 191.88
  24 PAY SEMI-MONTHLY
INDIVIDUAL 448 8.20 449 126.11
SUBSCRIBER + ONE 472 46.18 473 249.29
FAMILY 474 54.50 475 308.12
FLES 476 20.46 477 207.86
CHART N (PAIRED D/OEs 8T/8R PRE-TAX) (SORT CODE 00054)
CTCARE HMO OPEN ACCESS (PAIRED D/OEs 8Q/8R POST-TAX) (SORT CODE 00054)
26 PAY BI-WEEKLY
 
INDIVIDUAL 524 1.13 525 114.53
SUBSCRIBER + ONE 526 25.57 527 228.88
FAMILY 528 36.22 529 276.05
FLES 530 14.92 531 181.70
  24 PAY SEMI-MONTHLY
INDIVIDUAL 541 1.22 542 124.08
SUBSCRIBER + ONE 543 27.71 544 247.94
FAMILY 545 39.24 547 299.06
FLES 548 16.17 549 196.83

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