State of Connecticut

ATTACHMENT TO MEMORANDUM 2002-17

OFFICE OF THE STATE COMPTROLLER

MSA TABLES
7/1/2002 TO 6/30/2003 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 32.02 011 174.93
SUBSCRIBER + ONE 012 108.49 013 346.80
FAMILY 014 128.85 015 429.91
FLES 018 71.91 019 279.90
24 PAY SEMI-MONTHLY
INDIVIDUAL 216 34.69 217 189.51
SUBSCRIBER + ONE 218 117.54 219 375.69
FAMILY 220 139.59 221 465.74
FLES 224 77.91 225 303.22
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 11.76
FAMILY 178 7.25 179 28.67
FLES 180 3.72 181 20.44
24 PAY SEMI-MONTHLY
INDIVIDUAL 382 0.00 383 12.74
FAMILY 384 7.85 385 31.07
FLES 386 4.03 387 22.15
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 3.12 043 11.76
FAMILY 044 13.09 045 28.67
FLES 174 6.44 175 20.44
24 PAY SEMI-MONTHLY
INDIVIDUAL 248 3.39 246 12.74
FAMILY 247 14.17 251 31.07
FLES 380 6.96 381 22.15
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 2.47 047 135.57
SUBSCRIBER + ONE 048 30.52 049 273.17
FAMILY 050 43.23 051 329.48
FLES 052 17.81 053 216.86
24 PAY SEMI-MONTHLY
INDIVIDUAL 252 2.68 253 146.87
SUBSCRIBER + ONE 254 33.07 255 295.93
FAMILY 256 46.84 257 356.93
FLES 258 19.30 259 234.93
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 8.88 083 136.59
SUBSCRIBER + ONE 084 50.02 085 270.01
FAMILY 086 59.03 087 333.73
FLES 088 22.16 089 225.14
24 PAY SEMI-MONTHLY
INDIVIDUAL 288 9.62 289 147.97
SUBSCRIBER + ONE 290 54.19 291 292.51
FAMILY 292 63.95 293 361.55
FLES 294 24.01 295 243.90
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 0.00 764 113.56
SUBSCRIBER + ONE 765 20.91 766 228.93
FAMILY 767 28.76 768 277.86
FLES 769 11.83 770 181.23
24 PAY SEMI-MONTHLY
INDIVIDUAL 771 0.00 772 123.03
SUBSCRIBER + ONE 773 22.66 774 248.00
FAMILY 775 31.16 776 301.01
FLES 777 12.82 778 196.33
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 2.56 117 136.97
SUBSCRIBER + ONE 118 30.85 119 276.11
FAMILY 120 43.70 121 333.03
FLES 122 18.00 123 219.20
24 PAY SEMI-MONTHLY
INDIVIDUAL 260 2.77 261 148.39
SUBSCRIBER + ONE 262 33.42 263 299.12
FAMILY 264 47.34 265 360.78
FLES 272 19.51 273 237.46
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 7.66
SUBSCRIBER + ONE 142 2.76 143 14.09
FAMILY 144 3.90 145 16.77
FLES 146 1.60 147 11.41
24 PAY SEMI-MONTHLY
INDIVIDUAL 276 0.00 277 8.30
SUBSCRIBER + ONE 278 2.98 279 15.27
FAMILY 280 4.23 281 18.17
FLES 282 1.74 283 12.36
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 8.88 135 193.00
SUBSCRIBER + ONE 124 50.02 125 394.11
FAMILY 136 59.03 137 486.04
FLES 138 22.16 139 321.03
24 PAY SEMI-MONTHLY
INDIVIDUAL 344 9.62 345 209.08
SUBSCRIBER + ONE 340 54.19 341 426.95
FAMILY 346 63.95 347 526.54
FLES 348 24.01 349 347.78
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 0.16 267 131.66
SUBSCRIBER + ONE 268 24.27 269 265.74
FAMILY 270 33.39 271 322.53
FLES 274 13.74 275 210.36
24 PAY SEMI-MONTHLY
INDIVIDUAL 284 0.18 285 142.63
SUBSCRIBER + ONE 286 26.30 287 287.88
FAMILY 296 36.17 297 349.42
FLES 298 14.88 299 227.90
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 8.76 328 134.77
SUBSCRIBER + ONE 329 49.35 330 266.42
FAMILY 350 58.25 351 329.28
FLES 352 21.86 353 222.14
24 PAY SEMI-MONTHLY
INDIVIDUAL 354 9.49 355 146.00
SUBSCRIBER + ONE 356 53.47 357 288.61
FAMILY 358 63.10 359 356.73
FLES 360 23.69 361 240.65
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 0.25 398 136.48
SUBSCRIBER + ONE 399 25.18 400 275.62
FAMILY 401 34.63 402 334.53
FLES 403 14.25 404 218.19
24 PAY SEMI-MONTHLY
INDIVIDUAL 405 0.27 406 147.85
SUBSCRIBER + ONE 407 27.28 408 298.59
FAMILY 409 37.52 410 362.41
FLES 411 15.44 412 236.37
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 8.28 441 127.41
SUBSCRIBER + ONE 442 46.66 443 251.85
FAMILY 444 55.06 445 311.30
FLES 446 20.67 447 210.00
24 PAY SEMI-MONTHLY
INDIVIDUAL 448 8.97 449 138.03
SUBSCRIBER + ONE 472 50.55 473 272.84
FAMILY 474 59.65 475 337.24
FLES 476 22.39 477 227.50
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 1.78 525 124.81
SUBSCRIBER + ONE 526 27.99 527 250.50
FAMILY 528 39.65 529 302.13
FLES 530 16.33 531 198.87
24 PAY SEMI-MONTHLY
INDIVIDUAL 541 1.93 542 135.21
SUBSCRIBER + ONE 543 30.32 544 271.38
FAMILY 545 42.95 547 327.32
FLES 548 17.70 549 215.43

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