PLAN COMPARISON SUMMARIES & FEE PROPOSAL FORMS

PROPOSED BENEFITS

Detailed benefits information is provided in Exhibit E. Please note any deviation in proposed benefits in the charts below. The EUTF seeks to maintain the current level of benefits. Unless noted, it will be assumed that proposed benefits match the requested benefits exactly.

THE “WORD” FILE THAT IS AVAILABLE WITH THIS RFP MUST INCLUDE YOUR PROPOSED FEES AND RATES. YOU ARE TO INPUT YOUR PROPOSAL INTO THE “WORD” FILE AND PRINT OUT A COPY FOR YOUR ORIGINAL HARD COPY SUBMISSION.

[NOTE: For all of the following Sections, please read the instructions to OFFERORS concerning the disclosure of “trade secret” or “confidential” information and mark your responses in this RFP accordingly. Failure of the OFFEROR to appropriately identify the responses as such may result in the disclosure of any such information]. Please refer to the instructions for the submission of a redacted copy of your proposal in Section 1.11, Submission of Proposals.

Notes Applicable to Insured/Risk Sharing Proposed Rates

1. All proposals must include fees and taxes, and exclude fees mandated under ACA which are to be listed separately. ACA fees will be excluded from the rates should they no longer be mandated by the law.

2. All proposals should guarantee a fixed administration fee, inclusive of retention and profit, per employee/retiree per month. This guarantee must be separately stated for the initial contract term and the optional contract extensions.

3. You must separately list the guaranteed administration/retention fee on your proposal sheet for the fully insured options.

4. For the fully insured plans with risk sharing, if the total benefit paid, excluding ACA fees, at the end of the runout period is less than the total premiums collected, excluding ACA fees, the excess amount will be refunded to the EUTF. Each plan must be separately accounted although surpluses from one plan may be applied to offset deficits of another plan, but the active employee contract may not be merged with the retiree plan contract to offset deficits or surpluses. The two contracts must be accounted for independently. See example below.

Initial Reconciliation

The Contractor agrees to an initial reconciliation with six months of benefits run-out following the end of the contract period and a final reconciliation that shall occur with twelve months of benefits run-out following the end of the contract period. Both reconciliations will be done within 45 days after the respective run-out periods.

The initial reconciliation shall be calculated as follows: Paid premiums (excluding ACA PCORI and insurer fees), minus paid benefits, minus administration/retention fees, and minus reserves for incurred but not reported benefits. Administration/retention fees shall be calculated by multiplying the fixed dollar amounts (per employee/retiree per month rates) by the number of employees/retirees in each month of the contract period. Any surplus shall be returned to the EUTF within 30 days of

the initial reconciliation (Example 1). Any deficit shall be the responsibility of the Contractor (Example 2).

Example #1: Surplus returned to the EUTF

$1,000,000 paid premiums-$750,000 minus paid benefits-$60,000* minus administration/retention fees-$100,000 minus reserves for incurred but not reported benefits$90,000 surplus paid to EUTF*$4.00 per subscriber per month ($4.00 is an example only) x 15,000 (sum of enrolled employees/retirees in each month of the contract period) = $60,000

Example #2: Deficit is the responsibility of the Contractor

$1,000,000 paid premiums-$850,000 minus paid benefits-$68,000* minus administration/retention fees-$100,000 minus reserves for incurred but not reported benefits-$18,000 Contractor may not invoice EUTF*$4.00 per subscriber per month ($4.00 is an example only) x 17,000 (sum of enrolled employees/retirees in each month of the contract period) = $68,000

Final Reconciliation

The final reconciliation shall be calculated as follows: Paid premiums (excluding ACA PCORI and insurer fees), minus paid benefits, minus administration/retention fees, and minus reserves for incurred but not reported benefits (which will be calculated based upon the previous plan year run-out of claim experience for months 13-24 but not more than .20% of plan year benefits). Administration/retention fees shall be calculated by multiplying the fixed dollar amounts (per employee/retirees per month rates) by the number of employees/retirees in each month of the contract period.

If the final reconciliation surplus is greater than the initial reconciliation surplus, then the surplus from the final reconciliation less any surplus paid to the EUTF for the initial reconciliation shall be returned to the EUTF within 30 days of the final reconciliation (see example 1a). If the final reconciliation surplus is less than the initial reconciliation surplus, the Contractor may invoice the EUTF for the difference (see example 1b). If the initial reconciliation resulted in a surplus and the final reconciliation resulted in a deficit, the Contractor may invoice the EUTF the amount of the initial reconciliation surplus (see example 1c).

Example #1a: (Contractor paid EUTF $90,000 refund at initial reconciliation):

$1,000,000 paid premiums-$840,000 minus paid benefits-$60,000 minus administration/retention fees-$1,092 minus incurred but not reported benefits (for active employees, the calculation is $840,000 x 0.0013)*$98,908 final reconciliation surplus-$90,000 minus initial reconciliation surplus paid to EUTF$8,908 additional surplus to be refunded to EUTF

Example #1b: (Contractor paid EUTF $90,000 refund at initial reconciliation):

$1,000,000 paid premiums-$900,000 minus paid benefits

-$60,000 minus administration/retention fees-$1,170 minus incurred but not reported benefits (for active employees, the calculation is $900,000 x 0.0013)*$38,830 final reconciliation surplus

The Contractor may invoice the EUTF for $51,170, which represents the difference between the initial reconciliation refund and the final reconciliation surplus ($90,000 - $38,830 = $51,170).

Example #1c: (Contractor paid EUTF $90,000 refund at initial reconciliation):

$1,000,000 paid premiums-$1,000,000 minus paid benefits-$60,000 minus administration/retention fees-$1,300 minus incurred but not reported benefits (for active employees, the calculation is $1,000,000 x 0.0013)*-$61,300 final reconciliation deficit

The Contractor may invoice the EUTF for the $90,000 initial reconciliation surplus.

If the initial reconciliation resulted in a deficit, and the final reconciliation also results in a deficit, the Contractor shall not invoice the EUTF (see example 2a). If the initial reconciliation resulted in a deficit, and the final reconciliation results in a surplus, the surplus from the final reconciliation shall be returned to the EUTF (see example 2b).

Example #2a: (Contractor had an $18,000 deficit at initial reconciliation):

$1,000,000 paid premiums-$960,000 minus paid benefits-$68,000 minus administration/retention fees-$1,248 minus incurred but not reported benefits (for active employees, the calculation is $960,000 x 0.0013)*-$29,248 final reconciliation deficit

The Contractor may not invoice the EUTF for the final reconciliation deficit.

Example #2b: (Contractor had an $18,000 deficit at initial reconciliation):

$1,000,000 paid premiums-$850,000 minus paid benefits-$68,000 minus administration/retention fees-$1,105 minus incurred but not reported benefits (for active employees, the calculation is $850,000 x 0.0013)*$80,895 final reconciliation surplus to be refunded to EUTF

*Amount is for example purposes only

5. Deficits may not be carried forward to subsequent contract periods to be recovered from any future surplus. Each contract period must be separately accounted and surpluses must be returned 15 months after the conclusion of each contract period.

6. The financial experience of each plan must be independent of the financial experience of any other plan that may be awarded to a Contractor. Gains or losses from one plan may be applied to the gains or losses of another plan, but active plans must be rated separately from retiree plans. For example, the active EUTF Vision plan must be accounted for separately from the HSTA VB Vision plan, although on final reconciliation, the surplus or deficit from one plan may be used to offset a deficit in another, provided only within the same contract that is active contract versus retiree contract.

7. The EUTF reserves the right to offer multiple carrier options.

8. No adjustments to the proposed rates based on actual initial enrollment or subsequent enrollment changes are acceptable.

9. Rates must be quoted on a three tiered basis (self, two-party, and family). If this is not possible due to federal filing requirements, please note that exception clearly on each rate table that you are completing, but you must guarantee your administration/retention fee for the entire contract period and successive periods.

10. All underwriting rules/restrictions that apply to rates quoted must be listed as an attachment to the rate exhibit.

11. All rates quoted must exclude any commissions or payments to any third party.

12. Please list any rating method which uses a credibility factor less than 100% in your underwriting assumptions.

13. Rates shown must be valid for the contract periods contained in Section 1.4, Contract Period.

14. Rates must be filled out in the proposal sheets provided.

15. All rates must be guaranteed for the term of the contract, including any extensions.

16. If your proposal is accepted by the EUTF, the following additional rates will be required for various self-pay categories: Tiered Cobra Rates.

17. Amounts shall be in U.S. dollars unless a specific percent is requested.

18. All active rates must be rounded to even cents.

Important Self Insured Proposal Instructions and Information

1. The EUTF reserves the right to offer multiple carrier options.

2. All proposals must include all fees and taxes, and exclude fees mandated under ACA which are to be listed separately.

3. No adjustments to the proposed rates based on actual initial enrollment or subsequent enrollment changes are acceptable.

4. All services to be provided for the quoted fee should be listed including quantities and frequencies.

5. All fees quoted must exclude any commissions or payments to any third party.

6. Fees must be filled out in the proposal sheets provided.

7. Individual fee components will be assumed to be self-supporting standalone services.

8. Your fees must include any fee for PPO Leasing/Network Access for a national network to cover all 50 states, and the District of Columbia.

9. All rates must be guaranteed for the term of the contract, including any extensions.

10.List services/supplies not covered under the fees quoted above (i.e., custom reports, printing, etc.).

11.Fees quoted are to cover services for claims incurred on or after the contract effective date. All fees for the payment of run-out claims must be included in the monthly fees charged during the contract period.

12.Amounts shall be in U.S. dollars unless a specific percent is requested.

ACTIVE EUTF - VISION PLAN

TABLE AND PROPOSAL SHEETS #1

ACTIVEEUTF - VISION PLANTABLE AND PROPOSAL SHEETS #1

Detailed benefits information is provided in Exhibit E. Please note any deviation in proposed benefits in the charts below. Unless noted it will be assumed that proposed benefits match the requested benefits exactly. You must agree to a "no loss, no gain" provision with the current benefit plan.

TABLE - ACTIVE

ServiceVision Service Plan (VSP) NOTE ALL DEVIATIONS

IN YOUR COMPANY’S PROPOSED BENEFITSIn-Network Out-of-Network

ReimbursementsExam (once every plan year) 100% after $10 Copay Up to $45.00  Materials/Lenses (once every plan year):

100% after $25 Copay

Single Vision Lenses - Up to $45.00

Lined Bifocal Lenses - Up to $65.00

Lined Trifocal Lenses - Up to $85.00

 

-Single Vision Lenses, Lined Bifocals, Lined Trifocals  

-Polycarbonate (children up to age 18)  

-UV Coating  

Frames (once every other plan year)

$120 allowance, plus 20% off any out-of-pocket costs or $65

allowance at Costco (no additional discounts)

Up to $47.00  

Contact Lenses (once every plan year) Elective (Instead of Glasses)

$120 allowance (applies to cost of contacts and

fitting & evaluation)Up to $105.00  

Extra Discounts and Savings from Network Providers      

Glasses & Sunglasses

Average 35-40% savings on all non-covered lens options (such as tints, progressive lenses, anti-scratch coatings, etc.)  30% off additional glasses & sunglasses, including lens options, from the same network doctor on the same day as your exam. OR get 20% off any network doctor within 12 months of your last exam.  

Contact Lenses 15% off cost of contact lens exam (fitting & evaluation)  

Laser Vision CorrectionAverage 15% off the regular price or 5% off the promotional price from network facilities.

 

INSURED, RISK SHARINGProposal Sheet 1A

Vision Plan - EUTF Active onlyPremium Rate Table (Insured With Risk Sharing-Surplus Refund)

Complete the following table on a monthly, per capita tiered basis ONLY

The Vision Benefit Cost and Retention components must stand on their own. If the total benefit paid at the end of the runout period is less than the proposed benefit cost, the excess amount will be refunded to the EUTF.

Vision Plan Period 17/1/19-6/30/20

Period 27/1/20-6/30/21

Period 37/1/21-6/30/22

Period 47/1/22-6/30/23

Vision        

Monthly Benefit Cost:        Single        Two-Party        Family        

Maximum Benefit Cost Percent Increase from Prior Contract Period: N/A ______% ______% ______%

Monthly Administration and Retention:        

Single        Two-Party        Family        

Total Vision Premium (Including Administration and Retention):    Single        Two-Party        Family        

Monthly ACA Fees to be Added to the Above Total Vision Premium    

Insurer Fee:        Single        Two-Party        Family        

NOTES:(1) The EUTF reserves the right to offer multiple carrier options.(2) No adjustments to the proposed rates based on actual initial enrollment or subsequent enrollment changes are acceptable.

     Authorized Signature

     Title

     Name of Company

     Date

SELF-INSUREDProposal Sheet 1B

Vision Plan - EUTF Active onlyTarget Claims, Retention and Fees Tables (Self-Insured ASO)

Complete the following table on a monthly, composite and/or per capita tiered basis

Vision Plan Period 17/1/19-6/30/20

Period 27/1/20-6/30/21

Period 37/1/21-6/30/22

Period 47/1/22-6/30/23

Vision        

Monthly Vision ASO Fees (PEPM):        Composite        

Monthly Vision ASO Fees by Tier:        Single        Two-Party        Family        

Maximum Vision ASO Percent Increase from Prior Contract Period: N/A ______% ______% ______%

Estimated Monthly Vision Claims Cost:        

Single        Two-Party        Family        

NOTES:(1) The EUTF reserves the right to offer multiple carrier options.(2) No adjustments to the proposed rates based on actual initial enrollment or subsequent enrollment changes are acceptable.

     Authorized Signature

     Title

     Name of Company

     Date

ACTIVE HSTA VB - VISION PLAN

TABLE AND PROPOSAL SHEETS #2

ACTIVEHSTA VB - VISION PLANTABLE AND PROPOSAL SHEETS #2

Detailed benefits information is provided in Exhibit E. Please note any deviation in proposed benefits in the charts below. Unless noted it will be assumed that proposed benefits match the requested benefits exactly. You must agree to a "no loss, no gain" provision with the current benefit plan.

TABLE - ACTIVE

ServiceVision Service Plan (VSP) NOTE ALL DEVIATIONS

IN YOUR COMPANY’S PROPOSED BENEFITSIn-Network Out-of-Network

ReimbursementsExam (once every plan year) 100% after $10 Copay Up to $45.00  Materials/Lenses (once every plan year):

100% after $25 Copay

Single Vision Lenses - Up to $45.00

Lined Bifocal Lenses - Up to $65.00

Lined Trifocal Lenses - Up to $85.00

 

-Single Vision Lenses, Lined Bifocals, Lined Trifocals  

-Polycarbonate (children up to age 18)  

-UV Coating  

Frames (once every other plan year)

$120 allowance, plus 20% off any out-of-pocket costs or $65

allowance at Costco (no additional discounts)

Up to $47.00  

Contact Lenses (once every plan year) Elective (Instead of Glasses)

$120 allowance (applies to cost of contacts and

fitting & evaluation)Up to $105.00  

Extra Discounts and Savings from Network Providers      

Glasses & Sunglasses

Average 35-40% savings on all non-covered lens options (such as tints, progressive lenses, anti-scratch coatings, etc.)  30% off additional glasses & sunglasses, including lens options, from the same network doctor on the same day as your exam. OR get 20% off any nework doctor within 12 months of your last exam.  

Contact Lenses 15% off cost of contact lens exam (fitting & evaluation)  

Laser Vision CorrectionAverage 15% off the regular price or 5% off the promotional price from nework facilities.

 

INSURED, RISK SHARINGProposal Sheet 2A

Vision Plan - HSTA VB Active onlyPremium Rate Table (Insured With Risk Sharing-Surplus Refund)

Complete the following table on a monthly, per capita tiered basis ONLY

The Vision Benefit Cost and Retention components must stand on their own. If the total benefit paid at the end of the runout period is less than the proposed benefit cost, the excess amount will be refunded to the EUTF.

Vision Plan Period 17/1/19-6/30/20

Period 27/1/20-6/30/21

Period 37/1/21-6/30/22

Period 47/1/22-6/30/23

Vision        

Monthly Benefit Cost:        Single        Two-Party        Family        

Maximum Benefit Cost Percent Increase from Prior Contract Period: N/A ______% ______% ______%

Monthly Administration and Retention:        

Single        Two-Party        Family        

Total Vision Premium (Including Administration and Retention):    Single        Two-Party        Family        

Monthly ACA Fees to be Added to the Above Total Vision Premium    

Insurer Fee:        Single        Two-Party        Family        

NOTES:(1) The EUTF reserves the right to offer multiple carrier options.(2) No adjustments to the proposed rates based on actual initial enrollment or subsequent enrollment changes are acceptable.

     Authorized Signature

     Title

     Name of Company

     DateSELF-INSURED

Proposal Sheet 2BVision Plan - HSTA VB Active only

Target Claims, Retention and Fees Tables (Self-Insured ASO)Complete the following table on a monthly, composite and/or per capita tiered basis

Vision Plan Period 17/1/19-6/30/20

Period 27/1/20-6/30/21

Period 37/1/21-6/30/22

Period 47/1/22-6/30/23

Vision        

Monthly Vision ASO Fees (PEPM):        Composite        

Monthly Vision ASO Fees by Tier:        Single        Two-Party        Family        

Maximum Vision ASO Percent Increase from Prior Contract Period: N/A ______% ______% ______%

Estimated Monthly Vision Claims Cost:        

Single        Two-Party        Family        

NOTES:(1) The EUTF reserves the right to offer multiple carrier options.(2) No adjustments to the proposed rates based on actual initial enrollment or subsequent enrollment changes are acceptable.

     Authorized Signature

     Title

     Name of Company

     Date

RETIREE EUTF – VISION PLAN

TABLE AND PROPOSAL SHEETS #3

RETIREEEUTF - VISION PLANTABLE AND PROPOSAL SHEETS #3

Detailed benefits information is provided in Exhibit E. Please note any deviation in proposed benefits in the charts below. Unless noted it will be assumed that proposed benefits match the requested benefits exactly. You must agree to a "no loss, no gain" provision with the current benefit plan.

TABLE - RETIREE

ServiceVision Service Plan (VSP) NOTE ALL DEVIATIONS

IN YOUR COMPANY’S PROPOSED BENEFITSIn-Network Out-of-Network

ReimbursementsExam (once every calendar year) 100% after $10 Copay Up to $45.00  

Materials/Lenses (once every calendar year):

100% after $25 Copay

Single Vision Lenses - Up to $45.00

Lined Bifocal Lenses - Up to $65.00

Lined Trifocal Lenses - Up to $85.00

 

-Single Vision Lenses, Lined Bifocals, Lined Trifocals  

-Polycarbonate (children up to age 18)  

-UV Coating  

Frames (once every other calendar year)

$120 allowance, plus 20% off any out-of-pocket costs or $65 allowance at

Costco (no additional discounts)

Up to $47.00  

Contact Lenses (once every calendar year) Elective (Instead of Glasses)

$120 allowance (applies to cost of contacts and

fitting & evaluation)Up to $105.00  

Extra Discounts and Savings from Network Providers      

Glasses & Sunglasses

Average 35-40% savings on all non-covered lens options (such as tints, progressive lenses, anti-scratch coatings, etc.)  30% off additional glasses & sunglasses, including lens options, from the same network doctor on the same day as your exam. Or get 20% off any network doctor within 12 months of your last exam.  

Retinal ScreeningGuaranteed pricing on retinal screening as an enhancement to your exam; $39 maximum copay.  

Contact Lenses 15% off cost of contact lens exam (fitting & evaluation) 

Laser Vision CorrectionAverage 15% off the regular price or 5% off the promotional price from network facilities.

 

INSURED, RISK SHARINGProposal Sheet 3A

Vision Plan - EUTF Retiree onlyPremium Rate Table (Insured With Risk Sharing-Surplus Refund)

Complete the following table on a monthly, per capita tiered basis ONLY

The Vision Benefit Cost and Retention components must stand on their own. If the total benefit paid at the end of the runout period is less than the proposed benefit cost, the excess amount will be refunded to the EUTF.

Vision Plan Period 11/1/19-12/31/19

Period 21/1/20-12/31/20

Period 31/1/21-12/31/21

Period 41/1/22-12/31/22

Vision        

Monthly Benefit Cost:        Single        Two-Party        Family        

Maximum Benefit Cost Percent Increase from Prior Contract Period: N/A ______% ______% ______%

Monthly Administration and Retention:        

Single        Two-Party        Family        

Total Vision Premium (Including Administration and Retention):    Single        Two-Party        Family        

Monthly ACA Fees to be Added to the Above Total Vision Premium    

Insurer Fee:        Single        Two-Party        Family        

NOTES:(1) The EUTF reserves the right to offer multiple carrier options.(2) No adjustments to the proposed rates based on actual initial enrollment or subsequent enrollment changes are acceptable.

     Authorized Signature

     Title

     Name of Company

     DateSELF-INSURED

Proposal Sheet 3BVision Plan - EUTF Retirees only

Target Claims, Retention and Fees Tables (Self-Insured ASO)Complete the following table on a monthly, composite and/or per capita tiered basis

Vision Plan Period 11/1/19-12/31/19

Period 21/1/20-12/31/20

Period 31/1/22-12/31/22

Period 41/1/23-12/31/23

Vision        

Monthly Vision ASO Fees (PRPM):        Composite        

Monthly Vision ASO Fees by Tier:        Single        Two-Party        Family        

Maximum Vision ASO Percent Increase from Prior Contract Period: N/A ______% ______% ______%

Estimated Monthly Vision Claims Cost:        

Single        Two-Party        Family        

NOTES:(1) The EUTF reserves the right to offer multiple carrier options.(2) No adjustments to the proposed rates based on actual initial enrollment or subsequent enrollment changes are acceptable.

     Authorized Signature

     Title

     Name of Company

     Date

RETIREE HSTA VB - VISION PLAN

TABLE AND PROPOSAL SHEETS #4

RETIREEHSTA VB - VISION PLANTABLE AND PROPOSAL SHEETS #4

Detailed benefits information is provided in Exhibit E. Please note any deviation in proposed benefits in the charts below. Unless noted it will be assumed that proposed benefits match the requested benefits exactly. You must agree to a "no loss, no gain" provision with the current benefit plan.

TABLE - RETIREE

ServiceVision Service Plan (VSP) NOTE ALL DEVIATIONS

IN YOUR COMPANY’S PROPOSED BENEFITSIn-Network Out-of-Network

ReimbursementsExam (once every calendar year) 100% after $10 Copay Up to $45.00  

Materials/Lenses (once every calendar year):

100% after $25 Copay

Single Vision Lenses - Up to $45.00

Lined Bifocal Lenses - Up to $65.00

Lined Trifocal Lenses - Up to $85.00

 

-Single Vision Lenses, Lined Bifocals, Lined Trifocals  

-Polycarbonate (children up to age 18)  

-UV Coating  

Frames (once every other calendar year)

$120 allowance, plus 20% off any out-of-pocket costs or $65

allowance at Costco (no additional discounts)

Up to $47.00  

Contact Lenses (once every calendar year) Elective (Instead of Glasses)

$120 allowance (applies to cost of contacts and

fitting & evaluation)Up to $105.00  

Extra Discounts and Savings from Network Providers      

Glasses & Sunglasses

Average 35-40% savings on all non-covered lens options (such as tints, progressive lenses, anti-scratch coatings, etc.)  30% off additional glasses & sunglasses, including lens options, from the same network doctor on the same day as your exam. Or get 20% off any network doctor within 12 months of your last exam.  

Retinal ScreeningGuaranteed pricing on retinal screening as an enhancement to your exam; $39 maximum copay.  

Contact Lenses 15% off cost of contact lens exam (fitting & evaluation)  

Laser Vision CorrectionAverage 15% off the regular price or 5% off the promotional price from network facilities.

 

INSURED, RISK SHARINGProposal Sheet 4A

Vision Plan - HSTA VB Retiree onlyPremium Rate Table (Insured With Risk Sharing-Surplus Refund)

Complete the following table on a monthly, per capita tiered basis ONLY

The Vision Benefit Cost and Retention components must stand on their own. If the total benefit paid at the end of the runout period is less than the proposed benefit cost, the excess amount will be refunded to the EUTF.

Vision Plan Period 11/1/19-12/31/19

Period 21/1/20-12/31/20

Period 31/1/21-12/31/21

Period 41/1/22-12/31/22

Vision        

Monthly Benefit Cost:        Single        Two-Party        Family        

Maximum Benefit Cost Percent Increase from Prior Contract Period: N/A ______% ______% ______%

Monthly Administration and Retention:        

Single        Two-Party        Family        

Total Vision Premium (Including Administration and Retention):    Single        Two-Party        Family        

Monthly ACA Fees to be Added to the Above Total Vision Premium    

Insurer Fee:        Single        Two-Party        Family        

NOTES:(1) The EUTF reserves the right to offer multiple carrier options.(2) No adjustments to the proposed rates based on actual initial enrollment or subsequent enrollment changes are acceptable.

     Authorized Signature

     Title

     Name of Company

     DateSELF-INSURED

Proposal Sheet 4BVision Plan - HSTA VB Retirees only

Target Claims, Retention and Fees Tables (Self-Insured ASO)Complete the following table on a monthly, composite and/or per capita tiered basis

Vision Plan Period 11/1/19-12/31/19

Period 21/1/20-12/31/20

Period 31/1/21-12/31/21

Period 41/1/22-12/31/22

Vision        

Monthly Vision ASO Fees (PRPM):        Composite        

Monthly Vision ASO Fees by Tier:        Single        Two-Party        Family        

Maximum Vision ASO Percent Increase from Prior Contract Period: N/A ______% ______% ______%

Estimated Monthly Vision Claims Cost:        

Single        Two-Party        Family        

NOTES:(1) The EUTF reserves the right to offer multiple carrier options.(2) No adjustments to the proposed rates based on actual initial enrollment or subsequent enrollment changes are acceptable.

     Authorized Signature

     Title

     Name of Company

     Date