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Program Information

Company NameAcme 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

Enrollment & Funding Summary

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

YTD Claims Summary

Claim Type Amount
Medical $345,251
Dental $17,346
Vision $8,623
Rx $54,657
Paid Claims $425,878

Service Team Contact Information

Simplicity Health Plans Susan Smith, Customer Service Representative
444-555-2389
sampleEmail@xyzCorp.com
Claims Administration Jean Trimble, Claims Administrator
321-321-0123
sampleB@xyzCorp.com
Utilization Review Comparison Shopper Prescription Drugs Barb Johnson, RN; Utilization Review Specialist
123-456-7890
sampleC@xyzCorp.com
Case/Disease Management Karen Dietz, RN; Case Manager
987-654-3210
sampleD@xyzCorp.com