| 2010 Medical Premium Rates |
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| Employee Medical Rates |
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View as a PDF
2010 Employee Medical Plan Monthly Premium Rates
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Employee |
Employee & Spouse/Partner |
Employee & Children |
Employee & Family |
PEBB’s Statewide Plan1
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$892.19
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$1,195.39
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$1,025.95
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$1,222.17
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Kaiser Permanente2
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835.16
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1,119.11
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960.45
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1,144.17
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Providence Choice1
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771.69
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1,034.03
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887.45
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1,057.20
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PEBB’s Statewide Plan: Part-time3
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710.42
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951.87
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816.94
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973.21
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Kaiser Permanente: Part-time4
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707.01
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947.39
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813.05
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968.60
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Providence Choice: Part-time3
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611.04
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818.78
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702.71
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837.12
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1 Routine vision services through VSP.
2 Kaiser Permanente routine vision services.
3 No vision benefit.
4 Vision exam only.
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| Retiree Medical Rates |
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View as a PDF
2010 Retiree Medical Plan Monthly Premium Rates
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Retiree |
Retiree & Spouse/ Partner |
Retiree & Children |
Retiree & Family |
Child(ren) Only5 |
PEBB’s StatewidePlan1
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$895.70
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$1,200.11
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$1,029.99
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$1,226.98
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$461.30
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Kaiser Permanente2
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838.48
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1,123.56
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964.27
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1,148.72
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427.61
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Providence Choice1
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774.73
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1,038.11
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890.94
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1,061.36
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403.81
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PEBB’s Statewide Plan Retiree3
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713.21
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955.62
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820.15
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977.04
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367.15
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Kaiser Permanente Retiree4
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709.82
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951.16
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816.28
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972.45
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362.00
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Providence Choice Retiree3
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613.45
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822.01
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705.47
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840.42
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312.85
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1 Routine vision services through VSP.
2 Kaiser Permanente routine vision services.
3 No vision benefit.
4 Vision exam only.
5 Child(ren) Only coverage is available only to COBRA & Retiree participants.
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| COBRA Medical Rates |
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View as a PDF
2010 COBRA Medical Plan Monthly Premium Rates
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Self |
Self & Spouse/ partner |
Self & Children |
Self & Family |
Child(ren) Only5 |
PEBB’s StatewidePlan1
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$909.76
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$1,218.93
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$1,046.15
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$1,246.24
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$468.53
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Kaiser Permanente2
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851.76
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1,141.36
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$979.54
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1,166.92
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434.39
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Providence Choice1
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786.89
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1,054.39
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904.92
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1,078.02
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410.15
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PEBB’s Statewide Plan Part-time3
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724.40
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970.61
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833.02
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992.36
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372.91
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Kaiser Permanente Part-time4
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721.06
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966.23
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829.21
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987.85
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367.74
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Providence Choice Part-time3
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623.07
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834.90
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716.54
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853.60
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317.76
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1 Routine vision services through VSP.
2 Kaiser Permanente routine vision services.
3 No vision benefit.
4 Vision exam only.
5 Child(ren) Only coverage is available only to COBRA & Retiree participants.
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| Self-pay Medical Rates |
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View as a PDF
2010 Self-pay Medical Plan Monthly Premium Rates
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Self |
Self & Spouse/ Partner |
Self & Children |
Self & Family |
PEBB’s Statewide Plan1
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$902.49
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$1,205.69
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$1,036.25
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$1,232.47
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Kaiser Permanente HMO2
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845.46
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1,129.41
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970.75
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1,154.47
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Providence Choice1
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781.99
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1,044.33
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897.75
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1,067.50
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1 Routine vision services through VSP
2 Kaiser Permanente HMO routine vision services
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| Medical Opt-out Calculations |
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Calculation Worksheet for Employees Who Choose
to Opt Out of PEBB Medical Coverage
- Full-time Employees: Enter $233.00
- Part-time Employees: Multiply $233.00 by the percentage of hours you work compared with full time. For example, if you work 75 percent of full time, your contribution amount is $174.75 ($233.00 x 0.75= $174.75). Enter the result.
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1.___________
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- Enter $1.00. This is the monthly premium for mandatory basic life insurance.
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2.___________
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- Enter the monthly premium amount for your choice of dental plan. You are required to be enrolled in at least the employee-only tier for dental coverage. You may also choose to cover eligible dependents.
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3.___________
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- Add lines 2 and 3, and enter the total.
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4.___________
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- Subtract the amount on line 4 from the amount on line 1, and enter the balance on line 5. This is the estimated amount of opt-out cash you will receive as monthly taxable income.
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5.___________
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| Part-time Employee Worksheet |
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View as a PDF
1.a Prorated monthly benefit amount based on hours worked compared with full-time
Select the coverage tier that applies to you. Multiply the Full-time Monthly Benefit Amount for the coverage tier you selected by the percentage of hours you work compared with full time. The result is an estimate of your Prorated Monthly Benefit Amount.
Coverage Tier
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Full-time Monthly Benefit Amount |
Times % Hours Worked |
Prorated Monthly Benefit Amount |
Employee only
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$955.56 |
X _________ %
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= $____________
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Employee & spouse/ domestic partner
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$1,286.70 |
X _________ %
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= $____________
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Employee & children
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$1,100.39 |
X _________ %
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= $____________
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Employee & family
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$1,314.29 |
X _________ %
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= $____________
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1.b Subsidy amount if you enroll in a Part-time and Retiree Medical Plan
Next to your coverage tier, enter your Prorated Monthly Benefit Amount from the calculation above. Add the Subsidy for Part-time Plans for your coverage tier. The result is an estimate of your subsidized benefit amount if you enroll in a part-time plan.
Coverage Tier
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Prorated Monthly Benefit Amount |
Subsidy for Part-time Plan |
Subsidized Monthly Benefit Amount |
Employee only
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$_______________ |
+ $227.30 |
= $_____________
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Employee & spouse/ domestic partner
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$_______________ |
+ $290.10 |
= $_____________
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Employee & children
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$_______________ |
+ $258.63 |
= $_____________
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Employee & family
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$_______________ |
+ $294.42 |
= $_____________
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| 1. |
Enter the monthly benefit amount you calculated in 1.a or 1.b above.
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$______________
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| 2. |
Enter $1.00 for mandatory basic life insurance.
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$______________
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| 3. |
Enter your monthly medical premium cost.
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$______________
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| 4. |
Enter your monthly dental premium cost. (You must have at least employee-only dental coverage. You may also cover dependents.)
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$______________
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| 5. |
Enter the sum of 2 through 4. This is your monthly premium cost.
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$______________
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| 6. |
Subtract line 5 from line 1. This is the estimated monthly payroll deduction for your medical, dental and basic life coverage.
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$______________
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| Part-time Calculation Examples |
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Calculations show estimated premium costs for part-time employees working a given percentage of hours compared with full time. In no case will the monthly benefit amount plus subsidy exceed the cost of premiums for core benefits.
| 2010 Part-time & Retiree Kaiser Permanente with Part-time & Retiree ODS Dental |
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50% Contribution (works 50% of full time) |
80% Contribution (works 80% of full time) |
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Employee |
Employee, Spouse/Partner |
Employee, Child(ren) |
Employee, Family |
Employee |
Employee, Spouse/Partner |
Employee, Child(ren) |
Employee, Family |
Subsidized Contribution
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705.08
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933.45
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808.83
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951.57
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763.57
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1,022.84
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877.95
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1,045.72
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Medical Rate
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707.01
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947.39
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813.05
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968.60
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707.01
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947.39
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813.05
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968.60
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Dental Rate
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55.56
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74.45
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63.90
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76.12
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55.56
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74.45
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63.90
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76.12
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Basic Life
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1.00
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1.00
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1.00
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1.00
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1.00
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1.00
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1.00
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1.00
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Total Rate
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763.57
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1,022.84
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877.95
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1,045.72
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763.57
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1,022.84
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877.95
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1,045.72
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Employee Balance
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-58.49
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-89.39
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-69.12
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-94.15
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0.00
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0.00
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0.00
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0.00
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| 2010 Part-time & Retiree Providence Choice with Part-time & Retiree ODS Dental |
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50% Contribution (works 50% of full time) |
80% Contribution (works 80% of full time) |
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Employee |
Employee, Spouse/Partner |
Employee, Child(ren) |
Employee, Family |
Employee |
Employee, Spouse/Partner |
Employee, Child(ren) |
Employee, Family |
Subsidized Contribution
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667.60
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894.23
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767.61
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914.24
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667.60
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894.23
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767.61
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914.24
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Medical Rate
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611.04
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818.78
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702.71
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837.12
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611.04
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818.78
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702.71
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837.12
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Dental Rate
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55.56
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74.45
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63.90
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76.12
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55.56
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74.45
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63.90
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76.12
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Basic Life
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1.00
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1.00
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1.00
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1.00
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1.00
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1.00
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1.00
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1.00
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Total Rate
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667.60
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894.23
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767.61
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914.24
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667.60
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894.23
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767.61
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914.24
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Employee Balance
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0.00
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0.00
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0.00
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0.00
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0.00
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0.00
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0.00
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0.00
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| 2010 Part-time & Retiree Statewide Plan with Part-time & Retiree ODS Dental |
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50% Contribution (works 50% of full time) |
80% Contribution (works 80% of full time) |
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Employee |
Employee, Spouse/Partner |
Employee, Child(ren) |
Employee, Family |
Employee |
Employee, Spouse/Partner |
Employee, Child(ren) |
Employee, Family |
Subsidized Contribution
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705.08
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933.45
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808.83
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951.57
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766.98
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1,027.32
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881.84
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1,050.33
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Medical Rate
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710.42
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951.87
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816.94
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973.21
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710.42
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951.87
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816.94
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973.21
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Dental Rate
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55.56
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74.45
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63.90
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76.12
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55.56
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74.45
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63.90
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76.12
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Basic Life
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1.00
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1.00
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1.00
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1.00
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1.00
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1.00
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1.00
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1.00
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Total Rate
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766.98
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1,027.32
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881.84
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1,050.33
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766.98
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1,027.32
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881.84
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1,050.33
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Employee Balance
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-61.90
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-93.87
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-73.01
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-98.76
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0.00
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0.00
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0.00
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0.00
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| 2010 Part-time & Retiree Kaiser Permanente with Part-time & Retiree Kaiser Dental |
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50% Contribution (works 50% of full time) |
80% Contribution (works 80% of full time) |
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Employee |
Employee, Spouse/Partner |
Employee, Child(ren) |
Employee, Family |
Employee |
Employee, Spouse/Partner |
Employee, Child(ren) |
Employee, Family |
Subsidized Contribution
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705.08
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933.45
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808.83
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951.57
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761.94
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1,020.65
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876.07
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1,043.49
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Medical Rate
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707.01
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947.39
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813.05
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968.60
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707.01
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947.39
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813.05
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968.60
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Dental Rate
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53.93
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72.26
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62.02
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73.89
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53.93
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72.26
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62.02
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73.89
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Basic Life
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1.00
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1.00
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1.00
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1.00
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1.00
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1.00
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1.00
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1.00
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Total Rate
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761.94
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1,020.65
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876.07
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1,043.49
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761.94
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1,020.65
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876.07
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1,043.49
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Employee Balance
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-56.86
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-87.20
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-67.24
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-91.92
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0.00
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0.00
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0.00
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0.00
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| 2010 Part-time & Retiree Providence Choice with Part-time & Retiree Kaiser Dental |
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50% Contribution (works 50% of full time) |
80% Contribution (works 80% of full time) |
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Employee |
Employee, Spouse/Partner |
Employee, Child(ren) |
Employee, Family |
Employee |
Employee, Spouse/Partner |
Employee, Child(ren) |
Employee, Family |
Subsidized Contribution
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665.97
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892.04
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765.73
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912.01
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665.97
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892.04
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765.73
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912.01
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Medical Rate
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611.04
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818.78
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702.71
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837.12
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611.04
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818.78
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702.71
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837.12
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Dental Rate
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53.93
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72.26
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62.02
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73.89
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53.93
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72.26
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62.02
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73.89
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Basic Life
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1.00
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1.00
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1.00
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1.00
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1.00
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1.00
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1.00
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1.00
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Total Rate
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665.97
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892.04
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765.73
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912.01
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665.97
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892.04
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765.73
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912.01
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Employee Balance
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0.00
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0.00
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0.00
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0.00
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0.00
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0.00
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0.00
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0.00
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| 2010 Part-time & Retiree Statewide Plan with Part-time & Retiree Kaiser Dental |
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50% Contribution (works 50% of full time) |
80% Contribution (works 80% of full time) |
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Employee |
Employee, Spouse/Partner |
Employee, Child(ren) |
Employee, Family |
Employee |
Employee, Spouse/Partner |
Employee, Child(ren) |
Employee, Family |
Subsidized Contribution
|
705.08 |
933.45 |
808.83 |
951.57 |
765.35 |
1,025.13 |
879.96 |
1,048.10 |
Medical Rate
|
710.42 |
951.87 |
816.94 |
973.21 |
710.42 |
951.87 |
816.94 |
973.21 |
Dental Rate
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53.93 |
72.26 |
62.02 |
73.89 |
53.93 |
72.26 |
62.02 |
73.89 |
Basic Life
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1.00 |
1.00 |
1.00 |
1.00 |
1.00 |
1.00 |
1.00 |
1.00 |
Total Rate
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765.35 |
1,025.13 |
879.96 |
1,048.10 |
765.35 |
1,025.13 |
879.96 |
1,048.10 |
Employee Balance
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-60.27 |
-91.68 |
-71.13 |
-96.53 |
0.00 |
0.00 |
0.00 |
0.00 |
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