Page 19 - B12797-ITDR-Enrollment-Guide-2020
P. 19
Calculating your monthly credits & costs
Use the following worksheet to calculate how much your monthly cost or Health Reimbursement Account (HRA) contribution will be after your Defined Dollar Credit is applied.
Example Calculation*
(For Medicare eligible retire and spouse with 25+ years of service)
Insert the actual amount of your credits and the premium costs of the plans you selected below
$292.00
$146.00
$438.00
$313.13 (Retiree)
$313.13 (Spouse)
$84.28
$14.46
$725.00
($438.00)
$287.00
Credits
Retiree Defined Dollar Credit Spouse Defined Dollar Credit
Total Defined Dollar Credit Costs
Medical Monthly Premium
Dental Monthly Premium Vision Monthly Premium
Total costs
Less the Total Defined Dollar Credit
Your Monthly Bill or HRA Contribution
If the difference between your total costs and your total Defined Dollar Credit is a positive number, this is the amount of your monthly bill.
If the difference between your Total Costs and the Total Defined Dollar Credit is a negative number, this is the Defined Dollar Credit amount that will be contributed to your HRA each month.
*Example for illustrative purposes only. Credits shown are based on a Medicare eligible retiree with 25+ years of service and Medicare eligible spouse. Costs shown are based on the Aetna Medicare Advantage Premier PPO Plan (per person rate). Aetna Dental Plan (retiree and spouse rate) and Aetna Vision Plan (retiree and spouse rate). Grandfathered retirees who choose the Kaiser plan are not eligible for HRA.
19
