ESBD_360338_1716477846878_Attachment D.2 - March 2024 invoice with counts.pdf
PDF 137 KB Posted
- Solicitation number
- RFp2024-P11
- Issued by
- Hays County, Texas
About this file
This document appears to be an invoice from an employee benefits plan provider to the County of Hays in Texas for their group health, dental, and employee assistance plan coverage from January 1, 2021 through March 31, 2024. The invoice details the active employees, COBRA participants, retirees, and surviving spouses enrolled in various medical and dental plans, along with the associated premium charges totaling $285,585.03 due by April 1, 2024.
The related state and local contract opportunity is a Request for Proposals (RFP) issued by Hays County, Texas seeking proposals from qualified companies to provide employee health, dental, and employee assistance plans, effective January 1, 2025 with open enrollment starting October 1, 2024. The County is looking for a comprehensive package including medical, pharmacy, dental, and employee wellness/assistance plan, and is open to evaluating any combination of plan designs, networks, and services as well as value-added services to achieve competitive long-term and stable financial success while offering a robust benefits package.
View the file
Other files
Show all 23
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Atlanta, GA 30374-0376
DPS$$$PKG
COUNTY OF HAYS
SHARI MILLER
712 S STAGECOACH TRL STE 1063
SAN MARCOS TX 78666-6230
Manage your Account:
www.employereservices.com Invoice No: 956805911733 Invoice Date: 03/14/2024 Customer No: 0912772 Bill Group No: 1 Coverage Period: 01/01/2021 - 03/31/2024 Due Date: 04/01/2024 Current Charges: $285,585.03
Customer Name County of Hays
Customer Number
0912772
Payment Due Date
04/01/2024
Invoice #
956805911733
Send payment to:
Amount due: $285,585.03
Amount Enclosed
956804593100100000285585039568059117333
UHS Premium Billing
PO BOX 94017
Palatine, IL 60094-4017
Thank you for your business.
About Your Payment
We offer several payment options to help you manage your account.
Pay Online. Go to employereservices.com to make a one-time payment or schedule monthly payments directly from your bank account.
Pay By Phone. Call 1-888-842-4571, TTY 711, 8 a.m. – 8 p.m. ET, Monday – Friday, to make a payment directly from your bank account.
Pay by wire or Automated Clearing House (ACH). Contact your Billing Representative for banking information required for these electronic payment options. Your bank may charge you a fee to use this option.
Pay By Check. Send a check to the address listed below. Checks returned for lack of funds or checks that can’t be cashed for any reason are not considered payment.
Questions. For any other questions about your invoice or payment, please contact your assigned Billing Analyst.
Payment is due in full on or before the due date above. Your payment will be automatically deposited when it is received. However, even if a payment is deposited, there is no guarantee it will be accepted.
Account Summary
Amount Due Date
Past Due Amount $0.00
Current Charges $285,585.03 04/01/2024
Total Balance Due $285,585.03
Past Due Amount: Total of outstanding invoices, fees, or charges that are past their due date For a breakdown of past due amounts, please review the most recent letter in the ‘Notifications’ tab of employereservices.com Current Charges: Total amount billed on this invoice
The account summary shown above is a snapshot of your account as of the invoice date shown in the top-right corner of this page. Any payments, credits, or charges that occurred after that date may change the amounts listed here. Please visit employereservices.com for real-time account information, to make payments, or to request adjustments.
Invoice No: 956805911733 Invoice Date: 03/14/2024 Bill Group: 1 Coverage Period: 01/01/2021 - 03/31/2024 Due Date: 04/01/2024
County of Hays Customer No: 0912772
Questions? We’re here to help.
www.employereservices.com
Summary
Description Employee Count
Total Volume
(000’s)
Rate Net Amount
ACTIVE
ASO 2007 CH EP1 AGU2 UHPD PLAN 2
Employee Only 430 0.00 $133.34 $57,336.20
Subtotal, ACTIVE - ASO 2007 CH EP1 AGU2 UHPD PLAN 2 430 $57,336.20
ACTIVE
ASO 2007 CH+ PS1 AGU2 HSA PLAN 3
Employee Only 69 0.00 $133.34 $9,200.46
Subtotal, ACTIVE - ASO 2007 CH+ PS1 AGU2 HSA PLAN 3 69 $9,200.46
ACTIVE
ASO 2007 CH+ PS1 AGU2 UHPD PLAN 1
Employee Only 405 0.00 $133.34 $54,002.70
Subtotal, ACTIVE - ASO 2007 CH+ PS1 AGU2 UHPD PLAN 1 405 $54,002.70
ACTIVE
DENTAL DHMO PLAN D094C
EE + Family 7 0.00 $28.23 $197.61 EE + Spouse 2 0.00 $21.27 $42.54 EE +1 or more Children 10 0.00 $22.55 $225.50 Employee Only 10 0.00 $11.40 $114.00
Subtotal, ACTIVE - DENTAL DHMO PLAN D094C 29 $579.65
ACTIVE
DENTAL PPO PLAN 4P648
Employee Only 899 0.00 $3.36 $3,020.64
Subtotal, ACTIVE - DENTAL PPO PLAN 4P648 899 $3,020.64
CAD
ASO 2007 CH EP1 AGU2 UHPD PLAN 2
Employee Only 18 0.00 $133.34 $2,400.12
Subtotal, CAD - ASO 2007 CH EP1 AGU2 UHPD PLAN 2 18 $2,400.12
CAD
ASO 2007 CH+ PS1 AGU2 HSA PLAN 3
Employee Only 1 0.00 $133.34 $133.34
Subtotal, CAD - ASO 2007 CH+ PS1 AGU2 HSA PLAN 3 1 $133.34
CAD
ASO 2007 CH+ PS1 AGU2 UHPD PLAN 1
Employee Only 16 0.00 $133.34 $2,133.44
Subtotal, CAD - ASO 2007 CH+ PS1 AGU2 UHPD PLAN 1 16 $2,133.44
Invoice Date: 03/14/2024 Bill Group: 1 Coverage Period: 01/01/2021 - 03/31/2024 Due Date: 04/01/2024
County of Hays Customer No: 0912772
Questions? We’re here to help.
www.employereservices.com
Summary
Description Employee Count
Total Volume
(000’s)
Rate Net Amount
CAD
DENTAL PPO PLAN 4P648
Employee Only 36 0.00 $3.36 $120.96
Subtotal, CAD - DENTAL PPO PLAN 4P648 36 $120.96
COBRA
ASO 2007 CH EP1 AGU2 UHPD PLAN 2
Employee Only 1 0.00 $133.34 $133.34
Subtotal, COBRA - ASO 2007 CH EP1 AGU2 UHPD PLAN 2 1 $133.34
COBRA
ASO 2007 CH+ PS1 AGU2 UHPD PLAN 1
Employee Only 1 0.00 $133.34 $133.34
Subtotal, COBRA - ASO 2007 CH+ PS1 AGU2 UHPD PLAN 1 1 $133.34
COBRA
DENTAL PPO PLAN 4P648
Employee Only 2 0.00 $3.36 $6.72
Subtotal, COBRA - DENTAL PPO PLAN 4P648 2 $6.72
RETIREES
ASO 2007 CH EP1 AGU2 UHPD PLAN 2
Employee Only 40 0.00 $133.34 $4,249.82
Subtotal, RETIREES - ASO 2007 CH EP1 AGU2 UHPD PLAN 2 40 $4,249.82
RETIREES
ASO 2007 CH+ PS1 AGU2 HSA PLAN 3
Employee Only 3 0.00 $133.34 $400.02
Subtotal, RETIREES - ASO 2007 CH+ PS1 AGU2 HSA PLAN 3 3 $400.02
RETIREES
ASO 2007 CH+ PS1 AGU2 UHPD PLAN 1
Employee Only 94 0.00 $133.34 $7,596.74
Subtotal, RETIREES - ASO 2007 CH+ PS1 AGU2 UHPD PLAN 1 94 $7,596.74
RETIREES
DENTAL DHMO PLAN D094C
EE + Spouse 2 0.00 $21.27 $42.54 EE +1 or more Children 1 0.00 $22.55 $22.55 Employee Only 1 0.00 $11.40 $11.40
Subtotal, RETIREES - DENTAL DHMO PLAN D094C 4 $76.49
Invoice Date: 03/14/2024 Bill Group: 1 Coverage Period: 01/01/2021 - 03/31/2024 Due Date: 04/01/2024
County of Hays Customer No: 0912772
Questions? We’re here to help.
www.employereservices.com
Summary
Description Employee Count
Total Volume
(000’s)
Rate Net Amount
RETIREES
DENTAL PPO PLAN 4P648
Employee Only 144 0.00 $3.36 $483.84
Subtotal, RETIREES - DENTAL PPO PLAN 4P648 144 $483.84
SURVIVING SPOUSES
ASO 2007 CH EP1 AGU2 UHPD PLAN 2
Employee Only 2 0.00 $133.34 $266.68
Subtotal, SURVIVING SPOUSES - ASO 2007 CH EP1 AGU2
UHPD PLAN 2
2 $266.68
SURVIVING SPOUSES
DENTAL PPO PLAN 4P648
Employee Only 1 0.00 $3.36 $3.36
Subtotal, SURVIVING SPOUSES - DENTAL PPO PLAN 4P648 1 $3.36
Fees/Credits $0.00
Adjustments See Adjustment Summary below $143,307.17
Subtotal, Adjustments $143,307.17
TOTAL 2195 $285,585.03
Invoice Date: 03/14/2024 Bill Group: 1 Coverage Period: 01/01/2021 - 03/31/2024 Due Date: 04/01/2024
County of Hays Customer No: 0912772
Questions? We’re here to help.
www.employereservices.com
Invoice Date: 03/14/2024 Bill Group: 1 Coverage Period: 01/01/2021 - 03/31/2024 Due Date: 04/01/2024
County of Hays Customer No: 0912772
Questions? We’re here to help.
www.employereservices.com
Adjustment Summary
Description Invoice Period Employee Count Total Volume (000's)
Net Amount
ACTIVE
ASO 2007 CH EP1 AGU2
UHPD PLAN 2
02/01/2024 - 02/29/2024 428 $57,069.52
ASO 2007 CH EP1 AGU2
UHPD PLAN 2
01/01/2024 - 01/31/2024 12 -$546.28
ASO 2007 CH EP1 AGU2
UHPD PLAN 2
12/01/2023 - 12/31/2023 2 -$257.34
ASO 2007 CH EP1 AGU2
UHPD PLAN 2
11/01/2023 - 11/30/2023 1 -$128.67
ASO 2007 CH EP1 AGU2
UHPD PLAN 2
10/01/2023 - 10/31/2023 1 -$128.67
ASO 2007 CH EP1 AGU2
UHPD PLAN 2
09/01/2023 - 09/30/2023 1 -$128.67
ASO 2007 CH EP1 AGU2
UHPD PLAN 2
08/01/2023 - 08/31/2023 1 -$128.67
ASO 2007 CH EP1 AGU2
UHPD PLAN 2
07/01/2023 - 07/31/2023 1 -$128.67
ASO 2007 CH EP1 AGU2
UHPD PLAN 2
06/01/2023 - 06/30/2023 1 -$128.67
ASO 2007 CH EP1 AGU2
UHPD PLAN 2
05/01/2023 - 05/31/2023 1 -$128.67
ASO 2007 CH EP1 AGU2
UHPD PLAN 2
04/01/2023 - 04/30/2023 1 -$128.67
ASO 2007 CH EP1 AGU2
UHPD PLAN 2
03/01/2023 - 03/31/2023 1 -$128.67
ASO 2007 CH EP1 AGU2
UHPD PLAN 2
02/01/2023 - 02/28/2023 1 -$128.67
ASO 2007 CH EP1 AGU2
UHPD PLAN 2
01/01/2023 - 01/31/2023 1 -$128.67
ASO 2007 CH EP1 AGU2
UHPD PLAN 2
12/01/2022 - 12/31/2022 1 -$116.39
ASO 2007 CH EP1 AGU2
UHPD PLAN 2
11/01/2022 - 11/30/2022 1 -$116.39
ASO 2007 CH EP1 AGU2
UHPD PLAN 2
10/01/2022 - 10/31/2022 1 -$116.39
ASO 2007 CH+ PS1 AGU2
HSA PLAN 3
02/01/2024 - 02/29/2024 71 $9,467.14
ASO 2007 CH+ PS1 AGU2
HSA PLAN 3
01/01/2024 - 01/31/2024 5 -$133.34
ASO 2007 CH+ PS1 AGU2
HSA PLAN 3
12/01/2023 - 12/31/2023 1 -$128.67
ASO 2007 CH+ PS1 AGU2
HSA PLAN 3
11/01/2023 - 11/30/2023 1 -$128.67
ASO 2007 CH+ PS1 AGU2
HSA PLAN 3
10/01/2023 - 10/31/2023 1 -$128.67
ASO 2007 CH+ PS1 AGU2
HSA PLAN 3
09/01/2023 - 09/30/2023 1 -$128.67
Account Adjustments $0.00
Subtotal Adjustments $143,307.17
Invoice Date: 03/14/2024 Bill Group: 1 Coverage Period: 01/01/2021 - 03/31/2024 Due Date: 04/01/2024
County of Hays Customer No: 0912772
Questions? We’re here to help.
www.employereservices.com
Adjustment Summary
Description Invoice Period Employee Count Total Volume (000's)
Net Amount
ASO 2007 CH+ PS1 AGU2
HSA PLAN 3
08/01/2023 - 08/31/2023 1 -$128.67
ASO 2007 CH+ PS1 AGU2
HSA PLAN 3
07/01/2023 - 07/31/2023 1 -$128.67
ASO 2007 CH+ PS1 AGU2
HSA PLAN 3
06/01/2023 - 06/30/2023 1 -$128.67
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
02/01/2024 - 02/29/2024 403 $53,736.02
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
01/01/2024 - 01/31/2024 17 -$946.30
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
12/01/2023 - 12/31/2023 3 -$386.01
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
11/01/2023 - 11/30/2023 2 -$257.34
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
10/01/2023 - 10/31/2023 2 -$257.34
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
09/01/2023 - 09/30/2023 2 -$257.34
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
08/01/2023 - 08/31/2023 2 -$257.34
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
07/01/2023 - 07/31/2023 2 -$257.34
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
06/01/2023 - 06/30/2023 1 -$128.67
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
05/01/2023 - 05/31/2023 1 -$128.67
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
04/01/2023 - 04/30/2023 1 -$128.67
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
03/01/2023 - 03/31/2023 1 -$128.67
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
02/01/2023 - 02/28/2023 1 -$128.67
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
01/01/2023 - 01/31/2023 1 -$128.67
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
12/01/2022 - 12/31/2022 1 -$116.39
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
11/01/2022 - 11/30/2022 1 -$116.39
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
10/01/2022 - 10/31/2022 1 -$116.39
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
09/01/2022 - 09/30/2022 1 -$116.39
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
08/01/2022 - 08/31/2022 1 -$116.39
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
07/01/2022 - 07/31/2022 1 -$116.39
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
06/01/2022 - 06/30/2022 1 -$116.39
Invoice Date: 03/14/2024 Bill Group: 1 Coverage Period: 01/01/2021 - 03/31/2024 Due Date: 04/01/2024
County of Hays Customer No: 0912772
Questions? We’re here to help.
www.employereservices.com
Adjustment Summary
Description Invoice Period Employee Count Total Volume (000's)
Net Amount
DENTAL DHMO PLAN
D094C
02/01/2024 - 02/29/2024 27 $535.83
DENTAL DHMO PLAN
D094C
01/01/2024 - 01/31/2024 5 -$36.82
DENTAL PPO PLAN 4P648 02/01/2024 - 02/29/2024 901 $3,027.36
DENTAL PPO PLAN 4P648 01/01/2024 - 01/31/2024 24 -$40.32
DENTAL PPO PLAN 4P648 12/01/2023 - 12/31/2023 4 -$13.44
DENTAL PPO PLAN 4P648 11/01/2023 - 11/30/2023 3 -$10.08
DENTAL PPO PLAN 4P648 10/01/2023 - 10/31/2023 3 -$10.08
DENTAL PPO PLAN 4P648 09/01/2023 - 09/30/2023 3 -$10.08
DENTAL PPO PLAN 4P648 08/01/2023 - 08/31/2023 3 -$10.08
DENTAL PPO PLAN 4P648 07/01/2023 - 07/31/2023 3 -$10.08
DENTAL PPO PLAN 4P648 06/01/2023 - 06/30/2023 2 -$6.72
DENTAL PPO PLAN 4P648 05/01/2023 - 05/31/2023 1 -$3.36
DENTAL PPO PLAN 4P648 04/01/2023 - 04/30/2023 1 -$3.36
DENTAL PPO PLAN 4P648 03/01/2023 - 03/31/2023 1 -$3.36
DENTAL PPO PLAN 4P648 02/01/2023 - 02/28/2023 1 -$3.36
DENTAL PPO PLAN 4P648 01/01/2023 - 01/31/2023 1 -$3.36
DENTAL PPO PLAN 4P648 12/01/2022 - 12/31/2022 1 -$3.36
DENTAL PPO PLAN 4P648 11/01/2022 - 11/30/2022 1 -$3.36
DENTAL PPO PLAN 4P648 10/01/2022 - 10/31/2022 1 -$3.36
DENTAL PPO PLAN 4P648 09/01/2022 - 09/30/2022 1 -$3.36
DENTAL PPO PLAN 4P648 08/01/2022 - 08/31/2022 1 -$3.36
DENTAL PPO PLAN 4P648 07/01/2022 - 07/31/2022 1 -$3.36
DENTAL PPO PLAN 4P648 06/01/2022 - 06/30/2022 1 -$3.36
Subtotal, ACTIVE $115,839.90
CAD
ASO 2007 CH EP1 AGU2
UHPD PLAN 2
02/01/2024 - 02/29/2024 18 $2,400.12
ASO 2007 CH EP1 AGU2
UHPD PLAN 2
01/01/2024 - 01/31/2024 1 -$133.34
ASO 2007 CH+ PS1 AGU2
HSA PLAN 3
02/01/2024 - 02/29/2024 1 $133.34
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
02/01/2024 - 02/29/2024 16 $2,133.44
DENTAL PPO PLAN 4P648 02/01/2024 - 02/29/2024 36 $120.96
DENTAL PPO PLAN 4P648 01/01/2024 - 01/31/2024 1 -$3.36
Subtotal, CAD $4,651.16
COBRA
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
02/01/2024 - 02/29/2024 1 $133.34
DENTAL PPO PLAN 4P648 02/01/2024 - 02/29/2024 1 $3.36
Subtotal, COBRA $136.70
Invoice Date: 03/14/2024 Bill Group: 1 Coverage Period: 01/01/2021 - 03/31/2024 Due Date: 04/01/2024
County of Hays Customer No: 0912772
Questions? We’re here to help.
www.employereservices.com
Adjustment Summary
Description Invoice Period Employee Count Total Volume (000's)
Net Amount
RETIREES
ASO 2007 CH EP1 AGU2
UHPD PLAN 2
02/01/2024 - 02/29/2024 40 $4,249.82
ASO 2007 CH EP1 AGU2
UHPD PLAN 2
01/01/2024 - 01/31/2024 29 $3,505.10
ASO 2007 CH+ PS1 AGU2
HSA PLAN 3
02/01/2024 - 02/29/2024 3 $400.02
ASO 2007 CH+ PS1 AGU2
HSA PLAN 3
01/01/2024 - 01/31/2024 3 $361.26
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
02/01/2024 - 02/29/2024 94 $7,476.32
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
01/01/2024 - 01/31/2024 51 $6,167.26
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
12/01/2023 - 12/31/2023 1 -$114.70
ASO 2007 CH+ PS1 AGU2
UHPD PLAN 1
01/01/2021 - 01/31/2021 2 -$199.40
DENTAL DHMO PLAN
D094C
02/01/2024 - 02/29/2024 4 $76.49
DENTAL PPO PLAN 4P648 02/01/2024 - 02/29/2024 142 $477.12
DENTAL PPO PLAN 4P648 01/01/2024 - 01/31/2024 3 $10.08
Subtotal, RETIREES $22,409.37
SURVIVING SPOUSES
ASO 2007 CH EP1 AGU2
UHPD PLAN 2
02/01/2024 - 02/29/2024 2 $266.68
DENTAL PPO PLAN 4P648 02/01/2024 - 02/29/2024 1 $3.36
Subtotal, SURVIVING SPOUSES $270.04
File details come from the government source that posted it. Updated .