2019 Participating Agency Empire Plan Cost Estimate Calculator

Rate Per Coverage Type	2019 Monthly Rate	Enter the Total Number of Individual Enrollees in Each Coverage Type	Total
Individual Coverage	$1,042.85	=	$
Family Coverage (Individuals & Dependents)	$2,412.77	=	$
Medicare-primary - Individual	$403.27	=	$
Medicare-primary - Family (with one Medicare)	$1,773.19	=	$
Medicare-primary - Family (with two Medicare)	$1,133.57	=	$
Total Number of Individual Enrollees:			Total Monthly Premium: $

Other Monthly Charges

Administrative Charge Per Enrollee	$2.493 x Total Enrollees as Reported Above =	$
Medicare Reimbursement (If Agency covers Medicare primary enrollees) Note: this rate is based on the Base Medicare Reimbursement Rate.	$135.50 * x (Enter total # of Medicare Primary Enrollees and Dependents ) =	$ Total Medicare Reimbursement
Total Monthly Cost to Agency:		$
Total Annual Cost:		$

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* Note: You may have enrollees subject to Income - Related Medicare Adjustment Amount (IRMMA). For more information, visit www.medicare.gov.

Department of Civil Service