Health Reinsurance Association

Individual

Conversion

	PPO
	SHCP

Portability

TAA

2010 HRA PLAN RATES
Monthly Premium Rates per Individual
Special Low Income - Conversion Plan

Attained Age	Male	Female	One Child	Children
<30	$245.94	$478.64	$239.5	$480.46
30-39	$312.40	$499.29
40-49	$432.48	$538.37
50-59	$725.56	$696.93
60-64	$1,068.22	$904.91

Special Non Low Income - Conversion Plan

Attained Age	Male	Female	One Child	Children
<30	$669.57	$1,303.10	$652.05	$1,308.07
30-39	$850.51	$1,359.33
40-49	$1,177.43	$1,465.72
50-59	$1,975.35	$1,897.42
60-64	$2,908.25	$2,463.62

Please note: When you or any covered family member has a birthday that moves you to the next age bracket, the rate will change the month after the birthday occurs.

How to figure out your cost of coverage

1. Go to the above rate chart and get a rate for your coverage based on your age and gender.

2. Get rates for other family members to be covered based on their ages and genders.

3. Add together all the rates for your family members. This your total monthly cost of coverage

Low Income Guidelines

Family Members	1	2	3	4
Adjusted Gross Income	$32,490	$43,710	$54,930	$66,150
(On last Federal Tax Return)

Family Members	5	6	7	8
Adjusted Gross Income	$77,370	$88,590	$99,810	$111,030
(On last Federal Tax Return)

Add $11,220 to the base for each additional family member.

**If you did not file a Federal Tax Return, please call the Treasury Dept. at 1-800-829-1040 and request letter #1722(ICP) or Form 4506T to verify income.