CHART E Employee Costs
This Chart estimates the cost for each covered employee and their covered family members using the region adjusted employer contribution assuming they purchase a plan that costs the same as the region adjusted Baseline Plan cost.
Name
Relationship Age
ICHRA Factor
EE Contribution
ER Contribution
Premium Total Family Premium
Jeremiah D'Annunzio Dana D'Annunzio Lucas D'Annunzio Addison D'Annunzio
Employee 41
1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000
$190.57 $696.13 $401.92 $401.92 $464.96 $164.81 $162.44 $401.00 $438.95
$493.47 $684.04 $2,648.97
Spouse
42
$0.00 $696.13 $0.00 $401.92 $0.00 $401.92 $0.00 $464.96
Child Child Child
9
14 17
Tyler Razzaq Jessica Bell Ju'el Beasley
Employee 22 Employee 29
$379.01 $543.82 $543.82 $424.11 $586.55 $987.54
Ezekiel Lambert Michelle Maciel Marco Maciel Kenzo Maciel Araceli Cannon Jasmisa Blackmon Kailee Nixon Alana Sanders Spencer Massey
Child
6
$0.00 $401.00
Employee 58
$965.72 $1,404.67 $3,453.78
Spouse
63 12
$1,627.38
$0.00 $1,627.38 $0.00 $421.73
Child
$421.73 $146.96 $177.69 $173.16 $226.58 $163.79 $205.36 $543.82
Employee 25 Employee 34 Employee 32 Employee 33 Employee 29 Employee 38
$380.52 $527.48 $527.48 $460.12 $637.81 $637.81 $448.36 $621.52 $621.52 $454.06 $680.64 $680.64 $424.11 $587.90 $587.90 $472.24 $677.60 $1,221.42
Ashley Battle Lanya Dixon Melvin Miller Tyja VanHook Mark Peters Hannah Wood
Child
22
$0.00 $543.82
Employee 69 Employee 23 Employee 40 Employee 30
$0.00
$1,137.03 $0.00 $1,137.03 $379.01 $568.15 $568.15 $484.38 $490.22 $490.22 $430.18 $596.31 $596.31 $430.18 $617.24 $617.24 $454.06 $651.50 $651.50 $448.36 $621.52 $621.52 $493.47 $626.65 $626.65 $529.48 $733.96 $733.96 $411.98 $571.09 $571.09 $439.27 $607.52 $1,008.52
$189.14
$5.84
$166.13 $187.06 $197.44 $173.16 $133.18 $204.48 $159.11 $168.25 $401.00 $139.04 $146.37 $137.21 $95.05 $152.13 $114.53 $149.88 $219.56 $169.65 $159.11 $116.10 $214.67 $159.11 $401.92 $401.92
Shamekiandra Hamm Employee 30
Courtney Bates Summer Peterson Christina Delgman Davarshea Williams Ashley Dunn Adrinne Brown Ava Sanders Rashaad Moore Caneia White Georgina Cox Andrea Buchanan Madison Spradlin Tameyra Drake Ashley Walker Shaneka Leverette Sandra Thomaston
Employee 33 Employee 32 Employee 41 Employee 44 Employee 28 Employee 31
Child
7
$0.00 $401.00
Employee 34 Employee 22 Employee 33 Employee 30 Employee 27 Employee 22 Employee 26 Employee 46 Employee 31 Employee 28 Employee 30 Employee 30 Employee 28
$460.12 $599.16 $599.16 $379.01 $525.38 $525.38 $454.06 $591.27 $591.27 $430.18 $525.23 $525.23 $397.20 $549.33 $549.33 $379.01 $493.54 $493.54 $388.11 $537.99 $537.99 $568.51 $788.07 $788.07 $439.27 $608.92 $608.92 $411.98 $571.09 $571.09 $430.18 $546.28 $546.28 $430.18 $644.85 $644.85 $411.98 $571.09 $1,374.93
Graham Gill
Elizabeth Greene Arnolda Shaho
Victoria Dietz Hazel Dietz
Child Child
3 5
$0.00 $401.92 $0.00 $401.92
Lilah Dietz
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