Dependent Children Health Benefit Plan
Premium Increase Notice
Dear Member:
You currently have a child(ren) enrolled in the SAMBA Dependent Children Health Benefit Plan (DHBP).
This notice is to inform you of an increase in the DHBP premium effective April 1, 2006.
SAMBA offers the DHBP as a cost effective means of providing a comprehensive health insurance plan for your dependent child(ren) between the ages of 22 and 27. Unfortunately, due to the increasing cost of medical care, we find it necessary to increase the premium at this time. We have not had a premium increase in four years.
Effective April 1, 2006 the DHBP premium will increase from $70 to
$85 per pay period. For members who have more than one child enrolled in the DHBP, we must now impose a supplemental premium of $40 per pay period for each additional child enrolled. (A member with two covered children between the ages of 22 and 27 will now pay $125 per pay period.)
To continue your child(ren)’s enrollment in this Plan, sign and date the enclosed SAMBA Payroll Allotment Form 299 and return it in the enclosed pre-addressed envelope by
March 15, 2006. If you fail to return the form by this date, your child(ren)’s DHBP coverage will be terminated as of March 31, 2006 for nonpayment of premium.
Should you wish to cancel your child(ren)’s coverage, use the enclosed SAMBA Payroll Allotment Form 299 and check the appropriate box in section 7 of the form. In the space provided after “Only Cancel for Plans Listed Below”, write in “DHBP”. Sign, date, and return the form to SAMBA.
Note: You must return the Allotment Form 299 to SAMBA, even if you cancel your child(ren)’s coverage. SAMBA cannot change your DHBP payroll allotment until we have the signed and dated form from you.
If you have any questions, please do not hesitate to contact a SAMBA Group Plans service representative at 1-800-638-6589 or 301-984-1440 between the hours of 8:00 am and 4:00 pm EST.
We are confident that you will agree that in today’s health insurance market, the DHBP plan remains an exceptional value.
Sincerely,
SAMBA Group Plans Department
Enclosure
This notice updates the Dependent Children Health Benefit Plan Summary Plan Description previously issued.
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