Contract - United Healthcare Insurance Co - 12/7/2023 United Healthcare Insurance Company
A Stock Company
185 Asylum Street,Hartford,Connecticut
Phone: 1-877-294-1429
AMENDMENT NO.3
Amendment to be attached to and made a part of Group Policy No. GA-925175AL, issued by
UnitedHealthcare Insurance Company (herein called "Company") to City of Round Rock (herein called
"Policyholder").
It is agreed by and between the Company and the Policyholder that
1. The page entitled "Schedule Of Benefits" as contained in the Policy is hereby replaced with the
attached page entitled"Schedule Of Benefits".
2. This Amendment will hereby be effective as of January 1,2024.
UnitedHealthcare Insurance Company
William J Golden,President Timothy J.Burch,Secretary
ACCEPTED BY: , M/
Title: Craig organ,1/ayor
Date: !2/ `l 12 7
2023-413
UHIC AMEND(07/06)
UnitedHealthcare Insurance Company
A Stock Company
185 Asylum Street,Hartford,Connecticut
Phone: 1-877-294-1429
SCHEDULE OF BENEFITS
This Schedule of Benefits is only applicable to Excess Loss Insurance provided by the Company during the
Policy Period shown below.
Policyholder: City of Round Rock
Policy Number: GA-925175AL
Effective Date: January 1,2024
Administrator: United HealthCare Services,Inc.
Coverage specified herein is applicable only during the Policy Period from January 1, 2024 through
December 31,2024,and is further subject to all terms and conditions of this Policy.
SPECIFIC EXCESS LOSS INSURANCE
Benefit Period: Covered Expenses Incurred from January 1, 2022 through December 31, 2024 and Paid
from January 1,2024 through December 31,2024.
Specific Deductible per Covered Person:$200,000
Specific Percentage Reimbursable: 100%
Maximum Specific Benefit per Covered Person:Unlimited
Specific Excess Loss Insurance includes:
• Medical
• Stand Alone Prescription Drug Program
Specific Excess Loss Premium:$147.41 per subscriber per month
AGGREGATE EXCESS LOSS INSURANCE
Benefit Period: Covered Expenses Incurred from January 1, 2022 through December 31, 2024 and Paid
from January 1,2024 through December 31,2024.
Aggregate Excess Loss Insurance includes:
• Medical
• Stand Alone Prescription Drug Program
Aggregate Percentage Reimbursable: 100%
Maximum Aggregate Benefit:$1,000,000 per Policy Year
UHIELIP(07/06) 1 SCHED
Minimum Annual Aggregate Deductible: $15,914,014 or 95%of the first Monthly Aggregate Deductible
amount times 12,whichever is greater.
Maximum Covered Expenses per Covered Person accumulating toward the Maximum Aggregate Benefit:
$200,000
Monthly Aggregate Factors:
• Choice Plus Plan-$1,463.28 per subscriber
• Nexus Plan-$1,463.28 per subscriber
Aggregate Excess Loss Premium:$3.86 per subscriber per month
UHIELIP(07/06) 2 SCHED