Summary of Benefits & Coverage

EFFECTIVE January 1, 2025

Class I and II

• Class I – Contribution Rate $4.40 to $4.99 per hour
  • Spanish Version
• Class I – Contribution Rate $5.00 to $5.49 per hour
  • Spanish Version
• Class I – Contribution Rate $5.50 an hour and over
  • Spanish Version
• Class II – Contribution Rate $4.40 to $4.99 per hour
  • Spanish Version
• Class II – Contribution Rate $5.00 to $5.49 per hour 
  • Spanish Version
• Class II – Contribution Rate $5.50 an hour and over 
  • Spanish Version

Class III and IV

• Class III – Contribution Rate $4.40 to $4.99 per hour 
  • Spanish Version
• Class III – Contribution Rate $5.00 to $5.49 per hour 
  • Spanish Version
• Class III – Contribution Rate $5.50 and hour and over 
  • Spanish Version
• Class IV – Contribution Rate $4.40 to $4.99 per hour 
  • Spanish Version
• Class IV – Contribution Rate $5.00 to $5.49 per hour 
  • Spanish Version
• Class IV – Contribution Rate $5.50 an hour and over 
  • Spanish Version

EFFECTIVE January 1, 2024

Class I and II

• Class I – Contribution Rate $4.00 to $4.69 per hour
  • Spanish Version
• Class I – Contribution Rate $4.70 to $5.09 per hour
  • Spanish Version
• Class I – Contribution Rate $5.10 an hour and over
  • Spanish Version
• Class II – Contribution Rate $4.00 to $4.69 per hour
  • Spanish Version
• Class II – Contribution Rate $4.70 to $5.09 per hour 
  • Spanish Version
• Class II – Contribution Rate $5.09 an hour and over 
  • Spanish Version

Class III and IV

• Class III – Contribution Rate $4.00 to $4.69 per hour 
  • Spanish Version
• Class III – Contribution Rate $4.70 to $5.09 per hour 
  • Spanish Version
• Class III – Contribution Rate $5.10 and hour and over 
  • Spanish Version
• Class IV – Contribution Rate $4.00 to $4.69 per hour 
  • Spanish Version
• Class IV – Contribution Rate $4.70 to $5.09 per hour 
  • Spanish Version
• Class IV – Contribution Rate $5.10 an hour and over 
  • Spanish Version

EFFECTIVE January 1, 2023

Class I and II

• Class I – Contribution Rate $4.00 to $4.69 per hour
  • Spanish Version
• Class I – Contribution Rate $4.70 to $5.09 per hour
  • Spanish Version
• Class I – Contribution Rate $5.10 an hour and over
  • Spanish Version
• Class II – Contribution Rate $4.00 to $4.69 per hour
  • Spanish Version
• Class II – Contribution Rate $4.70 to $5.09 per hour 
  • Spanish Version
• Class II – Contribution Rate $5.09 an hour and over 
  • Spanish Version

Class III and IV

• Class III – Contribution Rate $4.00 to $4.69 per hour 
  • Spanish Version
• Class III – Contribution Rate $4.70 to $5.09 per hour 
  • Spanish Version
• Class III – Contribution Rate $5.10 and hour and over 
  • Spanish Version
• Class IV – Contribution Rate $4.00 to $4.69 per hour 
  • Spanish Version
• Class IV – Contribution Rate $4.70 to $5.09 per hour 
  • Spanish Version
• Class IV – Contribution Rate $5.10 an hour and over 
  • Spanish Version

EFFECTIVE January 1, 2022

Class I and II

• Class I – Contribution Rate $4.00 to $4.39 per hour
  • Spanish Version
• Class I – Contribution Rate $4.40 to $4.79 per hour
  • Spanish Version
• Class I – Contribution Rate $4.80 an hour and over
  • Spanish Version
• Class II – Contribution Rate $4.00 to $4.39 per hour
  • Spanish Version
• Class II – Contribution Rate $4.40 to $4.79 per hour 
  • Spanish Version
• Class II – Contribution Rate $4.80 an hour and over 
  • Spanish Version

Class III and IV

• Class III – Contribution Rate $4.00 to $4.39 per hour 
  • Spanish Version
• Class III – Contribution Rate $4.40 to $4.79 per hour 
  • Spanish Version
• Class III – Contribution Rate $4.80 and hour and over 
  • Spanish Version
• Class IV – Contribution Rate $4.00 to $4.39 per hour 
  • Spanish Version
• Class IV – Contribution Rate $4.40 to $4.79 per hour 
  • Spanish Version
• Class IV – Contribution Rate $4.80 an hour and over 
  • Spanish Version

EFFECTIVE January 1, 2021

Class I and II

• Class I – Contribution Rate $4.00 to $4.39 per hour
  • Spanish Version
• Class I – Contribution Rate $4.40 to $4.79 per hour
  • Spanish Version
• Class I – Contribution Rate $4.80 an hour and over
  • Spanish Version
• Class II – Contribution Rate $4.00 to $4.39 per hour
  • Spanish Version
• Class II – Contribution Rate $4.40 to $4.79 per hour 
  • Spanish Version
• Class II – Contribution Rate $4.80 an hour and over 
  • Spanish Version

Class III and IV

• Class III – Contribution Rate $4.00 to $4.39 per hour 
  • Spanish Version
• Class III – Contribution Rate $4.40 to $4.79 per hour 
  • Spanish Version
• Class III – Contribution Rate $4.80 and hour and over 
  • Spanish Version
• Class IV – Contribution Rate $4.00 to $4.39 per hour 
  • Spanish Version
• Class IV – Contribution Rate $4.40 to $4.79 per hour 
  • Spanish Version
• Class IV – Contribution Rate $4.80 an hour and over 
  • Spanish Version

EFFECTIVE January 1, 2020

Class I and II

• Class I – Contribution Rate $4.00 to $4.39 per hour
  • Spanish Version
• Class I – Contribution Rate $4.40 to $4.79 per hour
  • Spanish Version
• Class I – Contribution Rate $4.80 an hour and over
  • Spanish Version
• Class II – Contribution Rate $4.00 to $4.39 per hour
  • Spanish Version
• Class II – Contribution Rate $4.40 to $4.79 per hour 
  • Spanish Version
• Class II – Contribution Rate $4.80 an hour and over 
  • Spanish Version

Class III and IV

• Class III – Contribution Rate $4.00 to $4.39 per hour 
  • Spanish Version
• Class III – Contribution Rate $4.40 to $4.79 per hour 
  • Spanish Version
• Class III – Contribution Rate $4.80 and hour and over 
  • Spanish Version
• Class IV – Contribution Rate $4.00 to $4.39 per hour 
  • Spanish Version
• Class IV – Contribution Rate $4.40 to $4.79 per hour 
  • Spanish Version
• Class IV – Contribution Rate $4.80 an hour and over 
  • Spanish Version