HomeMy WebLinkAboutCity Council Meeting - Council - Regular Agenda - 06/07/2022
KENT CITY COUNCIL AGENDA
Tuesday, June 7, 2022
7:00 PM
Chambers
A live broadcast is available on Kent TV21,
www.facebook.com/CityofKent, and
www.youtube.com/user/KentTV21
To listen to this meeting,
call 1-888-475-4499 or 1-877-853-5257
and enter Meeting ID: 875 6940 5814, Passcode: 912367
Mayor Dana Ralph
Council President Bill Boyce
Councilmember Brenda Fincher Councilmember Zandria Michaud
Councilmember Satwinder Kaur Councilmember Toni Troutner
Councilmember Marli Larimer Councilmember Les Thomas
**************************************************************
COUNCIL MEETING AGENDA - 7 P.M.
1. CALL TO ORDER/FLAG SALUTE
2. ROLL CALL
3. AGENDA APPROVAL
Changes from Council, Administration, or Staff.
4. PUBLIC COMMUNICATIONS
A. Public Recognition
1. Employee of the Month
2. Appointment to King County Landmarks and Heritage Commission
3. Proclamation for National Gun Violence Awareness Day
4. Proclamation for Main Street Week
5. Proclamation for LGBTQ+ Pride Month
B. Community Events
5. REPORTS FROM COUNCIL AND STAFF
A. Mayor Ralph's Report
B. Chief Administrative Officer's Report
City Council Meeting City Council Regular Meeting June 7, 2022
C. Councilmembers' Reports
6. PUBLIC HEARING
7. PUBLIC COMMENT
The Public Comment period is your opportunity to speak to the Council and Mayor on issues
that relate to the business of the city of Kent or to agenda items Council will consider at this
meeting. Comments that do not relate to the business of the city of Kent are not permitted.
Additionally, the state of Washington prohibits people from using this Public Comment period
to support or oppose a ballot measure or candidate for office.
If you wish to provide comment to the Mayor and Council at this meeting, please contact the
City Clerk by 4 p.m. on the day of the meeting at 253-856-5725 or CityClerk@KentWA.gov. If
you intend to speak in person, please see the Clerk at the beginning of the me eting to sign up.
When called to speak during the meeting, please state your name and city of residence for the
record. You will have up to three minutes to provide comment. Please address all comments to
the Mayor and Council as a whole. The Mayor and Council may not be in a position to answer
questions during the meeting. Alternatively, you may email the Mayor and Council at
Mayor@KentWA.gov and CityCouncil@KentWA.gov. Emails are not read into the record.
8. CONSENT CALENDAR
A. Approval of Minutes
i. Council Workshop - Workshop Regular Meeting - May 17, 2022 5:00
PM
ii. City Council Meeting - City Council Regular Meeting - May 17, 2022
7:00 PM
B. Payment of Bills - Authorize
C. Accept the 2021 Storm and Sewer Cured-in-Place Pipe Lining Project as
Complete - Accept
D. Appointment to the King County Landmarks and Heritage Commission -
Confirm
E. Cancel Council's Regular Meeting Scheduled for July 5, 2022 - Direct
F. Medical, Dental and Vision Vendor Contracts - Authorize
G. Amendment to LifeWise Assurance Company Contract for Stop Loss
Insurance - Authorize
H. Consultant Services Agreement with Natural Systems Design, Inc. for
Wetland Mitigation Design - Authorize
9. OTHER BUSINESS
10. BIDS
A. Kherson Park Redevelopment Bid - Award
11. EXECUTIVE SESSION AND ACTION AFTER EXECUTIVE SESSION
City Council Meeting City Council Regular Meeting June 7, 2022
12. ADJOURNMENT
NOTE: A copy of the full agenda is available in the City Clerk's Office and at
KentWA.gov.
Any person requiring a disability accommodation should contact the City Clerk's
Office in advance at 253-856-5725. For TDD relay service, call the Washington
Telecommunications Relay Service 7-1-1.
PROCLAMATION
WHEREAS, every day, more than 110 Americans are killed by the use of a gun,
alongside more than 200 who are shot and wounded; and
wHEREAS,
WHEREAS,
Washington has an average of 810 gun deaths every year, with a rate
of 10.5 deaths per 100,000 people; and
according to the 2021 Public Health Report on Gun Violence Among
Youth and Young Adults, the use of firearms is the leading cause of
homicide deaths among youth and young adults in King County; and
WHEREAS,cities across the nation, including Kent, are working with local agenciesto implement strategies to reduce firearm-related homicide and
violence, and ensure all young people are healthy, hopeful, safe, and
thriving; and;
WHEREAS, support for the Second Amendment rights of law-abiding citizens goes
hand-in-hand with keeping guns away from people with dangerous
histories; and
wHEREAS,on June 3, which is recognized as National Gun Violence Awareness
Day, Public Health - Seattle & King County's Zero Youth Detention
team and community partners will launch their Safer Summer
strategy, and the Regional Peacekeepers Collective and the Seattle
Community Safety Initiative Partners will raise awareness, conduct
gun safety activities, and provide education and resources to
community residents in Seattle, Skyway and Kent; and
wHEREAS,we renew our commitment to reduce the use of guns with violent
intent and pledge to do all we can to keep firearms out of the wrong
hands, and encourage responsible gun ownership to help keep our
community and our children safe.
NOW THEREFORE, I, DANA RALPH, MAYOR OF KENT, DO HEREBY PROCLAIM
JUNE 3t 2022 TO BE
National Gun Violence Awareness Day
In Kent Washington and encourage all citizens to support local community efforts to
prevent the tragic effects of gun violence and to honor and value human lives.
In witness whereof, I have hereunto set my hand this 3rd day of June 2022.
KENTWAsHrNcroN
Mayor Ralph
4.A.3
Packet Pg. 4 Communication: Proclamation for National Gun Violence Awareness Day (Public Recognition)
PROCLAMATION
WHEREAS, downtowns and main streets are the birthplace and heart of our
communities across Washington State and are a testament to the
resilience of our small businesses; and
wHEREAS,designated Washington Main Street districts represent the second
largest private sector employers in the State, supporting over 65,000
jobs in nearly 7,OOO businesses generating nearly $10 billion in revenue
annually; and
WHEREAS,Washington State's 36 designated Main Street Communities have led
revitalization efforts that include over 380,000 volunteer hours
leveraged, over 3,000 events hosted and an economic impact of nearly
$900 Million dollars since 2011; and
wHEREAS,Main Street Communities delivered a broad range of much-needed
pandemic-related resources and services to downtown business,
supporting Main Street businesses in their effort to be resilient
throughout the pandemic and aiding in recovery; and
wHEREAS,Main Streets Organizations including Kent Downtown Partnership
provided 1,118 small businesses with direct technical assistance and
3,610 businesses with information and education; and
WHEREAS,the City of Kent supports and joins in this statewide effort to help
Washington's Main Street businesses do what they do best, create jobs,
and ensure that our communities remain as vibrant tomorrow as they
are today.
NOW, THEREFORE, I, DANA RALPH, MAYOR OF KENT, DO HEREBY PROCLAIM
JUNE 6-t2,2O22t TO BE
Main Street Week
In Kent Washington and call upon our residents to join in this special observance by
supporting and celebrating our Main Street Businesses.
In witness whereof, I have hereunto set my hand this 7th day of June 2022
KENT
WASHTNcToN
Mayor Dana Ra lph
4.A.4
Packet Pg. 5 Communication: Proclamation for Main Street Week (Public Recognition)
WHEREAS,
wHEREAS,
wHEREAS,
WHEREAS,
wHEREAS,
wHEREAS,
PROCLAMATION
the month of June was designated Pride Month to honor the Stonewall
Riots, and is generally recognized as the catalyst of the lesbian, gay,
bisexual, transgender, queer, intersex, and asexual (LGBTQ+) rights
movement; and
LGTBQ+ residents, students, city employees, and business owners
within the City of Kent contribute to the enrichment of our City; and
Washington state and King County have led the nation in protecting the
civil rights of our lesbian, gdy, bisexual, transgender, and queer
neighbors, coworkers, friends, and family members; as well as provide
allyship; and
while further progress is needed, it is important to recognize and
celebrate the substantial gains that have been achieved; and
the City of Kent, in partnership and communication with residents,
businesses, and schools, is dedicated to building an inclusive city with
opportunities for all; and
LGBTQ+ residents contribute to the cultural fabric of our community,
and donate their time, talent, labor and financial resources to various
community organizations; and
NOltll' THEREFORE, I, Dana Ralph, Mayor of Kent, do hereby proclaim June 2022
LGBTQ+ Pride Month
in Kent Washington and the Kent City Council and Mayor invites everyone to reflect on
ways we all can live and work together with a commitment to mutual respect and
understanding and to join us in this special observance and recognize the numerous
contributions of LGBTQ+ individuals in the city.
In witness whereof, I have hereunto set my hand this 7th day of June, 2022.
Mayo ana Ralph
KENT
WASHTNGToN
4.A.5
Packet Pg. 6 Communication: Proclamation for LGBTQ+ Pride Month (Public Recognition)
Page 1 of 11
Administration
• The recruitment for the Chief
Administrative Officer position has gone
live. The first review of applications will
occur on July 3, 2022.
• Instances of positive COVID cases for City
employees have risen sharply. Staff will be
meeting to discuss how the increase is
impacting employees who work in the field,
and how we can efficiently continue to
provide services while keeping members of
the workforce safe.
• Staff began the budget development
process with a kick-off meeting last week.
The next steps will be for departments to
develop their budgets and review them
with Finance and Administration.
Clerk’s Office
• During the month of May, the City Clerk’s
Office conducted two bid openings,
processed 102 contracts, responded to
over 640 requests for public records,
including reviewing/redacting over 3,075
minutes of body worn camera police video
and reviewed more than 8,000 emails.
• The Clerk’s Office is in the process of
uploading content to and designing the
soon-to-be-released Boards and
Commissions webpage that will be located
on the City’s main website. Unique board
information, terms of members and board
documents will be available on the
webpage.
• The Clerk’s Office is working in conjunction
with the City’s Information Technology
Department, its outside vendor CDI, and
the Parks Department and Corrections on
the conversion of their City records from
the City’s legacy records management
system (Oracle) to Laserfiche.
Economic Development
• ECD organized a series of meetings
between community-based organizations
and other technical assistance providers
that support small businesses with the
CDFI experts operating the FlexFund.
Meetings were aimed at answering
questions about which business owners
may best benefit, and soliciting partners to
promote the fund to businesses, and assist
with the application process if needed.
• ECD staff has been meeting one-on-one
with members of LISC (Local Initiatives
Support Corporation) first Housing Equity
Accelerator cohort aimed at providing
professional training, mentorship, and
capacity-building to real estate developers
of color as well as pre-development funding
for any affordable projects they have
planned. Several developers in the cohort
have roots in Kent and expressed interest
in finding sites to develop here.
• ECD kicked off a second phase of planning
with King County on the Kent Valley Food
Entrepreneurship Center. The second
phase of the project will focus on the
programmatic elements of a business
accelerator and facilitation of cooperative
agreements between parties interested in
supporting a food business accelerator. The
City is using Port Partnership funding
alongside City general fund matching
ADMINISTRATION
ECD
June 7, 2022
5.B
Packet Pg. 7 Communication: Chief Administrative Officer's Report (Reports from Council and Staff)
Page 2 of 11
dollars while managing partner King
County is supplying in-kind staff time and
other resources to the project.
• ECD met recently with Green River College
SBDC and their new permit specialist
working as a technical advisor to their
business advisory group. This new capacity
is a direct outgrowth of the pilot project the
City led last year to provide help for very
small businesses in tackling some of the
outset barriers to opening new commercial
spaces.
• PSRC of the Urban Land Institute
Northwest hosted an information session
on tax increment financing—a tool newly
available in this state, and how it might
intersect with transit-oriented
development. ECD staff attended as this
could support new projects in the areas
near the light rail stations currently under
construction.
• Sound Transit’s Transit Oriented
Development staff presented on outreach
and analysis work performed to date
around the Kent/Des Moines light rail
station. ECD, as well as King County
housing development staff persons, as
Sound Transit staff partners, were on-hand
to help answer questions.
The audience, which numbered over 60
people, included community-based
organizations, potential non-profit partners
(some of which are part of organizing
initiatives), as well as developers of both
affordable and market rate housing.
Building Services
• Inspectors completed 1115 inspections
during the month of May while the plan
review team reviewed 123 new applications
and an additional 55 resubmittals.
• By the end of May 2022, the Tax Division
will be implementing new electronic
working papers that are used to calculate
differences in tax, penalty, and interest
due. These are used any time an
assessment or refund is issued for City-
imposed taxes and help to ensure that
additional amounts due to the City or
refunds due back to the taxpayer are
calculated correctly. The working papers
also serve as a repository for changes to a
business’s tax returns and audit history. A
larger project is currently ongoing with IT
to incorporate the working papers into the
online B&O Tax System.
• The Consumer Price Index (CPI) is a
measure of the change in prices paid over
a time for a fixed market of goods and
services, as calculated by the U.S. Bureau
of Labor Statistics (BLS). Many
governmental entities, including the City of
Kent, use the Consumer Price Index for
Urban Wage Earners and Clerical Workers
(CPI-W) for various purposes, such as cost-
of-living adjustments (COLA) for
employees who are part of collective
bargaining agreements, automatic
increases for system charges (storm and
surface water), or certain fees or revenue
sources. The April 2022 CPI-W for the
Seattle-Tacoma-Bellevue area hit a four-
decade high of 8.5%, up from 8.1% in
February of 2022 and 6.3% in June of
2021. The City uses the June CPI-W for
calculations related to any fee or revenue
increases that are tied to CPI. This region’s
data is released every two months and the
June 2022 CPI-W is scheduled to be
released on July 13, 2022.
Information Technology Projects
• Corrections Camera Upgrade - replace the
jail’s internal analog cameras and migrate
to the digital capture, storage and
retention of the OnSSI system. Which will
then be integrated with the jail controller
and intercom.
• CUES - CCTV (Pipe Camera) GraniteNet
Upgrade - to upgrade and enhance the
capabilities and functionality of the CUES
GraniteXP software platform to GraniteNet.
By upgrading this software platform, the
City will be able to fully integrate the CUEs
and Cityworks software, configure and
automate the complete CCTV inspection
FINANCE
HR
IT
5.B
Packet Pg. 8 Communication: Chief Administrative Officer's Report (Reports from Council and Staff)
Page 3 of 11
workflow, resulting in one system of record
for City assets.
Information Technology operational support
for May 22, 2022 to May 31, 2022
• Number of tickets opened – 173
• Number of tickets closed – 265
Enterprise GIS
General:
• Continued normalization of address
database
• Working with PW to organize the GIS data-
drive
• Updating connect explorer data utilizing
new rest end point
• Supporting PD DEI officer with data
collection
• Working with Esri to complete preparation
on the rearchitect of GIS system
implementation
• Amanda stabilization
Weekly Customer Service Requests:
• Connect Explorer date update preparation
• Working with staff on various dashboard
access
• Providing customer support to help staff
connect to GIS data
• Managing Connect Explorer login access
• EGIS participating in citywide software
implementations and providing GIS support
• Assisted the HR Department in a number of
sensitive employment and labor related
matters.
• Assisted City departments in reviewing and
negotiating contract terms for a number of
contracts related to construction,
technological, and development projects.
• Assisted outside counsel on a number of
cases currently in litigation.
• Continued to help support the negotiations
with Avenue 55 for the purchase and
development of the Naden assemblage.
• A total of nine cases were set for trial the
week of May 9-13: two cases were
dismissed, one due to evidentiary issues
and one because necessary witnesses
failed to timely appear; four cases were
continued to future trial dates; one case
resulted in a guilty plea to DUI; and two
proceeded to trial, both for domestic
violence assault. Of those cases that went
to trial, one was recessed until June 13th
due to witness availability issues, and the
other resulted in a guilty verdict.
Recreation and Cultural Services
• The 2022 Summer Art Exhibit opens on
Wednesday, June 8 with a reception from
6:30-8:00 p.m. The event will feature light
refreshments, a first look at the art, and an
opportunity to meet many of the artists; it
is free and open to all. The exhibit includes
60 artworks from 33 Washington state
artists.
• Cultural Programs and Kent Commons staff
are assisting various groups (13 as of May
26) in park use and planning the
production of community events at parks
throughout the summer.
• Kent Creates exhibit, “Here Comes the
Sun” is now open through June 30. Five
winners will be selected based on Arts
Commissioner votes.
• The Youth and Teen Division has been busy
recruiting, interviewing, and hiring part-
time summer staff. Staff have attended
local hiring events, networked with high
school career specialist, conducted walk-in
interviews, posted hiring banners as well as
yard signs to get the word out about all the
wonderful summer opportunities for
children and teens. Eight summer camp
counselors have been hired and one co-
director. Still looking to fill the last camp
co-director position. Staff training will
begin in June.
• The Youth and Teen Division, in
partnership with local service clubs, held
the 2022 Fishing Experience on Saturday,
May 21, after a two-year hiatus due to
Covid. The Fishing Experience brought
together community organizations, leaders,
city departments, caring citizens, friends,
and families to give 142 children, ages 14
and under an opportunity to learn not only
how to fish but patience, coordination,
respect for nature and respect for others.
Special guests included the U.S. Coast
Guard, Puget Sound Fire Authority, and the
LAW
PARKS, RECREATION, AND
COMMUNITY SERVICES
5.B
Packet Pg. 9 Communication: Chief Administrative Officer's Report (Reports from Council and Staff)
Page 4 of 11
Kent Police Department to provide
information on water safety and
environmental stewardship to keep parks,
lakes, rivers, and waterways clean and safe
for all. Of the nearly 2000 trout planted in
the Old Fishing Hole through funding from
the Rotary Club of Kent and a donation of
1000 fish from the Washington State
Department of Fish and Wildlife, only 62
trout were caught. If you were there, you
would know success of the event was not
measured by the number of fish caught but
by laughter, smiles and happiness of the
children and their families as they worked
with caring volunteers to learn to fish. The
day also included an opportunity to win
prizes and gather “swag” to take home.
Facilities
• Detectives TI project at Centennial Center
3rd floor is at substantial completion.
Furniture is scheduled to be installed this
week. New chairs all arrived as of 4/12/22.
• Generator Building repairs are underway
and going well. There’s a slight delay due
to parts in the fire investigation, hoping to
have resolved this week. Generator 2 still
online and operational.
• Solar grant application for the Senior
Center roof was submitted last week.
• Courthouse and Corrections generator
project pre-construction meeting was last
week, and anticipated project start date is
about two weeks away. Generator lead
time is still projected at 8-12 months.
• Police HQ renovation is in progress. The
upstairs locker room is complete. Main
focus of the project is the new training
room and lunchroom space.
• Senior Center Roof is out for bid. Bids due
6/9/22.
• IT Annex remodel is out for bid. Bids due
6/16/22.
• New TLT Facilities Capital Projects
Manager, Todd Kanyer, started on 5/16/22.
Welcome Todd!
• UpKeep (CMMS) system continues to help
the team overall. Thanks again to everyone
using the system.
• Maintenance Supervisor, Tony Thiessen,
returned 6/1/22.
• Parking lot seal coating projects for the
summer are being finalized. A full list is still
forthcoming.
• EV charging station for the City Hall
campus parking garage is ordered and
install scheduled as soon as it arrives in
about three weeks. The electrical was
completed 5/10/22.
• KMP roof top unit (RTU) scheduled to be
replaced. Pending permit.
• The City entered into an IAA to work with
DES on some HVAC project coming up.
• All cooling systems are prepped and ready
to be switched over when the weather
turns a bit warmer. We’re closely
monitoring, and it seems to be about two
weeks away.
• Kent Commons gym floor scheduled to be
sanded, refinished, and restriped starting
next week, 6/6/22 to 7/8/22.
Parks Planning & Development
• The 2022 Parks and Open Space Plan is
now in the final draft phase and moving
through the Council adoption process,
which includes Parks Committee on 6/2,
Economic and Community Development
Committee on 6/13, and City Council on
6/21. Once adopted, the final plan will be
submitted to Recreation and Conservation
Office to ensure Kent Parks is eligible for
grant funding in the current year grant
cycle. A story map will be posted online to
allow the public to interface with the plan
content and track progress over the next
six years.
• The Kherson Park project bids were opened
in late May and the apparent low bid is
moving to City Council for approval on 6/7.
The project scope includes a space-themed
children’s play area with Lunar Rover
Replica, Astronaut, Lunar Lander, and
Mission Control play elements; wall
projection system; open lawn area;
lighting; and seating for day-time use.
Construction will begin in July.
• The 4th and Willis Greenways project is
nearing completion with final landscape
plantings and hydroseed complete as of
May 31. The contractor is currently working
to install the flag pole and dedication
plaque at the northeast corner with a
ceremony planned for July. Once grass is
5.B
Packet Pg. 10 Communication: Chief Administrative Officer's Report (Reports from Council and Staff)
Page 5 of 11
established later this summer, the
greenways will re-open to the public.
• Construction is anticipated to begin in early
June for the renovation of Salt Air Vista
Park. Improvements to this park include
renovated and expanded playground, new
nature-play area, nature-trail connectivity
improvements, and stormwater
improvements to prevent ongoing erosion
issues. The park will be under construction
through the summer and re-open to the
public in the fall.
Staff Changes - Hiring/Retirement/
Recruitment/ Leaves/Promotions
• Entry Level Officer Nicholas De Var started
on May 2.
• Corrections Officer John Morasco separated
May 4.
• Officer Tom Burnside retired May 15.
Significant crime activities/arrests
/investigations
• On May 10, at 1:52 pm, officers were
dispatched to Webster Court regarding
threats with a weapon. The suspect came
to the location to drop off her daughter
with the father. The father was with his
new girlfriend (victim) and an argument
began between the victim and the
suspect. The victim and suspect engaged in
a mutual physical fight which ended when
the suspect escalated the situation by
pulling out a firearm. The suspect was
arrested and booked into jail.
• On May 10, at 7:42 pm, officers were
dispatched to the Island Park Apartments
regarding a shooting. The victim stated her
adult daughter (witness) arrived at her
residence informing her that she had just
got into an argument with her girlfriend
(suspect). A few hours later the suspect
arrived at the apartment and requested to
talk to the witness. The victim confronted
the suspect in the parking lot saying that
her daughter (witness) was not going to
come out and talk to her. The conversation
turned into an argument at which point the
victim said to the suspect, “I’ll die behind
my kids.” This prompted the suspect to pull
out a firearm and say, “I’ll kill you.” The
suspect then fired multiple rounds into the
air. During this altercation, the witness
came out of the apartment and watched
what occurred. The victim backed away
into her residence while the suspect and
witness left in a vehicle. Detectives are
investigating.
• On May 12, at 4:50 pm, officers were
dispatched to an armed robbery at the
Grocery Outlet located at 26104 Pacific
Hwy S. The suspect had been in the store
shoplifting. When the suspect started to
walk out with the stolen items and was
confronted by employees; the suspect
pulled out a handgun. The employees
backed off and the suspect left the area
with the stolen items. Detectives are
investigating.
• On May 12, at 5:50 pm, officers were
dispatched to a threats with a weapon at
Deals Auto Sales located at 622 Central
Ave S. The suspect had arrived in a white
SUV and was inquiring about the price of a
couple vehicles on the lot. The suspect
asked the employee to check out his white
SUV which prompted the employee to open
the back hatch. The suspect asked the
employee why he had opened the trunk
and said that he was going to kill him. The
suspect pulled out a handgun and pointed
it at the employee. The employee backed
away with his hands up and the suspect
fled the area in the white SUV. Detectives
are investigating.
• On May 12, at 11:48 pm, officers were
dispatched to a physical domestic between
roommates in the 27600 block of 123rd Ave
SE. Dispatch advised that CPR was being
performed on one of the involved parties.
The suspect was the person performing
CPR on the victim. The suspect was
detained, fire responded to provide medical
attention, but the victim did not survive his
injuries. The suspect confessed that he got
into an argument with his roommate and
punched him several times knowing that he
just killed him. The suspect was booked
into jail.
• On May 17, at 11:26 am, officers were
dispatched to the Phoenix Court
Apartments regarding a shooting. An off-
duty officer working security was parked
POLICE
5.B
Packet Pg. 11 Communication: Chief Administrative Officer's Report (Reports from Council and Staff)
Page 6 of 11
near the office when he heard what he
believed to be fireworks. The officer saw a
subject near the office and confronted
him. The subject pulled out a rifle and
began firing in the direction of the
officer. When the subject fled the area, he
gave chase and confronted the suspect a
second time. This prompted the suspect to
point the rifle again at him. An extensive
search was conducted, but the suspect was
not located. Detectives are investigating.
• On May 18, at 4:18 pm, officers were
dispatched to the Pines Apartments
regarding a threat with a weapon. The
victim, a tow truck driver, was sent to the
apartment complex to tow vehicles
requested by management. When he was
hooking up one of the vehicles, the suspect
came out with a handgun demanding he
drop the vehicle. The victim eventually
complied and 911 was called. The suspect
was on scene and pointed out to the
officers. This prompted the suspect to run
on foot but was later captured. Officers
located the handgun used as the suspect
attempted to hide it while he was running
from them.
• On May 20, at 7:58 am, officers were
dispatched to the Indigo Springs
Apartments. An apartment window was
broken out and the person inside the
apartment appeared to be
deceased. Officers saw a significant
amount of money and drugs. The body of
the deceased did not have any signs of
trauma that would be considered a cause
of death. Officers collected and seized five
firearms, $167K in cash, and over 95
pounds of narcotics which included heroin,
methamphetamine, cocaine, and fentanyl.
• On May 21, at 10:00 pm, officers were
dispatched to an illegal discharge at the
City Zen apartments. They located
numerous spent casings in a stairwell. On
May 22, at 2:19 am, officers were
dispatched to the same location for a
shooting. They located a victim who had
gunshot wounds to both arms. The victim
provided context to what occurred during
both incidents. He admitted to being the
person who fired off rounds during the first
incident and then left. When he returned,
he was confronted by the individuals at the
party, and someone shot him. Detectives
are investigating.
• On May 23, at 11:31 am, officers were
dispatched to the Hometowne Suites
located at 25104 Pacific Hwy S regarding
CPR in progress on a 2-year-old child. After
the officers were on scene, the child passed
away. There already was an open CPS
referral regarding the child being allegedly
abused by his parents. The cause of death
is unknown at this point. Detectives are
investigating.
• On May 26, at 8:59 pm, officers were
dispatched to the 24400 block of 94th Ave S
regarding threats with a weapon. A subject
had pointed a rifle at his parents after
physically assaulting them. The parents
relayed their adult son had been suffering
from some sort of undiagnosed mental
health issue and had been acting strange
inside their home. When the mother
confronted him, she was assaulted. The
incident progressed when their adult son
armed himself with a .22 rifle and was
aiming it at his father in the driveway. The
subject was taken in custody. On May 28,
officers responded again to this residence
after the male was released from King
County Regional Justice Center and walked
home. He was destroying his father’s
property. The male was arrested for
Malicious Mischief and booked into the City
of Kent Correctional Facility.
• On May 29, at 1:15 am officers were
dispatched to a large fight at Gators Sports
Bar. Fights started over a patron not
paying her $249.00 bill. She assaulted an
employee. Another male out in the parking
lot was assaulted by five other males.
Another patron tried to assist and was
assaulted and transported to hospital for
fractures to face. Detectives are
investigating.
• On May 29, at 11:35 am, officers were
dispatched to Tractor Supply regarding a
shooting. A subject had been run over with
a vehicle and then gun shots were heard.
No one associated with the incident was
located, but they did find spent casings in
the parking lot. A short time later patrol
received a call from the alleged victim who
5.B
Packet Pg. 12 Communication: Chief Administrative Officer's Report (Reports from Council and Staff)
Page 7 of 11
was at his residence in the 700 block of 5th
Ave S. He had a gunshot wound to the arm
and claimed he had been robbed across the
street at the Denny’s. The victim was taken
to Harborview Medical center. Detectives
are investigating.
• On May 30, at 1:44 pm, officers
investigated a juvenile male spray-painting
gang tags on the 7-11 building at 104th and
240th St. After contacting him, he ran east,
and he confronted unknown subjects from
a rival gang. We heard gun shots and saw
him running through the parking lot of
Value Village. The juvenile was contacted
and said one of the rival gang members
had a machete and tried to assault him
with it. Someone fired two shots and he
was grazed in the inner thigh. The juvenile
was transported to Valley Medical Center
for treatment. Detectives are investigating.
Events and awards
• Letter of Commendation:
o On February 3, 2022, Officer Jason
Nixon was investigating an abandoned
stolen vehicle that had been left in the
westbound lanes of travel on Canyon
Drive near the intersection of 94th Ave.
S. At the conclusion of his investigation
a tow truck was called to impound the
stolen vehicle. The tow truck was
unable to lift the vehicle from the front
and as it moved away to reposition to
the back, the vehicle began rolling down
Canyon Drive. Officer Nixon quickly
raced to get ahead of the runaway
vehicle and slowed down in front of it to
block it, allowing it to rear-end his
patrol vehicle and come to a stop about
100 feet away. Officer Nixon was
commended for his quick thinking to
prevent the vehicle from going down
the hill. The vehicle would have likely
picked up an excessive amount of speed
if it had been allowed to continue rolling
down the hill which could have resulted
in a catastrophic head on collision with
other motorists. The actions of Officer
Nixon exemplify our department’s
mission statement of protecting and
caring for people in our community and
our value of service.
o On January 24, 2022, Officer Garrett
Gunderson and Detective Nick Grave
investigated a report of an allegation of
child molestation. Officer Gunderson
conducted his initial investigation in the
middle of the night, determining the
extent of a horrific allegation of sexual
abuse of a child by a trusted family
member. Officer Gunderson established
a rapport with the family, a timeline of
suspected abuse, and ensured the
safety of the victim. Officer Gunderson
and Detective Grave arranged a forensic
interview of the initial identified child
victim in this case, obtaining significant
disclosures of historic and on-going
sexual assault. Detective Grave
recorded an interview in which the
suspect admitted to multiple incidents
of sexual assault against the child victim
from this case. Detective Grave
subsequently took the suspect into
custody and he was booked into the
King County Jail. Detective Grave
continued his investigation after the
arrest as he suspected the suspect
likely had sexually assaulted and/or
molested other individuals. Detective
Grave confirmed the existence of a
second victim and filed his case with the
King County Prosecutor's Office
charging the suspect with multiple
crimes. Detective Grave made sure the
victims and their families were
connected to outside resources to
obtain services to assist in the
beginning of the healing process for
these child victims. Detective Grave and
Officer Gunderson are commended for
their dedication to the victims in this
case, a thorough investigation, and
attention to detail which ultimately led
to the capture and confession of a child
sexual predator. The success of this
collaborative investigation is a
testament to Detective Grave and
Officer Gunderson's commitment to
protecting the citizens of Kent and is in
keeping with the highest standards and
traditions of the Kent Police
Department.
5.B
Packet Pg. 13 Communication: Chief Administrative Officer's Report (Reports from Council and Staff)
Page 8 of 11
o On March 9, 2022 at 11:57 pm, Officer
Jordan Axelson arrived with other
officers at a physical domestic in
progress, where the 15-year-old
daughter was calling to say her
stepfather had assaulted her mother.
The mom was being held against her
will upstairs by dad. Officers were able
to get mom to crawl out to them and
they set up a defensive position at the
front door when dad refused to come
out. Officer Axelson noted the obvious
injuries to the female and developed PC
to arrest the male. He quickly wrote a
search warrant to go inside and get the
male. After the male was arrested,
Axelson went to the hospital to
interview the victim. The interview
along with the victim's extensive
injuries enabled Officer Axelson to
charge the suspect with multiple
felonies. Officer Axelson was
commended for his extremely thorough
and well documented work on this case.
Officer Axelson exemplifies our
department’s mission of protecting and
caring for people in our community, our
value of service, and our vision of
improving the lives of our community
members.
Land Survey/PW GIS
• Land Survey field staff are fulfilling internal
requests for mapping on: Mill Creek re-
establishment, 224th phase III and the
Washington Ave. pump station. Office staff
are preparing legal descriptions for the
Little property and the 224th phase III ROW
(Right of Way). Record of Surveys (ROS)
are being prepared for recording at King
County for portions of Kent Kangley Rd.,
Reith Rd. and the 228th St. corridor.
• Public Works GIS staff have supported the
Cityworks software update, GIS Server
upgrade and have been coordinating with
EGIS on data and service management. A
vegetation dashboard is being built and
tested for the Streets Department. Private
development project as-builts are current
with exception of some with deferred
easement recordings. A handful of legacy
CIP projects are being verified for current
locations & relevant data. Public Records
requests are being facilitated as they are
received by multiple PW GIS staff. Staff
continue support of PW Operations staff
projects and Cityworks.
Design
• 76th Ave North: advertisement scheduled
for June 14. WSDOT has certified Right-of-
Way. Sent documents to WSDOT to
obligate construction funds.
• Linda Heights Pumpstation: working to
finalize site layout to begin permitting
processes. 60% package distributed for
review May 19. Comments due June 3.
• Meet Me on Meeker Kent Elementary
Frontage (Design Only): Sent documents to
WSDOT to obligate design funds
(Transportation Alternatives Program - TAP
grant).
• Mill Creek Reestablishment: channel
reestablishment/mitigation and utility
relocation designs and coordination at Little
property underway.
Construction:
• West Hill Reservoir: tank – layout and
fabrication of roof continues. Roof set
scheduled for morning of Friday, June 24.
Welding roof angle on upper tank ring
where roof will set. Layout and installation
of spiral staircase and other tank
appurtenances continues.
Chlorination/Control building – interior
electrical work continues this week. Metal
roofing installed. 38th Ave S is closed
between S 248th St and S 247th St for the
duration of the project. Pedestrian access
through this closure will be maintained.
• 2021 Asphalt Overlays: permanent
channelization continues at various
locations at night this week as weather
permits. Paving of 94th completed week of
5/31. Raising of hardware to follow.
• S. 212th St. preservation (Green River
Bridge to Orillia Rd/Kent city limits):
Council has authorized the award of this
project to Lakeside Industries of Covington,
WA. The contract is executed and we are
working on scheduling the preconstruction
meeting. Notice to proceed is anticipated
on Monday, June 13.
PUBLIC WORKS
5.B
Packet Pg. 14 Communication: Chief Administrative Officer's Report (Reports from Council and Staff)
Page 9 of 11
• PSE/Asplundh 2022 franchise routine
maintenance permit – annual tree
maintenance within the city limits will be
ongoing for the next several weeks.
Environmental
• Lakes Monitoring: City helping King County
Lakes Stewardship staff look for volunteers
for Lake Fenwick to do the water sampling.
We need someone with access to a boat
and a few hours each month.
• Mayor’s Homeless Outreach Team/On-Call
Garbage Contract: the Mayor’s Homeless
Outreach Team met on Wednesday, May
25th when staff was able to provide updates
on hot spot areas Public Works is working
in including 196th and 72nd, Downey and
Frager, Veteran’s Drive, McSorley, and
others. Police, PWO staff, and Totem
Logistics met on site at Veteran’s Drive
Tuesday, May 31 to post camp sites and to
get an estimate on how much it would be
to clean up the camps.
• 2022 Recycle Collection Events: the next
recycle event is Saturday, June 4 at Kent
Phoenix Academy, on the East Hill, from 9
am to 3 pm. Items collected will include:
appliances, batteries, bulky wood/yard
debris, cardboard, CFC appliances,
concrete, brick, rock, documents for
shredding, electronics, mattresses,
propane tanks, porcelain, scrap metal,
styrofoam, textiles. Event brochures will be
mailed to 63,000 households this week.
This is a free event to all residents. Full
details can be found on our website
www.kentwa.gov/talkingtrash.
• Freeway on/off ramp cleanup: the on and
off ramps of I-5 and Hwy 167 have been
collecting litter for several years with the
pandemic. Staff requested the Ecology
South King County Litter Crew come out to
clean up those state-owned areas. The
crew of three people will be out for a few
days over the next couple of weeks to
clean the on and off ramps of I-5 at S
272nd St and Kent Des Moines Road.
Streets
• Street maintenance performed sidewalk
grinding on S 194th St, stripped forms,
prepped for pour, poured new sidewalks
and backfilled sidewalks on 64th Ave S
between S 231st St and S 228th St, prepped
and paved an asphalt pad for water at
KEHOC, replaced bollards on SE 206th Pl,
repaired a monument on SE 228th St,
swept sidewalks on Central Ave S, repaired
a shoulder on 79th Ave S, prepped a
shoulder for paving on SE 256th St, swept
the roadway on SE 207th St, placed
messaging boards on Military Rd S and
prepped for paving at the shop yard.
• Signs and Markings installed bases on
Veteran’s Dr, signs on Canyon Dr, bases
and signs on 42nd Ave S, took inventory
and updated the GIS system Citywide and
performed sign maintenance on the East
Hill, Valley South and Valley North areas.
Crews also ordered some barricades in
preparation for Cornucopia Days.
• Solid Waste cleaned up debris in several
locations including along SE 280th St,
Pacific Hwy S, 116th Ave SE, 152nd Ave SE,
104th Ave SE, S 252nd St and along Kent
Kangley Rd.
• Water Vegetation mowed and line trimmed
multiple locations such as at the 108th well,
208th well, Garrison Creek well, pump
station #4, pump station #5, Kent Springs,
Guiberson Corrosion Facility, the 3.5 tank,
the Renton Inter-tie, the West Hill sites and
at the water section vactor site along 114th
Ave SE.
• Street Vegetation staff worked on traffic
island beautification including pulling
weeds, spot spraying, and removing litter
from the traffic islands on Pacific Hwy S, SE
256th St, Kent Kangley Rd, S 204th St, W
Valley Hwy, 4th Ave N, SE 223rd Dr and W
James St. Crews also mowed, line-trimmed
and spot sprayed along the roadways in
several locations including along SE 256th
St, SE 208th St, S Reith Rd, N Lincoln Ave
and 64th Ave S.
• The Sidearms mowed on 152nd Ave SE,
108th Ave SE, 116th Ave SE, 124th Ave SE,
E Guiberson St, Frager Rd, SE 274th Way,
132nd Ave SE, SE 256th St, S 208th St,
Benson Hwy, S 212th St, Riverview Blvd S
and on Reith Rd. Crews also worked on
finishing the fence on 113th Ave SE.
• Wetland Mitigation crews focused on line
trimming at the bike path, KOA, 72nd Ave
and Frager Rd sites, removing litter from
the Downey, Leber and Hytek sites and
5.B
Packet Pg. 15 Communication: Chief Administrative Officer's Report (Reports from Council and Staff)
Page 10 of 11
spraying the weeds at the Barn Rd
Mitigation and Frager Rd sites. Staff also
transplanted seedlings, fertilized and
removed weeds at the GRNRA Nursery.
• Wetland Maintenance mowed and line
trimmed at the 196th Corridor Wetland on
72nd Ave S, Twin Creeks and Kent Meridian
Place on 132nd Ave SE, Country Club North
on 136th Ave SE, Chelmsford A, B and C
and Birdsong Meadows on 116th Ave SE,
Gages Grove on SE 235th St, Glencarin
Trace on 121st Pl SE, Linda Highlands A and
B on 127th Ln SE, Linda Crest A and B on
SE 201st Pl, Maplewood Grove on 108th Ave
SE, Redondo on 27th Ave S, Signal Electric
on 3rd Ave S, 72nd Ave Diversion Channel
on 72nd Ave S and at Horseshoe Bend on
80th Ave S.
• Holding Pond crew mowed and line
trimmed at Stillwater Div 1 and 2 on 127th
Ave SE, Canterbury Glen (Locust Lane) on
SE Kent Kangley Rd, Hazelnut Grove
Townhomes (Meridian Meadows) on SE
268th St, Sun Meadows #1 and Taco West
Building (Brossard) on SE 277th Pl, Sun
Meadows #2 on SE 249th Pl, Sun Meadows
#3 on SE 282nd Way, Cantera on SE 278th
Pl and on SE 280th St, Kentridge Estates #4
and #5 on 123rd Pl SE, Andrew’s Landing
on SE 277th St, Springwood Park on SE
274th St and at Hycroft on 126th Pl SE.
Crews also cleared trash and debris and
trimmed bushes at various pump stations
such as the Horseshoe Storm pump station
on S Central Ave, 3rd Ave pump station on
3rd Ave S, Washington Ave pump station on
S 251st St, James pump station on E James
St, Uppermill Creek Storm pump and
Uppermill Sewer pump station on 104th Ave
SE, Lindental pump station and the
easement on 118th Pl SE, Union Pacific
pump station on S 260th St, 81st Ave pump
station on 81st Ave S, 84th Ave pump
station on 84th Ave S, Foster Park pump
station on 74th Ave S, Linda Heights PS on
S 248th St, Skyline pump station on S 222nd
Pl, Victoria Ridge pump station on S 272nd
Pl, Fenwick pump station on Lake Fenwick
Rd, Frager pump station on Frager Rd S,
Kentview pump station on Frager Rd and
the 64th Ave pump station on 64th Ave S.
Water
• Staff have worked on wrapping up the
water main installation portion of the S
268th St Shops Inc. project on the West
Hill. Pressure testing, water purity
sampling, and water service renewal are
next up to complete the project. Staff
continued to work on fire hydrant repairs
from vehicle incidents. Back-ordered parts
have been received for a programable logic
controller upgrade at our pump station no.
7 and replacement is underway.
Storm/Sewer
• Storm crews installed a culvert and catch
basin at 934 3rd Ave S and bollards on SE
260th St, cleaned storm outfalls on S 218th
St, performed ditch maintenance on 132nd
Ave SE, SE 224th St and at the 277th
corridor, cleaned storm lines on 132nd Ave
SE, SE 220th Pl and E Smith St, performed
shoulder blading at 25007 146th Ave SE,
assessed and took inventory of ditches on
SE 231st St and on S 204th Pl, performed
hydro-excavation and repairs to a catch
basin on SE 206th St and installed signs at
the Vactor site. Crews also performed
National Pollutant Discharge Elimination
System (NPDES) assessing on SE 226th St,
118th Pl SE and SE 234th St, pumping on SE
256th St, SE 231st Way, S 204th Pl and SE
235th St and repairs at locations Citywide.
• Sewer crews TV’d for 2023 overlays
between 113th Ave SE and 109th Ave SE, in
the Wildwood Estates neighborhood around
SE 231st St and the sewer and storm lines
in the Fox Subdivision neighborhood
around 107th Pl SE, they cleaned existing
sewer lines with the Vactor between SE
240th St and SE 256th St from 116th Ave SE
to 124th Ave SE, performed manhole
vacuum tests at Skyline at 3301 S 222nd Pl
and manhole repairs on 84th Ave S, Central
Ave S and on 68th Ave S, replaced a section
of pipe on W Meeker St, performed frame
and lid inspections Citywide, changed lube,
oil and filters on station generators at
various pump stations throughout the City
and hauled spoils to Cedar Hills.
Fleet/Warehouse
• The Warehouse crew prepared supplies for
and will be assisting with the recycle event
at Phoenix Academy on 6/4/22, continued
5.B
Packet Pg. 16 Communication: Chief Administrative Officer's Report (Reports from Council and Staff)
Page 11 of 11
to assist with CDL training, maintained the
shops yard, keeping it clean and free of
litter and debris, cleaned and maintained
the wash rack, washed and vacuumed
motor pool vehicles, issued Personal
Protection Equipment (PPE’s) and motor
pool vehicles to staff and hydrant meters
and public notice boards to contractors,
repaired small equipment as needed,
received parts and inventory orders, hauled
spoils as time and equipment were
available and continued to manually open
and close the broken East Gate daily and
locked and unlocked the gates in the
employee south parking lot at the
beginning and close of the work day.
• Fleet staff prepared items for auction,
worked on adding racks and moving
inventory to the other shop, installed
emergency lights on a used truck for the
Special Emphasis crew, worked on mower
and Vactor repairs, ordered and received a
new walk behind mower for Streets and a
new mower for Parks and worked on
scheduled and non-scheduled maintenance
and repairs. Other techs also programmed
UID numbers and lightbars for Radio while
the Radio Tech position is being
determined.
###
5.B
Packet Pg. 17 Communication: Chief Administrative Officer's Report (Reports from Council and Staff)
Pending Approval
City Council Workshop
Workshop Regular Meeting
Minutes
May 17, 2022
Date: May 17, 2022
Time: 5:00 p.m.
Place: Chambers
I. CALL TO ORDER
Councilmember Michaud called the meeting to order.
Attendee Name Title Status Arrived
Bill Boyce Council President Excused
Brenda Fincher Councilmember Present
Satwinder Kaur Councilmember Present
Marli Larimer Councilmember Present
Zandria Michaud Councilmember Present
Toni Troutner Councilmember Present
Les Thomas Councilmember Present
Dana Ralph Mayor Present
II. PRESENTATIONS
1 2022-2027 Parks and Open Space Plan
- Final Draft
Terry Jungman 45 MIN.
Parks, Planning and Development Manager, Terry Jungman presented the
Council with the Kent Parks and Open Space Plan 2022.
Jungman advised this is the final presentation on Parks and Open Space Plan
after over a year of work on this plan. Jungman expressed appreciation of
the City’s consultants, staff and advised this plan is a reflection of what the
City heard from the community. Jungman advised the Kent School District
supports this plan.
Jungman reviewed the project process that included an overall timeline and
distinct phases. There was lots of information collection, engagement and
collected data statistics behind the engagement. The City now has over
3,000 touch points with the community.
The City did Geospatial mapping and has a full inventory of assets in GIS.
The City is currently in the Reporting and Final Engagement phase of the Plan
that covers where we are going and how we get there.
Jungman talked about the details of studying the system, including
benchmarking using the 2021 National Agency Performance Review that
8.A.1
Packet Pg. 18 Minutes Acceptance: Minutes of May 17, 2022 5:00 PM (Approval of Minutes)
City Council Workshop Workshop Regular
Meeting
Minutes
May 17, 2022
Kent, Washington
Page 2 of 4
represents a broader set of data that was not used during the creation of the
2016 plan.
Jungman talked about the traditional level of service in comparison to the
performance-based levels of service. The City needs to look at both
traditional and performance based levels of service to develop a plan that
covers reinvestment, maintenance, development and acquisition.
Jungman talked about the geospatial mapping and layers of information to
inform strategic projects and potential areas of acquisition.
The Nature Score for amenity top priority investments was reviewed.
Next Steps:
Secure funding for Natural Resource Management
Update scoring and tie to geospatial mapping
The Athletic Capacity Study data was reviewed and Jungman advised the City
needs to focus investment in horizonal field space and also talked about how
to solve the problem of athletic field capacity.
Strategic moves could include:
· Targeted potential Kent School District partnerships
· Conversions from natural grass to synthetic turf
· Smaller fields for youth sports
· One use type - overlays
· Upgrade lighting
· Opportunistic land acquisitions
The goals of strategizing projects include:
Transparency and Communication
Physical access for all
Diversity of high-quality amenity
System resiliency
Outcomes include: access, programming, natural resources, athletics,
operations and maintenance, equity, strategic amenities, trails and
partnerships
Jungman talked about project priorities for near, mid and long-term projects
for the West Hill, Downtown Region, Green River Region, East Hill South
Region and East Hill North Region.
Jungman covered funding:
· Capital reinvestment and operating and budget that meets need and demand
· Operating budget that fails to meet need and demand
· Capital reinvestment that fails to meet needs and demand
8.A.1
Packet Pg. 19 Minutes Acceptance: Minutes of May 17, 2022 5:00 PM (Approval of Minutes)
City Council Workshop Workshop Regular
Meeting
Minutes
May 17, 2022
Kent, Washington
Page 3 of 4
Jungman detailed the Capital funding need per year to maintain the existing
system, to implement new capital projects, the current funding and total
needed to implement all projects in the 2022 Parks and Open Space Plan (an
additional $4M per year).
Jungman detailed the operating and maintenance funding needed per year
for proposed strategic projects - current and to implement new capital
projects (an increase of $300k every other year).
Jungman advised that one option to fill the City’s current operating and
maintenance and capital funding is for a voter-approved levy or voter-
approved Park District.
Jungman covered the next steps that will include:
Finalizing a Story map
Acquiring asset management software
Additional funding for operating and capital budgets
Nature score methodology
Goals and polices update
Hire full-time GIS position
Kent School District partnership
Parks strategic framework
CPRA accreditation
Michaud expressed appreciation of the Kent School District for their support
and for the entire Parks Department for their work on this plan.
2 Budget Discussion Paula Painter 45 MIN.
Finance Director, Paula Painter opened the budget presentation by talking
about factors impacting the 2023-2024 Biennial Budget.
Painter talked about the unexpected increasing inflation rates that are
hovering around 8%. The CPI is tied to salaries and benefits and employee
contracts. Personnel Costs are uncertain due to upcoming labor negotiations
and a non-represented salary.
Painter covered major general fund revenues. Twenty-five percent of the
General Fund is property tax which capped at 1% growth with new
construction.
Constraints include growth in property tax compared to growth in
expenditures.
Painter reviewed sales tax numbers and compared 2019-Feb, 2022.
8.A.1
Packet Pg. 20 Minutes Acceptance: Minutes of May 17, 2022 5:00 PM (Approval of Minutes)
City Council Workshop Workshop Regular
Meeting
Minutes
May 17, 2022
Kent, Washington
Page 4 of 4
The General Fund forecast was reviewed that did not include projections for
salaries and benefits. Ending in 2021 the City had a 44M fund balance.
Other factors that will affect the 2023-2024 budget include:
Insurance funds - rapid increases in expenditures
Fleet allocation
Other internal fund allocations
Internal cost allocation
During the Council’s retreat, the following direction was provided:
· Community engagement budget roadshows
· Preserve and protect core services that the City must provide
· No new initiatives or staff
· No new taxes or unplanned increases to taxes
· Use of some fund balance to preserve programs and services
Painter reviewed current and proposed splits of revenue and provided
forecasts if the revenues were shifted:
· Property Tax
· Sales Tax
· Utility tax - Internal
· B&O Tax
· REET
Pros:
· The majority of the revenue sources in the General Fund will be more aligned
with inflation
· Still gives us a consistent revenue stream to maintain capital funding
· Revenues will remain constant in times of recession - property taxes are a
source of stability
· Slows the growth of the capital program.
Painter indicated code amendments to taxes will need to be made to ensure
council’s intent for revenues are still being met.
Painter reviewed the 2023-2024 timeline for a status quo budget that will
include tapping into the fund balance.
Meeting ended at 6:05 p.m.
Kimberley A. Komoto
City Clerk
8.A.1
Packet Pg. 21 Minutes Acceptance: Minutes of May 17, 2022 5:00 PM (Approval of Minutes)
Pending Approval
Kent City Council
City Council Regular Meeting
Minutes
May 17, 2022
Date: May 17, 2022
Time: 7:01 p.m.
Place: Chambers
1. CALL TO ORDER/FLAG SALUTE
Mayor Ralph called the meeting to order.
2. ROLL CALL
Attendee Name Title Status Arrived
Dana Ralph Mayor Present
Bill Boyce Council President Present
Brenda Fincher Councilmember Present
Satwinder Kaur Councilmember Present
Marli Larimer Councilmember Remote
Toni Troutner Councilmember Present
Les Thomas Councilmember Present
Zandria Michaud Councilmember Present
3. AGENDA APPROVAL
A. I move to approve the agenda.
RESULT: MOTION PASSES [UNANIMOUS]
MOVER: Bill Boyce, Council President
SECONDER: Les Thomas, Councilmember
AYES: Boyce, Fincher, Kaur, Larimer, Troutner, Thomas, Michaud
4. PUBLIC COMMUNICATIONS
A. Public Recognition
i. Proclamation for National Police Week
Mayor Ralph presented the Proclamation for National Police Week to Chief
Rafael Padilla. Chief Padilla accepted the Proclamation and expressed words
of appreciation for law enforcement personnel.
ii. Proclamation for National Public Works Week
Mayor Ralph presented the Proclamation for National Public Works Week to
Public Works employees Kalyn Auelua and Etuate Lolohea.
iii. Proclamation for Women in Aerospace Day
Mayor Ralph presented the Proclamation for Women in Aerospace Day to
Nikki Malcom, Chief Executive Officer and Executive Director of the NW
8.A.2
Packet Pg. 22 Minutes Acceptance: Minutes of May 17, 2022 7:00 PM (Approval of Minutes)
Kent City Council City Council Regular Meeting
Minutes
May 17, 2022
Kent, Washington
Page 2 of 8
Women's Alliance.
iv. Appointment to the Civil Service Commission
Mayor Ralph recognized Pauline Thomas and requested the Council confirm
Pauline Thomas to the Civil Service Commission.
B. Community Events
Council President Boyce advised of upcoming events at the accesso ShoWare
Center.
Councilmember Fincher advised of the May 20th mini recycling event at the
Kent United Methodist Church
Councilmember Kaur invited the public to attend the raising of the Pride flag
event at 2 p.m. on June 1st.
C. Public Safety Report
Chief Padilla gave the Public Safety Report and advised he presented
Lifesaving awards to Sergeant Koehler and Officer Cortinas.
Chief Padilla presented Exceptional Duty awards to Sergeant Butenschoen,
Sergeant Johnson, Officer Flesher and Officer Holloman.
Chief presented a Citizen Commendation to Scott Kober, from Super Jump
for
his professionalism and genuine care for the public.
Chief Padilla provided details on the current status of hiring and recruiting.
Since 2021, the 23 officers voluntarily resigned or retired early.
Since 2021, the City has have hired 23 officers.
Chief Padilla advised he plans on focusing on recruiting and retention.
• Kent offers the best salary and benefit package in the state
• Hiring incentives
• The City has added recruiting personnel
• The Police Department has a new approach to recruiting diversity and women
candidates
• Emphasis in in-person relationship building with candidate, get candidates
and keep them connected, be everywhere in the community
• Added resources - Partnership with Communications and Multimedia
Chief invited the public to attend Coffee with the Chief on May 18th at Macrina
Bakery from 8-10 a.m.
5. REPORTS FROM COUNCIL AND STAFF
8.A.2
Packet Pg. 23 Minutes Acceptance: Minutes of May 17, 2022 7:00 PM (Approval of Minutes)
Kent City Council City Council Regular Meeting
Minutes
May 17, 2022
Kent, Washington
Page 3 of 8
A. Mayor Ralph's Report
Mayor Ralph attended the South King Transportation Board meeting that
received a presentation from Metro on their transition to zero emissions, and
fare enforcement/reform.
Mayor Ralph provided an update on the Regional Transportation Policy
council that is preparing for the renewal of the Veterans and Human Services
Levy.
Mayor Ralph advised the Kent Kiwanis Club received a presentation from
Judge Matthew York to discuss the implementation of community court at the
district court level.
Mayor Ralph expressed appreciation of the Kent Bicycle Advisory Board and
Public Works Transportation staff for hosting the bicycle rodeo and helmet
give-away.
B. Chief Administrative Officer's Report
Interim Chief Administrative Officer, Pat Fitzpatrick advised his report is in
today’s agenda packet and there is an executive session tonight relating to
litigation, is expected to last 10 minutes with no action following the session.
C. Councilmembers' Reports
Council President Boyce provided a recap of today's Operations and Public
Safety Committee meeting agenda items.
Councilmember Michaud provided a recap of today's workshop agenda items.
Michaud serves on Kent’s Human Services Commission and advised of the
agenda items that included reviewing grant applications in addition to going
through equity training with consultants. The Commission added community
members to help with evaluating applications.
Councilmember Kaur serves on K4C that recently discussed Target zero.
Heat and electric pump requirements and waste management were
discussed.
Kaur serves on the Domestic Violence Initiative Task Force that discussed
HB1901 and 1320 relating to protection orders.
Kaur serves as the Chair of the Puget Sound Clean Air Agency that recently
discussed the Strategic Plan draft. Kaur provided details on all presentations.
Councilmember Troutner serves as the Chair of the City's Economic and
Community Development Committee and provided a recap of recent agenda
items.
8.A.2
Packet Pg. 24 Minutes Acceptance: Minutes of May 17, 2022 7:00 PM (Approval of Minutes)
Kent City Council City Council Regular Meeting
Minutes
May 17, 2022
Kent, Washington
Page 4 of 8
Councilmember Thomas serves on the Puget Sound Regional Fire Authority
Governance Board that is currently reviewing goals and objectives.
Councilmember Fincher serves as the Chair of the Public Works Committee
and provided a recap of the recent agenda items.
Fincher serves on the Kent Arts commission and provided details on the
upcoming summer concert series and also talked about the current art
contest titled "Here comes the Sun"
6. PUBLIC HEARING
I move to close the public hearing.
There were no public comments.
RESULT: MOTION PASSES [UNANIMOUS]
MOVER: Bill Boyce, Council President
SECONDER: Les Thomas, Councilmember
AYES: Boyce, Fincher, Kaur, Larimer, Troutner, Thomas, Michaud
A. Public Hearing on the 2023-2028 Transportation Improvement
Program - Adopt
Mayor Ralph provided an overview of the public hearing process and opened
the public hearing.
Transportation Engineering Manager, Rob Brown gave the staff presentation
on the 2023-2028 Six-Year Transportation Improvement Program.
Brown advised the Plan is a short range planning document that is to be
updated annually and declares list of projects, plans and programs by year.
Brown details the projects removed, projects changed and plans added.
Following the adoption of the Transportation Master Plan, the 2022-2027 TIP
was a major revision to align our short-term program with our new long-term
Program. This year’s TIP update is a minor revision the City’s short-term
program.
MOTION: I move to adopt Resolution No. 2044, adopting the
2023-2028 Six-Year Transportation Improvement Program.
8.A.2
Packet Pg. 25 Minutes Acceptance: Minutes of May 17, 2022 7:00 PM (Approval of Minutes)
Kent City Council City Council Regular Meeting
Minutes
May 17, 2022
Kent, Washington
Page 5 of 8
RESULT: MOTION PASSES [UNANIMOUS]
MOVER: Brenda Fincher, Councilmember
SECONDER: Satwinder Kaur, Councilmember
AYES: Boyce, Fincher, Kaur, Larimer, Troutner, Thomas, Michaud
7. PUBLIC COMMENT
None.
8. CONSENT CALENDAR
RESULT: APPROVED [UNANIMOUS]
MOVER: Bill Boyce, Council President
SECONDER: Les Thomas, Councilmember
AYES: Boyce, Fincher, Kaur, Larimer, Troutner, Thomas, Michaud
A. Approval of Minutes
1. Council Workshop - Workshop Regular Meeting - May 3, 2022 5:00 PM
2. City Council Meeting - City Council Regular Meeting - May 3, 2022 7:00
PM
B. Payment of Bills - Authorize
MOTION: I move to authorize the payment of bills received
through 4/30/22 and paid on 4/30/22 and authorize the
checks issued for payroll 4/16/22-4/30/22 and paid on
5/5/22, all audited by the Operations and Public Safety
Committee on 5/3/22.
C. Appointment to Civil Service Commission - Confirm
MOTION: I move to confirm the Mayor’s appointment of Pauline
Thomas to an initial six-year term on the Civil Service
Commission that will begin on May 1, 2022 and end on April 30,
2028.
D. Lodging Tax Grant Applications & Funding Levels as
Recommended by the Lodging Tax Advisory Committee -
Approve
MOTION: I move to authorize the Council award a total of $200,000
to the 2022 Lodging Tax Advisory Grant Applicants at funding levels
identified by the Lodging Tax Advisory Committee.
E. Consolidating Budget Adjustment Ordinance for Adjustments
between January 1, 2022 and March 31, 2022 - Adopt
8.A.2
Packet Pg. 26 Minutes Acceptance: Minutes of May 17, 2022 7:00 PM (Approval of Minutes)
Kent City Council City Council Regular Meeting
Minutes
May 17, 2022
Kent, Washington
Page 6 of 8
MOTION: I move to adopt Ordinance No. 4429, consolidating
budget adjustments made between January 1, 2022 and March
31, 2022, reflecting an overall budget increase of $11,636,600.
F. Consultant Services Agreement with Consor North America,
Inc. DBA Murraysmith, Inc. for the Sanitary Sewer Comp Plan -
Authorize
MOTION: I move to authorize the Mayor to sign a contract with
Consor North America, Inc. DBA Murraysmith, Inc. to prepare
the 2023 Sanitary Sewer Comprehensive Plan Update in an
amount not to exceed $679,565, subject to final terms and
conditions acceptable to the City Attorney and Public Works
Director.
G. Russell Road - Meeker to Hogan Complete Streets, TIB Grant
Acceptance - Authorize
MOTION: I move to authorize the Mayor to accept grant funds
from the Transportation Improvement Board for the Russell
Road -Meeker to Hogan Complete Streets Award, in the amount
of $750,000, amend the budget, authorize the expenditure of
the grant funds accordingly, and authorize the Mayor to sign all
necessary documents, subject to final terms and conditions
acceptable to the City Attorney and Public Works Director.
H. Meeker Street Multimodal, Kent Elementary School, PSRC TAP
Grant Acceptance - Authorize
MOTION: I move to authorize Mayor to accept federal funds in
the amount of $149,904 for the Meeker St Multimodal, Kent
Elementary School project and direct staff to establish a budget
for the funds.
I. Consultant Agreement with KBA, Inc. for the S. 212th Street
Preservation Project - Authorize
MOTION: I move to authorize the Mayor to sign the Consultant
Agreement with KBA, Inc. in the amount of $205,032 for
contract administration, management, quality control, and
inspection of the S 212th St Preservation (Green River Bridge to
Orillia Rd) project, subject to final terms and conditions
acceptable to the Public Works Director and City Attorney.
9. OTHER BUSINESS
A. Resolution setting June 21, 2022 as the Date for the Public
Hearing on the Street Vacation at Naden Avenue Assembly -
Adopt
Public Works Director, Chad Bieren provided an overview of the street
vacation at Naden.
8.A.2
Packet Pg. 27 Minutes Acceptance: Minutes of May 17, 2022 7:00 PM (Approval of Minutes)
Kent City Council City Council Regular Meeting
Minutes
May 17, 2022
Kent, Washington
Page 7 of 8
MOTION: I move to adopt Resolution No. 2045, setting June 21,
2022 as the date for the public hearing on the petition for the
vacation of a portion of Naden Street.
RESULT: MOTION PASSES [UNANIMOUS]
MOVER: Brenda Fincher, Councilmember
SECONDER: Satwinder Kaur, Councilmember
AYES: Boyce, Fincher, Kaur, Larimer, Troutner, Thomas, Michaud
B. Resolution Setting June 21, 2022, as the Date for the Public
Hearing on the Street Vacation of Alleyway - Adopt
Public Works Director, Chad Bieren provided an overview of the vacation of
alleyway.
MOTION: I move to adopt Resolution No. 2046, setting June 21,
2022 as the date for the public hearing on the petition for the
vacation of a portion of right-of-way between Railroad Avenue
S., and Bridges Avenue S. and E. Russell Street and E. Morton
Street.
RESULT: MOTION PASSES [UNANIMOUS]
MOVER: Brenda Fincher, Councilmember
SECONDER: Satwinder Kaur, Councilmember
AYES: Boyce, Fincher, Kaur, Larimer, Troutner, Thomas, Michaud
10. BIDS
A. Salt Air Vista Park Renovation Project Bid - Award
Parks Planning and Development Manager, Terry Jungman presented details
on the Salt Air Vista Park Renovation Project and recommended awarding to
L.W. Sundstrom, Inc.
MOTION: I move to award the Salt Air Vista Park Renovation
project to L.W. Sundstrom, Inc. in the amount of $495,394.95,
including Washington State Sales Tax, and authorize the Mayor
to sign all necessary documents, subject to final terms and
conditions acceptable to the City Attorney and Park Director.
RESULT: MOTION PASSES [UNANIMOUS]
MOVER: Zandria Michaud, Councilmember
SECONDER: Satwinder Kaur, Councilmember
AYES: Boyce, Fincher, Kaur, Larimer, Troutner, Thomas, Michaud
11. EXECUTIVE SESSION AND ACTION AFTER EXECUTIVE SESSION
A. Current or Potential Litigation, as per RCW 42.30.110(1)(i)
8.A.2
Packet Pg. 28 Minutes Acceptance: Minutes of May 17, 2022 7:00 PM (Approval of Minutes)
Kent City Council City Council Regular Meeting
Minutes
May 17, 2022
Kent, Washington
Page 8 of 8
At 8:20 p.m., the Council moved into executive session for 10 minutes.
At 8:30 p.m., executive session was extended for 5 additional minutes.
At 8:36 p.m. the Council reconvened into regular session.
12. ADJOURNMENT
With no action following executive session, Mayor Ralph adjourned the
meeting.
Meeting ended at 8:36 p.m.
Kimberley A. Komoto
City Clerk
8.A.2
Packet Pg. 29 Minutes Acceptance: Minutes of May 17, 2022 7:00 PM (Approval of Minutes)
DATE: June 7, 2022
TO: Kent City Council
SUBJECT: Payment of Bills - Authorize
MOTION: I move to authorize the payment of bills received through
5/15/22 and paid on 5/15/22, and approve the checks issued for payroll
5/1/22-5/15/22 and paid on 5/20/22, all audited by the Operations and
Public Safety Committee on 5/17/22.
SUMMARY:
Approval of payment of the bills received through:05/15/22
and paid 05/15/22
Approval of checks issued for Vouchers:
Date Amount
05/15/22 Wire Transfers 9200 9218 $2,390,589.87
05/15/22 Regular Checks 761118 761422 $3,168,920.82
05/15/22 Payment Plus 104163 104200 $146,634.61
Void Checks $0.00
Void Payment Plus $0.00
05/15/22 Use Tax Payable $2,577.20
Total Accounts Payable:$5,708,722.50
Approval of checks issued for Payroll:05/01/22-05/15/22
and paid 05/20/22
Date Amount
05/20/22 Checks $2,118,814.46
Voids and Reissues $0.00
05/20/22 Advices FR&P 463369 463377 $7,163.89
Total Payroll:$2,125,978.35
Document Numbers
Document Numbers
SUPPORTS STRATEGIC PLAN GOAL:
Sustainable Services - Providing quality services through responsible financial management,
economic growth, and partnerships.
8.B
Packet Pg. 30
05/17/22 Operations and Public Safety Committee MOTION
PASSES
RESULT: MOTION PASSES [UNANIMOUS] Next: 6/7/2022
7:00 PM
MOVER: Les Thomas, Councilmember
SECONDER: Toni Troutner, Councilmember
AYES: Boyce, Fincher, Kaur, Larimer, Michaud, Thomas,
Troutner
8.B
Packet Pg. 31
DATE: June 7, 2022
TO: Kent City Council
SUBJECT: Accept the 2021 Storm and Sewer Cured-in-Place Pipe
Lining Project as Complete - Accept
MOTION: I move to accept the 2021 Storm Sewer Cured-in-Place Pipe
Lining Project as complete and direct staff to release retainage to
Insituform Technologies, LLC, upon receipt of standard releases from the
State and the release of any liens.
SUMMARY: This project included approximately 5,600 lineal feet of cured-in-place
pipe lining of existing 8, 12, 15, and 18-inch diameter storm and sewer pipes
throughout the City. The cured-in-place pipes will extend the life of the sewer mains
and avoid much higher replacement costs.
The final contract total paid was $567,295.76 which is $107,008.39 under the
original contract amount of $674,304.15.
BUDGET IMPACT: The project was paid for using Drainage Funds.
SUPPORTS STRATEGIC PLAN GOAL:
Innovative Government - Delivering outstanding customer service, developing leaders, and
fostering innovation.
Sustainable Services - Providing quality services through responsible financial management,
economic growth, and partnerships.
8.C
Packet Pg. 32
DATE: June 7, 2022
TO: Kent City Council
SUBJECT: Appointment to the King County Landmarks and Heritage
Commission - Confirm
MOTION: I move to confirm the Mayor’s appointment of Linda Martinez to
the Kent Special Member Position of the King County Landmarks and
Heritage Commission.
SUMMARY: The King County Landmarks and Heritage Commission (KCLHC) was
established in 1980 to ensure that historic places, material culture, and traditions
are preserved for future generations. On September 5, 2006, Kent City Council
approved the addition of a Landmarks Designation and Preservation chapter to Kent
City Code (KCC 14.12) which designates the KCLHC to act as the City of Kent’s
landmarks commission.
In 2014, Kent’s Mill Creek Neighborhood was designated as a historic district,
following nomination by residents, support by the City, and approval by the KCLHC.
As a historic district, any new structures or exterior modifications first require a
Certificate of Appropriateness. King County Historic Preservation staff conduct that
review for Kent under an interlocal agreement, then bring the proposal before the
KCLHC for ultimate approval.
To ensure the City of Kent has representation on the KCLHC, a Special Member is
assigned to the commission by Mayoral appointment and confirmation of the Kent
City Council. Nancy Simpson, the former Special Member, has stepped down
following the completion of her 3-year term.
An extensive recruitment process included promotion on the City's webpage and
social media posts. Staff also sent notification of commissioner openings directly to
existing board commission members, the complete database of recent applicants,
Cultural Community board members, the Kent Chamber of Commerce, and the Kent
Downtown Partnership.
Four candidates applied, and after an interview with Mayor Ralph and Kent Planning
Staff, Linda Martinez was chosen to fill the vacancy. Linda is a member of the
Greater Kent Historical Society and a long-time owner and restorer of a historic
home on Scenic Hill. Her unique knowledge of Kent as well as her interests in
historic home preservation make her a well-qualified candidate for this role. I am
8.D
Packet Pg. 33
pleased to recommend the appointment of Linda Martinez to the Kent Special
Member Position of the King County Landmarks and Heritage Commission.
SUPPORTS STRATEGIC PLAN GOAL:
Inclusive Community - Embracing our diversity and advancing equity through genuine community
engagement.
8.D
Packet Pg. 34
DATE: June 7, 2022
TO: Kent City Council
SUBJECT: Cancel Council's Regular Meeting Scheduled for July 5,
2022 - Direct
MOTION: I move to direct the City Clerk to cancel Council’s regular meeting
scheduled for July 5, 2022, and to give the required public notice of that
cancellation.
SUMMARY: Through KCC 2.01.020, the Kent City Council has scheduled its regular
full City Council meetings to occur on the first and third Tuesday of each month at 7
p.m. This year, Council’s first meeting in July occurs the day after the Fourth of July
holiday. A question was raised as to whether Council wishes to cancel its regular
meeting on July 5, 2022, so that business that would otherwise occur at that
meeting would be scheduled to occur at the following meeting on July 19, 2022.
RCW 35A.12.110 provides that Council meetings are to occur at least once a
month, “at a place and at such times as may be designated by the city council,” but
it is silent on the issue of cancelling a meeting, as is the Open Public Meetings Act,
the Kent City Code, and Council bylaws, rules and procedures, adopted through
Resolution No. 2025.
Council noted at its May 17th Committee meeting that it desired to cancel its July 5,
2022 meeting. In the absence of any delegation to another of Council’s authority to
designate its meetings, it would be best for Council to adopt the proposed motion
that directs the City Clerk to cancel the July 5, 2022, meeting and give public notice
of the same.
05/17/22 Operations and Public Safety Committee MOTION
PASSES
RESULT: MOTION PASSES [UNANIMOUS] Next: 6/7/2022
7:00 PM
MOVER: Les Thomas, Councilmember
SECONDER: Zandria Michaud, Councilmember
AYES: Boyce, Fincher, Kaur, Larimer, Michaud, Thomas,
Troutner
8.E
Packet Pg. 35
DATE: June 7, 2022
TO: Kent City Council
SUBJECT: Medical, Dental and Vision Vendor Contracts - Authorize
MOTION: I move to authorize the Mayor to approve renewal of the
following contracts:
• Medical plan with Kaiser Permanente for one year
• Dental administrative services with Delta Dental for three years
• Vision administrative services with Vision Service Plan Vision Care
for four years, all contracts being subject to final terms and conditions
acceptable to the Human Resources Director and the City Attorney.
SUMMARY: The City contracts with Kaiser Permanente for the City’s fully-insured
Health Maintenance Organization plan. The renewal is 6.9% less than the 2021
rates.
The City contracts with Delta Dental of Washington and Vision Service Plan Vision
Care, Inc., VSP for dental and vision claims administration and access to their
provider networks. The City is self-insured for these programs. Delta Dental offered
a renewal at 4.2% increase in cost ($1,350 per year). There is no cost change for
the VSP renewal.
The City's Human Resources Department recommends the City renew with these
vendors based on the strength of their plans, overall costs, customer service,
discounts, and overall administration and billing accuracy.
BUDGET IMPACT:
Kaiser Permanente - $481,944 for a one-year contract
Delta Dental - $176,833 for a three-year contract
Vision Service Plan (VSP) - $84,841 for a four-year contract
The cost for these contracts is budgeted in the Health & Wellness fund.
SUPPORTS STRATEGIC PLAN GOAL:
8.F
Packet Pg. 36
Innovative Government - Delivering outstanding customer service, developing leaders, and
fostering innovation.
Sustainable Services - Providing quality services through responsible financial management,
economic growth, and partnerships.
ATTACHMENTS:
1. Kaiser Agreement 2022 (PDF)
2. Delta Dental ASC 2022_2024 (PDF)
3. VSP ASC 2022_2025 (PDF)
05/17/22 Operations and Public Safety Committee MOTION
PASSES
RESULT: MOTION PASSES [UNANIMOUS] Next: 6/7/2022
7:00 PM
MOVER: Les Thomas, Councilmember
SECONDER: Satwinder Kaur, Councilmember
AYES: Boyce, Fincher, Kaur, Larimer, Michaud, Thomas,
Troutner
8.F
Packet Pg. 37
CA-188822 1
Kaiser Foundation Health Plan of Washington
A nonprofit health maintenance organization
Group Medical Coverage Agreement
Kaiser Foundation Health Plan of Washington (“KFHPWA”) is a nonprofit health maintenance organization, duly
registered under the laws of the State of Washington, furnishing health care coverage on a prepayment basis. The
Group identified below wishes to purchase such coverage. This Group Medical Coverage Agreement (“Group
Agreement”) sets forth the terms under which that coverage will be provided, including the rights and
responsibilities of the contracting parties; requirements for enrollment and eligibili ty; and benefits to which those
enrolled under this Group Agreement are entitled.
The Group Medical Coverage Agreement between KFHPWA and the Group consists of the following:
• Standard Provisions
• Evidence of Coverage
City of Kent, #0036900
This Group Agreement will continue in effect until terminated or renewed as herein provided for and is effect ive
January 1, 2022.
8.F.a
Packet Pg. 38 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
2
Standard Provisions
1. KFHPWA agrees to provide benefits as set forth in the attached Evidence of Coverage (EOC) to enrollees
of the Group.
2. Monthly Premium Payments.
For the initial term of this Group Agreement, the Group shall submit to KFHPWA for each Member the
monthly premiums set forth in the current Premium Schedule and a verification of enrollment. Payment must be
received on or before the due date and is subject to a grace period of 10 days. Premiums are subj ect to change
by KFHPWA upon 30 days written notice. Premium rates will be revised as a part of the annual renewal
process.
KFHPWA reserves the right to re-rate this benefit package if the demographic characteristics change by more
than 15%.
3. Dissemination of Information.
Unless the Group has accepted responsibility to do so, KFHPWA will disseminate information describing
benefits set forth in the EOC attached to this Group Agreement.
4. Identification Cards.
KFHPWA will furnish cards, for identification purposes only, to all Members enrolled under this Group
Agreement.
5. Administration of Group Agreement.
KFHPWA may adopt reasonable policies and procedures to help in the administration of this Group Agreement.
This may include, but is not limited to, policies or procedures pertaining to benefit entitlement and coverage
determinations.
6. Modification of Group Agreement.
Except as required by federal and Washington State law, this Group Agreement may not be modified without
agreement between both parties.
No oral statement of any person shall modify or otherwise affect the benefits, limitations and exclusions of this
Group Agreement, convey or void any coverage, increase or reduce any benefits under this Group Agreement or
be used in the prosecution or defense of a claim under this Group Agreement.
7. Indemnification.
KFHPWA agrees to indemnify and hold the Group harmless against all claims, damages, losses and expenses,
including reasonable attorney’s fees, arising out of KFHPWA’s failure to perform, negligent performance or
willful misconduct of its directors, officers, employees and agents of their express obligations under this Group
Agreement.
The Group agrees to indemnify and hold KFHPWA harmless against all claims, damages, losses and expenses,
including reasonable attorney’s fees, arising out of the Group’s failure to perform, negligent performances or
willful misconduct of its directors, officers, employees and agents of their express obligations under this Group
Agreement.
The indemnifying party shall give the other party prompt notice of any claim covered by this section and
provide reasonable assistance (at its expense). The indemnifying party shall have the right and duty to assume
the control of the defense thereof with counsel reasonably acceptable to the other party. Either party may take
part in the defense at its own expense after the other party assumes the control thereof.
8. Compliance With Law.
The Group and KFHPWA shall comply with all applicable state and federal laws and regulations in
performance of this Group Agreement.
8.F.a
Packet Pg. 39 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
3
This Group Agreement is entered into and governed by the laws of Washington State, except as otherwise pre-
empted by ERISA and other federal laws.
9. Governmental Approval.
If KFHPWA has not received any necessary government approval by the date when notice is required under this
Group Agreement, KFHPWA will notify the Group of any changes once governmental approval has been
received. KFHPWA may amend this Group Agreement by giving notice to the Group upon receipt of
government approved rates, benefits, limitations, exclusions or other provisions, in which case such rates,
benefits, limitations, exclusions or provisions will go into effect as required by the governmental agency. All
amendments are deemed accepted by the Group unless the Group gives KFHPWA written notice of non-
acceptance within 30 days after receipt of amendment, in which event this Group Agreement and all rights to
services and other benefits terminate the first of the month following 30 days after receipt of non-acceptance.
10. Grandfathered Health Plan.
For any coverage identified in an EOC as a "grandfathered health plan" under the Patient Protection and
Affordable Care Act (a/k/a the ACA), Group must immediately inform KFHPWA if thi s coverage does not
meet (or no longer meets) the requirements for grandfathered sta tus including but not limited to any change in
its contribution rate to the cost of any grandfathered health plan(s) during the plan year. Group represents that,
for any coverage identified as a “grandfathered health plan” in the applicable EOC, Group has not decreased its
contribution rate more than five percent (5%) for any rate tier for such grandfathered health plan when
compared to the contribution rate in effect on Mar ch 23, 2010 for the same plan. Health Plan will rely on
Group’s representation in issuing and/or continuing any and all grandfathered health plan coverage
11. Confidentiality.
Each party acknowledges that performance of its obligations under this Group Agreement may involve access
to and disclosure of data, procedures, materials, lists, systems and information, including medical records,
employee benefits information, employee addresses, social security numbers, e -mail addresses, phone numbers
and other confidential information regarding the Group’s employees (collectively the “informati on”). The
information shall be kept strictly confidential and shall not be disclosed to any third party other than: (i)
representatives of the receiving party (as permitted by applicable state and federal law) who have a need to
know such information in order to perform the services required of such party pursuant to this Group
Agreement, or for the proper management and administration of the receiving part y, provided that such
representatives are informed of the confidentiality provisions of this Group Agreement and agree to abide by
them, (ii) pursuant to court order or (iii) to a designated public official or agency pursuant to the requirements of
federal, state or local law, statute, rule or regulation. The disclosing party will provide the other party with
prompt notice of any request the disclosing party receives to disclose information pursuant to applicable legal
requirements, so that the other party may object to the request and/or seek an appropriate protective order
against such request. Each party shall maintain the confidentiality of medical records and confidential patient
and employee information as required by applicable law.
12. HIPAA.
Definition of Terms. Terms used, but not otherwise defined, in this section shall have the same meaning as
those terms have in the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).
Transactions Accepted. KFHPWA will accept Standard Transactions, pursuant to HIPAA, if the Group elects
to transmit such transactions. The Group shall ensure th at all Standard Transactions transmitted to KFHPWA by
the Group or the Group’s business associates are in compliance with HIPAA standards for electronic
transactions. The Group shall indemnify KFHPWA for any breach of this section by the Group.
13. Termination of Entire Group Agreement.
This is a guaranteed renewable Group Agreement and cannot be terminated without the mutual approval of each
of the parties, except in the circumstances set forth below.
a. Nonpayment or Non-Acceptance of Premium. Failure to make any monthly premium payment or
contribution in accordance with Subsection 2. above shall result in termination of this Group Agreement as
8.F.a
Packet Pg. 40 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
4
of the premium due date. The Group’s failure to accept the revised premiums provided as part of the annual
renewal process shall be considered nonpayment and result in non-renewal of this Group Agreement. The
Group may terminate this Group Agreement upon 15 days written notice of premium increase, as set forth
in Subsection 2. above.
b. Misrepresentation. KFHPWA may rescind or terminate this Group Agreement upon written notice in the
event that intentional misrepresentation, fraud or omission of information was used in order to obt ain
Group coverage. Either party may terminate this Group Agreement in the event of intentional
misrepresentation, fraud or omission of information by the other party in performance of its responsibilities
under this Group Agreement.
c. Underwriting Guidelines. KFHPWA may terminate this Group Agreement in the event the Group no
longer meets underwriting guidelines established by KFHPWA that were in effect at the time the Group
was accepted.
d. Federal or State Law. KFHPWA may terminate this Group Agreement in the event there is a change in
federal or state law that no longer permits the continued offering of the coverage described in this Group
Agreement.
14. Withdrawal or Cessation of Services.
a. KFHPWA may determine to withdraw from a Service Area or from a segment of its Service Area after
KFHPWA has demonstrated to the Washington State Office of the Insurance Commissioner that
KFHPWA’s clinical, financial or administrative capacity to service the covered Members would be
exceeded.
b. KFHPWA may determine to cease to offer the Group’s current plan and replace the plan with another plan
offered to all covered Members within that line of business that includes all of the health care services
covered under the replaced plan and does not significantly lim it access to the services covered under the
replaced plan. KFHPWA may also allow unrestricted conversion to a fully comparable KFHPWA product.
KFHPWA will provide written notice to each covered Member of the discontinuation or non -renewal of the
plan at least 90 days prior to discontinuation.
15. Limitation on Enrollment.
The Group Agreement will be open for applications for enrollment as described in the group master application.
Subject to prior approval by the Washington State Office of the Insurance Commissioner, KFHPWA may limit
enrollment, establish quotas or set priorities for acceptance of new applications if it determines that KFHPWA’s
capacity, in relation to its total enrollment, is not adequate to provide services to additional persons.
16. Acceptance of Group Agreement
The Group agrees as having accepted the terms and conditions of this Group Agreement and any amendments
issued during the term of this Group Agreement, upon receipt by KFHPWA of any amount of premium
payment.
8.F.a
Packet Pg. 41 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
Your
Kaiser Foundation Health Plan of
Washington
Evidence of Coverage
8.F.a
Packet Pg. 42 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 1
Kaiser Foundation Health Plan of Washington
A nonprofit health maintenance organization
2022 Evidence of Coverage
C0B5710036900
8.F.a
Packet Pg. 43 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 2
Important Notice Under Federal Health Care Reform
Kaiser Foundation Health Plan of Washington (“KFHPWA”) recommends each Member choose a Network Personal
Physician. This decision is important since the designated Network Personal Physician provides or arranges for
most of the Member’s health care. The Member has the right to designate any Network Personal Physician who
participates in one of the KFHPWA networks and who is available to accept the Member or the Member’s family
members. For information on how to select a Network Personal Physician, and for a list of the participating
Network Personal Physicians, please call Kaiser Permanente Member Services at (206) 630-4636 in the Seattle area,
or toll-free in Washington, 1-888-901-4636.
For children, the Member may designate a pediatrician as the primary care provider.
The Member does not need Preauthorization from KFHPWA or from any other person (including a Network
Personal Physician) to access obstetrical or gynecological c are from a health care professional in the KFHPWA
network who specializes in obstetrics or gynecology. The health care professional, however, may be required to
comply with certain procedures, including obtaining Preauthorization for certain services, fol lowing a pre-approved
treatment plan, or procedures for obtaining Preauthorization. For a list of participating health care professionals
who specialize in obstetrics or gynecology, please call Kaiser Permanente Member Services at (206) 630-4636 in the
Seattle area, or toll-free in Washington, 1-888-901-4636.
Women’s health and cancer rights
If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the
mastectomy, the Member will also receive coverage for:
• All stages of reconstruction of the breast on which the mastectomy has been performed.
• Surgery and reconstruction of the other breast to produce a symmetrical appearance.
• Prostheses.
• Treatment of physical complications of all stages of mastectom y, including lymphedemas.
These services will be provided in consultation with the Member and the attending physician and will be subject to
the same Cost Shares otherwise applicable under the Evidence of Coverage (EOC).
Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act
Carriers offering group health coverage generally may not, under federal law, restrict benefits for any hospital length
of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal
delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the
mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or newborn
earlier than 48 hours (or 96 hours as applicable). In any case, carriers may not, under federal law, require that a
provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours (or 96 hours).
Also, under federal law, a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of
the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion
of the stay.
For More Information
KFHPWA will provide the information regarding the types of plans offered by KFHPWA to Members on request.
Please call Kaiser Permanente Member Services at (206) 630-4636 in the Seattle area, or toll-free in Washington, 1-
888-901-4636.
8.F.a
Packet Pg. 44 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 3
Table of Contents
I. Introduction ................................................................................................................................................... 6
II. How Covered Services Work ........................................................................................................................ 6
A. Accessing Care. ........................................................................................................................................ 6
B. Administration of the EOC. ..................................................................................................................... 9
C. Confidentiality.......................................................................................................................................... 9
D. Modification of the EOC. ......................................................................................................................... 9
E. Nondiscrimination. ................................................................................................................................... 9
F. Preauthorization. .................................................................................................................................... 10
G. Recommended Treatment. ..................................................................................................................... 10
H. Second Opinions. ................................................................................................................................... 10
I. Unusual Circumstances. ......................................................................................................................... 10
J. Utilization Management. ........................................................................................................................ 11
III. Financial Responsibilities ........................................................................................................................... 11
A. Premium. ................................................................................................................................................ 11
B. Financial Responsibilities for Covered Services. ................................................................................... 11
C. Financial Responsibilities for Non-Covered Services. ........................................................................... 12
IV. Benefits Details ............................................................................................................................................ 13
Annual Deductible ......................................................................................................................................... 13
Coinsurance ................................................................................................................................................... 13
Lifetime Maximum ....................................................................................................................................... 13
Out-of-pocket Limit ...................................................................................................................................... 13
Pre-existing Condition Waiting Period ......................................................................................................... 13
Acupuncture .................................................................................................................................................. 14
Allergy Services ............................................................................................................................................ 14
Ambulance .................................................................................................................................................... 14
Cancer Screening and Diagnostic Services ................................................................................................... 15
Circumcision ................................................................................................................................................. 15
Clinical Trials ................................................................................................................................................ 15
Dental Services and Dental Anesthesia ......................................................................................................... 16
Devices, Equipment and Supplies (for home use) ......................................................................................... 16
Diabetic Education, Equipment and Pharmacy Supplies .............................................................................. 17
Dialysis (Home and Outpatient) .................................................................................................................... 18
Drugs - Outpatient Prescription ..................................................................................................................... 18
Emergency Services ...................................................................................................................................... 21
Gender Health Services ................................................................................................................................. 22
Hearing Examinations and Hearing Aids ...................................................................................................... 22
Home Health Care ......................................................................................................................................... 22
Hospice .......................................................................................................................................................... 23
Hospital - Inpatient and Outpatient ............................................................................................................... 24
Infertility (including sterility) ........................................................................................................................ 25
Infusion Therapy ........................................................................................................................................... 25
Laboratory and Radiology ............................................................................................................................. 25
Manipulative Therapy ................................................................................................................................... 26
Maternity and Pregnancy ............................................................................................................................... 26
8.F.a
Packet Pg. 45 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 4
Mental Health and Wellness .......................................................................................................................... 27
Naturopathy ................................................................................................................................................... 28
Newborn Services ......................................................................................................................................... 28
Nutritional Counseling .................................................................................................................................. 29
Nutritional Therapy ....................................................................................................................................... 29
Obesity Related Services ............................................................................................................................... 29
On the Job Injuries or Illnesses ..................................................................................................................... 30
Oncology ....................................................................................................................................................... 30
Optical (vision) .............................................................................................................................................. 30
Oral Surgery .................................................................................................................................................. 31
Outpatient Services ....................................................................................................................................... 31
Plastic and Reconstructive Surgery ............................................................................................................... 32
Podiatry ......................................................................................................................................................... 32
Preventive Services ....................................................................................................................................... 32
Rehabilitation and Habilitative Care (massage, occupational, physical and speech therapy, pulmonary and
cardiac rehabilitation) and Neurodevelopmental Therapy ..................................................................... 33
Reproductive Health ...................................................................................................................................... 35
Sexual Dysfunction ....................................................................................................................................... 35
Skilled Nursing Facility................................................................................................................................. 35
Sterilization ................................................................................................................................................... 36
Substance Use Disorder................................................................................................................................. 36
Telehealth Services ....................................................................................................................................... 38
Temporomandibular Joint (TMJ) .................................................................................................................. 39
Tobacco Cessation ......................................................................................................................................... 39
Transplants .................................................................................................................................................... 40
Urgent Care ................................................................................................................................................... 40
V. General Exclusions ...................................................................................................................................... 41
VI. Eligibility, Enrollment and Termination ................................................................................................... 42
A. Eligibility. .............................................................................................................................................. 42
B. Application for Enrollment. ................................................................................................................... 43
C. When Coverage Begins. ......................................................................................................................... 45
D. Eligibility for Medicare. ......................................................................................................................... 45
E. Termination of Coverage. ...................................................................................................................... 45
F. Continuation of Inpatient Services. ........................................................................................................ 46
G. Continuation of Coverage Options. ........................................................................................................ 46
VII. Grievances .................................................................................................................................................... 47
VIII. Appeals ......................................................................................................................................................... 48
IX. Claims ........................................................................................................................................................... 49
X. Coordination of Benefits ............................................................................................................................. 50
Definitions. .................................................................................................................................................... 50
Order of Benefit Determination Rules........................................................................................................... 51
Effect on the Benefits of this Plan. ................................................................................................................ 53
Right to Receive and Release Needed Information. ...................................................................................... 53
Facility of Payment. ...................................................................................................................................... 53
Right of Recovery. ........................................................................................................................................ 53
Effect of Medicare. ........................................................................................................................................ 53
8.F.a
Packet Pg. 46 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 5
XI. Subrogation and Reimbursement Rights .................................................................................................. 54
XII. Definitions .................................................................................................................................................... 55
8.F.a
Packet Pg. 47 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 6
KFHPWA believes this plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act
of 2010. Questions regarding this status may be directed to Kaiser Permanente Member Services at toll-free 1-888-
901-4636. Members may also contact the Employee Benefits Security Administration, U.S. Dep artment of Labor at
toll-free 1-866-444-3272 or www.dol.gov/ebsa/healthreform.
I. Introduction
This EOC is a statement of benefits, exclusions and other provisions as set forth in the Group Medical Coverage
Agreement between Kaiser Foundation Health Plan of Washington (“KFHPWA”) and the Group. The benefits were
approved by the Group who contracts with KFHPWA for health care coverage. This EOC is not the Group medical
coverage agreement itself. In the event of a conflict between the Group Medical Coverage Agreement and the EOC,
the EOC language will govern.
The provisions of the EOC must be considered together to fully understand the benefits available under the EOC.
Words with special meaning are capitalized and are defined in Section XII.
Contact Kaiser Permanente Member Services at 206-630-4636 or toll-free 1-888-901-4636 for benefits questions.
II. How Covered Services Work
A. Accessing Care.
1. Members are entitled to Covered Services from the following:
Your Provider Network is KFHPWA’s Core Network (Network). Members are entitled to Covered
Services only at Network Facilities and Network Providers, except for Emergency services and care
pursuant to a Preauthorization.
Benefits under this EOC will not be denied for any health care service performed by a registered nurse
licensed to practice under chapter 18.88 RCW, if first, the service performed was within the lawful scope of
such nurse’s license, and second, this EOC would have provided benefit if such service had been performed
by a doctor of medicine licensed to practice under chapter 18.71 RCW.
A listing of Core Network Personal Physicians, specialists, women’s health care providers and KFHPWA-
designated Specialists is available by contacting Member Services or accessing the KFHPWA website at
www.kp.org/wa. Information available online includes each physician’s location, education, credentials,
and specialties. KFHPWA also utilizes Health Care Benefit Managers for certain services. To see a list of
Health Care Benefit Managers, go to wa.kaiserpermanente.org and type Health Care Benefit Manager in
the search bar.
Health Care Benefit Managers:
• OptumRx
• Magellan Healthcare
• Tivity Health
• First Choice Health
• Cogitativo
• Multiplan
Receiving Care in another Kaiser Foundation Health Plan Service Area
If you are visiting in the service area of another Kaiser Permanente region, visiting member services may
be available from designated providers in that region if the services would have been covered under this
EOC. Visiting member services are subject to the provisions set forth in this EOC including, but not limited
to, Preauthorization and cost sharing. For more information about receiving visiting member services in
other Kaiser Permanente regional health plan service areas, including provider and facility locations, please
call Kaiser Permanente Member Services at (206) 630-4636 in the Seattle area, or toll-free in Washington,
8.F.a
Packet Pg. 48 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 7
1-888-901-4636. Information is also available online at
www.wa.kaiserpermanente.org/html/public/services/traveling.
KFHPWA will not directly or indirectly prohibit Members from freely contracting at any time to obtain
health care services from Non-Network Providers and Non-Network Facilities outside the Plan. However,
if you choose to receive services from Non-Network Providers and Non-Network Facilities except as
otherwise specifically provided in this EOC, those services will not be covered under this EOC and you
will be responsible for the full price of the services. Any amounts you pay for non-covered services will not
count toward your Out-of-Pocket Limit.
2. Primary Care Provider Services.
KFHPWA recommends that Members select a Network Personal Physician when enrolling. One personal
physician may be selected for an entire family, or a different personal physician may be selected for each
family member. For information on how to select or change Network Personal Physicians, and for a list of
participating personal physicians, call Kaiser Permanente Member Services at (206) 630-4636 in the Seattle
area, or toll-free in Washington at 1-888-901-4636 or by accessing the KFHPWA website at
www.kp.org/wa. The change will be made within 24 hours of the receipt of the request if the selected
physician’s caseload permits. If a personal physician accepting new Members is not available in your area,
contact Kaiser Permanente Member Services, who will ensure you have access to a personal physician by
contacting a physician’s office to request they accept new Members.
To find a personal physician, call Member Services or access the KFHPWA website at www.kp.org/wa to
view physician profiles. Information available online includes each physician’s location, education,
credentials, and specialties.
For your personal physician, choose from these specialties:
• Family medicine
• Adult medicine/internal medicine
• Pediatrics/adolescent medicine (for children up to 18)
Be sure to check that the physician you are considering is accepting new patients.
If your choice does not feel right after a few visits, you can change your personal physician at any time, for
any reason. If you don’t choose a physician when you first become a KFHPWA member, we will match
you with a physician to make sure you have one assigned to you if you get sick or injured.
In the case that the Member’s personal physician no longer participates in KFHPWA’s network, the
Member will be provided access to the personal physician for up to 60 days following a written notice
offering the Member a selection of new personal physicians from which to choose.
3. Specialty Care Provider Services.
Unless otherwise indicated in Section II. or Section IV., Preauthorization is required for specialty care and
specialists that are not KFHPWA-designated Specialists and are not providing care at facilities owned and
operated by Kaiser Permanente.
KFHPWA-designated Specialist.
Preauthorization is not required for services with KFHPWA-designated Specialists at facilities owned and
operated by Kaiser Permanente. To access a KFHPWA-designated Specialist, consult your KFHPWA
personal physician. For a list of KFHPWA-designated Specialists, contact Member Services or view the
Provider Directory located at www.kp.org/wa. The following specialty care areas are available from
KFHPWA-designated Specialists: allergy, audiology, cardiology, chiropractic/manipulative therapy,
dermatology, gastroenterology, general surgery, hospice, mental hea lth and wellness, nephrology,
neurology, obstetrics and gynecology, occupational medicine, oncology/hematology, ophthalmology,
optometry, orthopedics, otolaryngology (ear, nose and throat), physical therapy, smoking cessation,
speech/language and learning services, substance use disorder and urology.
8.F.a
Packet Pg. 49 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 8
4. Hospital Services.
Non-Emergency inpatient hospital services require Preauthorization. Refer to Section IV. for more
information about hospital services.
5. Emergency Services.
Emergency services at a Network Facility or non-Network Facility are covered. Members must notify
KFHPWA by way of the Hospital notification line (1-888-457-9516 as noted on your Member
identification card) within 24 hours of any admission, or as soon thereafter as medically possible. Coverage
for Emergency services at a non-Network Facility is limited to the Allowed Amount. Refer to Section IV.
for more information about Emergency services.
Members are covered for Emergency care and Medically Necessary urgent care anywhere in the world. If
you think you are experiencing an emergency, go immediately to the nearest emergency care facility or call
911. Go to the closest urgent care center for an illness or injury that requires prompt medical attention but
is not an emergency. Examples include, but are not limited to minor injuries, wounds, and cuts needing
stiches; minor breathing issues; minor stomach pain. If y ou are unsure whether urgent care is your best
option, call the consulting nurse helpline for advice at 1-800-297-6877 or 206-630-2244.
If you need Emergency care while traveling and are admitted to a non-network hospital, you or a family
member must notify us within 48 hours after care begins, or as soon as is reasonably possible. Call the
notification line listed on the back of your KFHPWA Member ID card to help make sure your claim is
accepted. Keep receipts and other paperwork from non-network care. You’ll need to submit them with any
claims for reimbursement after returning from t ravel.
Access to non-Emergency care across the Core network service area: your Plan provides access to all
providers in the Core Network, including many physicians and services at Kaiser Permanente medical
facilities and Core Network facilities across the state. Find links to providers at kp.org/wa/directory or
contact Member Services at 1-888-901-4636 for assistance.
6. Urgent Care.
Inside the KFHPWA Service Area, urgent care is covered at a Kaiser Permanente medical center, Kaiser
Permanente urgent care center or Network Provider’s office. Outside the KFHPWA Service Area, urgent
care is covered at any medical facility. Refer to Section IV. for more information about urgent care.
For urgent care during office hours, you can call your personal ph ysician’s office first to see if you can get
a same-day appointment. If a physician is not available or it is after office hours, you may speak with a
licensed care provider anytime at 1-800-297-6877 or 206-630-2244. You may also check
kp.org/wa/directory or call Member Services to find the nearest urgent care facility in your network.
7. Women’s Health Care Direct Access Providers.
Female Members may see a general and family practitioner, physician’s assistant, gynecologist, certified
nurse midwife, licensed midwife, doctor of osteopathy, pediatrician, obstetrician or advance registered
nurse practitioner who is unrestricted in your KFHPWA Network to provide women’s health care services
directly, without Preauthorization, for Medically Necessary maternity care, covered reproductive health
services, preventive services (well care) and general examinations, gynecological care and follow -up visits
for the above services. Women’s health care services are covered as if the Member’s Network Personal
Physician had been consulted, subject to any applicable Cost Shares. If the Member’s women’s health care
provider diagnoses a condition that requires other specialists or hospitalization, the Member or the chosen
provider must obtain Preauthorization in accordance with applicable KFHPWA requirements. For a list of
KFHPWA providers, contact Member Services or view the Provider Directory located at www.kp.org/wa.
8. Travel Advisory Service.
Our Travel Advisory Service offers recommendations tailored to your travel outside the United States.
Nurses certified in travel health will advise you on any vaccines or medications you need based on your
destination, activities, and medical history. The consultation is not a covered benefit and there is a fee for a
8.F.a
Packet Pg. 50 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 9
KFHPWA Member using the service for the first time. Travel-related vaccinations and medications are
usually not covered. Visit kp.org/wa/travel-service for more details.
9. Process for Medical Necessity Determination.
Pre-service, concurrent or post-service reviews may be conducted. Once a service has been reviewed,
additional reviews may be conducted. Members will be notified in writing when a de termination has been
made.
First Level Review:
First level reviews are performed or overseen by appropriate clinical staff using KFHPWA approved
clinical review criteria. Data sources for the review include, but are not limited to, referral forms, admission
request forms, the Member’s medical record, and consultation with qualified health professionals and
multidisciplinary health care team members. The clinical information used in the review may include
treatment summaries, problem lists, specialty evalu ations, laboratory and x-ray results, and rehabilitation
service documentation. The Member or legal surrogate may be contacted for information. Coordination of
care interventions are initiated as they are identified. The reviewer consults with the health care team when
more clarity is needed to make an informed medical necessity decision. The reviewer may consult with a
board-certified consultative specialist and such consultations will be documented in the review text. If the
requested service appears to be inappropriate based on application of the review criteria, the first level
reviewer requests second level review by a physician or designated health care professional.
Second Level (Practitioner) Review:
The practitioner reviews the treatment plan and discusses, when appropriate, case circumstances and
management options with the attending (or referring) physician. The reviewer consults with the health care
team when more clarity is needed to make an informed coverage decision. The reviewer may consult with
board certified physicians from appropriate specialty areas to assist in making determinations of coverage
and/or appropriateness. All such consultations will be documented in the review text. If the reviewer
determines that the admission, continued stay or service requested is not a covered service, a notice of non-
coverage is issued. Only a physician, behavioral health practitioner (such as a psychiatrist, doctoral-level
clinical psychologist, certified addiction medicine specialist), dentist or pharmacist who has the clinical
expertise appropriate to the request under review with an unrestricted license may deny coverage based on
Medical Necessity.
B. Administration of the EOC.
KFHPWA may adopt reasonable policies and procedures to administer the EOC. This may include, but is not
limited to, policies or procedures pertaining to benefit entitlem ent and coverage determinations.
C. Confidentiality.
KFHPWA is required by federal and state law to maintain the privacy of Member personal and health
information. KFHPWA is required to provide notice of how KFHPWA may use and disclose personal and
health information held by KFHPWA. The Notice of Privacy Practices is distributed to Members and is
available in Kaiser Permanente medical centers, at www.kp.org/wa, or upon request from Member Services.
D. Modification of the EOC.
No oral statement of any person shall modify or otherwise affect the benefits, limitations and exclusions of the
EOC, convey or void any coverage, increase or reduce any benefits under the EOC or be used in the prosecution
or defense of a claim under the EOC.
E. Nondiscrimination.
KFHPWA does not discriminate on the basis of physical or mental disabilities in its employment practices and
services. KFHPWA will not refuse to enroll or terminate a Member’s coverage and will not deny care on the
basis of age, sex, sexual orientation, gender identity, race, color, religion, national origin, citizenship or
immigration status, veteran or military status, occupation or health status.
8.F.a
Packet Pg. 51 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 10
F. Preauthorization.
Refer to Section IV. or https://wa.kaiserpermanente.org/html/public/services/pre-authorization for more
information regarding which services KFHPWA requires Preauthorization. Failure to obtain Preauthorization
when required may result in denial of coverage for those services; and the member may be responsible for the
cost of these non-Covered services. Members may contact Member Services to request Preauthorization.
Preauthorization requests are reviewed and approved based on Medical Necessity, eligibility and benefits.
KFHPWA will generally process Preauthorization requests and provid e notification for benefits within the
following timeframes:
• Standard requests – within 5 calendar days
o If insufficient information has been provided a request for additional information will be made within
5 calendar days. The provider or facility has 5 c alendar days to provide the necessary information. A
decision will be made within 4 calendar days of receipt of the information or the deadline for receipt of
the requested information.
• Expedited requests – within 2 calendar days
o If insufficient information has been provided a request for additional information will be made within
1 calendar day. The provider or facility has 2 calendar days to provide the necessary information. A
decision will be made within 2 calendar days of receipt of the information or the deadline for receipt of
the requested information.
G. Recommended Treatment.
KFHPWA’s medical director will determine the necessity, nature and extent of treatment to be covered in each
individual case and the judgment will be made in good faith. Members have the right to appeal coverage
decisions (see Section VIII.). Members have the right to participate in decisions regarding their health care. A
Member may refuse any recommended services to the extent permitted by law. Members who obtain care not
recommended by KFHPWA’s medical director do so with the full understanding that KFHPWA has no
obligation for the cost, or liability for the outcome, of such care.
New and emerging medical technologies are evaluated on an ongoing basis by the following committees – the
Interregional New Technologies Committee, Medical Technology Assessment Committee, Medical Policy
Committee, and Pharmacy and Therapeutics Committee. These physician evaluators consider the new
technology’s benefits, whether it has been proven safe and effective, and under what conditions its use would be
appropriate. The recommendations of these committees inform what is covered on KFHPWA health plans.
H. Second Opinions.
The Member may access a second opinion from a Network Provider regarding a m edical diagnosis or treatment
plan. The Member may request Preauthorization or may visit a KFHPWA-designated Specialist for a second
opinion. When requested or indicated, second opinions are provided by Network Providers and are covered with
Preauthorization, or when obtained from a KFHPWA-designated Specialist. Coverage is determined by the
Member's EOC; therefore, coverage for the second opinion does not imply that the services or treatments
recommended will be covered. Preauthorization for a second opinion does not imply that KFHPWA will
authorize the Member to return to the physician providing the second opinion for any additional treatment.
Services, drugs and devices prescribed or recommended as a result of the consultation are not covered unless
included as covered under the EOC.
I. Unusual Circumstances.
In the event of unusual circumstances such as a major disaster, epidemic, military action, civil disorder, labor
disputes or similar causes, KFHPWA will not be liable for administering coverage beyond the limitations of
available personnel and facilities.
In the event of unusual circumstances such as those described above, KFHPWA will make a good faith effort to
arrange for Covered Services through available Network Facilities and personnel. KFHPWA shall have no other
liability or obligation if Covered Services are delayed or unavailable due to unusual circumstances.
8.F.a
Packet Pg. 52 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 11
J. Utilization Management.
Case management means a care management plan developed for a Member whose diagnosis requires timely
coordination. All benefits, including travel and lodging, are limited to Covered Services that are Medically
Necessary and set forth in the EOC. KFHPWA may review a Member's medical records for the purpose of
verifying delivery and coverage of services and items. Based on a prospective, concurrent or retrospective
review, KFHPWA may deny coverage if, in its determination, such services are not Medically Necessary. Such
determination shall be based on established clinical criteria and may require Preauthorization.
KFHPWA will not deny coverage retroactively for services with Preauthorization and which have already been
provided to the Member except in the case of an intentional misrepresentation of a material fact by the patient,
Member, or provider of services, or if coverage was obtained based on inaccurate, false, or misleading
information provided on the enrollment application, or for nonpayment of premiums.
III. Financial Responsibilities
A. Premium.
The Subscriber is liable for payment to the Group of their contribution toward the monthly premium, if any.
B. Financial Responsibilities for Covered Services.
The Subscriber is liable for payment of the following Cost Shares for Covered Services provided to the
Subscriber and their Dependents. Payment of an amount billed must be received within 30 days of the billing
date. Charges will be for the lesser of the Cost Shares for the Covered Service or the actual charge for that
service. Cost Shares will not exceed the actual charge for that service.
1. Annual Deductible.
Covered Services may be subject to an annual Deductible. Charges subject to the annual Deductible shall
be borne by the Subscriber during each year until the annual Deductible is met. Covered Services must be
received from a Network Provider at a Network Facility, unless the Member has received Preauthorization
or has received Emergency services.
There is an individual annual Deductible amount for each Member and a maximum annual Deductible
amount for each Family Unit. Once the annual Deductible amount is reached for a Family Unit in a
calendar year, the individual annual Deductibles are also deemed reached for each Member during that
same calendar year.
Individual Annual Deductible Carryover. Under this EOC, charges from the last 3 months of the prior
year which were applied toward the individual annual Deductible will also apply to the current year
individual annual Deductible. The individual annual Deductible carryover will apply only when expenses
incurred have been paid in full. The Family Unit Deductible does not carry over into the next year.
2. Plan Coinsurance.
After the applicable annual Deductible is satisfied, Members may be required to pay Plan Coinsurance for
Covered Services.
3. Copayments.
Members shall be required to pay applicable Copayments at the time of service. Payment of a Copayment
does not exclude the possibility of an additional billing if the service is determined to be a non -Covered
Service or if other Cost Shares apply.
4. Out-of-pocket Limit.
Out-of-pocket Expenses which apply toward the Out-of-pocket Limit are set forth in Section IV. Total Out-
of-pocket Expenses incurred during the same calendar year shall not exceed the Out-of-pocket Limit.
8.F.a
Packet Pg. 53 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 12
C. Financial Responsibilities for Non-Covered Services.
The cost of non-Covered Services and supplies is the responsibility of the Member. The Subscriber is liable for
payment of any fees charged for non-Covered Services provided to the Subscriber and their Dependents at the
time of service. Payment of an amount billed must be received within 30 days of the billing date.
8.F.a
Packet Pg. 54 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 13
IV. Benefits Details
Benefits are subject to all provisions of the EOC. Members are entitled only to receive benefits and services that are
Medically Necessary and clinically appropriate for the treatment of a Medical Condition as determined by
KFHPWA’s medical director and as described herein. All Covered Services are subject to case management and
utilization management.
Annual Deductible Member pays $0 per Member per calendar year or $0 per Family Unit per calendar year
Coinsurance Plan Coinsurance: Member pays nothing
Lifetime Maximum No lifetime maximum on covered Essential Health Benefits
Out-of-pocket Limit Limited to a maximum of $2,000 per Member or $4,000 per Family Unit per calendar year
The following Out-of-pocket Expenses apply to the Out-of-pocket Limit: Ambulance
coinsurance/Copayment, diagnostic laboratory and radiology Copayment, Emergency
services Copayment, hospital inpatient Copayment, hospital outpatient Copayment,
outpatient services Copayment, oral chemotherapy Copayment
The following expenses do not apply to the Out -of-pocket Limit: Benefit-specific
coinsurances, prescription drug Copayment, premiums, charges for services in excess of a
benefit, charges in excess of Allowed Amount, charges for non-Covered Services
Pre-existing Condition
Waiting Period
No pre-existing condition waiting period
8.F.a
Packet Pg. 55 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 14
Acupuncture
Acupuncture needle treatment.
Limited to 8 visits per medical diagnosis per calendar year
without Preauthorization. Additional visits are covered with
Preauthorization.
No visit limit for treatment for Substance Use Disorder.
Member pays $10 Copayment
Exclusions: Herbal supplements; any services not within the scope of the practitioner’s licensure
Allergy Services
Allergy testing. Member pays $10 Copayment
Allergy serum and injections. Member pays $10 Copayment
Ambulance
Emergency ambulance service is covered only when:
• Transport is to the nearest facility that can treat your
condition
• Any other type of transport would put your health or
safety at risk
• The service is from a licensed ambulance.
Emergency air or sea medical transportation is covered only
when:
• The above requirements for ambulance service are
met, and
• Geographic restraints prevent ground Emergency
transportation to the nearest facility that can treat
your condition, or ground Emergency transportation
would put your health or safety at risk
Member pays 20% ambulance coinsurance
Non-Emergency ground or air interfacility transfer to or from
a Network Facility when Preauthorized by KFHPWA.
Contact Member Services for Preauthorization.
Member pays 20% ambulance coinsurance
Hospital-to-hospital ground transfers: No charge;
Member pays nothing
8.F.a
Packet Pg. 56 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 15
Cancer Screening and Diagnostic Services
Routine cancer screening covered as Preventive Services in
accordance with the well care schedule established by
KFHPWA and the Patient Protection and Affordable Care Act
of 2010. The well care schedule is available in Kaiser
Permanente medical centers, at www.kp.org/wa, or upon
request from Member Services. See Preventive Services for
additional information.
Member pays $10 Copayment
Diagnostic laboratory and diagnostic services for cancer. See
Diagnostic Laboratory and Radiology Services for additional
information. Preventive laboratory/radiology services are
covered as Preventive Services.
No charge; Member pays nothing
Circumcision
Circumcision.
Non-Emergency inpatient hospital services require
Preauthorization.
Hospital - Inpatient: No charge; Member pays
nothing
Hospital - Outpatient: Member pays $10
Copayment
Outpatient Services: Member pays $10 Copayment
Clinical Trials
Notwithstanding any other provision of this document, the
Plan provides benefits for Routine Patient Costs of qualified
individuals in approved clinical trials, to the extent benefits
for these costs are required by federal and state law.
Routine patient costs include all items and services consistent
with the coverage provided in the plan (or coverage) that is
typically covered for a qualified individual who is not
enrolled in a clinical trial.
Clinical trials are a phase I, phase II, phase III, or phase IV
clinical trial that is conducted in relation to the prevention,
detection, or treatment of cancer or other life-threatening
disease or condition. “Life threatening condition” means any
disease or condition from which the likelihood of d eath is
probable unless the course of the disease or condition is
interrupted.
Clinical trials require Preauthorization.
Hospital - Inpatient:
No charge; Member pays nothing
Hospital - Outpatient:
Member pays $10 Copayment
Outpatient Services:
Member pays $10 Copayment
Exclusions: Routine patient costs do not include: (i) the investigational item, device, or service, itself; (ii) items and
services that are provided solely to satisfy data collection and analysis needs and that are not u sed in the direct clinical
8.F.a
Packet Pg. 57 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 16
management of the patient; or (iii) a service that is clearly inconsistent with widely accepted and established standards
of care for a particular diagnosis
Dental Services and Dental Anesthesia
Dental services (i.e., routine care, evaluation and treatment)
including accidental injury to natural teeth.
Not covered; Member pays 100% of all charges
Dental services in preparation for treatment including but not
limited to: chemotherapy, radiation therapy, and organ
transplants. Dental services in preparation for treatment
require Preauthorization.
Dental problems such as infections requiring emergency
treatment outside of standard business hours are covered as
Emergency Services.
Hospital - Inpatient: No charge; Member pays
nothing
Hospital - Outpatient: Member pays $10
Copayment
Outpatient Services: Member pays $10 Copayment
General anesthesia services and related facility charges for
dental procedures for Members who are under 7 years of age
or are physically or developmentally disabled or have a
Medical Condition where the Member’s health would be put
at risk if the dental procedure were performed in a dentist’s
office.
General anesthesia services for dental procedures require
Preauthorization.
Hospital - Inpatient: No charge; Member pays
nothing
Hospital - Outpatient: Member pays $10
Copayment
Exclusions: Dentist’s or oral surgeon’s fees; dental care, surgery, services and appliances, including: treatment of
accidental injury to natural teeth, reconstructive surgery to the jaw in preparation for dental implants, dental implants,
periodontal surgery; any other dental service not specifically listed as covered
Devices, Equipment and Supplies (for home use)
• Durable medical equipment: Equipment which can
withstand repeated use, is primarily and customarily used
to serve a medical purpose, is useful only in the presence
of an illness or injury and is used in the Member’s home.
Durable medical equipment includes hospital beds,
wheelchairs, walkers, crutches, canes, blood glucose
monitors, external insulin pumps (including related
supplies such as tubing, syringe cartridges, cannulae and
inserters), oxygen and oxygen equipment, and
therapeutic shoes, modifications and shoe inserts for
severe diabetic foot disease. KFHPWA will determine if
equipment is made available on a rental or purchase
basis.
• Orthopedic appliances: Items attached to an impaired
Member pays 20% coinsurance
Annual Deductible does not apply to strip-based
blood glucose monitors, test strips, lancets or control
solutions.
8.F.a
Packet Pg. 58 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 17
body segment for the purpose of protecting the segment
or assisting in restoration or improvement of its function.
• Ostomy supplies: Supplies for the removal of bodily
secretions or waste through an artificial opening.
• Post-mastectomy bras/forms, limited to 2 every 6
months. Replacements within this 6-month period are
covered when Medically Necessary due to a change in
the Member’s condition.
• Prosthetic devices: Items which replace all or part of an
external body part, or function thereof.
• Sales tax for devices, equipment and supplies.
When provided in lieu of hospitalization, benefits will be the
greater of benefits available for devices, equipment and
supplies, home health or hospitalization. See Hospice for
durable medical equipment provided in a hospice setting.
Devices, equipment and supplies including repair, adjustment
or replacement of appliances and equipment require
Preauthorization.
Exclusions: Arch supports, including custom shoe modifications or inserts and their fittings not related to the
treatment of diabetes; orthopedic shoes that are not attached to an appliance; wigs/hair prosthesis; take-home
dressings and supplies following hospitalization; supplies, dressings, appliances, devices or services not specifically
listed as covered above; same as or similar equipment already in the Member’s possession; replacement or repair due
to loss, theft, breakage from willful damage, neglect or wrongful use, or due to personal preference; structural
modifications to a Member’s home or personal vehicle
Diabetic Education, Equipment and Pharmacy Supplies
Diabetic education and training. Member pays $10 Copayment
Diabetic equipment: Blood glucose monitors and external
insulin pumps (including related supplies such as tubing,
syringe cartridges, cannulae and inserters), and therapeutic
shoes, modifications and shoe inserts for severe diabetic foot
disease. See Devices, Equipment and Supplies for additional
information.
Member pays 20% coinsurance
Annual Deductible does not apply to strip-based
blood glucose monitors, test strips, lancets or control
solutions.
Diabetic pharmacy supplies: Insulin, lancets, lancet devices,
needles, insulin syringes, disposable insulin pens, pen
needles, glucagon emergency kits, prescriptive oral agents
and blood glucose test strips for a supply of 30 days or less
per item. Certain brand name insulin drugs will be covered at
the generic level. See Drugs – Outpatient Prescription for
additional pharmacy information.
Preferred generic drugs (Tier 1): Member pays
$10 Copayment per 30-days up to a 90-day supply
Preferred brand name drugs (Tier 2): Member
pays $10 Copayment per 30-days up to a 90-day
supply
Non-Preferred generic and brand name drugs
(Tier 3): Not covered; Member pays 100% of all
charges
8.F.a
Packet Pg. 59 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 18
Annual Deductible does not apply to strip-based
blood glucose monitors, test strips, lancets or control
solutions.
Note: A Member will not pay more than $100, not
subject to the Deductible, for a 30-day supply of
insulin to comply with state law requirements. Any
cost sharing paid will apply toward the annual
Deductible.
Diabetic retinal screening. No charge; Member pays nothing
Dialysis (Home and Outpatient)
Dialysis in an outpatient or home setting is covered for
Members with acute kidney failure or end-stage renal disease
(ESRD).
Dialysis requires Preauthorization.
Outpatient Services: Member pays $10 Copayment
Injections administered by a Network Provider in a clinical
setting during dialysis.
Outpatient Services: Member pays $10 Copayment
Self-administered injectables. See Drugs – Outpatient
Prescription for additional pharmacy information.
Preferred generic drugs (Tier 1): Member pays
$10 Copayment per 30-days up to a 90-day supply
Preferred brand name drugs (Tier 2): Member
pays $10 Copayment per 30-days up to a 90-day
supply
Non-Preferred generic and brand name drugs
(Tier 3): Not covered; Member pays 100% of all
charges
Drugs - Outpatient Prescription
Prescription drugs, supplies and devices for a supply of 30
days or less including diabetic pharmacy supplies (insulin,
lancets, lancet devices, needles, insulin syringes, disposable
insulin pens, pen needles and blood glucose test strips),
mental health and wellness drugs, self-administered
injectables, medications for the treatment arising from sexual
assault, and routine costs for prescription medications
provided in a clinical trial. “Routine costs” means items and
services delivered to the Member that are consistent with and
typically covered by the plan or coverage for a Member who
is not enrolled in a clinical trial.
All drugs, supplies and devices must be obtained at a
Preferred generic drugs (Tier 1): Member pays
$10 Copayment per 30-days up to a 90-day supply
Preferred brand name drugs (Tier 2): Member
pays $10 Copayment per 30-days up to a 90-day
supply
Non-Preferred generic and brand name drugs
(Tier 3): Not covered; Member pays 100% of all
charges
8.F.a
Packet Pg. 60 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 19
KFHPWA-designated pharmacy except for drugs dispensed
for Emergency services or for Emergency services obtained
outside of the KFHPWA Service Area, including out of the
country. Information regarding KFHPWA-designated
pharmacies is reflected in the KFHPWA Provider Directory
or can be obtained by contacting Kaiser Permanente Member
Services.
Prescription drug Cost Shares are payable at the time of
delivery. Certain brand name insulin drugs are covered at the
generic drug Cost Share.
Members may be eligible to receive an emergency fill for
certain prescription drugs filled outside of KFHPWA’s
business hours or when KFHPWA cannot reach the prescriber
for consultation. For emergency fills, Members pay the
prescription drug Cost Share for each 7-day supply or less, or
the minimum packaging size available at the time the
emergency fill is dispensed. A list of prescription drugs
eligible for emergency fills is available on the pharmacy
website at www.kp.org/wa/formulary. Members can request
an emergency fill by calling 1-855-505-8107.
Certain drugs are subject to Preauthorization as shown in the
Preferred drug list (formulary) available at
www.kp.org/wa/formulary.
Annual Deductible does not apply to strip-based
blood glucose monitors, test strips, lancets or control
solutions.
Note: A Member will not pay more than $100, not
subject to the Deductible, for a 30-day supply of
insulin to comply with state law requirements. Any
cost sharing paid will apply toward the annual
Deductible.
Injections administered by a Network Provider in a clinical
setting.
Member pays $10 Copayment
Over-the-counter drugs not included under Reproductive
Health
Not covered; Member pays 100% of all charges
Mail order drugs dispensed through the KFHPWA-designated
mail order service.
Member pays the prescription drug Cost Share for
each 30 day supply or less
Annual Deductible does not apply to strip-based
blood glucose monitors, test strips, lancets or control
solutions.
Note: A Member will not pay more than $100, not
subject to the Deductible, for a 30-day supply of
insulin to comply with state law requirements. Any
cost-sharing paid will apply toward the annual
Deductible.
The KFHPWA Preferred drug list is a list of prescription drugs, supplies, and devices considered to have acceptable
efficacy, safety and cost-effectiveness. The Preferred drug list is maintained by a committee consisting of a group of
physicians, pharmacists and a consumer representative who review the scientific evidence of these products and
determine the Preferred and Non-Preferred status as well as utilization management requirements. Preferred drugs
generally have better scientific evidence for safety and effectiveness and are more affordable than Non-Preferred
drugs. The preferred drug list is available at www.kp.org/wa/formulary, or upon request from Member Services.
8.F.a
Packet Pg. 61 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 20
Members may request a coverage determination by contacting Mem ber Services. Coverage determination reviews
may include requests to cover non-preferred drugs, obtain Preauthorization for a specific drug, or exceptions to other
utilization management requirements, such as quantity limits. If coverage of a non -Preferred drug is approved, the
drug will be covered at the Preferred drug level.
Prescription drugs are drugs which have been approved by the Food and Drug Administration (FDA) and which can,
under federal or state law, be dispensed only pursuant to a prescription order. These drugs, including off-label use of
FDA-approved drugs (provided that such use is documented to be effective in one of the standard reference
compendia; a majority of well-designed clinical trials published in peer-reviewed medical literature document
improved efficacy or safety of the agent over standard therapies, or over placebo if no standard therapies exist; or by
the federal secretary of Health and Human Services) are covered. “Standard reference compendia” means the
American Hospital Formulary Service – Drug Information; the American Medical Association Drug Evaluation; the
United States Pharmacopoeia – Drug Information, or other authoritative compendia as identified from time to time by
the federal secretary of Health and Human Services. “Peer-reviewed medical literature” means scientific studies
printed in health care journals or other publications in which original manuscripts are published only after having been
critically reviewed for scientific accuracy, validity and reliability by unbiased independent experts. Peer-reviewed
medical literature does not include in-house publications of pharmaceutical manufacturing companies.
Generic drugs are dispensed whenever available. A generic drug is a drug that is the pharmaceutical equivalent to one
or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting
the same standards of safety, purity, strength and effectiveness as the brand name drug. Brand name drugs are
dispensed if there is not a generic equivalent. In the event the Member elects to purchase a brand-name drug instead of
the generic equivalent (if available), the Member is responsible for paying the difference in cost in addition to the
prescription drug Cost Share, which does not apply to the Out-of-pocket Limit.
Drug coverage is subject to utilization management that includes Preauthorization, step therapy (when a Member tries
a certain medication before receiving coverage for a similar, but non -Preferred medication), limits on drug quantity or
days supply and prevention of overutilization, underutilization, therapeutic duplication, drug -drug interactions,
incorrect drug dosage, drug-allergy contraindications and clinical abuse/misuse of drugs. If a Member has a new
prescription for a chronic condition, the Member may request a coordination of medications so that medications for
chronic conditions are refilled on the same schedule (synchronized). Cost -shares for the initial fill of the medication
will be adjusted if the fill is less than the standard quantity. Please contact Member Services for more information.
Specialty drugs are high-cost drugs prescribed by a physician that requires close supervision and monitoring for
serious and/or complex conditions, such as rheumatoid arthritis, hepatitis or multiple sclerosis. Specialty drugs must
be obtained through KFHPWA’s preferred specialty pharmacy vendor and/or network of specialty pharmacies and are
covered at the appropriate cost share above. For a list of specialty drugs or more information about KFHPWA’s
specialty pharmacy network, please go to the KFHPWA website at www.kp.org/wa/formulary or contact Member
Services at 206-630-4636 or toll-free at 1-888-901-4636.
The Member’s Right to Safe and Effective Pharmacy Services: State and federal laws establish standards to assure
safe and effective pharmacy services, and to guarantee Members’ right to know what drugs are covered and the
coverage limitations. Members who would like more information about the drug coverage policies, or have a ques tion
or concern about their pharmacy benefit, may contact KFHPWA at 206-630-4636 or toll-free 1-888-901-4636 or by
accessing the KFHPWA website at www.kp.org/wa.
Members who would like to know more about their rights under the law, or think any services received while enrolled
may not conform to the terms of the EOC, may contact the Washington State Office of Insurance Commissioner at
toll-free 1-800-562-6900. Members who have a concern about the pharmacists or pharmaci es serving them may call
the Washington State Department of Health at toll-free 1-800-525-0127.
8.F.a
Packet Pg. 62 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 21
Prescription Drug Coverage and Medicare: This benefit, for purposes of Creditable Coverage, is actuarially equal
to or greater than the Medicare Part D prescription drug benefit. Members who are also eligible for Medicare Part D
can remain covered and will not be subject to Medicare-imposed late enrollment penalties should they decide to enroll
in a Medicare Part D plan at a later date; however, the Member could be subject to payment of higher Part D
premiums if the Member subsequently has a break in creditable coverage of 63 continuous days or longer before
enrolling in a Part D plan. A Member who discontinues coverage must meet eligibility requirements in order to re-
enroll.
Exclusions: Over-the-counter drugs, supplies and devices not requiring a prescription under state law or regulations;
drugs and injections for anticipated illness while traveling; drugs and injections for cosmetic purposes; vitamins,
including most prescription vitamins; replacement of lost, stolen, or damaged drugs or devices; administration of
excluded drugs and injectables; drugs used in the treatment of sexual dysfunction disorders; compounds which include
a non-FDA approved drug; growth hormones for idiopathic short stature without growth hormone deficiency;
prescription drugs/products available over-the-counter or have an over-the-counter alternative that is determined to be
therapeutically interchangeable.
Emergency Services
Emergency services at a Network Facility or non-Network
Facility. See Section XII. for a definition of Emergency.
Emergency services include professional services, treatment
and supplies, facility costs, outpatient charges for patient
observation and medical screening exams required to stabilize
a patient.
Members must notify KFHPWA by way of the Hospital
notification line within 24 hours of any admission, or as soon
thereafter as medically possible.
If a Member is admitted as an inpatient directly from an
emergency department, any Emergency services Copayment
is waived. Coverage is subject to the hospital services Cost
Share.
If two or more Members in the same Family Unit require
Emergency services as a result of the same accident, coverage
for all Members will be subject to only one Emergency
services Copayment.
If a Member is hospitalized in a non-Network Facility,
KFHPWA reserves the right to require transfer of the
Member to a Network Facility upon consultation between a
Network Provider and the attending physician. If the Member
refuses to transfer to a Network Facility or does not notify
KFHPWA within 24 hours following admission, all further
costs incurred during the hospitalization are the responsibility
of the Member.
Follow-up care which is a direct result of the Emergency must
be received from a Network Provider, unless Preauthorization
is obtained for such follow-up care from a non-Network
Provider.
Network Facility: Member pays $75 Copayment
Non-Network Facility: Member pays $125
Copayment
8.F.a
Packet Pg. 63 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 22
Gender Health Services
Medically Necessary medical and surgical services for gender
reassignment. Consultation and treatment requires
Preauthorization.
Prescription drugs are covered the same as for any other
condition (see Drugs - Outpatient Prescription for coverage).
Counseling services are covered the same as for any other
condition (see Mental Health and Wellness for coverage).
Non-Emergency inpatient hospital services require
Preauthorization.
Hospital - Inpatient: No charge; Member pays
nothing
Hospital - Outpatient: Member pays $10
Copayment
Outpatient Services: Member pays $10 Copayment
Exclusions: Cosmetic services and surgery not related to gender affirming treatment (i.e., face lift or calf implants),
complications of non-Covered Services
Hearing Examinations and Hearing Aids
Hearing exams for hearing loss and evaluation are covered
only when provided at KFHPWA-approved facilities.
Cochlear implants or Bone Anchored Hearing Aids (BAHA)
when in accordance with KFHPWA clinical criteria.
Covered services for cochlear implants and BAHA include
diagnostic testing, pre-implant testing, implant surgery, post-
implant follow-up, speech therapy, programming and
associated supplies (such as transmitter cable, and batteries).
Hospital - Inpatient:
No charge; Member pays nothing
Hospital - Outpatient:
Member pays $10 Copayment
Outpatient Services:
Member pays $10 Copayment
Hearing aids including hearing aid examinations.
Not covered; Member pays 100% of all charges
Exclusions: Programs or treatments for hearing loss or hearing care including, but not limited to, externally worn
hearing or surgically implanted hearing aids and the surgery and services necessary to implant them except as
described above; hearing screening tests required under Preventive Services
Home Health Care
Home health care when the following criteria are met:
• Except for patients receiving palliative care services, the
Member must be unable to leave home due to a health
problem or illness. Unwillingness to travel and/or arrange
for transportation does not constitute inability to leave the
home.
No charge; Member pays nothing
8.F.a
Packet Pg. 64 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 23
• The Member requires intermittent skilled home health
care, as described below.
• KFHPWA’s medical director determines that such
services are Medically Necessary and are most
appropriately rendered in the Member’s home.
Covered Services for home health care may include the
following when rendered pursuant to a KFHPWA-approved
home health care plan of treatment: nursing care; restorative
physical, occupational, respiratory and speech therapy;
durable medical equipment; medical social worker and
limited home health aide services.
Home health services are covered on an intermittent basis in
the Member’s home. “Intermittent” means care that is to be
rendered because of a medically predictable recurring need
for skilled home health care. “Skilled home health care”
means reasonable and necessary care for the treatment of an
illness or injury which requires the skill of a nurse or
therapist, based on the complexity of the service and the
condition of the patient and which is performed directly by an
appropriately licensed professional provider.
Home health care requires Preauthorization.
Exclusions: Private duty nursing; housekeeping or meal services; any care provided by or for a family member; any
other services rendered in the home which do not meet the definition of skilled home health care above
Hospice
Hospice care when provided by a licensed hospice care
program. A hospice care program is a coordinated program of
home and inpatient care, available 24 hours a day. This
program uses an interdisciplinary team of personnel to
provide comfort and supportive services to a Member and any
family members who are caring for the member, who is
experiencing a life-threatening disease with a limited
prognosis. These services include acute, respite and home
care to meet the physical, psychosocial and special needs of
the Member and their family during the final stages of illness.
In order to qualify for hospice care, the Member’s provider
must certify that the Member is terminally ill and is eligible
for hospice services.
Inpatient Hospice Services. For short-term care, inpatient
hospice services are covered with Preauthorization.
Respite care is covered to provide continuous care of the
Member and allow temporary relief to family members from
the duties of caring for the Member for a maximum of 5
consecutive days per 3-month period of hospice care.
Other covered hospice services, when billed by a licensed
No charge; Member pays nothing
8.F.a
Packet Pg. 65 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 24
hospice program, may include the following:
• Inpatient and outpatient services and supplies for injury
and illness.
• Semi-private room and board, except when a private
room is determined to be necessary.
• Durable medical equipment when billed by a licensed
hospice care program.
Hospice care requires Preauthorization.
Exclusions: Private duty nursing; financial or legal counseling services; meal services; any services provided by
family members
Hospital - Inpatient and Outpatient
The following inpatient medical and surgical services are
covered:
• Room and board, including private room when
prescribed, and general nursing services.
• Hospital services (including use of operating room,
anesthesia, oxygen, x-ray, laboratory and radiotherapy
services).
• Drugs and medications administered during confinement.
• Medical implants.
• Withdrawal management services.
Outpatient hospital includes ambulatory surgical centers.
Alternative care arrangements may be covered as a cost-
effective alternative in lieu of otherwise covered Medically
Necessary hospitalization or other Medically Necessary
institutional care with the consent of the Member and
recommendation from the attending physician or licensed
health care provider. Alternative care arrangements in lieu of
covered hospital or other institutional care must be
determined to be appropriate and Medically Necessary based
upon the Member’s Medical Condition. Such care is covered
to the same extent the replaced Hospital Care is covered.
Alternative care arrangements require Preauthorization.
Members receiving the following nonscheduled services are
required to notify KFHPWA by way of the Hospital
notification line within 24 hours following any admission, or
as soon thereafter as medically possible: acute withdrawal
management services, Emergency psychiatric services,
Emergency services, labor and delivery and inpatient
admissions needed for treatment of Urgent Conditions that
cannot reasonably be delayed until Preauthorization can be
obtained.
Coverage for Emergency services in a non-Network Facility
and subsequent transfer to a Network Facility is set forth in
Emergency Services.
Hospital - Inpatient: No charge; Member pays
nothing
Hospital - Outpatient: Member pays $10
Copayment
8.F.a
Packet Pg. 66 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 25
Non-Emergency hospital services require Preauthorization.
Exclusions: Take home drugs, dressings and supplies following hospitalization; internally implanted insulin pumps,
artificial larynx and any other implantable device that have not been approved by KFHPWA’s medical director
Infertility (including sterility)
General counseling and one consultation visit to diagnose
infertility conditions.
Member pays $10 Copayment
Specific diagnostic services, treatment and prescription drugs.
Not covered; Member pays 100% of all charges
Infusion Therapy
Administration of Medically Necessary infusion therapy in an
outpatient setting.
Member pays $10 Copayment
Administration of Medically Necessary infusion therapy in
the home setting.
To receive benefits for the administration of select infusion
medications in the home setting, the drugs must be obtained
through KFHPWA’s preferred specialty pharmacy and
administered by a provider we identify. For a list of these
specialty drugs or for more information about KFHPWA’s
specialty pharmacy network, please go to the KFHPWA
website at www.kp.org/wa/formulary or contact Member
Services.
No charge; Member pays nothing
Associated infused medications includes, but is not limited to:
• Antibiotics.
• Hydration.
• Chemotherapy.
• Pain management.
No charge; Member pays nothing
Laboratory and Radiology
Nuclear medicine, radiology, ultrasound and laboratory
services, including high end radiology imaging services such
as CAT scan, MRI and PET which are subject to
Preauthorization except when associated with Emergency
services or inpatient services. Please contact Member
Services for any questions regarding these services.
No charge; Member pays nothing
Urine Drug Screening: No charge, Member pays
nothing. Limited to 2 tests per calendar year.
8.F.a
Packet Pg. 67 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 26
Services received as part of an emergency visit are covered as
Emergency Services.
Preventive laboratory and radiology services are covered in
accordance with the well care schedule established by
KFHPWA and the Patient Protection and Affordable Care Act
of 2010. The well care schedule is available in Kaiser
Permanente medical centers, at www.kp.org/wa, or upon
request from Member Services.
Benefits are applied in the order claims are received
and processed.
After Allowance: No charge; Member pays nothing
Manipulative Therapy
Manipulative therapy of the spine and extremities when in
accordance with KFHPWA clinical criteria, limited to a total
of 10 visits per calendar year. Preauthorization is not
required.
Member pays $10 Copayment
Exclusions: Supportive care rendered primarily to maintain the level of correction already achieved; care rendered
primarily for the convenience of the Member; care rendered on a non-acute, asymptomatic basis; charges for any other
services that do not meet KFHPWA clinical criteria as Medically Necessary
Maternity and Pregnancy
Maternity care and pregnancy services, including care for
complications of pregnancy and prenatal and postpartum care
are covered for all female Members including dependent
daughters.
Delivery and associated Hospital Care, including home births
and birthing centers. Home births are considered outpatient
services.
Members must notify KFHPWA by way of the Hospital
notification line within 24 hours of any admission, or as soon
thereafter as medically possible. The Member’s physician, in
consultation with the Member, will determine the Member’s
length of inpatient stay following delivery.
Prenatal testing for the detection of congenital and heritable
disorders when Medically Necessary as determined by
KFHPWA’s medical director and in accordance with Board
of Health standards for screening and diagnostic tests during
pregnancy.
Hospital - Inpatient: No charge; Member pays
nothing
Hospital - Outpatient: Member pays $10
Copayment
Outpatient Services: Member pays $10 Copayment
Termination of pregnancy.
Non-Emergency inpatient hospital services require
Preauthorization.
Hospital - Inpatient: No charge; Member pays
nothing
Hospital - Outpatient: Member pays $10
Copayment
8.F.a
Packet Pg. 68 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 27
Outpatient Services: Member pays $10 Copayment
Exclusions: Birthing tubs; genetic testing of non-Members; fetal ultrasound in the absence of medical indications
Mental Health and Wellness
Mental health and wellness services provided at the most
clinically appropriate and Medically Necessary level of
mental health care intervention as determined by KFHPWA’s
medical director. Treatment may utilize psychiatric,
psychological and/or psychotherapy services to achieve these
objectives.
Mental health and wellness services including medical
management and prescriptions are covered the same as fo r
any other condition.
Applied behavioral analysis (ABA) therapy, limited to
outpatient treatment of an autism spectrum disorder or, has a
developmental disability for which there is evidence that
ABA therapy is effective, as diagnosed and prescribed by a
neurologist, pediatric neurologist, developmental pediatrician,
psychologist or psychiatrist experienced in the diagnosis and
treatment of autism. Documented diagnostic assessments,
individualized treatment plans and progress evaluations are
required.
Services for any involuntary court-ordered treatment program
shall be covered only if determined to be Medically
Necessary by KFHPWA’s medical director. Services
provided under involuntary commitment statutes are covered.
If a Member is admitted as an inpatient directly from an
emergency department, any Emergency services Copayment
is waived. Coverage is subject to the hospital services Cost
Share. Coverage for services incurred at non-Network
Facilities shall exclude any charges that would otherwise be
excluded for hospitalization within a Network Facility.
Members must notify KFHPWA by way of the Hospital
notification line within 24 hours of any admission, or as soon
thereafter as medically possible.
Mental health and wellness services rendered to treat mental
disorders are covered. Mental Disorders means mental
disorders covered in the most recent edition of the Diagnostic
and Statistical Manual of Mental Disorders published by the
American Psychiatric Association, except as otherwise
excluded under Sections IV. or V. Mental Health and
Wellness Services means Medically Necessary outpatient
Hospital - Inpatient: No charge; Member pays
nothing
Hospital - Outpatient: Member pays $10
Copayment
Outpatient Services: Member pays $10 Copayment
Group Visits: No charge; Member pays nothing
8.F.a
Packet Pg. 69 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 28
services, Residential Treatment, partial hospitalization
program, and inpatient services provided by a licensed facility
or licensed providers; including advanced practice psychiatric
nurses, mental health and wellness counselors, marriage and
family therapists and social workers, except as otherwise
excluded under Sections IV. or V.
Inpatient mental health and wellness services, Residential
Treatment and partial hospitalization programs must be
provided at a hospital or facility that KFHPWA has approved
specifically for the treatment of mental disorders.
Non-Emergency inpatient and outpatient hospital services,
including Residential Treatment and partial hospitalization
programs, require Preauthorization.
Exclusions: Academic or career counseling; personal growth or relationship enhancement; assessment and treatment
services that are primarily vocational and academic; court-ordered or forensic treatment, including reports and
summaries, not considered Medically Necessary; work or school ordered assessment and treatment not considered
Medically Necessary; counseling for overeating not considered Medically Necessary; specialty treatment programs
such as “behavior modification programs” not considered Medically Necessary; relationship counseling or phase of
life problems (Z code only diagnoses); custodial care; experimental or investigational therapies, such as wilderness
therapy.
Naturopathy
Naturopathy.
Limited to 3 visits per medical diagnosis per calendar year
without Preauthorization. Additional visits are covered with
Preauthorization.
Laboratory and radiology services are covered only when
obtained through a Network Facility.
Member pays $10 Copayment
Exclusions: Herbal supplements; nutritional supplements; any services not within the scope of the practitioner’s
licensure
Newborn Services
Newborn services are covered the same as for any other
condition. Any Cost Share for newborn services is separate
from that of the mother.
Preventive services for newborns are covered under
Preventive Services.
See Section VI.A.3. for information about temporary
coverage for newborns.
Hospital - Inpatient: No charge; Member pays
nothing
During the baby’s initial hospital stay while the birth
mother and baby are both confined, any applicable
Deductible and Copayment for the newborn are
waived
Hospital - Outpatient: Member pays $10
Copayment
8.F.a
Packet Pg. 70 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 29
Outpatient Services: Member pays $10 Copayment
Nutritional Counseling
Nutritional counseling.
Services related to a healthy diet to prevent obesity are
covered as Preventive Services.
Member pays $10 Copayment
Exclusions: Nutritional supplements; weight control self-help programs or memberships, such as Weight Watchers,
Jenny Craig, or other such programs
Nutritional Therapy
Medical formula necessary for the treatment of
phenylketonuria (PKU), specified inborn errors of
metabolism, or other metabolic disorders.
No charge; Member pays nothing
Enteral therapy is covered when Medical Necessity criteria is
met and when given through a PEG, J tube or orally, or for an
eosinophilic gastrointestinal disorder.
Necessary equipment and supplies for the administration of
enteral therapy are covered as Devices, Equipment and
Supplies.
Member pays 20% coinsurance
Parenteral therapy (total parenteral nutrition).
Necessary equipment and supplies for the administration of
parenteral therapy are covered as Devices, Equipment and
Supplies.
No charge; Member pays nothing
Exclusions: Any other dietary formulas, medical foods, or oral nutritional supplements that do not meet Medical
Necessity criteria or are not related to the treatment of inborn errors of metabolism; special diets; prepared
foods/meals
Obesity Related Services
Bariatric surgery and related hospitalizations when KFHPWA
criteria are met.
Services related to obesity screening and counseling are
covered as Preventive Services.
Obesity related services require Preauthorization.
Hospital - Inpatient: No charge; Member pays
nothing
Hospital - Outpatient: Member pays $10
Copayment
Outpatient Services: Member pays $10 Copayment
8.F.a
Packet Pg. 71 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 30
Exclusions: All other obesity treatment and treatment for morbid obesity including any medical services, drugs or
supplies, regardless of co-morbidities, except as described above; specialty treatment programs such as weight control
self-help programs or memberships, such as Weight Watchers, Jenny Craig or other such pr ograms; medications and
related physician visits for medication monitoring
On the Job Injuries or Illnesses
On the job injuries or illnesses.
Hospital - Inpatient: Not covered; Member pays
100% of all charges
Hospital - Outpatient: Not covered; Member pays
100% of all charges
Outpatient Services: Not covered; Member pays
100% of all charges
Exclusions: Confinement, treatment or service that results from an illness or injury arising out of or in the course of
any employment for wage or profit including injuries, illnesses or conditions incurred as a result of self -employment
Oncology
Radiation therapy, chemotherapy, oral chemotherapy.
See Infusion Therapy for infused medications.
Radiation Therapy and Chemotherapy:
Member pays $10 Copayment
Oral Chemotherapy Drugs:
Preferred generic drugs (Tier 1): Member pays
$10 Copayment per 30-days up to a 90-day supply
Preferred brand name drugs (Tier 2): Member
pays $10 Copayment per 30-days up to a 90-day
supply
Non-Preferred generic and brand name drugs
(Tier 3): Not covered; Member pays 100% of all
charges
Optical (vision)
Routine eye examinations and refractions, limited to once
every 12 months.
Eye and contact lens examinations for eye pathology and to
monitor Medical Conditions, as often as Medically
Routine Exams: Member pays $10 Copayment
Exams for Eye Pathology: Member pays $10
Copayment
8.F.a
Packet Pg. 72 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 31
Necessary.
Contact lenses or framed lenses for eye pathology when
Medically Necessary.
One contact lens per diseased eye in lieu of an intraocular
lens is covered following cataract surgery provided the
Member has been continuously covered by KFHPWA since
such surgery. In the event a Member's age or medical
condition prevents the Member from having an intraocular
lens or contact lens, framed lenses are available. Replacement
of lenses for eye pathology, including fo llowing cataract
surgery, is covered only once within a 12 -month period and
only when needed due to a change in the Member’s
prescription.
Frames and Lenses: Not covered; Member pays
100% of all charges
Contact Lenses or Framed Lenses for Eye
Pathology: No charge; Member pays nothing
Exclusions: Eyeglasses; contact lenses, contact lens evaluations, fittings and examinations not related to eye
pathology; orthoptic therapy (i.e. eye training); evaluations and s urgical procedures to correct refractions not related
to eye pathology and complications related to such procedures
Oral Surgery
Reduction of a fracture or dislocation of the jaw or facial
bones; excision of tumors or non-dental cysts of the jaw,
cheeks, lips, tongue, gums, roof and floor of the mouth; and
incision of salivary glands and ducts.
KFHPWA’s medical director will determine whether the care
or treatment required is within the category of Oral Surgery or
Dental Services.
Oral surgery requires Preauthorization.
Hospital - Inpatient: No charge; Member pays
nothing
Hospital - Outpatient: Member pays $10
Copayment
Outpatient Services: Member pays $10 Copayment
Exclusions: Care or repair of teeth or dental structures of any type; tooth extractions or impacted teeth; services
related to malocclusion; services to correct the misalignment or malposition of teeth; any other services to the mouth,
facial bones or teeth which are not medical in nature
Outpatient Services
Covered outpatient medical and surgical services in a
provider’s office, including chronic disease management and
treatment arising from sexual assault. See Preventive Services
for additional information related to chronic disease
management.
See Hospital - Inpatient and Outpatient for outpatient hospital
medical and surgical services, including ambulatory surgical
Member pays $10 Copayment
8.F.a
Packet Pg. 73 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 32
centers.
Plastic and Reconstructive Surgery
Plastic and reconstructive services:
• Correction of a congenital disease or congenital anomaly.
• Correction of a Medical Condition following an injury or
resulting from surgery which has produced a major effect
on the Member’s appearance, when in the opinion o f
KFHPWA’s medical director such services can
reasonably be expected to correct the condition.
• Reconstructive surgery and associated procedures,
including internal breast prostheses, following a
mastectomy, regardless of when the mastectomy was
performed. Members are covered for all stages of
reconstruction on the non-diseased breast to produce a
symmetrical appearance. Complications of covered
mastectomy services, including lymphedemas, are
covered.
Plastic and reconstructive surgery requires Preauthoriza tion.
Hospital - Inpatient: No charge; Member pays
nothing
Hospital - Outpatient: Member pays $10
Copayment
Outpatient Services: Member pays $10 Copayment
Exclusions: Cosmetic services including treatment for complications resulting from cosmetic surgery; cosmetic
surgery; complications of non-Covered Services
Podiatry
Medically Necessary foot care.
Routine foot care covered when such care is directly related
to the treatment of diabetes and, when approved by
KFHPWA’s medical director, other clinical conditions that
effect sensation and circulation to the feet.
Member pays $10 Copayment
Exclusions: All other routine foot care
Preventive Services
Preventive services in accordance with the well care schedule
established by KFHPWA. The well care schedule is available
in Kaiser Permanente medical centers, at www.kp.org/wa, or
upon request from Member Services.
Screening and tests with A and B recommendations by the
U.S. Preventive Services Task Force (USPSTF).
Services, tests and screening contained in the U.S. Health
Resources and Services Administration Bright Futures
guidelines as set forth by the American Academy of
Pediatricians.
Member pays $10 Copayment
8.F.a
Packet Pg. 74 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 33
Services, tests, screening and supplies recommended in the
U.S. Health Resources and Services Administration women’s
preventive and wellness services guidelines.
Immunizations recommended by the Centers for Disease
Control’s Advisory Committee on Immunization Practices.
Flu vaccines are covered up to the Allowed Amount when
provided by a non-Network Provider.
Preventive services include, but are not limited to, well adult
and well child physical examinations; immunizations and
vaccinations; pap smears; routine mammography screening;
routine prostate screening; and colorectal cancer screening for
Members who are age 50 or older or who are under age 50
and at high risk.
Preventive care for chronic disease management includes
treatment plans with regular monitoring, coordination of care
between multiple providers and settings, medication
management, evidence-based care, quality of care
measurement and results, and education and tools for patient
self-management support. In the event preventive, wellness or
chronic care management services are not available from a
Network Provider, non-network providers may provide these
services without Cost Share when Preauthorized.
Services provided during a preventive services visit, including
laboratory services, which are not in accordance with the
KFHPWA well care schedule are subject to Cost Shares. Eye
refractions are not included under preventive services.
Exclusions: Those parts of an examination and associated reports and immunizations that are not deemed Medically
Necessary by KFHPWA for early detection of disease; all other diagnostic services not otherwise stated above
Rehabilitation and Habilitative Care (massage,
occupational, physical and speech therapy, pulmonary
and cardiac rehabilitation) and Neurodevelopmental
Therapy
Rehabilitation services to restore function following illness,
injury or surgery, limited to the following restorative
therapies: occupational therapy, physical therapy, massage
therapy and speech therapy. Services are limited to those
necessary to restore or improve functional abilities when
physical, sensori-perceptual and/or communication
impairment exists due to injury, illness or surgery.
Outpatient services require a prescription or order from a
physician that reflects a written plan of care to restore
function and must be provided by a rehabilitation team that
may include a physician, nurse, physical therapist,
occupational therapist, massage therapist or speech therapist.
Hospital - Inpatient: No charge; Member pays
nothing
Outpatient Services: Member pays $10 Copayment
Group visits (occupational, physical, speech
therapy or learning services):
Member pays one half of the office visit Copayment
and applicable Plan Coinsurance
8.F.a
Packet Pg. 75 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 34
Preauthorization is not required.
Habilitative care includes Medically Necessary services or
devices designed to help a Member keep, learn, or improve
skills and functioning for daily living. Services may include:
occupational therapy, physical therapy, speech therapy when
prescribed by a physician. Examples include therapy for a
child who is not walking or talking at the expected age. These
services may include physical and occupational therapy,
speech-language pathology and other services for people with
disabilities in a variety of inpatient and/or outpatient settings.
Neurodevelopmental therapy to restore or improve function
including maintenance in cases where significant
deterioration in the Member’s condition would result without
the services, limited to the following therapies: occupational
therapy, physical therapy and speech therapy. There is no
visit limit for Neurodevelopmental Therapy services.
Limited to a combined total of 60 inpatient days and 60
outpatient visits per calendar year for all Rehabilitation and
Habilitative care.
Services with mental health diagnoses are covered with no
limit.
Non-Emergency inpatient hospital services require
Preauthorization.
Cardiac rehabilitation is covered up to a total of 36 visits per
cardiac event when clinical criteria is met.
Limited to a combined total of 60 inpatient days and 60
outpatient visits per calendar year for all Rehabilitation and
Habilitative care.
Member pays $10 Copayment
Group visits (occupational, physical, speech
therapy or learning services):
Member pays one half of the office visit Copayment
and applicable Plan Coinsurance
Pulmonary rehabilitation is covered when clinical criteria is
met.
Preauthorization is required after initial visit.
Limited to a combined total of 60 inpatient days and 60
outpatient visits per calendar year for all Rehabilitation and
Habilitative care.
Member pays $10 Copayment
Group visits (occupational, physical, speech
therapy or learning services):
Member pays one half of the office visit Copayment
and applicable Plan Coinsurance
Exclusions: Specialty treatment programs; inpatient Residential Treatment services; specialty rehabilitation programs
including “behavior modification programs”; recreational, life-enhancing, relaxation or palliative therapy;
8.F.a
Packet Pg. 76 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 35
implementation of home maintenance programs
Reproductive Health
Medically Necessary medical and surgical services for
reproductive health, including consultations, examinations,
procedures and devices, including device insertion and
removal.
See Maternity and Pregnancy for termination of pregnancy
services
Reproductive health is the care necessary to support the
reproductive system and the ability to reproduce.
Reproductive health includes contraception, cancer and
disease screenings, termination of pregnancy, maternity,
prenatal and postpartum care.
Hospital - Inpatient: No charge; Member pays
nothing
Hospital - Outpatient: No charge; Member pays
nothing
Outpatient Services: No charge; Member pays
nothing
All methods for Medically Necessary FDA-approved
(including over-the-counter) contraceptive drugs, devices and
products. Condoms are limited to 120 per 90-day supply.
Contraceptive drugs may be allowed up to a 12-month supply
and, when available, picked up in the provider’s office.
No charge; Member pays nothing
Sexual Dysfunction
One consultation visit to diagnose sexual dysfunction
conditions.
Member pays $10 Copayment
Specific diagnostic services, treatment and prescription drugs. Not covered; Member pays 100% of all charges
Exclusions: Diagnostic testing and medical treatment of sexual dysfunction regardless of origin or cause; devices,
equipment and supplies for the treatment of sexual dy sfunction
Skilled Nursing Facility
Skilled nursing care in a skilled nursing facility when full -
time skilled nursing care is necessary in the opinion of the
attending physician, limited to a total of 30 days per condition
per calendar year.
Care may include room and board; general nursing care;
drugs, biologicals, supplies and equipment ordinarily
provided or arranged by a skilled nur sing facility; and short-
term restorative occupational therapy, physical therapy and
speech therapy.
Skilled nursing care in a skilled nursing facility requires
No charge; Member pays nothing
8.F.a
Packet Pg. 77 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 36
Preauthorization.
Exclusions: Personal comfort items such as telephone and television; rest cures; domiciliary or Convalescent Care
Sterilization
FDA-approved female sterilization procedures, services and
supplies.
Non-Emergency inpatient hospital services require
Preauthorization.
No charge; Member pays nothing
Vasectomy.
Non-Emergency inpatient hospital services require
Preauthorization.
No charge; Member pays nothing
Exclusions: Procedures and services to reverse a sterilization
Substance Use Disorder
Substance use disorder services including inpatient
Residential Treatment; diagnostic evaluation and education;
organized individual and group counseling; and/or
prescription drugs unless excluded under Sections IV. or V.
Substance use disorder means a substance-related or addictive
disorder listed in the most current version of the Diagnostic
and Statistical Manual of Mental Disorders (DSM). For the
purposes of this section, the definition of Medically
Necessary shall be expanded to include those services
necessary to treat a substance use disorder condition that is
having a clinically significant impact on a Member’s
emotional, social, medical and/or occupational functioning.
Substance use disorder services are limited to the services
rendered by a physician (licensed under RCW 18.71 and
RCW 18.57), a psychologist (licensed under RCW 18.83), a
substance use disorder treatment program licensed for the
service being provided by the Washington State Department
of Social and Health Services (pursuant to RCW 70.96A), a
master’s level therapist (licensed under RCW 18.225.090), an
advance practice psychiatric nurse (licensed under RCW
18.79) or, in the case of non-Washington State providers,
those providers meeting equivalent licensing and certification
requirements established in the state where the provider’s
practice is located.
The severity of symptoms designates the appropriate level of
care and should be determined through a thorough assessment
completed by a licensed provider who recommends treatment
based on medical necessity criteria.
Hospital - Inpatient: No charge; Member pays
nothing
Outpatient Services: Member pays $10 Copayment
Group Visits: No charge; Member pays nothing
8.F.a
Packet Pg. 78 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 37
Court-ordered substance use disorder treatment shall be
covered only if determined to be Medically Necessary.
Preauthorization is required for outpatient, intensive
outpatient, and partial hospitalization services.
Preauthorization is required for Residential Treatment and
non-Emergency inpatient hospital services provided at out-of-
state facilities.
Preauthorization is not required for Residential Treatment and
non-Emergency inpatient hospital services provided in-state.
Member is given two days of treatment and is then subject to
medical necessity review for continued care. Member or
facility must notify KFHPWA within 24 hours of admission,
or as soon as possible. Member may request prior
authorization for Residential Treatment and non-Emergency
inpatient hospital services. Members may contact Member
Services to request Preauthorization.
Withdrawal Management Services for Alcoholism and
Substance Use Disorder.
Withdrawal management services means the management of
symptoms and complications of alcohol and/or substance
withdrawal. The severity of symptoms designates the
appropriate level of care and should be determined through a
thorough assessment completed by a licensed provider who
recommends treatment based on medical necessity criteria.
Outpatient withdrawal management services means the
symptoms resulting from abstinence are of mild/moderate
severity and withdrawal from alcohol and/or other drugs can
be managed with medication at an outpatient level of care by
an appropriately licensed clinician. Subacute withdrawal
management means symptoms associated with withdrawal
from alcohol and/or other drugs can be managed through
medical monitoring at a 24-hour facility or other outpatient
facility.
Preauthorization is required for outpatient withdrawal
management and subacute withdrawal management services.
"Acute withdrawal management services" means the
symptoms resulting from abstinence are so severe that
withdrawal from alcohol and/or drugs require medical
management in a hospital setting or behavioral health agency
(licensed and certified under RCW 71.24.037), which is
needed immediately to prevent serious impairment to the
Member's health.
Coverage for acute withdrawal management services are
provided without Preauthorization. If a Member is admitted
Emergency Services Network Facility: Member
pays $75 Copayment
Emergency Services Non-Network Facility:
Member pays $125 Copayment
Hospital - Inpatient: No charge; Member pays
nothing
8.F.a
Packet Pg. 79 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 38
as an inpatient directly from an emergency department, any
Emergency services Copayment is waived. Coverage is
subject to the hospital services Cost Share. Members must
notify KFHPWA by way of the Hospital notification line
within 24 hours of any admission, or as soon thereafter as
medically possible.
Member is given no less than two days of treatment,
excluding weekends and holidays, in a behavioral health
agency that provides inpatient or residential substance abuse
treatment; and no less than three days in a behavioral health
agency that provides withdrawal management services prior
to conducting a medical necessity review for continued care.
Member or facility must notify KFHPWA within 24 hours of
admission, or as soon as possible. Members may request
Preauthorization for Residential Treatment and non-
Emergency inpatient hospital services by contacting Member
Services.
KFHPWA reserves the right to require transfer of the
Member to a Network Facility/program upon consultation
between a Network Provider and the attending physician. If
the Member refuses transfer to a Network Facility/program,
all further costs incurred during the hospitalization are the
responsibility of the Member.
Exclusions: Experimental or investigational therapies, such as wilderness programs or aversion therapy; facilities and
treatment programs which are not certified by the Department of Social Health Services
Telehealth Services
Telemedicine
Services provided by the use of real-time interactive audio
and video communications or store and forward technology
between the patient at the originating site and a Network
Provider at another location. Store and forward technology
means sending a Member’s medical information from an
originating site to the provider at a distant site for later
review. The provider follows up with a medical diagnosis for
the Member and helps manage their care. Services must meet
the following requirements:
• Be a Covered Service under this EOC.
• The originating site is qualified to provide the
service.
• If the service is provided through store and forward
technology, there must be an associated office visit
between the Member and the referring provider.
• Is Medically Necessary.
No charge; Member pays nothing
Telephone Services and Online (E-Visits)
Scheduled telephone visits with a Network Provider are
covered.
No charge; Member pays nothing
8.F.a
Packet Pg. 80 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 39
Online (E-Visits): A Member logs into the secure Member
site at www.kp.org/wa and completes a questionnaire. A
KFHPWA medical provider reviews the questionnaire and
provides a treatment plan for select conditions, including
prescriptions. Online visits are not available to Members
during in-person visits at a KFHPWA facility or pharmacy.
More information is available at
https://wa.kaiserpermanente.org/html/public/services/e-visit.
Exclusions: Fax and e-mail; telehealth services with non-contracted providers; telehealth services in states where
prohibited by law; all other services not listed above
Temporomandibular Joint (TMJ)
Medical and surgical services and related hospital charges for
the treatment of temporomandibular joint (TMJ) disorders
including:
• Medically Necessary orthognathic procedures for the
treatment of severe TMJ disorders which have failed
non-surgical intervention.
• Radiology services.
• TMJ specialist services.
• Fitting/adjustment of splints.
Non-Emergency inpatient hospital services require
Preauthorization.
Hospital - Inpatient: No charge; Member pays
nothing
Hospital - Outpatient: Member pays $10
Copayment
Outpatient Services: Member pays $10 Copayment
TMJ appliances. See Devices, Equipment and Supplies for
additional information.
Member pays 20% coinsurance
Exclusions: Treatment for cosmetic purposes; bite blocks; dental services including orthodontic therapy and braces
for any condition; any orthognathic (jaw) surgery in the absence of a diagnosis of TMJ, or severe obstructive sleep
apnea; hospitalizations related to these exclusions
Tobacco Cessation
Individual/group counseling and educational materials. No charge; Member pays nothing
Approved pharmacy products. See Drugs – Outpatient
Prescription for additional pharmacy information.
KFHPWA-designated tobacco cessation program:
No charge; Member pays nothing when prescribed as
part of the KFHPWA-designated tobacco cessation
program and dispensed through the KFHPWA-
designated mail order service
Other approved pharmacy products:
Preferred generic drugs (Tier 1): Member pays
$10 Copayment per 30-days up to a 90-day supply
Preferred brand name drugs (Tier 2): Member
8.F.a
Packet Pg. 81 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 40
pays $10 Copayment per 30-days up to a 90-day
supply
Non-Preferred generic and brand name drugs
(Tier 3): Not covered; Member pays 100% of all
charges
Transplants
Transplant services, including heart, heart-lung, single lung,
double lung, kidney, pancreas, cornea, intestinal/multi-
visceral, liver transplants, and bone marrow and stem cell
support (obtained from allogeneic or autologous peripheral
blood or marrow) with associated high dose chemotherapy.
Services are limited to the following:
• Inpatient and outpatient medical expenses for evaluation
testing to determine recipient candidacy, donor matching
tests, hospital charges, procurement center fees,
professional fees, travel costs for a surgical team and
excision fees. Donor costs for a covered organ recipient
are limited to procurement center fees, travel costs for a
surgical team and excision fees.
• Follow-up services for specialty visits.
• Rehospitalization.
• Maintenance medications during an inpatient stay.
Transplant services must be provided through locally and
nationally contracted or approved transplant centers. All
transplant services require Preauthorization. Contact Member
Services for Preauthorization.
Hospital - Inpatient: No charge; Member pays
nothing
Hospital - Outpatient: Member pays $10
Copayment
Outpatient Services: Member pays $10 Copayment
Exclusions: Donor costs to the extent that they are reimbursable by the organ donor’s insurance; treatment of donor
complications; living expenses except as covered under Section J. Utilization Management
Urgent Care
Inside the KFHPWA Service Area, urgent care is covered at a
Kaiser Permanente medical center, Kaiser Permanente urgent
care center or Network Provider’s office.
Outside the KFHPWA Service Area, urgent care is covered at
any medical facility.
See Section XII. for a definition of Urgent Condition.
Network Emergency Department: Member pays
$75 Copayment
Network Urgent Care Center: Member pays $10
Copayment
Network Provider’s Office: Member pays $10
Copayment
8.F.a
Packet Pg. 82 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 41
Non-Network Provider: Member pays $125
Copayment
V. General Exclusions
In addition to exclusions listed throughout the EOC, the following are not covered:
1. Benefits and related services, supplies and drugs that are not Medically Necessary for the treatment of an
illness, injury, or physical disability, that are not specifically listed as covered in the EOC, except as required by
federal or state law.
2. Services Related to a Non-Covered Service: When a service is not covered, all services related to the non-
covered service (except for the specific exceptions described below) are also excluded from coverage. Members
who have received a non-covered service, such as bariatric surgery, and develop an acute medical complication
(such as band slippage, leak or infection) as a result, shall have coverage for Medically Necessary intervention
to stabilize the acute medical complication. Coverage does not include complications that occur during or
immediately following a non-covered service. Additional surgeries or other medical services in addition to
Medically Necessary intervention to resolve acute medical complications resulting from non-covered services
shall not be covered.
3. Services or supplies for which no charge is made, or for which a charge woul d not have been made if the
Member had no health care coverage or for which the Member is not liable; services provided by a family
member, or self-care.
4. Convalescent Care.
5. Services to the extent benefits are “available” to the Member as defined herein under the terms of any vehicle,
homeowner’s, property or other insurance policy, except for individual or group health insurance, pursuant to
medical coverage, medical “no fault” coverage, personal injury protection coverage or similar medical coverage
contained in said policy. For the purpose of this exclusion, benefits shall be deemed to be “available” to the
Member if the Member receives benefits under the policy either as a named insured or as an insured individual
under the policy definition of insured.
6. Services or care needed for injuries or conditions resulting from active or reserve military service, whether such
injuries or conditions result from war or otherwise. This exclusion will not apply to conditions or injuries
resulting from previous military service unless the condition has been determined by the U.S. Secretary of
Veterans Affairs to be a condition or injury incurred during a period of active duty. Further, this exclusion will
not be interpreted to interfere with or preclude coordi nation of benefits under Tri-Care.
7. Services provided by government agencies, except as required by federal or state law.
8. Services covered by the national health plan of any other country.
9. Experimental or investigational services.
KFHPWA consults with KFHPWA’s medical director and then uses the criteria described below to decide if a
particular service is experimental or investigational.
a. A service is considered experimental or investigational for a Member’s condition if any of the following
statements apply to it at the time the service is or will be provided to the Member:
1) The service cannot be legally marketed in the United States without the approval of the Food and Drug
Administration (“FDA”) and such approval has not been granted.
2) The service is the subject of a current new drug or new device application on file with the FDA.
8.F.a
Packet Pg. 83 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 42
3) The service is the trialed agent or for delivery or measurement of the trialed agent provided as part of a
qualifying Phase I or Phase II clinical trial, as the expe rimental or research arm of a Phase III clinical
trial.
4) The service is provided pursuant to a written protocol or other document that lists an evaluation of the
service’s safety, toxicity or efficacy as among its objectives.
5) The service is under continued scientific testing and research concerning the safety, toxicity or efficacy
of services.
6) The service is provided pursuant to informed consent documents that describe the service as
experimental or investigational, or in other terms that indicate that the s ervice is being evaluated for its
safety, toxicity or efficacy.
7) The prevailing opinion among experts, as expressed in the published authoritative medical or scientific
literature, is that (1) the use of such service should be substantially confined to rese arch settings, or (2)
further research is necessary to determine the safety, toxicity or efficacy of the service.
b. The following sources of information will be exclusively relied upon to determine whether a service is
experimental or investigational:
1) The Member’s medical records.
2) The written protocol(s) or other document(s) pursuant to which the service has been or will be
provided.
3) Any consent document(s) the Member or Member’s representative has executed or will be asked to
execute, to receive the service.
4) The files and records of the Institutional Review Board (IRB) or similar body that approves or reviews
research at the institution where the service has been or will be provided, and other information
concerning the authority or actions of the IRB or similar body.
5) The published authoritative medical or scientific literature regarding the service, as applied to the
Member’s illness or injury.
6) Regulations, records, applications and any other documents or actions issued by, filed with or taken by,
the FDA or other agencies within the United States Department of Health and Human Services, or any
state agency performing similar functions.
Appeals regarding KFHPWA denial of coverage can be submitted to the Member Appeal Department, or to
KFHPWA's medical director at P.O. Box 34593, Seattle, WA 98124-1593.
10. Hypnotherapy and all services related to hypnotherapy.
11. Directed umbilical cord blood donations.
12. Prognostic (predictive) genetic testing and related services, unless specifically provided in Section IV. Testing
for non-Members.
13. Autopsy and associated expenses.
VI. Eligibility, Enrollment and Termination
A. Eligibility.
In order to be accepted for enrollment and continuing coverage, individuals must reside or work in the Service
Area and meet all applicable requirements set forth below, except for temporary residency outside the Service
Area for purposes of attending school, court-ordered coverage for Dependents or other unique family
arrangements, when approved in advance by KFHPWA. KFHPWA has the right to verify eligibility.
1. Subscribers.
Bona fide employees as established and enforced by the Group shall be eligible for enrollment. Please
contact the Group for more information.
2. Dependents.
8.F.a
Packet Pg. 84 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 43
The Subscriber may also enroll the following:
a. The Subscriber's legal spouse.
b. The Subscriber’s state-registered domestic partner (as required by Washington state law) or if
specifically included as eligible by the Group, the Subscriber’s non-state registered domestic partner.
State-registered domestic partners will be extended the same rights as spouses.
c. Children who are under the age of 26.
"Children" means the children of the Subscriber, spouse or eligible domestic partner, including adopted
children, stepchildren, children for whom the Subscriber has a qualified court order to provide
coverage and any other children for whom the Subscriber is the legal guardian.
Eligibility may be extended past the Dependent’s limiting age as set forth above if the Depen dent is
totally incapable of self-sustaining employment because of a developmental or physical disability
incurred prior to attainment of the limiting age, and is chiefly dependent upon the Subscriber for
support and maintenance. Enrollment for such a Dependent may be continued for the duration of the
continuous total incapacity, provided enrollment does not te rminate for any other reason. Medical
proof of incapacity and proof of financial dependency must be furnished to KFHPWA upon request,
but not more frequently than annually after the 2-year period following the Dependent's attainment of
the limiting age.
3. Temporary Coverage for Newborns.
When a Member gives birth, the newborn is entitled to the benefits set forth in the EOC from birth through
3 weeks of age. All provisions, limitations and exclusions will apply except Subsectio ns F. and G. After 3
weeks of age, no benefits are available unless the newborn child qualifies as a Dependent and is enrolled.
B. Application for Enrollment.
Application for enrollment must be made on an application approved by KFHPWA. The Group is responsible
for submitting completed applications to KFHPWA.
KFHPWA reserves the right to refuse enrollment to any person whose coverage under any medical coverage
agreement issued by Kaiser Foundation Health Plan of Washington Options, Inc. or Kaiser Foundation Health
Plan of Washington has been terminated for cause.
1. Newly Eligible Subscribers.
Newly eligible Subscribers and their Dependents may apply for enrollment in writing to the Group within
31 days of becoming eligible.
2. New Dependents.
A written application for enrollment of a newly dependent person, other than a newborn or adopted child,
must be made to the Group within 31 days after the dependency occurs.
A written application for enrollment of a newborn child must be made to the Group within 60 days
following the date of birth when there is a change in the monthly premium payment as a result of the
additional Dependent.
A written application for enrollment of an adoptive child must be made to the Group within 60 days from
the day the child is placed with the Subscriber for the purpose of adoption or the Subscriber assumes total
or partial financial support of the child if there is a change in the monthly premium payment as a result of
the additional Dependent.
8.F.a
Packet Pg. 85 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 44
When there is no change in the monthly p remium payment, it is strongly advised that the Subscriber enroll
the newborn or newly adoptive child as a Dependent with the Group to avoid delays in the payment of
claims.
3. Open Enrollment.
KFHPWA will allow enrollment of Subscribers and Dependents who did not enroll when newly eligible as
described above during a limited period of time specified by the Group and KFHPWA.
4. Special Enrollment.
a. KFHPWA will allow special enrollment for persons:
1) Who initially declined enrollment when otherwise eligible because such persons had other health
care coverage and have had such other coverage terminated due to one of the following events:
• Cessation of employer contributions.
• Exhaustion of COBRA continuation coverage.
• Loss of eligibility, except for loss of eligibility for cause; or
2) Who initially declined enrollment when otherwise eligible because such persons had other health
care coverage and who have had such other coverage exhausted because such person reached a
lifetime maximum limit.
KFHPWA or the Group may require confirmation that when initially offered coverage su ch persons
submitted a written statement declining because of other coverage. Application for coverage must be
made within 31 days of the termination of previous coverage.
b. KFHPWA will allow special enrollment for individuals who are eligible to be a Subscriber and their
Dependents (other than for nonpayment or fraud) in the event one of the following occurs:
1) Divorce or Legal Separation. Application for coverage must be made within 60 days of the
divorce/separation.
2) Cessation of Dependent status (reaches maximum age). Application for coverage must be made
within 30 days of the cessation of Dependent status.
3) Death of an employee under whose coverage they were a Dependent. Application for coverage
must be made within 30 days of the death of an employee.
4) Termination or reduction in the number of hours worked. Application for coverage must be made
within 30 days of the termination or reduction in number of hours worked.
5) Leaving the service area of a former plan. Application for coverage must be made within 30 days
of leaving the service area of a former plan.
6) Discontinuation of a former plan. Application for coverage must be m ade within 30 days of the
discontinuation of a former plan.
c. KFHPWA will allow special enrollment for individuals who are eligible to be a Subscriber and their
Dependents in the event one of the following occurs:
1) Marriage. Application for coverage must be made within 31 days of the date of marriage.
2) Birth. Application for coverage for the Subscriber and Dependents other than the newborn child
must be made within 60 days of the date of birth.
3) Adoption or placement for adoption. Application for coverage for the Subscriber and Dependents
other than the adopted child must be made within 60 days of the adoption or placement for
adoption.
4) Eligibility for premium assistance from Medicaid or a state Children’s Health Insurance Program
(CHIP), provided such person is otherwise eligible for coverage under this EOC. The request for
special enrollment must be made within 60 days of eligibility for such premium assistance.
5) Coverage under a Medicaid or CHIP plan is terminated as a result of loss of eligibility for such
coverage. Application for coverage must be made within 60 days of the date of termination under
Medicaid or CHIP.
6) Applicable federal or state law or regulation otherwise provides for special enrollment.
8.F.a
Packet Pg. 86 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 45
C. When Coverage Begins.
1. Effective Date of Enrollment.
• Enrollment for a newly eligible Subscriber and listed Dependents is effec tive on the date eligibility
requirements are met, provided the Subscriber's application has been submitted to and approved by
KFHPWA. Please contact the Group for more information.
• Enrollment for a newly dependent person, other than a newborn or adoptive child, is effective on the 1st
of the month following date eligibility requirements are met. Please contact the Group for more
information.
• Enrollment for newborns is effective from the date of birth.
• Enrollment for adoptive children is effective from the date that t he adoptive child is placed with the
Subscriber for the purpose of adoption or the Subscriber assumes total or partial financial support of
the child.
2. Commencement of Benefits for Persons Hospitalized on Effective Date.
Members who are admitted to an inpatient facility prior to their enrollment will receive covered benefits
beginning on their effective date, as set forth in Subsection C.1. above. If a Member is hospitalized in a
non-Network Facility, KFHPWA reserves the right to require transfer of the Me mber to a Network Facility.
The Member will be transferred when a Network Provider, in consultation with the attending physician,
determines that the Member is medically stable to do so. If the Member refuses to transfer to a Network
Facility, all further costs incurred during the hospitalization are the responsibility of the Member.
D. Eligibility for Medicare.
An individual shall be deemed eligible for Medicare when they have the option to receive Part A Medicare
benefits. Medicare secondary payer regulations and guidelines will determine primary/secondary payer status
for individuals covered by Medicare.
A Member who is enrolled in Medicare has the option of continuing coverage under this EOC while on
Medicare coverage. Coverage between this EOC and Medicare will be coordinated as outlined in Section IX.
The Group is also responsible for providing KFHPWA with a prospective timely notice of Members’
ineligibility for Medicare Advantage coverage under the Group, as well as providing a prospective notice to i ts
Members alerting them of the termination event. In the event the Group does not obtain Medicare Advantage
coverage, the loss of Medicare drug coverage, other coverage options that may be available to the Member, and
the possibility of late enrollment penalties if the Member does not apply for Medicare coverage within the
required timeframe will also need to be provided.
E. Termination of Coverage.
The Subscriber shall be liable for payment of all charges for services and items provided to the Subscriber an d
all Dependents after the effective date of termination.
Termination of Specific Members.
Individual Member coverage may be terminated for any of the following reasons:
a. Loss of Eligibility. If a Member no longer meets the eligibility requirements and is not enrolled for
continuation coverage as described in Subsection G. below, coverage will terminate at the end of the
month during which the loss of eligibility occurs, unless otherwise specified by the Group.
b. For Cause. In the event of termination for cause, KFHPWA reserves the right to pursue all civil
remedies allowable under federal and state law for the collection of claims, losses or other damages .
Coverage of a Member may be terminated upon 10 working days written notice for:
1.) Material misrepresentation, fraud or omission of information in order to obtain coverage.
2.) Permitting the use of a KFHPWA identification card or number by another person or using
another Member’s identification card or number to obtain care to which a person is not entitled.
8.F.a
Packet Pg. 87 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 46
c. Premium Payments. Nonpayment of premiums or contribution for a specific Member by the Group.
Individual Member coverage may be retroactively terminated upon 30 days written notice and only in the
case of fraud or intentional misrepresentation of a material fact; or as otherwise allowed under applicable
law or regulation. Notwithstanding the foregoing, KFHPWA reserves the right to retroactively terminate
coverage for nonpayment of premiums or contributions by the Group as described above.
In no event will a Member be terminated solely on the basis of their physical or mental condition provided
they meet all other eligibility requirements set for th in the EOC.
Any Member may appeal a termination decision through KFHPWA’s appeals process.
F. Continuation of Inpatient Services.
A Member who is receiving Covered Services in a hospital on the date of termination shall continue to be
eligible for Covered Services while an inpatient for the condition which the Member was hospitalized, until one
of the following events occurs:
• According to KFHPWA clinical criteria, it is no longer Medically Necessary for the Member to be an
inpatient at the facility.
• The remaining benefits available for the hospitalization are exhausted, regardless of whether a new
calendar year begins.
• The Member becomes covered under another agreement with a group health plan that provides benefits for
the hospitalization.
• The Member becomes enrolled under an agreement with another car rier that provides benefits for the
hospitalization.
This provision will not apply if the Member is covered under another agreement that provides benefits for the
hospitalization at the time coverage would terminate, except as set forth in this section, or if the Member is
eligible for COBRA continuation coverage as set forth in Subsection G. below.
G. Continuation of Coverage Options.
1. Continuation Option.
A Member no longer eligible for coverage (except in the event of termination for cause, as set for th in
Subsection E.) may continue coverage for a period of up to 3 month s subject to notification to and self-
payment of premiums to the Group. This provision will not apply if the Member is eligible for the
continuation coverage provisions of the Consolid ated Omnibus Budget Reconciliation Act of 1985
(COBRA). This continuation option is not available if the Group no longer has active employees or
otherwise terminates.
2. Leave of Absence.
While on a Group approved leave of absence, the Subscriber and listed Dependents can continue to be
covered provided that:
• They remain eligible for coverage, as set forth in Subsection A.,
• Such leave is in compliance with the Group’s established leave of absence policy that is consistently
applied to all employees,
• The Group’s leave of absence policy is in compliance with the Family and Med ical Leave Act when
applicable, and
• The Group continues to remit premiums for the Subscriber and Dependents to KFH PWA.
3. Self-Payments During Labor Disputes.
In the event of suspension or termination of employee compensation due to a strike, lock -out or other labor
dispute, a Subscriber may continue uninterrupted coverage through payment of monthly premiums directl y
8.F.a
Packet Pg. 88 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 47
to the Group. Coverage may be continued for the lesser of the term of the strike, lock-out or other labor
dispute, or for 6 months after the cessation of work.
If coverage under the EOC is no longer available, the Subscriber shall have the opportunity t o apply for an
individual KFHPWA group conversion plan or, if applicable, continuation coverage (see Subsection 4.
below), or an individual and family plan at the duly approved rates.
The Group is responsible for immediately notifying each affected Subscr iber of their rights of self-payment
under this provision.
4. Continuation Coverage Under Federal Law.
This section applies only to Groups who must offer continuation coverage under the applicable provisions
of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, or the Uniformed
Services Employment and Reemployment Rights Act (USERRA) and only applies to grant con tinuation of
coverage rights to the extent required by federal law. USERRA only applies in certain situations to
employees who are leaving employment to serve in the United States Armed Forces.
Upon loss of eligibility, continuation of Group coverage may be available to a Member for a limited time
after the Member would otherwise lose eligibility, if required by COBRA. The Group shall inform
Members of the COBRA election process and how much the Member will be required to pay directly to the
Group.
Continuation coverage under COBRA or USERRA will terminate when a Member becomes covered by
Medicare or obtains other group coverage, and as set forth under Subsection E.
5. KFHPWA Group Conversion Plan.
Members whose eligibility for coverage, including continuation coverage, is terminated for any reason
other than cause, as set forth in Subsection E., and who are not eligi ble for Medicare or covered by another
group health plan, may convert to an individual KFHPWA group conversion plan. If coverage under the
EOC terminates, any Member covered at termination (including spouses and Dependents of a Subscriber
who was terminated for cause) may convert to a KFHPWA group conv ersion plan. Coverage will be
retroactive to the date of loss of eligibility.
An application for conversion must be made within 31 days following termination of coverage or within 31
days from the date notice of the termination of coverage is received, whichever is later. A physical
examination or statement of health is not required for enrollment in a KFHPWA group conversion plan.
Persons wishing to purchase KFHPWA’s individual and family coverage should con tact KFHPWA.
VII. Grievances
Grievance means a written or verbal complaint submitted by or on behalf of a covered person regarding service
delivery issues other than denial of payment for medical services or non-provision of medical services, including
dissatisfaction with medical care, waiting time for medical services, provider or staff attitude or demeanor, or
dissatisfaction with service provided by the health carrier. The grievance process is outlined as follows:
Step 1: It is recommended that the Member contact the person involved or the manager of the medical
center/department where they are having a problem, explain their concerns and what they would like to have
done to resolve the problem. The Member should be specific and make their position clear. Most concerns can
be resolved in this way.
Step 2: If the Member is still not satisfied, they should call or write to Member Services at PO Box 34590,
Seattle, WA 98124-1590. 206-630-4636 or toll-free 1-888-901-4636. Most concerns are handled by phone
within a few days. In some cases, the Member will be asked to write down their concerns and state what they
think would be a fair resolution to the problem. An appropriate representative will investigate the Member’s
8.F.a
Packet Pg. 89 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 48
concern by consulting with involved staff and their supervisors, and reviewing pertinent records, relevant plan
policies and the Member Rights and Responsibilities statement. This process can take up to 30 days to resolve
after receipt of the Member’s written or verbal statement.
If the Member is dissatisfied with the resolution of the complaint, they may contact Member Services. Assistance is
available to Members who are limited-English speakers, who have literacy problems, or who have physical or
mental disabilities that impede their ability to request review or participate in the review process.
VIII. Appeals
Members are entitled to appeal through the appeals process if/when coverag e for an item or service is denied due to
an adverse determination made by the KFHPWA medical director. The appeals process is available for a Member to
seek reconsideration of an adverse benefit determination (action). Adverse benefit determination (action) means any
of the following: a denial, reduction, or termination of, o r a failure to provide or make payment (in whole or in part)
for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based
on a determination of a Member’s eligibility to participate in a plan , and including, a denial, reduction, or
termination of, or a failure to provide or make payment, in whole or in part, for a benefit resulting from the
application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise
provided because it is determined to be experimental or investigational or not Medically Necessary or appropriate.
KFHPWA will comply with any new requirements as necessary under federal laws and regulations. Assistance is
available to Members who are limited-English speakers, who have literacy problems, or who have physical or
mental disabilities that impede their ability to request review or participate in the review process. The most current
information about your appeals process is available by contacting KFHPWA’s Member Appeal Department at the
address or telephone number below.
1. Initial Appeal
If the Member or any representative authorized in writing by the Member wishes to appeal a KFHPWA
decision to deny, modify, reduce or terminate coverage of or payment for health care services, they must submit
a request for an appeal either orally or in writing to KFHPWA’s Member Appeal Department, specifying why
they disagree with the decision. The appeal must be submitted within 180 days from the date of the initial denial
notice. KFHPWA will notify the Member of its receipt of the request within 72 hours of receiving it. Appeals
should be directed to KFHPWA’s Member Appeal Department, P.O. Box 34593, Seattle, WA 98124-1593, toll-
free 1-866-458-5479.
A party not involved in the initial coverage determination and not a subordinate of the party making the initial
coverage determination will review the appeal request. KFHPWA will then notify the Member of its
determination or need for an extension of time within 14 days of receiving the request for appeal. Under no
circumstances will the review timeframe exceed 30 days with out the Member’s written permission.
For appeals involving experimental or investigational services KFHPWA will make a decision and
communicate the decision to the Member in writing within 20 days of receipt of the appeal.
There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using the
standard appeal review process will seriously jeopardize the Member’s life, health or ability to regain maximum
function or subject the Member to severe pain that cannot be manag ed adequately without the requested care or
treatment. The Member can request an expedited/urgent appeal in writing to the above address, or by calling
KFHPWA’s Member Appeal Department toll-free 1-866-458-5479. The nature of the patient’s condition will be
evaluated by a physician and if the request is not accepted as urgent, the member will be notified in writing of
the decision not to expedite and given a description on how to grieve the decision. If the request is made by the
treating physician who believes the member’s condition meets the definition of expedited, the request will be
processed as expedited.
The request for an expedited/urgent appeal will be processed and a decision issued no later than 72 hours after
receipt of the request.
8.F.a
Packet Pg. 90 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 49
The Member may also request an external review at the same time as the internal appeals process if it is an
urgent care situation or the Member is in an ongoing course of treatment.
If the Member requests an appeal of a KFHPWA decision denying benefits for care currently being received,
KFHPWA will continue to provide coverage for the disputed benefit pending the outcome of the appeal. If the
KFHPWA determination stands, the Member may be responsible for the cost of coverage received during the
review period.
The U.S. Department of Health and Human Services has designated the Washington State Office of the
Insurance Commissioner’s Consumer Protection Division as the health insurance consumer ombudsman. The
Consumer Protection Division Office can be reached by mail at Washington State Insurance Commissioner,
Consumer Protection Division, P.O. Box 40256, Olympia, WA 98504-0256 or at toll-free 1-800-562-6900.
More information about requesting assistance from the Consumer Protection Division Office can be found at
http://www.insurance.wa.gov/your-insurance/health-insurance/appeal/.
2. Next Level of Appeal
If the Member is not satisfied with the decision regarding medical necessity, medical appropriateness, health
care setting, level of care, or if the requested service is not efficacious or otherwise unjustified under evidence -
based medical criteria, or if KFHPWA fails to adhere to the requirements of the appeals process, the Member
may request a second level review by an external independent review organization not legally affiliated with or
controlled by KFHPWA. KFHPWA will notify the Member of the name of the external independent review
organization and its contact information. The external independent review organization will accept additional
written information for up to five business days after it receives the assignment for the appeal. The external
independent review will be conducted at no cost to the Member. Once a decision is made through an
independent review organization, the decision is final and cannot be appealed through KFHPWA.
If the Member requests an appeal of a KFHPWA decision denying benefits for care currently being received,
KFHPWA will continue to provide coverage for the disputed benefit pending the outcome of the appeal. If the
KFHPWA determination stands, the Member may be responsible for the cost of coverage received during the
review period.
A request for a review by an independent review organization must be made within 180 days after the date of
the initial appeal decision notice.
IX. Claims
Claims for benefits may be made before or after services are obtained. KFHPWA recommends that the provider
requests Preauthorization. In most instances, contracted providers submit claims directly to KFHPWA. If your
provider does not submit a claim to make a claim for benefits, a Member must contact Member Services, or submit a
claim for reimbursement as described below. Other inquiries, such as asking a health care provider about care or
coverage, or submitting a prescription to a pharmacy , will not be considered a claim for benefits.
If a Member receives a bill for services the Member believes are covered, the Member must, within 90 days of the
date of service, or as soon thereafter as reasonably possible, either (1) contact Member Services to make a claim or
(2) pay the bill and submit a claim for reimbursement of Covered Services, or (3) for out-of-country claims
(Emergency care only) – submit the claim and any associated medical records , including the type of service,
charges, and proof of travel to KFHPWA, P.O. Box 30766, Salt Lake City, UT 84130-0766. In no event, except in
the absence of legal capacity, shall a claim be accepted later than 1 year from the date of service.
KFHPWA will generally process claims for benefits within the following timeframes after KFHPWA receives the
claims:
• Immediate request situations – within 1 business day.
• Concurrent urgent requests – within 24 hours.
• Urgent care review requests – within 48 hours.
• Non-urgent preservice review requests – within 5 calendar days.
• Post-service review requests – within 30 calendar days.
8.F.a
Packet Pg. 91 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 50
Timeframes for pre-service and post-service claims can be extended by KFHPWA for up to an additional 15 days.
Members will be notified in writing of such extension prior to the expiration of the initial timeframe.
X. Coordination of Benefits
The coordination of benefits (COB) provision a pplies when a Member has health care coverage under more than one
plan. Plan is defined below.
The order of benefit determination rules govern the order in w hich each plan will pay a claim for benefits. The plan
that pays first is called the primary plan. The primary plan must pay benefits according to its policy terms without
regard to the possibility that another plan may cover some expenses. The plan that p ays after the primary plan is the
secondary plan. In no event will a secondary plan be required to pay an amount in excess of its maximum benefit
plus accrued savings.
If the Member is covered by more than one health benefit plan, and the Member does not know which is the primary
plan, the Member or the Member’s provider should contact any one of the health plans to verify which plan is
primary. The health plan the Member contacts is responsible for work ing with the other plan to determine which is
primary and will let the Member know within 30 calendar days.
All health plans have timely claim filing requirements. If the Member or the Member’s provider fails to submit the
Member’s claim to a secondary health plan within that plan’s claim filing time limit, the plan can deny the claim. If
the Member experiences delays in the processing of the claim by the primary health plan, the Member or the
Member’s provider will need to submit the claim to the secondary health plan within its claim filing time limit to
prevent a denial of the claim.
If the Member is covered by more than one health benefit plan, the Member or the Member’s provider should file all
the Member’s claims with each plan at the same time. If M edicare is the Member’s primary plan, Medicare may
submit the Member’s claims to the Member’s secondary carrier.
Definitions.
A. A plan is any of the following that provides benefits or services for medical or dental care or treatment. If
separate contracts are used to provide coordinated coverage for Members of a Group, the separate contracts
are considered parts of the same plan and there is no COB among those separate contracts. However, if
COB rules do not apply to all contracts, or to all benefits in the same contract, the contract or benefit to
which COB does not apply is treated as a separate plan.
1. Plan includes: group, individual or blanket disability insurance contracts and group or individual
contracts issued by health care service contractors or health maintenance organizations (HMO), closed
panel plans or other forms of group coverage; medical care components of long-term care contracts,
such as skilled nursing care; and Medicare or any other federal governmental plan, as permitted by
law.
2. Plan does not include: hospital indemnity or fixed payment coverage or other fixed indemnity or fixed
payment coverage; accident only coverage; specified disease or specified accident coverage; limited
benefit health coverage, as defined by state law; school accident type coverage; benefits for non-
medical components of long-term care policies; automobile insurance policies required by statute to
provide medical benefits; Medicare supplement policies; Medicaid coverage; or coverage under other
federal governmental plans; unless permitted by law.
Each contract for coverage under Subsection 1. or 2. is a separate plan. If a plan has two parts and COB
rules apply only to one of the two, each of the parts is treated as a separate plan.
B. This plan means, in a COB provision, the part of the contract providing the health care benefits to which
the COB provision applies and which may be reduced because of t he benefits of other plans. Any other part
8.F.a
Packet Pg. 92 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 51
of the contract providing health care benefits is separate from this plan. A contract may apply one COB
provision to certain benefits, such as dental benefits, coordinating only with similar benefits, and may appl y
another COB provision to coordinate other benefits.
C. The order of benefit determination rules determine whether this plan is a primary plan or secondary plan
when the Member has health care coverage under more than one plan.
When this plan is primary, it determines payment for its benefits first before those of any other plan without
considering any other plan’s benefits. When this plan is secondary, it d etermines its benefits after those of
another plan and must make payment in an amount so that, when combined with the amount paid by the
primary plan, the total benefits paid or provided by all plans for the claim equal 100% of the total allowable
expense for that claim. This means that when this plan is secondary, it must pay the amount which, when
combined with what the primary plan paid, totals 100% of the allowable expense. In addition, if this plan i s
secondary, it must calculate its savings (its amoun t paid subtracted from the amount it would have paid had
it been the primary plan) and record these savings as a benefit reserve for the covered Member. This
reserve must be used by the secondary plan to pay any allowable expenses not otherwise paid, that are
incurred by the covered person during the claim determination period.
D. Allowable Expense. Allowable expense is a health care expense, coinsurance or copayments and without
reduction for any applicable deductible, that is covered at least in part by any plan covering the person.
When a plan provides benefits in the form of services, the reasonable cash value of each service will be
considered an allowable expense and a benefit paid. An expense that is not covered by any plan covering
the Member is not an allowable expense.
The following are examples of expenses that are not allowable expenses:
1. The difference between the cost of a semi-private hospital room and a private hospital room is not an
allowable expense, unless one of the plans provides co verage for private hospital room expenses.
2. If a Member is covered by two or more plans that co mpute their benefit payments on the basis of usual
and customary fees or relative value schedule reimbursement method or other similar reimbursement
method, any amount in excess of the highest reimbursement amount for a specific benefit is not an
allowable expense.
3. If a Member is covered by two or more plans that provide benefits or services on the basis of
negotiated fees, an amount in excess of the highest of the negotiated fees is not an allowable expense.
4. An expense or a portion of an expense that is not covered by any of the plans covering the person is
not an allowable expense.
E. Closed panel plan is a plan that provides health care benefits to c overed persons in the form of services
through a panel of providers who are primarily employed by the plan, and that excludes coverage for
services provided by other providers, except in cases of Emergen cy or referral by a panel member.
F. Custodial parent is the parent awarded custody by a court decree or, in the absence of a court decree, is the
parent with whom the child resides more than one half of the calendar year excluding any temporary
visitation.
Order of Benefit Determination Rules.
When a Member is covered by two or more plans, the rules for determining the order of benefit payments are as
follows:
A. The primary plan pays or provides its benefits according to its terms of coverage and without regard to the
benefits under any other plan.
8.F.a
Packet Pg. 93 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 52
B. (1) Except as provided below (subsection 2), a plan that does not contain a coordination of benefits
provision that is consistent with this chapter is always primary unless the provisions of both plans st ate that
the complying plan is primary.
(2) Coverage that is obtained by virtue of membership in a Group that is designed to supplement a part of a
basic package of benefits and provides that this supplementary coverage is excess to any other parts of th e
plan provided by the contract holder. Examples include major medical coverages that are superimposed
over hospital and surgical benefits, and insurance type coverages that are written in connection with a
closed panel plan to provide out-of-network benefits.
C. A plan may consider the benefits paid or provided by another plan in calculating payment of its benefits
only when it is secondary to that other plan.
D. Each plan determines its order of benefits using the first of the following rules that apply :
1. Non-Dependent or Dependent. The plan that covers the Member other than as a Dependent, for
example as an employee, member, policyholder, Subscrib er or retiree is the primary plan and the plan
that covers the Member as a Dependent is the secondary plan. However, if the person is a Medicare
beneficiary and, as a result of federal law, Medicare is secondary to the plan covering the Member as a
Dependent, and primary to the plan covering the Member as other than a Dependent (e.g., a retired
employee), then the order of benefits between the two plans is reversed so that the plan covering the
Member as an employee, member, policyholder, Subscriber or retiree is the secondary plan and the
other plan is the primary plan.
2. Dependent child covered under more than one plan. Unless there is a court decree stating otherwise,
when a dependent child is covered by more than one plan the order of benefits is deter mined as
follows:
a) For a dependent child whose parents are married or are living together, whether or n ot they have
ever been married:
• The plan of the parent whose birthday falls earlier in the calendar year is the primary plan; or
• If both parents have the same birthday, the plan that has covered the parent the longest is the
primary plan.
b) For a dependent child whose parents are divorced or separated or no t living together, whether or
not they have ever been married:
i. If a court decree states that one of the parents is responsible for the dependent child’s health
care expenses or health care coverage and the plan of that parent has actual knowledge of
those terms, that plan is primary. This rule applies to claim determination periods
commencing after the plan is given notice of the court decree;
ii. If a court decree states one parent is to assume primary financial responsibility for the
dependent child but does not mention responsibility for health care expenses, the plan of the
parent assuming financial responsibility is primary;
iii. If a court decree states that both parents are responsible for the dependent child’s health care
expenses or health care coverage, the provisions of a) above determine the order of benefits;
iv. If a court decree states that the parents have joint custody without specifying that one parent
has responsibility for the health care expenses or health care coverage of the dependent child,
the provisions of Subsection a) above determine the order of benefits; or
v. If there is no court decree allocating responsibility for the dependent child’s health care
expenses or health care coverage, the order of benefits for the child are as follows:
• The plan covering the custodial parent, first;
• The plan covering the spouse of the custodial parent, second;
• The plan covering the non-custodial parent, third; and then
• The plan covering the spouse of the non -custodial parent, last.
c) For a dependent child covered under more than one plan of individuals who are not the parents of
the child, the provisions of Subsection a) or b) above determine the order of benefits as if those
individuals were the parents of the child.
8.F.a
Packet Pg. 94 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 53
3. Active employee or retired or laid-off employee. The plan that covers a Member as an active
employee, that is, an employee who is neither laid off nor retired, is the primary plan. The plan
covering that same Member as a retired or laid off employe e is the secondary plan. The same would
hold true if a Member is a Dependent of an active employee and that same Member is a Dependent of a
retired or laid-off employee. If the other plan does not have this rule, and as a result, the plans do not
agree on the order of benefits, this rule is ignored. This rule does not apply if the rule under Section
D.1. can determine the order of benefits.
4. COBRA or State Continuation Coverage. If a Member whose coverage is provided under COBRA or
under a right of continuation provided by state or other federal law is covered under another plan, the
plan covering the Member as an employee, member, Subscriber or retir ee or covering the Member as a
Dependent of an employee, member, Subscriber or retiree is the primary plan and the COBRA or state
or other federal continuation coverage is the secondary plan. If the other plan does not have this rule,
and as a result, the plans do not agree on the order of benefits, this rule is ignored. This rule does not
apply if the rule under Section D.1 can determine the order of benefits.
5. Longer or shorter length of coverage. The plan that covered the Member as an employee, member ,
Subscriber or retiree longer is the primary plan and the plan that covered the Member the shorter
period of time is the secondary plan.
6. If the preceding rules do not determine the order of benefits, the allowable expenses must be shared
equally between the plans meeting the definition of plan. In addition, this plan will not pay more than it
would have paid had it been the primary plan.
Effect on the Benefits of this Plan.
When this plan is secondary, it must make payment in an amount so that, when combined with the amount paid by
the primary plan, the total benefits paid or provided by all plans for the claim equal one hundred percent of the total
allowable expense for that claim. However, in no event shall the secondary plan be required to pay an am ount in
excess of its maximum benefit plus accrued savings. In no event should the Member be responsible for a deductible
amount greater than the highest of the two deductibles.
Right to Receive and Release Needed Information.
Certain facts about health care coverage and services are needed to apply these COB rules and to determine benefits
payable under this plan and other plans. KFHPWA may get the facts it needs from or give them to other
organizations or persons for the purpose of applying these rules and determining benefits payable under this plan
and other plans covering the Member claiming benefits. KFHPWA need not tell, or get the consent of, any Member
to do this. Each Member claiming benefits under this plan must give KFHPWA any facts it needs to apply those
rules and determine benefits payable.
Facility of Payment.
If payments that should have been made under this plan are made by another plan, KFHPWA has the right, at its
discretion, to remit to the other plan the amount it determines appropriate to satisfy the intent of this provision. The
amounts paid to the other plan are considered benefits paid under this plan. To the extent of such payments,
KFHPWA is fully discharged from liability under this plan.
Right of Recovery.
KFHPWA has the right to recover excess payment whenever it has paid allowable expenses in excess of the
maximum amount of payment necessary to satisfy the intent of this provision. KFHPWA may recover excess
payment from any person to whom or for whom payment was made or any other issuers or plans.
Questions about Coordination of Benefits? Contact the State Insurance Department.
Effect of Medicare.
Medicare primary/secondary payer guidelines and regulations will determine primary/secondary payer status, and
will be adjudicated by KFHPWA as set forth in this section. KFHPWA will pay primary to Medicare when required
8.F.a
Packet Pg. 95 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 54
by federal law. When Medicare, Part A and Part B or Part C are primary, Medicare's allowable amount is the highest
allowable expense.
When a Network Provider renders care to a Member who is eligible for Medicare benefits, and Medicare is deemed
to be the primary bill payer under Medicare secondary payer guidelines and regulations, KFHPWA will seek
Medicare reimbursement for all Medicare covered services.
XI. Subrogation and Reimbursement Rights
The benefits under this EOC will be available to a Member for injury or illness caused by another party, subject to
the exclusions and limitations of this EOC. If KFHPWA provides benefits under this EOC for the treatment of the
injury or illness, KFHPWA will be subrogated to any rights that the Member may have to recover compensation or
damages related to the injury or illness and the Member shall reimburse KFHPWA for all benefits provided, from
any amounts the Member received or is entitled to receive from any source on account of such injury or illness,
whether by suit, settlement or otherwise, including but not limited to:
• Payments made by a third party or any insurance company on behalf of the third party;
• Any payments or awards under an uninsured or underinsured motorist coverage policy;
• Any Workers’ Compensation or disability award or settlement;
• Medical payments coverage under any automobile policy, premises or homeowners’ medical payments
coverage or premises or homeowners’ insurance coverage; and
• Any other payments from a source intended to compensate an Injured Person for injuries resulting from an
accident or alleged negligence.
This section more fully describes KFHPWA’s subrogation and reimbursement rights.
"Injured Person" under this section means a Member covered by the EOC who sustains an injury or illness and any
spouse, dependent or other person or entity that may recover on behalf of such Member including the estate of the
Member and, if the Member is a minor, the guardian or parent of the Member. When referred to in this section, "
KFHPWA's Medical Expenses" means the expenses incurred and the value of the benefits provided by KFHPWA
under this EOC for the care or treatment of the injury or illness sustained by the Injured Person.
If the Injured Person’s injuries were caused by a third party giving rise to a claim of legal liability against the third
party and/or payment by the third party to the Injured Person and/or a settlement between the third party and th e
Injured Person, KFHPWA shall have the right to recover KFHPWA's Medical Expenses from any source available
to the Injured Person as a result of the events causing the injury. This right is commonly referred to as
"subrogation." KFHPWA shall be subrogated to and may enforce all rights of the Injured Person to the full extent of
KFHPWA's Medical Expenses.
By accepting benefits under this plan, the Injured Person also specifically acknowledges KFHPWA’s right of
reimbursement. This right of reimbursement attaches when this KFHPWA has provided benefits for injuries or
illnesses caused by another party and the Injured Person or the Injured Person’s representative has recovered any
amounts from a third party or any other source of recovery. KFHPWA’s right of rei mbursement is cumulative with
and not exclusive of its subrogation right and KFHPWA may choose to exercise either or both rights of recovery.
In order to secure KFHPWA’s recovery rights, the Injured Person agrees to assign KFHPWA any benefits or claims
or rights of recovery they may have under any automobile policy or other coverage, to the full extent of the plan’s
subrogation and reimbursement claims. This assignment allows KFHPWA to pursue any claim the Injured Person
may have, whether or not they choose to pursue the claim.
KFHPWA’s subrogation and reimbursement rights shall be limited to the excess of the amount required to fully
compensate the Injured Person for the loss sustained, including general damages.
Subject to the above provisions, if the Injured Person is entitled to or does receive money from any source as a result
of the events causing the injury or illness, including but not limited to any liability insurance or
uninsured/underinsured motorist funds, KFHPWA’s Medical Expenses are secondary, not primary.
8.F.a
Packet Pg. 96 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 55
The Injured Person and their agents shall cooperate fully with KFHPWA in its efforts to collect KFHPWA's Medical
Expenses. This cooperation includes, but is not limited to, supplying KFHPWA with information about the cause of
injury or illness, any potentially liable third parties, defendants and/or insurers related to the Injured Person's claim.
The Injured Person shall notify KFHPWA within 30 days of any claim that may give rise to a claim for subrogation
or reimbursement. The Injured Person shall provide periodic updates about any facts that may impact KFHPWA’s
right to reimbursement or subrogation as requested by KFHPWA, and shall inform KFHPWA of any settlement or
other payments relating to the Injured Person’s injury. The Injured Person and their agents shall permit KFHPWA,
at KFHPWA's option, to associate with the Injured Person or to intervene in any legal, quasi-legal, agency or any
other action or claim filed.
The Injured Person and their agents shall do nothing to prejudice KFHPWA’s subrogation and reimbursement
rights. The Injured Person shall promptly notify KFHPWA of any tentative settlement with a third party and shall
not settle a claim without protecting KFHPWA’s interest. The Injured Person shall provide 21 days advance notice
to KFHPWA before there is a disbursement of proceeds from any settlement with a third party that may give rise to
a claim for subrogation or reimbursement. If the Injured Person fails to cooperate fully with KFHPWA in recovery
of KFHPWA’s Medical Expenses, and such failure prejudices KFHPWA’s subrogation and/or reimbursement
rights, the Injured Person shall be responsible for directly reimbursing KFHPWA for 100% of KFHPWA’s Medical
Expenses.
To the extent that the Injured Person recovers funds from any source that in any manner relate to the injury or illness
giving rise to KFHPWA’s right of reimbursement or subrogation, the Injured Person agrees to hold such monies in
trust or in a separate identifiable account until KFHPWA’s subrogation and reimbursement rights are fully
determined and that KFHPWA has an equitable lien over such monies to the full extent of KFHPWA’s Medical
Expenses and/or the Injured Person agrees to serve as constructive trustee over the monies to the extent of
KFHPWA’s Medical Expenses. In the event that such monies are not so held, the funds are recoverable even if they
have been comingled with other assets, without the need to trace the source of the funds. Any party who distributes
funds without regard to KFHPWA’s rights of subrogation or reimbursement will be personally liable to KFHPWA
for the amounts so distributed.
If reasonable collections costs have been incurred by an attorney for the Injured Person in connection with obtaining
recovery, KFHPWA will reduce the amount of reimbursement to KFHPWA by the amount of an equitable
apportionment of such collection costs between KFHPWA and the Injured Person. This reduction will be made only
if each of the following conditions has been met: (i) KFHPWA receives a list of the fees and associated costs before
settlement and (ii) the Injured Person’s attorney’s actions were directly related to securing recovery for the Injured
Party.
To the extent the provisions of this Subrogation and Reimbursem ent section are deemed governed by ERISA,
implementation of this section shall be deemed a part of claims administration and KFHPWA shall therefore have
discretion to interpret its terms.
XII. Definitions
Allowance The maximum amount payable by KFHPWA for certain Covered Services.
Allowed Amount The level of benefits which are payable by KFHPWA when expenses are incurred from a
non-Network Provider. Expenses are considered an Allowed Amount if the charges are
consistent with those normally charged to others by the provider or organization for the
same services or supplies; and the charges are within the general range of charges made
by other providers in the same geographical area for the same services or supplies.
Members shall be required to pay any difference between a non-Network Provider’s
charge for services and the Allowed Amount, except for Emergency services and for
ancillary services provided by a non-Network provider at a Network Facility. For more
information about balance billing protections, please visit:
https://healthy.kaiserpermanente.org/washington/support/forms.
8.F.a
Packet Pg. 97 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 56
Convalescent Care Care furnished for the purpose of meeting non-medically necessary personal needs
which could be provided by persons without professional skills or training, such as
assistance in walking, dressing, bathing, eating, preparation of special diets, and taking
medication.
Copayment The specific dollar amount a Member is required to pay at the time of service for certain
Covered Services.
Cost Share The portion of the cost of Covered Services for which the Member is liable. Cost Share
includes Copayments, coinsurances and Deductibles.
Covered Services The services for which a Member is entitled to coverage in the Evidence of Coverage.
Creditable Coverage Coverage is creditable if the actuarial value of the coverage equals or exceeds the
actuarial value of standard Medicare prescription drug coverage, as demonstrated
through the use of generally accepted actuarial principles and in accordance with CMS
actuarial guidelines. In general, the actuarial determination measures whether the
expected amount of paid claims under KFHPWA’s prescription drug coverage is at least
as much as the expected amount of paid claims under the standard Medicare prescription
drug benefit.
Deductible A specific amount a Member is required to pay for certain Cover ed Services before
benefits are payable.
Dependent Any member of a Subscriber's family who meets all applicable eligibility requirements,
is enrolled hereunder and for whom the premium has been paid.
Emergency The emergent and acute onset of a medical, mental health or substance use disorder
symptom or symptoms, including but not limited to severe pain or emotional distress,
that would lead a prudent layperson acting reasonably to believe that a health condition
exists that requires immediate medical attention, if failure to provide medical attention
would result in serious impairment to bodily function or serious dysfunction of a bodily
organ or part, or would place the Member’s health, or if the Member is pregnant, the
health of the unborn child, in serious jeopardy, or any other situations which would be
considered an emergency under applicable federal or state law.
Essential Health
Benefits
Benefits set forth under the Patient Protection and Affordable Care Act of 2010,
including the categories of ambulatory patient services, Emergency services,
hospitalization, maternity and newborn care, mental health and substance use disorder
services, including behavioral health treatment, prescription drugs, rehabilitative and
habilitative services and devices, laboratory services, preventive and wellness services
and chronic disease management and pediatric services, including oral and vision care.
Evidence of Coverage The Evidence of Coverage is a statement of benefits, exclusions and other provisions as
set forth in the Group Medical Coverage Agreement between KFHPWA and the Group.
Family Unit A Subscriber and all their Dependents.
Group An employer, union, welfare trust or bona-fide association which has entered into a
Group Medical Coverage Agreement with KFHPWA.
Hospital Care Those Medically Necessary services generally provided by acute general hospitals for
admitted patients.
8.F.a
Packet Pg. 98 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 57
KFHPWA-designated
Specialist
A specialist specifically identified by KFHPWA.
Medical Condition A disease, illness or injury.
Medically Necessary Pre-service, concurrent or post-service reviews may be conducted. Once a service has
been reviewed, additional reviews may be conducted. Members will be notified in
writing when a determination has been made. Appropriate and clinically necessary
services, as determined by KFHPWA’s medical director according to generally accepted
principles of good medical practice, which are rendered to a Member for the diagnosis,
care or treatment of a Medical Condition and which meet the standards set forth below.
In order to be Medically Necessary, services and supplies must meet the following
requirements: (a) are not solely for the convenience of the Member, their family member
or the provider of the services or supplies; (b) are the most appropriate level of service or
supply which can be safely provided to the Member; (c) are for the diagnosis or
treatment of an actual or existing Medical Condition unless being provided under
KFHPWA’s schedule for preventive services; (d) are not for recreational, life-enhancing,
relaxation or palliative therapy, except for treatment of terminal conditions; (e) are
appropriate and consistent with the diagnosis and which, in accordance with accepted
medical standards in the State of Washington, could not have been omitted without
adversely affecting the Member’s condition or the quality of health services rendered; (f)
as to inpatient care, could not have been provided in a provider’s office, the outpatient
department of a hospital or a non-residential facility without affecting the Member’s
condition or quality of health services rendered; (g) are not primarily for research and
data accumulation; and (h) are not experimental or investigational. The length and type
of the treatment program and the frequency and modality of visits covered shall be
determined by KFHPWA’s medical director. In addition to being medically necessary, to
be covered, services and supplies must be otherwise included as a Covered Service and
not excluded from coverage.
Medicare The federal health insurance program for people who are age 65 or older, certain
younger people with disabilities, and people with End-Stage Renal Disease (permanent
kidney failure requiring dialysis or a transplant, sometimes called ESRD).
Member Any enrolled Subscriber or Dependent.
Network Facility A facility (hospital, medical center or health care center) owned or operated by Kaiser
Foundation Health Plan of Washington or otherwise designated by KFHPWA, or with
whom KFHPWA has contracted to provide health care services to Members.
Network Personal
Physician
A provider who is employed by Kaiser Foundation Health Plan of Washington or
Washington Permanente Medical Group, P.C., or contracted with KFHPWA to provide
primary care services to Members and is selected by each Member to provide or arrange
for the provision of all non-emergent Covered Services, except for services set forth in
the EOC which a Member can access without Preauthorization. Network Personal
Physicians must be capable of and licensed to provide the majority of primary health
care services required by each Member.
Network Provider The medical staff, clinic associate staff and allied health professionals employed by
Kaiser Foundation Health Plan of Washington or Washington Permanente Medical
Group, P.C., and any other health care professional or provider with whom KFHPWA
has contracted to provide health care services to Members, including, but not limited to
physicians, podiatrists, nurses, physician assistants, social workers, optometrists,
psychologists, physical therapists and other professionals engaged in the delivery of
8.F.a
Packet Pg. 99 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 58
healthcare services who are licensed or certified to practice in accordance with Title 18
Revised Code of Washington.
Out-of-pocket Expenses Those Cost Shares paid by the Subscriber or Member for Covered Services which are
applied to the Out-of-pocket Limit.
Out-of-pocket Limit The maximum amount of Out-of-pocket Expenses incurred and paid during the calendar
year for Covered Services received by the Subscriber and their Dependents within the
same calendar year. The Out-of-pocket Expenses which apply toward the Out-of-pocket
Limit are set forth in Section IV.
Plan Coinsurance The percentage amount the Member is required to pay for Covered Services received.
Preauthorization An approval by KFHPWA that entitles a Member to receive Covered Services from a
specified health care provider. Services shall not exceed the limits of the
Preauthorization and are subject to all terms and conditions of the EOC. Members who
have a complex or serious medical or psychiatric condition may receive a standing
Preauthorization for specialty care provider services.
Residential Treatment A term used to define facility-based treatment, which includes 24 hours per day, 7 days
per week rehabilitation. Residential Treatment services are provided in a facility
specifically licensed in the state where it practices as a residential treatment center.
Residential treatment centers provide active treatment of patients in a controlled
environment requiring at least weekly physician visits and offering tre atment by a multi-
disciplinary team of licensed professionals.
Service Area Washington counties of Benton, Columbia, Franklin, Island, King, Kitsap, Lewis,
Mason, Pierce, Skagit, Snohomish, Spokane, Thurston, Walla Walla, Whatcom,
Whitman and Yakima.
Subscriber A person employed by or belonging to the Group who meets all applicable eligibility
requirements, is enrolled and for whom the premium has been paid.
Urgent Condition The sudden, unexpected onset of a Medical Condition that is of sufficient severity to
require medical treatment within 24 hours of its onset.
8.F.a
Packet Pg. 100 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 59
8.F.a
Packet Pg. 101 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
C0B571-0036900 60
8.F.a
Packet Pg. 102 Attachment: Kaiser Agreement 2022 (3154 : Medical Insurance Contract Renewal - Authorize)
2022-01-00611-RC LG PPOL 20220101
1 of 14
Dental Care Service Contract
Declaration Page
Group Number(s) 00611
Group Name City of Kent
Effective Date 12:01 a.m. Pacific Time January 01, 2022
Term 36 Months
Plan Type Delta Dental PPO℠ Local Plan
Group identified above agrees to a Dental Care Service Contract with Delta Dental of Washington (“DDWA”). This Contract
is issued and delivered in the state of Washington and is governed by Washington State laws. It is subject to the terms
listed on these Declaration Page, the general Terms and Conditions, the Certificate of Coverage, and any appendices and
amendments, all of which are incorporated and made part this Contract.
Rates
The monthly Administrative Fee payable by Group under this Contract Term during the period January 01, 2022 through
December 31, 2024 shall be $7.42 per Enrolled Employee. Group’s payment shall be in the form of a check or electronic
transfer and shall accompany the eligibility listing. DDWA will then update the files and send a new billing to Group for
the next month of coverage.
Accepted By: Accepted By:
City of Kent Delta Dental of Washington
220 4th Ave S Post Office Box 75983
Kent, WA 98032-5895 Seattle, WA 98175-0983
Signed: Signed:
Title: Title: Vice President
Underwriting and Actuarial
Date: Date: December 03, 2021
8.F.b
Packet Pg. 103 Attachment: Delta Dental ASC 2022_2024 (3154 : Medical Insurance Contract Renewal - Authorize)
2022-01-00611-RC LG PPOL 20220101
2 of 14
Benefit Period
Benefit Period Start January 1 Benefit Period End December 31
Eligibility, Enrollment, and Termination
Eligibility - Employee As defined by Group Eligibility - Dependent As defined by Group
Start Date Election Yes End Date Election No
Probationary Period As defined by Group Probationary Period Waiver No
Retroactive Additions 180 Days Retroactive Terminations 180 Days
Participation
Minimum Enrollment 100
Participation % Employee Tied to Medical Participation % Dependent Tied to Medical
Expenses
Runout Period 6 Months
8.F.b
Packet Pg. 104 Attachment: Delta Dental ASC 2022_2024 (3154 : Medical Insurance Contract Renewal - Authorize)
2022-01-00611-RC LG PPOL 20220101
3 of 14
Plan 02 – All Medical Plans
Plan Maximums
Plan Maximum $2,000 (19 years of age or older)
Unlimited (under the age of 19)
Orthodontic Maximum $1,800 Lifetime* Temporomandibular
Maximum
Not Covered
*Medically Necessary Orthodontic treatment for members under the age of 19, as defined in the Certificate of Coverage, does not
accrue to the Orthodontic lifetime maximum.
Plan Deductibles
Individual In-Network $50 Family In-Network $150
Individual Out-of-Network $50 Family Out-of-Network $150
Deductible Waived on Class I;Orthodontic Benefits;Accidental Injury Benefits
Plan Coinsurance
Covered Dental Benefits
Delta Dental PPO Dentists Delta Dental Premier Dentists
Dentists Outside of Washington
State
Non-Participating Dentists in
Washington State
Class I 100% 100%
Class II 80% 80%
Class III 80% 80%
Temporomandibular Joint Not Covered Not Covered
Orthodontic 50% 50%
Accidental Injury 100% 100%
8.F.b
Packet Pg. 105 Attachment: Delta Dental ASC 2022_2024 (3154 : Medical Insurance Contract Renewal - Authorize)
2022-01-00611-RC LG PPOL 20220101
4 of 14
Plan 03 – Retirees
Plan Maximums
Plan Maximum $1,500 (19 years of age or older)
Unlimited (under the age of 19)
Orthodontic Maximum $1,000 Lifetime* Temporomandibular
Maximum
Not Covered
*Medically Necessary Orthodontic treatment for members under the age of 19, as defined in the Certificate of Coverage, does not
accrue to the Orthodontic lifetime maximum.
Plan Deductibles
Individual In-Network $50 Family In-Network $150
Individual Out-of-Network $50 Family Out-of-Network $150
Deductible Waived on Class I;Orthodontic Benefits;Accidental Injury Benefits
Plan Coinsurance
Covered Dental Benefits
Delta Dental PPO Dentists Delta Dental Premier Dentists
Dentists Outside of Washington
State
Non-Participating Dentists in
Washington State
Class I 100% 100%
Class II 80% 80%
Class III 50% 50%
Temporomandibular Joint Not Covered Not Covered
Orthodontic 50% 50%
Accidental Injury 100% 100%
8.F.b
Packet Pg. 106 Attachment: Delta Dental ASC 2022_2024 (3154 : Medical Insurance Contract Renewal - Authorize)
2022-01-00611-RC LG PPOL 20220101
5 of 14
Deviations
All of the Terms and Conditions in this Contract apply, except if specifically modified in this Deviations section. Any
modifications listed here supersede all referenced Articles in the standard Terms and Conditions section below.
The following custom language is added by this reference.
Section # Custom Language
Global - Plan 03 For the purposes of Plan 03, the term Retiree may be inferred in place of the term Employee,
where applicable.
8.9. Leave of Absence
Coverage for a subscriber and enrolled dependents may be continued for up to 180 days when the
employer grants the subscriber a leave of absence and premium charges continue to be paid. If a
medical leave is granted, the City of Kent may pay the required monthly charge for the employee
and enrolled dependents for up to 180 days. The 180-day leave of absence period counts toward
the maximum COBRA continuation period, except as prohibited by the Family and Medical Leave
Act of 1993.
8.F.b
Packet Pg. 107 Attachment: Delta Dental ASC 2022_2024 (3154 : Medical Insurance Contract Renewal - Authorize)
2022-01-00611-RC LG PPOL 20220101
6 of 14
Dental Care Service Contract
Terms and Conditions
1. Definitions
1.1. Administrative Fee: The monthly amount payable by Group as designated on the Declaration Pages.
1.2. Benefit Period: The time period that applies to the frequencies and limitations. The Benefit Period is shown on the
Declaration Page.
1.3. Certificate of Coverage: The benefit booklet, which describ es in summary form the essential features of the Plan coverage,
and to or for whom the benefits hereunder are payable. In the ev ent that contracts are changed or amended, new
certificates or a clearly understandable benefit booklet insert to existing certi ficates shall be furnished. The Certificate of
Coverage is incorporated into this Contract by this reference as if it were fully written in this document.
1.4. Contract: This agreement between DDWA and Group, including the Declaration Page, Certificates of Coverage and any and
all appendices and amendments. This Contract constitutes the entire Contract between the parties and supersedes any
prior agreement, understanding or negotiation between the parties.
1.5. Covered Dental Benefit: Dental services that are covered under this Contract, subject to the limitations and exclusi ons set
forth in the Certificate of Coverage.
1.6. DDWA: Delta Dental of Washington, a nonprofit corporation incorporated in Washington State. DDWA is a member of the
Delta Dental Plans Association.
1.7. Declarations Page(s): The front page(s) of this Plan that provides the Group specific information and group specific
elections referred to in the Terms and Conditions.
1.8. Delta Dental: Delta Dental Plans Association: A nationwide not-for-profit organization of dental benefit carriers offering a
range of group dental benefit plans.
1.9. Delta Dental PPO℠ Dentist: A Participating Dentist who has agreed to render services and receive payment in accordance
with the terms and conditions of a written Delta Dental PPO provider agreement, which includes looking solely to Delta
Dental for payment for covered services.
1.10. Delta Dental Premier® Dentist: A Delta Dental Participating Dentist who has agreed to render services and receive payment
in accordance with the terms and conditions of a written Delta Dental provider agreement between DDWA and such
Dentist.
1.11. Delta Dental Participating Dentist: A licensed Dentist who has agreed to render services and receive payment in
accordance with the terms and conditions of a written Delta Dental Provider Agreement, which includes looking solely to
Delta Dental for payment for covered services. Delta De ntal Participating Dentists include Delta Dental PPO Dentists and
Delta Dental Premier Dentists.
1.12. Dentist: A licensed dentist legally authorized to practice dentistry at the time and in the place services are performed. This
Contract provides covered services only if those services are performed by or under direction of a licensed Dentist or other
Licensed Professional operating within the scope of their license.
1.13. Eligibility Date: The date on which an Eligible Person becomes eligible to enroll in the Plan.
1.14. Eligible Dependent, Eligible Employee, or Eligible Person: Any dependent, employee or person who meets the conditions of
eligibility set forth on the Declaration Page.
1.15. Employee: A person who is designated as an employee by the Group for the purposes of this Plan.
1.16. Enrolled Dependent, Enrolled Employee, or Enrolled P erson: Any Eligible Dependent, Eligible Employee or Eligible Person,
as applicable, who has completed the enrollment process and for whom Group has submitt ed the monthly Administrative
Fee to DDWA.
8.F.b
Packet Pg. 108 Attachment: Delta Dental ASC 2022_2024 (3154 : Medical Insurance Contract Renewal - Authorize)
2022-01-00611-RC LG PPOL 20220101
7 of 14
1.17. Filed Fee: The negotiated fee for a specific dental procedure performed by a Delta Dental Participating Dentist.
1.18. Group: The employer or entity that is contracting for dental benefits for its Employees in this Contract.
1.19. Licensed Professional: An individual legally authorized to perform services as defined in their license. Licensed Professional
includes, but is not limited to, denturists, hygienists, and radiology technicians.
1.20. Lifetime Maximum: The maximum amount DDWA will pay in the specified Covered Dental Benefit class for an insured
individual during the time that individual is o n this Plan or any other Plan offered by this Employer.
1.21. Maximum Allowable Fee: The maximum dollar amount that will be allowed toward the reimbursement for any service
provided for a Covered Dental Benefit.
1.22. Non-Participating Dentist: A licensed Dentist who has not agreed to render services and receive payment in accordance
with the terms and conditions of a written Participating Dentist Agreement between a member of the Delta Dental Plans
Association and such Dentist.
1.23. Open Enrollment Period: The annual period in which Eligible Employees can select benefits Plans and add or delete Eligible
Dependents.
1.24. Participating Plan: Delta Dental of Washington and any other member of the Delta Dental Plans Association with wh ich
Delta Dental contracts to assist in administering the Covered Dental Benefits described in this Contract.
1.25. Plan Coinsurance: The applicable percentage of Maximum Allowable Fees for Covered Dental Benefits that shall be paid by
DDWA as set forth in the Declaration Page. Sometimes this is referred to as the payment level.
1.26. Plan: This Contract that provides dental benefits. Any other Contract that provides dental benefits and meets the definition
of a "Plan" in the "Coordination of Benefits" section of the Certificate of Coverage is a plan for the purpose of coordinatio n
of benefits only.
1.27. Service Area: Washington State, the geographic area in which DDWA will issue this policy. Dental Benefits are p rovided for
covered services received outside of Washington State.
1.28. Standard Terms and Conditions: The non-Group specific terms and conditions that control this Contract, unless specifically
modified on the Declaration Page.
2. Eligibility, Enrollment, and Termination
2.1. Employee Eligibility, Enrollment, and Termination
2.1.1. Employees are eligible to enroll in this Plan if they meet the condition of eligibility designated on the Declaration
Page.
2.1.2. Eligible Employees may enroll in this Plan on the effective date of this Contract. An employee hire d after the effective
date of this Contract may enroll in this Plan after satisfying the probationary period indicated on the Declaration
Page.
2.1.3. Employees are eligible to enroll in this Plan on the first of the month after satisfying any probationary period
designated on the Declaration Page unless the Group has elected the 'Start Date' option on th e Declaration Page. For
'Start Date' election, the Employee enrollment will start on the date the Employee is eligible. An Employee shall
continue to be eligible to enroll in this Plan during the time this Contract is in effect as long as the Employee rema ins
an Eligible Employee.
2.1.4. If indicated on the Declaration Page, DDWA will waive the Employee probationary period for an Employee hired after
the effective date of this Contract who is transferring into the Plan from enrollment in any other dental plan.
Enrollment for such Employee must be completed within 30 days of the transfer and the Employee mu st have been
enrolled for benefits under the prior dental plan in the month of transfer or immediately prior to the month of
transfer. The effective date of coverage for such Employee shall be the first day of the calendar month following
enrollment. Notification of previous coverage is required at the time of enrollment.
8.F.b
Packet Pg. 109 Attachment: Delta Dental ASC 2022_2024 (3154 : Medical Insurance Contract Renewal - Authorize)
2022-01-00611-RC LG PPOL 20220101
8 of 14
2.1.5. Eligible Employees become Enrolled Employees after fully completing the enrollment process, including payment of
Administrative Fee by Group to DDWA, and remain Enrolled Employees as long as they remain eligible under this Plan
and Group has made timely payments of monthly Administrative Fees on behalf of the Employee.
2.1.6. An Enrolled Employee terminates from this Plan at the end of the month that the employee is no longer eligible for
enrollment unless the Group has elected the 'End Date' option on the Declaration Page. For 'End Date' election, the
Employee terminates on the date the Employee is no longer eligible. An Employee will also terminate from this Plan
at the end of the calendar month for which Group has made the last timely payment of the monthly Administrative
Fees on behalf of the Enrolled Employee, or upon termination of this Contract, whichever occurs first.
2.2. Dependent Eligibility, Enrollment, and Termination
2.2.1. Dependent coverage under this plan is available as indicated on the Declaration Page.
2.2.2. If covered, an Eligible Dependent is a dependent of an En rolled Employee who meets the requirements for eligibility
established by the Group. Dependent eligibility validation documentation shall be maintained and verified by the
Group.
2.2.3. An Eligible Dependent shall become eligible to enroll in this Plan on the date the Eligible Employee becomes eligible
to enroll in this Plan, or on the first day of the calendar month following the month in which such person became an
Eligible Dependent of the Eligible Employee.
2.2.4. If covered, a foster child is covered from the time of placement.
2.2.5. A newborn is covered from the moment of birth, and an adopted child is covered from the date of assumption of a
legal obligation for total or partial support or upon placement of the child in anticipation of adoption of the child.
2.2.6. Eligible Dependents become Enrolled Dependents after fully completing the enrollment process, including payment
of Administrative Fee by the Group to DDWA. An Enrolled Depend ent shall continue to be enrolled as long as the
Group has made timely payment of the monthly Administrative Fees on behalf of the Enrolled Employee to DDWA.
2.2.7. If the enrollment process is not completed within the time period selected which is represented in the Certificate of
Coverage, enrollment will not be accepted until the next Open Enrollment Period unless specified, or unless there is a
change in family status as defined in the Special Enrollment Period section of the Certificate of Coverage. If an
additional Administrative Fee for coverage is required and enrollment is not completed within the time period
selected, the newborn, adopted or foster child(ren) will be covered from the effective date of enrollment as defined
in the Certificate of Coverage.
2.2.8. An Enrolled Dependent terminates from this Plan when they are no longer an Eligible Dependent of an Eligible
Employee, or at the end of the calendar month for which Group has made timely p ayment of the monthly
Administrative Fees on behalf of the Enrolled Employee, or upon termination of this Contract, whichever occurs first.
2.2.9. An Enrolled Employee may terminate coverage of an Enrolled Dependent or reinstate an Eligible Dependent only at
renewal or extension of this Plan, or if there is a chan ge in family status, as defined in the Special Enrollment Period
section of the Certificate of Coverage.
2.3. General Enrollment Information
2.3.1. An Enrolled Employee must complete the enrollment process for themselves or any newly Eligible Dependents within
the time period represented in the Certificate of Coverage. Late en rollment will not be accepted until the next Open
Enrollment Period unless specified, or unless there is a change in family status as defined in the Special Enrollment
Period section of the Certificate of Coverage.
2.3.2. DDWA requests that all completed enrollment information is received from the Group within 60 days of the
employee or dependent's eligibility date.
2.3.3. Retroactive additions and terminations of enrollment for administrative purposes w ill only be accepted for the time
period indicated on the Declaration Page.
2.3.4. While satisfying the various requirements of the FML A, the Paid Family and Medical Leave Act, and COBRA laws rests
primarily with the Group, DDWA will fully cooperate with Group in complying with these laws.
8.F.b
Packet Pg. 110 Attachment: Delta Dental ASC 2022_2024 (3154 : Medical Insurance Contract Renewal - Authorize)
2022-01-00611-RC LG PPOL 20220101
9 of 14
3. Participation Requirements, Administrative Fees, Invoicing, Payment, and Reimbursement of Claims
3.1. Participation Requirements
3.1.1. This Contract requires participation of the required percentage or segment of Eligible Employees and Eligible
Dependents as indicated on the Declaration Page.
3.1.2. For Groups that elect a specific percentage of employee participation, Group will assure that percentage of Eligibl e
Employees are participating in this Plan.
3.1.3. For Groups that elect a specific percentage of dep endent participation, Group will assure that specified percentage of
all Enrolled Employees enroll all of their Eligible Dependents, unless those dependents are enrolled in another dental
plan.
3.1.4. For Groups that elect to have employee or depe ndent enrollment in this Plan tied to enrollment in their Group-
sponsored medical plan, all Eligible Employees and their Eligible Dependents who are enrolled in the Group-
sponsored medical plan must be enrolled in this Plan regardless of whether or not they are enrolled as a dependent
in another dental plan. Eligible Employees or their Eligible Dependents who are not enrolled in the Group-sponsored
medical plan may not enroll in this Plan.
3.1.5. For Groups that elect voluntary enrollment, there is no participation requirement. All other enrollment requirements
apply.
3.2. Administrative Fee
3.2.1. Group shall submit a list of Enrolled Persons to DDWA prior to the beginning of each monthly eligibility period.
3.2.2. Group shall permit DDWA, at DDWA's expense, on reasonable advance written notice, to inspect e ligibility records to
verify the accuracy of information submitted to DDWA. An equitable adjustment of Administrative Fee shall be made
in the event of errors or delays in reporting eligibility.
3.2.3. DDWA shall not be obligated to recoup any funds paid to providers for treatment performed in good faith that the
patient's eligibility was current and accurate at the time of treatment.
3.2.4. Legislative Surcharge Clause. If any governmental unit imposes any new tax or assessment or increases the rate of
any current tax or assessment that is measured directly by the payments made to DDWA by Group, or payment made
by DDWA for claims, then DDWA is authorized to increase the monthly Administrative Fee by the amount of such
new tax, assessment or increase, or pass through the exact tax amount to the Group separately.
3.2.5. If Group does not agree to the proposed adjustment within 30 days, DDWA may terminate this Contract at the end of
the month for which Administrative Fee had been received by DDWA prior to the date of such notice to Group and in
accordance with the provisions of this Contract.
3.2.6. The monthly Administrative Fee indicated on the Declaration Page will be remitted fully by Group as invoiced.
3.3. Invoicing and Payment
3.3.1. The Group shall pay the full invoiced amount to DDWA on or before the first day of each calendar month for which
benefits are to be provided.
3.3.2. Payment of Administrative Fee is by Electronic Funds Transfer (EFT) unless other specific payment methods are
approved by DDWA.
3.3.3. If Group objects to any portion of an invoice, Group will notify DDWA prior to the payment due date and specify the
amount and cause of the dispute. Group will pay any undisputed amounts in a timely manner. Any disputed amounts
will be resolved by direct negotiation between DDWA and Group.
3.3.4. If payment is not received within 30 days, DDWA may give written notice that payment is past due and may, at its
discretion, terminate all benefits and be released from all further obligations as set forth herein.
3.3.5. No person shall be entitled to benefits under this Contract during any month for whic h Administrative Fee payment
has not been received by DDWA.
8.F.b
Packet Pg. 111 Attachment: Delta Dental ASC 2022_2024 (3154 : Medical Insurance Contract Renewal - Authorize)
2022-01-00611-RC LG PPOL 20220101
10 of 14
3.4. Reimbursement of Claims
3.4.1. DDWA shall notify Group monthly of the actual amount of claims paid by DDWA for that month. Notification will be
via email, which will constitute an invoice. Group will then have two business days to transfer funds electronically to
the appropriate DDWA bank account in an amount equal to total claims paid for the month.
3.4.2. Funds are due on the date notified. If th e funds are not transferred within five days of notification, a late fee of one
percent of total claim dollars on that invoice will be charged. An additional late charge of one percent of the total
claim dollars on that invoice will be charged if payment is not received within 30 days of the due date and an
additional late charge of one percent of the total claim dollars on that invoice for each subsequent 30 -day period for
which payment is not received. The charges shall be included by DDWA with a subseque nt payment notification.
4. Benefits and Benefit Disputes
4.1. Benefits
4.1.1. Covered Dental Benefits, Limitations, and Exclusions are as described in the Certificate of Coverage and are subject to
the Plan maximum and deductible as defined on the Declaratio n Page.
4.1.2. Covered Dental Benefits are available for an Enrolled Person from the effective date o f their coverage until such
enrollment terminates.
4.1.3. The percentages of the Maximum Allowable Fe e, Filed Fee, or the Dentists' actual charges payable by DDWA for
Covered Dental Benefits provided to an Enrolled Person are defined on the Declaration P age.
4.1.4. To determine Covered Dental Benefits for certain treatments, DDWA may require an Enrolled Person to obtain an
independent examination from a DDWA-appointed dentist. DDWA will pay all the charges incurred for this
examination.
4.2. Providers
4.2.1. Payment for services provided by a Delta Dental Participating Dentist will be made directly to the dentist. Contracts
between Delta Dental and its Delta Dental Participating Dentists provide that, if Del ta Dental fails to pay the dentist
any amount owed, the Enrolled Person shall not be liable to the dentist for any sums owed by Delta Dental.
4.2.2. An Enrolled Person may elect the services of any licensed dentist. DDWA is not responsible for availability of any
particular licensed dentist. DDWA shall not be held liable for any act or omission on the par t of the selected dentist.
4.2.3. DDWA shall be entitled to receive from any attending dentist, or from hospitals in which a dentist's care is rendered,
any records relating to treatment rendered to an En rolled Person as may be required in the administration of claims.
4.2.4. The provider dispute resolution process as outlined in individual provider contracts is available upon request.
4.2.5. Fees paid to a provider for Covered Dental Benefits under this Plan are based on the lesser of the provider's actual
fee or the Maximum Allowable Fee of the fee schedule defined below:
PPO Local Plan
Provider Type Fee Schedule
Delta Dental PPO Participating Dentist PPO Participating Dentist – State Specific
Delta Dental Premier Participating Dentist Premier Participating Dentist – State Specific
Non-Participating Dentist in Washington State Non-Participating Dentist – State Specific
Non-Participating Dentists out of Washington State Participating Dentist
5. Plan Details
5.1. Plan Maximum
5.1.1. The maximum amount payable by DDWA for Class I, II, and III Covered Dental Benefits per Enrolled Person during
each Benefit Period is indicated on the Declaration Page. Charges for dental procedures requiring multiple treatment
8.F.b
Packet Pg. 112 Attachment: Delta Dental ASC 2022_2024 (3154 : Medical Insurance Contract Renewal - Authorize)
2022-01-00611-RC LG PPOL 20220101
11 of 14
dates shall be considered incurred on the date the service is completed. Amounts for such procedures shall be
applied to the Plan maximum based on such incurred d ate.
5.1.2. If Orthodontic Benefits are covered, the annual or lifetime maximum amount payable by DDW A for Orthodontic
Benefits provided to an Enrolled Person will be indicated on the Declaration Page. If Orthodontic Benefits are covered
for children only, the maximum will apply only to those members.
5.1.3. If Temporomandibular Joint (TMJ) services are covered, the annual or lifetime maximum amount payable by DDWA
for dental services related to the treatment of TMJ disorders will be indicated on the Declaration Page.
5.2. Plan Coinsurance
Plan coinsurance amounts are indicated on the Declaration Page.
5.3. Plan Deductible
5.3.1. The plan deductible, if elected, is indicated on the Declaration Page.
5.3.2. Deductibles may apply to In-Network and Out-of-Network combined, In-Network and Out-of-Network separately, or
for Out-of-Network only, as indicated on the Declaration Page.
5.3.3. DDWA is not obligated to pay for Covered Dental Benefits until the deductible amount is satisfied during eac h Benefit
Period for each individual, unless the family deductible has been met during that Benefit Period. The family
deductible is accrued by deductible payments of the Enrolled Employee or any Enrolled Dependent.
5.3.4. Any elected deductible is waived on designated classes of benefits as indicated on the Declaration Page.
6. DDWA’s Obligations
6.1. Certificates of Coverage
6.1.1. DDWA will issue to Group an electronic version of the Certificate of Coverage for this Plan in the form of a standard
DDWA benefit booklet, which summarizes the Covered Dental Benefits and other essential features of the Plan. If any
amendment to this Contract materially affects any benefits described in book lets, electronic versions of corrected
booklets or booklet inserts showing the change will be issued to Group. Generally, new Booklets and/or Inserts are
not issued mid-Contract Term unless as otherwise specified in this Contract.
6.1.2. Upon receipt of a written request, DDWA will provide to Group one printed booklet for each employee enrolled in
the Plan, plus an additional ten percent for a reserve supply . Group will reimburse DDWA for any additional costs due
to variation in booklet size or paper requested by Group. DDWA will have booklets delivered to Group within 15
business days after receipt of a s igned booklet approval form from Group.
6.2. Confirmation of Treatment and Cost (also known as predetermination of benefits)
6.2.1. DDWA will provide descriptions of Confirmation of Treatment and Costs, claim review, and complaint and appeal
procedures in the benefit booklets issued to Group.
6.2.2. If a dentist or an Enrolled Person submits a request for a Confirmation of Treatment and Cost, DDWA will provide a
Confirmation of Treatment and Cost for the Enrolled Person. Such Confirmation of Treatment and Cost w ill be valid
when issued based on the information available at that time. A Confirmation of Treatment and Costs is not an
authorization for services nor a guarantee of payment but is a notification of Covered Dental Benefits available.
6.3. Quality Management
DDWA may utilize its Quality Management and Clinical Review processes to provide professional review of the adequacy,
appropriateness, and alignment with DDWA's established clinical criteria of services rendered to Enrolled Persons.
6.4. Provider Directories
DDWA shall provide Delta Dental Participating Dentist Directories to Group. Th is directory is available online, and may also
be requested by telephone as indicated in the Certificate of Cove rage. It is understood that the composition of such
directory is subject to change. DDWA reserves the right to change the directory without noti ce.
8.F.b
Packet Pg. 113 Attachment: Delta Dental ASC 2022_2024 (3154 : Medical Insurance Contract Renewal - Authorize)
2022-01-00611-RC LG PPOL 20220101
12 of 14
6.5. Dental Services Obligations
6.5.1. DDWA shall not be obligated to make payment for any services r endered to a person who is not an Enrolled Person at
the time the services were performed.
6.5.2. Nothing contained in this Contract shall be construed as obligating DDWA to render dental services; its sole obliga tion
being to pay the agreed-upon portion of dentist's charges for Covered Dental Benefits in accordance with the terms
of this Contract.
7. Group’s Obligations
7.1. Notification to Enrolled Employees
Group shall provide information to all Enrolled Employees as to the existence and terms of this Contract. Group shall make
the Certificate of Coverage available to each Enrolled Employee.
7.2. Summary Plan Descriptions
If Group elects to prepare and print its own summary plan description, it does so at its own risk and expense. The Group-
prepared summary plan description must be based on the most current Certificate of Coverage provided by DDWA, and
will be for informational purposes only, not incorporated into this Contract. Group is responsible for assuring the accuracy
of any summary plan description that it elects to prepare and distribute. DDWA is not obligated to review or approve any
summary plan description prepared by Group, and will not provide any warranty for the content of the Group-produced
summary plan description.
7.3. Execution of Contract
7.3.1. Group shall sign and return any and all Contract documents within 30 days of the effective date or the date DDWA
sends the Contract document to Group or its authorized representative or agent, whichever is later.
7.3.2. If a signed Contract is not received by DDWA from the Group or the Group's legal representative(s) by the effective
date, but Group remits Administrative Fee, both parties agree to perform under this Contract in good faith until a
signed Contract is received, or until a notice of termination is received as detailed herein.
8. General Provisions
8.1. Modification
No change in this Contract shall be valid unless evidenced by written amendment signed by an authorized representative
or agent of DDWA and an authorized representative or agent of Group.
8.2. Legal Action
Legal action to recover benefits provided f or in this Contract may not be initiated prior to 60 days after receipt of claim by
DDWA. In addition, such legal action must commence within 6 years from the date the claim was received by DDWA.
8.3. Severability
Any provision of this Contract that is in conflict with any governing law or regulation of the State of Washington is h ereby
amended to comply with the minimum requirements of such law or regulation.
8.4. Indemnification
8.4.1. DDWA shall indemnify and hold harmless Group, its affiliates and their respective directors, officers, employees and
agents, for that portion of any liability, settlement and related expense (including reasonable attorneys' fees)
resulting solely and directly from DDWA's breach of this Contract, negligence, willful misconduct, criminal conduct,
fraud or its breach of a fiduciary responsibility related to or arising out of this Contr act.
8.4.2. Group shall indemnify and hold harmless DDWA, its affiliates and their respective directo rs, officers, employees and
agents, for that portion of any liability, se ttlement and related expense (including reasonable attorneys' fees)
resulting solely and directly from Group's breach of this Contract, negligence, willful misconduct, criminal conduc t,
fraud or its breach of a fiduciary responsibility related to or arisin g out of this Contract.
8.F.b
Packet Pg. 114 Attachment: Delta Dental ASC 2022_2024 (3154 : Medical Insurance Contract Renewal - Authorize)
2022-01-00611-RC LG PPOL 20220101
13 of 14
8.5. Force Majeure
In the event DDWA is unable to perform its obligations u nder this Contract by reason of fire, casualty, lockout, strike, labor
condition, riot, war, act of God or by ordinance, law, order or decree of any legally constituted authority, the n this
Contract may, at the option of DDWA, be suspended. During any period of suspension, DDWA shall not be required to
perform any service under this Contract, nor shall DDWA be liable for any damages arising from any event that
precipitated the suspension. If this Contract is suspended pursuant to this provision, Group's obl igation to make
Administrative Fee payments shall also be suspended for the same period of time.
8.6. Privacy
DDWA and Group will act in accordance with applicable state and federal privacy requirements and disclosure
requirements, such as the Gramm-Leach-Bliley Act (GLBA) and the Health Insurance Portability and Accountability Act
(HIPAA), including any applicable regulations.
8.7. Domestic Partnership and Gender
For the purposes of this contract, the terms spouse, marriage, marital, husband, wife, widow, widower, next of kin, and
family shall be interpreted as applying equally to domestic partnerships or individuals in domestic partnerships as well as
to marital relationships and married persons. References to dissolution of marriage shall apply equally to domestic
partnerships that have been terminated, dissolved, or invalidated, to the extent that such interpretation does not conflict
with federal law. Where necessary, gender-specific terms such as husband and wife used in any part of this contract shall
be construed to be gender neutral, and applicable to individuals in domestic partnerships. This definition does not change
the election of the Group with regard to coverage for domestic partnerships .
8.8. Notice
Any notice under this Contract shall be sufficient if given by either Group or DDWA b y regular mail to the other addressed
to the office stated on the front page of this Contract or to such other address as may be designated by written notice to
the other.
9. Termination
9.1. Termination Notice
This Contract may be terminated effective at the end of the term by either Group or DDWA, or by either party giving
written notice to the other at least 30 days prior to the end of the Contract term, except as otherwise specifically provided
herein.
9.2. DDWA Termination
9.2.1. DDWA may elect to terminate this Contract, without prior approval of the Washington State Insurance
Commissioner, if any of the events outlined in this Section occur. Termination would be effective at the end of the
month for which Administrative Fees have been received by DDWA prior to the time of such electio n. If termination
occurs, DDWA will provide written notice to Group. If DDWA elects to terminate because of default by Group, then
Group shall be indebted to and agrees to pay DDWA the sum of all claims payments and expenses incurred for dental
services rendered from the date of default until the date of termination, including costs of recovery.
9.2.2. Events that allow termination:
a. A failure to pay Administrative Fee or perform Group's other obligations when due.
b. Any violation of published policies of DDWA.
c. Change or implementation of federal or state health care reform laws that no longer permit the continued
offering of such coverage.
9.2.3. Events that allow termination if the Group does not take corrective action consistent with their obligations under this
Contract:
a. Enrolled Persons committing fraudulent acts against DDWA.
b. Enrolled Persons who materially breach the terms of this Contract.
8.F.b
Packet Pg. 115 Attachment: Delta Dental ASC 2022_2024 (3154 : Medical Insurance Contract Renewal - Authorize)
2022-01-00611-RC LG PPOL 20220101
14 of 14
9.3. Administrative Fee Reimbursement
If on termination of this Contract, Group has paid Administrative Fee to DDWA applicable to a period of time after the
termination date, DDWA shall, within 30 days after notification of termination, return such portion of Administrative Fee
to Group less any amounts due to DDWA.
9.4. Reinstatement
9.4.1. Acceptance by DDWA of the proper amount of Administrative Fee, after termination of this Contract and without
requiring a new application, shall reinstate the Contract as though it had never terminated, unless DDWA shall, within
5 business days of receipt of such payment, either:
a. Refund the payment so made, or
b. Issue to Group a new Contract accompanied by written notice stating clearly those respects in wh ich the new
Contract differs from the terminated Contract in benefits, coverage or otherwise.
9.5. Expenses
Upon termination of this Plan, all claim payments and expenses incurred prior to the termination of the Plan, but not
submitted to DDWA within the runout period after the date of treatment will be excluded from any ben efit consideration.
8.F.b
Packet Pg. 116 Attachment: Delta Dental ASC 2022_2024 (3154 : Medical Insurance Contract Renewal - Authorize)
Vision Care for Life
VSP VISION CARE, INC.
3333 QUALITY DRIVE
RANCHO CORDOVA, CALIFORNIA 95670
GROUP VISION CARE PLAN
ADMINISTRATIVE SERVICES PROGRAM
Group Name CITY OF KENT
Plan Number 12229020
State of Delivery WASHINGTON
Effective Date JANUARY 1, 2022
Plan Term FORTY-EIGHT (48) MONTHS
Premium Due Date FIRST DAY OF MONTH
In consideration of the statements and agreements contained in the Group Application and in consideration of
payment by Group of the administrative fees and other amounts due as herein provided, VSP VISION CARE, INC. ("VSP")
agrees to provide certain individuals under this Group Vision Care Plan (“Plan”) the benefits provided herein, subject to the
exceptions, limitations and exclusions hereinafter set forth. This Plan is delivered in and governed by the laws of the State of
Delivery and is subject to the terms and conditions recited on the subsequent pages hereof, which are a part of this Plan.
COPY
____________________________________________
Kate Renwick-Espinosa, President
VSP-GVCP-ASP-5/07 11/10/21 Ank
8.F.c
Packet Pg. 117 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
TABLE OF CONTENTS
I. DEFINITIONS.............................................................................................................. 1
II. TERM, TERMINATION, AND RENEWAL................................................................... 3
III. OBLIGATIONS OF VSP.............................................................................................. 4
IV. OBLIGATIONS OF THE GROUP................................................................................ 8
V. OBLIGATIONS OF COVERED PERSONS UNDER THE PLAN............................. 10
VI. ELIGIBILITY FOR COVERAGE................................................................................... 13
VII. CONTINUATION OF COVERAGE.............................................................................. 16
VIII. ARBITRATION OF DISPUTES.................................................................................... 17
IX. NOTICES..................................................................................................................... 18
X. MISCELLANEOUS...................................................................................................... 19
EXHIBIT A
SCHEDULE OF BENEFITS........................................................................... 21
SCHEDULE OF BENEFITS........................................................................... 26
SCHEDULE OF BENEFITS........................................................................... 31
EXHIBIT B
SCHEDULE OF PREMIUMS......................................................................... 36
SCHEDULE OF PREMIUMS......................................................................... 37
ADDENDUM
ADDITIONAL BENEFIT - DIABETIC EYECARE........................................... 38
8.F.c
Packet Pg. 118 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
I.
DEFINITIONS
Key terms used in this Plan are defined and shall have the meaning set forth as follows, unless the context of a term’s
usage clearly requires otherwise.
1.01 ADMINISTRATIVE FEE: The payments made to VSP by or on behalf of Group in consideration of
administrative services rendered.
1.02. ADMINISTRATIVE SERVICES PROGRAM: A group vision care plan whereby Group pays VSP for the Plan
Benefits in addition to a monthly Administrative Fee.
1.03. ADVANCE PAYMENT: The amount paid in advance to VSP by or on behalf of Group to cover the estimated
benefit costs of Group for one (1) month.
1.04. BENEFIT AUTHORIZATION: Authorization issued by VSP identifying the individual named as a Covered
Person of VSP, and identifying those Plan Benefits to which Covered Person is entitled.
1.05. CLAIMS AMOUNT: Total charges for benefits delivered, including the cost of professional services and
ophthalmic materials, charges for VSP services related to materials purchased, and taxes.
1.06. CONFIDENTIAL MATTER: All confidential or personal information concerning the medical, personal,
financial or business affairs of Covered Persons acquired in the course of providing Plan Benefits hereunder.
1.07. COPAYMENTS: Any amounts required to be paid by or on behalf of a Covered Person for Plan Benefits
which are not fully covered.
1.08. COVERED PERSON: An Enrollee or Eligible Dependent who meets VSP's eligibility criteria and who is
covered under this Plan.
1.09. ELIGIBLE DEPENDENT: Any legal dependent of an Enrollee of Group who meets t he criteria for eligibility
established by Group and approved by VSP in Article VI of this Plan under which such Enrollee is covered.
1.10. EMERGENCY CONDITION: A condition, with sudden onset and acute symptoms, that requires the Covered
Person to obtain immediate medical care, or an unforeseen occurrence calling for immediate, non -medical action.
1.11. ENROLLEE: An employee or member of Group who meets the criteria for eligibility specified under VI.
ELIGIBILITY FOR COVERAGE.
1
8.F.c
Packet Pg. 119 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
1.12. EXPERIMENTAL NATURE: Procedure or lens that is not used universally or accepted by the vision care
profession, as determined by VSP.
1.13. GROUP: An employer or other entity which contracts with VSP for coverage under this Plan in order to
provide vision care coverage to its Enrollees and their Eligible Dependents.
1.14. GROUP APPLICATION: The form signed by an authorized representative of the Group to signify the
Group's intention to have its Enrollees and their Eligible Dependents become Covered Persons of VSP.
1.15. GROUP VISION CARE PLAN (also, "THE PLAN"): The Plan provided by VSP in favor of a Group, under
which its Enrollees, and their Eligible Dependents are entitled to become Covered Persons of VSP and receive Plan Benefits
in accordance with the terms of such Plan.
1.16. MEMBER DOCTOR: An optometrist or ophthalmologist licensed and otherwise qualified to practice vision
care and/or provide vision care materials who has contracted with VSP to provide vision care services and/or vision care
materials on behalf of Covered Persons of VSP.
1.17. NON-MEMBER PROVIDER: Any optometrist, optician, ophthalmologist, or other licensed and qualified
vision care provider who has not contracted with VSP to provide vision care services and/or vision care materials to Covered
Persons of VSP.
1.18. PLAN BENEFITS: The vision care services and vision care materials which a Covered Person is entitled to
receive by virtue of coverage under this Plan, as defined in the Schedule of Benefits attached hereto as Exh ibit A.
1.19. RENEWAL DATE: The date on which the Plan shall renew, or terminate if proper notice is given.
1.20. SCHEDULE OF BENEFITS: The document, attached hereto as Exhibit A, which lists the vision care
services and vision care materials which a Covered Person is entitled to receive by virtue of this Plan.
1.21. SCHEDULE OF ADVANCE PAYMENT AND ADMINISTRATIVE FEE: The document, attached hereto as
Exhibit B, which states the payments to be made to VSP by or on behalf of a Covered Person to entitle him to Plan Benefits.
2
8.F.c
Packet Pg. 120 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
II.
TERM, TERMINATION, AND RENEWAL
2.01. Plan Term: This Plan shall become effective on the Effective Date and shall remain in effect for the Plan
Term. At the end of the Plan Term, it will renew on a month to month basis unless either party notifies the other in writing , at
least sixty (60) days before the end of the Plan Term, that the party is unwilling to renew the Plan. If such notice is given, the
Plan will terminate at 12:00 midnight on the last day of the Plan Term, unless the parties reach mutual agreement on its
renewal. If the Plan continues on a month to month basis after the Plan Term, either Party may thereafter terminate the Plan
upon thirty (30) days advance written notice to the other party.
If VSP issues written renewal materials to Group at least sixty (60) days before the end of the Pla n Term and Group
fails to accept the new terms and/or rates in writing prior to the end of the Plan Term, this Plan shall terminate at 12:00
midnight on the last day of the Plan Term as noted above.
2.02. Termination: Either party may terminate the agreement upon a sixty (60) day advance written notice. Group
agrees to pay all Claims Amount and Administrative Fees for Plan Benefits provided pursuant to Benefit Authorizations issued
prior to the Plan termination date, provided claims for such Plan Benefits a re filed with VSP within six (6) months after
termination of this Plan.
3
8.F.c
Packet Pg. 121 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
III.
OBLIGATIONS OF VSP
3.01. Coverage of Covered Persons: VSP will enroll each eligible Enrollee and his Eligible Dependents, if
dependent coverage is provided, all of whom shall be referred to as "Covered Persons." To institute coverage, Group may be
required to complete and sign a Group Application and forward such application to VSP, along with information regarding
Enrollees and Eligible Dependents, and applicable amounts due. (Refer to VI. ELIGIBILITY FOR COVERAGE for further
details.)
Following enrollment, VSP will provide Group with Member Benefit Summaries for Covered Persons. Such Member
Benefit Summaries will summarize the terms and conditions of this Plan.
3.02. Provision of Plan Benefits: Through its Member Doctors (or through other licensed vision care providers in
cases where a Covered Person is eligible for, and chooses to receive Plan Benefits from a Non-Member Provider) VSP shall
provide Covered Persons such Plan Benefits listed in the Schedule of Benefits, Exhibit A hereto, subject to any limitations,
exclusions, or Copayments therein stated.
Benefit Authorization must be obtained prior to a Covered Person obtaining Plan Benefits from a Member Doctor.
When a Covered Person desires to receive Plan Benefits from a Member Doctor, the Covered Person must schedule an
appointment and identify himself as a VSP Covered Person in order for the Member Doctor to obtain Benefit Authorization
from VSP. VSP shall provide Benefit Authorization to the Member Doctor to authorize the provision of Plan Benefits to the
Covered Person. Each Benefit Authorization will contain an expiration date, allowing a specific period of time for the Covered
Person to obtain Plan Benefits. Benefit Authorization shall be issued by VSP in accordance with the latest eligibility
information furnished by Group and the Covered Person’s past service utilization, if any. Any Benefit Authorization so issued
by VSP shall constitute a certification to the Member Doctor that payment will be made. VSP shall not be held liable to Grou p
for any Benefit Authorization issued in error in reliance on the latest eligibility information available to VSP as provided by the
Group. Notwithstanding any other provision, no references to services shall be operative unless and to the extent that
services are specifically set forth in the Schedule of Benefits, and when purchased by Client, the Additional Benefit Rider.
Retail chains may not offer all Plan Benefits. Covered Person may contact Member Doctor for information describing vision
care services and vision care materials offered.
VSP shall pay or deny claims for Plan Benefits provided to Covered Persons, less any applicable Copayment, within
a reasonable time but not more than thirty (30) calendar days after VSP has received a completed claim, unless special
circumstances require additional time. In such cases, VSP may obtain an extension of fifteen (15) calendar days of this time
limit by providing notice to the claimant of the reasons for the extension.
4
8.F.c
Packet Pg. 122 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
3.03. Provision of Information to Covered Persons: Upon request, VSP will make available to Covered Persons
necessary information describing Plan Benefits and procedures. A copy of this Plan will be placed with Group. The Plan wil l
also be available at the offices of VSP for copying or inspection by Covered Persons. VSP shall provide Group with an
updated list twice annually of Member Doctors' names, addresses, and telephone numbers for distribution to Covered
Persons. Covered Persons may also obtain a copy of the latest Member Doctor list by contacting VSP’s Customer Service
Department in writing or via the toll-free Customer Service telephone line, or by visiting VSP's Web site at www.vsp.com.
3.04. Confidentiality and Non-Disclosure Agreements VSP and Group have delivered, or will deliver, upon
execution and delivery of this Plan, certain information about the properties and operations of their respective
businesses. VSP and Group, therefore, agree as follows:
a) Definition of Confidential Information. For purposes of this Plan, “Confidential Information” means
any data and/or information, in any form, disclosed by the disclosing Party (“Discloser”) to the receiving Party (“Recipient”)
either before or after the Effective Date, which relates to Discloser a nd/or its Affiliates, and solely by way of illustration and not
in limitation shall include the following information: (i) current or future product(s), services, methodologies, plans, designs,
costs, prices, customer or doctor names and addresses, finance s or financial information (including budgets), marketing plans
or strategies (including e-commerce development plans), business plans, matters, opportunities or offerings, equipment and
other purchase matters, strategic matters, research, development, know-how and/or personnel, (ii) is identified as confidential
at the time of disclosure, (iii) given the nature of the information disclosed and the circumstances surrounding its disclosu re,
reasonably ought to be treated as Confidential Information by a person in the same industry as Discloser, or (iv) by law must
be protected as Confidential Information. Recipient acknowledges that the Confidential Information is proprietary to Discloser
and has been developed and obtained through great efforts by Discloser. Confidential Information shall not, however, include
information that (A) at the time of disclosure is, or subsequently becomes, available to the public or the industry through n o
fault or breach on the part of Recipient; (B) Recipient can demonstrate to have had rightfully in its possession prior to
disclosure by Discloser; (C) is independently developed by Recipient without the use of any Confidential Information; or (D)
Recipient rightfully obtains from a third party who has the right to transfer or dis close it. Confidential Information shall also be
deemed to include any and all confidential information defined as Confidential Matters hereunder, the treatment of which shal l
be as set forth in Paragraph 3.04 of this Plan.
b) Non-Disclosure and Non-Use of Confidential Information. Recipient shall not, directly or
indirectly, without the prior written approval of Discloser in each instance or unless otherwise expressly permitted herein,
5
8.F.c
Packet Pg. 123 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
use for its own benefit, publish or otherwise disclose to others, or authorize the use by others for their benefit, or to the
detriment of Discloser, any of Discloser’s Confidential Information. Recipient shall carefully restrict access to Discloser’s
Confidential Information to only those of its and its Affiliates’ officers, directors, employees, agents and representatives
(collectively, “Representatives”) who (i) clearly require such access in order to enable to perform their respective obligati ons
under this Plan (ii) who are bound by confidentiality ob ligations that protect third party information which are at least as
restrictive and protective as those contained in this Plan, and (iii) are not (or do not work for) direct competitors of Disc loser.
Recipient shall not use, copy, distribute and/or remove any of Discloser’s Confidential Information from Recipient’s premises
except to the extent necessary or appropriate to carry out its respective obligations under the Plan, without the prior conse nt of
Discloser. Recipient and its Representatives will employ all security measures used for their own proprietary information of
similar nature but in no event using less than a reasonable degree of care. Recipient agrees to advise and require its
Representatives of their obligations to keep such information conf idential and shall each be liable for any acts and omissions
of their Representatives related thereto.
c) Return or Destruction of Confidential Information. The Receiving Party, including its Personnel,
its employees and/or agents shall upon request of Discloser (i) immediately return to Discloser’s designated representative
any and all documents or other information and materials in whatever form which contain Discloser’s Confidential Information,
or as permitted by Discloser, (ii) destroy all copies thereof, and certify to Discloser in writing that all copies of such documents
or other information and materials have been destroyed; provided, however, that the Receiving Party may retain one set of
such documents and other information and materials for archi val purposes only, subject to the continuing confidentiality and
security obligations set forth under this Plan. Recipient may disclose Discloser’s Confidential Information if and to the ext ent
required by a judicial or governmental request, requirement or order; provided that Recipient will take reasonable steps to give
Discloser sufficient prior notice (to the extent that sufficient time is available) of such request, requirement or order for
Discloser to contest, limit and/or protect such disclosure.
d) Injunctive Relief. The Parties understand and acknowledge that any disclosure or misappropriation
of any Confidential Information in violation of this Plan may cause irreparable harm, for which monetary damages alone may
not be an adequate remedy and, therefore, agrees that Discloser shall have the right to apply to a court of competent
jurisdiction for an order immediately restraining any such further disclosure or misappropriation and for other equitable rel ief,
without objection and without the requirement of posting a bond or other form of security. Such right of each Party is in addition
to the remedies otherwise available under this Plan or otherwise at law or equity.
e) Survival: The obligations laid down in this Section 3.04 shall continue and sur vive beyond the
termination of this Plan.
6
8.F.c
Packet Pg. 124 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
3.05. Emergency Vision Care: When vision care is necessary for Emergency Conditions, Covered Persons may
obtain Plan Benefits by contacting a Member Doctor or Out -of-Network Provider. No prior approval from VSP is required for
Covered Person to obtain vision care for Emergency Conditions of a medical nature. However, services for medical
conditions, including emergencies, are covered by VSP only under the Acute EyeCare and Supplemental Primary EyeCare
Plans. If Group has not purchased one of these plans, Covered Persons are not covered by VSP for medical services and
should contact a physician under Covered Persons' medical insurance plans for care. For emergency conditions of a
non-medical nature, such as lost, broken or stolen glasses, the Covered Person should contact VSP's Customer Service
Department for assistance. Reimbursement and eligibility are subject to the terms of this Plan.
7
8.F.c
Packet Pg. 125 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
IV.
OBLIGATIONS OF THE GROUP
4.01. Identification of Eligible Enrollees: An Enrollee is eligible for coverage under this Plan, if he satisfies the
enrollment criteria specified in Paragraph 6.01(a) and/or as mutually agreed to by VSP and Group. Group shall provide
monthly eligibility information to VSP in a mutually agreed upon format and medium to identify all Enrollees who are eligible for
coverage under this Plan. Group will supply to VSP, on or before the last day of each month, eligibility information sufficient to
identify all Enrollees to be added to or deleted from VSP's coverage rosters for the coming month. The eligibility informati on
shall include designation of family status for each such Enrollee, if dependent coverage is provided. Group shall, when
requested, make available for inspection by VSP records having a bearing on the coverage of Covered Persons under this
Plan.
4.02. Claims Amounts and Advance of Payment: Group shall provide all funds necessary to pay the Claims
Amount associated with Covered Persons pursuant to this Plan. In order to assure timely and adequate payment, Group
agrees to make an Advance Payment as outlined on the attached Schedule of Advance Payment and Administrative Fee,
Exhibit B. This Advance Payment is an estimat e of the Claims Amount for one (1) month. Group agrees to pay the actual
Claims Amounts on a monthly basis within ten (10) days after receipt of VSP's statement. The Advance Payment amount may
be adjusted each Plan Term if the average of monthly Claims A mount increases or decreases. The parties agree that such
Advance Payment is reimbursable to the Group upon termination of this Plan, after the Group's indebtedness to VSP and/or its
benefit providers has been satisfied. However, amounts paid to VSP as A dvance Payment shall not be considered assets of
the Group, and need not be held in trust by VSP.
4.03. Administrative Fee: Additionally, on or before the first day of each month, Group shall remit to VSP an
Administrative Fee as outlined on the attached Schedule of Advance Payment and Administrative Fee, Exhibit B. Change will
not be made to the Administrative Fee during any Plan Term unless there is a change in the Schedule of Benefits or a material
change in any other terms and conditions of the Plan, provided any such change is mutually agreed upon in writing between
VSP and Group.
Notwithstanding the above, VSP reserves the right to increase amounts due hereunder during a Plan Term by the
amount of any tax or assessment not now in effect which is subsequently levied by any taxing authority, which is attributable to
the amount due VSP from Group.
4.04. Grace Period: Group shall be allowed a grace period of thirty-one (31) days following the due date for
making any payment of amounts due under this Plan. During the grace period, this Plan will remain in full force and effect for
all Covered Persons. Late payments will be considered by VSP at the time of Plan renewal and may impact Group's
8
8.F.c
Packet Pg. 126 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
Advance Payment and Administrative Fees in future Plan Terms.
If Group fails to make any payment of amounts due by the end of any grace period, VSP may notify Group that the
payment of amounts due has not been made, that coverage is canceled and that the G roup is responsible for payment for the
Claims Amount associated with Plan Benefits provided to Covered Persons after the last period for which amounts due were
fully paid, including the grace period and through the effective date of the termination. Grou p shall also remain responsible for
payment, in accordance with Paragraph 2.02, of any Claims Amount associated with Benefit Authorizations outstanding at the
time of termination, and for any legal and/or collection fees incurred by VSP in collecting amoun ts due under this Plan.
4.05. Distribution of Required Documents: Group agrees to distribute to Enrollees any disclosure forms, plan
summaries or other materials that may be required to be given to plan subscribers by any regulatory authority. Such mater ials
shall be distributed by Group no later than thirty (30) days after receipt or as otherwise required under state law.
9
8.F.c
Packet Pg. 127 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
V.
OBLIGATIONS OF COVERED PERSONS UNDER THE PLAN
5.01. General: By this Plan, Group makes coverage available to its Enrollees and their Eligible Dependents, if
dependent coverage is provided. However, this Plan may be amended or terminated by agreement between VSP and Group
as indicated herein, without the consent or concurrence of Covered Persons. This Plan, an d all Exhibits, Riders and
attachments hereto , constitute VSP's sole and entire undertaking to Covered Persons under this Plan.
As a conditions of coverage, all Covered Persons under this Plan shall have the following obligations:
5.02. Copayments for Services Received: Where, as indicated in Exhibit A (Schedule of Benefits), Copayments
are required for certain Plan Benefits, Copa yments shall be the personal responsibility of the Covered Person receiving the
care and must be paid to the Member Doctor the date services are rendered.
5.03. Obtaining Services from Member Doctors: Benefit Authorization must be obtained prior to receiving Plan
Benefits from a Member Doctor. When a Covered Person desires to receive Plan Benefits, the Covered Person must select a
Member Doctor, schedule an appointment, and identify himself as a Covered Person so the Member Doctor can obtain Benefit
Authorization from VSP. Should the Covered Person receive Plan Benefits from a Member Doctor without such Benefit
Authorization, then for the purposes of those Plan Benefits provided to the Covered Person, the Member Doctor will be
considered a Non-Member Provider and the benefits available will be limited to those for a Non -Member Provider, if any.
Retail chains may not offer all Plan Benefits. Covered Person may contact Member Doctor for information describing vision
care services and vision care materials offered.
5.04. Submission of Non-Member Provider Claims: If Non-Member Provider coverage is indicated Exhibit A
(Schedule of Benefits) written proof (receipt and the Covered Person's identification information) of all claims for services
received from Non-Member Providers shall be submitted by Covered Persons to VSP within three hundred sixty-five (365)
days of the date of service. VSP may reject such claims filed more than three hundred sixty -five (365) days after the date of
service..
Failure to submit a claim within this time period, however, shall not invali date or reduce the claim if it was not
reasonably possible to submit the claim within such time period, provided the claim was submitted as soon as was reasonably
possible and in no event, except in absence of legal capacity, later than one year from the r equired date of three hundred
sixty-five (365) days after the date of service.
5.05. Complaints and Grievances: Covered Persons shall report any complaints and/or grievances to VSP at
the address given herein. Complaints and grievances are disagreements regarding access to care, quality of care,
10
8.F.c
Packet Pg. 128 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
treatment or service. Complaints and grievances may be submitted to VSP verbally or in writing. A Covered Person may
submit written comments or supporting documentation concerning his/her c omplaint or grievance to assist in VSP's review.
VSP will resolve the complaint or grievance within thirty (30) calendar days after receipt.
5.06. Claim Denial Appeals: If, under the terms of this Plan, a claim is denied in whole or in part, a request may be
submitted to VSP by Covered Person or Covered Person's authorized representative for a full review of the denial. Covered
Person may designate any person, including his/her provider, as his/her authorized representative. References in this section
to "Covered Person" include Covered Person's authorized representative, where applicable.
a) Initial Appeal: The request must be made within one hundred eighty (180) da ys following denial of
a claim and should contain sufficient information to identify the Covered Person for whom the claim was denied, including the
VSP Enrollee's name, the VSP Enrollee's Member Identification Number, the Covered Person's name and date of birth, the
provider of services and the claim number. The Covered Person may review, during normal working hours, any documents
held by VSP pertinent to the denial. The Covered Person may also submit written comments or supporting documentation
concerning the claim to assist in VSP's review. VSP's determination, including specific reasons for the decision, shall be
provided and communicated to the Covered Person within thirty (30) calendar days after receipt of a request for appeal from
the Covered Person or Covered Person’s authorized representative.
b) Second Level Appeal: If the Covered Person disagrees with the response to the initial appeal of the
claim, the Covered Person has a right to a second level appeal. Within sixty (60) calendar days afte r receipt of VSP's
response to the initial appeal, the Covered Person may submit a second appeal to VSP along with any pertinent
documentation. VSP shall communicate its final determination to the Covered Person in compliance with all applicable state
and federal laws and regulations and shall include the specific reasons for the determination.
11
8.F.c
Packet Pg. 129 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
c) Other Remedies: When Covered Person has completed the appeals process stated herein,
additional voluntary alternative dispute resolution o ptions may be available, including mediation, or Group should advise
Covered Person to contact the U.S. Department of Labor or the state insurance regulatory agency for details. Additionally,
under the provisions of ERISA (Section 502(a)(1)(B)) [29 U.S.C. 1132(a)(l)(B)], Covered Person has the right to bring a civil
action when all available levels of review of denied claims, including the appeals process, have been completed, the claims
were not approved in whole or in part, and Covered Person disagrees w ith the outcome.
5.07. Time of Action: No action in law or in equity shall be brought to recover on the Plan prior to the Covered
Person exhausting his/her grievance rights under this Plan and/or prior to the expiration of sixty (60) days after the claim and
any applicable invoices have been filed with VSP. No such action shall be brought after the expiration of six (6) years from the
last date that the claim and any applicable invoices were submitted to VSP, in accordance with the terms of this Plan.
5.08. Insurance Fraud: Any Group and/or person who intends to defraud, knowingly facilitates a fraud or submits
an application or files a claim with a false or deceptive statement, is guilty of insurance fraud. Such an act is grounds fo r
immediate termination of the Plan for the Group or individual that committed the fraud.
12
8.F.c
Packet Pg. 130 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
VI.
ELIGIBILITY FOR COVERAGE
6.01. Eligibility Criteria: Individuals will be accepted for coverage hereunder only upon meeting all the applicable
requirements set forth below.
(a) Enrollees: To be eligible for coverage, a person must:
(1) currently be an employee or member of the Group, and
(2) meet the criteria established in the coverage criteria mutually agreed upon by Group and VSP.
(b) Eligible Dependents: If dependent coverage is provided, the persons eligible for dependent
coverage are:
(1) the legal spouse of any Enrollee, and
(2) any child of an Enrollee, including any natural child from the moment of birth, legally adopted child
from the moment of placement for adoption with the Enrollee, or other child for whom a court holds the Enrollee responsible;
Such dependent shall be eligible until the end of the month in which they attain the age of 26 years.
(3) as further defined by Group.
If a dependent unmarried child, prior to attainment of the prescribed age for termination of eligibility, becomes and
continues to be, incapable of self-sustaining employment because of mental or physical disability, that Eligible Dependent's
coverage shall not terminate. Coverage will continue as long as he remains chiefly dependent on the Enrollee for support and
the Enrollee's coverage remains in force; PROVIDED satisfactory proof of the dependent's incapacity can be furnished to VSP
within thirty-one (31) days of the date the Eligible Dependent's coverage would have otherwise terminated, and at such other
times as VSP may request proof, but not more frequently than annually.
6.02. Documentation of Eligibility: Persons satisfying the requirements for coverage under either of the above
classes shall be eligible if:
(a) in the case of an Enrollee, the individual's name and Social Security Number have been reported by the
Group to VSP in the manner provided hereunder, and
(b) in the case of changes to an Eligible Dependent's status, the change has been reported by the Group to
VSP in the manner provided herein. As indicated in Paragraph 4.01 above, VSP may elect to inspect the Group's records in
order to verify eligibility of Enrollees and dependents. Plan Benef its will be available only to persons on whose behalf
applicable amounts due have been paid for the current period, or Grace Periods outlined above in Paragraph 4.04. If a cleric al
error is made, it will not affect the coverage to which the Covered Person is entitled under the Plan.
13
8.F.c
Packet Pg. 131 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
6.03. Retroactive Eligibility Changes: Retroactive eligibility changes are limited to sixty (60) days prior to the
date notice of any such requested change is received by VSP. If coverage is retroactively terminated for an individual, Group
shall remain responsible for the Claims Amount associated with any Plan Benefits provided to that individual pursuant to the
Benefit Authorization issued by VSP in reliance on the latest eligibility information availabl e to VSP at the time of such Benefit
Authorization.
6.04. Change of Participation Requirements, Contribution of Fees, and Eligibility Rules: Composition of the
Group, percentage of Enrollees covered under the Plan, and Group’s contribution and Group's eli gibility requirements are all
material to VSP's obligations under this Plan. During the term of this Plan, Group must provide VSP with written notice of
changes to its composition, percentage of Enrollees covered, contribution or eligibility requirements. Any such change which
materially affects VSP's obligations hereunder must be mutually agreed upon in writing between VSP and Group and may
constitute a material change to the terms and conditions of this Plan for purposes of Paragraph 4.03. Nothing in th is section
shall limit Group's ability to add Enrollees and/or Eligible Dependents in accordance with the terms of this Plan.
6.05. Change in Family Status: In the event Group is notified of any change in a Covered Person's family status
(by marriage, the addition (e.g., newborn or adopted child) or deletion of dependent children, etc.) Group shall provide noti ce
of such change to VSP via the next eligibility listing required under Paragraph 4.01. If such notice is given, the change in the
Covered Person's status will be effective on the first day of the month following the request for change, or at a requested l ater
date. Notwithstanding any other provision in this section, a newborn child will be covered for thirty-one (31) days after birth
and an adopted child will be covered for thirty-one (31) days after the date the Enrollee or Enrollee's spouse acquires the right
to control the health care of the child. To continue coverage for a newborn or adopted child beyond the initial thirty -one (31)
day period, the Group must be properly notified of the Enrollee's change in family status and applicable amounts due must be
paid to VSP on behalf of the child.
14
8.F.c
Packet Pg. 132 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
6.06. Family and Medical Leave Act: The federal Family and Medical Leave Act of 1993 (FMLA), requires that
under certain circumstances health plan benefits available to an eligible Enrollee and his or her Eligible Dependents be made
available during certain periods of leave. Benefits will be available at the level and under the conditions coverage would have
been provided if the eligible Enrollee had not gone on leave. If, and only to the extent, FMLA applies to the parties to thi s Plan,
VSP shall make the statutorily-required continuation coverage available based on the eligibility information provided by the
Group.
15
8.F.c
Packet Pg. 133 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
VII.
CONTINUATION OF COVERAGE
7.01. COBRA: The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires that, under
certain circumstances, health plan benefits available to an Enrollee and his or her Eligible Dependents be made available for
purchase by said persons upon the occurrence of a COBRA-qualifying event. If, and only to the extent, COBRA applies, VSP
shall make the statutorily-required continuation coverage available for purchase in accordance with COBRA.
7.02. Replacement Coverage: VSP reserves the right to offer replacement VSP coverage to individuals whose
previous VSP coverage has terminated or is subject to termination. Any such offer of replacement coverage shall be separate
and distinct from, and not in lieu of, any COBRA-required offer of continuation coverage.
16
8.F.c
Packet Pg. 134 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
VIII.
ARBITRATION OF DISPUTES
8.01. Dispute Resolution: Any dispute or question arising between VSP and Group or any Covered Person
involving the application, interpretation, or performance under this Plan shall be settled, if possible, by amicable and info rmal
negotiations. This will allow such opportunity as may be appropriate under the circumstances for fact-finding and mediation. If
any issue cannot be resolved in this fashion, it shall be submitted to arbitration.
8.02. Procedure: The procedure for arbitration hereunder shall be conducted pursuant to the Rules of the
American Arbitration Association in effect at the time of the dispute.
8.03. Choice of Law: Question(s) and dispute(s) hereunder are to be resolved by arbitration. However, if there
are any matters arising in connection with this Plan which do become the subject of legal process, the applicable law shall be
that of the State of delivery of this Plan.
17
8.F.c
Packet Pg. 135 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
IX.
NOTICES
9.01. Required Notices: Any notices to be given under this Plan to either the Group or VSP shall be in writing and
delivered by United States First Class Mail. Notices sent to the Group will be mailed to the address shown on the Group
Application. Notices sent to VSP shall be sent to the address shown on this Plan. Any notices may be hand -delivered by
either party to an appropriate representative of the party, with the burden being on the party effecting such hand -delivery, to
prove, if questioned, that such delivery was mad e.
18
8.F.c
Packet Pg. 136 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
X.
MISCELLANEOUS
10.01. Entire Plan: This Plan, the Group Application, and all Exhibits and attachments, and any amendments
hereto, constitute the entire understanding between the parties and supersedes any prior understandings an d agreements
between them, either written or oral. Any change or amendment to the Plan must be approved by an officer of VSP and
attached to be valid. No agent has the authority to change this Plan or waive any of its provisions. Communication material s
prepared by Group for distribution to Enrollees do not constitute a part of this Plan.
10.02. Indemnity: VSP agrees to indemnify, defend and hold harmless Group, its shareholders, directors, officers,
agents, employees, successors and assigns from and aga inst any and all liability, claim, loss, injury, cause of action and
expense (including defense costs and legal fees) of any nature whatsoever arising from the failure of VSP, its officers, agen ts
or employees, to perform any of the activities, duties or r esponsibilities specified herein. Group agrees to indemnify, defend
and hold harmless VSP, its members, shareholders, directors, officers, agents, employees, successors and assigns from and
against any and all liability, claim, loss, injury, cause of acti on and expense (including defense costs and legal fees) of any
nature whatsoever arising or resulting from the failure of Group, its officers or employees to perform any of the duties or
responsibilities specified herein.
10.03. Liability: VSP arranges for the provision of vision care services and materials through agreements with
Member Doctors, who are independent contractors responsible for exercising independent judgment. VSP does not itself
directly furnish vision care services or supply materials. Under no circumstances shall VSP or Group be liable for the
negligence, wrongful acts or omissions of any doctor, laboratory, or any other person or organization performing services or
supplying materials in connection with this Plan.
10.04. Assignment: Neither this Plan nor any of the rights or obligations of either of the parties may be assigned or
transferred, except as noted herein, without the prior written consent of both parties.
10.05. Severability: Should any provision of this Plan be declared invalid, the remaining provisions shall remain in
full force and effect.
10.06. Governing Law: This Plan shall be governed by and construed in accordance with applicable federal and
state law. Any provision that is in conflict with, or not in compliance with, applicable federal or state statutes or regulations is
hereby amended to conform with the requirements of such statutes or regulations, now or hereafter existing.
10.07. Gender: All pronouns used herein are deemed to refer to the masculine, feminine, neuter, singular, or plural,
as the identity(ies) of the person(s) may require.
19
8.F.c
Packet Pg. 137 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
10.08. Communication Materials: All Communication materials created by Group which relate to this vision care
Plan must adhere to VSP's Member Communication Guidelines, distributed to Group by VSP. Such communication materials
may be sent to VSP for review and approval in advance of mailing to Enrollees. VSP’s review of such materials shall be
limited to approving the accuracy of Plan Benefits and shall not encompass or constitute certification that Group’s materials
meet any applicable legal or regulatory requirements, including, but not limited to, ERISA requirements.
20
8.F.c
Packet Pg. 138 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
EXHIBIT A
VSP VISION CARE, INC.
SCHEDULE OF BENEFITS
Signature Plan
GENERAL
This Schedule lists the vision care services and vision care materials to which Covered Persons of VSP VISION CARE, INC.
("VSP") are entitled, subject to any Copayments and other conditions, limitations and/or ex clusions stated herein. If Plan
Benefits are available for Non-Member Provider services, as indicated by the reimbursement provisions below, vision care
services and vision care materials may be received from any licensed optometrist, ophthalmologist, or d ispensing optician,
whether Member Doctors or Non-Member Providers. This Schedule forms a part of the Plan or Certificate to which it is
attached.
When Plan Benefits are received from Member Doctors, benefits appearing in the first column below are applicable subject to
any Copayments as stated below. When Plan Benefits are available and received from Non -Member Providers, the Covered
Person is reimbursed for such benefits according to the schedule in the second column below less any applicable
Copayments.
COPAYMENT
The benefits described herein are available to each Covered Person subject only to payment of the applicable Copayment by
the Covered Person. Copayments are required for Plan Benefits received from Member Doctors and Non -Member Providers.
Covered Persons must also follow the proper procedures for obtaining Benefit Authorization.
There shall be no Copayment for the examination. If materials (lenses and frames) are provided, there shall be a Copayment
of $25.00 payable at the time the materials are ordered. However, the Copayment for materials shall not apply to elective
contact lenses.
PLAN BENEFITS
MEMBER DOCTOR
BENEFIT
NON-MEMBER
PROVIDER BENEFIT
VISION CARE SERVICES
Eye Examination Covered in Full* Up to $ 45.00*
Complete initial vision analysis which includes an appropriate examination of visual functions, including the prescription of
corrective eyewear where indicated.
Subsequent regular eye examinations once every plan year beginning on January 1st.
*Less any applicable Copayment.
21
8.F.c
Packet Pg. 139 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
VISION CARE MATERIALS
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Lenses
Single Vision Covered in full* Up to $ 42.00*
Bifocal Covered in full* Up to $ 72.00*
Trifocal Covered in full* Up to $ 82.00*
Lenticular Covered in full* Up to $ 122.00*
Polycarbonate lenses are covered in full for dependent children up to the end of the month in which they turn age 26.
Standard Progressive Lenses covered in full
Available once every plan year beginning on January 1st.
Frames Covered up to Plan
Allowance*
Up to $ 45.00*
Available once every other plan year beginning on January 1st.
*Less any applicable Copayment.
Frame allowance may be applied towards non-prescription sunglasses for post PRK, LASIK, or Custom LASIK patients.
Lenses and frames include such professional services as are necessary, which shall include:
• Prescribing and ordering proper lenses;
• Assisting in the selection of frames;
• Verifying the accuracy of the finished lenses;
• Proper fitting and adjustment of frames;
• Subsequent adjustments to frames to maintain comfort and efficiency;
• Progress or follow-up work as necessary.
22
8.F.c
Packet Pg. 140 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
CONTACT LENSES
Contact lenses are available once every plan year in lieu of all other lens and frame benefits available h erein. When contact
lenses are obtained, the Covered Person shall not be eligible for lenses and frames again for one plan year.
Necessary-
Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered
Person's Member Doctor or Non-Member Provider. Prior review and approval by VSP are not required for Covered Person to
be eligible for Necessary Contact Lenses.
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Professional Fees and Materials Professional Fees and Materials
Covered in full* Up to $210.00*
Elective -
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Professional Fees** and Materials Professional Fees and Materials
Up to $200.00 Up to $125.00
*Subject to Copayment
**15% discount applies to Member Doctor’s usual and customary professional fees for contact lens evaluation
and fitting.
23
8.F.c
Packet Pg. 141 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
LOW VISION BENEFIT
The Low Vision benefit is available to Covered Persons who have severe visual problems that are not correctable with regular
lenses.
MEMBER DOCTOR
BENEFIT
NON-MEMBER
PROVIDER BENEFIT
Supplementary Testing Covered in Full Up to $125.00
Complete low vision analysis/diagnosis, which includes a comprehensive examination of visual functions, including the
prescription of corrective eyewear or vision aids where indicated.
Supplemental Care Aids 75% of Cost 75% of Cost
Subsequent low vision aids.
Copayment for Supplemental Aids: 25% payable by Covered Person.
Benefit Maximum
The maximum benefit available is $1000.00 (excluding Copayment) every two years.
NON-MEMBER PROVIDER BENEFIT
Low Vision benefits secured from a Non-Member Provider are subject to the same time limits and Copayment arrangements
as described above for a Member Doctor. The Covered Person should pay the Non -Member Provider his full fee. The
Covered Person will be reimbursed in accordance with an amount not to exceed what VSP would pay a Member Doctor in
similar circumstances. NOTE: There is no assurance that this amount will be within the 25% Copayment feature.
24
8.F.c
Packet Pg. 142 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
EXCLUSIONS AND LIMITATIONS OF BENEFITS
Some brands of spectacle frames may be unavailable for purchase as Plan Benefits, or may be subject to additional
limitations. Covered Persons may obtain details regarding frame brand availability from their VSP Member Doctor or by
calling VSP’s Customer Care Division at (800) 877 -7195.
PATIENT OPTIONS
This Plan is designed to cover visual needs rather than cosmetic materials. When the Covered Person selects any of the
following extras, the Plan will pay the basic cost of the allowed lenses or frames, and the Covered Person will pay the
additional costs for the options.
• Optional cosmetic processes.
• Anti-reflective coating.
• Color coating.
• Mirror coating.
• Scratch coating.
• Blended lenses.
• Cosmetic lenses.
• Laminated lenses.
• Oversize lenses.
• Polycarbonate lenses.
• Photochromic lenses, tinted lenses except Pink #1 and Pink #2.
• Progressive multifocal lenses.
• UV (ultraviolet) protected lenses.
• Certain limitations on low vision care.
• A frame that costs more than the Plan allowance.
• Contact lenses (except as noted elsewhere herein).
NOT COVERED
There is no benefit for professional services or materials connected with:
• Orthoptics or vision training and any associated supplementa l testing; plano lenses (less than a ± .50 diopter power); or
two pair of glasses in lieu of bifocals;
• Replacement of lenses and frames furnished under this Plan which are lost or broken, except at the normal intervals when
services are otherwise available;
• Medical or surgical treatment of the eyes;
• Corrective vision treatment of an Experimental Nature;
• Costs for services and/or materials above Plan Benefit allowances;
• Services and/or materials not indicated on this Schedule as covered Plan Benefits.
VSP MAY, AT ITS DISCRETION, WAIVE ANY OF THE PLAN LIMITATIONS IF, IN THE OPINION OF VSP's OPTOMETRIC
CONSULTANTS, IT IS NECESSARY FOR THE VISUAL WELFARE OF THE COVERED PERSON.
25
8.F.c
Packet Pg. 143 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
EXHIBIT A
VSP VISION CARE, INC.
SCHEDULE OF BENEFITS
Signature Plan
Child Age 0-19
GENERAL
This Schedule lists the vision care services and vision care materials to which Covered Persons of VSP VISION CARE, INC.
("VSP") are entitled, subject to any Copayments and other conditions, limitations and/or exclusions stated herein. If Plan
Benefits are available for Non-Member Provider services, as indicated by the reimbursement provisions below, vision care
services and vision care materials may be received from any licensed optometrist, ophthalmologist, or dispensing optician,
whether Member Doctors or Non-Member Providers. This Schedule forms a part of the Plan or Certificate to which it is
attached.
When Plan Benefits are received from Member Doctors, benefits appearing in the first column below are applicable subject to
any Copayments as stated below. When Plan Benefits are available and received from Non -Member Providers, the Covered
Person is reimbursed for such benefits according to the schedule in the second column below less any applicable
Copayments.
COPAYMENT
The benefits described herein are available to each Covered Person subject only to payment of the applicable Copayment by
the Covered Person. Copayments are required for Plan Benefits received from Member Doctors and Non -Member Providers.
Covered Persons must also follow the proper procedures for obtaining Benefit Authorization.
There shall be no Copayment payable by the Covered Person to the Member Doctor at the time services are rendered.
PLAN BENEFITS
VISION CARE SERVICES
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Eye Examination Covered in Full* Up to $ 999.99*
Complete initial vision analysis which includes an appropriate examination of visual functions, including the prescription of
corrective eyewear where indicated.
Subsequent regular eye examinations once every plan year beginning on January 1st.
*Less any applicable Copayment.
26
8.F.c
Packet Pg. 144 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
PLAN BENEFITS
VISION CARE MATERIALS
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Lenses
Single Vision Covered in full* Covered in full *
Bifocal Covered in full* Covered in full *
Trifocal Covered in full* Covered in full *
Lenticular Covered in full* Covered in full *
Polycarbonate lenses are covered in full for dependent children up to age 26.
Standard Progressive Lenses covered in full
Available once every plan year beginning on January 1st.
Frames Covered up to Plan
Allowance*
Covered in full *
Available once every plan year beginning on January 1st.
*Less any applicable Copayment.
Frame allowance may be applied towards non-prescription sunglasses for post PRK, LASIK, or Custom LASIK patients.
Lenses and frames include such professional services as are necessary, which shall include:
• Prescribing and ordering proper lenses;
• Assisting in the selection of frames;
• Verifying the accuracy of the finished lenses;
• Proper fitting and adjustment of frames;
• Subsequent adjustments to frames to maintain comfort and efficiency;
• Progress or follow-up work as necessary.
Lens Options
Anti-reflective coating Covered in full Not Covered
Scratch coating Covered in full Not Covered
High Index Covered in full Not Covered
Blended lenses Covered in full Covered in full
Color coating Covered in full Not Covered
Mirror coating Covered in full Not Covered
Laminated lenses Covered in full Not Covered
Polycarbonate lenses Covered in full Not Covered
Premium and Custom Progressive
lenses
Covered in full Covered in full
Tinted/Photochromic Covered in full Not Covered
UV (ultraviolet) protected Covered in full Not Covered
27
8.F.c
Packet Pg. 145 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
CONTACT LENSES
Contact lenses are available once every plan year in lieu of all other lens and frame benefits available herein. When contac t
lenses are obtained, the Covered Person shall not be eligible for lenses and frames again for one plan year.
Necessary-
Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered
Person's Member Doctor or Non-Member Provider. Prior review and approval by VSP are not required for Covered Person to
be eligible for Necessary Contact Lenses.
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Professional Fees and Materials Professional Fees and Materials
Covered in full* Covered in full*
Elective -
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Professional Fees** and Materials Professional Fees and Materials
Covered in full* Covered in full*
*Subject to Copayment
**15% discount applies to Member Doctor’s usual and customary professional fees for contact lens evaluation
and fitting.
28
8.F.c
Packet Pg. 146 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
LOW VISION BENEFIT
The Low Vision benefit is available to Covered Persons who have severe visual problems that are not correctable with regular
lenses.
MEMBER DOCTOR
BENEFIT
NON-MEMBER
PROVIDER BENEFIT
Supplementary Testing Covered in Full Up to $125.00
Complete low vision analysis/diagnosis, which includes a comprehensive examination of visual functions, including the
prescription of corrective eyewear or vision aids where indicated.
Supplemental Care Aids 75% of Cost 75% of Cost
Subsequent low vision aids.
Copayment for Supplemental Aids: 25% payable by Covered Person.
Benefit Maximum
The maximum benefit available is $1000.00 (excluding Copayment) every two years.
NON-MEMBER PROVIDER BENEFIT
Low Vision benefits secured from a Non-Member Provider are subject to the same time limits and Copayment arrangements
as described above for a Member Doctor. The Covered Person should pay the Non -Member Provider his full fee. The
Covered Person will be reimbursed in accordance with an amount not to exceed what VSP would pay a Member Doctor in
similar circumstances. NOTE: There is no assurance that this amount will be within the 25% Copayment feature.
29
8.F.c
Packet Pg. 147 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
EXCLUSIONS AND LIMITATIONS OF BENEFITS
Some brands of spectacle frames may be unavailable for purchase as Plan Benefits, or may be subject to additional
limitations. Covered Persons may obtain details regarding frame brand availability from their VSP Member Doctor or by
calling VSP’s Customer Care Division at (800) 877 -7195.
PATIENT OPTIONS
This Plan is designed to cover visual needs rather than cosmetic materials. When the Covered Person selects any of the
following extras, the Plan will pay the basic cost of the allowed lenses or frames, and the Covered Person will pay the
additional costs for the options.
• Optional cosmetic processes.
• Cosmetic lenses.
• Oversize lenses.
• Certain limitations on low vision care.
• A frame that costs more than the Plan allowance.
• Contact lenses (except as noted elsewhere herein).
NOT COVERED
There is no benefit for professional services or materials connected with:
• Orthoptics or vision training and any associated supplemental testing; plano lenses (less than a ± .50 diopter power); or
two pair of glasses in lieu of bifocals;
• Replacement of lenses and frames furnished under this Plan which are lost or broken, except at the normal intervals when
services are otherwise available;
• Medical or surgical treatment of the eyes;
• Corrective vision treatment of an Experimental Nature;
• Costs for services and/or materials above Plan Benefit allowances;
• Services and/or materials not indicated on this Schedule as covered Plan Benefits.
VSP MAY, AT ITS DISCRETION, WAIVE ANY OF THE PLAN LIMITATIONS IF, IN THE OPINION OF VSP's OPTOMETRIC
CONSULTANTS, IT IS NECESSARY FOR THE VISUAL WELFARE OF THE COVERED PERSON.
30
8.F.c
Packet Pg. 148 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
EXHIBIT A
VSP VISION CARE, INC.
SCHEDULE OF BENEFITS
Signature Plan
GENERAL
This Schedule lists the vision care services and vision care materials to which Covered Persons of VSP VISION CARE, INC.
("VSP") are entitled, subject to any Copayments and other conditions, limitations and/or exclusions stated herein. If Plan
Benefits are available for Non-Member Provider services, as indicated by the reimbursement provisions below, vision care
services and vision care materials may be received from any licensed optometrist, ophthalmologist, or dispensing optician,
whether Member Doctors or Non-Member Providers. This Schedule forms a part of the Plan or Certificate to which it is
attached.
When Plan Benefits are received from Member Doctors, benefits appearing in the first column below are applicable subject to
any Copayments as stated below. When Plan Benefits are available and received from Non -Member Providers, the Covered
Person is reimbursed for such benefits according to the schedule in the second column below less any applicable
Copayments.
COPAYMENT
The benefits described herein are available to each Covered Person subject only to payment of the applicable Copayment by
the Covered Person. Copayments are required for Plan Benefits received from Member Doctors and Non -Member Providers.
Covered Persons must also follow the proper procedures for obtaining Benefit Authorization.
There shall be no Copayment for the examination. If materials (lenses and frames) are provided, there shall be a Copayment
of $25.00 payable at the time the materials are ordered. However, the Copayment fo r materials shall not apply to elective
contact lenses.
PLAN BENEFITS
MEMBER DOCTOR
BENEFIT
NON-MEMBER
PROVIDER BENEFIT
VISION CARE SERVICES
Eye Examination Covered in Full* Up to $ 45.00*
Complete initial vision analysis which includes an appropriate examination of visual functions, including the prescription of
corrective eyewear where indicated.
Subsequent regular eye examinations once every plan year beginning on January 1st.
*Less any applicable Copayment.
31
8.F.c
Packet Pg. 149 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
VISION CARE MATERIALS
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Lenses
Single Vision Covered in full* Up to $ 42.00*
Bifocal Covered in full* Up to $ 72.00*
Trifocal Covered in full* Up to $ 82.00*
Lenticular Covered in full* Up to $ 122.00*
Polycarbonate lenses are covered in full for dependent children up to the end of the month in which they turn age 26.
Standard Progressive Lenses covered in full
Available once every plan year beginning on January 1st.
Frames Covered up to Plan
Allowance*
Up to $ 45.00*
Available once every other plan year beginning on January 1st.
*Less any applicable Copayment.
Frame allowance may be applied towards non-prescription sunglasses for post PRK, LASIK, or Custom LASIK patients.
Lenses and frames include such professional services as are necessary, which shall include:
• Prescribing and ordering proper lenses;
• Assisting in the selection of frames;
• Verifying the accuracy of the finished lenses;
• Proper fitting and adjustment of frames;
• Subsequent adjustments to frames to maintain comfort and efficiency;
• Progress or follow-up work as necessary.
32
8.F.c
Packet Pg. 150 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
CONTACT LENSES
Contact lenses are available once every plan year in lieu of all other lens and frame benefits available h erein. When contact
lenses are obtained, the Covered Person shall not be eligible for lenses and frames again for one plan year.
Necessary-
Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered
Person's Member Doctor or Non-Member Provider. Prior review and approval by VSP are not required for Covered Person to
be eligible for Necessary Contact Lenses.
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Professional Fees and Materials Professional Fees and Materials
Covered in full* Up to $210.00*
Elective -
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Professional Fees** and Materials Professional Fees and Materials
Up to $200.00 Up to $125.00
*Subject to Copayment
**15% discount applies to Member Doctor’s usual and customary professional fees for contact lens evaluation
and fitting.
33
8.F.c
Packet Pg. 151 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
LOW VISION BENEFIT
The Low Vision benefit is available to Covered Persons who have severe visual problems that are not correctable with regular
lenses.
MEMBER DOCTOR
BENEFIT
NON-MEMBER
PROVIDER BENEFIT
Supplementary Testing Covered in Full Up to $125.00
Complete low vision analysis/diagnosis, which includes a comprehensive examination of visual functions, including the
prescription of corrective eyewear or vision aids where indicated.
Supplemental Care Aids 75% of Cost 75% of Cost
Subsequent low vision aids.
Copayment for Supplemental Aids: 25% payable by Covered Person.
Benefit Maximum
The maximum benefit available is $1000.00 (excluding Copayment) every two years.
NON-MEMBER PROVIDER BENEFIT
Low Vision benefits secured from a Non-Member Provider are subject to the same time limits and Copayment arrangements
as described above for a Member Doctor. The Covered Person should pay the Non -Member Provider his full fee. The
Covered Person will be reimbursed in accordance with an amount not to exceed what VSP would pay a Member Doctor in
similar circumstances. NOTE: There is no assurance that this amount will be within the 25% Copayment feature.
34
8.F.c
Packet Pg. 152 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
EXCLUSIONS AND LIMITATIONS OF BENEFITS
Some brands of spectacle frames may be unavailable for purchase as Plan Benefits, or may be subject to additional
limitations. Covered Persons may obtain details regarding frame brand availability from their VSP Member Doctor or by
calling VSP’s Customer Care Division at (800) 877 -7195.
PATIENT OPTIONS
This Plan is designed to cover visual needs rather than cosmetic materials. When the Covered Person selects any of the
following extras, the Plan will pay the basic cost of the allowed lenses or frames, and the Covered Person will pay the
additional costs for the options.
• Optional cosmetic processes.
• Anti-reflective coating.
• Color coating.
• Mirror coating.
• Scratch coating.
• Blended lenses.
• Cosmetic lenses.
• Laminated lenses.
• Oversize lenses.
• Polycarbonate lenses.
• Photochromic lenses, tinted lenses except Pink #1 and Pink #2.
• Progressive multifocal lenses.
• UV (ultraviolet) protected lenses.
• Certain limitations on low vision care.
• A frame that costs more than the Plan allowance.
• Contact lenses (except as noted elsewhere herein).
NOT COVERED
There is no benefit for professional services or materials connected with:
• Orthoptics or vision training and any associated supplemental testing; plano lenses (less than a ± .50 diopter power); or
two pair of glasses in lieu of bifocals;
• Replacement of lenses and frames furnished under this Plan which are lost or broken, except at the normal intervals when
services are otherwise available;
• Medical or surgical treatment of the eyes;
• Corrective vision treatment of an Experimental Nature;
• Costs for services and/or materials above Plan Benefit allowances;
• Services and/or materials not indicated on this Schedule as covered Plan Benefits.
VSP MAY, AT ITS DISCRETION, WAIVE ANY OF THE PLAN LIMITATIONS IF, IN THE OPINION OF VSP's OPTOMETRIC
CONSULTANTS, IT IS NECESSARY FOR THE VISUAL WELFARE OF THE COVERED PERSON.
35
8.F.c
Packet Pg. 153 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
EXHIBIT B
VSP VISION CARE, INC.
SCHEDULE OF ADVANCE PAYMENT AND ADMINISTRATIVE FEE
Signature Plan
VSP shall be entitled to receive amounts due for each month on behalf of each Enrollee and his/her Eligible Dependents, if
any in the amounts specified below:
ADVANCE PAYMENT: $0.00
ADMINISTRATIVE FEE: $2.67 PER ELIGIBLE ENROLLEE
NOTICE: The amount due under this Plan is subject to change upon renewal (after the end of the Plan Term or any
subsequent Plan Term) or upon change of the Schedule of Benefits or a material change in any other terms or conditions of
the Plan.
36
8.F.c
Packet Pg. 154 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
EXHIBIT B
VSP VISION CARE, INC.
SCHEDULE OF ADVANCE PAYMENT AND ADMINISTRATIVE FEE
Signature Plan
VSP shall be entitled to receive amounts due for each month on behalf of each Enrollee and his/her Eligible Dependents, if
any in the amounts specified below:
ADVANCE PAYMENT: $0.00
ADMINISTRATIVE FEE: $2.63 PER ELIGIBLE ENROLLEE
NOTICE: The amount due under this Plan is subject to change upon renewal (after the end of the Plan Term or any
subsequent Plan Term) or upon change of the Schedule of Benefits or a material change in any other terms or conditions of
the Plan.
37
8.F.c
Packet Pg. 155 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
ADDENDUM
VSP VISION CARE, INC.
ADDITIONAL BENEFIT RIDER
DIABETIC EYECARE PLUS PROGRAM
GENERAL
This Rider lists additional vision care benefits to which Covered Persons of VSP VISION CARE, INC. ("VSP") are entitled,
subject to any applicable Copayments and other conditions, limitations and/or exclusions stated herein or in the Schedule of
Benefits with which it is associated. Plan Benefits under the Diabetic Eyecare Program are available to Covered Persons who
have been diagnosed with type 1 or type 2 diabetes and specific ophthalmological conditions. This Rider forms a part of the
PLAN or Evidence of Coverage to which it is attached.
ELIGIBILITY
The following are Covered Persons under this Plan, pursuant to eligibility criteria established by Client:
• Enrollee.
• The legal spouse of Enrollee.
• Any child of Enrollee, including any natural child from the date of birth, legally adopted child from t he date of placement for
adoption with the Enrollee, or other child for whom a court or administrative agency holds the Enrollee responsible.
Dependent children are covered up to the end of the month in which they attain the age of 26 years.
A dependent, unmarried child over the limiting age may continue to be eligible as a dependent if the child is incapable of
self-sustaining employment because of mental or physical disability, and chiefly dependent upon Enrollee for support and
maintenance.
38
8.F.c
Packet Pg. 156 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
PROGRAM DESCRIPTION
The Diabetic Eyecare Plus Program (“DEP Plus”) is intended to be a supplement to Covered Person's group medical plan.
Providers will first submit a claim to Covered Person's group medical insurance plan, and then to VSP. Any amounts not paid
by the medical plan will be considered for payment by VSP. (This is referred to as “Coordination of Benefits” or “COB." Please
refer to the Coordination of Benefits section of Covered Person’s Evidence of Coverage for additional information regarding
COB.) If Covered Person does not have a group medical plan, providers will submit claims directly to VSP.
Examples of symptoms which may result in an Covered Person seeking services under DEP Plus may include, but are not
limited to:
• blurry vision • trouble focusing
• transient loss of vision • “floating” spots
Examples of conditions which may require management under DEP Plus may include, but are not limited to:
• diabetic retinopathy • rubeosis
• diabetic macular edema
REFERRALS
If Covered Person's Member Doctor cannot provide Covered Services, the doctor will refer the Covered Person to another
Member Doctor or to a physician whose offices provide the necessary services.
If the Covered Person requires services beyond the scope of DEP Plus, the Member Doctor will refer the Covered Person to a
physician.
Referrals are intended to insure that Covered Person receive the appropriate level of care for their presenting condition.
Covered Persons do not require a referral from a Member Doctor in order to obtain Plan Benefits.
39
8.F.c
Packet Pg. 157 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
PLAN BENEFITS
MEMBER DOCTORS
COVERED SERVICES
Eye Examination: Covered in full after a Copayment of $20.00.
Special Ophthalmological Services: Covered in Full.
EXCLUSIONS AND LIMITATIONS OF BENEFITS
The Diabetic Eyecare Plus Program provides coverage for limited, vision -related medical services. A current list of these
procedures will be made available to Covered Person upon request. The frequency at which these services may be provided
is dependent upon the specific service and the diagnosis associated with such service.
NOT COVERED
1. Services and/or materials not specifically included in this Rider as Plan Benefits.
2. Frames, lenses, contact lenses or any other ophthalmic materials.
3. Orthoptics or vision training and any associated supplemental testing.
4. Surgery of any type, and any pre- or post-operative services.
5. Treatment for any pathological conditions.
6. An eye exam required as a condition of employment.
7. Insulin or any medications or supplies of any type.
8. Local, state and/or federal taxes, except where VSP is required by law to pay.
DIABETIC EYECARE PROGRAM DEFINITIONS
Diabetes A disease where the pancreas has a problem either making, or making and using, insulin.
Type 1 Diabetes A disease in which the pancreas stops making insulin.
Type 2 Diabetes A disease in which the pancreas either makes too little insulin or cannot properly use the
insulin it makes to convert blood glucose to energy.
Diabetic Retinopathy
A weakening in the small blood vessels at the back of the eye.
Rubeosis
Abnormal blood vessel growth on the iris and the structures in the front of the eye.
Diabetic Macular Edema
Swelling of the retina in diabetes mellitus due to leaking of fluid from blood vessels within the
macula.
40
8.F.c
Packet Pg. 158 Attachment: VSP ASC 2022_2025 (3154 : Medical Insurance Contract Renewal - Authorize)
DATE: June 7, 2022
TO: Kent City Council
SUBJECT: Amendment to LifeWise Assurance Company Contract for
Stop Loss Insurance - Authorize
MOTION: I move to authorize the Mayor to sign Amendment No. 13 to the
stop loss insurance policy with LifeWise Assurance Company for one year,
subject to approval of final terms and conditions acceptable to the Human
Resources Director and the City Attorney.
SUMMARY: The City contracts with LifeWise Assurance Company for individual and
aggregate stop loss insurance coverage. The best offer received for 2022 was from
LifeWise with a 9.1% increase. Contracting with LifeWise provides an additional
discount from Premera on the stop loss integration fee.
This stop loss policy provides added coverage to the City for individual medical
claims exceeding $200,000 per employee or dependent for each calendar year.
Medical costs exceeding this amount are reimbursed to the City under this policy.
The City received $185,788 in stop loss reimbursements in 2021.
BUDGET IMPACT: The cost for the one-year contract is $1,062,785 and is paid out
of the City’s health and wellness fund.
SUPPORTS STRATEGIC PLAN GOAL:
Innovative Government - Delivering outstanding customer service, developing leaders, and
fostering innovation.
Sustainable Services - Providing quality services through responsible financial management,
economic growth, and partnerships.
ATTACHMENTS:
1. LifeWise Amendment No. 13 (PDF)
05/17/22 Operations and Public Safety Committee MOTION
PASSES
8.G
Packet Pg. 159
RESULT: MOTION PASSES [UNANIMOUS] Next: 6/7/2022
7:00 PM
MOVER: Les Thomas, Councilmember
SECONDER: Toni Troutner, Councilmember
AYES: Boyce, Fincher, Kaur, Larimer, Michaud, Thomas,
Troutner
8.G
Packet Pg. 160
AMENDMENT NO. 13
To be attached to and made part of Policy WA518212 issued to City of Kent as Policyholder
It is hereby agreed the Policy shall be amended as follows
Effective January 1, 2022:
The following Section has been replaced
Section 1, Declarations.
The following Rider renews for the 2022Policy Year:
. Specific Advance Funding Rider.
All other terms and conditions of the contract remain unchanged
LifeWise Assurance ComPanY
Name and Title of Officer
Signature of Officer
Date of Signature
Rick Grover
President and Ghief Executive Officer
LifeWise Assurance GomPanY
1 . Sign and return copy to LifeWise Assurance Company
2. Retain copy with Your PolicY.
PSL-500 WAAM (9-18)Amendment
8.G.a
Packet Pg. 161 Attachment: LifeWise Amendment No. 13 (3155 : Stop Loss Insurance Contract Renewal - Authorize)
This Declarations for Policy Number WA 518212 apply to the Policy Term January 1,2022 through
December 31,2022 in its entirety.
SECTION 1 - DECLARATIONS
A. POLICY INFORMATION
1. Policy Number
2. Policyholder
3. Policy Term
4. Covered Underlying Plan
5. Claim Administrator
w4518212
City of Kent
January 1,2022 through December 31,2022
City of Kent's Health Plan
Premera Blue Cross
B. SPECIFIC BENEFIT SCHEDULE
For all Eligible Losses except those to which a Special Risk Limitation applies:
1. Covered Loss Basis
Covered Services lncurred from January 1 , 2010 through December 31 ,2022 and Paid from
January 1,2022 through December 31,2022.
If an Eligible Claim Expense is denied by the Covered Underlying Plan and that denial is
subsequently reversed by an lndependent Review Organization (lRO), the date such Eligible
Claim Expense was originally denied by the Covered Underlying Plan will be considered the
"Paid" date under the above referenced Policy.
2. Covered Services include
Medical
Prescription Drug
3. Number of Covered Units
Composite 711
4. Specific Deductible per Participant $200,000
(Ple a se n ote : Specific ded u ctib le per Pa rticipa nl shall not exceed the lesse r of 5/o of
expected claims or $100,000).
5. Specific Payable Percentage (in excess of Specific Deductible) 100o/o
6. Maximum Specific Benefit in excess of the Specific Deductible
Per Policy Term Unlimited
Per Lifetime Unlimited
IPSL-500 WA (9-18)
8.G.a
Packet Pg. 162 Attachment: LifeWise Amendment No. 13 (3155 : Stop Loss Insurance Contract Renewal - Authorize)
C. AGGREGATE BENEFIT SCHEDULE
For all Eligible Losses except those to which a Special Risk Limitation applies:
1. Covered Loss Basis
Covered Services lncurred from January 1, 2010 through December 31 ,2022 and Paid from
January 1,2022 through December 31,2022.
lf an Eligible Claim Expense is denied by the Covered Underlying Plan and that denial is
subsequently reversed by an lndependent Review Organization (lRO), the date such Eligible
Claim Expense was originally denied by the Covered Underlying Plan will be considered the
"Paid" date under the above referenced Policy.
2. Covered Services include
Medical
Prescription Drug
3. Number of Covered Units
Composite 711
4. Aggregate Payable Percentage in excess of Deductible 100o/o
5. Aggregate Corridor 2OOoh
(Ptease note: Aggrcgate Conidor will never be /ess fhan 120% of expected claims).
6. Minimum Aggregate Deductible
The greater of:
A. $24,833,409.84', or
B. The sum of Aggregate Monthly Factors, multiplied by the corresponding number of
Covered Units used to calculate premium in the first month of the Policy Term, multiplied
by the number of months in the Policy Term, multiplied by 95%.
7. Annual Aggregate Deductible
ls equal to the greater of A or B, where:
A = The sum of the Monthly Aggregate Deductible Amounts applicable to each Policy Month
in the Policy Term
B = The Minimum Aggregate Deductible
Please Note: Annual Aggregate Deductible cannot be finalized until the Monthly Aggregate
Deductible Amounts are calculated for each Policy Month of the Policy Term'
8. Aggregate Monthly Factor per Covered Unit
Composite
9. Maximum Aggregate Eligible Loss per Participant
10. Maximum Aggregate Benefit per Policy Term
$2,910.62
$200,000
$1,000,000
2PSL-s00 WA (9-18)
8.G.a
Packet Pg. 163 Attachment: LifeWise Amendment No. 13 (3155 : Stop Loss Insurance Contract Renewal - Authorize)
D. PREMIUM
Specific Monthly Premium Rate
Composite $140 56
Specific Rate Guarantee Period 12 Months
Aggregate Monthly Premium Rate Per Covered Unit
Composite $0'02
Aggregate Rate Guarantee Period 12 Months
The Specific Monthly Premium Rate and the Aggregate Monthly Premium Rate apply only to this
Policy Term.
E. SPECIAL RISK LIMITATIONS
Retirees lncluded Yes
YesOther:
Lasered lndividual
Member lD: 60015680802
Specific Deductible: $300,000\piiO Ctaims between $200,000 and $300,000 are not eligible under the Aggregate Benefit
F. AFFILIATE
Name
None
Covered Underlyinq Plan
3PSL-500 WA (9-18)
8.G.a
Packet Pg. 164 Attachment: LifeWise Amendment No. 13 (3155 : Stop Loss Insurance Contract Renewal - Authorize)
DATE: June 7, 2022
TO: Kent City Council
SUBJECT: Consultant Services Agreement with Natural Systems
Design, Inc. for Wetland Mitigation Design - Authorize
MOTION: I move to authorize the Mayor to sign the consultant services
agreement with Natural Systems Design, in the amount of $126,569 for
wetland mitigation design work on the "Little Property," subject to final
terms and conditions acceptable to the City Attorney and Public Works
Director.
SUMMARY: The Mill Creek Reestablishment Project (Project) includes removal of
sediment from the stream channel and improvements to habitat and wetland
functions. The Project is designed to reduce flood levels and flood duration during
larger storm events by improving in-channel conveyance.
Natural Systems Design will complete wetland mitigation and side channel
relocation design packages for the city-owned “Little Property” located north of
James Street and east of Kent Memorial Park. The design package is required as
part of the application for federal, state, and local environmental permits.
Currently, Mill Creek flows through the Little Property in a linear channel. After the
project is completed, it will include meanders, habitat elements, and native
plantings. This portion of the Project will also increase channel capacity, thereby
reducing flood impacts near James Street.
Background:
The Project is designed to reduce flood risks, improve fish passage and
stream/riparian habitat, and protect city roadways and utility infrastructure.
BUDGET IMPACT: $126,569 expense paid for by the Drainage Utility Fund.
SUPPORTS STRATEGIC PLAN GOAL:
Evolving Infrastructure - Connecting people and places through strategic investments in physical
and technological infrastructure.
Thriving City - Creating safe neighborhoods, healthy people, vibrant commercial districts, and
inviting parks and recreation.
8.H
Packet Pg. 165
Inclusive Community - Embracing our diversity and advancing equity through genuine community
engagement.
ATTACHMENTS:
1. Agreement (PDF)
05/16/22 Public Works Committee MOTION PASSES
RESULT: MOTION PASSES [UNANIMOUS] Next: 6/7/2022
7:00 PM
MOVER: Satwinder Kaur, Councilmember
SECONDER: Brenda Fincher, Committee Chair
AYES: Brenda Fincher, Satwinder Kaur
ABSENT: Marli Larimer
8.H
Packet Pg. 166
CONSULTANT SERVICES AGREEMENT - 1
(Over $20,000)
CONSULTANT SERVICES AGREEMENT
between the City of Kent and
Natural Systems Design, Inc.
THIS AGREEMENT is made between the City of Kent, a Washington municipal corporation (hereinafter
the "City"), and Natural Systems Design, Inc. organized under the laws of the State of Washington, located
and doing business at 1900 N. Northlake Way #211, Seattle, WA 98105, Phone: (530) 574-1821, Contact:
Laura Zanetto (hereinafter the "Consultant").
I. DESCRIPTION OF WORK.
The Consultant shall perform the following services for the City in accordance with the following
described plans and/or specifications:
The Consultant shall develop a wetland and stream design for the Little Property for the Mill
Creek Reestablishment Project. For a description, see the Consultant's Scope of Work which
is attached as Exhibit A and incorporated by this reference.
The Consultant further represents that the services furnished under this Agreement will be performed
in accordance with generally accepted professional practices within the Puget Sound region in effect at the
time those services are performed.
II. TIME OF COMPLETION. The parties agree that work will begin on the tasks described in
Section I above immediately upon the effective date of this Agreement. The Consultant shall complete the
work described in Section I by December 31, 2023.
III. COMPENSATION.
A. The City shall pay the Consultant, based on time and materials, an amount not to exceed One
Hundred Twenty Six Thousand, Five Hundred Sixty Nine Dollars ($126,569), for the services
described in this Agreement. This is the maximum amount to be paid under this Agreement
for the work described in Section I above, and shall not be exceeded without the prior written
authorization of the City in the form of a negotiated and executed amendment to this
agreement. The Consultant agrees that the hourly or flat rate charged by it for its services
contracted for herein shall remain locked at the negotiated rate(s) for a period of one (1) year
from the effective date of this Agreement. The Consultant's billing rates shall be as delineated
in Exhibit A.
B. The Consultant shall submit monthly payment invoices to the City for work performed, and a
final bill upon completion of all services described in this Agreement. The City shall provide
payment within forty-five (45) days of receipt of an invoice. If the City objects to all or any
portion of an invoice, it shall notify the Consultant and reserves the option to only pay that
portion of the invoice not in dispute. In that event, the parties will immediately make every
effort to settle the disputed portion.
C. Card Payment Program. The Consultant may elect to participate in automated credit card
payments provided for by the City and its financial institution. This Program is provided as an
alternative to payment by check and is available for the convenience of the Consultant. If the
8.H.a
Packet Pg. 167 Attachment: Agreement (3148 : Natural Systems Design Little Property Mitigation Design)
CONSULTANT SERVICES AGREEMENT - 2
(Over $20,000)
Consultant voluntarily participates in this Program, the Consultant will be solely responsible
for any fees imposed by financial institutions or credit card companies. The Consultant shall
not charge those fees back to the City.
IV. INDEPENDENT CONTRACTOR. The parties intend that an Independent Contractor-
Employer Relationship will be created by this Agreement. By their execution of this Agreement, and in
accordance with Ch. 51.08 RCW, the parties make the following representations:
A. The Consultant has the ability to control and direct the performance and details of its
work, the City being interested only in the results obtained under this Agreement.
B. The Consultant maintains and pays for its own place of business from which the
Consultant’s services under this Agreement will be performed.
C. The Consultant has an established and independent business that is eligible for a
business deduction for federal income tax purposes that existed before the City
retained the Consultant’s services, or the Consultant is engaged in an independently
established trade, occupation, profession, or business of the same nature as that
involved under this Agreement.
D. The Consultant is responsible for filing as they become due all necessary tax
documents with appropriate federal and state agencies, including the Internal Revenue
Service and the state Department of Revenue.
E. The Consultant has registered its business and established an account with the state
Department of Revenue and other state agencies as may be required by the
Consultant’s business, and has obtained a Unified Business Identifier (UBI) number
from the State of Washington.
F. The Consultant maintains a set of books dedicated to the expenses and earnings of its
business.
V. TERMINATION. Either party may terminate this Agreement, with or without cause, upon
providing the other party thirty (30) days written notice at its address set forth on the signature block of
this Agreement. After termination, the City may take possession of all records and data within the
Consultant’s possession pertaining to this project, which may be used by the City without restriction. If the
City’s use of the Consultant’s records or data is not related to this project, it shall be without liability or legal
exposure to the Consultant.
VI. FORCE MAJEURE. Neither party shall be liable to the other for breach due to delay or failure
in performance resulting from acts of God, acts of war or of the public enemy, riots, pandemic, fire, flood,
or other natural disaster or acts of government (“force majeure event”). Performance that is prevented or
delayed due to a force majeure event shall not result in liability to the delayed party. Both parties represent
to the other that at the time of signing this Agreement, they are able to perform as required and their
performance will not be prevented, hindered, or delayed by the current COVID-19 pandemic, any existing
state or national declarations of emergency, or any current social distancing restrictions or personal
protective equipment requirements that may be required under federal, state, or local law in response to
the current pandemic.
If any future performance is prevented or delayed by a force majeure event, the party whose
performance is prevented or delayed shall promptly notify the other party of the existence and nature of
the force majeure event causing the prevention or delay in performance. Any excuse from liability shall be
effective only to the extent and duration of the force majeure event causing the prevention or delay in
performance and, provided, that the party prevented or delayed has not caused such event to occur and
continues to use diligent, good faith efforts to avoid the effects of such event and to perform the obligation.
Notwithstanding other provisions of this section, the Consultant shall not be entitled to, and the City
shall not be liable for, the payment of any part of the contract price during a force majeure event, or any
8.H.a
Packet Pg. 168 Attachment: Agreement (3148 : Natural Systems Design Little Property Mitigation Design)
CONSULTANT SERVICES AGREEMENT - 3
(Over $20,000)
costs, losses, expenses, damages, or delay costs incurred by the Consultant due to a force majeure event.
Performance that is more costly due to a force majeure event is not included within the scope of this Force
Majeure provision.
If a force majeure event occurs, the City may direct the Consultant to restart any work or
performance that may have ceased, to change the work, or to take other action to secure the work or the
project site during the force majeure event. The cost to restart, change, or secure the work or project site
arising from a direction by the City under this clause will be dealt with as a change order, except to the
extent that the loss or damage has been caused or exacerbated by the failure of the Consultant to fulfill its
obligations under this Agreement. Except as expressly contemplated by this section, all other costs will be
borne by the Consultant.
VII. DISCRIMINATION. In the hiring of employees for the performance of work under this
Agreement or any subcontract, the Consultant, its subcontractors, or any person acting on behalf of the
Consultant or subcontractor shall not, by reason of race, religion, color, sex, age, sexual orientation, national
origin, or the presence of any sensory, mental, or physical disability, discriminate against any person who
is qualified and available to perform the work to which the employment relates. The Consultant shall execute
the attached City of Kent Equal Employment Opportunity Policy Declaration, Comply with City Administrative
Policy 1.2, and upon completion of the contract work, file the attached Compliance Statement.
VIII. INDEMNIFICATION. The Consultant shall defend, indemnify and hold the City, its officers,
officials, employees, agents and volunteers harmless from any and all claims, injuries, damages, losses or
suits, including all legal costs and attorney fees, arising out of or in connection with the Consultant's
performance of this Agreement, except for that portion of the injuries and damages caused by the City's
negligence.
The City's inspection or acceptance of any of the Consultant's work when completed shall not be
grounds to avoid any of these covenants of indemnification.
Should a court of competent jurisdiction determine that this Agreement is subject to RCW 4.24.115,
then, in the event of liability for damages arising out of bodily injury to persons or damages to property
caused by or resulting from the concurrent negligence of the Consultant and the City, its officers, officials,
employees, agents and volunteers, the Consultant's duty to defend, indemnify, and hold the City harmless,
and the Consultant’s liability accruing from that obligation shall be only to the extent of the Consultant's
negligence.
IT IS FURTHER SPECIFICALLY AND EXPRESSLY UNDERSTOOD THAT THE INDEMNIFICATION
PROVIDED HEREIN CONSTITUTES THE CONSULTANT'S WAIVER OF IMMUNITY UNDER INDUSTRIAL
INSURANCE, TITLE 51 RCW, SOLELY FOR THE PURPOSES OF THIS INDEMNIFICATION. THE PARTIES
FURTHER ACKNOWLEDGE THAT THEY HAVE MUTUALLY NEGOTIATED THIS WAIVER.
In the event the Consultant refuses tender of defense in any suit or any claim, if that tender was
made pursuant to this indemnification clause, and if that refusal is subsequently determined by a court
having jurisdiction (or other agreed tribunal) to have been a wrongful refusal on the Consultant’s part, then
the Consultant shall pay all the City’s costs for defense, including all reasonable expert witness fees and
reasonable attorneys’ fees, plus the City’s legal costs and fees incurred because there was a wrongful refusal
on the Consultant’s part.
The provisions of this section shall survive the expiration or termination of this Agreement.
IX. INSURANCE. The Consultant shall procure and maintain for the duration of the Agreement,
insurance of the types and in the amounts described in Exhibit B attached and incorporated by this reference.
X. EXCHANGE OF INFORMATION. The City will provide its best efforts to provide reasonable
accuracy of any information supplied by it to the Consultant for the purpose of completion of the work under
this Agreement.
8.H.a
Packet Pg. 169 Attachment: Agreement (3148 : Natural Systems Design Little Property Mitigation Design)
CONSULTANT SERVICES AGREEMENT - 4
(Over $20,000)
XI. OWNERSHIP AND USE OF RECORDS AND DOCUMENTS. Original documents, drawings,
designs, reports, or any other records developed or created under this Agreement shall belong to and
become the property of the City. All records submitted by the City to the Consultant will be safeguarded by
the Consultant. The Consultant shall make such data, documents, and files available to the City upon the
City’s request. The Consultant acknowledges that the City is a public agency subject to the Public Records
Act codified in Chapter 42.56 of the Revised Code of Washington. As such, the Consultant agrees to
cooperate fully with the City in satisfying the City’s duties and obligations under the Public Records Act. The
City’s use or reuse of any of the documents, data, and files created by the Consultant for this project by
anyone other than the Consultant on any other project shall be without liability or legal exposure to the
Consultant.
XII. CITY'S RIGHT OF INSPECTION. Even though the Consultant is an independent contractor
with the authority to control and direct the performance and details of the work authorized under this
Agreement, the work must meet the approval of the City and shall be subject to the City's general right of
inspection to secure satisfactory completion.
XIII. WORK PERFORMED AT CONSULTANT'S RISK. The Consultant shall take all necessary
precautions and shall be responsible for the safety of its employees, agents, and subcontractors in the
performance of the contract work and shall utilize all protection necessary for that purpose. All work shall
be done at the Consultant's own risk, and the Consultant shall be responsible for any loss of or damage to
materials, tools, or other articles used or held for use in connection with the work.
XIV. MISCELLANEOUS PROVISIONS.
A. Recyclable Materials. Pursuant to Chapter 3.80 of the Kent City Code, the City requires its
contractors and consultants to use recycled and recyclable products whenever practicable. A price
preference may be available for any designated recycled product.
B. Non-Waiver of Breach. The failure of the City to insist upon strict performance of any of the
covenants and agreements contained in this Agreement, or to exercise any option conferred by this
Agreement in one or more instances shall not be construed to be a waiver or relinquishment of those
covenants, agreements or options, and the same shall be and remain in full force and effect.
C. Resolution of Disputes and Governing Law. This Agreement shall be governed by and
construed in accordance with the laws of the State of Washington. If the parties are unable to settle any
dispute, difference or claim arising from the parties’ performance of this Agreement, the exclusive means
of resolving that dispute, difference or claim, shall only be by filing suit exclusively under the venue, rules
and jurisdiction of the King County Superior Court, King County, Washington, unless the parties agree in
writing to an alternative dispute resolution process. In any claim or lawsuit for damages arising from the
parties' performance of this Agreement, each party shall pay all its legal costs and attorney's fees incurred
in defending or bringing such claim or lawsuit, including all appeals, in addition to any other recovery or
award provided by law; provided, however, nothing in this paragraph shall be construed to limit the City's
right to indemnification under Section VIII of this Agreement.
D. Written Notice. All communications regarding this Agreement shall be sent to the parties at
the addresses listed on the signature page of the Agreement, unless notified to the contrary. Any written
notice hereunder shall become effective three (3) business days after the date of mailing by registered or
certified mail, and shall be deemed sufficiently given if sent to the addressee at the address stated in this
Agreement or such other address as may be hereafter specified in writing.
E. Assignment. Any assignment of this Agreement by either party without the written consent
of the non-assigning party shall be void. If the non-assigning party gives its consent to any assignment,
the terms of this Agreement shall continue in full force and effect and no further assignment shall be made
without additional written consent.
F. Modification. No waiver, alteration, or modification of any of the provisions of this Agreement
shall be binding unless in writing and signed by a duly authorized representative of the City and the
Consultant.
8.H.a
Packet Pg. 170 Attachment: Agreement (3148 : Natural Systems Design Little Property Mitigation Design)
CONSULTANT SERVICES AGREEMENT - 5
(Over $20,000)
G. Entire Agreement. The written provisions and terms of this Agreement, together with any
Exhibits attached hereto, shall supersede all prior verbal statements of any officer or other representative
of the City, and such statements shall not be effective or be construed as entering into or forming a part of
or altering in any manner this Agreement. All of the above documents are hereby made a part of this
Agreement. However, should any language in any of the Exhibits to this Agreement conflict with any
language contained in this Agreement, the terms of this Agreement shall prevail.
H. Compliance with Laws. The Consultant agrees to comply with all federal, state, and municipal
laws, rules, and regulations that are now effective or in the future become applicable to the Consultant's
business, equipment, and personnel engaged in operations covered by this Agreement or accruing out of
the performance of those operations.
I. Public Records Act. The Consultant acknowledges that the City is a public agency subject to
the Public Records Act codified in Chapter 42.56 of the Revised Code of Washington and documents, notes,
emails, and other records prepared or gathered by the Consultant in its performance of this Agreement may
be subject to public review and disclosure, even if those records are not produced to or possessed by the
City of Kent. As such, the Consultant agrees to cooperate fully with the City in satisfying the City’s duties
and obligations under the Public Records Act.
J. City Business License Required. Prior to commencing the tasks described in Section I,
Contractor agrees to provide proof of a current city of Kent business license pursuant to Chapter 5.01 of the
Kent City Code.
8.H.a
Packet Pg. 171 Attachment: Agreement (3148 : Natural Systems Design Little Property Mitigation Design)
CONSULTANT SERVICES AGREEMENT - 6
(Over $20,000)
K. Counterparts and Signatures by Fax or Email. This Agreement may be executed in any
number of counterparts, each of which shall constitute an original, and all of which will together constitute
this one Agreement. Further, upon executing this Agreement, either party may deliver the signature page
to the other by fax or email and that signature shall have the same force and effect as if the Agreement
bearing the original signature was received in person.
IN WITNESS, the parties below execute this Agreement, which shall become effective on
the last date entered below. All acts consistent with the authority of this Agreement and prior
to its effective date are ratified and affirmed, and the terms of the Agreement shall be deemed
to have applied.
CONSULTANT:
By:
Print Name:
Its
DATE:
CITY OF KENT:
By:
Print Name: Dana Ralph
Its Mayor
DATE:
NOTICES TO BE SENT TO:
CONSULTANT:
Laura Zanetto
Natural Systems Design, Inc.
1900 N. Northlake Way #211
Seattle, WA 98105
(530) 574-1821 (telephone)
N/A (facsimile)
NOTICES TO BE SENT TO:
CITY OF KENT:
Chad Bieren, P.E.
City of Kent
220 Fourth Avenue South
Kent, WA 98032
(253) 856-5500 (telephone)
(253) 856-6500 (facsimile)
APPROVED AS TO FORM:
Kent Law Department
ATTEST:
Kent City Clerk
Natural Systesm Design - Mill Creek Reestablishment 7/Dahl
8.H.a
Packet Pg. 172 Attachment: Agreement (3148 : Natural Systems Design Little Property Mitigation Design)
EEO COMPLIANCE DOCUMENTS - 1
DECLARATION
CITY OF KENT EQUAL EMPLOYMENT OPPORTUNITY POLICY
The City of Kent is committed to conform to Federal and State laws regarding equal opportunity.
As such all contractors, subcontractors and suppliers who perform work with relation to this
Agreement shall comply with the regulations of the City’s equal employment opportunity policies.
The following questions specifically identify the requirements the City deems necessary for any
contractor, subcontractor or supplier on this specific Agreement to adhere to. An affirmative
response is required on all of the following questions for this Agreement to be valid and binding.
If any contractor, subcontractor or supplier willfully misrepresents themselves with regard to the
directives outlines, it will be considered a breach of contract and it will be at the City’s sole
determination regarding suspension or termination for all or part of the Agreement;
The questions are as follows:
1. I have read the attached City of Kent administrative policy number 1.2.
2. During the time of this Agreement I will not discriminate in employment on the basis of sex,
race, color, national origin, age, or the presence of all sensory, mental or physical disability.
3. During the time of this Agreement the prime contractor will provide a written statement to
all new employees and subcontractors indicating commitment as an equal opportunity
employer.
4. During the time of the Agreement I, the prime contractor, will actively consider hiring and
promotion of women and minorities.
5. Before acceptance of this Agreement, an adherence statement will be signed by me, the
Prime Contractor, that the Prime Contractor complied with the requirements as set forth
above.
By signing below, I agree to fulfill the five requirements referenced above.
By: ___________________________________________
For: __________________________________________
Title: _________________________________________
Date: _________________________________________
8.H.a
Packet Pg. 173 Attachment: Agreement (3148 : Natural Systems Design Little Property Mitigation Design)
EEO COMPLIANCE DOCUMENTS - 2
CITY OF KENT
ADMINISTRATIVE POLICY
NUMBER: 1.2 EFFECTIVE DATE: January 1, 1998
SUBJECT: MINORITY AND WOMEN SUPERSEDES: April 1, 1996
CONTRACTORS APPROVED BY Jim White, Mayor
POLICY:
Equal employment opportunity requirements for the City of Kent will conform to federal and state
laws. All contractors, subcontractors, consultants and suppliers of the City must guarantee equal
employment opportunity within their organization and, if holding Agreements with the City
amounting to $10,000 or more within any given year, must take the following affirmative steps:
1. Provide a written statement to all new employees and subcontractors indicating
commitment as an equal opportunity employer.
2. Actively consider for promotion and advancement available minorities and women.
Any contractor, subcontractor, consultant or supplier who willfully disregards the City’s
nondiscrimination and equal opportunity requirements shall be considered in breach of contract
and subject to suspension or termination for all or part of the Agreement.
Contract Compliance Officers will be appointed by the Directors of Planning, Parks, and Public
Works Departments to assume the following duties for their respective departments.
1. Ensuring that contractors, subcontractors, consultants, and suppliers subject to these
regulations are familiar with the regulations and the City’s equal employment opportunity
policy.
2. Monitoring to assure adherence to federal, state and local laws, policies and guidelines.
8.H.a
Packet Pg. 174 Attachment: Agreement (3148 : Natural Systems Design Little Property Mitigation Design)
EEO COMPLIANCE DOCUMENTS - 3
CITY OF KENT
EQUAL EMPLOYMENT OPPORTUNITY COMPLIANCE STATEMENT
This form shall be filled out AFTER COMPLETION of this project by the Contractor awarded the
Agreement.
I, the undersigned, a duly represented agent of
Company, hereby acknowledge and declare that the before-mentioned company was the prime
contractor for the Agreement known as that was entered
into on the (date), between the firm I represent and the City of
Kent.
I declare that I complied fully with all of the requirements and obligations as outlined in the City
of Kent Administrative Policy 1.2 and the Declaration City of Kent Equal Employment Opportunity
Policy that was part of the before-mentioned Agreement.
By: ___________________________________________
For: __________________________________________
Title: _________________________________________
Date: _________________________________________
8.H.a
Packet Pg. 175 Attachment: Agreement (3148 : Natural Systems Design Little Property Mitigation Design)
EXHIBIT A 8.H.a
Packet Pg. 176 Attachment: Agreement (3148 : Natural Systems Design Little Property Mitigation Design)
8.H.a
Packet Pg. 177 Attachment: Agreement (3148 : Natural Systems Design Little Property Mitigation Design)
8.H.a
Packet Pg. 178 Attachment: Agreement (3148 : Natural Systems Design Little Property Mitigation Design)
8.H.a
Packet Pg. 179 Attachment: Agreement (3148 : Natural Systems Design Little Property Mitigation Design)
8.H.a
Packet Pg. 180 Attachment: Agreement (3148 : Natural Systems Design Little Property Mitigation Design)
8.H.a
Packet Pg. 181 Attachment: Agreement (3148 : Natural Systems Design Little Property Mitigation Design)
8.H.a
Packet Pg. 182 Attachment: Agreement (3148 : Natural Systems Design Little Property Mitigation Design)
8.H.a
Packet Pg. 183 Attachment: Agreement (3148 : Natural Systems Design Little Property Mitigation Design)
8.H.a
Packet Pg. 184 Attachment: Agreement (3148 : Natural Systems Design Little Property Mitigation Design)
EXHIBIT B INSURANCE REQUIREMENTS FOR CONSULTANT SERVICES AGREEMENTS
Insurance
The Consultant shall procure and maintain for the duration of the Agreement,
insurance against claims for injuries to persons or damage to property which
may arise from or in connection with the performance of the work hereunder
by the Consultant, their agents, representatives, employees or
subcontractors.
A. Minimum Scope of Insurance
Consultant shall obtain insurance of the types described below:
1. Automobile Liability insurance covering all owned, non-owned,
hired and leased vehicles. Coverage shall be written on Insurance
Services Office (ISO) form CA 00 01 or a substitute form providing
equivalent liability coverage. If necessary, the policy shall be
endorsed to provide contractual liability coverage.
2. Commercial General Liability insurance shall be written on ISO
occurrence form CG 00 01 and shall cover liability arising from
premises, operations, independent contractors, products-completed
operations, personal injury and advertising injury, and liability
assumed under an insured contract. The City shall be named as an
insured under the Consultant’s Commercial General Liability
insurance policy with respect to the work performed for the City
using ISO additional insured endorsement CG 20 10 11 85 or a
substitute endorsement providing equivalent coverage.
3. Workers’ Compensation coverage as required by the Industrial
Insurance laws of the State of Washington.
4. Professional Liability insurance appropriate to the Consultant’s
profession.
B. Minimum Amounts of Insurance
Consultant shall maintain the following insurance limits:
1. Automobile Liability insurance with a minimum combined single
limit for bodily injury and property damage of $1,000,000 per
accident.
2. Commercial General Liability insurance shall be written with limits
no less than $1,000,000 each occurrence, $2,000,000 general
aggregate and a $1,000,000 products-completed operations
aggregate limit.
8.H.a
Packet Pg. 185 Attachment: Agreement (3148 : Natural Systems Design Little Property Mitigation Design)
EXHIBIT B (Continued)
3. Professional Liability insurance shall be written with limits no less
than $1,000,000 per claim and $1,000,000 policy aggregate limit.
C. Other Insurance Provisions
The insurance policies are to contain, or be endorsed to contain, the following
provisions for Automobile Liability and Commercial General Liability
insurance:
1. The Consultant’s insurance coverage shall be primary insurance as
respect the City. Any Insurance, self-insurance, or insurance pool
coverage maintained by the City shall be excess of the Consultant’s
insurance and shall not contribute with it.
2. The Consultant’s insurance shall be endorsed to state that coverage
shall not be cancelled by either party, except after thirty (30) days
prior written notice by certified mail, return receipt requested, has
been given to the City.
3. The City of Kent shall be named as an additional insured on all
policies (except Professional Liability) as respects work performed
by or on behalf of the Consultant and a copy of the endorsement
naming the City as additional insured shall be attached to the
Certificate of Insurance. The City reserves the right to receive a
certified copy of all required insurance policies. The Consultant’s
Commercial General Liability insurance shall also contain a clause
stating that coverage shall apply separately to each insured against
whom claim is made or suit is brought, except with respects to the
limits of the insurer’s liability.
D. Acceptability of Insurers
Insurance is to be placed with insurers with a current A.M. Best rating of not
less than A:VII.
E. Verification of Coverage
Consultant shall furnish the City with original certificates and a copy of the
amendatory endorsements, including but not necessarily limited to the
additional insured endorsement, evidencing the insurance requirements of
the Contractor before commencement of the work.
F. Subcontractors
Consultant shall include all subcontractors as insureds under its policies or
shall furnish separate certificates and endorsements for each subcontractor.
All coverages for subcontractors shall be subject to all of the same insurance
requirements as stated herein for the Consultant.
8.H.a
Packet Pg. 186 Attachment: Agreement (3148 : Natural Systems Design Little Property Mitigation Design)
DATE: June 7, 2022
TO: Kent City Council
SUBJECT: Kherson Park Redevelopment Bid - Award
MOTION: I move to award the Kherson Park Redevelopment project to
Green Tech Excavation Inc, in the amount of $1,627,278.00 (including
Washington State Sales Tax), and authorize the Mayor to sign all necessary
documents, subject to final terms and conditions acceptable to the City
Attorney and Park Director.
SUMMARY: This project is the redevelopment of Kherson Park. The construction of
this park will include new children’s play features intended to capture the
imagination and historical ties to Kent’s legacy in the aerospace industry. New
improvements include space-themed play elements, a 40-foot backdrop for the
Lunar Rover Replica, video projection system, lighting, and daytime use areas. This
project will also include some right of way improvements.
All advertised bid items, on the primary Schedule A scope of work as well as the
alternate Schedule B scope of work, will be awarded.
A public bidding process yielded a total of three bids, with the lowest responsible
bidder being Green Tech Excavation Inc.
The Engineer’s estimate for this project is $950,000 - $1.15 Million.
BUDGET IMPACT: Expense impact to the Downtown Placemaking-Kherson capital
budget
SUPPORTS STRATEGIC PLAN GOAL:
Evolving Infrastructure - Connecting people and places through strategic investments in physical
and technological infrastructure.
Thriving City - Creating safe neighborhoods, healthy people, vibrant commercial districts, and
inviting parks and recreation.
ATTACHMENTS:
1. 06072022 Kherson Redevelopment Award EXHIBIT (PDF)
10.A
Packet Pg. 187
PROJECT NAME: Kherson Park Redevelopment
PROJECT #: PK20-01
ENGINEER’S ESTIMATE: $950,000 - $1.15 Million
BID DUE DATE & TIME: Friday, 05/13/2022, 2:00PM
BID OPENING
DATE & TIME:
Immediately
After Due
BID OPENING LOCATION: Kent City Hall, First Floor ADDENDA: One (1)
Bidder
Schedule A
Total Bid Amount
Schedule B
Total Bid Amount
Bid
Bond
Add-
enda
L.W. Sundstrom, Inc. $1,540,000.00 $60,000.00 X X
Green Tech Excavation Inc. $1,452,000.00 $26,000.00 X X
A-1 Landscaping &
Construction $1,810,333.00 $45,000.00 X X
$ $
$ $
$ $
$ $
$ $
$ $
$ $
Schedule A
* Apparent Low Bidder: Green Tech Excavation Inc.
Schedule B
* Apparent Low Bidder: Green Tech Excavation Inc.
Schedule A and B
* Apparent Low Bidder: Green Tech Excavation Inc.
* All bids require review by City of Kent staff. Awarded contractor will be notified directly.
Kent City Clerk
10.A.a
Packet Pg. 188 Attachment: 06072022 Kherson Redevelopment Award EXHIBIT (3175 : Kherson Park Redevelopment Bid - Award)
KENT
PROJECT NAME:
PROJECT #:
ENGINEER'S ESTIMATE:
BID DUE DATE & TIME:
BID OPENING LOCATION:
Kherson Park Redevelopment
PK20-01
$950.000 - $1.15 Million
Friday, O5 I 73 / 2022. 2:OOPM
Kent City Hall, First Floor
BID OPENING
DATE & TIME:
ADDENDA:
Immediately
After Due
One (1)
Bidder
Schedule A
Total Bid Amount
Schedule B
Total Bid Amount
Bid
Bond
Add-
enda
L . t,tJ. SundStyovr't, lnc.$ l,5L{o ,.66D $ bo,66t)
Crr.unTe ch f-irartation Tta-.$ l, Ll1A,6bD
,$ 7b. hhD v
A' I tani Sf rr:nna J0nrn\hr*l $ l,Rln 3\7 $ 46, obo
I O ,
$$
$$
$$
$$
$$
$$
$$
CIR*T..v Ev r=\nrkSchedule A* Apparent Low Bidder:
Schedule B* Aooarent Low Bidder:Grr.o,^.Tr\r. Evraua/
Schedule A and B* Aooarent Low Bidder:hv€evr-\ec\n Dxc ^, r,
I^"
,bc.
-+-Fc.
* All bids require review by City of Kent staff. Awarded contractor will be notified directly.
a&^-n
10.A.a
Packet Pg. 189 Attachment: 06072022 Kherson Redevelopment Award EXHIBIT (3175 : Kherson Park Redevelopment Bid - Award)