HomeMy WebLinkAboutCity Council Committees - Operations and Public Safety Committee - 05/17/2022 4^* Operations and Public Safety
• Committee
KEN T Tuesday, May 17, 2022
WASH I NGTON 4:0 0 PM
Chambers
To listen to this meeting,
call 1-888-475-4499 or 1-877-853-5257
and enter Meeting ID 842 5335 9184, Passcode: 444374
Chair Bill Boyce
Councilmember Brenda Fincher Councilmember Satwinder Kaur
Councilmember Marli Larimer Councilmember Zandria Michaud
Councilmember Les Thomas Councilmember Toni Troutner
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Item Description Action Speaker Time
1. Call to Order Chair
2. Roll Call Chair
3. Agenda Approval Chair
4. Business Chair
A. Approval of Minutes
Approval of May 3, 2022 YES Chair 01 MIN.
Minutes
B. Payment of Bills - Authorize YES Paula Painter 01 MIN.
C. Cancel Council's Regular YES Tammy White 05 MIN.
Meeting Scheduled for July
5, 2022 - Direct
D. Medical, Dental and Vision YES Laura Horea 10 MIN.
Vendor Contracts -
Authorize
E. Amendment to LifeWise YES Laura Horea 10 MIN.
Assurance Company
Unless otherwise noted, the Operations and Public Safety Committee meets at 4 p.m. on the
first and third Tuesday of each month in Kent City Hall, Council Chambers East, 220 Fourth
Avenue South, Kent, WA 98032.
For additional information please contact Kim Komoto at 253-856-5728, or mail
Kkomoto@kentwa.gov.
Any person requiring a disability accommodation should contact the City Clerk's Office at
253-856-5725 in advance. For TDD relay service call Washington Telecommunications Relay
Service at 7-1-1.
Operations and Public Safety Committee CC Ops and May 17, 2022
PS Regular Meeting
Contract for Stop Loss
Insurance - Authorize
F. INFO ONLY: March 2022 NO Paula Painter 10 MIN.
Financial Report and 2021
Year-End Financial Report
5. Adjournment Chair
Pending Approval
Operations and Public Safety
KENT Committee
WA9H... CC Ops and PS Regular Meeting
Minutes
May 3, 2022
Date: May 3, 2022
Time: 4:01 p.m.
Place: Chambers
Members: Bill Boyce, Chair
Brenda Fincher, Councilmember
Satwinder Kaur, Councilmember
Marli Larimer, Councilmember
Zandria Michaud, Councilmember
Les Thomas, Councilmember o
Toni Troutner Councilmember
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Agenda: a
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1. Call to Order 4:01 p.m. a
Council President Boyce called the meeting to order.
2. Roll Call N
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Attendee Name T6 Title Status Arrived
Bill Boyce Chair Present
Brenda Fincher Councilmember Present c
Satwinder Kaur Councilmember Excused
Marli Larimer Councilmember Present c
Zandria Michaud Councilmember Present
Les Thomas Councilmember Present U
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Toni Troutner Councilmember Present 2
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3. Agenda Approval a
1. I move to approve the agenda as amended. a
Council President Boyce advised items C. INFO ONLY: March 2022 Financial
Report and E. INFO ONLY: Equity Strategic Plan Update are being removed
from the agenda.
RESULT: MOTION PASSES [UNANIMOUS]
MOVER: Les Thomas, Councilmember
SECONDER: Toni Troutner, Councilmember
AYES: Boyce, Fincher, Larimer, Michaud, Thomas, Troutner
4. Business
A. Approval of Minutes
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Page 1 of 2 Packet Pg. 3
Operations and Public Safety Committee CC Ops May 3, 2022
and PS Regular Meeting Kent, Washington
Minutes
................................................................................................................................................................................................................................................................................................ _............................................................................................................................................................................................................
Approval of Minutes dated April 19, 2022
MOTION: Move to approve the Minutes dated April 19, 2022
SER ULT: APPROVED [UNANIMOUS]
MOVER: Les Thomas, Councilmember
SECONDER: Toni Troutner, Councilmember
AYES: Boyce, Fincher, Larimer, Michaud, Thomas, Troutner
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 May 3, 2022. o
RESULT: MOTION PASSES [UNANIMOUS] Next: 5/17/2022 7:00 PM o
MOVER: Les Thomas, Councilmember Q
SECONDER: Toni Troutner, Councilmember
AYES: Boyce, Fincher, Larimer, Michaud, Thomas, Troutner a
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C. Consolidating Budget Adjustment Ordinance for Adjustments
between January 1, 2022 and March 31, 2022 - Adopt N
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Michelle Ferguson, Finance Budget Manager, presented the First Quarter N
2022 Supplemental Budget Adjustment Ordinance No. 4429. The budget fund ;,
adjustments for January 1, 2022 through March 31, 2022 reflect an overall
increase of $11,636,600. Ferguson reviewed the previously approved items o
and budget increases pending approval.
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MOTION: 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.
RESULT: MOTION PASSES [UNANIMOUS] Next: 5/17/2022 7:00 PM
MOVER: Les Thomas, Councilmember Q
SECONDER: Toni Troutner, Councilmember
AYES: Boyce, Fincher, Larimer, Michaud, Thomas, Troutner
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5. Adjournment 4:12 p.m.
Council President Bill Boyce adjourned the meeting.
Ki4vLUe Ley K0-0Wt0-
Committee Secretary
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Page 2 of 2 Packet Pg. 4
4.B
FINANCE DEPARTMENT
Paula Painter, CPA
220 Fourth Avenue South
\117KENT Kent, WA 98032
W A S ENT
N G T O N 253-856-5264
DATE: May 17, 2022
TO: Operations and Public Safety Committee
SUBJECT: Payment of Bills - Authorize
MOTION: I move to authorize the payment of bills.
SUMMARY:
BUDGET IMPACT:
SUPPORTS STRATEGIC PLAN GOAL:
Sustainable Services - Providing quality services through responsible financial management,
economic growth, and partnerships.
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4.0
OFFICE OF THE CITY ATTORNEY
Tammy White, Acting City Attorney
220 Fourth Avenue South
KENT Kent, WA 98032
WASHINGTON 253-856-5770
DATE: May 17, 2022
TO: Operations and Public Safety Committee
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.
This item has been placed on the Operations and Public Safety Committee's agenda
for Council to have a discussion as to whether it will cancel its July 5, 2022,
meeting.
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.
If Council desires to cancel its July 5, 2022 meeting, and in the absence of any
delegation to another of Council's authority to designate its meetings, it would be
best for Council to adopt a motion that directs the City Clerk to cancel the July 5,
2022, meeting and give public notice of the same.
Packet Pg. 6
4.D
HUMAN RESOURCES DEPARTMENT
Teri Smith, SHRM-CP, PHR
• 220 Fourth Avenue South
KENT Kent, WA 98032
WASHINGTON 253-856-5270
DATE: May 17, 2022
TO: Operations and Public Safety Committee
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 subject to approval of final terms and conditions by 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.
Our recommendation is to 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:
Innovative Government - Delivering outstanding customer service, developing leaders, and
fostering innovation.
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4.D
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)
Packet Pg. 8
4.D.a
KAISER PERMANENTE®
Kaiser Foundation Health Plan of Washington
A nonprofit health maintenance organization
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Group Medical Coverage Agreement `0
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Kaiser Foundation Health Plan of Washington("KFHPWA")is a nonprofit health maintenance organization,duly 3
registered under the laws of the State of Washington,furnishing health care coverage on a prepayment basis.The c
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 eligibility;and benefits to which those i
enrolled under this Group Agreement are entitled. c
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The Group Medical Coverage Agreement between KFHPWA and the Group consists of the following: 4)
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• Standard Provisions �
• Evidence of Coverage
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City of Kent,#0036900
This Group Agreement will continue in effect until terminated or renewed as herein provided for and is effective
January 1,2022. 'n
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4.D.a
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 subject to change
by KFHPWA upon 30 days written notice. Premium rates will be revised as a part of the annual renewal
process. NL
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KFHPWA reserves the right to re-rate this benefit package if the demographic characteristics change by more 3
than 15%. Q
3. Dissemination of Information. m
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. M
KFHPWA will furnish cards,for identification purposes only,to all Members enrolled under this Group p
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Agreement. d
5. Administration of Group Agreement. L
KFHPWA may adopt reasonable policies and procedures to help in the administration of this Group Agreement. w
This may include,but is not limited to,policies or procedures pertaining to benefit entitlement and coverage c
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.
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No oral statement of any person shall modify or otherwise affect the benefits,limitations and exclusions of this M
Group Agreement,convey or void any coverage,increase or reduce any benefits under this Group Agreement or N
be used in the prosecution or defense of a claim under this Group Agreement. N
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7. Indemnification.
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KFHPWA agrees to indemnify and hold the Group harmless against all claims,damages,losses and expenses, m
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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 Q
Agreement. y
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The Group agrees to indemnify and hold KFHPWA harmless against all claims,damages,losses and expenses, Y
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
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The indemnifying party shall give the other party prompt notice of any claim covered by this section and Q
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.
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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 L
services and other benefits terminate the first of the month following 30 days after receipt of non-acceptance. z
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10. Grandfathered Health Plan. Q
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 this coverage does not m
meet(or no longer meets)the requirements for grandfathered status 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 March 23,2010 for the same plan.Health Plan will rely on c
Group's representation in issuing and/or continuing any and all grandfathered health plan coverage V
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11. Confidentiality.
Each party acknowledges that performance of its obligations under this Group Agreement may involve access w
to and disclosure of data,procedures,materials,lists, systems and information,including medical records, c
employee benefits information,employee addresses,social security numbers,e-mail addresses,phone numbers
and other confidential information regarding the Group's employees(collectively the"information").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
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Agreement,or for the proper management and administration of the receiving party,provided that such M
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 N
federal,state or local law,statute,rule or regulation. The disclosing party will provide the other party with N
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
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against such request.Each party shall maintain the confidentiality of medical records and confidential patient d
and employee information as required by applicable law.
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12. HIPAA. y
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Definition of Terms.Terms used,but not otherwise defined,in this section shall have the same meaning as Y
those terms have in the Health Insurance Portability and Accountability Act of 1996("HIPAA").
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Transactions Accepted.KFHPWA will accept Standard Transactions,pursuant to HIPAA,if the Group elects
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to transmit such transactions.The Group shall ensure that all Standard Transactions transmitted to KFHPWA by
the Group or the Group's business associates are in compliance with HIPAA standards for electronic Q
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
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4.D.a
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 obtain
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.
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c. Underwriting Guidelines.KFHPWA may terminate this Group Agreement in the event the Group no 0
longer meets underwriting guidelines established by KFHPWA that were in effect at the time the Group 3
was accepted. Q
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. M
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a. KFHPWA may determine to withdraw from a Service Area or from a segment of its Service Area after V
KFHPWA has demonstrated to the Washington State Office of the Insurance Commissioner that 0
KFHPWA's clinical,financial or administrative capacity to service the covered Members would be L
exceeded.
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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 2
covered under the replaced plan and does not significantly limit access to the services covered under the
replaced plan.KFHPWA may also allow unrestricted conversion to a fully comparable KFHPWA product.
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KFHPWA will provide written notice to each covered Member of the discontinuation or non-renewal of the M
plan at least 90 days prior to discontinuation.
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15. Limitation on Enrollment. N
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 m
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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.
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16. Acceptance of Group Agreement y
The Group agrees as having accepted the terms and conditions of this Group Agreement and any amendments M
issued during the term of this Group Agreement,upon receipt by KFHPWA of any amount of premium Y
payment.
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4.D.a
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Kaiser Foundation Health Plan of
Washington
Evidence of Coverage
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4.D.a
KAISER PERMANENTE®
Kaiser Foundation Health Plan of Washington
A nonprofit health maintenance organization
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2022 Evidence of Coverage
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1 COB571-0036900
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4.D.a
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.
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For children,the Member may designate a pediatrician as the primary care provider. L
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The Member does not need Preauthorization from KFHPWA or from any other person (including a Network 3
Personal Physician) to access obstetrical or gynecological care from a health care professional in the KFHPWA Q
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, following a pre-approved m
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.
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Women's health and cancer rights p
If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the V
mastectomy,the Member will also receive coverage for:
• All stages of reconstruction of the breast on which the mastectomy has been performed. L
• Surgery and reconstruction of the other breast to produce a symmetrical appearance. 0
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• Prostheses.
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• Treatment of physical complications of all stages of mastectomy,including lymphedemas.
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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).
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Statement of Rights Under the Newborns' and Mothers' Health Protection Act M
Carriers offering group health coverage generally may not,under federal law,restrict benefits for any hospital length N
of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal N
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delivery,or less than 96 hours following a cesarean section.However,federal law generally does not prohibit the N
mother's or newborn's attending provider,after consulting with the mother,from discharging the mother or newborn
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earlier than 48 hours(or 96 hours as applicable).In any case,carriers may not,under federal law,require that a E
provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours(or 96 hours). i
Also,under federal law,a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of Q
the 48-hour(or 96-hour)stay is treated in a manner less favorable to the mother or newborn than any earlier portion
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For More Information Y
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KFHPWA will provide the information regarding the types of plans offered by KFHPWA to Members on request. E
Please call Kaiser Permanente Member Services at(206) 63 0-463 6 in the Seattle area,or toll-free in Washington, 1-
888-901-4636. +°
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4.D.a
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
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F. Preauthorization.....................................................................................................................................10
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G. Recommended Treatment. .....................................................................................................................10 z
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H. Second Opinions....................................................................................................................................10 Q
I. Unusual Circumstances..........................................................................................................................10
J. Utilization Management.........................................................................................................................11
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III. Financial Responsibilities...........................................................................................................................11 d
A. Premium.................................................................................................................................................11
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B. Financial Responsibilities for Covered Services....................................................................................11
C. Financial Responsibilities for Non-Covered Services............................................................................12 0
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IV. Benefits Details............................................................................................................................................13 d
Annual Deductible.........................................................................................................................................13
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Coinsurance...................................................................................................................................................13 0
LifetimeMaximum.......................................................................................................................................13 c
Out-of-pocket Limit......................................................................................................................................13
Pre-existing Condition Waiting Period.........................................................................................................13 3
Acupuncture..................................................................................................................................................14
AllergyServices............................................................................................................................................14
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Ambulance....................................................................................................................................................14 M
Cancer Screening and Diagnostic Services...................................................................................................15 N
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Circumcision.................................................................................................................................................15 G
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ClinicalTrials................................................................................................................................................15
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Dental Services and Dental Anesthesia.........................................................................................................16 E
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Devices,Equipment and Supplies(for home use).........................................................................................16
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Diabetic Education,Equipment and Pharmacy Supplies ..............................................................................17 Q
Dialysis(Home and Outpatient)....................................................................................................................18 y
Drugs-Outpatient Prescription.....................................................................................................................18 Y
EmergencyServices......................................................................................................................................21 +�
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GenderHealth Services.................................................................................................................................22 m
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Hearing Examinations and Hearing Aids......................................................................................................22
Home Health Care.........................................................................................................................................22
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Hospice..........................................................................................................................................................23
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Hospital-Inpatient and Outpatient...............................................................................................................24
Infertility(including sterility)........................................................................................................................25
InfusionTherapy...........................................................................................................................................25
Laboratoryand Radiology.............................................................................................................................25
ManipulativeTherapy...................................................................................................................................26
Maternityand Pregnancy...............................................................................................................................26
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MentalHealth and Wellness..........................................................................................................................27
Naturop athy...................................................................................................................................................28
NewbornServices.........................................................................................................................................28
NutritionalCounseling..................................................................................................................................29
NutritionalTherapy.......................................................................................................................................29
ObesityRelated Services...............................................................................................................................29
On the Job Injuries or Illnesses.....................................................................................................................30
Oncology.......................................................................................................................................................30
Optical(vision)..............................................................................................................................................30 1-
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OralSurgery..................................................................................................................................................31 r
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OutpatientServices.......................................................................................................................................31 Q
Plastic and Reconstructive Surgery...............................................................................................................32
Podiatry.........................................................................................................................................................32 m
PreventiveServices.......................................................................................................................................32 aa)
Rehabilitation and Habilitative Care(massage,occupational,physical and speech therapy,pulmonary and
cardiac rehabilitation)and Neurodevelopmental Therapy.....................................................................33 i
Reproductive Health......................................................................................................................................35
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SexualDysfunction.......................................................................................................................................35 V
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SkilledNursing Facility.................................................................................................................................35
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Sterilization...................................................................................................................................................36 0
SubstanceUse Disorder.................................................................................................................................36 c
TelehealthServices.......................................................................................................................................38
Temporomandibular Joint(TMJ)..................................................................................................................39
TobaccoCessation.........................................................................................................................................39
Transplants....................................................................................................................................................40
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UrgentCare...................................................................................................................................................40 c
V. General Exclusions......................................................................................................................................41 N
VI. Eligibility,Enrollment and Termination...................................................................................................42 0
A. Eligibility 42 N
B. Application for Enrollment....................................................................................................................43 m
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C. When Coverage Begins..........................................................................................................................45
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D. Eligibility for Medicare..........................................................................................................................45 Q
E. Termination of Coverage. ......................................................................................................................45
F. Continuation of Inpatient Services.........................................................................................................46 A
G. Continuation of Coverage Options.........................................................................................................46 Y
VII. Grievances....................................................................................................................................................47
m
VIII. Appeals.........................................................................................................................................................48 E
IX. Claims...........................................................................................................................................................49
0
X. Coordination of Benefits.............................................................................................................................50
Definitions.....................................................................................................................................................50 Q
Order of Benefit Determination Rules...........................................................................................................51
Effect on the Benefits of this Plan.................................................................................................................53
Right to Receive and Release Needed Information.......................................................................................53
Facilityof Payment.......................................................................................................................................53
Rightof Recovery. ........................................................................................................................................53
Effectof Medicare.........................................................................................................................................53
4 COB571-0036900
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4.D.a
Xi. Subrogation and Reimbursement Rights..................................................................................................54
XII. Definitions....................................................................................................................................................55
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4.D.a
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.Department 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, L
the EOC language will govern. z
r
The provisions of the EOC must be considered together to fully understand the benefits available under the EOC. Q
Words with special meaning are capitalized and are defined in Section XII.
3
Contact Kaiser Permanente Member Services at 206-630-4636 or toll-free 1-888-901-4636 for benefits questions.
II. How Covered Services Work
L
A. Accessing Care. c
V
1. Members are entitled to Covered Services from the following:
Your Provider Network is KFHPWA's Core Network(Network). Members are entitled to Covered L
Services only at Network Facilities and Network Providers,except for Emergency services and care w
pursuant to a Preauthorization. c
Benefits under this EOC will not be denied for any health care service performed by a registered nurse 2
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.
LO
A listing of Core Network Personal Physicians,specialists,women's health care providers and KFHPWA-
M
designated Specialists is available by contacting Member Services or accessing the KFHPWA website at N
www.kp.org/wa.Information available online includes each physician's location,education,credentials, N
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
E
the search bar. d
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Health Care Benefit Managers: Q 2.
• OptumRx m
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• Magellan Healthcare M
• Tivity Health
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• First Choice Health
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• Cogitativo E
• Multiplan V
Receiving Care in another Kaiser Foundation Health Plan Service Area Q
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,
6 COB571-0036900
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4.D.a
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.
d
2. Primary Care Provider Services. L
KFHPWA recommends that Members select a Network Personal Physician when enrolling. One personal 0
physician may be selected for an entire family,or a different personal physician may be selected for each 3
family member.For information on how to select or change Network Personal Physicians,and for a list of Q
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 m
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.
c
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To find a personal physician,call Member Services or access the KFHPWA website at www.kp.org/wa to V
view physician profiles.Information available online includes each physician's location,education,
credentials,and specialties. L
For your personal physician,choose from these specialties: c
• 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.
Ln
If your choice does not feel right after a few visits,you can change your personal physician at any time,for M
any reason.If you don't choose a physician when you first become a KFHPWA member,we will match N
you with a physician to make sure you have one assigned to you if you get sick or injured. N
c
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 d
offering the Member a selection of new personal physicians from which to choose.
Q
3. Specialty Care Provider Services. y
Unless otherwise indicated in Section II.or Section IV.,Preauthorization is required for specialty care and M
specialists that are not KFHPWA-designated Specialists and are not providing care at facilities owned and Y
operated by Kaiser Permanente. c
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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 Q
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 health 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.
7 COB571-0036900
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4.D.a
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. L
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Members are covered for Emergency care and Medically Necessary urgent care anywhere in the world.If 3
you think you are experiencing an emergency,go immediately to the nearest emergency care facility or call Q
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 you 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 W
member must notify us within 48 hours after care begins,or as soon as is reasonably possible. Call the c
notification line listed on the back of your KFHPWA Member ID card to help make sure your claim is V
accepted.Keep receipts and other paperwork from non-network care.You'll need to submit them with any
claims for reimbursement after returning from travel. L
0
Access to non-Emergency care across the Core network service area:your Plan provides access to all c
providers in the Core Network,including many physicians and services at Kaiser Permanente medical M
facilities and Core Network facilities across the state.Find links to providers at kp.org/wa/diregM or
contact Member Services at 1-888-901-4636 for assistance. m
6. Urgent Care.
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Inside the KFHPWA Service Area,urgent care is covered at a Kaiser Permanente medical center,Kaiser M
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. N
0
N
For urgent care during office hours,you can call your personal physician'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
E
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.
Q
7. Women's Health Care Direct Access Providers. y
Female Members may see a general and family practitioner,physician's assistant,gynecologist,certified M
nurse midwife,licensed midwife,doctor of osteopathy,pediatrician,obstetrician or advance registered Y
nurse practitioner who is unrestricted in your KFHPWA Network to provide women's health care services c
directly,without Preauthorization,for Medically Necessary maternity care,covered reproductive health
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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 0
Physician had been consulted,subject to any applicable Cost Shares.If the Member's women's health care Q
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 COB571-0036900
Packet Pg. 21
KFHPWA Member using the service for the first time.Travel-related vaccinations and medications are
usually not covered.Visit lkp.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 determination has been
made.
First Level Review:
d
First level reviews are performed or overseen by appropriate clinical staff using KFHPWA approved L
clinical review criteria.Data sources for the review include,but are not limited to,referral forms,admission z
request forms,the Member's medical record,and consultation with qualified health professionals and 3
multidisciplinary health care team members.The clinical information used in the review may include Q
treatment summaries,problem lists,specialty evaluations,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. c
V
Second Level(Practitioner)Review:
c
The practitioner reviews the treatment plan and discusses,when appropriate,case circumstances and w
management options with the attending(or referring)physician.The reviewer consults with the health care c
team when more clarity is needed to make an informed coverage decision. The reviewer may consult with M
board certified physicians from appropriate specialty areas to assist in making determinations of coverage 0
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
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clinical psychologist,certified addiction medicine specialist),dentist or pharmacist who has the clinical M
expertise appropriate to the request under review with an unrestricted license may deny coverage based on
Medical Necessity. N
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B. Administration of the EOC.
KFHPWA may adopt reasonable policies and procedures to administer the EOC.This may include,but is not
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limited to,policies or procedures pertaining to benefit entitlement and coverage determinations.
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C. Confidentiality. Q
KFHPWA is required by federal and state law to maintain the privacy of Member personal and health y
information.KFHPWA is required to provide notice of how KFHPWA may use and disclose personal and M
health information held by KFHPWA. The Notice of Privacy Practices is distributed to Members and is Y
available in Kaiser Permanente medical centers,at www.kp.org/wa,or upon request from Member Services. c
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D. Modification of the EOC.
V
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 Q
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.
9 COB571-0036900
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4.D.a
F. Preauthorization.
Refer to Section IV. or hllps://wa.kaiserpermanente.or /hg tml/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 provide 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 calendar days to provide the necessary information.A z
decision will be made within 4 calendar days of receipt of the information or the deadline for receipt of Q
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.
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G. Recommended Treatment. p
KFHPWA's medical director will determine the necessity,nature and extent of treatment to be covered in each V
individual case and the judgment will be made in good faith.Members have the right to appeal coverage c
decisions(see Section VIII.). Members have the right to participate in decisions regarding their health care.A L
Member may refuse any recommended services to the extent permitted by law.Members who obtain care not
N
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.
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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
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technology's benefits,whether it has been proven safe and effective,and under what conditions its use would be M
appropriate. The recommendations of these committees inform what is covered on KFHPWA health plans.
N
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H. Second Opinions. N
The Member may access a second opinion from a Network Provider regarding a medical diagnosis or treatment m
plan. The Member may request Preauthorization or may visit a KFHPWA-designated Specialist for a second E
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 Q
Member's EOC;therefore,coverage for the second opinion does not imply that the services or treatments
2.
recommended will be covered.Preauthorization for a second opinion does not imply that KFHPWA will y
authorize the Member to return to the physician providing the second opinion for any additional treatment. Y
Services,drugs and devices prescribed or recommended as a result of the consultation are not covered unless
included as covered under the EOC. c
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I. Unusual Circumstances.
V
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 Q
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.
10 COB571-0036900
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4.D.a
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 L
information provided on the enrollment application,or for nonpayment of premiums. r
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III. Financial Responsibilities Q
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 o
date.Charges will be for the lesser of the Cost Shares for the Covered Service or the actual charge for that V
service. Cost Shares will not exceed the actual charge for that service.
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1. Annual Deductible.
Covered Services may be subject to an annual Deductible.Charges subject to the annual Deductible shall c
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 2
or has received Emergency services.
There is an individual annual Deductible amount for each Member and a maximum annual Deductible
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amount for each Family Unit.Once the annual Deductible amount is reached for a Family Unit in a M
calendar year,the individual annual Deductibles are also deemed reached for each Member during that
same calendar year. N
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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 E
individual annual Deductible.The individual annual Deductible carryover will apply only when expenses d
incurred have been paid in full.The Family Unit Deductible does not carry over into the next year. Q
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2. Plan Coinsurance. Y
After the applicable annual Deductible is satisfied,Members may be required to pay Plan Coinsurance for
Covered Services.
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3. Copayments. 0
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 Q
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.
11 COB571-0036900
Packet Pg. 24
4.D.a
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.
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4.D.a
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 N
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Coinsurance Plan Coinsurance:Member pays nothing '
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Lifetime Maximum No lifetime maximum on covered Essential Health Benefits
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Out-of-pocket Limit Limited to a maximum of$2,000 per Member or$4,000 per Family Unit per calendar year V
d
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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 0
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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
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benefit,charges in excess of Allowed Amount,charges for non-Covered Services M
N
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Pre-existing Condition No pre-existing condition waiting period N
Waiting Period c
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13 C 0 B 5 71-0036900
Packet Pg. 26
4.D.a
Acupuncture
Acupuncture needle treatment. Member pays$10 Copayment
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.
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Exclusions: Herbal supplements;any services not within the scope of the practitioner's licensure Q
3
Allergy Services
Allergy testing. Member pays$10 Copayment
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Allergy serum and injections. Member pays$10 Copayment c
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N
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Ambulance
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Emergency ambulance service is covered only when: Member pays 20%ambulance coinsurance
• Transport is to the nearest facility that can treat your LO
condition
• Any other type of transport would put your health or N
safety at risk c
• The service is from a licensed ambulance.
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Emergency air or sea medical transportation is covered only m
when: 4)
• The above requirements for ambulance service are Q
met,and
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• Geographic restraints prevent ground Emergency y
transportation to the nearest facility that can treat Y
your condition,or ground Emergency transportation
would put your health or safety at risk
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Q
Non-Emergency ground or air interfacility transfer to or from Member pays 20%ambulance coinsurance
a Network Facility when Preauthorized by KFHPWA.
Contact Member Services for Preauthorization.
Hospital-to-hospital ground transfers:No charge;
Member pays nothing
14 COB571-0036900
Packet Pg. 27
4.D.a
Cancer Screening and Diagnostic Services
Routine cancer screening covered as Preventive Services in Member pays$10 Copayment
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.
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Diagnostic laboratory and diagnostic services for cancer. See No charge;Member pays nothing `o
Diagnostic Laboratory and Radiology Services for additional
3
information. Preventive laboratory/radiology services are Q
covered as Preventive Services. '
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Circumcision
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Circumcision. Hospital-Inpatient:No charge;Member pays
nothing p
Non-Emergency inpatient hospital services require V
Preauthorization.
Hospital-Outpatient: Member pays$10 L
Copayment w
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Outpatient Services:Member pays$10 Copayment
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Clinical Trials c i
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Notwithstanding any other provision of this document,the Hospital-Inpatient: c
Plan provides benefits for Routine Patient Costs of qualified No charge;Member pays nothing N
individuals in approved clinical trials,to the extent benefits
for these costs are required by federal and state law. E
Hospital-Outpatient: CD
Routine patient costs include all items and services consistent Member pays$10 Copayment Q
with the coverage provided in the plan(or coverage)that is
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typically covered for a qualified individual who is not y_
enrolled in a clinical trial. Outpatient Services: M
Member pays$10 Copayment Y
Clinical trials are a phase I,phase II,phase III,or phase IV
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clinical trial that is conducted in relation to the prevention, E
detection,or treatment of cancer or other life-threatening 0
disease or condition."Life threatening condition"means any
disease or condition from which the likelihood of death is Q
probable unless the course of the disease or condition is
interrupted.
Clinical trials require Preauthorization.
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 used in the direct clinical
15 COB571-0036900
Packet Pg. 28
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) Not covered;Member pays 100%of all charges
including accidental injury to natural teeth.
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Dental services in preparation for treatment including but not Hospital-Inpatient:No charge;Member pays 0
limited to: chemotherapy,radiation therapy,and organ nothing 3
transplants.Dental services in preparation for treatment Q
require Preauthorization.
Hospital-Outpatient: Member pays$10 3
Dental problems such as infections requiring emergency Copayment
treatment outside of standard business hours are covered as
Emergency Services.
Outpatient Services:Member pays$10 Copayment
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General anesthesia services and related facility charges for Hospital-Inpatient:No charge;Member pays
dental procedures for Members who are under 7 years of age nothing L
or are physically or developmentally disabled or have a w
Medical Condition where the Member's health would be put
at risk if the dental procedure were performed in a dentist's Hospital-Outpatient: Member pays$10
office. Copayment V
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General anesthesia services for dental procedures require
Preauthorization.
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N
N
Exclusions: Dentist's or oral surgeon's fees;dental care,surgery,services and appliances,including:treatment of N
accidental injury to natural teeth,reconstructive surgery to the jaw in preparation for dental implants,dental implants, m
periodontal surgery;any other dental service not specifically listed as covered E
m
d
L
Devices,Equipment and Supplies(for home use) Q
m
A
• Durable medical equipment: Equipment which can Member pays 20%coinsurance Y
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. E
Durable medical equipment includes hospital beds,
wheelchairs,walkers,crutches,canes,blood glucose Annual Deductible does not apply to strip-based
monitors,external insulin pumps(including related blood glucose monitors,test strips,lancets or control Q
supplies such as tubing,syringe cartridges,cannulae and solutions.
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
16 COB571-0036900
Packet Pg. 29
4.D.a
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. N
L
• Sales tax for devices,equipment and supplies. 0
z
r
When provided in lieu of hospitalization,benefits will be the Q
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 M
Preauthorization.
0
c.�
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 M
listed as covered above; same as or similar equipment already in the Member's possession;replacement or repair due c
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 0
13
m
Diabetic Education,Equipment and Pharmacy SuppliesLn
T
M
Diabetic education and training. Member pays$10 Copayment N
N
O
N
C
Diabetic equipment:Blood glucose monitors and external Member pays 20%coinsurance E
insulin pumps(including related supplies such as tubing, i
syringe cartridges,cannulae and inserters),and therapeutic Q
shoes,modifications and shoe inserts for severe diabetic foot Annual Deductible does not apply to strip-based
disease. See Devices,Equipment and Supplies for additional blood glucose monitors,test strips,lancets or control y
information. solutions. M
Y
Diabetic pharmacy supplies: Insulin,lancets,lancet devices, Preferred generic drugs(Tier 1): Member pays
needles,insulin syringes,disposable insulin pens,pen $10 Copayment per 30-days up to a 90-day supply E
needles,glucagon emergency kits,prescriptive oral agents
and blood glucose test strips for a supply of 30 days or less Preferred brand name drugs(Tier 2): Member
per item.Certain brand name insulin drugs will be covered at pays$10 Copayment per 30-days up to a 90-day Q
the generic level. See Drugs—Outpatient Prescription for supply
additional pharmacy information.
Non-Preferred generic and brand name drugs
(Tier 3):Not covered;Member pays 100%of all
charges
17 COB571-0036900
Packet Pg. 30
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. N
L
0
Diabetic retinal screening. No charge;Member pays nothing E
Q
Dialysis(Home and Outpatient) m
c
Dialysis in an outpatient or home setting is covered for Outpatient Services: Member pays$10 Copayment W
Members with acute kidney failure or end-stage renal disease
(ESRD).
c
0
Dialysis requires Preauthorization. V
d
Injections administered by a Network Provider in a clinical Outpatient Services:Member pays$10 Copayment L
setting during dialysis. w
c
Self-administered injectables. See Drugs—Outpatient Preferred generic drugs(Tier 1): Member pays 2
Prescription for additional pharmacy information. $10 Copayment per 30-days up to a 90-day supply m
Preferred brand name drugs(Tier 2):Member
Ln
pays$10 Copayment per 30-days up to a 90-day M
supply N
N
Non-Preferred generic and brand name drugs N
(Tier 3):Not covered;Member pays 100%of all
charges E
m
d
L
Q
L
Drugs-Outpatient Prescription y
M
Y
Prescription drugs,supplies and devices for a supply of 30 Preferred generic drugs(Tier 1): Member pays };
days or less including diabetic pharmacy supplies(insulin, $10 Copayment per 30-days up to a 90-day supply m
lancets,lancet devices,needles,insulin syringes,disposable E
insulin pens,pen needles and blood glucose test strips), Preferred brand name drugs(Tier 2):Member 0
mental health and wellness drugs, self-administered pays$10 Copayment per 30-days up to a 90-day Q
injectables,medications for the treatment arising from sexual supply
assault,and routine costs for prescription medications
provided in a clinical trial."Routine costs"means items and Non-Preferred generic and brand name drugs
services delivered to the Member that are consistent with and (Tier 3):Not covered;Member pays 100%of all
typically covered by the plan or coverage for a Member who charges
is not enrolled in a clinical trial.
All drugs,supplies and devices must be obtained at a
18 COB571-0036900
Packet Pg. 31
KFHPWA-designated pharmacy except for drugs dispensed Annual Deductible does not apply to strip-based
for Emergency services or for Emergency services obtained blood glucose monitors,test strips,lancets or control
outside of the KFHPWA Service Area,including out of the solutions.
country.Information regarding KFHPWA-designated
pharmacies is reflected in the KFHPWA Provider Directory Note:A Member will not pay more than$100,not
or can be obtained by contacting Kaiser Permanente Member subject to the Deductible,for a 30-day supply of
Services. insulin to comply with state law requirements.Any
cost sharing paid will apply toward the annual
Prescription drug Cost Shares are payable at the time of Deductible.
delivery.Certain brand name insulin drugs are covered at the N
generic drug Cost Share. `o
z
r
Members may be eligible to receive an emergency fill for Q
certain prescription drugs filled outside of KFHPWA's '
business hours or when KFHPWA cannot reach the prescriber 3
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 i
eligible for emergency fills is available on the pharmacy c
website at www.kp.or,a/wa/formulary.Members can request V
an emergency fill by calling 1-855-505-8107. a)
c
Certain drugs are subject to Preauthorization as shown in the
Preferred drug list(formulary)available at
www.kp.org/wa/formulary.
M
V
Injections administered by a Network Provider in a clinical Member pays$10 Copayment
setting.
Ln
T
Over-the-counter drugs not included under Reproductive Not covered;Member pays 100%of all charges
Health N
0
N
Mail order drugs dispensed through the KFHPWA-designated Member pays the prescription drug Cost Share for
mail order service. each 30 day supply or less
E
m
d
L
Annual Deductible does not apply to strip-based Q
blood glucose monitors,test strips,lancets or control `m
solutions. y
M
Y
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. Q
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/formulM,or upon request from Member Services.
19 COB571-0036900
Packet Pg. 32
4.D.a
Members may request a coverage determination by contacting Member 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 N
improved efficacy or safety of the agent over standard therapies,or over placebo if no standard therapies exist;or by `o
the federal secretary of Health and Human Services)are covered. "Standard reference compendia"means the E
American Hospital Formulary Service—Drug Information;the American Medical Association Drug Evaluation;the Q
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 3
printed in health care journals or other publications in which original manuscripts are published only after having been c
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.
M
L
Generic drugs are dispensed whenever available.A generic drug is a drug that is the pharmaceutical equivalent to one c
or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting V
the same standards of safety,purity,strength and effectiveness as the brand name drug. Brand name drugs are a)
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. w
c
Drug coverage is subject to utilization management that includes Preauthorization,step therapy(when a Member tries 0
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 'n
T
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. N
0
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 E
be obtained through KFHPWA's preferred specialty pharmacy vendor and/or network of specialty pharmacies and are m
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/formulM or contact Member Q
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 Y
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 question
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.
Q
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 pharmacies serving them may call
the Washington State Department of Health at toll-free 1-800-525-0127.
20 COB 5 71-0036900
Packet Pg. 33
4.D.a
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, N
including most prescription vitamins;replacement of lost, stolen,or damaged drugs or devices;administration of `o
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; Q
prescription drugs/products available over-the-counter or have an over-the-counter alternative that is determined to be '
therapeutically interchangeable. 3
m
c
d
Emergency Services 0
M
L
Emergency services at a Network Facility or non-Network Network Facility: Member pays$75 Copayment c
Facility. See Section XII.for a definition of Emergency. V
d
Emergency services include professional services,treatment Non-Network Facility: Member pays$125 L
and supplies,facility costs,outpatient charges for patient Copayment w
observation and medical screening exams required to stabilize c
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.
Ln
M
If a Member is admitted as an inpatient directly from an
emergency department,any Emergency services Copayment N
is waived. Coverage is subject to the hospital services Cost N
Share.
m
E
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 Q
services Copayment. y
M
If a Member is hospitalized in a non-Network Facility, Y
KFHPWA reserves the right to require transfer of the
Member to a Network Facility upon consultation between a
E
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 Q
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.
21 COB571-0036900
Packet Pg. 34
4.D.a
Gender Health Services
Medically Necessary medical and surgical services for gender Hospital-Inpatient: No charge;Member pays
reassignment.Consultation and treatment requires nothing
Preauthorization.
Prescription drugs are covered the same as for any other Hospital-Outpatient: Member pays$10
condition(see Drugs-Outpatient Prescription for coverage). Copayment
d
N
Counseling services are covered the same as for any other `0
condition(see Mental Health and Wellness for coverage). Outpatient Services:Member pays$10 Copayment
3
Q
Non-Emergency inpatient hospital services require '
Preauthorization. 3
m
c
d
Exclusions: Cosmetic services and surgery not related to gender affirming treatment(i.e.,face lift or calf implants),
complications of non-Covered Services i
c
0
c.�
a�
Hearing Examinations and Hearing Aids
L
Hearing exams for hearing loss and evaluation are covered Hospital-Inpatient: c
only when provided at KFHPWA-approved facilities. No charge;Member pays nothing @
13
Cochlear implants or Bone Anchored Hearing Aids(BAHA)
when in accordance with KFHPWA clinical criteria. Hospital-Outpatient:
Member pays$10 Copayment
Covered services for cochlear implants and BAHA include M
diagnostic testing,pre-implant testing,implant surgery,post-
implant follow-up,speech therapy,programming and Outpatient Services: N
associated supplies(such as transmitter cable,and batteries). Member pays$10 Copayment N
c
m
E
Hearing aids including hearing aid examinations. Not covered;Member pays 100%of all charges
L
Q
L
Exclusions: Programs or treatments for hearing loss or hearing care including,but not limited to,externally worn y
hearing or surgically implanted hearing aids and the surgery and services necessary to implant them except as Y
described above;hearing screening tests required under Preventive Services
c
m
E
Home Health Care
Q
Home health care when the following criteria are met: No charge;Member pays nothing
• 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.
22 COB 5 71-0036900
Packet Pg. 35
4.D.a
• 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; N
durable medical equipment;medical social worker and z
limited home health aide services. 3
Q
Home health services are covered on an intermittent basis in
the Member's home. "Intermittent"means care that is to be 3
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 M
therapist,based on the complexity of the service and the o
condition of the patient and which is performed directly by an 0
appropriately licensed professional provider. 4)
c
Home health care requires Preauthorization.
N
C
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 0
13
m
Hospice
Ln
T
M
Hospice care when provided by a licensed hospice care No charge;Member pays nothing
program.A hospice care program is a coordinated program of c
home and inpatient care,available 24 hours a day. This N
program uses an interdisciplinary team of personnel to m
provide comfort and supportive services to a Member and any E
family members who are caring for the member,who is d
experiencing a life-threatening disease with a limited
prognosis. These services include acute,respite and home Q
care to meet the physical,psychosocial and special needs of y
the Member and their family during the final stages of illness. Y
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. Q
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
23 COB 5 71-0036900
Packet Pg. 36
4.D.a
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.
N
L
Exclusions: Private duty nursing;financial or legal counseling services;meal services;any services provided by z
family members 3
Q
3
Hospital-Inpatient and Outpatient �
c
d
The following inpatient medical and surgical services are Hospital-Inpatient:No charge;Member pays
covered: nothing
• Room and board,including private room when
prescribed,and general nursing services. V
• Hospital services(including use of operating room, Hospital-Outpatient: Member pays$10
anesthesia,oxygen,x-ray,laboratory and radiotherapy Copayment
services).
• Drugs and medications administered during confinement. w
• Medical implants.
c
• Withdrawal management services.
.a
Outpatient hospital includes ambulatory surgical centers.
Alternative care arrangements may be covered as a cost- T
effective alternative in lieu of otherwise covered Medically
Necessary hospitalization or other Medically Necessary N
institutional care with the consent of the Member and c
recommendation from the attending physician or licensed N
health care provider.Alternative care arrangements in lieu of
covered hospital or other institutional care must be m
determined to be appropriate and Medically Necessary based 0)
upon the Member's Medical Condition. Such care is covered Q
to the same extent the replaced Hospital Care is covered.
Alternative care arrangements require Preauthorization. y
M
Y
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 E
as soon thereafter as medically possible: acute withdrawal 0
management services,Emergency psychiatric services, Q
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.
24 COB 5 71-0036900
Packet Pg. 37
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)
d
General counseling and one consultation visit to diagnose Member pays$10 Copayment L
infertility conditions. z
r
Q
Specific diagnostic services,treatment and prescription drugs. Not covered;Member pays 100%of all charges
3
as
c
as
M
L
a
Infusion Therapy V
d
Administration of Medically Necessary infusion therapy in an Member pays$10 Copayment
outpatient setting.
N
C
Administration of Medically Necessary infusion therapy in No charge;Member pays nothing
the home setting.
To receive benefits for the administration of select infusion
medications in the home setting,the drugs must be obtained LO
through KFHPWA's preferred specialty pharmacy and
administered by a provider we identify. For a list of these N
specialty drugs or for more information about KFHPWA's c
specialty pharmacy network,please go to the KFHPWA N
website at www.kp.org/wa/formulary or contact Member
Services. E
m
d
L
Associated infused medications includes,but is not limited to: No charge;Member pays nothing
Q
• Antibiotics.
CD
• Hydration. y
M
• Chemotherapy. Y
• Pain management.
m
E
V
Laboratory and Radiology
Q
Nuclear medicine,radiology,ultrasound and laboratory No charge;Member pays nothing
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. Urine Drug Screening:No charge,Member pays
nothing. Limited to 2 tests per calendar year.
25 COB571-0036900
Packet Pg. 38
Services received as part of an emergency visit are covered as Benefits are applied in the order claims are received
Emergency Services. and processed.
Preventive laboratory and radiology services are covered in After Allowance:No charge;Member pays nothing
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.
d
N
L.
0
Manipulative Therapy 3
Q
Manipulative therapy of the spine and extremities when in Member pays$10 Copayment
accordance with KFHPWA clinical criteria,limited to a total
of 10 visits per calendar year.Preauthorization is not
required.
M
L
Exclusions: Supportive care rendered primarily to maintain the level of correction already achieved;care rendered r_
0
primarily for the convenience of the Member;care rendered on a non-acute,asymptomatic basis;charges for any other V
services that do not meet KFHPWA clinical criteria as Medically Necessary
c
0
L
N
Maternity and Pregnancy
Maternity care and pregnancy services,including care for Hospital-Inpatient:No charge;Member pays .a
complications of pregnancy and prenatal and postpartum care nothing
are covered for all female Members including dependent
daughters. Ln
Hospital-Outpatient: Member pays$10 c i
Delivery and associated Hospital Care,including home births Copayment N
and birthing centers.Home births are considered outpatient c
services. N
Outpatient Services:Member pays$10 Copayment
m
Members must notify KFHPWA by way of the Hospital E
notification line within 24 hours of any admission,or as soon i
thereafter as medically possible. The Member's physician,in Q
consultation with the Member,will determine the Member's L
length of inpatient stay following delivery. y
M
Prenatal testing for the detection of congenital and heritable `1
disorders when Medically Necessary as determined by
KFHPWA's medical director and in accordance with Board E
of Health standards for screening and diagnostic tests during 0
pregnancy.
Q
Termination of pregnancy. Hospital-Inpatient:No charge;Member pays
nothing
Non-Emergency inpatient hospital services require
Preauthorization.
Hospital-Outpatient: Member pays$10
Copayment
26 COB 5 71-0036900
Packet Pg. 39
Outpatient Services:Member pays$10 Copayment
Exclusions: Birthing tubs;genetic testing of non-Members;fetal ultrasound in the absence of medical indications
d
Mental Health and Wellness N
L
O
Mental health and wellness services provided at the most Hospital-Inpatient:No charge;Member pays 3
clinically appropriate and Medically Necessary level of nothing Q
mental health care intervention as determined by KFHPWA's
medical director.Treatment may utilize psychiatric, 3
psychological and/or psychotherapy services to achieve these Hospital-Outpatient: Member pays$10
objectives. Copayment
Mental health and wellness services including medical
management and prescriptions are covered the same as for Outpatient Services:Member pays$10 Copayment c
any other condition. V
d
Applied behavioral analysis(ABA)therapy,limited to L
outpatient treatment of an autism spectrum disorder or,has a Group Visits:No charge;Member pays nothing w
developmental disability for which there is evidence that
ABA therapy is effective,as diagnosed and prescribed by a
neurologist,pediatric neurologist,developmental pediatrician, .2
psychologist or psychiatrist experienced in the diagnosis and
treatment of autism.Documented diagnostic assessments,
individualized treatment plans and progress evaluations areLn
required. M
Services for any involuntary court-ordered treatment program c
shall be covered only if determined to be Medically N
Necessary by KFHPWA's medical director. Services
provided under involuntary commitment statutes are covered. E
m
d
If a Member is admitted as an inpatient directly from an
emergency department,any Emergency services Copayment Q
is waived. Coverage is subject to the hospital services Cost y
Share.Coverage for services incurred at non-Network Y
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 E
notification line within 24 hours of any admission,or as soon 0
thereafter as medically possible.
Q
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
27 COB 5 71-0036900
Packet Pg. 40
4.D.a
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 N
specifically for the treatment of mental disorders. `o
z
r
Non-Emergency inpatient and outpatient hospital services, <
Q
including Residential Treatment and partial hospitalization '
programs,require Preauthorization. 3
m
c
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 M
Medically Necessary;counseling for overeating not considered Medically Necessary;specialty treatment programs o
such as"behavior modification programs"not considered Medically Necessary;relationship counseling or phase of V
life problems(Z code only diagnoses);custodial care;experimental or investigational therapies,such as wilderness 4)
therapy.
L
N
C
Naturopathy
Naturopathy. Member pays$10 Copayment
Limited to 3 visits per medical diagnosis per calendar year
Ln
without Preauthorization.Additional visits are covered with r
M
Preauthorization.
N
N
Laboratory and radiology services are covered only when N
obtained through a Network Facility.
m
E
Exclusions: Herbal supplements;nutritional supplements;any services not within the scope of the practitioner's
d
licensure
Q
L
m
A
Newborn Services M
Y
Newborn services are covered the same as for any other Hospital-Inpatient: No charge;Member pays
condition.Any Cost Share for newborn services is separate nothing E
from that of the mother. 0
Preventive services for newborns are covered under During the baby's initial hospital stay while the birth Q
Preventive Services. mother and baby are both confined,any applicable
Deductible and Copayment for the newborn are
See Section VI.A.3.for information about temporary waived
coverage for newborns.
Hospital-Outpatient: Member pays$10
Copayment
28 COB571-0036900
Packet Pg. 41
4.D.a
Outpatient Services: Member pays$10 Copayment
Nutritional Counseling
Nutritional counseling. Member pays$10 Copayment
N
L
Services related to a healthy diet to prevent obesity are G
z
covered as Preventive Services. 3
Q
Exclusions:Nutritional supplements;weight control self-help programs or memberships,such as Weight Watchers,
Jenny Craig,or other such programs
c
d
Nutritional Therapy
L
Medical formula necessary for the treatment of No charge;Member pays nothing V
phenylketonuria(PKU),specified inborn errors of
d
metabolism,or other metabolic disorders.
c
L
Enteral therapy is covered when Medical Necessity criteria is Member pays 20%coinsurance w
met and when given through a PEG,J tube or orally,or for an
eosinophilic gastrointestinal disorder.
.a
Necessary equipment and supplies for the administration of
enteral therapy are covered as Devices,Equipment and
Supplies. Ln
T
M
Parenteral therapy(total parenteral nutrition). No charge;Member pays nothing N
N
O
Necessary equipment and supplies for the administration of N
parenteral therapy are covered as Devices,Equipment and
Supplies. m
d
L
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 Q
foods/meals v�i
M
Y
c
Obesity Related Services
Bariatric surgery and related hospitalizations when KFHPWA Hospital-Inpatient:No charge;Member pays
criteria are met. nothing Q
Services related to obesity screening and counseling are
covered as Preventive Services. Hospital-Outpatient: Member pays$10
Copayment
Obesity related services require Preauthorization.
Outpatient Services:Member pays$10 Copayment
29 COB 5 71-0036900
Packet Pg. 42
4.D.a
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 programs;medications and
related physician visits for medication monitoring
On the Job Injuries or Illnesses
d
On the job injuries or illnesses. Hospital-Inpatient:Not covered;Member pays L
100%of all charges 0
r
Q
Hospital-Outpatient:Not covered;Member pays
100%of all charges
c
d
Outpatient Services:Not covered;Member pays
100%of all charges M
c
0
c.�
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 L
N
C
Oncology
m
Radiation therapy,chemotherapy,oral chemotherapy. Radiation Therapy and Chemotherapy:
Member pays$10 Copayment Ln
See Infusion Therapy for infused medications.
N
N
O
Oral Chemotherapy Drugs: N
Preferred generic drugs(Tier 1): Member pays
m
$10 Copayment per 30-days up to a 90-day supply E
d
L
Preferred brand name drugs(Tier 2): Member Q
pays$10 Copayment per 30-days up to a 90-day L
supply y
M
Non-Preferred generic and brand name drugs `1
(Tier 3):Not covered;Member pays 100%of all
charges E
M
W
Q
Optical(vision)
Routine eye examinations and refractions,limited to once Routine Exams: Member pays$10 Copayment
every 12 months.
Eye and contact lens examinations for eye pathology and to Exams for Eye Pathology: Member pays$10
monitor Medical Conditions,as often as Medically Copayment
30 COB571-0036900
Packet Pg. 43
Necessary.
Contact lenses or framed lenses for eye pathology when Frames and Lenses: Not covered;Member pays
Medically Necessary. 100%of all charges
One contact lens per diseased eye in lieu of an intraocular
lens is covered following cataract surgery provided the Contact Lenses or Framed Lenses for Eye
Member has been continuously covered by KFHPWA since Pathology: No charge;Member pays nothing
such surgery.In the event a Member's age or medical N
condition prevents the Member from having an intraocular `o
lens or contact lens,framed lenses are available.Replacement
of lenses for eye pathology,including following cataract Q
surgery,is covered only once within a 12-month period and '
only when needed due to a change in the Member's 3
m
prescription. �
d
M
L
Exclusions:Eyeglasses;contact lenses,contact lens evaluations,fittings and examinations not related to eye o
pathology;orthoptic therapy(i.e. eye training);evaluations and surgical procedures to correct refractions not related 0
to eye pathology and complications related to such procedures 4)
c
L
N
C
Oral Surgery
.a
Reduction of a fracture or dislocation of the jaw or facial Hospital-Inpatient:No charge;Member pays m
bones;excision of tumors or non-dental cysts of the jaw, nothing
cheeks,lips,tongue,gums,roof and floor of the mouth;and
Ln
incision of salivary glands and ducts. M
Hospital-Outpatient: Member pays$10
KFHPWA's medical director will determine whether the care Copayment c
or treatment required is within the category of Oral Surgery or N
Dental Services. c
Outpatient Services:Member pays$10 Copayment E
Oral surgery requires Preauthorization. d
L
Q
L
Exclusions: Care or repair of teeth or dental structures of any type;tooth extractions or impacted teeth; services y
related to malocclusion; services to correct the misalignment or malposition of teeth; any other services to the mouth, Y
facial bones or teeth which are not medical in nature
c
m
E
Outpatient Services 0
W
Covered outpatient medical and surgical services in a Member pays$10 Copayment Q
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
31 COB571-0036900
Packet Pg. 44
4.D.a
centers.
Plastic and Reconstructive Surgery
Plastic and reconstructive services: Hospital-Inpatient:No charge;Member pays
• Correction of a congenital disease or congenital anomaly. nothing
• 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 of Hospital-Outpatient: Member pays$10 L
KFHPWA's medical director such services can Copayment G
z
reasonably be expected to correct the condition. Q
• Reconstructive surgery and associated procedures, ,
including internal breast prostheses,following a Outpatient Services:Member pays$10 Copayment
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 0
mastectomy services,including lymphedemas,are
covered. c
V
Plastic and reconstructive surgery requires Preauthorization.
L
Exclusions: Cosmetic services including treatment for complications resulting from cosmetic surgery;cosmetic w
surgery;complications of non-Covered Services
.a
Podiatry 2
Medically Necessary foot care. Member pays$10 Copayment T
M
Routine foot care covered when such care is directly related N
to the treatment of diabetes and,when approved by c
KFHPWA's medical director,other clinical conditions that
effect sensation and circulation to the feet.
m
E
a)
Exclusions:All other routine foot care 0)
a�
Q
L
m
Preventive Services y
M
Y
Preventive services in accordance with the well care schedule Member pays$10 Copayment
established by KFHPWA.The well care schedule is available m
in Kaiser Permanente medical centers,at www.kp.org/wa,or
upon request from Member Services. 0
Q
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.
32 COB571-0036900
Packet Pg. 45
4.D.a
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.
d
N
Preventive services include,but are not limited to,well adult `o
and well child physical examinations;immunizations and
vaccinations;pap smears;routine mammography screening; <
Q
routine prostate screening;and colorectal cancer screening for '
Members who are age 50 or older or who are under age 50 3
and at high risk. c
d
Preventive care for chronic disease management includes
treatment plans with regular monitoring,coordination of care i
between multiple providers and settings,medication c
management,evidence-based care,quality of care V
measurement and results,and education and tools for patient 4)
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 w
c
services without Cost Share when Preauthorized.
M
V
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. r
M
Exclusions: Those parts of an examination and associated reports and immunizations that are not deemed Medically N
Necessary by KFHPWA for early detection of disease; all other diagnostic services not otherwise stated above N
c
m
Rehabilitation and Habilitative Care(massage,
occupational,physical and speech therapy,pulmonary
and cardiac rehabilitation)and Neurodevelopmental Q
Therapy y
M
Rehabilitation services to restore function following illness, Hospital-Inpatient:No charge;Member pays Y
injury or surgery,limited to the following restorative nothing
therapies: occupational therapy,physical therapy,massage
E
therapy and speech therapy. Services are limited to those
necessary to restore or improve functional abilities when Outpatient Services:Member pays$10 Copayment
physical,sensori-perceptual and/or communication Q
impairment exists due to injury,illness or surgery.
Outpatient services require a prescription or order from a Group visits(occupational,physical,speech
physician that reflects a written plan of care to restore therapy or learning services):
function and must be provided by a rehabilitation team that Member pays one half of the office visit Copayment
may include a physician,nurse,physical therapist, and applicable Plan Coinsurance
occupational therapist,massage therapist or speech therapist.
33 COB571-0036900
Packet Pg. 46
4.D.a
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 N
disabilities in a variety of inpatient and/or outpatient settings. `o
z
r
Neurodevelopmental therapy to restore or improve function Q
including maintenance in cases where significant '
deterioration in the Member's condition would result without 3
the services,limited to the following therapies: occupational
therapy,physical therapy and speech therapy.There is no
visit limit for Neurodevelopmental Therapy services.
M
L
Limited to a combined total of 60 inpatient days and 60 p
outpatient visits per calendar year for all Rehabilitation and V
Habilitative care.
c
L
Services with mental health diagnoses are covered with no
N
limit.
C
Non-Emergency inpatient hospital services require 2
13
Preauthorization. m
Cardiac rehabilitation is covered up to a total of 36 visits per Member pays$10 CopaymentLO
cardiac event when clinical criteria is met. M
N
N
O
Group visits(occupational,physical,speech N
Limited to a combined total of 60 inpatient days and 60 therapy or learning services):
outpatient visits per calendar year for all Rehabilitation and Member pays one half of the office visit Copayment m
Habilitative care. and applicable Plan Coinsurance i
a�
Q
L
m
A
Pulmonary rehabilitation is covered when clinical criteria is Member pays$10 Copayment M
Y
met.
c
m
Preauthorization is required after initial visit. E
Group visits(occupational,physical,speech
therapy or learning services): Q
Limited to a combined total of 60 inpatient days and 60 Member pays one half of the office visit Copayment
outpatient visits per calendar year for all Rehabilitation and and applicable Plan Coinsurance
Habilitative care.
Exclusions: Specialty treatment programs;inpatient Residential Treatment services;specialty rehabilitation programs
including"behavior modification programs";recreational,life-enhancing,relaxation or palliative therapy;
34 COB571-0036900
Packet Pg. 47
4.D.a
implementation of home maintenance programs
Reproductive Health
Medically Necessary medical and surgical services for Hospital-Inpatient:No charge;Member pays
reproductive health,including consultations,examinations, nothing
procedures and devices,including device insertion and
removal. Hospital-Outpatient:No charge;Member pays
nothing L
See Maternity and Pregnancy for termination of pregnancy G
z
services Outpatient Services:No charge;Member pays 3
nothing Q
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. 0
M
L
All methods for Medically Necessary FDA-approved No charge;Member pays nothing c
(including over-the-counter)contraceptive drugs,devices and V
products. Condoms are limited to 120 per 90-day supply.
c
Contraceptive drugs may be allowed up to a 12-month supply w
and,when available,picked up in the provider's office. c
.a
m
Sexual Dysfunction
Ln
One consultation visit to diagnose sexual dysfunction Member pays$10 Copayment
conditions.
N
N
O
N
++
Specific diagnostic services,treatment and prescription drugs. Not covered;Member pays 100%of all charges
E
Exclusions: Diagnostic testing and medical treatment of sexual dysfunction regardless of origin or cause;devices, i
equipment and supplies for the treatment of sexual dysfunction 0
Q
L
m
A
Skilled Nursing Facility Y
Skilled nursing care in a skilled nursing facility when full- No charge;Member pays nothing
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. Q
Care may include room and board;general nursing care;
drugs,biologicals,supplies and equipment ordinarily
provided or arranged by a skilled nursing facility;and short-
term restorative occupational therapy,physical therapy and
speech therapy.
Skilled nursing care in a skilled nursing facility requires
35 COB571-0036900
Packet Pg. 48
4.D.a
Preauthorization.
Exclusions: Personal comfort items such as telephone and television;rest cures;domiciliary or Convalescent Care
Sterilization
FDA-approved female sterilization procedures,services and No charge;Member pays nothing
supplies.
N
•L
Non-Emergency inpatient hospital services require 0
Preauthorization. 3
Q
Vasectomy. No charge;Member pays nothing
3
Non-Emergency inpatient hospital services require
Preauthorization.
Exclusions: Procedures and services to reverse a sterilization
c
0
c.�
a�
Substance Use Disorder
c
0
L
Substance use disorder services including inpatient Hospital-Inpatient:No charge;Member pays w
Residential Treatment;diagnostic evaluation and education; nothing r_
organized individual and group counseling;and/or
prescription drugs unless excluded under Sections IV.or V. .a
Outpatient Services:Member pays$10 Copayment
Substance use disorder means a substance-related or addictive
disorder listed in the most current version of the Diagnostic Ln
and Statistical Manual of Mental Disorders(DSM).For the
purposes of this section,the definition of Medically Group Visits:No charge;Member pays nothing N
Necessary shall be expanded to include those services c
necessary to treat a substance use disorder condition that is N
having a clinically significant impact on a Member's
emotional,social,medical and/or occupational functioning. m
d
L
Substance use disorder services are limited to the services
rendered by a physician(licensed under RCW 18.71 and Q
RCW 18.57),a psychologist(licensed under RCW 18.83),a v0i
substance use disorder treatment program licensed for the M
Y
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 E
advance practice psychiatric nurse(licensed under RCW 0
18.79)or,in the case of non-Washington State providers, Q
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.
36 COB571-0036900
Packet Pg. 49
4.D.a
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. N
L
0
Preauthorization is not required for Residential Treatment and z
non-Emergency inpatient hospital services provided in-state. Q
Member is given two days of treatment and is then subject to '
medical necessity review for continued care.Member or 3
facility must notify KFHPWA within 24 hours of admission, c
or as soon as possible.Member may request prior
authorization for Residential Treatment and non-Emergency
inpatient hospital services.Members may contact Member i
Services to request Preauthorization. c
0
c.�
a�
Withdrawal Management Services for Alcoholism and Emergency Services Network Facility: Member
Substance Use Disorder. pays$75 Copayment
N
C
Withdrawal management services means the management of
symptoms and complications of alcohol and/or substance Emergency Services Non-Network Facility: 0
withdrawal. The severity of symptoms designates the Member pays$125 Copayment
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 'n
T
nothing
Outpatient withdrawal management services means the N
symptoms resulting from abstinence are of mild/moderate N
severity and withdrawal from alcohol and/or other drugs can c
be managed with medication at an outpatient level of care by
an appropriately licensed clinician. Subacute withdrawal m
management means symptoms associated with withdrawal
from alcohol and/or other drugs can be managed through Q
medical monitoring at a 24-hour facility or other outpatient
facility. y
M
Y
Preauthorization is required for outpatient withdrawal
management and subacute withdrawal management services. E
"Acute withdrawal management services"means the 0
symptoms resulting from abstinence are so severe that Q
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
37 COB571-0036900
Packet Pg. 50
4.D.a
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 N
treatment;and no less than three days in a behavioral health `o
agency that provides withdrawal management services prior E
to conducting a medical necessity review for continued care. Q
Member or facility must notify KFHPWA within 24 hours of '
admission,or as soon as possible.Members may request 3
Preauthorization for Residential Treatment and non- m
c
Emergency inpatient hospital services by contacting Member
Services.
M
L
KFHPWA reserves the right to require transfer of the c
Member to a Network Facility/program upon consultation V
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 0
treatment programs which are not certified by the Department of Social Health Services 3
Telehealth Services r
M
Telemedicine No charge;Member pays nothing N
Services provided by the use of real-time interactive audio N
and video communications or store and forward technology
between the patient at the originating site and a Network
E
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 Q
review. The provider follows up with a medical diagnosis for y
the Member and helps manage their care. Services must meet M
the following requirements: Y
• Be a Covered Service under this EOC. c
m
• The originating site is qualified to provide the E
service.
• If the service is provided through store and forward
technology,there must be an associated office visit Q
between the Member and the referring provider.
• Is Medically Necessary.
Telephone Services and Online(E-Visits) No charge;Member pays nothing
Scheduled telephone visits with a Network Provider are
covered.
38 COB571-0036900
Packet Pg. 51
4.D.a
Online(E-Visits):A Member logs into the secure Member
site at www.kp.ore/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
hlt2s://wa.kaisep2ermanente.oriz/html/public/services/e-visit.
d
N
L
Exclusions: Fax and e-mail;telehealth services with non-contracted providers;telehealth services in states where z
prohibited by law;all other services not listed above Q
Temporomandibular Joint(TMJ) m
c
d
Medical and surgical services and related hospital charges for Hospital-Inpatient:No charge;Member pays
the treatment of temporomandibular joint(TMJ)disorders nothing
including:
• Medically Necessary orthognathic procedures for the C
treatment of severe TMJ disorders which have failed Hospital-Outpatient: Member pays$10
non-surgical intervention. Copayment
L
• Radiology services. �
• TMJ specialist services.
• Fitting/adjustment of splints. Outpatient Services:Member pays$10 Copayment —
Non-Emergency inpatient hospital services require
Preauthorization.
TMJ appliances. See Devices,Equipment and Supplies for Member pays 20%coinsurance r
additional information.
N
N
O
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 E
m
d
L
Q
Tobacco Cessation
M
Individual/group counseling and educational materials. No charge;Member pays nothing Y
c
Approved pharmacy products. See Drugs—Outpatient KFHPWA-designated tobacco cessation program:
Prescription for additional pharmacy information. No charge;Member pays nothing when prescribed as
part of the KFHPWA-designated tobacco cessation c�a
program and dispensed through the KFHPWA- Q
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
39 COB571-0036900
Packet Pg. 52
4.D.a
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
d
Transplants N
L
O
Transplant services,including heart,heart-lung,single lung, Hospital-Inpatient:No charge;Member pays 3
double lung,kidney,pancreas,cornea,intestinal/multi- nothing Q
visceral,liver transplants,and bone marrow and stem cell
support(obtained from allogeneic or autologous peripheral 3
blood or marrow)with associated high dose chemotherapy. Hospital-Outpatient: Member pays$10
Copayment
Services are limited to the following:
L
• Inpatient and outpatient medical expenses for evaluation +,
testing to determine recipient candidacy,donor matching Outpatient Services:Member pays$10 Copayment c
tests,hospital charges,procurement center fees, V
professional fees,travel costs for a surgical team and
excision fees.Donor costs for a covered organ recipient L
are limited to procurement center fees,travel costs for a w
surgical team and excision fees. c
• Follow-up services for specialty visits.
• Rehospitalization. :a
• Maintenance medications during an inpatient stay.
Transplant services must be provided through locally andLn
nationally contracted or approved transplant centers. All M
transplant services require Preauthorization. Contact Member 04
Services for Preauthorization. c
N
++
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 E
m
d
L
Q
Urgent Care
Inside the KFHPWA Service Area,urgent care is covered at a Network Emergency Department: Member pays Y
Kaiser Permanente medical center,Kaiser Permanente urgent $75 Copayment +�
care center or Network Provider's office.
E
Outside the KFHPWA Service Area,urgent care is covered at Network Urgent Care Center: Member pays$10
any medical facility. Copayment Q
See Section XII.for a definition of Urgent Condition.
Network Provider's Office: Member pays$10
Copayment
40 COB 5 71-0036900
Packet Pg. 53
4.D.a
Non-Network Provider: Member pays$125
Copayment
V. General Exclusions a
In addition to exclusions listed throughout the EOC,the following are not covered:
d
1. Benefits and related services,supplies and drugs that are not Medically Necessary for the treatment of an o
illness,injury,or physical disability,that are not specifically listed as covered in the EOC,except as required by r
federal or state law. 3
Q
2. Services Related to a Non-Covered Service: When a service is not covered,all services related to the non- 3
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 V
shall not be covered.
d
c
3. Services or supplies for which no charge is made,or for which a charge would 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 w
member,or self-care.
4. Convalescent Care. .a
m
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 ,LO
medical coverage,medical"no fault"coverage,personal injury protection coverage or similar medical coverage c i
contained in said policy.For the purpose of this exclusion,benefits shall be deemed to be"available"to the N
Member if the Member receives benefits under the policy either as a named insured or as an insured individual c
under the policy definition of insured. N
c
m
6. Services or care needed for injuries or conditions resulting from active or reserve military service,whether such E
injuries or conditions result from war or otherwise.This exclusion will not apply to conditions or injuries i
resulting from previous military service unless the condition has been determined by the U.S. Secretary of 0
Veterans Affairs to be a condition or injury incurred during a period of active duty.Further,this exclusion will Q
not be interpreted to interfere with or preclude coordination of benefits under Tri-Care. y
M
7. Services provided by government agencies, except as required by federal or state law. `1
c
m
8. Services covered by the national health plan of any other country. E
V
9. Experimental or investigational services.
Q
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.
41 COB571-0036900
Packet Pg. 54
4.D.a
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 11 clinical trial,as the experimental 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 service is being evaluated for its
safety,toxicity or efficacy.
7) The prevailing opinion among experts,as expressed in the published authoritative medical or scientific L
literature,is that(1)the use of such service should be substantially confined to research settings,or(2) 0
further research is necessary to determine the safety,toxicity or efficacy of the service. 3
Q
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. C
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. C
0
4) The files and records of the Institutional Review Board(IRB)or similar body that approves or reviews V
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. L
5) The published authoritative medical or scientific literature regarding the service,as applied to the to
illness or injury. c
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 2
state agency performing similar functions.
Appeals regarding KFHPWA denial of coverage can be submitted to the Member Appeal Department,or to
Ln
KFHPWA's medical director at P.O.Box 34593, Seattle,WA 98124-1593. M
10. Hypnotherapy and all services related to hypnotherapy. N
0
N
11. Directed umbilical cord blood donations. c
m
E
12. Prognostic(predictive)genetic testing and related services,unless specifically provided in Section IV.Testing
for non-Members.
Q
13. Autopsy and associated expenses. y
M
VI. Eligibility,Enrollment and Termination Y
c
A. Eligibility. E
E
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 Q
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.
42 COB 5 71-0036900
Packet Pg. 55
4.D.a
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.
d
N
"Children"means the children of the Subscriber,spouse or eligible domestic partner,including adopted o
children,stepchildren,children for whom the Subscriber has a qualified court order to provide r
coverage and any other children for whom the Subscriber is the legal guardian. 3
Q
Eligibility may be extended past the Dependent's limiting age as set forth above if the Dependent is 0)
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 i
continuous total incapacity,provided enrollment does not terminate for any other reason.Medical
proof of incapacity and proof of financial dependency must be furnished to KFHPWA upon request, C
V
but not more frequently than annually after the 2-year period following the Dependent's attainment of
the limiting age. c
L
3
N
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 Subsections F.and G.After 3
weeks of age,no benefits are available unless the newborn child qualifies as a Dependent and is enrolled. g
B. Application for Enrollment. T
Application for enrollment must be made on an application approved by KFHPWA.The Group is responsible n
for submitting completed applications to KFHPWA. N
N
O
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. E
m
d
L
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. y
M
Y
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 Q
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.
43 COB 5 71-0036900
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4.D.a
When there is no change in the monthly premium 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.
d
a. KFHPWA will allow special enrollment for persons: L
1) Who initially declined enrollment when otherwise eligible because such persons had other health z
care coverage and have had such other coverage terminated due to one of the following events: 3
• Cessation of employer contributions. Q
• Exhaustion of COBRA continuation coverage. 3
• 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.
L
KFHPWA or the Group may require confirmation that when initially offered coverage such persons o
submitted a written statement declining because of other coverage.Application for coverage must be V
made within 31 days of the termination of previous coverage. c
L
b. KFHPWA will allow special enrollment for individuals who are eligible to be a Subscriber and their w
Dependents(other than for nonpayment or fraud)in the event one of the following occurs: r-
1) Divorce or Legal Separation.Application for coverage must be made within 60 days of the
divorce/separation. :a
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 coverageLn
must be made within 30 days of the death of an employee. M
4) Termination or reduction in the number of hours worked.Application for coverage must be made N
within 30 days of the termination or reduction in number of hours worked. c
5) Leaving the service area of a former plan.Application for coverage must be made within 30 days N
of leaving the service area of a former plan.
6) Discontinuation of a former plan.Application for coverage must be made within 30 days of the E
discontinuation of a former plan.
L
c. KFHPWA will allow special enrollment for individuals who are eligible to be a Subscriber and their Q
Dependents in the event one of the following occurs: y
1) Marriage.Application for coverage must be made within 31 days of the date of marriage. Y
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 Q
(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.
44 COB 5 71-0036900
Packet Pg. 57
4.D.a
C. When Coverage Begins.
1. Effective Date of Enrollment.
• Enrollment for a newly eligible Subscriber and listed Dependents is effective 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 1 S`
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. d
• Enrollment for adoptive children is effective from the date that the adoptive child is placed with the L.
Subscriber for the purpose of adoption or the Subscriber assumes total or partial financial support of r
the child.
Q
2. Commencement of Benefits for Persons Hospitalized on Effective Date. 3
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 Member 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. V
d
D. Eligibility for Medicare. V
c
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 w
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' ,LO
ineligibility for Medicare Advantage coverage under the Group,as well as providing a prospective notice to its M
Members alerting them of the termination event.In the event the Group does not obtain Medicare Advantage N
coverage,the loss of Medicare drug coverage,other coverage options that may be available to the Member,and N
0
the possibility of late enrollment penalties if the Member does not apply for Medicare coverage within the N
required timeframe will also need to be provided.
m
E
E. Termination of Coverage. d
The Subscriber shall be liable for payment of all charges for services and items provided to the Subscriber and Q
all Dependents after the effective date of termination.
m
A
Termination of Specific Members. M
Individual Member coverage may be terminated for any of the following reasons:
Y
c
m
a. Loss of Eligibility.If a Member no longer meets the eligibility requirements and is not enrolled for E
continuation coverage as described in Subsection G.below,coverage will terminate at the end of the 0
month during which the loss of eligibility occurs,unless otherwise specified by the Group. Q
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.
45 COB571-0036900
Packet Pg. 58
4.D.a
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 forth in the EOC.
N
L
Any Member may appeal a termination decision through KFHPWA's appeals process. z
r
F. Continuation of Inpatient Services. Q
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 c
calendar year begins. V
• The Member becomes covered under another agreement with a group health plan that provides benefits for
the hospitalization. L
• The Member becomes enrolled under an agreement with another carrier that provides benefits for the w
hospitalization.
1a
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.
Ln
G. Continuation of Coverage Options. M
N
1. Continuation Option. N
0
A Member no longer eligible for coverage(except in the event of termination for cause,as set forth in N
Subsection E.)may continue coverage for a period of up to 3 months subject to notification to and self-
payment of premiums to the Group.This provision will not apply if the Member is eligible for the E
continuation coverage provisions of the Consolidated Omnibus Budget Reconciliation Act of 1985 i
(COBRA).This continuation option is not available if the Group no longer has active employees or Q
otherwise terminates.
m
2. Leave of Absence. Y
While on a Group approved leave of absence,the Subscriber and listed Dependents can continue to be
covered provided that: m
• They remain eligible for coverage,as set forth in Subsection A., E
• Such leave is in compliance with the Group's established leave of absence policy that is consistently
applied to all employees, Q
• The Group's leave of absence policy is in compliance with the Family and Medical Leave Act when
applicable,and
• The Group continues to remit premiums for the Subscriber and Dependents to KFHPWA.
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 directly
46 COB 5 71-0036900
Packet Pg. 59
4.D.a
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 to 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 Subscriber of their rights of self-payment
under this provision.
d
4. Continuation Coverage Under Federal Law. L
This section applies only to Groups who must offer continuation coverage under the applicable provisions z
of the Consolidated Omnibus Budget Reconciliation Act of 1985(COBRA),as amended,or the Uniformed 3
Services Employment and Reemployment Rights Act(USERRA)and only applies to grant continuation of Q
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.
c
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 W
Group. p
V
Continuation coverage under COBRA or USERRA will terminate when a Member becomes covered by 0
Medicare or obtains other group coverage,and as set forth under Subsection E. L
5. KFHPWA Group Conversion Plan. c
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 eligible for Medicare or covered by another 2
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 conversion plan.Coverage will be
Ln
retroactive to the date of loss of eligibility. M
An application for conversion must be made within 31 days following termination of coverage or within 31 N
days from the date notice of the termination of coverage is received,whichever is later.A physical N
examination or statement of health is not required for enrollment in a KFHPWA group conversion plan.
m
E
Persons wishing to purchase KFHPWA's individual and family coverage should contact KFHPWA. d
L
Q
"ievances y
M
Grievance means a written or verbal complaint submitted by or on behalf of a covered person regarding service Y
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
E
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 Q
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
47 COB 5 71-0036900
Packet Pg. 60
4.D.a
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.
_ Appeals
d
Members are entitled to appeal through the appeals process if/when coverage for an item or service is denied due to L
an adverse determination made by the KFHPWA medical director. The appeals process is available for a Member to z
seek reconsideration of an adverse benefit determination(action).Adverse benefit determination(action)means any 3
of the following:a denial,reduction,or termination of,or a failure to provide or make payment(in whole or in part) Q
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 m
termination of,or a failure to provide or make payment,in whole or in part,for a benefit resulting from the d
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 c
mental disabilities that impede their ability to request review or participate in the review process.The most current V
information about your appeals process is available by contacting KFHPWA's Member Appeal Department at the
address or telephone number below. L
1. Initial Appeal c
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
Ln
should be directed to KFHPWA's Member Appeal Department,P.O.Box 34593, Seattle,WA 98124-1593,toll- M
free 1-866-458-5479.
N
N
A party not involved in the initial coverage determination and not a subordinate of the party making the initial N
coverage determination will review the appeal request. KFHPWA will then notify the Member of its c
determination or need for an extension of time within 14 days of receiving the request for appeal.Under no m
E
circumstances will the review timeframe exceed 30 days without the Member's written permission. d
L
For appeals involving experimental or investigational services KFHPWA will make a decision and Q
communicate the decision to the Member in writing within 20 days of receipt of the appeal. y
M
There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using the Y
standard appeal review process will seriously jeopardize the Member's life,health or ability to regain maximum c
CD
function or subject the Member to severe pain that cannot be managed adequately without the requested care or E
E
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 Q
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.
48 COB571-0036900
Packet Pg. 61
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, L
Consumer Protection Division,P.O.Box 40256,Olympia,WA 98504-0256 or at toll-free 1-800-562-6900. z
More information about requesting assistance from the Consumer Protection Division Office can be found at 3
hllp://www.insurance.wa.jzov/your-insurance/health-insurance/appeal/. Q
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 W
controlled by KFHPWA.KFHPWA will notify the Member of the name of the external independent review c
organization and its contact information. The external independent review organization will accept additional V
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 L
independent review organization,the decision is final and cannot be appealed through KFHPWA. w
c
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 2
KFHPWA determination stands,the Member may be responsible for the cost of coverage received during the
review period.
Ln
A request for a review by an independent review organization must be made within 180 days after the date of M
the initial appeal decision notice.
N
N
IX. Claims N
++
C
Claims for benefits may be made before or after services are obtained.KFHPWA recommends that the provider m
E
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 Q
coverage,or submitting a prescription to a pharmacy,will not be considered a claim for benefits. y
M
If a Member receives a bill for services the Member believes are covered,the Member must,within 90 days of the Y
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 m
E
(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. Q
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.
49 COB 5 71-0036900
Packet Pg. 62
4.D.a
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.
IX. Coordination of Benefits
The coordination of benefits(COB)provision applies 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 which 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 L
regard to the possibility that another plan may cover some expenses.The plan that pays after the primary plan is the z
secondary plan.In no event will a secondary plan be required to pay an amount in excess of its maximum benefit 3
plus accrued savings. Q
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 working with the other plan to determine which is
primary and will let the Member know within 30 calendar days.
M
L
All health plans have timely claim filing requirements.If the Member or the Member's provider fails to submit the c
Member's claim to a secondary health plan within that plan's claim filing time limit,the plan can deny the claim.If V
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 L
prevent a denial of the claim. w
c
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 Medicare is the Member's primary plan,Medicare may .2a
submit the Member's claims to the Member's secondary carrier.
Definitions.
Ln
A. A plan is any of the following that provides benefits or services for medical or dental care or treatment.If M
separate contracts are used to provide coordinated coverage for Members of a Group,the separate contracts N
are considered parts of the same plan and there is no COB among those separate contracts.However,if N
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.
E
m
d
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 Q
panel plans or other forms of group coverage;medical care components of long-term care contracts, m`
such as skilled nursing care;and Medicare or any other federal governmental plan,as permitted by M
law.
Y
c
2. Plan does not include:hospital indemnity or fixed payment coverage or other fixed indemnity or fixed
E
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 Q
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 the benefits of other plans.Any other part
50 COB571-0036900
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4.D.a
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 apply
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 determines 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 L
expense for that claim. This means that when this plan is secondary,it must pay the amount which,when z
combined with what the primary plan paid,totals 100%of the allowable expense.In addition,if this plan is 3
secondary,it must calculate its savings(its amount paid subtracted from the amount it would have paid had Q
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
0
considered an allowable expense and a benefit paid.An expense that is not covered by any plan covering V
the Member is not an allowable expense.
c
The following are examples of expenses that are not allowable expenses: w
c
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 coverage for private hospital room expenses.
m
2. If a Member is covered by two or more plans that compute their benefit payments on the basis of usual
and customary fees or relative value schedule reimbursement method or other similar reimbursement
Ln
method,any amount in excess of the highest reimbursement amount for a specific benefit is not an M
allowable expense.
N
N
3. If a Member is covered by two or more plans that provide benefits or services on the basis of N
negotiated fees,an amount in excess of the highest of the negotiated fees is not an allowable expense.
m
E
4. An expense or a portion of an expense that is not covered by any of the plans covering the person is d
not an allowable expense.
Q
E. Closed panel plan is a plan that provides health care benefits to covered persons in the form of services y
through a panel of providers who are primarily employed by the plan,and that excludes coverage for M
services provided by other providers,except in cases of Emergency or referral by a panel member. Y
c
F. Custodial parent is the parent awarded custody by a court decree or,in the absence of a court decree,is the
E
parent with whom the child resides more than one half of the calendar year excluding any temporary
visitation.
Q
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.
51 COB571-0036900
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4.D.a
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 state 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 the
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.
d
C. A plan may consider the benefits paid or provided by another plan in calculating payment of its benefits L
only when it is secondary to that other plan. z
r
3
D. Each plan determines its order of benefits using the first of the following rules that apply: Q
1. Non-Dependent or Dependent.The plan that covers the Member other than as a Dependent,for
example as an employee,member,policyholder,Subscriber 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. a retired `°
p p rY p g p ( g•�
employee),then the order of benefits between the two plans is reversed so that the plan covering the c
Member as an employee,member,policyholder,Subscriber or retiree is the secondary plan and the V
other plan is the primary plan.
c
2. Dependent child covered under more than one plan.Unless there is a court decree stating otherwise, w
when a dependent child is covered by more than one plan the order of benefits is determined as c
follows:
a) For a dependent child whose parents are married or are living together,whether or not they have 2
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
LO
primary plan. M
b) For a dependent child whose parents are divorced or separated or not living together,whether or
not they have ever been married: N
i. If a court decree states that one of the parents is responsible for the dependent child's health N
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 E
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 Q
dependent child but does not mention responsibility for health care expenses,the plan of the
parent assuming financial responsibility is primary; y
iii. If a court decree states that both parents are responsible for the dependent child's health care Y
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: Q
• 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.
52 COB 5 71-0036900
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4.D.a
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 employee 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 L
plan covering the Member as an employee,member, Subscriber or retiree or covering the Member as a 0
Dependent of an employee,member,Subscriber or retiree is the primary plan and the COBRA or state 3
or other federal continuation coverage is the secondary plan.If the other plan does not have this rule, Q
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.
c
5. Longer or shorter length of coverage.The plan that covered the Member as an employee,member,
d
Subscriber or retiree longer is the primary plan and the plan that covered the Member the shorter
period of time is the secondary plan. W
c
0
6. If the preceding rules do not determine the order of benefits,the allowable expenses must be shared V
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. L
Effect on the Benefits of this Plan. c
When this plan is secondary,it must make payment in an amount so that,when combined with the amount paid by a
the primary plan,the total benefits paid or provided by all plans for the claim equal one hundred percent of the total 2
allowable expense for that claim.However,in no event shall the secondary plan be required to pay an amount 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.
Ln
M
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 N
payable under this plan and other plans.KFHPWA may get the facts it needs from or give them to other N
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
E
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.
Q
Facility of Payment. y
If payments that should have been made under this plan are made by another plan,KFHPWA has the right,at its M
discretion,to remit to the other plan the amount it determines appropriate to satisfy the intent of this provision.The Y
amounts paid to the other plan are considered benefits paid under this plan.To the extent of such payments, c
KFHPWA is fully discharged from liability under this plan.
E
Right of Recovery.
KFHPWA has the right to recover excess payment whenever it has paid allowable expenses in excess of the Q
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
53 COB571-0036900
Packet Pg. 66
4.D.a
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 L
injury or illness,KFHPWA will be subrogated to any rights that the Member may have to recover compensation or z
damages related to the injury or illness and the Member shall reimburse KFHPWA for all benefits provided,from 3
any amounts the Member received or is entitled to receive from any source on account of such injury or illness, Q
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;
d
• 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 V
accident or alleged negligence.
c
This section more fully describes KFHPWA's subrogation and reimbursement rights.
N
"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 2
under this EOC for the care or treatment of the injury or illness sustained by the Injured Person.
LO
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 the N
Injured Person,KFHPWA shall have the right to recover KFHPWA's Medical Expenses from any source available c
to the Injured Person as a result of the events causing the injury. This right is commonly referred to as N
"subrogation."KFHPWA shall be subrogated to and may enforce all rights of the Injured Person to the full extent of
KFHPWA's Medical Expenses. E
m
d
L
By accepting benefits under this plan,the Injured Person also specifically acknowledges KFHPWA's right of Q
reimbursement.This right of reimbursement attaches when this KFHPWA has provided benefits for injuries orCD
L
illnesses caused by another party and the Injured Person or the Injured Person's representative has recovered any y_
amounts from a third party or any other source of recovery.KFHPWA's right of reimbursement is cumulative with M
Y
and not exclusive of its subrogation right and KFHPWA may choose to exercise either or both rights of recovery.
c
m
In order to secure KFHPWA's recovery rights,the Injured Person agrees to assign KFHPWA any benefits or claims E
or rights of recovery they may have under any automobile policy or other coverage,to the full extent of the plan's 0
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. Q
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.
54 COB 5 71-0036900
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4.D.a
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.
d
The Injured Person and their agents shall do nothing to prejudice KFHPWA's subrogation and reimbursement L
rights.The Injured Person shall promptly notify KFHPWA of any tentative settlement with a third parry and shall z
not settle a claim without protecting KFHPWA's interest. The Injured Person shall provide 21 days advance notice 3
to KFHPWA before there is a disbursement of proceeds from any settlement with a third party that may give rise to Q
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 m
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 o
trust or in a separate identifiable account until KFHPWA's subrogation and reimbursement rights are fully V
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 L
KFHPWA's Medical Expenses.In the event that such monies are not so held,the funds are recoverable even if they w
have been comingled with other assets,without the need to trace the source of the funds. Any party who distributes c
funds without regard to KFHPWA's rights of subrogation or reimbursement will be personally liable to KFHPWA M
for the amounts so distributed. 0
m
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
LO
apportionment of such collection costs between KFHPWA and the Injured Person.This reduction will be made only M
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 N
Party. N
c
To the extent the provisions of this Subrogation and Reimbursement section are deemed governed by ERISA,
E
implementation of this section shall be deemed a part of claims administration and KFHPWA shall therefore have
discretion to interpret its terms.
Q
XII.Definitions y
M
Y
Allowance The maximum amount payable by KFHPWA for certain Covered Services.
m
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 0
consistent with those normally charged to others by the provider or organization for the Q
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:
hqps://healthy.kaiserpermanente.org/washington/sLipport/fonns.
55 COB571-0036900
Packet Pg. 68
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. N
L
0
Covered Services The services for which a Member is entitled to coverage in the Evidence of Coverage. z
3
Q
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 c
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 M
drug benefit.
0
0
Deductible A specific amount a Member is required to pay for certain Covered Services before a)
benefits are payable.
L
Dependent Any member of a Subscriber's family who meets all applicable eligibility requirements, c
is enrolled hereunder and for whom the premium has been paid.
13
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
LO
exists that requires immediate medical attention,if failure to provide medical attention M
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 N
health of the unborn child,in serious jeopardy,or any other situations which would be N
considered an emergency under applicable federal or state law.
m
E
Essential Health Benefits set forth under the Patient Protection and Affordable Care Act of 2010, m
d
Benefits including the categories of ambulatory patient services,Emergency services,
hospitalization,maternity and newborn care,mental health and substance use disorder Q
services,including behavioral health treatment,prescription drugs,rehabilitative and y
habilitative services and devices,laboratory services,preventive and wellness services M
and chronic disease management and pediatric services,including oral and vision care. Y
c
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. Q
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.
56 COB571-0036900
Packet Pg. 69
4.D.a
KFHPWA-designated A specialist specifically identified by KFHPWA.
Specialist
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, N
care or treatment of a Medical Condition and which meet the standards set forth below. `o
In order to be Medically Necessary,services and supplies must meet the following E
requirements: (a)are not solely for the convenience of the Member,their family member Q
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 3
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 M
medical standards in the State of Washington,could not have been omitted without o
adversely affecting the Member's condition or the quality of health services rendered; (f) V
as to inpatient care,could not have been provided in a provider's office,the outpatient a)
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 0
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 r
younger people with disabilities,and people with End-Stage Renal Disease(permanent
kidney failure requiring dialysis or a transplant, sometimes called ESRD). N
N
O
N
Member Any enrolled Subscriber or Dependent.
m
Network Facility A facility(hospital,medical center or health care center)owned or operated by Kaiser d
Foundation Health Plan of Washington or otherwise designated by KFHPWA,or with
whom KFHPWA has contracted to provide health care services to Members. Q
m
Network Personal A provider who is employed by Kaiser Foundation Health Plan of Washington or A
Physician Washington Permanente Medical Group,P.C.,or contracted with KFHPWA to provide Y
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. Q
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
57 COB571-0036900
Packet Pg. 70
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. N
L
O
Plan Coinsurance The percentage amount the Member is required to pay for Covered Services received. 3
Q
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.
M
L
Residential Treatment A term used to define facility-based treatment,which includes 24 hours per day,7 days c
per week rehabilitation.Residential Treatment services are provided in a facility V
specifically licensed in the state where it practices as a residential treatment center.
Residential treatment centers provide active treatment of patients in a controlled L
environment requiring at least weekly physician visits and offering treatment by a multi- w
disciplinary team of licensed professionals.
Service Area Washington counties of Benton,Columbia,Franklin,Island,King,Kitsap,Lewis, 2
Mason,Pierce, Skagit, Snohomish,Spokane,Thurston,Walla Walla,Whatcom, m
Whitman and Yakima.
Ln
Subscriber A person employed by or belonging to the Group who meets all applicable eligibility M
requirements,is enrolled and for whom the premium has been paid.
N
N
Urgent Condition The sudden,unexpected onset of a Medical Condition that is of sufficient severity to N
require medical treatment within 24 hours of its onset.
E
m
d
L
Q
L
A
M
Y
c
m
E
v
Q
58 COB571-0036900
Packet Pg. 71
4.D.a
Notice of Nondiscrimination
Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options,Inc.
("Kaiser Permanente")comply with applicable Federal and Washington state civil rights laws and do not
discriminate,exclude people,or treat them differently on the basis of race,color,national origin,age,
disability,sex,sexual orientation,gender identity,or any other basis protected by applicable federal,
state,or local law.We also: IF
N
• Provide free aids and services to people with disabilities to communicate effectively with us, c
such as: r
— Qualified sign language interpreters Q
— Written information in other formats(large print,audio,accessible electronic formats,and io
other formats) aa)
c
— Assistive devices(magnifiers,Pocket Talkers,and other aids)
• Provide free language services to people whose primary language is not English,such as: j
cv
— Qualified interpreters
— Information written in other languages O
U
If you need these services,contact Member Services at 1-888-901-4636(TTY 711). L)
C
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another
way on the basis of race,color,national origin,age,disability,sex,sexual orientation,or gender identity, N
you can file a grievance with our Civil Rights Coordinator by writing to P.O.Box 35191,Mail Stop: c
RCR-A3S-03,Seattle,WA 98124-5191 or calling Member Services at the number listed above.You can file L)
a grievance by mail,phone,or online at kp.org/wa/feedback. If you need help filing a grievance,our Civil
d
Rights Coordinator is available to help you.
You can also file a civil rights complaint with:
• The U.S.Department of Health and Human Services,Office for Civil Rights electronically through
the Office for Civil Rights Complaint Portal,available at N
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf,or by mail or phone at: U.S.Department of Health p
and Human Services,200 Independence Avenue SW.,Roam 509F,HHH Building,Washington, DC r
C
20201,1-800-368-1019,800-537-7697(TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.htmi d
• The Washington State Office of the Insurance Commissioner,electronically through the
Office of the Insurance Commissioner Complaint portal available at Q
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https://www.insurance.wa.gov/file-complaint-or-check-your-complaint-status,or by phone at N
800-562-6900,360-586-0241(TDD).Complaint forms are available at
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Multi-language Interpreter Services
English:ATTENTION:If you speak a language other than English,language assistance services,free of
charge,are available to you.Call 1-888-901-4636(TTY 711).
Espanol(Spanish):ATENCI6N:si habla otro idioma que no sea espanol,tiene a su disposici6n servicios
gratuitos de asistencia en su idioma. Hame al 1-888-901-4636(TTY 711).
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XB0001444-57-21
60 COB 5 71-0036900
Packet Pg. 73
4.D.b
Delta Dental of Washington
Dental Care Service Contract
Declaration Page
Group Number(s) 00611
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Group Name City of Kent r
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Effective Date 12:01 a.m. Pacific Time January 01, 2022 '
Term 36 Months 3
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Plan Type Delta Dental PPOS" Local Plan
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Group identified above agrees to a Dental Care Service Contract with Delta Dental of Washington ("DDWA").This Contract L
is issued and delivered in the state of Washington and is governed by Washington State laws. It is subject to the terms o
listed on these Declaration Page, the general Terms and Conditions, the Certificate of Coverage, and any appendices and U
amendments,all of which are incorporated and made part this Contract.
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The monthly Administrative Fee payable by Group under this Contract Term during the period January 01, 2022 through M
December 31, 2024 shall be$7.42 per Enrolled Employee. Group's payment shall be in the form of a check or electronic m
transfer and shall accompany the eligibility listing. DDWA will then update the files and send a new billing to Group for M
the next month of coverage.
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Accepted By: Accepted By:
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City of Kent Delta Dental of Washington
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220 4th Ave S Post Office Box 75983
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Kent, WA 98032-5895 Seattle, WA 98175-0983
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Signed: Signed: Q
Title: Title: Vice President
Underwriting and Actuarial
Date: Date: December 03, 2021
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11 0 Delta Dental of Washington
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 N
Retroactive Additions 180 Days Retroactive Terminations 180 Days `o
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Participation Q
Minimum Enrollment 100 3
Participation%Employee Tied to Medical Participation%Dependent Tied to Medical
Expenses
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Runout Period 6 Months V
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Delta Dental of Washington
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 Not Covered
Maximum
*Medically Necessary Orthodontic treatment for members under the age of 19,as defined in the Certificate of Coverage,does not N
accrue to the Orthodontic lifetime maximum. o
Plan Deductibles Q
Individual In-Network $50 Family In-Network $150 3
Individual Out-of-Network $50 1 Family Out-of-Network $150 =
Deductible Waived on Class(;Orthodontic Benefits;Accidental Injury Benefits
Plan Coinsurance
0
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Delta Dental PPO Dentists Delta Dental Premier Dentists
Covered Dental Benefits
Dentists Outside of Washington Non-Participating Dentists in
State Washington State
Class 1 100% 100%
Class II 80% 80% 3
Class III 80% 80% 4)
Temporomandibular Joint Not Covered Not Covered
Orthodontic 50% 50% Ln
Accidental Injury 100% 100%
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Delta Dental of Washington
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 Not Covered
Maximum
*Medically Necessary Orthodontic treatment for members under the age of 19,as defined in the Certificate of Coverage,does not N
accrue to the Orthodontic lifetime maximum. o
Plan Deductibles Q
Individual In-Network $50 Family In-Network $150 3
Individual Out-of-Network $50 1 Family Out-of-Network $150 =
Deductible Waived on Class(;Orthodontic Benefits;Accidental Injury Benefits
Plan Coinsurance
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Delta Dental PPO Dentists Delta Dental Premier Dentists
Covered Dental Benefits
Dentists Outside of Washington Non-Participating Dentists in
State Washington State
Class 1 100% 100%
Class II 80% 80% 3
Class III 50% 50% 4)
Temporomandibular Joint Not Covered Not Covered
Orthodontic 50% 50% Ln
Accidental Injury 100% 100%
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11 Delta Dental of Washington
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, m
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where applicable. 1-
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8.9. Leave of Absence
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Coverage for a subscriber and enrolled dependents may be continued for up to 180 days when the Q
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 3
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.
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Delta Dental of Washington
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 N
Declaration Page. `p
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1.3. Certificate of Coverage:The benefit booklet,which describes in summary form the essential features of the Plan coverage, Q
and to or for whom the benefits hereunder are payable. In the event that contracts are changed or amended, new ,
certificates or a clearly understandable benefit booklet insert to existing certificates shall be furnished.The Certificate of 3
Coverage is incorporated into this Contract by this reference as if it were fully written in this document. M
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1.4. Contract:This agreement between DDWA and Group, including the Declaration Page,Certificates of Coverage and any and W
all appendices and amendments.This Contract constitutes the entire Contract between the parties and supersedes any 0
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 exclusions set V
forth in the Certificate of Coverage.
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1.6. DDWA: Delta Dental of Washington,a nonprofit corporation incorporated in Washington State. DDWA is a member of the
Delta Dental Plans Association. N
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1.7. Declarations Page(s):The front page(s)of this Plan that provides the Group specific information and group specific R
elections referred to in the Terms and Conditions. 0
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1.8. Delta Dental: Delta Dental Plans Association:A nationwide not-for-profit organization of dental benefit carriers offering a M
range of group dental benefit plans.
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1.9. Delta Dental PPO'" Dentist:A Participating Dentist who has agreed to render services and receive payment in accordance M
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. c
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1.10.Delta Dental Premier°Dentist:A Delta Dental Participating Dentist who has agreed to render services and receive payment NI
in accordance with the terms and conditions of a written Delta Dental provider agreement between DDWA and such N
Dentist.
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1.11.Delta Dental Participating Dentist:A licensed Dentist who has agreed to render services and receive payment in Q
accordance with the terms and conditions of a written Delta Dental Provider Agreement,which includes looking solely to ;a
Delta Dental for payment for covered services. Delta Dental Participating Dentists include Delta Dental PPO Dentists and
Delta Dental Premier Dentists.
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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.
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1.13.Eligibility Date:The date on which an Eligible Person becomes eligible to enroll in the Plan.
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1.14.Eligible Dependent, Eligible Employee,or Eligible Person:Any dependent,employee or person who meets the conditions of r
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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 Person:Any Eligible Dependent, Eligible Employee or Eligible Person,
as applicable,who has completed the enrollment process and for whom Group has submitted the monthly Administrative
Fee to DDWA.
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Delta Dental of Washington
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 on 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 N
provided for a Covered Dental Benefit. c
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1.22.Non-Participating Dentist:A licensed Dentist who has not agreed to render services and receive payment in accordance Q
with the terms and conditions of a written Participating Dentist Agreement between a member of the Delta Dental Plans ,
Association and such Dentist. ;
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1.23.Open Enrollment Period:The annual period in which Eligible Employees can select benefits Plans and add or delete Eligible c
Dependents.
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1.24.Participating Plan: Delta Dental of Washington and any other member of the Delta Dental Plans Association with which L
Delta Dental contracts to assist in administering the Covered Dental Benefits described in this Contract.
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1.25.Plan Coinsurance:The applicable percentage of Maximum Allowable Fees for Covered Dental Benefits that shall be paid by V
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DDWA as set forth in the Declaration Page.Sometimes this is referred to as the payment level.
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1.26.Plan:This Contract that provides dental benefits.Any other Contract that provides dental benefits and meets the definition 3
of a"Plan"in the"Coordination of Benefits"section of the Certificate of Coverage is a plan for the purpose of coordination c
of benefits only. R
1.27.Service Area:Washington State,the geographic area in which DDWA will issue this policy. Dental Benefits are provided 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 specificallyLO
modified on the Declaration Page. M
2. Eligibility, Enrollment, and Termination o
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2.1. Employee Eligibility, Enrollment,and Termination NI
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2.1.1. Employees are eligible to enroll in this Plan if they meet the condition of eligibility designated on the Declaration N
Page. y
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2.1.2. Eligible Employees may enroll in this Plan on the effective date of this Contract.An employee hired after the effective
date of this Contract may enroll in this Plan after satisfying the probationary period indicated on the Declaration
Page. 0
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2.1.3. Employees are eligible to enroll in this Plan on the first of the month after satisfying any probationary period m
designated on the Declaration Page unless the Group has elected the 'Start Date'option on the 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 remains E
an Eligible Employee.
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2.1.4. If indicated on the Declaration Page, DDWA will waive the Employee probationary period for an Employee hired after Q
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 must 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.
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Delta Dental of Washington
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.
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2.2. Dependent Eligibility, Enrollment,and Termination c
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2.2.1. Dependent coverage under this plan is available as indicated on the Declaration Page. Q
2.2.2. If covered,an Eligible Dependent is a dependent of an Enrolled Employee who meets the requirements for eligibility
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established by the Group. Dependent eligibility validation documentation shall be maintained and verified by the 3
Group. a)
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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 L
Eligible Dependent of the Eligible Employee.
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2.2.4. If covered,a foster child is covered from the time of placement. V
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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. 3
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2.2.6. Eligible Dependents become Enrolled Dependents after fully completing the enrollment process, including payment S
of Administrative Fee by the Group to DDWA.An Enrolled Dependent shall continue to be enrolled as long as the a
Group has made timely payment of the monthly Administrative Fees on behalf of the Enrolled Employee to DDWA. 0
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 aLO
change in family status as defined in the Special Enrollment Period section of the Certificate of Coverage. If an M
additional Administrative Fee for coverage is required and enrollment is not completed within the time period le
selected,the newborn,adopted or foster child(ren)will be covered from the effective date of enrollment as defined c
in the Certificate of Coverage. N�
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2.2.8. An Enrolled Dependent terminates from this Plan when they are no longer an Eligible Dependent of an Eligible N
Employee,or at the end of the calendar month for which Group has made timely payment of the monthly V
Administrative Fees on behalf of the Enrolled Employee,or upon termination of this Contract,whichever occurs first. Q
2.2.9. An Enrolled Employee may terminate coverage of an Enrolled Dependent or reinstate an Eligible Dependent only at ;a
renewal or extension of this Plan,or if there is a change in family status,as defined in the Special Enrollment Period
section of the Certificate of Coverage.
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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 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. r
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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 will only be accepted for the time
period indicated on the Declaration Page.
2.3.4. While satisfying the various requirements of the FMLA,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.
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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 Eligible
Employees are participating in this Plan.
3.1.3. For Groups that elect a specific percentage of dependent participation,Group will assure that specified percentage of N
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all Enrolled Employees enroll all of their Eligible Dependents, unless those dependents are enrolled in another dental t
plan.
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3.1.4. For Groups that elect to have employee or dependent 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-
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sponsored medical plan must be enrolled in this Plan regardless of whether or not they are enrolled as a dependent c
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. o
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3.2. Administrative Fee N
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3.2.1. Group shall submit a list of Enrolled Persons to DDWA prior to the beginning of each monthly eligibility period.
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3.2.2. Group shall permit DDWA,at DDWA's expense,on reasonable advance written notice,to inspect eligibility 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.
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3.2.3. DDWA shall not be obligated to recoup any funds paid to providers for treatment performed in good faith that the M
patient's eligibility was current and accurate at the time of treatment.
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3.2.4. Legislative Surcharge Clause. If any governmental unit imposes any new tax or assessment or increases the rate of FIL
any current tax or assessment that is measured directly by the payments made to DDWA by Group,or payment made q
by DDWA for claims,then DDWA is authorized to increase the monthly Administrative Fee by the amount of such Q
new tax,assessment or increase,or pass through the exact tax amount to the Group separately. 04
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3.2.5. If Group does not agree to the proposed adjustment within 30 days, DDWA may terminate this Contract at the end of N
the month for which Administrative Fee had been received by DDWA prior to the date of such notice to Group and in U
accordance with the provisions of this Contract. Q
3.2.6.The monthly Administrative Fee indicated on the Declaration Page will be remitted fully by Group as invoiced.
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3.3. Invoicing and Payment
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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.
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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 Q
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 which Administrative Fee payment
has not been received by DDWA.
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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 the 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 N
which payment is not received.The charges shall be included by DDWA with a subsequent payment notification. c
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4. Benefits and Benefit Disputes a
4.1. Benefits
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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 Declaration Page.
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4.1.2. Covered Dental Benefits are available for an Enrolled Person from the effective date of their coverage until such N
enrollment terminates.
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4.1.3.The percentages of the Maximum Allowable Fee, Filed Fee,or the Dentists'actual charges payable by DDWA for U
Covered Dental Benefits provided to an Enrolled Person are defined on the Declaration Page.
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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.
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4.2. Providers
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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 Delta Dental fails to pay the dentist le
any amount owed,the Enrolled Person shall not be liable to the dentist for any sums owed by Delta Dental. M
4.2.2. An Enrolled Person may elect the services of any licensed dentist. DDWA is not responsible for availability of any le
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particular licensed dentist. DDWA shall not be held liable for any act or omission on the part of the selected dentist. Q
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4.2.3. DDWA shall be entitled to receive from any attending dentist,or from hospitals in which a dentist's care is rendered, N
any records relating to treatment rendered to an Enrolled Person as may be required in the administration of claims. N
4.2.4.The provider dispute resolution process as outlined in individual provider contracts is available upon request. y
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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 E
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fee or the Maximum Allowable Fee of the fee schedule defined below:
PPO Local Plan
Provider Type Fee Schedule
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Delta Dental PPO Participating Dentist PPO Participating Dentist—State Specific r
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Delta Dental Premier Participating Dentist Premier Participating Dentist—State Specific
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Non-Participating Dentist in Washington State Non-Participating Dentist—State Specific
Non-Participating Dentists out of Washington State Participating Dentist
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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
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Delta Dental of Washington
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 date.
5.1.2. If Orthodontic Benefits are covered,the annual or lifetime maximum amount payable by DDWA 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.
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5.2. Plan Coinsurance N
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Plan coinsurance amounts are indicated on the Declaration Page. 3
5.3. Plan Deductible Q
5.3.1.The plan deductible, if elected,is indicated on the Declaration Page. 3
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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 each Benefit
Period for each individual, unless the family deductible has been met during that Benefit Period.The family o
deductible is accrued by deductible payments of the Enrolled Employee or any Enrolled Dependent. V
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5.3.4. Any elected deductible is waived on designated classes of benefits as indicated on the Declaration Page.
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6. DDWA's Obligations
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6.1. Certificates of Coverage V
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 booklets,electronic versions of corrected LO
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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. N
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6.1.2. Upon receipt of a written request, DDWA will provide to Group one printed booklet for each employee enrolled in NI
the Plan, plus an additional ten percent for a reserve supply.Group will reimburse DDWA for any additional costs due N
to variation in booklet size or paper requested by Group. DDWA will have booklets delivered to Group within 15 N
business days after receipt of a signed booklet approval form from Group. L)
6.2. Confirmation of Treatment and Cost(also known as predetermination of benefits) Q
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6.2.1. DDWA will provide descriptions of Confirmation of Treatment and Costs,claim review,and complaint and appeal
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procedures in the benefit booklets issued to Group.
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6.2.2. If a dentist or an Enrolled Person submits a request for a Confirmation of Treatment and Cost, DDWA will provide a 0)
Confirmation of Treatment and Cost for the Enrolled Person.Such Confirmation of Treatment and Cost will be valid
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when issued based on the information available at that time.A Confirmation of Treatment and Costs is not an
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authorization for services nor a guarantee of payment but is a notification of Covered Dental Benefits available. E
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6.3. Quality Management
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DDWA may utilize its Quality Management and Clinical Review processes to provide professional review of the adequacy, Q
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.This directory is available online,and may also
be requested by telephone as indicated in the Certificate of Coverage. It is understood that the composition of such
directory is subject to change. DDWA reserves the right to change the directory without notice.
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6.5. Dental Services Obligations
6.5.1. DDWA shall not be obligated to make payment for any services rendered 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 obligation
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 3
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7.1. Notification to Enrolled Employees o
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Group shall provide information to all Enrolled Employees as to the existence and terms of this Contract.Group shall make Q
the Certificate of Coverage available to each Enrolled Employee.
7.2. Summary Plan Descriptions
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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 L
of any summary plan description that it elects to prepare and distribute. DDWA is not obligated to review or approve any o
summary plan description prepared by Group,and will not provide any warranty for the content of the Group-produced U
summary plan description. 0
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7.3. Execution of Contract M
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7.3.1. Group shall sign and return any and all Contract documents within 30 days of the effective date or the date DDWA S
sends the Contract document to Group or its authorized representative or agent,whichever is later. a
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 m
date, but Group remits Administrative Fee, both parties agree to perform under this Contract in good faith until a M
signed Contract is received,or until a notice of termination is received as detailed herein.
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8. General Provisions FIL
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8.1. Modification N
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No change in this Contract shall be valid unless evidenced by written amendment signed by an authorized representative N�
or agent of DDWA and an authorized representative or agent of Group. c
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8.2. Legal Action U
Legal action to recover benefits provided for in this Contract may not be initiated prior to 60 days after receipt of claim by Q
DDWA. In addition,such legal action must commence within 6 years from the date the claim was received by DDWA.
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8.3. Severability
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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.
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8.4. Indemnification m
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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) Q
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 Contract.
8.4.2. Group shall indemnify and hold harmless DDWA,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 Group'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 Contract.
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8.5. Force Maieure
In the event DDWA is unable to perform its obligations underthis 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,then 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 obligation to make
Administrative Fee payments shall also be suspended for the same period of time.
8.6. Privacy N
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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 Q
(HIPAA), including any applicable regulations.
8.7. Domestic Partnership and Gender 3
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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 L
partnerships that have been terminated,dissolved,or invalidated,to the extent that such interpretation does not conflict 1�
with federal law.Where necessary,gender-specific terms such as husband and wife used in any part of this contract shall V
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.
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8.8. Notice N
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Any notice under this Contract shall be sufficient if given by either Group or DDWA by regular mail to the other addressed R
to the office stated on the front page of this Contract or to such other address as may be designated by written notice to 2
the other.
9. Termination
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9.1. Termination Notice FIL
This Contract may be terminated effective at the end of the term by either Group or DDWA,or by either party giving le
written notice to the other at least 30 days prior to the end of the Contract term,except as otherwise specifically provided N�
herein. N
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9.2. DDWA Termination N
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9.2.1. DDWA may elect to terminate this Contract,without prior approval of the Washington State Insurance Q
Commissioner, if any of the events outlined in this Section occur.Termination would be effective at the end of the av
month for which Administrative Fees have been received by DDWA prior to the time of such election. If termination
occurs, DDWA will provide written notice to Group. If DDWA elects to terminate because of default by Group,then
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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.
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9.2.2. Events that allow termination:
a. A failure to pay Administrative Fee or perform Group's other obligations when due. t
b. Any violation of published policies of DDWA.
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C. Change or implementation of federal or state health care reform laws that no longer permit the continued Q
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.
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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: o
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a. Refund the payment so made,or
b. Issue to Group a new Contract accompanied by written notice stating clearly those respects in which the new Q
Contract differs from the terminated Contract in benefits,coverage or otherwise.
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9.5. Expenses
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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 benefit consideration. L
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•
VS1 on Care for Life
VSP VISION CARE, INC.
3333 QUALITY DRIVE
RANCHO CORDOVA, CALIFORNIA 95670
GROUP VISION CARE PLAN
ADMINISTRATIVE SERVICES PROGRAM
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Group Name CITY OF KENT
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Plan Number 12229020
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State of Delivery WASHINGTON
Effective Date JANUARY 1, 2022 L
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Plan Term FORTY-EIGHT(48) MONTHS
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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")
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agrees to provide certain individuals under this Group Vision Care Plan ("Plan") the benefits provided herein, subject to the Mn
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exceptions, limitations and exclusions hereinafter set forth. This Plan is delivered in and governed by the laws of the State of N,
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Delivery and is subject to the terms and conditions recited on the subsequent pages hereof, which are a part of this Plan. N
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COPY
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Kate Renwick-Espinosa, President
VSP-GVCP-ASP-5/07 Packet Pg. 88
4.D.c
TABLE OF CONTENTS
I. DEFINITIONS.............................................................................................................. 1
II. TERM, TERMINATION, AND RENEWAL................................................................... 3 N
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III. OBLIGATIONS OF VSP.............................................................................................. 4 13
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IV. OBLIGATIONS OF THE GROUP................................................................................ 8
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V. OBLIGATIONS OF COVERED PERSONS UNDER THE PLAN............................. 10
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VI. ELIGIBILITY FOR COVERAGE................................................................................... 13
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VI I. CONTINUATION OF COVERAGE.............................................................................. 16
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VIII. ARBITRATION OF DISPUTES.................................................................................... 17
IX. NOTICES..................................................................................................................... 18
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X. MISCELLANEOUS...................................................................................................... 19
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EXHIBIT A M
SCHEDULE OF BENEFITS........................................................................... 21 ul)
SCHEDULE OF BENEFITS........................................................................... 26 N
SCHEDULE OF BENEFITS........................................................................... 31 N�
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EXHIBIT B u
SCHEDULE OF PREMIUMS......................................................................... 36 a
SCHEDULE OF PREMIUMS......................................................................... 37 a
ADDENDUM
ADDITIONAL BENEFIT- DIABETIC EYECARE........................................... 38 E
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Packet Pg. 89
4.D.c
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
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administrative services rendered. o
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1.02. ADMINISTRATIVE SERVICES PROGRAM: A group vision care plan whereby Group pays VSP for the Plan Q
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
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benefit costs of Group for one (1) month.
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1.04. BENEFIT AUTHORIZATION: Authorization issued by VSP identifying the individual named as a Covered 0
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Person of VSP, and identifying those Plan Benefits to which Covered Person is entitled. L
1.05. CLAIMS AMOUNT: Total charges for benefits delivered, including the cost of professional services and S
ophthalmic materials, charges for VSP services related to materials purchased, and taxes.
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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.
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1.07. COPAYMENTS: Any amounts required to be paid by or on behalf of a Covered Person for Plan Benefits o
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which are not fully covered. o
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1.08. COVERED PERSON: An Enrollee or Eligible Dependent who meets VSP's eligibility criteria and who is u
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covered under this Plan. a
1.09. ELIGIBLE DEPENDENT: Any legal dependent of an Enrollee of Group who meets the criteria for eligibility
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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 a
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 Packet Pg. 90
4.D.c
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 N
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which its Enrollees, and their Eligible Dependents are entitled to become Covered Persons of VSP and receive Plan Benefits
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in accordance with the terms of such Plan.
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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
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materials on behalf of Covered Persons of VSP. o
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1.17. NON-MEMBER PROVIDER: Any optometrist, optician, ophthalmologist, or other licensed and qualified
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vision care provider who has not contracted with VSP to provide vision care services and/or vision care materials to Covered
Persons of VSP.
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1.18. PLAN BENEFITS: The vision care services and vision care materials which a Covered Person is entitled to M
receive by virtue of coverage under this Plan, as defined in the Schedule of Benefits attached hereto as Exhibit A.
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1.19. RENEWAL DATE: The date on which the Plan shall renew, or terminate if proper notice is given. N
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1.20. SCHEDULE OF BENEFITS: The document, attached hereto as Exhibit A, which lists the vision care N�
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services and vision care materials which a Covered Person is entitled to receive by virtue of this Plan. C4
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1.21. SCHEDULE OF ADVANCE PAYMENT AND ADMINISTRATIVE FEE: The document, attached hereto as a
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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.
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2 Packet Pg. 91
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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
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renewal. If the Plan continues on a month to month basis after the Plan Term, either Party may thereafter terminate the Plan
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upon thirty(30) days advance written notice to the other party. a
If VSP issues written renewal materials to Group at least sixty(60) days before the end of the Plan Term and Group 3
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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. L
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2.02. Termination: Either party may terminate the agreement upon a sixty(60)day advance written notice. Group
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agrees to pay all Claims Amount and Administrative Fees for Plan Benefits provided pursuant to Benefit Authorizations issued i
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prior to the Plan termination date, provided claims for such Plan Benefits are filed with VSP within six(6) months after
termination of this Plan.
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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.) N
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. a
3.02. Provision of Plan Benefits: Through its Member Doctors (or through other licensed vision care providers in
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cases where a Covered Person is eligible for, and chooses to receive Plan Benefits from a Non-Member Provider) VSP shall
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provide Covered Persons such Plan Benefits listed in the Schedule of Benefits, Exhibit A hereto, subject to any limitations, o
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exclusions, or Copayments therein stated.
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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
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Covered Person. Each Benefit Authorization will contain an expiration date, allowing a specific period of time for the Covered LO
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Person to obtain Plan Benefits. Benefit Authorization shall be issued by VSP in accordance with the latest eligibility N,
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information furnished by Group and the Covered Person's past service utilization, if any. Any Benefit Authorization so issued N
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by VSP shall constitute a certification to the Member Doctor that payment will be made. VSP shall not be held liable to Group a
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for any Benefit Authorization issued in error in reliance on the latest eligibility information available to VSP as provided by the >
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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.
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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 Packet Pg. 93
4.D.c
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 will
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 N
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execution and delivery of this Plan, certain information about the properties and operations of their respective
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businesses. VSP and Group, therefore, agree as follows:
3
a) Definition of Confidential Information. For purposes of this Plan, "Confidential Information"means
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any data and/or information, in any form, disclosed by the disclosing Party ("Discloser") to the receiving Party ("Recipient")
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either before or after the Effective Date,which relates to Discloser and/or its Affiliates, and solely by way of illustration and not cc
in limitation shall include the following information: (i) current or future product(s), services, methodologies, plans, designs,
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costs, prices, customer or doctor names and addresses,finances or financial information (including budgets), marketing plans
or strategies (including e-commerce development plans), business plans, matters, opportunities or offerings, equipment and
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other purchase matters, strategic matters, research, development, know-how and/or personnel, (ii) is identified as confidential
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at the time of disclosure, (iii) given the nature of the information disclosed and the circumstances surrounding its disclosure, LO
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reasonably ought to be treated as Confidential Information by a person in the same industry as Discloser, or(iv) by law must N
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be protected as Confidential Information. Recipient acknowledges that the Confidential Information is proprietary to Discloser "I
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and has been developed and obtained through great efforts by Discloser. Confidential Information shall not, however, include C,
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information that(A) at the time of disclosure is, or subsequently becomes, available to the public or the industry through no a
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fault or breach on the part of Recipient; (B) Recipient can demonstrate to have had rightfully in its possession prior to
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disclosure by Discloser; (C) is independently developed by Recipient without the use of any Confidential Information; or(D) E
Recipient rightfully obtains from a third party who has the right to transfer or disclose it. Confidential Information shall also be a
deemed to include any and all confidential information defined as Confidential Matters hereunder,the treatment of which shall
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 Packet Pg. 94
4.D.c
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 obligations
under this Plan (ii) who are bound by confidentiality obligations 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 Discloser.
Recipient shall not use, copy, distribute and/or remove any of Discloser's Confidential Information from Recipient's premises N
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except to the extent necessary or appropriate to carry out its respective obligations under the Plan,without the prior consent of
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Discloser. Recipient and its Representatives will employ all security measures used for their own proprietary information of
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similar nature but in no event using less than a reasonable degree of care. Recipient agrees to advise and require its
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Representatives of their obligations to keep such information confidential and shall each be liable for any acts and omissions
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of their Representatives related thereto. 0
c) Return or Destruction of Confidential Information. The Receiving Party, including its Personnel,
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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,
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or as permitted by Discloser, (ii)destroy all copies thereof, and certify to Discloser in writing that all copies of such documents
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or other information and materials have been destroyed; provided, however, that the Receiving Party may retain one set of
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such documents and other information and materials for archival purposes only, subject to the continuing confidentiality and N
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security obligations set forth under this Plan. Recipient may disclose Discloser's Confidential Information if and to the extent N�
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required by a judicial or governmental request, requirement or order; provided that Recipient will take reasonable steps to give C,
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Discloser sufficient prior notice (to the extent that sufficient time is available) of such request, requirement or order for a
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Discloser to contest, limit and/or protect such disclosure.
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d) Injunctive Relief.The Parties understand and acknowledge that any disclosure or misappropriation E
of any Confidential Information in violation of this Plan may cause irreparable harm, for which monetary damages alone may a
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 relief,
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 survive beyond the
termination of this Plan.
6 Packet Pg. 95
4.D.c
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 N
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non-medical nature, such as lost, broken or stolen glasses, the Covered Person should contact VSP's Customer Service
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Department for assistance. Reimbursement and eligibility are subject to the terms of this Plan.
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4.D.c
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 information N
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 a
Plan.
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4.02. Claims Amounts and Advance of Payment: Group shall provide all funds necessary to pay the Claims
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Amount associated with Covered Persons pursuant to this Plan. In order to assure timely and adequate payment, Group o
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agrees to make an Advance Payment as outlined on the attached Schedule of Advance Payment and Administrative Fee,
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Exhibit B. This Advance Payment is an estimate 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 Amount 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
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benefit providers has been satisfied. However, amounts paid to VSP as Advance Payment shall not be considered assets of LO
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the Group, and need not be held in trust by VSP. NI
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4.03. Administrative Fee: Additionally, on or before the first day of each month, Group shall remit to VSP an N
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Administrative Fee as outlined on the attached Schedule of Advance Payment and Administrative Fee, Exhibit B. Change will a
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not be made to the Administrative Fee during any Plan Term unless there is a change in the Schedule of Benefits or a material >
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change in any other terms and conditions of the Plan, provided any such change is mutually agreed upon in writing between
VSP and Group.
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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 1 Packet Pg. 97
4.D.c
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 Group 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. Group 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 amounts due under this Plan. N
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4.05. Distribution of Required Documents: Group agrees to distribute to Enrollees any disclosure forms, plan
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summaries or other materials that may be required to be given to plan subscribers by any regulatory authority. Such materials
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shall be distributed by Group no later than thirty (30) days after receipt or as otherwise required under state law.
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4.D.c
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, and 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: N
5.02. Copayments for Services Received: Where, as indicated in Exhibit A(Schedule of Benefits), Copayments
are required for certain Plan Benefits, Copayments shall be the personal responsibility of the Covered Person receiving the Q
care and must be paid to the Member Doctor the date services are rendered.
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5.03. Obtaining Services from Member Doctors: Benefit Authorization must be obtained prior to receiving Plan
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Benefits from a Member Doctor. When a Covered Person desires to receive Plan Benefits, the Covered Person must select a cc
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Member Doctor,schedule an appointment, and identify himself as a Covered Person so the Member Doctor can obtain Benefit
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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
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considered a Non-Member Provider and the benefits available will be limited to those for a Non-Member Provider, if any.
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Retail chains may not offer all Plan Benefits. Covered Person may contact Member Doctor for information describing vision M
care services and vision care materials offered. N
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5.04. Submission of Non-Member Provider Claims: If Non-Member Provider coverage is indicated Exhibit A N'
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(Schedule of Benefits) written proof (receipt and the Covered Person's identification information) of all claims for services
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received from Non-Member Providers shall be submitted by Covered Persons to VSP within three hundred sixty-five (365) a
days of the date of service. VSP may reject such claims filed more than three hundred sixty-five (365) days after the date of r
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Failure to submit a claim within this time period, however, shall not invalidate or reduce the claim if it was not a
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 required 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 1 Packet Pg. 99
4.D.c
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 complaint 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 maybe
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. N
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a) Initial Appeal: The request must be made within one hundred eighty(180) days following denial of
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a claim and should contain sufficient information to identify the Covered Person for whom the claim was denied, including the
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VSP Enrollee's name, the VSP Enrollee's Member Identification Number, the Covered Person's name and date of birth, the
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provider of services and the claim number. The Covered Person may review, during normal working hours, any documents
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held by VSP pertinent to the denial. The Covered Person may also submit written comments or supporting documentation 0
concerning the claim to assist in VSP's review. VSP's determination, including specific reasons for the decision, shall be
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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.
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b) Second Level Appeal: If the Covered Person disagrees with the response to the initial appeal of the
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claim, the Covered Person has a right to a second level appeal. Within sixty (60) calendar days after receipt of VSP's
LO response to the initial appeal, the Covered Person may submit a second appeal to VSP along with any pertinent o
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documentation. VSP shall communicate its final determination to the Covered Person in compliance with all applicable state o
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and federal laws and regulations and shall include the specific reasons for the determination. L)
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11 Packet Pg. 100
4.D.c
c) Other Remedies: When Covered Person has completed the appeals process stated herein,
additional voluntary alternative dispute resolution options 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)(1)(13)], 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 with 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 N
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Person exhausting his/her grievance rights under this Plan and/or prior to the expiration of sixty (60) days after the claim and
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any applicable invoices have been filed with VSP. No such action shall be brought after the expiration of six(6)years from the
3
last date that the claim and any applicable invoices were submitted to VSP, in accordance with the terms of this Plan.
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5.08. Insurance Fraud: Any Group and/or person who intends to defraud, knowingly facilitates a fraud or submits r
an application or files a claim with a false or deceptive statement, is guilty of insurance fraud. Such an act is grounds for 00
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4.D.c
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. N
(b) Eligible Dependents: If dependent coverage is provided, the persons eligible for dependent
coverage are:
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(1) the legal spouse of any Enrollee, and
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(2)any child of an Enrollee, including any natural child from the moment of birth, legally adopted child
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from the moment of placement for adoption with the Enrollee, or other child for whom a court holds the Enrollee responsible; o
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Such dependent shall be eligible until the end of the month in which they attain the age of 26 years.
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(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
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the Enrollee's coverage remains in force; PROVIDED satisfactory proof of the dependent's incapacity can be furnished to VSP LO
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within thirty-one (31) days of the date the Eligible Dependent's coverage would have otherwise terminated, and at such other N1
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times as VSP may request proof, but not more frequently than annually. Co
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6.02. Documentation of Eligibility: Persons satisfying the requirements for coverage under either of the above a
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classes shall be eligible if: >
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(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
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(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 Benefits 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 clerical
error is made, it will not affect the coverage to which the Covered Person is entitled under the Plan.
13 1 Packet Pg. 102
4.D.c
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 available 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 eligibility requirements are all N
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material to VSP's obligations under this Plan. During the term of this Plan, Group must provide VSP with written notice of
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changes to its composition, percentage of Enrollees covered, contribution or eligibility requirements. Any such change which
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materially affects VSP's obligations hereunder must be mutually agreed upon in writing between VSP and Group and may
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constitute a material change to the terms and conditions of this Plan for purposes of Paragraph 4.03. Nothing in this section
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shall limit Group's ability to add Enrollees and/or Eligible Dependents in accordance with the terms of this Plan. 0
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6.05. Change in Family Status: In the event Group is notified of any change in a Covered Person's family status
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(by marriage, the addition (e.g., newborn or adopted child) or deletion of dependent children, etc.) Group shall provide notice
of such change to VSP via the next eligibility listing required under Paragraph 4.01. If such notice is given, the change in the
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Covered Person's status will be effective on the first day of the month following the request for change, or at a requested later
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date. Notwithstanding any other provision in this section, a newborn child will be covered for thirty-one (31) days after birth
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and an adopted child will be covered for thirty-one(31)days after the date the Enrollee or Enrollee's spouse acquires the right N
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to control the health care of the child. To continue coverage for a newborn or adopted child beyond the initial thirty-one (31) N1
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day period, the Group must be properly notified of the Enrollee's change in family status and applicable amounts due must be CN
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paid to VSP on behalf of the child. a
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4.D.c
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 this Plan,
VSP shall make the statutorily-required continuation coverage available based on the eligibility information provided by the
Group.
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15 Packet Pg. 104
4.D.c
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 (I
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. Q
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16 Packet Pg. 105
4.D.c
Vill.
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 informal
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 (I
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 a
are any matters arising in connection with this Plan which do become the subject of legal process, the applicable law shall be
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that of the State of delivery of this Plan.
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4.D.c
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 made. N
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18 Packet Pg. 107
4.D.c
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 and 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 materials
prepared by Group for distribution to Enrollees do not constitute a part of this Plan. N
10.02. Indemnity: VSP agrees to indemnify, defend and hold harmless Group, its shareholders, directors, officers,
agents, employees, successors and assigns from and against any and all liability, claim, loss, injury, cause of action and a
expense (including defense costs and legal fees)of any nature whatsoever arising from the failure of VSP, its officers, agents
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or employees, to perform any of the activities, duties or responsibilities specified herein. Group agrees to indemnify, defend
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and hold harmless VSP, its members, shareholders, directors, officers, agents, employees, successors and assigns from and o
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against any and all liability, claim, loss, injury, cause of action and expense (including defense costs and legal fees) of any
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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
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directly furnish vision care services or supply materials. Under no circumstances shall VSP or Group be liable for the LO
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negligence, wrongful acts or omissions of any doctor, laboratory, or any other person or organization performing services or N1
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supplying materials in connection with this Plan. CO
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10.04. Assignment: Neither this Plan nor any of the rights or obligations of either of the parties may be assigned or a
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10.05. Severability: Should any provision of this Plan be declared invalid, the remaining provisions shall remain in
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full force and effect.
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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 Packet Pg. 108
4.D.c
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.
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4.D.c
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. N
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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 a
Person is reimbursed for such benefits according to the schedule in the second column below less any applicable
Copayments.
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COPAYMENT
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The benefits described herein are available to each Covered Person subject only to payment of the applicable Copayment by o
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.
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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 7i
contact lenses.
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PLAN BENEFITS
MEMBER DOCTOR NON-MEMBER
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BENEFIT PROVIDER BENEFIT N
VISION CARE SERVICES N,
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Eye Examination Covered in Full* Up to $ 45.00* U)
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Complete initial vision analysis which includes an appropriate examination of visual functions, including the prescription of >
corrective eyewear where indicated.
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Subsequent regular eye examinations once every plan year beginning on January 1st.
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*Less any applicable Copayment. a
21 Packet Pg. 110
4.D.c
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* N
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Polycarbonate lenses are covered in full for dependent children up to the end of the month in which they turn age 26.
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Standard Progressive Lenses covered in full
Available once every plan year beginning on January 1st.
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Frames Covered up to Plan Up to $ 45.00*
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Available once every other plan year beginning on January 1st.
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*Less any applicable Copayment.
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Frame allowance may be applied towards non-prescription sunglasses for post PRK, LASIK, or Custom LASIK patients.
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Lenses and frames include such professional services as are necessary, which shall include: (D
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• Assisting in the selection of frames;
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• Progress or follow-up work as necessary. N
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4.D.c
CONTACT LENSES
Contact lenses are available once every plan year in lieu of all other lens and frame benefits available herein. 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 N
BENEFIT PROVIDER BENEFIT o
Professional Fees and Materials Professional Fees and Materials Q
Covered in full* Up to$210.00*
Elective -
IY
r
MEMBER DOCTOR NON-MEMBER r
BENEFIT PROVIDER BENEFIT 0
a
Professional Fees** and Materials Professional Fees and Materials
cu
Up to $200.00 Up to $125.00 N
*Subject to Copayment
**15% discount applies to Member Doctor's usual and customary professional fees for contact lens evaluation
and fitting.
LO
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LO
N
O
N
I
N
N
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23 Packet Pg. 112
4.D.c
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 NON-MEMBER
BENEFIT 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.
a�
N
Supplemental Care Aids 75% of Cost 75% of Cost 0
Subsequent low vision aids. Q
Copayment for Supplemental Aids: 25% payable b Covered Person.
pP pY Y �
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Benefit Maximum
L
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The maximum benefit available is $1000.00 (excluding Copayment) every two years.
a
NON-MEMBER PROVIDER BENEFIT
c
cu
L
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.
LO
M
LO
N
O
N
I
N
N
Co
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24 Packet Pg. 113
4.D.c
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.
a�
N
• Optional cosmetic processes. 0
• Anti-reflective coating. ;
• Color coating. Q
• Mirror coating.
• Scratch coating.
• Blended lenses.
• Cosmetic lenses.
• Laminated lenses. r
• Oversize lenses. o
• Polycarbonate lenses.
• Photochromic lenses, tinted lenses except Pink#1 and Pink#2.
CU
• Progressive multifocal lenses. N
• 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).
LO
NOT COVERED M
There is no benefit for professional services or materials connected with: LO
N
O
• Orthoptics or vision training and any associated supplemental testing; plano lenses (less than a ± .50 diopter power); or NI
two pair of glasses in lieu of bifocals; Co
U
• Replacement of lenses and frames furnished under this Plan which are lost or broken, except at the normal intervals when a
services are otherwise available; a
• Medical or surgical treatment of the eyes;
E
• Corrective vision treatment of an Experimental Nature;
r
a
• 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 Packet Pg. 114
4.D.c
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, N
whether Member Doctors or Non-Member Providers. This Schedule forms a part of the Plan or Certificate to which it is o
attached.
a
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 ZD
Copayments. r
M
L
f+
COPAYMENT o
U
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.
a�
PLAN BENEFITS
LO
M
VISION CARE SERVICES
LO
MEMBER DOCTOR NON-MEMBER N
BENEFIT PROVIDER BENEFIT N1
N
N
O
Eye Examination Covered in Full* Up to $ 999.99* L)
U)
Q
Complete initial vision analysis which includes an appropriate examination of visual functions, including the prescription of
corrective eyewear where indicated. >
r
c
Subsequent regular eye examinations once every plan year beginning on January 1 st. E
*Less any applicable Copayment. a
26 Packet Pg. 115
4.D.c
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 * F
Lenticular Covered in full* Covered in full * o
a
Polycarbonate lenses are covered in full for dependent children up to age 26.
3
m
Standard Progressive Lenses covered in full
Available once every plan year beginning on January 1st.
U
L
Frames Covered up to Plan Covered in full * o
Allowance*
a�
c
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:
LO
• Prescribing and ordering proper lenses;
• Assisting in the selection of frames; N
• Verifying the accuracy of the finished lenses; N�
• Proper fitting and adjustment of frames; N
• Subsequent adjustments to frames to maintain comfort and efficiency; N
• Progress or follow-up work as necessary. N
a
a
Lens Options >
Anti-reflective coating Covered in full Not Covered
Scratch coating Covered in full Not Covered
High Index Covered in full Not Covered a
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 Covered in full Covered in full
lenses
Tinted/Photochromic Covered in full Not Covered
UV(ultraviolet) protected Covered in full Not Covered
27 Packet Pg. 116
4.D.c
CONTACT LENSES
Contact lenses are available once every plan year in lieu of all other lens and frame benefits available herein. 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 N
BENEFIT PROVIDER BENEFIT o
Professional Fees and Materials Professional Fees and Materials Q
Covered in full* Covered in full*
Elective -
IY
r
MEMBER DOCTOR NON-MEMBER r
BENEFIT PROVIDER BENEFIT 0
a�
Professional Fees** and Materials Professional Fees and Materials
cu
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.
LO
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N
O
N
I
N
N
CO
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28 Packet Pg. 117
4.D.c
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 NON-MEMBER
BENEFIT 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.
a�
N
Supplemental Care Aids 75% of Cost 75% of Cost 0
Subsequent low vision aids. Q
Copayment for Supplemental Aids: 25% payable b Covered Person.
pP pY Y �
aD
IY
Benefit Maximum
L
f+
The maximum benefit available is $1000.00 (excluding Copayment) every two years.
a
NON-MEMBER PROVIDER BENEFIT
c
cu
L
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.
LO
M
LO
N
O
N
I
N
N
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29 Packet Pg. 118
4.D.c
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.
a�
N
• Optional cosmetic processes. 0
• Cosmetic lenses.
• Oversize lenses. Q
• Certain limitations on low vision care.
• A frame that costs more than the Plan allowance.
• Contact lenses (except as noted elsewhere herein).
r
NOT COVERED r
There is no benefit for professional services or materials connected with:
a
• Orthoptics or vision training and any associated supplemental testing; plano lenses (less than a ± .50 diopter power); or
cu
two pair of glasses in lieu of bifocals; N
• Replacement of lenses and frames furnished under this Plan which are lost or broken, except at the normal intervals when
services are otherwise available; a
• Medical or surgical treatment of the eyes; LO
M
• Corrective vision treatment of an Experimental Nature; LO
N
O
• Costs for services and/or materials above Plan Benefit allowances; N1
Cq
O
• Services and/or materials not indicated on this Schedule as covered Plan Benefits. U
U)
Q
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. >
r
c
E
r
a
30 Packet Pg. 119
4.D.c
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. N
O
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 a
Person is reimbursed for such benefits according to the schedule in the second column below less any applicable
Copayments.
aD
COPAYMENT
L
f+
The benefits described herein are available to each Covered Person subject only to payment of the applicable Copayment by o
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.
cu
L
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 7i
contact lenses.
aD
LO
PLAN BENEFITS
MEMBER DOCTOR NON-MEMBER
LO
BENEFIT PROVIDER BENEFIT N
VISION CARE SERVICES N,
N
N
O
N
Eye Examination Covered in Full* Up to $ 45.00* U)
a
a
Complete initial vision analysis which includes an appropriate examination of visual functions, including the prescription of >
corrective eyewear where indicated.
c
Subsequent regular eye examinations once every plan year beginning on January 1st.
r
*Less any applicable Copayment. a
31 Packet Pg. 120
4.D.c
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* N
O
Polycarbonate lenses are covered in full for dependent children up to the end of the month in which they turn age 26.
a
Standard Progressive Lenses covered in full
Available once every plan year beginning on January 1st.
_
(D
Frames Covered up to Plan Up to $ 45.00*
Allowance* L
r
0
Available once every other plan year beginning on January 1st.
CU
*Less any applicable Copayment.
_
_
Frame allowance may be applied towards non-prescription sunglasses for post PRK, LASIK, or Custom LASIK patients.
a
Lenses and frames include such professional services as are necessary, which shall include: (D
v
• Prescribing and ordering proper lenses; LO
• Assisting in the selection of frames;
• Verifying the accuracy of the finished lenses; o
• Proper fitting and adjustment of frames; N1
• Subsequent adjustments to frames to maintain comfort and efficiency; o
• Progress or follow-up work as necessary. N
U
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32 Packet Pg. 121
4.D.c
CONTACT LENSES
Contact lenses are available once every plan year in lieu of all other lens and frame benefits available herein. 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 N
BENEFIT PROVIDER BENEFIT o
Professional Fees and Materials Professional Fees and Materials Q
Covered in full* Up to$210.00*
Elective -
IY
r
MEMBER DOCTOR NON-MEMBER r
BENEFIT PROVIDER BENEFIT 0
a
Professional Fees** and Materials Professional Fees and Materials
cu
Up to $200.00 Up to $125.00 N
*Subject to Copayment
**15% discount applies to Member Doctor's usual and customary professional fees for contact lens evaluation
and fitting.
LO
M
LO
N
O
N
I
N
N
CO
N
U
U)
Q
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33 Packet Pg. 122
4.D.c
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 NON-MEMBER
BENEFIT 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.
a�
N
Supplemental Care Aids 75% of Cost 75% of Cost 0
Subsequent low vision aids. Q
Copayment for Supplemental Aids: 25% payable b Covered Person.
pP pY Y �
aD
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Benefit Maximum
L
f+
The maximum benefit available is $1000.00 (excluding Copayment) every two years.
a
NON-MEMBER PROVIDER BENEFIT
c
cu
L
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.
LO
M
LO
N
O
N
I
N
N
Co
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U
U)
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34 Packet Pg. 123
4.D.c
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.
a�
N
• Optional cosmetic processes. 0
• Anti-reflective coating. ;
• Color coating. Q
• Mirror coating.
• Scratch coating.
• Blended lenses.
• Cosmetic lenses.
• Laminated lenses. r
• Oversize lenses. o
• Polycarbonate lenses.
• Photochromic lenses, tinted lenses except Pink#1 and Pink#2.
CU
• Progressive multifocal lenses. N
• 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).
LO
NOT COVERED M
There is no benefit for professional services or materials connected with: LO
N
O
• Orthoptics or vision training and any associated supplemental testing; plano lenses (less than a ± .50 diopter power); or NI
two pair of glasses in lieu of bifocals; Co
U
• Replacement of lenses and frames furnished under this Plan which are lost or broken, except at the normal intervals when a
services are otherwise available; a
• Medical or surgical treatment of the eyes;
E
• Corrective vision treatment of an Experimental Nature;
r
a
• 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 Packet Pg. 124
4.D.c
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
a�
N
O
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 a
the Plan.
3
(D
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36 Packet Pg. 125
4.D.c
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
a�
N
O
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 a
the Plan.
3
(D
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37 Packet Pg. 126
4.D.c
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 N
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.
a
ELIGIBILITY
The following are Covered Persons under this Plan, pursuant to eligibility criteria established by Client:
• Enrollee.
• The legal spouse of Enrollee. r
• Any child of Enrollee, including any natural child from the date of birth, legally adopted child from the date of placement for o
adoption with the Enrollee, or other child for whom a court or administrative agency holds the Enrollee responsible.
c
cu
Dependent children are covered up to the end of the month in which they attain the age of 26 years. N
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.
LO
M
LO
N
O
N
I
N
N
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38 Packet Pg. 127
4.D.c
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 N
• transient loss of vision 0 "floating" spots 0
Examples of conditions which may require management under DEP Plus may include, but are not limited to: Q
• diabetic retinopathy rubeosis
• diabetic macular edema
r
REFERRALS
r
0
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.
cu
If the Covered Person requires services beyond the scope of DEP Plus, the Member Doctor will refer the Covered Person to a
physician.
a
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. v
LO
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39 Packet Pg. 128
4.D.c
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 N
procedures will be made available to Covered Person upon request. The frequency at which these services may be provided t
is dependent upon the specific service and the diagnosis associated with such service.
a
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.
cu
7. Insulin or any medications or supplies of any type. N
8. Local, state and/or federal taxes, except where VSP is required by law to pay.
DIABETIC EYECARE PROGRAM DEFINITIONS a
Diabetes A disease where the pancreas has a problem either making, or making and using, insulin.
LO
Type 1 Diabetes A disease in which the pancreas stops making insulin. LO
N
O
Type 2 Diabetes A disease in which the pancreas either makes too little insulin or cannot properly use the N�
insulin it makes to convert blood glucose to energy. o
N
U
Diabetic Retinopathy A weakening in the small blood vessels at the back of the eye. a
a
U)
Rubeosis Abnormal blood vessel growth on the iris and the structures in the front of the eye. >
w
c
Diabetic Macular Edema Swelling of the retina in diabetes mellitus due to leaking of fluid from blood vessels within the E
macula.
r
a
40 Packet Pg. 129
4.E
HUMAN RESOURCES DEPARTMENT
Teri Smith, SHRM-CP, PHR
220 Fourth Avenue South
KENT Kent, WA 98032
W A S H i N G T O N 253-856-5270
DATE: May 17, 2022
TO: Operations and Public Safety Committee
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 by 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)
Packet Pg. 130
4.E.a
AMENDMENT NO. 13
To be attached to and made part of Policy WA 518212 issued to City of Kent as Policyholder.
It is hereby agreed the Policy shall be amended as follows.
as
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Effective January 1, 2022: r
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The following Section has been replaced:
3
Section 1, Declarations.
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The following Rider renews for the 2022 Policy Year:
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Specific Advance Funding Rider.
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All other terms and conditions of the contract remain unchanged.
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LifeWise Assurance Company
Name and Title of Officer
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Signature of Officer a
Rick Grover
President and Chief Executive Officer
Date of Signature LifeWise Assurance Company
1. Sign and return copy to LifeWise Assurance Company.
2. Retain copy with Your Policy.
PSL-500 WA AM (9-18) Amendment
Packet Pg. 131
4.E.a
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 WA 518212 •N N
2. Policyholder City of Kent t
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3. Policy Term January 1, 2022 through December 31, 2022 Q
4. Covered Underlying Plan City of Kent's Health Plan
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5. Claim Administrator Premera Blue Cross
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B. SPECIFIC BENEFIT SCHEDULE
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For all Eligible Losses except those to which a Special Risk Limitation applies: �o
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1. Covered Loss Basis
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Covered Services Incurred from January 1, 2010 through December 31, 2022 and Paid from f°
January 1, 2022 through December 31, 2022. N
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If an Eligible Claim Expense is denied by the Covered Underlying Plan and that denial is o
subsequently reversed by an Independent Review Organization (IRO), the date such Eligible
Claim Expense was originally denied by the Covered Underlying Plan will be considered the o
"Paid"date under the above referenced Policy. U)
2. Covered Services include LO
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Medical
Prescription Drug
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3. Number of Covered Units Z
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Composite 711
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4. Specific Deductible per Participant $200,000
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(Please note: Specific deductible per Participant shall not exceed the lesser of 5%of Q
expected claims or$100,000). N
5. Specific Payable Percentage (in excess of Specific Deductible) 100% _
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6. Maximum Specific Benefit in excess of the Specific Deductible
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Per Policy Term Unlimited E
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Per Lifetime Unlimited
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PSL-500 WA(9-18) 1
Packet Pg. 132
4.E.a
C. AGGREGATE BENEFIT SCHEDULE
For all Eligible Losses except those to which a Special Risk Limitation applies:
1. Covered Loss Basis
Covered Services Incurred 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 N
subsequently reversed by an Independent Review Organization (IRO), the date such Eligible 0
Claim Expense was originally denied by the Covered Underlying Plan will be considered the
"Paid"date under the above referenced Policy. Q
2. Covered Services include
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Prescription Drug
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3. Number of Covered Units r
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4 Aggregate Payable Percentage in excess of Deductible 100%
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5. Aggregate Corridor 200%
(Please note: Aggregate Corridor will never be less than 120%of expected claims). N
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6. Minimum Aggregate Deductible a
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The greater of: i)
A. $24,833,409.84; or LO
B. The sum of Aggregate Monthly Factors, multiplied by the corresponding number of r
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%.
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7. Annual Aggregate Deductible Z
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Is equal to the greater of A or B, where: m
A =The sum of the Monthly Aggregate Deductible Amounts applicable to each Policy Month
in the Policy Term
B =The Minimum Aggregate Deductible Q
Please Note:Annual Aggregate Deductible cannot be finalized until the Monthly Aggregate ,n
Deductible Amounts am calculated for each Policy Month of the Policy Term.
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8 Aggregate Monthly Factor per Covered Unit J
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Composite $2,910.62
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9. Maximum Aggregate Eligible Loss per Participant $200,000
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10. Maximum Aggregate Benefit per Policy Term $1,000,000 Q
PSL-500 WA(9-18) 2
Packet Pg. 133
4.E.a
D. PREMIUM
Specific Monthly Premium Rate
Composite $140.56
Specific Rate Guarantee Period 12 Months
Aggregate Monthly Premium Rate Per Covered Unit N
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Composite $0.02 0
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Aggregate Rate Guarantee Period 12 Months Q
The Specific Monthly Premium Rate and the Aggregate Monthly Premium Rate apply only to this
Policy Term.
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E. SPECIAL RISK LIMITATIONS
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Retirees Included Yes 0
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Other: Yes
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Member ID: 60015680802 U)
Specific Deductible: $300,0001 0
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Paid Claims between $200,000 and$300,000 are not eligible under the Aggregate Benefit
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None
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PSL-500 WA(9-18) 3
Packet Pg. 134
4.F
FINANCE DEPARTMENT
Paula Painter, CPA
220 Fourth Avenue South
KENT Kent, WA 98032
WASHINGTON 253-856-5264
DATE: May 17, 2022
TO: Operations and Public Safety Committee
SUBJECT: INFO ONLY: March 2022 Financial Report and 2021 Year-End
Financial Report
SUMMARY: Finance Director, Paula Painter will present the March 2022 Financial
Report and 2021 Year-end Financial Report.
SUPPORTS STRATEGIC PLAN GOAL:
Sustainable Services - Providing quality services through responsible financial management,
economic growth, and partnerships.
ATTACHMENTS:
1. March 2022 Financial Report (PDF)
Packet Pg. 135
March 2022
Monthly Report
City of Kent, . •
General Fund Overview
2022 2022
0
a
m
Revenues 127,511,410 18,246,356
Expenditures 129,698,570 23,125,600 c
Net Revenues Less Expenditures (2,187,160) (4,879,245)
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Beginning Fund Balance 43,321,480
Ending Fund Balance 41,134,320 N
31.7% N
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Required Ending Fund Balance Calculation o
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Budgeted Expenditures for 2022 (from above) 129,698,570
18.0% c
18% GF Ending Fund Balance 23,345,743 c
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in millions General Fund Ending Fund Balance 10-year History (excluding
Annexation)
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45.00 41.97 45.28 0
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30.00 °?
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18.92 20.65 0
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2012 2013 2014 2015 2016 2017 2018 2019 2020 Prelim N
2021 N
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Page 1 of 14
Packet Pg. 136
4.F.a
March 2022 MonthlyReport
City of . •
General Fund Overview - Revenues
BudgetRevenue Categories 2022 2022
Adj G
a
m
Taxes:
Property 32,451,450 1,345,401
Sales & Use 21,027,000 6,504,682
Utility 19,507,350 5,674,218 u-
Business & Occupation 19,100,000 73,759 w
Other 879,790 10,515
Licenses and Permits 7,400,610 1,877,093 >-
r
Intergovernmental Revenue 2,865,880 641,746 c
Charges for Services 6,309,570 1,363,224 -0
Fines and Forfeitures 1,172,910 136,800 0
Miscellaneous Revenue 2,348,500 333,917 0
Q.
Transfers In 14,448,350 285,000
Total Revenues 127,511,410 18,246,356
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B&O Taxes
2022 Budgeted 15%
Other Taxes
General Fund 1% Licenses and
Permits Intergovernmental
Revenues Utility Taxes 6% 2% Z
15% 0
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Charges for Z
Services ao
5%
Fines and Forfeit
1% L
Other O
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21%
Misc&
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13%
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Sales Taxes N
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17% 2
Property Taxes
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25%
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Page 2 of 14
Packet Pg. 137
4.F.a
March 2022 Monthly Financial Report
City of Kent, Washington
General Fund Revenues ($ in Thousands)
All Revenues Sources
Prior Year Budgeted Actual
$140,000 O
January 5,898 6,949 6,113 m
$120,000 w
February 4,174 6,322 5,033
$100,000 March 6,127 8,776 7,100 Z
$80,000 April 21,521 21,425 0 c
May 7,927 9,460 0 j,L
$60,000 June 5,491 7,444 0
$40,000 • July 9,733 9,253 0 W
August 6,326 6,633 0 M
$20,000 September 5,725 7,315 0 T"
$0 October 21,552 22,466 0 c
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec November 8,364 9,137 0 N
December 10,968 12,333 0
22 Bud f 21 Act 22 Act Total 113,807 127,511 18,246 R
O
PropertyPrior Year Budgeted Actual
$35,000 Revenues Revenues Revenues Ma
ca
January - 0 0 S
$30,000 - LL
February 217 250 57 N
$25,000 March 1,438 1,150 1,289 N
$20,000 April 13,218 12,649 0 v
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May 1,945 2,439 0 �
$15,000 June 198 617 0
$10,000 _ July 80 145 0 J
August 190 135 0 ZO
$5,000 September 394 587 0 O
LL
$0 October 12,046 12,095 0 Z
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec November 2,123 2,142 0 co
December 203 242 0
22Bud f21Act 4 22Act Total 32,053 32,451 1,345
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Prior Year Budgeted Actual
$25,000Revenues RevenuesC
January 1,802 1,640 2,063
c
$20,000 - February 2,264 1,941 2,329 ii
March 1,786 1,619 2,112 c
$15,000 - April 1,753 1,493 0 N
t
May 2,270 1,799 0 i
$10,000 June 2,005 1,646 0 R
July 2,061 1,519 0
$5,000 August 2,172 1,859 0
September 2,070 1,740 0
$0 October 2,023 1,771 0 ;a
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec November 2,150 1,887 0 Q
December 2,473 2,112 0
�22 Bud f21 Act -4--22 Act Total 24,829 21,027 6,505
Page 3 of 14 Packet Pg. 138
4.F.a
March 2022 Monthly Financial Report
City of Kent, Washington
General Fund Revenues ($ in Thousands)
Prior Year Budgeted Actual Utility Tax
$25,000 1 Revenues Revenues Revenues 0-
d
January 2,141 1,935 1,980
ca
$20,000 February 1,215 1,644 1,889 v
March 1,583 1,666 1,805
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$15,000 - April 1,700 1,768 0 jL
May 1,542 1,569 0
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$10,000 June 1,312 1,438 0 LLLJ
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July 2,420 1,729 0 y
$5,000 August 1,632 1,505 0
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September 1,621 1,697 0 c
$0 October 1,588 1,471 0 N
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec November 1,625 1,564 0
December 1,884 1,521 0 0
22Bud f21Act �22Act Total 20,263 19,507 5,674 0-
Other Taxesv
BudgetedPrior Year
$20,000 Revenues Revenues Revenues
LL
$18,000 - January 283 86 2 N
$16,000 February 2 3 3 N
$14,000 March (156) 134 79 t
$12,000 April 2,912 3,091 0ca
$10,000 May 1,008 1,296 0
$8,000 June 203 231 0 J
$6,000 July 2,966 3,717 0 Z
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$4,000 - August 11219 943 0 0
$2,000 September 107 125 0 LL
Z_
$0 October 3,083 3,864 0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec November 1,107 994 0 in
T-
December 4,940 5,496 0
22Bud f21Act 22Act Total 17,674 19,980 84 V
Other Revenues 0
d'
(Intergovernmental, Licenses & Permits, Charges for Service, Fines & Forfeits, and Misc Revenues)
.0
Prior Year Budgeted Actual
C
$35,000 Revenues Revenues Revenues
LL
$30,000 _ January 1,672 3,425 2,068 N
February 475 1,316 755 C
N
$25,000 March 1,476 3,488 1,815
$20,000 - - - _ April 1,938 2,569 0
May 1,161 2,133 0
$15,000 June 1,773 3,456 0
0
$10,000 July 2,205 21746 0 t
August 1,113 1,937 0 0
$5,000 September 1,533 3,124 0 Q
$0 1 October 2,812 3,279 0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec November 1,359 2,269 0
December 1,469 4,803 0
22 Bud f 21 Act �22 Act
Total 18,988 34,546 4,638
Page 4 of 14 Packet Pg. 139
March 2022
Monthly Report
City of •
General Fund Overview - Expenditures
2022
Department o
0-
0
City Council 293,240 76,254
Administration 3,280,590 290,592
Economic & Community Dev 9,403,640 1,794,318 c
Finance 3,199,480 666,731
U_
Fire Contracted Services 3,877,220 1,064,245 w
Human Resources 2,109,860 477,930
Law 1,639,480 350,650 >-
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Municipal Court 3,868,530 817,761 c
N
Parks, Recreation & Comm Svcs 22,354,160 4,099,376 -0
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Police 49,437,690 11,827,788
Non-Departmental 30,234,680 1,659,953 o
Total Expenditures 129,698,570 23,125,600
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2022 Budgeted General Fund Expenditures N
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Non-Departmental City Council
23% 0.23% J
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A inistration
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Law ILL
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7% U
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Finance
3%
Fire Contracted
Parks, Recreation & Services
Municipal Court E
Comm Svcs 3% 3%
17%
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Page 5 of 14
Packet Pg. 140
March 2022
Monthly Report
City of •
General Fund
Actual Prelim Adj Budget YTD c
Beginning Fund Balance 34,399,775 41,969,900 43,321,480 43,321,480
Revenues
c
Taxes:
ii
Property 31,374,827 32,052,967 32,451,450 1,345,401
Sales & Use 23,629,972 24,828,972 21,027,000 6,504,682 w
L
Utility 18,970,715 20,262,726 19,507,350 5,674,218
Business & Occupation 14,784,795 17,060,649 19,100,000 73,759 r
Other 418,235 613,502 879,790 10,515 N
Licenses and Permits 7,223,420 7,171,129 7,400,610 1,877,093
Intergovernmental Revenue 3,196,701 3,322,233 2,865,880 641,746
t=
Charges for Services 3,658,232 5,299,515 6,309,570 1,363,224 0
Fines and Forfeitures 776,948 809,293 1,172,910 136,800
Miscellaneous Revenue 1,954,937 943,344 2,348,500 333,917
Transfers In 4,820,343 1,442,364 14,448,350 285,000
c�
Total Revenues 110,809,127 113,806,695 127,511,410 18,246,356
N
N
Expenditures CD
City Council 384,062 272,914 293,240 76,254
Administration 1,774,808 2,847,633 3,280,590 290,592
Economic & Community Dev 6,711,489 7,469,721 9,403,640 1,794,318 J
Finance 2,323,636 2,574,151 3,199,480 666,731 z
O
Fire Contracted Services 3,674,401 3,280,458 3,877,220 1,064,245 O
LL
Human Resources 1,405,219 1,524,097 2,109,860 477,930 z
Information Technology 172,932 co
Law 1,452,088 1,444,860 1,639,480 350,650 M
Municipal Court 3,402,314 3,394,639 3,868,530 817761
L
Parks, Recreation & Comm Svcs 16,631,899 17,758,211 22,354,160 4,099:376 Q.
Police 43,464,679 45,793,526 49,437,690 11,827,788
Public Works 629,087 (720)
Non-Departmental 20,802,826 21,907,021 30,234,680 1,659,953
Total Expenditures 102,829,440 108,266,510 129,698,570 23,125,600
N
N
Net Revenues less Expenditures 7,979,686 5,540,186 (2,187,160) (4,879,245) c
N
t
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Ending Fund Balance 42,379,461 47,510,086 41,134,320 38,442,235 2
r
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m
Ending Fund Balance Detail: E
General Fund Reserves 41,969,900 43,321,480 41,134,320
based on same year actuals/budget 40.8% 40.0% 31.7% a
Page 6 of 14
Packet Pg. 141
ReportMarch 2022 Monthly Financial
City of Kent, Washington
General Fund
Year-to-Year Month Comparison
c
thru March thru March thru March Variance Budget a
m
Revenues
Taxes: f°.v
Property 1,707,775 1,655,004 1,345,401 (309,603) -18.7% 4.1%
Sales & Use 6,726,852 5,852,796 6,504,682 651,886 11.1% 30.9%
Utility 5,438,850 4,939,249 5,674,218 734,969 14.9% 29.1% u-
Business & Occupation 30,660 115,976 73,759 (42,217) -36.4% 0.4% W
Other 5,278 12,791 10,515 (2,276) -17.8% 1.2% i
Licenses and Permits 1,956,509 1,530,345 1,877,093 346,748 22.7% 25.4%
Intergovernmental Revenue 751,001 614,853 641,746 26,893 4.4% 22.4% r
Charges for Services 1,654,252 873,102 1,363,224 490,122 56.1% 21.6% c
Fines and Forfeitures 499,911 226,792 136,800 (89,992) -39.7% 11.7% N
Miscellaneous Revenue 165,323 378,191 333,917 (44,274) -11.7% 14.2%
Transfers In 450,000 2,076,762 285,000 (1,791,762) -86.3% 2.0%
Total Revenues 19,386,411 18,275,859 18,246,356 (29,503) -0.2% 14.3% 0
a�
Expenditures
City Council 103,031 71,561 76,254 4,693 6.6% 26.0% U
Administration 443,252 446,358 290,592 (155,766) -34.9% 8.9% c
Economic &Community Dev 1,666,094 1,792,490 11794,318 1,828 0.1% 19.1% ii
Finance 578,489 662,585 666,731 4,146 0.6% 20.8% N
Fire Contracted Services 676,985 (30,078) 1,064,245 1,094,323 -3638.3% 27.4% N
Human Resources 422,363 378,520 477,930 99,410 26.3% 22.7%
Information Technology 124,699 -
Law 386,905 344,870 350,650 5,780 1.7% 21.4% 2
Municipal Court 887,494 805,440 817,761 12,321 1.5% 21.1% J
Parks, Recreation &Comm Svcs 4,158,200 3,580,455 4,099,376 518,922 14.5% 18.3% z
Police 11,183,488 11,040,491 11,827,788 787,297 7.1% 23.9% 0
Public Works 337,080 - - LL
u.
Non-Departmental 2,332,896 134,866 1,659,953 1,525,087 1130.8% 5.5% Z
Total Expenditures 23,300,979 19,227,558 23,125,600 3,898,042 20.3% 17.8% co
u�
M
GF Revenues thru March GF Expenditures thru March Q
8,000,000 14,000,000
7,000,000 12,000,000
.0
_ C
6,000,000 10,000,000 -
5,000,000 li
4,000,000 02020 8,000,000 92020 N
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3,000,000 02021 6,000,000 a 2021 N
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2,000,000 Ir 2022 4,000,000 V 2022
1,000,000 - 2,000,000 L
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Property Sales& Utility Other Police Parks *General ECD Non-Dept&
Taxes Use Taxes Taxes Revenues Govt. Other v
*General Govt. includes City Council, Mayor/Clerk, HR, IT, &Finance Q
Page 7 of 14
Packet Pg. 142
4.F.a
March 2022 Monthly • •
City of Kent, Washington
Fund Balances
0
2022 2022Estimated Estimated
-
m
Beginning Estimated Estimated Ending Fund
Fund
Balance Revenues Expenditures
c
U_
Operating revenues and expenditures only; capital and non-capital projects are excluded.
w
L
General Fund
General Fund 43,321,480 127,511,600 129,698,600 41,1341480 N
0
Special Revenue Funds
N
C
Street Fund 9,736,452 17,853,670 18,968,770 8,621,352
LEOFF 1 Retiree Benefits 1,293,114 1,386,060 1,572,840 1,106,334 00.
Lodging Tax 115,838 864,600 509,050 471,388
Youth/Teen Programs 334,472 1,137,800 925,650 546,622
Capital Resources 25,145,315 18,047,430 19,076,560 24,116,185
Criminal Justice 10,185,251 10,388,880 10,214,860 10,359,271 ;i
Human Services 1,341,314 3,684,000 3,684,000 1,341,314 N
0
ShoWare Operating 4,449,395 1,159,000 2,993,600 2,614,795 N
Other Operating 517,607 113,320 121,630 509,297
Debt Service Funds
Councilmanic Debt Service 2,949,057 6,847,680 7,456,470 2,340,267
J
z
Special Assessments Debt Service 587,812 691,660 682,020 597,452 O
O
LL
Enterprise Funds z
Water Utility 16,064,903 33,230,980 29,219,840 20,076,043 co
u�
Sewer Utility 3,360,825 40,667,300 34,615,610 9,412,515
Drainage Utility 19,679,465 27,903,340 31,028,660 16,554,145 i
Solid Waste Utility 308,807 758,900 873,330 194,377 00.
a�
Golf Complex 366,666 3,213,700 2,990,300 590,066
Internal Service Funds
ca
Fleet Services 4,126,131 8,609,300 9,194,910 3,540,521 S
ii
Central Services 106,989 463,610 414,110 156,489 N
Information Technology 2,202,039 13,212,340 12,125,850 3,288,529 N
Facilities 3,579,671 7,449,100 8,965,980 2,062,791
L
Unemployment 1,368,106 160,690 219,010 1,309,786
Workers Compensation 1,484,860 1,200,260 1,575,610 1,109,510
Employee Health & Wellness 8,740,415 15,502,710 15,580,790 8,662,335
E
Liability Insurance 3,076,750 2,065,130 3,794,070 1,347,810
0
Property Insurance 1,044,143 1,389,600 785,750 1,647,993 a
Other
Impact Fee Trust Fund 3,922,390 3,922,390
Page 8 of 14
Packet Pg. 143
2022 Monthly - . •
4.F.a
City
of . •
Other Funds Overview (Revenues and Expenditures)
• • 2021 2022 •
Actual Prelim Budget YTD
a
Operating revenues and expenditures only; capital and non-capital projects are excluded.
In instances where expenditures exceed revenues, fund balance is being utilized.
Special Revenue Funds
cv
c
Street Fund LL
Revenues 19,350,928 20,419,435 18,630,900 3,919,354 w
Expenditures 19,205,266 16,768,746 18,968,770 3,469,826 Z.
Net Revenues Less Expenditures 145,662 3,650,689 (337,870) 449,529
r
LEOFF 1 Retiree Benefits c
Revenues 1,232,575 1,199,965 1,277,880 271,160
Expenditures 1,571,585 1,519,460 1,572,840 366,668
0
Net Revenues Less Expenditures (339,010) (319,495) (294,960) (95,508:
0
Q.
Lodging Tax
Revenues 158,384 221,252 582,740 330,474 R
Expenditures 270,532 165,720 509,050 3,522 Z
Net Revenues Less Expenditures (112,148) 55,532 73,690 326,953
Youth/Teen Programs
Revenues 897,527 977,243 931,380 284,047 c
Expenditures 691,260 822,054 925,650 1,570 N
Net Revenues Less Expenditures 206,267 155,189 5,730 282,477 i
Capital Resources
Revenues 22,885,707 28,353,626 19,937,010 6,292,583
Expenditures 27,520,426 18,092,140 19,076,560 467,307 Z
Net Revenues Less Expenditures (4,634,719) 10,261,487 860,450 5,825,276 O
O
Criminal Justice LL
z
Revenues 8,673,794 9,774,373 8,686,810 2,414,459
Expenditures 8,504,672 7,540,042 10,214,860 2,003,906 co
Net Revenues Less Expenditures 169,122 2,234,331 (1,528,050) 410,552 M
Human Services
Revenues 163,728 3,796,657 3,684,000 980,534 0a.
Expenditures 116,660 2,502,411 3,684,000 8,931 W
Net Revenues Less Expenditures 47,068 1,294,246 971,602
ShoWare Operating
Revenues 1,512,589 3,079,558 1,150,000
Expenditures 1,451,752 2,091,661 2,993,600 666,838 N
Net Revenues Less Expenditures 60,837 987,897 (1,843,600) (666,838: c
N
Other Operating
Revenues 105,155 128,175 121,630
Expenditures 106,003 104,945 121,630 258 2
Net Revenues Less Expenditures (848) 23,230 (258-
Debt Service Funds E
Councilmanic Debt Service
Revenues 9,144,587 7,988,547 6,847,680 a
Expenditures 8,679,761 8,348,722 7,456,470 9,933
Net Revenues Less Expenditures 464,826 (360,174) (608,790) (9,933'd
Page 9 of 14
Packet Pg. 144
2022 Monthly - . •
4.F.a
City
of . •
Other Funds Overview (Revenues and Expenditures)
• • 2021 2022 •
Actual Prelim Budget YTD
a
Operating revenues and expenditures only; capital and non-capital projects are excluded.
In instances where expenditures exceed revenues, fund balance is being utilized.
c
Special Assessment Debt Service c
Revenues 784,469 1,035,745 691,660 10,364 LL
Expenditures 1,386,712 858,473 682,020 1,633 c
Net Revenues Less Expenditures (602,243) 177,272 9,640 8,731 w
0
Enterprise Funds
m
r
Water Utility N
0
N
Revenues 29,573,424 29,810,341 29,334,150 6,180,955
Expenditures 26,464,133 28,183,254 29,219,840 3,912,230 0
Net Revenues Less Expenditures 3,109,291 1,627,087 114,310 2,268,724 0
Sewer Utility
Revenues 33,513,294 34,846,524 34,750,070 8,813,004
Expenditures 32,252,706 33,974,459 34,615,610 7,990,813
Net Revenues Less Expenditures 1,260,588 872,065 134,460 822,191 c�a
c
ii
Drainage Utility N
N
Revenues 24,537,483 25,408,140 23,506,990 6,125,257 N
Expenditures 21,804,802 23,609,481 31,028,660 4,166,677
Net Revenues Less Expenditures 2,732,681 1,798,659 (7,521,670) 1,958,579
Solid Waste Utility
Revenues 837,309 855,492 644,510 168,159
Expenditures 876,871 995,385 873,330 319,865 p
Net Revenues Less Expenditures (39,562) (139,893) (228,820) (151,706; p
U_
Golf Complex z
Revenues 5,938,183 2,526,316 3,007,180 457,175 "
00
Expenditures 3,070,899 4,513,837 2,990,300 649,142
Net Revenues Less Expenditures 2,867,283 (1,987,522) 16,880 (191,96T ='
L
0
Internal Service Funds
Q
Fleet Services
Revenues 5,478,589 5,674,822 7,819,690 1,441,222 '2
Expenditures 6,559,539 4,894,499 9,194,910 1,295,954
Net Revenues Less Expenditures (1,080,950) 780,323 (1,375,220) 145,268
U_
Central Services N
Revenues 309,535 355,897 436,600 63,397 coi
Expenditures 277,640 320,247 414,110 25,892
Net Revenues Less Expenditures 31,895 35,650 22,490 37,505
Information Technology
Revenues 9,062,099 10,506,136 11,633,360 2,790,973
Expenditures 10,531,892 10,411,640 12,125,850 2,904,826
Net Revenues Less Expenditures (1,469,793) 94,496 (492,490) (113,853;
Facilities a
Revenues 6,327,140 6,704,998 6,547,280 1,376,075
Expenditures 5,125,026 6,222,434 8,965,980 1,166,024
Net Revenues Less Expenditures 1,202,114 482,564 (2,418,700) 210,052
Page 10 of 14
Packet Pg. 145
2022
Monthly Report
City of Kent, Washington
Other Funds Overview (Revenues and Expenditures)
Actual Prelim Budget YTD
2020 2021 2022 2022
a
Operating revenues and expenditures only; capital and non-capital projects are excluded.
In instances where expenditures exceed revenues, fund balance is being utilized.
c
Unemployment c
Revenues 166,229 134,862 148,170 39,833 u_
Expenditures 151,350 161,765 219,010 34,490 c
Net Revenues Less Expenditures 14,879 (26,902) (70,840) 5,343 w
0
Workers Compensation >_
Revenues 1,551,522 1,019,589 1,468,360 363,206 N
Expenditures 2,106,616 1,788,435 1,575,610 660,531 N
Net Revenues Less Expenditures (555,093) (768,845) (107,250) (297,325;
c
Employee Health & Wellness
Revenues 15,929,224 15,795,365 15,580,790 3,974,599 Q.
Expenditures 14,097,298 14,736,998 15,580,790 3,390,841
Net Revenues Less Expenditures 1,831,926 1,058,367 583,758 R
U
Liability Insurance
Revenues 38,104 8,119,358 3,081,170 776,053
Expenditures 2,852,665 4,307,222 3,794,070 2,001,741 N
Net Revenues Less Expenditures (2,814,561) 3,812,136 (712,900) (1,225,689; N
Property Insurance
Revenues 578,755 605,819 785,750 195,403
Expenditures 587,011 677,950 785,750 355,389
Net Revenues Less Expenditures (8,257) (72,131) (159,986:
z
OtherO
O
LL
Impact Fee Trust Fund Z
Revenues 3,957,718 3,922,390 646,938
Expenditures 3,958,033 3,922,390 609,796 [Ono
Net Revenues Less Expenditures (315) 37,142
L
0
Other Fund Revenues Other Fund Expenditures0.
80,000,000 70,000,000 F0
o Special o Special
70,000,000 60,000,000 c
60,000,000 — Revenue Revenue
50,000,000 — Funds 50,000,000 Funds
LA Enterprise 40,000,000 U Enterprise u_
40,000,000 N
30,000,000 Funds 30,000,000 Funds c
20,000,000 20,000,000 N
o Internal o Internal
10,000,000 10,000,000 2
0kh Service 0 Service c`o
2020 2021 2022
Funds 2020 2021 2022 Funds r
Actuals Prelim Budget Actuals Prelim Budget
E
t
v
.r
Q
Page 11 of 14
Packet Pg. 146
March 2022 Monthly Report
City of Kent, Washington
Other Funds Overview (Revenues and Expenditures)
Year-to-Year Month Comparison
0
thru March thru March thru March Variance
a
m
Operating revenues and expenditures only; capital and non-capital projects are excluded.
Special Revenue Funds
c
0
c
Street Fund ii
Revenues 3,196,891 3,465,254 3,919,354 454,101 13.10/a c
Expenditures 1,836,752 2,360,680 3,469,826 1,109,146 47.00/c w
Net Revenues Less Expenditures 1,360,138 1,104,574 449,529
LEOFF I Retiree Benefits04
Revenues 144,390 210,751 271,160 60,408 28.70/c N
Expenditures 390,904 365,610 366,668 1,058 0.30/c
Net Revenues Less Expenditures (246,514) (154,858) (95,508) coo
Lodging Tax Q.
Revenues 55,518 31,623 330,474 298,852 945.10/c
Expenditures 86,757 42,304 3,522 (38,782) -91.70/c R
Net Revenues Less Expenditures (31,238) (10,681) 326,953 c
c�
c
Youth/Teen Programs ii
Revenues 263,395 264,975 284,047 19,072 7.20/c N
Expenditures 1,773 1,950 1,570 (380) -19.50/c N
Net Revenues Less Expenditures 261,623 263,025 282,477
L
Capital Resources
Revenues 5,795,372 3,617,325 6,292,583 2,675,258 74.00/c
Expenditures 223,187 1,175,876 467,307 (708,568) -60.3%
Net Revenues Less Expenditures 5,572,186 2,441,449 5,825,276 Z
O
O
Criminal Justice U_
Revenues 2,500,238 2,095,031 2,414,459 319,428 15.20/c Z
Expenditures 1,393,772 1,518,401 2,003,906 485,505 32.00/c co
Net Revenues Less Expenditures 1,106,466 576,629 410,552 v'
M
Human Services
0
Revenues 319,471 980,534 661,063 206.90/c
Expenditures 8,931 8,931
Net Revenues Less Expenditures 319,471 971,602
c
ShoWare Operating
Revenues 23,196 855 (855) -100.0% ii
Expenditures (86,640) 513,399 666,838 153,439 29.90/c N
Net Revenues Less Expenditures 109,836 (512,544) (666,838) N
t
Admissions Tax revenues received quarterly (April, July, September, January) 2
0
Other Operating
r
Revenues
m
Expenditures 61,520 3,378 258 (3,120) -92.4% E
Net Revenues Less Expenditures (61,520) (3,378) (258)
Combines several small programs, including City Art Program and Neighborhood Matching Grants Q
Page 12 of 14 1 Packet Pg. 147
March 2022 Monthly Report
City of Kent, Washington
Other Funds Overview (Revenues and Expenditures)
Year-to-Year Month Comparison
0
thru March thru March thru March Variance
a
m
Operating revenues and expenditures only; capital and non-capital projects are excluded.
Debt Service Funds
c
0
c
Councilmanic Debt Service ii
Revenues
c
Expenditures 31,424 6,493 9,933 3,440 53.00/c w
Net Revenues Less Expenditures (31,424) (6,493) (9,933)
Debt service payments are generally due in June and December. r
N
Special Assessments Debt Service N
Revenues 86,012 130,440 10,364 (120,076) -92.10/c
Expenditures 325,797 1,528 1,633 105 6.90/c 0
Net Revenues Less Expenditures (239,786) 128,912 8,731 V_
0
Q.
Enterprise Funds
a�
R
U
Water Utility
Revenues 6,688,153 6,823,530 6,180,955 (642,576) -9.4% S
LL
Expenditures 3,785,504 3,800,782 3,912,230 111,448 2.90/c N
Net Revenues Less Expenditures 2,902,650 3,022,748 2,268,724 c
N
Sewer Utility
Revenues 8,578,450 8,634,529 8,813,004 178,474 2.10/c "M
Expenditures 7,195,285 7,450,575 7,990,813 540,237 7.30/c
Net Revenues Less Expenditures 1,383,165 1,183,954 822,191 J
z
Drainage Utility O
Revenues 5,658,952 5,836,215 6,125,257 289,042 5.00/c 0
Expenditures 3,263,039 4,369,041 4,166,677 (202,363) -4.60/c z_
Net Revenues Less Expenditures 2,395,913 1,467,174 1,958,579
00
Solid Waste Utility M
Revenues 168,427 168,000 168,159 160 0.1O/C ..
Expenditures 285,879 221,284 319,865 98,581 44.50/c o
Net Revenues Less Expenditures (117,451) (53,285) (151,706)
Golf Complex
Revenues 164,779 312,546 457,175 144,629
Expenditures 573,372 2,326,718 649,142 (1,677,576) -72.10/.
Net Revenues Less Expenditures (408,594) (2,014,172) (191,967)
ii
N
N
Internal Service Funds O
N
t
Fleet Services 2
Revenues 1,342,998 1,403,565 1,441,222 37,657 2.70/c
Expenditures 1,189,557 1,166,339 1,295,954 129,615 11.10/c r
Net Revenues Less Expenditures 153,441 237,226 145,268 m
E
Central Services
0
Revenues 88,153 84,131 63,397 (20,734)
Expenditures 100,360 54,827 25,892 (28,935) -52.8% Q
Net Revenues Less Expenditures (12,207) 29,304 37,505
Page 13 of 14 Packet Pg. 148
2022 Monthly Report
City of Kent, Washington
Other Funds Overview (Revenues and Expenditures)
Year-to-Year Month Comparison
0
thru March thru March thru March Variance
a
m
Operating revenues and expenditures only; capital and non-capital projects are excluded.
Information Technology
Revenues 2,241,093 2,330,318 2,790,973 460,655 19.80/c
Expenditures 2,713,410 2,564,049 2,904,826 340,776 13.30/c ii
Net Revenues Less Expenditures (472,317) (233,732) (113,853)
w
Facilities
Revenues 1,298,124 1,373,304 1,376,075 2,771 0.20/c
Expenditures 1,109,087 1,046,071 1,166,024 119,953 11.50/c r
Net Revenues Less Expenditures 189,037 327,233 210,052 c
N
Unemployment
Revenues 35,178 39,567 39,833 266 0.70/c cco
Expenditures 55,871 63,393 34,490 (28,903) -45.60/c o
Net Revenues Less Expenditures (20,694) (23,825) 5,343
Workers Compensation
Revenues 282,663 178,517 363,206 184,689 103.5%
Expenditures 384,940 345,040 660,531 315,492 91.40/c
Net Revenues Less Expenditures (102,278) (166,523) (297,325)
Employee Health & Wellness N
Revenues 3,208,359 4,027,290 3,974,599 (52,691) -1.3% N
Expenditures 3,431,919 3,264,889 3,390,841 125,952 3.9%
Net Revenues Less Expenditures (223,560) 762,401 583,758
Liability Insurance
Revenues 748,796 805,745 776,053 (29,692) -3.7% J
Expenditures 1,012,520 1,634,883 2,001,741 366,858 22.40/c O
Net Revenues Less Expenditures (263,724) (829,138) (1,225,689) 0
w
Property Insurance Z
Revenues 144,918 153,832 195,403 41,571 27.0%
00
Expenditures 250,531 305,368 355,389 50,021 16.4%
Net Revenues Less Expenditures (105,613) (151,536) (159,986) �?
FundsOther 0
Impact Fee Trust Fund
Revenues 646,938 646,938
Expenditures 609,796 609,796
Net Revenues Less Expenditures 37,142
c
Other Fund Revenues thru March Other Fund Expenditures thru March N
0
25,000,000 18,000,000 N
16,000,000 2
20,000,000 - 14,000,000
12,000,000
15,000,000 10,000,000
■2020
■2020 8,000,000 t
10,000,000 v
0 2021 6,000,000 0 2021 �
5,000,000 4,000,000 u 2022 Q
u 2022 2,000,000 ti
0 0
Special Enterprise Internal Special Enterprise Internal
Revenue Funds Service Funds Revenue Funds Service
Funds Funds Fu
Page 14 of 14 1 Packet Pg. 149