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City Council Committees - Operations and Public Safety Committee - 03/21/2023 (2)
4^* Operations and Public Safety • Committee KEN T SPECIAL MEETING WAS H I N GTO N Tuesday, March 21, 2023 5:00 PM Chambers To listen to this meeting, call 1-888-475-4499 or 1-877-853-5257 and enter Meeting ID 867 9911 3935 Passcode: 517517 Chair Bill Boyce Councilmember Brenda Fincher Councilmember Satwinder Kaur Councilmember Marli Larimer Councilmember Zandria Michaud Councilmember Les Thomas Councilmember Toni Troutner ************************************************************** Item Description Action Speaker Time 1. Call to Order Chair 2. Roll Call Chair 3. Agenda Approval Chair 4. Business Chair 1. Approval of Minutes Approval of March 7, 2023 YES Chair 01 MIN. Minutes 2. Payment of Bills - Approve YES Paula Painter 05 MIN. 3. Medical, Stop Loss and YES Laura Horea 10 MIN. Wellness Vendor Contracts - Authorize 5. Adjournment Chair The public may submit written public comments that relate to a committee agenda item by emailing: cityclerk@kentwa.gov by 3:30 p.m. on the day of this committee meeting. After 3:30 p.m., written public comments may only be submitted in person by presenting them to the committee secretary at the public meeting. Written public comments that do not relate to a committee agenda item are not permitted. Written public comments are not read into the record. Operations and Public Safety Committee CC Ops and March 21, 2023 PS Special Meeting Unless otherwise noted, the Operations and Public Safety Committee meets at 4 p.m. on the first and third Tuesday of each month in the Kent City Hall, Council Chambers, 220 Fourth Avenue South, Kent, WA 98032 For additional information please contact Kim Komoto at 253-856-5728, or email 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. Pending Approval Operations and Public Safety KENT Committee WA9H... CC Ops and PS Regular Meeting Minutes March 7, 2023 Date: March 7, 2023 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 c Toni Troutner Councilmember 0 L Agenda: a a 1. Call to Order 4:01 p.m. a Council President Boyce called the meeting to order. o 2. Roll Call N 0 N Attendee Name Title Status Arrived Bill Boyce Chair Present Brenda Fincher Councilmember Present 0 Satwinder Kaur Councilmember Excused Marli Larimer Councilmember Remote Zandria Michaud Councilmember Present Les Thomas Councilmember Present Toni Troutner Councilmember Present CC .- 0 3. Agenda Approval a 1. I move to approve the agenda as presented a 0 c RESULT: MOTION PASSES [UNANIMOUS] MOVER: Les Thomas, Councilmember SECONDER: Toni Troutner, Councilmember AYES: Boyce, Fincher, Larimer, Michaud, Thomas, Troutner 4. Business 1. Approval of Minutes Approval of Minutes dated February 21, 2023 MOTION: Move to approve the Minutes dated February 21, 2023 ......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Page I of 2 Packet Pg. 3 Operations and Public Safety Committee CC Ops March 7, 2023 and PS Regular Meeting Kent, Washington Minutes ......................................................................................................................................................................................................................................................................................................._............................................................................................................................................................................................................... RESULT: APPROVED [UNANIMOUS] MOVER: Les Thomas, Councilmember SECONDER: Toni Troutner, Councilmember AYES: Boyce, Fincher, Larimer, Michaud, Thomas, Troutner 2. Payment of Bills - Approve MOTION: I move to approve the payment of bills. RESULT: MOTION PASSES [UNANIMOUS] Next: 3/21/2023 7:00 PM N MOVER: Les Thomas, Councilmember SECONDER: Toni Troutner, Councilmember AYES: Boyce, Fincher, Larimer, Michaud, Thomas, Troutner - 3. INFO ONLY: Fourth Quarter 2022 Investment Report o 0 Cash and Investment Officer, Joe Bartlemay present the fourth quarter 2022 a Investment Report. Q Bartlemay reviewed the details of the investment portfolio that includes cash, o funds in the Washington state LGIP, and the PFM Managed Portfolio. M N The five quarter comparison of cash and investments by type for the 2021 N Q4 and 2022 Q1-Q4. Bartlemay reviewed the cash and investments month ending balances for 2020-2022. Quarterly interest earnings over five quarters Q4, 2021 and Q1-Q4, 2022 were reviewed. 4- 0 Total cash and investments by fund ending December 31, 2022 were reviewed, along with the PFM Managed long-term portfolio summary. Bartlemay advised the City is well within portfolio compliance policy allocations. Bartlemay also reviewed the quarterly sector allocations throughout 2022. a a� S. Adjournment 4:09 p.m. Q Council President Boyce adjourned the meeting. r Ki,m b-eA,e�y Kv-ww-to- 0 Committee Secretary ......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Page 2 of 2 Packet Pg. 4 4.2 FINANCE DEPARTMENT Paula Painter, CPA 220 Fourth Avenue South \117KENT Kent, WA 98032 WASHINGTON 253-856-5264 DATE: March 21, 2023 TO: Operations and Public Safety Committee SUBJECT: Payment of Bills - Approve MOTION: I move to approve the payment of bills. SUMMARY: BUDGET IMPACT: Packet Pg. 5 4.3 HUMAN RESOURCES DEPARTMENT Natalie Winecka, Interim Human Resources Director • 220 Fourth Avenue South KENT Kent, WA 98032 W A S H i N G T O N 253-856-5270 DATE: March 21, 2023 TO: Operations and Public Safety Committee SUBJECT: Medical, Stop Loss and Wellness 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 • Stop Loss Insurance with LifeWise for one year • Wellness platform with Vitality Group for 3 years and 9 months with the option to renew automatically for a successive period of 1 year each, all subject to approval of final terms and conditions acceptable to the Interim Human Resources Director and the City Attorney. SUMMARY: Medical The City contracts with Kaiser Permanente for the City's fully insured health maintenance organization plan (HMO). The renewal has a 4.9% rate increase for 2023. Stop Loss The City contracts with LifeWise Assurance Company for our individual and aggregate stop loss insurance coverage. The best offer received for 2023 was from LifeWise with a 10.5% increase. Contracting with LifeWise provides us 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. Wellness Employee health and well-being continues to be a priority for the City. Vitality's Wellness platform offers a solid plan design and meets the functionality needs of our employees and is critical for our Wellness Program. The renewal has a 4.3% increase ($1,686 annual increase) Packet Pg. 6 4.3 Staff recommends these renewals based on the strength of their plans, overall costs, customer service, discounts, and overall administration and billing accuracy. BUDGET IMPACT: The cost for these contracts is budgeted in the Health and Wellness fund. Kaiser Permanente - $484,789 for a 1-year contract LifeWise - $1,189,290 for a 1-year contract Vitality - $40,622 for a 3-year and 9 months contract SUPPORTS STRATEGIC PLAN GOAL: Sustainable Services - Providing quality services through responsible financial management, economic growth, and partnerships. ATTACHMENTS: 1. Kaiser - Agreement 2023 (PDF) 2. LifeWise - Amendment 2023 (PDF) 3. Vitality SOW 3 April 2023 to December 2026 (PDF) Packet Pg. 7 4.3.a KAISER PERMANENTEO Kaiser Foundation Health Plan of Washington A nonprofit health maintenance organization a� N 0 t r� 7 Group Medical Coverage Agreement Q L Kaiser Foundation Health Plan of Washington("KFHPWA")is a nonprofit health maintenance organization,duly O 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 w enrolled under this Group Agreement are entitled. 0 c The Group Medical Coverage Agreement between KFHPWA and the Group consists of the following: • Standard Provisions U) • Evidence of Coverage 0. 0 City of Kent,#0036900 M 0 This Group Agreement will continue in effect until terminated or renewed as herein provided for and is effective January 1,2023. 0 0 LO M M N O N r C N E N N L Q d M Y c d E t v r Q COB5710036900 1 Packet Pg. 8 4.3.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 N received on or before the due date and is subject to a grace period of 10 days.Premiums are subject to change o by KFHPWA upon 30 days written notice. Premium rates will be revised as a part of the annual renewal process. Q KFHPWA reserves the right to re-rate this benefit package if the demographic characteristics change by more than 15%. i c 3. Dissemination of Information. V Unless the Group has accepted responsibility to do so,KFHPWA will disseminate information describing `o benefits set forth in the EOC attached to this Group Agreement. m 4. Identification Cards. w KFHPWA will furnish cards,for identification purposes only,to all Members enrolled under this Group c Agreement. d 5. Administration of Group Agreement. vi KFHPWA may adopt reasonable policies and procedures to help in the administration of this Group Agreement. c This may include,but is not limited to,policies or procedures pertaining to benefit entitlement and coverage -J determinations. c .r 6. Modification of Group Agreement. M Except as required by federal and Washington State law,this Group Agreement may not be modified without 0 agreement between both parties. No oral statement of any person shall modify or otherwise affect the benefits,limitations and exclusions of this c Group Agreement,convey or void any coverage,increase or reduce any benefits under this Group Agreement or M be used in the prosecution or defense of a claim under this Group Agreement. M N 7. Indemnification. N KFHPWA agrees to indemnify and hold the Group harmless against all claims,damages,losses and expenses, including reasonable attorney's fees,arising out of KFHPWA's failure to perform,negligent performance or willful misconduct of its directors,officers,employees and agents of their express obligations under this Group Agreement. Q The Group agrees to indemnify and hold KFHPWA harmless against all claims,damages,losses and expenses, including reasonable attorney's fees,arising out of the Group's failure to perform,negligent performances or 2 willful misconduct of its directors,officers,employees and agents of their express obligations under this Group Y Agreement. c d The indemnifying party shall give the other party prompt notice of any claim covered by this section and t provide reasonable assistance(at its expense). The indemnifying party shall have the right and duty to assume U the control of the defense thereof with counsel reasonably acceptable to the other party.Either party may take Q 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. 2 Packet Pg. 9 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, N benefits,limitations,exclusions or provisions will go into effect as required by the governmental agency. All o 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 Q services and other benefits terminate the first of the month following 30 days after receipt of non-acceptance. 10. Grandfathered Health Plan. L For any coverage identified in an EOC as a"grandfathered health plan"under the Patient Protection and r_ Affordable Care Act(a/k/a the ACA),Group must immediately inform KFHPWA if this coverage does not V meet(or no longer meets)the requirements for grandfathered status including but not limited to any change in `o 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 N 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 — d 11. Confidentiality. vi Each party acknowledges that performance of its obligations under this Group Agreement may involve access c to and disclosure of data,procedures,materials,lists, systems and information,including medical records, _J employee benefits information,employee addresses,social security numbers,e-mail addresses,phone numbers c and other confidential information regarding the Group's employees(collectively the"information").The v� information shall be kept strictly confidential and shall not be disclosed to any third party other than: (i) M representatives of the receiving party(as permitted by applicable state and federal law)who have a need to 0 know such information in order to perform the services required of such party pursuant to this Group Agreement,or for the proper management and administration of the receiving party,provided that such representatives are informed of the confidentiality provisions of this Group Agreement and agree to abide by c them,(ii)pursuant to court order or(iii)to a designated public official or agency pursuant to the requirements of M federal,state or local law,statute,rule or regulation. The disclosing party will provide the other party with prompt notice of any request the disclosing party receives to disclose information pursuant to applicable legal N requirements,so that the other party may object to the request and/or seek an appropriate protective order N against such request.Each party shall maintain the confidentiality of medical records and confidential patient and employee information as required by applicable law. E a� a� 12. HIPAA. Q Definition of Terms.Terms used,but not otherwise defined,in this section shall have the same meaning as those terms have in the Health Insurance Portability and Accountability Act of 1996("HIPAA"). M Y Transactions Accepted.KFHPWA will accept Standard Transactions,pursuant to HIPAA,if the Group elects to transmit such transactions.The Group shall ensure that all Standard Transactions transmitted to KFHPWA by y the Group or the Group's business associates are in compliance with HIPAA standards for electronic E transactions. The Group shall indemnify KFHPWA for any breach of this section by the Group. U r 13. Termination of Entire Group Agreement. Q 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 3 Packet Pg. 10 4.3.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 N misrepresentation,fraud or omission of information by the other party in performance of its responsibilities o under this Group Agreement. Q c. Underwriting Guidelines.KFHPWA may terminate this Group Agreement in the event the Group no ' longer meets underwriting guidelines established by KFHPWA that were in effect at the time the Group was accepted. L c d. Federal or State Law.KFHPWA may terminate this Group Agreement in the event there is a change in V federal or state law that no longer permits the continued offering of the coverage described in this Group `0 Agreement. m 14. Withdrawal or Cessation of Services. w 0 m a. KFHPWA may determine to withdraw from a Service Area or from a segment of its Service Area after KFHPWA has demonstrated to the Washington State Office of the Insurance Commissioner that KFHPWA's clinical,financial or administrative capacity to service the covered Members would be vi exceeded. 0 J b. KFHPWA may determine to cease to offer the Group's current plan and replace the plan with another plan c offered to all covered Members within that line of business that includes all of the health care services v� covered under the replaced plan and does not significantly limit access to the services covered under the M replaced plan.KFHPWA may also allow unrestricted conversion to a fully comparable KFHPWA product. 0 13 m KFHPWA will provide written notice to each covered Member of the discontinuation or non-renewal of the plan at least 90 days prior to discontinuation. c U) M 15. Limitation on Enrollment. The Group Agreement will be open for applications for enrollment as described in the group master application. N Subject to prior approval by the Washington State Office of the Insurance Commissioner,KFHPWA may limit N 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. E a� a� 16. Acceptance of Group Agreement The Group agrees as having accepted the terms and conditions of this Group Agreement and any amendments Q issued during the term of this Group Agreement,upon receipt by KFHPWA of any amount of premium payment. M Y c d E t v r Q 4 Packet Pg. 11 4.3.a YourN O t Kaiser Foundation Health Plan of N Washington O Evidence of Coverage 0 y N O J Q O R v d O O LO M M . • N KAISER PERMAN ELATE® E O L Q d Y c aD E t r r Q Packet Pg. 12 4.3.a KAISER PERMANENTE® Kaiser Foundation Health Plan of Washington A nonprofit health maintenance organization a� N �L O Q N V L 2023 Evidence of Coverage O U L O S a) 3.1 N O J O_ O U) R v d O O LO M M N O N r C N E N N L Q d Y c m E t v r r Q CA-1888a23 1 COB571-0036900 Packet Pg. 13 4.3.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, N or toll-free in Washington, 1-888-901-4636. p z For children,the Member may designate a pediatrician as the primary care provider. Q The Member does not need Preauthorization from KFHPWA or from any other person (including a Network W Personal Physician) to access obstetrical or gynecological care from a health care professional in the KFHPWA L network who specializes in obstetrics or gynecology. The health care professional, however, may be required to r_ comply with certain procedures, including obtaining Preauthorization for certain services, following a pre-approved C) treatment plan, or procedures for obtaining Preauthorization. For a list of participating health care professionals `o who specialize in obstetrics or gynecology,please call Kaiser Permanente Member Services at(206)630-4636 in the Seattle area,or toll-free in Washington, 1-888-901-4636. Women's health and cancer rights If the Member is receiving benefits for a covered mastectomy and elects breast reconstruction in connection with the — mastectomy,the Member will also receive coverage for: • All stages of reconstruction of the breast on which the mastectomy has been performed. vi • Surgery and reconstruction of the other breast to produce a symmetrical appearance. c • Prostheses. Ja • Treatment of physical complications of all stages of mastectomy,including lymphedemas. c .r These services will be provided in consultation with the Member and the attending physician and will be subject to M the same Cost Shares otherwise applicable under the Evidence of Coverage(EOC). m Statement of Rights Under the Newborns' and Mothers' Health Protection Act Carriers offering group health coverage generally may not,under federal law,restrict benefits for any hospital length c LO of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery,or less than 96 hours following a cesarean section.However,federal law generally does not prohibit the mother's or newborn's attending provider,after consulting with the mother,from discharging the mother or newborn c earlier than 48 hours(or 96 hours as applicable).In any case,carriers may not,under federal law,require that a N r provider obtain authorization from the carrier for prescribing a length of stay not in excess of 48 hours(or 96 hours). Also,under federal law,a carrier may not set the level of benefits or out-of-pocket costs so that any later portion of E the 48-hour(or 96-hour)stay is treated in a manner less favorable to the mother or newborn than any earlier portion L of the stay. Q For More Information `m M KFHPWA will provide the information regarding the types of plans offered by KFHPWA to Members on request. Y 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. E z U r Q 2 COB571-0036900 Packet Pg. 14 4.3.a Table of Contents I. Introduction...................................................................................................................................................6 II. How Covered Services Work........................................................................................................................6 A. Accessing Care.........................................................................................................................................6 B. Administration of the EOC. .....................................................................................................................9 C. Assignment...............................................................................................................................................9 N D. Confidentiality..........................................................................................................................................9 0 E. Modification of the EOC..........................................................................................................................9 F. Nondiscrimination....................................................................................................................................9 Q G. Preauthorization.......................................................................................................................................9 0 H. Recommended Treatment. .....................................................................................................................10 L I. Second Opinions....................................................................................................................................10 r_ 0 J. Unusual Circumstances..........................................................................................................................10 V L K. Utilization Management.........................................................................................................................10 c III. Financial Responsibilities...........................................................................................................................11 > A. Premium.................................................................................................................................................11 w B. Financial Responsibilities for Covered Services....................................................................................11 c C. Financial Responsibilities for Non-Covered Services............................................................................11 IV. Benefits Details............................................................................................................................................12 AnnualDeductible.........................................................................................................................................12 N 0 Coinsurance...................................................................................................................................................12 0. LifetimeMaximum.......................................................................................................................................12 0 Out-of-pocket Limit......................................................................................................................................12 Pre-existing Condition Waiting Period.........................................................................................................12 0 13 Acupuncture..................................................................................................................................................13 AdvancedCare at Home................................................................................................................................13 0 AllergyServices............................................................................................................................................15 Q Ambulance....................................................................................................................................................15 `h Cancer Screening and Diagnostic Services...................................................................................................15 N 0 Circumcision.................................................................................................................................................16 N r ClinicalTrials................................................................................................................................................16 Dental Services and Dental Anesthesia.........................................................................................................16 4E) a) Devices,Equipment and Supplies(for home use).........................................................................................17 Diabetic Education,Equipment and Pharmacy Supplies ..............................................................................18 Q Dialysis(Home and Outpatient)....................................................................................................................18 N Drugs-Outpatient Prescription.....................................................................................................................19 Y EmergencyServices......................................................................................................................................22 c GenderHealth Services.................................................................................................................................22 d E Hearing Examinations and Hearing Aids......................................................................................................23 HomeHealth Care.........................................................................................................................................23 r Hospice..........................................................................................................................................................24 Q Hospital-Inpatient and Outpatient...............................................................................................................25 Infertility(including sterility)........................................................................................................................25 InfusionTherapy...........................................................................................................................................26 Laboratoryand Radiology.............................................................................................................................26 3 COB571-0036900 Packet Pg. 15 ManipulativeTherapy...................................................................................................................................27 Maternityand Pregnancy...............................................................................................................................27 MentalHealth and Wellness..........................................................................................................................28 Naturopathy...................................................................................................................................................29 NewbornServices.........................................................................................................................................29 NutritionalCounseling..................................................................................................................................30 Nutritional Thera 30 N 0 ObesityRelated Services...............................................................................................................................30 Z On the Job Injuries or Illnesses.....................................................................................................................31 Q Oncology.......................................................................................................................................................31 y Optical(vision)..............................................................................................................................................31 L OralSurgery..................................................................................................................................................32 0 OutpatientServices.......................................................................................................................................32 t� L Plastic and Reconstructive Surgery...............................................................................................................32 0 Podiatry.........................................................................................................................................................33 c PreventiveServices.......................................................................................................................................33 w Rehabilitation and Habilitative Care(massage,occupational,physical and speech therapy,pulmonary and cardiac rehabilitation)and Neurodevelopmental Therapy.....................................................................34 ReproductiveHealth......................................................................................................................................35 SexualDysfunction.......................................................................................................................................36 c SkilledNursing Facility.................................................................................................................................36 —J a Sterilization...................................................................................................................................................36 Substance Use Disorder.................................................................................................................................37 U) TelehealthServices.......................................................................................................................................39 0 Temporomandibular Joint(TMJ)..................................................................................................................40 TobaccoCessation.........................................................................................................................................40 0 Transplants....................................................................................................................................................40 LO UrgentCare...................................................................................................................................................41 M V. General Exclusions......................................................................................................................................41 N VI. Eligibility,Enrollment and Termination...................................................................................................43 N A. Eligibility. ..............................................................................................................................................43 c a� B. Application for Enrollment....................................................................................................................44 E a� C. When Coverage Begins..........................................................................................................................45 L a� D. Eligibility for Medicare..........................................................................................................................46 Q E. Termination of Coverage. ......................................................................................................................46 F. Continuation of Coverage Options.........................................................................................................46 cv VII. Grievances....................................................................................................................................................47 Y VIII. Appeals.........................................................................................................................................................48 c d IX. Claims...........................................................................................................................................................49 E X. Coordination of Benefits.............................................................................................................................50 U Definitions.....................................................................................................................................................50 r Order of Benefit Determination Rules...........................................................................................................52 Q Effect on the Benefits of this Plan.................................................................................................................53 Right to Receive and Release Needed Information.......................................................................................53 Facilityof Payment.......................................................................................................................................54 Rightof Recovery.........................................................................................................................................54 4 COB571-0036900 Packet Pg. 16 4.3.a Effectof Medicare.........................................................................................................................................54 XI. Subrogation and Reimbursement Rights..................................................................................................54 XII. Definitions....................................................................................................................................................56 a� N �L O Q N V L O U L O 13 C N N O J O_ O U) R v 13 d O CO LO M M N O N r C N E N N L Q d Y c m E t v r r Q 5 COB571-0036900 Packet Pg. 17 4.3.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 N Agreement between Kaiser Foundation Health Plan of Washington("KFHPWA")and the Group. The benefits were 0 approved by the Group who contracts with KFHPWA for health care coverage.This EOC is not the Group medical t coverage agreement itself.In the event of a conflict between the Group Medical Coverage Agreement and the EOC, < Q the EOC language will govern. 0 The provisions of the EOC must be considered together to fully understand the benefits available under the EOC. L Words with special meaning are capitalized and are defined in Section XII. r_ 0 c.� Contact Kaiser Permanente Member Services at 206-630-4636 or toll-free 1-888-901-4636 for benefits questions. `0 c II. How Covered Services Work A. Accessing Care. 1. Members are entitled to Covered Services from the following: Your Provider Network is KFHPWA's Core Network(Network). Members are entitled to Covered vi Services only at Network Facilities and Network Providers,except for Emergency services and care c pursuant to a Preauthorization. _J 0. 0 Benefits under this EOC will not be denied for any health care service performed by a registered nurse v� licensed to practice under chapter 18.88 RCW,if first,the service performed was within the lawful scope of M such nurse's license,and second,this EOC would have provided benefit if such service had been performed by a Doctor of Medicine licensed to practice under chapter 18.71 RCW. A listing of Core Network Personal Physicians,specialists,women's health care providers and KFHPWA- c designated Specialists is available by contacting Member Services or accessing the KFHPWA website at M www.kp.org/wa.Information available online includes each physician's location,education,credentials, and specialties.KFHPWA also utilizes Health Care Benefit Managers for certain services.To see a list of N Health Care Benefit Managers,go to hqps://healLhy.kaiselpermanente.org/washinaton/sLipport/forms n/support/forms and C14 click on the"Evidence of coverage"link. a� E Receiving Care in another Kaiser Foundation Health Plan Service Area If you are visiting in the service area of another Kaiser Permanente region,visiting member services may be available from designated providers in that region if the services would have been covered under this Q 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 Y call Kaiser Permanente Member Services at(206)630-4636 in the Seattle area,or toll-free in Washington, 1-888-901-4636.Information is also available online at y www.wa.kaiserpermanente.org/html/public/services/traveling E t U KFHPWA will not directly or indirectly prohibit Members from freely contracting at any time to obtain Q 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. 6 COB571-0036900 Packet Pg. 18 4.3.a 2. Primary Care Provider Services. KFHPWA recommends that Members select a Network Personal Physician when enrolling. One personal physician may be selected for an entire family,or a different personal physician may be selected for each family member.For information on how to select or change Network Personal Physicians,and for a list of participating personal physicians,call Kaiser Permanente Member Services at(206)630-4636 in the Seattle area,or toll-free in Washington at 1-888-901-4636 or by accessing the KFHPWA website at www.kp.ore/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, N contact Kaiser Permanente Member Services,who will ensure you have access to a personal physician by o contacting a physician's office to request they accept new Members. Q To find a personal physician,call Member Services or access the KFHPWA website at www.kp.org/wa to view physician profiles.Information available online includes each physician's location,education, W credentials,and specialties. M c For your personal physician,choose from these specialties: C) • Family medicine `o • Adult medicine/internal medicine • Pediatrics/adolescent medicine(for children up to 18) Be sure to check that the physician you are considering is accepting new patients. If our choice does not feel right after a few visits you can change our personal physician at an time for Y g �Y g Y P p Y Y any reason.If you don't choose a physician when you first become a KFHPWA member,we will match vi you with a physician to make sure you have one assigned to you if you get sick or injured. c J In the case that the Member's personal physician no longer participates in KFHPWA's network,the c Member will be provided access to the personal physician for up to 60 days following a written notice v� offering the Member a selection of new personal physicians from which to choose. M V 3. Specialty Care Provider Services. Unless otherwise indicated in Section 11.or Section IV.,Preauthorization is required for specialty care and specialists that are not KFHPWA-designated Specialists and are not providing care at facilities owned and c operated by Kaiser Permanente. LO M KFHPWA-designated Specialist. N Preauthorization is not required for services with KFHPWA-designated Specialists at facilities owned and N operated by Kaiser Permanente. To access a KFHPWA-designated Specialist,consult your KFHPWA personal physician.For a list of KFHPWA-designated Specialists,contact Member Services or view the E 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, Q neurology,obstetrics and gynecology,occupational medicine,oncology/hematology,ophthalmology, optometry,orthopedics,otolaryngology(ear,nose and throat),physical therapy, smoking cessation, 2 speech/language and learning services,substance use disorder and urology. Y 4. Hospital Services. d Non-Emergency inpatient hospital services require Preauthorization.Refer to Section IV. for more E information about hospital services. U M r 5. Emergency Services. Q 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. 7 COB571-0036900 Packet Pg. 19 4.3.a Members are covered for Emergency care and Medically Necessary urgent care anywhere in the world.If you think you are experiencing an emergency,go immediately to the nearest emergency care facility or call 911. Go to the closest urgent care center for an illness or injury that requires prompt medical attention but is not an emergency.Examples include,but are not limited to minor injuries,wounds,and cuts needing stiches;minor breathing issues;minor stomach pain.If 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. m N If you need Emergency care while traveling and are admitted to a non-network hospital,you or a family p member must notify us within 24 hours after care begins,or as soon as is reasonably possible.Call the notification line listed on the back of your KFHPWA Member ID card to help make sure your claim is Q 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. U) M L Access to non-Emergency care across the Core network service area:your Plan provides access to all r_ providers in the Core Network,including many physicians and services at Kaiser Permanente medical C) facilities and Core Network facilities across the state.Find links to providers at kp.org/wa/diregM or `o contact Member Services at 1-888-901-4636 for assistance. c m 6. Urgent Care. w Inside the KFHPWA Service Area,urgent care is covered at a Kaiser Permanente medical center,Kaiser c 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. vi For urgent care during office hours,you can call your personal physician's office first to see if you can get c a same-day appointment.If a physician is not available or it is after office hours,you may speak with a _J licensed care provider anytime at 1-800-297-6877 or 206-630-2244. You may also check c kp.org/wa/directory or call Member Services to find the nearest urgent care facility in your network. v� M 7. Women's Health Care Direct Access Providers. 0 Female Members may see a general and family practitioner,physician's assistant,gynecologist,certified nurse midwife,licensed midwife,doctor of osteopathy,pediatrician,obstetrician or advance registered nurse practitioner who is unrestricted in your KFHPWA Network to provide women's health care services c directly,without Preauthorization,for Medically Necessary maternity care,covered reproductive health M 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 N Physician had been consulted,subject to any applicable Cost Shares. If the Member's women's health care N 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 E KFHPWA providers,contact Member Services or view the Provider Directory located at www.kp.org/wa. L 8. Travel Advisory Service. Q 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 2 destination,activities,and medical history.The consultation is not a covered benefit and there is a fee for a Y KFHPWA Member using the service for the first time.Travel-related vaccinations and medications are usually not covered.Visit kp.org/wa/travel-service for more details. y E t 9. Process for Medical Necessity Determination. U Pre-service,concurrent or post-service reviews may be conducted. Once a service has been reviewed, Q additional reviews may be conducted. Members will be notified in writing when a determination has been made. First Level Review: 8 COB571-0036900 Packet Pg. 20 4.3.a First level reviews are performed or overseen by appropriate clinical staff using KFHPWA approved clinical review criteria.Data sources for the review include,but are not limited to,referral forms,admission request forms,the Member's medical record,and consultation with qualified health professionals and multidisciplinary health care team members.The clinical information used in the review may include treatment summaries,problem lists,specialty 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 N board-certified consultative specialist and such consultations will be documented in the review text.If the 0 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. Q Second Level(Practitioner)Review: M L The practitioner reviews the treatment plan and discusses,when appropriate,case circumstances and r_ 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 `0 board certified physicians from appropriate specialty areas to assist in making determinations of coverage and/or appropriateness.All such consultations will be documented in the review text.If the reviewer > determines that the admission,continued stay or service requested is not a covered service,a notice of non- N coverage is issued.Only a physician,behavioral health practitioner(such as a psychiatrist,doctoral-level clinical psychologist,certified addiction medicine specialist),dentist or pharmacist who has the clinical — expertise appropriate to the request under review with an unrestricted license may deny coverage based on Medical Necessity. 0 B. Administration of the EOC. KFHPWA may adopt reasonable policies and procedures to administer the EOC.This may include,but is not 0. limited to,policies or procedures pertaining to benefit entitlement and coverage determinations. v� M C. Assignment 0 13 The Member may not assign this EOC or any of the rights,interests,claims for money due,benefits,or obligations here under without prior written consent. 0 0 D. Confidentiality. M KFHPWA is required by federal and state law to maintain the privacy of Member personal and health information.KFHPWA is required to provide notice of how KFHPWA may use and disclose personal and N health information held by KFHPWA. The Notice of Privacy Practices is distributed to Members and is c014 available in Kaiser Permanente medical centers,at www.kp.org/wa,or upon request from Member Services. a� E E. Modification of the EOC. No oral statement of any person shall modify or otherwise affect the benefits,limitations and exclusions of the EOC,convey or void any coverage,increase or reduce any benefits under the EOC or be used in the prosecution Q or defense of a claim under the EOC. m F. Nondiscrimination. 0 Y 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 y basis of age,sex,sexual orientation,gender identity,race,color,religion,national origin,citizenship or E immigration status,veteran or military status,occupation or health status. U M r G. Preauthorization. Q Refer to Section IV. or Authorizations&Clinical Review Overview I Kaiser Permanente Washington for more information regarding which services,equipment and facility types 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. 9 COB571-0036900 Packet Pg. 21 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 decision will be made within 4 calendar days of receipt of the information or the deadline for receipt of N the requested information. `0 • Expedited requests—within 2 calendar days o If insufficient information has been provided a request for additional information will be made within Q 1 calendar day.The provider or facility has 2 calendar days to provide the necessary information.A N decision will be made within 2 calendar days of receipt of the information or the deadline for receipt of 0 the requested information. M c 0 H. Recommended Treatment. C) KFHPWA's medical director will determine the necessity,nature and extent of treatment to be covered in each 0 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 > 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. cd New and emerging medical technologies are evaluated on an ongoing basis by the following committees—the vi Interregional New Technologies Committee,Medical Technology Assessment Committee,Medical Policy 0 Committee,and Pharmacy and Therapeutics Committee. These physician evaluators consider the new J technology's benefits,whether it has been proven safe and effective,and under what conditions its use would be o appropriate. The recommendations of these committees inform what is covered on KFHPWA health plans. M I. Second Opinions. 13 The Member may access a second opinion from a Network Provider regarding a medical diagnosis or treatment plan. The Member may request Preauthorization or may visit a KFHPWA-designated Specialist for a second opinion.When requested or indicated,second opinions are provided by Network Providers and are covered with c Preauthorization,or when obtained from a KFHPWA-designated Specialist. Coverage is determined by the M Member's EOC;therefore,coverage for the second opinion does not imply that the services or treatments recommended will be covered.Preauthorization for a second opinion does not imply that KFHPWA will c authorize the Member to return to the physician providing the second opinion for any additional treatment. c14 Services,drugs and devices prescribed or recommended as a result of the consultation are not covered unless included as covered under the EOC. E aD aD J. Unusual Circumstances. In the event of unusual circumstances such as a major disaster,epidemic,military action,civil disorder,labor Q disputes or similar causes,KFHPWA will not be liable for administering coverage beyond the limitations of available personnel and facilities. M Y 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 d liability or obligation if Covered Services are delayed or unavailable due to unusual circumstances. t U K. Utilization Management. Q "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. 10 COB571-0036900 Packet Pg. 22 4.3.a KFHPWA will not deny coverage retroactively for services with Preauthorization and which have already been provided to the Member except in the case of an intentional misrepresentation of a material fact by the patient, Member,or provider of services,or if coverage was obtained based on inaccurate,false,or misleading information provided on the enrollment application,or for nonpayment of premiums. III. Financial Responsibilities m N A. Premium. p The Subscriber is liable for payment to the Group of their contribution toward the monthly premium,if any. Q B. Financial Responsibilities for Covered Services. N 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 M date.Charges will be for the lesser of the Cost Shares for the Covered Service or the actual charge for that r_ service. Cost Shares will not exceed the actual charge for that service. C) L O 1. Annual Deductible. c Covered Services may be subject to an annual Deductible. Charges subject to the annual Deductible shall be borne by the Subscriber during each year until the annual Deductible is met. Covered Services must be N received from a Network Provider at a Network Facility,unless the Member has received Preauthorization c or has received Emergency services. — d There is an individual annual Deductible amount for each Member and a maximum annual Deductible vi amount for each Family Unit.Once the annual Deductible amount is reached for a Family Unit in a c calendar year,the individual annual Deductibles are also deemed reached for each Member during that _J same calendar year. c .r Individual Annual Deductible Carryover.Under this EOC,charges from the last 3 months of the prior M year which were applied toward the individual annual Deductible will also apply to the current year :a individual annual Deductible.The individual annual Deductible carryover will apply only when expenses incurred have been paid in full.The Family Unit Deductible does not carry over into the next year. 0 0 2. Plan Coinsurance. `n M After the applicable annual Deductible is satisfied,Members may be required to pay Plan Coinsurance for M Covered Services. c N r 3. Copayments. Members shall be required to pay applicable Copayments at the time of service. Payment of a Copayment E does not exclude the possibility of an additional billing if the service is determined to be a non-Covered y Service or if other Cost Shares apply. Q 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. Y c C. Financial Responsibilities for Non-Covered Services. E The cost of non-Covered Services and supplies is the responsibility of the Member.The Subscriber is liable for t payment of any fees charged for non-Covered Services provided to the Subscriber and their Dependents at the U time of service.Payment of an amount billed must be received within 30 days of the billing date. Q 11 COB571-0036900 Packet Pg. 23 4.3.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. m N 0 t Annual Deductible Member pays$0 per Member per calendar year or$0 per Family Unit per calendar year Q Coinsurance Plan Coinsurance: Member pays nothing L c 0 0 Lifetime Maximum No lifetime maximum on covered Essential Health Benefits `- 13 Out-of-pocket Limit Limited to a maximum of$2,000 per Member or$4,000 per Family Unit per calendar year The following Out-of-pocket Expenses apply to the Out-of-pocket Limit: Ambulance coinsurance/Copayment,diagnostic laboratory and radiology Copayment,Emergency services Copayment,hospital inpatient Copayment,hospital outpatient Copayment, outpatient services Copayment,oral chemotherapy Copayment vi 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 c benefit,charges in excess of Allowed Amount,charges for non-Covered Services Pre-existing Condition No pre-existing condition waiting period 2 13 Waiting Period 0 0 U) M M N O N r C N E N N L Q d M Y c d E t v r Q 12 COB571-0036900 Packet Pg. 24 4.3.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 m N Preauthorization. 0 z No visit limit for treatment for Substance Use Disorder. Q Exclusions: Herbal supplements; any services not within the scope of the practitioner's licensure W M L Advanced Care at Home V L 0 Advanced Care at Home is a personalized,patient-centered No charge,Member pays nothing program that provides care for patients with certain clinical > conditions in their homes,or at another appropriate care N location such as a family member's home or temporary residence. — d Advanced Care at Home services must be associated with an vi acute episode in which the member is treated for a brief but c severe episode of illness,for conditions that are the result of disease such as,but not exclusive to,congestive heart failure, o pneumonia,upper urinary tract infection or cellulitis. The treatment plan may include restorative care associated with M the acute episode.The duration of an episode of care(which 0 13 includes acute and restorative phases)is limited to a total of 30 days. 0 0 To receive advanced care in the home: LO M • The member must be referred into the advanced care program by the managing provider at a Network c emergency room setting, c14 • Advanced Care at Home requires Preauthorization c a� based on the Member's health status,treatment plan, E and home setting or another appropriate care y location within the Service Area, Lai • The clinical condition must meet inpatient Medical Q Necessity criteria, `m • The Member must consent to receiving advanced 2 M care described in the treatment plan, 1 • The care location,such as the member's residence, must be within 30 minutes ground travel time of an d emergency department,and t • The care location,such as the member's residence, must,have cell service. Q Advanced Care at Home is provided through Medically Home,our Network provider,and will provide the following services in the Member's home or appropriate care location: • Home visits by RNs,physical therapists, 13 COB571-0036900 Packet Pg. 25 4.3.a occupational therapists,speech therapists,respiratory therapists,nutritionist,health aides,and other healthcare professionals in accordance with the Advanced Care at Home treatment plan and the provider's scope of practice and licensure. • Communication devices to allow the Member to contact the medical command center 24 hours a day, N 7 days a week.This includes needed communication o technology to support reliable connection for communication,and a personal emergency response 0 system alert device to contact the medical command Q center if the Member is unable to get to a phone. M L Additional services covered under this benefit include: c • The following equipment necessary to ensure that V you are monitored appropriately in your home:blood `o pressure cuff/monitor,pulse oximeter,scale,and thermometer. > • Mobile imaging and tests such as X-rays, w ultrasounds,and EKGs. w m • Safety items when Medically Necessary,such as E shower stools,raised toilet seats,grabbers,long handled shoehorn,and sock aids. vi • Meals when Medically Necessary while you are w 0 receiving advanced care at home will be provided through our network provider,Medically Home. 0 .r In addition,cost sharing is waived for the following covered M services and items when the services and items are prescribed 0 13 as part of your Advanced Care at Home treatment plan: • Durable Medical Equipment. • Medical Supplies. c • Member transportation to and from Network M facilities when Member transport is Medically Necessary will be arranged by Medically Home c based on the most appropriate mode of c14 transportation which could be ambulance,cabulance or otherwise. E • Physician Assistant and Nurse Practitioner house y calls. Lai • Emergency Department visits associated with this Q benefit. L m 2 The cost share is not waived and will apply to any services Y that are not part of your Advanced Care at Home treatment plan(for example,DME not specified in your Advanced Care E at Home treatment plan). t U 0 For outpatient prescription drug cost shares, see Drugs- Q Outpatient Prescription. Exclusions: Private Duty Nursing;housekeeping or meal services not part of your Advanced Care at Home treatment plan;any care provided by or for a family member;any other services rendered in the home which are not specified in 14 COB571-0036900 Packet Pg. 26 4.3.a your Advanced Care at Home treatment plan Allergy Services Allergy testing. Member pays$10 Copayment m N O Allergy serum and injections. Member pays$10 Copayment Z 0 Q U) Ambulance L c 0 Emergency ambulance service is covered only when: Member pays 20%ambulance coinsurance V L • Transport is to the nearest facility that can treat your 0 condition m • Any other type of transport would put your health or > safety at risk N • The service is from a licensed ambulance. c • The ambulance transports you to a location where you receive covered services. vi Emergency air or sea medical transportation is covered only 0 when: 0. 0 • The above requirements for ambulance service are met,and • Geographic restraints prevent ground Emergency 0 transportation to the nearest facility that can treat 3 your condition,or ground Emergency transportation would put your health or safety at risk c 0 LO M Non-Emergency ground or air interfacility transfer to or from Member pays 20%ambulance coinsurance N a Network Facility where you receive covered services when o N Preauthorized by KFHPWA.Contact Member Services for Hospital-to-hospital ground transfers:No charge; Preauthorization. Member pays nothing E a) a) L Cancer Screening and Diagnostic Services Q Routine cancer screening covered as Preventive Services in Member pays$10 Copayment N accordance with the well care schedule established by Y KFHPWA and the Patient Protection and Affordable Care Act of 2010.The well care schedule is available in Kaiser y Permanente medical centers,at www.kp.org/wa,or upon E t request from Member Services. See Preventive Services for U additional information. Q Diagnostic laboratory and diagnostic services for cancer. See No charge;Member pays nothing Diagnostic Laboratory and Radiology Services for additional information. Preventive laboratory/radiology services are covered as Preventive Services. 15 COB571-0036900 Packet Pg. 27 4.3.a Circumcision Circumcision. Hospital-Inpatient:No charge;Member pays nothing Non-Emergency inpatient hospital services require Preauthorization. Hospital-Outpatient: Member pays$10 N Copayment o t Outpatient Services:Member pays$10 Copayment Q U) Within 60 days of birth:No charge;Member pays L nothing 0 c.� L 0 Clinical Trials c m Notwithstanding any other provision of this document,the Hospital-Inpatient: N Plan provides benefits for Routine Patient Costs of qualified No charge;Member pays nothing c individuals in approved clinical trials,to the extent benefits — for these costs are required by federal and state law. Hospital-Outpatient: Member pays$10 Copayment vi Routine patient costs include all items and services consistent c with the coverage provided in the plan(or coverage)that is Outpatient Services: _J typically covered for a qualified individual who is not Member pays$10 Copayment 0. enrolled in a clinical trial. v� M Clinical trials are a phase I,phase II,phase III,or phase IV 0 13 clinical trial that is conducted in relation to the prevention, detection,or treatment of cancer or other life-threatening disease or condition."Life threatening condition"means any c disease or condition from which the likelihood of death is M probable unless the course of the disease or condition is interrupted. N 0 N Clinical trials require Preauthorization. a� E Exclusions: Routine patient costs do not include: (i)the investigational item,device,or service,itself;(ii)items and aD a� services that are provided solely to satisfy data collection and analysis needs and that are not used in the direct clinical management of the patient;or(iii)a service that is clearly inconsistent with widely accepted and established standards Q of care for a particular diagnosis M Y Dental Services and Dental Anesthesia d Dental services(i.e.,routine care,evaluation and treatment) Not covered;Member pays 100%of all charges t including accidental injury to natural teeth. U r Q Dental services in preparation for treatment including but not Hospital-Inpatient:No charge;Member pays limited to: chemotherapy,radiation therapy,and organ nothing transplants.Dental services in preparation for treatment require Preauthorization. Hospital-Outpatient: Member pays$10 Copayment 16 COB571-0036900 Packet Pg. 28 Dental problems such as infections requiring emergency treatment outside of standard business hours are covered as Outpatient Services:Member pays$10 Copayment Emergency Services. 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 or are physically or developmentally disabled or have a N Medical Condition where the Member's health would be put Hospital-Outpatient: Member pays$10 at risk if the dental procedure were performed in a dentist's Copayment z office. Q General anesthesia services for dental procedures require Preauthorization. M L Exclusions: Dentist's or oral surgeon's fees;dental care,surgery,services and appliances,including:treatment of C V accidental injury to natural teeth,reconstructive surgery to the jaw in preparation for dental implants,dental implants, `o periodontal surgery;any other dental service not specifically listed as covered 3 m Devices,Equipment and Supplies(for home use) c Durable medical equipment: Equipment which can withstand Member pays 20%coinsurance repeated use,is primarily and customarily used to serve a vi medical purpose,is useful only in the presence of an illness or c injury and is used in the Member's home. J Annual Deductible does not apply to strip-based o • Examples of covered durable medical equipment include: blood glucose monitors,test strips,lancets or control v� hospital beds,wheelchairs,walkers,crutches,canes, solutions. M blood glucose monitors,external insulin pumps 0 13 (including related supplies such as tubing,syringe cartridges,cannulae and inserters),oxygen and the rental of equipment to administer oxygen(including tubing, o 0 connectors,and masks),and therapeutic shoes, M modifications and shoe inserts for severe diabetic foot disease.KFHPWA will determine if equipment is made c available on a rental or purchase basis. c14 • Orthopedic appliances:Items attached to an impaired c body segment for the purpose of protecting the segment E or assisting in restoration or improvement of its function. y • Ostomy supplies: Supplies for the removal of bodily Q secretions or waste through an artificial opening. , • Post-mastectomy bras/forms,limited to 2 every 6 `m months.Replacements within this 6-month period are 2 M covered when Medically Necessary due to a change in Y the Member's condition. • Prosthetic devices: Items which replace all or part of an d external body part,or function thereof. t • Sales tax for devices,equipment and supplies. r Q When provided in lieu of hospitalization,benefits will be the greater of benefits available for devices,equipment and supplies,home health or hospitalization. See Advanced Care at Home for durable medical equipment provided in an Advanced Care at Home setting. See Hospice for durable 17 COB571-0036900 Packet Pg. 29 4.3.a medical equipment provided in a hospice setting. Devices,equipment and supplies including repair,adjustment or replacement of appliances and equipment require Preauthorization. Exclusions:Arch supports,including custom shoe modifications or inserts and their fittings not related to the N 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 o 0 listed as covered above; same as or similar equipment already in the Member's possession;replacement or repair due Q 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 M L ++ r_ Diabetic Education,Equipment and Pharmacy Supplies V L 0 Diabetic education and training. Member pays$10 Copayment m Diabetic equipment:Blood glucose monitors and external Member pays 20%coinsurance insulin pumps(including related supplies such as tubing, — syringe cartridges,cannulae and inserters),and therapeutic Annual Deductible does not apply to strip-based : shoes,modifications and shoe inserts for severe diabetic foot blood glucose monitors,test strips,lancets or control vi disease. See Devices,Equipment and Supplies for additional solutions. c information. J a 0 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 M needles,glucagon emergency kits,prescriptive oral agents 0 13 and blood glucose test strips for a supply of 30 days or less Preferred brand name drugs(Tier 2): Member m per item.Certain brand name insulin drugs will be covered at pays$10 Copayment per 30-days up to a 90-day the generic level. See Drugs—Outpatient Prescription for supply c additional pharmacy information. M Non-Preferred generic and brand name drugs (Tier 3):Not covered;Member pays 100%of all c charges c14 r c a� E Annual Deductible does not apply to strip-based y blood glucose monitors,test strips,lancets or control solutions. Q Note:A Member will not pay more than$35,not m subject to the Deductible,for a 30-day supply of Y insulin to comply with state law requirements.Any cost sharing paid will apply toward the annual d Deductible. E z U 0 Diabetic retinal screening. No charge;Member pays nothing Q Dialysis(Home and Outpatient) Dialysis in an outpatient or home setting is covered for Outpatient Services:Member pays$10 Copayment 18 COB571-0036900 Packet Pg. 30 4.3.a Members with acute kidney failure or end-stage renal disease (ESRD). Dialysis requires Preauthorization. Injections administered by a Network Provider in a clinical Outpatient Services:Member pays$10 Copayment setting during dialysis. N Self-administered injectables. See Drugs—Outpatient Preferred generic drugs(Tier 1): Member pays 0 Prescription for additional pharmacy information. $10 Copayment per 30-days up to a 90-day supply 3 Q Preferred brand name drugs(Tier 2): Member pays$10 Copayment per 30-days up to a 90-day L supply 0 0 Non-Preferred generic and brand name drugs `o (Tier 3):Not covered;Member pays 100%of all 3 charges m Drugs-Outpatient Prescription E d Prescription drugs,supplies and devices for a supply of 30 Preferred generic drugs(Tier 1): Member pays vi days or less including diabetic pharmacy supplies(insulin, $10 Copayment per 30-days up to a 90-day supply c lancets,lancet devices,needles,insulin syringes,disposable J insulin pens,pen needles and blood glucose test strips), Preferred brand name drugs(Tier 2): Member c mental health and wellness drugs, self-administered pays$10 Copayment per 30-days up to a 90-day injectables,medications for the treatment arising from sexual supply M assault,and routine costs for prescription medications 0 13 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 c is not enrolled in a clinical trial. LO M All drugs,supplies and devices must be obtained at a Annual Deductible does not apply to strip-based N KFHPWA-designated pharmacy except for drugs dispensed blood glucose monitors,test strips,lancets or control N for Emergency services or for Emergency services obtained solutions. c outside of the KFHPWA Service Area,including out of the E E country.Information regarding KFHPWA-designated Note:A Member will not pay more than$35,not a) a) pharmacies is reflected in the KFHPWA Provider Directory subject to the Deductible,for a 30-day supply of or can be obtained by contacting Kaiser Permanente Member insulin to comply with state law requirements.Any Q Services. cost sharing paid will apply toward the annual Deductible. N Prescription drug Cost Shares are payable at the time of Y delivery.Certain brand name insulin drugs are covered at the generic drug Cost Share. d E t Members may be eligible to receive an emergency fill for U certain prescription drugs filled outside of KFHPWA's Q business hours or when KFHPWA cannot reach the prescriber for consultation.For emergency fills,Members pay the prescription drug Cost Share for each 7-day supply or less,or the minimum packaging size available at the time the emergency fill is dispensed.A list of prescription drugs 19 COB571-0036900 Packet Pg. 31 4.3.a eligible for emergency fills is available on the pharmacy website at www.kp.oriz/wa/formulary.Members can request an emergency fill by calling 1-855-505-8107. Certain drugs are subject to Preauthorization as shown in the Preferred drug list(formulary)available at www.kp.orgg/wa/formulary. N For outpatient prescription drugs and/or items that are 0 covered under the Drugs—Outpatient Prescription section and 3 obtained at a pharmacy owned and operated by KFHPWA,a Q Member may be able to use approved manufacturer coupons N as payment for the Cost Sharing that a Member owes,as L allowed under KFHPWA's coupon program.A Member will c owe any additional amount if the coupon does not cover the 0 entire amount of the Cost Sharing for the Member's c prescription.When a Member uses an approved coupon for payment of their Cost Sharing,the coupon amount and any additional payment that you make will accumulate to their w Out-of-Pocket Limit.More information is available regarding w m the Kaiser Permanente coupon program rules and limitations at kp.or /g rxcoupons. Injections administered by a Network Provider in a clinical Member pays$10 Copayment U) setting. � a 0 Over-the-counter drugs not included under Reproductive Not covered;Member pays 100%of all charges Health M 0 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 0 Annual Deductible does not apply to strip-based Ln blood glucose monitors,test strips,lancets or control solutions. M N O N Note:A Member will not pay more than$35,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 L Deductible. Q The KFHPWA Preferred drug list is a list of prescription drugs,supplies,and devices considered to have acceptable N efficacy,safety and cost-effectiveness. The Preferred drug list is maintained by a committee consisting of a group of M Y 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 y generally have better scientific evidence for safety and effectiveness and are more affordable than Non-Preferred E drugs.The preferred drug list is available at www.kp.org/wa/formul4a,or upon request from Member Services. U 0 r Members may request a coverage determination by contacting Member Services. Coverage determination reviews Q 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. 20 COB 5 71-0036900 Packet Pg. 32 Prescription drugs are drugs which have been approved by the Food and Drug Administration(FDA)and which can, under federal or state law,be dispensed only pursuant to a prescription order.These drugs,including off-label use of FDA-approved drugs(provided that such use is documented to be effective in one of the standard reference compendia;a majority of well-designed clinical trials published in peer-reviewed medical literature document improved efficacy or safety of the agent over standard therapies,or over placebo if no standard therapies exist;or by the federal secretary of Health and Human Services)are covered. "Standard reference compendia"means the American Hospital Formulary Service—Drug Information;the American Medical Association Drug Evaluation;the N 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 z printed in health care journals or other publications in which original manuscripts are published only after having been Q 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. N M Generic drugs are dispensed whenever available. A generic drug is a drug that is the pharmaceutical equivalent to one W or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting C the same standards of safety,purity,strength and effectiveness as the brand name drug. Brand name drugs are c 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 m Drug coverage is subject to utilization management that includes Preauthorization,step therapy(when a Member tries a certain medication before receiving coverage for a similar,but non-Preferred medication),limits on drug quantity or days supply and prevention of overutilization,underutilization,therapeutic duplication,drug-drug interactions, incorrect drug dosage,drug-allergy contraindications and clinical abuse/misuse of drugs.If a Member has a new N prescription for a chronic condition,the Member may request a coordination of medications so that medications for 0 chronic conditions are refilled on the same schedule(synchronized).Cost-shares for the initial fill of the medication c will be adjusted if the fill is less than the standard quantity.Please contact Member Services for more information. Specialty drugs are high-cost drugs prescribed by a physician that requires close supervision and monitoring for 0 serious and/or complex conditions,such as rheumatoid arthritis,hepatitis or multiple sclerosis. Specialty drugs must 3 be obtained through KFHPWA's preferred specialty pharmacy vendor and/or network of specialty pharmacies and are 2 covered at the appropriate cost share above.For a list of specialty drugs or more information about KFHPWA's c specialty pharmacy network,please go to the KFHPWA website at www.kp.org/wa/formulary or contact Member Q Services at 206-630-4636 or toll-free at 1-888-901-4636. M M The Member's Right to Safe and Effective Pharmacy Services: State and federal laws establish standards to assure N 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 E 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 i may not conform to the terms of the EOC,may contact the Washington State Office of Insurance Commissioner at N toll-free 1-800-562-6900.Members who have a concern about the pharmacists or pharmacies serving them may call Y the Washington State Department of Health at toll-free 1-800-525-0127. c d Prescription Drug Coverage and Medicare: This benefit,for purposes of Creditable Coverage,is actuarially equal E 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 r in a Medicare Part D plan at a later date;however,the Member could be subject to payment of higher Part D Q 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. 21 COB571-0036900 Packet Pg. 33 Exclusions: Over-the-counter drugs,supplies and devices not requiring a prescription under state law or regulations; drugs and injections for anticipated illness while traveling;drugs and injections for cosmetic purposes;vitamins, including most prescription vitamins;replacement of lost, stolen,or damaged drugs or devices;administration of excluded drugs and injectables;drugs used in the treatment of sexual dysfunction disorders;compounds which include a non-FDA approved drug;growth hormones for idiopathic short stature without growth hormone deficiency; prescription drugs/products available over-the-counter or have an over-the-counter alternative that is determined to be therapeutically interchangeable. N 0 z Emergency Services Q Emergency services at a Network Facility or non-Network Network Facility: Member pays$75 Copayment Facility. See Section XII.for a definition of Emergency. L Non-Network Facility: Member pays$125 r_ Emergency services include professional services,treatment Copayment V and supplies,facility costs,outpatient charges for patient `0 observation,medical screening exams required to stabilize a patient,and post stabilization treatment. m w Members must notify KFHPWA by way of the Hospital aa) notification line within 24 hours of any admission,or as soon E thereafter as medically possible. vi If a Member is admitted as an inpatient or to Advanced Care w 0 at Home directly from an emergency department,any _J Emergency services Copayment is waived.Coverage is 0 subject to the hospital services Cost Share. v� M If two or more Members in the same Family Unit require 0 13 Emergency services as a result of the same accident,coverage for all Members will be subject to only one Emergency services Copayment. 00 LO If a Member is hospitalized in a non-Network Facility, M KFHPWA reserves the right to require transfer of the N Member to a Network Facility upon consultation between a N Network Provider and the attending physician.If the Member refuses to transfer to a Network Facility or does not notify KFHPWA within 24 hours following admission,all further costs incurred during the hospitalization are the responsibility of the Member. Q Follow-up care which is a direct result of the Emergency must U)i be received from a Network Provider,unless Preauthorization M Y is obtained for such follow-up care from a non-Network c Provider. y E t U Gender Health Services Q Medically Necessary medical and surgical services for gender Hospital-Inpatient:No charge;Member pays affirmation. Consultation and treatment requires nothing Preauthorization. Hospital-Outpatient: Member pays$10 22 COB 5 71-0036900 Packet Pg. 34 4.3.a Prescription drugs are covered the same as for any other Copayment condition(see Drugs-Outpatient Prescription for coverage). Outpatient Services:Member pays$10 Copayment Counseling services are covered the same as for any other condition(see Mental Health and Wellness for coverage). Non-Emergency inpatient hospital services require Preauthorization. N 0 z Exclusions: Cosmetic services and surgery not related to gender affirming treatment(i.e.,face lift or calf implants), Q complications of non-Covered Services M L Hearing Examinations and Hearing Aids o V Hearing exams for hearing loss and evaluation are covered Hospital-Inpatient: `o only when provided at KFHPWA-approved facilities. No charge;Member pays nothing c m Cochlear implants or Bone Anchored Hearing System Hospital-Outpatient: w (BAHS)when in accordance with KFHPWA clinical criteria. Member pays$10 Copayment m c Covered services for initial cochlear implants and BAHS Outpatient Services: include diagnostic testing,pre-implant testing,implant Member pays$10 Copayment vi surgery,post-implant follow-up,speech therapy, w 0 programming and associated supplies(such as transmitter cable,and batteries). 0 .r Replacement devices and associated supplies—see Devices, M Equipment and Supplies Section. 0 13 m Hearing aids including hearing aid examinations. Not covered;Member pays 100%of all charges 0 Exclusions: Programs or treatments for hearing loss or hearing care including,but not limited to,externally worn M hearing or surgically implanted hearing aids and the surgery and services necessary to implant them except as described above;hearing screening tests required under Preventive Services N 0 N r C N Home Health Care E a) a) L Home health care when the following criteria are met: No charge;Member pays nothing Q • 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 2 for transportation does not constitute inability to leave the Y home. c • The Member requires intermittent skilled home health d care,as described below. z • KFHPWA's medical director determines that such 2 services are Medically Necessary and are most Q 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 23 COB 5 71-0036900 Packet Pg. 35 4.3.a physical,occupational,respiratory and speech therapy; durable medical equipment;medical social worker and limited home health aide services. Home health services are covered on an intermittent basis in the Member's home."Intermittent"means care that is to be rendered because of a medically predictable recurring need for skilled home health care. "Skilled home health care" means reasonable and necessary care for the treatment of an z illness or injury which requires the skill of a nurse or Q therapist,based on the complexity of the service and the , condition of the patient and which is performed directly by an N appropriately licensed professional provider. L c Home health care requires Preauthorization. C V L Exclusions: Private Duty Nursing;housekeeping or meal services; any care provided by or for a family member;any 3 other services rendered in the home which do not meet the definition of skilled home health care above m m Hospice E d Hospice care when provided by a licensed hospice care No charge;Member pays nothing vi program.A hospice care program is a coordinated program of c home and inpatient care,available 24 hours a day. This _J program uses an interdisciplinary team of personnel to 0 provide comfort and supportive services to a Member and any v� family members who are caring for the member,who is M experiencing a life-threatening disease with a limited 0 13 prognosis. These services include acute,respite and home care to meet the physical,psychosocial and special needs of the Member and their family during the final stages of illness. 0 In order to qualify for hospice care,the Member's provider M must certify that the Member is terminally ill and is eligible for hospice services. N 0 N Inpatient Hospice Services.For short-term care,inpatient c hospice services are covered with Preauthorization. a) E a� a� Respite care is covered to provide continuous care of the Member and allow temporary relief to family members from Q the duties of caring for the Member for a maximum of 5 consecutive days per 3-month period of hospice care. M Y Other covered hospice services,when billed by a licensed hospice program,may include the following: d • Inpatient and outpatient services and supplies for injury E t and illness. U • Semi-private room and board,except when a private Q room is determined to be necessary. • Durable medical equipment when billed by a licensed hospice care program. Hospice care requires Preauthorization. 24 COB 5 71-0036900 Packet Pg. 36 4.3.a Exclusions: Private Duty Nursing;financial or legal counseling services;meal services;any services provided by family members Hospital-Inpatient and Outpatient The following inpatient medical and surgical services are Hospital-Inpatient:No charge;Member pays N covered: nothing o • Room and board,including private room when prescribed,and general nursing services. Hospital-Outpatient: Member pays$10 Q • Hospital services(including use of operating room, Copayment anesthesia,oxygen,x-ray,laboratory and radiotherapy services). M • Drugs and medications administered during confinement. o • Medical implants. V L • Withdrawal management services. G c Outpatient hospital includes ambulatory surgical centers. > Alternative care arrangements may be covered as a cost- effective alternative in lieu of otherwise covered Medically Necessary hospitalization or other Medically Necessary institutional care with the consent of the Member and vi recommendation from the attending physician or licensed J health care provider.Alternative care arrangements in lieu of a covered hospital or other institutional care must be c .r determined to be appropriate and Medically Necessary based upon the Member's Medical Condition. Such care is covered M to the same extent the replaced Hospital Care is covered. �a Alternative care arrangements require Preauthorization. Members receiving the following nonscheduled services are c required to notify KFHPWA by way of the Hospital M notification line within 24 hours following any admission,or as soon thereafter as medically possible: acute withdrawal N 0 management services,Emergency psychiatric services, N r Emergency services,labor and delivery and inpatient a� admissions needed for treatment of Urgent Conditions that E cannot reasonably be delayed until Preauthorization can be L obtained. a� Q Coverage for Emergency services in a non-Network Facility `m and subsequent transfer to a Network Facility is set forth in 2 Emergency Services. Y c Non-Emergency hospital services require Preauthorization. E t Exclusions: Take home drugs,dressings and supplies following hospitalization;internally implanted insulin pumps, M artificial larynx and any other implantable device that have not been approved by KFHPWA's medical director Q Infertility(including sterility) General counseling and one consultation visit to diagnose Member pays$10 Copayment 25 COB571-0036900 Packet Pg. 37 4.3.a infertility conditions. Specific diagnostic services,treatment and prescription drugs. Not covered;Member pays 100%of all charges Exclusions: Diagnostic testing and medical treatment of sterility and infertility regardless of origin or cause; all charges and related services for donor materials;all forms of artificial intervention for any reason including artificial insemination and in-vitro fertilization;prognostic(predictive)genetic testing for the detection of congenital and N heritable disorders;surrogacy o z 3 Q Infusion Therapy ' U) Administration of Medically Necessary infusion therapy in an Member pays$10 Copayment M outpatient setting. 0 c.� Preauthorization is required. `0 c Administration of Medically Necessary infusion therapy in No charge;Member pays nothing > the home setting. N m To receive benefits for the administration of select infusion E medications in the home setting,the drugs must be obtained through KFHPWA's preferred specialty pharmacy and vi administered by a provider we identify. For a list of these c specialty drugs or for more information about KFHPWA's J 0. specialty pharmacy network,please go to the KFHPWA o website at www.kp.org/wa/fonnulary or contact Member Services. M 0 �a Associated infused medications include,but are not limited No charge;Member pays nothing to: 0 • Antibiotics. o LO • Hydration. M • Chemotherapy. • Pain management. cm N r C N Laboratory and Radiology E a� L Nuclear medicine,radiology,ultrasound and laboratory No charge;Member pays nothing Q services,including high end radiology imaging services such ' L as CAT scan,MRI and PET which are subject to N Preauthorization except when associated with Emergency Y services or inpatient services.Please contact Member Urine Drug Screening:No charge,Member pays Services for any questions regarding these services. nothing. Limited to 2 tests per calendar year. Benefits are applied in the order claims are received E Services received as part of an emergency visit are covered as and processed. Emergency Services. r After Allowance:No charge;Member pays nothing Q Preventive laboratory and radiology services are covered in accordance with the well care schedule established by KFHPWA and the Patient Protection and Affordable Care Act of 2010.The well care schedule is available in Kaiser Permanente medical centers,at www.kp.org/wa,or upon 26 COB 5 71-0036900 Packet Pg. 38 4.3.a request from Member Services. Manipulative Therapy Manipulative therapy of the spine and extremities when in Member pays$10 Copayment accordance with KFHPWA clinical criteria,limited to a total N of 10 visits per calendar year.Preauthorization is not o required. z Q Rehabilitation services,such as massage or physical therapy, provided with manipulations is covered under the Rehabilitation and Habilitative Care(massage,occupational, L physical and speech therapy,pulmonary and cardiac o rehabilitation)and Neurodevelopmental Therapy section. C) L O Exclusions: Supportive care rendered primarily to maintain the level of correction already achieved;care rendered primarily for the convenience of the Member;care rendered on a non-acute,asymptomatic basis;charges for any other services that do not meet KFHPWA clinical criteria as Medically Necessary N m c d Maternity and Pregnancy vi Maternity care and pregnancy services,including care for Hospital-Inpatient:No charge;Member pays J complications of pregnancy and prenatal and postpartum care nothing a are covered for all female Members including dependent c .r daughters. Hospital-Outpatient: Member pays$10 Copayment M Delivery and associated Hospital Care,including home births �a and birthing centers.Home births are considered outpatient Outpatient Services:Member pays$10 Copayment services. LO 0 Members must notify KFHPWA by way of the Hospital notification line within 24 hours of any admission,or as soon thereafter as medically possible. The Member's physician,in c consultation with the Member,will determine the Member's N r length of inpatient stay following delivery. a� E Prenatal testing for the detection of congenital and heritable L disorders when Medically Necessary as determined by Q KFHPWA's medical director and in accordance with Board , of Health standards for screening and diagnostic tests during `m pregnancy. 2 M Y Termination of pregnancy. Hospital-Inpatient:No charge;Member pays nothing d Non-Emergency inpatient hospital services require t Preauthorization. Hospital-Outpatient: Member pays$10 U Copayment Q Outpatient Services:Member pays$10 Copayment Exclusions: Birthing tubs;genetic testing of non-Members;fetal ultrasound in the absence of medical indications 27 COB 5 71-0036900 Packet Pg. 39 4.3.a Mental Health and Wellness Mental health and wellness services provided at the most Hospital-Inpatient:No charge;Member pays clinically appropriate and Medically Necessary level of nothing mental health care intervention as determined by KFHPWA's medical director.Treatment may utilize psychiatric, Hospital-Outpatient: Member pays$10 N psychological and/or psychotherapy services to achieve these Copayment o objectives. z Outpatient Services:Member pays$10 Copayment Q Mental health and wellness services including medical , management and prescriptions are covered the same as for any other condition. Group Visits:No charge;Member pays nothing L c Applied behavioral analysis(ABA)therapy,limited to V outpatient treatment of an autism spectrum disorder or,has a `o developmental disability for which there is evidence that ABA therapy is effective,as diagnosed and prescribed by a > neurologist,pediatric neurologist,developmental pediatrician, w psychologist or psychiatrist experienced in the diagnosis and m treatment of autism.Documented diagnostic assessments, E individualized treatment plans and progress evaluations are required. vi Services for any involuntary court-ordered treatment program � shall be covered only if determined to be Medically c Necessary by KFHPWA's medical director. Services provided under involuntary commitment statutes are covered. M V If a Member is admitted as an inpatient directly from an m emergency department,any Emergency services Copayment is waived. Coverage is subject to the hospital services Cost o Share.Coverage for services incurred at non-Network M Facilities shall exclude any charges that would otherwise be �- excluded for hospitalization within a Network Facility. N Members must notify KFHPWA by way of the Hospital N notification line within 24 hours of any admission,or as soon thereafter as medically possible. E a� Mental health and wellness services rendered to treat mental L a� disorders are covered.Mental Disorders means mental Q disorders covered in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the ui American Psychiatric Association,except as otherwise M Y excluded under Sections IV.or V. Mental Health and Wellness Services means Medically Necessary outpatient y services,Residential Treatment,partial hospitalization E program,and inpatient services provided by a licensed facility U or licensed providers;including advanced practice psychiatric Q 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 28 COB571-0036900 Packet Pg. 40 4.3.a Treatment and partial hospitalization programs must be provided at a hospital or facility that KFHPWA has approved specifically for the treatment of mental disorders. Non-Emergency inpatient hospital services,including Residential Treatment and partial hospitalization programs, require Preauthorization.Outpatient specialty services, N including rTMS,ECT,and Esketamine require Preauthorization.Routine outpatient therapy and psychiatry t services with contracted network providers do not require Q Preauthorization. , U) Exclusions:Academic or career counseling;personal growth or relationship enhancement;assessment and treatment L services that are primarily vocational and academic;court-ordered or forensic treatment,including reports and c summaries,not considered Medically Necessary;work or school ordered assessment and treatment not considered C V 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 3 life problems(Z code only diagnoses);custodial care;experimental or investigational therapies,such as wilderness > therapy. w N am c Naturopathy vi Naturopathy. Member pays$10 Copayment c J Limited to 3 visits per medical diagnosis per calendar year c without Preauthorization.Additional visits are covered with v� Preauthorization. M V 13 Laboratory and radiology services are covered only when obtained through a Network Facility. 0 0 Exclusions: Herbal supplements;nutritional supplements;any services not within the scope of the practitioner's Ln M licensure M N O N r Newborn Services a� E Newborn services are covered the same as for any other Hospital-Inpatient: No charge;Member pays L condition.Any Cost Share for newborn services is separate nothing Q from that of the mother. , During the baby's initial hospital stay while the birth N Preventive services for newborns are covered under mother and baby are both confined,any applicable M Preventive Services. Deductible and Copayment for the newborn are Y waived c See Section VI.A.3. for information about temporary d coverage for newborns. Hospital-Outpatient: Member pays$10 U Copayment r Q Outpatient Services: Member pays$10 Copayment 29 COB 5 71-0036900 Packet Pg. 41 4.3.a Nutritional Counseling Nutritional counseling. Member pays$10 Copayment Services related to a healthy diet to prevent obesity are covered as Preventive Services. See Preventive Services for additional information. m N Exclusions:Nutritional supplements;weight control self-help programs or memberships,such as Weight Watchers, Jenny Craig,or other such programs 0 Q Nutritional Therapy L c Medical formula necessary for the treatment of No charge;Member pays nothing C) phenylketonuria(PKU),specified inborn errors of `0 metabolism,or other metabolic disorders. c m Enteral therapy is covered when Medical Necessity criteria is Member pays 20%coinsurance N met and when given through a PEG,J tube or orally,or for an eosinophilic gastrointestinal disorder. d Necessary equipment and supplies for the administration of vi enteral therapy are covered as Devices,Equipment and c Supplies. J a 0 Parenteral therapy(total parenteral nutrition). No charge;Member pays nothing M Necessary equipment and supplies for the administration of 0 13 parenteral therapy are covered as Devices,Equipment and m Supplies. 0 0 Exclusions:Any other dietary formulas,medical foods,or oral nutritional supplements that do not meet Medical M Necessity criteria or are not related to the treatment of inborn errors of metabolism; special diets;prepared foods/meals N 0 N r C N Obesity Related Services aEi a) L Bariatric surgery and related hospitalizations when KFHPWA Hospital-Inpatient:No charge;Member pays criteria are met. nothing Q L Services related to obesity screening and counseling are Hospital-Outpatient: Member pays$10 covered as Preventive Services. Copayment Y c Obesity related services require Preauthorization. Outpatient Services: Member pays$10 Copayment d E t U 0 Exclusions:All other obesity treatment and treatment for morbid obesity including any medical services,drugs or Q 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 30 COB571-0036900 Packet Pg. 42 4.3.a On the Job Injuries or Illnesses On the job injuries or illnesses. Hospital-Inpatient:Not covered;Member pays 100%of all charges Hospital-Outpatient:Not covered;Member pays 100%of all charges N Outpatient Services:Not covered;Member pays t 100%of all charges Q U) Exclusions: Confinement,treatment or service that results from an illness or injury arising out of or in the course of L any employment for wage or profit including injuries,illnesses or conditions incurred as a result of self-employment j_ 0 c.� L 0 Oncology m Radiation therapy,chemotherapy,oral chemotherapy. Radiation Therapy and Chemotherapy: N Member pays$10 Copayment c See Infusion Therapy for infused medications. — d Oral Chemotherapy Drugs: vi Preferred generic drugs(Tier 1): Member pays c $10 Copayment per 30-days up to a 90-day supply _J 0. 0 Preferred brand name drugs(Tier 2): Member v) pays$10 Copayment per 30-days up to a 90-day M supply 3 m Non-Preferred generic and brand name drugs (Tier 3):Not covered;Member pays 100%of all c charges Ln M M N O Optical(vision) N r c a� Routine eye examinations and refractions,limited to once Routine Exams: Member pays$10 Copayment E every 12 months. L Exams for Eye Pathology: Member pays$10 Q Eye and contact lens examinations for eye pathology and to Copayment monitor Medical Conditions,as often as Medically `0 Necessary. N M Y Contact lenses or framed lenses for eye pathology when Frames and Lenses: Not covered;Member pays Medically Necessary. 100%of all charges E t One contact lens per diseased eye in lieu of an intraocular Contact Lenses or Framed Lenses for Eye M lens is covered following cataract surgery provided the Pathology: No charge;Member pays nothing Q Member has been continuously covered by KFHPWA since such surgery.In the event a Member's age or medical condition prevents the Member from having an intraocular lens or contact lens,framed lenses are available.Replacement of lenses for eye pathology,including following cataract 31 COB571-0036900 Packet Pg. 43 4.3.a surgery,is covered only once within a 12-month period and only when needed due to a change in the Member's prescription. Exclusions:Eyeglasses;contact lenses,contact lens evaluations,fittings and examinations not related to eye pathology;orthoptic therapy(i.e.,eye training);evaluations and surgical procedures to correct refractions not related to eye pathology and complications related to such procedures N 0 z Oral Surgery Q Reduction of a fracture or dislocation of the jaw or facial Hospital-Inpatient:No charge;Member pays bones;excision of tumors or non-dental cysts of the jaw, nothing M cheeks,lips,tongue,gums,roof,and floor of the mouth;and r_ incision of salivary glands and ducts. Hospital-Outpatient: Member pays$10 V Copayment `0 KFHPWA's medical director will determine whether the care or treatment required is within the category of Oral Surgery or Outpatient Services:Member pays$10 Copayment > Dental Services. w m Oral surgery requires Preauthorization. E d Exclusions: Care or repair of teeth or dental structures of any type;tooth extractions or impacted teeth; services vi related to malocclusion; services to correct the misalignment or malposition of teeth; any other services to the mouth, c facial bones,or teeth which are not medical in nature J 0. 0 Outpatient Services M .a Covered outpatient medical and surgical services in a Member pays$10 Copayment provider's office,including chronic disease management and treatment arising from sexual assault. See Preventive Services o for additional information related to chronic disease c`Vi management. N O See Hospital-Inpatient and Outpatient for outpatient hospital N r medical and surgical services,including ambulatory surgical centers. E a) a) L Q Plastic and Reconstructive Surgery L 2 Plastic and reconstructive services: Hospital-Inpatient:No charge;Member pays Y • Correction of a congenital disease or congenital anomaly. nothing • Correction of a Medical Condition following an injury or resultingfrom sure which has produced a major effect Hospital-Outpatient: Member pays$10 E surgery p J p• P pY E on the Member's appearance,when in the opinion of Copayment KFHPWA's medical director such services can r reasonably be expected to correct the condition. Outpatient Services:Member pays$10 Copayment Q • Reconstructive surgery and associated procedures, including internal breast prostheses,following a mastectomy,regardless of when the mastectomy was performed.Members are covered for all stages of 32 COB571-0036900 Packet Pg. 44 4.3.a reconstruction on the non-diseased breast to produce a symmetrical appearance.Complications of covered mastectomy services,including lymphedemas,are covered. Plastic and reconstructive surgery requires Preauthorization. m Exclusions: Cosmetic services including treatment for complications resulting from cosmetic surgery;cosmetic o surgery;complications of non-Covered Services t Q Podiatry N M L Medically Necessary foot care. Member pays$10 Copayment o V Routine foot care covered when such care is directly related `o to the treatment of diabetes and,when approved by KFHPWA's medical director,other clinical conditions that > effect sensation and circulation to the feet. w m Exclusions:All other routine foot care d vi Preventive Services o J Q. Preventive services in accordance with the well care schedule Member pays$10 Copayment established by KFHPWA.The well care schedule is available in Kaiser Permanente medical centers,at www.kp.org/wa,or M upon request from Member Services. �a m Screening and tests with A and B recommendations by the U.S.Preventive Services Task Force(USPSTF). LO Services,tests and screening contained in the U.S.Health Resources and Services Administration Bright Futures c guidelines as set forth by the American Academy of N r Pediatricians. a� E Services,tests,screening and supplies recommended in the L U.S.Health Resources and Services Administration women's Q preventive and wellness services guidelines. L Immunizations recommended by the Centers for Disease N M Control's Advisory Committee on Immunization Practices. Y Flu vaccines are covered up to the Allowed Amount when provided by a non-Network Provider. d E t Preventive services include,but are not limited to,well adult M and well child physical examinations;immunizations and Q vaccinations;pap smears;routine mammography screening; routine prostate screening;and colorectal cancer screening for Members who are age 45 or older or who are under age 45 and at high risk. 33 COB571-0036900 Packet Pg. 45 4.3.a Preventive care for chronic disease management includes treatment plans with regular monitoring,coordination of care between multiple providers and settings,medication management,evidence-based care,quality of care measurement and results,and education and tools for patient self-management support.In the event preventive,wellness or chronic care management services are not available from a N Network Provider,non-network providers may provide these services without Cost Share when Preauthorized. 0 Z 3 Services provided during a preventive services visit,including Q laboratory services,which are not in accordance with the KFHPWA well care schedule are subject to Cost Shares.Eye L refractions are not included under preventive services. c 0 0 Exclusions: Those parts of an examination and associated reports and immunizations that are not deemed Medically `o Necessary by KFHPWA for early detection of disease;all other diagnostic services not otherwise stated above 3 m Rehabilitation and Habilitative Care(massage, aNi occupational,physical and speech therapy,pulmonary and cardiac rehabilitation)and Neurodevelopmental Therapy vi 0 Rehabilitation services to restore function following illness, Hospital-Inpatient: No charge;Member pays _J injury or surgery,limited to the following restorative nothing c therapies: occupational therapy,physical therapy,massage therapy and speech therapy. Services are limited to those Outpatient Services: Member pays$10 Copayment M necessary to restore or improve functional abilities when 0 13 physical,sensori-perceptual and/or communication impairment exists due to injury,illness or surgery. Group visits(occupational,physical,speech therapy or learning services): c Outpatient services require a prescription or order from a Member pays one half of the office visit Copayment M physician that reflects a written plan of care to restore and applicable Plan Coinsurance function and must be provided by a rehabilitation team that N may include a physician,nurse,physical therapist, N occupational therapist,massage therapist or speech therapist. Preauthorization is not required. E aD a� Habilitative care includes Medically Necessary services or devices designed to help a Member keep,learn,or improve Q skills and functioning for daily living. Services may include: occupational therapy,physical therapy,and speech therapy 2 when prescribed by a physician.Examples include therapy for Y a child who is not walking or talking at the expected age. These services may include physical and occupational y therapy,speech-language pathology and other services for E people with disabilities in a variety of inpatient and/or U outpatient settings. Q Neurodevelopmental therapy to restore or improve function including maintenance in cases where significant deterioration in the Member's condition would result without the services,is limited to the following therapies: 34 COB571-0036900 Packet Pg. 46 4.3.a occupational therapy,physical therapy and speech therapy. There is no visit limit for Neurodevelopmental Therapy services. Limited to a combined total of 60 inpatient days and 60 outpatient visits per calendar year for all Rehabilitation and _ Habilitative care. N N .` O Services with mental health diagnoses are covered with no Z limit. Q Non-Emergency inpatient hospital services require Preauthorization. L c Cardiac rehabilitation is covered up to a total of 36 visits per Member pays$10 Copayment C� cardiac event when clinical criteria is met. `0 c Group visits(occupational,physical,speech > Limited to a combined total of 60 inpatient days and 60 therapy or learning services): N outpatient visits per calendar year for all Rehabilitation and Member pays one half of the office visit Copayment Habilitative care. and applicable Plan Coinsurance vi Pulmonary rehabilitation is covered when clinical criteria is Member pays$10 Copayment 0 met. a 0 Preauthorization is required after initial visit. Group visits(occupational,physical,speech therapy or learning services): M Member pays one half of the office visit Copayment 3 Limited to a combined total of 60 inpatient days and 60 and applicable Plan Coinsurance outpatient visits per calendar year for all Rehabilitation and 0 Habilitative care. o Ln M M Exclusions: Specialty treatment programs;inpatient Residential Treatment services;specialty rehabilitation programs c including"behavior modification programs";recreational,life-enhancing,relaxation or palliative therapy; r implementation of home maintenance programs E aD a� L Reproductive Health Q Medically Necessary medical and surgical services for Hospital-Inpatient:No charge;Member pays N reproductive health,including consultations,examinations, nothing M procedures and devices,including device insertion and Y removal. Hospital-Outpatient:No charge;Member pays d nothing E See Maternity and Pregnancy for termination of pregnancy U services Outpatient Services:No charge;Member pays r 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,and maternity 35 COB571-0036900 Packet Pg. 47 4.3.a prenatal and postpartum care. All methods for Medically Necessary FDA-approved No charge;Member pays nothing (including over-the-counter)contraceptive drugs,devices and products. Condoms are limited to 120 per 90-day supply. Contraceptive drugs may be allowed up to a 12-month supply N and,when available,picked up in the provider's office. o z Q Sexual Dysfunction N M L One consultation visit to diagnose sexual dysfunction Member pays$10 Copayment o conditions. C) L 0 13 Specific diagnostic services,treatment and prescription drugs. TNot covered;Member pays 100%of all charges m Exclusions: Diagnostic testing and medical treatment of sexual dysfunction regardless of origin or cause;devices, N equipment and supplies for the treatment of sexual dysfunction d Skilled Nursing Facility N 0 J Skilled nursing care in a skilled nursing facility when full- No charge;Member pays nothing 0. time skilled nursing care is necessary in the opinion of the 0 attending physician,limited to a total of 30 days per condition per calendar year. M 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- Q term restorative occupational therapy,physical therapy and speech therapy. M N O Skilled nursing care in a skilled nursing facility requires N r Preauthorization. a� E Exclusions: Personal comfort items such as telephone and television;rest cures;domiciliary or Convalescent Care L a� Q Sterilization M FDA-approved female sterilization procedures,services and No charge;Member pays nothing Y supplies. E Non-Emergency inpatient hospital services require Preauthorization. r Q Vasectomy. No charge;Member pays nothing Non-Emergency inpatient hospital services require Preauthorization. 36 COB571-0036900 Packet Pg. 48 4.3.a Exclusions: Procedures and services to reverse a sterilization Substance Use Disorder Substance use disorder services including inpatient Hospital-Inpatient:No charge;Member pays Residential Treatment;diagnostic evaluation and education; nothing N organized individual and group counseling;and/or o prescription drugs unless excluded under Sections IV.or V. Outpatient Services:Member pays$10 Copayment Q Substance use disorder means a substance-related or addictive disorder listed in the most current version of the Diagnostic Group Visits:No charge;Member pays nothing N and Statistical Manual of Mental Disorders(DSM).For the L purposes of this section,the definition of Medically o Necessary shall be expanded to include those services t� necessary to treat a substance use disorder condition that is `0 having a clinically significant impact on a Member's emotional,social,medical and/or occupational functioning. Substance use disorder services are limited to the services aNi rendered by a physician(licensed under RCW 18.71 and E RCW 18.57),a psychologist(licensed under RCW 18.83),a substance use disorder treatment program licensed for the vi service being provided by the Washington State Department 0 0 of Social and Health Services(pursuant to RCW 70.96A),a _J master's level therapist(licensed under RCW 18.225.090),an 0 advance practice psychiatric nurse(licensed under RCW 18.79)or,in the case of non-Washington State providers, M those providers meeting equivalent licensing and certification 0 requirements established in the state where the provider's practice is located. 0 The severity of symptoms designates the appropriate level of M care and should be determined through a thorough assessment completed by a licensed provider who recommends treatment N based on medical necessity criteria. N r c Court-ordered substance use disorder treatment shall be covered only if determined to be Medically Necessary. 44)) L Preauthorization is required for outpatient,intensive Q outpatient,and partial hospitalization services. Preauthorization is required for Residential Treatment and Y non-Emergency inpatient hospital services provided at out-of- state facilities. 4) d E Preauthorization is not required for Residential Treatment and U 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 facility must notify KFHPWA within 24 hours of admission, or as soon as possible.Member may request prior authorization for Residential Treatment and non-Emergency 37 COB571-0036900 Packet Pg. 49 4.3.a inpatient hospital services.Members may contact Member Services to request Preauthorization. Withdrawal Management Services for Alcoholism and Emergency Services Network Facility: Member Substance Use Disorder. pays$75 Copayment m Withdrawal management services means the management of Emergency Services Non-Network Facility: o symptoms and complications of alcohol and/or substance Member pays$125 Copayment t withdrawal. The severity of symptoms designates the 3 appropriate level of care and should be determined through a Hospital-Inpatient: No charge;Member pays Q thorough assessment completed by a licensed provider who nothing recommends treatment based on medical necessity criteria. L c Outpatient withdrawal management services means the C V symptoms resulting from abstinence are of mild/moderate `o severity and withdrawal from alcohol and/or other drugs can be managed with medication at an outpatient level of care by > an appropriately licensed clinician. Subacute withdrawal w management means symptoms associated with withdrawal m from alcohol and/or other drugs can be managed through E medical monitoring at a 24-hour facility or other outpatient facility. vi Preauthorization is required for outpatient withdrawal � management and subacute withdrawal management services. 0. 0 "Acute withdrawal management services"means the - symptoms resulting from abstinence are so severe that 0 withdrawal from alcohol and/or drugs require medical 3 management in a hospital setting or behavioral health agency (licensed and certified under RCW 71.24.037),which is c needed immediately to prevent serious impairment to theLO Member's health. M Coverage for acute withdrawal management services is N provided without Preauthorization.If a Member is admitted r 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 Q within 24 hours of any admission,or as soon thereafter as i medically possible. N M Member is given no less than two days of treatment, Y excluding weekends and holidays,in a behavioral health agency that provides inpatient or residential substance abuse E treatment;and no less than three days in a behavioral health agency that provides withdrawal management services prior r 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 Preauthorization for Residential Treatment and non- Emergency inpatient hospital services by contacting Member Services. 38 COB571-0036900 Packet Pg. 50 4.3.a KFHPWA reserves the right to require transfer of the Member to a Network Facility/program upon consultation between a Network Provider and the attending physician.If the Member refuses transfer to a Network Facility/program, all further costs incurred during the hospitalization are the responsibility of the Member. N Exclusions: Experimental or investigational therapies,such as wilderness programs or aversion therapy;facilities and t treatment programs which are not certified by the Department of Social Health Services Q Telehealth Services L c Telemedicine No charge;Member pays nothing V Services provided by the use of real-time interactive audio 0 and video communications or store and forward technology between the patient at the originating site and a Network > Provider at another location.Audio-only communication N requires an Established Relationship. Store and forward c technology means sending a Member's medical information — from an originating site to the provider at a distant site for later review.The provider follows up with a medical vi diagnosis for the Member and helps manage their care. c Services must meet the following requirements: • Be a Covered Service under this EOC. o .r • The originating site is qualified to provide the service. M • If the service is provided through store and forward :a technology,there must be an associated office visit between the Member and the referring provider. • Is Medically Necessary. 0o LO M Telephone Services and Online(E-Visits) No charge;Member pays nothing �� Scheduled telephone visits with a Network Provider are c covered. N r c a� Online(E-Visits):A Member logs into the secure Member aEi site at www.kp.org/wa and completes a questionnaire.A L KFHPWA medical provider reviews the questionnaire and Q provides a treatment plan for select conditions,including L prescriptions. Online visits are not available to Members N during in-person visits at a KFHPWA facility or pharmacy. Y More information is available at https://wa.kaiserpermanente.org/httnl/public/services/e-visit. y E z U Exclusions:Fax and e-mail;telehealth services with non-contracted providers;telehealth services in states where Q prohibited by law;all other services not listed above 39 COB571-0036900 Packet Pg. 51 4.3.a Temporomandibular Joint(TMJ) 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 Hospital-Outpatient: Member pays$10 treatment of severe TMJ disorders which have failed Copayment N non-surgical intervention. • Radiology services. Outpatient Services:Member pays$10 Copayment t • TMJ specialist services. 3 Q • Fitting/adjustment of splints. N U) Non-Emergency inpatient hospital services require L Preauthorization. c 0 c.� TMJ appliances. See Devices,Equipment and Supplies for Member pays 20%coinsurance `0 additional information. c m > w 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 E apnea;hospitalizations related to these exclusions vi 0 Tobacco Cessation a 0 Individual/group counseling and educational materials. No charge;Member pays nothing M 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 program and dispensed through the KFHPWA- c designated mail order service M Other approved pharmacy products: c Preferred generic drugs(Tier 1): Member pays N $10 Copayment per 30-days up to a 90-day supply E Preferred brand name drugs(Tier 2): Member y pays$10 Copayment per 30-days up to a 90-day supply Q `m Non-Preferred generic and brand name drugs (Tier 3):Not covered;Member pays 100%of all Y charges d E t U M Transplants Q Transplant services,including heart,heart-lung,single lung, Hospital-Inpatient:No charge;Member pays double lung,kidney,pancreas,cornea,intestinal/multi- nothing visceral,liver transplants,and bone marrow and stem cell support(obtained from allogeneic or autologous peripheral Hospital-Outpatient: Member pays$10 40 COB 5 71-0036900 Packet Pg. 52 4.3.a blood or marrow)with associated high dose chemotherapy. Copayment Services are limited to the following: Outpatient Services: Member pays$10 Copayment • Inpatient and outpatient medical expenses for evaluation testing to determine recipient candidacy,donor matching tests,hospital charges,procurement center fees, professional fees,travel costs for a surgical team and N excision fees.Donor costs for a covered organ recipient o are limited to procurement center fees,travel costs for a z surgical team and excision fees. 3 • Follow-up services for specialty visits. Q • Rehospitalization. � • Maintenance medications during an inpatient stay. L c Transplant services must be provided through locally and V nationally contracted or approved transplant centers. All `o transplant services require Preauthorization. Contact Member Services for Preauthorization. > w Exclusions: Donor costs to the extent that they are reimbursable by the organ donor's insurance;treatment of donor aa) complications; living expenses except as covered under Section II.K.Utilization Management d vi Urgent Care c J a Inside the KFHPWA Service Area,urgent care is covered at a Network Emergency Department: Member pays 0 Kaiser Permanente medical center,Kaiser Permanente urgent $75 Copayment care center or Network Provider's office. M Network Urgent Care Center: Member pays$10 13 Outside the KFHPWA Service Area,urgent care is covered at Copayment any medical facility. 0 0 See Section XII.for a definition of Urgent Condition. Network Provider's Office: Member pays$10 M Copayment M N O N r Non-Network Provider: Member pays$125 Copayment E a) a) L Q V. General Exclusions m In addition to exclusions listed throughout the EOC,the following are not covered: M Y 1. Benefits and related services,supplies and drugs that are not Medically Necessary for the treatment of an y illness,injury,or physical disability,that are not specifically listed as covered in the EOC,except as required by t federal or state law. U r 2. Services Related to a Non-Covered Service: When a service is not covered,all services related to the non- Q 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 41 COB571-0036900 Packet Pg. 53 4.3.a Medically Necessary intervention to resolve acute medical complications resulting from non-covered services shall not be covered. 3. Services or supplies for which no charge is made,or for which a charge 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 member,or self-care. 4. Convalescent Care. N 0 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 Q medical coverage,medical"no fault"coverage,personal injury protection coverage or similar medical coverage ' contained in said policy.For the purpose of this exclusion,benefits shall be deemed to be"available"to the W Member if the Member receives benefits under the policy either as a named insured or as an insured individual L under the policy definition of insured. r_ 0 c.� 6. Services or care needed for injuries or conditions resulting from active or reserve military service,whether such `0 injuries or conditions result from war or otherwise.This exclusion will not apply to conditions or injuries resulting from previous military service unless the condition has been determined by the U.S. Secretary of > Veterans Affairs to be a condition or injury incurred during a period of active duty.Further,this exclusion will N not be interpreted to interfere with or preclude coordination of benefits under Tri-Care. c 7. Services provided by government agencies, except as required by federal or state law. vi 8. Services covered by the national health plan of any other country. c J 9. Experimental or investigational services. c .r KFHPWA consults with KFHPWA's medical director and then uses the criteria described below to decide if a M particular service is experimental or investigational 0 13 m 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: c 1) The service cannot be legally marketed in the United States without the approval of the Food and Drug M 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. N 3) The service is the trialed agent or for delivery or measurement of the trialed agent provided as part of a N qualifying Phase I or Phase II clinical trial,as the experimental or research arm of a Phase III clinical trial. E 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 Q of services. 6) The service is provided pursuant to informed consent documents that describe the service as N experimental or investigational,or in other terms that indicate that the service is being evaluated for its Y safety,toxicity or efficacy. 7) The prevailing opinion among experts,as expressed in the published authoritative medical or scientific y literature,is that(1)the use of such service should be substantially confined to research settings,or(2) E further research is necessary to determine the safety,toxicity or efficacy of the service. U M r b. The following sources of information will be exclusively relied upon to determine whether a service is Q experimental or investigational: 1) The Member's medical records. 2) The written protocol(s)or other document(s)pursuant to which the service has been or will be provided. 42 COB 5 71-0036900 Packet Pg. 54 4.3.a 3) Any consent document(s)the Member or Member's representative has executed or will be asked to execute,to receive the service. 4) The files and records of the Institutional Review Board(IRB)or similar body that approves or reviews research at the institution where the service has been or will be provided,and other information concerning the authority or actions of the IRB or similar body. 5) The published authoritative medical or scientific literature regarding the service,as applied to the Member's illness or injury. 6) Regulations,records,applications and any other documents or actions issued by,filed with or taken by, N the FDA or other agencies within the United States Department of Health and Human Services,or any 0 state agency performing similar functions. Q Appeals regarding KFHPWA denial of coverage can be submitted to the Member Appeal Department,or to ' KFHPWA's medical director at P.O.Box 34593, Seattle,WA 98124-1593. W M L 10. Hypnotherapy and all services related to hypnotherapy. r_ 0 c.� 11. Directed umbilical cord blood donations. `0 c 12. Prognostic(predictive)genetic testing and related services,unless specifically provided in Section IV.Testing for non-Members. w m 13. Autopsy and associated expenses. cd VI. Eligibility,Enrollment and Termination vi 0 A. Eligibility. _J In order to be accepted for enrollment and continuing coverage,individuals must reside or work in the Service c Area and meet all applicable requirements set forth below,except for temporary residency outside the Service v� Area for purposes of attending school,court-ordered coverage for Dependents or other unique family M arrangements,when approved in advance by KFHPWA.KFHPWA has the right to verify eligibility. 0 m 1. Subscribers. Bona fide employees as established and enforced by the Group shall be eligible for enrollment.Please c contact the Group for more information. M 2. Dependents. c The Subscriber may also enroll the following: N r c a� a. The Subscriber's legal spouse. E a� a� b. The Subscriber's state-registered domestic partner(as required by Washington state law)or if Q 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. `m M C. Children who are under the age of 26. Y c "Children"means the children of the Subscriber,spouse or eligible domestic partner,including adopted E children,stepchildren,children for whom the Subscriber has a qualified court order to provide coverage and any other children for whom the Subscriber is the legal guardian. M r Q Eligibility may be extended past the Dependent's limiting age as set forth above if the Dependent is totally incapable of self-sustaining employment because of a developmental or physical disability incurred prior to attainment of the limiting age,and is chiefly dependent upon the Subscriber for support and maintenance.Enrollment for such a Dependent may be continued for the duration of the continuous total incapacity,provided enrollment does not terminate for any other reason.Medical 43 COB 5 71-0036900 Packet Pg. 55 4.3.a proof of incapacity and proof of financial dependency must be furnished to KFHPWA upon request, but not more frequently than annually after the 2-year period following the Dependent's attainment of the limiting age. 3. Temporary Coverage for Newborns. When a Member gives birth,the newborn is entitled to the benefits set forth in the EOC from birth through 3 weeks of age.All provisions,limitations and exclusions will apply except Subsection F. After 3 weeks of age,no benefits are available unless the newborn child qualifies as a Dependent and is enrolled. N 0 B. Application for Enrollment. Application for enrollment must be made on an application approved by KFHPWA.The Group is responsible Q for submitting completed applications to KFHPWA. KFHPWA reserves the right to refuse enrollment to any person whose coverage under any medical coverage M agreement issued by Kaiser Foundation Health Plan of Washington Options,Inc. or Kaiser Foundation Health r- Plan of Washington has been terminated for cause. C) L 0 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. N am 2. New Dependents. c 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. vi 0 A written application for enrollment of a newborn child must be made to the Group within 60 days following the date of birth when there is a change in the monthly premium payment as a result of the 0. additional Dependent. v� M 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. c Ln M 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 N claims. N r c 3. Open Enrollment. E KFHPWA will allow enrollment of Subscribers and Dependents who did not enroll when newly eligible as 4) described above during a limited period of time specified by the Group and KFHPWA. Q 4. Special Enrollment. a. KFHPWA will allow special enrollment for persons: Y 1) Who initially declined enrollment when otherwise eligible because such persons had other health care coverage and have had such other coverage terminated due to one of the following events: y • Cessation of employer contributions. E t • Exhaustion of COBRA continuation coverage. U • Loss of eligibility,except for loss of eligibility for cause;or Q 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. 44 COB 5 71-0036900 Packet Pg. 56 4.3.a KFHPWA or the Group may require confirmation that when initially offered coverage such persons submitted a written statement declining because of other coverage.Application for coverage must be made within 31 days of the termination of previous coverage. b. KFHPWA will allow special enrollment for individuals who are eligible to be a Subscriber and their Dependents(other than for nonpayment or fraud)in the event one of the following occurs: 1) Divorce or Legal Separation.Application for coverage must be made within 60 days of the divorce/separation. N 2) Cessation of Dependent status(reaches maximum age).Application for coverage must be made o within 30 days of the cessation of Dependent status. 3) Death of an employee under whose coverage they were a Dependent.Application for coverage Q must be made within 30 days of the death of an employee. ' 4) Termination or reduction in the number of hours worked.Application for coverage must be made W within 30 days of the termination or reduction in number of hours worked. L 5) Leaving the service area of a former plan.Application for coverage must be made within 30 days r_ of leaving the service area of a former plan. C) 6) Discontinuation of a former plan.Application for coverage must be made within 30 days of the `o discontinuation of a former plan. m c. KFHPWA will allow special enrollment for individuals who are eligible to be a Subscriber and their N Dependents in the event one of the following occurs: 1) Marriage.Application for coverage must be made within 31 days of the date of marriage. — 2) Birth.Application for coverage for the Subscriber and Dependents other than the newborn child must be made within 60 days of the date of birth. vi 3) Adoption or placement for adoption.Application for coverage for the Subscriber and Dependents c other than the adopted child must be made within 60 days of the adoption or placement for adoption. c 4) Eligibility for premium assistance from Medicaid or a state Children's Health Insurance Program (CHIP),provided such person is otherwise eligible for coverage under this EOC.The request for M special enrollment must be made within 60 days of eligibility for such premium assistance. 0 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. c 6) Applicable federal or state law or regulation otherwise provides for special enrollment. LO M C. When Coverage Begins. N 0 N 1. Effective Date of Enrollment. • Enrollment for a newly eligible Subscriber and listed Dependents is effective on the date eligibility E requirements are met,provided the Subscriber's application has been submitted to and approved by y KFHPWA.Please contact the Group for more information. • Enrollment for a newly dependent person,other than a newborn or adoptive child,is effective on the 1st Q 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. Y • Enrollment for adoptive children is effective from the date that the adoptive child is placed with the Subscriber for the purpose of adoption or the Subscriber assumes total or partial financial support of E the child. t U 2. Commencement of Benefits for Persons Hospitalized on Effective Date. Q 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. 45 COB571-0036900 Packet Pg. 57 4.3.a D. Eligibility for Medicare. An individual shall be deemed eligible for Medicare when they have the option to receive Part A Medicare benefits.Medicare secondary payer regulations and guidelines will determine primary/secondary payer status for individuals covered by Medicare. A Member who is enrolled in Medicare has the option of continuing coverage under this EOC while on Medicare coverage.Coverage between this EOC and Medicare will be coordinated as outlined in Section IX. N .` 0 The Group is also responsible for providing KFHPWA with a prospective timely notice of Members' Z ineligibility for Medicare Advantage coverage under the Group,as well as providing a prospective notice to its Q Members alerting them of the termination event.In the event the Group does not obtain Medicare Advantage coverage,the loss of Medicare drug coverage,other coverage options that may be available to the Member,and the possibility of late enrollment penalties if the Member does not apply for Medicare coverage within the M required timeframe will also need to be provided. r- 0 c.� E. Termination of Coverage. `0 The Subscriber shall be liable for payment of all charges for services and items provided to the Subscriber and all Dependents after the effective date of termination. > w Termination of Specific Members. Individual Member coverage may be terminated for any of the following reasons: a. Loss of Eligibility. If a Member no longer meets the eligibility requirements and is not enrolled for vi continuation coverage as described in Subsection F.below,coverage will terminate at the end of the 0 month during which the loss of eligibility occurs,unless otherwise specified by the Group. J a 0 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. M Coverage of a Member may be terminated upon 10 working days written notice for: .0 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. c Ln M c. Premium Payments.Nonpayment of premiums or contribution for a specific Member by the Group. M N O Individual Member coverage may be retroactively terminated upon 30 days written notice and only in the N 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 E coverage for nonpayment of premiums or contributions by the Group as described above. y L In no event will a Member be terminated solely on the basis of their physical or mental condition provided Q they meet all other eligibility requirements set forth in the EOC. `m Any Member may appeal a termination decision through KFHPWA's appeals process. Y c F. Continuation of Coverage Options. E t 1. Continuation Option. U A Member no longer eligible for coverage(except in the event of termination for cause,as set forth in Q 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 continuation coverage provisions of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).This continuation option is not available if the Group no longer has active employees or otherwise terminates. 46 COB 5 71-0036900 Packet Pg. 58 4.3.a 2. Leave of Absence. While on a Group approved leave of absence,the Subscriber and listed Dependents can continue to be covered provided that: • They remain eligible for coverage,as set forth in Subsection A., • Such leave is in compliance with the Group's established leave of absence policy that is consistently applied to all employees, m • The Group's leave of absence policy is in compliance with the Family and Medical Leave Act when applicable,and ° z • The Group continues to remit premiums for the Subscriber and Dependents to KFHPWA. Q 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 0 dispute,a Subscriber may continue uninterrupted coverage through payment of monthly premiums directly c to the Group. Coverage may be continued for the lesser of the term of the strike,lock-out or other labor V dispute,or for 6 months after the cessation of work. O 13 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. m c The Group is responsible for immediately notifying each affected Subscriber of their rights of self-payment under this provision. vi 4. Continuation Coverage Under Federal Law. J This section applies only to Groups who must offer continuation coverage under the applicable provisions Q. of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA),as amended,or the Uniformed ° Services Employment and Reemployment Rights Act(USERRA)and only applies to grant continuation of coverage rights to the extent required by federal law.USERRA only applies in certain situations to M employees who are leaving employment to serve in the United States Armed Forces. 3 Upon loss of eligibility,continuation of Group coverage may be available to a Member for a limited time c after the Member would otherwise lose eligibility,if required by COBRA.The Group shall inform Q Members of the COBRA election process and how much the Member will be required to pay directly to the Group. M N O Continuation coverage under COBRA or USERRA will terminate when a Member becomes covered by N r Medicare or obtains other group coverage,and as set forth under Subsection E. aa) E 5. KFHPWA Group Conversion Plan. L 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 Q group health plan,may convert to an individual KFHPWA group conversion plan.If coverage under the N EOC terminates,any Member covered at termination(including spouses and Dependents of a Subscriber M who was terminated for cause)may convert to a KFHPWA group conversion plan. Coverage will be Y retroactive to the date of loss of eligibility. d An application for conversion must be made within 31 days following termination of coverage or within 31 days from the date notice of the termination of coverage is received,whichever is later.A physical examination or statement of health is not required for enrollment in a KFHPWA group conversion plan. Q Persons wishing to purchase KFHPWA's individual and family coverage should contact KFHPWA. VILGrievances - 47 COB 5 71-0036900 Packet Pg. 59 Grievance means a written or verbal complaint submitted by or on behalf of a covered person regarding service delivery issues other than denial of payment for medical services or non-provision of medical services,including dissatisfaction with medical care,waiting time for medical services,provider or staff attitude or demeanor,or dissatisfaction with service provided by the health carrier. The grievance process is outlined as follows: Step 1: It is recommended that the Member contact the person involved or the manager of the medical center/department where they are having a problem,explain their concerns and what they would like to have done to resolve the problem.The Member should be specific and make their position clear.Most concerns can N be resolved in this way. p z Step 2: If the Member is still not satisfied,they should call or write to Member Services at PO Box 34590, Q 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 W think would be a fair resolution to the problem.An appropriate representative will investigate the Member's M concern by consulting with involved staff and their supervisors,and reviewing pertinent records,relevant plan C policies and the Member Rights and Responsibilities statement.This process can take up to 30 days to resolve C) after receipt of the Member's written or verbal statement. `o 13 c 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 N mental disabilities that impede their ability to request review or participate in the review process. c d vi Members are entitled to appeal through the appeals process if/when coverage for an item or service is denied due to c an adverse determination made by the KFHPWA medical director. The appeals process is available for a Member to seek reconsideration of an adverse benefit determination(action).Adverse benefit determination(action)means any c of the following:a denial,reduction,or termination of,or a failure to provide or make payment(in whole or in part) a) for,a benefit,including any such denial,reduction,termination,or failure to provide or make payment that is based M on a determination of a Member's eligibility to participate in a plan,and including,a denial,reduction,or termination of,or a failure to provide or make payment,in whole or in part,for a benefit resulting from the application of any utilization review,as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not Medically Necessary or appropriate. c KFHPWA will comply with any new requirements as necessary under federal laws and regulations.Assistance is M available to Members who are limited-English speakers,who have literacy problems,or who have physical or mental disabilities that impede their ability to request review or participate in the review process.The most current N information about your appeals process is available by contacting KFHPWA's Member Appeal Department at the N address or telephone number below. c a) E 1. Initial Appeal If the Member or any representative authorized in writing by the Member wishes to appeal a KFHPWA decision to deny,modify,reduce or terminate coverage of or payment for health care services,they must submit Q 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 Y should be directed to KFHPWA's Member Appeal Department,P.O.Box 34593, Seattle,WA 98124-1593,toll- free 1-866-458-5479. d E A party not involved in the initial coverage determination and not a subordinate of the party making the initial U coverage determination will review the appeal request. KFHPWA will then notify the Member of its Q determination or need for an extension of time within 14 days of receiving the request for appeal.Under no circumstances will the review timeftame exceed 30 days without the Member's written permission. For appeals involving experimental or investigational services KFHPWA will make a decision and communicate the decision to the Member in writing within 20 days of receipt of the appeal. 48 COB571-0036900 Packet Pg. 60 4.3.a There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using the standard appeal review process will seriously jeopardize the Member's life,health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment.The Member can request an expedited/urgent appeal in writing to the above address,or by calling KFHPWA's Member Appeal Department toll-free 1-866-458-5479. The nature of the patient's condition will be evaluated by a physician and if the request is not accepted as urgent,the member will be notified in writing of the decision not to expedite and given a description on how to grieve the decision.If the request is made by the treating physician who believes the member's condition meets the definition of expedited,the request will be N processed as expedited. 0 z The request for an expedited/urgent appeal will be processed and a decision issued no later than 72 hours after Q receipt of the request. 0 The Member may also request an external review at the same time as the internal appeals process if it is an M urgent care situation or the Member is in an ongoing course of treatment. r_ 0 c.� If the Member requests an appeal of a KFHPWA decision denying benefits for care currently being received, `0 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. N m 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, vi Consumer Protection Division,P.O.Box 40256,Olympia,WA 98504-0256 or at toll-free 1-800-562-6900. c More information about requesting assistance from the Consumer Protection Division Office can be found at _J http://www.insurance.wa.,_o�v/your-insurance/health-insurance/appeal/. 0. 2. Next Level of Appeal M If the Member is not satisfied with the decision regarding medical necessity,medical appropriateness,health 0 13 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 c controlled by KFHPWA.KFHPWA will notify the Member of the name of the external independent review M organization and its contact information. The external independent review organization will accept additional written information for up to five business days after it receives the assignment for the appeal.The external N independent review will be conducted at no cost to the Member.Once a decision is made through an N independent review organization,the decision is final and cannot be appealed through KFHPWA. a� E If the Member requests an appeal of a KFHPWA decision denying benefits for care currently being received, a� 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 Q review period. A request for a review by an independent review organization must be made within 180 days after the date of Y the initial appeal decision notice. c d IX. Claims U Claims for benefits may be made before or after services are obtained.KFHPWA recommends that the provider Q requests Preauthorization.In most instances,contracted providers submit claims directly to KFHPWA.If your provider does not submit a claim to make a claim for benefits,a Member must contact Member Services,or submit a claim for reimbursement as described below. Other inquiries,such as asking a health care provider about care or coverage,or submitting a prescription to a pharmacy,will not be considered a claim for benefits. 49 COB 5 71-0036900 Packet Pg. 61 4.3.a If a Member receives a bill for services the Member believes are covered,the Member must,within 90 days of the date of service,or as soon thereafter as reasonably possible,either(1)contact Member Services to make a claim or (2)pay the bill and submit a claim for reimbursement of Covered Services,or(3)for out-of-country claims (Emergency care only)—submit the claim and any associated medical records,including the type of service, charges,and proof of travel to KFHPWA,P.O.Box 30766, Salt Lake City,UT 84130-0766.In no event,except in the absence of legal capacity,shall a claim be accepted later than 1 year from the date of service. KFHPWA will generally process claims for benefits within the following timeframes after KFHPWA receives the N claims: 0 0 • Immediate request situations—within 1 business day. • Concurrent urgent requests—within 24 hours. Q • Urgent care review requests—within 48 hours. N • Non-urgent preservice review requests—within 5 calendar days. 0 • Post-service review requests—within 30 calendar days. c 0 Timeframes for pre-service and post-service claims can be extended by KFHPWA for up to an additional 15 days. V L Members will be notified in writing of such extension prior to the expiration of the initial timeframe. 0 c �X. Coordination of Benefits 6 > 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 governs the order in which each plan will pay a claim for benefits.The plan N that pays first is called the primary plan. The primary plan must pay benefits according to its policy terms without 0 regard to the possibility that another plan may cover some expenses.The plan that pays after the primary plan is the 0. secondary plan.In no event will a secondary plan be required to pay an amount in excess of its maximum benefit 0 plus accrued savings. M 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. o Ln M All health plans have timely claim filing requirements.If the Member or the Member's provider fails to submit the �� Member's claim to a secondary health plan within that plan's claim filing time limit,the plan can deny the claim.If c the Member experiences delays in the processing of the claim by the primary health plan,the Member or the N r Member's provider will need to submit the claim to the secondary health plan within its claim filing time limit to prevent a denial of the claim. E W a� L If the Member is covered by more than one health benefit plan,the Member or the Member's provider should file all Q the Member's claims with each plan at the same time.If Medicare is the Member's primary plan,Medicare may , submit the Member's claims to the Member's secondary carrier. `m M Definitions. Y c A. A plan is any of the following that provides benefits or services for medical or dental care or treatment.If d separate contracts are used to provide coordinated coverage for Members of a Group,the separate contracts t are considered parts of the same plan and there is no COB among those separate contracts.However,if U COB rules do not apply to all contracts,or to all benefits in the same contract,the contract or benefit to Q which COB does not apply is treated as a separate plan. 1. Plan includes: group,individual or blanket disability insurance contracts and group or individual contracts issued by health care service contractors or health maintenance organizations(HMO),closed panel plans or other forms of group coverage;medical care components of long-term care contracts, 50 COB571-0036900 Packet Pg. 62 such as skilled nursing care;and Medicare or any other federal governmental plan,as permitted by law. 2. Plan does not include:hospital indemnity or fixed payment coverage or other fixed indemnity or fixed payment coverage; accident only coverage; specified disease or specified accident coverage;limited benefit health coverage,as defined by state law; school accident type coverage;benefits for non- medical components of long-term care policies;automobile insurance policies required by statute to provide medical benefits;Medicare supplement policies;Medicaid coverage;or coverage under other N federal governmental plans;unless permitted by law. p z Each contract for coverage under Subsection 1. or 2. is a separate plan.If a plan has two parts and COB Q 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 L the COB provision applies and which may be reduced because of the benefits of other plans.Any other part of the contract providing health care benefits is separate from this plan.A contract may apply one COB C) provision to certain benefits, such as dental benefits,coordinating only with similar benefits,and may apply `o another COB provision to coordinate other benefits. m C. The order of benefit determination rules determine whether this plan is a primary plan or secondary plan N when the Member has health care coverage under more than one plan. c 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 vi another plan and must make payment in an amount so that,when combined with the amount paid by the c primary plan,the total benefits paid or provided by all plans for the claim equal 100%of the total allowable expense for that claim.This means that when this plan is secondary,it must pay the amount which,when c combined with what the primary plan paid,totals 100%of the allowable expense.In addition,if this plan is a) secondary,it must calculate its savings(its amount paid subtracted from the amount it would have paid had M it been the primary plan)and record these savings as a benefit reserve for the covered Member. This 0 13 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. 0 0 D. Allowable Expense.Allowable expense is a health care expense,coinsurance or copayments and without M 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 N considered an allowable expense and a benefit paid.An expense that is not covered by any plan covering coi the Member is not an allowable expense. a� E The following are examples of expenses that are not allowable expenses: 4) L 1. The difference between the cost of a semi-private hospital room and a private hospital room is not an Q allowable expense,unless one of the plans provides coverage for private hospital room expenses. 2. If a Member is covered by two or more plans that compute their benefit payments on the basis of usual Y and customary fees or relative value schedule reimbursement method or other similar reimbursement method,any amount in excess of the highest reimbursement amount for a specific benefit is not an y allowable expense. E t U 3. If a Member is covered by two or more plans that provide benefits or services on the basis of Q negotiated fees,an amount in excess of the highest of the negotiated fees is not an allowable expense. 4. An expense or a portion of an expense that is not covered by any of the plans covering the person is not an allowable expense. 51 COB571-0036900 Packet Pg. 63 E. Closed panel plan is a plan that provides health care benefits to covered persons in the form of services through a panel of providers who are primarily employed by the plan,and that excludes coverage for services provided by other providers,except in cases of Emergency or referral by a panel member. F. Custodial parent is the parent awarded custody by a court decree or,in the absence of a court decree,is the parent with whom the child resides more than one half of the calendar year excluding any temporary visitation. m N Order of Benefit Determination Rules. 0 When a Member is covered by two or more plans,the rules for determining the order of benefit payments are as follows: Q 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. M c B. (1)Except as provided below(subsection 2),a plan that does not contain a coordination of benefits C) provision that is consistent with this chapter is always primary unless the provisions of both plans state that `0 the complying plan is primary. m (2)Coverage that is obtained by virtue of membership in a Group that is designed to supplement a part of a N basic package of benefits and provides that this supplementary coverage is excess to any other parts of the c 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. vi 0 C. A plan may consider the benefits paid or provided by another plan in calculating payment of its benefits _J only when it is secondary to that other plan. 0. .r D. Each plan determines its order of benefits using the first of the following rules that apply: M 0 13 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 c beneficiary and,as a result of federal law,Medicare is secondary to the plan covering the Member as a M Dependent,and primary to the plan covering the Member as other than a Dependent(e.g.,a retired employee),then the order of benefits between the two plans is reversed so that the plan covering the N Member as an employee,member,policyholder,Subscriber or retiree is the secondary plan and the N other plan is the primary plan. a� E 2. Dependent child covered under more than one plan.Unless there is a court decree stating otherwise, 0 a) when a dependent child is covered by more than one plan the order of benefits is determined as follows: Q a) For a dependent child whose parents are married or are living together,whether or not they have ever been married: N_ • The plan of the parent whose birthday falls earlier in the calendar year is the primary plan;or 0 Y • If both parents have the same birthday,the plan that has covered the parent the longest is the primary plan. E b) For a dependent child whose parents are divorced or separated or not living together,whether or E not they have ever been married: U i. If a court decree states that one of the parents is responsible for the dependent child's health Q care expenses or health care coverage and the plan of that parent has actual knowledge of those terms,that plan is primary.This rule applies to claim determination periods commencing after the plan is given notice of the court decree; ii. If a court decree states one parent is to assume primary financial responsibility for the dependent child but does not mention responsibility for health care expenses,the plan of the parent assuming financial responsibility is primary; 52 COB 5 71-0036900 Packet Pg. 64 4.3.a iii. If a court decree states that both parents are responsible for the dependent child's health care expenses or health care coverage,the provisions of a)above determine the order of benefits; iv. If a court decree states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or health care coverage of the dependent child, the provisions of Subsection a)above determine the order of benefits;or v. If there is no court decree allocating responsibility for the dependent child's health care expenses or health care coverage,the order of benefits for the child are as follows: • The plan covering the custodial parent,first; N • The plan covering the spouse of the custodial parent,second; `0 • The plan covering the non-custodial parent,third;and then • The plan covering the spouse of the non-custodial parent,last. Q c) For a dependent child covered under more than one plan of individuals who are not the parents of rn the child,the provisions of Subsection a)or b)above determine the order of benefits as if those 0 individuals were the parents of the child. c 0 3. Active employee or retired or laid-off employee.The plan that covers a Member as an active V L employee,that is,an employee who is neither laid off nor retired,is the primary plan. The plan 0 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 N 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 N under a right of continuation provided by state or other federal law is covered under another plan,the 0 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 0 .r or other federal continuation coverage is the secondary plan.If the other plan does not have this rule, and as a result,the plans do not agree on the order of benefits,this rule is ignored.This rule does not M apply if the rule under Section D.1 can determine the order of benefits. �a m 5. Longer or shorter length of coverage.The plan that covered the Member as an employee,member, Subscriber or retiree longer is the primary plan and the plan that covered the Member the shorter c period of time is the secondary plan. M M 6. If the preceding rules do not determine the order of benefits,the allowable expenses must be shared N 0 equally between the plans meeting the definition of plan.In addition,this plan will not pay more than it N r would have paid had it been the primary plan. a� E Effect on the Benefits of this Plan. y When this plan is secondary,it must make payment in an amount so that,when combined with the amount paid by Q the primary plan,the total benefits paid or provided by all plans for the claim equal one hundred percent of the total , allowable expense for that claim.However,in no event shall the secondary plan be required to pay an amount in `m 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. Y c Right to Receive and Release Needed Information. d Certain facts about health care coverage and services are needed to apply these COB rules and to determine benefits t payable under this plan and other plans.KFHPWA may get the facts it needs from or give them to other M organizations or persons for the purpose of applying these rules and determining benefits payable under this plan Q and other plans covering the Member claiming benefits. KFHPWA need not tell,or get the consent of,any Member to do this.Each Member claiming benefits under this plan must give KFHPWA any facts it needs to apply those rules and determine benefits payable. 53 COB571-0036900 Packet Pg. 65 4.3.a Facility of Payment. If payments that should have been made under this plan are made by another plan,KFHPWA has the right,at its discretion,to remit to the other plan the amount it determines appropriate to satisfy the intent of this provision.The amounts paid to the other plan are considered benefits paid under this plan.To the extent of such payments, KFHPWA is fully discharged from liability under this plan. Right of Recovery. KFHPWA has the right to recover excess payment whenever it has paid allowable expenses in excess of the N maximum amount of payment necessary to satisfy the intent of this provision.KFHPWA may recover excess 0 payment from any person to whom or for whom payment was made or any other issuers or plans. Q Questions about Coordination of Benefits?Contact the State Insurance Department. U) Effect of Medicare. L Medicare primary/secondary payer guidelines and regulations will determine primary/secondary payer status,and r_ will be adjudicated by KFHPWA as set forth in this section.KFHPWA will pay primary to Medicare when required V by federal law.When Medicare,Part A and Part B or Part C are primary,Medicare's allowable amount is the highest `0 allowable expense. m When a Network Provider renders care to a Member who is eligible for Medicare benefits,and Medicare is deemed N to be the primary bill payer under Medicare secondary payer guidelines and regulations,KFHPWA will seek Medicare reimbursement for all Medicare covered services. — d XI. Subrogation and Reimbursement Rights vi 0 The benefits under this EOC will be available to a Member for injury or illness caused by another party,subject to _J the exclusions and limitations of this EOC. If KFHPWA provides benefits under this EOC for the treatment of the c injury or illness,KFHPWA will be subrogated to any rights that the Member may have to recover compensation or U) damages related to the injury or illness and the Member shall reimburse KFHPWA for all benefits provided,from M any amounts the Member received or is entitled to receive from any source on account of such injury or illness, 0 13 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; 0 • Any Workers' Compensation or disability award or settlement; M • Medical payments coverage under any automobile policy,premises or homeowners'medical payments coverage or premises or homeowners' insurance coverage;and N 0 • Any other payments from a source intended to compensate an Injured Person for injuries resulting from an N r accident or alleged negligence. E This section more fully describes KFHPWA's subrogation and reimbursement rights. L a� "Injured Person"under this section means a Member covered by the EOC who sustains an injury or illness and any Q spouse,dependent or other person or entity that may recover on behalf of such Member including the estate of the `m Member and,if the Member is a minor,the guardian or parent of the Member.When referred to in this section, " U) KFHPWA's Medical Expenses"means the expenses incurred and the value of the benefits provided by KFHPWA Y under this EOC for the care or treatment of the injury or illness sustained by the Injured Person. d If the Injured Person's injuries were caused by a third-party giving rise to a claim of legal liability against the third t party and/or payment by the third party to the Injured Person and/or a settlement between the third party and the U Injured Person,KFHPWA shall have the right to recover KFHPWA's Medical Expenses from any source available Q to the Injured Person as a result of the events causing the injury. This right is commonly referred to as "subrogation."KFHPWA shall be subrogated to and may enforce all rights of the Injured Person to the full extent of KFHPWA's Medical Expenses. By accepting benefits under this plan,the Injured Person also specifically acknowledges KFHPWA's right of reimbursement.This right of reimbursement attaches when this KFHPWA has provided benefits for injuries or 54 COB 5 71-0036900 Packet Pg. 66 4.3.a illnesses caused by another party and the Injured Person or the Injured Person's representative has recovered any amounts from a third party or any other source of recovery.KFHPWA's right of reimbursement is cumulative with and not exclusive of its subrogation right and KFHPWA may choose to exercise either or both rights of recovery. In order to secure KFHPWA's recovery rights,the Injured Person agrees to assign KFHPWA any benefits or claims or rights of recovery they may have under any automobile policy or other coverage,to the full extent of the plan's subrogation and reimbursement claims. This assignment allows KFHPWA to pursue any claim the Injured Person may have,whether or not they choose to pursue the claim. N 0 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. Q 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 M uninsured/underinsured motorist funds,KFHPWA's Medical Expenses are secondary,not primary. C 0 c.� The Injured Person and their agents shall cooperate fully with KFHPWA in its efforts to collect KFHPWA's Medical `0 Expenses.This cooperation includes,but is not limited to,supplying KFHPWA with information about the cause of 3 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 w 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 Inured Person and their agents shall permit KFHPWA p Y g J j rY• J g at KFHPWA's option,to associate with the Injured Person or to intervene in any legal,quasi-legal,agency or any vi other action or claim filed. 0 J The Injured Person and their agents shall do nothing to prejudice KFHPWA's subrogation and reimbursement 0. rights.The Injured Person shall promptly notify KFHPWA of any tentative settlement with a third party and shall v� not settle a claim without protecting KFHPWA's interest. The Injured Person shall provide 21 days advance notice M to KFHPWA before there is a disbursement of proceeds from any settlement with a third party that may give rise to 0 a claim for subrogation or reimbursement.If the Injured Person fails to cooperate fully with KFHPWA in recovery of KFHPWA's Medical Expenses,and such failure prejudices KFHPWA's subrogation and/or reimbursement rights,the Injured Person shall be responsible for directly reimbursing KFHPWA for 100%of KFHPWA's Medical c Expenses. LO To the extent that the Injured Person recovers funds from any source that in any manner relate to the injury or illness N giving rise to KFHPWA's right of reimbursement or subrogation,the Injured Person agrees to hold such monies in N trust or in a separate identifiable account until KFHPWA's subrogation and reimbursement rights are fully c determined and that KFHPWA has an equitable lien over such monies to the full extent of KFHPWA's Medical E Expenses and/or the Injured Person agrees to serve as constructive trustee over the monies to the extent of (D KFHPWA's Medical Expenses.In the event that such monies are not so held,the funds are recoverable even if they have been comingled with other assets,without the need to trace the source of the funds. Any party who distributes Q funds without regard to KFHPWA's rights of subrogation or reimbursement will be personally liable to KFHPWA for the amounts so distributed. N M Y 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 y apportionment of such collection costs between KFHPWA and the Injured Person.This reduction will be made only r if each of the following conditions has been met: (i)KFHPWA receives a list of the fees and associated costs before U settlement and(ii)the Injured Person's attorney's actions were directly related to securing recovery for the Injured Q Party. To the extent the provisions of this Subrogation and Reimbursement section are deemed governed by ERISA, implementation of this section shall be deemed a part of claims administration and KFHPWA shall therefore have discretion to interpret its terms. 55 COB571-0036900 Packet Pg. 67 4.3.a XII.Definitions Allowance The maximum amount payable by KFHPWA for certain Covered Services. Allowed Amount The level of benefits which are payable by KFHPWA when expenses are incurred from a non-Network Provider.Expenses are considered an Allowed Amount if the charges are consistent with those normally charged to others by the provider or organization for the N same services or supplies;and the charges are within the general range of charges made o by other providers in the same geographical area for the same services or supplies. t Members shall be required to pay any difference between a non-Network Provider's Q charge for services and the Allowed Amount,except for Emergency services,including , post stabilization and for ancillary services provided by a non-Network provider at a U) Network Facility.For more information about balance billing protections,please visit: L https://health. .k�rpermanente.oriz/washin tg on/support/fonns and click on the"Billing W forms"link. C V L Convalescent Care Care furnished for the purpose of meeting non-medically necessary personal needs 3 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 w medication. N am c Copayment The specific dollar amount a Member is required to pay at the time of service for certain Covered Services. vi Cost Share The portion of the cost of Covered Services for which the Member is liable.Cost Share � includes Copayments,coinsurances and Deductibles. 0. Covered Services The services for which a Member is entitled to coverage in the Evidence of Coverage. M 13 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 00 actuarial guidelines.In general,the actuarial determination measures whether the M 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 N drug benefit. 0 r c Deductible A specific amount a Member is required to pay for certain Covered Services before benefits are payable. 4) L 0 Dependent Any member of a Subscriber's family who meets all applicable eligibility requirements, Q is enrolled hereunder and for whom the premium has been paid. m T) Emergency The emergent and acute onset of a medical,mental health or substance use disorder M Y 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 y exists that requires immediate medical attention,if failure to provide medical attention E t would result in serious impairment to bodily function or serious dysfunction of a bodily U organ or part,or would place the Member's health,or if the Member is pregnant,the Q health of the unborn child,in serious jeopardy,or any other situations which would be considered an emergency under applicable federal or state law. Essential Health Benefits set forth under the Patient Protection and Affordable Care Act of 2010, Benefits including the categories of ambulatory patient services,Emergency services, 56 COB571-0036900 Packet Pg. 68 4.3.a hospitalization,maternity and newborn care,mental health and substance use disorder services,including behavioral health treatment,prescription drugs,rehabilitative and habilitative services and devices,laboratory services,preventive and wellness services and chronic disease management and pediatric services,including oral and vision care. Established Member must have had at least one in-person appointment or at least one real-time Relationship interactive appointment using both audio and visual technology in the past year,with the N provider providing audio only telemedicine or with a provider employed at the same o medical group,at the same clinic,or by the same integrated delivery system operated by z KFHPWA. Or the Member was referred to the provider providing audio-only Q telemedicine by a provider who they have had an in-person appointment within the past , year. M L Evidence of Coverage The Evidence of Coverage is a statement of benefits,exclusions and other provisions as c set forth in the Group Medical Coverage Agreement between KFHPWA and the Group. 0 V L 0 Family Unit A Subscriber and all their Dependents. 3 m Group An employer,union,welfare trust or bona-fide association which has entered into a w Group Medical Coverage Agreement with KFHPWA. 0 c Hospital Care Those Medically Necessary services generally provided by acute general hospitals for admitted patients. vi 0 KFHPWA-designated A specialist specifically identified by KFHPWA. _J Specialist 0 .r Medical Condition A disease,illness or injury. M 13 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 c services,as determined by KFHPWA's medical director according to generally accepted M principles of good medical practice,which are rendered to a Member for the diagnosis, care or treatment of a Medical Condition and which meet the standards set forth below. N In order to be Medically Necessary,services and supplies must meet the following N requirements: (a)are not solely for the convenience of the Member,their family member or the provider of the services or supplies;(b)are the most appropriate level of service or E supply which can be safely provided to the Member; (c)are for the diagnosis or 4) 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, Q relaxation or palliative therapy,except for treatment of terminal conditions;(e)are appropriate and consistent with the diagnosis and which,in accordance with accepted medical standards in the State of Washington,could not have been omitted without 0 Y adversely affecting the Member's condition or the quality of health services rendered; (f) as to inpatient care,could not have been provided in a provider's office,the outpatient y department of a hospital or a non-residential facility without affecting the Member's E condition or quality of health services rendered;(g)are not primarily for research and U data accumulation;and(h)are not experimental or investigational.The length and type Q of the treatment program and the frequency and modality of visits covered shall be determined by KFHPWA's medical director.In addition to being medically necessary,to be covered,services and supplies must be otherwise included as a Covered Service and not excluded from coverage. 57 COB571-0036900 Packet Pg. 69 Medicare The federal health insurance program for people who are age 65 or older,certain younger people with disabilities,and people with End-Stage Renal Disease(permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD). Member Any enrolled Subscriber or Dependent. Network Facility A facility(hospital,medical center or health care center)owned or operated by Kaiser N Foundation Health Plan of Washington or otherwise designated by KFHPWA,or with r whom KFHPWA has contracted to provide health care services to Members. Network Personal A provider who is employed by Kaiser Foundation Health Plan of Washington or Q Physician Washington Permanente Medical Group,P.C.,or contracted with KFHPWA to provide U) primary care services to Members and is selected by each Member to provide or arrange L for the provision of all non-emergent Covered Services,except for services set forth in c the EOC which a Member can access without Preauthorization.Network Personal V Physicians must be capable of and licensed to provide the majority of primary health `o care services required by each Member. m Network Provider The medical staff,clinic associate staff and allied health professionals employed by w 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, vi psychologists,physical therapists and other professionals engaged in the delivery of c healthcare services who are licensed or certified to practice in accordance with Title 18 _J Revised Code of Washington. c 0 Out-of-pocket Expenses Those Cost Shares paid by the Subscriber or Member for Covered Services which are M applied to the Out-of-pocket Limit. 0 13 am Out-of-pocket Limit The maximum amount of Out-of-pocket Expenses incurred and paid during the calendar 2 year for Covered Services received by the Subscriber and their Dependents within the 00 same calendar year.The Out-of-pocket Expenses which apply toward the Out-of-pocket M Limit are set forth in Section IV. M N Plan Coinsurance The percentage amount the Member is required to pay for Covered Services received. N r c Preauthorization An approval by KFHPWA that entitles a Member to receive Covered Services from a E specified health care provider. Services shall not exceed the limits of the y 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 Q Preauthorization for specialty care provider services. Private Duty Nursing The hiring of a nurse by a family or Member to provide long term and/or continuous one Y (or 24-hour nursing on one care with or without oversight by a home health agency.The care may be skilled, care) supportive or respite in nature. t Residential Treatment A term used to define facility-based treatment,which includes 24 hours per day,7 days U per week rehabilitation.Residential Treatment services are provided in a facility Q specifically licensed in the state where it practices as a residential treatment center. Residential treatment centers provide active treatment of patients in a controlled environment requiring at least weekly physician visits and offering treatment by a multi- disciplinary team of licensed professionals. 58 COB571-0036900 Packet Pg. 70 Service Area Washington counties of Benton,Columbia,Franklin,Island,King,Kitsap,Lewis, Mason,Pierce, Skagit,Snohomish,Spokane,Thurston,Walla Walla,Whatcom, Whitman and Yakima. Subscriber A person employed by or belonging to the Group who meets all applicable eligibility requirements,is enrolled and for whom the premium has been paid. m Urgent Condition The sudden,unexpected onset of a Medical Condition that is of sufficient severity to 0 require medical treatment within 24 hours of its onset. Q 0 L r- �O♦ V L O d d O J Q. O r.+ M V 13 d O O LO M M N O N r C N E N N L Q d M Y c d E t v r Q 59 COB571-0036900 Packet Pg. 71 4.3.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 O N discriminate,exclude people,or treat them differently on the basis of race,color,national origin,age, L- disability,sex,sexual orientation,gender identity,or any other basis protected by applicable federal, state,or local law.We also: O Q • Provide free aids and services to people with disabilities to communicate effectively with us, y r such as: v cv L — Qualified sign language interpreters O — Written information in other formats(large print,audio,accessible electronic formats,and U L other formats) 0 — Assistive devices(magnifiers,Pocket Talkers,and other aids) d • Provide free language services to people whose primary language is not English,such as: y — Qualified interpreters d c — Information written in other languages If you need these services,contact Member Services at 1-888-901-4636(TTY 711). N If you believe that Kaiser Permanente has failed to provide these services or discriminated in another O J way on the basis of race,color,national origin,age,disability,sex,sexual orientation,or gender identity, Q you can file a grievance with our Civil Rights Coordinator by writing to P.O. Box 35191,Mail Stop: 0 RCR-A35-03,Seattle,WA 98124-5191 or calling Member Services at the number listed above.You can file U) a grievance by mail,phone,or online at kp.org/wa/feedback. If you need help filing a grievance,our Civil v Rights Coordinator is available to help you. m You can also file a civil rights complaint with: • The U.S. Department of Health and Human Services,Office for Civil Rights electronically through p LO the Office for Civil Rights Complaint Portal,available at https://ocrportal.hhs.gov/ocr/portal/lobby.isf,or by mail or phone at: U.S. Department of C 1 Health and Human Services,200 Independence Avenue SW.,Room 509F,HHH Building, p Washington,DC 20201, 1-800-368-1019,800-537-7697(TDD) r Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.htmi aa)i E • The Washington State Office of the Insurance Commissioner,electronically through the Office of the Insurance Commissioner Complaint portal available at https://www.insurance.wa.gov/file-complaint-or-check-your-complaint-status,or by phone at Q 800-562-6900,360-586-0241(TDD).Complaint forms are available at https://fortress.wa.gov/oic/onlineservices/cc/pub/complaintinformation.aspx N Y c m E t 2022-XB-7_ACA_Notice_Taglines Vim° KAISER PERMANEWE® Q 60 COB571-0036900 Packet Pg. 72 4.3.a 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). N N Espan"ol(Spanish):ATENCI6N:Si habla espanol,tiene disponibles servicios de ayuda con el idioma sin cargo. i- Hame al 1-888-901-4636(TTY 711). 7 L�3t(Chinese) rTAZK 1-888-901-4636 Q (TTY 711) y r v Tieng Viet(Vietnamese):CHID N:N6u quy vi n6i tieng Viet,quy vi co the six dung dich vu ho trd ng6n ngix i mien phi c6a chung t6i.Xin goi so"1-888-901-4636(TTY 711). 0 a> 12�1 (Korean):J�jl:a�-�t 1�1'1 RL h}-$-o}Al o-T, 111°j 7,l a M til Z -q--7- A]� ��t-q L 1-888-901-4636(TTY 711)-Li ---,-i 91 oIA�h1 o. C PYCCKHN(Russian):BHNMAHNE! ECAm Bbi roBopmTe n0-pycCKW,BaM AOCTynHbi 6ecnnaTHbie ycnyr" j nepeBO,ALIMKa.3BOHHTe no Homepy 1-888-901-4636(TTY 711). N d Tagalog:PAUNAWA:Kung nagsasalita ka ng Tagalog,maaari kang gumamit ng mga serbisyo ng tulong sa S wika nang walang bayad.Tumawag sa 1-888-901-4636(TTY 711). d 3.1 YKpaIHCbKa(Ukrainian):YBAfA!FIKLL�0 BN p03MOBAACTe yKpaIHCb K0M MOBOK),BaM AOCTynHI 6e3KOWTOBHi y nocnyrL1 nepeKnaAy.Tene4)OHYt Te 3a HoMepoM 1-888-901-4636(TTY 711). 00 J a 0. Fil€U1121 (Khmer)' CiSf3PSSi5Gt5OMwli5o PSSf3Si5t5Scii5S312iiSjS31tSF3 0 fi l 91[i 1S5' FUO 1-888-901-4636(TTY 711)`l U) R S ao(Japanese):;±'Z*EX : *f40)H*AaZ0)aap 1�— N � 1�L\LLif-d-z to v 1-888-901-4636(TTY 711) J�Z. f&�'�<tE t Lxo hOYC'r(Amharic)*07AML.Ff 4"�S74,fi 5V35�A"40�h0 4+C?-P h7H frig AACWv PqC A-: o WY 1-888-901-4636(TTY 711),P,9aA-r: Q M Oromiffa(Oromo):XIYYEEFFANNAA:Afaan dubbattu Oroomiffa yoo We,tajaajila gargaarsa afaanii, kanfaltiidhaan ala,ni argama. 1-888-901-4636(TTY 711)irraatti bilbilaa. N 0 N IIRQ(Punjabi):f4*rrc7 t�:4-5F ifrT�$��t�c�,3T-!gT$T��!oAjo3cTraFoNu3QLfKkikiZ-6i � 1-888-901-4636(TTY 711)`�qFF-q�I E N .ULl_«JJ&�sy>�a g:JJI o rsl oJl uL r�1s�a_yJl a;JJI u ti aS151:olwl:(Arabic)ZeyJl W (TTY 711) 1-888-901-4636 P9�1 �J�31 Q Deutsch(German):ACHTUNG:Wenn Sie Deutsch sprechen,stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur VerfOgung. Rufnummer: 1-888-901-4636(TTY 711). to (Lao):1L$c)sl-)e): ccaiz�ava3ri�z�v�n�a����c�n�c��r�����Fc��vc���i:2�nccrien�a�.Fen 1-888-901-4636(TTY 711). E t v R r XB0001444-58-22 Q 61 COB571-0036900 Packet Pg. 73 4.3.b AMENDMENT NO. 14 To be attached to and made part of Policy WA 518212 issued to City of Kent as Policyholder. m N It is hereby agreed the Policy shall be amended as follows: 0 a Effective January 1, 2023: c� The following Section has been replaced: O Section 1, Declarations. o c a� a� The following Rider renews for the 2023 Policy Year: as Specific Advance Funding Rider. O J Q O r N fC v N O O LO All other terms and conditions of the contract remain unchanged. M N O N C N E C d E Q d N LifeWise Assurance Company Name and Title of Officer J Signature of Officer E Rick Grover President and Chief Executive Officer Q 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. 74 4.3.b This Declarations for Policy Number WA 518212 apply to the Policy Term January 1, 2023 through December 31, 2023 in its entirety. SECTION 1 — DECLARATIONS IF A. POLICY INFORMATION N 0 1. Policy Number WA 518212 a 2. Policyholder City of Kent 3. Policy Term January 1, 2023 through December 31, 2023 i c 4. Covered Underlying Plan City of Kent's Health Plan ° U L 5. Claim Administrator Premera Blue Cross ° c a� B. SPECIFIC BENEFIT SCHEDULE > For all Eligible Losses except those to which a Special Risk Limitation applies: c 1. Covered Loss Basis Covered Services Incurred from January 1, 2010 through December 31, 2023 and Paid from vi January 1, 2023 through December 31, 2023. 0 J 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 in Claim Expense was originally denied by the Covered Underlying Plan will be considered the "Paid"date under the above referenced Policy. W 2. Covered Services include Medical o 0 Prescription Drug .LOM. M 3. Number of Covered Units o N Composite 701 m 4. Specific Deductible per Participant $200,000 c (Please note: Specific deductible per Participant shall not exceed the lesser of 5%of expected claims or$100,000). Q 5. Specific Payable Percentage (in excess of Specific Deductible) 100% N 6. Maximum Specific Benefit in excess of the Specific Deductible _ J Per Policy Term Unlimited r c Per Lifetime Unlimited E c� Q PSL-500 WA(9-18) 1 Packet Pg. 75 4.3.b 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, 2023 and Paid from N January 1, 2023 through December 31, 2023. o t If an Eligible Claim Expense is denied by the Covered Underlying Plan and that denial is subsequently reversed by an Independent Review Organization (IRO),the date such Eligible Q Claim Expense was originally denied by the Covered Underlying Plan will be considered the "Paid"date under the above referenced Policy. cLa c 2. Covered Services include v Medical o Prescription Drug c a� 3. Number of Covered Units N Composite 701 a� 4. Aggregate Payable Percentage in excess of Deductible 100% vi 5. Aggregate Corridor 200% J (Please note: Aggregate Corridor will never be less than 120%of expected claims). o r N 6. Minimum Aggregate Deductible _ The greater of: :a A. $29,344,420.80; or B. The sum of Aggregate Monthly Factors, multiplied by the corresponding number of c Covered Units used to calculate premium in the first month of the Policy Term, multiplied LO by the number of months in the Policy Term, multiplied by 95%. M 7. Annual Aggregate Deductible c N Is equal to the greater of A or B,where: A=The sum of the Monthly Aggregate Deductible Amounts applicable to each Policy Month E in the Policy Term c B =The Minimum Aggregate Deductible °' E Please Note:Annual Aggregate Deductible cannot be finalized until the Monthly Aggregate Q Deductible Amounts are calculated for each Policy Month of the Policy Term. N 8. Aggregate Monthly Factor per Covered Unit Composite $3,488.40 J r c 9. Maximum Aggregate Eligible Loss per Participant $200,000 E 10. Maximum Aggregate Benefit per Policy Term $1,000,000 Q PSL-500 WA(9-18) 2 Packet Pg. 76 4.3.b D. PREMIUM Specific Monthly Premium Rate Composite $155.28 m Specific Rate Guarantee Period 12 Months ^' 0 Aggregate Monthly Premium Rate Per Covered Unit Composite $0.02 a Aggregate Rate Guarantee Period 12 Months i c The Specific Monthly Premium Rate and the Aggregate Monthly Premium Rate apply only to this 0 Policy Term. L 0 c E. SPECIAL RISK LIMITATIONS > Retirees Included Yes c a� Other: Yes vi Lasered Individual N 0 J Member ID: 600156808-02 a Specific Deductible: $300,000 0 Paid Claims between$200,000 and $300,000 are not eligible under the Aggregate Benefit. N F. AFFILIATE 0 Name Covered Underlying Plan c None M N O N C N >_ C d E Q d N J r C N E L V cC Q PSL-500 WA(9-18) 3 Packet Pg. 77 4.3.c • KENT - SOW - 3 TIM STATEMENT OF WORK-PROGRAM LAUNCH This KENT-SOW-3 effective as of April 1,2023("SOW Effective Date")is entered into pursuant to and incorporates N herein by reference the terms and conditions of the Vitality Master Services Agreement(the"Agreement")by and between o The Vitality Group, LLC("TVG")and CITY OF KENT,AWASHINGTONMUNICIPF('�Gu&torner").Services performed under this SOW will be 0 provided in accordance with and subject to the terms and conditions of this SOW,the Agreement and any applicable ' Amendments. Q 1. SCOPE OF WORK AND SCHEDULE. c This SOW shall cover and define all services to be provided by TVG as described under Section 3 of this SOW. U L 0 2. DEFINITIONS. c a� All capitalized terms not otherwise defined herein shall have the meaning ascribed to such term in the Agreement. > a� 2.1 "Program Launch"means the first day the Vitality Services will be accessible by eligible persons. as 2.2. "Vitality Bucks"means the currency that is provided to a Member to be redeemed for Vitality Rewards. If Member spends Vitality Bucks,the Member's Vitality Points do not change. 0 J CL 2.3. "Vitality Champ"means Customer's employee who are interested in promoting healthy living within the workplace. o Their role is to help other employees engage in the Vitality Program using tools provided. 2.4. "Vitality Program"means an incentive based wellness program which incorporates Vitality Points,Vitality Status and Vitality Rewards into a meaningful tool for the benefit of the Customer and Members. 2.5. "Vitality Points"means the unit that is earned by Members for participating in the Vitality Program. c LO M 2.6. "Vitality Program Year"means the rolling twelve month period your Vitality Program Year will begin and end twelve months later. 04 0 N 2.7. "Vitality Rewards"means the benefits available to Members according to an earned Vitality Status. 2.8."Vitality Status"means the threshold levels that Members may achieve by engagement in the Vitality 0 Program. 0 0 r M N O 3. DESCRIPTION OF SERVICES. L Q Below is a high level description of the"Vitality Services."Full requirements will be detailed throughout this SOW. Q M 3.1. TVG shall provide Vitality Services,which shall include,but not be limited to the following components. 0 3.1.1. A suite of health and wellness-oriented activities,clinical goals/measures,educational programs,and other objectives for members to pursue("Engagements"). 3.1.2. Health risk assessments and other or similar tool(s)to identify a member's current health and wellness levels, > conditions,activities, risks,and related factors. 3.1.3. A designated wellness strategy manager to assist in leading a standard ninety day implementation and building Customer's strategy for running a wellness portal. 3.1.4. A points based incentive structure to encourage members to pursue Engagements. 3.1.5. Various"Vitality Rewards"which members may qualify for through engagement in the Vitality Program,which a may include Earn Apple Watch with Apple Watch fulfillment. ................................................................................................................................................................................. Agency-Vitality SOW#3 1 4.3.c • TM KENT - SOW - 3 4. RESPONSIBILITIES OF TVG. 4.1. Program Launch. TVG shall accurately implement and launch the Vitality Program on April 1, 2019 N (the"Program Launch Date")in accordance with the program selection of this SOW. However,in the event that 0 Customer has not satisfied the obligations of Section 4 of KENT-SOW- 1 TVG may in its sole discretion delay the Program Launch Date to the first day of the following month. Q 4.2. On Going. Effective upon Program Launch,TVG shall provide a designated wellness strategy manager throughout the p 9 p 9 9Y 9 9 � term of this SOW.The designated wellness strategy manager shall be responsible for: c 4.2.1. Developing with Customer an annual strategy engagement and roadmap including specific objectives and goals U prior to the start of each Vitality Program Year. o c 4.2.2. Leading and scheduling a monthly call to discuss engagement strategy,communication plans,troubleshoot escalated issues and any updates on the Vitality Program a� 4.2.3. Providing and assisting in the review of the standard monthly,quarterly and annual reports.' a� 4.2.4. Provideing training prior to Program Launch on: 4.2.4.1. The Vitality Information Portal o 4.2.4.2. Vitality Champs _J a 0 4.2.5. Up to once a month,if requested,attending via teleconference a monthly Vitality Champ ongoing training session y 4.2.6. Delivering a monthly client newsletter to Customer a� 5. RESPONSIBILITIES OF CUSTOMER. 0 5.1. Ongoing. Effective upon Program Launch, Customer shall provide a designated point of contact throughout the term LO of this SOW.The designated point of contact shall be responsible for: m N 5.1.1. Develop with TVG an annual strategy engagement and roadmap c N L 5.1.2. Regularly attend TVG standard trainings2 5.1.3. Reasonably cooperating with the TVG wellness strategy manager to promote engagement and use of the U Vitality Program using TVG provided tools such as: o 5.1.3.1.Attending monthly teleconferences with TVG call to discuss engagement strategy,communication plans, troubleshoot escalated issues and any updates on the Vitality Program N 5.1.3.2. Developing regular communications using the TVG provided communication center. In the event Customer N creates non-standard communication materials,Customer agrees to seek TVG approval prior to distribution. 5.1.3.3. Using the C-Suite Tool Kit to promote engagement and communication at the executive level Q- Q 5.1.3.4.Vitality Champ recruitment,training and use including a monthly call with TVG and a Vitality Champ r� 5.1.3.5.Sponsoring TVG approved activities with allocated additional Vitality Points 5.1.3.6. Informing and educating any new hires of the Vitality Program using TVG provided materials y If at the end of any quarter,fewer than fifty(50)eligible employees have completed the Vitality Health Review,certain standard reports may > not be available due to privacy and security concerns. :: c 2 All trainings are subject to change as the program evolves,Customer will be provided adequate notice prior to any new training to best equip E Customer to get the full value of the Vitality Program c� Q ....................................................................................................................................................................... Agency-Vitality SOW#3 2 Packet Pg. 79 KENT - SCQ4. .c TM 5.1.4. Provide TVG an ongoing,accurate Eligibility File no less frequently than once permonth3 5.1.4.1. In the event an Eligibility File contains errors, it shall be the Customer's responsibility to review the TVG provided error reports and make all appropriate changes N 5.1.5. Provide TVG with reasonable notice of any business changes such as changes to the&Suite, main contacts, t Human Resources or Benefits Department as well as any changes to business entity structure to enable the wellness strategy manager and Customer to update and modify any objectives,goals or overall strategy as Q required. r 6. TERM 6.1. The Services described in this SOW shall commence April 1,2023 and continue until December 31,2026 � 0 ("Renewal Term"). Following the Renewal Term,a new SOW shall be automatically generated to renew c� for a successive period of one(1)year each(each a"Renewal Terri'). o 6.2. During any Renewal Term,either Party may terminate this SOW with ninety(90)days written notice.The termination shall be effective the last day of the month following the ninety(90)day notice period > a� c a� vi O J Q O r R 7. VITALITY PROGRAM SELECTIONS and COMPENSATION SCHEDULE 0 a� 7.1. Customer shall provide TVG with a minimum of ninety(90)days'notice in the event Customer chooses to change any oc of their Vitality Program selections as shown below.Any change to Vitality Program offering may only occur at the M renewal of each Vitality Program Year and be agreed to in an amendment to this SOW m 7.2. After Renewal Term, Once per year,all fees outlined below are subject to change with ninety(90)days written notice to c Customer.Any changes to the PEPM Administration Fee will be limited to the percentage increase in the Consumer Price Index-Urbai ci over a corresponding time period. E a� a� 7.3. In the event Customer requests any work, reports or integrations be done by TVG or with the support of TVG outside o of what is contained herein,additional fees may apply. Program Selection Charge Basis(If Applicable) Amount o N NAtality Program a Activate Q • Elevate "' Members shall be: Per Employee Per Month $ 5.06 0 0 En ooyees Only (PEPW Administration Fee ;, Employees and eligible dependents(no children) Employees and eligible dependents(with children) w c a� 3 The Customer shall provide TVG,on a regular basis,an electronic file in a format specified by TVG("Digibility File")of all members along with E such information as is reasonably required to enable TVG to verify the identity of r w-bers and administer the Vitality Program.The Customer's updating of its Eligibility File shall serve as notice to TVG of any additions,changes,deletions or modifications to the list of members and TVG f° shall be entitled to rely on the accuracy and completeness of the enrollment and eligibility data in providing the Vitality Program In no event shall Q TVG be required to revise the eligibility retroactively. 4 If an employee had access for at least one day at any pant during the calendar month,the full PEPM will be owed. Agency-Vitality buvvg.s Packet Pg. 80 4.3.c KENT -Im a� N O t 3 Member Education Sessions5: Q 2 included following Program Launch Travel and expenses only r c additional in the first Vitality Program Year $850/visit plus travel and expenses Varies v `o additional in the subsequent Vitality Program Years $850/visit plus travel and expenses > Add-On Vitality Rewards: Mall: Customer shall be responsible for O No Mall funding any items purchased in the Mall Varies Q Low Mall via a reimbursement on each bill. o Q Standard Mall a 0 Vitality Squares Vitality Squares is included in the y Administration Fee N/A - U Vitality HealthyFood V�alrrert Vitality HeaIthyF is included in the N/A Nutrisavi Admnistration Fee c LO M Welliness Rebates: Customer shall be responsible for funding c any Rebates redeetred via a 04 rein-burserrent on each bill. d No Wellness Rebates E ®SniJdng Cessation Up to$200/Rebate Redeemed'a ©Wight Loss Up to$200/Rebate Redeemedsb Vanes o Rebate/Subsi per verified workouts 0 GO M N O N L Q Q M 0 N SA Member Education Session includes use of a TVG employee for a business day.Sites within a close proximity that can be traveled to within the time frame > allotted may,at TVG's discretion,be considered one site.Customer may exchange an on-site visit for a business day of up to four(4)Member education a� webinars.A webinar is an hour long session which may be recorded during the session and distributed after. Reasonable time for meals and short breaks must E be provided for TVG employees. All Member educations,whether done via recorded webinar or onsite must be agreed and approved by TVG at time of U scheduling.Travel expenses are not included and will be charged to Customer by TVG at cost. Q 60 Members may earn each rebate once per lifetime. ................................................................................................................................................................................. Agency-Vitality SOW#3 4 4.3.c TM Active Rewards: Customer shall be responsible for Not Offered funding the total value of any gift Varies 4 cards redeemed via a o ® Offered reimbursement on each bill. a Earn Apple Watch Earn Apple Watch Administration Fee Not Offered PEPM c ® Offered EE-Only In addition, Customer shall be 0 Varies ® Offered EE+Spouses responsible for funding the -L_°0 discounted monthly Apple Watch payments earned by Members" > Biometric Screenings Submission: Integrated Partner B aTietric Screener No Charge N/A v; 0 J ®Devate Integrated Non-Partner Biometric Screener One-Tirre Set Up Fee 9a $2,000 OrrCoing Maintenance Fee $3,500/Year y ®Activate Integrated Non-Partner B m-dric Screener One-Tirre Set Up Fee9b $3,500 Cn-Gang Mair-tenanoe Fee $4,500/Year Paper form Member submission $3/Form Varies c LO M INTENDING TO BE BOUND,this SOW has been duly executed by the authorized representatives of the parties set forth below. c N L CUSTOMER THE MTALJTY GROUP,LLC E E 0 U By: w�,,,,.,,,,� 0 Name: Name: M N O Title: Title: 04 L Q Dated: Dated: Q M O N 7A Member's monthly Apple Watch payments will be lowered in accordance with his or her qualifying activity during the previous month.Customer will be responsible for the amount by which each Member's monthly Apple Watch payment has been lowered.These charges will be applied to the Vitality Rewards cost section on each monthly invoice. > BEarn Apple Watch allows Members the opportunity to pay for an Apple Watch over a twenty-four month period(the"Apple Watch Repayment Period").Members can lower C their monthly payment for as long as this SOW is active.Upon termination of this SOW,TVG may charge Customer an Earn Apple Watch termination fee that will be 4) calculated based on i)the total amount remaining in each Apple Watch Repayment Period;ii)ongoing administration costs and;iii)expected bad debt.Alternatively,if Customer ends the Earn Apple Watch benefit,but does not terminate this SOW,Customer may elect to continue paying the Earn Apple Watch Administration Fee and allowing Earn Apple Watch Members to earn monthly discounts until the Apple Watch Repayment Period has ended or been settled on all Member Apple Watches. Q 90 Fee applies for set-up of a one time file feed in TVG's standard file format. Agency-Vitality SOW#3 5 Packet Pg. 82