TABLE OF CONTENTS Employee Benefits 2013

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1 ion s i V e c n ra u Ins l ca i d e M ss A e e y plo n la P e c n ista t n e D a r u s In u ns I l a nce e c n a li p m Co e c n ra s e c i t o N 3 1 e 0 e 2 y o l p m s E t i f e n e B Em Tax S x e l F p g n i d en ce an sur n I e f i L r lte e h S y it u n An Keep for reference during 2013

2 TABLE OF CONTENTS Employee Benefits 2013 General Information Insurance Changes During the Year....2 Monthly Insurance Rates o Administrative, Classified and Full-time Certified o Part-time Certified Employees.. 5 Medical Plan Information. 6 o Kaiser Permanente Deductible HMO..7 o Kaiser Permanente Deductible MultiChoice POS..15 Delta Dental Plan Information o Delta PPO Plus Premier..29 o Delta EPO..30 Vision Service Plan Information.. 31 Life Insurance Information...33 Flexible Spending Accounts for Health and Dependent Care Additional Benefits and Information...44 o Information Regarding Tax Sheltered Accounts..45 o Employee Assistance Program..46 o Horizons North Credit Union...47 o Sick Bank and Short-Term Disability. 49 Compliance Notices 50 o Family Medical Leave Act 51 o COBRA Information and Rates..52 o HIPAA Privacy Notice..54 o HIPAA Special Enrollment...61 o Medicaid and the Children s Health Insurance Program (CHIP) 62 o Women s Health and Cancer Rights Act...65 o Patient Protection Disclosure..65

3 Welcome to Adams 12 Five Star Schools General Information This book provides benefit information regarding general guidelines, summary of benefits, current insurance premiums and other valuable information. Please keep this book for reference during the 2013 calendar year. Insurance coverage begins the first of the month following a benefit-eligible employee s date of hire or status change that affects benefit eligibility. Newborns or newly adopted, added to insurance, are effective the date of birth or adoption. You may elect to provide coverage for your dependents. Dependents include: A. Your Spouse. Spouse is considered a person of the opposite gender with whom you are legally married. It also includes a common-law spouse or a domestic partner (same gender). An affidavit is required for common-law spouse and domestic partner - contact Human Resources/Benefits for the form. Any other person living with you that does not qualify as a spouse, common-law spouse or domestic partner, cannot be considered a dependent and cannot be on your district insurance. B. Your or your spouse s children may be covered through the end of the month of their 26th birthday. Dependent children include: natural child, step child, adopted/placed for adoption, child with a court-appointed legal guardianship. District plans do not cover the following: grandchild without legal guardianship, foster child, son-in-law or daughter-in-law. C. Your or your spouse s unmarried children of any age who are medically certified as disabled and dependent upon you or your spouse are eligible to continue coverage beyond age 26 if the following requirements are met: i. they are a tax-qualified dependent of you or your spouse; and ii. you give proof of the dependent s disability and dependency annually if requested. Dependent children who are attending college outside of the service area: For information regarding the level of medical care available to students while outside the service area, contact your health plan providers. 1

4 Insurance Changes During the Year Insurance changes during the year for medical, dental, vision and flexible spending accounts may ONLY be made if the employee experiences an IRS approved qualifying event which includes a special enrollment event (refer to Compliance Notices). Changes may only be made within your plan, i.e., you may add and/or delete dependents but cannot change from plan to plan. Generally, changes made will be effective the first of the month following the qualifying event except for a newborn or newly adopted child where coverage starts on the date of birth or adoption. You must notify the Benefits Department, complete a change form, and submit appropriate documentation within 31 days of the qualifying event. o Qualifying Events for changes during the calendar year include: þþ Change in legal marital status (e.g. marriage, divorce/legal separation, death) þþ Change in number or status of dependents (e.g. birth, adoption, death). þþ Change in employee/spouse/dependents employment status, work schedule, or residence that affects their eligibility for benefits. þþ Coverage of a child due to a Qualified Medical Child Support Order (QMCSO). þþ Entitlement or loss of entitlement to Medicare or Medicaid. þþ Certain changes in the cost of coverage, composition of coverage or curtailment of coverage of the employee or spouse s plan. þþ Changes consistent with Special Enrollment rights and FMLA leaves. (Refer to Compliance Notices.) 2

5 Enclosed are insurance rate sheets for: Administrative/Technical Resource, Full-time Certified, Classified 11/12 month employees MONTHLY INSURANCE RATES Part-time Certified employees Following are insurance rate sheets for: Classified 9 and 10 month hourly employees Administrative, If you Classified* have dependents and Full-time on your Certified insurance, employees summer benefit deductions will be made from February, March, April and May paychecks. Increased Part-time Certified premiums emplyees for these months are not reflected on the enrollment form or *9-Month and confirmation 10-Month statement. Classified review employees: the appropriate Employee rate deduction sheet for these deduction amounts. will be higher from January 31 thru May 31 to pre-pay for July and August insurance. Increased premiums for those months are not reflected on the online enrollment form or confirmation statement. RATES 3 3

6 Monthly Medical, Dental and Vision Rates Administrative, Classified* and Full-time Certified Effective January 1, December 31, 2013 PLAN COVERAGE LEVEL TOTAL PREMIUM DISTRICT PAID EMPLOYEE DEDUCTION Kaiser Deductible HMO Employee Only $ $ $22.63 * Employee & Spouse/DP $ $ $ * Employee & Child(ren) $ $ $ * Emp. SP/DP & Child(ren) $1, $ $ * RATES Kaiser Deductible MultiChoice POS Employee Only $ $ $ Employee & Spouse/DP $1, $ $ * Employee & Child(ren) $1, $ $ * Emp. SP/DP & Child(ren) $1, $ $1, * Delta EPO Employee Only $33.75 $32.06 $1.69 * Employee & Spouse/DP $68.10 $32.06 $36.04 * Employee & Child(ren) $83.43 $32.06 $51.37 * Emp. SP/DP & Child(ren) $ $32.06 $85.73 * Delta PPO+Premier Employee Only $43.08 $32.06 $11.02 * Employee & Spouse/DP $83.63 $32.06 $51.57 * Employee & Child(ren) $78.81 $32.06 $46.75 * Emp. SP/DP & Child(ren) $ $32.06 $90.79 * Vision Service Plan Employee Only $7.82 $7.43 $0.39 * Employee +1 $20.26 $7.43 $12.83 * Employee + 2 or more $35.53 $7.43 $28.10 * * 9 and 10 month Classified Employees: Employee deduction will be higher from January 31 thru May 31 to pre-pay for July and August insurance. 4 Rev. 10/2012

7 Monthly Medical, Dental and Vision Rates Part-Time Certified Employees Effective January 1, December 31, 2013 PLAN COVERAGE LEVEL TOTAL PREMIUM FTE EMPLOYEE PAYS FTE EMPLOYEE PAYS FTE EMPLOYEE PAYS Employee pays 75% 50% 25% Kaiser Deductible HMO Employee Only $ $ $ $ Employee & Spouse/DP $ $ $ $ Employee & Child(ren) $ $ $ $ Emp. SP/DP & Child(ren) $1, $1, $1, $ Kaiser Deductible Multichoice POS Employee Only $ $ $ $ Employee & Spouse/DP $1, $1, $1, $ Employee & Child(ren) $1, $1, $ $ Emp. SP/DP & Child(ren) $1, $1, $1, $1, RATES Delta EPO Employee Only $33.75 $25.73 $17.72 $9.70 Employee & Spouse/DP $68.10 $60.08 $52.07 $44.05 Employee & Child(ren) $83.43 $75.41 $67.40 $59.38 Emp. SP/DP & Child(ren) $ $ $ $93.74 Delta PPO Plus Premier Employee Only $43.08 $35.06 $27.05 $19.03 Employee & Spouse/DP $83.63 $75.61 $67.60 $59.58 Employee & Child(ren) $78.81 $70.79 $62.78 $54.76 Emp. SP/DP & Child(ren) $ $ $ $98.80 Vision Service Plan Employee Only $7.82 $5.96 $4.10 $2.25 Employee +1 $20.26 $18.40 $16.54 $14.69 Employee + 2 or more $35.53 $33.67 $31.81 $

8 Medical Plan Information MEDICAL PLANS MEDICAL PLAN INFORMATION Following are Colorado Health Benefit Plan Description Forms for the medical plans offered by the district. Plan packets are available in Human Resources. Kaiser, Group #0271, offers the choice of two medical plans. Benefited employees who live or work in the Denver/Boulder area may choose between two plans. 1. Kaiser DHMO: This deductible/coinsurance HMO plan offers in-network providers and facilities located throughout the Denver/Boulder area. 2. MultiChoice POS: This plan is a buy-up option. It is a deductible/coinsurance plan with three tiers of service: Tier 1: In-Network - Kaiser Providers Tier 2: Preferred Provider Network - PHCS/Kaiser Providers Tier 3: Out-of-Network Licensed Providers Healthy Lifestyle Programs: Additional Information: Customer Service: Kaiser Contacts: Primary Care Physician Services Clinical Pharmacy Call Center Medical Financial Counseling

9 KAISER DHMO 2013 Colorado Health Benefit Plan Description Form Kaiser Foundation Health Plan of Colorado Plan DHMO ADAMS 12 FIVE STAR SCHOOLS - Group # Denver/Boulder Large Group PART A: TYPE OF COVERAGE 1. TYPE OF PLAN Health Maintenance Organization (HMO) 2. OUT-OF-NETWORK CARE COVERED? 1 Only for Emergency Care 3. AREAS OF COLORADO WHERE PLAN IS AVAILABLE Plan is available only in the following areas: Adams, Arapahoe, Boulder, Broomfield, Clear Creek, Denver, Douglas, Elbert, Gilpin, Jefferson, Larimer, Park and Weld Counties as determined by zip code. PART B: SUMMARY OF BENEFITS Important Note: This form is not a contract, it is only a summary. The contents of this form are subject to the provisions of the policy, which contains all terms, covenants and conditions of coverage. Your plan may exclude coverage for certain treatments, diagnoses, or services not noted below. The benefits shown in this summary may only be available if required plan procedures are followed (e.g., plans may require prior authorization, a referral from your primary care physician, or use of specified providers or facilities). Consult the actual policy to determine the exact terms and conditions of coverage. Coinsurance and copayment options reflect the amount the covered person will pay. IN-NETWORK ONLY (Out-of-Network care is not covered except as noted) 4. Deductible Type 2 Calendar Year 4a. ANNUAL DEDUCTIBLE 2a a) Individual 2b b) Family 2c b) $1,500 per calendar year The Individual and Family Deductibles are separate Deductibles. For Families, individual family members are responsible for meeting the Family Deductible, only up to the Individual Deductible amount. If your group has a Pharmacy Deductible, please see Box 11 for information regarding the Pharmacy Deductible. (Note: The Pharmacy Deductible is separate from the medical Deductible (Deductible), noted above) 5. OUT-OF-POCKET ANNUAL MAXIMUM 3 a) Individual b) Family c) Is deductible included in the out-ofpocket maximum? 6. LIFETIME OR BENEFIT MAXIMUM PAID BY THE PLAN FOR ALL CARE a) $1,500 per calendar year b) $3,000 per calendar year c) No For Families, the individual family members are responsible for meeting the Family Out-of Pocket (OPM), only up to the Individual OPM amount. None 7A. COVERED PROVIDERS Colorado Permanente Medical Group, P.C. See provider directory for a complete list of current providers 2013 DB-LG-DED Kaiser Permanente 7

10 2013 Colorado Health Benefit Plan Description Form Kaiser Foundation Health Plan of Colorado PART B: SUMMARY OF BENEFITS CONTINUED 7B. With respect to network plans, are all the providers listed in 7A accessible to me through my primary care physician? 8. MEDICAL OFFICE VISITS 4 a) Primary Care Providers b) Specialists Yes IN-NETWORK ONLY (Out-of-Network care is not covered except as noted) Copayment --not subject to the Deductible; does not apply to the OPM Coinsurance -- subject to the Deductible; applies to OPM a) $20 Copayment each primary care office visit b) $40 Copayment each specialist care office visit Subject to the Deductible; applies to the OPM 10% Coinsurance for procedures received during an office visit (including Office Administered Drugs) after Deductible is met KAISER DHMO 9. PREVENTIVE CARE a) Children's services b) Adults' services 10. MATERNITY a) Prenatal care b) Delivery & inpatient well baby care PRESCRIPTION DRUGS 6 Level of coverage and restrictions on prescriptions. Not subject to the Deductible; does not apply to the OPM a) No Charge (100% covered) b) No Charge (100% covered) The Copayment or Coinsurance for certain preventive care services may differ from the Copayment or Coinsurance listed above. a) Routine Prenatal Care - Not subject to the Deductible; does not apply to the OPM $0 Copayment Subject to the Deductible; applies to the OPM 10% Coinsurance for procedures received during an office visit after Deductible is met. b) Copayment --not subject to the Deductible; does not apply to the OPM Coinsurance - subject to the Deductible; applies to OPM 10% Coinsurance after Deductible is met Not subject to the Deductible; does not apply to the OPM $15 Generic/$30 Brand Tobacco cessation and contraceptive drugs No Charge (100% covered) up to a 30-day supply, /20% Coinsurance for specialty drugs including self-administered injectables, up to a maximum of $250 per drug dispensed/ per prescription Mail-order drugs available for up to a 90-day supply for two Copayments - Certain drugs limited to a 30-day supply For drugs on our approved list, please contact your Clinical Pharmacy Call Center at or toll-free at or TTY INPATIENT HOSPITAL Copayment --not subject to the Deductible; does not apply to the OPM Coinsurance -- subject to the Deductible; applies to OPM 10% Coinsurance after Deductible is met 13. OUTPATIENT/AMBULATORY SURGERY 10% Coinsurance for inpatient professional visits after Deductible is met. Subject to the Deductible; applies to the OPM 10% Coinsurance for outpatient surgery performed in any setting other than inpatient after Deductible is met DB-LG-DED Kaiser Permanente 8

11 2013 Colorado Health Benefit Plan Description Form Kaiser Foundation Health Plan of Colorado PART B: SUMMARY OF BENEFITS CONTINUED IN-NETWORK ONLY (Out-of-Network care is not covered except as noted) 14. DIAGNOSTICS a) Diagnostic Lab a) Laboratory & X-ray Not subject to the Deductible; does not apply to the OPM b) MRI, nuclear medicine, and other No Charge (100% covered) for laboratory services received during an office high-tech services visit, in a Plan Medical Office, or in a contracted free-standing facility (excluding Plan Hospitals) Not subject to the Deductible; does not apply to the OPM No Charge (100% covered) for laboratory services in the outpatient department of a Plan Hospital. Diagnostic X-ray, including Therapeutic Not subject to the Deductible; does not apply to the OPM No Charge (100% coverd). Therapeutic X-ray - Not subject to the Deductible; does not apply to the OPM $20 Copayment each visit b) MRI/CT/PET Copayment --not subject to the Deductible; does not apply to the OPM Coinsurance -- subject to the Deductible; applies to OPM 10% Coinsurance after Deductible is met 15. EMERGENCY CARE 7, 8 Copayment --not subject to the Deductible; does not apply to the OPM Coinsurance -- subject to the Deductible; applies to OPM 10% Coinsurance at a Kaiser Permanente designated Plan or non-plan emergency room after Deductible is met 10% Coinsurance for Line 14b procedures (Special Procedures) performed while receiving Emergency Services after Deductible is met 16. AMBULANCE Not subject to the Deductible; does not apply to the OPM 17. URGENT, NON-ROUTINE, AFTER-HOURS CARE 10% Coinsurance up to $500 per trip Copayment --not subject to the Deductible; does not apply to the OPM Coinsurance -- subject to the Deductible; applies to OPM For urgent, non-routine care after-hours $40 Copayment each after-hours visit at a Kaiser Permanente designated after-hours Plan Facility inside the Service Area 10% Coinsurance for procedures received during the visit after Deductible is met 2013 DB-LG-DED Kaiser Permanente 9

12 2013 Colorado Health Benefit Plan Description Form Kaiser Foundation Health Plan of Colorado PART B: SUMMARY OF BENEFITS CONTINUED 18. BIOLOGICALLY-BASED MENTAL ILLNESS CARE OTHER MENTAL HEALTH CARE a) Inpatient care b) Outpatient care IN-NETWORK ONLY (Out-of-Network care is not covered except as noted) Coverage is no less extensive than the coverage provided for any other physical illness a) Inpatient Copayment --not subject to the Deductible; does not apply to the OPM Coinsurance -- subject to the Deductible; applies to OPM 10% Coinsurance after Deductible is met Subject to the Deductible; applies to the OPM 10% Coinsurance for inpatient professional visits after Deductible is met. b) Outpatient Copayment --not subject to the Deductible; does not apply to the OPM Coinsurance -- subject to the Deductible; applies to OPM $20 Copayment Group visits will be charged at half the Copayment of an individual visit, rounded down to the nearest dollar. KAISER DHMO 20. ALCOHOL & SUBSTANCE ABUSE a) Inpatient Medical Detoxification Copayment --not subject to the Deductible; does not apply to the OPM Coinsurance - subject to the Deductible; applies to OPM 10% Coinsurance after Deductible is met Detoxification is limited to removing toxic substance from the body Inpatient Residential Rehabilitation Copayment --not subject to the Deductible; does not apply to the OPM Coinsurance -- subject to the Deductible; applies to OPM 10% Coinsurance after Deductible is met Subject to the Deductible; applies to the OPM 10% Coinsurance for inpatient professional visits after Deductible is met a) Outpatient Chemical Dependency Copayment --not subject to the Deductible; does not apply to the OPM Coinsurance -- subject to the Deductible; applies to OPM $20 Copayment Group visits will be charged at half the Copayment of an individual visit, rounded down to the nearest dollar DB-LG-DED Kaiser Permanente 10

13 2013 Colorado Health Benefit Plan Description Form Kaiser Foundation Health Plan of Colorado PART B: SUMMARY OF BENEFITS CONTINUED IN-NETWORK ONLY (Out-of-Network care is not covered except as noted) 21. PHYSICAL, OCCUPATIONAL, & For conditions subject to significant improvement within two (2) months SPEECH THERAPY Inpatient Subject to the Deductible; applies to the OPM 10% Coinsurance after Deductible is met Outpatient Copayment --not subject to the Deductible; does not apply to the OPM Coinsurance - subject to the Deductible; applies to OPM $20 Copayment each visit for up to 20 visits per year for each type of therapy (i.e. physical, occupational and speech therapy) Therapy for congenital defects and birth abnormalities are covered for children from age 3 to age 6 for both acute and chronic conditions. For children ages 0-3 services may be available as part of Early Intervention Services as defined by State law. Therapies for the treatment of autism spectrum disorders are not subject to any visit limits and include long term rehabilitation. 22. DURABLE MEDICAL EQUIPMENT Not subject to the Deductible; does not apply to the OPM 10% Coinsurance within the Service Area - $2,000 annual benefit maximum per calendar year Prosthetic arms and legs covered at 10% Coinsurance with no annual maximum (the coinsurance must equal DME coinsurance or 20% whichever is lower). See policy for types and circumstances of coverage 23. OXYGEN Not subject to the Deductible; does not apply to the OPM 10% Coinsurance 24. ORGAN TRANSPLANTS a) Inpatient see Box 12, Inpatient Hospital b) Outpatient see applicable benefit in this Health Benefit Plan Description Form Covered transplants are limited to kidney, kidney/pancreas, pancreas, heart, heartlung, lung, some bone marrow, cornea, liver, small bowel, and small bowel/liver. Subject to the Deductible; applies to the OPM 10% Coinsurance for inpatient professional visits after Deductible is met. 25. HOME HEALTH CARE Subject to the Deductible; applies to the OPM 10% Coinsurance for prescribed medically necessary part-time home health services after Deductible is met. Not covered outside the Service Area. 26. HOSPICE CARE Subject to the Deductible; applies to the OPM 10% Coinsurance for hospice care after Deductible is met. Not covered outside the Service Area. 27. SKILLED NURSING FACILITY CARE Subject to the Deductible; applies to the OPM 10% Coinsurance for up to 100 days per calendar year for prescribed skilled nursing facility services at approved skilled nursing facilities after Deductible is met. Not covered outside the Service Area. 28. DENTAL CARE Not covered 29. VISION CARE Copayment --not subject to the Deductible; does not apply to the OPM Coinsurance --subject to the Deductible; applies to OPM $20 Copayment per eye wellness and refraction exams performed by an Optometrist Hardware not covered. 30. CHIROPRACTIC CARE Not subject to the Deductible; does not apply to the OPM $20 Copayment each visit for up to 20 visits per calendar year 31. SIGNIFICANT ADDITIONAL COVERED SERVICES (list up to 5) Pre-Hospice Special Services Hospice Program, Hearing aids for minors, Travel Clinic-pre-travel assessment/ prescription, Post-mastectomy breast reconstruction, Kaiser Permanente Cancer Screening Guidelines (attached) 2013 DB-LG-DED Kaiser Permanente 11

14 PART C: LIMITATIONS AND EXCLUSIONS 32. PERIOD DURING WHICH PRE- EXISTING CONDITIONS ARE NOT COVERED EXCLUSIONARY RIDERS Can an individual's specific, pre-existing condition be entirely excluded from the policy? 34. HOW DOES THE POLICY DEFINE A PRE-EXISTING CONDITION? 35. WHAT TREATMENTS AND CONDITIONS ARE EXCLUDED UNDER THIS POLICY? 2013 Colorado Health Benefit Plan Description Form Kaiser Foundation Health Plan of Colorado IN-NETWORK ONLY (Out-of-Network care is not covered except as noted) Not Applicable. Plan does not impose limitation periods for pre-existing conditions. No Not Applicable. Plan does not exclude coverage for pre-existing conditions Exclusions vary by policy. List of exclusions is available immediately upon request from your carrier, agent, or plan sponsor (e.g., employer). Review them to see if a service or treatment you may need is excluded from the policy. PART D: USING THE PLAN 36. Does the enrollee have to obtain a referral and/or prior authorization for specialty care in most or all cases? 37. Is prior authorization required for surgical procedures and hospital care (except in an emergency)? 38. If the provider charges more for a covered service than the plan normally pays, does the enrollee have to pay the difference? 39. What is the main customer service number? 40. Whom do I write/call if I have a complaint or want to file a grievance? Whom do I contact if I am not satisfied with the resolution of my complaint or grievance? 42. To assist in filing a grievance, indicate the form number of this policy; whether it is individual, small, or large group; and if it is a short-term policy. 43. Does the plan have a binding arbitration clause? Endnotes No Yes No IN-NETWORK ONLY (Out-of-Network care is not covered except as noted) Member Services can be reached at or toll-free at or TTY Member Services 2500 South Havana Street Aurora, CO or toll-free at or TTY Write to: Colorado Division of Insurance ICARE Section 1560 Broadway, Suite 850 Denver, CO Policy forms LG_DHMO_EOC(01-13) and GA-DENCOS(01-13) Large Group Yes KAISER DHMO 1 Network refers to a specified group of physicians, hospital, medical clinics and other health care providers that your plan may require you to use in order to get any coverage at all under the plan, or that the plan may encourage you to use because it pays more of your bill if you use their network providers (i.e., go in-network) than if you don't (i.e., go out-of-network). 2 Deductible Type indicates whether the deductible period is Calendar Year (January 1 through December 31) or Benefit Year (i.e., based on a benefit year beginning on the policy s anniversary date) or if the deductible is based on other requirements such as a Per Accident or Injury or Per Confinement DB-LG-DED Kaiser Permanente 12

15 2013 Colorado Health Benefit Plan Description Form Kaiser Foundation Health Plan of Colorado 2a Deductible means the amount you will have to pay for allowable covered expenses under a health plan during a specified time period (e.g., a calendar year or benefit year) before the carrier will cover those expenses. The specific expenses that are subject to deductible may vary by policy. Expenses that are subject to deductible should be noted in boxes 8 through 31. 2b Individual means the deductible amount you and each individual covered by a non-hsa qualified policy will have to pay for allowable covered expenses before the carrier will cover those expenses. Single means the deductible amount you will have to pay for allowable covered expenses under an HSA-qualified health plan when you are the only individual covered by the plan. 2c Family is the maximum deductible amount that is required to be met for all family members covered by a non-hsa qualified policy and it may be an aggregated amount (e.g., $3,000 per family ) or specified as the number of individual deductibles that must be met (e.g., 3 deductibles per family ). Non-single is the deductible amount that must be met by one or more family members covered by an HSA-qualified plan before any covered expenses are paid. 3 Out-of-pocket maximum means the maximum amount you will have to pay for allowable covered expenses under a health plan, which may or may not include the deductibles or copayments, depending on the contract for that plan. The specific deductibles or copayments included in the out-of-pocket maximum may vary by policy. Expenses that are applied toward the out-of-pocket maximum should be noted in boxes 8 through Medical office visits include physician, mid-level practitioner, and specialist visits, including outpatient psychotherapy visits for biologically-based mental illness. 5 Well baby care includes an in-hospital newborn pediatric visit and newborn hearing screening. The hospital copayment applies to mother and well-baby together; there are not separate copayments. 6 Prescription drugs otherwise excluded are not covered, regardless of whether preferred generic, preferred brand-name, or nonpreferred. 7 Emergency care means all services delivered in an emergency care facility, that are necessary to screen and stabilize a covered person. The plan must cover this care if a prudent lay person having average knowledge of health services and medicine and acting reasonably would have believed that an emergency medical condition or life or limb threatening emergency existed. 8 Non-emergency care delivered in an emergency room is covered only if the covered person receiving such care was referred to the emergency room by his/her carrier or primary care physician. If emergency departments are used by the plan for non-emergency afterhours care, then urgent care copayments apply. 9 Biologically based mental illnesses means schizophrenia, schizoaffective disorder, bipolar affective disorder, major depressive disorder, specific obsessive-compulsive disorder, and panic disorder. 10 Waiver of pre-existing condition exclusions. State law requires carriers to waive some or all of the pre-existing condition exclusion period based on other coverage you recently may have had. Ask your carrier or plan sponsor (e.g., employer) for details. 11 Grievances. Colorado law requires all plans to use consistent grievance procedures. Write the Colorado Division of Insurance for a copy of those procedures DB-LG-DED Kaiser Permanente 13

16 Colorado Health Plan Benefit Description Form Addendum Kaiser Permanente Cancer Screening Guidelines (Charges may apply) Screening (Frequency subject to Physician Kaiser Permanente Recommendation recommendation) Clinical breast exam Annually As jointly determined by physician and patient Mammogram Available annually for all women beginning at age 40 or earlier based upon patient risk At least every 2 years, particularly after age 50 Genetic testing for inherited susceptibility for breast cancer Available upon referral of a Kaiser Permanente provider For those women who meet the following criteria: Patients with a 10% or greater risk of inherited gene defect Colon and Rectal Cancer: Screening (Frequency subject to Physician Kaiser Permanente Recommendation recommendation) Fecal occult blood test (FIT) Annually after age 50 Annually beginning at age 50 through age 75 (if not screened with colonoscopy) Flexible sigmoidoscopy On an individual basis Not a routine recommendation Barium enema On an individual basis Not a routine recommendation Colonoscopy Every 10 years, more frequently for high risk patients Every 10 years beginning at age 50 through age 75. High risk patients may start at an earlier age and may be screened more frequently. Cervical Cancer: Screening (Frequency subject to Physician Kaiser Permanente Recommendation recommendation) Pap test Annually Every 2 years, starting at age 21; more frequently if high risk. For ages 65 and older, not recommended if long history of normal PAP smears and not high risk. Prostate Cancer: Screening (Frequency subject to Physician Kaiser Permanente Recommendation recommendation) Digital rectal exam Annually As jointly determined by physician and patient Serum prostatic specific antigen (PSA) Annually As jointly determined by physician and patient. Not recommended for those over 75. KAISER DHMO 14

17 KAISER MultiChoice POS PART A: TYPE OF COVERAGE 2013 Colorado Health Benefit Plan Description Form Kaiser Foundation Health Plan of Colorado Plan DHMO ADAMS 12 FIVE STAR SCHOOLS - Group # Denver/Boulder Large Group 1. TYPE OF PLAN Health Maintenance Organization (HMO) 2. OUT-OF-NETWORK CARE COVERED? 1 Only for Emergency Care 3. AREAS OF COLORADO WHERE PLAN IS AVAILABLE Plan is available only in the following areas: Adams, Arapahoe, Boulder, Broomfield, Clear Creek, Denver, Douglas, Elbert, Gilpin, Jefferson, Larimer, Park and Weld Counties as determined by zip code. PART B: SUMMARY OF BENEFITS Important Note: This form is not a contract, it is only a summary. The contents of this form are subject to the provisions of the policy, which contains all terms, covenants and conditions of coverage. Your plan may exclude coverage for certain treatments, diagnoses, or services not noted below. The benefits shown in this summary may only be available if required plan procedures are followed (e.g., plans may require prior authorization, a referral from your primary care physician, or use of specified providers or facilities). Consult the actual policy to determine the exact terms and conditions of coverage. Coinsurance and copayment options reflect the amount the covered person will pay. IN-NETWORK ONLY (Out-of-Network care is not covered except as noted) 4. Deductible Type 2 Calendar Year 4a. ANNUAL DEDUCTIBLE 2a a) Individual 2b b) Family 2c a) $500 per calendar year b) $1,500 per calendar year The Individual and Family Deductibles are separate Deductibles. For Families, individual family members are responsible for meeting the Family Deductible, only up to the Individual Deductible amount. 5. OUT-OF-POCKET ANNUAL MAXIMUM 3 a) Individual b) Family c) Is deductible included in the out-ofpocket maximum? 6. LIFETIME OR BENEFIT MAXIMUM PAID BY THE PLAN FOR ALL CARE If your group has a Pharmacy Deductible, please see Box 11 for information regarding the Pharmacy Deductible. (Note: The Pharmacy Deductible is separate from the medical Deductible (Deductible), noted above) a) $1,500 per calendar year b) $3,000 per calendar year c) No For Families, the individual family members are responsible for meeting the Family Out-of Pocket (OPM), only up to the Individual OPM amount. None 7A. COVERED PROVIDERS Colorado Permanente Medical Group, P.C. See provider directory for a complete list of current providers 15

18 2013 Colorado Health Benefit Plan Description Form Kaiser Foundation Health Plan of Colorado PART B: SUMMARY OF BENEFITS CONTINUED For Families, the individual family members are responsible for meeting the Family OPM, only up to the Individual OPM amount. 6. LIFETIME OR BENEFIT MAXIMUM PAID BY THE PLAN FOR ALL CARE None 7A. COVERED PROVIDERS Denver Boulder service area: Colorado Permanente Medical Group, P.C. Northern Colorado Service area: Colorado Permanente Medical Group, P.C. and Kaiser Permanente Northern Colorado Plan Providers See online provider directory for complete list at IN-NETWORK PREFERRED PROVIDER NETWORK OUT-OF-NETWORK Private Healthcare Systems, Inc. (PHCS) See online provider directory for complete list at None All providers licensed or certified to provide covered benefits 7B. With respect to network plans, are all the providers listed in 7A. accessible to me through my primary care physician? 8. MEDICAL OFFICE VISITS 4 a) Primary Care Providers b) Specialists Yes Yes Not Applicable Not subject to the Deductible; does not apply to the OPM a) $20 Copayment each primary care office visit Not subject to the Deductible; does not apply to the OPM a) $20 Copayment each primary care office visit Subject to Deductible; applies toward OPM a) 30% Coinsurance after Deductible is met b) $40 Copayment each specialist care office visit b) $40 Copayment each specialist care office visit b) 30% Coinsurance after Deductible is met 10% Coinsurance for covered services received during an office visit, (including Office Administered Drugs), after Deductible is met. (Note: Covered services received during an office visit (including Office Administered Drugs) are Subject to the Deductible; do apply to the OPM) Only Diagnostic Lab and X-ray performed in a physician s office are included in the office visit Copayment. 10% Coinsurance applies after Deductible for all other services. (Note: Covered services received during an office visit are Subject to the Deductible; do apply to the OPM) Routine Lab & Diagnostic X-ray orders may be brought to Kaiser Permanente facilities and completed at the IN-NETWORK benefit level KAISER MultiChoice POS 2013 LG-POS-MC Kaiser Permanente 16

19 2013 Colorado Health Benefit Plan Description Form Kaiser Foundation Health Plan of Colorado PART B: SUMMARY OF BENEFITS CONTINUED 9. PREVENTIVE CARE a) Children's services b) Adults' services 10. MATERNITY a) Prenatal care b) Delivery & inpatient well baby care 5 IN-NETWORK PREFERRED PROVIDER NETWORK OUT-OF-NETWORK Not subject to the Deductible; does not apply to the OPM a) No Charge (100% covered) b) No Charge (100% covered) The Copayment or Coinsurance for certain preventive care services may differ from the Copayment or Coinsurance shown above a) Routine Prenatal Care - Not subject to the Deductible; does not apply to the OPM $0 Copayment each visit 10% Coinsurance for covered services received during an office visit after Deductible is met. (Note: Covered services received during an office visit are Subject to the Deductible; do apply to the OPM) b) Subject to the Deductible; does apply to the OPM 10% Coinsurance after Deductible is met. Not subject to the Deductible; does not apply to the OPM a) No Charge (100% covered) each visit b) No Charge (100% covered) each visit Limited adult services available The Copayment or Coinsurance for certain preventive care services may differ from the Copayment or Coinsurance listed above a) Routine Prenatal Care - Not subject to the Deductible; does not apply to the OPM No Charge (100% covered) each visit 10% Coinsurance for covered services received during an office visit after Deductible is met. (Note: Covered services received during an office visit are Subject to the Deductible; do apply to the OPM) b) Subject to the Deductible; does apply to the OPM 10% Coinsurance after Deductible is met. Not subject to Deductible; Does not apply toward OPM a) $70 per visit copay b) $70 per visit copay Limited adult services available The Copayment or Coinsurance for certain preventive care services may differ from the Copayment or Coinsurance listed above a) Routine Prenatal Care - Subject to Deductible; applies toward OPM 30% Coinsurance after Deductible is met. b) Subject to Deductible; applies toward OPM 30% Coinsurance after Deductible is met LG-POS-MC Kaiser Permanente 17

20 2013 Colorado Health Benefit Plan Description Form Kaiser Foundation Health Plan of Colorado PART B: SUMMARY OF BENEFITS CONTINUED 11. PRESCRIPTION DRUGS 6 Level of coverage and restrictions on prescriptions. IN-NETWORK PREFERRED PROVIDER NETWORK OUT-OF-NETWORK Not subject to the Deductible; does not apply to the OPM Not subject to the Deductible; does not apply to the OPM $15 generic/$30 brand/50% non-preferred per prescription Tobacco cessation drugs at No Charge; /20% Coinsurance for specialty drugs, including self-injectables up to a 30-day supply. Mail-order drugs available for up to a 90-day supply for two Copayments - Certain drugs limited to a 30-day supply Drugs must be purchased through Kaiser Permanente pharmacies. For drugs on our approved list, please contact your Clinical Pharmacy Call Center at or toll-free at or TTY $20 preferred generic/$35 preferred brand copay 50% Coinsurance (non-preferred) 20% Coinsurance for specialty drugs, including self-injectables (up to a maximum of $250 per drug dispensed) Limited to a 30-day supply through MedImpact pharmacies Mail-order drugs available for up to a 90-day supply for two Copayments No coverage at Out-of-Network pharmacies For drugs on the MedImpact Preferred Drug List, or to locate Network pharmacies, please contact MedImpact toll-free at or visit Prescriptions for medications on the Kaiser Permanente formulary may also be filled at Kaiser Permanente pharmacies for the applicable IN-NETWORK benefit. Preferred drug status for individual drugs may vary between Kaiser Permanente formulary and the MedImpact Preferred Drug List. Note: The Pharmacy Deductible, if applicable, is not subject to the Deductible and does not apply to the OPM 12. INPATIENT HOSPITAL Subject to the Deductible; does apply to the OPM 10% Coinsurance, after Deductible is met. 10% Coinsurance for inpatient professional visits, after Deductible is met. Subject to the Deductible; does apply to the OPM 10% Coinsurance, after Deductible is met. Precertification required. 10% Coinsurance for inpatient professional visits, after Deductible is met. Subject to Deductible; applies toward OPM 30% Coinsurance after Deductible is met. Precertification required. 30% Coinsurance for inpatient professional visits, after Deductible is met. KAISER MultiChoice POS 2013 LG-POS-MC Kaiser Permanente 18

21 2013 Colorado Health Benefit Plan Description Form Kaiser Foundation Health Plan of Colorado PART B: SUMMARY OF BENEFITS CONTINUED IN-NETWORK PREFERRED PROVIDER NETWORK OUT-OF-NETWORK Subject to the Deductible; does apply to the OPM Subject to Deductible; applies toward OPM 13. OUTPATIENT/ AMBULATORY SURGERY 14. DIAGNOSTICS a) Laboratory & X-ray b) MRI, nuclear medicine, and other high-tech services 10% Coinsurance for outpatient surgery performed in any setting other than inpatient, after Deductible is met. a) Diagnostic Lab Not subject to the Deductible; does not apply to the OPM No Charge (100% covered) for laboratory services received during an office visit, in a Plan Medical Office, or in a contracted free-standing facility (excluding Plan Hospitals) 10% Coinsurance for laboratory services in the outpatient department of a Plan Hospital after Deductible is met. (Note: laboratory services in the outpatient department of a Plan Hospital are Subject to the Deductible; do apply to the OPM) Subject to the Deductible; does apply to the OPM 10% Coinsurance for outpatient surgery performed in any setting other than inpatient, after Deductible is met. Precertification required. a) Subject to Deductible; applies toward OPM 10% Coinsurance after Deductible is met b) Subject to Deductible; applies toward OPM 10% Coinsurance after Deductible is met. Precertification required for MRI/CT/PET. 30% Coinsurance for outpatient surgery performed in any setting other than inpatien after Deductible is met. Precertification required. a) Subject to Deductible; applies toward OPM 30% Coinsurance after Deductible is met b) Subject to Deductible; applies toward OPM 30% Coinsurance after Deductible is met Precertification required for MRI/CT/PET Diagnostic X-ray, including Therapeutic Subject to Deductible; applies toward OPM 10% Coinsurance after Deductible is met. b) MRI/CT/PET Subject to Deductible; applies toward OPM 10% Coinsurance after Deductible is met. Routine Lab and Diagnostic X-ray orders may be brought to Kaiser Permanente facilities and completed at the IN-NETWORK benefit level 15. EMERGENCY CARE 7, 8 Subject to Deductible; applies toward OPM Covered as IN-NETWORK benefit, regardless of location 10% Coinsurance at a Kaiser Permanente designated Plan or non-plan emergency room, after Deductible is met. 16. AMBULANCE Not subject to the Deductible; does not apply to the OPM Covered as IN-NETWORK benefit, regardless of location 10% Coinsurance up to $500 per trip 2013 LG-POS-MC Kaiser Permanente 19

22 2013 Colorado Health Benefit Plan Description Form Kaiser Foundation Health Plan of Colorado PART B: SUMMARY OF BENEFITS CONTINUED 17. URGENT, NON- ROUTINE, AFTER- HOURS CARE IN-NETWORK PREFERRED PROVIDER NETWORK OUT-OF-NETWORK Copayment not subject to the Deductible; does not apply to the OPM Coinsurance subject to the deductible; applies to OPM $40 Copayment each after-hours visit at a Kaiser Permanente designated after-hours Plan Facility inside the Service Area a) Urgent care 7 - Subject to Deductible; applies toward OPM 10% Coinsurance at a participating provider Urgent care facility after Deductible is met. Emergency Room Care covered as IN- NETWORK benefit a) Urgent care 7-30% Coinsurance at a non-participating provider emergency room outside the Service Area, after Deductible is met Emergency Room Care covered as IN- NETWORK benefit 10% Coinsurance for covered services received during the visit, after Deductible is met. (Note: Covered services received during the visit are Subject to the Deductible; do apply to the OPM) b) Non-routine care - Not subject to the Deductible; does not apply to the OPM $20 Copayment during normal office hours at a PREFERRED PROVIDER medical office b) Non-routine care - Subject to Deductible; applies toward OPM 30% Coinsurance after Deductible, each visit at an OUT-OF-NETWORK medical office 10% Coinsurance for covered services received during the visit, after Deductible is met. (Note: Covered services received during the visit are Subject to the Deductible; do apply to the OPM c) After-hours care - Not subject to the Deductible; does not apply to the OPM $40 Copayment each after-hours visit at PREFERRED PROVIDER NETWORK medical office c) After-hours care - Subject to Deductible; applies toward OPM 30% Coinsurance after Deductible is met, each after-hours visit at an OUT- OF-NETWORK medical office 10% Coinsurance for covered services received during the visit, after Deductible is met. (Note: Covered services received during the visit are Subject to the Deductible; do apply to the OPM) 2013 LG-POS-MC Kaiser Permanente KAISER MultiChoice POS 20

23 2013 Colorado Health Benefit Plan Description Form Kaiser Foundation Health Plan of Colorado PART B: SUMMARY OF BENEFITS CONTINUED IN-NETWORK PREFERRED PROVIDER NETWORK OUT-OF-NETWORK 18. BIOLOGICALLY- BASED MENTAL See Box 19, below ILLNESS CARE OTHER MENTAL HEALTH CARE a) Inpatient Subject to Deductible; applies toward OPM a) Inpatient Subject to Deductible; applies toward OPM a) Inpatient - Subject to Deductible; applies toward OPM a) Inpatient care b) Outpatient care 10% Coinsurance, after Deductible is met. 10% Coinsurance, after Deductible is met. Pre-certification required. 30% Coinsurance after Deductible is met Pre-certification required. b) Outpatient Not subject to the Deductible; does not apply to the OPM b) Outpatient - Not subject to the Deductible; does not apply to the OPM b) Outpatient Subject to Deductible; applies toward OPM $20 Copayment 10% Coinsurance for inpatient professional visits, after Deductible is met. (Note: inpatient professional visit are Subject to the Deductible; do apply to the OPM) $20 Copayment 10% Coinsurancefor inpatient professional visits, after Deductible is met. (Note: inpatient professional visit are Subject to the Deductible; do apply to the OPM) 30% Coinsurance after Deductible is met 20. ALCOHOL & SUBSTANCE ABUSE a) Inpatient care a) Inpatient Medical Detoxification Subject to the Deductible; does apply to the OPM 10% Coinsurance per admission, after Deductible is met. Detoxification is limited to removing toxic substance from the body Inpatient Residential Rehabilitation Subject to Deductible; applies toward OPM 10% Coinsurance per admission, after Deductible is met. a) Inpatient Medical Detoxification Subject to the Deductible; does apply to the OPM 10% Coinsurance per admission,. after Deductible is met. Detoxification is limited to removing toxic substance from the body Inpatient Residential Rehabilitation - Subject to the Deductible; does apply to the OPM 10% Coinsurance, after Deductible is met. Precertification required. a) Inpatient Medical Detoxification 30% Coinsurance after Deductible is met Inpatient Residential Rehabilitation - Subject to Deductible; applies toward OPM 30% Coinsurance after Deductible is met. Pre-certification required LG-POS-MC Kaiser Permanente 21

24 2013 Colorado Health Benefit Plan Description Form Kaiser Foundation Health Plan of Colorado PART B: SUMMARY OF BENEFITS CONTINUED IN-NETWORK PREFERRED PROVIDER NETWORK OUT-OF-NETWORK b) Outpatient Chemical Dependency 20. ALCOHOL & SUBSTANCE ABUSE b) Outpatient care b) Outpatient Chemical Dependency Not subject to the Deductible; does not apply to the OPM $20 Copayment each visit b) Outpatient Chemical Dependency Not subject to the Deductible; does not apply to the OPM $20 Copayment each visit 30% Coinsurance after Deductible is met 21. PHYSICAL, OCCUPATIONAL, & SPEECH THERAPY 10% Coinsurance for inpatient professional visits, after Deductible is met. (Note: inpatient professional visits are Subject to the Deductible; do apply to the OPM) Inpatient Subject to Deductible; applies toward OPM 10% Coinsurance, after Deductible is met. Outpatient Not subject to the Deductible; does not apply to the OPM $20 Copayment each visit for up to 20 visits per year for each type of therapy, (i.e. physical, occupational and speech therapy) Therapy for congenital defects and birth abnormalities is covered for children from age 3 to age 6 for both acute and chronic conditions. This benefit is also available for eligible children under the age of 3 who are not participating in Early Intervention Services. 10% Coinsurance for inpatient professional visits, after Deductible is met. (Note: inpatient professional visits are Subject to the Deductible; do apply to the OPM) For conditions subject to significant improvement within two (2) months Inpatient - Benefits covered IN-NETWORK only Outpatient -Not subject to the Deductible; does not apply to the OPM $20 Copayment each visit for up to 20 visits per year for each type of therapy (i.e. physical, occupational and speech therapy) Inpatient* - Benefits covered IN-NETWORK only Outpatient* - Subject to Deductible; applies toward OPM 30% Coinsurance after Deductible is met Limited to a combined (PREFERRED PROVIDER NETWORK and OUT-OF-NETWORK) maximum of 20 visits per calendar year for conditions subject to improvement within two months. Limited to a combined maximum of 20 visits per therapy per calendar year for both acute and chronic conditions for children with congenital defects and birth abnormalities from age 3 to age 6. This benefit is also available for eligible children under the age of 3 who are not participating in Early Intervention Services. Therapies for the treatment of autism spectrum disorders are not subject to any visit limits and include long term rehabilitation. KAISER MultiChoice POS 2013 LG-POS-MC Kaiser Permanente 22

25 2013 Colorado Health Benefit Plan Description Form Kaiser Foundation Health Plan of Colorado PART B: SUMMARY OF BENEFITS CONTINUED 22. DURABLE MEDICAL EQUIPMENT IN-NETWORK PREFERRED PROVIDER NETWORK OUT-OF-NETWORK Not subject to the Deductible; does not apply to the OPM Subject to Deductible; applies toward OPM 10% Coinsurancewithin the Service Area, - $2,000 annual benefit maximum per calendar year. Prosthetic arms and legs covered at 10% Coinsurance with no annual maximum. See policy for types and circumstances of coverage. 23. OXYGEN Not subject to the Deductible; does not apply to the OPM Prosthetic replacement of arms or legs covered at 20% Coinsurance after PREFERRED PROVIDER NETWORK deductible with no annual maximum (the coinsurance must equal DME coinsurance or 20% which ever is lower). Subject to Deductible; applies toward OPM Prosthetic replacement of arms or legs covered at 20% Coinsurance after OUT- OF-NETWORK Deductible with no annual maximum (the coinsurance must equal DME coinsurance or 20% which ever is lower).. All other DME orders must be obtained IN-NETWORK. Benefit covered IN-NETWORK only 24. ORGAN TRANSPLANTS 25. HOME HEALTH CARE 10% Coinsurance For inpatient, see Box 12, Inpatient Hospital.. For outpatient, see applicable benefit in this Health Benefit Plan Description Form Covered transplants are limited to kidney, kidney/pancreas, pancreas, heart, heart-lung, lung, some bone marrow, cornea, liver, small bowel, and small bowel/liver. Subject to Deductible; applies toward OPM 10% Coinsurance for prescribed medically necessary parttime home health services, after Deductible is met. Not covered outside the Service Area. Benefits covered IN-NETWORK only Subject to the Deductible; does apply to the OPM Combined maximum of 60 home health visits per calendar year 10% Coinsurance after Deductible is met. 30% Coinsurance after Deductible is met 26. HOSPICE CARE Subject to Deductible; applies toward OPM Subject to the Deductible; does apply to the OPM 10% Coinsurance for hospice care, after Deductible is met. Not covered outside the Service Area. Limited to $150 per day per benefit period (3 months) to a combined maximum while insured of 3 benefit periods for hospice care program; precertification required 10% Coinsurance after Deductible is met 30% Coinsurance after Deductible is met 27. SKILLED NURSING FACILITY CARE Subject to Deductible; applies toward OPM 10% Coinsurance for up to 100 days per calendar year for prescribed skilled nursing facility services at approved skilled nursing facilities, after Deductible is met. Not covered outside the Service Area. 28. DENTAL CARE Not Covered Benefits covered IN-NETWORK only 2013 LG-POS-MC Kaiser Permanente 23