2015 small business CALIFORNIA PLAN HIGHLIGHTS METAL PLANS

Transcription

1 2015 small business CALIFORNIA PLAN HIGHLIGHTS METAL PLANS For effective dates January 1 June 1, 2015

2 Notes for all plans All plans have an unlimited lifetime maximum benefit while insured. Kaiser Permanente plans do not include a pre-existin condition clause. The copayment HMO plans, HSA-qualified deductible HMO plans, deductible HMO plans, and the deductible HMO plans with HRA are underwritten by Kaiser Foundation Health Plan, Inc. (KFHP). Kaiser Permanente Insurance Company (KPIC), a subsidiary of KFHP, underwrites the Preferred Provider Oranization (PPO) plans as well as the Premier and PPO dental plans, and the PPO chiropractic/acupuncture plan. The chiropractic/acupuncture plan is administered by American Specialty Health Plans of California, Inc. All plans cover the essential health benefits, as defined by Affordable Care Act (ACA) reulations, which include child dental services. When employees and dependents enroll in the medical plan(s) you ve chosen, we ll also enroll them in a separate child dental plan underwritten by Delta Dental of California. For PPO medical plans, child dental benefits are part of the PPO medical plans coverae and not a separate dental plan. This booklet is a summary only. The KFHP Evidence of Coverae and the KPIC Certificate of Insurance contain a complete explanation of benefits, exclusions, and limitations. The information provided in this brochure is not intended to describe all of the benefits included in each plan, nor is it desined to serve as the Evidence of Coverae or Certificate of Insurance. Summary of Benefits and Coverae (SBC) documents for all of our plans are available at kp.or/smallbusiness-sbc/ca to help you make an informed choice about your health plan(s). These documents summarize important information about your health coverae options, so you can easily compare Kaiser Permanente benefits and coverae with those of other carriers. Small Business January 2015

3 What s inside Your plan options...2 Health payment accounts...3 Understandin health plans...4 Kaiser Permanente Bronze plans...5 Kaiser Permanente Silver plans...6 Kaiser Permanente Gold plans...7 Kaiser Permanente Platinum plans...8 Dental plans Chiropractic and acupuncture plans Small Business January

4 Your plan options When it comes to health care, you expect plans that are simple and easy to use not just for you, but for your employees. You need options that ive you flexibility and control over your health care dollars. And you want it all from a trusted partner who can uide you every step of the way. That s the solution you et with Kaiser Permanente. All of our plans ive your employees what they need to be healthier and more productive every day top doctors, focus on prevention, innovative health promotion tools, and hih-quality, personalized care. Copayment HMO plans Predictable copayments and out-of-pocket maximums Deductible HMO plans More choice and lower premiums HSA-qualified deductible HMO plans Lower premiums plus tax savins* Deductible HMO with HRA plans Lower premiums plus tax savins* PPO Referral-free access to contracted PHCS physicians or any other licensed provider of choice, alon with the benefits of sinle carrier administration Supplemental coverae Dental and combined chiropractic/acupuncture plans *Tax references relate to federal income tax only. Consult with your financial adviser for more information about state income tax laws. 2 Small Business January 2015

5 Health Payment Accounts Now you can choose a consumer-directed health care solution that is simple and easy to use not just for you, but for your employees. With Health Payment Accounts administered throuh Kaiser Permanente, you et health reimbursement arranement (HRA) and health savins account (HSA) options that ive you flexibility and control over your health care dollars, all from a trusted partner who can uide you every step of the way. Health reimbursement arranements support and flexibility You can offer your eliible employees enrolled in a Kaiser Permanente deductible HMO with HRA plan the option to set up an HRA administered throuh Kaiser Permanente. With an HRA, your employees have the option of usin funds contributed by you to pay for qualified medical expenses on a tax-free basis. There are several HRA types available, ranin from comprehensive to more limited coverae, with options for point-of-service payment usin our health payment card or convenient reimbursement throuh our claims exchane. HRA employer fees: Monthly HRA administrative fee - $3.75 per account per month Setup fee - none Health savins accounts empower your employees You can offer your eliible employees enrolled in a Kaiser Permanente HSA-qualified health plan the option to set up an HSA administered throuh Kaiser Permanente. HSAs are employee-owned accounts that can be used to pay for qualified medical expenses, includin services not covered under the Kaiser Permanente health plan. The money your employees contribute to their HSA throuh payroll withholdins isn t considered part of their waes, so they won t be taxed on it. Additionally, they won t pay taxes on HSA funds when they re withdrawn to pay for qualified medical expenses.* HSA employer fees: Monthly HSA administrative fee - $3.25 per account per month (employer has the option of payin this fee or havin the employee pay this fee) Setup fee - none Easy online access Your employees can take advantae of 24-hour access to their health plan and payment account via sinle sin-on access at kp.or and throuh Kaiser Permanente s Balance Tracker app for smartphones and mobile devices. Added convenience with a variety of payment options Dependin on the Health Plan Account you choose, your employees will et a convenient payment option that makes access to funds simple while reducin paperwork. Our HSA and certain HRA types come with our Health Payment card, which works just like a debit card. This means employees don t have to submit claims or file for reimbursement when makin eliible purchases usin their card. Other HRA types offer the convenience of our claims exchane platform, which takes processed medical claims for services provided at our facilities and automatically files them for reimbursement from your employees accounts for easy payment. With our health payment accounts, you ll et interated account capabilities and experienced customer support every step of the way. To learn more about a strateic partnership with Kaiser Permanente or to et started with a benefits solution today contact your Kaiser Permanente representative. *Refer to IRS publication 502 for a list of qualified medical and dental expenses. Only available for certain HRA types Small Business January

6 Understandin health plans In the followin Plan hihlihts section, you will et an overview of what your employees can expect to pay for certain services under our plans. There are four main cateories of coverae, known as metal plans Bronze, Silver, Gold, and Platinum. These four cateories offer different levels of copayments, coinsurance, and deductibles for essential health benefits. Here s a quick look at how you can use the charts to understand the plans. 2 5 Here s a quick look at how to use the chart. FEATURES Bronze 60 HMO 5000/60 w/ child dental*,,31 Deductible HMO Plan PLAN DEDUCTIBLE Individual/Family $5,000/$10, OUT-OF-POCKET MAXIMUM Individual/Family $6,250/$12,500 1,10 IN THE MEDICAL OFFICE Primary care visits $60 (after deductible) 2 Urent care visits $60 (after deductible) 2 Specialty office visits Preventive exams, vaccines (immunizations) $0 12 Prenatal care $0 3 Postpartum care $0 3 Well-child preventive care visits $0 23 Allery injections $70 (after deductible) $5 (after deductible) Infertility services Not covered 17 Physical, occupational, and speech therapy Most laboratory tests Most X-rays and dianostic testin Most MRI/CT/PET scans Outpatient surery (per procedure) EMERGENCY SERVICES Emerency Department visits (waived if admitted directly to hospital) Ambulance PRESCRIPTIONS Generic drus Brand-name drus $60 (after deductible) 30% (after deductible) 30% (after deductible) 30% (after deductible) 30% (after deductible) $300 (after deductible) $300 (after deductible) (up to a 30-day supply) $15 (after plan deductible) 24 (up to a 30-day supply) $50 (after plan deductible) 24 (up to a 100-day supply) 30% (after plan deductible) 24 Specialty drus HOSPITAL CARE Physicians services, room and board, tests, medications, supplies, therapies, birth services 30% (after deductible) Skilled nursin facility care (up to 100 days per benefit period) 30% (after deductible) MENTAL HEALTH SERVICES In the medical office $60 (after deductible) 2 In the hospital 30% (after deductible) CHEMICAL DEPENDENCY SERVICES In the medical office $60 (after deductible) 2 In the hospital (detoxification only) OTHER Certain durable medical equipment (DME) 30% (after deductible) 30% (after deductible) 6 (base only) Certain prosthetic and orthotic devices $0 Pediatric optical (eyewear) lenses, or contact lenses Pediatric vision exam $0 Adult optical (eyewear) Not covered 8 Adult vision exam (for eye refraction) $0 Home health care (up to 100 visits per year) $0 (after deductible) Hospice care Refer to pae 9 for the footnotes for medical plans. Refer to pae 10 for the child dental plans. 6 $0 (after deductible) Actuarial value The percentae of total averae costs for covered benefits that a plan will cover. For example, if a plan has an actuarial value of 70%, on averae, members would be responsible for 30% of the costs of all covered benefits. However, members could be responsible for a hiher or lower percentae of the total costs of covered services for the year, dependin on their actual health care needs and the terms of their insurance policy. 2. Plan deductible The amount employees pay before the plan starts helpin them pay for covered services. This is included in the out-ofpocket maximum. 3. Areate accumulation When a plan has an areate deductible accumulation, families with two or more members must meet the entire family deductible before copayments or coinsurance apply for individual family members. Also, the entire family out-of-pocket maximum must be reached before individual family members are no loner subject to cost sharin. Not all services may be subject to the deductible and/or out-ofpocket maximum. 4. Embedded accumulation If the plan has an embedded deductible accumulation, each individual family member will bein payin copayments or coinsurance after meetin his or her individual deductible, or when the family deductible is satisfied, whichever comes first. Also, individual family members are no loner subject to cost sharin when they reach their individual out-of-pocket maximum, or when the family out-of-pocket maximum is met, whichever comes first. Not all services may be subject to the deductible and/or out-of-pocket maximum. 5. Out-of-pocket maximum The most an employee will pay for care durin the policy period before the plan starts payin 100% for most or all covered services. 6. Preventive care at no chare Most preventive services are covered at no chare and are not subject to the deductible. 7. Copayment The set amount employees will pay for certain services. 8. Coinsurance The percentae of the total cost for certain services that an employee will pay after meetin the deductible. 4 Small Business January 2015

7 Kaiser Permanente Bronze plans Plan Hihlihts For effective dates 1/1/15 6/1/15 *ALSO AVAILABLE IN COVERED CALIFORNIA ALSO AVAILABLE IN CALIFORNIACHOICE FEATURES Small Business January 2015 Bronze 60 HMO 5000/60*,,31 w/ child dental Deductible HMO Plan PLAN DEDUCTIBLE Individual/Family $5,000/$10, OUT-OF-POCKET MAXIMUM Individual/Family $6,250/$12,500 1,10 Bronze 60 HSA 3500/30,31 w/ child dental HSA-Qualified Deductible HMO Plan $3,500/$7, $6,250/$12,500 10,29 Bronze 60 HSA 4500/40%*,,31 w/ child dental HSA-Qualified Deductible HMO Plan $4,500/$9, (areate) $6,250/$12,500 25,29 (areate) Bronze 60 PPO 5000/60 w/ child dental Pendin reulatory approval Participatin providers (in-network) 9 $5,000/$10, $6,250/$12,500 10,11 Non-participatin providers (out-of-network) 9 $10,000/$20, $12,500/$25,000 10,11 IN THE MEDICAL OFFICE Primary care visits $60 (after deductible) 2 $30 (after deductible) 40% (after deductible) $60 (after deductible) 2 50% (after deductible) Urent care visits $60 (after deductible) 2 $30 (after deductible) 40% (after deductible) $120 (after deductible) 2 50% (after deductible) Specialty office visits $70 (after deductible) $30 (after deductible) 40% (after deductible) $70 (after deductible) 50% (after deductible) Preventive exams, vaccines (immunizations) $0 12 $0 12 $0 12 $ % 12 Prenatal care $0 3 $0 4 $0 4 $0 13,14 50% (after deductible) 13,14 Postpartum care $0 3 $0 (after deductible) 16 $0 (after deductible) 16 $0 (after deductible) 16 50% (after deductible) Well-child preventive care visits $0 23 $0 23 $0 23 $0 50% Allery injections $5 (after deductible) $5 (after deductible) 40% (after deductible) 30% (after deductible) 50% (after deductible) Infertility services Not covered 17 Not covered 17 Not covered 17 50% (after deductible) 15 Not covered Physical, occupational, and speech therapy $60 (after deductible) $30 (after deductible) 40% (after deductible) $60 (after deductible) 50% (after deductible) Most laboratory tests 30% (after deductible) $30 (after deductible) 40% (after deductible) 30% (after deductible) 50% (after deductible) Most X-rays and dianostic testin 30% (after deductible) $30 (after deductible) 40% (after deductible) 30% (after deductible) 50% (after deductible) Most MRI/CT/PET scans 30% (after deductible) 30% (after deductible) 40% (after deductible) 30% (after deductible) 50% (after deductible) Outpatient surery (per procedure) 30% (after deductible) 30% (after deductible) 40% (after deductible) 30% (after deductible) 50% (after deductible) EMERGENCY SERVICES Emerency Department visits (waived if admitted directly to hospital) $300 (after deductible) 30% (after deductible) 40% (after deductible) $300 (after deductible) $300 (after deductible) Ambulance $300 (after deductible) 30% (after deductible) 40% (after deductible) $300 (after deductible) $300 (after deductible) PRESCRIPTIONS (up to a 30-day supply) (up to a 30-day supply) (up to a 100-day supply) (up to a 30-day supply) Generic drus $15 (after plan deductible) 24 $15 (after plan deductible) 24 40% (after plan deductible) 24 $15 (after plan deductible) 18,19 Brand-name drus (up to a 30-day supply) $50 (after plan deductible) 24 (up to a 30-day supply) $40 (after plan deductible) 24 (up to a 100-day supply) 40% (after plan deductible) 24 (up to a 30-day supply) $50 (after plan deductible) 18,19 Specialty drus (up to a 100-day supply) 30% (after plan deductible) 24 (up to a 100-day supply) 30% (after plan deductible) 24 (up to a 100-day supply) 40% (after plan deductible) 24 (up to a 100-day supply) 30% (after plan deductible) 19,20 HOSPITAL CARE Physicians services, room and board, tests, medications, supplies, therapies, birth services 30% (after deductible) 30% (after deductible) 40% (after deductible) 30% (after deductible) 50% (after deductible) Skilled nursin facility care (up to 100 days per benefit period) 30% (after deductible) 30% (after deductible) 40% (after deductible) 30% (after deductible) 50% (after deductible) MENTAL HEALTH SERVICES In the medical office $60 (after deductible) 2 $30 (after deductible) 40% (after deductible) $60 (after deductible) 2 50% (after deductible) In the hospital 30% (after deductible) 30% (after deductible) 40% (after deductible) 30% (after deductible) 50% (after deductible) CHEMICAL DEPENDENCY SERVICES In the medical office $60 (after deductible) 2 $30 (after deductible) 40% (after deductible) $60 (after deductible) 2 50% (after deductible) In the hospital (detoxification only) 30% (after deductible) 30% (after deductible) 40% (after deductible) 30% (after deductible) 50% (after deductible) OTHER Certain durable medical equipment (DME) 30% (after deductible) 6 (base only) 30% (after deductible) 6 (base only) 40% (after deductible) 6 (base only) 30% (after deductible) 21,22 (supplemental and base) 50% (after deductible) 21,22 (supplemental and base) Certain prosthetic and orthotic devices $0 $0 (after deductible) $0 (after deductible) 30% (after deductible) 50% (after deductible) Pediatric optical (eyewear) 30% (after deductible)7 Pediatric vision exam $0 $0 $0 $0 $0 (after deductible) 7 Adult optical (eyewear) Not covered 8 Not covered 8 Not covered 8 Not covered Not covered Adult vision exam (for eye refraction) $0 $0 $0 $0 Not covered Home health care (up to 100 visits per year) $0 (after deductible) $0 (after deductible) $0 (after deductible) 30% (after deductible) 50% (after deductible) Hospice care $0 (after deductible) $0 (after deductible) $0 (after deductible) $0 (after deductible) 50% (after deductible) Refer to pae 9 for the footnotes for medical plans. Refer to pae 10 for the child dental plans. 5

8 Kaiser Permanente Silver plans For effective dates 1/1/15 6/1/15 Plan Hihlihts *ALSO AVAILABLE IN COVERED CALIFORNIA ALSO AVAILABLE IN CALIFORNIACHOICE Silver 70 HMO 1000/40*,,31 w/ child dental Silver 70 HMO 1500/45*,,31 w/ child dental FEATURES Deductible HMO Plan Deductible HMO Plan PLAN DEDUCTIBLE Individual/Family $1,000/$2, OUT-OF-POCKET MAXIMUM Individual/Family $6,250/$12,500 1,10 $1,500/$3, $6,250/$12,500 1,10 Silver 70 HSA 1500/20%*,,31 w/ child dental HSA-Qualified Deductible HMO Plan $1,500/$3, (areate) $6,250/$12,500 25,29 (areate) Silver 70 PPO 1500/45 w/ child dental Pendin reulatory approval Participatin providers (in-network) 9 $1,500/$3, $6,250/$12,500 10,11 Non-participatin providers (out-of-network) 9 $3,000/$6, $12,500/$25,000 10,11 IN THE MEDICAL OFFICE Primary care visits $40 $45 20% (after deductible) $45 40% (after deductible) Urent care visits $40 $45 20% (after deductible) $90 40% (after deductible) Specialty office visits $40 $65 20% (after deductible) $65 40% (after deductible) Preventive exams, vaccines (immunizations) $0 12 $0 12 $0 12 $ % 12 Prenatal care $0 3 $0 3 $0 4 $0 13,14 40% (after deductible) 13,14 Postpartum care $0 3 $0 3 $0 (after deductible) 16 $0 (after deductible) 16 40% (after deductible) Well-child preventive care visits $0 23 $0 23 $0 23 $0 40% Allery injections $5 $5 20% (after deductible) 20% (after deductible) 40% (after deductible) Infertility services Not covered 17 Not covered 17 Not covered 17 50% 15 Not covered Physical, occupational, and speech therapy $40 $45 20% (after deductible) $45 40% (after deductible) Most laboratory tests $30 $45 20% (after deductible) $45 40% (after deductible) Most X-rays and dianostic testin $40 $65 20% (after deductible) $65 40% (after deductible) Most MRI/CT/PET scans 30% (after deductible) $250 20% (after deductible) 20% (after deductible) 40% (after deductible) Outpatient surery (per procedure) 30% (after deductible) 20% 20% (after deductible) 20% 40% (after deductible) EMERGENCY SERVICES Emerency Department visits (waived if admitted directly to hospital) 30% (after deductible) $250 (after deductible) 20% (after deductible) $250 (after deductible) $250 (after deductible) Ambulance 30% (after deductible) $250 (after deductible) 20% (after deductible) $250 (after deductible) $250 (after deductible) PRESCRIPTIONS (up to a 30-day supply) (up to a 30-day supply) (up to a 100-day supply) (up to a 30-day supply) Generic drus $25 24 $ % (after plan deductible) 24 $15 18,19 Brand-name drus Specialty drus (up to a 30-day supply) (up to a 30-day supply) $50 24 $50 (after $500 brandname dru deductible) 24 (up to a 100-day supply) (up to a 100-day supply) 20% 24 20% (after $500 brandname dru deductible) 24 (up to a 100-day supply) (up to a 30-day supply) 20% (after plan deductible) 24 $50 (after $500 brand-name dru deductible) 18,19 (up to a 100-day supply) (up to a 100-day supply) 20% (after plan deductible) 24 20% (after $500 brand-name dru deductible) 19,20 HOSPITAL CARE Physicians services, room and board, tests, medications, supplies, therapies, birth services 30% (after deductible) 20% (after deductible) 20% (after deductible) 20% (after deductible) 5 40% (after deductible) Skilled nursin facility care (up to 100 days per benefit period) 30% (after deductible) 20% (after deductible) 20% (after deductible) 20% (after deductible) 40% (after deductible) MENTAL HEALTH SERVICES In the medical office $40 $45 20% (after deductible) $45 40% (after deductible) In the hospital 30% (after deductible) 20% (after deductible) 20% (after deductible) 20% (after deductible) 5 40% (after deductible) CHEMICAL DEPENDENCY SERVICES In the medical office $40 $45 20% (after deductible) $45 40% (after deductible) In the hospital (detoxification only) 30% (after deductible) 20% (after deductible) 20% (after deductible) 20% (after deductible) 5 40% (after deductible) OTHER Certain durable medical equipment (DME) 30% 6 (base only) 20% 6 (base only) 20% (after deductible) 6 (base only) 20% 21,22 (supplemental and base) 40% (after deductible) 21,22 (supplemental and base) Certain prosthetic and orthotic devices $0 $0 $0 (after deductible) 20% 40% (after deductible) Pediatric optical (eyewear) 20% (after deductible) 7 Pediatric vision exam $0 $0 $0 $0 $0 (after deductible) 7 Adult optical (eyewear) Not covered 8 Not covered 8 Not covered 8 Not covered Not covered Adult vision exam (for eye refraction) $0 $0 $0 $0 Not covered Home health care (up to 100 visits per year) $0 $0 $0 (after deductible) 20% 40% (after deductible) Hospice care $0 $0 $0 (after deductible) $0 40% (after deductible) Refer to pae 9 for the footnotes for medical plans. Refer to pae 10 for the child dental plans. 6 Small Business January 2015

9 Kaiser Permanente Gold plans Plan Hihlihts For effective dates 1/1/15 6/1/15 *ALSO AVAILABLE IN COVERED CALIFORNIA ALSO AVAILABLE IN CALIFORNIACHOICE Gold 80 HMO 0/30*,,31 w/ child dental Gold 80 HMO 500/30*,,31 w/ child dental FEATURES Copayment HMO Plan Deductible HMO Plan PLAN DEDUCTIBLE Individual/Family $0 OUT-OF-POCKET MAXIMUM Individual/Family $6,250/$12,500 1,28 $500/$1, $6,250/$12,500 1,10 Gold 80 HRA 2000/30 w/ child dental Deductible HMO with HRA Plan 30 $2,000/$4, $0 Gold 80 PPO 0/30 w/ child dental Pendin reulatory approval Participatin providers (in-network) 9 Non-participatin providers (out-of-network) 9 $1,000/$2, $6,250/$12,500 1,10 $12,500/$25,000 10,11 $6,250/$12, IN THE MEDICAL OFFICE Primary care visits $30 $30 $30 $30 40% (after deductible) Urent care visits $30 $30 $30 $60 40% (after deductible) Specialty office visits $50 $30 $30 $50 40% (after deductible) Preventive exams, vaccines (immunizations) $0 12 $0 12 $0 12 $ % 12 Prenatal care $0 3 $0 3 $0 3 $0 13,14 40% (after deductible) 13,14 Postpartum care $0 3 $0 3 $0 3 $ % (after deductible) Well-child preventive care visits $0 23 $0 23 $0 23 $0 40% Allery injections $5 $5 $5 (after deductible) 20% 40% (after deductible) Infertility services Not covered 17 Not covered 17 Not covered 17 50% 15 Not covered Physical, occupational, and speech therapy $30 $30 $30 (after deductible) $30 40% (after deductible) Most laboratory tests $30 $20 20% (after deductible) $30 40% (after deductible) Most X-rays and dianostic testin $50 $20 20% (after deductible) $50 40% (after deductible) Most MRI/CT/PET scans $250 $250 20% (after deductible) 20% 40% (after deductible) Outpatient surery (per procedure) $600 $600 (after deductible) 20% (after deductible) 20% 40% (after deductible) EMERGENCY SERVICES Emerency Department visits (waived if admitted directly to hospital) $250 $250 (after deductible) 20% $250 $250 Ambulance $250 $250 (after deductible) 20% (after deductible) $250 $250 PRESCRIPTIONS Generic drus (up to a 30-day supply) $15 24 $15 24 $15 24 $15 18,19 Brand-name drus (up to a 30-day supply) $50 24 $50 24 $30 24 $50 18,19 Specialty drus (up to a 100-day supply) 20% 24 20% 24 20% 24 20% 19,20 HOSPITAL CARE Physicians services, room and board, tests, medications, supplies, therapies, birth services $600 per day up to 5 days per admission 26 Skilled nursin facility care (up to 100 days per benefit period) $300 per day up to 5 days per admission 26 MENTAL HEALTH SERVICES $600 per day up to 5 days per admission (after deductible) 26 20% (after deductible) 20% 40% (after deductible) $250 per day up to 5 days per admission (after deductible) 26 20% (after deductible) 20% 40% (after deductible) In the medical office $30 $30 $30 $30 40% (after deductible) In the hospital $600 per day up to 5 days per admission 26 $600 per day up to 5 days per admission (after deductible) 26 20% (after deductible) 20% 40% (after deductible) CHEMICAL DEPENDENCY SERVICES In the medical office $30 $30 $30 $30 40% (after deductible) In the hospital (detoxification only) $600 per day up to 5 days per admission 26 $600 per day up to 5 days per admission (after deductible) 26 20% (after deductible) 20% 40% (after deductible) OTHER Certain durable medical equipment (DME) 20% 6 (base only) 20% 27 (supplemental and base) 50% 6 (base only) 20% 21,22 (supplemental and base) 40% (after deductible) 21,22 (supplemental and base) Certain prosthetic and orthotic devices $0 $0 $0 20% 40% (after deductible) Pediatric optical (eyewear) 20% (after deductible)7 Pediatric vision exam $0 $0 $0 $0 $0 (after deductible) 7 Adult optical (eyewear) Not covered 8 Not covered 8 Not covered 8 Not covered Not covered Adult vision exam (for eye refraction) $0 $0 $0 $0 Not covered Home health care (up to 100 visits per year) $0 $0 $0 20% 40% (after deductible) Hospice care $0 $0 $0 $0 40% (after deductible) Refer to pae 9 for the footnotes for medical plans. Refer to pae 10 for the child dental plans. Small Business January

10 Kaiser Permanente Platinum plans Plan Hihlihts For effective dates 1/1/15 6/1/15 *ALSO AVAILABLE IN COVERED CALIFORNIA ALSO AVAILABLE IN CALIFORNIACHOICE FEATURES PLAN DEDUCTIBLE Individual/Family Platinum 90 HMO 0/20*,,31 w/ child dental Copayment HMO Plan $0 $0 Participatin providers (in-network) 9 Platinum 90 PPO 0/20 w/ child dental Pendin reulatory approval Non-participatin providers (out-of-network) 9 $500/$1, $8,000/$16,000 10,11 OUT-OF-POCKET MAXIMUM Individual/Family $4,000/$8,000 1,28 $4,000/$8, IN THE MEDICAL OFFICE Primary care visits $20 $20 30% (after deductible) Urent care visits $20 $40 30% (after deductible) Specialty office visits $40 $40 30% (after deductible) Preventive exams, vaccines (immunizations) $0 12 $ % (after deductible) 12 Prenatal care $0 3 $0 13,14 30% 13,14 Postpartum care $0 3 $ % 16 Well-child preventive care visits $0 23 $0 30% Allery injections $5 10% 30% (after deductible) Infertility services Not covered 17 50% 15 Not covered Physical, occupational, and speech therapy $20 $20 30% (after deductible) Most laboratory tests $20 $20 30% (after deductible) Most X-rays and dianostic testin $40 $40 30% (after deductible) Most MRI/CT/PET scans $150 10% 30% (after deductible) Outpatient surery (per procedure) $250 10% 30% (after deductible) EMERGENCY SERVICES Emerency Department visits (waived if admitted directly to hospital) $150 $150 $150 Ambulance $150 $150 $150 PRESCRIPTIONS Generic drus (up to a 30-day supply) $5 24 $5 18,19 Brand-name drus (up to a 30-day supply) $15 24 $15 18,19 Specialty drus (up to a 100-day supply) 10% 24 10% 19,20 HOSPITAL CARE Physicians services, room and board, tests, medications, supplies, therapies, birth services $250 per day up to 5 days per admission 26 10% 30% (after deductible) Skilled nursin facility care (up to 100 days per benefit period) $150 per day up to 5 days per admission 26 10% 30% (after deductible) MENTAL HEALTH SERVICES In the medical office $20 $20 30% (after deductible) In the hospital $250 per day up to 5 days per admission 26 10% 30% (after deductible) CHEMICAL DEPENDENCY SERVICES In the medical office $20 $20 30% (after deductible) In the hospital (detoxification only) $250 per day up to 5 days per admission 26 10% 30% (after deductible) OTHER Certain durable medical equipment (DME) 10% 6 (base only) 10% 21,22 (supplemental and base) 30% (after deductible) 21,22 (supplemental and base) Certain prosthetic and orthotic devices $0 10% 30% (after deductible) Pediatric optical (eyewear) lenses, or contact lenses lenses, or contact lenses 10% (after deductible) 7 Pediatric vision exam $0 $0 $0 (after deductible) 7 Adult optical (eyewear) Not covered 8 Not covered Not covered Adult vision exam (for eye refraction) $0 $0 Not covered Home health care (up to 100 visits per year) $0 10% 30% (after deductible) Hospice care $0 $0 30% (after deductible) Refer to pae 9 for the footnotes for medical plans. Refer to pae 10 for the child dental plans. 8 Small Business January 2015

11 Footnotes for medical plans For effective dates 1/1/15 6/1/15 Cost-share amounts for all in-network services accumulate toward the out-of-pocket maximum. Preventive services are available at no cost share except for services from non-participatin providers. For a complete list of preventive services, please refer to the Evidence of Coverae, Certificate of Insurance, or businessnet.kp.or. Kaiser Permanente plans do not include a pre-existin condition clause. 1 Out-of-pocket maximum is the maximum amount an individual or family will pay for certain services in a year. 2 Deductible waived for first three visits combined for non-preventive primary care, urent care, and individual mental/behavioral health and substance use disorder services. 3 Scheduled prenatal visits and the first postpartum visit 4 Scheduled prenatal visits 5 Deductible does not apply for physician/sureon fee. 6 Please refer to the Evidence of Coverae for information on what is included in your DME benefit. Coverae is limited. 7 Under ae 19 8 Kaiser Permanente members are entitled to a 20 percent discount on eyelasses and contact lenses purchased at Kaiser Permanente optical centers. These discounts may not be combined with any other Health Plan vision benefit. The discounts will not apply to any sale, promotion, or packaed eyewear proram, for any contact lens extended purchase areement, or to low-vision aids or devices. Visit kp2020.or for Kaiser Permanente optical locations. 9 Payments are based upon the maximum allowable chare for covered services. Maximum allowable chare means the lesser of: the usual, customary, and reasonable chares; the neotiated rate; or the actual billed chares. The maximum allowable chare may be less than the amount actually billed by the provider. Covered persons may be responsible for payment of any amounts in excess of the maximum allowable chare for a covered service. 10 This plan has an embedded deductible and out-of-pocket maximum. Each family member will bein payin copayments or coinsurance after meetin his or her individual deductible, or when the family deductible is satisfied. Individual family members are no loner subject to cost sharin when they reach their individual out-of-pocket maximum, or when the family out-of-pocket maximum is met. 11 Covered chares incurred toward satisfaction of the out-of-pocket maximum at the non-participatin providers level will not accumulate toward satisfaction of the outof-pocket maximum on the PHCS network level. Likewise, covered chares incurred toward satisfaction of the out-of-pocket maximum on the PHCS network level will not accumulate toward satisfaction of the out-of-pocket maximum on the non-participatin providers level. 12 Preventive lab tests, X-rays, and immunizations are covered as part of the preventive exam. 13 Routine prenatal care office visits are covered as required under the Affordable Care Act (ACA). This includes the initial and subsequent histories, physical examinations, recordin of weiht, blood pressures, fetal heart tones, and routine chemical urinalysis. 14 Delivery and inpatient care for mother and baby are covered under your inpatient services benefit. For a complete understandin of birth services, please see your KPIC Certificate of Insurance. 15 Benefits payable for treatment of infertility are limited to $1,000 per year for services provided by PHCS network providers. Infertility includes GIFT. In vitro fertilization is not covered. Benefits payable for dianosis of infertility will be covered on the same basis as any other illness. 16 First postpartum visit only covered at no chare. 17 Infertility benefits can be added to this plan for an additional cost. For more information, contact your broker or Kaiser Permanente representative. 18 Insured is responsible for payin the brand-name copay plus the difference in cost between the eneric dru and the brand-name dru when the Insured requests a brandname dru and a eneric version is available. 19 Your plan does not have a prescription dru formulary; however, select prescription drus may be excluded from coverae. Please refer to your KPIC Certificate of Insurance for a complete list of limitations and exclusions. Reardless of your provider, prescriptions must be filled at a MedImpact participatin pharmacy. Please call MedImpact at for a participatin pharmacy. 20 For PPO plans, specialty drus include self-administered injectables. Self-administered injectable medications are covered under your plan, are limited to a 30-day maximum supply, and are not available under the mail-order service. Prescriptions for insulin are covered under the brand or eneric cost-share amounts. 21 Both base and supplemental DME are covered. Supplemental DME is limited to a combined maximum benefit of $2,000 per year for services from PHCS network and non-participatin providers, excludin diabetic-testin supplies and equipment. 22 Diabetic equipment and supplies are limited to infusion set and syrine with needle for external insulin pumps, testin strips, lancets, skin barrier, adhesive remover wipes, and transparent film. Coinsurance amounts are based on actual billed chares and are not subject to the DME maximum limit of $2,000 per year. 23 Well-child visits throuh ae 23 months 24 Prescription drus are covered in accordance with our formulary when prescribed by a Plan physician and obtained at Plan pharmacies. A few drus have different copayments; please refer to the Evidence of Coverae for detailed information about prescription dru copayments. Specialty drus are hih-cost drus that are on our specialty dru list. To obtain a list of specialty drus that are on our formulary, or to find out if a non-formulary dru is on the specialty dru list, please call our Member Service Contact Center. 25 This plan has an areate deductible and out-of-pocket maximum. The entire family deductible must be met before copayments or coinsurance apply for individual family members. Also, the entire family out-of-pocket maximum must be reached before individual family members are no loner subject to cost sharin. 26 After the 5 days, the hospital stay for the same admission is covered at no chare. 27 Base coverae: deductible waived Supplemental coverae: $2,000 benefit limit per year (after deductible) 28 This plan has an embedded out-of-pocket maximum. Individual family members are no loner subject to cost sharin when they reach their individual out-of-pocket maximum, or when the family out-of-pocket maximum is met. 29 Out-of-pocket maximum is the maximum amount an individual or family will pay for all covered services in a year. 30 Groups selectin the Gold HRA 2000/30 Deductible HMO with HRA plan must establish and fund an HRA for each enrolled employee. The allowable fundin rane is $300 to $700 per employee. If the roup covers dependents, the allowable fundin rane per family is $600 to $1, Refer to the CaliforniaChoice marketplace flier at kp.or/smallbusinessplans/ca for Kaiser Permanente plan names. Small Business January

12 Dental plans Choose from a variety of dental plans, which you can pair with any of our medical plans for reater flexibility and access. These plans are administered by Delta Dental of California, one of the nation s larest and most experienced dental benefits providers. Child dental benefits For effective dates 1/1/15 6/1/15 Child dental services is one of the essential health benefits required to be provided in conjunction with your ACA metal medical plan(s). When employees and their dependents enroll in the HMO medical plan(s) you ve chosen, we will also enroll them in a separate child dental benefit underwritten by Delta Dental of California. Child dental benefits for HMO plans Child dental benefits for PPO plans* SERVICES Member pays Member pays DEDUCTIBLE $0 $0 OUT-OF-POCKET (OOP) MAXIMUM $350/child $700/multichild $0 WAITING PERIOD None None OFFICE VISIT $0 $0 PREVENTIVE Periodic and comprehensive oral evaluation $0 $0 Bitewin X-rays $0 $0 Prophylaxis cleanin $0 $0 Fluoride treatments $0 $0 Space maintainers $0 $0 Sealants $0 $0 PERIODONTICS Maintenance Not covered Not covered Scalin and root planin $85 50% Surery osseous (includes flap entry and closure) $350 50% RESTORATIVE Fillins primary or permanent amalam $25 20% Composite crowns resin-based $115 20% Crown porcelain $350 20% Inlay metallic Not covered Not covered ENDODONTICS Therapeutic pulpotomy $85 50% Root amputation $170 50% Root canal anterior $300 50% Root canal molar $300 50% PROSTHODONTICS Complete denture $350 50% Reline maxillary denture chairside and limitations is Partial $195 50% Reline maxillary denture laboratory and limitations is Partial $210 50% Extraction erupted tooth or exposed root $65 50% Surical removal of erupted tooth $165 50% ORTHODONTICS (MEDICALLY NECESSARY) $350 50% *The child dental benefits are embedded into all metal PPO medical plans. No separate child dental OOP Maximum applied to medical OOP Maximum Orthodontics includes medically necessary orthodontia only. 10 Small Business January 2015

13 Kaiser Permanente Insurance Company KPIC Fee-for-Service (Premier) dental plans These dental insurance plans are underwritten by Kaiser Permanente Insurance Company, a subsidiary of Kaiser Foundation Health Plan, Inc., and administered by Delta Dental of California. The plans below are not intended to satisfy the ACA child dental benefits. PLAN C PLAN D PLAN E PLAN E WITH ORTHO* SERVICE PLAN PAYS PLAN PAYS PLAN PAYS PLAN PAYS NO DEDUCTIBLE APPLIES TO THESE PROCEDURES. Exam 100% 100% 100% 100% Twice in a year Bitewin X-rays X-rays of the top and bottom molars and premolars to show decay between teeth or under fillins For effective dates 1/1/15 6/1/15 LIMITATIONS 100% 100% 100% 100% Twice a year for children throuh ae 18, or once a year for adults aes 19 and over Other X-rays 80% 80% 80% 80% Full-mouth X-rays, sinle X-rays, and panoraphic X-rays once in any five-year period Prophylaxis A professional cleanin to remove plaque, calculus (mineralized plaque), and stains to help prevent dental disease Fluoride treatments A treatment with a chemical compound that prevents cavities and makes the tooth surface stroner so the teeth can resist decay DEDUCTIBLES APPLY TO PROCEDURES UNDER PLANS D, E, AND E WITH ORTHODONTICS. 100% 100% 100% 100% Twice a year 100% 100% 100% 100% Only for children throuh ae 18, twice a year Deductible No deductible $25 $25 $25 Per person, per year, up to a family maximum of $75 per year Benefit maximum $500 $1,000 $1,000 $1,000 The benefit maximum represents the total amount paid by the plan per person, per year Palliative care Any form of medical care or treatment that concentrates on reducin the severity of disease symptoms; the oal is to prevent and relieve sufferin and improve quality of life 80% 80% 80% 80% Usual, customary, and reasonable Denture relines Not covered 80% 80% 80% Twice a year (limited to two upper, two lower, or any combination) Space maintainers 100% 100% 100% 100% Usual, customary, and reasonable Fillins 80% 80% 80% 80% Usual, customary, and reasonable Stainless steel crowns 80% 80% 80% 80% Primary teeth only Endodontics A dental specialty concerned with treatment of the root and nerve of the tooth Periodontics A dental specialty concerned with the treatment of ums, tissue, and bone that supports the teeth Not covered 80% 80% 80% Usual, customary, and reasonable Not covered 80% 80% 80% Usual, customary, and reasonable Oral surery Not covered 80% 80% 80% Usual, customary, and reasonable Crowns and cast restorations The artificial coverin of a tooth with metal porcelain or porcelain fused to metal; covers teeth that are weakened by decay or severely damaed or chipped Prosthodontics A dental specialty concerned with restoration and/or replacement of missin teeth with artificial materials Orthodontics A dental specialty concerned with straihtenin or movin misalined teeth and/or jaws with braces and/or surery * Plan E with Orthodontics requires at least 10 subscribers. Benefits payable will be based on the lesser of the usual, customary, and reasonable fees or the fees actually chared. Limitation applies only to Plan D. Not covered Not covered 50% 50% Includes replacements after five years, but only if oriinally covered by KPIC dental plan Not covered Not covered 50% 50% Standard removable prosthetic appliance (includes replacements after five years, but only if oriinally covered by KPIC dental plan) Not covered Not covered Not covered 50% For eliible dependent children throuh ae 18, $1,500 lifetime maximum per insured (Replacement or repair of an orthodontic appliance paid for in part or in full by this plan is not covered.) Small Business January

14 Kaiser Permanente Insurance Company KPIC PPO dental plans These dental insurance plans are underwritten by Kaiser Permanente Insurance Company, a subsidiary of Kaiser Foundation Health Plan, Inc., and administered by Delta Dental of California. The plans below are not intended to satisfy the ACA child dental benefits. SERVICE NO DEDUCTIBLE APPLIES TO THESE PROCEDURES. PLAN PAYS* (PPO NETWORK) For effective dates 1/1/15 6/1/15 PPO D 1500 PPO E 1000 PPO E 1500 LIMITATIONS PLAN PAYS (OUT-OF- NETWORK) PLAN PAYS* (PPO NETWORK) PLAN PAYS (OUT-OF- NETWORK) PLAN PAYS* (PPO NETWORK) PLAN PAYS (OUT-OF- NETWORK) Exam 100% 50% 100% 50% 100% 50% Twice a year Bitewin X-rays X-rays of the top and bottom molars and premolars to show decay between teeth or under fillins 100% 50% 100% 50% 100% 50% Twice a year for children throuh ae 18, or once a year for adults aes 19 and over Other X-rays 80% 50% 80% 50% 80% 50% Full-mouth X-rays, sinle X-rays, and panoraphic X-rays once in any five-year period Prophylaxis A professional cleanin to remove plaque, calculus (mineralized plaque), and stains to help prevent dental disease Fluoride treatments A treatment with a chemical compound that prevents cavities and makes the tooth surface stroner so the teeth can resist decay DEDUCTIBLES APPLY TO PROCEDURES BELOW. 100% 50% 100% 50% 100% 50% Twice a year 100% 50% 100% 50% 100% 50% Only for children throuh ae 18, twice a year Deductible $25 $50 $25 $50 $25 $50 Per person, per year, up to a family maximum of $75 (in-network) and $150 (out-of-network) Benefit maximum $1,500 $1,500 $1,000 $1,000 $1,500 $1,500 Benefit maximum represents the total amount paid by the plan per person, per year Palliative care Any form of medical care or treatment that concentrates on reducin the severity of disease symptoms; the oal is to prevent and relieve sufferin and improve quality of life 80% 50% 80% 50% 80% 50% Denture relines 80% 50% 80% 50% 80% 50% Twice a year Space maintainers 100% 50% 100% 50% 100% 50% Fillins 80% 50% 80% 50% 80% 50% Stainless steel crowns 80% 50% 80% 50% 80% 50% Primary teeth only Endodontics A dental specialty concerned with treatment of the root and nerve of the tooth Periodontics A dental specialty concerned with the treatment of ums, tissue, and bone that supports the teeth 80% 50% 80% 50% 80% 50% 80% 50% 80% 50% 80% 50% Oral surery 80% 50% 80% 50% 80% 50% Crowns and cast restorations The artificial coverin of a tooth with metal porcelain or porcelain fused to metal; covers teeth that are weakened by decay or severely damaed or chipped Prosthodontics A dental specialty concerned with restoration and/or replacement of missin teeth with artificial material Orthodontics A dental specialty concerned with straihtenin or movin misalined teeth and/or jaws with braces and/or surery Not covered Not covered Not covered * Benefits payable will be based on the maximum allowable chare. Not covered Not covered Not covered 50% 50% 50% 50% Includes one replacement in any five-year period, but only if oriinally covered by KPIC dental plan 50% 50% 50% 50% Standard removable prosthetic appliances (includes one replacement in any five-year period, but only if oriinally covered by KPIC dental plan) Not covered Not covered Not covered Not covered Not covered 12 Small Business January 2015

15 DeltaCare HMO plans For effective dates 1/1/15 6/1/15 DeltaCare USA is underwritten and administered by Delta Dental of California. The plans below are not intended to satisfy the ACA child dental benefits. DELTACARE 10A DELTACARE 13B SERVICES MEMBER PAYS MEMBER PAYS LIMITATIONS PREVENTIVE CARE Periodic and comprehensive oral evaluation No cost No cost Twice a year Bitewin X-rays No cost No cost Twice a year for children throuh ae 18, or once a year for adults aes 19 and over Prophylaxis No cost No cost Twice a year Fluoride treatments No cost No cost Only for children up to ae 19, twice a year Space maintainers $10 $50 Removable unilateral PERIODONTICS Maintenance No cost $35 Twice a year Scalin and root planin No cost $50 Limited to four quadrants per year Surery osseous (includes flap entry and closure) $175 $300 Four or more teeth per quadrant RESTORATIVE Fillins primary or permanent amalam No cost No cost Four or more surfaces Composite crowns resin-based No cost $55 Anterior Crown porcelain $195 $355 Inlay metallic No cost $145 One surface ENDODONTICS Therapeutic pulpotomy No cost $25 Excludes final restoration Root amputation No cost $70 Per root Root canal anterior $45 $95 Excludes final restoration Root canal molar $205 $335 Excludes final restoration PROSTHODONTICS Complete denture $100 $285 Reline maxillary or mandibular denture chairside No cost $50 Complete or partial Reline maxillary or mandibular denture laboratory $35 $85 Complete or partial The enrollee must continue to be eliible, and the service must be provided at the contract dentist facility where the denture was oriinally delivered. ORAL AND MAXILLOFACIAL SURGERY Extraction erupted tooth or exposed root No cost $5 Elevation and/or forceps removal Surical removal of erupted tooth $15 $45 Complete or partial ORTHODONTICS Comprehensive orthodontic child $1,700 $1,900 Child or adolescent to ae 19 Comprehensive orthodontic adult $1,900 $2,100 Adults, includin covered dependent adult children Benefits listed above are only a sample of provided services and associated costs. Costs will vary. Please see the Evidence of Coverae for a comprehensive list of all services and costs. DeltaCare benefits are only covered when performed by an in-network California DeltaCare HMO provider. In California, DeltaCare USA is underwritten and administered by Delta Dental of California. Small Business January

16 For effective dates 1/1/15 6/1/15 Important information for the KPIC Fee-for-Service (Premier) and PPO dental insurance plans The followin services are not covered under any Kaiser Permanente Insurance Company (KPIC) roup dental insurance plans: Any treatment or procedure not listed as covered. Chares in excess of the maximum allowable chare. Services for injuries or conditions covered under workers compensation or employer s liability laws. Cosmetic surery, dentistry, or services to correct hereditary, conenital, or developmental malformations. Restoration of tooth structure crowns, and/or cast restorations, or chewin surfaces for damaes due to wear. Prosthodontic services or procedures started prior to a person s date of eliibility. Prescribed drus, premedication, or pain relievers. Experimental procedures. Hospital costs or extra chares for hospital treatment. Anesthesia (except eneral anesthesia for oral surery). Extra-oral rafts, implants, or implant removal. Treatment related to the temporomandibular joint (TMJ). Plaque-control prorams, oral hyiene, or dietary instructions. Orthodontic treatment, except for eliible dependent children under Plan E with Orthodontics. Treatment plans that are more expensive than those customarily provided, or specialized techniques used instead of standard procedures; for example, a precision denture where a standard denture would suffice. Pit and fissure sealants, except for first molars of children throuh ae 8 and second molars for children throuh ae 15. The molar must have no decay and no restoration, and the occlusal surface must be intact. Coverae does not include the repair or replacement of a sealant on any tooth within three years of application. Services provided to the covered person by any federal or state overnmental aency or provided without cost to the covered person by any municipality, county, or other political subdivision, except Medi-Cal benefits. Chares by any hospital or other surical treatment facility, or any additional fees chared by the dentist for treatment in any such facility. Implants (materials implanted into or on bone or soft tissue) or the repair or removal of implants. Replacement of existin restoration for any purpose other than active tooth decay. Intravenous sedation, occlusal uards, or complete occlusal adjustment. Chares for replacement or repair of an orthodontic appliance paid in part or in full by this proram. Hypnosis. Chares for completion of forms. Chares for speech therapy. Chares for lost or stolen appliances. Services for which no chare is normally made in the absence of insurance. Predetermination of benefits is recommended for services in excess of $300. This document is not intended as a summary plan description, nor is it desined to serve as the Certificate of Insurance or the Schedule of Coverae. It contains only a summary of benefits, exclusions, and limitations. If you have specific questions reardin benefit structure, limitations, or exclusions, consult the Certificate of Insurance and the Schedule of Coverae or contact Delta Dental s Customer Service Department at , 8 a.m. to 5 p.m., Monday throuh Friday. For a list of in-network providers, contact Delta Dental s Customer Service Department. This dental insurance plan is underwritten by Kaiser Permanente Insurance Company, a subsidiary of Kaiser Foundation Health Plan, Inc., and administered by Delta Dental of California. 14 Small Business January 2015

17 DeltaCare HMO plans The DeltaCare HMO plans are not intended to satisfy the ACA child dental benefits. For effective dates 1/1/15 6/1/15 The DeltaCare HMO dental plan is not available for employees enrolled in a PPO medical plan and livin outside of California. Exclusions of benefits for the DeltaCare HMO dental plans Exclusions Any procedure that in the professional opinion of the contract dentist: has poor pronosis for a successful result and reasonable lonevity based on the condition of the tooth or teeth and/or surroundin structures, or is inconsistent with enerally accepted standards for dentistry. Services solely for cosmetic purposes, with the exception of procedure D9972 (external bleachin, per arch), or for conditions that are a result of hereditary or developmental defects, such as cleft palate, upper and lower jaw malformations, conenitally missin teeth, and teeth that are discolored or lackin enamel, except for the treatment of newborn children with conenital defects or birth abnormalities. Porcelain crowns, porcelain fused to metal, cast metal or resin with metal type crowns, and fixed partial dentures (brides) for children under 16 years of ae. Lost or stolen appliances includin, but not limited to, full or partial dentures, space maintainers, crowns, and fixed partial dentures (brides). Procedures, appliances, or restoration, if the purpose is to chane vertical dimension, or to dianose or treat abnormal conditions of the temporomandibular joint (TMJ). Precious metal for removable appliances, metallic or permanent soft bases for complete dentures, porcelain denture teeth, precision abutments for removable partials or fixed partial dentures (overlays, implants, and appliances associated therewith), and personalization and characterization of complete and partial dentures. Implant-supported dental appliances and attachments; implant placement, maintenance, or removal; and all other services associated with a dental implant. Consultations for noncovered benefits. Dental services received from any dental facility other than the assined contract dentist, a preauthorized dental specialist, or a contract orthodontist except for Emerency Services as described in the contract and/ or Evidence of Coverae. All related fees for admission, use, or stays in a hospital, outpatient surery center, extended care facility, or other similar care facility. Prescription drus. Dental expenses incurred in connection with any dental or orthodontic procedure started before the enrollee s eliibility with the DeltaCare USA proram. Examples include: teeth prepared for crowns, root canals in proress, full or partial dentures for which an impression has been taken, and orthodontics unless qualified for the orthodontic treatment in proress provision. Lost, stolen, or broken orthodontic appliances. Chanes in orthodontic treatment necessitated by accident of any kind. Myofunctional and parafunctional appliances and/or therapies. Composite or ceramic brackets, linual adaptation of orthodontic bands, and other specialized or cosmetic alternatives to standard fixed and removable orthodontic appliances. Treatment or appliances that are provided by a dentist whose practice specializes in prosthodontic services. For additional benefit information or a directory of Delta dentists, please call Delta Dental at or visit deltadentalins.com. Small Business January

18 For effective dates 1/1/15 6/1/15 Chiropractic and acupuncture plans Your employees can et the care they need with our combined coverae for chiropractic and acupuncture care and they don t need a referral from their primary care doctor. Chiropractic and Acupuncture Plan for Kaiser Permanente HMO and HRA plans $15 Copay/20 Visits SERVICES ARE ADMINISTERED BY AMERICAN SPECIALTY HEALTH PLANS OF CALIFORNIA, INC. (ASH PLANS) FEATURES Office visit copayment Office visit limit Chiropractic appliance benefit $15 per visit 20 combined visits per year Chiropractic appliances are provided up to a maximum of $50 per year when prescribed and provided by an ASH Plans participatin chiropractor as part of your chiropractic care. X-rays and laboratory tests $0 Services Chiropractic services are covered when a participatin chiropractor finds that the services are medically necessary to treat or dianose neuromusculoskeletal disorders. Acupuncture services are covered when a participatin acupuncturist finds that the services are medically necessary to treat or dianose neuromusculoskeletal disorders, nausea, or pain. You can obtain services from any ASH Plans participatin chiropractors and acupuncturists without a referral from a Kaiser Permanente Plan physician. Office visits: Covered services are limited to medically necessary chiropractic and acupuncture services authorized and provided by ASH Plans participatin chiropractors and acupuncturists. X-rays and laboratory tests: Medically necessary X-rays and laboratory tests are covered when prescribed as part of your chiropractic care by a participatin chiropractor and provided by an appropriately licensed participatin provider that has contracted with ASH Plans to provide those services. Emerency services: Covered chiropractic services are those emerency services provided for the sudden and unexpected onset of an injury or condition affectin the neuromusculoskeletal system. Covered acupuncture services are those emerency services provided for the sudden and unexpected treatment of a neuromusculoskeletal disorder, nausea, or pain. These conditions and injuries must manifest themselves by acute symptoms of sufficient severity, includin severe pain, such that a reasonable layperson with no special knowlede of health, medicine, chiropractic care, or acupuncture could reasonably expect that a delay of immediate chiropractic care or acupuncture could result in (1) placin your health in serious jeopardy, (2) serious impairment to your bodily functions, or (3) serious dysfunction of any bodily oran or part. Participatin chiropractors and acupuncturists ASH Plans contracts with participatin chiropractors and other participatin providers to provide covered chiropractic services, includin laboratory tests, X-rays, and chiropractic appliances. ASH Plans (continues on pae 17) 16 Small Business January 2015

19 For effective dates 1/1/15 6/1/15 (continued from pae 16) contracts with participatin acupuncturists to provide acupuncture care (includin adjunctive therapies, such as acupressure, cuppin, moxibustion, or breathin techniques, when provided durin the same course of treatment and in conjunction with acupuncture). You must receive covered services from a participatin provider, except for emerency chiropractic and acupuncture services and services that are not available from participatin providers that are previously authorized by ASH Plans. The list of participatin chiropractors and acupuncturists is available on the ASH Plans website at ashcompanies.com/kp or from the ASH Plans Member Services Department at The list of participatin chiropractors and acupuncturists is subject to chane at any time without notice. How to obtain covered services To obtain covered services, call a participatin chiropractor or acupuncturist to schedule an initial examination. If additional services are required, your participatin chiropractor or acupuncturist will prepare a treatment plan. The ASH Plans Clinical Services Manaer will authorize the treatment plan if the services are medically necessary chiropractic services and acupuncture services for you. ASH Plans will disclose to you, upon request, the process that it uses to authorize a treatment plan. If you have questions or concerns, please contact the ASH Plans Member Services Department. This is a summary and is intended to hihliht only the most frequently asked questions about the chiropractic and acupuncture benefit, includin copayments. This benefit cannot be offered with the HSA-qualified deductible HMO plans or the PPO plans. Please refer to the Combined Chiropractic and Acupuncture Services Amendment of the Kaiser Foundation Health Plan, Inc., Evidence of Coverae for a detailed description of the chiropractic and acupuncture benefits, includin exclusions and limitations, emerency chiropractic services, and emerency acupuncture services. Kaiser Foundation Health Plan, Inc. (Health Plan), contracts with American Specialty Health Plans of California, Inc. (ASH Plans), to make the ASH Plans network of participatin chiropractors and participatin acupuncturists available to you. You can obtain covered services from any participatin chiropractor or participatin acupuncturist without a referral from a Plan physician. Cost sharin is due when you receive covered services. Please see the definitions section of your Combined Chiropractic and Acupuncture Services Amendment of the Kaiser Foundation Health Plan, Inc., Evidence of Coverae for terms you should know. Gettin assistance If you have a question or concern reardin the services you received from a participatin provider, you may call ASH Plans Member Services at (TTY users call 711) weekdays from 5 a.m. to 6 p.m., or write ASH Plans at: ASH Plans Member Services P.O. Box San Dieo, CA Dispute resolution You can file a rievance with Kaiser Permanente reardin any issue. Your rievance must explain your issue, such as why you believe a decision was in error or why you are dissatisfied with services you received. You may submit your rievance orally or in writin to Kaiser Permanente as described in the Dispute Resolution section of your Health Plan Evidence of Coverae. Small Business January

20 For effective dates 1/1/15 6/1/15 Chiropractic and Acupuncture Plan for Kaiser Permanente PPO Plans $15 Copay/20 Visits FEATURES Office visit copayment Office visit limit Chiropractic appliance benefit X-rays and laboratory tests $15 per visit 20 combined visits per year Chiropractic appliances are covered under medical plan DME benefits when prescribed by a PHCS participatin chiropractor as part of your care. 30% (covered under PPO medical plans) Services You can obtain chiropractic and acupuncture services from any participatin provider without a referral from a physician. Except for the initial examination, your chiropractic benefits are limited to medically necessary chiropractic services for the treatment or dianosis of neuromusculoskeletal disorders that are due to subluxation and are treatable by manual manipulation of the spine. Office visits: Covered services are limited to medically necessary chiropractic and acupuncture services* authorized and provided by a PHCS network provider. How to obtain services You must receive chiropractic or acupuncture services from a participatin provider in the PHCS network. Choose from more than 2,000 providers in California and thousands of others nationwide. To find a provider near you, visit multiplan.com/kaiser. Deductibles or copayments paid under the chiropractic and acupuncture coverae do not count toward satisfyin your medical deductible and out-of-pocket maximum. Chiropractic and acupuncture coverae for Kaiser Permanente PPO Plans is underwritten by Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc. This is only a summary of your benefits and is intended to hihliht only the most frequently asked questions about the chiropractic and acupuncture benefit, includin copayments. Benefits may vary dependin on the terms of your plan. Please refer to the KPIC Certificate of Insurance and Schedule of Coverae for a detailed description of your chiropractic and acupuncture benefits, includin exclusions, limitations, and emerency chiropractic services. * Medically necessary acupuncture is covered under your PPO medical plan. The above chiropractic and acupuncture plan covers the same medically necessary acupuncture, but at a lower copayment. It is possible that your chiropractor may perform physical therapy related services not covered under your chiropractic benefits. Please refer to your KPIC Certificate of Insurance for complete details about which services are covered. KPIC has contracted with PHCS to ive you access to providers with a commitment to keepin out-of-pocket costs low throuh contracted rates. 18 Small Business January 2015