2015 PLAN UPDATES. We re here for you! A more robust medical plan portfolio. New Added Choice plan options

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1 2015 PLAN UPDATES What s new for 2015 Washington small business group plans This booklet contains a summary of important information you will want to know about our 2015 small group plans. For more details on plan design, refer to the Medical Plans Overview for Washington Small Businesses. NEW IN 2015 We re here for you! You re a valued business partner, and we re committed to improving the health of your employees and your business. As your trusted partner, we re here to provide information to help you make the right decisions for your business. Under the Affordable Care Act (ACA), you have many options as a small employer to compare and purchase coverage. Your producer/agent and we will help you decide what works best for your business and your employees. One of your options is to simply renew your coverage with us. We re pleased to offer renewal plan options that provide a wide array of choice and meet the new plan design requirements of ACA. A more robust medical plan portfolio Our plan portfolio now offers more choice for more flexibility. We have added plans to the Gold, Silver, and Bronze metal tiers and still provide a choice of traditional non-deductible plans, deductible plans, Added Choice plans, and High Deductible Health Plans that are HSA-qualified. All plans may be purchased with and without a vision hardware allowance (with the exception of one plan). New Added Choice plan options Our new plan portfolio has restored Added Choice plan options. We now offer a two-tier plan that provides an in-network benefit tier for services provided by Select Providers and Select Facilities and a non-participating benefit tier for all other providers. The non-participating benefit tier on the Added Choice plan includes a $100,000 benefit maximum for all plan paid expenses. (The Evidence of Coverage provides a complete definitition of Select Provider and Select Facilities.) We also offer one three-tier plan design that includes an additional benefit tier for services provided by PPO providers and facilities and facilities through the First Choice network. For more information on network providers, please visit kp.org/addedchoice. Both Added Choice plan options are available with or without built-in coverage for adult vision hardware. All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest. 500 NE Multnomah St., Suite 100, Portland, OR

2 Automatic renewals For your renewal in 2015, we will automatically provide you with coverage that is most similar to your current plan, but you can choose from any of our other plans available to small employers if you prefer. Consult your producer or account manager for information about our new plans. We ll need you to respond back whether you decide to accept the renewal as offered or make changes. Starting in 2015, Kaiser Permanente will no longer collect or maintain information about group waiting periods. Instead, we will rely on groups to monitor new employees eligibility dates and to let us know when to enroll their employees. According to final regulations published by the U.S. Department of Labor (DOL), Treasury, and Health and Human Services (HHS) on February 24, 2014, the Affordable Care Act (ACA) requires that, for plan years beginning on or after January 1, 2015, a group health plan or health insurance issuer offering group health insurance coverage shall not apply any waiting period that exceeds 90 calendar days from the date of eligibility PLAN HIGHLIGHTS AND REMINDERS Consumer engagement meets high-quality care With consumer-directed health care HRAs, HSAs, and FSAs you can have a workforce that s more fully engaged in maintaining their health. Kaiser Permanente has been guiding our members toward healthier behavior for more than six decades. Now our partnership with Evolution1 pairs one of the nation s most experienced consumer-directed health care administrators with the high-quality integrated care that sets Kaiser Permanente apart. You pick the plan design that works for you from a wide range of deductibles, copays, and coinsurance. Your employees will be encouraged to participate in managing their health not only from a financial standpoint due to plan design, but because that s how we deliver care. Increased network and facility options Kaiser Permanente is focused on providing high-quality, affordable health care that s easy and convenient for our members. Legacy Salmon Creek Medical Center became our primary Health Plan hospital for Clark County. The partnership built around principles of patient-centered, physician-directed care brings together two, industry-leading health care organizations to better serve the Clark County area s health needs. Good news for your employees who live or work on the west side of Portland. Kaiser Permanente Westside Medical Center Washington County s first new hospital in more than 40 years has been operating since August Effective January 1, 2014, Kaiser Permanente members have access to The Portland Clinic, in seven locations, with the same coverage and services they receive from Kaiser Permanente providers. Ask your producer or account manager about Kaiser Permanente s expanded network through The Portland Clinic. 2

3 Bundle plan options (multiple plan offerings) We still provide the same flexible bundle options at no additional charge. This allows you to tailor your plan offerings, giving employees more choice and more control over their monthly premium cost. You contribute the same amount toward each plan and let your employees decide if they want the base plan or to pay more for a buy-up option. For more details, refer to the Medical Plans Overview for Washington Small Businesses. Prescription drug coverage is automatically covered on all medical plans All of our plans come with built-in coverage for outpatient prescription drugs. All prescription drug plans have a four-tier benefit design with different cost-sharing amounts for generic, formulary brand, approved non-formulary brand, and specialty drugs. Pediatric vision coverage on all medical plans All of our plans cover pediatric vision exams and one pair of standard frames or a six-month supply of contact lenses for children at no charge. Alternative care rider Your plan covers up to 12 acupuncture treatments per calendar year without referral and additional visits are available by referral. Your plan still provides coverage for self-referred spinal manipulation (chiropractic) therapy. Benefits that accrue to the medical out-of-pocket maximum Most benefits, including copays and coinsurance for services not subject to deductible, as well as the deductible itself, now accrue to the medical out-of-pocket maximum. Copays and coinsurance that accrue to the out-ofpocket maximum are waived once an individual or family has reached that maximum. Underwriting guidelines Several changes apply to our underwriting guidelines for Please be sure to review the Rating and Underwriting Assumptions Policy effective January 1, 2015, for Washington groups with 50 or fewer employees. 3

4 Summary of changes and clarifications for Washington small employer groups This is a summary of changes and clarifications that we have made to your Group Agreement. The Group Agreement includes the Evidence of Coverage (EOC), Benefit Summary, and any applicable endorsement documents. This summary does not include minor changes and clarifications we are making to improve the readability and accuracy of the Group Agreement. These changes and clarifications do not include changes that may occur throughout the remainder of the year as a result of federal or state mandates. Other Group-specific or product-specific plan design changes may apply, such as moving to standard benefits. Refer to the Plan Updates document for information about these types of changes. To the extent that this summary of changes and clarifications conflicts with, modifies, or supplements the information contained in your Group Agreement, the information contained in the Group Agreement shall supersede what is set forth below. Unless another date is listed, the changes in this document are effective when your Group renews in The products named below are offered and underwritten by Kaiser Foundation Health Plan of the Northwest. TRADITIONAL, DEDUCTIBLE, HIGH DEDUCTIBLE (HSA-QUALIFIED) AND ADDED CHOICE MEDICAL PLANS Small Group Medical Plans* GOLD SILVER BRONZE Traditional plans KP WA GOLD 0/30* 0/50* Deductible plans KP WA GOLD 500/20* 1500/30* KP WA BRONZE 3500/50* KP WA GOLD 1000/20* 2000/35* High deductible (HSA-qualified) plans 1750/25% HSA* KP WA BRONZE 5000/60 HSA Added Choice plans KP WA GOLD 600/35 3T* 2000/40 2T* *Some plans offered outside Washington Healthplanfinder come with or without a built-in benefit for adult vision hardware. See plan descriptions for details. Changes to Senior Advantage plans are explained on page 8 of this document. Medical EOC Form Numbers: EWSGTRADG0115 EWSGHDHPB0115 EWSGDEDBVX0115 EWSGTRADGVX0115 EWSGDEDG0115 EWSG3TPOSDED0115 EWSGTRADS0115 EWSGDEDGVX0115 EWSG3TPOSDEDVX0115 EWSGTRADSVX0115 EWSGDEDS0115 EWSG2TPOSDED0115 EWSGHDHPS0115 EWSGDEDSVX0115 EWSG2TPOSDEDVX0115 EWSGHDHPSVX0115 EWSGDEDB0115 4

5 BENEFIT OR ELIGIBILITY CHANGES THAT APPLY TO ALL PLANS For Traditional, Deductible, and High Deductible Health Plans, the definition of Usual and Customary Fee in the EOC Definitions section has been deleted and replaced with Allowed Amount. Allowed Amount is based on billed Charges or 160 percent of the Medicare fee, whichever is lower. For Deductible and Added Choice Plans, Deductible carry-over has been removed. Charges paid for Services received during the last three months of the previous Calendar Year will no longer count toward the Deductible. Amounts a Member pays for non-essential Health Benefits, such as physician-referred alternative care Services (acupuncture, chiropractic, massage therapy, and naturopathy Services), infertility Services, and routine vision exams for Members 19 years and older, do not accumulate toward the Out-of-Pocket Maximum. The Post-Stabilization Care EOC section has been modified. For all plans, prior authorization for Post-Stabilization Care from a Non-Participating Facility or Non-Participating Provider must be obtained no later than 24 hours after any admission, or as soon as reasonably possible. For three-tier Added Choice Plans, this also applies when obtaining prior authorization for Post-Stabilization Care from PPO Facilities or PPO Providers. Coverage for Post-Stabilization Care at a Non-Participating Facility or a Non-Participating Provider is limited to the Allowed Amount. The Infertility Services EOC section has been modified. Inpatient and outpatient Services for the treatment of infertility are excluded from coverage. The Outpatient Prescription Drugs and Supplies and the Transplant Services EOC sections have been modified. Post-surgical immunosuppressive drugs are subject to Deductible, Copayment, and/or Coinsurance amounts for the applicable prescription drug tier. The Pediatric Vision Services Exclusions section within the Pediatric Vision Services EOC section has been modified to identify lens materials that are not covered. The Outpatient Prescription Drugs and Supplies provision in the EOC Benefits section has been modified. References to Formulary Brand and Non-formulary Brand Name Drugs have been replaced by Preferred Brand and Non-preferred Brand Name Drugs to align with terms used on our drug formulary. Additionally, a Prior Authorization and Step Therapy Prescribing Criteria section has been added. Certain prescription drugs and supplies are subject to prior authorization and step therapy prescribing criteria. A Surrogacy Arrangement EOC section has been added to the Reductions EOC section. This section provides information about Member obligations to Company in connection with a surrogacy arrangement, including Member obligations to reimburse Company for any Services received, and provides information about who may be financially responsible for any Services received by the baby (or babies). Administrative changes or clarifications The Certificates of Creditable Coverage EOC section under Termination of Membership provision has been deleted. In addition, the HIPAA Certificates of Creditable Coverage section of the Group Agreement has been deleted. Issuing certificates of creditable coverage is no longer a requirement. HIPAA Certificates of Creditable Coverage will be issued upon request only. 5

6 ADDITIONAL CHANGES AND CLARIFICATIONS THAT APPLY TO ADDED CHOICE MEDICAL PLANS ONLY Benefit changes The definition of Usual and Customary Fee in the EOC Definitions section has been deleted. The definition of Allowed Amount in the EOC Definitions section has changed. Allowed Amount is based on billed Charges or 100 percent of the Medicare fee, whichever is lower. Previously, it was based on billed charges or 160 percent of the Medicare fee, whichever is lower. Administrative changes or clarifications Throughout the EOC, all references to Permanente Advantage have been deleted. Kaiser Foundation Health Plan of the Northwest will provide Tier 2 utilization management and prior authorization services. The Tier 1 Referrals and Tier 1 Prior Authorization Review Requirements EOC sections have been modified. A PPO Provider (for three-tier Added Choice Plans) or a Non-Participating Provider (for two-tier and three-tier Added Choice Plans) may refer a Member directly to a Specialist who is a Select Provider, subject to utilization review criteria. The Outpatient Prescription Drug and Supplies Benefit Summary and EOC sections have been modified. All references to the Catamaran pharmacy network option have been replaced with the MedImpact pharmacy network. 6

7 MEDICAL PLAN CHANGES CURRENT PLAN REPLACEMENT PLAN Benefit KP WA Silver 2000/40 KP WA Silver 2000/35 Out-of-pocket maximum $4,250 $4,500 Benefit KP WA Silver 1500/30 KP WA Silver 1500/30 Specialty drugs $150 30% Benefit KP WA Silver 2000/40 KP WA Silver 2000/35 Emergency services 30% after deductible 20% after deductible Hospital stay 30% after deductible 20% after deductible Primary care visit to treat an injury or illness $40 $35 Specialist visit $50 $45 Mental/behavioral health outpatient services $40 $35 Imaging (CT/PET scans, MRIs) 30% after deductible 20% after deductible PT/OT/ST $50 after deductible $45 after deductible Laboratory tests $40 $30 X-rays and diagnostic testing $50 $40 Skilled nursing care 30% after deductible 20% after deductible Outpatient surgery facility 30% after deductible 20% after deductible DENTAL PLANS Traditional ZJ no deductible ZJ-5 $50 deductible ZJ-10 $100 deductible adult-only plans ZB no deductible ZB-5 $50 deductible ZB-10 $100 deductible ZA no deductible ZA-5 $50 deductible ZA-10 $100 deductible ZD no deductible ZD-5 $50 deductible ZD-10 $100 deductible PPO YN-5 $50 deductible YN-10 $100 deductible adult-only plans YI-5 $50 deductible YI-10 $100 deductible YH-5 $50 deductible YH-10 $100 deductible YG-5 $50 deductible YG-10 $100 deductible Participating Providers In the Dental Choice PPO Plan, the DenteMax definition has been deleted and Participating Provider definition has been revised. Dental Choice Participating Providers are not limited to DenteMax providers. Dental EOC Form Numbers: EWSGADULTDNTDEDPPO0115 EWSGOXADULTDNTDED0115 EWSGOXADULTDNT0115 7

8 CHANGES AND CLARIFICATIONS THAT APPLY TO ALL SENIOR ADVANTAGE PLANS The following changes take effect as groups renew in 2015 unless otherwise noted. Benefit changes To better align with industry standards, outpatient administered medications, including those given in medical office settings, will now have a cost share. This change is reflected in your EOC in the Medicare Part B prescription drugs Medical Benefits Chart section under drugs that usually aren t self-administered and injectable osteoporosis drugs. businessnet.kp.org/nw 2015 Kaiser Foundation Health Plan of the Northwest