2018 PLAN UPDATES. What s new for Washington s Clark and Cowlitz counties small business group plans WASHINGTON

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1 2018 PLAN UPDATES What s new for Washington s Clark and Cowlitz counties small business group plans WASHINGTON 2018 This booklet contains a summary of important information you will want to know about our 2018 small group plans. For more details on plan design, refer to the Medical Plans Overview for Washington Small Businesses. account.kp.org _NW-WA_12/17 All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest. 500 NE Multnomah St., Suite 100, Portland, OR

2 Your partner in good health At Kaiser Permanente, we offer a fully integrated health care delivery system with providers, hospitals, pharmacies, and labs working together to provide coordinated care for our members. What s new at Kaiser Permanente Northwest We are proud to be part of the Greater Portland, Southwest Washington, Salem, and Lane County communities. With 34 medical offices, 20 dental offices, and access to all locations of The Portland Clinic, there s sure to be a clinic convenient to your home, work, or school. Save time, stay comfortable, and get the urgent, primary, or specialty care you need from home, work, or anywhere else on your camera-equipped computer, tablet, or smartphone. If appropriate for your condition, we offer , phone, and video visits. Sign on to kp.org to self-schedule an appointment. Care Essentials by Kaiser Permanente offers a convenient neighborhood clinic in the Pearl District to treat members and nonmembers for common, nonemergency health issues. Schedule an appointment at careessentials.org or Cedar Hills Dental and Medical Office, which opened early 2017, merges dental with an embedded, low-acuity medical capability. Additionally, Kaiser Permanente will continue to expand its dental access points with new offices opening in Johnson Creek and Salem, as well as an expansion at the Clackamas location. Our focus on integrated care helps us provide communication between your medical and dental providers. Our dentists can easily access your relevant health records and communicate with your Kaiser Permanente medical clinicians, so you can rest easier knowing we re looking out for your total health. Vision Essentials by Kaiser Permanente is now open to serve you on Saturdays at Beaverton Medical Office, Cascade Park Medical Office, and Clackamas Eye Care. We have improved the overall level of service and support for our valued Added Choice members by adding a new dedicated Member Services phone line available for questions Monday through Friday, 8 a.m. to 6 p.m., at medical plan portfolio Our plan portfolio offers choice and flexibility. We have multiple plans to choose from in all 4 metal levels. It was necessary to make changes to certain cost shares on some plans such as the deductible,, copays, and out-of-pocket maximum amounts in order to keep the plans within their metal level and cover a similar percentage of health care costs as the prior year. Two of our plans (KP WA Silver 1500/35 and KP WA Silver 0/50) are being discontinued and replaced with other plan offerings. However, we have added 1 new plan in the Gold metal level (KP WA Gold 1500/35). Read on for a detailed list of specific benefit changes to each plan. Automatic renewals For your renewal in 2018, we will automatically provide you with coverage from one of the plans that best matches the plan or plans your business offers today. But you can choose from any of our other plans available to small employers if you prefer. Please indicate on the Renewal Decision Form whether you decide to accept the renewal as offered or make changes. 2

3 Vision coverage We offer comprehensive eye care services to help keep your world in focus. All the plans in our portfolio may be purchased with or without an adult routine eye exam and hardware benefit. To offer choice and affordability, plans that are not purchased with this option do not include adult routine eye exams. Go to kp2020.org for more information, including our 10 optical locations. Bundle options As you consider alternatives to lower your health care costs, consider offering employees a plan with 1 or 2 buyup alternatives. These bundle plan options are provided at no additional charge and allow 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 (no less than 50% of the lowest premium plan) and let your employees decide if they want to pay more for a buy-up option. For more details, refer to the Medical Plans Overview for Washington Small Businesses PLAN HIGHLIGHTS AND REMINDERS Prescription drug coverage is automatically covered on all medical plans All our plans come with built-in coverage for outpatient prescription drugs. All prescription drug plans have a 4-tier benefit design with different cost-sharing amounts for generic, preferred brand, non-preferred brand, and specialty drugs. Your employees can save time and money by ordering prescription refills online or by phone. Members can get a 90-day supply for only twice the 30-day supply copay when we mail your prescription. We can mail most prescription drugs to you within 10 days, and you don t pay any extra cost for standard U.S. postage. Pediatric vision coverage on all medical plans All our plans cover pediatric vision exams and 1 pair of frames or a 12-month supply of contact lenses, for children 18 and younger, at no additional charge. Alternative care benefits To help your employees achieve total health, your plan covers up to 12 acupuncture treatments per calendar year without referral, and additional visits are available by referral. Your plan also provides coverage for selfreferred spinal manipulation (chiropractic) therapy up to 10 visits per calendar year. Visit chpgroup.com to find a participating provider. 3

4 Dental plans and coverage All traditional and PPO dental plan designs will continue for adults only (19 and older), and pediatric dental coverage will continue to be provided as part of the medical plan. As a reminder, we offer plans that may be purchased with adult cosmetic orthodontia coverage. We also offer stand-alone pediatric dental options that allow employees to cover their entire family. These plans provide ACA-compliant pediatric dental coverage even if the group or the employee is not enrolled in a Kaiser Permanente medical plan. If you currently offer dental coverage, the same plan will be provided for your automatic renewal. If you want to choose a different plan, you may do so as well. Benefits that accrue to the medical out-of-pocket maximum Most benefits, including copays and for services not subject to deductible, as well as the deductible itself, accrue to the medical out-of-pocket maximum. Copays and that accrue to the out-of-pocket maximum are waived once an individual or family has reached that maximum. Underwriting guidelines Please be sure to review the Rating and Underwriting Assumptions Policy effective January 1, 2018, for Washington groups with 50 or fewer employees. TRADITIONAL, DEDUCTIBLE, HIGH DEDUCTIBLE (HSA-QUALIFIED), AND ADDED CHOICE MEDICAL PLANS Small group medical plans PLATINUM GOLD SILVER BRONZE Traditional plans KP WA PLATINUM 0/20 (2018) KP WA GOLD 0/30 (2018) Deductible plans KP WA PLATINUM 250/20 (2018) KP WA GOLD 500/20 (2018) KP WA SILVER 2000/40 (2018) KP WA BRONZE 5000/50 (2018) KP WA GOLD 1000/20 (2018) KP WA SILVER 3500/40 (2018) KP WA BRONZE 6600/40 (2018) KP WA GOLD 1500/35 (2018) High deductible (HSA-qualified) plans KP WA SILVER 2700/25% HSA (2018) KP WA BRONZE 5200/20 HSA (2018) Added Choice plans KP WA PLATINUM 250/10 3T POS (2018) KP WA GOLD 600/35 3T POS (2018) KP WA GOLD 1000/35 3T POS (2018) 4 KP WA SILVER 2500/40 3T POS (2018) Any of the above medical plans can be purchased with a built-in benefit for adult vision hardware and exam. See plan descriptions for details. Changes to Kaiser Permanente Senior Advantage plans are explained on page 12 of this document. Medical EOC form numbers: EWSGTRAD0118 EWSGHDHP0118 EWSGDEDRXD0118 EWSGDED0118 EWSG3TPOSDED0118

5 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. 5

6 CHANGES AND CLARIFICATIONS THAT APPLY TO TRADITIONAL, DEDUCTIBLE, HIGH DEDUCTIBLE, AND ADDED CHOICE MEDICAL PLANS Changes to the Senior Advantage plan are explained at the end of this summary. Benefit changes Gender Affirming Treatment. We have added the definition of Gender Affirming Treatment to the Definitions section of the EOC. We have also added Gender Affirming Treatment to the list of covered Services in the Benefits for Outpatient Services and Benefits for Inpatient Services sections of the EOC. Mental Health Services. The Mental Health Services section of the EOC has been modified to add assertive community treatment to the description of covered outpatient mental health services. Services require a referral and are subject to utilization management. Virtual Care Services. The Virtual Care Services section of the EOC has been modified to include coverage for scheduled telephone visits. Additionally, language has been added to reflect that all virtual care Services are subject to the deductible on High Deductible Health Plans as required for HSA-qualified plans. Benefit clarifications Benefits for Outpatient Services. We have added cochlear implants to the internally implanted devices bullet in the Benefits for Outpatient Services section of the EOC. Emergency, Post-Stabilization, and Urgent Care. The Emergency, Post-Stabilization, and Urgent Care section has been modified. Emergency Services and Post-Stabilization Care are subject to the same Copayments or Coinsurance as the same Service, were it not an Emergency or Post-Stabilization, and references to Urgent Care within this description were removed as Urgent Care has a unique cost share, listed on the Benefits Summary. High Deductible Health Plan. The High Deductible Health Plan Benefit Summary documents have been modified to ensure after deductible language is included on all benefits that are not preventive as required for HSA-qualified plans. Limited Dental Services Exclusions. We have removed the Injuries to teeth resulting from biting or chewing. exclusion from the Limited Dental Services Exclusions section. Service Area. Service Area references throughout the EOC have been modified. We have removed language indicating that covered Services must be provided in the Service Area. Service Area is a condition of eligibility. We provide covered Services using Participating Providers in Traditional, Deductible, and High Deductible Health Plans. We provide covered Services using Select Providers, PPO Providers, and in some instances Non- Participating Providers in Added Choice plans. When You Can Enroll and When Coverage Begins. The When You Can Enroll and When Coverage Begins section has been modified. The Special Enrollment language is now more generalized in response to the federal Market Stabilization Rule. The section now states that qualifying events and special enrollment rights are administered under applicable state and federal law. 6

7 Administrative changes or clarifications Receiving Care in Another Kaiser Foundation Health Plan Service Area. This section in the EOC has been modified for clarity. Medically Necessary. We have modified the definition of Medically Necessary to a more industrystandard definition and to provide more information about the process we use to determine if a service is Medically Necessary. Nondiscrimination. The Nondiscrimination section of the EOC has been modified to specify that we do not discriminate on the basis of actual or perceived gender. Provider network names. The provider network names for the Traditional Copayment Plans, Deductible Plans, and High Deductible Health Plans have been changed from Participating Medical, CHP Group, Permanente Dental Associates, and Scion Dental to the Classic + Dental Choice network. The provider network names for the Deductible Added Choice Plans have been changed from Select Provider, CHP Group, PPO, and MedImpact to the Added Choice + Dental Choice network. ADDITIONAL CHANGES AND CLARIFICATIONS THAT APPLY TO ADDED CHOICE MEDICAL PLANS ONLY Administrative changes or clarifications Employee eligibility. The employee eligibility provisions of the Added Choice EOC have been modified to clarify that employees must live or work in the Service Area to be eligible. Employers are responsible to identify any ineligible employee and to submit a request for disenrollment. Any reference to out of area in our subgroup naming scheme will be removed. Outpatient Durable Medical Equipment. The Tier 1 section under the Outpatient Durable Medical Equipment (DME) section has been modified for clarity and consistency across product lines regarding decisions to repair, adjust, or replace the DME. Out-of-Pocket Maximums. The Tier 1 and Tier 2 Out-of-Pocket Maximums section has been modified to list all benefit riders that do not apply to the Out-of-Pocket Maximum for clarity. 7

8 2018 MEDICAL PLAN CHANGES PLAN NAME KP WA GOLD 0/30 KP WA GOLD 0/30 INDIVIDUAL/FAMILY $5,000/$10,000 $5,250/$10,500 EMERGENCY $200 $300 GENERIC DRUGS $10 $15 BRAND DRUGS $20 $30 PLAN NAME KP WA SILVER 0/50 (discontinued) 2018 KP WA GOLD 0/30 INDIVIDUAL/FAMILY $6,850/$13,700 $5,250/$10,500 COINSURANCE 50% 35% PRIMARY CARE OFFICE VISIT $50 $30 SPECIALTY OFFICE VISIT $60 $40 X-RAY $60 $30 LAB $50 $30 OUTPATIENT SURGERY 50% 35% MENTAL HEALTH OUTPATIENT $50 $30 INPATIENT HOSPITAL 50% EMERGENCY 50% $300 URGENT CARE $70 $50 GENERIC DRUGS $20 $15 BRAND DRUGS $40 $30 NON-PREFERRED BRAND DRUGS DOCTOR-REFERRED ALTERNATIVE CARE 50% $60 $60 $40 AMBULANCE 50% $200 DURABLE MEDICAL EQUIPMENT 50% 35% THERAPIES $60 $40 SKILLED NURSING 50% ADULT HEARING AIDS 50% 35% PEDIATRIC HEARING AIDS 50% 35% $500 copay per day, up to $2,500 per admission $500 copayper day, up to $2,500 per admission 8

9 PLAN NAME KP WA GOLD 500/20 (2017) KP WA GOLD 500/20 (2018) INDIVIDUAL/FAMILY $5,350/$10,700 $5,850/$11,700 GENERIC DRUGS $10 $15 BRAND DRUGS $20 $30 PLAN NAME KP WA GOLD 1000/20 (2017) KP WA GOLD 1000/20 (2018) INDIVIDUAL/FAMILY $5,000/$10,000 $6,000/$12,000 PLAN NAME KP WA SILVER 1500/35 (discontinued) 2018 KP WA SILVER 2000/40 DEDUCTIBLE INDIVIDUAL/FAMILY $1,500/$3,000 $2,000/$4,000 INDIVIDUAL/FAMILY $7,150/$14,300 $7,350/$14,700 PRIMARY CARE OFFICE VISIT $35 $40 MENTAL HEALTH OUTPATIENT $35 $40 GENERIC DRUGS $20 $30 BRAND DRUGS $40 $50 PLAN NAME KP WA SILVER 3500/40 (2017) KP WA SILVER 3500/40 (2018) INDIVIDUAL/FAMILY $6,850/$13,700 $7,350/$14,700 GENERIC DRUGS $20 $30 BRAND DRUGS $40 $50 PLAN NAME KP WA BRONZE 6600/35 KP WA BRONZE 6600/40 9

10 PLAN NAME KP WA SILVER 2600/25% HSA (2017) KP WA SILVER 2700/25% HSA (2018) DEDUCTIBLE $2,600/$5,200 $2,700/$5,400 INDIVIDUAL/FAMILY $5,200/$10,400 $5,400/$10,800 PLAN NAME KP WA GOLD 600/35 3T POS (2017) KP WA GOLD 600/35 3T POS (2018) Tier INDIVIDUAL/FAMILY $2,000/ $4,000 $6,000/ $12,000 $8,000/ $16,000 $2,500/ $5,000 $6,000/ $12,000 $8,000/ $16,000 PLAN NAME KP WA SILVER 2000/40 3T POS (2017) KP WA SILVER 2500/40 3T POS (2018) Tier DEDUCTIBLE $2,000/ $4,000 $4,000/ $8,000 $6,000/ $12,000 $2,500/ $5,000 $4,500/ $9,000 $6,500/ $13,000 OUT OF POCKET INDIVIDUAL/ FAMILY $5,750/ $11,500 $7,150/ $14,300 $12,000/ $24,000 $6,500/ $13,000 $7,350/ $14,700 $12,500/ $25,000 X-RAY 30% after deductible 40% after deductible 50% after deductible $40 40% after deductible 50% after deductible LAB 30% after deductible 40% after deductible 50% after deductible $40 40% after deductible 50% after deductible GENERIC DRUGS $20 Not covered $30 $30 Not covered $30 10

11 2018 DENTAL PLAN CHANGES AND REMINDERS In compliance with Washington state benchmark requirements for pediatric dental coverage, the member cost share for preventive services is $0 on all pediatric (stand-alone and embedded) plans. CHANGES AND CLARIFICATIONS THAT APPLY TO DENTAL PLANS Benefit changes Schedule of Covered Pediatric Dental Procedures. The Schedule of Covered Pediatric Dental Procedures has been modified to comply with Oregon and Washington benchmark requirements for pediatric dental coverage. Benefit clarifications All references of plastic restorations have been updated to composite for accuracy. In the Limitations section, the timeframe for the repair or replacement of interim fixed and removable prosthetic devices due to normal wear and tear has been clarified as once every 12 months. Administrative changes or clarifications Nondiscrimination. The Nondiscrimination section of the EOC has been modified to specify that we do not discriminate on the basis of actual or perceived gender. Provider network names. The provider network names for the Dental Choice PPO Pediatric Dental Plans have been changed from Permanente Dental Associates and Scion Dental to the Dental Choice network. 11

12 DENTAL PLANS PPO pediatric plans KP WA Choice 100 Pediatric Dental Plan KP WA Choice Ortho Pediatric Dental Plan Traditional adult-only plans KP WA Adult Traditional 80 $1,000 Max KP WA Adult Traditional 100 $100 Ded/$1,500 Max KP WA Adult Traditional 80 $50 Ded/$1,000 Max KP WA Adult Traditional 100 $1,500 Max + Ortho KP WA Adult Traditional 80 $100 Ded/$1,000 Max KP WA Adult Traditional 100 $2,000 Max KP WA Adult Traditional 80 $1,000 Max + Ortho KP WA Adult Traditional 100 $50 Ded/$2,000 Max KP WA Adult Traditional 100 $1,000 Max KP WA Adult Traditional 100 $100 Ded/$2,000 Max KP WA Adult Traditional 100 $50 Ded/$1,000 Max KP WA Adult Traditional 100 $2,000 Max + Ortho KP WA Adult Traditional 100 $100 Ded/$1,000 Max KP WA Adult Traditional 100 $50 Ded/$2,500 Max KP WA Adult Traditional 100 $1,000 Max + Ortho KP WA Adult Traditional 100 $100 Ded/$2,500 Max KP WA Adult Traditional 100 $1,500 Max KP WA Adult Traditional 100 $2,500 Max + Ortho KP WA Adult Traditional 100 $50 Ded/$1,500 Max PPO adult-only plans KP WA Adult Choice 80 $50 Ded/$1,000 Max KP WA Adult Choice 80 $100 Ded/$1,000 Max KP WA Adult Choice 80 $1,000 Max + Ortho KP WA Adult Choice 100 $50 Ded/$1,000 Max KP WA Adult Choice 80 $100 Ded/$1,000 Max KP WA Adult Choice 100 $1,000 Max + Ortho KP WA Adult Choice 100 $50 Ded/$1,500 Max KP WA Adult Choice 100 $100 Ded/$1,500 Max KP WA Adult Choice 100 $1,500 Max + Ortho KP WA Adult Choice 100 $50 Ded/$2,000 Max KP WA Adult Choice 100 $100 Ded/$2,000 Max KP WA Adult Choice 100 $2,000 Max + Ortho KP WA Adult Choice 100 $50 Ded/$2,500 Max KP WA Adult Choice 100 $100 Ded/$2,500 Max KP WA Adult Choice 100 $2,500 Max + Ortho PPO family plans KP WA Adult Choice Child Ortho* *This plan does not meet the essential health benefit requirements for pediatric dental. Dental EOC form numbers: EWSGPEDDNTDEDPPO0118 EWSGADULTDNTDED0118 EWSGADULTDNT0118 EWSGADULTDNTDEDORTHPPO0118 EWSGPEDDNTDEDPPOORTH0118 EWSGADULTDNTDEDORTH0118 EWSGADULTDNTDEDPPO0118 EWSGADULTPLUSDNTDEDPPO0118 CHANGES AND CLARIFICATIONS THAT APPLY TO THE SENIOR ADVANTAGE PLAN Outpatient Durable Medical Equipment. We have added coverage for wigs limited to 1 synthetic wig per year following chemotherapy or radiation therapy to the Outpatient Durable Medical Equipment section. account.kp.org _NW-WA_12/ Kaiser Foundation Health Plan of the Northwest