Summary of Contract Changes Washington Insured Group Plans (200 or more employees)

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1 Group Name: WA Technology Industry Association Employee Benefit Trust Group Number: Effective Date: December 1, 2018 Summary of Contract Changes Washington Insured Group Plans (200 or more employees) NON-GRANDFATHERED PLANS Premera Blue Cross has made changes to non-grandfathered medical plans and to dental plans for Washington groups that are scheduled to take effect at your upcoming renewal. This summary lists the major changes and also shows which changes are mandated by federal or state law or regulation. Not all the changes listed may apply to your plan or plans. Please take note of the bold subheadings on some of the changes below that show when the change applies. Check your benefit booklet if you need more details about your current coverage. MEDICAL BOOKLETS Cover and Introduction Preferred Choice plans: The Preferred Choice plan name is now shown on the booklet cover and introduction page. Summary Of Your Costs (new) Deductible, copay and coinsurance information for each benefit will now appear in table form toward the beginning of the booklet. The table is in a new section initiative called the Summary Of Your Costs. The out-of-pocket maximum will also appear in this section. The benefit descriptions will no longer include the costshare and benefit information. The cost-share tables in the Prescription Drugs benefit and the Preventive Care benefit have been moved to the Summary Of Your Costs. How Providers Affect Your Costs The Foundation network will no longer be offered. Throughout The name of the How Does Selecting A Provider Affect My Benefits? section has been shortened to How Providers Affect Your Costs. The term "network provider" is now "in-network provider." The term "non-network provider" is now "out-of-network provider." Important Plan Information (new) Covered Services (new) Emergency Ambulance Services benefit We have clarified that covering out-of-network providers at the in-network level means that the in-network member cost-shares apply. The allowed amount is still the lower allowed amount for out-of-network providers. We have made some organizational and terminology changes to make your booklet easier for members to understand: initiative Initiative Dimensions 200+Insured Group Summary of Changes ( ) Non-Grandfathered Plans Page 1 An Independent Licensee of the Blue Cross Blue Shield Association

2 Diagnostic Services benefit We added a new section called Important Plan Information. This new section Diagnostic Mammography benefit explains how the plan's deductible, coinsurance, and copays work. Pregnancy And Childbirth benefit The new section includes a subsection called Allowed Amount (formerly Outpatient Surgery Center benefit Rehabilitation Therapy benefit "allowable charge") that we moved from the Definitions section). The Important Plan Information section replaces the What Types Of Expenses Am I Responsible For Paying? section. The What Are My Benefits? section is removed: Allowed Amount section in Important Plan Information Dialysis benefit The specific cost-share amounts that apply to your plan now appear in the Summary Of Your Costs. Some of the descriptive information about your cost-shares now appears in Important Plan Information. The Medical Services part of the What Are My Benefits? section is now a separate section called Covered Services. The Covered Services section also includes some changes: For plans that include Orthognathic Surgery, Vision or Hearing benefits, those benefits have been integrated into the alphabetical list of covered services. The Ambulatory Surgical Center benefit has been renamed the Outpatient Surgery Center benefit. It now appears above the Surgical Services benefit in the list of benefits in the Summary Of Your Costs and Covered Services section. The Ambulance Services benefit has been renamed Emergency Ambulance Services. It still appears after the Acupuncture benefit. The Diagnostic Mammography benefit has been made a part of the Diagnostic Services benefit. The Obstetrical Care benefit has been renamed Pregnancy And Childbirth and moved down in the alphabetical list of covered services. The Rehabilitation Therapy and Chronic Pain Care benefit has been renamed Rehabilitation Therapy. We have also removed some confusing language about chronic pain care. We have removed the subsection about dialysis in the Allowed Amount subsection of Important Plan Information. All Plans But Your Future Plans: We have also removed references to the amount paid for dialysis from the Dialysis benefit. Further alignment with existing discussion of allowed amounts for non-contracted providers elsewhere in the subsection Dimensions 200+Insured Group Summary of Changes ( ) Non-Grandfathered Plans Page 2

3 Chemotherapy And Radiation Therapy benefit (new) Community Wellness benefit Diagnostic Services benefit Home-Based Chronic Care benefit (new) Home And Hospice Care benefit Medical Equipment And Supplies benefit (Medical Vision Hardware) Mental Health Care benefit Definition of "Provider" Coverage for chemotherapy and radiation therapy will now be addressed in their own benefit. The plan's coverage is not changing, but the procedures were never specifically mentioned before. The Community Wellness benefit will no longer be offered. Many of the services covered under this benefit do not qualify as medical care for income tax purposes. Services that were covered under the Community Wellness benefit and that qualify as preventive are covered under the Preventive Care benefit. We have explained that the benefit covers services recommended for medical conditions or symptoms. We have added a benefit for home-based chronic care services to your plan. This benefit is for members who have at least 4 chronic conditions that the program has determined would benefit from extra care coordination. The member does not pay cost-shares for the program team visits and services. We have bulleted and rewritten the description of the hospice and palliative services covered under the Hospice Care section to make the distinction between these services easier to understand. We have added some conditions to the list of conditions for which medical vision hardware is covered. They are progressive high (degenerative) myopia, irregular astigmatism, and aniridia. We have clarified that Washington State now licenses applied behavioral health analysts. This means that board-certified analysts who are not licensed by Washington state will no longer be covered. Prescription Drugs benefit Prescription vitamins are now listed alphabetically in the What's Covered list instead of in the opening paragraph. Human growth hormone has been added to the What's Covered list. It is covered only for medical conditions that affect growth. This coverage is not new. It has been shown as an exception in the What's Not Covered section of the booklet. The exceptions to the supply limits shown in the Getting Prescriptions Filled table are now shown in question 6 in Questions And Answers About Your Pharmacy Benefits. Clarity, and to be consistent with metallic small group plans. Federal regulatory guidance Washington State Office Of Insurance Commissioner Washington state licensing law Dimensions 200+Insured Group Summary of Changes ( ) Non-Grandfathered Plans Page 3

4 We have added a provision about tablet splitting. Premera has identified pills that can be cut with a tablet splitter without jeopardizing the quality or effectiveness of the resulting doses. The tablet-splitting program is optional for members who take those drugs. Premera gives the member the tablet splitter. Members who opt to take part in this program will buy the double-strength dose of a drug and then cut the tablet in half to get single-strength doses. The double-strength doses are usually less expensive for the member. The section about prior authorization for prescription drugs has been moved to the Prescription Drugs benefit. "Prior Authorization" has been changed to "pre-approval." The Your Right To Safe And Effective Pharmacy Services paragraph has been renamed Your Prescription Drug Rights and rewritten. Questions 1 and 2 in Questions And Answers About Your Prescription Drug Benefits now provided more detail about how our drug lists are created and maintained. If your plan includes mandatory generic substitution that allows a member and provider to ask for exceptions, the exception language has been expanded. If your plan uses the Essentials drug list, questions 1 and 2 have been revised to provide more detail about how to request an exception for coverage of a drug that is not on the drug list. Plans will start covering up to a 12-month supply of contraceptive drugs when requested by the member and provider. When the member does not use an in-network retail pharmacy, any out-of-network cost-shares, such as copays, will apply for each 30-day supply. This exception is added to the list of exceptions in question 6 of Questions And Answers About Your Pharmacy Benefits. The Drug Discount Programs section has been moved to the end of the benefit. We have changed the term drug benefit manager, which refers to Express Scripts, to pharmacy benefit manager. initiative Washington state prescription drug disclosure regulation Washington state prescription drug disclosure regulation Washington state prescription drug disclosure regulation Affordable Care Act regulations Washington state law Initiative Dimensions 200+Insured Group Summary of Changes ( ) Non-Grandfathered Plans Page 4

5 Preventive Care benefit Nutritional Therapy benefit Professional Visits And Services benefit The Preventive Care benefit has been reorganized, expanded and rewritten in simpler terms in order to give members easier access to all the plan's preventive benefits. The Preventive Care benefit now addresses coverage for: Psychological and Neuropsychological Testing benefit Sleep Studies benefit Surgical Services benefit Screening mammograms. References to screening mammograms have been moved to the Preventive Care benefit. The reference to nicotine dependency consultations and treatment has also been removed from the Professional Visits And Services benefit. The separate Nutritional Therapy benefit is removed. Its covered services are now listed under Nutritional Counseling and Therapy in the Preventive Care benefit. Other Preventive Care benefit changes: We have also clarified that nutritional counseling and therapy includes intensive behavioral interventions with multiple activities to help members set and achieve weight loss goals. We have clarified that the preventive colon cancer screening coverage includes barium enemas. For Your Choice and Your Focus plans, the benefit is no longer subject to the professional visit copay if the plan does not include an in-network deductible and in-network coinsurance but does include the professional visit copay. In this case, no cost-shares will apply. Medically necessary sleep studies will now be addressed in a separate benefit, in order to encourage members to have sleep studies at home. All plans but Your Future and Preferred Choice QHDHP: The benefit waives the cost-shares for sleep studies done in the member's home. Your Future and Preferred Choice QHDHP plans: The benefit waives coinsurance for sleep studies done in the member's home. In all plans, home sleep studies are covered only for members 19 or older. We now address coverage for repairs of defects that result from injuries and corrections of function disorders in the Surgical Services benefit. These were formerly exceptions in the exclusion for cosmetic surgery in the What's Not Covered? section. We have also added the clarification that removal of excess skin or fat related to weight-loss surgery or drugs is not covered. Federal Affordable Care Act preventive guidance Federal Affordable Care Act preventive requirements Dimensions 200+Insured Group Summary of Changes ( ) Non-Grandfathered Plans Page 5

6 Transgender benefit We have moved the description of coverage for surgery and medical services to Washington Insurance treat gender identity disorder and gender dysphoria to a Transgender benefit. Commissioner's Office The Mental Health Care will continue to cover mental health services for these conditions. The Prescription Drugs benefit will continue to cover drugs related to transgender services. The coverage and cost-shares continue to be the same as Federal Affordable Care Act for other covered medical conditions. We have clarified that the plan does not cover: Transgender surgery for members under age 18 Cosmetic procedures that are not medically necessary, including cosmetic revisions to prior surgeries These are not coverage changes; they have not been specified in the booklet before. Transplants benefit Some changes have been made to the Travel and Lodging part of the Transplants benefit. The changes will help groups and members comply with federal income tax rules on travel and lodging related to health care. The changes are: The plan will have per-day dollar limits that match the Internal Revenue Service (IRS) maximum amounts allowed per day for travel and lodging. The plan will comply with changes to these limits that are made by the IRS. Lodging other than in the home of a family member or friend is covered. Expenses for pets or animals, other than service animals, are not covered. We have added an exclusion for organ, bone marrow and stem cell transplants not specifically stated under the Transplants benefit. This exclusion was formerly in the What's Not Covered? section. BlueCard Program And Other Inter-Plan The BlueCard Worldwide program has changed its name to "Blue Cross Blue Arrangements Shield Global Core." Pre-Approval "Prior authorization" has been changed to "pre-approval." The section has also been rewritten for clarity. We have also added that we will allow time for the provider to get us information needed to complete the pre-approval. What's Not Covered? The following exclusions have been removed because they duplicate language in the benefits that provide coverage: Chemical Dependency Coverage Exceptions. Medical Equipment And Supplies. Blue Cross Blue Shield Association requirement initiative Washington state prior authorization regulation Dimensions 200+Insured Group Summary of Changes ( ) Non-Grandfathered Plans Page 6

7 On-Line or Telephone Consultations And Telehealth Services. Rehabilitation Services. Skilled Nursing Facility Coverage Exceptions. Transplant Coverage Exceptions. The exceptions in the Cosmetic Services exclusion have been moved as needed to the benefits providing coverage. The purpose is to make it easier for the readers to find their benefits. In the Private Duty Nursing exclusion, we have defined what private duty nursing is. What the plan excludes is nursing that is arranged by a separate contract between the member or the member's family and the nurse. Leaves of Absence We have clarified that the FMLA does not require the plan to cover FMLA Federal Family and leave to care for a domestic partner. Medical Leave Act The Other Leaves of Absence paragraph now states that the requirements and lengths of other leaves required by law may vary. The member should contact the group for details. Complaints And Appeals The Complaints And Appeals section has been simplified to make it more understandable and easier to use. If your plan uses the Essentials drug list, we have clarified that members can appeal decisions not to cover a drug that is not on the drug list. Other Information About This Plan Definitions, "Service Area" We have added a new provision called Health Care Providers - Independent Contractors. It clarifies that the providers that belong to our provider networks are not Premera's employees or agents. The providers provide services to members as independent contractors. We have clarified that the service area is the area in which Premera directly operates provider networks. The service area is not intended to reflect the area in which the group does business. Other state and federal leave laws Premera Customer focus initiative Federal Affordable Care Act requirement Dimensions 200+Insured Group Summary of Changes ( ) Non-Grandfathered Plans Page 7

8 EMPLOYER AGREEMENT Agreement Sections Affected Description of Change Reason for Change Contract We have clarified that if there is a conflict between the standard provisions, benefit booklet, or other documents, the benefit booklet (as currently amended) will govern. BlueCard And Other Inter-Plan The BlueCard Worldwide program has changed its name to "Blue Cross Blue Blue Cross Blue Shield Arrangements Shield Global Core." Association requirement Retroactive Changes To Enrollment Retroactive enrollments for high deductible health plans cannot be made effective before the first day of the current calendar year. FUNDING ARRANGEMENT Agreement Sections Affected Description of Change Reason for Change III.B. Late Payments For fully insured, non-refunding funding arrangements: We have clarified in the last sentence of the Late Payments paragraph that acceptance of a partial payment will not waive Premera's right to demand timely payment or terminate the contract for non-payment if a subsequent payment is late. IV.A. Accounting We have clarified that, although Premera absorbs most gains and losses, Premera will provide refunds as required by law. Federal Affordable Care Act requirements Dimensions 200+Insured Group Summary of Changes ( ) Non-Grandfathered Plans Page 8

9 STATE-MANDATED BENEFIT OFFERINGS FOR INSURED GROUPS At each renewal, all health carriers must present the state-mandated chiropractic coverage offering to insured groups that do not include them in their plans currently. If your plan's benefits don't match the descriptions shown in column 2, you don't have to do anything. But, if your current coverage does match the descriptions shown in column 2 below, then please tell us if you want to upgrade your current benefit. If you want to upgrade, please contact your Account Manager. If you do not want to upgrade, please check the "No" box and add your initials. If you would like more information about this offering, please contact your Premera Blue Cross representative. Benefit Chiropractic Care If Your Current Coverage Is This: Combined with osteopathic manipulations up to a set number of visits per year PLEASE NOTE: Rates will be provided upon request. You Can Upgrade Coverage To This: No Initials Covered on the same basis as other physician care (no visit limit) OTHER PLAN CHANGES Please tell us about eligibility changes you want to make to your plan at this year's renewal. If you have an IRS Section 125 cafeteria plan, please make sure your book explains any midyear family status changes that trigger enrollment or plan changes. Please note any change in the Group's legal name or address, or if you want to add or drop affiliates or subsidiaries from your plan. Dimensions 200+Insured Group Summary of Changes ( ) Non-Grandfathered Plans Page 9