October Dear Valued Employee,

Transcription

1 October 2015 Dear Valued Employee, This booklet includes Summaries of Material Modification (SMMs) that provide important updates about your benefits as well as legally required annual notices. Each SMM indicates the employee groups to which the changes apply. Summaries of Material Modification PPO and POS plans closure Improvements to your dental plan coverage Increase in the maximum HCSA annual contribution Statute of Limitations for claims and actions under the Kaiser Permanente Retirement Plan Statute of limitations for claims and actions under the defined contribution plans listed above Additional information about your defined contribution plan Updates to the Legal and Administrative section of your Summary Plan Description Additional important information as required by law Grandfathered Health Plans, if applicable Patient Protection Disclosure, if applicable Notice of Privacy Practices Women s Health and Cancer Rights Act Enrollment Notice Continuation of Benefits Under COBRA Premium Assistance Notice under Medicaid and the Children s Health Insurance Program (CHIP) Please read this information carefully and keep the booklet with your Summary Plan Description (SPD) for future reference. For more information about your benefits, please sign on to My HR at kp.org/myhr. You may also access an electronic version of your most current SPD at any time on My HR. Sincerely, Kaiser Permanente Human Resources, Shared Services Organization In case of any omission or conflict between what is written in the enclosed Summaries of Material Modification (SMMs) and what is written in the plan documents, contracts, or agreements, the plan documents, contracts, or agreements always govern. Kaiser Permanente reserves the right to modify, amend, change, replace, or terminate the benefit plans described in these SMMs at any time. Benefits may be modified or eliminated through the negotiation process as well, if applicable. You will be advised of any significant changes in your benefit program. Fall Compendium All October 2015 v1

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3 SUMMARY OF MATERIAL MODIFICATION October 2015 To: Represented employees eligible for the PPO and POS plans (see the list of employee groups on page 2) Re: PPO and POS plans closure This document updates the Health Care section of your Summary Plan Description (SPD). Please read this document carefully and keep it with your SPD for future reference. Overview In order to provide a more consistent approach to the medical plans offered to employees, Kaiser Permanente will phase out the Preferred Provider Organization (PPO) and Point-of-Service (POS) plans. As a Kaiser Permanente employee, you will continue to have access to comprehensive medical coverage and high-quality care through Kaiser Foundation Health Plan (KFHP/HMO) or Kaiser Employee Medical Health Plan/Exclusive Provider Organization (KEMHP/EPO) medical plans. Effective January 1, 2017, the following medical plans will close: Preferred Provider Organization (PPO) Plan Added Choice Point-of-Service (POS) Plan in Colorado and Hawaii Added Choice Plan in the Northwest Kaiser Permanente Point-of-Service (POS) Plan in Georgia If you are currently enrolled in one of these plans, you may elect to stay in the plan for 2016, but you will be required to choose a different health plan option for The following information is added to your Summary Plan Description: PPO and POS Plan Closure Beginning January 1, 2016, the following plans will no longer accept new enrollees. If you are not currently enrolled in one of these plans, you may not elect the plans during open enrollment for 2016 coverage. Preferred Provider Option (PPO) Plan Added Choice Point-of-Service (POS) Plan in Colorado and Hawaii Added Choice Plan in the Northwest Kaiser Permanente Point-of-Service (POS) Plan in Georgia All employees who are currently enrolled in one of these plans can choose to stay in that plan until the end of However, these plans will be closed effective January 1, Therefore, you will have to elect a different option during the 2016 open enrollment for the 2017 plan year. Please refer to your Summary Plan Description (SPD) for more information about your coverage options. For More Information For more information about your benefits and the health plan options available to you, refer to your SPD available on My HR at kp.org/myhr. SMM Union PPO and POS Plans Closure October 2015 Page 1 of 2

4 Employee groups to which this Summary of Material Modification applies: Colorado - International Union of Operating Engineers, Local 1 - Service Employees International Union, Local United Food and Commercial Workers, Local 7, Mental Health Workers - United Food and Commercial Workers, Local 7, Professional and Health Care Georgia - United Food and Commercial Workers Union, Local 1996 (Professional Unit and Technical/Clerical Units) Hawaii - Hawaii Nurses Association, OPEIU Local 50 - Hawaii Nurses Association, OPEIU Local 50 (Oahu Home Health Care) Northern California - Engineers & Scientists of California, Local 20, IFPTE, AFL-CIO & CLC, Genetic Counselors and Genetic Counselor Coordinators - United Healthcare Workers West, Health Educators - United Healthcare Workers West, Registered Dietitians - United Healthcare Workers West, Medical Social Workers Northwest - International Longshore and Warehouse Union, Local 28 - International Union of Operating Engineers, Local Oregon Federation of Nurses and Health Professionals, Local 5017 Professionals and Lab Professionals SMM Union PPO and POS Plans Closure October 2015 Page 2 of 2

5 SUMMARY OF MATERIAL MODIFICATION October 2015 To: Re: Benefited Employees with Kaiser Permanente-sponsored dental plans Improvements to your dental plan coverage This Summary of Material Modification updates the Health Care section of your Summary Plan Description (SPD). Please read this document carefully and keep it with your SPD for future reference. OVERVIEW Effective January 1, 2016, Kaiser Permanente is implementing dental plan improvements. The changes apply to the dental plans and employee groups identified below. These improvements update the current Summary Plan Description for your respective employee group. All other dental plans and plan provisions remain the same. Please note: where No change is indicated, those groups already have the $1,500 annual maximum. Region Employee Group Dental Plan Annual Maximum Increased to Orthodontics (Covered at 50%. Applies to children up to age 26 only) Lifetime Maximum Increased to Colorado All employee groups (excluding Resident Physicians) Delta Dental Comprehensive plan $1,500 $1,500 Georgia Hawaii Mid- Atlantic States National Business Units All employee groups Hawaii Nurses Association, OPEIU L50 Hawaii Nurses Association HHH (Oahu Home Health) Non-Union Non-Exempt Employees Salaried Employees and Resident Physicians OPEIU L2, Washington, D.C. and Baltimore UFCW L400 and L27 Non-represented Salaried Exempt and Non-Exempt OPEIU L2 Optometrists and Pharmacists Desktop Support Workers Executives IT Program Offices Delta Dental High and Mid plans Hawaii Dental Services (HDS) $1,500 $1,500 $1,500 $1,500 Delta Dental $1,500 $1,500 Delta Dental High and Mid plans Delta Dental Basic and Comprehensive plans No change No change $1,500 $1,500 SMM Multi Dental Plan Changes October 2015 Page 1 of 4

6 Region Employee Group Dental Plan Annual Maximum Increased to Orthodontics (Covered at 50%. Applies to children up to age 26 only) Lifetime Maximum Increased to Northern California ESC L20 Clinical Laboratory Scientists Mental Health Trainees OPEIU, L29 ESC L20 Optometrists Residents UHW-West UHW-West Medical Social Workers ESC L20 Genetic Counselors Nurse Anesthetists Physician Assistants Physical/Occupational/Speech Therapists Psych/PSW KFHP/KFH Salaried and Non- Union Non-Exempt TPMG Salaried and Non- Exempt Employees UHW-West Dieticians UHW-West Health Educators Salaried Exempt and Non- Exempt Employees IUOE, L701 ILWU, L28 OFNHP L5017 Professionals and Laboratory Professionals Delta Dental $1,500 $1,500 Delta Dental Basic and Comprehensive plans KFHP Dental Plan A+ KFHP Dental Plan A $1,500 $1,500 N/A N/A Northwest UFCW L555 Non-Registered Drug UFCW L555 Imaging Services Kaiser Permanente Dental Plan No change New Benefit $1,500 OFNHP L5017 Registered Nurses OFNHP L5017 Technical Employees and Dental Hygienists SEIU L49 Kaiser Permanente Dental Plan N/A Oregon Nurses Association SMM Multi Dental Plan Changes October 2015 Page 2 of 4

7 Region Employee Group Dental Plan Annual Maximum Increased to Orthodontics (Covered at 50%. Applies to children up to age 26 only) Lifetime Maximum Increased to Southern California KPASCO KPNAA OPEIU L30, CSC OPEIU L30 Resident Physicians SEIU L121 Teamsters L166 UFCW Bakersfield L1036 UFCW L770 Kern County Administrative UFCW Clinical Lab Scientists United Steel Workers of America L7600 UHW Moreno Valley UHW West UNAC/UHCP Genetic Counselors Midwives Lifestyle Ed & Research Nurses Non-Union Hourly Non-union Moreno Valley Physician Assistants KFHP/KFH Salaried and Non-Union, Non-Exempt KPMWON SCNSC SCPMG Salaried and Non-Union, Non-Exempt UNAC Pharmacists UTSC Delta PPO $1,500 $1,500 Delta Dental Basic and Comprehensive Plans $1,500 $1,500 SMM Multi Dental Plan Changes October 2015 Page 3 of 4

8 Change from Two to Three-Tier Dental Plan Options For the following employee groups in the Northwest Region: Guild for Professional Pharmacists OFNHP Registered Nurses OFNHP Technical Employees OFNHP Dental Hygienists Oregon Nurses Association Service Employees International Union Local 49 UFCW Non-Registered Drug Services UFCW Imaging Services Effective January 1, 2016, Kaiser Permanente Dental plans for the employee groups listed above will provide three tiers of coverage instead of two. Current Tier Options: Participant only; Participant +1 or more dependents New Tier Options: Participant only; Participant +1 dependent; Participant +2 or more dependents If you currently cover dependents, you will automatically be placed in the appropriate tier based on the number of dependents covered. This change does not affect your cost share for dental benefits; however, if you cover a domestic partner or civil union partner (and his or her dependents) under your benefits, the fair market value of that coverage may increase. SMM Multi Dental Plan Changes October 2015 Page 4 of 4

9 SUMMARY OF MATERIAL MODIFICATION October 2015 To: All executives and employees eligible for the Health Care Spending Account (HCSA) Re: Increase in the maximum HCSA annual contribution This document updates the Flexible Benefits and Health Care sections of your Summary Plan Description (SPD). Please read this document carefully and keep it with your SPD for future reference. Overview Effective January 1, 2016, the maximum Health Care Spending Account (HCSA) annual contribution will increase from $2,500 to $2,550. Updates to Your SPD Flexible Benefits Section The language below replaces the Health Care Spending Account row of the Flexible Benefits chart in the Overview of Benefits by Design section. The revised information is underlined. Flexible Benefits Health Care Spending Account Choices Up to $2,550 annually Health Care Section The language below replaces the first paragraph of Your Contributions in the Health Care Spending Account section. The revised information is underlined. Your Contributions The maximum HCSA annual contribution is $2,550. Your contributions are deducted from your pay in 24 equal amounts, which are reflected on the first two pay statements of each month throughout the year. The minimum pay period contribution is $10. If you become eligible for HCSA in mid-year, the annual maximum is still available to you. In other words, you may elect a higher per-pay-period contribution in order to contribute the maximum amount over the remaining pay periods for that calendar year. For More Information For more information about your benefits, you may refer to your SPD available on My HR at kp.org/myhr. SMM ALL HCSA Contribution Increase October 2015

10 SUMMARY OF MATERIAL MODIFICATION May 2015 To: Re: Participants in the Kaiser Permanente Retirement Plan Statute of Limitations for Claims and Actions under the Kaiser Permanente Retirement Plan This document updates the Disputes, Claims, and Appeals section of your Summary Plan Description (SPD). Please read this document carefully and keep it with your SPD for future reference. Overview The statute of limitations on filing claims and legal actions provisions under the Kaiser Permanente Retirement Plan (KPRP) have been amended effective March 24, KPRP is the base plan for all Kaiser Foundation Health Plan, Inc., and Kaiser Foundation Hospitals defined benefit pension plans. Update to Your SPD Effective March 24, 2015, the language below is hereby incorporated into Defined Benefit Plan Claims under the Disputes, Claims, and Appeals section of your SPD, to reflect amendments to the statute of limitations on filing claims and legal actions provisions under KPRP. Statute of Limitations Any claim regarding the failure to timely pay your previously determined benefit as of the benefit commencement date, your form of payment, and/or any adjustment to your benefits either before or after the normal retirement date must be filed within one year of your benefit commencement date. In addition, any claim under KPRP must be filed within two years following the latest of (i) December 31, 2017, (ii) your termination of employment, and (iii) the date you were provided with written notice of your vested status and/or the components of your benefit payment. Moreover, any legal action must be brought in the U.S. District Court of the Northern District of California. For More Information For more information about your benefits, you may refer to your SPD available on My HR at kp.org/myhr. SMM All KPRP SOL May 2015 Page 1 of 1

11 SUMMARY OF MATERIAL MODIFICATION May 2015 To: Re: Employees eligible for the following Defined Contribution plans: Kaiser Permanente 401(k) Retirement Plan (KP401K) Kaiser Permanente Tax-Sheltered Annuity Plan (TSA) Kaiser Permanente Supplemental Savings and Retirement Plan (Plan B) Kaiser Permanente Supplemental Savings and Retirement Plan for Union Groups (KPSSRPUG) Kaiser Permanente Northwest Supplemental Retirement Plan (KPNSRP) Health Care Management Solutions, LLC 401(k) Plan (HCMS 401K) Statute of Limitations for Claims and Actions under the Defined Contribution Plans listed above This document updates the Disputes, Claims, and Appeals section of your Summary Plan Description (SPD). Please read this document carefully and keep it with your SPD for future reference. Overview The statute of limitations on filing claims and legal actions under the defined contribution plans listed above (collectively, the Plans), has been amended effective March 24, Update to Your SPD Effective March 24, 2015, the language below is hereby incorporated into Defined Contribution Plan Claims under the Disputes, Claims, and Appeals section of your SPD, to reflect amendments to the statute of limitations on filing claims and legal action provisions under the Plans. Statute of Limitations Any claim regarding your form of payment or the failure to timely pay, in whole or in part, your account as of your benefit starting date must be filed within one year of your benefit starting date. In addition, any claim for benefits under the defined contribution plan(s) must be filed by the later of (i) December 2016, or (ii) two years following the date you knew or should have known that a contribution should have been made to your account. No legal action can be brought more than one year after the later of (i) the date of the initial denial of your claim, or (ii) if a timely request for appeal of the denial had been made, the date of the denial of your appeal. Any legal action must be brought in the U.S. District Court of the Northern District of California. For More Information For more information about your benefits, you may refer to your SPD available on My HR at kp.org/myhr. SMM All DC SOL May 2015 Page 1 of 1

12 SUMMARY OF MATERIAL MODIFICATION October 2015 To: Re: Employees eligible for the following defined contribution plans: Kaiser Permanente 401(k) Retirement Plan (KP401K) Kaiser Permanente Northwest Supplemental Retirement Plan (KPNSRP) Kaiser Permanente Supplemental Retirement Income Plan (SRIP) Kaiser Permanente Supplemental Retirement Income Plan for TPMG (SRIP-TPMG) Kaiser Permanente Supplemental Savings and Retirement Plan (Plan B) Kaiser Permanente Supplemental Savings and Retirement Plan (Plan B SCPMG) Kaiser Permanente Supplemental Savings and Retirement Plan for Union Groups (KPSSRPUG) Kaiser Permanente Tax Sheltered Annuity Plan (TSA) Kaiser Permanente Tax Sheltered Annuity Plan II (TSA II) Southern California Permanente Medical Group Tax Savings Retirement Plan (TSR) The Permanente 401(k) Plan The Permanente Money Purchase Pension Plan TPMG Salary Deferral Retirement Plan Additional information about your defined contribution plan This document updates the Retirement Programs section of your Summary Plan Description (SPD). Please read this document carefully and keep it with your SPD for future reference. Overview The following is additional information about your defined contribution plan: Vanguard Brokerage Option: You are eligible to invest up to 50 percent of your fully vested account in this option. Vanguard Managed Account Program (VMAP) and Personal Online Advisor: These tools and services are available to help you make investment decisions. Vanguard app: This app gives you the ability to access information and make changes to your account on your mobile phone. Updates to Your SPD The language below replaces the Choosing Your Investment Funds paragraphs in the Retirement Programs section of your SPD. The updated language includes information about the brokerage option and other services that your plan offers. Choosing Your Investments You can invest your account among a diversified lineup of investment options. Investment funds are reviewed by the Investment Committee on an ongoing basis, and the actual funds offered through the plan are subject to change. In addition, you are eligible to invest your account through the Vanguard Brokerage Option. You can invest up to 50 SMM Multi DC Plan Updates October 2015 Page 1 of 2

13 percent of your fully vested account in the Vanguard Brokerage Option. A complete list of funds and more information about the Vanguard Brokerage Option are available online at or by calling Vanguard s VOICE network at Upon becoming a participant, any contributions to your account will be invested in the Qualified Default Investment Alternative (QDIA) until you select an investment option. The QDIA is the KP Retirement Path Fund with the target date closest to the year in which you will reach age 65. The KP Retirement Path Funds are invested in several broadly diversified funds and are subject to the risks of their underlying funds. The year in the fund name refers to the approximate year (the target date) when an investor in the fund would attain age 65. The fund will gradually shift its emphasis from more aggressive investments to more conservative ones based on its target date. Contact Vanguard to learn about your QDIA fund. The plan is intended to satisfy the requirements of Section 404(c) of the Employee Retirement Income Security Act (ERISA) and Department of Labor Regulation Section c-1. In general, this means that you are solely responsible for any investment losses caused by your investment decisions. Kaiser Permanente, its directors, officers, employees, subsidiaries, plan fiduciaries, and the trustee do not guarantee or insure the performance of any of the investment funds offered by the plan, and will not be liable for those losses. Since you alone will be responsible for the losses or gains that result from your investment decisions, it is very important that you carefully consider the investment options available to you. You should note that in the event that a proxy voting decision is required regarding shares of the investment funds, the investment fund shares will be voted on by the fiduciary for the plan in accordance with the investment guidelines for the plan. The plan administrator is the plan fiduciary responsible for providing participants and beneficiaries with the information necessary for making informed decisions under the plan. To request additional information from the plan administrator, please see the contact information provided in this Summary Plan Description. In addition, the plan provides a variety of tools and services available to help you make your investment decisions, like the Vanguard Managed Account Program (VMAP) and Personal Online Advisor. More information is available online at or by calling Vanguard s VOICE network at Changing Your Investments You can change the investment of your account online at by calling Vanguard s VOICE network, or on your mobile device using the Vanguard app. You can redirect all future contributions to new investment option (a contribution allocation change) as well as reinvest your balance including your past contributions among options (an exchange). Receiving Information About Your Investments You may obtain information and make changes to your account online at The Vanguard website provides you with an easy way to monitor the activity in your plan accounts as well as initiate transactions. You may obtain information and make changes to your account on your mobile device. Go to vanguard.com/bemobile to download the Vanguard app so you can access your account on the go. You may also access information by calling the Vanguard VOICE network, an automated toll-free telephone service that enables you to request account information and execute transactions via a touch-tone telephone. With the touch of a few buttons, you can obtain your account balance, confirm your investment allocations for future contributions, or request a transaction. Updated information about account transactions is available at approximately 8 a.m. Eastern time on the day after the transaction is processed. For More Information For more information about your benefits, you may refer to your SPD available on My HR at kp.org/myhr. SMM Multi DC Plan Updates October 2015 Page 2 of 2

14 SUMMARY OF MATERIAL MODIFICATION October 2015 To: Re: All active employees of Kaiser Foundation Health Plan, Inc. (KFHP), Kaiser Foundation Hospitals (KFH), and the Southern California Permanente Medical Group (SCPMG) Updates to the Legal and Administrative Section of your Summary Plan Description This document updates the Legal and Administrative section of your Summary Plan Description (SPD). Please read this document carefully and keep it with your SPD for future reference. Overview The following changes have been made to the Welfare and Retirement Plans chart in the Legal and Administrative section of your Summary Plan Description (SPD): Employees of Kaiser Foundation Health Plan, Inc. (KFHP) or Kaiser Foundation Hospitals (KFH): Your health and welfare plans are now grouped under HEALTH AND WELFARE PROGRAMS as follows: Plan Name: Kaiser Foundation Health Plan, Inc. Health and Welfare Plan Plan Sponsor EIN No.: I.D. No.: 560 Employees of the Southern California Permanente Medical Group, Inc. (SCPMG): Your health and welfare plans are now grouped under HEALTH AND WELFARE PROGRAMS as follows: Plan Name: The Southern California Permanente Medical Group Health and Welfare Plan Plan Sponsor EIN No.: I.D. No.: 560 For More Information For more information about your benefits, you may refer to your SPD available on My HR at kp.org/myhr. SMM KFHP/KFH and SCPMG Legal and Administrative Updates October 2015

15 ADDITIONAL IMPORTANT INFORMATION To comply with the requirements of the Employee Retirement Income Security Act of 1974 (ERISA) and the Affordable Care Act, your employer annually sends the following notices to all company employees. These notices do not reflect a change in any of your employee benefits; you do not need to take any action as a result of receiving these notices. Grandfathered Health Plans Patient Protection Disclosure Notice of Privacy Practices Women s Health and Cancer Rights Act Enrollment Notice Continuation of Benefits Under COBRA Premium Assistance Under Medicaid and the Children s Health Insurance Program (CHIP) SMM Multi Legal Notices 10/2015 Page 1

16 Grandfathered Health Plans This notice does NOT apply to the following employee groups: Northern California Region - Guild for Professional Pharmacists - National Union of Healthcare Workers - Optical Workers Unit Northwest Region - Guild for Professional Pharmacists - Northwest International Union of Operating Engineers, Local 701 Southern California Region - United Nurses Associations of California/Union of Healthcare Professionals - Pharmacists - National Union of Healthcare Workers - Health Care Professionals Chapter - National Union of Healthcare Workers - Psych-Social Chapter - Southern California International Union of Operating Engineers, Local 501 All non-represented employee groups eligible for the Preferred Provider Plus plan Kaiser Permanente believes that your employer-provided medical plans are grandfathered health plans under the Patient Protection and Affordable Care Act (PPACA). As permitted by the PPACA, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your health plan may not include certain consumer protections of the PPACA that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the PPACA, such as the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator listed in the Legal and Administrative Information section of your Summary Plan Description. You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at or This website has a table summarizing which protections do and do not apply to grandfathered health plans. SMM Multi Legal Notices 10/2015 Page 2

17 Patient Protection Disclosure This notice applies only to the following employee groups: Northern California Region - Guild for Professional Pharmacists - National Union of Healthcare Workers - Optical Workers Unit Northwest Region - Guild for Professional Pharmacists - Northwest International Union of Operating Engineers, Local 701 Southern California Region - United Nurses Associations of California/Union of Healthcare Professionals - Pharmacists - National Union of Healthcare Workers - Health Care Professionals Chapter - National Union of Healthcare Workers - Psych-Social Chapter - Southern California International Union of Operating Engineers, Local 501 Kaiser Foundation Health Plan (KFHP) generally allows the designation of a primary care provider. You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. Until you make this designation, KFHP designates one for you. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact Member Services at For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from KFHP or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact Member Services at Notice of Privacy Practices The Notice of Privacy Practices describes how medical information about you may be used and disclosed, and how you can get access to it. Under the federal Health Insurance Portability and Accountability Act (HIPAA), you must be notified whenever there is a change to the document. To get a copy of the latest Notice of Privacy Practices, members of Kaiser Foundation Health Plan should visit participants in the Kaiser Employee Medical Health Plan should visit unsecure/kpme/benefits/notice_privacy_prac.pdf. SMM Multi Legal Notices 10/2015 Page 3

18 Women s Health and Cancer Rights Act Enrollment Notice If you have had or expect to have a mastectomy, you may be entitled to certain rights under the Women s Health and Cancer Rights Act of For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient for the following: all stages of reconstruction of the breast on which the mastectomy was performed; surgery and reconstruction of the other breast to produce a symmetrical appearance; prostheses; and treatment of physical complications of the mastectomy, including lymphedema. These benefits are covered under the Kaiser Foundation Health Plan (KFHP), the Kaiser Employee Medical Health Plan (KEMHP) and the Point-of-Service plans, and certain medical plans under the Kaiser Permanente Self-Funded Benefit Plan that are administered by Harrington Health, and are subject to the same provisions applicable to benefits for special services related to surgery. For more information, or if you believe that you have not been provided with any of these benefits, please contact: The Member Services or Customer Services number found on the back of your membership ID card if you are enrolled in Kaiser Foundation Health Plan or Kaiser Employee Medical Health Plan medical coverage. Harrington Health at if you are enrolled in the Preferred Provider Organization plan, the Alternate Medical plan, or the Comprehensive Medical plan. Continuation of Benefits Under COBRA Under the federal law known as the Consolidated Omnibus Budget Reconciliation Act (COBRA), you and your eligible dependents are entitled to continue group medical and dental coverage under certain circumstances when these coverages would otherwise end. You will be required to pay the full group rate for COBRA coverage (plus a small administrative fee). If you or your eligible dependents enroll in COBRA, your benefits will be the same as the coverage for active employees. Therefore, if there are any changes to the plan(s) including costs COBRA benefits will also change. Please note that COBRA premium rates change on an annual basis. If you are currently enrolled in the Health Care Spending Account (HCSA), you may also choose to continue participation in HCSA through COBRA. For detailed COBRA information, sign on to the My HR website at kp.org/myhr. Go to the KP & Me tab and click more under Benefits, Pay & Employment. From there, choose more under Working at KP, select Termination, and then click on the COBRA link. SMM Multi Legal Notices 10/2015 Page 4

19 Premium Assistance Under Medicaid and the Children s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren t eligible for Medicaid or CHIP, you won t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial KIDS NOW or to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren t already enrolled. This is called a special enrollment opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at or call EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, Contact your State for more information on eligibility. ALABAMA Medicaid Website: Phone: ALASKA Medicaid Website: Phone (Outside of Anchorage): Phone (Anchorage): COLORADO Medicaid Medicaid Website: Medicaid Customer Contact Center: GEORGIA Medicaid Website: - Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP) Phone: INDIANA Medicaid Website: Phone: IOWA Medicaid Website: Phone: SMM Multi Legal Notices 10/2015 Page 5

20 FLORIDA Medicaid Website: Phone: KENTUCKY Medicaid Website: Phone: LOUISIANA Medicaid Website: Phone: MAINE Medicaid Website: Phone: TTY MASSACHUSETTS Medicaid and CHIP Website: Phone: MINNESOTA Medicaid Website: Click on Health Care, then Medical Assistance Phone: MISSOURI Medicaid Website: pp.htm Phone: MONTANA Medicaid Website: Phone: KANSAS Medicaid Website: Phone: NEW HAMPSHIRE Medicaid Website: Phone: NEW JERSEY Medicaid and CHIP Medicaid Website: medicaid/ Medicaid Phone: CHIP Website: CHIP Phone: NEW YORK Medicaid Website: Phone: NORTH CAROLINA Medicaid Website: Phone: NORTH DAKOTA Medicaid Website: Phone: OKLAHOMA Medicaid and CHIP Website: Phone: OREGON Medicaid Website: Phone: SMM Multi Legal Notices 10/2015 Page 6

21 NEBRASKA Medicaid Website: Phone: NEVADA Medicaid Medicaid Website: Medicaid Phone: SOUTH CAROLINA Medicaid Website: Phone: SOUTH DAKOTA - Medicaid Website: Phone: TEXAS Medicaid Website: Phone: UTAH Medicaid and CHIP Website: Medicaid: CHIP: Phone: VERMONT Medicaid Website: Phone: PENNSYLVANIA Medicaid Website: Phone: RHODE ISLAND Medicaid Website: Phone: VIRGINIA Medicaid and CHIP Medicaid Website: Medicaid Phone: CHIP Website: CHIP Phone: WASHINGTON Medicaid Website: index.aspx Phone: ext WEST VIRGINIA Medicaid Website: ages/default.aspx Phone: , HMS Third Party Liability Website: WISCONSIN Medicaid and CHIP Phone: WYOMING Medicaid Website: Phone: To see if any other states have added a premium assistance program since July 31, 2015, or for more information on special enrollment rights, contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services EBSA (3272) , Menu Option 4, Ext OMB Control Number (expires 10/31/2016) SMM Multi Legal Notices 10/2015 Page 7

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24 National Human Resources Service Center P.O. Box 2074 Oakland, CA Please Read: Important benefits information enclosed In case of any omission or conflict between what is written in the enclosed Summaries of Material Modification (SMMs) and what is written in the plan documents, contracts, or agreements, the plan documents, contracts, or agreements always govern. Kaiser Permanente reserves the right to modify, amend, change, replace, or terminate the benefit plans described in these SMMs at any time. Benefits may be modified or eliminated through the negotiation process as well, if applicable. You will be advised of any significant changes in your benefit program. A publication of Benefits Compliance Communications National Employee Benefits 2015 Compendium