PERS Health Insurance Program (PHIP) Benefit Guide. January 1 December 31, 2019

Transcription

1 PERS Health Insurance Program (PHIP) Benefit Guide January 1 December 31, 2019

2 September 2018 Dear PERS Health Insurance Program (PHIP) member, As health care costs continue to escalate - industry wide - in both the medical and pharmacy arenas, PHIP took a different approach in looking at the PHIP plan offerings for In keeping with our responsibility to you, the member, and maintaining our core values as a program; stability of premiums, stability of coverage and stability of Contracted Health Plans (CHP s); PHIP released a formal Request for Proposal (RFP) soliciting medical, pharmacy and optional dental services bids. Throughout the RFP process, PHIP, its consultants and advisory committee approached the 2019 plan year, with a strategic goal in mind; to assess the insurance marketplace, come up with a selection of plan offerings to meet the needs of both our Medicare and non-medicare populations while still managing costs and mitigating a reduction in benefits. As a result of this multi-year process, PHIP is making the following changes to the program effective January 1, 2019: Medicare: y PERS Moda Health PPORx (PPO) plan will no longer be available. y UnitedHealthcare Group Medicare Advantage (PPO) is a new plan option that offers nationwide coverage. y PacificSource Medicare Essentials Rx 803 plan is expanding into Clackamas, Multnomah and Washington counties in Oregon and Clark County in Washington. If you are currently enrolled in the PERS Moda Health PPORx plan, your coverage will automatically default to the new UnitedHealthcare Group Medicare Advantage (PPO) plan. The 2019 benefit outlines are on pages and the 2019 premium rates on pages The annual Plan Change period, which is October 1 through November 15, allows you the opportunity to make changes to your elected coverage. To change plans during the Plan Change period: (See page 9 for more detailed instructions) y Complete a Disenrollment Form from your current plan. y Complete an Enrollment Request Form selecting the new plan you wish to enroll in. y Submit both completed and signed forms to PHIP no later than November 15, All changes will be effective January 1, The Enrollment Request Form and Disenrollment Form are available at If you are currently enrolled in the Moda Health Medicare Supplement Plan, Kaiser Permanente Senior Advantage, PacificSource Medicare Essentials Rx 803 or either Providence Medicare Align or Providence Medicare Flex plans and wish to stay with that plan, NO ACTION IS NEEDED. Your current coverage will continue, and the 2019 premium rate and benefit changes will automatically take effect January 1, 2019.

3 Non-Medicare: y PacificSource, Providence and Moda Health non-medicare plans are no longer available. y UnitedHealthcare is a new plan option with nationwide coverage. y Kaiser Permanente is expanding into specific zips codes within Lane County. y The Core Value plans deductible will increase from $500 to $1,000. y The Select Value plans are no longer available. y A new plan offering is a HSA-qualified High Deductible Health Plan (HDHP). If you are currently enrolled in a Moda Health, PacificSource or Providence non-medicare plan, your coverage will automatically default to the new UnitedHealthcare Choice Plus Core Value PPO ($1,000 deductible) plan. If you are currently enrolled in the Kaiser Select Value plan, you will automatically default to the Kaiser Traditional Core Value plan. If you are currently enrolled in the Kaiser Core Value plan, your coverage will remain the same and NO ACTION IS NEEDED. Your current coverage will continue, and the 2019 premium rate and benefit changes will automatically take effect January 1, The 2019 benefit outlines for both Medicare and non-medicare are on pages and the 2019 premium rates are on pages The annual Plan Change period, which is October 1 through November 15, allows you the opportunity to make changes to your elected coverage. To change plans during the Plan Change period: (See page 9 for more detailed instructions) y Complete a Disenrollment Form from your current plan. y Complete an Enrollment Request Form selecting the new plan you wish to enroll in. y Submit both completed and signed forms to PHIP no later than November 15, All changes will be effective January 1, The Enrollment Request Form and Disenrollment Form are available at This year, Plan Change presentations begin September 6 and end October 10, Representatives from PHIP and the Contracted Health Plans will be there to answer your questions. Each meeting is 1.5 to 2 hours long and no registration is required. If you attend one of the Plan Change presentations, please bring your 2019 PHIP Benefit Guide with you. For more information or to view the current PERS Health Insurance Program (PHIP) Member Guide, please visit our website at If you need assistance or have questions, contact PHIP customer service at (800) Sincerely, PERS Health Insurance Program

4 Contents Changes to Plans page PHIP Plan Change Meeting Schedule page 6 Health Plan Enrollment Service Areas page 15 Plan Benefits & Rate Outlines page Medicare Benefit Outlines page Core Value Plan Benefit Outlines page High Deductible Health Plan Benefit Outlines page Dental Benefit Outlines page Medicare Rates page Non-Medicare Rates page 44 Required Notices page 46 Contact Information page 48

5 Please note The information provided in this guide is for general comparison only. Any error or omission is purely unintentional. Please refer to your individual health plan member benefit handbook, Evidence of Coverage (EOC) or Annual Notice of Changes (ANOC) for a full explanation of benefits including exclusions and limitations. It is your responsibility as a PHIP member to review the PERS Health Insurance Program Member Guide and understand your obligation as a PHIP participant. You can find program specific information through the following additional PHIP member materials: PERS Health Insurance Program (PHIP) Medicare Enrollment Guide PERS Health Insurance Program (PHIP) Member Guide To obtain the above member materials or other information regarding your PERS Health Insurance Program visit or call customer service at (800) To view the complete PHIP eligibility and enrollment Oregon Administrative Rules (OAR) visit

6 2018 PHIP Plan Change Presentations PHIP has scheduled presentations for current members to review the 2019 plan year changes. Pre-registration is not required and meetings last approximately hours. For directions, you may contact the locations directly. Represented Plans: K = Kaiser Permanente, M = Moda Health, P = Providence, PS = PacificSource, U = UnitedHealthcare Area Date Time(s) Site Plans Portland 9/6 Thursday 9:30 a.m. & 1:30 p.m. Sheraton Portland Airport 8235 NE Airport Way ALL Salem 9/10 Monday 9:30 a.m. & 1:30 p.m. Oregon State Fair and Expo Center th St. NE (Cascade Hall) K, M, P, U Gresham 9/11 Tuesday 9:30 a.m. Four Points Sheraton 1919 NE 181st Ave ALL Oregon City 9/11 Tuesday 2:00 p.m. Museum of the Oregon Territory 211 Tumwater Drive ALL Eugene 9/12 Wednesday 9:30 a.m. & 1:30 p.m. Lane Events Center 796 West 13th Ave ALL Keizer 9/13 Thursday 9:30 a.m. & 1:30 p.m. Keizer Civic Center 930 Chemawa Road NE K, M, P, U Prineville 9/17 Monday 1:30 p.m. Meadow Lakes Golf Course 300 SW Meadow Lakes Dr M, P, PS, U John Day 9/18 Tuesday 9:30 a.m. Malheur National Forest, Federal Building 431 Patterson Bridge Rd M, PS, U Ontario 9/19 Wednesday 9:30 a.m. Four Rivers Cultural Center 676 SW 5th Ave M, U Baker City 9/19 Wednesday 2:00 p.m. Geiser Grand Hotel 1996 Main St M, U La Grande 9/20 Thursday 9:30 a.m. Blue Mountain Conference Center th St M, U Pendleton 9/20 Thursday 1:30 p.m. Red Lion Hotel 304 SE Nye Ave M, U The Dalles 9/21 Friday 9:30 a.m. Columbia Gorge Discovery Center 5000 Discovery Dr M, PS, U Roseburg 9/24 Monday 9:30 a.m. Douglas County Fairgrounds 2110 SW Frear St M, U Grants Pass 9/24 Monday 2:00 p.m. Oak Room II 900 SE 8th M, U 6 PHIP Plan Change Meeting Schedule

7 Area Date Time(s) Site Plans Medford 9/25 Tuesday 9:30 a.m. Inn at the Commons 200 N. Riverside Ave M, U Klamath Falls 9/26 Wednesday 9:30 a.m. Klamath Fairgrounds 3531 S 6th St M, U La Pine 9/26 Wednesday 2:30 p.m. La Pine Senior Center Victory Way M, P, PS, U Bend 9/27 Tuesday 9:30 a.m. & 1:30 p.m. Mt. Bachelor Village Resort Mt. Bachelor Dr M, P, PS, U Corvallis 10/1 Monday 9:30 a.m. Corvallis Country Club 1850 SW Whiteside Dr K, M, P, U Albany 10/1 Monday 2:00 p.m. Linn County Expo Center 3700 Knox Butte Road K, M, P, U McMinnville 10/2 Tuesday 9:30 a.m. Yamhill County Fairground 2070 NE Lafayette Ave K, M, P, U Tigard 10/2 Tuesday 2:00 p.m. Embassy Suites 9000 SW Washington Square Rd ALL Portland 10/3 Wednesday 9:30 a.m. & 1:30 p.m. Embassy Suites 7900 NE 82nd Ave ALL Salem 10/4 Thursday 9:30 a.m. & 1:30 p.m. Oregon State Fairgrounds th St NE (Cascade Hall) K, M, P, U Hillsboro 10/8 Monday 9:30 a.m. Hillsboro Civic Center 150 E Main St ALL St. Helens 10/8 Monday 2:30 p.m. Columbia Center 375 S 18th St K, M, P, U Astoria 10/9 Tuesday 9:30 a.m. Holiday Inn Express 204 West Marine Dr M, U Tillamook 10/9 Tuesday 2:30 p.m. Tillamook County Library rd St M, U Lincoln City 10/10 Wednesday 9:30 a.m. Inn at Spanish Head 4009 SW Highway 101 M, U Florence 10/10 Wednesday 2:30 p.m. Florence Events Center 715 Quince St ALL Please note: Due to unforeseen circumstances, the printed schedule may change. Any changes to the schedule can be found on For questions regarding the meeting schedule, contact PHIP at (800) PHIP Plan Change Meeting Schedule 7

8 Enrollment Opportunities Current Member Medicare Eligibility Eligibility for Medicare begins the first of the month of your 65th birthday or, if receiving Social Security due to disability, on the 25th month of receiving Social Security Disability benefits. If you are currently enrolled in a PHIP non-medicare plan and need to change to a PHIP Medicare plan, you must fill out a Disenrollment Form for your current plan and submit an Enrollment Request Form for the new PHIP Medicare plan within 30 days of your initial Medicare eligibility, if enrolled in both Medicare Part A and Part B. Failure to submit a new Enrollment Request Form for Medicare coverage will result in cancellation of your non-medicare medical plan coverage under PHIP, upon Medicare eligibility with no future opportunities to enroll. Current Member Enrolling a spouse or dependent child Dependents can enroll during any of the enrollment periods available to retirees. If a spouse or dependent has an enrollment opportunity after the retiree is enrolled, he or she will be eligible to enroll under the retiree s account. Adding a new spouse or dependent child New dependents can be enrolled within 30 days of the family status change (e.g., birth, marriage). If the spouse has a different last name than the retiree, a copy of the marriage certificate will be required. Dependents must enroll in the same health plan as the retiree. To add a new spouse and/ or dependent, complete and submit a PHIP Enrollment Request Form. Effective date of coverage will be the first of the month after receipt of the completed PHIP Enrollment Request Form. This is not a complete list of PHIP enrollment opportunities. For a complete list of PHIP enrollment opportunities for new and current PHIP members, please contact PHIP to request a PERS Health Insurance Program Member Guide or visit 8 Enrollment Opportunities

9 After Enrollment Plan Change PHIP offers an annual Plan Change Period from October 1 to November 15. During the Plan Change period, you can change your medical and/or dental plan to another plan available within your residing area. This annual Plan Change Period is not an opportunity to add dental coverage or dependents. Plan changes made during this period become effective January 1 of the following year. If you are enrolled and do not want to change plans, no paperwork is required. If you want to make a change, you must fill out a Disenrollment Form for the plan you are ending as well as an Enrollment Request Form for the new plan coverage. Submit both forms to PHIP before the November 15 deadline. Forms can be found at or by calling PHIP customer service. If you do not submit a change during this period, you will be unable to change your enrollment midyear, unless you experience a family status change or new enrollment opportunity. You must fill out a Disenrollment Form for the plan you are ending and an Enrollment Request Form for the new coverage when leaving the area and when returning. Please contact PHIP for more information about this option. Change of address Address changes must be submitted in writing by the member or authorized party. Complete, sign, date, and submit a Change of Address Form to PHIP. Address changes may be sent via mail or fax. requests will not be accepted. PHIP will notify the appropriate health plan, however PHIP will not update your address with the PERS Pension office. To update your address with the PERS Pension office, contact PERS directly at the address listed on the back cover of this handbook. Late payments Failure to notify PHIP within 30 days of moving outside a service area can result in involuntary termination of coverage. You must maintain a primary residence within the United States to be eligible for PHIP. If you reside in another country, you are not eligible to retain PHIP coverage. Premium payments are due on or before the first of each month, with no grace period. If payment is not received by the first day of the month, the account is considered delinquent. If you do not pay your premium upon notification, your health plan coverage will be canceled. If your coverage is terminated because of a delinquent payment, you may be responsible for all claims incurred on or after that termination date, except to the extent that those claims are covered under Original Medicare. OAR (3) If payment is by check or money order, the check or money order must be physically received by the Third Party Administrator on or before the due date. (4) Failure to make the payment by the due date shall result in termination of a person s PERS-sponsored health insurance coverage. After Enrollment 9

10 Disenrollment Voluntary disenrollment PHIP and Medicare guidelines require a written request for voluntary disenrollment from PHIP health insurance coverage. Disenrollment will occur the first of the month following receipt of your completed PHIP Disenrollment Form unless a later date is requested. The member, spouse and dependent child (over age 18) must sign the written request for termination, if enrolled. If one member of your family wishes to terminate their dental coverage, the whole family will lose dental coverage. Involuntary termination In some instances, PHIP may be required to terminate your coverage. Examples of when you may lose your coverage are: y Loss of Medicare Part A and/or Part B y Enrolling in another non-phip Medicare Advantage or Medicare Part D Prescription Drug Plan y Loss of program eligibility due to failure to adhere to premium payment guidelines y Loss of retirement status (returning to work) If your PHIP coverage is terminated by the health plan, you may not re-enroll in PHIP unless you experience a new enrollment opportunity. You will be required to bring your account current in the event you have any outstanding balance. For a complete list of PHIP enrollment opportunities, please contact PHIP. Death notification of PERS Retiree or Spouse y If you are the PERS retiree: Upon the death of your spouse, your PHIP coverage will continue as usual. To terminate your spouse s coverage, mail a photocopy of the death certificate to PHIP and the PERS Pension office. y If you are the surviving spouse or dependent child of a PERS retiree: Upon the death of the PERS retiree your PHIP coverage will continue automatically. You must mail a copy of the retiree s death certificate to PHIP and separately to the PERS Pension office for your account to remain active. If you would like to terminate your coverage, a written request is required. Health Coverage While Traveling Before you travel, contact your health plan to determine your travel benefits. All PHIP health plans cover urgent and emergent care when you travel. If you receive medical services outside of the United States request an itemized statement of care (in English if possible) and submit to your health plan for claim reimbursement consideration. Medicare Supplement foreign travel emergency coverage has a lifetime limit of $50,000. Members temporarily visiting other Kaiser Permanente regions may receive visiting member care from designated providers in those areas. Medicare does not provide coverage outside of the United States. You may choose to buy a travel insurance policy to get coverage outside of the United States. Travel insurance may not include health insurance so make sure to read the conditions or restrictions carefully. 10 After Enrollment

11 PHIP enrollment or eligibility appeals Pursuant to Oregon Administrative Rule (OAR) , if you receive a letter denying PHIP eligibility (program or subsidy) or enrollment and you disagree with that determination, you may request a review by writing to the PERS Director within 60 days after the date of the denial letter. Your request must include the following information: 1. A description of the determination you want reviewed. 2. A short statement describing how and why you think the determination is wrong. 3. A statement of facts that you believe show the determination is wrong. 4. A list of any statutes, rules, or court decisions that you believe support your position. 5. A statement of the action you seek. 6. A request for review. Oregon Revised Statutes are available from the Office of Legislative Counsel, or can be located on the Internet at Oregon Administrative Rules are available from the Oregon State Archives Health plan appeals Appeals, complaints or grievances related to your health plan benefits or claims should be directed to the health plan in which you are enrolled. Refer to your health plan s Evidence of Coverage (EOC) booklet or member benefit handbook for more information about your health plans appeal and grievance process. To obtain a copy of your EOC or member benefit handbook contact your health plan directly. Mail appeal to: Public Employees Retirement System Attn: Appeals PO Box Tigard, OR When the Director receives your request, they may ask a Division Administrator to act on it. Your request for a review may be denied if it does not contain the required information listed above. You will be mailed a response letter within 45 days after we receive your request. After Enrollment 11

12 Changes to Plans Important Notice for the 2019 Plan Year For a full list of plan changes, refer to your health plan s Annual Notice Of Change (ANOC) and Evidence of Coverage (EOC) documents. Medicare Your current enrollment in the PERS Moda Health PPORX (PPO) Medicare Advantage plan will automatically default to the UnitedHealthcare Group Medicare Advantage (PPO) plan. You may choose to elect another Medicare plan that is available in the service area where you reside during the Plan Change Period, October 1 through November 15, Non-Medicare Your current enrollment in the Moda Health, PacificSource, or Providence Health Plan Core Value and Select Value plans will automatically default to the UnitedHealthcare Choice Plus Core Value plan. You may choose to elect another non-medicare plan through UnitedHealthcare or Kaiser Permanente if you reside in the Kaiser service area during the Plan Change Period, October 1 through November 15, If you choose to move to an HSA-qualified High Deductible Health Plan (HDHP) during the Plan Change Period, please be aware that once enrolled under the HSA-qualified HDHP plan, you will not be able to move back to the Core Value plan (lower deductible/kaiser Traditional HMO) at any time, for any reason. Kaiser Foundation Health Plan of the NW Medicare y Outpatient therapies (Occupational, Physical, and Speech) are covered in full. y The Prescription Drug out-of-pocket maximum per person per calendar year is $5,100. Non-Medicare y Kaiser will no longer serve the following zip code areas in Lewis County Washington: 98591, 98593, y The Kaiser service area has expanded into the following zip code areas: Benton County: Lane County: 97401, 97402, 97403, 97404, 97405, 97408, 97409, 97419, 97424, 97426, 97431, 97437, 97438, 97440, 97448, 97451, 97452, 97454, 97455, 97461, 97475, 97477, 97478, 97487, Linn County: Core Value y No benefit changes. Select Value y This plan is no longer available. HSA-Qualified HDHP *New Offering* See Plan outlines for benefit details! 12 Changes to Plans

13 Moda Health Medicare y The Prescription Drug out-of-pocket maximum per person per calendar year is $5,100. PERS Moda Health PPORX (PPO) y This plan is no longer available. Non-Medicare Core Value and Select Value Plans y These plans are no longer available through Moda Health. PacificSource Medicare Medicare y The service area has expanded to include Clackamas, Multnomah, and Washington counties and Clark County Washington. Members may elect PacificSource coverage in those areas. y The Prescription Drug out-of-pocket maximum per person per calendar year is $5,100. Non-Medicare Core Value and Select Value Plans y These plans are no longer available through PacificSource. UnitedHealthcare Medicare *New Offering* See Plan outlines for benefit details! Non-Medicare *New Offering* See Plan outlines for benefit details! Dental Delta Dental Plan of Oregon y Composite fillings are covered for posterior teeth. y For members under age 19, full mouth debridement is limited to once in a 2-year period. For members age 19 and older, full mouth debridement is limited to once in a 2-year period only if there has been no cleaning within 24 months. Kaiser Foundation Health Plan of the NW y No benefit changes. Providence Health Assurance Medicare y The Prescription Drug out-of-pocket maximum per person per calendar year is $5,100. Non-Medicare Core Value and Select Value Plans y These plans are no longer available through Providence Health Assurance. Changes to Plans 13

14 14 Changes to Plans

15 Health Plan Enrollment Service Areas In selecting a PHIP health plan, you must reside in the United States and maintain a permanent residence (not mailing) within a health plan s service area in order to participate in PHIP Moda Health Plan, Inc. Nationwide Delta Dental of Oregon Nationwide Health Plan Enrollment Service Areas 15

16 Kaiser Foundation Health Plan of the NW Medicare Oregon Benton: 97330, 97331, 97333, 97339, 97370; Clackamas (excluding 97028); Columbia; Hood River: 97014, Linn: 97321, 97322, 97335, 97355, 97358, 97360, 97374, 97389; Marion (excluding 97350); Multnomah; Polk; Washington; Yamhill Washington Clark; Cowlitz; Skamania: 98639, 98648; Wahkiakum: 98612, Non-Medicare and Dental Oregon Benton: 97330, 97331, 97333, 97339, 97370, 97456; Clackamas (excluding 97028); Columbia; Hood River: 97014; Lane: 97401, 97402, 97403, 97404, 97405, 97408, 97409, 97419, 97424, 97426, 97431, 97437, 97438, 97440, 97448, 97451, 97452, 97454, 97455, 97461, 97475, 97477, 97478, 97487, 97489; Linn: 97321, 97322, 97335,97355, 97358, 97360, 97374, 97389, 97446; Marion (excluding 97350); Multnomah; Polk; Washington; Yamhill Washington Clark; Cowlitz; Skamania: 98639, 98648; Wahkiakum: 98612, Health Plan Enrollment Service Areas

17 PacificSource Medicare Oregon Clackamas; Coos; Crook; Curry; Deschutes; Grant; Hood River; Jefferson; Klamath: 97731, 97733, 97737, 97739; Multnomah; Lake: 97638, 97641, 97735, 97739; Lane; Sherman; Wasco; Washington; Wheeler Washington Clark Providence Health Assurance Oregon Benton, Clackamas, Columbia, Crook, Deschutes, Hood River, Jefferson, Lane, Linn, Marion, Multnomah, Polk, Washington, Wheeler and Yamhill Washington Clark County UnitedHealthcare Nationwide Health Plan Enrollment Service Areas 17

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19 2019 Medicare Plan Benefit Outlines For questions on plan benefits, exclusions and limitations; Refer to your plan s Evidence of Coverage (EOC) or member benefit handbook. You can obtain either by contacting your health plan directly. For the Moda Health Medicare Supplement Plan, you can also refer to the Medicare and You Handbook which can be obtained through CMS. Contact information is on page 48 of this publication.

20 Moda Health Medicare Supplement Medicare Enrollment Service Area: Nationwide Benefit Description Eligible Providers Medicare Supplement Any licensed Medicare Provider Member Pays: Calendar Year Deductible $183 per individual 1 Calendar Year Medical Out-of-Pocket Maximum Inpatient Care: y Inpatient Hospital Care y Skilled Nursing Facility Outpatient Care: y Physician Office Visits y Specialist Office Visits y Outpatient Surgery y Ambulance (worldwide/air-ground) y Emergency Services (worldwide) y Urgent Care (worldwide) y DME y Lab Test y X-ray y Diagnostic Procedures (CT/MRI/PET) y OT/PT/ST Therapies Preventive Care: y Annual Wellness Exam y Women s Preventive y Prostate Cancer Screening yimmunizations None y Covered in full y Covered in full 2 y Covered in full y Covered in full y Covered in full y Covered in full y Covered in full y Covered in full y Covered in full y Covered in full y Covered in full y Covered in full y Covered in full 3 y Covered in full 4 y Covered in full 4 y Covered in full 4 y Covered in full 4 20 Moda Health Benefit Outline

21 Benefit Description Other Services: y Chiropractic Care y Vision Routine Eye Exam y Vision Hardware Pharmacy: This is a Medicare Part D Prescription Drug Plan y Brand and Generic y Calendar Year Pharmacy Out-of-Pocket Maximum Travel Benefits: y Outside Service Area within USA y Outside Service Area outside USA y Time Frame Medicare Supplement y Covered in full 5 y Discounts available y Discounts available y 40% of charge up to a $250 maximum per prescription for a 31-day supply y $5,100 per member y Covers Emergency, Urgent Care, and Ambulance in full y 20% coinsurance for Emergency, Urgent Care, and Ambulance. Coverage limited to $50,000 per lifetime y Six months per CMS guidelines for travel within and outside USA This is a summary of benefits only, for general comparison. Any errors or omissions are purely unintentional. Should any discrepancies be found between this guide and the health plan document, the information in the health plan document shall prevail Part B Deductible Part B Deductible is not available at this time. 2 Coverage applies to a Medicare certified facility for up to 100 days/medicare benefit period. 3 Outpatient rehab: OT = Occupational Therapy, PT = Physical Therapy, ST = Speech Therapy 4 Medicare covered services only. 5 Medicare covered Chiropractic Services only. Contact health plan customer service for more details. Moda Health Benefit Outline 21

22 Kaiser Foundation Health Plan of the NW Medicare Senior Advantage Medicare Enrollment Service Area: Oregon Counties: Benton: 97330, 97331, 97333, 97339, 97370; Clackamas (excludes 97028); Columbia; Hood River: 97014; Linn: 97321, 97322, 97335, 97355, 97358, 97360, 97374, 97389; Marion (excludes 97350); Multnomah; Polk; Washington and Yamhill. Washington Counties: Clark; Cowlitz; Skamania: 98639, 98648; Wahkiakum: 98612, Benefit Description Eligible Providers Medicare Senior Advantage Kaiser Permanente and the Portland Clinic Physicians and Hospitals Member Pays: Calendar Year Deductible Calendar Year Medical Out-of-Pocket Maximum Inpatient Care: yinpatient Hospital Care yskilled Nursing Facility Outpatient Care: yphysician Office Visits yspecialist Office Visits youtpatient Surgery yambulance (worldwide/air-ground) yemergency Services (worldwide) yurgent Care (worldwide) ydme ylab Test yx-ray ydiagnostic Procedures (CT/MRI/PET) yot/pt/st Therapies None $1,000 per individual y$200 copay per admit y$15 copay y$15 copay y$15 copay y$50 copay y$50 copay y$15 copay y20% Kaiser Permanente Health Benefit Outline

23 Benefit Description Preventive Care: yannual Wellness Exam ywomen s Preventive yprostate Cancer Screening yimmunizations Other Services: ychiropractic Care yvision Routine Eye Exam yvision Hardware Pharmacy: This is a Medicare Part D Prescription Drug Plan ybrand and Generic ycalendar Year Pharmacy Out-of-Pocket Maximum Travel Benefits: youtside Service Area within USA youtside Service Area outside USA ytime Frame Medicare Senior Advantage y$15 copay 8 y$15 copay y$100 credit every 2 years for lenses, frames and/or contacts y40% of charge up to a $250 maximum per prescription for a 30-day supply y$5,100 per member ycovers routine, preventive and follow-up care outside Kaiser network at 20% as part of the $1,000 annual worldwide travel benefit maximum 9 ycovers routine, preventive and follow-up care outside Kaiser network at 20% as part of the $1,000 annual worldwide travel benefit maximum 9 ysix months per CMS guidelines for travel within/outside USA 9 This is a summary of benefits only, for general comparison. Any errors or omissions are purely unintentional. Should any discrepancies be found between this guide and the health plan document, the information in the health plan document shall prevail. 6 Applies to Medicare approved supplies/equipment only and may require Pre-Authorization. Some diabetic supplies are covered in full. 7 Outpatient Rehab: OT = Occupational Therapy, PT = Physical Therapy, ST = Speech Therapy 8 Medicare covered chiropractic services only. 9 Members temporarily visiting other Kaiser Permanente regions may receive visiting member care from designated providers in those areas. Kaiser Permanente Health Benefit Outline 23

24 PacificSource Medicare Medicare Advantage HMO Medicare Enrollment Service Area: Oregon Counties: Clackamas; Coos; Crook; Curry; Deschutes; Grant; Hood River; Jefferson; Klamath: 97731, 97733, 97737, 97739; Lake: 97638, 97641, 97735, 97739; Lane; Multnomah; Sherman; Wasco; Washington and Wheeler. Washington County: Clark Benefit Description Medicare Advantage Essentials RX 803 Eligible Providers Plan Physicians and Hospitals Member Pays: Calendar Year Deductible Calendar Year Medical Out-of-Pocket Maximum Inpatient Care: yinpatient Hospital Care yskilled Nursing Facility Outpatient Care: yphysician Office Visits yspecialist Office Visits youtpatient Surgery yambulance (worldwide/air-ground) yemergency Services (worldwide) yurgent Care (worldwide) ydme ylab Test yx-ray ydiagnostic Procedures (CT/MRI/PET) yot/pt/st Therapies None $3,400 per individual y$125 copay/day; $500 max. per admit y$15 copay y$20 copay y$125 copay y$50 copay y$50 copay y$20 copay y20% 10 y10% y10% y$20 copay PacificSource Health Benefit Outline

25 Benefit Description Medicare Advantage Essentials RX 803 Preventive Care: yannual Wellness Exam ywomen s Preventive yprostate Cancer Screening yimmunizations Other Services: ychiropractic Care yvision Routine Eye Exam yvision Hardware Pharmacy: This is a Medicare Part D Prescription Drug Plan ybrand and Generic ycalendar Year Pharmacy Out-of-Pocket Maximum Travel Benefits: youtside Service Area within USA youtside Service Area outside USA ytime Frame y$15 copay 12 y$15 copay y$100 credit every 2 calendar years for lenses, frames and/or contacts y40% of charge up to a $250 maximum per prescription for a 31-day supply y$5,100 per member ycovers Emergency, Urgent Care and Ambulance at copays listed above 13 ycovers Emergency, Urgent Care and Ambulance 13 ysix months per CMS guidelines for travel within/outside USA 13 This is a summary of benefits only, for general comparison. Any errors or omissions are purely unintentional. Should any discrepancies be found between this guide and the health plan document, the information in the health plan document shall prevail. 10 Applies to Medicare approved supplies/equipment only and may require Pre-Authorization Some diabetic supplies are covered in full. 11 Outpatient Rehab: OT = Occupational Therapy, PT = Physical Therapy, ST = Speech Therapy 12 Medicare covered chiropractic services only. 13 Includes out-of-area dialysis services. All services do not require prior authorization. PacificSource Health Benefit Outline 25

26 Providence Health Assurance Medicare Advantage HMO Medicare Enrollment Service Area: Oregon Counties: Benton; Clackamas; Columbia; Crook; Deschutes; Hood River; Jefferson; Lane; Linn; Marion; Multnomah; Polk; Washington; Wheeler and Yamhill. Washington County: Clark Benefit Description Eligible Providers Medicare Advantage Align Plan + Rx Plan Physicians and Hospitals Member Pays: Calendar Year Deductible Calendar Year Medical Out-of-Pocket Maximum Inpatient Care: yinpatient Hospital Care yskilled Nursing Facility Outpatient Care: yphysician Office Visits yspecialist Office Visits youtpatient Surgery yambulance (worldwide/air-ground) yemergency Services (worldwide) yurgent Care (worldwide) ydme ylab Test yx-ray ydiagnostic Procedures (CT/MRI/PET) yot/pt/st Therapies None $1,500 per individual y$100 copay/day; $500 max. per admit y$15 copay y$20 copay y$75 copay y$50 copay y$50 copay y$25 copay y20% 14 y10% y10% y$20 copay Providence Health Benefit Outline

27 Benefit Description Preventive Care: yannual Wellness Exam ywomen s Preventive yprostate Cancer Screening yimmunizations Other Services: ychiropractic Care yvision Routine Eye Exam yvision Hardware Pharmacy: This is a Medicare Part D Prescription Drug Plan ybrand and Generic ycalendar Year Pharmacy Out-of-Pocket Maximum Travel Benefits: youtside Service Area within USA youtside Service Area outside USA ytime Frame Medicare Advantage Align Plan + Rx y$20 copay 16 y$15 copay, any licensed provider y$100 credit every 2 years for lenses, frames and/or contacts, any licensed provider y40% of charge up to a $250 maximum per prescription for a 31-day supply y$5,100 per member y20% to maximum allowance of $1,000 for follow-up services ycovers Emergency, Urgent Care, and Ambulance ysix months per CMS guidelines for travel within/outside US This is a summary of benefits only, for general comparison. Any errors or omissions are purely unintentional. Should any discrepancies be found between this guide and the health plan document, the information in the health plan document shall prevail. 14 Applies to Medicare approved supplies/equipment only and may require Pre-Authorization. Some diabetic supplies are covered in full. 15 Outpatient Rehab: OT = Occupational Therapy, PT = Physical Therapy, ST = Speech Therapy 16 Medicare covered chiropractic services only. Providence Health Benefit Outline 27

28 Providence Health Assurance Medicare Advantage HMO-POS Medicare Enrollment Service Area: Oregon Counties: Benton; Clackamas; Columbia; Crook; Deschutes; Hood River; Jefferson; Lane; Linn; Marion; Multnomah; Polk; Washington; Wheeler and Yamhill. Washington County: Clark Benefit Description Medicare Advantage Flex Plan + Rx Eligible Providers In-Network Plan Physicians and Hospitals Out-of-Network Any Licensed Medicare Provider Member Pays: Calendar Year Deductible Calendar Year Medical Out-of-Pocket Maximum None $3,000 per individual Inpatient Care: yinpatient Hospital Care yskilled Nursing Facility Outpatient Care: yphysician Office Visits yspecialist Office Visits youtpatient Surgery yambulance (worldwide/air-ground) yemergency Services (worldwide) yurgent Care (worldwide) ydme ylab Test yx-ray ydiagnostic Procedures (CT/MRI/PET) yot/pt/st Therapies y$125 copay/day; $500 max. per admit 17 y$20 copay y$25 copay 18 y$150 copay y$50 copay (one-way) y$65 copay y$25 copay y20% 19 y10% y10% y$25 copay 20 y20% y20% y$30 copay y$35 copay y20% y$50 copay (one-way) y$65 copay y$25 copay y20% 19 y20% y20% y20% y$35 copay Providence Health Benefit Outline

29 Benefit Description Medicare Advantage Flex Plan + Rx Preventive Care: yannual Wellness Exam ywomen s Preventive yprostate Cancer Screening yimmunizations Other Services: ychiropractic Care yvision Routine Eye Exam yvision Hardware In-Network y$20 copay 21 y$20 copay, any licensed provider y$100 credit every 2 years for lenses, frames and/ or contacts, any licensed provider Out-of-Network y$35 copay 21 y$20 copay, any licensed provider y$100 credit every 2 years for lenses, frames and/or contacts, any licensed provider Pharmacy: This is a Medicare Part D Prescription Drug Plan ybrand and Generic ycalendar Year Pharmacy Out-of-Pocket Maximum Travel Benefits: youtside Service Area within USA youtside Service Area outside USA ytime Frame y40% of charge up to a $250 maximum per prescription for a 31-day supply y$5,100 per member y$30 or $35 copay or 20% coinsurance ycovers Emergency, Urgent Care and Ambulance ysix months per CMS guidelines for travel within/outside USA This is a summary of benefits only, for general comparison. Any errors or omissions are purely unintentional. Should any discrepancies be found between this guide and the health plan document, the information in the health plan document shall prevail. 17 Days 1-20, covered in full; Days , $50 copay per day. 18 If no referral is in place when seeing an In-Network Specialist, $35 copay applies. 19 Applies to Medicare approved supplies/equipment only and may require pre-authorization. Some diabetic supplies are covered in full. 20 Outpatient Rehab: OT = Occupational Therapy, PT = Physical Therapy, ST = Speech Therapy. 21 Medicare covered chiropractic services only. Providence Health Benefit Outline 29

30 UnitedHealthcare Medicare Advantage PPO Medicare Enrollment Service Area: Nationwide Benefit Description Group Medicare Advantage (PPO) In-Network Out-of-Network 22 Eligible Providers Medicare Advantage Network Providers Any Licensed Medicare Provider Member Pays: Calendar Year Deductible Calendar Year Medical Out-of-Pocket Maximum None $2,500 per individual Inpatient Care: yinpatient Hospital Care yskilled Nursing Facility Outpatient Care: yphysician Office Visits yspecialist Office Visits youtpatient Surgery yambulance (worldwide/air-ground) yemergency Services (worldwide) yurgent Care (worldwide) ydme ylab Test yx-ray ydiagnostic Procedures (CT/MRI/PET) yot/pt/st Therapies y$100 copay/day; $300 max. per admit y$15 copay y$20 copay 23 y$125 copay y$50 copay (one-way) y$65 copay y$20 copay y20% 24 y10% y10% y$20 copay 25 y$100 copay/day; $300 max. per admit y$15 copay y$20 copay 23 y$125 copay y$50 copay (one-way) y$65 copay y$20 copay y20% 24 y10% y10% y$20 copay UnitedHealthcare Health Benefit Outline

31 Benefit Description Group Medicare Advantage (PPO) Preventive Care: yannual Wellness Exam ywomen s Preventive yprostate Cancer Screening yimmunizations Other Services: ychiropractic Care yvision Routine Eye Exam yvision Hardware In-Network y$20 copay 27 y$20 copay y$100 credit every 24 months for lenses, frames and/ or contacts Out-of-Network y$20 copay 27 y$20 copay y$100 credit every 24 months for lenses, frames and/ or contacts Pharmacy: This is a Medicare Part D Prescription Drug Plan ybrand and Generic ycalendar Year Pharmacy Out-of-Pocket Maximum Travel Benefits: youtside Service Area within USA youtside Service Area outside USA ytime Frame y40% of charge up to a $250 maximum per prescription for a 31-day supply y$5,100 per member yinpatient, outpatient, and preventive care are covered in full as long as the provider accepts Medicare ycovers Emergency, Urgent, and Ambulance to nearest facility ysix months per CMS guidelines for travel within/outside USA This is a summary of benefits only, for general comparison. Any errors or omissions are purely unintentional. Should any discrepancies be found between this guide and the health plan document, the information in the health plan document shall prevail. 22 Out-of-network Medicare providers are paid up to the Medicare limiting charge. 23 Referrals not required. 24 Applies to Medicare approved supplies/equipment only and may require pre-authorization. Some diabetic supplies are covered in full. 25 Outpatient rehab: OT = Occupational Therapy, PT = Physical Therapy, ST = Speech Therapy. 26 Medicare covered services only. 27 Medicare covered chiropractic services only. UnitedHealthcare Health Benefit Outline 31

32

33 2019 Non-Medicare Plan Benefit Outlines A Note About Qualified High Deductible Health Plans (HDHP) The PHIP qualified HDHP can be used with a Health Saving Account (HSA). To be eligible for an HSA qualified HDHP you can have no other health insurance coverage such as Medicare, military health or other health insurance plans. Additionally, you may not be claimed as a dependent on another person s tax return. Health Savings Account (HSA) Basics An HSA is a special savings account that you contribute money to, then withdraw funds to be used for qualified medical, pharmacy, dental and vision expenses. HSA s are funded by individual contributions and have annual contribution limits set by the IRS. Additionally, HSA s allow balances to carry over year after year. For individuals age 55 and older an additional annual catch-up contribution may be available. If you change plans or when you become Medicare eligible you can keep the account and the money in it, which you can continue to use for qualified expenses. The HSA belongs to you and you are responsible for setting one up through a financial institution. HSA and Medicare You are no longer eligible to contribute to your HSA once you become Medicare eligilble but may be able to cover some expenses with HSA funds, including Medicare premiums and long-term care. Contact a tax advisor for specific rules regarding HSA s.

34 Kaiser Foundation Health Plan of the NW Traditional Core Value Plan Non-Medicare Enrollment Service Area: Oregon Counties: Benton: 97330, 97331, 97333, 97339, 97370, 97456; Clackamas (excludes 97028); Columbia; Hood River: 97014; Lane: 97401, 97402, 97403, 97404, 97405, 97408, 97409, 97419, 97424, 97426, 97431, 97437, 97438, 97440, 97448, 97451, 97452, 97454, 97455, 97461, 97475, 97477, 97478, 97487, 97489; Linn: 97321, 97322, 97335, 97355, 97358, 97360, 97374, 97389, 97446; Marion (excludes 97350); Multnomah; Polk; Washington and Yamhill. Washington Counties: Clark; Cowlitz; Skamania: 98639, 98648; Wahkiakum: 98612, Benefit Description Eligible Providers Non-Medicare Traditional Core Value Kaiser Permanente and the Portland Clinic Physicians and Hospitals Member Pays: Calendar Year Deductible Calendar Year Medical Out-of-Pocket Maximum Inpatient Care: yinpatient Hospital Care yskilled Nursing Facility Outpatient Care: yphysician Office Visits yspecialist Office Visits youtpatient Surgery yambulance (worldwide/air-ground) yemergency Services (worldwide) yurgent Care (worldwide) ydme ylab Test yx-ray ydiagnostic Procedures (CT/MRI/PET) yot/pt/st Therapies None $2,000 per individual $4,000 per family (2 or more) y$200 copay/day; $1,000 max per admit y$30 copay y$40 copay y$200 copay y$100 copay (one-way) y$200 copay y$30 copay y20% y$30 copay y$30 copay y20% y$40 copay Kaiser Permanente Health Benefit Outline

35 Benefit Description Preventive Care: yannual Wellness Exam ywomen s Preventive yprostate Cancer Screening yimmunizations Other Services: yalternative Care yvision Routine Eye Exam yvision Hardware Pharmacy: ybrand and Generic ycalendar Year Pharmacy Out-of-Pocket Maximum Travel Benefits: youtside Service Area within USA youtside Service Area outside USA Non-Medicare Traditional Core Value y$25 copay 29 y$30 copay ynot covered y40% of charge up to a $250 maximum per prescription for a 30-day supply y$5,000 per member yurgent/emergent coverage only 30 yurgent/emergent coverage only 30 This is a summary of benefits only, for general comparison. Any errors or omissions are purely unintentional. Should any discrepancies be found between this guide and the health plan document, the information in the health plan document shall prevail. 28 Outpatient rehab: OT = Occupational Therapy, PT = Physical Therapy, ST = Speech Therapy. Benefit is limited to 20 visits per calendar year. 29 Spinal manipulation and acupuncture are limited to 12 combined visits per calendar year. Naturopathy included. No massage therapy coverage. 30 Members temporarily visiting other Kaiser Permanente regions may receive visiting member care from designated providers in those areas. Kaiser Permanente Health Benefit Outline 35

36 UnitedHealthcare Core Value Plan Non-Medicare Enrollment Service Area: Nationwide Benefit Description Non-Medicare Choice Plus Core Value Eligible Providers In-Network Preferred physicians and facilities Out-of-Network Any Licensed Physician or facitily Member Pays: Calendar Year Deductible Calendar Year Medical/Pharmacy Out-of-Pocket Maximum $1,000 per Individual/$2,000 per Family $6,350 + $1,000 Deductible = $7,350/Individual; $12,700 + $2,000 Deductible = $14,700/Family Inpatient Care: yinpatient Hospital Care yskilled Nursing Facility Outpatient Care: yphysician Office Visits yspecialist Office Visits youtpatient Surgery yambulance (worldwide/air-ground) yemergency Services (worldwide) yurgent Care (worldwide) ydme ylab Test yx-ray ydiagnostic Procedures (CT/MRI, PET) yphysical Therapy yot/st Therapies y$20 copay, no deductible y$20 copay, no deductible y$200 copay, then 20%, no deductible y$20 copay, no deductible y20%, no deductible y20%, no deductible y20%, no deductible 31,32 y20% after deductible 31,32 y$200 copay, then 20%, no deductible y40% after deductible 31,32 y40% after deductible 31,32 36 UnitedHealthcare Health Benefit Outline

37 Benefit Description Non-Medicare Choice Plus Core Value Preventive Care: yannual Wellness Exam ywomen s Preventive yprostate Cancer Screening yimmunizations Other Services: yalternative Care In-Network y$25 copay, no deductible 33 Out-of-Network y40% after deductible 33 Prescription Drugs: ybrand ygeneric yspecialty ycalendar Year Pharmacy Out-of-Pocket Maximum Travel Benefits: youtside Service Area within USA youtside Service Area outside USA y40%, no cap or deductible y40%, no cap or deductible y40%, no cap or deductible ycombined with Medical yall services are available through network providers nationally yemergency, Urgent, and Ambulance to nearest facility This is a summary of benefits only, for general comparison. Any errors or omissions are purely unintentional. Should any discrepancies be found between this guide and the health plan document, the information in the health plan document shall prevail. 31 Outpatient rehab: OT = Occupational Therapy, PT = Physical Therapy, ST = Speech Therapy. 32 Limited to 30 visits per calendar year; this 30-visit limitation encompasses all therapy modalities combined. 33 Spinal Manipulation and acupuncture are limited to 12 combined visits per calendar year. No massage therapy coverage. UnitedHealthcare Health Benefit Outline 37

38 Kaiser Foundation Health Plan of the NW High Deductible Health Plan Non-Medicare Enrollment Service Area: Oregon Counties: Benton: 97330, 97331, 97333, 97339, 97370, 97456; Clackamas (excludes 97028); Columbia; Hood River: 97014; Lane: 97401, 97402, 97403, 97404, 97405, 97408, 97409, 97419, 97424, 97426, 97431, 97437, 97438, 97440, 97448, 97451, 97452, 97454, 97455, 97461, 97475, 97477, 97478, 97487, 97489; Linn: 97321, 97322, 97335, 97355, 97358, 97360, 97374, 97389, 97446; Marion (excludes 97350); Multnomah; Polk; Washington; Yamhill. Washington Counties: Clark; Cowlitz; Skamania: 98639, 98648; Wahkiakum: 98612, Benefit Description Eligible Providers Non-Medicare Qualified HDHP Plan Kaiser Permanente and the Portland Clinic Physicians and Facilities Member Pays: Calendar Year Medical/Pharmacy Deductible Calendar Year Medical/Pharmacy Out-of-Pocket Maximum Inpatient Care: yinpatient Hospital Care yskilled Nursing Facility $3,000 per individual If enrolled as a family, a total of $6,000 for all members combined. 34 $6,650 per individual $13,300 per family 38 Kaiser Permanente Health Benefit Outline

39 Benefit Description Outpatient Care: yphysician Office Visits yspecialist Office Visits youtpatient Surgery yambulance (worldwide/air-ground) yemergency Services (worldwide) yurgent Care (worldwide) ydme ylab Test yx-ray ydiagnostic Procedures (CT/MRI/PET) yot/pt/st Therapies Routine Preventive Care: yannual Wellness Exam ywomen s Preventive yprostate Cancer Screening yimmunizations Other Services: yalternative Care Perscription Drugs: ybrand ygeneric yspecialty Travel Benefits: youtside Service Area within USA youtside Service Area outside USA Non-Medicare Qualified HDHP Plan 35,36 37 yurgent/emergent coverage only 38 yurgent/emergent coverage only 38 This is a summary of benefits only, for general comparison. Any errors or omissions are purely unintentional. Should any discrepancies be found between this guide and the health plan document, the information in the health plan document shall prevail. 34 A family has to meet the entire family deductible before covered expenses are paid at the plan coinsurance level for any of the family members. 35 Outpatient rehab: OT = Occupational Therapy, PT = Physical Therapy, ST = Speech Therapy. 36 Limited to 30-visits per calendar year; this 30-visit limitation encompasses all therapy modalities combined. 37 Spinal manipulation and acupuncture are limited to 12 combined visits per calendar year. Naturopathy included. No massage therapy coverage. 38 Limitations exist on visiting Member services for HDHP members. Kaiser Permanente Health Benefit Outline 39

40 UnitedHealthcare High Deductible Health Plan Non-Medicare Enrollment Service Area: Nationwide Benefit Description Non-Medicare Qualified HDHP Plan Eligible Providers In-Network Preferred physicians and facilities Out-of-Network Any Licensed Physician or facitily Member Pays: Calendar Year Deductible Calendar Year Medical/Pharmacy Out-of-Pocket Maximum $3,000 per individual. If enrolled as a family, a total of $6,000 for all members combined. 39 $6,650 per individual $13,300 per family Inpatient Care: yinpatient Hospital Care yskilled Nursing Facility Outpatient Care: yphysician Office Visits yspecialist Office Visits youtpatient Surgery yambulance (worldwide/ air-ground/one-way) yemergency Services (worldwide) yurgent Care (worldwide) ydme ylab Test yx-ray ydiagnostic Procedures (CT/MRI) yot/pt/st Therapies 40,41 40,41 40 UnitedHealthcare Health Benefit Outline

41 Benefit Description Non-Medicare Qualified HDHP Plan Preventive Care: yannual Wellness Exam ywomen s Preventive yprostate Cancer Screening yimmunizations Other Services: yalternative Care Prescription Drugs: ybrand ygeneric yspecialty 42 y20%, after deductible y20%, after deductible y20%, after deductible 42 Travel Benefits: youtside Service Area within USA youtside Service Area outside USA yall services are available through network providers nationally. yemergency, Urgent, and Ambulance to nearest facility This is a summary of benefits only, for general comparison. Any errors or omissions are purely unintentional. Should any discrepancies be found between this guide and the health plan document, the information in the health plan document shall prevail. 39 A family has to meet the entire family deductible before covered expenses are paid at the plan coinsurance level for any of the family members. 40 Outpatient rehab: OT = Occupational Therapy, PT = Physical Therapy, ST = Speech Therapy. 41 Limited to 30-visits per calendar year; this 30-visit limitation encompasses all therapy modalities combined. 42 Spinal manipulation and acupuncture are limited to 12 combined visits per calendar year. No massage therapy coverage. UnitedHealthcare Health Benefit Outline 41

42 2019 Dental Benefit Outlines You can enroll in either dental plan regardless of your medical plan selection. Providers/Network Kaiser Permanente* Kaiser Permanente Dental Associates Member Pays: Delta Dental of Oregon Premier and PPO Dental Providers and Non-Participating Providers 1 Member Pays: Calendar year deductible None $25 per individual Calendar year benefit maximum (plan pays) $1,500 per individual 2 $1,500 per individual 2 Preventive Care yexams ycleanings ydiagnostic Limit of two cleanings per calendar year y$10 copay per visit 2 y$10 copay per visit 2 y$10 copay per visit 2 Available twice in a calendar year 2 2 2,3 Basic Services yrestorative yoral surgery (extractions) yendodontic/periodontic y$10 copay, then 20% y$10 copay, then 20% y$10 copay, then 20% Major Services ycrowns ycast restorations ydentures/bridge work yimplants y$10 copay, then 50% y$10 copay, then 50% y$10 copay, then 50% y$10 copay, then 50% y50% after deductible 4 y50% after deductible 4 y50% after deductible 4 y50% after deductible 4 Out-of-area coverage Kaiser Permanente allows a benefit of up to $100 of Worldwide for emergency services only reimbursement on an approved out-of-area emergency claim. Rates Adult $65.34 $62.42 Child $26.44 $25.27 This is a summary of benefits only, for general comparison. Any errors or omissions are purely unintentional. Should any discrepancies be found between this guide and the health plan document, the information in the health plan document shall prevail. * To be enrolled in the Kaiser Permanente dental plan, you must live in the Kaiser Permanente dental service area. 1 The amounts payable for services of a non-participating provider are limited to the amount in the PPO Fee Schedule. The dentist may balance bill. 2 Charges for preventive services do not apply to the calendar year benefit maximum. 3 Some limitations apply. 4 There is a 12-month waiting period for basic and major services following enrollment unless member has had continuous employer-sponsored dental coverage for the previous 12 months immediately preceding PHIP dental enrollment. 42 Dental Benefit Outlines

43 2019 Medicare Rates Medical and prescription drug monthly premium rate comparison The monthly premiums shown below are without the $60 RHIA premium subsidy contribution. The RHIA premium subsidy contribution can only be applied once per account. More information on the RHIA premium subsidy contribution eligibility is located on our website at Health Plan Adult rate* Child Rate** Moda Health Medicare Supplement Plan $ $ Kaiser Permanente Senior Advantage $ $ PacificSource Medicare Essentials RX 803 Providence Medicare Align Group Plan + Rx (HMO) Providence Medicare Flex Group Plan + Rx (HMO-POS) UnitedHealthcare Group Medicare Advantage (PPO) $ $ $ $ $ $ $ $ Oregon Administrative Rules (OAR): (1) and describe PERS Health Insurance Program (PHIP) eligibility requirements. If you have questions about your eligibility, or if you would like a copy of the complete OAR eligibility rules, please call PHIP at the number listed in the back of this guide or visit Non-Medicare rates are available on page 44. To calculate your premium rates, use the Rate Calculation Worksheet on page 45. * Adult rate includes retiree, spouse and dependent domestic partner ** Child rate includes dependent child regardless of age. Eligibility requirements apply for dependents over the age of 26, to view dependent eligibility refer to No additional premium (cost) for more than two children. Medicare Rates 43

44 2019 Non-Medicare Rates Medical and prescription drug monthly premium rate comparison The monthly premiums shown below are without the the RHIPA premium subsidy contribution. The RHIPA premium subsidy contribution can only be applied once per account. More information on the RHIPA premium subsidy contribution eligibility is located on our website at Health Plan Adult rate* Child Rate** Kaiser Permanente Core Value Plan $ $ United Healthcare Core Value Plan $1, $ Kaiser Permanente Qualified HDHP $ $ United Healthcare Qualified HDHP $ $ Oregon Administrative Rules (OAR): (1) and describe PERS Health Insurance Program (PHIP) eligibility requirements. If you have questions about your eligibility, or if you would like a copy of the complete OAR eligibility rules, please call PHIP at the number listed in the back of this guide or visit Medicare rates are available on page 43. To calculate your premium rates, use the Rate Calculation Worksheet on page 45. * Adult rate includes retiree, spouse and dependent domestic partner ** Child rate includes dependent child regardless of age. Eligibility requirements apply for dependents over the age of 26, to view dependent eligibility refer to No additional premium (cost) for more than two children. 44 Non-Medicare Rates

45 Premium Calculation Worksheet 1. Medicare Health Plan (Enter monthly Medicare premium rate from page 43) 2019 Medicare Rates a. Retiree Premium Amount (Adult Rate 1 ) 1a. $ b. Spouse Premium Amount (Adult Rate 1 ) 1b. $ c. Dependent Premium Amount (Child Rate 2 ) 1c. $ d. Total Medicare Premium Amount (add 1a through 1c) 1d. $ 2. Non-Medicare Health Plan (Enter monthly non-medicare premium rate from page 44) 2019 Non-Medicare Rates a. Retiree Premium Amount (Adult Rate 1 ) 2a. $ b. Spouse Premium Amount (Adult Rate 1 ) 2b. $ c. Dependent Premium Amount (Child Rate 2 ) 2c. $ d. Total Non-Medicare Premium (add 2a through 2c) 2d. $ 3. Dental Plan (Enter monthly dental premium rate from page 42) 2019 Dental Rates a. Retiree Premium Amount (Adult Rate 1 ) 3a. $ b. Spouse Premium Amount (Adult Rate 1 ) 3b. $ c. Dependent Premium Amount (Child Rate 2 ) 3c. $ d. Total Dental Premium (add 3a through 3c) 3d. $ 4. This is your total monthly premium rate Total Rate add 1d+2d+3d $ 1 The monthly premium calculated does not include the Retirement Health Insurance Account (RHIA) nor the Retiree Health Insurance Premium Account (RHIPA) premium subsidy contribution. A premium subsidy contribution will be applied automatically if eligible and only one per account. More information on the PHIP premium subsidies eligibility is located on our website at 2 If more than one dependent (child) multiply rate by 2. No additional cost for more than two children. Premium Calculation Worksheet 45

46 Required Notices Women s Health and Cancer Rights Act Beginning in 1999, federal law requires group health plans to provide coverage for the following services to an individual receiving plan benefits in connection with a mastectomy: y Reconstruction on the breast on which the mastectomy has been performed; y Surgery and reconstruction of the other breast to produce a symmetrical appearance; and y Prostheses and coverage for physical complications for all stages of a mastectomy, including lymphedemas (swelling associated with the removal of lymph nodes). The health plan must determine the manner of coverage in consultation with the attending physician and patient. Coverage for breast reconstruction and related services will be subject to deductibles, coinsurance amounts and copayments that are consistent with those that apply to other benefits under the plan. Power of Attorney/Authorization to Disclose Information PHIP requires that a Durable Power of Attorney for Health Care (DPAHC) of Authorization to Disclose Information be on file with the program office for anyone acting on a member s behalf. PHIP is unable to release information to anyone who is not authorized by the PHIP member. To disclose or change information after the death of a member, please provide one of the following: executor, letter of probate or trustee documentation, or Last Will and Testament. COBRA continuation of coverage In accordance with federal and state of Oregon guidelines, PHIP provides opportunities for the continuation of coverage through COBRA following specific qualifying events. If you experience one of the qualifying events listed below, please contact PHIP for additional information. A qualifying event will occur if eligibility for coverage is lost because of: y Cancellation of PERS retirement status y The divorce or legal separation of a retiree s covered spouse; PHIP must be notified within 60 days from the signed Dissolution of Marriage document y A spouse or dependent child no longer meeting eligibility requirements (e.g., a child reaches the maximum age limit, or a spouse loses coverage because the retiree does not enroll in PHIP upon the last enrollment opportunity) Once COBRA has been secured, timely payment of premiums is essential. Timely COBRA premium payments The initial premium must be paid within 45 days of the date COBRA is elected. Thereafter, premiums are due the first day of each month for that month s coverage. If payment is not postmarked or received on or before the 45th day (for the initial premium) or the 30th day following the monthly due date, coverage will be terminated and cannot be reinstated. 46 Required Notices

47 Resources Getting Assistance with your PHIP plan If you are a PERS member and are considering retirement or already retired and will be turning 65 years of age within the next 12 months or for general eligibility and enrollment questions you can contact PHIP at the following: Online By Phone (503) (local) (800) (toll-free) Monday through Friday, 7:30 a.m. to 5:30 p.m. TTY: 711 By Mail PERS Health Insurance Program PO Box Portland, OR Additional Member Resources Centers for Medicare and Medicaid Services (CMS) (800) (toll-free) TTY: (877) Social Security Administration (SSA) (800) (toll-free) TTY: (800) PERS Pension Office Pension questions only In Portland: (503) Toll-free: (888) By Fax (503) (local) (888) (toll-free) In Person Call PHIP to schedule an appointment. Resources 47

48 Contacting Your Health Plan For questions on plan benefits, limitations and exclusions, deductibles (if applicable) refer to your plan s EOC or benefit handbook. You can obtain either by contacting your health plan directly or from Note: For Medicare Supplement members, refer to your Medicare & You handbook for plan benefits, limits and exclusions. Medical Kaiser Foundation Health Plan of the NW (Medicare and Non-Medicare) In Portland: (503) Toll-free: (800) TTY: (800) Medicare Members: (877) my.kp.org/pers Moda Health Plan, Inc. In Portland: (503) Toll-free: (800) PacificSource Medicare In Oregon: (541) Toll-free: (888) TTY: (800) medicare.pacificsource.com/pers/2019/or medicare.pacificsource.com/pers/2019/wa Providence Health Assurance Prospective members: In Portland: (503) Toll-free: (855) Enrolled Medicare members: In Portland: (503) Toll-free: (800) UnitedHealthcare (Medicare and Non-Medicare) Medicare plan: Toll-free: (844) TTY: Non-Medicare plans: Toll-free: (844) TTY: Contact information for Pharmacy and Dental are located on the following page. 48 Contact Information

49 Contacting Your Health Plan (cont.) Pharmacy Kaiser Foundation Health Plan of the NW (Medicare and Non-Medicare) Mail-order pharmacy: In Portland: (503) Toll-free: (800) my.kp.org/pers Moda Health Plan, Inc. In Portland: (503) Toll-free: (888) PacificSource Medicare Medicare members: Toll-free: (888) TTY: (800) medicare.pacificsource.com/pers/2019/or medicare.pacificsource.com/pers/2019/wa Providence Health Assurance In-Portland: (503) Toll-free: (877) UnitedHealthcare (Medicare and Non-Medicare) Medicare plan: Toll-free: (844) TTY: Dental Kaiser Foundation Health Plan of the NW In Portland: (503) Toll-free: (800) my.kp.org/pers Delta Dental of Oregon In Portland: (503) Toll-free: (800) Non-Medicare plans: Toll-free: (844) TTY: Contact Information 49

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52 P.O. Box Portland, OR PRST STD US POSTAGE PAID PORTLAND, OR PERMIT NO Important plan information about your enrollment (8/18)