BENEFIT PACKAGES AVAILABLE: JANUARY 1, 2015

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1 BENEFIT SUMMARY PREPARED FOR THE ACTIVE EMPLOYEES OF: YAKIMA COUNTY BENEFIT PACKAGES AVAILABLE: JANUARY 1, 2015 PLAN #1 INNOVA BUY-UP PLAN: REGENCE MEDICAL/VISION/ DDWA DENTAL/ USABLE LIFE/AD&D PLAN #2 INNOVA BASE PLAN: REGENCE MEDICAL/DDWA DENTAL/USABLE LIFE/AD&D PLAN #3 QUALIFIED HDHP: REGENCE MEDICAL/KEY BANK HSA/DDWA DENTAL/USABLE LIFE/AD&D DOS/DOC OFFICERS, CORPORALS & SERGEANTS PLAN: PLEASE SEE YOUR UNION STEWARD; NORTHWEST ADMINISTRATORS MEDICAL AND VISION/ UEBT DENTAL/USABLE LIFE/AD&D DOC CLERICAL PLAN: NORTHWEST ADMINISTRATORS MEDICAL/UEBT DENTAL AND VISION/USABLE LIFE/AD&D SOLID WASTE PLAN: NORTHWEST ADMINISTRATORS MEDICAL/DENTAL AND VISION/USABLE LIFE/AD&D DEPUTIES PLAN: PEBB UNIFORM CLASSIC PLAN KEY CONTACTS: Yakima County Human Resources General Office (509) Brokered By: 603 North 39 th Avenue, Suite 102 Yakima WA /(509) On March 23, 2010, the Affordable Care Act was signed into law. The Act puts in place comprehensive health insurance reform through 2014 and beyond. Please see page 5 for important changes that have already begun. Customer Service Telephone Numbers: Regence BlueShield Delta Dental of Washington USAble Life Allegiance If you (and/or your dependents) have Medicare or will become eligible for Medicare in the next 12 months, Federal law gives you more choices about your prescription drug coverage. Please see page 8 for more details. PLEASE NOTE: This has been prepared to briefly highlight key features of your plan and is not to replace your insurance contract or booklet. We have compiled information into summary form to answer questions we most commonly receive. Please refer to the insurance carriers contracts and booklets for more detailed information and plan limitations. Actual claims paid are subject to the terms and conditions of the individual carriers contracts. ba; 9/24/14

2 Medical & Vision Benefit Outline Regence BlueShield PLAN #1 PLAN #2 PLAN #3 BUY-UP PLAN - INNOVA BASE PLAN - INNOVA QUALIFIED HDHP PCY = Per Calendar Year Category 1 Category 2 Category 3 Category 1 Category 2 Category 3 Category 1 Category 2 Category 3 Deductible (individual/family) $300/$600 $750/$1,500 $1,500/$3,000 Family: Members must pay all the costs up to the family deductible amount before this plan pays for any member s covered services. Out-of-Pocket Maximum** $3,300/$6,600 $5,750/$11,500 $3,000/$6,000 (individual/family) After the deductible is satisfied, your cost shares will be as follows: Family: no one family member is eligible for 100% coverage until the entire family out-of-pocket maximum is met Physician Services $30 co-pay* $45 co-pay* 40% $30 co-pay* $45 co-pay* 40% 20% 40% 40% office visits for first 6 visits PCY 20% thereafter 40% thereafter Outpatient Surgery 20% 40% 40% 20% 40% 40% 20% 40% 40% Covered in Covered in Covered in Covered in Covered in Covered in Covered in Covered in Preventive Care 40%* Full* Full* Full* Full* Full* Full* Full* Full* Vision Exam - once PCY Covered in Covered in Covered in Full* Full* Full* Not Covered Not Covered Vision Hardware up to $200 PCY Not Covered Not Covered Hearing Exam - once PCY 20% 40% 40% 20% 40% 40% Not Covered Acupuncture 20% 40% 40% 20% 40% 40% 20% 40% 40% up to 12 visits PCY up to 12 visits PCY up to 12 visits PCY Spinal Manipulations 20% 40% 40% 20% 40% 40% 20% 40% 40% up to 12 visits PCY up to 12 visits PCY up to 10 visits PCY Rehabilitation Services Inpatient 20% 40% 40% 20% 40% 40% 20% 40% 40% up to 30 days PCY up to 30 days PCY up to 30 days PCY Outpatient 20% 40% 40% 20% 40% 40% 20% 40% 40% up to 50 visits PCY up to 50 visits PCY up to 25 visits PCY Category 1: Preferred Providers; Category 2: Participating Providers; Category 3: Any Licensed Provider. If you receive services from a Category 3 provider, you may be responsible for balances beyond deductible, copayment and/or coinsurance. * Deductible Waived ** The out-of-pocket maximum includes deductibles, coinsurance, copayments, or similar charges and any other required expenditure that is a qualified medical expense with respect to essential health benefits covered under the plan. To assist you in making decisions regarding your health care coverage, your plan makes available a Summary of Benefits and Coverage (SBC), which summarizes important information about any health coverage option in a standard format, as required by Health Care Reform regulations. The SBC is available on the web at A paper copy of the SBC is also available, free of charge. Please contact our HR Department at human.resources@co.yakima.wa.us. Prepared by Gallagher Benefit Services, Inc. Yakima County Page 1

3 Medical & Vision Benefit Outline, Continued Regence BlueShield PLAN #1 PLAN #2 PLAN #3 BUY-UP PLAN - INNOVA BASE PLAN - INNOVA QUALIFIED HDHP PCY = Per Calendar Year Category 1 Category 2 Category 3 Category 1 Category 2 Category 3 Category 1 Category 2 Category 3 Prescription Drugs - 30-day supply At Preferred Pharmacies Only* At Preferred Pharmacies Only* At Preferred Pharmacies Only* Generic $10 co-pay $10 co-pay 20% co-pay, after plan deductible Brand Name Deductible $100 per member PCY $100 per member PCY N/A medical deductible applies Brand Name, Formulary $30 co-pay** $30 co-pay** 20% co-pay, after plan deductible Brand Name, Non Formulary $60 co-pay** $60 co-pay** 20% co-pay, after plan deductible Mail Order up to 90-day supply 2 x co-pay for up to 90-day supply 2 x co-pay for up to 90-day supply 20% co-pay, after plan deductible Hospital/Facility Services 20% 40% 40% 20% 40% 40% 20% 40% 40% semi-private room/board, ICU, CCU, ancillary charges, maternity Mental Health 20% 20% 40% 20% 20% 40% 20% 20% 40% (inpatient) Chemical Dependency 20% 20% 40% 20% 20% 40% 20% 20% 40% (inpatient) TMJ 20% 40% 40% Not Covered 20% 40% 40% Emergency Room Services $125 co-pay per visit then 20% $125 co-pay per visit then 20% 20% 20% 20% (co-pay waived if admitted) Outpatient Diagnostic Lab & X-ray Covered in Covered in Covered in Covered in Covered in Covered in Full* Full* Full* Full* Full* Full* 20% 40% 40% (including mammography) for the first $400 PCY; thereafter: for the first $400 PCY; thereafter: 20% 40% 40% 20% 40% 40% Lifetime and Annual Maximums Unlimited Unlimited Unlimited Category 1: Preferred Providers; Category 2: Participating Providers; Category 3: Any Licensed Provider. If you receive services from a Category 3 provider, you may be responsible for balances beyond deductible, copayment and/or coinsurance. * Medical plan deductible waived. Plans #1 and #2 have a Brand Name Prescription Drug deductible which will apply. Qualified HDHP deductible applies to all Prescription Drug benefits, except for Value-based medications. Contact Regence BlueShield for a complete list of Value-based medications. **If an equivalent generic medication is available and a brand-name medication is chosen, the member is responsible for paying the applicable brand name deductible & co-payment plus the difference in price between the equivalent generic medication and the brand-name medication not to exceed total retail cost. This outline is for illustrative purposes only. Actual claims paid are subject to the terms and conditions of the contract. Prepared by Gallagher Benefit Services, Inc. Yakima County Page 2

4 Dental Benefit Outline Delta Dental of Washington Delta Dental PPO and Premier Dentists or Any Licensed Dentist Calendar Year Deductible Per Person/Family $25/$75 Calendar Year Maximum Benefit Per Person $1,500 After the deductible is satisfied, your cost share will be as follows: Diagnostic and Preventive Services routine oral exams (twice in a benefit period), cleanings (twice in a benefit period), full mouth x-rays (once per 5 years), topical fluoride application (twice in a benefit period), space maintainers (once per lifetime per tooth area), sealants (once per tooth, every 2 years on permanent molar teeth) Basic Services fillings, extractions, periodontics, oral surgery, endodontics, general anesthesia Major Services Covered in Full (deductible waived) 20% of allowed amount (deductible applies) 50% of allowed amount inlays, onlays, crowns, bridges, dentures, implants (deductible applies) Orthodontia Covered in Full Adult and child (deductible waived) $250 maximum for initial banding up to $500 lifetime maximum Please refer to benefit booklet or customer service to confirm benefits, predetermination procedures and benefit limitations. Delta Dental PPO and Premier dentists will not balance bill. This outline is for illustrative purposes only. Actual claims paid are subject to the terms and conditions of the contract. Prepared by Gallagher Benefit Services, Inc. Yakima County Page 3

5 Life/AD&D Benefit Outline USAble Life (All Eligible Employees) Benefit Amount Life Insurance Accidental Death & Dismemberment Dependent Coverage Spouse Child (6 months to age 26) Child (birth to 6 months of age) $10,000 $10,000 Benefits Reduce to 65% at age 70; 45% at age 75; terminate at retirement Active employees and their dependents must be enrolled on a Yakima County medical plan to be eligible for coverage. $1,000 $1,000 $100 Voluntary Benefits See brochures for rates and coverage opportunities: vchoice (Employee/Spouse/Child Life, Long Term Disability, Short Term Disability, Vision, Long Term Care, Group Accident, Critical Illness, Injury Accident and Pet Insurance) Flexible Spending Account (Health and Dependent Care) Limited purpose FSA only allowed for employees who enroll in the Qualified HDHP. Health Savings Account Only allowed with enrollment in Qualified HDHP PLEASE NOTE: Life/AD&D and all Voluntary Benefits may not apply depending on your employment status (Active Employee, Retiree or COBRA Participant). This outline is for illustrative purposes only. Actual claims paid are subject to the terms and conditions of the contract. Prepared by Gallagher Benefit Services, Inc. Yakima County Page 4

6 Important Notes ORGAN TRANSPLANT Transplants are limited to the plan annual maximum with a six (6) month waiting period. Members may receive credit from prior medical coverage. Transplants must be pre-authorized and performed by a facility designated by Regence BlueShield. WOMEN S HEALTH AND CANCER RIGHTS ACT The Women's Health and Cancer Rights Act of 1998 requires group health plans that provide medical and surgical coverage for mastectomies also provide coverage for reconstructive surgery following such mastectomies in a manner determined in consultation with the attending physician and the patient. Coverage must include: All stages of reconstruction of the breast on which the mastectomy has been performed, Surgery and reconstruction of the other breast to produce a symmetrical appearance, and Prostheses and treatment of physical complications of all stages of mastectomy, including lymphedemas. Benefits for the above coverage are payable on the same basis as any other physical condition covered under the plan, including any applicable deductible and/or co-pays and co-insurance amounts. OUT-OF-AREA BENEFITS The BlueCard program is a unique program that enables you to access hospitals and physicians when traveling outside the four-state area Regence serves (Idaho, Oregon, Utah and Washington), as well as receive care in 200 countries around the world. Find a provider near you at or call BLUE (2583). HIPAA PRIVACY NOTICE UPDATE The HIPAA law requires Yakima County to notify its employees that a privacy notice is available from the Human Resources Department. To request a copy of Yakima County s Privacy Notice or for additional information, please contact Human Resources. SPECIAL ENROLLMENT RIGHTS If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents other coverage). However, you must request enrollment within 30 days after your or your dependents other coverage ends (or after the employer stops contributing toward the other coverage). You may also be able to enroll yourself or your dependents in the future if you or your dependents lose health coverage under Medicaid or your state Children s Health Insurance Program, or become eligible for state premium assistance for purchasing coverage under a group health plan, provided that you request enrollment within 60 days after that coverage ends or after you become eligible for premium assistance. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 60 days after the marriage, birth, adoption, or placement for adoption. To request special enrollment or obtain more information, contact your Human Resources Department. EXTENSION OF DEPENDENT COVERAGE TO AGE 26 Under the new law, young adults will be allowed to stay on their parents plan until they turn 26 years old. PREVENTIVE CARE Certain preventive care services must be provided by non-grandfathered group health plans without member cost-sharing (such as deductibles or copays) when these services are provided by a network provider. A list of these preventive services can be found on the HHS website at: healthcare.gov/what-are-my-preventive-care-benefits/. Prepared by Gallagher Benefit Services, Inc. Yakima County Page 5

7 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 healthcare.gov. 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 insurekidsnow.gov 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 askebsa.dol.gov 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 KANSAS Medicaid Website: Website: Phone: Phone: ALASKA Medicaid KENTUCKY Medicaid Website: Website: Phone (Outside of Anchorage): Phone: Phone (Anchorage): LOUISIANA Medicaid ARIZONA CHIP Website: Website: Phone: Phone (Outside of Maricopa County): MAINE Medicaid COLORADO Medicaid Website: Medicaid Website: Phone: Medicaid Phone (In state): TTY Medicaid Phone (Out of state): MASSACHUSETTS Medicaid and CHIP FLORIDA Medicaid Website: Website: Phone: Phone: MINNESOTA Medicaid GEORGIA Medicaid Website: Website: Click on Health Care, then Medical Assistance Click on Programs, then Medicaid, then Health Insurance Premium Payment Phone: (HIPP) Phone: MISSOURI Medicaid IDAHO Medicaid and CHIP Website: Medicaid Website: Phone: Medicaid Phone: MONTANA Medicaid CHIP Website: Website: CHIP Phone: Phone: INDIANA Medicaid NEBRASKA Medicaid Website: Website: Phone: Phone: IOWA Medicaid NEVADA Medicaid Website: Medicaid Website: Phone: Medicaid Phone: Prepared by Gallagher Benefit Services, Inc. Yakima County Page 6

8 PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN S HEALTH INSURANCE PROGRAM (CHIP) CONTINUED NEW HAMPSHIRE Medicaid SOUTH CAROLINA Medicaid Website: Website: Phone: Phone: NEW JERSEY Medicaid and CHIP SOUTH DAKOTA - Medicaid Medicaid Website: Website: dmahs/clients/medicaid/ Phone: Medicaid Phone: TEXAS Medicaid CHIP Website: Website: CHIP Phone: Phone: NEW YORK Medicaid UTAH Medicaid and CHIP Website: Website: Phone: Phone: NORTH CAROLINA Medicaid VERMONT Medicaid Website: Website: Phone: Phone: NORTH DAKOTA Medicaid VIRGINIA Medicaid and CHIP Website: Medicaid Website: Phone: Medicaid Phone: OKLAHOMA Medicaid and CHIP CHIP Website: Website: CHIP Phone: Phone: WASHINGTON Medicaid OREGON Medicaid and CHIP Website: Website: Phone: ext WEST VIRGINIA Medicaid Phone: Website: PENNSYLVANIA Medicaid Phone: , HMS Third Party Liability Website: WISCONSIN Medicaid Phone: Website: RHODE ISLAND Medicaid Phone: Website: WYOMING Medicaid Phone: Website: Phone: To see if any more States have added a premium assistance program since July 31, 2014, or for more information on special enrollment rights, you can contact either: U.S. Department of Labor Employee Benefits Security Administration EBSA (3272) U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services , Menu Option 4, Ext Ext , Ext Prepared by Gallagher Benefit Services, Inc. Yakima County Page 7

9 Certificate of Creditable Prescription Drug Coverage Important Notice from Yakima County About Your Prescription Drug Coverage and Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Yakima County and about your options under Medicare s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. Yakima County has determined that the prescription drug coverage offered by the Regence BlueShield is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 th through December 7 th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current Yakima County coverage may be affected. Your current coverage pays for other health expenses in addition to prescription drugs. If you enroll in a Medicare prescription drug plan, you and your eligible dependents may still be eligible to receive all of your current health and prescription drug benefits. If you do decide to join a Medicare drug plan and drop your current Yakima County coverage, be aware that you and your dependents may be able to get this coverage back by enrolling back into the Yakima County benefit plan during the open enrollment period under the Yakima County benefit plan. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Yakima County and don t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For More Information About This Notice Or Your Current Prescription Drug Coverage Contact the person listed below for further information. NOTE: You ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Yakima County changes. You also may request a copy of this notice at any time. For More Information About Your Options Under Medicare Prescription Drug Coverage More detailed information about Medicare plans that offer prescription drug coverage is in the Medicare & You handbook. You ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. Prepared by Gallagher Benefit Services, Inc. Yakima County Page 8

10 Certificate of Creditable Prescription Drug Coverage, Continued For more information about Medicare prescription drug coverage: Visit Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the Medicare & You handbook for their telephone number) for personalized help Call MEDICARE ( ). TTY users should call If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at or call them at (TTY ). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). Date: January 1, 2015 Name of Entity/Sender: Yakima County Contact--Position/Office: Human Resources Address: 128 North 2nd Street Courthouse, Room B27 Yakima, WA Phone Number: (509) Prepared by Gallagher Benefit Services, Inc. Yakima County Page 9