Program Reference Guide The CHOICE Administrators Program Reference Guide is designed to provide you with the most up-to-date information on the programs offered by CHOICE Administrators the underwriting, eligibility and participation requirements, enrollment documentation, plan co-pays, and much more. It also includes contact information for all product lines including the names of renewal specialists in your area who are ready, willing, and able to assist you with your renewals. Contents MEDICAL CaliforniaChoice...3 CaliforniaChoice 51+...13 HSA California...17 Kaiser Permanente Choice Solution...25 ANCILLARY CONSUMER EXCHANGE PROGRAM Choice Builder...33 DENTAL CaliforniaChoice...39 HSA California...41 Kaiser Permanente Choice Solution...43 TO OUR BROKERS: The information in this reference guide is accurate to the best of our knowledge at the time of printing. However, since this publication is intended strictly as a guide and plan specifications may change we recommend that you verify any data with your CHOICE Administrators sales representative before basing any decisions on the information provided.
www.choiceadmin.com Important Telephone Numbers If you ever have any questions about coverages, or need a quote, please contact the appropriate program listed below: (800) 542-4218 (866) 226-7431 (800) 416-4395 (866) 251-4625 (866) 412-9254 2
MEDICAL www.choiceadmin.com Del rte Siskiyou Modoc The following HMOs have an Excellent rating from the NCQA for their commercial products: Kaiser Foundation Health Plan, Inc. - Southern California (HMO) Kaiser Foundation Health Plan, Inc. - rthern California (HMO) Western Health Advantage The following HMO has a Commendable rating from the NCQA for their commercial products: Anthem Blue Cross Life and Health Insurance Company (PPO) Health Net of California, Inc. (HMO) Humboldt Trinity Tehama Shasta Plumas Lassen (See next page for carrier telephone and address information) Mendocino Marin Lake Sonoma San Francisco San Mateo Glenn Colusa Napa Santa Cruz Yolo Solano Butte Sutter Yuba Contra Costa Alameda Santa Clara Sacramento San Joaquin El Dorado Amador San Benito Sierra Stanislaus Nevada Placer Calaveras Merced Alpine Tuolumne Mariposa Madera Fresno Mono ;PPO Only Counties HMO & PPO Counties Plan may not be available in all Zip Codes within county. Check with your CaliforniaChoice representative to confirm if coverage is available for your group location. Inyo Monterey Kings Tulare San Luis Obispo Kern Santa Barbara Ventura Los Angeles San Bernardino Orange Riverside San Diego Imperial 3
www.choiceadmin.com MEDICAL Carrier Contact Information Member Support CaliforniaChoice Customer Service Center 800-558-8003 Anthem Blue Cross 866-524-5659 Health Net 800-361-3366 Kaiser Permanente English 800-464-4000 Spanish 800-788-0616 Sharp Health Plan 800-359-2002 Western Health Advantage 888-563-2250 CaliforniaChoice Bilingual Support 800-558-8003, Press #9 for Spanish Internet Support www.calchoice.com Provider Eligibility Verification 800-558-8003 Broker Services & Commissions 714-542-6992 - Ext. 4390 Broker of Record Changes Fax 714-972-7368 Adds/Terms Fax 714-558-8000 Billing Questions 800-558-8003 Claims Contact carriers directly To contact by mail, or for payment submission: CaliforniaChoice 721 South Parker, Suite 200 Orange, CA 92868 Tax ID Number 33-0115986 4
MEDICAL www.choiceadmin.com Products Offered HMO CalChoice HMO 15 CalChoice HMO 25 CalChoice HMO 25 Value CalChoice HMO 30 CalChoice HMO 30 Value CalChoice HMO 40 CalChoice HMO 40 Value Elect Open Access Elect Open Access 25+ Elect Open Access 40+ Salud HMO y Más Salud Mexico PPO CalChoice PPO 750 CalChoice PPO 750 GenRx CalChoice PPO 1000 CalChoice PPO 1000 GenRx CalChoice PPO 3000 CalChoice PPO 4000 CaliforniaChoice PPO plan availability based on group eligibility and may be subject to change Provider Information NETWORKS Networks vary according to Health Care Service Plan (HCSP) Consumer Directed Healthcare HSA-Compatible PPO HRA-Compatible MRP-Compatible Lumenos HSA 1800 * PPO PPO Lumenos HSA 2500 * Multi Option (Mix And Match) Maximum Choice For Employees Each employee's health care needs are different. The CaliforniaChoice program provides employees the maximum choice in meeting those needs with these health plans all within one program: Anthem Blue Cross PPO Anthem Blue Cross HMO Anthem Blue Cross Select HMO Health Net HMO Elect Open Access (from Health Net) Salud HMO y Más Health Net Silver HMO Optional Benefits Available Discount or Buy-up Discount or Buy-up t Available Kaiser Permanente HMO Sharp Health Plan HMO Western Health Advantage HMO COBRA enrollees are not counted toward total group size. Life Only enrollees are not counted toward total group size. Dental Only enrollees are not counted toward total group size. GROUP SIZE PLEASE NOTE: t all health plans are available in all areas CaliforniaChoice PPO Guidelines Group Size Plans Available 2-9 medically enrolled All HMO and HMO Value Plans and CalChoice PPO 750 GenRx, employees CalChoice PPO 1000, CalChoice PPO 1000 GenRx, CalChoice PPO 3000, CalChoice PPO 4000, Lumenos HSA 1800 & Lumenos HSA 2500 10+ medically enrolled employees CaliforniaChoice CaliforniaChoice All HMO and HMO Value Plans and CalChoice PPO 750, CalChoice PPO 750 GenRx, CalChoice PPO 1000, CalChoice PPO 1000 GenRx, CalChoice PPO 3000, CalChoice PPO 4000, Lumenos HSA 1800 & Lumenos HSA 2500 LIFE DENTAL VISION INFERTILITY CHIROPRACTIC ACUPUNCTURE CaliforniaChoice * HSA-Qualified High Deductible Health Plan PPO plan availability based on group eligibility and may be subject to change For Salud HMO y Más, only Salud network optional benefits are shown here. SIMNSA network benefits vary call your CaliforniaChoice representative for details Chiro only or Chiro & Acupuncture Riders Available Combined Chiro & Acupuncture Rider Available SELECTION How often can members change their Primary Care Physician (PCP)? Refer to summary on pages 8-9 Can family members each choose a PCP from a different IPA/Medical Group? Refer to summary on pages 8-9 SPECIALIST REFERRALS Self-referral available? Varies by Health Care Service Plan (See summary on pages 8-9 Express referral available? Varies by Health Care Service Plan (See summary on pages 8-9) 24 HOUR COVERAGE Is Workers' Comp required on corporate officers, partners and sole proprietors? Is on-the-job covered for corporate officers, partners and sole proprietors? Is there a premium adjustment for 24 hour coverage? MASSAGE THERAPY Varies by HCSP 5
www.choiceadmin.com MEDICAL Plan Eligibility Requirements Wrap* Requirements CaliforniaChoice ENROLLMENT GROUP SIZE Min. # of employees Max. # of employees AFTER INITIAL ISSUE 2 2 50* * Over 50 only if group is SB 578 qualified. (If group has less than 50 employees, for 50% of the preceding calendar quarter or preceding calendar year) GROUP Can be written with another SIZE carrier's PPO or indemnity plan? MINIMUM EMPLOYER CONTRIBUTION Employees For Dependents % of Total Cost: GROUP SIZE 50% of lowest cost plan GROUP Can be written with another SIZE carrier's HMO, POS or EPO? *Indicates flexibility in being offered with products of another carrier. PARTICIPATION Contributory Employees Dependents n-contributory Employees Dependents COVERAGE RESTRICTIONS GROUP SIZE Those covered by another plan are NOT considered eligible in calculating participation. In order to NOT be considered eligible, the other coverage must be a group plan, Champus, Medicare or Medi-Cal * 1 Life groups allowed Employer contribution is 100% of employee lowest cost HMO plan or more Are Commission employees allowed? if on quarterly/annual wage report and showing at least minimum wages and withholdings Are 1099 employees allowed? 2-2 3-50 *100% 70% *100% CaliforniaChoice 100% of employees not covered by group insurance and 70% of all employees regardless of other coverage Are employees covered if traveling out of USA? Only for emergency benefits Carve Outs* EXCLUSIONS ALLOWED BY CARRIER: Hourly/Salary? Management/n-management? CaliforniaChoice Union/n-union? coverage available for non-union only. Group must submit union billing to underwriting for verification that all other employees have union coverage Minimum group size 2 Does carrier underwrite and rate carve out groups according to AB1672 guidelines? * Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage. Is coverage available for out-of-state employees? CalChoice PPO 750, CalChoice PPO 750 GenRx, CalChoice PPO 1000, CalChoice PPO 1000 GenRx, CalChoice PPO 3000, CalChoice PPO 4000, Lumenos HSA 1800* and Lumenos HSA 2500* *HSA-Qualified High Deductible Health Plan Max. % of employees residing out-of-state allowed 49% (Main office must be located in California) 6
MEDICAL www.choiceadmin.com Enrollment Information & Requirements Carrier's Effective Date Premium Amount Required for 20th? Employee Waiting Periods Available Applications must be dated within: Spouse/Domestic Partner Employees - 1 application or 2? Employee Waiver Cards Required at enrollment? Are Telephone Interviews done by Underwriting? Must Brokers Carry Errors & Omissions Insurance? Does Carrier Offer Open Enrollment? CaliforniaChoice 1st of the month only Balance Due Min: 30 Max: 365 60 days (if enrolling separately, Use either 1 or 2 applications 2 applications required) 60 days prior to anniversary DOCUMENTATION & PAYMENT INFORMATION Quarterly/annual wage report required? Payroll Records OK if no quarterly/annual wage report? Call representative Is a Prior Booklet required? * Is Prior Billing required? * Must submit check with initial application? Check Made payable to: CaliforniaChoice *Only if any employees take PPO Dental FEES Enrollment Fee Amount Type of Enrollment Fee Monthly Billing Fee DEDUCTIBLE CREDIT Prior carrier deductible credit given? 4th quarter deductible carry-over credit given? ne 1-8 9-20 21+ $20 $25 $30 HMO: PPO: * *This does NOT include credit for the RX deductible Medical Underwriting Requirements Current Employees Timely Add-ons Rating Information GROUP SIZE 2-14 15-50 Employee Medical Questionnaire n Medical RAF Increments ( lives) Rate Guarantee Apply Trend Factor? Use Employee Zips? Master App (Employer Questions) 2-4: 1.10 5-50: 1.00 15-50: 1.00* *Groups may qualify for a 0.90. See quote for details. 12 Months n Medical HMO: PPO: CaliforniaChoice According to the California Insurance Code The standard employee risk rates applied to a small employer for new business shall be in effect for no less than six months. ITEMS Items Reviewed REVIEWED In IN RAF RAF Calculation CALCULATION Medical Conditions Years in Business # of Pregnancies Virgin Group Type of Industry Percent of Owners Group Size % of COBRA Insureds % of Family Related Participation Plan(s) Requested 24 HR Coverage Req'd Employer Contribution Bankruptcy Gender Mix Call 800-511-0001 www.choiceadmin.com 7
www.choiceadmin.com MEDICAL Benefit Summary Provider Information CaliforniaChoice How often can family members change their Primary Care Physician? (PCP) HMO Anthem Blue Cross HMO Once a month changes are effective at the beginning of the following month, provided the member is not in the course of treatment or hospitalized and no pending authorizations. Health Net HMO, Elect Open Access, & Salud HMO y Más* (*only Salud network benefits shown) Once a month NOTE: Each HCSP HMO has their own PCP change approval process Kaiser Permanente HMO Anytime Can family members each choose a PCP from a different IPA/Medical Group? from Kaiser Permanente Physicians Do plans have these types of programs to speed the specialist referral process in network: Self referral? Express referral? referrals come directly from PCP HMO: Self: if Rapid Access provider Elect Open Access: member may self refer to any doctor in PPO network for a higher copay Self: to OB/GYN and certain other specialties (list varies by region) Express: referral direct from physician Is there an Out-of-Network benefit? s CaliforniaChoice If generic available, and doctor has not indicated dispense as written, will member receive a generic equivalent rather than a name brand drug? or you must pay the Generic copay plus the difference in cost between the brand name & generic equivalent or must pay brand copay + difference in cost between brand name & generic equivalent If doctor writes dispense as written on prescription, is brand name available at the brand copay? Does health plan use Rx formulary? If medically necessary, are non-formulary drugs covered? What is copay for covered non-formulary drugs? CalChoice HMO15: CalChoice HMO 25: CalChoice HMO 30: CalChoice HMO 40: CalChoice HMO 25 Value: CalChoice HMO 40 Value: Mail order CalChoice HMO15: CalChoice HMO 25: CalChoice HMO 30: CalChoice HMO 40: CalChoice HMO 25 Value: CalChoice HMO 40 Value: * non-formulary copay applies *Prior authorization may be required for certain medications $40 $50 $50 $50 $50 $50 90 day supply: $10/$40/$80 $15/$60/$100 $15/$60/$100 $20/$60/$100 $15/$60/$100 $15/$60/$100 * $50 non-formulary copay applies *Prior authorization may be required for certain medications Generic Brand A $50 non-formulary copay applies for: CalChoice HMO 15, CalChoice HMO 25, CalChoice HMO 25 Value, CalChoice HMO 30, CalChoice HMO 30 Value, CalChoice HMO 40, CalChoice HMO 40 Value, Elect Open Access, Elect Open Access 25+, Elect Open Access 40+ and Salud HMO y Más 90 day supply double retail copay if deemed medically necessary by Kaiser Permanente Physician Generic $10 $15 $15 $15 Brand $20 $25 $30 $30 100 day supply double the retail copay *generic copay/brand name copay/non-formulary copay if applicable FOR DETAILED BENEFIT INFO, LIMITATIONS AND EXCLUSIONS, PLEASE REFER TO BOOKLET CERTIFICATE/EVIDENCE OF COVERAGE, OR CONTACT YOUR CALIFORNIACHOICE REPRESENTATIVE 8
MEDICAL www.choiceadmin.com Provider Information Benefit Summary BENEFIT SUMMARY CaliforniaChoice Sharp Health Plan Western Health Advantage PPO Anthem Blue Cross Life and Health Insurance Company How often can family members change their Primary Care Physician? (PCP) Once a month Once a month changes are effective at beginning of following month, provided the member is not in the course of treatment or hospitalized and no pending authorizations NOTE: Each HCSP HMO has their own PCP change approval process Anytime in a PPO, you do not have to choose a PCP Can family members each choose a PCP from a different IPA/Medical Group? but only from network physicians each family member can make their own physician choice Do plans have these types of programs to speed the specialist referral process in network: Self referral? Express referral? Self: available through medical group (some medical groups offer direct access to certain specialists) Advantage Referral Program allows PCP referral to most specialists in the WHA network in a PPO, you can choose any physician Is there an Out-of-Network benefit? Negotiated Fee Schedule s CaliforniaChoice If generic available, and doctor has not indicated dispense as written, will member receive a generic equivalent rather than a name brand drug? If doctor writes dispense as written on prescription, is brand name available at the brand copay? Does health plan use Rx formulary? If medically necessary, are non-formulary drugs covered? What is copay for covered non-formulary drugs? CalChoice HMO15: CalChoice HMO 25: CalChoice HMO 30: CalChoice HMO 40: CalChoice HMO 25 Value: CalChoice HMO 40 Value: Mail order *generic copay/brand name copay/non-formulary copay if applicable * non-formulary copay applies *Prior authorization may be required for certain medications Generic Brand Double the formulary brand copay 90 day supply double the 30-day retail copay non-formulary: Call your CaliforniaChoice representative or must pay the brand copay plus the difference in cost between the brand name and generic equivalent * non-formulary copay applies *Prior authorization may be required for certain medications $35 $50 $50 $50 CalChoice HMO 40 Value $50 90 day supply CalChoice HMO 15: $25/$50/$88 CalChoice HMO 25: $38/$75/$125 CalChoice HMO 30: $38/$75/$125 CalChoice HMO 40: $50/$75/$125 CalChoice HMO 40 Value: $50/$75/$125 or you must pay the Generic copay plus the difference in cost between the brand name & generic equivalent member will have to pay the generic copay plus the difference in cost between generic and brand Participating Pharmacy: $50 n-participating Pharmacy: 50% of Maximum allowed amount* n-formulary Benefits for GenRx The brand deductible will apply: PPO 750 - $150 PPO 1000 - $200 PPO 3000 - $250 PPO 4000 - $250 Lumenos HSA 1800 - subject to medical deductible Lumenos HSA 2500 - subject to medical deductible 90 day supply: $15/$60/$100 n-participating Pharmacy: t Covered n-formulary Benefits for GenRx The brand deductible will apply: PPO 750 - $150 PPO 1000 - $200 PPO 3000 - $250 PPO 4000 - $250 Lumenos HSA 1800 - subject to medical deductible Lumenos HSA 2500 - subject to medical deductible FOR DETAILED BENEFIT INFO, LIMITATIONS AND EXCLUSIONS, PLEASE REFER TO BOOKLET CERTIFICATE/EVIDENCE OF COVERAGE, OR CONTACT YOUR CALIFORNIACHOICE REPRESENTATIVE *HSA-Qualified High Deductible Health Plan 9
www.choiceadmin.com MEDICAL Benefit Summary Diabetic Benefits CaliforniaChoice Are the following items covered under the Drug Benefit, Durable Medical Equipment Benefit or Diabetes Care Benefit of the member s selected plan design? HMO Anthem Blue Cross HMO Health Net HMO, Elect Open Access, & Salud HMO y Más* (*only Salud network benefits shown) Kaiser Permanente HMO Insulin Needles & Syringes Chem-Strips and/or Testing Agents (Blood Test Strips) Covered under the s Blood test strips are covered under Durable Medical Equipment; Urine test strips are covered under Insulin Pump Supplies Durable Medical Equipment Benefit Covered at: CalChoice HMO 15-90% CalChoice HMO 25-80% CalChoice HMO 25 Value - 80% CalChoice HMO 30-80% CalChoice HMO 30 Value - 80% CalChoice HMO 40-80% Cal Choice HMO 40 Value - 80% Elect Open Access - 80% Elect Open Access 25+ - 80% Elect Open Access 40+ - 80% Salud HMO y Más - 80% Durable Medical Equipment Benefit Glucose Monitor Free Glucometer Program for certain manufacturers; otherwise, covered under Durable Medical Equipment: CalChoice HMO 15 90% CalChoice HMO 25 70% CalChoice HMO 30 50% CalChoice HMO 40 50% CalChoice HMO 25 Value 50% CalChoice HMO 40 Value 50% Covered under the Drug Benefit (Preferred monitors only) All other monitors covered at: CalChoice HMO 15-90% CalChoice HMO 25-80% CalChoice HMO 25 Value - 80% CalChoice HMO 30-80% CalChoice HMO 30 Value - 80% CalChoice HMO 40-80% CalChoice HMO 40 Value - 80% Elect Open Access - 80% Elect Open Access 25+ - 80% Elect Open Access 40+ - 80% Salud HMO y Más - 80% Durable Medical Equipment Benefit Insulin Pump Vendors for Diabetes Equipment: Durable Medical Equipment Benefit Please see carrier website for list of providers Covered at: CalChoice HMO 15-90% CalChoice HMO 25-80% CalChoice HMO 25 Value - 80% CalChoice HMO 30-80% CalChoice HMO 30 Value - 80% CalChoice HMO 40-80% CalChoice HMO 40 Value - 80% Elect Open Access - 80% Elect Open Access 25+ - 80% Elect Open Access 40+ - 80% Salud HMO y Más - 80% Benefits are typically covered under the pharmacy benefit with participating pharmacies. Health Net will only cover certain machines. Durable Medical Equipment Benefit Pending Self-Injectable s CaliforniaChoice Are self-injectable drugs (other than insulin) covered under the Drug benefit or Medical Benefit? May depend on the medication. Call Pharmacy Services at 800-700-2533 to confirm Medical Benefit Is pre-authorization required? Some medications and/or dosages may require prior authorization Must be prescribed by a plan physician Must self-injectables (other than insulin) be purchased via the carrier-contracted mail order RX vendor? Certain drugs must go through mail-order provider. Call Pharmacy Services at 800-700-2533 to confirm use doctor's contracted vendor Must use plan pharmacies (including affiliated pharmacies) 10
MEDICAL www.choiceadmin.com Benefit Summary Diabetic Benefits CaliforniaChoice Are the following items covered under the Drug Benefit, Durable Medical Equipment Benefit or Diabetes Care Benefit of the member s selected plan design? Sharp Health Plan Western Health Advantage PPO Anthem Blue Cross Life and Health Insurance Company Insulin Needles & Syringes Durable Medical Equipment Benefit Chem-Strips and/or Testing Agents Durable Medical Equipment Benefit (Blood Test Strips) Covered under the s Insulin Pump Supplies Durable Medical Equipment Benefit Durable Medical Equipment Benefit Durable Medical Equipment Benefit Glucose Monitor Durable Medical Equipment Benefit Durable Medical Equipment Benefit Free Glucometer Program for certain manufacturers; otherwise, covered under Durable Medical Equipment In-Network: 50% Out-of-Network: 50% Insulin Pump Durable Medical Equipment Benefit Durable Medical Equipment Benefit Durable Medical Equipment Benefit Vendors for Diabetes Equipment: ADS Advanced Diabetes Supply 390 Oak Avenue, Suite "N" Carlsbad, CA 92008 800-730-9887 Contract is with Medical Group. See PCP Please see carrier website for list of providers Edgepark 1810 Summit Commerce Park Twinsburg, OH 44087 800-321-0591 Self-Injectable s CaliforniaChoice Are self-injectable drugs (other than insulin) covered under the Drug benefit or Medical Benefit? May depend on medication Medical Benefit May depend on the medication. Call Pharmacy Services at 800-700-2533 to confirm Is pre-authorization required? Some medications and/or dosages may require prior authorization Some medications and/or dosages may require prior authorization Must self-injectables (other than insulin) be purchased via the carrier-contracted mail order RX vendor? mail order not required Depends on medical group Certain drugs must go through mail-order provider. Call Pharmacy Services at 800-700-2533 to confirm 11
www.choiceadmin.com Salud HMO y Más plan design varies depending on whether the Salud provider network or the SIMNSA provider network is utilized by the employee and dependents. The information outlined on this page only reflects the Salud provider network. Call your CaliforniaChoice representative for Mexico benefit details. Special Concerns* MEDICAL CaliforniaChoice Infertility HMO: PPO: * Unless otherwise noted, information shown in this section reflects in-network benefits. s $1500 lifetime maximum on infertility drugs. Evaluation & treatment using covered procedures (no in-vitro fertilization) 50% of allowed charges. te: Covered procedures & allowed charges will vary by HCSP (Health Care Service Plan). See Evidence of Coverage or Benefit Booklet See Evidence of Coverage or Benefit Booklet GENERIC VS. BRAND NAME If generic available, and doctor has not indicated dispense as written, will member receive a generic equivalent rather than a brand name drug? Refer to summary on pages 10-11 If doctor writes dispense as written on prescription, is brand name available at the brand copay amount? Refer to summary on pages 10-11 Hearing treatment HMO: Routine hearing screening in PCP's office only office visit copay applies PPO: Covers ear screenings to determine the need for audiograms for dependent children through age 18 only Are Hearing Aids covered? CaliforniaChoice now offers EPIC Hearing Service Plan (HSP) to all CaliforniaChoice members at no additional cost Speech therapy HMO: Outpatient covered if HCSP determines there will be significant improvement in 60 days office visit copay applies PPO: Covered for certain conditions (see Evidence of Coverage or call representative) subject to deductible and coinsurance CaliforniaChoice FORMULARY VS. NON-FORMULARY Does carrier use Rx formulary? Refer to summary on pages 10-11 Are non-formulary drugs available? Refer to summary on pages 10-11 MAIL ORDER - 90 DAY SUPPLY Refer to summary on pages 10-11 Are oral contraceptives covered? subject to the Drug Formulary for the Health Care Service Plan selected by member Discounts, Awards & Other Value-Added Benefits CaliforniaChoice Which health care plans offer these discounts, awards and other value-added benefits? Eyewear & lenses discount...abc, HN, KP 1 Health Club Membership or fitness equipment/sporting goods discount...abc, HN, KP, WH Health Literature, telephone tapes and/or videos (no charge)...hn, KP, SH available in the following languages: Spanish Personalized, dynamic online tools on health information...abc Home childproofing products discount...abc, HN Infant car seat: discount...hn awarded upon prenatal class completion...hn Nurses 24 Hour Hotline...ABC, HN, KP, SH Vitamins and/or herbal supplements discount...abc, HN, KP 2, SH Weight control program discount...abc, HN, KP 3, SH * All CaliforniaChoice medical members are eligible for discounts on eye exams, lenses, frames, and contacts through the Vision One Eye Care Program administered by Cole Managed Vision/EyeMed Vision Care. 1 Discounts of frames and lenses available through Kaiser Permanente facilities. 2 Discounts on vitamins and herbal supplements available through the Affinity Program which links Kaiser Permanente members to Healthy Roads 3 Member must use a Kaiser Permanente weight loss program. KEY TO HEALTH CARE SERVICE PLANS OFFERING LISTED PROGRAM ABC Anthem Blue Cross HN Health Net KP Kaiser Permanente SH Sharp Health Plan WH Western Health Advantage 12
MEDICAL Del rte Siskiyou Modoc The following HMOs have an Excellent rating from the NCQA for their commercial products: Kaiser Foundation Health Plan, Inc. - Southern California (HMO) Kaiser Foundation Health Plan, Inc. - rthern California (HMO) Western Health Advantage The following HMO has a Commendable rating from the NCQA for their commercial products: Health Net of California, Inc. (HMO) Health Net Life Insurance Company (PPO) Humboldt Trinity Shasta Lassen Mendocino Marin Lake Sonoma San Francisco San Mateo Tehama Glenn Colusa Napa Santa Cruz Yolo Solano Butte Sutter Yuba Contra Costa Alameda Santa Clara Sacramento San Joaquin Plumas El Dorado Amador San Benito Sierra Stanislaus Nevada Placer Calaveras Merced Alpine Tuolumne Mariposa Madera Fresno Mono ;PPO Only Counties HMO & PPO Counties Plan may not be available in all Zip Codes within county. Check with your CaliforniaChoice 51+ representative to confirm if coverage is available for your group location. Inyo Monterey Kings Tulare San Luis Obispo Kern Santa Barbara Ventura Los Angeles San Bernardino Orange Riverside San Diego Imperial 13
www.choiceadmin.com Carrier Contact Information Member Support CaliforniaChoice 51+ Customer Service Center 866-451-7587 Health Net 800-361-3366 Kaiser Permanente English 800-464-4000 Spanish 800-788-0616 Western Health Advantage 888-563-2250 CaliforniaChoice 51+ Bilingual Support 866-451-7587, Press #9 for Spanish Internet Support www.calchoiceplus.com Provider Eligibility Verification 866-451-7587 Broker Services & Commissions 714-567-4390 Commissions@calchoiceplus.com Broker of Record Changes Fax 714-972-7368 Adds/Terms Fax 714-664-1711 Billing Questions 866-451-7587 Claims Contact carriers directly To contact by mail, or for payment submission: CaliforniaChoice 51+ 721 South Parker, Suite 200 Orange, CA 92868 Tax ID Number 33-0115986 14
MEDICAL www.choiceadmin.com Products Offered CaliforniaChoice 51+ HMO CalChoice 51+ HMO 15 CalChoice 51+ HMO 15 Value CalChoice 51+ HMO 25 CalChoice 51+ HMO 20/$500 Value CalChoice 51+ HMO 25 Value CalChoice 51+ HMO 40 CalChoice 51+ HMO 40 Value Elect Open Access Salud HMO y Más PPO PPO 250 PPO 500 PPO 1000 PPO 1500 PPO plan availability based on group eligibility and may be subject to change Consumer Directed Healthcare INDEMNITY Flex Net (Out of Area Only) CaliforniaChoice 51+ Provider Information Networks vary according to Health Care Service Plan (HCSP) SELECTION NETWORKS How often can members change their Primary Care Physician (PCP)? Varies by plan type. Contact your CaliforniaChoice 51+ representative HSA-Compatible HMO HDHP 1500 HSA 1800 HSA-Compatible PPO HSA 1500 HSA 2000 Multi Option (Mix And Match) CaliforniaChoice 51+ Can family members each choose a PCP from a different IPA/Medical Group? Varies by plan type. Contact your CaliforniaChoice 51+ representative Maximum Choice For Employees Each employee's health care needs are different. The CaliforniaChoice 51+ program provides employees the maximum choice in meeting those needs with these health plans all within one program: Health Net HMO Kaiser Permanente HMO Western Health Advantage HMO Health Net PPO SPECIALIST REFERRALS Self-referral available? Varies by plan type. Contact your CaliforniaChoice 51+ representative Ancillary CaliforniaChoice 51+ DENTAL Prepaid FDH 100 Prepaid 1000 Prepaid 3000 PPO EPO 3000 EPO 3500 EPO 4000 EPO 5000 Express referral available? Varies by plan type. Contact your CaliforniaChoice 51+ representative 24 HOUR COVERAGE Is Workers' Comp required on corporate officers, partners and sole proprietors? VISION Vision Discounts Voluntary Vision Is on-the-job covered for corporate officers, partners and sole proprietors? LIFE Term Life & AD&D Is there a premium adjustment for 24 hour coverage? 15
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MEDICAL www.choiceadmin.com The following HMOs have an Excellent rating from the NCQA for their commercial products: Del rte Siskiyou Modoc Kaiser Foundation Health Plan, Inc. - Southern California (HMO) Kaiser Foundation Health Plan, Inc. - rthern California (HMO) Western Health Advantage (HMO) Humboldt Trinity Tehama Shasta Plumas Lassen (See next page for carrier telephone and address information) Mendocino Marin Lake Sonoma San Francisco San Mateo Glenn Colusa Napa Santa Cruz Yolo Sacramento Sutter Solano Butte Contra Costa Alameda Santa Clara Yuba San Joaquin El Dorado Amador San Benito Sierra Stanislaus Nevada Placer Calaveras Merced Alpine Tuolumne Mariposa Madera Fresno Mono ;PPO Only Counties HMO & PPO Counties Plan may not be available in all Zip Codes within county. Check with your HSA California representative to confirm if coverage is available for your group location. Inyo Monterey Kings Tulare San Luis Obispo Kern Santa Barbara Ventura Los Angeles San Bernardino Orange Riverside San Diego Imperial 17
www.choiceadmin.com MEDICAL Carrier Contact Information HSA California Member Support HSA California Customer Service 866-251-4718 Health Net 800-361-3366 Western Health Advantage 888-563-2250 Kaiser Permanente English 800-464-4000 Spanish 800-788-0616 Bilingual Support 866-251-4718, Press #9 for Spanish Internet Support www.hsacalifornia.com Provider Eligibility Verification 866-251-4718 Broker Services & Commissions Fax 714-972-7368 Billing Questions 866-251-4718 Claims Contact carriers directly Missing BOR Changes Fax 714-972-7368 To contact by mail or for payment submissions HSA California 721 South Parker, Ste. 200 Orange, CA 92868 Tax ID Number 33-0115986 18
MEDICAL www.choiceadmin.com Products Offered HSA California Provider Information HMO HMO 1800 HMO 2200 HMO 2600 HMO 2800B PPO PPO 2500 PPO 3500 PPO 4500 NETWORKS Networks vary according to Health Care Service Plan (HCSP) Multi Option (Mix And Match) Maximum Choice For Employees Each employee's health care needs are different. The HSA California program provides employees the maximum choice in meeting those needs with these health plans all within one program: Health Net PPO Kaiser Permanente HMO Western Health Advantage HMO HSA California SELECTION How often can members change their Primary Care Physician (PCP)? Refer to summary on page 22 Can family members each choose a PCP from a different IPA/Medical Group? Refer to summary on page 22 PLEASE NOTE: t all health plans are available in all areas SPECIALIST REFERRALS Self-referral available? Varies by Health Care Service Plan (See summary on page 22) Express referral available? Varies by Health Care Service Plan (See summary on page 22) 24 HOUR COVERAGE Optional Benefits HSA California LIFE DENTAL GROUP SIZE Available Buy-up Is Workers' Comp required on corporate officers, partners and sole proprietors? Is on-the-job covered for corporate officers, partners and sole proprietors? VISION INFERTILITY MASSAGE THERAPY Discount or Buy-up t Available Varies by HCSP Is there a premium adjustment for 24 hour coverage? 19
www.choiceadmin.com MEDICAL Plan Eligibility Requirements Wrap* Requirements HSA California ENROLLMENT GROUP SIZE Min. # of employees Max. # of employees AFTER INITIAL ISSUE 2 2 50* * Over 50 only if group is SB 578 qualified. (If group has less than 50 employees, for 50% of the preceding calendar quarter or preceding calendar year) GROUP Can be written with another SIZE carrier's PPO or indemnity plan? MINIMUM EMPLOYER CONTRIBUTION Employees For Dependents % of Total Cost: GROUP SIZE 50% of lowest cost plan GROUP Can be written with another SIZE carrier's HMO, POS or EPO? *Indicates flexibility in being offered with products of another carrier. PARTICIPATION Contributory Employees Dependents n-contributory Employees Dependents *100% 70% *100% Those covered by another plan are NOT considered eligible in calculating participation. In order to NOT be considered eligible, the other coverage must be a group plan, Champus, Medicare or Medi-Cal * 1 Life groups allowed Employer contribution is 100% of employee lowest cost HMO plan or more COVERAGE RESTRICTIONS Are Commission employees allowed? if on quarterly/annual wage report and showing at least minimum wages and withholdings Are 1099 employees allowed? GROUP SIZE 2-2 3-50 HSA California 100% of employees not covered by group insurance and 70% of all employees regardless of other coverage Are employees covered if traveling out of USA? Only for emergency benefits Carve Outs* EXCLUSIONS ALLOWED BY CARRIER: Hourly/Salary? Management/n-management? HSA California Union/n-union? coverage available for non-union only. Group must submit union billing to underwriting for verification that all other employees have union coverage Minimum group size 2 Does carrier underwrite and rate carve out groups according to AB1672 guidelines? * Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage. Is coverage available for out-of-state employees? * PPO 2500, PPO 3500, PPO 4500 *Except for employees in Hawaii Max. % of employees residing out-of-state allowed 49% (Main office must be located in California) 20
MEDICAL www.choiceadmin.com Enrollment Information & Requirements Carrier's Effective Date Premium Amount Required for 20th? Employee Waiting Periods Available Applications must be dated within: Spouse/Domestic Partner Employees - 1 application or 2? Employee Waiver Cards Required at enrollment? Are Telephone Interviews done by Underwriting? Must Brokers Carry Errors & Omissions Insurance? Does Carrier Offer Open Enrollment? HSA California 1st of the month only Min: 30 Max: 365 60 days (if enrolling separately, Use either 1 or 2 applications 2 applications required) 60 days prior to anniversary DOCUMENTATION & PAYMENT INFORMATION Quarterly/annual wage report required? Payroll Records OK if no quarterly/annual wage report? Call representative Is a Prior Booklet required? * Is Prior Billing required? * Must submit check with initial application? Check Made payable to: HSA California *Only if any employees take PPO Dental FEES Enrollment Fee Amount Type of Enrollment Fee Monthly Billing Fee DEDUCTIBLE CREDIT Prior carrier deductible credit given? 4th quarter deductible carry-over credit given? ne 1-8 9-20 21+ $20 $25 $30 HMO: PPO: * *This does NOT include credit for the RX deductible Medical Underwriting Requirements Current Employees Timely Add-ons Rating Information GROUP SIZE 2-14 15-50 Employee Medical Questionnaire n Medical RAF Increments ( lives) Rate Guarantee Apply Trend Factor? Use Employee Zips? Master App (Employer Questions) 2-4: 1.10 5-50: 1.00 15-50: 1.00* *Groups may qualify for a 0.90 See quote for details. 12 Months n Medical HMO: PPO: According to the California Insurance Code The standard employee risk rates applied to a small employer for new business shall be in effect for no less than six months. HSA California ITEMS Items Reviewed REVIEWED In IN RAF RAF Calculation CALCULATION Medical Conditions Years in Business # of Pregnancies Virgin Group Type of Industry Percent of Owners Group Size % of COBRA Insureds % of Family Related Participation Plan(s) Requested 24 HR Coverage Req'd Employer Contribution Bankruptcy Gender Mix Call 800-511-0001 www.choiceadmin.com 21
www.choiceadmin.com MEDICAL Benefit Summary FOR DETAILED BENEFIT INFO, LIMITATIONS AND EXCLUSIONS, PLEASE REFER TO BOOKLET CERTIFICATE/EVIDENCE OF COVERAGE, OR CONTACT YOUR HSA CALIFORNIA REPRESENTATIVE Provider Information HSA California Kaiser Permanente HMO Western Health Advantage HMO Health Net PPO How often can family members change their Primary Care Physician? (PCP) Anytime NOTE: Each HCSP HMO has their own PCP change approval process Once a month changes are effective at beginning of following month, provided the member is not in the course of treatment or hospitalized and no pending authorizations Anytime in a PPO, you do not have to choose a PCP Can family members each choose a PCP from a different IPA/Medical Group? but only Plan Physicians each family member can make their own physician choice Do plans have these types of programs to speed the specialist referral process in network: Self referral? Express referral? referrals come directly from PCP; no other approval is needed Advantage Referral Program allows PCP to refer a member to a specialist who participates in WHA s Advantage Referral program in a PPO, you don't have to go through a specialist referral process Is there an Out-of-Network benefit? s HSA California If generic available, and doctor has not indicated dispense as written, will member receive a generic equivalent rather than a name brand drug? or you must pay the brand copay plus the difference in cost between brand name & generic equivalent or you must pay the brand copay plus the difference between the cost of the brand name & generic If doctor writes dispense as written on prescription, is brand name available at the brand copay? Does health plan use Rx formulary? If medically necessary, are non-formulary drugs covered? * non-formulary copay applies * Prior authorization may be required for certain medications What is copay for covered non-formulary drugs? HMO 2200 $10 Generic $20 Brand HMO 2600 $10 Generic $30 Brand HMO 1800 Charge HMO 2800B $50 Copay Participating Pharmacy $50 n-formulary n-participating Pharmacy 50% Prior authorization may be required for certain medications Mail order *generic copay/brand name copay/non-formulary copay if applicable HMO 2200 $20 Generic $40 Brand HMO 2600 $20 Generic $60 Brand HMO 1800 Charge HMO 2800B $25 Generic $75 Brand $125 n-formulary Participating Pharmacy $30 Generic $60 Brand $100 n-formulary n-participating Pharmacy t Covered 22
MEDICAL www.choiceadmin.com Benefit Summary FOR DETAILED BENEFIT INFO, LIMITATIONS AND EXCLUSIONS, PLEASE REFER TO BOOKLET CERTIFICATE/EVIDENCE OF COVERAGE, OR CONTACT YOUR HSA CALIFORNIA REPRESENTATIVE Diabetic Benefits HSA California Are the following items covered under the or the Durable Medical Equipment Benefit of the member s selected plan design? Kaiser Permanente HMO Western Health Advantage HMO Health Net PPO Insulin Needles & Syringes Chem-Strips and/or Testing Agents Blood test strips- Durable Medical Equipment Urine test strips - s Durable Medical Equipment Benefit Insulin Pump Supplies Durable Medical Equipment Benefit Durable Medical Equipment Benefit: HMO 1800: 100% HMO 2800B: 80% Durable Medical Equipment PPO 2500 & 3500: In-Network: 70% Out-of-Network: 50% PPO 4500: In-Network: 60% Out-of-Network: 40% Glucose Monitor Durable Medical Equipment rather than HMO 2200 : 75% HMO 2600: 70% Durable Medical Equipment rather than HMO 1800: 100% HMO 2800B: 80% (preferred monitors only) All other monitors covered as Durable Medical Equipment PPO 2500 & 3500: In-Network: 70% Out-of-Network: 50% PPO 4500: In-Network: 60% Out-of-Network: 40% Insulin Pump Durable Medical Equipment Benefit Durable Medical Equipment Benefit: HMO 1800: 100% HMO 2800B: 80% Durable Medical Equipment PPO 2500 & 3500: In-Network: 70% Out-of-Network: 50% PPO 4500: In-Network: 60% Out-of-Network: 40% Vendors for Diabetes Equipment: Pending Contract is with Benefits are typically covered Medical Group. under the pharmacy benefit with participating pharmacies. Health See PCP Net will only cover certain machines Self-Injectable s HSA California Are self-injectable drugs (other than insulin) covered under the Drug benefit or Medical Benefit? Medical Benefit Medical Benefit Is pre-authorization required? Must be prescribed by Plan physician, in accord with our drug formulary guidelines required through Pharmacy Must self-injectables (other than insulin) be purchased via the carrier-contracted mail order RX vendor? Must use plan pharmacies (including affiliated pharmacies) Depends on Medical Group May use mail order vendor or contracted pharmacy vendor 23
www.choiceadmin.com MEDICAL Special Concerns* Infertility t Covered * Unless otherwise noted, information shown in this section reflects in-network benefits. HSA California Hearing treatment HMO: Routine hearing screening in PCP's office only office visit copay applies PPO: Covers ear screenings to determine the need for audiograms for dependent children through age 18 only Are Hearing Aids covered? HSA California now offers EPIC Hearing Service Plan (HSP) to all HSA California members at no additional cost Speech therapy HMO: Outpatient covered if HCSP determines there will be significant improvement in 60 days office visit copay applies PPO: Covered for certain conditions (see Evidence of Coverage or call representative) subject to deductible and coinsurance s GENERIC VS. BRAND NAME If generic available, and doctor has not indicated dispense as written, will member receive a generic equivalent rather than a brand name drug? Refer to summary on page 22 If doctor writes dispense as written on prescription, is brand name available at the brand copay amount? Refer to summary on page 22 FORMULARY VS. NON-FORMULARY Does carrier use Rx formulary? Refer to summary on page 22 Are non-formulary drugs available? Refer to summary on page 22 MAIL ORDER - 90 DAY SUPPLY $20 generic/$40 brand Refer to summary on page 22 HSA California Discounts, Awards & Other Value-Added Benefits HSA California Which health care plans offer these discounts, awards and other value-added benefits? Eyewear & lenses discount...kp 1 Health Club Membership or fitness equipment/sporting goods discount...hn, KP, WH Health Literature, telephone tapes and/or videos (no charge)...hn, KP available in the following languages: Spanish Home childproofing products discount...hn Infant car seat: discount...hn awarded upon prenatal class completion...hn Nurses 24 Hour Hotline...HN, KP Vitamins and/or herbal supplements discount...hn, KP 2 Weight control program discount...hn, KP 3 * All HSA California medical members are eligible for discounts on eye exams, lenses, frames, and contacts through the Vision One Eye Care Program administered by Cole Managed Vision/EyeMed Vision Care. 1 Discounts of frames and lenses available through Kaiser Permanente facilities. 2 Discounts on vitamins and herbal supplements available through the Affinity Program which links Kaiser Permanente members to Healthy Roads 3 Member must use a Kaiser Permanente weight loss program. KEY TO HEALTH CARE SERVICE PLANS OFFERING LISTED PROGRAM HN KP WH Health Net Kaiser Permanente Western Health Advantage 24
MEDICAL www.choiceadmin.com Kaiser Foundation Health Plan, Inc. - Southern California (HMO) Del rte Siskiyou Modoc Kaiser Foundation Health Plan, Inc. - rthern California (HMO) Humboldt Trinity Shasta Lassen (See next page for carrier telephone and address information) Mendocino Marin Lake Sonoma San Francisco San Mateo Tehama Glenn Colusa Napa Santa Cruz Yolo Sacramento Sutter Solano Butte Contra Costa Alameda Santa Clara Yuba San Joaquin Plumas El Dorado Amador San Benito Sierra Stanislaus Nevada Placer Calaveras Merced Alpine Tuolumne Mariposa Madera Fresno Mono ;All Plan Types Available HMO, POS & PPO PPO Only Plan may not be available in all Zip Codes within county. Check with your Kaiser Permanente Choice Solution representative to confirm if coverage is available for your group location. Inyo Monterey Kings Tulare San Luis Obispo Kern Santa Barbara Ventura Los Angeles San Bernardino Orange Riverside San Diego Imperial 25
www.choiceadmin.com MEDICAL Carrier Contact Information Member Support Kaiser Permanente Choice Solution Customer Service Center English 800-580-9626 Kaiser Permanente Kaiser Permanente Choice Choice Solution Solution Kaiser Permanente English 800-464-4000 Spanish 800-788-0616 Bilingual Support 800-580-9626, Press #9 for Spanish Internet Support www.kpchoicesolution.com Provider Eligibility Verification 800-580-9626 Renewal Changes Employer Fax 800-566-7803 Employee Fax 800-566-8514 Commissions/Broker Services 800-542-4218, Ext. 4390 Adds/Terms Fax 800-566-8514 Missing BOR Changes Fax 800-580-9626 Claims Kaiser Permanente Claims 800-464-4000 To contact by mail or for payment submissions CHOICE Administrators 721 South Parker Suite 200 Orange, CA 92868 Tax ID Number 33-0115986 26
MEDICAL www.choiceadmin.com Products Offered Kaiser Permanente Choice Solution Provider Information HMO PPO POS HMO 10 HMO 30 HMO 20/$1,000 30/$500 20/$1,000 HMO/EPO NETWORKS Kaiser Permanente POS/PPO Private Healthcare Systems (PHCS) Consumer Directed Healthcare HSA-Compatible DHMO HDHP 1900* HDHP 2700* HRA-Compatible PPO *HSA-Qualified High Deductible Health Plan Kaiser Permanente Choice Solution MRP-Compatible PPO SELECTION How often can members change their Primary Care Physician (PCP)? Anytime change is effective immediately Can family members each choose a PCP from a different IPA/Medical Group? HMO: From Kaiser Permanente physicians POS/PPO: From PHCS Network SPECIALIST REFERRALS Self-referral available? prior authorization or referral for OB/GYN (can be primary provider) Other specialists: to certain specialties. Self-refer specialties list varies by geographical region Express referral available? referral direct from physician 24 HOUR COVERAGE Optional Benefits LIFE GROUP SIZE Available Is Workers' Comp required on corporate officers, partners and sole proprietors? DENTAL VISION INFERTILITY CHIROPRACTIC ACUPUNCTURE MASSAGE THERAPY Available t Available HMO: Benefits vary by plan POS/PPO: Benefits vary by plan t Available t Available t Available Is on-the-job covered for corporate officers, partners and sole proprietors? Is there a premium adjustment for 24 hour coverage? 27
www.choiceadmin.com MEDICAL Plan Eligibility Requirements Wrap* Requirements Kaiser Permanente Choice Solution ENROLLMENT GROUP SIZE AFTER INITIAL ISSUE Min. # of employees 2 2 Max. # of employees 50* * Over 50 only if group is SB 578 qualified. (If group has less than 50 employees, for 50% of the preceding calendar quarter or preceding calendar year) GROUP SIZE Can be written with another carrier's PPO or indemnity plan? contact your Kaiser Permanente Choice Solution representative regarding guidelines MINIMUM EMPLOYER CONTRIBUTION Employees For Dependents % of Total Cost: GROUP SIZE 50% of lowest cost plan GROUP SIZE Can be written with another carrier's HMO, POS or EPO? contact your Kaiser Permanente Choice Solution representative regarding guidelines *Indicates flexibility in being offered with products of another carrier. PARTICIPATION Contributory Employees Dependents n-contributory Employees Dependents GROUP SIZE 2-2 3-50 *100% 70% *100% 100% of employees not covered by group insurance and 70% of all employees regardless of other coverage Those covered by another plan are NOT considered eligible in calculating participation. In order to NOT be considered eligible, the other coverage must be a group plan, Champus, Medicare or Medi-Cal * 1 Life groups allowed Employer contribution is 100% of employee lowest cost HMO plan or more COVERAGE RESTRICTIONS Are Commission-Only employees allowed? if on quarterly/annual wage report and showing at least minimum wages and withholdings Carve Outs* EXCLUSIONS ALLOWED BY CARRIER: Hourly/Salary? Management/n-management? Union/n-union? coverage available for non-union only. Group must submit union billing to underwriting for verification that all other employees have union coverage Minimum group size 2 Does carrier underwrite and rate carve out groups according to AB1672 guidelines? Kaiser Permanente Choice Solution Are 1099 employees allowed? * Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage. Are employees covered if traveling out of USA? Only for emergency benefits Is coverage available for out-of-state employees? Max. % of employees residing out-of-state allowed 49% (At least 51% of eligible employees must live or work in California) 28
MEDICAL www.choiceadmin.com Enrollment Information & Requirements Carrier's Effective Date Premium Amount Required for 20th? Employee Waiting Periods Available Applications must be dated within: Spouse/Domestic Partner Employees - 1 application or 2? Employee Waiver Cards Required at enrollment? Are Telephone Interviews done by Underwriting? Must Brokers Carry Errors & Omissions Insurance? Does Carrier Offer Open Enrollment? Kaiser Permanente Choice Solution 1st of the month Min: 1st of the month following date of hire Max: 365 days 60 days (if enrolling separately, Use either 1 or 2 applications 2 applications required) 60 days prior to anniversary DOCUMENTATION & PAYMENT INFORMATION Quarterly/annual wage report required? Payroll Records OK if no quarterly/annual wage report? Call representative Is a Prior Booklet required? * Is Prior Billing required? * Must submit check with initial application? Check Made payable to: Kaiser Permanente *Only if any employees take PPO Dental Choice Solution FEES Enrollment Fee Amount Type of Enrollment Fee Monthly Billing Fee DEDUCTIBLE CREDIT Prior carrier deductible credit given? 4th quarter deductible carry-over credit given? ne 2-8 9-20 21+ $20 $25 $30 HMO: PPO: * *This does NOT include credit for the RX deductible Medical Underwriting Requirements Current Employees Timely Add-ons Rating Information Group Size Rate Guarantee Apply Trend Factor? Use Employee Zips? GROUP SIZE 2-14 15-50 Employee Medical Questionnaire n Medical 2-5: 1.10 6-15: 1.00 16-50: 0.90 12 Months Master App (Employer Questions) n Medical Kaiser Permanente Choice Solution Items Reviewed In RAF Calculation Medical Conditions Years in Business # of Pregnancies Virgin Group Type of Industry Percent of Owners Group Size % of COBRA Insureds % of Family Related Participation Plan(s) Requested 24 HR Coverage Req'd Employer Contribution Bankruptcy Gender Mix According to the California Insurance Code The standard employee risk rates applied to a small employer for new business shall be in effect for no less than six months. 29
www.choiceadmin.com MEDICAL Special Concerns* Infertility HMO: 50% for diagnosis and treatment of cause of infertility. POS/PPO: Benefits vary by plan * Unless otherwise noted, information shown in this section reflects in-network benefits. For Triple Option plans, the most managed plans are shown. Hearing treatment HMO: POS/PPO: Medical exams of the ear and audiometric exam to measure hearing Call your Kaiser Permanente Choice Solution representative Are Hearing Aids covered? Call your Kaiser Permanente Choice Solution representative Speech therapy HMO: PPO: POS: Covered if medically necessary Covered if medically necessary Covered if medically necessary Kaiser Permanente Choice Solution Kaiser Permanente Aetna Diabetic & Self-Injectable s Choice Solution Are the following items covered under the or the Durable Medical Equipment Benefit of the member s selected plan design? DIABETES BENEFITS Insulin Needles & Syringes Chem-Strips and/or Testing Agents Insulin Pump Supplies Insulin Pump Glucose Monitor Rx Durable Medical Equipment Benefit Vendors for Diabetes Equipment: See kp.org for vendors Urine test strips Blood test strips SELF-INJECTABLE DRUG BENEFITS Are self-injectable drugs (other than insulin) covered under the or Medical Benefit? Is pre-authorization required? *Must self-injectables (other than insulin) be purchased via the carrier-contracted mail order Rx vendor? HMO Use plan pharmacies (including affiliated) POS Use plan pharmacies (including affiliated) PPO Use plan pharmacies (including affiliated) These services may change at any time without notice. Please contact your Kaiser Permanente Choice Solution rep for specific inquiries on listed services s GENERIC VS. BRAND NAME If generic available, and doctor has not indicated dispense as written, will member receive a generic equivalent rather than a brand name drug? HMO/POS/PPO: If doctor writes dispense as written on prescription, is brand name available at the brand copay amount? HMO/POS/PPO: Kaiser Permanente Choice Solution FORMULARY VS. NON-FORMULARY Does carrier use Rx formulary? Are non-formulary drugs available? MAIL ORDER - 90 DAY SUPPLY Are oral contraceptives covered? BENEFIT INFORMATION SHOWN ON THIS PAGE IS A BRIEF SUMMARY. LIMITATIONS AND EXCLUSIONS APPLY. PLEASE REFER TO CERTIFICATE BOOK, EVIDENCE OF COVERAGE OR CALL REPRESENTATIVE FOR DETAILS. 30
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ANCILLARY CONSUMER EXCHANGE PROGRAM www.choiceadmin.com California Coverage Area Coverage area varies by plan. Please contact your Choice Builder representative for a quote Out-of-State Coverage Customer Service Center Choice Builder 866-412-9279 Member Service Dental Ameritas Group 800-487-5553 Delta Dental HMO 800-422-4234 Delta Dental PPO 888-335-8227 Madison National Life 866-412-9279 Vision Madison National Life (Davis Vision) 800-999-5431 EyeMed (provided by Ameritas) 866-289-0614 VSP 800-877-7195 Chiropractic/Acupuncture Landmark Healthplan 800-638-4557 Life Assurity Life Insurance Company 800-869-0355 Commissions Choice Builder 714-567-4390 Add-ons/Deletes Choice Builder Fax 866-412-9280 Dental Claims Delta Dental 12898 Towne Center Drive Cerritos, CA 90703 Ameritas Group P.O. Box 82520 Lincoln, NE 68501 Fax 402-467-7336 Madison National life CX015 Grouplink Inc. P.O. Box 20593 Indianapolis, IN 46220 877-223-4693 What coverage is offered for Out-of-State employees? Out-of-State employees have access to the Delta Dental DHMO in TX, GA and FL. Residents of all other states will have the PPO/Indemnity carrier chosen by the employer What is the minimum % of employees required in CA? What states are allowed (or not allowed) for Out-of-State Coverage? Delta Dental DHMO available in FL, GA and TX only. Residents of all other states (except Hawaii) have the PPO/Indemnity carriers chosen by the employer What dental benefits (or plan types, such as PPO, Indemnity, etc.) are offered for Out-of-State employees? Out-of-State employees have access to the Delta Dental DHMO in TX, GA and FL only. All others have the PPO/Indemnity carrier chosen by the employer Are dental rates for Out-of-State employees based on the CA Employer Zip Code or based on Out-of-State Zip Code? Delta Dental DHMO is rated by employee Zip Code, all other carriers are rated by employer Zip Code Any other rules, restrictions or guidelines not mentioned: Employer s home office must be located in CA. If incorporated in another state, documents must show a home office address in CA. Products Offered Benefits are offered both as Employer Sponsored and Voluntary (except Life). Employer must purchase dental in order to offer any other line of coverage. Group must offer 1 PPO/Indemnity/EPO dental carrier to go along with the Delta Dental DHMO carrier. Group Size: 2-99 Dental HMO Delta Dental HMO Silver* HMO Gold* PPO Ameritas Group PPO Silver* PPO Gold* PPO Platinum* Delta Dental PPO Gold (Employer sponsored only) PPO Silver (Voluntary sponsored only) Madison National Life Insurance Company PPO Gold* EPO Madison National Life Insurance Company EPO Silver* Indemnity Madison National Life Insurance Company Indemnity Platinum* Vision EyeMed Silver* Gold* Platinum* VSP Silver Gold* Platinum* Madison National Life Insurance Company Silver* Gold* Platinum* *Available both Employer Sponsored and Voluntary. Dual Option (Mix and Match) 3 Dental Carriers / 3 Vision Carriers / Chiro-Acupuncture / Life. Call your Choice Builder representative for more details. Chiropractic/Acupuncture Landmark Healthplan* Call your Choice Builder representative for more details 33 Life Assurity Life Call your Choice Builder representative for more details Provider Information Ameritas Group PPO network Delta Dental HMO DeltaCare USA Delta Dental PPO Delta Dental PPO Network EyeMed (provided by Ameritas Group) Access Network Madison National Life Dental (Provided by GroupLink Inc.) FDH Network Madison National Life Vision (Provided by Davis Vision) Landmark Healthplan Chiropractic VSP - Vision VSP Network
www.choiceadmin.com ANCILLARY CONSUMER EXCHANGE PROGRAM Plan Eligibility Requirements Dental Benefits Employer Sponsored Participation Requirements Minimum Employee participation must be at least 70% Minimum Dependent participation is 0% Minimum Employer Contribution The Employer must contribute at least 50% of the lowest cost benefit design Employer contribution is required for Dependent Coverage Voluntary Participation Requirements Minimum of 10 eligible Employees with a minimum participation of at least 5 enrolled in dental Minimum Dependent participation is 0% Minimum Employer Contribution Employer contribution required Vision Benefits Employer Sponsored Participation Requirements Minimum Employee participation must be at least 70% Minimum Dependent participation is 0% Minimum Employer Contribution The employer must contribute at least 50% of the lowest cost benefit design Employer contribution is required for Dependent Coverage Voluntary Participation Requirements minimum participation required Minimum Employer Contribution Employer contribution required Chiropractic/Acupuncture Benefits Employer Sponsored Participation Requirements 100% Employee participation is required Minimum Dependent participation is 0% Minimum Employer Contribution The Employer must contribute 100% of the Employee premium Dependent Coverage is included as this is a discount plan only Voluntary Participation Requirements minimum participation required Minimum Employer Contribution Employer contribution required Life Benefits Employer Sponsored Participation Requirements 100% Employee participation is required Minimum Employer Contribution The Employer must contribute 100% of the Employee premium 34
ANCILLARY CONSUMER EXCHANGE PROGRAM www.choiceadmin.com Rating Information Group Size Rate Guarantee Rates vary by Industry? Coverage Requirements Are Commission-Only employees allowed? Are 1099 employees allowed? Any ineligible industries? Delta Dental PPO Employer sponsored plan contact your Choice Builder representative; and Dental offices for Madison National Life Virgin groups eligible? 2-99 12 months Dental- varies by carrier Life - Vision & Chiro - Quarterly/annual wage report required? Upon request Out-of-Network Claim Adjudication HMO: Madison National Life Indemnity 90th percentile; EPO Max. allowable charge. Ameritas Group Silver Benefits Average prevailing fee; Gold/Platinum Benefits 80th percentile of U&C Delta Dental PPO Max. allowable charge. Carve Outs* EXCLUSIONS ALLOWED BY CARRIER: Hourly/Salary? Management/n-management? Union/n-union? eligible non-union members only. Employer to submit union billing Minimum group size 2 * Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage. Orthodontic Coverage Delta Dental DHMO (included) no wait Delta Dental DPPO Employer sponsored: no wait Voluntary: 12 months Ameritas Group 24 month wait Madison National Life Employer Sponsored: 12 months; Voluntary: 12 month wait Ameritas Dental optional ortho benefit only available to groups of 5 or more employees. Waiting Periods can be waived if there is a minimum of 10 employees enrolled on a Choice Builder PPO dental plan and the employer has a current comparable PPO dental plan inforce. Partial and/or Full Credit given for entire initial enrolling population. Billing from 12 months ago and current bill is required at underwriting, and possibly the current carrier s Benefit Booklet. Delta Dental employer sponsored plan optional ortho benefit only available to groups of 10 or more employees, voluntary plan optional ortho benefit only available to groups of 25 or more employees. Waiting Period Waiver/Takeover Delta Dental DHMO Delta Dental PPO Madison National Life At initial group enrollment, groups with 10+ eligible employees and prior continuous orthodontic dental coverage, will waive up to 12 months waiting period based on group s number of prior continuous uninterrupted orthodontic coverage. Ameritas Group At initial enrollment, employer-sponsored groups with 10+ eligible employees and prior continuous dental coverage of 12+ months, will waive major waiting period of 12 months. Will waive orthodontic waiting period of 24 months, if employer-sponsored group had prior continuous uninterrupted orthodontic coverage of 12+ months. All newly enrolled employees after initial enrollment are subject to wait periods below (Basic / Major / Ortho): Ameritas Group Employer Sponsored or Voluntary: 3/12/24 months Madison National Life Employer Sponsored or Voluntary: 3/12/12 months 35
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