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HomeMy WebLinkAboutContract � ��� . • � � � • � � � � � . . . � - - � . - 1 • 1 1 ___._. ___. ___�..,._ __... ., ,. _ _ _ _ . ..,. _ _ _ _...__ . .. ..__ �_ __ ___ _ � Core f ; Core HMO _._____.._-,__� _____-- ------_ __..-___.__ __._-- -,----- ____� _.._-_ ._------ ---.---_.. .----_.__._ ---- , ----.__. ------.._.___,__..._---._____.____.__.___�_._____: Inside Network ` ________.._�._____�_�._ ___...__...____._._,_ _�_ ._ ___ ..,______..__.__ �_.__ _____._----_ .__._.____ _.__....__�___�- _.____ .---.__..__._. .__.__ _�_.,._.__ ..__________.____..____._�_.___..�,.___._.________.; iGroup Name City of Renton-Leoff I Retirees _.._. .._.._..____�._.._._.._._,_ .___._..... _ _._ ._... __._.__._. ..,...,..______.. _....__.._._ .. ._._._.___.,....._..,___._ ..._,. _.... . _..__._ . _. .._ ...__ _ . . _ . ___..._._._.�____._..___..________.___.._.______.__._._ Type of Offering 1 Dual Choice �.____.._.._.__._..___-_____ --.__ ___,_ .._. _--- --- _.- -- ----- _.__ _ _ -----. .- --- _� _._ .. . -.-- --____..________ . .___..- ----._________._---_______.__.____; �Deductible(UF) ; None i _..�_.__.._ �.�.,_.__._., ___. __.__._. .�__.._--.. _. __.. ._« ___._._ ._ _---_ . _... . __.__ ...._.__._ ..�..--_._ ____.. --.----. _. ._...._ .__--._____..._..__ __.___,__- - ----_,. ._....._.._._._.___.._.----__._�_� ;Coinsurance ; None ' _._____ __.____m.. ____..____.____. __---_�__._.. __._.______ ________________ _-,-________ � ..�___ _____.. __ _�___._ __._.._...._�_____�.__ __ ___ �______.__.___�_..___._.._�_____.....� 'OOP Max(1/F) $2,000/2x ..___P_________._ ;, . _. .. _. ---_.._ .._____.. _ .._._.___._ ___. .___...__ _._..___._____�_ .._.. ._._...___.,_. . _._ ._.__ .. _ ..._._. _____�_. _._ _._. .�_ _. _.,__ _ _._._____.__.__.____�.__.__.__w._____---__�_._.____,..__.., iIP Hos ital Covered in full j _ __ __ __. _ __ _ ._-- .. ___ __.- --.__ _-- - --�, _._ � --. __ _.-__ _�___�______ _ _ � _., ;Outpatient Svs ' $25 copay ! __ _. . __�___ �__ _._ _ ._ _ . ____ �__________ _ .__ _ _ __ _. _. _ _- -- _ ___ ...�-- - --.___ ;ER(designated/ { � � inon-des facility) $75 copay!$125 copay Supp'Y___._. __._.. �_....�____._..,_...._.__. ..w._ .�....��.. . .__.._.. jPharmacy-30day' _____._._,_.._ _�.__.__ __.,__ __���._... ��__�__._�_�._��...__.___..___...__._...._._.._�_.__...._._._........___._._�___.._.__ _ _..._....,.�._.__�..._ $10 copay -_. __._�_.__ __.._____. --�_.. ._ ._.___. ___ _.___ , -- -__ _ .___ ____. _ .__._ .______ _____ _. _ �__ ._._ __.._. _.._ __.___._ ..._----- ._ .___......_.._._...__..__..__,._._._._.__.____..___�__ iOptical Hardware � $100 per 24 months r._.____..._.. ....._ ..__ ....._.__.,. _.__..._. ._.__. ,__._.. _..___»_ _.._..____..__._ ..__. .___ ._._ ___.___._. .____._,.._.._.__...�_ ...._._.___._.___ ... _.._._.. . _._...._._____._.._._. .______._______.._�__„__..�__..___.__.._._.__.__,_..�,..._,.�..,_�_......_..; �Rates by Tier j RQ-127782 w_._.._.__.._w._.__._._. __ .. __..__ _ .. .,_ ._ _. __..... _.._. __. _ _ _.-- --- - - _ . �_, __. _._ ___.. � . . ._.. ,. ._..._ .. _. .. - - . _ _ . _.. __ . _.. .. _ __._ _ . . . ___.... �. . . ....... . ... ..__.. ..... ._ .___...,_ ;; � EE� $1,034.35 __.._ _.._� � __.___ __---,._. _____._._..__ _...___.- - ---- ___.._ __. _- -.._ _.___ _.____._ __. �J___�_S'�� $1,175.45 _�_. __ . .__.___ ____ _.__.._.___._a _ ( ; ; ___ __ _ _, __ ___. _ _ _... ._ .._ _ _ __.._�___ �, 1C, $621 09 �� �E AAC _._ ___ __. �_ _� .. _ _..___ _ ._ . . _ �__._. ._ . _.__ _ -$-832.37_ _ _._. __ ___ . ._ _ _ _.-- -_- -___ ___. ____ _ �' � d � ._._.___.._._._��Y._.....a�__.... ..________, � _' _'_"'_._ ... """,..__...__.."_ ' ___ . ..._........_. ......_..____.. _. _,_,_" '._.._..__. ___—.�_...__. ....__ . ,. _ _..,_. _ __. .. _...__� "'.._..__._.._� _....._ .._. ._._�_. .��_. ._...___ ...._._..LL..____ ___i Commission Inciuded ___..__._ .___._._ ._____ _ .___ . ___-_. ___ _ . ___ ___ _ _ � � �_ __ ____... __ — ____ ____ ._�._�_ ..____ . _____ _�___ _-__ ___.__._ _.__, j Medicare Part D Creditable:Y _,_ __._.._._. .._____. __..�___ _.__..___ _--__ _ _________,_____�__.___.___________..�___ ___.__.__ _.__.___... ____._. . _-___.. ._____ ____..__ .e�___._,_�______________.___�___ ____.__._____._ __.� ; � All plans offered and underwritten by Kaiser Foundation Health Plan of Washington 277GG11-O6 • � � • � ■ ■ ■ � • • •' • •�� Effective Date 1/1/2019 Health Plan Core HMO Ref RQ-127768 ��.______.__..______._____..�.___.___._.._�_____._e__, __._�_____.______.�_._:_�a__.�__,_...____.M _..._w.__�..___.____.m_._._._._._�.��__.___W__��_._.._._____� 's This is a brief summary of benefits.THIS IS NOT A CONTRACT OR CERTIFICATE OF COVERAGE.All benefit descriptions,including aitemative care, i ?are for medically necessary services.The Member will be charged the lesser of the cost share for the covered service or the actual charge for that service. � ;For full coverage provisions,including limitations,please refer to your certificate of coverage. � jf ;In accordance with the Patient Protection and Affordable Care Act of 2010, � � � � ; • The lifetime maximum on the dollar value of covered essential health benefits no longer applies.Members whose coverage ended by reason of f ; reaching a lifetime limit under this plan are eligib�e to enroll in this plan,and j • Dependent children who are under the age of twenty-six(26)are eligible to enroll in this plan. , ; � _ � . ._ ._ . ._:.� � ,�.� ____� _� _�� _ e. �._�_�___._..e__.__.-_._ ,_ ..._; :-_-= -_. _�._. _ -___ . _ -�� _ _,�_ .�__ ._ a.____—.- _._�_.__ �_. �Benefits �Inside Network � � ______� .. _.,.__.. _ _.. . ___ . _ .._ ___ . _---- ----_..,__. ...,..... __..___ ___._ . ___....__ __.� t Plan deductible No annual deducfible ; �_.—__—__...__._.______._________._._ ._..__..._ .___.__._ ..� ____.__.__.. ._..... . .._..._ .. ..._ _ _..,... _..__.. � , r__. ...� . _.. _._.._. _____._.. __.__._ ._. �individual deductible i � Not appiicable a ;carryover r ._.....__ . . _. . .__ .. _. _. _. _,.e. .. .__..._v . _._____. .e _� . ., .._ _.__.. �,_._a._a __. , �._r______.�.___�_______....._____ ;Plan coinsurance No plan coinsurance r______�..�_.___�___�._.�_.___ _.._... ___ a.._. _ . _._ _ . _. . , , .., _ , _..__. ._ _. . __. . . �Individual out-of-pocket limit:$2,000 �Family out-of-pocket limit:$4,000 �Out-of-pocket limit Out-of-pocket expenses for the foilowing covered services are included in the out-of-pocket limit: i All cost shares for covered services ; :_.�_. ._.____.___W__..__ _._____ _ _ . _ . _ ._ _ _ _ _ , __ __.. _- ; � Pre-existing condition i No PEC {(PEC)waiting period � --.�_.________�.._ ____--_ -� -_ . __ __ ___ _ _ _ . _ i Lifetime maximum 1 Unlimited i_�_�._.__..__..__� __._._-_.__d_..,__ ., _ _ _ ._. . _ _ .. .___ �.. _ _.. _ _ ___.__ �Outpatient services �$25 copay t ;(Office visits) � ' _._.. _...._..__...�.__ . _. . . ___. _. _., . . __. . . _.. _ _ .__ . � ._ ., ____.._._ . __._..._ .__. . ..�_ ...... .._.. F Hospital services ��npatient services: Covered in fuli Outpatient surgery: $25 copay __.._.__�___---__,__._______.....�____ � _ ., _ . . i Prescription drugs �(some injectable drugs may Preferred generic and/or brand i be covered under Outpatient $10 copay per 30 day supply ' j services) � �_�.____.____._�_...___.^__ � _ _ _ _ . _; �Prescription mail order �3 x prescription cost share per 90 day supply � _ ,___�_____ ___. _ .___...._.. _.. .. _ ---.__ ____. __ _._.. _ ___ e. . _ ___. . . .__. . __ _ __ . _.__. __ �Acupuncture �$25 co aup to 12 visits per calendar year �_r_._�_r.��__.�.��. __.___P_Y_..e._ _ ___ _ _�__ _ _ _._.�. . . .��_� . �__. _ .____��. _._._ ,__._._�. _. _�.__ ! �Ambulance services �Plan pays 80%,you pay 20% �____.____�..��__________._ __.. __._..__.. _.. _ _ _ __ ..._ . _ _. .._ ._._ _._ _._, _-___.. i Chemical dependency Inpatient: Covered in full ; Outpatient:$25 copay _. _ . , �---_—__--._.----_ __ .._-----� .__ . _ _ _ Devices,equipment and , !supplies i • Durable medica� Covered at 80°/o equipment � • Orthopedic ' appliances � • Post-mastectomy ' ; bras limited to two(2) ' ? every six(6)months 1 • Ostomy supplies � • Prosthetic devices � ;---.__ ___--.—__________ ___ _ _.. _. ___ _ ._ � ..._._e __ _. ____ ___ ___ _ _ �Insulin,needles,syringes and lancets-see Prescription drugs.External insulin pumps,blood glucose monitors,testing {Diabetic supplies �reagents and supplies-see Devices,equipment and supplies.When Devices,equipment and supplies or Prescription drugs , are covered and have benefit limits,diabetic supplies are not sub�ect to these hmits ' �.__...�___��_._�__�._._ __,.�.__ _,_.___. . _,._..__ .__._.__.. __._.__�__ _____ _..__._. ..... _„_,. ...__ __ .�_. . _ _._.__ . ,_.__ __._. ? �Inpatient: Covered under Hospital services ;Diagnostic lab and X-ray j Outpatient: Covered in full =services � �High end radiology imaging services such as CT, MRI and PET must be determined Medically Necessary and require prior ' j �authorization except when associated with Emergency care or inpatient services. ', _._._� _..__..,. ____._ .�_ �,.__. ..,_ . ._. .. _ �... __._. _._ . _ - _. ..._._. ..__ .. ,_... _. _ _ _ . . ;Emergency services $75 copay at a designated facility i(copay waived if admitted) �$75 copay at a non designated facility ! ,.______ ____ ,.._ _ . __ __._ . __.. .., ,____ _. _ _ _ `Hearing exams(routine) �$25 copay ' ._ .___.____. _.____..____._.___..__ ___._._ . ____.. __ __. _.._ __._._ _..._._. _.._.._. __. _ _ _ _._; �Hearing hardware Not covered ( �Home health services Covered in full.No wsit limit. � � �w�m��4�����..__.._�__._._..____._._._.._ �..�._.__�����_ �..��� Hospice services� ��Covered in full � __ _ _ _ _:_ . � Infertility services Not covered ..._ ___. m_..� . _,_� m __. _.._ . _ C �Manipulative therapy Covered up to 10 visits per ca�endar year without prior authorization � ������$25 copay� � � _ ___.�._:_�.._._._m_. _____ ..__._. _....._ _.. , ._..___�____.__.__ . ___.. �Massage services �See Rehabilitation services s �_.�.._�_ �__��___._ . _. __. _. __.___._.�___ __� _._ ___ __ . �Maternity services Inpatient: Covered in full � Outpatient: $25 copay.Routine care not subject to outpatient services copay _ _ . __._._..__._ ._. _ __�.._______ _______.__ ___.__._ ____. _,____�_.__,__ _� _._ _. Mental Health �npatient: Covered in full � ____ ___ � Outpatient: $25 copay � ._�___,.��___._._.._..__..___._._.___.__._�__�____,._ , ......_____ .___._ __.__.._ . .___.._,_. . ._,._. .. . ._.._.._ _. _..___... .___..__.. ..______ ____.,a_._.,___„_. ___K..,. . _..�.._,_._i Covered up to 3 visits per medical diagnosis per calendar year without prior authorization,additional visits when approved ( Naturopathy by the plan E $25 copay � _ .__..-- . _.._. _._.._ .._..__ ..._..._ . _�_._._. ._..___..____.___�____._.__..__._�__..__. _. _� _.__ _. _,___ �Newborn Services �ny applicable coinsurance applies to the newborn while both mother and baby are confined.Otherwise,all applicable � � , inpatient cost shares apply.Office visits:See Outpatient Services Routine well care:See Preventive care _..___�__.__�_.__..______ _____.._.W_._.__�___ . .__..____�.�_.,__�___.__._ ,____._.,. .___,_-----. _.__._._�_._..___.___._.____�______._._..__...�._�____-.� �Obesi related sur e ? ty� g ry Covered at cost shares when medical criteria is met �(bariatric) � __.__.____._._._ �.__, ____.w__ __... _ _ ._.�. __ . ,.. _ __ __. __ _ ___ _._._ .__. ._ __... _,._._._� � �Unlimited,no waiting period � i i Organ transplants j Inpatient: Covered in full i j Outpatient $25 copay _____.__._ �_�_.� ._,___. .._.__. ..__ ,.__.._,____�_.._ ..._ ._ __ _.. _, _ _.. _. __. _. ._...__. __ . ,_.._,,..� ;�Preventive care i Well-care physicals, Covered in full ; �immunizations,Pap smear Women's contraception is covered as preventive,and Men's contraception is covered in full. � !exams,mammograms I �.__m___.____..._____�..__,__...,__. _. . _ _. __ ._ __. . __ __ . ._m."� I Rehabilitation services �npatient: 60 days Rehabilitation visits are a total�Covered in full ( Outpatient: 60 visits of combined therapy visits per i �$25 copay calendar year I � .._..._ . _., _ . ___., � _.._.._. _....._. ._ .__. ___�___. . ___.._. __...._. . ._._�__� ._.�__.___ ,._.._..___; �Skilled nursing facility Covered in full up to 60 days per calendar year � � �_._.v. ____._ .--- .__._--- - --__. __._� .____ _ .. __�._ _.�_��.�.�._�___�..�t __,___ __...___ _ ._ ._ _,_,_ . . _ � Inpatient: Covered in full ; Sterilization(vasectomy, Outpatient: CUSTOMIZED LANGUAGE � �tubal ligation) Outpatient Surgery:See Hospital services;Outpatient surgery section Women's sterilization procedures are covered in full. s�.____..__._._.�e________._�� __._ _. ._ ____ , . . _ . �_ . ... ._..__ __ � _.._._ w__ _ _._. �_ _._..._ , �Temporomandibular Joint Inpatient:Covered in full � ,(TMJ)services Outpatient $25 copay j __._w_,___�._w.._�. � ____._ _. .___�__ ._ ._ _ . _ . _. _ , _._..__ _ _._ _ _.__. . ...... . . ....__._ ___.; I Tobacco cessation i 1 counseling Quit for Life Program-covered in full ; _._.�_.____�__,_ .�____._,._._.__ __. _, . _.,. __. . _..._._ __.� _ _.__.... ,_..,._ . _._ �Routine vision care � � � ��� �� � �(1 visit every 12 months) $25 copay r__.___________�________�__.r...._. . ._._� . .. . _._._. . _ _.. _.. _.. __ __ __, . .. __ .,.w . ____ _.__.._. ....... ...... . .�._.. ., jOptical hardware ; Lenses,including contact Members under 19: 1 pair of frames and lenses per year or contact lenses covered at 50%coinsurance i j lenses and frames Members age 19 and over:$100 per 24 months -----.__ ------_._._.___ __ __.,_.._ _-.___ -- . . . _._ _ __ _ _.-- -___ ___ ___... _-._____� All plans offered and underwritten by Kaiser Foundation Health Plan of Washington RQ-127768 P4KAISERPERMANENTE®LQtgeGroupSolutionsMasterapplicationforgroupsof51ormoteemployeesSelectONEORMOREhealthplans:KAISERFOUNDATIONHEALTHPLANKAISERFOUNDATIONHEALTHPLANOFWASHINGTON(KFHPWA)OFWASHINGTONOPTIONS,INC.(KFHPWAO)lCoreEAccessPPODOptionsIfofferinganHRAorHSA,doyouwantabankingarrangementwithHealthEquity?EYesDNa1.GENERALGROUPINFORMATIONEffectivedate:1/1/2019Groupnumber(s):1162600&0057500Group’slegalname:CityofRentonDoingbusinessas(ifapplicable):Group’sphysical/mailingaddress:1055SGradyWay.Renton,WA98057NameofCEO,president,orowner:_____________________________________________________________________________Title:Typeofbusiness:municipalitySIC#:9111TaxID#:91-6001271Howlonginbusiness?1901Parentcompany:Affiliates/subsidiaries/otherofficelocationstobecoveted:______________________________________________________________Primarygroupcontact:WendyRittereiserTitle:HRBenefitsManagerBusinessaddress:1055SGradyWay,Renton,WA98057Phone:425-430-7659Fax:425-430-7665Email:writtereiset@rentonwa.govBillingcontactname:JenniferBechtTitle:FinancialServicesSupervisorBillingaddress(ifdifferentthanbusinessaddress):________________________________________________________________________Phone:425-430-7659Fax:______________________Email:jbechtrentonwagov2018-LG-MASTER-APP-2Page1of7XB00012L7-51-17 COBRAbillingcontactthesameasbillingcontact?YesElNoIfno,pleasecompletethefollowing:COBRAbillingcontactname:___________________________________________Title:_________________________Billingaddress:Phone:_______________________Fax:_______________________Email:________________________________TosignupfortheKaiserPermonenteemployerswebsite,pleaseseetheinstructionsonhttps://kp.org/wo/employers2.EMPLOYEEELIGIBILITYOpenenrollmentmonth(s):NovemberThisgroupdefinesabonafideemployeeasonewhoworksaminimumof80hoursElperweekpermonthEmployeeswillbeeligibleforbenefitsupon(selectone):ElDateofhire1Firstofthemonthfollowing:l1DateofhireEl30daysEl60daysElFirstofthemonthfollowingorcoincidentwith:ElDateofhireEl30daysEl60daysElOther—Nolongerthan90daysfromdatethatemployeeisotherwiseeligibletoenroll.Anyorientationperiodrequiredforonemployeetobeeligibletoenrollmaynotexceedonecalendarmonth(pleasespecify).*Employeetransfersfrompart-timetofull-time(selectone):iProbationaryperiodbeginsupondateemployeetransferstofull-timeElProbationaryperiodisretroactivetooriginaldateofhireRehirePolicy:X1NoneORElWaiveprobationaryperiodifhiredwithin:El30daysEl60daysEl90daysElOther___________________________________________Coverageterminates:ElDateofterminationEndofmonthfollowingterminationElOther____________________________________________________________________________________Note:ContinuationofcoverageisavailableuponrequestinaccordancewithWashingtonstatelawtoemployerswhochoosetoexercisethisoptionfortheiremployeeswhobecomeineligibleforgroupcoverage.Otherclassesofeligibleemployeesordependents:N/ANote:Childrenareeligibleuntilage26,inaccordancewithfederalandstatelaws.Otherclassesoreligibilityinformation:*N/ANote:State-registereddomesticpartnerswillbetreatedasspousesasrequitedbyWashingtonstatelaw.Otherdomesticpartnercoverage?ElYesNoTheemployeragreestomakethefollowingcontributiontowardtheemployeeanddependentcoverage:Employee$or%___________________________________Dependents$or%____________________*Attachadditionalsheetsifnecessary.Page2of7 3.GROUPPARTICIPATION3A.Totalnumberofemployeesonpayroll,regardlessofhoursworked8633B.Employeesnoteligibletoenrolli.Employeesworkingfewerthontheminimumhours(seeSection2)B.Employeeswhoorefulfillingtheirnewhireprobationaryperiod+7iii.Employeeswhoaretemporary,seasonal,orsubstitute+228iv.EmployeespoidviaIRSFormO99+v.Employeeswhoseclassisineligibleforgroupcoverage;descriptionofgroup’sineligibleclass:__________________________________________________________________+(Forexample,governmentplan,othergroupcoveroge,collectivebargainingagreement)Totalemployeesnoteligibletoenroll(thesumofi.throughv.)2353C.Numberofeligibleemployeesnotenrollingduetocoverageunderagovernmentplan(Medicare/Medicaid,TRICARE)orothergroupcoveragewithavalidwaiver23D.Totalnumberofemployeeseligibletoenroll(3Aminus3Bminus3C)6263E.Totalnumberofeligibleemployeesenrolling6213F.Percentofeligibleemployeesenrolling(3Edividedby3D)9936.Doesyourplancoverretirees?YesLINoIfyes,numberofretireeseligibleforbenefits843H.NumberofCOBRA/continuationofcoveragesubscribers,ifapplicable1531.Doesthenumberofemployeesreportedin3Aincludeallemployeeseligibleonaworldwidebasis?YesLINoIfno,whatisthetotalnumberofworldwideemployees?Doesthenumberofemployeesreportedin3AincludeeligibleemployeesemployedoutsideWashingtonstate?LIYesNoIfyes,pleaseprovidenumberofemployeesineachstoteState:#ofemployees:Note:Underwritingguidelinesrequirethat75percentofalleligibleemployeesareenrolledincompany-sponsoredhealthcoverage,excludingthosewaivingcoverage.Page3of7 4.FEDERALREQUIREMENTSTip:Ifyouneedassistance,werecommendthatyouinquirewithabenefitsconsultantorlegalcounsel.Thesummariesbelowarenotintendedtobeorreplacelegaladvice.Itisthegroupsresponsibilitytoinformusiffactschangewhichwouldcausethegroup’sanswersbelowtochange.tiATEFRA/DEFRA:IsthegroupsubjecttothefederalMedicareSecondaryPayer(MSP)lawsthatprohibitdiscriminationagainstindividualswithgroupcoveragebasedontheirforospouse’s)currentemploymentstatuswhohasMedicateduetoage:Yes.ThisplanwillpayprimarytoMedicateasrequiredbyfederallow.ElNo.Thisgrouphasfewerthan20employees.Tip:Theserequirementsgenerallydonotapplytoanyemployerwhodidnotemploy20employeesormoreforeachworkingdayineachof20ormorecalendarweeksineitherthecurrentorprecedingcalendaryear.Forthesesmallgroupplans,Medicarepaysprimarytothegroupplan.“Employees”includeallfull-timeandpart-timeemployeesaswellasthoseemployeesondisabilityandsubjecttoFICAtaxes.SeeCFRt1J106forfurtherinformationaboutwhichindividualsconstituteanemployeeforthispurpose.tiB.COBRA:IsthegroupsubjecttoCOBRA?F1YesElNoTip:Generally,thisappliestoanon-churchemployerthatemployed20ormoreemployeesonatleast50percentofitsworkingdaysintheprecedingcalendaryear.“Employees”arefull-timeandpart-timecommon-lawemployees.Self-employedworkersaredefinedinIRC554.4980B-2.SeeQ/A5forguidanceoncountingapart-timeemployeeasafractionofafull-timeemployee.tiC.OBRA:IsthegroupsubjecttothefederalMedicareSecondaryPayer(MSP)lawsthatprohibitdiscriminationagainstindividualswithgroupcoveragebasedontheirfarafamilymember’s)currentemploymentstatuswhohaveMedicareduetodisability?Yes.ThisplanwillpayprimarytoMedicareasrequiredbyfederallaw.ElNo.Thisgrouphasfewerthan100employees.Tip:Generally,theserequirementsapplytoanyemployerthatemployedatleast100employeeson50%ormoreofitsworkingdaysintheprecedingcalendaryear.Seethetipin4Aaboveforadefinitionof‘employee”forthispurpose.tiD.ERISA:IsthegroupsubjecttoERISA?ElYes.EnterthemonththeERISAplanyearends:______________________________No.Givethelegalreasonforexemption:GovernmentorpublicplanElChurchplanElOther(pleasespecify):Tip:Generally,ERISAappliestoallemployerhealthplansexceptgovernment,public,orchurchplans.NonprofitstatusalonedoesnotexemptanemployerfromERISA.5.OTHERCARRIERINFORMATIONDoyouofferanothermedicalplantoyouremployees,otherthanoneofourplans?YesElNoIfyes,pleaselistthecarriername:Self-fundedmedicalplanPageLiof7 6.CONFIRMEDRATESANDBENEFITSSELECTION6A.Pleasesignattachedtateconfirmationsheet.ConfirmedRQ/QRnumber:RQ-132211andRQ1322126B.RateStabilizationReserveFundingAgreementLIYesNoIfyes,TerminalLiabilityisheldby:LIClientLIKFHPWAorKFHPWAO6C.Grandfatheredplan:Inordertobeincompliance,ourdocumentationmustestablishthefollowinggrandfatheredplancriteriahavebeeninplacesincesinceMatch23,2070.Doesthegroupmeetthecriteriabelow?LIYesN/A•Theplanwasnotamendedtoeliminatebenefitsforaspecificcondition.•Thepercentageoffixedamountcost-sharingpercentagerequirementsfortheplan,ifapplicable,wasnotincreasedwhenmeasuredfromMarch23,2010.•Thefixedcost-sharingrequirementsotherthancopaymentsdidnotincreasebyatotalpercentagemorethanthemedicalinflationtateplus15percent.•Copaymentsdidnotincreasebymorethanthemedicalinflationrateplus15percentorfivedollars(adjustedfarinflation),whicheverisgreater.•Theemployer’scontributionrateforanytierofcoveragedidnotdecreasebymorethanfivepercent.•Theplanwasnotamendedtoimposeanannualdollarlimitottoadoptanoverallannualdollarlimitonbenefitsthatislessthanthelifetimelimit.7.PRODUCERINFORMATIONDoyouhaveaproducerofrecord?YesLINoIfno,continuetoSection8.IhaveappointedRLEvansCompany,Inc.asmyproducerofrecordwithrespecttothecoveragedescribedinthisapplication,effective1/1/2019Producer’sname:DouglasEvansTitle:PresidentProducer’scompanyname:RLEvansCompanyLicensenumber:52064Producer/representative’sSocialSecurityortaxIDnumber:91-0849754Companyaddress:3535FactoriaBlvdSE,#120,Bellevue,WA98006LIConsultantProducerLICommissiontobepaidto:RLEvansCompanyPhone:425-455-0501Fax:425-467-5264Email:dougerlevansco.com8.ACKNOWLEDGMENTSANDCERTIFICATIONApplicantacknowledgesthatiftherequestedcoverageisacceptedbytheapplicablehealthcarrier(KFHPWAorKFHPWAO)underthecarrier’scurrentrulesandpractices,acoverageagreementwillbeissuedandeffectiveonthedatedeterminedbythecarrier.Applicantfurtheracknowledgesandagreesthatpaymentofanypremiumdueforthecoverageshallconstituteapplicant’sacceptanceofthecoverageagreementissued.ForSection2,“EmployeeEligibility,”applicantatteststohavingclearlystatedthetermsofeligibilityconditionsorwaitingperiodsimposedonemployeesbeforetheyareeligibletobecomecoveredunderthetermsoftheplan.Applicantfurtherattestsitwillprovideuswithanychangesrelatedtosuchconditions.Page5of7 SALLSLOCATIONSP0Box35002Seattle,WA9812L1SeattleSales206-L1c18-ti1Li0Toll-free1-800-5L12-6312Fox:206-877-0655950Paci&Ave.,Suite900Tacoma,WA98L102TacomaSales206-tiL18-LiL0Toll-free1-800-51i2-6312Fax:253-383-78252211RimlandDrive,Suite9J1Bellingham,WA98226BellinghamSales206-LiLi8-L140Toll-free1-800-5L12-6312Fax:360-6Li7-72L97601W.ClearwaterAve.,Suite205Kennewick,WA99336CentralWashingtonSales509-783-3L18L1Toll-free1-800-L58-5L50Fax:509-736-19105615W.SunsetHighwayEasternWashington?Spokane,WA9922L1NorthIdahoSales206-LL8-Li1Li0Toll-free1-800-5L12-6312Fax:509-L159-1080Page7of7