HomeMy WebLinkAboutContract CAG-17-217
�fi� KAISER PERMANENTE�
Kaiser Foundation Health Plan of Washington
BENEFIT BOOKLET REVISIONS
Effective January 1, 2018
This is the most current list of revisions;this list may be subject to change at any time.
Benefit Booklet Revision Explanation
How Covered Services Work
Visiting member services A clarification has been added to state that visiting member services
may be available from another Kaiser regional health plan as
directed by that other plan so long as such services would be
covered underthe member's current KFHPWA plan.
Benefit Details
Drugs-Outpatient A clarification has been added to state that contraceptive drugs may
be allowed up to a 12-month supply.
This change is in compliance with Washington state requirements.
Maternity and Pregnancy A clarification has been added to state that prenatal testing for the
detection of congenital and heritable disorders is covered when
medically necessary.
Nutritional Therapy A clarification has been made to the nutritional therapy exclusionary
provision to state that oral nutritional supplements not related to
the treatment of inborn errors of inetabolism are excluded.
Claims
Claims submission requirement A clarification has been made to state that members (at the
member's expense) must submit the claim and any associated
medical records translated into English (including the type of service,
charges in U.S. dollars, and proof of travel)to KFHPWA for out-of-
country claims(for emergency care only).
Page 1 of 1
• .
• ' - •
- �. - � : � •
The below rates have been quoted for lhe following plan(s).Please sign below to confirm rates-
Applicant further acknowledges and agrees that payment of any premium due for the coverage shall constitute applicanYs acceptance of the coverage agreement issued.
Core
Core HMO
_._._�_ _----._�--
Group Name City of Renton
_ __ —�.�
Group Number ; 1162600
_______ _r _ — RQ-116595
___.. �___------___ _.____ .�
. EE ._. _..:�:. $78676 �-
' EE/S $1,985.62
_---
!Rates by Tier EE/1 C $1,361.32
� ----
EE/2+C $1,863.16
_ – .. ....__.... �. .,......_. __._._,...__ _.__.�__—_---- --..----------
' EE/S/1 C $2,560.15
EE/S/2+C $3,061.98
All plans offered and undenvritten by Kaiser Foundation Health Plan of Washington � �� ����� '
This heaRh coverage meets or exceeds the minimum essential coverage requirements and the minimum value standard for the benefits it '
provides.
I '��.This outpatient prescriplion drug coverage meets the Medicare Part D standard for creditable coverage.
1 '
Signature Date
(�
Mayor Denis L
```�a������ni�i�,����
tteSt ' ��,``�������0�„R���NTp���'
A �. �/ ���� " ' � /'_ '=
�lason th ity C rk : * = S E A L ; * :
, , _ _ _ -
: y=� '�° =o „
: �' ''% .`'� �, �
��i���p �������u��N�"��` tp.���
����i����RATED1 SEQ����```.
526GG07-0317
. .
• ' - • • '
- e, - � : � •
The below rates have been quoted for the following plan(s).Please slgn below to confirm rates.
Applicant further acknowledges and agrees that payment of any premium due for the coverage shall constitute applicanYs acceptance of the coverage agreement issued.
Core
Core HMO
_ .____. ...__.. _�.___._.____._._...__._ __.___----_ ___...____.__.
Group Name City of Renton-Leoff I Retirees
Group Number 0057500
RQ-116596
EE<65 Years Old $1,034.35
_.
EE>65 Years Old,Not Enrolled Medicare $1,175A5
Rates by Tier -- -
9-E $-6�'�.9'J
._._ ._.. .__.. .._....__�__..
RR6 ..... $"'�
_.—
,_....-�--�----....--�---��----�
Medicare Rates by Tier � MedicareAB $54578 �,
All plans offered and undenvritten by Kaiser Foundation Health Plan of Washington '
This health coverage meets or exceeds the minimum essential coverage requiremenis and the minimum value standard for the benefits it
provides. �
This outpatient prescription drug coverage meets the Medicare Part D standard for creditable coverage.
Signature Date I` Z�
Mayor Denis Law
``������«�u��►,,,,
� p F RF �'''
.�� y ��.
,� ,� �
`��.`� `���,,,,,�,���,,,,,, TO�,,,,
Attes �� �` �7 _ _ ' x ''�-,ti';
Jas Seth,` M , ity CI rk " * ' s E A L ; *=
= � ; •�. _ :
: '�, ,.'o�;
'��i��'pA������hrni���a����� \�i`�
����i��t�R�4TED SEP;��`���`
526GG07-0377