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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