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TABLE OF CONTENTS4 Contact Information5 Plan Overview17 Kaiser Permanente*22 Kaiser Permanente HMO Select*24 Kaiser Permanente Flexible Choice**27 Kaiser Permanente Flexible Choice** RX Plan29 UnitedHealthcare*42 UnitedHealthcare Choice High Plan*51 UnitedHealthcare Choice High RX Plan*54 UnitedHealthcare Choice Plus**63 UnitedHealthcare Choice Plus RX Plan**74 Dental Insurance*79 Vision Insurance*81 Life Insurance***82 Medical Insurance Comparison*FULLY PAID BY PFLAG**EMPLOYEE/PFLAG COST SHARE***PFLAG PAYS FOR COVERAGE UP TO $50,000, EMPLOYEE HAS THE OPTION TOPURCHASE ADDITIONAL VIA PRE-TAX PAYROLL DEDUCTIONSPOUSE OR PARTNER COVERAGE AVAILABLE:PFLAG AND EMPLOYEE 50%/50% COST SHARE OF ADDITIONAL PREMIUM (SEERATE SHEET/ASK DAVID OR ADAM FOR DETAILS).ALL FORMS AND A COPY OF THIS PROGRAM ARE AVAILABLE FOR DOWNLOAD ATHTTPS://INTRANET.PFLAG.ORG
http://intranet.pflag.org/http://intranet.pflag.org/7/30/2019 2013 PFLAG Health Plans
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Intranet PFLAG Benefits Resources (click for more information):
Health Insurance
403(b) Retirement Plan
Online Pay Stub Access
BikeShare
Short-term and Long-term disability Insurance
Employee Assistance Program (EAP)
Employee Discount Program
Flexible Spending Account
Microsoft Home Use Program
SmarTrip and Parking
Wells Fargo at Work Program
Worldwide Travel Assistance
ZipCar Discount
https://www.google.com/url?q=https%3A%2F%2Fsites.google.com%2Fa%2Fpflag.org%2Fportal%2Fhr%2Fbenefits%2Fzipcar&sa=D&sntz=1&usg=AFQjCNF4C-H1ub9iPVJoN37I6-pgNb8RaQhttps://www.google.com/url?q=https%3A%2F%2Fsites.google.com%2Fa%2Fpflag.org%2Fportal%2Fhr%2Fbenefits%2Fworldwide-travel-assistance&sa=D&sntz=1&usg=AFQjCNGGU6sfp-Zni1uyLTRQUBD3zINH1Ahttps://www.google.com/url?q=https%3A%2F%2Fsites.google.com%2Fa%2Fpflag.org%2Fportal%2Fhr%2Fbenefits%2Fwells-fargo&sa=D&sntz=1&usg=AFQjCNFsczYABIt3xY4sL8_1uO49yqqvjghttps://www.google.com/url?q=https%3A%2F%2Fsites.google.com%2Fa%2Fpflag.org%2Fportal%2Fhr%2Fbenefits%2Fsmartrip-and-parking&sa=D&sntz=1&usg=AFQjCNG39te4VqnzyJ-fP4CVdTWfKH8YSAhttps://www.google.com/url?q=https%3A%2F%2Fsites.google.com%2Fa%2Fpflag.org%2Fportal%2Fhr%2Fbenefits%2Fmicrosoft-home-use-program&sa=D&sntz=1&usg=AFQjCNGEHIXqUPbnafWvqQganlb3XqGhEQhttps://www.google.com/url?q=https%3A%2F%2Fsites.google.com%2Fa%2Fpflag.org%2Fportal%2Fhr%2Fbenefits%2Fhealth-insurance%2Fflex&sa=D&sntz=1&usg=AFQjCNEHgt2mFUOdD6V2BBXLp64aKj6Sqwhttps://www.google.com/url?q=https%3A%2F%2Fsites.google.com%2Fa%2Fpflag.org%2Fportal%2Fhr%2Fbenefits%2Fdiscounts&sa=D&sntz=1&usg=AFQjCNEhH_rdVrYbXSh08mhW2h8NXIvkMghttps://www.google.com/url?q=https%3A%2F%2Fsites.google.com%2Fa%2Fpflag.org%2Fportal%2Fhr%2Fbenefits%2Feap&sa=D&sntz=1&usg=AFQjCNF7S4OErDJhAsKHZbpx1VVAWbb3Owhttps://www.google.com/url?q=https%3A%2F%2Fsites.google.com%2Fa%2Fpflag.org%2Fportal%2Fhr%2Fbenefits%2Fdisabilityinsurance&sa=D&sntz=1&usg=AFQjCNHb0_S9IHfTgz7gJSON5Bn229LUYQhttps://www.google.com/url?q=https%3A%2F%2Fsites.google.com%2Fa%2Fpflag.org%2Fportal%2Fhr%2Fbenefits%2Fbikeshare&sa=D&sntz=1&usg=AFQjCNGuzf8LmkTQ2dD6hl_WjB0D3lxwuwhttps://www.google.com/url?q=https%3A%2F%2Fsites.google.com%2Fa%2Fpflag.org%2Fportal%2Fhr%2Fbenefits%2Fadp-online-pay-stub-access&sa=D&sntz=1&usg=AFQjCNEgy20xB8uyUnmR0DmSazvVJFggUAhttps://www.google.com/url?q=https%3A%2F%2Fsites.google.com%2Fa%2Fpflag.org%2Fportal%2Fhr%2Fbenefits%2F403b&sa=D&sntz=1&usg=AFQjCNFQE1t0UvT0sXnHfdA9n-7So2mPAAhttps://www.google.com/url?q=https%3A%2F%2Fsites.google.com%2Fa%2Fpflag.org%2Fportal%2Fhr%2Fbenefits%2Fhealth-insurance&sa=D&sntz=1&usg=AFQjCNHVgaTtboyYjwFuCibKamMYIyOKPg7/30/2019 2013 PFLAG Health Plans
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www.nonprofitadvancement.org 202 457 0540 3
CENTER FOR NONPROFIT ADVANCEMENTS HEALTH PROGRAM
www.nonprofitadvancement.org 202 457 0540 3
April 2013
Dear Health Program Participant,
Welcome to Open Enrollment 2013-2014 and our 30th year providing big benefits to your
nonprofit.
The Center for Nonprofit Advancements Benefits Trust (Health Program) continues to be
the best choice for your organization. Again this year, we are proud to offer renewal rate
increases lower than the regional average, comprehensive high quality benefits and peace of
mind in todays changing healthcare environment.
This 2013-2014 Health Program Book is an important guide, offering you the latest informa-
tion on each of this years plans and technology updates including:
increased vision benefit - now offering $125 for glasses at the same premium cost
two new dental plans - offering no maximum annual benefit, no annual deductible and
new orthodontia benefits.
new online capabilities - individual employees can review, update and/or change Open
Enrollment elections online.
This book has been revised to reflect that, for legal reasons, each Participating Employer has
adopted the Health Program as its own stand-alone employer welfare program for purposes
of the Employee Retirement Income Act of 1974, as amended. The Center for Nonprofit
Advancement will continue to provide certain administrative services with respect to the
Health Program as it has done in the past. This new designation further strengthens our
group plan and provides another compliance seal of approval.
Remember, Open Enrollment is your annual opportunity to make changes or additions to
your insurance. The Open Enrollment period runs from May 1 to June 14, 2013 with changes
effective July 1, 2013. Every employee at a participating member organization can log-in at
www.nonprofitadvancement.org for additional information.
Please share this resource with peer organizations and partners. We look forward to a
dynamic 30th year serving you.
All the best,
Glen O'Gilvie
CEO, Center for Nonprofit Advancement
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Center for Nonprofit Advancement General
Contact and Membership Information:
1666 K Street NW, Suite 440,
Washington, DC 20006
Tel: 202 457 0540
E-mail: info@nonprofitadvancement
Web: www.nonprofitadvancement.org
For Information on the Health Program:
Tel: 202 457 0540
Fax: 202 457 5850
E-mail: [email protected]
Ext.203,BenefitsTrustDirector(HealthProgram
Compliance)
Ext209,BillingandCollectionsAssociate(Billing
questions and payments)
Ext212,CustomerServiceManager(Health
Program inquires and enrollment)
Ext.211,CustomerServiceAssociate(Health
Program inquires and enrollment questions)
Ext.200,HealthProgramAssociate(Health
Program inquiries)
HEALTH PAYMENTS ONLY should be
mailed to:
Center for Nonprofit Advancements Benefits Trust
c/o M&T Bank Trust Department
P.O. Box 4623
Buffalo, NY 14240-4623
Please mail all forms and correspondence to:
Center for Nonprofit Advancement,
Attn: Health Dept.
1666 K Street NW, Suite 440
Washington, DC 20006
For the most current, up-to-date information aboutthe Health Program, visit the members-only section
of our Web site. Available online:
Plandescriptions
Downloadallforms
Broker for the Health Program
R. David Dixon
Early, Cassidy & Schilling
Tel: 301 948 5822, ext. 136
E-mail: [email protected]
CENTER FOR NONPROFIT ADVANCEMENTS HEALTH PROGRAM
CONTACT INFORMATION
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The Center for Nonprofit Advancement has estab-
lished the Center for Nonprofit Advancement
Benefits Trust (the Health Program) for thepurpose of providing eligible employers with the
means to deliver various health and welfare bene-
fits to their employees. This booklet is the summary
plan description (SPD) for the Health Program and
explains the rules governing the Health Program,
including those concerning eligibility, participa-
tion and enrollment. This SPD also summarizes the
benefits offered under the Health Program to eligible
employees.
In order to be eligible to elect benefits in the
Health Program, your employer (an Employer or
Participating Employer) must participate in theHealth Program pursuant to the rules and proce-
dures established by the Center for Nonprofit
Advancement, and you must be employed in a clas-
sification that is eligible for the Health Program. To
participate in the Health Program, your Employer
must, with the consent of the Center for Nonprofit
Advancement, execute an agreement adopting the
Health Program. In so doing, your Employer estab-
lishes a single employer welfare plan under the
Employee Retirement Income Security Act of 1974.
Your Employer may provide other benefits, plans
or programs that are not provided by the Center for
Nonprofit Advancement. Such benefits, plans andprograms are not part of the Health Program and
are not described in this SPD. For detailed informa-
tion about those benefits, if any, you should refer to
any separate summary plan descriptions provided to
you by your Employer.
The benefits of the Health Program are provided
through one or more insurance companies (the
Insurer). The rules, requirements and covered
benefits of your coverages are described in this SPD
and any related documents provided by the Insurers,
including the Evidence of Coverage. The Center for
Nonprofit Advancement or your Employer will sendyou any additional insurance documents that relate
to the benefits in which you are enrolled.
The rules and operation of the Health Program are
described in this SPD as clearly as possible with
minimal use of the technical terms appearing in the
official legal documents (including the applicable
insurance documents). However, the official legal
documents remain the final authority and, in the
event of a conflict with this SPD, shall govern in
all cases. All decisions regarding eligibility for and
the amount of any benefit provided through the
Health Program are made by the applicable Insurers
Neither the Center for Nonprofit Advancement noyour Employer has any authority to make benefits
claims decisions regarding the Health Program. You
may request a copy of the official legal documents
from the Center for Nonprofit Advancement.
All members participating in the Health Program are
responsible for communicating to their employees
all information regarding benefits they offer unde
the Health Program. Providing your employees with
timely and accurate information is the responsibility
of your organization and the Center for Nonprofit
Advancements Benefits Trust is not held liable.
Who Can Enroll
Medical plans are available to Participating
Employers with two or more employees, working
20 or more hours per week. In addition, vision, life
and dental plans are available to organizations with
one employee working at least 20 hours per week.
Employee:
Only W-2 employees working 20 or more hours
per week at a member organization may enroll
No independent contractors, board members o
volunteers are eligible to participate in the Health
Program
In all circumstances, the Center for Nonprofi
Advancement and the applicable Insurer deter
mine whether an entity is a Participating Employe
and whether any employee is eligible to participate
in the Health Program. Any such determination
made by the Center for Nonprofit Advancemen
and an Insurer shall be conclusive and binding on
all parties involved.
The following Dependents are eligible to enroll:
Spouse
Domestic Partner* (not eligible for COBRA
coverage)
Children (minors) - biological, adopted (or placed
for adoption with you) and foster child
Adult children - up to age 26 for all medical insur
ance regardless of their financial, student and
marital status and age 25 for dental and vision
plans. Adult children must be unmarried to partici-
pate in the dental or vision plans.
CENTER FOR NONPROFIT ADVANCEMENTS HEALTH PROGRAM
PLAN OVERVIEW
The medical plans
in this booklet are
not available to
employee groups of
2 - 50 in Maryland,
as a result of the
Maryland Small
Group Insurance
Reform law.
For details, call
Dave Dixon atEarly, Cassidy &
Schilling, Inc., at
301 948 5800.
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* Domestic partners are subject to additional eligi-
bility requirements, and you must complete a sepa-
rate domestic partner enrollment document.
The insurers of the benefits offered under the Health
Program may have additional eligibility requirements.
Please note your coverage will terminate if you no
longer satisfy the eligibility requirements, if your
employer no longer satisfies the requirements to
participate in the Health Program or if your employ-
ers participation in the Health Program otherwise
ends or is terminated.
ENROLLMENT PROCESS
Authorizing Signature: All forms must be signed
by the authorized person(s) indicated on the Group
Participation Request Form. (If there are changes in
the contacts or the person authorized to sign your
enrollment forms, the organization must provide
written authorization on the organizations letter-
head signed by the Chief Executive Offer/Executive
Director.) In the absence of a Chief Executive Officer/
Executive Director, the Board Chair or President
should sign this document.
Incomplete Documents:We will make one telephone
call and send one E-mail to request corrections to
incomplete documents submitted to our office. If we
do not receive a response for requested information,
paperwork will be returned.
Life Insurance Requirement: In the absence of any
other group life insurance policy, basic life insur-
ance in the amount of $10,000 is required to receive
medical insurance.
For any questions about the status of your enroll-
ment, call the Health Program between 9:00 a.m. and
5:00 p.m. Monday through Friday (excluding holi-
days) at 202-457-0540. Send your e-mail to health@
nonprofitadvancement.org.
NEW HIRE
Each new employee (or newly-eligible employee)
must enroll within 30 days of the date he or she
becomes eligible for coverage. Coverage begins
on the first day of the month COINCIDING WITH
OR FOLLOWING the date the employee becomes
eligible for benefits and completes the waiting
period, if any, applied by his or her Employer.
If a new employee waives/declines coverage, a
Waiver of Coverage form must be completed
within 30 days of the date he or she becomes eligible
for coverage and submitted to the Health Program.
OPEN ENROLLMENT
Open Enrollment occurs annually from May 1 to
June 14. During this time, participants may add or
drop coverage, add or drop dependents or change
their coverage options with changes effective July
1. If no documentation is submitted, the prior year'selections will continue during the 2013-2014 plan
year. If you are electing to make no changes, waive
participation in the Health Program or making
changes to your coverage, you will complete the
2013 Open Enrollment Election Notice.
Participating employers must submit all open
enrollment paperwork by June 14, 2013. Failure to
submit all your open enrollment paperwork by June
14, 2013 will mean that your employees open enroll-
ment selections may not take effect. Furthermore,
submission of late paperwork will incur an addi-
tional fee of $100 per employee.
During Open Enrollment, eligible dependents may
be added to any qualifying program. The insurers of
the benefits offered under the Health Program may
have additional eligibility and enrollment require-
ments. This is a once-a-year opportunity to make
changes to your existing coverage. Coverage cannot
be modified until the next Open Enrollment period
(see exceptions below).
CLASSES ELIGIBLE FOR REHIRE
Rehires who may be eligible for service restora-
tion include employees who had completed theircompany introductory period and who were part
of a reduction in force or who voluntarily resigned.
SERVICE RESTORATION RULES FOR REHIRED
EMPLOYEES
If a former employee with less than one years prior
service is rehired, the employee will be considered
a new employee and must meet the new hire eligi-
bility requirement of the Participating Employer.
If a former employee with more than one years
prior service is rehired, the employees eligibility
to participate in the Health Program will be bridged
if the employee is rehired where the period of
prior company service exceeded the duration of
the period of absence. Coverage begins on the
first day of the month coinciding with or following
the date when the employee becomes eligible.
If a former employee with more than one years prior
service is rehired where the duration of the period
of absence exceeded the period of prior company
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service, the employee will be considered a new
employee and must meet the new hire eligibility
requirement of the Participating Employer
SPECIAL ENROLLMENT OPPORTUNITIES
OTHER THAN AT HIRING OR OPEN
ENROLLMENT:
Employees have special rights to enroll in the Health
Program benefits for any of the following reasons:
Loss of Other Coverage: The employee previously
declined (a " Waiver of Coverage" notice must be on
file) to enroll in the Health Program because he or his
dependents had other coverage and that coverage
was lost because -
The other coverage was COBRA coverage and the
COBRA period was exhausted; or
The other coverage was non-COBRA coverageand terminated due to a loss of eligibility or the
employer stopped contributing to the cost of the
coverage.
The employee must provide acceptable evidence
that the other coverage that formed the basis for the
Waiver of Coverage has been lost and must request
enrollment within 30 days.
Qualifying Event: The employee has a new depen-
dent as a result of marriage, birth, adoption, or
placement for adoption and wants to enroll himself
and his dependents. The employee and eligible
dependents can enroll due to divorce or legal sepa-ration, death or court order. The employee must
provide acceptable evidence that a qualifying event
has occurred and must request enrollment within
30 days.
Special Rule for Newborns: If you have a newborn
child, employees must call the Health Program at
202-457-0540 to enroll your newborn child. You
must call the Health Program within 30 days after
birth, and enrollment will then be effective as of
your childs birth. Failure to call within 30 days
of birth means that you will not be able to enroll
your newborn child until the next Open Enrollment
period (or another future qualifying event, if earlier).
This rule applies regardless of whether the medical
carrier pre-enrolls your newborn at birth.
CHIPRA: The employee's or his dependent's
coverage under a Medicaid plan or a State Childrens
Health Insurance Program (CHIP) plan termi-
nates due to loss of eligibility, or the employee or
his dependents become eligible for Medical Plan
premium assistance under a Medicaid plan or a
CHIP plan. Enrollment must be requested within 60
days of termination of such coverage or the date
the employee or his dependent is determined to be
eligible for such assistance.
Part-time employees who become Full-time: This
is based on the policy of the employer. The Health
Program will enroll an employee on the 1st of the
month following the full-time hire date if a partici
pating employer does not have a policy.
Failure to timely request special enrollment wil
result in the member having to wait until the next
Open Enrollment period.
Termination ProcessTERMINATIONS
A. Of Individual Employee Coverage
The Combined Termination form, available on
the Centers website, must be submitted for each
employee who wants to terminate benefits. The
form must provide accurate address information for
each terminating employee and be returned within
30 days of the termination date. Coverage will end
on the last day of the month when the employee
ceases to be eligible. Please provide current and
accurate address information. If an employee loseseligibility for coverage, you must send notice and al
applicable documentation to the Center s Enrollmen
Department within 30 days of the date the eligibility
is lost. Your organization will be financially liable fo
additional premiums due for failure to submit termi
nation forms within the required 30 days.
COBRA packages are generated based on a complete
Combined Termination form. They are generated
on a weekly basis and mailed to the last known
address on file. (For additional details, please read
the COBRA section of the book.)
Employees may voluntarily terminate their participation in any benefits offered by their Employer
though the Health Program during open enrollment
or following a Qualifying Event by providing 30-days
written notice to the Health Program. Employees
may not voluntarily terminate their participation a
any other time.
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CENTER FOR NONPROFIT ADVANCEMENTS HEALTH PROGRAM
B. Qualifying Events
A. For Employees
1. Termination of employment for any reason
other than gross misconduct
2. Reduction in the number of hours of
employment
3. Divorce
4. Legal separation
B. For Spouses
1. The reasons listed under Employee above
2. Covered employee becomes entitled to
Medicare
3. Divorce or legal separation of the spouse
from the covered employee or
4. Death of the covered employee
C. For Dependent Children
1. All the reasons listed under Employee or
Spouse above
2. Loss of dependent child status due to
reaching age 26 for all medical plans and
age limit of 25 for dental and vision plans
C. Of Employer Coverage
A Participating Employer may voluntarily terminate
its participation in the Health Program, or any bene-
fits offered under the Health Program, by providing
a 30-day notice to the Health Program on its letter-
head. The termination request must be signed by
the CEO/Executive Director. If the final premium is
not paid, the effective date of termination will be
the end of the last month which was paid in full. A
Participating Employer may not rejoin the Health
Program on a guaranteed issue basis for twenty-four
(24) months for any benefits for which it requested
voluntary termination. Your Employer is responsiblefor notifying its former employees on COBRA of its
new insurance carrier.
Definitions
HMO (Health Maintenance Organization): A network
of physicians, other health care practitioners, and
facilities that provide a wide spectrum of health care
services.
Indemnity: What was once the "traditional" medical
plan: members pay for medical services then are
reimbursed according to a fixed price schedule
POS (Point of Service): A network of physicians,
health care practitioners, and facilities that allows
members to seek care from any physician, health
care practitioner, or facility, with or without a
referral from a primary care physician. Out-of-
pocket expenses will vary, depending upon whether
a physician, health care practitioner or facility is in
the POS network and whether the member has a
referral from a primary care physician.
PPO (Preferred Provider Organization): A network-
based plan that encourages members to receive
covered services from preferred physicians, health
care practitioners or facilities. Members may use
other health care practitioners or facilities, but
generally will have higher out-of-pocket costs and
more administrative tasks if they do.
Use The Right Forms
OPEN ENROLLMENT:
If you are changing your health plan during Open
Enrollment, please send the Health Program:
Open Enrollment Election Notice form and;
An enrollment form for the plan you are joining.
To add or remove dependents from your current plan,
request a change in coverage using the following
enrollment forms (UnitedHealthcare, Kaiser, United
Concordia, DentaQuest or Advantica Eyecare).
OPEN ENROLLMENT AND NEW HIRE:
UnitedHealthcare (UHC): Use the UHC form to enroll
or change medical coverage. Select either HMO
Low, HMO High, Choice Plus or Optimum Choice
HMO plan.
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Kaiser Permanente: Use the Kaiser multipurpose
form to enroll or change medical coverage. Select
either HMO Select, HMO Signature, Deductible
HMO (DHMO) or Kaiser Permanente Flex Choice.
United Concordia: Use the United Concordias Dental
Plan form to enroll or change dental coverage.
DentaQuest: Use the DentaQuest form to enroll or
change coverage.
Advantica Eyecare: Use the Advantica Eyecare form
to enroll or change coverage.
Life Insurance: In the absence of any other group
life insurance policy, basic life insurance in the
amount of $10,000 is required to receive medical
insurance. Use the life enrollment form. Include theemployers name, address and phone number.
Optional Voluntary Life Insurance: This insurance
is paid for by the employee on a voluntary basis.
If you decline this coverage, please mark the no
box on the enrollment form. You cannot enroll in the
voluntary life insurance without basic life insurance.
Additional term life insurance is available in amounts
up to 150,000.
If you do not enroll in voluntary life insurance when
you were hired, you will pay a late enrollment fee,
complete the evidence of insurability form and theinsurance company may require a medical exam.
Cost of Coverage
Every Participating Employer pays the same
premiums for the same benefits, regardless of your
groups size or pre-existing condition. The cost of
coverage paid by enrolled members is equal to the
premiums charged by the applicable carrier for the
benefit or benefits in which the member is enrolled
plus a nominal administration fee that is retained
by the Center for Nonprofit Advancement Benefits
Trust. The administration fee is used by the Trust to
pay for plan administration expenses. Although the
fee varies from year-to-year and differs based on the
particular benefit, on average the fee is projected
to be roughly 3% of the monthly cost of coverage
paid by each member. This fee changes annually
Updated amounts can be obtained by contacting the
Health Program.
If you enroll a domestic partner or same-gende
spouse, special imputed income tax rules will apply
for purposes of Federal income taxes (and in some
cases State income taxes as well). Imputed income
taxes are added to your taxable compensation
and reported on your Form W-2 each year by your
employer. You should contact your employer fo
additional information regarding the amount and
frequency of imputed income.
COBRA
WHO IS ENTITLED TO CONTINUATION
OF COVERAGE?
There is COBRA Administration available for active
members of the Health Program.
There are three basic requirements that must be
met in order for you to be entitled to elect COBRA
continuation coverage:
Your group health plan must be covered by
COBRA;
A qualifying event;
You must be a qualified beneficiary for that eventCOBRA continuation coverage will be provided
to all COBRA qualifying individuals, regardless
of the number of employees of the Participating
Employer. This rule only applies during the time
that your employer is a Participating Employer in
the Health Program.
QUALIFYING EVENTS
A. For Employees
1. Termination of employment for any reason
other than gross misconduct
2. Reduction in the number of hours o
employment
3. Divorce
4. Legal separation
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CENTER FOR NONPROFIT ADVANCEMENTS HEALTH PROGRAM
B. For Spouses
1. The reasons listed under Employee above
2. Covered employee becomes entitled to
Medicare
3. Divorce or legal separation of the spousefrom the covered employee or
4. Death of the covered employee
C. For Dependent Children
1. All the reasons listed under Employee or
Spouse above
2. Loss of dependent child status due to
reaching age 26 for all medical plans and
age limit of 25 for dental and vision plans
Special Notice for Employees: For the qualifying
events of divorce or legal separation of the employee
and spouse, or a dependent child loses eligibility for
coverage as a dependent child, you must notify the
Health Program at 202-457-0540 within 60 days after
the qualifying event occurs.
If your Employer elects to terminate its participation
in the Health Program, you will not be entitled to
continue your coverage under the Health Program
through COBRA and any existing COBRA coverage
offered through the Health Program will be termi-
nated. You may, however, be entitled to COBRA
continuation coverage through another health plan
sponsored by your Employer.
QUALIFIED BENEFICIARIES
A qualified beneficiary is an individual who was
covered by a group health plan on the day before a
qualifying event occurred that caused him or her to
lose coverage.
Qualified Beneficiaries:
1. Covered Employee
2. Employees covered spouse or former spouse
3. Employees covered dependent child
Special Rule for Domestic Partners and Same-
Gender Spouses: Based on Federal law, COBRA
does not apply to a domestic partner or a same-
gender spouse. A domestic partner or same-gender
spouse is not a qualified beneficiary and will not be
able to continue coverage under COBRA.
COBRA Process
A. Combined Termination Form
The employer submits a Combined Termination Form
to terminate coverage under the group plan within
30 days of the qualifying event. Please provide the
last known address of the employee.
When the Health Program receives a notice to
terminate coverage from an employer, we send theemployee an election notice of his or her rights with
forms for temporary continuation of benefits under
the Federal Consolidated Omnibus Reconciliation
Act of 1985, known as COBRA.
COBRA packages are mailed to the last known
address on file.
B. Employer Benefits
Coverage under the former employer will continue
until the last day of the month.
C. COBRA
COBRA is not active until the COBRA Continuation
Coverage Election Notice is returned to the Health
Program. The election notice must be returned
within 60 days of receiving the notice.
Once the employee returns the COBRA Continuation
Election Notice, the coverage in place at the time
of termination will be reinstated with no lapse in
coverage. The coverage will be identical to the
coverage that you had immediately before the quali-
fying event.
Please contact us if you have any questions regardingdetails of this program at 202 457 0540 or send your
questions to [email protected].
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CENTER FOR NONPROFIT ADVANCEMENTS HEALTH PROGRAM
Summary of Benefits andCo-Payments
On the following pages are summaries of the benefits
and co-payments for each of the insurance carriers
offered by the Center for Nonprofit Advancement
Health Program. It is the employers responsibility
to communicate which benefits are offered to their
employees.
This booklet is a summary of certain features of the
Center for Nonprofit Advancement Health Program.
It is a partial, general description of benefits, proce-
dures, limitations, and exclusions and is not meant
as a contract or any part of one.
For more information, see plan descriptions found
on the members-only section of the Web site.
For a complete description of the available benefits,including procedures, exclusions, and limitations,
please refer to the official plan documents, which are
the evidence of coverage (mailed to each member
upon enrollment).
In the event of any difference between this guide
and the official plan documents, the plan documents
prevail. You may contact a health plan representative
for questions regarding benefits, co-payments and
exclusions.
All forms and a copy of this program are available for
download at the Center for Nonprofit Advancement
Web site at www.nonprofitadvancement.org.
Regulatory Coverage andCompliance
Plans within the Center for Nonprofit Advancement
Health Program are covered by corresponding federal
regulations and policies. The staff and management
employ every means at our disposal to ensure that
Health Insurance Portability and Accountability Act
(HIPAA) protections are being followed. For specific
HIPAA information about a particular plan, contact
that insurer or provider.
Below are the regulations that cover Health Care
Program plans and benefits, and ensure the highest
quality standards are being met. For detailed infor-
mation on regulations that affect health plans go the
Department of Labor Web site at www.dol.gov/dol/
topic/health-plans/index.htm.
The Employee Retirement Income Security Act o
1974 (ERISA) is a federal law that sets minimum stan
dards for most voluntarily established pension and
health plans in private industry to provide protec
tion for individuals in these plans. ERISA requires
plans to provide participants with plan informationincluding important information about plan features
and funding; provides fiduciary responsibilities fo
those who manage and control plan assets; requires
plans to establish a grievance and appeals process
for participants to get benefits from their plans; and
gives participants the right to sue for benefits and
breaches of fiduciary duty.
There have been a number of amendments to ERISA
expanding the protections available to health benefit
plan participants and beneficiaries.
One important amendment, the Consolidated
Omnibus Budget Reconciliation Act (COBRA)
provides some workers and their families with the
right to continue their health coverage for a limited
time after certain events, such as the loss of a job.
Another amendment to ERISA is the Health Insurance
Portability and Accountability Act (HIPAA), which
provides important new protections for working
Americans and their families who have preex
isting medical conditions or might otherwise suffe
discrimination in health coverage based on factors
that relate to an individual's health. Other importan
amendments include the Newborns' and Mothers
Health Protection Act, the Mental Health Parity Actand the Women's Health and Cancer Rights Act.
The Women's Health and Cancer Rights Act o
1998 (WHCRA) includes protections for individuals
who elect breast reconstruction in connection with
a mastectomy. WHCRA provides that group health
plans and health insurance issuers that provide
coverage for medical and surgical benefits with
respect to mastectomies must also cover certain
post-mastectomy benefits, including reconstructive
surgery and the treatment of complications (such as
lymphedema).
The Newborns' and Mothers' Health Protection Act
of 1996 (Newborns' Act) requires group health plans
that offer maternity hospital benefits for mothers and
newborns to pay for at least a 48-hour hospital stay
for the mother and newborn following childbirth (or
in the case of a cesarean section, a 96-hour hospita
stay), unless the attending provider, in consultation
with the mother, decides to discharge earlier.
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CENTER FOR NONPROFIT ADVANCEMENTS HEALTH PROGRAM
The Mental Health Parity Act of 1996 (MHPA)provides
for parity in the application of aggregate lifetime and
annual dollar limits on mental health benefits with
dollar limits on medical/surgical benefits. A plan that
does not impose an annual or lifetime dollar limit
on medical and surgical benefits may not imposesuch a dollar limit on mental health benefits offered
under the plan. MHPA does not apply to benefits for
substance abuse or chemical dependency. Health
plans are not required to include mental health bene-
fits in their benefits package. MHPA only applies to
those plans that do offer mental health benefits.
The Mental Health Parity and Addiction Equity Act
of 2008 (MHPAEA) does not require that group health
plans (or health insurance offered in connection with
such a plan) provide mental health or substance use
disorder benefits. However, the MHPAEA states that,
if a group health provides such benefits, the finan-cial requirements (i.e., deductibles, copayments,
coinsurance, out-of-pocket expenses, etc.) and treat-
ment limitations (i.e., limits on the frequency of treat-
ment, number of visits, days of coverage, or other
similar limits on the scope or duration of treatment)
for these benefits may not be more restrictive than
the most frequent financial requirements and treat-
ment limitations applied to substantially all medical
and surgical benefits covered under the plan. This
represents a significant expansion from the previous
mental health parity provisions, which applied only
to annual and lifetime dollar limitations and applied
only to mental health benefits, not substance usedisorder benefits. Note that the MHPAEA defines
"mental health benefits" and "substance use disorder
benefits" to mean services for mental health condi-
tions and for substance use disorders, as defined
under the terms of the plan and in accordance with
applicable Federal and State law. Thus, plans remain
free to define the benefits covered, subject to appli-
cable law.
In addition to the above, the MHPAEA adds two other
requirements on group health plans: (1) If the plan
provides coverage for medical or surgical benefits
provided by out-of-network providers, the plan mustalso provide coverage for mental health or substance
use disorder benefits provided by out-of-network
providers in a manner consistent with the other
parity provisions of the MHPAEA (i.e., the financial-
requirements and treatment-limitations provisions
discussed above); and (2) subject to regulations
to be issued, plans will be required to (a) disclose,
upon request by any current or potential participant,
beneficiary, or contracting provider, the criteria for
medical necessity determinations made under the
plan for mental health or substance use disorder
benefits, and (b) make available to the participant or
beneficiary the reason for any denial of reimburse-ment or payment for services for mental health or
substance use disorder benefits.
The Genetic Information Nondiscrimination Act of
2008 (GINA) is a federal law which, among other
things, generally prohibits group health plans and
health insurers from discriminating against employees
based on the employees genetic information. Under
GINA, employer-sponsored group health plans and
health insurers are prohibited from (i) restricting
enrollment or adjusting premiums based on genetic
information, (ii) requiring or requesting genetic infor-
mation or genetic testing prior to or after enrollmentunless an exception applies, and (iii) using genetic
information for purposes of underwriting. Genetic
information includes information about an individu-
als genetic tests, the genetic tests of family members
of the individual, the manifestation of a disease or
disorder in family members of the individual or any
request for or receipt of genetic services, or participa-
tion in clinical research that includes genetic services
by the individual or a family member of the individual.
In addition, GINA required amendments to the HIPAA
privacy rule to make it clear that genetic information
is protected health information and may not be used
or disclosed for underwriting purposes.
The Childrens Health Insurance Program
Reauthorization Act of 2009 (CHIPRA) provides new
special enrollment opportunities. Plans and insurers
must permit employees and dependents who are
eligible for, but not enrolled in, a group health
plan to enroll in the plan upon losing eligibility for
coverage under a State Medicaid or CHIP program
or becoming eligible for State premium assistance
under Medicaid or CHIP.
The employee or dependent must request coverage
within 60 days of being terminated from Medicaid or
CHIP coverage or within 60 days of being determined
to be eligible for premium assistance.
The Patient Protection and Affordable Care Act of
2010, as amended, enacts significant changes to our
health care system. This new legislation goes into
effect for the Health Program on July 1, 2011. The
Affordable Care Act adds a number of new benefit
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design and administrative requirements for group
health plans and insurers. For example, new health
plan mandates go into effect beginning as early as
2010, including required coverage for adult children
to age 26, no annual and lifetime limits on essential
health benefits, no pre-existing condition exclusions
and limits on waiting periods. Additional mandates
apply to health plans that are not grandfathered
plans. Most dental and vision plans are exempt from
these health plan mandates.
IMPORTANT NOTICE REGARDING HEALTH
CARE REFORM
The Center for Nonprofit Advancement believes
that the Medical Plans offered under the Health
Program are grandfathered health plans under the
Affordable Care Act. As permitted by the Affordable
Care Act, a grandfathered health plan can preservecertain basic health coverage that was already in
effect when that law was enacted. Being a grandfa-
thered plan means that the Medical Plans may not
include certain consumer protections contained in
the Affordable Care Act that apply to other plans. For
example, the requirement that health plans provide
preventive care services without any cost sharing
does not apply to a grandfathered health plan.
However, grandfathered health plans must comply
with certain protections in the Affordable Care Act,
such as for example, the elimination of lifetime limits
on essential health benefits.
Questions regarding which protections apply and
which protections do not apply to a grandfathered
health plan and what might cause a plan to lose its
grandfathered health plan status can be directed to
the Center using the contact information located at
the beginning of this book. You may also contact
the Employee Benefits Security Administration, U.S.
Department of Labor at 1-866-444-3272 or www.dol.
gov/ebsa/healthreform. This web site has a table
summarizing which protections do and do not apply
to grandfathered health plans.
ADMINISTRATIVE INFORMATION
Plan Information
The Center for Nonprofit Advancement sponsors
the Center for Nonprofit Advancement Benefits
Trust (referred to as the Health Program), which
is a prototype welfare plan that certain eligible
employers may adopt for the benefit of their eligible
employees by signing an adoption agreement. When
your Employer adopts the Health Program by signing
an Adoption Agreement, your Employer establishes
a single employee welfare benefit plan under the
Employee Retirement Income Security Act of 1974
(ERISA), as amended, that benefits only the eligible
employees of your Employer. Your Employer is the
sponsor of your plan.
For the official name of your Employers plan, you
should contact your Employer. The financial and
other records for the plan are kept on a fiscal yea
basis. The plan year ends on each June 30.
Plan Sponsor and Plan Administrator
Your Employer is the plan sponsor and plan adminis
trator. For the plan sponsor s and plan administrators
contact information, contact your Employer.
Agent for Service of Legal Process
Legal process may be served on your Employer.
Third-Party Administrator
Each Participating Employer has appointed the
Center for Nonprofit Advancement to provide certain
third-party administration services related to you
Employers plan. Contact information for the Center
for Nonprofit Advancement is located elsewhere in
this SPD.
Insurers
The medical, dental, vision and life insurance
coverage offered under the Health Program is fully
insured by the applicable Insurers. The Insurers also
provide administrative services, including claims
processing and payment. Additional information
including the contact information for the Insurers
is located in each Insurers Evidence of Coverage o
other related insurance documents, which will be
provided to you upon enrollment. If you do not have a
copy of the insurance documents, please contact the
Center for Nonprofit Advancement or your Employer
Plan Funding
Each Participating Employer must make monthly
contributions to the Center for Nonprofit Advancemen
to pay for the benefits offered under the Health
Program to their respective eligible employees. These
contributions include the cost of the insurance as
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determined by the applicable Insurers, plus an addi-
tional charge for the cost of the Center for Nonprofit
Advancement to administer the Health Program. The
contributions made by Participating Employers are
made to and deposited into the Center for Nonprofit
Advancement Trust (the Trust). You may obtainadditional information about the Trust and its trustees
by contacting the Center for Nonprofit Advancement.
The Participating Employer then decides what portion,
if any, of the monthly contribution will be charged to
its eligible employees for the benefit coverages. In
all cases, each Participating Employer is responsible
for paying both the Employer and eligible employee
contributions to the Health Program. Neither the
Center for Nonprofit Advancement, Health Program,
the Trust, nor any other entity or individual is respon-
sible for ensuring that Participating Employer contri-
butions are timely made. Each Participating Employeris responsible for ensuring that contributions are
timely made. Coverage for eligible employees may
be terminated monthly contributions are not paid
when due.
Qualified Medical Child Support Orders
A Qualified Medical Child Support Order (QMCSO)
is a medical child support order creating or recog-
nizing your childs right to receive coverage under
a medical, dental and/or vision plan established
by your Employer and offered through the Health
Program. Orders that need to be qualified should be
sent to the Center for Nonprofit Advancement. You
may obtain a free copy of the procedures governing
the qualification of QMCSOs by contacting the Center
for Nonprofit Advancement.
No Guarantee of Employment
Nothing in the Health Program or this SPD may or
can be interpreted as a guarantee of future employ-
ment or continued employment for any duration.
Amendment and Termination
The Center for Nonprofit Advancement reserves the
right to discontinue or terminate Health Programcoverage, or to reduce, amend or modify Health
Program coverage in whole or in part and in any
respect (including providing different cost sharing
among Employers). The Insurers also have the right
to revise the provisions of the applicable insurance
documents. This may be done at any time and without
advance notice. Benefits for claims occurring after
the effective date of a modification or termination are
payable in accordance with the revised provisions of
the Health Program and insurance documents.
In addition, your Employer reserves the right to
discontinue or terminate its participation in the Health
Program, or to reduce, amend or modify Health
Program coverage in whole or in part and in any
respect (including providing different cost sharing
between your Employer and eligible employees). This
may be done at any time and without advance notice.
Benefits for claims occurring after the effective date
of a modification or termination are payable in
accordance with the revised provisions of the Health
Program and insurance documents.
All statements in this SPD and all representa-
tions by your Employer, the Center for Nonprofit
Advancement and their personnel are subject to
this right of amendment and termination. This right
applies without limitation even after an individuals
circumstances have changed by retirement, termi-
nation or otherwise. Health Program coverage and
benefits do not become vested at any time.
Your Rights Under ERISA
The following statement is required by federal law.
As a participant in the group health plan you are
entitled to certain rights and protections under the
Employee Retirement Income Security Act of 1974(ERISA). ERISA provides that all plan participants
shall be entitled to the following rights:
Receive Information About Your Plan and Benefits
You may examine, without charge, at the Employers
office and at other specified locations, such as work-
sites, all documents governing the plans, including
insurance contracts and a copy of the latest annual
report (Form 5500 Series) filed by the plan with the
U.S. Department of Labor and available at the Public
Disclosure Room of the Employee Benefits Security
Administration.
You may obtain, upon written request to the Employer,
copies of documents governing the operation of the
plan, including insurance contracts and copies of the
latest annual report (Form 5500 Series) and updated
summary plan descriptions. The Employer may make
a reasonable charge for the copies.
CENTER FOR NONPROFIT ADVANCEMENTS HEALTH PROGRAM
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You will receive a summary of the plans annual
financial reports. The Employer is required by law to
furnish each participant with a copy of this summary
annual report.
Continue Group Health Plan Coverage
You may continue health care coverage for yourself,
spouse or dependents if there is a loss of coverage
under the plan as a result of a qualifying event. You or
your dependents may have to pay for such coverage.
Review this SPD and the documents governing the
plan on the rules governing your COBRA continuation
coverage rights and reduction or elimination of exclu-
sionary periods of coverage for preexisting conditions
under your group health plan, if you have creditable
coverage from another plan. You should be provided
a certificate of creditable coverage, free of charge,
from your group health plan or health insurance
issuer when you lose coverage under the plan, when
you become entitled to elect COBRA continuation
coverage, when your COBRA continuation coverage
ceases, if you request it before losing coverage, or if
you request it up to 24 months after losing coverage.
Without evidence of creditable coverage, you may
be subject to a preexisting condition exclusion for
12 months (18 months for late enrollees) after your
enrollment date in your coverage.
Prudent Actions by Plan Fiduciaries
In addition to creating rights for plan participants,
ERISA imposes duties upon the people who areresponsible for the operation of the employee
benefit plans. The people who operate your plans,
called fiduciaries of the plan, have a duty to do so
prudently and in the interest of you and other plan
participants and beneficiaries. No one, including your
Employer or any other person, may fire you or other-
wise discriminate against you in any way to prevent
you from obtaining a plan benefit or exercising your
rights under ERISA.
Enforce Your Rights
If your claim for a plan benefit is denied or ignored,in whole or in part, you have a right to know why this
was done, to obtain copies of documents relating
to the decision without charge, and to appeal any
denial, all within certain time schedules.
Under ERISA, there are steps you can take to enforce
the above rights. For instance, if you request a copy
of the plan documents and/or the latest annual repor
from the plan and do not receive them within 30
days, you may file suit in a Federal court. In such a
case, the court may require the Employer to provide
the materials and pay you up to $110 a day until you
receive the materials, unless the materials were no
sent because of reasons beyond the control of the
Employer. If you have a claim for benefits which is
denied or ignored, in whole or in part, you may file
suit in a state or Federal court. In addition, if you
disagree with the plans decision or lack thereo
concerning the qualified status of a medical child
support order, you may file suit in a Federal court
If it should happen that plan fiduciaries misuse theplans money, or if you are discriminated against for
asserting your rights, you may seek assistance from
the U.S. Department of Labor, or you may file suit
in a Federal court. The court will decide who should
pay court costs and legal fees. If you are successfu
the court may order the person you have sued to pay
these costs and fees. If you lose, the court may orde
you to pay these costs and fees if, for example, it
finds your claim is frivolous.
Assistance With Your Questions
If you have any questions about a plan, you should
contact your Employer. If you have any questions
about this statement or about your rights under
ERISA, or if you need assistance in obtaining docu
ments from your Employer, you should contact the
nearest office of the Employee Benefits Security
Administration, U.S. Department of Labor, listed in
your telephone directory or the Division of Technica
Assistance and Inquiries, Employee Benefits Security
Administration, U.S. Department of Labor, 200
Constitution Avenue, N.W., Washington, D.C. 20210
You may also obtain certain publications about you
rights and responsibilities under ERISA by calling
the publications hotline of the Employee Benefits
Security Administration.
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KAISER PERMANENTE
Kaiser PermanenteHealth PlansBeing different from the ground up allows Kaiser Permanente to provide supe-
rior care, convenience and affordability to you and your family. In the Washington
and Baltimore metropolitan areas, more than 500,000 members count on Kaiser
Permanente for quality care. Nationwide, 8.2 million people have chosen Kaiser
Permanente as their health plan.
YOUR ONLINE CONNECTION TO GOOD HEALTH
Kaiser Permanentes website is the easy way to access the very latest in health
care information and Kaiser Permanente services. In addition to many other
features, members can consult with a Kaiser Permanente advice nurse or phar-
macist or join any of our discussion groups, which are moderated by Kaiser
Permanente health care professionals. Also, members can quickly and easily
request non-urgent care appointments online. Its easy to get connected. Visit
www.members.kaiserpermanente.org. Then click on For Our Members.
Customer service can be reached at 301-468-6000.
The Kaiser Permanente
health care plans in this
booklet are not available
to employee groups of
2 - 50 in Maryland, as a
result of the Maryland
Small Group Insurance
Reform law. For details,call Dave Dixon at Early,
Cassidy & Schilling, Inc.,
at 301 948 5800.
www.nonprofitadvancement.org
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KAISER PERMANENTE HMO SELECT
2012 Summary of Benefits
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.2101 East Jefferson Street, Rockville, Maryland 20852
CENTERS FORNON PROFIT ADVANCEMENT
HMO SEL Mid-Large Groups ($15/$25)(District of Columbia)
The following is a limited description of benefits offered by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (KFHP-MAS). Not all services and procedures are covered by your benefits contract. This Summary of Benefits is for comparisonpurposes only and does not create rights not given through the benefit plan.
IMPORTANT NOTICE - Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. believes that your Plan is "a grandfatheredhealth plan" under the Patient Protection and Affordable Care Act (PPACA). As permitted by PPACA, a grandfathered healthplan can preserve certain basic health coverage that was already in effect when PPACA was enacted. Being a grandfatheredhealth plan means that your Plan may not include certain consumer protections of the PPACA that apply to other plans.However, grandfathered health plans must comply with certain other consumer protections in the PPACA.
Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what mightcause your Plan to change from grandfathered health plan status can be directed to your plan administrator. If your Plan isgoverned by ERISA, you may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-
444-3272 or www.dol.gov./ebsa/healthreform. You may also contact the U.S. Department of Health and Human Services atwww.healthreform.gov.
PLAN DETAILS
Copayments $15 (PCP) / $25 (Specialty)
Coinsurance (Plan pays / Member pays) 100% / 0% except as otherwise indicated
Deductible None
Maximum Annual Copayment Individual: $3,500 Family: $9,400
BENEFITS MEMBER PAYS
OUTPATIENT SERVICES
Preventive Health Office Visit No charge
Preventive Health Screening Tests No charge
Office Visit for Illness
Primary Care Office Visit $15 per visit (Copayment waived for children under age 5)Specialty Care Office Visit $25 per visit
Routine pre-natal visit (after confirmation of pregnancy) and firstpost-natal visit
No charge
Diagnostic Tests and Procedures, X-rays & Laboratory Services No charge
Specialty Imaging (e.g., CT, MRI, PET scan & Nuclear Medicine) No charge
Outpatient Surgery (other than in a providers office) $25 per procedure
HOSPITAL SERVICES
Inpatient hospital care, including inpatient maternity care $250 per admission
Inpatient physician services No charge
CHEMICAL DEPENDENCY AND MENTAL HEALTH SERVICES
Inpatient hospital care $250 per admission
Outpatient services $15 per visit for individual therapy; $7 per visit for group therapy
THERAPY & REHABILITATION SERVICES
Inpatient hospital care $250 per admission
Outpatient services (Up to 90 consecutive days of treatment perinjury, incident or condition)
$25 per visit
INFERTILITY SERVICES
Office visits 50% of allowable charge
All other covered services for treatment of infertility 50% of allowable chargeURGENT CARE & EMERGENCY SERVICES
Urgent Care Office Visit $15 per visit (PCP) / $25 per visit (Specialty)
After hours Urgent Care or Urgent Care Center $25 per visit
Hospital Emergency Room (waived if admitted as inpatient) $50 per visit
Ambulance No charge
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BENEFITS MEMBER PAYS
HOSPITAL ALTERNATIVES
Skilled Nursing Facility (limited to 100 days per contract year) $250 per admission
Home Health Care No charge
Hospice Care No charge
OTHER SERVICES
Durable Medical Equipment (DME)Basic DME No charge
Oxygen equipment No charge for 1st 3 months then 50% of allowable charge thereafter
Prosthetics
Internal prosthetics No charge
External prosthetics No charge
Vision
Office visit for medical conditions of the eye $15 per visit (PCP) / $25 per visit (Specialty)
Routine eye refractions to determine need for visioncorrection
$15 per visit with Optometrist$25 per visit with Ophthalmologist (referral required)
Eyeglass frames and lenses(limited to one pair of glasses per contract year)
Member receives 25% discount off retail price when purchased fromPlan Providers
Contact lenses Member receives 15% discount off retail price on initial pair of contact
lenses only, when purchased from Plan ProvidersPrescription Drugs
Covered prescription drugs (up to a 60-day supply)
(Up to a 90-day supply for 1.5 copays at Plan andParticipating Pharmacies
(Up to a 90-day supply for 1 copay through Mail Order)
Plan Pharmacy $10 Generic / $20 Preferred Brand / $35 Non-Preferred BrandParticipating Network Pharmacy $20 Generic / $40 Preferred Brand / $55 Non-Preferred BrandMail Order $8 Generic / $18 Preferred Brand / $33 Non-Preferred Brand
RIDERED BENEFITS MEMBER PAYS
Complementary Alternative Medicine
Chiropractic Services(Limited to 20 visits per contract year)
$25 per visit
Acupuncture Services(Limited to 20 visits per contract year)
$25 per visit
Dental
Covered dental services Plan C - $30 for preventive dental care services
This Benefit and Service Summary does not fully describe the exclusions and limitations associated with your KaiserPermanente coverage. For a full list of the general and benefit specific exclusions under your coverage, please refer to yourKFHP-MAS Evidence of Coverage (EOC). Your EOC provides you with information on what services and supplies will not becovered, regardless of whether the service is medically necessary.
NOTE: This Summary of Benefits is for comparison purposes only and does not create rights not given through thebenefit plan.
Form Numbers: DC-GRP-SEC1(01/12); DC-GRP-SEC2(01/12); DC-GRP-SEC3(01/12); DCLG-ALL-SEC4(01/10); DC-GRP-SEC5(07/11); DC-GRP-SEC6(01/11); DC-GRP-SEC7(01/12); DC-GRP-APPX-DEF(01/12); DC-GRP-HMO-COST(01/12); andany amendments or riders attached thereto.
KAISER PERMANENTE HMO SELECT
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KAISER PERMANENTE FLEXIBLE CHOICE
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.2101 East Jefferson Street, Rockville, Maryland 20852
Kaiser Permanente Insurance CompanyOne Kaiser Plaza, Oakland, California 94612
2012 Summary of BenefitsCENTERS FOR
NON PROFIT ADVANCEMENTFlexible Choice Mid-Large GroupsPlan 15 (100/90/70 $10/$20-$20/$30)
(District of Columbia)
GF+ 1 [KPIC ID] 3TPOS DCLG Plan 15 w/CAM & Dental 12
The following is a limited description of the Flexible Choice coverage provided through Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.(KFHP-MAS) and Kaiser Permanente Insurance Company (KPIC). This is only a summary and does not fully describe your benefit coverage. Forcomplete details on your HMO benefit coverage, please refer to your employer's Group Agreement Face Sheet, Group Evidence of Coverage, Group
Agreement, and applicable Riders. For complete details on your Participating Provider coverage and your Out -of-Network coverage, please refer toyour employers Group Policy, Certificate of Insurance, Schedule of Coverage and applicable riders. The Evidence of Coverage is the legal bindingdocument between KFHP-MAS and its members and the Group Policy, which incorporates the current Certificate of Insurance is the legal bindingdocument between KPIC and the Policyholder. In the event of ambiguity, or a conflict between this summary and the Evidence of Coverage and/or theGroup Policy, the Evidence of Coverage and/or the Group Policy will control.
The Covered Services listed below contain limitations and exclusions that apply to the benefits outlined in the KFHP-MAS Evidence of Coverage and theKPIC Group Policy. Those exclusions apply to all services that would otherwise be covered under the Evidence of Coverage and/or Group Policy. Nopayment will be made under any benefit of the plan for expenses incurred in connection with an excluded service.
Option 1 Benefits only (KFHP-MAS Providers) - Under your Option 1 benefits only, a Primary Care Physician must be selected. If not, one will beassigned to you by the Health Plan. With the exception of Emergency Services and Out-of-Area Urgent Care Services, all covered Services must be
provided by or arranged for by your Plan Primary Care Physician and authorized by the Health Plan. Services such as medically necessary routinegynecological exams, mental health and substance abuse services, and optometry services may be obtained without a referral from your Plan PrimaryCare Physician; however, they must be provided by a Plan Physician or other Plan Provider.
IMPORTANT NOTICE - Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. believes that your Plan is "a grandfathered health plan" under thePatient Protection and Affordable Care Act (PPACA). As permitted by PPACA, a grandfathered health plan can preserve certain basic health coveragethat was already in effect when PPACA was enacted. Being a grandfathered health plan means that your Plan may not include certain consumerprotections of the PPACA that apply to other plans. However, grandfathered health plans must comply with certain other consumer protections in thePPACA.
Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause your Plan tochange from grandfathered health plan status can be directed to your plan administrator. If your Plan is governed by ERISA, you may also contact theEmployee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or www.dol.gov./ebsa/healthreform. You may also contact theU.S. Department of Health and Human Services at www.healthreform.gov.
DEDUCTIBLE APPLIES TO OPTIONS 2 AND 3, EXCEPT WHERE OTHERWISE INDICATED
PLAN DETAILS Option 1KFHP-MAS Providers
Option 2Participating Providers
Option 3Out-of-Network Providers
Copayments (PCP / Specialty) $10/$20 $20/$30 N/A
Coinsurance (Plan pays / Member pays) 100% / 0% except asotherwise indicated
90% / 10% MAC* except as otherwiseindicated
70% / 30% MAC except asotherwise indicated
Deductible(per policy year)
NoneIndividual: $200
Family: $400Individual: $400
Family: $800
Out-of-Pocket Maximum(per policy year)
Individual: $1,000Family: $2,000
Individual: $2,000Family: $4,000
Individual: $4,000Family: $8,000
MEMBER PAYSBENEFITS Option 1
KFHP-MAS ProvidersOption 2
Participating ProvidersOption 3
Out-of-Network Providers
OUTPATIENT SERVICES
Preventive Health Office Visit No charge No charge 30% of MAC* after Deductible metOffice Visit for Illness
Primary Care $10 per visit(Copayment waived forchildren under age 5)
$20 per visit (Deductible waived) 30% of MAC* after Deductible met
Specialist Care $20 per visit $30 per visit (Deductible waived) 30% of MAC* after Deductible metDiagnostic Tests and Procedures, X-rays & Laboratory Services
No charge 10% of MAC* after Deductible met 30% of MAC* after Deductible metRoutine pre-natal visit and first post-natal visit
No charge(After confirmation of
pregnancy)
$20 per visit (Deductible waived) 30% of MAC* after Deductible met
MAC = Maximum Allowable Charge
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KAISER PERMANENTE FLEXIBLE CHOICE
Deductible applies to Options 2 and 3, except where otherwise indicated
MEMBER PAYSBENEFITS Option 1
KFHP-MAS ProvidersOption 2
Participating ProvidersOption 3
Out-of-Network ProvidersSpecialty Imaging (e.g., CT, MRI, PETscan & Nuclear Medicine)
$50 per test 10% of MAC* after Deductible met 30% of MAC* after Deductible met
Outpatient Surgery $25 per procedure 10% of MAC* after Deductible met 30% of MAC* after Deductible metHOSPITAL SERVICES
Inpatient hospital care, includinginpatient maternity care
No charge 10% of MAC* after Deductible met 30% of MAC* after Deductible metInpatient physician services No charge 10% of MAC* after Deductible met 30% of MAC* after Deductible met
CHEMICAL DEPENDENCY AND MENTAL HEALTH SERVICES
Inpatient hospital care No charge 10% of MAC* after Deductible met 30% of MAC* after Deductible met
Outpatient services Individual Therapy: $10 pervisit
Group Therapy: $5 per visit
Individual Therapy: $20 per visit(Deductible waived)
Group Therapy: $20 per visit(Deductible waived)
Individual Therapy: 30% of MAC*after Deductible met
Group Therapy: 30% of MAC* afterDeductible met
THERAPY & REHABILITATION SERVICES
10% of MAC* after Deductible met 30% of MAC* after Deductible metInpatient hospital care No charge(Up to 90 consecutive daysof treatment per injury,
incident or condition)
Limited to a maximum benefit of 60 days per policy year for Options 2 & 3combined
$30 per visit (Deductible waived) 30% of MAC* after Deductible metOutpatient services $20 per visit(Up to 90 consecutive days
of treatment per injury,incident or condition)
Limited to a maximum benefit of 90 visits per policy year for Options 2 & 3combined
INFERTILITY SERVICES
Infertility (Diagnosis & Treatment) 50% of AC 50% of MAC* after Deductible met(Copayments apply to office visits)
50% of MAC* after Deductible met
URGENT CARE & EMERGENCY SERVICES
After hours Urgent Care or UrgentCare Center
Office Visit: $20 per visit
Other Services: No charge
Office Visit: $30 per visit(Deductible waived)
Other Services: 10% of MAC* after
Deductible met
Office Visit: 30% of MAC* afterdeductible met
Other Services: 30% of MAC* after
Deductible metHospital Emergency Room $75 per visit Covered in Option 1 Only
Ambulance (Emergency transport) Emergency Transport: $100per encounter
Non-emergency ScheduledTransport: $100 per
encounter
Emergency Transport: EmergenciesCovered under Option 1
Non-emergency Scheduled Transport:Not available
Emergency Transport: EmergenciesCovered under Option 1
Non-emergency ScheduledTransport: 30% of MAC* after
deductible met
HOSPITAL ALTERNATIVES
10% of MAC* after Deductible met 30% of MAC* after Deductible metSkilled Nursing Facility No charge(Limited to 60 days per
policy year)Limited to a maximum benefit of 40 days per policy year for Options 2 & 3combined
10% of MAC* after Deductible met 30% of MAC* after Deductible metHome Health Care No charge
Limited to a maximum benefit of 60 days per policy year for Options 2 & 3combined
10% of MAC* after Deductible met 30% of MAC* after Deductible metHospice Care No chargeInpatient care limited to a maximum benefit of 30 days per policy yearfor Options 2 & 3 combined
OTHER SERVICES
Durable Medical Equipment (DME)
Basic DME 50% of AC 50% of MAC* after Deductible met 50% of MAC* after Deductible met
Prosthetics
Internal prosthetics 50% of AC 50% of MAC* after Deductible met 50% of MAC* after Deductible met
Emergency Room Copayment waived if admitted.
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KAISER PERMANENTE FLEXIBLE CHOICE
Deductible applies to Options 2 and 3, except where otherwise indicated
MEMBER PAYS
BENEFITS Option 1
KFHP-MAS Providers
Option 2
Participating Providers
Option 3
Out-of-Network Providers
External prosthetics Not covered except for
breast prostheses,mastectomy bras, urologic
& ostomy supplies
Not covered except for breast
prostheses, mastectomy bras, urologic& ostomy supplies
Not covered except for breast
prostheses, mastectomy bras,urologic & ostomy supplies
Vision
Office visit for medical conditionsof the eye
$10 (PCP) / $20 (Specialist)per visit
$20 / $30 per visit(Deductible waived)
30% of MAC* after Deductible met
Routine eye refractions todetermine need for visioncorrection
Optometrist: $10 per visit
Ophthalmologist: $20 pervisit
(Referral required)
Optometrist: $20 per visit(Deductible waived)
Ophthalmologist: $30 per visit(Deductible waived)
30% of MAC* after Deductible met
Eyeglass lenses 25% discount off retail pricewhen purchased from Plan
Providers
1 per 12 months
Not Available 30% of MAC* after Deductible met
Limited to a benefit maximum of
$150 once every 24-months
An eyeglass frame 25% discount off retail pricewhen purchased from Plan
Providers1 per 12 months
Not Available 30% of MAC* after Deductible met
Limited to a benefit maximum of $100once every 24-months
Contact lenses 15% discount off retail priceon initial fitting for 1st pair
only, when purchased fromPlan Providers
Not Available 30% of MAC* after Deductible met
Limited to a benefit maximum of $50once every 24-months
MEMBER PAYS
RIDERED BENEFITS Option 1
KFHP-MAS Providers
Option 2
Participating Providers
Option 3
Out-of-Network Providers
Complementary Alternative Medicine
Chiropractic Services(Limited to 20 visits per policy year)
$20 per visit
Available in Option 1 Only
Acupuncture Services(Limited to 20 visits per policy year)
$20 per visit Available in Option 1 Only
Dental
Covered dental services Plan C - $30 for preventivedental care services
Available in Option 1 Only
MAC = Maximum Allowable Charge
This Benefit and Service Summary does not fully describe the exclusions and limitations associated with your Flexible Choicecoverage. For a full list of the general and benefit specific exclusions and limitations under your Flexible Choice coverage,please refer to your KFHP-MAS Evidence of Coverage (EOC) and/or KPIC Certificate of Insurance (COI). Your EOC and/or COIprovides you with information on what services and supplies will not be covered, regardless of whether the service is medicallynecessary. Pre-certification is required for all Option 2 and 3 inpatient services and certain outpatient services.
NOTE: This Summary of Benefits is for comparison purposes only and does not create rights not given through thebenefit plan.
Form Numbers:
KFHP-MAS: DC-GRP-SEC1(01/12); DC-GRP-SEC2(01/12); DC-GRP-SEC3(01/12); DCLG-ALL-SEC4(01/10); DC-GRP-SEC5(07/11); DC-GRP-SEC6(01/11); DC-GRP-SEC7(01/12); DC-GRP-APPX-DEF(01/12); DC-GRP-HMO-COST(01/12); andany amendments or riders attached thereto.
KPIC: GC-FP-DC (09/06); GC-TOC-DC; GC-INTRO-DC (09/06); GC GDEF-DC-Rev.2;GC-ELIG-DC; GC-PRECERT-DC (09/06);GC-DED-DC (09/06); GC-GBEN-DC-Rev.2; GC-OOA-EXCL-DC (1/09); GC-OPBEN-DC (09/06); GC-POS-OPBEN-DC (09/06);GC-COC-FED-DC;GC-COC-DC; GC-POS-CONV; GC-COB-DC (09/06); GC-GPROV-DC (09/06); GC-ERISA; GC-SCH-POS-DC-Rev.2; GP-POS-DC and any amendments or riders attached thereto.
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KAISER PERMANENTE FLEXIBLE CHOICE RX PLAN
2012 Rx Summary of BenefitsFlexible Choice Rx Plan 5
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.2101 East Jefferson Street, Rockville, Maryland 20852
Kaiser Permanente Insurance CompanyOne Kaiser Plaza, Oakland, California 94612
($10/$20/$35 - $20/$35/$50)Outpatient Prescription Drug Program
GF+ 1 FCRX5 (12)
The Kaiser Permanente Flexible Choice plan is a dual offering, jointly underwritten by Kaiser Foundation Health Plan of the Mid-AtlanticStates, Inc. and Kaiser Permanente Insurance Company. KPIC is a subsidiary of Kaiser Foundation Health Plan, Inc.
The following is a limited description of the Kaiser Permanente Flexible Choice prescription drug coverage provided through KaiserFoundation Health Plan of the Mid-Atlantic States, Inc. (KFHP-MAS) and Kaiser Permanente Insurance Company (KPIC). This is only asummary and does not fully describe your prescription drug benefit coverage. For details on your HMO prescription drug benefit coverage,please refer to your Group Evidence of Coverage and applicable Riders. The Evidence of Coverage is the legally binding documentbetween KFHP-MAS and its members. For details on your Participating Provider pharmacy (Medimpact) coverage and your Out -of-Networkpharmacy coverage, please refer to your Certificate of Insurance and Schedule of Coverage. The Certificate of Insurance and Schedule ofCoverage are the legally binding documents between KPIC and its insureds. In the event of ambiguity or a conflict between this summaryand the Evidence of Coverage and/or Certificate of Insurance, the Evidence of Coverage and/or Certificate of Insurance shall control.The prescription drug program is based on the KFHP-MAS Prescription Drug List as well as the KPIC preferred drug list. The Mid-AtlanticStates Region Pharmacy and Therapeutics Committee is responsible for evaluating drug products for addition or removal from the covereddrugs list. The committee conducts a thorough review of the medical li terature and incorporates the opinions of practicing physicians in bothprimary care and specialty departments into the final decision. The Preferred Drug List is updated frequently in response to these reviews aswell as in response to Food and Drug Administration (FDA) requirements. To determine whether a prescription drug is part of the KFHP-MAS Preferred Drug List visit our website at www.kaiserpermanente.org. The KPIC preferred drug list contains the list of prescriptiondrugs that KPIC has designated as preferred drugs. Prescription drugs purchased under Option 2 or Option 3 of the Flexible Choiceoutpatient prescription drug program that do not appear on the KPIC preferred drug list are considered non-preferred prescription drugs. Todetermine whether a prescription drug is part of the KPIC preferred drug list, visit the Medimpact website at www.Medimpact.com/client(then click on link to Resource Center).
You should contact your physician or pharmacist if you have any questions concerning your prescription, i.e. side-effects, potential druginteractions, storage requirements, etc. If you have questions concerning your prescription drug coverage or the preferred drug list, pleasecontact Member Services at 1-888-225-7202.IMPORTANT NOTICE - Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. believes that your Plan is "a grandfathered healthplan" under the Patient Protection and Affordable Care Act (PPACA). As permitted by PPACA, a grandfathered health plan can preservecertain basic health coverage that was already in effect when PPACA was enacted. Being a grandfathered health plan means that your Planmay not include certain consumer protections of the PPACA that apply to other plans. However, grandfathered health plans must complywith certain other consumer protections in the PPACA.
Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause yourPlan to change from grandfathered health plan status can be directed to your plan administrator. If your Plan is governed by ERISA, youmay also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 orwww.dol.gov./ebsa/healthreform. You may also contact the U.S. Department of Health and Human Services at www.healthreform.gov.
PRESCRIPTION DRUG PLAN
Limited to a 30-day supplyKaiser Permanente Medical
Center Pharmacies*Participating Community(Medimpact) Pharmacies
Non-Participating Pharmacies
Generic:Preferred Brand Name:Non-Preferred Brand Name:
$10 Copay$20 Copay$35 Copay
$20 Copay (Deductible waived)$35 Copay (Deductible waived)$50 Copay (Deductible waived)
$20 Copay (Deductible waived)$35 Copay (Deductible waived)$50 Copay (Deductible waived)
PLAN DETAILS MEMBER PAYS DESCRIPTIONDeductible There is no Deductible The amount you must pay in the benefit period for covered
outpatient prescription drugs before we will cover such drugsin that benefit period.
Prescription Drug (Up to a 30-day supply)Generic Drug
Option 1*Kaiser Permanente Medical Center Pharmacy
$10
Option 2 Medimpact Pharmacy
$20
Option 3 Out-of-Network Pharmacy
$20
A Generic Drug is a prescription drug that does not bear thetrademark of a specific manufacturer. It is, by law,chemically the same as its corresponding Brand Name Drug.
Preferred Brand DrugOption 1*Kaiser Permanente Medical Center Pharmacy
$20
Option 2 Medimpact Pharmacy
$35
Option 3 Out-of-Network Pharmacy
$35
A Brand Name Drug is a prescription drug that has beenpatented and is produced by only one manufacturer. APreferred Brand Name Drug is a Brand Name Drug that is onthe Preferred Drug List.
* You may also obtain a 30-day supply of your prescription drug for the Option 1 copayment through the Mail Service Delivery Program offered byKFHP-MAS. The Mail Service Delivery Program is a program operated by KFHP-MAS that distributes prescription drugs to Members via mail.Certain drugs that require special handling are not provided through the mail-delivery service. This includes, but is not limited to, drugs that are timeor temperature sensitive, drugs that cannot legally be sent by U.S. mail, and drugs that require professional administration or observation.
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KAISER PERMANENTE FLEXIBLE CHOICE RX PLAN
GF+ 2 FCRX5 (12)
The Kaiser Permanente Flexible Choice plan is a dual offering, jointly underwritten by Kaiser Foundation Health Plan of the Mid-AtlanticStates, Inc. and Kaiser Permanente Insurance Company. KPIC is a subsidiary of Kaiser Foundation Health Plan, Inc.
PLAN DETAILS MEMBER PAYS DESCRIPTIONNon-Preferred Brand Drug
Option 1*Kaiser Permanente Medical Center Pharmacy
$35
Option 2 Medimpact Pharmacy
$50
Option 3
Out-of-Network Pharmacy
$50
A Non-Preferred Brand Name Drug is a Brand Name Drugthat is not on the Preferred Drug List.
Maintenance Medications (Up to a 90-day supply)Generic Drug
Option 1**Kaiser Permanente Medical Center Pharmacy
$20
Option 2 Medimpact Pharmacy
$40
Option 3 Out-of-Network Pharmacy
$40
Preferred Brand DrugOption 1**Kaiser Permanente Medical Center Pharmacy
$40
Option 2 Medimpact Pharmacy
$70
Option 3
Out-of-Network Pharmacy$70
Non-Preferred Brand DrugOption 1**Kaiser Permanente Medical Center Pharmacy
$70
Option 2 Medimpact Pharmacy
$100
Option 3 Out-of-Network Pharmacy
$100
A Maintenance Medication is a covered drug anticipated tobe required for six (6) months or more to treat a chroniccondition.
Up to a 90-day supply of Maintenance Medications areavailable for 2 times your copayment at a pharmacy.
**You may also obtain a 90-day supply of your Maintenance Medications for the Option 1 copayment through the Mail Service DeliveryProgram offered by KFHP-MAS. The Mail Service Delivery Program is a program operated by KFHP-MAS that distributes prescription drugsto Members via mail. Certain drugs that require special handling are not provided through the mail-delivery service. This i