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5249
KPS HEALTH PLANS
Coveraqe Contracts
Human Resources
LEG 12-1
1/1/2013
12/31/2013
9/30/2013
2015
Plan A, Plan B, Under 65 LEOFF I Retirees
KPS Health Plans
Business Address
400 Warren Avenue
Bremerton, WA 98337
CiTY OF BREMERTON — PLAN A
COVERAGE CONTRACT
Group Number• 1000780
Effectrve Date: January 1, 2013
Contract Renewal Month: January
Open Enrollment Period: December
This Coverage Contract includes the following
Attachment A.
Attachment B
Benefits Booklet
Premwm Rates and Underwritmg Criteria
Mailmg Address
P O Box 34803
Seattle, WA 98124-1803
This Contract is entered mto and delivered in the state of Washmgton and is governed by Washington
State laws, except to the extent state laws are preempted by federal law
Signature by an authorized Group representatrve or payment of the Premium shall constitute
acceptance of the terms and cond�tions set forth herein.
FoR KPS•
C,�.� �_�
W James Page Jr , President
April 10, 2013
Date
FOR GROUP:
!1� q- .3 20 �3
Date
I�l�c�,u o �
Title
�
KPS Health Plans
Busmess Address
400 Warren Avenue
Bremerton, WA 98337
CITY OF BREMERTON — PLAN A
COVERAGE CONTRACT
Group Number:
Effective Date:
Contract Renewal Month:
4pen Enrollment Period:
This Coverage Contract includes the following
Attachment A•
Attachment B•
Benefits Booklet
1000780
January 1, 2013
January
December
Premium Rates and Underwriting Critena
Mailmg Address
P O Box 34803
Seattle, WA 98124-1803
KPS Health Plans (KPS) is a licensed health care services contractor (HCSC) in Washington State In its
capacity as an HCSC, KPS agrees to underwnte and provide the benefits and services described m any
Benefits Booklet that may be listed above (heremafter collectively referred to as "Attachment A"), as
applicable to the eligible Employees and their Eligible Dependents of the above-named Group, provided
the Group, its eligible Employees, and their Eligible Dependents meet and comply with the provisions of
this Coverage Contract ("ContracY')
C136REMA
9
TABLE OF CONTENTS
DEFINITIONS
CONTRACT EXAMINATION PERIOD
EFFECTIVE DATE, DURATION, AND RENEWAL
PREMIUM PAYMENT PROVISIONS
Payment Due Date/Grace Period
Premium Rate Ad�ustments
Premiums Paid by Subscnbers/Dependents
Premium Refunds
ELIGIBILITY AND ENROLLMENT
Group Eligibility
Subscriber/Dependent Eligibdity Requirements
Eligibility of Newborn and Adopted Children
Court-ordered Coverage for Eligible Dependent Children
Enrollment Reporting Requirements
Enrollment Timeframes
When Coverage Begins
Coverage Waitmg Periods
TERMINATION OF COVERAGE
Contmuity of Coverage
Termination or Rescission of Contract
Termmation or Rescission of Enrollee Coverage
COBRA (Consolidated Omnibus Budget Reconcdiation Act - 1985)
Fraudulent Information
Re-Enrollment/Reinstatement
SUBSCRIBER/DEPENDENT LIABILITY AND RIGHTS
Subscriber/Dependent Liability
GENERAL TERMS AND CONDITIONS
Applicable Law
Assignment of Benefits
Binding Agreement
Confidentiality
Contract Modifications
Coverage Limits
Entire Agreement
Equity of Application
Force Ma�eure
Group Cooperation
Headings
Notices
Severability
Third Party Beneficianes
Waiver of Breach
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COVERAGE CONTRACT
DEFINITIONS
Capitalized words found in the text of this Contract are defined below or may be found in Attachment A
Child or Children
(i) Natural chddren, adopted chddren, stepchildren or other legally designated ward under the Limitmg
Age who is a dependent of the Subscriber or the Subscriber's Spouse
(ii) Children under the Limitmg Age who are legally entitled to receive medical coverage as a result of a
court order binding either the Subscriber or the Subscriber's Spouse, regardless of whether or not
the Subscriber or Subscriber's Spouse has legal custody of the child(ren)
(iii) Children who have reached the Limiting Age, or are older than the Limitmg Age, are mcapable of
self-sustaining employment due to developmental disabdity or physical handicap, and are
dependent upon the Subscriber or the Subscriber's Spouse for total or partial support and
maintenance (see the Continued Eligibility for Disabied Dependent Children section of
Attachment A)
Contract this document and any other attachments, exhibits, Riders, or Endorsements listed on the title
page or otherwise described herein, and any subsequent amendments or modifications to the Contract or
its attachments, exhibits, Riders, or Endorsements
Contract Renewal Month the calendar month specified on the title page of this Contract durmg which the
Group may renew its coverage each year
Covered Benefits and Services those Medically Necessary benefits and services descnbed in
Attachment A that an Enrollee is entitled to receive
Eligible Dependent the legal Spouse and/or Children of a LEOFF I or LEOFF II law enforcement officer
Employee �
(a) LEOFF I employees who are full-time law enforcement officers or firefighters hired prior to October
1, 1977, and who are members of the LEOFF system as defined in Sections (3) and (4), CH 131,
Law of 1972, 1� Ex Session, or
(b) LEOFF II employees who are full-time law enforcement officers or firefighters hired on or after
October 1, 1977, and who are not members of the LEOFF system as defined in Sections (3) and
(4), CH 131, Law of 1972, 1 g ' Ex Session
Endorsement an amendment to the conditions of coverage or the benefits provided by this Group Plan
Enrollee a person enrolled m this Group Plan
Group the employer entity, association, or other group that has entered into this Contract with KPS
Group Master Application the application form completed by the Group and submitted to KPS pnor to
securing coverage under this Group Plan
Group Plan: the Premium rates and benefits chosen by the Group as listed in Attachment A, any Riders
and Endorsements, Attachment B— Premium Rates and Underwriting Criteria, plus other attachments
that state the terms and conditions for eligibility and administration of Covered Benefits and Services
Limiting Age the age at which Children may no longer be covered under this Group Plan as an Eligible
Dependent of the Subscnber The Limiting Age is specified in the Benefits Summary section of
Attachment A
Medical Director the licensed physician acting as chief inedical advisor for KPS
Open Enroilment Period the 31-day period or some other penod agreed to by both KPS and the Group,
begmning one (1) month prior to the Group's Renewal Month or at some other mutually agreeable time but
at least annually During the Open Enrollment Period, Subscribers may add or delete Eligible Dependents,
and all eligible Employees and their Eligible Dependents have the opportunity to select from alternative
health plans offered by the Group Coverage will be effective as of the renewal date
Page 1
COVERAGE CONTRACT
Participatmg Facdity: an accredited facdity, which has contracted with KPS, either directly or indirectly, to
provide health care services to Enrollees Participating Facilities have agreed to accept the KPS allowance
for Covered Benefits and Services as payment in full, except for Deductible, Copayment, and Coinsurance
amounts, which are the responsibility of the Enrollee
Participating Provider• a Provider who has contracted with KPS, either directly or indirectly, to provide
health care services to Enrollees Participating Providers have agreed to accept the KPS allowance for
Covered Benefits and Services as payment in full, except for Deductible, Copayment, and Coinsurance
amounts, which are the responsibility of the Enrollee
Premium the periodic payment made by, or on behalf of, the Enrollee as consideration for this Group Plan
and in accordance with the terms of this Contract '
Premium Due Date the scheduled, periodic dates by which Premium payments must be received by KPS
as a condition for continued enrollment in this Group Plan This date is typically the first day of each month
of coverage
Provider a licensed or certified health care practitioner acting within the scope of his/her license or
certificate
Rider an additional benefit over and above those listed in the Benefits Summary section of Attachment
A Rider documents are attached at the back of Attachment A and provide detaded benefit information
Spouse:
(i) An individual who is living in a marital relationship with the Subscriber The marital relationship must
be legally recognized by the state of Washington
(u) An individual who is living with the Subscriber as a state registered domestic partner
Subscriber an eligible employee who is enrolled in this Group Plan, or any other eligible person, who is
the principal Enrollee in this Group Plan
Page 2
COVERAGE CONTRACT
CONTRACT EXAMINATION PERIOD
If, after examination, the Group is not satisfied with this Contract for any reason, the Group may return the
Contract to KPS withm ten (10) days of the date it is received Upon receipt of the returned Contract, KPS
will refund to the Group any pre-paid Premiums The Contract shall subsequently be deemed null and void
EFFECTIVE DATE, DURATION, AND RENEWAL
This Contract shall begin at 12 01 a m Pacific Time on the effective date (as indicated on the title page),
and shall remain m effect until the Contract Renewal Month unless termmated accordmg to the provisions
set forth herein
Thereafter, this Contract may be renewed automatically at 12 01 a m on the same date (month and day) m
subsequent calendar years, unless otherwise terminated according to the provisions set forth herem
PREMIUM PAYMENT PROVISIONS
Payment Due Date/Grace Period
The mitial Premium payment is due and payable to KPS on or before the effective date of this Contract
mdicated on the title page Thereafter, Premium payments are due and payable on or before the first day of
every month ("Premium Due Date") for which coverage is provided A roster of current enrollment and
enroliment changes must accompany each Premium payment
A ten (10) day grace period following the Premium Due Date is allowed, durmg which time this Contract
shall not be termmated if payment is not received within the ten (10) day grace period, KPS may, at its sole
discretion, elect to extend the grace period for up to 60 days from the Premium Due Date or terminate this
Contract without notice to the Group
If KPS elects to terminate this Contract due to non-payment of Premium, the effective date of termination
will be retroactive to the last day of the month for which payment was received No further liabiliry for claims
wdl accrue to KPS Enrollees m this Group Plan shall not be entitled to benefits durmg any calendar month
for which the Premium, on his/her behalf, was not received by KPS
Premium payments, if applicable, must accompany all applications for coverage.
Premium Rate Adjustments
The Premium rates applicable to this Group Plan are defined in Attachment B- Prem�um Rates and
Underwr�ting Criteria Rates are guaranteed until the Contract Renewal Month each calendar year
Notwithstanding the foregoing, KPS reserves the right to revise the rates as follows
➢ As part of the annual Contract renewal process �
➢ As a result of any state or federal law or regulation that imposes an additional tax, new tax, or other
assessment on KPS revenue
➢ In the event there is a material change in the basis upon which KPS assumed risk under this
Contract Such changes may include inaccurate mformation presented by the Group, changes in
the benefits, or other Contract terms required by statute or regulation, underwriting guidelines, or
fluctuations of ten percent (10%) or more in the number of enrolled Subscribers and/or Eligible
Dependents KPS will give the Group 60 days prior written notice of any change m Premium rates
not associated with the annual Contract renewal process
KPS wdl give the Group 30 days prior written notice of rate increases associated with the annual Contract
renewal process
Page 3
COVERAGE CONTRACT
Premiums Paid by Subscribers/Dependents
In certam instances, Subscribers and their enrolled Eligible Dependents may be required to self-pay their
Premiums in order to continue coverage Those instances include
➢ Strikes, lockouts, and other labor disputes that cause a disruption in Employee benefits
➢ When the Subscriber and/or Eligible Dependent(s) elects to continue coverage under a COBRA
provision or other coverage continuation provision available under this Group Plan
The Group is required to collect self-paid Premwms for continuation coverage and forward payments to
KPS on or before the Premium Due Date In the instance of strikes, lockouts, and labor disputes, the
Enrollee may self-pay their Premium directly to the Group on or before the Premium Due Date
Premium Refunds
KPS will refund to the Group any Premium paid, in advance, for periods after the termination date of this
Group Plan
In the case of ineligible persons enrolled in this Group Plan, KPS will refund to the Group any Premium
paid, during a period of ineligibility, that is in excess of claim payments made on behalf of the ineligible
person(s), during the period of ineligibility This refund wdl not exceed an amount equal to three (3) months
of Premium payments
ELIGIBILITY AND ENROLLMENT
Group Eligibility
In order to be eligible to participate m this Group Plan, the Group must'continuously meet all eligibility,
participation, Group size, contnbution, and other requirements specified m the Group Master Application
form
KPS reserves the nght to audit the Group's employment, payroll, and eligibility records to ensure that the
Group continues to meet its participation requirements and to ensure that eligible Employees and their
Eligible Dependents are properly enrolled in this Group Plan
Subscriber/Dependent Eligibility Requirements
Active, full-time LEOFF I and LEOFF II Employees, as defined in the Definitions section are eligible to
enroll in this Group Plan
Eligible Dependents of an active, full-time LEOFF I or LEOFF II law enforcement officer, as defined in the
Defmit�ons section, are also eligible to enroll in this Group Plan
The chddren of an Eligible Dependent, other than the Children of the Spouse, are not eligible to enroll in this
Group Plan
Subscribers and their Eligible Dependents who do not enroll when they are initially eligible must wait until
the next Open Enrollment Period, except in certain circumstances (see the Enrollment Under Special
Circumstances section of Attachment A)
Eligibility of Newborn and Adopted Children
Newborn, adopted Children, and Children placed for adoption are initially eligible for coverage as follows
➢ Natural newborn Children are eligible as of the date of birth and are covered automatically for a
period of three (3) weeks In order for coverage to continue after the initial three (3) week period,
the Children must qualify as an Eligible Dependent If additional Premwm is required, the
application and Premium for the Children must be received by KPS within 60 days of birth
Page 4
COVERAGE CONTRACT
➢ Adopted Children and Children placed for adoption are eligible (i) on the date of their adoption, (ii)
on the date the Subscnber or Spouse assumes legal obligation for total or partial support m
anticipation of adoption, or (in) on the date the Subscriber or Spouse acquires partial or complete
legal custody If additional Premium is required, the application and Premium for coverage must be
received by KPS within 60 days of the date of placement for adoption
NOTE When additional Premium is not required, we encourage enrollment as soon as possible to
prevent delays in claims processing
Court-ordered Coverage for Eligible Dependent Children
In the case of court-ordered coveraQe, dependent Chddren become mitially eligible on the date the
Subscriber or Spouse receives the order to provide medical coverage for the Child, even if neither the
Subscriber nor the Spouse is the custodial parent KPS requests that an application for coverage be
submitted within 31 days of the date of the court order Coverage wdl become effective on the first day of
the month, following the effectwe date of the court order
Enrollment Reporting Requirements
The Group will verify enrollment of all Employees and their dependents eligible for enrollment under this
Contract and ensure that appropnate documentation is submitted to KPS for approval
Enrollment Timeframes
Current LEOFF I and LEOFF II Employees, including Eligible Dependents of active, full-time LEOFF I and
LEOFF II law enforcement officers, are initially eligible to apply for coverage begmnmg on the effective date
of this Group Plan Application for coverage must be received by KPS within 31 days of initial eligibility
New LEOFF II Employees, mcluding Eligible Dependents of active, full-time LEOFF I and LEOFF II law
enforcement officers, may initially apply for coverage on the first day of the first full month followmg their first
day of employment Application for coverage must be received by KPS withm 31 days of mitial eligibility
Those Employees who do not enroll immediately following their probationary period(s) must wait until the
next Open Enrollment Period
A new Spouse and the Spouse's Children may initially apply for coverage as of the date of marriage
Application for coverage must be received by KPS withm 31 days of initial eligibility
When Coverage Begins
Coverage for new Enrollees begms on their date of mitial eligibdity provided they enrolled in this Group Plan
withm the specified time limits (see Enrollment Timeframes) and any applicable Premium amounts have
been paid
If the Employee enrolls dunng an Open Enrollment Perrod, coverage will begm on the first of the month,
following the Open Enrollment Period
Newborn Children who meet eligibility requirements are covered automatically for a period of three (3)
weeks from the date of birth, provided either the female Subscriber, or male Subscnber's Spouse, is eligible
for maternity coverage under this Group Plan at the time of the Child's birth If additional Premium is
required, coverage will not extend beyond the three- (3) week period unless the Child is enrolled within 60
days of the date of birth Any applicable Premium amount must accompany the enrollment application
If additional Premium is required coverage for adopted Children is retroactive to the date the Chddren were
adopted, legally placed for adoption, or when the Subscriber or Subscriber's Spouse assumes legal
obligation for total or partial support of the Chddren in anticipation of adoption, provided that the application
and applicable Premium for the Children are received by KPS within �0 days from the date of adoption,
placement for adoption, or assumption of financial responsibility
NOTE When additional Premium is not required, we encourage enrollment as soon as possible to prevent
delays m claims processmg
Page 5
COVERAGE CONTRACT
Coverage Waiting Periods
(This section does not apply to LEOFF I Employees)
Pre-ex►stmg Cond�t�ons
Enrollees age 19 and older must be enrolled in this Group Plan for a period of three (3) consecutive months
before KPS will provide benefits for a Pre-existmg Condition A Pre-ex►sfing Condit�on is any condition for
which you received medical advice during the three (3) month period immediately preceding your date of
enrollment in this Group Plan or for which your Provider recommended or provided treatment Genetic
mformation shall not be treated as a Pre-existmg Condition, unless there has been a diagnosis of the
condition related to the specific genetic information
No Pre-existing Condition limitations apply to Enrollees under 19 years of age
Transp/ant Procedures
KPS provides coverage for transplant procedures only after you have been continuously enrolled under this
Group Plan for six (6) months This transplant waiting period applies to the transplant procedure, as well as
any pre- and post-transplant care directly related to a transplant you receive whde covered under this Group
Plan
Cred�tab/e Coverage
If you were required to complete an employer imposed probationary period, the waiting periods begin on the
first day of your probationary period The Pre-existmg Condition and transplant procedures waiting periods
may be reduced by the number of months of Creditable Coverage you have accrued under other health
care programs prior to your enrollment in this Group Plan Creditable Coverage means periods of other
health coverage an Enrollee may use to reduce Pre-existing Condition and transplant procedures waiting
periods These include
o Group health coverage
o Part A or Part B of Medicare
o Medicaid
o Military health coverage
o Indian Health Service or tribal coverage
o State High Risk Pool
o Federal or Public Health Plans
o Peace Corps Plan
o State Children's Health Insurance Program
o Other health insurance coverage
The Enrollee will receive credit for prior Creditable Coverage if it was continuous and terminated not more
than three (3) months immediately preceding enrollment in this Group Plan Health coverage will be
considered continuous if there was not more than a three (3) month break between any Creditable
Coverage No credit wdl be given if there was more than a three (3) month break between any coverage
between the Enrollee's pnor plan and their effective date of enrollment in this Group Plan Any Employer
imposed probationary period wdl not be considered a break in coverage or creditable coverage
To request a credit to the Pre-existing Condition waitmg period, the Enrollee must submit a Certificate of
Creditable Coverage from the prior health plan carrier with his/her enrollment application In lieu of a
Certificate of Creditable Coverage, the Enrollee must provide all of the following information
➢ The name of the pnor health plan carrier
➢ The dates of coverage under the prior plan
➢ Proof of coverage under the prior plan that documents the coverage penod(s)
There are no waiting penods for
➢ Pregnancy
➢ Formulas necessary for the treatment of phenylketonuria (PKU)
➢ Prescription drugs included in the Pharmacy Benefit
➢ Newborn Chddren or adopted Chddren
Page 6
COVERAGE CONTRACT
TERMINATION OF COVERAGE
Continuity of Coverage
Continuity of coverage under this Contract is guaranteed to all Enrollees provided the Group contmues to
meet eligibility requirements and contmues to pay applicable Premium payments on a timely basis
Termination or Rescission of Contract
This Contract may be terminated as of the date on which any of the following occurs
➢ The Group fads to make full Premium payments
➢ The Group violates, or refuses to comply with, the terms and conditions of this Contract
➢ The Group violates, or refuses to comply with, any published KPS policies and procedures that
have been approved by the Insurance Commissioner
➢ There is a change to, or implementation of, federal or state law that prohibits the contmued offering
of this Group Plan
➢ KPS replaces this Group Plan In this case, the replacement plan wdl (i) include the services
covered under the replaced Group Plan, (ii) be offered to the Group's eligible Employees and their
Eligible Dependents, and (ni) not significantly limit access to the kmd of services covered under the
replaced Group Plan
In addition, the Group may termmate this Contract, at any time, by providing thirty (30) days written notice to
KPS
KPS may rescind or terminate this Contract upon thirty (30) days written notice in the event that intentional
misrepresentation of material fact or fraud was used m order to obtain Group coverage In no event will
coverage be termmated or rescinded solely on the basis of an Enrollee's physical or mental condition
provided they meet all other eligibdity requirements set forth by the Group The Group may appeal a
termination or rescission decision through the KPS appeals process Either party may termmate this
agreement m the event of intentional misrepresentation, fraud, or omission of information by the other party
in performance of its responsibilities under this agreement
If this Contract is termmated coverage for all Enrollees wdl end automatically on the effective date of
termination, or on the last day of the last month for which the Group paid the Premium, whichever occurs
first KPS will refund to the Group any Premium paid for periods after the termination date
In the case of termmation or non-renewal of this Contract, KPS shall be responsible for providmg the
effective date of termmation of coverage to all affected Subscribers and their Eligible Dependents
Termination or Rescission of Enrollee Coverage
Coverage for an mdividual Enrollee under this Contract will end as of the date on which any one of the
following events occurs
➢ Non-payment of any Premium amount, when Premium payment is the responsibility of the Enrollee
➢ The Enrollee loses eligibdity for coverage under this Contract
➢ The Enrollee refuses to comply with the terms and conditions of this Group Plan as described in
Attachment A
➢ The Enrollee obtains coverage through intentional misrepresentation of material fact or fraud
➢ The Enrollee voluntardy disenrolls from this Group Plan
➢ There is a change in either state or federal laws that no longer permit KPS from offenng this Group
Plan
➢ This Contract is terminated
Page 7
COVERAGE CONTRACT
Additionally, Eligible Dependent coverage ends if
➢ The Subscriber is no longer employed or no longer meets eligibility requirements
➢ The Subscriber dies
➢ The Chddren reach the Limiting Age
Coverage ends on the last day of the month in which the Enrollee was eligible for coverage, provided all
applicable Premium amounts have been paid In the case of non-payment of Premium, coverage ends on
the last day of the month for which KPS received a Premium payment KPS wdl be entitled to recover
claims payments for services received by the Enrollee after the termination date, unless there was prior
authorization for those services
Upon termination of coverage either KPS or the Group shall issue a Certificate of Creditable Coverage
certifying the period(s) during which the Enrollee was enrolled in this Group Plan
An Enrollee who loses coverage under this Group Plan may be eligible to continue coverage or enroll in a
KPS Conversion Plan (see the Continuation of Coverage section of Attachment A)
A Subscriber who voluntarily disenrolls from this Group Plan wdl not be eligible to re-enroll in this Group
Plan, untd the next Open Enrollment Period See the Enroliment Under Special Circumstances section of
Attachment A for exceptions to this policy
COBRA (Consolidated Omnibus Budget Reconciliation Act -1985)
If an Enrollee loses eligibility for coverage under this Group Plan, they may be eligible to continue their
coverage for a period of time specified by federal law and regulations then m effect This continuation of
coverage is referred to as COBRA and applies generally to groups of 20 or more employees KPS offers
coverage o� when
➢ Groups are required by law to provide COBRA coverage for their employees, and
➢ KPS is notified of a beneficiary's election of COBRA coverage within 31 days of that election being
made
Contmuation of coverage under COBRA is not automatic Enrollees must apply for continuation of their
Group coverage within 60 days of the date they receive a COBRA election notice from the Group KPS
offers COBRA coverage to Groups only as required by law
The Group Plan Administrator is required to notify KPS of an Enrollee's election of COBRA contmuation
coverage within 31 days of that election Failure on the Enrollee's part to make a timely election, or failure
on the part of the Group Plan Administrator to provide KPS with timely notification of the election, will be
interpreted by KPS as a waiver of the Enrollee's right to continue coverage under this provision Failure by
the Group Plan Admmistrator to provide timely notification to KPS may not, in all cases, eliminate the
Group's obligation to provide continuation coverage It will, however, elimmate any obligation on the part of
KPS to provide the Enrollee with COBRA continuation coverage under this Group Plan
Fraudulent Information
In the event it is discovered that the Group has provided false or misleading information in connection with
the provisions of this Contract for the purpose of defrauding KPS, KPS reserves the right to terminate or
rescmd coverage and shall inform the appropriate state and regulatory authorities, including, but not limited
to, the Washington State Office of the Insurance Commissioner (OIC) for a determination of the Group's
habibty
Re-Enrollment/Reinstatement
If this Contract has been termmated by KPS due to non-payment of Premium, the Group automatically
forfeits ali nghts to guaranteed renewal of coverage afforded under the Health Insurance Portability and
Accountability Act (HIPAA) of 1996 Any decision to reinstate or re-enroll the Group is at the sole discretion
of KPS
Page 8
COVERAGE CONTRACT
SUBSCRIBER/DEPENDENT LIABILITY AND RIGHTS
Subscriber/Dependent Liability
Subscribers and their Eligible Dependents who are enrolled m this Group Plan are liable for the followmg
costs
➢ Deductible (defined in Attachment A)
➢ Copayments (defined m Attachment A)
➢ Charges for non-Covered Benefits and Services
➢ Comsurance, up to the Comsurance Maximum limit (defined in Attachment A)
➢ Charges incurred after an annual or lifetime maximum benefit for a specific service or supply has
been exhausted
➢ Charges m excess of the amount allowed by KPS for Non-Participatmg Providers
If KPS fails to reimburse a Participating Prowder for the cost of Medically Necessary Covered Benefits and
Services provided in accordance with the terms of this Contract, neither the Enrollee nor the Group shall be
required to compensate the Participating Provider for such services beyond the limit of Deductibles,
Copayments, or Coinsurance amounts specified m Attachment A
What happens ►f a Prov�der no /onger part�c�pates with KPS?
If a Participating Provider chooses to terminate their agreement with KPS, we will notify the affected
Enrollees of the termination The notification wdl allow Enrollees at least 60 days to either (i) complete their
course of treatment, or (u) appropriately transfer their care to another Participatmg ,Provider After the 60
days, services received from a Provider who has termmated their agreement with KPS will be covered at
the Non-Participating Provider benefit level
GENERAL TERMS AND CONDITIONS
Applicable Law
This Contract shall be governed by the laws of the state of Washington and is entered mto in Bremerton
Washington Any controversy or claim arising out of or relating to this Contract shall be resolved in a court
of competent �urisdiction in Kitsap County, Washmgton or the U S District for the Western District of
Washington
Assignment of Benefits
The benefits of this Contract shall accrue to Subscnbers and their enrolled Eligible Dependents This
Contract, payments, or Covered Benefits and Services are not assignable to a third party KPS reserves the
right to make benefit payments to the Subscnber, their Provider(s), or �omtly, as KPS deems necessary and
appropriate, sub�ect to federal and/or state laws
Binding Agreement
This Contract is binding on KPS and the Group, as well as their respective executors, administrators,
successors, and/or assigns By election of coverage or payment of applicable Premiums, or if the Group's
Subscnbers or their enrolled Eligible Dependents seek the services provided under this Contract, all of the
terms, covenants, and conditions contained herein shall become bmding on the Group and its Subscribers
and any enrolled Eligible Dependents, notwithstanding the failure of the Group to sign this Contract
This Contract shall not bind KPS until (i) a person authonzed by KPS signs it, and (ii) a signed copy is
delivered to the Group
Page 9
COVERAGE CONTRACT
Confidentiality
The underwriting and financial terms of this Contract are confidential and shall not be disclosed except as is
necessary for the performance of this Contract or as required by law
Contract Modifications
Except as set forth under the Premium Rate Ad�ustments section, KPS reserves the right to modify the
provisions of this Contract, or the services described in Attachment A, upon 30-days wntten notice to the
Group The Group may elect to re�ect such modifications by providing KPS with 15-days written notice
However, re�ection of a modification will result in the termination of this Contract as of the last day of the
month for which Premium payment has been received Lack of notification of re�ection by the Group shall be
interpreted as acceptance of the modification, and this Contract wdl be renewed as modified
No modification of the terms of this Contract shall be binding upon KPS unless endorsed, in writing, and
signed by an authonzed officer of KPS Such endorsement shall be deemed a part of this Contract, effective
as of the effective date of the endorsement Any amendment or Contract modification required by law or
regulation shall become effective as of the effective date required by such law or regulation
Coverage Limits
The Covered Benefits and Services offered under this Contract are sub�ect to the coverage limits and
maximums set forth in Attachment A
Entire Agreement
This Contract, together with Attachment A, any Riders and/or Endorsements attached hereto, and
Attachment B— Prem ium Rates and Underwriting Criteria, constitutes the entire agreement This
Contract supersedes all previous communications, representations, or agreements, whether verbal or
written, befinreen KPS and the Group
Equity of Application
This Contract is intended to apply equally to all Enrollees
Force Majeure
In the event KPS is unable to perform its obligations hereunder by reason of fire, casualty, lockout, strike,
labor condition, riot, war, act of God, or by ordinance, law, order, or decree by any legal authonty, the
Contract may, at the option of KPS, be suspended During any period of suspension, KPS shall not be
required to perform any service hereunder, nor shall KPS be liable for any damages arising from any event
that precipitated the suspension If this Contract is suspended pursuant to this provision, any obligation by
the Group and%or an Enrollee to make Premium payments also shall be suspended for the same period of
time
Group Cooperation
The Group agrees to cooperate with KPS in the admirnstration of this Contract by
➢ Advismg Subscribers and their enrolled Eligible Dependents of policies and procedures applicable
to this Group Plan
➢ Providing Subscribers and their enrolled Eligible Dependents with Attachment A, ID cards, and
any applicable notices or other information regarding this Group Plan
➢ Providing information about Enrollees that is relevant to the determination of eligibility, claim
reimbursement, coordination of benefits, or other information required for the administration of this
Contract
➢ Making appropriate payroll deductions, if applicable, to facilitate Premium payment
Page 10
COVERAGE CONTRACT
Headings
The headings of sections and paragraphs in this Contract are for convenience and reference purposes only
and do not affect in any way the meaning or interpretation of any prowsion of this Contract
Notices
Any notice that may affect the prowsions of this Contract shall be deemed delivered to the Group when
deposited in the United States mail, with prepaid postage, addressed to the Group at the most recent
address listed for the Group
Any notice that may affect the provisions of this Contract shall be deemed delivered to KPS when deposited
in the Urnted States mail, with prepaid postage, addressed to
KPS Health Plans
P O Box 34803
Seattle, WA 98124-1803
Any requirement of KPS to provide notice to Enrollees shall be fulfilled when the Group has received such
notice It is the responsibility of the Group to dissemmate notices to Enrollees within 31 days of receipt
Severability
If a court of competent �urisdiction deems any term, provision, Endorsement, or condition of this Contract
invalid or unenforceable, the same shall be deemed severable from this Contract The remaming provisions
of this Contract shall remain in full force and shall m no way be affected or mvalidated as a result of such
decision
Third Party Beneficiaries
There are no third party beneficiaries to this Contract
Waiver of Breach
Waiver of a breach of any provision of this Contract shall not be deemed to be a waiver of any other breach
of the same or different provision
The foliowmg topics are described in deta�l in Attachment A. Please refer to the Table of
Contents in Attachment A to locate each section.
ELIGIBILITY AND ENROLLMENT
➢ Contmuation of Inpatient Coverage
➢ Continued Eligibility for Disabied Dependent Children
BENEFITS SUMMARY
CONTINUATION OF COVERAGE >
➢ Coverage Durmg a Labor Dispute
➢ Continuation of Group Coverage
➢ Conversion Coverage
COORDINATION OF BENEFITS (COB)
KPS'S RIGHT OF REIMBURSEMENT AND SUBROGATION
COMPLAINTS AND APPEALS PROCESS
ENROLLEES RIGHTS
➢ KPS Privacy Pohcy
➢ Statement of ERISA Rights
Page 1
KPS Health Plans
400 Warren Avenue
Bremerton, WA 98337
City of Bremerton - Plan A
Benefits Booklet
This Benefits Booklet has been prepared for City of Bremerton — Plan A It contains information
you need to know concerning eligibdity, enrollment, plan benefits, and your rights under this Group Plan
The Group Plan you have chosen is a Preferred Prowder Option ("PPO") Plan Under this PPO
Plan, you are entitled to receive care either from a Participatmg or Non-Participating Provider or Facility
The level of benefit coverage you receive depends on the Provider you choose for your care In most
cases, your overall coverage is greatest, and your out-of-pocket expenses are the lowest, when you
choose a Participating Provider or Participating Facility
The terms "you" and "your" refer to the person(s) enrolled in this Group Plan The terms, "we,",
"us," and "our," refer to KPS The capitalized words used throughout this Benefits Booklet have specific
meanmgs The definitions of capitalized words can be found m the Definitions section at the end of this
Benefits Booklet
KPS Health Plans believes this plan is a"grandfathered health plan" under the Patient Protection and
Affordable Care Act As permitted by the Affordable Care Act, a grandfathered health plan can preserve
certain basic health coverage that was already in effect when that law was enacted Bemg a
grandfathered health plan means that your plan may not include certam consumer protections of the
Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive
health services without any cost sharing However, grandfathered health plans must comply with certam
other consumer protections in the Affordable Care Act, for example, the elimmation of lifetime limits on
benefits
Questions regardmg which protections apply and which protections do not apply to a grandfathered
health plan and what might cause a plan to change from grandfathered health plan status can be directed
to KPS Customer Service at 360-478-6796, or toll-free at 1-800-552-7114 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 website has a table summanzing which protections do and do not
apply to grandfathered health plans
66136REM-A
Table of Contents
ELIGIBILITY AND ENROLLMENT ......................................................................................................1
Who Can Enroll in This Group Plan �
When to Enroll in This Group Plan 1
Enroliment Under Special Circumstances 1
How to Enroll - 2
Enrollment Changes � 2
When Coverage Begins 2
When Coverage Ends 3
Continuation of Inpatient Coverage 3
Continued Eligibility for Disabled Dependent Children 4
HOW THE GROUP PLAN WORKS ....................................................................................................4
Waiting Periods (Does not apply to LEOFF I Employees) 4
Choosing a Provider or Hospital 5
Services Which Require Prior Authorization 6
You must get prior authorization from KPS before receivmg the following services 6
How to Submit Ciaims for Payment 7
Benefits Management 8
YOUR OUT-OF-POCKET COSTS .....................................................................................................8
Deductible 8
Copayments 8
Annual Comsurance Maximum g
BENEFITS SUMMARY ..................................................................................................................1 O
Occupational In�ury Coverage 14
DESCRIPTION OF COVERED BENEFITS AND SERVICES ..................................................................
Preventive Care 15
Professional Services 16
Hospital Services 16
Acupuncture Needle Treatment 17
Ambulance Transportation 17
Anesthesia for Dental Procedures — Not Received in the Dentist Office 17
Blood Bank 17
Bone Bank 17
Card�ac Rehabilitation 18
Colorectal Cancer Screening 18
Contraceptive Services 18
Diabetic Education, Equipment, and Supplies 18
Home Health and Hospice Care 18
Kidney Dialysis 20
Laboratory and Radiology Services 20
Mastectomy Care 20
Maternity Care 20
Medicai Equipment and Supplies 21
Mental Health Care 22
Neurodevelopmental Therapies 23
Newborn Care 23
Nutritional Guidance Counselmg 23
Oral Surgery 24
Organ, Bone Marrow, Stem Cell and Tissue Transplants 24
Oxygen and Oxygen Supplies 26
Phenylketonuria (PKU) Formulas � 26
Plastic and Reconstructive Surgery 26
Private Duty Nursmg 26
Rehabilitation 26
Skilled Nursing Facility Care
Sleep Disorders
Spinal and Extremity Manipulation
Substance Use Disorder Treatment (Chemical Dependency)
Termination of Pregnancy
Vision Examination
Women's Heaith Care Services
Pharmacy Benefits
27
27
28
28
28
28
29
29
LIMITATIONS EXCLUSIONS ...................................................................................................
CONTINUATION COVEFiAGE ....................................................................................................
Coverage During a Labor Dispute 33
Continuation of Group Coverage 33
COBRA (Consolidated Omnibus Budget Reconciliation Act - 1985) 33
Conversion Coverage 34
COORDINATION OF BENEFITS (COB) ...........................................................................................
General Provision 35
Definitions 35
Order of Benefit Determination Rules 36
Effect on Benefits 38
Right to Receive and Release Information 38
Facility of Payment 38
Right of Recovery 38
Notice to Enroilees 3$
Additional Information 38
KPS'S RIGHT OF REIMBURSEMENT AND SUBROGATION ...............................................................
Collection and Reimbursement by Enrollee 39
Underinsured or Uninsured Motorist Coverage 39
Cooperation 40
Recovery of Claims Payments 40
COMPLAINTS AND APPEALS PROCESS ........................................................................................41
If You Have a Complamt 41
Standard Appeals Process 41
First Level Appeal 42
Independent Review Organization (IRO) 42
Second Level Appeal (OPTIONAL) 43
Expedited Appeals Process 43
Appeals Related to Continuation of Care 43
ENROLLEE ...................................................................................
KPS Privacy Pol�cy
Disclosure of Information
Statement of ERISA Rights
Women's Right to Direct Access
Your Right to Safe and Effective Pharmacy Services
................................ 43
43
45
45
46
46
HOW YOU CAN STOP HEALTH CARE FRAUD ................................................................................47
DEFINITIONS ..............................................................................................................................48
CONTACT .............................................................................................................................52
Benefits Booklet
ELIGIBILITY AND ENROLLMENT
Who Can Enroll in This Group Plan
LEOFF I and LEOFF II Employees, and the Dependents of LEOFF I and LEOFF II law enforcement
officers, are eligible to enroll in this Group Plan
The chddren of an Eligible Dependent Child cannot enroll in this Group Plan
When to Enroll in This Group Plan
You and your Eligible Dependents must apply for coverage under this Group Plan 31 days followmg the
date of your mitial eligibility If additional Premium is required, the application and Premium for newborn or
adopted Children must be received by KPS within 60 days of the Child's date of birth, adoption,
placement for adoption, or when you or your Spouse assume legal obligation for the total or partial
support of a Child in anticipation of adoption If you do not enroll when you are initially eligible you must
wait until the next Open Enroliment Period, except in certain circumstances (see the Enrollment Under
Special Circumstances section)
NOTE When additional Premium is not required, we encourage enrollment as soon as possible to
prevent delays in claims processing
Please contact your Group Plan Admirnstrator for more information regarding eligibdity and enrollment
Enrollment Under Special Circumstances
Loss of Other Coverage
If you and/or your Eligible Dependents involuntanly lose coverage under another health plan, you may
apply for coverage under this Group Plan if the following applies
➢ You declmed enrollment in this Group Plan
➢ You lose eligibility in another health plan or your coverage is terminated due to the following
o Legal separation or divorce
o Cessation of dependent status
o Death of employee
o Termination of employment or employer contributions
o Reduction in hours
o Loss of individual or group market,coverage because of move from plan area or
termination of benefit plan
o Exhaustion of COBRA coverage
➢ Your application to enroll rn this Group Plan is received by KPS withm 31 days of losing other
coverage Coverage will be effective the first day of the month following receipt of application
If these conditions are not met, you must wait until the next Open Enrollment Period to apply for coverage
NOTE Dependents may not enroll in this Group Plan, unless the employee is a Subscriber
State Sponsored Coverage
If you declined coverage when you were eligible to enroll in this Group Plan, you may subsequently apply
for coverage in the event that the Department of Social and Health Services (DSHS) has determined that
it is cost-effective to enroll you or your Eligible Dependents in this health plan Application for coverage
must be submitted to KPS withm 60 days followmg the determmation by DSHS Coverage will be effective
as of the first day of the month followmg receipt of application
City of Bremerton Plan A Page 1
Benefts Booklet
Marriage, B�rth, Adopt�on, or P/acement for Adopt►on
If you declined enrollment in this Group Plan, you may apply for coverage for yourself and your Eligible
Dependents in the event of marriage, birth of a Child, adoption, placement for adoption, or when you or
your Spouse assume legal obligation for total or partial support of a Child in anticipation of adoption
Application for enrollment must be received by KPS
➢ Within 31 days following the date of marnage
➢ Within 60 days, if additional Premium is required, following the date of birth, adoption, placement for
adoption, or when you or your Spouse assume legal obligation for total or partial support of a Child m
antiapation of adoption
➢ At the next Open Enroliment Period if these time frames are not met
NOTE When additional Premium is not required, we encourage enrollment as soon as possible to
prevent delays in claims processing
Court ordered Coverage
If you decimed coverage when you were eligible to enroll in this Group Plan, you may subsequently apply
for coverage m the event you are required to provide health care coverage for Eligible Dependent
Children as a result of a court order KPS requests that any application for coverage be submitted w�thm
31 days following the date of the court order Coverage wdl become effective on the first day of the month
following the effective date of the court order
How to Enroll
To enroll in this Group Plan, complete an enrollment application form You may obtain an enrollment
application form from your Group Plan Admmistrator To avoid possible delays in processing your
application, please provide all the requested information for every person who will be covered under this
Group Plan Delays caused by an incomplete application could result in delayed payment of your medical
claims
If you are required to pay all or a portion of your Premium, you must include the Premium payment for
your first month of coverage with your enrollment application
Please submit enrollment forms and Premium payments to your Group Plan Administrator
Enrollment Changes
If you need to add or remove an Eligible Dependent, please contact your Group Plan Administrator to
obtain the necessary forms Return all completed forms to your Group Plan Admmistrator See the When
Coverage Begins and When Coverage Ends sections for additional information on when Eligible
Dependent coverage begins and ends
When Coverage Begins
Coverage begins on your initial date of eligibdity, provided you enrolled withm the specified time period,
and you paid the applicable Premium
If you enrolled during an Open Enrollment Period, your coverage will begin on the first of the month
following the Open Enrollment Period
Newborn Chddren who meets eligibdity requirements is covered automatically for a period of three (3)
weeks from the date of birth, provided either the female Subscriber, or male Subscriber's Spouse, is
eligible for maternity coverage under this Group Plan at the time of the Child's birth If additional Premium
is required, coverage wdl not extend beyond the three (3) week penod, unless the Child is enrolled within
60 days of the date of birth Any applicable Premium must accompany the enrollment application
Page 2 City of Bremerton Plan A
Benefits Booklet
If additional Premium is required, coverage for adopted Children begms on the date the Children are
adopted, legally placed for adoption, or when you or your Spouse assume legal obligation for total or
partial support of the Chddren in anticipation of adoption, provided that the Chddren are enrolled within 60
days from the date of placement or financial responsibility and the applicable Premium is paid by the
Premium Due Date
NOTE When additional Premium is not required, we encourage enrollment as soon as possible to
prevent delays m claims processing
When Coverage Ends
Your coverage ends on the last day of the month in which you lose eligibility provided all applicable
Premium amounts have been paid In the case of non-payment of Premium, coverage ends on the last
day of the month for which KPS received payment
If you lose coverage under this Group Plan, you may be eligible to continue coverage or enroll m a KPS
Conversion Plan Please see the Continuation of Coverage section regardmg your nghts under the
Consolidated Omnibus Reconciliation Act of 1985 (COBRA) and KPS Conversion coverage
If you voluntarily disenroll from this Group Plan while stdl an employee, you wdl not be eligible to re-enroll
in this Group Plan untd the next Open Enrollment Period Please see the Enrollment Under Special
C�rcumstances section for exceptions to this policy
Upon termination of coverage, either KPS or your Group Plan Administrator will issue you a Certificate of
Creditable Coverage, certifying the penod(s) durmg which you were enrolled in this Group Plan You
should present this certificate to any subsequent health plan in which you may enroll as proof of your prior
health care coverage to receive credit toward any Pre-existing Condition exclusion You may request a
Certificate of Creditable Coverage at any time during your enroliment m this Group Plan and up to 24
months after your enrollment ends A Certificate of Creditable Coverage may be requested by contacting
a KPS Customer Service Representative at 360-478-6796, or toll-free at 1-800-552-7114
If you obtained coverage through mtentional misrepresentation of material fact or fraud your coverage
may be rescmded or terminated upon thirty (30) calendar days written notice In no event wdl you be
termmated or rescinded solely on the basis of your physical or mental condition provided you meet all
other eligibility requirements set forth by the Group You may appeal a termination or rescission decision
through the KPS appeals process
Continuation of Inpatient Coverage
If you are receivmg inpatient care in an accredited general Hospital or other approved facdity on the date
that coverage would otherwise end, you are eligible to continue receivmg benefits under this Group Plan
provided the following conditions are met
➢ KPS pre-authorized the mpatient care (see the Services Which Require Prior Authorization
section)
➢ All applicable Premium amounts continue to be paid
KPS will continue to provide benefits under this Group Plan, until one of the following events occurs
➢ You are no longer receivmg mpatient care
➢ The KPS Medical Director determmes that inpatient care is no longer Medically Necessary
➢ You do not continue to pay your Premium
➢ Three (3) consecutive months have elapsed since the date your coverage would have otherwise
ended
➢ You enroll in another KPS plan or in any other health plan that provides mpatient Hospital
benefits
You are not eligible for the extended coverage described above if, on the date coverage would otherwise
end, one of the following applies
➢ You are covered under any other group or individual medical plan with simdar inpatient benefits
➢ You are eligible for continuation of coverage under COBRA or any other continuation provision
If you have any questions, please contact a KPS Customer Sennce Representative at 360-478-6796, or
tol I-free at 1-800-552-7114
City of Bremerton Plan A Page 3
Benefits Booklet
Continued Eligibility for Disabled Dependent Children
Coverage for an Eligible Dependent Chdd may be contmued after the Child reaches the Limitmg Age
provided both of the followmg conditions are met
➢ Your Child is incapable of self-sustaining employment due to developmental disability or physical
handicap
➢ Your Child is dependent upon you or your Spouse for total or partial support
Proof of your Child's dependence must be submitted to KPS withm 31 days of the date your Chdd reaches
the Limiting Age Thereafter, KPS may require that you resubmit proof of your Chdd's continuing
dependence This proof is requested no more frequently than annually after the finro-year period following
the Child's attainment of the Limiting Age Please contact your Group Plan Administrator for more
information regarding continuation of coverage for a disabled Chdd
A disabled Child will continue to be eligible for coverage until any one of the following events occurs
➢ You do not submit proof of your Child's contmumg dependence as a result of disability or physical
handicap
➢ It is determined that your Child is no longer developmentally disabled or physically handicapped
(based on the evidence submitted)
➢ You are no longer covered under this Group Plan
➢ You do not continue to pay your Premium
➢ KPS terminates this Group Plan
A Child who is no longer eligible for coverage as a disabled dependent Child may qualify for coverage
under COBRA or a KPS Conversion plan (see the Continuation of Coverage section)
HOW THE GROUP PLAN WORKS
Waiting Periods (Does not apply to LEOFF I Employees)
Pre-Ex�st�ng Cond�t�ons
If you are age 19 and older you must be enrolled in this Group Plan for a period of three (3) consecutive
months before KPS will provide benefits for a Pre-existing Condition A Pre-existing Cond►tion is any
condition for which you received medical advice during the three (3) month period immediately preceding
your date of enrollment in this Group Plan or for which your Provider recommended or provided
treatment Genetic information shall not be treated as a Pre-existing Condition, unless there has been a
diagnosis of the condition related to the specific genetic information
No Pre-existing Condition limitations apply to Enrollees under 19 years of age
Transp/ant Procedures
KPS provides coverage for transplant procedures only after you have been continuously enrolled under
this Group Plan for six (6) months This transplant waiting period applies to the transplant procedure, as
well as any pre- and post-transplant care directly related to a transplant you receive while covered under
this Group Plan
Cred►tab/e Coverage
If you were required to complete an employer imposed probationary period, the waiting penods begin on
the first day of your probationary period The Pre-existing Condition and transplant procedures waiting
periods may be reduced by the number of months of Creditable Coverage you have accrued under other
health care programs prior to your enroliment in this Group Plan Creditable Coverage means periods of
other health coverage an Enrollee may use to reduce Pre-existing Condition and transplant procedures
waiting penods These include
➢ Group health coverage
➢ Part A or Part B of Medicare
4 City of Bremerton Plan A
Benefits Booklet
➢ Medicaid
➢ Military health coverage
➢ Indian Health Service or tribal coverage
➢ State High Risk Pool
➢ Federal or Public Health plans
➢ Peace Corps Plan
➢ State Chddren's Health Insurance Program
➢ Other health insurance coverage
You will receive credit for pnor Creditable Coverage if it was contmuous and terminated no more than
three (3) months immediately precedmg enrollment m this Group Plan Health coverage will be
considered contmuous if there was no more than a three (3) month break between any Creditable
Coverage No credit will be given if there was more than a three (3) month break m coverage between
your prior plan and your effective date of enrollment in this Group Plan Any employer imposed
probationary period will not be considered a break m coverage or Creditable Coverage
Waiting period requirements do not app/y to the foilowing _
➢ Pregnancy
➢ Formulas necessary for the treatment of phenylketonuria (PKU)
➢ Prescription drugs included in Pharmacy Benefits
➢ Newborn Chddren or adopted Chddren
Choosing a Provider or Hospital
KPS pays for services rendered by the following types of Providers when the services provided are
Medically Necessary and are Covered Benefits and Seroices under this Group Plan and when Providers
are acting withm the scope of their medical license or certification
Advanced Registered Nurse Practitioner (A R N P)
Certified Chemical Dependency Provider
Certified Mental Health Provider
Chiropractor
Dentist
East Asian Medicme Practitioner (Acupunctunst)
Massage Therapist "'
Naturopath (N D )
Nurse Midwife
Occupational Therapist *
Physical Therapist *
Physician (M D or D O)
Physician's Assistant (P A )
Pod iatnst
Psychologist
Speech Therapist "
`Therapy services will be covered when prescribed by your physician
NOTE This list does not mclude all types of Providers covered by KPS If your Provider type is not listed
above, please contact KPS toll-free at 1-800-552-7114 to request more mformation
KPS has agreements with health care professionals and facilities, which are Participating Providers and
Facdities, to ensure you have access to all Covered Benefits and Services For a current listmg of
Participating Providers and Facilities m your area, piease contact KPS toll-free at 1-8Q0-552-7194, or visit
our Web site at www kpshealthpians com ,
KPS does not requ►re a referral for specialty care, however, therapy services requ►re a prescr►ption as
noted above As a gene�al rule, you may receive care from any licensed or certified healthcare Provider
or Facility Your choice of Providers and Facilities wdl affect the level of benefit coverage you receive as
well as your out-of-pocket costs
When you choose a Participating Provider or Facility, your out-of-pocket costs are less than if you choose
a Non-Participating Provider or Facility If you choose a Non-Participating Provider or Facility, your out-of-
pocket costs are significantly higher because KPS reduces the allowed amount for Covered Services by
twenty-five percent (25%) In addition, it is your responsibility to pay the difference between any amounts
bdled by the Non-Participatmg Provider or Facility and the amount paid by KPS
City of Bremerton Plan A Page 5
Benefits Booktet
In certain instances, the care you receive from a Non-Participating Provider or Facility is not sub�ect to the
reduction in the feveV of beneflt coverage Those instances are
➢ Medical Emergency Emergency care is covered in full after you have met any applicable
Deductible, Copayment, or Coinsurance If you are admitted to a Non-Participating Hospital as a
result of your Emergency, KPS reserves the right to arrange for your transportation to a
Participating Hospital (see the Emergency Admissions section)
➢ Services Not Avadable from Participating Providers/Facilit�es KPS has the nght to determine
whether care and sennces are, or are not, avadable from a Participatmg Provider or Facdity If you
believe the care or service you require is not available from a Participating Provider or Faality,
please call KPS Customer Service before obtaining the care or service and ask for a review to
determine if it is appropnate for you to access care from a Non-Participating Provider or Facdity If
KPS determines that the care or service you require can only be obtained from a Non-
Participating Provider or Facility, your care wdl be covered in full after you have met any
applicable Deductible, Copayment, or Coinsurance
IF you could have received your care from a Participating Provider or Facility, but chose to receive care
from a Non-Participating Provider or Facility, you are financially responsible for paying the difference
between the amount paid by KPS and the amount billed by the Non-Participating Provider or Facdity This
is called "balance bdling"
What happens ►f my Prov�der no longer part►c�pates w�th KPS1
If your Participating Provider chooses to terminate their agreement with KPS, we wdl notify you of the
termination The notification will allow at least 60 days to either, (i) complete your course of treatment, or
(u) appropriately transfer your care to another Participatmg Provider After the 60 days, services received
from a Provider who has terminated their agreement with KPS wdl be covered at the Non-Participating
Provider benefit level
Services Which Require Prior Authorization
NOTE The following list of services that require pnor authorization is not all-inclusive Enrollees and
Providers should contact KPS Customer Service for updated information whenever there is a question
concerning coverage
You must get pnor authorization from KPS before receiving the following services
➢ Anesthesia for dental procedures
➢ Home health and hospice care
➢ Inpatient care that is elective or non-emergent
➢ Organ transplants _
➢ Oxygen and oxygen supplies
➢ Plastic and reconstructive surgery
➢ Skdled Nursing Facility care
➢ Surgical treatment for sleep disorders
➢ Inpatient behavioral health (Mental Health Care and Substance Use Disorder Treatment
(Chemical Dependency)) NOTE Prior authorization of behavioral health care is not required in
the case of involuntary commitment or Emergency detoxification
Some services, such as certain medical equipment and supplies, require prior authorization for specific
items Please see the Description of Covered Benefits and Services section for more mformation
about services requirmg prior authorization To obta�n prior authonzation for care, ask your Provider to
contact KPS KPS will send both you and your Provider written confirmation that the care or service has
been authorized if your care is Medically Necessary, but your Provider did not get prior authorization
from KPS, payment to your Provrder will be reduced by 20% No coverage is provided for services that
are not Medically Necessary
All requests for prior authorization are reviewed and approved based on Medical Necessity, eligibility, and
benefits To determine Medical Necessity, KPS uses nationally accepted guidelines that are also
accepted by Medicare If a calendar year ends durmg the course of an ongoing treatment plan, you or
your provider must call for re-authorization for the new calendar year
Page 6 Ciry of Bremerton Plan A
Bene�ts Booklet
If there are urgent circumstances involving your health, KPS will make a decision regardmg the
authorization within 48 hours of receiving the request In non-urgent circumstances, both you and your
Provider wdl be notified of the decision withm five (5) calendar days following receipt of necessary
mformation
Authorizat�on Extens�ons
If you need to extend the care you are currently receiving, have your Provider contact KPS to request an
extension An extension should be requested before the current authorization for care ends
Elective and Non-emergent Hosp�tal Care
Coverage for elective and non-emergent inpatient care is provided only for the number of days approved
by KPS If your stay in the Hospital lasts longer than the number of approved days, your Provider must
obtain approval for the additional days In addition, KPS will monitor your mpatient stay to ensure
continued Medical Necessity and may assist your Provider with discharge plannmg
Emergency Admissions
If you are admitted to the Hospital as a result of an Emergency, you are not required to obtam prior
authorizat�on However, you or your Provider must contact KPS within 48 hours of your admission, or as
soon as is reasonably possible, to complete the certification process Fadure to do so could result in
reduced benefit coverage
if you are admitted to a Non-Partiapatmg Facility as a result of your Emergency, KPS may choose to
have you transferred to a Participating Facdity as soon as it is medically feasible KPS will work closely
with your Provider to determine when and if you can be safely transferred to a Partiapatmg Facility
In the event you are admitted to a Non-Participating Facdity as a result of your Emergency condition, your
benefits are paid at the higher Participating Provider level
How to Submit Claims for Payment
In most mstances, Participating Providers and Facilities submit claims directly to us on your behalf When
this is the case, you are not required to fill out any claim forms
if your Provider does not submit claims directly to KPS on your behalf, you must send the claim to KPS
yourself To submit a claim, you must include the followmg mformation
➢ The Subscriber's name and ID number (shown on your KPS identification card)
➢ The Group name and ID number (shown on your KPS identification card)
➢ The patienYs name and ID number (if the patient and the Subscriber are not the same person)
➢ The original itemized bill from your Provider
➢ For out claims (Emerqency care onlY1 provide all of the above information, translated
into English, mcluding the type of service, charges in U S Dollars, and proof of travel
Send the above information to
KPS Health Plans
Attn Customer Service
P O Box 34803
Seattle, WA 98124-1803
All claims must be filed withm 12 months, following the date of service KPS wdl not process any claims
that are older than 12 months
How Will 1 Know What Happened to My C/a�m?
After KPS processes your claim, an Explanation of Benefits (E06) form is sent to both you and your
Provider The EOB explains how your claim was processed and contains mformation regardmg your
rights if you have any questions regardmg the outcome
KPS processes most claims within 30 days, unless additional information is required to make a decision
regarding your benefits
City of Bremerton Plan A Page 7
Benefits Booklet
Benefits Management
In certain cases, KPS, at its sole discretion, may choose to authorize coverage for benefits or services
that are not otherwise included as Covered Benefits and Services under this Group Plan Such
authorization is done on a case-by-case basis if a particular benefit or service is �udged to be Medically
Necessary, beneficial, and cost effective However, KPS's decision to authorize services in one instance
does not commit KPS to cover the same or simdar services in other mstances KPS's decisi on to
authorize services does not constitute a waiver of KPS's right to enforce the provisions, limitations, and
exclusions of this Group Plan
YOUR OUT-OF-POCKET COSTS
Deductible
The Deductible is the amount you and/or your family are required to pay out-of-pocket each Calendar
Year before KPS pays for your Medically Necessary Covered Benefits and Services Please refer to the
Benefits Summary section for the Deductible applicable to this Group Plan
You and each of your Eligible Dependents must satisfy separate Deductible requirements However, if
you satisfy the famdy Deductible requirement in any one Calendar Year, then any remaining unmet
mdividual Deductibles for you and your Eligible Dependents are waived for that same Calendar Year
Only charges for Medically Necessary Covered Benefits and Services are counted toward the
accumulation of your Deductible The following amounts are not included in the calculation of your
Deductible
➢ Copayments
➢ Coinsurance
➢ Charges for non-Covered Benefits and Services
➢ Charges in excess of the amount allowed by KPS for Non-Participating Providers
➢ Charges for Covered Benefits and Services to which the Deductible does not apply
Pr�or Plan Deduct►b/e
If you met all or a portion of your Deductible under another KPS plan immediately prior to enrolling m this
Group Plan, KPS wdl credit the amount accrued under the prior plan provided that
➢ Those amounts were accrued during the same Calendar Year that you enrolled in this Group
Plan
➢ You had no break in coverage between KPS plans
Pr�or Year Carryover
Any portion of your Deductible which is met in the last quarter of the immediately pnor Calendar Year is
applied toward your Deductible for the current Calendar year
Inpatient Hosp�ta/ Care
If your hospitalization begins in the current Calendar Year and continues uninterrupted into the next, your
Deductible and Coinsurance for the next Calendar Year will not begin until after discharge ,
Copayments
A Copayment is an amount that you are required to pay your Provider at the time of service Professional
office visits that require a Copayment are not sub�ect to the Deductible, unless otherwise specified in the
Benefits Summary section
Copayments are not counted toward the calculation of your annual Deductible or any Coinsurance
Maximum You must continue to pay Copayments even after you have reached your Coinsurance
Maximum
Please refer to the Benefits Summary section for any applicable Copayments on this Group Plan
Page 8 City of Bremerton Plan A
Benefits Booklet
Annual Coinsurance Maximum
NOTE This section was formerly referred to as "Annual Out-of-Pocket Maximum on Comsured Benefits
(Stoploss) " The term Comsurance Maximum replaces the term Stoploss
Please refer to the Benefits Summary section for the Comsurance Maximum applicable to this Group
Plan
If, durmg a Calendar Year, the amount of Comsurance you have paid reaches or exceeds the
"Coinsurance Maximum Per Enrollee," KPS will provide reimbursement for Covered Benefits and
Services at 100% of the KPS allowance for the remainder of that Calendar Year
If, during a Calendar Year, the amount of Coinsurance you have paid in combination with your enrolled
Eligible Dependents reaches or exceeds the "Coinsurance Maximum Per Famdy," KPS will prowde
reimbursement for Covered Benefits and Services at 100% of the KPS allowance for the remainder of
that Calendar Year
The followmg costs are not used to calculate the Coinsurance Maximum
➢ Deductible — must be met before Coinsurance levels apply
➢ Copayments
➢ Charges for prescription drugs
➢ Charges incurred after an annual or lifetime maximum benefit for a specific service or supply has
been exhausted
➢ Charges for non-Covered Benefits and Services and supplies
➢ The difference between what a Non-Participatmg Provider charges for a service and what KPS
allows for the service
City of Bremerton Plan A Page 9
Benefits Bookletr
BENEFITS SUMMARY
Outlmed on the following pages are the basic benefits and benefit maximums provided by KPS to you, as
an Enrollee, in this Group Plan Also included are the limits of your financial responsibility, as well as
other specific limitations relative to coverage under this Group Plan For a more complete descnption of
the benefits provided, please read the Description of Covered Benefits and Services section
ANNUAL DEDUCTIBLE
Per Enrollee � $50 �
Per Family $150
COINSURANCE MAXIMUM
Per Enrollee — Medical and Surgical $200
Per Enrollee — Pharmacy $150
LIMITING AGE
Dependent Chddren Up to Age 26
Well-baby Care 36 Months
WAITING PERIODS
Pre-existing Conditions 3 Months
Transplant Procedures 6 Months
COPAYMENTS
Office/Home/Urgent Care Center Visits $10
Page 10 City of Bremerton Plan A
Benefits Booklet
KPS provides the followmg Medicaily Necessary benefits and services, at the indicated reimbursement
percentage. Benefits paid at 100% are not sub�ect to the annual Deduct�ble. Benefits paid at 80% will be
paid at 100% once the Coinsurance Maximum (prev�ousiy Stoploss) has been satisfied.
0 0 ,�
• � o
Preventroe Care
Well-baby Care — From birth through the limitmg age for well-baby care
— mcludes physical examinations and immunizations Not a benefit 80%
(Not sub�ect to the Deductible)
Chdd and Adult Preventive Care — mcludes routine physical
exammations, laboratory and x-ray services (except mammography and
prostate cancer screernng), immunizations See Laboratory and 100% 100%
Radiology Services for mammography and prostate cancer screernng
benefits
Professional Services — Med�cal and Surg�cal
Care and Services Received in a Hospital or Skdled Nursmg Facdity 100% 100%
Care and Services Recewed m the Office or Urgent Care Center 100% after $10 100% after $10
Copayment Copayment
Care and Services Received in Your Home 100% after $10 100% after $10
Copayment Copayment
Care and Services Received m an Ambulatory Surgical Center 100% 100%
Care Received in the Emergency Room 100% 100%
Hospital Serv�ces
Prior authorization required for non-emergent and elective care
Inpatient Medical and Surgical Services
Semi-pnvate Room and Board 100% 100%
Speaal Care Urnt (e g, ICU, CCU)
Outpatient Care
Medical and Surgical (mcludes ambulatory surgical centers) 100°/a 100%
Emergency Room Faality and Supplies 100% 100%
Acupuncture Needle Treatment 100% after $10 100% after $10
12 treatments maximum per Calendar Year Copayment Copayment
Ambulance
Ground and Air Transportation — benefits are provided on a'per tnp' 100% of first $50, 100% of first $50,
basis 80% thereafter 80% thereafter
Anesthesia for Dental Procedures — Prior authorization required 100% 100%
Blood Bank 80% 80%
Bone Bank 80% 80%
Cardiac Rehabil�tation so% so%
City of Bremerton Pian A Page 11
Benefits Booklet
KPS provides the following Medically Necessary benefits and services, at the indicated reimbursement
percentage. Benefits paid at 100% are not sub�ect to the annual Deductible. Benefits paid at 80% will be
paid at 100°/a once the Coinsurance Maximum (previously Stoploss) has been satisfied.
Colorectal Cancer Screening
Routine Screening
Diagnostic
Contraceptrve Services
Prescnption contraceptives are covered under Pharmacy Bene�ts
Diabetic Education, Equipment, and Supplies
Prior authonzation may be reqwred
Health Education and Training
Medical Eqwpment
Home Health Care — To a maximum of 130 visits per Calendar Year
Prior authonzation required
HospiCe Care — To a maximum of 6 months per Calendar Year
Pri authoriz req
Kidney Dialys�s — Outpatient facdity or Hospital
Laboratory and Radiology Services
Inpatient Hospital and Ambulatory Surgical Center
Emergency Room
Mammography Services
Routine Screening
Diagnostic
Prostate Cancer Screernng
R outine S creernng
Diagnostic
All Other Laboratory and Radiology Services
Mastectomy Care
Prior authorization reqwred for inpatient Hospital services only
Medical Services
Prostheses & mastectomy bras
Maternity Care - Subscnber and Spouse only
Medical Equipment and Supplies
Prior a may be req
Mental Health Care — Prior authonzation reqwred
Inpatient Care
Outpatient Care
100% I 100%
See Professional & Hospital Services Sections
See Professional Services Section
See Professional Services Section
80% 80%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
See Professional & Hospital Services Sections
100%
100%
See Professional & Hospital Services Sections
80%
100%
100% after $10
Copayment
80%
100%
100% after $10
Copayment
Page 12
City of Bremerton Plan A
Benefits Booklet
KPS provides the following Medically Necessary benefits and services, at the indicated reimbursement
percentage. Benefits paid at 100% are not sub�ect to the annual Deductible. Benefits paid at 80% will be
paid at 100% once the Coinsurance Maximum (previously Stoploss) has been satisfied.
' � �
� � .
Neurodevelopmental Therapies
Speech, Physical, Occupational Therapy Not a benefit 80%
Newborn Care
Routine Nursery Care Not a benefit 100%
See Professional &
All Other Care Not a benefit Hospital Services
Sections
Nutritional Guidance Counseling 100% 100%
Oral Surgery 100% Not a benefit
Organ, Bone Marrow, Stem Cell and Tissue Transplants
Prior authorization re uired
Participatmg Provider 100% 100%
Non-Participatmg Provider —$350,000 lifetime maximum 80% 80%
Oxygen and Oxygen Supplies — Prior authorization required 80% 80%
Phenylketonuria (PKU) Formulas 100% 100%
Plastic and ReconstruCtive Surgery — Prior authorization required See Professional & Hospital Services Sections
Prrvate Duty Nursmg
80% Not a benefit
LEOFF I employees only
Rehabilitation — Prescribed by your physician
Inpatient — 30 Days maximum per condition 100% ' 100%
Outpatient 100% 100% to $100,
80 /o thereafter
Skdled Nursing Facility — Pnor authonzation required
365 days lifetime maximum
Facdity and physician care 100% 100%
Physical Therapy 100% 100%
Sleep Disorders
Pnor authorization required for surgical treatments only
Sleep Studies
Medical Serwces See Professional & Hospital Services Sections
Durable Medical Equipment and Supplies o 0
(mcludmg CPAP machmes) 80 /0 80 /o
Surgical Treatment 80% 80%
Spinal and Extremity Manipulation 100% after $10 100% after $10
20 office visits maximum per Calendar Year Copayment Copayment
City of Bremerton Plan A Page 13
Benefits Booklet
KPS provides the follow�ng Medically Necessary benefits and services, at the indicated reimbursement
percentage. Benefits paid at 100% are not sub�ect to the annual Deductible Benefits paid at 80% will be
paid at 100% once the Coinsurance Maximum (previously Stoploss) has been sat�sfied.
Substance Use Disorder Treatment (Chemical Dependency)
Prior authorizat�on reqwred
Inpatient Care
Outpatient Care
Terminat�on of Pregnancy
Limited to one (1) per Calendar Year
Vision Examination
Limited to one (1) routme eye examination per Calendar Year
All prescriptions must be filled at a Participating network pharmacy except m
the case of an Emergency
Pharmacy benefits are not sub�ect to the Deductible requirements
Comsurance Maximum (Per Enrollee)
Tier 1 drugs — Preferred Generic d
Tier 2 drugs — Preferred Brand drugs
Tier 3 drugs — Non-pre Ge a nd Brand drugs
90-day supply of any Drug
Occupational In�ury Coverage
This benefit applies to LEOFF I Employees only
100% 100%
100°/a after $10 100% after $10
Copayment Copayment
See Professional & Hospital Services Sections
100% I Not a benefit
$150
80%
80%
80%
80%
Treatment of work-related ilinesses and in�uries is covered to the extent the service or procedure is included as a
Covered Benefit or Service in this Benefits Summary section
All applicable Deductible, Copayment, Coinsurance, and Coinsurance Maximum requirements apply
Page 14 City of Bremerton Plan A
Benefits Booklet
DESCRIPTION OF COVERED BENEFITS AND SERVICES
The Covered Benefits and Services descnbed below, plus any Riders or Endorsements included with this
Benefits Booklet, comprise the total benefits provided by KPS under this Group Plan
All benefits and services are sub�ect to the Deductible, Copayment, and Comsurance requirements
described m the Benefits Summary section unless othe i n d icated
Coverage is provided when ALL of the following conditions are met
➢ The benefit or service is Medically Necessary for the iliness, in�ury, or condition
➢ The benefit or service is provided by a licensed or certified health care Provider
➢ The benefit or service is not specifically excluded from coverage
➢ If necessary, KPS has given pnor approval for the benefit or service
The amount KPS pays for each benefit or service is based on the reimbursement rate shown m the
Benef�ts Summary section
Preventive Care
Preventive care is care that is provided m the absence of a specific diagnosis of dlness or in�ury
Preventive care is provided for the specific purpose of preventing illness and disease
Please see the Laboratory and Radiology Services section for mammography and prostate cancer
screenmg benefits, as well as the Benefits Summary section for specific limitations regarding age limits
and coverage
Preventive care, as listed below is not sub�ect to the Deductible
Well-baby Care
Coverage for well-baby care includes routme physical exammations and chddhood immunizations for
Children up to and mcluding the limitmg age for well-baby care
Routme Physica/ Examinations
Ongoing preventive care for Children (over the limitmg age for well-baby care) and adults includes
coverage for routme physical examinations, associated laboratory and x-ray services (except
mammography and prostate cancer screening), and immurnzations
Immumzations
Covered immunizations are based on guidelmes established by the Adwsory Committee on Immunization
Practices of the Centers for Disease Control
Please contact KPS Customer Service or visit the KPS Web site at www kpshealthqlans com, for current
mformation regarding covered immurnzations
There is no coverage under this benefit for immunizations required for employment purposes or drugs
and immunizations for travel purposes
City of Bremerton Plan A Page 15
Benefits Booklet
Professional Services
Covered professional services that are Medically Necessary and rendered by a Provider include the
following
➢ Medical, surgical, and behavioral health services in conJunction with an approved Hospital stay
➢ Medical, surgical, and behavioral health services m an outpatient facdity
➢ Medical and surgical services in an ambulatory surgery facility
➢ Medical, surgical, and behavioral health services in an urgent care center
➢ Office, home, Hospital, and nursing home visits and related services
➢ Consultations and second opinions
Office, home, and urgent care center visits are sub�ect to the office visit Copayment
Hospital Services
Inpat�ent Care (Requires prior authorization)
Non-emergent inpatient Hospital care must be pre-approved by KPS Coverage for pre-approved
inpatient care includes
➢ Semi-private room and board charges, unless KPS has specifically authonzed coverage for a
private room
➢ Intensive care unit (ICU) and coronary care unit (CCU) room charges
➢ Operating room and related equipment
➢ Anesthesia and anesthesia services, in conJunction with inpatient surgery
➢ Diagnostic x-ray and laboratory services
➢ Surgical dressings and supplies, including casting supplies and implantable prosthetics, such as
pacemakers and artificial �oints �,
➢ Pharmacy services (administered drugs must be listed in the U S Pharmacopoeia an d the
National Formulary of biologicals and solutions)
➢ Electrocardiograms and other diagnostic and morntonng services
➢ Blood and blood derivatives, including administration charges
➢ Radiation and inhalation therapy services
An inpatient stay for the purpose of Medically Necessary diagnostic testing is covered for the Subscriber
only
Outpat�ent Care
Coverage for outpatient care includes
➢ Outpatient medical and surgical care
➢ Anesthesia and anesthesia services, in con�unction with outpatient surgery
➢ Surgical dressings and supplies, including casting supplies and implantable prosthetics, such as
pacemakers and artificial �oints
➢ Radiation and inhalation therapy services
➢ Chemotherapy
➢ Hemodialysis services
➢ Blood transfusion services �
Emergency Room Care
Coverage under this benefit is for the Emergency room facility and the supplies associated with care
received while there
All other services received in the Hospital Emergency room are paid at the applicable Comsurance level
Please refer to the Benefits Summary section for this information
Page 16 City of Bremerton Plan A
Benefits Booklet
If you are admitted to the Hospital as a result of your Emergency, you, your Provider, or the Hospital must
contact KPS within 48 hours of your admission, or as soon as is reasonably possible If you have been
admitted to a Non-Participating Hospital, KPS may, followmg consultation with your Provider, arrange to
have you transferred to a Participating Hospital There is no cost to you if KPS arranges your transfer to a
Participatmg Hospital
A Medical Emergency is a sudden and acute onset of a symptom or symptoms, includmg severe pain,
that would lead a prudent layperson, acting reasonably, to believe that a health condition exists that
requires immediate medical attention, if fadure to provide medical attention would result in serious
impairment to boddy functions or senous dysfunction of a boddy organ or part, or would place the person's
health in serious �eopardy Examples of Medical Emergency conditions include, but are not limited to,
heart attacks, cardiovascular accidents, poisonmgs, loss of consciousness or respiration, broken bones,
automobde accidents, severe bleeding, and convulsions
The use of an Emergency room for care not related to a Medical Emergency is not covered
Acupuncture Needle Treatment
Coverage under this benefit is limited Please refer to the Benefits Summary section
Acupuncture needle treatment is covered only if Medically Necessary and therapeutically appropriate for
the treatment of a condition, such as the treatment and management of pam
Ambulance Transportation
In the case of a Medical Emergency, the services of a licensed ground or air ambulance service are
covered to transport you to the nearest accredited general hospital where adequate facilities for treatment
are available Coverage for ambulance services includes
➢ Ground transportation
➢ Air transportation
➢ All services associated with the transport (e g, specialized medical personnel, oxygen, IV fluids)
The use of any type of ambulance transportation for personal convenience is not covered under this
benefit
Anesthesia for Dental Procedures — Not Received in the Dentist Office
(Requires prior authorization)
Coverage under this benefit is provided for the professional and facdity charges for inpatient Hospital and
outpatient surgery centers when
➢ The Enrollee is either under the age of seven (7) or physically or developmentally disabled,
➢ The service cannot be safely and effectively treated m a dental office, or
➢ The service is not for the convenience of the dentist or Enrollee
This benefit is considered medical and is sub�ect to applicable Deductible, Copayments, and
Coinsurance
Blood Bank
Coverage under this benefit includes charges from a blood bank for processing blood and its derivatives,
blood cross-matching, charges for whole blood, blood components and blood derivatives, to the extent
these are not replaced by volunteer donors, and other blood bank serwces
Bone Bank
Coverage under this benefit mcludes charges from a bone bank in con�unction with a covered medical or
surgical procedure
City of Bremerton Plan A Page 17
Benefits Booklet
Cardiac Rehabilitation
Coverage for cardiac rehabditation is provided for conditions, such as
➢ Angioplasty
➢ Ischemic heart disease/coronary artery disease
➢ Myocardial infarction
➢ Stable angina pectoris
➢ Heart transplant surgery
➢ Bypass surgery
Colorectal Cancer Screening
Coverage under this benefit includes colorectal cancer examinations and laboratory testmg at the
frequency recommended under the guidelines of the United States Preventive Service 1"ask Force, or the
Centers for Disease Control and Prevention, and as deemed appropriate by your physician after
consultation with you Services are provided if you are (i) at least 50 years of age, or (u) less than 50
years of age and at a high risk or very high risk for colorectal cancer, based on the recommendations of a
physician
Contraceptive Services
Coverage under this benefit includes contraceptive services, including the fitting of intra-uterine devices
and diaphragms, and contraceptive implants and in�ections, when done in the Provider's office
Prescription contraceptives are covered under Pharmacy Benefits
Diabetic Education, Equipment, and Supplies
(Requires prior authorization for insulin pumps)
Coverage under this benefit, when recommended by your Provider, includes diabetic health education
and training, diabetic equipment (e g, insulin pumps, insulin infusion devices, glucometers, orthopedic
shoes and inserts when Medically Necessary), and supplies
Home Health and Hospice Care
(Requires prior authorization)
Home health and hospice care coverage is provided only as an alternative to hospitalization or care in a
Skdled Nursing Facility Coverage is sub�ect to approval of a written treatment plan submitted to KPS by
your attending Provider
Care must be Medically Necessary (or palliative for hospice only), ordered by your attending Provider in
consultation with you, and provided by a licensed hospice or home health agency
The services provided must be skilled services Skdled services are those services that are
➢ Provided by trained medical or paramedical personnel or persons, working under their direct
supervision
➢ Cannot be safely and adequately self-admirnstered or performed by the average, rational,
non-medical person without the direct supervision of trained medical or paramedical personnel
Coverage for Home Health and Hospice care is limited Please refer to the Benefits Summary section If
you exhaust your Hospice benefit limits, you may apply to KPS for an extension Extensions may be
authorized based on Medical Necessity
The services and supplies provided under this benefit do not duplicate any other coverage provided under
this Group Plan
Page 18 C�ty of Bremerton Plan A
Benefits Booklet
Home Health Care
Coverage under this benefit mcludes
➢ Intermittent in-home visits by a registered nurse (R N), licensed practical nurse (L P N) or a
home health aide working under the direct supervision of an R N, L P N or licensed therapist, as
ordered m the approved treatment plan
➢ Services provided by a licensed or registered physical, occupational, speech, or inhalation
therapist, when such services are Medically Necessary to maintain, restore, or improve functions
lost as a result of severe dlness, in�ury, or surgery
➢ Drugs and medications necessary for the treatment of the illness or m�ury that are supplied by the
home health agency, based on a written prescription from your attendmg Provider
➢ Medical supplies dispensed by the home health agency
➢ The rental or purchase, as determmed by KPS, of Medically Necessary durable medical
equipment, when prescribed by your attendmg Provider
Coverage for home health care is limited to 130 visits per Calendar Year A visit is defined as any
encounter, in person, with any authorized home health agency worker who provides services to you
Coverage is available only if you are homebound with the exception of post delivery follow-up care
ordered by the attending Provider m consultation with the mother
Hosp�ce Care
Hospice care is avadable only if you are m the latter stages of a termmal illness Coverage is provided
under this benefit for a period of six (6) months, unless KPS approves an extension
Coverage under this benefit includes
➢ Seven (7) days of inpatient hospice care
➢ Medically Necessary services and supplies provided by the hospice agency
➢ Drugs and medications necessary for the treatment of the illness or in�ury which are supplied by
the hospice agency, based on a written prescription from your attending Provider
➢ Intermittent m-home or hospice visits and correspondmg supplies required for pain management
(palliative care), when provided by a registered nurse (R N), licensed practical nurse (L P N),
medical social worker with a Masters in Social Work degree (M S W) or an aide under the
supervision of an R N or L P N
➢ Respite care, whether m the home or hospice facility, in order to provide temporary relief to your
primary care giver, coverage is limited to five (5) days of continuous care for every three (3)
month period
Exclus�ons
There is no coverage under either the Hospice Care or Home Heaith Care benefit for the followmg
➢ Financial or legal counselmg services
➢ Spiritual or bereavement counselmg
➢ Housekeeping or meal services
➢ Transportation, except as provided for under Ambulance Transportation.
➢ Supportive equipment, such as handrads or ramps
➢ Custodial or mamtenance care which is designed primanly to assist you in the activities of daily
liwng, including, but not limited to the followmg
o Walkmg
o Gettmg in and out of bed
o Bathmg
o Dressing
o Feeding
o Preparation of special diets
City of Bremerton Plan A Page 19
Benefits Booklet
o Supervision of inedications, which are ordinarily self-administered
o Any care given to sustam you, when there is no reasonable likelihood the disabdity wdl
be reduced by such care
➢ Services provided by volunteers, household members, friends, or family members
➢ Any other service not specifically listed as covered under this benefit, or any service which is
specifically excluded under this Group Plan
Kidney Dialysis
Coverage under this benefit is provided for the treatment of acute and chronic kidney conditions
Coverage includes '
➢ Periodic treatment and supplies at a Hospital or dialysis center
➢ Provider services associated with dialysis treatment
If you have chronic kidney failure, you are encouraged to apply for coverage under Medicare Parts A and B
Laboratory and Radiology Services
Diagnostic and therapeutic laboratory and radiology (x-ray) services are covered when prescribed in
con�unction with a covered medical condition, and when Medically Necessary for the diagnosis or
treatment of a covered condition Coverage under this benefit includes
➢ Inpatient and outpatient diagnostic laboratory and pathology services
➢ Inpatient and outpatient diagnostic radiology (x-ray) services
➢ Nuclear medicine, including radiation therapy
➢ Diagnostic ultrasound
Mammography Serv�ces
Coverage under this benefit includes routine screening and Medically Necessary diagnostic
mammography services, when such services are recommended by a physician (M D or D O), advanced
registered nurse practitioner (A R N P), or licensed physician's assistant (P A)
Prostate Cancer Screen�ng
Coverage under this benefit includes routine screening and Medically Necessary diagnostic prostate
cancer screening services, when such services are recommended by a physician (M D or D O),
advanced registered nurse practitioner (A R N P), or licensed physician's assistant (P A)
Mastectomy Care
(Pnor authorization is required for inpatient Hospital services only)
Coverage under this benefit includes the following services when received m connection with a
mastectomy and the election of breast reconstruction in connection with such mastectomy
➢ All stages of reconstruction of the breast on which the mastectomy has been perFormed
➢ Surgery and reconstruction of the other breast to produce a symmetrical appearance
➢ Prostheses and mastectomy bras
➢ Treatment of physical complications of all stages of mastectomy, including lymphedema
Maternity Care
Pregnancy and Ch�ldb�rth
Coverage for pregnancy and chddbirth is provided only if you are the Subscriber or a Subscriber's
enrolled Spouse Coverage is provided on the same basis as any other dlness or in�ury Coverage for
pregnancy and childbirth is not sub�ect to the waiting periods for Pre-existing Conditions
Page 20 City of Bremerton Plan A
Benefits Booklet
Coverage under this benefit includes the followmg sennces when pertormed by a licensed physician
(M D or D 0), a physician's assistant (P A), an advanced registered nurse practitioner (A R N P)
specializing m women's health care or midwifery, or a licensed midwife
➢ Pre- and post-natal care
➢ Screening and diagnostic testmg for congenital fetal disorders
➢ Obstetrical delivery and delivery by Caesarean section
➢ Treatment for the complications of preg nancy
➢ Treatment following a miscarriage
To the extent that maternity care is covered under this Group Plan, the Provider (as defined above), m
consultation with you, may decide on the length of the inpatient stay and the type and location of follow-
up care, mcluding in-person care Decisions regardmg patient care must be based on accepted medical
practice for the treatment of the diagnosis
Pregnancy and childbirth are not covered conditions for Eligible Dependent Children However,
complications of pregnancy are covered for enrolled Eligible Dependent Children on the same basis as
any other illness or in�ury Complications of pregnancy may include, but are not limited to, the followmg
conditions
Blighted ovum
Ectopic pregnancy
Gestational diabetes
Hydatidiform mole
Medical Equipment and Supplies
Hyperemesis gravidarum
Incompetent cenrix
Spontaneous miscarriage
Complications following abortion or ectopic pregnancy
Coverage under this benefit includes artificial limbs and the purchase or rental of inedical equipment and
supplies prescribed by your Provider for home use Equipment or supplies ordered before you enrolled in
this Group Plan wdl not be covered Equipment or supplies ordered whde you were enrolled, and
delivered within 30 days after your coverage ended, will be covered
Surgically implanted prosthetics, such as pace makers and artificial �omts, are covered under the
Hospital Services benefit
Home Med►ca/ Equ�pment and Supplies
Pnor authorization is required for the following medical equipment
➢ Equipment with a purchase pnce greater than $2,500, except wheelchairs
➢ Wheelchairs with a purchase price greater than $5,000
➢ Electric hospital beds
➢ Enteral therapy
➢ Ventdators
➢ Contmuous positive air pressure (CPAP) and bi-positive air pressure equipment (except when
used m con�unction with sleep studies)
➢ Bone growth stimulators
Not all home medical equipment and medical supplies are covered For specific information regarding
coverage of inedical equipment and supplies, please call KPS Customer Service at the numbers listed at
the end of th B e n e fi ts B
At the sole discretion of KPS, coverage is provided for either the rental or purchase of home medical
equipment and supplies prescribed by your� Provider for therapeutic use In addition, if KPS determines
that there is a less costly alternative to the prescribed equipment that serves the same medical purpose,
KPS wdl provide benefits on the basis of the less costly equipment
All home medical equipment and supplies must be prescnbed by your Provider and obtained from a
licensed home medical equipment supplier or pharmacy
City of Bremerton Plan A Page 21
Benefits Booklet
Home medical equipment includes such things as crutches, walkers, hospital beds, and wheelchairs
Home medical equipment is generally defined as equipment that meets all of the following cnteria
➢ It is appropriate for use in the home
➢ It can withstand repeated use
➢ It is used primanly and customarily to serve a medical purpose
➢ It is not generally useful to a person in the absence of an illness or in�ury
Examples of disposable medical supplies covered under this benefit mclude, but are not limited to
➢ Ostomy bags and related supplies
➢ Peritoneal dialysis supplies
➢ Syringes and needles
➢ Catheters
Coverage of repair and maintenance costs on home medical equipment is sub�ect to prior review and
approval by KPS In cases where replacement costs are less than repair costs, KPS may elect to limit
coverage to replacement of the equipment
There is no coverage under this benefit for
➢ Repair or maintenance costs that are the result of intentional damage or neglect
➢ Equipment which is primardy used for non-medical purposes
➢ Items used only for convenience
➢ Charges for equipment purchased or rented from a private party
➢ Separately bdled delivery and service charges ,
Prosthet�c Appl�ances
Coverage under this benefit includes the initial purchase of the artificial limb (arm or leg) and subsequent
repair or replacement costs necessitated by damage to the limb and/or physical growth
Medically Necessary contact lenses, both initial and replacement lenses, are covered following cataract
surgery
Mental Health Care
Prior authorization is required for inpatient mental health care, except in the case of involuntary
commitment Either you or your Provider may request authonzation for inpatient services Please refer to
the Services Which Require Pnor Authorization section for more information
Prior authorization of outpatient services is not required but you may contact KPS Customer Service for
assistance in finding Providers KPS Customer Service can be reached at 360-478-6796, or toll-free at 1-
800-552-7114
Coverage under this benefit includes the following
➢ Treatment in an acute inpatient psychiatric or general Hospital
➢ Treatment provided on a Partial Hospitalization basis
➢ Treatment provided on an outpatient basis
➢ Treatment provided in a Residential Mental Health Faality
In order to be covered, care must be provided by one of the following
➢ A licensed medical doctor (M D or D 0)
➢ A licensed psychologist r
➢ A licensed community mental health agency
➢ A licensed state Hospital
➢ Any other licensed Provider who has been credentialed and approved by KPS to provide mental
health care
Page 22 City of Bremerton Plan A
Benefits Booklet
Coverage under this benefit does not mclude the followmg
➢ Marriage and family seminars and/or encounter groups
➢ Sensitivity trammg
➢ Sexual dysfunction
➢ Outdoor youth programs
Court-ordered assessments or other assessments are not covered under this benefit, when the purpose
of the assessment is to determine the Medical Necessity of any court-ordered mental health care
Coverage under this benefit does not duplicate coverage for therapy services provided under any other
benefit of this Group Plan
Neurodevelopmental Therapies
Coverage under this benefit for the restoration and improvement of function in a neurodevelopmentally
disabled Eligible Dependent Child who is six (6) years of age or younger includes
➢ Inpatient and outpatient physical, speech, and occupational therapy
➢ Ongoing maintenance care m cases where sigrnficant detenoration of the Child's condition would
occur without the care
All therapy treatments must be performed by a physician (M D or D O), registered physical therapist
(P T), speech therapist certified by the American Speech Language Hearing Association, or an
occupational therapist certified by the American Occupational Therapy Association
No coverage is provided under this benefit for any Enrollee who is age seven (7) or older
Coverage under this benefit does not duplicate coverage for therapy services provided under any other
benefit of this Group Plan
Newborn Care
Coverage for newborn Children of the female Subscriber or enrolled female Spouse is provided
automatically for a penod of not less than three (3) weeks from the date of birth Coverage for newborns
shall be no less than the coverage provided to the mother, including
➢ Medical and surgical inpatient care, including inpatient care which is separate from the mother's
maternity admission
➢ Medical and surgical outpatient care
In order for coverage to continue after the mitial three (3) week period, the Chdd must qualify as an
Eligible Dependent If additional Premium is required, the Child must be enrolled in this Group Plan within
60 days of birth Please refer to the Enrollment Under Special Circumstances section
NOTE When additional Premium is not required, we encourage enrollment as soon as possible to
prevent delays m claims processing
Newborn Nursery Care
Routme newborn care provided in a Hospital nursery is not sub�ect to the Deductible Charges incurred as
a result of complications dunng or after birth are covered as any other medical condition
Nutritional Guidance Counseling
Coverage is provided on an outpatient basis for the services of nutritional guidance counselmg, when
recommended by your Provider for the followmg conditions
Anorexia and Bulimia
Cancer
Colibs
Coronary artery disease
Dysphagia
Endocnne conditions
Food allergies or intolerances
Gastritis
Hypercholesterolemia
Hyperlipidemia
Hypoglycemia
Short bowel syndrome (post surgery)
Swallowing difficulties followmg a stroke
City of Bremerton Plan A Page 23
Benefits Booklet
There is no coverage under this benefit for
➢ Weight control self-help programs, such as Weight Watchers, Jenny Craig, or other such
programs
➢ Medical or surgical treatment of obesity (including morbid obesity)
➢ Surgical procedures for weight reduction
Oral Surgery
(Subscriber Only)
Coverage for oral surgery includes
➢ The reduction or manipulation of fractures of the facial bones
➢ The removal of lesions, cysts and tumors of the �awbone, mouth, lips, or tongue
➢ Reconstruction of the mouth or lips to correct anatomical impairment caused by a congenital
defect
There is no coverage under this benefit for the followmg dental services
➢ Care or repair of teeth or dental structures of any type
➢ Tooth extractions or impacted teeth
➢ Services related to malocclusion
➢ Services to correct the misalignment or malposition of teeth
➢ Any other services to the mouth, facial bones or teeth, which are not medical in nature
Organ, Bone Marrow, Stem Cell and Tissue Transplants
(Requires prior authorization)
This benefit is sub�ect to a waiting period, please refer to the Waiting Periods and Benefits Summary
sections for additional information
Covered Procedures and Cond�t�ons
Services and treatment directly related to the procurement and implantation of human organs, bone
marrow, stem cells or tissues are covered subJect to prior approval by KPS Such approval is based on
the following cntena
➢ The transplant is Medically Necessary and warranted by your health condition
➢ The procedure is to be performed by a licensed and accredited physician who has demonstrated
proficiency in such procedures
➢ The procedure is to be performed at an accredited transplant facility
➢ The procedure is not considered to be an Experimental or Investigational procedure for the
treatment of the condition
➢ You have been accepted into the facdity's transplant program and comply with all program
requirements ,
Provided the above conditions have been met, coverage under this benefit includes the following organ
transplant procedures
Cornea
Heart
Heart/lung
Kidney
Kidney/pancreas
Liver
Lung
Pancreas
Page 24 City of Bremerton Plan A
Bene�ts Booklet
Autologous bone marrow stem cell and tissue transplants, and associated high-dose chemotherapy are
covered only for the treatment of the followmg conditions or malignancies
Acute lymphocytic and non-lymphocytic leukemia
Acute myelocytic leukemia
Germ cell cancer
Hodgkm's lymphoma
Neuroblastoma
Non-Hodgkin's lymphoma
Allogeneic (related and unrelated) bone marrow, stem cell and tissue transplants and associated high-
dose chemotherapy are covered only for the treatment of the following conditions or malignancies
Acute lymphocytic leukemia
Acute myelocytic leukemia
Aplastic anemia
Chrornc myelogenous leukemia
Hodgkin's lymphoma
Homozygous beta-thalassemia
Infantile malignant osteopetrosis
�
Neuroblastoma stage I II and IV (Children over 1 year old)
Non-Hodgkin's lymphoma
Severe combined immunodeficiency (SCID, not HIV AIDS)
Wiskott-Aldnch syndrome
Transplant Rec►p�ent Benefits
Covered Benefits and Services for you or your Eligible Dependents who are transplant recipients include
➢ Medical and surgical physician and Hospital services directly related to the transplant procedure
➢ Diagnostic tests and examinations directly related to the transplant procedure
➢ Donor retneval costs directly related to the transplant procedure
Donor Related Serv�ces
Donor-related services include, but are not limited to the following selection, removal, harvesting,
storage, transportation of the surgical harvesting team, and such other Medically Necessary procurement
costs as may be approved by KPS Donor-related services are covered only if the transplant procedure is
approved by KPS and the recipient of the transplant is covered under this Group Plan and has met any
applicable transplant benefit waiting periods
There is no coverage under this benefit for the following services
➢ Costs mcurred by a donor, including an Enrollee in this Group Plan, for services associated with
donor organ or bone marrow/stem cell/tissue acquisition if the recipient is not enrolled in this
Group Plan
➢ Costs incurred by a donor for the treatment of complications resultmg from organ donation or
bone marrow/stem cell/tissue acquisition if the donor is not enrolled m this Group Plan
Costs incurred by an Enrollee for Medically Necessary Covered Benefits and Services as a result of
complications from organ donation or bone marrow/stem cell/tissue acquisition are covered under this
Group Plan only to the extent these costs are not covered under the recipient's plan
Transp/ant Benefit Lim�tat�ons and Exc/usions
In addition to any coverage limitations or exclusions described above or listed m the Limitations and
Exclusions section of this Benefits Booklet, the following specific limitations and exclusions apply to the
Transplants benefit
➢ Any transplant not specifically listed
➢ Charges for transplant-related facdity services, which were not authorized in advance by KPS
➢ Donor and procurement senrices and costs incurred outside of the U S, unless specifically
authonzed in advance by KPS
➢ Expenmental and/or investigational transplant procedures
➢ Food and lodgmg
City of Bremerton Plan A F'age
Benefits Booklet
➢ Living (non-cadaver) donor transplants of the lung, liver, or other organs (except kidney
transplants), including selective islet cell transplants of the pancreas, unless otherwise authorized
in advance by KPS, based on current standards of care at the time of the request for
authorization
➢ Mechanical, artificial, or non-human transplants
➢ Prescription drugs dispensed on an outpatient basis, including anti-reJection medications and
self-administered drugs, except as may be covered under Pharmacy Benefits
➢ Transportation costs, except as specifically allowed for the actual organ/bone marrow/stem
cell/tissue harvesting or procurement for the transplant
Oxygen and Oxygen Supplies
(Requires prior authorization)
Coverage under this benefit includes oxygen, oxygen equipment, and related supplies, when prescribed
by your Provider for therapeutic use and obtamed from an approved medical equipment supplier
Phenylketonuria (PKU) Formulas
Special dietary formulas designed for use by you and/or your Eligible Dependents who have been
diagnosed with phenylketonuria are covered under this benefit
Plastic and Reconstructive Surgery
(Requires prior authorization)
Plastic and reconstructive surgenes are covered to
➢ Correct a physical disorder resulting from a congenital disease or anomaly
➢ Correct a physical disorder resulting from disease, Accidental In�ury, or trauma, provided the
repair is pertormed within 12 months or other medically appropriate period of time after the date
of the disease, in�ury, or trauma, which caused the physical disorder
➢ Reconstruct an inJured or diseased breast following a mastectomy, including reconstruction of the
healthy breast to produce a symmetncal appearance
Coverage under this benefit does not include
➢ Cosmetic services, supplies, or surgery to repair or reshape an essentially normal body structure
for the improvement of the patient's appearance or self-esteem
➢ Complications resultmg from cosmetic surgery
Except as set forth under this benefit, no other plastic, reconstructive, or cosmetic services are avadable
under this Group Plan
Prrvate Duty Nursing
(LEOFF I Employees only)
Professional, private nursing services are covered when Medically Necessary and ordered by a
Participating Provider The nurse may not be a person who ordinarily resides in your home or who is
related to you by blood or marriage
Rehabilitation
Coverage under this benefit includes speech, occupational, physical, and massage therapies performed
on an inpatient basis (in a Hospital, Skdled Nursing Facility, or other approved facdity) or on an outpatient
basis for conditions other than neurodevelopmental disabtlities Therapy services wdl be covered as
prescnbed by your physician
Page 26 City of Bremerton P�an A
Benefits Booklet
Coverage is provided under the following conditions
➢ KPS has approved the plan of treatment (mpatient only)
➢ The services rendered must be Medically Necessary to restore or improve function
➢ The loss of function was not the result of a work-related in�ury, except as provided for under the
Occupationai In�ury benefit
Coverage for mpatient services under this benefit is limited Please refer to the Benefits Summary
section Coverage under this benefit does not duplicate coverage for therapy services provided under any
other benefit of this Group Plan Please see the Home Health Care section
Skilled Nursing Facility Care
(Requires prior authonzation)
Medically Necessary therapeutic or restorative care in a Skdled Nursing Facility may be authorized by
KPS as an alternative to Medically Necessary confinement m a Hospital
Coverage is based on a written treatment plan submitted to KPS by your treatmg Provider and approved
by KPS Coverage is limited Please refer to the Benefits Summary
Skilled Nursmg Facility coverage includes
➢ Semi-private room and board
➢ General duty nursing
➢ Medically Necessary ancillary senrices and supplies
Maintenance or custodial care is not covered under this benefit Please see the Home Health and
Hosp�ce Care section
Sleep Disorders
(Requires prior authorization for surgical treatments only)
Coverage under this benefit is limited to sleep studies, including Provider serwces, appropriate durable
medical equipment obtained from an approved home medical supplier or pharmacy, and surgical
treatments No other benefits are provided for the purpose of studying, monitoring, and/or treatmg sleep
disorders, other than as described below
S/eep Studies, Includ►ng Appropriate Durable Med�ca/ Equ�pment
Coverage for sleep studies includes
➢ Polysomnographs
➢ Multiple sleep latency tests
➢ Continuous positive airway pressure (CPAP) studies
➢ Related durable medical equipment and supplies, mcluding CPAP machines
The condition givmg rise to the sleep disorder, such as narcolepsy or sleep apnea, must be diagnosed by
your Provider Prior authonzation of sleep studies is not required, however, your Provider must order the
sleep studies program for you
Surg�ca/ Treatments
Coverage for the Medically Necessary surgical treatment of diagnosed sleep disorders is covered under
this benefit Prior authorization of surg�cal procedures for the treatment of sleep d�sorders is
required Surgical treatment includes all professional and facility fees related to the surgical treatment
includmg pre- and post-operative care and complications
City of Bremerton Plan A Page
Benefits Booklet
Spinal and Extremity Manipulation
Coverage under this benefit is provided for the diagnosis and treatment of musculoskeletal disorders,
including bone and muscle subluxations (out of alignment) of body extremities and spinal column
Coverage under this benefit is limited Please refer to the Benefits Summary section
Substance Use Disorder Treatment (Chemical Dependency)
Prior authorization is required for inpatient substance use disorders treatment, except in the case of
Emergency detoxification Either you or your Provider may request authorization for inpatient services
Please refer to the Services Which Requ�re Pr�or Authorization section for more information about
Emergency admissions
Prior authorization of outpatient serwces is not required but you may contact KPS Customer Service for
assistance in finding providers KPS Customer Sennce can be reached at 360-478-6796, or toll-free at 1-
800-552-7114 ,
Coverage for the treatment of substance use disorders includes
➢ Medically Necessary inpatient and outpatient care provided as part of an Approved Treatment
Program
➢ Detoxification and supportive services
No coverage is provided under this benefit for the following
➢ Court-ordered assessments, or other assessments, when the purpose of the assessment is to
determine the Medical Necessity of any court-ordered substance use disorder treatment
➢ Court-ordered assessments or treatments related to the deferral of prosecution, deferral of
sentencing or suspended sentencing, or treatments ordered as a condition of retaining motor
vehicle drivmg rights, when the Medical Necessity for such assessments or treatment cannot be
established
➢ Information and referral services ,
➢ Residential treatment facilities, such as therapeutic boarding schools, outdoor youth programs,
and halfway houses
➢ Alcoholics Anonymous or other simdar programs and support groups
➢ Long term or custodial care
➢ Tobacco cessation programs
➢ Any other substance use disorder service or supply not specifically listed
In the case of a court-ordered assessment or treatment program, you are required to provide KPS with a
copy of the following documents
➢ The initial assessment of the need for substance use disorder treatment, provided by a certified
chemical dependency counselor who is employed by an Approved Treatment Program
➢ The treatment plan
Termination of Pregnancy
Coverage for the voluntary termination of pregnancy is included under this benefit
Coverage under this benefit is limited to one (1) voluntary termination of pregnancy per Calendar Year
Vision Examination
(Employee only)
One routine eye examination is covered every Calendar Year Eyeglasses are not covered Contact
lenses are covered only as descnbed under Medical Equipment and Supplies, Prosthetic Appliances.
Page 28 City of Bremerton Plan A
Benefits Booklet
Women's Health Care Services
Covered women's health care services are avadable without prior referral from another Provider and
mclude maternity care, reproductive health services, gynecological care, general exammation, preventive
care, and follow-up visits, when provided by a licensed physician (M D or D O), a physician's assistant
(P A), an advanced registered nurse practitioner (A R N P) specializmg in women's health care or
midwifery, or a licensed midwife, and any Participating Facility used by such Providers
Pharmacy Bene�ts
This benefit, for purposes of creditable coverage, is expected to pay out as much as the Medicare Part D
prescription drug benefit and is therefore considered creditable Enrollees who are a Iso eligible for
Medicare Part D pharmacy benefits can remam covered under this Group Plan and not be sub�ect to
Medicare-imposed late enrollment penalties should they decide to enroll m a Medicare Part D pharmacy
plan at a later date
Coverage
Coverage under this benefit mcludes
➢ Prescription drugs
➢ Insulin and diabetic supplies
➢ Self-administered drugs
➢ Pre-authorized Off-label Use of prescription drugs
➢ Prescnption Contraceptive drugs and devices
All drugs and supplies must be Medically Necessary for the condition and must be prescribed by a
Provider with prescriptive authority
All prescriptions must be filled at a Participating network pharmacy, except in the case of accidental in�ury
or medical emergency Prescnptions for specialty drugs may only be filled through the KPS specialty
pharmacy vendor
Prescription and refills are avadable on a 31-day or 90-day supply basis Please refer to the Benefits
Summary section for applicable coinsurance
Pharmacy benefits are based on a drug formulary Drug formulary (approved drug list is defined as a list
of covered drugs, supplies and devices This list is developed and mamtained by KPS Drugs on the
formulary are classified into one of three (3) tiers
➢ Tier 1— Preferred Generic drugs
➢ Tier 2— Preferred Brand drugs
➢ Tier 3— Non-preferred Generic and Brand drugs
The KPS drug formulary (approved drug list) is updated throughout the year For the most up-to-date
information about the drugs covered under your Group Plan, please visit the KPS Web site at
www kpshealthplans com, or call KPS Customer Service toll-free at 1-800-552-7114
How to Use Your Pharmacy P/an
Be sure to present your KPS identification card to your Participating network pharmacy when you have
your prescription filled or re-filled Your Participatmg nefinrork pharmacy will collect the 20% Coinsurance
amount due for each new and refilled prescription You are only required to pay up to $150 in
Coinsurance each Calendar Year Thereafter, coverage for any new or re-filled prescriptions for the
remainder of that Calendar Year is provided at 100% of the KPS allowed charge
For a list of Participating Pharmacies please visit the KPS Web site at www kpshealthplans com, or call
KPS Customer Service at 1-800-552-7114
When you use a Participating nefinrork pharmacy, you will not be responsible for submitting a claim form
In the event of an Accidental In�ury or Medical Emergency, you may utilize the services of a non-
participatmg network pharmacy For reimbursement, you must submit an itemized claim and a paid
receipt to
City of Bremerton Plan A Page 29
Benefits Booklet
Medlmpact
Attn DMR Department
10680 Treena Street, 5 floor
San Diego, CA 92131
Definitions
Brand Drug is a drug manufactured and sold exclusively under its brand-name by the manufacturing
pharmaceutical company that holds the original patent of drug development
Generic Drug is a drug approved by the Food and Drug Administration (FDA) as a therapeutic equivalent
Generic to a Brand drug Generic drugs may be manufactured and sold by more than one pharmaceutical
company
Preferred and Non-preferred drug status is determined by KPS based on scientific evidence of efficacy,
safety and cost-effectiveness Preferred Generic drugs are in Tier 1, Preferred Brand drugs are in Tier 2
of the Formulary
Off-label Use means the drug is prescribed for an indication other than those specified m its FDA-
approved labeling Coverage is allowed for the following when pre-authorized by KPS
➢ The stated use of the drug is recognized in one of the standard reference compendia
➢ The stated use of the drug is recognized as effective m the ma�ority of relevant peer-reviewed
medical literature
➢ The stated use of the drug is approved by the Federal Secretary of Health
➢ The stated use must meet Medical Necessity guidelines
Exclus�ons
No coverage is provided under this benefit for the following
➢ Over-the-counter drugs for which a prescription is not required, unless specifically provided for in
this Group Plan
➢ Over-the-counter contraceptive devices and/or supplies
➢ Vitamins, including pre-natal vitamins, unless specifically provided for in this Group Plan
➢ Drugs for the treatment of obesity
➢ Fluoride preparations
➢ Drugs used for cosmetic purposes
➢ Drugs taken home following an inpatient Hospital stay
➢ Non-self-administered drugs
➢ Self-administered drugs supplied by a Provider
➢ Drugs for the treatment of impotence and infertility
➢ Prescription drugs intended to ease nicotine withdrawal
➢ Drugs specifically designated as not covered
➢ Drugs which are not approved by the FDA
➢ Drugs which are not Medically Necessary for the treatment of a specific condition
➢ Investigational drugs and/or drugs used for investigation or experimental purposes
➢ Drugs for travel purposes
➢ Compounded Hormone Replacement Therapy drugs which have not been approved by the FDA
and which are not manufactured by a recognized drug company
➢ Replacement of lost or stolen medications, unless specifically included as a covered benefit
under this Group Plan
➢ Drugs that require prior authorization if your provider has not obtained prior authorization
Page 30 City of Bremerton Plan A
Benefits Booklet
LIMITATIONS AND EXCLUSIONS
Coverage under this Group Plan is limited to the diagnosis and therapeutic care or treatment of disease,
sickness, or m�ury, or the prevention of disease, sickness, or in�ury, as described in this Benefits Booklet
The following services are specifically excluded from coverage
1 Air conditioners, de-humidifiers, air punfiers
2 Any care, treatment, or service received prior to your effective date of coverage under this
Group Plan
3 Any care, treatment, or service received after coverage under this Group Plan has ended
4 Arch supports, shoe orthotics, corrective shoes, and elastic stockmgs, except as specifically
provided for under the Diabetic Education, Equipment, and Supplies benefit
5 Artificial insemination, in vitro fertilization, and gamete mtra-fallopian transplant (GIFT),
including any direct or indirect complications or after-effects other than pregnancy
6 Biofeedback, except in the case of unnary incontinence
7 Charges for non-Covered Benefits and Services, and resulting complications, mcluding services
not specifically described in this Benefits Booklet
8 Circumcision
9 Conditions resulting from acts of war, whether declared or undeclared
10 Cosmetic surgery, mcluding treatment for complications of cosmetic surgery, except as
provided for under the Plastic and Reconstructive Surgery benefit
11 Developmental delay, speech delay, or other learrnng disabilities, except as provided for under
the Neurodevelopmental Therapy benefit
12 Enuresis training equipment
13 Exercise equipment and whiripool baths
14 Experimental and Investigational procedures, as defined in this Benefits Booklet
15 Eye examinations (except employee), refractions, eyeglasses and contact lenses
16 Hearing aids, heanng devices, such as cochlear implants, and hearing examinations
17 Immunizations required for employment, travel, immigration, licensing, or msurance related
reports
18 Maintenance, custodial, or domicdiary care except as provided for under the Home Health and
Hospice Care benefit
19 Medical services paid by the Veterans Administration or by state, local, or federal governmental
programs, excluding Medicaid as defined by RCW 74 09 500
20 Non-surgical treatment for deformities of the toes and feet, including routine foot care, except
when such care is directly related to the treatment of diabetes
21 Obesity treatment, mcludmg, but not limited to, Provider office visits, surgical weight loss
procedures, pre-surgical diagnostics and procedures, weight reduction programs (e g Weight
Watchers), and dietary control programs
22 Orthoptics (eye exercise programs), pleoptics, visual analysis therapy and/or training, and
radial keratotomy
23 Over-the-counter products (except insulin supplies for the treatment of diabetes), including, but
not limited to, contraceptive devices or supplies, unless specifically listed as a benefit under this
Group Plan
24 Personal comfort items (e g, radios, telephones, televisions)
25 Reversal of sterilization
City of Bremerton Plan A Page 31
Benefits Booklet
26 Self-help care of any form, including, but not limited to, non-medical self-care, self-help training,
marital or sexual counseling
27 Services, supplies, and drugs, which are not Medically Necessary for the treatment of an
illness, in�ury, or physical disabdity, even though the services are not specifically listed as
exclusions
28 Services for any occupational illness or in�ury arising out of, or in the course of, an activity
pertaining to any trade, business, employment (including self-employment), or occupation for
wage or profit, whether or not a proper and timely claim was filed for such benefits under
another plan or policy, except LEOFF I Employees
29 Services and supplies for, or associated with, care or work on the teeth, x-rays of the teeth and
other dental procedures
30 Services for the treatment of complications arising from non-Covered Benefits and Services or
procedures, except for the complications of pregnancy
31 Services for which there is no charge to you
32 Services for which you are not legally required to pay
33 Services provided by a person who is related to you by blood, or marriage, or who resides in
your home
34 Sex change or other sexual transformation procedures
35 Speech, occupational, educational, mdieu, massage, and physical therapies, except as
specifically included under the Neurodevelopmental Therapy benefit, the Rehabilitation
benefit, or the Home Health and Hospice Care benefit
36 Sterilization
37 Treatment for abnormalities of the �aw, including malocclusion, �aw augmentation or reduction
surgery (orthognathic surgery), except as provided for under the Oral Surgery benefit or the
Plast�c and Reconstructive Surgery benefit, diagnosis and treatment of temporomandibular
�oint (TMJ) disorders
38 Treatment for sexual dysfunction, mcluding, but not limited to, stenlity, infertdity, impotence, or
frigidity
39 Unnecessary duplicate diagnostic services for a smgle ongoing illness Consultations for
second surgical opinions are covered under the Professional Services benefit
40 Services for elective care received m a foreign country
41 Services and supplies not specifically descnbed in this Benefits Booklet
Page 32 City of Bremerton Plan A
Benefits Booklet
CONTINUATION OF COVERAGE
If you and your Eligible Dependents are no longer eligible for coverage under this Group Plan, you may
be entitled to continue your Group Plan coverage or enroll in a KPS Conversion Plan Contact your Group
Plan Administrator for mformation regarding eligibility and enrollment requirements
The following paragraphs describe several options for contmuing your coverage Your employer is
obligated to provide you with information regarding any options that apply to you
Coverage During a Labor Dispute
In the event of a strike, lockout, or other labor dispute that causes a disruption in your health care
compensation benefits or wages, your Group may stop paying any Premium amounts required by this
Group Plan for you and your Eligible Dependents If this happens, you may choose to continue coverage
under this Group Plan for up to six (6) months by self-paying your Premiums Dunng this period, your
benefits and Premium may not be altered from that of your existing Group Plan
You must begin self-paying your Premium dunng the first month your Group stops making payments on
your behalf To be contmuously covered, you must pay your Premium each month If you fail to pay your
Premium for any month, your coverage will end on the last day of the month for which Premium was
received, and may not be reinstated Premium payments should be made directly to the Group
Premiums are due no later than the Premium Due Date
This provision does not apply if you or your Eligible Dependents are entitled to continue coverage under
COBRA or any other continuation of coverage provision
Once the six (6) month self-pay penod has ended, you have the right to apply for coverage under an
individual plan
Continuation of Group Coverage
If you lose your coverage under this Group Plan, you may be able to contmue coverage for you and your
Eligible Dependents for up to three (3) additional months unless
➢ Your coverage was termmated as a result of a strike, lockout, or other labor dispute
➢ Your employment was terminated for gross misconduct
Please check with your Group Plan Admmistrator to determme whether or not your group has chosen to
make this option available to all employees If your Group is required by faw to offer COBRA coverage,
this option for extended coverage may not be avadable
Extended coverage under this option is not automatic If this option for extended coverage is avadable
from your Group, you must apply withm 31 days of the date your coverage ends under the Group Plan If
you are required to self-pay your Premium, your first Premium payment must be submitted with your
application for coverage To be continuously covered, you must pay your Premium each month
Premium self-payments should be made directly to the Group Premiums are due no later than the
Premium Due Date If you fail to pay your Premium for any month, your coverage wdl end on the last day
of the month for which Premium was received and may not be reinstated
If you choose this contmuation option, your benefit coverage and Premium may not be altered from that of
the existing Group Plan
COBRA (Consolidated Omnibus Budget Reconciliation Act -1985)
If you lose eligibility for coverage under this Group Plan (except in the case of a labor dispute), you may
be eligible to continue your coverage for a period of time specified by federal law and regulations then in
effect This contmuation of coverage is referred to as COBRA and applies generally to groups of 20 or
more employees KPS offers coverage only when
➢ Groups are required by law to provide COBRA coverage for employees, and
➢ KPS is notified of a beneficiary's election of COBRA coverage withm 31 days of that election
being made
Continuation of coverage under COBRA is not automatic You must apply for contmuation of your Group
coverage withm 60 days of the date you Group provides you a COBRA election notice KPS offers
COBRA coverage to Groups only as required by law
City of Bremerton Plan A Page 33
Benefits Booklet
Your Group Plan Administrator is required to notify KPS of your election of COBRA continuation coverage
within 45 days of that election Failure on your part to make a timely election, or fadure on the part of your
Group Plan Administrator to provide KPS with timely notification of the election, wdl be interpreted by KPS
as a waiver of your right to continue coverage under this provision Fadure by your Group Plan
Administrator to provide timely notification to KPS may not, in all cases, eliminate the Group's obligation
to provide contmuation coverage It wdl, however, eliminate any obligation on the part of KPS to provide
you with continuation coverage under this Group Plan
If you are about to lose, or have lost, your coverage under this Group Plan, contact your Group Plan
Administrator for more information regarding COBRA and your right to continue receiving medical benefits
under this Group Plan
Conversion Coverage
If you are under age 65, you may be entitled to transfer to a KPS Conversion Plan if
➢ You are a permanent resident of Washington State
➢ You are not otherwise eligible for coverage under Medicare
➢ You are currently eligible for continuation of your Group Plan coverage but decline that option
➢ Your continuation coverage under this Group Plan or COBRA plan terminates (for any reason
except fraud or non-payment of Premium, when it is your responsibility to pay the Premium)
➢ Your employer's Group Plan terminates and your Employer does not provide other health care
coverage to its employees
An application for coverage under a KPS Conversion Plan for you and your Eligible Dependents must be
received by KPS within 31 days of either the date a) your coverage under this Group Plan or other KPS
continuation or COBRA plan ends, or b) you received notification that this Group Plan wdl terminate,
whichever occurs later Any applicable Premium amounts for your first month of coverage must be
submitted with your application You must pay all subsequent Premiums by the Premwm Due Date Your
coverage under a KPS Conversion Plan is guaranteed for as long as you contmue to meet the eligibility
requirements and pay your Premium If you fail to pay your Premium for any month, your coverage wdl
end on the last day of the month for which Premium was received
Your Eligible Dependents may apply for coverage separately under this option in the event they lose
coverage under this Group Plan due to one of the following reasons
➢ You lose eligibility under this Group Plan based on termination of employment due to misconduct
➢ The death of you, as the Subscriber
➢ You and your Spouse divorce
➢ Your eligible Dependent Children reach the Limiting Age
Credit for periods of continuous coverage under this Group Plan and/or a KPS continuation or COBRA
plan will be applied to your coverage under a KPS Conversion Plan
When you enroll in a conversion plan, you _lose certain protections guaranteed under the Health
Insurance Portability and Accountability Act (HIPAA) of 1996 If you decide to purchase an individual
product after receiving coverage in a KPS Conversion Plan, the new carner may ask about your health
conditions in the application process If you decide to decline conversion coverage and apply for an
individual plan, you will generally have the right to purchase the coverage without any questions about
your health conditions provided you had 18 months of Creditable Coverage and your former plan was a
group health plan if you have any questions, please contact KPS Customer Service at 360-478-6796 or
tol I-free at 1-800-552-7114
If you are age 65 or older and your coverage under this Group Plan terminates, you may be eligible for
coverage under a Medicare supplement plan To determine your eligibility for a Medicare supplement
plan, please contact KPS Customer Service
Page 34 City of Bremerton Plan A
Benefits Booklet
COORDINATION OF BENEFITS (COB)
General Provision
The Coordmation of Benefits (COB) provision applies when a person has health care coverage under
more than one Plan All of the benefits provided under this Group Plan are sub�ect to this COB provision
Definitions
"Plan" means any of the following that provide benefits or services for medical or dental care or treatment
➢ This Group Plan
➢ Group, mdividual, or blanket disability msurance contracts
➢ Group or individual contracts issued by health care service contractors or health mamtenance
organizations (HMOs)
➢ Closed Panel Plans or other forms of group or mdividual coverage
➢ Medical care components of long-term care contracts, such as skdled nursmg care
➢ Medicare or any other federal governmental plan, as permitted by law
Plan does not include
➢ Hospital mdemnity or fixed indemnity/payment coverage
➢ Accident only coverage
➢ Specified disease or specified accident coverage
➢ Limited benefit health coverage, as defined by state law
➢ School accident type coverage
➢ Benefits for non-medical components of long-term care policies
➢ Automobile msurance policies required by statute to provide medical benefits
➢ Medicare supplement policies, Medicaid coverage, or coverage under other federal governmental
plans, unless permitted by law
Each contract for coverage listed above is a separate Plan If the Plan has two parts and COB rules apply
only to one of the two, each of the parts is treated as a separate Plan
"Primary Plan" means the Plan that determmes payment for its benefits first before those of any other
Plan without considermg any other Plan's benefits
"Secondary Plan" means the Plan that determmes its benefits after those of another Plan and must make
payment in an amount so that, when combmed with the amount paid by the Primary Plan, the total
benefits paid or provided by all Plans for the claim equal 100% of the Total Allowable Expense for that
claim
When a Plan is secondary, it must pay the amount which, when combmed with what the Primary Plan
paid, totals 100% of the Allowable Expense In addition, if a Plan is secondary, it must calculate its
savmgs (its amount paid subtracted from the amount it would have paid had it been the Primary Plan) and
record these savings as a benefit reserve for the covered person This reserve must be used to pay any
expenses during that Calendar Year, whether or not they are an Allowable Expense under this Group
Plan If a Plan is secondary, it wdl not be required to pay an amount in excess of its maximum benefit plus
any accrued savmgs
"Allowable Expense" means a health care expense, includmg deductibles, copayments and comsurance,
which is covered at least in part by any of the Plans involved When a Plan provides benefits in the form
of services, the reasonable cash value of each service will be considered an Allowable Expense and a
benefit paid An expense that is not covered by any of the Plans mvolved is not an Allowable Expense
City of Bremerton Plan A Page
Benefits Booklet
The followmg are examples of expenses that are not Allowable Expenses
➢ The difference between the cost of a semi-private Hospital room and a private Hospital room is
not an Allowable Expense, unless one of the Plans provides coverage for private Hospital room
expenses
➢ If a person is covered by two or more Plans that compute their benefit payments on the basis of
usual and customary fees, or relative value schedule reimbursement method, or other simdar
reimbursement method, any amount in excess of the highest reimbursement amount for a
specific benefit is not an Allowable Expense
➢ If a person is covered by two or more Plans that provide benefits or services on the basis of
negotiated fees, an amount in excess of the highest of the negotiated fees is not an Allowable
Expense
"Total Allowable Exqenses" means the combined amount paid by both the Primary and Secondary Plans
After the Primary Plan's payment is determined, the Secondary Plan pays what is left, up to its maximum
benefit plus any accrued savings This total amount will not exceed 100% of the Allowable Expense
"Closed Panel Plan" means a Plan that provides health care benefits to covered persons in the form of
services through a panel of Providers who are pnmardy employed by the Plan and that excludes
coverage for services provided by other Providers, except in cases of an Emergency or referral by a
panel member
"Custodial Parent" means the parent awarded custody by a court decree or, in the absence of a court
decree, the parent with whom the Children reside more than one half of the Calendar Year excluding any
temporary visitation
Order of Benefit Determination Rules
The order of benefit determination rules govern the order in which each Plan wdl pay a claim for benefits
The Plan that pays first is called the Primary Plan The Primary Plan must pay benefits according to its
policy terms without regard to the possibility that another Plan may cover some expenses The Plan that
pays after the Primary Plan is the Secondary Plan The Secondary Plan may reduce the benefits it pays
so that payments from all Plans do not exceed 100% of the total Allowable Expense
When a person has health care coverage under more than one Plan, the order of benefit determination
rules determine which is the Pnmary Plan and which is the Secondary Plan
When you are covered by finro or more Plans, the rules for determining the order of benefit payments are
as follows
1 The Pnmary Plan pays or provides its benefits according to its terms of coverage and without
regard to the benefits under any other Plan
2 A Plan that does not contain a COB provision that is consistent with the COB provisions in this
section is always pnmary unless °
➢ The provisions of both Plans state that the complying Plan is primary, or
➢ The coverage that is obtained by virtue of inembership in a group designed to supplement a
part of a basic package of benefits provides that the supplementary coverage is in excess to
any other parts of the Plan provided by the contract holder Examples include ma�or medical
coverages that are superimposed over hospital and surgical benefits, and insurance type
coverages that are written in connection with a Closed Panel Plan to provide out-of-network
benefits
3 A Plan may consider the benefits paid or provided by another Plan in calculating payment of its
benefits only when it is Secondary to that other Plan
4 Each Plan determines its order of benefits using the first of the following rules that apply
➢ Dependent or Non-dependent - The Plan that covers a person other than as a dependent is
the Primary Plan and the Plan that covers a person as a dependent is the Secondary Plan
However, if the person is a Medicare beneficiary and, as a result of federal law, Medicare is
secondary to the Plan covering the person as a dependent, and primary to the Plan covering
the person as other than a dependent (e g, a retired employee), then the order of benefits
between the two Plans is reversed so that the Plan covenng the person other than as a
dependent is the Secondary Plan and the other Plan is the Primary Plan
Page 36 Cdy of Bremerton Plan A
Benefits Booklet
➢ Dependent Children Covered Under More Than One Plan - Unless there is a court decree
stating otherwise, when a dependent Child is covered by more than one Plan the order of
benefits is determmed as follows
(a) For dependent Children whose parents are married or are living together, whether or not
they have ever been marned
(Q The Plan of the parent whose birthday falls earlier m the Calendar Year is the
Primary Plan
(n) If both parents have the same birthday, the Plan that has covered the parent the
longest is the Primary Plan
(b) For dependent Children whose parents are divorced or separated or not livmg together,
whether or not they have ever been married
(i) If the court decree states that one of the parents is responsible for the dependent
Children's health care expenses or health care coverage and the Plan of that parent
has actual knowledge of those terms, that Plan is primary This rule applies to claim
determination periods commencing after the Plan is given notice of the court decree
(ii) If a court decree states one parent is to assume primary financial responsibility for
the dependent Children but does not mention responsibility for health care expenses,
the Plan of the parent assuming financial responsibdity is pnmary
(iii) If a court decree states that both parents are responsible for the dependent
Children's health care expenses or health care coverage, the provisions of
subparagraph (a) above determine the order of benefits
(iv) If a court decree states that the parents have �oint custody without specifying that
one parent has responsibility for the health care expenses or health care coverage of
the dependent Children, the provisions of subparagraph (a) above determme the
order of benefits
(v) If there is no court decree allocating responsibility for the dependent Children's health
care expenses or health care coverage, the order of benefits for the Children are as
follows
• The Plan covermg the Custodial Parent, first,
• The Plan covenng the spouse of the Custodial Parent, second,
• The Plan covering the non-Custodial Parent, third, and then
• The Plan covenng the spouse of the non-Custodial Parent, last
(c) For dependent Children covered under more than one Plan of individuals who are not the
parents of the Chddren, the provisions of subparagraph (a) or (b) above determme the
order of benefits as if those mdwiduals were the parents of the Chddren
➢ Active employee or Retired or Laid-off employee - The Plan that covers a person as an active
employee, that is, an employee who is neither laid-off nor retired, is the Pnmary Plan The
Plan covering that same person as a retired or laid-off employee is the Secondary Plan The
same applies if a person is a dependent of an active employee and that same person is a
dependent of a retired or laid-off employee If the other Plan does not have this rule, and as a
result, the Plans do not agree on the order of benefits, this rule is ignored This rule does not
apply if the Dependent or Non-dependent rule can determine the order of benefits
➢ COBRA or State Contmuation Coveraqe - If a person whose coverage is provided under
COBRA or under a right of continuation provided by state or other federal law is covered
under another Plan, the Plan covenng the person as an employee, subscnber, or retiree, or
covermg the person as a dependent of an employee, subscriber, or retiree is the Primary
Plan, and the COBRA or state or other federal continuation coverage is the Secondary Plan
If the other Plan does not have this rule, and as a result, the Plans do not agree on the order
of benefits, this rule is ignored This rule does not apply if the Dependent or Non-dependent
rule can determine the order of benefits
➢ Lonqer or Shorter Length of Coverage - The Plan that covered the person as an employee,
subscriber, or retiree longer is the Primary Plan and the Plan that covered the person the
shorter period of time is the Secondary Plan
If the precedmg rules do not determme the order of benefits, the Allowable Expenses must be shared
equally between the Plans meetmg the definition of Plan In addition, this Group Plan will not pay more
than it would have paid had it been the Primary Plan
City of Bremerton Plan A Page 37
Benefits Booklet
Effect on Benefits
When KPS is the Secondary Plan, we may reduce our benefits so that the total benefits paid or provided
by all Plans during a claim determination period are not more than the Total Allowable Expenses In
determining the amount to be paid for any claim, the Secondary Plan must make payment in an amount
so that, when combmed with the amount paid by the Primary Plan, the total benefits paid or provided by
all Plans for the claim equal 100% of the Total Allowable Expense for that claim In addition, the
Secondary Plan must credit to its Plan Deductible any amounts it would have credited to its Deductible in
the absence of other health care coverage
Right to Receive and Release Information
Certain facts about health care coverage and services are needed to apply these COB rules and to
determine benefits payable by KPS and other Plans KPS may get the facts it needs from, or give them
to, other organizations or persons for the purpose of applying these rules and determining benefits
payable by KPS and other Plans covering the person claiming benefits KPS does not need to tell, or get
the consent of, any person to do this Each person claiming benefits under this Group Plan must give
KPS any facts it needs to apply those rules and determine benefits payable
Facility of Payment
Whenever another Plan makes payments that should have been provided under this Group Plan and in
accordance with this COB provision, KPS may, at its sole discretion, choose to reimburse the Plan
making such other payments in the amount necessary to satisfy the intent of this COB provision Any
amount paid under this subsection shall be considered as benefits paid under this Group Plan, and KPS
shall be fully discharged from liability to the extent of such payments
Right of Recovery
KPS has the right to recover excess payment whenever it has paid Allowable Expenses in excess of the
maximum amount of payment necessary to satisfy the intent of this provision KPS may recover excess
payment from any person to whom, or for whom, payment was made or any other issuers or Plans
Notice to Enrollees
If you are covered by more than one health benefit plan, and you do not know which is your Primary Plan,
you or your Provider should contact any one of the Plans to verify which Plan is primary The Plan you
contact is responsible for working with the other Plan to determine which is primary and wdl let you know
within thirty calendar days
NOTE All Plans have timely claim filing requirements If you or your Provider fail to submit your claim to a
Secondary Plan within that Plan's claim filing time limit, the Plan can deny the claim If you experience
delays in the processing of your claim by the Primary Plan, you or your Provider will need to submit your
claim to the Secondary Plan within its claim filing time limit to prevent a denial of the claim
To avoid delays in claims processing, if you are covered by more than one Plan, you should promptly
report to your Providers and Plans any changes in your coverage
Additional Information
If you would like additional information regarding COB provisions, you may contact the Office of the
Insurance Commissioner toll-free at 1-800-562-6900
Page 38 City of Bremerton Plan A
Benefits Booklet
KPS'S RIGHT OF REIMBURSEMENT AND SUBROGATION
The benefits of this Plan wdl be avadable to you for m�ury or dlness caused by another party, sub�ect to
the exclusions and limitations of this Plan If KPS provides Plan benefits for the treatment of the m�ury or
dlness, KPS will be subrogated to any nghts that you may have to recover compensation or damages
related to the m�ury or dlness You and your representative(s) must cooperate fully with KPS in protecting,
preservmg, and recovenng the amounts KPS has paid, or will pay, on your behalf under this Group Plan
If you obtain a settlement or award that mcludes the recovery of inedical expenses paid by KPS as Plan
benefits for your m�ury or illness, you agree to reimburse KPS for the full amount of benefits paid after you
have been fully compensated for your loss, sub�ect to the following additional agreements
a You and/or your attorney or representative agree to provide KPS, in writing, the details of the
m�ury or diness, the names and addresses of the party or parties believed to be responsible,
and any insurer who may offer coverage, and any other information reasonably necessary to
protect KPS's subrogation rights,
b You agree to mform the responsible third party(ies) and any msurer(s) and attorneys of the
amount of the lien asserted by KPS for payments made on your behalf
c You agree to submit the bills relating to your in�uries or dlness to any insurer who may offer
coverage for them, including, but not limited to, medical payments coverage, personal in�ury
protection (PIP), or other plans or contracts providmg for a benefit or recovery,
d You agree to make a claim against, or otherwise pursue recovery from, all responsible parties
and their insurers for all payments advanced to you, or your medical care Providers, by KPS, or
to assign to KPS all of your nghts to a recovery authorize KPS to bring suit m your name and
to fully cooperate in the presentation of the claim(s),
e You agree to mclude in any claim or lawsuit on your behalf, against any other party or insurer, a
claim for repayment of the Plan benefits paid, or to be paid, by KPS on your behalf
f You agree to give KPS reasonable notice in advance of any settlement, mediation, arbitration,
or trial relating to the in�ury or iliness
g You agree not to enter into any agreement with any responsible party(ies) or insurer(s), or do
anything else that would in any way release KPS' lien or pre�udice our subrogation or
reimbursement rights, without first obtaining express prior written consent from KPS
h You agree, if requested, to hold in trust and to execute a trust agreement in the full amount of
the Plan benefits provided to you from any recovery, until such time as a final determination or
settlement has been reached regarding the amount that fully compensates you for your loss to
protect the rights of KPS as described in this section
When you have cooperated as set out above, and you are represented by an attorney, KPS agrees to
reduce the amount of its subrogated interest in Plan benefits m consideration of your attorney's fees and
costs, based on the services provided and recovery obtamed In no case will KPS pay a larger share of
fees and costs, as a percentage of its recovery, than you pay as a percentage of your recovery
Collection and Reimbursement by Enrollee
If you obtain a settlement or award that mcludes payment for the medical expenses covered by KPS as
Plan benefits, you agree to reimburse KPS for these benefits, unless the amount you recover fads to fully
compensate you KPS may recover its benefit payments from you only after you have been fully
compensated Whether or not you have been fully compensated wdl be determmed ob�ectively, based on
the facts of your recovery
Underinsured or Uninsured Motorist Coverage
In addition to the agreements set out above, when you recover benefits under any automobile uninsured
or underinsured motonst (UIM) coverage, KPS shall be entitled to reimbursement from your recovery for
any amount that exceeds full compensation for your loss By providing Plan benefits, KPS is not acting as
a volunteer, and is not waiving any rights to reimbursement or subrogation When you have cooperated
as set out above, and you are represented by an attorney, KPS agrees to reduce the amount of its
reimbursement or subrogation interest in consideration of your attorney's fees and costs, based on the
services provided and recovery obtained In no case wdl KPS pay a larger share of fees and costs, as a
percentage of its recovery, than you pay as a percentage of your recovery
C�ty of Bremerton Plan A Page 39
Benefits Booklet
Cooperation
You and your representative(s) must deal in good faith with KPS and follow all of the conditions set forth
in this section In turn, KPS agrees to cooperate with you and your representative(s) in your effort to
recover reimbursement and wdl advance payments on your behalf for in�unes or medical conditions
caused, or asserted by you to be caused, by any third party, sub�ect to the limitations and exclusions of
this Plan Fadure to cooperate may result in a delay or denial of otherwise eligible claims untd the
requested action or information is provided to KPS
Recovery of Claims Payments
Inel�g�b/e Persons
If KPS knowingly or unknowingly makes any payment on behalf of an individual who, for any reason, was
not eligible to receive the services and benefits provided herein, KPS will be entitled to full reimbursement
from such meligible individual or from a Subscriber who applied for the ineligible benefits on behalf of
such individual
If KPS knowingly or unknowingly receives Premium payment on behalf of an mdividual who, for any
reason, was not eligible to receive the services and benefits provided herein, KPS reserves the nght to
refund any Premium payment(s) in excess of claims paid for the time the individual was ineligible and
shall have the right to recover the cost of any benefit furnished whde such individual was improperly
enrolled in this Group Plan °
NOTE This section does not apply to services and benefits for which you or your Provider received prior
authorization from KPS Health Plans
Incorrect C/aim Payment
KPS is entitled to full reimbursement from the payee for any incorrect claim payment The term "incorrect
claim paymenY' includes, but is not limited to, the followmg
➢ Payment to the wrong Provider
➢ Payment for a service that is not covered
➢ Duplicate payment for the same service
➢ Incorrectly billed procedure or diagnosis
Page 40 City of Bremerton Plan A
Benefits Booklet
COMPLAINTS AND APPEALS PROCESS
KPS wdl comply with any new requirements as necessary under federal laws and regulations The most
current mformation about your Appeals process is available on our Web site at www kpshealthplans com
or by contacting Customer Service at 360-478-6796 or toll-free at 1-800-552-7114
If You Have a Complaint
You, or your designated representative, have a right to contact KPS whenever you have a complamt or
concern regarding
➢ The service you receive from KPS
➢ Your access to care or quality of care
➢ Any KPS Participating Provider
➢ Any other issue related to this KPS Plan or KPS
�
KPS Customer Service is available to help you Monday through Friday, from 8 00 a m until 5 00 p m
Pacific Time, except on nationally recognized holidays
To file a complaint, follow the steps outlined below
You must: Send a written statement of your complaint to
KPS Health Plans
Attn Customer Service
PO Box 34803
Seattle, WA 98124-1803
Fax 360-415-6514
OR
Call the Customer Service Department at 360-478-6796 or toll-free at 1-800-552-7114
For the deaf and hearing impaired, call TTY toll-free at 1-800-833-6388
KPS resolution. KPS wdl respond to a complaint within 30 days of receiving it If you call KPS
Customer Service with a complaint, they will respond to your complaint over the phone Complaints
received in writing wdl be acknowledged, and you wdl receive a response, in writmg, from KPS
Customer Service
Complaints about Participating Providers are mvestigated thoroughly and are reviewed penodically
Standard Appeals Process
Whenever KPS makes a decision regarding the denial, reduction or termmation of benefits under your
health care coverage, you, your designated representative, or your Provider has a right to appeal that
decision The KPS Standard Appeals Process is progressive and follows specific steps described m this
section The request for an appeal must be received by KPS withm 180 days of the date you receive an
Explanation of Benefits (EOB), letter, or other type of communication from KPS that contains an
unfavorable decision
Such decisions could affect
➢ Your eligibility for benefits
➢ Your plan benefits
➢ Termmation or rescission of coverage under this Group Plan (except termmation for non-payment
of Premium)
➢ Non-payment of a claim, either completely or partially
➢ A denial or modification of a request for pre-authorization or extended authonzation of any health
care service or supply
➢ A dernal of a request for coverage of an Experimental or Investigational service or supply
City of Bremerton Plan A Page 41
Benefits Booklet
To request an appeal, you, your designated representative, or your Provider may either call or write KPS
at the phone number or address listed below You may include any documentation you feel supports your
position
You must• Send a written statement of your appeal to
KPS Health Plans
Attn Appeals Department
PO Box 34593
Seattle, WA 98124-1593
Fax 1-206-901-7340
OR
Call the Appeals Department toll-free at 1-877-828-4514
For the deaf and hearing impaired, call TTY toll-free at 1-800-833-6388
First Level Appeal
The Appeals Department will notify you, in writing, within five (5) business days that we have received
your request and wdl process it under a First Level Appeal The First Level Appeal is an informal review of
all internal and submitted information and is conducted by the appropriate staff KPS will send you the
decision from the First Level Appeal within 14 calendar days of recewing your request for appeal KPS
may extend the review to 30 calendar days with notification to you, but may not extend beyond 30
calendar days without your approval KPS will respond to denials of Experimental and/or Investigational
Procedures or Supplies within 20 working days You have the right to send your appeal directly to an
Independent Review Organization (IRO) described below if KPS provides you with an unfavorable
decision of your First Level Appeal or if KPS does not adhere to this First Level Appeals Process
"Adverse Determination" means a decision by KPS to deny, modify, reduce, or terminate payment,
coverage, authorization, or provision of health care services or benefits, including the admission to, or
contmued stay in, a facdity
Independent Review Organization (IRO)
You have the right to request that KPS send an unfavorable First Level Appeal decision to an
Independent Review Organization (IRO) consisting of non-affiliated medical experts and/or medical
coverage agreement specialists who are qualified to review your case This nght is only avadable after
exhausting the First Level Appeal process or if KPS does not adhere to the Standard Appeals Process
You may request review by an IRO within 180 days from the date you receive an unfavorable decision of
the First Level Appeal or the optional Second Level Appeal as described below KPS wdl provide the IRO
all of your case information withm three (3) business days from the date of your request You have five (5)
business days, from the date you receive notice that your appeal was sent to an IRO, to submit in writing,
directly to the IRO, any additional information to be considered in the review KPS wdl pay the IRO fee
The IRO wdl notify you and KPS of their decision The IRO decision is final If the IRO overturns our First
Level Appeal or optional Second Level Appeal decision, KPS wdl promptly comply and notify you
You may request an expedited external review if the decision regarding a KPS denial of benefits concerns
an admission, avadability of care, continued stay, or health care service for which you received
emergency services but have not been discharged from a facdity, or involves a medical condition for
which the standard external review time frame of forty-five days would seriously �eopardize your life or
health or�eopardize your ability to regain maximum function The IRO must make its decision to uphold or
reverse the decision and notify you and KPS of the determination as promptly as possible but within not
more than seventy-two hours after the receipt of the request for expedited external review If the notice is
not in writing, the IRO must provide written confirmation of the decision within forty-eight hours after the
date of the notice of the decision
Page 42 City of Bremerton Plan A
Benefits Booklet
For claims mvolvmg expenmental or investigational treatments, the IRO must ensure that adequate
clmical and scientific experience and protocols are taken into account as part of the external review
process
Second Level Appeal (OPTIONAL)
if you do not agree with KPS's First Level Appeal decision, you may request an optional Second Level
Appeal by the KPS Appeals Committee prior to requestmg review by an IRO as described above Your
Second Level Appeal request must be received by KPS withm 180 days from receivmg an unfavorable
decision of the First Level Appeal Your case wdl be reviewed by members of the committee, including
medical staff who did not make the First Level Appeal decision, within thirty (30) busmess days of your
request KPS will not�fy you, m writmg, of the Second Level Appeal dec�sion within five (5) busmess days
after the KPS Appeals Committee meeting
If you elect this optional Second Level Appeal, you stdl have the right to appeal further to an IRO if the
Second Level Appeal decision is not in your favor
The optional Second Level Appeal is not available if the appeal request is for an Experimental or
Investigational procedure or service
Expedited Appeals Process
if your health care Provider, or the KPS Medical Director, reasonably determmes that followmg the
Standard Appeals Process would �eopardize your life, your health, your ability to regain maximum
function, or sub�ect you to severe pain that cannot be managed adequately without the requested care or
treatment, KPS wdl invoke an Expedited Appeals Process This means KPS wdl make a decision within
72 hours after your request for appeal is received if KPS expedites your appeal, you will receive notice of
this action
Appeals Related to Continuation of Care
KPS will continue to provide coverage for services and supplies for ongoing care that KPS denied,
reduced, modified, or terminated until the appeals process is complete However, if the final outcome
supports KPS's decision, you may then be responsible for any costs that were mcurred for the
continuation of that care
For more information regarding the appeals process and your rights during an appeal, please contact the
Appeals Department toll-free at 1-866-458-5479 For the deaf and hearing impaired, call TTY toll-free at
1-800-833-6388
ENROLLEE RiGHTS
KPS Privacy Policy
KPS is committed to protecting the pnvacy of your personal and health information We are required by
applicable federal and state law to mamtain the pnvacy of your personal and health information KPS also
is required to give you this notice to tell you how KPS may use and give out ("disclose") your personal
and health information held by KPS
Personal and health information (referred to m this notice as "personal information") means any
mformation that is identifiable to you as your personal mformat�on, mcluding �nformat�on regardmg your
health care and treatment, identifiable factors, such as your name, age, and address, or financial
information
We may collect personal information about you, or members covered by KPS through you, from the
following sources
➢ Information we receive from you, mcluding information you provide on applications or other forms
➢ Information we receive from your health care Providers or other companies (e g, other health
insurance companies, relating to your medical claims and billings
➢ General information about the health care services you have received, such as the quality and
availabdity of services
City of Bremerton Plan A Page 43
Benefits Booklet
We restrict access to personal information about you to only those who need to know that information to
provide treatment, payment, or health care operations services to you We maintain physical, electronic,
and procedural safeguards that comply with federal regulations to guard your personal information
We do not disclose any personal information about our members or former members to anyone, except
as permitted or required by law, however, KPS wdl use and give out your personal health information
➢ To you or someone who has the legal right to act for you (your personal representative) or close
famdy relative involved in your care or responsible for the payment of your services
➢ To the Secretary of the Department of Health and Human Services, if necessary, to make sure
your privacy is protected
➢ To law enforcement officials when investigating and/or prosecuting alleged civil or criminal
actions
➢ Where required by law
KPS has the right to use and give out your personal mformation to arrange for treatment, payment, and
health care operations services, including
➢ Med�cal quality reviews
➢ Accounting
➢ Legal and risk management services
KPS may use or give out your personal information for the following purposes under limited
circumstances
➢ For government health care oversight activities, such as fraud and abuse investrgations
➢ To avoid a serious and imminent threat to the health or safety of you or the public
By law, KPS must have your written permission (an "authorization") to use or give out your personal
information for any purpose that is not set out in this notice You may take back ("revoke") your wntten
permission at any time, except if KPS has already acted based on your permission
By law, you have the right to
➢ See, and get a copy of, your personal information held by KPS, except in certam limited
situations
➢ Make a reasonable request in writing to amend any of your personal information created by KPS
if you believe that it is wrong, or that information is missing, and KPS Health Plan agrees If KPS
disagrees, we wdl notify you why in writmg You may have a statement of your disagreement
added to your personal information
➢ Get a listing of those obtainmg your personal information from KPS in the past six (6) years The
listing will not include information that
o Was given to you or your personal representative or close famdy relative involved in your
care or payment of such care
o You authorized KPS to release
o Was given out for law enforcement purposes
o Was given out to pay for your health care claim or a disputed claim
➢ Request in wnting that KPS communicate with you in confidence about your personal information
by alternative means or to an alternative location If you advise us that disclosure of all or any part
of your personal information could endanger you, we must comply with any reasonable request
provided it specifies an alternative means or location
➢ Ask KPS to place additional restrictions on our use or disclosure of your personal information for
treatment, payment, health care operations, or to persons you identify We are not required to
agree to these additional restrictions and wdl notify you about the reasons regarding this action If
we do agree to the additional restrictions, we wdl abide by our agreement, except in an
Emergency
➢ Get a separate electronic or paper copy of this notice
For more information about exercismg your rights set out in this notice, contact KPS's Customer Service
department at 360-478-6796 or toll-free at 1-800-552-7114 You also can reach KPS's privacy o�cial for
this purpose toll-free at 1-800-552-7114
Page 44 City of Bremerton Plan A
Benefits Booklet
If you believe KPS has violated your pnvacy nghts set out in this notice, you may file a complamt with
KPS at the following address
KPS Health Plans
Compliance Department
P O Box 34803
Seattle, WA 98124-1803
Filing a complamt wdl not affect your benefits under KPS You also may file a complamt with the
� Secretary of the Department of Health and Human Sennces
KPS does have the right to change the way your personal information is used and given out If KPS
makes any changes, you will get a new notice by mad within 60 days of the change, and that notice wdl
become effective on the date the revised notice is issued
NOTE Telephone calls to and from KPS may be recorded for quality assurance and trainmg purposes
If you are the primary Subscriber with KPS and other persons are covered by KPS through you, we
suggest that you share this information with each other to ensure that each of you is aware of our policy
and your privacy rights
Please refer to KPS's Web site, at www KPSHealthPlans com for more information about our privacy
practices
Disclosure of Information
By law, you have the right to receive mformation about KPS, as well as your KPS Group Plan and how it
works Most of this mformation is provided to you when you enroll, however, othe� information is available
only upon request Please refer to the Your Access to Informat�on section at the end of this Benefits
Booklet
Statement of ERISA Rights
As a participant in this Group Plan you are entitled to certain rights and protections under the Employee
Retirement Income Security Act of 1974 (ERISA) ERISA provides that all Group Plan participants shall
be entitled to
➢ Examination, without charge, at the Group Plan Administrator's" office and at other locations, of
all Group Plan documents, including insurance contracts, collective bargaining agreements, and
copies of all documents filed by the Group Plan with the U S Department of Labor, such as
detaded annual reports and Group Plan descriptions *`
➢ Obtain copies of all Group Plan documents and other Group Plan information upon written
request to the Group Plan Administrator The Group Plan Administrator may make a reasonable
charge for the copies
➢ Receive a summary of the Group Plan's annual Form 5500 report The Group Plan Administrator
is required by law to furnish each participant with a copy of this summary annual report "`
In addition to creating rights for Group Plan participants, ERISA imposes duties upon the people who are
responsible for the operation of the employee benefit plan The people who operate your Group Plan,
called Group Plan Fiduciaries'`, have a duty to do so prudently and in the interest of you and other Group
Plan participants and beneficiaries No one, includmg your employer, your union, or any other person,
may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare
benefit or exercising your nghts under ERISA If your claim for a welfare benefit is denied in whole or in
part, you must receive a written explanation of the reason for the denial and copies of documents relatmg
to the decision without charge You have the right to appeal the denial within certam time schedules
Under ERISA, there are steps you can take to enforce the above rights For instance, if you request
materials from the Group Plan Administrator and do not receive them within 30 days, you may file a suit m
federal court In such a case, the court may require the Group Plan Admmistrator to provide the materials
and pay you up to $110 a day, until you receive the materials, unless the materials were not sent because
of reasons beyond the control of the Group Plan Admmistrator If you have a claim for benefits that is
denied or ignored, in whole or m pa�t, you may file a suit in a state or federal court If it should happen
that the Group Plan Fiduciaries misuse the Group Plan's money, or if you are discrimmated agamst for
City of Bremerton Plan A Page 45
Benefits Booklet
asserting your rights, you may seek assistance from the U S Department of Labor, or you may file suit m
a federal court The court wdl decide who should pay court costs and legal fees If you are successful, the
court may order the person you have sued to pay these costs and fees If you lose, the court may order
you to pay these costs and fees (e g, if it finds your claim is frivolous) If you have questions about your
Group Plan, you should contact your Group Plan Admmistrator If you have any questions about this
statement or about your rights under ERISA, you should contact the nearest Area Office of the U S
Labor-Management Services Administration, Department of Labor listed in your telephone directory
*Contact your employer to identify your "Group Plan Administrator" and "Group Plan Fiduciaries "
""Certain small employers are not required to file these reports
Women's Right to Direct Access
KPS and Washington State laws have established standards to ensure women's right to directly access
timely, appropriate, and Medically Necessary covered women's health care services, without the
necessity of prior referral from another Provider Covered women's health care services include maternity
care, reproductive health services, gynecological care, general examination, preventive care, and
follow- up visits, when provided by a licensed physician (M D or D 0), a physician's assistant (P A), an
advanced registered nurse practitioner (A R N P) specializing m women's health care or midwifery, or a
licensed midwife, and any Participatmg Facility used by such Providers
If you would like a more detailed description than is provided above regarding women's nght to direct
access under this Group Plan, or you have questions or concerns about any aspect of your women's
health care benefits, please contact KPS at 360-478-6796 or toll-free at 1-800-552-7114
Your Right to Safe and Effectrve Pharmacy Services
KPS and Washington State have established standards to ensure safe and effective pharmacy services,
to guarantee your right to know what drugs and medications are covered under this Group Plan, and to
understand the limitations of your pharmacy coverage under this Group Plan If you would like a more
detaded description than is provided above regarding your pharmacy benefits, please contact KPS at
360-478-6796 or toll-free at 1-800-552-7114
If you would like to know more about your rights under the law or if you think the information you have
received from KPS does not conform to the terms of your Group Plan, or your rights under the law, you
may contact the Office of the Insurance Commissioner toll-free at 1-800-562-6900 If you have a concern
about the pharmacists or pharmacies serving you, please call the Washington State Department of Health
at 1-360-236-4825
� Page 46 Ciry of Bremerton Plan A
Benefits Booklet
HOW YOU CAN STOP I'IEALTH CARE FRAUD
KPS is committed to meeting your health care needs at an affordable pnce Because fraud mcreases
health care expenses, it ultimately results in higher Premiums Beyond financial losses, fraudulent health
care practices can threaten your health and safety
KPS is dedicated to controllmg expenses and protectmg our Enrollees We are actively fightmg health
care fraud and want to increase your awareness of how to combat potential fraudulent acts and
situations Precautions you may take include, but are not limited to, the following
➢ Beware of "free" medical treatment offers
➢ Beware of people offering money to you if you agree to have medical procedures done (possibly
unnecessary and dangerous to your health)
➢ Be wary of people requesting that you travel to other states for medical procedures
➢ Protect your health msurance information and do not give it out to solicitors or to people over the
telephone without ensuring that person has the "right to know "
➢ Avoid using health care Providers who say that a service is not usually covered, but they know
how to bill us to have it paid
➢ Review your Explanation of Benefits (EOB) form to assess the accuracy of the claims payment
information As an example, fraud may appear on an EOB as charges for tests or procedures you
did not have
➢ Remember, if something sounds too good to be true, it likely is
➢ Ensure that only qualified family members are enrolled with you on the health plan
➢ Participating m health care fraud is dlegal and dangerous
Your continued health is our goal If you suspect health care fraud, please contact the KPS Fraud Hotlme
at 888-475-2366 or httqs //kpsfraudcompliancehotline alertline com to explain the circumstances
City of Bremerton Plan A Page 47
Benefits Booklet
DEFINITIONS
� � ' � �
Accidental In�ury Any bodily m�ury caused by an unexpected occurrence independent of
disease or bodily infirmity
Approved Treatment Program A discrete program of chemical dependency treatment provided by a
treatment program certified by the Washington State Department of
Social and Health Services, in compliance with RCW 70 96A 020(3)
Benefits Booklet The document that describes the terms and conditions applicable to this
Group Plan, as well as the benefits provided herein
Calendar Year The 12-month period beginning January 1 and ending December 31
Chdd or Children (i) Natural Chddren, adopted Chddren, stepchildren or other legally
designated ward(s) under the Limiting Age who are a dependent of
the Subscriber or the Subscriber's Spouse
(u) Children under the Limiting Age who are legally entitled to receive
medical coverage as a result of a court order binding either the
� Subscriber or the Subscriber's Spouse, regardless of whether or not
the Subscnber or Subscnber's Spouse has legal custody of the
Children
(ui) Children who have reached the Limiting Age (or are older than the
Limiting Age), are incapable of self-sustaining employment due to
developmental disability or physical handicap, and are dependent
upon the Subscriber or the Subscriber's Spouse for total or partial
support and mamtenance (see the Continued Eligibility for a
Disabled Dependent Children section)
Coinsurance The dollar amount of the KPS allowed expense that you pay to your
Provider This amount is usually expressed as a percentage on
applicable benefits
Coinsurance Maximum The maximum amount you pay for Coinsurance
Copayment An amount you are required to pay your Provider at the time of service
Covered Benefits and Services Those Medically Necessary services listed in this Benefits Booklet that
an Enrollee is entitled to receive
Deductible The amount you and/or your family are required to pay out-of-pocket
each Calendar Year before KPS pays for your Medically Necessary
Covered Benefits and Services
Eligible Dependent The Subscnber's legal Spouse and/or Children
Emergency (or Medical A sudden and acute onset of a symptom or symptoms, including severe
Emergency) pain, that would lead a prudent layperson, acting reasonably, to believe
that a health condition exists that requires immediate medical attention if
failure to provide medical attention would result in serious impairment to
boddy functions or serious dysfunction of a boddy organ or part, or would
place the person's health in serious �eopardy ,
Endorsement An amendment to the conditions of coverage or the benefits provided by
this Group Plan
Enrollee A Subscriber or Dependent enrolled in this Group Plan who is entitled to
the benefits provided herein
City of Bremerton Plan A
Benefits Booklet
� ,�� � o e t� � �,,, � � � � *
�,a
Essential Benefits Benefits covered under this Group Plan, in at least the following
categories ambulatory patient services, emergency services,
hospitalization, maternity and newborn care, mental health and
substance use disorder services, mcluding behavioral health treatment,
prescription drugs, rehabditative and habditative services and devices,
laboratory services, preventative and wellness services and chronic
disease management and pediatric services, including oral and vision
care Such benefits shall be consistent with those set forth under the
Patient Protection and Affordable Care Act of 2010 and any regulations
issued pursuant thereto For further detads about these sennces, please
visit our website at www kpshealthplans com or contact our Member
Services Department at 360-478-6796, or toll-free at 1-800-552-7114
Experimental or Investigational Medical or surgical treatments or procedures, drugs or drug use, medical
equipment, devices or supplies, or facilities (collectively referred to as
"services") are considered to be Experimental or Investigational if
➢ The services are not in general use m the Washmgton State
medical community
➢ The services pose a significant risk to the health or safety of the
patient
➢ The senrices are under continued scientific testmg and research
under Phase I or Phase II clinical trials
➢ The services are under the research, experimental, study or
mvestigational arm of a Phase III clinical trial
➢ Rel►able ewdence has not shown that the services result in greater
benefits for a particular dlness or disease than other � generally
avadable services �
➢ Rel�able evidence has not shown that the services are safe or
effective, or have any demonstrable benefit for a particular illness or
disease
For purposes of this definition, rel�able ev►dence means published
reports and articles m authoritative medical and scientific literature,
published evaluations of national medical associations and medical
consensus panels, written protocols used by the treatmg facdity or other
facilities that are studying substantially the same service as the treating
facdity, or wntten mformed consent notices used by the treatmg facdity or
, other facilities studying substantially the same service as the treatmg
facdity
Group The employer that has entered into this Group Plan on your behalf
Group Plan Administrator Your employer's Human Resources Department, or any other person or
company designated by your employer to admmister this Group Plan on
behalf of the Group's employees
Group Plan This Benefits Booklet plus any Riders, Endorsements, or other
attachments that state the terms and conditions for administration of
your benefits
Hospital A hospital that is accredited by the Jomt Commission on Accreditation of
Healthcare Organizations (JCAHO) or licensed by the state m which it is
located
KPS KPS Health Plans is a health care services contractor licensed to market
and sell health care coverage plans in Washmgton State KPS was
formerly known as Kitsap Physiaans Service
City of Bremerton Plan A Page 49
Benefits Booklet
,� , 4�� ., �, e a„��-� _ x a
�' � � ° � c o �'' ` "� *`*���t r 9, ,� n�qn �^��a _,� .a
Limiting Age The age at which Chddren may no longer be covered under this Group
Plan as an Eligible Dependent The Limiting Age is specified in the
Benefits Summary section of this Benefits Booklet
LEOFF I Employee A full-time law enforcement officer or firefighter hired prior to October 1,
1977, and who is a member of the LEOFF system as defined in Sections
(3) and (4), CH 131, Law of 1972, 1 Ex Session
LEOFF II Employee A full-time law enforcement officer or firefighter hired on or after October
1, 1977, and who is a member of the LEOFF system as defined in
Sections 3 and 4, CH 131, Law of 1972, 1 Ex Session
Medical Director The licensed physician acting as chief inedical advisor for KPS
Medical Emergency See Emergency
Medically Necessary/Medical To be considered Medically Necessary, Covered Benefits and Services
Necessity must meet all of the following criteria
➢ Be consistent with the symptoms or diagnosis and treatment of the
condition
➢ Be the most appropnate supply or level of service that is essential
to the Enrollee's needs
➢ When applied to an mpatient, it cannot be safely provided to the
Enrollee as an outpatient
➢ Be appropriate with regard to good medical practice
➢ Not be provided primardy for the convernence of the Enrollee or the
inpatient facdity
➢ Be the most cost-effective of the alternative levels of service or
supplies that are adequate and available
Non-Participating Provider or Any Provider or Facdity not contracted with KPS, either directly or
Facility indirectly
Open Enrollment Period Generally the calendar month immediately prior to the annual renewal
date for this Group Plan During the Open Enrollment Penod, persons
who did not enroll when they were initially eligible may enroll, and/or
Subscribers may add or delete Eligible Dependents Coverage wdl be
effective as of the renewal date
Partial Hospitalization A less restrictive type of mpatient care which allows the patient to
receive observation, evaluation, and mtense daily therapy but remam at
their home at rnght and on weekends and holidays
Part�cipatmg Facility An accredited facdity which has contracted with KPS, either directly or
indirectly, to provide health care services to Enrollees Participating
Facdities have agreed to accept the KPS allowance for Covered Benefits
and Services as payment in full, except for Deductible, Copayment, and
Coinsurance amounts, which are the responsibility of the Enrollee
Participating Provider A Provider who has contracted with KPS, either directly or indirectly, to
provide health care services to Enrollees Participating Providers have
agreed to accept the KPS allowance for Covered Benefits and Services
as payment in full, except for Deductible, Copayment, and Coinsurance
amounts, which are the responsibdity of the Enrollee
Premium A payment made to KPS on a scheduled periodic basis by, or on behalf
of, an Enrollee with the expectation of receiving the Covered Benefits
and Services provided under this Group Plan
Page 50 City of Bremerton Plan A
Benefts Booklet
� Fdt 4n-q. y a Rs � a Gx.rs F�' B �
r
3 air:wb � .`�ua"' a*`P IX4 �',.t� � d � `s� ,c1 d 2 '� "�^� °�''� Y� "'� �" ��.� " �.ff
Premium Due Date The scheduled, periodic dates by which Premium payments must be
received by KPS as a condition for contmued enrollment m this Group
Plan This date is the first day of each month of coverage
Provider Any one of the following licensed or certified health care practitioners
actmg withm the scope of their license or certificate
Chiropractor Physical Therapist
Dentist Physician (M D or D O)
East Asian Medicine Practitioner Physician's Assistant (P A)
� Massage Therapist Podiatrist
Naturopath (N D ) Psychologist
Nurse Midwife Speech Therapist
Occupational Therapist
Certified Chemical Dependency Provider
Certified Mental Health Provider
Advanced Registered Nurse Practitioner (A R N P)
NOTE This list does not include all types of Providers covered by KPS
If your Provider type is not listed above, please call KPS toll-free at
1-800-552-7114 to request more information
Residential Mental Health A facdity that provides 24-hour treatment, services, and supervision for a
Facdity mental health condition m a non-acute settmg
Rider An additional benefit over and above those listed m the Benefits
Summary section Rider documents are attached at the back of the
Benefits Booklet and provide detailed benefit information
Skdled Nursing Facility (SNF) A facdity, or the distmct section of a facility (such as a wing of an
accredited general Hospital), that is licensed primarily to provide skilled
nursing care and related services, or rehabilitation services, on a
24-hour basis The factlity must employ at least one registered nurse
(R N) who is on full-time duty, and one physician who is avadable to
provide necessary medical care in the event of an Emergency
Spouse (i) An mdividual who is livmg in a mantal relationship with the
Subscriber The marital relationship must be legally recognized by
the state of Washmgton
(n) An individual who is livmg with the Subscriber as a state registered
domestic partner
Subscriber An eligible employee who is enrolled in this Group Plan, or any other
eligible person, who is the pnncipal Enrollee in this Group Plan
City of Bremerton Plan A Page 51
Benefits Bookiet
CONTACT US
p -D
� � ��
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»R k ��''' �'��•
„r�r.....,' . �
KPS Heaith Plans is located at:
400 Warren Avenue
Bremerton, WA 98337
�
�,��
� �
`�
`��
For KPS Customer Service, please call:
� 360-478-6796
1-800-552-7114 (toll-free)
For the deaf & hearing-impaired call
TDD 1-800-833-6388 (toll-free)
Send mquiries, claims or complaints to:
KPS Health Plans
PO Box 34803
Seattle, WA 98124-1803
Fax mquiries to 360-415-6514
�� .,� � �
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r�-�:.�.�.� �,
�
Send e-mad inquiries to:
info@kpshealthplans com
Page 52 City of Bremerton Plan A
Your Access to Information
As a member of KPS Health Plans, you have the right to receive certain information about KPS, about your plan
benefits, and about how to access benefits When you enroll, KPS gives you documents or access resources
which contain this important information In order to ensure you get the highest possible benefit from your Group
Plan, you should read/access this information prior to seeking care from your Provider If you have lost or
misplaced any of the documents, please contact KPS Customer Service and we wdl send you a new copy
Documentllnformation: Contalns:
Benefits Booklet Information regarding
✓ Covered Benefits and Services
✓ Exclusions, reductions, and limitations to Covered Benefits and Services
✓ Amounts you are required to pay for your care, including
- Individual and famdy Deductibles
- Copayments
- Coinsurance
- Maximum annual out-of-pocket costs
✓ Pre-authorization requirements for certam services
✓ Requirements for specialty care
✓ Complaint and appeals process
✓ KPS's olic re ardin the disclosure of our ersonal health information
Access to Provider Directones Information regarding the following can be found at www kpshealthplans com or
by callmg KPS Customer Service at 360-478-6796 or toll-free at
1-800-552-7114
✓ Network primary care Providers
✓ Network specialty Providers
✓ Nefinrork harmacies if our Grou Plan covers rescri tion dru s
Access to Prescnption Drug Information regarding the following can be found at www kpshealthplans com or
Formulary by calling Medlmpact toll-free at 1-800-788-2949
✓ Drugs covered by your Group Plan
✓ Copayment amounts you are required to pay when you have a prescription
filled
✓ How often drugs are added to, or removed from, the list, and where you can
et more information
Pharmacy Questions and Information regarding the followmg can be found at www kpshealthplans com or
Answers by calling Medlmpact toll-free at 1-800-788-2949
✓ KPS drug formulary
✓ Covered and excluded drugs
✓ Drug substitutions
✓ How Copayments are determmed
✓ Where to et a listm of network harmacies
For More Information:
KPS also provides the following mformation to its members on request
❖ General information regarding the types of plans offered by KPS
❖ How KPS pays its network Providers for the care you receive
❖ An accounting of the payments KPS has made, which have been credited to your annual Deductible or
used to calculate any service limitations or maximums
❖ KPS' accreditation status and any publicly reported health employer data information set (HEDIS) data
If you would like a copy of any of the referenced information, please contacting KPS Customer Service at
360-478-6796 or toll-free at 1-800-552-7114
If you wish, you may send a written request for information to
KPS Health Plans
P O Box 34803
Seattle, WA 98124-1803
KPS Health Plans
400 Warren Avenue
P O Box 339
Bremerton, WA 98331-0039
Attachment B
Premium Rates and Undervvriting Criteria
For
City of Bremerton
Period: January 1, 2013 — December 31, 2013
Premium Rates
PLAN A 8� RETIREES
ACTIVE
LEOFF I Em lo ees ' 988 18
LEOFF II & non-LEOFF Em lo ees 717 54
S ouse 795 41
1 st Child 359 21
2nd Child + 289 12
LEOFF I RETIREES UNDER AGE 65
Subscnber 2585 92
S ouse 1416 64
1 st Child 353 43
2nd Child + 282 46
PLAN B 8� RETIREES
ACTIVE
LEOFF II & non-LEOFF Em lo ees 620 47
S ouse 695 04
1st Child 316 20
2nd Child + 246 03
LEOFF I RETIREES UNDER AGE 65
Subscriber N/A
S ouse 1176 60 '
1 st Child 299 05
2nd Child + 241 81
Note: Rates mclude Vision and is for Employees ONLY (Active and COBRA).
Underwriting Criteria
The Premium rates quoted above for this Group Plan are based on the following underwriting criteria
KPS reserves the nght to withdraw or rerate this offering if Group falls outside the scope of these criteria
➢ A change m Employer contribution may negate Grandfathered status. Grandfathered
plans cannot decrease the percent of premwms the Employer pays by more than 5
percentage points (for example, decrease their own share and increase the workers' share
of prem�um from 15% to 25%). Any change to the employer contribution percentage must
be communicated to KPS, in writing, no less than 30 days m advance of the effectrve date
of the contribution change
➢ Active Employees must work a minimum of twenty (20) hours per week unless otherwise
negotiated and agreed by both KPS and Group
➢ Sub�ect to prior KPS approval, two (2) or more health insurance carriers, including KPS, may
provide coverage to Group's Employees
➢ Sub�ect to prior KPS approval, Group may select multiple KPS health plan offenngs
➢ The mmimum level of participation required is seventy-five percent (75%) of eligible Employees
➢ Unless otherwise approved by KPS, no more than twenty-five percent (25%) of Group's eligible
Employees may reside outside of the State of Washington
➢ KPS reserves the right to rerate Group in the event actual enrollment fluctuates by ten percent
(10%) or more from the census provided to KPS by Group at the time Group was initially rated
KPS Health Plans
Business Address
400 Warren Avenue
Bremerton, WA 98337
CITY OF �REMERTON — PLAN B
COVERAGE CONTRACT
Group Number:
Effective Date.
Contract Renewal Month•
Open Enrollment Period:
This Coverage Contract includes the following
Attachment A:
Attachment B.
Benefits Booklet
1000780
January 1, 2013
January
December
Premium Rates and Underwriting Criteria
Mailing Address
P O Box 34803
Seattle, WA 98124-1803
������t
���
�PR 1 � 2f�1.�
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ls����„���
This Contract is entered mto and delivered in the state of Washmgton and is governed by Washmgton
State laws, except to the extent state laws are preempted by federal law
Signature by an authorized Group representative or payment of the Premwm shall constitute
acceptance of the terms and conditions set forth herem.
FoR KPS:
�!���
W James Page Jr , President
April 10, 2013
Date
FOR GROUP:
�
Signature
�a l�c�—�—
Pnnt Name
i(Yl�-� o �
Title
��J �3 2a�3
Date
KPS Health Plans
Business Address
400 Warren Avenue
Bremerton, WA 98337
CITY OF BREMERTON — PLAN B
COVERAGE CONTRACT
Group Number:
Effective Date•
Contract Renewai Month:
Open Enrollment Period:
This Coverage Contract includes the following
1000780
January 1, 2013
January
December
Attachment A• Benefits Booklet
Attachment B. Premium Rates and Underwritmg Criteria
Mailing Address
P O Box 34803
Seattle, WA 98124-1803
KPS Health Plans (KPS) is a licensed health care services contractor (HCSC) in Washington State In its
capacity as an HCSC, KPS agrees to underwnte and provide the benefits and services described m
Attachment A any Benefits Booklet that may be listed above (hereinafter collectively referred to as
"Attachment A"), as applicable to the eligible Employees and their Eligible Dependents of the
above-named Group, provided the Group, its eligible Employees, and their Eligible Dependents meet and
comply with the provisions of this Coverage Contract ("Contract")
C136REM6
TABLE OF CONTENTS
DEFINITIONS
CONTRACT EXAMINATION PERIOD
EFFECTIVE DATE, DURATION, AND RENEWAL
PREMIUM PAYMENT PROVISIONS
Payment Due Date/Grace Period
Premium Rate Ad�ustments
Premiums Paid by Subscnbers/Dependents
Premium Refunds
ELIGIBILITY AND ENROLLMENT
Group Eligibility
Subscriber/Dependent Eligibdity Requirements
Eligibility of Newborn and Adopted Child(ren)
Court-ordered Coverage for Eligible Dependent Child(ren)
Enrollment Reporting Requirements
Enroliment Timeframes
When Coverage Begins
Coverage Waitmg Periods
TERMINATION OF COVERAGE
Continuity of Coverage
Termination or Rescission of Contract
Termination or Rescission of Enrollee Coverage
COBRA (Consolidated Omnibus Budget Reconcdiation Act - 1985)
Fraudulent Information
Re-Enrollment/Remstatement
SUBSCRIBER/DEPENDENT LIABILITY AND RIGHTS
Subscriber/Dependent Liability
GENERAL TERMS AND CONDITIONS
Applicable Law
Assignment of Benefits
Binding Agreement
Confidenfiality
Contract Modifications
Coverage Limits
Entire Agreement
Equity of Application
Force Ma�eure
Group Cooperation
Headings
Notices
Severability
Third Party Beneficiaries
Waiver of Breach
1
3
3
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4
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4
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5
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11
COVERAGE CONTRACT
DEFINITIONS
Capitalized words found m the text of this Contract are defined below or may be found m Attachment A
Child or Chddren
(i) Natural children, adopted chddren, stepchildren, or other legally designated ward under the Limiting
Age who is a dependent of the Subscriber or the Subscriber's Spouse
(u) Children under the Limiting Age who are legally entitled to receive medical coverage as a result of a
court order binding either the Subscriber or the Subscriber's Spouse, regardless of whether or not
the Subscriber or Subscriber's Spouse has legal custody of the children
(ui) Children who have reached the Limitmg Ag, or are older than the Limitmg Age, are mcapable of
self-sustammg employment due to developmental disability or physical handicap, and are
dependent upon the Subscnber or the Subscriber's Spouse for total or partial support and
maintenance (see the Continued Eligibility for Disabled Dependent Children section of
Attachment A)
Contract: this document and any other attachments, exhibits, Riders, or Endorsements listed on the title
page or otherwise described herem, and any subsequent amendments or modifications to this document, its
attachments, exhibits, Riders or Endorsements
Contract Renewal Month the calendar month specified on the title page of this Group Contract durmg
which the Group may renew its coverage each year under this Group Plan
Covered Benefits and Services those Medically Necessary benefits and services described in
Attachment A that an Enrollee is entitled to receive
Eligible Dependents the legal Spouse and/or Children of an Eligible Employee, or the legal Spouse and/or
Children of an active, full-time LEOFF I or LEOFF II firefighter
Employee an active, full-time Employee who is not a LEOFF I or LEOFF II Employee
Endorsement an amendment to the conditions of coverage or the benefits provided by this Group Plan
Enrollee a person enrolled m this Group Plan
Group the employer entity, association, or other group that has entered into this Contract with KPS
Group Master Application the form completed by the Group and submitted to KPS prior to secunng
coverage under this Group Plan
Group Plan the Premium rates and benefits chosen by the Group as listed in Attachment A, any Riders
and Endorsements, Attachment B— Premium Rates and Underwriting Criteria, plus other attachments
that state the terms and conditions for eligibility and admmistration of Covered Benefits and Services
LEOFF 1 Employee an active, full-time law enforcement officer or firefighter hired pnor to October 1, 1977,
and who is a member of the LEOFF system as defined in Sections (3) and (4), CH 131, Law of 1972, 1� Ex
Session
LEOFF il Employee an active, full-time law enforcement officer or firefighter hired on or after October 1,
1977; and who is not a member of the LEOFF system as defined in Sections (3) and (4), CH 131, Law of
1972, 1 St Ex Session
Limiting Age the age at which Children may no longer be covered under this Group Plan as an Eligible
Dependent of the Subscriber The Limitmg Age is specified in the Benefits Summary section of
Attachment A
Medical Director the licensed physician actmg as chief inedical advisor for KPS
Open Enrollment Period the 31-day penod or some other period agreed to by both KPS and the Group,
begmning one (1) month prior to the Group's Renewal Month or at some other mutually agreeable time but
at least annually During the Open Enrollment Period, Subscribers may add or delete Eligible Dependents,
and all eligible Employees and their Eligible Dependents have the opportunity to select from alternative
health plans offered by the Group Coverage will be effective as of the renewal date
Page 1
COVERAGE CONTRACT
Participating Facility: an accredited facility, which has contracted with KPS either directly or indirectly, to
provide health care services to Enrollees Participating Facdities have agreed to accept the KPS allowance
for Covered Benefits and Services as payment in full, except for Deductible, Copayment, and Coinsurance
amounts, which are the responsibility of the Enrollee
Partic�pating Provider• a Prowder who has contracted with KPS, either directly or indirectly, to provide
health care services to Enrollees Participating Prov�ders have agreed to accept the KPS allowance for
Covered Benefits and Services as payment in full, except for Deductible, Copayment, and Coinsurance
amounts, which are the responsibility of the Enrollee
Premium the penodic payment made by, or on behalf of, the Enrollee as consideration for this Group Plan
and in accordance with the terms of this Contract
Premium Due Date the scheduled, periodic dates by which Premium payments must be received by KPS
as a condition for continued enrollment in this Group Plan This date is the first day of each month of
coverage
Provider a licensed or certified health care practitioner acting within the scope of his/her license or
certificate �
Rider an additional benefit over and above those listed in the Benefits Summary section of Attachment
A Rider documents are attached at the back of Attachment A and provide detailed benefit information
Spouse:
(i) An individual who is living in a marital relationship with the Subscriber The marital relationship must
be legally recognized by the state of Washington
(ii) An individual who is living with the Subscriber as a state registered domestic partner
Subscriber an eligible employee who is enrolled in this Group Plan, or any other eligible person, who is
the principal Enrollee in this Group Plan
Page 2
COVERAGE CONTRACT
CONTRACT EXAMINATION PERIOD
If, after exammation, the Group is not satisfied with this Contract for any reason, the Group may return the
Contract to KPS within ten (10) days of the date it is received Upon receipt of the returned Contract, KPS
will refund to the Group any pre-paid Premiums The Contract shall subsequently be deemed null and void
EFFECTIVE DATE, DURATION, AND RENEWAL
This Contract shall begin at 12 01 a m Pacific Time on the Effective Date (as mdicated on the title page),
and shall remain in effect until the Contract Renewal Month unless terminated accordmg to the provisions
set forth herein
Thereafter, this Contract may be renewed automatically at 12 01 a m on the same date (month and day) in
subsequent Calendar Years, unless otherwise terminated accordmg to the provisions set forth herein
PREMIUM PAYMENT PROVISIONS
Payment Due Date/Grace Period
The initial Premium payment is due and payable to KPS on or before the effective date of this Contract
indicated on the title page Thereafter, Premium payments are due and payable on or before the first day of
every month ("Premium Due Date") for which coverage is provided A roster of current enrollment and
enrollment changes must accompany each Premium payment
A ten (10) day grace period following the Premium Due Date is allowed, durmg which time this Contract
shall not be terminated if payment is not received within the ten (10) day grace period, KPS may, at its sole
discretion, elect to extend the grace penod for up to 60 days from the Premium Due Date or termmate this
Contract without notice to the Group
If KPS elects to termmate this Contract due to non-payment of Premium, the effective date of termmation
wdl be retroactive to the last day of the month for which payment was received No further liability for claims
will accrue to KPS Enrollees m this Group Plan shall not be entitled to benefits durmg any calendar month
for which the Premium, on his/her behalf, was not received by KPS
P�emium payments, if applicable, must accompany all appl�cations for coverage.
Premium Rate Adjustments
The Premium rates applicable to this Group Plan are defined in Attachment B- Premium Rates and
Underwr�ting Criteria Rates are guaranteed until the Contract Renewal Month each Calendar Year
Notwithstanding the foregomg, KPS reserves the nght to �ev�se the rates as follows
➢ As part of the annual Contract renewal process
➢ As a result of any state or federal law or regulation that imposes an additional tax, new tax or other
assessment on KPS revenue
➢ In the event there is a material change m the basis upon which KPS assumed risk under this
Contract Such changes may include inaccurate information presented by the Group, changes m
the benefits, or other Contract terms required by statute or regulation, underwritmg guidelines, or
fluctuations of ten percent (10%) or more in the number of enrolled Subscribers and/or Eligible
Dependents KPS will give the Group 60 days prior written notice of any change in Premium rates
not associated with the annual Contract renewal process
KPS wdl give the Group 30 days prior written notice of rate mcreases associated with the annual Contract
renewal process
Page 3
COVERAGE CONTRACT
Premiums Paid by Subscribers/Dependents
In certain instances, Subscribers and their enrolled Eligible Dependents may be required to self-pay their
Premiums in order to continue coverage Those instances include
➢ Strikes, lockouts, and other labor disputes that cause a disruption in Employee benefits
➢ When the Subscnber and/or Eligible Dependent(s) elects to continue coverage under a COBRA
provision or other coverage continuation prowsion available under this Group Plan
The Group is required to collect self-paid Premiums for contmuation coverage and forward payments to
KPS on or before the Premium Due Date In the instance of strikes, lockouts, and labor disputes, the
Enrollee may self-pay their Premium directly to the Group on or before the Premium Due Date
Premium Refunds
KPS wdl refund to the Group any Premium paid, in advance, for periods after the termination date of this
Group Plan
In the case of an ineligible person(s) enrolled in this Group Plan, KPS wdl refund to the Group any Premium
paid, during a period of ineligibility, that is in excess of claim payments made on behalf of the ineligible
person(s), dunng the period of ineligibility This refund wdl not exceed an amount equal to three (3) months
of Premium payments
ELIGIBILITY AND ENROLLMENT
Group Eligibihty �,
In order to be eligible to participate in this Group Plan, the Group must continuously meet all eligibility,
participation, Group size, contribution, and other requirements specified in the Group Master Application
form
KPS reserves the nght to audit the Group's employment, payroll, and eligibility records to ensure that the
Group continues to meet its participation requirements and to ensure that eligible Employees and their
Eligible Dependents are properly enrolled in this Group Plan
Subscriber/Dependent Eligibility Requirements
Active, full-time Employees, as defined in the Definitions section and their Eligible Dependents, are eligible
to enroll in this Group Plan �
Eligible Dependents of active, full-time LEOFF I or LEOFF II firefighters, as defined in the Definit�ons
section, are also eligible to enroll in this Group Plan
The Chddren of an Eligible Dependent, other than the Ct�ddren of the Spouse, are not eligible to enroll in
this Group Plan
Subscribers and their Eligible Dependents who do not enroll when they are mitially eligible must wait until
the next Open Enrollment Period, except in certain circumstances (see the Enrollment Under Special
Circumstances section of Attachment A)
Page 4
COVERAGE CONTRACT
Eligibility of Newborn and Adopted Children
Newborn, adopted Children, and Children placed for adoption are initially eligible for coverage as follows
➢ Natural newborn Children are eligible as of the date of birth and is covered automatically for a
period of three (3) weeks In order for coverage to contmue after the initial three (3) week penod,
the Children must qualify as an Eligible Dependent If additional Premium is required, the
application and Premium for the Children must be received by KPS withm 60 days of birth
➢ Adopted Children and Children placed for adoption are eligible (i) on the date of their adoption, (ii)
on the date the Subscnber or Spouse assumes legal obligation for total or partial support in
anticipation of adoption, or (ui) on the date the Subscriber or Spouse acquires partial or complete
legal custody If additional Premium is required, the application and Premium for coverage must be
received by KPS within 60 days of the date of placement for adoption
NOTE When additional Premium is not required, we encourage enrollment as soon as possible to
prevent delays in claims processmg
Court Coverage for Eligible Dependent Children
in the case of court-ordered coveraQe, dependent Children b ecomes initially eligible on the date the
Subscnber or Spouse receives the order to provide medical coverage for the Children, even if neither the
Subscriber nor the Spouse is the custodial parent KPS requests that an application for coverage be
submitted withm 31 days of the date of the court order Coverage will become effective on the first day of
the month, following the effective date of the court order
Enrollment Reporting Requirements
The Group will verify enrollment of all Employees and their dependents eligible for enrollment under this
Contract and ensure that appropriate documentation is submitted to KPS for approval
Enrollment Timeframes
Employees and their Eligible Dependents, includmg Eligible Dependents of active, full-time LEOFF I and
LEOFF II firefighters, may initially apply for coverage m this Group Plan, beginning on the Group's effective
date Application for coverage must be received by KPS within 31 days of initial eligibdity
New Employees and their Eligible Dependents, including Eligible Dependents of active, full-time LEOFF I
and LEOFF II firefighters, may initially apply for coverage on the first day of the first full month, followmg
their first day of employment Application for coverage must be received by KPS within 31 days of initial
eligibility Those Employees who do not enroll immediately following their probationary penod(s) must wait
until the next Open Enrollment Penod
A new Spouse and the Spouse's Children may initially apply for coverage as of the date of marnage
Application for coverage must be received by KPS withm 31 days of initial eligibility
When Coverage Begins
Coverage for new Enrollees begins on their date of initial eligibility, provided they e�rolled m this Group
Plan withm the spec�fied time Vimits (see Enrollment Timeframes) and any applicable Premium amounts
have been paid
If the Employee enrolls dunng an Open Enrollment Penod, coverage wdl begin on the first of the month
followmg the Open Enrollment Penod
Newborn Children who meets eligibility requirements is covered automatically for a period of three (3)
weeks from the date of birth, provided either the female Subscriber, or male Subscriber's Spouse, is eligible
for materrnty coverage under this Group Plan at the time of the Child's birth If additional Premium is
required, coverage wdl not extend beyond the three- (3) week period unless the Child is enrolled within 60
days of the date of birth Any applicable Premium amount must accompany the enrollment application
Page 5
COVERAGE CONTRACT
�
If additional Premium is required, coverage for adopted Children is retroactive to the date the Children were
adopted, legally placed for adoption, or when the Subscriber or Subscriber's Spouse assumes legal
obligation for total or partial support of Children in anticipation of adoption, provided that the application and
applicable Premium for the Children are received by KPS wi thin 60 days from the date of adoption,
placement for adoption, or assumption of financial responsibility
NOTE When additional Premium is not required, we encourage enrollment as soon as possible to prevent
delays in claims processing
Coverage Waiting Periods
Pre-exist�ng Cond�t�ons
Enrollees age 19 and older must be enrolled in this Group Plan for a period of three (3) consecutwe months
before KPS will provide benefits for a Pre-existing Condition A Pre-existing Cond►f�on is any condition for
which you received medical advice during the three (3) month period immediately preceding your date of
enrollment in this Group Plan or for which your Provider recommended or provided treatment Genetic
information shall not be treated as a Pre-existing Condition, unless there has been a diagnosis of the
condition related to the speci�c genetic information
No Pre-existing Condition limitations apply to Enrollees under 19 years of age
Transp/ant Procedures
KPS provides coverage for transplant procedures only after you have been continuously enrolled under this
Group Plan for six (6j months Thrs transplant waiting penod applies to the transplant procedure, as well as
any pre- and post-transplant care directly related to a transplant you recewe whde covered under this Group
Plan
Cred�tab/e Coverage
If you were required to complete an employer imposed probationary period, the waiting periods begin on the
first day of your probationary period The Pre-existing Condition and transplant procedures waiting periods
may be reduced by the number of months of Creditable Coverage you have accrued under other health
care programs prior to your enroliment in this' Group Plan Creditable Coverage means periods of other
health coverage an Enrollee may use to reduce Pre-existing Condition and transplant procedures waiting
periods These include
➢ Group health coverage
➢ Part A or Part B of Medicare
➢ Medicaid
➢ Military health coverage
➢ Indian Health Service or tnbal coverage
➢ State High Risk Pool
➢ Federal or Public Health Plans
➢ Peace Corps Plan
➢ State Chddren's Insurance Program
➢ Other health insurance coverage
The Enrollee wdl receive credit for prior Creditable Coverage if it was contmuous and term�nated not more
than three (3) months immediately preceding their date of enrollment in this Group Plan Health coverage
wdl be considered continuous if there was not more than a three (3) month break in Creditable Coverage
No credit wdl be given if there was more than a three (3) month break in coverage between the Enrollee's
prior plan and their effective date of enrollment in this Group Plan Any employer imposed probationary
period will not be considered a break in coverage or Creditable Coverage
Page 6
COVERAGE CONTRACT
To request a credit to the Pre-existing Condition waitmg period, the Enrollee must submit a Certificate of
Creditable Coverage from the prior health plan carner with his/her enrollment application In lieu of a
Certificate of Creditable Coverage, the Enrollee must provide all of the followmg information
➢ The name of the pnor health plan carrier
➢ The dates of coverage under the pnor plan
➢ Proof of coverage under the prior plan that documents the coverage period(s)
There are no waiting periods for
➢ Pregnancy
➢ Formulas necessary for the treatment of phenylketonuria (PKU)
➢ Prescnption drugs included m Pharmacy Benefits
➢ Newborn Children or adopted Chddren
TERMINATION OF COVERAGE
Continuity of Coverage
Contmuity of coverage under this Contract is guaranteed to all Enrollees provided the Group continues to
meet eligibility requirements and continues to pay applicable Premium payments on a timely basis
Termination or Rescission of Contract
This Contract may be terminated as of the date on which any of the following occurs
➢ The Group fads to make full Premium payments
➢ The Group violates, or refuses to comply with, the terms and,conditions of this Contract
➢ The Group violates, or refuses to comply with, any published KPS policies and procedures that
have been approved by the Insurance Commissioner
➢ There is a change to, or implementation of, federal or state law that prohibits the contmued offering
of this Group Plan
➢ KPS replaces this Group Plan In this case, the replacement plan wdl (i) include the services
covered under the replaced Group Plan, (ii) be offered to the Group's eligible Employees and their
Eligible Dependents, and (iii) not significantly limit access to the kind of services covered under the
replaced Group Plan
In addition, the Group may termmate this Contract, at any time, by providing thirty (30) days written notice to
KPS
KPS may rescind or termmate this Contract upon thirty (30) days wntten notice in the event that intentional
misrepresentation of material fact or fraud was used in order to obtam Group coverage In no event wdl
coverage be terminated or rescmded solely on the basis of an Enrollee's physical or mental condition
provided they meet all other eligibility requirements set forth by the Group The Group may appeal a
termination or rescission decision through the KPS appeals process Either party may terminate this
agreement in the event of intentional misrepresentation, fraud, or omission of information by the other party
in performance of its responsibilities under this agreement
If this Contract is termmated coverage for all Enrollees will end automatically on the effective date of
termmation, or on the last day of the last month for which the Group paid the Premium, whichever occurs
first KPS will refund to the Group any Premium paid for periods after the termination date
In the case of termination or non-renewal of this Contract, KPS shall be responsible for providing the
effective date of termmation of coverage to all affected Subscnbers and their Eligible Dependents
Page 7
COVERAGE CONTRACT
Termination or Rescission of Enrollee Coverage
Coverage for an indiwdual Enrollee under this Contract will end as of the date on which any one of the
following events occurs
➢ Non-payment of any Premium amount, when Premium payment is the responsibility of the Enrollee
➢ The Enrollee loses eligibility for coverage under this Contract
➢ The Enrollee refuses to comply with the terms and conditions of this Group Plan as described in
Attachment A
➢ The Enrollee obtams coverage through intentional misrepresentation of material fact or fraud
➢ The Enrollee voluntarily disenrolls from this Group Plan
➢ There is a change in either state or federal laws that no longer permit KPS from offenng this Group
Plan
➢ This Contract is terminated
Additionally, Eligible Dependent coverage ends if
➢ The Subscriber is no longer employed or no longer meets eligibility requirements
➢ The Subscnber dies
➢ The,Chddren reach the Limiting Age
Coverage ends on the last day of the month m which the Enrollee was eligible for coverage, provided all
applicable Premium amounts have been paid In the case of non-payment of Premium, coverage ends on
the last day of the month for which KPS received a Premium payment KPS will be entitled to recover
claims payments for services received by the Enrollee after the termination date, unless there was prior
authorization for those services
Upon termination of coverage either KPS or the Group shall issue a Certificate of Creditable Coverage
certifying the penod(s) during which the Enrollee was enrolled in this Group Plan
An Enrollee who loses coverage under this Group Plan may be eligible to contmue coverage or enroll in a
KPS Conversion Plan (see the Contmuation of Coverage section of Attachment A)
A Subscriber who voluntarily disenrolls from this Group Plan wdl not be eligible to re-enroll in this Group
Plan, untd the next Open Enroliment Period See the Enrollment Under Special Circumstances section of
Attachment A for exceptions to this policy
COBRA (Consolidated Omnibus Budget Reconciliation Act -1985)
If an Enrollee loses eligibility for coverage under this Group Plan, they may be eligible to continue their
coverage for a period of time specified by federal law and regulations then in effect This continuation of
coverage is referred to as COBRA and applies generally to groups of 20 or more employees KPS offers
coverage o� when
➢ Groups are required by law to prowde COBRA coverage for their employees, and
➢ KPS is notified of a beneficiary's election of COBRA coverage within 31 days of that election being
made
Continuation of coverage under COBRA is not automatic Enrollees must apply for continuation of their
Group coverage within 60 days of the date they receive a COBRA election notice from the Group KPS
offers COBRA coverage to Groups only as required by law
The Group Plan Administrator is required to notify KPS of an Enrollee's election of COBRA continuation
coverage within 31 days of that election Failure on the Enrollee's part to make a timely election, or fadure
on the part of the Group Plan Administrator to provide KPS with timely notification of the election, wdl be
interpreted by KPS as a waiver of the Enrollee's right to continue coverage under this provision Fadure by
the Group Plan Administrator to provide timely notification to KPS may not, in all cases, eliminate the
Group's obligation to provide continuation coverage It wdl, however, eliminate any obligation on the part of
KPS to provide the Enrollee with COBRA continuation coverage under this Group Plan
Page 8
COVERAGE CONTRACT
Fraudulent Information
In the event it is discovered that the Group has provided false or misleading information in connection with
the provisions of this Contract for the purpose of defraudmg KPS, KPS reserves the right to termmate or
rescmd coverage and shall mform the appropriate state and regulatory authorities, including, but not limited
to, the Washington State Office of the Insurance Commissioner (OIC) for a determmation of the Group's
liabihty
Re-Enrollment/Reinstatement
If this Contract has been termmated by KPS due to non-payment of Premium, the Group automatically
forfeits all rights to guaranteed renewal of coverage afforded under the Health Insurance Portability and
Accountab�lity Act (HIPAA) of 1996 Any decision to remstate or re-enroll the Group is at the sole discretion
of KPS
SUBSCRIBER/DEPENDENT LIABILITY AND RIGHTS
Subscriber/Dependent Liability
Subscribers and their Eligible Dependents who are enrolled in this Group Plan are liable for the following
costs
➢ Deduct�ble (defined m Attachment A)
➢ Copayments (defined in Attachment A)
➢ Charges for non-Covered Benefits and Services
➢ Coinsurance, up to the Coinsurance Maximum limit (defined in Attachment A)
➢ Charges incurred after an annual or lifetime maximum benefit for a specific service or supply has
been exhausted (e g, the annual maximum benefit for medical equ ipment and supplies)
➢ Charges in excess of the amount allowed by KPS for Non-Participating Providers
If KPS fails to reimburse a Participating Provider for the cost of Medically Necessary Covered Benefits and
Services prowded in accordance with the terms of this Contract, neither the Enrollee nor the Group shall be
required to compensate the Partiapating Provider for such services beyond the limit of Deductibles,
Copayments, or Coinsurance amounts specified m Attachment A '
What happens �f a Provider no longer partic�pates with KPS?
If a Participating Provider chooses to termmate their agreement with KPS, we wdl notify the affected
Enrollees of the termmation The notification wdl allow Enrollees at least 60 days to either (i) complete their
course of treatment, or (n) appropriately transfer their care to another Participating Provider After the 60
days, services received from a Provider who has termmated their agreement with KPS will be covered at
the Non-Participatmg Provider benefit level
GENERAL TERMS AND CONDITIONS
Applicable Law
This Contract shall be governed by the laws of the state of Washington and is entered into m Bremerton
Washmgton Any controversy or or claim arising out of or relatmg to this Contract shall be resolved in a
court of competent �urisdiction in Kitsap County, Washmgton or the U S Distnct for the Western District of
Washmgton
Page 9
COVERAGE CONTRACT
Assignment of Benefits
The benefits of this Contract shall accrue to Subscribers and their enrolled Eligible Dependents This
Contract, payments, or Covered Benefits and Services are not assignable to a third party KPS reserves the
right to make benefit payments to the Subscnber, their Provider(s), or �ointly, as KPS deems necessary and
appropriate, sub�ect to federal and/or state laws
Binding Agreement
This Contract is binding on KPS and the Group, as well as their respective executors, administrators,
successors, and/or assigns By election of coverage or payment of applicable Premiums, or if the Group's
Subscribers or their enrolled Eligible Dependents seek the services provided under this Contract, all of the
terms, covenants, and conditions contained herein shall become binding on the Group and its Subscribers
and any enrolled Eligible Dependents, notwithstanding the failure of the Group to sign this Contract
This Contract shall not bind KPS until (i) a person authorized by KPS signs it, and (ii) a signed copy is
delivered to the Group
Confidentiality
The underwriting and financial terms of this Contract are confidential and shall not be disclosed except as is
necessary for the performance of this Contract or as required by law
Contract Modifications
Except as set forth under the Prem�um Rate Ad�ustments section, KPS reserves the right to modify the
provisions of this Contract, or the services described in Attachment A, upon 30-days written notice to the
Group The Group may elect to re�ect such modifications by providing KPS with 15-days written notice
However, reJection of a modification will result in the termination of this Contract as of the last day of the
month for which Premium payment has been received Lack of notification of re�ection by the Group shall be
interpreted as acceptance of the modification, and this Contract wdl be renewed as modified
No modification of the terms of this Contract shall be binding upon KPS unless endorsed, in writing, and
signed by an authorized officer of KPS Such endorsement shall be deemed a part of this Contract, effective
as of the effective date of the endorsement Any amendment or Contract modification required by law or
regulation shall become effective as of the effective date required by such law or regulation
Coverage Limits
The Covered Benefits and Services offered under this Contract are sub�ect to the coverage limits and
maximums set forth in Attachment A
Entire Agreement
This Contract, together with Attachment A, any Riders and/or Endorsements attached hereto, and
Attachment B- Prem�um Rates and Underwriting Criteria, constitutes the entire agreement This
Contract supersedes all previous communications, representations, or agreements, whether verbal or
wntten, between KPS and the Group
Equity of Application
This Contract is intended to apply equally to all Enrollees
Page 10
COVERAGE CONTRACT
Force Majeure
In the event KPS is unable to perform its obligations hereunder by reason of fire, casualty, lockout, strike,
labor condition, not, war, act of God, or by ordinance, law, order, or decree by any legal authonty, the
Contract may, at the option of KPS, be suspended During any penod of suspension, KPS shall not be
required to perform any service hereunder, nor shall KPS be liable for any damages arismg from any event
that precipitated the suspension If this Contract is suspended pursuant to this provision, any obligation by
the Group and/or an Enrollee to make Premium payments also shall be suspended for the same penod of
time
Group Cooperation
The Group agrees to cooperate with KPS in the administration of this Contract by
➢ Advismg Subscribers and their enrolled Eligible Dependents of policies and procedures applicable
to this Group Plan
➢ Providing Subscnbers and their enrolled Eligible Dependents with Attachment A, ID cards and any
applicable notices or other information regarding this Group Plan
➢ Providmg mformation about Enrollees that is relevant to the determination of eligibdity, claim
reimbursement, coordination of benefits, or other information required for the administration of this
Contract
➢ Makmg appropnate payroll deductions, if applicable, to facilitate Premium payment
Headings
The headings of sections and paragraphs m this Contract are for convenience and reference purpqses only
and do not affect m any way the meaning or interpretation of any provision of this Contract
Notices
Any notice that may affect the provisions of this Contract shall be deemed delivered to the Group when
deposited in the United States mail, with prepaid postage, addressed to the Group at the most recent
address listed for the Group Any notice that may affect the provisions of this Contract shail be deemed
delivered to KPS when deposited m the United States mad, with prepaid postage, addressed to
KPS Health Plans
P 0 Box 34803
Seattle, WA 98124-1803
Any requirement of KPS to provide notice to Enrollees shall be fulfilled when the Group has received such
notice It is the responsibility of the Group to disseminate notices to Enrollees withm 31 days of receipt
Severability
If a court of competent �urisdiction deems any term, provision, Endorsement, or condition of this Contract
invalid or unenforceable, the same shall be deemed severable from this Contract The remainmg provisions
of this Contract shall remain in full force and shall m no way be affected or invalidated as a result of such
decision
Third Party Benefic�aries
There are no third party beneficiaries to this Contract
Waiver of Breach
Waiver of a breach of any provision of this Contract shall not be deemed to be a waiver of any other breach
of the same or different provision
Page 11
COVERAGE CONTRACT
The following topics are described in detail in Attachment A Please refer to the Table of Contents in
Attachment A to locate each section
ELIGIBILITY AND ENROLLMENT
➢ Continuation of Inpatient Coverage
➢ Continued Eligibility for Disabled Dependent Children
BENEFITS SUMMARY
CONTINUATION OF COVERAGE
➢ Coverage During a Labor Dispute
➢ Continuation of Group Coverage
➢ Conversion Coverage
, COORDINATION OF BENEFITS (COB)
KPS'S RIGHT OF REIMBURSEI1flENT AND SUBROGATION
COMPLAINTS AND APPEALS PROCESS
ENROLLEE RIGHTS
➢ KPS Privacy Policy
➢ Statement of ERISA Rights
Page 12
KPS Health Plans
400 Warren Avenue
Bremerton, WA 98337
City of Bremerton - Plan B
Benefits Booklet
This Benefits Booklet has been prepared for City of Bremerton — Plan B It contams information
you need to know concerning eligibility, enroliment, plan benefits, and your nghts under this Group Plan
The Group Plan you have chosen is a Preferred Provider Option ("PPO") Plan Under this PPO
Plan, you are entitled to receive care either from a Participatmg or Non-Participating Prowder or Facility
The level of benefit coverage you receive depends on the Provider you choose for your care In most
cases, your overall coverage is greatest, and your out-of-pocket expenses are the lowest, when you
choose a Participating Provider or Participating Facility
The terms "you" and "your" refer to the person(s) enrolled in this Group Plan The terms "we,"
"us," and "our," refer to KPS The capitalized words used throughout this Benefits Booklet have specific
meanings The definitions of capitalized words can be found m the Definitions section at the end of this
Benefits Booklet
KPS Health Plans believes this plan is a"grandfathered health plan" under the Patient Protection and
Affordable Care Act As permitted by the Affordable Care Act, a grandfathered health plan can preserve
certam basic health coverage that was already in effect when that law was enacted Bemg a
grandfathered health plan means that your plan may not mclude certain consumer protections of the
Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive
health services without any cost sharmg However, grandfathered health plans must comply with certain
other consumer protections in the Affordable Care Act, for example, the elimmation of lifetime limits on
benefits
Questions regarding which protections apply and which protections do not apply to a grandfathered
health plan and what might cause a plan to change from grandfathered health plan status can be directed
to KPS Customer Service at 360-478-6796, or toll-free at 1-800-552-7114 You may also contact the
Employee Benefits Security Admirnstration, U S Department of Labor at 1-866-444-3272 or
www dol gov/ebsa/healthreform This website has a table summarizing which protections do and do not
apply to grandfathered health plans
66136REM-B
Table of Contents
ELIGIBILITY ENROLLMENT ......................................................................................................1
Who Can Enroll m This Group Plan 1
When to Enroll in This Group Plan 1
Enrollment Under Special Circumstances 1
How to Enroll 2
Enrollment Changes 2
When Coverage Begins 2
When Coverage Ends 3
Continuation of Inpatient Coverage 3
Continued Eligibility for Disabled Dependent Children 4
HOW THE GROUP PLAN WORKS ....................................................................................................4
Waiting Periods 4
Choosing a Provider or Hospital 5
Services Which Require Prior Authorization 6
How to Submit Claims for Payment 7
Benefits Management 8
YOUR OUT-OF-POCKET COSTS .....................................................................................................8
Deductible 8
Copayments 9
Annual Comsurance Maximum 9
BENEFITS SUMMARY ..................................................................................................................1 O
DESCRIPTION OF COVERED BENEFITS AND SERVICES ..................................................................
Preventwe Care 15
Professional Services 16
Hospital Services 16
Acupuncture Needle Treatment 17
Ambulance Transportation 17
Anesthesia for Dental Procedures — Not Received in the Dentist Office 17
Blood Bank 17
Bone Bank 17
Cardiac Rehabilitation 18
Colorectal Cancer Screening 18
Contraceptive Services 18
Diabetic Education, Equipment, and Supplies 18
Home Health and Hospice Care 18
Kidney Dialysis - 20
Laboratory and Radiology Services 20
Mastectomy Care 20
Maternity Care 20
Medical Equipment and Supplies 21
Mental Health Care 22
Neurodevelopmental Therapies 23
Newborn Care 23
Nutritional Gu�dance Counseling 23
Oral Surgery 24
Organ, Bone Marrow, Stem Cell and Tissue Transplants 24
Oxygen and Oxygen Supplies 26
Phenylketonuria (PKU) Formulas 26
Plastic and Reconstructive Surgery 26
Rehabilitation 26
Skiiled Nursing Facility Care 27
Sieep Disorders 27
Spinal and Extremity Marnpulation
Substance Use Disorder Treatment (Chemical Dependency)
Termination of Pregnancy
Women's Health Care Services
Pharmacy Benefits
27
27
28
28
29
LIMITATIONS AND EXCLUSIONS ...................................................................................................
CONTINUATION OF COVERAGE ....................................................................................................
Coverage During a Labor Dispute 33
Contmuation of Group Coverage 33
COBRA (Consolidated Omnibus Budget Reconciliation Act - 1985) 33
Conversion Coverage 34
COORDINATION OF BENEFITS (COB) ...........................................................................................
General Provision 35
Definitions 35
Order of Benefit Determination Rules 36
Effect on Benefits 38
Right to Receive and Release Information 38
Facility of Payment 38
Right of Recovery 38
Notice to Enrollees 38
Additional Information 38
KPS'S RIGHT OF REIMBURSEMENT AND SUBROGATION ...............................................................
Collection and Reimbursement by Enrollee 39
Underinsured or Uninsured Motorist Coverage 39
Cooperation 40
Recovery of Claims Payments 40
COMPLAINTS AND APPEALS PROCESS ........................................................................................
If You Have a Complaint 41
Standard Appeals Process 41
First Level Appeal 42
Independent Review Organization (IRO) 42
Second Level Appeal (OPTIONAL) 43
Expedited Appeals Process 43
Appeals Related to Continuation of Care 43
ENROLLEE .....................................................................................................................43
KPS Privacy Pohcy `� 43
Disclosure of Information 45
Statement of ERISA Rights 45
Women's Right to Direct Access 46
Your Right to Safe and Effective Pharmacy Services 46
HOW YOU CAN STOP HEALTH CARE FRAUD ................................................................................47
DEFINITIONS ..............................................................................................................................48
CONTACT .............................................................................................................................52
Benefits Booklet
ELIGIBILITY AND ENROLLMENT
Who Can Enroll in This Group Plan
Active, full-time employees (except LEOFF I and LEOFF II Employees) and their Eligible Dependents are
eligible to enroll in this Group Plan Eligible Dependents of active, full-time LEOFF I and LEOFF II
flrefighters are also eligible to enroll in this Group Plan
The children of an Eligible Dependent Child cannot enroll m this Group Plan
When to Enroll in This Group Plan
You and your Eligible Dependents must apply for coverage under this Group Plan 31 days following the
date of your mitial eligibility If additional Premium is required, the application and Premium for newborn or
adopted Children must be received by KPS withm 60 days of the Child's date of birth, adoption,
placement for adoption, or when you or your Spouse assume legal obligation for the total or partial
support of a Chdd in anticipation of adoption If you do not enroll when you are mitially eligible, you must
wait until the next Open Enrollment Period, except in certain circumstances (see the Enrollment Under
Special Circumstances section)
NOTE When additional Premium is not required, we encourage enrollment as soon as possible to
prevent delays in claims processing
Please contact your Group Plan Admmistrator for more information regarding eligibility and enroliment
Enroliment Under Special Circumstances
Loss of Other Coverage
If you and/or your Eligible Dependents involuntarily lose coverage under another health plan, you may
apply for coverage under this Group Plan if the following applies
➢ You declined enrollment in this Group Plan
➢ You lose eligibility in another health plan or your coverage is termmated due to the followmg
o Legal separation or divorce
o Cessation of dependent status
o Death of Employee
o Termination of employment or employer contributions
o Reduction in hours
o Loss of mdividual or group market coverage because of move from plan area or
termination of benefit plan
o Exhaustion of COBRA coverage �
➢ Your application to enroll in this Group Plan is received by KPS within 31 days of losing other
coverage Coverage will be effective the first day of the month followmg receipt of application
If these conditions are not met, you must wait until the next Open Enrollment Penod to apply for coverage
NOTE Eligible Dependents may enroll in this Group Plan only with a Subscriber
State Sponsored Coverage
If you declined coverage when you were eligible to enroll in this Group Plan, you may subsequently apply
for coverage in the event that the Department of Social and Health Services (DSHS) has determmed that
it is cost-effective to enroll you or your Eligible Dependents in this health plan Application for coverage
must be submitted to KPS within 60 days following the determination by DSHS Coverage wdl be effective
as of the first day of the month following receipt of application
City of Bremerton Pian B , Page 1
Benefits Booklet
Marr�age, B�rth, Adoption, or Placement for Adopt�on
If you declined enrollment in this Group Plan, you may apply for coverage for yourself and your Eligible
Dependents in the event of marriage, birth of a Child, adoption, placement for adoption, or when you or
your Spouse assume legal obligation for total or partial support of a Child in anticipation of adoption
Application for enrollment must be received by KPS
➢ Within 31 days following the date of marriage
➢ Within 60 days, if additional Premium is required, following the date of birth, adoption, placement for
adoption, or when you or your Spouse assume legal obligation for total or partial support of a Chdd in
anticipation of adoption
➢ At the next Open Enrollment Period if these timeframes are not met
NOTE When additional Premium is not required, we encourage enroliment as soon as possible to
prevent delays in claims processing
Court-ordered Coverage
If you declined coverage when you were eligible to enroll in this Group Plan, you may subsequently apply
for coverage in the event you are required to provide health care coverage for Eligible Dependent
Children as a result of a court order KPS requests that any application for coverage be submitted within
31 days following the date of the court order Coverage wdl become effective on the first day of the month
following the effective date of the court order
How to Enroll
To enroll in this Group Plan, complete an enrollment application form You may obtain an enrollment
application form from your Group Plan Administrator To avoid possible delays in processing your
application, please provide all the requested information for every person who will be covered under this
Group Plan Delays caused by an incomplete application could result in delayed payment of your medical
claims
If you are required to pay all or a portion of your Premium, you must include the Premium payment for
your first month of coverage with your enrollment application
Please submit enrollment forms and Premium payments to your Group Plan Administrator
Enrollment Changes
if you need to add or remove an Eligible Dependent, please contact your Group Plan Administrator to
obtain the necessary forms Return all completed forms to your Group Plan Administrator See the When
Coverage Begins and When Coverage Ends sections for additional information on when Eligible
Dependent coverage begins and ends
When Coverage Begins
Coverage begins on your initial date of eligibility, provided you enrolled within the specified time penod,
and you paid the applicable Premium
If you enrolled during an Open Enrollment Penod, your coverage wdl begin on the first of the month
following the Open Enrollment Period
Newborn Children who meets eligibility requirements are covered automatically for a period of three (3)
weeks from the date of birth, provided either the female Subscriber, or male Subscriber's Spouse, is
eligible for maternity coverage under this Group Plan at the time of the Chdd's birth If additional Premium
is required, coverage will not extend beyond the three (3) week period, unless the Children are enrolled
within 60 days of the date of birth Any applicable Premium must accompany the enrollment application
Page 2 City of Bremerton Plan B
Benefits Booklet
if additional Premium is required, coverage for adopted Children begins on the date the Children are
adopted, legally placed for adoption, or when you or your Spouse assume legal obligation for total or
partial support of Children in anticipation of adoption, provided that the Children are enrolled within 60
days from the date of placement or financial responsibility and the applicable Premium is paid by the
Premium Due Date
NOTE When additional Premium is not required, we encourage enrollment as soon as possible to
prevent delays m claims processmg
When Coverage Ends
Your coverage ends on the last day of the month in which you lose eligibdity provided all applicable
Premium amounts have been paid In the case of non-payment of Premium, coverage ends on the last
day of the month for which KPS received payment
If you lose coverage under this Group Plan, you may be eligible to contmue coverage or enroll in a KPS
Conversion Plan Please see the Continuation of Coverage section regardmg your rights under the
Consolidated Omnibus Reconciliation Act of 1985 (COBRA) and KPS Conversion coverage
If you voluntardy disenroll from this Group Plan while stdl an Employee, you wdl not be eligible to re-enroll
in this Group Plan untd the next Open Enrollment Period Please see the Enroliment Under Special
Circumstances section for exceptions to this policy
Upon termmation of coverage, either KPS or your Group Plan Admmistrator wdl issue you a Certificate of
Creditable Coverage, certifymg the penod(s) during which you were enrolled in this Group Plan You
should present this certificate to any subsequent health plan in which you may enroll as proof of your pnor
health care coverage to receive credit toward any Pre-existing Condition exclusion You may request a
Certificate of Creditable Coverage at any time during your enrollment in this Group Plan and up to 24
months after your enrollment ends A Certificate of Creditable Coverage may be requested by contactmg
a KPS Customer Service Representative at 360-478-6796 or toll-free at 1-800-552-7114
If you obtamed coverage through intentional misrepresentation of material fact or fraud your coverage
may be rescmded or terminated upon thirty (30) calendar days written notice In no event will you be
terminated or rescinded solely on the basis of your physical or mental condition provided you meet all
other eligibility requirements set forth by the Group You may appeal a termination or rescission decision
through the KPS appeals process
Continuation of Inpatient Coverage
if you are receivmg inpatient care m an accredited general Hospital or other approved facility on the date
that coverage would otherwise end, you are eligible to contmue receiving benefits under this Group Plan
provided the following conditions are met
➢ KPS pre-authorized the mpatient care (see the Services Which Require Prior Authorization
section)
➢ All applicable Premium amounts contmue to be paid
KPS will continue to provide benefits under this Group Plan, untd one of the following events occurs
➢ You are no longer receiving inpatient care
➢ The KPS Medical Director determmes that inpatient care is no longer Medically Necessary
➢ You do not continue to pay your Premium
➢ Three (3) consecutive months have elapsed since the date your coverage would have otherwise
ended
➢, You enroll m another KPS plan or in any other health plan that provides inpatient Hospital
benefits
You are not eligible for the extended coverage described above if, on the date coverage would otherwise
end, one of the following applies
➢ You are covered under any other group or individual medical plan with simdar inpatient benefits
➢ You are eligible for continuation of coverage under COBRA or any other continuation provision
If you have any questions, please contact a KPS Customer Service Representative at 360-478-6796, or
tol I-free at 1-800-552-7114
City of Bremerton Plan B Page 3
Benefits Booklet
Continued Eligibility for Disabled Dependent Children
Coverage for an Eligible Dependent Chdd may be continued after the Child reaches the Limiting Age
provided both of the following conditions are met
➢ Your Child is incapable of self-sustaming employment due to developmental disabdity or physical
handicap �
➢ Your Child is dependent upon you or your Spouse for total or partial support
Proof of your Child's dependence must be submitted to KPS within 31 days of the date your Child reaches
the Limiting Age Thereafter, KPS may require that you resubmit proof of your Chdd's continuing
dependence This proof is requested no more frequently than annually after the two-year penod following
the Chdd's attainment of the Limitmg Age Please contact your Group Plan Administrator for more
mformation regardmg continuation of coverage for a disabled Chdd
A disabled Child will continue to be eligible for coverage until any one of the following events occurs
➢ You do not submit proof of your Child's continuing dependence as a result of disability or physical
handicap
➢ It is determined that your Child is no longer developmentally disabled or physically handicapped
(based on the evidence submitted)
➢ You are no longer covered under this Group Plan
➢ You do not continue to pay your Premium
➢ KPS terminates this Group Plan
A Chdd who is no longer eligible for coverage as a disabled dependent Child may qualify for coverage
under COBRA or a KPS Conversion plan (see the Continuation of Coverage section)
HOW THE GROUP PLAN WORKS
Waiting Periods ,
Pre-exist�ng Cond�t�ons
If you are age 19 and older you must be enrolled in this Group Plan for a period of three (3) consecutive
months before KPS wdl provide benefits for a Pre-existing Condition , A Pre-existing Cond►t►on is any
condition for which you received medical advice during the three (3) month period immediately preceding
your date of enrollment in this Group Plan or for which your Provider recommended or provided
treatment Genetic information shall not be treated as a Pre-existmg Condition, unless there has been a
diagnosis of the condition related to the specific genetic information
No Pre-existmg Condition limitations apply to Enrollees under 19 years of age
Transp/ant Procedures
KPS provides coverage for transplant procedures only after you have been continuously enrolled under
this Group Plan for six (6) months This transplant waiting period applies to the transplant procedure, as
well as any pre- and post-transplant care directly related to a transplant you receive while covered under
this Group Plan
Cred�table Coverage
If you were required to complete an employer imposed probationary period, the waiting periods begin on
the first day of your probationary period The Pre-existing Condition and transplant procedures waiting
periods may be reduced, by the number of months of Creditable Coverage you have accrued under other
health care programs prior to your enrollment in this Group Plan "Creditable Coverage" means penods
of other health coverage an Enrollee may use to reduce Pre-existing Condition and transplant procedures
waiting periods These mclude
➢ Group health coverage
➢ Part A or Part B of Medicare
➢ Medicaid
➢ Mditary health coverage
Page 4 City of Bremerton Plan B
Benefits Booklet
➢ Indian Health Service or tribal coverage
➢ State High Risk Pool
➢ Federal or Public Health Plans
➢ Peace Corps Plan
➢ State Children's Health Insurance Program
➢ Other health insurance coverage
You will receive credit for prior Creditable Coverage if it was contmuous and terminated no more than
three (3) months immediatelv precedinq enrollment in this Group Plan Health coverage will be
considered contmuous if there was no more than a three (3) month break between any Creditable
Coverage No credit wdl be given if the�e was mo�e than a three (3) month break in coverage befinreen
your prior plan and your effective date of enrollment in this Group Plan Any employer imposed
probationary period wdl not be considered a break in coverage or Creditable Coverage
Waiting period requirements do not apply to the followmg
➢ Pregnancy
➢ Formulas necessary for the treatment of phenylketonuria (PKU)
➢ Prescription drugs included in Pharmacy Benefits
➢ Newborn Chddren or adopted Children
Choosing a Provider or Hospital
KPS pays for services rendered by the followmg types of Providers when the services provided are
Medically Necessary and are Covered Benefits and Services under this Group Plan and when Providers
are acting withm the scope of their medical license or certification
Advanced Registered Nurse Practitioner (A R N P)
Certified Chemical Dependency Provider
Certified Mental Health Provider
Chiropractor
Dentist
East Asian Medicine Practitioner (Acupunctunst)
Massage Therapist "`
Naturopath (N D )
Nurse Midwife
Occupational Therapist *
Physical Therapist'`
Physician (M D or D O)
Physician's Assistant (P A )
Podiatrist
Psychologist
Speech Therapist *
"Therapy services will be covered when prescnbed by your physician
NOTE This list does not include all types of Providers covered by KPS if your Provider type is not listed
above, please contact KPS toll-free at 1-800-552-7114 to request more information
KPS has agreements with health care professionals and facdities, which are Participating Providers and
Facilities, to ensure you have access to all Covered Benefits and Services For a current listing of
Participating Providers and Facdities in your area, please contact KPS toll-free at 1-800-552-7114, or visit
our Web site at www kpshealthplans com
KPS does not require a referral for specia/ry care, however, therapy serv►ces require a prescnption as
noted above As a general rule, you may receive care from any licensed or certified health care Provider
or Facdity Your choice of Providers and Facilities wdl affect the level of benefit coverage you receive as
well as your out-of-pocket costs
When you choose a Participating Provider or Facility, your out-of-pocket costs are less than if you choose
a Non-Participating Provider or Facility If you choose a Non-Participatmg Provider or Facility, your out-of-
pocket costs are sigrnficantly higher because KPS reduces the allowed amount for Covered Services by
twenty-five percent (25%) In addition, it is your responsibility to pay the difference between any amounts
bdled by the Non-Participating Provider or Facility and the amount paid by KPS
City of Bremerton Plan B Page 5
Benefits Bookiet
In certain instances, the care you receive from a Non-Participating Provider or Facifity is not sub�ect to the
reduction in the level of benefit coverage Those instances are
➢ Medical Emergency Emergency care is covered in full after you have met any applicable
Deductible, Copayment, or Coinsurance if you are admitted to a Non-Participating Hospital as a
result of your Emergency, KPS reserves the right to arrange for your transportation to a
Participating Hospital (see the Emergency Admissions section)
➢ Services Not Avadable from Participating Providers/Facilities KPS has the nght to determine
whether care and services are, or are not, avadable from a Participating Provider or Facdity If you
believe the care or service you require is not avadable from a Participating Provider or Facdity,
please call KPS Customer Service before obtaining the care or service and ask for a review to
determine if it is appropriate for you to access care from a Non-Participating Provider or Facility If
KPS determines that the care or service you require can only be obtained from a Non-
Participating Provider or Facility, your care wdl be covered in full after you have met any
applicable Deductible, Copayment, or Coinsurance
IF you could have received your care from a Participating Provider or Facility, but chose to receive care
from a Non-Participating Provider or Facdity, you are financially responsible for paying the difference
between the amount paid by KPS and the amount billed by the Non-Participating Provider or Facdity This
is calle " balanc e bd l i ng "
What happens �f my Prov►der no /onger part►c�pates w►th KPS?
If your Participating Provider chooses to terminate their agreement with KPS, we wdl notify you of the
termination The notification wdl allow at least 60 days to either, (i) complete your course of treatment, or
(u) appropriately transfer your care to another Participating Provider After the 60 days, services received
from a Provider who has terminated their agreement w�th KPS wdl be covered at the Non-Participating
Provider benefit level
Services Which Require Prior Authorization
NOTE The following list of services that require prior authorization is not all-inclusive Enrollees and
Providers should contact KPS Customer Service for updated mformation whenever there is a question
concerning coverage
You must get prior authorization from KPS before receiving the following services
➢ Anesthesia for dental procedures
➢ Home health and hospice care
➢ Inpatient care that is elective or non-emergent
➢ Organ transplants
➢ Oxygen and oxygen supplies
➢ Plastic and reconstructive surgery
➢ Skdled Nursing Facility care
➢ Surgical treatment for sleep disorders
➢ Inpatient behavioral health (Mental Health Care and Substance Use Disorder Treatment
(Chemical Dependency)) NOTE Prior authorization of behavioral health care is not required in�
the case of mvoluntary commitment or Emergency detoxification
Some services, such as certain medical equipment and supplies, require prior authorization for specific
items Please see the Descr�ption of Covered Benefits and Services section for more information
about sennces requiring prior authorization To obtam prior authorization for care, ask your Provider to
contact KPS KPS will send both you and your Provider written confirmation that the care or service has
been authorized if your care is Medically Necessary, but your Provider did not get pnor authorization
from KPS, payment to your Provider wdl be reduced by 20% No coverage is provided for services that
are not Medically Necessary
Page 6 City of Bremerton Plan B
Benefits Booklet
All requests for pnor authorization are reviewed and approved based on Medical Necessity, eligibility, and
benefits To determme Medical Necessity, KPS uses nationally accepted guidelmes that are also
accepted by Medicare If a calendar year ends dunng the course of an ongoing treatment plan, you or
your provider must call for re-authorization for the new calendar year
If there are urgent circumstances involving your health, KPS wdl make a decision regarding the
authorization withm 48 hours of receivmg the request In non-urgent circumstances, both you and your
Provider wdl be notified of the decision within five (5) calendar days following receipt of necessary
information
Authorization Extens�ons
If you need to extend the care you are currently receiving, have your Provider contact KPS to request an
extenswn An extension should be requested before the current authorizatwn for care ends
E/ect�ve and Non-emergent Hosp�ta/ Care
Coverage for elective and non-emergent inpatient care is provided only for the number of days approved
by KPS If your stay in the Hospital lasts longer than the number of approved days, your Provider must
obtain approval for the additional days In addition, KPS will monitor your inpatient stay to ensure
continued Medical Necessity and may assist your Provider with discharge plannmg
Emergency Admissions
If you are admitted to the Hospital as a result of an Emergency, you are not required to obtam prior
authorization However, you or your Provider must contact KPS within 48 hours of your admission, or as
soon as is reasonably possible, to complete the certification process Failure to do so could result in
reduced benefit coverage
If you are admitted to a Non-Participating Facility as a result of your Emergency, KPS may choose to
have you transferred to a Participating Facility as soon as it is medically feasible KPS will work closely
with your Provider to determme when and if you can be safely transferred to a Participatmg Facility
In the event you are admitted to a Non-Participatmg Facility as a result of your Emergency condition, your
benefits are paid at the higher Participating Provider level
How to Submit Claims for Payment
In most instances, Participating Providers and Facilities submit claims directly to us on your behalf When
this is the case, you are not required to fill out any claim forms
If your Provider does not submit claims directly to KPS on your behalf, you must send the claim to KPS
yourself To submit a claim, you must include the following mformation
➢ The Subscribe�'s name and ID number (shown on your KPS identification card)
➢ The Group name and ID number (shown on your KPS identification card)
➢ The patienYs name and ID number (if the patient and the Subscriber are not the same person)
➢ The onginal itemized bill from your Provider
➢ For out-of-count� claims (Emergency care onlvl — provide all of the above information, translated
mto English, including the type of service, charges in U S Dollars, and proof of travel
Send the above information to
KPS Health Plans
Attn Customer Service
P O Box 34803
Seattle, WA 98124-1803
All claims must be filed within 12 months, following the date of service KPS will not process any claims
that are older than 12 months
City of Bremerton Plan B Page
Benefits Booklet
How Will I Know What Happened to My C/a�m?
After KPS processes your claim, an Explanation of Benefits (EOB) form is sent to both you and your
Provider The EOB explains how your claim was processed and contains information regarding your
rights if you have any questions regarding the outcome
KPS processes most claims within 30 days, unless additional information is required to make a decision
regarding your benefits
Benefits Management
In certain cases, KPS, at its sole discretion, may choose to authorize coverage for benefits or services
that are not otherwise included as Covered Benefits and Services under this Group Plan Such
authorization is done on a case-by-case basis if a particular benefit or service is �udged to be Medically
Necessary, beneficial, and cost effective However, KPS's decision to authorize services in one instance
does not commit KPS to cover the same or simdar services in other instances KPS's decisi on to
authonze services does not constitute a waiver of KPS's right to enforce the provisions, limitations, and
exclusions of this Group Plan
YOUR OUT-OF-POCKET COSTS
Deductible
The Deductible is the amount you and/or your famdy are required to pay out-of-pocket each Calendar
Year before KPS pays for your Medically Necessary Covered Benefits and Services Please refer �to the
Benefits Summary section for the Deductible applicable to this Group Plan
You and each of your Eligible Dependents must satisfy separate Deductible requirements However, if
you satisfy the famdy Deductible requirement in any one Calendar Year, then any remaining unmet
individual Deductibles for you and your Eligible Dependents are waived for that same Calendar Year
Only charges for Medically Necessary Covered Benefits and Services are counted toward the
accumulation of your Deductible The following amounts are not included in the calculation of your
Deductible
➢ Copayments
➢ Coinsurance �
➢ Charges for non-Covered Benefits and Services
➢ Charges in excess of the amount allowed by KPS for Non-Participating Providers
➢ Charges for Covered Benefits and Services to which the Deductible does not apply
Prior P/an Deduct�ble
If you met all or a portion of your Deductible under another KPS plan immediately prior to enrolling in this
Group Plan, KPS wdl credit the amount accrued under the prior plan provided that �
➢ Those amounts were accrued during the same Calendar Year that you enrolled in this Group
Plan
➢ You had no break in coverage between KPS plans
Pr�or Year Carryover
Any portion of your Deductible which is met in the last quarter of the immediately prior Calendar Year is
applied toward your Deductible for the current Calendar Year
Inpat�ent Hosp�ta/ Care
if your hospitalization begins m the current Calendar Year and contmues uninterrupted into the next, your
Deductible and Coinsurance for the next Calendar Year will not begin until after discharge
Page 8 C�ty of Bremerton Plan B
Benefits Booklet
Copayments
A Copayment is an amount that you are required to pay your Provider at the time of service Professional
office visits that require a Copayment are not sub�ect to the Deductible, unless otherwise specified in the
Benefits Summary section
Copayments are not counted toward the calculation of your annual Deductible or any Coinsurance
Maximum You must continue to pay Copayments even after you have reached your Coinsurance
Maximum
Please refer to the Benefits Summary section for any applicable Copayments on this Group Plan
Annual Coinsurance Maximum
NOTE This section was formerly referred to as "Annual Out-of-Pocket Maximum on Comsured Benefits
(Stoploss) " The term Coinsurance Maximum replaces the term Stoploss
Please refer to the Benefits Summary section for the Comsurance Maximum applicable to this Group
, Plan
If, dunng a Calendar Year, the amount of Comsurance you have paid reaches or exceeds the
"Comsurance Maximum Per Enrollee," KPS will provide reimbursement for Covered Benefits and
Services at 100% of the KPS allowance for the remamder of that Calendar Year
if, dunng a Calendar Year, the amount of Comsurance you have paid m combmation with your enrolled
Eligible Dependents reaches or exceeds the "Comsurance Maximum Per Family," KPS will provide
reimbursement for Covered Benefits and Services at 100% of the KPS allowance for the remainder of
that Calendar Year
The following costs are not used to calculate the Coinsurance Maximum
➢ Deductible — must be met before Coinsurance leveis apply
➢ Copayments
➢ Charges for prescription drugs
➢ Charges incurred after an annual or lifetime maximum benefit for a specific service or supply has
been exhausted, such as the annual maximum benefit for Medical Equipment and Supplies
➢ Charges for non-Covered Benefits and Services and supplies
➢ The difference between what a Non-Participating Provider charges for a service and what KPS
allows for the service
City of Bremerton Plan B Page 9
Benefits Booklet
BENEFITS SUMMARY
Outimed on the following pages are the basic benefits and benefit maximums provided by KPS to you, as
an Enrollee, in this Group Plan Also included are the limits of your financial responsibility, as well as
other specific limitations relative to coverage under this Group Plan For a more complete description of
the benefits provided, please read the Description of Covered Benefits and Services section
ANNUAL DEDUCTIBLE
Per Enrollee $100
Per Famdy $300
Coinsurance Maximum
Per Enrollee — Medical and Surgical $200
Per Enrollee — Pharmacy $150
LIMITING AGE
Dependent Chddren Up to Age 26
Well-baby Care 36 Months
WAITING PERIODS
Pre-existing Conditions 3 Months
Transplant Procedures 6 Months
COPAYMENTS
Office/Home/Urgent Care Center Visits $10
Page 10 City of Bremerton Plan B
Benefits Booklet
KPS provides the followmg Medically Necessary benefits and services, at the ind�cated reimbursement
percentage. Benefits paid at 100% are not sub�ect to the annual Deduct�bie. Benefits paid at 80% will be
paid at 100% once the Coinsurance Maximum (previously Stoploss) has been satisfied.
0 0 �
� � r
Preventive Care
Well-baby Care — From birth through the limitmg age for well-baby
care — mcludes physical examinations and immunizations Not a benefit 80%
(Not sub�ect to Deductible)
Child and Adult Preventive Care —includes routme physical
examinations, laboratory and x-ray services (except mammography
and prostate cancer screening), immurnzations See Laboratory and 100% 100%
Radiology Services for mammography and prostate cancer
screening benefits
Professional Services — Med�cal and Surg�cal
Care and Services Received m a Hospital or Skdled Nursing Facdity 100% 100%
Care and Services Received in the Office or Urgent Care Center 100% after $10 100% after $10
Copayment Copayment
Care and Services Received in Your Home 100% after $10 100% after $10
Copayment Copayment
Care and Services Received in an Ambulatory Surgical Center 80% 80%
Care Received in the Emergency Room 100% 100%
Hospital Services
Prior authonzation required for non-emergent and elective care
Inpatient Medical and Surgical Services
Semi-pnvate Room and Board ` 80% 80%
Special Care Urnt (e g, ICU, CCU)
Outpatient Care
Medical and Surgical 80 �� ° 80 �� °
Emergency Room Facdity and Supplies 90% 90%
Acupuncture Needle Treatment 100% after $10 100% after $10
12 treatments maximum per Calendar Year Copayment Copayment
Ambulance
Ground Transportation $�% 80 %
Air Transportation 80% 80%
Anesthesia for Dental Procedures — Prior authorization reqwred 80% 80%
Blood Bank 80% 80%
Bone Bank 80% 80%
Cardiac Rehabilitation 80% 80%
City of Bremerton Plan B Page 11
Benefits Booklet
KPS provides the foliowing Medically Necessary benefits and services, at the indicated reimbursement
percentage. Benefits paid at 100% are not sub�ect to the annual Deductible. Benefits paid at 80% wdl be
paid at 100% once the Coinsurance Maximum (previously Stoploss) has been satisfied.
• p
►
" • � ' D
Colorectal Cancer Screening
Routine Screenin 100% 100%
Diagnostic , See Professional & Hospital Services Sections
Contraceptive Services
Prescnption contraceptives are covered under Pharmacy Benefits See Professional Services Section
Diabetic Education, Equipment, and Suppl�es
Pnor authorization may be required
Health Education and Trairnng See Professional Services Section
Medical Eqwpment gp% gp�/,
Home Health Care — To a maximum of 130 vis�ts per Calendar Year 100% 100%
Prior authorization required
HospiCe Care — To a maximum of 6 months per Calendar Year 100% 100%
Prior authorization reqwred ,
Kidney Dialysis — Outpatient facdity or Hospital 80% 80%
Laboratory and Radiology Services
Inpatient Hospital and Ambulatory Surgical Center 100% 100%
Emergency Room 100% 100%
Mammography Services
Routine Screernng 100% 100%
Diagnostic 100% 100%
Prostate Cancer Screernng
Routine Screening 100% 100%
Diagnostic 100% 100%
All Other Laboratory and Radiology Services 100% 100%
Mastectomy Care
Prior authorization required for inpatient Hospital services only See Professional & Hospital Services Sections
Medical services
Prostheses & mastectomy bras 100% 100%
Maternity Care — Subscriber and Spouse only See Professional & Hospital Services Sections
Medical Equipment and Supplies g0% 80%
Prior authorization may be required
Mental Health Care — Pnor authorization reqwred
Inpatient Care 80% 80%
Outpatient Care 100% after $10 100% after $10
Copayment Copayment
Page 12 City of Bremerton Plan B
Benefits Booklet
KPS provides the following Medically Necessary benefits and services, at the indicated reimbursement
percentage. Benefits paid at 100% are not sub�ect to the annual Deductible. Benefits paid at 80% will be
paid at 100% once the Coinsurance Maximum (previously Stoploss) has been satisfied.
• o �
.
@ p D
Neurodevelopmental Therap�es Not a benefit 80%
Speech, Physical, Occupational Therapy
Newborn Care
Routme Nursery Care (Not sub�ect to Deductible) Not a benefit 80%
See Professional &
All Other Care Not a benefit Hospital Services
Sections
Nutrit�onal Guidance Counseling 80% 80%
Oral Surgery 80% Not a benefit
Organ, Bone Marrow, Stem Cell and Tissue Transplants
Prior authonzation re uired
Participating Provider 100% 100%
Non-Participating Provider —$350,000 lifetime maximum 80% 80%
Oxygen and Ouygen Supplies — Prior authorization required 80% 80%
Phenylketonuria (PKU) Formulas 100% 100%
Plastic and Reconstructive Surgery — Pnor authonzat�on requ�red 80% 80%
Rehabilitation — Prescnbed by your physician
Inpatient — 30 days maximum per condition 100% 100%
Outpatient 80% 80%
Skdled Nursmg Facil�ty — Prior authorization required
100% 100%
365 days lifetime maximum
Sleep Disorders
Pnor authonzation required for surgical treatments only
Sleep Studies
Medical Services See Professional & Hospital Services Sections
Durable Medical Equipment and Supplies o 0
(including CPAP machmes) 80 /0 80 /o
Surgical Treatment 80% 80%
Spinal and Extremity Manipulation 100% after $10 100% after $10
20 office visits maximum per Calendar Year Copayment Copayment ,
Substance Use Disorder Treatment (Chemical Dependency)
Prior authorization required
Inpatient Care 80% 80%
Outpatient Care 100% after $10 100% after $10
Copayment Copayment
City of Bremerton Plan B Page 13
Benefits Booklet
Page 14 City of Bremerton Plan B
Benefits Booklet
DESCRIPTION OF COVERED BENEFITS AND SERVICES
The Covered Benefits and Services described below, plus any Riders or Endorsements mcluded with this
Benefits Booklet, comprise the total benefits provided by KPS under this Group Plan
All benefits and services are sub�ect to the Deductible, Copayment, and Coinsurance requirements
described in the Benefits Summary section, unless otherwise mdicated
Coverage is provided when ALL of the followmg conditions are met
➢ The benefit or service is Medically Necessary for the dlness, in�ury, or condition
➢ The benefit or service is provided by a licensed or certified health care Provider
➢ The benefit or service is not specifically excluded from coverage
➢ If necessary, KPS has given prior approval for the benefit or service
The amount KPS pays for each benefit or service is based on the reimbursement rate shown in the
Benefits Summary section
Preventive Care
Preventive care is care that is provided m the absence of a specific diagnosis of dlness or in�ury
Preventive care is provided for the specific purpose of preventing illness and disease
Please see the Laboratory and Radiology Services section for mammography and prostate cancer
screening benefits, as well as the Benefits Summary section for specific limitations regardmg age limits
and coverage
Preventive care, as listed below, is not sub�ect to the Deductible
Well-baby Care
Coverage for well-baby care mcludes routine physical examinations and chddhood immunizations for
Children up to and including the limiting age for well-baby care
Routme Physical Exammat�ons
Ongoing preventive care for Children (over the limiting age for well-baby care) and adults mcludes
coverage for routme physical exammations, associated laboratory and x-ray sennces (except
mammography and prostate cancer screening), and immurnzations
Immunizat�ons
Covered immunizations are based on guidelines established by the Advisory Committee on Immunization
Practices of the Centers for Disease Control
Please contact KPS Customer Service, or visit the KPS Web site at www kpshealthplans com, for current
information regarding covered immurnzations
There is no coverage under this benefit for immunizations required for employment purposes or drugs
and immunizations for travel purposes
City of Bremerton Plan B Page 15
d
Professional Services
Benefits Booklet
Covered professional services that are Medically Necessary and rendered by a Provider include the
following
➢ Medical, surgical, and behavioral health services in conJunction with an approved Hospital stay
➢ Medical, surgical and behavioral health services in an outpatient facdity
➢ Medical and surgical services in an ambulatory surgery facility
➢ Medical, surgical, and behavioral health services in an urgent care center
➢ Office, home, Hospital, and nursmg home visits and related services
➢ Consultations and second opinions
Office, home, and urgent care center wsits are sub�ect to the o�ce visit Copayment
Hospital Services
Inpatient Care (Requires prior authorization)
Non-emergent inpatient Hospital care must be pre-approved by KPS Coverage for pre-approved
inpatient care includes ;
➢ Semi-private room and board charges, unless KPS has specifically authonzed coverage for a
private room '
➢ intensive care unit (ICU) and coronary care unit (CCU) room charges
➢ Operating room and related equipment
➢ Anesthesia and anesthesia services, in con�unction with inpatient surgery
➢ Diagnostic x-ray and laboratory services
➢ Surgical dressings and supplies, including castmg supplies and implantable prosthetics, such as
pacemakers and artificial �oints
➢ Pharmacy services (administered drugs must be listed in the U S Pharmacopoeia and the
National Formulary of biologicals and solutions)
➢ Electrocardiograms and other diagnostic and monitoring sennces
➢ Blood and blood derivatives, mcluding administration charges
➢ Radiation and inhalation therapy services '
An inpatient stay for the purpose of Medically Necessary diagnostic testing is covered for the Subscriber
only
Outpat�ent Care
Coverage for outpatient care includes
➢ Outpatient medical and surgical care
➢ Anesthesia and anesthesia services, in con�unction with outpatient surgery
➢ Surgical dressings and supplies, including casting supplies and implantable prosthetics, such as
pacemakers and artificial �oints
➢ Radiation and mhalation therapy services
➢ Chemotherapy
➢ Hemodialysis services
➢ Blood transfusion services
Emergency Room Care
Coverage under this benefit is for the Emergency room facility and the supplies associated with care
received while there
All other services received in the Hospital Emergency room are paid at the applicable Coinsurance level
Please refer to the Benefits Summary section for this information
Page 16 City of Bremerton Plan B
Benefits Booklet
If you are admitted to the Hospital as a result of your Emergency, you, your Provider, or the Hospital must
contact KPS withm 48 hours of your admission, or as soon as is reasonably possible If you have been
admitted to a Non-Participatmg Hospital, KPS may, following consultation with your Provider, arrange to
have you transferred to a Participating Hospital There is no cost to you if KPS arranges your transfer to a
Participatmg Hospital
A Medica/ Emergency is a sudden and acute onset of a symptom or symptoms, mcludmg severe pain,
that would lead a prudent layperson, actmg reasonably, to believe that a health condition exists that
requires immediate medical attention, if failure to provide medical attention would result in serious
impairment to bodily functions or serious dysfunction of a boddy organ or part, or would place the person's
health in senous �eopardy Examples of Medical Emergency conditions include, but are not limited to,
heart attacks, cardiovascular accidents, poisonmgs, loss of consciousness or respiration, broken bones,
automobile accidents, severe bleeding, and convulsions
The use of an Emergency room for care not related to a Medical Emergency is not covered
Acupuncture Needle Treatment
Coverage under this benefit is limited Please refer to the Benefits Summary section
Acupuncture needle treatment is covered only if Medically Necessary and therapeutically appropriate for
the treatment of a condition, such as the treatment and management of pain
Ambulance Transportation
In the case of a Medical Emergency, the services of a licensed ground or air ambulance service are
covered to transport you to the nearest accredited general Hospital where adequate facdities for
treatment are available Coverage for ambulance services mcludes
➢ Ground transportation
➢ Air transportation
➢ All services associated with the transport (e g, specialized medical personnel, oxygen, IV fluids)
The use of any type of ambulance transportation for personal convenience is not covered under this
benefit
Anesthesia for Dental Procedures — Not Received in the Dentist Office
(Requires prior authorization)
Coverage under this benefit is provided for the professional and facility charges for inpatient Hospital and
outpatient surgery centers when
➢ The Enrollee is either under the age of seven (7) or physically or developmentally disabled,
➢ The service cannot be safely and effectively treated in a dental office, or
➢ The service is not for the convenience of the dentist or Enrollee
This benefit is considered medical and is sub�ect to applicable Deductible, Copayments, and
Comsurance
Blood Bank
Coverage under this benefit includes charges from a blood bank for processmg blood and its derivatives,
blood cross-matchmg, charges for whole blood, blood components, and blood derivatives, to the extent
these are not replaced by volunteer donors, and other blood bank services
Bone Bank
Coverage under this benefit includes charges from a bone bank in con�unction with a covered medical or
surgical procedure
City of Bremerton Plan B Page 17
Benefits Booklet
Cardiac Rehabilitation
CoSerage for cardiac rehabditation is provided for conditions, such as
➢ Angioplasty
➢ Ischemic heart disease/coronary artery disease
➢ Myocardial infarction
➢ Stable angina pectoris
➢ Heart transplant surgery
➢ Bypass surgery
Colorectal Cancer Screening
Coverage under this benefit includes colorectal cancer examinations and laboratory testing at the
frequency recommended under the guidelines of the United States Preventive Service Task Force, or the
Centers for Disease Control and Prevention, and as deemed appropriate by your physician after
consultation with you Services are provided if you are (i) at least 50 years of age, or (u) less than 50
years of age and at a high risk or very high risk for colorectal cancer, based on the recommendations of a
physician
Contraceptive Services
Coverage under this benefit includes contraceptive services, including the fitting of intra-uterine devices
and diaphragms, and contraceptive implants and in�ections, when done in the Provider's office
Prescription contraceptives are covered under Pharmacy Benefits
Diabetic Education, Equipment, and Supplies
(Requires pnor authorization for insulin pumps)
Coverage under this benefit, when recommended by your Provider,
and traming, diabetic equipment (e g, insulm pumps, insulin infusion
shoes and inserts when Medically Necessary), and supplies
Home Health and Hospice Care
(Requires pnor authorization)
includes diabetic health education
devices, glucometers, orthopedic
Home health and hospice care coverage is provided only as an alternative to hospitalization or care in a
Skdled Nursing Facility Coverage is sub�ect to approval of a wntten treatment plan submitted to KPS by
your attending Provider
Care must be Medically Necessary (or palliative for hospice only), ordered by your attending Provider in
consultation with you, and provided by a licensed hospice or home health agency
The services provided must be skdled services Skdled services are those services that are
➢ Provided by trained medical or paramedical personnel or persons, working under their direct
supervision
➢ Cannot be safely and adequately self-administered or performed by the average, rational,
non-medical person without the direct supervision of trained medical or paramedical personnel
Coverage for home health and hospice care is limited Please refer to the Benefits Summary section If
you exhaust your Hospice Care benefit limits, you may apply to KPS for an extension Extensions may
be authorized based on Medical Necessity
The services and supplies provided under this benefit do not duplicate any other coverage provided under
this Group Plan
Page 18 City of Bremerton Plan B
Benefits Booklet
Home Health Care
Coverage under this benefit includes
➢ Intermittent m-home visits by a registered nurse (R N), licensed practical nurse (L P N) or a
home health aide workmg under the direct supervision of an R N, L P N or licensed therapist, as
ordered in the approved treatment plan
➢ Services provided by a licensed or registered physical, occupational, speech, or mhalation
therapist, when such services are Medically Necessary to mamtain, restore, or improve functions
lost as a result of severe illness, m�ury, or surgery
➢ Drugs and medications necessary for the treatment of the illness or in�ury that are supplied by the
home health agency, based on a written prescription from your attending Provider
➢ Medical supplies dispensed by the home health agency
➢ The rental or purchase, as determined by KPS, of Medically Necessary durable medical
equipment, when prescnbed by your attending Provider
Coverage for home health care is limited to 130 visits per Calendar Year A visit is defined as any
encounter, in person, with any authorized home health agency worker who provides services to you
Coverage is avadable only if you are homebound with the exception of post delivery follow-up care
ordered by the attendmg Provider in consultation with the mother
Hosp�ce Care
Hospice care is available only if you are m the latter stages of a termmal illness Coverage is provided
under this benefit for a penod of six (6) months, unless KPS approves an extension
Coverage under this benefit includes
➢ Seven (7) days of inpatient hospice care
➢ Medically Necessary services and supplies provided by the hospice agency
➢ Drugs and medications necessary for the treatment of the illness or in�ury which are supplied by
the hospice agency, based on a written prescription from your attending Provider
➢ Intermittent m-home or hospice visits and correspondmg supplies required for pam management
(palliative care), when provided by a registered nurse (R N), licensed practical nurse (L P N),
medical social worker with a Masters in Social Work degree (M S W) or an aide under the
supervision of an R N or L P N
➢ Respite care, whether m the home or hospice facility, in order to provide temporary relief to your
primary care giver, coverage is limited to five (5) days of contmuous care for every three (3)
month period
Exc/us�ons
There is no coverage under either the Home Health Care or Hospice Care benefit for the followmg
➢ Financial or legal counseling services
➢ Spintual or bereavement counseling
➢ Housekeepmg or meal services
➢ Transportation, except as provided for under Ambulance Transportation
➢ Supportive equipment, such as handrails or ramps
➢ Custodial or maintenance care, which is designed primardy to assist you m the activities of dady
living, including, but not limited to the followmg
° Walking
° Gettmg m and out of bed
° Bathing
° Dressing
° Feeding
° Preparation of special diets
City of Bremerton Plan B Page 19
Benefits Booklet
° Supervision of inedications which are ordinardy self-admmistered
° Any care given to sustain you, when there is no reasonable likelihood the disabdity will be
reduced by such care
➢ Services provided by volunteers, household members, friends, or family members
➢ Any other service not specifically listed as covered under this benefit, or any service which is
specifically excluded under this Group Plan
Kidney Dialysis
Coverage under this benefit is provided for the treatment of acute and chronic kidney conditions
Coverage includes
➢ Penodic treatment and supplies at a Hospital or dialysis center
➢ Provider services associated with dialysis treatment
If you have chronic kidney failure, you are encouraged to apply for coverage under Medicare Parts A and B
Laboratory and Radiology Services
Diagnostic and therapeutic laboratory and radiology (x-ray) services are covered when prescribed in
con�unction with a covered medical condition and when Medically Necessary for the diagnosis or
treatment of a covered condition Coverage under this benefit includes
➢ Inpatient and outpatient diagnostic laboratory and pathology services
➢ Inpatient and outpatient diagnostic radiology (x-ray) services
➢ Nuclear medicine, including radiation therapy
➢ Diagnostic ultrasound
Mammography Sernces �
Coverage under this benefit includes routine screernng and Medically Necessary diagnostic
mammography services, when such services are recommended by a physician (M D or D O), advanced
registered nurse practitioner (A R N P), or licensed physician's assistant (P A) z
Prostate Cancer Screen�ng �
Coverage under this benefit mcludes routine screenmg and Medically Necessary diagnostic prostate
cancer screernng services, when such services are recommended by a physician (M D or D O),
advanced registered nurse practitioner (A R N P), or licensed physician's assistant (P A)
Mastectomy Care
(Prior authorization is required for inpatient Hospital services only)
Coverage under this benefit includes the following services when received in connection with a
mastectomy and the election of breast reconstruction in connection with such mastectomy
➢ All stages of reconstruction of the breast on which the mastectomy has been perFormed
➢ Surgery and reconstruction of the other breast to produce a symmetrical appearance
➢ Prostheses and mastectomy bras
➢ Treatment of physical complications of all stages of mastectomy, including lymphedema
Maternity Care
Pregnancy and Chddb�rth
Coverage for pregnancy and childbirth is provided only if you are the Subscriber or a Subscriber's
enrolled Spouse Coverage is provided on the same basis as any other illness or in�ury Coverage for
pregnancy and childbirth is not sub�ect to the waiting periods for Pre-existing Conditions
Page 20 City of Bremerton Plan B
Benefits Booklet
Coverage under this benefit includes the following services when performed by a licensed physician
(M D or D O), a physician's assistant (P A), an advanced registered nurse practitioner (A R N P)
specializing in women's health care or midwifery, or a licensed midwife
➢ Pre- and post-natal care
➢ Screenmg and diagnostic testing for congenital fetal disorders
➢ Obstetrical delivery and delivery by Caesarean section
➢ Treatment for the complications of preg nancy
➢ Treatment followmg a miscarriage
To the extent that maternity care is covered under this Group Plan, the Provider (as defined above), m
consultation with you, may decide on the length of the inpatient stay and the type and location of follow-
up care, mcludmg in-person care Decisions regardmg patient care must be based on accepted medical
practice for the treatment of the diagnosis
Pregnancy and childbirth are not covered conditions for Eligible Dependent Children However,
complications of pregnancy are covered for enrolled Eligible Dependent Children on the same basis as
any other illness or m�ury Complications of p�egnancy may mclude, but are not limited to, the following
conditions
Blighted ovum
Ectopic pregnancy
Gestational diabetes
Hydatidiform mole
Medical Equipment and Supplies
Hyperemesis gravidarum
Incompetent cervix
Spontaneous miscarriage
Complications following abortion or ectopic pregnancy
Coverage under this benefit includes artificial limbs and the purchase or rental of inedical equipment and
supplies prescribed by your Provider for home use Equipment or supplies ordered before you enrolled in
this Group Plan wdl not be covered Equipment or supplies ordered while you were enrolled, and
delivered withm 30 days after your coverage ended, wdl be covered
Surgically implanted prosthetics, such as pace makers and artificial �omts, are covered under the
Hospital Services benefit
Home Med�ca/ Equipment and Suppl�es
Pnor authonzation is required for the followmg medical equipment
➢ Equipment with a purchase price greater than $2,500, except wheelchairs
➢ Wheelchairs with a purchase price greater than $5,000
➢ Electric hospital beds
➢ Enteral therapy
➢ Ventilators
➢ Contmuous positive air pressure (CPAP) and bi-positive air pressure equipment (except when
used in con�unction with sleep studies)
➢ Bone growth stimulators
Not all home medical equipment and medical supplies are covered For specific information regarding
coverage of inedical equipment and supplies, please call KPS Customer Service at the numbers listed at
the end of this Benefits Booklet
At the sole discretion of KPS, coverage is provided for either the rental or purchase of home medical
equipment and supplies prescribed by your Provider for therapeutic use In addition, if KPS determines
that there is a less costly alternative to the prescribed equipment that serves the same medical purpose,
KPS will provide benefits on the basis of the less costly equipment
All home medical equipment and supplies must be prescribed by your Provider and obtamed from a
licensed home medical equipment supplier or pharmacy
City of Bremerton Plan B Page 21
Benefits Booklet
Home medical equipment includes such things as crutches, walkers, hospital beds, and wheelchairs
Home medical equipment is generally defined as equipment that meets all of the following criteria
➢ It is appropriate for use in the home
➢ It can withstand repeated use
➢ It is used primarily and customardy to serve a medical purpose
➢ It is not generally useful to a person in the absence of an illness or in�ury
Examples of disposable medical supplies covered under this benefit include, but are not limited to
➢ Ostomy bags and related supplies
➢ Peritoneal dialysis supplies
➢ Syringes and needles
➢ Catheters �
Coverage of repair and maintenance costs on home medical equipment is sub�ect to prior review and
approval by KPS In cases where replacement costs are less than repair costs, KPS may elect to limit
coverage to replacement of the equipment
There is no coverage under this benefit for
➢ Repair or maintenance costs that are the result of intentional damage or neglect
➢ Equipment which is primarily used for non-medical purposes
➢ items used only for convenience
➢ Charges for equipment purchased or rented from a private party
➢ Separately billed delivery and service charges
Prosthet�c Appl�ances
Coverage under this benefit includes the initial purchase of the artificial limb (arm or leg) and subsequent
repair or replacement costs necessitated by damage to the limb and/or physical growth
Medically Necessary contact lenses, both initial and replacement lenses, are covered following cataract
surgery
Mental Health Care
Prior authorization is required for inpatient mental health care, except in the case of involuntary
commitment Either you or your Provider may request authorization for mpatient services Please refer to
the Services Which Require Prior Authorization section for more information
Prior authorization of outpatient services is not required but you may contact KPS Customer Service for
assistance in finding Providers KPS Customer Service can be reached at 360-478-6796, or toll-free at
1-800-552-7114
Coverage under this benefit includes the following
➢ Treatment in an acute inpatient psychiatnc or general Hospital
➢ Treatment provided on a Partial Hospitalization basis
➢ Treatment provided on an outpatient basis
➢ Treatment provided in a Residential Mental Health Facdity
In order to be covered, care must be provided by one of the following
➢ A licensed medical doctor (M D or D O)
➢ A licensed psychologist
➢ A licensed community mental health agency ,
➢ A licensed state Hospital
➢ Any other licensed Provider who has been credentialed and approved by KPS to provide mental
health care
Page 22 City of Bremerton Plan B
Benefits Booklet
Coverage under this benefit does not include the followmg
➢ Marriage and famdy seminars and/or encounter groups
➢ Sensitivity training
➢ Sexual dysfunction
➢ Outdoor youth programs
Court-ordered assessments or other assessments are not covered under this benefit, when the purpose
of the assessment is to determine the Medical Necessity of any court-ordered mental health care
Coverage under this benefit does not duplicate coverage for therapy services provided under any other
benefit of this Group Plan
Neurodevelopmental Therapies
Coverage under this benefit for the restoration and improvement of function in a neurodevelopmentally
disabled Eligible Dependent Child who is six (6) years of age or younger includes
➢ Inpatient and outpatient physical, speech, and occupational therapy
➢ Ongoing maintenance care in cases where significant deterioration of the Child's condition would
occur without the care
All therapy treatments must be performed by a physician (M D or D 0), registered physical therapist
(P T), speech therapist certified by the American Speech Language Hearing Association, or an
occupational therapist certified by the American Occupational Therapy Association
No coverage is provided under this benefit for any Enrollee who is age seven (7) or older
Coverage under this benefit does not duplicate coverage for therapy services provided under any other
benefit of this Group Plan
Newborn Care
Coverage for newborn Children of the female Subscriber or enrolled female Spouse is provided
automatically for a period of not less than three (3) weeks from the date of birth Coverage for newborns
shall be no less than the coverage provided to the mother, including
➢ Medical and surgical inpatient care, mcluding inpatient care which is separate from the mothe�'s
maternity admission
➢ Medical and surgical outpatient care
In order for coverage to continue after the initial three (3) week period, the Chdd must qualify as an
Eligible Dependent If additional Premium is required, the Child must be enrolled in this Group Plan within
60 days of birth Please refer to the Enrollment Under Special Circumstances section
NOTE When additional Premium is not required, we encourage enrollment as soon as possible to
prevent delays in claims processing
Newborn Nursery Care
Routine newborn care provided in a Hospital nursery is not sub�ect to the Deductible Charges mcurred as
a result of complications during or after birth are covered as any other medical condition
Nutritional Guidance Counseling
Coverage is provided on an outpatient basis for the services of nutritional guidance counselmg, when
recommended by your Provider for the following conditions
Anorexia and bulimia
Cancer
Colitis
Coronary artery disease
Dysphagia
Endocrine conditions
Food allergies or intolerances
Gastritis
Hypercholesterolemia
Hyperlipidemia
Hypoglycemia
Short bowel syndrome (post surgery)
Swallowing difficulties followmg a stroke
City of Bremerton Plan B Page 23
Benefits Booklet
There is no coverage under this benefit for
➢ Weight control self-help programs, such as Weight Watchers, Jenny Craig, or other such
programs
➢ Medical or surgical treatment of obesity (including morbid obesity)
➢ Surgical procedures for weight reduction
Oral Surgery
(Subscriber only)
Coverage for oral surgery includes
➢ The reduction or manipulation of fractures of the facial bones
➢' The removal of lesions, cysts, and tumors of the �awbone, mouth, lips, or tongue
➢ Reconstruction of the mouth or lips to correct anatomical impairment caused by a congenital
defect
There is no coverage under this benefit for the following dental services
➢ Care or repair of teeth or dental structures of any type
➢ Tooth extractions or impacted teeth
➢ Services related to malocclusion
➢ Services to correct the misalignment or malposition of teeth
➢ Any other services to the mouth, facial bones or teeth, which are not medical in nature
Organ, Bone Marrow, Ste�n Cell and Tissue Transplants
(Requires prior authorization)
This benefit is sub�ect to a wait�ng penod, please refer to the Waiting Periods and Benefits Summary
sections for additional information
Covered Procedures and Cond�t�ons
Services and treatment directly related to the procurement and implantation of human organs, bone
marrow, stem cells or tissues are covered subJect to prior approval by KPS Such approval is based on
the following criteria
➢ The transplant is Medically Necessary and warranted by your health condition
➢ The procedure is to be pertormed by a licensed and accredited physician who has demonstrated
proficiency in such procedures
➢ The procedure is to be performed at an accredited transplant facility
➢ The procedure is not considered to be an Experimental or Investigational procedure for the
treatment of the condition
➢ You have been accepted into the facdity's transplant program and comply with all program
requirements
Provided the above conditions have been met, coverage under this benefit includes the following organ
transplant procedures .
Cornea Kidney/pancreas
Heart Liver
Heart/lung Lung
Kidney Pancreas
Page 24 � City of Bremerton Plan B
Benefits Booklet
Autologous bone marrow stem cell and tissue transplants, and associated high-dose chemotherapy are
covered only for the treatment of the following conditions or malignancies
Acute lymphocytic and non-lymphocytic leukemia
Acute myelocytic leukemia
Germ cell cancer
Hodgkin's lymphoma
Neuroblastoma
Non-Hodgkin's lymphoma
Allogeneic (related and unrelated) bone marrow, stem cell and tissue transplants and associated high-
dose chemotherapy are covered only for the treatment of the following conditions or malignancies
Acute lymphocytic leukemia
Acute myelocytic leukemia
Aplastic anemia
Chronic myelogenous leukemia
Hodgkm's lymphoma
Homozygous beta-thalassemia
Infantile malignant osteopetrosis
Neuroblastoma stage ill and IV (Children over 1 year old)
Non-Hodgkin's lymphoma
Severe combined immunodeficiency (SCID, not HIV AIDS)
Wiskott-Aldrich syndrome
Transplant Rec�p�ent Benefits
Covered Benefits and Services for you or your Eligible Dependents who are transplant recipients mclude
➢ Medical and surgical physician and Hospital services directly related to the transplant procedure
➢ Diagnostic tests and exammations directly related to the transplant procedure
➢ Donor retneval costs directly related to the transplant procedure
Donor Re/ated Services
Donor-related services include, but are not limited to the followmg selection, removal, harvesting,
storage, transportation of the surgical harvesting team, and such other Medically Necessary procurement
costs as may be approved by KPS Donor-related services are covered only if the transplant procedure is
approved by KPS and the recipient of the transplant is covered under this Group Plan and has met any
applicable transplant benefit waiting periods
There is no coverage under this benefit for the following services
➢ Costs mcurred by a donor, including an Enrollee in this Group Plan, for services associated with
donor organ or bone marrow/stem cell/tissue acquisition if the recipient is not enrolled in this
Group Plan
➢ Costs incurred by a donor for the treatment of complications resultmg from organ donation or
bone marrow/stem cell/tissue acquisition if the donor is not enrolled m this Group Plan
Costs mcurred by an Enrollee for Medically Necessary Covered Benefits and Services as a result of
complications from organ donation or bone marrow/stem cell/tissue acquisition are covered under this
Group Plan only to the extent these costs are not covered under the recipient's plan
Transp/ant Benefit Lim�tat�ons and Exc/us�ons
In addition to any coverage limitations or exclusions described above or listed in the Limitations and
Exclusions section of this Benefits Booklet, the following specific limitations and exclusions apply to the
Transplants benefit
➢ Any transplant not specifically listed
➢ Charges for transplant-related facility services, which were not authorized m advance by KPS
➢ Donor and procurement services and costs incurred outside of the U S, unless specifically
authorized m advance by KPS
➢ Experimental and/or Investigational transplant procedures
` ➢ Food and lodging
City of Bremerton Plan B Page 25
Bene�ts Booklet
➢ Living (non-cadaver) donor transplants of the lung, liver, or other organs (except kidney
transplants), including selective islet cell transplants of the pancreas, unless otherwise authorized
in advance by KPS, based on current standards of care at the time of the request for
authorization
➢ Mechanical, artificial, or non-human transplants
➢ Prescription drugs dispensed on an outpatient basis, including anti-re�ection medications and
self-administered drugs, except as may be covered under Pharmacy Benefits
➢ Transpo�tation costs, except as specifically allowed for the actual organ/bone marrow/stem
cell/tissue harvesting or procurement for the transplant
Oxygen and Oxygen Supplies
(Requires prior authorization)
Coverage under this benefit includes oxygen, oxygen equipment, and related supplies, when prescribed
by your Provider for therapeutic use and obtained from an approved medical equipment supplier
Phenylketonuria (PKU) Formulas
Special dietary formulas designed for use by you and/or your Eligible Dependents who have been
diagnosed with phenylketonuria are covered under this benefit
Plastic and Reconstructive Surgery
(Requires prior authorization)
Plastic and reconstructive surgeries are covered to
➢ Correct a physical disorder resulting from a congenital disease or anomaly
➢ Correct a physical disorder resulting from disease, Accidental In�ury, or trauma, provided the
repair is performed within 12-months or other medically appropriate period of time after the date
of the disease, in�ury, or trauma, which caused the physical disorder
➢ Reconstruct an in�ured or diseased breast following a mastectomy, including reconstruction of the
healthy breast to produce a symmetrical appearance
Coverage under this benefit does not include
➢ Cosmetic services, supplies, or surgery to repair or reshape an essentially normal body structure
for the improvement of the patient's appearance or self-esteem
➢ Complications resulting from cosmetic surgery
Except as set forth under this benefit, no other plastic, reconstructive, or cosmetic services are available
under this Group Plan
Rehabilitation
Prior authonzation of a plan of treatment is required only for inpatient rehabilitative therapies
Coverage under this benefit includes speech, occupational, physical, and massage therapies performed
on an inpatient basis (in a Hospital, Skdled Nursing Facdity, or other approved facdity) or on an outpatient
basis for conditions other than neurodevelopmental disabilities Therapy services will be covered as
prescribed by your physician
Coverage is provided under the following conditions
➢ KPS has approved the plan of treatment (inpatient only)
➢ The services rendered must be Medically Necessary to restore or improve function
➢ The loss of function was not the result of a work-related in�ury
Coverage for inpatient services under this benefit is limited Please refer to the Benefits Summary
section Coverage under this benefit does not duplicate coverage for therapy services provided under any
other benefit of this Group Plan Please see the Home Health Care section
Page 26 City of Bremerton Plan B
Bene�ts Booklet
Skilled Nursing Facility Care
(Requires prior authorization)
Medically Necessary therapeutic or restorative care in a Skilled Nursing Facility may be authonzed by
KPS as an alternative to Medically Necessary confinement m a Hospital
Coverage is based on a wntten treatment plan submitted to KPS by your treating Provider and approved
by KPS Coverage is limited Please refer to the Benefits Summary section
Skilled Nursing Facility coverage includes
➢ Semi-private room and board
➢ General duty nursing
➢ Medically Necessary ancillary services and supplies
Maintenance or custodial care is not covered under this benefit Please see the Home Health and
Hospice Care section
Sleep Disorders
(Requires pnor authorization for surgical treatments only)
Coverage under this benefit is limited to sleep studies, including Provider services, appropriate durable
medical equipment obtained from an approved home medical supplier or pharmacy, and surgical
treatments No other benefits are provided for the purpose of studying, monitoring, and/or treating sleep
disorders, other than as descnbed below
S/eep Studles, Inc/udmg Appropr�ate Durab/e Medical Equipment
Coverage for sleep studies includes
➢ Polysomnographs
➢ Multiple sleep latency tests
➢ Continuous positive airway pressure (CPAP) studies
➢ Related durable medical equipment and supplies, including CPAP machmes
The condition giving rise to the sleep disorder, such as narcolepsy or sleep apnea, must be diagnosed by
your Provider Pnor authorization of sleep studies is not required, however, your Provider must order the
sleep studies program for you �
Surgica/ Treatments
Coverage for the Medically Necessary surgical treatment of diagnosed sleep disorders is covered under
this benefit Prior authorization of surgical procedures for the treatment of sleep disorders is
required Surgical treatment includes all professional and facility fees related to the surgical treatment
mcluding pre- and post-operative care and complications
Spinal and Extremity Manipulation
Coverage under this benefit is provided for the diagnosis and treatment of musculoskeletal disorders,
including bone and muscle subluxations (out of alignment) of body extremities and spinal column
Coverage under this benefit is limited Please refer to the Benefits Summary section
Substance Use Disorder Treatment (Chemical Dependency)
Prior authorization is required for mpatient substance use disorders treatment, except m the case of
Emergency detoxification Either you or your Prowder may request authorization for mpatient services
Please refer to the Services Which Require Prior Authorization section for more mformation about
Emergency admissions
City of Bremerton Plan B Page 27
Benefits Booklet
Prior authorization of outpatient services is not required but you may contact KPS Customer Service for
assistance in finding providers KPS Customer Service can be reached at 360-478-6796, or toll-free at
1-800-552-7114
Coverage for the treatment of substance use disorders includes
➢ Medically Necessary inpatient and outpatient care provided as part of an Approved Treatment
Program
➢ Detoxification and supportive services
No coverage is provided under this benefit for the followmg
➢ Court-ordered assessments, or other assessments, when the purpose of the assessment is to
determine the Medical Necessity of any court-ordered substance use disorder treatment
➢ Court-ordered assessments or treatments related to the deferral of prosecution, deferral of
sentencing or suspended sentencing, or treatments ordered as a condition of retaining motor
vehicle driving rights, when the Medical Necessity for such assessments or treatment cannot be
established
➢ information and referral services
➢ Residential treatment facdities, such as therapeutic boarding schools, outdoor youth programs,
and halfway houses
➢ Alcoholics Anonymous or other simdar programs and support groups
➢ Long term or custodial care
➢ Tobacco cessation programs
➢ Any other substance use disorder service or supply not specifically listed
In the case of a court-ordered assessment or treatment program, you are required to provide KPS with a
copy of the followmg documents
➢ The initial assessment of the need for substance use disorder treatment, provided by a certified
chemical dependency counselor who is employed by an Approved Treatment Program
➢ The treatment plan
Termination of Pregnancy
Coverage for the voluntary termination of pregnancy is included under this beneflt
Coverage under this benefit is limited to one (1) voluntary termination of pregnancy per Calendar Year
Vision Examination
(Employee only)
One routine eye examination is covered every Calendar Year Eyeglasses are not covered Contact
lenses are covered only as described under Medical Equipment and Supplies, Prosthetic Appliances.
Women's Health Care Services
Covered women's health care services are available without prior referral from another Provider and
include maternity care, reproductive health services, gynecological care, general examination, preventive
care, and follow-up visits, when provided by a licensed physician (M D or D O), a physician's assistant
(P A), an advanced registered nurse practitioner (A R N P) specializing in women's health care or
midwifery, or a licensed midwife, and any Participating Facdity used by such Providers
Page 28 City of Bremerton Plan B
Benefits Bookiet
Pharmacy Benefits
This benefit, for purposes of creditable coverage, is expected to pay out as much as the Medicare Part D
prescription drug benefit and is therefore considered creditable Enrollees who are a Iso eligible for
Medicare Part D pharmacy benefits can remam covered under this Group Plan and not be sub�ect to
Medicare-imposed late enroliment penalties should they decide to enroll m a Medicare Part D pharmacy
plan at a later date
Coverage
Coverage under this benefit includes
➢ Prescription drugs
➢ Insulm and diabetic supplies
➢ Self-administered drugs
➢ Pre-authorized Off-label Use of prescription drugs
➢ Prescription Contraceptive drugs and devices
All drugs and supplies must be Medically Necessary for the condition and must be prescribed by a
Provider with prescriptive authonty
All prescriptions must be filled at a Participating network pharmacy, except m the case of accidental m�ury
or medical emergency Prescnptions for specialty drugs may only be filled through the KPS specialty
pharmacy vendor
Prescriptions and refills are available on a 31-day or 90-day supply basis Please refer to the Benefits
Summary section for applicable comsurance
Pharmacy benefits are based on a drug formulary Drug formulary (approved drug list is defined as a list
of covered drugs, supplies and devices developed and maintained by KPS Drugs on the formulary are
classified into one of three (3) tiers
➢ Tier 1— Preferred Generic drugs
➢ Tier 2— Preferred Brand drugs
➢ Tier 3— Non-preferred Generic and Brand drugs
The KPS drug formulary (approved drug list) is updated throughout the year For the most up-to-date
mformation about the drugs covered under your Group Plan, please visit the KPS Web site at
www kpshealthplans com, or contact KPS Customer Service toll-free at 1-800-552-7114
How to Use Your Pharmacy Plan
Be sure to present your KPS identification card to your Participating nefinrork pharmacy when you have
your prescnption filled or re-filled Your Partiapating network pharmacy wdl collect the 20% Coinsurance
amount due for each new and refilled prescription You are only required to pay up to $150 in
Coinsurance each Calendar Year Thereafter, coverage for any new or re-filled prescriptions for the
remamder of that Calendar Year is provided at 100% of the KPS allowed charge
For a list of Participatmg network pharmacies please visit the KPS Web site at www kpshealthplans com,
or call KPS Customer Service toll-free at 1-800-552-7114
When you use a Participating network pharmacy, you will not be responsible for submitting a claim form
In the event of an Accidental in�ury or Medical Emergency, you may utilize the services of a non-
participating pharmacy For reimbursement, you must submit an itemized claim and a paid receipt to
Medimpact
Attn DMR Department
10680 Treena Street, 5'" floor
San Diego, CA 92131
Definit�ons
Brand Drug is a drug manufactured and sold exclusively under its brand-name by the manufacturing
pharmaceutical company that holds the onginal patent of drug development
City of Bremerton Plan B
Benefits Booklet
Generic Drug is a drug approved by the Food and Drug Administration (FDA) as a therapeutic equivalent
genenc to a Brand drug Generic drugs may be manufactured and sold by more than one pharmaceutical
company
Preferred and Non-preferred drug status is determined by KPS based on scientific evidence of efficacy,
safety and cost-effectiveness Preferred Generic drugs are in Tier 1, Preferred Brand drugs are in Tier 2
of the Formulary
Off-label Use means the drug is prescnbed for an indication other than those specified in its
FDA-approved labelmg Coverage is allowed for the following when pre-authorized by KPS
➢ The stated use of the drug is recognized in one of the standard reference compendia
➢ The stated use of the drug is recognized as effective in the ma�ority of relevant, peer-reviewed
medical literature
➢ The stated use of the drug is approved by the Federal Secretary of Health
➢ The stated use must meet Medical Necessity guidelines
Exc/us�ons
No coverage is provided under this benefit for the following
➢ Over-the-counter drugs for which a prescription is not required, unless specifically provided for in
this Group Plan
➢ Over-the-counter contraceptive devices and/or supplies
➢ Vitamins, including pre-natal vitamins, unless specifically provided for in this Group Plan
➢ Drugs for the treatment of obesity
➢ Fluoride preparations
➢ Drugs used for cosmetic purposes
➢ Drugs taken home following an inpatient Hospital stay
➢ Non-self-administered drugs
➢ Self-administered drugs supplied by a Provider
➢ Drugs for the treatment of impotence and mfertility
➢ Prescnption drugs intended to ease nicotine withdrawal
➢ Drugs specifically designated as not covered
➢ Drugs which are not approved by the FDA
➢ Drugs which are not Medically Necessary for the treatment of a specific condition
➢ Investigational drugs and/or drugs used for investigation or experimental purposes
➢ Drugs for travel purposes
➢ Compounded Hormone Replacement Therapy drugs which have not been approved by the FDA
and which are not manufactured by a recognized drug company
➢ Replacement of lost or stolen medications, unless specifically included as a covered bene�t
under this Group Plan
➢ Drugs that require prior authorization if your provider has not obtained prior authorization
Page 30 City of Bremerton Plan B
Benefits Booklet
LIMITATIONS AND EXCLUSIONS
Coverage under this Group Plan is limited to the diagnosis and therapeutic care or treatment of disease,
sickness, or m�ury, or the prevention of disease, sickness, or in�ury, as described in this Benefits Booklet
The following services are specifically excluded from coverage
1 Air conditioners, de-humidifiers, air purifiers
2 Any care, treatment, or service received prior to your effective date of coverage under this
Group Plan
3 Any care, treatment, or service received after coverage under this Group Plan has ended
4 Arch supports, shoe orthotics, corrective shoes, and elastic stockmgs, except as specifically
provided for under the Diabetic Education, Equipment, and Supplies benefit
5 Artificial insemmation, in vitro fertilization, and gamete intra-fallopian transplant (GIFT),
mcluding any direct or indirect complications or after-effects other than pregnancy
6 Biofeedback, except in the case of urinary mcontinence
7 Charges for non-Covered Benefits and Services and resulting complications, includmg services,
not specifically described in this Benefits Booklet
8 Circumcision
9 Conditions resulting from acts of war, whether declared or undeclared
10 Cosmetic surgery, including treatment for complications of cosmetic surgery, except as
provided for under the Plastic and Reconstructive Surgery benefit
11 Developmental delay, speech delay, or other learning disabilities, except as provided for under
the Neurodevelopmental Therapy benefit
12 Enuresis trainmg equipment
13 Exercise equipment and whiripool baths
14 Experimental and Investigational procedures, as defined in this Benefits Booklet
15 Eye exammations (except Employee), refractions, eyeglasses and contact lenses
16 Hearing aids, hearing devices, such as cochlear implants, and hearing examinations
17 Immunizations required for employment, travel, immigration, licensing, or msurance related
reports
18 Maintenance, custodial, or domicdiary care except as provided for under the Home Health and
Hospice Care benefit
19 Medical services paid by the Veterans Admmistration or by state, local, or federal governmental
programs, excluding Medicaid as defined by RCW 74 09 500
20 Non-surgical treatment for deformities of the toes and feet, including routine foot care, except
when such care is directly related to the treatment of diabetes
21 Obesity treatment, mcluding, but not limited to, Provider office visits, surgical weight loss
procedures, pre-surgical diagnostics and procedures, weight reduction programs (e g, Weight
Watchers), and dietary control programs
22 Orthoptics (eye exercise programs), pleoptics, visual analysis therapy and/or training, and
radial keratotomy
23 Over-the-counter products (except insulin supplies for the treatment of diabetes), including, but
not limited to, contraceptive devices or supplies, unless specifically listed as a benefit under this
Group Plan
�, 24 Personal comfort items (e g, radios, telephones, televisions)
25 Reversal of sterilization
City of Bremerton Pian B Page 31
Benefits Booklet
26 Self-help care of any form, including, but not limited to, non-medical self-care, self-help training,
marital or sexual counseling
27 Services, supplies, and drugs, which are not Medically Necessary for the treatment of an
dlness, in�ury, or physical disabdity, even though the services are not specifically listed as
exclusions
28 Services for any occupational illness or in�ury arising out of, or in the course of, an activity
pertaining to any trade, business, employment (including self-employment), or occupation for
wage or profit whether or not a proper and timely claim was filed for such benefits under
another plan or policy
29 Services and supplies for, or associated with, care or work on the teeth, x-rays of the teeth and
other dental procedures
30 Services for the treatment of complications arising from non-Covered Benefits and Services or
procedures, except for the complications of pregnancy
31 Services for which there is no charge to you
32 Services for which you are not legally required to pay
33 Services provided by a person who is related to you by blood or marnage, or who resides in
your home
34 Sex change or other sexual transformation procedures
35 Speech, occupational, educational, mdieu, massage, and physical therapies, except as
specifically included under the Neurod Therapy benefit, the Rehabilitation
benefit, or the Home Health and Hospice Care benefit
36 Sterilization
37 Treatment for abnormalities of the �aw, including malocclusion, �aw augmentation or reduction
surgery (orthognathic surgery) except as provided for under the Oral Surgery benefit or the
Plast�c and Reconstructrve Surgery benefit, diagnosis and treatment of temporomandibular
�oint (TMJ) disorders '
38 Treatment for sexual dysfunction, including, but not limited to, sterility, infertdity, impotence, or
frigidity
39 Unnecessary duplicate diagnostic services for a single ongoing illness Consultations for
second surgical opinions are covered under the Professional Services benefit
40 Services for elective care received in a foreign country
41 Services and supplies not specifically described in this Benefits Booklet
32 City of Bremerton Plan B
Benefits Booklet
CONTINUATION OF COVERAGE
If you and your Eligible Dependents are no longer eligible for coverage under this Group Plan, you may
be entitled to continue your Group Plan coverage or enroll in a KPS Conversion Plan Contact your Group
Plan Admmistrator for information regarding eligibility and enrollment requirements
The following paragraphs describe several options for contmuing your coverage Your empioyer is
obligated to provide you with information regarding any options that apply to you
Coverage During a Labor Dispute
In the event of a strike, lockout, or other labor dispute that causes a disruption in your health care
compensation benefits or wages, your Group may stop paymg any Premium amounts required by this
Group Plan for you and your Eligible Dependents if this happens, you may choose to contmue coverage
under this Group Plan for up to six (6) months by self-paying your Premiums Dunng this penod, your
benefits and Premium may not be altered from that of your existing Group Plan
You must begm self-paymg your Premium during the first month your Group stops makmg payments on
your behalf To be continuously covered, you must pay your Premium each month If you fail to pay your
Premium for any month, your coverage wdl end on the last day of the month for which Premium was
received and may not be reinstated Premium payments should be made directly to the Group Premiums
are due no later than the Premium Due Date
This provision does not apply if you or your Eligible Dependents are entitled to continue coverage under
COBRA or any other continuation of coverage provision
Once the six (6) month self-pay period has ended, you have the right to apply for coverage under an
mdividual plan
Continuation of Group Coverage
If you lose your coverage under this Group Plan, you may be able to continue coverage for you and your
Eligible Dependents for up to three (3) additional months unless
➢ Your coverage was terminated as a result of a stnke, lockout, or other labor dispute
➢ Your employment was terminated for gross misconduct
Please check with your Group Plan Administrator to determme whether or not your Group has chosen to
make this option avadable to all Employees If your Group is required by law to offer COBRA coverage,
this option for extended coverage may not be avadable
Extended coverage under this option is not automatic If this option for extended coverage is available
from your Group, you must apply within 31 days of the date your coverage ends under the Group Plan If
you are required to self-pay your Premium, your first Premium payment must be submitted with your
application for coverage To be continuously covered, you must pay your Premium each month
Premium self-payments should be made directly to the Group Premiums are due no later than the
Premium Due Date If you fail to pay your Premium for any month, your coverage wdl end on the last day
of the month for which Premium was received and may not be reinstated
If you choose this continuation option, your benefit coverage and Premium may not be altered from that of
the existmg Group Plan
COBRA (Consolidated Omnibus Budget Reconciliation Act -1985)
If you lose eligibility for coverage under this Group Plan (except in the case of a labor dispute), you may
be eligible to continue your coverage for a period of time specified by federal law and regulations then in
effect This contmuation of coverage is referred to as COBRA and applies generally to groups of 20 or
more employees KPS offers coverage only when
➢ Groups are required by law to provide COBRA coverage for Employees, and
➢ KPS is notified of a beneficiary's election of COBRA coverage within 31 days of that election
being made
City of Bremerton Plan B Page 33
Benefits Booklet
Continuation of coverage under COBRA is not automatic You must apply for contmuation of your Group
coverage within 60 days of the date your Group provides you a COBRA election notice KPS offers
COBRA coverage to Groups only as required by law
Your Group Plan Administrator is required to notify KPS of your election of COBRA continuation coverage
within 45 days of that election Failure on your part to make a timely election, or fadure on the part of your
Group Plan Admmistrator to provide KPS with timely notification of the election, will be interpreted by KPS
as a waiver of your right to continue coverage under this provision Failure by your Group Plan
Administrator to provide timely notification to KPS may not, in all cases, eliminate the Group's obligation
to provide continuation coverage It wdl, however, eliminate any obligation on the part of KPS to provide
you with continuation coverage under this Group Plan
If you are about to lose, or have lost, your coverage under this Group Plan, contact your Group Plan
Administrator for more information regard ing COBRA and your right to continue receiving medical benefits
under this Group Plan
Conversion Coverage
If you are under age 65, you may be entitled to transfer to a KPS Conversion Plan if
➢ You are a permanent resident of Washington State
➢ You are not othenivise eligible for coverage under Medicare
➢ You are currently eligible for continuation of your Group Plan coverage but decline that option
➢ Your continuation coverage under this Group Plan or COBRA plan terminates (for any reason
except fraud or non-payment of Premium, when it is your responsibility to pay the Premium)
➢ Your employer's Group Plan terminates and your employer does not provide other health care
coverage to its Employees
An application for coverage under a KPS Conversion Plan for you and your Eligible Dependents must be
received by KPS within 31 days of either the date a) your coverage under this Group Plan or other KPS
contmuation or COBRA plan ends, or b) you received notification that this Group Plan wdl terminate,
whichever occurs later Any applicable Premium amounts for your first month of coverage must be
submitted with your application You must pay all subsequent Premiums by the Premium Due Date Your
coverage under a KPS Conversion Plan is guaranteed for as long as you continue to meet the eligibility
requirements and pay your Premium If you fail to pay your Premium for any month, your coverage will
end on the last day of the month for which Premium was received
Your Eligible Dependents may apply for coverage separately under this option m the event they lose
coverage under this Group Plan due to one of the following reasons
➢ You lose eligibility under this Group Plan based on termination of employment due to misconduct
➢ The death of you, as the Subscriber
➢ You and your Spouse divorce
➢ Your eligible Dependent Children reach the Limiting Age
Credit for periods of continuous coverage under this Group Plan and/or a KPS continuation or COBRA
plan will be applied to your coverage under a KPS Conversion Plan
When you enroll in a conversion plan, you lose certain protections guaranteed you under the Health
Insurance Portability and Accountability Act (HIPAA) of 1996 If you decide to purchase an individual
product after receiving coverage in a KPS Conversion Plan, the new carrier may ask about your health
conditions in the application process If you decide to decline conversion coverage and apply for an
indiwdual plan, you wdl generally have the right to purchase the coverage without any questions about
your health conditions, provided you had 18 months of Creditable Coverage, and your former plan was a
group health plan If you have any questions, please contact KPS Customer Service at 360-478-6796 or
toll-free at 1-800-552-7114
If you are age 65 or older and your coverage under this Group Plan terminates, you may be eligible for
coverage under a Medicare supplement plan To determine your eligibility for a Medicare supplement
plan, please contact KPS Customer Service '
Page 34 City of Bremerton Plan B
Benefits Booklet
COORDINATION OF BENEFITS (COB)
General Provision
The Coordmation of Benefits (COB) provision applies when a person has health care coverage under
more than one Plan All of the benefits provided under this Group Plan are sub�ect to this COB provision
Definitions
"P1an" means any of the followmg that provide benefits or services for medical or dental care or treatment
➢ This Group Plan
➢ Group, individual, or blanket disability insurance contracts
➢ Group or mdividual contracts issued by health care service cont�actors or health maintenance
organizations (HMOs)
➢ Closed Panel Plans or other forms of group or individual coverage
➢ Medical care components of long-term care contracts, such as skilled nursing care
➢ Medicare or any other federal governmental plan, as permitted by law
Plan does not include
➢ Hospital indemnity or fixed indemnity/payment coverage
➢ Accident only coverage
➢ Specified disease or specified accident coverage
➢ Limited benefit health coverage, as defined by state law
➢ School accident type coverage
➢ Benefits for non-medical components of long-term care policies
➢ Automobile insurance policies required by statute to provide medical benefits
➢ Medicare supplement policies, Medicaid coverage, or coverage under other federal governmental
plans, unless permitted by law
Each contract for coverage listed above is a separate Plan If the Plan has finro parts and COB rules apply
only to one of the two, each of the parts is treated as a separate Plan
"Primarv Plan" means the Plan that determmes payment for its benefits first before those of any other
Plan without considering any other Plan's benefits
Secondary Plan means the Plan that determines its benefits after those of another Plan and must make
« ��
payment in an amount so that, when combined with the amount paid by the Primary Plan, the total
benefits paid or provided by all Plans for the claim equal 100% of the Total Allowable Expense for that
claim
When a Plan is secondary, it must pay the amount which, when combined with what the Pnmary Plan
paid, totals 100% of the Allowable Expense In addition, if a Plan is secondary, it must calculate its
savings (its amount paid subtracted from the amount it would have paid had it been the Primary Plan) and
record these savings as a benefit reserve for the covered person This reserve must be used to pay any
expenses durmg that Calendar Year, whether or not they are an Allowable Expense under this Group
Plan If a Plan is secondary, it will not be required to pay an amount in excess of its maximum benefit plus
any accrued savings
"Allowable Expense" means a health care expense, includmg deductibles, copayments, and coinsurance,
which is covered at least in part by any of the Plans involved When a Plan provides benefits in the form
of services, the reasonable cash value of each senrice will be considered an Allowable Expense and a
benefit paid An expense that is not covered by any of the Plans involved is not an Allowable Expense
City of Bremerton Ptan B Page 35
Benefits Booklet
The following are examples of expenses that are not Allowable Expenses
➢ The difference between the cost of a semi-pnvate Hospital room and a pnvate Hospital room is
not an Allowable Expense, unless one of the Plans provides coverage for private Hospital room
expenses
➢ If a person is covered by two or more Plans that compute their benefit payments on the basis of
usual and customary fees, or relative value schedule reimbursement method, or other simdar
reimbursement method, any amount in excess of the highest reimbursement amount for a
specific benefit is not an Allowable Expense
➢ If a person is covered by two or more Plans that provide benefits or services on the basis of
negotiated fees, an amount in excess of the highest of the negotiated fees is not an Allowable
Expense
"Total Allowable Expenses" means the combined amount paid by both the Primary and Secondary Plans
After the Primary Plan's payment is determined, the Secondary Plan pays what is left, up to its maximum
benefit plus any accrued savings This total amount will not exceed 100% of the Allowable Expense
"Closed Panel Plan" means a Plan thaf provides health care benefits to covered persons in the form of
services through a panel of Providers who are pnmarily employed by the Plan and that excludes
coverage for services prowded by other Providers, except in cases of an Emergency or referral by a
panel member
"Custodial ParenY' means the parent awarded custody by a court decree or, m the absence of a court
decree, the parent with whom the Children reside more than one half of the Calendar Year excluding any
temporary visitation
Order of Benefit Determination Rules
7he order of benefit determination rules govern the order in which each Plan will pay a claim for benefits
7he Plan that pays first is called the Pnmary Plan The Primary Plan must pay benefits according to its
policy terms without regard to the possibility that another Plan may cover some expenses The Plan that
pays after the Primary Plan is the Secondary Plan The Secondary Plan may reduce the benefits it pays
so that payments from all Plans do not exceed 100% of the total Allowable Expense
When a person has health care coverage under more than one Plan, the order of benefit determmation
rules determine which is the Primary Plan and which is the Secondary Plan
When you are covered by two or more Plans, the rules for determining the order of benefit payments are
as follows
1 The Primary Plan pays or provides its benefits according to its terms of coverage and without
regard to the benefits under any other Plan
2 A Plan that does not contain a COB provision that is consistent with the COB provisions in this
section is always primary unless
➢ The provisions of both Plans state that the complying Plan is primary, or
➢ The coverage that is obtained by virtue of inembership in a group designed to supplement a
part of a basic package of benefits prowdes that the supplementary coverage is in excess to
any other parts of the Plan provided by the contract holder Examples include ma�or medical
coverages that are supenmposed over hospital and surgical benefits, and msurance type
coverages that are written in connection with a Closed Panel Plan to provide out-of-nefinrork
benefits
3 A Plan may consider the benefits paid or provided by another Plan in calculating payment of its
benefits only when it is Secondary to that other Plan
4 Each Plan determines its order of benefits using the first of the following rules that apply
➢ Deaendent or Non-dependent - The Plan that covers a person other than as a dependent is
the Primary Plan and the Plan that covers a person as a dependent is the Secondary Plan
However, if the person is a Medicare beneficiary and, as a result of federal law, Medicare is
secondary to the Plan covering the person as a dependent, and primary to the Plan covering
the person as other than a dependent (e g, a retired employee), then the order of benefits
between the two Plans is reversed so that the Plan covenng the person other than as a
dependent is the Secondary Plan and the other Plan is the Primary Plan
Page 36 City of Bremerton Plan B
Benefits Booklet
➢ Dependent Children Covered Under More Than One Plan - Unless there is a court decree
stating otherwise, when a dependent Child is covered by more than one Plan the order of
benefits is determined as follows
(a) For dependent Children whose parents are marned or are living together, whether or not
they have ever been married
(i) The Plan of the parent
Primary Plan
(u) If both parents have the
longest is the Primary Plai
whose birthday falis earlier in the Calendar Year is the
same birthday, the Plan that has covered the parent the
(b) For dependent Chddren whose parents are divorced or separated or not livmg together,
whether or not they have ever been married
(�)
(ii)
(ni)
(iv)
(v)
If the court decree states that one of the parents is responsible for the dependent
Children's health care expenses or health care coverage and the Plan of that parent
has actual knowledge of those terms, that Plan is primary This rule applies to claim
determination periods commencing after the Plan is given notice of the court decree
if a court decree states one parent is to assume primary financial responsibility for
the dependent Chddren but does not mention responsibdity for health care expenses,
the Plan of the parent assuming financial responsibdity is pnmary
If a court decree states that both parents are responsible for the dependent
Children's health care expenses or health care coverage, the provisions of
subparagraph (a) above determine the order of benefits
If a court decree states that the parents have �oint custody without specifying that
one parent has responsibility for the health care expenses or health care cove�age of
the dependent Children, the provisions of subparagraph (a) above determine the
order of benefits
If there is no court decree allocating responsibility for the dependent Children's health
care expenses or health care coverage, the order of benefits for the Children are as
follows
• The Plan covenng the Custodial Parent, first,
• The Plan covenng the spouse of the Custodial Parent, second,
• The Plan covermg the non-Custodial Parent, third, and then
• The Plan covenng the spouse of the non-Custodial Parent, last
(c) For a dependent Children covered under more than one Plan of individuals who are not
the parents of the Chddren, the provisions of subparagraph (a) or (b) above determme
the order of benefits as if those mdividuals were the parents of the Children
➢ Active employee or Retired or Laid-off emplovee - The Plan that covers a person as an active
employee, that is, an employee who is neither laid-off nor retired, is the Primary Plan The
Plan covermg that same person as a retired or laid-off employee is the Secondary Plan The
same applies if a person is a dependent of an active employee and that same person is a
dependent of a retired or laid-off employee If the other Plan does not have this rule, and as a
result, the Plans do not agree on the order of benefits, this rule is ignored This rule does not
apply if the Dependent or Non-dependent rule can determine the order of benefits
➢ COBRA or State Contmuation CoveraQe - if a person whose coverage is provided under
COBRA or under a right of contmuation provided by state or other federal law is covered
under another Plan, the Plan covermg the person as an employee, subscriber, or retiree, or
covenng the person as a dependent of an employee, subscriber, or retiree is the Primary
Plan, and the COBRA or state or other federal contmuation coverage is the Secondary Plan
If the other Plan does not have this rule, and as a result, the Plans do not agree on the order
of benefits, this rule is ignored This rule does not apply if the Dependent or Non-dependent
rule can determine the order of benefits
➢ Lonqer or Shorter Lenqth of Coverage - The Plan that covered the person as an employee,
subscriber, or retiree longer is the Primary Plan and the Plan that covered the person the
shorter period of time is the Secondary Plan
City of Bremerton Plan B Page 37
Benefits Booklet
If the preceding rules do not determine the order of benefits, the Allowable Expenses must be shared
equally between the Plans meeting the definition of Plan In addition, this Group Plan wdl not pay more
than it would have paid had it been the Primary Plan
Effect on Benefits
When KPS is the Secondary Plan, we may reduce our benefits so that the total benefits paid or provided
by all Plans during a claim determination period are not more than the Total Allowable Expenses In
determirnng the amount to be paid for any claim, the Secondary Plan must make payment m an amount
so that, when combined with the amount paid by the Pnmary Plan, the total benefits paid or provided by
all Plans for the claim equal 100% of the Total A Ilowable Expense for that claim in addition, the
Secondary Plan must credit to its Plan Deductible any amounts it would have credited to its Deductible in
the absence of other health care coverage
Right to Receive and Release Information
Certain facts about health care coverage and services are needed to apply these COB rules and to
determine benefits payable by KPS and other Plans KPS may get the facts it needs from, or give them
to, other organizations or persons for the purpose of applying these rules and determining benefits
payable by KPS and other Plans covering the person claiming benefits KPS does not need to tell, or get
the consent of, any person to do this Each person claiming benefits under this Group Plan must give
KPS any facts it needs to apply those rules and determine benefits payable
Facility of Payment
Whenever another Plan makes payments that should have been provided under this Group Plan and m
accordance with this COB provision, KPS may, at its sole discretion, choose to reimburse the Plan
making such other payments in the amount necessary to satisfy the intent of this COB provision Any
amount paid under this subsection shall be considered as benefits paid under this Group Plan, and KPS
shall be fully discharged from liabdity to the extent of such payments
Right of Recovery
KPS has the right to recover excess payment whenever it has paid Allowable Expenses in excess of the
maximum amount of payment necessary to satisfy the intent of this provision KPS may recover excess
payment from any person to whom, or for whom, payment was made or any other issuers or Plans
Notice to Enrollees
If you are covered by more than one health benefit plan, and you do not know which is your Primary Plan,
you or your Provider should contact any one of the Plans to verify which Plan is primary The Plan you
contact is responsible for working with the other Plan to determine which is primary and wdl let you know
within thirty calendar days
NOTE All Plans have timely claim filing requirements If you or your Provider fail to submit your claim to a
Secondary Plan within that Plan's claim filing time limit, the Plan can deny the claim If you experience
delays in the processing of your claim by the Primary Plan, you or your Provider will need to submit your
claim to the Secondary Plan within its claim filing time limit to prevent a denial of the claim
To avoid delays in claims processing, if you are covered by more than one Plan, you should promptly
report to your Providers and Plans any changes in your coverage
Additional Information
If you would like additional information regardmg COB provisions, you may contact the Office of the
Insurance Commissioner toll-free at 1-800-562-6900
Page 38 Cdy of Bremerton Plan B
Benefits Booklet
KPS'S RIGHT OF REIMBURSEMENT AND SUBROGATION
The benefits of this Plan wdl be avadable to you for m�ury or dlness caused by another party, sub�ect to
the exclusions and limitations of this Plan If KPS provides Plan benefits for the treatment of the m�ury or
iliness, KPS will be subrogated to any rights that you may have to recover compensation or damages
related to the m�ury or illness You and your representative(s) must cooperate fully with KPS in protectmg,
preservmg, and recovenng the amounts KPS has paid, or wdl pay, on your behalf under this Group Plan
If you obtam a settlement or award that includes the recovery of inedical expenses paid by KPS as Plan
benefits for your in�ury or illness, you agree to reimburse KPS for the full amount of benefits paid after you
have been fully compensated for your loss, sub�ect to the followmg additional agreements
a You and/or your attorney or representative agree to prowde KPS, in writmg, the details of the
in�ury or illness, the names and addresses of the party or parties believed to be responsible,
and any insurer who may offer coverage, and any other information reasonably necessary to
protect KPS's subrogation rights
b You agree to inform the responsible third party(ies) and any msurer(s) and attorneys of the
amount of the lien asserted by KPS for payments made on your behalf
c You agree to submit the bills relating to your m�uries or dlness to any insurer who may offer
coverage for them, mcluding, but not limited to, medical payments coverage, personal in�ury
protection (PIP), or other plans or contracts prowding for a benefit or recovery
d You agree to make a claim against, or otherwise pursue recovery from, all responsible parties
and their insurers for all payments advanced to you, or your medical care Providers, by KPS, or
to assign to KPS all of your nghts to a recovery, authorize KPS to bring suit in your name, and
to fully cooperate in the presentation of the claim(s)
e You agree to include �n any claim or lawsuit on your behalf, agamst any other party or msurer, a
claim for repayment of the Plan benefits paid, or to be paid, by KPS on your behalf
f You agree to give KPS reasonable notice in advance of any settlement, mediation, arbitration,
or trial relating to the in�ury or dlness
g You agree not to enter mto any agreement with any responsible party(ies) or insurer(s), or do
anything else that would in any way release KPS' lien or pre�udice our subrogation or
reimbursement rights, without first obtaming express prior written consent from KPS
h You agree, if requested, to hold in trust and to execute a trust agreement in the full amount of
the Plan benefits provided to you from any recovery, until such time as a final determination or
settlement has been reached regarding the amount that fully compensates you for your loss to
protect the rights of KPS as described in this section
When you have cooperated as set out above, and you are represented by an attorney, KPS agrees to
reduce the amount of its subrogated mterest m Plan benefits in consideration of your attorney's fees and
costs, based on the services provided and recovery obtamed In no case will KPS pay a larger share of
fees and costs, as a percentage of its recovery, than you pay as a percentage of your recovery
Collection and Reimbursement by Enrollee
If you obtam a settlement or award that mcludes payment for the medical expenses covered by KPS as
Plan benefits, you agree to reimburse KPS for these benefits, unless the amount you recover fails to fully
compensate you KPS may recover its benefit payments from you only after you have been fully
compensated Whether or not you have been fully compensated wdl be determined ob�ectively, based on
the facts of your recovery
Underinsured or Uninsured Motorist Coverage
In addition to the agreements set out above, when you recover benefits under any automobile unmsured
or underinsured motorist (UIM) coverage, KPS shall be entitled to reimbursement from your recovery for
any amount that exceeds full compensation for your loss By providing Plan benefits, KPS is not actmg as
a volunteer, and is not waiving any nghts to reimbursement or subrogation When you have cooperated
as set out above, and you are represented by an attorney, KPS agrees to reduce the amount of its
reimbursement or subrogation interest in consideration of your attorney°s fees and costs, based on the
services provided and recovery obtamed In no case wdl KPS pay a larger share of fees and costs, as a
percentage of its recovery, than you pay as a percentage of your recovery
City of Bremerton Plan B Page 39
Benefits Booklet
Cooperation
You and your representative(s) must deal in good faith with KPS and follow all of the conditions set forth
in this section In turn, KPS agrees to cooperate with you and your representative(s) in your effort to
recover reimbursement and will advance payments on your behalf for in�uries or medical conditions
caused, or asserted by you to be caused, by any third party, sub�ect to the limitations and exclusions of
this Plan Fadure to cooperate may result in a delay or denial of otherwise eligible claims until the
requested action or mformation is provided to KPS
Recovery of Claims Payments
Ineligib/e Persons
If KPS knowingly or unknowingly makes any payment on behalf of an individual who, for any reason, was
not eligible to receive the services and benefits provided herein, KPS will be entitled to full reimbursement
from such ineligible individual or from a Subscriber who applied for the ineligible benefits on behalf of
such individual
If KPS knowingly or unknowingly receives Premium payment on behalf of an individual who, for any
reason, was not eligible to receive the services and benefits provided herein, KPS reserves the right to
refund any Premwm payment(s) in excess of claims paid for the time the individual was ineligible and
shall have the right to recover the cost of any benefit furnished whde such individual was improperly
enrolled m this Group Plan
NOTE This section does not apply to services and benefits for which you or your Provider received prior
authorization from KPS Health Plans
Incorrect Claim Payment
KPS is entitled to full reimbursement from the payee for any incorrect claim payment The term "incorrect
claim paymenY' includes, but is not limited to, the following
➢ Payment to the wrong Provider
➢ Payment for a service that is not covered
➢ Duplicate payment for the same service
➢ Incorrectly bdled procedure or diagnosis
Page 40 C+ty of Bremerton Plan B
Benefits Booklet
COMPLAINTS AND APPEALS PROCESS
KPS wdl comply with any new requirements as necessary under federal laws and regulations The most
current information about your Appeals process is available on our Web site at www kqshealthplans com
or by contactmg Member Services at 360-478-6796 or toll-free at 1-800-552-7114
If You Have a Complaint
You, or your designated representative, have a nght to contact KPS whenever you have a complamt or
concern regardmg
➢ The service you receive from KPS
➢ Your access to care or quality of care
➢ Any KPS Participating Provider
➢ Any other issue related to this KPS Plan or KPS
KPS Customer Service is available to help you Monday through Friday, from 8 00 a m until 5 00 p m
Pacific Time, except on nationally recognized holidays
To file a complaint, follow the steps outlined below
You must: Send a written statement of your complaint to
KPS Health Plans
Attn Customer Service
PO Box 34803
Seattle, WA 98124-1803
Fax 360-415-6514
OR
Call the Customer Service Department at 360-478-6796 or toll-free at 1-800-552-7114
For the deaf and hearmg impaired, call TTY toll-free at 1-800-833-6388
KPS resolution• KPS
Customer Service with
received m writmg will
Customer Service
wdl respond to a complamt within 30 days of receiving it If you call KPS
a complaint, they wdl respond to your complaint over the phone Complaints
be acknowledged, and you wdl receive a response, in writing, from KPS
Complamts about Participatmg Providers are investigated thoroughly and are reviewed periodically
Standard Appeals Process
Whenever KPS makes a decision regardmg the dernal, reduction or termination of benefits under your
health care coverage, you, your designated representative, or your Provider has a right to appeal that
decision The KPS Standard Appeals Process is progressive and follows specific steps descnbed m this
section The request for an appeal must be received by KPS within 180 days of the date you receive an
Explanation of Benefits (EOB), letter, or other type of communication from KPS that contains an
unfavorable decision
Such decisions could affect
➢ Your eligibility for benefits
➢ Your plan benefits
➢ Termination or rescission of coverage under this Group Plan (except termmation for non-payment
of Premium)
➢ Non-payment of a claim, either completely or partially
City of Bremerton Plan B Page 41
Benefits Booklet
➢ A denial or modification of a request for pre-authonzation or extended authorization of any health
care service or supply
➢ A denial of a request for coverage of an Expenmental or Investigational service or supply
To request an appeal, you, your designated representative, or your Provider may either call or write KPS
at the phone number or address listed below You may include any documentation you feel supports your
position
You must: Send a written statement of your appeal to
KPS Health Plans
Attn Appeals Department
PO Box 34593
Seattle, WA 98124-1593
Fax 1-206-901-7340
OR
Call the Appeals Department toll-free at 1-877-828-4514
For the deaf and hearmg impaired, call TTY toll-free at 1-800-833-6388
First Level Appeal
The Appeals Department wdl notify you, in writing, withm five (5) busmess days that we have received
your request and will process it under a First Level Appeal The First Level Appeal is an informal review of
all internal and submitted information and is conducted by the appropnate staff KPS wdl send you the
decision from the First Level Appeal withm 14 calendar days of receiving your request for appeal KPS
may extend the review to 30 calendar days with notification to you, but may not extend beyond 30
calendar days without your approval KPS will respond to denials of Experimental and/or Investigational
Procedures or Supplies withm 20 working days You have the right to send your appeal directly to an
Independent Review Organization (IRO) descnbed below if KPS provides you with an unfavorable
decision of your First Level Appeal or if KPS does not adhere to this First Level Appeals Process
"Adverse Determination" means a decision by KPS to deny, modify, reduce, or termmate payment,
coverage, authorization, or prowsion of health care sennces or benefits, including the admission to, or
continued stay in, a facdity
Independent Review Organization (IRO)
You have the right to request that KPS send an unfavorable First Level Appeal decision to an
Independent Review Organization (IRO) consisting of non-affiliated medical experts and/or medical
coverage agreement specialists who are qualified to review your case This right is only avadable after
exhausting the First Level Appeal process or if KPS does not adhere to the Standard Appeals Process
You may request review by an IRO withm 180 days from the date you receive an unfavorable decision of
the First Level Appeal or the optional Second Level Appeal as described below KPS will provide the IRO
all of your case information within three (3) business days from the date of your request You have five (5)
business days, from the date you recewe notice that your appeal was sent to an IRO, to submit in writing,
directly to the IRO, any additional information to be considered in the review KPS wdl pay the IRO fee
The IRO wdl notify you and KPS of their decision The IRO decision is final If the IRO overturns our First
Level Appeal or optional Second Level Appeal decision, KPS will promptly comply and notify you
You may request an expedited external review if the decision regarding a KPS denial of benefits concerns
an admission, avadability of care, continued stay, or health care service for which you received
emergency services but have not been discharged from a facdity, or involves a medical condition for
which the standard external review time frame of forty-five days would senously �eopardize your life or
health or�eopardize your ability to regain maximum function The IRO must make its decision to uphold or
reverse the decision and notify you and KPS of the determination as promptly as possible but within not
more than seventy-two hours after the receipt of the request for expedited external review If the notice is
Page 42 City of Bremerton Plan B
Benefits Booklet
not in wnting, the IRO must provide written confirmation of the decision withm forty-eight hours after the
date of the notice of the decision
For claims mvolvmg experimental or investigational treatments, the IRO must ensure that adequate
clinical and scientific experience and protocols are taken into account as part of the external review
process
Second Level Appeal (OPTIONAL)
If you do not agree with KPS's First Level Appeal decision, you may request an optional Second Level
Appeal by the KPS Appeals Committee prior to requesting review by an IRO as described above Your
Second Level Appeal request must be received by KPS w�thm 180 days from receiving an unfavorable
decision of the First Level Appeal Your case will be reviewed by members of the committee, includmg
medical staff who did not make the First Level Appeal decision, withm thirty (30) business days of your
request KPS wdl notify you, in wnting, of the Second Level Appeal decision within five (5) busmess days
after the KPS Appeals Committee meeting
If you elect this optional Second Level Appeal, you stdl have the right to appeal further to an IRO if the
Second Level Appeal decision is not in your favor
The optional Second Level Appeal is not avadable if the appeal request is for an Experimental or
Investigational procedure or service
Expedited Appeals Process
If your health care Provider, or the KPS Medical Director, reasonably determmes that followmg the
Standard Appeals Process would �eopardize your life, your health, your ability to regain maximum
function, or sub�ect you to severe pam that cannot be managed adequately without the requested care or
treatment, KPS wdl invoke an Expedited Appeals Process This means KPS wdl make a decision within
72 hours after your request for appeal is received if KPS expedites your appeal, you will receive notice of
this action
Appeals Related to Continuation of Care
KPS will contmue to provide coverage for services and supplies for ongomg care that KPS denied,
reduced, modified, or terminated until the appeals process is complete However, if the final outcome
supports KPS's decision, you may then be responsible for any costs that were incurred for the
continuation of that care
For more mformation regardmg the appeals process and your rights durmg an appeal, please contact the
Appeals Department toll-free at 1-866-458-5479 For the deaf and hearmg impaired, call TTY toll-free at
1-800-833-6388
ENROLLEE RIGHTS
KPS Privacy Policy
KPS is committed to protectmg the privacy of your personal and health mformation We are required by
applicable federal and state law to maintain the privacy of your personal and health information KPS also
is required to give you this notice to tell you how we may use and give out ("disclose") your personal and
health information held by KPS
Personal and health mformation (referred to in this notice as "personal information") means any
information that is identifiable to you as your personal information, including mformation regarding your
health care and treatment, identifiable factors, such as your name, age, and address, or financial
info�mation
We may collect personal information about you, or members covered by KPS through you, from the
followmg sources
--
City of Bremerton Plan B Page 43
Benefits Booklet
➢ Information we receive from you, including information you provide on applications or other forms
➢ Informat�on we receive from your health care Providers or other companies (e g, other health
insurance companies), relating to your medical claims and billings
➢ General information about the health care services you have received, such as the quality and
avadability of services
We restrict access to personal information about you to only those who need to know that mformation to
provide treatment, payment, or health care operations services to you We maintain physical, electronic,
and procedural safeguards that comply with federal regulations to guard your personal information
We do not disclose any personal information about our members or former members to anyone, except
as permitted or required by law, however, KPS wdl use and give out your personal health information
➢ To you or someone who has the legal right to act for you (your personal representative} or close
famdy relative involved in your care or responsible for the payment of your services
➢ To the Secretary of the Department of Health and Human Services, if necessary, to make sure
your privacy is protected
➢ To !aw enforcement officials when investigatmg and/or prosecuting alleged civd or criminal
actions
➢ Where required by law
KPS has the right to use and give out your personal information to arrange for treatment, payment, and
health care operations services, including
➢ Medical quality reviews
➢ Accounting
➢ Legal and risk management services
KPS may use or give out your personal information for the following purposes under limited
circumstances
➢ For government health care oversight activities, such as fraud and abuse investigations
➢ To avoid a serious and imminent threat to the health or safety of you or the public
By law, KPS must have your written permission (an "authorization") to use or give out your personal
mformation for any purpose that is not set out in this notice You may take back ("revoke") your wntten
permission at any time, except if KPS has already acted based on your permission
By law, you have the right to
➢ See, and get a copy of, your personal informat+on held by KPS, except in certain limited
situations
➢ Make a reasonable request in writing to amend any of your personal information created by KPS
if you believe that it is wrong, or that information is missmg, and KPS Health Plan agrees If KPS
disagrees, we wdl notify you why in writing You may have a statement of your disagreement
added to your personal information
➢ Get a listing of those obtainmg your personal mformation from KPS in the past six (6) years The
listing will not include information that
o' Was given to you or your personal representative or close family relative mvolved in your
care or payment of such care
o You authorized KPS to release
o Was given out for law enforcement purposes
o Was given out to pay for your health care claim or a disputed claim
➢ Request in writing that KPS communicate with you in confidence about your personal information
by alternative means or to an alternative location If you advise us that disclosure of all or any part
of your personal information could endanger you, we must comply with any reasonable request
provided it specifies an alternative means or location
Page 44 City of Bremerton Plan B
Benefits Booklet
➢ Ask KPS to place additional restrictions on our use or disclosure of your personal information for
treatment, payment, health care operations, or to persons you identify We are not required to
agree to these additional restrictions and wdl notify you about the reasons regarding this action If
we do agree to the additional restrictions, we wdl abide by our agreement, except �n an
Emergency
➢ Get a separate electronic or paper copy of this notice
For more mformation about exercismg your rights set out in this notice, contact KPS's Customer Service
department at 360-478-6796 or toll-free at 1-800-552-7114 You also can reach KPS's privacy official for
this purpose toll-free at 1-800-552-7114
If you believe KPS has violated your privacy rights set out in this notice, you may file a complaint with
KPS at the followmg address
KPS Health Plans
Compliance Department
P O Box 34803
Seattle, WA 98124-1803
Filmg a complamt wdl not affect your benefits under KPS You also may file a complaint with the
Secretary of the Department of Health and Human Services
KPS does have the right to change the way your personal information is used and given out If KPS
makes any changes, you will get a new notice by mad within 60 days of the change, and that notice wdl
become effective on the date the revised notice is issued
NOTE Telephone calls to and from KPS may be recorded for quality assurance and training purposes
If you are the primary Subscriber with KPS and other persons are covered by KPS through you, we
suggest that you share this information with each other to ensure that each of you is aware of our policy
and your privacy rights
Please refer to KPS's web site at www KPSHealthPlans com for more information about our privacy
practices
Disclosure of Information
By law, you have the nght to receive information about KPS, as well as your KPS Group Plan and how it
works Most of this information is provided to you when you enroll, however, other mformation is avadable
only upon request Please refer to the Your Access to Information section at the end of this Benefits
Booklet
Statement of ERISA Rights
As a participant m this Group Plan you are entitled to certain nghts and protections under the Employee
Retirement Income Security Act of 1974 (ERISA) ERISA provides that all Group Plan participants shall
be entitled to
➢ Examination, without charge, at the Group Plan Administrator's* office and at other locations, of
all Group Plan documents, mcluding msurance contracts, collective bargainmg agreements, and
copies of all documents filed by the Group Plan with the U S Department of Labor, such as
detaded annual reports and Group Plan descnptions *"
➢ Obtain copies of all Group Plan documents and other Group Plan information upon written
request to the Group Plan Administrator The Group Plan Admmistrator may make a reasonable
charge for the copies
➢ Receive a summary of the Group Plan's annual Form 5500 report The Group Plan Administrator
is required by law to furrnsh each participant with a copy of this summary annual report **
In addition to creatmg rights for Group Plan participants, ERISA imposes duties upon the people who are
responsible for the operation of the employee benefit plan The people who operate your Group Plan,
called Group Plan Fiducianes*, have a duty to do so prudently and in the mterest of you and other Group
Plan participants and beneficiaries No one, including your employer, your union, or any other person,
Ciry of Bremerton Plan B Page 45
Bene�ts Booklet
may fire you or otherwise discriminate against you in any way to prevent you from obtainmg a welfare
benefit or exercising your rights under ERISA If your claim for a welfare benefit is denied in whole or in
part, you must receive a written explanation of the reason for the denial and copies of documents relating
to the decision without charge You have the right to appeal the denial within certain time schedules
Under ERISA, there are steps you can take to enforce the above rights For instance, if you request
materials from the Group Plan Administrator and do not receive them within 30 days, you may file a suit in
federal court In such a case, the court may require the Group Plan Administrator to provide the materials
and pay you up to $110 a day, untd you receive the materials, unless the materials were not sent because
of reasons beyond the control of the Group Plan Admirnstrator If you have a claim for benefits that is
denied or ignored, in whole or in part, you may file a suit in a state or federal court If it should happen
that the Group Plan Fiduciaries misuse the Group Plan's money, or if you are discrimmated 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 successful, the
court may order the person you have sued to pay these costs and fees If you lose, the court may order
you to pay these costs and fees (e g, if it finds your claim is frivolous) If you have questions about your
Group Plan, you should contact your Group Plan Admmistrator If you have any questions about this
statement or about your rights under ERISA, you should contact the nearest Area Office of the U S
Labor-Management Services Administration, Department of Labor listed in your telephone directory
*Contact your employer to identify your "Group Plan Admmistrator" and "Group Plan Fiducianes "
**Certam employers are not required to file these reports '
Women's Right to Direct Access
KPS and Washington State laws have established standards to ensure women's nght to directly access
timely, appropriate, and Medically Necessary covered women's health care services, without the
necessity of pnor referral from another Provider Covered women's health care services include maternity
care, reproductive health services, gynecological care, general examination, preventive care, and
follow- up visits, when provided by a licensed physician (M D or D O), a physician's assistant (P A), an
advanced registered nurse practitioner (A R N P) specializing in women's health care or midwifery, or a
licensed midwife, and any Participatmg Facdity used by such Providers
if you would like a more detailed description than is prowded above regarding women's right to direct
access under this Group Plan, or you have questions or concerns about any aspect of your women's
health care benefits, please contact KPS at 360-478-6796 or toll-free at 1-800-552-7114
Your Right to Safe and Effective Pharmacy Services
KPS and Washington State have established standards to ensure safe and effective pharmacy services,'
to guarantee your right to know what drugs and medications are covered under th�s Group Plan, and to
understand the limitations of your pharmacy coverage under this Group Plan If you would like a more
detailed description than is provided above regarding your pharmacy benefits, please contact KPS at
360-478-6796 or toll-free at 1-800-552-7114
If you would like to know more about your rights under the law, or if you think the information you have
received from KPS does not conform to the terms of your Group Plan or your rights under the law, you
may contact the Office of the Insurance Commissioner toll-free at 1-800-562-6900 If you have a concern
about the pharmacists or pharmacies serving you, please call the Washington State Department of Health
at 360-236-4825
Page 46 Ciry of Bremerton Plan B
Benefits Booklet
HOW YOU CAN STOP HEALTH CARE FRAUD
KPS is committed to meeting your health care needs at an affordable price Because fraud increases
health care expenses, it ultimately results in higher Premiums Beyond financial losses, fraudulent health
care practices can threaten your health and safety
KPS is dedicated to controlling expenses and protectmg our enrollees We are actively fightmg health
care fraud and want to mcrease your awareness of how to combat potential fraudulent acts and
situations Precautions you may take include, but are not limited to the following
➢ Beware of "free" medical treatment offers
➢ Beware of people offering money to you if you agree to have medical procedures done (possibly
unnecessary and dangerous to your health)
➢ Be wary of people requesting that you travel to other states for medicai procedures
➢ Protect your health insurance information and do not give it out to solicitors or to people over the
telephone without ensurmg that person has the "nght to know "
➢ Avoid using health care Providers who say that a service is not usually covered, but they know
how to bill us to have it paid
➢ Review your Explanation of Benefits (EOB) form to assess the accuracy of the claims payment
mformation As an example, fraud may appear on an EOB as charges for tests or procedures you
did not have
➢ Remember, if somethmg sounds too good to be true, it likely is
➢ Ensure that only qualified family members are enro!!ed with you on the health plan
➢ Participatmg in health care fraud is dlegal and dangerous
Your continued health is our goal if you suspect health care fraud, please contact the KPS Fraud Hotline
at 888-475-2366 or https //kpsfraudcompliancehotline alertline com to explam the circumstances
City of Bremerton Plan B Page 47
Bene�ts Booklet
DEFINITIONS
� a
Accidental In�ury Any bodily in�ury caused by an unexpected occurrence independent of
disease or bodily infirmity
Approved Treatment Program A discrete program of chemical dependency treatment provided by a
treatment program certified by the Washington State Department of
Social and Health Services, in compliance with RCW 70 96A 020(3)
Benefits Booklet The document that describes the terms and conditions applicable to this
Group Plan, as well as the benefits provided herein
Calendar Year The 12-month period beginning January 1 and ending December 31
Child or Children (i) Natural children, adopted chddren, stepchildren or other legally
designated ward(s) under the Limiting Age who is a dependent of
the Subscriber or the Subscriber's Spouse
(n) Chddren under the Limiting age who are legally entitled to receive
medical coverage as a result of a court order binding either the
Subscriber or the Subscriber's Spouse, regardless of whether or not
the Subscriber or Subscriber's Spouse has legal custody of the
chddren
(ui) Chddren who have reached the Limiting (or is older than the
Limiting Age), is incapable of self-sustaming employment due to
developmental disabdity or physical handicap, and is dependent
upon the Subscriber or the Subscriber's Spouse for total or partial
support and maintenance (see the Continued Eligibdity for
Disabled Dependent Children section)
Coinsurance The dollar amount of the KPS allowed expense that you pay to your
Provider This amount is usually expressed as a percentage on
applicable benefits
Coinsurance Maximum The maximum amount you pay for Co�nsurance
Copayment An amount you are required to pay your Provider at the time of service
Covered Benefits and Services Those Medically Necessary services listed in this Benefits Booklet that
an Enrollee is entitled to receive
Deductible The amount you and/or your family are required to pay out-of-pocket
each Calendar Year before KPS pays for your Medically Necessary
Covered Benefits antl Services
Eligible Dependents The Subscriber's legal Spouse and/or Children, or the legal Spouse
and/or Chddren of an active, full-time LEOFF I or LEOFF II firefighter
Emergency (or Medical A sudden and acute onset of a symptom or symptoms, including severe
Emergency) pain, that would lead a prudent layperson, acting reasonably, to believe
that a health condition exists that requires immediate medical attention if
failure to provide medical attention would result in senous impairment to
boddy functions or serious dysfunction of a bodily organ or part, or would
place the person's health in serious �eopardy
Employee An active, full-time employee who is not a LEOFF I or LEOFF II
Employee
Endorsement An amendment to the conditions of coverage or the benefits provided by
this Group Plan
Page 48 City of Bremerton Plan B
Bene�ts Booklet
� .
Enrollee A Subscnber or Dependent enrolled in this Group Plan who is entitled to
the benefits provided herein
Essential Benefits Benefits covered under this Group Plan, m at least the following
categories ambulatory patient services, emergency services,
hospitalization, maternity and newborn care, mental health and
substance use disorder services, mcluding behavioral health treatment,
prescription drugs, rehabditative and habilitative services and devices,
laboratory services, preventative and wellness services and chronic
disease management and pediatnc services, mcluding oral and vision
care Such benefits shall be consistent with those set forth under the
Patient Protection and Affordable Care Act of 2010 and any regulations
issued pursuant thereto For further detads about these services, please
visit our website at www kpshealthplans com or contact our Member
Services Department at 360-478-6796, or toll-free at 1-800-552-7114
Experimental or Investigational Medical or surgical treatments or procedures, drugs or drug use, medical
equipment, devices or supplies, or faalities (collectively referred to as
"services") are considered to be Experimental or Investigational if
➢ The services are not in general use in the Washmgton State medical
community
➢ The services pose a significant risk to the health or safety of the
patient
➢ The services are under continued scientific testing and research
under Phase I or Phase II clinical tnals
➢ The services are under the research, expenmental, study or
investigational arm of a Phase III clinical trial
� ➢ Rel►able ewdence has not shown that the services result m greater
benefits for a particular illness or disease than other generally
available services
➢ Reliable evidence has not shown that the services are safe or
effective, or have any demonstrable benefit for a particular illness or
disease
For purposes of this definition, rel►able evidence means published
reports and articles in authoritative medical and scientific literature,
published evaluations of national medical associations and medical
consensus panels, written protocols used by the treatmg facdity or other
facilities that are studying substantially the same service as the treating
facility, or written mformed consent notices used by the treating facility or
other facilities studying substantially the same service as the treating
facdity
Group The employer, association or other entity that has entered into this
� Group Plan on your behalf
Group Plan Administrator Your employer's Human Resources Department, or any other person or
company designated by your employer to admmister this Group Plan on
behalf of the Group's Employees
Group Plan This Benefits Booklet plus any Riders, Endorsements, or other
attachments that state the terms and conditions for admmistration of
your benefits
Hospital A hospital that is accredited by the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) or licensed by the state m which it is
located
City of Bremerton Plan B Page 49
Benefits Booklet
o .
KPS KPS Health Plans is a health care services contractor licensed to market
and sell health care coverage plans in Washington State KPS was
formerly known as Kitsap Physicians Service
LEOFF I Employee A full-time law enforcement officer or firefighter hired pnor to October 1,
1977, and who is a member of the LEOFF system as defined m Sections
3 and 4, CH 131, Law of 1972, 1�` Ex Session
LEOFF II Employee A full-time law enforcement officer or firefighter hired on or after October
1, 1977, and who is a member of the LEOFF system as defined in
Sections 3 and 4, CH 131, Law of 1972, 1 Ex Session
Limiting Age The age at which Chddren may no longer be covered under this Group
Plan as an Eligible Dependent The Limiting Age is specified in the
Benefits Summary section of this Benefits Booklet
Medical Director The licensed physician acting as chief inedical advisor for KPS
Medical Emergency See Emergency ,
Medically Necessary/Medical To be considered Medically Necessary, Covered Benefits and Services
Necessity must meet all of the following criteria
➢ Be consistent with the symptoms or diagnosis and treatment of the
condition '
➢ Be the most appropriate supply or level of service that is essential
to the Enrollee's needs
➢ When applied to an inpatient, it cannot be safely provided to the
Enrollee as an outpatient
➢ Be appropnate with regard to good medical practice
➢ Not be provided primarily for the convenience of the Enrollee or the
inpatient facdity
➢ Be the most cost-effective of the alternatwe levels of service or
supplies that are adequate and available
�Non-Participatmg Provider or Any Provider or Facdity not contracted with KPS, either or directly
Facihry
Open Enrollment Period Generally the calendar month immediately prior to the annual renewal
date for this Group Plan During the Open Enrollment Penod, persons
who did not enroll when they were initially eligible may enroll, and/or
Subscribers may add or delete Eligible Dependents Coverage will be
effective as of the renewal date
Partial Hospitalization A less restrictive type of inpatient care which allows the patient to
receive observation, evaluation, and intense daily therapy but remain at
their home at night and on weekends and holidays
Participating Facility An accredited facility, which has contracted with KPS, either directly or
indirectly, to provide health care services to Enrollees Participating
Facdities have agreed to accept the KPS allowance for Covered Benefits
and Services as payment in full, except for Deductible, Copayment and
Coinsurance amounts, which are the responsibdity of the Enrollee
Participating Provider A Provider who has contracted with KPS, either directly or indirectly, to
provide health care senrices to Enrollees Participating Providers have
agreed to accept the KPS allowance for Covered Benefits and Services
as payment in full, except for Deductible, Copayment, and Comsurance
amounts, which are the responsibility of the Enrollee
Page 50 City of Bremerton Plan B
Benefits Booklet
� a a B • w � `"' ° �'s � ` �`� i�r 3 & x�+� '* '' �wrr a �
Premium A payment made to KPS on a scheduled periodic basis by, or on behalf
of, an Enrollee with the expectation of receiving the Covered Benefits
and Services provided under this Group Plan
Premium Due Date The scheduled, periodic dates by which Premium payments must be
received by KPS as a condition for continued enrollment in this Group
Plan This date is the first day of each month of coverage
Provider Any one of the following licensed or certified health care practitioners
actmg withm the scope of their license or certificate
Chiropractor Physical Therapist
Dentist Physician (M D or D O)
East Asian Medicine Practitioner Physician's Assistant (P A)
Massage Therapist Podiatrist
Naturopath (N D ) Psychologist
Nurse Midwife Speech Therapist
Occupational Therapist
Certified Chemical Dependency Provider
Certified Mental Health Provider
Advanced Registered Nurse Practitioner (A R N P)
NOTE This list does not include all types of Providers covered by KPS
If your Provider type is not listed above, please call KPS toll-free at
1-800-552-7114 to request more mformation
Residential Mental Health A facdity that provides 24hour treatment, services, and supervision for a
Facdity mental health condition in a non-acute setting
Rider An additional benefit over and above those listed m the Benefits
Summary section Rider documents are attached at the back of the
Benefits Booklet and provide detailed benefit information
Skdled Nursing Facility (SNF) A facdity, or the distinct section of a facdity (such as a wmg of an
accredited general Hospital), that is licensed pnmardy to provide skdled
nursmg care and related services, or rehabititation services, on a
24-hour basis The facility must employ at least one registered nurse
(R N) who is on full-time duty and one physician (M D or D O) who is
avadable to provide necessary medical care in the event of an
Emergency
Spouse (i) An mdividual who is living m a mantal relationship with the
Subscriber The marital relationship must be legally recognized by
the state of Washmgton
(ii) An individual who is livmg with the Subscriber as a state registered
domestic partner
Subscriber An eligible Employee who is enrolled m this Group Plan, or any other
eligible person, who is the principal Enrollee in this Group Plan
City of Bremerton Plan B Page 51
CONTACT US
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Benefits Booklet
KPS Health Plans is located at:
400 Warren Avenue
Bremerton, WA 98337
For KPS Customer Service, please call:
360-478-6796
1-800-552-7114 (toll-free)
For the deaf & hearing-impaired call
TDD
1-800-833-6388 (toll-free)
Send mquiries, claims or complaints to
KPS Health Plans
PO Box 34803
Seattle, WA 98124-1803,
Fax inquiries to 360-415-6514
Send e-mail inquiries to:
info@kpshealthplans com
Page 52 City of Bremerton Plan B
0
Your Access to Information
As a member of KPS Health Plans, you have the nght to receive certain information about KPS, about your plan
benefits, and about how to access benefits When you enroli, KPS gives you documents or access to resources,
which contain this important information In order to ensure you get the highest possible benefit from your Group
Plan, you should read/access this information prior to seekmg care from your Provider If you have lost or
misplaced any of the documents, please contact KPS Customer Service, and we wdl send you a new copy
Documentllnformation:` � Contains: �, z � � ° xw F .�, � ,.
n .� _ � _ _� a �.�. _ �_
Benefits Booklet Information regardmg
✓ Covered Benefits and Services
✓ Exclusions, reductions, and limitations to Covered Benefits and Services
✓ Amounts you are required to pay for your care, mcluding
- Individual and famdy Deductibles
- Copayments
- Coinsurance
- Maximum annual out-of-pocket costs
✓ Pre-authorization requirements for certam services
✓ Requirements for specialty care
✓ Complamt and appeals process
✓ KPS's olic re ardin the disclosure of our ersonal health information
Access to Provider Directories Information regarding the following can be found at www kqshealthplans com or
by callmg KPS Customer Service at 360-478-6796 or toll-free 1-800-552-7114
✓ Network primary care Providers
✓ Network specialty Providers
✓ Nefinrork harmacies If our Grou Plan covers rescri tion dru s
Access to Prescription Drug Information regardmg the followmg can be found at www kpshealthplans com or
Formulary by calling Medtmpact toll-free at 1-800-788-2949
✓ Drugs covered by your Group Plan
✓ Copayment amounts you are required to pay when you have a prescription
filled
✓ How often drugs are added to, or removed from, the list and where you can
et more information
Pharmacy Questions and Information regarding the following can be found at www kpshealthplans com or
Answers by calling Medlmpact toll-free at 1-800-788-2949
✓ KPS drug formulary
✓ Covered and excluded drugs
✓ Drug substitutions
✓ How Copayments are determined
✓ Where to et a listin of network harmacies
For More Information: � ��=r __ _ ti _ �_ _�_ __,, � __ _ - ��3 _ _ _ � _ �,p_�_
KPS also provides the followmg mformation to its members on request
❖ General information regarding the types of plans offered by KPS
❖ How KPS pays its network Providers for the care you receive
❖ An accountmg of the payments KPS has made, which have been credited to your annual Deductible or
used to calculate any service limitations or maximums
:• KPS's accreditation status and any publicly reported health employer data mformation set (HEDIS) data
If you would like a copy of any of the referenced information, please contact KPS Custome� Service at
360-478-6796 or toll-free at 1-800-552-7114
If you wish, you may send a wntten request for information to
KPS Health Plans
P O Box 34803
Seattle, WA 98124/1803
KPS Health Plans
400 Warren Avenue
P 0 Box 339
Bremerton, WA 98331-0039
Attachment B
Premium Rates and Underwriting Criteria
For
City of Bremerton
Period: January 1, 2013 — December 31, 2013
Premium Rates
Note: Rates include Vision and is for Employees ONLY (Actrve and COBRA).
Undervvriting Criteria
The Premium rates quoted above for this Group Plan are based on the followmg underwriting critena
KPS resenres the right to withdraw or rerate this offering if Group falls outside the scope of these criteria
➢ A change m Employer contribution may negate Grandfathered status. Grandfathered
plans cannot decrease the percent of premiums the Employer pays by more than 5
percentage points (for example, decrease their own share and increase the workers' share
of premwm from 15°/a to 25%). Any change to the employer contribution percentage must
PLAN A 8� RETIREES
PLAN B & RETIREES
be communicated to KPS, m writ�ng, no less than 30 days m advance of the effective date
of the contribution change
➢ Active Employees must work a mmimum of twenty (20) hours per week unless otherwise
negotiated and agreed by both KPS and Group
➢ Sub�ect to pnor KPS approval, two (2) or more health insurance carriers, including KPS, may
provide coverage to Group's Employees
➢ Sub�ect to prior KPS approval, Group may select multiple KPS health plan offerings
➢ The mmimum level of participation required is seventy-five percent (75%) of eligible Employees
➢ Unless otherwise approved by KPS, no more than twenty-five percent (25%) of Group's eligible
Employees may reside outside of the State of Washington
➢ KPS reserves the right to rerate Group in the event actual enrollment fluctuates by ten percent
(10%) or more from the census provided to KPS by Group at the time Group was initially rated
KPS Health Plans
Busmess Address
400 Warren Avenue
Bremerton, WA 98337
CITY OF BREMERTON
UNDER 65 LEOFF I RETIREES
COVERAGE CONTRACT
Group Number:
Effective Date:
Contract Renewal Month:
Open Enroliment Period•
This Coverage Contract mcludes the following
Attachment A:
Attachment B
Benefits Booklet
1000780
January 1, 2013
January
December
Premium Rates and Underwnting Critena
Mading Address
P O Box 34803
Seattle, WA 98124-1803
0
This Contract is entered mto and delivered in the state of Washmgton and is governed by Washmgton
State laws, except to the extent state laws are preempted by federal law
Signature by an authorized Group representat�ve or payment of the Premium shall constitute
acceptance of the terms and conditions set forth herem
FoR KPS:
�Z/
W James Page Jr , President
Apnl 10, 2013
Date
FOR GROUP:
Signature
� LQ�v��-
Print Na e
VVla.yo✓'
Title
� �3
Date
a
KPS Health Plans
Busmess Address
400 Warren Avenue
Bremerton, WA 98337
C{TY OF BREMERTON —
UNUER 65 LEOFF I RETIREES
COVERAGE CONTRACT
Group Number:
Effective Date:
1Q00780
January 1, 2013
Contract Renewal Month: January
Open Enrollment Period. December
m
This Coverage Contract mcludes the followmg
Attachment A: Benefits Booklet
Attachment B: Premium Rates and Underwriting Cnteria
Mailmg Address
P O Box 34803
Seattle, WA 98124-1803
KPS Health Plans (KPS) is a licensed health care services contractor (HCSC) in Washington State In its
capacity as an HCSC, KPS agrees to underwrite and provide the benefits and services described in any
Benefits Booklet that may be listed above (hereinafter collectively referred to as "Attachment A"), as
applicable to the eligible Employees of the above-named Group, provided the Group, its eligible
Employees meet and comply with the provisions of this Coverage Contract ("Contract")
�
C13BREMR
TABLE OF CONTENTS
DEFINITIONS
CONTRACT EXAMINATION PERIOD
EFFECTIVE DATE, DURATION, AND RENEWAL
PREMIUM PAYMENT PROVISIONS
Payment Due Date/Grace Period
Premium Rate Ad�ustments
Premiums Paid by Subscribers
Premium Refunds
ELIGIBILITY AND ENROLLMENT
Group Eligibility
Subscriber Eligibility Requirements
Enrollment Reporting Requirements
Enrollment Timeframes
Enroliment Under Special Circumstances
When Coverage Begins
TERMINATION OF COVERAGE
Continuity of Coverage
Termmation or Rescission of Contract
Termmation or Rescission of Enrollee Coverage
COBRA (Consolidated Omnibus Budget Reconciliation Act - 1985)
Fraudulent Information
Re-Enrollment/Remstatement
SUBSCRIBER LIABILITY AND RIGHTS
Subscriber Liabihty
GENERAL TERMS AND CONDITIONS
Applicable Law
Assignment of Benefits
Bmding Agreement
Confidentiality
Contract Modifications
Coverage Limits
Entire Agreement
Equity of Applicabon _
Force Ma�eure
Group Cooperation
Headings
Notices
Severabdity
Third Party Beneficianes
Waiver of Breach
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COVERAGE CONTRACT
DEFINITIONS
Capitalized words found m the text of this Contract are defined below or may be found in Attachment A
Contract: this document and any other attachments, exhibits, Riders, or Endorsements listed on the title
page or otherwise descnbed herem, and any subsequent amendments or modifications to this document, its
attachments, exhibits, Riders or Endorsements
Contract Renewal Month: the calendar month specified on the title page of this Group Contract during
which the Group may renew its coverage each year under this Group Plan
Covered Benefits and Services: those Medically Necessary benefits and services descnbed m
Attachment A that an Enrollee is entitled to receive
Employee: a retired LEOFF I Employee who is under the age 65 and who is eligible for a Premium
contribution by his/her payroll office
Endorsement: an amendment to the conditions of coverage or the benefits provided by this Group Plan
Enrollee: a person enrolled m this Group Plan
Group: the employer entity, association, or other group that has entered mto this Contract with KPS
Group Maste� Application: the form completed by the Group and submitted to KPS pnor to securing
coverage under this Group Plan
Group Plan: the Premium rates and benefits chosen by the Group as listed m Attachment A, any Riders
and Endorsements, Attachment B— Premium Rates and Underwritir�g Criteria, plus other attachments
that state the terms and conditions for eligibdity and admmistration of Covered Benefits and Services
LEOFF I Employee. a full-time law enforcement officer or firefighter hired prior to October 1, 1977, and who
is a member of the LEOFF system as defined in Sections (3) and (4), CH 131, Law of 1972, 1 Ex Session
Medicai Director: the licensed physician acting as chief inedical advisor for KPS
Open Enrollment Period: the 31-day period or some other period agreed to by both KPS and the Group,
beginnmg one (1) month prior to the Group's Renewal Month or at some other mutually agreeable time but
at least annually Coverage wdl be effective as of the renewal date
Participating Facility. an accredited facility which has contracted with KPS, either directly or indirectly, to
provide health care services to Enrollees Participating Facilities have agreed to accept the KPS allowance
for Covered Benefits and Services as payment m full, except for Deductible, Copayment, and Coinsurance
amounts, which are the responsibility of the Enrollee
Part�cipat�ng Provider• a Provider who has contracted with KPS, either directly or indirectly, to provide
health care services to Enrollees Participating Providers have agreed to accept the KPS allowance for
Covered Benefits and Services as payment in full, except for Deductible, Copayment, and Comsurance
amounts, which are the responsibility of the Enrollee
Premium: the periodic payment made by, or on behalf of the Enrollee, as consideration for this Group Plan
and in accordance with the terms of this Contract
Premium Due Date: the scheduled, periodic dates by which Premium payments must be received by KPS
as a condition for continued enrollment in this Group Plan This date is the first day of each month of
coverage
Provider: a licensed or certified health care practitioner actmg within the scope of his/her license or
certificate
Rider: an additional benefit over and above thase listed in the Benefits Summary section of Attachment
A Rider documents are attached at the back of Attachment A and provide detaded benefit information
Subscriber: the primary person, generally the Employee, enrolled in this Group Plan
Page 1
COVERAGE CONTRACT
CONTRACT EXAMINATION PERIOD
If, after examination, the Group is not satisfied with this Contract for any reason, the Group may return the
Contract to KPS within ten (10) days of the date it is received Upon receipt of the returned Contract, KPS
wdl refund to the Group any pre-paid Premiums The Contract shall subsequently be deemed null and void
EFFECTIVE DATE, DURATION, AND RENEWAL
This Contract shall begm at 12 01 a m Pacific Time on the effective date (as indicated on the title page),
and shall remain in effect until the Contract Renewal Month unless terminated according to the provisions
set forth herein
Thereafter, this Contract may be renewed automatically at 12 01 a m on the same date (month and day) in
subsequent Calendar Years, unless otherwise terminated according to the provisions set forth herein
PREMIUM PAYMENT PROVISIONS
Payment Due Date/Grace Period
The initial Premwm payment is due and payable to KPS on or before the effective date of this Contract
indicated on the title page Thereafter, Premium payments are due and payable on or before the first day of
every month ("Premium Due Date") for which coverage is provided A roster of current enroliment and
enrollment changes must accompany each Premium payment
A ten (10) day grace period following the Premium Due Date is allowed, during which time this Contract
shall not be termmated if payment is not received within the ten (10) day grace period, KPS may, at its sole
discretion, elect to extend the grace period for up to 60 days from the Premium Due Date or termmate this
Contract without notice to the Group
If KPS elects to terminate this Contract due to non-payment of Premium, the effective date of termination
will be retroactive to the last day of the month for which payment was received No further liability for claims
will accrue to KPS Enrollees in this Group Plan shall not be entitled to benefits during any calendar month
for which the Premium, on his/her behalf, was not received by KPS
Premium payments, if applicable, must accompany all applications for coverage.
Premium Rate Adjustments
The Premium rates applicable to this Group Plan are defined in Attachment B- Premium Rates and
Underwr�ting Criteria Rates are guaranteed until the Contract Renewal Month each Calendar Year
Notwithstanding the foregoing, KPS reserves the nght to revise the rates as follows
➢ As part of the annual Contract renewal process
➢ As a result of any state or federal law or regulation that imposes an additional tax, new tax or other
assessment on KPS revenue
➢ In the event there is a material change in the basis upon which KPS assumed risk under this
Contract Such changes may include inaccurate information presented by the Group, changes in
the benefits, or other Contract terms required by statute or regulation, underwriting guidelines, or
fluctuations of ten percent (10%) or more in the number of enrolled Subscnbers KPS wdl give the
Group 60 days prior written notice of any change in Premium rates not associated with the annual
Contract renewal process
KPS wdl give the Group 30 days prior written notice of rate increases associated with the annual Contract
renewal process
Page 2
COVERAGE CONTRACT
Premiums Paid by Subscribers
In certain instances, Subscribers may be required to self-pay their Premiums m order to contmue coverage
Those instances mclude
➢ Strikes, lockouts, and other labor disputes that cause a disruption in Employee benefits
➢ When the Subscriber elects to continue coverage under a COBRA provision or other coverage
continuation provision available under this Group Plan
The Group is required to collect self-paid Premiums for continuation coverage and fonivard payments to
KPS on or before the Premium Due Date In the instance of strikes, lockouts, and labor disputes, the
Enrollee may self-pay their Premium directly to the group on or before the Premium Due Date
Premium Refunds
KPS wdl refund to the Group any Premium paid, m advance, for periods after the termination date of this
Group Plan
In the case of an meligible person(s) enrolled m this Group Plan, KPS wdl refund to the Group any Premium
paid durmg a penod of ineligibility that is in excess of claim payments made on behalf of the meligible
person(s) during the period of ineligibility This refund wd� not exceed an amount equal to three (3) months
of Premium payments
ELIGIBILITY AND ENROLLMENT
Group Eligibility
In order to be eligible to participate in this Group Plan, the Group must continuously meet all eligibility,
participation, Group size, contribution, and other requirements specified m the Group Master Application
form
KPS reserves the right to audit the Group's employment, payroll, and eligibility records to ensure that the
Group continues to meet its participation requirements and to ensure that eligible Employees are properly
enrolled in this Group Plan
Subscriber Eligibility Requirements
Retired LEOFF I Employees, as defined in the Definitions section, are eligible to enroll m this Group Plan
As of March 1, 2001, Eligible Dependents of retired LEOFF I Employees are no longer eligible to enroll in
this Group Plan
Retired LEOFF I Employees who do not enroll when they are initially eligible may not apply for coverage at
a later date except m certain circumstances (see the Enrollment Under Spec�al Circumstances section of
Attachment A)
Enrollment Reporting Requirements
The Group will verify enrollment of all Employees eligible for enrollment under this Contract and ensure that
appropriate documentation is submitted to KPS for approval
Enrollment Timeframes
Currently retired LEOFF I Employees, are initially eligible to apply for coverage begmnmg on the effective
date of this Group Plan Application for coverage must be received by KPS within 31 days of initial eligibility
Newly retired LEOFF I Employees, may initially apply for coverage on their effective date of retirement
Application for coverage must be received by KPS within 31 days of initial eligibility
Page 3
COVERAGE CONTRACT
Enrollment Under Special Circumstances
Retired LEOFF I Employees who, when they were initially eligible to enroll, declined coverage in this Group
Plan, based on existing coverage under another health plan, may apply for coverage under this Group Plan
if they lose eligibdity for coverage under their other health plan, or if the other health plan terminates
Retired LEOFF I Employees must apply for coverage within 31 days of losing coverage under their prior
plan
When Coverage Begins
Coverage for new Enrollees begins on their date of initial eligibility provided they enrolled in this Group Plan
within the specified time limits (see Enroilment Timeframes) and any applicable Premium amounts have
been paid
TERMINATION OF COVERAGE
Continuity of Coverage
Continuity of coverage under this Contract is guaranteed to all Enrollees provided the Group continues to
meet eligibdity requirements and continues to pay applicable Premwm payments on a timely basis
Termination or Rescission of Contract
This Contract may be termmated as of the date on which any of the following occurs
➢ The Group fails to make full Premwm payments
➢ The Group violates, or refuses to comply with, the terms and conditions of this Contract
➢ The Group violates, or refuses to comply with, any published KPS policies and procedures that
have been approved by the Insurance Commissioner
➢ There is a change to, or implementation of, federal or state law that prohibits the continued offering
of this Group Plan
➢ KPS replaces this Group Plan In this case, the replacement plan wtll (i) include the services
covered under the replaced Group Plan, (ii) be offered to the Group's eligible Employees, and (iii)
not significantly limit access to the kind of services covered under the replaced Group Plan
In addition, the Group may terminate this Contract, at any time, by providing thirty (30) days written notice to
KPS
KPS may rescind or terminate this Contract upon thirty (30) days written notice in the event that intentional
misrepresentation of material fact or fraud was used in order to obtain Group coverage In no event wdl
coverage be terminated or rescinded solely on the basis of an Enrollee's physical or mental condition
provided they meet all other eligibility requirements set forth by the Group The Group may appeal a
termination or rescission decision through the KPS appeals process Either party may terminate this
agreement in the event of intentional misrepresentation, fraud, or omission of information by the other party
in performance of its responsibilities under this agreement
If this Contract is terminated coverage for all Enrollees wdl end automatically on the effective date of
termination, or on the last day of the last month for which the Group paid the Premwm, whichever occurs
first KPS will refund to the Group any Premium paid for periods after the termination date
In the case of termination or non-renewal of this Contract, KPS shall be responsible for prowding the
effective date of termination of coverage to all affected Subscribers
Page 4
COVERAGE CONTRACT
Termination or Rescission of En�ollee Coverage
Coverage for an individual Enrollee under this Contract wdl end as of the date on which any one of the
followmg events occurs
➢ Non-payment of any Premium amount, when Premium payment is the responsibility of the Enrollee
➢ The Enrollee loses eligibdity for coverage under this Contract
➢ The Enrollee refuses to comply with the terms and conditions of this Group Plan as described m
Attachment A
➢ The Enrollee obtains coverage through intentional misrepresentation of material fact or fraud
➢ The Enrollee voluntartly disenrolls from this Group Plan
➢ The�e is a change m e►ther state or federa{ laws that no longer permit KPS from offermg this Group
Plan
➢ This Contract is terminated
Coverage ends on the last day of the month in which the Enrollee was eligible for coverage, provided all
applicable Premium amounts have been paid In the case of non-payment of Premium, coverage ends on
the last day of the month for which KPS received a Premwm payment KPS wdl be entitled to recover
claims payments for services received by the Enrollee after the termination date, unless there was prior
authorization for those services �
Upon termination of coverage either KPS or the Group shall issue a Certificate of Creditable Coverage
certifying the period(s) during which the Enrollee was enrolled in this Group Plan
An Enrollee who loses coverage under this Group Plan may be eligible to contmue coverage or enroll in a
KPS Conversion Plan (see the Continuat�on of Coverage section of Attachment A)
A Subscnber who voluntanly disenrolls from this Group Plan wdl not be eligible to re-enroll in this Group
Plan, until the next Open Enroliment Period See the Enrollment Under Special Circumstances section of
Attachment A for exceptions to this policy
COBRA (Consolidated Omnibus Budget Reconciliation Act - 1985)
If an Enrollee loses eligibility for coverage under this Group Plan, they may be eligible to continue their
coverage for a period of time specified by federal law and regulations then m effect This contmuation of
coverage is referred to as COBRA and applies generally to groups of 20 or more employees KPS offers
coverage o� when
➢ Groups are required by law to provide COBRA coverage for their employees, and
➢ KPS is notified of a beneficiary's election of COBRA coverage within 31 days of that election being
made �
Continuation of coverage under COBRA is not automatic Enrollees must apply for continuation of their
Group coverage within 60 days of the date they receive a COBRA election notice from the Group KPS
offers COBRA coverage to Groups only as required by law
The Group Plan Administrator is required to notify KPS of an Enrollee's election of COBRA contmuat�on
coverage within 31 days of that election Failure on the Enrollee's part to make a timely election, or fadure
on the part of the Group Plan Administrator to provide KPS with timely notification of the election, will be
mterpreted by KPS as a waiver of the Enrollee's right to continue coverage under this provision Failure by
the Group Plan Administrator to provide timely notification to KPS may not, in all cases, elimmate the
Group's obligation to provide contmuation coverage It will, however, eliminate any obligation on the part of
KPS to provide the Enrollee with COBRA contmuation coverage under this Group Plan
Fraudulent Information
In the event it is discovered that the Group has provided false or misleading mformation in connection with
the provisions of this Contract for the purpose of defrauding KPS, KPS �eserves the nght to terminate or
rescind coverage and shall inform the appropriate state and regulatory authonties, includmg, but not limited
to, the Washington State Office of the Insurance Commissioner (OIC) for a determmation of the Group's
liability
Page 5
COVERAGE CONTRACT
Re-Enrollment/Reinstatement
If this Contract has been terminated by KPS due to non-payment of Premium, the Group automatically
forfeits ali nghts to guaranteed renewal of coverage afforded under the Health Insurance Portability and
Accountability Act (HIPAA) of 1996 Any decision to reinstate or re-enroll the Group is at the sole discretion
of KPS
SUBSCRIBER LIABILITY AND RIGHTS
Subscriber Liability
Subscribers who are enrolled in this Group Plan are liable for the following costs
➢ Deductible (defined in Attachment A)
➢ Copayments (defined in Attachment A)
➢ Charges for non-Covered Benefits and Services
➢ Coinsurance, up to the Coinsurance Maximum limit (defined in Attachment A)
➢ Charges incurred after an annual or lifetime maximum benefit for a specific service or supply has
been exhausted (e g, the annual maximum benefit for medical equipment and supplies)
➢ Charges in excess of the amount allowed by KPS for Non-Participating Providers
If KPS fads to reimburse a Participating Provider for the cost of Medically Necessary Covered Benefits and
Services provided m accordance with the terms of this Contract, neither the Enrollee nor the Group shall be
required to compensate the Participating Provider for such services beyond the limit of Deductibles,
Copayments, or Coinsurance amounts specified m Attachment A
What happens �f a Provider no /onger part�cipates w�th KPS?
If a Participating Provider chooses to terminate their agreement w�th KPS, wre wdl notify the affected
Enrollees of the termination The notification wdl allow Enrollees at least 60 days to either (i) complete their
course of treatment, or (ii) appropriately transfer their care to another Participating Provider After the 60
days, services received from a Provider who has terminated their agreement with KPS will be covered at
the Non-Participatmg Provider benefit level
GENERAL TERMS AND CONDITIONS
Applicable Law
This Contract shall be governed by the laws of the state of Washington and is entered into in Bremerton
Washington Any controversy or claim arising out of or relating to this Contract shall be resolved in a court
of competent�urisdiction in Kitsap County, Washington or the U S District for the Western District of
Washmgton
Assignment of Benefits
The benefits of this Contract shall a�crue to Subscribers This Contract, payments, or Covered Benefits and
Services are not assignable to a third party KPS reserves the right to make benefit payments to the
Subscriber, their Provider(s), or �ointly, as KPS deems necessary and appropriate, sub�ect to federal and/or
state laws
Binding Agreement
This Contract is binding on KPS and the Group, as well as their respective executors, administrators,
successors, and/or assigns By election of coverage or payment of applicable Premiums, or if the Group's
Subscribers seek the services provided under this Contract, all of the terms, covenants, and conditions
contained herein shall become binding on the Group and its Subscribers, notwithstandmg the failure of the
Group to sign this Contract
Page 6
COVERAGE CONTRACT
This Contract shall not bind KPS until (Q a person authonzed by KPS signs it, and (ii) a signed copy is
delivered to the Group
Confidentiality
The underwriting and financial terms of this Contract are confidential and shall not be disclosed except as is
necessary for the pertormance of this Contract or as required by law
Contract Modifications
Except as set forth under the Premium Rate Ad�ustments section, KPS reserves the right to modify the
provisions of this Contract, or the services described in Attachment A, upon 30-days written notice to the
Group The Group may elect to re�ect such modifications by providing KPS with 15-days written notice
However, re�ection of a modification wdl result in the termmation of this Contract as of the last day of the
month for which Premium payment has been received Lack of notification of re�ection by the Group shall be
interpreted as acceptance of the modification, and this Contract will be renewed as modified
No modification of the terms of this Contract shall be binding upon KPS unless endorsed, m writing, and
signed by an authorized officer of KPS Such Endorsement shall be deemed a part of this Contract,
effective as of the effective date of the Endorsement Any amendment or Contract modification required by
law or regulation shall become effective as of the effective date required by such law or regulation
_ Coverage Limits
The Covered Benefits and Services offered under this Contract are sub�ect to the coverage limits and
maximums set forth m Attachment A
Entire Agreement
This Contract, together with Attachment A, any Riders and/or Endorsements attached hereto, and
Attachment B— Prem ium Rates and Underwritmg Criteria, constitutes the entire agreement This
Contract supersedes all previous communications, representations, or agreements, whether verbal or
wntten, between KPS and the Group
Equity of Application
This Contract is intended to apply equally to all Enrollees
Force Ma�eure
In the event KPS is unable to perform its obligations hereunder by reason of fire, casualty, lockout, stnke,
labor condition, not, war, act of God, or by ordinance, law, order, or decree by any legal authority, the
Contract may, at the option of KPS, be suspended During any penod of suspension, KPS shall not be
required to perform any service hereunder, nor shall KPS be liable for any damages arismg from any event
that precipitated the suspension If this Contract is suspended pursuant to this provision, any obligation by
the Group and/or an Enrollee to make Premium payments also shall be suspended for the same period of
time
Group Cooperation
The Group agrees to cooperate with KPS in the admmistration of this Contract by
➢ Advising Subscribers of policies and procedures applicable to this Group Plan
➢ Providing Subscribers with Attachment A, ID cards, and any applicable notices or other
information regarding this Group Plan
Page 7
COVERAGE CONTRACT
➢ Providing mformation about Enrollees that is relevant to the determination of eligibility, claim
reimbursement, coordination of benefits, or other information required for the administration of this
Contract
➢ Makmg appropriate payroll deductions, if applicable, to facilitate Premium payment
Headings
The headings of sections and paragraphs in this Contract are for convenience and reference purposes only
and do not affect in any way the meaning or interpretation of any provision of this Contract
Notices
Any notice that may affect the provisions of this Contract shall be deemed delivered to the Group when
deposited in� the United States mad, with prepaid postage, addressed to the Group at the most recent
address listed for the Group -
Any notice that may affect the provisions of this Contract shall be deemed delivered to KPS when deposited
in the United States mad, with prepaid postage, addressed to
KPS Health Plans
P 0 Box 34803
Seattle, WA 98124-1803
Any requirement of KPS to provide notice to Enrollees shall be fulfilled when the Group has received such
notice It is the responsibility of the Group to disseminate notices to Enrollees within 31 days of receipt
Severability
If a court of competent Jurisdiction deems any term, provision, Endorsement, or condition of this Contract
invalid or unenforceable, the same shall be deemed severable from this Contract The remaining provisions
of this Contract shall remain in full force and shall in no way be affected or invalidated as a result of such
decision
Third Party Beneficiaries
There are no third party beneficiaries to this Contract
Waiver of Breach
Waiver of a breach of any provision of this Contract shall not be deemed to be a waiver of any other breach
of the same or different provision
Page 8
COVERAGE CONTRACT
The following topics are described in detad m Attachment A Please refer to the Table of Contents in
Attachment A to locate each section
ELIGIBILITY AND ENROLLMENT
➢ Continuation of Inpatient Coverage
BENEFITS SUMMARY
CONTINUATION OF COVERAGE
➢ Coverage During a Labor D�spute
➢ Continuation of Group Coverage
➢ Conversion Coverage
COORDINATION OF BENEFITS (COB)
KPS'S RIGHT OF REIMBURSEMENT AND SUBROGATION
COMPLAINTS AND APPEALS PROCESS
ENROLLEE RIGHTS
➢ KPS Privacy Policy
➢ Statement of ERISA Rights
Page 9
KPS Heaith Plans
400 Warren Avenue
P O Box 339
Bremerton, WA 98331-0039
Attachment B
Premium Rates and Underwrit�ng Criteria
For
City of Bremerton
Period. January 1, 2013 — December 31, 2013
Premium Rates
PLAN B 8� RETIREES
�'non-LEOFF Em lo ees 620 47
S ouse 695 04
1st Child 316 20
2nd Chiid + 246 03
LEOFF I RETIREES UNDER AGE 65
Subscriber N/A
nd Child +
Note. Rates mclude Vision and is for Employees ONLY (Active and COBRA).
Underwriting Criter�a
The Premium rates quoted above for this Group Plan are based on the follow�ng underwnt�ng criteria
KPS reserves the right to withdraw or rerate this offermg if Group falls outside the scope of these critena
➢ A change in Employer contribution may negate Grandfathered status. Grandfathered
plans cannot decrease the percent of premiums the Employer pays by more than 5
percentage points (for example, decrease their own share and increase the workers' share
of premium from 15% to 25%). Any change to the employer contribution percentage must
PLAN A & RETIREES
be communicated to KPS, in writing, no less than 30 days in advance of the effective date
of the contribution change
➢ Active Employees must work a mmimum of twenty (20) hours per week unless otherwise
negotiated and agreed by both KPS and Group
➢ Sub�ect to prior KPS approval, two (2) or more health insurance carriers, including KPS, may
provide coverage to Group's Employees
➢ Sub�ect to prior KPS approval, Group may select multiple KPS health plan offenngs
➢ The minimum level of participation required is seventy-five percent (75%) of eligible Employees
➢ Unless otherwise approved by KPS, no more than twenty-five percent (25%) of Group's eligible
Employees may reside outside of the State of Washington
➢ KPS reserves the nght to rerate Group in the event actual enrollment fluctuates by ten percent
(10%) or more from the census provided to KPS by Group at the time Group was initially rated
KPS Health Plans
400 Warren Avenue
Bremerton, WA 98337
City of Bremerton
Under 65 LEOFF I Retirees
Benefits Booklet
This Benefits Booklet has been prepared for City of Bremerton Under 65 LEOFF I Retirees It
contains information you need to know concernmg eligibility, enrollment, plan benefits, and your rights
under this Group Plan
_�
The Group Plan you have chosen is a Preferred Provider Option ("PPO") Plan Under this PPO
Plan, you are entitled to receive care either from a Participatmg or Non-Participatmg Provider or Facdity
The level of benefit coverage you receive depends on the Provider you choose for your care In most
cases, your overall coverage is greatest, and your out-of-pocket expenses are the lowest, when you
choose a Participating Provider or Participatmg Facility
The terms "you" and "your" refer to the person(s) enrolled in this Group Plan The terms, "we,"
"us," and "our," refer to KPS The capitalized words used throughout this Benefits Booklet have specific
meanings The definitions of capitalized words can be found in the Definitions section at the end of this
Benefits Booklet
KPS Health Plans believes this plan is a"grandfathered health plan" under the Patient Protection and
Affordable Care Act As permitted by the Affordable Care Act, a grandfathered health plan can preserve
certam basic health coverage that was already in effect when that law was enacted Being a
grandfathered health plan means that your plan may not include certain consumer protections of the
Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive
health services without any cost sharing However, grandfathered health plans must comply with certain
other consumer protections m the Affordable Care Act, for example, the elimination of lifetime limits on
benefits �
Questions regarding which protections apply and which protections do not apply to a grandfathered
health plan and what might cause a plan to change from grandfathered health plan status can be directed
to KPS Customer Service at 360-478-6796, or toll-free at 1-800-552-7114 You may also contact the
Employee Benefits Security Admmistration, U S Department of Labor at 1-866-444-3272 or
www dol gov/ebsa/healthreform This website has a table summarizing which protections do and �do not
apply to grandfathered health plans
66136REM-R
TABLE OF CONTENTS
ELIGIBILII AND ENROLLMENT ......................................................................................................1
Who Can Enroll in This Group Plan �
When to Enrolf in This Group Plan �
Enrollment Under Special Circumstances �
State Sponsored Coverage �
How to Enroll �
When Coverage Begins �
When Coverage Ends �
Contmuation of Inpatient Coverage 2
HOW THE GROUP PLAN WORKS ....................................................................................................
Choosing a Provider or Hospital 3
Services Which Require Prior Authorization 4
How to Submit Claims for Payment 5
Benefits Management 5
YOUR OUT-OF-POCKET COSTS .....................................................................................................6
Deductible 6
Copayments 6
Annual Coinsurance Maximum 6
BENEFITS SUMMARY ....................................................................................................................8
DESCRIPTION OF COVERED BENEFITS AND SERVICES ..................................................................12
Preventive Care � 2
Professional Services � 2
� Hospital Services 13
Acupuncture Needle Treatment � 1
Ambulance Transportation 14
Anesthesia for Dental Procedures — Not Received in the Dentist Office 14
Blood Bank 14
Bone Bank 14
Cardiac Rehabilitation 14
Colorectal Cancer Screening 15
Contraceptive Serv�ces 15
Diabetic Education, Equipment, and Supplies 15
Home Health and Hospice Care 15
Kidney Dialysis 16
Laboratory and Radiology Serv�ces � 7
Mastectomy Care � �
�� Maternity Care � 7
Medical Equipment and Supplies � 8
Mental Health Care � 9
Newborn Care � 9
Nutritional Guidance Counseling 20
Oral Surgery 20
Organ, Bone Marrow, Stem Cell and Tissue Transplants 20
Oxygen and Oxygen Supplies 22
Phenylketonuria (PKU) Formulas 22
Plastic and Reconstructive Surgery 22
Private Duty Nursmg 23
Rehabditation � 23
Skilled Nursing Facility Care 23
Sleep Disorders 23
Spinai and Extremity Manipulation 24
Substance Use Disorder Treatment (Chemical Dependency) 24
Termination of Pregnancy
Women's Health Care Services
Pharmacy Benefits
24
25
25
LIMITATIONSAND EXCLUSIONS ...................................................................................................27
CONTINUATIONOF COVERAGE ....................................................................................................29
Continuation of Group Coverage 29
COBRA (Consolidated Omnibus Budget Reconciliation Act - 1985) , 29
Conversion Coverage 30
COORDINATION OF BENEFITS (COB) ...........................................................................................31
General Provision 31
Definitions 31
Order of Benefit Determination Rules 32
Effect on Benefits 34
Right to Receive and Release Information 34
Facility of Payment 34
Right of Recovery 34
Notice to Enrollees 34
Additional Information 34
KPS'S RIGH7 OF REIMBURSEMENT AND SUBROGATION ...............................................................35
Collection and Reimbursement by Enrollee 35
Underinsured or Unmsured Motorist Coverage 36
Cooperation 36
Recovery of Claims Payments 36
COMPLAiNTS AND APPEALS PROCESS ........................................................................................37
If You Have a Complaint 37
Standard Appeals Process 37
First Level Appeal 38
Independent Review Organization (IRO) 38
Second Level Appeal (OPTIONAL) 39
Expedited Appeals Process 39
Appeals Related to Continuation of Care 39
ENROLLEERIGHTS .....................................................................................................................39
KPS Privacy Policy 39
Disciosure of Information 41
Statement of ERISA Rights 41
Women's Right to Direct Access 42
Your Right to Safe and Effective Pharmacy Services 42
HOW YOU CAN STOP HEALTH CARE FRAUD ................................................................................43
DEFINITIONS ..............................................................................................................................44
CONTQCT .............................................................................................................................48
Benefits Booklet
ELIGIBILITY AND ENROLLMENT
Who Can Enroll in This Group Plan
Retired LEOFF I Employees under age 65 are eligible to enroll in this Group Plan As of March 1, 2001
dependents of eligible employees are no longer eligible to enroll in this Group Plan
When to Enroll in This Group Plan
You must apply for coverage under this Group Plan 31 days following the date of your initial eligibility
Retirees who do no enroll when they are mitially eligible may not apply for coverage at a later date except
in certain circumstances (see Enrollment Under Special Circumstances section)
Please contact ypur Group Plan Admmistrator for more information regardmg eligibdity and enrollment
Enroliment Under Special Circumstances
Retired LEOFF I Employees who, when they were initially eligible to enroll declined coverage in this
Group Plan, based on existing coverage under another health plan, may apply for coverage under this
Group Plan if they lose eligibdity for coverage under their other health plan, or if the other health plan
terminates Retired LEOFF I Employees must apply for coverage within 31 days of losing coverage under
their prior plan
State Sponsored Coverage
If you declmed coverage when you were eligible to enroll in this Group Plan, you may subsequently apply
for coverage in the event that the Department of Social and Health Services (DSHS) has determined that
it is cost-effective to enroll you in this health plan Application for coverage must be submitted to KPS
within 60 days following the determination by DSHS Coverage will be effective as of the first day of the
month followmg receipt of application
How to Enroll
To enroll in this Group Plan, complete an enrollment application form You may obtam an enrollment
application form from your Group Plan Administrator To avoid possible delays m processmg your
application, please provide all the requested information for every person who will be covered under this
Group Plan Delays caused by an incomplete application could result m delayed payment of your medical
claims
if you are required to pay all or a portion of your Premium, you must include the Premium payment for
your first month of coverage with your enrollment application
Please submit enrollment forms and Premium payments to your Group Plan Admmistrator
When Coverage Begins
Coverage begins on your initial date of eligibdity, provided you enrolled withm the specified time period,
and you paid the applicable Premium
When Coverage Ends
Your coverage ends on the last day of the month m which you lose eligibility provided all applicable
Premium amounts have been paid In the case of non-payment of Premium, coverage ends on the last
day of the month for which KPS received payment
If you lose coverage under this Group Plan, you may be eligible to continue coverage or enroll in a KPS
Conversion Plan Please see the Continuation of Coverage section regarding your rights under the
Consolidated Omnibus Reconciliation Act of 1985 (COBRA) and KPS Conversion coverage
City of Bremerton Under 65 LEOFF I Retirees Page 1
Bene�ts Booklet
If you voluntarily disenroll from this Group Plan you are not eligible to re-enroll
Upon termination of coverage either KPS or your Group Plan Administrator wdl issue you a Certificate of
Creditable Coverage, certifying the period(s) during which you were enrolled in this Group Plan You
should present this certificate to any subsequent health plan in which you may enroll as proof of your prior
health care coverage to receive credit toward any Pre-existing Condition exclusion You may request a
Ce�tificate of Creditable Coverage at any time during your enrollment in this Group Plan and up to 24
months after your enrollment ends A Certificate of Creditable Coverage may be requested by contacting
a KPS Customer Service Representative at 360-478-6796 or toll-free at 1-800-552-7114
If you obtained coverage through intentional misrepresentation of material fact or fraud your coverage
may be rescmded or termmated upon thirty (30) calendar days written notice In no event will you be
terminated or rescinded solely on the basis of your physical or mental condition provided you meet all
other eligibdity requirements set forth by the Group You may appeal a termination or rescission decision
through the KPS appeals process
Continuation of Inpatient Coverage
If you are receiving inpatient care in an accredited general Hospital or other approved facility on the date
that coverage would otherwise end, you are eligible to continue receiving benefits under this Group Plan
provided the following conditions are met
➢ KPS pre-authonzed the inpatient care (see the Services Which Require Prior Authorization
section)
➢ All applicable Premium amounts continue to be paid
KPS wdl continue to provide benefits under this Group Plan, untd one of the following events occurs
➢ You are no longer receiving inpatient care
➢ The KPS Medical Director determines that inpatient care is no longer Medically Necessary
➢ You do not continue to pay your Premium
➢ Three (3) consecutive months have elapsed since the date your coverage would have otherwise
ended
➢ You enroll in another KPS plan or in any other health plan that provides inpatient Hospital
benefits
You are not eligible for the extended coverage described above if on the date coverage would otherwise
end one of the following applies
➢ You are covered under any other group or individual medical plan with simdar inpatient benefits
➢ You are eligible for continuation of coverage under COBRA or any other continuation provision
If you have any questions, please contact a KPS Customer Service Representative at 360-478-6796, or
toll-free at 1-800-552-7114
-
Page 2 City of Bremerton Under 65 LEOFF I Retirees
Benefits Booklet
HOW THE GROUP PLAN WORKS
Choosing a Provider or Hospital
KPS pays for services rendered by the following types of Providers when the services provided are
Medically Necessary and are Covered Benefits and Services under this Group Plan and when Providers
are acting within the scope of their medical license or certification
Advanced Registered Nurse Practitioner (A R N P)
Certified Chemical Dependency Provider
Certified Mental Health Provider
Chiropractor
Dentist
East Asian Medicine Practitioner (Acupuncturist)
Massage Therapist "'
Naturopath (N D )
Nurse Midwife
Occupational Therapist "
Physical Therapist "
Physician (M D or D O)
Physician's Assistant (P A )
Podiatrist
Psychologist
Speech Therapist "
*Therapy services wdl be covered when prescribed by your physician
NOTE This list does not include all types of Providers covered by KPS If your Provider type is not listed
above, please contact KPS toll-free at 1-800-552-7114 to request more information
KPS has agreements with health care professionals and facdities, which are Participating Providers and
Facdities, to ensure you have access to all Covered Benefits and Services For a current listmg of
Participatmg Providers and Facilities m your area, please contact KPS toll-free at 1-800-552-7114, or visit
our Web site at www kqshealthqlans com
KPS does not require a referral for specialty care, however, therapy services requ�re a prescription as
noted above As a general rule, you may receive care from any licensed or certified health care Provider
or Facdity Your choice of Providers and Facilities wdl affect the level of benefit coverage you receive as
well as your out-of-pocket costs
When you choose a Participating Provider or Facility, your out-of-pocket costs are less than if you choose
a Non-Participating Provider or Facility If you choose a Non-Participating Provider or Facility, your out-of-
pocket costs are significantly higher because KPS reduces the allowed amount for Covered Services by
twenty-five percent (25%) In addition, it is your responsibility to pay the difference between any amounts
bdled by the Non-Participating Provider or Facility and the amount paid by KPS
In certain mstances, the care you receive from a Non-Participating Provider or Facility is not sub�ect to the
reduction in the level of benefit coverage Those instances are
➢ Medical Emergency Emergency care is covered in full after you have met any applicable
Deductible, Copayment, or Coinsurance If you are admitted to a Non-Participating Hospital as a
result of your Emergency, KPS reserves the nght to arrange for your transportation to a
Participating Hospital (see the Emergency Admissions section)
➢ Services Not Available from Participatmg Providers/Facilities KPS has the nght to determine
whether care and services are, or are not, available from a Participating Provider or Facdity If you
believe the care or service you require is not available from a Participatmg Provider or Facility,
please call KPS Customer Service before obtainmg the care or service and ask for a review to
determine if it is appropriate for you to access care from a Non-Participating Prowder or Facdity If
KPS determines that the care or service you require can only be obtained from a Non-
Participating Provider or Facility, your care wdl be covered in full after you have met any
applicable Deductible, Copayment, or Coinsurance
IF you could have received your care from a Participatmg Provider or Facility, but chose to receive care
from a Non-Participating Provider or Facility, you are financially responsible for paying the difference
befinreen the amount paid by KPS and the amount bdled by the Non-Participating Provider or Facdity This
is called "balance bdling"
City of Bremerton Under 65 LEOFF I Retirees Page 3
Benefits Booklet
What happens �f my Prov�der no /onger part�c�pates with KPS?
If your Participating Provider chooses to terminate their agreement with KPS, we wdl notify you of the
termination The notification will allow at least 60 days to either, (i) complete your course of treatment, or
(u) appropriately transfer your care to another Participating Provider After the 60 days, services received
from a Provider who has terminated their agreement with KPS will be covered at the Non-Participating
Provider benefit level
Services Which Require Prior Authorization
NOTE The following list of services that require prior authonzation is not all-inclusive Enrollees and
Providers should contact KPS Customer Service for updated information whenever there is a question
concerning coverage
You must get prior authorization from KPS before receiving the following services
➢ Anesthesia for dental procedures
➢ Home health and hospice care
➢ Inpatient care that is elective or non-emergent
➢ Organ transplants
➢ Oxygen and oxygen supplies
➢ Plastic and reconstructive surgery
➢ Skilled Nursing Facility care
➢ Surgical treatment for sleep disorders
➢ inpatient behavioral health (Mental Health Care and Substance Use Disorder Treatment
(Chemical Dependency)) NOTE Prior authorization of behavioral health care is not required in
the case of mvoluntary commitment or Emergency detoxification
Some services, such as certain medical equipment and supplies, require prior authorization for specific
items Please see the Description of Covered Benefots and Services section for more information
about services requinng prior authorization To obtain prior authorization for care, ask your Provider to
contact KPS KPS will send both you and your Provider written confirmation that the care or service has
been authorized if your care is Medically Necessary, but your Provider did not get prior authorization
from KPS, payment to your Provider wdl be reduced by 20% No coverage is provided for services that
are not Medically Necessary
All requests for pnor authorization are reviewed and approved based on Medical Necessity, eligibility, and
benefits To determine Medical Necessity, KPS uses nationally accepted guidelines that are also
accepted by Medicare If a calendar year ends during the course of an ongoing treatment plan, you or
your prowder must call for re-authorization for the new calendar year
If there are urgent circumstances involving your health, KPS wdl make a decision regarding the
authorization within 48 hours of receiving the request In non-urgent circumstances, both you and your
Provider wdl be notified of the decision within five (5) calendar days following receipt of necessary
information
Author�zat�on Extens�ons
if you need to extend the care you are currently receiving, have your Provider contact KPS to request an
extension An extension should be requested before the current authorization for care ends
E/ect�ve and Non-emergent Hosp�ta/ Care
Coverage for elective and non-emergent inpatient care is provided only for the number of days approved
by KPS If your stay in the Hospital lasts longer than the number of approved days, your Provider must
obtain approval for the additional days In addition, KPS will monitor your inpatient stay to ensure
continued Medical Necessity and may assist your Provider with discharge planning
Page 4 City of Bremerton Under 65 LEOFF I Retirees
Benefits Booklet
Emergency Adm�ss�ons
if you are admitted to the Hospital as a result of an Emergency, you are not required to obtam prior
authorization However, you or your Provider must contact KPS within 48 hours of your admission, or as
soon as is reasonably possible, to complete the certification process Failure to do so could result in
reduced benefit coverage
If you are admitted to a Non-Participating Facility as a result of your Emergency, KPS may choose to
have you transferred to a Participatmg Facility as soon as it is medically feasible KPS will work closely
with your Provider to determme when and if you can be safely transferred to a Participatmg Facility
In the event you are admitted to a Non-Participating Facdity as a result of your Emergency condition, your
benefits are paid at the higher Participatmg Provider level
How to Submit Claims for Payment
In most mstances, Participating Providers and Facilities submit claims directly to us on your behalf When
this is the case, you are not required to fill out any claim forms
If your Provider does not submit claims directly to KPS on your behalf, you must send the claim to KPS
yourself To submit a claim, you must include the following mformation
➢ The Subscriber's name and ID number (shown on your KPS identification card)
➢ The Group name and ID number (shown on your KPS identification card)
➢ The patient's name and ID number (if the patient and the Subscriber are not the same person)
➢ The original itemized bill from your Provider
➢ For out-of-country claims (Emerqency care only,� — provide all of the above information, translated
into English, mcluding the type of service, charges m U S Dollars, and proof of travel
Send the above mformation to
KPS Health Plans
Attn Customer Service
P O Box 34803
Seattle, WA 98124-1803
All claims must be filed withm 12 months, following the date of service KPS will not process any claims
that are older than 12 months
How Will 1 Know What Happened to My C/a�m?
After KPS processes your claim, an Explanation of Benefits (EOB) form is sent to both you and your
Provider The EOB explains how your claim was processed and contains information regardmg your
rights if you have any questions regarding the outcome
KPS processes most claims within 30 days, unless additional information is required to make a decision
regarding your benefits
Benefits Management
In certain cases, KPS, at its sole discretion, may choose to authorize coverage for benefits or services
that are not otherwise included as Covered Benefits and Services under this Group Plan Such
authonzation is done on a case-by-case basis if a particular benefit or service is �udged to be Medically
Necessary, beneficial, and cost effective However, KPS's decision to authorize services in one instance
does not commit KPS to cover the same or simdar services m other instances KPS's decisi on to
authorize services does not constitute a waiver of KPS's right to enforce the provisions, limitations, and
exclusions of this Group Plan
C�ty of Bremerton Under 65 LEOFF I Retirees Page
Benefits Booklet
YOUR OUT-OF-POCKET COSTS
Deductible
The Deductible is the amount you are required to pay out-of-pocket each Calendar Year before KPS pays
for your Medically Necessary Covered Benefits and Services Please refer to the Benefits Summary
section for the Deductible applicable to this Group Plan
Only charges for Medically Necessary Covered Benefits and Services are counted toward the
accumulation of your Deductible The following amounts are not included in the calculation of your
Deductible
➢ Copayments
➢ Coinsurance
➢ Charges for non-Covered Benefits and Services
➢ Charges in excess of the amount allowed by KPS for Non-Participating Providers
➢ Charges for Covered Benefits and Services to which the Deductible does not apply
Pr�or P/an Deductib/e
If you met all or a portion of your Deductible under another KPS plan immediately prior to enrolling in this
Group Plan, KPS wdl credit the amount accrued under the prior plan provided that
➢ Those amounts were accrued during the same Calendar Year that you enrolled in this Group
Plan
➢ You had no break m coverage befinreen KPS plans
Prior Year Carryover
Any portion of your Deductible which is met in the last quarter of the immediately prior Calendar Year is
applies toward your Deductible for the current Calendar Year
Inpat�ent Hosp�ta/ Care
If your hospitalization begins in the current Calendar Year and continues uninterrupted into the next, your
Deductible and Comsurance for the next Calendar Year wdl not begin until after discharge
Copayments
A Copayment is an amount that you are required to pay your Provider at the time of service Professional
office visits that require a Copayment are not subJect to the Deductible, unless otherwise specified in the
Benef�ts Summary section
Copayments are not counted toward the calculation of your annual Deductible or any Coinsurance
Maximum You must continue to pay Copayments even after you have reached your Coinsurance
Maximum -
Please refer to the Benefits Summary section for any applicable Copayments on this Group Plan
Annual Coinsurance Maximum
NOTE This section was formerly referred to as "Annual Out-of-Pocket Maximum on Coinsured Benefits
(Stoploss) " The term Coinsurance Maximum replaces the term Stoploss
Please refer to the Benefits Summary section for the Coinsurance Maximum applicable to this Group
Plan
If, during a Calendar Year, the amount of Coinsurance you have paid reaches or exceeds the
"Coinsurance Maximum Per Enrollee," KPS will provide reimbursement for Covered Benefits and
Services at 100% of the KPS allowance for the remainder of that Calendar Year
Page 6 City of Bremerton Under 65 LEOFF I Retirees
Benefits Booklet
The followmg costs are not used to calculate the Comsurance Maximum
➢ Deductible — must be met before Coi nsurance levels apply
➢ Copayments
➢ Charges for prescription drugs
➢ Charges incurred after an annual or'lifetime maximum benefit for a specific service or supply has
been exhausted
➢ Charges for non-Covered Benefits and Services and supplies
➢ The difference between what a Non-Participating Provider charges for a service and what KPS
allows for the service
City of Bremerton Under 65 LEOFF I Retirees Page 7
Benefits Booklet
BENEFITS SUMMARY
Outlined on the following pages are the basic benefits and benefit maximums provided by KPS to you, as
an Enrollee, in this Group Plan Also included are the limits of your financial responsibility, as well as
other specific limitations relative to coverage under this Group Plan For a more complete description of
the benefits provided, please read the Description of Covered Benefits and Services section
ANNUAL DEDUCTIBLE
Per Enrollee $50
Coinsurance Maximum
Per Enrollee — Medical/Surgical $200
Per Enrollee — Pharmacy $100
Page 8 City of Bremerton Under 65 LEOFF I Retirees
Benefits Booklet
KPS provides the following Medically Necessary benefits and serv�ces, at the indicated reimbursement
percentage. Benefits pa�d at 100% are not subJect to the annual Deductible. Benefits paid at 80°/a wdl be
paid at 100% once the Coinsurance Maximum (previousiy Stoploss) has been sat�sfied.
� 0
�
Preventive Care
Preventive Care —mcludes routme physical examination, laboratory
and x-ray services (except mammography and prostate cancer 100%
screernng), immurnzaUons See Laboratory and Radiology
Services for mammography and prostate cancer screernng benefits
Professional Services — Med�cal and Surg�cal
Care and Services Received in a Hospital or Skdled Nursing Facdiry 100%
Care and Services Received m the Office or Urgent Care Center 100%
Care and Services Received m Your Home 100%
Care and Services Received m an Ambulatory Surgical Center 100%
Care Received in the Emergency Room 100%
Hosp�tal Serv�ces
Prior authorization reqwred for non-emergent and elective care
Inpatient Medical and Surgical Services
Semi-private Room and Board 100%
Special Care Urnt (e g, ICU, CCU)
Outpatient Care
Medical and Surgical (includes ambulatory surgical centers) 100%
Emergency Room Facdity and Supplies 100%
Acupuncture Needie Treatment
, 100%
12 treatments maximum per Calendar Year
Ambulance
Ground and air transportation — benefits are provided on a'per tnp' 100% of first $50, 80% thereafter
basis
Anesthesia for Dental Procedures — Prior authonzation required 100%
Blood Bank 80%
Bone Bank 80%
Cardiac Rehabilitation 80%
Colorectal Cancer Screening
Routine Screenin 100%
Diagnostic See Professional & Hospital Services Sections
Contraceptrve Services
See Professional Services Section
Prescnption contraceptives are covered under Pharmacy Benefits
Diabetic Education, Equipment, and Supplies
Pnor authorization may be required
Health Education and Trairnng See Professional Services Section
Medical Equipment 80%
City of Bremerton Under 65 LEOFF I Retirees Page 9
Benefits Booklet
KPS provides the following Medically Necessary benef�ts and services, at the ind�cated re�mbursement
percentage. Benefits paid at 100% are not subJect to the annuai Deductible. Benefits paid at 80°/a will be
paid at 100% once the Coinsurance Maximum (previously Stoploss) has been satisfied
Home Heaith Care — To a maximum of 130 visits per Calendar Year
Prior authorization reqwred
Hospice Care — To a maximum of 6 months per Calendar Year
Pnor authorization required
Kidney Dialysis — Outpatient facility or Hospital
Laboratory and Radiology Services
Inpatient Hospital and Ambulatory Surgical Center
Emergency Room
Mammography Services
Routine Screening
Diagnostic
Prostate Cancer Screening
Routine Screernng
Diagnostic
All Other Laboratory and Radiology Services
Mastectomy Care
Pnor authonzation reqwred for inpatient Hospital services only
Medical Services
Prostheses & Mastectomy Bras
Maternity Care
Medical Eqwpment and Supplies
Prior authorization may be required
Mental Health Care — Prior authonzation required
Inpatient Care
Outpatient Care
Newborn Care
Well-baby nursery care is not sub�ect to the Deductible
Coverage is limited to the first three (3) weeks followmg the date of
birth
Nutritional Guidance Counseling
Orai Surgery
Organ, Bone Marrow, Stem Cell and Tissue Transplants
100%
100%
10 0%
100%
100%
100%
100%
100%
1 00%
100%
100%
100%
100%
80%
100%
100%
100%
100%
100%
Participatmg Prowder — No lifetime maximum 100%
Non-Partiapating Provider —$350,000 lifetime maximum 80%
Oxygen and Oxygen Supplies — Prior authorization reqwred 80%
Phenylketonuria (PKU) Formulas 100%
Plastic and Reconstructrve Surgery — Pnor authorization required 80%
Page 10 City of Bremerton Under 65 LEOFF I Retirees
Benefits Booklet
KPS provides the following Medically Necessary benefits and services, at the indicated reimbursement
percentage. Benefits paid at 100% are not sub�ect to the annual Deductible. Benefits paid at 80% will be
paid at 100% once the Coinsurance Maximum (previously Stoploss) has been satisfied
� e
Rehabd�tat�on — Prescribed by your physician
Inpatient — 30 Days per condition 100%
Outpatient 100%
Skilled Nurs�ng Fac�l�ty — Pnor authorization required
Faality and physician care 100%
Physical therapy 100%
Sleep Disorders
Prior authorization required for surgical treatments only
Sleep Studies
Medical Services See Professional & Hospital Services Sections
Durable Medical Eqwpment and Supplies 80%
(including CPAP machmes)
Surgical Treatment 80%
Spinal and Extremity Manipulation 100%
20 office visits maximum per Calendar Year
Substance Use Disorder Treatment (Chemical Dependency)
Prior authorization required
Inpatient Care 100%
Outpatient Care 100%
Termmation of Pregnancy See Professional & Hospital Services Sections
Limited to one (1) per Calendar Year
V�sion Examination
Limited to one (1) routme eye examination per Calendar Year
100%
City of Bremerton Under 65 LEOFF I Retirees Page 11
Benefits Booklet
DESCRIPTION OF COVERED BENEFITS AND SERVICES
The Covered Benefits and Services described below, plus any Riders or Endorsements included with this
Benefits Booklet, comprise the total benefits provided by KPS under this Group Plan
All benefits and services are subJect to the Deductible, Copayment, and Coinsurance requirements
described in the B Summary sect un less ot h e rwise indica
Coverage is provided when ALL of the following conditions are met
➢ The benefit or service is Medically Necessary for the illness, in�ury, or condition
➢ The benefit or service is provided by a licensed or certified health care Prowder
➢ The benefit or service is not specifically excluded from coverage
➢ If necessary, KPS has given prior approval for the benefit or service
The amount KPS pays for each benefit or service is based on the reimbursement rate shown in the
Benefits Summary section
Preventive Care
Preventive care is care that is provided in the absence of a specific diagnosis of iliness or in�ury
Preventive care is provided for the speafic purpose of preventing dlness and disease
Please see the Laboratory and Radiology Services section for mammography and prostate cancer
screening benefits, as well as the Benefits Summary section for specific limitations regarding age limits
and coverage
Preventive care, as listed below, is not sub�ect to the Deductible
Rout�ne Phys�ca/ Examinations
Ongoing preventive care for adults includes coverage for routine physical examinations, associated
laboratory and x-ray services (except mammography and prostate cancer screening), and immunizations
Immun�zations
Covered immunizations are based on guidelines established by the Advisory Committee on Immunization
Practices of the Centers for Disease Control
Please contact KPS Customer Service or visit the KPS Web site at www kpshealthqlans com, for current
information regardmg covered immunizations
There is no coverage under this benefit for immurnzations required for either employment purposes or
drugs and immunizations for travel purposes
Professional Services
Covered professional services that are Medically Necessary and rendered by a Provider include the
following
➢ Medical, surgical, and behavioral health services in conJunction with an approved Hospital stay
➢ Medical, surgical, and behavioral health services in an outpatient facdity
➢ Medical and surgical services m an ambulatory surgery facdity
➢ Medical, surgical, and behavioral health services in an urgent care center
➢ Office, home, Hospital, and nursing home visits and related services
➢ Consultations and second opinions
Page 12 City of Bremerton Under 65 LEOFF I Retirees
Benefits Booklet
Hospital Services
Inpatlent Care (Requires prior authonzation)
Non-emergent inpatient Hospital care must be pre-approved by KPS Coverage for pre-approved
inpatient care includes
➢ Semi-private room and board charges, unless KPS has specifically authorized coverage for a
private room
➢ Intensive care unit (ICU) and coronary care urnt (CCU) room charges
➢ Operating room and related equipment
➢ Anesthesia and anesthesia sennces, m conJunction with inpatient surgery
➢ Diagnostic x-ray and laboratory services
➢ Surgical dressings and supplies, including castmg supplies and implantable prosthetics, such as
pacemakers and artificial �oints
➢ Pharmacy services (administered drugs must be listed in the U S Pharmacopoeia and the
National Formulary of biologicals and solutions)
➢ Electrocardiograms and other diagnostic and monitoring services
➢ Blood and blood derivatives, including admirnstration charges
➢ Radiation and inhalation therapy services
An inpatient stay for the purpose of Medically Necessary diagnostic testing is covered for the Subscriber
only
Outpat�ent Care
Coverage for outpatient care includes
➢ Outpatient medical and surgical care
➢ Anesthesia and anesthesia services, in conJunction with outpatient surgery
➢ Surgical dressings and supplies, including castmg supplies and implantable prosthetics, such as
pacemakers and artificial �oints
➢ Radiation and inhalation therapy services
➢ Chemotherapy
➢ Hemodialysis services
➢ Blood transfusion serwces
Emergency Room Care
Coverage under this benefit is for the Emergency room facility and the supplies associated with care
received while there
�
All other services received in the Hospital Emergency room are paid at the applicable Coinsurance level
Please refer to the Benefits Summary section for this mformation
If you are admitted to the Hospital as a result of your Emergency, you, your Provider, or the Hospital must
contact KPS withm 48 hours of your admission, or as soon as is reasonably possible If you have been
admitted to a Non-Participatmg Hospital, KPS may, following consultation with your Provider, arrange to
have you transferred to a Participating Hospital There is no cost to you if KPS arranges your transfer to a
Participating Hospital
A Medical Emergency is a sudden and acute onset of a symptom or symptoms, including severe pain,
that would lead a prudent layperson, actmg reasonably, to believe that a health condition exists that
requires immediate medical attention, if fadure to provide medical attention would result in serious
impairment to boddy functions or serious dysfunction of a bodily organ or part, or would place the person's
health in serious �eopardy Examples of Medical Emergency conditions include, but are not limited to,
heart attacks, cardiovascular accidents, poisonmgs, loss of consciousness or respiration, broken bones,
automobde accidents, severe bleedmg, and convulsions
The use of an Emergency room for care not related to a Medical Emergency is not covered
City of Bremerton Under 65 LEOFF I Retirees Page 13
Benefits Booklet
Acupuncture Needle Treatment
Coverage under this benefit is limited Please refer to the Benefits Summary section
Acupuncture needle treatment is covered only if Medically Necessary and therapeutically appropriate for
the treatment of a condition, such as the treatment and management of pain
Ambulance Transportation
In the case of a Medical Emergency, the services of a licensed ground or air ambulance service are
covered to transport you to the nearest accredited general Hospital where adequate facilities for
treatment are avadable Coverage for ambulance services includes
➢ Ground transportation
➢ Air transportation
➢ All services associated with the transport (e g, specialized medical personnel, oxygen, IV fluids)
The use of any type of ambulance transportation for personal convenience is not covered under this
benefit
Anesthesia for Dental Procedures — Not Recerved in the Dentist Office
(Requires prior authorization)
Coverage under this benefit is provided for the professional and facdity charges for inpatient Hospital and
outpatient surgery centers when
➢ The Enrollee is either under the age of (seven) 7, or physically or developmentally disabled,
➢ The service cannot be safely and effectively treated in a dental office, or
➢ The service is not for the convenience of the dentist or Enrollee
This benefit is considered medical and is sub�ect to applicable Deductible, Copayments, and
Coinsurance
Blood Bank
Coverage under this benefit includes charges from a blood bank for processing blood and its denvatives,
blood cross-matching, charges for whole blood, blood components and blood derivatives, to the extent
these are not replaced by volunteer donors, and other blood bank services
Bone Bank
Coverage under this benefit includes charges from a bone bank in con�unction with a covered medical or
surgical procedure
Cardiac Rehabilitation
Coverage for cardiac rehabditation is provided for conditions, such as
➢ Angioplasty
➢ Ischemic heart disease/coronary artery disease
➢ Myocardial infarction
➢ Stable angina pectoris
➢ Heart transplant surgery
➢ Bypass surgery
Page 14 C�ty of Bremerton Under 65 LEOFF I Retirees
Benefits Booklet
Colorectal Cancer Screening
Coverage under this benefit mcludes colorectal cancer examinations and laboratory testing at the
frequency recommended under the guidelines of the United States Preventive Service Task Force, or the
Centers for Disease Control and Prevention, and as deemed appropriate by your physician after
consultation with you Services are provided if you are (i) at least 50 years of age, or (u) less than 50
years of age and at a high nsk or very high nsk for colorectal cancer, based on the recommendations of a
physician
Contraceptive Services
Coverage under this benefit includes contraceptive services, mcludmg the fitting of intra-utenne devices
and diaphragms, and contraceptive implants and in�ections, when done in the Provider's office
Prescription contraceptives are covered under Pharmacy Benefits
Diabetic Education, Equipment, and Supplies
(Requires prior authorization for insulin pumps) �
Coverage under this benefit, when recommended by your Provider, includes diabetic health education
and training, diabetic equipment (e g, msulm pumps, insulm infusion devices, glucometers, orthopedic
shoes and mserts when Medically Necessary), and supplies
Home Health and Hospice Care
(Requires prior authorization)
Home health and hospice care coverage is provided only as an alternative to hospitalization or care m a
Skilled Nursing Facdity Coverage is sub�ect to approval of a written treatment plan submitted to KPS by
your attendmg Provider
Care must be Medically Necessary (or palliative for hospice only), ordered by your attending Provider m
consultation with you, and provided by a licensed hospice or home health agency
The seNices provided must be skdled services Skdled services are those services that are
➢ Provided by trained medical or paramedical personnel or persons, workmg under their direct
supervision
➢ Cannot be safely and adequately self-administered or performed by the average, rational,
non-medical person without the direct supervision of tramed medical or paramedical personnel
Coverage for home health and hospice care is limited Please refer to the Benefits Summary section If
you exhaust your Hospice Care benefit limits, you may apply to KPS for an extension Extensions may
be authorized based on Medical Necessity
The services and supplies provided under this benefit do not duplicate any other coverage provided under
this Group Plan
Home Health Care
Coverage under this benefit includes
➢ Intermittent m-home visits by a registered nurse (R N), licensed practical nurse (L P N) or a
home health aide working under the direct supervision of an R N, L P N or licensed therapist, as
ordered in the approved treatment plan
➢ Services provided by a licensed or registered physical, occupational, speech, or inhalation
therapist, when such services are Medically Necessary to maintain, restore, or improve functions
lost as a result of severe illness, in�ury, or surgery,
➢ Drugs and medications necessary for the treatment of the iliness or m�ury that are supplied by the
home health agency, based on a written prescription from your attending Provider,
➢ Medical supplies dispensed by the home health agency,
➢ The rental or purchase, as determined by KPS, of Medically Necessary durable medical
equipment, when prescribed by your attendmg Provider,
Ciry of Bremerton Under 65 LEOFF I Retirees Page 15
Benefits Booklet
Coverage for home health care is limited to 130 visits per Calendar Year A visit is defined as any
encounter, in person, with any authonzed home health agency worker who provides services to you
Coverage is available only if you are homebound with the exception of post delivery follow-up care
ordered by the attending Provider in consultation with the mother
Hosp�ce Care
Hospice care is avadable only if you are in the latter stages of a terminal illness Coverage is provided
under this benefit for a period of six (6) months, unless KPS approves an extension
Coverage under this benefit includes
➢ Seven (7) days of inpatient hospice care
➢ Medically Necessary services and supplies provided by the hospice agency
➢ Drugs and medications necessary for the treatment of the iliness or in�ury, which are supplied by
the hospice agency, based on a written prescription from your attendmg Provider
➢ intermittent in-home or hospice visits and corresponding supplies required for pain management
(palliative care), when provided by a registered nurse (R N), licensed practical nurse (L P N),
medical social worker with a Masters in Social Work degree (M S W) or an aide under the
supervision of an R N or L P N
➢ Respite care, whether in the home or hospice facility, in order to provide temporary relief to your
primary care giver, coverage is limited to five (5) days of continuous care for every three (3)
month period
Exc/us�ons
There is no coverage under either the Home Health Care or Hospice Care benefit for the following
➢ Financial or legal counseling services
➢ Spiritual or bereavement counseling
➢ Housekeeping or meal services
➢ Transportation, except as provided for under Ambulance Transportation
➢ Supportive equipment, such as handrails or ramps
➢ Custodial or maintenance care which is designed primardy to assist you in the activities of dady
living, including, but not limited to the following
o Walking
o Getting in and out of bed
o Bathing
o Dressing
o Feeding
o Preparation of special diets
o Supervision of inedications which are ordinarily self-administered �
o Any care given to sustain you, when there is no reasonable likelihood the disability will be
reduced by such care
➢ Services provided by volunteers, household members, friends, or famdy members
➢ Any other service not specifically listed as covered under this benefit, or any service which is
specifically excluded under this Group Plan
Kidney Dialysis
Coverage under this benefit is provided for the treatment of acute and chronic kidney conditions
Coverage includes
➢ Periodic treatment and supplies at a Hospital or dialysis center
➢ Provider services associated with dialysis treatment
If you have chronic kidney fadure, you are encouraged to apply for coverage under Medicare Parts A and B
Page 16 City of Bremerton Under 65 LEOFF I Retirees
Benefits Booklet
Laboratory and Radiology Services
Diagnostic and therapeutic laboratory and radiology (x-ray) services are covered when prescribed in
con�unction with a covered medical condition, and when Medically Necessary for the diagnosis or
treatment of a covered condition Coverage under this benefit includes
➢ Inpatient and outpatient diagnostic laboratory and pathology services
➢ Inpatient and outpatient diagnostic radiology (x-ray) services
➢ Nuclear medicine, mcluding radiation therapy
➢ Diagnostic ultrasound
Mammography Services
Coverage under this benefit includes routme screening and Medically Necessary diagnostic
mammography services, when such services are recommended by a physician (M D or D O), advanced
registered nurse practitioner (A R N P), or licensed physician's assistant (P A)
Prostate Cancer Screenmg
Coverage under this benefit includes routine screening and Medically Necessary diagnostic prostate
cancer screening senrices, when such services are recommended by a physician (M D or D 0),
advanced registered nurse practitioner (A R N P), or licensed physician's assistant (P A)
Mastectomy Care
(Prior authorization is required for mpatient Hospital services only)
Coverage under this benefit mcludes the following services when received in connection with a
mastectomy and the election of breast reconstruction in connection with such mastectomy
➢ All stages of reconstruction of the breast on which the mastectomy has been pertormed
➢ Surgery and reconstruction of the other breast to produce a symmetrical appearance
➢ Prostheses and mastectomy bras
➢ Treatment of physical complications of all stages of mastectomy, including lymphedema
Maternity Care
Pregnancy and Chddbirth
Coverage for pregnancy and childbirth is provided on the same basis as any other dlness or in�ury
Coverage under this benefit includes the following services when pertormed by a licensed physician
(M D or D O), a physician's assistant (P A), an advanced registered nurse practitioner (A R N P)
specializmg in women's health care or midwifery, or a licensed midwife
➢ Pre- and post-natal care
➢ Screening and diagnostic testmg for congenital fetal disorders
➢ Obstetrical delivery and delivery by Caesarean section
➢ Treatment for the complications of preg nancy
➢ Treatment following a miscarriage
To the extent that maternity care is covered under this Group Plan, the Provider (as defined above), in
consultation with you, may decide on the length of the inpatient stay and the type and location of follow-
up care, mcluding in-person care Decisions regarding patient care must be based on accepted medical
practice for the treatment of the diagnosis
City of Bremerton Under 65 LEOFF I Retirees Page 17
Benefits Booklet
Medical Equipment and Supplies
Coverage under this benefit includes artificial limbs and the purchase or rental of inedical equipment and
supplies prescnbed by your Provider for home use Equipment or supplies ordered before you enrolled in
this Group Plan will not be covered Equipment or supplies ordered while you were enrolled, and
delivered within 30 days after your coverage ended, wdl be covered
Surgically implanted prosthetics, such as pace makers and artificial �oints, are covered under the
Hospital Services benefit
Home Med�ca/ Equ�pment and Suppl�es
Prior authorization is required for the following medical equipment
➢ Equipment with a purchase price greater than $2,500, except wheelchairs
➢ Wheelchairs with a purchase price greater than $5,000
➢ Electric hospital beds
➢ Enteral therapy
➢ Ventilators
➢ Continuous positive air pressure (CPAP) and bi-positive air pressure equipment (except when
used in con�unction with sleep studies)
➢ Bone growth stimulators
Not all home medical equipment and medical supplies are covered For specific information regardmg
coverage of inedical equipment and supplies, please call KPS Customer Service at the numbers listed at
the end of this Benefits Booklet
Medical equipment and supplies must be prescribed by your Provider and obtained from a licensed
medical equipment supplier or pharmacy
At the sole discretion of KPS, coverage is provided for either the rental or purchase of home medical
equipment and supplies prescribed by your Provider for therapeutic use In addition, if KPS determines
that there is a less costly alternative to the prescribed equipment that serves the same medical purpose,
KPS wdl provide benefits on the basis of the less costly equipment
All home medical equipment and supplies must be prescribed by your Provider and obtained from an
approved home medical equipment supplier or pharmacy
Home medical equipment includes such things as crutches, walkers, hospital beds, and wheelchairs
Home medical equipment is generally defined as equipment that meets all of the following critena
➢ It is appropriate for use in the home
➢ It can withstand repeated use
➢ It is used primanly and customardy to serve a medical purpose
➢ It is not generally useful to a person in the absence of an illness or in�ury
Examples of disposable medical supplies covered under this benefit include, but are not limited to
➢ Ostomy bags and related supplies
➢ Peritoneal dialysis supplies
➢ Syringes and needles
➢ Catheters
Coverage of repair and maintenance costs on home medical equipment is sub�ect to prior review and
approval by KPS in cases where replacement costs are less than repair costs, KPS may elect to limit
coverage to replacement of the equipment
There is no coverage under this benefit for
➢ Repair or maintenance costs that are the result of intentional damage or neglect
➢ Equipment which is primarily used for non-medical purposes �
➢ Items used only for convenience
➢ Charges for equipment purchased or rented from a private party
➢ Separately billed delivery and service charges
Page 18 Ciry of Bremerton Under 65 LEOFF I Retirees
Benefits Booklet
Prosthet�c Appl►ances
Coverage under this benefit mcludes the mitial purchase of the artificial limb (arm or leg) and subsequent
repair or replacement costs necessitated by damage to the limb and/or physical growth
Medically Necessary contact lenses, both mitial and replacement lenses are covered following cataract
surgery
Mental Health Care
Prior authorization is required for inpatient mental health care, except in the case of mvoluntary
commitment Either you or your Provider may request authorization for inpatient services Please refer to
the Services Which Require Prior Authorization section for more information
Prior authonzation of outpatient services is not required but you may contact KPS Customer Service for
assistance m finding Providers KPS Customer Service can be reached at 360-478-6796, or toll-free at 1-
800-552-7114
Coverage under this benefit includes the following
➢ Treatment m an acute inpatient psychiatric or general Hospital
➢ Treatment provided on a Partial Hospitalization basis
➢ Treatment provided on an outpatient basis
➢ Treatment provided in a Residential Mental Health Facility
In order to be covered, care must be provided by one of the following
➢ A licensed medical doctor (M D or D 0)
➢ A licensed psychologist
➢ A licensed community mental health agency
➢ A licensed state Hospital
➢ Any other licensed Provider who has been credentialed and approved by KPS to provide mental
health care
Coverage under this benefit does not include the following
➢ Marriage and famdy semmars and/or encounter groups
➢ Sensitivity trairnng
➢ Sexual dysfunction
➢ Outdoor youth programs
Court-ordered assessments or other assessments are not covered under this benefit, when the purpose
of the assessment is to determine the Medical Necessity of any court-ordered mental health care
Coverage under this benefit does not duplicate coverage for therapy services provided under any other
benefit of this Group Plan
Newborn Care
Coverage for newborn Children of the female Subscriber is provided automatically for a period of not less
than three (3) weeks from the date of birth Coverage for newborns shall be no less than the coverage
provided to the mother, including
➢ Medical and surgical inpatient care, including inpatient care which is separate from the mother's
materrnty admission
➢ Medical and surgical outpatient care
Newborn Nursery Care
Routme newborn care provided in a Hospital nursery is not sub�ect to the Deductible Charges incurred as
a result of complications dunng or after birth are covered as any other medical condition
City of Bremerton Under 65 LEOFF I Retirees Page 19
Benefits Booklet
Nutritional Guidance Counseling
Coverage is provided on an outpatient basis for the services of nutritional guidance counseling, when
recommended by your Provider for the following conditions
Anorexia and bulimia
Cancer
Colitis
Coronary Artery Disease
Dysphagia
Endocrine conditions Hypoglycemia
Food Allergies or intolerances Short bowel syndrome (post surgery)
Gastritis Swallowing difficulties following a stroke
Hypercholesterolemia
Hyperlipidemia
There is no coverage under this benefit for
➢ Weight control self-help programs, such as Weight Watchers, Jenny Craig, or other such
programs
➢ Medical or surgical treatment of obesity (including morbid obesity)
➢ Surgical procedures for weight reduction
Oral Surgery
Coverage for oral surgery includes
➢ The reduction or manipulation of fractures of the facial bones
➢ The removal of lesions, cysts, and tumors of the �awbone, mouth, lips, or tongue
➢ Reconstruction of the mouth or lips to correct anatomical impairment caused by a congenital
defect
There is no coverage under this benefit for the following dental services
➢ Care or repair of teeth or dental structures of any type
➢ Tooth extractions or impacted teeth
➢ Services related to malocclusion ,
➢ Services to correct the misalignment or malposition of teeth
➢ Any other services to the mouth, facial bones, or teeth, which are not medical in nature
Organ, Bone Marrow, Stem Cell and Tissue Transplants
(Requires prior authonzation)
Covered Procedures and Cond�t�ons
Services and treatment directly related to the procurement and implantation of human organs, bone
marrow, stem cells or tissues are covered sub�ect to pnor approval by KPS Such approval is based on
the following critena
➢ The transplant is Medically Necessary and warranted by your health condition
➢ The procedure is to be performed by a licensed and accredited physician who has demonstrated
proficiency in such procedures
➢ The procedure is to be performed at an accredited transplant facdity
➢ The procedure is not considered to be an Experimental or Investigational procedure for the
treatment of the condition
➢ You have been accepted into the facdity's transplant program and comply with all program
requirements
Page 20 City of Bremerton Under 65 LEOFF I Retirees
Benefits Booklet
Provided the above conditions have been met, coverage under this benefit mcludes the following organ
transplant procedures
Cornea Kidney/pancreas
Heart Liver
Heart/lung Lung
Kidney Pancreas
Autologous bone marrow stem cell and tissue transplants, and associated high-dose chemotherapy are
covered only for the treatment of the following conditions or malignancies
Acute lymphocytic and non-lymphocytic leukemia
Acute myelocytic leukemia
Germ cell cancer
Hodgkm's lymphoma
Neuroblastoma
Non-Hodgkin's lymphoma
Allogeneic (related and unrelated) bone marrow, stem cell and tissue transplants and associated high-
dose chemotherapy are covered only for the treatment of the followmg conditions or malignancies
Acute lymphocytic leukemia
Acute myelocytic leukemia
Aplastic anemia
Chronic myelogenous leukemia
Hodgkin's lymphoma
Homozygous beta-thalassemia
Transp/ant Rec�p►ent Benefits
Infantile malignant osteopetrosis �
Neuroblastoma stage I II and IV (Children over 1 year old)
Non-Hodgkin's lymphoma
Severe combined immunodeficiency (SCID, not HIV AIDS)
Wiskott-Aldrich syndrome
Covered Benefits and Services for transplant recipients mclude
➢ Medical and surgical physician and Hospital services directly related to the transplant procedure
➢ Diagnostic tests and exammations directly related to the transplant procedure
➢ Donor retrieval costs directly related to the transplant procedure
Donor Related Serv�ces
Donor-related services include, but are not limited to the followmg selection, removal, harvesting,
storage, transportation of the surgical harvestmg team, and such other Medically Necessary procurement
costs as may be approved by KPS Donor-related services are covered only if the transplant procedure is
approved by KPS and the recipient of the transplant is covered under this Group Plan and has met any
applicable transplant benefit waiting penods
There is no coverage under this benefit for the following services
➢ Costs incurred by a donor, including an Enrollee m this Group Plan, for sennces associated with
donor organ or bone marrow/stem cell/tissue acquisition if the recipient is not enrolled in this
Group Plan
➢ Costs incurred by a donor for the treatment of complications resulting from organ donation or
bone marrow/stem cell/tissue acquisition if the donor is not enrolled in this Group Plan
Costs incurred by an Enrollee for Medically Necessary Covered Benefits and Services as a result of
complications from organ donation or bone marrow/stem cell/tissue acquisition are covered under this
Group Plan only to the extent these costs are not covered under the recipient's plan
City of Bremerton Under 65 LEOFF I Retirees Page 21
Benefits Booklet
Transp/ant Benefit L�m�tations and Exc/us�ons
In addition to any coverage limitations or exclusions described above or listed in the Limitations and
Exclusions section of this Benefits Booklet, the following specific limitations and exclusions apply to the
Transplants benefit
➢ Any transplant not specifically listed
➢ Charges for transplant-related facdity services, which were not authorized in advance by KPS
➢ Donor and procurement services and costs incurred outside of the U S, unless specifically
authorized in advance by KPS
➢ Experimental and/or Investigational transplant procedures
➢ Food and lodging
➢ Living (non-cadaver) donor transplants of the lung, liver, or other organs (except kidney
transplants), includmg selective islet cell transplants of the pancreas, unless otherwise authorized
in advance by KPS, based on current standards of care at the time of the request for
authonzation
➢ Mechanical, artificial, or non-human transplants
➢ Prescription drugs dispensed on an outpatient basis, mcluding anti-reJection medications and
self-administered drugs, except as may be covered under Pharmacy Benefits
➢ Transportation costs, except as specifically aliowed for the actual organ/bone marrow/stem
cell/tissue harvesting or procurement for the transplant
Oxygen and Oxygen Supplies
(Requires pnor authorization)
Coverage under this benefit includes oxygen, oxygen equipment, and related supplies, when prescribed
by your Provider for therapeutic use and obtained from an approved medical equipment supplier
Phenylketonuria (PKU) Formulas
Special dietary formulas designed for use by those who have been diagnosed with phenylketonuria are
covered under this benefit
Plastic and Reconstructive Surgery
(Requires prior authonzation)
Plastic and reconstructive surgeries are covered to
➢ Correct a physical disorder resulting from a congerntal disease or anomaly
➢ Correct a physical disorder resulting from disease, Accidental in�ury or trauma, provided the
repair is performed within 12 months or other medically appropriate period of time after the date
of the disease, in�ury, or trauma, which caused the physical disorder
➢ Reconstruct an in�ured or diseased breast following a mastectomy, includmg reconstruction of the
healthy breast to produce a symmetrical appearance
Coverage under this benefit does not include
➢ Cosmetic services, supplies, or surgery to repair or reshape an essentially normai body structure
for the improvement of the patient's appearance or self-esteem
➢ Complications resulting from cosmetic surgery
Except as set forth under this benefit, no other plastic, reconstructive, or cosmetic services are avadable
under this Group Plan
Page 22 City of Bremerton Under 65 LEOFF I Retirees
Benefits Booklet
Private Duty Nursing
Professional, private nursing services are covered when Medically Necessary and ordered by a
Participating Provider The nurse may not be a person who ordinarily resides in your home or who is
related to you by blood or marriage
Rehabilitation
Prior authorization of a plan of treatment is required only for inpatient rehabilitative therapies
Coverage under this benefit mcludes speech, occupational, physical, and massage therapies performed
on an mpatient basis (in a Hospital, Skdled Nursing Facdity or other approved facdity) or on an outpatient
basis for conditions other than neurodevelopmental disabdities Therapy services will be covered as
prescnbed by your physician
Coverage is provided under the followmg conditions
➢ KPS has approved the plan of treatment (inpatient only)
➢ The services rendered must be Medically Necessary to restore or imp�ove function
➢ The loss of function was not the result of a work-related in�ury
Coverage for inpatient sennces under this benefit is limited Please refer to the Benefits Summary
section Coverage under this benefit does not duplicate coverage for therapy services provided under any
other benefit of this Group Plan Please see the Home Health Care section
Skilled Nursing Facility Care
(Requires prior authonzation)
Medically Necessary therapeutic or restorative care in a Skdled Nursing Facility may be authorized by
KPS as an alternative to Medically Necessary confinement m a Hospital
Coverage is based on a written treatment plan submitted to KPS by your treating Provider and approved
by KPS Coverage is limited Please refer to the Benefits Summary
Skilled Nursing Facdity coverage includes
➢ Semi-private room and board
➢ General duty nursmg
➢ Medically Necessary ancillary services and supplies
Maintenance or custodial care is not covered under this benefit Please see the Home Health and
Hospice Care section
Sleep Disorders
(Requires prior authonzation for surgical treatment only)
Coverage under this benefit is limited to sleep studies, mcluding Provider services, appropriate durable
medical equipment obtained from an approved home medical supplier or pharmacy, and surgical
treatments No other benefits are provided for the purpose of studying, monitonng, and/or treatmg sleep
disorders, other than as described below
Sleep Stud►es, lnclud►ng Appropnate Durable Medical Equ�pment
Coverage for sleep studies includes
➢ Polysomnographs
➢ Multiple sleep latency tests
➢ Contmuous positive am�vay pressure (CPAP) studies
➢ Related durable medical equipment and supplies, mcluding CPAP machines
The condition giving rise to the sleep disorder, such as narcolepsy or sleep apnea, must be diagnosed by
your Provider Prior authorization of sleep studies is not required, however, your Provider must order the
sleep studies program for you
City of Bremerton Under 65 LEOFF I Retirees Page 23
Benefits Booklet
Surg�ca/ Treatments
Coverage for the Medically Necessary surgical treatment of diagnosed sleep disorders is covered under
this benefit Prior authorization of surgical procedures for the treatment of sleep disorders is
required Surgical treatment includes all professional and facility fees related to the surgical treatment
including pre- and post-operative care and complications
Spinal and Extremity Manipulation ,
Coverage under this benefit is provided for the diagnosis and treatment of musculoskeletal disorders,
including bone and muscle subluxations (out of alignment) of body extremities and spmal column
Coverage under this benefit is limited Please refer to the Benefits Summary section
Substance Use Disorder Treatment (Chemical Dependency)
Prior authorization is required for inpatient substance use disorders treatment, except in the case of
Emergency detoxification Either you or your Provider may request authorization for inpatient services
Please refer to the Services Which Require Pr�or Authorization section for more information about
Emergency admissions
Prior authorization of outpatient services is not required but you may contact KPS Customer Service for
assistance in finding providers KPS Customer Service can be reached at 360-478-6796, or toll-free at 1-
800-552-7114
Coverage for the treatment of substance use disorders includes
➢ Medically Necessary inpatient and outpatient care provided as part of an Approved Treatment
Program
➢ Detoxification and supportive services
No coverage is provided under this benefit for the following
➢ Court-ordered assessments, or other assessments, when the purpose of the assessment is to
determine the Medical Necessity of any court-ordered substance use disorder treatment
➢ Court-ordered assessments or treatments related to the deferral of prosecution, deferral of
sentencing or suspended sentencing, or treatments ordered as a condition of retaining motor
vehicle driving rights, when the Medical Necessity for such assessments or treatment cannot be
established
➢ Information and referral services
➢ Residential treatment faalities, such as therapeutic boarding schools, outdoor youth programs,
and halfway houses
➢ Alcoholics Anonymous or other simdar programs and support groups
➢ Long term or custodial care
➢ Tobacco cessation programs
➢ Any other substance use disorder service or supply not specifically listed
In the case of a court-ordered assessment or treatment program, you are required to provide KPS with a
copy of the following documents
➢ The initial assessment of the need for substance use disorder treatment, provided by a certified
chemical dependency counselor who is employed by an Approved Treatment Program
➢ The treatment plan
Termination of Pregnancy
Coverage for the voluntary termination of pregnancy is included under this benefit
Coverage under this benefit is limited to one (1) voluntary termination of pregnancy per Calendar Year
Page 24 City of Bremerton Under 65 LEOFF I Retirees
Bene�ts Booklet
Vision Examination
One routine eye exammation is covered every Calendar Year Eyeglasses are not covered Contact
lenses are covered only as descnbed under Medical Equipment and Supplies, Prosthetic Appliances.
Women's Health Care Services
Covered women's health care services are available without prior referral from another Provider, and
include maternity care, reproductive health sennces, gynecological care, general exammation, preventive
care, and follow-up visits, when provided by a licensed physician (M D or D O), a physician's assistant
(P A), an advanced registered nurse practitioner (A R N P) specializmg m women's health care or
midwifery, or a licensed midwife, and any Participatmg Facility used by such Providers
Pharmacy Benefits
This benefit, for purposes of creditable coverage, is expected to pay out as much as the Medicare Part D
prescription drug benefit and is therefore considered creditable Enrollees who are a Iso eligible for
Medicare Part D pharmacy benefits can remain covered under this Group Plan and not be sub�ect to
Medicare-imposed late enroliment penalties should they decide to enroll m a Medicare Part D pharmacy
plan at a later date
Coverage
Coverage under this benefit includes
➢ Prescnption drugs
➢ Insulm and diabetic supplies
➢ Self-administered drugs
➢ Pre-authorized Off-label Use of prescription drugs
➢ Prescription Contraceptive drugs and devices
All drugs and supplies must be Medically Necessary for the condition and must be prescribed by a
Provider with prescriptive authority
All prescnptions must be filled at a Participating nefinrork pharmacy, except m the case of accidental in�ury
or medical emergency Prescriptions for specialty drugs may only be filled through the KPS specialty
pharmacy vendor
Prescriptions and refills are available on a 31-day or 90-daysupply basis Please refer to the Benefits
Summary section for applicable comsurance
Pharmacy benefits are based on a drug formulary Drug formulary (approved drug list is defined as a list
of covered drugs, supplies and devices This list is developed and maintained by KPS Drugs on the
formulary are classified into one of three (3) tiers
➢ Tier 1— Preferred Generic drugs
➢ Tier 2— Preferred Brand drugs
➢ Tier 3— Non-preferred Genenc and Brand drugs
The KPS drug formulary (approved drug list) is updated throughout the year For the most up-to-date
information about the drugs covered under your Group Plan, please visit the KPS Web site at
www kqshealthqlans com, or call KPS Customer Service toll-free at 1-800-552-7114
How to Use Your Pharmacy P/an
Be sure to present your KPS identification card to your Participating network pharmacy when you have
your prescription filled or re-filled Your Participating network pharmacy will collect the 20% Comsurance
amount due for each new and refilled prescription You are only required to pay up to $100 in
Comsurance each Calendar Year Thereafter, coverage for any new or re-filled prescriptions for the
remainder of that Calendar Year is provided at 100% of the KPS allowed charge
For a list of Participatmg network pharmacies please visit the KPS Web site at www kpshealthplans com,
or call KPS Customer Service at 1-800-552-7114
City of Bremerton Under 65 LEOFF I Retirees
Benefits Booklet
When you use a Participating network pharmacy, you wdl not be responsible for submitting a claim form
In the event of an Accidental In�ury or Medical Emergency, you may utilize the services of a non-
participating pharmacy _
For reimbursement, you must submit an itemized claim and a paid receipt to
Medlmpact
Attn DMR Department
10680 Treena Street, 5 floor
San Diego, CA 92131
Defimtions
Brand Drug is a drug manufactured and sold exclusively under its brand-name by the manufacturing
pharmaceutical company that holds the onginal patent of drug development
Generic Drug is a drug approved by the Food and Drug Administration (FDA) as a therapeutic equivalent
generic to a Brand drug Generic drugs may be manufactured and sold by more than one pharmaceutical
company
Preferred and Non-preferred drug status is determined by KPS based on scientific evidence of efficacy,
safety and cost-effectiveness Preferred Generic drugs are in Tier 1, Preferred Brand drugs are in Tier 2
of the Formulary
Off-label Use means the drug is prescribed for an indication other than those specified in its FDA-
approved labeling Coverage is allowed for the following when pre-authorized by KPS
➢ The stated use of the drug is recognized in one of the standard reference compendia
➢ The stated use of the drug is recognized as effective in the ma�ority of relevant, peer-reviewed
medical literature
➢ The stated use of the drug is approved by the Federal Secretary of Health
➢ The stated use must meet Medical Necessity guidelines
Exc/us�ons
,
No coverage is provided under this benefit for the following
➢ Over-the-counter drugs for which a prescription is not required, unless specifically provided for in
this Group Plan
➢ Over-the-counter contraceptive devices and/or supplies
➢ Vitamins, including pre-natal vitamms, unless specifically provided for in this Group Plan
➢ Drugs for the treatment of obesity
➢ Fluoride preparations
➢ Drugs used for cosmetic purposes
➢ Drugs taken home following an inpatient Hospital stay
➢ Non-self-administered drugs
➢ Self-administered drugs supplied by a Provider
➢ Drugs for the treatment of impotence and infertility
➢ Prescription drugs mtended to ease nicotine withdrawal
➢ Drugs specifically designated as not covered
➢ Drugs which are not approved by the FDA
➢ Drugs which are not Medically Necessary for the treatment of a specific condition
➢ Investigational drugs and/or drugs used for investigation or experimental purposes
➢ Drugs for travel purposes
➢ Compounded Hormone Replacement Therapy drugs, which have not been approved by the FDA
and which are not manufactured by a recognized drug company
➢ Replacement of lost or stolen medications, unless specifically included as a covered benefit
under this Group Plan
➢ Drugs that require pnor authorization if your provider has not obtained prior authorization
Page 26 City of Bremerton Under 65 LEOFF I Retirees
Benefits Booklet
LIMITATIONS AND EXCLUSIONS
Coverage under this Group Plan is limited to the diagnosis and therapeutic care or treatment of disease,
sickness, or in�ury, or the prevention of disease, sickness, or in�ury, as described in this Benefits Booklet
The following services are specifically excluded from coverage �
1 Air conditioners, de-humidifiers, air punfiers ,
2 Any care, treatment, or service received prior to your effective date of coverage under this
Group Plan
3 Any care, treatment, or service received after coverage under this Group P{an has ended
4 Arch supports, shoe orthotics, corrective shoes, and elastic stockings except as specifically
provided for under the Diabetic Education, Equipment, and Supplies benefit
5 Artificial msemination, in vitro fertdization, and gamete mtra-fallopian transplant (GIFT),
mcludmg any direct or indirect complications or after-effects other than pregnancy
6 Biofeedback, except in the case of unnary incontinence
7 Charges for non-Covered Benefits and Services and resulting complications, mcluding services
not specifically described in this Benefits Booklet
8 Circumcision
9 Conditions resulting from acts of war, whether declared or undeclared
10 Cosmetic surgery, including treatment for complications of cosmetic surgery, except as
provided for under the Plastic and Reconstructrve Surgery benefit
11 Developmental delay, speech delay, or other learning disabilities
12 Enuresis trainmg equipment
13 Exercise equipment and whirlpool baths
14 Experimental or Investigational procedures, as defined m this Benefits Booklet
15 Eye examinations (except Subscriber), refractions, eyeglasses and contact lenses, except after
cataract surgery
16 Hearing aids, hearing devices such as cochlear implants, and hearmg examinations
17 Immunizations required for employment, travel, immigration, licensing or insurance related
reports
18 Maintenance, custodial, or domiciliary, care except as provided for under the Home Health and
Hospice Care benefit
19 Medical services paid by the Veterans Administration or by state, local, or federal governmental
programs, excluding Medicaid as defined by RCW 74 09 500
20 Non-surgical treatment for deformities of the toes and feet, mcluding routme foot care, except
when such care is directly related to the treatment of diabetes
21 Obesity treatment, including, but not limited to, Provider office visits, surgical weight loss
p�ocedures, pre-surgical diagnostics and procedures, weight reduction programs (e g, Weight
Watchers), and dietary control programs
22 Orthoptics (eye exercise programs), pleoptics, visual analysis therapy and/or training, and
radial keratotomy
23 Over-the-counter products (except msulm supplies for the treatment of diabetes), inciuding, but
not limited to, contraceptive devices or supplies, unless specifically listed as a benefit under this
Group Plan
24 Personal comfort items (e g, radios, telephones, televisions)
25 Reversal of sterilization
City of Bremerton Under 65 LEOFF I Retirees Page
Benefits Booklet
26 Self-help care of any form, including, but not limited to, non-medical self-care, self-help training,
marital or sexual counsel�ng ,
27 Services, supplies, and drugs, which are not Medically Necessary for the treatment of an
dlness, in�ury, or physical disability, even though the services are not specifically listed as
exclusions
28 Services for any occupational iilness or inJury arising out of, or in the course of, an activity
pertaining to any trade, business, employment (including self-employment), or occupation for
wage or profit, whether or not a proper and timely claim was filed for such benefits under
another plan or policy, except LEOFF I Retirees
29 Services and supplies for, or associated with, care or work on the teeth, x-rays of the teeth and
other dental procedures
30 Services for the treatment of complications arising from non-Covered Benefits and Services or
procedures, except for the complications of pregnancy
31 Services for which there is no charge to you
32 Serwces for which you are not legally required to pay
33 Services provided by a person who is related to you by blood or marriage, or who resides in
your home
34 Sex change or other sexual transformation procedures
35 Speech, occupational, educational, mdieu, massage, and physical therapies, except as
speciflcally included under the Rehabilitation benefit, or the Home Health and Hospice Care
benefit
36 Sterilization
37 Treatment for abnormalities of the �aw, including malocclusion, �aw augmentation or reduction
surgery (orthognathic surgery) except as provided for under the Oral Surgery benefit or the
Plastic and Reconstructive Surgery benefit, diagnosis and treatment of temporomandibular
�oint (TMJ) disorders
38 Treatment for sexual dysfunction, including, but not limited to, sterdity, mfertility, impotence, or
frigidity
39 Unnecessary duplicate diagnostic services for a single ongomg illness Consultations for
second surgical opinions are covered under the Professional Services benefit
40 Services for elective care received in a foreign country
41 Services and supplies not specifically described m this Benefits Booklet
Page 28 Ciry of Bremerton Under 65 LEOFF I Retirees
Benefits Booklet
CONTINUATION OF COVERAGE
If you are no longer eligible for coverage under this Group Plan, you may be entitled to continue your
Group Plan coverage or enroll in a KPS Conversion Plan Contact your Group Plan Administrator for
information regarding eligibility and enrollment requirements
The following paragraphs describe several options for continumg your coverage Your employer is
obligated to provide you with mformation regarding any options that apply to you
Continuation of Group Coverage
If you lose your coverage under this Group Plan, you may be able to contmue coverage for up to three (3)
additional months unless
➢ Your coverage was terminated as a result of a stnke, lockout, or other labor dispute
➢ Your employment was terminated for gross misconduct
Please check with your Group Plan Admmistrator to determine whether or not your Group has chosen to
make this option available to all employees If your Group is required by law to offer COBRA coverage,
this option for extended coverage may not be avadable
Extended coverage under this option is not automatic if this option for extended coverage is avadable
from your Group, you must apply within 31 days of the date your coverage ends under the Group Plan If
you are required to self-pay your Premium, your first Premium payment must be submitted with your
application for coverage To be continuously covered, you must pay your Premium each month
Premium self-payments should be made directly to the Group Premiums are due no later than the
Premium Due Date If you fail to pay your Premium for any month, your coverage wdl end on the last day
of the month for which Premium was received and may not be reinstated
If you choose this continuation option, your benefit coverage and Premium may not be altered from that of
the existing Group Plan
COBRA (Consolidated Omnibus Budget Reconciliation Act -1985)
If you lose eligibility for coverage under this Group Plan (except in the case of a labor dispute), you may
be eligible to continue your coverage for a period of time specified by federal law and regulations then in
effect This continuation of coverage is referred to as COBRA and applies generally to groups of 20 or
more employees KPS offers coverage only when
➢ Groups are required by law to provide COBRA coverage for employees, and
➢ KPS is notified of a beneficiary's election of COBRA coverage withm 31 days of that election
being made
Contmuation of coverage under COBRA is not automatic You must apply for continuation of your Group
coverage within 60 days of the date your Group provides you a COBRA election notice KPS offers
COBRA coverage to Groups only as required by law
Your Group Plan Administrator is required to notify KPS of your election of COBRA continuation coverage
within 45 days of that election Failure on your part to make a timely election, or fadure on the part of your
Group Plan Administrator to provide KPS with timely notification of the election, wdl be interpreted by KPS
as a waiver of your right to contmue coverage under this provision Fadure by your Group Plan
Administrator to provide timely notification to KPS may not, in all cases, eliminate the Group's obligation
to provide continuation coverage It wdl, however, eliminate any obligation on the part of KPS to provide
you with continuation coverage under this Group Plan
If you are about to lose, or have lost, your coverage under this Group Plan, contact your Group Plan
Admmistrator for more information regard mg COBRA and your right to continue receivmg medical benefits
under this Group Plan
City of Bremerton Under 65 LEOFF I Retirees Page 29
Benefits Bookle4
Conversion Coverage
If you are under age 65, you may be entitled to transfer to a KPS Conversion Plan if
➢ You are a permanent resident of Washington State
➢ You are not otherwise eligible for coverage under Medicare
➢ You are currently eligible for continuation of your Group Plan coverage but decline that option
➢ Your continuation coverage under this Group Plan or COBRA plan terminates (for any reason
except fraud or non-payment of Premium, when it is your responsibility to pay the Premium)
➢ Your employer's Group Plan terminates and your employer does not provide other health care
coverage to its employees
An application for coverage under a KPS Conversion Plan for must be received by KPS within 31 days of
either the date a) your coverage under this Group Plan or other KPS continuation or COBRA plan ends,
or b) you recewed notification that this Group Plan wdl termmate, whichever occurs later Any applicable
Premium amounts for your first month of coverage must be submitted with your application You must pay
all subsequent Premiums by the Premium Due Date Your coverage under a KPS Conversion Plan is
guaranteed for as long as you contmue to meet the eligibility requirements and pay your Premium If you
fad to pay your Premium for any month, your coverage will end on the last day of the month for which
Premium was received
Credit for penods of continuous coverage under this Group Plan and/or a KPS continuation or COBRA
plan wdl be applied to your coverage under a KPS Conversion Plan
When you enroll in a conversion plan, you lose certain protections guaranteed you under the Health
Insurance Portability and Accountability Act (HIPAA) of 1996 If you decide to purchase an individual
product after receiving coverage in a KPS Conversion Plan, the new carrier may ask about your health
conditions in the application process if you decide to decline conversion coverage and apply for an
individual plan, you will generally have the right to purchase the coverage without any questions about
your health conditions provided you had 18 months of Creditable Coverage and your former plan was a
group health plan If you have any questions, please contact KPS Customer Service at 360-478-6796 or
toll-free at 1-800-552-7114
If you are age 65 or older and your coverage under this Group Plan termmates, you may be eligible for
coverage under a Medicare supplement plan To determine your eligibility for a Medicare supplement
plan, please contact KPS Customer Service
Page 30 C�ty of Bremerton Under 65 LEOFF I Retirees
Benefits Booklet
COORDINATION OF BENEFITS (COB)
General Provision
The Coordmation of Benefits (COB) provision applies when a person has health care coverage under
more than one Plan All of the benefits provided under this Group Plan are sub�ect to this COB provision
Definitions
"Plan" means any of the followmg that provide benefits or services for medical or dental care or treatment
➢ This Group Plan
➢ Group, individual, or blanket disability insurance contracts
➢ Group or indiv�dual contracts issued by health care service contractors or health maintenance
organizations (HMOs)
➢ Closed Panel Plans or other forms of group or individual coverage
➢ Medical care components of long-term care contracts, such as skilled nursing care
➢ Medicare or any other federal governmental plan, as permitted by law
Plan does not include
➢ Hospital indemrnty or fixed indemnity/payment coverage
➢ Accident only coverage
➢ Specified disease or specified accident coverage �
➢ Limited benefit health coverage, as defined by state law
➢ School accident type coverage
➢ Benefits for non-medical components of long-term care policies
➢ Automobile msurance policies required by statute to provide medical benefits
➢ Medicare supplement policies, Medicaid coverage, or coverage under other federal governmental
plans, unless permitted by law
Each contract for coverage listed above is a separate Plan If the Plan has iwo parts and COB rules apply
only to one of the two, each of the parts is treated as a separate Plan
"Pnmary Plan" means the Plan that determines payment for its benefits first before those of any other
Plan without considermg any other Plan's benefits
"Secondary Plan" means the Pfan that determmes its benefits after those of another Plan and must make
payment in an amount so that, when combined with the amount paid by the Pnmary Plan, the total
benefits paid or provided by all Plans for the claim equal 100% of the Total Allowable Expense for that
claim
When a Plan is secondary, it must pay the amount which, when combmed with what the Pnmary Plan
paid, totals 100% of the Allowable Expense In addition, if a Plan is secondary, it must calculate its
savings (its amount paid subtracted from the amount it would have paid had it been the Primary Plan) and
record these savings as a benefit reserve for the covered person This reserve must be used to pay any
expenses during that Calendar Year, whether or not they are an Allowable Expense under this Group
Plan If a Plan is secondary, it wdl not be required to pay an amount in excess of its maximum benefit plus
any accrued savings
"Allowable Expense" means a health care expense, mcluding deductibles, copayments, and comsurance,
which is covered at least in part by any of the Plans involved When a Plan provides benefits in the form _
of services, the reasonable cash value of each service wdl be considered an Allowable Expense and a
benefit paid An expense that is not covered by any of the Plans mvolved is not an Allowable Expense
City of Bremerton Under 65 LEOFF I Retirees Page 31
Benefits Booklet
The following are examples of expenses that are not Allowable Expenses
➢ The difference between the cost of a semi-private Hospital room and a private Hospital room is
not an Allowable Expense, unless one of the Plans provides coverage for pnvate Hospital room
expenses
➢ If a person is covered by two or more Plans that compute their benefit payments on the basis of
usual and customary fees, or relative value schedule reimbursement method, or other simdar
reimbursement method, any amount in excess of the highest reimbursement amount for a
specific benefit is not an Allowable Expense
➢ If a person is covered by iwo or more Plans that provide benefits or services on the basis of
negotiated fees, an amount in excess of the highest of the negotiated fees is not an Allowable
Expense
"Total Allowable Expenses" means the combined amount paid by both the Primary and Secondary Plans
After the Primary Plan's payment is determmed, the Secondary Plan pays what is left, up to its maximum
benefit plus any accrued savings This total amount will not exceed 100% of the Allowable Expense
"Closed Panel Plan" means a Plan that provides health care benefits to covered persons in the form of
services through a panel of Providers who are primardy employed by the Plan and that excludes
coverage for services provided by other Providers, except in cases of an Emergency or referral by a
panel member
"Custodial ParenY' means the parent awarded custody by a court decree or, in the absence of a court
decree, the parent with whom the Children resides more than one half of the Calendar Year excluding
any temporary visitation
Order of Benefit Determination Rules
The order of benefit determination rules govern the order in which each Plan will pay a claim for benefits
The Plan that pays first is called the Primary Plan The Primary Plan must pay benefits according to its
policy terms without regard to the possibility that another Plan may cover some expenses The Plan that
pays after the Pnmary Plan is the Secondary Plan The Secondary Plan may reduce the benefits it pays
so that payments from all Plans do not exceed 100% of the total Allowable Expense
When a person has health care coverage under more than one Plan, the order of benefit determination
rules determine which is the Primary Plan and which is the Secondary Plan
When you are covered by finro or more Plans, the rules for determining the order of benefit payments are
as follows
1 The Pnmary Plan pays or provides its benefits according to its terms of coverage and without
regard to the benefits under any other Plan
2 A Plan that does not contain a COB provision that is consistent with the COB provisions in this
section is always primary unless
➢ The provisions of both Plans state that the complying Plan is primary, or �
➢ The coverage that is obtained by virtue of inembership in a group designed to supplement a
part of a basic package of benefits provides that the supplementary coverage is in excess to
any other parts of the Plan provided by the contract holder Examples include ma�or medical
coverages that are superimposed over hospital and surgical benefits, and insurance type
coverages that are written m connection with a Closed Panel Plan to provide out-of-network
benefits
3 A Plan may consider the benefits paid or provided by another Plan in calculating payment of its
benefits only when it is Secondary to that other Plan
4 Each Plan determines its order of benefits using the first of the following rules that apply
➢ Deqendent or Non-deaendent - The Plan that covers a person other than as a dependent is
the Primary Plan and the Plan that covers a person as a dependent is the Secondary Plan
However, if the person is a Medicare benefic�ary and, as a result of federal law, Medicare is
secondary to the Plan covering the person as a dependent, and pnmary to the Plan covering
the person as other than a dependent (e g, a retired employee), then the order of benefits
between the two Plans is reversed so that the Plan covenng the person other than as a
dependent is the Secondary Plan and the other Plan is the Primary Plan
Page 32 City of Bremerton Under 65 LEOFF I Retirees
Benefits Booklet
➢ Dependent Children Covered Under More Than One Plan - Unless there is a court decree
statmg otherwise, when a dependent Child is covered by more than one Plan the order of
benefits is determined as follows
(a) For dependent Children whose parents are married or are living together, whether or not
they have ever been married
(i) The Plan of the parent whose birthday falls earlier m the Calendar Year is the
Primary Plan
(u) If both parents have the same birthday, the Plan that has covered the parent the
longest is the Primary Plan
(b) For dependent Chddren whose parents are divorced or separated or not livmg together,
whether or not they have ever been married
(i) If the court decree states that one of the parents is responsible for the dependent
Children's health care expenses or health care coverage and the Plan of that parent
has actual knowledge of those terms, that Plan is primary This rule applies to claim
determmation periods commencmg after the Plan is given notice of the court decree
(ii) If a court decree states one parent is to assume primary financial responsibdity for
the dependent Children but does not mention responsibdity for health care expenses,
the Plan of the parent assummg financial responsibility is primary
(iii) If a court decree states that both parents are responsible for the dependent
Children's health care expenses or health care coverage, the provisions of
subparagraph (a) above determme the order of benefits
(iv) If a court decree states that the parents have �oint custody without specifying that
one parent has responsibdity for the health care expenses or health care coverage of
the dependent Children, the provisions of subparagraph (a) above determme the
order of benefits
(v) If there is no court decree allocating responsibility for the dependent Chddren's health
care expenses or health care coverage, the order of benefits for the Children are as
follows
• The Plan covenng the Custodial Parent, first,
• The Plan covering the spouse of the Custodial Parent, second,
• The Plan covering the non-Custodial Parent, third, and then
• The Plan covermg the spouse of the non-Custodial Parent, last
(c) For dependent Children covered under more than one Plan of individuals who are not the
parents of the Chddren, the provisions of subparagraph (a) or (b) above determme the
order of benefits as if those individuals were the parents of the Chddren
➢ Active emplovee or Retired or Laid-off employee - The Plan that covers a person as an active
employee, that is, an employee who is neither laid-off nor retired, is the Primary Plan The
Plan covermg that same person as a retired or laid-off employee is the Secondary Plan The
same applies if a person is a dependent of an active employee and that same person is a
dependent of a retired or laid-off employee If the other Plan does not have this rule, and as a
result, the Plans do not agree on the order of benefits, this rule is ignored This rule does not
apply if the Dependent or Non-dependent rule can determme the order of benefits
➢ COBRA or State Continuation Coveraqe - If a person whose coverage is provided under
COBRA or under a right of continuation provided by state or other federal law is covered
under another Plan, the Plan covering the person as an employee, subscriber, or retiree, or
covermg the person as a dependent of an employee, subscriber, or retiree is the Primary
Plan, and the COBRA or state or other federal contmuation coverage is the Secondary Plan
If the other Plan does not have this rule, and as a result, the Plans do not agree on the order
of benefits, this rule is ignored This rule does not apply if the Dependent or Non-deqendent
rule can determine the order of benefits
➢ Longer or Shorter Length of Coveraqe - The Plan that covered the person as an employee,
subscriber, or retiree longer is the Primary Plan and the Plan that covered the person the
shorter period of time is the Secondary Plan .
City of Bremerton Under 65 LEOFF I Retirees Page 33
Benefits Booklet
If the preceding rules do not determine the order of benefits, the Allowable Expenses must be shared
equally between the Plans meetmg the definition of Plan In addition, this Group Plan wdl not pay more
than it would have paid had it been the Primary Plan
Effect on Benefits
When KPS is the Secondary Plan, we may reduce our benefits so that the total benefits paid or provided
by all Plans dunng a claim determination period are not more than the Total Allowable Expenses in
determming the amount to be paid for any claim, the Secondary Plan must make payment in an amount
so that, when combined with the amount paid by the Pnmary Plan, the total benefits paid or provided by
all Plans for the claim equal 100% of the Total Allowable Expense for that claim In addition, the
Secondary Plan must credit to its Plan Deductible any amounts it would have credited to its Deductible in
the absence of other health care coverage
Right to Recerve and Release Information
Certain facts about health care coverage and services are needed to apply these COB rules and to
determine benefits payable by KPS and other Plans KPS may get the facts it needs from, or give them
to, other organizations or persons for the purpose of applymg these rules and determining benefits
payable by KPS and other Plans covering the person claiming benefits KPS does not need to tell, or get
the consent of, any person to do this Each person claiming benefits under this Group Plan must give
KPS any facts it needs to apply those rules and determine benefits payable
Facility of Payment
Whenever another Plan makes payments that should have been provided under this Group Plan and in
accordance with this COB provision, KPS may, at its sole discretion, choose to reimburse the Plan
making such other payments in the amount necessary to satisfy the intent of this COB prowsion Any
amount paid under this subsection shall be considered as benefits paid under this Group Plan, and KPS
shall be fully discharged from liabdity to the extent of such payments
Right of Recovery
KPS has the right to recover excess payment whenever it has paid Allowable Expenses in excess of the
maximum amount of payment necessary to satisfy the intent of this provision KPS may recover excess
payment from any person to whom, or for whom, payment was made or any other issuers or Plans
Notice to Enrollees
If you are covered by more than one health benefit plan, and you do not know which is your Pnmary Plan,
you or your Provider should contact any one of the Plans to verify which Plan is primary The Plan you
contact is respons�ble for working with the other Plan to determine which is primary and wdl let you know
within thirty calendar days
NOTE All Plans have timely claim �ling requirements If you or your Provider fail to submit your claim to a
Secondary Plan within that Plan's claim filing time limit, the Plan can deny the claim If you experience
delays in the processing of your claim by the Primary Plan, you or your Provider wdl need to submit your
claim to the Secondary Plan within its claim filing time limit to prevent a denial of the claim
To avoid delays in claims processmg, if you are covered by more than one Plan, you should promptly
report to your Providers and Plans any changes in your coverage
Addit�onal Information
If you would like additional information regardmg COB provisions, you may contact the Office of the
Insurance Commissioner toll-free at 1-800-562-6900 '
Page 34 City of Bremerton Under 65 LEOFF I Retirees
Bene�ts Booklet
KPS'S RIGHT OF REtMBURSEMENT AND SUBROGATION
The benefits of this Plan will be avadable to you for inJury or dlness caused by another party, sub�ect to
the exclusions and limitations of this Plan If KPS provides Plan benefits for the treatment of the m�ury or
dlness, KPS will be subrogated to any rights that you may have to recover compensation or damages
related to the in�ury or illness You and your representative(s) must cooperate fully with KPS m protectmg,
preservmg, and recovering the amounts KPS has paid, or wdl pay, on your behalf under this Group Plan
if you obtain a settlement or award that includes the recovery of inedical expenses paid by KPS as Plan
benefits for your �n�ury or �Ilness, you agree to reimburse KPS for the full amount of benefits paid after you
have been fully compensated for your loss, sub�ect to the followmg additional agreements
a You and/or your attorney or representative agree to provide KPS, in writing, the detads of the
m�ury or illness, the names and addresses of the party or parties believed to be responsible,
and any insurer who may offer coverage, and any other mformation reasonably necessary to
protect KPS's subrogation rights
b You agree to inform the responsible third party(ies) and any insurer(s) and attorneys of the
amount of the lien asserted by KPS for payments made on your behalf
c You agree to submit the bdis relatmg to your in�uries or dlness to any insurer who may offer
coverage for them, mcluding, but not limited to, medical payments coverage, personal m�ury
protection (PIP), or other plans or contracts providmg for a benefit or recovery
d You agree to make a claim against, or otherwise pursue recovery from, ali responsibie parties
and their msurers for all payments advanced to you, or your medical care Providers, by KPS, or
to assign to KPS all of your rights to a recovery, authorize KPS to bring suit in your name and to
fully cooperate in the presentation of the claim(s) �
e You agree to mclude m any claim or lawsuit on your behalf, agamst any other party or msurer, a
claim for repayment of the Plan benefits paid, or to be paid, by KPS on your behalf `
f You agree to give KPS reasonable notice in advance of any settlement, mediation, arbitration
or trial relatmg to the m�ury or illness
g You agree not to enter into any agreement with any responsible party(ies) or insurer(s), or do
anything else that would m any way release KPS' lien or pre�udice our subrogation or
reimbursement rights, without first obtaming express prior written consent from KPS
h You agree, if requested, to hold m trust and to execute a trust agreement m the full amount of
the Plan benefits provided to you from any recovery, until such time as a final determmation or
settlement has been reached regarding the amount that fully compensates you for your loss to
protect the r�ghts of KPS as descnbed m this section
When you have cooperated as set out above, and you are represented by an attorney, KPS agrees to
reduce the amount of its subrogated interest in Plan benefits in consideration of your attorney's fees and
costs, based on the services provided and recovery obtamed In no case will KPS pay a larger share of
fees and costs, as a percentage of its recovery, than you pay as a percentage of your recovery
Collection and Reimbursement by Enrollee
If you obtain a settlement or award that mcludes payment for the medical expenses covered by KPS as
Plan benefits, you agree to reimburse KPS for these benefits, unless the amount you recover fails to fully
compensate you KPS may recover its benefit payments from you only after you have been fully
compensated Whether or not you have been fully compensated will be determmed ob�ectively, based on
the facts of your recovery
City of Bremerton Under 65 LEOFF I Retirees Page 35
Benefits Booklet
Underinsured or Uninsured Motorist Coverage
In addition to the agreements set out above, when you recover benefits under any automobde uninsured
or underinsured motorist (UIM) coverage, KPS shall be entitled to reimbursement from your recovery for
any amount that exceeds full compensation for your loss By providing Plan benefits, KPS is not acting as
a volunteer, and is not waiwng any rights to reimbursement or subrogation When you have cooperated
as set out above, and you are represented by an attorney, KPS agrees to reduce the amount of its
reimbursement or subrogation interest in consideration of your attorney's fees and costs, based on the
services provided and recovery obtained In no case will KPS pay a larger share of fees and costs, as a
percentage of its recovery, than you pay as a percentage of your recovery
Cooperation
You and your representative(s) must deal in good faith with KPS and follow all of the conditions set forth
in this section In turn, KPS agrees to cooperate with you and your representative(s) in your effort to
recover reimbursement and wdl advance payments on your behalf for in�uries or medical conditions
caused, or asserted by you to be caused, by any third party, sub�ect to the limitations and exclusions of
this Plan Fadure to cooperate may result m a delay or denial of otherwise eligible claims unttl the
requested action or mformation is provided to KPS
Recovery of Claims Payments
Inel�g�b/e Persons
If KPS knowingly or unknowmgly makes any payment on behalf of an individual who, for any reason, was
not eligible to receive the services and benefits provided here�n, KPS will be entitled to full reimbursement
from such ineligible individual or from a Subscriber who applied for the ineligible benefits on behalf of
such individual
If KPS knowingly or unknowmgly receives Premium payment on behalf of an individual who, for any
reason, was not eligibVe to receive the services and benefits provided herein, KPS reserves the right to
refund any Premium payment(s) in excess of claims paid for the time the individual was ineligible and
shall have the right to recover the cost of any benefit furnished whde such individual was improperly
enrolled in this Group Plan
NOTE This section does not apply to services and benefits for which you or your Provider received prior
authorization from KPS Health Plans
Incorrect C/a�m Payment
KPS is entitled to full reimbursement from the payee for any incorrect claim payment The term "incorrect
claim paymenY' includes, but is not limited to, the following
➢ Payment to the wrong Provider
➢ Payment for a senrice that is not covered
➢ Duplicate payment for the same service
➢ Incorrectly billed procedure or diagnosis
Page 36 City of Bremerton Under 65 LEOFF I Retirees
Benefits Booklet
COMPLAINTS AND APPEALS PROCESS
KPS wdl comply with any new requirements as necessary under federal laws and regulations The most
current information about your Appeals process is available on our Web site at www kpshealthplans com
or by contacting Member Services at 360-478-6796 or toll-free at 1-800-552-7114
If You Have a Complaint
You, or your designated representative, have a right to contact KPS whenever you have a complaint or
concern regardmg
➢ The service you receive from KPS
➢ Your access to care or quality of care
➢ Any KPS Participating Provider
➢ Any other issue related to this KPS Plan or KPS
KPS Customer Service is avadable to help you Monday through Friday, from 8 00 a m until 5 00 p m
Pacific Time, except on nationally recognized holidays
To file a complamt, follow the steps outlmed below
You must: Send a written statement of your complaint to
KPS Health Plans
Attn Customer Service
PO Box 34802
Seattle, WA 98124-1803
Fax 360-415-6514
OR
Call the Customer Service Department at 360-478-6796 or toll-free at 1-800-552-7114
For the deaf and hearing impaired, call TTY toll-free at 1-800-833-6388
KPS resolution. KPS will respond to a complaint withm 30 days of receivmg it If you call KPS
Customer Service with a complamt, they will respond to your complaint over the phone Complaints
received in writing wdl be acknowledged, and you wdl receive a response, in writing, from KPS
Customer Senrice
Complamts about Participatmg Providers are investigated thoroughly and are reviewed periodically
Standard Appeals Process
Whenever KPS makes a decision regarding the denial, reduction or termination of benefits under your
health care coverage, you, your designated representative, or your Provider has a right to appeal that
decision The KPS Standard Appeals Process is progressive and follows specific steps described m this
section The request for an appeal must be received by KPS within 180 days of the date you receive an
Explanation of Benefits (EOB), letter, or other type of communication from KPS that contains an
unfavorable decision
Such decisions could affect
➢ Your eligibility for benefits
➢ Your plan benefits
➢ Termination or rescission of coverage under this Group Plan (except termination for non-payment
of Premium)
➢ Non-payment of a claim, either completely or partially
➢ A denial or modification of a request for pre-authonzation or extended authorization of any health
care service or supply
➢ A denial of a request for coverage of an Experimental or Investigational sennce or supply
City of Bremerton Under 65 LEOFF I Retirees
Page 37
Benefits Booklet
To request an appeal, you, your designated representative, or your Provider may either call or write KPS
at the phone number or address listed below You may include any documentation you feel supports your
position
You must: Send a written statement of your appeal to
KPS Health Plans
Attn Appeals Department
PO Box 34593
Seattle, WA 98124-1593
Fax 1-206-901-7340
OR
Call the Appeals Department toll-free at 1-877-828-4514
For the deaf and hearing impaired, call TTY toll-free at 1-800-833-6388
First Level Appeal
The Appeals Department will notify you, in writing, within five (5) business days that we have received
your request and will process it under a First Level Appeal The First Level Appeal is an informal review of
all mternal and submitted mformation and is conducted by the appropriate staff KPS will send you the
decision from the First Level Appeal withm 14 calendar days of receiving your request for appeal KPS
may extend the review to 30 calendar days with notification to you, but may not extend beyond 30
calendar days without your approval KPS will respond to denials of Experimental and/or Investigational
Procedures or Supplies within 20 working days You have the right to send your appeal directly to an
Independent Review Organization (IRO) described below if KPS provides you with an unfavorable
decision of your First Level Appeal or if KPS does not adhere to this First Level Appeals Process
"Adverse Determmation" means a decision by KPS to deny, modify, reduce, or terminate payment,
coverage, authorization, or provision of health care services or benefits, including the admission to, or
continued stay in, a facdity
Independent Review Organization (IRO)
You have the nght to request that KPS send an unfavorable First Level Appeal decision to an
Independent Review Organization (IRO) consisting of non-affiliated medical experts and/or medical
coverage agreement specialists who are qualified to review your case This right is only available after
exhausting the First Level Appeal process or if KPS does not adhere to the Standard Appeals Process
You may request review by an IRO within 180 days from the date you receive an unfavorable decision of
the First Level Appeal or the optional Second Level Appeal as described below KPS will provide the IRO
all of your case information within three (3) business days from the date of your request You have five (5)
business days, from the date you receive notice that your appeal was sent to an IRO to submit in writing,
directly to the IRO, any additional information to be considered in the review KPS wdl pay the IRO fee
The IRO will notify you and KPS of their decision The IRO decision is final If the IRO overturns our First
Level Appeal or optional Second Level Appeal decision, KPS will promptly comply and notify you
You may request an expedited external review if the decision regarding a KPS denial of benefits concerns
an admission, avadability of care, continued stay, or health care service for which you received
emergency services but have not been discharged from a facdity, or involves a medical condition for
which the standard external review time frame of forty-five days would seriously �eopardize your life or
health or�eopardize your ability to regain maximum function The IRO must make its decision to uphold or
reverse the decision and notify you and KPS of the determination as promptly as possible but within not
more than seventy-two hours after the receipt of the request for expedited external review If the notice is
not m writing, the IRO must provide written confirmation of the decision within forty-eight hours after the
date of the notice of the decision
Page 38 City of Bremerton Under 65 LEOFF I Retirees
Benefits Booklet
For claims mvolving expenmental or investigational treatments, the IRO must ensure that adequate
clmical and scientific experience and protocols are taken into account as part of the external review
process
Second Level Appeal (OPTIONAL)
If you do not agree with KPS's First Level Appeal decision, you may request an optional Second Level
Appeal by the KPS Appeals Committee prior to requestmg review by an IRO as descnbed above Your
Second Level Appeal request must be received by KPS withm 180 days from receivmg an unfavorable
decision of the First Level Appeal Your case wdl be rewewed by members of the committee, including
medical staff who did not make the First Level Appeal decision, within thirty (30) busmess days of your
request KPS wdl notify you, in wnting, of the Second Level Appeal decision within five (5) busmess days
after the KPS Appeals Committee meetmg
If you elect this optional Second Level Appeal, you stdl have the right to appeal further to an IRO if the
Second Level Appeal decision is not m your favor
The optional Second Level Appeal is not avadable if the appeal request is for an Experimental or
Investigational procedure or service
Expedited Appeals Process
If your health care Provider, or the KPS Medical Director, reasonably determmes that following the
Standard Appeals Process would �eopardize your life, your health, your ability to regain maximum
function, or sub�ect you to severe pain that cannot be managed adequately without the requested care or
treatment, KPS will invoke an Expedited Appeals Process This means KPS wdl make a decision within
72 hours after your request for appeal is received if KPS expedites your appeal, you wdl receive notice of
this action
Appeais Related to Continuation of Care
KPS wdl contmue to provide coverage for services and supplies for ongomg care that KPS denied,
reduced, modified, or terminated until the appeals process is complete However, if the final outcome
supports KPS's decision, you may then be responsible for any costs that were mcurred for the
continuation of that care
For more information regarding the appeals process and your rights during an appeal, please contact the
Appeals Department toll-free at 1-866-458-5479 For the deaf and hearing impaired, call TTY toll-free at
1-800-833-6388
ENROLLEE RIGHTS
KPS Privacy Policy
KPS is committed to protectmg the privacy of your personal and health information We are required by
applicable federal and state law to maintam the pnvacy of your personal and health mformation KPS also
is required to give you this notice to tell you how we may use and give out ("disclose") your personal and
health information held by KPS
Personal and health information (referred to m this notice as "personal information") means any
information that is identifiable to you as your personal information, mcludmg mformation regardmg your
health care and treatment, identifiable factors, such as your name, age, and address, or financial
information
City of Bremerton Under 65 LEOFF I Retirees Page 39
Benefits Booklet
We may collect personal information about you, or members covered by KPS through you, from the
followmg sources
➢ Information we receive from you, including information you provide on applications or other forms
➢ Information we receive from your health care Providers or other companies (e g, other health
insurance comparnes, relating to your medical claims and bdlings
➢ General information about the health care services you have received, such as the quality and
availabdity of services
We restrict access to personal information about you to only those who need to know that mformation to
provide treatment, payment, or health care operations services to you We maintain physical, electronic,
and procedural safeguards that comply with federal regulations to guard your personal information
We do not disclose any personal information about our members or former members to anyone, except
as permitted or required by law, however, KPS will use and give out your personal health information
➢ To you or someone who has the legal right to act for you (your personal representative) or close
famdy relative mvolved in your care or responsible for the payment of your services
➢ To the Secretary of the Department of Health and Human Services, if necessary, to make sure
your privacy is protected
➢ To law enforcement officials when investigating and/or prosecuting alleged civd or crimmal
actions
➢ Where required by law
KPS has the right to use and give out your personal mformation to arrange for treatment, payment, and
health care operations services, including
➢ Medical quality reviews
➢ Accounting
➢ Legal and risk management services
KPS may use or give out your personal information for the followmg purposes under limited
circumstances
➢ For government health care oversight activities, such as fraud and abuse investigations
➢ To avoid a serious and imminent threat to the health or safety of you or the public
By law, KPS must have your written permission (an "authorization") to use or give out your personal
information for any purpose that is not set out in this notice You may take back ("revoke") your written
permission at any time, except if KPS has already acted based on your permission
By law, you have the right to
➢ See, and get a copy of, your personal information held by KPS, except in certain limited
situations
➢� Make a reasonable request in wnting to amend any of your personal mformation created by KPS
if you believe that it is wrong, or that information is missing, and KPS Health Plan agrees If KPS
disagrees, we wdl notify you why m writing You may have a statement of your disagreement
added to your personal information
➢ Get a listing of those obtaining your personal information from KPS in the past six (6) years The
listing wdl not include information that
o Was given to you or your personal representative or close famdy relative mvolved in your
care or payment of such care
o You authorized KPS to release
o Was given out for law enforcement purposes
o Was given out to pay for your health care claim or a disputed claim
➢ Request in wnting that KPS commurncate with you in confidence about your personal information
by alternative means or to an alternative location If you advise us that disclosure of all or any part
of your personal information could endanger you, we must comply with any reasonable request
provided it specifies an alternative means or location
Page 40 City of Bremerton Under 65 LEOFF I Retirees
Bene�ts Booklet
➢ Ask KPS to place additional restrictions on our use or disclosure of your personal information for
treatment, payment, health care operations, or to persons you identify We are not required to
agree to these additional restnctions and wdl notify you about the reasons regarding this act�on If
we do agree to the additional restrictions, we wdl abide by our agreement, except m an
Emergency
➢ Get a separate electronic or paper copy of this notice
For more information about exercismg your rights set out m this notice, contact KPS's Customer Service
department at 360-478-6796 or toll-free at 1-800-552-7114 You also can reach KPS's privacy official for
this purpose toll-free at 1-800-552-7114
If you believe KPS has violated your privacy nghts set out in this notice, you may file a complamt with
KPS at the following address
KPS Health Plans
Compliance Department
P 0 Box 34803
Seattle, WA 98124-1803
Fding a complaint wdl not affect your benefits under KPS You also may file a complamt with the
Secretary of the Department of Health and Human Services
KPS does have the right to change the way your personal information is used and given out If KPS
makes any changes, you wdl get a new notice by mad withm 60 days of the change, and that notice will
become effective on the date the revised notice is issued
NOTE Telephone calls to and from KPS may be recorded for quality assurance and traming purposes
If you are the primary Subscriber with KPS and other persons are covered by KPS through you, we
suggest that you share this mformation with each other to ensure that each of you is aware of our policy
and your privacy rights
Please refer to KPS's Web site at www KPSHealthPlans com for more information about our privacy
practices
Disclosure of Information
By law, you have the right to rece�ve mformation about KPS, as well as your KPS Group Pian and how it
works Most of this information is provided to you when you enroll, however, other information is avadable
only upon request Please refer to the Your Access to Information section at the end of this Benefits
Booklet
Statement of ERISA Rights
As a participant in this Group Plan you are entitled to certam nghts and protections under the Employee
Retirement Income Security Act of 1974 (ERISA) ERISA provides that all Group Plan participants shall
be entitled to
➢ Examination, without charge, at the Group Plan Administrator's" office and at other locations, of
all Group Plan documents, including insurance contracts, collective bargaining agreements, and
copies of all documents filed by the Group Plan with the U S Department of Labor, such as
detaded annual reports and Group Plan descnpt�ons "*
➢ Obtain copies of all Group Plan documents and other Group Plan information upon written
request to the Group Plan Administrator The Group Plan Administrator may make a reasonable
charge for the copies
➢ Receive a summary of the Group Plan's annual Form 5500 report The Group Plan Administrator
is required by law to furnish each participant with a copy of this summary annual report **
In addition to creating rights for Group Plan pa�ticipants, ERISA imposes duties upon the people who are
responsible for the operation of the employee benefit plan The people who operate your Group Plan,
called Group Plan Fiduciaries", have a duty to do so prudently and in the mterest of you and other Group
Plan participants and beneficiaries No one, including your Employer, your union, or any other person,
City of Bremerton Under 65 LEOFF I Retirees Page 41
Benefits Booklet
may fire you or otherwise discriminate agamst you in any way to prevent you from obtaining a welfare
benefit or exercising your rights under ERISA If your claim for a welfare benefit is denied in whole or in
part, you must receive a wntten explanation of the reason for the denial and copies of documents relating
to the decision without charge You have the right to appeal the denial within certain time schedules
Under ERISA, there are steps you can take to enforce the above rights For instance, if you request
materials from the Group Plan Administrator and do not receive them within 30 days, you may file a suit in
federal court in such a case, the court may require the Group Plan Admmistrator to provide the materials
and pay you up to $110 a day, untd you receive the materials, unless the materials were not sent because
of reasons beyond the control of the Group Plan Administrator If you have a claim for bene�ts that is
denied or ignored, m whole or m part, you may file a suit m a state or federal court If it should happen
that the Group Plan Fiduciaries misuse the Group Plan's 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 successful, the
court may order the person you have sued to pay these costs and fees If you lose, the court may order
you to pay these costs and fees, (e g, if it finds your claim is frivolous) if you have questions about your
Group Plan, you should contact your Group Plan Administrator If you have any questions about this
statement or about your rights under ERtSA, you should contact the nearest Area Office of the U S
Labor-Management Services Administration, Department of Labor listed in your telephone directory
''Contact your Employer to identify your "Group Plan Administrator" and "Group Plan Fiduciaries "
*"Certain small Employers are not required to file these reports
Women's Right to Direct Access
KPS and Washington State laws have established standards to ensure women's right to directly access
timely, appropnate, and Medically Necessary covered women's health care services, without the
necessity of prior referral from another Provider Covered women's health care services include maternity
care, reproductive health services, gynecological care, general examination, preventive care, and follow-
up visits, when provided by a licensed physician (M D or D 0), a physician's assistant (P A), an
advanced registered nurse practitioner (A R N P) specializing in women's health care or midwifery, or a
licensed midwife, and any Participating Facility used by such Providers
If you would like a more detailed description than is provided above regarding women's right to direct
access under this Group Plan, or you have questions or concerns about any aspect of your women's
health care benefits, please contact KPS at 360-478-6796 or toll-free at 1-800-552-7114
Your Right to Safe and Effective Pharmacy Services
KPS and Washington State have established standards to ensure safe and effective pharmacy services,
to guarantee your right to know what drugs and medications are covered under this Group Plan, and to
understand the limitations of your pharmacy coverage under this Group Plan If you would like a more
detaded description than is provided above regarding your pharmacy benefits, please contact KPS at
360-478-6796 or toll-free at 1-800-552-7114
If you would like to know more about your nghts under the law or if you thmk the information you have
received from KPS does not conform to the terms of your Group Plan, or your rights under the law, you
may contact the Office of the Insurance Commissioner toll-free at 1-800-562-6900 If you have a concern
about the pharmacists or pharmacies serving you, please call the Washington State Department of Health
at 360-236-4825
Page 42 City of Bremerton Under 65 LEOFF I Retirees
Benefits Booklet
HOW YOU CAN STOP HEALTH CARE FRAUD
KPS is committed to meeting your health care needs at an affordable pnce Because fraud mcreases
health care expenses, it ultimately results m higher Premiums Beyond financial losses, fraudulent health
care practices can threaten your health and safety
KPS is dedicated to controlling expenses and protecting our Enrollees We are actively fighting health
care fraud and want to increase your awareness of how to combat potential fraudulent acts and
situations Precautions you may take include, but are not limited to, the following
➢ Beware of "free" medical treatment offers
➢ Beware of people offering money to you if you agree to have medical procedures done (possibly
unnecessary and dangerous to your health)
➢ Be wary of people requesting that you travel to other states for medical procedures
➢ Protect your health insurance mformation and do not give it out to solicitors or to people over the
telephone without ensurmg that person has the "right to know"
➢ Avoid using health care Providers who say that a service is not usually covered, but they know
how to bill us to have it paid
➢ Review your Explanation of Benefits (EOB) form to assess the accuracy of the claims payment
information As an example, fraud may appear on an EOB as charges for tests or procedures you
did not have
➢ Remember, if somethmg sounds too good to be true, it likely is
➢ Ensure that only qualified famdy members are enrolled with you on the health plan
➢ Participating in health care fraud is dlegal and dangerous
Your continued health is our goal If you suspect health care fraud, please contact the KPS Fraud Hotline
at 888-475-2366 or https //kpsfraudcomqliancehotlme alertlme com to explain the circumstances
City of Bremerton Under 65 LEOFF I Retirees Page
Benefits Booklet
DEFINITIONS
�° o .
Accidental In�ury Any boddy inJury caused by an unexpected occurrence mdependent of
disease or bodily infirmity
Approved Treatment Program A discrete program of chemical dependency treatment provided by a
treatment program certified by the Washington State Department of
Social and Health Services, in compliance with RCW 70 96A 020(3)
Benefits Booklet The document that describes the terms and conditions applicable to this
Group Plan, as well as the benefits provided herein
Calendar Year The 12-month penod beginning January 1 and ending December 31
Coinsurance The dollar amount of the KPS allowed expense that you pay to your
Provider This amount is usually expressed as a percentage on
applicable benefits
Coinsurance Maximum The maximum amount you pay for Coinsurance �
Copayment An amount you are required to pay your Provider at the time of service
Covered Benefits and Services Those Medically Necessary services listed in this Benefits Booklet that
an Enrollee is entitled to receive
Deductible The amount you and/or your family are required to pay out-of-pocket
each Calendar Year before KPS pays for your Medically Necessary
Covered Benefits and Services
Emergency (or Medical A sudden and acute onset of a symptom or symptoms, includmg severe
Emergency) pain, that would lead a prudent layperson, acting reasonably, to believe
that a health condition exists that requires immediate medical attention if
failure to provide medical attention would result m serious impairment to
boddy functions or senous dysfunction of a boddy organ or part, or would
place the person's health in serious �eopardy
Endorsement An amendment to the conditions of coverage or the benefits provided by
this Group Plan
Enrollee A Subscriber enrolled in this Group Plan who is entitled to the benefits
provided herein
Essential Benefits Benefits covered under this Group Plan, in at least the following
categories ambulatory patient services, emergency services,
hospitalization, maternity and newborn care, mental health and
substance use disorder services, including behavioral health treatment,
prescription drugs, rehabilitative and habilitative services and devices,
laboratory services, preventative and wellness services and chronic
disease management and pediatnc services, including oral and vision
care Such benefits shall be consistent with those set forth under the
Patient Protection and Affordable Care Act of 2010 and any regulations
issued pursuant thereto For further detads about these services, please
visit our website at www kpshealthplans com or contact our Member
Services Department at 360-478-6796, or toll-free at 1-800-552-7114
Page 44 City of Bremerton Under 65 LEOFF I Retirees
Benefits Booklet
e .
Experimental or Investigational Medical or surgical treatments or procedures, drugs or drug use, medical
equipment, devices or supplies, or facilities (collectively referred to as
� "services") are considered to be Expenmental or I nvestigational if
➢ The services are not in general use m the Washington State
medical community
➢ The services pose a significant risk to the health or safety of the
patient
➢ The services are under continued scientific testmg and research
under Phase i or Phase II clmical trials
➢ The services are under the research, experimental, study or
� investigational arm of a Phase III clmical tnal
➢ Rel►able ewdence has not shown that the services result m greater
benefits for a particular dlness or disease than other generally
available services
➢ Reliable evidence has not shown that the senrices are safe or
effective, or have any demonstrable benefit for a particular dlness or
disease
For purposes of this definition, reliable ev►dence means published
reports and articles in authoritative medical and scientific literature,
published evaluations of national medical associations and medical
consensus panels, written protocols used by the treating facdity or other
facilities that are studymg substantially the same service as the treating
facdity, or wntten informed consent notices used by the treating facility or
other facilities studying substantially the same service as the treating
facility
Group The employer, association or other entity that has entered mto this
Group Plan on your behalf
Group Plan Administrator Your employer's Human Resources Department, or any other person or
company designated by your employer to admmister this Group Plan on
behalf of the Group's Employees
Group Plan This Benefits Booklet plus any Riders, Endorsements, or other
attachments that state the terms and conditions for admmistration of
your benefits
Hospital A hospital that is accredited by the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) or licensed by the state m which it is
located ,
KPS KPS Health Plans is a health care services contractor licensed to market
and sell health care coverage plans in Washmgton State KPS was
formerly known as Kitsap Physicians Service
LEOFF I Employee A full-time law enforcement officer or firefighte� hired prior to October 1,
1977, and who is a member of the LEOFF system as defined in Sections
3 and 4, CH 131, Law of 1972, 1� Ex Session
Medical Director The licensed physician acting as chief inedical advisor for KPS
Medical Emergency See Emergency
City of Bremerton Under 65 LEOFF I Retirees Page 45
r
Benefits Booklet
o• .
Medically Necessary/Medical To be considered Medically Necessary, Covered Benefits or Services
Necessity must meet all of the following cnteria
➢ Be consistent with the symptoms or diagnosis and treatment of the
condition
➢ Be the most appropriate supply or level of service that is essential to
the Enrollee's needs
➢ When applied to an mpatient, it cannot be safely provided to the
Enrollee as an outpatient
➢ Be appropriate with regard to good medical practice
➢ Not be provided pnmanly for the convenience of the Enrollee or the
inpatient facdity
➢ Be the most cost-effective of the alternative levels of service or
supplies that are adequate and available
Non-Participating Provider or Any Provider or Facdity not contracted with KPS, either directly or
Facility indirectly
Open Enrollment Period Generally the calendar month immediately prior to the annual renew�l
date for this Group Plan During the Open Enrollment Period, persons
who did not enroll when they were initially eligible may enroll Coverage
wdl be effective as of the renewal date
Partial Hospitalization A less restnctive type of inpatient care which allows the patient to
receive observation, evaluation, and intense daily therapy but remain at
their home at night and on weekends and holidays
Participating Facility An accredited facdity, which has contracted with KPS, either directly or
mdirectly, to provide health care services to Enrollees Participating
Facdities have agreed to accept the KPS allowance for Covered Benefits
and Services as payment in full, except for Deductible, Copayment and
Coinsurance amounts, which are the responsibility of the Enrollee
Participating Provider A Provider who has contracted with KPS, either directly or indirectly, to
provide health care services to Enrollees Participating Providers have
agreed to accept the KPS allowance for Covered Benefits and Services
as payment in full, except for Deductible, Copayment, and Coinsurance
amounts, which are the responsibility of the Enrollee
Premium A payment made to KPS on a scheduled penodic basis by, or on behalf
of, an Enrollee with the expectation of receiving the Covered Benefits
and Services provided under this Group Plan
Premium Due Date The scheduled, periodic dates by which Premium payments must be
received by KPS as a condition for continued enrollment in this Group
Plan This date is the first day of each month of coverage
Page 46 City of Bremerton Under 65 LEOFF I Retirees
Benefits Booklet
{ � g .�, �� « � �� � , $ � ,�,ri �; � -� s � �
° "� Y "� � �P�'�a,�i 3 `�a � � � � v�� '�l'is*' .�.e ..��s,..1 de� ° "u. tl i m a 4`e � �;,.
Provider Any one of the following licensed or certified health care practitioners
acting within the scope of their license or certificate
Chiropractor Physical Therapist
Dentist Physician (M D or D O)
East Asian Medicine Practitioner Physician's Assistant (P A)
Massage Therapist Podiatrist
Naturopath (N D ) Psychologist
Nurse Midwife Speech Therapist
Occupational Therapist
Certified Chemical Dependency Provider
Certified Mental Health Provider
Advanced Registered Nurse Practitioner (A R N P)
NOTE This list does not include all types of Providers covered by KPS
If your Provider type is not listed above, please call KPS toll-free at
1-800-552-7114 to request more mformation
Residential Mental Health A facdity that provides 24-hour treatment, services, and supervision for a
Facility mental health condition in a non-acute settmg
Rider An additional benefit over and above those listed m the Benefits
Summary section Rider documents are attached at the back of the
Benefits Booklet and provide detailed benefit information
Skdled Nursmg Facility (SNF) A facdity, or the distmct section of a facdity (such as a wmg of an
accredited general Hospital), that is licensed primardy to provide skdled
nursmg care and related services, or rehabilitation services, on a
24-hour basis The facdity must employ at least one registered nurse
(R N) who is on full-time duty and one physician who is avadable to
provide necessary medical care in the event of an Emergency
Subscriber An eligible employee who is enrolled m this Group Plan, or any other
eligible person, who is the prmcipal Enrollee in this Group Plan
City of Bremerton Under 65 LEOFF I Retirees Page 47
CONTACT US
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Page 48
Benefits Booklet
KPS Health Plans is located at:
400 Warren Avenue
Bremerton, WA 98337
For KPS Customer Service, please call:
360-478-6796
1-800-552-7114 (toll-free)
For the deaf & hearing-impaired call
TDD 360-478-6849
� 1-800-420-5699 (toll-free)
Send inquiries, claims or compla�nts to:
KPS Health Plans
PO Box 34803
Seattle, WA 98124-1803
Fax inqwries to 360-415-6514
Send e-mail inquiries to:
info@kpshealthplans com
Ciry of Bremerton Under 65 LEOFF I Retirees
Your Access to Information
As a member of KPS Health Plans, you have the right to receive certain information about KPS, about your plan
benefits, and about how to access benefits When you enroll, KPS gives you documents or access to resources,
which contain this important information In order to ensure you get the highest possible benefit from your Group
Plan, you should read/access this information prior to seeking care from your Provider If you have lost or
misplaced any of the documents, please contact KPS Customer Service, and we wdl send you a new copy
Document/lnformat�on: Contains:
Benefits Booklet Information regarding
✓ Covered Benefits and Services
✓ Exclusions, reductions, and limitations to Covered Benefits and Services
✓ Amounts you are required to pay for your care, including
- Individual and family Deductibles
- Copayments
- Coinsurance
- Maximum annual out-of-pocket costs
✓ Pre-authorization requirements for certain services
✓ Requirements for specialty care
✓ Complamt and appeals process
✓ KPS's olic re ardm the disclosure of our ersonal health information
Access to Provider Information regarding the following can be found at www kqshealthqlans com or by
Directories calling KPS Customer Service at 360-478-6796 or toll-free at 1-800-562-7114
✓ Nefinrork primary care Providers
✓ Network specialty Providers
✓ Network harmacies If our Grou Plan covers rescri tion dru s
Access to Prescription Drug Information regarding the following can be found at www kqshealthplans com or by
Formulary calling Medlmpact toll-free at 1-800-788-2949
✓ Drugs covered by your Group Plan
✓ Copayment amounts you are required to pay when you have a prescription
filled
✓ How often drugs are added to, or removed from, the list and where you can get
more information
Pharmacy Questions and Information regarding the followmg can be found at www kqshealthplans com or by
Answers calling Medlmpact toll-free at 1-800-788-2949
✓ KPS drug formulary
✓ Covered and excluded drugs
✓ Drug substitutions
✓ How Copayments are determined
✓ Where to et a listin of network harmacies
For More Information:
KPS also provides the following information to its members on request
❖ General information regarding the types of plans offered by KPS
❖ How KPS pays its network Providers for the care you receive
❖ An accounting of the payments KPS has made, which have been credited to your annual Deductible or
used to calculate any service limitations or maximums
❖ KPS's accreditation status and any publicly reported health employer data information set (HEDIS) data
If you would like a copy of any of the referenced information, please contact KPS Customer Service at
360-478-6796 or toll-free at 1-800-552-7114
If you wish, you may send a written request for information to
KPS Health Plans
P O Box 34803
Seattle, WA 98124-1803