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KPS HEALTH PLANS
Coverage Contract - Plan A
Human Resources
LEG 12-1
1/1/2014
1/1/2015
2015
Comments :
KPS Health Plans
Business Address:
400 Warren Avenue
Bremerton, WA 98337
CITY OF BREMERTON — PLAN A
COVERAGE CONTRACT
Group Number:
Effective Date:
Contract Renewal Month
Open Enroliment Period:
This Coverage Contract includes the following:
Attachment A:
Attachment B:
Benefits Booklet
1000780
January 1, 2014
January
December
Premium Rates and Underwriting 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 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 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').
C14BREMA
TABLE OF CONTENTS
DEFINITIONS................................................................................................................................1
CONTRACT EXAMINATION PERIOD .................................................................................................3
EFFECTIVE DATE, DURATION, AND RENEWAL .................................................................................3
PREMIUM PAYMENT PROVISIONS ...................................................................................................3
Payment Due Date/Grace Period .......................................... ..................................... .................... ...... 3
PremiumRate Adjustments ............... . . .............................................................. ................................... 3
Premiums Paid by Subscnbers/Dependents ............................................ .................. ............................ 4
PremiumRefunds . ..................... .. ......................... ........................................... .................................... 4
ELIGIBILITY AND ENROLLMENT .......................................................................................................4
GroupEligibility .............. . .............................. . .................... .. ................. .... ...................... ................. 4
Subscriber/Dependent Eligibility Requirements ............. ......................................................................... 4
Eligibility of Newborn and Adopted Children ........................................................................... ................ 4
Court-ordered Coverage for Eligible Dependent Children .... .. .................... ... ...................................... 5
Enrollment Reporting Requirements .. . .......................... .. .............................. ................. . .. ............... 5
EnrollmentTimeframes ........... .............................. .. .............................. ...................... .. ...................... 5
WhenCoverage Begins ......................... . . . ......................... ............................... ........................ ......... 5
CoverageWaiting Penods .............................. ...................................................................................... .. 6
TERMINATION OF COVERAGE .........................................................................................................6
Continuityof Coverage ... . ....................................................................................................................... 6
Termination or Rescission of Contract ............ ............................... ...... ................................................. 6
Termination or Rescission of Enrollee Coverage .................. .................................................................. 7
COBRA (Consolidated Omnibus Budget Reconciliation Act - 1985) ....................................................... 8
FraudulentInformation ................................................. ............................ . .. ............................. .. . ....... 8
Re-Enrollment/Reinstatement .................................................................................................................. 8
SUBSCRIBER/DEPENDENT LIABILITY AND RIGHTS ...........................................................................8
SubscribeNDependentLiability ................................................................................................................. 8
GENERAL TERMS AND CONDITIONS ...............................................................................................9
ApplicableLaw .......................................................................................................................................... 9
Assignmentof Benefits ........ ...................................... .. ............................ .... .......................... ............. 9
BindingAgreement ....... ....................... .... . .... . ........................................................... .. ...................... 9
Confidentiality ............... .... .. ...................................... ..................... . . ..... . .. ....................... . ............. 9
ContractModifications ..... ...................................... .. .............................................................................. 9
CoverageLimits ....................... ............................................ ............................ . .............................. ..... 9
EntireAgreement ..................... .. ................................................................... ........................... ............. 9
Equityof Application ................................. .............................. .............................. ............................... 10
ForceMajeure ....... . ............................................................................................................................... 10
GroupCooperation ................................................................................................................................. 10
Headings.................. ................................. . . ........................... .. ...................... .... ....... ..................... 10
Notices............................. .. ........................... ....... .......................... .. . .. . .................... . . . . . .......... 10
Severability............ ......................................................................................... ...................................... 10
ThirdParty Beneficiaries ..... . . .... ............................................................................................ ............ 11
Waiverof Breach ............ .... ............................................................... . .. ....................... .... ................ 11
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 children, adopted children, stepchildren or other legally designated ward under the Limiting
Age who is a dependent of the Subscriber or the Subscriber's Spouse.
(ii) 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 child(ren).
(iii) 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
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 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 during which the
Group may renew its coverage each year.
Covered Benefits and Services: those Medically Necessary benefits and services described 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 11 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 Ex. Session.
Endorsement: an amendment to the conditions of coverage or the benefits provided by this Group Plan.
Enrollee: a person enrolled in 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 prior 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 Subscriber. 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 Enrollment Period: the 31-day period or some other period agreed to by both KPS and the Group,
beginning one (1) month prior to the Group's Renewal Month or at some other mutually agreeabie 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 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 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 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 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 examination, the Group is not satisfied w�th 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 af 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.
PREWIIUM 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, during 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 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 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
Underwriting 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 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 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 increases 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 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 Premiums 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 will not exceed an amount equal to three (3) months
of Premium payments.
ELIGIBILITY AND ENROLLWIEIVT
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 in 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 Empfoyees and their
Eligible Dependents are properly enrolled in this Group Plan.
Subscriber/Dependent Eligibility Rec�uirements
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 ofFcer, as defined in the
Definitions section, are also eligible to enroll in this Group Plan.
The children 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 Chddren, and Children placed for adoption are initialfy efigible 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 Chddren must qualify as an Eligible Dependent. If additional Premium 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 Subscriber or Spouse assumes legal obligation for total or partial support in
anticipation of adoption; or (iii) 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 Coverage for Eligible Dependent Children
In the case of court-ordered coveraae, dependent Children become initially eligible on the date the
Subscriber or Spouse receives the order to provide medical coverage for the Child, even �f 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 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
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 beginning 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, including 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 following 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 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 within 31 days of initial eligibility.
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 Enrollment Timeframes) and any applicable Premium amounts have
been paid.
If the Employee enrolls during an Open Enrollment Period, coverage will begin 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 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 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 Children were
adopted, legally placed for adoption, or when the Subscriber or Subscriber's Spouse assumes legal
obligation for total or partial support of the Children in anticipation of adoption, provided that the application
and applicable Premium for the Children are received by KPS within 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.
Page 5
COVERAGE CONTRACT
Coverage Waiting Periods
(This section does not apply to LEOFF I Employees)
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.
Creditable 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 transplant procedures waiting period 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 transplant procedures waiting period. 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 will be given if there was more than a three (3) month break befinreen any 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.
To request a credit to the transplant procedures waiting 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 prior health plan carrier.
➢ The dates of coverage under the prior plan.
➢ Proof of coverage under the prior plan that documents the coverage period(s)
TERMINATION OF COVERAGE
Continuity of Coverage
Continuity 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 fails 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.
Page: 6
COVERAGE CONTRACT
➢ 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 will: (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 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 will
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 will 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 termination or non-renewal of this Contract, KPS shall be responsible for providing the
effective date of termination of coverage to all affected Subscribers and their Eligible Dependents.
Termination or Rescission of Enrollee Coverage
Coverage for an individual 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 obtains 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 offering 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 Subscriber dies.
➢ The Children 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 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 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 will not be eligible to re-enroll in this Group
Plan, until the next Open Enrollment Period. See the Enrollment Under Special Circumstances section of
Attachment A for exceptions to this policy.
Page 7
COVERAGE COMTRACT
COBRA (Consolidated Omnibus Budget Reconcil6ation 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 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 continuation
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 Administrator to provide timely notification to KPS may not, in all cases, eliminate the
Group's obligation to provide continuation coverage. It will, however, eliminate any obligation on the part of
KPS to provide the Enrollee with COBRA continuation coverage under this Group Plan.
Fraudulent Information
tn 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
rescind 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
liability.
Re-Enrollment/Reinstatement
If this Contract has been terminated 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
Accountability Act (HIPAA) of 1996. Any decision to reinstate 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:
➢ 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 a benefit maximum for a specific service or supply has been exhausted.
➢ 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 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 in Attachment A.
What happens if a Provider no longer participates with KPS?
If a Participating Provider chooses to terminate their agreement with KPS, we will notify the affected
Enrollees of the termination. The notification will allow Enrollees at least 60 days to either: (i) complete their
Page: 8
COVERAGE CONTRACT
course of treatment, or (ii) appropriately transfer their care to another Participating Provider. After the 60
days, senrices 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 jurisdiction in Kitsap County, Washington or the U.S. District for the Western District of
Washington
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 Subscriber, their Provider(s), or �ointly, as KPS deems necessary and
appropriate, subject 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 Premium Rate Adjustments 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 reject 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 rejection 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, 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 subject 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— Premium Rates and Underwriting Criteria, constitutes the entire agreement. This
Page 9
COVERAGE CONTRACT
Contract supersedes all previous communications, representations, or agreements, whether verbal or
written, between 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 authority, 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 administration of this Contract by:
➢ Advising 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.
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 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 United 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 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.
Page: 10
COVERAGE CONTRACT
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 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 REIMBURSEMENT AND SUBROGATION
COMPLAINTS AND APPEALS PROCESS
ENROLLEES RIGHTS
➢ KPS Privacy Policy
➢ Statement of ERISA Rights
Page 11
KPS Health Plans
Business Address:
400 Warren Avenue
Bremerton, WA 98337
CITY OF BREMERTON — PLAN A
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, 2014
January
December
Premium Rates and Underwriting Criteria
Mailing Address:
P.O. Box 34803
Seattle, WA 98124-1803
This Contract is entered into and delivered in the state of Washington and is governed by Washington
State laws, except to the extent state laws are preempted by federal law.
Signature by an authorized Group representative or payment of the Premium shall constitute
acceptance of the terms and conditions set forth herein.
FoR KPS:
<�
W. James Page Jr., President
February 28, 2014
FOR GROUP:
� �
Signature
� L�ijllT
A"t�l�
Print Name
/N/�/��
Title
f�2�'�'/� � �, � /`f -
Date
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 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 Participating 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
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
certain 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 in 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 Administration, 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.
B6146REM-A
Table of Contents
ELIGIBILITY AND ENROLLMENT ......................................................................................................1
Who Can Enroll in This Group Plan .........................................................................................1
When to Enroll in This Group Plan ..........................................................................................1
Enrollment Under Special Circumstances ...............................................................................1
Howto Enroll ...........................................................................................................................2
EnrollmentChanges ................................................................................................................2
WhenCoverage Begins ..........................................................................................................2
WhenCoverage Ends .............................................................................................................3
Continuation of Inpatient Coverage .........................................................................................3
Continued Eligibility for Disabled Dependent Children .............................................................4
HOWTHE 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 receiving the following services : ................6
How to Submit Claims for Payment .........................................................................................7
BenefitsManagement .............................................................................................................7
YOUR OUT-OF-POCKET COSTS .....................................................................................................8
Deductible............................................................................................................................... 8
Copayments............................................................................................................................ 8
Annual Coinsurance Maximum ................................................................................................8
BENEFITSSUMMARY ..................................................................................................................1 O
OccupationalInjury Coverage ...............................................................................................14
DESCRIPTION OF COVERED BENEFITS AND SERVICES ..................................................................15
Preventive ....................................................................................................................15
Professional Services ............................................................................................................16
HospitalServices ..................................................................................................................16
Acupuncture Needle Treatment .............................................................................................17
Ambulance Transportation ....................................................................................................17
Anesthesia for Dental Procedures — Not Received in the Dentist Office ................................17
BloodBank ............................................................................................................................17
BoneBank ............................................................................................................................17
CardiacRehabilitation ...........................................................................................................18
Colorectal Cancer Screening .................................................................................................18
Contraceptive Services .........................................................................................................18
Diabetic Education, Equipment, and Supplies .......................................................................18
,
Home Health and Hospice Care ............................................................................................18
KidneyDialysis ......................................................................................................................20
Laboratory and Radiology Services .......................................................................................20
MastectomyCare ..................................................................................................................20
MaternityCare .......................................................................................................................20
Medical Equipment and Supplies ..........................................................................................21
MentalHealth Care ...............................................................................................................22
Neurodevelopmental Therapies ............................................................................................23
NewbornCare ....................................................................................................................... 23
Nutritional Guidance Counseling ...........................................................................................23
OralSurgery ..........................................................................................................................24
Organ, Bone Marrow, Stem Cell and Tissue Transplants ......................................................24
Oxygenand Oxygen Supplies ............................................................................................... 26
Phenylketonuria (PKU) Formulas ..........................................................................................26
Plastic and Reconstructive Surgery .. .......................................................................................26
PrivateDuty Nursing .............................................................................................................26
Rehabilitation........................................................................................................................26
Skilled Nursing Facility Care ..................................................................................................27
Sleep Disorders .....................................................................................................................27
Spinal and Extremity Manipulation ........................................................................................28
Substance Use Disorder Treatment (Chemical Dependency) ................................................28
Termination of Pregnancy .....................................................................................................28
VisionExamination ................................................................................................................28
Women's Health Care Services .............................................................................................29
Pharmacy Benefits ................................................................................................................ 29
LIMITATIONS AND EXCLUSIOMS ...................................................................................................
CONTINUATION COVERAGE ....................................................................................................
Coverage During a Labor Dispute .........................................................................................33
Continuation of Group Coverage ...........................................................................................33
COBRA (Consolidated Omnibus Budget Reconciliation Act - 1985) ...................................... 33
Conversion ............................................................................................................34
COORDINATION OF BENEFITS (COB� ...........................................................................................
GeneralProvision ..................................................................................................................35
Definitions .............................................................................................................................35
Order of Benefit Determination Rules ....................................................................................36
Effect Benefits .................................................................................................................. 38
Right to Receive and Release Information ............................................................................38
Facility Payment ................................................................................................................38
Right Recovery ..................................................................................................................38
Noticeto 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
FirstLevel Appeal .................................................................................................................42
Independent Review Organization (IRO) ...............................................................................42
Second Level Appeal (OPTIONAL) .......................................................................................43
Expedited Process ...................................................................................................43
Appeals Related to Continuation of Care ...............................................................................43
ENROLLEE .....................................................................................................................
KPS Privacy Policy ................................................................................................................43
Disclosure of Information .......................................................................................................45
Statement 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
Bene�ts 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 children 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 following the
date of your initial 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 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 Administrator for more mformation regard�ng eligibility and enrollment.
Enrollment 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 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 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 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 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 Plan A Page 1
�enefits Booklet
Marriage, Birth, Adoption, or Placement for Adoption
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 Vegal obligation for total or partial support of a Child in
anticipation of adoption.
➢ At the next Open Enrollment 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 declined coverage when you were efigible 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 will become effective on the first day of the month
following the effe�tive 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 period,
and you paid the applicable Premium.
If you enrolled during an Open Enrollment Period, your coverage wdl begin on the first of the month
following the Open Enrollment Period.
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 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 must accompany the enrollment application.
Page 2 City of Bremerton Plan A
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 the 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 possibfe to
prevent delays in 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 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.
If you voluntarily disenroll from this Group Plan while still an employee, you will not be eligible to re-enroll
in this Group Plan until the next Open Enrollment Period. Please see the Enrollment Under Special
Circumstances 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 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 transplant procedure waiting period. 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 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 rescinded 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 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-authorized the inpatient 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 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 m 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 similar 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 A Page 3
Benefits Booklet
Continued Eligibility for Disabled Depenc9ent Children
Coverage for an Eligible Dependent Child may be continued after the Child reaches the Limiting Age
provided both of the following 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 within 31 days of the date your Child reaches
the Limiting Age. Thereafter, KPS may require that you resubmit proof of your Child's continuing
dependence. This proof is requested no more frequently than annually after the two-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 Child.
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 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).
F�OW THE GROUP PLAN WORKS
Waiting Periods (Does not apply to LEOFF I Employees)
Transplant 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.
Creditable 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 transplant procedures waiting period 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:
➢ Group health coverage
➢ Part A or Part B of Medicare
➢ Medicaid
➢ Military health coverage
➢ 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.
Page 4 City of Bremerton Plan A
Benefits Booklet
You will receive credit for prior Creditable Coverage if it was continuous and terminated no more than
three (3) months immediately preceding enrollment in this Group Plan. Health coverage will be
considered continuous 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 in 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 in coverage or Creditable Coverage.
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 will 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 facilities, 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 Facilities 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 specialty care; however, therapy services require a prescription as
noted above. As a general rule, you may receive care from any licensed or certified healthcare Provider
or Facility. Your choice of Providers and Facilities will 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
billed by the Non-Participating Provider or Facility and the amount paid by KPS.
In certain instances, 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 right to arrange for your transportation to a
Participating Hospital (see the Emergency Admissions section).
➢ Services Not Available from Participating Providers/Facilities. KPS has the right to determine
whether care and services are, or are not, available from a Participating Provider or Facility. If you
believe the care or service you require is not available from a Participating Provider or Facility,
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 will be covered in full after you have met any
applicable Deductible, Copayment, or Coinsurance.
City of Bremerton Plan A Page 5
Benef6ts �ooklet
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
befinreen the amount paid by KPS and the amount billed by the Non-Participating Provider or Facility. This
is called "balance billing".
What happens if my Provider no longer participates with KPS?
If your Participating Provider chooses to terminate their agreement with KPS, we will notify you of the
termination. The notification will allow at least 60 days to either; (i) complete your course of treatment, or
(ii) 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 Authoriza4ion
NOTE: The following list of services that require prior 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 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 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 information
about services requiring 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 orservice has
been authorized. If your care is Medically Necessary, but your Provider did not get prior authorization
from KPS, payment to your Provider 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 during 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 will make a decision regarding the
authorization within 48 hours of receiving the request. In non-urgent circumstances, both you and your
Provider will be notified of the decision within five (5) calendar days following receipt of necessary
information.
Authorization Extensions
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 Hospital 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 6 City of Bremerton Plan A
Bene�ts Booklet
Emergency Admissions
If you are admitted to the Hospital as a result of an Emergency, you are not required to obtain 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 determine when and if you can be safely transferred to a Participating Facility.
In the event you are admitted to a Non-Participating 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 information:
➢ 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 (Emergency care only� — provide all of the above information, translated
into 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.
How Will 1 Know What Happened to My Claim?
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 judged 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 similar services in other instances. KPS's decision to
authorize services does not constitute a waiver of KPS's right to enforce the provisions, limitations, and
exclusions of this Group Plan.
City of Bremerton Plan A Page 7
Benefits �ooklet
YOUR OUT-OF-�OCKET 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 family 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 m 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 Plan Deductible
If you met all or a portion of your Deductible under another KPS plan immediately prior to enrolling in this
Group Plan, KPS will 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 befinreen KPS plans.
Prior Year Carryover
Any portion of your Deductible which is met m the last quarter of the immediately prior Calendar Year is
applied toward your Deductible for the current Calendar year.
Inpatient Hospital 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 subject 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 Maxisnurn
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.
Page 8 City of Bremerton Plan A
Bene�ts Booklet
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.
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 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 levels apply.
➢ Copayments.
➢ Charges for prescription drugs.
➢ Charges incurred after a benefit maximum for a specific service or supply has been exhausted
(i.e., acupuncture needle treatments).
➢ 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 A Page 9
Benefits �ooklet
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
Per Family $150
COINSURANCE MAXIMUM
Per Enrollee — Medical and Surgical $200
Per Enrollee — Pharmacy $150
LIMITING AGE
Dependent Children Up to Age 26
Well-baby Care 36 Months
WAITING PERIODS
Pre-existing Conditions None
Transplant Procedures 6 Months
COPAYMENTS
Office/Home/Urgent Care Center Visits $10
Page 10 City of Bremerton Plan A
Bene$its Booklet
KPS provides the following Medically Necessary benefits and services, at the indicated reimbursement
percentage. Benefits paid at 100% are not subject to the annual Deductible. Bene�ts paid at 80% wiil be
paid at 100% once the Coinsurance Maximum (previously Stoploss) has been satisfied.
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Preventive Care
Well-baby Care — From birth through the limiting age for wel!-baby care
— includes physical examinations and immurnzations. Not a benefit 80%
(Not sub�ect to the Deductible)
Child and Adult Preventive Care — includes routine physical
examinations; laboratory and x-ray services (except mammography and
prostate cancer screening); immunizations. See Laboratory and 100% 100%
Radiology Services for mammography and prostate cancer screening
benefits.
Professional Services — Medical and Surgical ,
Care and Services Received in a Hospital or Skilled Nursing Facility 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 100% 100%
Care Received in the Emergency Room 100% 100%
Hospital Services
Prior authorization required for non-emergent and elective care
Inpatient Medical and Surgical Services
Semi-private Room and Board 100% 100%
Special Care Unit (e.g., ICU, CCU)
Outpatient Care
Medical and Surgical (includes ambulatory surgical centers) 100% 100%
Emergency Room Facility 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 trip' 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 Rehabilitation 80% 80%
City of Bremerton Plan A Page 11
Beroe�ts Booklet
KPS provides the following Medically iVecessary benefits and services, at the indicated reimbursement
percentage. Benefits paid at 100°10 are not subject to the annual Deductible. Benefits paid at 80% will be
paid at 100% once the Coinsurance Maximum (previousiy Stoploss) has been satisfied.
� . ' � � . , , � Y ��' '. °- � .,��. ' . � ° . .
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Colorectal Cancer Screening
Routine Screening
Diagnostic
Contraceptive Services
Prescription contraceptives are covered under Pharmacy Benefits
Diabetic Education, Equipment, and Supplies
Pri a may be required
Health E and Training
Medica Eq
Home Health Care — To a maximum of 130 visits per Calendar Year
Prior authorizat r equ ir ed
HospiCe CaPe — To a maximum of 6 months per Calendar Year
Prior authoriza required
Kidney Dialysis — Outpatient facility or Hospital
Laboratory and Radiology S
I npatient Hospital and Ambulatory Surgical Center
Emergency Ro
Mammography Services
Routine Sc
Diagnostic
Prostate Cancer Screening
Routine Sc reening
Diagnostic
All Other Labor atory and Radiology Services
Mastectomy Care
Prior authorization required for inpatient Hospital services only
Medical Services
Prostheses & mastectomy b ras
Mate rnity Care - Subscriber and Spouse only
Medical Equipment and Supplies
P ri o r aut h o riz at ion may be required
Mental Health Care
Inpatient Care — Prior authorization required
Outpatient Care
� . f'�p l°?GJCr� . . �.
� L�uu'L'i.=�u p • � ' •
100% 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
�enefits Booklet
KPS provides the following BAedically Necessary benefits and services, at the indicated reimbursement
percentage. Benefits paid at 100% are not subject to the annual Deductible. Benefits paid at 80% will be
paid at 100% once the Coinsurance Maximum (previously Stoploss) has been satisfied.
. . ��°Jl.Jl1/1AlG,' ' 'YnSll �.1r � ' l°>L51:A�UU�J
. PC�p Pas�3
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Neurodevelopmental Therapies
Not a benefit 80%
Speech, Physical, Occupational Therapy
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
Participating Provider 100% 100%
Non-Participating 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
Private Duty Nursing
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
Skilled Nursing Facility — Prior authorization required
365 days lifetime maximum
Facility and physician care 100% 100%
Physical Therapy 100% 100%
Sleep Disorders
Prior authorization required for surgical treatments only
Sleep Studies
Medical Services See Professional & Hospital Services Sections
Durable Medical Equipment and Supplies
80% 80%
(including CPAP machines)
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
�ene�ots Booklet
KPS provides the following Medically Necessary benefits and services, at the indicated reimbursement
percentage. Benefits paid at 100% are not subject to the annual Deductible. Benefits paid at 80% will be
paid at 100% once the Coinsurance Nlaximum {previously Stoploss) has been satisfied.
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Substance Use Disorder Treatment (Chemical Dependency)
Prior au required
Inpatient Care
Outpatient Care
Termination of Pregnancy
Limited to o ( 1) p er Calen Year
Vision Examination
Limited to one (1) routine eye examination per Calendar Year
100% 100%
100% after $10 100% after $10
Copayment Copayment
See Professional & Hospital Services Sections
100% I Not a benefit
. ... . � . .. -� ; �or� C � �: �; � .
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All prescriptions must be filled at a Participating network pharmacy except in
the case of an Emergency.
Pharmacy benefits are not subject to the Deductible requirements.
Coinsurance Maximum (Per Enrollee) $150
Tier 1 drugs — Preferred Generic drugs 80%
Tier 2 drugs — Preferred Brand drugs 80%
Tier 3 drugs — Non-preferred Generic and Brand drugs 80%
90-day supply of any Drug 80%
Occupational Injuuy Coverage
This benefit applies to LEOFF I Employees only.
OF
Treatment of work-related illnesses and injuries 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 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 Benefits Summary section unless otherwise indicated.
Coverage is provided when ALL of the following conditions are met:
➢ The benefit or service is Medically Necessary for the illness, injury, 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 senrice.
The amount KPS pays for each benefit or senrice 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 illness or injury.
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 regarding age limits
and coverage.
Preventive care, as listed below is not subject to the Deductible.
Well-baby Care
Coverage for well-baby care includes routine physical examinations and childhood immunizations for
Children up to and including the limiting age for well-baby care.
Routine Physical Examinations
Ongoing preventive care for Children (over the limiting age for well-baby care) and adults includes
coverage for routine physical examinations, associated laboratory and x-ray services (except
mammography and prostate cancer screening), and immunizations.
Immunizations
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 immunizations.
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
�enefits Booklet
Professional Services
Covered professional services that are Medically Necessary and rendered by a Provider include the
following:
➢ Medical, surgical, and behavioral health senrices in conjunction with an approved Hospital stay.
➢ Medical, surgical, and behavioral health services in an outpatient facility.
➢ 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 subject to the office 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 authorized 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 joints.
➢ 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 administration charges.
➢ Radiation and inhalation therapy services.
An inpatient stay for the purpose of Medically Necessary diagnostic testing is covered for the Subscriber
only.
Outpatient 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 casting supplies and implantable prosthetics, such as
pacemakers and artificial joints.
➢ 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 senrices 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 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, 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 Hospita!
A Medical Emergency is a sudden and acute onset of a symptom or symptoms, including severe 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 bodily functions or serious dysfunction of a bodily organ or part, or would place the person's
health in serious jeopardy. Examples of Medical Emergency conditions include, but are not limited to,
heart attacks, cardiovascular accidents, poisonings, 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 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 faalrty charges for inpatient Hosprtal 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 subject 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 services.
Bone Bank
Coverage under this benefit includes charges from a bone bank in conjunction with a covered medical or
surgical procedure.
City of Bremerton Plan A Page 17
Beneffits Booklet
Cardiac Rehabilitation
Coverage for cardiac rehabilitation 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 (ii) 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 serv�ces, including the fitting of intra-uterine devices
and diaphragms, and contraceptive implants and injections, 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,
and training, diabetic equipment (e.g., insulin pumps, insulin infusion
shoes and inserts when Medically Necessary), and supplies.
Home Health and Hospice Care
(Requires prior 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
Skilled Nursing Facility. Coverage is subject 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. Skilled 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 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 A
Benefits Booklet
Home Health Care
Coverage under this benefit includes:
➢ 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 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, injury, or surgery.
➢ Drugs and medications necessary for the treatment of the illness or injury 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 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 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.
Hospice Care
Hospice care is available 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 illness or injury which are supplied by
the hospice agency, based on a written prescription from your attending 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.
Exclusions
There is no coverage under either the Hospice Care or Home Health 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 primarily to assist you in the activities of daily
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.
City of Bremerton Plan A Page 19
Benefits Booklet
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 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
conjunction 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 pathofogy services.
➢ Inpatient and outpatient diagnostic radiology (x-ray) services.
➢ Nuclear medicine, including radiation therapy.
➢ Diagnostic ultrasound.
Mammography Services
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 Screening
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
(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 Childhirth
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 injury.
Page 20 City of Bremerton Plan A
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.
➢ Screening and diagnostic testing 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 the mother, may decide on the length of the inpatient stay and the type and location of
follow-up care, including in-person care. Decisions regarding 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 injury. Complications of pregnancy may include, 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 will not be covered. Equipment or supplies ordered while you were enrolled, and
delivered within 30 days after your coverage ended, will be covered.
Surgically implanted prosthetics, such as pace makers and artificial joints, are covered under the
Hospital Services benefit.
Home Medical Equipment and Supplies
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 conjunction 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
th end of t hi s Benefits 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 ta 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 obtained from a
licensed home medical equipment supplier or pharmacy.
City of Bremerton Plan A Page 21
Ber�e�ts 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 injury.
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 subject 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 billed delivery and service charges.
Prosthetic Appliances
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 inpatient 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 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:
Y 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 A
Benefits Booklet
Coverage under this benefit does not include the following:
➢ Marriage and family 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. 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 period of not less than th'ree (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 initial three (3) week period, the Child 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 subject to the Deductible. Charges incurred 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 counseling, 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 following a stroke
City of Bremerton Plan A Page 23
Bene�ts Boolclet
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 jawbone, 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 authorization)
This benefit is subject to a waiting period; please refer to the Waiting Periods and Benefits Summary
sections for additional information
Covered Procedures and Conditions
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 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 facility's transplant program and comply with all program
reqwrements.
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
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 ieukemia
Aplastic anemia
Chronic myelogenous leukemia
Hodgkin's lymphoma
Homozygous beta-thalassemia
Infantile malignant osteopetrosis
Neuroblastoma stage III and IV (Children over 1 year old)
Non-Hodgkin's lymphoma
Severe combined immunodeficiency (SCID; not HIV AIDS)
Wiskott-Aldrich syndrome
Transplant Recipient 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 retrieval costs directly related to the transplant procedure.
Donor Related Services
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 incurred 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 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 recipienYs plan
Transplant Bene�t Limitations and Exclusions
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
T�ansplants benefit:
➢ Any transplant not specifically listed.
➢ Charges for transplant-related facility 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.
City of Bremerton Plan A Page 25
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 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, injury, 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 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 patienYs 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.
Private 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, Skilled Nursing Facility, or other approved facility) or on an outpatient
basis for conditions other than neurodevelopmental disabilities. Therapy services will be covered as
prescribed by your physician.
Page 26 City of Bremerton Plan A
Benefits Booklet
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 injury, except as provided for under the
Occupational Injury benefit.
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.
Skilled Nursing Facility Care
(Requires prior authorization)
Medically Necessary therapeutic or restorative care m a Skilled Nursing Facility may be authorized by
KPS as an alternative to Medically Necessary confinement in 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 Facility coverage includes:
➢ Semi-private room and board.
➢ Generai 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 prior 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 described below.
S/eep Studies, Including Appropriate Durable 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 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.
Surgical 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.
City of Bremerton Plan A Page 27
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 Depender�cy)
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 Prior 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 nghts, 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 similar 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 described 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 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 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 also eligible for
Medicare Part D pharmacy benefits can remain covered under this Group Plan and not be subject to
Medicare-imposed late enrollment penalties should they decide to enroll in a Medicare Part D pharmacy
plan at a later date.
Coverage
Coverage under this benefit includes:
➢ Prescription drugs.
➢ Insulin 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 prescriptions must be filled at a Participating network pharmacy, except in the case of accidental injury
or medical emergency. Prescriptions for specialty drugs may only be filled through the KPS specialty
pharmacy vendor.
Prescription and refills are available 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 �s 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 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 Plan
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% 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 network pharmacy, you will not be responsible for submitting a claim form.
In the event of an Accidental Injury or Medical Emergency, you may utilize the services of a non-
participating network pharmacy. For reimbursement, you must submit an itemized claim and a paid
receipt to:
City of Bremerton Plan A Page 29
Bene�ts 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 in its FDA-
approved labeling. Co+verage 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 majority 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.
Exclusions
No coverage is provided under this benefit for the fo{{owing:
➢ 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.
Y 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
Bene�ts Booklet
LIMITATIONS AND EXCLUSIONS
Coverage under this Group Plan is limited to the diagnosis and therapeutic care or treatment of disease,
sickness, or injury, or the prevention of disease, sickness, or injury, 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 stockings, except as specifically
provided for under the Diabetic Education, Equipment, and Supplies benefit.
5. Artificial insemination, in vitro fertilization, and gamete intra-fallopian transplant (GIFT),
including any direct or indirect complications or after-effects other than pregnancy.
6. Biofeedback, except in the case of urinary incontinence.
7. Charges for non-Covered Benefits and Services, and resulting complications, including 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 or the Mental Health benefit.
12. Enuresis training equipment.
13. Exercise equipment and whirlpool 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, hearing devices, such as cochlear implants, and hearing 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, including routine 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
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 insulm 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, injury, or physical disability, even though the services are not specifically listed as
exclusions.
28. Services for any occupational illness 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 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, milieu, massage, and physical therapies; except as
specifically included under the Neurodevelopmental Therapy benefit, the Rehabilitation
benefit, the Home Health and Hospice Care benefit, or the Mental Health benefit.
36. Sterilization.
37. Treatment for abnormalities of the jaw, including malocclusion; jaw 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
joint (TMJ) disorders.
38. Treatment for sexual dysfunction, including, but not limited to, sterility, infertility, 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.
Page 32 City of Bremerton Plan A
Bene�ts 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 information regarding eligibility and enrollment requirements.
The following paragraphs describe several options for continuing 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. During this period, your
benefits and Premium may not be altered from that of your existing Group Plan.
You must begin self-paying your Premium during the first month your Group stops making 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 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 period 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 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 strike, fockout, or other labor dispute.
➢ Your employment was terminated for gross misconduct.
Please check with your Group Plan Administrator 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 available.
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 will 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 within 31 days of that election
being made.
Continuation of coverage under COBRA is not automatic. You must apply for continuation of your Group
coverage within 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
�eroefits 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 failure on the part of your
Group Plan Administrator 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 will, 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 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 will 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 in the event they lose
coverage under this Group Plan due to one of the foflowing 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 p{an, 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 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 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 P{an A
Bene�ts Booklet
COORDINATION OF BENEFITS (COB)
General Provision
The Coordination 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 subject 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 insurance contracts.
➢ Group or individual 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 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.
"Primary Plan" means the Plan that determines 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 Primary 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 savmgs 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 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, including 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 service 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 Plan A Page 35
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 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 similar
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 finro 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 that provides health care benefits to covered persons in the form of
services through a panel of Providers who are primarily 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 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 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 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 provides that the supplementary coverage is in excess to
any other parts of the Plan provided by the contract holder. Examples include major 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
befinreen the finro Plans is reversed so that the Plan covering 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 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 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.
(ii) 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 living 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 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 determine the order of benefits.
(iv) If a court decree states that the parents have joint 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 determine 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 covering the Custodial Parent, first;
• The Plan covering the spouse of the Custodiaf Parent, second;
• The Plan covering the non-Custodial Parent, third; and then
• The Plan covering 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 Children, the provisions of subparagraph (a) or (b) above determine the
order of benefits as if those individuals were the parents of the Children.
➢ Active emptoyee 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 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 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
covering 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 Coverac�e - 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 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 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 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. 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 will be available to you for injury or illness caused by another party, subject to
the exclusions and limitations of this Plan. If KPS provides Plan benefits for the treatment of the injury or
illness, KPS will be subrogated to any rights that you may have to recover compensation or damages
related to the injury or illness. You and your representative(s) must cooperate fully with KPS in protecting,
preserving, and recovering the amounts KPS has paid, or will 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 injury or illness, you agree to reimburse KPS for the full amount of benefits paid after you
have been fully compensated for your loss, subject to the following additional agreements:
a. You and/or your attorney or representative agree to provide KPS, in writing, 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 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 bills relating to your injuries or illness to any insurer who may offer
coverage for them, including, but not limited to, medical payments coverage, personal injury
protection (PIP), or other plans or contracts providing 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 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 include 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 injury 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 in any way release KPS' lien or prejudice 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 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.
Collection and Reimbursement by Enrollee
If you obtain a settlement or award that includes 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 determined objectively, 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 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 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 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.
Ciry of Bremerton Plan A Page 39
Bene�ts 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 injuries or medical conditions
caused, or asserted by you to be caused, by any third party, subject to the limitations and exclusions of
this Plan. Failure to cooperate may result in a delay or denial of otherwise eligible claims until the
requested action or information is provided to KPS.
Recovery of Claims Payments
Ineligible 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 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 while 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 Claim Payment
KPS is entitled to full reimbursement from the payee for any incorrect claim payment. The term "incorrect
claim payment" 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 billed procedure or diagnosis.
Page 40 City of Bremerton Plan A
Benefits Booklet
COMPLAINTS AND APPEALS PROCESS
KPS will 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 Customer Senrice 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 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 will 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 will be acknowledged, and you will receive a response, in writing, from KPS
Customer Service.
Complaints about Participating 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 in 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-authorization or extended authorization of any health
care service or supply.
➢ A denial 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 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 appropriate staff. KPS will send you the
decision from the First Level Appeal within 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 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
continued stay in, a facility.
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 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 will 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, availability of care, continued stay, or health care service for which you received
emergency services but have not been discharged from a facility; or involves a medical condition for
which the standard external review time frame of forty-five days would seriously jeopardize your life or
health or jeopardize 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 involving 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 within 180 days from receiving an unfavorable
decision of the First Level Appeal. Your case will be reviewed by members of the committee, including
medical staff who did not make the First Level Appeal decision, within thirty (30) business days of your
request. KPS will notify you, in writing, of the Second Level Appeal decision within five (5) business days
after the KPS Appeals Committee meeting.
If you elect this optional Second Level Appeal, you still 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 determines that following the
Standard Appeals Process would jeopardize your life, your health, your abi�ity to regain maximum
function, or subject 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 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 incurred 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 privacy of your personal and health information. 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 KPS may use and give out ("disclose") your personal
and health information held by KPS.
Personal and health information (referred to in this notice as "personal information") means any
information that is identifiable to you as your personal information, including information regarding 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, including information you provide on app�ications 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
availability 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 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
family 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 ofFcials 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 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
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 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 will notify you why in 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 will not include information that:
o Was given to you or your personal representative or close family 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 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.
➢ 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 will notify you about the reasons regarding this action. If
we do agree to the additional restrictions, we will abide by our agreement, except in an
Emergency.
➢ Get a separate electronic or paper copy of this notice.
For more information about exercising 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.
Page 44 City of Bremerton Plan A
Bene�ts Booklet
If you believe KPS has violated your privacy rights set out in this notice, you may file a complaint with
KPS at the following address:
KPS Health Plans
Compliance Department
P.O. Box 34803
Seattle, WA 98124-1803
Filing a complaint will 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 mail within 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 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 right 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 information is available
only upon request. Please refer to the Your Access to Information section at the end of this Benefits
Booklet.
Statement of ERISA Rights
If your group is subject to ERISA; 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 bargairnng agreements, and
copies of all documents filed by the Group Plan with the U.S. Department of Labor, such as
detailed 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, including your employer, your union, or any other person,
may flre you or otherwise discriminate against 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 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 Pfan 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, 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 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 discriminated against 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 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 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 AdministratoP' and "Group Plan Fiduciaries."
""Certain small employers are not required to file these reports.
Note: Please contact your employer to verify if your group is subject to ERISA.
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.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 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 Ef�ective 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
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 1-360-236-4825
Page 46 City of Bremerton Plan A
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 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 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 in health care fraud is illegal 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 explain the circumstances.
City of Bremerton Plan A Page 47
Benefits Booklet
DEFINITIONS
� D o ,
Accidental Injury Any bodily injury 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 Children, stepchildren or other legally
designated ward(s) under the Limiting Age who are a dependent of
the Subscriber or the Subscriber's Spouse.
(ii) 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.
(iii) 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 maintenance (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 IVledically 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 Subscriber'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
bodily functions or serious dysfunction of a bodily organ or part, or would
place the person's health in serious jeopardy
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.
Page 48 City of Bremerton Plan A
Bene�ts Booklet
4 - (�'j'�l D • o
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 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 details about these services, please
visit our website at www.kqshealthpians.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 in 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 testing and research
under Phase I or Phase II clinical trials.
➢ The services are under the research, experimental, study or
investigational arm of a Phase III clinical trial.
➢ Reliable evidence has not shown that the services result in greater
benefits for a particular illness or disease than other generally
available services.
➢ Reliab/e 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, reliable 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 treating facility or other
facilities that are studying substantially the same service as the treating
facility; or written informed consent notices used by the treating facility or
other facilities studying substantially the same service as the treating
facility.
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 administer 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 Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) or licensed by the state in which it is
located.
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.
City of Bremerton Plan A Page 49
Benefits Booklet
� � � ;i �'�� � �� .. .
Limiting Age The age at which Children 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 S ' 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 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 appropriate 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 alternative levels of service or
supplies that are adequate and available.
Non-Participating Provider or Any Provider or Facility 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 Period, 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
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 Prowder 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 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
Bene�ts Booklet
� �� a
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
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 information.
Residential Mental Health A facility that provides 24-hour treatment, services, and supervision for a
Facility mental health condition in a non-acute setting.
Rider An additional benefit over and above those listed in the Benefits
Summary section. Rider documents are attached at the back of the
Benefits Booklet and provide detailed benefit information.
Skilled Nursing Facility (SNF) A facility, or the distinct 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 facility must employ at least one registered nurse
(R.N.) who is on full-time duty, and one physician who is available to
provide necessary medical care in the event of an Emergency.
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.
City of Bremerton Plan A Page 51
Bene�ts Booklet
CONTACT US
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KPS Health Plans is located at:
400 Warren Avenue
Bremerton, WA 98337
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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)
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Send inquiries, claims or complaints to:
KPS Health Plans
PO Box 34803
Seattle, WA 98124-1803
Fax inquiries to: 360-415-6514
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Send e-mail 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 will send you a new copy.
Documentllnformation: 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 famdy Deductibles
- Copayments
- Coinsurance
- Maximum annual out-of-pocket costs
✓ Pre-authorization requirements for certain 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 calling KPS Customer Seroice at 360-478-6796 or toll-free at
1-800-552-7114:
✓ Network primary care Providers
✓ Nefinrork 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.kpshealthplans.com or
Formulary by calling KPS Customer Service toll-free at 1-800-552-7114:
✓ 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 KPS Customer Service toll-free at 1-800-552-7114:
✓ KPS drug formulary
✓ Covered and excluded drugs
✓ Drug substitutions
✓ How Copayments are determined
✓ Where to et a listin of network harmacies
For AAore 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 nefinrork Providers for the care you receive.
•3 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 Underwriting Criteria
For
City of Bremerton
Period: January 1, 2014 — December 31, 2014
Premium Rates
PLAN A & RETIREES
ACTIVE
LEOFF I Em lo ees 1076.13
LEOFF II & non-LEOFF Em lo ees 781.40
S ouse 866.20
1st Child 391.18
2nd Child + 314.85
LEOFF I RETIREES UNDER AGE 65
Subscriber 2816.07
S ouse 1542.72
1st Child 384.89
2nd Child + 307.60
PLAN B � RETIREES
ACTIVE
LEOFF II & non-LEOFF Em lo ees 675.69
S ouse 756.90
1 st Child 344.34
2nd Child + 267.93
LEOFF I RETIREES UNDER AGE 65
Subscriber N/A
S ouse 1281.32
1st Child 325.67
2nd Child + 263.33
Note: Rates include Vision and is for Employees ONLY (Active and COBRA).
Underwriting Criteria
The Premium rates quoted above for this Group Ptan are based on the following underwriting criteria.
KPS resenres the right to withdraw or rerate this offering if Group falls outside the scope of these criteria.
➢ A change in Employer contribution may negate Grandfathered status. Grandfathered
pfans 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
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 minimum of twenty (20) hours per week unless otherwise
negotiated and agreed by both KPS and Group.
➢ Subject to prior KPS approval, two (2) or more health insurance carriers, including KPS, may
provide coverage to Group's Employees.
➢ Subject to prior KPS approval, Group may select muitiple KPS health plan offerings.
➢ 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 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.