2013 PFLAG Health Plans

7/30/2019 2013 PFLAG Health Plans

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TABLE OF CONTENTS4 Contact Information5 Plan Overview17 Kaiser Permanente*22 Kaiser Permanente HMO Select*24 Kaiser Permanente Flexible Choice**27 Kaiser Permanente Flexible Choice** RX Plan29 UnitedHealthcare*42 UnitedHealthcare Choice High Plan*51 UnitedHealthcare Choice High RX Plan*54 UnitedHealthcare Choice Plus**63 UnitedHealthcare Choice Plus RX Plan**74 Dental Insurance*79 Vision Insurance*81 Life Insurance***82 Medical Insurance Comparison*FULLY PAID BY PFLAG**EMPLOYEE/PFLAG COST SHARE***PFLAG PAYS FOR COVERAGE UP TO $50,000, EMPLOYEE HAS THE OPTION TOPURCHASE ADDITIONAL VIA PRE-TAX PAYROLL DEDUCTIONSPOUSE OR PARTNER COVERAGE AVAILABLE:PFLAG AND EMPLOYEE 50%/50% COST SHARE OF ADDITIONAL PREMIUM (SEERATE SHEET/ASK DAVID OR ADAM FOR DETAILS).ALL FORMS AND A COPY OF THIS PROGRAM ARE AVAILABLE FOR DOWNLOAD ATHTTPS://INTRANET.PFLAG.ORG
http://intranet.pflag.org/http://intranet.pflag.org/


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Intranet PFLAG Benefits Resources (click for more information):

Health Insurance

403(b) Retirement Plan

Online Pay Stub Access

BikeShare

Short-term and Long-term disability Insurance

Employee Assistance Program (EAP)

Employee Discount Program

Flexible Spending Account

Microsoft Home Use Program

SmarTrip and Parking

Wells Fargo at Work Program

Worldwide Travel Assistance

ZipCar Discount
https://www.google.com/url?q=https%3A%2F%2Fsites.google.com%2Fa%2Fpflag.org%2Fportal%2Fhr%2Fbenefits%2Fzipcar&sa=D&sntz=1&usg=AFQjCNF4C-H1ub9iPVJoN37I6-pgNb8RaQhttps://www.google.com/url?q=https%3A%2F%2Fsites.google.com%2Fa%2Fpflag.org%2Fportal%2Fhr%2Fbenefits%2Fworldwide-travel-assistance&sa=D&sntz=1&usg=AFQjCNGGU6sfp-Zni1uyLTRQUBD3zINH1Ahttps://www.google.com/url?q=https%3A%2F%2Fsites.google.com%2Fa%2Fpflag.org%2Fportal%2Fhr%2Fbenefits%2Fwells-fargo&sa=D&sntz=1&usg=AFQjCNFsczYABIt3xY4sL8_1uO49yqqvjghttps://www.google.com/url?q=https%3A%2F%2Fsites.google.com%2Fa%2Fpflag.org%2Fportal%2Fhr%2Fbenefits%2Fsmartrip-and-parking&sa=D&sntz=1&usg=AFQjCNG39te4VqnzyJ-fP4CVdTWfKH8YSAhttps://www.google.com/url?q=https%3A%2F%2Fsites.google.com%2Fa%2Fpflag.org%2Fportal%2Fhr%2Fbenefits%2Fmicrosoft-home-use-program&sa=D&sntz=1&usg=AFQjCNGEHIXqUPbnafWvqQganlb3XqGhEQhttps://www.google.com/url?q=https%3A%2F%2Fsites.google.com%2Fa%2Fpflag.org%2Fportal%2Fhr%2Fbenefits%2Fhealth-insurance%2Fflex&sa=D&sntz=1&usg=AFQjCNEHgt2mFUOdD6V2BBXLp64aKj6Sqwhttps://www.google.com/url?q=https%3A%2F%2Fsites.google.com%2Fa%2Fpflag.org%2Fportal%2Fhr%2Fbenefits%2Fdiscounts&sa=D&sntz=1&usg=AFQjCNEhH_rdVrYbXSh08mhW2h8NXIvkMghttps://www.google.com/url?q=https%3A%2F%2Fsites.google.com%2Fa%2Fpflag.org%2Fportal%2Fhr%2Fbenefits%2Feap&sa=D&sntz=1&usg=AFQjCNF7S4OErDJhAsKHZbpx1VVAWbb3Owhttps://www.google.com/url?q=https%3A%2F%2Fsites.google.com%2Fa%2Fpflag.org%2Fportal%2Fhr%2Fbenefits%2Fdisabilityinsurance&sa=D&sntz=1&usg=AFQjCNHb0_S9IHfTgz7gJSON5Bn229LUYQhttps://www.google.com/url?q=https%3A%2F%2Fsites.google.com%2Fa%2Fpflag.org%2Fportal%2Fhr%2Fbenefits%2Fbikeshare&sa=D&sntz=1&usg=AFQjCNGuzf8LmkTQ2dD6hl_WjB0D3lxwuwhttps://www.google.com/url?q=https%3A%2F%2Fsites.google.com%2Fa%2Fpflag.org%2Fportal%2Fhr%2Fbenefits%2Fadp-online-pay-stub-access&sa=D&sntz=1&usg=AFQjCNEgy20xB8uyUnmR0DmSazvVJFggUAhttps://www.google.com/url?q=https%3A%2F%2Fsites.google.com%2Fa%2Fpflag.org%2Fportal%2Fhr%2Fbenefits%2F403b&sa=D&sntz=1&usg=AFQjCNFQE1t0UvT0sXnHfdA9n-7So2mPAAhttps://www.google.com/url?q=https%3A%2F%2Fsites.google.com%2Fa%2Fpflag.org%2Fportal%2Fhr%2Fbenefits%2Fhealth-insurance&sa=D&sntz=1&usg=AFQjCNHVgaTtboyYjwFuCibKamMYIyOKPg


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www.nonprofitadvancement.org 202 457 0540 3

CENTER FOR NONPROFIT ADVANCEMENTS HEALTH PROGRAM


April 2013

Dear Health Program Participant,

Welcome to Open Enrollment 2013-2014 and our 30th year providing big benefits to your

nonprofit.

The Center for Nonprofit Advancements Benefits Trust (Health Program) continues to be

the best choice for your organization. Again this year, we are proud to offer renewal rate

increases lower than the regional average, comprehensive high quality benefits and peace of

mind in todays changing healthcare environment.

This 2013-2014 Health Program Book is an important guide, offering you the latest informa-

tion on each of this years plans and technology updates including:

increased vision benefit - now offering $125 for glasses at the same premium cost

two new dental plans - offering no maximum annual benefit, no annual deductible and

new orthodontia benefits.

new online capabilities - individual employees can review, update and/or change Open

Enrollment elections online.

This book has been revised to reflect that, for legal reasons, each Participating Employer has

adopted the Health Program as its own stand-alone employer welfare program for purposes

of the Employee Retirement Income Act of 1974, as amended. The Center for Nonprofit

Advancement will continue to provide certain administrative services with respect to the

Health Program as it has done in the past. This new designation further strengthens our

group plan and provides another compliance seal of approval.

Remember, Open Enrollment is your annual opportunity to make changes or additions to

your insurance. The Open Enrollment period runs from May 1 to June 14, 2013 with changes

effective July 1, 2013. Every employee at a participating member organization can log-in at

www.nonprofitadvancement.org for additional information.

Please share this resource with peer organizations and partners. We look forward to a

dynamic 30th year serving you.

All the best,

Glen O'Gilvie

CEO, Center for Nonprofit Advancement


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Center for Nonprofit Advancement General

Contact and Membership Information:

1666 K Street NW, Suite 440,

Washington, DC 20006

Tel: 202 457 0540

E-mail: info@nonprofitadvancement

Web: www.nonprofitadvancement.org

For Information on the Health Program:

Tel: 202 457 0540

Fax: 202 457 5850

E-mail: [email protected]

Ext.203,BenefitsTrustDirector(HealthProgram

Compliance)

Ext209,BillingandCollectionsAssociate(Billing

questions and payments)

Ext212,CustomerServiceManager(Health

Program inquires and enrollment)

Ext.211,CustomerServiceAssociate(Health

Program inquires and enrollment questions)

Ext.200,HealthProgramAssociate(Health

Program inquiries)

HEALTH PAYMENTS ONLY should be

mailed to:

Center for Nonprofit Advancements Benefits Trust

c/o M&T Bank Trust Department

P.O. Box 4623

Buffalo, NY 14240-4623

Please mail all forms and correspondence to:

Center for Nonprofit Advancement,

Attn: Health Dept.

1666 K Street NW, Suite 440

Washington, DC 20006

For the most current, up-to-date information aboutthe Health Program, visit the members-only section

of our Web site. Available online:

Plandescriptions

Downloadallforms

Broker for the Health Program

R. David Dixon

Early, Cassidy & Schilling

Tel: 301 948 5822, ext. 136

E-mail: [email protected]


CONTACT INFORMATION


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6 www.nonprofitadvancement.org 202 457 0540

The Center for Nonprofit Advancement has estab-

lished the Center for Nonprofit Advancement

Benefits Trust (the Health Program) for thepurpose of providing eligible employers with the

means to deliver various health and welfare bene-

fits to their employees. This booklet is the summary

plan description (SPD) for the Health Program and

explains the rules governing the Health Program,

including those concerning eligibility, participa-

tion and enrollment. This SPD also summarizes the

benefits offered under the Health Program to eligible

employees.

In order to be eligible to elect benefits in the

Health Program, your employer (an Employer or

Participating Employer) must participate in theHealth Program pursuant to the rules and proce-

dures established by the Center for Nonprofit

Advancement, and you must be employed in a clas-

sification that is eligible for the Health Program. To

participate in the Health Program, your Employer

must, with the consent of the Center for Nonprofit

Advancement, execute an agreement adopting the

Health Program. In so doing, your Employer estab-

lishes a single employer welfare plan under the

Employee Retirement Income Security Act of 1974.

Your Employer may provide other benefits, plans

or programs that are not provided by the Center for

Nonprofit Advancement. Such benefits, plans andprograms are not part of the Health Program and

are not described in this SPD. For detailed informa-

tion about those benefits, if any, you should refer to

any separate summary plan descriptions provided to

you by your Employer.

The benefits of the Health Program are provided

through one or more insurance companies (the

Insurer). The rules, requirements and covered

benefits of your coverages are described in this SPD

and any related documents provided by the Insurers,

including the Evidence of Coverage. The Center for

Nonprofit Advancement or your Employer will sendyou any additional insurance documents that relate

to the benefits in which you are enrolled.

The rules and operation of the Health Program are

described in this SPD as clearly as possible with

minimal use of the technical terms appearing in the

official legal documents (including the applicable

insurance documents). However, the official legal

documents remain the final authority and, in the

event of a conflict with this SPD, shall govern in

all cases. All decisions regarding eligibility for and

the amount of any benefit provided through the

Health Program are made by the applicable Insurers

Neither the Center for Nonprofit Advancement noyour Employer has any authority to make benefits

claims decisions regarding the Health Program. You

may request a copy of the official legal documents

from the Center for Nonprofit Advancement.

All members participating in the Health Program are

responsible for communicating to their employees

all information regarding benefits they offer unde

the Health Program. Providing your employees with

timely and accurate information is the responsibility

of your organization and the Center for Nonprofit

Advancements Benefits Trust is not held liable.

Who Can Enroll

Medical plans are available to Participating

Employers with two or more employees, working

20 or more hours per week. In addition, vision, life

and dental plans are available to organizations with

one employee working at least 20 hours per week.

Employee:

Only W-2 employees working 20 or more hours

per week at a member organization may enroll

No independent contractors, board members o

volunteers are eligible to participate in the Health

Program

In all circumstances, the Center for Nonprofi

Advancement and the applicable Insurer deter

mine whether an entity is a Participating Employe

and whether any employee is eligible to participate

in the Health Program. Any such determination

made by the Center for Nonprofit Advancemen

and an Insurer shall be conclusive and binding on

all parties involved.

The following Dependents are eligible to enroll:

Spouse

Domestic Partner* (not eligible for COBRA

coverage)

Children (minors) - biological, adopted (or placed

for adoption with you) and foster child

Adult children - up to age 26 for all medical insur

ance regardless of their financial, student and

marital status and age 25 for dental and vision

plans. Adult children must be unmarried to partici-

pate in the dental or vision plans.


PLAN OVERVIEW

The medical plans

in this booklet are

not available to

employee groups of

2 - 50 in Maryland,

as a result of the

Maryland Small

Group Insurance

Reform law.

For details, call

Dave Dixon atEarly, Cassidy &

Schilling, Inc., at

301 948 5800.


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* Domestic partners are subject to additional eligi-

bility requirements, and you must complete a sepa-

rate domestic partner enrollment document.

The insurers of the benefits offered under the Health

Program may have additional eligibility requirements.

Please note your coverage will terminate if you no

longer satisfy the eligibility requirements, if your

employer no longer satisfies the requirements to

participate in the Health Program or if your employ-

ers participation in the Health Program otherwise

ends or is terminated.

ENROLLMENT PROCESS

Authorizing Signature: All forms must be signed

by the authorized person(s) indicated on the Group

Participation Request Form. (If there are changes in

the contacts or the person authorized to sign your

enrollment forms, the organization must provide

written authorization on the organizations letter-

head signed by the Chief Executive Offer/Executive

Director.) In the absence of a Chief Executive Officer/

Executive Director, the Board Chair or President

should sign this document.

Incomplete Documents:We will make one telephone

call and send one E-mail to request corrections to

incomplete documents submitted to our office. If we

do not receive a response for requested information,

paperwork will be returned.

Life Insurance Requirement: In the absence of any

other group life insurance policy, basic life insur-

ance in the amount of $10,000 is required to receive

medical insurance.

For any questions about the status of your enroll-

ment, call the Health Program between 9:00 a.m. and

5:00 p.m. Monday through Friday (excluding holi-

days) at 202-457-0540. Send your e-mail to health@

nonprofitadvancement.org.

NEW HIRE

Each new employee (or newly-eligible employee)

must enroll within 30 days of the date he or she

becomes eligible for coverage. Coverage begins

on the first day of the month COINCIDING WITH

OR FOLLOWING the date the employee becomes

eligible for benefits and completes the waiting

period, if any, applied by his or her Employer.

If a new employee waives/declines coverage, a

Waiver of Coverage form must be completed

within 30 days of the date he or she becomes eligible

for coverage and submitted to the Health Program.

OPEN ENROLLMENT

Open Enrollment occurs annually from May 1 to

June 14. During this time, participants may add or

drop coverage, add or drop dependents or change

their coverage options with changes effective July

1. If no documentation is submitted, the prior year'selections will continue during the 2013-2014 plan

year. If you are electing to make no changes, waive

participation in the Health Program or making

changes to your coverage, you will complete the

2013 Open Enrollment Election Notice.

Participating employers must submit all open

enrollment paperwork by June 14, 2013. Failure to

submit all your open enrollment paperwork by June

14, 2013 will mean that your employees open enroll-

ment selections may not take effect. Furthermore,

submission of late paperwork will incur an addi-

tional fee of $100 per employee.

During Open Enrollment, eligible dependents may

be added to any qualifying program. The insurers of

the benefits offered under the Health Program may

have additional eligibility and enrollment require-

ments. This is a once-a-year opportunity to make

changes to your existing coverage. Coverage cannot

be modified until the next Open Enrollment period

(see exceptions below).

CLASSES ELIGIBLE FOR REHIRE

Rehires who may be eligible for service restora-

tion include employees who had completed theircompany introductory period and who were part

of a reduction in force or who voluntarily resigned.

SERVICE RESTORATION RULES FOR REHIRED

EMPLOYEES

If a former employee with less than one years prior

service is rehired, the employee will be considered

a new employee and must meet the new hire eligi-

bility requirement of the Participating Employer.

If a former employee with more than one years

prior service is rehired, the employees eligibility

to participate in the Health Program will be bridged

if the employee is rehired where the period of

prior company service exceeded the duration of

the period of absence. Coverage begins on the

first day of the month coinciding with or following

the date when the employee becomes eligible.

If a former employee with more than one years prior

service is rehired where the duration of the period

of absence exceeded the period of prior company



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service, the employee will be considered a new

employee and must meet the new hire eligibility

requirement of the Participating Employer

SPECIAL ENROLLMENT OPPORTUNITIES

OTHER THAN AT HIRING OR OPEN

ENROLLMENT:

Employees have special rights to enroll in the Health

Program benefits for any of the following reasons:

Loss of Other Coverage: The employee previously

declined (a " Waiver of Coverage" notice must be on

file) to enroll in the Health Program because he or his

dependents had other coverage and that coverage

was lost because -

The other coverage was COBRA coverage and the

COBRA period was exhausted; or

The other coverage was non-COBRA coverageand terminated due to a loss of eligibility or the

employer stopped contributing to the cost of the

coverage.

The employee must provide acceptable evidence

that the other coverage that formed the basis for the

Waiver of Coverage has been lost and must request

enrollment within 30 days.

Qualifying Event: The employee has a new depen-

dent as a result of marriage, birth, adoption, or

placement for adoption and wants to enroll himself

and his dependents. The employee and eligible

dependents can enroll due to divorce or legal sepa-ration, death or court order. The employee must

provide acceptable evidence that a qualifying event

has occurred and must request enrollment within

30 days.

Special Rule for Newborns: If you have a newborn

child, employees must call the Health Program at

202-457-0540 to enroll your newborn child. You

must call the Health Program within 30 days after

birth, and enrollment will then be effective as of

your childs birth. Failure to call within 30 days

of birth means that you will not be able to enroll

your newborn child until the next Open Enrollment

period (or another future qualifying event, if earlier).

This rule applies regardless of whether the medical

carrier pre-enrolls your newborn at birth.

CHIPRA: The employee's or his dependent's

coverage under a Medicaid plan or a State Childrens

Health Insurance Program (CHIP) plan termi-

nates due to loss of eligibility, or the employee or

his dependents become eligible for Medical Plan

premium assistance under a Medicaid plan or a

CHIP plan. Enrollment must be requested within 60

days of termination of such coverage or the date

the employee or his dependent is determined to be

eligible for such assistance.

Part-time employees who become Full-time: This

is based on the policy of the employer. The Health

Program will enroll an employee on the 1st of the

month following the full-time hire date if a partici

pating employer does not have a policy.

Failure to timely request special enrollment wil

result in the member having to wait until the next

Open Enrollment period.

Termination ProcessTERMINATIONS

A. Of Individual Employee Coverage

The Combined Termination form, available on

the Centers website, must be submitted for each

employee who wants to terminate benefits. The

form must provide accurate address information for

each terminating employee and be returned within

30 days of the termination date. Coverage will end

on the last day of the month when the employee

ceases to be eligible. Please provide current and

accurate address information. If an employee loseseligibility for coverage, you must send notice and al

applicable documentation to the Center s Enrollmen

Department within 30 days of the date the eligibility

is lost. Your organization will be financially liable fo

additional premiums due for failure to submit termi

nation forms within the required 30 days.

COBRA packages are generated based on a complete

Combined Termination form. They are generated

on a weekly basis and mailed to the last known

address on file. (For additional details, please read

the COBRA section of the book.)

Employees may voluntarily terminate their participation in any benefits offered by their Employer

though the Health Program during open enrollment

or following a Qualifying Event by providing 30-days

written notice to the Health Program. Employees

may not voluntarily terminate their participation a

any other time.



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B. Qualifying Events

A. For Employees

1. Termination of employment for any reason

other than gross misconduct

2. Reduction in the number of hours of

employment

3. Divorce

4. Legal separation

B. For Spouses

1. The reasons listed under Employee above

2. Covered employee becomes entitled to

Medicare

3. Divorce or legal separation of the spouse

from the covered employee or

4. Death of the covered employee

C. For Dependent Children

1. All the reasons listed under Employee or

Spouse above

2. Loss of dependent child status due to

reaching age 26 for all medical plans and

age limit of 25 for dental and vision plans

C. Of Employer Coverage

A Participating Employer may voluntarily terminate

its participation in the Health Program, or any bene-

fits offered under the Health Program, by providing

a 30-day notice to the Health Program on its letter-

head. The termination request must be signed by

the CEO/Executive Director. If the final premium is

not paid, the effective date of termination will be

the end of the last month which was paid in full. A

Participating Employer may not rejoin the Health

Program on a guaranteed issue basis for twenty-four

(24) months for any benefits for which it requested

voluntary termination. Your Employer is responsiblefor notifying its former employees on COBRA of its

new insurance carrier.

Definitions

HMO (Health Maintenance Organization): A network

of physicians, other health care practitioners, and

facilities that provide a wide spectrum of health care

services.

Indemnity: What was once the "traditional" medical

plan: members pay for medical services then are

reimbursed according to a fixed price schedule

POS (Point of Service): A network of physicians,

health care practitioners, and facilities that allows

members to seek care from any physician, health

care practitioner, or facility, with or without a

referral from a primary care physician. Out-of-

pocket expenses will vary, depending upon whether

a physician, health care practitioner or facility is in

the POS network and whether the member has a

referral from a primary care physician.

PPO (Preferred Provider Organization): A network-

based plan that encourages members to receive

covered services from preferred physicians, health

care practitioners or facilities. Members may use

other health care practitioners or facilities, but

generally will have higher out-of-pocket costs and

more administrative tasks if they do.

Use The Right Forms

OPEN ENROLLMENT:

If you are changing your health plan during Open

Enrollment, please send the Health Program:

Open Enrollment Election Notice form and;

An enrollment form for the plan you are joining.

To add or remove dependents from your current plan,

request a change in coverage using the following

enrollment forms (UnitedHealthcare, Kaiser, United

Concordia, DentaQuest or Advantica Eyecare).

OPEN ENROLLMENT AND NEW HIRE:

UnitedHealthcare (UHC): Use the UHC form to enroll

or change medical coverage. Select either HMO

Low, HMO High, Choice Plus or Optimum Choice

HMO plan.


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Kaiser Permanente: Use the Kaiser multipurpose

form to enroll or change medical coverage. Select

either HMO Select, HMO Signature, Deductible

HMO (DHMO) or Kaiser Permanente Flex Choice.

United Concordia: Use the United Concordias Dental

Plan form to enroll or change dental coverage.

DentaQuest: Use the DentaQuest form to enroll or

change coverage.

Advantica Eyecare: Use the Advantica Eyecare form

to enroll or change coverage.

Life Insurance: In the absence of any other group

life insurance policy, basic life insurance in the

amount of $10,000 is required to receive medical

insurance. Use the life enrollment form. Include theemployers name, address and phone number.

Optional Voluntary Life Insurance: This insurance

is paid for by the employee on a voluntary basis.

If you decline this coverage, please mark the no

box on the enrollment form. You cannot enroll in the

voluntary life insurance without basic life insurance.

Additional term life insurance is available in amounts

up to 150,000.

If you do not enroll in voluntary life insurance when

you were hired, you will pay a late enrollment fee,

complete the evidence of insurability form and theinsurance company may require a medical exam.

Cost of Coverage

Every Participating Employer pays the same

premiums for the same benefits, regardless of your

groups size or pre-existing condition. The cost of

coverage paid by enrolled members is equal to the

premiums charged by the applicable carrier for the

benefit or benefits in which the member is enrolled

plus a nominal administration fee that is retained

by the Center for Nonprofit Advancement Benefits

Trust. The administration fee is used by the Trust to

pay for plan administration expenses. Although the

fee varies from year-to-year and differs based on the

particular benefit, on average the fee is projected

to be roughly 3% of the monthly cost of coverage

paid by each member. This fee changes annually

Updated amounts can be obtained by contacting the

Health Program.

If you enroll a domestic partner or same-gende

spouse, special imputed income tax rules will apply

for purposes of Federal income taxes (and in some

cases State income taxes as well). Imputed income

taxes are added to your taxable compensation

and reported on your Form W-2 each year by your

employer. You should contact your employer fo

additional information regarding the amount and

frequency of imputed income.

COBRA

WHO IS ENTITLED TO CONTINUATION

OF COVERAGE?

There is COBRA Administration available for active

members of the Health Program.

There are three basic requirements that must be

met in order for you to be entitled to elect COBRA

continuation coverage:

Your group health plan must be covered by

COBRA;

A qualifying event;

You must be a qualified beneficiary for that eventCOBRA continuation coverage will be provided

to all COBRA qualifying individuals, regardless

of the number of employees of the Participating

Employer. This rule only applies during the time

that your employer is a Participating Employer in

the Health Program.

QUALIFYING EVENTS

A. For Employees

1. Termination of employment for any reason

other than gross misconduct

2. Reduction in the number of hours o

employment

3. Divorce

4. Legal separation



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B. For Spouses

1. The reasons listed under Employee above

2. Covered employee becomes entitled to

Medicare

3. Divorce or legal separation of the spousefrom the covered employee or

4. Death of the covered employee

C. For Dependent Children

1. All the reasons listed under Employee or

Spouse above

2. Loss of dependent child status due to

reaching age 26 for all medical plans and

age limit of 25 for dental and vision plans

Special Notice for Employees: For the qualifying

events of divorce or legal separation of the employee

and spouse, or a dependent child loses eligibility for

coverage as a dependent child, you must notify the

Health Program at 202-457-0540 within 60 days after

the qualifying event occurs.

If your Employer elects to terminate its participation

in the Health Program, you will not be entitled to

continue your coverage under the Health Program

through COBRA and any existing COBRA coverage

offered through the Health Program will be termi-

nated. You may, however, be entitled to COBRA

continuation coverage through another health plan

sponsored by your Employer.

QUALIFIED BENEFICIARIES

A qualified beneficiary is an individual who was

covered by a group health plan on the day before a

qualifying event occurred that caused him or her to

lose coverage.

Qualified Beneficiaries:

1. Covered Employee

2. Employees covered spouse or former spouse

3. Employees covered dependent child

Special Rule for Domestic Partners and Same-

Gender Spouses: Based on Federal law, COBRA

does not apply to a domestic partner or a same-

gender spouse. A domestic partner or same-gender

spouse is not a qualified beneficiary and will not be

able to continue coverage under COBRA.

COBRA Process

A. Combined Termination Form

The employer submits a Combined Termination Form

to terminate coverage under the group plan within

30 days of the qualifying event. Please provide the

last known address of the employee.

When the Health Program receives a notice to

terminate coverage from an employer, we send theemployee an election notice of his or her rights with

forms for temporary continuation of benefits under

the Federal Consolidated Omnibus Reconciliation

Act of 1985, known as COBRA.

COBRA packages are mailed to the last known

address on file.

B. Employer Benefits

Coverage under the former employer will continue

until the last day of the month.

C. COBRA

COBRA is not active until the COBRA Continuation

Coverage Election Notice is returned to the Health

Program. The election notice must be returned

within 60 days of receiving the notice.

Once the employee returns the COBRA Continuation

Election Notice, the coverage in place at the time

of termination will be reinstated with no lapse in

coverage. The coverage will be identical to the

coverage that you had immediately before the quali-

fying event.

Please contact us if you have any questions regardingdetails of this program at 202 457 0540 or send your

questions to [email protected].


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Summary of Benefits andCo-Payments

On the following pages are summaries of the benefits

and co-payments for each of the insurance carriers

offered by the Center for Nonprofit Advancement

Health Program. It is the employers responsibility

to communicate which benefits are offered to their

employees.

This booklet is a summary of certain features of the

Center for Nonprofit Advancement Health Program.

It is a partial, general description of benefits, proce-

dures, limitations, and exclusions and is not meant

as a contract or any part of one.

For more information, see plan descriptions found

on the members-only section of the Web site.

For a complete description of the available benefits,including procedures, exclusions, and limitations,

please refer to the official plan documents, which are

the evidence of coverage (mailed to each member

upon enrollment).

In the event of any difference between this guide

and the official plan documents, the plan documents

prevail. You may contact a health plan representative

for questions regarding benefits, co-payments and

exclusions.

All forms and a copy of this program are available for

download at the Center for Nonprofit Advancement

Web site at www.nonprofitadvancement.org.

Regulatory Coverage andCompliance

Plans within the Center for Nonprofit Advancement

Health Program are covered by corresponding federal

regulations and policies. The staff and management

employ every means at our disposal to ensure that

Health Insurance Portability and Accountability Act

(HIPAA) protections are being followed. For specific

HIPAA information about a particular plan, contact

that insurer or provider.

Below are the regulations that cover Health Care

Program plans and benefits, and ensure the highest

quality standards are being met. For detailed infor-

mation on regulations that affect health plans go the

Department of Labor Web site at www.dol.gov/dol/

topic/health-plans/index.htm.

The Employee Retirement Income Security Act o

1974 (ERISA) is a federal law that sets minimum stan

dards for most voluntarily established pension and

health plans in private industry to provide protec

tion for individuals in these plans. ERISA requires

plans to provide participants with plan informationincluding important information about plan features

and funding; provides fiduciary responsibilities fo

those who manage and control plan assets; requires

plans to establish a grievance and appeals process

for participants to get benefits from their plans; and

gives participants the right to sue for benefits and

breaches of fiduciary duty.

There have been a number of amendments to ERISA

expanding the protections available to health benefit

plan participants and beneficiaries.

One important amendment, the Consolidated

Omnibus Budget Reconciliation Act (COBRA)

provides some workers and their families with the

right to continue their health coverage for a limited

time after certain events, such as the loss of a job.

Another amendment to ERISA is the Health Insurance

Portability and Accountability Act (HIPAA), which

provides important new protections for working

Americans and their families who have preex

isting medical conditions or might otherwise suffe

discrimination in health coverage based on factors

that relate to an individual's health. Other importan

amendments include the Newborns' and Mothers

Health Protection Act, the Mental Health Parity Actand the Women's Health and Cancer Rights Act.

The Women's Health and Cancer Rights Act o

1998 (WHCRA) includes protections for individuals

who elect breast reconstruction in connection with

a mastectomy. WHCRA provides that group health

plans and health insurance issuers that provide

coverage for medical and surgical benefits with

respect to mastectomies must also cover certain

post-mastectomy benefits, including reconstructive

surgery and the treatment of complications (such as

lymphedema).

The Newborns' and Mothers' Health Protection Act

of 1996 (Newborns' Act) requires group health plans

that offer maternity hospital benefits for mothers and

newborns to pay for at least a 48-hour hospital stay

for the mother and newborn following childbirth (or

in the case of a cesarean section, a 96-hour hospita

stay), unless the attending provider, in consultation

with the mother, decides to discharge earlier.


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The Mental Health Parity Act of 1996 (MHPA)provides

for parity in the application of aggregate lifetime and

annual dollar limits on mental health benefits with

dollar limits on medical/surgical benefits. A plan that

does not impose an annual or lifetime dollar limit

on medical and surgical benefits may not imposesuch a dollar limit on mental health benefits offered

under the plan. MHPA does not apply to benefits for

substance abuse or chemical dependency. Health

plans are not required to include mental health bene-

fits in their benefits package. MHPA only applies to

those plans that do offer mental health benefits.

The Mental Health Parity and Addiction Equity Act

of 2008 (MHPAEA) does not require that group health

plans (or health insurance offered in connection with

such a plan) provide mental health or substance use

disorder benefits. However, the MHPAEA states that,

if a group health provides such benefits, the finan-cial requirements (i.e., deductibles, copayments,

coinsurance, out-of-pocket expenses, etc.) and treat-

ment limitations (i.e., limits on the frequency of treat-

ment, number of visits, days of coverage, or other

similar limits on the scope or duration of treatment)

for these benefits may not be more restrictive than

the most frequent financial requirements and treat-

ment limitations applied to substantially all medical

and surgical benefits covered under the plan. This

represents a significant expansion from the previous

mental health parity provisions, which applied only

to annual and lifetime dollar limitations and applied

only to mental health benefits, not substance usedisorder benefits. Note that the MHPAEA defines

"mental health benefits" and "substance use disorder

benefits" to mean services for mental health condi-

tions and for substance use disorders, as defined

under the terms of the plan and in accordance with

applicable Federal and State law. Thus, plans remain

free to define the benefits covered, subject to appli-

cable law.

In addition to the above, the MHPAEA adds two other

requirements on group health plans: (1) If the plan

provides coverage for medical or surgical benefits

provided by out-of-network providers, the plan mustalso provide coverage for mental health or substance

use disorder benefits provided by out-of-network

providers in a manner consistent with the other

parity provisions of the MHPAEA (i.e., the financial-

requirements and treatment-limitations provisions

discussed above); and (2) subject to regulations

to be issued, plans will be required to (a) disclose,

upon request by any current or potential participant,

beneficiary, or contracting provider, the criteria for

medical necessity determinations made under the

plan for mental health or substance use disorder

benefits, and (b) make available to the participant or

beneficiary the reason for any denial of reimburse-ment or payment for services for mental health or

substance use disorder benefits.

The Genetic Information Nondiscrimination Act of

2008 (GINA) is a federal law which, among other

things, generally prohibits group health plans and

health insurers from discriminating against employees

based on the employees genetic information. Under

GINA, employer-sponsored group health plans and

health insurers are prohibited from (i) restricting

enrollment or adjusting premiums based on genetic

information, (ii) requiring or requesting genetic infor-

mation or genetic testing prior to or after enrollmentunless an exception applies, and (iii) using genetic

information for purposes of underwriting. Genetic

information includes information about an individu-

als genetic tests, the genetic tests of family members

of the individual, the manifestation of a disease or

disorder in family members of the individual or any

request for or receipt of genetic services, or participa-

tion in clinical research that includes genetic services

by the individual or a family member of the individual.

In addition, GINA required amendments to the HIPAA

privacy rule to make it clear that genetic information

is protected health information and may not be used

or disclosed for underwriting purposes.

The Childrens Health Insurance Program

Reauthorization Act of 2009 (CHIPRA) provides new

special enrollment opportunities. Plans and insurers

must permit employees and dependents who are

eligible for, but not enrolled in, a group health

plan to enroll in the plan upon losing eligibility for

coverage under a State Medicaid or CHIP program

or becoming eligible for State premium assistance

under Medicaid or CHIP.

The employee or dependent must request coverage

within 60 days of being terminated from Medicaid or

CHIP coverage or within 60 days of being determined

to be eligible for premium assistance.

The Patient Protection and Affordable Care Act of

2010, as amended, enacts significant changes to our

health care system. This new legislation goes into

effect for the Health Program on July 1, 2011. The

Affordable Care Act adds a number of new benefit


14/70

design and administrative requirements for group

health plans and insurers. For example, new health

plan mandates go into effect beginning as early as

2010, including required coverage for adult children

to age 26, no annual and lifetime limits on essential

health benefits, no pre-existing condition exclusions

and limits on waiting periods. Additional mandates

apply to health plans that are not grandfathered

plans. Most dental and vision plans are exempt from

these health plan mandates.

IMPORTANT NOTICE REGARDING HEALTH

CARE REFORM

The Center for Nonprofit Advancement believes

that the Medical Plans offered under the Health

Program are grandfathered health plans under the

Affordable Care Act. As permitted by the Affordable

Care Act, a grandfathered health plan can preservecertain basic health coverage that was already in

effect when that law was enacted. Being a grandfa-

thered plan means that the Medical Plans may not

include certain consumer protections contained in

the Affordable Care Act that apply to other plans. For

example, the requirement that health plans provide

preventive care services without any cost sharing

does not apply to a grandfathered health plan.

However, grandfathered health plans must comply

with certain protections in the Affordable Care Act,

such as for example, the elimination of lifetime limits

on essential health benefits.

Questions regarding which protections apply and

which protections do not apply to a grandfathered

health plan and what might cause a plan to lose its

grandfathered health plan status can be directed to

the Center using the contact information located at

the beginning of this book. You may also contact

the Employee Benefits Security Administration, U.S.

Department of Labor at 1-866-444-3272 or www.dol.

gov/ebsa/healthreform. This web site has a table

summarizing which protections do and do not apply

to grandfathered health plans.

ADMINISTRATIVE INFORMATION

Plan Information

The Center for Nonprofit Advancement sponsors

the Center for Nonprofit Advancement Benefits

Trust (referred to as the Health Program), which

is a prototype welfare plan that certain eligible

employers may adopt for the benefit of their eligible

employees by signing an adoption agreement. When

your Employer adopts the Health Program by signing

an Adoption Agreement, your Employer establishes

a single employee welfare benefit plan under the

Employee Retirement Income Security Act of 1974

(ERISA), as amended, that benefits only the eligible

employees of your Employer. Your Employer is the

sponsor of your plan.

For the official name of your Employers plan, you

should contact your Employer. The financial and

other records for the plan are kept on a fiscal yea

basis. The plan year ends on each June 30.

Plan Sponsor and Plan Administrator

Your Employer is the plan sponsor and plan adminis

trator. For the plan sponsor s and plan administrators

contact information, contact your Employer.

Agent for Service of Legal Process

Legal process may be served on your Employer.

Third-Party Administrator

Each Participating Employer has appointed the

Center for Nonprofit Advancement to provide certain

third-party administration services related to you

Employers plan. Contact information for the Center

for Nonprofit Advancement is located elsewhere in

this SPD.

Insurers

The medical, dental, vision and life insurance

coverage offered under the Health Program is fully

insured by the applicable Insurers. The Insurers also

provide administrative services, including claims

processing and payment. Additional information

including the contact information for the Insurers

is located in each Insurers Evidence of Coverage o

other related insurance documents, which will be

provided to you upon enrollment. If you do not have a

copy of the insurance documents, please contact the

Center for Nonprofit Advancement or your Employer

Plan Funding

Each Participating Employer must make monthly

contributions to the Center for Nonprofit Advancemen

to pay for the benefits offered under the Health

Program to their respective eligible employees. These

contributions include the cost of the insurance as




15/70


determined by the applicable Insurers, plus an addi-

tional charge for the cost of the Center for Nonprofit

Advancement to administer the Health Program. The

contributions made by Participating Employers are

made to and deposited into the Center for Nonprofit

Advancement Trust (the Trust). You may obtainadditional information about the Trust and its trustees

by contacting the Center for Nonprofit Advancement.

The Participating Employer then decides what portion,

if any, of the monthly contribution will be charged to

its eligible employees for the benefit coverages. In

all cases, each Participating Employer is responsible

for paying both the Employer and eligible employee

contributions to the Health Program. Neither the

Center for Nonprofit Advancement, Health Program,

the Trust, nor any other entity or individual is respon-

sible for ensuring that Participating Employer contri-

butions are timely made. Each Participating Employeris responsible for ensuring that contributions are

timely made. Coverage for eligible employees may

be terminated monthly contributions are not paid

when due.

Qualified Medical Child Support Orders

A Qualified Medical Child Support Order (QMCSO)

is a medical child support order creating or recog-

nizing your childs right to receive coverage under

a medical, dental and/or vision plan established

by your Employer and offered through the Health

Program. Orders that need to be qualified should be

sent to the Center for Nonprofit Advancement. You

may obtain a free copy of the procedures governing

the qualification of QMCSOs by contacting the Center

for Nonprofit Advancement.

No Guarantee of Employment

Nothing in the Health Program or this SPD may or

can be interpreted as a guarantee of future employ-

ment or continued employment for any duration.

Amendment and Termination

The Center for Nonprofit Advancement reserves the

right to discontinue or terminate Health Programcoverage, or to reduce, amend or modify Health

Program coverage in whole or in part and in any

respect (including providing different cost sharing

among Employers). The Insurers also have the right

to revise the provisions of the applicable insurance

documents. This may be done at any time and without

advance notice. Benefits for claims occurring after

the effective date of a modification or termination are

payable in accordance with the revised provisions of

the Health Program and insurance documents.

In addition, your Employer reserves the right to

discontinue or terminate its participation in the Health

Program, or to reduce, amend or modify Health

Program coverage in whole or in part and in any

respect (including providing different cost sharing

between your Employer and eligible employees). This

may be done at any time and without advance notice.

Benefits for claims occurring after the effective date

of a modification or termination are payable in

accordance with the revised provisions of the Health

Program and insurance documents.

All statements in this SPD and all representa-

tions by your Employer, the Center for Nonprofit

Advancement and their personnel are subject to

this right of amendment and termination. This right

applies without limitation even after an individuals

circumstances have changed by retirement, termi-

nation or otherwise. Health Program coverage and

benefits do not become vested at any time.

Your Rights Under ERISA

The following statement is required by federal law.

As a participant in the group health plan you are

entitled to certain rights and protections under the

Employee Retirement Income Security Act of 1974(ERISA). ERISA provides that all plan participants

shall be entitled to the following rights:

Receive Information About Your Plan and Benefits

You may examine, without charge, at the Employers

office and at other specified locations, such as work-

sites, all documents governing the plans, including

insurance contracts and a copy of the latest annual

report (Form 5500 Series) filed by the plan with the

U.S. Department of Labor and available at the Public

Disclosure Room of the Employee Benefits Security

Administration.

You may obtain, upon written request to the Employer,

copies of documents governing the operation of the

plan, including insurance contracts and copies of the

latest annual report (Form 5500 Series) and updated

summary plan descriptions. The Employer may make

a reasonable charge for the copies.



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16

www.nonprofitadvancement.org

202 457 0540

You will receive a summary of the plans annual

financial reports. The Employer is required by law to

furnish each participant with a copy of this summary

annual report.

Continue Group Health Plan Coverage

You may continue health care coverage for yourself,

spouse or dependents if there is a loss of coverage

under the plan as a result of a qualifying event. You or

your dependents may have to pay for such coverage.

Review this SPD and the documents governing the

plan on the rules governing your COBRA continuation

coverage rights and reduction or elimination of exclu-

sionary periods of coverage for preexisting conditions

under your group health plan, if you have creditable

coverage from another plan. You should be provided

a certificate of creditable coverage, free of charge,

from your group health plan or health insurance

issuer when you lose coverage under the plan, when

you become entitled to elect COBRA continuation

coverage, when your COBRA continuation coverage

ceases, if you request it before losing coverage, or if

you request it up to 24 months after losing coverage.

Without evidence of creditable coverage, you may

be subject to a preexisting condition exclusion for

12 months (18 months for late enrollees) after your

enrollment date in your coverage.

Prudent Actions by Plan Fiduciaries

In addition to creating rights for plan participants,

ERISA imposes duties upon the people who areresponsible for the operation of the employee

benefit plans. The people who operate your plans,

called fiduciaries of the plan, have a duty to do so

prudently and in the interest of you and other plan

participants and beneficiaries. No one, including your

Employer or any other person, may fire you or other-

wise discriminate against you in any way to prevent

you from obtaining a plan benefit or exercising your

rights under ERISA.

Enforce Your Rights

If your claim for a plan benefit is denied or ignored,in whole or in part, you have a right to know why this

was done, to obtain copies of documents relating

to the decision without charge, and to appeal any

denial, all within certain time schedules.

Under ERISA, there are steps you can take to enforce

the above rights. For instance, if you request a copy

of the plan documents and/or the latest annual repor

from the plan and do not receive them within 30

days, you may file suit in a Federal court. In such a

case, the court may require the Employer to provide

the materials and pay you up to $110 a day until you

receive the materials, unless the materials were no

sent because of reasons beyond the control of the

Employer. If you have a claim for benefits which is

denied or ignored, in whole or in part, you may file

suit in a state or Federal court. In addition, if you

disagree with the plans decision or lack thereo

concerning the qualified status of a medical child

support order, you may file suit in a Federal court

If it should happen that plan fiduciaries misuse theplans money, or if you are discriminated against for

asserting your rights, you may seek assistance from

the U.S. Department of Labor, or you may file suit

in a Federal court. The court will decide who should

pay court costs and legal fees. If you are successfu

the court may order the person you have sued to pay

these costs and fees. If you lose, the court may orde

you to pay these costs and fees if, for example, it

finds your claim is frivolous.

Assistance With Your Questions

If you have any questions about a plan, you should

contact your Employer. If you have any questions

about this statement or about your rights under

ERISA, or if you need assistance in obtaining docu

ments from your Employer, you should contact the

nearest office of the Employee Benefits Security

Administration, U.S. Department of Labor, listed in

your telephone directory or the Division of Technica

Assistance and Inquiries, Employee Benefits Security

Administration, U.S. Department of Labor, 200

Constitution Avenue, N.W., Washington, D.C. 20210

You may also obtain certain publications about you

rights and responsibilities under ERISA by calling

the publications hotline of the Employee Benefits

Security Administration.



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KAISER PERMANENTE

Kaiser PermanenteHealth PlansBeing different from the ground up allows Kaiser Permanente to provide supe-

rior care, convenience and affordability to you and your family. In the Washington

and Baltimore metropolitan areas, more than 500,000 members count on Kaiser

Permanente for quality care. Nationwide, 8.2 million people have chosen Kaiser

Permanente as their health plan.

YOUR ONLINE CONNECTION TO GOOD HEALTH

Kaiser Permanentes website is the easy way to access the very latest in health

care information and Kaiser Permanente services. In addition to many other

features, members can consult with a Kaiser Permanente advice nurse or phar-

macist or join any of our discussion groups, which are moderated by Kaiser

Permanente health care professionals. Also, members can quickly and easily

request non-urgent care appointments online. Its easy to get connected. Visit

www.members.kaiserpermanente.org. Then click on For Our Members.

Customer service can be reached at 301-468-6000.

The Kaiser Permanente

health care plans in this

booklet are not available

to employee groups of

2 - 50 in Maryland, as a

result of the Maryland

Small Group Insurance

Reform law. For details,call Dave Dixon at Early,

Cassidy & Schilling, Inc.,

at 301 948 5800.


202 457 054017


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KAISER PERMANENTE HMO SELECT

2012 Summary of Benefits

Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.2101 East Jefferson Street, Rockville, Maryland 20852

CENTERS FORNON PROFIT ADVANCEMENT

HMO SEL Mid-Large Groups ($15/$25)(District of Columbia)

The following is a limited description of benefits offered by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (KFHP-MAS). Not all services and procedures are covered by your benefits contract. This Summary of Benefits is for comparisonpurposes only and does not create rights not given through the benefit plan.

IMPORTANT NOTICE - Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. believes that your Plan is "a grandfatheredhealth plan" under the Patient Protection and Affordable Care Act (PPACA). As permitted by PPACA, a grandfathered healthplan can preserve certain basic health coverage that was already in effect when PPACA was enacted. Being a grandfatheredhealth plan means that your Plan may not include certain consumer protections of the PPACA that apply to other plans.However, grandfathered health plans must comply with certain other consumer protections in the PPACA.

Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what mightcause your Plan to change from grandfathered health plan status can be directed to your plan administrator. If your Plan isgoverned by ERISA, you may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-

444-3272 or www.dol.gov./ebsa/healthreform. You may also contact the U.S. Department of Health and Human Services atwww.healthreform.gov.

PLAN DETAILS

Copayments $15 (PCP) / $25 (Specialty)

Coinsurance (Plan pays / Member pays) 100% / 0% except as otherwise indicated

Deductible None

Maximum Annual Copayment Individual: $3,500 Family: $9,400

BENEFITS MEMBER PAYS

OUTPATIENT SERVICES

Preventive Health Office Visit No charge

Preventive Health Screening Tests No charge

Office Visit for Illness

Primary Care Office Visit $15 per visit (Copayment waived for children under age 5)Specialty Care Office Visit $25 per visit

Routine pre-natal visit (after confirmation of pregnancy) and firstpost-natal visit

No charge

Diagnostic Tests and Procedures, X-rays & Laboratory Services No charge

Specialty Imaging (e.g., CT, MRI, PET scan & Nuclear Medicine) No charge

Outpatient Surgery (other than in a providers office) $25 per procedure

HOSPITAL SERVICES

Inpatient hospital care, including inpatient maternity care $250 per admission

Inpatient physician services No charge

CHEMICAL DEPENDENCY AND MENTAL HEALTH SERVICES

Inpatient hospital care $250 per admission

Outpatient services $15 per visit for individual therapy; $7 per visit for group therapy

THERAPY & REHABILITATION SERVICES

Inpatient hospital care $250 per admission

Outpatient services (Up to 90 consecutive days of treatment perinjury, incident or condition)

$25 per visit

INFERTILITY SERVICES

Office visits 50% of allowable charge

All other covered services for treatment of infertility 50% of allowable chargeURGENT CARE & EMERGENCY SERVICES

Urgent Care Office Visit $15 per visit (PCP) / $25 per visit (Specialty)

After hours Urgent Care or Urgent Care Center $25 per visit

Hospital Emergency Room (waived if admitted as inpatient) $50 per visit

Ambulance No charge

3

22


202 457 0540


19/70

BENEFITS MEMBER PAYS

HOSPITAL ALTERNATIVES

Skilled Nursing Facility (limited to 100 days per contract year) $250 per admission

Home Health Care No charge

Hospice Care No charge

OTHER SERVICES

Durable Medical Equipment (DME)Basic DME No charge

Oxygen equipment No charge for 1st 3 months then 50% of allowable charge thereafter

Prosthetics

Internal prosthetics No charge

External prosthetics No charge

Vision

Office visit for medical conditions of the eye $15 per visit (PCP) / $25 per visit (Specialty)

Routine eye refractions to determine need for visioncorrection

$15 per visit with Optometrist$25 per visit with Ophthalmologist (referral required)

Eyeglass frames and lenses(limited to one pair of glasses per contract year)

Member receives 25% discount off retail price when purchased fromPlan Providers

Contact lenses Member receives 15% discount off retail price on initial pair of contact

lenses only, when purchased from Plan ProvidersPrescription Drugs

Covered prescription drugs (up to a 60-day supply)

(Up to a 90-day supply for 1.5 copays at Plan andParticipating Pharmacies

(Up to a 90-day supply for 1 copay through Mail Order)

Plan Pharmacy $10 Generic / $20 Preferred Brand / $35 Non-Preferred BrandParticipating Network Pharmacy $20 Generic / $40 Preferred Brand / $55 Non-Preferred BrandMail Order $8 Generic / $18 Preferred Brand / $33 Non-Preferred Brand

RIDERED BENEFITS MEMBER PAYS

Complementary Alternative Medicine

Chiropractic Services(Limited to 20 visits per contract year)

$25 per visit

Acupuncture Services(Limited to 20 visits per contract year)

$25 per visit

Dental

Covered dental services Plan C - $30 for preventive dental care services

This Benefit and Service Summary does not fully describe the exclusions and limitations associated with your KaiserPermanente coverage. For a full list of the general and benefit specific exclusions under your coverage, please refer to yourKFHP-MAS Evidence of Coverage (EOC). Your EOC provides you with information on what services and supplies will not becovered, regardless of whether the service is medically necessary.

NOTE: This Summary of Benefits is for comparison purposes only and does not create rights not given through thebenefit plan.

Form Numbers: DC-GRP-SEC1(01/12); DC-GRP-SEC2(01/12); DC-GRP-SEC3(01/12); DCLG-ALL-SEC4(01/10); DC-GRP-SEC5(07/11); DC-GRP-SEC6(01/11); DC-GRP-SEC7(01/12); DC-GRP-APPX-DEF(01/12); DC-GRP-HMO-COST(01/12); andany amendments or riders attached thereto.

KAISER PERMANENTE HMO SELECT


202 457 054023


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KAISER PERMANENTE FLEXIBLE CHOICE


Kaiser Permanente Insurance CompanyOne Kaiser Plaza, Oakland, California 94612

2012 Summary of BenefitsCENTERS FOR

NON PROFIT ADVANCEMENTFlexible Choice Mid-Large GroupsPlan 15 (100/90/70 $10/$20-$20/$30)

(District of Columbia)

GF+ 1 [KPIC ID] 3TPOS DCLG Plan 15 w/CAM & Dental 12

The following is a limited description of the Flexible Choice coverage provided through Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.(KFHP-MAS) and Kaiser Permanente Insurance Company (KPIC). This is only a summary and does not fully describe your benefit coverage. Forcomplete details on your HMO benefit coverage, please refer to your employer's Group Agreement Face Sheet, Group Evidence of Coverage, Group

Agreement, and applicable Riders. For complete details on your Participating Provider coverage and your Out -of-Network coverage, please refer toyour employers Group Policy, Certificate of Insurance, Schedule of Coverage and applicable riders. The Evidence of Coverage is the legal bindingdocument between KFHP-MAS and its members and the Group Policy, which incorporates the current Certificate of Insurance is the legal bindingdocument between KPIC and the Policyholder. In the event of ambiguity, or a conflict between this summary and the Evidence of Coverage and/or theGroup Policy, the Evidence of Coverage and/or the Group Policy will control.

The Covered Services listed below contain limitations and exclusions that apply to the benefits outlined in the KFHP-MAS Evidence of Coverage and theKPIC Group Policy. Those exclusions apply to all services that would otherwise be covered under the Evidence of Coverage and/or Group Policy. Nopayment will be made under any benefit of the plan for expenses incurred in connection with an excluded service.

Option 1 Benefits only (KFHP-MAS Providers) - Under your Option 1 benefits only, a Primary Care Physician must be selected. If not, one will beassigned to you by the Health Plan. With the exception of Emergency Services and Out-of-Area Urgent Care Services, all covered Services must be

provided by or arranged for by your Plan Primary Care Physician and authorized by the Health Plan. Services such as medically necessary routinegynecological exams, mental health and substance abuse services, and optometry services may be obtained without a referral from your Plan PrimaryCare Physician; however, they must be provided by a Plan Physician or other Plan Provider.

IMPORTANT NOTICE - Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. believes that your Plan is "a grandfathered health plan" under thePatient Protection and Affordable Care Act (PPACA). As permitted by PPACA, a grandfathered health plan can preserve certain basic health coveragethat was already in effect when PPACA was enacted. Being a grandfathered health plan means that your Plan may not include certain consumerprotections of the PPACA that apply to other plans. However, grandfathered health plans must comply with certain other consumer protections in thePPACA.

Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause your Plan tochange from grandfathered health plan status can be directed to your plan administrator. If your Plan is governed by ERISA, you may also contact theEmployee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or www.dol.gov./ebsa/healthreform. You may also contact theU.S. Department of Health and Human Services at www.healthreform.gov.

DEDUCTIBLE APPLIES TO OPTIONS 2 AND 3, EXCEPT WHERE OTHERWISE INDICATED

PLAN DETAILS Option 1KFHP-MAS Providers

Option 2Participating Providers

Option 3Out-of-Network Providers

Copayments (PCP / Specialty) $10/$20 $20/$30 N/A

Coinsurance (Plan pays / Member pays) 100% / 0% except asotherwise indicated

90% / 10% MAC* except as otherwiseindicated

70% / 30% MAC except asotherwise indicated

Deductible(per policy year)

NoneIndividual: $200

Family: $400Individual: $400

Family: $800

Out-of-Pocket Maximum(per policy year)

Individual: $1,000Family: $2,000



MEMBER PAYSBENEFITS Option 1

KFHP-MAS ProvidersOption 2

Participating ProvidersOption 3

Out-of-Network Providers

OUTPATIENT SERVICES

Preventive Health Office Visit No charge No charge 30% of MAC* after Deductible metOffice Visit for Illness

Primary Care $10 per visit(Copayment waived forchildren under age 5)

$20 per visit (Deductible waived) 30% of MAC* after Deductible met

Specialist Care $20 per visit $30 per visit (Deductible waived) 30% of MAC* after Deductible metDiagnostic Tests and Procedures, X-rays & Laboratory Services

No charge 10% of MAC* after Deductible met 30% of MAC* after Deductible metRoutine pre-natal visit and first post-natal visit

No charge(After confirmation of

pregnancy)

$20 per visit (Deductible waived) 30% of MAC* after Deductible met

MAC = Maximum Allowable Charge

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Deductible applies to Options 2 and 3, except where otherwise indicated

MEMBER PAYSBENEFITS Option 1

KFHP-MAS ProvidersOption 2

Participating ProvidersOption 3

Out-of-Network ProvidersSpecialty Imaging (e.g., CT, MRI, PETscan & Nuclear Medicine)

$50 per test 10% of MAC* after Deductible met 30% of MAC* after Deductible met

Outpatient Surgery $25 per procedure 10% of MAC* after Deductible met 30% of MAC* after Deductible metHOSPITAL SERVICES

Inpatient hospital care, includinginpatient maternity care

No charge 10% of MAC* after Deductible met 30% of MAC* after Deductible metInpatient physician services No charge 10% of MAC* after Deductible met 30% of MAC* after Deductible met

CHEMICAL DEPENDENCY AND MENTAL HEALTH SERVICES

Inpatient hospital care No charge 10% of MAC* after Deductible met 30% of MAC* after Deductible met

Outpatient services Individual Therapy: $10 pervisit

Group Therapy: $5 per visit

Individual Therapy: $20 per visit(Deductible waived)

Group Therapy: $20 per visit(Deductible waived)

Individual Therapy: 30% of MAC*after Deductible met

Group Therapy: 30% of MAC* afterDeductible met

THERAPY & REHABILITATION SERVICES

10% of MAC* after Deductible met 30% of MAC* after Deductible metInpatient hospital care No charge(Up to 90 consecutive daysof treatment per injury,

incident or condition)

Limited to a maximum benefit of 60 days per policy year for Options 2 & 3combined

$30 per visit (Deductible waived) 30% of MAC* after Deductible metOutpatient services $20 per visit(Up to 90 consecutive days

of treatment per injury,incident or condition)

Limited to a maximum benefit of 90 visits per policy year for Options 2 & 3combined

INFERTILITY SERVICES

Infertility (Diagnosis & Treatment) 50% of AC 50% of MAC* after Deductible met(Copayments apply to office visits)

50% of MAC* after Deductible met

URGENT CARE & EMERGENCY SERVICES

After hours Urgent Care or UrgentCare Center

Office Visit: $20 per visit

Other Services: No charge

Office Visit: $30 per visit(Deductible waived)

Other Services: 10% of MAC* after

Deductible met

Office Visit: 30% of MAC* afterdeductible met

Other Services: 30% of MAC* after

Deductible metHospital Emergency Room $75 per visit Covered in Option 1 Only

Ambulance (Emergency transport) Emergency Transport: $100per encounter

Non-emergency ScheduledTransport: $100 per

encounter

Emergency Transport: EmergenciesCovered under Option 1

Non-emergency Scheduled Transport:Not available

Emergency Transport: EmergenciesCovered under Option 1

Non-emergency ScheduledTransport: 30% of MAC* after

deductible met

HOSPITAL ALTERNATIVES

10% of MAC* after Deductible met 30% of MAC* after Deductible metSkilled Nursing Facility No charge(Limited to 60 days per

policy year)Limited to a maximum benefit of 40 days per policy year for Options 2 & 3combined

10% of MAC* after Deductible met 30% of MAC* after Deductible metHome Health Care No charge

Limited to a maximum benefit of 60 days per policy year for Options 2 & 3combined

10% of MAC* after Deductible met 30% of MAC* after Deductible metHospice Care No chargeInpatient care limited to a maximum benefit of 30 days per policy yearfor Options 2 & 3 combined

OTHER SERVICES

Durable Medical Equipment (DME)

Basic DME 50% of AC 50% of MAC* after Deductible met 50% of MAC* after Deductible met

Prosthetics

Internal prosthetics 50% of AC 50% of MAC* after Deductible met 50% of MAC* after Deductible met

Emergency Room Copayment waived if admitted.


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Deductible applies to Options 2 and 3, except where otherwise indicated

MEMBER PAYS

BENEFITS Option 1

KFHP-MAS Providers

Option 2

Participating Providers

Option 3


External prosthetics Not covered except for

breast prostheses,mastectomy bras, urologic

& ostomy supplies

Not covered except for breast

prostheses, mastectomy bras, urologic& ostomy supplies

Not covered except for breast

prostheses, mastectomy bras,urologic & ostomy supplies

Vision

Office visit for medical conditionsof the eye

$10 (PCP) / $20 (Specialist)per visit

$20 / $30 per visit(Deductible waived)


Routine eye refractions todetermine need for visioncorrection

Optometrist: $10 per visit

Ophthalmologist: $20 pervisit

(Referral required)

Optometrist: $20 per visit(Deductible waived)

Ophthalmologist: $30 per visit(Deductible waived)


Eyeglass lenses 25% discount off retail pricewhen purchased from Plan

Providers

1 per 12 months

Not Available 30% of MAC* after Deductible met

Limited to a benefit maximum of

$150 once every 24-months

An eyeglass frame 25% discount off retail pricewhen purchased from Plan

Providers1 per 12 months


Limited to a benefit maximum of $100once every 24-months

Contact lenses 15% discount off retail priceon initial fitting for 1st pair

only, when purchased fromPlan Providers


Limited to a benefit maximum of $50once every 24-months

MEMBER PAYS

RIDERED BENEFITS Option 1

KFHP-MAS Providers

Option 2

Participating Providers

Option 3


Complementary Alternative Medicine

Chiropractic Services(Limited to 20 visits per policy year)

$20 per visit

Available in Option 1 Only

Acupuncture Services(Limited to 20 visits per policy year)

$20 per visit Available in Option 1 Only

Dental

Covered dental services Plan C - $30 for preventivedental care services

Available in Option 1 Only

MAC = Maximum Allowable Charge

This Benefit and Service Summary does not fully describe the exclusions and limitations associated with your Flexible Choicecoverage. For a full list of the general and benefit specific exclusions and limitations under your Flexible Choice coverage,please refer to your KFHP-MAS Evidence of Coverage (EOC) and/or KPIC Certificate of Insurance (COI). Your EOC and/or COIprovides you with information on what services and supplies will not be covered, regardless of whether the service is medicallynecessary. Pre-certification is required for all Option 2 and 3 inpatient services and certain outpatient services.

NOTE: This Summary of Benefits is for comparison purposes only and does not create rights not given through thebenefit plan.

Form Numbers:

KFHP-MAS: DC-GRP-SEC1(01/12); DC-GRP-SEC2(01/12); DC-GRP-SEC3(01/12); DCLG-ALL-SEC4(01/10); DC-GRP-SEC5(07/11); DC-GRP-SEC6(01/11); DC-GRP-SEC7(01/12); DC-GRP-APPX-DEF(01/12); DC-GRP-HMO-COST(01/12); andany amendments or riders attached thereto.

KPIC: GC-FP-DC (09/06); GC-TOC-DC; GC-INTRO-DC (09/06); GC GDEF-DC-Rev.2;GC-ELIG-DC; GC-PRECERT-DC (09/06);GC-DED-DC (09/06); GC-GBEN-DC-Rev.2; GC-OOA-EXCL-DC (1/09); GC-OPBEN-DC (09/06); GC-POS-OPBEN-DC (09/06);GC-COC-FED-DC;GC-COC-DC; GC-POS-CONV; GC-COB-DC (09/06); GC-GPROV-DC (09/06); GC-ERISA; GC-SCH-POS-DC-Rev.2; GP-POS-DC and any amendments or riders attached thereto.


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KAISER PERMANENTE FLEXIBLE CHOICE RX PLAN

2012 Rx Summary of BenefitsFlexible Choice Rx Plan 5


Kaiser Permanente Insurance CompanyOne Kaiser Plaza, Oakland, California 94612

($10/$20/$35 - $20/$35/$50)Outpatient Prescription Drug Program

GF+ 1 FCRX5 (12)

The Kaiser Permanente Flexible Choice plan is a dual offering, jointly underwritten by Kaiser Foundation Health Plan of the Mid-AtlanticStates, Inc. and Kaiser Permanente Insurance Company. KPIC is a subsidiary of Kaiser Foundation Health Plan, Inc.

The following is a limited description of the Kaiser Permanente Flexible Choice prescription drug coverage provided through KaiserFoundation Health Plan of the Mid-Atlantic States, Inc. (KFHP-MAS) and Kaiser Permanente Insurance Company (KPIC). This is only asummary and does not fully describe your prescription drug benefit coverage. For details on your HMO prescription drug benefit coverage,please refer to your Group Evidence of Coverage and applicable Riders. The Evidence of Coverage is the legally binding documentbetween KFHP-MAS and its members. For details on your Participating Provider pharmacy (Medimpact) coverage and your Out -of-Networkpharmacy coverage, please refer to your Certificate of Insurance and Schedule of Coverage. The Certificate of Insurance and Schedule ofCoverage are the legally binding documents between KPIC and its insureds. In the event of ambiguity or a conflict between this summaryand the Evidence of Coverage and/or Certificate of Insurance, the Evidence of Coverage and/or Certificate of Insurance shall control.The prescription drug program is based on the KFHP-MAS Prescription Drug List as well as the KPIC preferred drug list. The Mid-AtlanticStates Region Pharmacy and Therapeutics Committee is responsible for evaluating drug products for addition or removal from the covereddrugs list. The committee conducts a thorough review of the medical li terature and incorporates the opinions of practicing physicians in bothprimary care and specialty departments into the final decision. The Preferred Drug List is updated frequently in response to these reviews aswell as in response to Food and Drug Administration (FDA) requirements. To determine whether a prescription drug is part of the KFHP-MAS Preferred Drug List visit our website at www.kaiserpermanente.org. The KPIC preferred drug list contains the list of prescriptiondrugs that KPIC has designated as preferred drugs. Prescription drugs purchased under Option 2 or Option 3 of the Flexible Choiceoutpatient prescription drug program that do not appear on the KPIC preferred drug list are considered non-preferred prescription drugs. Todetermine whether a prescription drug is part of the KPIC preferred drug list, visit the Medimpact website at www.Medimpact.com/client(then click on link to Resource Center).

You should contact your physician or pharmacist if you have any questions concerning your prescription, i.e. side-effects, potential druginteractions, storage requirements, etc. If you have questions concerning your prescription drug coverage or the preferred drug list, pleasecontact Member Services at 1-888-225-7202.IMPORTANT NOTICE - Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. believes that your Plan is "a grandfathered healthplan" under the Patient Protection and Affordable Care Act (PPACA). As permitted by PPACA, a grandfathered health plan can preservecertain basic health coverage that was already in effect when PPACA was enacted. Being a grandfathered health plan means that your Planmay not include certain consumer protections of the PPACA that apply to other plans. However, grandfathered health plans must complywith certain other consumer protections in the PPACA.

Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause yourPlan to change from grandfathered health plan status can be directed to your plan administrator. If your Plan is governed by ERISA, youmay also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 orwww.dol.gov./ebsa/healthreform. You may also contact the U.S. Department of Health and Human Services at www.healthreform.gov.

PRESCRIPTION DRUG PLAN

Limited to a 30-day supplyKaiser Permanente Medical

Center Pharmacies*Participating Community(Medimpact) Pharmacies

Non-Participating Pharmacies

Generic:Preferred Brand Name:Non-Preferred Brand Name:

$10 Copay$20 Copay$35 Copay

$20 Copay (Deductible waived)$35 Copay (Deductible waived)$50 Copay (Deductible waived)

$20 Copay (Deductible waived)$35 Copay (Deductible waived)$50 Copay (Deductible waived)

PLAN DETAILS MEMBER PAYS DESCRIPTIONDeductible There is no Deductible The amount you must pay in the benefit period for covered

outpatient prescription drugs before we will cover such drugsin that benefit period.

Prescription Drug (Up to a 30-day supply)Generic Drug

Option 1*Kaiser Permanente Medical Center Pharmacy

$10

Option 2 Medimpact Pharmacy

$20

Option 3 Out-of-Network Pharmacy

$20

A Generic Drug is a prescription drug that does not bear thetrademark of a specific manufacturer. It is, by law,chemically the same as its corresponding Brand Name Drug.

Preferred Brand DrugOption 1*Kaiser Permanente Medical Center Pharmacy

$20


$35


$35

A Brand Name Drug is a prescription drug that has beenpatented and is produced by only one manufacturer. APreferred Brand Name Drug is a Brand Name Drug that is onthe Preferred Drug List.

* You may also obtain a 30-day supply of your prescription drug for the Option 1 copayment through the Mail Service Delivery Program offered byKFHP-MAS. The Mail Service Delivery Program is a program operated by KFHP-MAS that distributes prescription drugs to Members via mail.Certain drugs that require special handling are not provided through the mail-delivery service. This includes, but is not limited to, drugs that are timeor temperature sensitive, drugs that cannot legally be sent by U.S. mail, and drugs that require professional administration or observation.

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KAISER PERMANENTE FLEXIBLE CHOICE RX PLAN

GF+ 2 FCRX5 (12)

The Kaiser Permanente Flexible Choice plan is a dual offering, jointly underwritten by Kaiser Foundation Health Plan of the Mid-AtlanticStates, Inc. and Kaiser Permanente Insurance Company. KPIC is a subsidiary of Kaiser Foundation Health Plan, Inc.

PLAN DETAILS MEMBER PAYS DESCRIPTIONNon-Preferred Brand Drug

Option 1*Kaiser Permanente Medical Center Pharmacy

$35


$50

Option 3

Out-of-Network Pharmacy

$50

A Non-Preferred Brand Name Drug is a Brand Name Drugthat is not on the Preferred Drug List.

Maintenance Medications (Up to a 90-day supply)Generic Drug

Option 1**Kaiser Permanente Medical Center Pharmacy

$20


$40


$40

Preferred Brand DrugOption 1**Kaiser Permanente Medical Center Pharmacy

$40


$70

Option 3

Out-of-Network Pharmacy$70

Non-Preferred Brand DrugOption 1**Kaiser Permanente Medical Center Pharmacy

$70


$100


$100

A Maintenance Medication is a covered drug anticipated tobe required for six (6) months or more to treat a chroniccondition.

Up to a 90-day supply of Maintenance Medications areavailable for 2 times your copayment at a pharmacy.

**You may also obtain a 90-day supply of your Maintenance Medications for the Option 1 copayment through the Mail Service DeliveryProgram offered by KFHP-MAS. The Mail Service Delivery Program is a program operated by KFHP-MAS that distributes prescription drugsto Members via mail. Certain drugs that require special handling are not provided through the mail-delivery service. This i

2013 PFLAG Health Plans

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