Summary of Benefit and Coverage (SBC) Job Aid

1. Summary of Benefit and Coverage (SBC)Job Aid National Sales and Account Management May 2013

2. SBC Job Aid 1 2 How to use this tool: This job aid has been created to provide you with the information needed to accurately request edit and validate the SBC. The circled numbers for each section correlate to the National Universal Request form (NURF). Each section is color coded and the color key is located below: Header Section a b c 3 4 Disclaimer Section 5 a b 6

3. SBC Job Aid Numbers 1- 6 5 • Group personalized website • KP group Microsite or KP website 4 Header Section Disclaimer Section • KP identifier and group name must be in bold 16 point font • EXCEPTION - NW – will display contact information pursuant to Marketing Collateral requirement • appears on first page only, unless otherwise requested 1 Name of the company the employees will contact for more details on coverage and cost a 6 Phone number of the company in 6a. 2 • Customer Coverage Period- use MM/DD/YYYY format. [If End Date is unknown, user Coverage Period beginning on or after (MM/DD/YYYY)] b 3 Options are: Individual + family, member + family, All Coverage Tiers 4 • HMO – includes DHMO products • MAS will include jurisdiction (MD, VA, DC) • HDHP – for HDHP compatible (HSA) plans • EPO – for Self Funded plans • POS – for Point of Service Plans • PPO – for PPO Plans • OOA – for Indemnity Plans

4. SBC Job Aid Numbers 7-9 8 9 7 a b Footer Section TTY/TTD is only provided in some regions and when the employees are instructed to call Kaiser Permanente a b c d

5. SBC Job Aid Numbers 7- 8 7 Is there an overall limit on what the plan pays? • The answer is always “NO” Do I need a referral to see a specialist? • Yes. Written approval is required to see most specialists. • EXCEPTION - CO – you can have a consultation without referral Are there services this plan doesn’t cover? • Yes. Only indicate no if services are covered regardless of medical necessity 7 8 Does this plan use a network of providers? 8 • Group personalized website • KP group Microsite or KP website 9 a b • If KP website in 8a – Regional # will be used • If Group personalized website – provide # for 8a. • What is not included in the out–of–pocket limit? • We will always display the 3 required items: Premiums, balance-billed charges (except for CA), and health care this plan doesn’t cover • Additional entries may include: deductibles and/or copayments Additional language cannot be personalized or edited What is the overall deductible? • $XX individual / $XX family • Include major categories that are not subject to the deductible Are there other deductibles for specific services? • $ XX individual / $XX family • If less than 3 service specific deductibles – must end the entry with There are no other specific deductibles. Is there an out–of–pocket limit on my expenses? • Yes. $XX individual / $XX family

6. SBC Job Aid Number 9 4 Footer Section • appears on the first and last page only, unless otherwise requested • Page numbers are displayed on all pages For Your Reference • Kaiser Permanente or • Name of the company answering questions on behalf of the group 9 a b • Regional specific phone number or number of the company personalized in 9a. • Website specific to the answer provided in 9a c • Phone number to request a glossary . A Kaiser Permanente or the number personalized by the company who can provide a glossary to their employees d

7. Common Medical Events Information will vary by region 11 10 Information will vary by region

8. Common Medical Events Section Con’t 10 11 Information will vary by region

9. SBC Job Aid Numbers 10-11 10 11 • EXCEPTION: NW & OH use the words “Participating Provider & Non-Participating Provider” in column headings • Validate the benefit and cost share information against the sold plan • Cost Sharing Standards are as follows: XX% coinsurance, $XX per visit (Word copayment is not added), No charge (if covered and at no cost) or Not covered • Validate the days limits and benefit maximums against the sold plan • Validate any cost shares reflected in this column against the sold plan • The wording in this section can vary by region. • The Regional SBC teams will manage this language to be compliant with all regional/state/federal requirements. • Language is based on variable content from health plan data. Any change in language MUST be escalated to the Regional SBC team for review and approval.

10. SBC Job Aid Numbers 10&11 - Additional Supporting Information 16 Services You May Need and Limitations and Exception Detail specific to the Common Medical Events Section • Other Practitioner office visit = We will reflect Chiropractic and Acupuncture coverage when rider is purchased • Exception: NW will show alternative treatment offering as part of their HMO plan design • Diagnostic test and Imaging - displayed as “ per test” or “per encounter” • Preventive Care/Screening/immunization – Displayed are the Routine Physical, Preventive Screening & Preventive immunizations • Drugs - All Rx categories will display both the retail and mail order benefit (if group has MOI) • For Women’s Preventive Serviceplans, generic drugs limitations & exceptions will also include: No charge for contraceptives (subject to formulary guidelines). • For Outpatient Surgery and Hospitalization categories - For copayment plans: If there is one charge for both facility and physician charges, then physician/surgeon fees will display: Included in facility fee • Emergency room services – We populate benefit for both the plan and non plan provider columns • Emergency medical transportation - Displayed as: XX% coinsurance OR $XX per trip. We populate benefit for plan and non plan provider columns • Urgent Care - We populate benefit for plan and non plan provider columns. Limitation & Exception: Non-participating provider urgent care covered only if you are temporarily outside of our service area. • Mental Health and Substance Abuse outpatient services = Displayed individual and group cost share (not applicable in HI) • Prenatal and Postnatal care - Limitation & Exception : “After confirmation of pregnancy” or “cost sharing for first postnatal visit only” • Rehabilitation Services – Where appropriate we can provided the outpatient and inpatient benefit • Durable Medical Equipment - Limitation and Exception: “Coverage is limited to items on our DME formulary” • (exception: HI, as they have very limited DME outside of diabetic DME) • Eye Exam When there is a cost share, benefit is displayed as “XX% coinsurance OR $XX per visit for refractive exam” 7

11. Common Medical Events Section Con’t 11 13 12 Excluded Services & Other Covered Services Section Your rights to Continue Coverage Section

12. SBC Job Aid Numbers 12-13 16 CORE LIST OF 13 SERVICES Acupuncture Bariatric surgery Chiropractic care Cosmetic surgery Dental care (Adult) Hearing aids Infertility treatment Long-term care Non-emergency care when traveling outside the U.S. Private-duty nursing Routine eye care (Adult) Routine foot care Weight loss programs 12 7 • Your Rights to Continue Coverage • The wording must be replicated as provided by Health and Human Services (HHS), only the phone number may be updated 13 • For more information on your rights to continue coverage: • Regionally specific phone number • Group personalized phone number Excluded Services and Other Covered Services • All 13 Services must appear in either “Services Your Plan does NOT cover” or “Other Covered Services” • They must be in alphabetical order within each box • Services listed as Not Covered in the Common Medical Events chart must be added to “Services Your Plan does NOT cover” on page 1 in the last box of the “Why this Matters” section

13. Your Grievance and Appeals Rights Section Language Access Services Section 15 14

14. SBC Job Aid Number 14 • For questions about your rights, this notice, or assistance contact the plan at : • Regionally specific phone number • Group personalized phone number 1 • Your Grievance and Appeals Rights • The wording must be replicated as provided by Health and Human Services (HHS) Consumer Assistance Programs (CAP) in CA, NW, GA, MAS; no CAP for other regions) 14

15. SBC Job Aid Number 15 • Regionally specific phone number • Group personalized phone number 1 • Language Access Services • All 4 language access disclaimers must be displayed • Spanish (Español): Para obtenerasistencia en Español, llame al • Tagalog (Tagalog): Kung kailanganninyoangtulongsaTagalogtumawagsa • Chinese (中文): 如果需要中文的帮助, 请拨打这个号码 • Navajo (Dine): Dinek'ehgoshikaat'ohwolninisingo, kwiijigoholne’ 15

16. SBC Job Aid – Coverage Examples • Footer Section (see more details on slide #5) : • Appears on first and last page only, unless otherwise requested • Page numbers displayed on all pages

17. SBC Job Aid The Coverage Example Page will display “Total amounts are based on subscriber only coverage” in space designated by HHS • KP does not require pre-notification for maternity or diabetic care, no additional information is required for this Cost share benefit updates may change Patient and Plan liability amounts Do NOT change ANYTHING on this page

18. SBC Job Aid - Other Helpful Information Please work closely with your NA UWC on any of these types of requests Minimum Essential Coverage: Minimum Value Statement: 4

19. Naming Conventions by Process Step #1– Saving critical documents to complete the NURF: NPS: Customer Name_Contract Effective Year_RegionAbbreviation_Sold Plan Type_NPS.pdf Example: Marriott_2014_CA_Hi Ded 1000_NPS.pdf Benefit Summary: BS_GroupName_Contract Effective Yr_Region _Sold benefits abbreviation_Population.pdf Example: BS_Marriott_2014_GA_Hi Ded 1000_Salary.pdf CRTS(for CA only): CRTS_GroupName_ContractEffective Year_Sold benefits abbreviation_Population.pdf Example: CRTS_Marriott_2014_Hi Ded 1000_Salary.pdf Step #2 – Saving the Completed NURF in SC on WHQ record: NURF: NURF_GroupName_Contract Effective Year_Date Saved [YYMMDD].pdf Example: NURF_Marriott_2014_130513.pdf Step #3 – Saving and sending SBC to Customer: SBC: Group Name_Contract Effective Year_RegionAbbreviation_Sold Plan Type_SBC.pdf Example: Marriott_2014_CA_Hi Ded 1000_SBC.pdf • Miscellaneous Documents and Critical Information: