CHOICE Administrators Program Reference Guide Reference Guide Contents TO OUR BROKERS: The...

Program Reference Guide

Contents

TO OUR BROKERS:The information in this reference guide is accurate to the best of our knowledge at the time of printing. However, since thispublication is intended strictly as a guide – and plan specifications may change – we recommend that you verify any datawith your CHOICE Administrators sales representative before basing any decisions on the information provided.

The CHOICE Administrators® Program Reference Guide is designed to provide you with the most up-to-date information on the programs offered by CHOICE Administrators – the underwriting, eligibility and participation requirements, enrollment documentation, plan co-pays, and much more.

It also includes contact information for all product lines – including the names of renewal specialistsin your area who are ready, willing, and able to assist you with your renewals.

MEDICAL

CaliforniaChoice® ............................................................3 CaliforniaChoice 51+ ....................................................13 HSA California® ..............................................................17 Kaiser Permanente Choice Solution..............................25

ANCILLARY CONSUMER EXCHANGE PROGRAM

Choice Builder®..............................................................33

DENTAL

CaliforniaChoice ............................................................39 HSA California ..............................................................41 Kaiser Permanente Choice Solution..............................43

www.choiceadmin.com

If you ever have any questions about coverages, or need a quote, please contact the appropriate program listed below:

Important Telephone Numbers

2

(800) 542-4218

(866) 226-7431

(866) 251-4625

(800) 416-4395

(866) 412-9254

MEDICAL www.choiceadmin.com

Colusa

Calaveras Marin

Monterey

Sacra- mento

Alameda

Alpine Amador

Butte

Contra Costa

Del Norte

El Dorado

Fresno

Glenn

Humboldt

Imperial

Inyo

Kern

Kings

Lake

Lassen

Los Angeles

Madera

Mariposa

Mendocino

Merced

Modoc

Mono

Napa

Nevada

Orange

Placer

Plumas

Riverside

San Benito

San Bernardino

San Diego

San Francisco

San Joaquin

San Luis

Obispo

San Mateo

Santa Barbara

Santa Clara

Santa Cruz

Shasta

Sierra

Siskiyou

Solano

Sonoma

Stanislaus

Sut- ter

Tehama

Trinity

Tulare

Tuolumne

Ventura

Yolo

Yuba Lakke La �PPO Only Counties

HMO & PPO Counties Plan may not be available in all Zip Codes within county. Check with your CaliforniaChoice representative to confirm if coverage is available for your group location.

3

The following HMOs have an “Excellent” rating from the

NCQA for their commercial products:

Kaiser Foundation Health Plan, Inc. -Southern California (HMO)

Kaiser Foundation Health Plan, Inc. -Northern California (HMO)

Western Health Advantage

The following HMO has a“Commendable” rating from the


Anthem Blue Cross Life and HealthInsurance Company (PPO)

Health Net of California, Inc. (HMO)

(See next page for carrier telephoneand address information)

4

CaliforniaChoice®Carrier Contact Information

Member SupportCaliforniaChoice Customer Service Center 800-558-8003Anthem Blue Cross 866-524-5659Health Net 800-361-3366Kaiser Permanente

English 800-464-4000Spanish 800-788-0616

Sharp Health Plan 800-359-2002Western Health Advantage 888-563-2250

Bilingual Support 800-558-8003, Press #9 for Spanish

Internet Support www.calchoice.com

Provider Eligibility Verification 800-558-8003

Broker Services & Commissions 714-542-6992 - Ext. 4390

Broker of Record Changes Fax 714-972-7368

Adds/Terms Fax 714-558-8000

Billing Questions 800-558-8003

Claims Contact carriers directly

To contact by mail, or for payment submission: CaliforniaChoice

721 South Parker, Suite 200Orange, CA 92868

Tax ID Number 33-0115986

www.choiceadmin.com MEDICAL

CaliforniaChoice®

Available

Discount or Buy-up

Discount or Buy-up

Not Available

Chiro only or Chiro & Acupuncture Riders Available

Combined Chiro & Acupuncture Rider Available

Varies by HCSP

Anthem Blue Cross PPOAnthem Blue Cross HMOAnthem Blue Cross Select HMOHealth Net HMOElect Open Access (from Health Net)Salud HMO y MásHealth Net Silver HMO

Kaiser Permanente HMOSharp Health Plan HMOWestern Health Advantage HMO

COBRA enrollees are not counted toward total group size.“Life Only” enrollees are not counted toward total group size.

“Dental Only” enrollees are not counted toward total group size.

How often can members change their Primary Care Physician (PCP)?

Can family members each choose a PCP from a differentIPA/Medical Group?

Refer to summary on pages 8-9

Refer to summary on pages 8-9Maximum Choice For EmployeesEach employee's health care needs are different. The CaliforniaChoiceprogram provides employees the maximum choice in meeting thoseneeds with these health plans—all within one program:

HMO

2-50

Networks vary according toHealth Care Service Plan (HCSP)

No

No

Yes

PLEASE NOTE: Not all health plans are available in all areas

Products Offered

Multi Option (Mix And Match)

OptionalBenefits

Provider Information

Group Size Plans Available2-9 medically enrolled

employeesAll HMO and HMO Value Plans and CalChoice PPO 750 GenRx,

CalChoice PPO 1000, CalChoice PPO 1000 GenRx, CalChoice PPO 3000, CalChoice PPO 4000, Lumenos HSA 1800 & Lumenos HSA 2500

10+ medically enrolledemployees

All HMO and HMO Value Plans and CalChoice PPO 750,CalChoice PPO 750 GenRx, CalChoice PPO 1000, CalChoice

PPO 1000 GenRx, CalChoice PPO 3000, CalChoice PPO 4000,Lumenos HSA 1800 & Lumenos HSA 2500

CaliforniaChoice PPO Guidelines

For Salud HMO y Más,only Salud network

optional benefits areshown here. SIMNSA

network benefits vary—call your CaliforniaChoicerepresentative for details

CaliforniaChoice

CaliforniaChoice®

CaliforniaChoice

LIFE

DENTAL

VISION

INFERTILITY

CHIROPRACTIC

ACUPUNCTURE

MASSAGE THERAPY

24 HOUR COVERAGE

SPECIALIST REFERRALS

Self-referral available?

Express referral available?Varies by Health Care Service Plan (See summary on pages 8-9)

Varies by Health Care Service Plan (See summary on pages 8-9

Consumer Directed Healthcare

HSA-Compatible PPO HRA-CompatiblePPO

MRP-CompatiblePPOLumenos HSA 1800 †*

Lumenos HSA 2500 †*

N/A

N/A

CalChoice® HMO 15CalChoice HMO 25

CalChoice HMO 25 ValueCalChoice HMO 30

CalChoice HMO 30 ValueCalChoice HMO 40

CalChoice HMO 40 ValueElect Open Access

Elect Open Access 25+ Elect Open Access 40+

Salud HMO y MásSalud Mexico

PPOCalChoice PPO 750 †

CalChoice PPO 750 GenRx †

CalChoice PPO 1000 †

CalChoice PPO 1000 GenRx †



CaliforniaChoice

Is Workers' Comp required on corporate officers, partners and sole proprietors?

Is on-the-job covered for corporate officers, partners and sole proprietors?

Is there a premium adjustment for24 hour coverage?

SELECTION

NETWORKS

* HSA-Qualified High Deductible Health Plan† PPO plan availability based on group eligibility and may be subject to change

† PPO plan availability based on group eligibility and may be subject to change

5

www.choiceadmin.comMEDICAL

GROUP SIZE

GROUP SIZE

COVERAGE RESTRICTIONS

Are Commission employees allowed? Yes—if on quarterly/annual wage report and showing atleast minimum wages and withholdings

Are 1099 employees allowed? No

Are employees covered if traveling out of USA?Only for emergency benefits

Is coverage available for out-of-state employees? Yes—CalChoice PPO 750, CalChoice PPO 750 GenRx,CalChoice PPO 1000, CalChoice PPO 1000 GenRx,CalChoice PPO 3000, CalChoice PPO 4000, LumenosHSA 1800* and Lumenos HSA 2500*

*HSA-Qualified High Deductible Health Plan

Max. % of employees residing out-of-state allowed49% (Main office must be located in California)

2-50

50% of lowest cost plan

N/A

N/A

2 2

50* N/A 2-50 No

2-50 No

◆ Those covered by another plan are NOT considered eligible in calculating participation. In order to NOT be considered eligible, the other coverage must be a group plan, Champus, Medicare or Medi-Cal * No 1 Life groups allowed † Employer contribution is 100% of employee lowest cost HMO plan or more

* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.

Employees

For Dependents

% of Total Cost:

Plan Eligibility Requirements

MINIMUM EMPLOYER CONTRIBUTION

PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

Carve Outs*

Wrap* Requirements

*Indicates flexibility in being offered with products of another carrier.

GROUP Can be written with another SIZE carrier's HMO, POS or EPO?

GROUP Can be written with another SIZE carrier's PPO or indemnity plan?

100% of employees not coveredby group insurance and 70% of allemployees regardless of othercoverage

†

CaliforniaChoice®

CaliforniaChoice

CaliforniaChoice

AFTER INITIAL ISSUE

ENROLLMENT GROUP SIZE

Min. # of employees Max. # of employees

No

No

Yes—coverage available for non-union only. Group must submit union billing to underwriting for verification that all other employees have union coverage

2

Yes

EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?

Management/Non-management?

Union/Non-union?

Minimum group size

Does carrier underwrite and ratecarve out groups according to AB1672 guidelines?

* Over 50 only if group is SB 578 qualified. (If group has less than 50 employees, for 50% of the preceding calendar quarter or preceding calendar year)

6


*100% ◆70%

N/A N/A

Employees

Dependents

2-2 3-50

*100%

N/A N/A

Employees

Dependents

Medical Underwriting Requirements

Current Employees

TimelyAdd-ons

Enrollment Information & Requirements

Carrier's Effective Date

Premium Amount Required for 20th?

Employee Waiting Periods Available

Applications must be dated within:

Spouse/Domestic Partner Employees - 1 application or 2?

Employee Waiver Cards Required at enrollment?

Are Telephone Interviews done by Underwriting?

Must Brokers Carry Errors & Omissions Insurance?

Does Carrier Offer Open Enrollment?

DOCUMENTATION & PAYMENT INFORMATION

Quarterly/annual wage report required?

Payroll Records OK if no quarterly/annual wage report?

Is a Prior Booklet required?

Is Prior Billing required?

Must submit check with initial application?

Check Made payable to:

FEES

Enrollment Fee Amount

Type of Enrollment Fee

Monthly Billing Fee

DEDUCTIBLE CREDITPrior carrier deductible credit given?

4th quarter deductiblecarry-over credit given?

GROUP SIZE

ITEMS REVIEWED IN RAF CALCULATION

Rating Information

Call 800-511-0001www.choiceadmin.com†† According to the California Insurance Code “The standard

employee risk rates applied to a small employer for new business shall be in effect for no less than six months.”

Items Reviewed In RAF Calculation

Medical Conditions

Years in Business

# of Pregnancies

Virgin Group

Type of Industry

Percent of Owners

Group Size

% of COBRA Insureds

% of Family Related

Participation

Plan(s) Requested

24 HR Coverage Req'd

Employer Contribution

Bankruptcy

Gender Mix

1st of the month only

Balance Due

Min: 30 Max: 365

60 days

Use either 1 or 2 applications

Yes

Yes

Yes

Yes—60 days prior to anniversary

Yes None

N/A

1-8 9-20 21+$20 $25 $30

No

No

No

No

No

No

Yes

No

No

No

No

No

No

No

No

*Only if any employees take PPO Dental

2-4: 1.105-50: 1.0015-50: 1.00**Groups may qualify for a 0.90. See quote for details.

12 Months

No

HMO: YesPPO: Yes

2-14 15-50 Employee Master App Medical (EmployerQuestionnaire Questions) Non Non Medical Medical

CaliforniaChoice®

CaliforniaChoice

(if enrolling separately, 2 applications required)

HMO: N/APPO: Yes*

No

RAF Increments (2-50 lives)

Rate Guarantee††

Apply Trend Factor?

Use Employee Zips?

*This does NOT include credit for the RX deductible

7

Call representative

Yes*

Yes*

Yes

CaliforniaChoice®


Yes —if deemed medicallynecessary by KaiserPermanente Physician


Prescriptions

If generic available, anddoctor has not indicated“dispense as written,” willmember receive a genericequivalent rather than aname brand drug?

If doctor writes “dispense as written” on prescription, is brand name available at the brand copay?

Does health plan use Rx formulary?

If medically necessary, arenon-formulary drugs covered?

Mail order

Benefit Summary

*generic copay/brand namecopay/non-formulary copay if applicable

NOTE: Each HCSP HMO has their own PCP change approval process

FOR DETAILED BENEFIT INFO, LIMITATIONS AND EXCLUSIONS, PLEASE REFER TO BOOKLET CERTIFICATE/EVIDENCE OF COVERAGE, OR CONTACT YOUR CALIFORNIACHOICE REPRESENTATIVE

Anthem Blue Cross HMO

Once a month – changes are effective at the beginning of the following month,provided the member is not in thecourse of treatment or hospitalized andno pending authorizations.

Yes

No

Yes—or you must paythe Generic copay plusthe difference in costbetween the brandname & generic equivalent

Yes

Yes

90 day supply:

Yes – referrals comedirectly from PCP

No

Yes

Health Net HMO, Elect Open Access,& Salud HMO y Más*(*only Salud network benefits shown)

Once amonth

HMO: Self: Yes— if Rapid Access provider

Yes—or must pay brandcopay + difference in costbetween brand name &generic equivalent

Yes* — $50 non-formularycopay applies*Prior authorization may be required for certain medications

90 day supply—double retail copay

Yes

Yes

What is copay for covered non-formulary drugs?

CalChoice® HMO15:CalChoice HMO 25:CalChoice HMO 30:CalChoice HMO 40:

CalChoice HMO 25 Value:CalChoice HMO 40 Value:

$40$50$50$50$50$50

A $50 non-formulary copay applies for:CalChoice HMO 15, CalChoice HMO 25,

CalChoice HMO 25 Value, CalChoice HMO 30,CalChoice HMO 30 Value, CalChoice HMO 40,CalChoice HMO 40 Value, Elect Open Access,

Elect Open Access 25+, Elect Open Access 40+and Salud HMO y Más

Generic Brand

Elect Open Access:Yes—member may selfrefer to any doctor in PPOnetwork for a higher copay

CaliforniaChoice®

CaliforniaChoice

Kaiser Permanente HMO

Generic Brand

Anytime

Yes—from KaiserPermanentePhysicians

Self: Yes—to OB/GYN andcertain other specialties(list varies by region)Express: Yes—referral directfrom physician

Yes

Yes

100 day supply—double the retail copay

No

Yes

$10$15$15$15

$20 $25 $30$30

How often can family members change theirPrimary Care Physician?(PCP)

Can family memberseach choose a PCP from a differentIPA/Medical Group?

Do plans have these types of programs to speed the specialist referral process in network: Self referral?Express referral?

Is there an Out-of-Network benefit?

8

Yes* — non-formularycopay applies*Prior authorization may be required for certain medications

CalChoice HMO15:CalChoice HMO 25:CalChoice HMO 30:CalChoice HMO 40:


$10/$40/$80$15/$60/$100$15/$60/$100$20/$60/$100$15/$60/$100$15/$60/$100

HMO


FOR DETAILED BENEFIT INFO, LIMITATIONS AND EXCLUSIONS, PLEASE REFER TO BOOKLET CERTIFICATE/EVIDENCE OF COVERAGE, OR CONTACT YOUR CALIFORNIACHOICE REPRESENTATIVE

SharpHealth Plan

Once a month

Yes

Self: Yes—availablethrough medical group(some medical groupsoffer direct access tocertain specialists)

Yes

Yes

Yes* — non-formularycopay applies *Prior authorization may be required for certain medications

90 day supply—double the30-day retail copay

non-formulary:Call your

CaliforniaChoice representative

No

Yes

Generic Brand

Double theformulary brand

copay


Prescriptions


BENEFIT SUMMARYBENEFIT

SUMMARYProvider Information

Anytime—in a PPO, you do nothave to choose a PCP

Yes—each family member canmake their own physician choice

Yes – in a PPO, you can choose anyphysician

Yes—Negotiated Fee Schedule

Yes—or you must pay the Generic copay plusthe difference in cost between the brand name& generic equivalent

Yes

Participating Pharmacy: $50Non-Participating Pharmacy: 50% of Maximum allowedamount*No Non-Formulary Benefits for GenRxThe brand deductible will apply:

No

WesternHealth Advantage

Yes—but only fromnetwork physicians

Yes—Advantage Referral Program allowsPCP referral to most specialists in the WHAnetwork

Yes—or must pay thebrand copay plus thedifference in costbetween the brandname and genericequivalent

Yes

90 day supply—

Yes

Once a month—changes areeffective at beginning of followingmonth, provided the member isnot in the course of treatment orhospitalized and no pendingauthorizations

CaliforniaChoice®

CaliforniaChoice

No—member will have to pay the generic copayplus the difference in cost between generic andbrand

PPO 750 - $150PPO 1000 - $200PPO 3000 - $250PPO 4000 - $250Lumenos HSA 1800 - subject to medical deductibleLumenos HSA 2500 - subject to medical deductible

Benefit Summary

90 day supply: $15/$60/$100Non-Participating Pharmacy: Not CoveredNo Non-Formulary Benefits for GenRxThe brand deductible will apply:

$35 $50 $50$50

CalChoice HMO 40 Value $50


CalChoice HMO 15: $25/$50/$88CalChoice HMO 25: $38/$75/$125CalChoice HMO 30: $38/$75/$125CalChoice HMO 40: $50/$75/$125CalChoice HMO 40 Value: $50/$75/$125

Yes* — non-formularycopay applies *Prior authorization may be required for certain medications

9

Anthem Blue Cross Life and HealthInsurance Company

PPO 750 - $150PPO 1000 - $200PPO 3000 - $250PPO 4000 - $250Lumenos HSA 1800 - subject to medical deductibleLumenos HSA 2500 - subject to medical deductible

PPO


If doctor writes “dispense as written” onprescription, is brand name available at the brand copay?


If medically necessary, arenon-formulary drugs covered?

Mail order


CalChoice® HMO15:CalChoice HMO 25:CalChoice HMO 30:CalChoice HMO 40:


How often can family members change theirPrimary Care Physician?(PCP)

Can family memberseach choose a PCP from a differentIPA/Medical Group?




Diabetic Benefits

Are self-injectable drugs(other than insulin) covered under thePrescription Drug benefitor Medical Benefit?

Benefit Summary

Anthem BlueCross HMO

Health Net HMO, Elect Open Access,& Salud HMO y Más*(*only Salud network benefits shown)

Self-Injectable Drug Benefits

CaliforniaChoice®

CaliforniaChoice


Insulin

Is pre-authorizationrequired?

Must self-injectables(other than insulin) bepurchased via the carrier-contracted mailorder RX vendor?

Needles & Syringes

Glucose Monitor†

Chem-Strips and/orTesting Agents

Insulin Pump†

Insulin Pump Supplies

May depend on themedication. CallPharmacy Services at 800-700-2533 to confirm

Some medicationsand/or dosagesmay requireprior authorization

Certain drugs must gothrough mail-order provider.Call Pharmacy Services at800-700-2533 to confirm

PrescriptionDrug Benefit


Covered under the Prescription DrugBenefit (Preferred monitors only) All other monitors covered at: CalChoice HMO 15 - 90%CalChoice HMO 25 - 80%CalChoice HMO 25 Value - 80%CalChoice HMO 30 - 80%CalChoice HMO 30 Value - 80%CalChoice HMO 40 - 80%CalChoice HMO 40 Value - 80%Elect Open Access - 80% Elect Open Access 25+ - 80% Elect Open Access 40+ - 80%Salud HMO y Más - 80%


Covered at:CalChoice HMO 15 - 90%CalChoice HMO 25 - 80%CalChoice HMO 25 Value - 80%CalChoice HMO 30 - 80%CalChoice HMO 30 Value - 80%CalChoice HMO 40 - 80%CalChoice HMO 40 Value - 80%Elect Open Access - 80% Elect Open Access 25+ - 80% Elect Open Access 40+ - 80%Salud HMO y Más - 80%

Covered at:CalChoice HMO 15 - 90%CalChoice HMO 25 - 80%CalChoice HMO 25 Value - 80%CalChoice HMO 30 - 80%CalChoice HMO 30 Value - 80%CalChoice HMO 40 - 80%Cal Choice HMO 40 Value - 80%Elect Open Access - 80% Elect Open Access 25+ - 80% Elect Open Access 40+ - 80%Salud HMO y Más - 80%

Medical Benefit

Yes

No—use doctor'scontracted vendor



Durable MedicalEquipment Benefit

Blood test strips are covered under DurableMedical Equipment; Urine test strips are cov-ered under Prescription Drug Benefit




Must be prescribedby a planphysician

Must use planpharmacies(including affiliatedpharmacies)

HMOAre the following items covered under the Prescription DrugBenefit, Durable MedicalEquipment Benefit orDiabetes Care Benefit of the member’s selected plan design?



Free Glucometer Program for certain manufacturers;otherwise, covered underDurable Medical Equipment:

CalChoice® HMO 15—90%CalChoice HMO 25—70%CalChoice HMO 30—50%CalChoice HMO 40—50%CalChoice HMO 25 Value–50%CalChoice HMO 40 Value–50%

(Blood Test Strips)Covered under thePrescription Drug Benefits



10

† Vendors for Diabetes Equipment:

Benefits are typically covered under the pharmacy benefit withparticipating pharmacies. Health Netwill only cover certain machines.

PendingPlease see carrierwebsite for list ofproviders


SharpHealth Plan


Insulin



Needles & Syringes

Glucose Monitor†


Insulin Pump†








May depend onmedication


No—mail ordernot required

Diabetic Benefits

Benefit Summary

Anthem Blue Cross Life and HealthInsurance Company

WesternHealth Advantage

CaliforniaChoice®

Self-Injectable Drug Benefits CaliforniaChoice



Free Glucometer Program for certain manufacturers;otherwise, covered underDurable Medical Equipment

In-Network: 50%Out-of-Network: 50%

(Blood Test Strips) Covered underthe Prescription Drug Benefits



May depend on the medication. Call PharmacyServices at 800-700-2533 to confirm


Certain drugs must go through mail-order provider.Call Pharmacy Services at 800-700-2533 to confirm







Medical Benefit

Yes

Depends onmedical group

PPOAre the following items covered under the Prescription DrugBenefit, Durable MedicalEquipment Benefit orDiabetes Care Benefit of the member’s selected plan design?

11

† Vendors for Diabetes Equipment:

ADSAdvanced Diabetes Supply 390 Oak Avenue, Suite "N"Carlsbad, CA 92008800-730-9887

Edgepark1810 Summit Commerce ParkTwinsburg, OH 44087800-321-0591

Please see carrierwebsite for list ofproviders

Contract is withMedical Group.See PCP


MEDICAL

12

GENERIC VS. BRAND NAMEIf generic available, and doctor has not indicated“dispense as written,” will member receive a genericequivalent rather than a brand name drug?Refer to summary on pages 10-11

If doctor writes “dispense as written” on prescription, is brand name available at the brandcopay amount?Refer to summary on pages 10-11

Special Concerns*

Hearing treatment

Prescriptions

FORMULARY VS. NON-FORMULARYDoes carrier use Rx formulary?Refer to summary on pages 10-11

Are non-formulary drugs available?Refer to summary on pages 10-11

MAIL ORDER - 90 DAY SUPPLYRefer to summary on pages 10-11

Are oral contraceptives covered?Yes—subject to the Drug Formulary for the HealthCare Service Plan selected by member

HMO: Routine hearing screening in PCP's office only—office visit copay applies

PPO: Covers ear screenings to determine the need foraudiograms for dependent children through age18 only

* Unless otherwise noted, information shown in this section reflects in-network benefits.

Salud HMO y Más plan design varies depending onwhether the Salud provider network or the SIMNSA providernetwork is utilized by the employee and dependents. Theinformation outlined on this page only reflects the Saludprovider network. Call your CaliforniaChoice® representativefor Mexico benefit details.

CaliforniaChoice®

CaliforniaChoice

InfertilityHMO: $1500 lifetime maximum on infertility drugs.

Evaluation & treatment using covered procedures(no in-vitro fertilization)—50% of allowed charges.Note: Covered procedures & allowed charges willvary by HCSP (Health Care Service Plan).

See Evidence of Coverage or Benefit Booklet

PPO: See Evidence of Coverage or Benefit Booklet

Speech therapy

HMO: Outpatient covered if HCSP determines there will be significant improvement in 60 days—office

visit copay appliesPPO: Covered for certain conditions (see Evidence of

Coverage or call representative)—subject todeductible and coinsurance

Are Hearing Aids covered?NoCaliforniaChoice now offers EPIC Hearing Service Plan(HSP) to all CaliforniaChoice members at no additionalcost

KEY TO HEALTH CARE SERVICE PLANSOFFERING LISTED PROGRAM

ABC Anthem Blue CrossHN Health NetKP Kaiser PermanenteSH Sharp Health PlanWH Western Health Advantage

* All CaliforniaChoice® medical members are eligible for discounts on eye exams,lenses, frames, and contacts through the Vision One Eye Care Programadministered by Cole Managed Vision/EyeMed Vision Care.

1 Discounts of frames and lenses available through Kaiser Permanente facilities.

2 Discounts on vitamins and herbal supplements available through the “AffinityProgram” which links Kaiser Permanente members to Healthy Roads

3 Member must use a Kaiser Permanente weight loss program.

Which health care plans offer these discounts, awards and other value-added benefits?Eyewear & lenses discount ............................................................................................................................ABC, HN, KP 1

Health Club Membership or fitness equipment/sporting goods discount ..............................................ABC, HN, KP, WHHealth Literature, telephone tapes and/or videos (no charge) ..........................................................................HN, KP, SH available in the following languages: SpanishPersonalized, dynamic online tools on health information ............................................................................................ABCHome childproofing products discount ..................................................................................................................ABC, HNInfant car seat: discount ............................................................................................................................................................HN awarded upon prenatal class completion ..........................................................................................................HNNurses 24 Hour Hotline..............................................................................................................................ABC, HN, KP, SHVitamins and/or herbal supplements discount ........................................................................................ABC, HN, KP 2, SHWeight control program discount............................................................................................................ABC, HN, KP 3, SH

Discounts, Awards & Other Value-Added Benefits CaliforniaChoice

www.choiceadmin.com

13

Colusa

Calaveras Marin

Monterey

Sacra- mento

Alameda

Alpine Amador

Butte

Contra Costa

Del Norte

El Dorado

Fresno

Glenn

Humboldt

Imperial

Inyo

Kern

Kings

Lake

Lassen

Los Angeles

Madera

Mariposa

Mendocino

Merced

Modoc

Mono

Napa

Nevada

Orange

Placer

Plumas

Riverside

San Benito

San Bernardino

San Diego

San Francisco

San Joaquin

San Luis

Obispo

San Mateo

Santa Barbara

Santa Clara

Santa Cruz

Shasta

Sierra

Siskiyou

Solano

Sonoma

Stanislaus

Sut- ter

Tehama

Trinity

Tulare

Tuolumne

Ventura

Yolo

Yuba Lakke La

�PPO Only Counties

HMO & PPO Counties Plan may not be available in all Zip Codes within county. Check with your CaliforniaChoice 51+ representative to confirm if coverage is available for your group location.

The following HMOs have an “Excellent” rating from the


Kaiser Foundation Health Plan, Inc. -Southern California (HMO)

Kaiser Foundation Health Plan, Inc. -Northern California (HMO)

Western Health Advantage

The following HMO has a“Commendable” rating from the


Health Net of California, Inc. (HMO)

Health Net Life Insurance Company(PPO)

MEDICAL

14

CaliforniaChoice®Carrier Contact Information

Member SupportCaliforniaChoice 51+ Customer Service Center 866-451-7587Health Net 800-361-3366Kaiser Permanente

English 800-464-4000Spanish 800-788-0616

Western Health Advantage 888-563-2250


Internet Support www.calchoiceplus.com


Broker Services & Commissions 714-567-4390

[email protected]

Broker of Record Changes Fax 714-972-7368




To contact by mail, or for payment submission: CaliforniaChoice 51+

721 South Parker, Suite 200Orange, CA 92868


CaliforniaChoice 51+

www.choiceadmin.com

Is Workers' Comp required on corporate officers, partners and sole proprietors?No

Is on-the-job covered for corporate officers, partners and sole proprietors?Yes

Is there a premium adjustmentfor 24 hour coverage?No

MEDICAL

15

How often can members change their Primary Care Physician (PCP)?Varies by plan type. Contact yourCaliforniaChoice 51+ representative

Can family members each choose a PCP from a differentIPA/Medical Group?Varies by plan type. Contact yourCaliforniaChoice 51+ representative

HMO


Products Offered Provider InformationCaliforniaChoice 51+

24 HOUR COVERAGE



Express referral available?Varies by plan type. Contact yourCaliforniaChoice 51+ representative

Varies by plan type. Contact yourCaliforniaChoice 51+ representative

CalChoice® 51+ HMO 15CalChoice 51+ HMO 15 ValueCalChoice 51+ HMO 25CalChoice 51+ HMO 20/$500 ValueCalChoice 51+ HMO 25 ValueCalChoice 51+ HMO 40CalChoice 51+ HMO 40 ValueElect Open AccessSalud HMO y Más

PPO

PPO 250†

PPO 500†

PPO 1000†

PPO 1500†

SELECTION

NETWORKS

† PPO plan availability based on group eligibility and may be subject to change

Prepaid

FDH 100Prepaid 1000Prepaid 3000

PPO

EPO 3000EPO 3500EPO 4000EPO 5000

DENTAL

Vision DiscountsVoluntary Vision

VISION

Term Life & AD&D

LIFE

www.choiceadmin.com

Products Offered CaliforniaChoice 51+


HSA-Compatible HMOHDHP 1500HSA 1800

CaliforniaChoice 51+

INDEMNITY

Flex Net (Out of Area Only)

HSA-Compatible PPOHSA 1500HSA 2000

Ancillary CaliforniaChoice 51+

Health Net HMOKaiser Permanente HMOWestern Health Advantage HMOHealth Net PPO

Maximum Choice For EmployeesEach employee's health care needs are different. The CaliforniaChoice 51+program provides employees the maximum choice in meeting those needswith these health plans—all within one program:

Multi Option (Mix And Match) CaliforniaChoice 51+

Colusa

CalaverasMarin

Monterey

Sacra-mento

Alameda

AlpineAmador

Butte

ContraCosta

Del Norte

El Dorado

Fresno

Glenn

Humboldt

Imperial

Inyo

Kern

Kings

Lake

Lassen

Los Angeles

Madera

Mariposa

Mendocino

Merced

Modoc

Mono

Napa

Nevada

Orange

Placer

Plumas

Riverside

SanBenito

San Bernardino

San Diego

San Francisco

SanJoaquin

SanLuis

Obispo

SanMateo

SantaBarbara

Santa Clara

SantaCruz

Shasta

Sierra

Siskiyou

Solano

Sonoma

Stanislaus

Sut-ter

Tehama

Trinity

Tulare

Tuolumne

Ventura

Yolo

Yuba �PPO Only Counties

HMO & PPO Counties

Plan may not be available in all Zip Codes within county. Check with your HSA California representative to confirm if coverage is available for your group location.

17

The following HMOs have an “Excellent” rating from the NCQA for their commercial products:

Kaiser Foundation Health Plan, Inc. - Southern California (HMO)Kaiser Foundation Health Plan, Inc. - Northern California (HMO)

Western Health Advantage (HMO)

www.choiceadmin.com


MEDICAL

18

HSA California®

www.choiceadmin.com

Carrier Contact Information

Member SupportHSA California ® Customer Service 866-251-4718Health Net 800-361-3366Western Health Advantage 888-563-2250Kaiser Permanente

English 800-464-4000Spanish 800-788-0616


Internet Support www.hsacalifornia.com


Broker Services &Commissions Fax 714-972-7368



Missing BOR Changes Fax 714-972-7368

To contact by mail or for payment submissions HSA California

721 South Parker, Ste. 200Orange, CA 92868


MEDICAL

HSA California®

Is Workers' Comp required oncorporate officers, partners and sole proprietors?

Is on-the-job covered for corporate officers, partners and sole proprietors?

Is there a premium adjustment for24 hour coverage?

How often can members change their Primary Care Physician (PCP)?Refer to summary on page 22

Can family members each choose a PCP from a differentIPA/Medical Group?Refer to summary on page 22

Maximum Choice For EmployeesEach employee's health care needs are different. The HSA Californiaprogram provides employees the maximum choice in meeting those needswith these health plans—all within one program:

HMO

Available

Buy-up

Discount or Buy-up

Not Available

Varies by HCSP

2-50


No

No

Yes

PLEASE NOTE: Not all health plans are available in all areas

Products Offered

Multi Option (Mix And Match)

OptionalBenefits

GROUP SIZE


HSA California

HSA California®

HSA California

LIFE

DENTAL

VISION

INFERTILITY

MASSAGE THERAPY

Health Net PPOKaiser Permanente HMOWestern Health Advantage HMO

24 HOUR COVERAGE



Express referral available?Varies by Health Care Service Plan (See summary on page 22)

Varies by Health Care Service Plan (See summary on page 22)

HMO 1800HMO 2200HMO 2600

HMO 2800B

PPOPPO 2500PPO 3500PPO 4500

SELECTION

NETWORKS

19


*100%

N/A N/A

*100% ◆70%

N/A N/A


Employees

Dependents


Are Commission employees allowed?

Are 1099 employees allowed?

Are employees covered if traveling out of USA?

Is coverage available for out-of-state employees?

Max. % of employees residing out-of-state allowed

Yes—if on quarterly/annual wage report and showing at least minimum wages and withholdings

No

Only for emergency benefits

Yes*— PPO 2500, PPO 3500, PPO 4500

*Except for employees in Hawaii

49% (Main office must be located in California)

2-50


N/A

N/A

2 2

50* N/A 2-50 No

2-50 No




Carve Outs*

Wrap* Requirements





HSA California®

HSA California

HSA California

AFTER INITIAL ISSUE



No

No


2

Yes



Union/Non-union?

Minimum group size



20


GROUP SIZEPARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

†

Employees

For Dependents

% of Total Cost:

2-2 3-50

Employees

Dependents


Current Employees

TimelyAdd-ons











FEES



Monthly Billing Fee



GROUP SIZE

ITEMS REVIEWED IN RAF CALCULATION

Rating Information

†† According to the California Insurance Code “The standardemployee risk rates applied to a small employer for new business shall be in effect for no less than six months.”


Medical Conditions

Years in Business

# of Pregnancies

Virgin Group

Type of Industry

Percent of Owners

Group Size

% of COBRA Insureds

% of Family Related

Participation

Plan(s) Requested



Bankruptcy

Gender Mix

1st of the month only

N/A

Min: 30 Max: 365

60 days


Yes

Yes

Yes


None

N/A

1-8 9-20 21+$20 $25 $30

No

No

No

No

No

No

Yes

No

No

No

No

No

No

No

No

2-4: 1.105-50: 1.0015-50: 1.00**Groups may qualify for a 0.90See quote for details.

12 Months

No

HMO: YesPPO: Yes


HSA California®

HSA California


HMO: N/APPO: Yes*

No

RAF Increments (2-50 lives)


Apply Trend Factor?

Use Employee Zips?

*This does NOT include credit for the RX deductible

21








Yes


Call representative

Yes*

Yes*

Yes

HSA California®


Call 800-511-0001www.choiceadmin.com


Prescriptions


If doctor writes “dispense as written” on prescription, is brand name available at the brand copay?


If medically necessary, are non-formulary drugs covered?

Mail order

Benefit Summary



FOR DETAILED BENEFIT INFO, LIMITATIONS AND EXCLUSIONS, PLEASE REFER TO BOOKLET CERTIFICATE/EVIDENCE OF COVERAGE, OR CONTACT YOUR HSA CALIFORNIA® REPRESENTATIVE


HSA California®

HSA California


HMO 2200$10 Generic$20 BrandHMO 2600$10 Generic$30 Brand

Anytime

Yes—but only PlanPhysicians

Yes—referrals comedirectly from PCP; no other approval is needed

Yes

Yes

Yes

No

Yes

How often can familymembers change theirPrimary Care Physician?(PCP)

Can family memberseach choose a PCP froma different IPA/MedicalGroup?



HMO 2200$20 Generic$40 BrandHMO 2600$20 Generic$60 Brand

Western HealthAdvantage HMO

Yes

Yes—Advantage ReferralProgram allows PCP to refer amember to a specialist who participates in WHA’sAdvantage Referral program

Yes—or you must paythe brand copay plusthe difference in costbetween brand name& generic equivalent

Yes

No

Yes

HMO 1800No Charge

HMO 2800B$25 Generic$75 Brand

$125 Non-Formulary

HMO 1800No Charge

HMO 2800B$50 Copay

Yes* — non-formulary copayapplies*Prior authorization may be requiredfor certain medications

Health NetPPO

Anytime—in a PPO,you do not have tochoose a PCP

Yes—each familymember can make theirown physician choice

Yes—in a PPO, youdon't have to gothrough a specialistreferral process

Yes—or you must paythe brand copay plusthe differencebetween the cost of the brand name & generic

Yes

Yes

Yes

Participating Pharmacy$30 Generic$60 Brand

$100 Non-Formulary

Non-ParticipatingPharmacy

Not Covered

Participating Pharmacy$50 Non-Formulary

Non-Participating Pharmacy50%

Prior authorization may berequired for certain medications

Yes

22

Once a month—changes are effectiveat beginning of following month,provided the member is not in thecourse of treatment or hospitalized andno pending authorizations


Benefit SummaryFOR DETAILED BENEFIT INFO, LIMITATIONS AND EXCLUSIONS, PLEASE REFER TO

BOOKLET CERTIFICATE/EVIDENCE OF COVERAGE, OR CONTACT YOUR HSA CALIFORNIA® REPRESENTATIVE



Are the following items covered under the Prescription Drug Benefit or the Durable MedicalEquipment Benefit of themember’s selected plan design?

Insulin



Needles & Syringes

Glucose Monitor†


Insulin Pump†


Diabetic Benefits HSA California®

Self-Injectable Drug Benefits



Durable MedicalEquipment ratherthan PrescriptionDrug BenefitHMO 2200 : 75%HMO 2600: 70%

Blood test strips- Durable Medical Equipment

Urine test strips - Prescription Drug Benefits




Must be prescribed byPlan physician, inaccord with our drugformulary guidelines

Must use plan pharmacies (including affiliated pharmacies)



Prescription Drug Benefit (preferredmonitors only) All other monitors covered as Durable Medical Equipment PPO 2500 & 3500:In-Network: 70% Out-of-Network: 50% PPO 4500:In-Network: 60% Out-of-Network: 40%


Durable Medical Equipment PPO 2500 & 3500:In-Network: 70% Out-of-Network: 50% PPO 4500:In-Network: 60% Out-of-Network: 40%

Durable Medical Equipment PPO 2500 & 3500:In-Network: 70% Out-of-Network: 50% PPO 4500:In-Network: 60% Out-of-Network: 40%

Medical Benefit

Yes—required through Pharmacy

May use mail order vendor or contracted pharmacy vendor

Health NetPPO

Western HealthAdvantage HMO



Durable MedicalEquipment ratherthan PrescriptionDrug BenefitHMO 1800: 100%HMO 2800B: 80%


Durable MedicalEquipment Benefit:HMO 1800: 100%HMO 2800B: 80%

Durable MedicalEquipment Benefit:HMO 1800: 100%HMO 2800B: 80%

Medical Benefit

Yes

Depends on Medical Group

23

HSA California

† Vendors for Diabetes Equipment: Pending Benefits are typically covered

under the pharmacy benefit withparticipating pharmacies. Health Net will only cover certain machines

Contract is with Medical Group. See PCP


GENERIC VS. BRAND NAMEIf generic available, and doctor has not indicated “dis-pense as written,” will member receive a genericequivalent rather than a brand name drug?

Refer to summary on page 22

Special Concerns*

Hearing treatmentHMO: Routine hearing screening in PCP's office only—office visit copay applies

PPO: Covers ear screenings to determine the need foraudiograms for dependent children through age18 only

Are Hearing Aids covered?No

HSA California now offers EPIC Hearing Service Plan (HSP) toall HSA California members at no additional costSpeech therapyHMO: Outpatient covered if HCSP determines there will be significant improvement in 60 days—office

visit copay applies

PPO: Covered for certain conditions (see Evidence ofCoverage or call representative)—subject todeductible and coinsurance

Prescriptions

FORMULARY VS. NON-FORMULARYDoes carrier use Rx formulary?Refer to summary on page 22

Are non-formulary drugs available?Refer to summary on page 22

MAIL ORDER - 90 DAY SUPPLY$20 generic/$40 brandRefer to summary on page 22

* Unless otherwise noted, information shown in this section reflects in-network benefits.

HSA California®

HSA California

InfertilityNot Covered

If doctor writes “dispense as written” on prescription, is brand name available at the brandcopay amount?Refer to summary on page 22

24

KEY TO HEALTH CARE SERVICE PLANSOFFERING LISTED PROGRAM

HN Health NetKP Kaiser PermanenteWH Western Health Advantage

* All HSA California ® medical members are eligible for discounts on eye exams,lenses, frames, and contacts through the Vision One Eye Care Programadministered by Cole Managed Vision/EyeMed Vision Care.

1 Discounts of frames and lenses available through Kaiser Permanente facilities.

2 Discounts on vitamins and herbal supplements available through the “Affinity Program” which links Kaiser Permanente members to Healthy Roads3

Member must use a Kaiser Permanente weight loss program.

Which health care plans offer these discounts, awards and other value-added benefits?Eyewear & lenses discount..............................................................................................................................................KP 1

Health Club Membership or fitness equipment/sporting goods discount ........................................................HN, KP, WHHealth Literature, telephone tapes and/or videos (no charge)..................................................................................HN, KP available in the following languages: SpanishHome childproofing products discount ..........................................................................................................................HNInfant car seat: discount ............................................................................................................................................................HN awarded upon prenatal class completion ..........................................................................................................HNNurses 24 Hour Hotline ............................................................................................................................................HN, KPVitamins and/or herbal supplements discount ........................................................................................................HN, KP 2

Weight control program discount............................................................................................................................HN, KP 3

Discounts, Awards & Other Value-Added Benefits HSA California


Colusa

CalaverasMarin

Monterey

Sacra-mento

Alameda

AlpineAmador

Butte

ContraCosta

Del Norte

El Dorado

Fresno

Glenn

Humboldt

Imperial

Inyo

Kern

Kings

Lake

Lassen

Los Angeles

Madera

Mariposa

Mendocino

Merced

Modoc

Mono

Napa

Nevada

Orange

Placer

Plumas

Riverside

SanBenito

San Bernardino

San Diego

San Francisco

SanJoaquin

SanLuis

Obispo

SanMateo

SantaBarbara

Santa Clara

SantaCruz

Shasta

Sierra

Siskiyou

Solano

Sonoma

Stanislaus

Sut-ter

Tehama

Trinity

Tulare

Tuolumne

Ventura

Yolo

Yuba Plan may not be available in all Zip Codes withincounty. Check with your Kaiser Permanente ChoiceSolution representative to confirm if coverage isavailable for your group location.�All Plan Types Available

HMO, POS & PPO

PPO Only

25



Kaiser Foundation Health Plan, Inc. - Southern California (HMO)

Kaiser Foundation Health Plan, Inc. - Northern California (HMO)

26

Kaiser Permanente Choice Solution

www.choiceadmin.com

Carrier Contact Information

Member Support Kaiser Permanente Choice SolutionCustomer Service Center

English 800-580-9626

Kaiser PermanenteEnglish 800-464-4000Spanish 800-788-0616


Internet Support www.kpchoicesolution.com


Renewal Changes Employer Fax 800-566-7803 Employee Fax 800-566-8514

Commissions/Broker Services 800-542-4218, Ext. 4390


Missing BOR Changes Fax 800-580-9626

Claims Kaiser Permanente Claims 800-464-4000

To contact by mail or for payment submissions CHOICE Administrators ®

721 South Parker Suite 200 Orange, CA 92868


MEDICAL


LIFE

DENTAL

VISION

INFERTILITY

CHIROPRACTIC

ACUPUNCTURE

MASSAGE THERAPY

Products Offered

OptionalBenefits

GROUP SIZE


HMO PPO POS


HSA-CompatibleDHMO

HRA-CompatiblePPO

MRP-CompatiblePPO

Available

Available

Not Available

HMO: Benefits vary by planPOS/PPO: Benefits vary by plan

Not Available

Not Available

Not Available

HMO 10HMO 30

HMO 20/$1,000

N/A

30/$500 20/$1,000

HDHP 1900*HDHP 2700*

N/A



2-50

Is Workers' Comp required on corporate officers, partners and sole proprietors?

Is on-the-job covered for corporate officers, partners and sole proprietors? Yes

Is there a premium adjustment for24 hour coverage? No


How often can members change their Primary Care Physician (PCP)?

Can family members each choose a PCP from a differentIPA/Medical Group?Yes—HMO: From Kaiser Permanentephysicians

POS/PPO: From PHCS Network

HMO/EPO

Kaiser Permanente

POS/PPOPrivate Healthcare Systems (PHCS)

Anytime—change is effective immediately

No

24 HOUR COVERAGE


No prior authorization or referralfor OB/GYN (can be primaryprovider)Other specialists: Yes—to certainspecialties. Self-refer specialtieslist varies by geographical region

Yes—referral direct from physician

Express referral available?

SELECTION

NETWORKS


27







Union/Non-union?

Minimum group size



Employees

For Dependents

% of Total Cost:


Carve Outs*

Wrap* Requirements




Are Commission-Only employees allowed?

Are 1099 employees allowed?

Are employees covered if traveling out of USA?

Is coverage available for out-of-state employees?

Max. % of employees residing out-of-state allowed

Yes—if on quarterly/annual wage report and showing at least minimum wages and withholdings

No

Only for emergency benefits

Yes

49% (At least 51% of eligible employees must live or work in California)

2-50


N/A

N/A

2 2

50* N/A 2-50 Yes—contact your Kaiser Permanente Choice Solution representative regarding guidelines

2-50 Yes—contact your Kaiser Permanente Choice Solution representative regarding guidelines


No

No


2

Yes

2 2

50* N/A

AFTER INITIAL ISSUE




28


GROUP SIZE


PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE


†

*100% ◆70%

N/A N/A

Employees

Dependents

2-2 3-50

*100%

N/A N/A

Employees

Dependents


Current Employees

TimelyAdd-ons

Group Size


Apply Trend Factor?

Use Employee Zips?











FEES



Monthly Billing Fee



GROUP SIZE

Rating Information

†† According to the California Insurance Code “The standardemployee risk rates applied to a small employer for new business shall be in effect for no less than six months.”


Medical Conditions

Years in Business

# of Pregnancies

Virgin Group

Type of Industry

Percent of Owners

Group Size

% of COBRA Insureds

% of Family Related

Participation

Plan(s) Requested



Bankruptcy

Gender Mix



1st of the month

N/A

Min: 1st of the month following date of hire Max: 365 days

60 days


Yes

Yes

Yes


None

N/A

2-8 9-20 21+$20 $25 $30

No

No

No

No

No

No

Yes

No

No

No

No

No

No

No

No


2-5: 1.106-15: 1.00

16-50: 0.90

12 Months

No

Yes


HMO: N/APPO: Yes*

No*This does NOT include credit for the RX deductible


29








Yes

Call representative

Yes*

Yes*

Yes

Kaiser PermanenteChoice Solution


Special Concerns*

Infertility

Prescriptions

GENERIC VS. BRAND NAMEIf generic available, and doctor has not indicated“dispense as written,” will member receive a genericequivalent rather than a brand name drug?HMO/POS/PPO: Yes

If doctor writes “dispense as written” on prescription, is brand name available at the brandcopay amount?HMO/POS/PPO: Yes

FORMULARY VS. NON-FORMULARYDoes carrier use Rx formulary?Yes

Are non-formulary drugs available?Yes

MAIL ORDER - 90 DAY SUPPLYYes

Are oral contraceptives covered?Yes

* Unless otherwise noted, information shown in this section reflects in-network benefits. For Triple Option plans, the most managed plans are shown.

BENEFIT INFORMATION SHOWN ON THIS PAGE IS A BRIEF SUMMARY. LIMITATIONS AND EXCLUSIONS APPLY. PLEASE REFER TO CERTIFICATE BOOK, EVIDENCE OF COVERAGE OR CALL REPRESENTATIVE FOR DETAILS.

Hearing treatmentHMO: Medical exams of the ear and audiometric

exam to measure hearingPOS/PPO: Call your Kaiser Permanente Choice Solution

representative

Are Hearing Aids covered?Call your Kaiser Permanente Choice Solution representativeSpeech therapyHMO: Covered if medically necessaryPPO: Covered if medically necessaryPOS: Covered if medically necessary



HMO: 50% for diagnosis and treatment of cause ofinfertility.

POS/PPO: Benefits vary by plan

Aetna

SELF-INJECTABLE DRUGBENEFITS

Are self-injectable drugs(other than insulin)covered under the

Prescription Drug Benefitor Medical Benefit?


*Must self-injectables(other than insulin)

be purchased via thecarrier-contracted

mail order Rx vendor?

HMO Prescription Drug Benefit No Use plan pharmacies

(including affiliated)

POS Prescription Drug Benefit No Use plan pharmacies


PPO Prescription Drug Benefit No Use plan pharmacies


Diabetic & Self-Injectable Drug BenefitsAre the following items covered under the Prescription Drug Benefit or the Durable Medical Equipment Benefit of the member’s selected plan design?

DIABETES BENEFITS

InsulinNeedles &Syringes


Insulin PumpSupplies Insulin Pump† Glucose Monitor†

Rx Drug Benefit ■ ■ ■ Urine test strips


■ Blood test strips ■ ■ ■

†Vendors for Diabetes Equipment: See kp.org for vendors

These services may change at any time without notice. Please contact your Kaiser Permanente Choice Solution rep for specific inquiries on listed services


30


Ancillary ConsumerExchange Program

31

PPO Silver*PPO Gold*PPO Platinum*

Ameritas GroupPPO

Out-of-State Coverage

California Coverage Area

Dual Option (Mix and Match)

3 Dental Carriers / 3 Vision Carriers / Chiro-Acupuncture / Life. Call your Choice Builder representative for more details.


Products Offered

What coverage is offered for Out-of-State employees?

What is the minimum % of employees required in CA?

What dental benefits (or plan types, such as PPO,Indemnity, etc.) are offered for Out-of-State employees?

What states are allowed (or not allowed) for Out-of-State Coverage?

Are dental rates for Out-of-State employees based on the CA Employer Zip Code or based on Out-of-State ZipCode?

Any other rules, restrictions or guidelines not mentioned:

HMO Silver*HMO Gold*

Ameritas Group – PPO network Delta Dental HMO – DeltaCare USADelta Dental PPO – Delta Dental PPONetworkEyeMed (provided by Ameritas Group)Access NetworkMadison National Life – Dental (Providedby GroupLink Inc.) –FDH NetworkMadison National Life – Vision (Providedby Davis Vision)Landmark Healthplan – ChiropracticVSP - Vision – VSP Network

Coverage area varies by plan. Please contactyour Choice Builder® representative for a quote

Delta Dental

Out-of-State employees have access to the Delta Dental DHMOin TX, GA and FL. Residents of all other states will have thePPO/Indemnity carrier chosen by the employer

N/A

Delta Dental DHMO available in FL, GA and TX only. Residents ofall other states (except Hawaii) have the PPO/Indemnity carrierschosen by the employer

Out-of-State employees have access to the Delta Dental DHMOin TX, GA and FL only. All others have the PPO/Indemnity carrierchosen by the employer

Delta Dental DHMO is rated by employee Zip Code, all other carriers are rated by employer Zip Code

Employer’s home office must be located in CA. If incorporated inanother state, documents must show a home office address in CA.

Benefits are offered both as Employer Sponsored and Voluntary (except Life).Employer must purchase dental in order to offer any other line of coverage. Group must offer 1 PPO/Indemnity/EPO dental carrier to go along withthe Delta Dental DHMO carrier. Group Size: 2-99

HMO

EPO Silver*

Madison NationalLife Insurance Company

EPO Indemnity

Indemnity Platinum*

Madison National Life Insurance Company

Dental

EyeMedSilver*Gold*Platinum*

VisionVSPSilverGold*Platinum*

Madison National LifeInsurance CompanySilver*Gold*Platinum*

*Available both Employer Sponsored and Voluntary.

Landmark Healthplan*Call your Choice Builder representative for more details

Chiropractic/AcupunctureAssurity LifeCall your Choice Builder representative for more details

Life

33

PPO Gold (Employer sponsored only)PPO Silver (Voluntary sponsored only)

Delta Dental

PPO Gold*

Madison NationalLife Insurance Company

www.choiceadmin.com

Customer Service CenterChoice Builder 866-412-9279Member Service DentalAmeritas Group 800-487-5553Delta Dental HMO 800-422-4234Delta Dental PPO 888-335-8227Madison National Life 866-412-9279VisionMadison National Life (Davis Vision) 800-999-5431 EyeMed (provided by Ameritas) 866-289-0614VSP 800-877-7195Chiropractic/AcupunctureLandmark Healthplan 800-638-4557LifeAssurity Life Insurance Company 800-869-0355Commissions Choice Builder 714-567-4390Add-ons/Deletes Choice Builder Fax 866-412-9280

Dental Claims Delta Dental12898 Towne Center DriveCerritos, CA 90703

Ameritas GroupP.O. Box 82520Lincoln, NE 68501Fax 402-467-7336

Madison National lifeCX015 Grouplink Inc.P.O. Box 20593 Indianapolis, IN 46220877-223-4693

ANCILLARY CONSUMER EXCHANGE PROGRAM


Employer Sponsored

• Minimum Employee participation must be at least 70%• Minimum Dependent participation is 0%

Dental Benefits

Participation Requirements

Voluntary

• Minimum of 10 eligible Employees with a minimum participation of at least 5 enrolled in dental

• Minimum Dependent participation is 0%


• The Employer must contribute at least 50% of the lowest cost benefit design

• No Employer contribution is required for Dependent Coverage

Minimum Employer Contribution

• No Employer contribution requiredMinimum Employer Contribution

Employer Sponsored

• Minimum Employee participation must be at least 70%• Minimum Dependent participation is 0%

Vision Benefits


Voluntary

• No minimum participation requiredParticipation Requirements

• The employer must contribute at least 50% of the lowest cost benefit design

• No Employer contribution is required for Dependent Coverage



Employer Sponsored

• 100% Employee participation is required• Minimum Dependent participation is 0%

Chiropractic/Acupuncture Benefits


Voluntary

• No minimum participation requiredParticipation Requirements

• The Employer must contribute 100% of the Employee premium

• Dependent Coverage is included as this is a discount plan only



Employer Sponsored

• 100% Employee participation is required

Life Benefits


• The Employer must contribute 100% of the Employee premiumMinimum Employer Contribution

34

www.choiceadmin.com ANCILLARY CONSUMER EXCHANGE PROGRAM

Are Commission-Only employees allowed? No


Any ineligible industries? Yes—Delta Dental PPO Employer sponsored plan—contact your Choice Builder representative; and Dental offices for Madison National Life

Virgin groups eligible? Yes

Quarterly/annual wage report required?Upon request

Rating Information

EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?No

Management/Non-management?No

Union/Non-union?Yes—eligible non-union members only. Employer tosubmit union billing

Minimum group size2

Carve Outs*

Orthodontic Coverage

Waiting Period Waiver/Takeover

Out-of-Network Claim Adjudication


Group Size

Rate Guarantee

Rates vary by Industry?

Coverage Requirements

2-99

12 months

Delta Dental DHMO – (included) no wait

Delta Dental DPPO ††† – Employer sponsored: no waitVoluntary: 12 months

Ameritas Group†† – 24 month wait†

Madison National Life†† – Employer Sponsored: 12 months;Voluntary: 12 month wait

† Ameritas Dental optional ortho benefit only available togroups of 5 or more employees.

†† Waiting Periods can be waived if there is a minimum of 10employees enrolled on a Choice Builder PPO dental plan andthe employer has a current comparable PPO dental planinforce. Partial and/or Full Credit given for entire initialenrolling population. Billing from 12 months ago and currentbill is required at underwriting, and possibly the currentcarrier’s Benefit Booklet.

††† Delta Dental employer sponsored plan optional ortho benefitonly available to groups of 10 or more employees, voluntaryplan optional ortho benefit only available to groups of 25 ormore employees.

All newly enrolled employees after initial enrollment aresubject to wait periods below (Basic / Major / Ortho):

Ameritas Group – Employer Sponsored or Voluntary:3/12/24 months

Madison National Life – Employer Sponsored or Voluntary:3/12/12 months

HMO: N/AMadison National LifeIndemnity – 90th percentile; EPO – Max. allowable charge.

Ameritas GroupSilver Benefits – Average prevailing fee; Gold/Platinum Benefits – 80th percentile of U&C

Delta Dental PPOMax. allowable charge.

Delta Dental DHMO – N/A

Delta Dental PPO – N/A

Madison National Life – At initial group enrollment, groups with 10+ eligibleemployees and prior continuous orthodontic dentalcoverage, will waive up to 12 months waiting period basedon group’s number of prior continuous uninterruptedorthodontic coverage.

Ameritas Group – At initial enrollment, employer-sponsored groups with 10+eligible employees and prior continuous dental coverage of12+ months, will waive major waiting period of 12 months.Will waive orthodontic waiting period of 24 months, ifemployer-sponsored group had prior continuousuninterrupted orthodontic coverage of 12+ months.

Dental- varies by carrierLife - YesVision & Chiro - No

35

www.choiceadmin.comANCILLARY CONSUMER EXCHANGE PROGRAM

Dental

37



Products Offered

Is Coverage Offered for Out-of-State employees?


What plans (or plan types, such as PPO, Indemnity, etc)are offered for Out-of-State employees?


Are rates for Out-of-State employees based on the CAEmployer Zip Code or based on Out-of-State Zip Code?


CaliforniaChoice has optional dental that can be offered along with medical.Employers may elect to offer one of the following to their employees:

■ All buy-up dental plans: Prepaid 1000 & 3000, EPO 3000 & 3500, and PPO 4000& 5000 WITHOUT Ortho

■ All buy-up dental plans: Prepaid 1000 & 3000, EPO 3000 & 3500*, and PPO4000* & 5000* WITH Ortho

■ Voluntary Prepaid 3000 and FDH Access 100**■ FDH Access 100 only**

Employees may select the best dental plan to fit their needs out of those plansoffered by their employer.

* PPO plans with Ortho are only available to groups with 5 or more eligible employees.

** FDH Access 100 is included in the program at no additional cost and offers services atreduced fees. Employees and dependents (if applicable) must be enrolled for medicalcoverage through the CaliforniaChoice Program.

FDH 100: All CountiesSmileSaver Plan 1000 & 3000: All Counties

Plan 3000 & 3500: All Counties


Plan 3000Plan 3500

2-502-50

Plan 4000Plan 5000

2-502-50

Yes

California HMO Counties:

California EPO Counties:

California PPO Counties:

† If employer currently is not offering dental, FDH (First Dental Health) Access 100 Dental Program (if elected) is included at noadditional cost for employees and their dependents enrolled in CaliforniaChoice medical.

* Prepaid 3000 also is available on a voluntary basis with no minimum employee participation requirement.

FDH Access 100+ Plan 3000* Plan 1000

2-502-502-50

Prepaid/HMO Group Size

EPO Group Size

PPO Group Size


CaliforniaChoice dental is available only to groups with CaliforniaChoice medical coverage

FDH Access 100:First Dental Health Access

Plan 1000 & 3000:SmileSaver Dental

PROVIDER INFORMATION

Indemnity Network


Plan 3000 & 3500:First Dental Health EPO

Plan 4000 & 5000:Ameritas PPO

51%

All are allowed except Hawaii

PPO and EPO

It is based on the Employer Zip Code

N/A

39

www.choiceadmin.com

Customer Service CenterCaliforniaChoice® 800-558-8003Member ServiceAmeritas Group 877-203-0036FDH Access 800-558-8003 SmileSaver 800-880-1800CommissionsCaliforniaChoice 714-542-6992 x4390Dental ClaimsAmeritas Group (EPO/PPO): Ameritas Group

P.O. Box 82520 Lincoln NE 68501 877-203-0036 Fax 402-467-7336

SmileSaver SmileSaver Attn: Claims Dept. P.O. Box 30920 Laguna Hills, CA 92654 800-880-1800Add-ons/DeletesCaliforniaChoice Fax 714-558-8000

HMO Network

EPO Network

PPO Network

DENTAL

HMO N/A

EPO & PPO For groups with 10 or more employees, the12 month waiting period for major serviceswill be waived for individuals who wereenrolled under this employer’s comparablegroup dental plan for 12 months or more.Groups without prior comparable dentalcoverage are subject to the waiting period.Credit will be given for time on the priorplan. If orthodontia was covered oncomparable prior plan, credit will be giventoward the 24 month ortho waiting period.


FDH Access 100—$4,277 copay for child or adult ortho Plan 1000 & 3000—$1600 copay for child/$1950 copay foradult

Employees

Dependents

Employees

Dependents

Employees

For Dependents

% of Total Cost:

Rating Information

MINIMUMEMPLOYERCONTRIBUTION

PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE

◆ Those covered by another plan are NOT considered eligible in calculating participation◆◆ In order to NOT be considered eligible, the other coverage must be a group plan



Union/Non-union?

Minimum group size

Carve Outs*

HMO


Out-Of-Network Claim Adjudication


Group Size

Rate Guarantee


COVERAGE REQUIREMENTS



Union/Non-union?

Minimum group size

Are Commission-Only employees allowed? Yes—if on quarterly/annual wage report and showing atleast minimum wages and withholdings

Are 1099 employees allowed?No

Any ineligible industries?No

Virgin groups eligible?Yes

Quarterly/annual wage report required?Yes

No

No

Yes – coverage available for non-union only. Group must submit union billing to underwriting forverification that all other employees have medical coverage.

2

2-50

2-50

2-50

12 Months

No

2-50 Plan 3000Voluntary

0%

0%

0%


0%

0%

◆◆ 100%

0%

0%

0%

EPO & PPO

0%

0%

50% of employee only premiumfor lowest cost plan offered

◆◆ 70%

0%

Coverage RequirementsWaiting Period Waiver/Takeover

Special ConsiderationsEnrollment for spouse and children is contingent on employeeenrollment. Dependent enrollees for dental cannot differ fromdependent enrollees for medical coverage (except for childrenunder age 3). However, if dependents do not enroll in medical,then any dependent make-up for dental is acceptable.

HMO N/A

EPO Plan 3000 & 3500 - Out of network claims are paid basedupon the maximum allowable charge or scheduled charge. Forgroups of 2-4 employees, out-of-network restorative is coveredat 50% with no waiting period.

PPO Plan 4000 & 5000 - Out of network claims are paid basedon U & C 80th percentile. For groups of 2-4 employees, out-of-network restorative is covered at 50% with no waiting period.

40

www.choiceadmin.com

Plan 3500, 4000 & 5000—Optional benefit* available togroups of 5 or more eligible employees. 50% to No AnnualMaximum/$1000 Lifetime Maximum 24-month wait except for10+ groups that meet the criteria outlined in waiting periodwaiver section below.

* Orthodontia is an optional benefit chosen for theentire group by the employer.

DENTAL

41



Dual Option (Mix and Match) Provider Information

Products Offered







SmileSaver Plan 1000 & 3000: All Counties



Yes

California HMO Counties:

California EPO Counties:


51%

All are allowed except Hawaii

PPO and EPO

It is based on the Employer Zip Code

N/A

HSA California has optional dental that can be offered along with medical.Employers may elect to offer one of the following to their employees:

■ All buy-up dental plans: Prepaid 1000 & 3000, EPO 3000 & 3500, and PPO 4000& 5000 WITHOUT Ortho

■ All buy-up dental plans: Prepaid 1000 & 3000, EPO 3000 & 3500*, and PPO4000* & 5000* WITH Ortho

■ Voluntary Prepaid 3000

Employees may select the best dental plan to fit their needs out of those plansoffered by their employer.

* PPO plans with Ortho are only available to groups with 5 or more eligible employees.

Plan 3000Plan 3500

2-502-50

Plan 4000Plan 5000

2-502-50

* Plan 3000 is also available on a voluntary basis with no minimum employee participation requirement.

Plan 3000* Plan 1000

2-502-50

Prepaid/HMO Group Size

EPO Group Size

PPO Group Size

HSA California dental is available only to groups with HSA California medical coverage

Plan 1000 & 3000:SmileSaver Dental

Plan 3000 & 3500: First Dental Health Network

Plan 4000 & 5000:Ameritas PPO

www.choiceadmin.com

Customer ServiceHSA California® 866-251-4718Member ServiceAmeritas Group 877-203-0036SmileSaver 800-880-1800CommissionsHSA California 714-542-6992 x4390Dental ClaimsAmeritas Group (EPO/PPO): Ameritas Group

P.O. Box 82520 Lincoln, NE 68501 877-203-0036 Fax 402-467-7336

SmileSaver SmileSaver Attn: Claims Dept. P.O. Box 30920 Laguna Hills, CA 92654 800-880-1800Fax (Add-ons/Deletes)HSA California 866-251-4724

EPO Network

HMO Network

PPO Network

DENTAL

Employees

Dependents

Employees

Dependents

Employees

For Dependents

% of Total Cost:

Rating Information

PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE


Carve Outs*



Group Size

Rate Guarantee



MINIMUMEMPLOYERCONTRIBUTION

2-50

2-50

2-50

12 Months

No


0%

0%

0%


0%

0%

◆◆ 100%

0%

0%

0%

0%

0%

50% of employee only premiumfor lowest cost plan offered

◆◆ 70%

0%



Union/Non-union?

Minimum group size

No

No

Yes – coverage available for non-union only. Group must submit union billing to underwriting for veri-fication that all other employees have medical coverage.

2

Are Commission-Only employees allowed? Yes, if on quarterly/annual wage report and showing at least minimum wages and withholdings

Are 1099 employees allowed?No

Any ineligible industries?No

Virgin groups eligible?Yes

Quarterly/annual wage report required?Yes


HMO N/A

EPO & PPO For groups with 10 or more employees, the12 month waiting period for major serviceswill be waived for individuals who wereenrolled under this employer’s comparablegroup dental plan for 12 months or more.All new hires and groups without priorcomparable dental coverage are subject tothe waiting period. Credit will be given fortime on the prior plan. If orthodontia wascovered on comparable prior plan, creditwill be given toward the 24 month orthowaiting period.


Plan 1000 & 3000—$1600 copay for child/$1950 copay for adult

Plan 3500, 4000 & 5000—Optional benefit* available togroups of 5 or more eligible employees. 50% to No AnnualMaximum/$1000 Lifetime Maximum 24-month wait except for10+ groups that meet the criteria outlined in waiting periodwaiver section below.

* Orthodontia is an optional benefit chosen for theentire group by the employer..

HMO

EPO & PPO


Special ConsiderationsEnrollment for spouse and children is contingent on employeeenrollment. Dependent enrollees for dental cannot differ fromdependent enrollees for medical coverage (except for childrenunder age 3). However, if dependents do not enroll in medical,then any dependent make-up for dental is acceptable.

42

www.choiceadmin.com

HMO N/A

EPO Plan 3000 & 3500 - Out of network claims are paid basedupon the maximum allowable charge or scheduled charge. Forgroups of 2-4 employees, out-of-network restorative is covered at50% with no waiting period.

PPO Plan 4000 & 5000 - Out of network claims are paid basedon U & C 80th percentile. For groups of 2-4 employees, out-of-network restorative is covered at 50% with no waiting period.

DENTAL

43




California DHMO Counties:

Boxes containing asterisks indicate that these coordinate plans offered by this carrier can be writtentogether to create a dual option package. The number indicates the minimum enrollment requiredon each of the coordinate plans. Blank boxes indicate which plans cannot be written together


Products Offered


California Indemnity Counties:







DHMO—DeltaCare® USA eligible Zip Codes

PPO—Delta Preferred Counties

FFS—Delta Premier (all counties)

DeltaCare® USA

Delta PPOPPO

*

FFS

2-50 PPO

Prepaid/DHMO Group Size

PPO Group Size

Indemnity Group Size

2-50 FFS

* PPO—only available if employee resides in PPO plan service area FFS—only available to employees outside PPO plan service area DHMO—only available to employees residing in DHMO service area

Delta Premier

Yes

51%

All states eligible

Fee for Service Only

Employee Zip Codes

Employer may only elect dental at initial or open enrollment. Employer cannot elect dental as a standalone product.

DHMO *

PPO

*

2-50 DHMO

www.choiceadmin.com

Customer Service CenterKaiser Permanente Choice Solution800-580-9626

Fax (Add-ons/Deletes)800-566-8514

Commissions800-542-4218, Ext. 4390

ClaimsContact carriers directly

PPO Network

Indemnity Network

DHMO Network

DENTAL

Employees

Dependents

Employees

Dependents

Are Commission-Only employees allowed? Yes—if on quarterly/annual wage report and showing at least minimum wages and withholdings


Any ineligible industries? No

Virgin groups eligible? Yes

Quarterly/annual wage report required?No—payroll OK

Employees

For Dependents

% of Total Cost:

Rating Information


PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE




Union/Non-union?

Minimum group size

Carve Outs*

Special Considerations

DHMO






Group Size

Rate Guarantee


PPO

FFS


No waiting period

Yes

No

No

Non-union only

2

All plans

2-50

2-50

12 Months

No

◆◆ 100%

0%

50%

0%50% of employee only premium

for lowest cost plan offered

◆◆ 70%

0%Yes—$1,500 lifetime maximum

Yes—$1,500 lifetime maximum

DHMO—only available if employee resides in DHMOplan service area

PPO—only available if employee resides in PPO planservice area

FFS—only available to employees outside PPO planservice area

44

www.choiceadmin.com

PPO Delta-approved fee schedule

FFS Plan allowance based on fees that satisfy the majority of Delta dentists or submitted fees (whichever is less)

DENTAL

www.choiceadmin.com721 South Parker, Suite 200Orange, CA 92868

800.511.0001

CHOICE Administrators Program Reference Guide Reference Guide Contents TO OUR BROKERS: The...

Documents

Transcript of CHOICE Administrators Program Reference Guide Reference Guide Contents TO OUR BROKERS: The...