HomeMy WebLinkAboutAgreement A-20-496 with Kaiser Permanente.pdfGroup Agreement
Kaiser Foundation Health Plan, Inc.
Northern California Region
A nonprofit corporation
Group Agreement for
COUNTY OF FRESNO, RETIREE
Group ID: 604334 Contract: 1 Version: 24
January 1, 2021, through December 31, 2021
Agreement No. 20-496
TABLE OF CONTENTS
Introduction............................................................................................................................................................................1
Term of Agreement and Renewal ..........................................................................................................................................1
Term of Agreement............................................................................................................................................................1
Renewal..............................................................................................................................................................................1
Amendment of Agreement.....................................................................................................................................................2
Amendments Effective on your Group’s Anniversary Date..............................................................................................2
Amendments Related to Government Approval................................................................................................................2
Amendment Due to Medicare Changes..............................................................................................................................2
Amendment Due to Tax or Other Charges.........................................................................................................................2
Other Amendments.............................................................................................................................................................2
Acceptance of Amendments...............................................................................................................................................3
Termination of Agreement.....................................................................................................................................................3
Termination on Notice........................................................................................................................................................3
Termination Due to Nonacceptance of Amendments ........................................................................................................3
Termination for Nonpayment.............................................................................................................................................4
Termination for Fraud or Intentionally Furnishing Incorrect or Incomplete Information.................................................4
Termination for Violation of Contribution or Participation Requirements........................................................................4
Termination for Discontinuance of a Product or all Products within a Market.................................................................4
Contribution and Participation Requirements........................................................................................................................5
Miscellaneous Provisions.......................................................................................................................................................5
Assignment.........................................................................................................................................................................5
Attorney Fees and Costs.....................................................................................................................................................5
Confidential Information about Health Plan or its Affiliates.............................................................................................6
Contract Providers..............................................................................................................................................................6
Delegation of Claims Review.............................................................................................................................................7
Enrollment Application Requirements...............................................................................................................................7
Grandfathered Health Plan Coverage.................................................................................................................................7
Governing Law...................................................................................................................................................................7
Group Delegation to Health Plan of Clerical COBRA Functions......................................................................................7
Member Information ..........................................................................................................................................................8
No Waiver ..........................................................................................................................................................................9
Notices................................................................................................................................................................................9
Open Enrollment ................................................................................................................................................................9
Other Group coverage that covers Essential Health Benefits ..........................................................................................10
Reporting Membership Changes and Retroactivity .........................................................................................................10
Representation Regarding Waiting Periods .....................................................................................................................11
Right to Examine Records................................................................................................................................................11
Social Security and Tax Identification Numbers .............................................................................................................11
Premiums..............................................................................................................................................................................11
Due Date and Payment of Premiums ...............................................................................................................................11
New Members ..................................................................................................................................................................11
Membership Termination.................................................................................................................................................12
Premium Rebates..............................................................................................................................................................12
Medicare...........................................................................................................................................................................12
Subscriber Contributions for Medicare Part C and Part D Coverage...............................................................................13
Calculating Premiums......................................................................................................................................................14
Monthly Premiums for Kaiser Permanente Traditional HMO Plan — EOC # 1.............................................................14
Monthly Premiums for Kaiser Permanente Senior Advantage (HMO) with Part D — EOC # 2....................................16
Monthly Premiums for American Specialty Health Plans Chiropractic Plan — EOC # 3..............................................17
Monthly Premiums for Kaiser Permanente Senior Advantage (HMO) with Part D — EOC # 4....................................17
Monthly Premiums for Kaiser Permanente Traditional HMO Plan — EOC # 5.............................................................17
Monthly Premiums for American Specialty Health Plans Chiropractic Plan — EOC # 9..............................................19
Agreement Signature Page...................................................................................................................................................20
Acceptance of Agreement................................................................................................................................................20
Binding Arbitration..........................................................................................................................................................20
Signatures.........................................................................................................................................................................20
COUNTY OF FRESNO, RETIREE
Group ID: 604334
Contract: 1 Version: 24 Effective: 1/1/21 12/31/21
Date: November 6, 2020 Page 1
Introduction
This Group Agreement (Agreement), including the Evidence of Coverage (EOC) and other document(s) listed below, the
group application that Group submitted to Health Plan, and any amendments to any of them, all of which are incorporated
into this Agreement by reference, constitute the contract between Kaiser Foundation Health Plan, Inc., (Health Plan) and
COUNTY OF FRESNO, RETIREE (Group).
In consideration of timely payment of Premium, Health Plan will provide or arrange for covered Services to Members in
accord with the following document(s):
Health Plan products, including Ancillary Coverage offered by Health Plan:
Product name Contract option name for product EOC #
Kaiser Permanente Traditional HMO Plan TRADITIONAL PLAN HIGH 1
Kaiser Permanente Senior Advantage (HMO) with Part D SENIOR ADVANTAGE HIGH 2
American Specialty Health Plans Chiropractic Plan CHIROPRACTIC BENEFIT 3
Kaiser Permanente Senior Advantage (HMO) with Part D SENIOR ADVANTAGE - LOW OPTION 4
Kaiser Permanente Traditional HMO Plan TRADITIONAL PLAN - LOW OPTION 5
Chiropractic Services and Silver&Fit Healthy Aging and
Exercise Program
SLVRFIT CHIRO NCR 7
Chiropractic Services and Silver&Fit Healthy Aging and
Exercise Program
NCR SLVRFIT CHIRO 8
American Specialty Health Plans Chiropractic Plan HMO CHIRO ACN NCR 9
Pediatric dental coverage:
Not applicable
Other Ancillary Coverage:
Not applicable
In this Agreement, some capitalized terms have special meaning; please see the “Definitions” section in the EOC
document(s) for definitions of terms that are used in EOC document(s) and this Agreement.
Term of Agreement and Renewal
Term of Agreement
Unless terminated as set forth in the “Termination of Agreement” section, this Agreement is effective from January 1, 2021,
through December 31, 2021.
Renewal
This Agreement does not automatically renew. If Group complies with all of the terms of this Agreement, Health Plan will
offer to renew the Agreement, upon 60 days prior written notice to Group, by doing one of the following:
Providing Group with a new Group Agreement to become effective immediately after termination of this Agreement
Extending the term of this Agreement and making other changes pursuant to “Amendments Effective on your Group’s
Anniversary Date” in the “Amendment of Agreement” section
Sending Group a renewal notice, which will include a summary of changes to this Agreement that will become effective
immediately after termination of this Agreement. The new Group Agreement will incorporate the changes summarized
COUNTY OF FRESNO, RETIREE
Group ID: 604334
Contract: 1 Version: 24 Effective: 1/1/21 12/31/21
Date: November 6, 2020 Page 2
in the renewal notice. Health Plan will send Group the new Group Agreement after Group confirms it wants to make
additional changes or 60 days after Group’s Anniversary Date, if Group does not confirm
If Group does not want to renew the Agreement, Group must give Health Plan written notice as described under
“Termination on Notice” or “Termination due to Nonacceptance of Amendments” in the “Termination of Agreement”
section.
Note: Your Group’s Anniversary Date is January 1.
Amendment of Agreement
Amendments Effective on your Group’s Anniversary Date
Upon 60 days prior written notice to Group, Health Plan may extend the term of this Agreement and make other changes by
amending this Agreement effective January 1 (the Anniversary Date).
Amendments Related to Government Approval
If Health Plan notified Group that Health Plan had not received all necessary governmental approvals related to this
Agreement, Health Plan may amend this Agreement by giving written notice to Group after receiving all necessary
governmental approvals. Any such government-approved provisions go into effect on January 1, 2021 (unless the
government requires a later effective date).
Amendment Due to Medicare Changes
Health Plan contracts on a calendar year basis with the Centers for Medicare & Medicaid Services (CMS) to offer Kaiser
Permanente Senior Advantage. Health Plan may amend this Agreement to change any Kaiser Permanente Senior Advantage
EOCs and Premiums effective January 1, 2022 (unless the federal government requires or allows a different effective date).
The amendment may include an increase or decrease in Premiums and benefits (including Member Cost Sharing and any
Medicare Part D coverage level thresholds). Health Plan will give Group written notice of any such amendment.
In addition, Health Plan may amend this Agreement at any time by giving written notice to Group, in order to increase any
benefits of any Medicare product approved by the Centers for Medicare & Medicaid Services (CMS).
Amendment Due to Tax or Other Charges
If a government agency or other taxing authority imposes or increases a tax or other charge (other than a tax on or measured
by net income) upon Health Plan or Plan Providers (or any of their activities), then upon 60 days prior written notice,
Health Plan may increase Group’s Premiums to include Group’s share of the new or increased tax or charge. Group’s share
will be determined by dividing the number of Members enrolled through Group by the total number of members enrolled in
Health Plan’s Northern California Region.
Other Amendments
Health Plan may amend this Agreement at any time by giving written notice to Group, in order to address any law or
regulatory requirement, which may include an increase in Premiums to reflect an increase in costs to Health Plan or Plan
Providers (Health Plan will give Group 60 days prior written notice of any increase in Premiums or reduction in benefits).
COUNTY OF FRESNO, RETIREE
Group ID: 604334
Contract: 1 Version: 24 Effective: 1/1/21 12/31/21
Date: November 6, 2020 Page 3
Acceptance of Amendments
All amendments are deemed accepted by Group unless Group gives Health Plan written notice of nonacceptance within 15
days after the date of Health Plan’s amendment notice, in which case this Agreement will terminate pursuant to
“Termination due to Nonacceptance of Amendments” in the “Termination of Agreement” section.
Termination of Agreement
This Agreement will terminate under any of the conditions listed below. All rights to benefits under this Agreement end on
the termination date, except as expressly provided in the “Termination of Membership” or “Continuation of Membership”
sections of an Evidence of Coverage. The termination date is the first day when this Agreement is no longer in effect (for
example, if the termination date is January 1, 2022, the last minute this Agreement was in effect was at 11:59 p.m. on
December 31, 2021).
If Health Plan terminates this Agreement, Health Plan will give Group written notice. In the case of “Termination for
Nonpayment,” “Termination for Fraud or Intentionally Furnishing Incorrect or Incomplete Information,” and “Termination
for Discontinuance of a Product or all Products within a Market,” Health Plan will provide both advance notice of the
termination in addition to a final notice of termination. Within five business days of receipt of an advance or final notice of
termination, Group will mail to each Subscriber a legible copy of the notice and will give Health Plan proof of that mailing
and of the date thereof.
Termination on Notice
If Group has Kaiser Permanente Senior Advantage Members
If Group has Senior Advantage Members enrolled under this Agreement at the time Health Plan receives written notice
from Group that it is terminating this Agreement, Group may terminate this Agreement effective January 1 (the Anniversary
Date) by giving at least 30 days’ prior written notice to Health Plan and remitting all amounts payable relating to this
Agreement, including Premiums, for the period prior to the termination date.
If Group does not have Kaiser Permanente Senior Advantage Members
If Group does not have Senior Advantage Members enrolled under this Agreement at the time Health Plan receives written
notice from Group that it is terminating this Agreement, Group may terminate this Agreement effective January 1 (the
Anniversary Date) by giving at least 15 days’ prior written notice to Health Plan and remitting all amounts payable relating
to this Agreement, including Premiums, for the period prior to the termination date.
Termination Due to Nonacceptance of Amendments
All amendments are deemed accepted by Group unless Group gives Health Plan written notice of nonacceptance within 15
days after the date of Health Plan’s amendment notice and Group remits all amounts payable related to this Agreement,
including Premiums, for the period prior to the amendment effective date, in which case this Agreement will terminate on
the following date, as applicable:
In the case of amendments described in the “Amendment of Agreement” section under “Amendments Related to
Government Approval” and “Amendments Due to Medicare Changes,” and amendments described under “Other
Amendments” that do not require 60 days notice by Health Plan, if Group has Kaiser Permanente Senior Advantage
Members enrolled under this Agreement at the time Health Plan receives written notice of nonacceptance, the
termination date will be first of the month following 30 days after Health Plan receives written notice of nonacceptance
In all other cases, the termination date will be the day before the effective date of the amendment
COUNTY OF FRESNO, RETIREE
Group ID: 604334
Contract: 1 Version: 24 Effective: 1/1/21 12/31/21
Date: November 6, 2020 Page 4
Termination for Nonpayment
Premiums are due for the Full Premium owed as described in the “Premiums” section. If Health Plan does not receive the
required Premium payment for all coverage issued under this Agreement on or before the due date, we will send a notice of
nonpayment to Group as described under “Notices” in the “Miscellaneous Provisions” section. This notice will include the
following information:
A statement that we have not received Full Premium payment and that we will terminate this Agreement for nonpayment
if we do not receive the required Premiums by the specified date
The amount of Premiums that are due
If we do not receive the required Premiums when due, the Agreement will terminate and all coverage issued under the
Agreement will end on the date specified in the notice of nonpayment, which will be at least 30 days after the date of the
notice. The Agreement will remain in effect during this grace period, but upon termination Group will be responsible for
paying all past due Premiums, including the Premiums for this grace period.
We will mail a termination notice to Group as described under “Notices” in the “Miscellaneous Provisions” section if we
do not receive Full Premium payment within 30 days after the date of the notice of nonreceipt of payment.
If Group has Kaiser Permanente Senior Advantage Members enrolled under this Agreement at the time Health Plan gives
written notice to Group, Health Plan may terminate this Agreement effective on one date with respect to Members other
than Senior Advantage Members and effective on a later date with respect to Senior Advantage Members, in order to
comply with CMS termination notice requirements.
Termination for Fraud or Intentionally Furnishing Incorrect or Incomplete Information
If Group commits fraud or intentionally furnishes incorrect or incomplete material information to Health Plan, Health Plan
may terminate this Agreement by giving advance written notice to Group, and Group is liable for all unpaid Premiums up to
the termination date.
If Group has Kaiser Permanente Senior Advantage Members enrolled under this Agreement at the time Health Plan gives
written notice to Group, Health Plan may terminate this Agreement effective on one date with respect to Members other
than Senior Advantage Members and effective on a later date with respect to Senior Advantage Members, in order to
comply with CMS termination notice requirements.
Termination for Violation of Contribution or Participation Requirements
If Group fails to comply with Health Plan’s participation or contribution requirements (including those discussed in the
“Contribution and Participation Requirements” section), Health Plan may terminate this Agreement by giving advance
written notice to Group, and Group is liable for all unpaid Premiums up to the termination date.
If Group has Kaiser Permanente Senior Advantage Members enrolled under this Agreement at the time Health Plan gives
written notice to Group, Health Plan may terminate this Agreement effective on one date with respect to Members other
than Senior Advantage Members and effective on a later date with respect to Senior Advantage Members, in order to
comply with CMS termination notice requirements.
Termination for Discontinuance of a Product or all Products within a Market
Grandfathered products
Health Plan may terminate a particular product or all products offered in a small or large group market as permitted or
required by law. If Health Plan discontinues offering a particular grandfathered product in a market, Health Plan may
terminate this Agreement with respect to that product upon 90 days prior written notice to Group. Health Plan will offer
Group another product that it makes available to groups in the small or large group market, as applicable. If Health Plan
COUNTY OF FRESNO, RETIREE
Group ID: 604334
Contract: 1 Version: 24 Effective: 1/1/21 12/31/21
Date: November 6, 2020 Page 5
discontinues offering all products to groups in a small or large group market, as applicable, Health Plan may terminate this
Agreement upon 180 days prior written notice to Group and Health Plan will not offer any other product to Group. A
“product” is a combination of benefits and services that is defined by a distinct Evidence of Coverage.
All other products
Health Plan may terminate a particular product or all products offered in the group market as permitted or required by law.
If Health Plan discontinues offering a particular product (other than a grandfathered product) in the group market, Health
Plan may terminate this Agreement with respect to that product upon 90 days prior written notice to Group. Health Plan will
offer Group another product that it makes available the group market. If Health Plan discontinues offering all products in
the group market, Health Plan may terminate this Agreement upon 180 days prior written notice to Group and Health Plan
will not offer any other product to Group. A “product” is a combination of benefits and services that is defined by a distinct
Evidence of Coverage.
Contribution and Participation Requirements
No change in Group’s contribution or participation requirements listed below is effective for purposes of this Agreement
unless Health Plan consents in writing. As a condition to consenting to Group’s revised contribution and participation
requirements, Health Plan may require Group to agree to amend the Premiums, benefits, or other provisions of this
Agreement.
Group must:
Ensure that:
all Subscribers live or work inside the Service Area applicable to their coverage when they enroll (except that Group
must ensure that Subscribers live inside the Service Area applicable to their coverage when they enroll if Group
chooses not to have a “live or work” eligibility rule, and that Kaiser Permanente Senior Advantage Members live
inside the Service Area applicable to their coverage when they enroll in Senior Advantage and thereafter)
at least one employee, proprietor, or partner who lives or works inside the Service Area is eligible to enroll as a
Subscriber
Meet all applicable legal and contractual requirements, such as:
meet all Health Plan requirements set forth in the “Rate Assumptions and Requirements” section of the Rate
Proposal document (Group’s Health Plan account manager can provide Group with a copy of the Rate Proposal if
Group does not have one)
offer enrollment in accord with eligibility requirements in state law (for example, domestic partners must be eligible
if married spouses are eligible and disabled dependents must be eligible if dependent children are eligible)
Miscellaneous Provisions
Assignment
Health Plan may assign this Agreement. Group may not assign this Agreement or any of the rights, interests, claims for
money due, benefits, or obligations hereunder without Health Plan’s prior written consent. This Agreement shall be binding
on the successors and permitted assignees of Health Plan and Group.
Attorney Fees and Costs
If Health Plan or Group institutes legal action against the other to collect any sums owed under this Agreement, the party
that substantially prevails will be reimbursed for its reasonable litigation expenses, including attorneys’ fees, by the other
party.
COUNTY OF FRESNO, RETIREE
Group ID: 604334
Contract: 1 Version: 24 Effective: 1/1/21 12/31/21
Date: November 6, 2020 Page 6
Confidential Information about Health Plan or its Affiliates
For the purposes of this “Confidential Information about Health Plan or its Affiliates” section, “Confidential Information”
means any oral, written, or electronic information concerning Health Plan or its affiliates, if the information either is
marked “confidential” or is by its nature proprietary or non-public, except that it does not include any of the following:
Information that is or becomes available to the public other than as a result of disclosure by Group or its employees,
advisors, or representatives
Information that was available to Group or within its knowledge before Health Plan disclosed it to Group
Information that becomes available to Group from a source other than Health Plan, but only if that source is not bound
by a confidentiality agreement with Health Plan
If Group receives any Confidential Information, it will use that information only to evaluate Health Plan and actual or
proposed group agreements with Health Plan. Group will ensure that the information is not disclosed to anyone other than a
limited number of Group’s employees and advisors, and only to the extent necessary in connection with the evaluation of
Health Plan and actual or proposed group agreements with Health Plan. Group will inform any such employees and
advisors that the information is confidential and that they must treat it confidentially.
Upon Health Plan’s request Group will promptly return to Health Plan all Confidential Information, and will destroy any
other copies and any notes or other Group documents about the information.
If Group is requested or required (by oral questions, interrogatories, request for information or documents, subpoena, civil
investigative demand, or similar process) to disclose any Confidential Information, Group will give Health Plan prompt
notice of the request or requirement, and Group will cooperate with Health Plan in seeking to legally avoid the disclosure.
If, in the absence of a protective order, Group is legally compelled, in the opinion of its counsel, to disclose any of the
information, Health Plan either will seek and obtain appropriate protective orders against the disclosure or will be deemed
to waive Group’s compliance with the provisions of this “Confidential Information about Health Plan or its Affiliates”
section to the extent necessary to satisfy the request or requirement.
Group understands (and will inform any employees and advisors who receive Confidential Information) that United States
securities laws prohibit anyone who has material non-public information about a company from buying or selling that
company’s securities in reliance upon that information or from communicating the information to any other person or entity
under circumstances in which it is reasonably foreseeable that the person or entity is likely to buy or sell that company’s
securities in reliance upon the information. Group agrees that it and its affiliates, associates, employees, agents, and
advisors will not rely on any Confidential Information in directly or indirectly buying or selling any Health Plan securities.
Monetary damages would not be a sufficient remedy for any breach or threatened breach of this “Confidential Information
about Health Plan or its Affiliates” section. Health Plan will be entitled to equitable relief by way of injunction or specific
performance if Group or any of its officers, directors, employees, attorneys, accountants, agents, advisors, or
representatives breach, or threaten to breach, any of the provisions of this “Confidential Information about Health Plan or
its Affiliates” section.
Group’s obligations under this “Confidential Information about Health Plan or its Affiliates” section will continue
indefinitely and will survive the termination or expiration of this Agreement.
Contract Providers
Health Plan will give Group written notice within a reasonable time of any termination or breach of contract by, or inability
to perform of, any health care provider that contracts with Health Plan if Group may be materially and adversely affected
thereby.
COUNTY OF FRESNO, RETIREE
Group ID: 604334
Contract: 1 Version: 24 Effective: 1/1/21 12/31/21
Date: November 6, 2020 Page 7
Delegation of Claims Review
Group delegates to Health Plan the discretion to determine whether a Member is entitled to benefits under this Agreement.
In making these determinations, Health Plan has discretionary authority to review claims in accord with the procedures
contained in this Agreement and to construe this Agreement to determine whether the Member is entitled to benefits. If
coverage under an EOC is subject to the Employee Retirement Income Security Act (ERISA) claims procedure regulation
(29 CFR 2560.503-1), Health Plan is a “named claims fiduciary” to review claims under that EOC.
Enrollment Application Requirements
Group must use enrollment application forms that are provided by Health Plan. If Group wants to use a different form or
system for enrolling Members, Group must obtain Health Plan’s approval of the form or system. Other forms and systems
include a “universal” enrollment application form, interactive voice recording (IVR) enrollment system, or intranet online
enrollment system. All forms and systems must meet Health Plan requirements for enrolling Members, including disclosure
of binding arbitration in accord with Section 1363.1 of the California Health and Safety Code and other applicable law.
Group must retain documentation of each Member’s acceptance of the use of binding arbitration, and upon request, must be
able to produce documentation relating to a specific Member to Health Plan at any time. In the event that the contract
between Health Plan and Group terminates or Group is unable to comply with this document retention requirement, Group
must transfer possession of all such documentation to Health Plan in a mutually agreeable manner. Group’s Health Plan
account manager can provide Group with Health Plan’s current requirements for enrollment application forms and systems.
Grandfathered Health Plan Coverage
For any coverage identified in an EOC as a “grandfathered health plan” under the Patient Protection and Affordable Care
Act and regulations, Group must immediately inform Health Plan if this coverage does not meet (or no longer meets) the
requirements for grandfathered status including but not limited to any change in its contribution rate to the cost of any
grandfathered health plan(s) during the plan year. Group represents that, for any coverage identified as a “grandfathered
health plan” in the applicable EOC, Group has not decreased its contribution rate more than five percent (5%) for any rate
tier for such grandfathered health plan when compared to the contribution rate in effect on March 23, 2010 for the same
plan. Health Plan will rely on Group’s representation in issuing and continuing any and all grandfathered health plan
coverage.
Governing Law
Except as preempted by federal law, this Agreement will be governed in accord with California law and any provision that
is required to be in this Agreement by state or federal law, shall bind Group and Health Plan whether or not set forth in this
Agreement.
Group Delegation to Health Plan of Clerical COBRA Functions
Group hereby delegates to Health Plan the following clerical COBRA functions:
Billing and collecting COBRA Premiums under this Agreement. Group authorizes Health Plan to include in COBRA
Premiums the COBRA administrative charge listed under “Calculating Premiums” in the “Premiums” section. The total
COBRA Premiums will not exceed the maximum permitted by COBRA law
Terminating the memberships of Group’s COBRA Members for nonpayment of COBRA Premiums, or for expiration of
the expected time limit that Group specified for the Member’s COBRA coverage
Group retains all other COBRA responsibilities, such as notifying qualified beneficiaries of COBRA rights and processing
COBRA elections. In addition, it is understood that Group relies on its own sources (for example, Group’s legal counsel)
for information about Group’s responsibilities under COBRA law. Health Plan is not responsible for advising Group about
Group’s responsibilities. Health Plan is not a named fiduciary for purposes of administration of COBRA coverage.
COUNTY OF FRESNO, RETIREE
Group ID: 604334
Contract: 1 Version: 24 Effective: 1/1/21 12/31/21
Date: November 6, 2020 Page 8
When a COBRA qualified beneficiary makes a COBRA election and enrolls through Group in Health Plan, Group will
notify Health Plan of the enrollment, the COBRA qualifying event (for example, termination of employment), and the
expected time limit for the COBRA membership (for example, 36 months for a Spouse if the COBRA qualifying event is
divorce). Health Plan will then bill and collect Premiums from the appropriate Member for the Family’s COBRA Members.
Group will notify Health Plan when a Member’s COBRA membership terminates (except for terminations that Health Plan
initiates) or changes status (for example, if a Subscriber requests any membership change or there is a disability
determination that makes a COBRA Member eligible for the disability extension of COBRA eligibility).
Health Plan will send Group a monthly report of the membership status of COBRA Members. This report will include the
names and the current billing addresses (according to Health Plan’s records) of all COBRA Members. The report will also
list the following:
Members whose COBRA Premiums are delinquent. Unless Group notifies Health Plan that Group does not want Health
Plan to terminate the membership of one or more of these Members, Health Plan will terminate the membership of these
Members for nonpayment if Health Plan does not receive payment by the due date specified in Health Plan’s notice to
the Member
Members whose membership Health Plan has terminated for nonpayment or for expiration of the expected time limit
that Group specified for the Member’s COBRA coverage
Group will notify Health Plan immediately if one of the following occurs:
Group disagrees with a Member’s COBRA expiration date listed on the report
The report lists a COBRA Member whose Premiums are delinquent or whose membership has been terminated for
nonpayment, and Group does not want that Member’s membership terminated for nonpayment
Note: Nothing in this “Group Delegation to Health Plan of Clerical COBRA Functions” section is intended to prohibit
Health Plan from terminating memberships without Group’s consent in accord with the EOC, for example, in the case of
termination for cause.
Member Information
Group will inform Members and prospective Members of eligibility requirements for Subscribers and Dependents and
when coverage becomes effective and terminates.
When Health Plan notifies Group about changes to this Agreement or provides Group other information that affects
Members, Group will disseminate the information to Members by the next regular communication to them, but in no event
later than 30 days after Group receives the information.
For each Health Plan coverage included in this Agreement, Health Plan will provide Group with the following disclosures
for Group to distribute in accord with applicable laws (“Member Materials”):
A Disclosure Form (DF) for each non-Medicare coverage. Group will provide DFs (or combined DF/EOCs) to
Subscribers and potential Subscribers when the coverage is offered
A Summary of Benefits and Coverage (SBC) for each non-Medicare coverage other than retiree plans with fewer than
two current employees. Group will provide electronic or paper SBCs to Members and potential Members to the extent
required by law, except that Health Plan will provide SBCs to Members who make a request to Health Plan
Pre-enrollment materials that CMS requires for Kaiser Permanente Senior Advantage coverage, which are available
upon request from Health Plan. Group will provide these materials to potential Members before they enroll in Senior
Advantage coverage
An EOC for each non-Medicare coverage. Group will provide EOCs (or combined DF/EOCs) to Subscribers, except
that Health Plan will provide EOCs (or combined DF/EOCs) to Members and potential Members who make a request to
Health Plan
COUNTY OF FRESNO, RETIREE
Group ID: 604334
Contract: 1 Version: 24 Effective: 1/1/21 12/31/21
Date: November 6, 2020 Page 9
If Group receives the Agreement or Member Materials in electronic form, Group is not authorized to modify or alter in any
way the text or the formatting of the electronic Agreement or Member Materials.
Health Plan assumes no responsibility for any changes in text or formatting that may occur in the Agreement or Member
Materials after they are provided to Group. If Group posts the electronic Agreement or Member Materials on its intranet
site, it shall do so in such a way so as to permit employees of Group to download and print a complete and accurate copy of
the Agreement or Member Materials.
In the event Health Plan reasonably concludes that Group is either using the electronic Agreement or Member Materials in a
manner not permitted by this Agreement or is not providing Subscribers with access to the Member Materials in accord
with applicable laws, then Health Plan will print copies of the Agreement or Member Materials and Group will cooperate
with Health Plan to ensure that printed copies of the Agreement or Member Materials are provided in a timely manner to all
employees of Group enrolled with Health Plan. Group agrees to reimburse Health Plan for the reasonable cost of printing
and delivering the Agreement or Member Materials.
No Waiver
Health Plan’s failure to enforce any provision of this Agreement will not constitute a waiver of that or any other provision,
or impair Health Plan’s right thereafter to require Group’s strict performance of any provision.
Notices
Notices must be sent to the addresses listed below. Health Plan or Group may change its addresses for notices by giving
written notice to the other. All notices are deemed given when delivered in person or deposited in a U.S. Postal Service
receptacle for the collection of U.S. mail.
Notices from Health Plan to Group must be sent to:
PAUL NERLAND, PERSONNEL / SERVICE MANAGER
COUNTY OF FRESNO, RETIREE
2220 TULARE ST FL 14
FRESNO, CA 93721-2122
If Group has chosen to receive group agreements electronically through Health Plan’s website at kp.org/yourcontract,
Health Plan will send a notice to Group at the address listed above when a group agreement has been posted to that website.
Note: When Health Plan sends Group a new (renewed) Agreement, Health Plan will enclose a summary of changes that
discusses the changes Health Plan has made to the Group Agreement. Groups that want information about changes before
receiving the Agreement may request advance information from Group’s Health Plan account manager. Also, if Group
designates a third party in writing (for example, “Broker of Record” statements), Health Plan may send the advance
information to the third party rather than to Group (unless Group requests a copy too).
Notices from Group to Health Plan must be sent to:
Kaiser Permanente
1950 Franklin Street
Oakland, CA 94612
Attn: Wade J. Overgaard, Senior Vice President, Health Plan Operations
Open Enrollment
Group must hold an annual open enrollment period during which all eligible people, in accord with state law, may enroll in
Health Plan or in any other health care plan available through Group. Also, Group must not hold open enrollment for 2022
until Group receives its 2022 group agreement Premium and coverage information from Health Plan. If Group holds the
COUNTY OF FRESNO, RETIREE
Group ID: 604334
Contract: 1 Version: 24 Effective: 1/1/21 12/31/21
Date: November 6, 2020 Page 10
open enrollment without receiving 2022 group agreement Premium and coverage information, Health Plan may change
Premiums and coverage (including benefits and Cost Sharing) when it offers to renew Group’s Agreement as described
under “Renewal” in the “Term of Agreement and Renewal” section
Other Group coverage that covers Essential Health Benefits
For each non-grandfathered non-Medicare Health Plan coverage, except for any retiree-only coverage, Group must do all of
the following if Group provides Health Plan Members with other medical or dental coverage (for example, separate
pharmacy coverage) that covers any Essential Health Benefits:
Notify Health Plan of the out-of-pocket maximum (OOPM) that applies to the Essential Health Benefits in each of the
other medical or dental coverage.
Ensure that the sum of the OOPM in Health Plan’s coverage plus the OOPMs that apply to Essential Health Benefits in
all of the other medical and dental coverage does not exceed the annual limitation on cost sharing described in 45 CFR
156.130.
Reporting Membership Changes and Retroactivity
Group must report membership changes (including sending appropriate membership forms) within the time limit for
retroactive changes and in accord with any applicable “rescission” provisions of the Patient Protection and Affordable Care
Act and regulations. Except for Senior Advantage membership terminations discussed below, the time limit for retroactive
membership changes is the calendar month when Health Plan’s California Service Center receives Group’s notification of
the change plus the previous 2 months.
Representation regarding communication of membership changes
Group represents that its communication regarding membership changes to Health Plan is accurate. Group and its
representative are bound by all membership data, including any changes or updates that it, or its representative, submits to
Health Plan via any medium, electronic or otherwise, including but not limited to the following:
Electronic data submissions regarding enrollment and eligibility
Health Plan approved online tool for submission of data
Paper enrollments submitted through postal mail or fax
Health Plan’s Administrative Handbook includes the details about how to report membership changes. Group’s Health Plan
account manager can provide Group with an Administrative Handbook if Group does not have one.
Involuntary Kaiser Permanente Senior Advantage Membership Terminations
Group must give Health Plan’s California Service Center 30 days’ prior written notice of Senior Advantage involuntary
membership terminations. An involuntary membership termination is a termination that is not in response to a
disenrollment notice issued by CMS to Health Plan or received by Health Plan directly from a Member (these events are
usually in response to a Member’s request for disenrollment to CMS because the Member has enrolled in another Medicare
health plan or wants Original Medicare coverage or has lost Medicare eligibility). The membership termination date is the
first of the month following 30 days after the date when Health Plan’s California Service Center receives a Senior
Advantage membership termination notice unless Group specifies a later termination date. For example, if Health Plan’s
California Service Center receives a termination notice on March 5 for a Senior Advantage Member, the earliest
termination date is May 1 and Group is required to pay applicable Premiums for the months of March and April.
Voluntary Kaiser Permanente Senior Advantage Membership Terminations
If Health Plan’s California Service Center receives a disenrollment notice from CMS or a membership termination request
from the Member, the membership termination date will be in accord with CMS requirements.
COUNTY OF FRESNO, RETIREE
Group ID: 604334
Contract: 1 Version: 24 Effective: 1/1/21 12/31/21
Date: November 6, 2020 Page 11
Representation Regarding Waiting Periods
By entering into this Agreement, Group hereby represents that Group does not impose a waiting period exceeding 90 days
on employees who meet Group’s eligibility requirements. For purposes of this requirement, a “waiting period” is the period
that must pass before coverage for an individual who is otherwise eligible to enroll in non-Medicare coverage under the
terms of a group health plan can become effective in accord with the waiting period requirements in the Patient Protection
and Affordable Care Act and regulations.
In addition, Group represents that eligibility data provided by the Group to Health Plan will include coverage effective
dates for Group’s employees that correctly account for eligibility in compliance with the waiting period requirements in the
Patient Protection and Affordable Care Act and regulations and will not exceed the waiting period established by Group.
For example, if the hire date of an otherwise-eligible employee is January 19, the waiting period begins on January 19 and
the effective date of coverage cannot be any later than April 19. Note: If the effective date of your Group’s coverage is
always on the first day of the month, in this example the effective date cannot be any later than April 1.
Right to Examine Records
Upon reasonable notice, Health Plan may examine Group’s records with respect to contribution and participation
requirements, eligibility, and payments under this Agreement.
Social Security and Tax Identification Numbers
Within 60 days after Health Plan sends Group a written request, Group will send Health Plan a list of all Members covered
under this Agreement, along with the following:
The Social Security number of the Member
The tax identification number of the employer of the Subscriber in the Member’s Family
Any other information that Health Plan is required by law to collect
Premiums
Only Members for whom Health Plan (or its designee) has received the Full Premium payment as described below are
entitled to coverage under this Agreement, and then only for the period for which Health Plan (or its designee) has received
required Premium payment. Group is responsible for paying Premiums, except that Members who have Cal-COBRA
coverage under an EOC that is included in this Agreement are responsible for paying Premiums for Cal-COBRA coverage.
Due Date and Payment of Premiums
The payment due date for each enrollment unit (or subgroup) associated with Group will be reflected on the monthly
membership invoice if applicable to Group (if not applicable, then as specified in writing by Health Plan). If Group does
not pay Full Premiums by the first of the coverage month, the Premiums may include an additional administrative charge
upon renewal. “Full Premiums” means 100 percent of monthly Premiums for all of the coverage issued to each enrolled
Member, as set forth under “Calculating Premiums” in this “Premiums” section.
New Members
Premiums are payable for the entire month for a new Member whose coverage effective date falls between the first day of
the month and the fifteenth day of the month. No Premiums are due for the month for a new Member whose coverage
becomes effective after the fifteenth day of that month.
COUNTY OF FRESNO, RETIREE
Group ID: 604334
Contract: 1 Version: 24 Effective: 1/1/21 12/31/21
Date: November 6, 2020 Page 12
Note: Membership begins at the beginning (12:00 a.m.) of the effective date of coverage.
Membership Termination
Premiums are payable for the entire month for Members whose last day of coverage is on or after the sixteenth day of that
month. No Premiums are due for the month for a Member whose last day of coverage is before the sixteenth day of that
month.
Note: The membership termination date is the first day a Member is not covered (for example, if the termination date is
January 1, 2022, the last minute of coverage was at 11:59 p.m. on December 31, 2021).
Involuntary Kaiser Permanente Senior Advantage Membership Terminations
Group must give Health Plan’s California Service Center 30 days’ prior written notice of Senior Advantage involuntary
membership terminations. An involuntary membership termination is a termination that is not in response to a
disenrollment notice issued by CMS to Health Plan or received by Health Plan directly from a Member (these events are
usually in response to a Member’s request for disenrollment to CMS because the Member has enrolled in another Medicare
health plan or wants Original Medicare coverage or has lost Medicare eligibility). The membership termination date is the
first of the month following 30 days after the date when Health Plan’s California Service Center receives a Senior
Advantage membership termination notice unless Group specifies a later termination date. For example, if Health Plan’s
California Service Center receives a termination notice on March 5 for a Senior Advantage Member, the earliest
termination date is May 1 and Group is required to pay applicable Premiums for the months of March and April.
Voluntary Kaiser Permanente Senior Advantage Membership Terminations
If Health Plan’s California Service Center receives a disenrollment notice from CMS or a membership termination request
from the Member, the membership termination date will be in accord with CMS requirements.
Premium Rebates
If state or federal law requires Health Plan to rebate premiums from this or any earlier contract year and Health Plan rebates
premiums to Group, Group represents that Group will use that rebate for the benefit of Members, in a manner consistent
with the requirements of the Public Health Service Act and the Affordable Care Act and if applicable with the obligations
of a fiduciary under the Employee Retirement Income Security Act (ERISA).
Medicare
Medicare as primary coverage
For Members who are (or the subscriber in the family is) retired, age 65 or over, and eligible for Medicare as primary
coverage, Premiums are based on the assumption that Health Plan or its designee will receive Medicare payments for
Medicare-covered services provided to Members whose Medicare coverage is primary. If a Member age 65 or over is (or
becomes) eligible for Medicare as primary coverage and is not for any reason enrolled through Group under a Kaiser
Permanente Senior Advantage EOC (including inability to enroll under that EOC because they do not meet the plan’s
eligibility requirements, the plan is not available through Group, or the plan is closed to enrollment), Group must pay the
Premiums listed below for the EOC under which the Member is enrolled that apply to Members age 65 or over who are not
enrolled through Group under one of Health Plan’s Medicare plans.
If a Member age 65 or over who is eligible for Medicare as primary coverage and enrolled under a Kaiser Permanente
Senior Advantage EOC is no longer eligible for that plan, Health Plan may transfer the Member’s membership to one of
Group’s plans that does not require Members to have Medicare, and Group must pay the Premiums listed below for the
EOC under which the Member is enrolled that apply to Members age 65 or over who are not enrolled through Group under
one of Health Plan’s Medicare plans.
COUNTY OF FRESNO, RETIREE
Group ID: 604334
Contract: 1 Version: 24 Effective: 1/1/21 12/31/21
Date: November 6, 2020 Page 13
Medicare as secondary coverage
Medicare is the primary coverage except when federal law requires that Group’s health care coverage be primary and
Medicare coverage be secondary. Members entitled to Medicare when Medicare is secondary by law are subject to the same
Premiums and receive the same benefits as Members who are under age 65 and not eligible for Medicare. In addition,
Members for whom Medicare is secondary who meet the Kaiser Permanente Senior Advantage eligibility requirements may
also enroll in the Senior Advantage plan under this Agreement that is applicable when Medicare is secondary. These
Members receive the benefits and coverage described in both the EOC for the non-Medicare plan (the plan that does not
require Members to have Medicare) and the Senior Advantage EOC that is applicable when Medicare is secondary.
Subscriber Contributions for Medicare Part C and Part D Coverage
Medicare Part C coverage
This “Medicare Part C coverage” section applies to Group’s Kaiser Permanente Senior Advantage coverage. Group’s
Senior Advantage Premiums include the Medicare Part C premium for coverage of items and services covered under
Parts A and B of Medicare, and supplemental benefits. Group may determine how much it will require Subscribers to
contribute toward the Medicare Part C premium for each Senior Advantage Member in the Subscriber’s Family, subject to
the following restrictions:
If Group requires different contribution amounts for different classes of Senior Advantage Members for the Medicare
Part C premium, then Group agrees to the following:
any such differences in classes of Members are reasonable and based on objective business criteria, such as years of
service, business location, and job category
Group will not require different Subscriber contributions toward the Medicare Part C premium for Members within
the same class
Group will not require Subscribers to pay a contribution for Medicare Part C coverage for a Senior Advantage Member
that exceeds the Medicare Part C Premium for items and services covered under Parts A and B of Medicare, and
supplemental benefits. As applicable, Health Plan will pass through monthly payments received from CMS (the monthly
payments described in 42 C.F.R. 422.304(a)) to reduce the amount the Member contributes toward the Medicare Part C
premium
Medicare Part D coverage
This “Medicare Part D coverage” section applies only to Group’s Kaiser Permanente Senior Advantage coverage that
includes Medicare Part D prescription drug coverage. Group’s Senior Advantage Premiums include the Medicare Part D
premium. Group may determine how much it will require Subscribers to contribute toward the Medicare Part D premium
for each Senior Advantage Member in the Subscriber’s Family, subject to the following restrictions:
If Group requires different contribution amounts for different classes of Senior Advantage Members for the Medicare
Part D premium, then Group agrees to the following:
any such differences in classes of Members are reasonable and based on objective business criteria, such as years of
service, business location, and job category, and are not based on eligibility for the Medicare Part D Low Income
Subsidy (the subsidies described in 42 C.F.R. Section 423 Subpart P, which are offered by the Medicare program to
certain low-income Medicare beneficiaries enrolled in Medicare Part D, and which reduce the Medicare
beneficiaries’ Medicare Part D premiums and/or Medicare Part D cost-sharing amounts)
Group will not require different Subscriber contributions toward the Medicare Part D premium for Members within
the same class
Group will not require Subscribers to pay a contribution for prescription drug coverage for a Senior Advantage Member
that exceeds the Premium for prescription drug coverage (including the Medicare Part D premium). The Group will pass
through direct subsidy payments received from CMS to reduce the amount the Member contributes toward the Medicare
Part D premium
Health Plan will credit Group with any Low Income Subsidy amounts that Health Plan receives from CMS for Group’s
Members, and Health Plan will identify those Members for Group as required by CMS. For those Members, Group will
first credit the Low Income Subsidy amount toward the Subscriber’s contribution for that Member’s Senior Advantage
Premium for the same month, and will then apply any remaining portion of the Member’s Low Income Subsidy toward
COUNTY OF FRESNO, RETIREE
Group ID: 604334
Contract: 1 Version: 24 Effective: 1/1/21 12/31/21
Date: November 6, 2020 Page 14
the portion of the Senior Advantage Premium that Group pays on behalf of that Member for that month. If Group is
unable to reduce the Subscriber’s contribution before the Subscriber makes the contribution, Group shall, consistent
with CMS guidance, refund the Low Income Subsidy amount to the Subscriber (up to the amount of the Subscriber
Premium contribution for the Member for that month) within 45 days after the date Health Plan receives the Low
Income Subsidy amount from CMS. Health Plan reserves the right to periodically require Group to certify that Group is
either reducing Subscribers’ monthly Premium contributions or refunding the Low Income Subsidy amounts to
Subscribers in accord with CMS guidance
For any Members who are eligible for the Low Income Subsidy, if the amount of that Low Income Subsidy is less than
the Member’s contribution for the Medicare Part D premium, then Group should inform the Member of the financial
consequences of the Member’s enrolling in the Member’s current coverage, as compared to enrolling in another
Medicare Part D plan with a monthly premium equal to or less than the Low Income Subsidy amount
Late Enrollment Penalty. If any Members are subject to the Medicare Part D late enrollment penalty, Premiums for those
Members will increase to include the amount of the penalty.
Calculating Premiums
To calculate the amount of Full Premiums that apply to a Family (a Subscriber and all of their Dependents):
1. Determine the coverage (EOCs and contract options) that apply to each Member in the Family (for example,
Traditional Plan and any Ancillary Coverage).
2. Determine the family role type and Medicare status of each Member (for family role types, please see the “Definitions”
section of the EOC for the definition of Subscriber, Dependent, and Spouse).
3. Identify the Premiums for each Member for each EOC and contract option (including contract options issued through a
separate contract) based on the family role type and Medicare status of each Member:
Premiums for coverage issued under this Agreement appear in the Premium tables below.
If Ancillary Coverage has been issued under a separate contract and Premiums for that coverage are not listed in
the Premium tables below, refer to that contract for Premiums. This Ancillary Coverage is part of the contract
options selected by Group, and Group submits payment for this Ancillary Coverage as part of Full Premium.
4. Add the amount of Premiums for each Member together to arrive at the total, Full Premiums required for the Family.
Monthly Premiums for Kaiser Permanente Traditional HMO Plan — EOC # 1
TRADITIONAL PLAN HIGH
Members under age 65 who are not eligible for Medicare
Family role type Premiums
Subscriber $1,308.09
Spouse $1,098.80
1st child without Spouse $706.37
1st child with Spouse $680.20
Each additional Dependent $0.00
Members under age 65 who are eligible for or have Medicare Part A only
Family role type Premiums
Subscriber $1,308.09
Spouse $1,098.80
1st child without Spouse $706.37
1st child with Spouse $680.20
Each additional Dependent $0.00
COUNTY OF FRESNO, RETIREE
Group ID: 604334
Contract: 1 Version: 24 Effective: 1/1/21 12/31/21
Date: November 6, 2020 Page 15
Members under age 65 who are eligible for or have Medicare Part B only
Family role type Premiums
Subscriber $1,308.09
Spouse $1,098.80
1st child without Spouse $706.37
1st child with Spouse $680.20
Each additional Dependent $0.00
Members under age 65 who are eligible for or have Medicare Parts A&B
Family role type Premiums
Subscriber $1,308.09
Spouse $1,098.80
1st child without Spouse $706.37
1st child with Spouse $680.20
Each additional Dependent $0.00
Members under age 65 who are enrolled in another carrier’s Medicare Risk product
Family role type Premiums
Subscriber $1,916.91
Spouse $1,916.91
1st child without Spouse $1,916.91
1st child with Spouse $1,916.91
Each additional Dependent $1,916.91
Members under age 65 when Medicare is secondary
Family role type Premiums
Subscriber $1,308.09
Spouse $1,098.80
1st child without Spouse $706.37
1st child with Spouse $680.20
Each additional Dependent $0.00
Members age 65 and over whose Medicare eligibility is unknown
Family role type Premiums
Subscriber $1,916.91
Spouse $1,916.91
1st child without Spouse $1,916.91
1st child with Spouse $1,916.91
Each additional Dependent $1,916.91
Members age 65 and over who are eligible for or have Medicare Part A only
Family role type Premiums
Subscriber $1,506.26
Spouse $1,506.26
1st child without Spouse $1,506.26
1st child with Spouse $1,506.26
Each additional Dependent $1,506.26
COUNTY OF FRESNO, RETIREE
Group ID: 604334
Contract: 1 Version: 24 Effective: 1/1/21 12/31/21
Date: November 6, 2020 Page 16
Members age 65 and over who are eligible for or have Medicare Part B only
Family role type Premiums
Subscriber $1,916.91
Spouse $1,916.91
1st child without Spouse $1,916.91
1st child with Spouse $1,916.91
Each additional Dependent $1,916.91
Members age 65 and over who are eligible for or have Medicare Parts A&B
Family role type Premiums
Subscriber $1,506.26
Spouse $1,506.26
1st child without Spouse $1,506.26
1st child with Spouse $1,506.26
Each additional Dependent $1,506.26
Members age 65 and over who are enrolled in another carrier’s Medicare Risk product
Family role type Premiums
Subscriber $1,916.91
Spouse $1,916.91
1st child without Spouse $1,916.91
1st child with Spouse $1,916.91
Each additional Dependent $1,916.91
Members age 65 and over when Medicare is secondary
Family role type Premiums
Subscriber $1,308.09
Spouse $1,098.80
1st child without Spouse $706.37
1st child with Spouse $680.20
Each additional Dependent $0.00
Note: Members who are “eligible for” Medicare Part A or B are those who would qualify for Medicare Part A or B
coverage if they applied for it. Members who “have” Medicare Part A or B are those who have been granted Medicare
Part A or B coverage. Medicare Part A provides inpatient coverage and Part B provides outpatient coverage.
Monthly Premiums for Kaiser Permanente Senior Advantage (HMO) with Part D —
EOC # 2
SENIOR ADVANTAGE HIGH
Family role type Medicare Parts A & B Medicare Part B only
Subscriber $321.29 $631.29
1st Dependent $321.29 $631.29
2nd Dependent $321.29 $631.29
Each additional Dependent $321.29 $631.29
COUNTY OF FRESNO, RETIREE
Group ID: 604334
Contract: 1 Version: 24 Effective: 1/1/21 12/31/21
Date: November 6, 2020 Page 17
Monthly Premiums for American Specialty Health Plans Chiropractic Plan — EOC # 3
CHIROPRACTIC BENEFIT
Family role type Premiums
Subscriber $1.84
Spouse $1.55
1st child without Spouse $1.00
1st child with Spouse $0.96
Monthly Premiums for Kaiser Permanente Senior Advantage (HMO) with Part D —
EOC # 4
SENIOR ADVANTAGE - LOW OPTION
Family role type Medicare Parts A & B Medicare Part B only
Subscriber $247.76 $557.76
1st Dependent $247.76 $557.76
2nd Dependent $247.76 $557.76
Each additional Dependent $247.76 $557.76
Monthly Premiums for Kaiser Permanente Traditional HMO Plan — EOC # 5
TRADITIONAL PLAN - LOW OPTION
Members under age 65 who are not eligible for Medicare
Family role type Premiums
Subscriber $1,308.09
Spouse $1,098.80
1st child without Spouse $706.37
1st child with Spouse $680.20
Each additional Dependent $0.00
Members under age 65 who are eligible for or have Medicare Part A only
Family role type Premiums
Subscriber $1,308.09
Spouse $1,098.80
1st child without Spouse $706.37
1st child with Spouse $680.20
Each additional Dependent $0.00
Members under age 65 who are eligible for or have Medicare Part B only
Family role type Premiums
Subscriber $1,308.09
Spouse $1,098.80
1st child without Spouse $706.37
1st child with Spouse $680.20
Each additional Dependent $0.00
COUNTY OF FRESNO, RETIREE
Group ID: 604334
Contract: 1 Version: 24 Effective: 1/1/21 12/31/21
Date: November 6, 2020 Page 18
Members under age 65 who are eligible for or have Medicare Parts A&B
Family role type Premiums
Subscriber $1,308.09
Spouse $1,098.80
1st child without Spouse $706.37
1st child with Spouse $680.20
Each additional Dependent $0.00
Members under age 65 who are enrolled in another carrier’s Medicare Risk product
Family role type Premiums
Subscriber $1,916.91
Spouse $1,916.91
1st child without Spouse $1,916.91
1st child with Spouse $1,916.91
Each additional Dependent $1,916.91
Members under age 65 when Medicare is secondary
Family role type Premiums
Subscriber $1,308.09
Spouse $1,098.80
1st child without Spouse $706.37
1st child with Spouse $680.20
Each additional Dependent $0.00
Members age 65 and over whose Medicare eligibility is unknown
Family role type Premiums
Subscriber $1,916.91
Spouse $1,916.91
1st child without Spouse $1,916.91
1st child with Spouse $1,916.91
Each additional Dependent $1,916.91
Members age 65 and over who are eligible for or have Medicare Part A only
Family role type Premiums
Subscriber $1,506.26
Spouse $1,506.26
1st child without Spouse $1,506.26
1st child with Spouse $1,506.26
Each additional Dependent $1,506.26
Members age 65 and over who are eligible for or have Medicare Part B only
Family role type Premiums
Subscriber $1,916.91
Spouse $1,916.91
1st child without Spouse $1,916.91
1st child with Spouse $1,916.91
Each additional Dependent $1,916.91
COUNTY OF FRESNO, RETIREE
Group ID: 604334
Contract: 1 Version: 24 Effective: 1/1/21 12/31/21
Date: November 6, 2020 Page 19
Members age 65 and over who are eligible for or have Medicare Parts A&B
Family role type Premiums
Subscriber $1,506.26
Spouse $1,506.26
1st child without Spouse $1,506.26
1st child with Spouse $1,506.26
Each additional Dependent $1,506.26
Members age 65 and over who are enrolled in another carrier’s Medicare Risk product
Family role type Premiums
Subscriber $1,916.91
Spouse $1,916.91
1st child without Spouse $1,916.91
1st child with Spouse $1,916.91
Each additional Dependent $1,916.91
Members age 65 and over when Medicare is secondary
Family role type Premiums
Subscriber $1,308.09
Spouse $1,098.80
1st child without Spouse $706.37
1st child with Spouse $680.20
Each additional Dependent $0.00
Note: Members who are “eligible for” Medicare Part A or B are those who would qualify for Medicare Part A or B
coverage if they applied for it. Members who “have” Medicare Part A or B are those who have been granted Medicare
Part A or B coverage. Medicare Part A provides inpatient coverage and Part B provides outpatient coverage.
Monthly Premiums for American Specialty Health Plans Chiropractic Plan — EOC # 9
HMO CHIRO ACN NCR
Family role type Premiums
Subscriber $1.84
Spouse $1.55
1st child without Spouse $1.00
1st child with Spouse $0.96
Agreement Signature Page
Acceptance of Agreement
Group acknowledges acceptance of this Agreement by signing the Signature Page and returning it to Health Plan . If Group
does not return it to Health Plan , Group will be deemed as having accepted this Agreement if Group pays Health Plan any
amount toward Premiums.
Group may not change this Agreement by adding or deleting wo rds, and any s uch addition or deletion is void. Health Plan
might not respond to any changes or comments submitted on or with this Signature Page . Group may not construe Health
Plan 's lack ofresponse to any submitted changes or comments to imply acceptance. If Group wishes to change anything in
thi s Agreement, Group must contact its Hea lth Plan acco unt manager. Health Plan will issue a new Agreement or
amendment if Health Plan and Group agree on any changes.
Binding Arbitration
As more fully set forth in the arbitration provision in the applicable Evidence of Coverage, disputes between Members,
their heirs , relatives, or associated parti es (on the one hand) and Health Plan , Kaiser Permanente health care providers, or
other associated parties ( on the other hand) fo r a lleged violatio n of any duty arising out of or related to this Agreement,
including any claim for medical or hospital malpractice (a claim that medical services or items were unnecessary or
unauthorized or were improperly , negli gentl y, or incompetently rendered), for premises liability, or re lating to the coverage
for, or delivery of, services or items pursuant to this Agreement, irrespective of legal theory, must be decided by binding
arbitration an d not by laws uit or resort to court process, except as app li cable law provides for judicial review of arbitration
proceedings. Members enrolled under this Agre ement thus give up their right to a court or jury trial , and instead accept the
use of binding arbitration as specified in the applicable Evidence of Coverage except that the following types of claims are
not subject to binding arbitration:
• Claims within the jurisdiction of the Small C laims Court
• Claims s ubject to a Medicare appeals procedure as applicable to Kaiser Permanente Senior Advantage Members
• Claims that cannot be s ubject to binding arbitration under governing law
Signatures
COUNTY OF FRESNO, RETIREE Kaiser Foundation He alth Plan , Inc .
Northern California Regio n
~~-I d-~
uthorized Group officer signa~ Wade J. Overgaard
Authorized officer
Ernest Buddy Mendes, Chairman of the Board of Supervisors
Please print yo ur name an d title
Date signed
Senior Vice President, Health Plan Operations
Executed in San Diego , CA effective 1/1/21
Date : 11/6/20
Please keep this copy with your Agreement. An extra copy of the Signatur e Page is enclosed for mailing to Health Plan 's
California Service Center at P.O. Box 23448, San Diego , CA 92193-3448 .
ATTEST:
BERNICE E. SEIDEL
Clerk of the Board of Supervisors
County of Fresno , State of California
By ~ ~ D,puty
Page 20