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This Benefits Book is for Training Partnership students and Health Benefits Trust beneficia understand their benefits.
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2012-2013 BENEFITS BOOK 1
YOUR BENEFITS
2012-2013 GUIDE TO TRAINING AND HEALTH BENEFITS
2012-2013
SECOND EDITION
2 MYSEIUBENEFITS.ORG
WELCOMEWelcome to the second “Your Benefits” book from the SEIU Healthcare NW
Training Partnership and Health Benefits Trust. This book is designed to serve
as a complete guide to your training and health benefits. It features resources
and information to make it easier to get the support you need.
As a Home Care Aide, your training and health benefits are a critical part of
the compensation you receive. Quality training and affordable health benefits
provide the skills foundation and personal stability needed to help you deliver
excellent care to your consumers and create future career pathways.
You are the key to quality care in Washington’s long-term care system. Thank
you for all you do to promote excellence in home care.
Charissa RaynorExecutive Director, Training Partnership and Health Benefits Trust
David RolfBoard Chair, Training Partnership and Health Benefits Trust
President, SEIU Healthcare 775NW
USERNAME
PASSWORD
MANAGE TRAINING / BENEFITS ONLINE www.myseiubenefits.orgEnter your Username and Password below for easy reference
PRIMARY CARE DOCTOR NAME PHONE
URGENT CARE CENTER NAME AND ADDRESS
PRIMARY CARE PROVIDER (DOCTOR) / URGENT CARE CENTERWrite your Doctor and nearest Urgent Care Center here for reference
PLAN NAME
YOUR HEALTH PLAN Write your Health Benefits Plan name here
2012-2013 BENEFITS BOOK 3
TRAIN
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SICSTRA
ININ
G STA
ND
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SPO
LICIESH
EALTH
BEN
EFITSW
ELLNESS
POLICIESCO
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NTS
Quick Start GuideYour Benefits Book 4
If You Need Assistance 5
Multi-language Assistance 6
Quick Start: Training and Health 7
How to Access www.myseiubenefits.org 8
Update Online Preferences 10
2012-2013 Benefit Highlights 11
MySEIUBenefits.org Overview 12
Online Continuing Education Overview 13
Online Continuing Education Classes 14
Home Care Aide Magazine Preview 15
Training BasicsTraining Overview 17
How to Get the Most from Your Training 21
Interpretation 22
How to Help Improve Future Classes 23
Training StandardsTraining Standards Overview 25
Training Standards Chart 26
Home Care Aide Categories 27
Support Contacts 28
Safety and Orientation 29
Training PoliciesFrequently Asked Questions 30
Classroom Policies 32
Reasonable Accommodation Policy 34
Health BenefitsHealth Benefits Overview 37
Participating Employers 38
Benefits Basics 39
2012-2013 Medical Plan Highlights 40
Prescription/RX Co-pay Grid 41
Plan and Network Grid 42
Medical Plan Highlights Grid 43
Group Health Urgent Care Centers 45
Dental and Vision Benefits 47
WellnessYour Wellness 49
Health Benefits Quick Start 55
Health Benefits PoliciesFrequently Asked Questions 56
Benefit Summaries 63
Willamette Dental 64
Delta Dental 66
Kaiser Permanente Health 71
Group Health 74
Questions and Appeals 81
Notices 83
Glossary 84
Home Care Aide Categories 86
Training Standards Chart 87
One-Stop Resource for Training, Health BenefitsTo make it easier to understand your training and health ben-efits, the Training Partnership and Health Benefits Trust put together this “Your Benefits” book to help guide you. These benefits are effective Aug. 1, 2012 through July 31, 2013. This Benefits Book will be in effect until July 31, 2013.
Inside, you will find important benefits information, including:
Training Benefits• Training standards • Classroom policies• Glossary• Student resources
Health Benefits(For eligible Individual Providers or Home Care Aides covered through their employers)• Eligibility• Benefit summaries• Wellness guide
Where to Find UpdatesIf there are changes to training standards or other information after the book is re-leased, we will update this “Your Benefits” book the following ways:
ONLINE - Updates will be available online at www.myseiubenefits.org/benefits
YOUR MAGAzINE- Updates will also be in Home Care InSight, the magazine for Home Care Aides. See Page 15 for more information.
COLOR CODED - Throughout the book, you will see information for both Individual Providers (IPs) and Agency Providers (APs). To help keep them straight, look for these colors:
n Individual Providers n Agency Providers
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2012-2013 BENEFITS BOOK 1
YOUR BENEFITS
2012-2013 GUIDE TO TRAINING AND HEALTH BENEFITS
2012-2013
SECOND EDITION
QUICK REFERENCE GUIDEYOUR BENEFITS BOOK
4 MYSEIUBENEFITS.ORG
DID YOU kNOw? Did you know there is an online version of the Benefits Book? The online ver-sion of the Benefits Book is a useful tool if you misplace your book or want to view your benefits information from anywhere. You can view the online Benefits Book at www.myseiubenefits.org/benefits
2012-2013 BENEFITS BOOK 5
General Training and Health Benefits SupportFill out a Contact Form at www.myseiubenefits.org/contact
Member Resource Center1-866-371-3200Mon.-Fri., 7 a.m.-7 p.m. The MRC is closed the following holidays:New Year’s DayMartin Luther King, Jr. DayPresidents’ DayMemorial Day Independence DayLabor DayThanksgiving
Day after ThanksgivingChristmas Eve DayChristmas Day Check www.myseiubenefits.org/MRC for office closures and the most updated hours
QU
ICK REFERENCE G
UID
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Medical Plan SupportGroup Healthwww.ghc.org1-888-901-4636Mon.-Fri., 8 a.m.-5 p.m.
kaiser Permanente1-800-813-2000www.kp.org
Dental Plan SupportDelta Dental (Dental)1-800-554-1907www.deltadentalwa.com
willamette Dental1-800-359-6019www.willamettedental.com
For answers to medical or dental plan questions, contact:
QUICK REFERENCE GUIDEIF YOU NEED ASSISTANCE
Specific Health Benefits Support
Specific Training SupportSee chart on Page 28 for who to contact for specific training-related questions.
n Individual Providers: If you need information about your training or benefits eligibility, log in to www.myseiubenefits.org first. If you cannot find the answer to your question, contact help.
n Agency Providers: Contact your employer for support.
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For AssistanceComuníquese con el Centro de Recursos para Miembros al 1-866-371-3200 si necesita asistencia para registrarse en su entrenameinto o para saber cuál es su elegibilidad para los beneficios de salud.
Hãy gọi Trung Tâm Nguồn Lực Thành Viên theo số 1-866-371-3200 nếu quý vị cần được trợ giúp trong việc lên lịch đào tạo hoặc tìm hiểu về điều kiện để nhận phúc lợi y tế.
훈련일정을 잡거나 건강혜택 자격 확인을 위해 도움이 필요하시면
회원지원센터 1-866-371-3200로 전화주세요.
如需在安排培训日程或了解您是否有资格获取保健福利方面获取协
助,请致电 1-866-371-3200 联系会员资源中心。
Если у Вас есть вопросы, связанные с определением расписания занятий, или относительно получения Вами пособия по нетрудоспособности, обращайтесь в Учебно-методический центр по телефону 1-866-371-3200.
6 MYSEIUBENEFITS.ORG
2012-2013 BENEFITS BOOK 7
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Training Quick Start1. Find Your Training Standards
n Individual Providers: • There are different training standards depending on what type of care you provide.• Use the online Training Wizard – a tool to help you know which category
applies to you – to find your individual training standards. Go to: www.myseiubenefits.org/wizard to complete the Wizard.
n Agency Providers: • Your employer can help you understand your training standards. Contact your
employer to get your training standard information.
2. Watch the Safety and Orientation DVDs - If Required• Look at the training grid on Page 26 to see your requirement.
3. Schedule Training Early Schedule within first two weeks of hire to ensure the best choices.
n Individual Providers:• Create your Username and Password to login to the training portal at
www.myseiubenefits.org.• Go online to www.myseiubenefits.org to log in to register for training
or call the Member Resource Center at 1-866-371-3200.
n Agency Providers: • Check with your employer on the best way to register. Your employer has
policies on scheduling for training.
Health Benefits Quick Start1. Check your eligibility for health insurance benefits and enroll
n Individual Providers: Go online to www.myseiubenefits.org to log in to see your eligibility and enroll online, or call the Member Resource Center at 1-866-371-3200. Your eligibility for health insurance depends on the number of hours you work.
n Agency Providers: Contact your employer to see if you are eligible for health benefits through your employer.
2. Make an appointment with your primary care doctorGo to your health insurance provider’s website or contact them by phone (see contact info on Page 5) to find available doctors and other providers. See the Health Benefits section for more details.
QUICK START
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Manage Training and Benefits Easily OnlineThe best way to manage your training and find your eligibility for benefits is through the www.myseiubenefits.org website. We have improved the Username and Password process to make it easier for you to access the site.
How to Log In to the Website 1. Sign up for a First Time Username and Password
2. Verify Your Information
You can enter EITHER your Student ID (the card sent to you by the Training Partner-ship) OR the last four of your Social Security Number and your birthdate. Note: If you work for DSHS, you should use the Student ID option.
8 MYSEIUBENEFITS.ORG
2012-2013 BENEFITS BOOK 9
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ACCESS MYSEIUBENEFITS.ORG
3. Create Your Username and Password
4. Confirm Your Username and Password
Note: You can choose any username or password you like
5. You’re Done!
Now You’re Ready to Log in to the Website!
Please write your Username and
Password on Page 2 of this book
to remember.
10 MYSEIUBENEFITS.ORG
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10 MYSEIUBENEFITS.ORG
UPDATE PREFERENCES
1. Log in.
Update Your Preferences for a Better Student ExperienceKeeping your language and contact preferences updated is an important way
to help the Training Partnership provide you with the best possible training
experience. Make sure to update your preferences as soon as possible so we
can reach you effectively.
2. Click “Manage … Profile” link on the left side of the screen:
3. Modify the settings you wish to, and click the “Save Preferences” button.
2012-2013 BENEFITS BOOK 11
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2012-2013 BENEFIT HIGHLIGHTSWhat’s New and Improved?TRAINING
More Online Continuing Education ClassesThe Training Partnership now has 26 English Online Continuing Education classes for students to take at their convenience. In addition, there are 10 Online CE courses available for students in Russian and Spanish. For more on Online CE, visit www.myseiubenefits.org/online-continuing-education
Home Care InSight MagazineThe Training Partnership will be offering the second issue of Home Care InSight Magazine in Fall 2012. This magazine will be a resource for Training Partner-ship students and Health Benefits Trust members to learn about best practices in training and wellness as well as get important updates on their benefits.
Print Your Own CertificatesNow, students who have completed their training can print their own certifi-cates, quickly and easily through the online learning portal.
HEALTH BENEFITS
Group Health Offers Free Mail Prescriptions for Value-Based DrugsIn an exciting new benefit for Health Benefits Trust members, Group Health is now offering some mail-order Value-Based drugs at no cost to members. This is in addition to lower costs on other prescriptions as well.
Cash Incentives for Using Health Benefits The Health Benefits Trust will continue to offer incentives to members who use important parts of their health benefits:
Initial Primary Care Appointment = $10 Members who make an initial primary care appointment within the first three months of coverage will receive a $10 check.
Complete a Health Profile = $25 Members who complete a Health Profile either online or on paper will receive a $25 check from the Health Benefits Trust.
Same Low Cost for Members Health Benefits Trust members still pay $25 a month for health, dental and vision benefits.
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GET ONLINE
12 MYSEIUBENEFITS.ORG
MYSEIUBENEFITS.ORGYour easy online source for online CE, training standards, class registration
Once you get your online login and
password, you’re ready to go online to
manage and take training!
Over the past year, the Training Partner-
ship has worked to increase the quantity
and depth of the resources available on
the website www.myseiubenefits.org.
In addition to the ability to register
online, find training standards and
other resources, students can now take
a robust number of Online Continuing
Education courses – right from their
computer.
Why go online?
Online Training WizardThe online Training Wizard will give you a customized understanding of the
training you need. The easy online Training Wizard is found at
www.myseiubenefits.org/wizard.
Register for Training If you are an Individual Provider, you can register for training yourself online.
You can view available courses and pick times that work for you.
Online Continuing Education Students can now take their Continuing Education conveniently online –
anytime, anywhere! See the following page for details on Online Continuing
Education.
www.myseiubenefits.org
2012-2013 BENEFITS BOOK 13
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ONLINE CONTINUING EDUCATIONAs of July 2012, there
are 26 English Con-
tinuing Education (CE)
classes you can take
online by going to
www.myseiubenefits.
org. In addition, there
are 10 online CE
courses in Russian
and Spanish available
as well.
With online classes you pick the time and
topics that work for you. You can see the
available courses, register and access
courses, receive credit, and navigate help in-
formation – all online and all 24 hours a day!
Each online course takes about one hour
to complete, which may vary depending on
learning style, material covered and Internet
connection speed.
‘‘ I loved being able to
take the Multiple
Sclerosis module
online. I learned a
lot and I could do it
at home!
– Abdul, Training
Partnership Student
14 MYSEIUBENEFITS.ORG
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ENGLISHHearing and Vision Conditions
Cultural Competency: Pain Management and Health Literacy
Arthritis & Acute Mental Status Changes
Cultural Competency: Pain Management and Assumptions
Gaining Consumer Cooperation for Oral Health
Oral Health Basics
Denture Care and Cleaning
Using Household Cleaning Chemicals Safely
Green Cleaning
Cultural Competency - Nutrition
Best Practices for the Professional HCA
Multiple Sclerosis
Traumatic Brain Injury
Body Mechanics
Infection Control and Workplace Safety
Better Health through Nutritious Cooking
An Introduction to Developmental Dis-abilities
An Introduction to Physical Disabilities
An Introduction to Mental Illness
An Introduction to Dementia
Best Practices for the Professional HCA
Multiple Sclerosis
Traumatic Brain Injury
Body Mechanics
Important Note: The following courses were available in early 2011 for a short time so if you took them at that time, you cannot take them again. If you did not take them then, they are available to take online.
Relationships Between Consumers
Home Care Aides Make a Difference
Supporting Consumer Independence
The Faces of Down Syndrome
Dispelling Disability Myths
Promoting Creativity
Online Continuing Education Classes as of July 2012
SPANISH & RUSSIANBest Practices for the Professional HCA
Multiple Sclerosis
Traumatic Brain Injury
Body Mechanics
Infection Control and Workplace Safety
Better Health through Nutritious Cooking
An Introduction to Developmental Dis-abilities
An Intro to Physical Disabilities
An Introduction to Mental Illness
An Introduction to Dementia
Important Note: The following courses were available in early 2011 for a short time so if you took them at that time, you cannot take them again. If you did not take them then, they are available to take online.
Relationships Between Consumers
Home Care Aides Make a Difference
Supporting Consumer Independence
The Faces of Down Syndrome
Dispelling Disability Myths
Promoting Creativity
2012-2013 BENEFITS BOOK 15
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MAGAZINE
Fall 2012 - Next Issue of Home Care InSight Magazine
As a community of Home Care Aides, you do
important work and you have an important
story to tell. You can help raise understanding
of common challenges and experiences
for Home Care Aides to help improve the
profession.
To help share knowledge and skills with
the Home Care Aide community, a new
magazine will be published to focus on
you and your work. Look for the next issue in
the Fall of 2012.
Magazine HighlightsTraining and Health
• Training standards updates
• Best practices for Home Care Aides
• Knowledge and skills builders
• Student participation policies and news
• Health benefits policies and news
• Your safety at work
Important Updates to the “Your Benefits” book• Updates to the “Your Benefits” book will be printed in the magazine
as well as posted online; be sure to check your magazine for updates
SEND US YOUR STORY IDEAS!Do you have an interesting story to share of your successes or challenges as a Home Care Aide? Do you have a story about personal health and wellness? Do you have suggestions for stories or profiles you would like to see in the magazine? Send them to us! Go to www.myseiubenefits.org/stories to submit your story idea.
16 MYSEIUBENEFITS.ORGTRAI
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2012-2013 BENEFITS BOOK 17
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VisionOur vision is that every long-term care worker is a professional who has been trained rigorously, whose work is well respected and well compensated, who has meaningful opportunities for professional development and career growth, and who provides high quality care.
‘‘ The classes were very helpful and they gave me new, healthier ways to
deal with challenges at work.
– Jasmine, Training Partnership Student
QUALITY TRAINING, QUALITY CAREThe Training Partnership under-
stands that adult learners bring a
broad set of life experiences, educa-
tion levels, and English language
proficiency to the classroom. To
meet that diversity, learning experi-
ences are designed for you, adult
students who bring previous knowl-
edge and a passion for their work to
class. The focus is on practical skill
development that will help you to do your job.
What Can You Expect from Basic Training Courses?• As a student, you can expect to meet an instructor with direct care
experience who is passionate about supporting Home Care Aides in their
professional growth.
• You can expect opportunities to learn using different methods like watch-
ing video clips, completing written activities, and presenting to others.
• You can expect to learn specific skills, see them demonstrated and then
have a chance to demonstrate the skill yourself.
• You can expect to use a student guide during class which you can keep
as a future resource.
18 MYSEIUBENEFITS.ORG
2012-2013 BENEFITS BOOK 19
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What Characterizes the Work of the Training Partnership?There are several themes that infuse the courses, actions, and work of the Training Partnership. They are:
• Dignity of the work and the Home Care Aides who do the work;
• Dignity of the consumer whose preferences, individuality, and needs must be respected;
• Empowerment of the Home Care Aide to improve their lives and the lives of consumers;
• Professionalism of the workforce; and
• Cultural competency and inclusiveness to honor differences.
• You can expect to be asked
what you think, to share what
you know, to contribute to
discussion, and to answer
questions.
What Can You Expect from Continuing Education Courses?• You can expect options in course formats, including in-person and online
learning choices.
• You can expect choice in the style courses are taught, from expert lec-
tures to interactive videos.
• You can expect variety in subjects, from broad overviews to in-depth
explorations on specific topics.
• You can expect to have online courses in multiple languages available to
take 24-hours-a-day, seven days a week.
• You can expect online learning courses that present information and ask
you to apply what you have learned through interactive activities.
MissionOur mission is to train and develop professional long-term care workers to deliver high quality care.
20 MYSEIUBENEFITS.ORG
2012-2013 BENEFITS BOOK 21
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HOW TO GET THE MOST FROM YOUR TRAININGUse the Training WizardStart with the easy online Training Wizard to find the training you need.
Go to: www.myseiubenefits.org/wizard to complete the Wizard.
Register Early for TrainingIf you need Basic Training, we encourage you to register for your classes within
the first two weeks of hire to get the best choice of class options. If you want
Instructor Led Continuing Education (CE) classes, register as early as possible to
get the best choice of class options before your deadline.
Take Online Learning for Continuing Education CreditsOnline Continuing Education courses are an easy and convenient way to get the
CE hours you need as a Home Care Aide. You can view available courses, take
classes and view your credits all from your computer – 24/7.
Go Online for Convenient Service and SupportThe www.myseiubenefits.org web portal is your comprehensive resource for
available classes, your current training status, benefits eligibility and much
more. Log in to the portal first to get the answers you need. Instructions for get-
ting a username and password are on Page 8.
Update Your Contact InfoEnsure you are receiving the most current information about your training by
updating your contact information with your employer. If are you an Individual
Provider, update your information with your primary DSHS contact. If you are an
Agency Provider, update your information with your employer.
Sign Up for News and AlertsHelp make sure you get all the latest
news and information you need on
training standards, deadlines and new
online learning courses. Sign up to
receive news and alerts through email.
22 MYSEIUBENEFITS.ORG
INTERPRETATIONn Individual Providers: The Community Interpretation option is available to you. You need to tell the Training
Partnership you are using a community interpreter at time of registration.
n Agency Providers: Indicate to the person who registers you for class that you will be bringing
a Community Interpreter.
Community InterpretationThe Training Partnership values the diversity of Home Care Aides. Basic Training courses
are offered in English, Cantonese, Spanish, Russian, Korean, and Vietnamese. For those
students who speak another primary language and are unable to take courses in English,
we offer a Community Interpretation option.
Steps to Register for Community Interpretation
1. Notify the Training Partnership: At the time of course registration, tell us either using the
online portal or the Member Resource Center if you will be bringing someone with you to
serve as your interpreter. If you are bringing someone to interpret, you are responsible for
telling them when and where the class will be held and for reserving space for them in
the class.
2. Orientation:
Online Orientation Video: You and your Community Interpreter should watch a helpful
online Orientation before their first community interpretation session. This Orientation will
help prepare your Community Interpreter and you for the class. It is very important that
your interpreter watches this orientation before your first class, especially if they do not
have training in interpreting.
Tip Sheet: If you have a friend or family member interpret for you, we offer a tip sheet and
other information that will help prepare your interpreter to assist you in class.
View orientation info and tip sheet here: www.myseiubenefits.org/training/interpretation
2012-2013 BENEFITS BOOK 23
HELP IMPROVE FUTURE CLASSESParticipate in strengthening future classes – a call to action
Course ReviewsAll Home Care Aides are encouraged to
complete a course review online at
www.myseiubenefits.org after each course
they take. Course reviews allow the Training
Partnership to make adjustments in course
content and instructors. Your feedback is
taken seriously.
How do you submit a course review? Course
reviews are available on your student
profile.
1. When a course has been completed, login to the online learning portal,
look at the “Completed Training” box, and click the “Review Now” link for the
course you wish to review.
2. Complete the form, and click the “Submit Answers” button below the form.
TRAIN
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Course ReviewsHow do you submit a course review? Course reviews are available on your student profile. Log in with your username and password, select “manage my training,” and under the completed training box, click “review now.”
24 MYSEIUBENEFITS.ORGTRAI
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TRAINING STANDARDSUPDATED JUNE 2012
The passage of Initiative 1163 in November 2011 reinstated the comprehen-
sive training and certification standards for most new Home Care Aides (ex-
empting those caring for a parent or child). These higher standards had been
suspended in July 2011.
Home Care Aides who have already
taken Basic Training will not need
to take the more in-depth training.
Training standards vary for differ-
ent types of workers. Be sure to
check your own training standards
through the online wizard and see
the training standards chart on
Page 26.
Basic Training CurriculumDifferent types of workers have different Basic Training standards. Basic Train-
ing is the introductory training you take to understand the fundamentals of
Home Care Aide work.
Continuing EducationDifferent types of workers have different Continuing Education standards.
The Training Partnership provides quality instructor-led and online Continuing
Education (CE) classes across the state. Continuing Education is ongoing or
refresher training covering a broad range of subjects. You choose the ones that
are most suited to your interests and the consumers you serve.
Training WizardAs training standards change, you may wonder: “How do I know what my training standards are?” The Training Partnership has a conve-nient and easy online Training Wizard to help. The Wizard – in addition to the Training Standards Chart on Page 26 - will help you understand the training you need.
Go to www.myseiubenefits.org/wizard to get started!
www.yes1163.com
26 MYSEIUBENEFITS.ORG
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2012-2013 BENEFITS BOOK 27
Home Care Aide (HCA)Provides care to a consumer living in his or her home. Employed by a private homecare agency or DSHS.
Agency Provider (AP)Provides care to a consumer living in his or her home. Employed by a private homecare agency.
Certified Home Care Aide
Provides care to a consumer living in his or her home having successfully passed the DOH certification exam. Employed by a private homecare agency or DSHS.
Individual Provider (IP)Provides care to a consumer living in his or her home. Employer of record is DSHS.
Credentialed Agency Provider
This is an AP with a current healthcare credential as a Registered Nurse (RN), Licensed Practical Nurse (LPN), Nursing Assistant Certified (NAC), Physical Therapist, Occupational Therapist or Medicare-Certified Home Health Aide.
Credentialed Individual Provider
This is an IP with a current healthcare credential as a Registered Nurse (RN), Licensed Practical Nurse (LPN), Nursing Assistant Certified (NAC), Physical Therapist, Occupational Therapist or Medicare-Certified Home Health Aide.
Parent Individual Provider (HCS/AAA)
This is an IP who provides care to his/her own adult child and is contracted through Home and Community Services (HCS) and/or an Area Agency on Aging (AAA).
Parent DD Individual Provider (DDD)
This is an IP who provides care to his/her own adult child with a developmental disability and is contracted through the Department of Developmental Disabilities (DDD).
Limited Service Provider (HCS/AAA/DDD)
This is any IP who provides care 20 hours a month or less for one consumer.
Adult Child Individual Provider
An adult child providing care for his/her biological, step or adoptive parent.
Effective Jan. 7, 2012 HOME CARE AIDE CATEGORIES
TRAIN
ING
STAN
DA
RDS
The Training Partnership provides training to a variety of Home Care Aides (HCA). The chart below describes the different categories of HCAs.
Provide care to a consumer living in his or her home. Employed by a private homecare agency or DSHS.
28 MYSEIUBENEFITS.ORG
WHO TO CONTACT FOR TRAINING SUPPORT
INDIvIDUAL PROvIDERS
AGENCY PROvIDERS(visiting Nurse
Homecare, Senior Life Resources,
Oly CAP, CoastalCAP, Concerned
Citizens, Full Life)
AGENCY PROvIDERS
(Addus, Chesterfield, KWA, ResCare, SeaMar,
Amicable)
AGENCY PROvIDERS
(Catholic Community Services -
Agency Provider, CDM)
Class registration and rescheduling Website or MRC Website or MRC Your Employer Your Employer
How to complete your training Website or MRC Website or MRC Your Employer Your Employer
Username and Password assistance Website or MRC Website or MRC Website, MRC
or Employer Your Employer
Confirmation Code Website or MRC Website or MRC MRC Your Employer
Requesting a student ID Website or MRC Website or MRC MRC Your Employer
Requesting a certificate See Next Page See Next Page See Next Page See Next Page
Confirming class schedule Website or MRC Website or MRC Website, MRC
or Employer Your Employer
Training requirement and deadlines Primary DSHS Contact Your Employer Your Employer Your Employer
Questions about payment Primary DSHS Contact Your Employer Your Employer Your Employer
Change of address Primary DSHS Contact Your Employer Your Employer Your Employer
Change in training standards due to change in employment status
Primary DSHS Contact Your Employer Your Employer Your Employer
2012-2013 BENEFITS BOOK 29
If you are in a category that requires
either the Training Partnership’s Safety or
Orientation training (or both) you should
have received a kit at the time of hiring
or contracting.
The kit contains the following:
1. Instructions on “How to Com-
plete and Receive Credit for
Safety and/or Orientation.”
2. Three DVDs: Orientation,
Safety Training Part 1, and
Safety Training Part 2.
3. Supplemental information titled, “Orientation & Safety – A Reference
Tool for Individual Providers.”
Agencies may supplement this training with an agency specific orientation program.
If you did not receive the Safety and Orientation Kit, please contact your employer.
Safety and Orientation Verification Line: 1-866-483-1397
SAFETY AND ORIENTATION
TRAIN
ING
STAN
DA
RDS
SAFETY &ORIENTATION
SEIU HEALTHCARE NW TRAINING PARTNERSHIPThe Training Partnership trains and develops professional long-term
care workers to deliver high quality care and support to older adults
and people with disabilities.
S E I U H E A L T H C A R E N WT R A I N I N G PA RT N E R S H I P
WWW.MYSEIUBENEFITS.ORG 635 ANDOVER PARK WEST SUITE 200, TUKWILA, WA 98188
NEED HELP? CONTACT THE MEMBER RESOURCE CENTER1-866-371-3200
INDIvIDUAL PROvIDERS
AGENCY PROvIDERS(visiting Nurse
Homecare, Senior Life Resources,
Oly CAP, CoastalCAP, Concerned
Citizens, Full Life)
AGENCY PROvIDERS
(Addus, Chesterfield, KWA, ResCare, SeaMar,
Amicable)
AGENCY PROvIDERS
(Catholic Community Services -
Agency Provider, CDM)
Class registration and rescheduling Website or MRC Website or MRC Your Employer Your Employer
How to complete your training Website or MRC Website or MRC Your Employer Your Employer
Username and Password assistance Website or MRC Website or MRC Website, MRC
or Employer Your Employer
Confirmation Code Website or MRC Website or MRC MRC Your Employer
Requesting a student ID Website or MRC Website or MRC MRC Your Employer
Requesting a certificate See Next Page See Next Page See Next Page See Next Page
Confirming class schedule Website or MRC Website or MRC Website, MRC
or Employer Your Employer
Training requirement and deadlines Primary DSHS Contact Your Employer Your Employer Your Employer
Questions about payment Primary DSHS Contact Your Employer Your Employer Your Employer
Change of address Primary DSHS Contact Your Employer Your Employer Your Employer
Change in training standards due to change in employment status
Primary DSHS Contact Your Employer Your Employer Your Employer
1. 2.
That’s it, you’re done! It’s fast and easy and you can do it from home.
CERTIFICATESStudents (and Agency employers and DSHS staff) can now print their own certifi-
cates. Once you have completed your training, log in to your account and go to:
30 MYSEIUBENEFITS.ORG
1. what is www.myseiubenefits.org?
The website www.myseiuben-efits.org is where you can read important announcements from the Training Partner-ship, learn about our different programs and ask questions. On the website, you can register for classes, see your training history and track your progress.
You can also take online Continuing Education classes by going to this website.
2. How do I log in to www.myseiubenefits.org?
Logging into your account is an easy process from the website.
Follow the instructions on Page 8 to log in.
3. How do I get a Student ID?
As a new student you will receive an ID card in the Welcome Packet that is sent to you.
If you do not receive your ID card, please check with your employer to make sure your address is correct. Replacement cards can take up to six weeks to receive. For fastest class check in, bring your student ID card. If you don’t have a student ID card, bring driver’s license, passport, or other legal identification to class.
Refer to the Support chart on Page 28 if you need assistance.
4. How do I change my address with the Training Partnership?
Ensure you are receiving the most current information about your train-ing by updating your contact information with your employer. If you are an Individual Provider, update your information with your primary DSHS contact. If you are an Agency Provider, update your information with your employer.
I have a question about wages for training? Contact your employer or your DSHS case manager. The Training Partnership cannot answer questions regarding wages.
FREQUENTLY ASKED QUESTIONS
2012-2013 BENEFITS BOOK 31
5. I arrived to class and I am not on the roster, what do I do?
Only registered students and interpreters can attend Training Partner-ship classes. If you are not on the roster, you will need to reschedule your class.
6. How do I provide feedback about a class?
Your feedback is very important to us and we want to know about your class experience with the Training Partnership. You can complete a course review after attending a class by going to www.myseiubenefits.org.
For more information on submitting feedback, see Page 23.
7. How do I get my training certificate?
You now have access to printing your own certificate at any time. Once you’ve completed all your training requirements, you can log on your record on the Website www.myseiubenefits.org and get your certificate of completion at your convenience.
Refer to the Certificate section on Page 29 if you need assistance.
8. I have a question about wages for training.
Contact your employer or your DSHS contact. The Training Partnership cannot answer questions regarding wages.
POLICIES
FREQUENTLY ASKED QUESTIONS
‘‘ The class on mental health really helped me understand the issue better
and gave me tools. I feel more prepared to help my client with mental
health issues now.
– Marcos, Training Partnership Student
32 MYSEIUBENEFITS.ORG
At the Training Partner-
ship we know you have
taken your valuable time
to come to class. To sup-
port each other and en-
sure everyone can get the
most out of each class,
we have created the
following polices in order
to create a successful
learning environment.
Class Registration• Students need to be registered for class and on the class roster in
order to take a class.
• If you have not previously registered for a class, you will not be able to take the class.
• If you are not on the class roster, you will not get credit for the class.
Only Registered Students and Interpreters are Allowed in Class• The only people allowed in class are registered students and
registered interpreters.
• Students may not bring consumers, children, or any other visitors to class.
Classes Start On Time• If you arrive to class after the start time, you will be considered late,
you will need to reschedule your class.
• You should arrive to class 15 minutes before the start time to
avoid being late.
Bring Picture ID• Students are expected to show valid picture ID to sign in for class.
• You should bring your Training Partnership ID if you have one.
CLASSROOM POLICIES
2012-2013 BENEFITS BOOK 33
Student Participation• Students are expected to fully participate in the learning experience.
• Personal phone calls or other personal matters should be taken care of during breaks.
Class Cancellation• A student will need to cancel class registration at least 72 hours in
advance of the class time.
• If the Training Partnership has to cancel a class, a notification of the class cancellation will be sent to you based on the communication preference in your online profile. The Training Partnership will work with you to reschedule the class.
No Shows• Cancelling late or not attending class results in a no show. After two
no shows, you will have to pay a $25 no-show fee to access training.
Appeals Process• If you wish to appeal the $25 “no show” fee because you believe
you had a good reason for not attending the class you must file an appeal.
• The appeal must be filed on an appeal form that is available at www.myseiubenefits.org.
Inclement Weather• If the Training Partnership has to cancel a class due to inclement
weather, a notification of the class cancellation will be sent based on the communication preference in your profile. The Training Partner-ship will work with you to reschedule the class.
POLICIES
CLASSROOM POLICIES
34 MYSEIUBENEFITS.ORG
Policy on Reasonable Accommodation of Students with DisabilitiesThe SEIU Healthcare NW Training
Partnership (“Training Partnership”)
admits students regardless of race,
color, national origin, ethnic origin,
gender, age, disability and sexual ori-
entation to all the rights, privileges,
programs, and activities gener-
ally accorded or made available to
students by the Training Partnership.
It does not discriminate on the basis
of race, color, national origin, ethnic
origin, gender, age, disability and
sexual orientation in administration
of its training and educational poli-
cies, admissions policies, scholar-
ship and loan programs, and other
Training Partnership administered
programs.
Students with disabilities have the
right to request and receive reason-
able accommodation so that students may have the opportunity to take full
advantage of the Training Partnership’s programs and activities.
When is a person regarded as having a disability?For purposes of accommodation, a person is regarded as having a disability if
he or she has a sensory, mental, or physical impairment that is medically cog-
nizable or diagnosable or exists as a record or history or is perceived to exist.
What is Reasonable Accommodation?Reasonable accommodation means modifying or adjusting practices, proce-
dures, policies, educational services and delivery, or the training environment
so that a student with a disability can enjoy equal educational opportunity, so
long as (1) there is sufficient medical evidence establishing a relationship be-
tween the disability and the need addressed by the specific accommodation;
and (2) it does not impose an undue hardship on the Training Partnership.
REASONABLE ACCOMMODATION POLICY
What is Reasonable Accommodation?Reasonable accommodation means modifying or adjust-ing practices, procedures, policies, educational services and delivery, or the training environment so that a student with a disability can enjoy equal educational opportu-nity, so long as (1) there is sufficient medical evidence establishing a relationship between the disability and the need addressed by the specific accommodation; and (2) it does not impose an un-due hardship on the Training Partnership.
2012-2013 BENEFITS BOOK 35
What is Undue Hardship?Undue hardship means, among other things, an excessively costly, extensive,
substantial or disruptive modification or one that would fundamentally alter the
nature or operations of the Training Partnership or its programs.
Overview of Accommodation ProcessTo request reasonable accommodation, a student with a disability should re-
quest accommodation from the Training Partnership by completing the “ADA
Request Form” found at www.myseiubenefits.org/ADA_policy or by calling
the Member Resource Center. Once the request is received by the Training
Partnership, the Accommodation process will start, during which the student
will be asked to provide current documentation of his or her disability, the
functional limitations resulting from the disability and recommendations for
specific accommodations.
As part of the Accommodation process, the Training Partnership will confer
with the student to identify appropriate and reasonable accommodations that
may be warranted under the particular circumstances.
The Training Partnership has the right to establish qualifications and other
essential standards and requirements for its courses, programs, activities and
services. All students are expected to meet these essential qualifications, stan-
dards, and requirements with or without reasonable accommodations.
More detailed information on the Accommodation process can be found at
www.myseiubenefits.org/ADA_policy.
REASONABLE ACCOMMODATION POLICYPO
LICIES
36 MYSEIUBENEFITS.ORGHEAL
TH B
ENEF
ITS
2012-2013 BENEFITS BOOK 37
AFFORDABLE HEALTH BENEFITS FOR YOUFor eligible Individual Providers and Agency Providers, the
Health Benefits Trust is a nonprofit organization providing affordable health
coverage focused on keeping you healthy. The health care benefits offered by
the Health Benefits Trust are part of a community of care that starts with the
wellness of you, the Home Care Aide.
2012-2013 Benefits PlanThe Health Benefits Trust designed the 2012-2013 benefits, which took effect
on Aug. 1, 2012, to fulfill the following goals:
• Lower out-of-pocket costs for Home Care Aides
• Emphasis on preventive care to encourage wellness
• Increased participation in health risk assessments
• Higher use of urgent care facilities in urgent situations that don’t
require emergency-room care
• Encouraging convenient, lower-cost prescriptions through mail order
• Making mail prescriptions for some chronic conditions free
• Encouraging use of in-network providers
The 2012-2013 benefits plan accomplishes those goals and allows for the continuation of affordable, quality benefits for all eligible Home Care Aides. You may be eligible if you worked 86 hours in each of the previous three months. Your coverage will begin the first of the second month after you be-come eligible and enroll. For example, if you begin work in January and work more than 86 hours in January, February and March, you will be come eligible to enroll in April and your coverage will start on May 1. Once enrolled in health coverage, your coverage will continue as long as you work at least 86 hours every month and pay your monthly co-premium.
How to Enrolln Individual Providers: You can enroll by logging in to
www.myseiubenefits.org and by filling out the enrollment form.
Call the Member Resource Center toll-free at 1-866-371-3200 to get answers
to your questions about eligibility for benefits.
n Agency Providers: Contact your employer for assistance and enrollment
information.
HEALTH BENEFITS BASICS
38 MYSEIUBENEFITS.ORG
PARTICIPATING EMPLOYERSWashington employers whose employees are eligible for benefits through the Health Ben-
efits Trust. NOTE: This list may change, check with your employer to verify participation.
AAA Residential ServicesAddus HealthcareAmicable HealthcareCatholic Community Services (Agency Provider)CDMChesterfield HealthcareConcerned CitizensFull LifeHome Care Services of Montana
KWALower Columbia CACOlympic CAPCoastal CAPResCareSenior Life Resources NorthwestState of Washington (employer of record)
Visiting Nurse Home Care
ELIGIBILITY AND ENROLLMENTHow many hours do I have to work for continuing coverage?
After your coverage begins, you must work at least 86 hours each month to have continuous coverage.
How do I enroll?
Individual Provider: Log on to www.myseiubenefits.org to complete enrollment or call the Member Resource Center at 1-866-371-3200.
Agency Provider: Contact your employer to coordinate your enrollment.
2012-2013 BENEFITS BOOK 39
BENEFITS BASICSHome Care Aides get the following comprehensive benefits through
the Health Benefits Trust:
MedicalNobody ever plans to get sick, but the Health Benefits Trust has you covered.
Depending on where you live, your medical, vision and prescription drug
coverage will be provided by Group Health or Kaiser Permanente. You pay very
little out-of-pocket for the following services:
• Doctor office visits
• In-patient hospitalization
• X-rays and diagnostic imaging
• Laboratory services
• Mental health
• Hearing exams
• Chiropractor visits
• Acupuncture
• Mammograms
• Allergy shots and other injections
• Routine immunizations
• Rehabilitative therapies
• Maternity services
Vision• Routine exams
• Hardware, such as glasses and contacts Prescription Drugs• Generic drugs
• Brand-name drugs DentalThe Health Benefits Trust helps with routine dental care as well as dental
emergencies. Dental benefits are provided by Delta Dental and Willamette
Dental.
Preventive care: There is no annual
deductible for preventive proce-
dures. Covered procedures include
check-ups, cleanings and X-rays.
Basic procedures: Covered proce-
dures include fillings, oral surgery,
periodontics (gum disease) and
endodontics (root canals).
Major procedures: Covered procedures
include crowns, dentures and bridges.
HOW MUCH DOES IT COST? The Health Benefits Trust works hard to keep your out-of-pocket costs low. You pay $25 per month toward the premium for medical/prescription/vision and dental coverage. You cannot enroll for only medical or only dental coverage.
HEALTH BENEFITS BASICS
40 MYSEIUBENEFITS.ORG
2012-2013 Medical Plan Highlights • Prescriptions for some value-based drugs will be free using
mail order services• Office visit co-pay will change from $10 to $15• Prescription/Rx co-pays will be cheaper (except for non-
formulary brand name drugs)• Self-Insured Dental network will change to Delta Dental
(Washington Dental Service) • All changes are effective 8/1/2012• Your $25 monthly payroll deduction will stay at $25
Your Current Insurance Plan
If you are currently enrolled in the Trust, you are enrolled in one of the follow-ing plans depending on your ZIP code:
Group Health POS – you live within 30 miles of a Group Health Medical Center or contracted facility
Group Health PPO – you live more than 30 miles from Group Health Medical Center or contracted facility
kaiser Permanente HMO – you live within the Kaiser Permanente service area (southwest Washington/ Portland, OR only)
If You Enroll for Coverage Effective 8/1/12 or Later
If you enroll for coverage effective 8/1/12 or later and you live within 30 miles of a Group Health Medical Center of contracted facility, you will be covered under Group Health Options Select - HMO Plan. This plan only has coverage in-network. There are no out-of-network benefits.
Monthly Cost Share Unchanged The monthly cost share for Home Care Aides will remain the same at $25 per month.
Understanding Health Insurance TermsCo-payThe amount you will pay at the time of your visit.
DeductibleThe amount that you pay for covered services before the plan begins paying in a given year. You need only to satisfy your deduct-ible once in a calendar year.
In-networkYou don’t have to pay as much when you use this group of providers. HMO: You only have coverage in-network.
Out-of-networkA bigger group of providers where you may access care but your out of pocket expenses will be higher than with in-network providers.
2012-2013 BENEFITS BOOK 41
A Little More About These Changes
The Office Visit Co-pay will increase from $10 to $15. However, preventive care visits will continue with a $0 co-pay.
Insurance Carrier for Dental
The Trust’s self-insured dental plan will be adminis-tered by Delta Dental (Washington Dental Service) instead of Premera Blue Cross. To receive the highest level of benefits, you should choose a Delta Dental PPO Provider. You also have a choice of dental insurance plans: Delta Dental (Washington Dental Service) or Willamette Dental. There are no changes to the dental benefits for either dental programs.
Group Health: No Cost for Value Based Prescriptions by Mail
The Rx co-pay will be lowered for value based drugs that treat diabetes, high blood pressure, high cholesterol and heart failure. The co-pay will also be lowered for other generic drugs, and formulary brand name drugs. However, if you choose to use brand name drugs that are not a part of Group Health or Kaiser’s formulary, your co-pay will increase to $50.
Use Mail Order for your Prescriptions: You will have the lowest co-pay, or no co-pay, by using mail order prescription drugs.
Health Profile = $25 for youFill out your Health Profile, offered by Group Health Options or the Total Health Assessment, offered by Kaiser Permanente and the Health Benefits Trust will send you a check for $25! Good for your health, good for your wallet.
HEALTH BENEFITS BASICS
Rx Co-pay (In-network) for
30 day supply
Current Effective 8/1/12 Effective 8/1/12Mail order
Value Based Drugs*
Group Health $15 $4 $0
Kaiser $15 $5 $10 for 90 day supply
Generic drugs
Group Health $15 $8 $3
Kaiser $15 $5 $10 for 90 day supply
Formulary brand name drugs
Group Health $30 $25 $20
Kaiser $30 $25 $50 for 90 day supply
Non-formulary brand name drugs
Group Health $30 $50 $45
Kaiser (requires approval)
$30 $50 $100 for 90 day supply
Value Based Drugs are for Diabetes: metformin, glipizide, glyburide, insulin NPH High Cholesterol: simvastatin, lovastatin, pravastatin Heart Failure: carvedilol, metoprolol XL, spironolactone High Blood Pressure: hydrochlorothiazide, chlorthalidone, lisinopril, enalapril, captopril, ramipril, lisinopril/HCTZ, amlodipine, verapamil, diltiazem, metoprololIR, atenolol
PRESCRIPTION/Rx CO-PAY GRID
42 MYSEIUBENEFITS.ORG
WHICH PLAN AND NETWORK APPLIES TO ME?
New Plan Group Health Options Select – HMO Plan for members who enroll 8/1/2012
or later
Group Health “Options Select”– POS Planif you have been previously enrolled prior to 8/1/2012 and are re-enrolling:
Group Health “Options”– PPO Plan
Your network is called: “Group Health Options Select”
If you are enrolling effective 8/1/2012 or later, you will be automatically enrolled in this plan if you live within 30 miles of a Group Health Facility or Contracted Provider.
Your network is called: “Group Health Options Select” If you are enrolling effective 8/1/2012 or later, you will be automatically enrolled in this plan if you live within 30 miles of a Group Health Facility or Contracted Provider.
Your in-network is called: “Options Select”
Your in-network is called: “Options”
You will be automatically enrolled in this plan if you live farther than 30 miles from a Group Health Facility or Contracted Provider or live in Montana.
All care is provided at Group Health Medical Centers and from other Group Health contracted providers
No out-of-network coverage is available.
In-Network care is provided at Group Health Medical Centers and from other Group Health contracted providers
Out-of-Network care is provided by First Choice Health Network Providers
The First Choice Health Network has an extensive panel of preferred providers in WA, OR, ID, AK and MT.
In-Network care is provided by Group Health Medical Centers; other Group Health contracted providers; First Choice Health Network Providers and Beech Street Providers
The First Choice Health Network has an extensive panel of preferred providers in WA, OR, ID, AK and MT.
Out-of-Network care is any other licensed provider
Link to look up Group Health Providers http://myseiu.be/imSCSp
Group Health PHARMACY
HMO Plan POS Plan PPO PlanAny Group Health Medical Center or contracted community pharmacy.
In-Network: Any Group Health Medical Center or contracted Community Pharmacy
Out-of-Network: Med Impact Pharmacies
In-Network: Group Health Medical Centers and Med Impact Pharmacies
Out-of-Network: All other pharmacies
KAISER PERMANENTEIf you live in the Kaiser Permanente Service Area (please see FAQ #30) you will be automatically enrolled in this plan. You must access a Kaiser Permanente provider/facility for your care. There is no out-of-network coverage under this plan.
Link to look up Kaiser Permanente Providers http://myseiu.be/mTdBBa
DENTAL PLANSYou have a choice of dental plans, however you would only choose Willamette Dental if you lived near a Willamette Dental Clinic.
Delta Dental (washington Dental Service) PPO Plan willamette Dental In-network: You will have the highest level of coverage by using a Delta Dental PPO dentist. You can find a Delta Dental PPO network dentist by visiting their Web site at www.DeltaDentalWA.com. Click on the Patients tab and then on the Find a Dentist tab at the top of the screen to begin your search. Choose the “Delta Dental PPO” option for participating dentists under the In a Certain Plan or Network. Be sure to check the Delta Dental PPO network.
For dentists outside of Washington state, click on the green “search the national Delta Dental directory” link. This will take you to the national directory.
Coverage for this plan is only offered at Willamette Dental Clinics. You can find the locations of Willamette Dental clinics by visiting www.willamettedental.com. Click on the Locations tab for your state.
PLAN
AND
NET
WOR
K GR
ID
2012-2013 BENEFITS BOOK 43
2012-2013 BENEFIT IN-NETWORK OUT-OF-NETWORK POS PLAN ONLY NOTES
Preventive Care Covered In Full
Covered in full up to $300; 80% covered
Mammograms Covered In Full
$500 deduct, 80% Covered
Routine mammograms
Urgent Care
Group Health $15$15 co-pay, deductible and coinsurance apply
Kaiser $30 No out-of-network allowed
Emergency Room $200 co-pay $200 co-pay Waived if admitted
Out-of-Network Deductible
Group Health $0
$500 and services may not be cov-ered depending on your plan
Kaiser $0 Not allowed No out-of-network allowed
MEDICAL PLAN HIGHLIGHTS
44 MYSEIUBENEFITS.ORG
2012-2013 BENEFITS BOOK 45
Group Health Urgent Care CentersSeven Group Health medical centers have Urgent Care Centers, most with evening, weekend, and holiday hours. Use the Group Health Provider Directory at www.ghc.org to find urgent care providers in other areas. You can also find urgent care locations, hours and wait times from the Group Health iPhone and Android App. Call the Consulting Nurse Line at 1-800-297-6877 for the nearest location.
URGENT CARE SAVES MONEY
$200 vs. $15The out-of-pocket cost for a trip to the emergency room is $200 (waived if you are admitted to the hospital) vs. just $15 for a trip to Urgent Care with Group Health and $30 with Kaiser.
HEALTH BENEFITS BASICS
Bellevue Medical Center11511 N.E. 10th St.Bellevue, WA 98004425-502-4120Open 24 hours a day, 7 days a week
Everett Medical Center2930 Maple St.Everett, WA 98201425-261-1660Mon.-Fri. 4:30 pm-8 pm Sat. 9 am - 3:30 pm Sun. 9 am - 12:30 pm
Olympia Medical Center700 Lilly Road N.E. Olympia, WA 98506360-923-7740Mon.-Fri. 8 am-11 pm Weekends 9 am-7 pm
Seattle Capitol Hill201 16th Ave. E.Seattle, WA 98112206-326-3175Open 24 hours a day, 7 days a week
Silverdale Medical Center10452 Silverdale Way NW Silverdale, WA 98383360-307-7300
Mon.-Fri. 3-11 pm Weekends 11 am-7 pm
Spokane Riverfront322 North River DriveSpokane, WA 99201509-324-6464Mon.-Fri. 1-9 p.m. Weekends 9 a.m.-9 p.m.
Tacoma (coming in Fall 2012)209 MLK Jr. Way Tacoma, WA 98405253-596-3300Open 24 hours a day, 7 days a week
Bothell-Northshore11913 N.E. 195th St.Bothell, WA 98011425-489-3100
Burien140 S.W. 146th St.Burien, WA 98166206-901-2400
Federal way 301 S. 320th St.Federal Way, WA 98003253-874-7000
Lynnwood20200 54th Ave. W.Lynnwood, WA 98036425-672-6400
Renton275 Bronson Way N.E.Renton, WA 98056425-235-2800
Seattle-Northgate9800 4th Ave. N.E. Seattle, WA 98115206-302-1200
Saturday Clinics - 9 a.m.-12:30 p.m. In addition to the Centers above, these clinics are for mi-nor injuries or issues that require immedidate attention.
46 MYSEIUBENEFITS.ORG
2012-2013 BENEFITS BOOK 47
Dental BenefitsHealthy teeth and gums are a critical part of
your overall health. That’s why comprehensive
dental benefits are included in the coverage
you receive through the Health Benefits Trust.
To keep your teeth healthy, your dental
benefits include at no additional cost to you
for in-network services:
• Routine exams
• Regular cleanings
• X-rays
• Gum care
• Fillings
Depending on your plan, some of the cost of the following procedures may
also be covered:
• Crowns, inlays
• Dentures
• Implants
To take the best care of your teeth, gums and overall health, you should see
your dentist every six months for a complete exam and cleaning.
Vision BenefitsKeeping your eyes healthy and regularly updating optical prescriptions are
important to your overall health and well being. Vision benefits through the
Health Benefits Trust are an affordable way to ensure your sight is protected.
•For a $15 co-pay per visit, you receive routine
vision care.
•Every two years you receive $200 worth of optical
supplies, including contact lenses and frames.
Did You Know? The American Dental Association says healthy gums are linked to a healthy heart? Another reason to visit your dentist regularly.
HEALTH BENEFITS BASICS
Did You Know? As part of a complete wellness plan, everyone should have regular eye exams, even if you’re not having problems with your vision.
48 MYSEIUBENEFITS.ORGWEL
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2012-2013 BENEFITS BOOK 49
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YOUR WELLNESS Working Together To Keep You HealthyAs a Home Care Aide, you know how important it is to stay healthy. With the
benefits you receive from the Health Benefits Trust, you have excellent health
care, dental and vision benefits at a low cost.
There are three things we can all do to ensure that health care for Home Care
Aides continues for years to come:
• Keep ourselves healthy
• Keep out-of-pocket costs low
• Help control health care costs (for example through limiting use of the emergency room, using mail order, generic prescriptions) so we do not have to pay more next year
Four Steps to Better HealthThere are four key ways you can maximize your benefits for better health:
• Making your first appointment with a Primary Care Provider (and earning $10!)
• Using urgent care vs. the emergency room when appropriate
• Managing prescriptions
• Completing a Health Profile or Assessment (and earning $25!)
Follow the steps below and on the following pages to get started.
URGENT CARE
URGENT CARE
URGENT CARE URGENT CARE
HEALTHYHOmE CARE AIDE
See a Primary Care ProviderFind a doctor, set up your first visit
Earn $10! See P. 50
Health Profile or AssessmentFill out an easy online quiz
Earn $25! See P. 51
Find Urgent Care CentersLocate the centers near you
manage Your PrescriptionsTransfer prescriptions to your provider, use mail order
50 MYSEIUBENEFITS.ORG
See a Primary Care Provider1One of the most important things for you to do is to select
a Primary Care Provider and set up your first visit. A strong
relationship with your Primary Care Provider is at the heart of
your care, and helping you stay healthy.
How to Select Your Primary Care Provider
Go Online: Use the provider directory at www.ghc.org or www.kp.org to find a
personal physician who’s a good match for you. or
Call: Group Health Customer Service at 1-888-901-4636
Kaiser Permanente Customer Service at 1-800-813-2000
Make an Initial Primary Care Appointment = Earn $10!
Establishing a relationship with your Primary Care Provider is important to your
health. If you complete a preventive care/wellness visit with your Primary Care
Provider within the first three months of
your coverage effective date, the Health
Benefits Trust will pay you $10. You can
only receive this benefit once.
What’s a Primary Care Provider?
A Primary Care Provider is a family prac-
tice, general practice, internal medicine,
or pediatrics physician who provides most
of a member’s primary care. A PCP helps
coordinate a member’s specialty care.
URGENT CARE
DID YOU KNOW?Your out-of-pocket expenses are much less when you use in-network providers. Assuming you have four office visits this year, your out-of-pocket expenses using a Group Health provider would be $60 vs. $500 or more with an out-of-network provider.
2012-2013 BENEFITS BOOK 51
Complete a Health Profile
How Healthy are You?
Filling out an easy health quiz called a Health Profile or
Health Risk Assessment will help you find out!
• What are your daily eating habits?
• How often do you exercise?
• How often do you drink alcohol?
Find out how the answers to questions like these affect your health.
Your Health Profile (Group Health) or Total Health Assessment (Kaiser) are
online quizzes to help you and your doctor take better control of your health.
Filling out a Health Profile is a key step on the path to better health.
Fill out a Health Profile, Earn $25!
Home Care Aides who complete a Group Health Profile or kaiser Permanente Total
Health Assessment will receive a $25 check from the Health Benefits Trust. You
will receive a check within 6–8 weeks of submitting your health profile. You can
also fill out a paper version of the profile by contacting your provider.
2
URGENT CARE
Register for myGroupHealth for members at ghc.orgTo access the Health Profile, you need to upgrade your MyGroupHealth account so you have access to online services. To register, visit www.ghc.org or call Website Customer Service at 1-888-874-1620.
Register for Kaiser Online AccessUsing Kaiser online access, you can fill out your Total Health Assessment. Register at www.kp.org
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52 MYSEIUBENEFITS.ORG
Locate Closest Urgent Care Center
It is important to locate your Urgent Care Center in
advance because in the event you need urgent care, it is
often a difficult time to look for an Urgent Care Center.
3URGENT CARE
DID YOU KNOW?Urgent Care is a much more affordable option for Home Care Aides through the Health Benefits Trust. The out-of-pocket cost for a trip to the emergency room is $200 (waived if you are admitted to the hospital) vs. just $15 for a trip to Urgent Care with Group Health Options and $30 with kaiser.
Where to Find Urgent CareGROUP HEALTH: Many Group Health medical
clinics have Urgent Care Centers, most with
evening, weekend, and holiday hours. Use
the Provider Directory online to find urgent
care providers in other areas.
Find an Urgent Care Center at www.ghc.org
or call 1-888-901-4636.
kAISER: Find an Urgent Care Center at www.kp.org or call 1-800-813-2000.
URGENT CARE - $15 per visitAllergiesAsthma Attack (Minor)Cold, Flu, FeverCoughDizzinessFracturesNauseaMinor BurnsMinor Cuts/LacerationsSore ThroatSprainsStitches
EMERGENCY ROOM - $200 per visit (waived if admitted)Chest PainCompound Fractures (Bone Visible)High FeverIngestion of PoisonMajor Head InjurySeizuresSevere Asthma AttackSevere BurnsShockUncontrollable Bleeding
When to Use Urgent Care vs. Emergency RoomHere are some examples of when to use urgent care or the emergency room. This is not intended to be a complete list.
2012-2013 BENEFITS BOOK 53
Manage Your Prescriptions 4Your prescriptions are a big part of your health benefits.
Make the most of them by managing them wisely.
Transfer PrescriptionsIf you have existing prescriptions, have them transferred to Group Health or Kai-
ser Permanente to receive the best benefit from your coverage.
Mail Order PrescriptionsGetting your prescriptions by mail does not cost any more than the co-pays.
Group Health members get a co-pay discount of up to $5 vs. filling your prescrip-
tion at the pharmacy. Kaiser members can obtain 3 months supply for only 2
co-pays vs. 3 co-pays at the pharmacy.
New Prescription Benefit: Value-Based Prescriptions Free for YouFor some Value-Based prescriptions through Group Health, there is no co-pay
when you have drugs mailed to you through convenient mail order services. See
Page 41 for a list of the prescriptions available for this benefit.
URGENT CARE
How to Transfer Your PrescriptionGroup Health: Go online to www.ghc.org to transfer your prescription or call Customer Service at 1-888-901-4636.
kaiser Permanente: Go online to www.kp.org or call Customer Ser-vice at 1-800-813-2000.
How to Set Up mail Order PrescriptionsGroup Health: After setting up an online account you can order refills online or by phone and have them mailed to you – free of charge.
kaiser Permanente: After setting up an online account you can order refills online and have them mailed to you – free of charge.
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54 MYSEIUBENEFITS.ORG
2012-2013 BENEFITS BOOK 55
Check Your Eligibility for Health Benefits• You must work at least 86 hours per month for three consecutive
months to be eligible for these benefits. You do not need to wait until you are eligible to enroll, you can complete the form after you’re hired.
Enrolln Individual Providers: You can enroll by logging in to www.myseiubenefits.org and filling out the enrollment form.
n Agency Providers: Talk with your employer about enrollment.
Look for Your ID CardAfter you are eligible and enroll you should receive an ID card in the mail. You will need the ID card number to access your benefits. If you do not receive the card by the 10th of the month that your coverage starts, call the MRC at 1-866-371-3200 if you are an Individual Provider or, if you are an Agency Provider, talk with your employer. Look for and write down your nearest Urgent Care Center and keep it with your card for reference.
Fill Out Your Health ProfileThe Health Profile is an online quiz and report to help you manage your health. To help encourage participation, you will receive a check for $25 for filling it out. If you do not have com-puter access, you can fill out the profile in paper format as well.
Make a Primary Care AppointmentUse the online provider directory at www.ghc.org or www.kp.org to find a primary care doctor who’s a good match for you. You will receive $10 for attending a primary care appointment within the first three months of your coverage.
Locate Your Nearest Urgent Care CenterAs soon as possible, you should identify the closest urgent care center to you in case of an emergency. You can find urgent care centers online at www.ghc.org or www.kp.org.
Manage Your PrescriptionsIf you have existing prescriptions, have them transferred to Group Health or Kaiser Permanente. Next, set up mail order prescription refills online to save money and save time.
HEALTH BENEFITS QUICK START
URGENT CARE
URGENT CARE
URGENT CARE
URGENT CARE
URGENT CARE
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56 MYSEIUBENEFITS.ORG
COVERAGE BASICS1. when I am outside washington state or the United States am I covered by the plan?
Yes, but you must contact the health insurance provider for specific benefits and claim submission procedures at: Group Health 1-888-901-4636 Kaiser 1-800-813-2000 Delta Dental 1-800-554-1907 Willamette (contact the clinic where the services were provided)
2. Can I add dependents to my plan?
n Individual Provider: Dependents are not covered. The Individual Provider benefits do not allow coverage for dependents under this plan.
n Agency Provider: If you are covered by the Health Benefits Trust, you can cover dependents by paying the full premium for them through payroll deduc-tion. Dependents can only be added when they are initially eligible or during the annual open enrollment period. Check with your employer for information.
3. How do I cancel my coverage and the corresponding paycheck deductions?
The request must be made in writing and sent to the Health Benefits Trust via fax or U.S. Mail. Fax to 206-859-2637 or mail to SEIU Healthcare NW Health Benefits Trust PO Box 6, Mukilteo, WA 98275. Requests in writing received before the 15th of the month will stop further payroll deductions.
4. If I haven’t received an ID card, who do I call?
Allow up to 10 days after your coverage begins for processing and mailing your ID cards. After you enroll and are eligible you should receive an ID card in the mail. You will need the ID card number to access your benefits. If you do not re-ceive the card by the 10th of the month that your coverage starts, call the MRC at 1-866-371-3200 if you are an Individual Provider or if you are an Agency Provider, talk with your employer. Look for and write down your nearest Urgent Care Center and keep it with your card for reference.
5. Is dental or vision coverage included with this plan?
Yes. Vision coverage is part of your medical plan administered by your medi-cal health insurance provider – Group Health or Kaiser. You have the choice of dental coverage either through Delta Dental or Willamette.
6. Is there a pre-existing condition waiting period?
No.
FREQUENTLY ASKED QUESTIONS
2012-2013 BENEFITS BOOK 57
ELIGIBILITY7. Can I use authorized, unclaimed hours from a previous month to satisfy my hour requirement in a subsequent month?
No. For the purpose of health care insur-ance eligibility, hours are only applicable to the month in which they are authorized, not when they are claimed or paid.
8. How do I enroll for coverage?
n Individual Provider: Log on to www.myseiubenefits.org to complete enroll-ment or call the Member Resource Center at 1-866-371-3200.
n Agency Provider: Contact your employer to coordinate your enrollment.
9. How many hours do I have to work for continuing coverage?
After your coverage begins, you must work at least 86 hours each month to have continuous coverage.
10. I don’t have enough hours some months resulting in a lapse in coverage, do I have to meet the initial eligibility requirements again?
If you are not covered by the plan for 12 months in a row, you will need to re-qualify for the initial eligibility requirements.
11. I work for a Home Care Agency and I’m also an Individual Provider. If I’m currently enrolled in my agency employer’s plan, can I terminate that coverage and enroll in the Health Benefits Trust as an Individual Provider instead of keeping my agency plan?
Yes, but please keep in mind the initial eligibility requirements when determining your cancellation date. You’ll need to keep your current plan until your coverage as an Individual Provider begins. NOTE: You cannot be covered under both the Health Benefits Trust as an Individual Provider and another employer’s plan.
12. what happens if I work less than 86 hours in a month after I am enrolled in the plan?
For all Grandfathered Agency Providers - (this means you were an Agency Provider and must have had health care coverage by the Trust in the month of September 2011).
Your coverage will terminate the first day of the following month.
FREQUENTLY ASKED QUESTIONSPO
LICIES
HOW DO I ENROLL FOR COVERAGE? n Individual Provider: Log on to www.myseiubenefits.org to complete enrollment or call the Member Resource Center at 1-866-371-3200.
n Agency Provider: Contact your employer to coordinate your enrollment.
58 MYSEIUBENEFITS.ORG
Example: If you work less than 86 hours in May, your health care coverage will end that month and you will NOT have coverage starting June 1st.
For all Individual Providers and all Non-Grandfathered Agency Providers
Your coverage will continue for one month and end the first of day of the second month.
Example: If you work less than 86 hours in May, you WILL have health care coverage in June, but you will NOT have coverage starting July 1st.
If you lose coverage, you may choose to pay the full monthly (COBRA) premium out of pocket. In this case, the Health Benefits Trust will send you a COBRA notice and election form explaining your coverage option and the cost.
13. when can I submit my enrollment form for coverage?
n Individual Provider: You should enroll as soon as you have authorization to work as an Individual Provider.
n Agency Provider: Contact your employer to coordinate your enrollment.
MISCELLANEOUS14. I am an Individual Provider. what if I report my hours to Social Service Payment System (SSPS) so late that they don’t make the $25 deduction from my check?
You will need to notify the Health Benefits Trust and mail in a check or money order for $25 payable to SEIU Healthcare NW Benefits Trust, PO Box 6, Mukilteo, WA 98275. You will also need to send a copy of your paycheck stub (aka Remittance Advice) and invoice showing you claimed at least 86 hours for that month.
It is very important to report your hours to SSPS in a timely manner to avoid having to make a payment by mail. Your health insurance provider may not be able to verify your eligibility and your coverage will be considered lapsed until we receive your check and supporting documentation.
15. Can I be covered by another plan at the same time that I’m enrolled in the Health Benefits Trust Plan and use it as secondary coverage?
Participants may not have comprehensive health care benefits or insurance through other individual, family, employment-based, military or veterans cover-age or insurance.
16. How do I notify you that my address has changed?
A request for an address change must be made to either your DSHS case worker or to Social Service Payment System (SSPS) directly if you are an Individual Pro-
FREQUENTLY ASKED QUESTIONS
Is dental or vision coverage included with this plan?
2012-2013 BENEFITS BOOK 59
vider. If you are an Agency Provider, contact your employer to make this change.
17. I currently have coverage, but not through the Health Benefits Trust plan. Can I enroll in the Health Benefits Trust plan if my other current coverage terminates?
Yes.
18. I want to change my dental insurance provider, how can I do this?
Typically, this is only allowed during the annual open enrollment period that takes place in July of each year and has an August 1 effective date. If you are an Agency Provider, please contact your employer about open enrollment or other location change options available. If you are an Individual Provider, please call the Member Resource Center toll-free at 1-866-371-3200 about options for changing dental insurance providers.
19. If I cancel my insurance, can I enroll again later?
Yes, but if you have voluntarily cancelled your coverage, you will have to meet the initial eligibility requirements again in order to regain coverage. If you are an Agency provider, you cannot enroll again until the next annual open enrollment.
20. If I have coverage through my spouse, can I cancel that coverage and sign up for the Health Benefits Trust plan?
Yes, but please keep in mind the initial eligibility requirements when determining your cancellation date.
21. what benefit plans are offered by the Health Benefits Trust?
Currently, three insurance providers provide fully insured medical and/or dental coverage and one insurance provider provides self-insured dental coverage. Providers currently include: Group Health, Kaiser Permanente, Delta Dental Self-insured Dental, and Willamette Dental Group. Trust enrollees are automati-cally enrolled in the Group Health coverage unless they reside in the Kaiser Permanente service area (southwest Washington and Portland, OR areas). Trust enrollees have a choice of dental insurance providers.
22. what if I am currently on COBRA through another plan? Can I cancel COBRA and enroll?
Yes. There is a place on the enrollment application to indicate the current plan termination date.
FREQUENTLY ASKED QUESTIONSPO
LICIES
IS DENTAL OR VISION COVERAGE INCLUDED WITH THIS PLAN? Yes. Vision coverage is part of your medical plan administered by your medical insurance pro-vider – Group Health or Kaiser. You have the choice of dental coverage either through Delta Dental or Willamette.Is dental or vision
coverage included with this plan?
60 MYSEIUBENEFITS.ORG
23. what if I have washington’s Basic Health Plan (BHP) coverage? Can I enroll in this plan?
Only if you cancel your BHP coverage. You cannot have both. There is a place on the Health Benefit Trust’s enrollment application to indicate the termination date of the current coverage.
24. when will my coverage be effective?
n Individual Providers: Call the Member Resource Center at 1-866-371-3200 to determine.
n Agency Providers: Please contact your Human Resources department to coordi-nate your enrollment.
FREQUENTLY ASKED QUESTIONS
26. what if I don’t want to see any doctors who practice with Group Health Medical Centers?
If you are a new enrollee in the Health Benefits Trust effective 8/1/2012 or later, and you live within 30 miles of a Group Health Medical Center or contracted provider, your health care coverage is only for using Group Health Medical Centers or con-tracted providers. There is no out-of-network coverage.
For all other enrollees, each time you seek health care services, you can choose to use your in-network providers, or not. Your highest level of benefits ($0 deductible) will be found using in-network providers: Group Health Physicians for the POS (Op-tions) plan and First Choice Health Network / Beech Street Network of Providers for the PPO (Options PPO) plan.
You will pay more out of pocket costs by using an out-of-network provider. For ex-ample, you will have a $500 deductible.
27. what does Group Health HMO vs. POS vs. PPO mean?
If you live within 30 miles of a Group Health facility or contracted provider, and your coverage begins 8/1/2012 or later, you will automatically be enrolled in the HMO plan. If you are already enrolled, then your coverage is through the POS Plan.
If you live beyond 30 miles, you will automatically be enrolled in the PPO plan.
In the POS and PPO Plans, you have the choice of in-network or out-of-network providers each time you seek service.
Group Health Specific Questions
2012-2013 BENEFITS BOOK 61
FREQUENTLY ASKED QUESTIONSPO
LICIES
28. How do I look for a provider available to me through Group Health?
For POS Plan (within 30 miles of Group Health facilities):
On right hand side of www.ghc.org, under “Find a Doctor or Medical Facility” click on “Provider & Facility Directory”; then click on “Doctors and Other Providers”; then under “*Health plan provider network:” choose “Options PPO” or “Options POS” or “Options Select” (for the HMO plan)
For PPO Plan (all others): On right hand side of www.ghc.org, under “Find a Doctor or Medical Facility” click on “Provider & Facility Directory,” click on “Doctors and Other Providers”; then under “*Health plan provider network:” choose Options PPO.
Or call Group Health Customer Service toll free: 1-888-901-4636 • Findingaprovider • Specificbenefitquestions • Complexmedicalcarecasemanagement • Inpatientcarecasemanagement
WHO DO I CONTACT IF I HAVE QUESTIONS ABOUT MY BENEFITS?Contact your insurance provider directly for an explanation of benefits and/or questions you have about claims.
Group Health (POS, POS, HMO) 1-888-901-4636 www.ghc.org
kaiser Permanente 1-800-813-2000 www.kp.org
Delta Dental (Dental) 1-800-554-1907 www.deltadentalwa.com
willamette Dental 1-800-359-6019 www.willamettedental.com
WHO DO I CALL TO ENROLL OR ASK ELIGIBILITY QUESTIONS?n Individual Providers: Contact the Member Resource Center toll-free at 1-866-371-3200.
n Agency Providers: Contact your employer
62 MYSEIUBENEFITS.ORG
FREQUENTLY ASKED QUESTIONSKaiser Permanente Specific Questions
30. what is kaiser Permanente’s service area?
If you live in any of the following counties/zip codes, your medical coverage will be provided by Kaiser Permanente’s HMO plan.
Washington counties: Clark, Cowlitz, Lewis 98591 98593 98596, Skamania 98639 98648, Wahkiakum 98612 98647
Oregon counties: Multnomah, Polk, Washington, Yamhill
31. Do I have out-of-network coverage under kaiser Permanente?
No (with the exception of emergency services). To access your comprehensive coverage, you must use a Kaiser Permanente provider/facility.
www.kp.org
Link to find Kaiser Permanente Providers
http://myseiu.be/mTdBBa
32. kaiser Permanente Membership Services
Or call Kaiser Permanente Membership Services toll free: 1-800-813-2000
• Chooseaprimarycareprovider• Specificbenefitquestions• Complexmedicalcarecasemanagement• Inpatientcarecasemanagement• Speaktoanadvicenurse• AskaboutKaiserPermanentefacilitiesacrossthecountry
33. Register for kaiser Online Access where you Can:
• E-mail your doctor’s office• View select test results• Order prescription refills (and have them mailed to you, with free shipping)• Request or cancel routine appointments• Review recent past office visits• See a list of your recent immunizations and allergies• Act for a family member (e-mail your child’s doctor, and more)• Receive a monthly e-newsletterRegister at https://members.kaiserpermanente.org/redirects/register
POLICIES
2012-2013 BENEFITS BOOK 63
BENEFIT SUMMARIESThe following pages are benefit summaries, only, and are not intended to replace
the specifics of the individual plan’s Certificate of Coverage, Contract, or Evidence
of Insurance. If there is a contradiction, the Certificate of Coverage, Contract, or
Evidence of Insurance will take precedence.
IF YOU HAVE QUESTIONSIf you have questions about your plan’s coverage,
contact your health insurance provider.
Group Healthwww.ghc.org1-888-901-4636Mon.-Fri., 8 a.m.-5 p.m.
kaiser Permanente1-800-813-2000www.kp.org
Delta Dental 1-800-554-1907 www.deltadentalwa.com
willamette Dental1-800-359-6019www.willamettedental.com
64 MYSEIUBENEFITS.ORG
WILLAMETTE DENTAL - Benefit SummariesQuestions?1-800-359-6019
www.willamettedental.com
NOTE: This is a benefit summary only and is not intended to replace the
specifics of the Self-funded Dental Plan Document. If there is a contradiction,
the Plan Document will govern.
IP Plan &Agency Plan
2012-2013 BENEFITS BOOK 65
BENEFIT CO-PAYMENT
Annual Maximum No Annual Maximum*
Deductible No Deductible
General Office Visit $15 per Visit
DIAGNOSTIC AND PREVENTIVE SERVICES
Routine and Emergency Exams Covered at 100%
All X-rays Covered at 100%
Teeth Cleaning Covered at 100%
Fluoride Treatment Covered at 100%
Sealants Covered at 100%
Head and Neck Cancer Screening Covered at 100%
Oral Hygiene Instruction Covered at 100%
Periodontal Charting Covered at 100%
Periodontal Evaluation Covered at 100%
RESTORATIVE DENTISTRY
Fillings (Amalgam) Covered at 100%
Stainless Steel Crown Covered at 100%
Porcelain-Metal Crown $250
PROSTHETICS
Complete Upper or Lower Denture $400
Bridge (per Tooth) $250
ENDODONTICS AND PERIODONTICS
Root Canal Therapy – Anterior $85
Root Canal Therapy – Bicuspid $105
Root Canal Therapy – Molar $130
Osseous Surgery (per Quadrant) $150
Root Planing (per Quadrant) $75
ORAL SURGERY
Routine Extraction (Single Tooth) Covered at 100%
Surgical Extraction $100
ORTHODONTIA
Pre-Orthodontic Service $150**
Comprehensive Orthodontia Value Added Services Available
MISCELLANEOUS
Local Anesthesia (Novocain) Covered at 100%
Dental Lab Fees Covered at 100%
Nitrous Oxide $40 per Visit
Specialty Office Visit $30 per Visit
Emergency Office Visit $50 per Visit
Out of Area Emergency Care Reimbursement up to $250*TMJ has a $1000 annual maximum / $5000 lifetime maximum
IP Plan &Agency Plan
**Fee credited towards
comprehensive orthodontic
co-payment if patient accepts treatment plan.
Form No. 015-WA (4/08) Contract No. 001-WA (4/06)
66 MYSEIUBENEFITS.ORG
This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, cost sharing, out-of-pocket maximums, exclusions, or limitations, nor does it list all benefits and cost sharing. For a complete explana-
tion, please refer to the applicable EOC, or to the Disclosure Form for California, or to the Member Handbook for Hawaii.
Delta Dental – In Service Area
Group NameDelta Dental PPO - Program # 00018
Effective August 1, 2012
Washington Dental Service - Delta DentalPO Box 75983 Seattle, WA 98175-0983
Customer Service (206) 522-1300
Toll-free (800) 554-1907
Monday – Friday 8 a.m. to 5 p.m PST
NOTE: This is a brief summary of benefits only and does not constitute a contract. You will
receive a benefits booklet that completely details your Delta Dental PPO dental benefits.
Please feel free to call our Customer Service Department if you have any questions.
2012-2013 BENEFITS BOOK 67
PAYMENT LEVELS
Members utilizing “Delta Dental PPO”
Dentists
Members utilizing “Non-PPO Dentists”
Class I - Diagnostic & PreventiveExams, cleanings, x-rays, sealants,
fluoride treatment100% 80%
Class II - BasicFillings, periodontal maintenance,
periodontics, endodontics, oral surgery
100% 60%
Class III – Major Crowns, onlays, dentures, partials,
bridges, implants80% 40%
Maximum per Benefit PeriodBenefit period: January 1 –
December 31$1,000 $1,000
Deductible – waived on Class IPer person per benefit period
$0 $50
Benefit Summary
Highlights of Covered BenefitsCLASS I – DIAGNOSTIC & PREvENTIvE
• Exams (covered twice in a benefit period)
• Regular Cleanings (covered twice in a benefit period or up to four times for patients
with advanced periodontal disease)
• Bitewing X-rays (covered once in a benefit period)
CLASS II - BASIC
• Fillings (covered on the same surface per tooth once every two years)
• Oral Surgery & Simple Extractions
• Periodontics
• Periodontal Cleanings (covered twice in a benefit period or up to four times for patients
with advanced periodontal disease)
• Endodontics (root canals covered once per tooth in a two year period)
CLASS III - mAJOR
• Crowns (covered once in a seven year period per tooth)
• Dentures (covered once in a seven year period per tooth)
• Bridges (covered once in a seven year period per tooth)
• Onlays (covered once in a seven year period per tooth)
68 MYSEIUBENEFITS.ORG
This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, cost sharing, out-of-pocket maximums, exclusions, or limitations, nor does it list all benefits and cost sharing. For a complete explana-
tion, please refer to the applicable EOC, or to the Disclosure Form for California, or to the Member Handbook for Hawaii.
Delta Dental - Out of Service Area
Group NameDelta Dental PPO - Program # 00018
Effective August 1, 2012
Washington Dental Service/Delta DentalPO Box 75983 Seattle, WA 98175-0983
Customer Service (206) 522-1300
Toll-free (800) 554-1907
Monday – Friday 8 a.m. to 5 p.m PST
NOTE: This is a brief summary of benefits only and does not constitute a contract. You will
receive a benefits booklet that completely details your Delta Dental PPO dental benefits.
Please feel free to call our Customer Service Department if you have any questions.
2012-2013 BENEFITS BOOK 69
PAYMENT LEVELS
Members utilizing “Delta Dental PPO”
Dentists
Members utilizing “Non-PPO Dentists”
Class I - Diagnostic & PreventiveExams, cleanings, x-rays, sealants,
fluoride treatment100% 100%
Class II - BasicFillings, periodontal maintenance,
periodontics, endodontics, oral surgery
100% 80%
Class III – Major Crowns, onlays, dentures, partials,
bridges, implants80% 50%
Maximum per Benefit PeriodBenefit period: January 1 –
December 31$1,000 $1,000
Deductible – waived on Class IPer person per benefit period
$0 $50
Benefit Summary
Highlights of Covered BenefitsCLASS I – DIAGNOSTIC & PREvENTIvE
• Exams (covered twice in a benefit period)
• Regular Cleanings (covered twice in a benefit period or up to four times for patients
with advanced periodontal disease)
• Bitewing X-rays (covered once in a benefit period)
CLASS II - BASIC
• Fillings (covered on the same surface per tooth once every two years)
• Oral Surgery & Simple Extractions
• Periodontics
• Periodontal Cleanings (covered twice in a benefit period or up to four times for patients
with advanced periodontal disease)
• Endodontics (root canals covered once per tooth in a two year period)
CLASS III - mAJOR
• Crowns (covered once in a seven year period per tooth)
• Dentures (covered once in a seven year period per tooth)
• Bridges (covered once in a seven year period per tooth)
• Onlays (covered once in a seven year period per tooth)
70 MYSEIUBENEFITS.ORG
How to use your Delta Dental PPO programThe dental plan offered to your group is Delta Dental PPO, a preferred provider plan.
You can choose any dentist – in or out of the PPO network – at the time of treatment.
However, if you select a dentist who is part of the Delta Dental PPO network, you will
receive a higher level of benefits and your out-of-pocket expenses may be lower.
Washington Dental Service/Delta Dental in Seattle, Washington, will handle all customer
service and claims for your plan. Until you receive your identification card(s), tell your
dentist you are covered by Washington Dental Service/Delta Dental and give him or her
your employer name and the program number.
Delta Dental PPO dentistsYou will receive a higher level of benefits by choosing a Delta Dental PPO dentist. Delta
Dental PPO dentists complete claim forms and submit them directly to Washington
Dental Service/Delta Dental. PPO dentists receive payment based on their lower,
pre-approved PPO fees and they cannot charge you more than these fees. You are
responsible only for your stated deductible, coinsurance and/or amounts in excess of
the program maximums. You can find a Delta Dental PPO dentist in your area by visiting
their web site at www.DeltaDentalWA.com. Go to “Looking for a Dentist” and click on
“Find a Dentist.” This will bring you to our online dentist directory. For dentists outside
of Washington state, click on the green “search the national Delta Dental directory” link
under the Mileage section. Be sure to select the Delta Dental PPO plan and follow the
prompts.
Non-PPO dentists You are not limited to visiting a Delta Dental PPO dentist. By choosing a non-PPO dentist,
your benefits will be paid at a lower benefit level. You may also be responsible for having
the dentist complete and sign claim forms. Claim payments to Delta Dental Premier
dentists will be based off their maximum allowable fee with Delta Dental. They cannot
charge you above these allowable fees. Claim payment for nonparticipating dentists will
be based on Delta Dental’s maximum allowable fees for nonparticipating dentists in the
state in which services are performed. You will be responsible for any balance remaining.
Please be aware that Delta Dental has no control over nonparticipating dentists’ charges
or billing procedures.
Please Note: This is a brief summary of benefits only and does not constitute a contract. You will receive a benefits booklet that completely details your Delta Dental PPO dental benefits. Please feel free to call our Customer Service Department if you have any questions.
2012-2013 BENEFITS BOOK 71
Kaiser Medical Plan B - Individual and Agency Providers
Summary of Medical Benefits
Washington Traditional Plan B Individual and Agency ProvidersAugust 1, 2012 through July 31, 2013
All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest.
500 NE Multnomah St., Suite 100, Portland, OR 97232
Questions? Call Membership Services (M-F, 8 am-6 pm) or visit kp.org
Portland area: 503-813-2000
All other areas: 1-800-813-2000
TTY: 1-800-735-2900
Language Interpretation Services, all areas: 1-800-324-8010
NOTE: This is not a contract. This benefit summary does not fully describe your
benefit coverage with Kaiser Foundation Health Plan of the Northwest. For more
details on your benefit coverage, claims review, and adjudication procedures,
please see your Evidence of Coverage (EOC) or call Membership Services. In the
case of conflict between this summary and the EOC, the EOC will prevail.
72 MYSEIUBENEFITS.ORG
Kaiser Plan B - Individual and Agency ProvidersOut-of-pocket Maximum (Not all services apply to the maximum; refer to your Evidence of Coverage for clarification.) You pay
For one Member $750 per calendar year
For an entire Family (AP workers Only) $2,250 per calendar year
Preventive Care Services You pay
Prenatal care and first postpartum visit $0
Immunizations $0
Preventive tests $0
Outpatient Services
Primary care visit $15
Specialty care visit $15
Routine eye exam $10
Allergy shots and other injections $5
Urgent Care visit $30
Emergency department visit $200 (Waived if admitted)
Outpatient surgery visit $50
Physician-referred acupuncture and naturopathy visit $15
Spinal and Extremity Manipulation therapy
(after 12 visits, prior authorization needed) $15
Inpatient Hospital Services$100 per admission
Ambulance Services $75 per transport
Chemical Dependency Services
Outpatient Services $15
Inpatient hospital & residential Services $100 per admission
Mental Health Services
Outpatient Services $15
Inpatient hospital & residential Services $100 per admission
Outpatient Durable Medical Equipment (DME), External Prosthetic Devices, and Orthotic Devices
20% Coinsurance
Outpatient Laboratory, X-ray, Imaging, and Special Diagnostic Procedures
$0 per department visit; $50 for specialized scans, i.e., MRI, CT, PET
Outpatient Rehabilitative Therapy Services (up to 20 visits per therapy per Calendar Year)
Physical, Speech, and Occupational therapies $15
All other therapies $15
(Not all services apply to the maximum; refer to your Evidence of Coverage forclarification.)
2012-2013 BENEFITS BOOK 73
Out-of-pocket Maximum (Not all services apply to the maximum; refer to your Evidence of Coverage for clarification.) You pay
For one Member $750 per calendar year
For an entire Family (AP workers Only) $2,250 per calendar year
Preventive Care Services You pay
Prenatal care and first postpartum visit $0
Immunizations $0
Preventive tests $0
Outpatient Services
Primary care visit $15
Specialty care visit $15
Routine eye exam $10
Allergy shots and other injections $5
Urgent Care visit $30
Emergency department visit $200 (Waived if admitted)
Outpatient surgery visit $50
Physician-referred acupuncture and naturopathy visit $15
Spinal and Extremity Manipulation therapy
(after 12 visits, prior authorization needed) $15
Inpatient Hospital Services$100 per admission
Ambulance Services $75 per transport
Chemical Dependency Services
Outpatient Services $15
Inpatient hospital & residential Services $100 per admission
Mental Health Services
Outpatient Services $15
Inpatient hospital & residential Services $100 per admission
Outpatient Durable Medical Equipment (DME), External Prosthetic Devices, and Orthotic Devices
20% Coinsurance
Outpatient Laboratory, X-ray, Imaging, and Special Diagnostic Procedures
$0 per department visit; $50 for specialized scans, i.e., MRI, CT, PET
Outpatient Rehabilitative Therapy Services (up to 20 visits per therapy per Calendar Year)
Physical, Speech, and Occupational therapies $15
All other therapies $15
Skilled Nursing Facility Services
(up to 100 days per Calendar Year) $0
Optional Benefits
Alternative Care (self-referred) Not covered
Hearing Aids Not covered
Outpatient Prescription Drugs, Supplies, and Supplements
$5 generic/$25 brand/$50 approved nonformulary brand & generic up to 30-day supply; up to 90-day supply of maintenance drugs for two Co-payments when you use mail delivery.
Vision Hardware Optical Services Balance after $200 allowance every 24 months
Travel Services Not covered
Exclusions and Limitations
The Services listed below are either completely excluded from coverage or partially limited. This applies to all Services that would otherwise be covered and is in addition to the exclusions and limitations that apply only to a particular Service as listed in the description of that Service in your Evidence of Coverage, to be provided after you enroll for coverage.
Certain exams and Services; Cosmetic Services; Custodial Services; Dental Services. Except when Medically Necessary for Members who have a medical condition that would place undue risk if performed in a dental office. The procedure must be approved.; Designated blood donations; Detained or confined members; Employer responsibility; Experimental or investigational Services; Eye surgery; Family Services. Services provided by a member of your immediate family.; Genetic testing; Government agency responsibility; Hearing aids. Unless the Hearing Aid rider has been purchased.; Hypnotherapy; Non-medically Necessary Services; Nonreusable medical supplies; Outpatient Prescription Drugs. Unless the Outpatient Prescription Drug rider has been purchased. Kaiser Permanente formulary applies. We cover non-formulary drugs only when you meet exception criteria unless specifically covered by your prescription drug plan.; Services related to a non-covered Service; Sexual reassignment surgery; Supportive care and other Services; Travel and lodging. Limited to: (a) Medically Necessary “Ambulance Services” in this Summary, and (b) certain expenses that we preauthorize.; Travel Services. All travel-related Services including travel-only immunizations (such as yellow fever, typhoid, and Japanese encephalitis), unless the Travel Services rider has been purchased.; vision hardware optical Services. Unless the Vision Hardware Optical Services rider has been purchased.; vision therapy and orthoptics or eye exercises; Professional Services for fitting and follow-up care for contact lenses; Low-vision aids.
This is not a contract. This benefit summary does not fully describe your benefit coverage with Kaiser Foundation Health Plan of the Northwest. For more details on your benefit coverage, claims review, and adjudication procedures, please see your Evidence of Coverage (EOC) or call Membership Services. In the case of conflict between this summary and the EOC, the EOC will prevail.
74 MYSEIUBENEFITS.ORG
Group Health Options - Plan B HMO Individual and Agency Providers
Summary of Medical Benefits Group Number: 1363700 - IP HmO
Group Number: 1363800 - AP HmO
Effective Date: 8/1/2012
Health Plan: Options Select
Ref: RQ-58241
This is a brief summary of benefits. THIS IS NOT A CONTRACT OR CERTIFICATE
OF COVERAGE. All benefit descriptions, including alternative care, are for
medically necessary services. The Member will be charged the lesser of the cost
share for the covered service or the actual charge for that service. For full coverage
provisions, including limitations, please refer to your certificate of coverage.
In accordance with the Patient Protection and Affordable Care Act of 2010,
• The lifetime maximum on the dollar value of covered essential health benefits
no longer applies. Members whose coverage ended by reason of reaching a
lifetime limit under this plan are eligible to enroll in this plan, and
• Dependent children who are under the age of twenty-six (26) are eligible to
enroll in this plan.
2012-2013 BENEFITS BOOK 75
Benefits Inside Network
Plan deductible No annual deductible
Individual deductible carryover Not applicable
Plan coinsurance No plan coinsurance
Out-of-pocket limit
Individual out-of-pocket limit: $1,000 per calendar year
Family out-of-pocket limit (AP workers Only): $2,000 per calendar year
Out-of-pocket expenses for the following covered services are included in the out-of-pocket limit: Inpatient services, outpatient services, emergency services at a Managed Health Care Network (MHCN) or non-MHCN facility and ambulance services.
Pre-existing condition (PEC) waiting period No PEC
Lifetime maximum Unlimited
Outpatient services (Office visits) $15 co-pay
Hospital servicesInpatient services: $100 co-pay, per day for up to 5 days per admit
Outpatient surgery: $50 co-pay
Prescription drugs(some injectable drugs may be
covered under Outpatient services)
Value based/formulary generic/formulary brand $4/$8/$25 co-pay per 30 day supply
Prescription mail order $5 discount per 30 day supply
AcupunctureCovered up to 8 visits per medical diagnosis per calendar year without prior authorization; additional visits when approved by the plan
$15 co-pay
Ambulance services Plan pays 80%, you pay 20%
Chemical dependencyInpatient: $100 co-pay, per day for up to 5 days per admit
Outpatient: $15 co-pay
Devices, equipment and suppliesDurable medical equipmentOrthopedic appliancesPost- mastectomy bras limited
to two (2) every six (6) months
Ostomy suppliesProsthetic devices
Covered at 50%
Diabetic supplies
Insulin, needles, syringes and lancets-see Prescription drugs. External insulin pumps, blood glucose monitors, testing reagents and supplies-see Devices, equipment and supplies. When Devices, equipment and supplies or Prescription drugs are covered and have benefit limits, diabetic supplies are not subject to these limits.
Diagnostic lab and X-ray services
Inpatient: Covered under Hospital services
Outpatient: Covered in full. MRI/PET/CT - $50 co-pay
High end radiology imaging services such as CT, MR and PET must be determined Medically Necessary and require prior authorization except when associated with Emergency care or inpatient services.
Emergency services(co-pay waived if admitted)
$200 co-pay at a designated facility
$200 co-pay at a non designated facility
Hearing exams (routine) $15 co-pay
Group Health Plan B HMO - Individual and Agency Providers
76 MYSEIUBENEFITS.ORG
Hearing hardware Not covered
Home health services Covered in full. No visit limit.
Hospice services Covered in full
Infertility services Not covered
Manipulative therapyCovered up to 10 visits per calendar year without prior authorization
$15 co-pay
Massage services See Rehabilitation services
Maternity servicesInpatient: $100 co-pay, per day for up to 5 days per admit
Outpatient: $15 co-pay. Routine care not subject to outpatient services co-pay.
Mental HealthInpatient: $100 co-pay, per day for up to 5 days per admit
Outpatient: $15 co-pay
NaturopathyCovered up to 3 visits per medical diagnosis per calendar year without prior authorization; additional visits when approved by plan
$15 co-pay
Newborn ServicesInitial hospital stay: See Hospital Services; Office visits: See Outpatient Services; Routine well care: See Preventive care. Any applicable cost share for newborn services is separate from that of the mother.
Obesity-related surgery (bariatric) Not covered
Organ transplantsDonor search & harvest applies
to lifetime max
Unlimited, no waiting period
Inpatient: $100 co-pay, per day for up to 5 days per admit
Outpatient: $15 co-pay
Preventive care Well-care physicals,
immunizations, Pap smear exams, mammograms
Covered in full
Women's preventive care services (including contraceptive drugs and devices and sterilization) are covered in full.
Rehabilitation services(Occupational, speech,
physical including services for neurodevelopmentally disabled children age six and under)
Rehabilitation visits are a total of combined therapy visits per calendar year
Inpatient: 60 days per calendar year $100 co-pay, per day for up to 5 days per admit
Outpatient: 60 visits per calendar year $15 co-pay
Skilled nursing facility Covered in full up to 60 days per calendar year
Sterilization (vasectomy, tubal ligation)
Inpatient: $100 co-pay, per day for up to 5 days per admit
Outpatient: $15 co-pay
Women's sterilization procedures are covered in full.
Temporomandibular Joint (TMJ) services
$1,000 per calendar year; $5,000 lifetime max
Inpatient: $100 co-pay, per day for up to 5 days per admit
Outpatient: $15 co-pay
Tobacco cessation counseling Quit for Life Program - covered in full
Routine vision care(1 visit every 12 months)
$15 co-pay
Optical hardwareLenses, including contact lenses
and frames$200 per 24 months
2012-2013 BENEFITS BOOK 77
Group Health Options Plan B POS Group Health Options Plan B PPO Individual and Agency Providers
Summary of Medical BenefitsGroup Number: 6356700 - IP POS
Group Number: 6356800 - IP PPO
Group Number: 6356200 - AGENCY POS
Group Number: 6356300 - AGENCY PPO
Effective Date: 8/1/2012
Health Plan Options
Ref: RQ-58241
This is a brief summary of benefits. THIS IS NOT A CONTRACT OR
CERTIFICATE OF COVERAGE. All benefit descriptions, including alternative care,
are for medically necessary services. The Member will be charged the lesser of
the cost share for the covered service or the actual charge for that service. For
full coverage provisions, including limitations, please refer to your certificate of
coverage.
In accordance with the Patient Protection and Affordable Care Act of 2010,
• The lifetime maximum on the dollar value of covered essential health benefits
no longer applies. Members whose coverage ended by reason of reaching a
lifetime limit under this plan are eligible to enroll in this plan, and
• Dependent children who are under the age of twenty-six (26) are eligible to
enroll in this plan.
78 MYSEIUBENEFITS.ORG
Benefits Inside Network Outside Network
Plan deductible No annual deductible
Individual deductible: $500 per calendar year
Family deductible (AP workers only): $1,000 per calendar year
Individual deductible carryover Not applicable 4th quarter carryover applies
Plan coinsurance No plan coinsurance Plan pays 80%, you pay 20% of the Usual, Customary and Reasonable (UCR) charges.
Out-of-pocket limit
Individual out-of-pocket limit: $1,000 per calendar year
Family out-of-pocket limit (AP workers only): $2,000 per calendar year
Out-of-pocket expenses for the following covered services are included in the out-of-pocket limit:
Inpatient services, outpatient services, emergency services at a Managed Health Care Network (MHCN) facility and ambulance services.
Individual out-of-pocket limit: $2,000 per calendar year
Family out-of-pocket limit (AP workers only): $4,000 per calendar year
Out-of-pocket expenses for the following covered services are included in the out-of-pocket limit:
Plan coinsurance, emergency services at a non-Managed Health Care Network (MHCN) facility.
Pre-existing condition (PEC) waiting period No PEC Same as in-network
Lifetime maximum Unlimited Same as in-network maximum
Outpatient services (Office visits) $15 co-pay
$15 co-pay, deductible and coinsurance apply
Hospital servicesInpatient services: $100 co-pay, per day for up to 5 days per admit
Outpatient surgery: $50 co-pay
Inpatient services: $100 co-pay, per day for up to 5 days per admit
Deductible and coinsurance apply
Outpatient surgery: $50 co-pay, deductible and coinsurance apply
Prescription drugs(some injectable drugs may be covered
under Outpatient services)
Value based/formulary generic/formulary brand/non-formulary $4/$8/$25/$50 co-pay per 30 day supply
Formulary generic/formulary brand/non-formulary $13/$30/$55 co-pay per 30 day supply
Prescription mail order $5 discount per 30 day supply Not covered
Acupuncture
Covered up to 8 visits per medical diagnosis per calendar year without prior authorization; additional visits when approved by the plan
$15 co-pay
$15 co-pay, deductible and coinsurance apply
Ambulance services Plan pays 80%, you pay 20% Same as in-network
Chemical dependencyInpatient: $100 co-pay, per day for up to 5 days per admit
Outpatient: $15 co-pay
Inpatient: $100 co-pay, per day for up to 5 days per admit
Deductible and coinsurance apply
Outpatient: $15 co-pay, deductible and coinsurance apply
Devices, equipment and supplies Durable medical equipmentOrthopedic appliancesPost-mastectomy bras limited to two (2)
every six (6) monthsOstomy suppliesProsthetic devices
Covered at 50% Covered at 50%, deductible applies
Group Health Options Plan B POS, PPO - Individual and Agency Providers
2012-2013 BENEFITS BOOK 79
Diabetic supplies
Insulin, needles, syringes and lancets-see Prescription drugs. External insulin pumps, blood glucose monitors, testing reagents and supplies-see Devices, equipment and supplies. When Devices, equipment and supplies or Prescription drugs are covered and have benefit limits, diabetic supplies are not subject to these limits.
Insulin, needles, syringes and lancets-see Prescription drugs. External insulin pumps, blood glucose monitors, testing reagents and supplies-see Devices, equipment and supplies. When Devices, equipment and supplies or Prescription drugs are covered and have benefit limits, diabetic supplies are not subject to these limits.
Diagnostic lab and X-ray services
Inpatient: Covered under Hospital services
Outpatient: MRI/PET/CT - $50 co-pay
High end radiology imaging services such as CT, MR and PET must be determined Medically Necessary and require prior authorization except when associated with Emergency care or inpatient services.
Inpatient: Covered under Hospital services
Outpatient: MRI/PET/CT - $50 co-pay
High end radiology imaging services such as CT, MR and PET must be determined Medically Necessary and require prior authorization except when associated with Emergency care or inpatient services.
Emergency services(co-pay waived if admitted)
$200 co-pay $200 co-pay
Hearing exams (routine) $15 co-pay $15 co-pay, deductible and coinsurance apply
Hearing hardware Not covered Not covered
Home health services Covered in full. No visit limit. No visit limit Deductible and coinsurance apply
Hospice services Covered in full Deductible and coinsurance apply
Infertility services Not covered Not covered
Manipulative therapyCovered up to 10 visits per calendar year without prior authorization
$15 co-pay
Visit limits shared with in-network
$15 co-pay, deductible and coinsurance apply
Massage services See Rehabilitation services See Rehabilitation services
Maternity services
Inpatient: $100 co-pay, per day for up to 5 days per admit
Outpatient: $15 co-pay. Routine care not subject to outpatient services co-pay.
Inpatient: $100 co-pay, per day for up to 5 days per admit
Deductible and coinsurance apply
Outpatient: $15 co-pay, deductible and coinsurance apply. Routine care not subject to outpatient services co-pay.
Mental HealthInpatient: $100 co-pay, per day for up to 5 days per admit
Outpatient: $15 co-pay
Inpatient: $100 co-pay, per day for up to 5 days per admit
Deductible and coinsurance apply
Outpatient: $15 co-pay, deductible and coinsurance apply
Naturopathy
Covered up to 3 visits per medical diagnosis per calendar year without prior authorization; additional visits when approved by plan
$15 co-pay
$15 co-pay, deductible and coinsurance apply
Newborn Services
Initial hospital stay: See Hospital Services; Office visits: See Outpatient Services; Routine well care: See Preventive care. Any applicable cost share for newborn services is separate from that of the mother.
Initial hospital stay: See Hospital Services; Office visits: See Outpatient Services; Routine well care: See Preventive care. Any applicable cost share for newborn services is separate from that of the mother.
80 MYSEIUBENEFITS.ORG
Obesity-related surgery(bariatric)
Not covered Not covered
Organ transplantsDonor search & harvest applies to
lifetime max
Unlimited, no waiting period
Inpatient: $100 co-pay, per day for up to 5 days per admit
Outpatient: $15 co-pay
Shared with in-network
Inpatient: $100 co-pay, per day for up to 5 days per admit
Deductible and coinsurance apply
Outpatient: $15 co-pay, deductible and coinsurance apply
Preventive careWell-care physicals, immunizations,
Pap smear exams, mammograms
Covered in full
Women’s preventive care services (including contraceptive drugs and devices and sterilization) are covered in full.
$300 per person; $600 per family per calendar year
Coinsurance applies
Women’s preventive care services (including contraceptive drugs and devices and sterilization) are subject to the applicable Preventive Care cost share and benefit maximums.
Routine mammograms: Deductible and coinsurance apply
Rehabilitation services(Occupational, speech, physical
including services for neurodevelopmentally disabled children age six and under)
Rehabilitation visits are a total of combined therapy visits per calendar year
Inpatient: 60 days per calendar year
$100 co-pay, per day for up to 5 days per admit
Outpatient: 60 visits per calendar year
$15 co-pay
Inpatient: Day limits shared with in-network
$100 co-pay, per day for up to 5 days per admit
Deductible and coinsurance apply Outpatient: Visit limits shared with in-network
$15 co-pay, deductible and coinsurance apply
Skilled nursing facility Covered in full up to 60 days per calendar year
Day limits shared with in-network benefit, deductible and coinsurance apply
Sterilization (vasectomy, tubal ligation)
Inpatient: $100 co-pay, per day for up to 5 days per admit
Outpatient: $15 co-pay
Women’s sterilization procedures are covered in full.
Inpatient: $100 co-pay, per day for up to 5 days per admit
Deductible and coinsurance apply
Outpatient: $15 co-pay, deductible and coinsurance apply
Women’s sterilization procedures are covered subject to the applicable Preventive Care cost share and benefit maximums.
Temporomandibular Joint (TMJ) services
$1,000 per calendar year; $5,000 lifetime max
Inpatient: $100 co-pay, per day for up to 5 days per admit
Outpatient: $15 co-pay
Shared with in-network
Inpatient: $100 co-pay, per day for up to 5 days per admit
Deductible and coinsurance apply
Outpatient: $15 co-pay, deductible and coinsurance apply
Tobacco cessation counseling Quit for Life Program - covered in full
Applicable cost shares apply
Routine vision care (1 visit every 12 months) $15 co-pay
$15 co-pay, deductible and coinsurance apply
Optical hardwareLenses, including contact
lenses and frames$200 per 24 months Shared with in-network
2012-2013 BENEFITS BOOK 81
When you have questions or a complaint about health or dental coverage:Call the Customer Service Department of your insurer, or for the Trust’s self-
funded dental plan, Delta Dental:
Group Health
1-800-542-6312
www.ghc.org
kaiser Permanente
1-800-813-2000
www.kp.org
willamette Dental
Oregon: 1-800-461-8994
Washington: 1-800-359-6019
www.willamettedental.com
Self-funded Dental Plan
Claims Administered by
Delta Dental
1-800-547-9515
What if I Have a Health Insurance or Dental Coverage Question or an Appeal?
QUESTIONS & APPEALS
82 MYSEIUBENEFITS.ORG
www.deltadentalwa.com
When you have an appeal:An appeal is a request to reconsider a decision to deny, modify, reduce, or
end payment, coverage or authorization of coverage (known as an “adverse
decision”).
The appeal process for each of the Trust’s health and dental plans is different.
You should review the Summary Plan Description of appeals procedures in
your Benefits Summary provided by your insurer or, in the case of the Trust’s
self-funded dental coverage, by Delta Dental. The Summary Plan Description
contains a full explanation of the appeals process.
You may also call the Customer Service Department of your insurer or, in the case
of the Trust’s self-funded dental coverage, Delta Dental, for specific information
about the appeals process. Those numbers are listed on the previous page.
Your rights in an appeal:
• You must submit your appeals within 180 calendar days of the date you
received notice of an “adverse decision.” Keep track of these deadlines
as appeals that are filed late may not be considered.
• You may request an expedited 72-hour review of your appeal when the
adverse determination could jeopardize your life or health.
• You may request all of the documents relevant to your request and the
decision by the insurer or administrator.
• You may submit additional comments, documents or other information to
support your appeal.
More information about how to file an appeal can be found at “How to Appeal
a Health Care Insurance Decision, A Guide for Consumers in Washington
State” on the Office of the Insurance Commissioner’s website,
www.insurance.wa.gov/consumers/health/Appeal/Table-of-Contents.shtml
QUESTIONS & APPEALS
2012-2013 BENEFITS BOOK 83
About This Guide
This handbook is intended to be an overview of your benefits and a general
resource. For more detailed information about your health and dental ben-
efits, you should consult the Summary Plan Description (SPD) and Certificate
of Coverage for those benefits. This handbook is not a “Plan document” or
the official SPD. In case of any conflict between this document and any “Plan
document,” the terms of the Plan Document shall govern.
The handbook is not a promise of benefits. All benefits described in the hand-
book are provided pursuant to existing collective bargaining agreements (CBA)
and employer participation agreements with the SEIU Healthcare NW Health
Benefits Trust and Training Partnership. Should the CBA or other agreements
with the Health Benefits Trust and/or Training Partnership terminate, change
or otherwise become ineffective, the benefits described in this book may also
terminate or change.
Equal Opportunity
The SEIU Healthcare NW Training Partnership (“Partnership”) admits students
regardless of race, color, national origin, ethnic origin, gender, age, disability
and sexual orientation to all the rights, privileges, programs, and activities gen-
erally accorded or made available to students by the Training Partnership. It
does not discriminate on the basis of race, color, national origin, ethnic origin,
gender, age, disability and sexual orientation in administration of its training
and educational policies, admissions policies, scholarship and loan programs,
and other Training Partnership administered programs.
NOTICES
84 MYSEIUBENEFITS.ORG
GLOSSARYAAA – Area Agency on Aging
ABT – Accelerated Basic Training
ADSA – Aging and Disability Services Administration Department of Department of Social and Health Services serving adults with chronic illnesses or conditions and people with developmental disabilities.
AP – Agency Provider A Home Care Aide who works for an agency – agency provider
ARC – Advocates for the Rights of Citizens with Developmental Disabilities
ARNP – Advanced Registered Nurse Practitioner. Can be a Primary Care Pro-vider.
BHP – Basic Health Plan of Washington
CNA – Certified Nursing Assistant
CE – Continuing Education Supplemental training required for skills development
COBRA – A private-pay insurance that covers you if you have a lapse in cover-age or you are between jobs
cultural competency – An awareness of the customs, beliefs and religious practices of others
DDD – Division of Developmental Disabilities
diagnostic imaging – MRI (Magnetic Resonance Imaging), X-rays, mammograms
DME – Durable Medical Equipment Walkers, crutches, etc.
DSHS – Department of Social and Health Services
HCS – Home Community Services The Home Community Services (HCS) Division of DSHS promotes, plans, develops and provides long-term care services for persons with disabilities and older adults who may need state funds (Medicaid) to help pay for them.
health insurance provider – The company that manages your health insurance, for example Group Health, Kaiser Permanente.
2012-2013 BENEFITS BOOK 85
GLOSSARYHealth Risk Assessment or Health Profile – An online health assessment or questionnaire that assesses your general health and wellness through a series of questions
IP – Individual Provider A Home Care Aide that provides care to a consumer living in his or her home and whose employer of record is the Department of Social and Health Services.
LPN – Licensed Practical Nurse
MFOC – Modified Fundamentals of Caregiving
MRC – Member Resource Center
NDC – Nurse Delegated Core
NDD – Nurse Delegation Diabetes
orthopedic appliances – braces, splints, etc.
PCP – Primary Care Provider The doctor or ARNP you choose to oversee your care
POS – Point of Service Insurance pays percentage of doctor visit that is out-of-network
PPO – Preferred Provider Organization A provider who is in-network
RN – Registered Nurse
RNA – Registered Nurse’s Assistant
S&O – Safety and Orientation
TBI – Traumatic Brain Injury
Training wizard – A computer program that assists you in getting started at the Training Partnership www.myseiubenefits.org/wizard
Home Care Aide (HCA) Provide care to a consumer living in his or her home. Employed by a private homecare agency or DSHS.
Agency Provider (AP)Provide care to a consumer living in his or her home. Employed by a private homecare agency.
Certified Home Care Aide
Provide care to a consumer living in his or her home having succesfully passed the DOH certification exam. Employed by a private homecare agency or DSHS.
Individual Provider (IP)Provide care to a consumer living in his or her home. Employer of record is DSHS.
Credentialed Agency Provider
This is an AP with a current healthcare credential as a Registered Nurse (RN), Licensed Practical Nurse (LPN), Nursing Assistant Certified (NAC), Physical Therapist, Occupational Therapist or Medicare-Certified Home Health Aide.
Credentialed Individual Provider
This is an IP with a current healthcare credential as a Registered Nurse (RN), Licensed Practical Nurse (LPN), Nursing Assistant Certified (NAC), Physical Therapist, Occupational Therapist or Medicare-Certified Home Health Aide.
Parent Individual Provider (HCS/AAA)
This is an IP who provides care to his/her own adult child and contracted through Home and Community Services (HCS) and/or an Area Agency on Aging (AAA).
Parent DD Individual Provider (DDD)
This is an IP who provides care to his/her own adult child with a developmental disability and is contracted through the Department of Developmental Disabilities (DDD).
Limited Service Provider (HCS/AAA/DDD)
This is any IP who provides care 20 hours a month or less for one consumer.
Adult Child Individual Provider
An adult child providing care for his/her biological, step or adoptive parent.
HOME CARE AIDE CATEGORIES Effective Jan. 7, 2012
The Training Partnership provides training to a variety of Home Care Aides. The chart below describes the different categories of HCAs
2012-2013 BENEFITS BOOK 87
TRAINING STANDARDS UPDATED JUNE 2012
ORIEN
TATION
AN
D SA
FETYB
ASIC TRA
ININ
GCO
NTIN
UIN
G
EDU
CATION
Orientation 2 HoursSafety Training 3 Hours
Accelerated Basic Training 30 Hours
Basic Training 70 Hours
Parent Provider (DDD Only) Class 7 Hours
Continuing Education 12 HoursHCA CertificationRequired?
Agency Provider (AP)
Completed prior to
providing careCom
pleted prior to providing care
Not requiredW
ithin 120 days of em
ployment
Not required12 hours/year for the renewal of certification
Yes
Individual Provider (IP)
Completed prior to
providing careCom
pleted prior to providing care
Not requiredW
ithin 120 days of em
ployment
Not required12 hours/year for the renewal of certification
Yes
Individual Providers or Agency Providers hired before 1/7/2012
Not requiredNot required
Not requiredNot required
Not required
As of 7/1/2012, 12 credits/year by your birthday. Use training wizard at www.m
yseiubenefits.org/wizard or call the M
RC to see your requirement.
No
Credentialed AP (per RCW
18.88B.041)Not required
Not requiredNot required
Not requiredNot required
12 hours/year by their birthday
No
Credentialed IP (per RCW
18.88B.041)Not required
Not requiredNot required
Not requiredNot required
12 hours/year by their birthday
No
Parent Individual Provider (HCS/AAA)
Completed prior to
providing careCom
pleted prior to providing care
Within 120 days
of employm
entNot required
Not requiredNot required, unless voluntarily certificed as a HCA.
No
Parent DD IP (DDD)Com
pleted prior to providing care
Completed prior
to providing careNot required
Not requiredW
ithin 120 days of em
ployment
Not required, unless voluntarily certificed as a HCA.
No
Limited Service Provider
Completed prior to
providing careCom
pleted prior to providing care
Within 120 days
of employm
entNot required
Not requiredNot required, unless voluntarily certificed as a HCA.
No
Adult Child Individual Provider (HCS/AAA/DDD)
Completed prior to
providing careCom
pleted prior to providing care
Within 120 days
of employm
entNot required
Not required12 hours/year by birthday
No
88 MYSEIUBENEFITS.ORG
2013-2013 YOUR BENEFITS BOOKA GUIDE TO TRAINING & HEALTH BENEFITS
Featured Inside:• Updated Training Standards and Benefits• Ways to stay healthy, save money and save time• How to take Online Continuing Education
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