School Employee Enrollment Guide 2021

HCA 20-0049 (10/20)

SCHOOL EMPLOYEES BENEFITS BOARD

School Employee

Enrollment Guide

Your SEBB benets for

2021

2021 Monthly

premiums

page 36

Eligibility

pages 11–15

Medical benets

comparison

pages 36–45

Quick start guide

page 6

How to enroll

page 16

Who to contact for help

 



Contact the plans directly for help

with:

• 

• 

• 

• 



• 

• 

Contact your payroll or benets ofce

for help with:

• 



• 

• 

• 



• 

• 



• 

Help with SEBB My Account



Medical plans

Kaiser Foundation Health Plan of the Northwest









Kaiser Foundation Health Plan of Washington



Kaiser Foundation Health Plan of Washington

Options, Inc.









Premera Blue Cross







Uniform Medical Plan (UMP), administered by

Regence BlueShield































Dental plans

DeltaCare, administered by Delta Dental of

Washington





Uniform Dental Plan, administered by Delta Dental of

Washington





Willamette Dental Group





Vision plans

Davis Vision, underwritten by HM Life Insurance

Company





EyeMed Vision Care, underwritten by

Fidelity Security Life Insurance Company





MetLife Vision Plan, underwritten by Metropolitan Life

Insurance Company





Additional contacts

HealthEquity







SmartHealth







Metropolitan Life Insurance Company







Navia Benet Solutions









Standard Insurance Company















Contents

 ......................................................................................................................... 2

 ................................................................................................................................................ 5

 ................................................................................................................................... 6

 ................................................................................................................. 8

 ............................................................................................................................ 10

 ............................................................................................................................ 11

 ........................................................................................................................... 13

 ....................................................................................................................................... 16

 .............................................................................................................................. 18

 ................................................................................................................... 19

 .............................................................................................................................. 20

 ............................................................................................................................ 22

 ........................................................................................................................ 24

 ...................................................................................................................... 25

 .................................................................. 27

 ................................................................................................................. 29

 ............................................................................................... 30

 .................................................................................................................... 32

 ................................................................................................... 36

 ........................................................................................................................ 46

 ................................................................................................................. 47

 ......................................................................................................................... 48

 .................................................................................................................. 49

 ..................................................................................................................... 52

 ............................................................................................................ 56

 ......................................................................................................................... 58

 ........................................................................................................................................ 60

 .................................................................................................................................... 62

 ...................................................................................................................... 64

 

 ............................................................................................................................ 70

 ............................................................................................................................................... 73

 ................................................................................................................................ 75

Welcome

























 

Quick start guide





Good to know!





1. Find out if you’re eligible







”



2. Learn about your benets







”













”



3. Get ready to enroll your eligible

dependents







”

Information you need to enroll

eligible dependents





• 

• 

• 

• 







4. Choose your health plans

Health plans available to you



,” 



















Compare health plan benets and premiums

”  

”







Virtual benets fair









.

ALEX







.

Good to know!





5. Enroll using SEBB My Account





.









































Attest to the premium surcharges

























6. Consider these additional

benets





























7. What’s next





Good to know!





















How to use SEBB My Account







What can I do in SEBB My

Account?

• 

• 

• 

• 

• 

• 









• 



• 

• 

Good to know!





Help with SEBB

My Account

Setting up your account

 











 





 





 



 









 





 



When can I access SEBB My

Account?









How to enroll with SEBB My

Account







 





 



































 









 























Good to know!























Medical

Flexible Spending Arrangement and Dependent

Care Assistance Program Enrollment Form







Enrollment checklist

{ 

{ 

{ 

{ 

{ 

{ 

{ 

{ 

{ 

{ 

{ 





{ 

{ 

{ 

{ 

Your 2021 SEBB benets

• 



• 



• 

• 

• 

• 



• 

• 

• 

• 

• 

• 

Good to know!

Get the latest news and updates from the

SEBB Program by going paperless. When you

receive general information and newsletters by

email, it’s faster for you and 



 

Subscriber eligibility

Who is eligible for SEBB benets?

























































Eligibility based on a revision to

your anticipated work pattern or

actual hours worked



















































Eligibility based upon date of hire

























Eligibility based on hours worked

the previous two school years

























Eligibility based on work within

one district, charter school, or ESD















Returning employees have

uninterrupted coverage















Eligibility when changing jobs

between SEBB organizations





























What if I’m eligible for SEBB

benets both as an employee and

as a dependent?













Employees eligible for locally

negotiated benets















Dependent eligibility



• 

• 











• 



How are children dened?





• 





• 





• 



• 







• 





• 



• 



Extended dependents





















Children with disabilities

























































Proving dependent eligibility

















• 



• 





























Documents to enroll a spouse



• 



• 



• 







• 

• 

• 



• 

Documents to enroll a state-registered

domestic partner or partner of a legal union



• 











• 



• 



• 



• 



























Documents to enroll children



• 









• 















• 





• 

• 

• 



• 









What happens when I am

required to provide health plan

coverage for a child?

























• 



• 





• 



• 





• 





• 









Good to know!









What happens when my

dependent loses eligibility?































• 







• 





• 



• 







What happens if I die, or my

dependent dies?



How to enroll

When do I enroll?













How do I enroll?







• 

• 

• 











































Additional required forms









 







 

















• 





• 





• 



• 





• 







Good to know!



Forms &

publications

Am I required to enroll? What

happens if I don’t waive or enroll?





















• 









• 





• 



• 





• 







• 





Can I enroll on two SEBB

accounts?

















• 



















• 









Can I enroll in SEBB benets

and also have PEBB insurance

coverage as a dependent?

















How does being enrolled in both SEBB and

PEBB affect the premium surcharge?







































Weigh the options of dual enrollment



































Medicare and SEBB







When you retire













Waiving SEBB medical





























Deferring Medicare Parts A and B













 .

























Deciding on Medicare Part D































If you lose or terminate SEBB

medical coverage





























Be aware of enrollment deadlines









Good to know!







Waiving medical coverage

What does waiving mean?

















If you waive enrollment in medical

coverage

• 





• 

• 





• 









How do I waive medical coverage?













What if I’m already enrolled in

SEBB health plan coverage?









• 



















• 











How do I enroll later if I’ve waived

medical coverage?

















What happens if I don’t enroll in

or waive medical coverage?



















































Paying for benefits

What does my employer pay?













What do I pay?

Monthly premiums











Premium surcharges













Out-of-pocket costs





















How much will my monthly

premiums be?









Payroll deductions and taxes























Why would I pay my monthly premiums with

pretax dollars?











Would it benet me not to have a pretax

deduction?































Good to know!











Can I change my mind about having my

premium payments withheld pretax?













Good to know!







SEBB

Premium Payment Plan Election/Change



Premium surcharges





• 

• 







Tobacco use premium surcharge













• 





• 

























How to attest to this surcharge





















How to report a change in tobacco use



• 



• 



• 







• 











• 



• 







Good to know!





































Spouse or state-registered

domestic partner coverage

premium surcharge

















• 







• 

• 



How to attest to this surcharge

































To report a change to this surcharge





































Good to know!





















SEBB Premium Surcharge Attestation Help

SheetForms & publications 





Choosing your benefits









Benets comparison charts















Certicates of coverage













Good to know!











Summary of Benets and

Coverage









• 

• 

• 













, 















Virtual benets fair

































ALEX











.

Next step









Good to know!











Selecting a medical plan

























































Good to know!











What types of plans are available?









































• 

• 

• 

• 

• 

• 

• 











• 

• 

• 

• 

• 

• 

• 

• 



• 















• 













• 



How can I compare the medical

plans?













Medical plan differences to

consider













































































































































































UMP High Deductible with a health

savings account (HSA)





















.



Who is not eligible for UMP High

Deductible with an HSA?



• 



• 







• 









• 

• 













• 





check 











Employer contributions









• 



• 















Your contributions





• 



• 



















Other features of UMP High

Deductible with an HSA

















Can I enroll in UMP High

Deductible and Medicare

Part A or Part B?















Are there special considerations

if I enroll in UMP High Deductible

mid-year?









How do I designate or update

beneciaries for my HSA?













What happens to my HSA when I

leave UMP High Deductible?































Behavioral health coverage

Ensuring timely access to care

















































 



Compare coverage by plan























Crisis information





For immediate help:





For suicide prevention:





For additional support:



 



Washington Recovery Help Line:

 



















Washington

Clark

Cowlitz

Benton

Columbia

Franklin

Island

King

Kitsap

Kittitas

Lewis

Mason

Pierce

Skagit

Snohomish

Spokane

Thurston

Walla Walla

Whatcom

Whitman

Yakima

Benton

Columbia

Franklin

Island

Kittitas

Lewis

Mason

Skagit

Walla Walla

Whatcom

Whitman

Yakima

King

Kitsap

Pierce

Snohomish

Spokane

Thurston

Note: Not all contracted providers in Spokane County are in the SoundChoice

network. Please make sure your provider is in-network before your visit.

Island

King

Kitsap

Lewis

Mason

Pierce

Skagit

Snohomish

Spokane

Thurston

Whatcom

Adams

Asotin

Benton

Chelan

Clallam

Columbia

Cowlitz

Ferry

Franklin

Gareld

Grant

King

Kitsap

Lewis

Lincoln

Mason

Okanogan

Pend Oreille

Pierce

Skagit

Skamania

Spokane

Stevens

Thurston

Wahkiakum

Walla Walla

Whatcom

Whitman

Yakima

Kaiser Permanente NW 1

Kaiser Permanente NW 2

Kaiser Permanente NW 3

Kaiser Permanente

WA Core 1

Kaiser Permanente

WA Core 2

Kaiser Permanente

WA Core 3

Kaiser Permanente

WA SoundChoice

Kaiser Permanente WA

Access PPO 1

Kaiser Permanente WA

Access PPO 2

Kaiser Permanente WA

Access PPO 3

Premera High PPO

2021 Medical plans available

by county

All school employees are oered a selection of plans based on their county of residence or the

county where their school district, charter school, or educational service district is based. Some school

employees may have more plan options if they work in a district that crosses county lines

(see the school districts by county list starting on page 32 for more information). Be sure to call the

medical plan(s) you are interested in to ask about provider availability.

Adams

Asotin

Benton

Chelan

Clallam

Columbia

Cowlitz

Ferry

Franklin

Gareld

Grant

Grays Harbor

Jeerson

King

Kitsap

Lewis

Lincoln

Mason

Okanogan

Pacic

Pend Oreille

Pierce

Skagit

Skamania

Snohomish

Spokane

Stevens

Thurston

Wahkiakum

Walla Walla

Whatcom

Whitman

Yakima

Pierce Thurston Spokane

Available in all Washington counties and worldwide.

Chelan

Douglas

King

Kitsap

Pierce

Snohomish

Thurston

Yakima

King

Kitsap

Pierce

Skagit

Snohomish

Spokane

Thurston

Available in all Oregon counties and worldwide.

Available in all Idaho counties and worldwide.

Premera Standard PPO

Premera Peak Care EPO

Uniform Medical Plan (UMP)

Achieve 1

UMP Achieve 2

UMP High Deductible

UMP Plus–Puget Sound High

Value Network

UMP Plus–UW Medicine

Accountable Care Network

Uniform Medical Plan (UMP)

Achieve 1

UMP Achieve 2

UMP High Deductible

Uniform Medical Plan (UMP)

Achieve 1

UMP Achieve 2

UMP High Deductible

Oregon

Idaho

Benton (ZIP Codes:

97330, 97331,

97333, 97339,

97370, 97456)

Clackamas

Columbia

Hood River (ZIP

Code: 97014)

Lane

Linn (ZIP Codes:

97321, 97322,

97335, 97348,

97355, 97358,

97360, 97374,

97377, 97389, and

97446)

Marion

Multnomah

Polk

Washington

Yamhill

Kaiser Permanente NW 1

Kaiser Permanente NW 2

Kaiser Permanente NW 3

If you move out of the medical plan’s service area or change jobs to a dierent district,

charter school, or educational service district, you may need to change plans. You must

report your new address and any request to change your health plan to your payroll or benets

oce no later than 60 days after your move.

School districts by county

Use this chart to look up what county your school district is in. Districts with an asterisk (*) cross

county lines and are listed under more than one county in the chart. Be sure to check all the counties

your school district is listed in to maximize the amount of plans available to you.

Asotin

Asotin-Anatone Clarkston*

Adams

Benge

Endicott*

LaCrosse*

Lamont*

Lind

North Franklin*

Odessa*

Othello*

Ritzville*

Sprague*

Warden*

Washtucna*

Benton

Finley

Grandview*

Kennewick

Kiona-Benton City

Paterson

Prosser*

Richland

Chelan

Cascade

Cashmere

Entiat

Lake Chelan*

Manson

Pateros*

Stehekin

Wenatchee

Clallam

Cape Flattery

Crescent

Port Angeles

Quillayute Valley*

Sequim*

Clark

Battle Ground

Camas

Green Mountain

Evergreen

Hockinson

La Center

Mt. Pleasant*

Ridgeeld

Vancouver

Washougal*

Woodland*

Columbia

Dayton

Pomeroy*

Prescott*

Starbuck

Waitsburg*

Cowlitz

Castle Rock*

Kalama

Kelso

Longview

Toutle Lake

Woodland*

Douglas

Brewster*

Bridgeport*

Coulee-Hartline*

Eastmont

Ephrata*

Grand Coulee Dam*

Lake Chelan*

Manseld

Orondo

Palisades

Quincy*

Waterville

Ferry

Curlew*

Inchelium

Keller

Kettle Falls*

Orient*

Republic*

Franklin

Kahlotus

North Franklin*

Othello*

Pasco

Star

Washtucna*

Gareld

Clarkston* Pomeroy*

Grant

Almira*

Coulee-Hartline*

Ephrata*

Grand Coulee Dam*

Moses Lake

Odessa*

Othello*

Quincy*

Royal

Soap Lake

Wahluke*

Warden*

Wilson Creek*

Grays Harbor

Aberdeen

Cosmopolis

Elma*

Hoquiam

Lake Quinault

Mary M. Knight*

McCleary*

Montesano

North Beach

North River*

Oakville*

Ocosta*

Satsop

Taholah

Wishkah Valley

Island

Coupeville Oak Harbor South Whidbey Standwood-Camano*

Jefferson

Brinnon

Chimacum

Port Townsend

Queets-Clearwater

Quilcene

Quillayute Valley*

Sequim*

King

Auburn*

Bellevue

Enumclaw

Federal Way

Fife*

Highline

Issaquah

Kent

Lake Washington

Mercer Island

Northshore*

Renton

Riverview

Seattle

Shoreline

Skykomish

Snoqualmie Valley

Tahoma

Tukwila

Vashon Island

Kitsap

Bainbridge Island

Bremerton

Central Kitsap

North Kitsap

North Mason*

South Kitsap

Kittitas

Cle Elum-Roslyn

Damman

Easton

Ellensburg

Kittitas

Naches Valley*

Selah*

Thorp

Klickitat

Bickleton*

Centerville

Glenwood

Goldendale

Klickitat

Lyle

Prosser*

Roosevelt

Trout Lake

White Salmon Valley*

Wishram

Lewis

Adna

Boistfort

Castle Rock*

Centralia*

Chehalis

Eatonville*

Evaline

Morton

Mossyrock

Napavine

Oakville*

Onalaska

Pe Ell*

Rochester*

Toledo

White Pass

Winlock

Lincoln

Almira*

Creston

Davenport

Grand Coulee Dam*

Harrington

Odessa*

Reardan-Edwall*

Ritzville*

Sprague*

Wilbur

Wilson Creek*

Mason

Elma*

Grapeview

Hood Canal

Mary M. Knight*

McCleary*

North Mason*

Pioneer

Shelton

Southside

Okanogan

Brewster*

Bridgeport*

Curlew*

Grand Coulee Dam*

Lake Chelan*

Methow Valley

Nespelem

Okanogan

Omak

Oroville

Pateros*

Republic*

Tonasket

Pacic

Naselle-Grays

River Valley*

North River*

Ocean Beach

Ocosta*

Pe Ell*

Raymond

South Bend

Willapa Valley

Pend Oreille

Cusick

Deer Park*

Loon Lake*

Newport*

Riverside*

Selkirk

Pierce

Auburn*

Bethel

Carbonado

Clover Park

Dieringer

Eatonville*

Fife*

Franklin Pierce

Orting

Peninsula

Puyallup

Steilacoom Historical

Sumner

Tacoma

University Place

White River

Yelm*

San Juan

Lopez Island Orcas Island San Juan Island Shaw Island

Skagit

Anacortes

Burlington-Edison

Concrete*

Conway

Darrington*

La Conner

Mount Vernon

Sedro-Woolley*

Skamania

Mill A

Mt. Pleasant*

Skamania

Stevenson-Carson

Washougal*

White Salmon Valley*

Woodland*

Snohomish

Arlington

Darrington*

Edmonds

Everett

Granite Falls

Index

Lake Stevens

Lakewood

Marysville

Monroe

Mukilteo

Northshore*

Snohomish

Stanwood-Camano*

Sultan

Spokane

Central Valley

Cheney*

Deer Park*

East Valley

Freeman

Great Northern

Liberty

Mead

Medical Lake

Newport*

Nine Mile Falls*

Orchard Prairie

Reardan-Edwall*

Riverside*

Rosalia*

Spokane

St. John*

Tekoa*

West Valley

Stevens

Chewelah

Columbia

Colville

Deer Park*

Evergreen

Kettle Falls*

Loon Lake*

Mary Walker

Nine Mile Falls*

Northport

Onion Creek

Orient*

Summit Valley

Valley

Wellpinit

Thurston

Centralia*

Grin

North Thurston

Olympia

Rainier

Rochester*

Tenino

Tumwater

Yelm*

Wahkiakum

Naselle-Grays River Valley* Wahkiakum

Walla Walla

College Place

Columbia

Dixie

Prescott*

Touchet

Waitsburg*

Walla Walla

Whatcom

Bellingham

Blaine

Concrete*

Ferndale

Lynden

Meridian

Mount Baker

Nooksack Valley

Sedro-Woolley*

Whitman

Cheney*

Clarkston*

Colfax

Colton

Endicott*

Gareld

LaCrosse*

Lamont*

Oakesdale

Palouse

Pullman

Rosalia*

St. John*

Steptoe

Tekoa*

Yakima

Bickleton*

East Valley

Grandview*

Granger

Highland

Mabton

Mount Adams

Naches Valley*

Selah*

Sunnyside

Toppenish

Union Gap

Wahluke*

Wapato

West Valley

Yakima

Zillah

2021 Medical benefits and premiums

The chart below briey compares the medical deductibles and per-visit out-of-pocket costs of some in-network benets for

SEBB medical plans. Copays and coinsurances may apply; some copays and coinsurance do not apply until after you have

paid your annual deductibles. Call the plans directly for more information on specic benets, including preauthorization

requirements and exclusions. If anything in these charts conicts with the plan’s certicate of coverage (COC), the C

OC takes

precedence and prevails.

Annual costs (what you pay) Monthly Premium Medical deductible

(applies to medical out-

of-pocket limit)

Medical out-of-pocket limit (see

separate prescription drug out-of-

pocket limit for some plans)

Prescription drug deductible Prescription drug out-of-pocket limit

Subscriber Subscriber

& spouse

Subscriber

& children

Subscriber,

spouse

, &

children

Kaiser Foundation Health Plan of the Northwest

Kaiser Permanente NW 1 $39 $78 $68 $117 $1,250/person $2,500/family $4,000/person $8,000/family

None

Applies to medical out-of-pocket limit

Kaiser Permanente NW 2 $52 $104 $91 $156 $750/person $1,500/family $3,500/person $7,000/family

None

Applies to medical out-of-pocket limit

Kaiser Permanente NW 3 $119 $238 $208 $357 $125/person $250/family $2,000/person $4,000/family

None

Applies to medical out-of-pocket limit

Kaiser Foundation Health Plan of Washington

Kaiser Permanente WA Core 1 $16 $32 $28 $48 $1,250/person $3,750/family $4,000/person $8,000/family None Applies to medical out-of-pocket limit

Kaiser Permanente WA Core 2 $21 $42 $37 $63 $750/person $2,250/family $3,000/person $6,000/family None Applies to medical out-of-pocket limit

Kaiser Permanente WA Core 3 $91 $182 $159 $273 $250/person $750/family $2,000/person $4,000/family None Applies to medical out-of-pocket limit

Kaiser Permanente WA SoundChoice $51 $102 $89 $153 $125/person $375/family $2,000/person $4,000/family None Applies to medical out-of-pocket limit

Kaiser Foundation Health Plan of Washington Options, Inc.

Kaiser Permanente WA Options Access PPO 1 $66 $132 $116 $198 $1,250/person $3,750/family $4,500/person $9,000/family None Applies to medical out-of-pocket limit

Kaiser Permanente WA Options Access PPO 2 $97 $194 $170 $291 $750/person $2,250/family $3,500/person $7,000/family None Applies to medical out-of-pocket limit

Kaiser Permanente WA Options Access PPO 3 $146 $292 $256 $438 $250/person $750/family $2,500/person $5,000/family None Applies to medical out-of-pocket limit

Premera Blue Cross

Premera High PPO $76 $152 $133 $228 $750/person $1,875/family $3,500/person $7,000/family $125/person $312/family

Applies to medical out-of-pocket limit

Premera Peak Care EPO $37 $74 $65 $111 $750/person $1,875/family $3,500/person $7,000/family $125/person $312/family

Applies to medical out-of-pocket limit

Premera Standard PPO $28 $56 $49 $84 $1,250/person $3,125/family $5,000/person $10,000/family $250/person $750/family

Applies to medical out-of-pocket limit

Uniform Medical Plan (administered by Regence BlueShield)

UMP Achieve 1 $33 $66 $58 $99 $750/person $2,250/family $3,500/person $7,000/family Tier 2 and specialty except covered insulins;

$250 person $750/family (applies to prescrip-

tion out-of-pocket limit)

$2,000/person $4,000/family

UMP Achieve 2 $98 $196 $172 $294 $250/person $750/family $2,000/person $4,000/family Tier 2 and specialty except covered insulins;

$100/person $300/family (applies to

prescription out-of-pocket limit)

$2,000/person $4,000/family

UMP High Deductible $25 $50 $44 $75 $1,400/person $2,800/family

$4,200/person $8,400/family

Combined (medical and prescription)

deductible

Combined (medical and prescription)

out-of-pocket limit

UMP Plus

(both PSHVN and UW Medicine ACN)

$68 $136 $119 $204 $125 person $375/family $2,000/person $4,000/family None $2,000/person $4,000/family

Or state-registered domestic partner

You pay the monthly medical premium shown regardless of how many children you enroll

Kaiser Foundation Health Plan of the Northwest oers plans in Clark and Cowlitz counties in Washington and select

counties in Oregon.

Waived for preferred generic prescription drugs

Combined medical and prescription drug deductible

Out-of-pocket expenses for a single family member are not to exceed $7,000

36 37

Benets (what you pay) Ambulance

(air or ground)

per trip

Diagnostic tests,

laboratory, and

x-rays

Durable medical

equipment, supplies,

and prosthetics

Emergency

room (copay

waived if

admitted)

Routine

annual

hearing

exam

Hearing

hardware

(deductible waived)

Home health Therapy: Physical, occupational,

speech, and neurodevelopmental

(per-ofce visit cost)

Kaiser Foundation Health Plan of the Northwest

(Diagnostic tests, lab, and x-rays not subject to deductible)

Kaiser Permanente NW 1 20% $30

20% 20% $40

One hearing aid per ear

covered in full up to the

plan’s allowed amount,

during any consecutive

60-month period.

20% for 130 days/year $40

(60 combined visits/year)

Kaiser Permanente NW 2 20% $25

20% 20% $35

20% for 130 days/year $35

(60 combined visits/year)

Kaiser Permanente NW 3 20% $20

20% 20% $30

20% for 130 days/year $30

(60 combined visits/year)

Kaiser Foundation Health Plan of Washington

Kaiser Permanente WA Core 1 20% First $500 covered in

full, then 20%

20% ($300 allowance/year

for orthotic devices)

$150+20% $30

2, 3

One hearing aid per ear

covered in full up to the

plan’s allowed amount,

during any consecutive

60-month period.

Covered in full for

130 days/year

$40

(60 combined visits/year)

Kaiser Permanente WA Core 2 20% First $500 covered in

full, then 20%

20% ($300 allowance/year

for orthotic devices)

$150+20% $25

2, 3

Covered in full for

130 days/year

$35

(60 combined visits/year)

Kaiser Permanente WA Core 3 20% 20% 20% ($300 allowance/year

for orthotic devices)

$150+20% $20

2, 3

Covered in full for

130 days/year

$30

(60 combined visits/year)

Kaiser Permanente WA SoundChoice 20% 15% 15% ($300 allowance/year

for orthotic devices)

$150+15% $0 Covered in full for

130 days/year

$30

(60 combined visits/year)

Kaiser Foundation Health Plan of Washington Options, Inc.

Kaiser Permanente WA Options Access PPO 1 20% First $500 covered in

full, then 20%

20% ($300 allowance/year

for orthotic devices)

$150+20% $30

2, 3

($20

2, 3, 4

) One hearing aid per ear

covered in full up to the

plan’s allowed amount,

during any consecutive

60-month period.

20% for 130 days/year $40

($30

, 60 combined visits/year)

Kaiser Permanente WA Options Access PPO 2 20% First $500 covered in

full, then 20%

20% ($300 allowance/year

for orthotic devices)

$150+20% $25

2, 3

($15

2, 3, 4

) 20% for 130 days/year $35

($25

, 60 combined visits/year)

Kaiser Permanente WA Options Access PPO 3 20% 20% 20% ($300 allowance/year

for orthotic devices)

$150+20% $20

2, 3

($10

2, 3, 4

) 20% for 130 days/year $30

($20

, 60 combined visits/year)

Premera Blue Cross

Premera High PPO 25% 25% 25% $150+25% $0 One hearing aid per ear

covered in full, up to the

plan’s allowed amount, once

every ve calendar years.

25% $40 (45 PT/ST/OT combined/year)

$40 (45 NDT/year)

Premera Peak Care EPO 25% 25% 25% $150+25% $0 25% $40 (45 PT/ST/OT combined/year)

$40 (45 NDT/year)

Premera Standard PPO 20% 20% 20% $150+20% $0 20% $40 (45 PT/ST/OT combined/year)

$40 (45 NDT/year)

Uniform Medical Plan (administered by Regence BlueShield)

UMP Achieve 1 20% 20% 20% $75+20% $0 One hearing aid per ear cov-

ered in full, up to the plan’s

allowed amount, once every

ve calendar years.

20% 20% (80 combined visits/year)

UMP Achieve 2 20% 15% 15% $75+15% $0 15% 15% (80 combined visits/year)

UMP High Deductible 20% 15% 15% 15% 15%

One hearing aid per ear cov-

ered in full, once every ve

calendar years.

15% 15% (80 combined visits/year)

UMP Plus (both PSHVN and UW Medicine ACN) 20% 15% 15% $75+15% $0 One hearing aid per ear cov-

ered in full, up to the plan’s

allowed amount, once every

ve calendar years.

15% 15% (60 combined visits/year)

Kaiser Foundation Health Plan of the Northwest oers plans in Clark and Cowlitz counties in Washington and select

counties in Oregon.

Not subject to deductible.

Primary care copayments are waived for ages 17 and under.

Enhanced benet: Enhanced in-network cost shares apply when a member uses designated integrated providers and pharmacies

(Kaiser Permanente medical centers and providers, or other designated providers as identied in the provider directory).

38 39

Benets (what you pay) Inpatient services

(hospitals, resi-

dential treatment

centers, psychiatric

hospitals, etc.)

Outpatient

services

(hospital afliated

clinics, outpatient

facilities, freestand-

ing clinics, etc.)

Ofce visit:

Primary care

Ofce visit:

Urgent care

Ofce visit:

Specialist

Ofce visit:

Mental health

(independent

provider ofces,

medical groups,

freestanding

clinics, etc.)

Virtual care or

telemedicine

Care received

from a licensed

physician with-

out an in-person

visit

Chiropractic Acupuncture Massage

therapy

Kaiser Foundation Health Plan of the Northwest

Kaiser Permanente NW 1 20% 20% $30

2, 3

$50

$40

$30

2, 3

$40

No limit $40

20 visits/year $25

20 visits/year

Kaiser Permanente NW 2 20% 20% $25

2, 3

$45

$35

$25

2, 3

$35

No limit $35

20 visits/year $25

20 visits/year

Kaiser Permanente NW 3 20% 20% $20

2, 3

$40

$30

$20

2, 3

$30

No limit $30

20 visits/year $25

20 visits/year

Kaiser Foundation Health Plan of Washington

Kaiser Permanente WA Core 1 20% 20% $30

2, 3

$30

$40

$30

2, 3

$30

2, 3

20 visits/year $30

2, 3

20 visits/year $40

20 visits/year

Kaiser Permanente WA Core 2 20% 20% $25

2, 3

$25

$35

$25

2, 3

$25

2, 3

20 visits/year $25

2, 3

20 visits/year $35

20 visits/year

Kaiser Permanente WA Core 3 20% 20% $20

2, 3

$20

$30

$20

2, 3

$20

2, 3

20 visits/year $20

2, 3

20 visits/year $30

20 visits/year

Kaiser Permanente WA SoundChoice 15% 15% $0

$30

20 visits/year $0 20 visits/year $30

20 visits/year

Kaiser Foundation Health Plan of Washington Options, Inc.

Kaiser Permanente WA Options Access PPO 1 20% 20% $30

2, 3

($20

2, 3, 4

) $30

2, 3

($20

2, 3, 4

) $40

($30

2, 4

) $30

2, 3

($20

2, 3, 4

) $0

$30

2, 3

20 visits/year $30

2, 3

20 visits/year $40

20 visits/year

Kaiser Permanente WA Options Access PPO 2 20% 20% $25

2, 3

($15

2, 3, 4

) $25

2, 3

($15

2, 3, 4

) $35

($25

2, 4

) $25

2, 3

($15

2, 3, 4

) $0

$25

2, 3

20 visits/year $25

2, 3

20 visits/year $35

20 visits/year

Kaiser Permanente WA Options Access PPO 3 20% 20% $20

2, 3

($10

2, 3, 4

) $20

2, 3

($10

2, 3, 4

) $30

($20

2, 4

) $20

2, 3

($10

2, 3, 4

) $0

$20

2, 3

20 visits/year $20

2, 3

20 visits/year $30

20 visits/year

Premera Blue Cross

Premera High PPO 25% 25% $20

25% $40

$20

Varies, see COC 25% 12 visits/year 25% 12 visits/year 25% 12 visits/year

Premera Peak Care EPO 25% 25% $20

25% $40

$20

Varies, see COC 25% 12 visits/year 25% 12 visits/year 25% 12 visits/year

Premera Standard PPO 20% 20% $20

20% $40

$20

Varies, see COC 20% 12 visits/year 20% 12 visits/year 20% 12 visits/year

Uniform Medical Plan (administered by Regence BlueShield)

UMP Achieve 1 $200/day up to $600

for facility + 20% for

professional services

20% 20% 20% 20% 20% Varies, see COC 20% 16 visits/year 20% 16 visits/year 20% 16 visits/year

UMP Achieve 2 $200/day up to $600

for facility + 15% for

professional services

15% 15% 15% 15% 15% Varies, see COC 15% 16 visits/year 15% 16 visits/year 15% 16 visits/year

UMP High Deductible 15% professional

services

15% 15% 15% 15% 15% Varies, see COC 15% 16 visits/year 15% 16 visits/year 15% 16 visits/year

UMP Plus (both PSHVN and UW Medicine ACN) $200/day up to $600

for facility + 15% for

professional services

15% $0; 15% for

other services

such as lab and

x-rays

15% 15% 15% Varies, see COC 15% 10 visits/year 15% 16 visits/year

15% 16 visits/year

Kaiser Foundation Health Plan of the Northwest oers plans in Clark and Cowlitz counties in Washington and select

counties in Oregon.

Not subject to deductible.

Primary care copayments are waived for ages 17 and under.

Enhanced benet: Enhanced in-network cost shares apply when a member uses designated integrated providers and pharmacies

(Kaiser Permanente Medical Centers and providers, or other designated providers as identied in the provider directory).

40 41

Bene ts (what you pay)

Prescription drugs: Retail pharmacy

(up to a 30-day supply)

Value Tier

(speci c high-value prescription

drugs used to treat certain chronic

conditions)

Tier 1

(primarily low-cost

generic drugs)

Tier 2

(preferred brand-name drugs, high-cost

generic drugs, and specialty drugs for

UMP)

Tier 3

(nonpreferred brand-name drugs and

nonpreferred generic drugs

)

Tier 4

(specialty and certain high cost

generic drugs)

Kaiser Foundation Health Plan of the Northwest

Kaiser Permanente NW 1 N/A $20

$40

50% up to $100

50% up to $150

Kaiser Permanente NW 2 N/A $15

$30

50% up to $100

50% up to $150

Kaiser Permanente NW 3 $5 $10

$20

50% up to $100

50% up to $150

Kaiser Foundation Health Plan of Washington

Kaiser Permanente WA Core 1 N/A $5

$25

$50

50% up to $150

Kaiser Permanente WA Core 2 N/A $10

$25

$50

50% up to $150

Kaiser Permanente WA Core 3 N/A $10

$25

$50

50% up to $150

Kaiser Permanente WA SoundChoice N/A $10

$25

$50

50% up to $150

Kaiser Foundation Health Plan of Washington Options, Inc.

Kaiser Permanente WA Options Access PPO 1 N/A $10

($5

3, 4

) $50

($40

3, 4

) 50% up to $125

50% up to $150

Kaiser Permanente WA Options Access PPO 2 N/A $10

($5

3, 4

) $50

($40

3, 4

) 50% up to $125

50% up to $150

Kaiser Permanente WA Options Access PPO 3 N/A $10

($5

3, 4

) $50

($40

3, 4

) 50% up to $125

50% up to $150

Premera Blue Cross

Premera High PPO N/A $7

$30 30% See mail order bene t on next page.

Premera Peak Care EPO N/A $7

$30 30% See mail order bene t on next page.

Premera Standard PPO N/A $7

30% 50% See mail order bene t on next page.

Uniform Medical Plan ( prescription drugs administered by Washington State Rx Service s)

UMP Achieve 1 5% up to $10 10% up to $25 30% up to $75 after deductible N/A N/A

UMP Achieve 2 5% up to $10 10% up to $25 30% up to $75 after deductible N/A N/A

UMP High Deductible 15% after combined (medical and prescrip-

tion) deductible

15% after combined (medical and

prescription) deductible

15% after combined (medical and

prescription) deductible

N/A N/A

UMP Plus (both PSHVN and UW Medicine ACN) 5% up to $10 10% up to $25 30% up to $75 N/A N/A

Includes nonpreferred generic drugs for Kaiser Permanente WA, Kaiser Permanente WA Options, and Premera plans.

Kaiser Foundation Health Plan of the Northwest o ers plans in Clark and Cowlitz counties in Washington and select

counties in Oregon .

Not subject to deductible.

Enhanced bene t: Enhanced in-network cost shares apply when a member uses designated integrated providers and pharmacies

(Kaiser Permanente Medical Centers and providers, or other designated providers as identi ed in the provider directory).

All plans pay 100% for covered preventive prescription drugs, with no deductible. Exception: On the UMP High

Deductible plan, male condoms and male spermicides are paid at 100% after you meet the plan deductible.

Benets (what you pay)

Prescription drugs: Retail pharmacy

(up to a 30-day supply)

Value Tier

(specic high-value prescription

drugs used to treat certain chronic

conditions)

Tier 1

(primarily low-cost

generic drugs)

Tier 2

(preferred brand-name drugs, high-cost

generic drugs, and specialty drugs for

UMP)

Tier 3

(nonpreferred brand-name drugs and

nonpreferred generic drugs

)

Tier 4

(specialty and certain high cost

generic drugs)

Kaiser Foundation Health Plan of the Northwest

Kaiser Permanente NW 1 N/A $20

$40

50% up to $100

50% up to $150

Kaiser Permanente NW 2 N/A $15

$30

50% up to $100

50% up to $150

Kaiser Permanente NW 3 $5 $10

$20

50% up to $100

50% up to $150

Kaiser Foundation Health Plan of Washington

Kaiser Permanente WA Core 1 N/A $5

$25

$50

50% up to $150

Kaiser Permanente WA Core 2 N/A $10

$25

$50

50% up to $150

Kaiser Permanente WA Core 3 N/A $10

$25

$50

50% up to $150

Kaiser Permanente WA SoundChoice N/A $10

$25

$50

50% up to $150

Kaiser Foundation Health Plan of Washington Options, Inc.

Kaiser Permanente WA Options Access PPO 1 N/A $10

($5

3, 4

) $50

($40

3, 4

) 50% up to $125

50% up to $150

Kaiser Permanente WA Options Access PPO 2 N/A $10

($5

3, 4

) $50

($40

3, 4

) 50% up to $125

50% up to $150

Kaiser Permanente WA Options Access PPO 3 N/A $10

($5

3, 4

) $50

($40

3, 4

) 50% up to $125

50% up to $150

Premera Blue Cross

Premera High PPO N/A $7

$30 30% See mail order benet on next page.

Premera Peak Care EPO N/A $7

$30 30% See mail order benet on next page.

Premera Standard PPO N/A $7

30% 50% See mail order benet on next page.

Uniform Medical Plan (prescription drugs administered by Washington State Rx Services)

UMP Achieve 1 5% up to $10 10% up to $25 30% up to $75 after deductible N/A N/A

UMP Achieve 2 5% up to $10 10% up to $25 30% up to $75 after deductible N/A N/A

UMP High Deductible 15% after combined (medical and prescrip-

tion) deductible

15% after combined (medical and

prescription) deductible

15% after combined (medical and

prescription) deductible

N/A N/A

UMP Plus (both PSHVN and UW Medicine ACN) 5% up to $10 10% up to $25 30% up to $75 N/A N/A

Includes nonpreferred generic drugs for Kaiser Permanente WA, Kaiser Permanente WA Options, and Premera plans.

Kaiser Foundation Health Plan of the Northwest oers plans in Clark and Cowlitz counties in Washington and select

counties in Oregon.

Not subject to deductible.

Enhanced benet: Enhanced in-network cost shares apply when a member uses designated integrated providers and pharmacies

(Kaiser Permanente Medical Centers and providers, or other designated providers as identied in the provider directory).

All plans pay 100% for covered preventive prescription drugs, with no deductible. Exception: On the UMP High

Deductible plan, male condoms and male spermicides are paid at 100% after you meet the plan deductible.

42 43

Benets (what you pay)

Prescription drugs: Mail order

(up to a 90-day supply)

Value Tier

(specic high-value prescription

drugs used to treat certain chronic

conditions)

Tier 1

(primarily low-cost

generic drugs)

Tier 2

(preferred brand-name drugs)

Tier 3

(nonpreferred brand-name drugs and

nonpreferred

generic drugs

)

Tier 4 (Specialty)

Kaiser Foundation Health Plan of the Northwest

Kaiser Permanente NW 1 N/A $40

$80

50% up to $200

N/A

Kaiser Permanente NW 2 N/A $30

$60

50% up to $200

N/A

Kaiser Permanente NW 3 N/A $20

$40

50% up to $200

N/A

Kaiser Foundation Health Plan of Washington

Kaiser Permanente WA Core 1 N/A $10

$50

$100

N/A

Kaiser Permanente WA Core 2 N/A $20

$50

$100

N/A

Kaiser Permanente WA Core 3 N/A $20

$50

$100

N/A

Kaiser Permanente WA SoundChoice N/A $20

$50

$100

N/A

Kaiser Foundation Health Plan of Washington Options, Inc.

Kaiser Permanente WA Options Access PPO 1 N/A $10

$80

50% up to $250

N/A

Kaiser Permanente WA Options Access PPO 2 N/A $10

$80

50% up to $250

N/A

Kaiser Permanente WA Options Access PPO 3 N/A $10

$80

50% up to $250

N/A

Premera Blue Cross

Premera High PPO N/A $14

$60 30% $50 for a 30-day supply

Premera Peak Care EPO N/A $14

$60 30% $50 for a 30-day supply

Premera Standard PPO N/A $14

30% 50% 40% for a 30-day supply

Uniform Medical Plan (prescription drugs administered by Washington State Rx Services)

UMP Achieve 1 5% up to $30 10% up to $75 30% up to $225 N/A N/A

UMP Achieve 2 5% up to $30 10% up to $75 30% up to $225 N/A N/A

UMP High Deductible 15% after combined (medical and prescrip-

tion) deductible

15% after combined (medical

and prescription) deductible

15% after combined (medical and prescrip-

tion) deductible

N/A N/A

UMP Plus (both PSHVN and UW Medicine ACN) 5% up to $30 10% up to $75 30% up to $225 N/A N/A

Includes nonpreferred generic drugs for Kaiser Permanente WA, Kaiser Permanente WA Options, and Premera plans.

Kaiser Foundation Health Plan of the Northwest  oers plans in Clark and Cowlitz counties in Washington and select

counties in Oregon.

Not subject to deductible.

All plans pay 100% for covered preventive prescription drugs, with no deductible. Exception: On the UMP High Deductible

plan, male condoms and male spermicides are paid at 100% after you meet the plan deductible.

44 45

Selecting a dental plan























Check with the plan to see if your

provider is in the plan’s network

















How do the DeltaCare and

Willamette Dental Group plans

work?





































How does the Uniform Dental

Plan (UDP) work?





























Dental plan options



    

  



 





 















 











Dental benefits comparison









 

 

 

















 



 





 





 

















  

 











 



 

 























 











 















 

































 









 

 



 

 



 

Selecting a vision plan



























Vision plan options



• 

• 



• 



Vision benefits comparison











Adults (19 and older) — what you pay for in-network services

 







MetLife





  























































  

 







MetLife

 

  



 

  



 

 

 



 

 

 



 

 



 

 

 



 

 

 



 

 

 

 















MetLife













































   

 







MetLife

   

  







 

 

 





Children (under age 19) – what you pay for in-network services













MetLife

   

 

















   

   

 







MetLife

   

   

   

   

   

   

   













MetLife











 











 

   

 







MetLife

   







 

 



Life and AD&D insurance









































What is (employer-paid) basic life

insurance?















What is (employee-paid)

supplemental life insurance?





















Supplemental life insurance for spouse or state-

registered domestic partner





















Supplemental life insurance for children



















Evidence of insurability





• 





• 



• 





What does supplemental life

insurance cost?







Supplemental life insurance

monthly rates for employees,

spouse or state-registered

domestic partner, and children

  

  

  

  

  

  

  

  

  

  

  

  





 

Good to know!











 

 

 

When can I enroll in supplemental

life insurance?











• 



• 



• 



































How do I enroll in supplemental

life insurance?









How do I create an online account

with MetLife?

 





 



 

 

 











How do I designate beneciaries

for my life insurance?















Can I waive life and AD&D

insurance?







• 

• 











If I leave employment, can I

continue life insurance coverage?













Portability Provision





























Conversion Provision

















Is there an accelerated benet

in SEBB Program life insurance

coverage?

























What is (employer-paid) basic

AD&D insurance?











What is (employee-paid)

supplemental AD&D insurance?





Supplemental AD&D insurance for employees











Supplemental AD&D insurance for your

spouse or state-registered domestic partner









Supplemental AD&D insurance for children









What does supplemental AD&D

insurance cost?





Supplemental AD&D insurance

monthly rates



 







 

Good to know!











 

 

 

When can I enroll in supplemental

AD&D insurance?





How do I enroll in supplemental

AD&D insurance?









How do I designate beneciaries

for my AD&D insurance?















Long-term disability insurance





































  





What is (employer-paid) basic

LTD insurance?

















Waiting period before benets

become payable for basic and

supplemental LTD





• 

• 







• 











What is (employee-paid)

supplemental LTD insurance?





















What does supplemental LTD

insurance cost?













Supplemental LTD rates based on your age on

January 1, 2021

 

 

 

 

 

 

 

 

 

 

Good to know!







 

 

 

When can I enroll in supplemental

LTD insurance?

















How do I enroll in supplemental

LTD insurance?





























Terms and conditions apply









What is considered a disability?







 





























What is the maximum benet

period?







 

 







 



 



 



 

 

 

 

 

Medical FSA and DCAP





















What is a Medical Flexible

Spending Arrangement (FSA)?



















How does the Medical FSA work?















































What is the Dependent Care

Assistance Program (DCAP)?







































How does DCAP work?



















When can I enroll in Medical FSA

and DCAP?





• 

• 



• 





How do I enroll in Medical FSA

and DCAP?





























When can I change my Medical

FSA or DCAP election?































SmartHealth

















Who is eligible?

















What is the wellness incentive?





































How do I get started?

1. Visit the SmartHealth

portal at

smarthealth.hca.wa.gov

and click Get Started.

2. Take the SmartHealth

well-being assessment.

 It only takes 15

minutes.

 This is the ﬁrst step

to qualify for the

wellness incentive.

 Learn your top

strengths and areas

to improve.

3. Join and track activities to

earn at least 2,000 points

by your deadline to

qualify for a $125

wellness incentive

(distributed by

January 31, 2022).

What is my deadline to qualify for

the wellness incentive?





• 





• 



What if I don’t have internet

access?





SmartHealth contacts











After you enroll

What to expect next























When do my benets begin?











September start work dates













Other start work dates





























Returning employees











When do my benets begin when I am

regaining eligibility?































Changing jobs





























Good to know!

















Good to know!











When coverage begins

SEBB Program annual open enrollment



Newly eligible enrollment (outside September 1 through

rst day of school)



Marriage or registering a domestic partnership















Birth, adoption, or assumed legal obligation for total or

partial support in anticipation of adoption

















































Child becomes eligible as an extended dependent



Other events that create a special open enrollment

















Changing your coverage

How do I make changes in my

health plan coverage?





• 



• 



• 





What changes can I make

anytime?





• 





• 











• 













• 









• 







• 









• 







What changes can I make during

annual open enrollment?





















• 

• 

• 



• 



• 



• 

• 

• 



What is a special open

enrollment?

































What changes can I make with a

special open enrollment?







How do I make changes during a

special open enrollment?















Good to know!













Changes you can make with a special open enrollment

 



 



 



   



 





 







 



 













   



 













     













     













   



 



















   



 









     











   



 















     





66 67



 









     









     







     













     





     













     















  



  















     



68 69

When coverage ends



• 







• 







• 



















What happens if I or my

dependent lose eligibility?

























What are my options when

coverage ends?





















• 

• 

• 











How does SEBB Continuation

Coverage work?











































































PEBB retiree insurance































































What happens to my Medical FSA

funds when coverage ends?































Good to know!















What happens to my DCAP funds

when coverage ends?



















What happens to my HSA when

coverage ends?





































What happens to my life and

AD&D insurance when coverage

ends?

















If I die, are my surviving

dependents eligible?



































What happens when a dependent

dies?















































Appeals

How do I appeal a decision made

by a health plan?













How do I appeal a decision

from my employer or the SEBB

Program?







 



How do I appeal a decision made

by a SEBB Appeals presiding

ofcer?





























Deadline for requesting an appeal







How can I make sure my personal

representative has access to my

health information?





















Instructions and deadlines

If your situation is:







• 

• 

• 

• 

• 

• 

• 



• 

• 

















If your situation is:

























If your situation is:





• 

• 

• 

• 

• 

• 

• 

• 



• 



• 

• 





If your situation is:





• 

• 



• 







Enrollment forms



SEBB Premium Surcharge Attestation Help Sheet



SEBB Long-term Disability Enrollment Form

standard.com/eforms/7533_756494.pdf