Notas a las cuentas anuales consolidadas continuación
2 Resumen de políticas contables significativas continuación
Name of Plan and Plan Number
Providence Health & Services Health and Welfare Benefit Plan Welfare Benefit Plan, which includes The Providence Health & Services Group Insurance Plan (PN 501).
Type of Plan The Plans are group health welfare plans providing the following types of benefits:
Self-Insured Benefits
1. Medical Insurance 2. Dental Insurance 3. Vision Insurance
4. Health Care and Dependent Care Flexible Spending Accounts
Insured Benefits
1. Health Maintenance Organization Medical Insurance in Southern California 1. Basic Employee Life Insurance
2. Supplemental Accidental Death and Dismemberment Insurance 3. Supplemental Employee and Dependent Life Insurance 4. Long Term Disability Insurance
5. Short Term Disability Insurance for Hood River Oregon employees 6. Employee Assistance Program
7. Dental Insurance for Specific Employee Group within the Southern California Region
Plan Year The plan year is January 1 to December 31.
Plan Administrator, Plan Sponsor, and Employer Identification Number for PN 501
Plan Administrator and Plan Sponsor
Senior Vice President, Chief Human Resources Officer, Providence Strategic and Management Services (or his/her designee)
Providence Health & Services - Washington 1801 Lind Avenue SW, #9016
Renton WA 98057 (425) 525-3355 EIN # 51-0216586
Contributions, Funding, and Administration
Medical, Dental and Vision benefits are self-insured by participating employers. Participating employers include:
● Providence Strategic and Management Services ● Providence Alaska Region
● Providence Southern California Region ● Providence Oregon Region
● Providence Washington Regions/Service Areas: Northwest Service Area, Providence Health Care, Senior and Community Services, Southeast Washington, Southwest Service Area
● Providence Western Montana Region
Medical and dental certain benefits offered in the Providence Southern California Region are insured:
● Health Maintenance Organization Medical Plans ● Dental Maintenance Organization (legacy)
Administration the Plans are paid first from any monies received from plan participants. Medical, Dental and Vision claims are paid from the general assets of participating employers. Two HMO medical plans in the Southern California Region are insured through insurance contracts paid for by employer and employee contributions. For these HMO Plans, the participating employers have delegated authority to the insurance company to administer benefit claims under the Plans.
Health Care Spending Accounts is funded by pre-tax participant contributions.
Medical claims are paid by:
Providence Health Plan P.O. Box 4447
Portland, OR 97208 Toll-free: 1-800-878-4445
Blue Shield of California (UHW PSJMC legacy plans - see Summary of Material Modification in appendix for California employees)
P.O. Box 272540 Chico, CA 95927-2540 1-888-235-1766
For Group Health HMO (Washington) claims, see Appendix
For Montana employees, medical claims are administered by Allegiance Benefit Management, Inc.; information provided in separate medical plans summary.
Dental claims are paid by:
Delta Dental/Washington Dental Service P.O. Box 75983
Seattle, WA 98175 Toll-free: 1-800-554-1907
For the fully insured DeltaCare HMO: Toll-free 1-800-650-1583
Vision claims are paid by:
Vision Service Plan 3333 Quality Drive
Rancho Cordova, CA 95670-7985 Group Number: 12295028 Toll-free: 1-800-877-7195
Health Care and Dependent Care Flexible Spending Account claims are paid by:
HealthEquity, Inc.
15 W Scenic Point Dr., Ste 400 Draper, UT 84020
1-801-727-1000
As claims administrators for the Plans described above, these entities—subject to Providence Health & Services’ overall authority as Plan Administrator—have discretionary authority to interpret plan provisions, to decide questions of eligibility for coverage or benefits under the Plan, to adjudicate claims, and to decide any appeals of denied claims.
All other Providence Health and Welfare Benefit Plan benefits are insured through insurance contracts paid for by employer and/or employee contributions. For these Plans, the participating employers have delegated authority to the insurance company to administer benefit claims under the Plans.
Contributions, Funding, and Administration (cont.)
California Health Maintenance Organization Medical insurance benefits are funded,
administered, and paid through the purchase of insurance. Benefits are guaranteed in accordance with the provisions of the insurance contract.
Blue Shield of California 50 Beale Street, 22nd Floor San Francisco, CA 94105
California Dental HMO Program benefits are funded, administered, and paid through the purchase of insurance. Benefits are guaranteed in accordance with the provisions of the insurance contract. Delta Dental of California
DeltaCare USA Customer Servcies P.O. Box 1803
Alpharetta, CA 30023 800-422-4234
Basic Employee Life, Supplemental Employee Life Insurance, Dependent Life Insurance and Supplemental Accidental Death and Dismemberment Insurance benefits are funded, administered, and paid through the purchase of insurance. Benefits are guaranteed in accordance with the provisions of the insurance contract.
Metropolitan Life Insurance Company 200 Park Avenue
New York, NY 10166 1-800-638-6420
Policy Number: 121359-1-G
Long Term Disability and Short Term Disability for Hood River OR Insurance benefits are funded, administered, and paid through the purchase of insurance. Benefits are guaranteed in accordance with the provisions of the insurance contract.
Unum Life Insurance Company of America 2211 Congress Street
Portland, ME 04122 1-800-858-6843
Policy Number: 138177-002 (LTD)
Employee Assistance Program benefits are funded, administered, and paid through a service agreements. Benefits are guaranteed in accordance with the provisions of the agreement. APS Healthcare Bethesda, Inc. ValueOptions
8403 Colesville Road, Suite 1600 240 Corporate Blvd. Sliver Spring, MD 20910 Norfolk, VA 23502 1-757-459-5100
Magellan Behavioral Health, Inc. Providence Health & Services - Oregon 14100 Magellan Plaza Drive dba Providence EAP
Maryland Heights, MO 63043 4900 NE Glisan St.
1-800-478-2812 Portland, OR 97213 503-215-3561
Agent for Service of Legal Process for PN 501
The registered agent on behalf of the Plan Administrator and Plan Sponsor is: Business Filings Incorporated
1801 West Bay Drive NW, Suite 206 Olympia, Washington 98502 800-981-7183
plans as defined in ERISA. The fiduciary acts on your behalf to make sure the Plans are administered fairly, honestly, and in accordance with legal standards and the terms of the plan documents. In exercising fiduciary responsibilities, the Plan Administrator will have discretionary authority (a) to determine whether and to what extent Participants and beneficiaries are entitled to plan benefits, and (b) to construe the Plan terms. The Plan Administrator will be deemed to have properly exercised such discretionary authority unless the Plan Administrator has abused discretion hereunder by acting arbitrarily and capriciously.
Blue Shield of California is the named claims fiduciary for the Health Maintence Organization medical plans in California, as defined in ERISA. Blue Shield will administer the Plan in accordance with ERISA and has discretionary authority to make decisions on claim appeals and to interpret the terms of the Health Maintenance Organization plans.
Unum is the named claims fiduciary for the Long Term Disability Plan and Short Term Disability Plan for Hood River OR employees, as defined in ERISA. Unum will administer the Plan in accordance with ERISA and has discretionary authority to make decisions on claim appeals and to interpret the terms of the LTD Plan.
MetLife is the named claims fiduciary for the Basic and Supplemental Life and Accidental Death & Dismemberment Plans, and Long Term Care insurance, as defined in ERISA. MetLife will administer the Plans in accordance with ERISA and has discretionary authority to make decisions on claim appeals and to interpret the terms of the Plans.
Delta Dental of California is the named claims fiduciary for the DeltaCare USA Dental HMO Program, as defined in ERISA. Delta Dental will administer the Plan in accordance with ERISA and has discretionary authority to make decisions on claim appeals and to interpret the terms of the Dental HMO Program.
Magellan, ValueOptions, APS Healthcare and Providence Health & Services - Oregon dba Providence EAP, are the named claims fiduciary for the Employee Assistance Program for the state(s) to which they are designated as the provider, as defined in ERISA. Magellan, ValueOptions, APS Healthcare and Providence Health & Services - Oregon dba Providence EAP will administer the Plan in accordance with ERISA and has discretionary authority to make decisions on claim appeals and to interpret the terms of the Employee Assistance Program.
Business Travel Accident Insurance (non-ERISA)
Business Travel Accident Insurance benefits are funded, administered, and paid through the
purchase of insurance. Benefits are guaranteed in accordance with the provisions of the insurance contract.
CHUBB Group of Insurance Companies Embarcadero Center West
275 Battery Street, Suite 1200 San Francisco, CA 94111 1-800-939-9850