COBRA and Unpaid Leave (2024)

2024 PEBB Continuation Coverage Monthly Premiums E昀昀ective January 1, 2024 Kaiser Foundation Health Plan of the Northwest o昀昀ers plans in Clark and Cowlitz counties in Washington and select counties in Oregon. UMP is administered by Regence BlueShield and Washington State Rx Services. The term "spouse" is interchangeable with state regisetered domestic partner (SRDP). Non-Medicare medical plan premiums (for members not enrolled in Medicare) Managed Care Plans Preferred Provider Organization (PPO) Plans What you Kaiser Foundation Kaiser Foundation Health pay Health Plan of Plan of Washington Uniform Medical Plan ̸̣ the Northwest Classic CDHP Classic CDHP SoundChoice Value Classic CDHP Select UMP Plus Monthly premiums Subscriber only $1,039.18 $907.72 $933.56 $738.98 $777.41 $919.37 $831.68 $747.79 $766.61 $816.50 Subscriber $2,072.40 $1,808.12 $1,861.16 $1,470.63 $1,548.87 $1,832.77 $1,657.40 $1,488.26 $1,527.27 $1,627.04 & spouse Subscriber & $1,814.10 $1,597.60 $1,629.26 $1,302.30 $1,356.00 $1,604.42 $1,450.97 $1,317.73 $1,337.10 $1,424.41 children Subscriber, $2,847.32 $2,439.67 $2,556.86 $1,975.63 $2,127.45 $2,517.83 $2,276.69 $1,999.87 $2,097.76 $2,234.95 spouse, & children Medical premium surcharges (for non-Medicare subscribers only) Two premium surcharges may apply in addition to your monthly medical premium (if you, the subscriber, are not enrolled in Medicare Part A and Part B). You will be charged for them if the conditions described below apply, or if you do not attest to the surcharges when required. Visit Surcharges on HCA’s website at hca.wa.gov/pebb-continuation for more information. • A monthly $25-per-account medical premium surcharge will apply if you or any dependent (age 13 and older) enrolled in PEBB medical coverage uses tobacco products. • A monthly $50 medical premium surcharge will apply if you enroll a spouse or state-registered domestic partner in PEBB medical coverage, and they have chosen not to enroll in another employer-based group medical plan that is comparable to PEBB’s UMP Classic. Dental plan premiums Managed Care Plans Preferred Provider What you Organization (PPO) Plans pay DeltaCare Willamette Dental Group Uniform Dental Plan ̸̣ Monthly premiums Subscriber only $41.50 $48.87 $48.92 Subscriber & spouse $83.00 $97.74 $97.84 Subscriber & children $83.00 $97.74 $97.84 Subscriber, spouse, & children $124.50 $146.61 $146.76 HCA 50-0300 (9/23) 1