That risk adjusting and validated a piece of it. I would present several pieces that go into that calculation and im sure that is one, but im not sure its the main driver. I would be interested in seeing that level of detail. Sure. The higher the risk or the more medicare reimburses you, right . They were doing with the upcoding. Yeah, two components. So the higher risk score and again not an area of officexper but its the relative risk across the program. So medicare for us is not dependent on your utilization. Its Community Rated and then risk adjusted. On the commercial side its entirely utilization based. So if youre a higher utilizer, youre rate is higher. If youre lower risk, your rate is lower. On the medicare side, its a Community Rate approach and then adjusted for risk. So its an adjusted community rating. So the higher our total program is in risk, the more reimbursement we would receive, also dependent on geography and other factors. The risk adjustment that is changing whether we go up or down and what we do in terms of reconciliation from year to year, is we get final notification of what that reimbursement will be. And thats a portion of it. But a bigger portion is the risk adjustment on that Community Rate on whether your populations risk is higher or lower than others within that community. That is the change. So it doesnt necessarily mean your group got substantially sicker. Its the comparison amongst the entire medicare population that were rating as a community. Its not the most straight forward approach. It is not unique. It is what is different is that we actually do the reconciliation, where others will provide their best estimate and then that is the rate. Were saying if we come out early, we want to provide the right rate. We dont want it to be higher or lower than we need it to be. So we want to reconcile. If we were to do the rate in july or august, there would not be reconciliation from year to year. We would have the data we needed in order to develop a firm rate for you. To followup on the request, can you give us that data analysis, the past 35 years, because its curious to go from 13. 2 decrease to 11. 4 increase. Sure. And part of it is the swing. There is a reconciliation down and then reconciliation up. So its like the hip tax. When we took it off, it went down a point. When you put it on, it goes up a point. The delta is two points, even though its only a onepoint change. So a good portion of that is there is reduction going down and then a reduction going up, so it makes the swing really big. It is still big, its just not this big. Its only this big. But absolutely, we can provide that. Thank you. Thank you. The final thing ill note is the proposed 2020 rate for kpsa even with the increase is actually lower than what the 2018 rate was. So 2019 received a substantial benefit from this adjustment methodology. I know there is at least one vocal representative in our audience today that says people are not living on 2018 income, theyre living on 2020 income. And there is impact to them. President breslin any Public Comment on this item . Seeing none. Weve been doing this for an hour and a half. Would anybody like to item 14. Review approve Medicare Advantage preferred provider. Mike clark. So now were going to start our actual rate presentations with the United Health care Medicare Advantage ppo. The uhg ma ppo. As part of this discussion, if you look on page 2, the recommendations that we have to present to you today include two different scenarios, so one is what were calling a status quo scenario, that is just straight renewal. No Design Changes, no Program Changes, but we do feel that a package of one recommended Design Change and one recommended new program for the 2020 plan year is the suggested approach, the recommended approach, but we do have information on both scenarios in this document. You can see the rates on the middle of page 2 for 2019 plan year expressed on a per member, per month, or pmpm basis. So 2019, the rate currently is 371. 68 per medicare member. That is a. 7 decrease, thats due to the waiver of the aca hip tax. With aca hitback, 2020 rates are increasing 17 on a status quo basis, or 16. 6 with the combination of the plan Design Change and Program Change that were recommending today. I include for reference the page numbers for the actual rates and cards. And changes in total rates and member and employer contributions for each of these two scenarios. We will be suggesting and recommending for approval, the with proposed design and Program Changes approach. Well walk through that. So brief introduction which i mostly covered in the prior presentation in my opening statements, again, almost 16,000 medicare eligible retirees in this plan. Page 5, i talked about this as well, the fact that the majority of the increase is due to the return of the aca hip. This is 10 of the overall increase. The remaining 7 is underwriting claims and forecast, et cetera, so really the underlying insurance part of this renewal is a 7 increase. Which is in line with our National Health care costs trend expectations. And then just as reminder of page 6 when we set the total premiums you see today, we also include the Vision Service plan, vsp basic plan premiums as well as the Health Care Sustainability fund charge of 3 per retiree per month. And the Expert Opinion service is no longer offered starting in 2020. We formally included that in the cost. With the recent board decision to allow that contract to expire, youll no longer see those doctors in the rate cards. With that can i ask a question. Why are they applying the hit tax and kaiser did not . Its a function of what each particular organization, what they pass on their writs. Rates. United health care is choosing to pass it and kaiser does not pass it. Are there any rules that we dont allow either one . We have nothing to say about it . I can ask a kaiser and or United Health care representative to speak to their organizational positions. It is a tax that is placed on Health Insurers by the federal government, because these are full insured plans, its the Health Insurers responsibility to compensate the tax back to the federal government. Every plan differs in terms of their approach as to whether they choose to cascade it in theyre rates. Is there a Health Care Representative here . United Health Care Care . This is a huge addition to our increase. They all have to pay it. We understand that. Good afternoon. Hi, so from our perspective we see the hit tax, it is something we have to pay. So we see it as a passthrough only, so were just calculating the tax based on the equation given to us by the federal government and then passing that on to the client based on the premium. Its a 2. 01 . And each firm is taxed differently, depending on their tax status. We are forprofit company, so we get the full impact of the tax. But thats very much like some of the mandates that we have here in San Francisco and whether a person in a restaurant setting decides to pass on the full amount and increase their menu rates or whether theyre going to absorb that to some degree to maintain a client base coming to their restaurant. So im raising a question. Not about your tax status, but about the policy or the perspective of passing it totally through, versus assuming some portion of it. Absolutely. We do standardly pass the full thing through as a passthrough with all of our clients, regardless of size and status, et cetera. But i can absolutely take it back as a question. But its something that we have consistently passed through. I understand your current practice. Im asking for the rationale. The policy rationale as to why you would do that versus absorbing some portion of it on behalf of your members . I think thats the thrust of our question. Its 10 . And its a big hit. And so youve elected to do it. And im only asking why . Absolutely. And we can follow up with a direct answer on that. At this point in time, what weve been given as why we passed the tax through is because were being charged it. Its a cost of business that we dont typically have. Its been off one year, on the other. We do give a credit back each year when its not taxed, so were just doing a pass through. There is no calculation. It comes in after the fact of the renewal calculation. However, i can come back with additional responses. Thank you for the explanation. I have a question. Just one followup on the hit tax topic. If you recall from last month, kaiser does pass the hit tax in their nonmedicare premiums, theyre just not passed on the kpsa premiums. Ill explain each in further detail as to why we recommend these in subsequent pages. One plan Design Change is suggested to aid in lowering the premium rate increase for 2020, as well as to provide a coverage for the cost of the recommended new program below. So that is the increase the Specialist Office copay from 15 to 20 proposed. And then the new program to support members is 14 annual male benefit from moms meals nourish care. This is in addition to the program implemented in 2019 in this plan. To the copay change on page 9. Currently, office visit copayments for the uhg ma ppo are 5 for primary care provider. And 15 for a specialist physician. You can also see for kpsa 20 copayments apply for all office visits, primary or specialist. Were recommending the increase to 20 to partially offset the 17 rate increase. Its a 2. 50pmpm increment. But we also feel that the primary care physician copayment should remain at 5 to enhance the importance of primary care to members. And with the increased focus of enhancing access to quality and nutrition options to these medicare members, thats why we also recommend the new Meal Delivery benefit which we present on the next page, knowing that the funding for this benefit does come from this specialist copayment change. Just background on page 10. Around cms now allowing for medicare plans to allow enhanced benefits. You see the list of programs that were implemented for 2019 into the uhg ma ppo plan from transition support with Transportation Services and Meal Delivery post discharge, routine Transportation Services and Nutrition Counseling benefits. What were recommending with the 14 Meal Delivery which is the same organization that provides the post hospital discharge Delivery Service today. And more information on the moms and meals program, we list out on slide 11. So this is a onetime shipment of 14 meals, home delivered, freshly made, annually per member. These are regardless of medical requirements. So there is no particular diagnosis, no medical reason to then qualify for these. These are available to all members who participate in the uhg ma ppo program. They would call the service, moms meals nourish care to access the benefit. You can see an array of meal options to tailor to a particular individuals needs. Breakfast, lunch and dinner options are available and a wide array of culturally diverse meal options as well. The meals remain fresh in the refrigerator up to 14 days and can be frozen up to 90 days. So this comes in one shipment, 14 meals, members do have the ability to purchase meals on their own after this annual benefit has been exhausted at the cost of 6. 99 per meal with free shipping. The rate increase for this particular Meal Delivery benefit is 1. 05, pmpm. Quick question. Do you have any information i understand this is new in 2019 as a percentage of members that took advantage of that new program . So the post discharge Meal Delivery at this point, only two have taken advantage of the post discharge Meal Delivery. One did use the entire 84meal allotment. Another member used a 21meal allotment. I can follow up with the information on the Transportation Services and the enhanced access to nutritional counseling will follow up and have available for you after the meeting. President breslin how much extra did we pay for those meals, per member, per month . Ill have to follow up. I remember the total pmpm for all three, i just dont remember how they portioned out. You have 22 people using this, you know, these things need to be looked at. That just yeah, they certainly do. And one of the things that weve identified, a this is a function of a referral mechanism on a post discharge. And at discharge process in most hospitals is complex and there are many case managers involved. So clearly this is a very useful and needed, necessary benefit. The breakdown is occurring somewhere in the referral process. It could be i ran a number of these programs, the cms innovation programs and part of this is often having, in our case, the member know about it from a trusted source. So we have some responsibility here to make sure our members know when theyre offered these services that theyre sanctioned by us and theyre not something just falling from the sky. Because none of us really like strangers knocking on our door giving us anything, right . So it has to be from a trusted source. So there is work to be done. But the efficacy of post discharge in meals has been proven over and again, but we have to figure out have to get the uptake on the service. But two people out of 16,000 or whatever we have. Its ridiculous were paying for that. You know, of course its a good thing, but if nobody is going to use it, what good is it . And people dont trust that. Its like just for reference, so its available to anybody after a hospital discharge and that was three months the first three months of information, so granted a low number just with the recognition, thats a threemonth number. And only those discharged from hospitals would be able to access the benefit. Under this particular new program youre saying anybody can access it . Correct. So all members have access to this 14meal proposed benefit. Im sure my mother will turn over in her grave, she was a nutritionist. Its hard to question moms [laughter] four words in the program, nourish, meals, care. Theyre great words. Were not questioning the data or the value of post discharge nourishment and some monitoring of that, which this program could help, but i guess the question i have, are there data on providing 14 additional meals over the course of the rest of the year for whatever reason . I did go online and look at their website, and you know, its impressive. Everything is frozen. Im sure they have good vendors who make all this. And im sure its produced more locally and hopefully more sustainably, were not getting corn from somewhere outside our borders, but i dont know that this is really essential based on a datadriven analysis. That 14 more meals will make a difference for our members who are otherwise healthy and not been hospitalized or suffering illnesses that would complicate their ability to acquire good food from their family, friends or themselves. President breslin i just, when i first looked at this, 14 meals delivered at one time. So youre going to keep them in the refrigerator for a week or you can freeze them. They lose a lot of their nutritional value right there probably, but i just so this would cost 1. 05 per person per month for this nutrition program. And people are paying losing 5 on the copay for the specialist, so if you had the extra 5 for the copay, 10 of those would give you 14 well not quite 14, but they said you can purchase these meals for 6. 99. Well, thats not a bad deal, but to have this added i dont know. I just really question because i dont know anything about how the meals are. You know, i just dont know what kind of a deal this is. Costs 200,000 annually, probably for this plan. Correct. President breslin 200,000 plus annually. And we dont know how many people take it. Im all for people keeping healthy, as everybody knows, thats my big deal. And we have were also paying 3 for the Health Care Sustainability, for the Wellness Program basically. So this is kind of extra in that direction, but is it really effective . I just i really question it. I ask everybody else what they think about this. Im curious, the basis for the recommended add. The basis is that this is a social determinate of health is the adequate nutrition of our membership. All Health Care Systems are looking at how we can impact the health of our members outside of an institution. And so these programs that, you know, we started with the post discharge program, we already addressed those challenges. Then this program was a way to introduce our seniors that may not have access to affordable food, a way of getting that delivered to them appropriately and delving into addressing one of the major social determinates of health. I guess the question, is this something we should be doing, or the health plans should be doing it . People would hope that those in need of this would have the diagnoses and have access or the counseling about how to acquire this. The thing that bothers me about this, and the first proposal as well, is that were the people who are the most ill and see the most specialists are going to be paying more to see those specialists. And theyre already under financial strain. Now this alleviates a little bit of that. Provides 14 additional meals, assuming they havent been hospitalized, but i think its a small fraction of what they would be paying. I was a specialist. Im actually concerned more about the additional cost to our ill medicare members of seeing a specialist which is critical to their ongoing health, and 5 doesnt seem like much if youre only doing it once a year, but many of these people have several specialists that theyre seeing, sometimes monthly, or quarterly, or semiannually. And so i question actually both of these in terms of cost effectiveness for our goals. President breslin any other comments . Okay. Well going to page 13 where we present two sets of 2020 rate cards. The first set is pure status quo. No plan Design Change, no Program Change, incorporating the 17. 0 uhg ma ppo rate increase. And then with the proposed design and Program Changes version reflecting a 16. 6 rate increase in the uhg ma ppo. We present each of these versions with columns that represent the array of plans that nonmedicare dependents can enroll when the medicare retiree is under the uhg ma ppo plan. Page 14. Just a reminder that the rate cards we present in the document represent the full employer contribution for Retiree Medical coverage that is available to retired medical employees hired on or before january 9, 2009. There is Retiree Medical coverage available, but with no employer contribution to those retired employees hired on or after january 10, 2009, but at least five, and less than 10 years. On page 15, you see that retired medical coverage at the 50 employee charter contribution rate is available to retired employees hired on or after january 10, 2009 with greater than ten years of accredited service, but less than 15 years accredited service. The segment receives 50 of the contributions for each Retiree Medical plan, coverage here is reflected in the rate cards. Again, just a reminder there are varying levels of employer contributions, what we present in the rate cards are the full employer contribution version. So on page 16, before we look at the rate cards and the full rate comparison. This is really the bottom line for the member. This is the page where we look at the actual contributions the retirees would pay for each level of coverage. And we do have some additional coverage tiers with medicare families in the appendix as well. Between the status quo retiree contributions, so no Design Change, no Program Change, the top half of the table. And then with proposed changes, design and program at the bottom half of the table. So this allows you to see the difference in retiree contribution for retiree only, zeros throughout. The city charter contribution formula covers the full cost of the retiree only coverage, but for those who are covering dependents, well see various differences in the contribution levels required of those retirees, depending on the tier. Not a great deal of difference between the contributions for 2020, between the status quo and the with proposed changes. So for the member, covering dependen dependents, while there is difference between the two scenarios, not a great deal of difference, but because the overall rate increase is less under the with proposed changes scenario, the contributions required of the member are slightly less in the bottom table versus the top table. But, again, this is not including the impact of the specialist copay change on the member financially. This is strictly the monthly difference in member contribution. Can i just point out, im going to restate what i already stated. That is that so for all of our medicare retirees with one or two or more dependents saving 70 cents roughly per month is subsidizing what will be a bigger expense for our ill medicare patients who are seeing specialists at 5 more a visit. Im not going to speak for our healthy medicare retirees. Theyre here and can speak for themselves. The question is, are you willing to accept a 70 cents reduction so that your colleagues and former colleagues pay more . Out of pocket. Because they happen to be ill . And im not sure that is fair. From a societal standpoint. Its always a question of how much the value of prevention is. You know, i mean, we have this argument all the time in public health. How much do you invest in prevention in order to keep people from becoming ill. And its more or less a rhetorical question, but i think thats the question. Can i just respond to that, because i think its a good question. I tried to do a literature search in anticipation of this constitution. Unfortunately, the literature is actually not robust. Its fairly robust around emergency room copays. And what happens when up institute copays in emergency room and the impact of people 50 reduction in emergency room visits for people who never should have gone to the emergency room anyway. But 30 of reduction for business who should have gone to the emergency room, were not even talking about that. We start to look at primary care and Specialty Care and the impact of these on sort of a societal basis and this has been looked at in australia. It was looked at in one of the European Union countries and i saw very little impact across the board on quality or utilization. They couldnt measure it, or they said we dont know. But on individual basis, i would still argue if you have coronary artery disease, diabetes, peripheral neuropathy, and are seeing a specialist, this adds up to them, frankly. They cant reverse these diagnoses by more attendance to our Wellness Center at this point in their lives. Okay. So just as a refresher, page 17 is the rate card under the status quo scenario. So as a board, if you decide that is the scenario, page 17 contains the rate card with page 18, the year over Year Comparison and contributions and total rates. The with proposed Design Change program rate card is on page 19. And page 20 contains the year overYear Comparison of with proposed Design Change and Program Change scenario. So on page 22, the recommendation is that the Health Service board accept the uhg ma ppo retiree rates as accepted today under the with program design, which include the two changes that are outlined on page 22. But again, with the reminder that weve presented both rate cards knowing that we ultimately need a rate approval for the uhg ma ppo today. So weve provided both rate cards for that purpose. Ill be a sacrificial lamb. I move that we accept the status quo rate cards for the 2020 for this program. Second. President breslin any discussion . Any Public Comment . Good afternoon, dennis kruger, active and retired firefighter and their spouses. A couple of years ago we tried to improve the dental program by offering a higher amount of coverage. And the board sent out a questionnaire to everybody. At that time there were different rates for different amount of increase of coverage. And the majority of the people that sent back the questionnaire, said, no, i cant afford this, even though some of it was 15 a month and the max i think was 50 a month. I tend to agree with dr. Follansbee, that the 5 difference to the people who couldnt afford that improve their dental benefits, are the same people affected by the rate increase. So i would hope that you support the doctors motion and that we dont raise the specialist to 20. Thank you. President breslin thank you. Good afternoon, commissioners and welcome commissioner canning. Representing sciu west bay retirees. Quite frankly, im going back to what nancy jin told us many years ago. She said what members said, what retirees said at that time, if you increase my monthly premium, i can budget and figure out what i have to do, but if you increase my copays, especially to specialists, but the regular copays, i dont know and i cant budget, because i dont know when i have to go see the doctor. Or maybe i have to see three doctors this month and five next month. We dont know. So, dr. Follansbee, we support strongly maintaining the status quo. Those copayments are onerous to many members across the board. And for many of these things, im not sure that the benefit is justified, but the copay issue is significant and very difficult for a lot of our members to deal with. Especially the older retirees who are on the more restricted income. We appreciate your proposal and hope that all of you vote to support dr. Follansbees motion. President breslin thank you. Next. Good afternoon. Im the director of Strategic Partnerships for moms meal nourish care. I wanted to say thank foss are the opportunity. I also wanted to say this was not a Business Development function. I didnt find out this was a part of the benefit until i was asked to come to the meeting. I think your concerns are well founded from that standpoint. You know, any questions you have, i want to kind of leave you with an independent survey we did in the fall of 2017. We did jay group out of chicago did a survey with a thousand medicare recipients, as well as a thousand medicaid recipients, asking them how they would like to take care of their conditions, chronic conditions. They had a list of 10. We were hoping from the meal standpoint wed be in the upper half. Eating healthy was the number one way they wanted to handle their conditions. Some of the lower stuff, doesnt mean they wouldnt do it, but stuff like nurses, its over the phone. Prescription medication was low on both sides. So eating healthy was something they wanted to do. So weve seen through the social determinates of Health Initiatives over the last year or so, how important that is, not just to keep them out of the hospital, but to keep them with a healthy lifestyle. What i can tell from this proposal, it was a way to get them okay, heres a way to test eating healthy and then a way do it affordably on a longterm basis. Thats what we looked at. We have all the data, post discharge, chronic care, we participate in nih funded studies to show that piece. But its gotten big ferry the standpoint bigger from the standpoint of eating healthy. I understand concerns from that and welcome any questions you have about moms meal nourish cares and the meals itself. President breslin thank you. Any other Public Comment . There is a motion on the floor to approve the status quo. So for clarity, page 17 page 17, thank you. All those in favor . All those opposed . The motion passes unanimously for the status quo. May i make a comment . Yes, please. Number one, i dont like to increase premiums even if they can be budgeted, but and i would hope that we as a board are not saying were rejecting a component of what might be a Broader Program as were looking at revising and reviewing the whole plan landscape next month, that, yes, there are things we need to take into account in making planned Design Changes. And they may have these broader implications about social determinates of health, but it needs to be put into a context rather than just like a oneoff thing to reduce the impact or the premium. So its not that im necessarily against meals. And that kind of context. But it needs to be part of a broader approach, all right . Thats where im coming down on this. And i always defer to my colleague, dr. Follansbee and his logic and research. [laughter] president breslin thank you. Item number 15. 15. Review and approve Kaiser Permanente senior advantage medicare fully insured retiree rates and premium contributions for california. Presented by mike clark from aon. Mike clark, aon. Were going to present the kpsa fully retiree rates fort 2020 plan year. Page 2, outlines the recommendation that ill talk you through in this document. That we recommend adoption of the rate cards, display them as material that are based on the rate of 365. 76 per member per month. Which would be a 12. 2 increase from 2019. This does include provision for a new recommended transportation benefit rider that ill talk through shortly. So i know that our representative from Kaiser Permanente talked through the cms reconciliation process. This illustrates the transition of the 2019 rate, 325. 89 per member per month to the 365. 76 and all of the elements that play into that. I will note that of the increase, only 2 is underwriting trends. So underlying experience of the plan is increasing only at 2 rate, very favorable to national trends. The other elements of the increase are due to the reconciliation adjustments and the 2. 75 for the recommended transportation benefit rider. President breslin do we have data on how this transportation benefit was used in United Health care . Because that was added on last year, right . Well need to follow up with that information. If i recall off the top of my head, its i dont want to speak a number im not accurate about. Well follow up. Its only three months in. I think its been somewhere in the hundred number range, but well follow up with the exact number through the first three months. Agree, its a good benefit, just are people using it . It goes back to something that director yant said about publicizing these, somehow featuring them on the website or in communications with the Retiree Community could help to, if we want people to utilize these things, to help them to do that. I recognize its a short period of time, but we need to give operational thought about how we communicate to the membership. Its just a recommendation. Can i just add to that and say we have an all claims database. That lags often behind the real discharge, et cetera. But there are lots of opportunities for followup nutritional counseling, calling someone from our program saying did you take advantage of the meal Program Since you were discharged . Or have you taken advantage of our transportation . Because once a member finds out that he or she didnt take advantage of it, theyre more likely to take advantage of it the next time and also to say to their friends, gee, kaiser provides, or United Health care provide transportation. So we have a responsibility to make sure not only that were publicizing it ahead of time, but i cant remember what my dental benefit is unless someone tells me when i ask. So we have the of responsibility here. And hopefully, we have the staff. One of the tenants of the strategic plan, assuming our budget goes through as its currently written, there is a position in there for an engagement specialist to help us understand the segment of the population and match the benefits. We have a very Large Population that is diverse and needs to receive the message in a way that they can act on it. Hopefully that representative from the board who is not here today, will also understand that budget recommendation and advocate for us. Page 4, just includes information that i talked through. Page 5, rate increase history or decrease and now the increase. Particular note, page 5, the status quo, rate card information, page 16 and 17, with transportation rider added, pages 18 and 19. Page 6, i know our kaiser representative walked us through in more detail than page 6, but happy to entertain any questions on funding reconciliation before we move into evaluating the transportation rider, or if there happened to any remaining questions. Okay. And page 7, just a reminder that we include the v. S. P. Vision basic premiums in the rate cards. So page 9, talks about the transportation rider in further detail. So weve talked about how this benefit was added to the uhc ma ppo in 2019. And in 2020, making a similar rider available. Please do note the footnote that kaiser is working on implementation of this benefit now. Its targeted at this point for january 1, but with the recognition that the actual implementation may vary on any given month and if there are unforeseen challenges as part of this benefit development, and if that occurs there will be a mechanism for kind of future crediting of the premium paid for a service that may not be available, depending on the actual month of availability. But the transportation benefit rider would provide nonmedical transportation, so not ambulance, wheelchair, transport. But otherwise nonmedical transportation up to 24 oneway trips for routine and post discharge needs with a 50mile distance limit per trip. Can i ask a question at this point . I know that kaiser has fairly vigorous Home Care Program that people who are bed bound and require an ambulance or gurney can get home care. Im assuming United Health care has some similar Home Care Program that they oversee as well. You know, riding Public Transportation as i do, i dont consider wheelchair bound people as medical transportation. I consider that transportation to the citizens and others in the city and county of San Francisco. So i guess the question i have is really about this exclusion of wheelchairs. Since the city can provide this through their transportation, why are we allowing hour health plans not to provide wheelchair transportation . Kaiser has advised us that its due to vendor limitations. I dont know if a representative from kaiser may be available to be able to speak more thoroughly on that . Were looking to expand the benefit. Were trying to go live with it january 1. In collaboration with San Francisco hss to provide this benefit to their retirees. That is a piece of the benefit that well be looking at expanding. Were just not able to accommodate right now, because we dont have the types of vehicles that we would need to accommodate that. Are you actually excuse me through the chair, are you actually providing the transportation, or are you subcontracting it to someone else . Well be subcontracting it with the voen door. Vendor. There are Partnership Opportunities like San Francisco para transit and on and on. They do this stuff every day. Theyve got wheelchairs and walkers and all kinds of mechanisms to do this. Even uber and lyft. Yeah, so i will take thats great feedback. I will take that back as we build out this benefit. Right now were trying to make the benefit go live, were working within the limitations. I wouldnt say that this is the final product. Right now were bringing it to market specifically for San Francisco hss. I understand and appreciate that and thank you for the opportunity to partnership, but i think waiting a year to try to find a remedy for wheelchairs is a little long. And so i hope you can advance the schedule on that. Im not talking about impacting into our program, but in your planning model, seeing if you can look at an alternative vendor that might be readily available that does this type to have stuff. Okay, ill take it under advisement and share it with the team. I will second that. To exclude wheelchair postpone it, is really a disservice to certainly our members. And so sometimes wheelchairs are only necessary for a month or two after orthopedic procedures or whatever, but it is a disservice. If were paying for transport in our new rates, we need to make sure were paying for all of our members as best we can. Okay. President breslin do you know if United Health care covers wheelchairs . Okay thank you. Thank you for what youve done to date on this. United health care did say yes, just to add that on the record. On page 10, the additional premium to add the rider is 2. 75 pmpm. It is recommended this be added to coverage effective january 1, 2020, in support of those members with need of Transportation Services and to provide consistency to the plan enhancement. You can see what the rates are before transportation rider and with transportation rider on a per member per month basis on the bottom of page 10. So transitioning to page 12, like we did with the uhc ma ppo presentation, we have two sets of rate cards. A status quo rate cards incorporating the rate increase. Its recommended that the rider rate card. Pages 13 and 14, just a reminder of what the rate cards represent and the different employer contribution structures for the retiree plans. Page 15 is illustration of the member contributions, under each of these two scenarios. And so it allows you to see what the impact of adding the transportation rider does to retiree contributions in kpsa for those who are covering at least one dependent. Again, there are no member contributions for retiree medicare only, but there are member contributions for each of the tiers where at least one dependent is covered. So as an example, a retiree plus one, all medicare, the contribution differential, the member contribution differential on a monthly basis is approximately 1. 37 different. Page 16 shows the rate cards without the transportation rider, again the page 17, the comparison year over year of rates. With transportation rider, somewhere exhibits, pages 18 and 19. With that, on page 20, our recommendation is the Health Service board accept the kpsa rates presented today under the with transportation rider scenario that includes adoption of the new transportation benefit described in this presentation for kpsa in 2020. As part of this new as part of this new rate card. In other words i second the motion with the clarification that information be brought back to us at an early meeting. So that we kind of directionally know that its being worked on, these are the options or what have you. If its going do be operational day one, well know that as well, but im not willing to support this by delaying it a full year, as seemly was presented. So i think we can explain to our members its a new benefit, kaiser is working on it and its going to go live march 1, versus january 1, whatever. Thank you and you have anns commitment to work with kaiser to assure we bring frequent updates on this to hsb for the duration of 2019. Can i just add to commissioner scotts statement and support it, but i would like to hold us to, not prejudge what is an appropriate delay. Three months is okay, but six months is not. Six months is okay, but i think we need to hear this and well make a separate determination at that point what to do to make sure that our members on wheelchairs who have kaiser have access to this transportation benefit. But without the sort of waffling over how long is okay. At this point. Okay. Ill defer. So i think you should clarify that for the benefit of the record. And our secretary. So it is easier to take down. Restate the motion, please. Okay. I recommend that we accept the kpsa medicare retiree rates with the transportation rider to include transportation for all of our medicare members, including those in wheelchairs as of the january 1, 2020. Second. President breslin some of the other exclusions were like for ambulance or whatever, so we want to make sure were not talking about that either. I was not including my intent was not to include that because i think there are other options for transportation and care available. But wheelchairs are something that i think we all are not necessarily medical conditions that an ambulance or a gurney would indicate. All right. Public comment on this item. I have a second. Yes, i second it. President breslin Public Comment on this item . Seeing none. All those in favor. Opposed . There are none. Unanimous. In favor of the motion. By the way, my neighbor is using something for transportation, called gogo grandmas. And they actually use lyft and uber, this organization. But i like the term. [laughter] okay. Item number 16. Item 16, review and approve