KAISER FOUNDATION HEALTH PLAN INC.

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KAISER PERMANENTE.; Date: 12/20/2021 Mobile Health Vehicle Services for CalPERS — City of Santa Ana Group wishes to engage Kaiser Foundation Health Plan, Inc. ("KP") to arrange for the Kaiser Permanente Mobile Health Vehicle (MHV) to provide the services described below at Group's worksite (the "Services"), and KP wishes to provide such Services: (check only one that is applicable) ®Biometric Screenings ❑Community Event ❑Limited Screenings ❑Primary Care services to members of KP ❑Care Gap Closure to members of KP fully -insured health plans TERMS & CONDITIONS FOR KAISER PERMANENTE WORKSITE SERVICES FEES: Biometric Screenings (blood pressure, BMI, glucose and cholesterol) Biometric screenings are charged at $39 per participant for both KP members and non- members. Kaiser Permanente will be covering the cost in full. Limited Screenings (blood pressure. BMI and glucose) • Limited screenings are at no cost to the employer. No fees apply. Care Gap Closures to members of KP • Care Gap Closures are at no cost to the employer. Standard member copayments may apply if a non -preventive service is delivered on the mobile health vehicle. Primary Care to members of KP fully -insured health plans ■ Primary Care services are at no cost to the employer. Standard member copayments and deductibles apply and will be collected either at the time of service or via mailed invoice. PARTICIPATION GUIDELINES: Biometric Screenings ■ Minimum 6 participants per hour and at least 32 participants in total for biometric screenings, or $1,120 will be assessed. Limited Screenings • Minimum of 6 participants per hour for limited screenings. Care Gap Closures • Minimum 2 participants per hour for Care Gap services. Service includes a review of the member's medical record to check if the member is up to date with recommended care, to close any gaps in care and to provide limited biometric screenings. Primary Care • Minimum 2 participants per hour for primary care services. (LOA07032019)