Kaiser Permanente: DEDUCTIBLE PLAN WITH HRA
Kaiser Permanente: DEDUCTIBLE PLAN WITH HRASummary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage Period: 01/01/2017-12/31/2017Coverage for: Individual Family Plan Type: DHMOKaiser Permanente: DEDUCTIBLE PLAN WITH HRAonly a summary. If you want more detail about your coverage and w.kp.org/plandocumentsorandby callingSummarydocumentof BenefitsatandCoverage: What this plan coverswhat it 1-800-278-3296.costs.Coverage for: Individual FamilyPlantype: DHMOImportantQuestions AnswersWhy this Matters:What is the overalldeductible? 3,000 Individual/ 6,000 Family (See chartstarting on page 2 for when deductible iswaived.)you can get the complete terms in the policy or planYou must pay all the costs up to the deductible amount before this plan beginsto pay for covered services you use. Check your policy or plan document to seewhen the deductible starts over (usually, but not always, January 1). TheCommon Medical Events chart below shows how much you pay for coveredservices after you meet the deductible.Are there otherdeductibles for specific No.services?You don’t have to meet deductibles for specific services, but see the chartstarting on page 2 for other costs for services this plan covers.Is there an out–of–pocket limit on myexpenses?The out-of-pocket limit is the most you could pay during a coverage period(usually one year) for your share of the cost of covered services. This limit helpsyou plan for health care expenses.Yes. 6,000 Individual/ 12,000 FamilyWhat is not included in Premiums, health care this plan doesn'tthe out–of–pocketcover, and cost sharing for certain serviceslimit?listed in plan documents.Even though you pay these expenses, they don't count toward the out-of-pocketlimit.Is there an overallannual limit on whatthe plan pays?No.The chart starting on page 2 describes any limits on what the plan will pay forspecific covered services, such as office visits.Does this plan use anetwork of providers?Yes. For a list of plan providers, seewww.kp.org or call 1-800-278-3296.If you use an in-network doctor or other health care provider, this plan will paysome or all of the costs of covered services. Be aware, your in-network doctor orhospital may use an out-of-network provider for some services. Plans use theterm in-network, preferred, or participating for providers in their network. Seethe chart starting on page 2 for how this plan pays different kinds ofproviders.Do I need a referral tosee a specialist?Yes, but you may self-refer to certainspecialists.This plan will pay some or all of the costs to see a specialist for covered servicesbut only if you have the plan’s permission before you see the specialist.Are there services thisplan doesn’t cover?Yes.Some of the services this plan doesn’t cover are listed on page 5. See yourpolicy or plan document for additional information about excluded services.Questions: Call 1-800-278-3296 or 711 (TTY), or visit us at www.kp.org.PID:35335If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view theGlossary at www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-800-278-3296 or 711 (TTY) to request a copy.BOARD OF PENSIONSCNTR:1 EU:N/A Plan ID:7823 SBC ID:2696121 of 10
Copayments are fixed dollar amounts (for example, 15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, ifthe plan’s allowed amount for an overnight hospital stay is 1,000, your coinsurance payment of 20% would be 200. This may change ifyou haven’t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than theallowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges 1,500 for an overnight stay andthe allowed amount is 1,000, you may have to pay the 500 difference. (This is called balance billing.) This plan may encourage you to use plan providers by charging you lower deductibles, copayments and coinsurance amounts.CommonMedical EventServices YouYour cost if you use aMay NeedPlan ProviderPrimary care visit totreat an injury or30% coinsurance per visitillnessLimitations & ExceptionsNot CoveredAfter deductible.30% coinsurance per visitNot CoveredAfter deductible. Services related to infertilitycovered at 50% coinsurance per visit.30% coinsurance per visit foracupuncture services.Not CoveredAfter deductible. Chiropractic care not covered.Physician referred acupuncture.Preventive care/screening/immunizationNo ChargeNot CoveredDeductible waived. Some preventive screenings(such as lab and imaging) may be at a differentcost share.Diagnostic test (xray, blood work)X-Ray: 30% coinsurance perencounter; Lab tests: 30%coinsurance per encounterNot CoveredAfter deductible.Imaging (CT/PETscans, MRI's)30% coinsurance perprocedureNot CoveredAfter deductible.If you visit a health Specialist visitcare provider’sOther practitioneroffice or clinicoffice visitIf you have a testYour cost if you use aNon-Plan Provider2 of 10
CommonMedical EventIf you need drugsto treat your illnessor conditionServices YouMay NeedGeneric drugsYour cost if you use aPlan Provider30% coinsurance perprescription up to 50maximum for 1 to 100 daysYour cost if you use aNon-Plan ProviderLimitations & ExceptionsNot CoveredOverall deductible waived. In accordance withformulary guidelines. Certain drugs may becovered at a different cost share.Preferred branddrugs30% coinsurance perprescription up to 100maximum for 1 to 100 daysNot CoveredOverall deductible waived. In accordance withformulary guidelines. Certain drugs may becovered at a different cost share.Non-preferredbrand drugsSame as preferred brand drugs Not CoveredSame as preferred brand drugs when approvedthrough exception process.Specialty drugs30% coinsurance perprescription up to 150maximum for 1 to 30 daysNot CoveredOverall deductible waived. In accordance withformulary guidelines. Certain drugs may becovered at a different cost share.Facility fee (e.g.,coinsurance perambulatory surgery 30%procedurecenter)Not CoveredAfter deductible.Physician/surgeonfees30% coinsurance perprocedureNot CoveredAfter deductible.Emergency roomservices30% coinsurance per visit30% coinsurance per visitAfter deductible.If you needmedical 30% coinsurance per tripimmediate medical Emergencytransportationattention30% coinsurance per tripAfter deductible.More informationabout prescriptiondrug coverage isavailable atwww.kp.org/formulary .If you haveoutpatient surgeryIf you have ahospital stayUrgent care30% coinsurance per visit30% coinsurance per visitAfter deductible. Non-Plan providers coveredwhen outside the service area.Facility fee (e.g.,hospital room)30% coinsurance peradmissionNot CoveredAfter deductible.Physician/surgeonfee30% coinsurance peradmissionNot CoveredAfter deductible.3 of 10
CommonMedical EventServices YouMay NeedMental/Behavioralhealth outpatientservicesYour cost if you use aNon-Plan ProviderLimitations & ExceptionsNot CoveredIndividual and group visits: After deductible;Other outpatient services: After deductible.30% coinsurance peradmissionNot CoveredAfter deductible.30% coinsurance perindividual visit; 30%coinsurance per group visit.30% coinsurance per day forother outpatient servicesNot CoveredIndividual and group visits: After deductible;Other outpatient services: After deductible.Substance usedisorder inpatientservices30% coinsurance peradmissionNot CoveredAfter deductible.Prenatal andpostnatal carePrenatal care: No Charge;Postnatal care: No ChargePrenatal care: Not covered;Postnatal care: Not coveredPrenatal care: Deductible waived. Cost sharingis for routine preventive care only; Postnatalcare: Deductible waived. Cost sharing is for thefirst postnatal visit only.Delivery and allinpatient services30% coinsurance peradmissionNot CoveredAfter deductible.Mental/BehavioralIf you have mental health inpatienthealth, behavioral serviceshealth, orsubstance abuseSubstance useneedsdisorder outpatientservicesIf you are pregnantYour cost if you use aPlan Provider30% coinsurance perindividual visit; 30%coinsurance per group visit.30% coinsurance per day forother outpatient services4 of 10
CommonMedical EventServices YouMay NeedYour cost if you use aPlan ProviderYour cost if you use aNon-Plan ProviderLimitations & ExceptionsHome health careNo ChargeNot CoveredDeductible waived. Up to 2 hours maximumper visit, up to 3 visits maximum per day, up to100 visits maximum per year.RehabilitationservicesInpatient: 30% coinsuranceper admission; Outpatient:30% coinsurance per visitNot CoveredAfter deductible.Not CoveredAfter deductible.Not CoveredAfter deductible. Up to 100 days maximum perbenefit period.HabilitationIf you need help30% coinsurance per visitrecovering or have servicesother specialcoinsurance perSkilled nursing care 30%health needsadmissionDurable medicalequipment30% coinsurance per itemNot CoveredDeductible waived. Must be in accordance withformulary guidelines. Requires priorauthorization.Hospice serviceNo ChargeNot CoveredDeductible waived. Limited to diagnoses of aterminal illness with a life expectancy of twelvemonths or less.Eye examNo ChargeNot CoveredDeductible waived.Not CoveredNot –––––––––Not CoveredNot CoveredYou may have other dental coverage notdescribed here.If your child needs Glassesdental or eye careDental check-upExcluded Services & Other Covered Services:Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.) Chiropractic care Cosmetic surgery Dental care (Adult) Hearing aids Long-term care Non-emergency care when travelingoutside the U.S. Private-duty nursing Routine foot care unless medicallynecessary Weight loss programs5 of 10
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for theseservices.) Acupuncture (plan provider referred) Bariatric surgery Infertility treatment Routine eye care (Adult)Your Rights to Continue Coverage:If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep healthcoverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you paywhile covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continuecoverage, contact the plan at 1-800-278-3296. You may also contact your state insurance department; the U.S. Department of Labor, Employee BenefitsSecurity Administration, at 1-866-444-3272 or www.dol.gov/ebsa; or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 orwww.cciio.cms.gov .Your Grievance and Appeals Rights:If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questionsabout your rights, this notice, or assistance, you can contact: Kaiser Permanente at 1-800-278-3296 or online at www.kp.org/memberservices.If this coverage is subject to ERISA, you may contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) orwww.dol.gov/ebsa/heatlhreform, and the California Department of Insurance at 1-800-927-HELP (4357) or www.insurance.ca.gov.If this coverage is not subject to ERISA, you may also contact the California Department of Insurance at 1-800-927-HELP (4357) or www.insurance.ca.gov.Additionally, this consumer assistance program can help you file your appeal:Department of Managed Health Care Help Center1-888-466-2219980 9th Street, Suite 500www.healthhelp.ca.govSacramento, CA 95814helpline@dmhc.ca.govDoes this Coverage Provide Minimum Essential Coverage?The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy doesprovide minimum essential coverage.6 of 10
Does this Coverage Meet the Minimum Value Standard?The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). Thishealth coverage does meet the minimum value standard for the benefits it provides.Language Access Services:SPANISH (Español): Para obtener asistencia en Español, llame al 1-800-788-0616 or TTY/TDD 711TAGALOG (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-278-3296 or TTY/TDD 711CHINESE (中文): � 1-800-757-7585 or TTY/TDD 711NAVAJO (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-278-3296 or TTY/TDD �––––––To see examples of how this plan might cover costs for a sample medical situation, see the next –––––––7 of 10
About these CoverageExamples:These examples show how this plan might covermedical care in given situations. Use theseexamples to see, in general, how much financialprotection a sample patient might get if they arecovered under different plans.This is not acostestimator.Don’t use these examples toestimate your actual costsunder this plan. The actual careyou receive will be differentfrom these examples, and thecost of that care will also bedifferent.See the next page forimportant information aboutthese examples.Having a babyManaging type 2 diabetes(normal delivery)(routine maintenance of a well-controlledcondition)Amount owed to providers: 7,540Plan pays 3,040Patient pays 4,500Amount owed to providers: 5,400Plan pays 3,120Patient pays 2,280Sample care costs:Hospital charges (mother)Routine obstetric careHospital charges (baby)AnesthesiaLaboratory testsPrescriptionsRadiologyVaccines, other preventiveTotal 2,700 2,100 900 900 500 200 200 40 7,540Patient Pays:DeductiblesCopaysCoinsuranceLimits or exclusionsTotal 3,000 0 1,300 200 4,500Sample care costs:PrescriptionsMedical Equipment and SuppliesOffice Visits and ProceduresEducationLaboratory testsVaccines, other preventiveTotal 2,900 1,300 700 300 100 100 5,400Patient Pays:DeductiblesCopaysCoinsuranceLimits or exclusionsTotal 1,000 0 1,200 80 2,2808 of 10
Questions and answers about the Coverage Examples:What are some of theassumptions behind theCoverage Examples? Costs don’t include premiums. Sample care costs are based on nationalaverages supplied by the U.S.Department of Health and HumanServices, and aren’t specific to aparticular geographic area or healthplan. The patient’s condition was not anexcluded or preexisting condition. All services and treatments started andended in the same coverage period. There are no other medical expenses forany member covered under this plan. Out-of-pocket expenses are based onlyon treating the condition in theexample. The patient received all care from innetwork providers. If the patient hadreceived care from out-of-networkproviders, costs would have beenhigher.What does a Coverage Exampleshow?For each treatment situation, the CoverageExample helps you see how deductibles,copayments, and coinsurance can add up. It alsohelps you see what expenses might be left up toyou to pay because the service or treatment isn’tcovered or payment is limited.Does the Coverage Examplepredict my own care needs?No. Treatments shown are just examples.The care you would receive for this conditioncould be different based on your doctor’sadvice, your age, how serious your conditionis, and many other factors.Does the Coverage Examplepredict my future expenses?No. Coverage Examples are not costCan I use Coverage Examples tocompare plans?Yes. When you look at the Summary ofBenefits and Coverage for other plans, you’llfind the same Coverage Examples. When youcompare plans, check the “Patient Pays” boxin each example. The smaller that number,the more coverage the plan provides.Are there other costs I shouldconsider when comparing plans?Yes. An important cost is the premium youpay. Generally, the lower your premium, themore you’ll pay in out-of-pocket costs, suchas copayments, deductibles, andcoinsurance. You should also considercontributions to accounts such as healthsavings accounts (HSAs), flexible spendingarrangements (FSAs) or healthreimbursement accounts (HRAs) that helpyou pay out-of-pocket expenses.estimators. You can’t use the examples toestimate costs for an actual condition. Theyare for comparative purposes only. Your owncosts will be different depending on the careyou receive, the prices your providers charge,and the reimbursement your health planallows.Questions: Call 1-800-278-3296 or, 711 (TTY), visit us at www.kp.org.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the GlossaryPENSIONSa copy.at www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf, or call 1-800-278-3296 or 711BOARD(TTY) OFto requestQuestions: Call 1-800-278-3296 or 711 (TTY), or visit us at www.kp.org.BOARDPENSIONSPID:35335 CNTR:1 EU:N/A Plan ID:7823 SBCOFID:269612If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view thePID:353359 of 10Glossary at www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-800-278-3296 or 711 (TTY) to request a copy.CNTR:1EU:N/APlan ID:7823SBC ID:269612
This page is intentionally left blank.
Kaiser Permanente does not discriminate on the basis of age, race, ethnicity, color, national origin, cultural background, ancestry, religion, sex, genderidentity, gender expression, sexual orientation, marital status, physical or mental disability, source of payment, genetic information, citizenship, primarylanguage, or immigration status.Language assistance services are available from our Member Services Contact Center 24 hours a day, seven days a week (except closed holidays).Interpreter services, including sign language, are available at no cost to you during all hours of operation. We can also provide you, your family, and friendswith any special assistance needed to access our facilities and services. In addition, you may request health plan materials translated in your language, andmay also request these materials in large text or in other formats to accommodate your needs. For more information, call 1-800-464-4000 (TTY users call711).A grievance is any expression of dissatisfaction expressed by you or your authorized representative through the grievance process. A grievance includes acomplaint or an appeal. For example, if you believe that we have discriminated against you, you can file a grievance. Please refer to your Evidence ofCoverage or Certificate of Insurance, or speak with a Member Services representative for the disputeresolution options that apply to you. This is especiallyimportant if you are a Medicare, MediCal, MRMIP, MediCal Access, FEHBP, or CalPERS member because you have different disputeresolution optionsavailable.You may submit a grievance in the following ways: By completing a Complaint or Benefit Claim/Request form at a Member Services office located at a Plan Facility (please refer to Your Guidebook foraddresses) By mailing your written grievance to a Member Services office at a Plan Facility (please refer to Your Guidebook for addresses) By calling our Member Service Contact Center toll free at 1-800-464-4000 (TTY users call 711) By completing the grievance form on our website at kp.orgPlease call our Member Service Contact Center if you need help submitting a grievance.The Kaiser Permanente Civil Rights Coordinator will be notified of all grievances related to discrimination on the basis of race, color, national origin, sex, age,or disability. You may also contact the Kaiser Permanente Civil Rights Coordinator directly at One Kaiser Plaza, 12th Floor, Suite 1223, Oakland, CA 94612.You ca
After deductible. Chiropractic care not covered. Physician referred acupuncture. Preventive care/ screening/ immunization No Charge Not Covered Deductible waived. Some preventive screenings (such as lab and imaging) may be at a different cost share. If you have a test Diagnostic test (x-ray,
KAISER PERMANENTE PROGRAMS AND SERVICES Kaiser Permanente has many resources to help you increase your physical activity. Healthy Living Helpline g For help increasing your physical activity, call us toll free at 1-866-402-4320. This service is available to Kaiser Permanente members only. The Kaiser Permanente Web site at kp.org:
Kaiser Permanente Medicare health plan provides services covered by Medicare (including Medicare Part D prescription drug coverage). . In Virginia, Kaiser Permanente is a Cost plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal. Benefits, premiums and/or copayments/coinsurance may change on January 1 .
Kaiser Permanente Vallejo/Vacaville Anthony Cook, MSN, CRNA Kaiser Permanente Oakland/Richmond East Bay Region Flo Braun, MSNA, CRNA Kaweah Delta Memorial Hospital Kevin Rhoden, MSN, CRNA Kaiser Permanente Fresno Scott Johnson, MS, CRNA Saint Helena Hospital Jaci Cho, MSN, CRNA Ray Cabagbag, MSN, CRNA Kaiser Permanente San
Kaiser Permanente LLNL-PRES-xxxxxx 8 High Deductible Health Plan (HDHP) Must live in plan's service area - Californiaonly-No out-of-network coverage (except emergency) Deductible- 1,500individual- 3,000family - must meet cumulative family deductible-After deductible you pay10% Pharmacy-Until deductible is met you pay 100% of drug cost-
May 20, 2020 · Medical Plan 1 Kaiser Permanente Network. Medical Plan 2 Kaiser Permanente Network. v2 5/20/2020. applicable. NA - Not 1 Deductible waived. 2 Individual deductible and out-of-pocket maximum apply to single coverage only. Family deductible and out-of-pocket maximum ap
within a Kaiser Permanente facility. 3.0 Scope/Coverage 3.1 This policy applies to all Progr am Participants who arepar ticipating in unpaidfield experience and training in any of the following entities: 3.1.1 Kaiser Foundation Health Plan, Inc. (KFHP) and Kaiser Foundation Hospitals (KFH); 3.1.2 Southern California Permanente Medical Group .
Kaiser Permanente is an integrated health care delivery system comprised of Kaiser Foundation . state-of-the-art care delivery, and world-class chronic disease management. Kaiser Permanente is dedicated to care innovations, clinical research, health education, and the support of . Obesity, HEAL, Diabetes 5. Maternal and Infant Health 6 .
Kaiser Foundation Hospital-Panorama City/Antelope Valley Southern California Region 2 I. Introduction and Background A. About Kaiser Permanente Founded in 1942 to serve employees of Kaiser Industries and opened to the public in 1945, Kaiser Permanente is recognized as one of America’s leading health care providers and nonprofit health plans.
