Transcription

: IBMSummary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage Period: 01/01/2016 – 12/31/2016Coverage for: All Tiers Plan Type: DHMOThis is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plandocument at http://www.my.kp.org/ibm or by calling 1-888-865-5813.Important QuestionsWhat is the overalldeductible?AnswersWhy this Matters: 250 Individual / 500 FamilyDoes not apply to preventive care servicesYou 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 1st). See thechart starting on page 2 for how much you pay for covered services after youmeet the deductible.Are there other deductiblesNo.for specific 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–pocketlimit on my expenses?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 helps youplan for health care expenses.Yes. 2,000 Individual / 4,000 FamilyWhat is not included in the Premiums, balance-billed charges, and healthout–of–pocket limit?care this plan doesn't cover.Even though you pay these expenses, they don’t count toward the out-of-pocketlimit.Is there an overall annuallimit on what the 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.Yes. For a list of participating providers seehttp://www.my.kp.org/ibm or call 1-888865-5813If 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 doctoror hospital may use an out-of-network provider for some services. Plans usethe term in-network, preferred, or participating for providers in their network.See the chart starting on page 2 for how this plan pays different kinds ofproviders.Do I need a referral to seea specialist?Yes. Written approval is required to see mostspecialists. No referral needed for PlanProvidersThis plan will pay some or all of the costs to see a specialist for coveredservices but only if you have the plan’s permission before you see the specialist.Are there services this planYes.Some of the services this plan doesn’t cover are listed on page 5. See yourDoes this plan use anetwork of providers?Questions: Call Kaiser Permanente at 1-888-865-5813/TTY/TDD 711 or visit us at http://www.my.kp.org/ibmIf you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atwww.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-888-865-5813/TTY/TDD 711 to request a copy.1 of 8

doesn’t cover?policy or plan document for additional information about excluded services. 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, if theplan’s allowed amount for an overnight hospital stay is 1,000, your coinsurance payment of 20% would be 200. This may change if youhaven’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 the allowedamount, you may have to pay the difference. For example, if an out-of-network hospital charges 1,500 for an overnight stay and the allowedamount 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 EventIf you visit a healthcare provider’s officeor clinicIf you have a testIf you need drugs totreat your illness orconditionYour cost if you use aServices You MayNeedPlan ProviderNon PlanProviderLimitations & ExceptionsNot subject to overall deductible. If youreceive services in addition to an officevisit, additional copayments, deductibles,or coinsurance may apply.Not subject to overall deductible. If youreceive services in addition to an officevisit, additional copayments, deductibles,or coinsurance may apply.Not subject to overall deductible.Coverage limited to 30 visits forchiropractic services.Primary care visit totreat an injury orillness 20 per visitNot coveredSpecialist visit 30 per visitNot coveredOther practitioneroffice visit 20 per visitNot coveredNo chargeNot coveredNot subject to overall deductible.Not –––––––––Not –––––––––Not coveredCovers up to a 30 day supply (retail); 31-90day supply (mail order). NetworkPharmacies limited to one time fill. Nocharge for contraceptives (subject toformulary guidelines). Not subject tooverall gnostic test (x-ray,blood work)Imaging (CT/PETscans, MRIs)Generic drugsNo charge office visit;10% coinsurance outpatient setting10% coinsurance per procedure in office andoutpatient setting 10 per prescription(retail); 20 per prescription (network pharmacies); 20 per prescription (mail order)2 of 8

CommonMedical EventServices You MayNeedIf you need drugs totreat your illness orconditionPreferred brand drugsMore informationabout prescriptiondrug coverage isavailable at www.kp.org/formulary.If you haveoutpatient surgeryIf you needimmediate medicalattentionIf you have ahospital stayIf you have mentalhealth, behavioralhealth, or substanceabuse needsNon-preferred branddrugsSpecialty drugsFacility fee (e.g.,ambulatory surgerycenter)Physician/surgeonfeesYour cost if you use aPlan Provider 40 per prescription(retail); 50 per prescription (network pharmacies); 80 per prescription (mail order)Not coveredNot coveredNot covered 40 per prescription(retail); 50 per prescription (network pharmacies); 80 per prescription (mail order)Not covered10% coinsuranceNot covered10% coinsuranceNot coveredEmergency roomservices10% coinsuranceEmergency medicaltransportation10% coinsuranceUrgent care 40 per visitFacility fee (e.g.,hospital room)10% coinsurancePhysician/surgeon feeMental/Behavioralhealth outpatientservicesNon PlanProvider10% coinsurance 20 per visit (individual); 10 per visit (group)Limitations & ExceptionsCovers up to a 30 day supply (retail); 31-90day supply (mail order). NetworkPharmacies limited to one time fill. Notsubject to overall ––––––Not coveredNot subject to overall deductible. Nonparticipating provider urgent care coveredonly if you are temporarily outside of ourservice area. If you receive services inaddition to an office visit, additionalcopayments, deductibles, or coinsurancemay apply.Not –––––––––Not –––––––––Not coveredNot subject to overall deductible. If youreceive services in addition to an officevisit, additional copayments or deductiblemay apply.3 of 8

CommonMedical EventMental/Behavioralhealth inpatientservicesIf you have mentalhealth, behavioralhealth, or substanceabuse needsIf you are pregnantIf your child needsdental or eye carePlan ProviderLimitations & ––––––––––Substance use disorder 20 per visit (individual);outpatient services 20 per visit (group)Not coveredSubstance use disorder10% coinsuranceinpatient servicesNot subject to overall deductible. If youreceive services in addition to an officevisit, additional copayments or deductiblemay apply.Not –––––––––Prenatal and postnatalcareNo chargeNot coveredDelivery and allinpatient servicesNot subject to overall deductible. Afterconfirmation of pregnancy, for the normalseries of regularly scheduled routine visits10% coinsuranceNot –––––––––Not coveredNot subject to overall deductible.Coverage is limited to 120 visits per year.Private duty nursing not coveredNot coveredCoverage is limited to 20 outpatient visitsper year combined for Occupational andPhysical therapy. Speech therapy is limitedto 20 outpatient visits per yearRehabilitation services10% coinsuranceNon PlanProviderNot coveredHome health careIf you need helprecovering or haveother special healthneedsYour cost if you use aServices You MayNeedNo charge10% coinsuranceHabilitation services10% coinsuranceNot coveredSkilled nursing careDurable medicalequipmentHospice serviceEye examGlassesDental check-up10% coinsuranceNot covered10% coinsuranceNot coveredNo charge 30 per visit for refractive examNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredCoverage is limited to 20 outpatient visitsper year combined for Occupational andPhysical therapy. Speech therapy is limitedto 20 outpatient visits per yearCoverage is limited to 100 days per yearCoverage is unlimited to items on ourDME formularyNot subject to overall deductible.Not subject to overall deductible.No coverage for glassesNo dental coverage4 of 8

Excluded 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.) Acupuncture Hearing aids Private-duty nursing Bariatric surgery Long-term care Routine foot care Cosmetic surgery Weight loss programs Dental care (Adult)Non-emergency care when traveling outsidethe U.S.Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for theseservices.) Chiropractic care Infertility treatment Routine eye care (Adult)5 of 8

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 pay whilecovered under the plan. Other limitations on your rights to continue coverage may also apply.For more information on your rights to continue coverage, contact the plan at 1-888-865-5813. You may also contact your state insurance department, the U.S.Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and HumanServices at 1-877-267-2323 x61565 or www.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: Member Services at 1-888-865-5813, Monday through Friday, 7:00 AM to 7:00 PM. If you areenrolled through a plan that is subject to the Employee Retirement Income Security Act (ERISA), you may file a civil action under section 502(a) of the federalERISA statute. To understand these rights, you should check with your benefits office or contact the Employee Benefits Security Administration (part of the U.S.Department of Labor) at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file yourappeal. You may contact the State Department of Insurance at: Georgia Office of Insurance and Safety Fire Commissioner, Consumer Services Division,2 Martin Luther King, Jr. Drive, West Tower, Suite 716, Atlanta, Georgia 30334, 800-656-2298, http://www.oci.ga.gov/ConsumerService/. Alternatively, ifyour plan is not subject to ERISA (for example, most state or local government plans and church plans or all individual plans), you may have a right to requestreview in state court. You may contact the State Department of Insurance as shown above.Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coveragethat qualifies as "minimum essential coverage." This plan or policy does provide minimum essential coverage.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). This healthcoverage does meet the minimum value standard for the benefits it provides.Language Access Services:SPANISH: SPANISH (Español): Para obtener asistencia en Español, llame al 1-888-865-5813 or TTY/TDD 711TAGALOG:TAGALOG (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-888-865-5813 or TTY/TDD 711CHINESE: 若有問題:請撥打1-888-865-5813 或 TTY/TDD 711NAVAJO: NAVAJO (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-888-865-5813 or TTY/TDD ––––––To see examples of how this plan might cover costs for a sample medical situation, see the next –––––––6 of 8

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 isnot a costestimator.Don’t use these examples toestimate your actual costsunder this plan. The actualcare you receive will bedifferent from theseexamples, and the cost ofthat care will also bedifferent.See the next page forimportant information aboutthese examples.Managing type 2 diabetesHaving a baby(normal delivery) Amount owed to providers: 7,540 Plan pays 6,620 Patient pays 920Sample care costs:Hospital charges (mother)Routine obstetric careHospital charges (baby)AnesthesiaLaboratory testsPrescriptionsRadiologyVaccines, other preventiveTotalPatient pays:DeductiblesCopaysCoinsurance after deductibleLimits or exclusionsTotal 2,700 2,100 900 900 500 200 200 40 7,540 300 20 400 200 920(routine maintenance ofa well-controlled condition) Amount owed to providers: 5,400 Plan pays 4,420 Patient pays 980Sample care costs:PrescriptionsMedical Equipment and SuppliesOffice Visits and ProceduresEducationLaboratory testsVaccines, other preventiveTotalPatient pays:DeductiblesCopaysCoinsurance after deductibleLimits or exclusionsTotal 2,900 1,300 700 300 100 100 5,400 0 900 0 80 980Total amounts above are based on subscriber only coverage7 of 8

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 health plan.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 the example.The patient received all care from innetwork providers. If the patient hadreceived care from out-of-networkproviders, costs would have been higher.What does a Coverage Exampleshow?Can I use Coverage Examplesto compare plans?For each treatment situation, the CoverageExample helps you see how deductibles,copayments, and coinsurance can add up. Italso helps you see what expenses might be leftup to you to pay because the service ortreatment isn’t covered or payment is limited. Yes. When you look at the Summary ofDoes the Coverage Examplepredict my own care needs? No. Treatments shown are just examples.The care you would receive for thiscondition could be different based on yourdoctor’s advice, your age, how serious yourcondition is, and many other factors.Does the Coverage Examplepredict my future expenses? No. Coverage Examples are not costestimators. You can’t use the examples toestimate costs for an actual condition. Theyare for comparative purposes only. Yourown costs will be different depending onthe care you receive, the prices yourproviders charge, and the reimbursementyour health plan allows.Benefits and Coverage for other plans,you’ll find the same Coverage Examples.When you compare plans, check the“Patient Pays” box in each example. Thesmaller that number, the more coveragethe plan provides.Are there other costs I shouldconsider when comparingplans? Yes. An important cost is the premiumyou pay. Generally, the lower yourpremium, the more you’ll pay in out-ofpocket costs, such as copayments,deductibles, and coinsurance. Youshould also consider contributions toaccounts such as health savings accounts(HSAs), flexible spending arrangements(FSAs) or health reimbursement accounts(HRAs) that help you pay out-of-pocketexpenses.Questions: Call Kaiser Permanente at 1-888-865-5813/TTY/TDD 711 or visit us at http://www.my.kp.org/ibmIf you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atwww.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-888-865-5813/TTY/TDD 711 to request a copy.8 of 8