Los Rios Community College District KAISER PERMANENTE

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1 Los Rios Community College District KAISER PERMANENTE GROUP # : Early Retiree DHMO Plan (under age 65 or over 65 w/o Medicare A & B) Senior Advantage (age 65+ with Medicare A & B) In order to continue with one of the Los Rios Kaiser plans at the time of retirement, you must reside within the Kaiser Service area. Service area is determined by your zip code. To determine if your zip code is in a covered service area, contact Kaiser s member services department at When you join the Los Rios sponsored plan you are enrolled in Northern California Kaiser. When visiting Southern California, you can receive care as a visiting member. If you reside in Southern California you may do an interregional transfer and remain in the Los Rios group plan. Kaiser coverage for retirees residing outside the state of California, in another state in which Kaiser is an option, requires disenrollment from the Los Rios sponsored plan and enrollment in the state in which the retiree resides. The Kaiser plan would no longer be a Los Rios group plan, therefore premiums and coverage may differ from the Los Rios group plan. The retiree is still entitled to the District contribution provided proof of premium amount is submitted. If you have a medical emergency you may go to the nearest hospital and Kaiser will cover emergency care anywhere in the world. Once your condition is deemed stable by the physician, post stabilization care from a non-plan provider requires prior authorization. If you are outside your service area and have an urgent care need due to an unforeseen illness or injury, Kaiser will cover medically necessary services to prevent serious deterioration of your health.

2 EARLY RETIREE DHMO PLAN: The Kaiser Deductible HMO (DHMO) Plan is for retirees and/or dependents of the retiree under age 65 or those over the age of 65 who do not have Medicare A and B. With a DHMO plan office visits, lab tests, radiology services and prescriptions are covered by a co-payment or co-insurance. Hospital related care requires you meet an annual deductible before the services are covered by a co-payment or co-insurance. Annual deductibles are based on a calendar year. Also, with the DHMO plan there is a limit on your annual out of pocket expenses. Once that maximum has been met, Kaiser will pay the full cost of most covered services for the remainder of the calendar year. Refer to the Benefit Summary below for a detailed list of co-payment and deductible information. S UNDER 65 RETIREE $1, ($1, $256) = $ DEPENDENT $1, $1, RETIREE & DEPENDENT $1, OVER 65 W/O A & B RETIREE $1, ($1, $256) = $1, DEPENDENT $1, $1, RETIREE & DEPENDENT $2, BENEFIT SUMMARY ANNUAL OUT-OF-POCKET MAXIMUM FOR CERTAIN SERVICES For any one member in a family of two or more members For an entire family of two or more members $6,000 per calendar year

3 DEDUCTIBLE FOR CERTAIN SERVICES AS SPECIFIED For any one member in a family of two For an entire family of more than two members $500 per calendar year $500 per calendar year $1,000 per calendar year SERVICES Physical Exams Eye Exams for Refraction Hearing Tests Primary and Specialty Care Visits Urgent Care Visits Physical Therapy Allergy Testing Visits Allergy Injection Visits X-rays & Lab Tests MRI, CT & PET Ambulance Service Outpatient Surgery Hospitalization Home Health Care (100 visits/calendar yr) Skilled Nursing Facility Care (100 days/benefit period) Hospice Care $10 per encounter (Deductible doesn t apply) $50 per procedure (Deductible doesn t apply) $150 per trip (Deductible doesn t apply) 10% Coinsurance after Deductible 10% Coinsurance after Deductible 10% Coinsurance (Deductible doesn t apply) Prescription Drug Coverage $10 for up to a 30 day supply, $20 for a day supply, or $30 for a day supply $10 for up to a 30 day supply, or $20 for a day supply, $30 for up to a 30 day supply, $60 for a day supply, or $90 for a day supply $30 for up to a 30 day supply, or $60 for a day supply Deductible doesn t apply to prescriptions. Generic items from a Plan Pharmacy Generic refills from Kaiser s mail order service Brand name items from a Plan Pharmacy Brand name refills from Kaiser s mail order service

4 SENIOR ADVANTAGE WITH PART D: Senior Advantage requires enrollment in Medicare A and B. Just prior to turning 65, you may begin receiving information regarding Senior Advantage. Unless the information comes from Los Rios or has the group number then the information you receive is not for the Los Rios group plan. Completing the application and returning it directly to Kaiser may result in your coverage being removed from the Los Rios group plan and placed in an individual plan. Individual Senior Advantage plans may have different premiums as well as different coverage. You may elect an Individual Senior Advantage plan by cancelling your group coverage with Los Rios; however you will not be able to enroll in the Los Rios group plan at a later date. Retirees are still eligible for the District contribution upon providing proof of the premium. The Los Rios group Senior Advantage plan does have Medicare D (prescription drug coverage) associated with the plan, so it is not necessary to enroll in a separate supplemental Part D plan. You may not be enrolled in two Medicare health plans at the same time. The Centers for Medicare and Medicaid Services (CMS) does monitor enrollment. If you have more than one Medicare plan CMS will automatically disenroll you from one of the plans. S SENIOR ADVANTAGE RETIREE $ ($ $256) = $ DEPENDENT $ $ RETIREE & DEPENDENT $ The Los Rios group Senior Advantage Plan does not have any deductibles or lifetime maximum coverage amounts.

5 BENEFIT SUMMARY ANNUAL OUT-OF-POCKET MAXIMUM FOR CERTAIN SERVICES For any one member in a family of two or more members For an entire family of two or more members $1,500 per calendar year $1,500 per calendar year SERVICES Physical Exams Eye Exams for Refraction & Glaucoma Screening Hearing Tests Primary and Specialty Care Visits Urgent Care Visits Physical Therapy Allergy Testing Visits Allergy Injection Visits X-rays & Lab Tests Ambulance Service Outpatient Surgery Hospitalization Home Health Care (part-time, intermittent) Skilled Nursing Facility Care (100 days/benefit period) Eyewear purchased from plan optical sales office every 24 months $50 per trip $500 per admission $150 allowance Back to Retiree Health Plans Benefits Homepage