Individual and Family Plans Georgia Kaiser Permanente Plan Highlights

Transcription

1 Individual and Family Plans Georgia 2016 Kaiser Permanente Plan Highlights

2 Important deadlines There s a deadline to apply for health care coverage, whether you apply during open enrollment or during a special enrollment period. Get started today This booklet will show you how to find a new plan that best fits your needs. Important deadlines... 2 Health plan benefit highlights... 3 Working out your rate... 8 Enrolling in a Kaiser Permanente plan on the Marketplace...10 Enrolling during the 2016 open enrollment period You may change or apply for 2016 coverage during the open enrollment period, which runs from November 1, 2015, through January 31, You can do so either through the Health Insurance Marketplace or through Kaiser Permanente. To start coverage on: Send your completed application and premium by: January 1, 2016 December 15, 2015 February 1, 2016 January 15, 2016 March 1, 2016 January 31, 2016 Enrolling during a special enrollment period Outside of open enrollment, you may enroll or change your coverage if you experience what s known as a triggering event. Examples of triggering events include getting married, having a baby, and losing coverage because you lost your job. From the date of your triggering event, the special enrollment period generally lasts 60 days. That means you have 60 days to change or apply for coverage for you and/or your dependents. If you know you are going to have a triggering event, you may be able to apply for new coverage ahead of time. For more information, please refer to the Enrolling During a Special Enrollment Period guide. If you didn t receive this guide, you can find it at buykp.org/apply, or you may call to request a copy. 31 To enroll during this open enrollment period, you must make sure we receive your completed Application for Health Coverage along with your first month s premium no later than January 31, Georgia

3 Health plan benefit highlights The charts on the next few pages show you a sample of each plan s benefits. Review the diagram below to help you understand how to read those charts. Here s a quick look at how to use the chart 2500/30 Plan type Deductible Features Annual medical $2,500/$5,000 Annual out-of-pocket maximum $6,850/$13,700 Benefits Preventive care Routine physical exam, mammograms, etc. No charge Outpatient services (per visit or procedure) Primary care office visit $30 Specialty care office visit $60 Office visit: 30% after Most X-rays First $300 of office visit charges at Most lab tests 30% after. Outpatient Hospital covered at 50% after. Office visit: $300 MRI, CT, PET Outpatient Hospital: $500 Outpatient surgery 30% after Mental health visit $60 Inpatient hospital care Room and board, surgery, anesthesia, X-rays, 30% after lab tests, medications, mental health care Maternity Routine prenatal care visit, 30% after first postpartum visit Delivery and inpatient well-baby care 30% after Emergency and urgent care Emergency Department visit 30% after Urgent care visit $100 Ambulance services 30% after Prescription drugs (up to a 30-day supply) Generic Preventive generic: $5* Preferred generic: $15* Preferred brand $45 1 after $500/$1,000 Non-preferred brand 50% after $500/$1,000 Specialty 50% after $500/$1,000 KP * Mail order: 90-day supply of qualified prescriptions for the cost of a 60-day supply M KP M Offered through Kaiser Permanente Offered through the Health Insurance Marketplace Annual You need to pay this amount before your plan starts helping you pay for most covered services. Under this sample plan, you d pay the full charges for covered services until you reach $2,500 for yourself or $5,000 for your family. Then you d start paying copays or coinsurance. Annual out-of-pocket maximum This is the most you ll pay for care during the calendar year before your plan starts paying 100% for most covered services. In this example, you d never pay more than $6,850 for yourself and no more than $13,700 for your family for your copays, coinsurance, and in a calendar year. Preventive care at no charge Most preventive care services including routine physical exams and mammograms are covered at no charge. Plus, they re not subject to the. Covered before you reach the With some services, you ll only pay a copay or coinsurance, regardless of whether you ve reached your. Under this plan, primary care visits are covered at a $30 copay even before you meet your. With our Silver plans, primary care, specialty care, and urgent care visits all are covered before you reach the. Coinsurance After reaching your, this is a percentage of the charges that you may pay for covered services. Here, you d pay 30% of the cost per day for your inpatient hospital care after you reach your. Your plan would pay the rest for the remainder of the calendar year. Copay This is the set amount you pay for covered services, usually after you reach your. In this example, you d start paying a $100 copay for urgent care visits, whether or not you have met your Georgia 2016

4 KP Offered through Kaiser Permanente M Offered through the Health Insurance Marketplace KP GA Bronze 6000/40%/HSA Financial assistance options with lower copays, coinsurance, and s are available for certain plans, and for Native Alaskans and American Indians on healthcare.gov. KP M KP M KP M KP M KP GA Bronze 5000/50 KP GA Bronze 4000/ /20%/HSA Plan type HSA-qualified Deductible Deductible HSA-qualified Features Annual medical Annual out-of-pocket maximum Benefits Preventive care $6,000/$12,000 $5,000/$10,000 $4,000/$8,000 $2,750/$5,500 $6,450/$12,900 $6,850/$13,700 $6,850/$13,700 $5,000/$10,000 Routine physical exam, mammograms, etc. No charge No charge No charge No charge Outpatient services (per visit or procedure) Primary care office visit Specialty care office visit Most X-rays Most lab tests MRI, CT, PET 40% after 40% after Office visit: 40% after Office visit: 40% after Office visit: 40% after 1 Mail order: 90-day supply of qualified prescriptions for the cost of a 60-day supply. First 3 office visits: $50 4+ visits: 40% after First 3 office visits: $70 4+ visits: 40% after Office visit: 40% after Office visit: 40% after Office visit: 40% after First 3 office visits: $20 4+ visits: 30% after First 3 office visits: $50 4+ visits: 30% after Office visit: 30% after Office visit: 30% after Office visit: $500 after Outpatient Hospital: $700 after 20% after 20% after Office visit: 20% after Office visit: 20% after Office visit: 20% after Outpatient surgery 40% after 40% after 30% after 20% after Mental health visit Inpatient hospital care Room and board, surgery, anesthesia, X-rays, lab tests, medications, mental health care Maternity Routine prenatal care visit, first postpartum visit 40% after First 3 office visits: $70 4+ visits: 40% after First 3 office visits: $50 4+ visits: 30% after 20% after 40% after 40% after 30% after 20% after 40% after 40% after 30% after 20% after Delivery and inpatient well-baby care 40% after 40% after 30% after 20% after Emergency and urgent care Emergency Department visit 40% after 40% after 30% after 20% after Urgent care visit 40% after $100 $100 20% after Ambulance services 40% after 40% after 30% after 20% after Prescription drugs (up to a 30-day supply) Generic Preferred generic: 40% after medical Preferred generic: $20 1 after medical Preventive generic: $51 Preferred generic: $15 Preferred generic: $ after medical Preferred brand 50% after medical 50% after medical 50% after $1,000/$2,000 $45 1 after medical Non-preferred brand 50% after medical 50% after medical 50% after $1,000/$2,000 50% after medical Specialty 50% after medical 50% after medical 50% after $1,000/$2,000 50% after medical This is a summary of the most frequently asked-about benefits and their copays, coinsurance, and s. Detailed information about your plan is in the Evidence of Coverage, which will be mailed to you upon enrollment or upon request. To request a copy of the Evidence of Coverage for a particular plan, please call us at or contact your broker. For services subject to the, you will have to pay health care expenses out of pocket until you meet your. Most s, copays, and coinsurance contribute to the out-of-pocket maximum Georgia

5 KP Offered through Kaiser Permanente M Offered through the Health Insurance Marketplace 2500/30 Financial assistance options with lower copays, coinsurance, and s are available for certain plans, and for Native Alaskans and American Indians on healthcare.gov. KP M KP M KP M KP M 1500/30 KP GA Gold 1500/20 KP GA Gold 1000/20 Plan type Deductible Deductible Deductible Deductible Features Annual medical Annual out-of-pocket maximum Benefits Preventive care $2,500/$5,000 $1,500/$3,000 $1,500/$3,000 $1,000/$2,000 $6,850/$13,700 $6,850/$13,700 $3,500/$7,000 $5,000/$10,000 Routine physical exam, mammograms, etc. No charge No charge No charge No charge Outpatient services (per visit or procedure) Primary care office visit $30 $30 $20 $20 Specialty care office visit $60 $60 $40 $40 Most X-rays Most lab tests MRI, CT, PET Office visit: 30% after First $300 of office visit charges at 30% after. Outpatient Hospital covered at 50% after. Office visit: $300 Outpatient Hospital: $500 1 Mail order: 90-day supply of qualified prescriptions for the cost of a 60-day supply. Office visit: 30% after First $300 of office visit charges at 30% after. Outpatient Hospital covered at 50% after. Office visit: $250 Outpatient Hospital: $500 First $100 of office visit charges at 20% after. Outpatient Hospital covered at 40% after. First $400 of office visit charges at 20% after. Outpatient Hospital covered at 40% after. Office visit: $150 Outpatient Hospital: $250 First $100 of office visit charges at 20% after. Outpatient Hospital covered at 40% after. First $400 of office visit charges at 20% after. Outpatient Hospital covered at 40% after. Office visit: $150 Outpatient Hospital: $250 Outpatient surgery 30% after 30% after 20% after 20% after Mental health visit $60 $60 $40 $40 Inpatient hospital care Room and board, surgery, anesthesia, X-rays, lab tests, medications, mental health care 30% after 30% after 20% after 20% after Maternity Routine prenatal care visit, first postpartum visit 30% after 30% after 20% after 20% after Delivery and inpatient well-baby care 30% after 30% after 20% after 20% after Emergency and urgent care Emergency Department visit 30% after 30% after 20% after 20% after Urgent care visit $100 $100 $75 $75 Ambulance services 30% after 30% after 20% after 20% after Prescription drugs (up to a 30-day supply) Generic Preferred generic: $15 1 Preferred generic: $15 1 Preferred generic: $10 1 Preferred generic: $10 1 Preferred brand $45 1 after $500/$1,000 $45 1 after $500/$1,000 $30 1 after $500/$1,000 $30 1 after $500/$1,000 Non-preferred brand 50% after $500/$1,000 50% after $500/$1,000 45% after $500/$1,000 45% after $500/$1,000 Specialty 50% after $500/$1,000 50% after $500/$1,000 45% after $500/$1,000 45% after $500/$1,000 This is a summary of the most frequently asked-about benefits and their copays, coinsurance, and s. Detailed information about your plan is in the Evidence of Coverage, which will be mailed to you upon enrollment or upon request. To request a copy of the Evidence of Coverage for a particular plan, please call us at or contact your broker. For services subject to the, you will have to pay health care expenses out of pocket until you meet your. Most s, copays, and coinsurance contribute to the out-of-pocket maximum Georgia 2016

6 KP Offered through Kaiser Permanente M Offered through the Health Insurance Marketplace KP KP GA Gold 500/20 Financial assistance options with lower copays, coinsurance, and s are available for certain plans, and for Native Alaskans and American Indians on healthcare.gov. M KP M M M KP GA Catastrophic 6850/ /30/73% CSR 2500/30/73% CSR 1500/30/87% CSR 2500/30/87% CSR Plan type Deductible Deductible Deductible Copay Features Annual medical Annual out-of-pocket maximum Benefits Preventive care $500/$1,000 $6,850/$13,700 $1,500/$3,000 None/None $6,350/$12,700 $6,850/$13,700 $5,200/$10,400 $2,250/$4,500 Routine physical exam, mammograms, etc. No charge No charge No charge No charge Outpatient services (per visit or procedure) Primary care office visit $20 First 3 office visits: no charge 4+ visits: no charge after $30 $15 Specialty care office visit $40 No charge after $50 $25 Most X-rays Most lab tests MRI, CT, PET First $100 of office visit charges at 30% (ded waived). Outpatient Hospital covered at 50% (ded waived). First $400 of office visit charges at 30% (ded waived). Outpatient Hospital covered at 50% (ded waived). Office visit: $250 Outpatient Hospital: $500 No charge after No charge after No charge after Office visit: 20% after First $300 of office visit charges covered at 100%, then remaining at 20% after. Outpatient Hospital covered at 40% after. Office visit: $250 Outpatient Hospital: $500 Office visit: 20% Outpatient Hospital: 40% First $300 of office visit charges at 20%. Outpatient Hospital covered at 40%. Office visit: $150 Outpatient Hospital: $300 Outpatient surgery 30% after No charge after 20% after 20% Mental health visit $40 First 3 office visits: no charge 4+ visits: no charge after $50 $25 Inpatient hospital care Room and board, surgery, anesthesia, X-rays, lab tests, medications, mental health care Maternity Routine prenatal care visit, first postpartum visit $500 per day up to 3 days after, then covered at 100% No charge after 20% after 20% No charge No charge after 20% after 20% Delivery and inpatient well-baby care $2,000 per admission No charge after 20% after 20% Emergency and urgent care Emergency Department visit $250 No charge after 20% after 20% Urgent care visit $75 No charge after $100 $50 Ambulance services $300 No charge after 20% after 20% Prescription drugs (up to a 30-day supply) Generic Preferred generic: $10 1 No charge after Preferred generic: $15 1 Preferred generic: $15 1 Preferred brand $30 1 after $500/$1,000 No charge after $45 1 after $250/$500 $45 1 Non-preferred brand 45% after $500/$1,000 No charge after 50% after $250/$500 50% Specialty 45% after $500/$1,000 No charge after 50% after $250/$500 50% 1 Mail order: 90-day supply of qualified prescriptions for the cost of a 60-day supply. 2 Only applicants under age 30, or applicants age 30 and older who provide a certificate from Health Insurance Marketplace in Georgia demonstrating hardship or lack of affordable coverage, may purchase a KP GA Catastrophic 6850/0 plan. This is a summary of the most frequently asked-about benefits and their copays, coinsurance, and s. Detailed information about your plan is in the Evidence of Coverage, which will be mailed to you upon enrollment or upon request. To request a copy of the Evidence of Coverage for a particular plan, please call us at or contact your broker. For services subject to the, you will have to pay health care expenses out of pocket until you meet your. Most s, copays, and coinsurance contribute to the out-of-pocket maximum Georgia

7 KP Offered through Kaiser Permanente M Offered through the Health Insurance Marketplace M 1500/30/94% CSR 2500/30/94% CSR Financial assistance options with lower copays, coinsurance, and s are available for certain plans, and for Native Alaskans and American Indians on healthcare.gov. 2750/20%/73% CSR /20%/87% CSR /20%/94% CSR 3 Plan type Copay Deductible Deductible Deductible M M M Features Annual medical Annual out-of-pocket maximum Benefits Preventive care None/None $1,400/$2,800 $500/$1,000 $100/$200 $1,900/$3,800 $5,000/$10,000 $2,250/$4,500 $1,400/$2,800 Routine physical exam, mammograms, etc. No charge No charge No charge No charge Outpatient services (per visit or procedure) Primary care office visit $5 20% after 10% after 5% after Specialty care office visit $10 20% after 10% after 5% after Most X-rays Most lab tests MRI, CT, PET Office visit: 5% Outpatient Hospital: 40% First $300 of office visit charges at 5%. Outpatient Hospital covered at 40%. Office visit: $50 Outpatient Hospital: $150 1 Mail order: 90-day supply of qualified prescriptions for the cost of a 60-day supply. Office visit: 20% after Office visit: 20% after Office visit: 20% after Office visit: 10% after Office visit: 10% after Office visit: 10% after Office visit: 5% after Office visit: 5% after Office visit: 5% after Outpatient surgery 5% 20% after 10% after 5% after Mental health visit $10 20% after 10% after 5% after Inpatient hospital care Room and board, surgery, anesthesia, X-rays, lab tests, medications, mental health care 5% 20% after 10% after 5% after Maternity Routine prenatal care visit, first postpartum visit 5% 20% after 10% after 5% after Delivery and inpatient well-baby care 5% 20% after 10% after 5% after Emergency and urgent care Emergency Department visit 5% 20% after 10% after 5% after Urgent care visit $20 20% after 10% after 5% after Ambulance services 5% 20% after 10% after 5% after Prescription drugs (up to a 30-day supply) Generic Preventive generic: $51 Preferred generic: $15 Preferred generic: $5 1 1 after medical Preferred generic: $5 1 after medical Preferred generic: $5 1 after medical Preferred brand $10 1 $45 1 after medical $10 1 after medical $10 1 after medical Non-preferred brand 50% 50% after medical 50% after medical 50% after medical Specialty 50% 50% after medical 50% after medical 50% after medical This is a summary of the most frequently asked-about benefits and their copays, coinsurance, and s. Detailed information about your plan is in the Evidence of Coverage, which will be mailed to you upon enrollment or upon request. To request a copy of the Evidence of Coverage for a particular plan, please call us at or contact your broker. For services subject to the, you will have to pay health care expenses out of pocket until you meet your. Most s, copays, and coinsurance contribute to the out-of-pocket maximum Georgia 2016

8 Working out your rate Use the monthly rates chart on the following page to help you evaluate your plan options, or apply on kp.org/apply to have your rate calculated automatically. Along with your monthly rate, consider what you will need to pay when you get care. What determines your rate? Your rate is based on the following: The plan you select Your age on your start date (effective date) Whether you use tobacco Rates are determined based on each person s age on the plan s start date, whether they apply individually or as a family. For example, if your 29th birthday is on February 14 and you submit your completed application on January 15, you ll have a start date of February 1 and the rate for a 28-year-old. However, if you submit your application on January 16, your start date will be March 1. Since this is after your birthday, you ll have the rate for a 29-year-old. The rates on page 9 apply to the counties below. Please check that your county is listed below. If it isn t, call us at for information on other rate areas. Service Area Counties Barrow Coweta Gwinnett Newton Bartow Dawson Hall Paulding Butts DeKalb Haralson Pickens Carroll Douglas Heard Pike Cherokee Fayette Henry Rockdale Clayton Forsyth Lamar Spalding Cobb Fulton Meriwether Walton Although family members can enroll in different plans, there are some advantages to enrolling family members in the same plan: Children can be covered under your plan until they reach age 26, whether or not they re in school or living at home. If you have more than 3 children under 21 on the same plan, you will only be charged for the 3 oldest. Other children under 21 are covered at no additional cost. If you have a child-only account and everyone on the account is under 21, you will only be charged for the subscriber and the 3 oldest children under Georgia

9 2016 Monthly rates Do you qualify for federal financial assistance? If so, you may pay lower rates than those listed in this chart. Age on 2016 effective date KP GA Bronze 6000/40%/ HSA KP GA Bronze 5000/50 KP GA Bronze 4000/ /20%/ HSA Rates are effective January 1, 2016, through December 31, / /30 KP GA Gold 1500/20 KP GA Gold 1000/20 KP GA Gold 500/20 KP GA Catastrophic 6850/ $ $ $ $ $ $ $ $ $ $ Georgia 2016

10 Enrolling in a Kaiser Permanente plan on the Marketplace Need help choosing a plan? Visit buykp.org, call us at , or contact your agent or broker. We can also help you apply for federal financial help through healthcare.gov. Kaiser Permanente makes it easy: 1. Get ready Here are some examples of documents and information you may need to complete your application: Most recent pay stub and tax return Birthdates of everyone in your family (even if they DON T want coverage) Social Security numbers for all family members who DO want coverage Proof of citizenship or immigration status Policy numbers of any current health insurance plan Paperwork for health insurance available through your employer 2. Get your plan Visit Select Get Coverage, then select Georgia and then click Get Coverage. Enter your ZIP code and select Start a marketplace application, followed by Create an Account. Fill in the account setup page. Sign in to your and click on the link that says verify your address. Accept the Terms and Conditions and complete all 4 sections. Review and sign. On the next page, click Find a Plan. In the Getting Started section, hit Continue. Choose Health as your Coverage Type, and click Continue. Under Decision Support for Medical, click Skip & View Plans. Use the green filter on the left to check Kaiser Permanente and hit Apply Filter. Select a plan and click Add to Cart. Finally, scroll up and hit Save and Continue to Checkout. Click Continue to confirm your selections on the next several screens. When you reach the Proceed to the Initial Payment Details page, click Make a Payment and then click Continue. Read and accept the User Agreement, add your digital signature, and hit Finish. Thank you for choosing Kaiser Permanente, the right choice for a healthier you Georgia

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13 The right choice for a healthier you Learn more about all that Kaiser Permanente has to offer. Visit kp.org/thrive or call us at (711 TTY for the deaf, hard of hearing, or speech impaired). Kaiser Foundation Health Plan of Georgia, Inc. kp.org Please recycle Georgia 2016