Payments for services. A limit on your expenses. Meeting your deductible. Prescription drug payments

Transcription

1 KAISER PERMANENTE HMO PLAN PREVENTIVE CARE S AND DOCTOR S OFFICE VISITS Section 2 A LOWER-COST OPTION FOR HIGH-QUALITY CARE With our HMO plans, you can get the health coverage you need at a price that fits your budget. You ll have lower monthly premiums than with our traditional HMO plan, and you ll still get the same high-quality care you ve come to expect from Kaiser Permanente. Under this plan, your preventive care services and doctor s office visits are covered at a copayment or coinsurance. For hospital care, radiology services, and lab tests, you ll need to meet an annual before those services are covered at a copayment or coinsurance. Meeting your The is a fixed amount of money defined by your plan benefits. At the start of each calendar year, you ll pay full charges out of your own pocket for hospital, radiology, and lab services, until you reach your plan s. For preventive care and doctor s office visits, you ll pay only a copayment or coinsurance, even if you haven t reached your. After you reach your, you ll pay only copayments or coinsurance for most covered services including hospital, radiology, and lab services for the rest of the calendar year. On January 1 of the next year, you ll start over and pay full charges for hospital, radiology, and lab services until you reach your again. Payments for services When you come in for care, you ll be asked to pay a copayment, coinsurance, or payment up front, depending on the service you re scheduled to receive. If you receive additional services during your visit that weren t originally scheduled, you ll be billed for those services later. To find out what the charges are for frequently used services, use our treatment fee tool at kp.org/plans. A limit on your expenses If you were to have a serious illness or accident, your expenses could continue to add up, even after you d reached your. Your plan offers you peace of mind by limiting the amount of money you have to pay out of your own pocket each year, including your copayments and coinsurance. This limit is called the annual out-of-pocket maximum. Once you reach the maximum, we ll pay the full cost of most covered services for the rest of the calendar year. Prescription drug payments Generic prescription drugs are covered at a copayment. Some plans have a separate brand-name drug. If your plan has a brand-name drug, you ll pay full charges for brand-name drugs until you meet this. After that, your brand-name drugs will be covered at a copayment. Prescription drug payments do not apply toward your medical. A FOCUS ON PREVENTION At Kaiser Permanente, we don t just care for you when you re sick we help you stay healthy too. One of the key features of our plans is that most preventive care services, like routine physical exams, mammograms, and cholesterol screenings, are available to you for a copayment or coinsurance, without having to meet your. Visit kp.org/plans to find out more about how preventive care services are covered.

2 UNDERSTANDING YOUR This table lists frequently used services and shows whether they are subject to your. Either you ll pay: Full charges for services that are subject to your until you reach your. After that, you ll pay only copayments or coinsurance. Or you ll pay: A copayment or coinsurance for services that are not subject to your. Copayments and coinsurance do not apply toward your. See the Your Health Plan Benefits section in this booklet for a list of services and their copayments or coinsurance. TYPE OF SUBJECT TO Professional services Outpatient services Primary and specialty care visits Routine preventive physical exams Well-child preventive care visits (0 23 months) Family planning visits Scheduled prenatal visit First postpartum visit Eye exams Hearing tests Physical, occupational, and speech therapy visits Outpatient surgery Allergy injection visits Allergy testing visits Immunizations X-rays, MRIs, CT scans, PET scans, and lab tests Health education classes and programs Hospital services Room and board, surgery, anesthesia, X-rays, lab tests, and drugs Emergency care Emergency Department visits Ambulance services Ambulance services Durable medical equipment Mental health Chemical dependency services Most durable medical equipment for home use in accordance with our DME formulary Inpatient psychiatric care Outpatient visits Inpatient detoxification Outpatient individual therapy visits Outpatient group therapy visits Transitional residential recovery services Home health services Home health care Other Skilled nursing facility care All diagnosis and treatment related to infertility Hospice care

3 HOW A HMO PLAN WORKS FOR AN INDIVIDUAL This sample scenario involves Kim, a member with the Deductible HMO Plan Preventive Care Services and Doctor s Office Visits. In this scenario, Kim has a plan with the following benefits: Copayment: $20 Coinsurance: 20% Individual : $1,000 Individual annual out-of-pocket maximum: $3,000 The amounts shown here are for illustration purposes only. Individual member visits COST OF KIM S BENEFIT TO KIM S WHAT KIM PAYS OUT-OF-POCKET Kim gets a physical exam. $165 Routine preventive exam is covered at a $20 copayment per visit. * $20 $20 Kim is sick and needs a chest X-ray. $75 Radiology services are at full charge before the $75 $75 $75 The chest X-ray shows that Kim needs to be admitted to the hospital. $3,500 Hospital services are covered at 20% coinsurance after the $925 $925 + ($2,575 x 20% = $515) $1,440 $1,440 Year-to-date totals $1,000 $1,535 $1,535 * Kim s preventive care is not subject to the, and her copayment does not apply toward the. Kim pays $925 to meet the rest of her $1,000, then pays coinsurance for the remaining hospital charges (20% of $2,575). Kim s has been met. For the rest of the year, until she reaches her out-of-pocket maximum, she will pay only copayments or coinsurance for her medical care.

4 HOW A HMO PLAN WORKS FOR A FAMILY With a family plan, each family member has a, and the family as a whole has a. If a family member meets his or her individual before the family meets the family, he or she will pay only a copayment or coinsurance for most covered services for the rest of the calendar year, until the out-of-pocket maximum is reached. Other family members will continue to pay for their care until they meet their individual s or until the family meets the family. Amounts applied toward individual s also apply toward the family. In these sample scenarios, Kim has a family. Her family plan has the following benefits: Copayment: $20 Coinsurance: 20% Individual : $1,000 Family : $2,000 Family annual out-of-pocket maximum: $6,000 The amounts shown here are for illustration purposes only. Kim s payments toward her individual in the previous scenario also apply toward the family, and her expenses of $1,535 apply toward the family annual out-of-pocket maximum. Family member visit 1 COST OF KIM S FAMILY BENEFIT CHILD S TO FAMILY WHAT KIM S FAMILY PAYS OUT-OF- POCKET Family s year-to-date totals from previous scenario $1,000 $1,535 $1,535 Kim s child needs emergency care. $1,000 Emergency Department visit is at full charge before the $1,000 $1,000 $1,000 $1,000 Year-to-date totals $1,000 * $2,000 $2,535 $2,535 * Kim s child s has been met. Amounts applied toward her child s individual also apply toward the family. The family has been met. For the rest of the year, until they reach their family out-of-pocket maximum, Kim and her family will pay only copayments or coinsurance for their medical care.

5 Family member visit 2 COST OF KIM S FAMILY BENEFIT HUSBAND S TO FAMILY WHAT KIM S FAMILY PAYS OUT-OF- POCKET Family s year-to-date totals from previous scenario $2,000 $2,535 $2,535 Kim s husband needs knee replacement surgery. $17,325 Inpatient hospital care is covered at 20% coinsurance after the $17,325 x 20% = $3,465 $3,465 Year-to-date totals $2,000 $6,000 $6,000 * * Kim s family annual out-of-pocket maximum has been met. For the rest of the year, Kim and her family will receive most of their medical care at no charge. Family member visit 3 COST OF KIM S FAMILY BENEFIT HUSBAND S TO FAMILY WHAT KIM S FAMILY PAYS OUT-OF- POCKET Family s year-to-date totals from previous scenario $2,000 $6,000 $6,000 Kim s husband requires six months of physical therapy. $3,000 Physical therapy is covered at a $20 copayment per visit. (out-of-pocket maximum (out-of-pocket maximum Year-to-date totals $2,000 $6,000 $6,000

6 COMMON TERMS Here are some terms you ll come across when reading about your HMO plan. Annual out-of-pocket maximum: The maximum amount you ll pay for eligible covered services in a calendar year. Once you ve reached that maximum, you won t have to pay any copayments, s, or coinsurance for most covered services for the rest of the calendar year. t all services are subject to the annual out-of-pocket maximum. Coinsurance: The percentage of charges you pay when you receive a covered service. For example, a 30 percent coinsurance for hospital services means you pay 30 percent of the total charges for covered hospital services. Coinsurance varies depending on your plan. Copayment (or copay): The fixed amount you pay when you receive covered medical services or prescriptions. For example, a $10 copay for doctor s office visits means you pay $10 for each visit. Copayments vary depending on your plan. Deductible: The fixed amount you must pay in a calendar year before we ll pay for certain services, not including your copayments or coinsurance. t all services are subject to the. Copayments and coinsurance do not apply toward the. WE RE HERE FOR YOUR HEALTH If you have questions about our HMO plans, go to kp.org/plans, or call our Member Service Call Center weekdays from 7 a.m. to 7 p.m. and weekends from 7 a.m. to 3 p.m English Spanish Chinese dialects TTY for the hearing/ speech impaired