2015 Summary of Benefits

Transcription

1 2015 Summary of Benefits Kaiser Permanente Senior Advantage (HMO) Group Plan Including Medicare Part D Prescription Drug Benefit Information Kaiser Foundation Health Plan, Inc. Northern and Southern California Regions A nonprofit corporation Health Maintenance Organization (HMO) January 1, 2015, through December 31,

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3 Kaiser Permanente Senior Advantage (HMO) (a Medicare Advantage Health Maintenance Organization (HMO) offered by KAISER FOUNDATION HP, INC. with a Medicare contract). Summary of Benefits January 1, 2015 December 31, 2015 This booklet gives you a summary of what we cover. To get a complete list of your Kaiser Permanente Senior Advantage (HMO) benefits, please refer to your Evidence of Coverage (EOC). Contact your employer or trust fund or call Kaiser Permanente Senior Advantage (HMO) and ask for the Evidence of Coverage. You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare (fee-forservice Medicare). Original Medicare is run directly by the Federal government. Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Kaiser Permanente Senior Advantage (HMO)), which is made available through your employer or trust fund. However, if you enroll in Original Medicare alone, you may endanger the coverage you receive through your employer or trust fund, and your benefits may be reduced. For information about the benefits available through your employer or trust fund, please see your EOC. No matter what you decide, you are still in the Medicare Program. Your employer or trust fund may restrict when you may join or leave its plan. Usually this is connected to your employer or trust fund's annual enrollment period. Please call your employer or trust fund for more information about enrollment periods. Tips for comparing your Medicare choices As a member who receives Kaiser Permanente Senior Advantage (HMO) coverage through an employer or trust fund, you will receive all of the benefits that the Original Medicare plan offers, plus additional benefits purchased for you by your employer or trust fund, which may change from year to year. Please see the enclosed Kaiser Permanente Senior Advantage (HMO) Summary of Benefits for benefits you receive through your employer or trust fund. If you want to know more about the coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Kaiser Permanente Senior Advantage Group Plan 2015 Summary of Benefits 1

4 Sections in this booklet Things to Know About Kaiser Permanente Senior Advantage (HMO) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical, Hospital Benefits, and Prescription Drug Benefits This document is available in other formats such as Braille and large print. This document may be available in a non-english language. For additional information, call us at Este documento puede estar disponible en otros idiomas aparte del inglés. Si desea información adicional, por favor llámenos al Things to Know About Kaiser Permanente Senior Advantage (HMO) Hours of Operation You can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Pacific time. Kaiser Permanente Senior Advantage (HMO) Phone Numbers and Website If you are a member of this plan, call toll-free If you are not a member of this plan, call toll-free Our website: kp.org/medicare Who can join? To join Kaiser Permanente Senior Advantage (HMO), you must be enrolled in Medicare Part B or have both Medicare Part A and Medicare Part B and live in our service area. In Northern California, the service area for this plan includes: Alameda, Amador*, Contra Costa, El Dorado*, Fresno*, Kings*, Madera*, Marin, Mariposa*, Napa*, Placer*, Sacramento, San Francisco, San Joaquin, San Mateo, Santa Clara*, Solano, Sonoma*, Stanislaus, Sutter*, Tulare*, Yolo*, and Yuba*. * denotes partial county Amador County: 95640, Kaiser Permanente Senior Advantage Group Plan 2015 Summary of Benefits

5 El Dorado County: , 95619, 95623, , 95651, 95664, 95667, 95672, 95682, Fresno County: 93242, 93602, , 93609, , 93616, , , , 93646, , 93654, , 93660, 93662, , 93675, , , , 93737, , , 93747, 93750, 93755, , , , 93786, , 93844, Kings County: 93230, 93232, 93242, 93631, Madera County: , 93604, 93614, 93623, 93626, , , 93653, 93669, Mariposa County: 93601, 93623, Napa County: 94503, 94508, 94515, , 94562, 94567, , 94576, 94581, , 94599, Placer County: , 95626, 95648, 95650, 95658, 95661, 95663, 95668, , 95681, 95692, 95703, 95722, 95736, , Santa Clara County: , 94035, , , , 94309, 94550, 95002, , 95011, , , 95026, , , 95042, 95044, 95046, , , 95076, 95101, 95103, 95106, , , , 95148, , 95164, 95170, , , Sonoma County: 94515, , , 94931, , 94972, 94975, 94999, , 95409, 95416, 95419, 95421, 95425, , 95433, 95436, 95439, , 95444, 95446, 95448, 95450, 95452, 95462, 95465, , 95476, , Sutter County: 95626, 95645, 95648, 95659, 95668, 95674, 95676, 95692, Tulare County: 93238, 93261, 93618, 93631, 93646, 93654, 93666, Yolo County: 95605, 95607, 95612, , 95645, 95691, , , 95776, Yuba County: 95692, 95903, In Southern California, the service area for this plan includes: Kern*, Los Angeles*, Orange, Riverside*, San Bernardino*, San Diego*, and Ventura*. * denotes partial county Kern County: 93203, , , 93220, 93222, , 93238, , 93243, , 93263, 93268, 93276, 93280, 93285, 93287, , , 93380, , , , , 93531, 93536, , Los Angeles County: , , , 90099, 90189, , , , , , 90245, , , , 90270, 90272, , , 90280, , , , , , 90623, , , , , , , , , 90723, , , 90755, , , 90822, , 90840, 90842, 90844, , 90853, 90895, 90899, 91001, 91003, Kaiser Permanente Senior Advantage Group Plan 2015 Summary of Benefits 3

6 , , , , , , 91046, 91066, 91077, , , 91121, , 91129, 91182, , , 91199, , 91214, , , , 91313, 91316, , , , 91337, , , , , 91367, , 91376, , 91390, , , 91416, 91423, 91426, 91436, 91470, 91482, , 91499, , 91510, , 91526, , , 91702, 91706, 91709, 91711, , , , , , , , , 91778, 91780, , , 91896, 91899, 93243, 93510, 93532, , 93539, , , 93560, 93563, 93584, 93586, , Riverside County: 91752, , , 92220, 92223, 92230, , , , 92253, 92255, 92258, , 92270, 92276, 92282, 92320, 92324, 92373, 92399, , , , , , 92548, , , 92567, , , , , 92599, 92860, San Bernardino County: 91701, , , 91737, 91739, 91743, , , 91766, , 91792, 92305, , , , , 92329, 92331, , , , 92350, 92352, 92354, , 92369, , 92382, , , 92397, 92399, , , 92413, 92415, 92418, 92423, 92427, San Diego County: , , 91921, , 91935, , , , , 91987, , , , , 92033, , 92046, 92049, , , , , , , , , , 92096, , , , , 92145, 92147, , , , 92163, , 92182, , , Ventura County: 90265, 91304, 91307, 91311, , , 91377, , , , , , , , 93094, 93099, Which doctors, hospitals, and pharmacies can I use? Kaiser Permanente Senior Advantage (HMO) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan s provider directory at our website (kp.org/medicare). You can see our plan s pharmacy directory at our website ( Or, call us and we will send you a copy of the provider and pharmacy directories. What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers and more. 4 Kaiser Permanente Senior Advantage Group Plan 2015 Summary of Benefits

7 Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. Our plan members also get more than what is covered by Original Medicare. Please see the enclosed Kaiser Permanente Senior Advantage (HMO) Summary of Benefits for benefits you receive through your employer or trust fund. We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, Or, call us and we will send you a copy of the formulary. How will I determine my drug costs? Our plan groups each medication into one of six tiers. You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug s tier and what stage of the benefit you have reached. Kaiser Permanente Senior Advantage Group Plan 2015 Summary of Benefits 5

8 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services How much is the monthly premium? Your group will notify you about your group's premium and the amount you will be expected to pay. If you have any questions about your contribution toward your group's premium, please contact your group's benefits administrator. In addition, you must keep paying your Medicare premium(s). How much is the deductible? Is there any limit on how much I will pay for my covered services? Please see the enclosed Kaiser Permanente Senior Advantage (HMO) Summary of Benefits to find out what the yearly limit is for your group's plan. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Please see the enclosed Kaiser Permanente Senior Advantage (HMO) Summary of Benefits to find out what the yearly limit is for your group's plan. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Kaiser Permanente is an HMO plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal. Covered Medical, Hospital Benefits, and Prescription Drug Benefits Please see the enclosed Kaiser Permanente Senior Advantage (HMO) Summary of Benefits for your group's benefits. 6 Kaiser Permanente Senior Advantage Group Plan 2015 Summary of Benefits

9 Additional information about Kaiser Permanente Senior Advantage (HMO) Covered services are provided in accord with Medicare coverage guidelines. Please see the Evidence of Coverage (EOC) for complete details, including other coverage limitations and exclusions. Getting care You must get covered services from plan providers except for authorized referrals, emergency care, and out-of-area urgent or dialysis care or as otherwise described in the EOC. Case management We have case management programs if you are managing many chronic conditions. Nurses, social workers, and your physician partner to meet your needs. They educate and teach self-care skills to help you manage your health. Please ask your physician for details. Grievances & appeals You can ask us to provide or pay for an item or service you think should be covered. If we deny your request, you can ask us to reconsider. You may ask for a fast decision if you think waiting could put your health at risk. If your doctor makes or supports the fast request, we will expedite our decision. If you have an issue unrelated to coverage, you can file a grievance with us. Please see the EOC for details. Privacy We protect the privacy of protected health information. Please see the EOC or view our Notice of Privacy Practices on kp.org to learn more. Kaiser Permanente Senior Advantage Group Plan 2015 Summary of Benefits 7

10 Multi-language Interpreter Services English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at Someone who speaks English/Language can help you. This is a free service. Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al Alguien que hable español le podrá ayudar. Este es un servicio gratuito. Chinese Mandarin: 我 们 提 供 免 费 的 翻 译 服 务, 帮 助 您 解 答 关 于 健 康 或 药 物 保 险 的 任 何 疑 问 如 果 您 需 要 此 翻 译 服 务, 请 致 电 我 们 的 中 文 工 作 人 员 很 乐 意 帮 助 您 这 是 一 项 免 费 服 务 Chinese Cantonese: 您 對 我 們 的 健 康 或 藥 物 保 險 可 能 存 有 疑 問, 為 此 我 們 提 供 免 費 的 翻 譯 服 務 如 需 翻 譯 服 務, 請 致 電 我 們 講 中 文 的 人 員 將 樂 意 為 您 提 供 幫 助 這 是 一 項 免 費 服 務 Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au service d'interprétation, il vous suffit de nous appeler au Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit. Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí. German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다. 통역 서비스를 이용하려면 전화 번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다. Y0043_N accepted CA

11 Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная. Arabic: ا ننا نقدم خدمات المترجم الفوري المجانية للا جابة عن ا ي ا سي لة تتعلق بالصحة ا و جدول الا دوية لدينا. للحصول على مترجم فوري ليس عليك سوى الاتصال بنا على سيقوم شخص.بمساعدتك. هذه خدمة مجانية ما يتحدث العربية Hindi: हम र स व स थ य य दव क य जन क ब र म आपक कस भ प रश न क जव ब द न क लए हम र प स म फ त द भ षय स व ए उपलब ध ह. एक द भ षय प र प त करन क लए, बस हम पर फ न कर. क ई व य क त ज हन द ब लत ह आपक मदद कर सकत ह. यह एक म फ त स व ह. Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito. Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito. French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis. Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer Ta usługa jest bezpłatna. Japanese: 当 社 の 健 康 健 康 保 険 と 薬 品 処 方 薬 プランに 関 するご 質 問 にお 答 えするため に 無 料 の 通 訳 サービスがありますございます 通 訳 をご 用 命 になるには にお 電 話 ください 日 本 語 を 話 す 人 者 が 支 援 いたします これは 無 料 のサービス です

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16 Kaiser Foundation Health Plan, Inc. 393 E. Walnut St. Pasadena, CA Member Service Contact Center (TTY 711) toll free Seven days a week, 8 a.m. to 8 p.m. kp.org/medicare Please recycle.