How deductible plans work

Transcription

1 Idividual ad Family Plas DEDUCTIBLE PLANS How deductible plas work Deductible plas geerally offer lower mothly premiums i exchage for payig more out of your ow pocket for services covered by your health pla. With a deductible pla, you pay full charge for certai covered services util your expeses meet a aual deductible. The, for covered services, you pay a coisurace or copay. Deductibles Uder a traditioal deductible pla, certai covered services are subject to the deductible the set amout for which you pay full charge i a cotract year. This meas you ll pay full charge for those services util you reach your aual deductible. No deductible for may services With some of our traditioal deductible plas, may services are available for a copay eve before you reach your deductible. With these deductible plas, services such as primary care, specialty care, ad urget care visits are available for a copaymet before you meet your deductible. Ad to ecourage you to receive prevetive care, may of these services are available for o charge before you meet your deductible. Out-of-pocket maximums Your out-of-pocket maximum puts a cap o how much you ll sped o most covered services each cotract year. This helps protect you fiacially if you have a serious illess or ijury. I all our deductible plas, the deductible applies toward the out-of-pocket maximum. For example, if you are a sigle subscriber o the KP 2000/30/Rx pla, you would pay full charge for most services util your out-of-pocket costs reach $2,000 to meet your deductible. The, you would pay a additioal $2,000 i copays ad coisurace to reach your $4,000 out-of-pocket maximum. After you reach your $4,000 out-of-pocket maximum, you wo t have to pay ay deductibles, copays, or coisurace for most covered services for the rest of the cotract year.

2 Idividual ad Family Plas DEDUCTIBLE PLANS Usig a deductible pla Let s say you ijure your akle ad visit your primary care physicia, who orders a X-ray. It s just a sprai, so the doctor prescribes a geeric pai medicatio. O the KP 2000/30/Rx pla, you have to pay $2,000 out of pocket before you are eligible to pay a copay or coisurace for most covered services. I this example, eve if you have ot met your deductible, you would pay a $30 copaymet (or copay) for the doctor s office visit because this service is ot subject to the deductible uder this pla. These copays would cotribute toward your out-of-pocket maximum but ot toward your deductible. However, if you have t met your medical deductible, you would pay full charge for the X-ray. Ad you would also pay full charge for the prescriptio util you meet the pharmacy deductible. The amout you pay for the X-ray would be applied to your $2,000 medical deductible. Ad the amout you pay for the geeric drug would be applied to your $200 pharmacy deductible. The HSA differece Some of our deductible plas are HSA-qualified deductible plas. These plas ca be paired with a optioal health savigs accout, or HSA. HSA-qualified plas work similarly to traditioal deductible plas with just a few differeces: If you re eligible, you ca ope a HSA with a HSA-qualified pla. Moey you deposit ito your HSA is deductible o your federal icome tax form. You ca use fuds from your HSA to pay for qualified medical expeses. Tax savigs relate to federal icome tax oly. For more iformatio, please cosult your fiacial or tax adviser. To lear more about health savigs accouts, visit or call Visit the treatmet fee tool at kp.org/treatmetestimates to estimate your out-of-pocket costs for upcomig services.

3 Idividual ad Family Plas DEDUCTIBLE PLANS Beefit highlights FEATURES DEDUCTIBLE PLANS KP 750/30/Rx KP 1000/30/Rx KP 1500/30 KP 2000/30/Rx The deductible ad most coisurace ad copays cotribute to the out-of-pocket maximum. Aual deductible (idividual/family) $750/$1,500 $1,000/$2,000 $1,500/$3,000 $2,000/$4,000 Aual out-of-pocket maximum (idividual/family) $3,500/$7,000 $4,000/$8,000 BENEFITS PREVENTIVE CARE OUTPATIENT SERVICES (per visit or procedure) Services ot subject to deductible uless otherwise idicated May prevetive care services, such as routie physical exams ad mammogram screeigs, are o charge. Primary care office visit $30 copay 1 Specialty care office visit $40 copay Outpatiet surgery 20% of AC* (after deductible) 30% of AC (after deductible) Diagostic labs ad X-rays 20% of AC (after deductible) 30% of AC (after deductible) MRI, CT, ad PET 20% of AC (after deductible) 30% of AC (after deductible) INPATIENT HOSPITAL CARE Hospital care ad professioal visits 20% of AC (after deductible) 30% of AC (after deductible) MATERNITY COVERAGE Routie preatal visits Routie postpartum ad other preatal visits Delivery ad ipatiet well-baby care 20% of AC (after deductible) 30% of AC (after deductible) EMERGENCY AND URGENT CARE Emergecy Departmet visit (waived if admitted) Urget care visit (after hours) PRESCRIPTION DRUGS $150 copay $40 copay (30-day supply filled at a Kaiser Permaete pharmacy) Pharmacy deductible (all drugs) $100 per member $150 per member N/A $200 per member Geeric drug $10 copay (after pharmacy deductible) Not covered Preferred brad/nopreferred brad drug $30 copay/$45 copay (after pharmacy deductible) Not covered Cotraceptives OTHER Detal services $10 copay (after pharmacy deductible) $35 copay/$50 copay (after pharmacy deductible) $30 copay for prevetive care services. See the Detal Pla sectio for more iformatio. These are oly highlights of pla coverage ad are ot iclusive. For specific beefit iformatio, referece the Guide to Your 2013 Beefits ad Services (KFHP-NG-KPIF-DC for District of Columbia residets, KFHP-NG-KPIF-VA for Virgiia residets, ad KFHP-NG-KPIF-MD for Marylad residets), which you will receive upo acceptace. Please call Member Services at or for additioal assistace. For a list of exclusios ad limitatios associated with the beefits show, please see the Exclusios ad Limitatios sectio. Uder the Affordable Care Act, your coverage will be cosidered o-gradfathered coverage because you purchased a Kaiser Permaete for Idividuals ad Families pla after March 23, The beefits that you select may chage o Jauary 1, At that time, i order to meet the ew beefit stadards uder the Affordable Care Act, we may chage the beefits ad rate you pay uder your pla, or ask you to select a ew pla. I ay case, we will otify you i advace ad provide optios for you to cotiue your coverage without a break. 1 Waived for childre uder age 5 *AC is the allowable charge.

4 Idividual ad Family Plas DEDUCTIBLE PLANS Beefit highlights FEATURES KP 4500/20%/Rx DEDUCTIBLE PLANS KP 8000/0%/Rx The deductible ad most coisurace ad copays cotribute to the out-of-pocket maximum. Aual deductible (idividual/family) $4,500/$9,000 $8,000/$16,000 Aual out-of-pocket maximum (idividual/family) $9,000/$18,000 $10,000/$20,000 BENEFITS PREVENTIVE CARE OUTPATIENT SERVICES (per visit or procedure) Services ot subject to deductible uless otherwise idicated May prevetive care services, such as routie physical exams ad mammogram screeigs, are o charge. Primary care office visit 20% of AC* (after deductible) (after deductible) Specialty care office visit 20% of AC (after deductible) (after deductible) Outpatiet surgery 20% of AC (after deductible) (after deductible) Diagostic labs ad X-rays 20% of AC (after deductible) (after deductible) MRI, CT, ad PET 20% of AC (after deductible) (after deductible) INPATIENT HOSPITAL CARE Hospital care ad professioal visits 20% of AC (after deductible) (after deductible) MATERNITY COVERAGE Routie preatal visits Routie postpartum ad other preatal visits (after deductible) Delivery ad ipatiet well-baby care 20% of AC (after deductible) (after deductible) EMERGENCY AND URGENT CARE Emergecy Departmet visit (waived if admitted) 20% of AC (after deductible) (after deductible) Urget care visit (after hours) 20% of AC (after deductible) (after deductible) PRESCRIPTION DRUGS Pharmacy deductible (all drugs) Geeric drug Preferred brad/nopreferred brad drug Cotraceptives OTHER Detal services (30-day supply filled at a Kaiser Permaete pharmacy) Subject to medical deductible $15 copay (after deductible) $35 copay/$50 copay (after deductible) $30 copay for prevetive care services. See the Detal Pla sectio for more iformatio. These are oly highlights of pla coverage ad are ot iclusive. For specific beefit iformatio, referece the Guide to Your 2013 Beefits ad Services (KFHP-NG-KPIF-DC for District of Columbia residets, KFHP-NG-KPIF-VA for Virgiia residets, ad KFHP-NG-KPIF-MD for Marylad residets), which you will receive upo acceptace. Please call Member Services at or for additioal assistace. For a list of exclusios ad limitatios associated with the beefits show, please see the Exclusios ad Limitatios sectio. Uder the Affordable Care Act, your coverage will be cosidered o-gradfathered coverage because you purchased a Kaiser Permaete for Idividuals ad Families pla after March 23, The beefits that you select may chage o Jauary 1, At that time, i order to meet the ew beefit stadards uder the Affordable Care Act, we may chage the beefits ad rate you pay uder your pla, or ask you to select a ew pla. I ay case, we will otify you i advace ad provide optios for you to cotiue your coverage without a break. *AC is the allowable charge.

5 Idividual ad Family Plas HSA-QUALIFIED DEDUCTIBLE PLANS How HSA-qualified deductible plas work A HSA-qualified pla is a deductible pla that is eligible to be paired with a optioal health savigs accout, or HSA. If you sig up for a HSA-qualified deductible pla ad ope a HSA, you ca pay for qualified medical expeses with tax-deductible dollars. 1 A HSA-qualified pla works much like a traditioal deductible pla. However, with a HSA-qualified pla, you pay full charge for all services (except certai prevetive care services) util you meet your deductible. The you are eligible to pay copaymets or coisurace for covered services for the rest of the cotract year. You ca also save moey with HSA-qualified plas because you ca pay for qualified medical expeses eve those ot covered by your health pla with tax-deductible dollars. However, qualified expeses ot covered by your health pla will ot cotribute to your deductible or out-of-pocket maximum. All you have to do is: Sig up for a HSA-qualified health pla. If you are eligible, ope a health savigs accout. 2 Cotribute tax-deductible dollars to this accout. Advatages of opeig a HSA Portability The moey belogs to you, so if you chage health plas, you ca take your HSA with you. Rollover of uused fuds There is o use it or lose it restrictio each year. What you do t use stays i your accout util you are ready to use it. 3 Cotrol You decide whe to put the moey i ad whe to take it out. Retiremet savigs The moey i your accout ca be ivested through the istitutio where you ope it. Ad after age 65, you ca use the fuds, taxed at your ordiary icome rate, for ay reaso without pealties. Flexibility You ca use the moey i your HSA to pay for qualified medical expeses, eve those your deductible pla does ot cover. Use those tax-free fuds to pay for qualified health care expeses. What you do t use rolls over to the ext year ad cotiues earig iterest. 3 1 Tax refereces relate to federal icome tax oly. The tax treatmet of health savigs accout cotributios ad distributios uder state icome tax laws differs from the federal tax treatmet. Cosult with your fiacial or tax adviser for more iformatio. 2 For 2013, the federally established maximum cotributio for a eligible idividual with self-oly coverage is $3,250. The aual maximum cotributio for a eligible idividual with family coverage is $6,450. This aual maximum is idexed aually for iflatio. Tax savigs relate to federal icome tax oly. For more iformatio, please cosult your fiacial or tax adviser. 3 Earigs vary depedig o the type of ivestmet pla you opt for ad/or the HSA provider you choose. Amout eared is based o the ivestmet pla ad market value, ad i some istaces, the accout may actually lose moey.

6 Idividual ad Family Plas HSA-QUALIFIED DEDUCTIBLE PLANS Usig a health savigs accout What are qualified medical expeses? You ca use a HSA to pay for deductibles ad may supplies ad services ot covered by your health pla. Geerally, these are expeses that would qualify for the medical ad detal expese deductio o your icome tax. Here are just a few examples of HSA-qualified expeses: Eyeglasses ad laser eye surgery Detal care Acupucture Chiropractic services Hearig aids For a complete list, see Publicatio 502, Medical ad Detal Expeses at Who s eligible for a HSA? To be eligible for a HSA, you eed to meet the followig requiremets: You ca t be erolled i Medicare. You ca t be eligible to be claimed as a depedet o someoe else s tax retur. You ca t have additioal health coverage that is ot a qualified deductible pla (with certai exceptios). You ca t have received beefits from the Departmet of Veteras Affairs i the past three moths. You may set up your HSA through ay fiacial istitutio that offers these accouts. 1 A HSA offers triple tax advatages Tax-deductible cotributios to your accout Usig a HSA-qualified deductible pla Let s say you ijure your akle ad visit your primary care physicia, who orders a X-ray. It s just a sprai, so the doctor prescribes a geeric pai medicatio. With our HSA-qualified plas, you pay full charge for all covered services (except may prevetive care services) util you meet your deductible. O the KP 1250/20/HSA/Rx pla, the deductible for a idividual is $1,250, so you would eed to pay $1,250 out-of-pocket to meet the deductible. The good ews is that the deductible cotributes toward the $3,000 out-of-pocket maximum i this pla. So, after spedig $3,000 out of pocket, you would ot have to pay ay charge for covered services for the rest of the year. I this example, if the total costs you have paid out of pocket so far this cotract year for covered services have ot met your deductible, you would pay full charge for the doctor s office visit, the X-ray, ad the medicatio. All the costs you pay for covered services would apply to your deductible, ad your deductible would cotribute to your out-of-pocket maximum. If you have met your $3,000 out-of-pocket maximum, the doctor s office visit, the X-ray, ad the geeric medicatio would be o charge uder this pla. Ad, if you opeed a HSA, you would be able to pay for these services with tax-free dollars. (Tax savigs relate to federal icome tax oly. For more iformatio, please cosult your fiacial or tax adviser. For more iformatio o health savigs accouts, please visit publicatios/p969/ar02.html.) Tax-free ivestmet earigs 2 Tax-free withdrawals whe fuds are used for qualified medical expeses 1 Kaiser Permaete does ot provide or admiister fiacial products, icludig HSAs, ad does ot offer fiacial, tax, or ivestmet advice. Members are resposible for their ow ivestmet decisios. If a member uses his or her HSA debit card to pay for somethig other tha a qualified medical expese, the expediture is subject to tax ad, for idividuals who are ot disabled or over 65, a 20 percet tax pealty. 2 Ivestmet losses may occur with HSA accouts. Earigs vary depedig o the type of ivestmet pla you choose ad/or the HSA provider you choose.

7 Idividual ad Family Plas HSA-QUALIFIED DEDUCTIBLE PLANS Beefit highlights FEATURES HSA-QUALIFIED DEDUCTIBLE PLANS KP 1250/20/HSA/Rx KP 2500/30/HSA/Rx The deductible, coisurace, ad copays cotribute to the out-of-pocket maximum. Aual deductible (idividual/family) $1,250/$2,500 $2,500/$5,000 Aual out-of-pocket maximum (idividual/family) $3,000/$6,000 $5,000/$10,000 BENEFITS Services ot subject to deductible uless otherwise idicated PREVENTIVE CARE May prevetive care services, such as routie physical exams ad mammogram screeigs, are o charge. OUTPATIENT SERVICES (per visit or procedure) Primary care office visit $20 copay (after deductible) 1 $30 copay (after deductible) 1 Specialty care office visit $30 copay (after deductible) $40 copay (after deductible) Outpatiet surgery 20% of AC* (after deductible) Diagostic labs ad X-rays 20% of AC (after deductible) MRI, CT, ad PET 20% of AC (after deductible) INPATIENT HOSPITAL CARE Hospital care ad professioal visits $500 copay per day (after deductible) MATERNITY COVERAGE Routie preatal visits Routie postpartum ad other preatal visits (after deductible) Delivery ad ipatiet well-baby care $500 copay per day (after deductible) EMERGENCY AND URGENT CARE Emergecy Departmet visit (waived if admitted) 20% of AC (after deductible) Urget care visit (after hours) $30 copay (after deductible) $40 copay (after deductible) PRESCRIPTION DRUGS (30-day supply filled at a Kaiser Permaete pharmacy) Pharmacy deductible (all drugs) Subject to medical deductible Geeric drug $10 copay (after deductible) $15 copay (after deductible) Preferred brad/nopreferred brad drug $35 copay/$50 copay (after deductible) Cotraceptives OTHER Detal services $30 copay for prevetive care services. See the Detal Pla sectio for more iformatio. These are oly highlights of pla coverage ad are ot iclusive. For specific beefit iformatio, referece the Guide to Your 2013 Beefits ad Services (KFHP-NG-KPIF-DC for District of Columbia residets, KFHP-NG-KPIF-VA for Virgiia residets, ad KFHP-NG-KPIF-MD for Marylad residets), which you will receive upo acceptace. Please call Member Services at or for additioal assistace. For a list of exclusios ad limitatios associated with the beefits show, please see the Exclusios ad Limitatios sectio. Uder the Affordable Care Act, your coverage will be cosidered o-gradfathered coverage because you purchased a Kaiser Permaete for Idividuals ad Families pla after March 23, The beefits that you select may chage o Jauary 1, At that time, i order to meet the ew beefit stadards uder the Affordable Care Act, we may chage the beefits ad rate you pay uder your pla, or ask you to select a ew pla. I ay case, we will otify you i advace ad provide optios for you to cotiue your coverage without a break. 1 Waived for childre uder age 5 *AC is the allowable charge (12/1/12 12/31/13)