DEDUCTIBLE HMO PLAN—PREVENTIVE CARE SERVICES AND DOCTOR’S OFFICE VISITS KAISER PERMANENTE

A LOWER-COST OPTION FOR HIGH-QUALITY CARE With our deductible 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 deductible before those services are covered at a copayment or coinsurance.

Meeting your deductible The deductible 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 deductible. For preventive care and doctor’s office visits, you’ll pay only a copayment or coinsurance, even if you haven’t reached your deductible. After you reach your deductible, 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 deductible again.

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Payments for services When you come in for care, you’ll be asked to pay a copayment, coinsurance, or deductible 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/deductibleplans.

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 deductible. 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 deductible. If your plan has a brand-name drug deductible, you’ll pay full charges for brand-name drugs until you meet this deductible. After that, your brand-name drugs will be covered at a copayment. Prescription drug payments do not apply toward your medical deductible.

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 deductible 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 deductible. Visit kp.org/deductibleplans to find out more about how preventive care services are covered.

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Section 2 | About Your Health Plan Options

UNDERSTANDING YOUR DEDUCTIBLE This table lists frequently used services and shows whether they are subject to your deductible. Either you’ll pay: •

Full charges for services that are subject to your deductible until you reach your deductible. 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 deductible. Copayments and coinsurance do not apply toward your deductible.

See the “Your Health Plan Benefits” section in this booklet for a list of services and their copayments or coinsurance.

Professional services

TYPE OF SERVICE

SUBJECT TO DEDUCTIBLE

Primary and specialty care visits

No

Routine preventive physical exams

No

Well-child preventive care visits (0–23 months)

No

Family planning visits

No

Scheduled prenatal visit

No

First postpartum visit

No

Eye exams

No

Hearing tests

No

Physical, occupational, and speech therapy visits

Yes

Outpatient surgery

Yes

Allergy injection visits

Yes

Allergy testing visits

No

Immunizations

No

X-rays, MRIs, CT scans, PET scans, and lab tests

Yes

Health education classes and programs

No

Hospital services

Room and board, surgery, anesthesia, X-rays, lab tests, and drugs

Yes

Emergency care

Emergency Department visits

Yes

Ambulance services

Yes

Most durable medical equipment for home use in accordance with our DME formulary

No

Inpatient psychiatric care

Yes

Outpatient visits

No

Inpatient detoxification

Yes

Outpatient individual therapy visits

No

Outpatient services

Ambulance services Durable medical equipment Mental health

Chemical dependency services

Home health services Other

Outpatient group therapy visits

No

Transitional residential recovery services

Yes

Home health care

No

Skilled nursing facility care

Yes

All diagnosis and treatment related to infertility

No

Hospice care

No

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HOW A DEDUCTIBLE 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 deductible: $1,000 Individual annual out-of-pocket maximum: $3,000 The amounts shown here are for illustration purposes only.

Individual member visits

SERVICE PROVIDED

Kim gets a physical exam.

Kim is sick and needs a chest X-ray.

The chest X-ray shows that Kim needs to be admitted to the hospital.

AMOUNT APPLIED TO KIM’S DEDUCTIBLE

WHAT KIM PAYS

AMOUNT APPLIED TO OUT-OF-POCKET MAXIMUM

$165

Routine preventive exam is covered at a $20 copayment per visit.

$0*

$20

$20

$75

Radiology services are at full charge before the deductible is met.

$75

$75

$75

$3,500

Hospital services are covered at 20% coinsurance after the deductible is met.

COST OF SERVICE

Year-to-date totals * Kim’s

KIM’S BENEFIT COVERAGE

$925

$925 + ($2,575 x 20% = $515)

$1,440

$1,440† $1,000‡

$1,535

$1,535

preventive care is not subject to the deductible, and her copayment does not apply toward the deductible.

Kim pays $925 to meet the rest of her $1,000 deductible, then pays coinsurance for the remaining hospital charges (20% of $2,575).

†

Kim’s deductible 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.

‡

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Section 2 | About Your Health Plan Options

HOW A DEDUCTIBLE HMO PLAN WORKS FOR A FAMILY With a family plan, each family member has a deductible, and the family as a whole has a deductible. If a family member meets his or her individual deductible before the family meets the family deductible, 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 deductibles or until the family meets the family deductible. Amounts applied toward individual deductibles also apply toward the family deductible. In these sample scenarios, Kim has a family. Her family plan has the following benefits: Copayment: $20 Coinsurance: 20% Individual deductible: $1,000 Family deductible: $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 deductible in the previous scenario also apply toward the family deductible, and her expenses of $1,535 apply toward the family annual out-of-pocket maximum.

Family member visit 1

SERVICE PROVIDED

COST OF SERVICE

KIM’S FAMILY BENEFIT COVERAGE

Family’s year-to-date totals from previous scenario

Kim’s child needs emergency care.

$1,000

Emergency Department visit is at full charge before the deductible is met.

Year-to-date totals

AMOUNT APPLIED TO CHILD’S DEDUCTIBLE

AMOUNT APPLIED TO FAMILY DEDUCTIBLE

WHAT KIM’S FAMILY PAYS

AMOUNT APPLIED TO OUT-OFPOCKET MAXIMUM

$0

$1,000

$1,535

$1,535

$1,000

$1,000

$1,000

$1,000

$1,000*

$2,000†

$2,535

$2,535

* Kim’s

child’s deductible has been met. Amounts applied toward her child’s individual deductible also apply toward the family deductible. The family deductible 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.

†

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Family member visit 2

SERVICE PROVIDED

COST OF SERVICE

KIM’S FAMILY BENEFIT COVERAGE

Family’s year-to-date totals from previous scenario

Kim’s husband needs knee replacement surgery.

$17,325

Inpatient hospital care is covered at 20% coinsurance after the deductible is met.

Year-to-date totals

AMOUNT APPLIED TO HUSBAND’S DEDUCTIBLE

AMOUNT APPLIED TO FAMILY DEDUCTIBLE

WHAT KIM’S FAMILY PAYS

AMOUNT APPLIED TO OUT-OFPOCKET MAXIMUM

$0

$2,000

$2,535

$2,535

$0 (family deductible already met)

$0 (family deductible already met)

$17,325 x 20% = $3,465

$3,465

$0

$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

SERVICE PROVIDED

COST OF SERVICE

KIM’S FAMILY BENEFIT COVERAGE

Family’s year-to-date totals from previous scenario Kim’s husband requires six months of physical therapy.

$3,000

Year-to-date totals

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Physical therapy is covered at a $20 copayment per visit.

AMOUNT APPLIED TO HUSBAND’S DEDUCTIBLE

AMOUNT APPLIED TO FAMILY DEDUCTIBLE

WHAT KIM’S FAMILY PAYS

AMOUNT APPLIED TO OUT-OFPOCKET MAXIMUM

$0

$2,000

$6,000

$6,000

$0 (family deductible already met)

$0 (family deductible already met)

$0 (out-of-pocket maximum already met)

$0 (out-of-pocket maximum already met)

$0

$2,000

$6,000

$6,000

Section 2 | About Your Health Plan Options

COMMON TERMS Here are some terms you’ll come across when reading about your deductible 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, deductibles, or coinsurance for most covered services for the rest of the calendar year. Not 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. Not all services are subject to the deductible. Copayments and coinsurance do not apply toward the deductible.

WE’RE HERE FOR YOUR HEALTH If you have questions about our deductible HMO plans, go to kp.org/deductibleplans, 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. •

1-800-390-3507 English

•

1-800-788-0616 Spanish

•

1-800-757-7585 Chinese dialects

•

1-800-777-1370 TTY for the hearing/ speech impaired

Section 2 | About Your Health Plan Options

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