Kaiser Permanente for Individuals and Families

2016 Enrollment Guide California

together in good health see how easy healthy can be

Making good health easier Experience the Kaiser Permanente difference The experience …

Without Kaiser Permanente

With Kaiser Permanente*

Choosing your doctor

All you know is that your doctor accepts your insurance.

You can search our doctor profiles on kp.org and choose the one who’s right for you. You can even change your doctor anytime.

Getting care in your language

Some health plans have few multilingual doctors.

We have multilingual doctors and staff, and we offer interpretation services by phone in 140+ languages.

Choosing how you get care

Even for minor concerns, you usually make an appointment, drive to the doctor’s office, and sit in the waiting room.

For minor concerns, you can request a phone appointment or email your doctor’s office with routine questions.

Calling for advice

When your child has a latenight fever, there’s often no medical advice available.

Specially trained Kaiser Permanente nurses can offer medical advice by phone, 24/7.

Making an appointment

Calling and waiting to schedule an appointment can take forever.

You can schedule routine appointments from your computer or mobile device — anytime, anywhere.

Seeing your doctor

Your doctor may need to flip through your files, hunting for details and looking for answers you’ve already given.

Your doctor has your medical history and prescriptions right at his or her fingertips through your electronic health record.

Remembering what your doctor said

Take lots of notes during your visit or trust your memory later.

You can view your past visit summaries and most lab test results online, whenever you want.

*These features are available when you get care at Kaiser Permanente facilities.

Kaiser Permanente for Individuals and Families

The right choice for your health Welcome to your Kaiser Permanente for Individuals and Families enrollment guide. This guide will help you select the right health plan for your needs. Read on to learn why Kaiser Permanente is the best choice.

How to use this guide Here are some questions you may have, and where you can find the answers in this guide. Why should I get health coverage?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Your health. Your way.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Good health begins with prevention. . . . . . . . . . . . . . . . . . . . . . . . . 3 Why you need coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

How do I enroll?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Important deadlines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Simple steps to enroll. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Which plan should I pick?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Understanding health plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Health plan benefit highlights. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Do you offer dental plans?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Optional Adult Dental Insurance Plan. . . . . . . . . . . . . . . . . . . . . . . 12 How much will coverage cost? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 You may qualify for federal financial assistance. . . . . . . . . . . . . . 15 Working out your rate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Where are you located?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Finding a facility near you. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Have questions? Call us at 1-800-494-5314.

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Or contact your agent or broker. 60330809 California 2016

Kaiser Permanente for Individuals and Families

Your health. Your way. Kaiser Permanente makes it easier for you to stay in charge of your health. It’s simple to make smart choices when you have great doctors and convenient facilities.

Choose and change your doctor

Care under one roof

It’s easy to stay connected

At Kaiser Permanente, we know how important it is to find a doctor who matches your specific needs. Even if you don’t need to see your doctor right away, having a doctor you connect with is an important part of taking care of your health.

Save time and avoid driving all over town for care.

As a Kaiser Permanente member, kp.org is your online gateway to great health. When you register on kp.org, you can securely access many time-saving tools and beneficial resources to help you manage your health and keep you feeling great.

To help you make the decision that’s right for you, you can browse our online doctor profiles where you can find information related to education, credentials, and specialties, as well as our doctors’ interest areas and if they are accepting new patients. You can also change your doctor at any time, for any reason.

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You’ll have many locations to choose from, and most of them offer multiple services under one roof. You can see your doctor, get a lab test or an X-ray, and pick up your medications — all without leaving the building.

Locations near you To find the location closest to your home, school, or office, visit buykp.org/facilities or turn to page 19 for a map of our locations.

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View most lab results.

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Refill most prescriptions.

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Getting care away from home Travel freely knowing that we’re committed to helping you take healthy trips away from home. At Kaiser Permanente, we’re available to help you understand what your health plan covers and how to get care before, during, and after your trip. Learn more at kp.org/travel.

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Email your doctor’s office with nonurgent questions. Schedule and cancel routine appointments. Print vaccination records for school, sports, and camp. Manage a family member’s health.

These features are available when you get care at Kaiser Permanente facilities.

For a guided tour of My Health Manager, visit kp.org/myhealthmanagertour.

Have questions? Call us at 1-800-494-5314. 60330809 California 2016

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Kaiser Permanente for Individuals and Families

Good health begins with prevention Kaiser Permanente gives you lots of healthy extras that can help you learn different ways to live healthier.

Preventive care at no cost

A website full of healthy ideas

Learn something new

No matter which Kaiser Permanente plan you choose, there’s no cost for preventive care services. These services can help you find health problems before they get serious, so you can treat them as soon as possible.

Get informed and inspired on our award-winning website, kp.org.

Fit wellness into your schedule, no matter how busy you are. With the many health classes offered at our facilities, there’s something for everyone. Try classes on yoga, eating well, baby care, ongoing health conditions, and much more. Classes vary by location and some may require a fee. Visit kp.org/ classes for course listings in your area.

Here are some examples of preventive care services: ■■

Routine physical exams

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Well-child visits

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Well-woman visits

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Annual flu shots

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Routine lab tests

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Autism screenings

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Mammogram screenings

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Contraceptive care and counseling

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Take charge of your health with articles, wellness topics, health calculators, and preferred rates on complementary health and fitness programs. Sign up for online wellness programs that can help you lose weight, stay active, reduce stress, sleep better, stop smoking, and much more. Check out our music channels, podcasts, fitness videos, and recipes from world-class chefs. Visit kp.org/livehealthy to explore more new and inspiring ways to live well and thrive.

Breastfeeding support For a complete list of our preventive care services, visit kp.org/prevention. ■■

Learn more about the doctors available in your area at kp.org/searchdoctors.

Have questions? Call us at 1-800-494-5314.

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Kaiser Permanente for Individuals and Families

Why you need coverage Health coverage is something you can’t afford to be without. Kaiser Permanente makes it easy for you to get great care and coverage.

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Health care reform — what you should know It’s now the law that most U.S. residents must have health coverage. If you go without it, you may have to pay a tax penalty to the federal government. When you do your taxes for 2015, you’ll have to submit a form to show proof you had health coverage to avoid the penalty (or show proof that you aren’t required to have coverage because you qualify for an exemption). Why choose Kaiser Permanente? ■

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All the plans you’ll see in this enrollment guide meet the standards of the new health care law, and offer the same basic services, such as doctor visits, hospital care, prescriptions, and preventive care at no cost. You can buy one of our plans from us or through the Health Insurance Marketplaces.

Health coverage — why you need it Almost everyone gets sick or hurt, or needs medical help at some point. To get better, you usually need care — like seeing a doctor, staying in a hospital, or taking medication. On top of that, health care helps keep you healthy. Preventive care — like mammograms and cholesterol tests — can help catch health problems early, when they’re easier to treat. Health coverage helps you pay for all this care and protects you financially — much like the coverage people get to protect their car or home. Without coverage, high medical bills can wipe out savings and even lead to personal bankruptcy.

Join our 4-star health plan today We’re proud to be awarded the highest rating of 4 stars from Covered California because of our quality doctors, care, customer service, and access.* But we’re even happier knowing that we can help our members statewide be their healthiest. *These scores are based on California data collected by the nationally recognized Consumer Assessment of Healthcare Providers and Systems (CAHPS). View the health plan ratings at http://hbex.coveredca.com/insurance-companies/ratings/.

Have questions? Call us at 1-800-494-5314. 60330809 California 2016

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Go to buykp.org/apply. 4

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Or contact your agent or broker.

Kaiser Permanente for Individuals and Families

Important deadlines There’s a deadline to apply for health care coverage, whether you apply during open enrollment or during a special enrollment period.

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, 2016.

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, 2016. You can do so either through Covered California or through Kaiser Permanente. To start coverage on:

Your completed application and premium must be received by:

January 1, 2016 February 1, 2016 March 1, 2016

December 15, 2015 January 15, 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 1-800-494-5314 to request a copy.

Have questions? Call us at 1-800-494-5314.

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Go to buykp.org/apply. 5

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Or contact your agent or broker. 60330809 California 2016

Kaiser Permanente for Individuals and Families

Simple steps to enroll 1. Choose a plan

You can cover your entire family under the same plan or separate plans.

2. Calculate your rate

Use the rate calculator on page 17 to find out what your monthly rate would be for the plan you choose.

3. See if you’re eligible for federal financial assistance

If you qualify, the federal government will pay any federal financial assistance to Kaiser Permanente on your behalf. Help may be available for monthly premiums or out-of-pocket costs, such as copays, coinsurance, or deductibles. See “You may qualify for federal financial assistance” on page 15 for more information.

4. Complete your application

Complete an online application at buykp.org/apply or use a paper application. 

5. Select your payment method

Payment for your first month’s coverage is required with your application. You can pay by check, money order, debit card, or credit card.

6. Sign the application 

7. Submit the application with payment and all necessary documentation ■

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Online: For the fastest response, enroll online today at buykp.org/apply. Or if you’re working with an agent or broker, use the personalized link he or she has provided. Fax: 1-866-816-5139 (if paying by debit or credit card) Mail: Kaiser Permanente, California Service Center — KPIF



P.O. Box 23219



San Diego, CA 92193-9921

Have questions? Call us at 1-800-494-5314. 60330809 California 2016

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Kaiser Permanente for Individuals and Families

Understanding health plans We offer a variety of plans to fit your needs and budget. All of them offer the same quality care, but the way they split the costs between the member and the health plan is different. Learn more below.

Copay and coinsurance plans

Deductible plans

HSA-qualified deductible plans

Platinum, Gold

Silver, Bronze

Silver, Bronze

Copay and coinsurance plans are the simplest. You know in advance how much you will pay for things like doctor visits and prescriptions. Your monthly rate is higher, but you’ll pay much less when you actually get care.

With a deductible plan, your monthly rate is lower, but you’ll have to reach a deductible. This means you’ll pay the full charges for covered services until you reach a set amount known as your deductible. Then you’ll start paying less — just a copay or coinsurance. Depending on your plan, some services, like office visits or prescriptions, may be available at a copay or coinsurance before you meet your deductible.

HSA-qualified deductible plans are just like deductible plans, with one added benefit. With this plan, you can set up a health savings account (HSA) to pay for health costs like copays, coinsurance, and deductible payments. And you won’t pay federal taxes on the money in this account. You can use your HSA anytime to pay for care, including some services that may not be covered by your plan, such as eyeglasses, adult dental care, or chiropractic services.* And if you have money left in your HSA at the end of the year, it will roll over for you to use the next year.

*For a complete list of services you can use your HSA to pay for, see Publication 502, Medical and Dental Expenses, at irs.gov.

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Kaiser Permanente for Individuals and Families

Choosing a plan based on your care needs If you need a lot of care, you may want a plan with a higher monthly rate so that you pay less when you come in for care. If you don’t go to the doctor much, you may want a plan with a lower monthly rate, keeping in mind you’ll pay more if and when you do get care. Monthly rate versus out-of-pocket costs

Metal name

What you pay for your monthly rate

What you pay when you get care (Emergency Department visit, lab test, etc.)

Platinum Gold Silver Bronze

An example of costs when you get care Let’s say you hurt your ankle. You visit your primary care doctor, who orders an X-ray. It’s just a sprain, so the doctor prescribes a generic pain medication. Here’s a sample of what you would pay out of pocket for these services with each type of health plan.

Office visit

X-ray

Generic drug

KP Gold 80 HMO Coinsurance (No deductible)

$35

$50

$15

KP Silver 70 HMO 1500/40 ($1,500 deductible)

$40

$40*

$20

40%*

40%*

40%*

Plan name

KP Bronze 60 HSA HMO ($4,500 deductible) *If you’ve met your deductible

The cost estimates above are from our estimate tools website, kp.org/treatmentestimates. Visit this site anytime to get an idea of what the charges for common services might be before you meet your deductible.

Have questions? Call us at 1-800-494-5314. 60330809 California 2016

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Kaiser Permanente for Individuals and Families

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

KP

Offered through Kaiser Permanente

M

Offered through the Marketplace, Covered California

KP Kaiser Permanente — Silver 70 HMO 1500/40 Plan type

Annual deductible

Deductible

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 $1,500 for yourself or $3,000 for your family. Then you’d start paying copays or coinsurance.

Features Annual medical deductible (individual/family)

$1,500/$3,000

Annual out-of-pocket maximum (individual/family)

$6,500/$13,000

Benefits Preventive care

Routine physical exam, mammograms, etc.

Annual out-of-pocket maximum

No charge

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 $6,500 for yourself and no more than $13,000 for your family for your copays, coinsurance, and deductible in a calendar year.

Outpatient services (per visit or procedure) Primary care office visit Specialty care office visit Most X-rays

$40 $40 $40 after deductible

Most lab tests

$35 after deductible

MRI, CT, PET

$250 after deductible

Outpatient surgery

30% after deductible

Mental health visit

$40

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 deductible.

Inpatient hospital care Room and board, surgery, anesthesia, X-rays, lab tests, medications, mental health care

30% after deductible

Covered before you reach the deductible

Maternity

Routine prenatal care visit, first postpartum visit Delivery and inpatient well-baby care

With some services, you’ll only pay a copay or coinsurance, regardless of whether you’ve reached your deductible. Under this plan, primary care visits are covered at a $40 copay — even before you meet your deductible. With our Silver deductible plans, primary care, specialty care, and urgent care visits all are covered before you reach the deductible.

No charge 30% after deductible

Emergency and urgent care Emergency Department visit Urgent care visit Ambulance services

$250 after deductible

$40 $250 after deductible

Coinsurance

Prescription drugs (up to a 30-day supply) Generic

After reaching your deductible, 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 deductible. Your plan would pay the rest for the remainder of the calendar year.

$20 ‡

Preferred brand

$50 after $250 brand deductible ‡

Non-preferred brand

$50 after $250 brand deductible ‡

Specialty

30% after $250 brand deductible, up to $250 per prescription

Copay This is the set amount you pay for covered services, usually after you reach your deductible. In this example, you’d start paying a $40 copay for urgent care visits, whether or not you have met your deductible.

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Kaiser Permanente for Individuals and Families KP

Offered through Kaiser Permanente

M

Offered through the Marketplace, Covered California

KP

M

Financial assistance options with lower copays, coinsurance, and deductibles are available for certain plans, and for Native Alaskans and American Indians on CoveredCA.com. KP

KP

KP

M

KP

M

Kaiser Permanente — Bronze 60 HMO

Kaiser Permanente — Bronze 60 HSA HMO 5500/40%

Kaiser Permanente — Bronze 60 HSA HMO

Kaiser Permanente — Silver 70 HSA HMO 2700/15%

Kaiser Permanente — Silver 70 HMO

Deductible

HSA-qualified

HSA-qualified

HSA-qualified

Deductible

Annual medical deductible (individual/family)

$6,000/$12,000

$5,500/$11,000

$4,500/$9,000

$2,700/$5,400

$2,250/$4,500

Annual out-of-pocket maximum (individual/family)

$6,500/$13,000

$6,500/$13,000

$6,500/$13,000

$6,500/$13,000

$6,250/$12,500

No charge

No charge

No charge

No charge

No charge

Primary care office visit

$70 after deductible*

40% after deductible

40% after deductible

15% after deductible

$45

Specialty care office visit

$90 after deductible*

40% after deductible

40% after deductible

15% after deductible

$70

Most X-rays

100% up to annual out-of-pocket maximum

40% after deductible

40% after deductible

15% after deductible

$65

Most lab tests

$40 (deductible waived)

40% after deductible

40% after deductible

15% after deductible

$35

MRI, CT, PET

100% up to annual out-of-pocket maximum

40% after deductible

40% after deductible

15% after deductible

$250

Outpatient surgery

100% up to annual out-of-pocket maximum

40% after deductible

40% after deductible

15% after deductible

20%

Mental health visit

$70 after deductible*

40% after deductible

40% after deductible

15% after deductible

$45

100% up to annual out-of-pocket maximum

40% after deductible

40% after deductible

15% after deductible

20% after deductible

No charge

No charge

No charge

No charge

No charge

100% up to annual out-of-pocket maximum

40% after deductible

40% after deductible

15% after deductible

20% after deductible

100% up to annual out-of-pocket maximum

40% after deductible

40% after deductible

15% after deductible

$300 per visit after deductible

Plan type Features

Benefits Preventive care Routine physical exam, mammograms, etc. Outpatient services (per visit or procedure)

Inpatient hospital care Room and board, surgery, anesthesia, X-rays, lab tests, medications, mental health care Maternity Routine prenatal care visit, first postpartum visit Delivery and inpatient well-baby care Emergency and urgent care Emergency Department visit Urgent care visit

$70 after deductible*

40% after deductible

40% after deductible

15% after deductible

$45

100% up to annual out-of-pocket maximum

40% after deductible

40% after deductible

15% after deductible

$250 after deductible

Generic

100% after $500 drug deductible, up to $500 per prescription†

40% after deductible

40% after deductible

15% after deductible

$15‡

Preferred brand

100% after $500 drug deductible, up to $500 per prescription†

40% after deductible

40% after deductible

15% after deductible

$50 after $250 brand deductible ‡

Non-preferred brand

100% after $500 drug deductible, up to $500 per prescription†

40% after deductible

40% after deductible

15% after deductible

$50 after $250 brand deductible ‡

Specialty

100% after $500 drug deductible, up to $500 per prescription†

40% after deductible

40% after deductible

15% after deductible

20% after $250 brand deductible, up to $250 per prescription

Ambulance services Prescription drugs (up to a 30-day supply)

‡  Mail order: 90-day supply of qualified prescriptions for the cost of a 60-day supply *The   Kaiser Permanente — Bronze 60 HMO plan includes 3 office visits for the benefit copay before you reach your deductible. Office visits include primary, specialty, urgent, postnatal, or outpatient mental health care. †  No charge after annual out-of-pocket maximum is reached.

This plan summary is intended to highlight only some of the most frequently asked-about benefits and their copays, coinsurance, and deductibles. Please refer to the Membership Agreement, Disclosure Form, and Evidence of Coverage for more details on your plan or for specific limitations and exclusions. To request a copy of the Membership Agreement, Disclosure Form, and Evidence of Coverage, please call us at 1-800-634-4579 or contact your broker. For services subject to the deductible, you’ll have to pay health care expenses out of pocket until you meet your deductible. Most deductibles, copays, and coinsurance contribute to the out-of-pocket maximum.

Have questions? Call us at 1-800-494-5314. 60330809 California 2016

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Go to buykp.org/apply. 10

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Or contact your agent or broker.

Kaiser Permanente for Individuals and Families KP

Offered through Kaiser Permanente

M

Offered through the Marketplace,

Financial assistance options with lower copays, coinsurance, and deductibles are available for certain plans, and for Native Alaskans and American Indians on CoveredCA.com.

Covered California

KP

KP

KP

Kaiser Permanente — Silver 70 HMO 1500/40

Kaiser Permanente — Gold 80 HMO Coinsurance

Kaiser Permanente — Gold 80 HMO Copay

Kaiser Permanente — Platinum 90 HMO

Kaiser Permanente — Minimum Coverage**

Deductible

Copayment

Copayment

Copayment

Deductible

Annual medical deductible (individual/family)

$1,500/$3,000

None/None

None/None

None/None

$6,850/$13,700

Annual out-of-pocket maximum (individual/family)

$6,500/$13,000

$6,200/$12,400

$6,200/$12,400

$4,000/$8,000

$6,850/$13,700

No charge

No charge

No charge

No charge

No charge

$40

$35

$35

$20

First 3 office visits no charge.†† Additional visits no charge after deductible.

Plan type

KP

M

KP

M

M

Features

Benefits Preventive care Routine physical exam, mammograms, etc. Outpatient services (per visit or procedure) Primary care office visit Specialty care office visit Most X-rays

$40

$55

$55

$40

No charge after deductible

$40 after deductible

$50

$50

$40

No charge after deductible

Most lab tests

$35 after deductible

$35

$35

$20

No charge after deductible

MRI, CT, PET

$250 after deductible

20%

$250

$150

No charge after deductible

Outpatient surgery

30% after deductible

20%

$655

$290

No charge after deductible

Mental health visit

$40

$35

$35

$20

First 3 office visits no charge.†† Additional visits no charge after deductible.

30% after deductible

20%

$655 per day up to 5 days§

$290 per day up to 5 days§

No charge after deductible

No charge

No charge

No charge

No charge

No charge

30% after deductible

20%

$655 per day up to 5 days

$250 after deductible

$250

$250

$150

No charge after deductible

$40

$35

$35

$20

No charge after deductible

$250 after deductible

$250

$250

$150

No charge after deductible

$20 ‡

$15‡

$15‡

$5‡

No charge after deductible

Preferred brand

$50 after $250 brand deductible ‡

$50 ‡

$50 ‡

$15‡

No charge after deductible

Non-preferred brand

$50 after $250 brand deductible ‡

$50 ‡

$50 ‡

$15‡

No charge after deductible

30% after $250 brand deductible, up to $250 per prescription

20% up to $250 per prescription

20% up to $250 per prescription

10% up to $250 per prescription

No charge after deductible

Inpatient hospital care Room and board, surgery, anesthesia, X-rays, lab tests, medications, mental health care Maternity Routine prenatal care visit, first postpartum visit Delivery and inpatient well-baby care

§

$290 per day up to 5 days

§

No charge after deductible

Emergency and urgent care Emergency Department visit Urgent care visit Ambulance services Prescription drugs (up to a 30-day supply) Generic

Specialty

 Mail order: 90-day supply of qualified prescriptions for the cost of a 60-day supply  After 5 days, there is no charge for covered services related to the admission. **O   nly applicants younger than age 30, or applicants age 30 and older who provide a certificate from Covered California demonstrating hardship or lack of affordable coverage, may purchase a Minimum Coverage plan. †† The   Kaiser Permanente — Minimum Coverage plan includes 3 office visits at no charge before you reach your deductible. Office visits include primary, urgent, postnatal, or outpatient mental health care. ‡ §

This plan summary is intended to highlight only some of the most frequently asked-about benefits and their copays, coinsurance, and deductibles. Please refer to the Membership Agreement, Disclosure Form, and Evidence of Coverage for more details on your plan or for specific limitations and exclusions. To request a copy of the Membership Agreement, Disclosure Form, and Evidence of Coverage, please call us at 1-800-634-4579 or contact your broker. For services subject to the deductible, you’ll have to pay health care expenses out of pocket until you meet your deductible. Most deductibles, copays, and coinsurance contribute to the out-of-pocket maximum.

Have questions? Call us at 1-800-494-5314.

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Or contact your agent or broker. 60330809 California 2016

Kaiser Permanente for Individuals and Families

Optional Adult Dental Insurance Plan Kaiser Permanente health plans include pediatric dental benefits for child members through the end of the month in which they turn 19. (For example, if a child member turns 19 on May 15, they would have dental coverage through May 31.) For adults, which includes those individuals whose eligibility for pediatric dental services has ended, we offer this optional Dental Insurance Plan.

How to enroll To enroll in the optional adult Dental Insurance Plan, simply check the right box on your application. ■■



About the plan Our dental plan features comparably low costs. Plus, you can choose from more than 25,000 Delta Dental providers in California, or select any other licensed dentist of your choice. When you see a Delta Dental provider

When you see another provider

You’ll pay the difference between what the dentist charges and what the plan pays. ■■

■■

You may be responsible for the entire bill up front.



For example, if the dentist charges $75* for a cleaning and the plan covers $43.20, you’ll pay $31.80.

Once enrolled, you can’t cancel your dental coverage without canceling your regular health coverage, unless you make the change during open enrollment.

You won’t have to file a claim.

Then you’ll need to file a claim and wait to receive reimbursement later.

You may pay less because the Delta Dental PPO network providers agree to contracted fees.

Your share of the bill will likely be higher than when you visit a Delta Dental PPO provider.

For a list of PPO or Premier providers in your area, visit deltadentalins.com.

2016 rate Monthly rate per adult member, which includes those individuals whose eligibility for pediatric dental services has ended

$27.54

The optional adult Dental Insurance Plan is administered by Delta Dental of California, one of the nation’s largest and most experienced dental benefits providers. The plan is underwritten by Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc. * Service charges vary.

Have questions? Call us at 1-800-494-5314. 60330809 California 2016

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Go to buykp.org/apply. 12

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Or contact your agent or broker.

Kaiser Permanente for Individuals and Families

What the plan covers If you enroll in the dental plan, you’ll get a Certificate of Insurance, which includes a Table of Allowances that lists all your covered services and the amount the plan pays for them.* Sample list† The following is a SAMPLE list of allowances. See your Certificate of Insurance for the complete Table of Allowances.

Procedure

What the plan pays

Diagnostic procedures Oral exam — new or existing patient

$25.20

X-rays — complete series including bitewings

$54.00

Preventive procedures Cleaning

$43.20

Restorative procedures Fillings Note: Fillings are subject to a 6-month waiting period.‡

Amalgam — one surface, primary or permanent

$35.00

Resin-based composite — one surface, anterior

$46.00

Crowns Note: Crowns are subject to a 6-month waiting period.‡

Resin with high noble metal

$182.00

Endodontic procedures Root canal Note: Root canals are subject to a 6-month waiting period.‡

Anterior (excluding final restoration)

$193.00

Bicuspid (excluding final restoration)

$227.00

Molar (excluding final restoration)

$306.00

Oral and maxillofacial surgical procedures Note: Oral and maxillofacial surgical procedures are subject to a 6-month waiting period.‡

Extraction, erupted tooth, or exposed root (elevation and/or forceps removal)

$39.00

Surgical removal of erupted tooth requiring removal of bone and/or section of tooth

$74.00

* The Table of Allowances lists the maximum amount, or allowance, that the plan will pay for each covered dental service. The plan will pay the lowest dollar amount among the following three: the dentist’s usual, customary, and reasonable fee; the fee actually charged; or the allowance. Any difference between the allowance and the dentist’s fee will be the responsibility of the patient. † Plan payment amounts are only a sample and are to be used for illustrative purposes only. Please refer to the Table of Allowances in the Certificate of Insurance for an accurate and complete list of benefits and allowances, as well as treatments and services not covered. To receive a Certificate of Insurance, call Delta Dental of California. ‡ The waiting period is the period of time you and your covered dependents are required to be continuously covered under the Dental Insurance Plan before a specific dental service becomes a covered benefit.

Have questions? Call us at 1-800-494-5314.

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Go to buykp.org/apply. 13

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Or contact your agent or broker. 60330809 California 2016

Kaiser Permanente for Individuals and Families

Optional Adult Dental Insurance Plan (continued)

➜

How the plan works • No deductible for preventive services. The deductible is the amount you pay for covered services each year before Delta Dental starts paying. With this plan, there’s no deductible for preventive or diagnostic services like cleanings and X-rays. For other services, there’s a $25 annual deductible per person, up to a maximum of $75 for your whole family. • Coverage requirements. If you enroll, every adult member of your family (which includes those individuals whose eligibility for pediatric dental services has ended) who’s covered by your regular health plan must also be enrolled. In other words, you can’t choose to enroll some members of your family in the dental plan and not others. • Annual maximum. The plan will pay up to a $1,000 toward dental services for each covered member per year. • Waiting periods. Some covered dental services are subject to a waiting period before the plan will cover the charges.* See the Table of Allowances in your Certificate of Insurance for the specific dental services subject to waiting periods.

➜

Have questions? If you have questions before enrolling, call 1-800-933-9312, 8 a.m. to 4 p.m., Monday through Friday. ■■

■■

You can also visit deltadentalins.com for a list of PPO or Premier providers in your area.

* The waiting period is the period of time you and your covered dependents are required to be continuously covered under the Dental Insurance Plan before a specific dental service becomes a covered benefit.

Have questions? Call us at 1-800-494-5314. 60330809 California 2016

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Go to buykp.org/apply. 14

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Or contact your agent or broker.

Kaiser Permanente for Individuals and Families

You may qualify for federal financial assistance Do you need help paying for health care? Under health care reform, the federal government will provide federal financial assistance for many people, depending on their income. Learn more below.

3 things to know: ■■

■■

■■

➜

Determine if you qualify

Financial assistance is available for premiums and out-of-pocket expenses.

Call us at 1-800-494-5314 or go to CoveredCA.com to see if you qualify for assistance. (For TTY for the deaf, hard of hearing, or speech impaired, call 711). Or contact your agent or broker.

If you qualify for assistance, the federal government will pay us directly for it.

Both your eligibility and the exact amount of your financial assistance will be determined by Covered California.

Assistance is available on a sliding scale, based on income and family size.

To quickly check if you may be eligible, use this chart, which shows the estimated family income levels that qualify people for help paying premiums.

Number of people in household

Annual family income level

1

$47,080 or below

2

$63,720 or below

3

$80,360 or below

4

$97,000 or below

5

$113,640 or below

6

$130,280 or below

7

$146,920 or below

8

$163,560 or below

You can also use our online calculator to find out if you may qualify. Just go to buykp.org.

➜

If you do qualify If you qualify, you’ll need to buy your plan through Covered California. If you’d like, we can help you enroll in one of our plans there. Just call us at 1-800-494-5314 (TTY 711 for the deaf, hard of hearing, or speech impaired). Avoid being billed twice: If you do enroll in a plan through Covered California, cancel your current Kaiser Permanente plan by calling our Member Service Contact Center at 1-800-464-4000 on or before the start date of your new plan.

➜

If you don’t qualify Even if you can’t get assistance from the federal government, you can buy a Kaiser Permanente plan from us or through Covered California.

Have questions? Call us at 1-800-494-5314.

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Go to buykp.org/apply. 15

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Or contact your agent or broker. 60330809 California 2016

Kaiser Permanente for Individuals and Families

Working out your rate Use the rate calculator and monthly rates chart on the following pages 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. See page 8 for more information.

What determines your rate?

The rates on page 18 apply to the ZIP codes below. Please check that your ZIP code is listed below. If it isn’t, call us at 1-800-494-5314 for information on other rate areas.

Your rate is based on the following: ■ ■ ■

The plan you select Where you live, based on your county and ZIP code

County and ZIP codes for Rate Area 14

Your age on your start date (effective date)

County

If you add the optional Dental Insurance Plan for adult family members, which includes those individuals whose eligibility for pediatric dental services has ended 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. ■

Kern ZIP codes within this county

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.

93203

93240–41

93285

93504–05

93205–06

93243

93287

93518–19

93215–16

93249–52

93301–09

93531

93220

93263

93311–14

93536

93222

93268

93380

93560–61

93224–26

93276

93383–90

93581

93238

93280

93501–02

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.

Have questions? Call us at 1-800-494-5314. 60331216 California 2016

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Go to buykp.org/apply. 16

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Or contact your agent or broker.

Kaiser Permanente for Individuals and Families

Rate calculator To figure out the total monthly rate for your health plan for you and your family, just follow these steps. Or, if you apply online through buykp.org/apply, your rate will be calculated automatically. 1. On the worksheet below, list everyone you want to cover: ■ ■ ■ ■

3. Find the rate for each family member, based on his or her age on the start date.

Yourself Your spouse or domestic partner Each adult child 21 through 25 Your 3 oldest children under 21 (other children under 21 are covered at no charge)

4. If you are adding the optional Dental Insurance Plan for adults, which includes those individuals whose eligibility for pediatric dental services has ended, please add $27.54 per adult to your monthly rates. 5. Add up the rates.

2. Find the plan you’re considering in the rate chart on the next page.

Your monthly rate worksheet Plan choice Family member name

A Family member age

Subtotal for health plan monthly rate Optional adult Dental Insurance Plan (add $27.54 per adult, which includes any individual whose eligibility for pediatric dental services has ended) Total health plan monthly rate

B

C

Rate for plan A

Rate for plan B

Rate for plan C

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

____ × $27.54 = $________ $

Have questions? Call us at 1-800-494-5314.

____ × $27.54 = $________ $

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Go to buykp.org/apply. 17

____ × $27.54 = $________ $

•

Or contact your agent or broker. 60331216 California 2016

Kaiser Permanente for Individuals and Families

Do you qualify for federal financial assistance?

Rate Area 14

Kaiser

Age on 2016 Permanente — Bronze 60 effective date HMO

0–18 19–20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64+

$123.22 123.22 194.05 194.05 194.05 194.05 194.82 198.70 203.36 210.93 217.14 220.24 224.90 229.56 232.47 235.57 237.12 238.68 240.23 241.78 244.89 247.99 252.65 257.11 263.32 271.08 280.20 291.07 303.29 317.27 331.04 346.57 361.90 378.78 395.85 414.29 432.72 452.71 472.89 494.43 505.10 526.64 545.27 557.50 572.82 582.15

If so, you may pay lower rates than those listed in this chart. See page 15 for details. Kaiser Permanente — Bronze 60 HSA HMO 5500/40%

Kaiser Permanente — Bronze 60 HSA HMO

Kaiser Permanente — Silver 70 HSA HMO 2700/15%

Kaiser Permanente — Silver 70 HMO

Kaiser Permanente — Silver 70 HMO 1500/40

Kaiser Permanente — Gold 80 HMO Coinsurance

Kaiser Permanente — Gold 80 HMO Copay

Kaiser Permanente — Platinum 90 HMO

$117.17 117.17 184.52 184.52 184.52 184.52 185.25 188.94 193.37 200.57 206.47 209.42 213.85 218.28 221.05 224.00 225.48 226.95 228.43 229.91 232.86 235.81 240.24 244.48 250.39 257.77 266.44 276.77 288.40 301.68 314.78 329.54 344.12 360.17 376.41 393.94 411.47 430.47 449.66 470.14 480.29 500.77 518.49 530.11 544.69 553.56

$120.05 120.05 189.05 189.05 189.05 189.05 189.80 193.59 198.12 205.50 211.55 214.57 219.11 223.64 226.48 229.51 231.02 232.53 234.04 235.55 238.58 241.60 246.14 250.49 256.54 264.10 272.99 283.57 295.48 309.09 322.52 337.64 352.58 369.02 385.66 403.62 421.58 441.05 460.71 481.70 492.09 513.08 531.23 543.14 558.07 567.15

$141.65 141.65 223.07 223.07 223.07 223.07 223.96 228.42 233.78 242.48 249.62 253.19 258.54 263.89 267.24 270.81 272.59 274.38 276.16 277.95 281.52 285.08 290.44 295.57 302.71 311.63 322.11 334.61 348.66 364.72 380.56 398.40 416.03 435.43 455.06 476.26 497.45 520.42 543.62 568.38 580.65 605.41 626.83 640.88 658.50 669.21

$161.81 161.81 254.81 254.81 254.81 254.81 255.83 260.93 267.04 276.98 285.14 289.21 295.33 301.44 305.27 309.34 311.38 313.42 315.46 317.50 321.57 325.65 331.77 337.63 345.78 355.97 367.95 382.22 398.27 416.62 434.71 455.10 475.23 497.40 519.82 544.03 568.23 594.48 620.98 649.27 663.28 691.56 716.03 732.08 752.21 764.43

$156.86 156.86 247.02 247.02 247.02 247.02 248.01 252.95 258.88 268.51 276.42 280.37 286.30 292.22 295.93 299.88 301.86 303.83 305.81 307.79 311.74 315.69 321.62 327.30 335.21 345.09 356.70 370.53 386.09 403.88 421.42 441.18 460.69 482.18 503.92 527.39 550.85 576.30 601.99 629.41 642.99 670.41 694.13 709.69 729.20 741.06

$183.93 183.93 289.65 289.65 289.65 289.65 290.81 296.61 303.56 314.85 324.12 328.76 335.71 342.66 347.01 351.64 353.96 356.27 358.59 360.91 365.54 370.18 377.13 383.79 393.06 404.65 418.26 434.48 452.73 473.58 494.15 517.32 540.20 565.40 590.89 618.41 645.93 675.76 705.89 738.04 753.97 786.12 813.93 832.18 855.06 868.95

$192.62 192.62 303.34 303.34 303.34 303.34 304.55 310.62 317.90 329.73 339.44 344.29 351.57 358.85 363.40 368.26 370.68 373.11 375.54 377.96 382.82 387.67 394.95 401.93 411.63 423.77 438.02 455.01 474.12 495.96 517.50 541.77 565.73 592.12 618.82 647.63 676.45 707.70 739.24 772.91 789.60 823.27 852.39 871.50 895.46 910.02

$208.50 208.50 328.34 328.34 328.34 328.34 329.65 336.22 344.10 356.91 367.41 372.67 380.55 388.43 393.35 398.61 401.23 403.86 406.49 409.11 414.37 419.62 427.50 435.05 445.56 458.69 474.12 492.51 513.20 536.84 560.15 586.42 612.36 640.92 669.82 701.01 732.20 766.02 800.17 836.61 854.67 891.12 922.64 943.32 969.26 985.02

Kaiser Permanente — Minimum Coverage

$109.78 109.78 172.88 172.88 172.88 172.88 173.57 177.03 181.18 187.92 193.45 196.22 200.37 204.52 207.11 209.88 211.26 212.64 214.02 215.41 218.17 220.94 225.09 229.06 234.60 241.51 249.64 259.32 270.21 282.66 294.93 308.76 322.42 337.46 352.67 369.10 385.52 403.33 421.31 440.50 450.00 469.19 485.79 496.68 510.34 518.64

Rates are effective January 1, 2016, through December 31, 2016.

Have questions? Call us at 1-800-494-5314. 60331216 California 2016

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Go to buykp.org/apply. 16 18

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Or contact your agent or broker.

Kaiser Permanente for Individuals and Families

Finding a facility near you

Our goal is to make it as easy and convenient as possible for you to get the care you need when you need it. Please refer to the map below or search for a facility by ZIP code or keywords at buykp.org/facilities to find the one nearest you. Northern California The following information can help you find Kaiser Permanente and affiliated facilities in your community.

Fresno County

Maps not to scale

n Kaiser Permanente medical centers (hospital and medical offices)

● Kaiser Permanente medical offices

Affiliated medical offices

Affiliated plan hospitals

Have questions? Call us at 1-800-494-5314.

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Go to buykp.org/apply. 19

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Or contact your agent or broker. 60331025 California 2016

Kaiser Permanente for Individuals and Families Sierra Nevada Mountains China Lake Naval Weapons Center

Southern California The following information can help you find Kaiser Permanente and affiliated facilities in your community. Tehachapi Mountains

Kern County area Edwards Air Force Base

San Bernardino National Forest

San Bernardino Mountains

Cleveland National Forest San Jacinto Mountains San Bernardino National Forest Santa Rosa Mountains

Anza-Borrego Desert State Park

Cleveland National Forest

Maps not to scale

n Kaiser Permanente medical centers (hospital and medical offices)

● Kaiser Permanente medical offices Affiliated plan hospitals

Have questions? Call us at 1-800-494-5314. 60331025 California 2016

Affiliated medical offices

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Go to buykp.org/apply. 20

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Or contact your agent or broker.

60033481

Help in your language Interpreter services, including sign language, are available during all hours of operation at no cost to you. We can also provide you, your family, and friends with any special assistance needed to access our facilities and services. In addition, you may request health plan materials translated in your language, and may also request these materials in large text or in other formats to accommodate your needs. For more information, call our Member Service Contact Center 24 hours a day, seven days a week (except closed holidays, and closed after 5 p.m. the day after Thanksgiving, after 5 p.m. on Christmas Eve, and after 5 p.m. on New Year’s Eve) at 1-800-464-4000 (TTY users call 711).

Ayuda en su idioma Se ofrecen servicios de intérprete sin costo alguno para usted durante todo el horario de atención, incluida la lengua de señas (sign language). También podemos ofrecerles a usted y a sus familiares y amigos todo tipo de ayuda especial que necesiten para tener acceso a nuestros centros y servicios. Además, puede solicitar que los materiales del plan de salud se traduzcan a su idioma, y que estos materiales sean con letra grande o en otros formatos que se acomoden a sus necesidades. Para obtener más información llame a la Central de Llamadas de Servicio a los Miembros las 24 horas del día, los siete días de la semana (excepto los días festivos y después de las 5 p. m. el día después de Thanksgiving [Día de Acción de Gracias], y las vísperas de Navidad y Año Nuevo) al 1-800-788-0616 (usuarios de TTY llamen al 711).

以您的語言提供協助 我們在辦公時間內免費為您提供口譯服務，包括手語在內。我們也可以向您本人、您的家人和 朋友提供使用我們設施和服務时所需的任何特別協助。此外，您可以要求將會員資料翻譯成您 的語言，並且要求這些資料以大字版或其他格式來滿足您的需求。如需更多資訊，請致電我們 的會員服務電話中心，我們每週7天，每天24小時為您服務（節假日全天以及感恩節翌日、聖 誕節前夕和新年前夕下午 5 時後休息），電話號碼是 1-800-757-7585（免費電話）（TTY使用 者請撥711）。

60341921

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 1-800-494-5314 (711 TTY for the deaf, hard of hearing, or speech impaired).

Kaiser Foundation Health Plan, Inc. California Service Center - KPIF P.O. Box 23219 San Diego, CA 92193-9921 Please recycle. 60329608 California 2016

kp.org