HMO PLANS What is an HMO plan? How does it work? Key terms Features

Transcription

1 HMO PLANS What is an HMO plan? How does it work? Key terms Features

2 HMO PLANS Value. Simplicity. Choice. Our HMO plans offer all three. If you re looking for great value and simplicity, then one of our HMO plans could be your best option. You can choose from six plans, each with different coverage and rates. When you choose a Kaiser Permanente HMO plan, you ll enjoy time-saving convenience and high-quality, personalized care. Our HMO plans offer the flexibility you need, with affordable choices ranging from plans with low copays and low deductibles, to plans with higher out-of-pocket costs but lower monthly premiums. If you want low copays and low deductibles and are willing to pay a higher monthly premium, consider our Premier Plan or Plan 500. If you want to keep your monthly premium at a minimum and are willing to pay more when you need care and service, consider Plan 1000, Plan 2000, Plan 3000, or Plan No matter which plan you choose, you can see a doctor for as low as $30. And the deductibles only apply to specific benefits. Services listed for a copayment are not subject to the medical deductible. (See Features at a Glance on pages 6 7 for more details.) 2

3 Seven good reasons to choose an HMO plan With premiums starting at around $78 a month, you re sure to find a plan that fits your budget. 1 Affordable coverage Copays for primary care visits are only $30. And no matter which plan you choose, your affordable monthly premiums include coverage for preventive care, hospitalization, and prescriptions. Wide selection of doctors In addition to the doctors at our 15 Kaiser Permanente medical centers, you ll have access to 1,800 affiliated doctors practicing in their own offices all over town. Personalized care You have the freedom to choose your own personal physician and to change your mind for any reason. You ll have a caring doctor who takes the time to listen and get to know you so you can get the personalized care you deserve. Online features You can order most prescription refills, request routine appointments, your doctor s office, and view most lab results and past office visit information right from home at kp.org. 2 Convenience You can often save time by seeing a doctor and getting lab, X-ray, and pharmacy services all in one building at most Kaiser Permanente medical centers. You can also see a doctor at night or on weekends at one of several locations, get nurse advice 24 hours a day by phone, or even make same-day appointments at our medical centers when available. 2,3 Simplicity You won t have to worry about filing claims when you visit our medical centers or any of our affiliated doctors and hospitals. Access You ll have direct access to select specialties, including Ob/Gyn, dermatology, optometry, ophthalmology, and behavioral health. 1 For single male subscriber, age 12 19, in Plan The rate you pay for your coverage depends on the plan you choose, your age and gender, and how many family members are enrolling. Rate charts are enclosed separately. 2 Available to members receiving care at Kaiser Permanente medical centers 3 Copays are higher for after-hours visits. See Features at a Glance on pages 6 7. kp.org 3

4 HMO PLANS MEET Wayne Taylor 1 Wayne is a single 32-year-old who s in great shape and very proactive about his health. Except for annual checkups and preventive tests, he rarely needs to see his doctor. Wayne wants to maintain his good health and be sure that he will be covered for any serious illnesses or injuries while paying lower premiums. What Wayne wants: Lower premiums Preventive care with no deductible Coverage for the big things Wayne s plan: Plan 1000 $1,000 individual deductible $2,000 individual out-of-pocket maximum (OOPM) $0 for preventive tests or exams (not subject to deductible) 2 $30 copay for primary care office visits (not subject to deductible) $50 copay for specialty care visits (not subject to deductible) $150 copay for Emergency Room visits (not subject to deductible) Prescription coverage Unlimited lifetime benefit maximum How this plan works for him During the year, Wayne enjoys his usual good health. He sees his primary care physician for a checkup and pays a $30 copay. His physician orders some preventive lab tests which are also no charge. His only mishap is a broken toe for which he has to pay an Emergency Room visit copay, which is not subject to the deductible. Since routine doctor visits and preventive tests are not subject to the deductible on deductible plans, Wayne is able to pay a copay for the services he is most likely to use from the first day of coverage. 1 These examples are for illustrative purposes only. Individual situations will vary depending on the specifics of the health care plan and other factors. 2 Office visit copay may apply 4

5 KEY TERMS Copayment (or copay): This is the specific dollar amount that you pay when you receive certain covered services or prescriptions. Coinsurance: This is the percentage of covered expenses that you must pay when you receive covered services. Deductible: This is the fixed amount that you must pay out of pocket in a calendar year before you are eligible for coinsurance payments for certain services. With our HMO family plans, there are two ways for an individual family member to satisfy his or her deductible. He or she can meet his or her individual deductible, or the combined costs of family members can meet the family deductible. Formulary: For benefit plans that cover prescription drugs, our formulary is the comprehensive list of medications available to Kaiser Permanente members. Lifetime maximum: This is the maximum of covered health care costs your health plan will cover over the life of your policy. Monthly rate/premium: This is the amount you pay every month for health care coverage. The amount depends on the benefit plan as well as the age and gender of the subscriber and the number of family members enrolling. Not subject to deductible: In plans with a medical deductible, some services are not subject to deductible. This means that from your first day of coverage, you can receive these services for the standard copayment, without having to first satisfy the deductible. Out-of-pocket maximum (OOPM): This is the maximum amount of coinsurance that you will pay for certain covered services that you receive in the same calendar year. Once you satisfy your plan s OOPM, Kaiser Permanente will pay 100 percent for most covered services for the remainder of that calendar year. With our HMO family plans, there are two ways for an individual family member to satisfy his or her OOPM. He or she can meet his or her individual OOPM, or the combined costs of family members can meet the family OOPM. Preventive care: Preventive care includes preventive exams, preventive labs and X-rays, and general immunization. Preventive care is not subject to the deductible. kp.org 5

6 features at a glance HMO Plans Features Premier PLAN plan 500 plan 1000 Annual deductible (individual/family) None $500/$1,500 $1,000/$3,000 Out-of-pocket maximum (coinsurance) (individual/family) Not applicable $2,000/$6,000 $2,000/$6,000 Lifetime benefit maximum 1 Unlimited Unlimited Unlimited BENEFITS OFFICE SERVICES Benefits shown with copays are not subject to the deductible. Benefits shown with coinsurance are subject to the deductible. Primary care office visit $30 per visit $30 per visit $30 per visit Specialist office visit $50 per visit $50 per visit $50 per visit Preventive screenings 2 No charge No charge No charge Pharmacy services (30-day supply) 90-day supply available through mail order for many prescription drugs Pharmacy deductible (individual/family) $200/$600 $200/$600 $200/$600 Prescription drugs generic (Kaiser Permanente pharmacy/network pharmacy) $15/$21 $15/$21 $15/$21 Prescription drugs brand (Kaiser Permanente pharmacy/network pharmacy) $30/$36 $30/$36 $30/$36 OUTPATIENT SERVICES Laboratory and radiology services No charge No charge No charge High-tech radiology (MRI, CT, etc.) $100 30% coinsurance 30% coinsurance Outpatient surgery facility $100 30% coinsurance 30% coinsurance Hospital outpatient facility $100 30% coinsurance 30% coinsurance Physician/Other professional charges No charge 30% coinsurance 30% coinsurance INPATIENT SERVICES Inpatient hospital (facility charge) $500 per admission 30% coinsurance 30% coinsurance Physician/Other professional charges No charge 30% coinsurance 30% coinsurance Inpatient mental health facility (30 days per calendar year) $500 per admission 30% coinsurance 30% coinsurance MATERNITY SERVICES Maternity (obstetrician/midwife) 3 $1,000 $1,000 $1,000 Maternity (hospital delivery) 3 $2,000 $2,000 $2,000 EMERGENCY SERVICES Emergency Room (copay waived if admitted) $150 per visit $150 per visit $150 per visit After-hours urgent care $60 $60 $60 Ambulance $150 per trip $150 per trip $150 per trip other SERVICES Rehabilitation therapies (Physical/Occupational/Speech) (20 visits per year combined) $50 30% coinsurance 30% coinsurance Vision exam $50 $50 $50 Note: Benefits with a copay are not subject to the deductible. Benefits with coinsurance are subject to the deductible. 6

7 HMO Plans This is a summary description and is not intended to replace the Evidence of Coverage, which contains the complete provisions of this coverage. Some services require preauthorization. Applicants are subject to medical review. plan 2000 plan 3000 plan 5000 Features $2,000/$6,000 $3,000/$9,000 $5,000/$15,000 Annual deductible (individual/family) $2,000/$6,000 $2,000/$6,000 $2,000/$6,000 Out-of-pocket maximum (coinsurance) (individual/family) Unlimited Unlimited Unlimited Lifetime benefit maximum 1 Benefits shown with copays are not subject to the deductible. Benefits shown with coinsurance are subject to the deductible. BENEFITS OFFICE SERVICES $30 per visit $30 per visit $30 per visit Primary care office visit $50 per visit $50 per visit $50 per visit Specialist office visit No charge No charge No charge Preventive screenings 2 90-day supply available through mail order for many prescription drugs $200/$600 $200/$600 $500/$1,500 $15/$21 $15/$21 $15/$21 $30/$36 $30/$36 $30/$36 Pharmacy services (30-day supply) Pharmacy deductible (individual/family) Prescription drugs generic (Kaiser Permanente pharmacy/network pharmacy) Prescription drugs brand (Kaiser Permanente pharmacy/network pharmacy) OUTPATIENT SERVICES No charge No charge No charge Laboratory and radiology services 30% coinsurance 30% coinsurance 30% coinsurance High-tech radiology (MRI, CT, etc.) 30% coinsurance 30% coinsurance 30% coinsurance Outpatient surgery facility 30% coinsurance 30% coinsurance 30% coinsurance Hospital outpatient facility 30% coinsurance 30% coinsurance 30% coinsurance Physician/Other professional charges INPATIENT SERVICES 30% coinsurance 30% coinsurance 30% coinsurance Inpatient hospital (facility charge) 30% coinsurance 30% coinsurance 30% coinsurance Physician/Other professional charges 30% coinsurance 30% coinsurance 30% coinsurance Inpatient mental health facility (30 days per calendar year) MATERNITY SERVICES $1,000 $1,000 $1,000 Maternity (obstetrician/midwife) 3 $2,000 $2,000 $2,000 Maternity (hospital delivery) 3 EMERGENCY SERVICES $150 per visit $150 per visit $150 per visit Emergency Room (copay waived if admitted) $60 $60 $60 After-hours urgent care $150 per trip $150 per trip $150 per trip Ambulance 30% coinsurance 30% coinsurance 30% coinsurance other SERVICES $50 $50 $50 Vision exam Rehabilitation therapies (Physical/Occupational/Speech) (20 visits per year combined) 1 Some benefits may have limitations. 2 Office visit copay may apply. Well-child visit: no charge up to age 2 3 Maternity charges for members are for Ob/Gyn and/or midwife services (pre/postnatal and delivery) and for inpatient facility charge. Other charges may apply for other professional services. kp.org 7

8 kp.org /GA Nine Piedmont Center 3495 Piedmont Road, NE Atlanta, GA Kaiser Foundation Health Plan of Georgia, Inc.