2016 kaiser permanente plan highlights - ehealthinsurance...enrolling during the 2016 open...

2016 Kaiser Permanente Plan Highlights

Individual and Family Plans Georgia

Have questions? Call us at 1-800-494-5314. • Go to buykp.org/apply. • Or contact your agent or broker.

Kaiser Permanente for Individuals and Families

260361911 Georgia 2016

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

Enrolling during the 2016 open enrollment periodYou 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 the Health Insurance Marketplace or through Kaiser Permanente.

To start coverage on: Send your completed application and premium by:

January 1, 2016 December 15, 2015February 1, 2016 January 15, 2016

March 1, 2016 January 31, 2016

Enrolling during a special enrollment periodOutside 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.

Get started today

This booklet will show you how to find a new plan that best fits your needs.

Important deadlines ....... 2

Health plan benefit highlights ............ 3

Working out your rate ..... 8

Enrolling in a Kaiser Permanente plan on the Marketplace ..............10

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.

31

http://buykp.org/apply

www.buykp.org/apply



3 60361911 Georgia 2016

Health plan benefit highlightsThe 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.

KP GA Silver 2500/30

Plan type Deductible

Features

Annual medical deductible(individual/family) $2,500/$5,000

Annual out-of-pocket maximum (individual/family) $6,850/$13,700

Benefits

Preventive care

Routine physical exam, mammograms, etc. No charge

Outpatient services (per visit or procedure)

Primary care office visit $30

Specialty care office visit $60

Most X-raysOffice visit: 30% after deductible

Outpatient Hospital: 50% after deductible

Most lab tests

First $300 of office visit charges covered at 100%, then remaining at

30% after deductible. Outpatient Hospital covered at 50% after

deductible.

MRI, CT, PET Office visit: $300 Outpatient Hospital: $500

Outpatient surgery 30% after deductible

Mental health visit $60

Inpatient hospital care

Room and board, surgery, anesthesia, X-rays, lab tests, medications, mental health care 30% after deductible

Maternity

Routine prenatal care visit, first postpartum visit 30% after deductible

Delivery and inpatient well-baby care 30% after deductible

Emergency and urgent care

Emergency Department visit 30% after deductible

Urgent care visit $100

Ambulance services 30% after deductible

Prescription drugs (up to a 30-day supply)

Generic Preventive generic: $5*Preferred generic: $15*

Preferred brand $451 after $500/$1,000 deductible

Non-preferred brand 50% after $500/$1,000 deductible

Specialty 50% after $500/$1,000 deductible

Here’s a quick look at how to use the chart

Annual deductibleYou 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 $2,500 for yourself or $5,000 for your family. Then you’d start paying copays or coinsurance.

KP Offered through Kaiser Permanente

M Offered through the Health Insurance Marketplace

Preventive care at no chargeMost preventive care services — including routine physical exams and mammograms — are covered at no charge. Plus, they’re not subject to the deductible.

CoinsuranceAfter 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.

Covered before you reach the deductibleWith 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 $30 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.

CopayThis is the set amount you pay for covered services, usually after you reach your deductible. In this example, you’d start paying a $100 copay for urgent care visits, whether or not you have met your deductible.

Annual out-of-pocket maximumThis 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 $6,850 for yourself and no more than $13,700 for your family for your copays, coinsurance, and deductible in a calendar year.

KP M

* Mail order: 90-day supply of qualified prescriptions for the cost of a 60-day supply



460361911 Georgia 2016

1Mail order: 90-day supply of qualified prescriptions for the cost of a 60-day supply.

KP GA Bronze 6000/40%/HSA

KP GA Bronze 5000/50


KP GA Silver 2750/20%/HSA

Plan type HSA-qualified Deductible Deductible HSA-qualified

Features

Annual medical deductible(individual/family) $6,000/$12,000 $5,000/$10,000 $4,000/$8,000 $2,750/$5,500

Annual out-of-pocket maximum (individual/family) $6,450/$12,900 $6,850/$13,700 $6,850/$13,700 $5,000/$10,000

Benefits

Preventive care

Routine physical exam, mammograms, etc. No charge No charge No charge No charge


Primary care office visit 40% after deductible First 3 office visits: $50 4+ visits: 40% after deductible

First 3 office visits: $20 4+ visits: 30% after deductible 20% after deductible

Specialty care office visit 40% after deductible First 3 office visits: $70 4+ visits: 40% after deductible




Office visit: 40% after deductible Outpatient Hospital: 50% after

deductible


deductible


deductible

Most lab testsOffice visit: 40% after deductible



deductible


deductible


deductible

MRI, CT, PETOffice visit: 40% after deductible



deductible

Office visit: $500 after deductible Outpatient Hospital: $700 after

deductible


deductible

Outpatient surgery 40% after deductible 40% after deductible 30% after deductible 20% after deductible

Mental health visit 40% after deductible First 3 office visits: $70 4+ visits: 40% after deductible



Room and board, surgery, anesthesia, X-rays, lab tests, medications, mental health care 40% after deductible 40% after deductible 30% after deductible 20% after deductible

Maternity

Routine prenatal care visit, first postpartum visit 40% after deductible 40% after deductible 30% after deductible 20% after deductible

Delivery and inpatient well-baby care 40% after deductible 40% after deductible 30% after deductible 20% after deductible


Emergency Department visit 40% after deductible 40% after deductible 30% after deductible 20% after deductible

Urgent care visit 40% after deductible $100 $100 20% after deductible

Ambulance services 40% after deductible 40% after deductible 30% after deductible 20% after deductible


GenericPreventive generic: $51

Preferred generic: 40% after medical deductible

Preventive generic: $51

Preferred generic: $201 after medical deductible


Preferred generic: $251



Preferred brand 50% after medical deductible 50% after medical deductible 50% after $1,000/$2,000 deductible $451 after medical deductible

Non-preferred brand 50% after medical deductible 50% after medical deductible 50% after $1,000/$2,000 deductible 50% after medical deductible

Specialty 50% after medical deductible 50% after medical deductible 50% after $1,000/$2,000 deductible 50% after medical deductible

This is a summary of the most frequently asked-about benefits and their copays, coinsurance, and deductibles. Detailed information about your plan is in the Evidence of Coverage, which will be mailed to you upon enrollment or upon request. To request a copy of the Evidence of Coverage for a particular plan, please call us at 1-800-634-4579 or contact your broker. For services subject to the deductible, you will 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.



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

KP KP KP KPM M M M


5 60361911 Georgia 2016




KP GA Gold 1500/20

KP GA Gold 1000/20

Plan type Deductible Deductible Deductible Deductible

Features

Annual medical deductible(individual/family) $2,500/$5,000 $1,500/$3,000 $1,500/$3,000 $1,000/$2,000


Benefits

Preventive care



Primary care office visit $30 $30 $20 $20

Specialty care office visit $60 $60 $40 $40




deductible

First $100 of office visit charges covered at 100%, then remaining

at 20% after deductible. Outpatient Hospital covered at 40% after

deductible.



deductible.

Most lab tests



deductible.



deductible.



deductible.



deductible.


Office visit: $250 Outpatient Hospital: $500



Outpatient surgery 30% after deductible 30% after deductible 20% after deductible 20% after deductible

Mental health visit $60 $60 $40 $40


Room and board, surgery, anesthesia, X-rays, lab tests, medications, mental health care 30% after deductible 30% after deductible 20% after deductible 20% after deductible

Maternity

Routine prenatal care visit, first postpartum visit 30% after deductible 30% after deductible 20% after deductible 20% after deductible

Delivery and inpatient well-baby care 30% after deductible 30% after deductible 20% after deductible 20% after deductible


Emergency Department visit 30% after deductible 30% after deductible 20% after deductible 20% after deductible

Urgent care visit $100 $100 $75 $75

Ambulance services 30% after deductible 30% after deductible 20% after deductible 20% after deductible


Generic Preventive generic: $51

Preferred generic: $151Preventive generic: $51




Preferred brand $451 after $500/$1,000 deductible $451 after $500/$1,000 deductible $301 after $500/$1,000 deductible $301 after $500/$1,000 deductible

Non-preferred brand 50% after $500/$1,000 deductible 50% after $500/$1,000 deductible 45% after $500/$1,000 deductible 45% after $500/$1,000 deductible

Specialty 50% after $500/$1,000 deductible 50% after $500/$1,000 deductible 45% after $500/$1,000 deductible 45% after $500/$1,000 deductible





KP KP KP KPM M M M



660361911 Georgia 2016

1Mail order: 90-day supply of qualified prescriptions for the cost of a 60-day supply.2 Only applicants under age 30, or applicants age 30 and older who provide a certificate from Health Insurance Marketplace in Georgia demonstrating hardship or lack of affordable coverage, may purchase a KP GA Catastrophic 6850/0 plan.

KP GA Gold 500/20

KP GA Catastrophic 6850/02

KP GA Silver 1500/30/73% CSR 2500/30/73% CSR


Plan type Deductible Deductible Deductible Copay

Features

Annual medical deductible(individual/family) $500/$1,000 $6,850/$13,700 $1,500/$3,000 None/None


Benefits

Preventive care



Primary care office visit $20 First 3 office visits: no charge4+ visits: no charge after deductible $30 $15

Specialty care office visit $40 No charge after deductible $50 $25

Most X-rays


30% (ded waived). Outpatient Hospital covered at 50% (ded waived).

No charge after deductibleOffice visit: 20% after deductible


Office visit: 20% Outpatient Hospital: 40%

Most lab tests


30% (ded waived). Outpatient Hospital covered at 50% (ded waived).

No charge after deductible

First $300 of office visit charges covered at 100%, then remaining at 20% after

deductible. Outpatient Hospital covered at 40% after deductible.


at 20%. Outpatient Hospital covered at 40%.

MRI, CT, PET Office visit: $250 Outpatient Hospital: $500 No charge after deductible Office visit: $250

Outpatient Hospital: $500 Office visit: $150

Outpatient Hospital: $300

Outpatient surgery 30% after deductible No charge after deductible 20% after deductible 20%

Mental health visit $40 First 3 office visits: no charge4+ visits: no charge after deductible $50 $25


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

$500 per day up to 3 days after deductible, then covered at 100% No charge after deductible 20% after deductible 20%

Maternity

Routine prenatal care visit, first postpartum visit No charge No charge after deductible 20% after deductible 20%

Delivery and inpatient well-baby care $2,000 per admission No charge after deductible 20% after deductible 20%


Emergency Department visit $250 No charge after deductible 20% after deductible 20%

Urgent care visit $75 No charge after deductible $100 $50

Ambulance services $300 No charge after deductible 20% after deductible 20%



Preferred generic: $101 No charge after deductible Preventive generic: $51



Preferred brand $301 after $500/$1,000 deductible No charge after deductible $451 after $250/$500 deductible $451

Non-preferred brand 45% after $500/$1,000 deductible No charge after deductible 50% after $250/$500 deductible 50%

Specialty 45% after $500/$1,000 deductible No charge after deductible 50% after $250/$500 deductible 50%





KP KPM M M M


7 60361911 Georgia 2016



KP GA Silver 2750/20%/73% CSR3



Plan type Copay Deductible Deductible Deductible

Features

Annual medical deductible(individual/family) None/None $1,400/$2,800 $500/$1,000 $100/$200


Benefits

Preventive care



Primary care office visit $5 20% after deductible 10% after deductible 5% after deductible

Specialty care office visit $10 20% after deductible 10% after deductible 5% after deductible

Most X-rays Office visit: 5% Outpatient Hospital: 40%


deductible


deductible


deductible

Most lab tests


at 5%. Outpatient Hospital covered at 40%.


deductible


deductible


deductible



deductible


deductible


deductible

Outpatient surgery 5% 20% after deductible 10% after deductible 5% after deductible

Mental health visit $10 20% after deductible 10% after deductible 5% after deductible


Room and board, surgery, anesthesia, X-rays, lab tests, medications, mental health care 5% 20% after deductible 10% after deductible 5% after deductible

Maternity

Routine prenatal care visit, first postpartum visit 5% 20% after deductible 10% after deductible 5% after deductible

Delivery and inpatient well-baby care 5% 20% after deductible 10% after deductible 5% after deductible


Emergency Department visit 5% 20% after deductible 10% after deductible 5% after deductible

Urgent care visit $20 20% after deductible 10% after deductible 5% after deductible

Ambulance services 5% 20% after deductible 10% after deductible 5% after deductible










Preferred brand $101 $451 after medical deductible $101 after medical deductible $101 after medical deductible

Non-preferred brand 50% 50% after medical deductible 50% after medical deductible 50% after medical deductible

Specialty 50% 50% after medical deductible 50% after medical deductible 50% after medical deductible





M MM M



860361911 Georgia 2016

Working out your rateUse the monthly rates chart on the following page 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.

What determines your rate?Your rate is based on the following:■ The plan you select■ Your age on your start date (effective date)■ Whether you use tobacco

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.

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.

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. If you have a child-only account and everyone on the account is under 21, you will only be charged for the subscriber and the 3 oldest children under 21.

The rates on page 9 apply to the counties below. Please check that your county is listed below. If it isn’t, call us at 1-800-494-5314 for information on other rate areas.

Service Area—Counties Barrow Coweta Gwinnett NewtonBartow Dawson Hall PauldingButts DeKalb Haralson PickensCarroll Douglas Heard PikeCherokee Fayette Henry RockdaleClayton Forsyth Lamar SpaldingCobb Fulton Meriwether Walton

www.kp.org/apply


9 60361911 Georgia 2016

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

Age on 2016 effective

date

KP GA Bronze 6000/40%/

HSA



KP GA Silver 2750/20%/

HSA



KP GA Gold 1500/20

KP GA Gold 1000/20

KP GA Gold

500/20

KP GA Catastrophic

6850/0

0–18 $123.61 $130.80 $134.28 $159.33 $159.79 $167.68 $189.71 $191.33 $196.67 $105.4519–20 123.61 130.80 134.28 159.33 159.79 167.68 189.71 191.33 196.67 105.45

21 194.63 205.95 211.43 250.87 251.60 264.01 298.70 301.25 309.65 166.0422 194.63 205.95 211.43 250.87 251.60 264.01 298.70 301.25 309.65 166.0423 194.63 205.95 211.43 250.87 251.60 264.01 298.70 301.25 309.65 166.0424 194.63 205.95 211.43 250.87 251.60 264.01 298.70 301.25 309.65 166.0425 195.36 206.72 212.22 251.80 252.54 265.00 299.82 302.38 310.81 166.6626 199.24 210.83 216.43 256.80 257.55 270.26 305.77 308.38 316.98 169.9627 203.84 215.70 221.44 262.74 263.50 276.50 312.84 315.51 324.31 173.8928 211.36 223.65 229.60 272.42 273.22 286.70 324.37 327.14 336.26 180.3029 217.66 230.32 236.44 280.54 281.36 295.24 334.04 336.89 346.29 185.6830 220.81 233.65 239.87 284.61 285.43 299.52 338.87 341.77 351.30 188.3731 225.41 238.53 244.87 290.54 291.39 305.77 345.94 348.90 358.63 192.3032 230.02 243.40 249.87 296.48 297.34 312.01 353.01 356.03 365.95 196.2233 232.93 246.48 253.03 300.23 301.10 315.96 357.47 360.53 370.58 198.7134 236.08 249.81 256.45 304.29 305.17 320.23 362.31 365.41 375.59 201.3935 237.77 251.61 258.30 306.47 307.37 322.53 364.91 368.03 378.29 202.8436 239.23 253.15 259.88 308.35 309.25 324.51 367.14 370.28 380.61 204.0837 240.93 254.94 261.72 310.54 311.44 326.81 369.75 372.91 383.31 205.5338 242.38 256.48 263.30 312.41 313.32 328.78 371.98 375.16 385.62 206.7739 245.53 259.81 266.72 316.47 317.39 333.05 376.82 380.04 390.63 209.4640 248.68 263.15 270.15 320.53 321.47 337.33 381.65 384.91 395.65 212.1541 253.29 268.02 275.15 326.47 327.42 343.58 388.72 392.04 402.97 216.0742 257.65 272.64 279.89 332.09 333.06 349.49 395.41 398.80 409.91 219.8043 263.95 279.31 286.73 340.21 341.21 358.04 405.09 408.55 419.94 225.1744 271.71 287.51 295.16 350.21 351.23 368.56 416.99 420.55 432.28 231.7945 280.92 297.26 305.16 362.08 363.14 381.06 431.12 434.81 446.93 239.6546 291.83 308.80 317.01 376.14 377.24 395.85 447.86 451.69 464.29 248.9547 303.94 321.63 330.18 391.76 392.90 412.29 466.46 470.45 483.57 259.2948 318.00 336.50 345.45 409.88 411.08 431.36 488.04 492.21 505.93 271.2849 331.82 351.12 360.46 427.69 428.94 450.10 509.24 513.59 527.91 283.0750 347.33 367.54 377.31 447.68 448.99 471.14 533.05 537.60 552.59 296.3051 362.84 383.95 394.16 467.68 469.04 492.18 556.85 561.61 577.27 309.5352 379.81 401.90 412.59 489.55 490.97 515.20 582.89 587.88 604.27 324.0153 396.78 419.86 431.02 511.42 512.90 538.21 608.93 614.14 631.26 338.4854 415.20 439.35 451.03 535.16 536.72 563.20 637.20 642.65 660.57 354.2055 433.86 459.10 471.31 559.21 560.84 588.52 665.84 671.54 690.26 370.1256 453.74 480.13 492.90 584.83 586.54 615.48 696.35 702.30 721.88 387.0757 474.10 501.67 515.01 611.07 612.85 643.09 727.59 733.81 754.27 404.4458 495.67 524.50 538.45 638.88 640.74 672.36 760.70 767.20 788.59 422.8459 506.33 535.79 550.03 652.62 654.53 686.82 777.07 783.71 805.56 431.9460 527.90 558.61 573.47 680.43 682.41 716.08 810.17 817.10 839.88 450.3561 546.57 578.36 593.74 704.48 706.54 741.40 838.81 845.99 869.57 466.2762 558.93 591.44 607.17 720.42 722.52 758.17 857.79 865.12 889.24 476.8163 574.20 607.60 623.76 740.10 742.26 778.88 881.22 888.75 913.53 489.84

64+ 583.65 617.60 634.03 752.28 754.47 791.70 895.73 903.39 928.57 497.90

2016 Monthly rates Do you qualify for federal financial assistance? If so, you may pay lower rates than those listed in this chart.



1060361911 Georgia 2016

1. Get readyHere are some examples of documents and information you may need to complete your application: Most recent pay stub and tax return

Birthdates of everyone in your family (even if they DON’T want coverage)

Social Security numbers for all family members who DO want coverage

Proof of citizenship or immigration status

Policy numbers of any current health insurance plan

Paperwork for health insurance available through your employer

2. Get your plan

Visit www.healthcare.gov. Select “Get Coverage,” then select Georgia and then click “Get Coverage.” Enter your ZIP code and select “Start a marketplace application,” followed by “Create an Account.” Fill in the account setup page. Sign in to your email and click on the link that says verify your email address.

Accept the Terms and Conditions and complete all 4 sections. Review and sign.

On the next page, click “Find a Plan.” In the Getting Started section, hit “Continue.” Choose “Health” as your Coverage Type, and click “Continue.”

Under Decision Support for Medical, click “Skip & View Plans.” Use the green filter on the left to check “Kaiser Permanente” and hit “Apply Filter.” Select a plan and click “Add to Cart.” Finally, scroll up and hit “Save and Continue to Checkout.”

Click “Continue” to confirm your selections on the next several screens. When you reach the Proceed to the Initial Payment Details page, click “Make a Payment” and then click “Continue.”

Read and accept the User Agreement, add your digital signature, and hit “Finish.”

Thank you for choosing Kaiser Permanente, the right choice for a healthier you.

Enrolling in a Kaiser Permanente plan on the Marketplace Need help choosing a plan? Visit buykp.org, call us at 1-800-494-5314, or contact your agent or broker. We can also help you apply for federal financial help through healthcare.gov.

Kaiser Permanente makes it easy:

http://www.healthcare.gov

www.buykp.org


11 60361911 Georgia 2016



1260361911 Georgia 2016

The right choice for a healthier youLearn 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).

Please recycle. 60361911 Georgia 2016

Kaiser Foundation Health Plan of Georgia, Inc.

kp.org

http://kp.org/thrive

www.kp.org

2016 kaiser permanente plan highlights - ehealthinsurance...enrolling during the 2016 open...

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