Kaiser Permanente Conversion Plan Brochure 2012

KAISER PERMANENTE

Conversion Plans and other coverage options

Summary of Benefits and Services for

2012

The Kaiser Permanente Conversion Plan As a former group member in good standing, you and any qualified dependents may have the option to enroll in one of the Kaiser Permanente Conversion Plans. You may also have the option to seek coverage under other individual health insurance plans, either through Kaiser Permanente or through another insurer. This brochure focuses on the Kaiser Permanente Conversion plans and provides general information about other options. The Kaiser Permanente Conversion Plans are an option that may be available to you and your family for continued membership with Kaiser Permanente. Eligibility is based on specific requirements. The Conversion Plans are available without medical screening and the rates and benefits are different from your group coverage. The Conversion Plans are HMO plans (not available for POS). In order to be enrolled in a Conversion Plan, you must submit a Conversion Plan application no later than thirty (30) days from your receipt of termination notification. Please Note: You may not be eligible for a Conversion Plan if Kaiser Permanente has previously terminated your membership for Cause, or if you are eligible for Medicare. Coverage will begin with no lapse in coverage from group to individual enrollment as assigned by the Health Plan. Please mail your Conversion application to: Kaiser Permanente Membership Administration P.O. Box 203008 Denver, CO 80220-9008

Kaiser Permanente Conversion Plans Copay Option: 2012 Monthly Rates

Deductible Option: 2012 Monthly Rates

2012 Conversion Copay Plan Single Age as of 1/1/12 0 1 2-14 15 16 17 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 65+*

Male

Female

$744.55 $744.55 $560.97 $561.88 $563.71 $564.62 $565.98 $568.71 $570.08 $571.26 $573.62 $574.80 $575.88 $578.06 $579.15 $581.26 $610.36 $612.47 $614.66 $712.51 $712.51 $712.51 $718.06 $725.78 $733.82 $757.46 $766.78 $777.05 $787.32 $880.63 $891.25 $909.96 $930.09 $951.61 $972.52 $1,023.87 $1,042.27 $1,051.62 $1,051.62 $1,151.27 $1,170.47 $1,170.47 $1,170.47 $1,170.47 $1,170.47 $1,270.15 $1,270.15 $1,358.01 $1,410.40 $1,475.17 $1,533.75 $1,585.50 $1,585.50 $1,645.61

$744.55 $689.53 $526.43 $526.43 $526.43 $539.38 $576.78 $650.64 $676.86 $676.86 $676.86 $676.86 $676.86 $676.86 $676.86 $676.86 $744.55 $770.78 $770.78 $854.65 $960.28 $960.28 $960.28 $960.28 $960.28 $993.26 $993.26 $993.26 $993.26 $1,026.42 $1,026.63 $1,026.74 $1,026.82 $1,026.87 $1,028.32 $1,031.16 $1,038.19 $1,049.40 $1,060.62 $1,071.83 $1,085.50 $1,101.63 $1,118.58 $1,136.35 $1,156.48 $1,178.96 $1,203.93 $1,240.55 $1,281.74 $1,318.36 $1,359.11 $1,408.11 $1,474.54 $1,645.61

Two-party Male

$1,175.34 $1,273.24 $1,273.24 $1,273.24 $1,344.98 $1,344.98 $1,344.98 $1,344.98 $1,344.98 $1,344.98 $1,458.93 $1,458.93 $1,458.93 $1,593.52 $1,593.52 $1,593.52 $1,593.52 $1,593.52 $1,593.52 $1,654.71 $1,654.71 $1,654.71 $1,654.71 $1,754.50 $1,766.68 $1,801.72 $1,831.85 $1,857.08 $1,889.53 $1,929.20 $1,968.90 $2,008.65 $2,048.39 $2,088.13 $2,138.05 $2,198.16 $2,261.66 $2,328.56 $2,333.35 $2,457.42 $2,457.42 $2,467.64 $2,554.63 $2,763.46 $2,763.46 $2,841.66 $2,954.70 $3,286.62

Female

$1,175.34 $1,292.88 $1,309.45 $1,309.45 $1,344.98 $1,344.98 $1,344.98 $1,344.98 $1,344.98 $1,344.98 $1,479.48 $1,532.89 $1,532.89 $1,562.84 $1,553.66 $1,553.52 $1,558.28 $1,567.93 $1,578.02 $1,588.54 $1,600.37 $1,613.51 $1,626.64 $1,813.96 $1,813.96 $1,813.96 $1,813.96 $1,813.96 $1,813.96 $1,902.00 $1,902.00 $1,902.00 $1,902.00 $2,099.09 $2,099.09 $2,099.09 $2,099.09 $2,099.09 $2,128.71 $2,203.32 $2,245.88 $2,323.82 $2,411.51 $2,489.45 $2,573.83 $2,671.06 $2,800.64 $2,982.04

2012 Conversion Deductible Plan Family Male

$2,013.13 $2,013.13 $2,013.13 $2,013.13 $2,013.13 $2,013.13 $2,013.13 $2,013.13 $2,013.13 $2,013.13 $2,184.02 $2,184.02 $2,184.02 $2,430.54 $2,655.02 $2,659.76 $2,669.30 $2,683.66 $2,698.63 $2,714.22 $2,731.66 $2,750.95 $2,785.67 $2,835.82 $2,878.33 $2,913.20 $2,944.83 $2,980.93 $3,030.11 $3,076.92 $3,115.29 $3,152.92 $3,190.56 $3,228.19 $3,275.54 $3,332.60 $3,392.91 $3,456.46 $3,496.25 $3,592.18 $3,659.28 $3,745.82 $3,843.18 $3,929.72 $4,022.48 $4,127.68 $4,266.95 $4,461.93

Female

$2,013.13 $2,013.13 $2,013.13 $2,013.13 $2,013.13 $2,013.13 $2,013.13 $2,013.13 $2,013.13 $2,013.13 $2,214.45 $2,294.99 $2,294.99 $2,529.04 $2,776.53 $2,776.68 $2,780.80 $2,788.92 $2,797.40 $2,806.26 $2,816.25 $2,827.36 $2,853.26 $2,893.97 $2,924.21 $2,943.98 $2,959.61 $2,978.48 $3,010.97 $3,042.27 $3,068.69 $3,097.64 $3,126.58 $3,155.52 $3,191.63 $3,234.90 $3,280.57 $3,328.63 $3,379.94 $3,434.52 $3,489.61 $3,563.76 $3,647.17 $3,721.31 $3,801.83 $3,895.11 $4,019.68 $4,194.07

Single Age as of 1/1/12 0 1 2-14 15 16 17 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 65+*

*non-Medicare eligible only These rates and benefits are effective from January 1, 2012 through December 31, 2012. You will be notified in writing of future rate and benefit changes.

Two-party

Family

Male

Female

Male

Female

Male

Female

$559.89 $559.89 $421.85 $422.53 $423.90 $424.59 $425.61 $427.67 $428.69 $429.58 $431.36 $432.24 $433.06 $434.70 $435.51 $437.10 $458.99 $460.58 $462.22 $535.80 $535.80 $535.80 $539.98 $545.78 $551.83 $569.61 $576.61 $584.34 $592.06 $662.23 $670.22 $684.29 $699.42 $715.61 $731.33 $769.94 $783.78 $790.81 $790.81 $865.75 $880.19 $880.19 $880.19 $880.19 $880.19 $955.14 $955.14 $1,021.22 $1,060.61 $1,109.32 $1,153.37 $1,192.28 $1,192.28 $1,237.49

$559.89 $518.52 $395.87 $395.87 $395.87 $405.61 $433.73 $489.28 $509.00 $509.00 $509.00 $509.00 $509.00 $509.00 $509.00 $509.00 $559.89 $579.62 $579.62 $642.69 $722.13 $722.13 $722.13 $722.13 $722.13 $746.93 $746.93 $746.93 $746.93 $771.86 $772.02 $772.10 $772.16 $772.20 $773.29 $775.43 $780.71 $789.14 $797.58 $806.01 $816.29 $828.42 $841.17 $854.53 $869.66 $886.57 $905.35 $932.88 $963.86 $991.40 $1,022.04 $1,058.89 $1,108.84 $1,237.49

$883.85 $957.47 $957.47 $957.47 $1,011.42 $1,011.42 $1,011.42 $1,011.42 $1,011.42 $1,011.42 $1,097.11 $1,097.11 $1,097.11 $1,198.32 $1,198.32 $1,198.32 $1,198.32 $1,198.32 $1,198.32 $1,244.33 $1,244.33 $1,244.33 $1,244.33 $1,319.37 $1,328.53 $1,354.88 $1,377.54 $1,396.51 $1,420.91 $1,450.75 $1,480.60 $1,510.49 $1,540.38 $1,570.26 $1,607.80 $1,653.00 $1,700.76 $1,751.06 $1,754.67 $1,847.97 $1,847.97 $1,855.65 $1,921.07 $2,078.11 $2,078.11 $2,136.92 $2,221.92 $2,471.52

$883.85 $972.24 $984.70 $984.70 $1,011.42 $1,011.42 $1,011.42 $1,011.42 $1,011.42 $1,011.42 $1,112.56 $1,152.73 $1,152.73 $1,175.25 $1,168.34 $1,168.24 $1,171.82 $1,179.08 $1,186.66 $1,194.58 $1,203.47 $1,213.35 $1,223.22 $1,364.09 $1,364.09 $1,364.09 $1,364.09 $1,364.09 $1,364.09 $1,430.29 $1,430.29 $1,430.29 $1,430.29 $1,578.51 $1,578.51 $1,578.51 $1,578.51 $1,578.51 $1,600.77 $1,656.88 $1,688.89 $1,747.50 $1,813.44 $1,872.06 $1,935.50 $2,008.62 $2,106.06 $2,242.48

$1,513.87 $1,513.87 $1,513.87 $1,513.87 $1,513.87 $1,513.87 $1,513.87 $1,513.87 $1,513.87 $1,513.87 $1,642.37 $1,642.37 $1,642.37 $1,827.75 $1,996.56 $2,000.12 $2,007.30 $2,018.09 $2,029.35 $2,041.07 $2,054.19 $2,068.70 $2,094.81 $2,132.52 $2,164.49 $2,190.71 $2,214.49 $2,241.64 $2,278.62 $2,313.83 $2,342.68 $2,370.98 $2,399.28 $2,427.58 $2,463.18 $2,506.10 $2,551.45 $2,599.24 $2,629.16 $2,701.30 $2,751.76 $2,816.84 $2,890.05 $2,955.13 $3,024.88 $3,103.99 $3,208.72 $3,355.34

$1,513.87 $1,513.87 $1,513.87 $1,513.87 $1,513.87 $1,513.87 $1,513.87 $1,513.87 $1,513.87 $1,513.87 $1,665.25 $1,725.82 $1,725.82 $1,901.82 $2,087.94 $2,088.04 $2,091.15 $2,097.25 $2,103.63 $2,110.30 $2,117.80 $2,126.16 $2,145.64 $2,176.25 $2,198.99 $2,213.86 $2,225.61 $2,239.80 $2,264.23 $2,287.77 $2,307.64 $2,329.40 $2,351.17 $2,372.93 $2,400.09 $2,432.63 $2,466.97 $2,503.11 $2,541.70 $2,582.74 $2,624.17 $2,679.93 $2,742.65 $2,798.40 $2,858.96 $2,929.10 $3,022.77 $3,153.92

Conversion Plans – Features at a Glance for 2012 When medically necessary and provided or authorized by a Plan physician.

COPAY

DEDUCTIBLE

Deductible None 1,500/Individual 3,000/Family Out of Pocket Maximum 2,000/Individual 3,000/Individual 6,000/Family 6,000/Family OUTPATIENT CARE

YOU PAY

YOU PAY

Office visits: • Primary • Specialty

$25 copay $45 copay

$35 copay $45 copay

Radiation therapy $25 copay

20% after deductible

Urgent care

$75 copay

$75 copay

Short-term physical, speech, and occupational therapy

30 visits per therapy per year $25 copay

20 visits per therapy per year 20% after deductible

Outpatient surgery

$250 copay


Laboratory and respiratory therapy

No charge


Most immunizations

No charge

No charge

Allergy treatment

$10 copay

$10 copay

Radiology & X-rays

No charge


CT, MRI, PET, Nuclear Medicine

$100 copay


$45 copay

$45 copay

VISION COVERAGE • Routine vision exams are provided through Plan ophthalmologists listed in our provider directory.

Conversion Plans – Features at a Glance for 2012

COPAY

DEDUCTIBLE

HOSPITAL INPATIENT CARE

YOU PAY

YOU PAY

No limit on covered days, including: • Physician and surgeon services; room and board, anesthesia, operating and recovery rooms; laboratory and diagnostic tests, X-rays; drugs, dressings, casts; respiratory and radiation therapy

$750 copay


Skilled Nursing Facility

100 days / No charge

7 days / 20% after deductible

Hospice

No charge

No charge

Home health services

No charge


$200 copay Waived if admitted

20% Coinsurance not subject to deductible

Maternity care • Physician and hospital services, delivery and normal nursery care. Separate charges will apply to the mother and the newborn. ALTERNATIVE CARE

EMERGENCY SERVICES Emergency services at a Plan or non-Plan Facility AMBULANCE SERVICE Only when your condition requires the use of medical $125 copay services and supplies that only a licensed ambulance can provide and the use of other means of transportation would endanger your health.

$125 copay after deductible

PREVENTIVE CARE Preventive Care

No Charge

No Charge

kp.org/continuingyourcoverage

Conversion Plans – Features at a Glance for 2012

COPAY

DEDUCTIBLE

MENTAL HEALTH SERVICES

YOU PAY

YOU PAY

Biologically Based Mental Illnesses Inpatient, unlimited days $750 copay


Outpatient Individual Therapy Outpatient Group Therapy Inpatient Alternative Services

$45 copay $45 copay $22 copay $22 copay $45 copay $45 copay

Other Mental Health Illnesses Inpatient (Up to 30 days of hospital care per year)

$750 copay

Not covered

Outpatient Individual Therapy (up to 20 visits per calendar year) Outpatient Group Therapy (up to 20 visits per calendar year) Inpatient Alternative Services

$45 copay $22 copay $45 copay

Not covered Not covered Not covered

Outpatient detoxification, individual therapy

$45 copay

Not covered

Group therapy Inpatient care in a specialized facility

$5 copay $750 copay

Not covered Not covered

PRESCRIPTION DRUGS Prescription Drugs

Not covered

Not covered

ADDITIONAL BENEFITS Infertility services Inpatient

30% of eligible charges


Outpatient



Dependent coverage

up to age 28

up to age 28

CHEMICAL DEPENDENCY SERVICES

• Medical detoxification and counseling • One detoxification admission per member per calendar year

Conversion Plans – Features at a Glance for 2012 This summary of benefits contains highlights only. This is not a contract. Specific benefits, exclusions, and limitations are contained in the Evidence of Coverage you will receive when you become a member. For specific questions about coverage, please call Customer Relations at 1-800-686-7100 or 1-877-676-6677 (TTY). DIRECT ACCESS FOR WOMEN’S HEALTH SERVICES Please note that a referral is not required for Obstetrics/Gynecology services. However, you must seek care from an Ob/Gyn specialist affiliated with your primary care physician. Contact Kaiser Permanente’s Customer Relations Department to verify affiliation at 1-800-686-7100.


Overview of your options Getting started: In the chart below, you’ll see several categories of continuing coverage. Follow these easy steps: • Ask yourself each question and see which boxes apply to you. • Review the information about each option. • For more detailed information, give us a call at the numbers listed below each option, or visit kp.org/continuingyourcoverage. Option

COBRA/State Continuation of Coverage (SCC)

Conversion

HIPAA

What it means

Temporary continuation of the same coverage you had through your employer.

Conversion from group coverage to an individual plan. Rates and benefits will differ from your group coverage.

Continuation coverage for members who are federally eligible according to the Health Insurance Portability and Accountability Act (HIPAA).

Eligibility overview

Must apply within 45 days of losing group coverage. No medical review required.

If you are eligible, we will send you an enrollment packet upon termination of your coverage. Must apply within 30 days of losing group coverage. No medical review required.

Must have exhausted COBRA coverage; must have 18 months of Creditable Coverage; must apply within 63 days of termination. No medical review required.

Plans available

Continuation of your employer group plan. Coverage lasts for up to 6 or 12 months through state continuation, and up to 18 or 36 months through COBRA.

HMO plan. Prescription drugs are not covered. No time limit for coverage.

HMO options available: Basic (prescription drugs not covered) and Standard (prescription drugs are covered). No time limit for coverage.

Premiums

Contact your employer.

No subsidy is available.

No subsidy is available.

Get more information

Contact your employer

1-800-686-7100 or 1-877-676-6677 (TTY)

1-800-524-7371, ext. 5613 or (216) 479-5613

Key terms Knowing these important terms will help as you’re comparing options. Coinsurance. Percentage of charges you pay when you receive a covered service. Copayment. Specific dollar amount you pay when you receive certain covered services or prescriptions. Copayments vary depending on the plan and the service. In general, copayment plans have higher premiums in exchange for lower out-ofpocket costs each time you access care.

Deductible. Fixed amount you must pay in a calendar year before Kaiser Permanente will cover certain services in that calendar year. Deductible plans typically have lower premiums but higher costs at the time of service. Health savings account (HSA). A taxadvantaged‡ trust or custodial account established for the purpose of paying for qualified medical expenses. HSA-qualified plans combine a qualified health care plan with an HSA.

Medical review. A process used to assess an applicant’s current and past health information to determine eligibility for health care coverage. Monthly rate/premium. The fixed amount that you’ll pay every month for health coverage. ‡

Tax references relate to federal income tax only. The tax treatment of health savings account contributions and distributions under state income tax laws differs from federal tax treatment. Consult with your financial or tax adviser for more information.

Kaiser Permanente for Individuals and Families Signature Plans

Kaiser Permanente Medicare Plus

Health Coverage Tax Credit (HCTC )/ Trade Adjustment Assistance (TAA )

A variety of types of health coverage for individuals and families.

Kaiser Permanente Medicare Plus* plans For people who are receiving: certain Trade combine Original Medicare benefits Adjustment Assistance Benefits; benefits with additional covered services. under the Alternative Trade Adjustment Assistance program; or benefits from the Pension Benefit Guaranty Corporation and are at least 55 years old.

All family members may apply. Medical review is required.

Anyone entitled to Medicare Part A and enrolled in Medicare Part B, or enrolled in Part B only and lives in the Kaiser Permanente Medicare Plus service area. Individuals with End Stage Renal Disease are generally not eligible to enroll in these plans unless they are enrolled in a Kaiser Permanente commercial product at the time of conversion.**

If you are eligible, the government will send you a packet in the mail.

Deductible HMO plans and HSA-qualified high deductible HMO plan.

HMO plans with and without prescription drug coverage.

HMO copayment plan and deductible HMO plan.

Costs and benefits vary by plan. Please see “Key terms” for more information about the types of plans.

Monthly premiums starting as low as $0 including part D – prescription drugs. Must continue to pay Medicare Part B premium if not otherwise paid for under Medicaid or by another third-party.

The tax credit pays 65% of qualified health insurance premiums (you pay the remaining 35%). (Subsidy available at time of print; subject to change based on government regulations.)

1-888-265-9080 or apply online at buykp.org

1-800-551-5353; TTY users please call 1-877-479-5741, 8 a.m. to 8 p.m., seven days a week kp.org/medicare

1-877-479-5117 or (216) 479-5117

*Kaiser Permanente is a Health Plan with a Medicare contract called Kaiser Permanente Medicare Plus. This contract is renewed annually. The availability of coverage beyond the current year is not guaranteed. **The Kaiser Permanente Medicare Plus service area consists of Cuyahoga, Geauga, Lake, Lorain, Medina, Portage, and Summit counties.


Health Plan Drug Formulary Kaiser Permanente of Ohio uses a closed drug formulary. The medications included in the Kaiser Permanente Formulary are chosen by a group of Kaiser Permanente physicians, pharmacists, and nurses known as the Pharmacy and Therapeutics Committee. This Committee meets regularly to evaluate and choose those medications that are effective, safe, and useful in caring for our members. Non-formulary drugs may be approved for coverage if certain criteria are met. Not all Kaiser Permanente health benefit plans include coverage for prescription drugs. Some drugs may be excluded from coverage. (Some plans have limitations on the dollar amount of coverage.) Some medications may have quantity restrictions limiting the amount of the drug you can receive per prescription or copayment. Coverage of certain formulary medications may also be subject to restrictions established by the Pharmacy and Therapeutics Committee. For more information regarding our prescription drug benefit procedures or your benefit, please call our Customer Relations Department at 1-800-686-7100 or 1-877-676-6677 (TTY) or visit kp.org to view the Member Drug Formulary. Protecting your privacy Your privacy is important to us. Our physicians and employees are required to keep your protected health information (PHI) confidential, and we have policies, procedures, and other safeguards in place to help protect your PHI from improper use and disclosure in all settings, as required by state and federal laws. We will release your PHI when you give us written authorization to do so, when the law requires us to disclose information, and under certain circumstances when the law permits us to use or disclose information without your permission. For example, in the course of providing

treatment, our health care professionals may use and disclose your PHI in order to provide and coordinate your care, without obtaining your authorization. Your PHI may also be used without your authorization to determine who is responsible to pay for medical care and for other health care operations purposes, such as quality assessment and improvement, customer service, and compliance programs. If you are enrolled in Kaiser Permanente through your employer or employee organization, we may be allowed under the law to disclose to them certain PHI, for example, regarding health plan eligibility or payment, or regarding a workers’ compensation claim. Sometimes, we contract with others (business associates) to perform services for us and in those cases, our business associates must agree to safeguard any PHI they receive. Our privacy policies and procedures include information on your right to access, amend, and obtain copies of your PHI. You may also ask us for a list of disclosures of your PHI that we are required to track under HIPAA law. For a more complete explanation of our privacy policies, please request a copy of our “Notice of Privacy Practices” which is on our Web site, in our medical offices, or by calling our Customer Service Department. If you have questions or concerns about our privacy practices, please contact our Customer Relations Department at 1-800-686-7100 or 1-877-676-6677 (TTY). Review of medical services At Kaiser Permanente, we use a utilization management program to ensure that the clinical services we offer are medically necessary and provided in an efficient, timely, and safe manner. Here in Ohio, our utilization management program is known as the “Medical Management Program,” which works with our providers to plan, organize, and deliver quality health care services. Some services require prior notification

and/or prior authorization by the Medical Management Program. Examples include, but are not limited to: • Inpatient admissions

• Serious jeopardy to the mental or physical health of the individual, or with respect to a pregnant woman, the health of the woman or her unborn child;

• Referrals for specialist care (except self-referral to select specialties)

• Serious impairment of the individual’s bodily function; or

• Outpatient surgery • Specialized services, such as home health and hospice care • Durable medical supplies and equipment • Skilled-nursing and inpatient rehabilitation facilities • Treatments initiated by a behavior health (mental health and or chemical dependency) specialist Some treatments and services have specific criteria developed or adopted by the Ohio Permanente Medical Group, or may be required by state or federal agencies, that define medical necessity. In any case, only physicians make the final decisions regarding medical necessity. Emergency care does not require prior authorization. You are strongly encouraged to contact Kaiser Permanente after emergency care is received so Kaiser Permanente can coordinate follow-up services. However, if you are admitted to a non-Plan hospital in connection with emergency care, you, a member of your family, or the admitting physician must contact us before you are admitted, so that we may decide whether to make arrangements for necessary continued hospitalization or transfer you to another facility. An “emergency” is medically necessary health care services that are immediately required for acute symptoms of sufficient severity, including severe pain, for which a prudent lay person who possesses an average knowledge of health and medicine could reasonably expect that the absence of immediate medical attention could result in:

• Serious dysfunction of any body organ or part. In the event any service is denied by our Medical Management Program, you may appeal.

© 2012 Kaiser Foundation Health Plan of Ohio

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