portfolio CalifORnia BROKER portfolio - Cal Choice · clients may not set up any kind of...

BROKER portfolio

kaiser permanente small group products

PRODUCT portfolio CalifORnia

2008

Kaiser Permanente plans for small groups—

2–50 eligible employees—present the perfect

mix of high-quality care, cost-effective coverage,

and exceptional flexibility. and with expanded

resources and better rewards, you can offer a

solution that also benefits your business.

Kaiser permanente small group productsA total solution for your small groups

1

ExTRa REwaRDs fOR yOUR haRD wORK

Take advantage of rewards for being a top producer, signing up new groups, or establishing Kaiser Permanente as the sole carrier. Visit brokers.kp.org for the latest ways to increase your earnings.

POwERfUl maRKETing aT yOUR fingERTiPs

Imagine reaching new clients with just a couple of clicks. The GroupTrak site gives you access to preapproved mailers that promote our most popular plans. Select from a library of templates, personalize, and mail—all from our one-stop online shop.

mORE flExibiliTy in OUR mUlTiPlE Plan OffERing

New options allow you to design a customized solution for every client. With a wider plan selection and financial tools that help to maximize your clients’ health care dollars, you can round out your client benefits packages with more coverage—at a great value.

CUsTOmizED REnEwal PaCKagEs

A customized renewal package provides you with clear information on your clients’ renewal, and a guide to presenting possible cost-saving solutions. You’ll now receive the following materials—all customized with your clients’ information:

• An informative cover letter with a broker summary page

• Renewal rate notification with census summary

• Summary of benefit changes

• Renewal options with census information

• Renewal confirmation and plan change forms

• Plan rates by rate area and Rate Adjustment Factor (RAF)

• FAQs

• Plan highlights (no rates)

• Multiple plan offering flyer

• Why do rates change? brochure

• Regulatory summary of changes

• COBRA information

Online resources ........................................................2

broaden your portfolio ...............................................3 Multiple plan offerings HSA Plans HRA Plans

small group, big choices ............................................4 California exchange products CaliforniaChoice highlights Kaiser Permanente Choice Solution

ancillary coverage......................................................5 Dental plans Chiropractic option

additional services ................................................. 6–7 Vision care Mail-order prescription program 10,000 Steps® program Services from Healthyroads Healthy lifestyle programs

scenarios ....................................................................8

Plan highlights ...................................................... 9–15 Copayment plans Deductible plans Deductible plans with HSA Deductible plans with HRA $35 POS plan $40/$1,000 PPO plan

small group rate area guide ............................... 16–17

Contact information .................................................18

A total solution for your small groups

whAt’s new contents

2

maRKETing TO nEw CliEnTs is EasiER OnlinE

No more waiting for approvals or staying up late to design marketing materials. The tools you need to sell Kaiser Permanente are just a few clicks away, so you can focus on what you do best—selling.

Simply select a preapproved piece, add your business information, and upload the mailing list of your choice. Your materials will print and mail on the date you specify. Or order a printed supply to distribute yourself. It’s easy and affordable.

The pieces promote our most popular plans, including the $30 copayment plan, $0/$1,500 deductible plan with HSA, and our multiple plan offering. Log on to brokers.kp.org, click on “Marketing materials” under the “Sales resources” tab, and link to the customized marketing site. Or call a Kaiser Permanente broker sales representative at 1-800-789-4661.

aCCEss a fUll RangE Of salEs anD EnROllmEnT maTERials

With your schedule, you need a single resource for impor-tant sales tools. Log on to brokers.kp.org for the health plan information and broker services you need. You can:

• Create instant quotes for small group proposals online.

• Get support for enrollment and renewal.

• Precomplete and submit e-mail forms.

• Download plan highlights in Chinese, Korean, Spanish, and Vietnamese.

• Catch up on the latest broker news.

• Save pages as Quick Links for instant access.

iT’s EasiER ElECTROniCally

Online account services for your clientsYour clients can manage their accounts easily with our online account services. Secure online services allow clients to:

• Quickly access their account status without making a phone call.

• Keep bills current by entering enrollments and terminations at any time.

• Maintain membership information directly on our system.

• Pay bills quickly and easily online with one-time payments or monthly debits.

• Work according to their schedule.

Questions about online account services? You and your clients can learn more by taking an online tour at employers.kp.org, or by calling our Customer Service Center at 1-800-790-4661, option 1.

EnROlling is Easy

Your clients simply download an online Account Services ID form and fax it to us. They can begin using the online services when they receive their user ID and password in the mail, usually within seven business days.

online resources

3

mUlTiPlE Plan OffERings anD COnsUmER-DiRECTED hEalTh CaRE

Multiple plans offer flexibility and cost sharing Rather than presenting just one option to their employees, your small group clients can now offer a wider selection of plans from Kaiser Permanente1. They’ll appreciate the convenience of having one carrier and one application form. Your clients can select from:

hsa Plans nOw havE inDiviDUal DEDUCTiblEs fOR EaCh family mEmbER

With our $0/$2,700 and $30/$2,700 plans, each family member is eligible for copayments after meeting his or her deductible. No more waiting for the aggregate family deductible to be met before copayments apply for each family member.

ThiRD-PaRTy REqUiREmEnTs fOR hRas anD hsas

When paired with a high deductible health plan, your clients’ HRA must be administered by SHPS. There are no third-party administrator requirements for the HSA, but clients may not set up any kind of reimbursement account, whether self-managed, administered by a third party, or by means of any other creative funding mechanism. Clients who sign up for HRA or HSA accounts must sign a Declara-tion of Understanding form at time of enrollment.

inCREasE salEs TO yOUR small gROUPs

Kaiser Permanente Custom Care HealthInvestor (HSA) and Kaiser Permanente Custom Care HealthBuilder (HRA) can help your clients attract and keep top talent. They offer tax rewards and they’re easy to administer. They’re also paired with online decision-support tools and health improve-ment programs that help your clients’ employees make smart health care decisions.

healthinvestor (hsa) combines a tax-exempt health savings account (HSA) with Kaiser Permanente’s HSA-qualified high deductible health plans. It allows clients’ employees to pay for current health care expenses and save for future qualified medical expenses on a tax-free basis4. Plus, it’s an excellent way to help clients who are struggling with the high cost of health care.

HSA highlights • Combines a Kaiser Permanente HSA-qualified high

deductible health plan (HDHP) with the CarePay® HSA, an employee financial account5.

• The CarePay HSA is owned by the employee.

• Contributions may be made by employer, employee, or both.

• Money invested in the CarePay HSA is tax deductible.

• The CarePay HSA is administered through Wells Fargo Bank.

healthbuilder (hRa) is an employer-funded health reimbursement arrangement (HRA) paired with a Kaiser Permanente deductible health plan. It also includes employee cash incentives for program participation and fitness club workouts.

HRA highlights• Combines a Kaiser Permanente deductible health plan

with the CarePay HRA, an IRS-regulated employee financial account.6

• Employers don’t pay federal and FICA taxes on HRA contributions.

• Contributions are tax free for employees.

• The CarePay HSA is administered by SHPS.

BroAden your portfolio

copayment plans $50 Copayment plan$30 Copayment plan$20 Copayment plan$15 Copayment plan$5 Copayment plan

deductible plans $30/$1,500 Deductible plan2

$30/$1,000 Deductible plandeductible plans with hsa option $30/$2,700 Deductible plan with Hsa

$0/$2,700 Deductible plan with Hsa $0/$1,500 Deductible plan with Hsa

deductible plans with hra $30/$2,500 Deductible plan with Hra $30/$1,500 Deductible plan with Hra

pos plan3 $35 pOs planppo plan3 $40/$1,000 ppO plan

4

CalifORnia ExChangE PRODUCTs

Small group clients want maximum flexibility and easy plan administration. Our expanded product suite for small groups gives you the opportunity to provide clients access to high-quality health coverage and premium cost management. Your clients can control their costs with preset employer contributions and give their employees the same benefit options of a large employer.

CalifORniaChoiCe highlighTs

• Designed for groups with 2–50 eligible employees.

• A single program offering employees their choice of seven health plans from Kaiser Permanente and other carriers.

• HMO and PPO benefits designs available.

• Ancillary options include dental, vision, and chiropractic/acupuncture.

• Offers cost control for employers.

• Simple online administration.

• Great recruitment and retention tool.

• Single-source billing.

• Brokers can earn commissions.

KaisER PERmanEnTE ChOiCE sOlUTiOn

With Kaiser Permanente Choice Solution, your clients can enjoy a wide selection of health plans with the convenience of single-source administration—including a consolidated invoice—handled by CHOICE Administrators, the nation’s leading facilitator of Consumer Choice Exchange programs.

Designed to address both employee needs and small-business owner budget concerns, Kaiser Permanente Choice Solution is a multiple plan offering based on nine plan designs and selected ancillary/complementary products. Clients offer the following options so their employees can choose the plan that best fits their needs:

Health care plans • HMO $10 copayment plan

• HMO $30 copayment plan

• HMO $1,000 deductible plan

• HMO $1,400 high deductible plan (HSA qualified)

• HMO $2,400 high deductible plan (HSA qualified)

• POS $20 copayment plan (Tier 2 with $1,000 deductible and 80% coinsurance)

• POS $30 copayment plan (Tier 2 with $1,500 deductible and 70% coinsurance)

• PPO $30 copayment, $500 deductible, 80% coinsurance plan

• Indemnity $25 copayment, $500 deductible, 70% coinsurance plan

Ancillary plans • Dental (KPIC Delta Dental PPO, KPIC Delta Dental

fee-for-service, and DeltaCare dental HMO plans)

• Term life

Kaiser Permanente Choice Solution is available through your Kaiser Permanente sales representative or through general agencies contracted by CHOICE Administrators. Go to kpchoicesolution.com for more information.

smAll group, Big choices

High-demand ancillary coverage such as dental and chiro-practic care helps you give clients what they want. Our dental7 and chiropractic benefits8 can be purchased as supplements to HMO, deductible HMO, deductible HMO with HSA, deductible HMO with HRA, and POS plans.

DEnTal Plans

Kaiser Permanente Insurance Company (KPIC) offers a number of dental insurance plans administered through Delta Dental of California, and two new Kaiser Permanente HMO dental plans for 2008. Visit brokers.kp.org to see available plan summaries, or call Delta Dental directly at 1-888-335-8227 (toll free).

ChiROPRaCTiC OPTiOn

Kaiser Permanente contracts with American Specialty Health Plans of California, Inc. (ASH Plans), to offer chiro-practic benefits. Members can obtain services from any ASH Plans participating chiropractor without a referral from a Plan physician. A list of participating chiropractors is available on the ASH Plans Web site at ashcompanies.com or from the ASH Plans Member Services Department at 1-800-678-9133.

5

AncillAry coverAge

6

mORE ways fOR mEmbERs TO sTay hEalThy anD fEEl ThEiR bEsT

Your clients will be pleased to learn about our services designed to help members live healthier lives at any age.

visiOn CaRE

All our plans include routine eye exams and screening for a range of eye disorders and health conditions such as diabetes. And members of select small business plans9 get a 20 percent discount on the eyeglasses, sunglasses, and contact lenses they buy at our optical stores. Your clients can visit kp.org/2020 to view promotions in their area. For more information, contact your sales representa-tive or account manager.

mail-ORDER PREsCRiPTiOn PROgRam

Our mail-order prescription program is included with all plans at no additional cost. Your clients’ employees can order up to a 100-day supply of their maintenance prescrip-tions for the price of just two copayments—a 33 percent savings over prescriptions filled in our pharmacies. They just submit a mail-order request via our automated phone refill system, by mail, or directly to one of our pharmacies by phone or fax. And seven business days later, their prescriptions arrive at their door.

10,000 sTEPs® PROgRam

This interactive, Web-based program is designed to help people increase their activity level by setting a goal of walking 10,000 steps a day. Program membership is offered at a discounted rate to our members and includes a pedometer. Members who sign up can log their steps on a personalized home page. And weekly e-mails help them stay motivated. For more information, visit kp.org/10000steps. 10,000 Steps® is a registered trademark of HealthPartners, Inc.

sERviCEs fROm hEalThyROaDs

Kaiser Permanente has contracted with American Specialty Health Networks, Inc., and its affiliate, Healthyroads, to provide members with various services at discounted rates. By visiting kp.org, Kaiser Permanente members have access to:

• 25 percent discounts on regular rates for chiropractic, acupuncture, and massage therapy services from a national network of more than 25,000 providers.

• Preferred rates on select fitness club memberships.

• free shipping for products purchased on healthyroads.com, which offers more than 2,400 brand-name health-related products.

Members pay the provider directly at the contracted discount or special rate and do not need a referral to access these services*.

* These products and services are provided by entities other than Kaiser Permanente. Some Kaiser Permanente benefit plans include coverage for certain of these discounted services. Plan benefits must be used before those discounted services are available. Members should check their Evidence of Coverage for details. Kaiser Permanente disclaims any liability for these discounted products and services. Should a problem arise, members may take advantage of the Kaiser Permanente grievance process by calling the Member Service Call Center at 1-800-464-4000.

AdditionAl services

hEalThy lifEsTylE PROgRams

These customized online programs, available at kp.org/healthylifestyles, are designed to give members support and confidence as they make healthy changes in their lives. Members complete an online assessment form and receive a personalized plan for achieving their goals. The programs are available to members at no charge through Kaiser Permanente in collaboration with HealthMedia®.

Members can access these healthy lifestyle programs:

• healthmedia® balance™—personalized strategies for weight loss.

• healthmedia® Relax™—tips to prevent and relieve stress.

• healthmedia® nourish™—education to make smart and healthful food choices.

• healthmedia® breathe™—step-by-step personalized guidance to quit smoking.

• healthmedia® succeed™—assess overall health and identify changes to improve well-being.

note: The programs described are provided to members as value-added services only; they are not part of Kaiser Permanente’s care delivery system. If you have questions about Kaiser Permanente value-added services, please contact your sales executive or account manager.

hEalThy REsUlTs fOR lifEsTylE PROgRams

becoming smoke-free—Of participating members surveyed after 180 days, 54 percent reported that they remained cigarette-free.

losing weight—Members surveyed who lost at least 8 percent of their body weight increased productivity by 12 percent. Overall, 55 percent of surveyed participants reported losing weight.

Reducing stress—Of 992 members surveyed, 59 percent reported decreased symptoms of extreme stress.

7

My health Manager— REDEfining ThE hOUsE Call

My health manager on kp.org makes online care easier than ever. your clients’ employees will enjoy these industry-leading online services:

• E-mail their doctor’s office

• view test results

• Refill prescriptions

• Request routine appointments

• and more

Deliver maximum value to your clients by helping their employees avoid unnecessary office visits, save money on copays or coinsurance, and stay productive at work.

8

scenArios for smAll groups

fOCUs On flExibiliTy

The 30 employees of a fitness equipment store represent a wide range of ages and health levels. The employer would like her employees to have the flexibility to choose from a variety of health plans.

Single carrier solutionmultiple plan offering10

Each employee can select a plan that provides the most appropriate coverage. Employees can select from five co-payment plans, two deductible plans, deductible plans with HSA or HRA, POS, or PPO. It’s a simple solution that pro-vides choice at the right price—and it’s easy to administer.

swEET sOlUTiOn

A commercial bakery wants to offer quality coverage to all of its 22 eligible employees, but some live outside the Kaiser Permanente service area. The employees are divided evenly between young singles without children and individuals with children.

Single carrier solution$35 POs Plan11

Our POS plan enables employees to receive care through Kaiser Permanente medical facilities in their area. Employees who live outside our service area can access care through any licensed provider.

ROOm fOR ChOiCEs

A small hotel has 42 eligible employees with widely differing opinions on the type of plan their employer should offer. The owner would like to offer a competitively priced solution that gives each person the coverage he or she needs with a minimum of paperwork.

Single carrier solutionKaiser Permanente Choice solution• HMO plans ($10, $30 copayment levels)

• POS plans ($20, $30 copayment levels)

• HMO deductible plan

• PPO plan

• Indemnity plan

Kaiser Permanente Choice Solution offers employers more convenience and flexibility in health care coverage. Employees can choose from a selection of seven health plans to obtain coverage that best fits their health care needs. Employers offer the spectrum of health plan choices in a defined contribution arrangement that allows them to address their budgetary needs. Employers gain added value by including ancillary/complementary plans, such as Delta Dental, with single-source administra-tion, including consolidated invoicing for multiple lines of coverage.

Help your clients find ways to keep their employees and their businesses healthy with Kaiser Permanente. Our expanded suite of products lets you offer coverage that meets your clients’ needs, at competitive prices. Visit brokers.kp.org for the most recent plan information.

plAn highlights

9

10

copAyment plAns effective 1/1/08–6/1/08

note: Kaiser Permanente plans do not include a pre-existing condition clause.

1 The annual out-of-pocket maximum is the limit to the total amount that an individual or family must pay for certain services in a calendar year (as discussed in the Evidence of Coverage).

2 Scheduled prenatal visits and the first postpartum visit 3 23 months or younger 4Prescription drugs are covered in accord with our formulary when prescribed by a Plan physician and obtained at Plan pharmacies. A few drugs have different copayments; please refer to the Evidence of Coverage for detailed information about prescription drug copayments.

5 This service is not subject to a deductible.

6 Visit or day limits do not apply to serious emotional disturbances of children and severe mental illnesses as described in the Evidence of Coverage.

7Most DME for home use is not covered. Please refer to your Evidence of Coverage for a description of limited covered items. 8 Kaiser Permanente members are entitled to a 20 percent discount on eyeglasses and contact lenses purchased at Kaiser Permanente optical centers. These discounts may not be coordinated with any other Health Plan vision benefit. The discounts do not apply to any sale, promotional, or packaged eyewear program, for any contact lenses extended purchase agreement, or to low-vision aids or devices. Visit kp.org/2020 for Kaiser Permanente optical locations.

9 Allowance toward the cost of eyeglass lenses, frames, and contact lenses fitting and dispensing every 24 months

most popular copayment plan

features $50 plan member pays

$30 plan member pays



$5 plan member pays

medical calendar-year deductible $0 $0 $0 $0 $0

pharmacy calendar-year deductible $250 for brand prescriptions

$250 for brand prescriptions

$0 $0 $0

annual out-of-pocKet maximum1

self-only enrollment/Family enrollment$3,500/$7,000 $3,500/$7,000 $3,000/$6,000 $3,000/$6,000 $1,500/$3,000

in the medical officeOffice visits $50 $30 $20 $15 $5preventive exams $50 $30 $20 $15 $5maternity/prenatal care2 $15 $0 $0 $0 $0Well-child preventive care visits3 $15 $0 $0 $0 $0Vaccines (immunizations) $0 $0 $0 $0 $0allergy injections $5 $5 $5 $5 $5infertility services not covered not covered not covered 50% 50% Occupational, physical, and speech therapy $50 $30 $20 $15 $5most labs and imaging $10 $10 $10 $10 $10mri/Ct/pet $50 $50 $50 $50 $50Outpatient surgery $250 per procedure $200 per procedure $150 per procedure $100 per procedure $5 per procedureemergency servicesemergency Department visits (waived if admitted directly to hospital)

$150 $100 $100 $100 $100

ambulance $300 $75 $75 $75 $75prescriptions4 Generic

(up to a 100-day supply)$105





Brand-name $35 (after pharmacy deductible)

$35 (after pharmacy deductible)

$305 $255 $155

hospital carephysicians’ services, room and board, tests, medications, supplies, therapies

$500 per day $400 per day $300 per day $200 per day $0

skilled nursing facility care (up to 100 days per benefit period)

$0 $0 $0 $0 $0

mental health services6

in the medical office (up to 20 visits per calendar year)in the hospital (up to 30 days per calendar year)

$50 individual$25 group$500 per day




$5 individual$2 group$0

chemical dependency servicesin the medical office in the hospital (detoxification only)

$50 individual $500 per day

$30 individual$400 per day



$5 individual$0

otherCertain durable medical equipment (Dme) not covered7 not covered7 20% ($2,000 maximum) 20% ($2,000 maximum) 20% Optical (eyewear) not covered8 not covered8 not covered8 $150 allowance9 $150 allowance9

Vision exam $50 $30 $20 $15 $5Home health care (up to 100 two-hour visits per calendar year)

$0 $0 $0 $0 $0

Hospice care $0 $0 $0 $0 $0

11

effective 1/1/08–6/1/08deductiBle plAns effective 1/1/08–6/1/08

features $30/$1,500 planmember pays

$30/$1,000 planmember pays

medical calendar-year deductibleindividual/Family $1,500/$3,000 $1,000/$2,000 pharmacy calendar-year deductible $250 for brand prescriptions $250 for brand prescriptionsannual out-of-pocKet maximum1

individual/Family $3,500/$7,000 $3,500/$7,000in the medical officeOffice visits $302 $302

preventive exams $302 $302

maternity/prenatal care3 $02 $02

Well-child preventive care visits4 $02 $02

Vaccines (immunizations) $02 $02

allergy injections $5 (after deductible) $5 (after deductible)

infertility services not covered not coveredOccupational, physical, and speech therapy $30 (after deductible) $30 (after deductible)

most labs and imaging $10 (after deductible) $10 (after deductible)

mri/Ct/pet $50 (after deductible) $50 (after deductible)

Outpatient surgery $250 (after deductible) $250 (after deductible)emergency servicesemergency Department visits (waived if admitted directly to hospital)

$100 (after deductible) $100 (after deductible)

ambulance $75 (after deductible) $75 (after deductible)prescriptions5 (up to a 100-day supply) (up to a 100-day supply)

Generic $102 $102

Brand $35 (after $250 pharmacy deductible) $35 (after $250 pharmacy deductible)hospital carephysicians’ services, room and board, tests, medications, supplies, therapies

$500 per day (after deductible) $500 per day (after deductible)

skilled nursing facility care $50 per day (after deductible) (up to 60 days per benefit period)

$50 per day (after deductible)(up to 60 days per benefit period)


in the medical office (up to 20 visits per calendar year) $30 (after deductible for individual therapy)$15 (after deductible for group therapy)

$30 (after deductible for individual therapy)$15 (after deductible for group therapy)

in the hospital (up to 30 days per calendar year) $500 per day (after deductible) $500 per day (after deductible)chemical dependency servicesin the medical office $30 (after deductible for individual therapy) $30 (after deductible for individual therapy)

in the hospital (detoxification only) $500 per day (after deductible) $500 per day (after deductible)otherCertain durable medical equipment (Dme)7 not covered not coveredOptical (eyewear)8 not covered not coveredVision exam $302 $302

Home health care (up to 100 two-hour visits per calendar year)

$02 $02

Hospice care $02 $02

note: Kaiser Permanente plans do not include a pre-existing condition clause. note: The $30/$1,500 Deductible Plan is only available if offered with at

least one copay plan. This option is available to groups with two or more eligible employees. If the $30/$1,500 Deductible Plan is offered with two or more copay plans, regular multiple plan offering rules apply.


2 This service is not subject to a deductible. 3 Scheduled prenatal visits and the first postpartum visit 4 23 months or younger

5 Prescription drugs are covered in accord with our formulary when prescribed by a Plan physician and obtained at Plan pharmacies. A few drugs have different copayments; please refer to the Evidence of Coverage for detailed information about prescription drug copayments.


7 Most DME for home use is not covered. Please refer to your Evidence of Coverage for a description of limited covered items.

8 Kaiser Permanente members are entitled to a 20 percent discount on eye-glasses and contact lenses purchased at Kaiser Permanente optical centers. These discounts may not be coordinated with any other Health Plan vision ben-efit. The discounts do not apply to any sale, promotional, or packaged eyewear program, for any contact lenses extended purchase agreement, or to low-vision aids or devices. Visit kp.org/2020 for Kaiser Permanente optical locations.

12

deductiBle plAns with hsA option effective 1/1/08–6/1/08

most popular deductible planfeatures $30/$2,700 plan with hsa

member pays$0/$2,700 plan with hsa

member pays$0/$1,500 plan with hsa

member paysmedical calendar-year deductibleindividual/Family $2,700/$5,4501 $2,700/$5,4501 $1,500/$3,0002 pharmacy calendar-year deductible n/a n/a n/aannual out-of-pocKet maximum3

self-only enrollment/Family enrollment $5,250/$10,500 $2,700/$5,450 $1,500/$3,000in the medical officeOffice visits $30 (after deductible) $0 (after deductible) $0 (after deductible)

preventive exams $304 $04 $04

maternity/prenatal care5 $104 $04 $04

Well-child preventive care visits6 $104 $04 $04

Vaccines (immunizations) $04 $04 $04

allergy injections $5 (after deductible) $0 (after deductible) $0 (after deductible)

infertility services not covered not covered not covered Occupational, physical, and speech therapy $30 (after deductible) $0 (after deductible) $0 (after deductible)

most labs and imaging $10 (after deductible) $0 (after deductible) $0 (after deductible)

mri/Ct/pet $50 (after deductible) $0 (after deductible) $0 (after deductible)

Outpatient surgery 30% (after deductible) $0 (after deductible) $0 (after deductible)emergency servicesemergency Department visits (waived if admitted directly to hospital)

30% (after deductible) $0 (after deductible) $0 (after deductible)

ambulance $100 (after deductible) $0 (after deductible) $0 (after deductible)prescriptions7 (up to a 100-day supply) (up to a 100-day supply) (up to a 100-day supply)

Generic $10 (after deductible) $0 (after deductible) $0 (after deductible)

Brand-name $30 (after deductible) $0 (after deductible) $0 (after deductible)hospital carephysicians’ services, room and board, tests, medications, supplies, therapies

30% per admission (after deductible) $0 per admission (after deductible) $0 per admission (after deductible)

skilled nursing facility care (up to 100 days per benefit period)

30% per admission (after deductible) $0 per admission (after deductible) $0 per admission (after deductible)


in the medical office (up to 20 visits per calendar year) $30 (after deductible for individual therapy) $0 (after deductible for individual therapy) $0 (after deductible for individual therapy)

$15 (after deductible for group therapy) $0 (after deductible for group therapy) $0 (after deductible for group therapy) in the hospital (up to 30 days per calendar year) 30% per admission (after deductible) $0 per admission (after deductible) $0 per admission (after deductible)chemical dependency servicesin the medical office $30 (after deductible for individual

therapy)$0 (after deductible for individual therapy) $0 (after deductible for individual therapy)

in the hospital (detoxification only) 30% per admission (after deductible) $0 per admission (after deductible) $0 per admission (after deductible)otherCertain durable medical equipment (Dme)9 not covered not covered not coveredOptical (eyewear) not covered10 not covered10 not covered10

Vision exam $30 (after deductible) $0 (after deductible) $0 (after deductible)


$0 (after deductible) $0 (after deductible) $0 (after deductible)

Hospice care $0 (after deductible) $0 (after deductible) $0 (after deductible)


1 Each family member becomes eligible for copayments after meeting his or her individual deductible.

2 The entire family deductible must be met before copayments apply for individual family members.


4 This service is not subject to a deductible. 5 Scheduled prenatal visits 6 23 months or younger

7 Prescription drugs are covered in accord with our formulary when prescribed by a Plan physician and obtained at Plan pharmacies. A few drugs have different copayments; please refer to the Evidence of Coverage for detailed information about prescription drug copayments.


9 Most DME for home use is not covered. Please refer to your Evidence of Coverage for a description of limited covered items.

10 Kaiser Permanente members are entitled to a 20 percent discount on eyeglasses and contact lenses purchased at Kaiser Permanente optical centers. These discounts may not be coordinated with any other Health Plan vision benefit. The discounts do not apply to any sale, promotional, or packaged eyewear program, for any contact lenses extended purchase agreement, or to low-vision aids or devices. Visit kp.org/2020 for Kaiser Permanente optical locations.

13

deductiBle plAns with hrA effective 1/1/08–6/1/08

features $30/$2,500 plan with hra member pays

$30/$1,500 plan with hra member pays

medical calendar-year deductible1

individual/Family $2,500/$5,000 $1,500/$3,000 pharmacy calendar-year deductible $250 for brand-name prescriptions $250 for brand-name prescriptionsannual out-of-pocKet maximum2

self-only enrollment/Family enrollment $5,000/$10,000 $3,000/$6,000in the medical officeOffice visits $30 (after deductible) $30 (after deductible)

preventive exams $303 $303

maternity/prenatal care4 $103 $103

Well-child preventive care visits5 $103 $103

Vaccines (immunizations) $03 $03

allergy injections $03 $03

infertility services not covered not coveredOccupational, physical, and speech therapy $30 (after deductible) $30 (after deductible)

most labs and imaging $10 (after deductible) $10 (after deductible)

mri/Ct/pet $50 (after deductible) $50 (after deductible)

Outpatient surgery 20% (after deductible) 20% (after deductible)emergency servicesemergency Department visits (waived if admitted directly to hospital)

20% (after deductible) 20% (after deductible)

ambulance $150 (after deductible) $150 (after deductible)prescriptions6 (up to a 100-day supply) (up to a 100-day supply)

Generic $103 $103

Brand-name $35 (after $250 pharmacy deductible) $35 (after $250 pharmacy deductible)hospital carephysicians’ services, room and board, tests, medications, supplies, therapies

20% per admission (after deductible) 20% per admission (after deductible)

skilled nursing facility care 20% per day (after deductible)(up to 100 days per benefit period)

20% per day (after deductible)(up to 100 days per benefit period)


in the medical office (up to 20 visits per calendar year) $30 (after deductible for individual therapy) $30 (after deductible for individual therapy) $15 (after deductible for group therapy) $15 (after deductible for group therapy)

in the hospital (up to 30 days per calendar year) 20% per admission (after deductible) 20% per admission (after deductible)chemical dependency servicesin the medical office $30 (after deductible for individual therapy) $30 (after deductible for individual therapy)

in the hospital (detoxification only) 20% per admission (after deductible) 20% per admission (after deductible)otherCertain durable medical equipment (Dme)8 not covered not coveredOptical (eyewear) not covered9 not covered9

Vision exam $309 $309


$03 $03

Hospice care $03 $03


1 Employer must choose a funding level percentage—either 40%, 50%, or 60%—of the health plan deductible.


3 This service is not subject to a deductible. 4 Scheduled prenatal visits and the first postpartum visit 5 23 months or younger 6 Prescription drugs are covered in accord with our formulary when

prescribed by a Plan physician and obtained at Plan pharmacies. A few drugs have different copayments; please refer to the Evidence of Coverage for detailed information about prescription drug copayments.


8Most DME for home use is not covered. Please refer to your Evidence of Coverage for a description of limited covered items. 9Kaiser Permanente members are entitled to a 20 percent discount on eyeglasses and contact lenses purchased at Kaiser Permanente optical centers. These discounts may not be coordinated with any other Health Plan vision benefit. The discounts do not apply to any sale, promotional, or packaged eyewear program, for any contact lenses extended purchase agreement, or to low-vision aids or devices. Visit kp.org/2020 for Kaiser Permanente optical locations.

14

$35 pos plAn effective 1/1/08–6/1/08

features Kaiser permanente plan providers (hmo)(in-networK)

member pays

phcs providers (ppo)

member pays

nonparticipating providers (out-of-networK)

member paysmedical calendar-year deductibleindividual/Family $0 $500/$1,0001

pharmacy calendar-year deductible $0 $0 not coveredannual out-of-pocKet maximum2,3

(calendar year)$3,000 individual$6,000 family

$3,000 individual$9,000 family

$6,000 individual$18,000 family

in the medical officeOffice visits $35 $45 50%preventive exams $35 $45 50%maternity/prenatal care4 $0 $25 50%5

Well-child preventive care visits $06 $257 50%7

Vaccines (immunizations) $0 not covered not coveredallergy injections $5 $25 50%infertility services not covered8 not covered8 not covered8

Occupational, physical, and speech therapy $35 $455 50%(combined 60-day limit per calendar year)

most labs and imaging $10 30% 50%5

mri/Ct/pet $50 30% 50%5

Outpatient surgery $100 30% 50%5

emergency servicesemergency Department visits (waived if admitted directly to hospital)

$100 emergency Department visits and ambulance for emergency medical conditions are covered as an HmO benefit for services

received at any provider.ambulance $75prescriptions

(up to a 100-day supply)Obtained at kaiser permanente plan pharmacies (including affiliated pharmacies)9

Obtained at participating medimpact pharmacies10

Generic $10 $15 not coveredBrand-name $35 $35 not coverednonformulary $40 $40 not coveredhospital carephysicians’ services, room and board, tests, medications, supplies, therapies

$200 per day 30%5 30%5

skilled nursing facility care $0 (up to 100 days per benefit period) 30%5 30%5


in the medical office (up to 20 visits per calendar year) $35 individual therapy $17 group therapy

$45 individual therapyGroup therapy not covered

50% individual therapy Group therapy not covered

in the hospital (up to 30 days per calendar year) $200 per day not covered not coveredchemical dependency servicesin the medical office (counseling for dependency; medical management of withdrawal symptoms)

$35 individual therapy$5 group therapy

individual therapy not coveredGroup therapy not covered

individual therapy not covered Group therapy not covered

in the hospital (medical management of withdrawal symptoms)

$200 per day not covered not covered

otherCertain durable medical equipment (Dme)12 Dme used during a covered stay in a plan hospital or a skilled nursing facility

$0 30%5 50%5

(combined $2,000 maximum per calendar year)

Dme used in the home not covered 30%5 50%5

(combined $2,000 maximum per calendar year)Optical (eyewear) not covered13 not covered not coveredVision exam $35 not covered not coveredHome health care $0 (up to 100 two-hour visits

per calendar year)20%5,14 20%5,14

Hospice care $0 30%5 50%5

(combined 180-day limit per calendar year)

note: For your group to be eligible for the $35 POS Plan or the $40/$1,000 PPO Plan, you must have Kaiser Permanente as your sole carrier, and the plan must be offered with at least one copayment plan as part of a multiple plan offering. If you include the PPO or POS plan in your multiple plan offering, at least 70 percent of all employees enrolled in the Health Plan must be enrolled in an HMO plan, and combined enrollment in KPIC medical plans must not exceed 30 percent. see footnotes and other important information for the POs and PPO plans on page 19.

15

$40/$1,000 ppo plAn effective 1/1/08–6/1/08

featuresphcs providers (ppo)15

member pays

nonparticipating providers (out-of-networK)15

member paysmedical calendar-year deductible1

$1,000/$2,000individual/Family annual out-of-pocKet maximum16

individual/Family $5,000/$10,000 $10,000/$20,000maximum benefit while insured17 $2 million hospital careroom, board, and critical care units 30% 50% (up to $600 per day)18

imaging, including X-rays and lab tests 30% 50% (up to $600 per day)18

transplants 30% 50% (up to $600 per day)18

physician, surgeon, and surgical services 30% 50%nursing care, anesthesia, and inpatient prescribed drugs 30% 50% (up to $600 per day)18

outpatient carephysician office visits $40 copay19,20 50%routine adult physical exams $40 copay19,20,21 not coveredadult preventive screening exam $40 copay19,20 50%20

Well-child preventive care visits (through age 18) $25 copay19,22 50%22

pediatric visits $40 copay19,20 50%Outpatient surgery 30% 50% (up to $400 per surgery)19

allergy testing visits 30% 50%allergy injection visits 30% 50%Gynecological visits $40 copay19,20 50%maternity/scheduled prenatal care and first postpartum visit 30% 50%imaging, including X-rays 30% 50%Lab tests 30% 50%eye exams for eyeglass prescriptions not covered not coveredHearing exams not covered not coveredOccupational, physical, respiratory, and speech therapy visits23 30% 50%Diabetic day care management 30% not coveredemergency services

emergency Department visits $100 (waived if admitted) $100 (waived if admitted)emergency ambulance service Covered at nonparticipating providers level 50% medically necessary nonemergency ambulance service Covered at nonparticipating providers level24 50%prescriptions25 medimpact pharmacy10 non-medimpact pharmacyGeneric drugs $15 copay19 (maximum 30-day supply) not coveredBrand-name drugs deductible (pharmacy and mail order) $200 deductible19 not coveredBrand-name drugs $35 copay19 (maximum 30-day supply) not coveredself-administered injectable medications26 $30%19 not coveredmail-order generic drugs $30 copay19 (maximum 100-day supply) not coveredmail-order brand-name drugs $70 copay19 (maximum 100-day supply) not coveredmental health careinpatient hospitalization severe mental illness and serious emotional disturbances of a child27

all other covered mental illness28

30%30%

50% (up to $600 per day)18

50% (up to $175 per day; 20 days maximum)Outpatient visits severe mental illness and serious emotional disturbances of a child27

all other covered mental illness29

$40 copay19,20

30%50%50%

alcohol and chemical dependency30

inpatient hospitalization28 30% (20 days maximum) 50% (up to $175 per day; 20 days maximum)Outpatient visits29 $40 copay19 not coveredadditional benefitsCare in a skilled nursing facility (60-day combined limit per calendar year) 30% 50%Home health care (100-day combined limit per calendar year)31 20% 20%Hospice care (180-day combined lifetime limit) 30% 50%infertility services32 30% 50%Durable medical equipment/prosthetics, orthotics, and special footwear33 30% 50%Diabetic equipment and supplies34 30% 30%

see footnotes and other important information for the POs and PPO plans on page 19.

16

smAll group rAte AreA guide

940029400594010–1194013–28940309403594037–4494060–66

9407094074940809408394085–8994101–1294114–4794150–56

94158–6494171–729417594177941889419994301–0694309

94401–049449794501–0294536–4694550–52945559455794560

945669456894577–8094586–8894601–1594617–259464994659–62

9466694701–10947129472094801–08948209485095002

95008–099501195013–1595020–219502695030–3395035–3895042

950449504695050–5695070–7195101951039510695108–13

95115–3695138–419514895150–61951649517095172–7395190–94

95196

94203–099421194229–309423294234–3794239–4094244–50942529425494256–5994261–6394267–69

9427194273–7494277–8094282–9194293–999450394505–3194533–3594547–49945539455694558–59

94561–659456794569–7694581–839458594589–9294595–999490194903–0494912–159492094922–31

9493394937–4294945–579496094963–6694970–7994998–9995201–139521595219–209522795230–31

9523495236–3795240–429525395258952679526995296–9795401–07954099541695419

954219542595430–3195433954369543995441–429544495446954489545095452

954629546595471–739547695486–879549295602–0595607–2195623–26956289563095632–35

95638–41956459564895650–529565595658–6495667–7495676–7895680–8395686–8895690–9895703

957229573695741–4295746–4795757–5995762–63957659577695798–9995811–3895840–4395851–53

9586095864–679588795894958999590395961

RaTE aREa 1—nORThERn CalifORniaThe following counties are entirely within Rate Area 1: San Francisco and San Mateo. Portions of the following counties are also within Rate Area 1: Alameda, Contra Costa, Santa Clara, and Santa Cruz.

93230932329324293601–029360493606–07

9360993611–149361693618–1993623–2793630–31

93636–3993643–4693648–5493656–579366093662

93666–69936739367593701–1293714–1893720–30

93740–4193744–4593747937509375593760–61

93764–6593771–80937849378693790–9493844

938889530495307953139531695319–20

953239532695328–3095336–3795350–5895360–61

9536395366–6895376–7895380–8295385–8795391

95397

RaTE aREa 2—nORThERn CalifORniaThe following counties are entirely within Rate Area 2: Napa and Solano.Portions of the following counties are also within Rate Area 2: Amador, Contra Costa, El Dorado, Marin, Placer, Sacramento, San Joaquin, Sonoma, Sutter, Yolo, and Yuba.

RaTE aREa 3—nORThERn CalifORniaPortions of the following counties are within Rate Area 3: Fresno, Kings, Madera, Mariposa, San Joaquin, Stanislaus, and Tulare.

Rate areas are current as of January 1, 2008. Please call our Member Service Call Center at 1-800-464-4000 if you have any questions.

17

RaTE aREa 4—sOUThERn CalifORniaPortions of the following counties are within Rate Area 4: Kern, Los Angeles, Riverside, San Bernardino, Tulare, and Ventura.

91301–11913139131691319–2291324–3191333–359133791340–4691350–659136791371–7291376–7791380–8891390

91392–969139991401–1391416914239142691436914709148291495–979149991601–1291614–1891701

91708–1091729–30917379173991743917529175891761–6491784–869179892201–0392210–119222092223

9223092234–3692240–4192247–4892252–569225892260–6492268922709227492276–789228292284–8692292

9230592307–0892313–1892320–2292324–26923299233192333–3792339–4192344–4692350923529235492357–59

9236992371–789238292385–8692391–95923979239992401–0892410–159241892423–249242792501–0992513–19

92521–2292530–3292543–469254892551–5792562–649256792570–7292581–8792589–9392595–96925999286092877–83

9320393205–0693215–16932209322293224–269323893240–419324393250–5293261932639326893276

93280932859328793301–0993311–1493380–9093501–0293504–059351093518–1993531–3293534–369353993543–44

93550–5393560–619356393581935849358693590–9193599

90620–2490630–339068090720–21

9074090742–4392602–0792609–10

9261292614–2092623–3092637

92646–6392672–7992683–8592688

92690–9492697–9892701–1292725

927289273592780–8292799

92801–0992811–1292814–1792821–23

9282592831–3892840–4692850

92856–579285992861–7192885–87

92899

90001–8490086–899009190093–969009990101–039018990201–0290209–1390220–2490230–3390239–429024590247–5190254–5590260–67

902709027290274–7590277–789028090290–9690301–1390397–9890401–1190501–1090601–109061290637–4090650–5290659–6290670–71

90701–0390706–0790710–179072390731–3490744–499075590801–1090813–159082290831–35908409084290844–489085390888

90899910019100391006–1291016–1791020–2191023–2591030–3191040–4391046910669107791101–1091114–189112191123–26

91129911319118291184–8591188–89911919119991201–109121491221–2291224–2691501–089151091521–239152691702

917069171191714–1691722–2491731–3591740–4191744–5091754–569175991765–7391775–76917789178091788–939179591797

9179991801–0491841918969189991901–0391908–179192191931–339193591941–4791950–5191962–6391976–809198791990

92007–1192013–1492018–2792029–309203392037–40920469204992051–5292054–5892064–6592067–6992071–7292074–7592078–7992081–85

92090–939209692101–2492126–4092142–43921459214792149–5092152–5592158–79921829218492186–8792190–999227593001–07

93009–1293015–1693020–2293030–3693040–4493060–6693093–9493099

RaTE aREa 5—sOUThERn CalifORniaPortions of the following counties are within Rate Area 5: Imperial, Los Angeles, San Diego, and Ventura.

RaTE aREa 6—sOUThERn CalifORniaPortions of Orange County are within Rate Area 6.

If you have any questions about our small group products or services, contact your Kaiser Permanente sales represen-tative or account manager, visit brokers.kp.org, or call 1-800-789-4661.

You can also call to receive written information regarding coverage offered to clients in the small group market. Topics include:

• Factors that affect rate setting and rate adjustments.

• Provisions related to renewing coverage.

• Premiums available to small groups.

• Geographic areas covered by the Health Plan.

Member Service Call Center 1-800-464-4000 English

1-800-788-0616 Spanish

1-800-757-7585 Chinese dialects

1-800-777-1370 TTY for the deaf, hard of hearing, or speech impaired

Quick help is just A cAll AwAy

18

19

notes

fOR POs anD PPO Plans 1 Medical calendar-year deductible amounts are combined for services provided by PHCS providers and nonparticipating providers. Deductibles do not count toward satisfying the out-of-pocket maximum (OOPM).

2 The annual OOPM is the limit to the total amount that an individual or family must pay for certain services in a calendar year (as discussed in the Evidence of Coverage and the Certificate of Insurance).

3 Covered charges incurred to satisfy the OOPM at the PHCS providers level will not be applicable toward satisfaction of the OOPM at the nonparticipating providers level. However, covered charges applied to satisfy the OOPM at the nonparticipating providers level will continue to be applicable toward satisfaction of the OOPM at the PHCS level. Covered charges incurred to satisfy the OOPM at the Kaiser Permanente in-network providers level will not be applicable toward satisfaction of the OOPM at the PHCS or nonparticipating providers level. Covered charges at the PHCS and nonparticipating providers level will not be applicable toward the satisfaction of the OOPM at the Kaiser Permanente in-network providers level.

4Scheduled prenatal visits and the first postpartum visit

5Based on maximum allowable charge

6 Covered by Kaiser Permanente Plan providers (HMO) only to age 23 months or younger

7Ages 0 to 18

8 In accordance with California law, health care plans and insurers are required to offer contract holders and policyholders the option to purchase coverage of infertility treatment (excluding in vitro fertilization). For details regarding this optional coverage, including how you may elect this coverage and the amount of additional rates, please contact your broker or the Account Management Team at 1-800-790-4661, option 2.

9 A few drugs have different copayments; please refer to the Evidence of Coverage for detailed information about prescription drug copayments. Nonformulary prescriptions that are not covered as an HMO benefit are underwritten by Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc.

10 Participating MedImpact pharmacy copayments and deductibles are not subject to, nor do they contribute toward satisfaction of, the calendar-year deductible or the OOPM. Select prescription medications are excluded from coverage. Please consult your participating phar-macy directory for a current list of participating pharmacies.

11 Visit or day limits do not apply to serious emotional disturbances of children and severe mental illnesses as described in the Evidence of Coverage and the KPIC Certificate of Insurance.

12 Please refer to the Evidence of Coverage and the Certificate of Insurance for more information; most DME is not covered under the HMO (in-network) tier. DME is limited to a combined maximum of $2,000 per calendar year for services provided by PHCS providers and nonparticipating providers.

13 Kaiser Permanente members are entitled to a 20 percent discount on eyeglasses and contact lenses purchased at Kaiser Permanente optical centers. These discounts may not be coordinated with any other Kaiser Permanente Health Plan vision benefit. The discounts do not apply to any sale, promotional, or packaged eyewear program, for any contact lenses extended purchase agreement, or to low-vision aids or devices. Visit kp.org/2020 for Kaiser Permanente optical locations.

14 Home health care is limited to a maximum of 100 visits per calendar year combined for services provided by PHCS providers and nonpartici-pating providers. Deductible amount is limited to a maximum of $50 per calendar year.

15 Payments are based upon the maximum allowable charge for covered services. Maximum allowable charge means the lesser of the usual, customary, and reasonable charges; the negotiated rate; or the actual billed charges. The maximum allowable charge may be less than the amount actually billed by the provider. Covered persons may be responsible for payment of any amounts in excess of the maximum allowable charge for a covered service.

16 Covered charges incurred toward satisfaction of the OOPM at the nonparticipating providers level will accumulate toward satisfaction of the OOPM at the PHCS providers level. Covered charges incurred toward satisfaction of the OOPM at the PHCS providers level will not accumulate toward satisfaction of the OOPM at the nonparticipating providers level.

17 Maximum benefit while insured is combined for services provided by PHCS providers and nonparticipating providers.

18 $600 per-day maximum is combined for all hospital care received from nonparticipating providers, excluding physician, surgeon, and surgical services.

19 Brand-name drug deductible, copayments, and coinsurance paid for physician office visits or paid for prescriptions filled at participating pharmacies are not subject to, nor do they contribute toward, satisfaction of either the calendar-year deductible or the OOPM.

20 Not subject to deductible

21 Routine adult physical exams are limited to one exam every 24 months and $400 per calendar year.

22 Well-child care is not subject to deductibles and includes immunizations.

23 All outpatient therapies are limited to 60 visits per calendar year combined for both PHCS providers and nonparticipating providers.

24 The PHCS provider network does not contract for ambulance service. Therefore, medically necessary nonemergency ambulance service is payable at the nonparticipating providers level. Nonemergency ambulance coverage is limited to a maximum of $2,000 per calendar year for all services.

25 Member is responsible for paying the brand-name copay plus the difference in cost between the generic drug and the brand-name drug when the patient requests a brand-name drug and a generic version is available.

26 Self-administered injectable medications are limited to a 30-day maximum supply and are not available under the mail-order service. Prescriptions for insulin are covered at the brand-name or generic copayment level.

27 Severe mental illness is limited to the following: schizophrenia, schizoaffective disorder, bipolar disorder (manic-depressive illness), major depressive disorders, panic disorder, obsessive-compulsive disorder, pervasive developmental disorder or autism, anorexia nervosa, and bulimia nervosa.

28 Benefits for treatment of other covered mental illnesses and alcohol and drug dependency are limited to 20 inpatient days per calendar year combined for both PHCS providers and nonparticipating providers.

29 Benefits for treatment of other covered mental illnesses and alcohol and drug dependency are limited to 20 outpatient visits per calendar year.

20

30 In addition to the specified day and visit limits noted, benefits payable for treatment of alcohol and drug dependency are subject to a combined limit of $10,000 per calendar year and $25,000 lifetime for services provided by PHCS providers and nonparticipating providers.

31 Combined maximum deductible of $50 per calendar year

32 Benefits payable for treatment of infertility are limited to $1,000 per calendar year combined for services provided by PHCS providers or nonparticipating providers. In vitro fertilization is not covered. Benefits payable for diagnosis of infertility will be covered on the same basis as a sickness.

33 Durable medical equipment is limited to a maximum of $2,000 per calendar year combined for services provided by PHCS providers and nonparticipating providers.

34 Diabetic equipment and supplies are limited to infusion set and syringe with needle for external insulin pumps, testing strips, lancets, skin barrier, adhesive remover wipes, and transparent film. Coinsurance amounts are based on actual billed charges and are not subject to the DME annual maximum limit of $2,000 per calendar year.

Precertification of services provided by PHCS and non–participating providers Precertification is required for all hospital confinements, including preadmission testing; inpatient care at a skilled nursing facility or other licensed, freestanding facilities, such as hospice care, home health care, or care at a rehabilitation facility; and select outpatient procedures. Failure to obtain precertification will result in an additional deductible of $500 per occurrence for covered charges incurred in connection with these services. This additional deductible will not count toward the satisfaction of any calendar-year deductibles or out-of-pocket maximums.

PHCS and non–participating providers exclusions and limitations Unless specifically covered under the group policy, expenses incurred in connection with the following services are excluded: charges, services, or care that are provided or reimbursed by Kaiser Foundation Health Plan; not medically necessary; in excess of the maximum allowable charge; not available in the United States; for personal comfort. Emergency Department facility fees or charges for nonemergency weekend (Friday through Sunday) hospital admissions. Charges arising from work or that can be covered under workers’ compensation or any similar law, or for which the group policyholder or member is required by law to maintain alternative insurance or coverage. Charges for military service–related conditions or where care is provided at government expense. Services or care provided in a member’s home, by a family member, or by a resident of the household. Dental care, appliances, or orthodontia, unless due to injury to natural teeth. Cosmetic services; plastic surgery; sex transformation; sexual dysfunction; surrogacy arrangements; biotechnology drugs or diagnostics; nonprescription drugs or medicines; treatment, procedures, or drugs Kaiser Permanente Insurance Company determines to be experimental or investigational. Education, counseling, therapy, or care for learning deficiencies or behavioral problems. Services, care, or treatment of or in connection with obesity or weight management. Services, care, or treatment of or in connection with craniomandibular or temporomandibular joint disorders, unless for medically necessary surgical treatment of the disorder. Services, care, or treatment of or in connection with musculoskeletal therapy; health education; biofeedback; hypnotherapy; routine adult physical exams;

immunizations; medical social services; hearing exams, aids, or therapy; radial keratotomy or similar procedures; reversal of sterilization; or routine foot care. Services or care required by a court of law or for insurance, travel, employment, school, camp, government licensing, or similar purposes. Transplants, including donor costs. Custodial care; care in an intermediate care facility; maintenance therapy for rehabilitation; or living or transportation expenses. Treatment of mental illness; substance abuse. Services or supplies necessary to treat an injury to which a contributing cause was a member’s: commission of or attempt to commit a felony; engagement in an illegal occupation; intoxication; or under the influence of a narcotic, unless administered by a physician. Services of a private-duty nurse. Vision care, including routine exams, eye refractions, orthoptics, glasses, contact lenses, or fittings; drugs and medicine for smoking cessation; well-child care and immunizations. Extended well-child care. Services for which no charge is normally made in the absence of insurance.

fOR all PlansHMO benefits are provided by Kaiser Foundation Health Plan, Inc., the nation’s largest nonprofit health plan.

KPIC has contracted with PHCS to provide access to hospitals and physicians with a commitment to keeping out-of-pocket costs low through contracted rates.

The traditional HMO plan and the in-network portion of the point-of-service (POS) plan are underwritten by Kaiser Foundation Health Plan, Inc. (KFHP). Kaiser Permanente Insurance Company (KPIC) underwrites the PHCS provider (PPO) plan and the out-of-network portion of the POS plan. KPIC is a subsidiary of KFHP.

Kaiser Permanente plans do not include a pre-existing condition clause.

This booklet is a summary only. The Kaiser Foundation Health Plan Evidence of Coverage and the KPIC Certificate of Insurance contain a complete explanation of benefits, exclusions, and limitations. The information provided in this brochure is not intended for use as a benefit summary, nor is it designed to serve as the Evidence of Coverage or Certificate of Insurance. Information in this brochure was accurate at the time of production. However, details may have changed since publication. For the most current information on our plans and services, check with your sales executive or account manager.

notes

end notes

1 multiple plan offering rules: Groups with three to five subscribers are eligible to enroll in a maximum of two Kaiser Permanente plans. Groups with six or more subscribers are eligible to enroll in one or more plans. If you include the PPO or POS plan in your multiple plan offering, at least 70 percent of all employees enrolled in the Health Plan must be enrolled in an HMO plan, and combined enrollment in Kaiser Permanente Insurance Company (KPIC) POS and PPO plans must not exceed 30 percent.

2 The $30/$1,500 Deductible Plan is only available if offered with at least one copay plan. This option is available to groups with two or more eligible employees. If the $30/$1,500 Deductible Plan is offered in conjunction with two or more copay plans, regular multiple plan offering rules apply.

3 The PPO plan and the out-of-network portion of the POS plan are underwritten by KPIC. The PPO and POS plans must be offered in conjunction with at least one copay plan. This option is available to groups with two or more eligible employees. If a PPO or POS plan is offered in conjunction with two or more copay plans, regular multiple plan offering rules apply. For your group to be eligible for the POS or PPO plan, you must have Kaiser Permanente as your sole carrier.

4 The tax references in this brochure relate to federal income tax only. Consult with your financial or tax advisor for more information about state income tax laws.

5 CarePay® is a registered trademark of Kaiser Permanente identifying financial products our members can access through our arrangements with preferred financial providers. The CarePay HSA is provided and administered by Wells Fargo Bank, N.A., which acts as trustee of the Wells Fargo Health Savings Accounts. Kaiser Permanente does not provide or administer financial products, including HSAs, and does not offer financial, tax, or investment advice. Members are responsible for their own investment decisions. Members can use their CarePay HSA Visa® debit card anywhere Visa is accepted, not limited to Kaiser Permanente facilities. For information about a Wells Fargo HSA, please contact Wells Fargo at 1-866-890-8308 (toll free).

6 CarePay® is a registered trademark of Kaiser Permanente identifying financial products our members can access through our arrangements with preferred financial providers. The CarePay HRA is administered by SHPS. Kaiser Permanente does not provide or administer financial products, including HRAs, and does not offer financial, tax, or investment advice. SHPS is not engaged in rendering tax advice. Federal and state tax laws and regulations are subject to change. If tax, investment, or legal advice is required, seek the services of a qualified professional.

7Dental Plan E with Ortho requires at least 10 subscribers.

8 This benefit cannot be offered with deductible plans with an HSA option.

9 Discount excludes Small Business $5 and $15 copayment plans. The discount applies to POS plans when members use in-network services and providers.

10 Multiple plan offering rules: Groups with three to five subscribers are eligible to enroll in a maximum of two Kaiser Permanente plans. Groups with six or more subscribers are eligible to enroll in one or more plans. If you include the PPO or POS plan in your multiple plan offering, at least 70 percent of all employees enrolled in the Health Plan must be enrolled in an HMO plan, and combined enrollment in Kaiser Permanente Insurance Company (KPIC) POS and PPO plans must not exceed 30 percent.

11 The $35 POS Plan is available only with a multiple plan offering. Eligible groups must have at least three enrolled employees to qualify. For your group to be eligible for the $35 POS Plan, Kaiser Permanente must be your sole carrier.

21

kp.orgBusiness Marketing Communications0403-0120-01-r98 December 2007

Date post:	29-Jun-2018
Category:	Documents
Upload:	tranxuyen
View:	213 times
Download:	0 times

portfolio CalifORnia BROKER portfolio - Cal Choice · clients may not set up any kind of...

Documents