COLORADO DEPARTMENT OF REGULATORY …

1 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: Beginning on or after 01/01/2017 *: 2017 Kaiser CO Bronze Coverage for: All Coverage Tiers | Plan Type: HDHP POS *The Kaiser Permanente Point-of-Service Plan is jointly underwritten by Kaiser Foundation Health Plan, Inc. (KFHP) and Kaiser Permanente Insurance Company(KPIC). The HMO portion is underwritten by KFHP and the PPO and the Out-of-Network portion is underwritten by KPIC, a subsidiary of KFHP. 1 of 6 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage see or call 1-877-580-6125 (TTY 711).

2 For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at or call 1-877-580-6125 (TTY 711) to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? Plan provider: $3,000 Individual / $6,000 Family, Non-plan provider: $3,000 Individual / $6,000 Family Generally, you must pay all of the costs from provider up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family. Are there services covered before you meet your deductible? Yes, preventive care and services indicated in chart starting on page 2. This plan covers some items and services even if you haven t yet met the deductible amount.

3 But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at Are there other deductibles for specific services? No. You don t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? Plan provider: $5,950 Individual / $11,900 Family, Non-plan provider: $11,900 Individual / $23,800 Family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance-billed charges, health care this plan doesn t cover and services indicated in chart starting on page 2. Even though you pay these expenses, they don t count toward the out of pocket limit.

4 Will you pay less if you use a network provider? Yes. See or call 1- 855-580-6125 (TTY 711) for a list of plan providers. This plan uses a provider network. You will pay less if you use a provider in the plan s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. 2 of 6 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Plan Provider (You will pay the least) Non-Plan Provider (You will pay the most) If you visit a health care provider s office or clinic Primary care visit to treat an injury or illness 20% coinsurance 40% coinsurance None Specialist visit 20% coinsurance 40% coinsurance None Preventive care/screening/ immunization No charge; deductible does not apply.

5 40% coinsurance You may have to pay for services that aren t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) 20% coinsurance 40% coinsurance None Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance Non-Plan provider: 50% penalty without pre-certification, up to $500. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at Generic drugs 20% coinsurance retail and mail order / prescription 40% coinsurance Up to a 90 day supply. Subject to formulary guidelines. Plan pharmacy: Generic drugs: Federally mandated over the counter items are covered with a prescription. Non-preferred drugs: Must be authorized through the non-preferred drug process. No charge for women s preventive contraceptives, in accordance with formulary guidelines.

6 All categories: Subject to formulary guidelines. Preferred brand drugs 20% coinsurance retail and mail order / prescription 40% coinsurance Non-preferred brand drugs 20% coinsurance retail and mail order / prescription 40% coinsurance Specialty drugs Applicable Generic, Preferred brand, or Non-preferred brand cost shares apply Applicable Generic, Preferred brand, or Non-preferred brand cost shares apply If you have outpatient surgery Facility fee ( , ambulatory surgery center) 20% coinsurance 40% coinsurance Non-Plan provider: 50% penalty without pre-certification, up to $500. Physician/surgeon fees 20% coinsurance 40% coinsurance Non-Plan provider: 50% penalty without pre-certification, up to $500. If you need immediate medical attention Emergency room care 20% coinsurance 20% coinsurance None Emergency medical transportation 20% coinsurance 20% coinsurance None Urgent care 20% coinsurance 40% coinsurance Non-Plan providers covered when temporarily outside the service area at the Plan Provider level.

7 3 of 6 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Plan Provider (You will pay the least) Non-Plan Provider (You will pay the most) If you have a hospital stay Facility fee ( , hospital room) 20% coinsurance 40% coinsurance Non-Plan provider: 50% penalty without pre-certification, up to $500. Physician/surgeon fees 20% coinsurance 40% coinsurance Non-Plan provider: 50% penalty without pre-certification, up to $500. If you need mental health, behavioral health, or substance abuse services Outpatient services 20% coinsurance 40% coinsurance None Inpatient services 20% coinsurance 40% coinsurance Non-Plan provider: 50% penalty without pre-certification, up to $500. If you are pregnant Office visits 20% coinsurance 40% coinsurance. Cost sharing does not apply to certain preventive services. Maternity care may include test and services described elsewhere in the SBC ( ).

8 Childbirth/delivery professional services 20% coinsurance 40% coinsurance. Non-Plan provider: 50% penalty without pre-certification, up to $500. Childbirth/delivery facility services 20% coinsurance 40% coinsurance. Non-Plan provider: 50% penalty without pre-certification, up to $500. 4 of 6 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Plan Provider (You will pay the least) Non-Plan Provider (You will pay the most) If you need help recovering or have other special health needs Home health care 20% coinsurance 40% coinsurance 120 visits / year Rehabilitation services Inpatient: 20% coinsurance Outpatient: 20% coinsurance 40% coinsurance Outpatient: 60 visits combined / year (combined rehabilitation and habilitation, autism spectrum disorders are not subject to the visit limit). Inpatient: Multi-disciplinary facility limited to 60 days per condition / year.

9 Non-Plan provider: 50% penalty without pre-certification, up to $500. Habilitation services 20% coinsurance 40% coinsurance 60 visits combined / year (combined rehabilitation and habilitation, autism spectrum disorders are not subject to the visit limit). Non-Plan provider: 50% penalty without pre-certification, up to $500. Skilled nursing care 20% coinsurance 40% coinsurance 120 day limit / year. Non-Plan provider: 50% penalty without pre-certification, up to $500. Durable medical equipment 20% coinsurance 40% coinsurance Subject to formulary guidelines. Prosthetic arms and legs 20% coinsurance. Non-Plan provider: 50% penalty without pre-certification, up to $500. Hospice services 20% coinsurance 40% coinsurance None If your child needs dental or eye care Children s eye exam Not covered Not covered No coverage for refraction eye exam Children s glasses Not covered Not covered None Children s dental check-up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

10 Children s glasses Cosmetic surgery Dental care (Adult and child) Long term care Non-emergency care when traveling outside the Routine eye care Routine foot care Weight loss programsOther Covered Services (Limitations may apply to these services. This isn t a complete list. Please see your plan document.) Acupuncture Bariatric surgery Chiropractic care (20 visit limit / year) Infertility treatment ($15,000 limit medical, $5,000limit drugs / lifetime) Private duty nursingHearing aids (Adults: 1 aid / ear, every 24 months; Children: no limit) 5 of 6 Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is shown in the chart below. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit or call 1-800-318-2596.