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Kaiser Permanente Summary of Benefits and Coverage: Gold ...

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2022. : Gold 80 HMO 0/30 + Child Dental Alt Coverage for: Individual / Family | Plan Type: HMO. 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, or call 1-800-278-3296 (TTY: 711). For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary.

Limited to two check-ups / year. Excluded Services & Other Covered Services: ... This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan

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Transcription of Kaiser Permanente Summary of Benefits and Coverage: Gold ...

1 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2022. : Gold 80 HMO 0/30 + Child Dental Alt Coverage for: Individual / Family | Plan Type: HMO. 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, or call 1-800-278-3296 (TTY: 711). For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary.

2 You can view the Glossary at or call 1-800-278-3296 (TTY: 711) to request a copy. Important Questions Answers Why This Matters: What is the overall $0 See the common Medical Events chart below for your costs for services this plan covers. deductible? This plan covers some items and services even if you haven't yet met the deductible Are there services amount. But a copayment or coinsurance may apply. For example, this plan covers certain covered before you Not Applicable. preventive services without cost-sharing and before you meet your deductible. See a list of meet your deductible? covered preventive services at Benefits /. Are there other deductibles for specific No. You don't have to meet deductibles for specific services. services?

3 What is the out-of- The out-of-pocket limit is the most you could pay in a year for covered services. If you have Medical: $7,000 Individual / $14,000 Family pocket limit for this other family members in this plan, they have to meet their own out-of-pocket limits until the Child Dental: $350 Child / $700 Children plan? overall family out-of-pocket limit has been met. Premiums, and health care services What is not included in this plan doesn't cover, indicated in Even though you pay these expenses, they don't count toward the out of pocket limit. the out-of-pocket limit? chart starting on page 2. This plan uses a provider network. You will pay less if you use a provider in the plan's Will you pay less if you Yes. See or call 1-800-278- network.

4 You will pay the most if you use an out-of-network provider, and you might receive use a network 3296 (TTY: 711) for a list of network a bill from a provider for the difference between the provider's charge and what your plan provider? providers. 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 Yes, but you may self-refer to certain This plan will pay some or all of the costs to see a specialist for covered services but only if to see a specialist? specialists. you have a referral before you see the specialist. Plan ID: 13305/13306_40513CA0410051-00_2022. Page 1 of 6. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

5 What You Will Pay Common Medical Services You May Non-Plan Provider Limitations, Exceptions, & Other Important Event Need Plan Provider Information (You will pay the (You will pay the least). most). Primary care visit to $30 / visit Not covered None treat an injury or illness If you visit a health Specialist visit $35 / visit Not covered None care provider's You may have to pay for services that aren't office or clinic Preventive preventive. Ask your provider if the services care/screening/ No charge Not covered needed are preventive. Then check what your plan immunization will pay for. Diagnostic test (x-ray, X-ray: $40 / encounter Not covered None blood work) Lab tests: $30 / encounter If you have a test Imaging (CT/PET. $250 / procedure Not covered None scans, MRIs).

6 Up to a 30-day supply retail and a 100-day supply $15 / prescription (retail), Generic drugs (Tier 1) Not covered mail order. Female contraceptives are no charge. $30 / prescription (mail order). If you need drugs to Subject to formulary guidelines. treat your illness or Up to a 30-day supply retail and a 100-day supply condition Preferred brand drugs $40 / prescription (retail), Not covered mail order. Female contraceptives are no charge. More information (Tier 2) $80 / prescription (mail order) Subject to formulary guidelines. about prescription drug coverage is The cost-sharing for non-preferred brand drugs available at Non-preferred brand $40 / prescription (retail), under this plan aligns with the cost-sharing for Not covered drugs (Tier 2) $80 / prescription (mail order) preferred brand drugs (Tier 2), when approved through the formulary exception process.

7 20% coinsurance up to $250 / Up to a 30-day supply (retail). Subject to formulary Specialty drugs (Tier 4) Not covered prescription guidelines. Facility fee ( , ambulatory surgery $320 / procedure Not covered None If you have center). outpatient surgery Physician/Surgeon Fee is included in the Facility Physician/surgeon fees Not Applicable Not covered Fee. Page 2 of 6. What You Will Pay Common Medical Services You May Non-Plan Provider Limitations, Exceptions, & Other Important Event Need Plan Provider Information (You will pay the (You will pay the least). most). Copayment is waived if admitted to hospital as Emergency room care $250 / visit $250 / visit inpatient. If you need Emergency medical immediate medical $250 / trip $250 / trip None transportation attention Non-Plan providers covered when temporarily Urgent care $30 / visit $30 / visit outside the service area.

8 Facility fee ( , $600 / day up to 5 days Not covered None If you have a hospital room). hospital stay Physician/Surgeon Fee is included in the Facility Physician/surgeon fees Not Applicable Not covered Fee. Mental / Behavioral health: $30 /. individual visit; No charge for other If you need mental outpatient services Mental / Behavioral health: $15 / group visit;. health, behavioral Outpatient services Not covered Substance Abuse: Substance Abuse: $5 / group visit health, or $30 / individual visit, $5 / day for substance abuse other outpatient services services Inpatient services $600 / day up to 5 days Not covered None Depending on the type of services, a copayment, coinsurance, or deductible may apply. Maternity Office visits No charge Not covered care may include tests and services described elsewhere in the SBC ( , ultrasound).

9 If you are pregnant Childbirth/delivery Professional services are included in the Facility Not Applicable Not covered professional services Fee. Childbirth/delivery $600 / day up to 5 days Not covered None facility services Up to 2 hours / visit, up to 3 visits / day, up to 100. Home health care No charge Not covered visits / year. If you need help Inpatient: $600 / day up to 5 days;. recovering or have Rehabilitation services Not covered None Outpatient: $30 / visit other special health Inpatient: $600 / day up to 5 days;. needs Habilitation services Not covered None Outpatient: $30 / visit Skilled nursing care $300 / day up to 5 days Not covered Up to 100 days limit / benefit period. Page 3 of 6. What You Will Pay Common Medical Services You May Non-Plan Provider Limitations, Exceptions, & Other Important Event Need Plan Provider Information (You will pay the (You will pay the least).)

10 Most). Durable medical Up to $2,000 supplemental benefit limit / year for 20% coinsurance Not covered equipment certain items. Requires prior authorization. Hospice services No charge Not covered None Children's eye exam No charge Not covered None Limited to one pair of glasses/year from select If your child needs Children's glasses No charge Not covered frames and lenses dental or eye care Children's dental No charge Not covered Limited to two check-ups / year. check-up 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.). Cosmetic surgery Infertility treatment Private-duty nursing Dental care (Adult) Long-term care Routine foot care Hearing aids Non-emergency care when traveling outside the Weight loss programs Other Covered Services (Limitations may apply to these services.


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