Download Virginia - Kaiser Permanente Brokers and Employers

A BETTER WAY TO TAKE CARE OF BUSINESS
Boost your small group sales
with the Simple Solutions package
Choose from our three most popular health plans to grow your book of business.
Kaiser Permanente’s small group plan portfolio offers a variety of plan types and choices at different
cost and benefit levels. All are designed to meet the specific needs of your small group clients. Our
new Simple Solutions package makes it easier for you to sell Kaiser Permanente plans to your small
group clients by narrowing down your choices into a package of our most popular plans. All three plans offer:
• Affordability and savings: Our small group plans can save your clients up to 24 percent,1
and are also affordable for their employees.
• Quality: Kaiser Permanente of the Mid-Atlantic States is one of the highest-rated private plans
in the nation. It’s one of only 11 out of 606 nationwide to earn a rating of 5 out of 5.2
• Member satisfaction: According to the J.D. Power U.S. Health Plan Study, we have the “Highest
Member Satisfaction among Commercial Health Plans in the Mid-Atlantic Region, Eight Years in a Row.”3
• Convenience: We’re rated highest in ease of doing business and can provide billing for all three
plans in the Simple Solutions package on one statement for further administrative ease.4
The Simple Solutions plans include:
Plan
Available directly
through Kaiser
Permanente
Available through the
Small Business Health
Options Program (SHOP)
Most flexibility and
provider choices
KP VA Gold 1000/25/3TPOS
(also known as Kaiser
Permanente Deductible
Flexible Choice)
X
n/a
Affordable plan with
First Dollar Coverage
KP VA Gold 0/20
X
X
Lowest monthly
premium
KP VA Bronze 4500/50
X
X
Your clients can select the plan(s) that best suits the needs of their business without sacrificing
affordability or quality of coverage for their employees.
1. Provider flexibility and choice—or $0 deductible plan and rich benefits
• KP VA Gold 1000/25/3TPOS: Also known as the Kaiser Permanente Deductible Flexible Choice
plan, this plan offers a solution for employers looking for maximum flexibility. It features the
most provider choice and more ways to manage out-of-pocket cost than any of our other plans.
• Other top-tier benefit plan offerings: Many employees value the convenience and quality
of the Kaiser Permanente model, and prefer a lower-cost HMO plan with no deductible. The
KP VA Platinum 0/20 is a low cost sharing plan and 13 percent less expensive than the next
comparable plan.5 It’s a reasonable option for employees who may not need as much flexibility
in provider choice, or are purchasing through the SHOP where Deductible Flexible Choice is
not offered.
2. Low-cost HMO plan with no deductible
• KP VA Gold 0/20: This plan is an alternative for employers who are looking for a lower-priced
plan while still providing affordability to employees, offering a 3 percent lower premium than
the next comparable plan.6
3. Low monthly premium
• KP VA Bronze 4500/50: This is the lowest priced (and a minimum value-plan option) of the Simple Solutions plans.
Other Benefits
After joining Kaiser Permanente, your clients and their employees will not only have low cost shares
for primary care office visits, Urgent Care, and generic drug prescriptions, they will also receive these
additional benefits as part of their coverage:
$0 copayment or coinsurance for video appointments with a doctor, or
medical advice by phone, email, or video.7
$0 copay for preventive care visits or primary care office visits for children under
five years of age.8
$0 additional monthly premium for adult preventive dental and vision benefits.
Low copay at Kaiser Permanente Medical Centers with Urgent Care hours throughout
the region and emergency care coverage anywhere in the world.
Online access to their Kaiser Permanente electronic medical records through My
Health Manager, with the ability to schedule and cancel routine appointments, email
their doctor, view most lab results, and more.9
2
A BETTER WAY TO TAKE CARE OF BUSINESS
Additional benefit highlights and cost shares for the Simple Solutions plans:10
Plan
Kaiser Permanente Deductible
Flexible Choice Plan11
(In-network Options 1 and 2 only*)
KP VA Platinum
0/20
KP VA Gold
0/20
KP VA Bronze
4,500/50
Option 1:
$0 subscriber only
$0 subscriber only
$4,500
$0/$0 individual/
$0/$0 individual/
subscriber only
family
family
$4,500/$9,000
$1,000 subscriber only
$1,000/$2,000 individual/family
Annual
deductible
Option 2:
individual/family
$2,000 subscriber only
$2,000/$4,000 individual/family
Option 1:
$2,500
$6,000
$6,850
$3,000 subscriber only
subscriber only
subscriber only
subscriber only
$2,500/$5,000
$6,000/$12,000
$6,850/$13,700
individual/family
individual/family
individual/family
$3,000/$6,000 individual/family
Annual out-of­
pocket maximum Option 2:
$3,850 subscriber only
$3,850/$7,700 individual/family
Primary care
office visit
Option 1: $25
Specialist
office visit
Option 1: $35
Option 2: $35
Option 2: $45
Option 1:
$20
$20
$30
$50
$150 per admission $300 per day,
$300 after deductible
Inpatient hospital
$50
$60 after
deductible
30%
up to 3 days
after deductible
Option 2:
25% after deductible
Prescription
drugs from Kaiser
Permanente
pharmacy
(deductible/
generic/brand/
non-preferred/
specialty)
Option 1:
None/$5/$25/$50/
$100 (waived for
$300 (waived for
None/$15/$40/$60/50%
50% up to $300
generic drugs)/
generic drugs)/
up to $300
$20/$55/$95/50%
$30/$60/50%/
Option 2:
up to $300 after
50% up to $300
deductible
after deductible
None/$25/$50/$80/50%
up to $300
*
Option 1 = Mid-Atlantic Permanente Medical Group, P.C. physicians (HMO)
Option 2 = Preferred provider organization (PPO)12
3
4
1
Based on premium comparison between Kaiser Permanente VA Gold 1500/30/HSA/HRA/Dental/PedDental Plan and other
health insurance carriers’ lowest-priced plan across all Gold plans for an individual age 40. The lowest premium quoted is only
applicable to a 40-year-old individual who enrolls in our Gold 1500/30/HSA/HRA/Dental/PedDental Plan. Source: VA-approved
rates published by the Virginia Bureau of Insurance (www.scc.virginia.gov/boi/SERFFInquiry/) effective January 1, 2016.
For costs and complete details, including exclusions and limitations of this and other small group plans, please call Kaiser
Foundation Health Plan of the Mid-Atlantic States, Inc.
2
The private plan of Kaiser Permanente of the Mid-Atlantic States, Inc., is rated 5 out of 5 among health insurance plans in
NCQA’s “Health Insurance Plan Ratings 2015–2016.” Out of 606 plans rated, it is the only one in Maryland, Virginia, and
Washington, DC, and one of only 11 nationwide to earn the 5 out of 5 rating. The ratings are based on measures of consumer
satisfaction and clinical quality in prevention and treatment services. The private plan was also rated the No. 1 private plan in
Maryland, Virginia, and Washington, DC, from 2012 to 2014. Visit reportcard.ncqa.org for more information.
3
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. received the highest numerical score among commercial health
plans in the Mid-Atlantic region in the J.D. Power 2008–2016 U.S. Member Health Plan Studies. 2016 study based on 31,867
responses from 6 plans measuring experiences and perceptions of members surveyed October–December 2015. Your
experiences may vary. Visit jdpower.com.
4
”Ease of doing business with the health plan.” Source: Kaiser Permanente 2015 Enterprise Broker Relationship Survey
conducted among small group brokers doing business with Kaiser Permanente, against key local competitors such as CareFirst,
Anthem, United Health Care, and Aetna.
5
Based on premium comparison between Kaiser Permanente VA Platinum 0/20/Dental/PedDental Plan and other health
insurance carriers’ comparable plans within a $500 deductible for an individual age 40. The lowest premium quoted is only
applicable to a 40-year-old individual who enrolls in our Platinum 0/20/Dental/PedDental Plan. Source: VA-approved rates
published by the Virginia Bureau of Insurance (www.scc.virginia.gov/boi/SERFFInquiry/) effective January 1, 2016. For costs and
complete details, including exclusions and limitations of this and other small group plans, please call Kaiser Foundation Health
Plan of the Mid-Atlantic States, Inc.
6
Based on premium comparison between Kaiser Permanente VA Gold 0/20/Dental/PedDental Plan and other health insurance
carriers’ comparably priced plans within a $500 deductible for an individual age 40. The lowest premium quoted is only
applicable to a 40-year-old individual who enrolls in our Gold 0/20/Dental/PedDental Plan. Source: VA-approved rates
published by the Virginia Bureau of Insurance (www.scc.virginia.gov/boi/SERFFInquiry/) effective January 1, 2016. For costs and
complete details, including exclusions and limitations of this and other small group plans, please call Kaiser Foundation Health
Plan of the Mid-Atlantic States, Inc.
7
Video appointments with primary care physicians (PCPs) available only with Permanente physicians. During a PCP visit, you
must be present in Maryland, Virginia, or Washington, DC. For urgent medical advice video visits, you may also be located in
Florida, North Carolina, West Virginia, or Pennsylvania. For members 18 and older. For certain medical conditions.
8
Applies to care received at a Kaiser Permanente medical facility, or a participating provider in Option 2 of the Deductible
Flexible Choice Plan.
9
These features are available only for care and services received at a Kaiser Permanente medical facility.
10
This is only a summary. It does not fully describe benefit coverage for every plan. For complete coverage details, including
exclusions, limitations, and plan terms, contact a Kaiser Permanente representative or refer to the group’s service agreement.
11
Option 1 is underwritten by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. Options 2 and 3 are underwritten by
Kaiser Permanente Insurance Company. Option 3 benefit coverage details are not shown here.
12
The preferred provider organization option is comprised of contracted Private Health Care Systems (PHCS) and MultiPlan
networks. The PHCS and MultiPlan network includes physicians and health care practitioners and facilities that are contracted
with Kaiser Permanente Insurance Company, a subsidiary of Kaiser Foundation Health Plan, Inc. For a list of network
participants, go to multiplan.com/kpmas.
A BETTER WAY TO TAKE CARE OF BUSINESS
EXCLUSIONS*
Annual Out-Of-Pocket Exclusions:
• Eyeglass lenses and frames, contact lenses that are available with a discount only
• Adult dental Services
• Adult routine eye exams
Prescription Exclusion:
The Rx Deductible does not apply to Generic, Contraceptives, Preventive Care Drugs, and Smoking
Cessation Drugs.
LIMITATIONS AND EXCLUSIONS*
Prescription Drugs
Prescription Drugs Limitations:
• For drugs prescribed by dentists, coverage is limited to antibiotics and pain relief drugs that are included on our Preferred Drug List and purchased at a Plan Pharmacy or a participating network pharmacy.
• In the event of a civil emergency or the shortage of one or more prescription drugs, we may limit availability in consultation with the Health Plan’s emergency management department and/or our Pharmacy and Therapeutics Committee. If limited, the applicable Cost Share per prescription will apply.
Prescription Drugs Exclusions:
• Drugs for which a prescription is not required by law, except for non-prescription drugs that are prescribed by a Plan Provider and are listed in our Preferred Drug List. • Compounded preparations that do not contain at least one ingredient requiring a prescription
and are not listed in our Preferred Drug List: 1) Drugs obtained from a non-Plan Pharmacy, except
when the drug is prescribed during an emergency or urgent care visit in which covered Services are
rendered, or 2) associated with a covered authorized referral outside the Service Area.
• Take home drugs received from a hospital, Skilled Nursing Facility, or other similar facility.
• Drugs that are not listed in our Preferred Drug List.
• Drugs that are considered to be experimental or investigational.
• Except as specifically covered, a drug (a) which can be obtained without a prescription, or (b) for which
there is a non-prescription drug that is the identical chemical equivalent (i.e., same active ingredient
and dosage) to a prescription drug.
• Drugs for which the Member is not legally obligated to pay, or for which no charge is made.
• Blood or blood products.
• Drugs or dermatological preparations, ointments, lotions, and creams prescribed for cosmetic
purposes including but not limited to drugs used to retard or reverse the effects of skin aging or to
treat nail fungus or hair loss.
• Medical foods.
5
• Drugs for the palliation and management of terminal illness if they are provided by a licensed hospice
agency to a Member participating in our hospice care program.
• Replacement prescriptions necessitated by theft or loss.
• Prescribed drugs and accessories that are necessary for Services that are excluded.
• Special packaging (e.g., blister pack, unit dose, unit of-use packaging) that is different from the Health
Plan’s standard packaging for prescription drugs.
• Alternative formulations or delivery methods that are (1) different from the Health Plan’s standard
formulation or delivery method for prescription drugs and (2) deemed not Medically Necessary.
• Durable medical equipment, prosthetic or orthotic devices, and their supplies, including: peak flow
meters, nebulizers, and spacers; and ostomy and urological supplies.
• Drugs and devices that are provided during a covered stay in a hospital or Skilled Nursing Facility,
or that require administration or observation by medical personnel and are provided to you in a
medical office or during home visits. This includes the equipment and supplies associated with the
administration of a drug.
• Bandages or dressings.
• Diabetic equipment and supplies.
• Growth hormone therapy (GHT) for treatment of adults age 18 or older, except when prescribed by a
Plan Physician, pursuant to clinical guidelines for adults.
• Immunizations and vaccinations solely for the purpose of travel.
• Any prescription drug product that is therapeutically equivalent to an over-the-counter drug, upon a
review and determination by the Pharmacy and Therapeutics Committee.
• Drugs for weight management.
• Drugs for treatment of sexual dysfunction disorder, such as erectile dysfunction.
*
6
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., (KFHP-MAS) and Kaiser Permanente
Insurance Company (KPIC) are not bound by the exclusions and limitations listed here; instead, the
benefits, services, exclusions, and limitations that apply are listed in the Group Agreement and Evidence
of Coverage provided in a separate document. Consult the Group Agreement and Evidence of Coverage
to determine governing contractual provisions including detailed benefits, exclusions and limitations
related to the group benefit plan. The Group Agreement and Evidence of Coverage is the legally binding
document between KFHP-MAS, KPIC, and groups. In the event of ambiguity, or a conflict between this
summary and the Group Agreement and Evidence of Coverage, the Group Agreement and Evidence of
Coverage shall control. Members enrolled with KFHP-MAS and/or KPIC will also receive a copy of the
Evidence of Coverage. In the event of ambiguity, or a conflict between this summary and the member’s
Evidence of Coverage, the Evidence of Coverage shall control.
A BETTER WAY TO TAKE CARE OF BUSINESS
NOTES:
7
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., 2101 E. Jefferson St., Rockville, MD 20852 60512215 MAS 9/1/16–12/31/16