better health is just a click away · we offer deductible and hsa-qualified deductible plans so you...

At Kaiser Permanente, you can take charge of your health with a variety of online tools — health links, calculators, podcasts — right at your fingertips. Think of them as your dashboard for healthy living. As a member, here are 10 helpful tools you can use:

6009202712379_09EnrollKitPO_M_d 1/1/13-12/31/13

Better health is just a click away

Healthy lifestylesGetting healthier is easier with a plan, so start with a customized online action plan from HealthMedia®. These healthy lifestyle programs can help you reach your health goals.

kp.org/healthylifestyles

Get walkingHit the trail with the Every Body Walk! app. Create a personalized walking plan, connect with new friends, and share your progress.

everybodywalk.org/app.html

Managing your weightYour weight is more than a number on a scale—it’s how you feel every day, inside and out. We’ve got the tools to help you reach or maintain a healthy weight.

kp.org/weight

VideosFrom inspiring messages on the benefits of exercise to simple ways to control asthma, our videos will instruct and motivate you to better health.

kp.org/video

Health encyclopediaLearn more about numerous health topics with our online health encyclopedia or visit our interactive health symptom checker.

kp.org/health

FitnessYou’re built to move. Our online resources are there to help with a fitness routine or to provide ideas for fun activities to get your family moving.

kp.org/fitness

ClassesThere’s something for everyone with our health classes and workshops offered at our facilities. Classes vary by location and fees may apply.

kp.org/classes

Quit tobaccoBreak the habit for good—free yourself from tobacco’s grip with our helpful resources like a personalized online action plan or phone counseling and coaching.

kp.org/quitsmoking

PodcastsYour mind and body are connected. Download our guided imagery programs to help you reduce stress, focus on healthy changes, and promote healing.

kp.org/listen

CalculatorsEnter your numbers online and check your health information such as your body mass index (BMI) or your daily calorie count.

kp.org/calculators

2013 Kaiser Permanente for Individuals and Families Enrollment Book

Try a better approach to health – apply now!

I can choose my doctor

I can email my doctor‘s office

It keeps getting better

We give you the information and tools you need for a healthier life—all in one easy-to-use package.

Great doctors A trusting relationship with your doctor is a big part of staying healthy. Our doctors are some of the most caring, skilled physicians around. And if you forget to ask something during a visit, you can always email their office. They’re there for you.

Community of care At Kaiser Permanente, your providers, facilities, and health plan are all part of the same team. Your doctors, nurses, and pharmacists work together to coordinate your care. And you don’t have to drive all over town for care because most of our medical offices include pharmacy, lab, and X-ray services in the same place.

We’re all connected Your electronic health record securely connects your entire care team to your up-to-date health information, medications you’re taking, and whether you’re due for a preventive screening.

Note: Many features identified in this book are available only to members receiving care at Kaiser Permanente medical facilities.

What you need, when you need it We make it simple for you to get healthier and stay healthier:

n Easy-to-schedule appointments

n Same-day, after-hours, and weekend health services at many locations

n Medical records, immunizations, and test results online

And all those little extras n Online prescription refills

n Online tools that help you set up a customized fitness program or cook nutritious meals

n Wellness classes at most facilities, most of which are free with your membership

With Kaiser Permanente, you get everything you need to stay informed and take an active role in your health. And we partner with you to help you make better choices every step of the way.

Together, we make a great team. Apply now!

160091025 Ohio/KPOH-128696539 January 2013

Individual and Family Plans | WHAT’S INSIDE

What’s inside

2 Getting startedTake charge of your health with our great doctors, convenient facilities, preventive care, and innovative electronic health record system.

5 Our plansWe offer deductible and HSA-qualified deductible plans so you can find the right fit for your needs.

6 Signature deductible plansThese plans feature low premiums in exchange for an annual deductible.

9 Signature HSA-qualified deductible planThis plan offers federal tax advantages if you open a health savings account (HSA).

12 Dental planThe Delta Dental of Ohio Plan is included with all our plans.

13 Vision planThe VSP Advantage PlanSM is included with our traditional deductible plans.

14 RatesFind the rates for the plans you’re interested in.

20 Our locationsWhether you need routine care from a physician, inpatient hospital care, or a specialized medical test, Kaiser Permanente offers you many convenient locations to choose from, so it’s easy to find a facility close to your home or workplace.

21 Key termsA glossary of terms you may find helpful

22 Frequently asked questionsHave a question? We have answers.

24 Important details and noticesKaiser Permanente Health Insurance Portability and Accountability Act (HIPAA) plans, privacy notices, and other important information

HAVE A QUESTION? WE’RE HERE TO HELP.

Call 1-800-494-5314 Visit buykp.org/apply Contact your agent or broker today!

Individual and Family Plans | GETTING STARTED


A better plan for a healthier you

Today you’re taking a big step toward a lifetime of better health. With Kaiser Permanente, a world of healthy choices awaits you. And we’re here to help you explore it.

BETTER CARE

Excellent care starts with having a great doctor. With Kaiser Permanente, you get a wide choice of skilled physicians from many of the top medical schools in the country. Our doctors are caring, supportive, and highly respected in their fields. This makes it easy to find the one who’s right for you and your family.

And because our doctors are not burdened with claim forms and paperwork, they can focus on being doctors. That means their most important job is taking care of you.

BETTER INFORMATION

At Kaiser Permanente, the health information you need is just a click or call away. You can email your doctor’s office or call an advice nurse 24/7. Plus, you can check most lab results and your health records — all from the convenience of your own computer.1

Your electronic health record — a Kaiser Permanente innovation — helps your doctors and health care team coordinate your care. When you visit your doctor, your health history, your prescriptions, lab tests, and X-rays are all at his or her fingertips.

BETTER CHOICES

One size doesn’t fit all in health plans. That’s why we offer a variety of affordable plans with different premiums and coverage options so you can find the best fit for you and your family. All feature the benefits you need and the quality care you deserve.

BETTER PREVENTION, BETTER HEALTH

We believe prevention really is the best way to keep you healthy. Not only are many preventive care services available for no charge, but we also send you reminders when you need a checkup or a mammogram.

Take a look at what we offer — and then give us a call at 1-800-494-5314. Or, if you’re working with an agent or a broker, contact him or her for assistance. He or she will be happy to walk you through the plan selection and application process.

If you call us, a licensed agent will explain your plan choices and help you decide which plan is best for you.

1Most features are available only to members receiving care at Kaiser Permanente medical facilities.

Call 1-800-494-5314 Visit buykp.org/apply Contact your agent or broker today!QUESTIONS?



Stay healthier with preventive care

Staying healthy is the ultimate goal. We believe preventive care is the foundation of good health, and we back that up with our coverage. Many of our preventive health care services are available for no charge. And you don’t have to meet a deductible first.

Preventive care services to help keep you well Our goal is to help you stay healthy. That’s why we provide preventive care services that monitor you when you’re well and can warn you when you’re at risk of becoming ill.

A SAMPLING OF OUR PREVENTIVE CARE SERVICES

n Most immunizations

n Well-child visits

n Preventive exams

n Preventive lab tests and X-rays

n Mammograms

n Screening flexible sigmoidoscopy

n Screening colonoscopy

n Contraceptive care and counseling

For a complete list of our preventive care services, visit kp.org/prevention.


www.kp.org/prevention



Manage your health online

Choose simplicity with online access. You can manage many of your health needs from your own computer, smart phone, or tablet.

My Health ManagerImagine emailing your doctor’s office with a question you forgot to ask, or checking most lab results as soon as they’re available.

My Health Manager, available to members at kp.org, makes managing your health easier. My Health Manager is available 24 hours a day, seven days a week — and registering is quick and easy.1

These free, secure features can help you spend less time managing your health and more time enjoying it. With My Health Manager, you’re in charge of your own health.

WITH MY HEALTH MANAGER YOU CAN:

n Email your doctor’s office.

n View most test results as soon as they’re available.

n Receive reminders for checkups and immunizations.

n Order most prescription refills (most can be mailed to you — postage-paid).

n Schedule, cancel, or review routine appointments.

n Review recent office visits, including recommended follow-up steps.


For a tour of all the services My Health Manager has to offer, please visit kp.org/experience.

1Most features are available only to members receiving care at Kaiser Permanente medical facilities.

www.kp.org/experience


Individual and Family Plans | OUR PLANS

Pick the right plan for you

We offer two types of health coverage for individuals and families. Both feature quality care— the main difference is how you pay for it. Many preventive care services are no charge, no matter which plan you choose.

SIGNATURE HSA-QUALIFIED DEDUCTIBLE PLAN

n Pay for health care with tax-deductible dollars

n No charge for covered services after deductible is met

When you open a health savings account (HSA), this plan offers quality medical coverage, our lowest premiums, and a tax-free way to build savings for qualified medical expenses.1

Our HSA-qualified deductible plan:n Plan 5000/10000

SIGNATURE DEDUCTIBLE PLANS

n Range of deductible levels

n Separate pharmacy deductible

With these plans, some services, such as doctor’s office visits and urgent care visits, are available for a copayment before you meet your deductible.

Our deductible plans:n Plan 1500/3000

n Plan 2000/4000

n Plan 3000/6000


1Tax references relate to federal income tax only. Please consult a financial or tax adviser for tax savings information.


Individual and Family Plans | DEDUCTIBLE PLANS

How deductible plans work

With these plans, you pay full charge for most covered services until your expenses meet an annual deductible. Then, for covered services, you pay a coinsurance or copay.

DeductiblesUnder a deductible plan, most covered services are subject to the deductible — the set amount for which you pay full charge in a calendar year. This means you’ll pay full charge for most services until you reach your annual deductible.

No deductible for select servicesIn our traditional deductible plans, some services are available for a copay or coinsurance before you meet your deductible. For example, primary care, specialty care, and urgent care visits are not subject to the deductible. And to encourage you to receive preventive care, many of these services are available for a copay or no charge before you meet your deductible.

Out-of-pocket maximumsYour out-of-pocket maximum puts a cap on how much you’ll spend on most covered services each calendar year. This helps protect you financially if you have a serious illness or injury.

In our traditional deductible plans, the deductible does not apply toward the out-of-pocket maximum. You must first meet your deductible before your copays and coinsurance start to apply to your out-of-pocket maximum.

For example, if you are a single subscriber on Plan 2000/4000, you would pay full charge for most services until your out-of-pocket costs reach $2,000. To reach your $4,000 out-of-pocket maximum, you would pay $4,000 in copays and coinsurance in addition to the $2,000 you paid toward your deductible.




Using a deductible planLet’s say you injure your ankle and visit your primary care physician, who orders an X-ray. It’s just a sprain, so the doctor prescribes a generic pain medication.

On Plan 1500/3000, you have to pay $1,500 out of your own pocket before you are eligible to pay coinsurance for most covered services.

In this example, even if you have not met your deductible, you would pay only a $25 copayment for the doctor’s office visit because this service is not subject to the deductible under this plan.

However, if you haven’t met your medical deductible, you would pay full charge for the X-ray. And you would also pay full charge for prescriptions until you meet the pharmacy deductible. The amount you pay for the X-ray would be applied to your $1,500 medical deductible. And the amount you pay for the generic drug would be applied to your $250 pharmacy deductible.

Visit the treatment fee tool at kp.org/treatmentestimates to estimate the cost of your next appointment or your potential out-of-pocket medical costs for the year.

The HSA differenceOne of our deductible plans is an HSA-qualified deductible plan, which can be paired with an optional health savings account, or HSA. HSA-qualified plans work similarly to traditional deductible plans with just a few differences.

n If you’re eligible, you can open an HSA with an HSA-qualified plan.

n Money you deposit into your HSA is deductible from your income on your federal income tax form.

n You can use funds from your HSA to pay for qualified medical expenses.

n With an HSA-qualified deductible plan, the deductible contributes to the out-of-pocket maximum. With traditional deductible plans, the deductible does not contribute to the out-of-pocket maximum.

Tax savings relate to federal income tax only. For more information, please consult your financial or tax adviser. To learn more about health savings accounts, visit www.irs.gov/publications/p969/ar02.html or call 1-800-829-1040.



Benefit highlights DEDUCTIBLE PLANS

Plan 1500/3000 Plan 2000/4000 Plan 3000/6000

FEATURES Deductible does not contribute to the out-of-pocket maximum.Most coinsurance and copays contribute to the out-of-pocket maximum.

Annual deductible (individual/family) $1,500/$3,000 $2,000/$4,000 $3,000/$6,000

Annual out-of-pocket maximum (individual/family)

$4,000/$8,000 (after deductible)



BENEFITS Services not subject to deductible unless otherwise indicated

PREVENTIVE CARE

Many preventive care services, such as routine physical exams and mammogram screenings, are no charge.

OUTPATIENT SERVICES (per visit or procedure)

Primary care/Specialty care office visit $25 copay/$35 copay $35 copay/$45 copay $35 copay/$45 copay

Most X-rays and lab tests/MRI, CT, and PET 20% coinsurance (after deductible)

30% coinsurance (after deductible)


Outpatient surgery 20% coinsurance (after deductible)



INPATIENT HOSPITAL CARE

Physician services, room and board, anesthesia, operating and recovery rooms, laboratory and diagnostic tests, X-rays, drugs, dressings, casts, and respiratory and radiation therapy




MATERNITY

Obstetrician, midwife, hospital delivery (inpatient) 20% coinsurance (after deductible)



Routine prenatal care visit No charge No charge No charge

EMERGENCY AND URGENT CARE

Emergency Department visit (waived if admitted) 20% coinsurance 30% coinsurance 30% coinsurance

Urgent care visit $75 copay $75 copay $75 copay

Ambulance service $125 copay (after deductible)

$125 copay (after deductible)

$125 copay (after deductible)

PRESCRIPTION DRUGS

Covered drugs (after $250 drug deductible) Generic: $15 copayBrand: $45 copay

Specialty: $150 copay

Generic: $25 copayBrand: $45 copay


Generic: $25 copayBrand: $45 copay


Contraceptives No charge No charge No charge

OTHER

Vision services provided by Vision Services Plan (VSP) Covered. See the “Vision Plan” section for more information.

Covered. See the “Vision Plan” section for more information.

Covered. See the “Vision Plan” section for more information.

Preventive dental care provided by Delta Dental of Ohio Covered. See the “Dental Plan” section for more information.

Covered. See the “Dental Plan” section for more information.

Covered. See the “Dental Plan” section for more information.


This is only a summary of the most frequently asked-about benefits and their copayments and coinsurance. It is not a contract. For more detailed information, including exclusions, limitations, and restrictions, please refer to the Evidence of Coverage, which you will receive upon acceptance. For specific questions about coverage, call us at 1-800-494-5314.

The benefits that you select may change on January 1, 2014. At that time, in order to meet the new benefit standards under the Affordable Care Act, we may change the benefits and rate you pay under your plan, or ask you to select a new plan.



Individual and Family Plans | HSA-QUALIFIED DEDUCTIBLE PLAN

How HSA-qualified deductible plans work

An HSA-qualified plan is a deductible plan that is eligible to be paired with an optional health savings account, or HSA. If you sign up for an HSA-qualified deductible plan and open an HSA, you can pay for qualified medical expenses with tax-deductible dollars.1

An HSA-qualified plan works much like a traditional deductible plan in that you pay full charge for most services out of pocket until you meet your deductible. In our HSA-qualified plan, however, once you meet your deductible, you can receive most covered services for no charge.

You can also save money with HSA-qualified plans because you can pay for qualified medical expenses —even those not covered by your health plan — with tax-deductible dollars. However, qualified expenses not covered by your health plan will not contribute to your deductible or out-of-pocket maximum.

All you have to do is:

n Sign up for an HSA-qualified health plan.

n If you are eligible, open a health savings account.

n Contribute tax-deductible dollars to this account.2

n Use those tax-free funds to pay for qualified health care expenses.

What you don’t use rolls over to the next year and continues earning interest.3

Advantages of opening an HSAn Portability The money belongs to you, so if you

change health plans, you can take your HSA with you.

n Rollover of unused funds There is no “use it or lose it” restriction each year. What you don’t use stays in your account until you are ready to use it.3

n Control You decide when to put the money in and when to take it out.

n Retirement savings The money in your account can be invested through the institution where you open it. And after age 65, you can use the funds, taxed at your ordinary income rate, for any reason without penalties.

n Flexibility You can use the money in your HSA to pay for qualified medical expenses, even those your deductible plan does not cover.

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

2 For 2013, the federally established maximum contribution for an eligible individual with self-only coverage is $3,250. The annual maximum contribution for an eligible individual with family coverage is $6,450. This annual maximum is indexed annually for inflation. Tax savings relate to federal income tax only. For more information, please consult your financial or tax adviser.

3 Earnings vary depending on the type of investment plan you opt for and/or the HSA provider you choose. Amount earned is based on the investment plan and market value, and in some instances, the account may actually lose money.




1 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. If a member uses his or her HSA debit card to pay for something other than a qualified medical expense, the expenditure is subject to tax and, for individuals who are not disabled or over 65, a 20 percent tax penalty.

What are qualified medical expenses?You can use an HSA to pay for deductibles and many supplies and services not covered by your health plan. Generally, these are expenses that would qualify for the medical and dental expense deduction on your income tax.

Here are just a few examples of HSA-qualified expenses:

n Eyeglasses and laser eye surgery

n Dental care

n Acupuncture

n Chiropractic services

n Hearing aids

For a complete list, see Publication 502, Medical and Dental Expenses at www.irs.gov.

Who’s eligible for an HSA?To be eligible for an HSA, you need to meet the following requirements:

n You can’t be enrolled in Medicare.

n You can’t be eligible to be claimed as a dependent on someone else’s tax return.

n You can’t have additional health coverage that is not a qualified deductible plan (with certain exceptions).

n You can’t have received benefits from the Department of Veterans Affairs in the past three months.

You may set up your HSA through any financial institution that offers these accounts.1

An HSA offers triple tax advantagesn Tax-deductible contributions to your account

n Tax-free investment earnings

n Tax-free withdrawals when funds are used for qualified medical expenses

Using an HSA-qualified deductible planLet’s say you injure your ankle and visit your primary care physician, who orders an X-ray. It’s just a sprain, so the doctor prescribes a generic pain medication.

With our HSA-qualified deductible plan, you pay full charge for all covered services (except many preventive care services) until you meet your deductible. On Plan 5000/10000 with HSA, the deductible for an individual is $5,000, so you would need to pay $5,000 out-of-pocket to meet the deductible.

The good news is that the deductible contributes toward the $5,000 out-of-pocket maximum in this plan. That means when you meet your deductible, you also meet your out-of-pocket maximum. So after spending $5,000 out of pocket, you would not have to pay any charge for covered services for the rest of the year.

In this example, if the total costs you have paid out of pocket so far this year for covered services have not met your deductible, you would pay full charge for the doctor’s office visit, the X-ray, and the medication. All the costs you pay for covered services will apply to your deductible, and your deductible will contribute to your out-of-pocket maximum.

If you have met your $5,000 deductible (and out-of-pocket maximum), the doctor’s office visit, the X-ray, and the generic medication would be no charge under this plan.

And, if you opened an HSA, you would be able to pay for these services with tax-free dollars. (Tax savings relate to federal income tax only. For more information, please consult your financial or tax adviser. For more information on health savings accounts, please visit www.irs.gov/publications/p969/ar02.html.)

Using a health savings account



Benefit highlights HSA-QUALIFIED DEDUCTIBLE PLAN

Plan 5000/10000

FEATURES Deductible contributes to out-of-pocket maximum

Annual deductible (individual/family) $5,000/$10,000

Annual out-of-pocket maximum (individual/family) $5,000/$10,000

BENEFITS Services not subject to deductible unless otherwise indicated

PREVENTIVE CARE

Many preventive care services, such as routine physical exams and mammogram screenings, are no charge.

OUTPATIENT SERVICES (per visit or procedure)

Primary care/Specialty care office visit No charge (after deductible)

Most X-rays and lab tests/MRI, CT, and PET No charge (after deductible)

Outpatient surgery No charge (after deductible)

INPATIENT HOSPITAL CARE

Physician services, room and board, anesthesia, operating and recovery rooms, laboratory and diagnostic tests, X-rays, drugs, dressings, casts, and respiratory and radiation therapy

No charge (after deductible)

MATERNITY

Obstetrician, midwife, hospital delivery (inpatient) No charge (after deductible)

Routine prenatal care visit No charge

EMERGENCY AND URGENT CARE

Emergency Department visit (waived if admitted) No charge (after deductible)

Urgent care visit No charge (after deductible)

Ambulance service No charge (after deductible)

PRESCRIPTION DRUGS

Covered drugs No charge (after medical deductible)

Contraceptives No charge

OTHER

Vision services Not covered

Preventive dental care provided by Delta Dental of Ohio Covered. See the “Dental Plan” section for more information.


This is only a summary of the most frequently asked-about benefits and their copayments and coinsurance. It is not a contract. For more detailed information, including exclusions, limitations, and restrictions, please refer to the Evidence of Coverage, which you will receive upon acceptance.

For specific questions about coverage, call us at 1-800-494-5314.

The benefits that you select may change on January 1, 2014. At that time, in order to meet the new benefit standards under the Affordable Care Act, we may change the benefits and rate you pay under your plan, or ask you to select a new plan.



Individual and Family Plans | DENTAL PLAN

In order to better meet your health care needs, we’ve arranged with Delta Dental of Ohio to provide a preventive dental plan to all Kaiser Permanente for Individuals and Families plan members.

How the plan worksThe Delta Dental PPO is a preferred provider program that can reduce your out-of-pocket expenses if you receive care from one of the many PPO dentists.4 For covered services provided by a participating PPO dentist, you pay your applicable coinsurance. Delta Dental of Ohio will then pay the remaining amount subject to the limitations and exclusions as covered in the Certificate of Coverage, which will be mailed to you from Delta Dental of Ohio upon acceptance.

n Oral exams, prophylaxes (cleanings), and fluoride treatment (to age 19) are payable twice per calendar year.

n Bitewing X-rays are payable once per calendar year, and full-mouth X-rays are payable once in any five-year period.

Freedom to chooseYou can choose any dentist from the Delta Dental of Ohio network of PPO dentists whenever you wish, and you can change dentists whenever you like. Delta Dental of Ohio will even help you find a PPO dentist near you.

All you need to do is contact Delta Dental of Ohio at 1-800-524-0149, or go online to deltadentaloh.com.

If you choose to see a dentist who is not a PPO member, you’re still covered. You’ll be responsible for paying the difference between the covered reimbursement of Delta Dental of Ohio (to your non–PPO dentist) and the dentist’s total fee. You’ll also be responsible for your copayment, coinsurance, and/or deductible for covered services.

Advantages of seeing a PPO dentist include no claim forms, no wait for reimbursement, and possibly a lower rate due to Delta Dental’s prenegotiated fees with its in-network dentists.

A reason to smile

1 The benefit year is January 1, 2013, through December 31, 2013.2 Used to diagnose and/or prevent dental abnormalities or disease (includes exams, cleanings, and fluoride treatments)3 Used to temporarily relieve pain4 Benefit levels and copayments are based on the Delta Dental PPO program underwritten and administered by Delta Dental of Ohio. Dental services do

not count toward medical deductibles or out-of-pocket maximums. For complete plan details, refer to the Certificate of Coverage, which will be mailed to you from Delta Dental of Ohio upon enrollment in the plan. Participation in the dental plan is not optional for Kaiser Permanente for Individuals and Families members.

Note: The maximum benefit is $250 per member per calendar year on Class I benefits.

COVERED SERVICES — CLASS I BENEFITS1 PLAN PAYS YOU PAY

Diagnostic and preventive services2 70% 30%

Emergency and palliative treatment3 70% 30%

Radiographs — X-rays 70% 30%



Individual and Family Plans | VISION PLAN

1 Vision benefits are administered by VSP® Vision Care. Upon acceptance, you will receive an Evidence of Coverage, which includes complete coverage details.

Your vision is an important part of your overall health. Whether or not your vision is 20/20, you should receive regular eye exams. That’s why we’re pleased to offer you vision coverage as part of our commitment to your total well-being.1 Our vision coverage provides affordable, quality vision care through the VSP Advantage Network. With this program, you will receive complete eye exams for only the cost of your Kaiser Permanente for Individuals and Families specialty care office visit copay.

For more information or a list of VSP preferred providers, visit vsp.com/advantage or call 1-800-877-7195.

EligibilityVision coverage is a benefit of our standard deductible plans. It is not optional. Vision coverage is not available with our HSA-qualified plan.

Vision hardware allowanceAs a member with vision coverage, you are eligible for a retail hardware allowance of $100 every 24 months along with your vision hardware discounts of 20 percent off retail prices. The allowance can be used toward eyeglass lenses, frames, and contact lenses when prescribed by a VSP provider.

The 24-month period begins at the initial point of sale for each member. Any unused portion of the coverage allowance at the point of sale can be used within the 24-month period at a later time. If you use your allowance to purchase frames, we also cover mounting of eyeglass lenses in the frames, original fitting of the frames, and subsequent adjustment.

To use this allowance, you must obtain your vision hardware, including lenses, frames, or contact lenses, from a VSP provider.

Contact lensesA contact lens exam is provided every 12 months with a $50 copay. Follow-up visits are no additional charge. Your $100 allowance can be used toward the purchase of contact lenses.

If you have a change in prescription of at least .50 diopter within 12 months of your initial exam, VSP will provide an interim benefit. You will receive a new hardware allowance identical to your original allowance.

For example, if your allowance is $100 and you meet the criteria for an interim benefit, you will receive an additional allowance of $100.

Out-of-network benefitUnder this plan, there is no out-of-network benefit. In order to take advantage of your vision coverage, you must obtain services from a convenient VSP provider location.

ExclusionsThe following services and materials are excluded from coverage under the policy:

n Industrial and athletic safety frames

n Eyeglass lenses and contact lenses with no refractive value

n Replacement of lost, broken, or damaged lenses, frames, and contact lenses

n Lens adornment, such as engraving, faceting, or jewelling

n Low-vision devices

n Nonprescription products, such as eyeglass holders, eyeglass cases, and repair kits

n Nonprescription sunglasses

n Coverage for lenses, frames, and/or contact lenses if we have paid for these items in the previous 24 months of membership under your membership contract, unless the prescription changes as described above

See what we can do for you



Individual and Family Plans | RATES — JANUARY 2013

Rates are effective January 2013 and are subject to change.

Important information about our rates

What determines your rateYour rate is based on the following:

n The plan (or plans) you select

n The subscriber’s age on January 1, 2013

n The subscriber’s gender

n How many family members are covered

If you move into a new age band in 2013, your rate won’t change until 2014. If you change plans, your monthly rate may change. Rates include the monthly premium for Delta Dental of Ohio, which is not optional.

Please note: Rates may be higher based on medical underwriting.

Who is the subscriber?In a plan with family coverage, you may choose which spouse will be the subscriber. Sometimes you may get a lower rate by listing the other spouse as the subscriber. You may switch subscribers later if you like. Simply send a letter signed and dated by the subscriber requesting the change to Kaiser Permanente Membership Accounting, P.O. Box 203008, Denver, CO 80220-9008.

Our service areaPlease check to see if you reside in our service area, based on your home address. You may apply for Kaiser Permanente for Individuals and Families coverage only if you permanently reside in Cuyahoga, Geauga, Lake, Lorain, Medina, Portage, Stark, Summit, or Wayne county.

Coverage for those under age 19We do not offer individual plans to children under age 19. However, children can be enrolled as dependents on a family plan.

If you are a 19-year-old who would like to apply as a subscriber, your rate will be based on your age on January 1. If you were 18 on January 1, you will find your rate in the age 18 rate band.

Try different combinationsFamily members do not have to enroll in the same plan. This choice allows you to select different levels of coverage for your family members, depending on their needs.

Medicare-eligible subscribersOur Kaiser Permanente for Individuals and Families plans are not available for new members age 65 and over who are eligible for Medicare. If you are 65+ years of age and Medicare eligible or are under age 65 and entitled to Medicare on the basis of Social Security disability, you may be eligible for lower rates under Kaiser Permanente Medicare Plus. Please call 1-877-408-3495 or 1-888-758-6054 (TTY for the deaf, hard of hearing, or speech impaired) for more information.

Affordable Care ActThe benefits that you select may change on January 1, 2014. At that time, in order to meet the new benefit standards under the Affordable Care Act, we may change the benefits and the rate you pay under your plan, or ask you to select a new plan. In any case, we value your membership and will provide options for you to continue your coverage without a break.




SubscriberDEDUCTIBLE PLANS HSA-QUALIFIED

DEDUCTIBLE PLANPlan 1500/3000 Plan 2000/4000 Plan 3000/6000 Plan 5000/10000

Subscriber’s age on January 1, 2013 Male Female Male Female Male Female Male Female

18 $130.95 $168.60 $115.20 $148.33 $103.02 $132.64 $97.87 $126.01 19 $132.27 $177.68 $116.36 $156.31 $104.06 $139.78 $98.86 $132.79 20 $132.93 $201.40 $116.95 $177.18 $104.58 $158.44 $99.35 $150.52 21 $133.51 $211.49 $117.45 $186.05 $105.03 $166.38 $99.78 $158.06 22 $134.65 $227.23 $118.46 $199.90 $105.93 $178.76 $100.63 $169.82 23 $135.22 $241.75 $118.96 $212.68 $106.38 $190.19 $101.06 $180.68 24 $135.75 $251.42 $119.42 $221.18 $106.79 $197.80 $101.45 $187.91 25 $136.80 $270.76 $120.35 $238.19 $107.62 $213.01 $102.24 $202.36 26 $137.33 $280.42 $120.81 $246.70 $108.04 $220.61 $102.64 $209.58 27 $138.35 $284.28 $121.71 $250.09 $108.84 $223.65 $103.40 $212.47 28 $140.40 $292.00 $123.51 $256.89 $110.45 $229.72 $104.93 $218.24 29 $141.42 $295.86 $124.41 $260.28 $111.26 $232.76 $105.69 $221.12 30 $142.48 $296.66 $125.34 $260.98 $112.09 $233.39 $106.49 $221.72 31 $144.60 $298.26 $127.21 $262.39 $113.76 $234.64 $108.07 $222.91 32 $147.27 $299.21 $129.56 $263.23 $115.86 $235.39 $110.07 $223.62 33 $150.50 $299.53 $132.40 $263.51 $118.40 $235.65 $112.48 $223.86 34 $153.99 $299.69 $135.47 $263.65 $121.14 $235.77 $115.09 $223.98 35 $157.73 $299.70 $138.76 $263.65 $124.09 $235.77 $117.88 $223.99 36 $161.62 $299.71 $142.18 $263.66 $127.15 $235.78 $120.79 $223.99 37 $165.67 $299.73 $145.75 $263.68 $130.33 $235.80 $123.82 $224.01 38 $170.18 $299.79 $149.72 $263.73 $133.89 $235.84 $127.19 $224.05 39 $175.16 $299.87 $154.10 $263.81 $137.80 $235.91 $130.91 $224.12 40 $180.14 $299.96 $158.47 $263.88 $141.72 $235.98 $134.63 $224.18 41 $185.12 $300.04 $162.85 $263.96 $145.63 $236.05 $138.35 $224.25 42 $192.14 $300.10 $169.03 $264.01 $151.16 $236.10 $143.60 $224.29 43 $201.21 $300.14 $177.01 $264.04 $158.29 $236.12 $150.38 $224.31 44 $210.96 $300.16 $185.59 $264.06 $165.96 $236.14 $157.67 $224.33 45 $221.39 $300.18 $194.76 $264.08 $174.17 $236.15 $165.46 $224.34 46 $230.59 $300.60 $202.85 $264.45 $181.40 $236.48 $172.33 $224.66 47 $241.35 $301.43 $212.32 $265.18 $189.87 $237.14 $180.38 $225.28 48 $250.26 $303.48 $220.16 $266.99 $196.88 $238.75 $187.04 $226.82 49 $258.27 $306.76 $227.21 $269.87 $203.18 $241.33 $193.02 $229.27 50 $266.28 $310.04 $234.25 $272.75 $209.48 $243.91 $199.01 $231.72 51 $274.28 $313.32 $241.30 $275.64 $215.78 $246.49 $204.99 $234.17 52 $284.44 $317.31 $250.23 $279.15 $223.77 $249.63 $212.58 $237.15 53 $296.73 $322.03 $261.04 $283.30 $233.44 $253.34 $221.77 $240.68 54 $309.74 $326.98 $272.49 $287.66 $243.67 $257.24 $231.49 $244.38 55 $323.46 $332.18 $284.56 $292.23 $254.47 $261.33 $241.74 $248.26 56 $323.64 $338.06 $284.71 $297.40 $254.61 $265.96 $241.88 $252.66 57 $351.97 $344.63 $309.64 $303.19 $276.90 $271.13 $263.05 $257.57 58 $365.40 $351.93 $321.45 $309.61 $287.46 $276.87 $273.09 $263.03 59 $381.96 $362.64 $336.02 $319.02 $300.49 $285.29 $285.47 $271.03 60 $400.60 $374.68 $352.42 $329.62 $315.16 $294.76 $299.40 $280.03 61 $417.16 $385.38 $366.99 $339.03 $328.19 $303.19 $311.78 $288.03 62 $434.66 $397.29 $382.39 $349.51 $341.96 $312.56 $324.86 $296.93 63 $454.03 $411.62 $399.43 $362.12 $357.19 $323.83 $339.33 $307.64 64 $479.41 $431.04 $421.76 $379.20 $377.16 $339.10 $358.30 $322.15

65+ $479.22 $479.22 $421.59 $421.59 $377.01 $377.01 $358.16 $358.16




Subscriber + spouseDEDUCTIBLE PLANS HSA-QUALIFIED



18 $341.79 $341.79 $300.68 $300.68 $268.89 $268.89 $255.45 $255.45 19 $345.40 $345.40 $303.86 $303.86 $271.73 $271.73 $258.14 $258.14 20 $381.47 $381.47 $335.59 $335.59 $300.11 $300.11 $285.10 $285.10 21 $393.64 $393.64 $346.29 $346.29 $309.68 $309.68 $294.19 $294.19 22 $397.33 $397.33 $349.55 $349.55 $312.59 $312.59 $296.96 $296.96 23 $430.13 $430.13 $378.40 $378.40 $338.39 $338.39 $321.47 $321.47 24 $436.43 $436.43 $383.94 $383.94 $343.35 $343.35 $326.18 $326.18 25 $449.04 $449.04 $395.04 $395.04 $353.27 $353.27 $335.60 $335.60 26 $471.64 $471.64 $414.92 $414.92 $371.05 $371.05 $352.49 $352.49 27 $471.64 $471.64 $414.92 $414.92 $371.05 $371.05 $352.49 $352.49 28 $471.64 $471.64 $414.92 $414.92 $371.05 $371.05 $352.49 $352.49 29 $490.23 $490.23 $431.27 $431.27 $385.67 $385.67 $366.39 $366.39 30 $490.23 $490.23 $431.27 $431.27 $385.67 $385.67 $366.39 $366.39 31 $484.52 $484.52 $426.25 $426.25 $381.18 $381.18 $362.12 $362.12 32 $470.11 $470.11 $413.57 $413.57 $369.84 $369.84 $351.35 $351.35 33 $470.11 $470.11 $413.57 $413.57 $369.84 $369.84 $351.35 $351.35 34 $470.11 $470.11 $413.57 $413.57 $369.84 $369.84 $351.35 $351.35 35 $470.11 $470.11 $413.57 $413.57 $369.84 $369.84 $351.35 $351.35 36 $470.56 $470.56 $413.96 $413.96 $370.19 $370.19 $351.68 $351.68 37 $474.71 $474.71 $417.62 $417.62 $373.46 $373.46 $354.79 $354.79 38 $479.37 $479.37 $421.72 $421.72 $377.12 $377.12 $358.27 $358.27 39 $484.53 $484.53 $426.26 $426.26 $381.19 $381.19 $362.13 $362.13 40 $489.70 $489.70 $430.81 $430.81 $385.25 $385.25 $365.99 $365.99 41 $494.87 $494.87 $435.35 $435.35 $389.32 $389.32 $369.85 $369.85 42 $502.09 $502.09 $441.70 $441.70 $395.00 $395.00 $375.25 $375.25 43 $511.37 $511.37 $449.87 $449.87 $402.30 $402.30 $382.19 $382.19 44 $518.71 $518.71 $456.33 $456.33 $408.07 $408.07 $387.67 $387.67 45 $524.10 $524.10 $461.07 $461.07 $412.31 $412.31 $391.70 $391.70 46 $532.12 $532.12 $468.12 $468.12 $418.62 $418.62 $397.69 $397.69 47 $542.78 $542.78 $477.50 $477.50 $427.01 $427.01 $405.66 $405.66 48 $553.75 $553.75 $487.15 $487.15 $435.64 $435.64 $413.86 $413.86 49 $565.03 $565.03 $497.08 $497.08 $444.52 $444.52 $422.29 $422.29 50 $576.32 $576.32 $507.01 $507.01 $453.40 $453.40 $430.73 $430.73 51 $587.60 $587.60 $516.93 $516.93 $462.27 $462.27 $439.16 $439.16 52 $617.86 $617.86 $543.55 $543.55 $486.08 $486.08 $461.77 $461.77 53 $618.76 $618.76 $544.34 $544.34 $486.78 $486.78 $462.44 $462.44 54 $636.72 $636.72 $560.14 $560.14 $500.91 $500.91 $475.87 $475.87 55 $655.64 $655.64 $576.79 $576.79 $515.80 $515.80 $490.01 $490.01 56 $673.47 $673.47 $592.47 $592.47 $529.83 $529.83 $503.33 $503.33 57 $696.60 $696.60 $612.82 $612.82 $548.02 $548.02 $520.62 $520.62 58 $717.33 $717.33 $631.06 $631.06 $564.33 $564.33 $536.11 $536.11 59 $744.60 $744.60 $655.05 $655.05 $585.78 $585.78 $556.50 $556.50 60 $775.28 $775.28 $682.04 $682.04 $609.92 $609.92 $579.42 $579.42 61 $802.55 $802.55 $706.03 $706.03 $631.37 $631.37 $599.80 $599.80 62 $831.96 $831.96 $731.90 $731.90 $654.51 $654.51 $621.79 $621.79 63 $865.65 $865.65 $761.55 $761.55 $681.02 $681.02 $646.97 $646.97 64 $910.45 $910.45 $800.95 $800.95 $716.26 $716.26 $680.45 $680.45

65+ $973.17 $973.17 $856.13 $856.13 $765.60 $765.60 $727.32 $727.32




Subscriber + one childDEDUCTIBLE PLANS HSA-QUALIFIED



18 $295.74 $331.22 $260.17 $291.39 $232.66 $260.58 $221.03 $247.55 19 $295.74 $353.09 $260.17 $310.62 $232.66 $277.78 $221.03 $263.89 20 $295.55 $364.58 $260.01 $320.73 $232.52 $286.82 $220.89 $272.48 21 $296.13 $374.11 $260.51 $329.11 $232.97 $294.31 $221.32 $279.60 22 $297.27 $394.28 $261.52 $346.87 $233.87 $310.19 $222.17 $294.68 23 $297.84 $414.20 $262.02 $364.39 $234.32 $325.86 $222.60 $309.57 24 $298.37 $414.20 $262.48 $364.39 $234.73 $325.86 $222.99 $309.57 25 $299.42 $433.38 $263.41 $381.26 $235.56 $340.94 $223.78 $323.89 26 $299.95 $462.46 $263.87 $406.84 $235.97 $363.82 $224.17 $345.63 27 $300.97 $462.46 $264.78 $406.84 $236.78 $363.82 $224.94 $345.63 28 $303.02 $462.46 $266.58 $406.84 $238.39 $363.82 $226.47 $345.63 29 $304.04 $475.76 $267.48 $418.54 $239.19 $374.29 $227.23 $355.57 30 $305.10 $475.76 $268.41 $418.54 $240.03 $374.29 $228.03 $355.57 31 $307.22 $470.42 $270.27 $413.85 $241.69 $370.09 $229.61 $351.58 32 $309.89 $466.69 $272.62 $410.56 $243.80 $367.15 $231.61 $348.79 33 $313.12 $466.69 $275.46 $410.56 $246.34 $367.15 $234.02 $348.79 34 $316.61 $466.69 $278.53 $410.56 $249.08 $367.15 $236.62 $348.79 35 $320.35 $466.69 $281.82 $410.56 $252.02 $367.15 $239.42 $348.79 36 $324.24 $466.69 $285.25 $410.56 $255.08 $367.15 $242.33 $348.79 37 $328.29 $462.41 $288.81 $406.79 $258.27 $363.78 $245.36 $345.59 38 $332.80 $462.41 $292.78 $406.79 $261.82 $363.78 $248.73 $345.59 39 $337.78 $462.49 $297.16 $406.87 $265.74 $363.85 $252.45 $345.66 40 $342.76 $462.58 $301.54 $406.95 $269.65 $363.92 $256.17 $345.72 41 $347.74 $462.67 $305.92 $407.02 $273.57 $363.98 $259.89 $345.78 42 $354.76 $462.72 $312.10 $407.07 $279.09 $364.03 $265.14 $345.83 43 $363.83 $462.76 $320.07 $407.10 $286.23 $364.06 $271.92 $345.85 44 $373.58 $462.78 $328.65 $407.12 $293.90 $364.08 $279.20 $345.87 45 $384.01 $462.80 $337.83 $407.14 $302.11 $364.09 $287.00 $345.88 46 $394.14 $463.22 $346.74 $407.51 $310.07 $364.42 $294.57 $346.20 47 $403.97 $464.05 $355.38 $408.24 $317.80 $365.07 $301.91 $346.82 48 $412.88 $466.10 $363.23 $410.05 $324.82 $366.69 $308.58 $348.36 49 $420.89 $469.38 $370.27 $412.93 $331.12 $369.27 $314.56 $350.81 50 $428.90 $472.66 $377.32 $415.82 $337.42 $371.85 $320.55 $353.25 51 $436.91 $475.94 $384.36 $418.70 $343.72 $374.43 $326.53 $355.70 52 $455.17 $479.94 $400.43 $422.22 $358.09 $377.57 $340.18 $358.69 53 $459.35 $484.65 $404.10 $426.36 $361.37 $381.28 $343.31 $362.22 54 $472.36 $489.61 $415.55 $430.72 $371.61 $385.18 $353.03 $365.92 55 $486.08 $494.80 $427.62 $435.29 $382.40 $389.26 $363.28 $369.80 56 $496.14 $500.68 $436.47 $440.47 $390.32 $393.89 $370.80 $374.20 57 $514.59 $507.25 $452.70 $446.25 $404.83 $399.06 $384.59 $379.11 58 $528.02 $514.55 $464.51 $452.67 $415.40 $404.81 $394.63 $384.56 59 $544.58 $525.26 $479.09 $462.09 $428.43 $413.23 $407.01 $392.56 60 $563.22 $537.30 $495.48 $472.68 $443.09 $422.70 $420.94 $401.56 61 $579.78 $548.00 $510.06 $482.10 $456.12 $431.12 $433.32 $409.56 62 $597.29 $559.92 $525.45 $492.58 $469.89 $440.49 $446.40 $418.47 63 $616.65 $574.24 $542.49 $505.18 $485.13 $451.76 $460.87 $429.17 64 $642.03 $593.66 $564.82 $522.26 $505.09 $467.04 $479.84 $443.69

65+ $677.56 $620.84 $596.08 $546.18 $533.05 $488.42 $506.39 $464.00




Subscriber + childrenDEDUCTIBLE PLANS HSA-QUALIFIED



18 $539.64 $569.51 $474.74 $501.01 $424.54 $448.04 $403.31 $425.63 19 $539.64 $587.50 $474.74 $516.85 $424.54 $462.20 $403.31 $439.09 20 $529.97 $601.96 $466.23 $529.57 $416.93 $473.57 $396.09 $449.89 21 $530.54 $608.52 $466.74 $535.34 $417.38 $478.73 $396.51 $454.80 22 $531.69 $628.70 $467.74 $553.09 $418.28 $494.61 $397.37 $469.88 23 $532.26 $651.59 $468.25 $573.22 $418.73 $512.61 $397.80 $486.98 24 $532.78 $651.59 $468.71 $573.22 $419.15 $512.61 $398.19 $486.98 25 $533.84 $667.79 $469.64 $587.48 $419.98 $525.36 $398.98 $499.09 26 $534.37 $699.84 $470.10 $615.68 $420.39 $550.57 $399.37 $523.05 27 $535.39 $699.84 $471.00 $615.68 $421.20 $550.57 $400.14 $523.05 28 $537.43 $699.84 $472.80 $615.68 $422.81 $550.57 $401.67 $523.05 29 $538.46 $713.15 $473.70 $627.38 $423.61 $561.04 $402.43 $532.99 30 $539.52 $713.15 $474.63 $627.38 $424.44 $561.04 $403.22 $532.99 31 $541.64 $707.81 $476.50 $622.68 $426.11 $556.84 $404.81 $529.00 32 $545.86 $704.07 $480.21 $619.39 $429.43 $553.90 $407.96 $526.21 33 $547.54 $704.07 $481.69 $619.39 $430.75 $553.90 $409.22 $526.21 34 $551.02 $704.07 $484.75 $619.39 $433.50 $553.90 $411.82 $526.21 35 $554.76 $704.07 $488.04 $619.39 $436.44 $553.90 $414.62 $526.21 36 $558.66 $704.07 $491.47 $619.39 $439.50 $553.90 $417.53 $526.21 37 $562.71 $699.79 $495.03 $615.63 $442.69 $550.53 $420.55 $523.01 38 $567.22 $697.78 $499.00 $613.86 $446.24 $548.95 $423.93 $521.50 39 $572.20 $697.78 $503.38 $613.86 $450.15 $548.95 $427.65 $521.50 40 $581.24 $701.06 $511.34 $616.75 $457.27 $551.53 $434.41 $523.96 41 $594.36 $709.29 $522.88 $623.98 $467.59 $558.00 $444.21 $530.10 42 $605.45 $713.41 $532.63 $627.61 $476.31 $561.25 $452.50 $533.19 43 $614.52 $713.45 $540.61 $627.64 $483.45 $561.28 $459.28 $533.21 44 $624.27 $713.47 $549.19 $627.66 $491.12 $561.29 $466.56 $533.23 45 $636.73 $715.52 $560.16 $629.47 $500.93 $562.91 $475.88 $534.76 46 $650.93 $720.01 $572.65 $633.42 $512.09 $566.44 $486.49 $538.12 47 $662.79 $722.87 $583.08 $635.94 $521.42 $568.69 $495.35 $540.26 48 $671.71 $724.93 $590.92 $637.74 $528.44 $570.31 $502.02 $541.79 49 $679.71 $728.21 $597.97 $640.63 $534.74 $572.89 $508.00 $544.24 50 $687.72 $731.49 $605.01 $643.51 $541.04 $575.47 $513.99 $546.69 51 $695.73 $734.76 $612.06 $646.40 $547.34 $578.05 $519.97 $549.14 52 $705.88 $738.76 $620.99 $649.91 $555.32 $581.19 $527.56 $552.13 53 $718.17 $743.47 $631.80 $654.06 $564.99 $584.90 $536.74 $555.65 54 $731.18 $748.43 $643.24 $658.42 $575.23 $588.80 $546.47 $559.36 55 $744.90 $753.62 $655.32 $662.99 $586.02 $592.88 $556.72 $563.24 56 $754.89 $759.51 $664.10 $668.16 $593.88 $597.51 $564.18 $567.64 57 $773.41 $766.08 $680.40 $673.94 $608.45 $602.68 $578.03 $572.55 58 $786.84 $773.38 $692.21 $680.37 $619.02 $608.42 $588.07 $578.00 59 $803.41 $784.08 $706.78 $689.78 $632.05 $616.85 $600.45 $586.00 60 $822.04 $796.12 $723.18 $700.38 $646.71 $626.32 $614.37 $595.00 61 $838.61 $806.83 $737.75 $709.79 $659.74 $634.74 $626.76 $603.00 62 $856.11 $818.74 $753.15 $720.27 $673.51 $644.11 $639.83 $611.91 63 $875.48 $833.07 $770.19 $732.88 $688.75 $655.38 $654.31 $622.61 64 $900.86 $852.48 $792.51 $749.96 $708.71 $670.66 $673.28 $637.12

65+ $936.39 $879.67 $823.77 $773.87 $736.67 $692.04 $699.83 $657.44




Subscriber, spouse + child(ren)DEDUCTIBLE PLANS HSA-QUALIFIED



18 $691.64 $691.64 $608.46 $608.46 $544.12 $544.12 $516.91 $516.91 19 $718.09 $718.09 $631.73 $631.73 $564.93 $564.93 $536.69 $536.69 20 $731.32 $731.32 $643.37 $643.37 $575.34 $575.34 $546.57 $546.57 21 $743.48 $743.48 $654.07 $654.07 $584.91 $584.91 $555.66 $555.66 22 $767.81 $767.81 $675.47 $675.47 $604.05 $604.05 $573.84 $573.84 23 $779.98 $779.98 $686.17 $686.17 $613.61 $613.61 $582.93 $582.93 24 $786.28 $786.28 $691.72 $691.72 $618.58 $618.58 $587.65 $587.65 25 $798.89 $798.89 $702.81 $702.81 $628.50 $628.50 $597.07 $597.07 26 $819.81 $819.81 $721.21 $721.21 $644.95 $644.95 $612.70 $612.70 27 $819.81 $819.81 $721.21 $721.21 $644.95 $644.95 $612.70 $612.70 28 $821.17 $821.17 $722.41 $722.41 $646.02 $646.02 $613.72 $613.72 29 $838.40 $838.40 $737.57 $737.57 $659.58 $659.58 $626.60 $626.60 30 $838.40 $838.40 $737.57 $737.57 $659.58 $659.58 $626.60 $626.60 31 $832.69 $832.69 $732.54 $732.54 $655.08 $655.08 $622.33 $622.33 32 $818.27 $818.27 $719.86 $719.86 $643.74 $643.74 $611.56 $611.56 33 $818.27 $818.27 $719.86 $719.86 $643.74 $643.74 $611.56 $611.56 34 $818.27 $818.27 $719.86 $719.86 $643.74 $643.74 $611.56 $611.56 35 $818.27 $818.27 $719.86 $719.86 $643.74 $643.74 $611.56 $611.56 36 $820.40 $820.40 $721.74 $721.74 $645.42 $645.42 $613.15 $613.15 37 $824.56 $824.56 $725.39 $725.39 $648.69 $648.69 $616.25 $616.25 38 $829.22 $829.22 $729.49 $729.49 $652.35 $652.35 $619.74 $619.74 39 $834.38 $834.38 $734.03 $734.03 $656.42 $656.42 $623.60 $623.60 40 $843.62 $843.62 $742.16 $742.16 $663.68 $663.68 $630.50 $630.50 41 $856.92 $856.92 $753.86 $753.86 $674.15 $674.15 $640.44 $640.44 42 $868.21 $868.21 $763.79 $763.79 $683.03 $683.03 $648.88 $648.88 43 $877.49 $877.49 $771.96 $771.96 $690.33 $690.33 $655.82 $655.82 44 $884.83 $884.83 $778.41 $778.41 $696.10 $696.10 $661.30 $661.30 45 $892.25 $892.25 $784.94 $784.94 $701.94 $701.94 $666.85 $666.85 46 $904.34 $904.34 $795.58 $795.58 $711.45 $711.45 $675.88 $675.88 47 $917.03 $917.03 $806.74 $806.74 $721.44 $721.44 $685.37 $685.37 48 $928.00 $928.00 $816.40 $816.40 $730.07 $730.07 $693.57 $693.57 49 $939.29 $939.29 $826.32 $826.32 $738.95 $738.95 $702.00 $702.00 50 $950.57 $950.57 $836.25 $836.25 $747.83 $747.83 $710.44 $710.44 51 $961.86 $961.86 $846.18 $846.18 $756.70 $756.70 $718.87 $718.87 52 $976.01 $976.01 $858.63 $858.63 $767.83 $767.83 $729.44 $729.44 53 $993.01 $993.01 $873.59 $873.59 $781.21 $781.21 $742.15 $742.15 54 $1,010.98 $1,010.98 $889.39 $889.39 $795.35 $795.35 $755.58 $755.58 55 $1,029.89 $1,029.89 $906.03 $906.03 $810.23 $810.23 $769.72 $769.72 56 $1,049.85 $1,049.85 $923.59 $923.59 $825.93 $825.93 $784.63 $784.63 57 $1,070.86 $1,070.86 $942.07 $942.07 $842.45 $842.45 $800.33 $800.33 58 $1,091.59 $1,091.59 $960.30 $960.30 $858.76 $858.76 $815.82 $815.82 59 $1,118.86 $1,118.86 $984.29 $984.29 $880.22 $880.22 $836.20 $836.20 60 $1,149.53 $1,149.53 $1,011.28 $1,011.28 $904.35 $904.35 $859.13 $859.13 61 $1,176.80 $1,176.80 $1,035.27 $1,035.27 $925.80 $925.80 $879.51 $879.51 62 $1,206.22 $1,206.22 $1,061.15 $1,061.15 $948.94 $948.94 $901.50 $901.50 63 $1,239.91 $1,239.91 $1,090.79 $1,090.79 $975.45 $975.45 $926.68 $926.68 64 $1,284.71 $1,284.71 $1,130.20 $1,130.20 $1,010.69 $1,010.69 $960.16 $960.16

65+ $1,347.42 $1,347.42 $1,185.37 $1,185.37 $1,060.03 $1,060.03 $1,007.03 $1,007.03



Individual and Family Plans | OUR LOCATIONS

n The above listing of Kaiser Permanente facilities is accurate as of the date of this publication. Please check buykp.org/locations for new facilities or changes to our locations.

n Our contract with the affiliated hospitals listed here is in effect as of the date of this publication. Kaiser Permanente reserves the right to modify our provider network at any time.

90

480

480

80

77

71

90

77

12

8

11

13

Lorain

Medina

Portage

Geauga

Lake

L A K E E R I E

2Cuyahoga

80

271

6

Summit

3

14

76

76

90

71

271

1

2

2

2

8

10

14

4

15

95

7

44

WayneStark10

77

21

22

32

31

2629

30

16

2027

28

25

23

18

3324

19

17

The Kaiser Permanente service area consists of Cuyahoga, Geauga, Lake, Lorain, Medina, Portage, Stark, Summit, and Wayne counties.

Kaiser Permanente medical facilities

1 Avon Medical OfficesAvon

2 Bedford Medical OfficesBedford

3 Chapel Hill Medical OfficesAkron

4 Cleveland Heights Medical CenterCleveland Heights

5 Concord Medical OfficesConcord

6 Fairlawn Medical OfficesFairlawn

7 Kent Medical OfficesKent

8 Medina Medical OfficesMedina

9 Mentor Medical OfficesMentor

10 North Canton Medical OfficesNorth Canton

11 Parma Medical CenterParma

12 Rocky River Medical OfficesRocky River

13 Strongsville Medical OfficesStrongsville

14 Twinsburg Medical OfficesTwinsburg

15 Willoughby Medical OfficesWilloughby

16 Akron General Medical CenterAkron

17 CCF Children’s Hospital for Rehabilitation Cleveland

18 Children’s Hospital Medical Center of Akron Akron

19 The Cleveland Clinic FoundationCleveland

20 Edwin Shaw Rehabilitation InstituteCuyahoga Falls

21 EMH Regional Medical CenterElyria

22 Fairview General Hospital (Obstetrical referrals only) Cleveland

23 Hillcrest Hospital (Obstetrical referrals only)Mayfield Heights

24 LakeWest Medical CenterWilloughby

Affiliated hospitals (specific services may vary)

25 Lodi Community HospitalLodi

26 Marymount HospitalGarfield Heights

27 Medina General HospitalMedina

28 Mercy Medical CenterCanton

29 MetroHealth Medical CenterCleveland

30 Parma Community General HospitalParma

31 Robinson Memorial HospitalRavenna

32 TriPoint Medical CenterConcord

33 Windsor Laurelwood Center for Behavioral MedicineWilloughby

Kaiser Permanente medical office

Affiliated hospital

Kaiser Permanente medical office/ emergency services

Having a wide selection of physicians and convenient medical facilities is important. Our members have their choice of Signature Network doctors with Ohio Permanente Medical Group, Inc., and can receive care at Kaiser Permanente medical facilities throughout Northeast Ohio.

Find a provider near you



Individual and Family Plans | KEY TERMS

Note: For more detailed definitions, please consult the Evidence of Coverage, available on request.

Key terms

Annual out-of-pocket maximumThe maximum amount you’ll pay for certain covered services in a calendar year. Once you’ve reached that maximum, you won’t have to pay any deductibles, copays, or coinsurance for most covered services for the rest of the calendar year. Not all services apply toward the annual out-of-pocket maximum. For HSA-qualified plans, all services, except for many preventive care services, are subject to the deductible, and all services apply toward the out-of-pocket maximum.

CoinsuranceThe percentage of charges you pay when receiving certain covered services. For example, 30 percent coinsurance for hospitalization means you pay 30 percent of the charges for covered hospital services. Coinsurance, which varies depending on your plan, doesn’t apply toward your deductible. But it does count toward your annual out-of-pocket maximum.

Copayment (or copay)The fixed fee you pay when you receive certain covered services or prescriptions. For example, a $35 office visit copay means you pay $35 for each office visit. Copayments, which vary depending on your plan, don’t apply toward your deductible. But they do count toward your annual out-of- pocket maximum.

DeductibleA set amount you pay in a calendar year before we provide most covered services at a copay or coinsurance. Not all services may count toward the deductible. For HSA-qualified plans, all services, except for many preventive care services, are subject to the deductible, and all services apply toward the out-of-pocket maximum.

Health savings account (HSA)An HSA is a savings account intended to be used for qualified medical expenses. HSAs have certain federal tax advantages as well as certain restrictions.

HSA-qualified deductible planThis is a deductible plan eligible to be paired with an optional health savings account. It is similar to traditional deductible plans but works differently in certain respects.

Not subject to deductibleIn deductible plans, some medical services are covered immediately and therefore are not subject to deductible. This means that you can receive these services for a copayment or coinsurance, without having to first satisfy the deductible. Many preventive care services are not subject to the deductible.



Individual and Family Plans | FREQUENTLY ASKED QUESTIONS

Frequently asked questions

Some of the most common questions people have about our plans are included here. If you have questions about a specific type of plan or a particular benefit, please see “Benefit Highlights.” Or you may call us at 1-800-494-5314 or contact your agent or broker. We’ll be happy to answer any questions.

How does the Affordable Care Act affect the plan I’m applying for?The benefits that you select may change on January 1, 2014. At that time, in order to meet the new benefit standards under the Affordable Care Act, we may change the benefits and the rate you pay under your plan, or ask you to select a new plan. In any case, we value your membership and will provide options for you to continue your coverage without a break.

I’ve heard about a Summary of Benefits and Coverage document. What is it? And how do I get one?As part of the Affordable Care Act, you now have access to Summary of Benefits and Coverage (SBC) documents to help you make an informed health plan choice. These documents summarize important information about your health coverage options, so you can easily compare Kaiser Permanente benefits and coverage with those of other carriers. SBCs for all our plans are available at healthcare.gov.

What is the difference between routine physical exams, primary care office visits, and specialty care office visits? n A routine physical exam is an annual office visit to your

primary care physician during which your doctor will perform preventive care screenings as indicated by your age, gender, and general health.

n A primary care office visit is a visit (other than a routine physical exam) to your primary care physician, usually a general practitioner in internal medicine, family practice, or pediatrics.

n A specialty care office visit is a visit to a doctor other than a primary care physician, such as a dermatologist or orthopedist.

For more information, see your Evidence of Coverage.

Is a physical exam required to apply?No. All you have to do is complete the medical questionnaire included in your Kaiser Permanente for Individuals and Families application form.

How do I choose a doctor?You’ll choose your personal primary care physician from our Signature Network which is staffed by the Ohio Permanente Medical Group. For a current listing of our Signature physicians, please visit kp.org.

Since our Signature doctors practice at Kaiser Permanente medical offices, you’ll often have the convenience of accessing many services, such as specialty care, laboratory, and pharmacy, in just one trip.

Can I apply to enroll my children?Yes. You may apply to enroll children as a part of your family plan.

I have children away at school. Are they covered outside of the service area?Members who are temporarily outside our service area, such as students, are covered for emergency and urgent care services. Routine or elective services, such as flu shots or annual physical exams, must be provided in your home service area by your primary care physician.

To what age can my children be covered on my plan?Your children can be covered as dependents on your plan until they turn 28.

Are preventive care services covered?Yes. Many are available for no charge. You don’t have to meet a deductible first for many preventive care services.



Individual and Family Plans | FREQUENTLY ASKED QUESTIONS

Frequently asked questions (continued)

Do I need a referral to get specialty care?You can see a Behavioral Health specialist or an obstetrician/gynecologist (Ob/Gyn) without a referral. Otherwise, if you need specialty care, your primary care doctor can refer you to one of our Signature Network physicians. If for any reason no referral specialist is available within Ohio Permanente Medical Group, your primary care physician will coordinate your care appropriately.

Are prescription medications covered? How do I get my prescriptions filled? Can I order my prescriptions by mail?All of our plans offer prescription coverage. You can order most refills online with My Health Manager and pick them up at your medical office or receive them by mail at no extra charge.

Is dental included?Yes. The preventive dental plan is a Delta Dental of Ohio insurance product made available to our members. It is not optional. When you become a Kaiser Permanente for Individuals and Families member, you are covered as a participant in the preventive dental plan.

How do HSA-qualified deductible plans work?HSA-qualified plans are a type of deductible plan designed to work with a health savings account, or HSA. The advantage of an HSA-qualified plan is that you can deposit tax-deductible dollars into the account that you can later use to pay for qualified medical expenses.1 Plus, any interest that the HSA might earn is tax free. And any funds you don’t use in one year will roll over to the next. There’s no “use it or lose it” with HSAs.

Do I have a copay or coinsurance on a traditional deductible plan?In a traditional deductible plan, you must meet your deductible before you are eligible to pay coinsurance for most covered services. However, there is no charge for many preventive care services. And in our HSA-qualified plan, once you meet your deductible, you can receive most covered services for no charge.

Are vision services covered?Vision services are offered with our traditional deductible plans but not with our HSA-qualified plan.

What is the difference between the deductible and the out-of-pocket maximum?In deductible plans and HSA-qualified deductible plans, the deductible is the set amount you must pay in a calendar year before Kaiser Permanente will begin to cover certain services. Once you pay that amount out of pocket, you are eligible to pay coinsurance.

The out-of-pocket maximum is the maximum amount of copayments and/or coinsurance you will have to pay for certain covered services in a calendar year. Your deductible does not count toward your out-of-pocket maximum in traditional deductible plans, but it does count toward your out-of-pocket maximum in our HSA-qualified Plan 5000/10000.

The services that apply toward your out-of-pocket maximum include professional services for basic health care, inpatient and outpatient hospital care (excluding nonbiologically based mental health care), and X-ray services. Dental and vision services do not apply toward your out-of-pocket maximum.

What if I need care when I’m traveling?You’re covered for emergency care anywhere in the world. If you’re temporarily outside your service area, you’re also covered for urgent care to prevent serious deterioration of your health if the care cannot be delayed until you return to your service area.

How should I complete the application if I’m working with a broker?If you are working with a broker to select a plan and apply for coverage, please call him or her for assistance. He or she will be able to provide you with a link to the online application and answer any questions you have about our plans or about how to complete the application.

1 Tax references relate to federal income tax only. Please consult a financial or tax adviser for tax savings information.



Individual and Family Plans | IMPORTANT DETAILS AND NOTICES

HIPAA AND OPEN ENROLLMENT PLANSIf you do not qualify for Kaiser Permanente for Individuals and Families, you may be eligible for HIPAA or Open Enrollment coverage. For eligibility rules, rates, benefit information, and an application, please visit www.kpifoe.org. For questions about HIPAA or Open Enrollment plans or to request an enrollment application, call 1-800-524-7371, ext. 5613.

PLAN COVERAGEUpon acceptance, you will receive an Evidence of Coverage, which includes exact terms and conditions of membership as well as plan exclusions and limitations. If you have specific questions or would like to receive an Evidence of Coverage before applying, please contact Customer Relations at 1-800-686-7100.

Please review this information carefully.

THE STATE OF OHIO REQUIRES THAT WE PROVIDE THE FOLLOWING NOTICES:

Important information about our providers Kaiser Foundation Health Plan of Ohio contracts with approximately 55 primary care physicians and approximately 98 specialists through the Ohio Permanente Medical

Group, Inc. No benefits are payable for covered services received outside Kaiser Permanente that have not been prescribed, directed, and arranged by a Kaiser Permanente physician and approved by the Health Plan. This applies to all covered services except emergency services.

Coverage limitations and exclusionsFor complete information about plan benefit limitations and exclusions, please refer to the “General exclusions/limitations/reductions” section of the appropriate 2013 Kaiser Permanente for Individuals and Families Evidence of Coverage for the plan for which you apply.

CONFIDENTIALITY AND YOUR PERSONAL INFORMATION

Privacy noticeBe a proactive member by knowing how we protect your personal information and when we may need to share it.

This notice is designed to inform you about the types of individually identifiable information collected, how such information is used, the circumstances under which we share it within our medical care program, and the circumstances under which nonpublic personal health and financial information is disclosed to persons outside our program.

Since Kaiser Permanente does not sell or otherwise disclose your information except as allowed by law, an “opt-out” provision is not offered.

Our policyKaiser Permanente is committed to protecting the privacy of its members and patients, including former members and patients. Kaiser Permanente considers maintaining the confidentiality of members’ personal health and financial information important to our mission of providing quality care to members.

We maintain policies regarding confidentiality of individually identifiable health and financial information, including policies regarding access to medical records and disclosure of health and financial information. All Kaiser Permanente staff and employees are required to maintain the confidentiality of members’ and former members’ individually identifiable health and financial information in any format (i.e., electronic, oral, and hard copy). The unauthorized disclosure of individually identifiable health and financial information is prohibited. Permanente Medical Group physicians and medical professionals and practitioners and providers with whom Kaiser Permanente contracts are also subject to maintaining confidentiality.

Important details and notices



(continues)


Important details and notices (continued)

Information collectedKaiser Permanente collects various types of nonpublic personal health and financial information either from you or from other sources in order to provide health care services and customer services, evaluate benefits and claims, administer health care coverage, and fulfill legal and regulatory requirements.

Examples include:

n Medical information, including medical and hospital records, mental health records, laboratory results, X-ray reports, pharmacy records, and appointment records

n Information contained on surveys, applications, and related forms, such as your name, address, date of birth, Social Security number, gender, marital status, and dependents

n Information about your relationship with Kaiser Permanente, such as medical coverage purchased, medical services received, account balances, payment history, and claims history

n Information provided by your employer, benefits plan sponsor, or association regarding any group coverage you may have

n Information from consumer or medical reporting agencies or other sources, such as credit history, medical history, financial background, and demographic information

n Information from visitors to our websites, such as online forms, site visit data, and online communications

Collection of informationKaiser Permanente collects information using a variety of techniques.

Examples include:

n Collecting information from you through surveys, applications, related forms, and other written requests and communications

n Collecting information from your employer, benefits plan sponsor, or association regarding group coverage that you may have through group applications, census data, and other written requests and communications

n Collecting information from visitors to our website, such as online forms, site visit data, and other online communications

n Collecting information from consumer or medical reporting agencies or other sources, such as insurance-support organizations and credit bureaus

Uses of shared informationCertain nonpublic personal health and financial information of members and former members will need to be used or shared during the normal course of providing you services. We may use or disclose nonpublic personal health and financial information under certain

circumstances, which may include the following:

n Personal health and financial information will be shared only with proper written authorization as required by law, or as expressly required or permitted by law without written authorization.

n Personal health and financial information will be shared within Kaiser Permanente in order to provide services to you and to meet our responsibilities under the law, such as quality assurance, reviewing the competence or qualifications of health care providers, conducting training programs for health care providers, fraud and abuse detection and compliance programs, certification, licensing and credentialing, research, compiling information for use in a legal proceeding, and billing and payment.

n Demographic information, such as information from your enrollment application, may be shared within Kaiser Permanente to enable us to provide customer service or account maintenance in connection with your benefits.

n Information such as your name, address, or telephone number may be used by Kaiser Permanente to tell you about other products or services that might be useful or beneficial to you.

n Personal health and financial information will be shared within Kaiser Permanente in order to provide services to you and to





meet our responsibilities under the law. Under the federal Fair Credit Reporting Act, we are permitted to share your name, address, and facts about your transactions and experiences with us, such as payment history, within Kaiser Permanente.

Information obtained from insurance support organizationsInformation obtained from reports prepared by insurance support organizations may be retained by the insurance support organizations and disclosed to other persons.

Information shared with nonaffiliated third partiesWe occasionally disclose nonpublic personal health and financial information of members and former members outside Kaiser Permanente for the following activities:

n State and federal law generally require that we disclose health and financial information when disclosure is compelled by a court, a board, a commission or administrative agency, a party to a proceeding before a court or administrative hearing pursuant to a subpoena or other provision authorizing discovery, an arbitrator or arbitration panel, a search warrant, or a coroner.

n State and federal law also require other disclosures. Examples include records of communicable diseases and workers’ safety or industrial accident records

disclosed to public agencies, birth and death information, and state tumor registries.

n State and federal law permit the disclosure of health information without patient authorization under specific circumstances. Examples include disclosures to providers or health plans for purposes of diagnosis or treatment of a patient, emergency medical personnel, peer review committees, insurance regulatory and public licensing agencies, and private accrediting bodies and other persons for purposes of performing business, professional, or insurance functions on behalf of Kaiser Permanente.

n Information may be shared with other companies that perform marketing services on our behalf to develop and mail offers to our customers about products and services.

n Information may be shared with medical care professionals, practitioners, and institutions for purposes of verifying coverage or benefits, informing you of medical problems of which you may not be aware, or conducting an operations or services audit to verify that you have been treated by the medical care professional or practitioner or at the medical care institution.

n Information may be shared with law enforcement or governmental authority to protect the interests of Kaiser Permanente in preventing or prosecuting acts of fraud or

otherwise investigating illegal activities that Kaiser Permanente reasonably believes have been committed.

n Information may be shared with employers, benefits plan sponsors, and associations regarding group coverage that you may have for the purpose of reporting claims experience or conducting program audits of Kaiser Permanente’s operations and services.

n Information may be shared for purposes of conducting actuarial or research studies.

Protecting informationKaiser Permanente protects the confidentiality and security of private information of members and former members. We maintain physical, electronic, and procedural safeguards that comply with federal and state standards to protect your private information and to assist us in preventing unauthorized access or use of that information. Employee access to personal health and financial information is provided on a need-to-know basis, such as to make benefit determinations, pay claims, manage care, manage the quality of care, underwrite coverage, administer a plan, or provide customer service.

Accessing, reviewing, and correcting informationYou have the right to look at or get a copy of your health and financial information. If you request copies, there may be a charge. If you believe





that information in your record is incorrect or if important information is missing, you have the right to request that we amend the existing information.

I. Kaiser Foundation Health Plan, Inc., and subsidiaries and affiliated entities:

Kaiser Foundation Health Plan, Inc.

Kaiser Foundation Health Plan of Colorado

Kaiser Foundation Health Plan of Georgia, Inc.

Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.

Kaiser Foundation Health Plan of the Northwest

Kaiser Foundation Health Plan of Ohio

Camp Bowie Service Center

Lokahi Assurance, Ltd.

Kaiser Health Alternatives

Kaiser Health Plan Asset Management, Inc.

Kaiser Permanente Insurance Company

Kaiser Permanente Oregon Plus, LLC

Kaiser Properties Services, Inc.

KP Cal, LLC

Oak Tree Assurance, Ltd.

OHP

Ordway Indemnity, Ltd.

Ordway International, Ltd.

Rainbow Dialysis, LLC

1800 Harrison Foundation

II. Kaiser Foundation Hospitalsand subsidiaries and affiliated entities:

Kaiser Foundation Hospitals

Archimedes, Inc.

HAMI – Colorado, LLC

Health Care Management Solutions, LLC

KP OnCall, LLC

Kaiser Hospital Asset Management, Inc.

Kaiser Permanente International

Kaiser Permanente Ventures, LLC

III. The Permanente Federationand affiliated entities:

The Permanente Federation, LLC

The Permanente Company, LLC

Colorado Permanente Medical Group, PC

Hawaii Permanente Medical Group, Inc.

Mid-Atlantic Permanente Medical Group, PC

Northwest Permanente PC, Physicians and Surgeons

Ohio Permanente Medical Group, Inc.

Permanente Dental Associates, PC

Southern California Permanente Medical Group

The Permanente Medical Group, Inc.

The Southeast Permanente Medical Group, Inc.

This notice is issued to comply with the strict terms of the federal Gramm-Leach-Bliley Act of 1999. Nothing in this notice shall be construed as a statement that any company operating within the Kaiser Permanente Medical Care Program is engaged in the business of insurance.

Protecting your privacyYour privacy is important to us. Our physicians and employees are required to keep your protected health information (PHI) confidential, and we have policies, procedures, and other safeguards in place to help protect your PHI from improper use and disclosure in all settings, as required by state and federal laws. We will release your PHI when you give us written authorization to do so, when the law requires us to disclose information, and under certain circumstances when the law permits us to use or disclose information without your permission. For example, in the course of providing treatment, our health care professionals may use and disclose your PHI in order to provide and coordinate your care, without obtaining your authorization.

Your PHI may also be used without your authorization to determine who is responsible to pay for medical care and for other health care operations purposes, such as quality assessment and improvement, customer service, and compliance programs. If you are enrolled in Kaiser Permanente through your employer or employee organization, we may be allowed under the law to disclose to them

(continues)





certain PHI, for example, regarding health plan eligibility or payment, or regarding a workers’ compensation claim. Sometimes, we contract with others (business associates) to perform services for us, and in those cases, our business associates must agree to safeguard any PHI they receive, whether electronic, oral or hard copy.

Our privacy policies and procedures include information on your right to see, correct or update, and receive copies of your PHI. You may also ask us for a list of our disclosures of your PHI that we are required to track under the law.

For a more complete explanation of our privacy policies, please request a copy of our Notice of Privacy Practices, which is available on our website, in our medical offices, or by calling Customer Relations. If you have questions or concerns about our privacy practices, please contact Customer Relations at 216-621-7100 or toll free at 1-800-686-7100. TTY lines for the deaf, hard of hearing, or speech impaired are 216-635-4444 or toll free at 1-877-676-6677.

REVIEW OF MEDICAL SERVICESAt Kaiser Permanente, we use a utilization management program to ensure that the clinical services we offer are medically necessary and provided in an efficient, timely, and safe manner. Here in Ohio, our utilization management program is known as the Medical Management Program, which works with our providers to plan,

organize, and deliver quality health care services. Some services require prior notification and/or prior authorization by the Medical Management Program.

Examples include but are not limited to:

n Inpatient admissions

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

n Outpatient surgery

n Specialized services, such as home health and hospice care

n Durable medical supplies and equipment

n Skilled nursing and inpatient rehabilitation facilities

n Treatments initiated by a behavioral health (mental health and/or chemical dependency) specialist

Some treatments and services have specific criteria developed or adopted by the Ohio Permanente Medical Group, or may be required by state or federal agencies, that define medical necessity. In any case, only physicians make the final decisions regarding medical necessity.

You are invited to call the Kaiser Permanente Nurse and Physician Advice Line if you are considering urgent care. In case of a true medical emergency, call 911. Emergency care

does not require prior authorization. You are strongly encouraged to contact Kaiser Permanente after emergency care is received so Kaiser Permanente can coordinate follow-up services. If you are admitted to a non–Plan hospital in connection with emergency care, you, a member of your family, or the admitting physician must contact us before you are admitted, within 24 hours, or as soon as medically possible, so that we may decide whether to make arrangements for necessary continued hospitalization or transfer you to another facility.

Emergency medical condition: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in any of the following:

n Placing the person’s health (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy

n Serious impairment to bodily functions

n Serious dysfunction of any bodily organ or part

In the event any service is denied by our Medical Management Program, you may appeal.


www.buykp.org/apply

It keeps getting better

We give you the information and tools you need for a healthier life—all in one easy-to-use package.

Together, we make a great team.Apply now!

Great doctorsA trusting relationship with your doctor is a big part of staying healthy. Our doctors are some of the most caring, skilled physicians around. And if you forget to ask something during a visit, you can always email their office. They’re there for you.

Community of careAt Kaiser Permanente, your providers, facilities, and health plan are all part of the same team. Your doctors, nurses, and pharmacists work together to coordinate your care. And you don’t have to drive all over town for care because most of our medical offices include pharmacy, lab, and X-ray services in the same place.

We’re all connectedYour electronic health record securely connects your entire care team to your up-to-date health information, medications you’re taking, and whether you’re due for a preventive screening.

What you need, when you need itWe make it simple for you to get healthier and stay healthier:

n Easy-to-schedule appointments

n Same-day, after-hours, and weekend health services at many locations

n Medical records, immunizations, and test results online

And all those little extrasn Online prescription refills

n Online tools that help you set up a customized fitness program or cook nutritious meals

n Wellness classes at most facilities, most of which are free with your membership

With Kaiser Permanente, you get everything you need to stay informed and take an active role in your health. And we partner with you to help you make better choices every step of the way.

Note: Many features identified in this book are available only to members receiving care at Kaiser Permanente medical facilities.

2013 Kaiser Permanente for Individuals and Families Enrollment Book

Try a better approach to health – apply now!

I can choose my doctor

I can email my doctor‘s office

Better health is just a click away

At Kaiser Permanente, you can take charge of your health with a variety of online tools — health links, calculators, podcasts — right at your fingertips. Think of them as your dashboard for healthy living. As a member, here are 10 helpful tools you can use:

Healthy lifestyles Getting healthier is easier with a plan, so start with a customized online action plan from HealthMedia® . These healthy lifestyle programs can help you reach your health goals.

Fitness You’re built to move. Our online resources are there to help with a fitness routine or to provide ideas for fun activities to get your family moving.

kp.org/healthylifestyles kp.org/fitness

Get walking Classes Hit the trail with the Every Body Walk! app. Create a personalized walking plan, connect with new friends, and share your progress.

There’s something for everyone with our health classes and workshops offered at our facilities. Classes vary by location and fees may apply.

everybodywalk.org/app.html kp.org/classes

Managing your weight Quit tobacco Your weight is more than a number on a scale— it’s how you feel every day, inside and out. We’ve got the tools to help you reach or maintain a healthy weight.

Break the habit for good—free yourself from tobacco’s grip with our helpful resources like a personalized online action plan or phone counseling and coaching.

kp.org/weight kp.org/quitsmoking

Videos Podcasts From inspiring messages on the benefits of exercise to simple ways to control asthma, our videos will instruct and motivate you to better health.

Your mind and body are connected. Download our guided imagery programs to help you reduce stress, focus on healthy changes, and promote healing.

kp.org/video kp.org/listen

Health encyclopedia Calculators Learn more about numerous health topics with our online health encyclopedia or visit our interactive health symptom checker.

Enter your numbers online and check your health information such as your body mass index (BMI) or your daily calorie count.

kp.org/health kp.org/calculators

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http://www.kp.org/healthylifestyles

http://www.kp.org/fitness

http://www.everybodywalk.org/app.html

http://www.kp.org/classes

http://www.kp.org/weight

http://www.kp.org/quitsmoking

http://www.kp.org/video

http://www.kp.org/listen

http://www.kp.org/health

http://www.kp.org/calculators

better health is just a click away · we offer deductible and hsa-qualified deductible plans so you...

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