kaiser permanente - denver...2016 plan comparison of kaiser permanente options. this summarizes...

Kaiser PermanenteKnow your Health PlanPresented by Candice Morrissey, Associate Account Manager

Large Group Account Management

2 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.July 20, 2016

Knowing your Kaiser Permanente Plans

Visit to your PCP from Start to Finish

Urgent Care vs Emergency Room

Preventive vs Diagnostic Visit

Reading and Understanding your Explanation of Benefits

Online Tools and Other Resources

Questions


Start to Finish

Visit to your Primary Care Physician

Choose or Change your Doctor– Physician biographies listed on kp.org will help you decide

– Call the Physician Selection services team at 303.338.4448

22 Medical Offices in the Denver / Boulder Area– Specialty Offices – out patient surgeries, MRI’s, CT Scans

Lone Tree Medical Office located south Denver

Franklin Medical Office located downtown Denver

Rock Creek Medical Office located north Denver

Visit to your Primary Care Physician continued

Primary Care or Specialty– Present your Kaiser Permanente

insurance card and a second photo id at the check in counter, or . . .

– Check in at the Kiosk by entering your first and last name, date of birth or your health record number

– Pay your copay amount for the service

– You will be billed for any diagnostic procedures provided

Primary Care or Specialty– Present your Kaiser Permanente

insurance card and a second photo id at the check in counter, or . . .

– Check in at the Kiosk by entering your first and last name, date of birth or your health record number

– You may be asked to pay $80 for consultation which will be credited toward your services provided at that visit


Checking In: DHMO Checking In: HDHP


Colorado Permanente Medical Group (CPMG) In network physicians, primary and specialty care at Kaiser

Permanente Medical Offices– Kaiser Permanente insurance only covers services with physicians in

the CPMG Network Referrals from a CPMG physician to an outside provider are covered

based on your plan Physicians are paid a salary which means they aren’t incented to

prescribe, order unnecessary procedures, diagnostics or over charge Integrated Health Care Model Video:

https://www.youtube.com/watch?v=fEpzClbGD8s

https://www.youtube.com/watch?v=fEpzClbGD8s

Preventive Visit

A woman goes to her doctor, and he reminds her that she has reached the recommended age for annual mammograms. She hasn’t noticed anything to give her any concern about her breasts, but receives a mammogram for screening purposes only. The mammogram is clear and the doctor recommends no further steps for the time being.The mammogram was ordered solely because the patient had reached the recommended age. In that case it would be considered a preventive service and would be 100 percent covered by the patient’s health plan.


Diagnostic Visit

A woman notices a lump in her breast, and she goes to see her physician. The doctor recommends that she receive a mammogram to further examine the lump and determine if anything is wrong with her breast.The doctor recommends the test because the woman is known to have a lump. So the mammogram would be considered a diagnostic service and the patient would share the cost of the exam.



Preventive and Diagnostic Screenings Preventive Screening

– Preventive care is the care you receive to prevent illnesses or diseases which can include counseling to prevent health problems. Providing these services at no cost is based on the idea that getting preventive care, such as screenings and immunizations, can help you and your family stay healthy.

Diagnostic Screening– Diagnoses are procedures that are used to

determine the cause of an illness or disorder. Diagnostic services provide health care practitioners with information about the presence, severity, and cause of diseases in patients.

9 July 20, 2016

What is Prevention Flip

This is a term that describes the situation where a member is scheduled for a preventive visit but during the course of the visit, a new diagnosis is discovered.

Lab, radiology or other services are ordered outside of what is considered preventive. This then “flips” the visit from a preventive visit to a diagnostic visit.

The member will receive an Explanation of Benefits (EOB) for the appropriate office services followed by a billing statement.

Patient Registration makes every effort to tell members this is a possibility.

Specialist Referrals:


After receiving the referral from PCP to specialist, whether within KP network or with our contracted providers, an appointment is made.

At time of service, member is expected to pay their specialty office visit copay.

Should there be additional procedures included within this appointment, member will receive their KP Explanation of Benefit (EOB).

These services will apply to deductible and coinsurance.

Once EOB has been processed by provider, member will then receive an invoice for services.

DHMO HDHP

After receiving the referral from PCP to specialist, whether within KP network or with our contracted providers, an appointment is made.

At time of service, if member has not satisfied their deductible, they will be asked to pay $80, which will be applied to their deductible which is an agreed upon amount.

If the member's visit cost more based on services provided, amount will apply to deductible/coinsurance

depending on the type of service. Once EOB has been processed by provider, member will then receive an invoice for services.


After Hours, Urgent and Emergency Care

KP After / Urgent Care Pediatric Urgent Care Emergency Care

Lone Tree Medical Office

East Denver Medical Office

Lakewood Medical Office

Westminster Medical Office

Children’s Hospital -Broomfield

Children’s Hospital, Uptown Denver

Children’s Hospital, Wheat Ridge

Rocky Mountain Hospital for Children

St. Joe’s

Good Samaritan

Sky Ridge

Swedish

ANY HOSPITAL; GET CARE!

Knowing your best option by calling for Medical Advice: 303.338.4545

City and County of Denver – HDHP – 2016 Annual deductible $1,350 employee only / $2,700 family

Annual out-of-pocket maximum (OPM) $2,700 employee only / $5,400 family

You must meet the family Deductible before plan moves to coinsurance. Deductible is included in the OPM.

Covered service You pay

Preventive care No cost for most services

Doctor’s office visit 20% coinsurance*

Diagnostic lab tests 20% coinsurance*

Imaging (x-ray, MRI, CT/PET scan) 20% coinsurance*

Outpatient surgery 20% coinsurance*

Hospitalization 20% coinsurance*

Emergency care 20% coinsurance*

Prescription drugs (in pharmacy) 20% coinsurance*

*Coinsurance applies after the Deductible is met.This is only a summary of some benefits and their copays and coinsurance. This chart does not describe the benefits. Refer to your Evidence of Coverage for information about coverage, limitations and exclusions of all benefits, including those not listed in this summary.

Contributing to your Health Savings Account – HDHP only

City and County of Denver providing tax-free seed money• Individual - $ 600• Family - $1,200

Annual HSA maximum contribution for Individual - $3,350• $3,350 - $600 = $2,750

Annual HSA maximum contribution for Family - $6,750• $6,750 - $1,200 = $5,550

Account balance rolls over from year to year without penalty

The IRS has provided tax benefits for your HSA funds.

• The funds in your HSA are not considered part of your wages, so they’re not subject to

federal income taxes

• HSA funds used to pay for qualified medical expenses are not subject to taxes

• Any interest earnings in an HSA is tax-free as long as they’re used for qualified medical

expenses

• Maximum annual amount that can be contributed for Individual is $3,350 and Family is

$6,750

Tax references in this document are related only to federal income tax. Consult your financial or tax advisor about state income tax law. Refer to the list of medical costs that meet the requirements, as defined under Internal Revenue Code Article 213(d); refer to IRS Publication 502, Medical and Dental Expenses, at irs.gov/publications.

DHMOAnnual Deductible

Annual Out-of-pocket MaximumPreventive Care

Doctor’s office visitPrimary Care/Specialist

Emergency Care

Urgent/After Hours Care

Outpatient / Inpatient Surgery

Diagnostic Imaging/Lab Tests

Prescription Drugs

HDHP w/HSA$ 500 Single/$1,500 Family $1,350 Single/$2,700 Family$3,000 Single/$6,000 Family $2,700 Single/$5,400 Family

100% Covered 100% Covered$30/$50 copay + 20%

coinsurance after deductible20% coinsurance after

deductible met$200 copay – imaging not

included20% coinsurance after

deductible is met$75 copay + 20% coinsurance

after deductible 20% coinsurance after

deductible is met20% coinsurance after

deductible met20% coinsurance after

deductible met

20% coinsurance/No charge 20% coinsurance after deductible met

$20 Generic/$40 Brand/$60 Non-preferred 20% coin after ded

2016 Plan Comparison of Kaiser Permanente Options

This summarizes major provisions in the Agreement between Kaiser Permanente and you or your group for eligible members. This chart does not explain benefits, cost sharing, out-of-pocket maximums, exclusions, limitations, nor does it list all benefits and cost sharing. Obtain further information by contacting Kaiser Permanente or by referring to the Evidence of Coverage. In the event of ambiguity or conflict between this summary and the Evidence of Coverage, the Evidence of Coverage shall control.

Dave, with the City and County of Denver, only covers himself on the plan. He is generally healthy, but has developed knee problems. He visits a specialist – orthopedic surgeon ($215). The specialist orders and MRI ($1,467), and based on the results, recommends outpatient surgery ($5,000). Dave also needs pain medication after the surgery (1 generic prescription).

Scenario 1: Employee Only Coverage – DHMO comparison to HDHP

Note: These are estimated costs only. Figures based on 2015 Sample Fee List.

DHMO HDHP w/HSA

Dave’s Annual Premium $817.20 $219.72

Employer HSA Contribution $ 0 $600.00

Employee HSA contribution $ 0 ?

Specialty Visit $50 copay $215 (DED)

MRI $500 (DED) then 20% of $967 = $193.40

$1,467 (DED) + $215 = $1,682 -$1350 = $332 at 20% = $66.40

Outpatient Surgery $5,000 at 20% = $1,000 $5,000 at 20% = $1,000

Prescription (Generic) $20 copay $ 25 at 20% = $5

Deductible / OOP $500 / $3,000 $1,350 / $2700

Total paid out (copays, deductible, coinsurance, premium)

$1,763.40 + $817.20 = $2,580.60 $2,421.40 + $219.72 = $2,641.12 - $600(HSA) = $2,041.12

DHMO HDHP w/HSA

Allison’s Family Annual Premium $4,358.50 $2,109.24

Employer HSA Contribution $ 0 $1,200

Employee HSA contribution $ 0 ?

Preventive Visits $ 0 $ 0

Specialty Visit (Sarah) $50 copay plus $58 (DED not met) $212

Inpatient Admission (Allison) $9,000 - $500 DED with balance of $8,500 at 20% = $1,700

$9,000 + $212 = $9,212 - $2,700 deductible = $6,512 at 20% = $1,302.40

Prescription (Generic) $20 copay x 4 = $ 80 $25 x 4 = $100

Deductible / OOP $1,500/ $6,000($500 single to $1,500 Family DED)

$2,700 / $5,400

Total paid out (copays, deductible, coinsurance and premium)

$2,388.00 + $4,358.50 = $6,746.50 $4,102.40 + $2,109.24 = $6,211.64 - $1,200= $5,011.64

Scenario 2Family Coverage – DHMO comparison to HDHPAllison, Department of Public Safety, she covers her husband and a daughter (Sarah) on the plan. She will deliver their second child in 4 months. The family has 4 preventive visits (including well baby visit), an inpatient stay for delivery ($9,000), 4 generic prescriptions after the baby is born and 1 specialist visit to the pulmonologist for their daughter’s allergies ($154 + $58 for a breathing test).

READING YOUR EXPLANATION OF BENEFITSProvider Date of Service

Billed Amount

Allowed Amount

Other Insurance Amount

Member Responsibility KaiserPaid

Remarks

Not Covered

Deductible Coinsurance Copay

Jones Health Clinic07/01/11 $ 900.00 $ 695.01 $ 0 $ 204.99 $ 500.00 $ 39.00 $ 0 $ 156.01 029

CLAIM TOTALS

$ 900.00 $ 695.01 $ 0 $ 204.99 $ 500.00 $ 39.00 $ 0 $ 156.01

*Member Responsibility is the amount, if any, owed to your provider. This may include amounts already paid to your provider at time of service.

Kaiser Paid $ 156.01Member Responsibility $ 539.00


Allowed Amount Amounts show the Kaiser Permanente member charges for services. This is NOT your liability

Member Responsibility This amount reflects your responsibility. This is difference between the Allowed Amount and Kaiser Paid.

Not Covered This amount is the difference between Allowed Amount and Billed Amount which is a provider write-off

Kaiser Paid This amount is what Kaiser Permanente is responsible for paying based on your plan option.

READING YOUR EXPLANATION OF BENEFITS

Satisfied to DateCore Tier 1Deductible

Core Tier 1Out of Pocket

Individual $ 500.00 $ 39.00Family $ 500.00 $ 39.00Plan Maximums Individual: $ 500.00 Individual: $ 2,000.00

Family: $ 1,500.00 Family: $ 4,500.00


Accumulation to Date: October 1, 2015DHMO or HDHP

Accumulation to Date This is a running tally of total charges that have been applied to your deductible and out of pocket maximum for the year. Core Tier 1 is the services received with Kaiser Permanente Medical offices

Tracking Individual Amounts

This is the deductible and out of pocket maximum totals for you and each member of your family. When a family member reaches their deductible, that family member will pay only a copay or coinsurance for most covered services.

Tracking Family Amounts

This is the total charges applied to your calendar year family deductible. After this deducible is met, every family member will pay only copays or coinsurance for most covered services

Online Tools and Other Resources

Kaiser Permanente Mobile App NEW Feature


Use the convenient features of My Health Manager right from your smartphone or other mobile device

• Email your doctor’s office• View most test results• Schedule or cancel routine

appointments• Refill most prescriptions• View past visits

Just download the Kaiser Permanente app at no cost from your preferred app site

To use your digital membership card, tap the card icon at the bottom of the Kaiser Permanente app dashboard


Video Visits

Care options with more convenience than ever before

Alternative to receiving an in-person visit No cost share in 2016; in 2017 cost share

may apply based on your plan Good internet connection, a computer,

smart phone or tablet with camera, microphone and speakers

Ask your provider if a VIDEO VISIT is an option for you!

Personalized Care: When and Where you need it


My Health Manager

Emergency Care

RX Mail Order

Formulary

View Lab Results

Email Your Doc

Cost Calculator

Schedule appointment

E-VisitsPlan

Information

My Health Manager is located at www.kp.org a registered trademark of Kaiser Permanente

ID Cards

http://www.kp.org/

Financial Counselors - 303-338-3025 or 1-800-659-2656 TTY for the hearing/speech impaired.

Clinical Pharmacy Call Center – 303-338-4503 or 303-338-4228 TTY for the hearing/speech impaired

Both departments can be reached Monday through Friday between 8 am and 6 pm

Additional Resources


Questions . . .

kaiser permanente - denver...2016 plan comparison of kaiser permanente options. this summarizes...

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