2017 PLAN UPDATES. What s new for 2017 Oregon small business group plans. account.kp.org

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1 2017 PLAN UPDATES O R E G O N 2017 What s new for 2017 Oregon small business group plans This booklet contains a summary of important information you will want to know about our 2017 small group plans. For more details on plan design, refer to the Medical Plans Overview for Oregon Small Businesses. account.kp.org _NW-OR_11/16 All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest. 500 NE Multnomah St., Suite 100, Portland, OR

2 Your partner in good health At Kaiser Permanente, we re a little different from other carriers and for a good reason. We offer a fully integrated health care delivery system with providers, hospitals, pharmacies, and labs working together to provide better health care for our members. By partnering with us, you get what other health plans simply can t offer: award-winning coordinated care, a choice of top docs, and unmatched member satisfaction that deliver superior value and quality to you and your employees medical plan portfolio Our plan portfolio continues to offer the additional plans and flexibility added in We have multiple plans to choose from in all 4 metal tiers. It was necessary to make minimal changes to certain cost shares on some plans such as the deductible, coinsurance, copays, and out-of-pocket maximum amounts in order to keep the plans within their metal tier and cover a similar percentage of health care costs as the prior year; however, no plans are being discontinued. Read on for a detailed list of specific benefit changes to each plan. Alternative care and vision hardware benefits This year we will continue to offer many plans outside of Oregon Health Insurance Marketplace with three buyup options: stand-alone self-referred alternative care, stand-alone vision hardware and exam, and self-referred alternative care and vision hardware and exam. As a reminder, to offer choice and affordability, plans purchased without the vision hardware benefit do not provide coverage for adult eye exams. Automatic renewals For your renewal in 2017, we will automatically provide you with coverage from one of the plans that best matches the plans or plans your business offers today. But you can choose from any of our other plans available to small employers if you prefer. Please respond back whether you decide to accept the renewal as offered or make changes. Adult vision hardware For plans that cover the buy-up option with vision hardware and eye exam for members 19 and older, the vision hardware benefits now refresh after a two-calendar-year period. Previously, the vision hardware benefit was on a rolling 24-month period. 2

3 Group Senior Advantage changes All group Senior Advantage members will have a new alternative care benefit. Only one Senior Advantage plan will be offered to our small employers in Groups previously offering the Senior Advantage Standard Plan to their eligible members will be mapped to the plan known as the Value Plan (renamed Senior Advantage Plan). This plan provides a lower monthly premium with limited increase to the member s annual out-of-pocket maximum. Read on for a detailed list of specific benefit changes. Bundle options As you consider alternatives to lower your health care costs, consider offering employees a base plan with one or two buy-up alternatives. These bundle plan options are provided at no additional charge and allow you to tailor your plan offerings, giving employees more choice and more control over their monthly premium cost. You contribute the same amount toward each plan (no less than 50 percent of the lowest premium plan) and let your employees decide if they want the base plan or to pay more for a buy-up option. For more details, refer to the Medical Plans Overview for Oregon Small Businesses. FEATURES OF ACA-COMPLIANT HEALTH CARE PLANS FOR SMALL BUSINESSES Prescription drug coverage is automatically covered on all medical plans All of our plans come with built-in coverage for outpatient prescription drugs. All prescription drug plans have a 4-tier benefit design with different cost-sharing amounts for generic, preferred brand, non-preferred brand, and specialty drugs. Your employees can save time and money by ordering prescription refills online or by phone. Members get a 90-day supply for only twice the 30-day supply copay when we mail your prescription. We can mail most prescription drugs to you within 10 days, and you don t pay any extra cost for standard U.S. postage. Pediatric vision coverage on all medical plans All of our plans cover pediatric vision exams and one pair of standard frames or a 12-month supply of contact lenses, for children 18 and younger, at no charge. 3

4 Pediatric dental services and coverage for your renewal Pediatric dental coverage for members is required by law, so all of our medical plans are offered along with an ACA-compliant pediatric dental plan. All three of our pediatric dental plans are Dental Choice (PPO) plans, which means you will get a choice of preferred providers, including those in our dental facilities and non-participating dentists. One of the three pediatric plans provides coverage for standard orthodontia for misaligned teeth. If you have an ACA-compliant pediatric dental plan offered by another carrier, you may opt out of our coverage by attesting to this fact on your New Group Application or Renewal Decision Form. If your group previously attested to having other ACA-compliant pediatric dental coverage and waived this coverage, you must provide an updated attestation upon renewal using the Renewal Decision Form. If a plan is not selected or an updated attestation received, coverage will be added. Adult-only dental plans All traditional and PPO dental plan designs will continue for adults only (19 and older), and pediatric dental coverage will be provided separately as indicated above. As a reminder, we offer five plans that may be purchased with adult cosmetic orthodontia coverage. If you currently offer dental coverage, the same plan will be provided for your automatic renewal. If you want to choose a different plan, you may do so as well. Standard plans Our plan portfolio includes standard plans that have been designed by the state of Oregon, and all carriers are required to offer these particular plans. Because they were not designed by Kaiser Permanente, the coverage may differ slightly from our typical plans. Differences include benefits such as hospice, infertility, reconstructive surgery, and dependent out of area. Please refer to your Sales Summary of Benefits for details. Benefits that accrue to the medical out-of-pocket maximum Most benefits, including copays and coinsurance for services not subject to deductible, as well as the deductible itself, accrue to the medical out-of-pocket maximum. Copays and coinsurance that accrue to the out-of-pocket maximum are waived once an individual or family has reached that maximum. Underwriting guidelines Please be sure to review the Rating and Underwriting Assumptions Policy effective January 1, 2017, for Oregon groups with 50 or fewer employees. 4

5 SUMMARY OF CHANGES AND CLARIFICATIONS FOR OREGON SMALL EMPLOYER GROUPS This is a summary of changes and clarifications that we have made to your Group Agreement. The Group Agreement includes the Evidence of Coverage (EOC) Benefit Summary and any applicable endorsement documents. This summary does not include minor changes and clarifications we are making to improve the readability and accuracy of the Group Agreement. These changes and clarifications do not include changes that may occur throughout the remainder of the year as a result of federal or state mandates. Other group-specific or product-specific plan design changes may apply, such as moving to standard benefits. Refer to the Plan Updates document for information about these types of changes. To the extent that this summary of changes and clarifications conflicts with, modifies, or supplements the information contained in your Group Agreement, the information contained in the Group Agreement shall supersede what is set forth below. Unless another date is listed, the changes in this document are effective when your group renews in The products named below are offered and underwritten by Kaiser Foundation Health Plan of the Northwest. 5

6 TRADITIONAL, DEDUCTIBLE, HIGH DEDUCTIBLE (HSA-QUALIFIED), ADDED CHOICE MEDICAL PLANS Small group base medical plans PLATINUM GOLD SILVER BRONZE Traditional plans KP OR PLATINUM 0/20 KP OR GOLD 0/30 KP OR SILVER 0/50 Deductible plans KP OR PLATINUM 250/20 KP OR GOLD 500/20 KP OR SILVER 1500/35 KP OR BRONZE 5000/50 KP OR GOLD 1000/20 KP OR STANDARD GOLD PLAN KP OR SILVER 2000/35 KP OR STANDARD SILVER PLAN KP OR SILVER 3500/40 KP OR BRONZE 6600/35 KP OR STANDARD BRONZE PLAN HSA-qualified High Deductible Health Plans KP OR SILVER 2600/25% HSA KP OR BRONZE 5200/20 HSA Added Choice plans KP OR PLATINUM 250/10 3T POS KP OR GOLD 600/35 3T POS KP OR SILVER 2000/40 3T POS KP OR PLATINUM 250/10 3T POS OOA KP OR GOLD 600/35 3T POS OOA KP OR GOLD 1000/35 3T POS KP OR SILVER 2000/40 3T POS OOA KP OR GOLD 1000/35 3T POS OOA Buy-up options Any of the above base medical plans, when purchased directly through Kaiser Permanente, can be paired with a buy-up option listed below, with the exception of the Standard plans. A. $200/2-year period Vision Hardware benefit and Vision Exam B. Alternative Care $20 chiro/natur/acu, $25 massage/$1000 MAX C. Bundle of option A and B Offered only outside the health insurance exchange. Changes to Senior Advantage plans are explained on page 16 of this booklet. Medical EOC form numbers: EOSGTRAD0117 EOSGHDHP0117 EOSGDED0117 EOSG3TPOSDED0117 Standard Plan EOSHDEDSTD0117 EOSGHDHPSTD0117 6

7 CHANGES AND CLARIFICATIONS THAT APPLY TO TRADITIONAL, DEDUCTIBLE, HIGH DEDUCTIBLE, AND ADDED CHOICE MEDICAL PLANS Changes to Senior Advantage plans are explained at the end of this summary. Benefit changes The Benefits for Inpatient Hospital Services section has been modified. Orthognathic surgery for treatment of temporomandibular joint disorder or injury, sleep apnea, or congenital anomaly is covered. The Hearing Services section has been modified. The section has been renamed Hearing Aid Services and coverage is included for all Members. The Outpatient Durable Medical Equipment (DME) Exclusions section has been modified to remove the exclusions for continuous glucose monitoring devices, systems, and supplies; and electronic monitors of bodily functions. For plans that cover Vision Hardware and Optical Services for Members age 19 and older, vision hardware benefits are no longer on a rolling 24-month period. The language has been updated to reflect that benefits now refresh after a two-year period. Benefit clarifications For Traditional, Deductible, and High Deductible Health Plans, the Referrals to Participating Providers and Participating Facilities section has been modified to clarify that a routine hearing exam appointment does not require a referral. For Added Choice plans, Referrals to Select Providers and Select Facilities under the Tier 1 Referrals section has been modified to clarify that a routine hearing exam appointment does not require a referral. For Traditional, Deductible, and High Deductible Health Plans, the Out-of-Area Coverage section has been renamed to Out-of-Area Coverage for Dependents to clarify this benefit is available to Dependent children who are outside any Kaiser Foundation Health Plan service area. The Benefits for Inpatient Hospital Services section has been clarified to add palliative care. The Outpatient Services section in the Benefit Summary has been modified. Routine hearing exams (audiology Services) are covered under specialty care visits. Pediatric vision Services are covered through the end of the month in which the Member turns 19 years of age. The Infertility Services Exclusions section has been modified to clarify that Services related to procurement and storage of a Member s own semen are excluded. The Outpatient Prescription Drugs and Supplies section has been modified to clarify FDA-approved contraceptive drugs and devices are covered, including injectable contraceptives and internally implanted time-release contraceptive drugs, emergency contraceptives, and contraceptive devices such as intrauterine devices, diaphragms, and cervical caps. When these drugs and devices are approved through an exception process, they will be covered at the cost share as shown in the Benefit Summary. Also, supplies for treatment of diabetes are covered, and FDA-approved formulary tobacco use cessation drugs are covered at the cost share as shown in the Benefit Summary. 7

8 The Mental Health Services section has been modified to clarify mental health services, as found in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, are covered. Weight Control or Obesity Services in the Exclusions and Limitations EOC section has been modified. This exclusion does not apply to Services that are covered under Preventive Care Services. Administrative changes or clarifications The Definitions section has been modified to replace the Calendar Year and Plan Year definitions with the definition of Year, as well as all references within the EOC. The Benefit Summary has been modified to indicate the accumulation period (either calendar year or plan year). The definition of Group has been modified to align with the definition per ORS The Post-Service Claims Services Already Received and Internal Claims and Appeals Procedures sections have been modified. Post-service claims to request repayment for Services already received must be submitted within 12 months after receiving that Service. The Outpatient Prescription Drugs and Supplies section has been modified. A drug or supply can be obtained at a Participating Pharmacy (or Select Pharmacy) or in a prepackaged take-home supply from a Participating Facility (or Select Facility) or Participating Medical Office. Also, the Drug Formulary Exception Process section has been clarified. When a Participating Provider (or a Select Provider) requests an exception if the non-formulary drug or supply is determined to be Medically Necessary, we will make a coverage determination within 72 hours of receipt for standard requests and within 24 hours of receipt for expedited requests. 8

9 2017 MEDICAL PLAN CHANGES BENEFIT CURRENT PLAN KP OR STANDARD GOLD PLAN 2016 REPLACEMENT PLAN KP OR STANDARD GOLD PLAN 2017 Out of Pocket Individual $6,350 $6,850 Out of Pocket Family $12,700 $13,700 Deductible Individual $1,250 $1,000 Deductible Family $2,500 $2,000 Plan Coinsurance 10% 20% Ambulance 10% 20% AD* Durable Medical Equipment 10% 20% AD* Emergency Room 10% 20% AD* Inpatient Hospital 10% 20% AD* Lab 10% 20% AD* X-Ray 10% 20% AD* CT, MRI, PET 10% 20% AD* Outpatient Surgery 10% AD* 20% AD* Skilled Nursing Facility 10% AD* 20% AD* BENEFIT KP OR STANDARD SILVER PLAN 2016 KP OR STANDARD SILVER PLAN 2017 Out of Pocket Individual $6,350 $6,850 Out of Pocket Family $12,700 $13,700 Primary Care Office Visit 30% AD* $35 Preventive Office Visit $35 $0 Urgent Care $90 $70 BENEFIT KP OR GOLD 500/20 KP OR GOLD 500/20 Out of Pocket Individual $4,500 $5,350 Out of Pocket Family $9,000 $10,700 *After deductible. 9

10 CURRENT PLAN REPLACEMENT PLAN BENEFIT KP OR SILVER 1500/35 KP OR SILVER 1500/35 Out of Pocket Individual $6,850 $7,150 Out of Pocket Family $13,700 $14,300 Plan Coinsurance 25% 30% Ambulance 25% AD* 30% AD* Durable Medical Equipment 25% AD* 30% AD* Emergency Room 25% AD* 30% AD* Inpatient Hospital 25% AD* 30% AD* CT, MRI, PET 25% AD* 30% AD* Outpatient Surgery 25% AD* 30% AD* Skilled Nursing Facility 25% AD* 30% AD* BENEFIT KP OR SILVER 2000/35 KP OR SILVER 2000/35 Out of Pocket Individual $6,850 $7,150 Out of Pocket Family $13,700 $14,300 Plan Coinsurance 25% 30% Ambulance 25% AD* 30% AD* Durable Medical Equipment 25% AD* 30% AD* Emergency Room 25% AD* 30% AD* Inpatient Hospital 25% AD* 30% AD* CT, MRI, PET 25% AD* 30% AD* Outpatient Surgery 25% AD* 30% AD* Skilled Nursing Facility 25% AD* 30% AD* Urgent Care $55 $50 *After deductible. 10

11 CURRENT PLAN REPLACEMENT PLAN BENEFIT KP OR SILVER 2000/40 3T POS KP OR SILVER 2000/40 3T POS Tier 1 Tier 2 Tier 3 Tier 1 Tier 2 Tier 3 Out of Pocket Individual $5,250 $6,850 $12,000 $5,750 $7,150 $12,000 Out of Pocket Family $10,500 $13,700 $24,000 $11,500 $14,300 $24,000 Plan Coinsurance 25% 40% 50% 30% 40% 50% Durable Medical Equipment 25% AD* 40% AD* 50% AD* 30% AD* 40% AD* 50% AD* Emergency Room 25% AD* 25% AD* 25% AD* 30% AD* 30% AD* 30% AD* Inpatient Hospital 25% AD* 40% AD* 50% AD* 30% AD* 40% AD* 50% AD* Lab 25% AD* 40% AD* 50% AD* 30% AD* 40% AD* 50% AD* X-Ray 25% AD* 40% AD* 50% AD* 30% AD* 40% AD* 50% AD* CT, MRI, PET 25% AD* 40% AD* 50% AD* 30% AD* 40% AD* 50% AD* Outpatient Surgery 25% AD* 40% AD* 50% AD* 30% AD* 40% AD* 50% AD* Skilled Nursing Facility 25% AD* 40% AD* 50% AD* 30% AD* 40% AD* 50% AD* Administered Medications 25% AD* 40% 50% AD* 30% AD* 40% AD* 50% AD* *After deductible. 11

12 BENEFIT CURRENT PLAN KP OR STANDARD BRONZE PLAN 2016 REPLACEMENT PLAN KP OR STANDARD BRONZE PLAN 2017 Out of Pocket Individual $6,350 $7,150 Out of Pocket Family $12,700 $14,300 Deductible Individual $5,000 $7,150 Deductible Family $10,000 $14,300 Plan Coinsurance 50% AD* 0% Ambulance 50% AD* 0% AD* Durable Medical Equipment 50% AD* 0% AD* Emergency Room 50% AD* 0% AD* Inpatient Hospital 50% AD* 0% AD* Lab 50% AD* 0% AD* X-Ray 50% AD* 0% AD* CT, MRI, PET 50% AD* 0% AD* Mental Health/Substance Abuse Outpatient $60 AD* $70 Outpatient Surgery 50% AD* 0% AD* Primary Care Office Visit $60 AD* $70 Preventive Office Visit $0 $0 Specialist Office Visit 50% AD* $115 Skilled Nursing Facility 50% AD* 0% AD* Therapies $60 AD* 0% AD* Urgent Care $120 AD* $100 Drug Deductible $0 $0 Generic $20 $35 Brand $80 0% AD* Non-Preferred Brand 50% AD* 0% AD* Specialty Drugs 50% AD* 0% AD* *After deductible. 12

13 CURRENT PLAN REPLACEMENT PLAN BENEFIT KP OR BRONZE 3800/50% HSA KP OR BRONZE 5200/20 HSA Out of Pocket Individual $6,450 $6,550 Out of Pocket Family $12,900 $13,100 Deductible Individual $3,800 $5,200 Deductible Family $7,600 $10,400 Mental Health/Substance Abuse Outpatient 50% AD* $20 AD* Primary Care Office Visit 50% AD* $20 AD* Specialist Office Visit 50% AD* $30 AD* Therapies 50% AD* $30 AD* Brand $80 AD* 50% AD* BENEFIT KP OR BRONZE 4500/50 KP OR BRONZE 5000/50 Out of Pocket Individual $6,850 $7,150 Out of Pocket Family $13,700 $14,300 Deductible Individual $4,500 $5,000 Deductible Family $9,000 $10,000 Plan Coinsurance 40% 30% Ambulance 40% AD* 30% AD* Durable Medical Equipment 40% AD* 30% AD* Emergency Room 40% AD* 30% AD* Inpatient Hospital 40% AD* 30% AD* Lab $60 AD* 30% AD* X-Ray $60 AD* 30% AD* CT, MRI, PET 40% AD* 30% AD* Mental Health/Substance Abuse Outpatient $60 AD* $50 Outpatient Surgery 40% AD* 30% AD* Skilled Nursing Facility 40% AD* 30% AD* Urgent Care $70 AD* 30% AD* Drug Deductible $200 $700 Generic $20 $25 Administered Medications 40% AD* 30% AD* BENEFIT KP OR BRONZE 6600/35 KP OR BRONZE 6600/35 Out of Pocket Individual $6,850 $7,150 Out of Pocket Family $13,700 $14,300 Primary Care Office Visit $35 $40 Drug Deductible $0 $400 *After deductible. 13

14 2017 DENTAL PLAN CHANGES AND REMINDERS The Affordable Care Act requires Exchange-certified pediatric dental coverage for all subscribers and dependents regardless of age. For pediatric dental plans, the annual out-of-pocket maximum is $350 for an individual under 19 and $700 for a family (of two or more pediatric members enrolled). Groups also have the option of adding adult dental coverage. Please make your selection from the options listed above. The dental plan names have been slightly modified to provide clarity; however, all benefits (with the exception of the nitrous oxide copay) will remain the same. The cost share for nitrous oxide is changing to $25 in 2017 from $15 previously. CHANGES AND CLARIFICATIONS THAT APPLY TO DENTAL PLANS Benefit changes The Exclusions and Limitations section has been modified. To comply with Oregon House Bill 4110, the exclusion for Services provided or arranged by criminal justice institutions for confined Members has been removed. The limitation on covering removable prosthetic device adjustments, repairs, and relines within six months of the initial placement has been removed. The Schedule of Covered Pediatric Dental Procedures has been modified to comply with Oregon and Washington benchmark requirements for pediatric dental coverage. Benefit clarifications Pediatric dental Services are covered through the end of the month in which the Member turns 19 years of age. The Benefits section has been modified for clarity. Coverage is based on the least costly treatment alternative. The Preventive and Diagnostic Services section has been modified to clarify that we cover up to two visits for oral prophylaxis treatments in any 12-consecutive-month period as Dentally Necessary. The Major Restorative Services section has been modified to clarify that noble metal gold crowns are covered. Administrative changes or clarifications The Definitions section has been modified for clarity. In addition, the Calendar Year definition has been replaced with the definition of Year, and references to Dental Group have been removed and replaced with Permanente Dental Associates, PC. The Dependents section under Who is Eligible has been modified for clarity. Any person under the Limiting Age, including if the person is incapable of self-sustaining employment by reason of developmental disability or physical handicap, may be eligible for coverage. The Post-Service Claims Services Already Received and Internal Claims and Appeals Procedures sections have been modified. Post-service claims to request repayment for Services already received must be submitted within 12 months after receiving that Service. 14

15 OREGON HEALTH INSURANCE MARKETPLACE CERTIFIED PEDIATRIC PLANS AND ADULT DENTAL PLANS PPO pediatric plans KP OR Choice 80 Pediatric Dental Plan KP OR Choice 100 Pediatric Dental Plan Traditional adult-only plans KP OR Adult Traditional 80 $1,000 Max KP OR Adult Traditional 80 $50 Ded/$1,000 Max KP OR Adult Traditional 80 $100 Ded/$1,000 Max KP OR Adult Traditional 80 $1,000 Max + Ortho KP OR Adult Traditional 100 $1,000 Max KP OR Adult Traditional 100 $50 Ded/$1,000 Max KP OR Adult Traditional 100 $100 Ded/$1,000 Max KP OR Adult Traditional 100 $1,000 Max + Ortho KP OR Adult Traditional 100 $1,500 Max KP OR Adult Traditional 100 $50 Ded/$1,500 Max PPO adult-only plans KP OR Adult Choice 80 $50 Ded/$1,000 Max KP OR Adult Choice 80 $100 Ded/$1,000 Max KP OR Adult Choice 80 $1,000 Max + Ortho KP OR Adult Choice 100 $50 Ded/$1,000 Max KP OR Adult Choice 100 $100 Ded/$1,000 Max KP OR Adult Choice 100 $1,000 Max + Ortho KP OR Adult Choice 100 $50 Ded/$1,500 Max KP OR Adult Choice 100 $100 Ded/$1,500 Max KP OR Choice Ortho Pediatric Dental Plan KP OR Adult Traditional 100 $100 Ded/$1500 Max KP OR Adult Traditional 100 $1,500 Max + Ortho KP OR Adult Traditional 100 $2,000 Max KP OR Adult Traditional 100 $50 Ded/$2,000 Max KP OR Adult Traditional 100 $100 Ded/$2,000 Max KP OR Adult Traditional 100 $2,000 Max + Ortho KP OR Adult Traditional 100 $50 Ded/$2,500 Max KP OR Adult Traditional 100 $100 Ded/$2,500 Max KP OR Adult Traditional 100 $2,500 Max + Ortho KP OR Adult Choice 100 $1,500 Max + Ortho KP OR Adult Choice 100 $50 Ded/$2,000 Max KP OR Adult Choice 100 $100 Ded/$2,000 Max KP OR Adult Choice 100 $2,000 Max + Ortho KP OR Adult Choice 100 $50 Ded/$2,500 Max KP OR Adult Choice 100 $100 Ded/$2,500 Max KP OR Adult Choice 100 $2,500 Max + Ortho Dental EOC form numbers: EOSGEXPEDDNTPPO0117 EOSGOMPEDDNTPPO0117 EOSGOMDNTPPO0117 EOSGOMDNT0117 CHANGES AND CLARIFICATIONS THAT APPLY TO ALL SENIOR ADVANTAGE PLANS The Senior Advantage Standard Plan has been discontinued. Groups will be automatically mapped to the Senior Advantage Plan. The Senior Advantage Value Plan has been renamed Senior Advantage Plan, as there will be only one group Senior Advantage plan offered in The Senior Advantage plan now includes coverage for Alternative Care inclusive of chiropractic,* naturopathic,* and acupuncture* visits. *CHP network only. 15

16 BENEFIT CURRENT PLAN SENIOR ADVANTAGE STANDARD PLAN REPLACEMENT PLAN SENIOR ADVANTAGE PLAN Annual Out-of-Pocket Maximum $600 $1,000 Primary Care $10 $20 Urgent Care $15 $25 Specialty Care $10 $20 Routine Eye Exam $10 $20 Outpatient Therapies $10 $20 Outpatient Surgery $10 $50 Inpatient Hospital Care per admit $0 $200 Ambulance Services $50 $100 Mental Health Services Inpatient psychiatric care $0 $200 Mental Health Services Residential treatment $0 $100 Mental Health Services Outpatient/day treatment $10 $20 Chemical Dependency Services Inpatient care $0 $200 Chemical Dependency Services Residential treatment $0 $100 Chemical Dependency Services Outpatient/day treatment $10 $20 Infertility Services Diagnosis and treatment $10 $50 Alternative Care $10 referral needed $20 self-referred chiropractic*/ naturopathic*/acupuncture* $25 self-referred massage copay Outpatient Prescription Drugs 50%; up to $25 limit per prescription $20 generic; $40 brand Vision Hardware $150 allowance every 24 months $100 allowance every 2-year period Maternity Care Inpatient $0 $200 *CHP network only. account.kp.org _NW-OR_11/ Kaiser Foundation Health Plan of the Northwest