MEDICAL PLANS OVERVIEW FOR OREGON SMALL BUSINESSES

Transcription

1 MEDICAL PLANS OVERVIEW FOR OREGON SMALL BUSINESSES OREGON 2018 SMALL BUSINESS with 1 50 eligible employees. For coverage on or after January 1, Why choose Kaiser Permanente ONLINE ACCESS ANYTIME, ANYWHERE: Through kp.org, members have access to information and tools to better manage their health. Use it 24 hours a day, 7 days a week. Access medical records doctor (no charge) Schedule routine appointments Refill most prescriptions Check lab results Kaiser Permanente mobile app Digital identification card Video or phone appointments MEMBER DISCOUNTS: kp.org/choosehealthy CHP Active and Healthy offers members discounted access to recreational, cultural, fitness and wellness-centered businesses, retail services, equipment, instruction, memberships, and tickets both regionally and nationally. CHP Active and Healthy Fitness club discounts Alternative and chiropractic care Vitamins and supplements TOOLS FOR EMPLOYERS: businessnet.kp.org These online services can help make your job easier. Online account management Benefit summaries Forms Occupational health View and print group agreements (contracts) INTEGRATED CARE UNDER 1 ROOF Doctors Dentists Labs and imaging services Pharmacy Vision services Electronic medical records QUALITY CARE With our commitment to quality care, we make it easier for you to stay healthy and feel your best. Coordinated teamwork, combined with expertise, helps make our doctors, nurses, and specialists better informed to provide the best care for your needs. GIVE US A CALL OR TALK TO YOUR BROKER We can answer your questions about medical coverage, eligibility, plan design, or renewal. Please contact us or your broker if you would like a booklet with more details about our plans and options. Portland area Toll free TTY Language interpretation services Fax FACILITIES AND SERVICES: kp.org/facilities Members have their choice of primary care doctors and specialists when they need them, at convenient locations. 34 medical offices 20 dental offices The Portland Clinic (6 locations) 6 Urgent Care locations 24-hour advice nurses Health coach services account.kp.org _SBG_04-18 All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest. 500 NE Multnomah St., Suite 100, Portland, OR

2 It starts with a plan All our plans give your employees what they need to help them be healthier and more productive every day prevention, health promotion, and care for ongoing health conditions. That s what we mean by a better way to take care of your business. You have lots of choices, from traditional HMOs to consumer-directed options to out-of-area coverage to dental coverage. Here s a quick overview of what we offer. For plan specifics, contact your Kaiser Permanente representative. Traditional copay plan Predictable copays and out-of-pocket maximums make it easier for employees to manage their health care spending and give them financial peace of mind. You ll appreciate the variety of copay options. Deductible plans Added Choice plans You ll get more options at an affordable cost. With the addition of an employee out-of-pocket cost, monthly payments are lower than for traditional HMO plans, so you ll be able to reduce premiums while still maintaining quality care and access to our physicians for your employees. Provide flexibility. An Added Choice plan gives your employees the opportunity to access care from their current doctor or have the option of seeing any licensed provider for covered services. HSA and HRA options Offer lower premiums than other plan types, plus tax savings.* With our HSA-qualified deductible plans and deductible plans with HRA, your employees will have more control over their health care dollars, helpful online decision-support tools, and the same high-value access to services as members of our traditional HMO plans. Out-of-area An indemnity coverage solution for employees who live or work outside the Kaiser Permanente and PHCS service areas. It provides first-dollar coverage for doctor s office visits and no-cost preventive care delivered by any licensed provider. Kaiser Permanente Senior Advantage plans Dental plans Provides your retirees over 65 with the benefits of Medicare Advantage. Our traditional dental plan allows you to choose from a wide range of options and mix and match deductibles or office visit copays for any plan combination. Our Dental Choice PPO is designed for flexibility and choice while providing comprehensive coverage, allowing members to see any dentist. Please contact your Kaiser Permanente representative for help building your health care strategy. *The tax references relate to federal income tax only. Consult with your financial or tax advisor for information about state income tax laws.

3 The right plan for your business Choosing a health plan that s right for your business is now easier than ever! You have the ability to customize a medical plan with vision hardware and eye exam and/or alternative care benefit options, based on your company s needs and budget. Follow the steps below and create a plan that will help you and your business thrive. STEP 1: CHOOSE YOUR MEDICAL PLAN(S) (See pages 4 to 10 for plan details) Traditional plans KP OR Platinum 0/20 KP OR Gold 0/30 Deductible plans KP OR Platinum 250/20 KP OR Gold 500/20 KP OR Gold 1000/20 KP Oregon Standard Gold Plan KP OR Gold 1500/35 KP OR Silver 2000/40 KP Oregon Standard Silver Plan KP OR Silver 3500/40 KP OR Bronze 5000/50 KP OR Bronze 6600/40 HSA-qualified High Deductible Health Plans KP OR Silver 2700/25% HSA KP OR Bronze 5200/20 HSA KP Oregon Standard Bronze HSA Plan Added Choice deductible plans 1 KP OR Platinum 250/10 3T POS KP OR Platinum 250/10 3T POS OOA 2 KP OR Gold 600/35 3T POS KP OR Gold 600/35 3T POS OOA 2 KP OR Gold 1000/35 3T POS KP OR Gold 1000/35 3T POS OOA 2 KP OR Silver 2500/40 3T POS KP OR Silver 2500/40 3T POS OOA 2 1 If you have employees who both live and work outside our service area, we may be able to set them up on an Added Choice plan. Rates and approval subject to underwriting. 2 POS OOA plans: Groups must meet underwriting requirements to purchase. STEP 2: CHOOSE YOUR OPTIONAL BUY-UP COVERAGE All our medical plans, with the exception of the Oregon Standard plans, can be paired with any of the following buy-up options when purchased directly through Kaiser Permanente: A. Vision: Adult vision hardware ($200 benefit/2-year period) with adult vision exam (primary care office visit cost share applies). B. Alternative Care: Chiropractic, naturopathic, acupuncture ($20/visit) and massage therapy ($25/visit, 12 visits per year), with a combined $1,000 benefit maximum. C. Vision + Alternative Care: Bundle of Option A and B above. STEP 3: APPLY OR RENEW YOUR COVERAGE New groups: Complete the Oregon Small Business employer application and submit it to a Kaiser Permanente sales executive by the 20th of the month prior to the effective date. Renewing groups: If you would like to elect 1 of these options, please indicate your selection on the Renewal Decision Form and return to your Kaiser Permanente account manager no later than the 15th of the month prior to your anniversary date. We will provide you with coverage options that best match the plan(s) your business offers today, but you can choose from any of our other plans available to small employers if you prefer.

4 OREGON PLAN COMPARISON Traditional plans Deductible plans PLAN NAME KP OR PLATINUM 0/20 KP OR GOLD 0/30 KP OR PLATINUM 250/20 KP OR GOLD 500/20 KP OR GOLD 1000/20 KP OREGON STANDARD GOLD PLAN DEDUCTIBLE PER MEMBER DEDUCTIBLE PER FAMILY $0 $0 $250 $500 $1,000 $1,000 $0 $0 $500 $1,000 $2,000 $2,000 OUT-OF-POCKET MAXIMUM PER MEMBER $3,000 $5,250 $2,000 $5,850 $6,000 $6,850 OUT-OF-POCKET MAXIMUM PER FAMILY $6,000 $10,500 $4,000 $11,700 $12,000 $13,700 BENEFIT PRIMARY CARE $20 $30 $20 $20 $20 $20 URGENT CARE $40 $50 $40 $40 $40 $60 PREVENTIVE CARE $0 $0 $0 $0 $0 $0 PRENATAL CARE $0 $0 $0 $0 $0 20% SPECIALTY CARE $30 $40 $30 $30 $30 $40 OUTPATIENT SURGERY $100 35% 10% 20% 20% 20% LAB VISITS $20 $30 $10 $20 $20 20% X-RAYS AND SPECIAL DIAGNOSTIC PROCEDURES $20 $30 $10 $20 $20 20% CT, MRI, AND PET SCANS $75 $300 $75 $300 $300 20% EMERGENCY CARE $150 $300 10% 20% 20% 20% INPATIENT HOSPITAL CARE $300/day, $1,500 per admit $500/day, $2,500 per admit 10% 20% 20% 20% OUTPATIENT THERAPIES (UP TO 30 VISITS PER YEAR) $30 $40 $30 $30 $30 $20 PRESCRIPTION DRUGS (30-DAY SUPPLY) $5 generic $15 preferred $50 non-preferred $15 generic $30 preferred $5 generic $15 preferred $50 non-preferred $15 generic $30 preferred $20 preferred $30 preferred 50% non-preferred

5 This is a high-level overview and plan comparison of the most frequently asked-about benefits within our plan offerings. Deductible plans KP OR GOLD 1500/35 KP OR SILVER 2000/40 KP OREGON STANDARD SILVER PLAN KP OR SILVER 3500/40 KP OR BRONZE 5000/50 KP OR BRONZE 6600/40 $1,500 $2,000 $2,500 $3,500 $5,000 $6,600 $3,000 $4,000 $5,000 $7,000 $10,000 $13,200 $6,000 $7,350 $7,350 $7,350 $7,150 $7,150 $12,000 $14,700 $14,700 $14,700 $14,300 $14,300 $35 $40 $40 $40 $50 First 3 visits per year at $40 not subject to the deductible, remaining visits at 50% coinsurance after deductible $55 $50 $70 $70 30% $100 $0 $0 $0 $0 $0 $0 $0 $0 30% $0 $0 $0 $45 $50 $80 $50 $60 50% 20% 30% 30% 30% 30% 50% $40 $40 30% $40 30% 50% $40 $40 30% $40 30% 50% $300 30% 30% 30% 30% 50% 20% 30% 30% 30% 30% 50% 20% 30% 30% 30% 30% 50% $45 $50 $40 $50 $60 50% $20 preferred $30 generic $50 preferred 30% non-preferred $15 generic $60 preferred 50% non-preferred $30 generic $50 preferred 30% non-preferred (subject to $700 drug deductible) $25 generic $60 preferred 50% non-preferred (subject to $400 drug deductible) $30 generic 30% preferred 50% non-preferred Offered only outside health insurance exchange.

6 OREGON PLAN COMPARISON PLAN NAME DEDUCTIBLE PER MEMBER DEDUCTIBLE PER FAMILY OUT-OF-POCKET MAXIMUM PER MEMBER OUT-OF-POCKET MAXIMUM PER FAMILY BENEFITS PRIMARY CARE URGENT CARE PREVENTIVE CARE PRENATAL CARE SPECIALTY CARE OUTPATIENT SURGERY LAB VISITS X-RAYS AND SPECIAL DIAGNOSTIC PROCEDURES CT, MRI, AND PET SCANS EMERGENCY CARE INPATIENT HOSPITAL CARE OUTPATIENT THERAPIES (UP TO 30 VISITS PER YEAR) Added Choice /deductible point-of-service plans KP OR PLATINUM 250/10 3T POS KP OR GOLD 600/35 3T POS Tier 1 Tier 2 Tier 3 Tier1 Tier 2 Tier 3 $250 $500 $750 $600 $1,800 $4,500 $500 $1,000 $1,500 $1,200 $3,600 $9,000 $2,000 $3,000 $6,000 $2,500 $6,000 $8,000 $4,000 $6,000 $12,000 $5,000 $12,000 $16,000 $10 $25 35% $35 $60 50% $40 $55 35% $60 $80 50% $0 $0 35% $0 $0 50% $0 $0 35% $0 $0 50% $20 $35 35% $45 $70 50% 10% 25% 35% 30% 50% 50% 10% 25% 35% $35 40% 50% $10 $25 35% 30% 40% 50% $100 25% 35% $200 50% 50% $100 after deductible 30% 10% 25% 35% 30% 50% 50% $20 $35 35% $45 $70 50% PRESCRIPTION DRUGS (30-DAY SUPPLY) $20 preferred $50 non-preferred $15 generic $30 preferred 50% non-preferred $20 preferred $25 generic $75 preferred 50% non-preferred Offered only outside health insurance exchange.

7 This is a high-level overview and plan comparison of the most frequently asked-about benefits within our plan offerings. Added Choice /deductible point-of-service plans KP OR GOLD 1000/35 3T POS KP OR SILVER 2500/40 3T POS Tier 1 Tier 2 Tier 3 Tier 1 Tier 2 Tier 3 $1,000 $2,000 $6,000 $2,500 $4,500 $6,500 $2,000 $4,000 $12,000 $5,000 $9,000 $13,000 $3,000 $5,000 $9,000 $6,500 $7,350 $12,500 $6,000 $10,000 $18,000 $13,000 $14,700 $25,000 $35 $60 50% $40 $60 50% $75 $100 50% $55 $75 50% $0 $0 50% $0 $0 50% $0 $0 50% $0 $0 50% $45 $70 50% $50 $70 50% 25% 40% 50% 30% 40% 50% $35 40% 50% $40 40% 50% $35 40% 50% $40 40% 50% $200 40% 50% 30% 40% 50% 25% 30% 25% 40% 50% 30% 40% 50% $45 $70 50% $50 $70 50% $20 preferred $25 generic $75 preferred 50% non-preferred $30 generic $40 preferred $50 non-preferred $30 generic $60 preferred 50% non-preferred Offered only outside health insurance exchange.

8 OREGON PLAN COMPARISON PLAN NAME KP OR SILVER 2700/25% HSA HSA-qualified high deductible plans KP OR BRONZE 5200/20 HSA KP OREGON STANDARD BRONZE HSA PLAN Senior Advantage plan* SENIOR ADVANTAGE PLAN DEDUCTIBLE PER MEMBER DEDUCTIBLE PER FAMILY $2,700 $5,200 $6,550 $0 $5,400 $10,400 $13,100 $0 OUT-OF-POCKET MAXIMUM PER MEMBER $5,400 $6,550 $6,550 $1,000 OUT-OF-POCKET MAXIMUM PER FAMILY $10,800 $13,100 $13,100 N/A BENEFITS PRIMARY CARE 25% $20 0% $20 URGENT CARE 25% 50% 0% $25 PREVENTIVE CARE 0% 0% $0 $0 PRENATAL CARE 0% 0% 0% $0 SPECIALTY CARE 25% $30 0% $20 OUTPATIENT SURGERY 25% 50% 0% $50 LAB VISITS 25% 50% 0% $0 X-RAYS AND SPECIAL DIAGNOSTIC PROCEDURES 25% 50% 0% $0 CT, MRI, AND PET SCANS EMERGENCY CARE INPATIENT HOSPITAL CARE 25% 50% 0% $0 25% 50% 0% $50 25% 50% 0% $200/admit OUTPATIENT THERAPIES (UP TO 30 VISITS PER YEAR) 25% $30 0% $20 PRESCRIPTION DRUGS (30-DAY SUPPLY) $20 generic $40 preferred 30% non-preferred $20 generic 50% preferred 50% non-preferred 0% 0% preferred 0% non-preferred 0% specialty $20 generic $40 preferred and specialty $3 generic/$7 preferred after TrOOP ($5,000) * Senior Advantage plan cannot be modified. The Senior Advantage plan now includes coverage for alternative care: $20 self-referred chiropractic/naturopathic/acupuncture (CHP network only) and $25 self-referred massage copay. Self-referred massage is limited to 12 visits per calendar year. There is a $1,000 limit per calendar year on all alternative care services.

9 This is a high-level overview and plan comparison of the most frequently asked-about benefits within our plan offerings. Added Choice /deductible point-of-service plans for members outside the KPNW service area KP OR PLATINUM 250/10 3T POS OOA KP OR GOLD 600/35 3T POS OOA Tier 1 Tier 2 Tier 3 Tier 1 Tier 2 Tier 3 $250 $250 $750 $600 $600 $4,500 $500 $500 $1,500 $1,200 $1,200 $9,000 $2,000 $2,000 $6,000 $2,500 $4,500 $8,000 $4,000 $4,000 $12,000 $5,000 $9,000 $16,000 $10 $10 35% $35 $35 50% $40 $40 35% $60 $60 50% $0 $0 35% $0 $0 50% $0 $0 35% $0 $0 50% $20 $20 35% $45 $45 50% 10% 10% 35% 30% 30% 50% 10% 10% 35% $35 $35 50% $10 $10 35% 30% 30% 50% $100 $100 35% $200 $200 50% $100 30% 10% 10% 35% 30% 30% 50% $20 $20 35% $45 $45 50% $20 preferred $50 non-preferred $20 preferred $50 non-preferred $20 preferred $20 preferred Offered only outside health insurance exchange.

10 OREGON PLAN COMPARISON This is a high-level overview and plan comparison of the most frequently asked-about benefits within our plan offerings. PLAN NAME KP OR GOLD 1000/35 3T POS OOA KP OR SILVER 2500/40 3T POS OOA Tier 1 Tier 2 Tier 3 Tier 1 Tier 2 Tier 3 DEDUCTIBLE PER MEMBER $1,000 $1,000 $6,000 $2,500 $2,500 $5,000 DEDUCTIBLE PER FAMILY $2,000 $2,000 $12,000 $5,000 $5,000 $10,000 OUT-OF-POCKET MAXIMUM PER MEMBER $3,500 $3,500 $9,000 $6,500 $7,150 $12,000 OUT-OF-POCKET MAXIMUM PER FAMILY $7,000 $7,000 $18,000 $13,000 $14,300 $24,000 BENEFITS PRIMARY CARE $35 $35 50% $40 $40 50% URGENT CARE $75 $75 50% $55 $55 50% PREVENTIVE CARE $0 $0 50% $0 $0 50% PRENATAL CARE $0 $0 50% $0 $0 50% SPECIALTY CARE $45 $45 50% $50 $50 50% OUTPATIENT SURGERY 30% 30% 50% 40% 40% 50% LAB VISITS $35 $35 50% 40% 40% 50% X-RAYS AND SPECIAL DIAGNOSTIC PROCEDURES $35 $35 50% 40% 40% 50% CT, MRI, PET SCANS $300 $300 50% 40% 40% 50% EMERGENCY CARE 30% 40% INPATIENT HOSPITAL CARE 30% 30% 50% 40% 40% 50% OUTPATIENT THERAPIES (UP TO 30 VISITS PER YEAR) $45 $45 50% $50 $50 50% PRESCRIPTION DRUGS (30-DAY SUPPLY) $20 preferred $20 preferred $20 generic $40 preferred $50 non-preferred $20 generic $40 preferred $50 non-preferred Offered only outside health insurance exchange.

11 BUNDLED PLAN OPTIONS WHEN YOU PURCHASE COVERAGE OUTSIDE THE HEALTH INSURANCE EXCHANGE You can offer 2 or 3 medical plans in a bundle, with the following limitations: Only 1 traditional plan per bundle Only 1 Added Choice plan per bundle Once you select your plan offerings, employees choose the plan that best meets their needs. PLAN HIGHLIGHTS Out-of-pocket maximum: All benefits displayed accumulate to the out-of-pocket maximum. Pediatric benefits: All plans include pediatric vision exams at $0 and pediatric vision hardware at no charge for 1 pair of standard frames from a selected list or 6-month supply of contact lenses per calendar year. Pediatric dental coverage is required, and we offer a choice of 3 different plans (please see the dental brochure). Standard plans: All plans noted as Standard have been designed by the state of Oregon and are required to be offered. ADULT VISION BENEFITS Vision exam: Covered at primary office visit cost share when buy-up option purchased. Hardware benefit: Vision hardware allowance of $200 every 2-year period for ages 19 and older. SELF-REFERRED ALTERNATIVE CARE Alternative care coverage up to $1,000 maximum ($20 copay, except massage is $25 with a 12-visit limit) per enrolled member. Plans offered outside the health insurance exchange come with or without these benefits (excluding all Standard plans). If you would like to select a buy-up option to pair with your medical plan, please refer to the section titled Buy-up Options and select 1 of the 3 options available. DOMESTIC PARTNER COVERAGE (SAME AND OPPOSITE SEX) Employers may elect to include opposite-sex domestic partners as eligible dependents. Same-sex coverage is offered on all small group contracts in compliance with state laws. EXPLANATION OF ADDED CHOICE BENEFITS Tier 1 services, in most cases, are provided by select providers and select facilities. The Evidence of Coverage provides a complete definition of select providers and select facilities and explains when Tier 1 services are provided by other providers and facilities. Tier 2 services are provided by PPO providers and facilities. Refer to the Evidence of Coverage for a complete definition of PPO providers and facilities. Tier 3 in a 3-tier plan covers services provided by nonparticipating providers and facilities. Refer to the Evidence of Coverage for a complete definition of non-participating providers and facilities. Deductible and out-of-pocket maximum amounts crossaccumulate between Tiers 1 and 2. There is a separate deductible and out-of-pocket maximum amount in Tier 3, which does not accumulate across any other tiers. IMPORTANT INFORMATION Contact your sales executive or account manager to get more information about health plans for small businesses. Our written material covers: Rates and factors that affect rates and rate adjustments Renewing coverage Geographic areas Underwriting guidelines This brochure provides summaries of various plans and is not a contract. These plans are subject to exclusions and limitations. Plan details, including all benefits, exclusions, and limitations, are provided in the Evidence of Coverage (EOC). For specific plan information about the plans referred to in this brochure, see the following forms: EOSGTRAD0118 EOSGDED0118 EOSG3TPOSDED0118 EOSGHDHP0118 EOSGDEDSTD0118 EOSGHDHPSTD0118 To obtain an EOC for a particular plan, call the Client Services Unit at

12 _SBG_ Kaiser Foundation Health Plan of the Northwest