Kaiser Foundation Health Plan, Inc. Northern California: High Option

Kaiser Foundation Health Plan, Inc. Northern California: High Option 01/01/2015-12/31/2015 This is only a summary. Please read the FEHB Plan brochure (RI 73-003) that contains the complete terms of this plan. All benefits are subject to the definitions, limitations, and exclusions set forth in the FEHB Plan brochure. Benefits may vary if you have other coverage, such as Medicare. You can get the FEHB Plan brochure at kp.org/feds or by calling 1-800-278-3296. Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? $0 per person $0 per family $0 $1,500 per person $3,000 per family Premiums, payments for health care this plan doesn't cover and other services outlined in plan documents. No Yes. For a list of Plan providers, see kp.org/feds or call 1-800-278-3296. Yes Yes You must pay all the costs up to the deductible amount before this plan begins to pay for certain covered services you use. Copayments and coinsurance amounts do not count toward your deductible, which generally starts over January 1st. When a covered service or supply is subject to a deductible, only the Plan allowance for the service or supply counts toward the deductible. See the chart starting on page 2 for how much you pay for covered services after you meet the deductible and for which services are subject to the deductible. You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. The out-of-pocket limit, or catastrophic maximum, is the most you could pay during the year for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the out-of-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-ofnetwork provider for some services. We use the term Plan, for providers in our network. See the chart starting on page 2 for how this plan pays different kinds of providers. This plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan's permission before you see the specialist. Some of the services this plan doesn t cover are listed on page 5. See this plan s FEHB brochure for additional information about excluded services. 1 of 8 You can view the Glossary at kp.org/feds or call 1-800-278-3296 to request a copy. 60266420

Kaiser Foundation Health Plan, Inc. Northern California: High Option Common Medical Event 01/01/2015-12/31/2015 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts. If you visit a health care provider s office or clinic If you have a test If you need drugs to treat your illness or condition More information about prescription drug coverage is available at kp.org/ formulary. Services You May Need Your Cost If You Use a Plan Your Cost If You Use a Non- Plan (plus you may be balance billed) Primary care visit to treat an injury or illness $15 per visit ---none--- Specialist visit $25 per visit ---none--- Other practitioner office visit $15 per visit for chiropractor Preventive care/screening/immunization No charge ---none--- Diagnostic test (x-ray, blood work) No charge ---none--- Imaging (CT/PET scans, MRIs) No charge ---none--- $10 copayment (retail); Generic drugs $20 copayment (mail order) Brand-name drugs Non-formulary brand-name drugs $30 copayment (retail); $60 copayment (mail order) $30 copayment (retail); $60 copayment (mail order) Limitations & Exceptions Up to 20 visits per calendar year. Up to a 30-day supply (retail); Up to a 100- day supply through mail order pharmacy. Up to a 30-day supply (retail); Up to a 100- day supply through mail order pharmacy. Requires approved formulary exception. 2 of 8 You can view the Glossary at kp.org/feds or call 1-800-278-3296 to request a copy. 60266420

Kaiser Foundation Health Plan, Inc. Northern California: High Option 01/01/2015-12/31/2015 Common Medical Event If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs If you are pregnant Services You May Need Specialty drugs Your Cost If You Use a Plan Cost share for generic, brand-name, or nonformulary brand-name drugs may apply Your Cost If You Use a Non- Plan (plus you may be balance billed) Limitations & Exceptions Follows the Generic, Brand-name, and Non-formulary brand-name Limitation & Exceptions. Facility fee (e.g., ambulatory surgery center) $50 per procedure ---none--- Physician/surgeon fees No charge ---none--- Emergency room services $100 per visit $100 per visit ---none--- Emergency medical transportation $50 per trip $50 per trip ---none--- Urgent care $15 per visit $15 per visit Non-Plan providers covered when outside a Kaiser Permanente service area. Facility fee (e.g., hospital room) $250 per admission ---none--- Physician/surgeon fee No charge ---none--- Mental/Behavioral health $15 per individual visit; outpatient services $7 per group visit ---none--- Mental/Behavioral health inpatient services $250 per admission ---none--- Substance use disorder $15 per individual visit; outpatient services $5 per group visit ---none--- Substance use disorder inpatient services $250 per admission ---none--- Prenatal and postnatal care No charge After the confirmation of pregnancy. Delivery and all inpatient services $250 per admission ---none--- 3 of 8 You can view the Glossary at kp.org/feds or call 1-800-278-3296 to request a copy. 60266420

Kaiser Foundation Health Plan, Inc. Northern California: High Option Common Medical Event If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Your Cost If You Use a Plan 01/01/2015-12/31/2015 Your Cost If You Use a Non- Plan (plus you may be balance billed) Limitations & Exceptions Home health care No charge ---none--- Rehabilitation services $15 per visit (outpatient); $250 per admission ---none--- (inpatient) Habilitation services $15 per visit (outpatient); $250 per admission (inpatient) Limited to services to maintain/improve skills or functioning at risk due to medical deficits. Skilled nursing care No charge Up to 100 days per benefit period. 20% coinsurance per Durable medical equipment item, except 50% Must be in accordance with KP DME coinsurance per external formulary guidelines. sexual dysfunction device Hospice service No charge Limited to diagnoses of a terminal illness with a life expectancy of twelve months or less. Eye exam No charge ---none--- Glasses Eye glasses are not covered. Dental check-up Dental care is not covered. Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check this plan s FEHB brochure for other excluded services.) Cosmetic surgery Dental care Eye glasses Long-term care Private-duty nursing Weight loss program 4 of 8 You can view the Glossary at kp.org/feds or call 1-800-278-3296 to request a copy. 60266420

Kaiser Foundation Health Plan, Inc. Northern California: High Option 01/01/2015-12/31/2015 Other Covered Services(This isn t a complete list. Check this plan's FEHB brochure for other covered services and your costs for these services.) Acupuncture (plan provider referred) Bariatric surgery Chiropractic care Hearing aids (child) Infertility treatment Non-emergency care when traveling outside the U.S. Routine eye care Routine foot care Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending on the circumstances, you may be eligible for a 31-day free extension of coverage, to convert to an individual policy, and to receive temporary continuation of coverage (TCC). Your TCC rights will be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. An individual policy may also provide different benefits than you had while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, see the FEHB Plan brochure, contact your HR office/retirement system, contact your plan at 1-800-278-3296 or visit www.opm.gov/healthcare-insurance. Your Appeal Rights: If you are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal. For information about your appeal rights please see Section 3, How you get care, and Section 8 The disputed claims process, in your plan's FEHB brochure. If you need assistance, you can contact: 1-800-278-3296. 5 of 8 You can view the Glossary at kp.org/feds or call 1-800-278-3296 to request a copy. 60266420

Kaiser Foundation Health Plan, Inc. Northern California: High Option 01/01/2015-12/31/2015 Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. Coverage under this plan qualifies as minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). The health coverage of this plan does meet the minimum value standard for the benefits the plan provides. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-800-788-0616 Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800- 523-1786 Chinese ( 中文 ): 如果需要中文的帮助, 请拨打这个号码 1-800-757-7585 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800- 523-1786 To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 8 You can view the Glossary at kp.org/feds or call 1-800-278-3296 to request a copy. 60266420

Kaiser Foundation Health Plan, Inc. Northern California: High Option 01/01/2015-12/31/2015 About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $7,040 Patient pays $500 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $0 Copays $300 Coinsurance $0 Limits or exclusions $200 Total $500 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $4,420 Patient pays $980 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $0 Copays $700 Coinsurance $200 Limits or exclusions $80 Total $980 7 of 8 You can view the Glossary at kp.org/feds or call 1-800-278-3296 to request a copy. 60266420

Kaiser Foundation Health Plan, Inc. Northern California: High Option 01/01/2015-12/31/2015 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. 8 of 8 You can view the Glossary at kp.org/feds or call 1-800-278-3296 to request a copy. 60266420

Kaiser Foundation Health Plan, Inc. Northern California: Standard Option 01/01/2015-12/31/2015 This is only a summary. Please read the FEHB Plan brochure (RI 73-003) that contains the complete terms of this plan. All benefits are subject to the definitions, limitations, and exclusions set forth in the FEHB Plan brochure. Benefits may vary if you have other coverage, such as Medicare. You can get the FEHB Plan brochure at kp.org/feds or by calling 1-800-278-3296. Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? $200 per person $400 per family $0 $2,000 per person $4,000 per family Premiums, payments for health care this plan doesn't cover and other services outlined in plan documents. No Yes. For a list of Plan providers, see kp.org/feds or call 1-800-278-3296. Yes Yes You must pay all the costs up to the deductible amount before this plan begins to pay for certain covered services you use. Copayments and coinsurance amounts do not count toward your deductible, which generally starts over January 1st. When a covered service or supply is subject to a deductible, only the Plan allowance for the service or supply counts toward the deductible. See the chart starting on page 2 for how much you pay for covered services after you meet the deductible and for which services are subject to the deductible. You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. The out-of-pocket limit, or catastrophic maximum, is the most you could pay during the year for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the out-of-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-ofnetwork provider for some services. We use the term Plan for providers in our network. See the chart starting on page 2 for how this plan pays different kinds of providers. This plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan's permission before you see the specialist. Some of the services this plan doesn t cover are listed on page 4. See this plan s FEHB brochure for additional information about excluded services. 1 of 8 You can view the Glossary at kp.org/feds or call 1-800-278-3296 to request a copy. 60266421

Kaiser Foundation Health Plan, Inc. Northern California: Standard Option 01/01/2015-12/31/2015 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need Your Cost If You Use a Plan Your Cost If You Use a Non- Plan (plus you may be balance billed) Limitations & Exceptions Primary care visit to treat an injury or illness $30 per visit Not subject to deductible. Specialist visit $40 per visit Not subject to deductible. Other practitioner office visit $15 per visit for chiropractor Up to 20 visits per calendar year. Not subject to deductible. Preventive care/screening/immunization No charge Not subject to deductible. Diagnostic test (x-ray, blood work) $10 per visit ---none--- Imaging (CT/PET scans, MRIs) $50 per procedure ---none--- 2 of 8 You can view the Glossary at kp.org/feds or call 1-800-278-3296 to request a copy. 60266421

Kaiser Foundation Health Plan, Inc. Northern California: Standard Option 01/01/2015-12/31/2015 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at kp.org/ formulary. If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Services You May Need Generic drugs Brand-name drugs Non-formulary brand-name drugs Specialty drugs Your Cost If You Use a Plan $15 copayment (retail) $30 copayment (mail order) $35 copayment (retail) $70 copayment (mail order) $35 copayment (retail) $70 copayment (mail order) Cost share for generic, brand-name, or nonformulary brand-name drugs may apply Your Cost If You Use a Non- Plan (plus you may be balance billed) Limitations & Exceptions Up to a 30-day supply (retail); Up to a 100- day supply through mail order pharmacy. Not subject to deductible. Up to a 30-day supply (retail); Up to a 100- day supply through mail order pharmacy. Requires approved formulary exception. Not subject to deductible. Follows the Generic, Brand-name, and Non-formulary brand-name Limitation & Exceptions. Facility fee (e.g., ambulatory surgery center) $200 per procedure ---none--- Physician/surgeon fees No charge ---none--- Emergency room services $150 per visit $150 per visit ---none--- Emergency medical transportation $150 per trip $150 per trip ---none--- Non-Plan providers covered when outside Urgent care $30 per visit $30 per visit a Kaiser Permanente service area. Not subject to deductible. Facility fee (e.g., hospital room) $500 per admission ---none--- Physician/surgeon fee No charge ---none--- 3 of 8 You can view the Glossary at kp.org/feds or call 1-800-278-3296 to request a copy. 60266421

Kaiser Foundation Health Plan, Inc. Northern California: Standard Option 01/01/2015-12/31/2015 Common Medical Event If you have mental health, behavioral health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Your Cost If You Use a Plan Your Cost If You Use a Non- Plan (plus you may be balance billed) Limitations & Exceptions Mental/Behavioral health $30 per individual visit; outpatient services $15 per group visit Not subject to deductible. Mental/Behavioral health inpatient services $500 per admission ---none--- Substance use disorder $30 per individual visit; outpatient services $5 per group visit Not subject to deductible. Substance use disorder inpatient services $500 per admission ---none--- Prenatal and postnatal care No charge After the confirmation of pregnancy. Not subject to deductible. Delivery and all inpatient services $500 per admission ---none--- Home health care No charge Not subject to deductible. $30 per visit (outpatient); Rehabilitation services $500 per admission ---none--- (inpatient) $30 per visit (outpatient); Limited to services to maintain/improve Habilitation services $500 per admission skills or functioning at risk due to medical (inpatient) deficits. Skilled nursing care No charge Up to 100 days per benefit period. Must be in accordance with KP DME 50% coinsurance per Durable medical equipment formulary guidelines. Not subject to item deductible. Hospice service No charge Limited to diagnoses of a terminal illness with a life expectancy of twelve months or less. Not subject to deductible. Eye exam No charge Not subject to deductible. Glasses Eye glasses are not covered. Dental check-up Dental care is not covered. 4 of 8 You can view the Glossary at kp.org/feds or call 1-800-278-3296 to request a copy. 60266421

Kaiser Foundation Health Plan, Inc. Northern California: Standard Option Excluded Services & Other Covered Services: 01/01/2015-12/31/2015 Services Your Plan Does NOT Cover (This isn t a complete list. Check this plan s FEHB brochure for other excluded services.) Cosmetic surgery Dental care Glasses Long-term care Private-duty nursing Weight loss program Other Covered Services (This isn t a complete list. Check this plan's FEHB brochure for other covered services and your costs for these services.) Acupuncture (plan provider referred) Bariatric surgery Chiropractic care Hearing aids (child) Infertility treatment Non-emergency care when traveling outside the U.S. Routine eye care Routine foot care Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending on the circumstances, you may be eligible for a 31-day free extension of coverage, to convert to an individual policy, and to receive temporary continuation of coverage (TCC). Your TCC rights will be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. An individual policy may also provide different benefits than you had while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, see the FEHB Plan brochure, contact your HR office/retirement system, contact your plan at 1-800-278-3296 or visit www.opm.gov/healthcare-insurance. Your Appeal Rights: If you are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal. For information about your appeal rights please see Section 3, How you get care, and Section 8 The disputed claims process, in your plan's FEHB brochure. If you need assistance, you can contact: 1-800-278-3296. 5 of 8 You can view the Glossary at kp.org/feds or call 1-800-278-3296 to request a copy. 60266421

Kaiser Foundation Health Plan, Inc. Northern California: Standard Option 01/01/2015-12/31/2015 Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. Coverage under this plan qualifies as minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). The health coverage of this plan does meet the minimum value standard for the benefits the plan provides. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-800-788-0616. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800- 523-1786 Chinese ( 中文 ): 如果需要中文的帮助, 请拨打这个号码 1-800-757-7585 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800- 523-1786 To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 8 You can view the Glossary at kp.org/feds or call 1-800-278-3296 to request a copy. 60266421

Kaiser Foundation Health Plan, Inc. Northern California: Standard Option 01/01/2015-12/31/2015 About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $6,540 Patient pays $1,000 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $200 Copays $600 Coinsurance $0 Limits or exclusions $200 Total $1,000 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $3,620 Patient pays $1,780 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $100 Copays $1,000 Coinsurance $600 Limits or exclusions $80 Total $1,780 7 of 8 You can view the Glossary at kp.org/feds or call 1-800-278-3296 to request a copy. 60266421

Kaiser Foundation Health Plan, Inc. Northern California: Standard Option 01/01/2015-12/31/2015 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. 8 of 8 You can view the Glossary at kp.org/feds or call 1-800-278-3296 to request a copy. 60266421

Kaiser Foundation Health Plan, Inc. Northern California: Basic Option 01/01/2015-12/31/2015 This is only a summary. Please read the FEHB Plan brochure (RI 73-003) that contains the complete terms of this plan. All benefits are subject to the definitions, limitations, and exclusions set forth in the FEHB Plan brochure. Benefits may vary if you have other coverage, such as Medicare. You can get the FEHB Plan brochure at kp.org/feds or by calling 1-800-278-3296. Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? $500 per person $1,000 per family $0 $5,500 per person $11,000 per family Premiums, payments for health care this plan doesn't cover and other services outlined in plan documents. No Yes. For a list of Plan providers, see kp.org/feds or call 1-800-278-3296. Yes Yes You must pay all the costs up to the deductible amount before this plan begins to pay for certain covered services you use. Copayments and coinsurance amounts do not count toward your deductible, which generally starts over January 1st. When a covered service or supply is subject to a deductible, only the Plan allowance for the service or supply counts toward the deductible. See the chart starting on page 2 for how much you pay for covered services after you meet the deductible and for which services are subject to the deductible. You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. The out-of-pocket limit, or catastrophic maximum, is the most you could pay during the year for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the out-of-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-ofnetwork provider for some services. We use the term Plan for providers in our network. See the chart starting on page 2 for how this plan pays different kinds of providers. This plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan's permission before you see the specialist. Some of the services this plan doesn t cover are listed on page 4. See this plan s FEHB brochure for additional information about excluded services. 1 of 8 You can view the Glossary at kp.org/feds or call 1-800-278-3296 to request a copy. 60266518

Kaiser Foundation Health Plan, Inc. Northern California: Basic Option 01/01/2015-12/31/2015 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need Your Cost If You Use a Plan Your Cost If You Use a Non- Plan (plus you may be balance billed) Limitations & Exceptions Primary care visit to treat an injury or illness $25 per visit Not subject to deductible. Specialist visit $35 per visit Not subject to deductible. Other practitioner office visit $15 per visit for chiropractor Preventive care/screening/immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) Up to 20 visits per calendar year. Not subject to deductible. No charge Not subject to deductible. 20% coinsurance per visit ---none--- 20% coinsurance per procedure ---none--- 2 of 8 You can view the Glossary at kp.org/feds or call 1-800-278-3296 to request a copy. 60266518

Kaiser Foundation Health Plan, Inc. Northern California: Basic Option 01/01/2015-12/31/2015 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at kp.org/ formulary. If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Services You May Need Generic drugs Brand-name drugs Non-formulary brand-name drugs Specialty drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room services Emergency medical transportation Your Cost If You Use a Plan $15 copayment (retail) $30 copayment (mail order) $35 copayment (retail) $70 copayment (mail order) $35 copayment (retail) $70 copayment (mail order) Cost share for generic, brand-name, or nonformulary brand-name drugs may apply 20% coinsurance per procedure 20% coinsurance per procedure 20% coinsurance per visit 20% coinsurance per trip Your Cost If You Use a Non- Plan (plus you may be balance billed) 20% coinsurance per visit 20% coinsurance per trip Urgent care $25 per visit $25 per visit Facility fee (e.g., hospital room) Physician/surgeon fee 20% coinsurance per admission 20% coinsurance per admission Limitations & Exceptions Up to a 30-day supply (retail); Up to a 100-day supply through mail order pharmacy. Not subject to deductible. Up to a 30-day supply (retail); Up to a 100-day supply through mail order pharmacy. Requires approved formulary exception. Not subject to deductible. Follows the Generic, Brand-name, and Nonformulary brand-name Limitation & Exceptions. ---none--- ---none--- ---none--- ---none--- Non-Plan providers covered when outside a Kaiser Permanente service area. Not subject to deductible. ---none--- ---none--- 3 of 8 You can view the Glossary at kp.org/feds or call 1-800-278-3296 to request a copy. 60266518

Kaiser Foundation Health Plan, Inc. Northern California: Basic Option 01/01/2015-12/31/2015 Common Medical Event If you have mental health, behavioral health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs Services You May Need Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services Your Cost If You Use a Plan $25 per individual visit; $12 per group visit 20% coinsurance per admission $25 per individual visit; $5 per group visit 20% coinsurance per admission Your Cost If You Use a Non- Plan (plus you may be balance billed) Limitations & Exceptions Not subject to deductible. ---none--- Not subject to deductible. ---none--- Prenatal and postnatal care No charge After the confirmation of pregnancy. Not subject to deductible. Delivery and all inpatient 20% coinsurance per services admission ---none--- Home health care No charge Not subject to deductible. $25 per visit (outpatient); Rehabilitation services 20% coinsurance per ---none--- admission (inpatient) Habilitation services Skilled nursing care $25 per visit (outpatient); 20% coinsurance per admission (inpatient) 20% coinsurance per admission Durable medical equipment 50% coinsurance per item Hospice service No charge Limited to services to maintain/improve skills or functioning at risk due to medical deficits. Up to 100 days per benefit period. Must be in accordance with KP DME formulary guidelines. Not subject to deductible. Limited to diagnoses of a terminal illness with a life expectancy of twelve months or less. Not subject to deductible. 4 of 8 You can view the Glossary at kp.org/feds or call 1-800-278-3296 to request a copy. 60266518

Kaiser Foundation Health Plan, Inc. Northern California: Basic Option Common Medical Event If your child needs dental or eye care Services You May Need Your Cost If You Use a Plan 01/01/2015-12/31/2015 Your Cost If You Use a Non- Plan (plus you may be balance billed) Limitations & Exceptions Eye exam No charge Not subject to deductible. Glasses Eye glasses are not covered. Dental check-up Dental care is not covered. Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check this plan s FEHB brochure for other excluded services.) Cosmetic surgery Dental care Glasses Long-term care Private-duty nursing Weight loss program Other Covered Services (This isn t a complete list. Check this plan's FEHB brochure for other covered services and your costs for these services.) Acupuncture (plan provider referred) Bariatric surgery Chiropractic care Hearing aids (child) Infertility treatment Non-emergency care when traveling outside the U.S. Routine eye care Routine foot care Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending on the circumstances, you may be eligible for a 31-day free extension of coverage, to convert to an individual policy, and to receive temporary continuation of coverage (TCC). Your TCC rights will be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. An individual policy may also provide different benefits than you had while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, see the FEHB Plan brochure, contact your HR office/retirement system, contact your plan at 1-800-278-3296 or visit www.opm.gov/healthcare-insurance. 5 of 8 You can view the Glossary at kp.org/feds or call 1-800-278-3296 to request a copy. 60266518

Kaiser Foundation Health Plan, Inc. Northern California: Basic Option 01/01/2015-12/31/2015 Your Appeal Rights: If you are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal. For information about your appeal rights please see Section 3, How you get care, and Section 8 The disputed claims process, in your plan's FEHB brochure. If you need assistance, you can contact: 1-800-278-3296. Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. Coverage under this plan qualifies as minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). The health coverage of this plan does meet the minimum value standard for the benefits the plan provides. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-800-788-0616. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800- 523-1786 Chinese ( 中文 ): 如果需要中文的帮助, 请拨打这个号码 1-800-757-7585 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800- 523-1786 To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 8 You can view the Glossary at kp.org/feds or call 1-800-278-3296 to request a copy. 60266518

Kaiser Foundation Health Plan, Inc. Northern California: Basic Option 01/01/2015-12/31/2015 About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $5,520 Patient pays $2,020 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $500 Copays $20 Coinsurance $1,300 Limits or exclusions $200 Total $2,020 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $3,720 Patient pays $1,680 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $100 Copays $900 Coinsurance $600 Limits or exclusions $80 Total $1,680 7 of 8 You can view the Glossary at kp.org/feds or call 1-800-278-3296 to request a copy. 60266518

Kaiser Foundation Health Plan, Inc. Northern California: Basic Option 01/01/2015 - Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. 12/31/2015 Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. 8 of 8 You can view the Glossary at kp.org/feds or call 1-800-278-3296 to request a copy. 60266518

Glossary of Health Coverage and Medical Terms This glossary has many commonly used terms, but isn t a full list. These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan. Some of these terms also might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan governs. (See your for information on how to get a copy of your policy or plan document.) Bold blue text indicates a term defined in this Glossary. See page 4 for an example showing how deductibles, co-insurance and out-of-pocket limits work together in a real life situation. Allowed Amount Maximum amount on which payment is based for covered health care services. This may be called eligible expense, payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.) Appeal A request for your health insurer or plan to review a decision or a grievance again. Balance Billing When a provider bills you for the difference between the provider s charge and the allowed amount. For example, if the provider s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services. Co-insurance Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. Jane pays Her plan pays You pay co-insurance 20% 80% plus any deductibles (See page 4 for a detailed example.) you owe. For example, if the health insurance or plan s allowed amount for an office visit is $100 and you ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount. Co-payment A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service. Deductible The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won t pay anything until you ve met Jane pays 100% Her plan pays 0% (See page 4 for a detailed example.) your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services. Durable Medical Equipment (DME) Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics. Emergency Medical Condition An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm. Emergency Medical Transportation Ambulance services for an emergency medical condition. Complications of Pregnancy Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a nonemergency caesarean section aren t complications of pregnancy. Emergency Room Care Emergency services you get in an emergency room. Emergency Services Evaluation of an emergency medical condition and treatment to keep the condition from getting worse. OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 Glossary of Health Coverage and Medical Terms Page 1 of 4