MMC Benefits Handbook
The Medical Plan Options at a Glance
The chart below outlines some important Plan features and coverage information that distinguish the two medical plan options available only to residents of California (CA), Colorado (CO), Georgia (GA), Maryland (MD), Virginia (VA), Oregon (OR), Washington (WA) and Washington D.C. (DC). Additional information is provided throughout this section of the Benefits Handbook, as well as in the Kaiser Permanente Evidence of Coverage available on Colleague Connect (https://mmcglobal.sharepoint.com/sites/home). Select Pay & Benefits, under Find a document, select Search all documents.
Please note: The Evidence of Coverage is the binding document between Kaiser Permanente and its members. A Plan physician must determine that the services and supplies are medically necessary to prevent, diagnose, or treat your medical condition. The services and supplies must be provided, prescribed, authorized, or directed by a Plan physician. You must receive the services and supplies at a Plan facility or skilled nursing facility inside our Service Area, except where specifically noted to the contrary in the Evidence of Coverage. For details on the benefit and claims review and adjudication procedures, please refer to Kaiser Permanente's Evidence of Coverage. If there are any discrepancies between benefits included in this Benefits Handbook section and the Evidence of Coverage (EOC), the EOC will govern.
For example: If you are enrolled with family coverage in the $1,600 Deductible Plan in California, your individual deductible will be limited to $3,200 ($3,200 for other regions) and your individual out-of-pocket maximum will be limited to $3,200 ($6,400 in other locations). Please refer to Kaiser Permanente's Evidence of Coverage available on Colleague Connect, for additional details.
|
Plan feature
|
$1,600 Deductible Plan1,6
|
$3,200 Deductible Plan1,6
|
||
|
Deductible
|
Employee: $1,600
Family2: $3,2004
|
Employee: $3,200
Family2: $6,4003
|
||
|
Out-of-pocket maximum
(including deductible)
|
Employee: $3,200
Family2: $6,4004
|
Employee: $5,900
Family2: $11,8003
|
||
|
Coverage levels
|
80% coinsurance after deductible
|
70% coinsurance after deductible
|
||
|
Physician office visits
|
||||
|
Primary Care Physician (PCP)/Specialist Visit
|
80% coinsurance after deductible
|
70% coinsurance after deductible
|
||
|
Specialist Visit
|
80% coinsurance after deductible
|
70% coinsurance after deductible
|
||
|
Hospital Facility
|
||||
|
Inpatient
|
80% coinsurance after deductible
|
70% coinsurance after deductible
|
||
|
Outpatient
|
80% coinsurance after deductible
|
70% coinsurance after deductible
|
||
|
Emergency Room (waived if admitted)
|
80% coinsurance after deductible
|
70% coinsurance after deductible
|
||
|
Prescription drugs
|
There is a pharmacy network for retail and mail order Prescription drugs. Prescriptions are purchased through Kaiser Permanente. There is a pharmacy located in most Kaiser Permanente medical centers.
|
|||
|
Retail Prescriptions5
(30-day supply)
|
||||
|
80% coinsurance after deductible
|
70% coinsurance after deductible
|
|||
|
80% coinsurance after deductible
|
70% coinsurance after deductible
|
|||
|
80% coinsurance after deductible
|
70% coinsurance after deductible
|
|||
|
Mail-order Prescriptions5
(90-day supply)
|
||||
|
80% coinsurance after deductible
|
70% coinsurance after deductible
|
|||
|
80% coinsurance after deductible
|
70% coinsurance after deductible
|
|||
|
80% coinsurance after deductible
|
70% coinsurance after deductible
|
|||
|
Contact Information
|
Contact for Medical and Prescription Drug Services:
Kaiser Permanente (Claims Administrator)
See the Kaiser Claims Administrator chart for address information.
Kaiser Customer Service: See the phone numbers listed by region below.
Website: www.kp.org.
Marsh McLennan does not administer claims under this plan. For medical and prescription drug claims, Kaiser's decisions are final and binding.
|
|||
1 These plans are named for the deductible applicable to the "individual" for in-network service providers. The deductibles applicable to any other coverage level (for example, "Family coverage") or for services provided by out-of-network service providers will be significantly higher than (in many instances, double) the amounts captured in the names of the plans.
2 "Family" applies to all coverage levels except, Employee-Only.
3 Not "True" Family: For the $3,200 Deductible Plan, if more than one person in a family is covered under this plan, there are two ways the plan will begin to pay benefits for a covered family member. When a covered family member meets his or her individual deductible, benefits begin for only that covered family member, and not for the other covered family members. When the family deductible is met, benefits begin for all covered family members whether or not each has met the individual deductible. The family deductible can only be met by a combination of covered family members, as amounts counted toward individual deductibles count toward the larger family deductible. The out-of-pocket maximum functions in the same way. When a covered family member meets his or her individual out-of-pocket maximum, the out-of-pocket maximum is satisfied for only that covered family member. When the family out-of-pocket maximum is met, the out-of-pocket maximum is satisfied for all covered family members, whether or not each has met the individual out-of-pocket maximum. The family out-of-pocket maximum can only be met by a combination of covered family members, as amounts counted toward individual out-of-pocket maximums count toward the larger family out-of-pocket maximum
4 "True" Family: For the $1,600 Deductible Plan, if more than one person in a family is covered under this plan, benefits begin for any one covered family member only after the family deductible is met by one covered family member or a combination of family members. This plan does not require that you or a covered family member must meet the "individual" deductible to meet the family deductible. The out-of-pocket maximum functions in the same way. If more than one person in a family is covered under this plan, the out-of-pocket maximum is met for any one covered family member only when the family out-of-pocket maximum is met by one covered family member or a combination of covered family members.
5 Please note your Rx benefits may vary from what is shown depending on your state of residence. Please refer to the Kaiser Permanente Evidence of Coverage for more detail.
6 Kaiser does not provide out-of-network coverage except in an emergency.
Kaiser Claims Administrator Address Information
Kaiser Permanente- Northern CA
P.O. Box 12923
Oakland, CA 94612
P.O. Box 12923
Oakland, CA 94612
Kaiser Permanente- Southern CA
P.O. Box 7004
Downey, CA 90242-0361
P.O. Box 7004
Downey, CA 90242-0361
Kaiser Permanente- CO
P.O. Box 373150
Denver, CO 80237-9998
P.O. Box 373150
Denver, CO 80237-9998
Kaiser Permanente- GA
P.O. Box 370010
Denver, CO 80237-9998
P.O. Box 370010
Denver, CO 80237-9998
Kaiser Permanente- Mid-Atlantic (MD, VA, DC)
P.O. Box 371860
Denver, CO 80237-9998
P.O. Box 371860
Denver, CO 80237-9998
Kaiser Permanente- Northwest (Oregon and Southwest WA)
P.O. Box 370050
Denver, CO 80237-9998
P.O. Box 370050
Denver, CO 80237-9998
Kaiser Permanente- Washington (Western Washington and Spokane area)
P.O. Box 30766
Salt Lake City, UT 84130-0766
P.O. Box 30766
Salt Lake City, UT 84130-0766
Kaiser Customer Service Phone Numbers