Kaiser Permanente On Exchange Enrollment Guide KPIF GA...

Kaiser Permanente for Individuals and Families

Healthy togetherCare and coverage that fits your life

buykp.org 2019 Enrollment | Georgia

http://buykp.org

Welcome to care that fits your life

Your doctor, your choiceChoose your doctor based on what’s important to you. Go to kp.org/searchdoctors for details about education,

specialties, languages spoken, and more. You can also change

doctors at any time.

Convenient cost estimates

Get an idea of what you’ll pay before you

come in for care. For a personalized estimate based on

your plan details, visit kp.org/costestimates.

More care optionsHow you get care

is up to you. Choose a phone or video

appointment,* email your doctor’s office with nonurgent questions, or come see us in person.†

Right care, right timeGet the care you need when you need it with

routine, specialty, urgent, and emergency care. If

you’re ever unsure where to go, call us for 24/7 care

advice by phone.

Many services under one roof

Do more in less time. In most of our facilities,

you can see your doctor, get a lab test, and pick up prescriptions — all

in a single trip.

*When appropriate and available.† These features are available when you get care at Kaiser Permanente facilities.

http://kp.org/searchdoctors

http://kp.org/costestimates


1 61178608 Georgia 2019

The right choice for your healthWelcome to your Kaiser Permanente for Individuals and Families enrollment guide. This guide will help you select the right health plan for your needs.

Simple steps to applyUse this guide to help you find a plan that works for you. Then, apply online or fill out a paper application.

Choose your health plan ................ 3

Find your rate ................................ 10

Find a facility near you ................. 13

Visit buykp.org/apply to compare plans, see if you qualify for federal financial assistance, calculate your rate, or apply online.

Important deadline for open enrollmentThe open enrollment period for 2019 coverage runs from November 1, 2018, through December 15, 2018. You can change or apply for coverage through Kaiser Permanente, or we can help you apply through the Health Insurance Marketplace.

For coverage that starts on January 1, 2019, we must receive your Application for Health Coverage and first month’s premium no later than December 15, 2018.

Enrolling during a special enrollment period

Are you getting married, having a baby, or losing your health coverage? You may also enroll or change your coverage throughout the year if you have a qualifying life event.

Visit kp.org/specialenrollment for a list of qualifying life events and instructions.

Have questions? Call us at 1-800-494-5314. • Go to buykp.org/apply. • Or contact your agent or broker.

http://buykp.org/apply

http://kp.org/specialenrollment



2 61178608 Georgia 2019

Your care, your wayGet care where, when, and how you want it. With more options to choose from, it’s easier to stay on top of your health.

Choose how you connect to care

Online

Stay on top of your care at kp.org. Once you’re registered, you can view your medical record, refill most prescriptions, schedule routine appointments, and more. Email your doctor’s office anytime with nonurgent questions. You’ll usually get a response within 2 business days.

VideoWant a convenient, secure way to see a doctor wherever you are? Meet face-to-face online. Call us or email your doctor’s office to see if video visits are available to you.

PhoneHave a condition that doesn’t require an in-person exam? Save yourself a trip to the office by scheduling a call with a Kaiser Permanente doctor.

In personMost of our locations have many services under one roof, so you can see your doctor, get lab services or X-rays, and pick up a prescription — all in the same trip.

Online wellness tools

Visit kp.org/healthyliving for wellness information, health calculators, fitness videos, podcasts, and recipes from world-class chefs.

Discounts for members

Enjoy discounts on products and services that can help you stay healthy — like gym memberships, massage therapy, and more. Explore your options at kp.org/choosehealthy.

Some features are availble only when you get care at Kaiser Permanente facilities.


http://kp.org

http://kp.org/healthyliving

http://kp.org/choosehealthy


3 61178608 Georgia 2019

Choose your health plan Understanding health plansWe offer a variety of plans to fit your needs and budget. All of them offer the same quality care, but the way they split the costs is different. Learn more below.

Deductible plans

Gold, Silver, Bronze, CatastrophicWith a deductible plan, your monthly rate is lower, but you’ll have to reach a deductible. This means you’ll pay the full charges for most covered services until you reach a set amount known as your deductible. Then you’ll start paying less — just a copay or coinsurance. Depending on your plan, some services, like office visits or prescriptions, may be available at a copay or coinsurance before you meet your deductible.

HSA-qualified deductible plans

Silver, BronzeHSA-qualified deductible plans are deductible plans with a special feature. With this plan, you can set up a health savings account (HSA) to pay for health costs like copays, coinsurance, and deductible payments. And you won’t pay federal taxes on the money in this account.

You can use your HSA anytime to pay for care, including some services that may not be covered by your plan, such as eyeglasses or adult dental.* And if you have money left in your HSA at the end of the year, it will roll over for you to use the next year.

* For a complete list of services you can use your HSA to pay for, see Publication 502, Medical and Dental Expenses, at irs.gov.



4 61049608 Georgia 2019

Choosing a plan based on your care needsIf you need a lot of care, you may want a plan with a higher monthly rate so that you pay less when you come in for care. If you don’t go to the doctor much, you may want a plan with a lower monthly rate, keeping in mind you’ll pay more if and when you do get care.

Monthly rate versus out-of-pocket costs

Plan levelWhat you pay for your monthly rate

What you pay when you get care (Emergency Department visit, lab test, etc.)

Gold

Silver

Bronze

An example of costs when you get care

Let’s say you hurt your ankle. You visit your primary care doctor, who orders an X-ray. It’s just a sprain, so the doctor prescribes a generic pain medication. Here’s a sample of what you would pay out of pocket for these services with each type of health plan.

Plan name Office visit X-ray Generic drug

KP GA Gold 1500/20 ($1,500 deductible)

$2030% after

deductibleTier 1: $5*

Tier 2: $10*

KP GA Silver 3000/30 ($3,000 deductible)

$3035% after

deductibleTier 1: $5*

Tier 2: $15*

KP GA Bronze 5000/50 ($5,000 deductible)

First 2 office visits $50, then 35% after deductible

35% after deductible

Tier 1: $5*Tier 2: $35*

*Mail order: 90-day supply of qualified prescriptions for the cost of a 60-day supply

The cost estimates above are from our estimate tools website, kp.org/treatmentestimates. Visit this site anytime to get an idea of what the charges for common services might be before you meet your deductible.



Understanding the plans: benefit highlights The charts on the next few pages show you a sample of each plan’s benefits. Review the diagram below to help you understand how to read those charts.

Here’s a quick look at how to use the chart

61097908 Georgia 2019

KP GA Silver 3000/30

Plan type Deductible

Features

Annual medical deductible(individual/family) $3,000/$6,000

Annual out-of-pocket maximum (individual/family) $7,150/$14,300

Benefits

Preventive care

Routine physical exam, mammograms, etc. No charge

Outpatient services (per visit or procedure)

Primary care office visit $30

Specialty care office visit $60

Most X-rays 35% after deductible

Most lab tests 35% after deductible

MRI, CT, PET $400

Outpatient surgery 35% after deductible

Mental health visit $60

Inpatient hospital care

Room and board, surgery, anesthesia, X-rays, lab tests, medications, mental health care 35% after deductible

Maternity

Routine prenatal care visit, first postpartum visit 35% after deductible

Delivery and inpatient well-baby care 35% after deductible

Emergency and urgent care

Emergency Department visit 35% after deductible

Urgent care visit $100

Prescription drugs (up to a 30-day supply)

Generic Tier 1: $5* Tier 2: $15*

Preferred brand $45* after $500/$1,000 pharmacy deductible

Non-preferred brand 50% after $500/$1,000 pharmacy deductible

Specialty 50% after $500/$1,000 pharmacy deductible

Whole health

Healthy servicesDiscounts on massage therapy,

acupuncture, and more. Visit kp.org/choosehealthy to learn more.‡

KP Offered through Kaiser Permanente

M Offered through the Health Insurance MarketplaceKP M

Annual deductibleYou need to pay this amount before your plan starts helping you pay for most covered services. Under this sample plan, you’d pay the full charges for covered services until you reach $3,000 for yourself or $6,000 for your family. Then you’d start paying copays or coinsurance.

Preventive care at no chargeMost preventive care services — including routine physical exams and mammograms — are covered at no charge. Plus, they’re not subject to the deductible.

CoinsuranceAfter reaching your deductible, this is a percentage of the charges that you may pay for covered services. Here, you’d pay 35% of the cost per day for your inpatient hospital care after you reach your deductible. Your plan would pay the rest for the remainder of the calendar year.

Covered before you reach the deductibleWith some services, you’ll only pay a copay or coinsurance, regardless of whether you’ve reached your deductible. Under this plan, primary care visits are covered at a $30 copay — even before you meet your deductible. With our Silver deductible plans, primary care, specialty care, and urgent care visits all are covered before you reach the deductible.

CopayThis is the set amount you pay for covered services, usually after you reach your deductible. In this example, you’d start paying a $100 copay for urgent care visits, whether or not you have met your deductible.

Annual out-of-pocket maximumThis is the most you’ll pay for care during the calendar year before your plan starts paying 100% for most covered services. In this example, you’d never pay more than $7,150 for yourself and no more than $14,300 for your family for your copays, coinsurance, and deductible in a calendar year.

*Mail order: 90-day supply of qualified prescriptions for the cost of a 60-day supply. ‡ Discount programs and other services shown may be provided by groups other than Kaiser

Permanente, and aren’t offered or guaranteed under your coverage. Additional fees you pay won’t count toward your deductible or out-of-pocket maximum.

61097908 Georgia 2019


M Offered through the Health Insurance Marketplace

Financial assistance options with lower copays, coinsurance, and deductibles are available for certain plans, and for Native Alaskans and American Indians on healthcare.gov.

If you live in Clayton, Cobb, DeKalb, Fulton, Gwinnett, or Henry counties, your plan will be in the KP Signature HMO network

KP GA Signature Bronze

6200/40%/HSAKP GA Bronze

6200/40%/HSA

KP GA Signature Bronze 5000/50

KP GA Bronze 5000/50

KP GA Signature Silver 4700/35




KP GA Signature Silver

3200/20%/HSAKP GA Silver 3200/20%/

HSA

Plan type HSA-qualified Deductible Deductible Deductible HSA-qualified

Features

Annual medical deductible (individual/family) $6,200/$12,400 $5,000/$10,000 $4,700/$9,400 $3,000/$6,000 $3,200/$6,400

Annual out-of-pocket maximum (individual/family) $6,550/$13,100 $7,350/$14,700 $7,350/$14,700 $7,150/$14,300 $6,000/$12,000

Benefits

Preventive care

Routine physical exam, mammograms, etc. No charge No charge No charge No charge No charge


Primary care office visit 40% after deductible First 2 office visits: $50, then 35% after deductible $35 $30 20% after deductible

Specialty care office visit 40% after deductible First 2 office visits: $70, then 35% after deductible $65 $60 20% after deductible

Most X-rays 40% after deductible 35% after deductible 35% after deductible 35% after deductible 20% after deductible

Most lab tests 40% after deductible 35% after deductible 35% after deductible 35% after deductible 20% after deductible

MRI, CT, PET 40% after deductible $550 after deductible 35% after deductible $400 20% after deductible

Outpatient surgery 40% after deductible 35% after deductible 35% after deductible 35% after deductible 20% after deductible

Mental health visit 40% after deductible First 2 office visits: $70, then 35% after deductible $65 $60 20% after deductible


Room and board, surgery, anesthesia, X-rays, lab tests, medications, mental health care 40% after deductible 35% after deductible 35% after deductible 35% after deductible 20% after deductible

Maternity

Routine prenatal care visit, first postpartum visit 40% after deductible 35% after deductible 35% after deductible 35% after deductible 20% after deductible

Delivery and inpatient well-baby care 40% after deductible 35% after deductible 35% after deductible 35% after deductible 20% after deductible


Emergency Department visit 40% after deductible 35% after deductible 35% after deductible 35% after deductible 20% after deductible

Urgent care visit 40% after deductible $100 $100 $100 20% after deductible


Generic Tier 1: $5*† Tier 2: 40% after deductible

Tier 1: $5* Tier 2: $35*

Tier 1: $5* Tier 2: $15*

Tier 1: $5* Tier 2: $15*

Tier 1: $5*† Tier 2: $15* after deductible

Preferred brand 50% after deductible 50% after $1,500/$3,000 pharmacy deductible $45* after deductible $45* after $500/$1,000

pharmacy deductible $45* after deductible

Non-preferred brand 50% after deductible 50% after $1,500/$3,000 pharmacy deductible 50% after deductible 50% after $500/$1,000

pharmacy deductible 50% after deductible

Specialty 50% after deductible 50% after $1,500/$3,000 pharmacy deductible 50% after deductible 50% after $500/$1,000

pharmacy deductible 50% after deductible

Whole health

Healthy services

Discounts on massage therapy, acupuncture, and more. Visit

kp.org/choosehealthy to learn more.‡









KP M KP M KP M KP M KP M

* Mail order: 90-day supply of qualified prescriptions for the cost of a 60-day supply.† HSA-qualified plans contain generics used for preventive care; deductible does not apply.‡ Discount programs and other services shown may be provided by groups other than Kaiser Permanente, and aren’t offered or guaranteed under your coverage. Additional fees you pay

won’t count toward your deductible or out-of-pocket maximum. ** Only applicants under age 30, or applicants age 30 and older who provide a certificate from Health Insurance Marketplace in Georgia demonstrating hardship or lack of affordable

coverage, may purchase a KP GA Catastrophic 7900/0 plan/KP GA Signature Catastrophic 7900/0 plan.

This plan summary is intended to highlight only some of the most frequently asked about benefits and their copays, coinsurance, and deductibles. Please refer to the Evidence of Coverage for more details on your plan or for specific limitations and exclusions. To request a copy of the Membership Agreement, Disclosure Form, and Evidence of Coverage, please visit kp.org/plandocuments, call us at 1-888-865-5813, or contact your broker. For services subject to the deductible, you’ll have to pay health care expenses out of pocket until you meet your deductible. Most deductibles, copays, and coinsurance contribute to the out-of-pocket maximum.




61097908 Georgia 2019


KP GA Signature Gold 1500/20

KP GA Gold 1500/20


KP GA Gold 500/20

KP GA Signature

Catastrophic 7900/0**KP GA Catastrophic

7900/0**


2100/30/73% CSR KP GA Silver

2100/30/73% CSR


0/15/87% CSRKP GA Silver

0/15/87% CSR

Plan type Deductible Deductible Deductible Deductible Copayment

Features

Annual medical deductible (individual/family) $1,500/$3,000 $500/$1,000 $7,900/$15,800 $2,100/$4,200 None/None

Annual out-of-pocket maximum (individual/family) $5,000/$10,000 $6,350/$12,700 $7,900/$15,800 $6,300/$12,600 $2,500/$5,000

Benefits

Preventive care

Routine physical exam, mammograms, etc. No charge No charge No charge No charge No charge


Primary care office visit $20 $20 First 3 office visits no charge, then no charge after deductible $30 $15

Specialty care office visit $40 $40 No charge after deductible $60 $25

Most X-rays 30% after deductible 30% No charge after deductible 35% after deductible 30%

Most lab tests 30% after deductible 30% No charge after deductible 35% after deductible 30%

MRI, CT, PET $250 $200 No charge after deductible $400 $250

Outpatient surgery 30% after deductible 30% after deductible No charge after deductible 35% after deductible 30%

Mental health visit $40 $40 First 3 office visits no charge, then no charge after deductible $60 $25


Room and board, surgery, anesthesia, X-rays, lab tests, medications, mental health care 30% after deductible 30% after deductible No charge after deductible 35% after deductible 30%

Maternity

Routine prenatal care visit, first postpartum visit 30% after deductible 30% after deductible No charge after deductible 35% after deductible 30%

Delivery and inpatient well-baby care 30% after deductible 30% after deductible No charge after deductible 35% after deductible 30%


Emergency Department visit 30% after deductible $250 No charge after deductible 35% after deductible 30%

Urgent care visit $75 $75 No charge after deductible $100 $50



Tier 1: $5* Tier 2: $10* No charge after deductible Tier 1: $5*

Tier 2: $15*Tier 1: $5*

Tier 2: $15*

Preferred brand $30* after $500/$1,000 pharmacy deductible

$30* after $500/$1,000 pharmacy deductible No charge after deductible $45* after $500/$1,000

pharmacy deductible $45 *

Non-preferred brand 45% after $500/$1,000 pharmacy deductible

45% after $500/$1,000 pharmacy deductible No charge after deductible 50% after $500/$1,000

pharmacy deductible 50%

Specialty 45% after $500/$1,000 pharmacy deductible

45% after $500/$1,000 pharmacy deductible No charge after deductible 50% after $500/$1,000

pharmacy deductible 50%

Whole health

Healthy services











KP M KP M KP M KP M KP M





61097908 Georgia 2019





KP GA Signature Silver 0/5/94% CSRKP GA Silver 0/5/94% CSR

KP GA Signature Silver 1700/20%/73% CSR

KP GA Silver 1700/20%/73% CSR





Plan type Copayment Deductible Deductible Deductible

Features

Annual medical deductible (individual/family) None/None $1,700/$3,400 $500/$1,000 $100/$200

Annual out-of-pocket maximum (individual/family) $1,500/$3,000 $6,000/$12,000 $2,500/$5,000 $1,000/$2,000

Benefits

Preventive care

Routine physical exam, mammograms, etc. No charge No charge No charge No charge


Primary care office visit $5 20% after deductible 10% after deductible 5% after deductible

Specialty care office visit $10 20% after deductible 10% after deductible 5% after deductible

Most X-rays 15% 20% after deductible 10% after deductible 5% after deductible

Most lab tests 15% 20% after deductible 10% after deductible 5% after deductible

MRI, CT, PET $100 20% after deductible 10% after deductible 5% after deductible

Outpatient surgery 15% 20% after deductible 10% after deductible 5% after deductible

Mental health visit $10 20% after deductible 10% after deductible 5% after deductible


Room and board, surgery, anesthesia, X-rays, lab tests, medications, mental health care 15% 20% after deductible 10% after deductible 5% after deductible

Maternity

Routine prenatal care visit, first postpartum visit 15% 20% after deductible 10% after deductible 5% after deductible

Delivery and inpatient well-baby care 15% 20% after deductible 10% after deductible 5% after deductible


Emergency Department visit 15% 20% after deductible 10% after deductible 5% after deductible

Urgent care visit $20 20% after deductible 10% after deductible 5% after deductible



Tier 1: $5* Tier 2: $15* after deductible



Preferred brand $10* $45* after deductible $20* after deductible $15 after deductible

Non-preferred brand 50% 50% after deductible 50% after deductible 50% after deductible

Specialty 50% 50% after deductible 50% after deductible 50% after deductible

Whole health



Discounts on massage therapy, acupuncture, and more. Visit kp.org/

choosehealthy to learn more.‡





KP M KP M KP M KP M









KP GA Signature Silver 2500/35/73% CSR

KP GA Silver 2500/35/73% CSR

KP GA Signature Silver 550/15/87% CSR

KP GA Silver 550/15/87% CSR"

KP GA Signature Silver 150/5/94% CSRKP GA Silver 150/5/94% CSR

Plan type Deductible Deductible Deductible

Features

Annual medical deductible(individual/family) $2,500/$5,000 $550/$1,100 $150/$300

Annual out-of-pocket maximum (individual/family) $6,000/$12,000 $2,500/$5,000 $1,000/$2,000

Benefits

Preventive care

Routine physical exam, mammograms, etc. No charge No charge No charge


Primary care office visit $35 $15 $5

Specialty care office visit $65 $25 $10

Most X-rays 30% after deductible 30% after deductible 10% after deductible

Most lab tests 30% after deductible 30% after deductible 10% after deductible

MRI, CT, PET 30% after deductible 30% after deductible 10% after deductible

Outpatient surgery 30% after deductible 30% after deductible 10% after deductible

Mental health visit $65 $25 $10


Room and board, surgery, anesthesia, X-rays, lab tests, medications, mental health care 30% after deductible 30% after deductible 10% after deductible

Maternity

Routine prenatal care visit, first postpartum visit 30% after deductible 30% after deductible 10% after deductible

Delivery and inpatient well-baby care 30% after deductible 30% after deductible 10% after deductible


Emergency Department visit 30% after deductible 30% after deductible 10% after deductible

Urgent care visit $100 $50 $20



Tier 1: $5* Tier 2: $10*

Tier 1: $5* Tier 2: $10*

Preferred brand $45* after deductible $20* after deductible $20* after deductible

Non-preferred brand 50% after deductible 50% after deductible 50% after deductible

Specialty 50% after deductible 50% after deductible 50% after deductible

Whole health



Discounts on massage therapy, acupuncture, and more.

Visit kp.org/choosehealthy to learn more.‡

Discounts on massage therapy, acupuncture, and more.

Visit kp.org/choosehealthy to learn more.‡

KP M KP M KP M

61097908 Georgia 2019







61178608 Georgia 2019

Find your rateUse the monthly rates charts on the following pages, or apply on buykp.org/apply to have your rate calculated automatically. Along with your monthly rate, consider what you’ll need to pay when you get care. See page 4 for more information.

What determines your rate?

Your rate is based on the following:• The plan you select• Where you live, based on your county• Your age on your start date (effective date)• If you use tobacco• If you qualify for federal financial assistance. Visit

buykp.org/apply or call us at 1-800-494-5314 tosee if you may qualify.

Interested in a family plan?Find the rate for each family member, based on his or her age on the start date.

• You• Your spouse/domestic partner• All adult children 21 through 25• Your 3 oldest children under 21

If you have more than 3 children under 21, you only have to pay for the 3 oldest. The other children under 21 will be covered at no charge.

The rates on pages 11–12 apply to the counties below. Please check that your county is listed below. If it isn’t, call us at 1-800-494-5314.

Service Area — Counties Signature HMO PlanClayton DeKalb GwinnettCobb Fulton Henry

Service Area — Counties HMO PlanBartow Fayette PikeButts Forsyth RockdaleCherokee Lamar SpaldingCoweta Newton WaltonDouglas Paulding




2019 Monthly rates If you live in Clayton, Cobb, DeKalb, Fulton, Gwinnett, or Henry counties, your rates will be the KP GA Signature plans.

Please note: These rates do not include the federal financial assistance you may be eligible to receive through the Health Insurance Marketplace.

61178608 Georgia 2019

Age on 2019 effective date

KP GA Signature Bronze

6200/40%/HSA

KP GA Bronze 6200/40%/HSA

KP GA Signature Bronze 5000/50

KP GA Bronze 5000/50





0–14 $252.81 $277.83 $257.06 $282.51 $316.38 $347.69 $341.21 $374.9815 275.28 302.53 279.91 307.62 344.50 378.60 371.54 408.3116 283.88 311.97 288.65 317.22 355.26 390.41 383.14 421.0617 292.47 321.41 297.39 326.82 366.01 402.23 394.73 433.8018 301.72 331.58 306.80 337.16 377.59 414.96 407.22 447.5319 310.98 341.75 316.21 347.50 389.17 427.68 419.71 461.2520 320.56 352.29 325.95 358.21 401.16 440.86 432.65 475.4621 330.47 363.18 336.03 369.29 413.57 454.50 446.03 490.1722 330.47 363.18 336.03 369.29 413.57 454.50 446.03 490.1723 330.47 363.18 336.03 369.29 413.57 454.50 446.03 490.1724 330.47 363.18 336.03 369.29 413.57 454.50 446.03 490.1725 331.80 364.63 337.38 370.77 415.22 456.32 447.81 492.1326 338.41 371.90 344.10 378.15 423.49 465.41 456.73 501.9327 346.34 380.61 352.16 387.01 433.42 476.31 467.44 513.7028 359.22 394.78 365.27 401.42 449.55 494.04 484.83 532.8129 369.80 406.40 376.02 413.23 462.78 508.58 499.10 548.5030 375.09 412.21 381.40 419.14 469.40 515.86 506.24 556.3431 383.02 420.93 389.46 428.01 479.33 526.76 516.95 568.1132 390.95 429.64 397.53 436.87 489.25 537.67 527.65 579.8733 395.91 435.09 402.57 442.41 495.46 544.49 534.34 587.2234 401.20 440.90 407.94 448.32 502.07 551.76 541.48 595.0735 403.84 443.81 410.63 451.27 505.38 555.40 545.05 598.9936 406.48 446.71 413.32 454.23 508.69 559.03 548.61 602.9137 409.13 449.62 416.01 457.18 512.00 562.67 552.18 606.8338 411.77 452.52 418.70 460.13 515.31 566.31 555.75 610.7539 417.06 458.33 424.07 466.04 521.92 573.58 562.89 618.5940 422.35 464.14 429.45 471.95 528.54 580.85 570.02 626.4441 430.28 472.86 437.51 480.81 538.47 591.76 580.73 638.2042 437.88 481.21 445.24 489.31 547.98 602.21 590.99 649.4843 448.45 492.84 456.00 501.13 561.21 616.76 605.26 665.1644 461.67 507.36 469.44 515.90 577.76 634.94 623.10 684.7745 477.20 524.43 485.23 533.25 597.19 656.30 644.06 707.8146 495.71 544.77 504.05 553.93 620.35 681.75 669.04 735.2647 516.53 567.65 525.22 577.20 646.41 710.38 697.14 766.1448 540.32 593.80 549.41 603.79 676.18 743.11 729.25 801.4349 563.79 619.59 573.27 630.01 705.55 775.38 760.92 836.2350 590.23 648.64 600.15 659.55 738.63 811.74 796.60 875.4451 616.33 677.33 626.70 688.72 771.31 847.64 831.84 914.1752 645.08 708.93 655.93 720.85 807.29 887.18 870.65 956.8153 674.17 740.89 685.51 753.35 843.68 927.18 909.90 999.9554 705.56 775.39 717.43 788.43 882.97 970.36 952.27 1,046.5155 736.96 809.89 749.35 823.51 922.26 1,013.53 994.64 1,093.0856 771.00 847.30 783.96 861.55 964.86 1,060.35 1,040.58 1,143.5757 805.36 885.07 818.91 899.96 1,007.87 1,107.61 1,086.97 1,194.5458 842.05 925.38 856.21 940.95 1,053.77 1,158.06 1,136.48 1,248.9559 860.22 945.36 874.69 961.26 1,076.52 1,183.06 1,161.01 1,275.9160 896.91 985.67 911.99 1,002.25 1,122.42 1,233.51 1,210.52 1,330.3261 928.63 1,020.54 944.25 1,037.70 1,162.13 1,277.14 1,253.34 1,377.3862 949.45 1,043.42 965.42 1,060.97 1,188.18 1,305.78 1,281.44 1,408.2663 975.56 1,072.11 991.97 1,090.14 1,220.85 1,341.68 1,316.67 1,446.98

64+ 991.41 1,089.53 1,008.09 1,107.86 1,240.70 1,363.49 1,338.07 1,470.50

Rates are effective January 1, 2019, through December 31, 2019.


61178608 Georgia 2019

2019 Monthly rates If you live in Clayton, Cobb, DeKalb, Fulton, Gwinnett, or Henry counties, your rates will be the KP GA Signature plans.

Please note: These rates do not include the federal financial assistance you may be eligible to receive through the Health Insurance Marketplace.

Age on 2019 effective date


3200/20%/HSA

KP GA Silver 3200/20%/HSA


KP GA Gold 1500/20


KP GA Gold 500/20

KP GA Signature Catastrophic

7900/0

KP GA Catastrophic

7900/0

0–14 $358.51 $358.51 $350.23 $384.89 $360.66 $396.36 $222.92 $244.9815 390.38 390.38 381.36 419.10 392.72 431.59 242.73 266.7516 402.57 402.57 393.26 432.18 404.98 445.06 250.31 275.0817 414.75 414.75 405.16 445.26 417.24 458.53 257.88 283.4118 427.87 427.87 417.98 459.35 430.44 473.04 266.04 292.3719 440.99 440.99 430.80 473.44 443.64 487.55 274.20 301.3420 454.59 454.59 444.08 488.03 457.31 502.57 282.65 310.6321 468.64 468.64 457.81 503.12 471.46 518.12 291.39 320.2322 468.64 468.64 457.81 503.12 471.46 518.12 291.39 320.2323 468.64 468.64 457.81 503.12 471.46 518.12 291.39 320.2324 468.64 468.64 457.81 503.12 471.46 518.12 291.39 320.2325 470.52 470.52 459.64 505.13 473.34 520.19 292.56 321.5126 479.89 479.89 468.80 515.20 482.77 530.55 298.39 327.9227 491.14 491.14 479.79 527.27 494.09 542.98 305.38 335.6028 509.42 509.42 497.64 546.89 512.47 563.19 316.75 348.0929 524.41 524.41 512.29 562.99 527.56 579.77 326.07 358.3430 531.91 531.91 519.62 571.04 535.10 588.06 330.73 363.4731 543.16 543.16 530.60 583.12 546.42 600.50 337.73 371.1532 554.41 554.41 541.59 595.19 557.73 612.93 344.72 378.8433 561.44 561.44 548.46 602.74 564.80 620.70 349.09 383.6434 568.93 568.93 555.78 610.79 572.35 628.99 353.75 388.7635 572.68 572.68 559.45 614.81 576.12 633.14 356.08 391.3336 576.43 576.43 563.11 618.84 579.89 637.28 358.42 393.8937 580.18 580.18 566.77 622.86 583.66 641.43 360.75 396.4538 583.93 583.93 570.43 626.89 587.43 645.57 363.08 399.0139 591.43 591.43 577.76 634.94 594.98 653.86 367.74 404.1340 598.93 598.93 585.08 642.99 602.52 662.15 372.40 409.2641 610.17 610.17 596.07 655.06 613.84 674.59 379.40 416.9442 620.95 620.95 606.60 666.64 624.68 686.50 386.10 424.3143 635.95 635.95 621.25 682.74 639.77 703.08 395.42 434.5644 654.70 654.70 639.56 702.86 658.62 723.81 407.08 447.3745 676.72 676.72 661.08 726.51 680.78 748.16 420.77 462.4246 702.97 702.97 686.72 754.68 707.18 777.17 437.09 480.3547 732.49 732.49 715.56 786.38 736.89 809.81 455.45 500.5348 766.23 766.23 748.52 822.60 770.83 847.12 476.43 523.5849 799.51 799.51 781.03 858.33 804.30 883.90 497.12 546.3250 837.00 837.00 817.65 898.58 842.02 925.35 520.43 571.9451 874.02 874.02 853.82 938.32 879.26 966.28 543.45 597.2452 914.79 914.79 893.65 982.09 920.28 1,011.36 568.80 625.1053 956.03 956.03 933.94 1,026.37 961.77 1,056.96 594.44 653.2854 1,000.56 1,000.56 977.43 1,074.16 1,006.56 1,106.18 622.13 683.7055 1,045.08 1,045.08 1,020.92 1,121.96 1,051.35 1,155.40 649.81 714.1256 1,093.35 1,093.35 1,068.08 1,173.78 1,099.91 1,208.76 679.82 747.1057 1,142.09 1,142.09 1,115.69 1,226.11 1,148.94 1,262.65 710.13 780.4158 1,194.11 1,194.11 1,166.51 1,281.95 1,201.27 1,320.16 742.47 815.9659 1,219.88 1,219.88 1,191.69 1,309.63 1,227.20 1,348.65 758.50 833.5760 1,271.90 1,271.90 1,242.50 1,365.47 1,279.53 1,406.16 790.84 869.1161 1,316.89 1,316.89 1,286.45 1,413.77 1,324.79 1,455.90 818.82 899.8662 1,346.42 1,346.42 1,315.29 1,445.47 1,354.49 1,488.55 837.18 920.0363 1,383.44 1,383.44 1,351.46 1,485.21 1,391.74 1,529.48 860.20 945.33

64+ 1,405.92 1,405.92 1,373.43 1,509.35 1,414.36 1,554.34 874.17 960.69

Rates are effective January 1, 2019, through December 31, 2019.


13 61178608 Georgia 2019


Find a facility near youOur goal is to make it as easy and convenient as possible for you to get the care you need when you need it. Please refer to the map below or search for a facility by ZIP code or keywords at kp.org/facilities to find the one nearest you.

Maps not to scale

http://kp.org/facilities


14

Important details and notices

About your coverage

Before you review the specific plan information, check to make sure you live within our service area. You’re eligible to apply for Kaiser Permanente for Individuals and Families (KPIF) coverage if you live in one of the following counties: Bartow, Butts, Cherokee, Clayton, Cobb, Coweta, DeKalb, Douglas, Fayette, Forsyth, Fulton, Gwinnett, Henry, Lamar, Newton, Paulding, Pike, Rockdale, Spalding, or Walton.

Once you are enrolled, you can enjoy the benefits of KPIF until you choose to leave the plan, regardless of health. However, please note that coverage can end for failure to pay premiums when due or for intentional misrepresentation of important information on your application.

When you turn 65 or become eligible for Medicare, you have the option to apply for our Senior Advantage plan. You can ask about our coverage for Medicare-eligible members by calling toll free 1–800–232–4404.

If you have any questions or would like more information, just call our Call Center at 1–800–494–5314 or check out the KPIF website at buykp.org.

Drug formulary

Kaiser Permanente uses a drug formulary for our HMO and HSA Option plans. Our drug formulary is a continually updated list of medications that are determined to be safe and effective. Use of formulary drugs enables us to provide quality care at a reasonable cost.

Certain prescriptions require expert review before they can be dispensed.

If you have any questions about the formulary, please visit kp.org/formulary or call 404–261–2590.

Preauthorization

When you need to obtain preauthorization for covered services or have a question about whether a service requires preauthorization, please contact Kaiser Permanente Quality Resource Management at 404–364–7320 or 1–800–221–2412 (TTY/TDD 1–800–255–0056).

At Kaiser Permanente, the Utilization Management Program works with participating providers to plan, organize, and deliver quality health care services by ensuring these services are medically appropriate, medically necessary, and provided in a cost-effective manner. Some services require preauthorization by the Utilization Management Program.

Examples include, but are not limited to:

• Elective inpatient admissions• Outpatient surgery• Specialized services such as home health, medical

supplies/equipment, and hospice care• Skilled nursing and acute rehabilitation facilities• Certain behavioral health services and/or

chemical dependency treatment

Failure to obtain preauthorization may result in penalties against your benefit payment, or we may deny all or part of your claim. In the event any service is denied because it does not meet criteria, you may request an appeal.

Except as prohibited by law, prior guarantee of payment will not result in payment for services that are covered benefits and medically necessary if you are not enrolled on the date that services were provided.

Kaiser Permanente does not use financial incentives to encourage barriers to care and service. Decisions involving utilization management are based only on appropriateness of care and service, and existence of coverage under the member’s benefit plan.

61098009 Georgia 2019


http://buykp.org

http://kp.org/formulary


15

Kaiser Permanente does not reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service, and does not use financial incentives that encourage decisions that result in underutilization.

Kaiser Permanente is prohibited from making decisions regarding hiring, promoting, or terminating its practitioners or other individuals based upon the likelihood or perceived likelihood that the individual will support or tend to support the denial of benefits.

Exclusions

As with all health plans, there are some exclusions. The following services are excluded from all coverage. (Please note that this is a summary — for a complete list, refer to the Evidence of Coverage.)

• Unless otherwise required by law, we decide if aService is Medically Necessary and our decision isfinal and conclusive subject to your right to appealas described in your Evidence of Coverage.

• Services that an employer or any governmentagency is responsible to provide, includingworkers’ compensation

• Items and Services that are not health careitems and services, such as teaching mannersor etiquette, academic coaching or tutoring, orvocational training.

• Custodial care or care in an intermediate carefacility

• Services to treat an injury incurred while committinga felony, except for Emergency Services.

• Services provided or arranged by criminal justiceinstitutions or mental health institutions for membersin the custody of law enforcement officers if youare confined in the institution, except foremergency services

• Cosmetic services (including drugs and injectables)• Cord blood procurement and storage for possible

future need or for a yet-to-be determinedmember recipient

• Physical examinations required for obtainingor maintaining employment or participation inemployee programs, or insurance or governmentlicensing

• Orthoptics (eye exercises)• Services and drugs related to the treatment

of obesity• Routine foot care services• Cost of semen and eggs• Services for conception by artificial means, including

infertility drugs• Reversal of voluntary infertility• Nonhuman and artificial organs and their

implantation• Court-ordered services• Testing for ability, aptitude, intelligence, or interest• Corrective shoes and orthotic foot supports

and inserts• More than one device for the same part of the

body or same function• Replacement of lost devices• Electronic monitors of bodily functions (except

infant apnea monitors and blood glucose monitors)• Devices to perform medical testing of body fluids,

excretions, or substances• Devices not medical in nature• Convenience, comfort, or luxury items• Reconstructive surgery following removal of breast

implants that were inserted for cosmetic reasons• Drugs for the treatment of sexual dysfunction

disorders• Most disposable supplies

Who provides the coverage

HMO and HSA Option plans are provided by Kaiser Foundation Health Plan of Georgia, Inc.

61098009 Georgia 2019



16

This is only a summary

This is a summary description and is not intended to replace your Individual Agreement or Evidence of Coverage, which contain the complete provisions of this coverage. If you have questions or need additional information, please call 404–261–2590.

For more information

Have a question that’s not answered in this information kit? Just contact our Call Center at 1–800–494–5314 or check out our website at buykp.org/apply.

Privacy practices

For more information about our privacy practices, visit kp.org/privacy and click on “Notice of Privacy Practices.”

Want to learn more?

For helpful information about getting care, and notices about doctor availability; utilization management procedures; potential network, service or benefit restrictions; privacy practices; pharmacy management procedures; and the Consumer Choice Option (CCO), visit kp.org/formsandpubs to view our Member Handbook and CCO Brochure online. For a paper copy, just call Member Services.

61098009 Georgia 2019



http://kp.org/privacy

http://kp.org/formsandpubs

60577109_ACA_1557_MarCom_GA_2017_Taglines

NONDISCRIMINATION NOTICE Kaiser Foundation Health Plan of Georgia, Inc. (Kaiser Health Plan) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also:

• Provide no cost aids and services to people with disabilities to communicateeffectively with us, such as:• Qualified sign language interpreters• Written information in other formats, such as large print, audio, and

accessible electronic formats

• Provide no cost language services to people whose primary language is notEnglish, such as:• Qualified interpreters• Information written in other languages

If you need these services, call 1-888-865-5813 (TTY: 711)

If you believe that Kaiser Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by mail at: Member Relations Unit (MRU),Attn: Kaiser Civil Rights Coordinator, Nine Piedmont Center, 3495 Piedmont Road, NE Atlanta, GA 30305-1736. Telephone Number: 1-888-865-5813.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

____________________________________________________________________

HELP IN YOUR LANGUAGE ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-888-865-5813 (TTY: 711).

አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎትተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-888-865-5813 (TTY: 711).

ملحوظة: إذا كنت تتحدث العربية، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. (Arabic) العربية.)711 :TTY( 1-888-865-5813 اتصل برقم

中文 (Chinese)注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電1-888-865-5813（TTY：711）。

توجه: اگر به زبان فارسی گفتگو می کنيد، تسهيالت زبانی بصورت رايگان برای (Farsi) فارسیتماس بگيريد. (711 :TTY) شما فراهم می باشد. با 1-888-865-5813

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

http://www.hhs.gov/ocr/office/file/index.html

60577109_ACA_1557_MarCom_GA_2017_Taglines

Français (French) ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-888-865-5813 (TTY: 711).

Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-888-865-5813 (TTY: 711).

ગજરાતી (Gujarati) સચના: જો તમે ગજરાતી બોલતા હો, તો નન:શલ્ક ભાષા સહાય સેવાઓ તમારા માટ ઉપલબ્ધ છ. ફોન કરો 1-888-865-5813 (TTY: 711).

ુ ુ ુ ુે ે

Kreyòl Ayisyen (Haitian Creole) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-888-865-5813 (TTY: 711).

हिन्दी (Hindi) ध्यान द: यहद आप हििंदी बोलत िैं तो आपके ललए मुफ्त में भाषा सिायता सेवाएिंउपलब्ध िैं। 1-888-865-5813 (TTY: 711) पर कॉल करें।

ें े

日本語 (Japanese)注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-888-865-5813（TTY: 711）まで、お電話にてご連絡ください。

한국어 (Korean)주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로이용하실 수 있습니다. 1-888-865-5813 (TTY: 711)번으로 전화해 주십시오.

Naabeehó (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee áká’ánída’áwo’déé’, t’áá jiik’eh, éí ná hóló, koji’ hódíílnih 1-888-865-5813 (TTY: 711).̖ ̖ ̖ ̖

Português (Portuguese) ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-888-865-5813 (TTY: 711).

Pусский (Russian) ВНИМАНИЕ: eсли вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-888-865-5813 (TTY: 711).

Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-865-5813 (TTY: 711).

Tagalog (Tagalog) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-865-5813 (TTY: 711).

Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-865-5813 (TTY: 711).


19 61178608 Georgia 2019

Notes



20 61178608 Georgia 2019

Notes


Care is just a click awayOnline tools designed to make your life easier

New member?Visit kp.org/newmember to get started. It’s easy to register at kp.org, choose your doctor, transfer your prescriptions, and schedule your first routine appointment. And if you need help, just give us a call.

Already a member?Manage your care online anytime at kp.org. If you haven’t already, go to kp.org/registernow so you can start emailing your doctor’s office with nonurgent questions, schedule routine appointments, order most prescription refills, and more.

http://kp.org/newmember

http://kp.org

http://kp.org

http://kp.org/registernow

The right choice for a healthier youHaving a good health plan is important. So is getting quality care. With Kaiser Permanente, you get both.

Want to learn more?Visit kp.org or call us at 1-800-494-5314. (For TTY, call 711.)

Stay connected to good health

Please recycle. 61045408 Georgia 2019

©2018 Kaiser Foundation Health Plan, Inc.

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@kpgeorgia, @kpthrive, @kpshare, @kptotalhealth

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