Embed Size (px)
Citation preview
MA0002162-50-19
Kaiser Permanente Options Federal plan and Medicare
Providing high-quality care and coverage to Federal employees since 1945.
A combination to cover most of your out-of-pocket medical expenses
kp.org/feds/wa-options2
3
Get more with our Options Federal health plan All-in-one care and coverage to help you thrive in your retirement
Kaiser Permanente Washington Options Federal offers a health plan that provides coverage to help you enjoy a healthy, happy retirement. With this plan as your secondary health care coverage to Medicare Parts A and B, you may have broader coverage and fewer unexpected health care expenses.
Why choose Kaiser Permanente?
World-class care, choice of doctors, prescription drug coverage, predictable costs — with Kaiser Permanente, you get the high-quality care and coverage you need in one health plan to support your health goals and help you thrive.
For more information on the Options Federal health plan, visit kp.org/feds.
Why combine the Options Federal plan with Medicare?
Kaiser Permanente Options Federal coverage can help pay for many expenses that are not covered by Medicare Parts A and B. When you combine the Options Federal Standard Option plan with Medicare coverage, your Kaiser Permanente coverage will make your Medicare coverage go further.
The Standard Option coordinates coverage with Medicare, so many of your out-of-pocket costs — such as deductibles, coinsurance, and some outpatient copays — are waived. And in most instances, you receive the same benefits whether you use providers in the Kaiser Permanente network or providers in the First Choice Health network or First Health network.
You’re free to use any provider you choose. However, with the in-network Options Federal providers, you get exclusive access to Kaiser Permanente providers, members of one of the highest-ranked medical groups in Washington.1 You’ll find the most current listing of Options Federal in-network providers by using the Find a Doctor tool at kp.org/feds/wa-options.
What’s inside this guide
Options Federal Standard Option 4
Your care, your way 6
Personalized care that fits your life 7
The 4 parts of Medicare — and what they cover 8
Ready to enroll with Kaiser Permanente? 11
Filing claims 12
kp.org/feds/wa-options4
When you combine the Options Federal Standard plan with Medicare Parts A and B, then Medicare is the primary payor. This means you won’t have to pay certain out-of-pocket costs, and you can receive care from any provider that accepts Medicare.
Benefit descriptionStandard Optionwithout Medicare
Standard Optionwith Medicare
Deductible In-network
$350 per person Up to $750 per family
$0
Out-of-pocket maximum In-network
$5,000 per person Up to $10,000 per family
$5,000 per person Up to $10,000 per family
Copays and coinsurance
Primary care physician $25 $0
Specialist $35 $0
Inpatient hospital 20% $0
Outpatient hospital 20% $0
Prescription drugs
Tier 1 — $20Tier 2 — $40Tier 3 — $60Tier 4 — Preferred specialty
25% to $200Tier 5 — Non-preferred specialty
35% to $300
Tier 1 — $20Tier 2 — $40Tier 3 — $60Tier 4 — Preferred specialty
25% to $200Tier 5 — Non-preferred specialty
35% to $300
Prescription drugs — mail order (90-day supply when available)
2x retail copay 2x retail copay
Options Federal Standard Option
This is a summary of the features of the Kaiser Foundation Health Plan of Washington Options, Inc. benefits. Before making a final decision, please read the Plan’s Federal brochure (73-051). All benefits are subject to the definitions, limitations, and exclusions set forth in the Federal brochure.
5
kp.org/feds/wa-options6
Your care, your wayAs a Kaiser Permanente member, you have many convenient options for getting care the way you want it.
Come inOne-stop shop
When you visit most Kaiser Permanente facilities, you can see your doctor, get lab work or X-rays done, and pick up your prescriptions — often in one trip. Or for quick, high-quality care of minor illnesses or injuries, you can walk into a CareClinic by Kaiser Permanente in 15 Bartell Drugs locations across the Puget Sound area.
CallCare by phone
If you have a condition that doesn’t require an in- person exam, you can save yourself a trip to the doctor’s office by scheduling a phone appointment with your Kaiser Permanente doctor. Plus, you can also get care guidance and advice with our 24/7 Consulting Nurse Service, at no extra cost to you.
ClickOnline care
To get medical advice in real time from a Kaiser Permanente care provider, use our online messaging feature, Care Chat. It’s available 24/7 — at no additional charge.
Or try an online visit to get a diagnosis, a treatment plan, and a prescription if needed, usually within 2 hours.
When you get care at a Kaiser Permanente facility, you can email your doctor’s office for nonurgent issues, view most test results, refill most prescriptions, and schedule or cancel appointments by signing in to kp.org/wa or by using the Kaiser Permanente Washington mobile app.
Find the care you needVisit kp.org/wa/getcare to learn about all your care options.
7
Personalized care that fits your lifeYou can feel confident about the care and coverage you get with Kaiser Permanente.
Better care with a connected teamYour Kaiser Permanente doctor, specialists, and nurses work together to keep you healthy. They’re connected to each other, and to you, through your electronic medical record. So, they know important things about your health — like when you’re due for a screening and what medications you’re taking. A connected care team helps ensure nothing gets missed or forgotten, so you can stay on track with being at your healthiest.
Choose your doctor — and change anytimeUse the Find a Doctor tool at kp.org/feds/wa-options to read our doctors’ profiles, so you can select your personal doctor based on what’s important to you — education, languages spoken, specialties, and more. Plus, you can switch to another Kaiser Permanente doctor any time you want.
Quality care with you at the centerIf you ever need specialty care, you’ll get access to a full range of Kaiser Permanente specialists, including cardiologists, orthopedists, audiologists, and more. Our doctors are some of the brightest minds in medicine and come from top medical schools. More importantly, they’re passionate about delivering excellent care. Equipped with the latest technology and proven treatments, they’ll help you recover quickly.
Care outside of WashingtonAs a Kaiser Permanente Washington Options Federal member, your benefits go beyond the Washington state service area. Wherever you go, you’re covered:
• Emergency room and urgent care visits — anywhere in the world.
• Care at any Kaiser Permanente facility in California, Colorado, Georgia, Hawaii, Maryland, Oregon, Virginia, and Washington, D.C.
• Care from in-network providers nationwide. You can self-refer to most providers.
• If you receive care from an out-of-network provider or facility, you may need to pay in full at the time of service, then mail us a claim form with your medical receipts for reimbursement of covered charges.
• Our Consulting Nurse Service is available 24 hours a day, 7 days a week, for advice or help deciding where to go for care.
• If you get your care at Kaiser Permanente facilities, email a nonurgent question to your doctor’s office get an answer within 48 hours and often that same day.
If you need care while traveling in the United States, call Member Services at 206-630-4636 or 1-888-901-4636 (TTY 1-800-833-6388 or 711), 8 a.m. to 5 p.m. Monday through Friday.
kp.org/feds/wa-options8
The 4 parts of Medicare — and what they cover
PART A PART B
Have any questions about Medicare?Call the Centers of Medicare & Medicaid Services at 1-800-633-4227 (TTY 1-877-486-2048), 24 hours a day, 7 days a week. Or visit medicare.gov.
Covers services and supplies considered medically necessary, including:
• Inpatient hospital care
• Skilled nursing facility care
• Hospice care
When can you sign up for Part A?
• When you turn age 65. Depending on your situation, you’ll either automatically get Part A or you’ll need to sign up for it.
• If you’re not 65 but have certain disabilities.
What does Part A cost?
If you or your spouse paid Medicare taxes while working for 10 years or 40 quarter years, you usually won’t pay a monthly premium for Medicare Part A. (You automatically qualify if you were a federal employee on January 1, 1983, and you’ve worked for at least 10 years.) If you haven’t worked for 10 years or 40 quarter years, you may be able to buy Part A.
Covers many services not covered by Part A, including:
• Doctor services
• Outpatient care
When can you sign up for Part B?
Your initial sign-up period begins 3 months before you turn 65 and ends 3 months after your 65th birthday.
What does Part B cost?
• You must pay a monthly premium for Part B.
• Your premium is usually paid out of your Social Security check or your retirement check.
9
PART C PART D
Covers prescription drugs
• If your income is above a certain limit, you may pay a higher amount. This is called a Part D Income Related Monthly Adjustment Amount (Part D IRMAA).
• If you decide to sign up for the Kaiser Permanente Options Federal Standard plan, you automatically get Part D at no extra premium for prescription drug coverage that is as good as or better than the standard Medicare Part D coverage.
Is there a penalty for not enrolling in Medicare Part B as soon as possible?
• If you choose not to enroll in Part B when you’re first able to, your Part B payments could go up by 10% for each year that you delay signing up for Part B. This is due to the Part B penalty applied by CMS. This penalty is subject to change.
• If you or your spouse keeps working, you may be able to delay your Part B enrollment without a penalty.
For more information about Medicare penalties, call Social Security at 1-800-772-1213 (TTY 1-800-325-0778), 7 a.m. to 7 p.m. Monday through Friday. Or visit socialsecurity.gov.
Also known as Medicare Advantage
• It includes both Part A and Part B.
• It’s offered by private insurance companies that are approved by Medicare.
kp.org/feds/wa-options10
To learn more about Medicare enrollment and eligibilityCall Social Security at 1-800-772-1213 (TTY 1-800-325-0778), Monday through Friday, 7 a.m. to 7 p.m.
Enrolling in MedicareHere’s what you need to know about signing up for Medicare:
65
Initial Enrollment Period
You’re eligible to sign up for Medicare Parts A, B, C, and D during this 7-month period:
• 3 months before you turn 65
• The month you turn 65
• 3 months after you turn 65
General Enrollment Period
If you don’t sign up for Parts A and B when you’re first eligible, you can sign up between January 1 and March 31 each year, for a July 1 start date of your Medicare coverage.
Part B Special Enrollment Period (SEP)
Part B SEP applies when you’re able to delay your enrollment in Medicare Part B because you have coverage from an employer. Medicare eligible members can sign up for Part B:
–Anytime you’re still covered by your employer’s health plan.
–During the 8-month period that begins the month after your employment or coverage ends, whichever happens first.
11
Ready to enroll with Kaiser Permanente?2
1. Sign up for an Options Federal plan.
2. Select the type of enrollment you want.
3. Sign up online or call.
Go to kp.org/feds/wa-options to see details about your options and enroll.
• Self only covers you.
• Self plus one covers you and one eligible family member.
• Self and family covers you and all eligible family members.
Find your enrollment code in the chart below. Then, visit opm.gov to enroll online or contact your employing agency or retirement office for next steps and other information.
Annuitants can contact the Retirement Information Center at 1-888-767-6738 or (TTY 1-855-887-4957) or [email protected].
Standard Option High Deductible Health Plan
Compare premiums: Nonpostal3
Biweekly / Monthly (Code) Biweekly / Monthly (Code)
Self only $100.18 / $217.05 (L11) $74.49 / $161.39 (L14)
Self plus one $241.68 / $523.64 (L13) $165.36 / $358.28 (L16)
Self plus family $199.33 / $431.88 (L12) $165.36 / $358.28 (L15)
Compare premiums: Postal3
Biweekly 1 / Biweekly 2 (Code) Biweekly 1 / Biweekly 2 (Code)
Self only $96.90 / $87.08 (L11) $71.51 / $61.83 (L14)
Self plus one $234.68 / $213.67 (L13) $158.75 / $137.25 (L16)
Self plus family $191.74 / $168.98 (L12) $158.75 / $137.25 (L15)
Enrollees covering themselves and one other eligible family member may choose either the “Self Plus One” or ”Self and Family“ enrollment type, whichever has a lower premium. If you enroll in the Standard Option, you will pay a lower premium if you choose “Self and Family.”
These rates do not apply to all enrollees. If you are in a special enrollment category, please refer to the FEHB Program website or contact the agency or Tribal Employer that maintains your health benefits enrollment.
kp.org/feds/wa-options12
Filing claims
You probably won’t need to file a claim form when you have both Kaiser Permanente Options Federal and Original Medicare.
Most providers will submit the claims for you.
• When the Kaiser Permanente Options Federal plan is your primary coverage, we’ll process the claim first.
• When Original Medicare is your primary coverage, Medicare will process your claim first. In most cases, you won’t need to do anything. Your claim will be coordinated automatically, and your Kaiser Permanente Options Federal plan will then provide secondary benefits for covered services.
If you need to file a claim and the Kaiser Permanente Options Federal plan is your primary coverage —
Submit your claim to us first. After processing your claim, we will send an Explanation of Benefits (EOB) to you. Send the EOB plus copies of all related claims to Medicare for processing.
If you need to file a claim and Original Medicare is your primary coverage —
Submit your claim to Medicare first. After processing the claim, Medicare will send you a Medicare Summary Notice (MSN). Send the MSN, plus copies of all related bills, to Kaiser Permanente for processing. We cannot process your claim without the MSN.
13
If you go back to work and get coverage through your new employer — Kaiser Permanente is required to coordinate coverage with your other health plan. It is your responsibility to notify us of your other health care coverage. Call Member Services at 206-630-4636 or 1-888-901-4636 (TTY 1-800-833-6388 or 711), 8 a.m. to 5 p.m. Monday through Friday, with any changes to your enrollment information.
If you have any questions about filing a claim or who is your primary coverage — Call Member Services at 206-630-4636 or 1-888-901-4636 (TTY 1-800-833-6388 or 711), 8 a.m. to 5 p.m. Monday through Friday. Or visit kp.org/feds/wa-options.
kp.org/feds/wa-options14
1 Washington Health Alliance 2018 Community Checkup report, www.wacommunitycheckup.org. Ranking applies to Kaiser Permanente Washington’s medical group, Washington Permanente Medical Group, P.C.
2 These are highlights of the FEHB enrollment process. Please refer directly to opm.gov and your employing agency or retirement office for FEHB coverage effective dates, enrollment procedures and deadlines, and other information. To add an eligible family member to your Kaiser Permanente Self and Family enrollment, complete and return an Enrollment Change Form to us. These forms can be obtained at kp.org/feds/wa-options or by calling Member Services.
3 These rates do not apply to all enrollees. If you are in a special enrollment category, please refer to FEHB Program website or contact the agency or Tribal Employer which maintains your health benefits enrollment.
Have any questions?
Member Services: 206-630-4636 or 1-888-901-4636 TTY WA Relay: 1-800-833-6388 or 711
Monday through Friday, 8 a.m. to 5 p.m.
kp.org/feds/wa-options
Kaiser Foundation Health Plan of Washington Options, Inc. 601 Union St., Ste. 3100
Seattle, WA 98101
Please recycle.©2019 Kaiser Foundation Health Plan of Washington Options, Inc. MA0002162-50-19
