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1 of 6 Summary of Benefits and Coverage Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 1/1/2020-12/31/2020 : Clark County – C20D Coverage for: Individual / Family | Plan Type: EPO All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage see www.kp.org/plandocuments or call 1-800-813-2000 (TTY: 711). For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at http://www.healthcare.gov/sbc-glossary or call 1-800-813-2000 (TTY: 711) to request a copy. Important Questions Answers Why This Matters: What is the overall $0 See the Common Medical Events chart below for your costs for services this plan covers. deductible? This plan covers some items and services even if you haven’t yet met the deductible Are there services amount. But a copayment or coinsurance may apply. For example, this plan covers covered before you Not applicable. certain preventive services without cost-sharing and before you meet your deductible. meet your deductible? See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles for specific No. You don’t have to meet deductibles for specific services. services? What is the out-of- The out-of-pocket limit is the most you could pay in a year for covered services. If you pocket limit for this $600 Individual / $1,200 Family have other family members in this plan, they have to meet their own out-of-pocket limits plan? until the overall family out-of-pocket limit has been met. Premiums, health care this plan doesn’t cover, What is not included in and services indicated in chart starting on page Even though you pay these expenses, they don’t count toward the out–of–pocket limit. the out-of-pocket limit? 2. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might Will you pay less if you Yes. See www.kp.org or call 1-800-813-2000 receive a bill from a provider for the difference between the provider’s charge and what use a network provider? (TTY: 711) for a list of participating providers. your plan pays (balance billing).Be aware your network provider might use an out-of- network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral This plan will pay some or all of the costs to see a specialist for covered services but only to see a specialist? Yes, but you may self-refer to certain if you have a referral before you see the specialist. 12020_1190-051_KWM_SBC-W-LG-TRAD-XX_{496175}_{C20D - 2020 PLAN D CUSTOM}_107201911281 Rev. (11/16) 1 of 6 specialists. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Common Limitations, Exceptions, & Other Important Services You May Need Select Provider Non-Participating Provider Medical Event Information (You will pay the least) (You will pay the most) Primary care visit to treat $20 / visit Not covered None an injury or illness If you visit a health Specialist visit $20 / visit Not covered None care provider’s You may have to pay for services that aren’t office or clinic Preventive care/screening/ preventive. Ask your provider if the services No charge Not covered immunization needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, X-ray: No charge Not covered None blood work) Lab tests: No charge If you have a test Imaging (CT/PET scans, Some services may require prior No charge Not covered MRIs) authorization. $15 retail; $30 mail order / Up to a 30-day supply (retail); 90-day supply Generic drugs Not covered If you need drugs prescription (mail order). Subject to formulary guidelines. to treat your illness $30 retail; $60 mail order / Up to a 30-day supply (retail); 90-day supply Preferred brand drugs Not covered or condition prescription (mail order). Subject to formulary guidelines. More information Up to a 30-day supply (retail); 90-day supply Applicable Generic or Preferred about prescription Non-preferred brand drugs Not covered (mail order). Subject to formulary guidelines, brand drug cost shares. drug coverage is when approved through exception process. available at Applicable Generic, Preferred, Up to a 30 day supply (retail). Subject to www.kp.org/formulary Specialty drugs Non-Preferred brand drug cost Not covered formulary guidelines, when approved through shares. exception process. Facility fee (e.g., ambulatory $20 / visit Not covered Prior authorization required. If you have surgery center) outpatient surgery Physician/surgeon fees Included in facilities fee Not covered Prior authorization required. If you need Copayment waived if admitted directly to the Emergency room care $75 / visit $75 / visit immediate medical hospital as an inpatient. 12020_1190-051_KWM_SBC-W-LG-TRAD-XX_{496175}_{C20D - 2020 PLAN D CUSTOM}_107201911281 Rev. (11/16) 2 of 6 What You Will Pay Common Limitations, Exceptions, & Other Important Services You May Need Select Provider Non-Participating Provider Medical Event Information (You will pay the least) (You will pay the most) attention Emergency medical $50 / trip $50 / trip None transportation Non-participating providers covered when Urgent care $20 / visit $20 / visit temporarily outside the service area. Facility fee (e.g., hospital $100 / day up to $500 / Not covered Prior authorization required. If you have a room) admission hospital stay Physician/surgeon fees Included in facilities fee Not covered Prior authorization required. If you need mental Outpatient services $20 / visit Not covered None health, behavioral health, or substance abuse services $100 / day up to $500 / Inpatient services Not covered Prior authorization required. admission Depending on the type of services, a copayment, coinsurance, or deductible may Office visits No charge Not covered apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. If you are pregnant ultrasound.) Childbirth/delivery Included in facilities fee Not covered None professional services Childbirth/delivery facility $100 / day up to $500 / Not covered None services admission 130 day limit / year. Prior authorization Home health care No charge Not covered required. If you need help Outpatient: $20 / visit Outpatient: 20 visit limit / therapy / year. Prior recovering or have Rehabilitation services Inpatient: $100 / day up to $500 Not covered authorization required. other special health / year Inpatient: Prior authorization required. needs Outpatient: $20 / visit Outpatient: 20 visit limit / therapy / year. Prior Habilitation services Inpatient: $100 / day up to $500 Not covered authorization required. / year Inpatient: Prior authorization required. 12020_1190-051_KWM_SBC-W-LG-TRAD-XX_{496175}_{C20D - 2020 PLAN D CUSTOM}_107201911281 Rev. (11/16) 3 of 6 What You Will Pay Common Limitations, Exceptions, & Other Important Services You May Need Select Provider Non-Participating Provider Medical Event Information (You will pay the least) (You will pay the most) 100 day limit / year. Prior authorization Skilled nursing care No charge Not covered required. Durable medical Subject to formulary guidelines. Prior 20% coinsurance Not covered equipment authorization required. Hospice services No charge Not covered Prior authorization required. Children’s eye exam No charge for refractive exam Not covered None If your child needs Limited to one pair of frames and lenses or Children’s glasses No charge Not covered dental or eye care contact lenses / 12 months. Children’s dental check-up Not covered Not covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Cosmetic surgery • Non-emergency care when traveling outside • Routine foot care • Dental care (Adult & Child) the U.S • Weight loss programs • Long-term care • Private-duty nursing Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Chiropractic care (12 visit limit / year) • Acupuncture (physician referred) • Infertility treatment • Hearing aids (Adult - $1500 limit / ear, every 3 • Bariatric surgery • Routine eye care (Adult) years) 12020_1190-051_KWM_SBC-W-LG-TRAD-XX_{496175}_{C20D - 2020 PLAN D CUSTOM}_107201911281 Rev. (11/16) 4 of 6 Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is shown in the chart below. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan.
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