Deductible HMO plans Q_A

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					Q&A   Deductible HMO plans

      With a deductible HMO plan, your clients can select from multiple plan
      designs to fit their employees’ needs—and protect their bottom line with
      affordable premiums. This Q&A will help you answer your clients’ questions
      about Kaiser Permanente’s deductible HMO plans.

      General information
      Q: What makes a deductible HMO plan different from a traditional HMO plan?

      A: For the employer, the most important difference between a deductible HMO plan and
        our traditional HMO plan is the lower monthly premium they’ll pay with a deductible
        HMO plan. Other differences include:

        • A medical deductible—which is a set amount the member is responsible for paying
          in full for certain covered services in a calendar year. After they’ve reached the
          deductible, they’ll pay just a copayment or coinsurance for covered services,
          depending upon their plan.

        • Out-of-pocket maximum—even if a member has reached the deductible, their
          medical expenses could continue to add up if they have a serious illness or get into
          a major accident. The deductible HMO plan offers peace of mind knowing there’s
          an annual out-of-pocket maximum. For most services, when a member spends
          money on care—whether to reach the deductible or for copayments or coinsur-
          ance—that amount counts toward the out-of-pocket maximum. Once the limit is
          reached, Kaiser Permanente will pay for most covered services for the rest of the
          calendar year.

        • Preventive care—even before members meet the deductible, most preventive care
          services—like routine physical exams, mammograms, and cholesterol screenings—
          are available at little or no cost.

      Q: Do deductible HMO members receive the same care as HMO members?

      A: Members receive the same high-quality care from all our plans. They can:

        • Choose a personal physician

        • Access a variety of medical services, from lab tests to X-rays to pharmacy services,
          often under the same roof

        • Attend Healthy Living classes and programs on topics like yoga and weight man-
          agement (some classes may require a fee)

        • Use online tools to manage their health anywhere, anytime
Q: What does “subject to the deductible” mean?                    Q: Do prescription drugs apply to the medical deduct-
                                                                     ible or out-of-pocket maximum?
A: When a service is subject to the deductible, a member
   pays full charges until they meet their deductible. When       A: Prescription drugs do not apply to the medical
   a service is not subject to a deductible, a member pays           deductible or out-of-pocket maximum on the
   a copayment or coinsurance for services, depending                deductible HMO and deductible HMO with health
   upon their plan.                                                  reimbursement arrangement (HRA) plans. Although
                                                                     some of these plans have a separate brand-name
Q: Are office visits subject to the deductible?                      drug deductible, on the health savings account
A: For some of our deductible HMO plans, office visits               (HSA)–qualified plans, prescription drugs apply to
   are not subject to the deductible. Preventive services            a combined medical and pharmacy deductible.
   like routine adult physical examinations and immuniza-
   tions are never subject to a deductible. To see specific       Plan availability
   plan information and a list of preventive services,
                                                                  Q: What types of deductible HMO plans are available
   please visit
                                                                     to large employer groups?

Q: Which services are not subject to the deductible?              A: Large employer groups (51 or more employees) can
                                                                     select from four deductible HMO plan types:
A: All deductible HMO plans provide preventive care visits
   and preventive screenings without members having                  • Hospital services—inpatient, outpatient, and
                                                                       emergency hospital services are subject to the
   to meet their deductible. Most preventive services
                                                                       deductible; all other services are not.
   are covered at little or no cost to members. Visit              • Preventive care services and doctor’s office visits—
                                                                       preventive care visits, preventive screenings, and
   to see which preventive services are not subject to
                                                                       doctor’s office visits are not subject to the deduct-
   the deductible.                                                     ible. All other services are subject to the deductible.

Q: Is the deductible amount based on calendar year                   • Preventive care services—preventive care visits and
                                                                       preventive screenings are not subject to the deduct-
   or plan year?
                                                                       ible. All other services are subject to the deductible.
A: Deductible amounts are based on the calendar year                 • Preventive care services (HSA)—preventive care vis-
   for all deductible HMO plans. Any dollars accrued                   its and preventive screenings are not subject to the
   toward the deductible will reset to $0 on January 1                 deductible for a high deductible health plan paired
                                                                       with an HSA account. It has a combined medical
   of the following year.
                                                                       and pharmacy deductible. All other services are
                                                                       subject to the deductible.
Q: Do Kaiser Permanente deductible HMO plans ever
   limit office visits?                                                To see a complete list of deductible plans available
                                                                       for large groups, go to
A: Our deductible HMO plans do not limit office visits.
   Depending on the type of care provided and whether
   members have reached their deductible that year,
   they simply pay a copayment, coinsurance, or the
   estimated cost of service at check-in.

Q: What types of deductible HMO plans are available               Q: Is there a deductible HMO plan available to
   to small business groups?                                         COBRA members?

A: Small business groups (2 to 50 employees) have three           A: COBRA benefits are driven by the group. If an em-
   deductible HMO plan types:                                        ployer offers a deductible HMO plan to the group’s

   • Preventive care services and doctor’s office                    current employees, COBRA-eligible members may
     visits—doctor’s office visits, preventive care visits,          elect it.
     and preventive screenings are not subject to the
     deductible. All other services are subject to the            Q: Is there a deductible HMO conversion plan?
                                                                  A: There are no group-level conversion plans available
   • Preventive care services—only available to small
                                                                     at this time. We offer two traditional HMO individual
     business groups when paired with an HRA; preven-
     tive care visits and preventive screenings are not              plans as conversion plans—the $25 and $50 copay-
     subject to the deductible. All other services are               ment age-rated plans. We also offer individual deduct-
     subject to the deductible.                                      ible HMO conversion plan options.
   • Preventive care services (HSA)—preventive care
     visits and preventive screenings are not subject to
     the deductible for a high deductible health plan
                                                                  Costs to members
     paired with an HSA account. It has a combined                Predicting the cost of care
     medical and pharmacy deductible. All other
     services are subject to the deductible.                      Q: What is the average member cost for an office visit?

   To see a complete list of deductible plans available for       A: Member costs are comparable to industry averages

   large groups, go to                             for similar HMO or preferred provider organization
                                                                     (PPO) plans. An office visit generally ranges in cost
Q: Can existing Kaiser Permanente groups move from                   from $40 to $90, depending on the types of services
   a Kaiser Permanente traditional HMO plan to a                     provided, but could be higher for more complex
   deductible HMO plan?                                              medical exams and consultations. However, most
                                                                     preventive services are covered at little or no cost to
A: Yes. You can move existing groups to our deduct-
                                                                     the member. Additional services such as labs and
   ible HMO plan upon renewal or at midyear. For small
                                                                     imaging are not included in the cost of an office visit.
   groups, HMO to deductible HMO plan changes can
   occur as long as they’re not within 120 days of renewal.       Q: Can members estimate the cost of services?
   Amounts paid toward the out-of-pocket maximum
   on the traditional HMO plan will not carry over to the         A: Yes. By using our sample fee list and treatment fee tool

   deductible HMO plan.                                              at, members can estimate
                                                                     the cost of their upcoming services. Note that actual
Q: Is there a Kaiser Permanente deductible HMO plan                  amounts billed may differ from the estimate depending
   for Medicare members?                                             on services received at the point of care. If the service
                                                                     they need is not on this list, they can call our Member
A: No. Our deductible HMO plans are not designed for
                                                                     Service Call Center toll free at (800) 464-4000, Monday
   Medicare members. But active group employees who
                                                                     through Friday, 7 a.m. to 5 p.m.
   are eligible for Medicare but haven’t enrolled with
   Medicare may enroll in a group-sponsored deductible
   HMO plan.

At the point of service                                          After service is provided

Q: Are members required to pay at the point of service?          Q: Will members receive a bill after receiving care?

A: Yes. Members are expected to pay for scheduled                A: Members will receive a bill if:
   services at check-in. Members may pay with                       • They didn’t pay the full amount for their scheduled
   cash, check, credit card, or personal debit card.                  service at check-in
   Members can also use their HRA or HSA funds to
                                                                    • They incurred additional charges (such as fees for
   pay for services. They will be billed later for any                labs or other treatment) that were not prepaid at
   other remaining charges for the scheduled care                     check-in during a scheduled office visit
   or for additional services received during the visit.            • There was a change in their plan’s eligibility
                                                                      or benefits
Q: If members are unable to pay at the time of service,
   will they be billed?                                          Q: What if a member overpays at the point of service?

A: Yes. Depending on the amount members have                     A: Overpayments will be applied to future charges unless
   accrued toward the deductible, they will be asked to             members request a refund by calling the Member
   pay for all or a portion of the cost of their scheduled          Service Call Center toll free at (800) 464-4000.
   services at check-in and are expected to pay for those           A representative will verify the refund request and
   services at that time. Medical services will never be            ensure that there are no outstanding charges. Upon
   delayed or deferred based on the member’s ability                confirmation, a check will be mailed to the member’s
   to pay at the point of service. However, members who             home address. In the case of a flexible spending
   are unable to pay the specified amount at check-in               account, HSA, or HRA overpayment, the refund will
   may be asked to pay a portion of the cost and billed             be issued back to the issuing account.
   for the remainder. Many of our medical facilities are
   staffed with financial counselors (either onsite or           Q: How can deductible HMO members track whether
   by phone) who are available to speak to members,                 they’ve met the deductible or their out-of-pocket
   if needed.                                                       maximum?

                                                                 A: Once members receive services, they receive
Q: Will the amount accumulated toward the deductible
                                                                    a Summary of Accumulation (SOA) which lists
   be current when the member comes in for care?
                                                                    service descriptions and summarizes amounts that
A: If care was provided recently—usually within the past            accumulate toward the deductible and out-of-pocket
   30 to 45 days—the information may not have been                  maximum. The SOA is then sent out every month
   processed or available at check-in. Members should               there is activity. The SOA is not a bill. If members have
   inform check-in staff about care they’ve recently                any outstanding payments due for services received,
   received. If members believe they’ve reached the                 they’ll also receive separate bills for those services.
   deductible, they will be charged as if the deductible            To view a sample SOA or bill, download the Paying
   has been met and will be billed later if there is any            for Care brochure in the Understanding Your Costs
   remaining balance.                                               section of

Q: Can Kaiser Permanente provide brokers with claim                 Q: Does Kaiser Permanente allow takeover of deductible
   information, payment detail, and other member                       credits from a previous non–Kaiser Permanente plan?
   billing information?
                                                                    A: Yes, large groups can elect to purchase a takeover op-
A: No. Under the current federal HIPAA privacy law,                    tion. With this option, any deductible or out-of-pocket
   it is unlawful for health plans or providers to release             maximum credits applied during the 90 days before a
   a member’s billing or claim payment information to                  member’s effective date with Kaiser Permanente will
   anyone other than the individual member without the                 apply toward the member’s new plan. HSA-qualified
   member’s express consent. This includes reports on                  plans are not eligible for takeover. Takeover is not
   member charges, deductible accumulation, and/or                     allowed for small business groups.
   payments. Brokers and employers must obtain and
   present a signed authorization to release personal
                                                                    Deductible funding arrangements
   billing and claims payment information from each
                                                                    Q: Which Kaiser Permanente deductible HMO plans allow
   individual member. To obtain a patient consent form,
                                                                       employers to contribute to employees’ cost share?
   call the Client Services Unit toll free at (800) 731-4661.
                                                                    A: Employers who want to contribute to their employees’
                                                                       medical cost sharing must choose from our suite of
Carryover/takeover of deductible credits
                                                                       consumer-directed health care deductible HMO plans
Q: Can deductible credits carry over?
                                                                       designed to be paired with either HSAs or HRAs:
A: Most of the time, the medical deductible and out-of-
                                                                       • Employers who choose a Kaiser Permanente
   pocket credits carry over if a group makes a midyear                  deductible HMO plan with HRA must contribute
   plan change from one Kaiser Permanente deductible                     to an employee’s HRA.
   HMO plan to another. The exception is when a group
                                                                       • Employers can fund an employee’s HSA only if the
   moves from a Kaiser Permanente non-HSA-qualified                      employee is enrolled in a Kaiser Permanente HSA-
   plan to a Kaiser Permanente HSA-qualified plan or                     qualified deductible HMO plan. Contributions must
   vice versa.                                                           be made in accordance with federal tax laws for
                                                                         HRAs and HSAs.
   For those plans that have a separate pharmacy
                                                                       For more information, go to the Working With Us sec-
   deductible, the pharmacy deductible credits never
                                                                       tion on, choose your area, and click
   carry over. Note that HSA-qualified plans have a
                                                                       on “Kaiser Permanente policies” under Compliance.
   combined medical and pharmacy deductible. When
   groups move between HSA-qualified plans, the entire
   deductible will carry over.

   A large group with a deductible HMO or deductible
   HMO with HRA plan can elect to purchase a fourth-
   quarter carryover option. With this option, any credits
   accumulated toward the deductible and out-of-pocket
   maximum between October 1 and December 31 will
   apply toward the following calendar year.

                                                                    Q: Are there any restrictions on employer contributions

                                          or reimbursement with our deductible HMO plans?

                                     A: Except as described previously with Kaiser Permanente consumer-directed health
                                          care product options, employers may not directly fund or reimburse employees
                                          for any Kaiser Permanente deductible, coinsurance, or copayment. This includes
                                          employer reimbursements of employee cost share through employee flexible spend-
                                          ing accounts or limited-purpose flexible spending accounts. These payments are
                                          always the employee’s financial responsibility.

                                          If a large group employer chooses to fund or directly reimburse employees for deduct-
                                          ibles, coinsurance, or copayments, the broker must inform their Kaiser Permanente sales
                                          executive or account manager prior to the start of any employer reimbursement. We will
                                          factor the funding arrangement into the group’s new or renewal process quotation.

                                     Where to go for help
                                     Q: What deductible HMO resources are available to help clients and their employees
                                          understand their deductible HMO plan?

                                     A: The following resources are available at

                                          • Paying for Care brochure—describes how the deductible HMO plan works and helps
                                             members understand how to read their bill and interpret the SOA

                                          • Sample fee lists and treatment fee tool—available for each Kaiser Permanente
                                             region to help members plan their health care costs
Please contact your
account manager or visit                  • Sample Summary of Accumulation (SOA)—sent following any activity on the sub- for                         scriber’s account, this summary lists a running tally of expenses applied toward the
more information.                            individual and family deductible and out-of-pocket maximum

For your large accounts,                  • Sample bill—if the member has any outstanding liability for the services rendered,
you may contact the                          the member will receive a bill for the balance due
Client Services Unit toll                 •—online tools and resources to help deductible HMO plan
free at (800) 731-4661,                      members understand how the deductible HMO plan works and how they can make
Monday through Friday,                       the most of it
8 a.m. to 5 p.m.
                                          • Deductible plan comparison chart—a summary of the most frequently asked-about
For questions about your                     benefits of our deductible HMO plans for large groups
small business accounts,
please contact the Small
Business Unit toll free
                                    * Kaiser Foundation Health Plan, Inc., Kaiser Foundation Hospitals, and their affiliates do not provide or administer financial
at (800) 790-4661,                    products, including HSAs and HRAs, and do not offer financial, tax, or investment advice. Members are responsible for their
                                      own investment decisions. Consult qualified professionals to discuss your situation.
Monday through Friday,
                                     Information in this publication was accurate at the time of production. For the most current information on our plans and
8:30 a.m. to 5 p.m.                  services, check with your sales executive or account manager.

Business Marketing Communications
49194 August 2010