Kaiser evidence of coverage 2021

Kaiser evidence of coverage 2021 DEFAULT

Fact Sheet #2

This fact sheet is intended to help Navigators answer specific questions that people with disabilities might ask about getting and using health plans’ Evidence of Coverage documents when purchasers are considering buying health insurance through the Marketplace

Click here for a pdf version of this Fact Sheet
Click here for a pdf version of a 1 page summary of this Fact Sheet

Q1. What is Evidence of Coverage?

A. The Evidence of Coverage (EOC) is a document that describes in detail the health care benefits covered by the health plan. It provides documentation of what that plan covers and how it works, including how much you pay. The EOC can also refer to a certificate or contract provided to a health plan member that contains information about coverage and other rights.

See the fact sheet on “Summary of Benefits and Coverage (SBC)”

Q2. Can I get the Evidence of Coverage for a plan I am considering buying?

A. First, check the health plans website to see whether the evidence of coverage is posted. Many health plans do not provide the Evidence of Coverage documents until you have purchased a health plan and are a paid member. However, if you need to know whether a health plan covers benefits you need, you can try asking for the EOC document from the plan before enrolling. You might find that it can be difficult to get the EOC, though, before you enroll in the plan.

We will be researching whether some states have laws that require some health plans to make the EOC available to people who are considering purchasing a plan, but this will vary depending on the state. For instance, California requires health plans to provide EEOC upon request.* If you cannot get the EOC through the plan, you should consider contacting your state’s department of insurance to learn if the state requires health plans to provide the EOC on request. If your state requires the plans to make the EOC available on request, then you should formerly request it from the plans whose policies you are considering.

Q3. What information can I get from the EOC?

A. The EOC provides information on payment (premiums, deductibles, copayments, coinsurance) eligibility, enrollment, and how to get services. It will also explain how to get services as well as the plan’s policy on benefits and cost sharing, including limitations. For example, a managed care health plan might require that you receive services only from Plan Providers. The EOC will also explain what services are not covered and any deductibles, copayments, and coinsurance you must pay, if any, for each covered service. For example, the plan might provide vaccines and tests used to identify disease such as mammograms, for free. It might charge a $30 copayment per day for inpatient physical, occupational, or speech therapy provided in a rehabilitation setting while not covering eyeglasses at all. It will also explain how much cost sharing the plan requires. This means how much money you must pay out of pocket every year until you reach the annual limit. The EOC will also explain how to file a grievance or appeal if you disagree with the plan&#;s decision about your care. In some states, a grievance is simply a complaint that service wasn’t good, rather than a request for review of a denial of coverage.

Q4. What can I do if the EOC does not provide the information I need?

A. In some cases, the EOC might refer you to member services for more information. If you live in a state that requires the plan to provide the EOC to you on request, then it is possible that member services will also be required to answer your questions. It is also possible that you will not be able to get this information before you purchase a plan.


* Section (6)(A)(i) of California’s Knox-Keene Health Care Service Plan Act as amended requires that managed care health plans’ disclosure form state that the Evidence of Coverage discloses the terms and conditions of coverage, and Section (6)(A)(ii) requires that the disclosure form state that the applicant has a right to view the Evidence of Coverage prior to enrollment and also specifies where the Evidence of Coverage can be obtained prior to enrollment.

Sours: https://nationaldisabilitynavigator.org/ndnrc-materials/fact-sheets/fact-sheet-2/

What to know about Kaiser Medicare dental coverage

Medicare covers many health-related services, but this usually excludes dental procedures.

If a person needs dental treatments, they may need to get additional dental coverage or enroll in a Medicare Advantage plan that offers dental benefits. Kaiser Permanente (Kaiser) are an example of a Medicare Advantage plan provider who offer dental services in their plans.

This article will explore Kaiser’s plans, including the dental benefits. It will also look at coverage and costs.

We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:

  • Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
  • Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
  • Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.

Kaiser are based in California and include the Kaiser Foundation Health Plan, the Permanente Medical Groups, and the Kaiser Foundation Hospitals and their subsidiaries.

The nonprofit health plan currently operates in eight states and the District of Columbia. In , an estimated million people were enrolled in the Kaiser health plans.

The Centers for Medicare and Medicaid Services rate Medicare Advantage (Part C) plans using a 5-star system, with 5 stars being the highest rating.

For , more than 20 Medicare Advantage plans got 5-star ratings, and Kaiser was represented in six plans nationwide. These were:

  • Kaiser Foundation HP (California)
  • Kaiser Foundation HP of Colorado
  • Kaiser Foundation HP of Georgia, Inc.
  • Kaiser Foundation HP (Hawaii)
  • Kaiser Foundation Health Plan of the Mid-Atlantic (Washington D.C., Maryland, and Virginia)
  • Kaiser Foundation HP of the NW (Oregon and Washington)

Considerations for star ratings include customer service, care coordination, screenings, coverage, and timely decisions regarding coverage appeals.

In , Kaiser offer services in the following regions:

  • California (Northern and Southern)
  • Colorado (Northern, Southern, and the Denver/Boulder area)
  • Georgia
  • Hawaii
  • Maryland
  • Oregon
  • Virginia
  • Washington
  • Washington D.C.

Most of the company’s plans are Health Maintenance Organization (HMO) plans, which means that enrollees need to use the plan’s in-network doctor and healthcare facilities.

Kaiser also offer some Special Needs Plans, which aim to help people with special health or financial needs.

Two plan types include dental coverage: the Kaiser Permanente Senior Advantage Basic (HMO) and the Kaiser Permanente Senior Advantage Enhanced (HMO).

Both plans include the following preventive and diagnostic dental services:

  • two oral exams
  • two teeth cleanings
  • two X-rays per calendar year

The table below outlines some costs for these plans:

Comprehensive coverage

In many areas, Kaiser offer an option of additional coverage known as Advantage Plus, which incurs an additional premium of $13 but provides comprehensive dental care.

Comprehensive dental care benefits vary based on the region. For example, in Kaiser’s Northern California region, a person enrolled in the Advantage Plus program and visiting an in-network dental provider would pay $0 for many preventive services, including oral evaluations, X-ray images, and caries risk assessments.

There may be additional costs, depending on the service the person uses. People can check this using the company’s Evidence of Coverage document.

In addition to preventive services, comprehensive services may also cover other procedures. The list below outlines some of these for the Northwest region:

  • restorative work, such as a composite, one-surface filling ($97) or crown ($ for resin with high noble metal)
  • endodontic procedures, such as a root canal ($ for an anterior tooth)
  • oral and maxillofacial surgery, such as the extraction of an erupted tooth ($80)
  • periodontal services, such as scaling and root planing ($ for four or more teeth per quadrant)
  • prosthodontics services, such as partial or complete dentures ($ for complete maxillary or upper dentures)

Medicare Advantage (Part C) is an alternative to original Medicare and offers the same basic coverage. Some plans may also offer additional benefits, such as dental, hearing, and vision coverage. Some plans also include prescription drug coverage.

Private health insurance companies offer these plans, though a person will continue to pay their Medicare Part B premium, which is $ in There may also be an additional Medicare Advantage plan premium, depending on the individual plan a person chooses.

Learn more about Medicare Advantage here.

Kaiser’s Medicare Advantage plan costs vary by region. A person can use this online tool to research the plans.

The costs for supplemental dental insurance and copays vary, and some Kaiser plans do not offer dental coverage. The table below provides more detail:

Kaiser’s Medicare Advantage plans offer basic or comprehensive dental coverage.

Before selecting a Kaiser dental plan, a person should check that their dental provider accepts it to ensure the greatest cost savings.

Plan premiums may vary based on a person’s region and the services they use.

Sours: https://www.medicalnewstoday.com/articles/does-kaiser-medicare-cover-dental
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Integrated Health Model (IHM) Plan

The Integrated Health Model Plan with Kaiser Permanente is not just health coverage — it’s a partnership in health. You receive most preventive care services at little or no cost to you, and online features let you manage most of your care around the clock. Your benefits include:

Your choice of a primary care physician for each family member for routine medical care

Simple copayments for most covered services

Virtually no paperwork to fill out, no bills, and no deductibles

No referrals needed for certain specialties, like optometry and routine obstetrics/gynecology

Your Evidence of Coverage or Summary Plan Description contains a complete explanation of benefits, exclusions, and limitations. The information provided here is not intended nor designed to serve as your Evidence of Coverage.

Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. in Maryland, Virginia, and Washington, D.C., E. Jefferson St., Rockville, MD

Integrated Health Model (IHM) Plan Downloads

Effective 1/1/ - 12/31/21

Effective 01/01/ - 12/31/

Additional benefit information

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Sours: https://my.kp.org/maryland/plan-details/state-of-maryland/
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Kaiser Permanente

There are two LACERA-administered Kaiser Permanente plans, a group model Health Maintenance Organization (HMO) plan and a Medicare Advantage Prescription Drug Plan HMO (MAPD HMO).

Group Model HMO

The Kaiser Permanente HMO is a group model plan, meaning that the HMO owns and operates the facility, and the physicians are HMO employees. The Kaiser HMO is available to all eligible retired LACERA members and their eligible dependents, based on service area availability.

Availability (Both Plans)

Current service areas are California, Hawaii, Georgia, Colorado (Denver area only), Oregon, and Washington. Service areas are subject to change. Contact us for more information regarding availability.

Features of this plan are:

  • Medical care must be received from a Kaiser physician at a Kaiser facility, except for a life-threatening emergency authorized by Kaiser.
  • No deductibles or annual benefit maximum amounts, except for skilled nursing care and mental health
  • No claim forms
  • Copayments are required for certain services
  • Continued enrollment if you are covered under Kaiser and move out of California to a state where a LACERA-administered Kaiser plan is also available, providing you contact LACERA and complete an enrollment form. Current service areas are Hawaii, Georgia, Colorado (Denver area only), Oregon, and Washington.

Senior Advantage MAPD HMO

The Kaiser Senior Advantage Medicare Advantage Prescription Drug Plan (MAPD) HMO is available to all eligible retired LACERA members and their eligible dependents, based on service area availability, who are enrolled in both Medicare Parts A and B.

Combined coverage: If you have Medicare Parts A and B and enroll in the Kaiser Senior Advantage MAPD plan, your non-Medicare eligible family members must enroll in the Kaiser Basic plan. See more about combined coverage on the Parts A and B page.

Features of this plan are:

  • All medical care must be received from a Kaiser physician at a Kaiser facility, except for a life-threatening emergency authorized by Kaiser.
  • No deductibles or annual benefit maximum amounts, except for skilled nursing care and mental health
  • No restrictions on coverage for pre-existing conditions
  • No claim forms
  • Small copayments for office visits
  • Health classes are available to develop healthy lifestyles
  • Medicare Part B premiums reimbursed by the County on a tax-free basis
  • Continued enrollment if you move out of California into another state that has Kaiser plans
  • Silver&Fit® Exercise and Health Aging Program

Evidence of Coverage

For full details of the services, coverage, and costs of care provided by your specific medical plan, review your latest Evidence of Coverage below. 

In State

Kaiser Permanente Traditional Plan—Southern California
Kaiser Permanente Traditional Plan—Northern California

Kaiser Permanente Senior Advantage with Part D—Southern California
Kaiser Permanente Senior Advantage with Part D—Northern California

Out of State

Kaiser Permanente (Colorado) Medicare
Kaiser Permanente (Colorado) Non-Medicare
Kaiser Permanente (Georgia)
Kaiser Permanente (Hawaii)
Kaiser Permanente (Oregon)

Sours: http://www.lacera.com/healthcare-plans/kaiser-permanente

Coverage 2021 kaiser evidence of

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