Summary of Benefits and Coverage: What this plan covers and What You Pay For Covered Services.Coverage for: Individual / FamilyPlan type: HMOKaiser Permanente: KP SILVER 2700/35/50/S10 ONCoverage Period: Beginning on or after 01/01/2023
Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after
01/01/2023
Kaiser Permanente Insurance Company
: KP SILVER 2700/35/50/S10 ON Coverage for: Individual / Family
| Plan Type: HMO
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 1-888-865-5813 (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 www.healthcare.gov/sbc-glossary/ or call
1-888-865-5813 (TTY: 711) to request a copy.
Important Questions Answers Why this Matters:
What is the overall
deductible?
$2,700 Individual / $5,400 Family
Generally, you must pay all of the costs from providers up to the deductible
amount before this plan begins to pay. If you have other family members on the
plan, each family member must meet their own individual deductible until the
total amount of deductible expenses paid by all family members meets the
overall family deductible.
Are there services
covered before you meet
your deductible?
Yes. Preventive care and services indicated in
chart starting on page 2.
This plan covers some items and services even if you haven’t yet met the
deductible amount. But a copayment or coinsurance may apply. For example,
this plan covers certain preventive services without cost sharing and before you
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
services?
Yes. $450 Individual / $900 Family for Brand, Non
Preferred and Specialty Drugs. There are no other
specific deductibles.
You must pay all of the costs for these services up to the specific deductible
amount before this plan begins to pay for these services.
What is the out-of-pocket
limit for this plan?
$8,900 Individual / $17,800 Family
The out-of-pocket limit is the most you could pay in a year for covered services. If
you have other family members in this plan, they have to meet their own out-of-
pocket limits until the overall family out-of-pocket limit has been met.
What is not included in
the out-of-pocket limit?
Premiums, health care this plan doesn't cover, and
services indicated in chart starting on page 2.
Even though you pay these expenses, they don't count toward the out-of-pocket
limit.
Will you pay less if you
use a network provider?
Yes. See www.kp.org or call 1-888-865-5813 (TTY:
711) for a list of network providers.
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 receive a bill from a provider for the difference between the provider’s
charge and what 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.
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Important Questions Answers Why this Matters:
Do you need a referral to
see a specialist?
Yes, but you may self-refer to certain specialists.
This plan will pay some or all of the costs to see a specialist for covered services
but only if you have a referral before you see the specialist.
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Common
Medical Event
Services You May
Need
What You Will Pay
Plan Provider
(You will pay the least)
What You Will Pay
Non-Plan Provider
(You will pay the most)
Limitations, Exceptions & Other Important
Information
If you visit a health
care provider's
office or clinic
Primary care visit to
treat an injury or
illness
$50 / visit, deductible does not
apply
Not covered None
Specialist visit
$80 / visit, deductible does not
apply
Not covered None
Preventive care/
screening/
immunization
No charge, deductible does not
apply
Not covered
You may have to pay for services that aren't
preventive. Ask your provider if the services
needed are preventive. Then check what your
plan will pay for.
If you have a test
Diagnostic test (x-
ray, blood work)
35% coinsurance regardless of
setting
Not covered None
Imaging (CT/PET
scans, MRI's)
$550 / scan regardless of
settings
Not covered None
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Common
Medical Event
Services You May
Need
What You Will Pay
Plan Provider
(You will pay the least)
What You Will Pay
Non-Plan Provider
(You will pay the most)
Limitations, Exceptions & Other Important
Information
If you need drugs to
treat your illness or
condition
More information
about prescription
drug coverage
is available at
www.kp.org/formulary
Generic drugs
$20 / prescription (retail),
deductible does not apply. $40 /
prescription (mail order),
deductible does not apply. $30 /
prescription (network
pharmacies), deductible does
not apply.
Not covered
Covers up to a 30 day supply (retail); 31-90 day
supply (mail order). Network Pharmacies limited
to one time fill. No charge for contraceptives
(subject to formulary guidelines).
Preferred brand
drugs
$50 / prescription (retail). $100 /
prescription (mail order). $70 /
prescription (network
pharmacies).
Not covered
Covers up to a 30 day supply (retail); 31-90 day
supply (mail order). Network Pharmacies limited
to one time fill. No charge for contraceptives
(subject to formulary guidelines). After $450
Individual / $900 Family Rx Deductible for KP/
Network Brand & Specialty drugs.
Non-preferred brand
drugs
$80 / prescription (retail). $160 /
prescription (mail order). $110 /
prescription (network
pharmacies).
Not covered
Covers up to a 30 day supply (retail); 31-90 day
supply (mail order). Network Pharmacies limited
to one time fill. After $450 Individual / $900
Family Rx Deductible for KP/Network Brand &
Specialty drugs.
Specialty drugs
35% coinsurance / prescription
(retail). 45% coinsurance /
prescription (network
pharmacies).
Not covered
Covers up to a 30-day supply (retail & network
pharmacies). Network Pharmacies limited to
one-time fill. Subject to formulary guidelines,
when approved through the exception process.
After $450 Individual / $900 Family Rx
Deductible for KP/Network Brand & Specialty
drugs.
If you have
outpatient surgery
Facility fee (e.g.,
ambulatory surgery
center)
35% coinsurance Not covered None
Physician/surgeon
fees
35% coinsurance Not covered None
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Common
Medical Event
Services You May
Need
What You Will Pay
Plan Provider
(You will pay the least)
What You Will Pay
Non-Plan Provider
(You will pay the most)
Limitations, Exceptions & Other Important
Information
If you need
immediate medical
attention
Emergency room
care
35% coinsurance 35% coinsurance None
Emergency medical
transportation
35% coinsurance 35% coinsurance None
Urgent care
$100 / visit, deductible does not
apply
Not covered
Non-Plan providers covered when temporarily
outside of the service area: $100 / visit,
deductible does not apply.
If you have a
hospital stay
Facility fee (e.g.,
hospital room)
35% coinsurance Not covered None
Physician/surgeon
fee
35% coinsurance Not covered None
If you need mental
health, behavioral
health, or substance
abuse services
Outpatient services
$50 / visit (individual), deductible
does not apply
Not covered $25 / visit (group), deductible does not apply.
Inpatient services 35% coinsurance Not covered None
If you are pregnant
Office visits 35% coinsurance Not covered
Cost sharing does not apply for preventive
services. Maternity care may include tests and
services described elsewhere in the SBC (i.e.
ultrasound.)
Childbirth/delivery
professional services
35% coinsurance Not covered None
Childbirth/delivery
facility services
35% coinsurance Not covered None
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Common
Medical Event
Services You May
Need
What You Will Pay
Plan Provider
(You will pay the least)
What You Will Pay
Non-Plan Provider
(You will pay the most)
Limitations, Exceptions & Other Important
Information
If you need help
recovering or have
other special health
needs
Home health care
No charge, deductible does not
apply
Not covered Coverage is limited to 120 visits / year.
Rehabilitation
services
$80 / visit (outpatient), deductible
does not apply. 35% coinsurance
(inpatient).
Not covered
Coverage is limited to 40 outpatient visits/
therapy/ year combined for Occupational and
Physical therapy. Speech therapy is limited to
40 outpatient visits/ therapy/ year.
Habilitation services
$80 / visit (outpatient), deductible
does not apply. 35% coinsurance
(inpatient).
Not covered
Coverage is limited to 40 outpatient visits/
therapy/ year combined for Occupational and
Physical therapy. Speech therapy is limited to
40 outpatient visits/ therapy/ year.
Skilled nursing care 35% coinsurance Not covered Coverage is limited to 150 days / year
Durable medical
equipment
35% coinsurance Not covered
Coverage is unlimited to items on our DME
formulary.
Hospice service
No charge, deductible does not
apply
Not covered None
If your child needs
dental or eye care
Children's eye exam
$50 / visit for refractive exam,
deductible does not apply
Not covered Coverage is limited to one exam / year.
Children's glasses
No charge, deductible does not
apply
Not covered
Eye wear provided to children up to age 19.
Coverage includes one pair of lenses &
collection frames or contact lenses / year.
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.)
● Acupuncture
● Bariatric surgery
● Cosmetic surgery
● Dental care (Adult)
● Hearing aids
● Infertility treatment
● Long-term care
● Non-emergency care when traveling outside
the U.S.
● Private-duty nursing
● Routine foot care
● Weight loss programs
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Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
● Chiropractic care (20 visit limit / year: Spinal
Manipulation only)
● Routine eye care (Adult) ●
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 on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or
assistance, contact the agencies in the chart below.
Contact Information for Your Rights to Continue Coverage & Your Grievance and Appeals Rights:
Kaiser Permanente Member Services 1-888-865-5813 (TTY: 711) or www.kp.org/memberservices
Department of Labor’s Employee Benefits Security Administration 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform
Department of Health & Human Services, Center for Consumer Information & Insurance Oversight 1-877-267-2323 x61565 or www.cciio.cms.gov
Georgia Department of Insurance 1-800-656-2298 or www.oci.ga.gov/
Does this plan provide Minimum Essential Coverage? Yes.
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,
CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax
credit.
Does this plan meet the Minimum Value Standards? Yes.
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services:
SPANISH (Español): Para obtener asistencia en Español, llame al 1-888-865-5813 (TTY: 711)
TAGALOG (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-888-865-5813 (TTY: 711)
CHINESE (中文): 如果需要中文的帮助，请拨打这个号码 1-888-865-5813 (TTY: 711)
NAVAJO (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-888-865-5813 (TTY: 711)
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
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About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different
depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles,
copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under
different health plans. Please note these coverage examples are based on self-only coverage.
Peg is Having a Baby
(9 months of in-network pre-natal care and a
hospital delivery)
The plan's overall deductible
Specialist copayment
Hospital (facility) coinsurance
Other (blood work) coinsurance
$2,700
$80
35%
35%
This EXAMPLE event includes services like:
Specialist office visits (prenatal care)
Childbirth/Delivery Professional Services
Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work)
Specialist visit (anesthesia)
Total Example Cost $12,700
In this example, Peg would pay:
Cost Sharing
Deductibles $2,700
Copayments $10
Coinsurance $3,400
What isn't covered
Limits or exclusions $50
The total Peg would pay is $6,160
Managing Joe's Type 2 Diabetes
(a year of routine in-network care of a well-
controlled condition)
The plan's overall deductible
Specialist copayment
Hospital (facility) coinsurance
Other (blood work) coinsurance
$2,700
$80
35%
35%
This EXAMPLE event includes services like:
Primary care physician office visits (including
disease education)
Diagnostic tests (blood work)
Prescription drugs
Durable medical equipment (glucose meter)
Total Example Cost $5,600
In this example, Joe would pay:
Cost Sharing
Deductibles $0
Copayments $1,800
Coinsurance $30
What isn't covered
Limits or exclusions $0
The total Joe would pay is $1,830
Mia's Simple Fracture
(in-network emergency room visit and follow up
care)
The plan's overall deductible
Specialist copayment
Hospital (facility) coinsurance
Other (x-ray) coinsurance
$2,700
$80
35%
35%
This EXAMPLE event includes services like:
Emergency room care (including medical supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)
Total Example Cost $2,800
In this example, Mia would pay:
Cost Sharing
Deductibles $400
Copayments $400
Coinsurance $600
What isn't covered
Limits or exclusions $0
The total Mia would pay is $1,400
The plan would be responsible for the other costs of these EXAMPLE covered services.
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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 communicate effectively 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 not English, 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 ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ 1-888-865-5813 (TTY: 711).
(Arabic) : . 1-888-865-5813 (TTY :).117
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）。
(Farsi) : . (711 :TTY) 1-888-865-5813 .
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).
ગજ
ુ
રાતી (Gujarati) સ
ુ
ચના:
, :
. 1-888-865-5813 (TTY: 711).
660577109_ACA_1557_MarCom_GA_2017_Taglines
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).
हिदी (Hindi) यान द
:
1-888-865-5813 (TTY: 711)
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 무료로 이용하실 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
t’áá jiik’eh, éí ná
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: если 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).
660577109_ACA_1557_MarCom_GA_2017_Taglines
