Active Employees & Pre-Retirees Under Age 65 : 2017

Description

Full-Time Employee * Contribution Per Pay Period

Employee Only: $0
Employee & Spouse/Partner: $127.94
Employee & Children: $109.66
Employee & Family: $176.68

Employee Only: $15.56
Employee & Spouse/Partner: $160.64
Employee & Children: $137.70
Employee & Family: $221.84

Employee Only: $128.22
Employee & Spouse/Partner: $397.18
Employee & Children: $340.42
Employee & Family: $548.48

Employee Only: $58.44
Employee & Spouse/Partner: $210.08
Employee & Children: $180.06
Employee & Family: $290.10

Employee Only: $16.50
Employee & Spouse/Partner: $119.22
Employee & Children: $102.20
Employee & Family: $164.64

Part-Time Employee *
Contribution Per Pay Period

Employee Only: $169.24
Employee & Spouse/Partner: $419.37
Employee & Children: $359.46
Employee & Family: $579.13

Employee Only: $184.80
Employee & Spouse/Partner: $452.07
Employee & Children: $387.50
Employee & Family: $624.29

Employee Only: $297.46
Employee & Spouse/Partner: $688.61
Employee & Children: $590.22
Employee & Family: $950.93

Employee Only: $227.68
Employee & Spouse/Partner: $501.51
Employee & Children: $429.86
Employee & Family: $692.55

Employee Only: $164.46
Employee & Spouse/Partner: $374.02
Employee & Children: $320.60
Employee & Family: $516.50

Overview

You may use only Kaiser Permanente doctors and facilities except in emergencies.

The Stanford HealthCare Alliance ACO plan requires you designate a primary care provider to coordinate all of your care. You may visit any Stanford HealthCare Alliance network doctor or hospital. Some services require prior authorization from your primary care physician.

There is no benefit if you see a Non-Network provider, except for emergency care or when clinically appropriate and prior authorized by Stanford HealthCare Alliance.

You may visit any Aetna network doctor or hospital.

For certain services or procedures Aetna may require use of certain providers within their network.

There is no benefit if you see a Non-Network provider, except for emergency or urgent care.

You may visit any doctor or hospital. You receive a higher level of benefits when you use Blue Shield PPO providers. You are responsible for ensuring all providers are in the network.

When you see a Non-Network provider you are responsible for the balance of your bill that is not covered by Blue Shield. The Out-of-Pocket Maximum does not apply to the balance of the bill not covered by Blue Shield.

This plan is compatible with an individual Health Savings Account (HSA), that you establish at a financial institution of your choice.

You may visit any doctor or hospital. You receive a higher level of benefits when you use Blue Shield PPO providers. You are responsible for ensuring all providers are in the network.

When you see a Non-Network provider you are responsible for the balance of your bill that is not covered by Blue Shield. The Out-of-Pocket Maximum does not apply to the balance of the bill not covered by Blue Shield.

This plan is compatible with an individual Health Savings Account (HSA), that you establish at a financial institution of your choice.

Pre-Authorization Requirement

Pre-authorization required for all elective inpatient and outpatient procedures.

PENALTY for not pre-authorizing: not covered.

Pre-authorization from your primary care provider is required for the following services: Advanced Imaging (CT, MRI, MRA and PET); all electively scheduled inpatient admissions; all elective outpatient procedures (example- endoscopic procedures, arthroscopic procedures, epidural steroid injections, etc.); physical therapy; durable medical equipment; speech therapy.

PENALTY for not pre-authorizing: the services will be considered not covered by the plan and the member is responsible for the full amount of the service.

Pre-authorization required for all elective inpatient and outpatient procedures.

PENALTY for not pre-authorizing: benefit reduced to 50% of Aetna Allowed Amount. You pay balance of all charges not covered by Aetna. Out-of-pocket maximum does not apply.

Pre-authorization required for all hospital stays and certain outpatient procedures.

PENALTY for not pre-authorizing: benefit reduced to 50% of Blue Shield Allowed Amount. Maximum reduction of $1,000. You pay balance of all charges not covered by Blue Shield. Out-of-pocket maximum does not apply. Certain benefits may be denied in full for failure to pre-authorize.

Pre-authorization required for all hospital stays and certain outpatient procedures.

PENALTY for not pre-authorizing: benefit reduced to 50% of Blue Shield Allowed Amount. Maximum reduction of $1,000. You pay balance of all charges not covered by Blue Shield. Out-of-pocket maximum does not apply. Certain benefits may be denied in full for failure to pre-authorize.

Care Management

Kaiser Permanente’s Complete Care℠, is a comprehensive multidisciplinary approach to identifying and treating members with chronic conditions. It addresses a wide range of chronic and acute conditions and comorbidities with a focus on prevention, risk reduction, and self-care. The program is integrated into the patient-centered, “whole person” continuum of care provided.

Program features include: Multidisciplinary disease management and case management; sophisticated electronic health information management and disease registries; proactive, targeted screening, intervention, and outreach; extensive support for implementing best practices and improved panel management; member self-care tools for improving health and quality of life; and health education to support self-management.

Participation in care management required for certain conditions and diseases.

Participation in care management required for certain conditions and diseases.

Participation in care management optional

Participation in care management optional

Deductible

No deductible

No deductible

No deductible

$1,750 per individual coverage/$3,500 per family coverage

Combined Network or Non-Network. Up to $2,600 of an individual's claims will apply toward the family deductible, and once that threshold is met the plan will begin sharing the costs for that individual.

$3,250 per individual coverage/$6,500 per family coverage in-network

$6,500 per individual coverage/$13,000 out-of-network. Up to $2,600 of an individual's claims will apply toward the family deductible, and once that threshold is met the plan will begin sharing the costs for that individual.

Office copay

$30 copay primary/$50 copay specialist

$30 copay primary/$75 copay specialist

$30 copay primary/$75 copay specialist

Network: 80% after deductible

Non-Network: 60% after deductible

Network: 60% after deductible

Non-Network: 50% after deductible

Coinsurance

100% after applicable copays

Network: 100% for preventive care; 80% after deductible for all other services, including prescriptions

Non-Network: 60% of allowed charges after deductible, including prescriptions

Network: 100% for preventive care; 60% after deductible for all other services, including prescriptions

Non-Network: 50% of allowed charges after deductible, including prescriptions

Out-of-Pocket Maximum

$3,500 per individual (in single employee enrollment or in family enrollment)
$7,000 family

A single out-of-pocket maximum applies to all coverage under the plan, including medical and prescription drugs. (This will cover prescriptions and medical expenses at 100% once the out-of-pocket maximum is met.)

$3,500 per individual/$7,000 family

A single out-of-pocket maximum applies to all coverage under the plan, including medical and prescription drugs. (This will cover prescriptions and medical expenses at 100% once the out-of-pocket maximum is met.)

$3,500 per individual/$7,000 family

Combined Network or Non-Network. A single out-of-pocket maximum applies to all coverage under the plan, including medical and prescription drugs. (This will cover prescriptions and medical expenses at 100% once the out-of-pocket maximum is met.)

$3,750 per individual/$7,500 per family

Combined Network or Non-Network

A single out-of-pocket maximum applies to all coverage under the plan, including medical and prescription drugs. (This will cover prescriptions and medical expenses at 100% once the out-of-pocket maximum is met.)

$6,500 per individual/$13,000 per family Network
$13,000 per individual/$26,000 per family Non-Network

A single out-of-pocket maximum applies to all coverage under the plan, including medical and prescription drugs. (This will cover prescriptions and medical expenses at 100% once the out-of-pocket maximum is met.)

Overall Lifetime Maximum Benefit