For more information. I can choose my doctor. Your 2013 CalPERS Enrollment Book

Transcription

1 Your 2013 CalPERS Enrollment Book For more information Visit us at kp.or/calpers or call our Member Service Contact Center, 24 hours a day, seven days a week (closed holidays) Enlish Spanish Chinese dialects TTY for the deaf, hard of hearin, or speech impaired I can choose my doctor Kaiser Foundation Health Plan, Inc Franklin St. Oakland, CA kp.or /calpers Please recycle. This material was produced from eco-responsible resources. Member and Marketin Communications [Month] 2012

2 A reat choice for ood health Kaiser Permanente is uniquely desined to ive you the information and support you need to live well, with everythin workin seamlessly toether. Better Informed. Better Toether. Makin smart decisions whether you re pickin a health plan for your family or dealin with a health condition can be easier than you think. All you need is a partner to ive you the riht information and support. Take a look at everythin you et with your membership, and you ll aree that Kaiser Permanente is the best choice for your health. your choice of top doctors With Kaiser Permanente, you et a wide choice of doctors from many of the top medical schools in the country. personalized care Your care team works with you, supported by your secure electronic health record which connects them to your up-to-date health info like lab test results, medications, and preventive screenins that are due. everythin under one roof Most of our locations include pharmacy, lab, and X-ray services, so you can do more and drive less. A better way to et and stay healthy Choose more than a health plan. We also offer our own reat doctors, convenient facilities, and advanced technoloy all toether in one easy-to-use packae. This makes it simple for you to et excellent, coordinated care. Excellent care Get an entire care team that works with you and for you. Your doctors, nurses, and specialists are connected to our electronic health record system, so they can work toether to provide the best care for your needs. lots of healthy extras Stay at your best with healthy resources like farmers markets and wellness classes, many of which are free. kp.or easy online access, anytime Use your computer, smartphone, or mobile device to your doctor s office, schedule routine appointments, view lab test results, refill prescriptions, and more. 1 a reat experience In the J.D. Power and Associates 2012 U.S. Member Health Plan Study SM, Kaiser Permanente ranked Hihest in Member Satisfaction amon Commercial Health Plans in California for the fifth year in a row. 2 Online access anytime, anywhere Stay better informed about your health and better able to manae it with online and mobile tools that help you et the information you want, when you want it. Convenient classes, resources, and more Take your health beyond checkups with a partner that provides the inspiration and support you need to live life to the fullest. Plans and locations Whatever your needs, we have a health plan with the resources and tools to help you stay healthy. And ettin the riht care is easy and convenient with our many locations throuhout California. 1 Available when you receive care at Kaiser Permanente facilities. 2 Kaiser Foundation Health Plan, Inc., received the hihest numerical score amon commercial health plans in the California reion in the proprietary J.D. Power and Associates U.S. Member Health Plan Studies SM study based on 32,868 total member responses, measurin eiht plans in the California reion (excludes Medicare and Medicaid). Proprietary study results are based on experiences and perceptions of members surveyed December 2011 January Your experiences may vary. Visit jdpower.com. Watch members share why they chose Kaiser Permanente at kp.or/thrive. 1

3 A better way to et and stay healthy Be better informed and take an active role in your health. You and your family et everythin you need to live well, and we work toether with you to help you make better choices every step of the way. Excellent care Get excellent care from doctors, nurses, and specialists who focus on you and your health. Your care team works toether, sharin best practices and coordinatin any specialty care you may need. This combination of teamwork and expertise helps make our doctors better informed, so they can provide the best care for your needs. What you need, when you need it Personalized care Everythin under one roof Your choice of top doctors Great specialists A focus on you and your family We make it simple for you to et care: easy-to-schedule appointments access to your doctor s office same-day, after-hours, and weekend services at many locations 24-hour telephone health advice from reistered nurses recent medical information and most test results online convenient locations emerency care coverae anywhere in the world Your doctors, nurses, and specialists take the time to know you and your health needs. Supported by your secure electronic health record, your entire care team is always up to speed and ready to take care of you. Havin a team that s informed and focused on you can lead to quicker, better dianoses and treatments. Most of our locations conveniently offer multiple services under one roof. You can see your doctor, et lab services and X-rays, and fill prescriptions all at the same place. That can help you save time and avoid drivin all over town. For prescription refills, you can even order online and have most mailed to your home with free shippin. Excellent care starts with havin a reat doctor. With Kaiser Permanente, you et a wide choice of skilled physicians from many of the top medical schools in the country. Our doctors are carin, supportive, and hihly respected in their fields, and many teach at prestiious universities throuhout the state. This makes it easy to find the one who s riht for you and your family. Just o online to view our doctor profiles or ive us a call. You also have access hihly trained specialists. They re ready to help dianose and treat most conditions that miht come up. Our doctors and specialists work toether, makin referrals easier. And you don t even need a referral for certain specialty departments, includin Obstetrics-Gynecoloy, Psychiatry, and Chemical Dependency Services. Our care model reduces the burden of administrative hassles, insurance claim forms, and other paperwork for our doctors, nurses, and specialists. And unlike most practitioners, our doctors aren t paid by procedure for most covered services. They re free to focus on what they do best deliver reat care that s riht for you. See how Kaiser Permanente has helped members at kp.or/carestories. Learn more about the doctors available in your area at kp.or/doctorsandlocations. Your electronic health record brins it all toether Our innovative electronic health record system is securely linked to every Kaiser Permanente facility in your reion, so you et coordinated care wherever you o. Your doctor s office Your electronic health record is updated with each visit, whether you see your personal physician or another Kaiser Permanente doctor. From department to department and facility to facility, your record oes where you o. Pharmacy, lab, and X-ray If your doctor prescribes you medications or orders lab tests, there s no paperwork to take with you. Just visit any of our pharmacies, and the pharmacist or technician will pull up your doctor s orders. Specialty care If your doctor refers you to a specialty department, you ll receive a call. When you come in, your specialist will have your health information riht at his or her finertips. At home or on the o My Health Manaer on kp.or is your personal link to your electronic health record. This set of online tools helps you stay connected and informed about your health. 2 3

4 Online access anytime, anywhere Plu into your health with a variety of online and mobile tools that help you et the information you want, when you want it. Whether you re on the o or just takin advantae of a quiet moment at home, we ve ot you covered. Convenient classes, resources, and more Fit wellness into your schedule, no matter how busy you are. We ive you lots of healthy extras that can help you stay informed about ways to live healthier mind, body, and spirit. And we ll work toether with you to provide the extra motivation you need to et started, stick with it, and maybe even cross a finish line. It s easy to stay connected A website full of healthy ideas Good health on the o Learn somethin new Fresh food in the parkin lot Maximize your health As a member reistered on kp.or, you have secure, 24- hour access to My Health Manaer. This online resource offers convenient tools for manain your care at our facilities. your doctor s office. View lab test results as soon as they re available. Refill prescriptions. Schedule or cancel routine appointments. Help take care of a family member, like a child or parent, usin these features and more. Get informed and inspired on our award-winnin website, kp.or. Take chare of your health anytime, anywhere, with online articles, wellness topics, and health calculators. And find new ways to live well with recipes from world-class chefs, music channels, podcasts, videos, and more. Our mobile apps make it easy to manae your health no matter where you are at home, at work, and when you re on the o. Just download our free apps for the iphone, ipad, or ipod touch from the App Store SM, or for the Android from Goole Play. Apple, iphone, ipad, and ipod touch are trademarks of Apple, Inc., reistered in the U.S. and other countries. App Store is a service mark of Apple, Inc. Android is a trademark of Goole, Inc. With the many health classes offered at our facilities, there s somethin for everyone. Try classes on yoa, eatin well, baby care, specific health conditions, and much more. Classes vary by location and some may require a fee. Eatin well is easier when you brin home fresh food from our farmers markets. They re conveniently located at many of our facilities, so you can pick up some healthy fruits and veies after your visit. Try our personalized online wellness prorams. They can help you lose weiht, stay active, reduce stress, sleep better, stop smokin, and much more. You can also download the free Every Body Walk! mobile app for your smartphone or mobile device from the App Store or Goole Play. It s a fun, interactive tool to help you create and maintain a daily walkin routine. For a uided tour of My Health Manaer, visit kp.or/experience. Find tools, tips, and information for livin well at kp.or/livehealthy. Top reasons to join Kaiser Permanente Better care You et reat care, backed by innovative technoloy. Your care team can securely access your up-to-date health information and make sure you et care that s riht for you. Better doctors You et top Kaiser Permanente doctors who aren t burdened with excessive insurance paperwork or paid by procedure. Their only focus and incentive is workin toether with you to deliver the care you really need. Better access You et information and tools that make it easy for you to et and stay healthy includin easy-to-schedule appointments, access to your doctor, telephone health advice, and helpful online tools. Better visits You et the convenience of bein able to take care of multiple services in one trip, with virtually no paperwork. At most locations, your doctor, lab services, X-rays, and pharmacy are all toether in one place. Watch members share why they chose Kaiser Permanente at kp.or/thrive. 4 5

5 Your CalPERS Basic Plan With your Kaiser Permanente health plan, your benefits include a wide rane of prorams and support to help you stay healthy. And you et a streamlined approach to care that helps you make choices simply and et thins done quickly so you can et well and et on with your life. Kaiser Permanente Senior Advantae (HMO) If you qualify for Medicare, the Kaiser Permanente Senior Advantae plan miht be riht for you. Our Medicare-eliible members enjoy health plans that celebrate independence and well-bein. Our plan ives you more benefits and services than Oriinal Medicare alone. Much more. And all at a value that will keep you feelin reat. The easier, the better Convenient access Call us to learn more Lower copays help protect your pocketbook Call us to learn more simple copays for most covered services, includin office visits and most prescriptions virtually no paperwork to fill out or bills for the services you receive no deductibles to keep track of or percentaes to fiure out no referrals for certain specialties, like optometry and obstetrics-ynecoloy When you need care, it s easy to find a Kaiser Permanente location near your home or work. Just visit kp.or/ doctorsandlocations or download our free Kaiser Permanente app for your smartphone or mobile device. Then use our convenient location finder to search by ZIP code or keyword. For an overview of our locations, see the facility maps in this brochure. For more information about your Basic Plan, visit kp.or/ calpers or call our Member Service Contact Center at , 24 hours a day, seven days a week (closed holidays). For TTY service for the hearin/speech impaired, call Here are just some of the benefits and services you can expect with our plan: low copays for routine preventive care and a $175 eyewear allowance every 24 months low copays for appointments with your personal physician Part D dru coverae includin drus throuh the coverae ap with low copays no chare for hospital services, X-rays, and lab tests a cap on medical expenses for the year, so your finances are always protected doctor s office, lab, and pharmacy services, often under one roof convenient online services, includin refillin most prescriptions and checkin most lab test results For more information about Kaiser Permanente Senior Advantae, call our Member Service Contact Center at or 711 (TTY for the hearin/speech impaired), 8 a.m. to 8 p.m., seven days a week. Kaiser Permanente is a health plan with a Medicare contract. You must reside in the Kaiser Permanente Senior Advantae service area in which you enroll. Benefits, formulary, pharmacy network, premiums, and copayments/coinsurance may chane on January 1 of each year and at other times in accord with your roup s contract with us. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. You must continue to pay your Medicare Part B premium and any other applicable Medicare premium(s), if not otherwise paid by Medicaid or another third party. 6 7

6 CalPERS summary of benefits for 2013 These benefits reflect the 2013 contract year. For a complete explanation of benefits, exclusions, and limitations, refer to the 2013 Combined Evidence of Coverae and Disclosure Form (Evidence of Coverae). For details about chanes to your prescription dru benefits, please see your Evidence of Coverae, and check with your aency for information about your monthly premiums. Find additional health resources to meet your needs. Get reduced rates on acupuncture, chiropractic care, and massae therapy, plus preferred rates on selected health club memberships at kp.or/choosehealthy. 1, 2 These convenient resources can help you stay on track for ood health. Physician services Hospital services Emerency care X-ray and lab tests Online service features (Available throuh My Health Manaer at kp.or/calpers) Prescription drus Routine preventive care Mental health Basic Plan $15 per visit No chare $50 per Emerency Department visit (does not apply if you are held for observation in a hospital unit outside the Emerency Department or if you are admitted directly to the hospital as an inpatient) No chare your doctor s office: No chare Take a total health assessment: No chare View most lab test results: No chare Schedule routine appointments: No chare View portions of your medical record: No chare Order prescription refills: No extra chare for delivery $5 eneric/$20 brand, up to a 30-day supply from a Plan pharmacy 3 $10 eneric/$40 brand, up to a 100-day supply by mail-order service (delivery at no extra chare) 3 Drus prescribed for treatment of sexual dysfunction now covered at 50% coinsurance for up to a 100-day supply from a Plan pharmacy or by mail-order service (delivery at no extra chare) 4 Periodic health exam: No chare Scheduled prenatal care and first postpartum visit: No chare Well-child visits (0 23 months): No chare Vaccines (immunizations): No chare Eye refraction exam: No chare (no chare for eyelasses or contact lenses followin cataract surery) Outpatient visits: $15 per individual visit; $7 per roup visit Inpatient psychiatric hospitalization: No chare Kaiser Permanente Senior Advantae (HMO) $10 per visit No chare $50 per Emerency Department visit (does not apply if you are held for observation in a hospital unit outside the Emerency Department or if admitted to the hospital as an inpatient within 24 hours for the same condition) No chare your doctor s office: No chare Take a total health assessment: No chare View most lab test results: No chare Schedule routine appointments: No chare View portions of your medical record: No chare Order prescription refills: No extra chare for delivery $5 eneric/$20 brand, up to a 30-day supply from a Plan pharmacy 3 $10 eneric/$40 brand, up to a 100-day supply by mail-order service (delivery at no extra chare) 3 Drus prescribed for treatment of sexual dysfunction now covered at 50% coinsurance for up to a 100-day supply from a Plan pharmacy or by mail-order service (delivery at no extra chare) 4 Periodic health exam: $10 per visit Scheduled prenatal care and first postpartum visit: $10 per visit Eye refraction exam and laucoma screenin: $10 per visit ($175 allowance for eyelasses and contact lenses every 24 months; no chare for eyelasses or contact lenses followin cataract surery, in accord with Medicare uidelines) Outpatient visits: $10 per individual visit; $5 per roup visit Inpatient psychiatric hospitalization: No chare 1 The products and services described above are neither offered nor uaranteed under our contract with the Medicare proram. In addition, they are not subject to the Medicare appeals process. Any disputes reardin these products and services may be subject to the Kaiser Permanente Senior Advantae rievance process. 2 These products and services are provided by entities other than Kaiser Permanente. Some Kaiser Permanente benefit plans include coverae for certain of these services. Plan benefits must be used before those services are available. Check your Evidence of Coverae for details. Kaiser Permanente disclaims any liability for these products and services. Should a problem arise, you may take advantae of the Kaiser Permanente rievance process by callin the Member Service Contact Center at or (TTY for the hearin/speech impaired), 24 hours a day, seven days a week (closed holidays). 3 Includes covered outpatient items in accord with our dru formulary uidelines. Hearin services Allery services Routine preventive hearin tests: No chare Hearin aid(s): $1,000 allowance every 36 months Allery injection visits: No chare Allery testin visits: $15 per visit Routine preventive hearin tests: $10 per visit Hearin aid(s): $1,000 allowance every 36 months Allery injection visits: $3 per visit Allery testin visits: $10 per visit 4 Episodic drus prescribed for the treatment of sexual dysfunction are covered up to a maximum of eiht doses in any 30-day period or 27 doses in any 100-day period. 8 9

7 What s new in Northern California Our new San Mateo Medical Offices make it easier for members to access a wide rane of services, includin family practice, adult care, obstetrics-ynecoloy, pediatrics, and optometry. This ecofriendly facility features bicycle and walkin paths linked to area trails, as well as free Wi-Fi. We re also expandin our South Sacramento Medical Center, which now includes more parkin, a trauma follow-up center, and a new hospital tower with an expanded Emerency Department and enhanced imain and lab facilities. What s new in Southern California Sierra Nevada Mountains Sierra Nevada Mountains China Lake Naval Weapons Center Our recently opened Ontario Medical Center is the first full-service hospital in the area in many years. Naval China Weapons Lake Center It features 224 beds and a 36-bed Emerency Department. In Bakersfield, our new Chester Avenue Medical Offices make it easier for members to take care of several needs in one trip. And the new Garfield Specialty Center in San Dieo ives members access to more specialty care. We ve also opened medical offices in South Los Aneles and Antelope Valley (Lancaster), brinin a wide rane of services to each community. Kern County area Fresno County n Kaiser Permanente medical centers (hospital and medical offices) Kaiser Permanente medical offices Affiliated plan hospitals Affiliated medical offices Maps not to scale n Kaiser Permanente medical centers (hospital and medical offices) Kaiser Permanente medical offices Affiliated plan hospitals Maps not to scale 10 11

8 The care you need, when you need it Whatever your care needs, we ve ot you covered. With our many facilities located throuhout the state, you ll have access to a broad array of services desined o meet almost any medical situation. See the chart below for an overview of the many types of care available to you, as well as details on which services miht be best dependin on your situation. We re always ready to help If you have an illness or injury and you re not sure what kind of care you need, our advice nurses can help. With access to your electronic health record, they can assess your situation and direct you to the appropriate facility, or even help you handle the problem at home until your next appointment. To et advice or schedule an appointment, just call the appointment/advice line listed for your area in Your Guidebook to Kaiser Permanente Services. Routine NonUrent care Other NonUrent Care Urent Care Emerency care What is it for? An expected care need, like a recommended preventive screenin or a visit for a health issue currently bein treated. A new health concern or a chane in an existin health condition that is not an urent care need. An illness or injury that requires prompt medical attention, but is not an emerency medical condition. A medical or psychiatric condition that requires immediate medical attention to prevent serious jeopardy to your health.* What should you know? Examples of routine nonurent care needs include: physical exams pre-travel exams pap tests well-child checkups medication checkups follow-up visits You can schedule an appointment online with your personal physician or ob-yn. If your doctor isn t available within a time frame that works for you, call us to request an appointment with another available physician. Examples of other nonurent care needs include: trouble sleepin eneral diestion problems radual skin chanes joint stiffness onoin anxiety issues weiht loss or ain Schedule an appointment online with your personal physician, or call us to request the next available appointment in the primary care department you need. Examples of urent care needs include: minor injuries sore throats and upper respiratory symptoms earaches couhs backaches frequent urination or burnin sensation when urinatin An urent care need may also include situations where you are experiencin new or worsenin symptoms, or have concerns about your medication. Symptoms that may indicate an emerency medical condition include: chest pain or pressure that may radiate to the arm, neck, back, shoulder, jaw, or wrist sudden onset of severe abdominal pain severe shortness of breath sudden decrease in or loss of consciousness sudden inability to talk or to move one side of the body, or sudden slurred speech severe, persistent bleedin that cannot be stopped major injuries like unshot or stab wounds or severe injuries from a vehicle accident active labor when there isn t time for a safe transfer to a desinated hospital before delivery What do you do? Make an appointment: Online throuh My Health Manaer at kp.or By phone at the appointment line listed for your area in Your Guidebook to Kaiser Permanente Services within a time frame that works for you, call us to request an appointment with another available physician. Make an appointment: Online throuh My Health Manaer at kp.or By phone at the appointment line listed for your area in Your Guidebook to Kaiser Permanente Services Call the advice line listed for your area in Your Guidebook to Kaiser Permanente Services. If you have an urent care need, we can direct you to the appropriate facility or assist you in schedulin a same-day or next-day appointment. Call 911 or o to the nearest hospital. * An emerency medical condition is a medical condition manifestin itself by acute symptoms of sufficient severity (includin severe pain) such that a reasonable person would have believed that the absence of immediate medical attention would result in any of the followin: (1) placin the person s health (or, with respect to a prenant woman, the health of the woman or her unborn child) in serious jeopardy; (2) serious impairment to bodily functions; or (3) serious dysfunction of any bodily oran or part. A mental health condition is an emerency medical condition when it meets the requirements of the pararaph above or, for members who are not enrolled in Kaiser Permanente Senior Advantae, when the condition manifests itself by acute symptoms of sufficient severity such that either of the followin is true: The person is an immediate daner to himself or herself or to others, or the person is immediately unable to provide for or use food, shelter, or clothin due to the mental disorder