Kaiser Permanente DHMO 5500 Southern California SBC

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 04/01/2024-03/31/2025 : DEDUCTIBLE PLAN Coverage for: Individual/Family | Plan Type: DHMO 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 https://kp.org/plandocuments or call 1-800-278-3296 (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 1-800-278-3296 (TTY: 711) to request a copy. Important Questions Answers Why this Matters: 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 What is the overall $5,500 Individual / $11,000 Family plan, each family member must meet their own individual deductible until the deductible? total amount of deductible expenses paid by all family members meets the overall family deductible. This plan covers some items and services even if you haven’t yet met the Are there services deductible amount. But a copayment or coinsurance may apply. For example, Yes. Preventive care and services indicated in covered before you meet this plan covers certain preventive services without cost sharing and before you chart starting on page 2. your deductible? 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 No. You don’t have to meet deductibles for specific services. services? The out-of-pocket limit is the most you could pay in a year for covered services. If What is the out-of-pocket $7,500 Individual / $15,000 Family you have other family members in this plan, they have to meet their own out-of- limit for this plan? pocket limits until the overall family out-of-pocket limit has been met. What is not included in Premiums, health care this plan doesn't cover, and Even though you pay these expenses, they don't count toward the out-of-pocket the out-of-pocket limit? services indicated in chart starting on page 2. limit. 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 Will you pay less if you Yes. See www.kp.org or call 1-800-278-3296 (TTY: you might receive a bill from a provider for the difference between the provider’s use a network provider? 711) for a list of network providers. 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. Do you need a referral to This plan will pay some or all of the costs to see a specialist for covered services Yes, but you may self-refer to certain specialists. see a specialist? but only if you have a referral before you see the specialist. TOTAL EDUCATION SOLUTIONS PID:233882 CNTR:1 EU:-1 Plan ID:13859 SBC ID:544572 1 of 8