Kaiser Permanente NW Classic SBC (2024)

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2024-12/31/2024 : Wa Health Care Authority Pebb – - Custom Deductible Plan Coverage for: Individual / Family | Plan Type: EPO All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest 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 1-800-813-2000 (TTY: 711). For 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 http://www.healthcare.gov/sbc-glossary or call 1-800-813-2000 (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 What is the overall deductible? $300 Individual / $900 Family 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. This plan covers some items and services even if you haven’t yet met the deductible Are there services covered before Yes. Preventive care and services amount. But a copayment or coinsurance may apply. For example, this plan covers you meet your deductible? indicated in chart starting on page 2. 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 No. You don’t have to meet deductibles for specific services. deductibles for specific services? What is the out-of-pocket limit for The out-of-pocket limit is the most you could pay in a year for covered services. If you this plan? $2,500 Individual / $5,000 Family 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 Premiums, health care this plan the out-of-pocket limit? doesn’t cover, and services indicated Even though you pay these expenses, they don’t count toward the out–of–pocket limit. in chart starting on page 2. This plan uses a provider network. You will pay less if you use a provider in the plan’s Yes. See www.kp.org or call 1-800- network. You will pay the most if you use an out-of-network provider, and you might Will you pay less if you use a 813-2000 (TTY: 711) for a list of receive a bill from a provider for the difference between the provider’s charge and what network provider? Participating Providers. 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. 12024_1983-101_KWNX_SBC-W-LG-DED-XX_{666604}_{WP24 - WA PEBB DHMO}_912202315325 Rev. (11/16) Page 1 of 6