Disclosure Form CSAC EIA - EL DORADO COUNTY HMO $15 Member Services
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1 Disclosure Form CSAC EIA - EL DORADO COUNTY HMO $15 Member Services Principal Benefits for Kaiser Permanente Traditional Plan (1/1/18 12/31/18) Health Plan believes this coverage is a "grandfathered health plan" under the Patient Protection and Affordable Care Act. If you have questions about grandfathered health plans, please call our Member Service Contact Center. Accumulation Period The Accumulation Period for this plan is 1/1/18 through 12/31/18 (calendar year). Out-of-Pocket Maximum(s) and Deductible(s) For Services that apply to the Plan Out-of-Pocket Maximum, you will not pay any more Cost Share for the rest of the Accumulation Period once you have reached the amounts listed below. Amounts Per Accumulation Period Family Coverage Family Coverage Self-Only Coverage Each Member in a Family of Entire Family of two or more (a Family of one Member) two or more Members Members Plan Out-of-Pocket Maxim um $1,500 $1,500 $3,000 Plan Deductible None None None Drug Deductible None None None Professional Services (Plan Provider office visits) Most Primary Care Visits and most Non-Physician Specialist Visits... $15 per visit Most Physician Specialist Visits... $15 per visit Routine physical maintenance exams, including well-woman exams... No charge Well-child preventive exams (through age 23 months)... No charge Family planning counseling and consultations... No charge Scheduled prenatal care exams... No charge Routine eye exams with a Plan Optometrist... No charge Urgent care consultations, evaluations, and treatment... $15 per visit Most physical, occupational, and speech therapy... $15 per visit Outpatient Services Outpatient surgery and certain other outpatient procedures... $15 per procedure Allergy injections (including allergy serum)... $3 per visit Most immunizations (including the vaccine)... No charge Most X-rays and laboratory tests... No charge Covered individual health education counseling... No charge Covered health education programs... No charge Hospitalization Services Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs... No charge Emergency Health Coverage Emergency Department visits... $50 per visit Note: This Cost Share does not apply if you are admitted directly to the hospital as an inpatient for covered Services (see "Hospitalization Services" for inpatient Cost Share). Ambulance Services Ambulance Services... No charge Prescription Drug Coverage Covered outpatient items in accord with our drug formulary guidelines: Most generic items at a Plan Pharmacy... $15 for up to a 30-day supply Most generic refills through our mail-order service... $30 for up to a 100-day supply Most brand-name items at a Plan Pharmacy... $30 for up to a 30-day supply Most brand-name refills through our mail-order service... $60 for up to a 100-day supply Most specialty items at a Plan Pharmacy... $30 for up to a 30-day supply (continues)
2 Disclosure Form Durable Medical Equipment (DME) DME items in accord with our DME formulary guidelines... No charge Mental Health Services Inpatient psychiatric hospitalization... No charge Individual outpatient mental health evaluation and treatment... $15 per visit Group outpatient mental health treatment... $7 per visit Chemical Dependency Services Inpatient detoxification... No charge Individual outpatient chemical dependency evaluation and treatment... $15 per visit Group outpatient chemical dependency treatment... $5 per visit Home Health Services Home health care (up to 100 visits per Accumulation Period)... No charge Other (continued) Hearing aid(s) every 36 months... Amount in excess of $2,500 Allowance per aid Skilled nursing facility care (up to 100 days per benefit period)... No charge Prosthetic and orthotic devices... No charge Hospice care... No charge This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Share, out-of-pocket maximums, exclusions, or limitations, nor does it list all benefits and Cost Share amounts. For a complete explanation, please refer to the EOC. Please note that we provide all benefits required by law (for example, diabetes testing supplies).
3 Your Kaiser Permanente Chiropractic benefit Chiropractic services are administered by American Specialty Health Plans of California, Inc. (ASH Plans). When you need chiropractic care, follow these simple steps: 1. Find an ASH Plans Participating Chiropractor near you Online at ashcompanies.com Or call ( TTY), weekdays from 5 a.m. to 6 p.m. Pacific time. 2. Schedule an appointment. 3. Pay for your office visit when you arrive for your appointment. Services Chiropractic services are covered when a Participating Chiropractor finds that the services are medically necessary to treat or diagnose neuromusculoskeletal disorders. You can obtain services from any ASH Plans Participating Chiropractor without a referral from a Plan physician. Copayments and Office Visit Maximums Office visit copayment: $10 per visit Office visit limit: 30 visits per calendar year Chiropractic appliance benefit: Chiropractic appliances are provided up to a maximum of $50 per calendar year when prescribed and provided by an ASH Plans Participating Chiropractor as part of your chiropractic care. Office visits: Covered services are limited to medically necessary chiropractic services authorized and provided by an ASH Plans Participating Chiropractor. X-rays and laboratory tests: Medically necessary X-rays and laboratory tests are covered at no charge when prescribed as part of your chiropractic care by a Participating Chiropractor and provided by an appropriately licensed Participating Provider that has contracted with ASH Plans to provide those services. Participating Chiropractors ASH Plans contracts with Participating Chiropractors and other Participating Providers to provide covered chiropractic services, including laboratory tests, X-rays, and chiropractic appliances. You must receive covered services from a Participating Provider, except for Emergency Chiropractic Services and services that are not available from Participating Providers that are prior authorized by ASH Plans. The list of Participating Chiropractors is available on the ASH Plans Web site at ashcompanies.com or from the ASH Plans Member Services Department at The list of Participating Chiropractors is subject to change at any time without notice. How to obtain services: To obtain covered services, call a Participating Chiropractor to schedule an initial examination. If additional services are required, your Participating Chiropractor will prepare a treatment plan. The ASH Plans Clinical Services Manager will authorize the treatment plan if the services are medically necessary chiropractic services for you. ASH Plans will disclose to you, upon request, the process that it uses to authorize a treatment plan. If you have questions or concerns, please contact ASH Plans Member Services Department. Emergency Chiropractic Services Covered chiropractic services provided for the sudden and unexpected onset of an injury or condition affecting the neuromusculoskeletal system that manifests itself by acute symptoms of sufficient severity, including severe pain, such that a reasonable layperson with no special knowledge of health, medicine, or chiropractic care could reasonably expect that a delay of immediate chiropractic care could result in (1) placing your (or your unborn child s) health in serious jeopardy, (2) serious impairment to your bodily functions, or (3) serious dysfunction of any bodily organ or part. This is a summary and is intended to highlight only the most frequently asked questions about the benefit, including copayments. This benefit is not to be offered in an HSA plan. Please refer to the Chiropractic Services Amendment of the Kaiser Foundation Health Plan, Inc., Evidence of Coverage for a detailed description of the chiropractic benefit, including exclusions and limitations and Emergency Chiropractic Services r98 Section 1 Your Health Plan Benefits
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7 Protect your vision with VSP. Get the best in eyecare and eyewear with CSAC EIA / COUNTY OF EL DORADO and VSP Vision Care. At VSP, we invest in the things you value most the best care at the lowest out-of-pocket costs. Because we re the only national not-for-profit vision care company, you can trust that we ll always put your wellness first. You'll like what you see with VSP. Value and Savings. You ll enjoy more value and the lowest out-of-pocket costs. High Quality Vision Care. You ll get the best care from a VSP provider, including a WellVision Exam the most comprehensive exam designed to detect eye and health conditions. Choice of Providers. The decision is yours to make choose a VSP doctor, a participating retail chain, or any out-of-network provider. Great Eyewear. It s easy to find the perfect frame at a price that fits your budget. Using your VSP benefit is easy. Register at vsp.com. Once your plan is effective, review your benefit information. Find an eyecare provider who s right for you. To find a VSP provider, visit vsp.com or call At your appointment, tell them you have VSP. There s no ID card necessary. If you d like a card as a reference, you can print one on vsp.com. That s it! We ll handle the rest there are no claim forms to complete when you see a VSP provider. See why we re consumers #1 choice in vision care 2. Contact us vsp.com Choice in Eyewear From classic styles to the latest designer frames, you'll find hundreds of options. Choose from featured frame brands like Anne Klein, bebe, Calvin Klein, Flexon, Lacoste, Nike, Nine West, and more 1. Visit vsp.com to find a VSP provider who carries these brands.
8 Your VSP Vision Benefits Summary CSAC EIA / COUNTY OF EL DORADO and VSP provide you with an affordable eyecare plan. VSP Coverage Effective Date: 01/01/2016 VSP Provider Network: VSP Choice Benefit Description Copay Frequency WellVision Exam Your Coverage with a VSP Provider Focuses on your eyes and overall wellness $25 for exam and glasses Every 12 months Prescription Glasses Frame $115 allowance for a wide selection of frames $135 allowance for featured frame brands 20% savings on the amount over your allowance $70 allowance for Costco frames Combined with exam Every 24 months Lenses Single vision, lined bifocal, and lined trifocal lenses Polycarbonate lenses for dependent children Combined with exam Every 24 months Lens Enhancements Standard progressive lenses Premium progressive lenses Custom progressive lenses Average savings of 20-25% on other lens enhancements $55 $95 - $105 $150 - $175 Every 24 months Contacts (instead of glasses) $105 allowance for contacts and contact lens exam (fitting and evaluation) 15% savings on a contact lens exam (fitting and evaluation) $0 Every 24 months Diabetic Eyecare Plus Program Services related to diabetic eye disease, glaucoma and age-related macular degeneration (AMD). Retinal screening for eligible members with diabetes. Limitations and coordination with medical coverage may apply. Ask your VSP doctor for details. $20 As needed Extra Savings Glasses and Sunglasses Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details. 20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12 months of your last WellVision Exam. Retinal Screening No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam Laser Vision Correction Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities Your Coverage with Out-of-Network Providers Visit vsp.com for details, if you plan to see a provider other than a VSP network provider. Exam...up to $45 Frame...up to $70 Single Vision Lenses...up to $30 Lined Bifocal Lenses...up to $50 Lined Trifocal Lenses...up to $65 Progressive Lenses...up to $50 Contacts...up to $105 VSP guarantees coverage from VSP network providers only. Coverage information is subject to change. In the event of a conflict between this information and your organization s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location. Contact us vsp.com 1 Brands/Promotion subject to change. 2 Blueocean Market Intelligence National Vision Plan Member Research, Vision Service Plan. All rights reserved. VSP, VSP Vision care for life, and WellVision Exam are registered trademarks of Vision Service Plan. Flexon is a registered trademark of Marchon Eyewear, Inc. All other brands are trademarks or registered trademarks of their respective owners.
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