Frequently
asked questions
about Kaiser Permanente for Individuals and Families
| Q: |
Is Kaiser Permanente
for Individuals and Families right for me? |
| A: |
To make sure Kaiser
Permanente for Individuals and Families is right for you, please
consider the following:
- Can my employer pay for part or all of my premium?
If your employer has more than 50 employees, they can assist you with premium payments. If your employer has between 2 and 50 employees who work 24 hours per week or more, insurance regulations do not allow your employer to assist you with premium payments or receive a tax deduction for your health care coverage.
- As a business group of one, can I pay my Kaiser Permanente for Individuals and Families premium from my business account?
Yes, however, we do offer small group options. Please call (303) 338-3700 for information.
- I'm 65 years old. Am I still eligible for Kaiser Permanente for Individuals and Families?
If you are 65+ years of age and Medicare eligible, or are under age 65 and entitled to Medicare on the basis of Social Security disability, call 1-800-509-7570 for information about Senior Advantage.
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| Q: |
Can I get my own rate quotes? |
| A: |
Yes. Just return to the home page to start the process. You'll need to provide some information, such as which type of plan you're interested in, the number of eligible dependents you intend to cover, birth dates, and a few other basic items. You'll have access to directions and to help, if needed, every step of the way. |
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| Q: |
Can I expect someone to contact me? |
| A: |
You'll be contacted only if you request to be contacted, or if you choose to apply for a plan. The quote process remains anonymous until you opt for contact, and even then your information will remain private. We will not make your specific data available to anyone. |
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| Q: |
How do I apply?
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| A: |
It's easy to apply. The online application process takes approximately 15 minutes. You'll be asked to provide additional information about yourself and any family members included in the application. Application processing takes about 48 hours. You will be notified via e-mail regarding the status of your application. We'll also contact you if we need additional information. Or, if you prefer, you can print, complete, and then submit the application to us by mail. For more information concerning the application process, call Kaiser Permanente at 1-800-634-4579. |
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| Q: |
How soon will my coverage become effective? |
| A: |
If we receive your application on or before the 23rd of the current month, your coverage usually begins on the first day of the following month. If we receive your application after the 23rd of the current month, your coverage usually begins on the first day of the month after the following month.
For example:
If your application is received on July 23, your coverage should begin on August 1.
If your application is received on July 27, your coverage should begin on September 1. |
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| Q: |
How can I select
the best plan for my family and me? |
| A: |
You may choose from one of six plans: $2,000 Deductible Plan (70%), $2,000 Deductible Plan (70%) with Rx, $2,000 Deductible Plan with HSA Option (80%), $2,000 Deductible Plan with HSA Option (100%), $5,000 Deductible Plan (70%) and $30 Copayment Plan.
Plan Types
We categorize our plans as copayment, deductible, or HSA-qualified, depending on how you share in paying the costs of the services you receive.
Copayment plan
Our $30 Copayment Plan enables you to know in advance your out-of-pocket costs for covered services. A copayment is the fixed dollar amount you pay for certain services and supplies.
Deductible plans
Our deductible plans, $2,000 deductible and 70 percent coverage with Rx coverage, $2,000 deductible and 70 percent coverage, and $5,000 deductible and 70 percent coverage, offer the lowest monthly premiums in exchange for having you share more of the costs in copayments, deductibles, and coinsurance when you come in for services.
Coinsurance is the percentage you pay of the full charges for certain services and supplies.
HSA -qualified plans
Our HSA -qualified plans provide traditional medical coverage and a tax-free way to help you build savings for future qualified medical expenses. To open a health savings account, or HSA, you first need to be enrolled in an HSA-qualified plan. If you're interested, you may want to consider our $2,000 deductible plans with HSA option (one with 100 percent coverage, another with 80 percent coverage, after the deductible is satisfied). To learn more about HSAs, see our HSA section. The insured must be treated by a Kaiser Permanente physician or referral physician in order to receive benefits. You can use our Plan Finder tool to compare benefits and find out which plan best suits your needs.
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| Q: |
Can I change plans if my circumstances change? |
| A: |
You may request a different plan at any time. However, in some cases the plan change you request will require a new medical review, and we may deny your request as a result of that review. We make as much information available to you as we can, and we encourage you to carefully consider the differences among plans. |
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| Q: |
Can I arrange to pay premiums automatically? |
| A: |
Yes. After you are accepted, we will send you a statement that contains information about how to arrange for automatic monthly withdrawals from your bank account or debits to your credit card. You must pay your first month's premium by check or money order. |
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| Q: |
I'm unfamiliar with many insurance industry terms. Can you help me understand the terminology? |
| A: |
We avoid industry jargon whenever possible and we also offer a glossary where you can find definitions of many terms. |
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| Q: |
What is an HMO? |
| A: |
HMO is an abbreviation for "health maintenance organization." An HMO is a managed care organization that combines the function of a health insurance company and a health care provider. A covered member selects a primary care physician (PCP) from the participating physician network when enrolling in an HMO. The PCP, who acts as the member's personal physician, manages the member's health care, including referrals to select specialists, and admission to hospitals, except in the case of a life-threatening emergency. Typically, benefits are not provided if the insured receives non-emergency treatment outside of the network. Members pay minimal copayments, and do not have to file their own claims.
Kaiser Permanente is America's largest not-for-profit HMO, serving 8 million members in 11 states and the District of Columbia. Kaiser Permanente is an integrated health delivery system that organizes and provides or coordinates members' care, including preventive care such as well-baby and prenatal care, immunizations and screening diagnostics, hospital and medical services, and pharmacy services.
Kaiser Permanente is composed of the nonprofit Kaiser Foundation Health Plan of Colorado and the for-profit Colorado Permanente Medical Group (CPMG). |
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| Q: |
I've heard that
HMOs pay physicians under a system called capitation, and that
this leads physicians to withhold treatment from their patients.
Is this true? |
| A: |
Capitation is a method of paying health care providers a fixed amount per covered member per month for preventive and medical services. It creates appropriate financial incentives for providers to emphasize preventive health care, wellness programs, and early interventions to keep members healthy and to avoid more costly treatment later.
Kaiser Permanente's capitation structure is based on the collective performance of CPMG physicians, not on individual performance. Because Permanente physicians are compensated primarily through their salaries, our physicians can practice medicine without the worry that individual patient care decisions will affect their incomes. Group capitation, as structured at Kaiser Permanente, is a highly ethical approach to providing patient care. |
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| Q: |
What is a PCP? |
| A: |
PCP is an abbreviation for "primary care physician." Your primary care physician is your personal physician who will manage and coordinate your health care, which may result in lower health care costs for you. You can change your PCP at any time for any reason, and our Member Services team will help you find a personal physician who fits your needs. |
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| Q: |
Can I select my own primary care physician? |
| A: |
We encourage you to choose a physician who specializes in internal medicine, family medicine, or pediatrics for your primary care. Physician profiles are posted on our Web site, kp.org. To select a physician, call Member Services at 303-338-3800. For the Kaiser Permanente for Individuals and Families coverage options, you'll be asked to select a PCP from an extensive list of highly qualified physicians. You may change your PCP at any time, for any reason. |
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| Q: |
What are the advantages of choosing and using a primary care physician? |
| A: |
At Kaiser Permanente, medical decisions are made by physicians in close consultation with their patients, not by health plan administrators. The doctor-patient relationship is the foundation of how we practice medicine-no third party is involved in medical decisions. |
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| Q: |
Can I self-refer to a specialist? |
| A: |
Yes, you can make an appointment, without a referral, for a consultation with our allergists, cardiologists, dermatologists, ear/nose/throat specialists, gastroenterologists, ophthalmologists, orthopedists, rheumatologists, and more! |
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| Q: |
Can I continue to see my current physician if I join Kaiser Permanente for Individuals and Families? |
| A: |
If you are switching from one Kaiser Permanente for Individuals and Families plan to another within the Denver metro area, you can keep your Kaiser Permanente physician when you change plans. If you are moving from another region, or switching from another health plan carrier, you will need to choose a Kaiser Permanente physician from our list of available qualified primary care physicians. |
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| Q: |
What is copayment? |
| A: |
A copayment is the fixed dollar amount you pay for certain services and supplies. Our $30 Copayment Plan enables you to know in advance your out-of-pocket costs for covered services. |
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| Q: |
What is coinsurance?
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| A: |
Coinsurance is the amount members are required to pay after they have met their deductible. The coinsurance rate is usually expressed as a percentage. The $2,000 Deductible Plan (70%), $2,000 Deductible Plan (70%) with Rx and $5,000 Deductible Plan (70%) are based on copayments and coinsurance. In these plans, for example, the 70 % refers to the percentage of cost of applicable procedures and services the plan will cover. Therefore, for a covered procedure or service, Kaiser Permanente will cover 70% of the cost, and the member will cover the remaining 30% coinsurance cost once any deductible limit has been met. |
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| Q: |
What are deductibles and out-of-pocket maximums? |
| A: |
A deductible is a set dollar limit of out-of-pocket costs a member must pay before a coinsurance rate for covered services kicks in. For example, our $2,000 Deductible Plan (70%) has a $2,000 annual deductible for individuals. That means an individual must pay the regular Kaiser Permanente price for all applicable services/procedures until they reach that $2,000 out-of-pocket limit. Once they reach that limit, all applicable procedures/services that are subject to having reached the deductible limit are then switched to a 30% coinsurance arrangement. In other words, once a member reaches the deductible limit, their out-of-pocket costs for applicable procedures/services will drop by as much as 70% and their financial responsibility for those covered services is now only 30% of the regular cost.
In addition, after the deductible has been met, a member's coinsurance payments apply toward their out-of-pocket (OOP) maximum. In the $2,000 Deductible Plan (70%) example, the annual OOP maximum for individuals is $5,000. Once a member's applicable coinsurance payments reach that OOP limit, the rest of that member's medical costs included in their plan are covered 100 % the rest of that coverage year. |
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| Q: |
Will my dependents
be covered under this plan? |
| A: |
Dependents are covered under a family plan up to specific age limits. Unmarried dependents are covered until the end of the month in which they reach age 19, or age 24 if currently a full-time student. An unmarried child medically certified as disabled and dependent upon the parent for support is covered at any age. |
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| Q: |
Can family members apply for different plans? |
| A: |
Yes. You can apply for the plan that best meets the needs of each family member. For example, you might choose to apply for the $2,000 Deductible Plan (70%) for yourself and have your spouse and children apply for the $30 Copayment Plan. You can also enroll just a child on a plan, with yourself as the responsible financial party. You might also consider enrolling family members separately as subscribers, even if you choose the same plan for them all. This may result in a lower combined monthly premium. |
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| Q: |
Will I have to take a physical exam? |
| A: |
No, each applicant (you and each family member to be covered) must answer questions about health status and certain medical conditions. It is important for all questions on the application to be answered completely to avoid a delay in issuing coverage. |
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| Q: |
Is membership guaranteed? |
| A: |
No. We carefully review each application received. You must live within our service area, be eligible under Colorado state law to join an individual health plan, and pass our medical review of your health status for the previous five years. If you do not meet requirements, we may deny membership. |
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| Q: |
What is a pre-existing condition? |
| A: |
A pre-existing condition is a condition for which medical advice, diagnosis, care or treatment was recommended or received. |
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| Q: |
Are maternity services covered? |
| A: |
Maternity services are not covered under any of our Kaiser Permanente for Individual and Family plans. |
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| Q: |
Are prescription drugs covered? |
| A: |
Prescriptions are covered under the $2,000 Deductible Plan (70%) with Rx and the $2,000 Deductible Plan with HSA Option (100%). Members in the four other plans can fill prescriptions at any Kaiser Permanente pharmacy at competitive member rates. If you are presently taking a prescribed medication, our clinical pharmacists will help you transition it into our pharmacy. By law we are limited to providing one refill. You must visit a Kaiser Permanente physician for further refills. |
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| Q: |
Are preventive care services covered? |
| A: |
At Kaiser Permanente, we believe prevention is the best medicine. So we offer a variety of preventive care services—including routine physicals, well-baby care, well-child visits, pap tests, mammograms, prenatal care, and cholesterol screenings—to help you and your family lead healthy, productive lives. |
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| Q: |
What types of health and wellness benefits are included in the plans? |
| A: |
Kaiser Permanente offers a wide variety of health education and wellness classes. Topics include stress management, yoga, and weight management, among others. Some classes are available through Kaiser Permanente members at no cost; others have a nominal registration fee. |
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Frequently
asked questions about
health savings accounts (HSAs)
| Q: |
What is a health savings account (HSA)? |
| A: |
An HSA is a tax-exempt trust or custodial account established for the purpose of paying qualified medical expenses. It allows you to pay for current health care expenses and to save for future qualified medical expenses and retiree health expenses on a tax-free basis. The money you invest in an HSA is tax deductible and any earnings on your HSA contributions accumulate on a tax-deferred basis. The money in your account can be withdrawn tax free and without penalty at any time to pay for qualified medical expenses. Unused balances roll over from year to year. |
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| Q: |
Who is eligible for an HSA? |
| A: |
To be eligible to make a contribution to an HSA, you must be covered by a qualifying deductible health plan, also known as a high-deductible health plan. Also, you generally may not be covered by other health insurance that is not a qualifying deductible health plan, with certain exceptions. Some of the exceptions include workers' compensation, specific injury insurance, and insurance for accidents, disability, dental care, vision care, or long-term care. You are not eligible for an HSA if you are enrolled in Medicare or are claimed as a dependent on someone else's tax return or if you have received medical benefits from the Veterans Health Administration at any time over the past three months. |
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| Q: |
How can I get an HSA? |
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For your convenience, Kaiser Permanente has selected Wells Fargo as our preferred HSA provider. For more information or to download an enrollment form, please visit www.wfbhs.com/kaiserpermanente. However, you can also choose to open an HSA with any HSA provider of your choice. Our HSA-eligible plans are designed to be compatible with all HSA providers. |
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| Q: |
What are the steps for enrolling in Kaiser Permanente's $2,000 Deductible Plans with HSA Option? |
| A: |
Getting started is easy. Just follow the steps below:
Step 1: Register and apply online on our secure Web site: kaiserpermanente.org.
Step 2: Choose the person(s) you want to cover.
Step 3: Choose the $2,000 Deductible Plan with HSA Option (80%) or $2,000 Deductible Plan with HSA Option (100%).
Step 4: Complete a medical questionnaire for yourself and for each family member applying for coverage. You can complete the questionnaire(s) online, or you may print it out and mail it in with your application.
Step 5: Submit your application. After completing steps 1 and 2, you can submit your application online using our secure Web site. Or, if you printed out the application in step 4, you can mail it to us.
Step 6: When we receive your application, we'll notify you of its status by mail. Once you're approved for membership, we'll send you a Member Resource Guide and your ID card.
Step 7: Once you are approved for membership in Kaiser Permanente's $2,000 Deductible Plan with HSA Option (80% or 100%), you can enroll with our preferred provider, Wells Fargo, or with an HSA trustee of your choice.
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| Q: |
Can I open an HSA account through Kaiser Permanente? |
| A: |
No. Kaiser Permanente has made arrangements for Wells Fargo (a qualified HSA trustee) to make its HSA services available to our health plan members. You can also establish an HSA through any qualified trustee of your choice. If you choose to open an account with Wells Fargo, you can:
- Call Wells Fargo at 1-866-890-8308 (toll free).
- Go to www.wfhbs.com/kaiserpermanente.
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| Q: |
Who can contribute to the HSA? |
| A: |
You, your family members, and your employer are all permitted to contribute to your HSA. The same annual limits on the contributions made to your account apply regardless of who makes the contributions. |
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| Q: |
Are my individual HSA contributions tax deductible? |
| A: |
All contributions into your HSA are tax deductible, whether you itemize or not.
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| Q: |
Who does the money in the HSA belong to? |
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The money in the HSA belongs to you. If you leave an employer who has made contributions, the money in your HSA account goes with you. |
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| Q: |
How much can be contributed to my HSA? |
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Annual contributions for 2007 are capped at $2,850 for individual coverage and $5,650 for family coverage. For 2008 and after, these maximums will be indexed for inflation. |
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| Q: |
If I become covered in the middle of the calendar year, how much can I contribute to my HSA? |
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You can make a full HSA contribution, regardless of the month during the year that you become eligible, based on the type of coverage you have in the last month of the year. Penalties may apply to a portion of your contribution if you do not remain in an HSA-eligible plan for a full year following the end of the first year. For more information, contact your financial and/or tax advisor.
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| Q: |
How can I spend my HSA funds? |
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HSA funds are intended to be used for out-of-pocket medical expenses such as deductibles, copayments, coinsurance, and qualified medical expenses that are not covered by your qualified deductible plan or other permitted insurance. While funds can be withdrawn for any purpose, the amount withdrawn is taxable if it is used for anything other than qualifying medical expenses. It will also be subject to a 10 percent penalty by the IRS if used for non-qualifying expenses before you reach age 65. After age 65, however, the 10 percent penalty does not apply. |
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| Q: |
What is the definition of a qualified medical expense? |
| A: |
Qualified medical expenses include the expenses defined in Section 213(d) of the Internal Revenue Code that you pay for your own medical care and that of your spouse and dependents. Some examples of medical expenses that qualify for favorable tax treatment for HSA purposes include:
- doctor visits
- ambulance and hospital services
- prescription drugs and certain over-the-counter medications
- durable medical equipment
- dental care
- acupuncture
- chiropractic services
- qualified long-term care services and limited long-term care premiums
- COBRA health care continuation coverage
- health insurance premiums for individuals receiving unemployment compensation
- Medicare Part A and Part B premiums, Medicare HMO premiums, and your share of premiums for employer-sponsored health insurance, if you're over 65
A medical expense is not a qualified medical expense if you receive reimbursement for it under your insurance coverage. Also, if an expense is paid or reimbursed by your HSA, you cannot include that expense for purposes of determining your itemized tax deductions. |
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| Q: |
Are dental and vision care qualified medical expenses under an HSA? |
| A: |
Yes, as long as these are deductible under the current rules. For example, cosmetic procedures, like cosmetic dentistry, are generally not deductible and would not be considered qualified medical expenses. |
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| Q: |
Can I pay for my health insurance premiums with my HSA funds? |
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No. The only exceptions are COBRA health care coverage, limited long-term care insurance premiums, and health insurance premiums while receiving unemployment compensation. Also, if you're over 65, you can use HSA funds for Medicare Part A and Part B premiums, Medicare HMO premiums, and your share of premiums for employer-sponsored health insurance. |
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| Q: |
Do I need to prove that I used my HSA dollars for qualified medical expenses? |
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Yes. You are expected to maintain records of your medical expenses to show that the distributions have been made exclusively for qualified expenses. If you do not maintain the necessary records you may be subject to taxes and penalties on the distributions made from your account. |
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| Q: |
If I don't use all of my HSA dollars by the end of the year, do I lose them? |
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No. Your unused HSA dollars will roll over year after year. In addition, you can take the balance with you if you change jobs or enroll in a different qualifying deductible plan. |
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| Q: |
What happens to the money in my HSA after I'm 65? |
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Once you're 65, the amounts can be used tax free for qualified medical expenses and to pay certain insurance premiums, like Medicare Part A and Part B, Medicare HMO, and your share of retiree medical insurance premiums. (It cannot be used to purchase a Medigap policy.) If used for permitted expenses, the amounts come out of the account tax free. If used for other expenses, the amount received will be taxable. |
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