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BENEFITS 1
BENEFITS 2
PAYING FOR CARE
PLAN TYPES
ACRONYMS
100
What is Coverage for medically appropriate emergency transport.
What is Ambulance Benefit
100
Medically necessary services that can be safely and effectively provided in the member's home by health care personnel and are directed by a Plan Provider. This could mean visits by registered nurses, practical nurses or home health aides who work under the supervision or direction of a registered nurse or medical doctor.
What is Home Health
100
The amount of money charged by the carrier for the plan the member has chosen. It is usually paid on a monthly basis. A member must pay their premium to keep their coverage active, regardless of whether they use it or not.
What are Premiums
100
This type of plan tends to have low monthly premiums and low cost-sharing, but they require PCP referrals and won’t pay for care out-of-network except in emergencies.
What is HMO
100
PCP
What is Primary Care Physician
200
This benefits includes things like: • Laboratory (blood) tests • Imaging services such as a x-ray or specialized imaging such as nuclear medicine studies, CT scans, PET scans and MRI’s, • Special procedures such as EKGs and EEGs and sleep studies
What is Diagnostic Services
200
This is a level of medical care that includes ongoing medical or nursing services. This might be care provided in a nursing home or in a hospital. In general, this benefit covers: • Room and board at the facility • Physician, nursing, therapy and social services care Most plans include a limit on the number of days of this care that are covered per contract year.
What is SNF (Skilled Nursing Facility)
200
A set amount the member has to pay every year toward their medical bills before the carrier starts paying. It varies by plan and some plans don’t have one.
What is a Deductible
200
This type of plan got that name because they have a network of providers they prefer that you use, but they’ll still pay for out-of-network care. Given that they’re less restrictive than most other plan types, they tend to have higher monthly premiums and require higher cost-sharing.
What is a PPO (Preferred Provider Organization)
200
MOOP
What is the Maximum out of Pocket Maximum
300
Under the this benefit, Kaiser Permanente covers the process that does the work for your kidneys when you have kidney failure.
What is Dialysis
300
These are defined as services that are required as the result of a sudden illness or injury, which requires prompt attention, but is not of an emergent nature.
What is Urgent Care
300
Copayment (Copay), Deductible, Coinsurance are types of these.
What is Cost Sharing
300
This type of plan has a deductible that must be paid down before certain benefits will be covered by their cost share.
What is DHMO
300
OOP
What is Out of Plan
400
All Kaiser Permanente members, regardless of their plan type, are covered for this type of care inside our service area and outside of our service area, unless the condition is one that the member knew they may need care for while they were away - like dialysis or post-operative care.
What is Emergency Care
400
The three main types of this care are Physical, Speech and Occupational
What is Therapy
400
This protects members financially by limiting the total amount of specified cost-sharing a member must pay over the course of a calendar year.
What is the Annual Out-Of-Pocket Maximum
400
These plans resemble an HMO but are less restrictive in that you’re allowed, under certain circumstances, to get care out-of-network like with a PPO. Like HMOs, these plans require you to have a PCP referral for all care whether it’s in or out-of-network.
What is a POS
400
LIS
What is Low Income Subsidy
500
This benefit includes coverage for: • Treatment of mental illnesses, emotional disorders, drug abuse and alcohol abuse, and • Services provided inpatient, outpatient or in a partial hospitalization, and • Medical treatment of withdrawal symptoms This benefit may also include individual or group therapy.
What is the Chemical Dependency / Mental Health Benefit
500
These types of healthcare services include things like routine physicals, routine well-woman gynecological exams, immunizations, HIV tests, cholesterol tests, colonoscopies, and mammograms, just to name a few.
What is Preventive Care
500
A fixed dollar amount a member pays when receiving care or service.
What is a Copayment
500
This type of plan got that name because they have a network of providers they use exclusively. The member must stick to providers on that list, or the Plan won’t pay.
What is EPO
500
EOC
What is Evidence of Coverage