Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services
Coverage Period: Beginning on or after 01/01/2023
: Silver Coverage for: Individual / Family | Plan Type: HMO
All plans offered and underwritten by Kaiser Foundation Health Plan of Washington
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 [Link]/plandocuments
or call 1-888-901-4636 (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 [Link]/sbc-glossary or call 1-888-901-4636 (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
$1,800 Individual / $3,600 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
[Link]
Are there other deductibles
No. You don’t have to meet deductibles for specific services.
for specific services?
The out-of-pocket limit is the most you could pay in a year for covered services.
What is the out-of-pocket
$8,400 Individual / $16,800 Family If 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.
Premiums, balance-billing charges, health care
What is not included in the Even though you pay these expenses, they don’t count toward the out–of–
this plan doesn’t cover, and services indicated in
out-of-pocket limit? pocket limit.
chart starting on page 2.
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 [Link]/wa or call 1-888-901-4636 you might receive a bill from a provider for the difference between the provider’s
use a network provider? (TTY: 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.
Page 1 of 7
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
What You Will Pay
Common Medical Limitations, Exceptions, & Other Important
Services You May Need Network Provider Non-Network Provider
Event Information
(You will pay the least) (You will pay the most)
Primary care visit to treat
$30 / visit Not covered None
an injury or illness
If you visit a health Specialist visit $60 / visit Not covered None
care provider’s You may have to pay for services that aren’t
office or clinic Preventive care/screening/ No charge, deductible does preventive. Ask your provider if the services
Not covered
immunization not apply. needed are preventive. Then check what your
plan will pay for.
Diagnostic test (x-ray,
30% coinsurance Not covered None
blood work)
If you have a test
Imaging (CT/PET scans, Preauthorization required or will not be
30% coinsurance Not covered
MRIs) covered.
$30 (retail); Up to a 90-day supply (retail & mail order).
Subject to formulary guidelines. After the first fill,
$25 (mail order) / prescription /
Preferred generic drugs Not covered maintenance drugs are required to be filled at a
30 days, deductible does not
KFHPWA Clinic or through KFHPWA mail
apply.
order.
If you need drugs to $60 (retail); Up to a 90-day supply (retail & mail order).
treat your illness or Subject to formulary guidelines. After the first fill,
$55 (mail order) / prescription /
condition Preferred brand drugs Not covered maintenance drugs are required to be filled at a
30 days, deductible does not
More information KFHPWA Clinic or through KFHPWA mail
apply.
about prescription order.
drug coverage is Up to a 90-day supply (retail & mail order).
available at Subject to formulary guidelines, when approved
50% coinsurance (retail);
[Link]/wa/7formulary2 through the exception process. After the first fill,
Non-preferred drugs 45% coinsurance (mail order) / Not covered
023 maintenance drugs are required to be filled at a
prescription / 30 days
KFHPWA Clinic or through KFHPWA mail
order.
Up to a 30-day supply (retail). Subject to
Specialty drugs 50% coinsurance (retail) Not covered formulary guidelines, when approved through
the exception process.
Page 2 of 7
What You Will Pay
Common Medical Limitations, Exceptions, & Other Important
Services You May Need Network Provider Non-Network Provider
Event Information
(You will pay the least) (You will pay the most)
Facility fee (e.g.,
If you have 30% coinsurance Not covered None
ambulatory surgery center)
outpatient surgery
Physician/surgeon fees 30% coinsurance Not covered None
You must notify Kaiser Permanente within 24
Emergency room care 30% coinsurance 30% coinsurance hours if admitted to a Non-network provider;
If you need limited to initial emergency only.
immediate medical Emergency medical
30% coinsurance 30% coinsurance None
attention transportation
Non-Network providers covered when
Urgent care $60 / visit 30% coinsurance
temporarily outside the service area.
Facility fee (e.g., hospital Preauthorization required or will not be
30% coinsurance Not covered
If you have a room) covered.
hospital stay Preauthorization required or will not be
Physician/surgeon fees 30% coinsurance Not covered
covered.
If you need mental Outpatient services $30 / visit Not covered None
health, behavioral
health, or substance Inpatient services Preauthorization required or will not be
30% coinsurance Not covered
abuse services covered.
Cost sharing does not apply for preventive
services. Maternity care may include tests and
Office visits 30% coinsurance Not covered
services described elsewhere in the SBC (i.e.
ultrasound.)
You must notify Kaiser Permanente within 24
Childbirth/delivery hours of admission, or as soon thereafter as
If you are pregnant 30% coinsurance Not covered
professional services medically possible. Newborn services cost
shares are separate from that of the mother.
You must notify Kaiser Permanente within 24
Childbirth/delivery facility hours of admission, or as soon thereafter as
30% coinsurance Not covered
services medically possible. Newborn services cost
shares are separate from that of the mother.
If you need help Home health care 30% coinsurance Not covered 130 visit limit / year. Preauthorization required
Page 3 of 7
What You Will Pay
Common Medical Limitations, Exceptions, & Other Important
Services You May Need Network Provider Non-Network Provider
Event Information
(You will pay the least) (You will pay the most)
recovering or have or will not be covered.
other special health Outpatient: 25 visit limit / year. Inpatient: 30-
needs day limit / year. Services with mental health
Outpatient: $60 / visit
Rehabilitation services Not covered diagnoses are covered with no limit.
Inpatient: 30% coinsurance
Inpatient: Preauthorization required or will not
be covered.
Outpatient:25 visit limit / year. Inpatient: 30-
day limit / year. Services with mental health
Outpatient: $60 / visit
Habilitation services Not covered diagnoses are covered with no limit.
Inpatient: 30% coinsurance
Inpatient: Preauthorization required or will not
be covered.
60-day limit / year. Preauthorization required
Skilled nursing care 30% coinsurance Not covered
or will not be covered.
Subject to formulary guidelines. Preauthorization
Durable medical equipment 30% coinsurance Not covered
required or will not be covered.
No charge, deductible does Preauthorization required or will not be
Hospice services Not covered
not apply covered.
No charge for refractive exam,
Children’s eye exam Not covered Limited to 1 exam / 12 months.
deductible does not apply.
If your child needs
No charge, deductible does Limited to one pair of frames and lenses or
dental or eye care Children’s glasses Not covered
not apply. contact lenses / year.
Children’s dental check-up Not covered Not covered None
Page 4 of 7
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Bariatric surgery • Hearing aids • Private-duty nursing
• Cosmetic surgery • Infertility treatment • Routine foot care
• Dental care (Adult and child) • Long-term care • Weight loss programs
• Non-emergency care when traveling outside the U.S.
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Acupuncture (12 visit limit / year) • Chiropractic care (10 visit limit / year) • Routine eye care (Adult)
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those
agencies is shown in the chart below. Other coverage options may be available to you, too, including buying individual insurance coverage through the Health
Insurance Marketplace. For more information about the Marketplace, visit [Link] or call 1-800-318-2596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a
grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also
provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or
assistance, contact the agencies in the chart below.
Contact Information for Your Rights to Continue Coverage & Your Grievance and Appeals Rights:
Kaiser Permanente Member Services 1-888-901-4636 (TTY:711) or [Link]/wa
Department of Labor’s Employee Benefits Security Administration 1-866-444-EBSA (3272) or [Link]/ebsa/healthreform
Department of Health & Human Services, Center for Consumer Information & Insurance Oversight 1-877-267-2323 x61565 or [Link]
Washington Department of Insurance 1-800‑562‑6900 or [Link]
Does this plan provide Minimum Essential Coverage? Yes.
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,
CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet the Minimum Value Standards? Yes.
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Page 5 of 7
Language Access Services:
[Spanish (Español): Para obtener asistencia en Español, llame al 1-888-901-4636 (TTY: 711).]
[Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-888-901-4636 (TTY: 711).]
[Chinese (中文): 如果需要中文的帮助, 请拨打这个号码 1-888-901-4636 (TTY: 711).]
[Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-888-901-4636 (TTY: 711).]
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
Page 6 of 7
About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different
depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts
(deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might
pay under different health plans. Please note these coverage examples are based on self-only coverage.
Peg is Having a Baby Managing Joe’s Type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow up
hospital delivery) controlled condition) care)
◼ The plan’s overall deductible $1,800 ◼ The plan’s overall deductible $1,800 ◼ The plan’s overall deductible $1,800
◼ Specialist copayment $60 ◼ Specialist copayment $60 ◼ Specialist copayment $60
◼ Hospital (facility) coinsurance 30% ◼ Hospital (facility) coinsurance 30% ◼ Hospital (facility) coinsurance 30%
◼ Other (blood work) coinsurance 30% ◼ Other (blood work) coinsurance 30% ◼ Other (x-ray) coinsurance 30%
This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical
Childbirth/Delivery Professional Services disease education) supplies)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Diagnostic test (x-ray)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Durable medical equipment (crutches)
Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)
Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800
In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $1,800 Deductibles $1,100 Deductibles $1,800
Copayments $10 Copayments $1,300 Copayments $300
Coinsurance $2,900 Coinsurance $0 Coinsurance $90
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $20 Limits or exclusions $0 Limits or exclusions $0
The total Peg would pay is $4,730 The total Joe would pay is $2,400 The total Mia would pay is $2,190
The plan would be responsible for the other costs of these EXAMPLE covered services. Page 7 of 7
