If you have health insurance through your work and you lose your job, it doesn’t mean that you have to lose your medical coverage as well. There’s a variety of ways to stay with Kaiser Permanente. The most common ways are: an Individual and Family Plan, COBRA, or a Conversion Plan, also known as HIPAA. Below are some comparisons to help you determine what’s best for you and your family.

Individual and Family Plans
Of the three options, these plans are oftentimes the lowest-priced option. There is an exception. If you worked for a large company (50 or more employees), then sometimes, a COBRA plan could be lower priced. Unlike group insurance, which usually offers a single one-size-fits all plan, Individual and Family Plans allow you to match the benefits and price to your needs. Individual and Family Plans are ideal for persons who have no, or minor, medical conditions. Eligibility is subject to medical underwriting, so enrollment is not guaranteed. If approved, however, you can stay on the Individual and Family Plan indefinitely; it’s not tied to your employment. Coverage is month-to-month, so if you wish you can cancel the insurance when your new employer’s plan kicks in. Individual and Family Plans are often the best option for people who are in-between jobs.

COBRA
If you need a plan that does not require medical underwriting, then you might consider COBRA. COBRA allows you to temporarily keep the same benefits that you had on your group insurance. The premium will be the amount you paid plus the amount subsidized by the employer. If you work for a large company, there is also an administration fee. New legislation may make COBRA a more affordable option than before. For information about the COBRA premium subsidy program, visit the Department of Labor’s website. Note: If the company has gone out of business, COBRA is not an available option.

Conversion
If you need a plan that does not require medical underwriting or the company has been dissolved, the Conversion or HIPAA (Health Insurance Portability and Accountability Act of 1998) Plan may be your only viable option. Conversion allows you to convert your existing group insurance into an individual plan. The benefits will not be the same as what you had under your group insurance and the cost will probably be more expensive, approximately 170% of Kaiser Permanente Individuals and Families Plan rates. The advantage of a Conversion Plan is that you won’t be denied for pre-existing conditions. To qualify, you must meet all of the following five requirements:
1. You must have at least 18 months of creditable coverage without a break in coverage of more than 63 days at any time.
2. Your most recent health care coverage must have been through a group health plan, governmental plan, or church plan.
3. You must have elected and exhausted all continuation health care coverage available under federal (COBRA) and state continuation coverage laws.
4. You must not currently have other health care coverage and not be eligible for coverage under any group health plan, governmental plan, church plan, state-administered Medicaid program, or Medicare.
5. Your most recent coverage was not terminated for fraud or failure to pay premiums.
For more information about the Conversion or HIPAA Plan, call Kaiser Member Services at 1-800-634-4579.

If you do lose your job, your employer may or may not be able to help redirect you to an alternative option. Knowing that options are available can make the transition a little bit smoother.

Posted: August 30th, 2010 under Kaiser Permanente.
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Follow our blog to stay updated on changes with regard to Health Care Reform and Kaiser Permanente health plans. Change is definitely in the air. If you’re navigating the medical insurance market these days, you will definitely want to stay up-to-date on what’s going on. Benefits are changing. Underwriting processes are adapting. Automatic issue coverage for minors is on the horizon. Click “Follow this blog” above to stay in the loop.

Posted: August 30th, 2010 under Kaiser Permanente.
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If going back to school includes getting heath insurance for your child, then, consider Kaiser Permanente’s many different options. You can find a fit that’s right for your pocketbook, and your child’s needs.

Pre-School or Elementary School Age
Young children tend to need low-ticket medical services more than major medical services. Often, this involves doctor visits, prescriptions, and immunizations. If you want a basic plan that covers at least these services right up front, consider one of the “HMO” Deductible plans. Most of the HMO Deductible plans allow for doctor visits, prescriptions, and immunizations without these services being subject to the deductible. If you want a more comprehensive plan for more peace of mind, then, check out the “Copayment” options. These plans don’t carry a deductible, so covered services are discounted right at the beginning.

Middle or High School Age
At this age, the most frequently needed medical services tend to be doctor visits and prescriptions. Consider an HMO Deductible plan. If the child is in sports, it may be good to go with a Copayment plan, or an HMO Deductible plan with a lower deductible.

College Age
For those looking for college-age student health insurance, doctor visits and prescription drugs may not be as crucial as when they were younger. Instead, having a good major medical plan may make more sense. An HSA or HMO Deductible plan may be the best fit. An HSA option gives you the bonus feature of being able to open an HSA bank account. The HSA bank account is optional. Your child can use it to pay for their out-of-pocket expenses. The advantage of an HMO Deductible plan is that under most HMO Deductible plans, doctor visits and prescriptions are covered without a deductible.

Premiums and your pocketbook
Copayment plans cost the highest premium, but if your child tends to need lab work, emergency visits, or other high-end services, this option will save you money in the long run. HSA Deductible plans tend to have the lowest premium, but high deductible amounts. If your child is rarely at the doctors, this may be a win-win situation. HMO Deductible plans are a good middle-of-the-road option. Premiums are lower than Copayment plans, but you still get the most frequently needed services of doctor visits and prescriptions without a deductible.

As your child begins a new school year, consider how Kaiser Permanente can support you and your family with their medical service needs.

Posted: August 23rd, 2010 under Kaiser Permanente.
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Kaiser Permanente California group health insurance plans are undergoing many changes due to the passage of the Patient Protection and Affordable Care Act (PPACA). We want to help you keep informed about how the federal health reform law affects your health coverage. We are pleased to announce the following positive changes to your KP California Group Plans, effective October 1, 2010. Preventive care services are now available for no charge from the first day of coverage. Also maximum benefit levels have been raised or eliminated entirely in some plans.

Copayment Plans
This group of plans includes the $50 Copay Plan, the $30 Copay Plan, the $20 Copay Plan, the $15 Copay Plan and the $5 Copay Plan. For preventative exams, formerly members had to pay the doctors copay, but now there is a $0 charge for preventative exams. With Regard to maternity/prenatal care, the $50 Copay Plan formerly required a $15 copay, but now there is a $0 charge for this service. For all other Copay Plans, there was and continues to be a $0 charge for maternity/prenatal care. Be aware that this is not referring to the hospitalization charges that are required upon delivery of the baby. Those same charges for in-patient care still apply according to the terms of your plan. For well-child preventative care visits, the $50 Copay Plan formerly charged $15, but now it is a $0 charge like the other Copay Plans. For vision exams, Kaiser Permanente formerly charged the same copay as for doctor visits on these plans, but now there is a $0 charge on all the Copay Plans for vision exams.

HSA-Qualified Deductible HMO Plans
The $30/$3,000 Deductible Plan with HSA is the only plan in this category that will be undergoing changes. The other HSA-qualified HMO plans will remain the same. On the $30/$3,000 Plan, formerly preventative exams cost $30 while maternity/prenatal care and well-child preventative care visits cost $10. As of October 1, 2010 there will be a $0 charge for these services on the $30/$3,000 Plan with HSA.

Deductible HMO Plans
This category includes three plans: the $40/$2,000 Deductible Plan, the $30/$1,500 Deductible Plan, and the $30/$1,000 Deductible Plan. All three of these plans will have improved coverage for preventative exams and vision exams starting on October 1st. Formerly, these exams required the payment of a doctors copay; however, on October 1st these Deductible Plans will have a $0 charge for both vision exams and preventative exams.

Posted: August 16th, 2010 under California Group.
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Regardless of which Kaiser Permanente Individual and Family Plan you are on, the cost for an annual routine Pap smear and mammogram will be either ‘no charge’ or a flat fee of $10.00. A deductible does not apply to these preventive tests, even if the results come back abnormal. However, if a follow-up pap smear and/or mammogram are needed, then the cost will be subject to the deductible, if you are on a deductible plan. If you are on a non-deductible plan, then the cost will be $10.

A Pap smear, also called a Pap test, is a procedure to test for cervical cancer in women. Generally, it is recommended every 3 years starting at age 21, or earlier if the woman is sexually active. The test is done as part of a routine pelvic exam, so the cost for the actual exam is included in the fee for the doctor’s visit. The Pap smear is a lab test and will be separate from the doctor’s visit. It will either be ‘no charge’ or $10, depending on the plan you are on.

A mammogram is an x-ray which helps detect breast cancer. It is recommended every 1 to 2 years for women age 40 to 74. Women age 75 and older may want to ask their doctor about whether they need this test.

Your doctor may recommend either of the above tests at a younger age if you or your family has a history of cancer, or if other risk factors apply.

Having these preventive tests done routinely is a good way of taking care of yourself at minimal cost.

Posted: August 12th, 2010 under Kaiser Permanente.
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As a Kaiser Permanente member, you can expect the following in the event of an emergency:
- Some of the services related to the emergency must be pre-authorized by Kaiser in order to be covered.
- If the member files a claim, they will still be billed and could be referred to collections if the bills remain unpaid.
- The claim process will vary depending on where the emergency and/or related services are obtained.

An “emergency” is a medical or psychiatric condition that puts a person’s health in serious jeopardy, or presents serious impairment to bodily functions, or a serious dysfunction of any bodily organ or part. Kaiser will cover emergency care anywhere in the world, even if the services are obtained at a non-Kaiser facility.

If a Kaiser member is experiencing a medical problem and needs professional advice, they can call their home Kaiser from anywhere in the world and speak with an advice nurse, 24 hours a day / 7 days a week. If the member is involved in an emergency, then, as soon as reasonably possible, they should contact the Kaiser Emergency Line at 1-800-225-8883 or the notification telephone number on the Kaiser ID card.

Once the doctor determines that the condition is clinically stable, then, any additional services (“post-stabilization care”) may need to be approved in advance by Kaiser in order to be covered. If the post-stabilization care is received at the member’s local Kaiser (“pass go”), pre-authorization and claim forms are not required. If the care is provided at Kaiser but in another state or region, pre-authorization is not needed, but a claim form would be. For post-stabilization care at a non-Kaiser facility, both pre-authorization and a claim form would be needed.

If the emergency and/or post-stabilization care is provided outside of the member’s local Kaiser, then, the treating facility will bill the member. To receive reimbursement, a claim would need to be submitted. The claim process can take from 30 days, up to 6 months. During this time, the member will be billed. If the member pays the bills, it will delay the reimbursement process by another 6-8 weeks approximately. If the member does not pay the bills, there is a possibility that a collections agency may get involved. However, adverse effects would be reversed once the claim is resolved. Note: The member is still responsible for their share of the cost, if any, depending on the insurance plan.

To file a claim form, call Kaiser Member Services at 1-800-464-4000 or the Claims Department at 1-800-390-3510 for assistance. For Kaiser members in California, claim forms and attachments can be mailed to:

For Northern CA Members:
Kaiser Foundation Health Plan, Inc.
Claims Department
P.O. Box 12923
Oakland, CA 94604-2923

For Southern CA Members:
Kaiser Foundation Health Plan, Inc.
Claims Department
P.O. Box 7004
Downey, CA 90242-7004

Emergencies are never pleasant, but at least, it’s good to know what to expect should an emergency arise.

Posted: August 2nd, 2010 under Kaiser Permanente.
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Kaiser Permanente and J.D. Power and Associates announced this month that four Kaiser Permanente regions rated the highest in customer satisfaction in the 2010 U.S. Member Health Insurance Plan Study. The Georgia Region was ranked 52 points higher than the average for the South Atlantic Region. Constantly, in study after study Kaiser Permanente is ranking #1 in quality of care while maintaining very competitive rates with their competition. Why has Kaiser Permanente experienced such success in the health care industry? Why are other health insurance carriers having a more and more difficult time competing with Kaiser Permanente?

In This System, It Pays to Keep You Healthy
The Kaiser Permanente Health Insurance Company with its integrated care model is becoming very difficult to compete with. The integrated model allows for high quality care at some of the most affordable rates available in the health insurance industry. This HMO integrated model makes it advantageous for the carrier to improve your health. HMO doctors benefit when their clients stay healthy. Not so with PPO doctors. With PPO models and those of most other health insurance carriers, it is to the advantage of the physicians for you to be sick, not for you to be well. The more doctor visits, surgeries and hospital stays you incur, the more money they make. With Kaiser’s integrated model, they make more money by keeping you healthy. They’d much rather keep you from needing the hospitalization or the surgery because it’s in their best interest (as well as yours).

Why You Can’t Email Your PPO Doctor
Recently a PPO doctor I spoke with raved about the Kaiser System. He pointed out that it’s hard to compete with Kaiser’s pricing and quality of care. Kaiser can save time and money by having doctors write emails to patients. “It makes sense to email your patients in the Kaiser model. We can’t do that in the PPO world,” he explained. “If we want to make money, we have to get them to come in for a doctor visit.” In the PPO world, there is a constant drive to give billable treatment, medical care that you can charge for whether or not it’s necessary.

Why Kaiser Permanente Is Years Ahead of Many Other Health Care Providers
Advances in medical science that increase health and decrease the need for expensive medical intervention are very appealing to Kaiser Permanente and not as appealing to physicians within the PPO realm. Kaiser doctors will not push you to get expensive surgeries or tests that aren’t needed. There is no need for duplicate tests in the Kaiser Permanente world. When you get labs, x-rays and other tests, your primary care physician and the specialists you see have access to those tests. Your specialist does not need to give duplicate tests that have already been done by your primary doctor. This saves you money and it saves Kaiser Permanente money. Ultimately, the HMO model of integrated care makes it advantageous for Kaiser Permanente to keep you healthy, to keep costs down, and to be constantly on top of the latest scientific advances in modern medicine.

The Power of Financial Incentive
Financial incentive drives PPO doctors to give you more and more unnecessary treatment, which increases costs to the health insurance carrier and ultimately increases the monthly premiums you pay without improving your health or advancing the quality of care dispensed. On the other hand, the financial incentives of the integrated HMO health insurance systems, drives Kaiser Permanente to stay cutting edge at all times on the latest research in the medical field and the latest advances in medical technology. Dispensing medical treatment is the business of the PPO doctors, while dispensing health is the business of Kaiser Permanente.

Posted: July 26th, 2010 under Kaiser Permanente.
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Looking at my HMO versus the PPO my mother has, I can really see the advantages of going with an HMO. I’m thankful to be with Kaiser Permanente, which offers HMO medical insurance. HMO stands for “Health Maintenance Organization”. The doctors are part of a network and my medical records are integrated. This means my doctors work like a team. Any of them can readily step in. Any of them can access my medical records at anytime. I don’t have to wait to speak with the last medical professional I saw or try to remember what the different doctors said. There’s no waiting or guesswork on who did what, why, or when. It’s seamless medical care.

My Mom is on a PPO (“Preferred Provider Organization”) plan. Her doctors and nurses have been exceptional: caring, professional, and knowledgeable. However, there are challenges when it comes to communication and medical records. The right hand doesn’t always know what the left hand is doing because the medical information is not readily accessible. This means when she’s at a hospital, the treating doctor or doctor on duty may not be in communication with her regular doctor. So when we need updates or additional information, it is often up to us to do the legwork. Sometimes, it’s like pulling teeth. Here is my family’s recent experience:

My Mom has had several medical issues this year. She’s frequented at least 4 different hospitals and had multiple emergency room visits. Recently, Mom was admitted for a peg-tube complication. She was released after a 3-day stay. When she came home, she was confused, agitated and quite feisty, totally unlike her usual self. Ordinarily, she is mellow and sweeter than pie. The strange behavior prompted me to call the hospital that discharged her. I was advised that it would be best to speak with her regular doctor. Her regular doctor never saw her at the hospital, so I asked who else could help me. The nurse recommended speaking with the last nurse who took care of Mom, except she had already left for the day, so best to call her regular doctor after all. Eventually, the nurse suggested I speak with the Head Nurse. The Head Nurse said to consult with the treating physician. But the treating physician advised her to have me consult with the doctor who released her, except she too was gone for the day. I was thankful the nurse decided to help me herself. I realize she had to bypass hospital protocol, but it was a good time for good sense.

Mom’s experience has made me more grateful to be with on an HMO with Kaiser. There may be a different kind of red tape, but at least, the medical professionals would have been better-able to coordinate. The right hand and left hand would have worked together in providing good administrative support on top of great medical care.

Posted: July 14th, 2010 under Kaiser Permanente.
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Kaiser Permanente’s individual health insurance application is designed to give a snapshot of an applicant’s medical history so that underwriting can make an informed decision. At times, however, underwriting needs additional detailed information related to medical history. That’s when Kaiser recruits the services of an agency called WFI, Western Field Investigations, to help them get copies of medical records.

What does WFI do?
WFI is an independent nationwide agency that specializes in records retrieval. When they are requested by Kaiser to obtain medical records, WFI goes into action mode and jumps through the necessary hoops to get medical records to Kaiser Permanente. First, WFI determines which authorization form is needed by the medical facility or doctor’s office. There is no one-size-fits-all form. For example, both Stanford and UCLA hospitals require their own authorization form. When the appropriate form version is identified, then WFI sends the form to the applicant for a signature. Once the applicant signs the form and returns it to WFI, they make an appointment to visit the facility to scan the medical records, which are then electronically forwarded to Kaiser. This entire process can be as short as 1 day or as long as 30 days.

How can I speed up the process for my application?
Applicants can make a big difference in expediting the process of getting their medical records to underwriting. When applicants are quick to sign and return the authorization form back to WFI, this cuts the processing time drastically.

How can I find out how things are moving along?
WFI will accept requests for status updates from applicants. They can be reached by telephone (1-800-999-9589) or by fax (1-626-768-7064). A general email address is not available, but if the field rep emails the request to the applicant, then an email address would be available. Once Kaiser receives the medical records, it takes underwriting on average 3-5 days, or up to 2 weeks sometimes, to review the additional information and render their decision regarding the approval of an application.

Posted: July 12th, 2010 under Kaiser Permanente.
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On January 1, 2014, health insurance carriers will no longer be able to deny coverage for pre-existing health conditions. However, for many with pre-existing health conditions this is simply too long to wait to get California health insurance coverage. Perhaps, they are unable to qualify for group insurance and they would be denied if they applied for an individual health insurance plan. Help is on the way. As of this September 23, 2010, health insurance carriers will no longer be able to deny coverage to minors ages 18 and under. Also, for those 19 and above, states will be offering Pre-Existing Condition Insurance Plans beginning this August, 2010. This program will be run by MRMIB (the Managed Risk Medical Insurance Board).

Qualifications for Enrollment
In order to qualify for health insurance coverage with the Pre-Existing Condition Insurance Program, you must meet the following criterion:
• You must be a United States citizen or national or be lawfully present in the USA.
• You must have gone without health insurance for a minimum of six months before applying.
• Due to a pre-existing condition, you must have had a problem getting health insurance coverage.

This medical insurance coverage under the Pre-Existing Condition Insurance Plan covers a wide range of benefits. These health benefits include primary and specialty doctor visits, hospitalization, and prescription drug coverage. These medical benefits will be available to all on the Pre-existing Condition Insurance Plan regardless of whether the care is being received for new medical conditions or for conditions present on or before the time of enrollment. Thus approval will not be denied for pre-existing conditions nor will coverage be withheld to treat medical conditions that existed before enrollment.

Benefits & Pricing Example
The following example describes the type of coverage and pricing you might receive. A 50 year old living in San Francisco would be placed on a $1500 Deductible Plan with a $2,500 Out of Pocket Limit. The premium for this plan would be $575 a month.

How do I Apply?
Please send an email to FHRP@mrmib.ca.gov to request enrollment forms. In your email, be sure to include the following:
• your name
• your mailing address

Or, you may mail this information to the address below:

Pre-Existing Condition Insurance Plan
California Managed Risk Medical Insurance Board
P.O. Box 2769
Sacramento, CA 95812-2769

Posted: July 5th, 2010 under California.
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