Kaiser Permanente's HMO Group Plan Benefit Summaries

Description of Benefits	2005 Small Group HMO Plan Options
	HMO A	HMO B	HMO C	HMO D
Lifetime Maximum	Unlimited	Unlimited	Unlimited	Unlimited
Calendar year Deductible (per member-max 3 members)	$0	$0	$0	$500
Coinsurance (amount insurance pays after deductible is met)	100%	100%	90%	80%
Out-of-Pocket Maximum for Calendar Year - Excludes Deductible Excludes copayments (per member-max 3 members)	$0	$0	$2,000	$2,000
Physicians Office Visit PCP/Specialist (includes x-ray and lab work done and billed by Drs. office)	$15/$25	$20/$30	$20/$30	$25/$35
Outpatient Diagnostic Testing includes x-ray, lab and preventive testing (Plan pays after deductible)	$0	$0	90%	80%
Outpatient Surgery Facility includes x-ray and lab (Plan pays after deductible)	$50	$100	90%	80%
Physician Outpatient Surgery Services (surgeon, radiologist, anesthesiologist, etc) (Plan pays after deductible)	100%	100%	90%	80%
Inpatient Hospital (Includes Maternity) (Plan pays after deductible)	$200	$500	90%	80%
Physician Inpatient Services (Includes Maternity) (surgeon, radiologist, anesthesiologist, etc) (Plan pays after deductible)	100%	100%	90%	80%
Durable Medical Equipment (Plan pays after deductible)	50%	50%	50%	50%
Inpatient Behavioral Health/Substance Abuse 30 Day calendar year max (Plan pays after deductible)	$200	$500	90%	80%
Outpatient Mental Health Individual Therapy/Group Therapy Individual Therapy -20 Visit calendar year max Group Therapy-Unlimited Visits	$25/$12	$30/$15	$30/$15	$35/$17
Outpatient Chemical Dependency Services (Detoxification Only)	$15	$20	$20	$25
Emergency Services Hospital ER/After Hours Urgent Care (per visit - waived if admitted)	$100/$30	$100/$40	$100/$40	$100/$50
Prescription Drug Deductible - All Tiers	$0	$50	$50	$150
Prescription Drug Copays Generic/Brand	$10/$20	$10/$20	$10/$20	$10/$20
Note: Plan benefits listed above are intended as a summary only and do not replace benefits listed in certificate of coverage. Some specific benefits may have limitations and/or exclusions. Refer to your policy for more detail.
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5 Dunwoody Park South, Suite 110 Atlanta, GA 30338	Call Bob, Holly or Terri at (770) 396-9517 Outside of the Atlanta area, call toll-free: 1-877-711-8376. Email: bryals@mindspring.com