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Kaiser Permanente HMO (California) - Group #7145 (Northern CA), Group #230178 (Southern CA)

Basics

Full-Time Employee * Contribution Per Pay Period

Employee Only $0.00
Employee & Spouse/Registered Domestic Partner $164.97
Employee & Child(ren) $141.40
Employee & Family $227.81

Part-Time Employee * Contribution Per Pay Period

Employee Only $218.21
Employee & Spouse/Registered Domestic Partner $540.72
Employee & Child(ren) $463.48
Employee & Family $746.69

Lifetime maximum

No maximum

Plan Year

2023

Pre-Authorization Requirement

Pre-authorization required for all elective inpatient and outpatient procedures.

PENALTY for not pre-authorizing: not covered.

Offered To

Employees

Care Management

Kaiser Permanente’s Complete Care℠, is a comprehensive multidisciplinary approach to identifying and treating members with chronic conditions. It addresses a wide range of chronic and acute conditions and comorbidities with a focus on prevention, risk reduction, and self-care. The program is integrated into the patient-centered, “whole person” continuum of care provided.

Program features include: Multidisciplinary disease management and case management; sophisticated electronic health information management and disease registries; proactive, targeted screening, intervention, and outreach; extensive support for implementing best practices and improved panel management; member self-care tools for improving health and quality of life; and health education to support self-management.

Body/Description

You may use only Kaiser Permanente doctors and facilities except in emergencies.

Coinsurance

100% after applicable co-pays

Office co-pay

$30 co-pay primary/$50 co-pay specialist

Deductible

No deductible

Benefit Type

Medical

Annual maximum

$3,500 per individual (in single employee enrollment or in family enrollment)
$7,000 family

A single Out-of-Pocket Maximum applies to all coverage under the plan, including medical and prescription drugs. (This will cover prescriptions and medical expenses at 100% once the Out-of-Pocket Maximum is met.)

X-rays

100%

Maternity Hospital Stay

$150 co-pay per admission

Baby's First Exam

100%

Birthing Centers

100%

Midwives

100% in hospital; if out-patient office visit: $50 co-pay

If midwife is available at Kaiser Permanente

Prenatal Visits

100%

Doctor Delivery Charge

100%

Reproductive Health

$50 co-pay

Mental Health

Kaiser Permanente must approve mental health care.
INPATIENT CARE
$150 co-pay per admission

OUTPATIENT CARE
[no visit limit]
$30 co-pay per visit, individual
$15 co-pay per visit, group

Autism

Behavioral health treatment for pervasive developmental disorder or autism (including applied behavior analysis and evidence-based behavior intervention programs) that develops or restores, to the maximum extent practicable, the functioning of a person with pervasive developmental disorder or autism that meet Kaiser's established criteria (refer to Evidence of Coverage booklet for specifics). The cost sharing for individual and group visits under this Mental Health section apply.

Substance Abuse

INPATIENT DETOXIFICATION
$150 co-pay per admission

OUTPATIENT CARE
[no visit limit]
$30 co-pay per visit, individual
$5 co-pay per visit, group

Transitional Residential Recovery Services
$150 co-pay per admission

Acupuncture

At a Kaiser facility:
$30 copay/visit
Referral required - limited basis by referral only as part of a comprehensive pain management program or for the treatment of nausea

Using the American Specialty Health (ASH) network:
$20 copay/visit for up to 40 combined chiropractic and acupuncture visits per year
No referral required.

Allergy Tests

$50 co-pay specialist

Allergy Treatment

$5 co-pay for injections

Alternative Medicine

Not covered

Ambulance charges

100% after $50 co-pay

CT Scans

100%

Chiropractors

$20 co-pay

Up to 40 combined chiropractic and acupuncture visits per year

American Specialty Health (ASH) Plans Participating Chiropractors

Christian Science Practitioners

Not covered

Cosmetic Surgery

Not covered

Dental Treatment

Not covered

Emergency Room

$200 co-pay (waived if admitted)

Urgent Care

$30 co-pay at Kaiser Permanente facility

Hearing Care

Exam Network: 100% as part of preventive care

Hearing aids not covered

Home Health Care

100%

Up to 100 two-hour visits/calendar year
[3 visits per day max]

Hospice Care

100%

Hospital Stay

$150 co-pay per admission

Infertility Treatment

Diagnosis and treatment of Infertility:
Office Visits: $50 per visit
Outpatient: $150 per procedure
Inpatient: $150 per hospitalization
Fertility Drugs: Covered under drug benefits
3 cycles lifetime/no maximum: IVF, GIFT, and ZIFT

*Artificial insemination and ovulation induction are covered regardless of partner status and without a diagnosis of infertility.

Laboratory Charges

100%

Magnetic resonance imaging - MRI

100%

Durable Medical Equipment

100%

Occupational Therapy

$30 co-pay

Organ Transplants

Contact Kaiser Permanente for information on transplant coverage benefits

Skilled Nursing

100% (Up to 100 days)

Physical Therapy

$30 co-pay

Surgery : Physician Services

INPATIENT
Covered under hospital co-pay

OUTPATIENT 
$150 co-pay per procedure

Surgery : Facility Charges

INPATIENT
$150 co-pay per admission

OUTPATIENT
$150 co-pay per procedure

Speech Therapy

$30 co-pay

Tubal Ligation

INPATIENT
100%

OUTPATIENT
100%

Vasectomy

$150 co-pay per procedure

X-rays

100%

Pharmacy (Retail)

KAISER PERMANENTE PHARMACY
Generic: $10 for up to a 30-day supply, $20 for a 31- to 60-day supply, or $30 for a 61- to 100-day supply

Brand: $40 for up to a 30-day supply, $80 for a 31- to 60-day supply, or $120 for a 61- to 100-day supply

Mail order drug program

KAISER PERMANENTE MAIL ORDER PHARMACY
Generic:  $20 for up to 100 day supply

Brand: $80 for up to 100 day supply; Some Specialty drugs are available via mail order, but there is no incentive as you will be paying for the full 100 day supply.  

Birth Control Pills

Included in Prescription Drug benefit, covered at 100%

Physical exams for adults

100%

Physical exams for children

100%

Pap smears

100%

Mammograms

100%

Immunizations

100% 
Office visit co-pay applies if provided during doctor office visit

Prostate Specific Antigen test - PSA

100%

Well-woman visits

100%

Vision care

100%


Eye exams only