Kaiser Permanente HMO (California) - Group #7145 (Northern CA), Group #230178 (Southern CA)
Basics
Full-Time Employee * Contribution Per Pay Period
Employee Only: $0
Employee & Spouse/Registered Domestic Partner: $143.87
Employee & Children: $123.32
Employee & Family: $198.68
Employee & Spouse/Registered Domestic Partner: $143.87
Employee & Children: $123.32
Employee & Family: $198.68
Part-Time Employee * Contribution Per Pay Period
Employee Only: $190.31
Employee & Spouse/Partner: $471.57
Employee & Children: $404.21
Employee & Family: $651.22
Employee & Spouse/Partner: $471.57
Employee & Children: $404.21
Employee & Family: $651.22
Lifetime maximum
No maximum
Plan Year
2020
Pre-Authorization Requirement
Pre-authorization required for all elective inpatient and outpatient procedures.
PENALTY for not pre-authorizing: not covered.
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.
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.)
$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: $30 co-pay
If midwife is available at Kaiser Permanente
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
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
$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.
$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
$30 co-pay
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
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 100%
Hearing aids not covered
Hearing aids not covered
Home Health Care
100%
Up to 100 two-hour visits/calendar year
[3 visits per day max]
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
50%
Fertility Drugs: Covered under drug benefits at 50%; In Vitro, GIFT, and ZIFT: Not covered.
Fertility Drugs: Covered under drug benefits at 50%; In Vitro, GIFT, and ZIFT: Not covered.
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
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
$150 co-pay per admission
OUTPATIENT
$150 co-pay per procedure
Speech Therapy
$30 co-pay
Tubal Ligation
INPATIENT
100%
OUTPATIENT
100%
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
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.
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
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. Discount program available for vision hardware
Eye exams only. Discount program available for vision hardware