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Kaiser Permanente HMO (California) Group #7145 (Northern CA) Group #230178 (Southern CA) - 2020

Ratings
National Committee For Quality Assurance (NCQA)
Up to four stars are given for each of the following criteria:
Overall Accredition Status: 
Accredited
Access & Services: 
3
Qualified Providers: 
4
Staying Healthy: 
2
Getting Better: 
1
Living With Illness: 
4
Basics

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

Description: 
Kaiser
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

Part-Time Employee * Contribution Per Pay Period: 

Employee Only: $190.31
Employee & Spouse/Partner: $471.57
Employee & Children: $404.21
Employee & Family: $651.22

Pre-Authorization Requirement: 

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

PENALTY for not pre-authorizing: not covered.

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.

Deductible: 

No deductible

Office co-pay: 

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

Coinsurance: 

100% after applicable co-pays

Out-of-Pocket 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.)

Overall Lifetime Maximum: 

No maximum

Maternity
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

Prenatal Visits: 

100%

Doctor Delivery Charge: 

100%

Pregnancy Termination: 

$50 co-pay

Mental Health/Substance Abuse
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

Other Services (A-D)
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: 

$30 co-pay

Allergy Treatment: 

$5 co-pay for injections

Alternative Medicine: 

Not covered

Ambulance charges: 

100% after $50 co-pay

CAT 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

Other Services (E-N)
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

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: 

50%

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%

Other Services (O-Z)
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%

Prescription Drugs
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%

Preventive Care
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. Discount program available for vision hardware