With your HMO enrollment, you agree that Kaiser Permanente will provide all your medical services, including doctor, specialist, hospital, outpatient, laboratory, home health care, hospice, mental health, emergency, vision exams, hearing exams and hearing aids, speech, occupational, and physical therapy, prescription drugs, well-baby care, and preventive care.
Your vision coverage and chemical dependency services are provided through Kaiser.
Your Dental benefits are provided through Delta Dental.
There are no annual deductibles to pay or claim forms to file.
But it is important to understand that all medical services, except covered emergencies, must be obtained from or with the permission of the HMO. You pay 100% of the charges for medical services and supplies obtained from any source except Kaiser Permanente, except in an emergency.
Kaiser Permanente, not the Health and Welfare Plan Trustees, sets the rules and conducts the appeals process for denied claims. It is the final authority in determining whether any services and supplies you may request, in or out of the HMO, are medically necessary and covered benefits.
The Services described below are covered only if all the following conditions are satisfied:
• The Services are Medically Necessary
• The Services are provided, prescribed, authorized, or directed by a Plan Physician and you receive the Services from Plan Providers inside our Service Area, except where specifically noted to the contrary in the Evidence of Coverage for authorized referrals, Emergency Care, Post-stabilization Care, Out-of-Area Urgent Care, and emergency ambulance services.
| ANNUAL OUT-OF-POCKET MAXIMUMS | |
|---|---|
| For any one Member in the same Family Unit | $1,500 per calendar year |
| For an entire Family Unit of two or more Members | $3,000 per calendar year |
| Copayments and Coinsurance for most Services count toward this maximum as desribed in the Evidence of Coverage | |
| Deductible or Lifetime Maximum | None |
| Coordination of Benefits | Included |
| PROFESSIONAL SERVICES (Plan Provider office visits) | |
| Primary and specialty care visits (includes routine and Urgent Care appointments) | $10 per visit |
| Routine preventive physical exams | $10 per visit |
| Well-child preventive care visits (0-23 months) | $5 per visit |
| Family planning visits | $10 per visit |
| Scheduled prenatal care and first postpartum visit | $5 per visit |
| Eye exams | $10 per visit |
| Hearing tests | $10 per visit |
| Physical, occupational, and speech therapy visits | $10 per visit |
| OUTPATIENT SERVICES | |
| Outpatient surgery | $10 per procedure |
| Allergy injection visits | $3 per visit |
| Allergy testing visits | $10 per visit |
| Vaccines (immunizations) | No charge |
| X-rays and lab tests | No charge |
| Health education | $10 per individual visit No charge for group visits |
| HOSPITILIZATION SERVICES | |
| Room and board, surgery, anesthesia, X-rays, lab tests, and drugs | $100 per admission |
| EMERGENCY HEALTH COVERAGE | |
| Emergency Department visits | $35 per visit (does not apply if admitted directly to the hospital as an inpatient) |
| AMBULANCE SERVICES | |
| Ambulance Services | $50 per trip |
| PRESCRIPTION DRUG COVERAGE | |
| Most covered outpatient items in accord with our drug formulary from Plan Pharmacies | $10 for up to a 100 day supply |
| DURABLE MEDICAL EQUIPMENT | |
| Covered durable medical equipment for home use in accord with our DME formulary | No charge |
| MENTAL HEALTH SERVICES | |
| Inpatient psychiatric care (up to 45 days per calendar year) | $100 per admission |
| Outpatient visits: | |
| Up to a total of 20 individual and group therapy visits per calendar year | $10 per individual therapy visit $5 per group therapy visit |
| Up to 20 additional group therapy visits that meet the Medical Group criteria in the same Calendar Year | $5 per group therapy visit |
| Note: Visit and day limits do not apply to serious emotional disturbances of children and severe mental illnesses as described in the Evidence of Coverage | |
| CHEMICAL DEPENDENCY SERVICES | |
| Inpatient detoxification | $100 per admission |
| Outpatient individual therapy visits | $10 per visit |
| Outpatient group therapy visits | $5 per visit |
| Transitional residential recovery Services (up to 60 days per calendar year, not to exceed 120 days in any five-year period) | $100 per admission |
| HOME HEALTH SERVICES | |
| Home health care (up to 100 two-hour visits per calendar year) | No charge |
| OTHER | |
| Eyewear purchased from Plan Optical Sales Offices every 24 months | Amount in excess of $175 Allowance |
| Skilled nursing facility care (up to 100 days per benefit period) | No charge |
| Hospice care | No charge |
| This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, exclusions, or limitations, and it does not list all benefits, Copayments, and Coinsurance. For a complete explanation, please refer to the Evidence of Coverage. Please note that we provide all benefits required by law (for example, diabetes testing supplies). | |
800.464.4000 (ENGLISH)
800.788.0616 (SPANISH)
Plan Booklet
Chiropractic Plan
Change Forms - English or Spanish
Evidence of Coverage