The following is a summary of the types of covered services under the Kaiser Permanente HMO for Hawaii and California. Note that the term "copayment" as used in this section may also be referred to as a "registration fee" by Kaiser Hawaii.
Be aware that there is an annual out-of-pocket maximum. This means that when you or a family member reaches the out-of-pocket limit, benefits for that person are paid at 100% of covered expenses for the balance of the calendar year. In Hawaii the out-of-pocket maximum is $2,500 per individual and $7,500 per family, and in California the maximum is $1,500 per individual and $3,000 per family.
For additional details on these and other covered services, refer to the Kaiser Permanente Member Handbook you received.
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At The Hospital
Emergency Room
Note that no benefits are paid for non-emergency care obtained in an emergency room of a non-Kaiser facility.
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Surgery
Inpatient
Note that benefits for reconstructive surgery may be limited. However, if you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:
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All stages of reconstruction of the breast on which the mastectomy was performed,
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Surgery and reconstruction of the other breast to produce a symmetrical appearance,
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Prostheses, and
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Treatment of physical complications of all stages of the mastectomy, including lymphedemas.
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this program.
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Mental Health/Substance Abuse Treatment
Note that copayments and limitations may not apply under the California Kaiser HMOs for certain diagnoses in accordance with California State Law (AB88) governing insured plans.
