What The Kaiser Permanente HMO Covers

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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Office Visits

Routine Office Visits

  • Kaiser Hawaii—Plan pays 100% after a $15 copayment.

  • Kaiser California—Plan pays 100% after a $20 copayment.

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Preventive Care

  • Kaiser Hawaii—Plan pays 100%. No charge for flu shots or routine immunization.

  • Kaiser California—Plan pays 100% after a $20 copayment.

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Well Child Care

  • Kaiser Hawaii—Plan pays 100%.

  • Kaiser California—Plan pays 100% after a $5 copayment for children through age 23 months.

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At The Hospital

Emergency Room

  • Kaiser Hawaii—Plan pays 100% after a $75 copayment at any emergency room in Hawaii.

  • Kaiser California—Plan pays 100% after a $50 copayment (this copayment is waived if the individual is hospitalized).

Note that no benefits are paid for non-emergency care obtained in an emergency room of a non-Kaiser facility.

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Semi-Private Room And Board

  • Kaiser Hawaii—Plan pays 100% after a $75 copayment per day.

  • Kaiser California—Plan pays 100% after a $250 per admission copayment.

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Inpatient X-ray And Lab Services

  • Kaiser Hawaii—Plan pays 100%.

  • Kaiser California—Plan pays 100%.

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Surgery

Outpatient

  • Kaiser Hawaii—Plan pays 100% after a $15 copayment.

  • Kaiser California—Plan pays 100% after a $20 copayment.

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Inpatient

  • Kaiser Hawaii—Plan pays 100% after a $75 per day copayment.

  • Kaiser California—Plan pays 100% after a $250 per admission copayment.

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:

  • All stages of reconstruction of the breast on which the mastectomy was performed,

  • Surgery and reconstruction of the other breast to produce a symmetrical appearance,

  • Prostheses, and

  • 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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Maternity Services

Office Visits

  • Kaiser Hawaii—Plan pays 100% after confirmation of a pregnancy.

  • Kaiser California—Plan pays 100% after a $5 copayment for prenatal and first postnatal visits; 100% after a $20 copayment for all other family planning visits.

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Hospital Services

  • Kaiser Hawaii—Plan pays 100%.

  • Kaiser California—Plan pays 100% after a $250 per admission copayment.

Important Notice Regarding Newborns' and Mothers' Health Protection Act

Federal law protects the benefit rights of mothers and newborns related to any hospital stay in connection with childbirth. In general, group health programs and health insurance issuers may not:

  • Restrict benefits for the length of hospital stay for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable).

  • Require that a provider obtain authorization from the program or the insurance issuer for prescribing a length of stay of up to 48 hours (or 96 hours).

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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.

Inpatient

  • Kaiser Hawaii-Plan pays 100% after a $75 per day copayment.

  • Kaiser California—Plan pays 100% after a $250 per admission copayment.

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Outpatient

  • Kaiser Hawaii—Plan pays 100% after a $15 copayment per visit.

  • Kaiser California—Plan pays 100% after a $20 copayment.

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Other Frequently Utilized Services

Prescription Drugs

  • Kaiser Hawaii—Plan pays 100% after a $15 copayment at Kaiser pharmacies for up to a 30-day supply of brand name or generic drugs (formulary); mail-order benefits are also available with a $30 copayment for up to a 90-day supply. Note: benefits for contraceptive drugs and devices will be covered at 50%.

  • Kaiser California—Plan pays 100% after a $10 copayment for generic drugs and a $30 copayment for brand name drugs at Kaiser pharmacies for up to a 30-day supply in accordance with the health plan formulary; benefit includes dental-related prescriptions. Mail-order benefits are also available with a $20 copayment for generic drugs and a $60 copayment for brand name drugs up to a 100-day supply.

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Vision (Eye Care) Services

  • Kaiser Hawaii—Plan pays 100% after a $15 copayment for eyeglass exams; 100% for standard lenses every 24 months (or 12 months if a change in prescription is required); 100% for frames up to $40 every 24 months; or 100% for contact lenses, up to $45 with a $70 professional fitting fee credit.

  • Kaiser California—Plan pays 100% after a $20 copayment for exams; 100% for standard lenses (as frequently as the prescription requires); and an allowance for frames of up to $175 every two years. Please contact your local Kaiser Permanente Optical Dispensing Department for an explanation of certain additional costs relating to the fitting and evaluation for contact lenses.

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Outpatient X-ray & Lab Services

  • Kaiser Hawaii—Plan pays 90%.

  • Kaiser California—Plan pays 100%.

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Skilled Nursing Facility

  • Kaiser Hawaii—Plan pays 100% for up to 60 days per benefit period.

  • Kaiser California—Plan pays 100% for up to 100 days per benefit period.

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Home Health Care

  • Kaiser Hawaii—Plan pays 100%.

  • Kaiser California—Plan pays 100% (limited to 100 two-hour visits per calendar year) when prescribed by a plan physician.

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Hospice Care

  • Kaiser Hawaii—Plan pays 100%.

  • Kaiser California—Plan pays 100%.

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Hearing Aids/Hearing Exams

  • Kaiser Hawaii—Plan pays 100% after a $15 copayment for an annual hearing exam to determine the need for correction; appliances (devices) are not covered.

  • Kaiser California—Plan pays 100% after a $20 copayment for examinations and 100% up to $2,500 per device per ear; two devices every 36 months.

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Durable Medical Equipment (DME)

  • Kaiser Hawaii—50% for diabetes equipment and 100% for internal prosthetics, devices, and aids.

  • Kaiser California—Plan pays 100% when medically necessary, prescribed by a Kaiser physician and in accordance with Kaiser's DME formulary guidelines.

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