Through FlexSolutions, you may be able to enroll in the Kaiser Permanente HMO, instead of either an HMSA or CIGNA Medical Plan. Whether you are eligible to enroll in Kaiser is based on where you live—if you are eligible for Kaiser, this option will be listed on your FlexSolutions Enrollment Form.
If you enroll in the Kaiser HMO, you will receive a separate document describing the benefits provided by the Plan. However, for your convenience, we have provided a brief description of the Kaiser HMO in this Handbook for your reference. Just keep in mind that this Plan is governed by the provisions outlined in the Kaiser Permanente Member Handbook you received, and is administered in accordance with the applicable state laws.
Back to TopThe Kaiser Permanente HMO, like most HMOs, emphasizes preventive care. Most covered services are provided at no cost to you, or with only a small copayment. Covered services include regular checkups, treatment of illness or injury, hospitalization, mental health/substance abuse treatment, prescription drugs, hearing aids, and vision care. Important: If you enroll in Kaiser, you are not eligible for the benefits provided through Vision Service Plan (VSP); instead, you are eligible to receive vision benefits through Kaiser as outlined in the section below.
However, these services are only covered when you use Kaiser providers and facilities. No benefits are paid for services obtained outside the Kaiser organization. There is one exception: If you are away from home and you require emergency care or urgent medical attention, your treatment at a non-Kaiser facility will be covered at 80% of reasonable and customary charges if you could not safely get to a Kaiser Permanente hospital. However, you must notify Kaiser as soon as possible after the accident. You must pay for the covered expenses at the time of service; keep all the receipts and file a claim with Kaiser upon returning home.
Note for Hawaii residents: If you move outside the Hawaii service area, the plan may terminate your coverage. Likewise, if you live outside the Hawaii service area, you may not enroll in Hawaii Kaiser Permanente. The only exception is for eligible dependent children attending college outside of Kaiser's Hawaii service area.
Back to TopThe following is a summary of the types of covered services under the Kaiser Permanente HMO for Hawaii and California. Note that plan provisions and benefit amounts may differ in Northern California and Southern California. These differences are noted as applicable. Note, too, 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 $2,000 per individual and $6,000 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.
Back to TopKaiser Hawaii—Plan pays 100% after a $14 copayment.
Kaiser California—Plan pays 100% after a $15 copayment.
Kaiser Hawaii—Plan pays 100% after a $14 copayment. Routine immunizations are covered at 100% for age 18 and under and $10 copay per dose for age 19 and over. No charge for flu shots.
Kaiser California—Plan pays 100% after a $15 copayment.
Kaiser Hawaii—Plan pays 100% after a $14 copayment.
Kaiser California—Plan pays 100% after a $5 copayment.
Kaiser Hawaii—Plan pays 100% after a $50 copayment at any emergency room in Hawaii. If care is received at a non-Kaiser facility, you must pay $50 inside the Hawaii service area; outside the Hawaii service area you must pay 20% of the "reasonable and customary" charges, plus any charges above the "reasonable and customary" amount.
Kaiser California—Plan pays 100% after $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.
Back to TopKaiser Hawaii—Plan pays 100% after a $50 copayment per day.
Kaiser California—Plan pays 100%.
Kaiser Hawaii—Plan pays 90%.
Kaiser California—Plan pays 100%.
Kaiser Hawaii—Plan pays 100% after a $14 copayment.
Kaiser California—Plan pays 100% after a $15 copayment.
Kaiser Hawaii—Plan pays 100% after $50 per day copayment.
Kaiser California—Plan pays 100%.
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.
Back to TopKaiser Hawaii—Plan pays 100% after confirmation of a pregnancy.
Kaiser California—Plan pays 100% after a $5 copayment for prenatal and postnatal visits.
Kaiser Hawaii—Plan pays 100%.
Kaiser California—Plan pays 100%.
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).
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.
Kaiser Hawaii—Plan pays 100% for inpatient services at a hospital, up to 30 days per calendar year. For treatment at a chemical dependency residential facility, the plan pays 80%, up to two treatments per lifetime.
Kaiser California—Plan pays 100% for inpatient services at a hospital, up to 45 days per calendar year.
Kaiser Hawaii—Plan pays 100% after a $14 copayment, up to 24 visits per calendar year (mental health and substance abuse treatment combined).
Kaiser California—Plan pays 100% after a $15 copayment (benefit limited to 20 visits per calendar year).
Kaiser Hawaii—Plan pays 100% after a $14 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 $28 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 $10 copayment for generic drugs and $20 copayment for brand name drugs, up to a 100-day supply in accordance with the health plan formulary; benefit includes dental-related prescriptions.
Kaiser Hawaii—Plan pays 100% after a $14 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 $15 copayment for exams; 100% for standard lenses (as frequently as the prescription requires); and an allowance for frames of up to $175 (Northern California) or $125 (Southern California) 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.
Kaiser Hawaii—Plan pays 90%.
Kaiser California—Plan pays 100%.
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.
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.
Kaiser Hawaii—Plan pays 100% after a $14 copayment for an annual hearing exam to determine the need for correction; appliances (devices) are not covered.
Kaiser California—Plan pays 100% after a $15 copayment for examinations and 100% up to $2,500 per device per ear; two devices every 36 months.
Kaiser Hawaii—50% for diabetes equipment and 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.
Because HMOs are governed by state laws, we cannot list all of the exclusions under each HMO. However, many of the general exclusions that are listed for the HMSA and CIGNA Medical Plans would apply. It's important to remember that, except in emergencies that occur outside your HMO's service area, you must receive all of your care through your HMO to be eligible for benefits. If you have any questions, you should contact your HMO directly or refer to the HMO Member Handbook you received.
Back to Top