What does the Kaiser Permanente 80 HMO health insurance plan cover?

What does the Kaiser Permanente 80 HMO health insurance plan cover?

As an insurance agent, I am asked on a daily basis the following questions:

-how much do I have to pay when I see a doctor?

-how much do I have to pay when I go to the hospital?

-how much do I have to pay for medication? 

-how much is the blood test lab? 

oh, and so many more questions related to what the specific plan covers. In an attempt to help everyone understand their health insurance plan, I've summed up the benefits of health insurance plans. 

:

Here is the summary of benefits for Kaiser Permanente 80 HMO plan for year 2016:

Calendar Year Medical Deductible -              $0 (this plan does not have a deductible)
Calendar Year Out-of-Pocket Maximum-                  $6,200 per individual/ $12,400 per family

Many people are confused with this concept. So what is the out-of-pocket maximum? It is the sum of deductible, copayments and coinsurance for covered services  during the calendar year. In other words, the out-of-pocket maximum is everything that an individual has to pay out of pocket for related medical services that are specified by the plan but not covered by the insurance.

Covered Services:

Primary care physician office visit:                                                                                     $35
Specialist physician office visit:                                                                                            $55

Allergy Testing and Treatment Benefits:               
Primary care physician office visits (includes visits for allergy serum injections):  $35
Specialist physician office visits (includes visits for allergy serum injections):                    $55
Allergy serum purchased separately for treatment                                                                 20%

Preventative health services:                                                                                                $0
(As required by applicable Federal and California law, there is no copaymentfor preventive health services, including an annual preventive care or well-baby care office visit. Other covered non-preventive services received during, or in connection with, the preventive care or well-baby care office visit are subject to the calendar year medical deductible and applicable member copayment/coinsurance.

X-Rays                                    $50
Most lab tests                          $35
MRI, Ct, PET                         20%    

Hospital Benefits:     

Outpatient surgery                                                                                                           20%
Outpatient visit:                                                                                                               20%

Outpatient services for treatment of illness or injury and necessary supplies      20%

Hospitalization Services

Inpatient physician fee                                                                                                20%

Inpatient non-emergency facility fee                                                                          20%

Inpatient Skilled Nursing Benefits                                                                           20%

(combined maximum of up to 100 days per benefit period; prior authorization is required; semi-private accommodations)

Emergency Health Coverage

Emergency room visit not resulting in admission - facility fee                                                           $250

(copayment does not apply if the member is directly admitted to the hospital for inpatient services)

Emergency room visit resulting in admission -facility fee                                                      20%

(when the member is admitted directly from the ER)

Emergency room visit not resulting in admission - physician fee                                          20%
 (copayment does not apply if the member is directly admitted to the hospital for inpatient services)

Emergency room visit resulting in admission -physician fee                                                  20%

Urgent Care                                                                                                                           $35

Ambulance Services Emergency or authorized transport (ground or air)                       $250

PRESCRIPTION DRUG (PHARMACY COVERAGE)

Retail Pharmacies (up to a 30-day supply)
Mail Service Pharmacies (up to 90-day supply)

Contraceptive drugs and devices                                                                                $0

Tier 1 Drugs:                                                   $15 per prescription
Tier 2 Drugs:                                                   $50 per prescription
Tier 3 Drugs:                                                   $50 per prescription
Tier 4 Drugs (excluding Specialty Drugs):    20% up to $250 maximum per prescription   

Pregnancy and Maternity Care benefits:                          
Prenatal and preconception physician office:                         $0

Infertility Services:                                                                not covered

                                    $35

Pediatric Vision Benefits: Pediatric vision benefits are available for members through the end of the month in which the member turns 19.

Pediatric Dental Benefits – Pediatric dental benefits are available for members through the end of the month in which the member turns 19.

 If you have questions about any of the above or would like to apply for health insurance, please feel free to contact us. We would be glad to provide free & confidential help! 

Here is how to reach us: 

by phone: 415-994-4121

web site: http://www.SFCheapInsurance.com 

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