Kaiser HI Choice HMO
Depending on where you live, a Health Maintenance Organization (HMO) plan may be available to you. This plan provides coverage only when you receive care from providers within the HMO network. Your Primary Care Provider (PCP) will coordinate your care to help manage costs.
How it works:
You pay the plan per-paycheck cost from your paycheck to have coverage.
- Copay: You pay a small fee at the time of service for doctor visits and prescriptions. Copays count towards your deductible.
- Deductible: For care that doesn’t charge a copay, such as hospital services, you pay 100% of the costs until you meet the annual deductible.
- Coinsurance: After meeting the deductible, you and the plan share the cost of certain services, with the plan paying the majority.
- Out-of-Pocket Maximum: You’re protected by an annual limit on costs — the plan pays 100% of any further covered expenses for the rest of the year.
Keep in mind
You pay nothing for in-network preventive care — it’s covered in full.
Do you have a PCP?
With an HMO, you should select a Primary Care Provider (PCP) who will manage your care and provide referrals if you need to see a specialist.
Contact Info
Documents
Kaiser HI Choice HMO Plan
| Kaiser HI Choice | |||
|---|---|---|---|
| In-Network (Plan Providers) | Out-of-Network (Participating Providers) | Out-of-Network Non-contracted (Non-participating Providers) |
|
| Annual Deductible | |||
| Individual | None | $100 | $100 |
| Family | None | $300 (Embedded) | $300 (Embedded) |
| Out of Pocket Maximum | |||
| Individual | $2,000 | $2,000 | $2,000 |
| Family | $6,000 | $6,000 | $6,000 |
| Coinsurance | 20% | 20% | 20% |
| Services | |||
| Preventive Care | Covered at 100% | 20%; deductible waived | 20%; deductible waived |
| Office Visit - PCP | $20 per visit | 20% coinsurance | 20% coinsurance |
| Office Visit - Specialist | $20 per visit | 20% coinsurance | 20% coinsurance |
| X-ray | $10 per encounter | 20% coinsurance | 20% coinsurance |
| Laboratory | $10 per encounter | 20% coinsurance | 20% coinsurance |
| Diagnostic Complex Imaging | 20% coinsurance | 20% coinsurance | 20% coinsurance |
| Inpatient Hospitalization | 10% coinsurance | 20% coinsurance | 20% coinsurance |
| Outpatient - Ambulatory Surgical Center | 10% coinsurance | 20% coinsurance | 20% coinsurance |
| Outpatient - Hospital | 10% coinsurance | 20% coinsurance | 20% coinsurance |
| Urgent Care | $20 / 20% if out of area | 20% coinsurance | 20% coinsurance |
| Emergency Room | 20% coinsurance | 20% coinsurance | 20% coinsurance |
| Ambulance | 20% coinsurance | 20% coinsurance | 20% coinsurance |
| Physical Therapy | Inpatient: 10% coinsurance Outpatient: $20 per visit | 20% coinsurance | 20% coinsurance |
| Chiropractic | Not covered | Not covered | Not covered |
| Pharmacy - Retail | |||
| Generic | $15 | 20% coinsurance; not less than $10/Rx | Not covered |
| Preferred | $50 | ||
| Non-Preferred | $50 | ||
| Pharmacy - Mail Order | |||
| Generic | $30 | 20% coinsurance; not less than $35/Rx | Not covered |
| Preferred | $100 | ||
| Non-Preferred | $100 | ||
| Specialty Drugs | |||
| $200 | 20% coinsurance; not less than $35/Rx | Not covered | |
| You must pay all of the cost from providers up to the deductible amount before the plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of the deductible expenses paid by all family members meets the overall family deductible | |||