Health Maintenance Organizations (HMOs)
HMOs offer health care for participants and their families through a limited network of health care providers. For more information visit the sections below.
How the Kaiser HMO Plans Work
HMOs require that participants receive all medical care exclusively from the HMO's network of providers in order for them to receive benefits. Participants would visit their Primary Care Physician (PCP) for all routine medical care and the PCP will refer the participant to a network specialist whenever he or she needs specialty care.
The Kaiser Permanente HMO plan makes it simple and convenient to get the care you need, when you need it and resources to stay in control of your plan and your health. When you go in for care, you pay just a copay or coinsurance for most services covered by your plan. Many preventive care services are covered at little or no charge.
After you reach your out-of-pocket maximum, you won’t have to pay copays or coinsurance for most covered services for the rest of the calendar year. This can help protect you financially if you have a serious illness or injury.
If a participant receives medical care without going through his or her PCP first, or if the participant's care is not authorized by the plan, the HMO may not pay any benefits, and the participant will pay the full cost of any out-of-network or unauthorized care. For most plans, emergency care received out-of-network or unauthorized by the plan will generally be covered.
For more information about how how the Kaiser plans work and what payments are required, participants should refer to their evidence of coverage booklet.
What the Kaiser Permanente HMO Plans Cover and Do Not Cover
Generally, HMOs cover preventive, wellness, emergency, surgical, and hospital services.
For a complete list of what is covered by Kaiser, participants should refer to the Evidence of Coverage.
Kaiser Foundation Health Plan Arbitration Agreement
The Kaiser Hawaii and California plans are required to use binding arbitration to settle disputes related to or arising out of care delivery. The California Health and Safety code 1363.1, and Hawaii Case Law requires Kaiser Permanente to notify the employee of the use of arbitration at the point of enrollment.
Note: If you do not agree to the arbitration language you should choose a different medical plan option.
By Enrolling in a Kaiser Permanente California Plan, you understand that this action will serve as your agreement to the conditions provided in the Kaiser Foundation Health Plan Arbitration Agreement and that by law this will have the same effect as a signature on a paper form.