Kaiser HMO

Kaiser HMO coverage will change as outlined below. The increase in the annual out-of-pocket maximum makes it the same as the Anthem PPO. With a new deductible being added to the Kaiser plan, members will begin to receive an Explanation of Benefits (EOB) statement monthly showing their deductible and out-of-pocket balance.

Feature Current Kaiser HMO Kaiser HMO
Effective January 1, 2019

Doctor office visit copays (decrease)

CA: $20

CO: $20 plus 10% for procedures performed

CA and CO: $10

Specialist office visit copays (decrease)

CA: $40

CO: $30 plus 10% for procedures performed

CA and CO: $20

Annual out-of-pocket maximum (increase)

CA: $1,500 per person/
$3,000 family maximum

CO: $2,000 per person/
$4,000 family maximum

CA and CO: $2,500 per person/$5,000 family maximum

Calendar year deductible for inpatient hospital, outpatient hospital and emergency room services (new)

None

CA and CO: $300 per person/ $600 family maximum

Inpatient hospital, outpatient hospital and emergency room services

CA and CO: various copays

CA and CO: 10% after annual deductible

Prescription drugs: Preferred Brand Retail — up to 30-day supply

CA: $35

CO: $30 Preferred;
$50 Non-Preferred

CA and CO: $30

Prescription drugs: Preferred Brand Mail Order (decrease in CA)

CA: $70 up to 100-day supply

CO: $60 up to 90-day supply

CA: $60 up to 100-day supply

CO: $60 up to 90-day supply

There are also improvements to prescription drug copays under the Kaiser HMO in California. Retail Preferred Brand, Non-Preferred Brand, and Specialty copays will decrease from $35 to $30 with no deductible (up to a 30-day supply). Mail order Preferred Brand and Non-Preferred Brand will decrease from $70 to $60 with no deductible (for up to a 100-day supply). Generic drug copays will continue to be $10.

The first difference relates to how each plan provides care. Under the Kaiser HMO, benefits are not paid for care provided from non-Kaiser network providers (except in cases of life-threatening emergency). Kaiser encourages members to choose a personal physician who will provide or coordinate all medical services. You’re free to change doctors within the Kaiser network any time, for any reason. In most cases, you’ll need to obtain a referral from your Kaiser personal physician to see a Kaiser specialist. You don’t need a referral for certain specialties, like obstetrics-gynecology, optometry, most psychiatry and substance abuse disorder treatment. With the Anthem PPO, you are not required to choose a primary care physician, and you can make an appointment directly with a specialist. You can also see providers outside Anthem’s network and receive benefits from the plan at the out-of-network level.

The second difference relates to your out-of-pocket costs for care. Under the Kaiser HMO, there is an annual deductible for certain services and you pay a flat copay for most covered services. For most covered services under the Anthem PPO, you must pay an annual deductible before the plan starts paying benefits. Then, you and the PPO share expenses (called “coinsurance”) until you reach the annual out-of-pocket maximum. At that point, the PPO pays 100% of covered expenses for the rest of the calendar year for the individual who reached the maximum. The Anthem PPO and the Kaiser HMO both pay 100% of the cost of in-network routine preventive care (like your annual physical) and related lab fees and tests, and no deductible applies to these services.

For 2019, there will be a new annual deductible under the Kaiser HMO for inpatient hospital stays, outpatient hospital visits and emergency room visits: $300 per person, with a maximum of $600 per family.

The annual out-of-pocket maximum under the Kaiser HMO will be $2,500 per person with a maximum of $5,000 per family—the same as it will be under the Anthem PPO.

In Southern Colorado, Kaiser members can use any pharmacy, not just Kaiser. For long-term drugs, you can use an outside pharmacy only once, then you must use a Kaiser pharmacy or the Kaiser mail order program. In other areas of Colorado and in California, you can use a Kaiser pharmacy or the Kaiser mail order program for long-term drugs.