KP HI Gold 0/30 Plus CAM - 60612HI0110007 Health Insurance Plan
Kaiser Foundation Health Plan, Inc. health insurance plan with the Plan ID 60612HI0110007. The plan is called KP HI Gold 0/30 Plus CAM.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.98% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.02% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 82.68% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 17.32% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 60612HI0110007 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Hawaii | ||||||||||||||||||
| Health Insurance Issuer | Kaiser Foundation Health Plan, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 60612HI0110007-01 | ||||||||||||||||||
| Provider Network(s) | ['HIN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 16 Apr 2024 06:19 GMT). |
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| Available Variants of the Health Plan | Standard On Exchange Plan - 60612HI0110007-01 |
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| Last Plan Update Date | Thu, 23 Feb 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 16 Apr 2024 06:19 GMT |
Benefits of KP HI Gold 0/30 Plus CAM Health Insurance Plan, 60612HI0110007-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Limit: 2.0 Procedure(s) per Lifetime When performed during an outpatient surgery in an ambulatory surgery center |
YES | 30.00% |
100.00% |
| Accidental Dental
Services of dentists are covered, but only when the dentist performs emergency or surgical services that could also be performed by a physician |
YES | $350.00 |
$350.00 |
| Active & Fit
Copay indicated is for basic fitness club and exercise center membership program. $10 Home Fitness program also available. |
YES | $200.00 |
100.00% |
| Acupuncture
12 combined visits per year for Chiropractic, Acupuncture and Massage Therapy |
YES | $20.00 |
100.00% |
| Allergy Testing
Drug covered at cost share indicated, additional office visit charge applies. |
YES | $30.00 |
100.00% |
| Bariatric Surgery
Cost share indicated is for services performed on an inpatient basis. |
YES | 30.00% |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
Drug covered at cost share indicated, additional office visit charge applies. |
YES | 20.00% |
100.00% |
| Chiropractic Care
12 combined visits per year for Chiropractic, Acupuncture and Massage Therapy |
YES | $20.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 30.00% |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
Copay indicated is for Primary Care visit. For visit with a Specialist, the Specialist office visit copay applies. |
YES | $30.00 |
100.00% |
| Dialysis
|
YES | 20.00% |
100.00% |
| Durable Medical Equipment
|
YES | 20.00% |
100.00% |
| Emergency Room Services
Must notify KP within 48 hours if admitted to a non-plan provider; limited to initial emergency only |
YES | $350.00 |
$350.00 |
| Emergency Transportation/Ambulance
|
YES | 20.00% |
20.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
YES | 30.00% |
100.00% |
| Generic Drugs
Copay refers to generic drugs used to treat certain chronic conditions. Subject to formulary guidelines. |
YES | $3.00 |
100.00% |
| Generic Drugs Other
Copay refers to all other generic drugs not used to treat certain chronic conditions. Subject to formulary guidelines. |
YES | $10.00 |
100.00% |
| Habilitation Services
Coverage limited to state-defined habilitative services. |
YES | $40.00 |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years Hearing aid(s) provided once every 36 months per ear. |
YES | 60.00% |
100.00% |
| Home Health Care Services
Physician visit covered at applicable office visit copay. |
YES | No Charge |
100.00% |
| Hospice Services
Physician visit covered at applicable office visit copay. |
YES | No Charge |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Cost share indicated is "per day" |
YES | $350.00 |
100.00% |
| Infertility Treatment
Limit: 1.0 Procedure(s) per Lifetime Copay indicated is for Primary Care visit. For visit with a Specialist, the Specialist office visit copay applies. Limited to initial consult only. In Vitro Fertilization provided at coinsurance indicated once per lifetime. |
YES | $30.00, 20.00% |
100.00% |
| Infusion Therapy
Drug covered at cost share indicated, additional office visit charge applies. |
YES | 20.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 30.00% |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 30.00% |
100.00% |
| Laboratory Outpatient and Professional Services
Cost share indicated is "per day" |
YES | $40.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Massage Therapy
12 combined visits per year for Chiropractic, Acupuncture and Massage Therapy. Referral required. |
YES | $20.00 |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | 30.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
No charge for primary care office visits for children through age 18 |
YES | $30.00 |
100.00% |
| Non-Preferred Brand Drugs
Subject to formulary guidelines |
YES | $55.00 |
100.00% |
| Nutritional Counseling
|
YES | No Charge |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $30.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 30.00% |
100.00% |
| Outpatient Rehabilitation Services
|
YES | $40.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 30.00% |
100.00% |
| Preferred Brand Drugs
Subject to formulary guidelines |
YES | $55.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
No charge for primary care office visits for children through age 18 |
YES | $30.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Cost share indicated is for services performed on an inpatient basis. |
YES | 30.00% |
100.00% |
| Radiation
|
YES | 20.00% |
100.00% |
| Reconstructive Surgery
Cost share indicated is for services performed on an inpatient basis. |
YES | 30.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
|
YES | $40.00 |
100.00% |
| Rehabilitative Speech Therapy
|
YES | $40.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
YES | $30.00 |
100.00% |
| Routine Eye Exam for Children
|
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 120.0 Days per Year Cost share indicated is for skilled nursing care. |
YES | 30.00% |
100.00% |
| Specialist Visit
|
YES | $70.00 |
100.00% |
| Specialty Drugs
Subject to formulary guidelines |
YES | $200.00 |
100.00% |
| Specialty Laboratory Services
Cost share indicated is "per day" |
YES | $350.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 30.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
No charge for primary care office visits for children through age 18 |
YES | $30.00 |
100.00% |
| Testing Services
Cost share indicated is "per test" |
YES | $15.00 |
100.00% |
| Transplant
Cost share indicated is for services performed on an inpatient basis. |
YES | 30.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Cost share indicated is for services performed on an inpatient basis. |
YES | 30.00% |
100.00% |
| Urgent Care Centers or Facilities
Copay indicated is for Primary Care visit. For visit with a Specialist, the Specialist office visit copay applies. Cost share indicated as a copay for in-network urgent care services received within the service area and as a coinsurance for urgent care services received outside of the service area |
YES | $30.00 |
20.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Cost share indicated is "per day" |
YES | $40.00 |
100.00% |
KP HI Gold 0/30 Plus CAM Health Insurance Plan Variant 60612HI0110007-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.826804238 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold On Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 0.9919 |
| First Tier Utilization | 100% |
| Formulary ID | HIF003 |
| Formulary URL | URL |
| HIOS Product ID | 60612HI011 |
| Import Date | 2/23/2023 20:01 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer Actuarial Value | 81.98% |
| Issuer ID | 60612 |
| Issuer Marketplace Marketing Name | Kaiser Permanente |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | HIN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Services |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Services, Urgent Care and Authorized Referrals |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 60612HI0110007-01 |
| Plan Marketing Name | KP HI Gold 0/30 Plus CAM |
| Plan Type | HMO |
| Plan Variant Marketing Name | KP HI Gold 0/30 Plus CAM |
| QHP/Non QHP | On the Exchange |
| SBC Scenario, Having a Baby, Coinsurance | $2,500 |
| SBC Scenario, Having a Baby, Copayment | $20 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $400 |
| SBC Scenario, Having Diabetes, Copayment | $1,300 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $800 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | HIS001 |
| Source Name | SERFF |
| Specialist Requiring a Referral | Referral required for certain specialists |
| Plan ID | 60612HI0110007 |
| State Code | HI |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 30.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $17400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8700 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,700 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of KP HI Gold 0/30 Plus CAM Health Insurance Plan, 60612HI0110007
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about KP HI Gold 0/30 Plus CAM, 60612HI0110007 Health Insurance Plan, 60612HI0110007
-
Does KP HI Gold 0/30 Plus CAM Health Insurance Plan, 60612HI0110007 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (60612HI0110007) Health Insurance Plan, Variant (60612HI0110007-01) offer Disease Management Programs?
Does (60612HI0110007) Health Insurance Plan, Variant (60612HI0110007-01) have Out Of Country Coverage?
Does (60612HI0110007) Health Insurance Plan, Variant (60612HI0110007-01) have Out of Service Area Coverage?
Does (60612HI0110007) Health Insurance Plan, Variant (60612HI0110007-01) offer Disease Management Programs?
Does KP HI Gold 0/30 Plus CAM Health Insurance Plan, Variant (60612HI0110007-01) offer Disease Management Programs for Asthma?
Does KP HI Gold 0/30 Plus CAM Health Insurance Plan, Variant (60612HI0110007-01) offer Disease Management Programs for Heart disease?
Does KP HI Gold 0/30 Plus CAM Health Insurance Plan, Variant (60612HI0110007-01) offer Disease Management Programs for Depression?
Does KP HI Gold 0/30 Plus CAM Health Insurance Plan, Variant (60612HI0110007-01) offer Disease Management Programs for Diabetes?
Does KP HI Gold 0/30 Plus CAM Health Insurance Plan, Variant (60612HI0110007-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Does KP HI Gold 0/30 Plus CAM Health Insurance Plan, Variant (60612HI0110007-01) offer Disease Management Programs for Low back pain?
Does KP HI Gold 0/30 Plus CAM Health Insurance Plan, Variant (60612HI0110007-01) offer Disease Management Programs for Pregnancy?
Does KP HI Gold 0/30 Plus CAM Health Insurance Plan, Variant (60612HI0110007-01) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 16 Apr 2024 06:19 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API