KP HI Gold 1000/30 - 60612HI0110011 Health Insurance Plan

Kaiser Foundation Health Plan, Inc. health insurance plan with the Plan ID 60612HI0110011. The plan is called KP HI Gold 1000/30.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 79.90% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 20.10% 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 80.65% (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 19.35% 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 60612HI0110011
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 60612HI0110011-01
Provider Network(s) ['HIN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers Hawaii All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard On Exchange Plan - 60612HI0110011-01

Open to Indians below 300% FPL - 60612HI0110011-02

Open to Indians above 300% FPL - 60612HI0110011-03

Last Plan Update Date Thu, 23 Feb 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of KP HI Gold 1000/30 Health Insurance Plan, 60612HI0110011-01

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 Copay after deductible

$350.00 Copay after deductible
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
NO
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
NO
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 Copay after deductible

$350.00 Copay after deductible
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 Copay after deductible

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
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

30.00% Coinsurance after deductible

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

30.00% Coinsurance after deductible

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% Coinsurance after deductible

100.00%
Specialist Visit
YES

$70.00

100.00%
Specialty Drugs

Subject to formulary guidelines

YES

30.00% Coinsurance after deductible

100.00%
Specialty Laboratory Services

Cost share indicated is "per day"

YES

$350.00 Copay after deductible

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 1000/30 Health Insurance Plan Variant 60612HI0110011-01 Attributes

Plan Attribute Value
AV Calculator Output Number 0.806528909
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
Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 50.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group $500 per group
Drug EHB Deductible, In Network (Tier 1), Family Per Person $250 per person
Drug EHB Deductible, In Network (Tier 1), Individual $250
Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Out of Network, Individual Not Applicable
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 0.9959
First Tier Utilization 100%
Formulary ID HIF004
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 79.90%
Issuer ID 60612
Issuer Marketplace Marketing Name Kaiser Permanente
Market Coverage Individual
Medical Drug Deductibles Integrated No
Medical Drug Maximum Out of Pocket Integrated Yes
Medical EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Medical EHB Deductible, In Network (Tier 1), Default Coinsurance 30.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $2000 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $1000 per person
Medical EHB Deductible, In Network (Tier 1), Individual $1,000
Medical EHB Deductible, Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Out of Network, Individual Not Applicable
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) 60612HI0110011-01
Plan Marketing Name KP HI Gold 1000/30
Plan Type HMO
Plan Variant Marketing Name KP HI Gold 1000/30
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 $50
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $1,300
SBC Scenario, Having Diabetes, Copayment $500
SBC Scenario, Having Diabetes, Deductible $250
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $200
SBC Scenario, Treatment of a Simple Fracture, Copayment $500
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,000
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 60612HI0110011
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
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 1000/30 Health Insurance Plan, 60612HI0110011

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about KP HI Gold 1000/30, 60612HI0110011 Health Insurance Plan, 60612HI0110011

  • Does KP HI Gold 1000/30 Health Insurance Plan, 60612HI0110011 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (60612HI0110011) Health Insurance Plan, Variant (60612HI0110011-01) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does (60612HI0110011) Health Insurance Plan, Variant (60612HI0110011-01) have Out Of Country Coverage?

    Yes. Details: Emergency Services

    Does (60612HI0110011) Health Insurance Plan, Variant (60612HI0110011-01) have Out of Service Area Coverage?

    Yes. Details: Emergency Services, Urgent Care and Authorized Referrals

    Does (60612HI0110011) Health Insurance Plan, Variant (60612HI0110011-01) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does KP HI Gold 1000/30 Health Insurance Plan, Variant (60612HI0110011-01) offer Disease Management Programs for Asthma?

    Yes, the KP HI Gold 1000/30 Health Insurance Plan Variant 60612HI0110011-01 offers Disease Management Program for Asthma.

    Does KP HI Gold 1000/30 Health Insurance Plan, Variant (60612HI0110011-01) offer Disease Management Programs for Heart disease?

    Yes, the KP HI Gold 1000/30 Health Insurance Plan Variant 60612HI0110011-01 offers Disease Management Program for Heart disease.

    Does KP HI Gold 1000/30 Health Insurance Plan, Variant (60612HI0110011-01) offer Disease Management Programs for Depression?

    Yes, the KP HI Gold 1000/30 Health Insurance Plan Variant 60612HI0110011-01 offers Disease Management Program for Depression.

    Does KP HI Gold 1000/30 Health Insurance Plan, Variant (60612HI0110011-01) offer Disease Management Programs for Diabetes?

    Yes, the KP HI Gold 1000/30 Health Insurance Plan Variant 60612HI0110011-01 offers Disease Management Program for Diabetes.

    Does KP HI Gold 1000/30 Health Insurance Plan, Variant (60612HI0110011-01) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the KP HI Gold 1000/30 Health Insurance Plan Variant 60612HI0110011-01 offers Disease Management Program for High blood pressure & high cholesterol.

    Does KP HI Gold 1000/30 Health Insurance Plan, Variant (60612HI0110011-01) offer Disease Management Programs for Low back pain?

    Yes, the KP HI Gold 1000/30 Health Insurance Plan Variant 60612HI0110011-01 offers Disease Management Program for Low back pain.

    Does KP HI Gold 1000/30 Health Insurance Plan, Variant (60612HI0110011-01) offer Disease Management Programs for Pregnancy?

    Yes, the KP HI Gold 1000/30 Health Insurance Plan Variant 60612HI0110011-01 offers Disease Management Program for Pregnancy.

    Does KP HI Gold 1000/30 Health Insurance Plan, Variant (60612HI0110011-01) offer Disease Management Programs for Weight loss programs?

    Yes, the KP HI Gold 1000/30 Health Insurance Plan Variant 60612HI0110011-01 offers Disease Management Program for Weight loss programs.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 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