KP VA Gold 1500/0%/HSA/Vision - 95185VA0500006 Health Insurance Plan

Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. health insurance plan with the Plan ID 95185VA0500006. The plan is called KP VA Gold 1500/0%/HSA/Vision.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.56% (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 18.44% 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 95185VA0500006
Health Insurance Plan Year 2023
State Virginia
Health Insurance Issuer Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.
Plan Formulary Description URL Formulary URL
Health Insurance Plan Variant 95185VA0500006-00
Provider Network(s) ['VAN002']
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 Virginia 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 Off Exchange Plan - 95185VA0500006-00

Standard On Exchange Plan - 95185VA0500006-01

Last Plan Update Date Wed, 17 Aug 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of KP VA Gold 1500/0%/HSA/Vision Health Insurance Plan, 95185VA0500006-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
YES

No Charge after deductible

100.00%
Accidental Dental

Includes dental work, to include oral/surgical correction needed to treat injuries to the jaw, sound natural teeth, mouth or face as a result of an accident. Dental appliances required to diagnose or treat an accidental injury to the teeth, and the repair of dental appliances damaged as a result of accidental injury to the jaw, mouth or face, are also covered. Treatment must begin within 12 months of the injury, or as soon after that as possible to be a covered service.

YES

No Charge after deductible

100.00%
Acupuncture
NO
Allergy Testing

Includes benefits for medically necessary allergy testing and treatment, including allergy serum and allergy shots.

YES

No Charge after deductible

100.00%
Bariatric Surgery
YES

No Charge after deductible

100.00%
Basic Dental Care - Adult
NO
Basic Dental Care - Child

Benefit limitations may apply to individual services.

YES

33.00%

100.00%
Chemotherapy
YES

No Charge after deductible

100.00%
Chiropractic Care

Limit: 30.0 Visit(s) per Benefit Period

Limited to 30 visits per benefit period. Includes therapy to treat problems of the bones, joints, joints of the spine, the nervous system, and the back, and osteopathic therapy which focuses on the joints and surrounding muscles, tendons and ligaments. The visit limit applies separately for rehablitative services and habilitative chiropractic services.

YES

No Charge after deductible

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care

Includes services needed during a normal or complicated pregnancy and for services needed for a miscarriage. Covered maternity services include: pregnancy testing; professional and facility services for childbirth including use of the delivery room and care for normal deliveries, in a facility or the home including the services of an appropriately licensed nurse midwife; anesthesia services to provide partial or complete loss of sensation before delivery; routine nursery care for the newborn during the mother?s normal hospital stay, including circumcision of a covered male dependent; allowed fetal screenings, which are genetic or chromosomal tests of the fetus. Hospital stay for childbirth for mother and newborn may not be limited to less than 48 hours after vaginal birth or less than 96 hours after a cesarean section, unless the mother and attending provider request it.

YES

No Charge after deductible

100.00%
Dental Check-Up for Children

Limit: 1.0 Treatment(s) per 6 Months

Limited to one (1) treatment(s) per 6 Months. Includes coverage for D1110, D1120, D1203, D1204, D1206, and D1208. $10 office visit charge applies to each visit.

YES

No Charge

100.00%
Diabetes Education

Includes education for diabetes care for all diabetics, including outpatient self-management training and education performed in-person; medical nutrition therapy, when provided by a certified, licensed, or registered health care professional. Diabetic education may be received from pharmacies that are authorized to perform this service.

YES

No Charge after deductible

100.00%
Dialysis

Includes services for acute renal failure and chronic (end-stage) renal disease, including hemodialysis, home intermittent peritoneal dialysis (IPD), home continuous cycling peritoneal dialysis (CCPD), and home continuous ambulatory peritoneal dialysis (CAPD). Dialysis treatments can be rendered in an outpatient dialysis Facility, doctor?s office, or home dialysis and training for the covered person and the person who will help with home self-dialysis.

YES

No Charge after deductible

100.00%
Durable Medical Equipment

Includes Medical Devices, Orthotics, Medical and Surgical Supplies. Benefits include equipment and devices (e.g., crutches and customized equipment, Hospital beds and wheelchairs, oxygen concentrator, ventilator, and negative pressure, wound therapy devices). Coverage for ongoing rental of equipment may be limited to the cost of purchasing the equipment. Benefits include repair and replacement costs as well as supplies and equipment needed for the use of the equipment or device, for example, a battery for a powered wheelchair. Oxygen and equipment for its administration are also covered services. Benefits are also available for cochlear implants. Benefits are available for certain types of orthotics (braces, boots, and splints). Covered Services include the initial purchase, fitting, and repair of a custom made rigid or semi-rigid supportive device used to support, align, prevent, or correct deformities or to improve the function of movable parts of the body, or which limits or stops motion of a weak or diseased body part. Also, includes coverage for devices and supplies, such as APAP, CPAP, BPAP and oral devices for sleep treatment, subject to medical necessity.

YES

No Charge after deductible

100.00%
Emergency Room Services

Benefits are available in a Hospital Emergency Room or an independent,free standing emergency facility for services and supplies to treat the onset of symptoms for a medical emergency.

YES

$350.00 Copay after deductible

$350.00 Copay after deductible
Emergency Transportation/Ambulance

Includes medically necessary transportation to the nearest appropriate hospital for a medical emergency, or between hospitals or other approved facilities. Includes ground, water, fixed wing and rotary air transportation. Benefits also include medically necessary treatment of a sickness or injury by medical professionals from an ambulance service, even if you are not taken to a facility. Benefits are only available for air ambulance when it is not appropriate to use a ground or water ambulance.

YES

No Charge after deductible

No Charge after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

Limited to one (1) item(s) per benefit period. Includes a choice of eyeglass lenses with factory scratch coating or contact lenses in one benefit period. Covered eyeglass lenses include standard plastic (CR39) lenses up to 55mm in: Single vision; Bifocal; Trifocal (FT 25-28); and Progressive. Members choose from a limited frame selection. Coverage for contact lenses includes elective or non-elective contact lenses. Non-elective contact lenses are covered only for the following medical conditions: Keratoconus when your vision is not correctable to 20/40 in either or both eyes using standard spectacle lenses; High Ametropia exceeding -12D or +9D in spherical equivalent; Anisometropia of 3D or more; when your vision can be corrected three lines of improvement on the visual acuity chart when compared to best corrected standard spectacle lenses.

YES

No Charge after deductible

100.00%
Gender Affirming Care
NO
Generic Drugs

Covers prescription legend drugs from either a Retail Pharmacy or the PBM?s Home Delivery Pharmacy; self-administered injectable drugs; self-injectable insulin and supplies and equipment used to administer insulin; self-administered contraceptives, including oral contraceptive drugs, self-injectable contraceptive drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the 'Preventive Care' benefit. Includes coverage for special food products or supplements when prescribed by a Doctor when medically necessary; Flu Shots (including administration). Inpatient or IV therapy drugs used in the treatment of cancer pain will not be denied on the basis that the dosage exceeds the recommended dosage of the pain relieving agent, if prescribed in compliance with established statutes pertaining to patients with intractable cancer pain. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply.

YES

$20.00 Copay after deductible

100.00%
Habilitation Services

Benefits that help you keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn?t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, medical devices, and other services for people with disabilities in a variety of inpatient and/or outpatient settings. Physical, occupational and speech therapy limited to 30 visits each per benefit period. Visit limits do not apply when received as part of hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. The visit limits apply separately for rehablitative services and habilitative services.

YES

No Charge after deductible

100.00%
Hearing Aids
NO
Home Health Care Services

Therapy Services limits for physical, occupational, speech therapy, or cardiac rehabilitation will not apply for therapy provided in the home. Benefit includes home infusion therapy, home dialysis, intermittent skilled nursing services by an R.N. or L.P.N.; Medical/social services; Diagnostic services; Nutritional guidance; Training of the patient and/or family/caregiver; Home health aide services; Therapy Services; Medical supplies; Durable medical equipment.

YES

No Charge after deductible

100.00%
Hospice Services

Short-term Inpatient Hospital care when needed in periods of crisis or as respite care. Skilled nursing services, home health aide services, and homemaker/custodial care services given by or under the supervision of a registered nurse. Social services and counseling services from a licensed social worker. Nutritional support such as intravenous feeding and feeding tubes. Physical therapy, occupational therapy, speech therapy, and respiratory therapy given by a licensed therapist. Pharmaceuticals, medical equipment, and supplies needed for pain management and the palliative care of your condition, including oxygen and related respiratory therapy supplies. Bereavement (grief) services, including a review of the needs of the bereaved family and the development of a care plan to meet those needs, both before and after the Member?s death. Bereavement services are available to surviving Members of the immediate family for one year after the Member?s death. Immediate family means your spouse, children, stepchildren, parents, brothers and sisters.

YES

No Charge after deductible

100.00%
Imaging (CT/PET Scans, MRIs)

Includes x-rays/regular imaging services; radiology (including mammograms), ultrasound or nuclear medicine; and advanced imaging, including CT scan, CTA scan, Magnetic Resonance Imaging (MRI); Magnetic Resonance Angiography (MRA); Magnetic Resonance Spectroscopy (MRS); Nuclear Cardiology; PET scans; PET/CT Fusion scans; QTC Bone Densitometry; Diagnostic CT Colonography; Single photon emission computed tomography (SPCECT) scans.

YES

No Charge after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy

Includes nursing, durable medical equipment and drug services that are delivered and administered to you through an I.V. in your home. Also includes Total Parenteral Nutrition (TPN), Enteral nutrition therapy, antibiotic therapy, pain care and chemotherapy. May include injections (intra-muscular, subcutaneous, continuous subcutaneous). Also covers prescription drugs when they are administered to you as part of a doctor?s visit, home care visit, or at an outpatient Facility.

YES

No Charge after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)

Benefits for room, board, and nursing services include: a room with two or more beds; a private room when medically necessary for isolation and no isolation facilities are available; a room in an approved special care unit; meals, special diets; general nursing services; operating, childbirth, and treatment rooms and equipment; prescribed drugs; anesthesia, anesthesia supplies and services given by the hospital or other provider; medical and surgical dressings and supplies, casts, and splints; blood and blood products; diagnostic services. Includes coverage for general anesthesia and hospitalization services when determined by dentist and treating physician that such services are required to effectively and safely provide dental care for (i) children under the age of 5, (ii) covered persons who are severely disabled, or (iii) covered persons who have a medical condition that requires admission to a hospital or Outpatient surgery facility.

YES

No Charge after deductible

100.00%
Inpatient Physician and Surgical Services

Includes medical care visits; intensive medical care when medically necessary; treatment for a health problem by a Doctor who is not your surgeon while you are in the Hospital for surgery; treatment by two or more Doctors during one Hospital stay when the nature or severity of your health problem calls for the skill of separate Doctors; a personal bedside exam by another Doctor when asked for by your Doctor; surgery and general anesthesia; professional charges to interpret diagnostic tests such as imaging, pathology reports, and cardiology. Surgeries and procedures to correct congenital abnormalities that cause functional impairment and congenital abnormalities in newborn children; other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or spine; endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy; treatment of fractures and dislocations; anesthesia and surgical support when medically necessary; medically necessary pre-operative and post-operative care. Medical benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is medically necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes surgical treatment of injuries and illnesses of the eye.

YES

No Charge after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

No Charge after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child

Benefit limitations may apply to individual services.

YES

39.00%

100.00%
Mental/Behavioral Health Inpatient Services

Includes services in a hospital or any facility required to be covered by state law. Inpatient benefits include individual psychotherapy, group psychotherapy, psychological testing, counseling with family members to assist with the patient?s diagnosis and treatment, convulsive therapy, detoxification, and rehabilitation.

YES

No Charge after deductible

100.00%
Mental/Behavioral Health Outpatient Services

Includes treatment in an outpatient department of a hospital and office visits, individual psychotherapy, group psychotherapy, psychological testing and medication management visits. Services may be received by a psychiatrist, psychologist, neuropsychologist, licensed clinical social worker (L.C.S.W.), clinical nurse specialist, licensed marriage and family therapist (L.M.F.T.), licensed professional counselor (L.P.C) or any agency licensed by the state to give these services that must be covered by law.

YES

No Charge after deductible

100.00%
Non-Preferred Brand Drugs

Covers prescription legend drugs from either a Retail Pharmacy or the PBM?s Home Delivery Pharmacy; self-administered injectable drugs; self-injectable insulin and supplies and equipment used to administer insulin; self-administered contraceptives, including oral contraceptive drugs, self-injectable contraceptive drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the 'Preventive Care' benefit. Includes coverage for special food products or supplements when prescribed by a Doctor when medically necessary; Flu Shots (including administration). Inpatient or IV therapy drugs used in the treatment of cancer pain will not be denied on the basis that the dosage exceeds the recommended dosage of the pain relieving agent, if prescribed in compliance with established statutes pertaining to patients with intractable cancer pain. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply.

YES

$75.00 Copay after deductible

100.00%
Nutritional Counseling
YES

No Charge after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child

Limit: 1.0 Treatment(s) per Lifetime

Limit applies to one comprehensive orthodontic treatment of the adolescent dentition.

YES

43.00%

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

No Charge after deductible

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

Includes coverage for blood and blood products, anesthesia and anesthesia supplies and services given by the Hospital or other Facility, medical and surgical dressings and supplies, casts, and splints. Includes coverage for general anesthesia and hospitalization services when determined by dentist and treating physician that such services are required to effectively and safely provide dental care for (i) children under the age of 5, (ii) covered persons who are severely disabled, or (iii) covered persons who have a medical condition that requires admission to a hospital or Outpatient surgery facility. Surgeries and procedures to correct congenital abnormalities that cause functional impairment and congenital abnormalities in newborn children; other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or spine; endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy; treatment of fractures and dislocations; anesthesia and surgical support when Medically Necessary; Medically Necessary pre-operative and post-operative care. Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes surgical treatment of injuries and illnesses of the eye.

YES

$100.00 Copay after deductible

100.00%
Outpatient Rehabilitation Services

Physical, occupational and speech therapy limited to 30 visits each per benefit period. Benefits are based on the setting in which covered services are received. Limit does not apply when received as part of hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. The visit limits apply separately for rehabilitative services and habilitative services.

YES

No Charge after deductible

100.00%
Outpatient Surgery Physician/Surgical Services

Includes coverage for blood and blood products, anesthesia and anesthesia supplies and services given by the Hospital or other Facility, medical and surgical dressings and supplies, casts, and splints. Includes coverage for general anesthesia and hospitalization services when determined by dentist and treating physician that such services are required to effectively and safely provide dental care for (i) children under the age of 5, (ii) covered persons who are severely disabled, or (iii) covered persons who have a medical condition that requires admission to a hospital or outpatient surgery facility. Surgeries and procedures to correct congenital abnormalities that cause functional impairment and congenital abnormalities in newborn children; other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or spine; endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy; treatment of fractures and dislocations; anesthesia and surgical support when Medically Necessary; Medically Necessary pre-operative and post-operative care. Benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is Medically Necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes surgical treatment of injuries and illnesses of the eye.

YES

$10.00 Copay after deductible

100.00%
Preferred Brand Drugs

Covers prescription legend drugs from either a Retail Pharmacy or the PBM?s Home Delivery Pharmacy; self-administered injectable drugs; self-injectable insulin and supplies and equipment used to administer insulin; self-administered contraceptives, including oral contraceptive drugs, self-injectable contraceptive drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the 'Preventive Care' benefit. Includes coverage for special food products or supplements when prescribed by a Doctor when medically necessary; Flu Shots (including administration). Inpatient or IV therapy drugs used in the treatment of cancer pain will not be denied on the basis that the dosage exceeds the recommended dosage of the pain relieving agent, if prescribed in compliance with established statutes pertaining to patients with intractable cancer pain. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply.

YES

$50.00 Copay after deductible

100.00%
Prenatal and Postnatal Care

Includes prenatal and postnatal services for the mother; postnatal services for the baby, including hemoglobinopathies screening; gonorrhea prophylactic medication; hypothyroidism screening, PKY screening and Rh incompatibility testing.

YES

No Charge

100.00%
Preventive Care/Screening/Immunization

Covers: (1) Services with an 'A' or 'B' rating from the United States Preventive Services Task Force; (2) Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; (3) Preventive care and screenings for infants, children and adolescents as listed in the guidelines supported by the Health Resources and Services Administration (including infant hearing screening); (4) Preventive care and screening for women as listed in the guidelines supported by the Health Resources and Services Administration; and (5) Counseling services related to nutrition, and to smoking and tobacco use cessation. Prescription drugs that help you stop smoking or reduce your dependence on tobacco products are also covered preventive services. Smoking cessation products and over the counter nicotine replacement products (limited to nicotine patches and gum) are covered when obtained with a prescription. Additionally, state law requires coverage for routine screening mammograms and routine prostate specific antigen testing and digital rectal exams.

YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness

Including doctor visits in the home and online visits.

YES

No Charge after deductible

100.00%
Private-Duty Nursing

Limit: 16.0 Hours per Benefit Period

Limited to 16 hours per benefit period.

YES

No Charge after deductible

100.00%
Prosthetic Devices

Includes benefits for prosthetics and components when they are medically necessary for activities of daily living. A prosthetic device is an artificial substitute to replace, in whole or in part, a limb or body part, such as an arm, leg, foot or eye. Coverage is also included for the repair, fitting, adjustments and replacement of a prosthetic device. In additional, components for artificial limbs are covered. Components are the materials and equipment needed to ensure the comfort and functioning of the prosthetic device. Covered services may include: 1) Artificial limbs and components (the materials and equipment needed to ensure the comfort and functioning of the prosthetic device); 2) Breast prosthesis (whether internal or external) after a mastectomy, as required by the Women?s Health and Cancer Rights Act. 3) Colostomy and other ostomy (surgical construction of an artificial opening) supplies directly related to ostomy care. 4) Restoration prosthesis (composite facial prosthesis) 5) Wigs needed after cancer treatment (limited to one wig per benefit period).

YES

No Charge after deductible

100.00%
Radiation

Includes treatment (tele therapy, brachytherapy and intraoperative radiation, photon or high-energy particle sources), materials and supplies needed, administration, and treatment planning.

YES

No Charge after deductible

100.00%
Reconstructive Surgery

Includes reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance. Also includes surgery performed to restore symmetry after a mastectomy. Reconstructive services needed as a result of an earlier treatment are covered only if the first treatment would have been a covered service. Hospital admissions for covered radical or modified radical mastectomy for the treatment of breast cancer shall be approved for a period of no less than 48 hours. Hospital admissions for a covered total or partial mastectomy with lymph node dissection for the treatment of breast cancer shall be approved for a period of no less than 24 hours.

YES

No Charge after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 30.0 Visit(s) per Benefit Period

Rehabilitative physical and occupational therapy limited to 30 visits each per benefit period. Includes treatment to restore a physically disabled person?s ability to do activities of daily living, such as walking, eating, drinking, dressing, using the toilet, moving from a wheelchair to a bed, bathing, and therapy for tasks needed for the person?s job. Also, includes the treatment by physical means to ease pain, restore health, and to avoid disability after an illness, injury, or loss of an arm or a leg by means of hydrotherapy, heat, physical agents, bio-mechanical and neuro-physiological principles and devices. Limit does not apply when received as part of hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. The visit limit applies separately for rehablitative services and habilitative services.

YES

No Charge after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 30.0 Visit(s) per Benefit Period

Limited to 30 visits per benefit period. Includes services to identify, assess, and treat speech, language, and swallowing disorders in children and adults. Therapy will develop or treat communication or swallowing skills to correct a speech impairment. Limit does not apply when received as part of hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. The visit limit applies separately for rehablitative services and habilitative services.

YES

No Charge after deductible

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
YES

No Charge after deductible

100.00%
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Benefit Period

Limited to one (1) eye exam per benefit period. Includes complete eye exam with dilation, as needed to check all aspects of vision, including the structure of the eyes and how well they work together.

YES

No Charge after deductible

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 100.0 Days per Stay

Limited to 100 days per stay. Includes room and board in semi-private accommodations; rehabilitative services; and drugs, biologicals, and supplies furnished for use in the skilled nursing facility and other medically necessary services and supplies. Your Plan will cover the private room charge when medically necessary.

YES

No Charge after deductible

100.00%
Specialist Visit
YES

No Charge after deductible

100.00%
Specialty Drugs

Maximum coinsurance for specialty drugs is $300 per 30-day supply. Covers prescription legend drugs from either a Retail Pharmacy or the PBM?s Home Delivery Pharmacy; self-administered injectable drugs; specialty drugs; self-injectable insulin and supplies and equipment used to administer insulin; self-administered contraceptives, including oral contraceptive drugs, self-injectable contraceptive drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the 'Preventive Care' benefit. Includes coverage for special food products or supplements when prescribed by a Doctor when medically necessary; Flu Shots (including administration). Inpatient or IV therapy drugs used in the treatment of cancer pain will not be denied on the basis that the dosage exceeds the recommended dosage of the pain relieving agent, if prescribed in compliance with established statutes pertaining to patients with intractable cancer pain. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply.

YES

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services

Includes services in a hospital or any facility required to be covered by state law. Inpatient benefits include individual psychotherapy, group psychotherapy, psychological testing, counseling with family members to assist with the patient?s diagnosis and treatment, convulsive therapy, detoxification, and rehabilitation.

YES

No Charge after deductible

100.00%
Substance Abuse Disorder Outpatient Services

Includes treatment in an outpatient department of a hospital and office visits, individual psychotherapy, group psychotherapy, psychological testing and medication management visits. Services may be received by a psychiatrist, psychologist, neuropsychologist, licensed clinical social worker (L.C.S.W.), clinical nurse specialist, licensed marriage and family therapist (L.M.F.T.), licensed professional counselor (L.P.C) or any agency licensed by the state to give these services that must be covered by law.

YES

No Charge after deductible

100.00%
Transplant

Includes coverage for medically necessary human organ, tissue, and stem cell/bone marrow transplants and infusions including necessary acquisition procedures, mobilization, harvest and storage. It also includes medically necessary myeloablative or reduced intensity preparative chemotherapy, radiation therapy, or a combination of these therapies. When a human organ transplant is provided from a living donor to a covered member, both the recipient and the donor may receive benefits.

YES

No Charge after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Includes services to treat temporomandibular and craniomandibular disorders, such as removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services. Dental benchmark plan covers occlusal orthotic devices for temporomandibular pain, dysfunction or associated musculature.

YES

No Charge after deductible

100.00%
Urgent Care Centers or Facilities

Includes X-ray services; Care for broken bones; Tests such as flu, urinalysis, allergy test, pregnancy test, rapid strep; Lab services; Stitches for simple cuts; and Draining an abscess. Non-plan providers are covered only outside the service area.

YES

No Charge after deductible

No Charge after deductible
Weight Loss Programs
NO
Well Baby Visits and Care

Includes immunizations for children recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; Preventive care and screenings for infants as listed in the guidelines supported by the Health Resources and Services Administration (including infant hearing screening).

YES

No Charge

100.00%
X-rays and Diagnostic Imaging

Includes benefits for tests or procedures to find or check a condition when specific symptoms exist, as well as benefits for interpretation of diagnostic tests such as imaging, and cardiology. Tests must be ordered by a Provider and include diagnostic services ordered before a surgery or Hospital admission. Benefits include the following services: x-rays/regular imaging services; radiology (including mammograms), ultrasound or nuclear medicine.

YES

No Charge after deductible

100.00%

KP VA Gold 1500/0%/HSA/Vision Health Insurance Plan Variant 95185VA0500006-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.815630036
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 Off Exchange Plan
Dental Only Plan No
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
First Tier Utilization 100%
Formulary ID VAF004
Formulary URL URL
HIOS Product ID 95185VA050
HSA/HRA Employer Contribution No
Import Date 8/17/2022 20:01
Inpatient Copayment Maximum Days 0
HSA Eligible Yes
New/Existing Plan Existing
Notice Required for Pregnancy Yes
Is a Referral Required for Specialist? Yes
Issuer ID 95185
Issuer Marketplace Marketing Name Kaiser Permanente
Market Coverage SHOP (Small Group)
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 VAN002
Out of Country Coverage Yes
Out of Country Coverage Description Emergency Care Only
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Emergency Care Only
Plan Effective Date 1/1/2023
Plan ID (Standard Component ID with Variant) 95185VA0500006-00
Plan Level Exclusions Yes
Plan Marketing Name KP VA Gold 1500/0%/HSA/Vision
Plan Type HMO
Plan Variant Marketing Name KP VA Gold 1500/0%/HSA/Vision
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $1,500
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $200
SBC Scenario, Having Diabetes, Deductible $1,500
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $10
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,500
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID VAS001
Source Name SERFF
Specialist Requiring a Referral Referrals are required for all Plan specialists with the exception of OB/GYN, Mental Health, Alcohol/Chemical Dependency, Routine Eye Exams.
Specialty Drug Maximum Coinsurance $300
Plan ID 95185VA0500006
State Code VA
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 0.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $3000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $3000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $1,500
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 $10000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $5000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $5,000
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 No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered Yes

Copay & Coinsurance of KP VA Gold 1500/0%/HSA/Vision Health Insurance Plan, 95185VA0500006

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

Frequently Asked Questions(FAQ) about KP VA Gold 1500/0%/HSA/Vision, 95185VA0500006 Health Insurance Plan, 95185VA0500006

  • Does KP VA Gold 1500/0%/HSA/Vision Health Insurance Plan, 95185VA0500006 support Mail Ordering?

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

  • Does (95185VA0500006) Health Insurance Plan, Variant (95185VA0500006-00) 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 (95185VA0500006) Health Insurance Plan, Variant (95185VA0500006-00) have Out Of Country Coverage?

    Yes. Details: Emergency Care Only

    Does (95185VA0500006) Health Insurance Plan, Variant (95185VA0500006-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Care Only

    Does (95185VA0500006) Health Insurance Plan, Variant (95185VA0500006-00) 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 VA Gold 1500/0%/HSA/Vision Health Insurance Plan, Variant (95185VA0500006-00) offer Disease Management Programs for Asthma?

    Yes, the KP VA Gold 1500/0%/HSA/Vision Health Insurance Plan Variant 95185VA0500006-00 offers Disease Management Program for Asthma.

    Does KP VA Gold 1500/0%/HSA/Vision Health Insurance Plan, Variant (95185VA0500006-00) offer Disease Management Programs for Heart disease?

    Yes, the KP VA Gold 1500/0%/HSA/Vision Health Insurance Plan Variant 95185VA0500006-00 offers Disease Management Program for Heart disease.

    Does KP VA Gold 1500/0%/HSA/Vision Health Insurance Plan, Variant (95185VA0500006-00) offer Disease Management Programs for Depression?

    Yes, the KP VA Gold 1500/0%/HSA/Vision Health Insurance Plan Variant 95185VA0500006-00 offers Disease Management Program for Depression.

    Does KP VA Gold 1500/0%/HSA/Vision Health Insurance Plan, Variant (95185VA0500006-00) offer Disease Management Programs for Diabetes?

    Yes, the KP VA Gold 1500/0%/HSA/Vision Health Insurance Plan Variant 95185VA0500006-00 offers Disease Management Program for Diabetes.

    Does KP VA Gold 1500/0%/HSA/Vision Health Insurance Plan, Variant (95185VA0500006-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the KP VA Gold 1500/0%/HSA/Vision Health Insurance Plan Variant 95185VA0500006-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does KP VA Gold 1500/0%/HSA/Vision Health Insurance Plan, Variant (95185VA0500006-00) offer Disease Management Programs for Low back pain?

    Yes, the KP VA Gold 1500/0%/HSA/Vision Health Insurance Plan Variant 95185VA0500006-00 offers Disease Management Program for Low back pain.

    Does KP VA Gold 1500/0%/HSA/Vision Health Insurance Plan, Variant (95185VA0500006-00) offer Disease Management Programs for Pregnancy?

    Yes, the KP VA Gold 1500/0%/HSA/Vision Health Insurance Plan Variant 95185VA0500006-00 offers Disease Management Program for Pregnancy.

    Does KP VA Gold 1500/0%/HSA/Vision Health Insurance Plan, Variant (95185VA0500006-00) offer Disease Management Programs for Weight loss programs?

    Yes, the KP VA Gold 1500/0%/HSA/Vision Health Insurance Plan Variant 95185VA0500006-00 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