Frequently Asked Questions - Individual and Family

Yes. They are available for no- or low-cost from the first day of coverage. You don't have to meet a deductible first for many preventive services.

Yes. Just complete a separate application for each plan you or your family members apply for.

Yes. The Kaiser Permanente Insurance Company offers three Individual and Family deductible plans that are compatible with a Heath Savings Account. They are the $0/$1500 Deductible, $0/$2700 Deductible, and the $30/$2700 Deductible Plans with HSA. If you are enrolled in one of these plans and would like to open a health savings account, you may set up an HSA Account with Wells Fargo or the financial institution of your choice.

Kaiser Permanente offers the Step Program for low-income families. For more information on qualification criteria and the application process, please call toll free at 1-800-255-5053. Kaiser Permanente also offers the Child Health Plan program for those 18 and under. For more details on qualification criteria and the application process, please call 1-800-464-4000.

The Senior Advantage program combines Medicare and Kaiser Permanente coverage into one, which means more benefits, more convenience, and more services than traditional Medicare. Seniors who are currently on Medicare may apply for Kaiser Permanente's Senior Advantage program. For more information, you may contact Senior Advantage at 1-877-882-2703 or go to www.kp.org/seniors.

Depending on the plan, a physical would require a low copayment or it would be free. If you are looking at the plan benefits, a physical would be the cost of a "preventative physical exam." Additional costs may apply for any lab or imaging work.

This is the copayment amount a subscriber pays each time they go in to get X-rays. For example, if a subscriber went in one day and had six X-rays, they would pay $10. Then if the same subscriber went in the next day and had eight X-rays, they would pay another $10.

The $1,500 Deductible Plan is the only plan that includes chiropractic. Members with this plan have up to 20 chiropractic visits per year for a $15 copayment per visit. In addition, all Kaiser Permanente members can access a select network of complementary health providers to receive a 25 percent discount off regular rates for chiropractic, acupuncture, and massage therapy services.

Note: Some Kaiser Permanente benefit plans include coverage for certain of these discounted services. Plan benefits must be used before those discounted services are available.

Depending on the plan, vision exams are covered either for a copay or are completely covered once the deductible is met. Eyewear is not covered. Refer to appropriate plans brochure.

Yes. Some plans cover prescription drugs for a copay. This can be before the deductible is met (most plans), whereas other plans cover prescriptions after the deductible is met (all the HSA plans). The exception to this is the $50 copayment plan which does not cover prescriptions at all. Refer to appropriate health plans brochure.

No, Kaiser Permanente does not cover infertility on any of the Individual and Family Plans. These benefits are available only on two of the small group plans (the $5 and $15 Copayment Plans).

Yes. Kaiser Permanente will cover you for emergencies and urgent care anywhere in the world. The deductibles and copayments associated with your plan will apply. For more information, please view the Traveling Member Brochure. In addition, to receive care in other Kaiser Permanente regions please view the Visiting Member Brochure.

HSA stands for "Health Savings Account". When you enroll in some of our higher deductible plans, you have the option of opening up an HSA account with Wells Fargo or the financial institution of your choice. Having an HSA enables you to set aside money for medically related expenses and deduct these expenses from your taxes at the federal level. For more information on Kaiser Health Savings Accounts.

The acronym HMO stands for Health Maintenance Organization. An HMO is an organization where the insurance company, doctors, and medical facilities are networked together in the same company. HMO subscribers choose healthcare professionals from within that network. Kaiser Permanente is an HMO. With the exception of two group plans, Kaiser Permanente does not give the option of receiving medical coverage outside the network.

Once a subscriber has accumulated the annual out of pocket maximum amount, they will not be required to pay any more copayments for doctor visits, hospital stays, surgery, etc. for the remainder of the calendar year. The expenses the subscriber will have (for the remainder of the calendar year) are the monthly premiums and the copayments for prescription drugs.

Note: The annual out of pocket maximum does not apply to some specialty ervices such as drug rehabilitation and some preventative care services.

Please call one of our individual/family plan representatives at 1-800-569-1156 or please use contact us form.
Note: For questions regarding existing accounts, appointments, billing, and locations call 1-800-464-4000.

Initially you will be sent a monthly invoice. If you wish to switch to an automatic payment option, you may do so once you receive your first bill.

Delta Dental can be added to any Kaiser Permanente Individual/Family plan within the first 30 days of your effective date. If you choose not to add this Delta Dental option when you apply, you may add dental coverage to your plan during open enrollment which is at the end of the year. Please call member services at 1-800-464-4000 for further information on how to add Delta Dental to your plan.

Yes, Kaiser Permanente offers supplemental Dental Coverage through Delta Dental of California. You can apply for coverage by selecting this option on your application. If you elect to enroll in the Dental Assistance Insurance Plan, all members of your family who are covered through the subscriber will also be enrolled.

Pregnancy is considered a pre-existing condition. Those applying for individual and family plans while pregnant will be automatically denied. However, for group applicants there is no medical underwriting to pass. Small group applications are issued automatically, thus applicants applying for group coverage will not be denied for pregnancy or pre-existing conditions.

Each applicant's medical history will be reviewed on a case-to-case basis. Medical underwriting determines the approval status. If an applicant receives a denial and feels it is unjust, they may appeal the decision. Each denial will state the reason denied, and give instructions on how to make any appeal if necessary.

No physical exam is required. You will only need to fill out a health questionnaire.

Pricing on individual and group plans vary case by case. Subscribers who are concerned they may be denied for a pre-existing health condition will often opt for group coverage because there is no medical underwriting. However, in the case that you may qualify for either, we recommend you get individual quotes and group quotes and compare the rates and coverage options.
NOTE: There are different plans and rates offered for groups and individuals. Please see group FAQ's for group eligibility criteria.

Below are the factors that will cause a subscriber's rates to change:

• Moving to a Zip Code in a different rate area
• When the subscriber moves into a different age bracket
• Annual rate changes in January

Your rates will remain the same through December 31st of this year. However if you move, your rates may change if the location is in a different rate area.

HIPAA (Health Insurance Portability and Accountability Act of 1996) offers health insurance to applicants who have been denied coverage under an individual/family plan. To qualify for HIPAA coverage an applicant must have been on COBRA and have completed the allowed coverage under the COBRA plan. HIPAA plans tend to be more expensive, but offer a viable way of gaining coverage for applicants who do not qualify for a standard individual/family plan.

Kaiser Permanente requires you to have a social security number or Tax ID number to enroll, with the exception of a child who is under the age of one. With a child under the age of one that does not have a social security or Tax ID number, please use the paper application to fax or mail enrollment.

Kaiser Permanente plans are effective the first of the month following the approval of the application. The deadline to apply is the 23rd of the month to obtain coverage for the next month.

Underwriting will notify you by mail of your status in two to three weeks. If three weeks have passed and you have not yet received a letter, you may request a "status update" by phone (1-800-569-1156) or use contact us form. Please provide the following information in order for us to check your status: name of subscriber(s), date of birth, and phone number used on the application.

Online Applications:

1. Complete application - 10-20 minutes
   You will begin the process by signing in as a New Customer and creating a password for your application account. From this point you will be lead through registration, a series of medical questions, and notification of plan agreements.
2. Underwriting will notify you by mail of your status in two to three weeks. If three weeks have passed and you have not yet received a letter, you may request a "status update" by phone (1-800-569-1156) or use contact us form. Please provide the following information in order for us to check your status: name of subscriber(s), date of birth, and phone number used on the application.

Paper Applications:

1. Fill out the application - 20-30 minutes
2. Fax or mail in the application form on the forms page here.
   Fax:
   1-800-376-4703   
   Mail: Health Coverage Insurance Services, Inc
   Po Box 9417
   Santa Rosa, CA 95405
3. Once your application is submitted, underwriting will notify you regarding your acceptance by mail in two to four weeks. If three weeks have passed and you have not yet received a letter, you may request a "status update" by using contact us form. Please provide the following information in order for us to check your status: name of subscriber(s), date of birth, and phone number used on the application.

Please call one of our individual/family plan representatives at 1-800-569-1156 or use contact us form.
Note: For current Kaiser Permanente members that have questions regarding appointments, billing, and locations call 1-800-464-4000.

Kaiser Permanente has joined with the American Association of Retired People, Families USA, HIP Health Insurance Plan, and Group Health Cooperative of Puget Sound in proposing consumer protection principles.

Kaiser Permanente, with the American College of Emergency Physicians, also supports national legislation that would assure appropriate access to emergency medical services. We believe that a single national standard should be developed so that the costs of conflicting or duplicate federal and state enforcement measures are reduced.

We contribute to a wide range of community programs and activities across the nation. These efforts include:

• providing health coverage through our dues subsidy programs to those who otherwise could not afford it
• providing subsidies to help individuals and small employer groups afford health coverage
• contributing to medical knowledge and to the improvement of clinical care nationally through our clinical and health services research projects
• offering education and training programs for physicians, nurses, and other health professionals
• partnering with local governments to meet community needs
• providing grants, equipment, expertise, and volunteer hours to community organizations

Kaiser Permanente has established a national program for uninsured children. We devote a minimum of $30 million annually to subsidize health care coverage for uninsured and underinsured children, with a goal of helping 70,000 children each year.

Advancing medical knowledge through clinical and health services research is a key part of helping to improve the health of communities. Our community investments support research for important medical and social needs such as:

• preventing violence
• preventing infectious disease
• improving health care for adolescents
• improving health care for underserved populations

For nearly 50 years, Kaiser Permanente researchers have turned modest grants into major discoveries that have served our communities, influenced national policy, and affected medical practices throughout the nation and the world.

Because we are a nonprofit health plan, Kaiser Permanente is not publicly traded. We do not have shareholders and, therefore, can invest our resources in providing affordable, quality health care for our members and the communities we serve.

At Kaiser Permanente, one of our top priorities is to continually improve the quality of health care we provide. By coordinating patient care and working closely with their fellow physicians, the Permanente Medical Group physicians lead the way in improving clinical practice, conducting medical research, and improving overall health care quality for our members and our communities.

Kaiser Permanente has developed prescription drug formularies—lists of drugs that have been approved by review boards of Kaiser Permanente physicians and pharmacists--to ensure that appropriate medications are available for our members, while also providing these drugs cost effectively. Kaiser Permanente's formularies are doctor-driven and quality-based.

As an integrated delivery system, Kaiser Permanente seeks input from the entire range of health care specialties in developing our formularies. In doing so, we evaluate each medication for:

• safety
• effectiveness
• patient convenience
• patient compliance
• effect on the number of calls and visits to physicians, emergency rooms, and hospitals
• quality of care
• number of side effects, and
• cost

At Kaiser Permanente, clinical decisions are made by physicians working with their patients. The decision of how long a mastectomy patient stays in the hospital, or whether a hospital stay is recommended, is based on what is medically and psychologically appropriate for each individual patient.

Outpatient mastectomies (in which the patient goes home the same day of surgery) are becoming more common, and many women choose to recover in the comfort of their homes, with appropriate support, instead of in the hospital.

Kaiser Permanente does not require mastectomies to be performed on an outpatient basis, and there are no restrictions on coverage for overnight hospitalization, if this is what the physician recommends. If, after surgery, a patient's medical or emotional state indicates the need for an overnight stay, this care is provided. Our highest priorities are the successful outcomes of surgeries, and the emotional well-being of our patients.

Our doctors are compensated as a result of a two-step process: (1) Health Plan pays the Medical Group; and (2) the Medical Group pays the doctors. A summary of these steps is provided below.

Health Plan pays the Medical Group

Each year at Kaiser Permanente, the Health Plan and the Medical Group in each region negotiate and agree on the total amount of money that is estimated will enable our physicians and other clinicians to provide the amount of professional medical care that our members are expected to need in the upcoming year. This estimate is based on the previous year's performance (and the years prior to that), and also includes administrative and other expenses associated with operating the Medical Group.

That total is then divided by 12 months, and then divided by the number of expected members in the coming year. That calculation results in an amount of money (the "capitation") that the Health Plan pays to the Medical Group on a monthly basis for each member.

In addition, the Health Plan reimburses the Medical Group for its actual cost for certain medical and other expenses that may be difficult to forecast, such as transplants and contingent expenditures. The total is called the "basic contractual payment."

In the event that the total of all payments, as adjusted throughout the year, is insufficient to provide the needed care, Kaiser Permanente dips into its reserves for shortfalls. Then, during the following year, dues may be raised and reserves replenished. If the basic contractual payments, including the capitated payments, are greater than the actual cost of the necessary medical care, then the Medical Group, as a whole, is permitted to share in some of the surplus.

The remainder is retained by the Health Plans to fund reserves, build hospitals and/or other medical facilities, keep dues lower than they otherwise would be, and the like. Some of the regional Health Plans also reward a Permanente Medical Group for improvements in member satisfaction and/or improvements in preventive medicine or other quality standards.

Medical Group pays the doctor

After the Health Plan pays the Medical Group, the Medical Group uses that money to pay its doctors and other personnel, and to meet its other expenses.

The primary compensation method used by all of the Medical Groups is salary. Salary generally varies with medical specialty and tenure. Smaller amounts of additional compensation may be paid for, among other things:

• board certification
• achievement of specified clinical quality measures
• achievement of member satisfaction levels
• productivity
• continuing medical education
• managerial work
• work performed in excess of normal work time, etc.

In addition, in some Medical Groups, the excess money that the Medical Group retains, if the basic contractual payments exceed the actual cost of care on a regional basis, also may be used to pay additional compensation to doctors and other personnel.

As of 2006, approximately 95 percent of physician compensation was paid in salary.

This is a summary of the arrangements between each of the regional Health Plans and Medical Groups and each of the Medical Groups and their respective doctors. These arrangements vary by region.

Some people believe that capitation payments carry an incentive for preventive medicine to keep patients healthy. Other people believe that capitation payments provide physicians an incentive to withhold treatment.

We believe that our compensation process does not create an incentive for our physicians to make patient care decisions based upon factors other than the medical needs of the patient because:

• Kaiser Permanente's form of capitation is based upon collective performance, rather than the individual performance of a physician, and
• Permanente physicians are compensated primarily by salary.

No. Kaiser Permanente strongly opposes "gag clauses" that prevent physicians from discussing treatments not covered by the Plan, possible referrals outside the Plan, or how physicians are compensated. Our physicians are encouraged to tell patients about all the treatment options that are available, no matter what the Plan covers. Information on how our physicians are compensated is provided below.

Keeping information from patients to benefit a health plan's bottom line is wrong and forces patients to second-guess their practitioners. At Kaiser Permanente, our physicians use their clinical expertise to let patients know about the full range of treatment options, and to help patients take an active role in health care decisions.

At Kaiser Permanente, medical decisions are made by physicians and their patients working together. The doctor-patient relationship is the foundation of our care.

If you switch employers, you have the right to carry your group health insurance coverage with you to a new job for up to 18 months under the Consolidated Omnibus Budget Reconciliation Act (COBRA).
You must pay the full premium, but at group rates that are far cheaper than the individual rates you would pay for similar coverage. Health insurance under COBRA is available if you are in the following situations:

• You leave a company and become unemployed or self-employed for up to 18 months.
• You are a widow or widower or child of an employee who dies while working for the same company for three years or more.
• You are the divorced spouse or child of an employee who has left the company he or she was employed at for at least three years.

You are the child of an employee who left a job and have not yet reached age 23. NOTE: If you need COBRA benefits, you must fill out the appropriate forms from your employer’s benefits department within 60 days of leaving your job. If you do not act within that time, you may be denied coverage.

Yes. If you are unemployed, self-employed, or decide to return to school you may want to buy an individual health insurance policy. To get a quote for individual health plans from Kaiser click on "get a quote" button below.

Here are a number of options that you may consider:

• Consider getting individual or family health insurance plan on your own.
• If you are married, see if your spouse’s employer will add you to its group plan.
• If you have pre-exisitng medical condition, try to join a group health plan through a trade association or alumni group or professional association may offer reasonable rates. If you are over age 50, you can join the American Association of Retired Persons (AARP), which offers an extensive plan.
• If you are self-employed, most of the health insurance premium will be tax-deductible.

If your employer gives you a choice of plans or you need to purchase your own coverage, it is crucial that you understand your health insurance choices and pick the insurance that is best for you and your family.
Here are some questions you should ask yourself when choosing a health insurance plan:
How affordable is the cost of care?

• What is the monthly premium I will have to pay?
• Should I try to insure most of my medical expenses or just the large ones?
• What deductibles will I have to pay out-of-pocket before insurance starts to reimburse me?
• After I’ve met my deductible, what percentage of my medical expenses are reimbursed?
• How much less am I reimbursed if I use doctors outside the insurance company’s network?

Does the insurance plan cover the services I am likely to use?

• Are the doctors, hospitals, laboratories and other medical providers that I use in the insurance company’s network?
• If I want to use a doctor outside the network, will the plan permit it?
• How easily can I change primary-care physicians if I want to?
• Do I need to get permission before I see a medical specialist?
• What are the procedures for getting care and being reimbursed in an emergency situation, both at home or out of town?
• If I have a preexisting medical condition, will the plan cover it?
• If I have a chronic condition such as asthma, cancer, AIDS or alcoholism, how will the plan treat it?
• Are the prescription medicines that I use covered by the plan?
• Does the plan reimburse alternative medical therapies such as acupuncture or chiropractic treatment?
• Does the plan cover the costs of delivering a baby?

What is the quality of the insurance plan I’m looking at?

• How have independent government and non-government organizations rated the plan? For example, the National Committee for Quality Assurance ( http://www.ncqa.org ) issues a Consumer Assessment of Health Plans (CAHPS) report for every medical plan and facility.
• What kind of accreditation has the plan received from groups such as NCQA or the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) ( www.jointcommission.org )?
• How many patient complaints were filed against the plan last year and how many were upheld by state regulatory agencies like the state insurance commission or the state medical licensing board?
• How many members drop out of the plan each year? State insurance departments keep track of “disenrollment rates.”
• Do the doctors, pharmacies and other services in the plans offer convenient times and locations?
• Does the plan pay for preventive health care such as diet and exercise advice, immunizations and health screenings?
• What do my friends and colleagues say about their experiences with the plan?
• What does my doctor say about his or her experience with the plan?

There are essentially two kinds of heath insurance: Fee-for-Service and Managed Care. Although these plans differ, they both cover an array of medical, surgical and hospital expenses. Most cover prescription drugs and some also offer dental coverage.

• Fee-for-Service
  These plans generally assume that the medical professional will be paid a fee for each service provided to the patient. Patients are seen by a doctor of their choice and the claim is filed by either the medical provider or the patient.
• Managed Care
  More than half of all Americans have some kind of managed-care plan. Various plans work differently and can include: health maintenance organizations (HM0s), preferred provider organizations (PPOs) and point-of-service (POS) plans. These plans provide comprehensive health services to their members and offer financial incentives to patients who use the providers in the plan.

In addition to our commitment to preventive care, you’ll get the Kaiser Permanente Healthwise Handbook, a useful self-care guide to more than 200 common health problems. Our member newsletter, Partners in Health, and the Kaiser Permanente Healthphone system keep you up-to-date with wellness tips and medical news.

Yes! As a member, you can log on to www.kaiserpermanente.org to take care of simple tasks like ordering prescription refills or requesting routine appointments. Our Web site features a wealth of information and educational resources, such as online health and drug encyclopedias, message boards, and programs to help you lead a healthier lifestyle.
Please note: To access secure features on the member section of our Web site, www.kaiserpermanente.org, all you need to do is register online as a Kaiser
Permanente member and we’ll mail your password to your home in three to seven days. Some services are not available in all areas.

We provide same-day appointments and night and weekend hours at most locations.

We cover emergency care from Plan providers and non-Plan providers
anywhere in the world.
If you have an emergency medical condition, call 911 or go to the nearest hospital. An emergency medical condition is (1) a medical or psychiatric condition that manifests itself by acute symptoms of sufficient severity (including severe pain) such that you could reasonably expect the absence of immediate medical attention to result in serious jeopardy to your health or serious impairment or dysfunction of your bodily functions or organs; or (2) when you are in active labor and there isn’t enough time for safe transfer to a Plan hospital before delivery, or if transfer poses a threat to your or your unborn child’s health and safety.

We’re proud to provide high-quality care to our members. But don’t just take our word for it. Kaiser Permanente has been recognized by independent organizations as the best in California for our quality of care and service. Sources: National Committee for Quality Assurance, State of Healthcare Quality 2004, www.ncqa.org. California Cooperative Health Reporting Initiative Report on Quality, 2004. www.cchri.org.

Yes, the choice is yours. From your first day as a member, we encourage you to begin a relationship with a personal physician from one of our primary care departments. And you don’t just get a personal physician—you get a whole team that includes nurses, specialists, and health educators who can help you find the resources to meet your health care goals.

You can now sign up for online healthy lifestyle programs to help you lose weight, reduce stress, eat better, and quit smoking. You also get access to chiropractic care, acupuncture, and massage therapy at a 25% discount from a network of providers. And you can get preferred rates at fitness clubs. All this and more, just for being a Kaiser Permanente member.

Please note: The products and services described are provided by entities other than Kaiser Permanente and are neither offered nor guaranteed under your Kaiser Foundation Health Plan contract. Kaiser Permanente does not endorse or make any representations regarding the quality or medical efficacy of such products and services, nor the financial integrity of these entities. Kaiser Permanente disclaims any liability for these products and services. Any disputes may be subject to Kaiser Foundation Health Plan's grievance process. Should a problem arise with any of these products or services, you may call the Member Service Call Center, and we will direct you as appropriate.

Some Kaiser Permanente members may have coverage through their health plan for some of the same services available through American Specialty Health Networks (ASHN).

We don’t just treat illness?our goal is to help you get healthy and stay that way. Whether you need primary or care, your personal physician
partners with you to help you get the care you need.

Health is much more than just not being sick. It’s an attitude. A way of life. Whether it’s through our health education classes or our online health tools, you can take advantage of a variety of resources to help you live a healthier life. • Our approach to medicine is built around preventive care—so we work to detect potentially dangerous conditions before you get sick. We provide access to screenings, such as mammograms and cholesterol tests, which can detect problems early on. We work to make sure your children get the immunizations they need to grow strong and healthy through regular well child visits.
• Our health education classes and programs can teach you how to make healthier lifestyle choices. We offer a variety of classes in most locations. Some classes may require a fee.
• Of course, we’re also here for you when you’re sick. You can also get advice by phone, learn to manage your chronic condition, and have peace of mind knowing we cover emergency care anywhere in the world.