Health & Welfare
Medical
Medical Costs At A Glance
Your medical cost at a glance
Information About the Independence PPO Plans
| Type of Service | Independence Active PPO Co-Pay | Independence Bronze PPO (limited offering) |
|---|---|---|
| Preventative Care | $0 | $0 |
| Annual Deductible | N/A | $3,000 self / $6,000 family |
| Office Visit/Specialist | $15/$30 per visit | N/A |
| Diagnostic X-Ray or Lab | $30 per visit | N/A |
| Chiropractor | $15 per visit (Limit 24 visits per year) |
N/A |
| Physician Office Visits, Urgent Care, Hospital Visits, Surgery, Lab, X-ray | N/A | 20% of the negotiated cost after the deductible is met. |
| Hospital Admission | $500 per admission | N/A |
| Outpatient Surgery | $250 per surgery | N/A |
| Emergency Room | $250 per visit | $250 plus 10% after the deductible is met. |
| Urgent Care | $50 per visit | N/A |
| Teladoc | $5.00 per visit | $5.00 - no deductible |
The examples are for in-network providers only. For coverage of out-of-network providers, see your Health Plan Benefits "At a Glance", the Summary Plan Description (SPD) or the Summary of Benefits and Coverage (SBC).
- The Independence Active Summary of Benefits and Coverage - A summary of covered benefits and costs
- The Independence Bronze Summary of Benefits and Coverage - A summary of covered benefits and costs
- The Schedule of Medical Benefits for the Independence Medical PPO Plan - A complete listing of covered benefits and costs
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Information About the Kaiser Permanente HMO Plan
(Only in California, Colorado, Washington and Oregon, Bronze Plan Excluded)
| Type of Service | Kaiser HMO Co-Pay |
|---|---|
| Office Visit/Specialist | $20/$30 per visit |
| Diagnostic X-ray/Lab | $10/$0 per encounter; 20% up to a maximum of $50 per procedure for MRI, CT, and PET scans |
| Chiropractor | CA: $15 per visit; CO: $20 per visit; limit 20 visits per year |
| Hospital Admission | 20% Coinsurance after Calendar Year Deductible is met |
| Outpatient Surgery | 20% Coinsurance after Calendar Year Deductible is met |
| Emergency Room | 20% Coinsurance after Calendar Year Deductible is met |
| Urgent Care | $20 per visit, deductible does not apply |
- Kaiser Summary of Benefits and Coverage - CA - A summary of covered benefits and costs
- Kaiser Summary of Benefits and Coverage - CO - A summary of covered benefits and costs
- Kaiser Summary of Benefits and Coverage - NW - A summary of covered benefits and costs
- Kaiser Summary of Benefits and Coverage - OR - A summary of covered benefits and costs
- Kaiser Evidence of Coverage - CA - A complete description of covered and limited benefits
- Kaiser Evidence of Coverage - CO - A complete description of covered and limited benefits
- Kaiser Evidence of Coverage - WA - A complete description of covered and limited benefit
- Kaiser Evidence of Coverage - NW - A complete description of covered and limited benefits
- Kaiser Chiropractic Services - A complete description of chiropractic services
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Visit the Kaiser Permanente Website to learn about:
- Kaiser Hospital and Medical Facilities
- Ways to get care
- In office
- E-visits
- Telemedicine
- Health and wellness
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