KP HI Bronze 6500/30% - 60612HI0110015 Health Insurance Plan
Kaiser Foundation Health Plan, Inc. health insurance plan with the Plan ID 60612HI0110015. The plan is called KP HI Bronze 6500/30%.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 61.95% (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 38.05% 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 | 60612HI0110015 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| 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 | 60612HI0110015-03 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | Standard On Exchange Plan - 60612HI0110015-01 |
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| Last Plan Update Date | Mon, 18 Dec 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of KP HI Bronze 6500/30% Health Insurance Plan, 60612HI0110015-03
| 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% Coinsurance after deductible |
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 | 30.00% Coinsurance after deductible |
30.00% Coinsurance 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% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
Cost share indicated is for services performed on an inpatient basis. For each inpatient hospital stay, copay is per day for the first 4 consecutive inpatient days and $0 for additional consecutive inpatient days. |
YES | 30.00% Coinsurance after deductible |
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 | 30.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
|
NO | ||
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 30.00% Coinsurance after deductible |
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% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
Must notify KP within 48 hours if admitted to a non-plan provider; limited to initial emergency only |
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
Copay refers to generic drugs used to treat certain chronic conditions. Subject to formulary guidelines. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Generic Drugs Maintenance
Copay refers to all other generic drugs not used to treat certain chronic conditions. Subject to formulary guidelines. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Habilitation Services
Coverage limited to state-defined habilitative services. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years Hearing aid(s) provided once every 36 months per ear. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
Physician visit covered at applicable office visit copay. |
YES | No Charge after deductible |
100.00% |
| Hospice Services
Physician visit covered at applicable office visit copay. |
YES | No Charge after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 30.00% Coinsurance 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% Coinsurance after deductible |
100.00% |
| Infusion Therapy
Drug covered at cost share indicated, additional office visit charge applies. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 30.00% Coinsurance after deductible |
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% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
No charge after deductible for primary care office visits for children through age 18 |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Non-Preferred Brand Drugs
Subject to formulary guidelines |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
YES | No Charge after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 30.00% Coinsurance after deductible |
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 after deductible for primary care office visits for children through age 18 |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Cost share indicated is for services performed on an inpatient basis. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Cost share indicated is for services performed on an inpatient basis. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
YES | 30.00% Coinsurance after deductible |
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. For each facility stay, copay is per day for the first 4 consecutive days and $0 for additional consecutive days. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Specialty Drugs
Subject to formulary guidelines |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Specialty Laboratory Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
No charge after deductible for primary care office visits for children through age 18 |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Testing Services
Cost share indicated is "per test" |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Transplant
Cost share indicated is for services performed on an inpatient basis. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Cost share indicated is for services performed on an inpatient basis. |
YES | 30.00% Coinsurance after deductible |
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% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 30.00% Coinsurance after deductible |
100.00% |
KP HI Bronze 6500/30% AI/LTD Health Insurance Plan Variant 60612HI0110015-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.619519893517173 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Limited Cost Sharing Plan Variation |
| 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 | 0.9961 |
| First Tier Utilization | 100% |
| Formulary ID | HIF010 |
| Formulary URL | URL |
| HIOS Product ID | 60612HI011 |
| Import Date | 2023-12-18 20:02:01 |
| 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 ID | 60612 |
| Issuer Marketplace Marketing Name | Kaiser Permanente |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Bronze |
| 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 | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 60612HI0110015-03 |
| Plan Marketing Name | KP HI Bronze 6500/30% |
| Plan Type | HMO |
| Plan Variant Marketing Name | KP HI Bronze 6500/30% AI/LTD |
| QHP/Non QHP | On the Exchange |
| SBC Scenario, Having a Baby, Coinsurance | $600 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $6,500 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $400 |
| SBC Scenario, Having Diabetes, Copayment | $200 |
| SBC Scenario, Having Diabetes, Deductible | $4,100 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,900 |
| 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 | 60612HI0110015 |
| State Code | HI |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 30.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $13000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $6500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $6,500 |
| 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 | $18300 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9150 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,150 |
| 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 HI Bronze 6500/30% Health Insurance Plan, 60612HI0110015
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about KP HI Bronze 6500/30%, 60612HI0110015 Health Insurance Plan, 60612HI0110015
-
Does KP HI Bronze 6500/30% Health Insurance Plan, 60612HI0110015 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (60612HI0110015) Health Insurance Plan, Variant (60612HI0110015-03) offer Disease Management Programs?
Does (60612HI0110015) Health Insurance Plan, Variant (60612HI0110015-03) have Out Of Country Coverage?
Does (60612HI0110015) Health Insurance Plan, Variant (60612HI0110015-03) have Out of Service Area Coverage?
Does (60612HI0110015) Health Insurance Plan, Variant (60612HI0110015-03) offer Disease Management Programs?
Does KP HI Bronze 6500/30% AI/LTD Health Insurance Plan, Variant (60612HI0110015-03) offer Disease Management Programs for Asthma?
Does KP HI Bronze 6500/30% AI/LTD Health Insurance Plan, Variant (60612HI0110015-03) offer Disease Management Programs for Heart disease?
Does KP HI Bronze 6500/30% AI/LTD Health Insurance Plan, Variant (60612HI0110015-03) offer Disease Management Programs for Depression?
Does KP HI Bronze 6500/30% AI/LTD Health Insurance Plan, Variant (60612HI0110015-03) offer Disease Management Programs for Diabetes?
Does KP HI Bronze 6500/30% AI/LTD Health Insurance Plan, Variant (60612HI0110015-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does KP HI Bronze 6500/30% AI/LTD Health Insurance Plan, Variant (60612HI0110015-03) offer Disease Management Programs for Low back pain?
Does KP HI Bronze 6500/30% AI/LTD Health Insurance Plan, Variant (60612HI0110015-03) offer Disease Management Programs for Pregnancy?
Does KP HI Bronze 6500/30% AI/LTD Health Insurance Plan, Variant (60612HI0110015-03) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 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