KP OR Gold 1750 - 71287OR0420005 Health Insurance Plan
Kaiser Foundation Healthplan of the NW health insurance plan with the Plan ID 71287OR0420005. The plan is called KP OR Gold 1750.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.02% (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 21.98% 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 | 71287OR0420005 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Oregon | ||||||||||||||||||
| Health Insurance Issuer | Kaiser Foundation Healthplan of the NW | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 71287OR0420005-03 | ||||||||||||||||||
| Provider Network(s) | TIER-ONE-REFERRAL-REQUIRED TIER-ONE | ||||||||||||||||||
| 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 Off Exchange Plan - 71287OR0420005-00 Standard On Exchange Plan - 71287OR0420005-01 |
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| Last Plan Update Date | Thu, 17 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of KP OR Gold 1750 Health Insurance Plan, 71287OR0420005-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
YES | $0.00 |
100.00% |
| Accidental Dental
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Acupuncture
Limit: 12.0 Visit(s) per Year |
YES | $25.00 |
100.00% |
| Allergy Testing
|
YES | $50.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | $50.00 |
100.00% |
| Chiropractic Care
Limit: 20.0 Visit(s) per Year |
YES | $25.00 |
100.00% |
| Cosmetic Surgery
Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Delivery and All Inpatient Services for Maternity Care
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
Limit: 3.0 Hours per Year Covers three hours of education per year if there is a significant change in condition or treatment; covers one diabetes self-management education program at the time of diagnosis. Telehealth visits (if clinically appropriate) $0 copay, refer to EOC. |
YES | $20.00 |
100.00% |
| Dialysis
|
YES | $50.00 |
100.00% |
| Durable Medical Equipment
$5,000 limit on non-Essential Health Benefit Durable Medical equipment. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | $350.00 Copay after deductible |
$350.00 Copay after deductible |
| Emergency Transportation/Ambulance
|
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Eye Glasses for Children
|
YES | $0.00 |
100.00% |
| Gender Affirming Care
Gender affirming care is covered when determined by a provider as medically necessary and follows accepted standards of care. Please check with the insurance carrier for coverage information, including any limitations and exclusions. |
YES | ||
| Generic Drugs
Insulin: $35 max out of pocket for 30 day supply prior to deductible |
YES | $10.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Year Visit limit does not apply to treatment of mental health conditions. Telehealth visits (if clinically appropriate) $0 copay, refer to EOC. |
YES | $50.00 |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years One hearing aid per hearing impaired ear if prescribed, fitted, and dispensed by a licensed audiologist with the approval of a licensed physician. Coverage will be provided every 36 months as medically necessary for the treatment of a member's hearing loss. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Hormone Therapy
|
YES | ||
| Hospice Services
Respite care provided in a nursing facility subject to a maximum of five consecutive days and to a lifetime maximum benefit of 30 days. |
YES | $0.00 |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $350.00 Copay after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | $50.00 |
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 | $50.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Medical Service Drugs
|
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Telehealth visits (if clinically appropriate) $0 copay, refer to EOC. |
YES | $20.00 |
100.00% |
| Non-Preferred Brand
|
YES | 50.00% |
100.00% |
| Non-Preferred Brand Drugs
Insulin: $35 max out of pocket for 30 day supply prior to deductible |
YES | 50.00% |
100.00% |
| Non-Preferred Generic
|
NO | ||
| Nutritional Counseling
Limit: 5.0 Visit(s) per Lifetime Visit limit does not apply to treatment of mental health conditions. Telehealth visits (if clinically appropriate) $0 copay, refer to EOC. |
YES | $20.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Telehealth visits (if clinically appropriate) $0 copay, refer to EOC. |
YES | $20.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year Visit limit does not apply to treatment of mental health conditions. Telehealth visits (if clinically appropriate) $0 copay, refer to EOC. |
YES | $50.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Preferred Brand
|
YES | $40.00 |
100.00% |
| Preferred Brand Drugs
Insulin: $35 max out of pocket for 30 day supply prior to deductible |
YES | $40.00 |
100.00% |
| Preferred Generic
Insulin: $35 max out of pocket for 30 day supply prior to deductible |
YES | $10.00 |
100.00% |
| Prenatal and Postnatal Care
Telehealth visits (if clinically appropriate) $0 copay, refer to EOC. |
YES | $0.00 |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | $0.00 |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Telehealth visits (if clinically appropriate) $0 copay, refer to EOC. |
YES | $20.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | $50.00 |
100.00% |
| Reconstructive Surgery
Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Visit limit does not apply to treatment of mental health conditions. Telehealth visits (if clinically appropriate) $0 copay, refer to EOC. |
YES | $50.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year 30 visits per condition per calendar year. Visit limit does not apply to treatment of mental health conditions. Telehealth visits (if clinically appropriate) $0 copay, refer to EOC. |
YES | $50.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
YES | $20.00 |
100.00% |
| Routine Eye Exam for Children
|
YES | $0.00 |
100.00% |
| Routine Foot Care
Covered for patients with diabetes mellitus. |
YES | $50.00 |
100.00% |
| Skilled Nursing Facility
Limit: 60.0 Days per Year |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
Telehealth visits (if clinically appropriate) $0 copay, refer to EOC. |
YES | $50.00 |
100.00% |
| Specialty Drugs
Insulin: $35 max out of pocket for 30 day supply prior to deductible |
YES | 50.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Telehealth visits (if clinically appropriate) $0 copay, refer to EOC. |
YES | $20.00 |
100.00% |
| Telehealth-Office Visit
Telehealth allows a Member, or person acting on the Member?s behalf, to interact with a Participating Provider who is not physically at the same location. We cover telehealth Services at no Charge when all of the following are true: The Service is otherwise covered under this EOC. The Service is determined by a Participating Provider to be Medically Necessary. Medical Group determines the Service may be safely and effectively provided using telehealth, according to generally accepted health care practices and standards. |
YES | $0.00 |
100.00% |
| Telehealth-Specialist Visit
Telehealth allows a Member, or person acting on the Member?s behalf, to interact with a Participating Provider who is not physically at the same location. We cover telehealth Services at no Charge when all of the following are true: The Service is otherwise covered under this EOC. The Service is determined by a Participating Provider to be Medically Necessary. Medical Group determines the Service may be safely and effectively provided using telehealth, according to generally accepted health care practices and standards. |
YES | $0.00 |
100.00% |
| Transplant
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | $40.00 |
$40.00 |
| Weight Loss Programs
Telehealth visits (if clinically appropriate) $0 copay, refer to EOC. |
NO | ||
| Well Baby Visits and Care
Telehealth visits (if clinically appropriate) $0 copay, refer to EOC. |
YES | $0.00 |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $50.00 |
100.00% |
| Zero Cost Share Preventative Drugs
|
NO |
KP OR Gold 1750 - AI/LTD Health Insurance Plan Variant 71287OR0420005-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.780158264323771 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Limited Cost Sharing Plan Variation |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 0.9940000000000001 |
| First Tier Utilization | 100% |
| Formulary ID | ORF001 |
| Formulary URL | URL |
| HIOS Product ID | 71287OR042 |
| Import Date | 2024-10-17 20:01:47 |
| 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 | 71287 |
| Issuer Marketplace Marketing Name | Kaiser Permanente |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 30.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $3500 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $1750 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $1,750 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | ORN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency medical conditions, including prescription drugs |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency medical conditions, including prescription drugs |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 71287OR0420005-03 |
| Plan Marketing Name | KP OR Gold 1750 |
| Plan Type | EPO |
| Plan Variant Marketing Name | KP OR Gold 1750 - AI/LTD |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,500 |
| SBC Scenario, Having a Baby, Copayment | $300 |
| SBC Scenario, Having a Baby, Deductible | $1,750 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,000 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $60 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,750 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ORS001 |
| Source Name | SERFF |
| Specialist Requiring a Referral | A referral is not required for outpatient Services provided in the following departments: Cancer Counseling, Chemical Dependency Services., Mental Health Services., Obstetrics/Gynecology, Occupational Health., Ophthalmology, and Optometry (routine eye exams), and Social Services. |
| Plan ID | 71287OR0420005 |
| State Code | OR |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $17000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,500 |
| 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 OR Gold 1750 Health Insurance Plan, 71287OR0420005
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about KP OR Gold 1750, 71287OR0420005 Health Insurance Plan, 71287OR0420005
-
Does KP OR Gold 1750 Health Insurance Plan, 71287OR0420005 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (71287OR0420005) Health Insurance Plan, Variant (71287OR0420005-03) offer Disease Management Programs?
Does (71287OR0420005) Health Insurance Plan, Variant (71287OR0420005-03) have Out Of Country Coverage?
Does (71287OR0420005) Health Insurance Plan, Variant (71287OR0420005-03) have Out of Service Area Coverage?
Does (71287OR0420005) Health Insurance Plan, Variant (71287OR0420005-03) offer Disease Management Programs?
Does KP OR Gold 1750 - AI/LTD Health Insurance Plan, Variant (71287OR0420005-03) offer Disease Management Programs for Asthma?
Does KP OR Gold 1750 - AI/LTD Health Insurance Plan, Variant (71287OR0420005-03) offer Disease Management Programs for Heart disease?
Does KP OR Gold 1750 - AI/LTD Health Insurance Plan, Variant (71287OR0420005-03) offer Disease Management Programs for Depression?
Does KP OR Gold 1750 - AI/LTD Health Insurance Plan, Variant (71287OR0420005-03) offer Disease Management Programs for Diabetes?
Does KP OR Gold 1750 - AI/LTD Health Insurance Plan, Variant (71287OR0420005-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does KP OR Gold 1750 - AI/LTD Health Insurance Plan, Variant (71287OR0420005-03) offer Disease Management Programs for Low back pain?
Does KP OR Gold 1750 - AI/LTD Health Insurance Plan, Variant (71287OR0420005-03) offer Disease Management Programs for Pregnancy?
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