Kaiser Foundation Health Plan, Inc. health insurance plan with the Plan ID 60612HI0110013. The plan is called KP HI Silver 4000 Ded/600 Rx Ded.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 94.30% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 5.70% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 94.23% (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 5.77% 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 | 60612HI0110013 | ||||||||||||||||||
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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 | 60612HI0110013-06 | ||||||||||||||||||
Provider Network(s) | PREFERRED | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 14 May 2024 06:16 GMT). |
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Available Variants of the Health Plan | Standard On Exchange Plan - 60612HI0110013-01 Open to Indians below 300% FPL - 60612HI0110013-02 Open to Indians above 300% FPL - 60612HI0110013-03 73% AV Silver Plan - 60612HI0110013-04 |
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Last Plan Update Date | Mon, 18 Dec 2023 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 14 May 2024 06:16 GMT |
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 | 10.00% 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 | 10.00% Coinsurance after deductible |
10.00% 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 | $5.00 |
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 | 10.00% 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 | 20.00% |
100.00% |
Chiropractic Care
|
NO | ||
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
|
YES | 10.00% 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 | $5.00 |
100.00% |
Dialysis
|
YES | 20.00% |
100.00% |
Durable Medical Equipment
|
YES | 10.00% |
100.00% |
Emergency Room Services
Must notify KP within 48 hours if admitted to a non-plan provider; limited to initial emergency only |
YES | 10.00% Coinsurance after deductible |
10.00% Coinsurance after deductible |
Emergency Transportation/Ambulance
|
YES | 20.00% |
20.00% |
Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | No Charge |
100.00% |
Gender Affirming Care
|
YES | 10.00% Coinsurance after deductible |
100.00% |
Generic Drugs
Copay refers to generic drugs used to treat certain chronic conditions. Subject to formulary guidelines. |
YES | $10.00 |
100.00% |
Generic Drugs Maintenance
Copay refers to all other generic drugs not used to treat certain chronic conditions. Subject to formulary guidelines. |
YES | $3.00 |
100.00% |
Habilitation Services
Coverage limited to state-defined habilitative services. |
YES | $10.00 |
100.00% |
Hearing Aids
Limit: 1.0 Item(s) per 3 Years Hearing aid(s) provided once every 36 months per ear. |
YES | 60.00% |
100.00% |
Home Health Care Services
Physician visit covered at applicable office visit copay. |
YES | No Charge |
100.00% |
Hospice Services
Physician visit covered at applicable office visit copay. |
YES | No Charge |
100.00% |
Imaging (CT/PET Scans, MRIs)
Cost share indicated is "per day" |
YES | $25.00 |
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 | $5.00, 20.00% |
100.00% |
Infusion Therapy
Drug covered at cost share indicated, additional office visit charge applies. |
YES | 20.00% |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 10.00% Coinsurance after deductible |
100.00% |
Inpatient Physician and Surgical Services
|
YES | 10.00% Coinsurance after deductible |
100.00% |
Laboratory Outpatient and Professional Services
Cost share indicated is "per day" |
YES | $5.00 |
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 | 10.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Outpatient Services
No charge for primary care office visits for children through age 18. |
YES | $5.00 |
100.00% |
Non-Preferred Brand Drugs
Subject to formulary guidelines |
YES | 5.00% |
100.00% |
Nutritional Counseling
|
YES | No Charge |
100.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
|
NO | ||
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $5.00 |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 10.00% Coinsurance after deductible |
100.00% |
Outpatient Rehabilitation Services
|
YES | $10.00 |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 10.00% Coinsurance after deductible |
100.00% |
Preferred Brand Drugs
Subject to formulary guidelines |
YES | 5.00% |
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 for primary care office visits for children through age 18 |
YES | $5.00 |
100.00% |
Private-Duty Nursing
|
NO | ||
Prosthetic Devices
Cost share indicated is for services performed on an inpatient basis. |
YES | 10.00% Coinsurance after deductible |
100.00% |
Radiation
|
YES | 20.00% |
100.00% |
Reconstructive Surgery
Cost share indicated is for services performed on an inpatient basis. |
YES | 10.00% Coinsurance after deductible |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
|
YES | $10.00 |
100.00% |
Rehabilitative Speech Therapy
|
YES | $10.00 |
100.00% |
Routine Dental Services (Adult)
|
NO | ||
Routine Eye Exam (Adult)
|
YES | $5.00 |
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 | 10.00% Coinsurance after deductible |
100.00% |
Specialist Visit
|
YES | $25.00 |
100.00% |
Specialty Drugs
Subject to formulary guidelines |
YES | 5.00% |
100.00% |
Specialty Laboratory Services
Cost share indicated is "per day" |
YES | $25.00 |
100.00% |
Substance Abuse Disorder Inpatient Services
|
YES | 10.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Outpatient Services
No charge for primary care office visits for children through age 18 |
YES | $5.00 |
100.00% |
Testing Services
Cost share indicated is "per test" |
YES | $15.00 |
100.00% |
Transplant
Cost share indicated is for services performed on an inpatient basis. |
YES | 10.00% Coinsurance after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
Cost share indicated is for services performed on an inpatient basis. |
YES | 10.00% 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 | $5.00 |
20.00% |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
|
YES | No Charge |
100.00% |
X-rays and Diagnostic Imaging
Cost share indicated is "per day" |
YES | $5.00 |
100.00% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.9422607764935759 |
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 | 94% AV Level Silver Plan |
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 | 5.00% |
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, Weight Loss Programs |
EHB Percent of Total Premium | 0.997 |
First Tier Utilization | 100% |
Formulary ID | HIF007 |
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 Actuarial Value | 94.30% |
Issuer ID | 60612 |
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 | 10.00% |
Medical EHB Deductible, In Network (Tier 1), Family Per Group | $50 per group |
Medical EHB Deductible, In Network (Tier 1), Family Per Person | $25 per person |
Medical EHB Deductible, In Network (Tier 1), Individual | $25 |
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 | Silver |
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) | 60612HI0110013-06 |
Plan Marketing Name | KP HI Silver 4000 Ded/600 Rx Ded |
Plan Type | HMO |
Plan Variant Marketing Name | KP HI Silver 25/5 CSR94 |
QHP/Non QHP | On the Exchange |
SBC Scenario, Having a Baby, Coinsurance | $800 |
SBC Scenario, Having a Baby, Copayment | $20 |
SBC Scenario, Having a Baby, Deductible | $25 |
SBC Scenario, Having a Baby, Limit | $0 |
SBC Scenario, Having Diabetes, Coinsurance | $600 |
SBC Scenario, Having Diabetes, Copayment | $200 |
SBC Scenario, Having Diabetes, Deductible | $0 |
SBC Scenario, Having Diabetes, Limit | $0 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $300 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $100 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $25 |
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 | 60612HI0110013 |
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 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $4000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $2000 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $2,000 |
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 | Yes |
URL for Enrollment Payment | URL |
URL for Summary of Benefits & Coverage | URL |
Wellness Program Offered | Yes |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 14 May 2024 06:16 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