Kaiser Permanente Medical Benefit Kaiser Permanente HMO Plan
This page provides basic information about the Kaiser Permanente HMO medical plan available through the UNITE HERE Local 11 Health Benefit Fund. For eligibility rules and full plan details, see the Summary Plan Description.
- Getting started
- What’s covered
- What you pay
- Get care in Southern California
- Submit a claim
Getting started
The Kaiser HMO Plan is an HMO medical plan provided through the Kaiser Foundation Health Plan (Kaiser), which has contracted with the Fund to provide you and your dependents with comprehensive health care coverage, including medical, hospital, mental/behavioral health, and substance use disorder benefits.
Get started in three easy steps:
Check the mail for your Kaiser Permanente member ID card. Your card will include your Medical Record Number (MRN), which you will need to create your online account. If you do not receive your insurance card within two weeks, or if you need care before receiving your card, call Kaiser at (800) 278-3296.
Create your account. Setting up your account is easy. Just register on kp.org and follow the instructions online. You’ll need your Medical Record Number, which you can find on your member ID card. Once you create an account you can make appointments, view your medical records, message your doctor and more.
Choose your doctor. Start by selecting a convenient facility, then browse Kaiser’s online doctor profiles. You can search by gender, languages spoken, education, and more. Each covered family member can choose a personal doctor with any of these specialties:
- Adult medicine/internal medicine
- Family medicine
- Pediatrics/adolescent medicine (for children up to 18)
- Obstetrics-gynecology — women 18 and older can choose an ob-gyn as well as a personal doctor
Call to make your first appointment by calling the appointment line on your card.
What’s covered
This is a simple summary. For detailed information about the Kaiser HMO Plan, including information on covered services, cost sharing, exclusions and limitations, and the procedures for filing claims and appeals, please refer to the Kaiser Permanente Evidence of Coverage (the “EOC”) in the Find Forms & Documents section of this website.
Primary Care $15
Preventive Care Screenings $0
Immunizations $0
Diagnostic Tests
(x-ray, bloodwork) $0
Medications
(generic, brand name, and specialty) provided by Express Scripts
Outpatient Surgery Stays $15 and Hospital Stay $0
Urgent Care $15 and ER Visits $150
Pregnancy and Pediatrics $0
Mental Health and Substance Use Disorders $15
Home Health Care $0 and Rehabilitation $15 per visit
Medical Equipment $0
Ambulance $50 per trip
Do not go out of network, or you will pay for all charges! Do NOT use Kaiser’s pharmacy as it is not in network!
Note: If there is a conflict between any description of the Kaiser HMO Plan’s benefits contained in this booklet and Kaiser’s EOC or the Fund’s contract with Kaiser, the EOC or the contract with Kaiser will control.
For other benefits, visit the following pages:
What you pay
See the Summary of Benefits and Coverage (SBC) for what the Plan covers and what you pay for covered services. You can find the SBC, EOC, and Summary Plan Description in the Forms & Documents section of this website.
Be aware, if you do not receive services from Kaiser providers, you will be responsible for 100% of the charges (except in the case of an emergency, in which case Kaiser will determine how much it will pay).
Get care in Southern California
When you enroll in the Kaiser HMO Plan, you must receive services from Kaiser Permanente health care providers at Kaiser facilities. You can call Kaiser Member Services at (800) 278-3296 or visit Kaiser’s website to make an appointment or find a Kaiser personal physician.
Make an appointment
Kaiser Permanente offers several care options from in-person appointments to video and phone visits. Visit the Get Care page for more information regarding cost and availability.
To access all your online care options, you will need to sign in or create a kp.org account.
If you are having a medical or mental health emergency, call 911 or go to the nearest hospital.
Specialty care
Generally, you will need a referral from a Kaiser physician to see a specialist. However, you don’t need referrals for certain specialties, like obstetrics-gynecology.
Emergency care
If you ever need emergency care, you can get care at the Emergency Room of a nearby hospital (even if it is not a Kaiser Hospital), and you do not need a referral or preauthorization.
All claims and appeals for benefits under the Kaiser HMO Plan must be submitted to Kaiser and will be processed according to Kaiser’s claims and appeals procedures, which are outlined in Kaiser Permanente Evidence of Coverage (the “EOC”) in the Find Forms & Documents section of this website.