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KAISER
PERMANENTE (Medical)
Southern California
Rates
and Benefits
Plan 30-S
The monthly rates for the Kaiser Permanente Plan are:
| AGE |
Single |
Husband & Wife |
Parent & Child |
Family |
| <30 |
$224 |
$626 |
$616 |
$871 |
| 30-39 |
$248 |
$674 |
$634 |
$964 |
| 40-49 |
$320 |
$736 |
$608 |
$971 |
| 50-54 |
$416 |
$865 |
$686 |
$1,106 |
| 55-59 |
$526 |
$1,104 |
$786 |
$1,270 |
| 60-64 |
$649 |
$1,232 |
$868 |
$1,438 |
| 65+ |
$736 |
$1,590 |
$1,106 |
$1,748 |
Rates effective 1/1/2010 to 1/1/2011
Rates for areas
not listed are available through
The OSSA Group at 1–800–582–8203 or
email.
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Kaiser Permanente
HMO Benefit Summary
|
Services |
Members Pay |
| MEDICAL CALENDAR-YEAR DEDUCTIBLE |
NONE |
| PHARMACY CALENDAR-YEAR DEDUCTIBLE |
$250 for brand prescriptions |
ANNUAL OUT-OF-POCKET MAXIMUM
(Individual/Family)
The annual out-of-pocket maximum is the limit to the total amount that an
individual or family must pay for certain services in a calendar year as
discussed in the Evidence of Coverage. |
$3,500/$7,000 |
| IN THE MEDICAL OFFICE |
|
|
|
$30 per visit |
| |
Preventive physical, vision and hearing exams |
|
$30 per visit |
| |
Maternity/prenatal care (Scheduled prenatal visits
and the first postpartum visit) |
|
No Charge |
| |
Well-Child preventive care visits (23 months or
younger) |
|
No Charge |
|
|
No Charge |
|
|
$5 per visit |
|
|
NOT COVERED |
| x |
Occupational, physical and speech therapy |
|
$30 per visit |
|
|
$10 per visit |
|
|
$50 per visit |
|
|
$200 per visit |
| EMERGENCY SERVICES |
|
| |
Emergency Department visits
(waived if admitted directly to the hospital) |
|
$100 per visit |
|
|
$75 per trip |
| PRESCRIPTIONS |
|
| |
Covered prescription drugs in accord with our
formulary when prescribed by a Plan physician and obtained at PLAN PHARMACIES.
A few drugs have different copayments; please refer to the Evidence
of Coverage for detailed information. |
|
|
|
|
$10
up to a 100 day supply |
|
|
$35
after pharmacy deductible |
| HOSPITAL CARE |
|
| |
Physicians' services, room and board, tests,
medications, supplies, therapies |
|
$400 per day |
| |
Skilled nursing facility care (up to 100 days per
benefit period) |
|
No Charge |
| MENTAL HEALTH SERVICES |
|
| |
In the medical office
(up to 20 visits per calendar year) |
|
$30 Individual
$15 Group |
| |
In the hospital
(up to 30 days per calendar year) |
|
|
| CHEMICAL DEPENDENCY SERVICES |
|
|
|
$30 Individual |
| |
In the hospital (detoxification only) |
|
$400 per day |
| OTHER |
|
| |
Certain durable medical equipment (DME)
Please refer to the Evidence of Coverage. Most DME is not
covered. |
|
NOT COVERED |
|
|
NOT COVERED |
|
|
$50 |
| |
Home health care
(up to 100 two-hour visits per calendar year) |
|
No Charge |
|
|
No Charge |
Additional information and member support are available
through the following Insurance Company websites:
Rate and Comparison charts on this website are provided for
informational purposes ONLY and are not to be considered as binding. Not all areas or
plans are listed. While every effort is made to maintain the accuracy of this information,
you should contact The OSSA Group to confirm rates and coverages available in your area.
If you are a current
MSSI employee and would like to receive an information pack outlining
the specific plans and rates available to you, contact Joe Marini at The OSSA Group, or call 1–800–582–8203
and he will get one in the mail to you.
|
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Medical Staffing Services, Inc.
P.O. Box 862 - 557 Cranbury Road -
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Phone: (732) 238-6050 - FAX: (732) 238-2152
Medical Staffing Services, Inc.
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122 East 42nd Street - Suite 2805 -
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