How deductible plans work
All of our deductible plans offer the quality care and services you expect from Kaiser Permanente. You get a wide range of programs and tools to help you stay in control of your health. Let’s look at the basics of how deductible plans work, starting with some key terms.
- Deductible — a set amount you must pay in a contract year before Kaiser Permanente will begin to partially cover services.
- Copayments (copays) — on the DHMO plan only, the fixed dollar amounts you pay for covered medical office visits and certain other benefits covered by your plan. For example, if you have a $30 office visit copay, you’d pay $30 for each office visit. Copays do not apply toward the deductible or out of pocket maximum, so you will continue to pay copayments after these amounts have been reached for the year.
- Coinsurance — percentage of charges you pay when you receive certain services covered by your plan after the deductible is met. For example, if you have 30 percent coinsurance for hospitalization, and your deductible has been satisfied, you’d pay 30 percent of the charges for those covered hospital services.
- Out-of-pocket maximum — the maximum amount of coinsurance you must pay in a year for service covered by your plan. On the DHMO, this amount is in addition to your yearly deductible. Please note that you will continue to pay copayments for applicable services or coinsurance for services that do not apply to the out-of-pocket maximum after the out-of-pocket maximum is met.
A focus on prevention
We believe preventive care is a great way to help you stay healthy. That’s why all our deductible plans offer most preventive care services — like routine physical exams, mammograms, and cholesterol screenings — at little or no cost to you, even before you reach your deductible. This helps you detect problems before they become serious and keep you from living life to the fullest.
Learn more about preventive care services. Also, find out when a preventive care visit might involve non-preventive services that require additional costs.
How a deductible works for a family
If your family is covered under your plan, you’ll typically have two types of deductible and out-of-pocket maximum that work together.
- Each family member has an individual deductible and an individual out-of-pocket maximum.
- The family as a whole has a family deductible and a family out-of-pocket maximum.
If you have an HSA-qualified plan, your family’s deductible and out-of-pocket maximum may work differently.
|Each family member has an individual deductible and an individual out-of-pocket maximum||
|The family as a whole has a family deductible and a family out-of-pocket maximum||
When the individual or family out-of-pocket maximum is met, we'll pay for the medical service that apply to the out-of-pocket-maximum for the family member or entire family for the rest of the calendar year.
To learn more about which type of deductible and out-of-pocket maximum you have, click on the links for your plan.