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KP CO Gold 2000/20

21032CO0410067
Gold
HMO

KP CO Gold 2000/20 is a Gold HMO plan by Kaiser Foundation Health Plan of Colo..

Locations

KP CO Gold 2000/20 is offered in the following counties.

Plan Overview

This is a plan overview for 2022 version of KP CO Gold 2000/20 21032CO0410067.
Insurer: Kaiser Foundation Health Plan of Colo.
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 21032CO0410067

Cost-Sharing Overview

KP CO Gold 2000/20 offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for KP CO Gold 2000/20?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

KP CO Gold 2000/20 offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Diabetes, High Blood Pressure & High Cholesterol
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions: Refer to EOC
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what KP CO Gold 2000/20 covers when you are out of the service area or out of the country.

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
National Network: No

Additional Benefits and Cost-Sharing

KP CO Gold 2000/20 includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Laboratory Outpatient and Professional Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Allergy Testing
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Autism Spectrum Disorders – Assessment and Evaluation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Nutritional Counseling
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Routine Eye Exam (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Telehealth Mental/Behavioral Health
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Generic Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Outpatient Rehabilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes60 Visit(s) per Year 20 visits for Occupational Therapy/20 visits for Physical Therapy/20 visits for Speech TherapySubstantially Equal
Private-Duty Nursing
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Non-Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Specialty Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Routine Dental Services (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Hearing Aids
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Adult Hearing Aids, 18 and over are not covered
Partial Hospitalization for Substance Use Disorder
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Rehabilitative Speech Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes20 Visit(s) per Year
Major Dental Care – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Dental Check-Up for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Postpartum Substance Use Disorder
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Preventive Care/Screening/Immunization
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Emergency Room Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Orthodontia – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Eye Glasses for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes1 Item(s) per 2 Years
Telehealth PCP
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Home Health Care Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes28 Hours per Week
Inpatient Physician and Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Diabetes Education
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Mental/Behavioral Health Prenatal Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Substance Abuse Disorder Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Accidental Dental
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Residential Day Treatment for Mental/Behavioral Health
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Urgent Care Centers or Facilities
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes40 Visit(s) per Year 20 visits for Occupational Therapy/20 visits for Physical TherapySubstantially Equal
Rehabilitative Physical Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes20 Visit(s) per Year Substantially Equal
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Ambulatory Surgery Centers may have a lower cost
Imaging (CT/PET Scans, MRIs)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Prosthetics: Legs and Arms
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Chiropractic Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes20 Visit(s) per Year
Postpartum Mental/Behavioral Health
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Rehabilitative Occupational Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes20 Visit(s) per Year Substantially Equal
Habilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes60 Visit(s) per Year 20 visits for Occupational Therapy/20 visits for Physical Therapy/20 visits for Speech Therapy
Mental/Behavioral Health Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Dialysis
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Partial Hospitalization for Mental/Behavioral Health
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Inpatient Rehabilitation
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes60 Days per Year Substantially Equal
Well Baby Visits and Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Hospice Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Chemotherapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Intensive Outpatient for Substance Use Disorder
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Acupuncture
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Telehealth Substance Use Disorder
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Mental/Behavioral Health Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Prosthetic Devices
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Intensive Outpatient for Mental/Behavioral Health
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Primary Care Visit to Treat an Injury or Illness
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Higher cost share applies to Affiliate providers
Substance Use Disorder Prenatal Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Treatment for Temporomandibular Joint Disorders
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
X-rays and Diagnostic Imaging
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Radiation
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Routine Foot Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Abortion for Which Public Funding is Prohibited
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Not EHB
Bariatric Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Applied Behavior Analysis Based Therapies
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Durable Medical Equipment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Specialist Visit
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Orthodontia – Child
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Delivery and All Inpatient Services for Maternity Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Basic Dental Care – Child
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Outpatient Surgery Physician/Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Skilled Nursing Facility
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes100 Days per Year
Cosmetic Surgery
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Prenatal and Postnatal Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Weight Loss Programs
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Residential Day Treatment for Substance Use Disorder
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Infertility Treatment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Telehealth Specialist
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Substance Abuse Disorder Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Infusion Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Reconstructive Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Routine Eye Exam for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Basic Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Emergency Transportation/Ambulance
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Major Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Long-Term/Custodial Nursing Home Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Transplant
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes

Free Preventive Services

There is no copayment or coinsurance for any of the following KP CO Gold 2000/20 preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Ready to sign up for KP CO Gold 2000/20?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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