KP MD Gold 1750/20/Vision
90296MD0610013
Gold
HMO
KP MD Gold 1750/20/Vision is a Gold HMO plan by Kaiser Permanente.
Locations
KP MD Gold 1750/20/Vision is offered in the following counties.
Plan Overview
This is a plan overview for 2022 version of KP MD Gold 1750/20/Vision 90296MD0610013.
| Insurer: | Kaiser Permanente |
| Network Type: | HMO |
| Metal Type: | Gold |
| HSA Eligible?: | No |
| Plan ID: | 90296MD0610013 |
Cost-Sharing Overview
KP MD Gold 1750/20/Vision offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for KP MD Gold 1750/20/Vision includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | 6950 | 6950 per person | $13900 per group |
| Deductible: | 1750 | 1750 per person | $3500 per group |
| Coinsurance: | 1750 per person | $3500 per group | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for KP MD Gold 1750/20/Vision will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | ||
| Out-of-Network Deductible: |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | 1750 |
| Copayment: | 10 |
| Coinsurance: | 2300 |
| Limit: | 60 |
| Deductible: | 2300 |
| Copayment: | 1000 |
| Coinsurance: | 300 |
| Limit: | 0 |
| Deductible: | 1750 |
| Copayment: | 400 |
| Coinsurance: | 100 |
| Limit: | 0 |
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 MD Gold 1750/20/Vision?
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 MD Gold 1750/20/Vision offers the following features and referral requirements.
| Wellness Program: | Yes |
| Disease Program: | Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, Weight Loss Programs, Low Back Pain, High Blood Pressure & High Cholesterol |
| Notice Pregnancy: | Yes |
| Referral Specialist: | Yes |
| Specialist Requiring Referral: | Referrals are required for all Plan specialists with the exception of OB/GYN, Mental Health, Alcohol/Chemical Dependency, Routine Eye Exams. |
| Plan Exclusions: | |
| Child Only Option?: | Allows Adult and Child-Only |
Network Details
The following network details will help you understand what KP MD Gold 1750/20/Vision 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 Care Only |
| Out of Service Area Coverage: | Yes |
| Out of Service Area Coverage Description: | Emergency Care Only |
| National Network: | No |
Additional Benefits and Cost-Sharing
KP MD Gold 1750/20/Vision includes the following benefits at the cost sharing rates listed below.
| Service | In-Network Copay / Coinsurance | Out-of-Network Copay / Coinsurance | Limits and Explanation |
|---|---|---|---|
| Prenatal and Postnatal Care Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 30 Visit(s) per Benefit Period 30 visits each per injury or illness per benefit period for each of OT, PT, and ST. |
| Home Health Care Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Unlimited when provided in lieu of hospitalization or confinement in a skilled nursing facility. Additional benefits for a member who receives less than forty eight hours of impatient hospitalization following the surgical removal of a testicle or Mastectomy, or who undergoes the surgical removal of a testicle or Mastectomy on an outpatient basis, benefits will be provided for Testicle and Mastectomy, Visits: One home visit scheduled to occur within 24 hours after discharge from the hospital or outpatient health care facility and additional home visit if prescribed by the Member’s attending physician. Additional visits for postpartum care as follows: If the mother and newborn child stay in the hospital less than 48 hours for vaginal delivery or 96 hours for cesarean section, one home visit within 24 hours after hospital discharge and an additional home visit if prescribed by attending provider. If the mother and child remain in the hospital for at least 48 hours after vaginal delivery or 96 hours after cesarean section, one home care visit, if prescribed by attending physician. |
| Well Baby Visits and Care Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Mental/Behavioral Health Outpatient Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Treatment for Temporomandibular Joint Disorders Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Includes services to treat temporomandibular and craniomandibular disorders, such as removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services. |
| Abortion for Which Public Funding is Prohibited Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Not EHB |
| Emergency Transportation/Ambulance Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Chiropractic Care Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 20 Visit(s) per Benefit Period |
| Preferred Brand Drugs Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Both covered under Nutritional Counseling; nurses and NPs mentioned in multiple other contexts. |
| Emergency Room Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Nutritional Counseling Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Substance Abuse Disorder Outpatient Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Skilled Nursing Facility Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 100 Days per Benefit Period |
| Generic Drugs Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Infusion Therapy Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Transplant Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Routine Eye Exam (Adult) Covered | Excluded from In-Network MOOP: Yes | Excluded from Out-of-Network MOOP: Yes | Not EHB |
| Laboratory Outpatient and Professional Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Accidental Dental Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Orthodontia – Adult Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Chemotherapy Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Major Dental Care – Child Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Benefit limitations may apply to individual services. |
| Reconstructive Surgery Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Basic Dental Care – Adult Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Weight Loss Programs Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Routine Dental Services (Adult) Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Primary Care Visit to Treat an Injury or Illness Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | $0 copay for children under age 5 |
| Outpatient Rehabilitation Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 30 Visit(s) per Benefit Period 30 visits each per injury or illness per benefit period for each of OT, PT, and ST. |
| Routine Eye Exam for Children Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 1 Exam(s) per Benefit Period |
| Outpatient Surgery Physician/Surgical Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Mental/Behavioral Health Inpatient Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Specialist Visit Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Radiation Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Orthodontia – Child Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Benefit limitations may apply to individual services. |
| Durable Medical Equipment Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Inpatient Physician and Surgical Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Bariatric Surgery Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Dental Check-Up for Children Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 2 Exam(s) per Benefit Period $10 office visit charge applies to each visit |
| Major Dental Care – Adult Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Non-Preferred Brand Drugs Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Urgent Care Centers or Facilities Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Non-plan providers are covered only outside the service area. |
| Substance Abuse Disorder Inpatient Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Diabetes Education Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Preventive Care/Screening/Immunization Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Private-Duty Nursing Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Allergy Testing Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Basic Dental Care – Child Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Benefit limitations may apply to individual services. |
| Routine Foot Care Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Specialty Drugs Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Hearing Aids Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 1 Item(s) per 3 Years 1 hearing aid per each hearing impaired ear every 36 months.Other Law/Regulation |
| Infertility Treatment Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Benefits are limited to: a) Infertility counseling; b) Testing; c) Artificial Insemination and Intrauterine Insemination, and d) In vitro fertilization. Benefits are available when: (1) The unmarried Member or the Member and the Member’s Spouse have a history of the inability to conceive after one (1) year of unprotected vaginal intercourse (opposite sex couples only); or three (3) attempts of artificial insemination over the course of 1 year that failed (same sex couples only); or infertility is associated with a medical condition; (2) The Member has had a fertility examination that resulted in a physician’s recommendation advising artificial insemination or intrauterine insemination; and, (3) The Member’s Spouse’s sperm is used (opposite sex couples only). Benefits are limited to three (3) attempts per live birth.Substantially Equal |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Cosmetic Surgery Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| X-rays and Diagnostic Imaging Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Prosthetic Devices Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Eye Glasses for Children Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 1 Item(s) per Benefit Period |
| Delivery and All Inpatient Services for Maternity Care Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Habilitation Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 30 Visit(s) per Benefit Period Limits only apply for adults, and are the same as rehab limits (30 visits per injury or illness per benefit period for each of PT, OT, ST). Habilitative defined as ‘the process of educating or training persons with a disadvantage or disability caused by a medical condition or injury to improve their ability to function in society, where such ability did not exist, or was severely limited, prior to the Habilitative education or training.’ For Members from birth to age nineteen (19) for treatment of Congenital or Genetic Birth Defects, Benefits for Habilitative services will be provided for services including services for cleft lip and cleft palate, orthodontics, oral surgery, otologic, audiological, and speech therapy, physical therapy, and occupational therapy. |
| Long-Term/Custodial Nursing Home Care Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Dialysis Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Rehabilitative Speech Therapy Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 30 Visit(s) per Benefit Period 30 visits each per injury or illness per benefit period for each of OT, PT, and ST. |
| Acupuncture Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Hospice Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | The Member must have a life expectancy of six (6) months or less. |
| Imaging (CT/PET Scans, MRIs) Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No |
Free Preventive Services
There is no copayment or coinsurance for any of the following KP MD Gold 1750/20/Vision 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.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Ready to sign up for KP MD Gold 1750/20/Vision?
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