Kaiser HMO HI

The Kaiser Health Maintenance Organization (HMO) Plan is only available to employees who live within Kaiser’s Hawaiian region service area. With the Kaiser HMO HI plan, you must see providers within the Kaiser network (except in an emergency). The plan requires that you select a Primary Care Physician (PCP) to coordinate all your healthcare needs, including arranging for hospitalization and referrals to specialists. Visit Find a Doctor to see if your provider is in-network.

The Kaiser HMO HI plan includes prescription drug coverage. Visit the Pharmacy page for more information.

With the Kaiser HMO HI plan, you are eligible to enroll in the General Purpose Flexible Spending Account (GPFSA) for your out-of-pocket expenses.

Kaiser HMO HI Plan Details

	In-Network	Out-of-Network
Annual Deductible	N/A	Not Covered
Annual Out-of-Pocket (OOP) Maximum¹	Individual: $2,500 Family: $7,500	Not Covered
Employee Coinsurance	Applies to certain medical procedures only	Not Covered
Preventive (Annual Physicals, Well Care Exams)	100% covered	Not Covered
Physician Visits	$15/visit	Not Covered
Lab and X-Ray	$10/visit 20% for complex imaging	Not Covered
Emergency Room²	$100/visit	Not Covered
Ambulance	20%	Not Covered
Hospitalization	10%	Not Covered
Chiropractic	$20/visit Up to a combined 30 visits/year with acupuncture	Not Covered
Acupuncture	$20/visit Up to a combined 30 visits/year with chiropractic	Not Covered
Massage	Not Covered	Not Covered
Speech Therapy²	$15/visit Short-term therapy only	Not Covered
Infertility/Fertility Preservation	^$15/visit 20% IVF³ (1 cycle/lifetime)	Not Covered

¹ OOP maximum includes Prescription Rx.
² Available to those with conditions of medical necessity.
³ IVF is in-vitro fertilization.

Employee Contributions for 2023 Per Paycheck¹

Plan	Employee Only	Employee + Spouse/Domestic Partner	Employee + Child(ren)	Employee + Family
Kaiser HMO HI	$96.67	$193.21	$173.89	$289.81

¹ Per paycheck contributions are 24 times per year. Contributions are pre-tax (except for Domestic Partner coverage).

Dependent Eligibility

Your spouse or domestic partner. Please note: after-tax contributions and imputed income may apply when covering a domestic partner. See the Domestic Partner Imputed Income Rate Table for details.
Your child(ren), your spouse’s / domestic partner’s child(ren), and the minor(s) you have legal guardianship of are eligible for medical coverage until age 26, regardless of marital or student status.

For more details see the Kaiser HI Summary of Benefits and Coverage (SBC).

Contact Us

Contact HR Source [VMware network access required]
ASK HR [VMware network access required]
Phone: 1-888-869-2738

Kaiser
Phone: 1-800-464-4000
Visit website

Included Health

Formerly Grand Rounds
Included Health is your personal healthcare assistant. Get an expert second opinion at no cost to you. You must be enrolled in a VMware medical plan to use Included Health services. For more information call 1-855-394-1635 or visit includedhealth.com/vmware.