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 subject to co-pay Not Covered
Physician Visits $15/visit Not Covered
Lab and X-Ray $10/visit
20% coinsurance for complex imaging
Not Covered
Emergency Room2 $100/visit Not Covered
Ambulance 20% coinsurance 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 2019

Per Paycheck1

Plan Employee Only Employee + 
Spouse/Domestic Partner
Employee + Child(ren) Employee + Family
Kaiser HMO HI $65.43 $130.86 $117.77 $196.29

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), 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

HR Source
ASK HR [VMware network access required]
Phone: 1-888-VMWARE8, option ‘US Benefits’
Internal Phone: ext. 29200


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

Resources

Benefits Contact Quick Reference Guide


Domestic Partner Imputed Income Rate Table


Kaiser HMO HI Claim Form


Kaiser HMO HI Evidence of Coverage (EOC) 2018


Kaiser HMO HI Evidence of Coverage (EOC) 2019


Kaiser HMO HI Summary of Benefits 2019


Kaiser HMO HI Summary of Benefits and Coverage (SBC)
2018


Kaiser HMO HI Summary of Benefits and Coverage (SBC)
2019


Key Benefit Terms


Travel Outside Kaiser Areas


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