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Benefits Unit
Kaiser Permanente Hospital Services DHMO
Kaiser Permanente's microsite for County of Sonoma employees
The Hospital Services DHMO plan provides a 17% savings compared to the current Kaiser Permanente $10 Copay Plan.
- Most doctor office visits, radiology services, lab tests, and prescriptions are available for a copay or coinsurance amount, even before you have reached the calendar year deductible.
- Most preventative services, such as well baby/child visits (up to 23 months), immunizations, routine physicals, mammograms, and routine preventative screenings are covered at no cost and are not subject to the calendar year deductible.
- However, if you have services that are subject to the deductible, such as hospitalizations and in- and out-patient surgeries, you will be required to meet the calendar year deductible before plan benefits will be paid.
- This plan has a calendar year out-of-pocket maximum, capping the cost paid by the member.
- The out-of-pocket maximum includes the calendar year deductible, copayments, and coinsurance.
Employees who have an HRA (Health Reimbursement Arrangement) or FSA (Flexible Spending Account) may submit Kaiser out-of-pocket expenses for reimbursement.
Benefit Charts
Employees and Retirees
Medical Plan Summary
Office Visits and Professional Services
Surgical and Hospital Services
Prescription Drugs
Premium Rates
For Employees
Employee Semi Monthly Medical Plan Premiums
Extra-Help Semi Monthly Medical Plan Premiums
For Retirees
Medicare Monthly Medical Plan Premiums
Non-Medicare Monthly Medical Plan Premiums
Medical Plan Summary
| Plan Information | Kaiser Permanente Hospital Services DHMO |
|---|---|
| Calendar Year Deductible | $1,000 Self-Only Enrollment
|
| Coinsurance | Varies - See Kaiser’s Evidence of Coverage |
| Calendar Year Out of Pocket Maximum
(Including Deductibles, Co-pays, and Coinsurance) | $3,000 Self-Only Enrollment
|
| Lifetime Maximum | None |
| Dependent Children Eligibility | Any Dependent child under age 26 Disabled: No age limit |
Office Visits and Professional Services
| Service | Kaiser Permanente Hospital DHMO |
|---|---|
| Physician and Specialist Office Visits | $20 co-pay, no deductible |
| Preventive Care Adult Routine Care | No Charge, no deductible |
| Preventive Care Adult Routine Care OB/GYN | No Charge, no deductible |
| Diagnostic Lab and X-Ray | $10 per encounter, no deductible |
| Physical Therapy (Medically necessary treatment only) | $20 co-pay, no deductible |
| Chiropractic | Discounted rates through Kaiser Choose Healthy |
| Mental Health & Substance Abuse
(Outpatient) | Individual Therapy: $20 co-pay, no deductible
Group Therapy: $10 co-pay, no deductible |
Surgical and Hospital Services
| Service | Kaiser Permanente Hospital Services DHMO |
|---|---|
| Inpatient Hospital and Physician Services | 20% Coinsurance after deductible |
| Outpatient Surgery | 20% Coinsurance after deductible |
| Maternity | 20% Coinsurance after deductible |
| Emergency Room | 20% Coinsurance after deductible |
| Ambulance | $150 per trip, no deductible |
| Mental Health & Substance Abuse (Inpatient) | 20% Coinsurance after deductible |
| Skilled Nursing Facility | 20% Coinsurance, no deductible
Up to 100 days per benefit |
| Home Health | No Charge (deductible doesn't apply)
100 days per year |
Prescription Drugs
| Service | Kaiser Permanente Hospital Services DHMO |
|---|---|
| Generic or Tier 1 | $10 co-pay 30 day supply, no deductible |
| Formulary Brand or Tier 2 | $30 co-pay 30 day supply, no deductible |
| Mail Order Benefit Generic or Tier 1 | $20 co-pay 100 day supply, no deductible |
| Mail Order Benefit Formulary Brand or Tier 2 | $60 co-pay 100 day supply, no deductible |
| Mandatory Mail Order | No |
| Mandatory Generic Program | Not available |