Medical
MRDA offers three medical plan options through Kaiser: a traditional PPO plan and two high-deductible health plans (HDHPs).
Before you enroll in medical coverage, take some time to fully understand how each plan works.
Helpful Kaiser Resources
BENEFIT PLAN COSTS
Listed below are the monthly costs for medical and dental insurance. MRDA will pay 100% of premiums for employees and 75% for their dependents. The amount you pay for coverage is deducted from your paycheck on a pre-tax basis, unless you request to pay your premiums through post-tax deductions.
MEDICAL INSURANCE—PPO
The table below summarizes the benefits of the PPO medical plan.
The coinsurance amounts listed reflect the amount you pay. Please refer to the official plan documents for additional information on coverage and exclusions.
(1) The PPO deductible and out-of-pocket (OOP) maximum are embedded. This means if you cover a member of your family, the individual deductible and out-of-pocket maximum apply to each covered member of the family. The total family deductible will not exceed $500 and the family OOP maximum will not exceed $8,000 (in-network). (2) Excepting video visits, which members pay 30% after deductible (plus any applicable balance billing).
MEDICAL INSURANCE—HSA
The table below summarizes the benefits of the HSA medical plan.
The coinsurance amounts listed reflect the amount you pay. Please refer to the official plan documents for additional information on coverage and exclusions.
(1) Embedded vs. non-embedded: The HSA deductible is non-embedded which means if you cover a member of your family, the entire family deductible must be met prior to the plan paying. The HSA out-of-pocket (OOP) maximum is embedded, which means if an individual meets the individual OOP maximum, the individual will receive 100% coverage for the remainder of the year. Once the family OOP maximum is met, everyone receives 100% coverage for the remainder of the year. (2) Virtual care is almost always cheaper than going in person, whether your deductible has been met or not. (3) Excepting video visits, which members pay 50% after deductible (plus any applicable balance billing). (4) Members only pay for two months of medication vs. three months.
MEDICAL INSURANCE—CA KAISER HMO HSA
The table below summarizes the benefits of the CA Kaiser HMO HSA plan.
The coinsurance amounts listed reflect the amount you pay. Please refer to the official plan documents for additional information on coverage and exclusions.
(1) The CA Kaiser HMO HSA deductible and out-of-pocket (OOP) maximum are embedded. This means if you cover a member of your family, the individual deductible ($2,800) and OOP maximum ($4,000) apply to each covered member of the family. The total family deductible will not exceed $4,000, and the family OOP maximum will not exceed $8,000 (in-network). (2) Virtual care is almost always cheaper than going in person, whether your deductible has been met or not.
NETWORK REMINDERS AND TIPS
Your network will depend on what plan you choose. Make sure to check if your provider is listed as in-network for your plan before you make an appointment.
PPO and HSA
CA Kaiser HMO HSA
Available network(s)
First Choice Health Network
fchn.com/providersearch
(Non-Kaiser Network Providers in WA, OR, MT, ID, AK)
First Health Network
myfirsthealth.com
(Non-Kaiser Network Providers in Other States, including CA)
Kaiser HMO Network
kp.org/doctors
(Kaiser Network Providers)
Kaiser HMO Network
kp.org/doctors
(Kaiser Network Providers)
Referral required to see a specialist
To see a Non-Kaiser Specialist: No
To see a Kaiser Specialist: Yes
Yes
PPO/HSA
When you see an in-network provider (under First Health, First Choice Health, or Kaiser HMO network), the provider’s bill is discounted, and both the plan and your share of the cost are paid based on the discounted rate. This saves you money and keeps the program costs down.
When you use an out-of-network provider, your benefits will be paid at a lower level based on the allowable charge for the service. Any excess between the billed charge and the plan’s allowable charge may be billed to you in addition to the higher coinsurance responsibility. This is commonly referred to as “balance billing.”
If your dependent(s) live in Washington, Alaska, Oregon, Idaho, or Montana (for example, if your child attends an out-of-state school), they can use the First Choice Health network. If they live in any other states, they can use the First Health network as well. You can also use these networks when you are traveling in the United States.
- When you want to see non-Kaiser providers: When you are asked what insurance you have, you should say “Kaiser”. Many non-Kaiser providers will say “we are not contracted with Kaiser”, then you will need to say it is covered by the “First Health” network which is printed on your ID card (or “First Choice Health” network when you are in WA, OR, MT, ID, AK). When your health care providers need to verify your enrollment, they should call Kaiser Provider Assistance Unit at 888-767-4670. Please write this number on your ID card for easy access.
- When you want to use a non-Kaiser pharmacy: When you are asked what insurance you have, you should say “Kaiser”. Many non-Kaiser providers or pharmacies will say “we are not contracted with Kaiser”, then you will need to say it is covered by the “OptumRx” network which is printed on your ID card. You may also need to provide the RxBIN and/or RxPCN numbers listed on your ID card. In order to make sure that your non-Kaiser pharmacy is contracted with “OptumRx”, first register yourself at optumrx.com/public/landing. Once you sign in, you can select “Pharmacy Locator” and search for a pharmacy.
- When you want to see Kaiser providers or use Kaiser pharmacies: Since these plans are based in Washington, your Kaiser ID card/number will not work for Kaiser providers and pharmacies outside of Washington state. Before you access care for the first time in another Kaiser service area (including California, Colorado, Georgia, Hawaii, Maryland, Oregon, Virginia, Washington state (Clark and Cowlitz counties), and Washington D.C.), call Kaiser Washington Member Services at 888-901-4636 to get a visiting member ID number for that region. Since there is no physical ID card for visiting member IDs, please save your ID number.
CA KAISER HMO HSA
When you select the CA Kaiser HMO HSA plan, you may only see providers in Kaiser facilities, except for emergency services.
- When you are traveling: Before you access care for the first time in another Kaiser service area (including Northern California, Colorado, Georgia, Hawaii, Maryland, Oregon, Virginia, Washington, and Washington D.C.), call the Away from Home Travel Line at 951-268-3900 to confirm the services that will be available in the area you are traveling to. You’ll receive a medical record number (MRN) or health record number (HRN) for the other Kaiser service area and information on making an appointment. If you are traveling outside of a Kaiser service area, the only access you will have will be for emergency services.
NEW KAISER MEMBERS
If you are new to the Kaiser family and on the PPO or HSA, visit healthy.kaiserpermanente.org/washington/new-members or call 888-844-4607 or 206-630-0029. For the CA Kaiser HMO HSA, visit healthy.kaiserpermanente.org/southern-california/new-members.
UNDERSTANDING THE MEDICAL PLANS
DIAGNOSTIC X-RAY AND LAB
For high-end radiology, please note that prior authorization is required for CT, MRI, MRA, PET, and Dexa scans. The doctor’s office is responsible for submitting this request for authorization before the procedure is performed. We recommend you call customer service to verify it has been approved.
URGENT CARE/EMERGENCY ROOM
It is highly recommended that, if possible and appropriate, you use urgent care offices when the needed care is not a true emergency. Seeking non-emergency services in an emergency room (ER) can easily cost you double or triple what an urgent care visit would cost.