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—KAISER HMO HSA
The table below summarizes the benefits of the 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 Kaiser HMO HSA deductible and out-of-pocket (OOP) maximum are non-embedded which means if you cover a member of your family, the entire family deductible must be met prior to the plan paying. 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.
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
Kaiser HMO HSA
Available network(s)
First Choice Health Network
fchn.com/providersearch/KFHPWAO
(Non-Kaiser Network Providers in WA, OR, MT, ID, AK)
First Health Network
myfirsthealth.com
(Non-Kaiser Network Providers in Other States)
Access PPO Network
kp.org/wa/directory
(Kaiser and Non-Kaiser Network Providers)
Kaiser Core Network
kp.org/wa/directory
(Kaiser Network Providers)
Primary care physician (PCP) designation required
To see a Non-Kaiser Provider: No
To see a Kaiser Provider: Yes
Yes
Referral required to see a specialist
No (both Kaiser and Non-Kaiser Specialists)
Yes
PPO/HSA
When you see an in-network provider (under Access PPO, First Choice Health, or First Health 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.
TIP: 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 “First Choice Health” network which is printed on your ID card (or “First Health” network when you are outside of WA, OR, MT, ID, AK).
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 Alaska, Oregon, Idaho, or Montana (for example, if your child attends an out-of-state school), they can use the First Choice Health network as well. If they live in any other states, they can use the First Health network. You can also use these networks when you are traveling in the United States.
WHEN YOU WANT TO USE A NON-KAISER PHARMACY (PPO AND HSA ONLY)
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”, visit kp.org/wa/optumrx-wa.
KAISER HMO HSA
When you select the Kaiser HMO HSA plan, you may only see providers in Kaiser facilities, except for emergency services.
IMPORTANT
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 Member Services at 888-901-4636 to get a visiting member ID number.
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 Member Services 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.
VISION
All three Kaiser plans (PPO, HSA, and Kaiser HMO HSA) include vision benefits (annual eye exam and hardware benefits). Most non-Kaiser providers (including Costco) will say they are not contracted with Kaiser or they don’t bill to Kaiser directly. Please pay up front and get reimbursed by completing the Kaiser Reimbursement Form.
KAISER VIRTUAL CARE
Help is available when you need it with virtual care options through Kaiser. Access care from the comfort of your home using your computer, tablet, or mobile device using one of the virtual care options below.
Visit healthy.kaiserpermanente.org/washington/get-care to utilize virtual care.
- Care Chat: Chat online with a Kaiser Permanente clinician to get immediate care, treatment, and prescriptions.
- E-visit: Get a personalized care plan or prescriptions for common health conditions — just by filling out a short questionnaire.
- Email: Message your Kaiser Permanente doctor’s office with non-urgent questions.
- Video visit (now): Talk to a clinician 24/7 for quality care when you need it — no appointment needed. There may be a wait time.
- Video visit (scheduled): Meet face-to-face with a clinician by video for the same high-quality care as an in-person visit.
- Phone visit (now): Talk to a clinician 24/7 for quality care when you need it — no appointment needed. There may be a wait time.
- Phone visit (scheduled): Schedule a time to talk with a primary care Kaiser Permanente doctor over the phone.
- Consulting nurse line (24/7): Talk with a licensed care clinician day or night for advice by phone or chat online.
KAISER ONLINE TOOLS
Once you have your member ID number, register online with Kaiser to take advantage of their online services. To register, go to kp.org/wa and enter the required information.
You’ll then have access to these secure online services for:
- Refill prescriptions
- Check your health coverage and benefit usage*
- Complete your Health Profile
- Easily search for doctors in your network
- Schedule some appointments with Kaiser providers
- View some lab results
- Email your Kaiser doctors
- Estimate procedure costs
- View your explanation of benefits (EOB) online
*You can see your own individual benefit usage information and the total of your family benefit usage information (including yourself). To inquire about individual limit tracking for your spouse and/or child(ren), call Member Services.
EXPLANATION OF BENEFITS (EOBS) FOR YOUR CHILD(REN)
EOBs are not available online for members under the age of 18. However, paper EOBs are automatically generated for claims processed with the below reasons and are mailed to your home address:
- Claims that are subject to deductible/coinsurance
- Denials for non-effective coverage
- Non-covered services
- Reprocessed claim (regardless of patient responsibility)
- Benefit for type of service has been exhausted
If your share of the cost for a service is $0 or if your only cost is a copay, paper EOBs are not automatically mailed. If you would like an EOB for one of these claims, you can contact Member Services to request that a paper copy be mailed. (If it is a claim for yourself, the EOB will also be available online through your Kaiser account.)
For teens (age 13–17): EOBs relating to Specially Protected Health Information (SPHI: information related to alcohol and/or drug abuse, mental health conditions, and reproductive care) will not automatically be mailed. Your teen may call Member Services to request a paper copy, but you cannot request one unless the teen has given written authorization to Kaiser to share such information with you. EOBs not related to SPHI will automatically be mailed to the teen’s address on file. You can also call Member Services to request a paper copy be mailed to you.
ACCESS TO YOUR CHILD(REN)’S MEDICAL RECORDS
After you register online with Kaiser, you can request access to your child’s online medical record if they get care at Kaiser Permanente medical offices in Washington. For more detailed information, visit healthy.kaiserpermanente.org/washington/support/parental-access.
If your child is 12 or younger (“Parental Access”): Except for EOBs and benefit usage, you will have access to the same tools and records as for yourself.
If your child is 13–17 (“Teen Proxy Access”): Washington State privacy laws make certain information confidential between teens and their health care providers. It also means some information can’t be automatically shared with parents and legal guardians. You will have access to some tools and records, but not all. Your teen will be able to create their own limited account where they can access some tools and records as well.