Kaiser Health Maintenance Organization (HMO) Medical Plan

The Kaiser HMO Medical Plan is available in California locations based on home zip code. While neither a Health Savings nor Health Reimbursement Account is available with this option, you can elect to participate in the Healthcare Flexible Spending Account (HCFSA), which you can use to pay for healthcare expenses through before-tax payroll deductions.

How the Plan Works

You pay a set fee (called a copay) when you visit the doctor, urgent care or the emergency room.
These copays count toward your yearly limit on how much you’ll spend.
There’s no deductible, so you don’t have to pay a big amount before the plan starts contributing.
If you have a real emergency and need care outside the Kaiser network, the plan will still help—as long as you let them know as soon as you can.
Your out-of-pocket max is $1,500 for individual coverage, or $3,000 if you’re covering family. Once you hit the out-of-pocket max, the plan pays 100% of eligible costs for the rest of the year.
Annual checkups and recommended screenings are covered at no cost when you stay in-network.

What doctors can I use?

With an HMO plan, you must stay in-network for coverage.

You’ll need to choose a primary care provider (PCP) from the HMO network to manage your care. If you need to see a specialist, your PCP will give you a referral. Without a referral or if you go outside the network, the plan won’t cover the cost.

Kaiser Medical Plan at-a-glance

Only in-network care is covered under an HMO. Below is a quick look at coverage under this option. For additional detail, go to mySHSbenefits.com.

Plan provision	In-network
Annual deductible	No deductible for in-network care
Preventive care	100% covered for most services
Office visits	You pay a $25 copayment
Specialist office visits	You pay a $45 copayment
Out-of-pocket maximum Includes medical and prescription drug	$1,500 per individual; limited to $3,000 per family

Other Coverage Highlights

Kaiser is changing the way it covers weight-loss medications. Effective January 1, 2025 Glucagon-like peptide 1 (GLP-1) drugs will only be covered under the following conditions:

Weight loss medications will remain covered when prescribed for diabetes and obesity with comorbidities (example: BMI over 30 and hypertension).
These medications will also be covered for morbid obesity (defined as BMI over 40), as required by state mandate.
GLP-1s will be excluded if prescribed solely for weight loss, without the comorbidities described in the two previous bullets.