The HMO with HMO Flex gives you more choices. You can continue to see your favorite primary care provider even if they are a non-Kaiser Permanente provider while still getting all the benefits of Kaiser Permanente’s integrated HMO.
Kaiser Permanente HMO:
Fully coordinated, high-quality care, generally the lowest cost of the two options.
- Choose from Kaiser Permanente Hawaii physicians at any one of our 22 facilities on Oahu, Maui, and Hawaii Island, and Kauai, and Kaiser Permanente contracted physicians on Kauai, Lanai, and Molokai.
- A primary care physician coordinates care. When specialty care is needed, they will find the specialist right for the member and coordinate the referral.
- Kaiser Permanente Plan Providers are connected to an electronic health record, so they’re up-to-date on members care.
- Generally lowest out-of-pocket costs compared to non-Kaiser Permanente providers and facilities.
- Most facilities offer many services conveniently under one roof, including pharmacy, imaging, lab, primary care physicians, and specialists.
- No claims paperwork is required.
Keep seeing your favorite non-Kaiser Permanente primary care provider:
- You can work directly with any licensed non-Kaiser Permanente primary care provider’s office statewide and on the U.S. mainland.*
- If you have a primary care provider you love, you don’t have to switch. Your visits will still be covered, as long as you don’t exceed the annual visit limit.
You can use your visits for these types of items/services under the HMO Flex rider benefit:
- You have 10 office visits with non-Kaiser Permanente providers for routine primary care**, including Affordable Care Act (ACA) covered immunizations and contraceptives.
- You have 10 combined diagnostic lab tests and X-rays (each test or X-ray counts separately toward your service limits).
- You have 10 prescriptions you can fill at a pharmacy outside of Kaiser Permanente pharmacies.
What’s the cost?
- Your cost share (copayment or coinsurance) will generally be higher if you choose to go out-of-network.
- Your costs under the out-of-network benefit are not subject to your deductible (if applicable), and they do not apply to your out-of-pocket maximum for the year.
What’s not covered out-of-network
- Office visits that are not from family practitioners, general practitioners, internists, pediatricians, obstetricians, gynecologists or behavioral health providers
- Inpatient services
- Outpatient surgery
- Chiropractic services
- Dental
- Physical therapy, occupational therapy and speech language pathology
- See your Evidence of Coverage (EOC) for details on other excluded benefits
- Services not covered under your base medical plan will not be covered under the out-of-network benefit
- To find out more about what is covered under the out-of-network benefit, refer to your Evidence of Coverage (EOC)
- Contact the human resources/benefits officer where you work
- Refer to your ID card or call Member Services, Monday through Friday, 8 a.m. to 5 p.m., Saturday, 8 a.m. to 12 p.m. HST at1-800-966-5955 (TTY 711)
*If you receive care or services within another Kaiser Permanente service area, our Visiting Member policy applies. Visit kp.org/travel and see our Visiting Member brochure (“Getting care in Kaiser Permanente service areas”) for details.
**Primary care is limited to services provided by the following types of physicians: family practice, general practice, internal medicine, pediatrics, obstetrics/gynecology, and behavioral health (mental health and chemical dependency).
- Keep your doctor. The out-of-network benefit allows you to keep your favorite non-Kaiser Permanente primary care provider while still getting all the great benefits of Kaiser Permanente.
- Pharmacy services. Prescriptions from Kaiser Permanente providers are covered at all Kaiser Permanente pharmacies. You also have the option of filling up to 10 prescriptions at non-Kaiser Permanente pharmacies when the prescription is written during a covered visit by a non-Kaiser Permanente primary care* provider.
*Primary care is limited to services provided by the following types of physicians: family practice, general practice, internal medicine, pediatrics, obstetrics/gynecology, and behavioral health (mental health and chemical dependence).
Check here for more about pharmacy services, finding doctors and facilities, and the benefits of HMO with HMO Flex.
Is HMO with HMO Flex right for you?
Here are some examples of how people use the HMO Flex rider benefit to get the care they want:
For employers, these plans are a great all-in-one solution:
- Give your valuable employees expanded choice in their providers and allow them to determine and manage their health care costs.
- Having more options gives your valued employees what they need to be healthier and more productive every day.
- The versatility and benefits of HMO with HMO Flex can help attract and retain employees.
How HMO with HMO Flex works for your company and employees.
With HMO with HMO Flex, you can offer your participating employees options when they receive care:
- Kaiser Permanente HMO: Members can receive in-network care from Kaiser Permanente Hawaii physicians at any one of our 22 facilities on Oahu, Maui, and Hawaii Island, and Kauai, and Kaiser Permanente contracted physicians on Kauai, Lanai, and Molokai through Kaiser Permanente’s high quality integrated healthcare delivery system. The Kaiser Permanente HMO provides the most coordinated care with the lowest out-of-pocket costs for most services. Preventive care is at no cost when you see a Kaiser Permanente provider. Plans also include pharmacy services, worldwide coverage, and customized case management services for serious, complicated, or high-cost illnesses.
- HMO Flex Rider: Members can receive services from any licensed primary care provider or facility they choose outside those included in the Kaiser Permanente HMO. Members generally pay higher cost shares when receiving services from non-Kaiser Permanente providers. So out-of-pocket costs are generally the highest with this option.
- Learn more about what’s included with HMO with HMO Flex and how it works.
Employers’ frequently asked questions
How do the annual visit and service limits work each year?
Your HMO Flex rider includes a limited number of office visits, outpatient services, and prescriptions from non-Kaiser Permanente providers and pharmacies each year. Each of the covered services will count as a separate HMO Flex rider benefit and will be applied toward it’s respective benefit limit.
Do my costs for non-Kaiser Permanente provider services under the HMO Flex rider accrue toward my deductible (if applicable) and out-of-pocket maximum?
Cost shares paid by you for services received under this HMO Flex rider will not be applied toward your deductible (if applicable) and/or annual copayment maximum. Depending on your traditional plan benefits, your costs under the Plus Benefit may apply to your deductible or out-of-pocket maximum for the year. Please refer to your Evidence of Coverage for details.
Learn more about what’s included with HMO with HMO Flex and how it works.
Do I need to submit claims?
You may be asked to pay the full Applicable Charges at the time of the visit. You will need to submit a claim form for reimbursement. Kaiser Permanente will reimburse you for the full Applicable Charges, less the Cost Shares specified in this HMO Flex rider.
Learn more about claims.
How are new members onboarded?
Onboarding includes a welcome call, and a help line for any questions, from accessing care to transferring prescriptions.
Who do we contact for product pricing or to purchase HMO with HMO Flex?
Please contact a member of your Kaiser Permanente’s sales team for any questions about plans and rates, enrollment materials, and Summary of Benefits. If you do not have a sales executive already dedicated to your account, please call (808) 432-5919 or email HI-Sales@kp.org, or contact Kaiser Permanente at any time through our Business Plans contact page.