Insurance Coverage Mix Reimbursement Protection Concept

Headquartered in Oakland, California, Kaiser Permanente is one the largest not-for-profit health plans in the United States, serving over 8 million Californians. The Kaiser Foundation Health Plan, Inc. is a subsidiary of Kaiser Permanente and offers a variety of health insurance plans and policies for individuals, families, and employers all over America.

Offering HMO (health maintenance organization) plans, HSA (health savings account) plans, high-deductible and catastrophic minimum coverage plans, and participating in Medi-Cal, California’s version of Medicaid (low-cost or free health insurance coverage for eligible individuals and subsidized by state and federal funds), Kaiser Foundation insurance plans feature a lot of options and comprehensive coverage choices for its members.

In Orange County, Kaiser Permanente insurance plans for families and individuals include different levels of coverage, such as low monthly premium (the amount paid each month for coverage) and high-deductible (the amount that must be reached for coverage to begin), bronze-level plans, and higher monthly premium with lower deductible platinum-level plans. Coverage is different based on the specific policy a person has; however, in response to the Affordable Care Act (ACA), Kaiser Foundation health plans will cover drug addiction treatment services similar to the rate at which other medical and surgical services are covered.

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Kaiser Foundation Insurance Coverage Explained

Insurance Coverage Mix Reimbursement Protection Concept

Kaiser Permanente plans cover services at the best rates when individuals use a provider that is considered in-network. An in-network provider contracts directly with the insurance provider to offer discounted services. Some plans only cover in-network providers.

To use Kaiser Foundation insurance to pay for drug addiction treatment, individuals may need to obtain verification, or a preauthorization. Plans may not require a referral from a primary care provider (PCP) in order to see a specialist, but verification is needed to ensure that services are deemed medically necessary. Verification is done through Kaiser Permanente directly, usually by filling out a form or talking to a representative on the phone.

Covered addiction treatment services through Kaiser Permanente can include diagnostic evaluations, individual and group therapy sessions, outpatient treatment, counseling, crisis intervention and stabilization, medication evaluation and management, outpatient detoxification, partial hospitalization programs (PHPs), intensive outpatient programs (IOPs), inpatient treatment programs, and recovery services.

Inpatient and hospital alternative services may also require approval from a plan mental health or substance abuse physician, which means that a person will need to see an eligible physician approved by their specific plan prior to enrollment in a drug rehab program. Outpatient and emergency services often require a copay at each visit, which is set amount that a person will pay each time they go in.

Insurance plans generally have an out-of-pocket maximum amount each year, and after individuals reach this amount, the rest of the approved treatment service costs are paid in full by the insurance provider. Policyholders are responsible for any coinsurance costs, which is the amount not covered by the provider. A coinsurance of 20 percent means that the member will pay 20 percent for services while Kaiser Foundation insurance covers the other 80 percent, for instance.

Examples of Kaiser Permanente coverage offered to Orange County residents and the rate of coverage for substance abuse treatment services are outlined below:

  • Deductible Catastrophic plan: This is a minimum coverage plan with a high annual deductible and out-of-pocket costs. It is only open to those under 30 or people demonstrating hardship. The first three mental health and/or substance abuse treatment office visits are covered, and the rest will be covered after the deductible is met. Inpatient care is covered in full after the deductible is met.

  • Copayment Gold plan: This plan has no deductible amount to be reached first, and mental health visits cost $25 a visit. Inpatient mental health treatment is covered at 80 percent with the policyholder being responsible for the remaining 20 percent up to the low annual out-of-pocket maximum amount.

  • HSA Bronze plan: With higher annual deductibles for individuals and families, this plan covers mental health and substance abuse services at 60 percent after the deductible is met, meaning that the policyholder is responsible for the remaining 40 percent of the cost until the annual out-of-pocket maximum amount is met.

  • Deductible Silver plan: This plan has a low deductible amount per year, and once met, 80 percent of inpatient mental health services are covered. Mental health office visits are $35 a visit.

For more information on exactly what is covered, how much of the cost is offset, and how to use insurance to pay for drug addiction treatment services, individuals should contact the Kaiser Foundation directly. Substance abuse treatment providers can help with understanding and maximizing insurance benefits for treatment services, so ask a desired provider for help.