Kaiser Foundation Health Plan of Washington Options, Inc. · BHT Industry Health Trust
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All supported filed details, including known conditions and limits. This is not the entire insurance contract. Unknown does not mean $0 or not covered.
| Benefit | PPO HSA 4500 |
|---|---|
Medical deductible | Source answer: Preferred provider: $4,500 Individual $7,350 Family Out-of-network provider: $9,000 Individual / $14,700 Family Benefit details: / Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the policy, the overall family deductible must be met before the plan begins to pay. Benefit details: Summary (Preferred Provider Network): Individual deductible: $4,500 per calendar year Family deductible: $7,350 per calendar year Until the total family annual deductible is met, benefits will not be provided for any family member Summary Out-of-Network: Individual deductible: $9,000 per calendar year Family deductible: $14,700 per calendar year Until the total family annual deductible is met, benefits will not be provided for any family member |
| Benefit | PPO HSA 4500 |
|---|---|
Are there other deductibles for specific services? | Source answer: No. Benefit details: You don’t have to meet deductibles for specific services. |
Outpatient services (Office visits) | Preferred Provider Network: No copay, deductible and coinsurance apply Summary Out-of-Network: No copay, deductible and coinsurance apply |
Diabetic supplies | Preferred Provider Network: Insulin, needles, syringes and lancets-see Prescription drugs. External insulin pumps, blood glucose monitors, testing reagents and supplies-see Devices, equipment and supplies. When Devices, equipment and supplies or Prescription drugs are covered and have benefit limits, diabetic supplies are not subject to these limits. Summary Out-of-Network: Insulin, needles, syringes and lancets-see Prescription drugs. External insulin pumps, blood glucose monitors, testing reagents and supplies-see Devices, equipment and supplies. When Devices, equipment and supplies or Prescription drugs are covered and have benefit limits, diabetic supplies are not subject to these limits. |
| Benefit | PPO HSA 4500 |
|---|---|
Maximum Out of Pocket for Medical and Drug Benefits (Total) | Source answer: Preferred provider: $6,750 Individual $7,900 Family Out-of-network provider: No limit Benefit details: / The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, the overall family out-of-pocket limit must be met. Benefit details: Summary (Preferred Provider Network): Individual out-of-pocket limit: $6,750 Family out-of-pocket limit: $7,900 Out-of-pocket expenses for the following covered services are included in the out-of-pocket limit: All cost shares for covered services If enrolled on the family plan you must meet the family out- of-pocket maximum Summary Out-of-Network: Individual out-of-pocket limit: No limit Family out-of-pocket limit: No limit Out-of-pocket expenses for the following covered services are included in the out-of-pocket limit: All cost shares for covered services If enrolled on the family plan you must meet the family out- of-pocket maximum |
Costs excluded from the out-of-pocket limit | Source answer: Premiums, balance-billing charges, care this plan doesn’t cover, and indicated in chart starting on page 2. Benefit details: health services Even though you pay these expenses, they don’t count toward the out-of-pocket limit. |
| Benefit | PPO HSA 4500 |
|---|---|
Primary Care Visit to Treat an Injury or Illness | In-network: 30% coinsurance Out-of-network: 50% coinsurance |
Specialist Visit | In-network: 30% coinsurance Out-of-network: 50% coinsurance |
Preventive Care/Screening/Immunization | In-network: No charge, deductible does not apply. Benefit details: You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Benefit details: Summary (Preferred Provider Network): Covered in full Women's contraception is covered as preventive, and Men's contraception is covered in full after annual deductible has been satisfied Out-of-network: 50% coinsurance Summary Out-of-Network: Deductible and coinsurance apply Women's preventive care services (including contraceptive drugs and devices and sterilization) are subject to the applicable Preventive Care cost share and benefit maximums. Routine mammograms: Deductible and coinsurance apply |
| Benefit | PPO HSA 4500 |
|---|---|
Diagnostic Test (X-Ray and Blood Work) | In-network: 30% coinsurance Benefit details: Summary (Preferred Provider Network): Inpatient: Covered under Hospital services Outpatient: Deductible and coinsurance apply High end radiology imaging services such as CT, MRI and PET must be determined Medically Necessary and require prior authorization except when associated with Emergency care or inpatient services. Out-of-network: 50% coinsurance Summary Out-of-Network: Inpatient: Covered under Hospital services Outpatient: Deductible and coinsurance apply High end radiology imaging services such as CT, MRI and PET must be determined Medically Necessary and require prior authorization except when associated with Emergency care or inpatient services. |
Imaging (CT/PET Scans, MRIs) | In-network: 30% coinsurance Benefit details: Preauthorization required Out-of-network: 50% coinsurance |
| Benefit | PPO HSA 4500 |
|---|---|
Generic Drugs | In-network: 30% or (20% enhanced) coinsurance (retail); 2x enhanced retail cost share (mail order) / prescription Benefit details: Up to a 30-day supply (retail); up to a 90-day supply (mail order). No charge for contraceptives. Subject to formulary guidelines. Out-of-network: Not covered |
Preferred Brand Drugs | In-network: 30% or (20% enhanced) coinsurance (retail); 2x enhanced retail cost share (mail order) / prescription Benefit details: Up to a 30-day supply (retail); up to a 90-day supply (mail order). Subject to formulary guidelines. Out-of-network: Not covered |
Non-Preferred Brand Drugs | In-network: 30% or (20% enhanced) coinsurance (retail); 2x enhanced retail cost share (mail order) / prescription Benefit details: Up to a 30-day supply (retail); up to a 90-day supply (mail order). Subject to formulary guidelines . Out-of-network: Not covered |
Specialty Drugs | In-network: Applicable Preferred generic, Preferred brand or Non-Preferred cost shares apply Benefit details: Up to a 30-day supply (retail). Subject to formulary guidelines, when approved through the exception process. Out-of-network: Not covered |
Prescription drugs (some injectable drugs may be covered under Outpatient services) | Preferred Provider Network: Preferred generic/preferred brand/non-preferred 30% or (20% enhanced) Plan Coinsurance up to a 30 day supply; Deductible applies. Certain preventive medications are covered in full (at a PPN pharmacy, 1st fill only, then covered at the PPN cost shares) Summary Out-of-Network: Preferred generic/preferred brand/non-preferred Not covered |
Prescription mail order | Preferred Provider Network: 2x the enhanced benefit prescription drug cost share up to a 90 day supply Summary Out-of-Network: Not covered |
| Benefit | PPO HSA 4500 |
|---|---|
Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | In-network: 30% coinsurance Out-of-network: 50% coinsurance |
Outpatient Surgery Physician/Surgical Services | In-network: 30% coinsurance Out-of-network: 50% coinsurance |
Inpatient Hospital Services (e.g., Hospital Stay) | In-network: 30% coinsurance Benefit details: You must notify Kaiser Permanente of admission or will not be covered. Out-of-network: 50% coinsurance |
Inpatient Physician and Surgical Services | In-network: 30% coinsurance Benefit details: You must notify Kaiser Permanente of admission or will not be covered. Out-of-network: 50% coinsurance |
Hospital services | Preferred Provider Network: Inpatient services: Deductible and coinsurance apply Outpatient surgery: No copay, deductible and coinsurance apply Summary Out-of-Network: Inpatient services: Deductible and coinsurance apply Outpatient surgery: No copay, deductible and coinsurance apply |
Organ transplants | Preferred Provider Network: Unlimited, no waiting period Inpatient: Deductible and coinsurance apply Outpatient: No copay, deductible and coinsurance apply Summary Out-of-Network: Not covered |
Cosmetic SurgeryNotes & sourceListed in the source exclusion summary. Check its exceptions and the issued contract for the exact terms. | Source statement: Cosmetic Surgery is listed in the source exclusions; review the qualifications. Source exclusion context: • Bariatric surgery • Children’s glasses • Cosmetic surgery • Dental care (Adult and child) • Infertility treatment • Long-term care • Non-emergency care when traveling outside the U.S. • Private-duty nursing • Routine foot care • Weight loss programs |
| Benefit | PPO HSA 4500 |
|---|---|
Emergency Room Services | In-network: 30% coinsurance Benefit details: You must notify Kaiser Permanente within 24 hours if admitted to an out-of-network provider; limited to initial emergency only. Benefit details: Summary (Preferred Provider Network): $0 copay Deductible and coinsurance apply Out-of-network: 30% coinsurance Summary Out-of-Network: $0 copay Preferred provider deductible and coinsurance apply |
Emergency Transportation/Ambulance | In-network: 30% coinsurance Benefit details: Summary (Preferred Provider Network): Deductible and coinsurance apply Out-of-network: 30% coinsurance Summary Out-of-Network: Preferred provider deductible and coinsurance apply |
Urgent Care Centers or Facilities | In-network: 30% coinsurance Out-of-network: 50% coinsurance |
| Benefit | PPO HSA 4500 |
|---|---|
Mental health and substance use outpatient services (SBC) | In-network: 30% coinsurance Out-of-network: 50% coinsurance |
Mental health and substance use inpatient services (SBC) | In-network: 30% coinsurance Benefit details: You must notify Kaiser Permanente of admission or will not be covered. Out-of-network: 50% coinsurance |
Substance Abuse Disorder Inpatient Services | Preferred Provider Network: Deductible and coinsurance apply Summary Out-of-Network: Deductible and coinsurance apply |
Substance Abuse Disorder Outpatient Services | Preferred Provider Network: No copay, deductible and coinsurance apply Summary Out-of-Network: No copay, deductible and coinsurance apply |
Mental/Behavioral Health Inpatient Services | Preferred Provider Network: Deductible and coinsurance apply Summary Out-of-Network: Deductible and coinsurance apply |
Mental/Behavioral Health Outpatient Services | Preferred Provider Network: No copay, deductible and coinsurance apply Summary Out-of-Network: No copay, deductible and coinsurance apply |
| Benefit | PPO HSA 4500 |
|---|---|
Prenatal and Postnatal Care | In-network: 30% coinsurance Benefit details: Cost sharing does not apply for preventive services. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Out-of-network: 50% coinsurance |
Delivery and All Inpatient Services for Maternity Care (Professional) | In-network: 30% coinsurance Benefit details: You must notify Kaiser Permanente within 24 hours of admission, or as soon thereafter as medically possible. Newborn services cost shares are separate from that of the mother. Out-of-network: 50% coinsurance |
Delivery and All Inpatient Services for Maternity Care | In-network: 30% coinsurance Benefit details: You must notify Kaiser Permanente within 24 hours of admission, or as soon thereafter as medically possible. Newborn services cost shares are separate from that of the mother. Out-of-network: 50% coinsurance |
Maternity services | Preferred Provider Network: Inpatient: Deductible and coinsurance apply Outpatient: No copay, deductible and coinsurance apply Summary Out-of-Network: Inpatient: Deductible and coinsurance apply Outpatient: No copay, deductible and coinsurance apply |
Newborn Services | Preferred Provider Network: Initial hospital stay: See Hospital Services; Office visits: See Outpatient Services; Routine well care: See Preventive care. Any applicable cost share for newborn services is separate from that of the mother. Summary Out-of-Network: Initial hospital stay: See Hospital Services; Office visits: See Outpatient Services; Routine well care: See Preventive care. Any applicable cost share for newborn services is separate from that of the mother. |
| Benefit | PPO HSA 4500 |
|---|---|
Home Health Care Services | In-network: 30% coinsurance Benefit details: 130 visit limit / year. Limits combined with preferred and out-of-network provider networks. You must notify Kaiser Permanente or will not be covered. Benefit details: Summary (Preferred Provider Network): Covered at deductible and coinsurance up to 130 visits total per calendar year Out-of-network: 50% coinsurance Summary Out-of-Network: Visit limit shared with preferred provider network Deductible and coinsurance apply |
Rehabilitation Services | In-network: Outpatient: 30% coinsurance Inpatient: 30% coinsurance Benefit details: Combined with Habilitation services: Outpatient: 45 visit limit / year. Inpatient: 30- day limit / year, preauthorization required. Benefit details: Summary (Preferred Provider Network): Inpatient: 30 days per calendar year. Services with mental health diagnoses are covered with no limit. Deductible and coinsurance apply Outpatient: 45 visits per calendar year. Services with mental health diagnoses are covered with no limit. No copay, deductible and coinsurance apply Out-of-network: Outpatient: 50% coinsurance Inpatient: 50% coinsurance Summary Out-of-Network: Inpatient: Day limits shared with preferred provider network Deductible and coinsurance apply Outpatient: Visit limits shared with preferred provider network No copay, deductible and coinsurance apply |
Habilitation Services | In-network: Outpatient: 30% coinsurance Inpatient: 30% coinsurance Benefit details: Combined with Rehabilitation services: Outpatient: 45 visit limit / year. Inpatient: 30- day limit / year, preauthorization required. Out-of-network: Outpatient: 50% coinsurance Inpatient: 50% coinsurance |
Skilled Nursing Facility | In-network: 30% coinsurance Benefit details: 60-day limit / year. Limits are combined with preferred and out-of-network provider networks. You must notify Kaiser Permanente of admission or will not be covered. Benefit details: Summary (Preferred Provider Network): Up to 60 days per calendar year, deductible and coinsurance apply Out-of-network: 50% coinsurance Summary Out-of-Network: Day limits shared with preferred provider network, deductible and coinsurance apply |
Durable Medical Equipment | In-network: 30% coinsurance Benefit details: Subject to formulary guidelines. Preauthorization may be required Benefit details: Summary (Preferred Provider Network): Deductible and coinsurance apply Out-of-network: 50% coinsurance Summary Out-of-Network: Deductible and coinsurance apply |
Hospice Services | In-network: 30% coinsurance Benefit details: You must notify Kaiser Permanente of admission or will not be covered. Benefit details: Summary (Preferred Provider Network): Deductible and coinsurance apply Out-of-network: 50% coinsurance Summary Out-of-Network: Deductible and coinsurance apply |
Massage Therapy | Preferred Provider Network: See Rehabilitation services Benefit details: Referenced summary Rehabilitation services: Inpatient: 30 days per calendar year. Services with mental health diagnoses are covered with no limit. Deductible and coinsurance apply Outpatient: 45 visits per calendar year. Services with mental health diagnoses are covered with no limit. No copay, deductible and coinsurance apply Summary Out-of-Network: See Rehabilitation services |
| Benefit | PPO HSA 4500 |
|---|---|
Routine Eye Exam for Children | In-network: No charge for refractive exam, deductible does not apply. Benefit details: Limited to 1 exam / 12 months Out-of-network: No charge for refractive exam, deductible does not apply. |
Eye Glasses for Children | In-network: Not covered Out-of-network: Not covered |
Dental Check-Up for Children | In-network: Not covered Out-of-network: Not covered |
Routine vision care (1 visit every 12 months) | Preferred Provider Network: Covered in full Summary Out-of-Network: Covered in full |
Optical hardware Lenses, including contact lenses and frames | Preferred Provider Network: Not covered Summary Out-of-Network: Not covered |
| Benefit | PPO HSA 4500 |
|---|---|
Specialist referrals | Source answer: No. Benefit details: You can see the specialist you choose without a referral. |
Provider network terms | Source answer: Yes. See www.kp.org or call 1-888-901- 4636 (TTY: 711) for a list of network providers. Benefit details: This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of- network provider for some services (such as lab work). Check with your provider before you get services. |
International coverage | Benefit details: Non-emergency care when traveling outside the U.S. Listed under services the plan generally does not cover; see the EOC for emergency and other travel terms. |
Plan network family (summary) | Access PPO Benefit details: Health Plan label from the exact January 2027 summary. EOC booklets are marked tbd; confirm the detailed provider network and current participation. |
| Benefit | PPO HSA 4500 |
|---|---|
Pre-existing condition (PEC) waiting period | Preferred Provider Network: No PEC Summary Out-of-Network: Same as preferred provider network |
Lifetime maximum | Preferred Provider Network: Unlimited Summary Out-of-Network: Shared with preferred provider maximum |
Plan exclusions | Benefit details: • Bariatric surgery • Children’s glasses • Cosmetic surgery • Dental care (Adult and child) • Infertility treatment • Long-term care • Non-emergency care when traveling outside the U.S. • Private-duty nursing • Routine foot care • Weight loss programs |
Other covered services | Benefit details: Limitations may apply; this is not a complete list. See the plan document. • Acupuncture (12 visit limit / year) • Chiropractic care (15 visit limit / year) • Hearing aids (1 aid / ear / 36 months) • Routine eye care (Adult) |
| Benefit | PPO HSA 4500 |
|---|---|
Having a baby example | Deductibles: $4,500 Copayments: $0 Coinsurance: $2,100 Limits or exclusions: $20 Benefit details: Standardized self-only illustration, not a cost estimator. Actual care and costs differ. |
Managing diabetes example | Deductibles: $4,500 Copayments: $0 Coinsurance: $100 Limits or exclusions: $0 Benefit details: Standardized self-only illustration, not a cost estimator. Actual care and costs differ. |
Simple fracture example | Deductibles: $2,800 Copayments: $0 Coinsurance: $0 Limits or exclusions: $0 Benefit details: Standardized self-only illustration, not a cost estimator. Actual care and costs differ. |
| Benefit | PPO HSA 4500 |
|---|---|
Sterilization (vasectomy, tubal ligation) | Preferred Provider Network: Women's sterilization is covered as preventive, and Men's sterilization is covered in full after the annual deductible has been satisfied. Summary Out-of-Network: Inpatient: Deductible and coinsurance apply Outpatient: No copay, deductible and coinsurance apply Outpatient Surgery: See Hospital services; Outpatient surgery section Women's sterilization procedures are covered subject to the applicable Preventive Care cost share and benefit maximums. |
Acupuncture | Preferred Provider Network: Covered up to 12 visits per calendar year No copay, deductible and coinsurance apply Summary Out-of-Network: Visit limits shared with preferred provider network |
Routine Hearing Exam (Adult) | Preferred Provider Network: No copay, deductible and coinsurance apply Summary Out-of-Network: No copay, deductible and coinsurance apply |
Hearing Aids | Preferred Provider Network: 1 aid per ear every 36 months; Deductible and coinsurance apply Summary Out-of-Network: Not covered |
Infertility Treatment | Preferred Provider Network: Not covered Summary Out-of-Network: Not covered |
Chiropractic Care | Preferred Provider Network: Covered up to 15 visits per calendar year without prior authorization; additional visits when approved by the plan No copay, deductible and coinsurance apply Summary Out-of-Network: Visit limits shared with preferred provider network No copay, deductible and coinsurance apply |
Naturopathy | Preferred Provider Network: No copay, deductible and coinsurance apply Summary Out-of-Network: No copay, deductible and coinsurance apply |
Bariatric Surgery | Preferred Provider Network: Not covered Summary Out-of-Network: Not covered |
Temporomandibular joint (TMJ) treatment | Preferred Provider Network: Inpatient: Deductible and coinsurance apply Outpatient: No copay, deductible and coinsurance apply Summary Out-of-Network: Inpatient: Deductible and coinsurance apply Outpatient: No copay, deductible and coinsurance apply |
Tobacco Cessation Counseling | Preferred Provider Network: Quit for Life Program - covered in full Summary Out-of-Network: Applicable cost shares apply |
Routine Foot CareNotes & sourceListed in the source exclusion summary. Check its exceptions and the issued contract for the exact terms. | Source statement: Routine Foot Care is listed in the source exclusions; review the qualifications. Source exclusion context: • Bariatric surgery • Children’s glasses • Cosmetic surgery • Dental care (Adult and child) • Infertility treatment • Long-term care • Non-emergency care when traveling outside the U.S. • Private-duty nursing • Routine foot care • Weight loss programs |
| Benefit | PPO HSA 4500 |
|---|---|
Virtual care (summary) | Preferred Provider Network: Deductible applies Summary Out-of-Network: Telemedicine: Applicable cost shares apply Telephone Services and Online (E-Visits): Not covered |
Telemedicine with Traditional Providers | Preferred Provider Network: Deductible applies Benefit details: Virtual Care Including Telemedicine, Telephone Services and Online (E-Visits). Exact 2027 summary wording; EOC booklets are marked tbd. Confirm the issued contract and deductible conditions. Out-of-Network: Telemedicine: Applicable cost shares apply Telephone Services and Online (E-Visits): Not covered |
Virtual General Medical | Preferred Provider Network: Deductible applies Benefit details: Virtual Care Including Telemedicine, Telephone Services and Online (E-Visits). Exact 2027 summary wording; EOC booklets are marked tbd. Confirm the issued contract and deductible conditions. Out-of-Network: Telemedicine: Applicable cost shares apply Telephone Services and Online (E-Visits): Not covered |
| Benefit | PPO HSA 4500 |
|---|---|
IHT source ID | iht-2027-kaiser-phsa-4500 |
Plan name | PPO HSA 4500 |
Legal issuer | Kaiser Foundation Health Plan of Washington Options, Inc. |
Plan type | HDHP |
Effective date | 2027-01-01 |
Expiration date | 2027-12-31 |
BHT metal classificationNotes & sourceBHT plan-design similarity classification, not a carrier metal designation or actuarial-value calculation. Unknown is retained when reference evidence is insufficient or disagrees. | BHT classification: N/A (similar to Silver) |
| Benefit | PPO HSA 4500 |
|---|---|
HSA in source plan nameNotes & sourceWhether the IHT source plan name contains HSA, including PHSA or HHSA. | Yes |
HSA-compatible planNotes & sourceBHT IHT name rule: HSA anywhere (including PHSA/HHSA) means Yes; otherwise No. Personal contribution eligibility is separate. | Yes |
| Benefit | PPO HSA 4500 |
|---|---|
Are there services covered before you meet your deductible? | Source answer: Yes. Preventive care and services indicated in chart starting on page 2. Benefit details: This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive- care-benefits. |
Individual deductible carryover | Preferred Provider Network: 4th quarter carryover does not apply Summary Out-of-Network: 4th quarter carryover does not apply |
Plan coinsurance | Preferred Provider Network: Plan pays 70%, you pay 30% Summary Out-of-Network: Plan pays 50%, you pay 50% of the Allowed Amount. |
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2027 · IHT plan ID iht-2027-kaiser-phsa-4500
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