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MultiEmployer
BenefitTabs™ for Health and Welfare - Kaiser HMO
Annual Deductibles
Individual
None
Family
Annual Out of Pocket Maximums
Pre-Existing Condition Limitation
Benefit Maximums
Lifetime
$1,000,000/person
Chiropractic/Year
60 consecutive days/incident
Skilled Nursing Facility/Year
60 consecutive days
Wellness/Year
One exam/year
Rehabilitation Therapy[Physical, Speech or Occupational]/Year
Outpatient Services (other than Family Planning and Mental Health/Substance Abuse Treatment)
Office Visits
$15 copayment/visit
Physical Exams [Wellness]
Well Child Care and Immunization
Surgical Facility
$75 copayment/visit
Lab and X-ray
No copayment
Inpatient Services
Hospitilization
$250 copayment/admission
Surgeon's Fees
Emergency Room Care [waived if admitted]
$50 copayment/visit
Durable Medical Equipment
Skilled Nursing Facility
$250 copayment
Family Planning
Prenatal Office Visits
$15 copayment/initial visit only
Delivery
Vasectomy/Tubal Ligation
$250 copayment/admission if hospitalized; $75 if outpatient
Infertility Office Visits
$20 copayment/visit
Prescription Drugs
Mental Health and Substance Abuse Treatment Annual Deductibles
Annual Out-Of-Pocket Maximum
Benefit Maximums, Mental Health
Inpatient Treatment
30 days/year
Benefit Maximums, Substance Abuse
Annual
Mental Health Treatment
$50 copayment/day
Outpatient Treatment(up to 30 visits/year)
$15/visit (visits 1-20)$25/visit (visits 21-30)
Substance Abuse Treatment
Outpatient Treatment
$15/visit (visits 1-20)$25/visit (visits 21-40)$30/visit (visits 41-60)up to 60 visits/year
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