HMO Plans—offered to Platinum Plus Participants only
Two HMO medical plans are available to Platinum Plus Participants who live in the HMO’s service areas:
- The Kaiser Permanente HMO, or
- The Blue Cross HMO
Refer to your Plan A or Plan B Benefits Chart as well as to the separate brochures and the Evidence of Coverage provided by the HMO for information about covered services.
About the Plan’s Coverage
Start here to learn about the services covered by the HMOs, including preventive care, doctor’s visits, and hospital visits
An HMO is a medical plan with a network of providers who have agreed to provide their services at a contracted rate. To receive benefits, you must see a provider who is affiliated with your HMO’s network. Except in the case of eligible emergency care, services received from a non-HMO provider are not covered.
HMO covered services include:
-
- Preventive care—including physical exams, immunizations, lab tests, cancer screenings
- Doctor office visits
- Surgery
- Urgent and emergency care
- Hospital care
- Family planning
- Speech therapy
- Hearing aids
- Durable medical equipment and medical supplies
- And more…
It’s also important to note that HMO Participants get certain services from outside the HMO:
- Ancillary benefits: Some ancillary benefits are provided through the Fund. These benefits include the Fund’s prescription drug program, acupuncture, chiropractic, vision care program, and some injectable drug benefits.
- Dental and orthodontia benefits: Coverage is provided for dental and orthodontic care under separate programs administered by the Fund. Refer to the “Dental and Orthodontic Care” section for more information.
- Mental/behavioral health and substance abuse benefits: Coverage depends on the HMO you’re enrolled in, as follows:
- Anthem Blue Cross HMO—Mental/behavioral health and substance abuse benefits are provided through the Fund’s Employee Member Assistance Program (EMAP), which is administered by HMC HealthWorks® (HMC). If you or a family member needs mental/behavioral health or substance abuse treatment, you must call HMC at 800-461-9179 to receive benefits. Lab work authorized by the program administrator will be provided through the Indemnity PPO Medical Plan.
- Kaiser Permanente HMO—Kaiser’s mental health/chemical dependency benefits are provided through Kaiser. Members are not eligible for Employee Member Assistance Program ( EMAP) benefits.
Refer to your plan’s Benefits Chart for a comparison of key features of the Kaiser and Anthem Blue Cross HMO Plans.
Paying for Health Care
Set copayments—which you pay at the time you receive care—apply; you are also protected from catastrophic expenses through a medical out-of-pocket maximum limit
- If you are enrolled in an HMO, the HMO pays most covered services in full after you pay a set copay at the time you receive your care.
- There is no deductible with the HMOs.
- An annual medical out-of-pocket expense maximum protects you from catastrophic health care expenses. After you meet this maximum, the HMO will pay 100% of your covered medical expenses for the remainder of the calendar year. The annual medical out-of-pocket maximum amount depends on whether you cover yourself only or yourself and your family.
Note: A Health Reimbursement Account is not offered with the HMO Plans
You are required to use your HMO’s providers and facilities, except in a life-threatening emergency. Here are phone numbers and links you can use to find a provider:
- If you’re enrolled in the Kaiser Permanente HMO Plan
800-464-4000
www.kp.org
- If you’re enrolled in the Anthem HMO Plan
800-627-5342
anthem.com/ca
Find an HMO provider in the Select Network:
SelectHMOSearch
Find an HMO provider in the Blue Cross HMO
(CACare) Network:
BlueCrossHMOSearch