Frequently Asked Questions

These questions and answers summarize some of the plan’s highlights. For a complete description of your benefits, please refer to the& Plan SummaryKaiser HMO Plan Summary - 2015
Detailed plan document for the Kaiser HMO plan. Includes information about coverage, benefits, copays and coinsurance, eligibility, claims, and grievance procedures.
document in the Resource Library. If there are any differences between this information and the plan document, the plan document will govern.

What is an HMO?

A Health Maintenance Organization (HMO) provides complete medical services from a specific network of doctors, hospitals and other care providers. Generally, benefits are not paid if you get care from a provider who is not part of your Kaiser network. In some cases, your primary care physician (PCP) and Kaiser may allow you to receive care outside the network. However, the care must be approved in advance.

What is a primary care physician (PCP)?

A primary care physician (PCP) is a doctor you choose to manage all your health care. Your PCP provides preventive and routine care as well as refers you to specialists and hospitals when you need them. A PCP can be an internist, a family or general practitioner, or a pediatrician for a child. You can choose a PCP from Kaiser’s network of doctors.

Do I have to choose a PCP?

When you enroll in the Kaiser Permanente plan, you are not required to choose a PCP.

Can each member of my family go to a different PCP?

Yes. You and your dependents can each have a different PCP.

Do I have to get a referral from my PCP to get an annual OB/GYN exam?

No. As long as the gynecologist is part of the Kaiser network, you can refer yourself.

Does the HMO plan cover emergencies?

Yes. HMO plans cover emergency care for injury or illness worldwide as long as you (or a family member, friend or representative) contacts your PCP or the plan’s Member Services within 48 hours of receiving emergency care. Important: There is no coverage for non-emergency treatment or routine care you receive out of the Kaiser network.

If you enroll in Kaiser and have questions about emergency care or getting care when you travel, call Kaiser Member Services toll free at 800-464-4000.

What happens if I get care outside the Kaiser network?

An HMO pays nothing toward the cost of care unless it is considered an out-of-area medical emergency.

Are there any pre-existing condition exclusions?

No. There are no pre-existing condition limits or exclusions in any of Stanford’s medical plans.

Does Kaiser offer a maternity benefit?

Yes. The Kaiser plan offers a maternity benefit for employees and eligible dependents. To compare the medical plans’ maternity benefits, look at the comparison chart.

You can also refer to Kaiser’s Plan SummaryKaiser HMO Plan Summary - 2015
Detailed plan document for the Kaiser HMO plan. Includes information about coverage, benefits, copays and coinsurance, eligibility, claims, and grievance procedures.
, or contact Kaiser directly.

Does Kaiser offer preventive care benefits?

Yes. The Kaiser plan covers routine physicals every year for adults and children, plus annual well-woman exams. To compare the medical plans’ preventive care benefits, look at the comparison chart.

You can also refer to Kaiser’s Plan SummaryKaiser HMO Plan Summary - 2015
Detailed plan document for the Kaiser HMO plan. Includes information about coverage, benefits, copays and coinsurance, eligibility, claims, and grievance procedures.
, or contact the HMO directly.

Does Kaiser cover vision care?

Kaiser covers routine eye exams and medically necessary treatment of your eyes, such as surgery. Other vision care services, such as eyeglasses and contact lenses, are covered by Stanford’s vision plan.

Does Kaiser cover work-related accidents or illnesses?

If you have a work-related accident or illness, contact your HR manager or Stanford’s Risk Management Department for assistance.

How are prescription drugs covered?

Your prescription drug coverage is part of your Kaiser plan. The cost of your medication depends on whether or not it can be dispensed in a generic form or if it is included in the Kaiser’s formulary.

What is a formulary?

A formulary is a list of approved prescription drugs covered by a medical plan. Kaiser’s formulary has two tiers: generic and formulary.

To find out if a particular medication is on Kaiser’s formulary, go to Kaiser’s website at my.kp.org/ca/stanforduniversity,or call Kaiser Member Services toll free at 800-464-4000.

What is coordination of benefits?

Coordination of benefits helps prevent duplication of payments for the same services when you or your dependents are covered under more than one medical plan. For additional information see your Plan SummaryKaiser HMO Plan Summary - 2015
Detailed plan document for the Kaiser HMO plan. Includes information about coverage, benefits, copays and coinsurance, eligibility, claims, and grievance procedures.
, or contact your HMO’s customer service number on your medical ID card.