aggregate deductible or out-of-pocket maximum
A family plan that has 1 deductible and 1 out-of-pocket for everyone in the family.

balance billing
This occurs when a provider, who is not part of your network, bills you for the difference between their out-of-network provider charges and the amount paid by your plan (e.g. Kaiser Permanente).

coinsurance
A percentage of the charges that you pay for covered services. For example, a 20 percent coinsurance for a $200 procedure means you pay $40.

copay
The set amount you pay for covered service. For example, $10 for an office visit.

deductible
The amount you pay for covered services each year before Kaiser Permanente starts paying. Depending on your plan, you may pay copays or coinsurance for some services without having to reach your deductible.

deductible/coinsurance HMO plan
Kaiser Permanente's deductible/coinsurance HMO plans usually offer broad coverage with lower premiums than traditional HMO plans. They are similar to traditional HMO plans in that members access a closed network of physicians and other health care providers, and hospitals. Preventive care is offered at no charge. For other services, such as hospitalization and outpatient surgery, a member and his or her family (if applicable) must meet the individual or family annual deductible. Once a member has met the deductible, he or she pays a portion of the charges for covered medical services (coinsurance or copayment). If a member has a lot of health care expenses in a year, a deductible/coinsurance plan can limit the amount paid out of pocket for most services.

embedded deductible or out-of-pocket maximum
A family plan with 2 kinds of deductibles and out-of-pocket maximums: 1 for each individual and 1 for the whole family.

formulary
Formulary drugs are medications that have been thoroughly reviewed by a team of expert pharmacists and physicians and identified as safe, effective, and beneficial for treating medical conditions. When deciding between drugs that are equally safe and effective, the formulary team considers the relative costs of medications. These savings are then passed on to members through lower premiums or lower out-of-pocket expenses.

health maintenance organization (HMO) plan
An HMO plan typically has a closed network of physicians and other health care providers, and hospitals. With a traditional HMO plan, a member receives services from the HMO's providers for a set copay. A member doesn't have to worry about submitting claim forms unless he or she receives medical services outside the network.

health reimbursement arrangement (HRA)
An account that gives you money to pay for care. Your employer sets up an account and puts money into it. Because the money isn’t part of your wages, you won’t pay taxes on it. You can use this money to help pay your health care costs.

health savings account (HSA)
An account you can set up and put money into. You won’t pay federal taxes on this money, and you can use it anytime to pay for care. Your account may earn interest, and you can take your money with you if you change jobs or retire.

HSA-qualified or HSA-compatible health plans (also referred to as "Kaiser Permanente HSA-Qualified Deductible HMO Plan")
HSA-qualified health plans give a member flexibility and control over how and when to use health care dollars. Members get health care coverage while saving for future medical expenses through a health savings account (HSA), which offers some tax benefits.

With an HSA-qualified health plan, a member typically receives preventive care that is not subject to a deductible at no charge. These services include copay or coinsurance, depending on the plan selected. For all other covered medical services and prescription drugs, the member and the member's family (if applicable) must meet the individual or family annual deductible. Once the member has met the deductible, he or she only pays a portion of the charges for covered medical services in the form of coinsurance or copayment. If the member has a lot of health care expenses in a year, an HSA-qualified health plan can limit the amount paid out of pocket for most services.

When a member enrolls in a Kaiser Permanente HSA-qualified health plan and chooses to open an HSA account with our preferred institution, the member will receive competitive pricing on fees with a range of investment options and dedicated customer service support.

in network
In network means a group of doctors, hospitals, pharmacies, and other providers that has contracted with a health plan to provide services to our members at negotiated rates. With all Kaiser Permanente health plans, you typically pay less out of pocket when seeking covered services from an in-network provider.

Letter of Medical Need
A Letter of Medical Need is a letter written by a doctor detailing a medical diagnosis and treatment.

The IRS requires that health care expenses reimbursed through a health reimbursement account be primarily for the diagnosis, treatment, or prevention of disease, or for treatments affecting any part of the body necessary for function. For example, a doctor may prescribe a vitamin to treat a member for a medical condition. Because vitamins are generally considered a non-covered expense, the member may be asked to submit a Letter of Medical Need along with the reimbursement request.

lifetime maximum
The lifetime maximum is the maximum amount of money a plan will pay toward a member's health care services.

member liability
The total of the deductible, coinsurance, and copayment amounts that a member pays out of their own pocket.

out-of-area plan
If a member lives outside the area covered by his or her health plan, the member may still obtain a wide range of health benefits by purchasing an out-of-area plan. The member may receive care for covered services from any licensed provider who is not part of the health plan's network. The member must meet an annual deductible, pay coinsurance, and submit claims for reimbursement.

out-of-network
Out-of-network means a group of doctors, hospitals, pharmacies, and other providers that has not contracted with a health plan to provide services to our members at negotiated rates.

Members typically pay more out of pocket when seeking services from an out-of-network provider. Depending on a member's plan benefits, the plan may or may not pay for a portion of the charges from out-of-network providers.

out-of-pocket maximum
The most you’ll pay for covered services each year. For a small number of services, you may need to keep paying copays or coinsurance after reaching your out-of-pocket maximum.

Point of Service (POS) plans (also referred to as "Kaiser Permanente Flexible Choice, Added Choice, Multi-Choice")
Members can mix and match services among the network options—coverage and cost are determined by where a member chooses to get care. For example, members can take their kids to see a pediatrician outside our network and pay slightly higher rates. A POS health plan provides flexibility for different lifestyles and budgets.A Kaiser Permanente Point of Service (POS) plan enables a member to receive care from either a Kaiser Permanente physician or any other physician or hospital, in or out of network, each time he or she needs health care services. Kaiser Permanente POS plans let our members decide how to manage their health care and costs to best meet their needs, each time they need care.

When enrolling in the Kaiser Permanente two-option or two-tier plan, a member has the choice of:

• receiving care from a Kaiser Permanente or affiliated physician, or
• receiving care from any licensed physician in the United States outside of the Kaiser Permanente network

When enrolling in the three-option or three-tier plan, a member has the choice of:

• receiving care from a Kaiser Permanente or affiliated physician
• receiving care from a doctor with our contracted preferred provider organization (PPO) network, or
• receiving care from any licensed physician in the United States outside of Kaiser Permanente and our contracted PPO networks

Members can mix and match services among the network options—coverage and cost are determined by where a member chooses to get care. For example, members can take their kids to see a pediatrician outside our network and pay slightly higher rates. A POS health plan provides flexibility for different lifestyles and budgets.

preferred provider organization (PPO) plan
In a Kaiser Permanente preferred provider organization (PPO) plan, members can choose from two coverage options each time they need medical care to get the health care that best meets their needs.

• In Option 1 or Tier 1 (contracted network), a member may receive care from a provider in a contracted network. (Networks vary by region.) The member is responsible for meeting a deductible and paying coinsurance for services.
• In Option 2 or Tier 2 (out of network), a member may receive care from any licensed provider or hospital that is not part of the health plan's network of contracted providers. When a member chooses this option, he or she will generally have higher out-of-pocket expenses than if they had used Tier 1. The member is also responsible for satisfying a deductible and/or paying coinsurance charges.

PPO plan with health savings account
A preferred provider organization (PPO) offers our members the freedom to choose who they want to see for health care. Combine a PPO plan with a health savings account (HSA) and our members get greater flexibility and control over how to use health care dollars while receiving tax advantages as they save for future health care expenses.

A PPO plan allows a member to choose his or her personal physician. The member pays lower out-of-pocket charges if he or she uses a physician from our nationwide preferred provider network, Private Healthcare Systems (PHCS), which has nearly 450,000 providers. The member's doctor may already be a part of the PHCS group. The member can still receive care outside of this network—all he or she needs to do is pay for the care and file a reimbursement claim.

Typically, in an HSA-qualified PPO, a member will not have to meet a deductible for preventive care such as physicals and well-baby visits. The member may also be able to access preventive care at no charge. For all other covered medical services and prescription drugs, the member and his or her family (if applicable) must meet an individual or family annual deductible. Once the member has met the deductible, he or she pays a portion of the charge of covered medical services (coinsurance or copayment). If the member has a lot of health care costs in a year, he or she will have peace of mind knowing that there's a limit to out-of-pocket charges.

When a member enrolls in a Kaiser Permanente HSA-qualified PPO and chooses to open an HSA with our preferred institution, the member will receive competitive pricing on fees with a range of investment options and dedicated customer service support.

qualified medical expenses
Medical costs that you can pay with money from your HSA, HRA, or FSA.

service area
A service area is a designated geographic area covered by a member's health plan.