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Home My WebLink AboutKaiser HMO 15 Plan Summary Disclosure Form Part One (continues) 233392 PRISM - SDRMA/GSRMA SOUTH Member Services 800-464-4000 Home Region: Southern California 1/1/26 through 12/31/26 Principal benefits for Kaiser Permanente Traditional HMO Plan Accumulation Period The Accumulation Period for this plan is January 1 through December 31. Out-of-Pocket Maximums and Deductibles For Services that apply to the Plan Out-of-Pocket Maximum, you will not pay any more Cost Share for the rest of the Accumulation Period once you have reached the amounts listed below. Amounts Per Accumulation Period Self-Only Coverage (a Family of one Member) Family Coverage Each Member in a Family of two or more Members Family Coverage Entire Family of two or more Members Plan Out-of-Pocket Maximum $1,500 $1,500 $3,000 Plan Deductible None None None Drug Deductible None None None Plan Provider Office Visits You Pay Most Primary Care Visits and most Non-Physician Specialist Visits ...... $15 per visit Most Physician Specialist Visits ............................................................. $15 per visit Routine physical maintenance exams, including well-woman exams .... No charge Well-child preventive exams (through age 23 months) .......................... No charge Routine eye exams with a Plan Optometrist .......................................... No charge Urgent care consultations, evaluations, and treatment .......................... $15 per visit Most physical, occupational, and speech therapy .................................. $15 per visit Telehealth Visits You Pay Primary Care Visits and Non-Physician Specialist Visits by interactive video or telephone .................................................................................. No charge Physician Specialist Visits by interactive video or telephone ................. No charge Outpatient Services You Pay Outpatient surgery and certain other outpatient procedures .................. $15 per procedure Most immunizations (including the vaccine) ........................................... No charge Most X-rays and laboratory tests ............................................................ No charge Hospital Inpatient Services You Pay Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs ..................................................................................................... No charge Emergency Services You Pay Emergency department visits ................................................................. $50 per visit Note: If you are admitted directly to the hospital as an inpatient for covered Services, you will pay the inpatient Cost Share instead of the emergency department Cost Share (see “Hospital Inpatient Services” for inpatient Cost Share) Ambulance Services You Pay Ambulance Services ............................................................................... No charge Prescription Drug Coverage You Pay Covered outpatient items in accord with our drug formulary guidelines: Most generic items (Tier 1) at a Plan Pharmacy ................................. $5 for up to a 30-day supply Most generic (Tier 1) refills through our mail-order service ................. $10 for up to a 100-day supply Most brand-name items (Tier 2) at a Plan Pharmacy .......................... $20 for up to a 30-day supply Most brand-name (Tier 2) refills through our mail-order service ......... $40 for up to a 100-day supply Most specialty items (Tier 4) at a Plan Pharmacy ............................... $20 for up to a 30-day supply Durable Medical Equipment (DME) You Pay DME items as described in the EOC ...................................................... No charge Mental Health Services You Pay Inpatient psychiatric hospitalization ........................................................ No charge Individual outpatient mental health evaluation and treatment ................ $15 per visit Group outpatient mental health treatment .............................................. $7 per visit Disclosure Form Part One (continued) 4202469.19.1.S000781965 Substance Use Disorder Treatment You Pay Inpatient detoxification ............................................................................ No charge Individual outpatient substance use disorder evaluation and treatment $15 per visit Group outpatient substance use disorder treatment .............................. $5 per visit Home Health Services You Pay Home health care (up to 100 visits per Accumulation Period) ............... No charge Other You Pay Skilled nursing facility care (up to 100 days per benefit period) ............. No charge Prosthetic and orthotic devices as described in the EOC ...................... No charge This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Share, out-of- pocket maximums, exclusions, or limitations, nor does it list all benefits and Cost Share amounts. For a complete explanation, please refer to the EOC. Disclosure Form Part Two The Disclosure Form Part Two provides an overview of important features of your Health Plan membership, including how to obtain Services, principal exclusions, and important notices. To view or download a copy, go to kp.org/choosekp or call Member Services at 1-800-464-4000 (TTY users call 711). Kaiser Foundation Health Plan, Inc. Southern California 2026 Disclosure Form Amendment for Combined Chiropractic and Acupuncture Services This document amends your Kaiser Foundation Health Plan, Inc. Disclosure Form to add coverage for Combined Chiropractic and Acupuncture Services. August 27, 2025 Disclosure Form Amendment for Combined Chiropractic and Acupuncture Services Issue Date: August 27, 2025 Page 1 Your Kaiser Permanente Combined Chiropractic and Acupuncture Benefit Benefit Highlights Professional Services (ASH Participating Provider office visits) You Pay Chiropractic and acupuncture office visits (up to a combined total of 30 visits per 12-month period) ........................................................................ $10 per visit Other You Pay X-rays and laboratory tests that are covered Chiropractic Services ............ No charge Chiropractic supports and appliances .......................................................... Amounts in excess of the $50 Allowance This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Share, out-of- pocket maximums, exclusions, or limitations, nor does it list all benefits and Cost Share amounts. For a complete explanation, refer to the Combined Chiropractic and Acupuncture Services amendment to your Health Plan EOC. Introduction Kaiser Foundation Health Plan, Inc. contracts with American Specialty Health Plans of California, Inc. (“ASH Plans”) to make the network of ASH Participating Providers available to you. When you need chiropractic care or acupuncture, you have direct access to more than 3,000 licensed chiropractors and more than 2,900 licensed acupuncturists in California. In addition to the terms defined in the “Definitions” section of your Disclosure Form, some capitalized terms have special meaning in this document, as described in the "Definitions" section at the end of this document. This amendment is only a summary of your chiropractic and acupuncture coverage. The Chiropractic and Acupuncture Services Amendment to your EOC provides details about the terms and conditions of your chiropractic and acupuncture coverage, including exclusions and limitations. To obtain the amendment to your EOC please contact your group. ASH Participating Providers The list of ASH Participating Providers is available on the ASH Plans Website at ashlink.com/ash/kp or from the ASH Plans Customer Service Department at 1-800-678-9133 (TTY users call 711) weekdays, hours may vary. The list of ASH Participating Providers is subject to change at any time without notice. How to Obtain Services You can obtain services from any ASH Participating Providers without a referral from a Plan Physician. To obtain services, call an ASH Participating Provider to schedule an initial examination. If additional Services are required after the initial examination, verification that the Services are Medically Necessary may be required. Your ASH Participating Provider will request any required medical necessity determinations. An ASH Plans' clinician in the same or similar specialty as the provider of Services under review will determine whether the Services are or were Medically Necessary Services. For more information about how to obtain covered Services, refer to the Combined Chiropractic and Acupuncture Services amendment to your Health Plan EOC. Disclosure Form Amendment for Combined Chiropractic and Acupuncture Services Issue Date: August 27, 2025 Page 2 Second Opinions You may request a second opinion in regard to covered Service by contacting another ASH Participating Provider. Your visit to another ASH Participating Provider for a second opinion generally will count toward any visit limit, if applicable. An ASH Participating Provider may also request a second opinion in regard to covered Services by referring you to another ASH Participating Provider in the same or similar specialty. If you are referred by an ASH Participating Provider to another ASH Participating Provider, or see an ASH Participating Provider for lab work or an X-ray, your visit to the other ASH Participating Provider will not count toward any visit limit. An authorization or denial of your request for a second opinion will be provided in an expeditious manner, as appropriate for your condition. If your request for a second opinion is denied, you will be notified in writing of the reasons for the denial, and of your right to file a grievance as described in your Health Plan EOC. Your Costs When you receive covered Services, you must pay the Cost Share as described in the Combined Chiropractic and Acupuncture Services amendment to your Health Plan EOC. The Cost Share does not apply toward the Plan Deductible or Plan Out-of-Pocket Maximum described in the Health Plan EOC. ASH Plans Customer Service If you have question about the Services you can get from an ASH Participating Provider, you may call the ASH Plans Customer Service Department toll free at 1-800-678-9133 (TTY users call 711) weekdays, hours may vary. Exclusions The items and services listed in this "Exclusions" section are excluded from coverage under the Combined Chiropractic and Acupuncture Services amendment. (Note: Some items and services listed in this “Exclusions” section may be covered Services under your Health Plan EOC. Please refer to your Health Plan EOC for details.) These exclusions apply to all Services that would otherwise be covered under the Combined Chiropractic and Acupuncture Services amendment regardless of whether the services are within the scope of a provider's license or certificate: • Acupuncture services for conditions other than Musculoskeletal and Related Disorders, nausea, and pain • Acupuncture performed with reusable needles • Services provided by an acupuncturist that are not within the scope of licensure for an acupuncturist licensed in California • For Acupuncture Services, adjunctive therapies unless provided during the same course of treatment and in conjunction with acupuncture • Services provided by a chiropractor that are not within the scope of licensure for a chiropractor licensed in California • For Chiropractic Services, adjunctive therapy not associated with spinal, muscle, or joint manipulations • Air conditioners, air purifiers, therapeutic mattresses, chiropractic appliances, durable medical equipment, supplies, devices, appliances, and any other item except those listed as covered under “Chiropractic Supports and Appliances” in the “Covered Services” section of this Amendment • Services for asthma or addiction, such as nicotine addiction • Hypnotherapy, behavior training, sleep therapy, and weight programs • Thermography • Experimental or investigational Services. If coverage for a Service is denied because it is experimental or investigational and you want to appeal the denial, refer to your Health Plan EOC for information about the appeal process Disclosure Form Amendment for Combined Chiropractic and Acupuncture Services Issue Date: August 27, 2025 Page 3 • CT scans, MRIs, PET scans, bone scans, nuclear medicine, and any other type of diagnostic imaging or radiology other than X-rays covered under the “Covered Services” section of this Amendment • Ambulance and other transportation • Education programs, non-medical self-care or self-help, any self-help physical exercise training, and any related diagnostic testing • Services for pre-employment physicals or vocational rehabilitation • Drugs and medicines, including non-legend or proprietary drugs and medicines • Services you receive outside the state of California, except for Services covered under “Emergency and Urgent Services Covered Under this Amendment” in the “Covered Services” section • Hospital services, anesthesia, manipulation under anesthesia, and related services • Dietary and nutritional supplements, such as vitamins, minerals, herbs, herbal products, injectable supplements, and similar products • Massage therapy • Maintenance care (services provided to Members whose treatment records indicate that they have reached maximum therapeutic benefit) Definitions Acupuncture Services: The stimulation of certain points on or near the surface of the body by the insertion of needles to prevent or modify the perception of pain or to normalize physiological functions and appropriate adjunctive therapies, such as hot/cold packs, infrared heat, or acupressure, when provided during the same course of treatment and in conjunction with acupuncture and when provided by an acupuncturist for the treatment of your Musculoskeletal and Related Disorder, nausea (such as nausea related to chemotherapy, post-surgery nausea, or nausea related to pregnancy), or joint pain (such as lower back, shoulder, or hip joint pain), and headaches. ASH Participating Provider: One of the following types of providers: • An acupuncturist who is licensed to provide acupuncture services in California and who has a contract with ASH Plans to provide Medically Necessary Acupuncture Services to you • A chiropractor who is licensed to provide chiropractic services in California and who has a contract with ASH Plans to provide Medically Necessary Chiropractic Services to you A list of ASH Participating Providers is available on the ASH Plans website at ashlink.com/ash/kaisercamedicare for Kaiser Permanente Senior Advantage Members, or ashlink.com/ash/kp for all other Members, or from the ASH Plans Customer Service Department toll free at 1-800-678-9133 (TTY users call 711). The list of ASH Participating Providers is subject to change at any time, without notice. If you have questions, please call the ASH Plans Customer Service Department. ASH Plans: American Specialty Health Plans of California, Inc., a California corporation. Chiropractic Services: Chiropractic services include spinal and extremity manipulation and adjunctive therapies such as ultrasound, therapeutic exercise, or electrical muscle stimulation, when provided during the same course of treatment and in conjunction with chiropractic manipulative services, and other services provided or prescribed by a chiropractor (including laboratory tests, X-rays, and chiropractic supports and appliances) for the treatment of your Musculoskeletal and Related Disorder. Musculoskeletal and Related Disorders: Conditions with signs and symptoms related to the nervous, muscular, and/or skeletal systems. Musculoskeletal and Related Disorders are conditions typically categorized as structural, degenerative, or inflammatory disorders; or biomechanical dysfunction of the joints of the body and/or related components of the muscle or Disclosure Form Amendment for Combined Chiropractic and Acupuncture Services Issue Date: August 27, 2025 Page 4 skeletal systems (muscles, tendons, fascia, nerves, ligaments/capsules, discs and synovial structures) and related manifestations or conditions. Treatment Plan: One of the following, depending on whether the Treatment Plan is for Chiropractic Services or Acupuncture Services: • The course of treatment for your Musculoskeletal or Related Disorder, which may include laboratory tests, X-rays, chiropractic supports and appliances, and a specific number of visits for chiropractic manipulations (adjustments), and adjunctive therapies that are Medically Necessary Chiropractic Services for you • The course of treatment for your Musculoskeletal or Related Disorder, nausea, or pain, which will include a specific number of visits for acupuncture (including adjunctive therapies) that are Medically Necessary Acupuncture Services for you