Modified: 20th Aug 2019

Founded in 1945, Kaiser Permanente is a not-for-profit healthcare provider and health service plan. Kaiser offers both employer group coverage and private insurance for individuals and families. Kaiser provides Medicare coverage for seniors who are 65 or older and for people qualified for Medicare with a disability. Kaiser Permanente insurance offers healthcare services in 8 states and by zip codes. Coverage areas include the following: 

  • Washington
  • Oregon
  • Colorado
  • California
  • Hawaii
  • Georgia
  • Virginia
  • Maryland
  • District of Columbia

Kaiser Permanente is a primary healthcare provider. Kaiser offers insurance plans for partial or full coverage of addiction treatment costs. Kaiser may reduce your health insurance costs and make it easier to find affordable treatment for recovery.

Before considering a rehab program, you must determine which drug and alcohol treatment services Kaiser will cover. Not all rehabilitation centers accept Kaiser insurance. For both inpatient and outpatient services, paying for treatment may be expensive. Knowing which drug and alcohol rehab treatment services Kaiser will cover is essential for recovery.

The 2008 Mental Health Parity and Addiction Equity Act

The Mental Health Parity and Addiction Equity Act (MHPAEA) preserves existing protections and extends parity requirements to substance use disorders. It requires a general equivalence in the way mental health (MH), and substance use disorders (SUD) and medical and surgical benefits are treated concerning the following:

  • Annual and lifetime dollar limits
  • Financial requirements
  • Treatment limitations

Large group health insurance plans and health plan insurers that CHOOSE to include mental health and substance use disorder benefits in their benefits packages must cover MH/SUD in the same manner, or without imposing less favorable benefit limitations, as coverage permits for medical and surgical procedures. The amount of coverage for substance abuse treatment, however, varies by state and depends upon the insurance plan you choose. The MHPAEA does not apply directly to small group health plans; indirectly, individuals who purchase through the marketplace under the Affordable Care Act (ACA) may have access to coverage through the essential health benefit (EHB) requirements. 

Non-federal government insurance plans are regulated by the Department of Health and Human Services (HHS). The Department of Labor (DOL) regulates private employment-based group plans.

Preliminary Questions

There are some standard questions you should ask yourself before you consider using Kaiser Permanente as your health insurance provider. Does Kaiser Permanente cover the following?

  • Substance abuse treatment and recovery services?
  • Inpatient and residential stay?
  • Medication-assisted treatment?
  • Outpatient services?
  • Aftercare and transitional planning?

Once you understand Kaiser Permanente insurance coverage, the next goal will be to locate an affordable specialized substance abuse treatment facility. Information about deductibles, copays, and other out-of-pocket costs will help you to develop a payment plan to pay for healthcare costs. 

Primary Care Physician

Patients must undergo an initial clinical assessment in a substance abuse treatment facility before a physician can authorize a referral to a specialist. Primary care physician (PCP) referrals are based upon medical necessity and serve as proof that required by insurance providers. 

Appointments

Patients can make appointments online or over the phone. Patients can address a nonurgent medical issue with their doctors via email. Patients can view lab results online as well as fill prescriptions. Patients can also speak with a nurse 24 hours a day, seven days a week.

Scope of Coverage

Kaiser Permanente covers the following treatment services in a specialized alcohol and drug rehabilitation facility for substance abuse treatment services:

  • Screenings for drugs and alcohol
  • Emergency care services
  • Detox
  • Residential inpatient treatment
  • Outpatient treatment services
  • Transitional recovery services

You will be required to meet copay and deductible costs. Standard coverage for an individual, family of one member, for substance abuse rehabilitation and treatment services might include the following fees and may overlap depending on inpatient/outpatient status:

  • $3,350: plan, out-of-pocket maximum
  • $0: plan deductible
  • $0: drug deductible
  • $15: per visit, primary care visit
  • $30: per visit, physician specialist visit
  • $0: covered individual health education counseling (outpatient)
  • $0: covered health education programs (outpatient)
  • $250: per day up to $1,250 per admission, room and board, surgery, anesthesia lab tests, drugs (inpatient detoxification)
  • $150: emergency department visits
  • $15: per visit, individual outpatient substance use disorder evaluation and treatment
  • $5: per visit, group outpatient substance use disorder treatment

Coverage may not eliminate costs. When treatment is not fully covered, substance abuse rehabilitation facilities often house financial advisors who understand the complexities of health insurance. They are professionals who are knowledgeable in drug and alcohol treatment center costs and how to help individuals pay for services with alternate funding. 

Coverage may extend to counseling and therapy services. Advise nurses and wellness coaches are available by phone to discuss counseling options, mental health goals, and support group meetings. Kaiser Permanente insurance programs also offer classes and support groups for chemical dependency.

Sample Plan & Type of Coverage

Kaiser Permanente offers both covered outpatient services and covered residential treatment services. For example, the Kaiser Permanent Platinum HMO plan includes inpatient and outpatient treatment. 

Inpatient Treatment

Inpatient treatment covers both drug and physician services. A patient receives inpatient detox for managing medical withdrawal from drugs and alcohol. The plan includes the following:

  • Room and board
  • Medical services
  • Medications
  • Education
  • Recovery services
  • Counseling 

The copay for these services is $250 per day up to a maximum of $1,250 per stay under the plan.

Outpatient Treatment

Outpatient treatment covers individuals attending therapy but returning home at night. The plan includes the following:

  • Intensive outpatient programming
  • Day treatment programming
  • Medical withdrawal treatment
  • Individual or group chemical dependency counseling 

The copay for outpatient treatment is $15 per visit for individual treatment but $5 per group session.

Residential Treatment

Residential treatment covers individual and group treatment services. The plan includes the following:

  • 24-hour care in a licensed facility
  • Individual and group counseling
  • Medical services and monitoring
  • Room and board
  • Social services
  • Medications and drugs prescribed by the plan provider
  • Discharge planning

The copay for residential treatment is $100 per admission. Residential services are covered when treatment is provided in a licensed treatment facility that operates 24 hours and offers individualized substance use disorder treatment. 

Medication-Assisted Treatment (MAT)

Medication-assisted treatment (MAT) is an effective treatment for drug and alcohol abuse recovery. Medication-assisted treatment is referred to as a “whole-patient approach” in which medical services include a combination of behavioral therapy and medication to treat withdrawal symptoms as a result of experiencing drug cravings. This treatment option reduces the risk of relapse and ushers the patient to recovery by easing discomfort. Medication coverage varies under Kaiser Permanente plans and by type of status. Inpatient settings require medication specialists to administer medication. Outpatient status requires a copay. Speak with a Kaiser Permanente representative for more information on financial responsibility. 

Types of Health Plans

There are three categories of Kaiser Permanente plans:

  • Group, which include employer-based
  • Individual, labeled Gold, Silver, Bronze, and Platinum
  • Medicare

Each category outlines deductibles, copays, and plan options.

Group

Group and employer-based plans are offered to employees of businesses. Premiums are deducted from employee paychecks. Employees may choose from five plan options:

  • Traditional/deductible plans: The participant pays fees until the deductible is met. Copays are typically necessary. There is a standard out-of-pocket annual maximum amount.
  • PPO plans: Preferred Provider Organization (PPO) plans are approved for individuals who live outside the Kaiser Permanente plan provider service regions. In-network coverage costs less. Out-of-network coverage is maintained at a higher rate for non-preferred physicians.
  • POS: Point of Service (POS) plans offer comprehensive coverage for plan participants using in-network Kaiser Permanente providers and network-contracted providers. Out-of-network plan participants pay higher costs for out-of-network providers. POS combines both HMO and PPO plans.
  • Out-of-Area Plans: Out-of-area plans are for individuals who live outside the Kaiser Permanente coverage areas. Individuals can receive healthcare services without a referral.
  • Consumer-Directed Health Plan: Consumer-Directed Health Plan is available as one of three healthcare savings account. The HRA is a health reimbursement account where employers contribute to the plan participant’s qualified medical expenses. The HSA is the health savings account that is tax-free account individuals create to pay for medical expenses. The FSA is a flexible savings account where individuals make pre-tax contributions for different medical expenses.

This is an overview of group plans. See Kaiser Permanente for more information.

Individual

Kaiser Permanente individual plans include different packages. Individuals can choose from Gold, Silver, Bronze, and Platinum healthcare benefits packages. Plans include maximum out-of-pocket fees, deductibles, and copay amounts. Coverage depends on area and type of program. The following programs are available directly through Kaiser Permanente:

  • Deductible plans: Deductible plans require payment of fees until the deductible is met. A copay is required. Preventative services may be covered.
  • Copay plans: Preventative services may be included. A copay is required for office visits and medical services.
  • HSA: Health Savings Account plans combine pharmacy and medical cost deductibles. Plan participants pay out-of-pocket costs until the deductible is met. Health savings accounts are established to provide a tax break on medical expenses. 
  • Deductible catastrophic: Plan participants younger than 30 years old and can prove financial hardship may qualify for deductible catastrophic. The insurance plan covers three doctor’s visits. The individual must pay out-of-pocket expenses until the annual maximum deductible is met. Preventative services may be included at no charge. 

This is an overview of individual plans. See Kaiser Permanente for more information.

Medicare

Medicare plans are offered to adults 65 years old and older. Medicare is a federal insurance program. Kaiser Permanente provides standard Medicare options. Kaiser’s Senior Advantage is an HMO program that varies by coverage region, has low copays, and usually has no copay for preventative services. Seniors needing substance abuse treatment services at a specialized treatment center can speak with a trained insurance professional for information on how to pay for services. 

References

Centers for Medicare & Medicaid Services. (n.d.). The mental health parity and addiction equity act (MHPAEA). The Center for Consumer Information & Insurance Oversight. Retrieved from https://www.cms.gov/cciio/programs-and-initiatives/other-insurance-protections/mhpaea_factsheet.html.

Resources

Kaiser Permanente Fast Facts:
https://about.kaiserpermanente.org/who-we-are/fast-facts

Kaiser Permanente Individual & Family Plans:
https://wa.kaiserpermanente.org/individual-family/plans

Kaiser Permanente Member Agreement (2019):
http://info.kaiserpermanente.org/healthplans/plandocuments/california/pdfs/2019/KPIF-Off-Exchange/800222_01_14_11_2019_KP_CA_Platinum_90_HMO_ON-OFF_FINAL_ADA_LCK.pdf

Article Reviewed by Dr. Keerthy Sunder, MD, DFAPA

Dr. Keerthy Sunder, MD, DFAPADr. Keerthy Sunder, MD is an accomplished and internationally recognized expert in the field of addiction. He has earned diplomates from the American Board of Psychiatry and Neurology, the American Board of Addiction Medicine, and the Royal College of Obstetricians and Gynecologists.