What is the Difference Between Kaiser HMO and DHMO Health Insurance Plans?

When it comes to choosing a health insurance plan, Kaiser Permanente offers two main options – HMO and DHMO plans. While they share some similarities, there are key differences between Kaiser’s HMO and DHMO plans that are important to understand when selecting coverage.

HMO vs PPO vs EPO

Before diving into the details between HMO and DHMO plans specifically, it helps to understand how HMOs compare to other common insurance plan types like PPOs and EPOs.

HMO

HMO stands for Health Maintenance Organization. Here are some key features:

Set network of doctors and hospitals
Primary care physician coordinates care
Referrals required to see specialists
No out-of-network coverage except emergencies
Lowest premiums of plan types

PPO

PPO stands for Preferred Provider Organization. Key features include:

Nationwide network of doctors and hospitals
No referrals required to see in-network specialists
Out-of-network care covered but costs more
More flexibility in choosing providers than HMO
Higher premiums than HMO plans

EPO

Exclusive Provider Organization. Characteristics are:

Set network of doctors and hospitals
No referrals required for in-network specialists
No out-of-network coverage except emergencies
Lower premiums than PPO but higher than HMO

Now let’s look at how Kaiser’s HMO and DHMO plans compare.

Kaiser HMO Overview

Kaiser HMO plans offer affordable premiums in exchange for staying within the Kaiser network and seeing your assigned primary care physician for referrals. Here are some details on how Kaiser HMO plans work:

Kaiser facilities and doctors only – Members must use Kaiser Permanente medical facilities and doctors except in emergencies. No out-of-network coverage.
Primary care physician – Each member selects or is assigned a primary care Kaiser physician who provides and coordinates all care.
Referrals to see specialists – Members need a referral from their Kaiser PCP before seeing any specialists like dermatologists, cardiologists etc. The PCP coordinates these referrals.
Pre-authorization for some services – Certain services like MRI scans, procedures, hospital stays etc. require pre-approval by Kaiser before being scheduled.
Limited service area – Kaiser HMOs only provide coverage in the Kaiser service region where facilities are located. Regions vary by state.
Affordable premiums – Monthly premium costs are usually the lowest of all plan types.
No deductible – Most Kaiser HMO plans do not have a deductible that must be met before coverage starts.
Copays for services – Member pays fixed dollar copays like $20 for office visit or $250 per day for hospital stay. No coinsurance.
No out-of-pocket max – There is no limit on how much you could pay per year for care since copays are fixed amounts.

The Kaiser HMO provides high quality care and benefits focused on prevention and wellness for an affordable monthly premium. But the network and referral limitations require using Kaiser facilities and doctors.

Kaiser DHMO Overview

Kaiser DHMO plans add the flexibility of seeing some out-of-network providers to the traditional HMO structure. Key aspects include:

Kaiser network focus – The DHMO still relies on the Kaiser network of facilities and doctors for most care.
Some out-of-network coverage – Members can see out-of-network providers for limited visits per year, covered at a higher cost. Allows some provider choice.
Number of out-of-network visits – The number of covered visits can range from 10-20 based on specific DHMO plan.
Higher cost for out-of-network – Member pays more for out-of-network care through higher copays or deductible and coinsurance.
Primary care doctor – A PCP is still assigned who coordinates Kaiser care. Referrals required for Kaiser specialists.
Pre-authorization required – Like the HMO, services like hospital stays and procedures need pre-approval.
Deductible and out-of-pocket max – Many DHMOs have deductible and/or max out-of-pocket costs that limit spending.
Limited service area – The DHMO is still restricted to the Kaiser coverage region. No nationwide coverage.

The DHMO allows some non-Kaiser care while providing the HMO benefits and premium savings. But out-of-network coverage is still limited.

Comparing Kaiser HMO and DHMO Features

Here is a detailed overview comparing the features of Kaiser HMO vs DHMO plans:

Plan Feature	Kaiser HMO	Kaiser DHMO
Premium cost	Lowest premium	Higher than HMO premium
Plan deductible	Usually no deductible	May have deductible
Out-of-pocket max	Typically none	Has annual out-of-pocket max
Primary care physician	Required	Required
Referrals to specialists	Required	Required for Kaiser providers
Out-of-network coverage	None except emergencies	Limited visits or services covered per year
Nationwide coverage	No	No
Hospital coverage	Kaiser facilities only	Kaiser facilities only
Lab test coverage	Kaiser facilities only	Kaiser facilities and limited out-of-network
Kaiser pharmacies	Must use	Must use
Copays for services	Yes	Varies by plan
Coinsurance	No	May apply to out-of-network services
Pre-authorization	Required for certain services	Required for certain services
Routine preventive care coverage	100% covered	100% covered in-network

While the DHMO removes some HMO restrictions, it still relies primarily on the integrated Kaiser system. Out-of-network coverage is limited compared to a PPO plan. But the premium savings and high quality care can make the tradeoffs worthwhile for many members.

Pros and Cons of Kaiser HMO vs DHMO

Kaiser HMO Pros

Lowest cost premiums
No deductible
Low copays for office visits and drugs
Integrated system with coordinated care
Good choice if you prefer Kaiser doctors
Quality preventive and routine care

Kaiser HMO Cons

Very limited provider choice
Referrals required to see specialists
Pre-authorization needed for many services
No coverage out-of-network except emergencies
No out-of-pocket maximum protection

Kaiser DHMO Pros

Lower premium cost than many plans
Out-of-network provider coverage
Deductible and/or out-of-pocket maximum
Can keep seeing some preferred providers

Kaiser DHMO Cons

Still limited provider network
Extra cost for non-Kaiser care
Pre-authorization still required
Out-of-network visits capped per year
No nationwide coverage

Who is eligible to enroll in Kaiser plans?

Kaiser HMO and DHMO plans are available to:

Individuals and families – Those without employer-sponsored coverage can enroll directly with Kaiser through state insurance exchanges or directly with Kaiser during open enrollment or special enrollment periods.
Employer groups – Kaiser insurance plans are offered to employees of many companies and organizations as part of employment benefits packages.
Medicare Advantage – Kaiser provides Medicare Advantage HMO and DHMO options for Medicare enrollees.

Eligibility depends on the subscriber’s resident zip code being within the Kaiser coverage service area. Plans vary based on region and state regulations. Employer plans must be offered by eligible groups.

How do you enroll in a Kaiser HMO or DHMO?

There are a few steps to enroll in a Kaiser Permanente medical insurance plan:

Determine eligibility – Confirm you meet regional, age, employment or other requirements for the HMO or DHMO plan you want.
Select a plan – Review plan details like copays, deductibles, prescription coverage and out-of-network visits. Choose the optimal plan for your needs and budget.
Complete enrollment application – Kaiser will have paper or electronic forms to complete with your personal information, dependents to be covered, and provider selections.
Submit premium payment – First month’s premium payment will be due at the time of enrollment to activate coverage. Subsequent monthly payments are made to maintain active coverage status.
Choose your primary care provider – All members must select a PCP doctor from the Kaiser network. Each family member can have their own or choose the same.
Receive ID cards – Kaiser will mail medical ID cards that you present when receiving care. You’ll get cards for each family member on your plan.

That covers the

What is an HMO, PPO, HDHP or EPO

FAQ

What is Dhmo Kaiser insurance?

Glossary. Your Kaiser Permanente Deductible HMO Plan is not just health coverage — it’s a partnership in health. You receive preventive care services at little or no cost to you, and online features let you manage most of your care around the clock.

What does Kaiser HMO mean?

Kaiser is an HMO (Health Maintenance Organization) with a closed network of providers. See updated information about coverage for COVID tests.

What is a Dhmo health insurance plan?

The complete form of dental DHMO is Dental Health Maintenance Organization. DHMO is prepaid dental insurance that focuses on minimizing dental expenses. In dental DHMO, you are provided with in-network dentists where you can choose any dentist that comes under your insurance network for various dental services.

What’s the difference between a PPO and a Kaiser HMO?

A PPO plan can be a better choice compared with an HMO if you need flexibility in which health care providers you see. More flexibility to use providers both in-network and out-of-network. You can usually visit specialists without a referral, including out-of-network specialists.