What your Kaiser Permanente contract says

In short

This is a health plan agreement with Kaiser Permanente, California's largest HMO. Kaiser is a "closed network" (meaning you generally have to use Kaiser doctors, hospitals, and pharmacies). The big upside is that everything is coordinated in one system and costs are predictable. The downside is that you can't just go to any doctor you want (except in emergencies). Your coverage is regulated under California's Knox-Keene Act, which gives you strong consumer protections including the right to an independent medical review if Kaiser denies a treatment. Costs vary based on whether you get Kaiser through your employer, Covered California, or buy it directly.

What you agree to do

• You must pay your monthly premium by the due date to keep your coverage active.
• You must use Kaiser Permanente facilities and doctors for non-emergency care.
• You must get a referral from your primary care doctor before seeing a specialist (in most cases).
• You must pay applicable copays and coinsurance at the time of service.

What you can ask for

• You can go to any emergency room in an emergency and Kaiser must cover it.
• You can request an Independent Medical Review (IMR) through the DMHC if Kaiser denies a treatment.
• You can cancel your plan during open enrollment or within 30 days of a qualifying life event.
• You cannot be denied coverage or charged more because of a pre-existing condition (ACA protection).
• You have the right to receive all preventive care services with no out-of-pocket cost.

Points worth knowing

• Closed network: limited doctor choiceYou must use Kaiser doctors and facilities for all non-emergency care. If you see an out-of-network provider without authorization, Kaiser will not pay for it. This is the biggest trade-off of an HMO.
• Prior authorization can delay treatmentSome procedures, medications, and specialist visits require prior authorization from Kaiser. If denied, treatment is delayed while you appeal (though California law sets strict timelines for urgent cases).
• Premium increases at renewalKaiser can raise premiums annually. Individual and small group rates must be approved by the California DMHC or CDI, but increases of 5-15% per year are common.
• Out-of-pocket maximum exposureEven with insurance, you can pay up to your annual out-of-pocket maximum ($9,450 individual / $18,900 family for 2026 ACA plans) before Kaiser covers 100%. A serious illness or surgery can get expensive fast.
• Binding arbitration for malpractice claimsKaiser requires you to resolve medical malpractice disputes through binding arbitration rather than a jury trial. This is a significant waiver of your legal rights.

Dates and deadlines

Open enrollment period

November 1 - January 15 annually for Covered California plans (check employer dates separately)

Monthly premium due date

Due on the 1st of each month; grace period of 30 days for Covered California plans

Urgent care authorization timeline

Kaiser must respond to urgent prior authorization requests within 72 hours under California law

IMR filing deadline

You have 6 months from Kaiser's denial to request an Independent Medical Review with the DMHC