Kaiser Permanente $50M Out-of-Network Claims Settlement

Kaiser Foundation Health Plan Inc.

California Kaiser Permanente members who paid out of pocket for out-of-network mental health or substance use disorder services after Jan. 1, 2021, because they could not access timely in-network care may qualify to claim expense reimbursement.

Kaiser Foundation Health Plan Inc. agreed to pay $50 million to settle a California Department of Managed Health Care investigation alleging it failed to provide timely access to in-network mental health and substance use disorder care, did not maintain adequate provider networks and lacked proper oversight and compliance with state law regarding behavioral health services.

Who can file a Kaiser Permanente claim?

Claimants must meet all of the following criteria:

They are or were a Kaiser Permanente member in California.
While they were a member, they paid out of pocket for out-of-network mental health or substance use disorder services because they attempted but could not access timely in-network care.
They received out-of-network care after Jan. 1, 2021.

Legal guardians or authorized representatives can submit a claim on behalf of a minor, incapacitated adult or deceased member.

Individuals may submit a claim even if they did not receive a notice by mail or email.

Who is excluded from the settlement?

Members enrolled in Medicare Advantage plans are not eligible for reimbursement under this process.
Payments for copays or cost-sharing amounts to out-of-network providers are not eligible if Kaiser Permanente referred the patient.

How much is the payout?

Eligible claimants may receive reimbursement for all or part of their out-of-pocket payments for covered out-of-network mental health or substance use disorder services. There is no fixed dollar amount per person.

The reimbursement applies only to costs members paid directly for services that would have been covered in-network as described in their evidence of coverage or summary plan description. Those who have unpaid bills for qualifying services may also be eligible for reimbursement for the amount owed.

How to claim a payment

Individuals must submit a claim within 180 days of receiving notice of the opportunity. They can file a claim online or download, print, complete and mail the PDF claim form to the settlement administrator.

Settlement administrator's mailing address: Kaiser Permanente Notice Administrator, 1650 Arch St., Suite 2210, Philadelphia, PA 19103

What proof or documentation is required to submit a claim?

Claimants must provide documentation to support their claim. This includes:

Invoices or itemized bills showing the dates and types of services
Proof of payment (such as receipts, canceled checks or bank records)

If the claim is for an unpaid bill, the claimant must affirm they owe the amount stated, and Kaiser Permanente may contact their provider to verify the claim.

Those who do not have these documents may be able to obtain them from their provider.

Claimants must also provide the following:

Their name and membership record number
The names and phone numbers of the out-of-network providers

Those submitting a claim for a minor, incapacitated adult or deceased member must include documentation proving their legal authority to act on their behalf.

Payout options

Eligible claimants will receive a reimbursement check by U.S. mail. Kaiser Permanente may contact those with unpaid bills and their providers to arrange payment.

$50 million settlement fund breakdown

The $50,000,000 settlement fund includes:

$40 million to be paid within 10 business days of the settlement's effective date
An additional $10 million if Kaiser Permanente fails to meet its obligations under the settlement agreement after a consultation period

Important dates

Deadline to file a claim: Individuals must submit a claim within 180 days of receiving notice or learning about the opportunity.

When is the Kaiser Permanente out-of-network payout date?

Kaiser Permanente will distribute payments as soon as possible following the conclusion of the claims submission review process.

Why did this settlement happen?

The California Department of Managed Health Care alleged Kaiser Foundation Health Plan Inc. failed to provide timely access to in-network mental health and substance use disorder care for its California members. The investigation found deficiencies in network adequacy, oversight of provider networks, timely access to care and compliance with behavioral health parity laws.

The settlement resolves these claims and includes a corrective action plan and investment commitments to improve behavioral health care access and oversight. Kaiser Permanente agreed to the settlement without admitting wrongdoing.