In an April 2026 letter of agreement, DMHC focused on Kaiser's violations of the Knox-Keene Health Care Service Plan Act re: Covid vaccines, dating to 2023. Here's the detailed letter:
https://wpso.dmhc.ca.gov/enfactions/docs/5097/1778257694677.pdf
Kaiser does a lot of hard things well, so I've never really understood their issues with vaccines. Whatever they are, I hope they improve moving forward.
Note: Most denials are not appealed, so the percentages in the second column are only for those that are.
Medicare Advantage is the only plan reported above because it includes Kaiser, but the full analysis for Exchange plans and Medicaid is given below for those interested.
Summary: https://www.beckerspayer.com/rankings-ratings/payers-ranked-by-prior-authorization-denial-rates/
Does anyone have any idea why no region other than Washington publishes its clinical guidelines and/or clinical review criteria? Clinical guidelines are publicly available for most other major healthcare insurance companies.
It's very helpful in navigating any healthcare system to know what they cover and what steps a patient needs to take to be covered for a given treatment. I'd even argue it's a matter of respect to provide such information to patients.
Instead, Kaiser members often engage in this game of sorts: a patient goes to the doctor and asks about treatment X; the doctor goes silent, looks uncomfortable, or doesn't directly respond; the patient does not know what this look means and goes to Reddit or some other social platform to figure out if Kaiser prohibits the use of this treatment. This process is infuriating, at least for me, and I regard it as a waste of time for both the member and the doctor. Just tell us the criteria.
Given that Washington is more transparent than the other regions, I would speculate that it's the doctors' or hospital groups within each region that are opposed. But why?
For routine Kaiser care, the Summary of Benefits & Coverage (SBC) typically provides sufficient information on co-pay amounts. But if you're contemplating a surgery or more intensive care, you might want all the details of your plan.
Here's the link to detailed plans for most Kaiser plans in Southern California. Note that you can select a different region at the top of the page.
https://healthy.kaiserpermanente.org/southern-california/support/forms/documents/individual-family
On this page, Kaiser says these are sample evidence of coverage (EOC) and you will receive the most current version after enrolling. But on other webpages, it says that these are the EOC for Kaiser plans. Please correct me if you know more about which documents people should be referencing.
I also looked on my KP account, and it has useful info under the "Benefits" tab. For each service category, it provides detailed information on my specific co-pay amounts as well as deductible and co-pay limits. This is substantially improved from the information it provided a few years ago, so if you haven't looked at it in a while, you might take a look.
I've had Kaiser for 5-10 years now, on and off, and I recently used telehealth to get a first-time prescription. I thought this would be easy enough within the Kaiser system, but then I needed additional blood tests, and one of the test results was "mildly elevated," which triggered another test for which I wasn't sure of the cost. The process became unwieldy, and I wanted to get started on treatment, so I turned to a third-party, non-KP telehealth platform.
Once I signed up, the platform imported my entire Kaiser record within 45 minutes, and within 2 hours, I had a 30-minute meeting with a super-helpful NP, who wrote me a script and explained all of my lab results.
What struck me is that it wasn't that expensive. The visit was $100, the follow-up labs in 3 months will be less than my lab co-pay, and the prescription cost was higher, but only when compared with Kaiser's mail program; to go to the pharmacy would have been more expensive.
I'm just curious if anyone else has had any positive or negative experiences with telehealth outside of Kaiser. It seems like a viable alternative for higher-end co-pays and dealing with Kaiser's bureaucracy.
Edited for clarity.
An article from today’s LA Times reports on allegations that Kaiser’s arbitration system is unfair to members.
Critics contend that Kaiser has greater knowledge of arbitrators’ past rulings, and this knowledge is difficult for members to obtain. Therefore, Kaiser has the advantage in picking favorable judges for arbitration cases.
https://www.latimes.com/business/story/2026-07-20/kaisers-mandatory-arbitration-said-to-be-unfair
In January 2026, the federal government announced that all insurers (including Kaiser) must cover the traditional Pap test and an at-home cervical cancer test for women at average risk of cervical cancer aged 30-65 beginning in January 2027.
https://www.hrsa.gov/about/news/press-releases/new-cervical-cancer-screening-guidelines
Kaiser piloted the at-home test as early as 2017 but has yet to roll it out to all of its regions. Washington State has the test, California has it in some areas, and I have no idea about the other plans. It's a throwback to the Covid vaccine testing days....
I get that this individual test may not impact you. You may not give a rat's behind about the Covid vaccine. In either case, you may be very grateful to have Kaiser insurance, as am I. But one day, Kaiser's bureaucracy and inaction may negatively impact you. For this reason, I hope people will give them a nudge on these issues and remind them that people don't want to wait indefinitely for timely implementation of new treatments, particularly those stipulated by the Feds.
