Kaiser HMO N. CA

The Kaiser Health Maintenance Organization (HMO) Plan is only available to employees who live within Kaiser’s Northern California region service area. With the Kaiser HMO N. CA plan, you must see providers within the Kaiser network (except in an emergency). The plan requires that you select a Primary Care Physician (PCP) to coordinate all your healthcare needs, including arranging for hospitalization and referrals to specialists. Visit Find a Doctor to see if your provider is in-network.

You must meet your annual deductible before the plan begins to pay benefits. However, co-pays for office, specialist visits and prescription drugs do not apply to your annual deductible, but do apply to your annual out-of-pocket maximum. For more information refer to the Kaiser HMO N.CA Summary of Benefits and Coverage (SBC). Visit the Pharmacy page for more information on your prescription drug benefits.

With the Kaiser HMO N. CA plan, you are eligible to enroll in the General Purpose Flexible Spending Account (GPFSA) for your out-of-pocket expenses.

Kaiser HMO N. CA Plan Details

	In-Network	Out-of-Network
Annual Deductible	Individual: $250 Family: $500	Not Covered
Annual Out-of-Pocket (OOP) Maximum¹	Individual: $1,500 Family: $3,000	Not Covered
Employee Coinsurance	10% after deductible	Not Covered
Preventive (Annual Physicals, Well Care Exams)	100% covered, not subject to deductible	Not Covered
Physician Visits	Primary Care: $20/visit Specialists: $30/visit	Not Covered
Lab and X-Ray	10% after deductible	Not Covered
Emergency Room²	10% after deductible	Not Covered
Ambulance	10% after deductible	Not Covered
Hospitalization	10% after deductible	Not Covered
Chiropractic	$15/visit Up to 30 visits/year	Not Covered
Acupuncture	$20/visit Referral required	Not Covered
Massage	Not Covered	Not Covered
Speech Therapy²	$20 after deductible	Not Covered
Infertility/Fertility Preservation	50% coinsurance/visit (Does not include GIFT, ZIFT or IVF)³	Not Covered

¹ OOP maximum includes Prescription Rx.
² Available to those with conditions of medical necessity.
³ GIFT is a gamete intrafallopian transfer. ZIFT is a zygote intrafallopian transfer. IVF is in-vitro fertilization.

Employee Contributions for 2019

Per Paycheck¹

Plan	Employee Only	Employee + Spouse/Domestic Partner	Employee + Child(ren)	Employee + Family
Kaiser HMO N. CA	$72.38	$159.23	$137.52	$231.61

¹ Per paycheck contributions are 24 times per year. Contributions are pre-tax (except for Domestic Partner coverage).

Dependent Eligibility

Your spouse or domestic partner. Please note: after tax contributions and imputed income may apply when covering a domestic partner. See the Domestic Partner Imputed Income Rate Table for details
Your child(ren), your spouse’s / domestic partner’s child(ren), the minor(s) you have legal guardianship of are eligible for medical coverage until age 26, regardless of marital or student status.

For more details see the Kaiser HMO N.CA Summary of Benefits and Coverage (SBC).

Contact Us

HR Source
ASK HR [VMware network access required]
Phone: 1-888-VMWARE8, option ‘US Benefits’
Internal Phone: ext. 29200

Kaiser
Phone: 1-800-464-4000
Visit website

LGBTQIA Benefits

See how Kaiser HMO N CA can assist with LGBTQIA health care choices.

Seeking Care Outside of N. CA Kaiser Area

Need care outside of the Kaiser HMO N. CA coverage area, don’t worry, you’re covered. You can be seen in other Kaiser Service Areas or if necessary, visit a non-Kaiser emergency or urgent care center. Be sure to call Kaiser before seeking treatment while traveling.