Kaiser HMO N. CA

The Kaiser Health Maintenance Organization (HMO) Plan is available to employees who live within Kaiser’s Northern California or Southern California 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.

This option allows S.CA and N.CA eligible members to enroll under the Kaiser N.CA medical plan and receive services in both N.CA and S.CA.

Enrollees will receive two membership ID cards (prefix 00 for S.CA and prefix 11 for N.CA). Carry both cards with you as it may be necessary to present when using services in different regions.

Kaiser is moving to laminated ID cards and digital ID cards – review Resources section on ID cards.

There is no plan deductible. However there are copays for office visits, emergency visits and prescription drugs which count towards the 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	N/A	Not Covered
Annual Out-of-Pocket (OOP) Maximum¹	Individual: $2,000 Family: $4,000	Not Covered
Employee Coinsurance	20% Durable Equipment	Not Covered
Preventive (Annual Physicals, Well Care Exams)	100% covered	Not Covered
Physician Visits	Primary Care: $20/visit Specialists: $20/visit	Not Covered
Lab and X-Ray	100% covered	Not Covered
Emergency Room²	$150 / visit	Not Covered
Ambulance	$50 / trip	Not Covered
Hospitalization	$250 / admission	Not Covered
Chiropractic	$15/visit Up to 30 visits/year	Not Covered
Acupuncture	$15/visit Up to 30 visits/year	Not Covered
Massage	Not Covered	Not Covered
Speech Therapy²	$20	Not Covered
Assisted Reproductive Technology (ART)	50% coinsurance/visit One treatment cycle per lifetime of member under any group – Review Resources for Kaiser EOC for details	Not Covered

¹ OOP maximum includes Prescription Rx.
² Available to those with conditions of medical necessity.

Employee Contributions for 2021

Per Paycheck¹

Plan	Employee Only	Employee + Spouse/Domestic Partner	Employee + Child(ren)	Employee + Family
Kaiser HMO N. CA	$93.02	$204.64	$176.74	$297.66

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

Grand Rounds

Grand Rounds is your personal healthcare assistant. Get an expert second opinion at no cost to you. You must be enrolled in a VMware medical plan to use Grand Rounds services. For more information call 1-855-394-1635 or visit groundrounds.com/vmware.

Seeking Care Outside of N. CA or S. CA Kaiser Area

Need care outside of the Kaiser 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.