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 | N/A | Not Covered |
| Annual Out-of-Pocket (OOP) Maximum1 | Individual: $2,000 Family: $4,000 |
Not Covered |
| Employee Coinsurance | 10% | 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 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 2020
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
Resources
Benefits Vendor Contact Information
Domestic Partner Imputed Income Rate Table
Kaiser HMO N. CA Benefit Summary
Kaiser HMO N. CA Chiropractic and Acupuncture Evidence of Coverage (EOC)
Kaiser HMO N. CA Evidence of Coverage (EOC)
Kaiser HMO N. CA Obtaining Personalized Estimates for Fees
Kaiser HMO N. CA Paying for
Care
Kaiser HMO N. CA Preventive Care Services
Kaiser HMO N. CA Sample Fee
List
Kaiser HMO N. CA Summary of Benefits and Coverage (SBC)
Kaiser HMO N. CA Understanding Your Cost
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