| |
| Kaiser
Permanente - RATES |
|
|
HMO Features
|
|
Plan
Features
|
|
PLAN A |
|
PLAN B |
|
Deductible |
|
$ - |
|
$ 500.00 |
|
Out of Pocket Max |
|
$ - |
|
$ - |
|
Primary
Care Physician Office Visit |
|
$ 20.00 |
|
$ 30.00 |
|
Preventive Care |
|
$ 20.00 |
|
$ 30.00 |
|
Hospital Inpatient
Copay |
|
$ 500.00* |
|
$ 500.00** |
|
Prescription |
|
$15/$21 |
|
$15/$21 # |
|
Maternity |
|
$1,000.00 |
|
$ 1,000.00 |
|
Emergency Services |
|
$ 75.00 |
|
$ 200.00 |
|
Mental Health |
|
$ 500.00 |
|
$ 500.00 |
|
Vision |
|
$ 20.00 |
|
$ 20.00 |
|
* Per Admission
** $500 deductible then apply 20% Coinsurance up to $2,000.00
# Apply a $150 deductible.
Please refer to plan details to clarify all deductibles and
plan details. |
| HMO
Monthly Rates |
|
AGE |
SINGLE |
|
PARENT/CHILD |
PARENT/CHILDREN |
COUPLE |
COUPLE/
CHILD |
COUPLE/ CHILDREN |
|
PLAN
A |
|
0-2 |
$ 147.00 |
$147.00 |
|
N/A |
N/A |
|
N/A |
N/A |
|
N/A |
|
N/A |
|
N/A |
|
3-11 |
$ 132.00 |
$132.00 |
|
N/A |
N/A |
|
N/A |
N/A |
|
N/A |
|
N/A |
|
N/A |
|
12-19 |
$ 100.00 |
$147.00 |
|
$ 246.00 |
$ 295.00 |
|
$ 382.00 |
$ 429.00 |
|
$ 246.00 |
|
$ 379.00 |
|
$ 460.00 |
|
20-24 |
$ 93.00 |
$135.00 |
|
$ 229.00 |
$ 270.00 |
|
$ 354.00 |
$ 393.00 |
|
$ 226.00 |
|
$ 349.00 |
|
$ 421.00 |
|
25-29 |
$ 110.00 |
$172.00 |
|
$ 247.00 |
$ 308.00 |
|
$ 373.00 |
$ 435.00 |
|
$ 279.00 |
|
$ 403.00 |
|
$ 472.00 |
|
30-34 |
$ 121.00 |
$206.00 |
|
$ 248.00 |
$ 330.00 |
|
$ 380.00 |
$ 460.00 |
|
$ 323.00 |
|
$ 450.00 |
|
$ 514.00 |
|
35-39 |
$ 136.00 |
$249.00 |
|
$ 265.00 |
$ 383.00 |
|
$ 428.00 |
$ 521.00 |
|
$ 388.00 |
|
$ 540.00 |
|
$ 592.00 |
|
40-44 |
$ 152.00 |
$247.00 |
|
$ 279.00 |
$ 369.00 |
|
$ 435.00 |
$ 494.00 |
|
$ 394.00 |
|
$ 530.00 |
|
$ 573.00 |
|
45-49 |
$ 194.00 |
$266.00 |
|
$ 317.00 |
$ 385.00 |
|
$ 470.00 |
$ 506.00 |
|
$ 454.00 |
|
$ 588.00 |
|
$ 620.00 |
|
50-54 |
$ 256.00 |
$289.00 |
|
$ 350.00 |
$ 425.00 |
|
$ 536.00 |
$ 563.00 |
|
$ 537.00 |
|
$ 673.00 |
|
$ 722.00 |
|
55-59 |
$ 327.00 |
$329.00 |
|
$ 423.00 |
$ 466.00 |
|
$ 614.00 |
$ 606.00 |
|
$ 646.00 |
|
$ 787.00 |
|
$ 825.00 |
|
60-64 |
$ 344.00 |
$335.00 |
|
$ 442.00 |
$ 475.00 |
|
$ 634.00 |
$ 618.00 |
|
$ 667.00 |
|
$ 809.00 |
|
$ 849.00 |
|
PLAN B |
|
0-2 |
$ 119.00 |
$119.00 |
|
N/A |
N/A |
|
N/A |
N/A |
|
N/A |
|
N/A |
|
N/A |
|
3-11 |
$ 107.00 |
$107.00 |
|
N/A |
N/A |
|
N/A |
N/A |
|
N/A |
|
N/A |
|
N/A |
|
12-19 |
$ 81.00 |
$119.00 |
|
$ 199.00 |
$ 239.00 |
|
$ 310.00 |
$ 348.00 |
|
$ 199.00 |
|
$ 308.00 |
|
$ 373.00 |
|
20-24 |
$ 76.00 |
$110.00 |
|
$ 185.00 |
$ 219.00 |
|
$ 287.00 |
$ 318.00 |
|
$ 183.00 |
|
$ 283.00 |
|
$ 341.00 |
|
25-29 |
$ 89.00 |
$139.00 |
|
$ 200.00 |
$ 250.00 |
|
$ 303.00 |
$ 352.00 |
|
$ 226.00 |
|
$ 327.00 |
|
$ 383.00 |
|
30-34 |
$ 98.00 |
$167.00 |
|
$ 201.00 |
$ 267.00 |
|
$ 308.00 |
$ 373.00 |
|
$ 262.00 |
|
$ 364.00 |
|
$ 417.00 |
|
35-39 |
$ 110.00 |
$202.00 |
|
$ 215.00 |
$ 310.00 |
|
$ 347.00 |
$ 422.00 |
|
$ 315.00 |
|
$ 438.00 |
|
$ 480.00 |
|
40-44 |
$ 123.00 |
$200.00 |
|
$ 226.00 |
$ 299.00 |
|
$ 352.00 |
$ 400.00 |
|
$ 319.00 |
|
$ 429.00 |
|
$ 465.00 |
|
45-49 |
$ 158.00 |
$215.00 |
|
$ 257.00 |
$ 312.00 |
|
$ 381.00 |
$ 410.00 |
|
$ 368.00 |
|
$ 477.00 |
|
$ 502.00 |
|
50-54 |
$ 207.00 |
$234.00 |
|
$ 284.00 |
$ 345.00 |
|
$ 434.00 |
$ 457.00 |
|
$ 435.00 |
|
$ 546.00 |
|
$ 585.00 |
|
55-59 |
$ 265.00 |
$267.00 |
|
$ 343.00 |
$ 378.00 |
|
$ 497.00 |
$ 491.00 |
|
$ 523.00 |
|
$ 638.00 |
|
$ 669.00 |
|
60-64 |
$ 279.00 |
$272.00 |
|
$ 359.00 |
$ 385.00 |
|
$ 514.00 |
$ 501.00 |
|
$ 541.00 |
|
$ 656.00 |
|
$ 688.00 |
|
PLAN
A with Consumer Choice |
|
0-2 |
$ 168.00 |
$168.00 |
|
N/A |
N/A |
|
N/A |
N/A |
|
N/A |
|
N/A |
|
N/A |
|
3-11 |
$ 151.00 |
$151.00 |
|
N/A |
N/A |
|
N/A |
N/A |
|
N/A |
|
N/A |
|
N/A |
|
12-19 |
$ 114.00 |
$168.00 |
|
$ 280.00 |
$ 337.00 |
|
$ 436.00 |
$ 489.00 |
|
$ 280.00 |
|
$ 433.00 |
|
$ 524.00 |
|
20-24 |
$ 106.00 |
$154.00 |
|
$ 261.00 |
$ 308.00 |
|
$ 404.00 |
$ 448.00 |
|
$ 258.00 |
|
$ 397.00 |
|
$ 480.00 |
|
25-29 |
$ 125.00 |
$196.00 |
|
$ 281.00 |
$ 351.00 |
|
$ 426.00 |
$ 495.00 |
|
$ 318.00 |
|
$ 459.00 |
|
$ 539.00 |
|
30-34 |
$ 138.00 |
$235.00 |
|
$ 283.00 |
$ 376.00 |
|
$ 433.00 |
$ 524.00 |
|
$ 369.00 |
|
$ 513.00 |
|
$ 586.00 |
|
35-39 |
$ 154.00 |
$283.00 |
|
$ 302.00 |
$ 437.00 |
|
$ 488.00 |
$ 594.00 |
|
$ 443.00 |
|
$ 615.00 |
|
$ 675.00 |
|
40-44 |
$ 173.00 |
$281.00 |
|
$ 318.00 |
$ 421.00 |
|
$ 496.00 |
$ 563.00 |
|
$ 449.00 |
|
$ 604.00 |
|
$ 654.00 |
|
45-49 |
$ 222.00 |
$303.00 |
|
$ 361.00 |
$ 439.00 |
|
$ 536.00 |
$ 577.00 |
|
$ 517.00 |
|
$ 671.00 |
|
$ 706.00 |
|
50-54 |
$ 291.00 |
$330.00 |
|
$ 399.00 |
$ 485.00 |
|
$ 611.00 |
$ 642.00 |
|
$ 612.00 |
|
$ 767.00 |
|
$ 823.00 |
|
55-59 |
$ 373.00 |
$375.00 |
|
$ 482.00 |
$ 531.00 |
|
$ 700.00 |
$ 691.00 |
|
$ 736.00 |
|
$ 897.00 |
|
$ 941.00 |
|
60-64 |
$ 392.00 |
$382.00 |
|
$ 504.00 |
$ 541.00 |
|
$ 723.00 |
$ 705.00 |
|
$ 760.00 |
|
$ 922.00 |
|
$ 968.00 |
|
PLAN
B with Consumer Choice |
|
0-2 |
$ 136.00 |
$136.00 |
|
N/A |
N/A |
|
N/A |
N/A |
|
N/A |
|
N/A |
|
N/A |
|
3-11 |
$ 122.00 |
$122.00 |
|
N/A |
N/A |
|
N/A |
N/A |
|
N/A |
|
N/A |
|
N/A |
|
12-19 |
$ 93.00 |
$136.00 |
|
$ 227.00 |
$ 273.00 |
|
$ 353.00 |
$ 396.00 |
|
$ 227.00 |
|
$ 351.00 |
|
$ 425.00 |
|
20-24 |
$ 86.00 |
$125.00 |
|
$ 211.00 |
$ 250.00 |
|
$ 327.00 |
$ 363.00 |
|
$ 209.00 |
|
$ 322.00 |
|
$ 389.00 |
|
25-29 |
$ 102.00 |
$159.00 |
|
$ 228.00 |
$ 285.00 |
|
$ 345.00 |
$ 402.00 |
|
$ 258.00 |
|
$ 372.00 |
|
$ 437.00 |
|
30-34 |
$ 112.00 |
$190.00 |
|
$ 229.00 |
$ 305.00 |
|
$ 351.00 |
$ 425.00 |
|
$ 299.00 |
|
$ 416.00 |
|
$ 475.00 |
|
35-39 |
$ 125.00 |
$230.00 |
|
$ 245.00 |
$ 354.00 |
|
$ 396.00 |
$ 482.00 |
|
$ 359.00 |
|
$ 499.00 |
|
$ 547.00 |
|
40-44 |
$ 141.00 |
$228.00 |
|
$ 258.00 |
$ 341.00 |
|
$ 402.00 |
$ 456.00 |
|
$ 364.00 |
|
$ 490.00 |
|
$ 530.00 |
|
45-49 |
$ 180.00 |
$245.00 |
|
$ 293.00 |
$ 356.00 |
|
$ 435.00 |
$ 468.00 |
|
$ 419.00 |
|
$ 544.00 |
|
$ 572.00 |
|
50-54 |
$ 236.00 |
$267.00 |
|
$ 324.00 |
$ 393.00 |
|
$ 495.00 |
$ 521.00 |
|
$ 496.00 |
|
$ 622.00 |
|
$ 667.00 |
|
55-59 |
$ 302.00 |
$304.00 |
|
$ 391.00 |
$ 431.00 |
|
$ 567.00 |
$ 560.00 |
|
$ 597.00 |
|
$ 727.00 |
|
$ 763.00 |
|
60-64 |
$ 318.00 |
$310.00 |
|
$ 409.00 |
$ 439.00 |
|
$ 586.00 |
$ 571.00 |
|
$ 616.00 |
|
$ 748.00 |
|
$ 784.00 |
|
Initial
rates are effective for the calendar year and are based on
your age as of January 1, 2003.
Family coverage is based on the age of the oldest family
member applying. |
|
|
|
