| Under the Kaiser HMO Plan, you must receive services at a Kaiser facility in order to receive coverage, except in an emergency. |
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| Medicare Part D |
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| In 2003, the Federal Government voted to expand Medicare coverage to include Pharmacy coverage known as Medicare Part D. This benefit became effective January 1, 2006. As a Member of LAPRA, you and your covered dependents already have pharmacy benefits provided by LAPRA through Blue Cross and Kaiser that are much better than those that are available through Medicare Part D. Consequently, the Federal Government has encouraged plans, such as ours, to continue to provide pharmacy coverage. If you or any of your covered dependents are eligible for, and enroll in, Medicare Part D through a plan other than the LAPRA Blue Cross or Kaiser plans, your premium costs may be higher. |
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| Medicare Definitions |
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| Part A: Pays for inpatient hospital, skilled nursing facility, and some home health care. For each benefit period Medicare pays all covered costs except the Medicare Part A deductible (2011 = $1,132) during the first 60 days and coinsurance amounts for hospital stays that last beyond 60 days and no more than 150 days. |
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| Part B: Covers Medicare eligible physician services, outpatient hospital services, certain home health services, and durable medical equipment. |
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| Part D: This is the prescription drug benefit that became available to Medicare Part A and/or Part B beneficiaries beginning January 1, 2006. Eligible individuals include all retirees and dependents eligible for Medicare Part A or enrolled in Part B. |
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| KAISER PERMANENTE RATES PER MONTH - EFFECTIVE 7/1/2011 |
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| Note: City Subsidy varies and is determined by retirement date, age and years of service. |
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| The following rate table reflects the various health plan options available to Retirees who elect Kaiser and are entitled to Medicare. Retirees enrolled in the Senior Advantage Plan must be enrolled in, and assign, Medicare Parts A & B to Kaiser and effective January 1, 2006, must purchase Medicare Part D through Kaiser. Members enrolled in Parts B and D only may purchase Part A from Kaiser Permanente. The Federal Medicare Agency, the Centers for Medicare and Medicaid Services (CMS), establishes eligibility requirements that impact members' cost and condition of enrollment. It is important to note that you must purchase and assign your Medicare benefits to Kaiser or be reclassified into an unknown or unassigned rate category which will significantly affect your cost as indicated below. |
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| KAISER PERMANENTE MONTHLY RETIREE RATES EFFECTIVE JULY 1, 2011 |
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| Note: City Subsidy varies and is determined by retirement date, age and years of service. |
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| Note: If you or any of your covered dependents are eligible for, and enroll in, Medicare Part D through a plan other than the LAPRA Kaiser plan, your premium costs will be higher. It is important to note that you must assign all of your Medicare benefits to Kaiser or be reclassified into an unknown or unassigned rate category, which will significantly affect your cost as indicated below. To enroll in Kaiser Senior Advantage, you must be enrolled in Medicare Parts A, B and D or B and D Only and assign your benefits to Kaiser. |
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| Retiree Non-Medicare rates (Member and dependents under age 65) |
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| PART CODES |
Coverage Category |
Monthly Premium Rate |
| 10 |
Single |
470.93 |
| 11 |
Two Party |
932.19 |
| 12 |
Family |
1,095.26 |
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| Retiree Senior Advantage (Member and Spouse Part B only enrolled with Kaiser unassigned prior to January 1, 1999 or assigned with Kaiser after January 1, 2003) |
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| 20 |
Member B&D |
538.50 |
| 21 |
2 Party: Member B&D; Spouse Medicare A&B&D |
759.98 |
| 22 |
2 Party: Member None (under 65); Spouse Medicare A&B&D |
692.41 |
| 23 |
2 Party: Member B&D; Spouse B&D |
1,071.98 |
| 24 |
2 Party: Member None (under 65); Spouse B&D |
1,004.41 |
| 25 |
2 Party: Member B&D; Spouse None (under 65) |
999.76 |
| 26 |
3 Party: Member B&D; Spouse None (under 65); Deps (under 65) |
1,162.83 |
| 27 |
3 Party: Member None (under 65); Spouse Medicare A&B&D; Deps (under 65) |
855.48 |
| 30 |
Member Only Medicare A&B&D |
226.50 |
| 31 |
2 Party: Member Medicare A&B&D; Spouse None (under 65) |
687.76 |
| 32 |
2 Party: Member Medicare A&B&D; Spouse B&D |
759.98 |
| 33 |
2 Party: Both Medicare A&B&D |
447.98 |
| 34 |
3 Party: Member Medicare A&B&D; Spouse None (under 65); Deps (under 65) |
850.83 |
| 35 |
3 Party: Member Medicare A&B&D; Spouse Medicare A&B&D; Deps (under 65) |
611.05 |
| 36 |
3 Party: Member None (under 65); Spouse (over 65) B&D, Deps (under 65) |
1,167.48 |
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| Medicare Cost Members (enrolled prior to 1988 - not eligible to enroll in Part D) |
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| 43 |
Member Medicare Cost Only; Medicare A&B |
707.19 |
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| Member and/or spouse unassigned 65 years and older; Member and/or Spouse unassigned B only (after January 1, 1999) "Medicare" = assigned to Kaiser |
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|
| 66 |
Member (over 65) A only |
849.99 |
| 67 |
2 Party: Member (over 65) A Only; Spouse Medicare A&B&D |
1,071.47 |
| 68 |
2 Party: Member (over 65) A Only; Spouse Medicare B&D |
1,383.47 |
| 69 |
2 Party: Member (over 65) A only; Spouse None (under 65) |
1,311.25 |
| 70 |
2 Party: Member (over 65) A only; Spouse (over 65) A only |
1,694.96 |
| 71 |
2 Party: Member (over 65) A only; Spouse (over 65) B only |
2,007.97 |
| 72 |
2 Party: Member Medicare A&B&D; Spouse (over 65) A only |
1,071.47 |
| 73 |
2 Party: Member Medicare B&D; Spouse (over 65) A only |
1,383.47 |
| 74 |
2 Party: Member None (under 65); Spouse (over 65) A only |
1,315.90 |
| 75 |
3 Party: Member (over 65) A only; Spouse Medicare A&B&D; Deps (under 65) |
1,234.54 |
| 76 |
3 Party: Member (over 65) A only; Spouse Medicare B&D; Deps (under 65) |
1,546.54 |
| 77 |
3 Party: Member (over 65) A only; Spouse None (under 65); Deps (under 65) |
1,474.32 |
| 78 |
3 Party: Member (over 65) A only; Spouse (over 65) A only; Deps (under 65) |
1,858.03 |
| 79 |
3 Party: Member (over 65) A only; Spouse (over 65) B only; Deps (under 65) |
2,171.04 |
| 80 |
3 Party: Member Medicare A&B&D; Spouse (over 65) A only; Deps (under 65) |
1,234.54 |
| 81 |
3 Party: Member Medicare B&D; Spouse (over 65) A only; Deps (under 65) |
1,546.54 |
| 82 |
3 Party: Member None (under 65); Spouse (over 65) A only; Deps (under 65) |
1,478.97 |
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| Member and/or spouse unassigned 65 years and older; Member and/or Spouse unassigned B only (after January 1, 1999) "Medicare" = assigned to Kaiser |
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|
| 83 |
Member over age 65 unassigned part B only |
1,163.00 |
| 84 |
2 Party: Member (over 65) B only; Spouse Medicare A&B&D |
1,384.48 |
| 85 |
2 Party: Member (over 65) B only; Spouse Medicare B&D |
1,696.48 |
| 86 |
2 Party: Member (over 65) B only; Spouse None (under 65) |
1,624.26 |
| 87 |
2 Party: Member (over 65) B only; Spouse (over 65) A only |
2,007.97 |
| 88 |
2 Party: Member Medicare A&B&D; Spouse (over 65) B only |
1,384.48 |
| 89 |
2 Party: Member Medicare B&D; Spouse (over 65) B only |
1,696.48 |
| 90 |
2 Party: Member None (under 65); Spouse (over 65) B only |
1,628.91 |
| 91 |
3 Party: Member (over 65) B only; Spouse Medicare A&B&D; Deps (under 65) |
1,547.55 |
| 92 |
3 Party: Member (over 65) B only; Spouse Medicare B&D; Deps (under 65) |
1,859.55 |
| 93 |
3 Party: Member (over 65) B only; Spouse None (under 65); Deps (under 65) |
1,787.33 |
| 94 |
3 Party: Member (over 65) B only; Spouse (over 65) A only; Deps (under 65) |
2,171.04 |
| 95 |
3 Party: Member Medicare A&B&D; Spouse (over 65) B only; Deps (under 65) |
1,547.55 |
| 96 |
3 Party: Member Medicare B&D; Spouse (over 65) B only; Deps (under 65) |
1,859.55 |
| 97 |
3 Party: Member None (under 65); Spouse (over 65) B only; Deps (under 65) |
1,791.98 |
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| Member (over 65) A&B unknown or unassigned with Kaiser "Medicare" = assigned to Kaiser |
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| A1 |
Member (over 65) A&B unknown or unassigned with KP |
1,163.00 |
| A2 |
2 Party: Member (over 65) A&B unknown/unassigned; Spouse Medicare A&B&D |
1,384.48 |
| A3 |
2 Party: Member (over 65) A&B unknown/unassigned; Spouse Medicare B&D |
1,915.85 |
| A4 |
2 Party: Member (over 65) A&B unknown/unassigned; Spouse None (under 65) |
1,624.26 |
| A5 |
2 Party: Member (over 65) A&B unknown/unassigned; Spouse (over 65) A only |
2,007.97 |
| A6 |
2 Party: Member (over 65) A&B unknown/unassigned; Spouse (over 65) B only |
2,320.98 |
| A7 |
2 Party: Member (over 65) A&B unknown/unassigned; Spouse A&B unknown/unassigned |
2,320.98 |
| A8 |
2 Party: Member Medicare A&B&D; Spouse (over 65) A&B unknown/unassigned |
1,384.48 |
| A9 |
2 Party: Member Medicare B&D; Spouse (over 65) A&B unknown/unassigned |
1,696.48 |
| B1 |
2 Party: Member None (under 65); Spouse (over 65) A&B unknown/unassigned |
1,628.91 |
| B2 |
2 Party: Member (over 65) A only; Spouse (over 65) A&B unknown/unassigned |
2,007.97 |
| B3 |
3 Party: Member (over 65) A&B unknown/unassigned; Spouse Medicare A&B&D; Deps (under 65) |
1,547.55 |
| B4 |
3 Party: Member (over 65) A&B unknown/unassigned; Spouse Medicare B&D; Deps (under 65) |
1,859.55 |
| B5 |
3 Party: Member (over 65) A&B unknown/unassigned; Spouse None (under 65); Deps (under 65) |
1,787.33 |
| B6 |
3 Party: Member (over 65) A&B unknown/unassigned; Spouse (over 65) A only; Deps (under 65) |
2,171.04 |
| B7 |
3 Party: Member (over 65) A&B unknown/unassigned; Spouse (over 65) B only; Deps (under 65) |
2,484.05 |
| B8 |
3 Party: Member Medicare A&B&D; Spouse (over 65) A&B unknown/unassigned; Deps (under 65) |
1,547.55 |
| B9 |
3 Party: Member Medicare B&D; Spouse (over 65) A&B unknown/unassigned; Deps (under 65) |
1,859.55 |
| C1 |
3 Party: Member None; Spouse (over 65) A&B unknown/unassigned; Deps (under 65) |
1,791.98 |
| C2 |
3 Party: Member (over 65) A only; Spouse (over 65) A&B unknown/unassigned; Deps (under 65) |
2,171.04 |
| C3 |
3 Party: Member (over 65) B only; Spouse (over 65) A&B unknown/unassigned; Deps (under 65) |
2,484.05 |
| C4 |
3 Party: Member (over 65) A&B unknown/unassigned; Spouse A&B unknown/unassigned; Deps |
2,484.05 |
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| KAISER PLAN BENEFIT OVERVIEW - EFFECTIVE 7/1/11 |
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| CALENDAR YEAR DEDUCTIBLE |
N/A |
| OUT-OF-POCKET MAXIMUM |
Co-pay maximum $1,500 per member $3,000 per family |
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| HOSPITAL SERVICES |
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| EMERGENCY ROOM |
$50 co-pay; waived if admitted |
| URGENT CARE VISITS |
For visits at an assigned medical group $10 co-pay |
| INPATIENT (Room, Board and Support Services) |
No Charge 365 days/cal year |
| INPATIENT MATERNITY CARE |
No Charge |
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| PHYSICIAN SERVICES |
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| OFFICE VISITS |
$10 co-pay |
| Physical Therapy, Physical Medicine, Occupational Therapy, Acupuncture Services |
$10 co-pay |
| Chiropractic Care (through American Specialty Health Plans - ASHN) limited to 40 visits/cal yr) |
$10 co-pay |
| SPEECH THERAPY (outpatient speech therapy following injury or organic disease) |
$10 co-pay |
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| HEALTH MAINTENANCE |
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| ROUTINE PHYSICAL EXAMINATIONS FOR SUBSCRIBERS AND DEPENDENTS |
No Charge |
| WELL WOMAN CARE |
No Charge |
| WELL BABY AND WELL CHILD CARE |
No Charge |
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| CHEMICAL DEPENDENCY AND SUBSTANCE ABUSE |
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| OUTPATIENT PHYSICIAN SERVICES |
$10 copay individual therapy
$5 copay group therapy |
| INPATIENT HOSPITAL |
No Charge |
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| MENTAL OR NERVOUS DISORDER |
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| OUTPATIENT PHYSICIAN SERVICES |
$10 copay individual therapy
$5 copay group therapy |
| INPATIENT HOSPITAL |
No Charge |
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| OTHER COVERED EXPENSES |
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| HEARING AID BENEFIT |
No Charge (limited to one aid per ear, every 36 months) |
| PRESCRIPTION DRUGS - RETAIL PHARMACY3 |
$10 for Generic. $15 for Brand (up to a 100 day supply ) |
| PRESCRIPTION DRUGS - MAIL ORDER3 |
$10 for Generic. $15 for Brand (up to a 100 day supply ) |
| VISION CARE |
No charge for vision exams. $350 allowance for medically necessary eyewear every 24 months. |
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| 3. For those who have assigned medicare Part D coverage to Kaiser: After a member has incured $3,600 in out-of-pocket expenses, the member will pay $3.00 for generic drugs and $10.00 for brand drugs. |
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| Note: Covered services for the treatment of severe mental disorders will not be subject to any limitations applicable to mental or nervous disorders. Such services will be subject to all other terms, conditions, limitations an exclusions, including applicable Medical Benefit Maximums. |
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| The foregoing brief description of benefits is provided for your convenience and is subject to all terms, conditions, limitations and exclusions of the Kaiser contract. Please refer to the Kaiser evidence of coverage for details on benefits. |
