3 / 7
3
Kaiser HMO Premium Rates
The tables on pages 3, 4 and 5 reflect the retiree monthly premium rates under the Kaiser HMO plan effective
July 1, 2017. Your cost is the monthly premium rate minus the Pension Department subsidy, based on your
retirement date, age and years of service.
Kaiser HMO Monthly Premium Rates (07/01/17 - 06/30/18)
Office Use Only
Coverage Tier
HMO
(CA Residents Only)
10
Member
$579.90
11
2 Party
$1,148.66
12
Family
$1,349.82
Retiree Senior Advantage Member and Spouse (Medicare Benefits assigned to Kaiser) (Member and Spouse B only
enrolled with Kaiser unassigned prior to 01/01/99 or assigned with Kaiser after 01/01/03)
20
Member B/D
$517.26
21
2 Party: Member B/D; Spouse Medicare A/B/D
$717.52
22
2 Party: Member None (under 65); Spouse Medicare A/B/D
$779.94
23
2 Party: Member B/D; Spouse B/D
$1,029.50
24
2 Party: Member None (under 65); Spouse B/D
$1,091.94
25
2 Party: Member B/D; Spouse None (under 65)
$1,086.22
26
3 Party: Member B/D; Spouse None (under 65); Deps (under 65)
$1,287.38
27
3 Party: Member None (under 65); Spouse Medicare A/B/D; Deps (under 65)
$981.10
30
Member Medicare A/B/D
$205.26
31
2 Party: Member Medicare A/B/D; Spouse None (under 65)
$774.22
32
2 Party: Member Medicare A/B/D; Spouse B/D
$717.52
33
2 Party: Both Medicare A/B/D
$405.50
34
3 Party: Member Medicare A/B/D; Spouse None (under 65); Deps (under 65)
$975.38
35
3 Party: Member Medicare A/B/D; Spouse Medicare A/B/D; Deps (under 65)
$606.66
36
3 Party: Member None (under 65); Spouse (over 65) B/D, Deps (under 65)
$1,293.10
Member and/or spouse with Part A only 65 years and older; (“Medicare” = assigned to Kaiser)
66
Member (over 65) A
$957.60
67
2 Party: Member (over 65) A ; Spouse Medicare A/B/D
$1,157.84
68
2 Party: Member (over 65) A ; Spouse Medicare B/D
$1,469.84
69
2 Party: Member (over 65) A ; Spouse None (under 65)
$1,526.56
70
2 Party: Member (over 65) A ; Spouse (over 65) A
$1,910.20
71
2 Party: Member (over 65) A ; Spouse (over 65) B
$2,223.22
72
2 Party: Member Medicare A/B/D; Spouse (over 65) A
$1,157.86
73
2 Party: Member Medicare B/D; Spouse (over 65) A
$1,469.86
74
2 Party: Member None (under 65); Spouse (over 65) A
$1,532.30
75
3 Party: Member (over 65) A ; Spouse Medicare A/B/D; Deps (under 65)
$1,359.00
76
3 Party: Member (over 65) A ; Spouse Medicare B/D; Deps (under 65)
$1,671.00
77
3 Party: Member (over 65) A ; Spouse None (under 65); Deps (under 65)
$1,727.72
78
3 Party: Member (over 65) A ; Spouse (over 65) A ; Deps (under 65)
$2,111.36
79
3 Party: Member (over 65) A ; Spouse (over 65) B ; Deps (under 65)
$2,424.38
80
3 Party: Member Medicare A/B/D; Spouse (over 65) A ; Deps (under 65)
$1,359.02
81
3 Party: Member Medicare B/D; Spouse (over 65) A ; Deps (under 65)
$1,671.02
82
3 Party: Member None (under 65); Spouse (over 65) A ; Deps (under 65)
$1,733.46