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4
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)
Member and/or spouse Part A&B unassigned 65 years and older (“Medicare” = assigned to Kaiser).
66a
Member (over 65) A/B Unassigned
$957.60
67a
2 Party: Member (over 65) A/B Unassigned; Spouse Medicare A/B/D
$1,157.84
68a
2 Party: Member (over 65) A/B Unassigned; Spouse Medicare B/D
$1,469.84
69a
2 Party: Member (over 65) A/B Unassigned; Spouse None (under 65)
$1,526.56
70a
2 Party: Member (over 65) A/B Unassigned; Spouse (over 65) A/B Unassigned
$1,910.20
71a
2 Party: Member (over 65) A/B Unassigned; Spouse (over 65) B
$2,223.22
72a
2 Party: Member Medicare A/B/D; Spouse (over 65) A/B Unassigned
$1,157.86
73a
2 Party: Member Medicare B/D; Spouse (over 65) A/B Unassigned
$1,469.86
74a
2 Party: Member None (under 65); Spouse (over 65) A/B Unassigned
$1,532.30
75a
3 Party: Member (over 65) A/B Unassigned; Spouse Medicare A/B/D; Deps (under 65)
$1,359.00
76a
3 Party: Member (over 65) A/B Unassigned; Spouse Medicare B/D; Deps (under 65)
$1,671.00
77a
3 Party: Member (over 65) A/B Unassigned; Spouse None (under 65); Deps (under 65)
$1,727.72
78a
3 Party: Member (over 65) A/B Unassigned; Spouse (over 65) A/B Unassigned; Deps (under 65)
$2,111.36
79a
3 Party: Member (over 65) A/B Unassigned; Spouse (over 65) B ; Deps (under 65)
$2,424.38
80a
3 Party: Member Medicare A/B/D; Spouse (over 65) A/B Unassigned; Deps (under 65)
$1,359.00
81a
3 Party: Member Medicare B/D; Spouse (over 65) A/B Unassigned; Deps (under 65)
$1,671.02
82a
3 Party: Member None (under 65); Spouse (over 65) A/B Unassigned; Deps (under 65)
$1,733.46
Member (over 65) unassigned Part B only after 01/01/99 (“Medicare” = assigned to Kaiser).
83
Member over age 65 unassigned part B
$1,270.62
84
2 Party: Member (over 65) B ; Spouse Medicare A/B/D
$1,470.86
85
2 Party: Member (over 65) B ; Spouse Medicare B/D
$1,782.86
86
2 Party: Member (over 65) B ; Spouse None (under 65)
$1,839.58
87
2 Party: Member (over 65) B ; Spouse (over 65) A
$2,223.22
88
2 Party: Member Medicare A/B/D; Spouse (over 65) B
$1,470.88
89
2 Party: Member Medicare B/D; Spouse (over 65) B
$1,782.88
90
2 Party: Member None (under 65); Spouse (over 65) B
$1,845.32
91
3 Party: Member (over 65) B ; Spouse Medicare A/B/D; Deps (under 65)
$1,672.02
92
3 Party: Member (over 65) B ; Spouse Medicare B/D; Deps (under 65)
$1,984.02
93
3 Party: Member (over 65) B ; Spouse None (under 65); Deps (under 65)
$2,040.74
94
3 Party: Member (over 65) B ; Spouse (over 65) A ; Deps (under 65)
$2,424.38
95
3 Party: Member Medicare A/B/D; Spouse (over 65) B ; Deps (under 65)
$1,672.04
96
3 Party: Member Medicare B/D; Spouse (over 65) B ; Deps (under 65)
$1,984.04
97
3 Party: Member None (under 65); Spouse (over 65) B ; Deps (under 65)
$2,046.48