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Kaiser
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- Forms
- Health Plan Descriptions
- Dental Plan Descriptions
- Supplemental Options and Rates
- New Employee Welcome Brochure
- Provider Directory
Click on the button below to obtain the appropriate forms. These are pdf files to be printed, completed, and faxed to our office.
| Employee Application Package for New Group | Add Employee to Existing Group Plan | Employee Waiver |
Other Forms:
Colorado Springs Employee Application
Employee forms can be faxed to our office at (303) 721-1085. Please confirm that application was received by calling (303) 721-1145. Please call with any questions regarding eligibility or waiting periods.
HMO Plans
| Health Plan Name |
Office Visit Copay |
Hospital Copay |
Outpatient Copay |
| Basic HMO | $150 | ||
| Standard HMO | $20 | $150/day, max $600 | |
| Classic 15 | $15 | $500 | |
| Classic 20 | $20 | $750 | $150 |
| Classic 30 | $30 | $1000 | $150 |
| Classic 35 | $30 | 20% to $4k max | $200 |
Deductible Plans
| Plan Name |
Office Visit Copay |
Deductible |
Coinsurance |
| $30 |
$750 |
20% to $2,500 max |
|
| $30 |
$2000 |
30% to $5,500 max |
HSA Plans
| Plan Name | Deductible | Coinsurance | Max Out-of-Pocket |
| $2,000/$4,000 |
100/0 |
$2000/$4000 |
|
| $2,500/$5,000 |
80/20 |
$5000/$10,000 |
Triple Option Plans
The following plans allow employees to use Kaiser facilities, use the Mountain Medical Affiliates network doctors, or go completely out-of-network for care. Benefits vary according to which option is chosen. Employees can choose to go to a Kaiser doctor for routine visits and pay the appropriate copay for the visit, and still continue to use a specialist outside of Kaiser with a separate deductible applying.
Supplemental Options and Rates
Supplemental Option Rates 2005
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