Kaiser

Employer Application
Package 		Employee Application Package for New Group
Add Employee to Existing
Group Plan 		Employee Waiver
Colorado Springs
Employee Application 		Continuation of
Coverage
Common Law Form Dependent Verification Form
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.
Plan Descriptions

HMO Plans

Health Plan Name
Office Visit Copay
Hospital Copay

Outpatient Copay

Basic HMO
$40

$500/day, max $2000

 $300
Standard HMO $25 $250/day, max $1000

$150
Classic 20 $20 $750 $150
Classic 20 Plus1 $20 $750 $150
Classic 30 $30 $1000 $150
Classic 30 Plus 1 $30 $1000 $150
Classic 35 1 $30 20% to $4k max $200
Classic 35A 1 $30 20% to $4k max $200
Classic 35A Plus 1 $30 20% to $4k max $200
Classic 40 1 $40 $1000/day, $4K max $200

Deductible Plans

Plan Name
Office Visit Copay
Deductible
Coinsurance
$30
$500

20% to $2,500 max
$30
$500

20% to $2,500 max
$30
$750
20% to $2,500 max
$30
$1,000
20% to $3,000 max
$30
$1,200
20% to $2,500 max
$30
$1,200
20% to $2,500 max
$30
$1,500
20% to $4,500 max
$30
$2,000
20% to $4,000 max
$30
$3,000
20% to $6,000 max
$30
$5,000
20% to $10,000 max
Health Savings Account Plans
Deductible
$1,500
0%
Deductible
$2,000
0%
Deductible
$2,500
0%
Deductible
$3,000
0%
Deductible
$5,000
0%

 

MultiChoice Plans

Plan Name Deductible Coinsurance Max Out-of-Pocket
$750
20%

20% to $2,500

$1,000
20%
20% to $4,000
$1,500
20%
20% to $6,500