California MRMIP Brochure 2007

California
Major Risk
Medical Insurance
Program
(MRMIP)
2007 Application and Handbook
Rates effective January 1, 2007

California Major Risk
Medical Insurance Program
Visit our website at: www.mrmib.ca.gov MRMIP Enrollment Unit
(800) 289-6574
Monday – Friday
8:30 a.m. – 7:00 p.m.
P.O. Box 2769 Table of Contents
Sacramento, CA 95812-2769
(916) 324-4695 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Arnold Schwarzenegger, Governor
How the Program Works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Board Members Description of Plans and Benefit Highlights
Clifford Allenby, Chair
Areta Crowell, Ph.D. Blue Cross of California . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Richard Figueroa Blue Shield of California (HMO) . . . . . . . . . . . . . . . . . . . . . . 10
Virginia Gotlieb, M.P.H.
Sophia Chang, M.D. Contra Costa Health Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Kaiser Permanente Northern California . . . . . . . . . . . . . . . . . 14
Ex Officio Members
Jack Campana Kaiser Permanente Southern California . . . . . . . . . . . . . . . . . 16
Kimberly Belshé
Sunne Wright McPeak
Monthly Subscriber Contributions . . . . . . . . . . . . . . . . . . . . . . . 18
Enrollment Application Checklist . . . . . . . . . . . . . . . . . . . . . . . . 24
Executive Director
Lesley Cummings Enrollment Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Americans With Disabilities Act

Section 504 of the Rehabilitation Act of 1973 states that no qualified disabled person shall, on the basis of
disability, be excluded from participating in, be denied the benefits of, or otherwise be subjected to
discrimination under any program or activity which receives or benefits from federal financial assistance.
The Americans with Disabilities Act of 1990 prohibits the Managed Risk Medical Insurance Board and its
contractors from discriminating on the basis of disability, protects its applicants and enrollees with disabilities in
program services, and requires the Board and its eligibility and enrollment contractors to make reasonable
accommodations to applicants and enrollees.
The Managed Risk Medical Insurance Board has designated an ADA Coordinator to carry out its responsibilities
under the Act. If you as a client, have any questions or concerns about ADA compliance by the Board or its
contractors, you may contact the Coordinator at the following address:
ADA Coordinator
Managed Risk Medical Insurance Board
P.O. Box 2769
(916) 324-4695 (Voice)
The hearing impaired can contact the ADA Coordinator through the California Relay Services at
1-800-735-2929.
Introduction state laws giving people under certain subscriber and/or their dependents
circumstances the right to continue (when applicable) in excess of the
The California Major Risk Medical coverage in an employee health plan MRMIP subscriber contribution
Insurance Program (MRMIP) is a for a limited time.) If you have amount.
program developed to provide health COBRA or CalCOBRA you may
Note: Letters from agents/brokers
insurance for Californians who are apply for deferred enrollment.
indicating that an individual is
unable to obtain coverage in the
4. You must be unable to secure unable to secure adequate private
individual insurance market. MRMIP is adequate coverage. This can be coverage will not be accepted as
administered by a five-member Board demonstrated in any of three ways: documentation for eligibility.
which established a comprehensive
benefit package. Services are delivered • You have been denied individual
coverage within the previous 12 Applicants Who Know They Are
through contracts with health insurance Currently Not Eligible But Expect
months. A letter/copy of a letter
plans. MRMIP subscribers participate To Be in the Future (Deferred
from a health insurance carrier,
in the payment for the cost of their Enrollment)
health plan or health maintenance
coverage by paying subscriber organization denying individual If you are not currently eligible for the
contributions on their own behalf. coverage within the last 12 months MRMIP, but anticipate becoming
MRMIP supplements those subscriber must be submitted with your eligible, you may also apply. Examples
contributions to cover the cost of care complete application. Insurance of this are: if you are currently enrolled
and is funded annually by $40 million denial notifications received through in COBRA or CalCOBRA coverage or
from tobacco tax funds. the internet that do not provide the if your employer has informed you that
reason for denial and the applicant’s
you will be involuntarily terminated
name will not be accepted.
Eligibility from insurance coverage sometime in
• You have been involuntarily the future.
In order to be eligible for the MRMIP:
terminated from health insurance
coverage within the previous 12 To apply for deferred enrollment,
1. You must be a resident of the state of
California. A resident is a person who months for reasons other than indicate when you will become eligible
is present in California with intent to nonpayment of premium or fraud. and include acceptable documentation.
remain in California except when A letter/copy of a letter indicating Acceptable documentation is a letter
absent for transitory or temporary involuntary termination from a from a health insurance carrier, health
purposes. However, a person who is health insurance carrier, health plan, plan, health maintenance organization,
absent from the state for a period health maintenance organization or or employer indicating when your
greater than 210 consecutive days employer for reasons other than coverage will end. The documentation
shall not be considered a resident. nonpayment of premium or fraud
must specify the exact date of when
must be submitted with your
2. You cannot be eligible for Medicare your current coverage will terminate.
complete application.
both Part A and Part B unless Enrollment in temporary policies does
eligible solely because of end-stage • You have been offered, in the not qualify for deferred status.
renal disease. Provide a Medicare previous 12 months, an individual,
eligibility letter with the application not a group, health insurance If the MRMIP is not at maximum
as proof of end-stage renal disease. premium in excess of the MRMIP enrollment and all other eligibility
(Being eligible for one part of subscriber contribution amount. A criteria are met, you will be enrolled in
Medicare or the other is acceptable.) letter/copy of a letter must be the MRMIP on the date that eligibility
submitted with the complete will occur. If the MRMIP is at
3. You cannot be eligible to purchase application indicating that, within maximum enrollment at the time you
any health insurance for continuation the last 12 months, you have been
become eligible, you will be placed on a
of benefits under COBRA or offered by a health insurance carrier,
CalCOBRA. (COBRA and waiting list. Your place on the waiting
health plan or health maintenance
CalCOBRA refer to the federal and list is determined by the date on which
organization, a premium for the
your complete application was received,
2
not the date that you became eligible subscriber contributions and a MRMIP. There are MRMIP benefit
for the MRMIP. copayment for services, which could be limits of $75,000 per calendar year and
more than $5,000 per year. Medi-Cal $750,000 in a lifetime.
Applicants for deferred enrollment must BIC cards cannot be used for MRMIP
submit their initial subscriber copayments. Subscriber Contributions
contribution with their application.
Subscriber contribution amounts are
Payment will be refunded to you How the Program Works updated on January first of each year. In
immediately if your deferred effective
addition, your subscriber contribution
date is more than sixty (60) days from
Choosing a Health Plan may change during the year if your
the date we receive your application.
The participating MRMIP health plans birthday moves you into a new age
provide comprehensive medical benefits category. For subscribers with enrolled
Agents/Brokers, Employers and dependents, the age category will be
for inpatient, outpatient hospital
Applicants based on the age of the applicant.
services and physician services. These
Insurance Code Section 12725.5 states benefits are outlined in the health plan Adjustments to subscriber contributions
that it shall constitute unfair competition description pages in this brochure. You due to age changes will occur on the
for an insurer, an insurance agent or may also call any MRMIP health plan first of the month following the
broker, or administrator to refer an at its toll-free number and ask for an birthdate of the applicant.
individual employee or their dependent(s) Evidence of Coverage or Certificate of
to apply for MRMIP with the purpose Subscriber contributions may also
Insurance booklet. Subscribers may
of separating that employee or their change when a member moves from
choose from any plan available to them
dependent(s) from group health one area of the State to another or if
depending on where they live, as listed
coverage provided in connection with a member transfers to a different plan.
on pages 18–23. Please review all
the employee’s employment. Adjustments to subscriber contributions
pages carefully to select a plan that is
will occur on the first of the month
right for you.
Insurance Code Section 12725.5 following notification of the move or on
further states that it shall constitute an the effective date of the transfer.
unfair labor practice contrary to public Benefits and Copayments
Each month you will receive a billing
policy for any employer to refer an Health Maintenance Organizations statement for your subscriber
individual employee or their (HMOs) in MRMIP require a fixed contribution. Subscriber contributions
dependent(s) to the MRMIP or to dollar copayment for some services and are payable in advance and are due the
arrange for an individual employee or up to a 20% copayment for other first day of every month. A subscriber
their dependent(s) to apply for MRMIP services. The Preferred Provider contribution billing statement will be
with the purpose of separating that Organization (PPO) in MRMIP may sent out thirty (30) days prior to the due
employee or their dependent(s) from also require a fixed dollar copayment for date. Please make check payable to the
group health coverage provided in certain services and up to a 15% California Major Risk Medical
connection with the employee’s copayment for other services. Insurance Program.
employment.
The out-of-pocket maximum per Subscribers now have several billing
Medi-Cal Beneficiaries calendar year for all MRMIP plans is options, which include monthly,
$2,500 for individuals and $4,000 for bi-monthly, and quarterly billing.
While Medi-Cal beneficiaries are not
an entire household covered by the
prohibited from enrolling in the Major Subscribers are responsible for their
MRMIP. This maximum does not apply
Risk Medical Insurance Program, a monthly subscriber contributions even if
to services rendered by providers that do
Medi-Cal beneficiary should carefully they do not receive a bill or if the
not participate in the subscriber’s subscriber contribution is paid by a
consider the cost before signing up for
chosen health plan’s provider network, third party.
MRMIP coverage. MRMIP subscribers
or to services not covered by the
are responsible for their monthly
3
A delinquency billing or final notice will withdrawals that are returned unpaid Post-Enrollment Waiting Period
be sent out on the 15th day following from the subscriber’s bank will result in
For subscribers and dependents enrolled
the due date. There is a grace period of removal from electronic withdrawal and in a Health Maintenance Organization
31 days from the due date. The require immediate payment by check or (HMO), there is a post-enrollment
member’s coverage will remain in effect money order. waiting period of 3 months. No health
during this time. care services are provided to subscribers
Upon written request to reinstate, the
and enrolled dependents during this
Disenrollment for nonpayment of a subscriber must include a check or
period. Subscribers will be informed of
subscriber contribution will occur on money order of subscriber contributions
when this period begins and ends.
the 32nd day after the due date. The to bring the account to current status
end date of coverage will be retroactive with an additional $25.00 processing No subscriber contributions are paid
fee. during this waiting period. The initial
to the last day of the month in which
one-month subscriber contribution will
the subscriber contribution was paid in You are required to submit your first be applied to the first month of service.
full. A disenrollment letter will be month’s subscriber contribution for
mailed to the subscriber. Subscribers are MRMIP health care coverage. This How You May Waive All or Part
responsible for the cost of any services payment is completely applied of the Exclusion/Waiting Period
received after the disenrollment date. towards your first month of coverage
Subscribers who are disenrolled for The exclusion/waiting period
if you are enrolled. Cashing your
nonpayment of their subscriber requirement may be waived in part
check does not guarantee
contributions may be reinstated upon or all if:
enrollment. Qualified insurance
written request only once in a rolling agents and brokers may be paid a 1. The subscriber and enrolled
12-month period. The subscriber must $50 fee by the State for explaining dependents have been on the
request reinstatement in writing within the MRMIP and assisting you in MRMIP waiting list for 180 days or
60 calendar days from the date of completing the application. The longer. In this circumstance, the
disenrollment and bring all delinquent State does not require an individual exclusion/waiting period will be
payments up to date. Any further applying to the MRMIP to pay any completely waived.
reinstatements will require a written fee, charge or commission to a
appeal to the Managed Risk Medical 2. The subscriber and enrolled
broker or agent. dependents were previously insured
Insurance Board for consideration.
by another health insurance policy
Subscribers may pay by check, money Pre-Existing Condition (including Medicare and Medi-Cal)
order or may elect to have their Exclusion Period and the application for enrollment in
monthly subscriber contribution the MRMIP was made within 63
“Pre-existing condition” means any days of the termination of the
automatically withdrawn from their condition for which medical advice,
checking account when accepted into previous coverage. In these
diagnosis, care, or treatment, including circumstances, you may be granted a
the MRMIP. In addition, a federally use of prescription drugs, was waiver up to 3 months. If the
recognized California Indian tribal recommended or received from a coverage was less than 3 months but
government can make required licensed health practitioner during the six was at least 1 month, the subscriber
subscriber contributions on behalf of months immediately preceding and enrolled dependents will be
a member of the tribe. enrollment in the MRMIP. given credit for either 1 or 2 months
Subscriber contribution checks and For subscribers and dependents enrolled toward their MRMIP
electronic withdrawals that are returned in a Preferred Provider Organization exclusion/waiting period.
by the subscriber’s bank for insufficient (PPO), there is a pre-existing condition 3. The subscriber and enrolled
funds may result in a retroactive exclusion period of 3 months. During dependents were insured by another
disenrollment date. The subscriber will this period, no benefits or services related health insurance policy that ended
be charged a processing fee for each to a pre-existing condition are covered. because of a loss of employment, or
However, subscriber contributions are because your employer stopped
payment received as having non-
paid during this period. offering or sponsoring health
sufficient funds. In addition, electronic
coverage, or because your employer
4
stopped making contributions doctors’ records which show that the spent solely on the waiting list does not
towards health coverage and dependent child cannot work for a count toward the 3 month pre-existing
application for enrollment in the living because of a physical or mental condition exclusion period or post-
MRMIP was made within 180 days disability which existed before the enrollment waiting period (once enrolled)
of the termination of the previous child became 23. unless the person has been on the waiting
coverage. In these circumstances, list for at least 180 days. If the person has
2. It is the responsibility of
you may be granted a waiver of up to
subscribers to notify the MRMIP been on the waiting list 180 days or
3 months.
about changes in the number of longer, the 3 month exclusion period will
4. The subscriber and enrolled dependents. Coverage for newborn be waived.
dependents were receiving children shall begin upon birth if the
coverage under a similar program in request is made within 60 days of
another state within the last 12 birth. Stepchildren are eligible for
Transfer of Enrollment
months. In this circumstance, the MRMIP dependent coverage upon Subscribers and enrolled dependents
exclusion/waiting period will be marriage by a subscriber to the may transfer from one participating
completely waived. stepchildren’s parent or at the time health plan to another if any of the
the stepchild loses other health following occur:
If you have met the criteria in #2, #3,
coverage. The domestic partner’s
or #4 to waive this exclusion/waiting
children are eligible for MRMIP 1. The subscriber requests, in writing,
period, please submit appropriate
dependent coverage upon the parent during the Program’s annual open
documentation and check the
being a registered domestic partner enrollment period held in November.
appropriate boxes on the application
with the subscriber or at the time the Subscribers will receive an open
(Program Eligibility Questions
children lose other health coverage. enrollment packet containing the
#5 and/or #6).
In all cases, the MRMIP must be plan choices and the new subscriber
All documentation must be received notified within 60 days. If eligible, contribution amounts.
prior to or with your first month’s dependents are covered within 90
subscriber contribution. days of the MRMIP being notified. All approved open enrollment
Dependents age 18 and under qualify transfers will be effective January 1.
The subscriber dependents age 18 and All enrolled dependents will also be
for a full pre-existing or post-
under are not subject to the pre- transferred to the new plan.
enrollment waiver. To add a
existing condition exclusion period or dependent to your policy, you may 2. The subscriber requests a transfer in
the post-enrollment waiting period. request an “Add Dependent” writing because the subscriber moved
application by calling (800) 289- and no longer resides in an area
Dependent Coverage Information 6574 and talking to a MRMIP served by their health plan. There
Enrollment Unit representative. must be at least one participating
1. Dependents may be covered under
3. Enrolled dependents of a deceased health plan available to serve the
the MRMIP and are defined as a
subscriber or dependents of a subscriber’s new area.
subscriber’s spouse, registered
domestic partner, and any unmarried subscriber who becomes eligible for 3. The subscriber or participating health
child who is an adopted child, a Medicare (Parts A and B) are eligible plan requests a transfer in writing
stepchild, a recognized natural child to continue coverage in the MRMIP because of the failure to establish a
under age 23, or a registered domestic as long as Program requirements satisfactory subscriber/plan relationship
partner’s own separate child. are met. and the Executive Director determines
that the transfer is in the best interest
A dependent also includes any
Waiting List of the MRMIP. There must be at least
unmarried child who is economically
one participating health plan available
dependent upon the applicant. An If the MRMIP reaches maximum
to serve the subscriber’s new area.
unmarried child over 23 years old enrollment, applicants and dependents
may be covered if that unmarried will be placed on a waiting list. Any transfer request must be in
child is incapable of self-support Applicants and dependents will be writing and mailed to:
because of physical or mental
enrolled when spaces become available Managed Risk Medical Insurance Board
disability which occurred before the
depending on the date the complete Benefits Division
age of 23. An applicant must provide
application was received. Any time P.O. Box 2769
documentation in the form of
5
Subscribers who transfer enrollment could be retroactive to the original Subscribers may file an appeal with the
are not subject to pre-existing effective date. Board on the following issues:
condition/waiting period exclusions.
Subscribers and dependents who have 1. Any action or failure to act which has
been disenrolled for any reason may not occurred in connection with a
Disenrollment
re-enroll in the MRMIP for a period of participating health plan’s coverage,
A subscriber and enrolled dependents 12 months.
will be disenrolled from the MRMIP 2. Determination of an applicant’s or
when any of the following occur: Health Plan’s dependent’s eligibility,
Dispute Resolution/Appeals
3. Determination to disenroll a
1. The subscriber requests disenrollment
If a subscriber is dissatisfied with any subscriber or dependent, and
in writing. The disenrollment will be
action, or inaction, of the plan/provider
effective at the end of the month in 4. Determination to deny a subscriber’s
which the request was received or organization in which they are enrolled,
the subscriber should first attempt to request or to grant a participating
disenrollment will be effective at the health plan request to transfer the
end of the month in which the resolve the dispute with the participating
plan/organization according to its subscriber to a different participating
subscriber contribution was paid
established policies and procedures. health plan.
in full.
2. The subscriber fails to make An appeal must be filed in writing and
subscriber contributions in
Binding Arbitration mailed within sixty (60) calendar days of
accordance with the MRMIP’s Each plan has its own rules for the action or failure to act or receipt of
existing subscriber contribution resolving disputes about the delivery of notice of the decision being appealed to:
payment and grace period practices. services and other matters. Some plans
Managed Risk Medical Insurance Board
The effective date of disenrollment say you must use binding arbitration for
P.O. Box 2769
for nonpayment of a subscriber disputes; others do not. Some plans say Sacramento, CA 95812-2769
contribution will be retroactive to that claims for malpractice must be
the last day of the month in which decided by binding arbitration; others Evidence of Coverage and
the subscriber contribution was paid do not. If the plan you choose requires Disclosure Forms
in full. binding arbitration, you are giving up
Evidence of Coverage and Disclosure
your right to a jury trial and cannot
3. The subscriber fails to meet the Forms are available from each health
have the dispute decided in court. To
residency requirement or becomes plan upon request. Please see each
find out more about how a plan
eligible for Medicare Part A and B, health plan description for a phone
resolves disputes, you can call the plan
unless eligible solely because of end- number to call to request one.
and ask for an Evidence of Coverage or
stage renal disease. Subscribers must
Certificate of Insurance booklet.
inform the MRMIP Enrollment Unit Coordination of Benefits
in writing when becoming eligible
Participating health plans will
for Medicare Part A and Part B. The Managed Risk Medical
coordinate coverage of benefits with any
Disenrollment will be effective at the Insurance Board (MRMIB)
Appeals Process other health insurance you may have.
end of the month in which the
The MRMIP is secondary to other
notification was received or The subscriber should first attempt to
insurance coverage and by State law will
disenrollment will be effective at the resolve the dispute with the
only pay after your other insurance has
end of the month in which the participating plan according to its
paid (not including Medi-Cal and other
subscriber contribution was paid in established policies and procedures.
State programs). Under the rules of the
full. This is a State program and the
MRMIP, the Program benefits will not
4. The subscriber or enrolled subscriber’s rights and obligations will
duplicate coverage you may have
dependent(s) has committed an act be determined under Part 6.5 Division
(whether you use it or not) under any
of fraud to circumvent the statutes or 2 of the California Insurance Code and
other program or plan.
regulations of the MRMIP. In the the regulations of Title 10, Chapter 5.5.
event of fraud, the disenrollment
6
Privacy Notification administration. You also have the right Most individuals who become eligible
This notice describes how medical to obtain a copy, or request to change for Medicare because of age or
information about you may be used the personal information you provided disability are entitled to purchase
and disclosed and how you can get to the MRMIP as long as the Program insurance to supplement their Medicare
access to this information. Please retains such information. You have the for six months after they first
review it carefully. right to obtain an explanation of how purchase Medicare Part B, and under
your personal information was certain other circumstances. For
When you apply for the MRMIP, the
disclosed, other than the use of your individuals who become eligible for
information you provide in the
information by MRMIP to carry out Medicare because of a disability, the
application is reviewed by a private
the operations of the Program. right to buy this supplemental
contractor. The private contractor is
insurance is the result of a recent state
hired by the State of California to assist MRMIP may revise the privacy law. You may call the HICAP Program
in the administration of the MRMIP. practices described here. The Program at 1-800-434-0222 for free information
The contractor uses your information will notify its subscribers in updated and counseling about these rights.
to determine whether you are eligible program handbooks or through direct
for MRMIP. The contractor and the mailed notices (within 60 days) of
State will use your information for such revisions. You may complain to
Program administration, evaluation, the MRMIP if you believe your
and for necessary purposes authorized privacy rights have been violated by
by law. contacting:
If you are determined eligible for HIPAA Coordinator
MRMIP, the contractor will send your MRMIP
information to the health insurance Managed Risk Medical Insurance Board
plan and provider that you select. P.O. Box 2769
This will begin your health insurance Sacramento, CA 95812-2769
coverage under that plan and you will (916) 324-4695
receive an insurance card. Once you Open Enrollment Period for
are enrolled, your health plan will Under Age 65 Disabled
forward information regarding the Medicare Beneficiaries
health care and services that you receive
You are ineligible for coverage through
to the State.
the MRMIP if you are eligible for
Uses and disclosures that are not part of Medicare Part A and Part B, unless you
the operations of the Program will only are eligible for Medicare solely because
be made with the subscriber’s written you have end-stage renal disease.
authorization or as required or You are obligated to inform the
permitted by law. This authorization Program when you become eligible
may later be revoked by written request. for Medicare Part A and Part B.
Please contact the MRMIP Enrollment

Your Rights Regarding How Your Unit at 1-800-289-6574. “Eligible” for
Personal Information Is Used Part A means that you are not required
to pay a premium for Part A. “Eligible”
You have the right to request that
for Part B simply means that you have
MRMIP restrict the use of your the right to purchase Part B because
personal information. The Program you are eligible for Part A. You are
may not agree to restrictions if it would ineligible for MRMIP even if you
interfere with its normal operations and choose not to pay the premium for
Medicare Part B.
7
Blue Cross of California Preferred Provider Organization (PPO)
(formerly known as Prudent Buyer) Administered by
(800) 289-6574
Plan Highlights The Blue Cross of California PPO plan Blue Cross contracts with most hospitals
includes the Blue Cross Prescription in California. However, benefits are not
No annual deductibles!
Drug Program with these important provided for care furnished by the few
Just your co-payment up front with features: hospitals without any Blue Cross
no paperwork for medical and agreement except in a medical emergency.
• No annual drug deductible!
prescription expenses!
• Lower cost: Blue Cross has
Customer service hours for faster service.
negotiated discounts with almost
How the Plan Works
8:30 am – 7:00 pm (pacific time) Quality Medical Service at
90% of California retail pharmacies,
Monday – Friday Discounted Rates
including all of the major chain
Blue Cross of California offers you our drugstores. You may choose any Blue Cross has found a way to control
Preferred Provider Organization (PPO) pharmacy, but your costs are much escalating medical expenses for
Plan. It covers your medical and lower if you stay in the network. members. We have negotiated
prescription expenses from your initial discounted rates with a network of
• Service: Network pharmacies are
visit so you never have to pay a physicians and hospitals across the state.
supported by an on-line electronic
deductible. Our PPO plan offers you These providers form the Preferred
network and will collect your co-
more freedom than an HMO in Provider Organization (PPO) plan.
payment when you pick up your
choosing doctors, hospitals, and They give Blue Cross members a
prescription. No claim forms to file!
other medical providers. It provides discount for care.
comprehensive health care coverage that • High value mail order program: For
is convenient and in tune with your many maintenance drugs, you can With no deductibles, members pay only
needs, such as: order up to a 60-day supply. There a $25 co-payment for office visits to the
are no claim forms and only a $5 in-network doctor of their choice. Blue
• No annual deductible! Cross pays the rest. For most other in-
co-payment per generic prescription.
• Extensive provider network network services, Blue Cross pays 85%
comprising more than 40,000 PPO of the discounted rate. Once you reach
physicians, 29,000 HMO physicians
Advantages of Plan your yearly maximum co-payment
and over 400 hospitals. Providers limit, Blue Cross pays 100% of the cost
• $25 office visit co-payment Access to one of the largest provider for in-network covered services for the
in-network. networks in California. rest of the year.
• Prescription drug coverage The Blue Cross Preferred Provider Blue Cross has been helping Californians
including pharmacy and mail order Organization (PPO) plan gives you get healthy and stay healthy for over 65
service–with no deductible. access to quality care through our years.
network of physicians, hospitals and
• 30–60% savings when you use our selected ambulatory surgical centers,
in-network providers. Important Information
infusion therapy, and durable medical
• No claim forms when you use our If you would like more information
equipment providers. Using network
in-network providers. prior to enrollment, please call Blue
providers ensures maximum member
Cross Customer Service at
• Yearly maximum co-payment limit savings.
(800) 289-6574.
in-network: Benefits are still available out-of-
– $2,500 per member. network. Please note that the information presented
– $4,000 per family. You can go outside the network and here is only a summary. The Blue Cross
• $75,000 annual maximum for still receive benefits. You will pay a Plan for MRMIP is subject to various
benefits paid. much greater share of the cost when limitations, exclusions and conditions, as
you use a non-participating provider fully described in the Evidence of
• $750,000 lifetime maximum for Coverage. For exact terms and conditions
benefits paid. as you will be responsible for a larger
co-payment and any charges which of coverage, you should refer to the
exceed the fee schedule. Evidence of Coverage booklet.
Blue Cross of California is an Independent Licensee of the Blue Cross Association.

The Blue Cross name and symbol are registered service marks of the Blue Cross Association.
8
Blue Cross of California
Summary of Benefits
What You Pay
Type of Service Description of Service Participating Provider Non-Participating Provider
Calendar Year Deductible There is no deductible 0 0
Co-payment Member’s amount due and payable to the provider of care See Below See Below
Yearly Maximum Member’s annual maximum co-payment limit when using $2,500 per member No yearly maximum co-payment limit
Co-Payment Limit participating providers $4,000 per family for non-participating providers.
You pay unlimited co-payments
If non-participating providers are used, billed charges which
exceed the customary and reasonable charges are the member’s
responsibility and do not apply to the yearly maximum co-payment limit
Annual Benefit Maximum You must pay for all services received after the combined total of all benefits paid
under the MRMIP reaches $75,000 in one calendar year for a member
Lifetime Benefit Maximum You must pay for all services received after the combined total of all benefits paid
under the MRMIP reaches $750,000 in a lifetime for a member
Hospital Services Inpatient medical services (semi-private room) 15% of negotiated fee rate All charges except for $650 per day
Outpatient services; ambulatory surgical centers 15% of negotiated fee rate All charges except for $380 per day
(No benefits are provided in a non contracting hospital or
non contracting dialysis treatment center in California,
except in the case of a medical emergency)
Physician Office Visits Services of a physician for medically necessary services $25 office visit 50% of customary and reasonable charges
and any in excess
Inpatient Professional Services Services of a physician for medically necessary services 15% of negotiated fee rate 50% of customary and reasonable charges
and any in excess
Diagnostic X-Ray and Lab Services Outpatient diagnostic x-ray and laboratory services 15% of negotiated fee rate 50% of customary and reasonable charges
and any in excess
Prescription Drugs Maximum 30 day supply per prescription when $5 for generic drugs All charges except 50% of drug limited fee
filled at a participating pharmacy $15 for brand drugs schedule for generic or brand name drugs
60 day supply for mail order $5 for generic drugs through mail service prescription drug program
(PrecisionRx)
$15 for brand drugs through mail service prescription drug program
(PrecisionRx)
Durable Medical Equipment Must be certified by a physician and required for 15% of negotiated fee rate 50% of customary and reasonable charges
and Supplies care of an illness or injury and any in excess
Pregnancy and Maternity Care Inpatient normal delivery and complications of pregnancy 15% of negotiated fee rate All charges except for $650 per day for
hospital services
Prenatal & postnatal care 15% of negotiated fee rate 50% of customary and reasonable charges
and any in excess
Ambulance Services Ground or air ambulance to or from a hospital for 15% of negotiated fee rate 15% of customary and reasonable charges
medically necessary services and any in excess
Emergency Health Care Services* Initial treatment of an acute serious illness or accidental 15% of negotiated fee rate 15% of customary and reasonable
injury. Includes hospital, professional and supplies. charges or billed charges, whichever
is less plus any charges in excess of
customary and reasonable for the
first 48 hours.
Mental Health Services* • Inpatient nervous and mental services 10 days each calendar year 15% of negotiated fee rate All charges except for $175 per day
and all costs for stays up to 10 days. In addition, all
over 10 days costs for stays over 10 days
• Outpatient nervous and mental visits 15 visits each calendar year 15% of negotiated fee rate 50% of customary and reasonable charges
Except for severe mental illnesses, and serious emotional for 15 visits per year. and any in excess. In addition, all costs
disturbances in children All costs for over 15 visits over 15 visits
Home Health Care Home health services through a home health agency 15% of negotiated fee rate 50% of customary and reasonable charges
or visiting nurse association. and any in excess
Hospice Hospice care for members who are not expected to live 15% of negotiated fee rate 50% of customary and reasonable charges
for more than 12 months and any in excess
Skilled Nursing Facilities Skilled nursing care Not covered unless Blue Cross recommends as a medically
appropriate more cost-effective alternative plan of treatment
Infusion Therapy* Therapeutic use of drugs, or other substances ordered 15% of negotiated fee rate You pay all charges in excess of $500
by a physician and administered by a qualified provider per day for all infusion therapy related
administrative, professional, and drugs
Physical/Occupational/ Services of physical therapists, occupational therapists, and 15% of negotiated fee rate You pay all charges except for
Speech Therapy speech therapists as medically appropriate on an outpatient basis. $25 per visit
* For exact terms and conditions of coverage, you should refer to your Evidence of Coverage booklet.
9
Blue Shield of California has a 60-year tradition of superior member service.
Our service professionals have continued to earn the trust and confidence of our
more than 2 million current members.
(800) 424-6521
Plan Highlights network. Plus, you may change Personal are using the Access + Specialist option.
Physicians for any reason at any time Your Personal Physician or his or her
Blue Shield’s revolutionary approach to
simply by calling Blue Shield Member designee is available 24 hours a day,
health care coverage makes it easier
Services. seven days a week.
than ever for you to get the care you
need and the service you deserve. Blue Shield’s Access + HMO Plan is Your Personal Physician or Physician
We offer the following special features available to MRMIP subscribers in the group will authorize any medically
to give you greater control over following California counties: necessary X-ray, laboratory, emergency
your health: or hospital services. Prescription drugs
Alameda San Bernardino can be filled at any Blue Shield
• Access + Specialist gives you the Contra Costa San Diego participating pharmacy, including most
option to go directly to a specialist in Fresno San Francisco major drugstore chains.
the same physician group as your Kern San Joaquin
Personal Physician without a referral Los Angeles San Mateo Copayments
for a $30 co-payment per visit. Of Marin Santa Barbara The maximum amount you pay in co-
course, you can always choose to go Nevada Santa Clara payments is $2,500 per individual and
through your Personal Physician and Orange Solano $4,000 per family in a calendar year.
pay your standard $15 co-payment Placer Sonoma
when you obtain a referral to a Riverside Stanislaus Important Information
specialist. Sacramento Ventura Selection of a Personal Physician
• Access + Satisfaction is our member from the Blue Shield HMO Physician
Please see the chart at the back of this
feedback program that offers to refund and Hospital Directory is required
brochure for the specific zip codes open
your standard $15 co-payment if you when enrolling in the plan. When you
to MRMIP.
are ever dissatisfied with the service select a personal physician, you are also
you receive during a covered office selecting the physician group and
visit with one of our HMO network
How the Plan Works
specialists affiliated with your personal
physicians. Your Personal Physician will provide or physician. To select a Personal Physician
coordinate all of your health care needs, or for more information on Blue Shield
With Access + HMO, there are virtually
except for Well-Woman exams and of California and the Access + HMO
no claim forms to file, and your
Access + Specialist visits. (To use the Plan, call us toll-free at (800) 424-6521.
dependents (spouse and unmarried
Access + Specialist option, your Personal We welcome your call.
children under age 23) are also eligible
Physician must belong to a physician
for coverage under the Access + HMO
group that has chosen to become an
Plan.
Access + Provider Group and offers the Please note that the information presented
An independent member of the Blue Shield Association.

Annual maximum benefits are $75,000 Access + Specialist option.) here is only a summary of the Access +
per covered individual, and lifetime HMO Plan. For exact terms and
To make an appointment with your
maximum benefits are $750,000 per conditions of coverage, you should refer to
Personal Physician or with a specialist
covered individual. the Evidence of Coverage booklet.
in the same physician group using the
Plan Providers Access + Specialist option, simply call the
physician’s office directly and identify
As an Access + HMO member, you yourself as an Access + HMO member.
have access to thousands of You will be asked for your Access +
participating physicians in 22 counties. HMO member identification card and
Odds are that your current doctor is a your co-payment at the time of your
member of our HMO provider visit. (When using the Access + Specialist
network. option, you will also need to show your
You and each covered family member Access + Specialist card.)
may choose his or her own Personal Always call your Personal Physician
Physician from our extensive provider when you need medical care, unless you
10
Blue Shield Access + HMO
Summary of Benefits
Type of Service Description of Service What You Pay
Calendar Year Deductible The amount that you must pay before Blue Shield assumes No deductible
liability for the remaining cost of covered services
Co-payment Your cost of covered services See specific service
Out-of-Pocket Maximum The amount you are responsible for paying per calendar year $2,500 (per covered person)
$4,000 (per covered family)
Hospital Services • Inpatient services, including semi-private room & board, $200 co-pay per inpatient day
general nursing care, and drugs
Physician Care • Office visits $15 co-pay per office visit

• Specialist visits Access + $30 co-pay per office visit
• Home visits by Plan Physicians $25 per visit
• Allergy testing No charge
• Routine physical examinations, hearing and vision tests No charge
• Immunizations No charge
Diagnostic X-Ray and Laboratory tests and X-rays, major diagnostic No charge
Laboratory Tests and mammography, ultraviolet light therapy
Outpatient Prescription Drugs Medically necessary drugs prescribed by physician and obtained at a Plan $10 generic/$10 generic mail order
(Closed Formulary) pharmacy, according to Formulary guidelines $15 brand/$20 brand mail order
Durable Medical Equipment, Durable medical equipment, oxygen and its administration, and home colostomy 20% co-pay of allowed charges
Supplies, Prosthetic Devices and ostomy supplies that meet the member’s medical needs and are
and Braces cost effective, prostheses, and orthoses. (Routine maintenance and repair due to
damage are not covered, and HMO rental charges in excess of purchase
price are not covered.)
Pregnancy and Maternity Care Prenatal and postnatal care $15 co-pay per office visit
Normal delivery, complications of pregnancy, C-section $200 co-pay per inpatient day
Ambulance Ground transportation as medically necessary No charge
Emergency Care Services Plan and non-plan emergency room visits $25 co-pay per visit,
waived if directly admitted as an inpatient
(Hospitalization co-pays apply)
Mental Health Care Mental health services

• Inpatient hospital and professional services 10 days each calendar year $200 co-pay per inpatient day
• Outpatient psychiatric care services up to 15 visits per calendar year $15 co-pay per visit
Except for severe mental illnesses, and serious emotional disturbances in children
Home Health Care Medically necessary visits by home health care agency personnel $10 per visit
Hospice Care Hospice care for members diagnosed as having a terminal $50 per day
illness with a life expectancy of 12 months or less
Skilled Nursing Services As medically necessary in lieu of hospitalization. Up to 100 days per calendar year $50 per day
Custodial care is not covered
Speech/Physical/ Rehabilitative therapy services by a physical, occupational, respiratory or speech

Occupational Therapy therapist in the following settings:
• In the rehabilitation unit of a hospital or skilled nursing facility for medically $50 per day
necessary days
• For services in an outpatient location $15 co-pay per visit
Other Blood (administration of blood & blood plasma, including No charge

the cost of blood, blood plasma & blood processing and in-hospital blood processing)
Access + HMO benefits are provided only for services that are medically necessary, as determined by the Personal Physician or Access + HMO specialist, and must
be received while the patient is a current member. All care must be prescribed by and received from a Blue Shield Access + HMO physician or a physician to
whom a Blue Shield HMO physician has referred you to for specific care. Payments for care that is not covered do not count toward your out-of-pocket maximum.
Please read the Evidence of Coverage booklet for complete details of coverage.
11
Contra Costa County’s own HMO, serving
residents since 1973.
Member Call Center
1-(877) 661-6230 (Press 2)
Plan Highlights will make sure you get all the preventive card. Call CCHP Member Services
care, routine care, and referrals for (877) 661-6230 (Press 2) with any
Contra Costa Health Plan (CCHP),
specialty care that you need. questions about your membership.
founded in 1973, is stable and secure.
CCHP is sponsored by the County of CCHP’s other “provider network” is the Your Co-payments and Prescription
Contra Costa, is licensed by the “Community Provider Network”. With Coverage
California State Department of offices throughout Contra Costa You will be responsible for paying a co-
Managed Health Care, and is a federally County, you will easily be able to select payment for some services, such as
qualified Health Maintenance a primary care Provider near you. These doctor visits and hospital stays. You will
Organization. Our over 65,000 community physicians are affiliated be charged 20% of the cost of your
members, therefore, have the assurance with one or more of six hospitals in the prescriptions, which must be obtained
of knowing that CCHP must conform area. The Contra Costa Regional at Plan-authorized pharmacies.
to the highest standards of care. Medical Center’s specialty services are The maximum amount of co-payments
also available to physicians and you will pay is $2,500 per person, or
Our members appreciate
members of this network. $4,000 per family, in any calendar year.
* Affordable care, plus service
How the Plan Works Maximum Benefits
* A comprehensive benefit package
Contra Costa Health Plan is available to Annual maximum benefits are $75,000
* Neighborhood Health Centers with MRMIP subscribers who live in Contra per covered person, with a maximum
extended hours for primary and Costa County. lifetime benefit of $750,000.
urgent care services, and access to
When you join the Contra Costa
Contra Costa Regional Medical
Health Plan, we encourage you to call
Important Information
Center To learn more about Contra Costa
our Member Services Department. Our
* An extensive network of community friendly Member Services Health Plan’s MRMIP, call
primary care and specialty physicians, Representatives will take as much time our Marketing Department at
and contracted community hospitals as you need to help with selecting your 1-(800) 221-8040 (Press 5).
* A 24-hour Advice Nurse service Primary Care Provider, and with any
available 365 days a year other questions you may have about The information presented on this page is
how to access your plan services. You only a summary. For exact terms and
* Emergency services covered conditions please refer to the Evidence of
worldwide can change primary care doctors at any
time, by calling Member Services and Coverage booklet.
Plan Providers choosing another doctor from either
When you select CCHP for yourself physician network.
and your family, you are gaining access The 24-hour Advice Nurses are
to over 150 primary care providers and available to members every day of the
over 300 specialist doctors. CCHP year. Advice Nurses offer confidential
offers a choice of two “provider and professional health advice, and
networks”: One, our Regional Medical important information about prenatal
Center Network, offers primary care care services.
and access to specialty care through
eight Health Centers and at the newest All new members will receive
hospital in the East Bay, the Contra Informational Materials, which include
Costa Regional Medical Center in a Member Handbook, Provider
Martinez. You would simply select the Directory, Combined Evidence of
Health Center most conveniently Coverage and Disclosure document,
located for you, and your doctor there and a Health Plan membership ID
12
Contra Costa Health Plan
Summary of Benefits
What You Pay
Type of Service Description of Service Contra Costa Health Plan
Provider
Calendar Year Deductible There is no deductible -0-
Co-payment Your out-of-pocket expense for the cost of authorized Inpatient medical $200/day
and covered expenses Inpatient psychiatric $200/day
Inpatient maternity $200/day
Outpatient ER $25/visit
Outpatient visits $15/visit
Out-of-pocket Maximum The annual maximum out-of-pocket expense you’re $2,500 (per covered person)
responsible for (excluding unauthorized or non-covered $4,000 (per family)
services)
Hospital Services Semi-private room & board, and all medically necessary
inpatient services and supplies including inpatient $200/day
visits by physicians
Physician Care Medical and surgical outpatient services performed or Office visits $15/visit
authorized by Contra Costa Health Plan provider Well baby $15/visit
Physical exams $15/visit
Diagnostic X-ray and Lab Tests Inpatient and outpatient diagnostic X-ray and laboratory -0-
Prescription Drugs Drugs prescribed by a physician 20% of the cost of prescription

obtained at Plan-authorized
pharmacies
Durable Medical Equipment Purchase or rental as authorized by Contra Costa Health -0-
& Supplies Plan and required for care of an illness or injury
Maternity Care Treated as any other medical condition:

Inpatient $200/day
Outpatient $15/visit
Ambulance Ambulance service when required for an emergency or $15 copay

approved by a Contra Costa Health Plan physician
Emergency Care Services Services in an emergency room for emergency care $25/visit
only – non-emergency care not covered
Mental Health Care Inpatient visits up to 10 days per calendar year $200/day
Outpatient visits up to 15 visits per calendar year $15/visit
Limitations do not apply to severe mental illnesses or serious emotional disturbances
in children
Home Health Care/ Medically necessary visits when authorized for -0-
Home Hospice Care diagnostic and treatment service and nursing care
Skilled Nursing Services Provided only when Contra Costa Health Plan authorizes -0-
as medically necessary and more cost effective
Speech/Physical/ Medical rehabilitation and the services of occupational therapists, physical therapists, $15/visit
Occupational Therapy and speech therapists as appropriate on an outpatient basis
Other Blood and blood plasma, 24-hour Advice -0-

Nurse, member services, health education, and case management
Note: All benefits are covered by Contra Costa Health Plan only if they are prescribed or directed by a Contra Costa Health Plan physician.
Other Plan limitations and exclusions apply. Please refer to the Evidence of Coverage for disclosure of Plan limitations and exclusions.
Contra Costa Health Plan is available only to residents in Contra Costa County.
13
Northern California (800) 464-4000
Plan Highlights Kaiser Permanente is available in the Co-payments

following Northern California counties: The maximum amount you pay in co-
For over 50 years, Kaiser Permanente
has provided quality care for the people Alameda Sacramento payments is $2,500 per individual and
of Northern California. You can receive Amador San Francisco $4,000 per family in a calendar year.
care at any of our locations in Northern Contra Costa San Joaquin
California, close to work or close to El Dorado San Mateo Important Information
home - or both. Fresno Santa Clara For more information about the
Kings Solano Northern California Kaiser Permanente
Your family (spouse and unmarried
Madera Sonoma MRMIP Plan, please call our Member
children under age 23) are also eligible
Marin Sutter Service Call Center at (800) 464-4000.
for coverage under Kaiser Permanente’s
Mariposa Tulare
MRMIP Plan. Annual maximum Please note that the information presented
Napa Yolo
benefits are $75,000 per covered on these pages is only a summary of the
Placer Yuba
individual, lifetime maximum benefits Kaiser Permanente MRMIP Plan for
are $750,000 per covered individual. Please see the chart at the back of this Northern California. For exact terms and
brochure for the specific zip codes open conditions of coverage, you should refer to
You do not need to file claim forms for
to MRMIP Plan enrollment. the Evidence of Coverage booklet.
the services you receive at Kaiser
Permanente facilities. How the Plan Works
Plan Providers Always carry your Kaiser Permanente
ID Card. You can make an
Representing virtually all major medical
appointment by calling the
and surgical specialties, our physicians
appointment desk at the Kaiser
work together in one of the nation’s
Permanente facility that is most
largest medical groups to care for you
convenient for you.
and your family.
Laboratories, X-ray services, and
We’re proud of the caliber of our
pharmacies are located at most medical
physicians. Many of them graduated
facilities. Urgent care is available on a
from the top medical schools, such as:
same-day basis at many facilities.
Harvard, Yale, Stanford, and UCLA.
Medical advice by phone and
You can choose your own Kaiser emergency services are available 24
Permanente primary care physician hours a day.
who will work with you to coordinate
As a group practice, our physicians can
all your health care needs. Of course,
easily refer you to a specialist within
you and your family are not restricted
your medical center or another Kaiser
to only one of our physicians or
Permanente facility.
facilities. You may receive care at any
of our locations in Northern California.
14
Kaiser Permanente Northern California
Summary of Benefits
Calendar Year Deductible The amount that you must pay before Kaiser Permanente No deductible
assumes liability for the remaining cost of covered services
Out-of-Pocket Maximum The maximum amount you’re responsible for paying for covered services $2,500 (per covered person)
per calendar year $4,000 (per covered family)
Hospital Services Room and board, anesthesia, X-rays, lab tests, and drugs $200 co-pay per inpatient day
Physician Care Primary and specialty care visits $20 co-pay per office visit
Allergy injections $3 co-pay per injection
Routine physical examinations; hearing and vision tests $20 co-pay per office visit
Immunizations No charge
Diagnostic X-Ray and Laboratory tests and X-rays, major diagnostic $5 per visit
Prescription Drugs Drugs prescribed by a plan physician and obtained at a plan $10 generic for up to a 100-day supply
pharmacy in accord with formulary guidelines $35 brand for up to a 100-day supply
Durable Medical Equipment, Durable medical equipment when prescribed by a plan physician and obtained 20% of member rate
Supplies, Prosthetic Devices from plan providers through Kaiser Permanente No charge during hospital stay
and Braces
Maternity Care Prenatal and postnatal care $15 co-pay per office visit
Inpatient care, complications of pregnancy, C-section $200 co-pay per inpatient day
Ambulance Ambulance services $75 per trip
Emergency Care Services Emergency department visits $100 co-pay per incident (waived if admitted
and hospitalization co-pays apply)
Mental Health Care Inpatient visits up to 10 days per calendar year $200 co-pay per inpatient day
Outpatient visits up to 15 visits per calendar year $20 co-pay per visit
Day and visit limits do not apply to severe mental illnesses and serious emotional
disturbances in children
Home Health Care/Hospice Care Medically necessary visits by home health personnel up to 100 visits per year No charge
Hospice care No charge
Skilled Nursing Services Up to 100 days per benefit period No charge up to 100 days per
benefit period
Speech/Physical/ Outpatient medical rehabilitation and the services of an occupational therapist, $20 co-pay per visit
Occupational Therapy physical therapists, and speech therapists
Inpatient No charge
Note: All care must be prescribed by and received from the Permanente Medical Group (TPMG) physician, or a physician to whom a TPMG physician has referred you for specific
care. Any care received outside of Kaiser Permanente Northern California Region is not covered, with the exception of emergencies.
This chart does not describe benefits. To learn what is covered for each benefit (including exclusions and limitations) and additional
benefits not included in this summary, please refer to the Evidence of Coverage for this plan.
15
Southern California (800) 464-4000
Plan Highlights Plan Providers • Referrals to specialists – As a group

practice, our physicians can easily
Kaiser Permanente’s medical care • When you select Kaiser Permanente
refer you to a specialist within your
program offers the kind of benefits as your MRMIP Plan provider, your
service area, at another Kaiser
you’ve been looking for: medical care is provided or arranged
Permanente service area.
Convenient Care by Kaiser Permanente physicians at
Kaiser Permanente medical facilities. • Co-payments – The maximum
• You can receive care at any of our Our dedicated physicians represent co-payments you pay in a calendar
locations in Southern California, virtually all major medical and year are $2,500 per individual and/or
close to work or close to home - surgical specialties, and work together $4,000 per family.
or both. in one of the nation’s largest medical
• MRMIP subscribers can get care in groups to care for you and your
parts of six Southern California
Important Information
family.
counties (Los Angeles, Orange, For more information about the Southern
• We’re proud of the caliber of our California Kaiser Permanente MRMIP
Riverside, San Bernardino, San physicians. Many of them graduated
Diego, and Ventura). Plan program, please call our Member
from top medical schools, such as: Service Call Center at (800) 464-4000.
• Please see the chart at the back of this Harvard, Yale, Stanford, and UCLA. Please note that the information presented
brochure for the specific zip codes • You can choose your own Kaiser on these pages is only a summary of the
open to MRMIP Plan enrollment. Permanente primary care physician Kaiser Permanente MRMIP Plan for
Broad-based Care who will work with you to coordinate Southern California. For exact terms and
• Your family (including spouse and all your health care needs. You or conditions of coverage, you should refer to
unmarried children under age 23) are your family may select a different the Evidence of Coverage.
also eligible for coverage under the physician at any time – your choice is
MRMIP Plan. Your annual maximum never restricted to any one physician
benefit total is $75,000 per covered or facility.
individual, and the lifetime maximum • Emergency and urgent care are
benefit is $750,000 per covered available from Kaiser Permanente
individual. 24 hours a day, 7 days a week.
• In addition to primary care visits,
your MRMIP Plan includes speciality How the Plan Works
care services, lab tests, • Always carry your Kaiser
X-rays and health education classes. Permanente ID Card. It has
A Plan That’s Easy to Use important information which will
assist you in making appointments
• You do not need to file claim forms and utilizing services. You can make
for services received at Kaiser an appointment by calling one of our
Permanente facilities. convenient appointment centers.
• When you present your Kaiser card at • Laboratories, X-ray services, and
one of our Health Plan facilities, our pharmacies – These are located at
computerized registration system will each medical center (many
identify your benefits and co-payments pharmacies are open 24 hours).
as described on the next page.
• Urgent care is available on a walk-in
• Upon enrollment in the MRMIP basis at each Medical Center. Medical
Plan, you will receive The Guidebook advice by phone and emergency
to Kaiser Permanente Services. This services are available 24 hours a day,
publication is a directory of all seven days a week.
Southern California facilities and
services available to our members.
16
Kaiser Permanente Southern California
Summary of Benefits
Calendar Year Deductible The amount that you must pay before Kaiser Permanente No deductible
assumes liability for the remaining cost of covered services
Out-of-Pocket Maximum The maximum amount you’re responsible for paying for covered services $2,500 (per covered person)
per calendar year $4,000 (per covered family)
Hospital Services Room and board, anesthesia, X-rays, lab tests and drugs $200 co-pay per inpatient day
Physician Care Primary and specialty care visits $20 co-pay per office visit
Allergy injections $3 co-pay per injection
Routine physical examinations, hearing and vision tests $20 co-pay per office visit
Immunizations No charge
Diagnostic X-Ray and Laboratory tests and X-rays, major diagnostic $5 per visit
Prescription Drugs Drugs prescribed by a plan physician and obtained at a plan $10 generic for up to a 100-day supply
pharmacy in accord with formulary guidelines $35 brand for up to a 100-day supply
Durable Medical Equipment, Durable medical equipment when prescribed by a plan physician and obtained 20% of member rate
Supplies, Prosthetic Devices from plan providers through Kaiser Permanente No charge during hospital stay
and Braces
Maternity Care Prenatal and postnatal care $15 co-pay per office visit
Inpatient care, complications of pregnancy, C-section $200 co-pay per inpatient day
Ambulance Ambulance Services $75 per trip
Emergency Care Services Emergency department visits $100 co-pay per incident (waived if admitted
and hospitalization co-pays apply)
Mental Health Care Inpatient visits up to 10 days per calendar year $200 co-pay per inpatient day
Outpatient visits up to 15 visits per calendar year $20 co-pay per visit
Day and visit limits do not apply to severe mental illnesses and serious emotional
disturbances in children
Home Health Care/Hospice Care Medically necessary visits by home health personnel up to 100 visits per year No charge
Hospice care No charge
Skilled Nursing Services Up to 100 days per benefit period No charge up to 100 days per
benefit period
Speech/Physical/ Outpatient medical rehabilitation and the services of an occupational therapist, $20 co-pay per visit
Occupational Therapy physical therapists, and speech therapists
Inpatient No charge
Note: All care must be prescribed by and received from the Permanente Medical Group (SCPMG) physician, or a physician to whom a SCPMG physician has referred you for specific
care. Any care received outside of Kaiser Permanente Southern California Region is not covered, with the exception of emergencies.
This chart does not describe benefits. To learn what is covered for each benefit (including exclusions and limitations) and additional
benefits not included in this summary, please refer to the Evidence of Coverage for this plan.
17
California Major Risk Medical Insurance Program
Monthly Subscriber Contributions
Area 1
Counties: Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, El Dorado, Glenn, Humboldt, Inyo, Kings, Lake, Lassen,
Mendocino, Modoc, Mono, Monterey, Nevada, Placer, Plumas, San Benito, Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity,
Tulare, Tuolumne, Yolo, Yuba.
See below for service areas and available zip codes.
Rating Group Age BC BS HMO1 KPNC2
Subscriber Only <15 $233.80 $646.36 $162.33

15-29 $306.30 $646.36 $240.80
30-34 $412.50 $810.85 $284.53
35-39 $460.00 $861.76 $305.53
40-44 $548.80 $933.42 $342.84
45-49 $623.80 $1,022.04 $376.66
50-54 $776.30 $1,120.10 $434.96
55-59 $951.30 $1,384.10 $497.93
60-64 $1,076.30 $1,778.21 $551.58
65-69 $1,205.00 $2,190.75 $732.28
70-74 $1,270.00 $2,637.08 $772.75
>74 $1,345.00 $3,118.97 $818.43
Subscriber & <15 $475.00 $1,259.64 $356.73
1 Dependent 15-29 $815.00 $1,259.64 $508.43
30-34 $941.30 $1,580.21 $578.40
35-39 $1,040.00 $1,683.92 $637.88
40-44 $1,105.00 $1,823.46 $699.68
45-49 $1,243.80 $1,995.06 $733.49
50-54 $1,522.50 $2,183.63 $874.59
55-59 $1,828.80 $2,696.54 $969.05
60-64 $2,031.30 $3,469.67 $1,103.15
65-69 $2,275.00 $4,274.63 $1,290.63
70-74 $2,396.30 $5,145.52 $1,363.54
>74 $2,538.80 $6,085.80 $1,449.65
Subscriber & <15 $708.80 $1,957.35 $592.68
2 or More Dependents 15-29 $1,137.50 $1,957.35 $832.61
30-34 $1,317.50 $2,391.06 $1,007.53
35-39 $1,421.30 $2,573.97 $1,007.53
40-44 $1,552.50 $2,715.39 $1,022.69
45-49 $1,683.80 $2,804.02 $1,022.69
50-54 $1,966.30 $2,845.51 $1,131.14
55-59 $2,317.50 $3,200.02 $1,131.14
60-64 $2,550.00 $3,899.61 $1,278.08
65-69 $2,856.30 $4,804.32 $1,665.98
70-74 $3,008.80 $5,783.12 $1,764.53
>74 $3,187.50 $6,839.91 $1,872.25
1 Blue Shield HMO available only to residents in 2 Kaiser Permanente Northern California available only to residents in
these zip codes in these counties: these zip codes in these counties:
Nevada–95712, 95924, 95945-46, 95949, 95959-60, 95975, Amador–95640 and 95669;
and 95986. El Dorado–95613-14, 95619, 95623, 95633-35, 95651, 95664,
Placer–95602-04, 95631, 95648, 95650, 95658, 95661, 95667, 95672, 95682, and 95762;
95663, 95677-78, 95681, 95701, 95703, 95713-15, 95717, 95722, Kings–93230 and 93232;
95736, 95746-7, and 95765. Placer–95602-04, 95648, 95650, 95658, 95661, 95663, 95677-78,
95681, 95692, 95703, 95722, 95736, 95746-47, and 95765;
Sutter–95626, 95648, 95659, 95668, 95674, and 95676;
Tulare–93238, 93261, 93618, 93631, 93666, and 93673;
BC = Blue Cross Yolo–95605, 95607, 95612, 95616-18, 95645, 95691, 95694-95,
BS HMO = Blue Shield HMO 95697-98, 95776, and 95798-99;
Yuba–95692, 95903, and 95961.
KPNC = Kaiser Permanente Northern California
18
Area 2
Counties: Fresno, Imperial, Kern, Madera, Mariposa, Merced, Napa, Sacramento, San Joaquin, San Luis Obispo, Santa
Cruz, Solano, Sonoma, Stanislaus.
Rating Group Age BC BS HMO3 KPNC4/KPSC5
Subscriber Only <15 $221.30 $617.00 $162.74
15-29 $292.50 $617.00 $240.80
30-34 $393.80 $771.25 $284.53
35-39 $441.30 $820.28 $305.53
40-44 $520.00 $886.27 $342.84
45-49 $592.50 $971.13 $376.66
50-54 $737.50 $1,063.53 $434.96
55-59 $902.50 $1,312.44 $497.93
60-64 $1,020.00 $1,687.69 $551.58
65-69 $1,142.50 $2,079.24 $735.28
70-74 $1,203.80 $2,502.85 $776.23
>74 $1,276.30 $2,960.21 $823.53
Subscriber & <15 $456.30 $1,199.30 $357.56
1 Dependent 15-29 $777.50 $1,199.30 $508.43
30-34 $900.00 $1,499.12 $578.40
35-39 $991.30 $1,599.07 $637.88
40-44 $1,051.30 $1,731.06 $699.68
45-49 $1,183.80 $1,891.35 $733.49
50-54 $1,448.80 $2,072.37 $874.59
55-59 $1,738.80 $2,558.88 $969.05
60-64 $1,941.30 $3,292.42 $1,103.15
65-69 $2,175.00 $4,056.26 $1,304.00
70-74 $2,290.00 $4,882.65 $1,375.85
>74 $2,426.30 $5,774.90 $1,455.08
Subscriber & <15 $677.50 $1,859.29 $607.08
30-34 $1,258.80 $2,266.60 $1,007.53
35-39 $1,352.50 $2,441.97 $1,007.53
40-44 $1,485.00 $2,575.85 $1,022.69
45-49 $1,600.00 $2,666.37 $1,022.69
50-54 $1,876.30 $2,700.31 $1,131.14
55-59 $2,213.80 $3,039.73 $1,131.14
60-64 $2,428.80 $3,705.38 $1,278.08
65-69 $2,720.00 $4,565.03 $1,694.45
70-74 $2,866.30 $5,495.08 $1,791.28
>74 $3,036.30 $6,499.24 $1,895.04
3 Blue Shield HMO available only to residents 4 Kaiser Permanente Northern California available only to residents in these zip codes in these counties:
in these zip codes in these counties: Fresno–93242, 93602, 93606-07, 93609, 93611-13, 93616, 93619, 93624-27, 93630-31, 93646, 93648-52,
Fresno–All zip codes; 93654, 93656-57, 93660, 93662, 93667-68, 93675, 93701-12, 93714-18, 93720-30, 93740-41, 93744-45,
Kern–93203, 93205-6, 93215-6, 93220, 93747, 93750, 93755, 93760-61, 93764-65, 93771-80, 93784, 93786, 93790-94, 93844, and 93888;
93222, 93224-6, 93238, 93240-1, 93243, Madera–93601, 93602, 93604, 93614, 93636-39, 93643-45, 93653, and 93669;
93249-52, 93255, 93263, 93268, 93276, Mariposa–93623;
93280, 93283, 93285, 93287, 93301-9, Napa–94503, 94508, 94515, 94558-59, 94562, 94567 (except the community of Knoxville), 94573-74,
93311-4, 93380-90, 93501-2, 93504-5, 94576, 94581, 94590, and 94599;
93516, 93518, 93519, 93524, 93531, Sacramento, San Joaquin, and Solano–All zip codes;
93560-1, 93570, 93581, 93596. Sonoma–94922-23, 94926-28, 94931, 94951-55, 94972, 94975, 94999, 95401-09, 95416, 95419, 95421,
Sacramento, San Joaquin, Solano, 95425, 95430-31, 95433, 95436, 95439, 95441-42, 95444, 95446, 95448, 95450, 95452, 95462, 95465,
Sonoma and Stanislaus–All zip codes. 95471-73, 95476, 95486-87, and 95492.
5 Kaiser Permanente Southern California available only to residents in these zip codes in these counties:
BC = Blue Cross Kern–93203, 93205-06, 93215-16, 93220, 93222, 93224-26, 93238, 93240-41, 93243, 93250-52, 93263,
93268, 93276, 93280, 93285, 93287, 93301-09, 93311-14, 93380-90, 93501-02, 93504-05, 93518-19,
BS HMO = Blue Shield HMO 93531, 93560-61, and 93581.
19
Area 3
Counties: Alameda, Contra Costa, Marin, San Francisco, San Mateo, Santa Clara.

Rating Group Age BC BS HMO CC6 KPNC7
Subscriber Only <15 $220.00 $603.15 $179.62 $160.54
15-29 $291.30 $603.15 $228.48 $240.80
30-34 $390.00 $758.05 $331.97 $284.53
35-39 $432.50 $808.96 $331.97 $305.53
40-44 $516.30 $874.96 $382.41 $342.84
45-49 $587.50 $954.16 $382.41 $376.66
50-54 $731.30 $1,044.67 $510.59 $434.96
55-59 $895.00 $1,293.58 $510.59 $497.93
60-64 $1,018.80 $1,661.29 $645.05 $551.58
65-69 $1,140.00 $2,046.71 $865.65 $718.89
70-74 $1,202.50 $2,463.70 $865.65 $758.78
>74 $1,273.80 $2,913.91 $865.65 $803.21
Subscriber & <15 $458.80 $1,174.79 $443.33 $352.75
1 Dependent 15-29 $772.50 $1,174.79 $443.33 $508.43
30-34 $886.30 $1,476.50 $588.32 $578.40
35-39 $973.80 $1,572.67 $588.32 $637.88
40-44 $1,046.30 $1,704.66 $726.99 $699.68
45-49 $1,185.00 $1,861.18 $726.99 $733.49
50-54 $1,451.30 $2,042.20 $995.94 $874.59
55-59 $1,732.50 $2,521.17 $995.94 $969.05
60-64 $1,940.00 $3,243.39 $1,285.89 $1,103.15
65-69 $2,172.50 $3,995.85 $1,687.21 $1,272.39
70-74 $2,290.00 $4,809.94 $1,687.21 $1,342.34
>74 $2,425.00 $5,688.90 $1,687.21 $1,422.24
Subscriber & <15 $685.00 $1,829.12 $817.34 $587.74
2 or More Dependents 15-29 $1,073.80 $1,829.12 $817.34 $832.61
30-34 $1,248.80 $2,232.66 $903.48 $1,007.53
35-39 $1,355.00 $2,406.14 $903.48 $1,007.53
40-44 $1,481.30 $2,538.14 $1,075.78 $1,022.69
45-49 $1,595.00 $2,623.00 $1,075.78 $1,022.69
50-54 $1,878.80 $2,658.82 $1,231.27 $1,131.14
55-59 $2,217.50 $2,996.36 $1,231.27 $1,131.14
60-64 $2,433.80 $3,646.93 $1,493.91 $1,278.08
65-69 $2,726.30 $4,493.01 $2,000.28 $1,597.75
70-74 $2,871.30 $5,408.39 $2,000.28 $1,737.29
>74 $3,042.50 $6,396.71 $2,000.28 $1,842.13
6 Contra Costa Health Plan available only in Contra Costa County.
7 Kaiser Permanente Northern California available only to residents in these zip
codes in these counties:
Alameda–All zip codes;
Contra Costa–All zip codes;
Marin–All zip codes;
San Francisco–All zip codes;
San Mateo–All zip codes;
Santa Clara–94022-24, 94035, 94039-43, 94085-89, 94301-06, 94309, 95002, 95008-09,
BC = Blue Cross 95011, 95013-15, 95020, 95021, 95026, 95030-33, 95035-38, 95042, 95044, 95046, 95050-56,
95070-71, 95076, 95101-03, 95106, 95108-42, 95148, 95150-61, 95164, 95170-73, 95190-94,
BS HMO = Blue Shield HMO and 95196.
CC = Contra Costa Health Plan
20
Area 4
Counties: Orange, Santa Barbara, Ventura.

Rating Group Age BC BS HMO KPSC8
Subscriber Only <15 $233.80 $447.27 $155.65
15-29 $297.50 $447.27 $223.45
30-34 $397.50 $560.05 $263.93
35-39 $453.80 $599.65 $283.86
40-44 $538.80 $648.68 $319.05
45-49 $621.30 $710.91 $349.55
50-54 $775.00 $778.79 $403.51
55-59 $951.30 $957.93 $462.16
60-64 $1,080.00 $1,233.24 $512.60
65-69 $1,208.80 $1,519.35 $678.40
70-74 $1,273.80 $1,828.90 $715.76
>74 $1,350.00 $2,163.11 $758.71
Subscriber & <15 $480.00 $874.96 $272.38
1 Dependent 15-29 $798.80 $874.96 $471.54
30-34 $928.80 $1,095.59 $536.06
35-39 $1,020.00 $1,169.13 $592.36
40-44 $1,091.30 $1,267.18 $649.84
45-49 $1,242.50 $1,380.33 $680.33
50-54 $1,523.80 $1,512.32 $811.71
55-59 $1,836.30 $1,868.72 $899.68
60-64 $2,042.50 $2,406.14 $1,024.03
65-69 $2,287.50 $2,964.37 $1,211.58
70-74 $2,410.00 $3,568.31 $1,279.31
>74 $2,553.80 $4,220.37 $1,355.63
Subscriber & <15 $720.00 $1,355.81 $395.38
30-34 $1,325.00 $1,655.64 $934.88
35-39 $1,417.50 $1,785.75 $934.88
40-44 $1,530.00 $1,880.03 $950.13
45-49 $1,692.50 $1,944.15 $950.13
50-54 $1,970.00 $1,972.43 $1,049.83
55-59 $2,362.50 $2,219.46 $1,049.83
60-64 $2,586.30 $2,704.08 $1,187.08
65-69 $2,896.30 $3,331.43 $1,486.15
70-74 $3,052.50 $4,010.15 $1,570.16
>74 $3,232.50 $4,742.96 $1,667.78
8 Kaiser Permanente Southern California available only to residents in these zip codes in these counties:
Orange–All zip codes;
Ventura–91319-20, 91358-62, 91377, 93001-07, 93009, 93010-12, 93015-16, 93020-21, 93022,
93030-36, 93040, 93041-44, 93060-61, 93062-66, 93093, 93094, 93099, and 93252.
BC = Blue Cross
BS HMO = Blue Shield HMO
KPSC = Kaiser Permanente Southern California
21
Area 5
County: Los Angeles.

Rating Group Age BC BS HMO9 KPSC 10
Subscriber Only <15 $251.30 $364.68 $152.48
15-29 $316.30 $364.68 $223.45
30-34 $428.80 $456.34 $263.93
35-39 $490.00 $486.51 $283.86
40-44 $576.30 $527.99 $319.05
45-49 $657.50 $578.91 $349.55
50-54 $832.50 $635.48 $403.51
55-59 $1,023.80 $780.68 $462.16
60-64 $1,152.50 $1,005.07 $512.60
65-69 $1,290.00 $1,238.25 $673.09
70-74 $1,358.80 $1,490.52 $710.26
>74 $1,440.00 $1,762.90 $752.63
Subscriber & <15 $512.50 $712.79 $263.74
1 Dependent 15-29 $852.50 $712.79 $471.54
30-34 $998.80 $891.93 $536.06
35-39 $1,106.30 $954.16 $592.36
40-44 $1,170.00 $1,031.47 $649.84
45-49 $1,345.00 $1,123.87 $680.33
50-54 $1,638.80 $1,233.24 $811.71
55-59 $1,976.30 $1,523.64 $899.68
60-64 $2,187.50 $1,959.23 $1,024.03
65-69 $2,450.00 $2,413.77 $1,203.13
70-74 $2,581.30 $2,905.54 $1,267.66
>74 $2,733.80 $3,436.49 $1,345.31
Subscriber & <15 $773.80 $1,106.90 $379.61
30-34 $1,406.30 $1,350.15 $934.88
35-39 $1,548.80 $1,453.87 $934.88
40-44 $1,652.50 $1,534.95 $950.13
45-49 $1,833.80 $1,582.09 $950.13
50-54 $2,143.80 $1,604.72 $1,049.83
55-59 $2,556.30 $1,810.26 $1,049.83
60-64 $2,817.50 $2,206.26 $1,187.08
65-69 $3,155.00 $2,718.11 $1,503.29
70-74 $3,325.00 $3,271.88 $1,589.90
>74 $3,522.50 $3,869.78 $1,686.33
9 Blue Shield HMO is available to residents in all zip codes in Los Angeles County except 90704 (Catalina Island).
10 Kaiser Permanente Southern California available to residents in all zip codes in Los Angeles County except 90704 (Catalina Island).
BC = Blue Cross
BS HMO = Blue Shield HMO
KPSC = Kaiser Permanente Southern California
22
Area 6
Counties: Riverside, San Bernardino, San Diego.

Rating Group Age BC BS HMO11 KPSC12
Subscriber Only <15 $221.30 $479.68 $153.54
15-29 $278.80 $479.68 $223.45
30-34 $378.80 $601.54 $263.93
35-39 $435.00 $639.25 $283.86
40-44 $503.80 $693.93 $319.05
45-49 $572.50 $756.16 $349.55
50-54 $726.30 $831.59 $403.51
55-59 $890.00 $1,025.82 $462.16
60-64 $1,011.30 $1,319.98 $512.60
65-69 $1,133.80 $1,626.22 $701.18
70-74 $1,193.80 $1,957.54 $739.00
>74 $1,265.00 $2,315.25 $782.91
Subscriber & <15 $450.00 $935.30 $297.88
1 Dependent 15-29 $740.00 $935.30 $471.54
30-34 $866.30 $1,172.90 $536.06
35-39 $966.30 $1,250.21 $592.36
40-44 $1,020.00 $1,352.04 $649.84
45-49 $1,148.80 $1,474.61 $680.33
50-54 $1,415.00 $1,619.81 $811.71
55-59 $1,736.30 $2,002.60 $899.68
60-64 $1,910.00 $2,570.20 $1,024.03
65-69 $2,138.80 $3,166.48 $1,247.55
70-74 $2,253.80 $3,811.60 $1,316.08
>74 $2,387.50 $4,508.12 $1,398.73
Subscriber & <15 $671.30 $1,451.98 $449.91
30-34 $1,247.50 $1,772.55 $934.88
35-39 $1,355.00 $1,910.20 $934.88
40-44 $1,443.80 $2,013.92 $950.13
45-49 $1,571.30 $2,079.92 $950.13
50-54 $1,842.50 $2,111.97 $1,049.83
55-59 $2,188.80 $2,374.08 $1,049.83
60-64 $2,417.50 $2,894.54 $1,187.08
65-69 $2,707.50 $3,566.07 $1,580.00
70-74 $2,852.50 $4,292.60 $1,667.33
>74 $3,022.50 $5,077.02 $1,771.83
11 Blue Shield HMO available only in the following zip codes: San Bernardino–91701, 91708-10, 91729-30, 91737, 91739, 91743, 91758,
Riverside–all zip codes; 91761-64, 91784-86, 91792, 91798, 92305, 92307-8, 92313-18, 92321-22,
San Bernardino–91701, 91708-10, 91729-30, 91737, 91739, 91743, 91758-9, 92324-26, 92329, 92331, 92333-37, 92339-41, 92344-46, 92350, 92352, 92354,
91761-4, 91784-6, 91798, 92252, 92256, 92267-8, 92277-8, 92284-6, 92301, 92357-59, 92369, 92371-78, 92382, 92385-86, 92391-95, 92397, 92399, 92401-8,
92304-5, 92307-18, 92321-7, 92329, 92332-42, 92344-47, 92350, 92352, 92354, 92410-15, 92418, 92420, 92423-24, and 92427.
92356-9, 92364-6, 92368-9, 92371-8, 92382, 92385-6, 92391-4, 92397-9, 92401-8, San Diego–91901-3, 91908-17, 91921, 91931-33, 91935, 91941-47, 91950-51,
92410-16, 92418, 92420, 92423-4, 92427, 93523, 93558, 93562, and 93592. 91962-63, 91976-80, 91987, 91990, 92007-92011, 92013, 92014, 92018-27,
San Diego–91901-3, 91905-6, 91908-17, 91921, 91931-5, 91941-48, 92029-30, 92033, 92037-40, 92046, 92049, 92051-52, 92054-58, 92064-65,
91950-51, 91962-3, 91976-80, 91987, 91990, 92003-4, 92007-11, 92013-4, 92067-69, 92071-72, 92074-75, 92078-79, 92081-85, 92090-93, 92096,
92018-30, 92033, 92036-40, 92046, 92049, 92051-2, 92054-61, 92064-72, 92101-24, 92126-40, 92142-43, 92145, 92147, 92149-50, 92152-55, 92158-79,
92074-5, 92078-9, 92081-6, 92088, 92090-3, 92096, 92101-24, 92126-40, 92182, 92184, 92186-87, and 92190-99.
92142-3, 92145, 92147, 92149-50, 92152-5, 92158-79, 92182, 92184, Riverside–91752, 92220, 92223, 92320, 92501-9, 92513-19, 92521-22,
92186-7, and 92190-9. 92530-32, 92543-46, 92548, 92551-57, 92562-64, 92567, 92570-72, 92581-87,
12 Kaiser Permanente Southern California available only to residents in these 92595-96, 92599, 92860, and 92877-83
zip codes in these counties:
BC = Blue Cross BS HMO = Blue Shield HMO KPSC = Kaiser Permanente Southern California
23
MRMIP Enrollment Application Checklist
Please use the following checklist to ensure that your application is complete:
❏ Review the handbook to learn about the eligibility requirements for the California Major Risk Medical
Insurance Program (MRMIP) and choose your health plan before completing the Enrollment Application.
❏ Complete the Enrollment Application on pages 25-28 of this handbook. All questions must be answered in
full. If you do not provide all necessary information (including the required documentation, signatures, and
payments), your application will be incomplete, which will delay the processing of your application.
❏ Sign and date the completed Enrollment Application on page 28.
❏ Attach the following items (your entire application may be returned to you if you do not provide
the following):
❏ Your supporting documentation that indicates your eligibility for MRMIP.
(Page 2 of this handbook describes how eligibility can be demonstrated.)
• Copy of denial for individual insurance within the last 12 months; or
• Copy of letter indicating involuntary termination of health insurance within the previous 12 months
for reasons other than nonpayment of premium or fraud; or
• Copy of letter indicating individual health insurance premium in excess of the MRMIP subscriber
contribution amount.
• If you are eligible for Medicare Part A and B, copy of a Medicare letter explaining that you have
end-stage renal disease.
• If you are applying for deferred enrollment, copy of letter indicating when coverage ends.
❏ A check for one month’s subscriber contribution for your chosen health plan.
Make check payable to California Major Risk Medical Insurance Program.
(Monthly subscriber contribution amounts are listed on pages 18-23 of this handbook).
Payments that do not equal the exact amount that is due will delay the processing of
your application.
❏ Proof of Qualifying Prior Coverage, if applicable to you, to waive all or part of your Exclusion/Waiting
Period must be received prior to or with your first month’s subscriber contribution for credit to be given.
(Please see pages 4–5 of this handbook for more information.)
❏ Insurance Agents or Brokers: You must complete all boxes at the bottom of page 25 of the Enrollment
Application to request reimbursement.
❏ Mail the completed Enrollment Application with your check and all necessary attachments to:
P.O. Box 9044
Oxnard, CA 93031-9044
24
MRMIP Enrollment Unit
(800) 289-6574
Mon. – Fri. from 8:30 a.m. to 7:00 p.m.

Enrollment Application
Instructions:
Thank you for applying for the California Major Risk Medical Insurance Program. Please follow these instructions
to allow us to better process your application.
• Read the handbook to learn about eligibility and choose your health plan before completing this application.
• You (the applicant/parent/legal guardian) must complete this application. You are solely responsible for its
accuracy and completeness.
• All questions must be answered in full. If you do not provide all necessary information (including the
required supporting documentation, signatures, and payments), your application will be incomplete,
which will delay the processing of your application or may result in a denial.
• Even if this application is approved, any misstatements or omissions may result in future claims being denied
and the policy being rescinded.
Attach check to page 26 where indicated.

Please submit one month’s subscriber contribution for your chosen health plan
(refer to pages 18–23).
Regardless of which plan you choose, make your check payable to
California Major Risk Medical Insurance Program.
Submit check, application and all necessary documentation to:

P.O. Box 9044
Oxnard, CA 93031-9044
INSURANCE AGENT and BROKER: If you assisted your client in completing this application, please complete this
section. You must complete all boxes. You will not be paid if you do not complete this section prior to submission.
Missing information cannot be submitted at a later date for payment. (Please see note to Agents on page 3 of the
handbook.) Use blue or black ink only.
Agent Name CA Agent/Broker License No. Tax I.D. No:/Soc. Sec. No.
Street Address I understand that no Agent payment will be made unless and until this
applicant is enrolled in the Program.
City State Zip
Phone No. FAX No: (if available)

Signature
12/06
25
1. Check One: New Enrollment Add Dependents Use blue or black ink only.
(Remember: Regardless of your choice of health plan, make check payable to
2. Choice of Health Plan: California Major Risk Medical Insurance Program.)
Health Plan Name Name of Primary Care Physician (for Blue Shield HMO only)
(If parent or legal guardian is completing this application for

3. Applicant Information: Applicant must complete this section. the applicant, please mark this box. )
Last Name First Name M.I. Social Security Number (optional) Age Birthdate 10 Male
Mo Day Yr
20 Female
Check One 1 Single 2 Married 3 Widowed Home Phone County

4 Divorced 5 Domestic Partner ( )
Street Suite or Unit # City State Zip
Address (must be completed; P.O. Box not acceptable)
Billing Name, if different
Billing Address, if different City State Zip
Employer, if employed Occupation Business Phone

( )
Employer Street Address City State Zip
4. Race/Ethnicity (Optional): Check box which best applies.

Hispanic Asian Pacific Islander
10 Aleut 21 Cuban 41 Asian Indian 61 Filipino
11 American Indian, Native American 22 Mexican, Mexican-American, 42 Cambodian 62 Guamanian
Chicano
12 Black/African American 43 Chinese 63 Samoan
23 Puerto Rican
13 Eskimo 44 Japanese
92 Other; please specify: Other not listed; please specify:
14 White 45 Korean 99
46 Laotian
47 Vietnamese
94 Other; please specify:
STAPLE CHECK HERE
payable to California Major Risk
5. Family Information: List all additional family members to be enrolled.

Last Name First Name M.I. Social Security Number (optional) Age Birthdate
30 Husband
Mo Day Year
40 Wife
30 Domestic
40 Partner
50 Son Marital Status

70 Daughter S M

71 Daughter S M

72 Daughter S M

73 Daughter S M

74 Daughter S M
If a dependent child is over 23 years of age, send doctor’s record showing that the dependent child cannot work for a living because of a physical or mental disability which
existed before becoming 23 years old with the application.
Is this dependent child covered by Medicare? Yes No 12/06
26
6. Program Eligibility: To be eligible for the Program you must answer “yes” to one of the first four questions. Provide a copy of
any letter or formal written communication from a health plan documenting all “yes” answers. Applicant Dependent
Yes No Yes No
1. Within the past 12 months, have you been denied individual health insurance?
2. Within the past 12 months, have you been involuntarily terminated from health insurance coverage for reasons other than fraud
or non-payment of premium?
3. Within the past 12 months, have you been offered an individual premium higher than the rate for the first choice health plan
listed on this application?
4. Are you currently ineligible, but anticipate becoming eligible, and want to apply for a deferred enrollment?
(See page 2.)
5. Have you and your dependent(s), if any, met the requirements to waive all or part of the exclusion/waiting period? (See pages 4-5
under “How You May Waive All or Part of the Exclusion/Waiting Period.’’) Please provide a copy of supporting documantation.
Name of prior insurance company:
Effective date of prior coverage:
Termination date of prior insurance:
6. Within the past 12 months, were you covered in a similar high risk pool sponsored by another state before becoming a
California resident?
7. Declarations: Please read each of the following statements carefully and initial each statement. Any untrue or inaccurate
responses may be reason for loss of enrollment or application of other sanctions. Applicant Dependent
Initials Initials
1. I declare that no individual listed on this application is eligible for both Part A (hospital) and Part B (professional) of
Medicare. If you are eligible solely because of end-stage renal disease, leave blank and provide Medicare eligibility letter as
proof of end-stage renal disease. (Medicare is a federal program that provides health services to older Americans and disabled
persons.)
2. I declare that all individuals listed on this application are residents of the state of California. (See page 2 under “Eligibility”
for the definition of California resident.)
3. I declare that I am not currently eligible to purchase any health insurance for continuation of benefits from my employer
under the provisions of 29 U.S. Code 1161 et seq. (COBRA), or under the provisions of Insurance Code Sections 10128.50
et seq. and Health and Safety Code Sections 1366.20 et seq. (Cal-COBRA). These are the laws which allow people to buy
into their employer’s health insurance for at least 36 months after they leave their employer. (If you are currently on COBRA,
leave blank and refer to page 2.)
4. I declare that all individuals listed on this application will abide by the rules of participation, the utilization review process
and the dispute resolution process of the participating health plan in which the individual is enrolled. A dispute resolution
process may include binding arbitration rather than a court trial to resolve any claim, including a claim for malpractice,
asserted by me, my enrolled dependents, heirs, personal representatives, or someone with a relationship to us, against the
participating health plan, or against the employees, partners, or agents, of the participating health plan.
5. I declare that I have reviewed the benefits offered by the MRMIP and the subscriber contribution amounts.
6. I declare that no individual listed on this application was excluded from group health coverage solely for the purpose of being
made eligible for the MRMIP.
7. I declare that I understand and will follow the rules and regulations of the MRMIP. I understand that depositing a subscriber
contribution check shall not constitute acceptance on the part of the MRMIP, or any of its subcontractors, if the application
is not approved or if the member has already been disenrolled for nonpayment of subscriber contribution, fails to meet
program eligibility requirements, commits program fraud, or because the dependent ceases to be a dependent, upon request
by the member, or for any other reason.
8. I declare that I have not been terminated within the last 12 months from a Post-MRMIP Graduate health plan, which
became available through guaranteed coverage after my eligibility for MRMIP ended (Health and Safety Code Section
1373.62 or Insurance Code Section 10127.15) due to nonpayment of premiums, as a result of my request to voluntarily
disenroll, or as a result of fraud.
12/06
27
8. Authorization and Conditions of Enrollment
Required by the Confidentiality of Medical Information Act of 1/1/80, Sect 56 et seq. of the California Civil Code for all applicants of
18 years and over. I authorize any insurance company, physician, hospital, clinic or health care provider to give Major Risk Medical
Insurance Program Administrator any and all records pertaining to any medical history, services or treatment provided to anyone listed
on this application for purpose of review, investigation or evaluation. This authorization becomes immediately effective and shall remain
in effect as long as Administrator requires. A photocopy of this Authorization is as valid as the original.
Privacy Notification
The Information Practices Act of 1977 and the Federal Privacy Act require this Program to provide the following to individuals who are
asked by the Major Risk Medical Insurance Program (established by Part 6.5 of Division 2 of the Insurance Code) to supply
information: The principal purpose for requesting personal and medical information is for subscriber identification and program
administration. Program regulations (Chapter 5.5 of Title 10 of the California Code of Regulations, Sections 2698.100 et seq.) require
every individual to furnish appropriate information for application to the Major Risk Medical Insurance Program. Failure to furnish this
information may result in the return of the application as incomplete. The following information on the application is voluntary: social
security number, race/ethnicity information and health history.
Personal information provided on this form will not be furnished to any other governmental agency.
An individual has a right of access to records containing his/her personal information that are maintained by the Major Risk Medical
Insurance Program. The official responsible for maintaining the information is: Deputy Director, Eligibility, Enrollment and Marketing,
Managed Risk Medical Insurance Board, PO Box 2769, Sacramento, CA 95812-2769. The Board may charge a small fee to cover the
cost of duplicating this information.
I understand that this is a state program and my rights and obligations under it will be determined under Part 6.5 Division 2 of
the California Insurance Code and at the regulation of Title 10, Chapter 5.5
I understand that if this application is approved, the effective date of coverage will be determined according to applicable laws
and regulations and I will be informed in writing of the effective date. (Do not cancel any current coverage until you hear from
MRMIP.)
I understand that this contract may have waiting periods for pre-existing conditions.
Each plan has its own rules for resolving disputes about the delivery of services and other matters. Some plans say you must use
binding arbitration for disputes; others do not. Some plans say that claims for malpractice must be decided by binding
arbitration; others do not. If the plan you choose requires binding arbitration, you are giving up your right to a jury trial and
cannot have the dispute decided in court. To find out more about how a plan resolves disputes, you can call the plan and
request an Evidence of Coverage or Certificate of Insurance booklet.
These plans DO NOT require binding arbitration: Blue Shield HMO and Contra Costa Health Plan.
These plans DO require binding arbitration of disputes: INCLUDING malpractice, so long as the disputes are beyond the
jurisdictional limit of the small claims court: Blue Cross of California and Kaiser Permanente.
I, the applicant, declare that I have read and understand the information on this form and agree to the Authorizations and
Conditions of Enrollment. I certify that the information provided on this application is true and correct.
X X
Signature of Applicant/Parent or Legal Guardian Required Date Signature of Applicant’s Spouse/Domestic Partner Required Date
(If listed on this application)
X X
Signature of Applicant’s Dependent Age 18 or over Required Date Signature of Applicant’s Dependent Age 18 or over Required Date
(If listed on this application) (If listed on this application)
After filling out the application, signing and securing all necessary documentation, submit
a check for one month’s subscriber contribution for your chosen health plan.
Make your check payable to California Major Risk Medical Insurance Program.
Mail your complete application to:
P.O. Box 9044
Oxnard, CA 93031-9044
12/06
28
Flex
Your
Power
California’s Energy Challenge
California is facing an energy challenge. To reduce the risk of power
outages, everyone can help by reducing the demand for electricity by
using less energy.
California has the power of the world’s sixth largest economy. Your
efforts, times 35 million Californians, will make a real difference.
All you have to do is

FLEX YOUR POWER
Simple things you can do right now to cut your energy costs are:
• Keep energy use low during peak demand hours from 5 a.m. to
9 a.m. and 4 p.m. to 7 p.m.
• Turn off unneeded lights and appliances. Unplug that spare
refrigerator out in the garage if you don’t really need it.
• Avoid using dishwashers, clothes washers, dryers and ovens during
the peak demand periods. Wash full loads of clothes/or dishes. Use
the cold setting on your washer if you can.
• In cool weather, turn your thermostats down to 68º degrees or
below. Set it at 55º degrees before going to sleep or when away for
the day. For every 1 degree reduction, you will save up to 5% on
your heating costs. Close your shades and blinds at night to keep
heat from being lost through windows.
• In warm weather, set your air conditioner to 78º degrees or higher.
When away from home set the thermostat to 85º degrees. These tips
can save you up to 20% on your air conditioner costs.
• Buy Energy Star appliances, products and lights.
• For more on saving energy and money, go to www.my.ca.gov on the
Web and click the California’s Energy Challenge site next to the
FLEX YOUR POWER logo.
1006 ME7208 printdate

California MRMIP Brochure 2007

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California MRMIP Brochure 2007

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California

2007 Application and Handbook

Rates effective January 1, 2007

Americans With Disabilities Act

Please contact the MRMIP Enrollment

Blue Cross of California is an Independent Licensee of the Blue Cross Association.

An independent member of the Blue Shield Association.

Co-payment Your cost of covered services See specific service

Physician Care • Office visits $15 co-pay per office visit

Ambulance Ground transportation as medically necessary No charge

Mental Health Care Mental health services

Speech/Physical/ Rehabilitative therapy services by a physical, occupational, respiratory or speech

Other Blood (administration of blood & blood plasma, including No charge

Calendar Year Deductible There is no deductible -0-

Prescription Drugs Drugs prescribed by a physician 20% of the cost of prescription

Maternity Care Treated as any other medical condition:

Ambulance Ambulance service when required for an emergency or $15 copay

Other Blood and blood plasma, 24-hour Advice -0-

Plan Highlights Kaiser Permanente is available in the Co-payments

Co-payment Your cost of covered services See specific service

Ambulance Ambulance services $75 per trip

Plan Highlights Plan Providers • Referrals to specialists – As a group

Co-payment Your cost of covered services See specific service

Ambulance Ambulance Services $75 per trip

Subscriber Only <15 $233.80 $646.36 $162.33

See below for service areas and available zip codes.

See below for service areas and available zip codes.

See below for service areas and available zip codes.

See below for service areas and available zip codes.

California Major Risk Medical Insurance Program

Attach check to page 26 where indicated.

Submit check, application and all necessary documentation to:

City State Zip

Phone No. FAX No: (if available)

(If parent or legal guardian is completing this application for

Check One 1 Single 2 Married 3 Widowed Home Phone County

Billing Name, if different

Billing Address, if different City State Zip

Employer, if employed Occupation Business Phone

4. Race/Ethnicity (Optional): Check box which best applies.

5. Family Information: List all additional family members to be enrolled.

50 Son Marital Status

51 Son Marital Status

52 Son Marital Status

53 Son Marital Status

54 Son Marital Status

All you have to do is

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