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- Closed Conversion HMO, Conversion Copayment 25 HMO, and HIPAA Copayment 25 HMO
- Grandfathered Conversion Copayment 25 HMO Plan F
- Conversion Deductible HMO 30/1500 and HIPAA Deductible HMO 30/1500
- Grandfathered Copayment 25 HMO
- Grandfathered Copayment 40 HMO
- Grandfathered Copayment 50 HMO
- Grandfathered Deductible HMO 0/1650 with HSA
- Grandfathered Deductible HMO 0/2700 with HSA
- Grandfathered Deductible HMO 20/500
- Grandfathered Deductible HMO 25/1000
- Grandfathered Deductible HMO 30/1500
- Grandfathered Deductible HMO 30/2700 with HSA
- Grandfathered Deductible HMO 40/2000
Individual & Family Plan Documents
These are sample evidence of coverage (EOC) documents for grandfathered plans. Enrolled members will receive the most current version that should be used to determine terms of coverage.
California Plans Closed to New Membership
- 2024 Combined Closed Conversion, Conversion Copayment 25 HMO, and HIPAA Copayment 25 HMO
- 2024 Combined Conversion Deductible HMO 30-1500 and HIPAA Deductible HMO 30-1500
- 2024 Conversion Copayment 25 HMO Plan F
- 2024 Copayment 25 HMO
- 2024 Copayment 40 HMO
- 2024 Copayment 50 HMO
- 2024 Deductible HMO 0-1500 with HSA
- 2024 Deductible HMO 0-2700 with HSA
- 2024 Deductible HMO 20-500
- 2024 Deductible HMO 25-1000
- 2024 Deductible HMO 30-1500
- 2024 Deductible HMO 30-2700 with HSA
- 2024 Deductible HMO 40-2000
Questions?
Have questions about the sample plan documents? Visit buykp.org or call 1-800-488-3590 (TTY 711).
Kaiser Permanente Member
The sample documents may vary from your actual benefits. To view a copy of your specific plan documents, please log into www.kp.org or contact Member Services.