Benefit Plan Documents EOC – Human Resources Department

Benefits Plan Documents

Evidence of Coverage

Kaiser Permanente Plans

The plans offered by Kaiser Permanente include:

Type	Name	Category	Actions
	Evidence of Coverage 2023-24 Plan Year	Kaiser Traditional HMO
	Benefit Summary 2023-24 Plan Year	Kaiser Traditional HMO
	Summary of Benefits & Coverage 2023 English	Kaiser Traditional HMO
	Benefit Summary 2023-24 Plan Year	KP Traditional COBRA HMO
	Summary of Benefits & Coverage 2023 English	KP Traditional COBRA HMO
	Evidence of Coverage 2023-24 Plan Year	KP Choice HMO
	Benefit Summary 2023-24 Plan Year	KP Choice HMO
	Summary of Benefits & Coverage 2023 English	KP Choice HMO
	Benefit Summary 2023-24 Plan Year	KP Choice COBRA HMO
	Summary of Benefits & Coverage 2023 English	KP Choice COBRA HMO
	Evidence of Coverage 2023-24 Plan Year	Kaiser Virtual Complete HMO
	Benefit Summary 2023-24 Plan Year	Kaiser Virtual Complete HMO
	Summary of Benefits & Coverage 2023 English	Kaiser Virtual Complete HMO
	Benefit Summary 2023-24 Plan Year	Kaiser Virtual Complete COBRA HMO
	Summary of Benefits & Coverage 2023 English	Kaiser Virtual Complete COBRA HMO
	Evidence of Coverage 2022-23 Plan Year	Kaiser Traditional HMO
	Benefit Summary 2022-23 Plan Year	Kaiser Traditional HMO
	Summary of Benefits & Coverage 2022 English	Kaiser Traditional HMO
	Evidence of Coverage 2022-23 Plan Year	KP Traditional COBRA HMO
	Benefit Summary 2022-23 Plan Year	KP Traditional COBRA HMO
	Summary of Benefits & Coverage 2022 English	KP Traditional COBRA HMO
	Evidence of Coverage 2022-23 Plan Year	KP Choice HMO
	Benefit Summary 2022-23 Plan Year	KP Choice HMO
	Summary of Benefits & Coverage 2022 English	KP Choice HMO
	Evidence of Coverage 2022-23 Plan Year	KP Choice COBRA HMO
	Benefit Summary 2022-23 Plan Year	KP Choice COBRA HMO
	Summary of Benefits & Coverage 2022 English	KP Choice COBRA HMO
	Evidence of Coverage 2021-22 Plan Year	KP Traditional HMO
	Benefit Summary 2021-22 Plan Year	KP Traditional HMO
	Summary of Benefits & Coverage 2021 English	KP Traditional HMO
	Evidence of Coverage 2021-22 Plan Year	KP Traditional COBRA HMO
	Benefit Summary 2021-22 Plan Year	KP Traditional COBRA HMO
	Summary of Benefits & Coverage 2021 English	KP Traditional COBRA HMO
	Evidence of Coverage 2021-22 Plan Year	KP Choice HMO
	Benefit Summary 2021-22 Plan Year	KP Choice HMO
	Summary of Benefits & Coverage 2021 English	KP Choice HMO
	Evidence of Coverage 2021-22 Plan Year	KP Choice COBRA HMO
	Benefit Summary 2021-22 Plan Year	KP Choice COBRA HMO
	Summary of Benefits & Coverage 2021 English	KP Choice COBRA HMO
	Evidence of Coverage 2020-21 Plan Year	KP Traditional HMO
	Benefit Summary 2020-21 Plan Year	KP Traditional HMO
	Summary of Benefits & Coverage 2020 English	KP Traditional HMO
	Summary of Benefits & Coverage 2020 Spanish	KP Traditional HMO
	Evidence of Coverage 2020-21 Plan Year	KP Choice HMO
	Benefit Summary 2020-21 Plan Year	KP Choice HMO
	Summary of Benefits & Coverage 2020 English	KP Choice HMO
	Summary of Benefits & Coverage 2020 Spanish	KP Choice HMO
	Evidence of Coverage 2020-21 Plan Year	KP Traditional COBRA HMO
	Benefit Summary 2020-21 Plan Year	KP Traditional COBRA HMO
	Summary of Benefits & Coverage 2020 English	KP Traditional COBRA HMO
	Summary of Benefits & Coverage 2020 Spanish	KP Traditional COBRA HMO
	Evidence of Coverage 2020-21 Plan Year	KP Choice COBRA HMO
	Benefit Summary 2020-21 Plan Year	KP Choice COBRA HMO
	Summary of Benefits & Coverage 2020 English	KP Choice COBRA HMO
	Summary of Benefits & Coverage 2020 Spanish	KP Choice COBRA HMO
	Senior Advantage (HMO) with Part D- Low Option	Kaiser Retirees
	Senior Advantage (HMO) with Part D – High Option	Kaiser Retirees
	Traditional HMO Plan – Low Option	Kaiser Retirees
	Deductible HMO Plan – High Option	Kaiser Retirees
	HSA-Qualified High Deductible Health Plan (HDHP) HMO	Kaiser Retirees
	Traditional Plan (HMO) – Summary of Benefits and	Kaiser Retirees
	HSA-Qualified High Deductible Health Plan (HDHP) HMO	Kaiser Retirees

Blue Shield Plans

The plans offered by Blue Shield

Type	Name	Category	Actions
	Evidence of Coverage 2023-24 Plan Year	Shield Trio HMO
	Benefit Summary 2023-24 Plan Year	Shield Trio HMO
	Summary of Benefits & Coverage 2023 English	Shield Trio HMO
	Evidence of Coverage 2023-24 Plan Year	Shield Signature HMO
	Evidence of Coverage 2022-23 Plan Year	Shield Signature HMO
	Evidence of Coverage 2021-22 Plan Year	Shield Signature HMO
	Evidence of Coverage 2020-21 Plan Year	Shield Signature HMO
	Benefit Summary 2023-24 Plan Year	Shield Signature HMO
	Benefit Summary 2022-23 Plan Year	Shield Signature HMO
	Benefit Summary 2020-21 Plan Year	Shield Signature HMO
	Summary of Benefits & Coverage 2023 English	Shield Signature HMO
	Summary of Benefits & Coverage 2022 English	Shield Signature HMO
	Summary of Benefits & Coverage 2020 English	Shield Signature HMO
	Evidence of Coverage 2023-24 Plan Year	Shield Access+ HMO
	Evidence of Coverage 2022-23 Plan Year	Shield Access+ HMO
	Evidence of Coverage 2021-22 Plan Year	Shield Access+ HMO
	Evidence of Coverage 2020-21 Plan Year	Shield Access+ HMO
	Benefit Summary 2023-24 Plan Year	Shield Access+ HMO
	Benefit Summary 2022-23 Plan Year	Shield Access+ HMO
	Benefit Summary 2021-22 Plan Year	Shield Access+ HMO
	Benefit Summary 2020-21 Plan Year	Shield Access+ HMO
	Summary of Benefits & Coverage 2023 English	Shield Access+ HMO
	Summary of Benefits & Coverage 2022 English	Shield Access+ HMO
	Summary of Benefits & Coverage 2021 English	Shield Access+ HMO
	Summary of Benefits & Coverage 2020 English	Shield Access+ HMO
	Evidence of Coverage 2023-24 Plan Year	Shield PPO
	Evidence of Coverage 2022-23 Plan Year	Shield PPO
	Evidence of Coverage 2021-22 Plan Year	Shield PPO
	Evidence of Coverage 2020-21 Plan Year	Shield PPO
	Benefit Summary 2023-24 Plan Year	Shield PPO
	Benefit Summary 2022-23 Plan Year	Shield PPO
	Benefit Summary 2021-22 Plan Year	Shield PPO
	Benefit Summary 2020-21 Plan Year	Shield PPO
	Summary of Benefits & Coverage 2023 English	Shield PPO
	Summary of Benefits & Coverage 2022 English	Shield PPO
	Summary of Benefits & Coverage 2021 English	Shield PPO
	Summary of Benefits & Coverage 2020 English	Shield PPO
	Evidence of Coverage 2023-24 Plan Year	Shield Needles PPO
	Evidence of Coverage 2022-23 Plan Year	Shield Needles PPO
	Evidence of Coverage 2021-22 Plan Year	Shield Needles PPO
	Evidence of Coverage 2020-21 Plan Year	Shield Needles PPO
	Benefit Summary 2023-24 Plan Year	Shield Needles PPO
	Benefit Summary 2022-23 Plan Year	Shield Needles PPO
	Benefit Summary 2021-22 Plan Year	Shield Needles PPO
	Benefit Summary 2020-21 Plan Year	Shield Needles PPO
	Summary of Benefits & Coverage 2023 English	Shield Needles PPO
	Summary of Benefits & Coverage 2022 English	Shield Needles PPO
	Summary of Benefits & Coverage 2020 English	Shield Needles PPO
	Evidence of Coverage 2023-24 Plan Year	Shield Bronze PPO
	Evidence of Coverage 2022-23 Plan Year	Shield Bronze PPO
	Evidence of Coverage 2021-22 Plan Year	Shield Bronze PPO
	Evidence of Coverage 2020-21 Plan Year	Shield Bronze PPO
	Benefit Summary 2023-24 Plan Year	Shield Bronze PPO
	Benefit Summary 2021-22 Plan Year	Shield Bronze PPO
	Benefit Summary 2020-21 Plan Year	Shield Bronze PPO
	Summary of Benefits & Coverage 2022 English	Shield Bronze PPO
	Summary of Benefits & Coverage 2020 English	Shield Bronze PPO

Delta Dental Plans

The plans offered by Delta Dental include:

Type	Name	Category	Actions
	Evidence of Coverage 2023-24 Plan Year	DeltaCare USA DHMO
	Evidence of Coverage 2022-23 Plan Year	DeltaCare USA DHMO
	Evidence of Coverage 2021-22 Plan Year	DeltaCare USA DHMO
	Evidence of Coverage 2020-21 Plan Year	DeltaCare USA DHMO
	Evidence of Coverage 2019-20 Plan Year	DeltaCare USA DHMO
	Benefit Summary 2021-22 Plan Year	DeltaCare USA DHMO
	Benefit Summary 2020-21 Plan Year	DeltaCare USA DHMO
	Benefit Summary 2019-20 Plan Year	DeltaCare USA DHMO
	Evidence of Coverage 2022-23 Plan Year	Delta Dental DPPO
	Evidence of Coverage 2021-22 Plan Year	Delta Dental DPPO
	Evidence of Coverage 2020-21 Plan Year	Delta Dental DPPO
	Evidence of Coverage 2019-20 Plan Year	Delta Dental DPPO
	Benefit Summary 2022-23 Plan Year	Delta Dental DPPO
	Benefit Summary 2021-22 Plan Year	Delta Dental DPPO
	Benefit Summary 2020-21 Plan Year	Delta Dental DPPO
	Benefit Summary 2019-20 Plan Year	Delta Dental DPPO
	EOC DeltaCare USA HMO	Delta Dental Retirees
	EOC Delta DPPO High Option	Delta Dental Retirees
	EOC Delta DPPO Low Option	Delta Dental Retirees
	EOC Delta DPPO High & Low Option (Texas Only)	Delta Dental Retirees
	DD Self-Funded DPPO Notice of Privacy Practices 2018

Type	Name	Actions
	401 (a) Plan Document
	401 (k) Plan Document
	457 (b) Plan Document
	Accidental Death & Dismemberment Certificate
	Dependent Care Assistance Plan (DCAP)
	Investment Policy Statement
	Kaiser Permamente Traditional HMO EOC 2018-2019
	SB County Term-Life Insurance Certificate 2018
	Long-Term Disability Plan 2015
	FSA Plan Document
	Part-Time, Seasonal and Temp Deferred Compensation Plan
	Retirement Benefits (SBCERA Compass)
	Retirement Medical Trust Agreement Plan
	Retirement Medical Trust Plan Document
	Section 125 Premium Conversion Plan 2020
	Short-Term Disability-Exempt 2015
	Short-Term Disability-Represented 2015
	Short-Term Disability-Pre-School Services 9 Month 2015
	Short-Term Disability-Probation 2015
	Short-Term Disability- SPO/SPS 2015
	Employee Group Term Life Certificate of Insurance
	How Much Life Insurance Do I Need?
	Portability and Conversion Information
	Plan Summary of Dependent Supplemental Life Insurance