Kaiser Foundation
Health Plan, Inc.
California Division
http:// www. kaiserpermanente. org
2001
A Health Maintenance Organization
Serving: Northern/
Southern California Service Area
Enrollment in this Plan is limited; see pages 7 and 8 for requirements.
Enrollment codes for this Plan:
Northern California
591 Self only
592 Self and family Southern California
621 Self only
622 Self and family
RI 73-003
This Plan has excellent accreditation from the NCQA
in the Northern
California Service Area.
See the 2001 Guide for more information on NCQA.
This Plan has commendable accreditation from the
NCQA in the Southern
California Service Area.
See the 2001 Guide for more information on NCQA.
1
1 Page 2 3
Table of Contents
Introduction
.....................................................................................................................................................................
5
Plain language
.................................................................................................................................................................
5
Section 1. Facts about this HMO Plan
........................................................................................................................
6
How we pay
providers................................................................................................................................
6
Patients' Bill of Rights
...............................................................................................................................
6
Service area
................................................................................................................................................
7
Section 2. How we change for 2001
...........................................................................................................................
9
Programwide changes
................................................................................................................................
9
Changes to this
Plan...................................................................................................................................
9
Section 3. How you get care
....................................................................................................................................
10
Identification
cards...................................................................................................................................
10
Where you get covered care
.....................................................................................................................
10
Plan providers
..................................................................................................................................
10
Plan facilities
...................................................................................................................................
10
What you must do to get covered
care.....................................................................................................
11
Primary
care.....................................................................................................................................
11
Specialty
care...................................................................................................................................
11
Hospital care
....................................................................................................................................
12
Circumstances beyond our
control...........................................................................................................
12
Services requiring our prior approval
......................................................................................................
12
Section 4. Your costs for covered
services................................................................................................................
13
Copayments......................................................................................................................................
13
Deductible
........................................................................................................................................
13
Coinsurance
.....................................................................................................................................
13
Fees when you fail to make your copayment
..................................................................................
13
Your out-of-pocket maximum for copayments and coinsurance
............................................................. 13
Section 5.
Benefits
....................................................................................................................................................
14
Overview..................................................................................................................................................
14
(a) Medical services and supplies provided by physicians and other health
care professionals........ 15
(b) Surgical and anesthesia services provided
by physicians and other health care professionals .... 23
(c) Services
provided by a hospital or other facility, and ambulance services
.................................. 27
(d) Emergency services/ accidents
.......................................................................................................
30
(e) Mental health and substance abuse benefits
.................................................................................
32
(f) Prescription drug benefits
.............................................................................................................
35
(g) Special
features..............................................................................................................................
39
(h) Dental benefits
..............................................................................................................................
42
(i) Non-FEHB benefits available to Plan members
........................................................................... 43
2001 Kaiser Foundation Health Plan, Inc. 2 Table of Contents 2
2 Page 3 4
Section 6. General exclusionsÑ things we don't
cover.............................................................................................
44
Section 7. Filing a claim for covered services
..........................................................................................................
45
Medical, hospital, and drug benefits
...............................................................................................
45
Deadline for filing your
claim.........................................................................................................
45
When we need more information
....................................................................................................
45
If you have a malpractice
claim.......................................................................................................
46
Section 8. The disputed claims process
....................................................................................................................
47
Section 9. Coordinating benefits with other coverage
..............................................................................................
49
When you have other health coverage
.....................................................................................................
49
What is Medicare?
...........................................................................................................................
49
The original Medicare
plan..............................................................................................................
49
Medicare managed care plan
...........................................................................................................
51
Enrollment in Medicare Part
B........................................................................................................
52
TRICARE.................................................................................................................................................
52
Workers' compensation
............................................................................................................................
52
Medicaid...................................................................................................................................................
52
When other government agencies are responsible for your care
............................................................. 52
When others
are responsible for injuries
.................................................................................................
53
Section 10. Definitions of terms we use in this
brochure...........................................................................................
54
Section 11. FEHB facts
...............................................................................................................................................
56
Coverage
information...............................................................................................................................
56
No preexisting condition
limitation.................................................................................................
56
Where you get information about enrolling in the FEHB
Program................................................ 56
Types of coverage
available for you and your
family...................................................................... 56
When benefits and premiums start
..................................................................................................
57
Your medical and claims records are
confidential...........................................................................
57
When you retire
...............................................................................................................................
57
When you lose
benefits............................................................................................................................
57
When FEHB coverage
ends.............................................................................................................
57
Spouse equity coverage
...................................................................................................................
57
Temporary Continuation of Coverage (TCC)
..................................................................................
57
Converting to individual
coverage...................................................................................................
58
Getting a Certificate of Group Health Plan Coverage
.................................................................... 58
Inspector General advisory: Stop health care fraud!
...............................................................................
58
Penalties for
fraud............................................................................................................................
58
Department of Defense/ FEHB Demonstration Project
................................................................................................
59
2001 Kaiser Foundation Health Plan, Inc. 3 Table of Contents 3
3 Page 4 5
Index..............................................................................................................................................................................
61
Summary of
benefits.....................................................................................................................................................
62
Rates................................................................................................................................................................
Back cover
2001 Kaiser Foundation Health Plan, Inc. 4 Table of Contents 4
4 Page 5 6
Kaiser Foundation Health Plan, Inc., California Division
1950 Franklin St., Oakland, CA 94612 (Northern California)
393 E. Walnut
St., Pasadena, CA 91188 (Southern California)
This brochure describes the benefits of Kaiser Foundation Health Plan, Inc.,
California Division, under our contract
(CS1044) with the Office of
Personnel Management (OPM), as authorized by the Federal Employees Health
Benefits law. This brochure is the official statement of benefits. No oral
statement can modify or otherwise affect the
benefits, limitations, and
exclusions of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for self
and family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to
benefits that were available before January 1, 2001, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2001, and are
summarized on page 14. Rates are
shown at the end of this brochure.
The president and vice president are making the government's communication
more responsive, accessible, and
understandable to the public by requiring
agencies to use plain language. In response, a team of Health Plan
representatives and OPM staff worked cooperatively to make this brochure
clearer. Except for necessary technical
terms, we use common words.
"You" means the enrollee or family member; "we" means Kaiser
Foundation Health
Plan, Inc.
The plain language team reorganized the brochure and the way we describe our
benefits. When you compare this
Plan with other FEHB plans, you will find
that the brochures have the same format and similar information to make
comparisons easier.
If you have comments or suggestions about how to improve this brochure, let
us know. Visit OPM's "Rate Us"
feedback area at www. opm. gov/
insure or e-mail us at fehbwebcomments@ opm. gov or write to OPM at
Insurance
Planning and Evaluation Division, P. O. Box 436, Washington, D. C.
20044-0436.
2001 Kaiser Foundation Health Plan, Inc. 5 Introduction/ Plain
language
Introduction
Plain language 5
5
Page 6 7
This Plan
is a health maintenance organization (HMO). We require you to see specific
physicians, hospitals, and
other providers that contract with us. These Plan
providers coordinate your health care services. HMOs emphasize
preventive
care, such as routine office visits, physical exams, well-baby care, and
immunizations, in addition to
treatment for illness and injury. Our
providers follow generally accepted medical practice when prescribing any
course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay
the copayments and coinsurance
described in this brochure. When you receive emergency services from non-Plan
providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because
a particular provider is available.
You cannot change plans because a
provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract
with us.
How we pay providers
We contract with individual physicians,
medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers accept a negotiated payment from us, and you will only be
responsible for your copayments or
coinsurance.
Patients' Bill of Rights
OPM requires that all FEHB plans comply
with the Patients' Bill of Rights, recommended by the President's
Advisory
Commission on Consumer Protection and Quality in the Health Care Industry. You
may get information
about us, our networks, providers, and facilities. OPM's
FEHB Web site (www. opm. gov/ insure) lists the specific
types of
information that we must make available to you. Some of the required information
is listed below.
We are a federally qualified health maintenance organization, and we have
provided health care services to
Californians since the 1950s. Kaiser
Foundation Health Plan, Inc., is a California not-for-profit organization. This
Plan is part of the Kaiser Permanente Medical Care Program, a group of
not-for-profit organizations and contracting
medical groups that serve more
than eight million members nationwide. Our Medical Groups, The Permanente
Medical Group, Inc., and the Southern California Permanente Medical Group,
operate Plan medical offices
throughout California.
If you want more information about us, call 1-800-464-4000, or write
to 1950 Franklin St., Oakland, CA 94612 or
393 E. Walnut St., Pasadena, CA
91188. You may visit our Web site at www. kaiserpermanente. org, which
lists the
specific types of information that we must make available to you.
2001 Kaiser Foundation Health Plan, Inc. 6 Section 1
Section 1. Facts about this HMO Plan 6
6
Page 7 8
Service
area
To enroll in this Plan, you must live or work in our service area.
This is where our providers practice. Our service
area is:
Northern California counties: Alameda, Contra Costa, Marin, Sacramento, San
Francisco, San
Joaquin, San Mateo, Solano, Stanislaus
Portions of the following counties, as indicated by the ZIP codes below, are
also within the service area:
Amador County: 95640, 95669
El Dorado County: 95613-14, 95619, 95623,
95633-35, 95651, 95664, 95667, 95672,
95682, 95762
Fresno County: 93242, 93602, 93606-07, 93609, 93611-13, 93616, 93624-27,
93630-31,
93646, 93648-52, 93654, 93656-57, 93660, 93662, 93667-68, 93675,
93701-12, 93714-18, 93720-22, 93724-29, 93740-41, 93744-45, 93747,
93750, 93755, 93759-62, 93764-65, 93771-80, 93782, 93784, 93786,
93790-94, 93844, 93888
Kings County: 93230-32
Madera County: 93601, 93604, 93614, 93637-39,
93643-45, 93653, 93669
Mariposa County: 93623
Napa County: 94503, 94508,
94515, 94558-59, 94562, 94567, 94573-74, 94576,
94581, 94599
Placer County: 95602-04, 95648, 95650, 95658, 95661, 95663, 95677-78, 95681,
95703, 95722, 95736, 95746-47, 95765
Santa Clara County: 94022-24, 94035, 94039-43, 94085-90, 94301-02, 94304-06,
94309-10,
95002, 95008-09, 95011, 95013-15, 95020-21, 95026, 95030-33,
95035-38, 95042, 95044, 95046, 95050-56, 95070-71, 95101-03, 95106,
95108-42, 95148, 95150-61, 95164, 95170-73, 95190-94, 95196
Sonoma County: 94922-23, 94926-28, 94931, 94951-55, 94972, 94975, 94999,
95401-09,
95416, 95419, 95421, 95425, 95430-31, 95433, 95436, 95439,
95441-
42, 95444, 95446, 95448, 95450, 95452, 95462, 95465, 95471-73,
95476, 95486-87, 95492
Sutter County: 95659, 95668, 95674, 95676
Tulare County: 93618, 93666,
93673
Yolo County: 95605, 95607, 95612, 95616-18, 95645, 95691, 95694-95,
95697-98,
95776, 95798-99
Yuba County: 95692, 95903, 95961
2001 Kaiser Foundation Health Plan, Inc. 7 Section 1 7
7 Page 8 9
Southern California counties: Orange and Los Angeles
(except ZIP code 90704)
Portions of the following counties, as indicated by
the ZIP codes below, are also within the service area:
Imperial: 92275
Kern: 93203, 93205-06, 93215-16, 93220, 93222, 93224-26, 93238, 93240-41,
93243, 93250-52, 93263, 93268, 93276, 93280, 93285, 93287, 93301-
09,
93311-13, 93380-90, 93501-02, 93504-05, 93518-19, 93531, 93560-
61, 93581
Riverside: 91752, 92201-03, 92210-11, 92220, 92223, 92230, 92234-36,
92240-41,
92253-55, 92258, 92260-64, 92270, 92274, 92276, 92282, 92292,
92320, 92501-09, 92513-19, 92521-22, 92530-32, 92543-46, 92548,
92551-57, 92562-64, 92567, 92570-72, 92581-87, 92595-96, 92599,
92860,
92877-83
San Bernardino: 91700-01, 91708-10, 91729-30, 91737, 91739, 91743, 91758,
91761-64,
91784-86, 91798, 92252, 92256, 92268, 92277, 92278, 92284-86,
92305, 92307-08, 92313-18, 92321-22, 92324-26, 92329, 92333-37,
92339-41, 92345-46, 92350, 92352, 92354, 92357-59, 92369, 92371-78,
92382, 92385-86, 92391-94, 92397, 92399, 92400-99
San Diego: 91901-03, 91908-17, 91921, 91931-33, 91935, 91941-47, 91950-51,
91962-63, 91976-80, 91990, 92007-09, 92014, 92018-27, 92029-30,
92033,
92037-40, 92046, 92049, 92051-52, 92054-58, 92064-65,
92067-69, 92071-72,
92074-75, 92078-79, 92082-85, 92090-93, 92096,
92101-24, 92126-40, 92142-43,
92145, 92147, 92149-50, 92152-55,
92158-79, 92182, 92184, 92186-87, 92190-99
Tulare: 93261
Ventura: 91319-20, 91358-63, 91377, 93001-07, 93009,
93010-12, 93015-16,
93020-21, 93022, 93030-35, 93040, 93041-44, 93060-61,
93062-66,
93093, 93099
Ordinarily, you must receive your care from physicians, hospitals, and other
providers who contract with us.
However, we are part of the Kaiser
Permanente Medical Care Program, and if you are visiting another Kaiser
Permanente service area, you can receive virtually all of the benefits of
this Plan at any other Kaiser Permanente
facility. We also pay for certain
follow-up services or continuing care services while you are traveling outside
the
service area, as described on page 41; and for emergency care obtained
from any non-Plan provider, as described on
page 30. We will not pay for any
other health care services.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your
dependents permanently reside outside of the
area, you should consider enrolling in another plan. If you or a family
member move, you do not have to wait until open season to change plans.
Contact your employment or retirement
office.
2001 Kaiser Foundation Health Plan, Inc. 8 Section 1 8
8 Page 9 10
Programwide changes
The plain language team
reorganized the brochure and the way we describe our benefits. We hope this will
make it easier for you to compare plans.
This year, the Federal Employees Health Benefits Program is implementing
mental health and substance abuse parity. This means that your coverage for
mental health, substance abuse, medical, surgical, and hospital services
from Plan providers will be the same with regard to coinsurance, copays, and
day and visit limitations when you
follow a treatment plan that we approve.
Previously, we placed day and visit limitations on mental health and
substance abuse services.
Many health care organizations have turned their attention this past year to
improving health care quality and patient safety. OPM asked all FEHB plans to
join them in this effort. You can find out more about patient safety
on the OPM Web site, www. opm. gov/ insure. To improve your health
care, take these five steps:
Speak up if you have questions or concerns.
Keep a list of all the medicines you take.
Make sure you get the results
of any test or procedure.
Talk with your doctor and health care team about
your options if you need hospital care.
Make sure you understand what will
happen if you need surgery.
We clarified the language to show that anyone
who needs a mastectomy may choose to have the procedure performed on an
inpatient basis and remain in the hospital up to 48 hours after the procedure.
Previously, the
language referenced only women.
Changes to this Plan
In Northern California, your share of the
non-postal premium will increase by 4.2 percent for self only or 4.2 percent for
self and family.
In Southern California, your share of the non-postal premium will increase by
1.4 percent for self only or 1.4 percent for self and family.
We increased
the copayment for the diagnosis and treatment of infertility from a $10
copayment to 50 percent of our allowance.
We provide allergy testing,
treatment, and injections (including materials such as allergy serum) at $3 per
visit. These services were previously provided at no charge.
We provide
diabetic testing equipment and supplies, including blood glucose monitors, at no
charge.
Certain self-administered base drugs formerly provided at no charge
will be provided at a copayment of $10 for up to a 100-day supply.
We limit the supply of certain outpatient drugs to a 30-day supply maximum in
any 30-day period.
Covered medications and accessories change from a $5 to a
$10 copayment.
We increased the copayment for prescription drugs, related to
the diagnosis and treatment of infertility, from a $5 copayment to 50 percent of
our allowance.
2001 Kaiser Foundation Health Plan, Inc. 9 Section 2
Section 2. How we change for 2001 9
9
Page 10 11
We will
send you an identification (ID) card when you enroll. You
should carry your
ID card with you at all times. You must show it
whenever you receive
services from a Plan provider, or fill a
prescription at a Plan pharmacy.
Until you receive your ID card, use
your copy of the Health Benefits
Election Form, SF-2809, your health
benefits enrollment confirmation (for
annuitants), or your Employee
Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at our
Member Service Call Center at 1-800-464-4000.
You get care from "Plan providers" and "Plan facilities."
You will only
pay copayments and/ or coinsurance, and you will not have to
file
claims.
Plan providers are physicians and other health care professionals in our
service area that we contract with to provide covered services to our
members. Health Plan contracts with The Permanente Medical Group,
Inc.,
the Southern California Permanente Medical Group, and
independent
multispecialty groups of physicians to provide or arrange
all necessary
physician care for Plan members. Medical care is provided
through
physicians, nurse practitioners, and other skilled medical
personnel working
as medical teams at Kaiser Permanente facilities. We
credential Plan
providers according to national standards. Specialists in
most major
specialties are available as part of the medical teams for
consultation and
treatment. Other necessary medical care, such as
physical therapy,
laboratory, and X-ray services, is also available. Plan
physicians also
arrange any necessary specialty care.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our Web site.
Plan facilities are hospitals and other facilities in our service area that
we contract with to provide covered services to our members. In
Northern
California, Kaiser Permanente offers comprehensive,
affordable health care
at 30 Plan facilities conveniently located
throughout the San Francisco Bay,
Sacramento, Stockton, and Fresno
areas. These facilities include medical
centers with full hospital facilities
and Plan medical offices. The Southern
California Service Area has 10
major medical centers and more than 90
medical offices conveniently
located throughout the Southern California
area.
The Plan's facility directory lists the Plan's facilities and services, with
the locations and phone numbers. Directories are updated on a regular
basis and are available at the time of enrollment or upon request by
calling our Member Service Call Center at 1-800-464-4000. You should
use this directory to:
Receive more information about facility locations and services. Receive
information about how to get established with a Plan
physician.
2001 Kaiser Foundation Health Plan, Inc. 10 Section 3
Section 3. How you get care
Identification cards
Where you get covered care
Plan providers
Plan facilities 10
10 Page 11 12
You must receive
your health services at Plan facilities, except if you
have an emergency. If
you are visiting another Kaiser Permanente
service area, you may receive
health care services at those Kaiser
Permanente facilities. Under the
circumstances specified in this
brochure, you may receive follow-up or
continuing care while you travel
anywhere.
It depends on the type of care you need. First, you and each family
member must choose a primary care physician. This decision is
important
since your primary care physician provides or arranges for
most of your
health care.
Your primary care physician can be either a family practitioner,
pediatrician, gynecologist, or internist. Your primary care physician will
provide most of your health care, or give you a referral to see a
specialist. Please notify the Plan of the primary care physician you
choose. If you need help choosing a primary care physician, call the
Plan. You may change your primary care physician at any time. You are
free to see other Plan physicians if your primary care physician is not
available, and to receive care at other Kaiser Permanente facilities.
If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.
Your primary care physician will refer you to a specialist for needed
care. However, you may see a mental health professional or chiropractor,
or visit optometry services, without a referral.
Here are other things you should know about specialty care:
If you need
to see a specialist frequently because of a chronic, complex, or serious medical
condition, your primary care physician
will develop a treatment plan that
allows you to see your specialist
for a certain number of visits without
additional referrals. Your
primary care physician will use our criteria when
creating your
treatment plan. (The physician may have to get an
authorization or
approval beforehand.)
If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will decide
what
treatment you need. If he or she decides to refer you to a
specialist, ask
if you can see your current specialist. If your current
specialist does not
participate with us, you must receive treatment
from a specialist who does.
Generally, we will not pay for you to see
a specialist who does not
participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call your
primary care physician, who will arrange for you to see another
specialist.
You may receive services from your current specialist until
we can make
arrangements for you to see someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
terminate our contract with your specialist for other than cause; or drop out
of the Federal Employees Health Benefits (FEHB)
Program and you enroll in
another FEHB plan; or
2001 Kaiser Foundation Health Plan, Inc. 11
Section 3
What you must do to get
covered care
Primary care
Specialty care 11
11 Page 12 13
reduce our service
area and you enroll in another FEHB plan,
you may be able to continue seeing
your specialist for up to 90 days
after you receive notice of the change.
Contact us, or if we drop out of
the program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access
to your specialist based on the above circumstances, you can continue to
see your specialist until the end of your postpartum care, even if it is
beyond the 90 days.
Your Plan primary care physician or specialist will make necessary
hospital arrangements and supervise your care. This includes admission to
a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our
Member Service Call Center immediately at 1-800-464-4000. If you are
new to the FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay
for the hospital stay until:
you are discharged, not merely moved to an alternative care center; or
the day your benefits from your former plan run out; or
the 92 nd day
after you become a member of this Plan;
whichever happens first.
These
provisions apply only to the hospital benefit of the hospitalized
person.
Under certain extraordinary circumstances, such as natural disasters, we
may have to delay your services or we may be unable to provide them. In
that case, we will make all reasonable efforts to provide you with the
necessary care.
Your primary care physician has the authority to refer you for most
services. In certain cases your primary care physician can arrange for
specialty services through a process we call a referral. Your physician
must write a referral for services such as neurology, orthopedics,
rheumatology, endocrinology, and any service that will not be provided
by Plan physicians.
If a Plan physician determines that a referral for medical care is necessary,
those arrangements will be prepared in writing and in advance of such
medical care. If you receive care outside the Plan without a referral, you
will be responsible for those expenses. We encourage you to participate in
your medical care and discuss any questions about our referral process
with your primary care physician. If your request for referral is denied,
please contact our Member Service Call Center at 1-800-464-4000 or
refer
to "Section 8" of this brochure.
2001 Kaiser Foundation Health Plan, Inc. 12 Section 3
Circumstances beyond our
control
Services requiring our
prior approval
Hospital care 12
12 Page 13 14
You must share the
cost of some services. You are responsible for:
A copayment is a fixed
amount of money you pay to a provider when
you receive services. Example:
When you see your primary care
physician, you pay a copayment of $10 per
office visit.
We do not have a deductible.
Note: If you change plans during open
season, you do not have to start a
new deductible under your old plan
between January 1 and the effective
date of your new plan. If you change
plans at another time during the
year, you must begin a new deductible under
your new plan.
Coinsurance is the percentage of our allowance that you must pay for
certain services you receive. Example: In our Plan, you pay 50 percent
of our allowance for infertility services.
If you do not pay your copayment at the time you receive services, we
will bill you. You will be required to pay a $10 charge for each bill sent
for unpaid services.
After your copayments and coinsurance total $1,500 per person or
$3,000
per family enrollment in any calendar year, you do not have to
pay for any
more covered services. However, copayments or coinsurance
for the following
services do not count toward your out-of-pocket
maximum. You must continue
to pay copayments or coinsurance for
these services:
Prescription drugs. Dental services.
Contraceptive devices. Cosmetic
services.
Chiropractic services. The $25 charge paid for follow-up or
continuing care outside the
service area.
Be sure to keep accurate
records of your copayments and coinsurance,
since you are responsible for
informing us when you reach the maximum.
2001 Kaiser Foundation Health Plan, Inc. 13 Section 4
Section 4. Your costs for covered services
Copayments
Deductible
Coinsurance
Your out-of-pocket maximum
for copayments and coinsurance
Fees when you fail to make your copayment 13
13 Page 14 15
Section 5. BenefitsÑ Overview
(See page 9 for how our benefits changed this year and page 62 for
a benefits summary.)
Note: This benefits section is divided into subsections. Please read
the important things you should keep in mind at
the beginning of each
subsection. Also read the "General exclusions" in "Section
6;" they apply to the benefits in the
following subsections. To obtain
claims forms, claims filing advice, or more information about our benefits,
contact
us at 1-800-464-4000 or our Web site at www.
kaiserpermanente. org.
(a) Medical services and supplies provided by physicians and other health
care professionals ........................... 15Ð 22
Diagnostic and
treatment services Lab, X-ray, and other diagnostic tests
Preventive care,
adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies
Rehabilitative
therapies
(b) Surgical and anesthesia services provided by physicians and other health
care professionals........................ 23Ð 26
Surgical procedures Oral and maxillofacial surgery Reconstructive surgery
Organ/ tissue transplants
Anesthesia (c) Services provided by a hospital or
other facility, and ambulance
services...................................................... 27Ð 29
Inpatient hospital Extended care benefits/ skilled nursing care facility
Outpatient hospital or ambulatory benefits
surgical center Hospice care
Ambulance
(d) Emergency services/ accidents
..........................................................................................................................
30Ð 31
Emergency within our service area Ambulance Emergency outside our
service area
(e) Mental health and substance abuse benefits
...................................................................................................
32Ð 34
(f) Prescription drug benefits
................................................................................................................................
35Ð 38
(g) Special
features.................................................................................................................................................
39Ð 41
Flexible benefits option Centers of excellence for transplants 24-hour nurse
line Services from other Kaiser Permanente Plans
Services for the deaf and
hearing impaired Travel benefit
(h) Dental benefits
........................................................................................................................................................
42
(i) Non-FEHB benefits available to Plan members
......................................................................................................
43
Summary of
benefits.....................................................................................................................................................
62
2001 Kaiser Foundation Health Plan, Inc. 14 Section 5
Hearing services (testing, treatment, and supplies) Vision services (testing,
treatment, and supplies)
Foot care Orthopedic and prosthetic devices
Durable medical equipment (DME) Home health services
Alternative
treatments Educational classes and programs 14
14
Page 15 16
2001
Kaiser Foundation Health Plan, Inc. 15 Section 5( a)
Section 5
(a). Medical services and supplies provided by physicians and
other health
care professionals
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure, and we cover them only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have no calendar
year deductible.
Be sure to read "Section 4, Your costs for covered
services" for valuable information about how cost sharing works. Also read
"Section 9" about coordinating benefits with other
coverage, including with Medicare.
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Benefit description You pay
Diagnostic and treatment services
Professional services of physicians and other health care professionals
$10 per office visit
In a physician's office.
In an urgent care center.
Second opinion within Plan.
During a hospital stay. Nothing
In a
skilled nursing facility.
Initial examination of a newborn child covered
under a family enrollment.
Consultations with specialists.
At home Nothing
Lab, X-ray, and
other diagnostic tests
Tests, such as: Nothing
Blood tests.
Urinalysis.
Nonroutine Pap tests.
Pathology.
X-rays.
Nonroutine mammograms.
CAT scans/ MRI.
Ultrasound.
Electrocardiogram and EEG. 15
15 Page 16 17
2001 Kaiser
Foundation Health Plan, Inc. 16 Section 5( a)
Preventive care,
adult You pay
Routine screenings, such as: Nothing
Blood lead level.
Total blood cholesterol.
Colorectal cancer screening, including:
Fecal occult blood test.
Sigmoidoscopy.
Prostate Specific Antigen
(PSA) test.
Routine Pap test.
Routine mammogramÑ covered for women age 35 and older, as follows:
Nothing
Age 35 through 39, one during this five-year period.
Age 40
through 64, one every calendar year.
At age 65 and older, once every two
consecutive calendar years.
Note: In addition to routine screening, we cover
mammograms when
medically necessary to diagnose or treat your illness.
Routine immunizations, including but not limited to: Nothing
Tetanus-diphtheria (Td) boosterÑ once every 10 years, ages 19 and
over (except as provided for under childhood immunizations).
Influenza/ Pneumococcal vaccines.
Hepatitis vaccinations.
Not
covered: All charges
Physical exams required for:
Obtaining or
continuing employment.
Insurance.
Attending school.
Travel.
Preventive care, children You pay
Well-child preventive care
visits (23 months and younger). Nothing
Childhood immunizations recommended
by the American Academy of
Pediatrics.
Well-child care charges for routine examinations age 24 months and $10 per
office visit
older, such as:
Eye exams to determine the need for vision correction.
Ear exams to determine the need for hearing correction. 16
16 Page 17 18
2001 Kaiser Foundation Health Plan, Inc. 17
Section 5( a)
Not covered: All charges
Physical exams required for:
Obtaining or continuing employment.
Insurance.
Attending school or camp.
Maternity care You pay
Complete maternity (obstetrical) care, such
as: Nothing
Prenatal care.
Delivery.
First scheduled postnatal care
visit.
Note: Here are some things to keep in mind:
You may remain in the
hospital up to 48 hours after a regular delivery and 96 hours after a cesarean
delivery. We will extend your
inpatient stay if medically necessary.
We cover routine nursery care of
the newborn child during the covered portion of the mother's maternity stay. We
will cover other
care of an infant who requires non-routine treatment only if we cover
the
infant under a self and family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See "Section 5( c)" for hospital benefits and
"Section 5( b)" for surgery benefits.
Not covered: All
charges
Routine sonograms to determine fetal age, size, or sex.
Family
planning You Pay
Voluntary sterilization. $10 per office visit
Genetic counseling.
Surgically implanted contraceptives.
Injectable
contraceptive drugs.
Intrauterine devices (IUDs).
Note: We cover
surgically implanted and injectable contraceptives and
intrauterine devices
under the prescription drug benefit.
Not covered: All charges
Reversal of voluntary surgical sterilization. 17
17 Page 18 19
2001 Kaiser Foundation Health Plan, Inc. 18
Section 5( a)
Infertility services You pay
Diagnosis and
treatment of infertility, such as: 50% of our allowance
Artificial
insemination:
Intravaginal insemination (IVI).
Intracervical
insemination (ICI).
Intrauterine insemination (IUI).
Note: We cover fertility drugs under the prescription drug benefit.
Not covered: All charges
Assisted reproductive technology
(ART) procedures, such as:
In vitro fertilization.
Embryo
transfer and GIFT.
Services and supplies related to excluded ART
procedures.
Cost of donor sperm and donor eggs and services related
to their
procurement and storage.
Allergy care You pay
Allergy testing, treatment, and injections $3
per office visit
Allergy serum Nothing
Not covered: All charges
Provocative food testing.
Sublingual allergy desensitization.
Treatment therapies You pay
Chemotherapy and radiation therapy.
Nothing for services provided by a non-
Note: We limit high-dose chemotherapy in association with autologous
physician provider
bone marrow transplants to those transplants listed under
"Organ/ tissue
transplants" on page 26.
Intravenous (IV)/ Infusion therapyÑ home IV and antibiotic therapy.
Respiratory and inhalation therapy. $10 per office visit
Growth hormone
therapy (GHT).
Note: We cover human growth hormone under the prescription
drug
benefit.
DialysisÑ hemodialysis and peritoneal dialysis.
Note: We waive the
$10 charge if you enroll in Medicare Part B and
assign your Medicare
benefits to the Plan.
$10 for services provided
by a non-physician provider 18
18 Page 19 20
2001 Kaiser Foundation Health Plan, Inc. 19
Section 5( a)
Not covered: All charges
Chemotherapy supported
by a bone marrow transplant or with stem
cell support, for any diagnosis not
listed as covered.
Rehabilitative therapies You pay
We cover initial courses of
therapy for up to two months per condition $10 per office visit when
for:
provided on an
outpatient basis
Physical therapy by qualified physical
therapists to restore bodily function when you have a total or partial loss of
bodily function due Nothing when provided
to illness or injury. on an inpatient basis
Speech therapy by speech
therapists to restore speech when you have a total or partial loss of functional
speech due to illness or
injury.
Occupational therapy by occupational therapists to assist you in
achieving and maintaining self-care and improved functioning in
other activities of daily life.
Note: We provide subsequent courses of
therapy for up to two months if
you show significant improvement in your
condition.
Cardiac rehabilitation following a heart transplant, bypass surgery, or a
myocardial infarction.
Not covered: All charges
Long-term rehabilitative therapy.
Exercise programs.
Hearing services (testing, treatment, and supplies) You pay
Hearing testing $10 per office visit
Not covered: All charges
Hearing aids.
Hearing tests to determine the most appropriate hearing aid.
Vision services (testing, treatment, and supplies) You pay
Diagnosis and treatment of diseases of the eye. $10 per office visit
Eye refractions to determine the need for vision correction and
provide
a prescription for eyeglasses.
Not covered: All charges
Eyeglasses or contact lenses.
Eye exercises and orthoptics.
Radial keratotomy and other refractive surgery. 19
19 Page 20 21
2001 Kaiser Foundation Health Plan, Inc. 20
Section 5( a)
We cover FDA-approved devices that are in general use
and are
required because a defect in form or function of a permanently
inoperative or malfunctioning body part, including but not limited to:
Artificial limbs and eyes and stump hose.
Externally worn breast
prostheses and surgical bras, including necessary replacements, following a
mastectomy.
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear
implants, intraocular implants following cataract removal,
and surgically
implanted breast implants following mastectomy.
Note: See "Section 5(
b)" for coverage of the surgery to insert the
device.
Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
Not covered:
Comfort, convenience, or luxury equipment or
features.
Orthopedic and corrective shoes.
Arch supports.
Foot orthotics.
Heel pads and heel cups.
Lumbosacral supports.
Corsets, trusses, elastic stockings,
support hose, and other
supportive devices.
Foot care You pay
Routine foot care when you are under active
treatment for a metabolic $10 per office visit
or peripheral vascular
disease, such as diabetes.
Not covered: All charges
Cutting, trimming, or removal of
corns, calluses, or the free edge of toenails, and similar routine treatment of
conditions of the foot,
except as stated above.
Treatment of weak, strained, or flat
feet, or bunions or spurs; and of any instability, imbalance, or subluxation of
the foot (unless the
treatment is by open cutting surgery).
Orthopedic and prosthetic devices You pay
All charges
Nothing 20
20 Page 21 22
2001 Kaiser
Foundation Health Plan, Inc. 21 Section 5( a)
You pay
Nothing
All charges
Nothing
You pay
Durable medical equipment (DME)
We cover DME during a covered stay
in a Plan hospital or skilled
nursing facility, and for use in the home when
intended to be used
repeatedly. Includes but is not limited to:
Oxygen and oxygen dispensing equipment.
Hospital beds.
Wheelchairs
including motorized wheelchairs when medically necessary.
Crutches.
Walkers.
Blood glucose testing monitors and related supplies.
Insulin pumps.
Ostomy and urological supplies.
Infant apnea
monitors.
Repairs and replacements resulting from normal use.
We limit
coverage to the standard item that meets your medical needs
consistent with
our Plan DME formulary guidelines. We decide
whether to rent or purchase the
item, and choose the vendor.
Note: We only provide DME in the Plan's service area.
Not covered:
Comfort, convenience, or luxury equipment or features.
Devices not medical in nature, such as sauna baths, exercise and
hygiene equipment.
Electronic monitors of the function of the heart or lungs, except for
infant apnea monitors.
Devices to perform medical tests on blood or
other bodily substances or excretions, except diabetic testing equipment and
supplies.
Dental appliances.
Experimental or research
equipment.
Modifications to the home or auto.
Home health services
Home health care ordered by a Plan physician and provided by a
registered nurse (RN), licensed practical nurse (LPN), licensed
vocational nurse (LVN), or home health aide.
Services include oxygen
therapy, intravenous therapy, and medications.
Note: We only provide these services in the Plan's service area. 21
21 Page 22 23
2001 Kaiser Foundation Health Plan, Inc. 22
Section 5( a)
All charges
All charges
$15 per office visit
Nothing
Nothing
Nominal charges
Not covered:
Nursing care requested by, or for the convenience
of, the patient or the patient's family.
Nursing care primarily for hygiene, feeding, exercising, moving the
patient, homemaking, companionship, or giving oral medication.
Services outside of our service area.
Alternative treatments
Chiropractic services are limited to 20 visits per year. You can access
services in the following ways:
Chiropractic services are provided through American Specialty Health
Plans (ASHP). You will have direct access to a participating ASHP
chiropractor without the need to obtain a Plan physician referral.
Participating chiropractors are listed in the ASHP Participating Provider
Directory.
Specific details of this chiropractic benefit are listed in the ASHP
Evidence of Coverage/ Disclosure Form. You phone the ASHP
chiropractor you have selected for an initial examination. After the
initial examination, and except for chiropractic emergency services, your
ASHP chiropractor is responsible for obtaining authorization from ASHP
for any additional chiropractic services on your behalf. ASHP will not
cover any chiropractic services if you were referred through your Plan
physician.
Note: When necessary and prescribed by an ASHP chiropractor, you may
receive up to $50 of chiropractic appliances per calendar year.
Not covered:
Naturopathic services.
Hypnotherapy.
Educational classes and programs
Education for specific
conditions.
Health education.
Educational classes for a wide variety of
subjects that do not relate directly to specific conditions.
Note: Call the Member Service Call Center at 1-800-464-4000 for
information on classes near you.
You pay
You pay 22
22 Page 23 24
2001 Kaiser
Foundation Health Plan, Inc. 23 Section 5( b)
Here are some
important things to keep in mind about these benefits:
Please remember
that all benefits are subject to the definitions, limitations, and exclusions in
this brochure, and we cover them only when we determine they are
medically necessary.
Plan physicians must provide or arrange your care.
We have no calendar year deductible.
Be sure to read "Section 4,
Your costs for covered services" for valuable information about how cost
sharing works. Also read "Section 9" about coordinating benefits
with other coverage, including with Medicare.
The amounts listed below
are for the charges billed by a physician or other health care professional for
your surgical care. Look in "Section 5( c)" for charges
associated with the facility (e. g., hospital, surgical center, etc.).
YOU MUST GET A REFERRAL FOR SOME SURGICAL PROCEDURES. Please refer to the
referral information shown in "Section 3" to be sure which services
require a referral and identify which surgeries require a referral.
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Section 5 (b). Surgical and anesthesia services provided by physicians and
other health care professionals
Benefit description You pay
Surgical procedures
Treatment of
fractures, including casting.
Treatment of burns.
Normal pre-and
postoperative care by the surgeon.
Correction of amblyopia and strabismus.
Endoscopy procedure.
Biopsy procedure.
Removal of tumors and cysts.
Correction of congenital anomalies (see reconstructive surgery).
Surgical treatment of morbid obesity.
Voluntary sterilization (tubal
ligation and vasectomy).
Insertion of internally implanted contraceptives
and intrauterine devices (IUDs).
Note: We cover contraceptive drugs and devices under the prescription
drug benefit.
Treatment for sexual dysfunction or inadequacy.
Insertion of internal
prosthetic devices. See "Section 5( a), Orthopedic and prosthetic
devices" for device coverage
information.
$10 per office visit when
provided on an outpatient basis
Nothing when provided on an
inpatient basis 23
23 Page 24 25
2001 Kaiser Foundation Health Plan, Inc. 24
Section 5( b)
All charges
$10 per office visit when
provided
on an outpatient basis
Nothing when provided on
an inpatient basis
Not covered:
Reversal of voluntary, surgical sterilization.
Routine treatment of conditions of the foot.
Reconstructive surgery
Surgery to correct a functional defect.
Surgery to correct a condition caused by injury or illness if:
the
condition produced a major effect on the member's appearance; and
the condition can reasonably be expected to be corrected by such surgery.
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital
anomalies are protruding ear deformities, cleft lip, cleft
palate,
birthmarks, webbed fingers, and webbed toes.
All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;
breast
prostheses and surgical bras and replacements (see prosthetic devices).
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.
Not covered:
Cosmetic surgeryÑ any surgical procedure
(or any portion of a procedure) performed primarily to improve physical
appearance
through change in bodily form, except repair of accidental injury.
Surgeries related to sex transformation.
All charges
You pay 24
24 Page
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2001 Kaiser Foundation Health
Plan, Inc. 25 Section 5( b)
Oral and maxillofacial surgery
Oral surgical procedures, limited to:
Reduction of fractures or
dislocations of the jaw or facial bones.
Surgical correction of cleft lip,
cleft palate, or severe functional malocclusion.
Removal of stones from salivary ducts.
Excision of leukoplakia or
malignancies.
Excision of cysts and incision of abscesses when done as
independent procedures.
Medical and surgical treatment of TMJ.
Other surgical procedures that do
not involve the teeth or their supporting structures.
Not covered:
Oral implants and transplants.
Procedures that involve the teeth or their supporting structures
(such as the periodontal membrane, gingiva, and alveolar bone).
You pay
$10 per office visit when
provided on an outpatient
basis
Nothing when provided on an
inpatient basis
All charges 25
25 Page 26 27
2001 Kaiser
Foundation Health Plan, Inc. 26 Section 5( b)
Organ/ tissue
transplants
Limited to:
Cornea.
Heart.
Heart/ Lung.
Kidney.
Kidney/ Pancreas.
Liver.
Lung: SingleÑ Double.
Pancreas.
Allogeneic (donor) bone marrow transplants.
Autologous
bone marrow transplants (autologous stem cell and peripheral stem cell support)
for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal,
retroperitoneal, and ovarian
germ cell tumors.
Limited benefits: Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved by
the Plan's medical director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor when
we
cover your transplant.
Not covered:
Donor screening tests and donor search expenses,
except those performed for the actual donor.
Implants of nonhuman artificial organs.
Transplants not listed
as covered.
Anesthesia
Professional services provided during a surgical
procedure
Hospital (inpatient).
Ambulatory surgery center (outpatient).
You pay
$10 per office visit when
provided on an outpatient
basis
Nothing when provided on an
inpatient basis
All charges
Nothing
You pay 26
26 Page 27 28
2001 Kaiser Foundation Health Plan, Inc. 27
Section 5( c)
Here are some important things to keep in mind about
these benefits:
Please remember that all benefits are subject to the
definitions, limitations, and exclusions in this brochure, and we cover them
only when we determine they are
medically necessary.
Plan physicians must provide or arrange your care
and you must be hospitalized in a Plan facility.
We have no calendar year deductible.
Be sure to read "Section 4,
Your costs for covered services" for valuable information about how cost
sharing works. Also read "Section 9" about coordinating benefits
with other coverage, including with Medicare.
The amounts listed below
are for the charges billed by the facility (e. g., hospital or surgical center)
or ambulance service for your surgery or care. Any costs associated
with the professional charge (e. g., physicians, etc.) are covered in
"Section 5( a)" or
"Section 5( b)."
Nothing
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Benefit description You pay
Inpatient hospital
Room and board,
such as
Ward, semiprivate, or intensive care accommodations.
General nursing care.
Meals and special diets.
Note: Your physician
may prescribe accommodation or private duty
nursing care if it is medically
necessary. If you want a private room when
it is not medically necessary,
you pay the additional charge above the
private room rate.
Section 5 (c). Services provided by a hospital or other facility, and
ambulance services 27
27 Page 28 29
2001 Kaiser
Foundation Health Plan, Inc. 28 Section 5( c)
Nothing
All
charges
Nothing
Other hospital services and supplies, such as:
Operating, recovery,
maternity, and other treatment rooms.
Prescribed drugs and medicines.
Diagnostic laboratory tests and X-rays.
Administration of blood and
blood products.
Blood or blood plasma.
Dressings, splints, casts, and
sterile tray services.
Medical supplies and equipment, including oxygen.
Anesthetics, including nurse anesthetist services.
Plan physicians' and
surgeons' services and supplies, including consultation and treatment by
specialists.
Take-home items.
Note: You may receive covered hospital services for
certain dental
procedures if a Plan physician determines you need to be
hospitalized for
reasons unrelated to the dental procedure. The conditions
for which we
will provide hospitalization include hemophilia and heart
disease. The
need for anesthesia, by itself, is not such a condition.
Not covered:
Custodial care and care in an intermediate care
facility.
Personal comfort items, such as barber services, guest
meals, and beds.
Private nursing care unless medically necessary.
Inpatient dental procedures.
Outpatient hospital or
ambulatory surgical center
Operating, recovery, and other treatment
rooms.
Prescribed drugs and medicines.
Diagnostic laboratory tests,
X-rays, and pathology services.
Administration of blood, blood plasma, and
other biologicals.
Blood and blood plasma.
Pre-surgical testing.
Dressings, casts, and sterile tray services.
Medical supplies, including
oxygen.
Anesthetics and anesthesia service.
You pay 28
28 Page
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2001 Kaiser Foundation Health
Plan, Inc. 29 Section 5( c)
You pay
Nothing
All charges
Extended care benefits/ skilled nursing care facility
benefits
Up to 100 days per benefit period when you need full-time skilled nursing
care. Your benefit period begins when you enter a hospital or skilled
nursing facility and ends when you have not been a patient in either a
hospital or skilled nursing facility for 60 consecutive days.
All necessary services are covered, including;
Bed, board, and general
nursing care.
Prescribed drugs and their administration, biologicals,
supplies, and equipment ordinarily provided or arranged by the skilled nursing
facility.
Not covered:
Custodial care.
Care in an intermediate
care facility.
Hospice care
Supportive and palliative care for a terminally ill
member:
You must reside in the service area.
Services are provided in
the home.
Services are provided in a Plan-approved hospice facility.
Services include inpatient care, outpatient care, and family counseling.
A Plan physician must certify that you have a terminal illness, with a life
expectancy of approximately six months or less.
Note: Hospice is a program for caring for the terminally ill that
emphasizes supportive services, such as home care and pain control,
rather than curative care of the terminal illness. A person who is
terminally ill may elect to receive hospice benefits. These palliative
and supportive services include nursing care, medical social services,
physician services, and short-term inpatient care for pain control and
acute and chronic symptom management. We also provide counseling and
bereavement services for the individual and family members, and therapy
for purposes of symptom control to enable the person to continue life
with as little disruption as possible. If you make a hospice election, you
are not entitled to receive other health care services that are related to
the
terminal illness. If you have made a hospice election, you may revoke
that
election at any time, and your standard health benefits will be
covered.
Ambulance
Local professional ambulance service when medically
appropriate
Not covered:
Transports that we determine are not medically necessary.
Nothing
Nothing
All charges
You pay
You pay 29
29 Page 30 31
What is a
medical emergency?
A medical emergency is the sudden and unexpected
onset of a condition or an injury that you believe endangers
your life or
could result in serious injury or disability, and requires immediate medical or
surgical care. Some
problems are emergencies because, if not treated
promptly, they might become more serious; examples include
deep cuts and
broken bones. Others are emergencies because they are potentially
life-threatening, such as heart
attacks, strokes, poisonings, gunshot
wounds, or sudden inability to breathe. There are many other acute
conditions that we may determine are medical emergenciesÑ what they
all have in common is the need for quick
action.
What to do in case of emergency
You are covered for medical
emergencies anywhere in the world. In a medical emergency, call 911. When the
operator answers, stay on the phone and answer all questions.
Emergencies within our service area
Emergency care is provided at
Plan hospitals 24 hours a day, 7 days a week. If you have a medical emergency,
go
to the closest Plan hospital. If you reasonably believe you have a
medical emergency condition and you cannot
safely go to a Plan hospital,
call 911 or go to the nearest hospital. If an ambulance comes, tell the
paramedics
that the person who needs help is a Kaiser Permanente member.
If you are within our service area, we will cover Out-of-Plan emergency care
only if you reasonably believe that
going to a Plan facility for treatment
will cause a delay resulting in permanent damage to your health. If you
need
to be hospitalized in a non-Plan facility, the Plan must be notified as soon as
reasonably possible. Call us
toll free in California at 1-800-772-3532.
The telephone number to call is also on your ID card. We will make
arrangements for necessary continued hospitalization or for transferring you
to a designated hospital.
Emergencies outside our service area
Benefits are available for
any medically necessary health service that is immediately required because of
injury
or unforeseen illness.
If you need to be hospitalized, the Plan must be notified as soon as is
reasonably possible. If a Plan physician
believes that care can be better
provided in a Plan hospital, we will transfer you when it is medically feasible.
You may obtain emergency and urgent care services from Kaiser Permanente
medical facilities and providers
when you are in the service area of another
Kaiser Permanente Plan. The facilities will be listed in the local
telephone
book under Kaiser Permanente. These numbers are available 24 hours a day, 7 days
a week. You may
also obtain information about the location of facilities by
calling 1-800-227-2415.
2001 Kaiser Foundation Health Plan, Inc. 30 Section 5( d)
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure, and we cover them only when we
determine they are
medically necessary.
We have no calendar year deductible.
Be sure to
read "Section 4, Your costs for covered services" for valuable
information about how cost sharing works. Also read "Section 9" about
coordinating benefits
with other coverage, including with Medicare.
Section 5 (d). Emergency services/ accidents
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2001
Kaiser Foundation Health Plan, Inc. 31 Section 5( d)
Benefit
description You pay
Emergency within our service area
Hospital
emergency room visit for emergency services
Note: We waive the $35 if you
are admitted to the hospital.
Not covered:
Elective care or
nonemergency care.
Urgent care at a non-Plan urgent care center.
Emergency outside our service area
Emergency care as an outpatient
or inpatient at a hospital, including
physicians' services
Emergency room visit for emergency services.
Emergency care at an urgent
care center.
Emergency care in a Kaiser Foundation Hospital in another
Kaiser Foundation Health Plan service area.
Note: See the "Travel benefit" for coverage of continuing or
follow-up care.
Not covered:
Elective care or nonemergency
care at non-Plan facilities.
Ambulance
Professional ambulance
service, including air ambulance, when medically
appropriate
Not covered:
Transports we determine are not medically necessary.
$35 per visit
$35 per visit
The amount you would be
charged if
you were a
member in that service area
All charges
All charges
Nothing
All charges 31
31 Page 32 33
Section 5 (e).
Mental health and substance abuse benefits
2001 Kaiser Foundation
Health Plan, Inc. 32 Section 5( e)
Parity
Beginning in
2001, all FEHBP plans' mental health and substance benefits will achieve
"parity" with other benefits. This means that we will provide
mental health and
substance abuse benefits differently than in the past.
When you get our approval for services and follow a treatment plan we
approve, cost
sharing and limitations for Plan mental health and substance
abuse benefits will be no
greater than for similar benefits for other
illnesses and conditions.
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure, and we cover them only when we
determine they are
medically necessary.
Plan physicians must provide or arrange your care.
We have no calendar year deductible.
Be sure to read "Section 4,
Your costs for covered services" for valuable information about how cost
sharing works. Also read "Section 9" about coordinating benefits
with other coverage, including with Medicare.
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Benefit description You pay
Mental health and substance abuse benefits
We cover all diagnostic and treatment services recommended by a Plan
provider and contained in a treatment plan. The treatment plan may
include services, drugs, and supplies described elsewhere in this brochure.
Note: We cover the services only when we determine that the care is
clinically appropriate to treat your condition, and only when you receive
the care as part of a treatment plan developed by a Plan provider.
Note: OPM will base its review of disputes about treatment plans on the
treatment plan's clinical appropriateness. OPM will generally not order us
to pay or provide one clinically appropriate treatment in favor of another.
Your cost sharing
responsibilities are no greater
than for other
illnesses or
conditions 32
32 Page 33 34
Diagnosis and
treatment of psychiatric conditions, mental illness, and
mental disorders.
Services include:
Diagnostic evaluation.
Treatment (including individual, family, and group
therapy visits).
Crisis intervention and stabilization for acute episodes.
Psychological testing that is medically necessary to determine the
appropriate psychiatric treatment.
Medication management and evaluation.
Diagnosis and treatment of alcoholism and drug abuse. Services include:
Treatment and counseling (including individual, family, and group therapy
visits).
Outpatient detoxification (medical management of withdrawal from the
substance).
Note: You may see a Plan mental health or substance abuse
provider for
outpatient treatment without a referral from your primary care
physician.
Inpatient psychiatric care.
Hospital alternative services, such as
partial hospitalization and intensive outpatient psychiatric treatment programs.
Inpatient substance abuse care and rehabilitation.
Inpatient
detoxification.
Methadone treatment for a pregnant woman throughout the
pregnancy and for two months after delivery.
Note: All inpatient admissions and hospital alternative services treatment
programs require approval by a Plan physician.
Recovery services in a nonmedical residential care facility.
Note: All
inpatient and alternative services treatment programs require
approval by a
Plan physician.
2001 Kaiser Foundation Health Plan, Inc. 33 Section 5( e)
$10 per office visit
Nothing
$100 per stay 33
33 Page 34 35
Not covered:
Care that is not clinically
appropriate for the treatment of your condition.
Continued services if you do not substantially follow your treatment plan.
Services we have not approved.
Intelligence, IQ, aptitude
ability, learning disorders, or interest testing not necessary to determine the
appropriate treatment of a psychiatric
condition.
Evaluation or therapy on court order or as a
condition of parole or probation, or otherwise required by the criminal justice
system, unless
determined by a Plan physician to be medically necessary and
appropriate.
Services that are custodial in nature.
Services rendered or
billed by a school or a member of its staff.
Services provided under
a federal, state, or local government program.
Psychoanalysis or
psychotherapy credited toward earning a degree or furtherance of education or
training, regardless of diagnosis or
symptoms.
2001 Kaiser Foundation Health Plan, Inc. 34 Section 5( e)
All charges
If a mental health or substance abuse professional
provider is treating
you under our Plan as of January 1, 2001, you will be
eligible for
continued coverage with your provider for up to 90 days under
the
following condition:
If your mental health or substance abuse professional provider with whom you
are currently in treatment leaves the Plan at our request
for other than cause.
If this condition applies to you, we will allow you
reasonable time to
transfer your care to a network mental health or
substance abuse
professional provider. During the transitional period, you
may continue
to see your treating provider and will not pay any more
out-of-pocket
costs than you did in the year 2000 for services. This
transitional period
will begin with our notice to you of the change in
coverage. The
transitional period will last for up to 90 days from the date
you receive
notice of the change. You may receive this notice prior to
January 1,
2001, and the 90-day period begins with receipt of the notice.
We may limit your benefits if you do not follow your treatment plan.
Benefit limitation
Special transitional benefit 34
34
Page 35 36
There are important features you should be aware of. These include:
Who can write your prescription. A Plan physician or any dentist must
write the prescription. Drugs prescribed by dentists are not covered if a Plan
physician determines that they are not medically necessary.
Where you can obtain them. You must fill the prescription at a Plan
pharmacy or another pharmacy that we designate, or through our mail-order
program.
We use a formulary. A formulary is a listing of preferred
pharmaceutical substances and formulas. A team of Kaiser Permanente physicians
and pharmacists independently and objectively evaluates the scientific
literature to identify the FDA-approved drugs best suited to treat specific
medical conditions. The Plan uses
this formulary to determine which
prescribed drugs will be provided to members.
Our formulary includes a list of prescription drugs that have been approved
by our Pharmacy and
Therapeutics Committee. This committee, which is
comprised of Plan physicians and other Plan providers,
selects prescription
drugs for the formulary based on a number of factors, including safety and
effectiveness
as determined from a review of medical literature and
research. The committee meets quarterly to consider
adding and removing
prescription drugs on the formulary. If you would like information about whether
a
particular drug is included on our formulary, please call the Member
Service Call Center at
1-800-464-4000.
If the physician specifically prescribes a non-formulary drug because it is
medically necessary, the non-formulary
drug will be covered. If you request
the non-formulary drug when your physician has prescribed
a substitution,
the non-formulary drug is not covered. However, you may purchase the
non-formulary drug
from a Plan pharmacy at prices charged to members for
non-covered drugs.
These are the dispensing limitations. We provide up to a 100-day
supply for most drugs. Maintenance
medications may be obtained for up to a
100-day supply when ordered through our mail-order program.
When you have to file a claim. When you receive drugs from a Plan
pharmacy, you do not have to file a claim. For a covered out-of-area emergency,
you will need to file a claim when you receive drugs from a
non-Plan pharmacy.
Prescription drug benefits begin on the next page.
2001 Kaiser Foundation Health Plan, Inc. 35 Section 5( f)
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure, and we cover them only when we
determine they are
medically necessary.
We have no calendar year
deductible.
Be sure to read "Section 4, Your costs for covered
services" for valuable information about how cost sharing works. Also read
"Section 9" about coordinating benefits with
other coverage, including with Medicare.
Section 5 (f). Prescription drug benefits
I M
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35
Page 36 37
2001
Kaiser Foundation Health Plan, Inc. 36 Section 5( f)
Benefit
description You pay
Covered medications and supplies
We cover the
following medications and supplies
Certain self-administered IV drugs and
fluids requiring specific types of parenteral infusion, and the supplies
required for their
administration.
Amino-acid modified products used to treat congenital
errors of amino acid metabolism.
Diabetes urine-testing supplies.
Vaccines and immunizations approved for
use by the Food and
Drug Administration.
Cancer chemotherapy drugs and critical adjuncts following a diagnosis of
cancer.
Drugs for the treatment of tuberculosis.
Drugs for the treatment of
life-threatening ventricular arrhythmias.
Low-weight molecular heparin for acute therapy of life-threatening thrombotic
disorders.
Human growth hormone for long-term treatment of pediatric
patients with growth failure from lack of adequate endogenous
growth hormone
secretion.
Epogen for dialysis patients in accord with Medicare guidelines
and for pre-dialysis ESRD patients to treat anemia.
Cytovene and postsurgical immunosuppressant outpatient drugs required as a
result of a covered transplant.
Elemental dietary enteral formula when used
as a sole source of nutrition according to Medicare guidelines and when used as
primary therapy for regional enteritis.
Ostomy supplies.
Note: We
will charge no copayment until July 1, 2001, when the
$10 copayment becomes
effective.
Nothing
$10 per prescription 36
36 Page 37 38
Drugs and
medicines that by United States federal law require a physician's prescription
for their purchase, except as excluded below.
We also cover certain drugs
that do not require a prescription by law
if they are listed on our drug
formulary.
Insulin.
Certain insulin-administration devices.
Disposable needles
and syringes for the administration of covered medications.
Smoking-cessation drugs are covered for one course of treatment per calendar
year, but only if you participate in, and pay the cost of, a
Plan-approved
behavioral intervention program.
Injectable and internally implanted,
time-release contraceptives.
Oral contraceptives.
Contraceptive devices.
Infertility drugs.
Sexual dysfunction drugs.
Episodic drugs will be provided up to a
maximum of 27 doses in any 100-day period. Additional prescribed doses during
the
same 100 days will be dispensed at our allowance.
Maintenance
(non-episodic) drugs that require doses at regulated intervals.
2001 Kaiser Foundation Health Plan, Inc. 37 Section 5( f)
$10 per prescription
$10 per 3-month supply
(not to exceed $200)
$10 (up to a 3-cycle supply)
$10 per device
50% of our allowance 37
37
Page 38 39
Specific drugs limited to a 30-day supply in any 30-day period.
(Additions to this list will occur no more than quarterly. Please contact
our Member Service Call Center at 1-800-464-4000 for the current
list.)
Neupogen (filgrastim, G-CSF).
Epogen (Epoetin alpha).
Roferon-A
(Interferon Alfa-2a).
Interferon alfacon-1 (Infergen by Amgen).
Intron-A
(Interferon Alfa-2b).
Rebetron (Ribavirin and Interferon Alfa-2b).
Human
growth hormone (Serostim, Humatrope, Protropin, Nutropin, Genatropin, etc).
Enoxaparin (Lovenox).
Not covered:
Drugs and supplies for cosmetic purposes.
Vitamins and
nutritional supplements that can be purchased without a prescription.
Nonprescription medicines, unless they are included in our drug formulary.
Medical supplies, such as dressings and antiseptics.
Drugs
to enhance athletic performance.
2001 Kaiser Foundation Health Plan, Inc. 38 Section 5( f)
$10 per prescription
All charges 38
38
Page 39 40
Under
the flexible benefits option, we determine the most effective way to
provide
services.
We may identify medically appropriate alternatives to traditional care and
coordinate other benefits as a less costly alternative benefit.
Alternative benefits are subject to our ongoing review.
By approving an
alternative benefit, we cannot guarantee you will get it in the future.
The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.
Our decision
to offer or withdraw alternative benefits is not subject to OPM review under the
disputed claims process.
For any of your health concerns, 24 hours a day, 7 days a week, you may
talk with a registered nurse who will discuss treatment options and answer
your health questions. You can obtain an advice nurse phone number for
the nearest Kaiser Permanente facility in the white pages of your phone
book under "Kaiser Permanente."
We provide a TTY/ text telephone numberÑ 1-800-777-1370. Sign
language services are also available.
Kaiser Permanente's National Transplant Network (NTN) was created to
offer members greater choice of, and access into, centers of excellence
(COE) that exceed minimum quality standards for experience (based on
volume of cases and transplant team composition), outcomes, and service
(waiting time and access to the center). The goal is to ensure that
members are treated at centers where optimal outcomes can be expected,
measured, and managed. Currently, the NTN contains 20 centers that
include 70 transplant programs. Transplant services provided through the
NTN are heart, lung, heart/ lung, liver, simultaneous kidney/ pancreas,
pancreas, small bowel, and bone marrow/ stem cell (autologous and
allogeneic).
2001 Kaiser Foundation Health Plan, Inc. 39 Section 5( g)
Section 5 (g). Special features
Feature Description
Flexible
benefits option
24-hour nurse line
Services for the deaf
and hearing impaired
Centers of excellence for
transplants 39
39 Page 40 41
When you are visiting in the service area of another
Kaiser Permanente
Plan, you are entitled to receive virtually all the
benefits described in this
brochure at any Kaiser Permanente medical office
or medical center. You
will have to pay the charges imposed by the Plan you
are visiting. If the
Plan you are visiting has a benefit that is different
from the benefits of
this Plan, you are not entitled to receive that
benefit.
Some services covered by this Plan, such as artificial reproductive
services and the services of specialized rehabilitation facilities, will not
be
available in other Kaiser Permanente service areas. If a benefit is
limited
to a specific number of visits or days, you are entitled to receive
only the
number of visits or days covered by the Plan in which you are
enrolled.
If you are seeking routine, non-emergent, or nonurgent services, you
should call the Kaiser Permanente Membership Services Department in
that
service area and request an appointment. You may obtain routine
follow-up or
continuing care from these Plans, even when you have
obtained the original
services in the service area of this Plan. If you
require emergency services
as the result of unexpected or unforeseen
illness that requires immediate
attention, you should go directly to the
nearest Kaiser Permanente facility
to receive care.
At the time you register for services, you will be asked to pay the charges
required by the local Plan.
If you plan to travel to an area with another Kaiser Permanente Plan and
wish to obtain more information about the benefits available to you from
the Kaiser Permanente Plan, please call our Member Service Call Center
at 1-800-464-4000.
2001 Kaiser Foundation Health Plan, Inc. 40 Section 5( g)
Services from other
Kaiser Permanente
Plans 40
40 Page 41 42
Kaiser Permanente's travel benefits for Federal
employees provide you
with outpatient follow-up or continuing medical care
when you are
outside your home service area by more than 100 miles or
outside of any
other Kaiser Permanente service area. These benefits are in
addition to
your emergency and urgent care benefits and include:
Outpatient follow-up care necessary to complete a course of treatment after a
covered emergency. Services include removal of
stitches, a catheter, or a cast.
Outpatient continuing care for
conditions diagnosed by a Kaiser Permanente health care provider or affiliated
Plan provider that have
been treated within the previous 90 days. Services include childhood
immunizations, dialysis, or prescription drug monitoring.
You pay $25 for each follow-up or continuing care office visit. This amount
will be deducted from the payment we make to you.
Your benefit is limited to $1,200 each calendar year.
For more
information about this benefit, call 1-800-390-3509.
File claims as
shown on page 45.
The following are not included in your travel benefits
coverage:
Nonemergency hospitalization.
Infertility treatments.
Medical and hospital costs resulting from a normal full-term delivery
of a baby outside the service area.
Transplants.
Prescription drugs (you may have prescriptions
filled by mail
through our prescription drug benefit).
2001 Kaiser Foundation Health Plan, Inc. 41 Section 5( g)
Travel benefit 41
41 Page 42 43
2001 Kaiser
Foundation Health Plan, Inc. 42 Section 5( h)
Here are some
important things to keep in mind about these benefits:
Please remember
that all benefits are subject to the definitions, limitations, and exclusions in
this brochure, and are payable only when we determine they are dentally
necessary.
We cover hospitalization for dental procedures at a Plan
hospital we designate only when a non-dental physical impairment exists which
makes hospitalization necessary
to safeguard the health of the patient; we do not cover the dental procedure
except as
described below.
Be sure to read "Section 4, Your costs for covered services" for
valuable information about how cost sharing works. Also read "Section
9" about coordinating benefits with
other coverage, including with Medicare.
I M
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Dental benefits
We have no dental benefits.
Section 5 (h). Dental benefits 42
42
Page 43 44
The
benefits on this page are not part of the FEHB contract or premium, and you
cannot file an FEHB
disputed claim about them. Fees you pay for these
services do not count toward FEHB deductibles or out-of-pocket
maximums.
Eyewear discount
As a Kaiser Permanente FEHBP member, you and your
eligible dependents will be able to purchase eyewear at
significant savings.
When you visit any of the California Division Health Plan Optical Departments,
you will
receive 25 percent off our allowance for frames and lenses and
options such as noline bifocals and prescription
and nonprescription
sunglasses. You will also be able to receive 25 percent off our allowance for
cosmetic contact
lenses and the required lens fitting.
Limitations and exclusions: This discount will apply only to purchased
eyewear under the FEHBP basic coverage.
The vision discount may not be
coordinated with any other Kaiser Permanente Health Plan vision benefit. This
discount will also not apply to any sale, promotional, or packaged eyewear
program or for any contact lens
extended purchase agreement (which includes
products purchased in this agreement).
Expanded dental benefits
Kaiser Permanente is pleased to offer
Federal employees, retirees, and dependents a choice of dental coverage to
supplement your medical plan.
Option I/ DeltaCare
DeltaCare offers dental health maintenance
organization (HMO) benefits that are administered by PMI, an
affiliate of
Delta Dental Plan of California. You select a dentist from the network of
contracting DeltaCare dental
offices that is most convenient for you and
your family. With DeltaCare, there are no claim forms to worry about.
DeltaCare also provides a full range of services that includes preventive,
restorative, endodontics, periodontics,
prosthetics, oral surgery, and
orthodontics. Under this program, the subscriber pays a specific copayment for
most
covered services.
Option II/ KPIC's Dental Plan
KPIC's Dental Plan, a table of
allowances program, allows you to select any licensed dentist. After you satisfy
a
deductible, KPIC's Dental Plan will pay a predetermined amount that is
specified in a table toward each covered
service, and you pay the remainder
of the fee. You do not need to satisfy a deductible toward covered preventive
services you receive. KPIC's Dental Plan offers a full range of services;
diagnostic, preventive, restorative,
endodontics, periodontics, oral
surgery, and both fixed and removable prosthodontics. Orthodontics is not
available under the KPIC's Dental Plan.
Monthly premium* Option I/ DeltaCare Option II/ KPIC's Dental Plan
Monthly premium Quarterly premium Monthly premium
Self only $ 8.66
$25.99 $21.49
Self and one party $14.49 $43.46 $38.23
Self and two or
more $21.97 $65.90 $57.46
KPIC's Dental Plan and DeltaCare are available only if you enroll or are
currently enrolled in the Kaiser
Permanente Plan for FEHB members. You do
not need to enroll in either dental plan if you choose not to. All
subscribers who enroll in either dental program, when eligible, must
continue enrollment in the selected dental
program until the next open
enrollment period. This does not apply if employment is terminated.
How to enroll
Please use the postage-paid card in the enclosed
dental brochure to send in your application. If you would like
more
information on KPIC's Dental Plan, please call 1-800-933-9312. A Delta
Dental representative will be able
to assist you Monday through Friday, 6 a.
m. to 6 p. m.
Payments for the KPIC's Dental Plan or DeltaCare programs will be made by
automatic withdrawal from your
checking, savings, or credit union account.
* These rates are effective January 1, 2001, through December 31, 2001.
2001 Kaiser Foundation Health Plan, Inc. 43 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members 43
43 Page 44 45
The exclusions in this section apply to all benefits.
Although we may list a specific service as a benefit, we will
not cover
it unless your Plan physician determines it is medically necessary to prevent,
diagnose, or treat your
illness, disease, injury, or condition.
We do not cover the following:
Care by non-Plan providers, except for
authorized referrals or emergencies (see "Section 5( d)"), services
under the "Travel benefit" (see "Section 5( g)"), and
services received from other Kaiser Permanente plans (see "Section
5( g)");
Services, drugs, or supplies you receive while you are not
enrolled in this Plan;
Services, drugs, or supplies that are not medically
necessary;
Services, drugs, or supplies not required according to accepted
standards of medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs, or devices;
Services, drugs, or supplies related to abortions, except when the life of
the mother would be endangered if the fetus were carried to term or when the
pregnancy is the result of an act of rape or incest;
Services, drugs, or supplies related to sex transformations; or
Services,
drugs, or supplies you receive from a provider or facility barred from the FEHB
Program.
2001 Kaiser Foundation Health Plan, Inc. 44 Section 6
Section 6. General exclusionsÑ things we don't cover 44
44 Page 45 46
When you see Plan physicians, receive services at Plan
hospitals and facilities, or fill your prescription drugs at Plan
pharmacies, you will not have to file claims. Just present your
identification card and pay your copayment or
coinsurance.
You will only need to file a claim when you receive emergency services from
non-Plan providers or when you use
the travel benefit. Sometimes these
providers bill us directly. Check with the provider. If you need to file a
claim,
here is the process:
In most cases, providers and facilities file claims for you.
Physicians
must file the form HCFA-1500, Health Insurance
Claim Form. Facilities will
file the UB-92 form. For claims
questions and assistance, call our Member
Service Call Center
at 1-800-464-4000.
When you must file a claim, such as for out-of-area care,
submit it on
the HCFA-1500 or a claim form that includes the
information shown below.
Bills and receipts should be itemized
and show:
Covered member's name and ID number; Name and address of the physician or
facility that
provided the service or supply;
Dates you received the
services or supplies; Diagnosis;
Type of each service or supply; The charge for each service or supply;
A
copy of the explanation of benefits, payments, or denial from any primary payer,
such as the Medicare
Summary Notice (MSN); and
Receipts, if you paid for
your services.
Submit your claims to:
Northern California Service Area:
Kaiser Foundation Health Plan, Inc.
Claims Department
P. O. Box
12923
Oakland, CA 94604-2923
Southern California Service Area:
Kaiser Foundation Health Plan, Inc.
Claims Department
P. O. Box 7102
Pasadena, CA 91109-9880
Send us all of the documents for your claim as soon as
possible. You must
submit the claim by December 31 of the
year after the year you received the
service, unless timely filing
was prevented by administrative operations of
government or
legal incapacity, provided the claim was submitted as soon as
reasonably possible.
Please reply promptly when we ask for additional information.
We may
delay processing or deny your claim if you do not
respond.
2001 Kaiser Foundation Health Plan, Inc. 45 Section 7
Section 7. Filing a claim for covered services
Deadline for filing
your claim
When we need more information
Medical, hospital, and drug benefits 45
45
Page 46 47
If you
have a malpractice claim because of services you did
receive, or did not
receive, from a Plan provider, you must
submit the claim to binding
arbitration. The Plan has the
information that describes the arbitration
process. Contact our
Member Service Call Center at 1-800-464-4000 for
copies of
our requirements. These will explain how you can begin the
binding arbitration process.
2001 Kaiser Foundation Health Plan, Inc. 46 Section 7
If you have a malpractice claim 46
46
Page 47 48
Follow
this Federal Employees Health Benefits Program disputed claims process if you
disagree with our decision on
your claim or request for services, drugs, or
supplies, including a request for a referral:
Step Description
Ask us in writing to reconsider our initial
decision. You must:
(a) Write to us within six months from the date of our decision; and
(b)
Send your request to us at: Kaiser Permanente, Member Relations, P. O. Box
12983, Oakland, CA
94604-2983; and
(c) Include a statement about why you believe our initial decision was wrong,
based on specific benefit
provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills,
medical records, and explanation of
benefits (EOB) forms.
We have 30 days from the date we receive your request to:
(a) Pay the
claim (or, if applicable, arrange for the health care provider to give you the
care); or
(b) Write to you and maintain our denial, go to step 4; or
(c)
Ask you or your provider for more information. If we ask your provider, we will
send you a copy of our
request. Go to step 3.
You or your provider must send the information so that we receive it within
60 days of our request. We
will then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30
days of the date the
information was due. We will base our decision on the
information we already have.
We will write to you with our decision.
If you do not agree with our
decision, you may ask OPM to review it.
You must write to OPM within:
90
days after the date of our letter upholding our initial decision; or 120 days
after you first wrote to us, if we did not answer that request in some way
within 30 days; or
120 days after we asked for additional information.
Write to OPM at:
Office of Personnel Management, Office of Insurance Programs, Contracts Division
3,
P. O. Box 436, Washington, D. C. 20044-0436.
2001 Kaiser Foundation Health Plan, Inc. 47 Section 8
Section 8. The disputed claims process
1
2
3
4 47
47 Page 48 49
Send OPM the
following information:
A statement about why you believe our decision was
wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies of
all letters we sent to you about the claim; and
Your daytime phone number
and the best time to call.
Note: If you want OPM to review different claims,
you must clearly identify which documents apply to which
claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your
representative, such as medical providers, must
provide a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because of
reasons beyond your control.
OPM will review your disputed claim request and will use the information it
collects from you and us to
decide whether our decision is correct. OPM will
send you a final decision within 60 days. There are no other
administrative
appeals.
If you do not agree with OPM's decision, your only recourse is to sue. If you
decide to sue, you must file the
suit against OPM in federal court by
December 31 of the third year after the year in which you received the
disputed services, drugs, or supplies. This is the only deadline that may
not be extended.
OPM may disclose the information it collects during the review process to
support their disputed claim
decision. This information will become part of
the court record.
You may not sue until you have completed the disputed claims process.
Further, federal law governs your
lawsuit, benefits, and payment of
benefits. The federal court will base its review on the record that was before
OPM when OPM decided to uphold or overturn our decision. You may recover
only the amount of benefits in
dispute.
Note: If you have a serious or life-threatening condition (one that
may cause permanent loss of bodily
functions or death if not treated as soon
as possible), and
(a) We haven't responded yet to your initial request for care or
preauthorization/ prior referral, then call us at
1-800-464-4000 and
we will expedite our review; or
(b) We denied your initial request for care or a referral, then:
If we
expedite our review and maintain our denial, we will inform OPM so that they can
give your claim expedited treatment too, or
You can call OPM's Health Benefits Contracts Division 3 at (202) 606-0755
between 8 a. m. and 5 p. m. eastern time.
2001 Kaiser Foundation Health Plan, Inc. 48 Section 8
5
6 48
48 Page
49 50
You must tell us if you are covered
or a family member is
covered under another group health plan or have
automobile
insurance that pays health care expenses without regard to
fault. This is called "double coverage."
When you have double coverage, one plan normally pays its
benefits in
full as the primary payer and the other plan pays a
reduced benefit as the
secondary payer. We, like other insurers,
determine which coverage is
primary according to the National
Association of Insurance Commissioners'
guidelines.
When we are the primary payer, we will pay the benefits
described in this
brochure.
When we are the secondary payer, we will determine our
allowance. After
the primary plan pays, we will pay what is left
of our allowance, up to our
regular benefit. We will not pay
more than our allowance. If we are the
secondary payer, and
you received your services from Plan providers, we may
bill the
primary carrier.
What is Medicare? Medicare is a health insurance program for:
People 65 years of age and older. Some people with disabilities, under 65
years of age.
People with end-stage renal disease (permanent kidney failure requiring
dialysis or a transplant).
Medicare has two parts:
Part A (hospital insurance). Most people do not
have to pay for Part A.
Part B (medical insurance). Most people pay monthly for Part B.
If you are eligible for Medicare, you may have choices in how
you get
your health care. Medicare+ Choice is the term used to
describe the various
health plan choices available to Medicare
beneficiaries. The information in
the next few pages shows
how we coordinate benefits with Medicare, depending
on the
type of Medicare managed care plan you have.
The original Medicare plan The original Medicare plan is available
everywhere in the United States. It is the way most people get their Medicare
Part
A and Part B benefits. You may go to any doctor, specialist, or
hospital that accepts Medicare. Medicare pays its share and you
pay your
share. Some things are not covered under original
Medicare, like
prescription drugs.
When you are enrolled in this Plan and original Medicare,
you still need
to follow the rules in this brochure for us to
cover your care. We will not
waive any of our copayments.
(Primary payer chart begins on next page.)
2001 Kaiser Foundation Health Plan, Inc. 49 Section 9
Section 9. Coordinating benefits with other coverage
When you have
other health coverage 49
49 Page 50 51
2001 Kaiser
Foundation Health Plan, Inc. 50 Section 9
The following chart
illustrates whether original Medicare or this Plan should be the primary payer
for you according
to your employment status and other factors determined by
Medicare. It is critical that you tell us if you or a covered
family member
has Medicare coverage so we can administer these requirements correctly.
Primary payer chart
A. When either you, or your covered spouse, are
age 65 or over and É Then the primary payer isÉ
Original Medicare This Plan
1) Are an active employee with the federal government (including
when you
or a family member are eligible for Medicare solely
because of a
disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the federal
government whenÉ
a) The position is excluded from FEHB, or . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . .
b) The position is not
excluded from FEHB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . .
Ask your employing office which of these applies
to you.
4) Are a federal judge who retired under title 28, U. S. C., or a
tax
court judge who retired under Section 7447 of title 26, U. S. C. (or if
your covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status,
(for Part B (for other
services) services)
6) Are a former federal employee receiving workers' compensation
and the
Office of Workers' Compensation Programs has determined (except for claims
that you are unable to return to duty. related to workers'
compensation)
B. When you, or a covered family member, have Medicare
based on
end-stage renal disease (ESRD) andÉ
1) Are within the first 30 months of eligibility to receive Part A
benefits solely because of ESRD,
2) Have completed the 30-month ESRD coordination period and are
still
eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to ESRD after Medicare became
primary
for you under another provision.
C. When you or a covered family member have FEHB andÉ
1)
Are eligible for Medicare based on disability, and
a) Are an annuitant, or .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . .
b) Are an active employee . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
50 Page 51 52
If you are eligible for Medicare, you may choose to
enroll in and get
your Medicare benefits from a Medicare managed care plan.
These are
health care choices (like HMOs) in some areas of the country. In
most
Medicare managed care plans, you can only go to doctors, specialists,
or
hospitals that are part of the plan. Medicare managed care plans cover
all Medicare Part A and B benefits. Some cover extras, like prescription
drugs. To learn more about enrolling in a Medicare managed care plan,
contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at
www. medicare. gov. If you enroll in a Medicare managed care plan,
the
following options are available to you:
This Plan and our Medicare managed care plan: You may enroll in
our Medicare managed care plan, known as Medicare+ Choice or Kaiser
Permanente Senior Advantage, and also remain enrolled in our FEHB
plan.
In this case, we waive some of our copayments and coinsurance
for your FEHB
and Medicare coverage. If you would like information
about our Medicare+
Choice plan, please call 1-800-638-6833. Your
Kaiser Permanente
Senior Advantage-FEHBP benefits are:
Prescriptions: $5 for each generic/ brand-name drug on the Plan
formulary up to a 100-day supply and $5 for each mail order of
generic/ brand-name drug on the Plan formulary up to a 100-day
supply.
Physician office visits: $0 for physician/ specialist office visits.
Emergency care: $20 for each emergency room visit.
Preventive
services: $0.
Routine physical and hearing exams: $0 for one
routine physical and hearing exam each year.
Immunizations: Pneumococcal pneumonia, flu, and Hepatitis B vaccines
provided at no charge.
Urgently needed care: $0 for each visit to a
Plan facility; $20 for each visit to a non-Plan facility in or out of the Plan's
service area.
Worldwide coverage.
Vision services:
$0 for one
routine eye exam each year.
$80 frame allowance, for one frame every two
years.
Up to $124 allowance for cosmetic contact lenses in lieu of
eyeglasses every 24 months.
$0 for lenses, for one pair every two years.
Dental services:
$0 for oral exams or X-rays.
$15 for cleanings, up to two office
visits each year.
No referral necessary for network providers.
Chiropractic services: Chiropractic care beyond what is covered by
Medicare, including:
$10 copayment for each office visit, up to 20 office visits each year.
No
referral necessary for any network providers. Members must use ASHP chiropractic
providers.
2001 Kaiser Foundation Health Plan, Inc. 51 Section 9
Medicare managed care plan 51
51 Page 52 53
You will also
enjoy:
Health/ Wellness education: No copayments for disease-specific
health education classes (costs may vary for wellness classes).
No deductibles and virtually no paperwork.
Online access to health
information and resources at our award-winning members only Web site.
Quarterly member communication in our Senior Outlook magazine.
You
must use Kaiser Permanente Plan and affiliated providers and
continue to pay
Medicare premiums.
This Plan and another plan's Medicare managed care plan: Yo u
may
enroll in another plan's Medicare managed care plan and also
remain enrolled
in our FEHB plan. We will still provide benefits when
your Medicare managed
care plan is primary if you use our Plan
providers, but we will not waive
any of our copayments or coinsurance.
Suspended FEHB coverage and a Medicare managed care plan: If
you
are an annuitant or former spouse, you can suspend your FEHB
coverage to
enroll in a Medicare managed care plan, eliminating your
FEHB premium. (OPM
does not contribute to your Medicare managed
care plan premium.) For
information on suspending your FEHB
enrollment, contact your retirement
office. If you later want to re-enroll
in the FEHB Program, generally you
may do so only at the next open
season unless you involuntarily lose
coverage or move out of the
Medicare managed care service area.
Note: If you choose not to enroll in Medicare Part B, you can still be
covered under the FEHB Program. We cannot require you to enroll in
Medicare.
TRICARE is the health care program for eligible dependents of
military
persons and retirees of the military. TRICARE includes the
CHAMPUS program.
If both TRICARE and this Plan cover you, we
pay first. See your TRICARE
health benefits advisor if you have
questions about TRICARE coverage.
We do not cover services that:
you need because of a workplace-related
disease or injury that the Office of Workers' Compensation Programs (OWCP) or a
similar
federal or state agency determines they must provide; or
OWCP or on a similar agency pays for through a third-party injury settlement
or other similar proceeding that is based on a claim you
filed under OWCP or
similar laws.
Once OWCP or a similar agency pays its maximum benefits for
your
treatment, we will cover your benefits. You must use our providers.
When you have this Plan and Medicaid, we pay first.
We do not cover services and supplies when a local, state,
or federal
government agency directly or indirectly pays for them.
2001 Kaiser Foundation Health Plan, Inc. 52 Section 9
Enrollment in Medicare Part B
TRICARE
Workers' compensation
Medicaid
When other government agencies
are responsible for your
care 52
52 Page
53 54
When you receive money to
compensate you for medical or hospital care
for injuries or illness caused
by another person, you must reimburse us
for any expenses we paid. However,
we will cover the cost of treatment
that exceeds the amount you received in
the settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures.
2001 Kaiser Foundation Health Plan, Inc. 53 Section 9
When others are responsible
for injuries 53
53 Page 54 55
January 1 through December 31 of the same year. For
new enrollees, the
calendar year begins on the effective date of their
enrollment and ends
on December 31 of the same year.
Coinsurance is the percentage of our allowance that you must pay for
your
care.
A copayment is a fixed amount of money you pay when you receive
covered
services.
Care we provide benefits for, as described in this brochure.
(1)
Assistance with activities of daily living, for example, walking,
getting in
and out of bed, dressing, feeding, toileting, and taking
medicine. (2) Care
that can be performed safely and effectively by
people who, in order to
provide the care, do not require medical licenses
or certificates or the
presence of a supervising licensed nurse.
A deductible is a fixed amount of covered expenses you must incur for
certain covered services and supplies before we start paying benefits for
those services.
We carefully evaluate whether a particular therapy is safe and effective
or offers a reasonable degree of promise with respect to improving
health outcomes. The primary source of evidence about health outcomes
of
any intervention is peer-reviewed medical or dental literature. When
the
service or supply, including a drug: (1) has not been approved by the
FDA;
or (2) is the subject of a new drug or new device application on
file with
the FDA; or (3) is part of a phase I or phase II clinical trial, as
the
experimental or research arm of a phase III clinical trial; or is
intended
to evaluate the safety, toxicity, or efficacy of the service; or (4)
is
available as the result of a written protocol that evaluates the service's
safety, toxicity, or efficacy; or (5) is subject to the approval or review
of
an institutional review board; or (6) requires an informed consent that
describes the service as experimental or investigational; then this Plan
considers that service, supply, or drug to be experimental, and not
covered by the Plan.
Health care benefits that are available as a result of your employment, or
the employment of your spouse, and that are offered by an employer or
through membership in an employee organization. Health care coverage
may
be insured or indemnity coverage, self-insured or self-funded
coverage, or
coverage through health maintenance organizations or other
managed care
plans. Health care coverage purchased through
membership in an organization
is also "group health coverage."
2001 Kaiser Foundation Health Plan, Inc. 54 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year
Coinsurance
Copayment
Covered services
Custodial care
Deductible
Experimental or
investigational services
Group health coverage 54
54 Page 55 56
All benefits need
to be medically necessary in order for them to be
covered benefits.
Generally, if your Plan physician provides the service
in accord with the
terms of this brochure, it will be considered
medically necessary. However,
some services are reviewed in advance of
your receiving them to determine if
they are medically necessary. When
we review a service to determine if it is
medically necessary, a Plan
physician will evaluate what would happen to you
if you do not receive
the service. If not receiving the service would
adversely affect your
health, it will be considered medically necessary. The
services must be a
medically appropriate course of treatment for your
condition. If they are
not medically necessary, we will not cover the
services. In case of
emergency services, the services that you received will
be evaluated to
determine if they were medically necessary.
The amount we use to determine your coinsurance. When you receive
services or supplies from Plan providers, it is the amount that we set for
the services or supplies if we were to charge for them. When you receive
services from non-Plan providers, we determine the amount that we
believe is usual and customary for the service or supply, and compare it
to the charges. Our allowance is based upon the reasonableness of the
charges. If the charges exceed what we believe is reasonable, you may
be
responsible for the excess over our allowance in addition to your
coinsurance.
Us and we refer to Kaiser Foundation Health Plan, Inc.
You refers to the
enrollee and each covered family member.
2001 Kaiser Foundation Health Plan, Inc. 55 Section 10
Medically necessary
Our allowance
Us/ We
Yo u 55
55 Page 56 57
We will not refuse to cover the treatment of a
condition that you had
before you enrolled in this Plan solely because you
had the condition
before you enrolled.
See www. opm. gov/ insure. Also, your employing or retirement office
can answer your questions, and give you a Guide to Federal Employees
Health Benefits Plans, brochures for other plans, and other materials
you need to make an informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for enrollment
begins.
We don't determine who is eligible for coverage and, in most cases,
cannot change your enrollment status without information from your
employing or retirement office.
Self only coverage is for you alone. Self and family coverage is for
you,
your spouse, and your unmarried dependent children under age 22,
including
any foster children or stepchildren your employing or
retirement office
authorizes coverage for. Under certain circumstances,
you may also continue
coverage for a disabled child 22 years of age or
older who is incapable of
self-support.
If you have a self only enrollment, you may change to a self and family
enrollment if you marry, give birth, or add a child to your family. You
may change your enrollment 31 days before, to 60 days after, that event.
The self and family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When
you change to self and family because you marry, the change is
effective
on the first day of the pay period that begins after your
employing office
receives your enrollment form; benefits will not be
available to your spouse
until you marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we.
Please tell us immediately when you add or remove family members
from
your coverage for any reason, including divorce, or when your
child under
age 22 marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan,
that
person may not be enrolled in or covered as a family member by
another FEHB
plan.
2001 Kaiser Foundation Health Plan, Inc. 56 Section 11
Section 11. FEHB facts
No pre-existing condition limitation
Where you get information about enrolling in the
FEHB Program
Types of coverage available for you and your family
Coverage information 56
56 Page 57 58
The benefits in
this brochure are effective on January 1. If you are new
to this Plan, your
coverage and premiums begin on the first day of your
first pay period that
starts on or after January 1. Annuitants' premiums
begin on January 1.
We will keep your medical and claims information confidential. Only
the
following will have access to it:
OPM, this Plan, and subcontractors when they administer this contract;
This Plan, and appropriate third parties, such as other insurance plans and
the Office of Workers' Compensation Programs (OWCP), when
coordinating
benefit payments and subrogating claims;
Law enforcement officials when
investigating and/ or prosecuting alleged civil or criminal actions;
OPM and the general accounting office when conducting audits;
Individuals
involved in bona fide medical research or education that does not disclose your
identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire, you can usually stay in the FEHB Program. Generally,
you
must have been enrolled in the FEHB Program for the last five
years of your
federal service. If you do not meet this requirement, you
may be eligible
for other forms of coverage, such as temporary
continuation of coverage
(TCC).
When you lose benefits
You will receive an additional 31 days of
coverage, for no additional
premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or temporary
continuation of coverage.
If you are divorced from a federal employee or annuitant, you may not
continue to get benefits under your former spouse's enrollment. But, you
may be eligible for your own FEHB coverage under the spouse equity
law.
If you are recently divorced or are anticipating a divorce, contact
your
ex-spouse's employing or retirement office to get RI 70-5, the
Guide to
Federal Employees Health Benefits Plans for Temporary
Continuation of
Coverage and Former Spouse Enrollees, or other
information about your
coverage choices.
If you leave federal service, or if you lose coverage because you no
longer qualify as a family member, you may be eligible for temporary
continuation of coverage (TCC). For example, you can receive TCC if
you
are not able to continue your FEHB enrollment after you retire.
You may not elect TCC if you are fired from your federal job due to
gross
misconduct.
2001 Kaiser Foundation Health Plan, Inc. 57 Section 11
When benefits and premiums start
Your medical and claims
records are confidential
When FEHB coverage ends
Spouse equity coverage
TCC
When you retire 57
57 Page 58 59
Get the RI 79-27,
which describes TCC, and the RI 70-5, the Guide to
Federal Employees
Health Benefits Plans for Temporary Continuation of
Coverage and Former
Spouse Enrollees, from your employing or
retirement office or from
www. opm. gov/ insure.
You may convert to a non-FEHB individual policy if:
Your coverage under
TCC or the spouse equity law ends. If you canceled your coverage or did not pay
your premium, you cannot
convert;
You decided not to receive coverage under TCC or the spouse
equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If
you leave federal service, your employing office will notify you of
your
right to convert. You must apply in writing to us within 31 days
after you
receive this notice. However, if you are a family member who
is losing
coverage, the employing or retirement office will not notify
you. You
must apply in writing to us within 31 days after you are no
longer eligible
for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and
we
will not impose a waiting period or limit your coverage due to pre-existing
conditions.
If you leave the FEHB Program, we will give you a Certificate of Group
Health Plan Coverage that indicates how long you have been enrolled
with
us. You can use this certificate when getting health insurance or
other
health care coverage. Your new plan must reduce or eliminate
waiting
periods, limitations, or exclusions for health-related conditions
based on
the information in the certificate, as long as you enroll within
63 days of
losing coverage under this Plan.
If you have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a
certificate from those plans.
Stop health care fraud! Fraud increases the cost of health care for
everyone. If you suspect that a physician, pharmacy, or hospital has
charged you for services you did not receive, billed you twice for the
same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error. If the
provider does not resolve the matter, call our Member Service
Call Center at 1-800-464-4000 and explain the situation.
If we do
not resolve the issue, call the HEALTH CARE FRAUD HOTLINE at (202) 418-3300
or write to: The United States Office
of Personnel Management, Office of the Inspector General Fraud
Hotline,
1900 "E" St., NW, Room 6400, Washington, D. C. 20415.
Anyone who falsifies a claim to obtain FEHB Program benefits can be
prosecuted for fraud. Also, the Inspector General may investigate
anyone
who uses an ID card if the person tries to obtain services for
someone who
is not an eligible family member, or is no longer enrolled
in the Plan and
tries to obtain benefits. Your agency may also take
administrative action
against you.
2001 Kaiser Foundation Health Plan, Inc. 58 Section 11
Converting to individual coverage
Getting a Certificate of
Group Health Plan Coverage
Inspector General advisory
Penalties for fraud 58
58 Page 59 60
The Department of
Defense/ FEHB Demonstration Project allows some active
and retired uniformed
service members and their dependents to enroll in the
FEHB Program. The
demonstration will last for three years and began with the
1999 open season
for the year 2000. Open season enrollments will be effective
January 1,
2001. DOD and OPM have set up some special procedures to
implement the
Demonstration Project, noted below. Otherwise, the provisions
described in
this brochure apply.
DOD determines who is eligible to enroll in the FEHB Program. Generally, you
may enroll if:
You are an active or retired uniformed service member and are eligible for
Medicare;
You are a dependent of an active or retired uniformed service member and are
eligible for Medicare;
You are a qualified former spouse of an active or
retired uniformed service member and you have not remarried; or
You are a
survivor dependent of a deceased active or retired uniformed service member; and
You live in one of the geographic demonstration areas.
If you are
eligible to enroll in a plan under the regular Federal Employees Health
Benefits Program, you are not eligible to enroll under the DOD/ FEHBP
Demonstration Project.
Dover AFB, DE Commonwealth of Puerto Rico Fort Knox, KY Greensboro/ Winston
Salem/ High Point, NC
Dallas, TX Humboldt County, CA New Orleans, LA Naval
Hospital, Camp Pendleton, CA
Adair County, IA Coffee County, GA
You may
enroll under the FEHB/ DOD Demonstration Project during the 2000
open
season, from November 13, 2000, through December 11, 2000. Your
coverage
will begin January 1, 2001. DOD has set up an information processing
center
(IPC) in Iowa to provide you with information about how to enroll. IPC
staff
will verify your eligibility and provide you with FEHB Program
information,
plan brochures, enrollment instructions, and forms. The toll-free
phone
number for the IPC is 1-877-DOD-FEHB (1-877-363-3342).
You may select coverage for yourself (self only) or for you and your family
(self
and family) during the 2000 and 2001 open seasons. Your coverage will
begin
January 1 of the year following the open season during which you
enrolled.
If you become eligible for the DOD/ FEHB Demonstration Project outside of
open season, contact the IPC to find out how to enroll and when your
coverage
will begin.
DOD has a Web site devoted to the Demonstration Project. You can view
information such as their Marketing/ Beneficiary Education Plan, frequently
asked questions, demonstration area locations, and ZIP code lists at
www. tricare. osd. mil/ fehbp. You can also view information about
the
demonstration project, including "The 2001 Guide to Federal
Employees Health
2001 Kaiser Foundation Health Plan, Inc. 59 DOD/ FEHB Demonstration
Project
Department of Defense/ FEHB Demonstration Project
What is it?
Who is eligible
The demonstration areas
When you can join 59
59 Page 60 61
Benefits Plans Participating in the DOD/ FEHB
Demonstration Project," on the
OPM Web site at www. opm. gov.
See "Section 11, FEHB facts;" it explains temporary continuation of
coverage
(TCC). Under this DOD/ FEHB Demonstration Project the only
individual
eligible for TCC is one who ceases to be eligible as a
"member of family" under
your self and family enrollment. This
occurs when a child turns 22, for example,
or if you divorce and your spouse
does not qualify to enroll as an unremarried
former spouse under title 10,
United States Code. For these individuals, TCC
begins the day after their
enrollment in the DOD/ FEHB Demonstration Project
ends. TCC enrollment
terminates after 36 months or the end of the
Demonstration Project,
whichever occurs first. You, your child, or another person
must notify the
IPC when a family member loses eligibility for coverage under
the DOD/ FEHB
Demonstration Project.
TCC is not available if you move out of a DOD/ FEHB Demonstration Project
area, you cancel your coverage, or your coverage is terminated for any
reason.
TCC is not available when the demonstration project ends.
The 31-day extension of coverage and right to convert do not apply to the
DOD/ FEHB Demonstration Project.
2001 Kaiser Foundation Health Plan, Inc. 60 DOD/ FEHB Demonstration
Project
TCC eligibility
Other features 60
60
Page 61 62
Do not
rely on this page; it is for your convenience and does not explain your benefit
coverage.
2001 Kaiser Foundation Health Plan, Inc. 61 Index
Index
Accidental injury 30 Allergy tests 18
Alternative
treatment 22
Ambulance 29, 31
Anesthesia 23
Autologous bone marrow
transplant
26
Biopsies 23 Blood and blood plasma 28
Breast cancer screening 26
Casts 23 Centers of excellence for
transplants
39
Changes for 2001 9
Chemotherapy 18
Cholesterol tests 14
Coinsurance 13
Colorectal cancer screening 16
Congenital anomalies
23
Contraceptive devices and drugs 37
Coordination of benefits 49
Covered providers 10
Crutches 21
Deaf and hearing-impaired
service 39
Deductible 13
Dental care 42, 43
Diagnostic services 15
Disputed
claims review 47
Donor expenses (transplants) 26
Dressings 28
Durable medical equipment (DME)
21
Educational classes and
programs 22
Effective date of enrollment 57
Emergency 30
Experimental or
investigational
44, 54
Eyeglasses 43
Family planning 17 Fecal
occult blood test 16
Flexible benefits options 39
General exclusions 44 Hearing
services 19
Home health services 21
Hospice care 29
Hospital 4, 6, 8, 12
Immunizations 16 Infertility 18
Inpatient hospital benefits 27
Insulin 37
Laboratory and pathological services 15
Magnetic Resonance
Imagings (MRIs) 15
Mail-order prescription drugs 35
Mammograms 16
Maternity benefits 17
Medicaid 52
Medically necessary 16, 20, 26,
28,
30, 31, 33
Medicare 49
Mental conditions/ substance abuse
benefits 32
Neurological testing 12 Newborn care 17
Non-FEHB benefits 43
Nurse
Licensed practical nurse 21
Nurse
anesthetist 28
Nurse practitioner 10
Registered nurse 21, 39
Nursery
charges 17
Obstetrical care 17 Occupational therapy 19
Ocular injury 20
Oral and maxillofacial surgery 25
Orthopedic devices
20
Ostomy and catheter supplies 21, 36
Out-of-pocket expenses 13, 34, 41
Oxygen 19, 21, 28
Pap test 16 Physical examination 4, 16, 14
Physical therapy 19
Preventive care, adult 16
Preventive care,
children 16
Preventive services 43, 51
Prior approval 12
Prostate
cancer screening 16
Prosthetic devices 20
Psychotherapy 34
Radiation therapy 18 Rehabilitation therapies 19, 33, 40
Renal dialysis 49
Room and board 27
Second surgical opinion 15
Services from other Kaiser
Permanente Plans 40
Skilled nursing facility care 29
Smoking
cessation 32
Speech therapy 19
Splints 28
Sterilization procedures 23
Subrogation 51
Substance
abuse 9, 8, 32, 33, 34
Surgery 23
Anesthesia 26
Oral 25
Outpatient 14, 26, 28
Reconstructive 24
Syringes 37
Temporary
continuation of coverage 57
Transplants 26
Travel benefit 41
Vision services 19
Well-child care 16
Wheelchairs 21
Workers' compensation 52
X-rays 15
24-hour nurse line 39 61
61 Page 62 63
Do not rely on
this chart alone. All benefits are provided in full unless indicated and are
subject to the definitions, limitations, and exclusions in this brochure. On
this page we summarize specific expenses we cover;
for more details, look
inside.
If you want to enroll or change your enrollment in this Plan, be
sure to put the correct enrollment code from the cover on your enrollment form.
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You pay Page
Medical services provided by physicians:
Diagnostic and treatment
services provided in the office ............ $10 per office visit 15
Services provided by a hospital:
Inpatient
........................................................................................
Nothing 27
Outpatient
.....................................................................................
Nothing 28
Emergency benefits:
In-area
...........................................................................................
$35 per visit 31
Out-of-area....................................................................................
$35 per visit 31
Mental health and substance abuse treatment
................................... Regular cost sharing 32
Prescription
drugs
..............................................................................
$10 per prescription 36
Dental care
.........................................................................................
No benefit 42
Vision
care..........................................................................................
Refractions; $10 per office visit 19
Special features: Flexible benefits
option; 24-hour nurse line; services for the deaf and hearing impaired; 39
centers of excellence for transplants; services from other Kaiser Permanente
Plans; travel benefit
Protection against catastrophic costs . . . . . . . . . . . . . . . . . . . .
. . . Nothing after $1,500/ self only or 13
(your out-of-pocket maximum) . .
. . . . . . . . . . . . . . . . . . . . . . . . . $3,000/ family enrollment per
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . year
Some costs do not count toward
this protection
2001 Kaiser Foundation Health Plan, Inc. 62 Summary
Summary of benefits for Kaiser Foundation Health Plan, Inc., California
DivisionÑ 2001 62
62 Page 63 64
63
63 Page 64
2001
rate information for
Kaiser Foundation Health Plan, Inc., California
Division
Non-postal rates apply to most non-postal enrollees. If you are in a
special enrollment
category, refer to the FEHB Guide for that
category or contact the agency that maintains your
health benefits
enrollment.
Postal rates apply to career postal service employees. Most employees
should refer to the FEHB
Guide for United States Postal Service
Employees, RI 70-2. Different postal rates apply and
special FEHB guides
are published for postal service nurses and tool and die employees (see RI
70-2B); and for postal service inspectors and office of Inspector General
(OIG) employees (see
RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of
any postal employee organization. Refer to the
applicable FEHB Guide.
Non-postal premium Postal premium
Biweekly Monthly Biweekly
Type of Gov't Your Gov't Your USPS Your
enrollment Code share share
share share share share
Location information
Northern California
Self only 591 $67.73
$22.57 $146.74 $48.91 $80.14 $10.16
Self and family 592 $161.68 $53.89
$350.30 $116.77 $191.32 $24.25
Southern California
Self only 621 $70.79 $23.60 $153.38 $51.13 $83.77
$10.62
Self and family 622 $163.62 $54.54 $354.51 $118.17 $193.62 $24.54
2001 Kaiser Foundation Health Plan, Inc. Rates
1034-0002-01 64