Pages 1--70 from Kaiser Foundation Health Plan

2001
A Health Maintenance Organization

Serving: Metropolitan Washington, DC Area and
Metropolitan Baltimore, Maryland Area

Enrollment in this Plan is limited; see page 66 for requirements.

Enrollment codes for this Plan:
E31 Self Only
E32 Self and Family

Authorized for distribution by the:

RI 73-047

This Plan has commendable
accreditation from the NCQA.
See the 2001 Guide for more
information on NCQA.

For
changes in

benefits see
page 7 1
1 Page 2 3
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 2 Table of Contents

Table of Contents
Introduction ................................................................................................................................................................ 4
Plain Language................................................................................................................................................................ 4
Section 1. Facts about this HMO plan ........................................................................................................................... 5
How we pay providers .................................................................................................................................. 5
Patients' Bill of Rights................................................................................................................................... 5
Service Area.................................................................................................................................................. 6
Section 2. How we change for 2001 .............................................................................................................................. 7
Program-wide changes.................................................................................................................................. 7
Changes to this Plan ...................................................................................................................................... 7
Section 3. How you get care ......................................................................................................................................... 8
Identification cards........................................................................................................................................ 8
Where you get covered care.......................................................................................................................... 8
Plan providers ......................................................................................................................................... 8
Plan facilities .......................................................................................................................................... 8
What you must do to get covered care .......................................................................................................... 9

Primary care............................................................................................................................................ 9
Specialty care.......................................................................................................................................... 9
Hospital care ......................................................................................................................................... 10
Circumstances beyond our control.............................................................................................................. 10
Services requiring our prior approval ......................................................................................................... 11
Section 4. Your costs for covered services .................................................................................................................. 12
Copayments .......................................................................................................................................... 12
Deductible............................................................................................................................................. 12
Coinsurance .......................................................................................................................................... 12
Fees when you fail to make your copayment or coinsurance............................................................... 12
Your out-of-pocket maximum for copayments and coinsurance................................................................ 12
Section 5. Benefits ....................................................................................................................................................... 13
Overview..................................................................................................................................................... 13
(a) Medical services and supplies provided by physicians and other health care professionals ........... 14
(b) Surgical and anesthesia services provided by physicians and other health care professionals........ 26
(c) Services provided by a hospital or other facility, and ambulance services...................................... 30
(d) Emergency services/ accidents.......................................................................................................... 34
(e) Mental health and substance abuse benefits..................................................................................... 36
(f) Prescription drug benefits................................................................................................................. 39
(g) Special features................................................................................................................................. 43
(h) Dental benefits.................................................................................................................................. 46
(i) Non-FEHB benefits available to Plan members............................................................................... 54 2
2 Page 3 4
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 3 Table of Contents

Section 6. General exclusions things we don't cover ................................................................................................ 56
Section 7. Filing a claim for covered services ............................................................................................................. 57
Medical, hospital, and drug benefits ........................................................................................................ 57
Deadline for filing your claim.................................................................................................................. 57
When we need more information ............................................................................................................. 57
Section 8. The disputed claims process........................................................................................................................ 58
Section 9. Coordinating benefits with other coverage ................................................................................................. 60
When you have other health coverage ........................................................................................................ 60
What is Medicare? ................................................................................................................................. 60
The Original Medicare Plan................................................................................................................... 60
Medicare managed care plan ................................................................................................................. 62
Enrollment in Medicare Part B .............................................................................................................. 62
TRICARE.................................................................................................................................................... 62
Workers' Compensation.............................................................................................................................. 62
Medicaid...................................................................................................................................................... 62
When other Government agencies are responsible for your care ............................................................... 63
When others are responsible for injuries..................................................................................................... 63
Section 10. Definitions of terms we use in this brochure ............................................................................................ 64
Section 11. FEHB facts ................................................................................................................................................ 66
Coverage information.............................................................................................................................. 66
No pre-existing condition limitation..................................................................................................... 66
Where you get information about enrolling in the FEHB Program...................................................... 66
Types of coverage available for you and your family .......................................................................... 66
When benefits and premiums start ....................................................................................................... 67
Your medical and claims records are confidential ............................................................................... 67
When you retire .................................................................................................................................... 67
When you lose benefits ........................................................................................................................... 67

When FEHB coverage ends.................................................................................................................. 67
Spouse equity coverage ........................................................................................................................ 67
Temporary Continuation of Coverage (TCC)....................................................................................... 67
Converting to individual coverage........................................................................................................ 68
Getting a Certificate of Group Health Plan Coverage .......................................................................... 68
Inspector General advisory: Stop health care fraud! ............................................................................... 68

Penalties for Fraud................................................................................................................................ 68
Index ................................................................................................................................................................. 69
Summary of benefits ..................................................................................................................................................... 70
Rates.. Back cover 3
3 Page 4 5
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 4 Introduction/ Plain Language

Introduction
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.
2101 East Jefferson Street
Rockville, Maryland 20849

This brochure describes the benefits of Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., under our
contract (CS 1763) 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 7. Rates are shown at the end of this brochure.

Plain Language
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 of the Mid-Atlantic States, 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 feedback area at
www. opm. gov/ insure/ Rate Us (fehbwebcomments@ opm. gov) or write to OPM at Insurance Planning and Evaluation
Division, P. O. Box 436, Washington, DC 20044-0436. 4
4 Page 5 6
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 5 Section 1

Section 1. Facts about this HMO plan
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 or benefits while
you travel 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 pay the Mid-Atlantic Permanente Medical Group, P. C., the Affiliated Primary Care Physician's Network
(APCPN) located in Baltimore, Maryland, Sheppard-Pratt Behavioral Health, Maryland Eye Care, Dental Benefit
Providers, and contracted community specialists and ancillary providers to provide your medical, surgical, mental
health, substance abuse, ophthalmological, optometry, and dental services. We contract with local community
hospitals to provide hospitalization services. These Plan providers accept a negotiated payment from us.

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 website (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.

Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (Kaiser Permanente) is a federally qualified Health Maintenance 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 over 8 million members nationwide.
Kaiser Permanente is a Maryland non-profit corporation licensed in the Commonwealth of Virginia, the District of Columbia and the state of Maryland.
Kaiser Permanente began delivering prepaid healthcare services to Washington, DC residents in December 1972. Kaiser Permanente presently serves approximately 555,000 members in the Washington, DC, and Baltimore,
Maryland metropolitan areas.
Kaiser Permanente credentials its Plan providers in accord with national standards.

If you want more information, call us at 301/ 468-6000 inside the Washington, DC metropolitan area or at 800/ 777-
7902 outside the Washington, DC metropolitan area. Our TDD telephone number is 301/ 816-6344. Or, write to us at
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., Attention: Member Services Department, P. O. Box
6103, Rockville, Maryland, 20849-6103. You may also contact us by fax at 301/ 816-6192 or visit our website at
http:// www. kaiserpermanente. org or by email at kponline. org. 5
5 Page 6 7
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 6 Section 1

Service Area
To enroll in this Plan, you must live or work in our service area. This is where our Plan Physicians practice and
provide covered services. A listing of specific zip codes, by county, may be obtained from any of our Plan facilities.

Our service area is:

The District of Columbia
The following Virginia counties:
Arlington Fairfax

Loudoun Prince William

The following Virginia cities:
Alexandria Falls Church

Fairfax Manassas
Manassas Park
The following Maryland counties:
Anne Arundel Baltimore

Carroll Harford
Howard Montgomery
Prince Georges
Portions of the following Maryland counties, as indicated by the zip codes below, are also within the service area:
Calvert 20639, 20689, 20714, 20732, 20736, and 20754 zip codes only Charles 20601, 20602, 20603, 20604, 20612, 20616, 20617, 20637, 20640, 20646, 20658, 20675, and

20695 zip codes only
Frederick 21702, 21705, 21709, 21710, 21714, 21716, 21717, 21718, 21754, 21755, 21758, 21762, 21769, 21770, 21774, 21777, 21790, and 21793 zip codes only

The following Maryland cities:
Baltimore city

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 45; and for emergency care obtained from any non-Plan provider, as described on
page 34-35. 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. 6
6 Page 7 8
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 7 Section 2

Section 2. How we change for 2001
Program-wide 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 or visit limitations on mental health and
substance abuse services.

Many healthcare organizations have turned their attention this past year to improving healthcare quality and patient safety. OPM asked all FEHB plans to join them in this effort. You can find specific information on our

patient safety activities by calling 301/ 816-5778. You can find out more about patient safety on the OPM
website, www. opm. gov/ insure. To improve your healthcare, 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
Your share of the non-Postal premium will increase by 12.5% for Self Only or 12.6% for Self and Family.
The prescription drug dispensing limitation (except for maintenance drugs) changes from a 90-day supply to a 60-day supply.

We cover in vitro fertilization if you meet certain criteria.
We cover habilitative services for children from birth to age 19 for treatment of congenital and genetic birth defects.

We cover one hair prosthesis if your hair loss results from chemotherapy or radiation treatment for cancer. 7
7 Page 8 9
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 8 Section 3

Section 3. How you get care
Identification cards 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 we have
received your enrollment from your payroll office, or if you need
replacement cards, call us at 301/ 468-6000 inside the Washington, DC
metropolitan area or at 800/ 777-7902 outside the Washington, DC
metropolitan area. Our TDD telephone number is 301/ 816-6344.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments or coinsurance, and you will not have to file claims,
except for emergency, urgent care services outside our service area, and
for covered services while you travel.

Plan providers Our Plan providers are physicians and other health care professionals in
our service area that we contract with to provide covered services to our
members. We contract with the Mid-Atlantic Permanente Medical
Group, P. C. and the Affiliated Primary Care Physician Network
(APCPN) to provide primary care services and some specialty services.
Mid-Atlantic Permanente Medical Group is a multi-specialty physician
group practice with over 28 years of experience in providing services to
members of our Plan. Specialists in most major specialties are available
as part of the medical teams for consultation and treatment. Medical
care is provided through physicians, nurse practitioners and other
skilled medical personnel working as medical teams at Kaiser
Permanente facilities. We contract with Sheppard-Pratt located in
Baltimore, Maryland to provide mental health and substance abuse
services to members, and with Maryland Eye Care and Dental Benefit
Providers to provide optometry, optical, and dental services to our
members.

The Mid-Atlantic Permanente Medical Group, P. C. also contracts with
other specialists who may see you after you obtain a referral from your
Plan physician. The Affiliated Primary Care Physician Network,
located in Baltimore, Maryland are independent primary care physicians
the Plan has contracted with to provide primary care services to
members. If your primary care physician, in consultation with you,
determines that you need to see a specialist, he or she will refer you to
one of our specialists.

Our Provider Directory lists the Plan providers, with locations and
phone numbers. Directories are updated twice a year and are available
at the time of enrollment. However, our online Provider Directory is
updated monthly. Our website address is
http:// www. kaiserpermanente. org.

Plan facilities Plan facilities are hospitals and other facilities in our service area that
we contract with to provide covered services to our members. Our Plan
physicians provide your health care at 23 Kaiser Foundation Health
Plan Medical Centers and one medical office conveniently located 8
8 Page 9 10
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 9 Section 3

throughout the Washington, DC and Baltimore, Maryland metropolitan
areas. We also contract with local community hospitals, Centers of
Excellence and other facilities, where you may get service after you
receive a referral from a Plan physician.

You must receive your health services at Plan facilities, except if you
have an emergency. We offer health care services at our Plan Medical
Centers, Affiliated Primary Care Physician Network medical offices,
community hospitals and other selected locations throughout the
Washington, DC, and Baltimore, Maryland metropolitan areas.

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.

Our Provider Directory lists the Plan facilities. Directories are updated
twice a year and are available at the time of enrollment. However, our
online Provider Directory is updated monthly. Our website address is
http:// www. kaiserpermanente. org.

What you must do to get covered
care

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.

To choose a primary care physician you can either select one from our
Provider Directory, or you can call us at 301/ 468-6000 inside the
Washington, DC metropolitan area or at 800/ 777-7902 outside the
Washington, DC metropolitan area. Our TDD telephone number is
301/ 816-6344. We are happy to assist you in selecting a primary care
physician.

Primary care We require you to choose a primary care physician when you enroll.
Your primary care physician can be an internal medicine physician, a
pediatrician, or a family practice physician. Your primary care
physician will provide most of your health care, or give you a referral to
see a specialist.

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.

Specialty care Your primary care physician will refer you to a specialist for needed
care. However, you may see a gynecologist, an optometrist, or our
mental health and substance abuse Plan providers 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 work with the specialist, in consultation with you, to 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.

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 9
9 Page 10 11
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 10 Section 3

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
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, you can
continue to see your specialist until the end of your postpartum care,
even if it is beyond the 90 days.

Hospital care 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 Services department immediately at 301/ 468-6000 inside
the Washington, DC metropolitan area or at 800/ 777-7902 outside the
Washington, DC metropolitan area. Our TDD telephone number is
301/ 816-6344.

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 benefits of the hospitalized person.

Circumstances beyond our
control

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. 10
10 Page 11 12
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 11 Section 3

Services requiring our prior
approval

Your primary care physician has authority to refer you for most
services. For certain services, however, your physician must obtain
approval from us. Before giving approval, we consider if the service is
covered, medically necessary, and follows generally accepted medical
practice.

We call this review and approval process precertification. Your
physician must obtain precertification for the following services:

Acupuncture All inpatient services
Adenoids or tonsil removal Breast surgery not associated with cancer
Carpal tunnel surgery Chiropractic services
Clinical trials Durable Medical Equipment
Gastric bypass surgery Home Health Care
Hospice Care Hysterectomy
Infertility treatment Infusion therapy
Injectable medications MRI
Nasal surgery Occupational therapy
Oral surgery Organ transplants
Pain clinics Physical therapy
Pulmonary therapy Prosthetics
Reconstructive surgery Sclerotherapy for varicose veins
Speech therapy Spinal surgery not associated with cancer
Sleep studies Surgical procedures
Temporomandibular Joint surgery Tubes in the ears

Requests for these services are made to your primary care physician just
like any other referral. Your primary care physician submits the
request, with supporting documentation. It takes an average of 2
working days to process the request. You should call your primary care
physician's office if you have not been notified of the outcome of the
review within 5 working days. If your request is not approved, you
have a right to appeal by calling inside the Washington, DC
Metropolitan area at 301/ 468-6000 or toll free at 800/ 777-7902. Our
TDD is 301/ 816-6344. If you wish additional services, you must make
the request to your primary care physician.

Emergency services do not require precertification. However, you or
your family member must notify the Plan within 48 hours, or as soon as
is reasonably possible. 11
11 Page 12 13
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 12 Section 4

Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider when
you receive services. Example: When you see your primary care
physician, you pay a copayment of $10 per office visit.

Deductible 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 you new plan.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for
certain services you receive. Example: In our Plan, you pay 50% of our
allowance for infertility services, ovulation stimulants, weight management
drugs, and smoking cessation drugs and oxygen and equipment for home
use after the first three months.

Fees when you fail to If you do not pay your copayment or coinsurance at the time you receive make your copayment services, we will bill you. You will be required to pay a $10 charge for
or coinsurance each bill sent for unpaid services.

Your out-of-pocket maximum After your copayments and coinsurance total $1,500 per person or $3,000
for copayments and coinsurance per family enrollment in any calendar year, you do not have to pay any more for covered services. However, copayments for the following

services do not count toward your out-of-pocket maximum, and you must
continue to pay copayments and coinsurance for these services:

Prescription drugs Chiropractic and acupuncture services
Dental services Follow-up and continuing care outside the service area
Infertility services Any non-FEHB benefits

Be sure to keep accurate records of your copayments and coinsurance since
you are responsible for informing us when you reach the maximum. 12
12 Page 13 14
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 13 Section 5

Section 5. Benefits OVERVIEW
(See page 7 for how our benefits changed this year and page 70 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 claim forms, claim filing advice, or more information about our benefits, contact us at
301/ 468-6000 inside the Washington, DC metropolitan area or at 800/ 777-7902 outside the Washington, DC
metropolitan area. Our TDD telephone number is 301/ 816-6344. You can also visit our website at
www. kaiserpermanente. org.

(a) Medical services and supplies provided by physicians and other health care professionals............................ 14-25
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

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals........................ 26-29
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services...................................................... 30-33
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice care Ambulance

(d) Emergency services/ accidents..................................................................................................... 34-35
Emergency within our service area Emergency outside our service area Ambulance

(e) Mental health and substance abuse benefits..................................................................................................... 36-38
(f) Prescription drug benefits................................................................................................................................. 39-42
(g) Special features................................................................................................................................................. 43-45

Flexible benefits option 24 hour nurse line
Services for deaf and hearing impaired
Centers of excellence for transplants Travel benefit
Services from other Kaiser Permanente Plans
(h) Dental benefits.................................................................................................................................................. 46-53

(i) Non-FEHB benefits available to Plan members............................................................................................... 54-55

Summary of benefits..................................................................................................................................................... 70 13
13 Page 14 15
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 14 Section 5( a)

Section 5 (a). Medical services and supplies provided by physicians
and other health care professionals

I M
P O
R T
A N
T

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.

I M
P O
R T
A N
T
Benefit Description You Pay

Diagnostic and treatment services
Professional services of physicians and other health care professionals $10 per office visit
In physician's office
In an urgent care center
Initial examination of a newborn child covered under a family enrollment

Second surgical opinion
During a hospital stay
In a skilled nursing facility
Nothing

At home (in the service area) Nothing
Lab, X-ray, and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Nonroutine pap smears
Pathology
X-rays
Non-routine mammograms
Cat scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing

Preventive care, adult You Pay
Routine screenings, such as: $10 per office visit 14
14 Page 15 16
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 15 Section 5( a)

Blood lead level
Total blood cholesterol once every three years, ages 19 through 64
Colorectal cancer screening, including
Fecal occult blood test
Sigmoidoscopy screening every five years starting at age 50
Bone mass measurement for prevention, diagnosis and treatment of osteoporosis

Prostate specific antigen one annually for men age 40 and older
Chlamydia screenings women under age 20 who are sexually active and women over age 20 with multiple risk factors

Routine pap smear
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster once every 10 years, ages19 and over (except as provided for under Childhood immunizations)

Influenza/ Pneumococcal vaccines, annually, age 65 and over
Note: You pay only one copayment if you receive your routine
screening or immunization on the same day as your office visit.

Routine mammogram Covered for women age 35 and older, as
follows:

From age 35 to 39, one during this five-year period
From age 40 to 64, one every calendar year
At age 65 and older, one every two consecutive calendar years

Nothing

Not covered:
Physical exams required for:
Obtaining or continuing employment
Participating in employee programs
Insurance or licensing
Court ordered for parole or probation
Attending schools
Travel
Travel immunizations

All charges

Preventive care, children You Pay
Childhood immunizations recommended by the American Academy of Pediatrics $10 per office visit from age 3 through age 22. Nothing for
infancy through age 2. 15
15 Page 16 17
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 16 Section 5( a)

Examinations, such as:
Eye exams through age 22 to determine the need for vision correction

Ear exams through age 22 to determine the need for hearing correction
Examinations done on the day of immunizations through age 22
Not covered:
Physical exams required for:
Obtaining or continuing employment
Participating in employee programs
Insurance or licensing
Court ordered for parole or probation
Attending schools
Travel
Travel immunizations

All charges

Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:

You do not need to precertify your normal delivery.
You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. Your inpatient stay

will be extended 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 will be covered
only if the infant is covered under a Self and Family enrollment.

We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and

Surgery benefits (Section 5b).

$10 for the first office visit to
confirm pregnancy. Nothing once
pregnancy is confirmed through the
post-partum office visit.

Not covered:
Routine sonograms to determine fetal age, size, or sex
All charges 16
16 Page 17 18
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 17 Section 5( a)

Family planning You Pay
Family planning services, including counseling
Voluntary sterilization
Information on birth control
Genetic counseling
Note: We cover surgically implanted contraceptives, injectable
contraceptive drugs and intrauterine devices (IUDs) under the
prescription drug benefit.

$10 per office visit

Not covered:
Reversal of voluntary surgical sterilization
All charges

Infertility services
Diagnosis and treatment of involuntary infertility
Artificial insemination
intravaginal insemination (IVI)
intra-cervical insemination (ICI)
intrauterine insemination (IUI)
In vitro fertilization, if:
your oocytes are fertilized with your spouse's sperm; and
you and your spouse have a history of infertility of at least 2 years duration as a result of endometriosis, exposure in utero to

diethylstilbestrol, commonly known as DES, blockage of, or
surgical removal of, one or both fallopian tubes (lateral or
bilateral salpingectomy, or abnormal male factors, including
oligospermia, contributing to the infertility; and

you have been unable to become pregnant through a less costly infertility treatment for which coverage is available under the

Plan
Fertility Drugs
Note: We cover injectable fertility drugs under the prescription drug
benefit.

50% of our allowance
50% of our allowance; Plan pays up
to $100,000 in a Member's lifetime 17
17 Page 18 19
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 18 Section 5( a)

Not covered:
Assisted reproductive technology (ART) procedures, such as:
embryo transfer
gamete intrafallopian transfer (GIFT)
zygote intrafallopian transfer (ZIFT)
Donor semen and donor eggs, including retrieval of eggs
Storage and freezing of eggs
Note: Infertility services are not available when either member of the
family has been voluntarily surgically sterilized.

All charges

Allergy care You Pay
Testing and treatment
Allergy injection
Note: Allergy serum is covered in full as a part of the $10 copayment
per office visit.

$10 per office visit

Not covered:
Provocative food testing
Sublingual allergy desensitization

All charges

Treatment therapies
Chemotherapy and radiation therapy
Note: We limit high dose chemotherapy in association with autologous
bone marrow transplants to those transplants listed under organ/ tissue
transplants on page 29.

Nothing

Respiratory and inhalation therapy
Intravenous IV/ Infusion Therapy Home IV and antibiotic therapy
Note: We cover growth hormone therapy (GHT) under the prescription
drug benefit.

Qualified medical clinical trials that provide treatment for life-threatening conditions or for preventive, early detection, or treatment

studies of cancer for Phases I, II, III, and IV

$10 per office visit

Dialysis Hemodialysis and peritoneal dialysis 18
18 Page 19 20
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 19 Section 5( a)

Not covered:
Long term rehabilitative therapy
Cognitive therapy
Chemotherapy supported by a bone marrow transplant or with stem cell support, for any diagnosis not listed as covered

Sleep therapy
Thermography and related services

All charges

Rehabilitative therapies You Pay
Inpatient Services up to 2 consecutive months of therapy per
condition:

Physical therapy by a qualified Plan therapist in consultation with a Plan physician to restore bodily function when you have a total or

partial loss of bodily function due to illness or injury
Speech therapy by a Plan therapist in consultation with a Plan physician to restore speech when you have a total or partial loss of

functional speech due to illness, injury, or a diagnosis of cleft lip,
cleft palate, or both

Occupational therapy by a Plan therapist in consultation with a Plan physician to assist you in achieving and maintaining self-care and

improved functioning in other activities of daily life
Outpatient physical therapy, occupational therapy, and speech therapy
We cover up to 40 office visits or 90 days (whichever is greater) per condition of out-patient physical therapy services

We cover up to 90 days per condition of out-patient occupational and speech therapy services

$10 per office visit

Habilitative services for children -from birth to age 19 for the treatment
of congenital and genetic birth defects

We cover services to help a child function age-appropriately within his or her environment and enhance his or her functional ability

without an effective cure

We provide multidisciplinary rehabilitation in a prescribed, organized program in a plan facility or skilled nursing facility for up
to two consecutive months for all covered rehabilitation services and
supplies you may receive at different sites for the same condition

Nothing 19
19 Page 20 21
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 20 Section 5( a)

Not covered:
Long-term rehabilitative therapy
Exercise programs
Cognitive rehabilitation programs
Vocational rehabilitation programs
Therapies done primarily for education purposes, except as may otherwise be covered above

Cardiac rehabilitation

All charges

Hearing services (testing, treatment, and supplies) You Pay
Hearing tests to determine the need for hearing correction $10 per office visit
Not covered:
Hearing aids, tests to determine their effectiveness, and examinations for them

All other hearing testing

All charges

Vision services (testing, treatment, and supplies)
Eye exam to determine the need for vision correction
Annual eye refractions
Diagnosis and treatment of diseases of the eye

$10 per office visit

Eyeglass frames purchased at Plan Optical Shops
Eyeglass lenses purchased at Plan Optical Shops
75% of our allowance

Initial fitting for contact lenses at a Plan facility
Insertion and removal of contact lens training
Three months of follow-up office visits
Note: These services are provided only in conjunction with obtaining
your first set of contact lenses at a Plan Optical Shop.

85% of our allowance

Not covered:
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery
Eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), far-sightedness

(hyperopia), and astigmatism
Cosmetic contact lenses
Cost of eyewear not purchased at Plan facilities
Sunglasses without corrective lenses

All charges 20
20 Page 21 22
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 21 Section 5( a)

Foot care You Pay
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease

Note: See orthopedic and prosthetic devices for information on
podiatric shoe inserts.

$10 per office visit

Not covered:
Cutting, trimming, or removal of corns, calluses, or the free edge of toenails, and similar routine treatment for 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)

All charges

Orthopedic and prosthetic devices
Externally worn breast prostheses and surgical bras including necessary replacements following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, 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

$10 per item

One hair prosthesis if your hair loss results from chemotherapy or radiation treatment for cancer $10 per item, up to $350 per member per calendar year
Not covered:
Comfort, convenience, or luxury equipment or features
External prosthetics and orthotics, such as braces, foot orthotics, artificial limbs, and lenses following cataract removal

Devices, equipment, supplies, and prosthetics related to sexual dysfunction
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

All charges 21
21 Page 22 23
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 22 Section 5( a)

Durable medical equipment (DME) You Pay
Durable medical equipment (DME) is equipment and supplies that are
intended for repeated use, medically necessary, primarily and
customarily used to serve a medical purpose, generally not useful to a
person who is not ill or injured, designed for prolonged use, appropriate
for use in the home, and serving a specific therapeutic purpose in the
treatment of an illness or injury.

We cover prescribed DME for home use for up to three months
following:

An authorized hospital admission
An authorized skilled nursing facility admission
An authorized rehabilitation facility admission
An authorized outpatient surgical procedure
Covered items include:

Hospital beds
Wheelchairs
Canes
Walkers
Portable commodes
Crutches

Nothing

Bilirubin lights and apnea monitors for infants up to age 3 for a period not to exceed 6 months
Oxygen and equipment for home use.
Note: Your Plan physician must recertify your medical need for oxygen and
equipment every 30 days.

Nothing for the first three months;
50% of our allowance for every 30
days thereafter

Asthmatic equipment (spacers, peak-flow meters, and nebulizers) for adults and children, when purchased at a Plan pharmacy.
Note: We decide whether to rent or purchase the equipment, and we
select the vendor. We will repair the equipment without charge, unless
the repair is due to loss or misuse. You must return the equipment to us
or pay us the fair market price of the equipment when it is no longer
prescribed.

Spacers: $5 per spacer
Peak-Flow Meters: $10 per meter
Nebulizers: $30 per nebulizer 22
22 Page 23 24
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 23 Section 5( a)

Not covered:
Liquid oxygen and oxygen tents
Motorized wheelchairs
Comfort, convenience, or luxury equipment or features
Exercise or hygiene equipment
Non-medical items such as sauna baths or elevators
Modifications to your home or car
Devices for testing blood or other body substances (glucose test strips are covered under your prescription drug benefits)

Electronic monitors of bodily functions, except apnea monitors and blood glucose monitors
Disposable supplies
Replacement of lost equipment
Repairs, adjustments, or replacements necessitated by misuse
More than one piece of durable medical equipment serving essentially the same function, except for replacements other than

those necessitated by misuse or loss
Devices, equipment, supplies, and prosthetics for the treatment of sexual dysfunction disorders

External and internally implanted hearing aids
Experimental or research equipment
Dental appliances

All charges

Home health services You Pay
If you are homebound and reside in the service area, we cover home
health care ordered by a Plan physician and provided by a registered
nurse, licensed practical nurse, licensed vocational nurse, physical
therapist, occupational therapist, speech and language pathologist, or
home health aide

Services include oxygen therapy, intravenous therapy, and medications

Note: Your Plan physician will periodically review the home health
program for continuing appropriateness and medical need.

Nothing 23
23 Page 24 25
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 24 Section 5( a)

Not covered:
Nursing care requested by, or for the convenience of, the patient or the patient's family

Custodial care
Homemaker services
Services outside the service area
Nursing care primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship, or giving oral medication

General maintenance care of colostomy, ileostomy, and ureterostomy
Medical supplies or dressings applied by you or a family caregiver
Care that a Plan physician determines may be provided in a Plan facility or skilled nursing facility and we provide or offer to provide

that care in one of those facilities
Transportation and delivery service costs of durable medical equipment, medications, drugs, medical supplies, and supplements to

the home
Personal care items

All charges

Alternative treatments You Pay
20 visits of acupuncture
20 visits of chiropractic services
Note: You receive these services when your Plan physician, in
consultation with the Complementary and Alternative Medicine
Department, determines that such care will result in improvement in
your condition.

$15 per office visit 24
24 Page 25 26
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 25 Section 5( a)

Not covered:
Naturopathic services
Hypnotherapy
Biofeedback
Massage therapy
Christian Science
Vitamins and supplements
Vax-D
Structural supports
Laboratory and pathology services, unless authorized by your primary care physician

Neurological testing, unless authorized by your primary care physician

All charges

Educational classes and programs You Pay
Health education for conditions such as diabetes, post-coronary, and nutritional counseling $10 per office visit

General health education classes such as Lamaze, weight control, smoking cessation, and stress management. Nominal fees ranging from $10 to $50 per class
Not covered:
Educational classes and programs not offered through this Plan
All charges 25
25 Page 26 27
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 26 Section 5( b)

Section 5 (b). Surgical and anesthetia services provided by physicians and other
health care professionals

I M
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A N
T

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 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 (i. e. hospital, surgical center, etc.).
YOU MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which

services require precertification and identify which surgeries require precertification.

I M
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Benefit Description You Pay
Surgical procedures
Treatment of fractures, including casting
Normal pre-and post-operative 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 --a condition in which an individual weighs 100 pounds or 100% over his or her normal

weight according to current underwriting standards; eligible
members must be age 18 or over

Insertion of internal prosthetic devices. See Section 5( a) orthopedic braces and prosthetic devices for device coverage

information.
Voluntary sterilization (tubal ligation and vasectomy)
Treatment of burns
Norplant (a surgically implanted contraceptive) and intrauterine devices (IUDs)

Note: We cover the cost of these devices under the prescription drug
benefit.

$10 per office visit for outpatient
services

Nothing for inpatient services 26
26 Page 27 28
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 27 Section 5( b)

Not covered:
Reversal of voluntary sterilization
Routine foot care; see Foot care

All charges

Reconstructive surgery You Pay
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
it 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, birth marks, web fingers, and 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.
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.

$10 per office visit for outpatient
services

Nothing for inpatient services

Not covered:
Cosmetic surgery any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance

and/ or treat a mental condition through change in bodily form
Surgeries related to sex transformation

All charges 27
27 Page 28 29
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 28 Section 5( b)

Oral and maxillofacial surgery You Pay
Oral surgical procedures, limited to:
Reduction of fractures of the jaws 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

Other surgical procedures that do not involve the teeth or their supporting structures

$10 per office visit for outpatient
services

Nothing for inpatient services

Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)

Shortening of the mandible or maxillae for cosmetic purposes and correction of malocclusion.

All charges 28
28 Page 29 30
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 29 Section 5( b)

Organ/ tissue transplants You Pay
Limited to:
Cornea
Heart
Heart/ Lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single -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, testicular, mediastinal, retroperitoneal and ovarian
germ cell tumors, breast cancer, multiple myeloma and epithelial
ovarian cancer

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 the recipient is covered by this Plan.

$10 per office visit for outpatient
services

Nothing for inpatient services

Not covered:
Donor screening tests and donor search expenses, except those performed for the actual donor

Implants of non-human or artificial organs
Transplants not listed as covered

All charges

Anesthesia
Professional services provided in:
Hospital (inpatient)
Hospital outpatient department
Ambulatory surgical center
Office

Nothing 29
29 Page 30 31
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 30 Section 5( c)

Section 5 (c). Services provided by a hospital or other facility, and
ambulance services

I M
P O
R T
A N
T

Here are some important things to remember 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

medically necessary.
Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.

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 (i. e., hospital or surgical center) or ambulance service for your surgery or care. Any costs

associated with the professional charge (i. e., physicians, etc.) are covered in
Section 5( a) or (b).

YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.

I M
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T

Benefit Description You Pay
Inpatient hospital
Room and board, such as:
Ward, semiprivate, or intensive care accommodations
General nursing care
Medically necessary special duty nursing
Meals and special diets
Note: If you want a private room when it is not medically necessary,
you pay the additional charge above the semiprivate room rate.

Nothing 30
30 Page 31 32
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 31 Section 5( c)

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, if donated or replaced
Dressings, splints, plaster casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics including nurse anesthetist services
Take-home items
Hospitalization for inpatient foot treatment
Note: You may receive covered medical hospital services for certain
dental procedures if a Plan physician determines that 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.

Nothing

Not covered:
Custodial care
Non-covered facilities
Personal comfort items, such as telephone, television, barber services, guest meals, and beds

Private nursing care
Whole blood and packed red blood cells not replaced by member
Any inpatient dental procedures

All charges

Outpatient hospital or ambulatory surgical center You Pay
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood and blood products
Blood and blood plasma, if donated or replaced
Pre-surgical testing
Dressings and casts and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service

$10 per office visit 31
31 Page 32 33
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 32 Section 5( c)

Not covered:
Whole blood and packed red blood cells not replaced by the member
All charges

Extended care benefits/ skilled nursing care facility
benefits
You Pay

Up to 100 days per calendar year when full-time skilled nursing care is
necessary and confinement in a skilled nursing facility is medically
appropriate. We cover the following:

Physician and nursing services
Room and board
Medical social services
Administration of blood, blood products, and derivatives
Durable medical equipment ordinarily furnished by a skilled nursing facility, including oxygen-dispensing equipment and oxygen

Respiratory therapy
Biological supplies
Medical supplies

Nothing

Not covered:
Custodial care
Care in an intermediate facility

All charges

Hospice care
Supportive and palliative care for a terminally ill member
You must reside in the service area
Services are provided in your home, or
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.

Nothing 32
32 Page 33 34
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 33 Section 5( c)

Not covered
Independent nursing

Homemaker services

All charges

Ambulance You Pay
Local professional ambulance service when medically appropriate Nothing
Not covered:
Transports that we determine are not medically necessary
All charges 33
33 Page 34 35
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 34 Section 5( d)

Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T

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.

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.

I M
P O
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A N
T
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 emergencies what they all have in common is the need for quick action.

What to do in case of emergency:
In a life threatening emergency-call the local emergency system (e. g., the local 911 telephone system). When the
operator answers, stay on the phone and answer all questions. If you are not sure whether you are experiencing a
medical emergency, please contact our Emergency Line at 800/ 677-1112.

Emergencies within our service area:
Emergency care is provided at Plan Hospitals 24 hours a day, seven days a week.

If you think you have a medical emergency condition and you cannot safely go to a Plan Hospital, call 911 or go to
the nearest hospital. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the
Plan. You or a family member must notify us within 48 hours, or as soon as is reasonably possible, by calling
703/ 359-7878 inside the Washington, DC metropolitan area or toll free 800/ 777-7904. Our TDD is 800/ 700-4901.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your
admission, unless it was not reasonably possible to notify us within that time. If you are hospitalized in non-Plan
facilities and Plan physicians believe care can be better provided in a Plan Hospital, we will transfer you when
medically feasible, with any ambulance charges covered in full.

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan provider
would result in death, disability or significant jeopardy to your condition.

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 within 48 hours or as soon as is reasonably possible. If a Plan
physician believes care can be better provided in a Plan Hospital, we will transfer you when medically feasible, with any
ambulance charges covered in full.

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, seven days a week. You may also
obtain information about the location of facilities by calling the Membership Services department at 301/ 468-6000
inside the Washington, DC metropolitan area or at 800/ 777-7902 outside the Washington, DC metropolitan area.
Our TDD telephone number is 800/ 700-4901. 34
34 Page 35 36
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 35 Section 5( d)

Benefit Description You Pay
Emergency within our service area
Emergency care as an outpatient or inpatient at a hospital, including physicians' services

Emergency care at a physician's office
Emergency care at a Plan urgent care center

$10 per visit

Emergency care in a hospital emergency room
Note: Your hospital emergency room visit copayment is waived if you
are admitted to a Plan Hospital

$35 per visit

Not covered:
Elective care or non-emergency care
All charges

Emergency outside our service area
Emergency care as an outpatient or inpatient at a hospital, including physicians' services

Emergency care at a physician's office
Emergency care at an urgent care center

$10 per visit

Emergency care in a Kaiser Foundation hospital in another Kaiser Foundation Health Plan service area
Emergency care in a non-Plan hospital emergency room
Note: Your copayment is waived if you are admitted to a Plan hospital.
See the Travel Benefit for coverage of continuing or follow-up care.

$35 per visit

Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

All charges

Ambulance
Professional ambulance service, including air ambulance, when
approved by the Plan.

Note: See Section 5( c) for non-emergency ambulance service.

Nothing

Not covered:
Transports we determine are not medically necessary
All charges 35
35 Page 36 37
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 36 Section 5( e)

Section 5 (e). Mental health and substance abuse benefits
I M
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A N
T

Parity
Beginning in 2001, all FEHBP plans' mental health and substance abuse 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 are payable only when we determine they are clinically appropriate to

treat your condition.
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.

I M
P O
R T
A N
T

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 36
36 Page 37 38
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 37 Section 5( e)

Diagnosis and treatment of psychiatric conditions, mental illness, or
disorders of children, adolescents, and adults. Outpatient services include:

Diagnostic evaluation
Crisis intervention and stabilization for acute episodes
Psychological testing necessary to determine the appropriate psychiatric treatment

Outpatient psychiatric treatment (including individual and group therapy visits)
Medication evaluation and management

Diagnosis and treatment of alcoholism and drug abuse. Services include:
Detoxification (medical management of withdrawal from the substance)

Treatment and counseling (including individual and group therapy visits) as part of intensive outpatient programs
Note: You may see a Plan provider for outpatient treatment without a
referral from your primary care physician.

Note: Your Plan provider will develop a treatment plan to assist you in
improving or maintaining your condition and functional level, or to
prevent relapse.

$10 per office visit

Inpatient psychiatric care
Hospital alternative services, such as partial hospitalization and intensive outpatient psychiatric treatment programs

Inpatient detoxification
Acute inpatient substance abuse rehabilitation
Intensive day treatment
Methadone treatment
Note: All inpatient admissions and hospital alternative services treatment
programs require approval by a Plan physician.

Nothing 37
37 Page 38 39
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 38 Section 5( e)

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 disabilities, 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
Marital, family, or educational services
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 that may be present

All charges

Special transitional benefit 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 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.

Benefit limitation We may limit your benefits if you do not follow your treatment plan. 38
38 Page 39 40
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 39 Section 5( f)

Section 5 (f). Prescription drug benefits
I
M
P
O
R
T
A
N
T

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 clinically appropriate to treat your condition.
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.

I
M
P
O
R
T
A
N
T

There are important features you should be aware of. These include:
Who can write your prescription. A Plan physician or licensed contracted dentist must write the prescription.
Where you can obtain them. You must fill the prescription at a Plan pharmacy, or by mail for a maintenance medication. We will pay for prescriptions written by a non-Plan physician and filled at a non-Plan pharmacy only
when the prescription was given during a hospital emergency room visit or an urgent care visit outside the service
area.

We use a formulary. We use a formulary. Our drug formulary is a list of prescribed drugs and accessories that have been approved by our Pharmacy and Therapeutics Committee for our Members. Unless otherwise specified
by your Plan physician or dentist, generic drugs may be used to fill prescriptions.
Our Pharmacy and Therapeutics Committee, which is comprised of Plan physicians, Plan providers, and our
pharmacists, selects prescription drugs and accessories for the drug formulary based on a number of factors,
including safety and effectiveness as determined from a review of medical literature and research. In addition, the
Committee sets dispensing limitations in accord with therapeutic guidelines based on the medical literature and
research. The Pharmacy and Therapeutics' Committee meets periodically to consider adding and removing
prescribed drugs and accessories on the formulary.

If you request a non-formulary drug when your physician feels there is an acceptable formulary alternative you
will be responsible for the full cost of that drug.

However, if your Plan physician believes that a non-formulary drug best treats your medical condition; a
formulary drug has been ineffective in the treatment of your medical condition; or a formulary drug causes or is
reasonably expected to cause a harmful reaction, then an exception process is available to your Plan physician. In
that case, your standard prescription drug copayment would apply.

If you would like information about whether a particular drug or accessory is included in our drug formulary,
please visit us on line at www. kaiserpermanente. org, or call our Member Services Department at 301/ 468-6000
inside the Washington, DC metropolitan area or at 800/ 777-7902 outside the Washington, DC metropolitan area.
Our TDD telephone number is 301/ 816-6344.

These are the dispensing limitations. We provide up to a 60-day supply based upon (a) the prescribed dosage, (b) the standard manufacturers package size, and (c) specified dispensing limits. Maintenance medications may be
obtained for up to a 90-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 39
39 Page 40 41
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 40 Section 5( f)

pharmacy. To file a claim, you should contact the Plan's Member Services Department at 301/ 468-6000 inside
the Washington, DC metropolitan area or at 800/ 777-7902 outside the Washington, DC metropolitan area and
obtain a claim form. Our TDD inside the Washington, DC metropolitan area is 301/ 816-6344 and 800/ 777-7902
outside the Washington, DC metropolitan area. A claim for reimbursement must be submitted to the Plan within
12 months after you purchased the prescribed drugs.

Prescription drug benefits begin on the next page. 40
40 Page 41 42
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 41 Section 5( f)

Benefit Description You Pay
Covered medications and supplies
We cover the following medications and supplies:
Drugs for which a physician's prescription is required by law
Insulin
Disposable needles and syringes for the administration of covered medications

Contraceptive drugs
Intrauterine devices (IUDs)
Implanted time-released drugs and injectable contraceptives, including

Norplant
Depo Provera
Self-injectable drugs, other than ovulation stimulants
Self-administered chemotherapeutic drugs and oral chemotherapeutic agents

Growth hormone therapy (GHT) for treatment of children with growth hormone deficiency
Blood glucose test strips (three (3) boxes of 50 count)

$7 per prescription if obtained at a
Plan medical center pharmacy

$5 per prescription if obtained
through our mail order delivery
system

Note: Compounded preparations must contain at least one ingredient
requiring a prescription.

Amino acid modified products used to treat congenital errors of amino acid metabolism (PKU)

Post-surgical immunosuppressant outpatient drugs required as a result of a covered transplant
Intravenous fluids and medications for home use
Chemotherapy drugs

Nothing

Asthma equipment, such as:
Spacers
Peak Flow Meters
Nebulizers

$5 per spacer
$10 per meter
$30 per nebulizer 41
41 Page 42 43
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 42 Section 5( f)

Smoking cessation products are provided for one course of therapy per calendar year, when:
prescribed by a Plan provider
you are in a formal smoking cessation program
Weight management drugs
Drugs for covered infertility treatments
Drugs for sexual dysfunction
Note: Drugs to treat sexual dysfunction have dispensing limitations. Please
contact the Plan for details.

50% of our allowance

Not covered:
Drugs or supplies for cosmetic purposes
Vitamins and nutritional supplements that can be purchased without a prescription

Nonprescription medicines or drugs for which there is a nonprescription equivalent available
Drugs obtained at a non-Plan pharmacy except for emergencies inside and outside the service area
Medical supplies such as dressings and antiseptics
Drugs to enhance athletic performance
Drugs related to non-covered infertility services
Drugs for non-covered services
Dental prescriptions other than those prescribed for pain relief or antibiotics

Replacement prescriptions necessitated by theft or loss
All drugs and accessories for the sole purpose of foreign travel

All charges 42
42 Page 43 44
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 43 Section 5( g)

Section 5 (g). Special features
Feature Description

Flexible benefits option 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.

24 hour nurse line For any of your health concerns, 24 hours a day, 7 days a week, you may call 703/ 359/ 7878 inside the Washington, DC metropolitan area or
800/ 777-7904 outside the Washington, DC metropolitan area or call our
TDD at 703/ 359-7616 or 800/ 700-4901 and talk with a registered nurse
who will discuss treatment options and answer your health questions.

Services for deaf and
hearing impaired

For any of your health concerns, 24 hours a day, 7 days a week, you may
call 703/ 359-7616 inside the Washington, DC metropolitan area or
800/ 700-4901 outside the Washington, DC metropolitan area and talk with
a registered nurse who will discuss treatment options and answer your
health questions.

During regular business hours Monday through Friday, you may contact our
Member Services Department with any questions concerning the Plan and
how to obtain services by calling 301/ 816-6344.

Centers of excellence
for transplants

The Centers of Excellence program began in Fall 1987. As new
technologies proliferate and become the standard of care, Kaiser
Permanente refers members to contracted "centers of excellence" for certain
specialized medical procedures.

We have developed a national contract network of Centers of Excellence
for organ transplantation, which consists of medical facilities that have met
stringent criteria for quality care in specific procedures. A national clinical
and administrative team has developed guidelines for site selection, site
visit protocol, volume and survival criteria for evaluation and selection of
facilities. The institutions have a record of positive outcomes and
exceptional standards of quality. 43
43 Page 44 45
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 44 Section 5( g)

Travel benefit 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 covered services 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 $1200 each calendar year.
For more information about this benefit call 800/ 390-3509.
File claims as shown on page 57.
The following are not included in your travel benefits coverage:

Non-emergency 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) 44
44 Page 45 46
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 45 Section 5( g)

Services from other
Kaiser Permanente
plans

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 non-urgent 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 Membership Services at 301/ 468-
6000 inside the Washington, DC metropolitan area or at 800/ 777-7902
outside the Washington, DC metropolitan area. Our TDD is 301/ 816-6344
inside the Washington, DC metropolitan area. 45
45 Page 46 47
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 46 Section 5( h)

Section 5 (h). Dental benefits
I M
P O
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A N
T

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 medically necessary.

Plan dentists must provide or arrange your care.
We have no calendar year deductible.
We cover hospitalization for dental procedures only when a nondental 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
P O
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A N
T

Dental Benefits
Accidental injury benefit You pay
We cover restorative services and supplies necessary
to promptly repair (but not replace) your sound
natural teeth that you have injured as the result of an
external force (not chewing). A sound natural tooth is
one that has not been weakened by existing dental
pathology such as, decay or periodontal disease, or
previously restored with a crown, inlay, onlay or
porcelain restoration, or treatment by endodontics.

Note: You must start to receive services within 60
days of your accident and complete them within 12
months of your accident. You are only covered for the
most cost effective procedure that will produce a
satisfactory result.

$10 per office visit, up to $2,000 per member per
accident

Not covered:
Injuries to non-sound natural teeth
Services required after the 12-month period
Services that are needed, but did not start until later than 60 days after the accident

Services for teeth that have been so severely damaged that restoration is impossible, in the
opinion of the Plan dental provider
Services for teeth that have been knocked-out

All charges 46
46 Page 47 48
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 47 Section 5( h)

Other dental benefits You pay
We cover general anesthesia and associated hospital or
ambulatory surgery facility charges in conjunction with
dental care provided by a fully accredited specialist in
pediatric dentistry, fully accredited specialist in oral and
maxillofacial surgery, or a dentist for whom hospital
privileges has been granted, for the following members:

Children, 7 years of age or younger, who are developmentally disabled, for whom a successful

result cannot be expected from dental care provided
under local anesthesia because of a physical,
intellectual, or other medically compromising
condition, for whom a superior result can be expected
from dental care provided under general anesthesia

Children, 17 years of age or younger, and extremely uncooperative, fearful, or uncommunicative with

dental needs of such magnitude that treatment should
not be delayed or deferred; and whom a lack of
treatment can be expected to result in oral pain,
infection, loss of teeth, or other increased oral or
dental morbidity

Adults, age 17 and older, whose medical condition requires that dental service be performed in a

hospital or ambulatory surgical center for their
safety (e. g., heart disease and hemophilia)

Nothing

Not covered:
The dentist's or specialist's professional services
Dental care for temporal mandibular joint (TMJ) disorders

All charges 47
47 Page 48 49
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 48 Section 5( h)

Discounted Fee -Dental Benefits
Kaiser Permanente has entered into an Agreement with Dental Benefit Providers (" DBP"), under which DBP will
provide or arrange for the administration of covered dental services to you through Participating Dental Providers.

All procedures listed in the following schedule of dental services and fees are covered dental services. When you receive any of the listed procedures from a Participating Dental Provider, you will pay the fee listed next to the

procedure description for that service. The Participating Dental Provider has agreed to accept that fee as payment in
full for that procedure. Neither Kaiser Permanente nor DBP are liable for payment of these fees or for any fees
incurred as the result of receipt of non-covered dental services.

You may select a Participating Dental Provider, who is a "general dentist," from whom you will receive covered dental services. With a large network of general dentists in our service area, you may select a general dentist from our

Dental Provider Directory for yourself and your family. You can obtain a Dental Provider Directory by calling our
Member Services Department at 301/ 468-6000 inside the Washington, DC metropolitan area or at 800/ 777-7902
outside the Washington, DC metropolitan area. Our TDD is 301/ 816-6344.

Specialty care is also available should further covered services be necessary; however, you must be referred to a Participating Dental Provider who is a specialist by your general dentist. Your discounted fees are slightly higher for

care received by a Participating Dental Provider who is a specialist. Please refer to the following schedule of dental
services and fees for those discounted fees.

When a dental emergency occurs outside our service area, Kaiser Permanente will reimburse you for the reasonable charges, less any discounted fee, upon proof of payment, not to exceed $50 per incident. We cover emergency dental

treatment required to alleviate pain, bleeding, or swelling. If post-emergency care is required, you must receive all
post-emergency care from your Participating Dental Provider.

The following schedule of dental services and fees list specific procedures with a "FC30" as the fee. This means you pay a fixed fee of $30 per office visit in which an exam, cleaning, or X-ray procedure, except when ADA codes

0210, Complete Series, and 0330 Panoramic are performed. The $5 sterilization fee cannot be charged for any office
visit in which the FC30 applies. Those fees that indicate a "NB" mean there is no benefit available. You must pay
the full cost of those services.

The schedule for dental services and fees are:
Dental Benefits You Pay
ADA
CODE PROCEDURE NAME
TO
DENTIST
TO
SPECIALIST
Diagnostic Services
00120 Periodic Oral Exam (every 6 months) FC30 NB
00140 Ltd Oral Evaluation Problem Focused FC30 NB
00150 Comprehensive Oral Examination FC30 NB
00210 Intraoral-Complete Series Including Bitewings 34 37
00220 Intraoral-Periapical-First Film FC30 9
00230 Intraoral-Periapical-Each Additional Film FC30 9
00240 Intraoral Occlusal Film FC30 9
00270 Bitewing-Single Film FC30 9
00272 Bitewing-Two Films FC30 9
00273 Bitewing Three Films FC30 16
00274 Bitewing Four Films FC30 25
00330 Panoramic Film 28 31
00460 Pulp Vitality Tests FC30 16
00470 Diagnostic Casts FC30 NB
Preventive Services
01110 Prophylaxis Adults (Every six months) FC30 NB
01120 Prophylaxis Child (Every six months) FC30 NB
01201 Topical Fluoride Incl Proph <16 yrs every 6 mos FC30 NB
01203 Topical Fluoride Excl Proph <16 yrs every 6 mos FC30 NB 48
48 Page 49 50
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 49 Section 5( h)

Dental Benefits You Pay
ADA
CODE PROCEDURE NAME
TO
DENTIST
TO
SPECIALIST
01330 Oral Hygiene Instruction FC30 NB
01351 Sealant Per Tooth To age 16 17 NB
01510 Space Maintainer Fixed Unilateral 184 NB
01515 Space Maintainer Fixed Bilateral 184 NB
01520 Space Maintainer Removable Unilateral 226 NB
01525 Space Maintainer Removable Bilateral 141 NB
01550 Recementation of Space Maintainer 21 NB
Restorative Services
02110 Amalgam One Surface Primary 27 NB
02120 Amalgam Two Surfaces Primary 35 NB
02130 Amalgam Three Surfaces Primary 39 NB
02131 Amalgam Four or More Surfaces Primary 50 NB
02140 Amalgam One Surface Permanent 30 NB
02150 Amalgam Two Surfaces Permanent 41 NB
02160 Amalgam Three Surface Permanent 51 NB
02161 Amalgam Four or More Surfaces Permanent 60 NB
02330 Resin One Surface Anterior 37 NB
02331 Resin Two Surfaces Anterior 51 NB
02332 Resin Three Surfaces Anterior 52 NB
02335 Resin >3 Sur or Inv Incisal Angle Ant 66 NB
02385 Resin -One Surface, Posterior Permanent 35 NB
02386 Resin -Two Surfaces, Posterior Permanent 56 NB
02387 Resin -3 or More Surfaces, Posterior Permanent 70 NB
02510 Inlay-Metallic-One Surface 307 NB
02520 Inlay-Metallic-Two Surfaces 334 NB
02530 Inlay-Metallic-Three Surfaces 371 NB
02540 Onlay-Metallic-Per T In Add to Inlay 408 NB
02610 Inlay-Porcelain/ Ceramic-One Surface 498 NB
02620 Inlay-Porcelain/ Ceramic Two Surfaces 498 NB
02630 Inlay-Porcelain/ Ceramic Three Surfaces 498 NB
02640 Onlay-Porc/ Ceramic-Per Tooth + Inlay 498 NB
02650 Inlay-Compos/ Resin-1 Surf (Lab Proc) 498 NB
02651 Inlay-Compos/ Resin-2 Surf (Lab Proc) 498 NB
02652 Inlay-Compos/ Resin-3 or More Surf (Lab) 498 NB
02710 Crown-Resin-Laboratory 235 NB
02740 Crown-Porcelain/ Ceramic Substrate 526 NB
02750 Crown-Porcelain Fused to Hi Noble Metal 531 NB
02751 Crown-Porcelain Fused to Predom Base Mental 472 NB
02752 Crown-Porcelain Fused to Noble Metal 502 NB
02790 Crown-Full Cast High Noble Metal 510 NB
02791 Crown-Full Cast Predom Base Metal 442 NB
02792 Crown-Full Cast Noble Metal 465 NB
02810 Crown-3/ 4 Cast Metallic 521 NB
02910 Recement Inlay 34 NB
02920 Recement Crown 34 NB
02930 Prefab Stainl Stl Crown-Prim Tooth 101 NB
02931 Prefab Stainl Stl Crown-Perm Tooth 106 NB
02932 Prefabricated Resin Crown 157 NB
02940 Sedative Fillings 34 NB
02950 Crown Buildup (Substructure) w/ pins 101 NB
02951 Pin Reten-Per Tooth in Add to Rest 22 NB
02952 Cast Post & Core In Add to Crown 146 NB
02954 Prefab Post & Core in Add to Crown 129 NB
02970 Temporary Crown (Fractured Tooth) 84 NB 49
49 Page 50 51
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 50 Section 5( h)

Dental Benefits You Pay
ADA
CODE PROCEDURE NAME
TO
DENTIST
TO
SPECIALIST
02980 Crown Repair 84 NB
Endodontic Services
03110 Pulp Cap-Direct Excl Final Rest 22 NB
03120 Pulp Cap-Indirect Excl Final Rest 22 NB
03220 Therapeutic Pulpotomy Exc Fin Rest 62 67
03310 RC Ther Ant Exc Final Restoration 253 319
03320 RC Ther-Bicuspid Exc Final Restoration 294 496
03330 RC Ther Molar Exc Final Restoration 313 614
03346 Retreatment of Prev RC Ther -Anterior NB 378
03347 Retreatment of Prev RC Ther -Bicuspid NB 584
03348 Retreatment of Prev RC Ther -Molar NB 732
03350 Apexification/ Recalc Per Trmt Visit 118 164
03410 Apicoectomy/ Periradicular Surg-Ant 148 381
03421 Apico/ perirad Surg-Bicus First Root 148 465
03425 Apico/ Perirad Srg-Molar First Root 148 487
03426 Apico/ Perirad Srg-Molar Ea Add Root 49 185
06430 Retrograde Filling Per Root 104 196
03450 Root Amputation-Per Root 104 252
03920 Hemisect W Rt Rem-Wo Root Canal Therapy 125 224
Periodontic Services
04210 Gingivectomy/ Gingivoplasty-Per Quad 222 297
04211 Gingivectomy/ Gingivoplasty-Per Tooth 59 90
04220 Ging Curettage Surg/ Quad-By Report 67 140
04240 Gingival Flap Incl Rt Health Plan-Per Quad 222 381
04249 Crn Lengthn-Hard/ Soft Tissue by Rep 260 358
04250 Muco-Gingival Surgery-Per Qdrant 260 370
04260 Oss Surg Inc Flap Ent, Grafts & Clos 371 661
04261 Osseous Graft 185 330
04262 Osseous Graft Multiple 185 330
04268 Guid Tis Rgen Inc Sur Re-Ent by Rep 358 358
04270 Pedicle Soft Tissue Graft Procedure 178 420
04271 Free Soft Tissue Graft & Donor Site 260 510
04320 Provisional Splinting Intracoronal 106 130
04321 Provisional Splinting Extracoronal 74 134
04341 Perio Scaling/ Root Health Planing-Per Quad 71 140
04355 FM Debridmt before Comp Trmt 67 140
04910 Perio Maint After Active Ther 45 67
Prosthetics -Removable
05110 Complete Denture Upper 525 NB
05120 Complete Denture Lower 525 NB
05130 Immediate Denture Upper 525 NB
05140 Immediate Denture Lower 525 NB
05211 Upper Part Dent-Resin Base Incl Clsp 381 NB
05212 Lower Part Dent-Resin Base Incl Clsp 470 NB
05213 Up Part Dent-Met Base, Res SDL Incl Clsp 567 NB
05214 Lo Part Dent-Met Base, Res SDL Incl Clsp 567 NB
05281 Uni Part Dent-Met Base, Cast Clsp 269 NB
05410 Adjust Dent-Comp or Part, Upr or Lwr 73 NB
05510 Repair Broken Complete Denture Base 56 NB
05520 Repl Miss/ Brkn T-Compl Den-Ea T 45 NB
05610 Repair Acrylic Saddle or Base 56 NB
05620 Repair Cast Framework 62 NB
05630 Repair or Replace Broken Clasp 50 NB
05640 Replace Broken Teeth-Per Tooth 50 NB 50
50 Page 51 52
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 51 Section 5( h)

Dental Benefits You Pay
ADA
CODE PROCEDURE NAME
TO
DENTIST
TO
SPECIALIST
05650 Add Tooth to Existing Part Denture 73 NB
05660 Add Clasp to Existing Part Denture 101 NB
05710 Rebase Dnt-Comp or Par, Upr or Lower 196 NB
05730 Reline Dnt-Comp or Part, Chair 134 NB
05750 Reline Dent-Comp or Part, Lab 148 NB
05820 Temp Part Stayplate-Upper or Lower 207 NB
05850 Tissue Conditioning Upper Denture 50 NB
05851 Tissue Conditioning Lower Denture 56 NB
Prosthetics -Fixed
06210 Pontic-Cast High Noble Metal 525 NB
06211 Pontic-Cast Predom Base Metal 484 NB
06212 Pontic-Cast Noble Metal 459 NB
06240 Pontic-Porc Fused to Hi Noble Metal 493 NB
06241 Pontic-Porc Fused to Predom Base Metal 431 NB
06242 Pontic-Porc Fused to Noble Metal 465 NB
06520 Inlay-Metallic-Two Surfaces 353 NB
06530 Inlay-Metallic 3 or More Surfaces 392 NB
06540 Only Metallic Per Tooth + Inlay 431 NB
06545 Rtain-Cast Mtl For Acide Etch Brdg 224 NB
06750 Crown-Porc Fused to Hi Noble Metal 504 NB
06751 Crown-Porc Fused to Predom Bse Metal 420 NB
06752 Crown-Porc Fused to Nobel Metal 454 NB
06780 Crown-3/ 4 Cast High Noble Metal 476 NB
06790 Crown-Full Cast High Noble Metal 537 NB
06791 Crown-Full Cast Predom Base Metal 478 NB
06792 Crown-Full Cast Noble Metal0 465 NB
06930 Recement Bridge 39 NB
Oral Surgery

07110 Single Tooth 47 53
07120 Each Additional Tooth 41 47
07130 Root Removal Exposed Roots 28 39
07210 Surgical Removal of Erupted Tooth 59 106
07220 Rem Impacted Tooth-Soft Tissue 52 129
07230 Rem Impacted Tooth-Part Bony 67 162
07240 Rem Impacted Tooth Compl Bony 111 190
07250 Surg Rem Resid T Roots-Cutting Proc 59 106
07260 Oroantral Fistula Closure 170 213
07270 Tooth Reimplantation 104 241
07280 Surg Expos Imp/ Unerup T-Ortho 125 207
07281 Surg Expos Imp/ Unerup T-Aid Erup 88 168
07285 Biopsy of Oral Tissue-Hard** 74 129
07286 Biopsy of Oral Tissue-Soft** 74 112
07291 Transseptal Fiberotomy 34 34
07310 Alveolopl In Conj w Extrac-Per Quad 59 118
07320 Alveolopl No Extract-Per Quad 74 134
07410 Rad Exc-Lesion to 1.25cm** 88 168
07420 Rad Exc-Lesion over 1.25cm** 141 286
07430 Exc Benign Tumor-Lesion to 1.25cm** 111 179
07431 Exc Benign Tumor-Lesion over 1.25cm** 140 281
07450 Rem Odont Cyc/ Tum-Les to 1.25cm 105 170
07451 Rem Odont Cyst/ Tum-Les over 1.25cm 140 281
07460 Rem NonOdont Cyst/ Tum-Les to 1.25cm 111 179
07461 Rem NonOdont Cyst/ Tum-Les over 1.25cm 148 297 51
51 Page 52 53
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 52 Section 5( h)

Dental Benefits You Pay
ADA
CODE PROCEDURE NAME
TO
DENTIST
TO
SPECIALIST
07470 Rem Exostosis-Maxilla or Mandible 193 280
07480 Part Ostectomy Gutter or Sauceriz 281 281
07510 I& D Abscess-Intraoral Soft Tissue 59 78
07520 I& D Abscess-Extraoral Soft-Tissue 59 78
07530 Rem Foreign Body/ Skn/ Subcut Areo Tissue 120 179
07550 Sequestrectomy for Osteomyelitis 162 162
07910 Suture Simple Wounds up to 5cm 39 39
07911 Suture of Complex Wounds up to 5cm 78 78
07960 Frenectomy Frenec/ Frenot-Sep Proc 91 196
07970 Exc of Hyperplastic Tissue-Per Arch 56 148
07971 Excision of Periocoronal Gingiva 67 95
Additional Procedures
09110 Palliative Treatment 28 NB
09210 Local Anesthesia 0 NB
09220 General Anesthesia-First 30 Minutes 74 185
09221 General Anesthesia-Each Add'l 15 Minutes 37 123
09230 Analgesia (per 30 Minutes) 17 22
09240 IV Sedation (per _ hour) 111 179
09310 Consult (No Add'l Procs Indicated) 45 49
09910 Appl Of Desensitizing Med 28 28
09940 Occlusal Guards by Report 162 269
09951 Occlusal Adjustment Limited 37 57
09952 Occlusal Adjustment-Complete 148 244
09980 Sterilization Surcharge (per visit) 5 5
09990 After Hours Surcharge 25 25
09999 Broken Appointment Fee Per _ Hour 15 15
Orthodontics Per Case
08070 Orthodontic Fully Banded 2 Yr. Case -Transitional NB 2375
08080 Orthodontic Fully Banded 2 Yr. Case -Adolescent NB 2375

Limitations to dental services:
Full mouth X-rays and panoramic X-rays are covered once every thirty-six (36) months
Full mouth debridement (ADA Code 4355) is limited to once every thirty-six (36) months
Perio Maintenance After Active Therapy (ADA Code 04910) is limited to twice within twelve (12) months after Osseous Surgery

Relinement of dentures (ADA Codes 05730 and 05750) is limited to once every thirty-six (36) months
Sealants (ADA Code 01351) are limited to the first and second permanent molars. Additionally, coverage is limited to members under age 16

Retreatment within one (1) year following the initial therapy is the responsibility of the original treating Participating Dental Provider
Orthodontic benefits are for Members ages 19 and under. Treatment beyond twenty-four (24) months is the responsibility of the Member 52
52 Page 53 54
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 53 Section 5( h)

Not covered:
Services of dentists or other practitioners of healing arts not associated with Kaiser Permanente and/ or DBP except upon referral arranged by a Participating Dental Provider and authorized by us, or when required in a

covered emergency. Such excluded services mean any kind of dental care and anything prescribed in
connection therewith.

Hospitalization for any dental procedure, except as may be otherwise covered by this Plan
Any cosmetic, beautifying, or elective procedure
Any procedure not performed in a dental office setting
Experimental procedures, implantations, or pharmacological regiments
Services for injuries or conditions which are covered under Workers' Compensation or Employer's Liability laws; services which are provided without cost to the Member by any municipality, county, or other political

subdivision. This exclusion does not apply to any services that are covered by Medicaid.
Replacement of denture, bridgework, and/ or dental appliances previously supplied under this benefit, due to loss or theft, or for any reason within sixty (60) months of initial insertion

Services which, in the opinion of the attending Participating Dental Provider, are not necessary for the member's dental health
Dental services pertaining, or related, to the Temporomandibular Joint (TMJ), except when those services are included on the attached dental fee schedule and are performed by the member's Participating Dental
Provider in that provider's office
Charges for failure to keep a scheduled dental appointment. The charges are listed in the attached dental fee schedule, and are charged by the general dentist and/ or specialist, for each missed _ appointment without

twenty-four (24) hours' notice.
Services of Pedodontists and/ or Prosthodontists
Charges for second opinions, unless previously authorized by Kaiser Permanente
Procedures requiring fixed prosthodontic restoration, which are necessary for complete oral rehabilitation or reconstruction

Procedures relating to the change and maintenance of vertical dimension or the restoration of occlusion
Orthodontic treatment for adults and orthodontic treatment related to Temporomandibular Joint (TMJ) dysfunction

Procedures not shown on the dental service and fees listing
Dental lab fees for excisions and biopsies. Procedures requiring lab fees are shown with asterisks ("**").
Orthodontic benefits are for ages 19 and under; adult orthodontics are not covered. Treatment beyond 24 months is the responsibility of the patient. Orthodontic treatment related to TMJ dysfunction is not covered. 53
53 Page 54 55
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 54 Section 5( i)

Section 5 (i). Non-FEHB benefits available to Plan members
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.

Feature Description
Medicare Prepaid Plan Enrollment We offer Medicare recipients the opportunity to enroll in our Plan through Medicare. Annuitants and former spouses
with FEHB coverage and Medicare Parts A and B may elect to either drop their FEHB coverage and enroll in a
Medicare prepaid plan or remain enrolled in the FEHB Program and simultaneously enroll in the Medicare prepaid plan
when one is available in their area. If you choose to disenroll from the FEHB Program you may then later re-enroll in
the FEHB Program.

Most federal annuitants have Medicare Part A (hospital coverage). Those without Medicare Part A may join this
Medicare prepaid plan after they have elected to purchase Medicare Part A in addition to continuing to pay for their
Part B premium. Before you drop your FEHB coverage and apply for coverage in the Medicare prepaid plan, please
contact us at the numbers listed below based on your residence:

The District of Columbia and the following cities and counties in Virginia: Alexandria, Arlington, Fairfax, Fairfax City, Falls Church, Loudoun, Manassas, Manassas Park, and Prince William, please call 800/ 281-8797.

The following cities and counties in the State of Maryland: Baltimore, Baltimore City, Howard and the following zip codes within Anne Arundel County: 20794, 21060, 21076, 21077, 21090, 21108, 21122, 21144,
21146, 21226 and 21240, please call 800/ 203-2808.
The following counties in the State of Maryland: Montgomery, Prince George's, and the following zip codes within
Charles County: 20601, 20602, 20603, 20604, 20612, 20616, 20617, 20637, 20640, 20643, 20646, 20658, 20675, and
20695, please call 800/ 229-5591.

Expanded Dental Benefits We are pleased to offer you a new choice of dental coverage to supplement what is currently available to you through
the FEHB program. This dental program is designed to enhance the level of dental benefits that you currently receive.
Your basic discounted dental coverage through the Plan is not affected by this enhanced product offering. This new
supplemental coverage is through Delta Dental, a national dental provider, and is only available to members of Kaiser
Permanente.

Dental Premier, a table of allowances program, allows you to choose any licensed dentist; however, discounted
pricing is available only through Delta's provider network. After you satisfy a deductible, Delta will pay a
predetermined amount toward each covered service. You will not need to satisfy a deductible toward covered
preventive services you receive. Delta Premier offers a full range of covered services: diagnostic, preventive,
restorative, endodontics, periodontics, oral surgery, and both fixed and removable prosthodontics. Orthodontic
coverage is not available. Covered services will be phased in over a three (3) year period.

Delta Premier is only available to you if you are enrolled in Kaiser Permanente's Plan for the FEHB. You do not need
to purchase this program to receive the basic dental coverage included in the Plan. Payments will be made directly to
Delta. Payroll deduction is not available for this program.

How to Enroll: An enrollment form for Delta Premier is included in your Kaiser Permanente enrollment kit. If you
would wish more information on Delta Premier, please call Delta Dental at 800/ 932-0783.

Monthly Premiums:
Self $18.45
Self and One Party $33.45
Family $52.45 54
54 Page 55 56
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 55 Section 6

Section 6. General exclusions --things we don't cover
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. 55
55 Page 56 57
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 56 Section 7

Section 7. Filing a claim for covered services
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. Sometimes these
providers bill us directly. Check with the provider. If you need to file the claim, here is the process:

Medical, hospital, and drug In most cases, providers and facilities file claims for you. Physicians
benefits must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form. For claims questions and

assistance, call us at 301/ 468-6000 inside the Washington, DC
metropolitan area or at 800/ 777-7902 outside the Washington, DC
metropolitan area. Our TDD telephone number is 301/ 816-6344.

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:
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.
Attention: Claims Department
P. O. Box 6233
Rockville, Maryland 20849-6233

Deadline for filing your claim 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.

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 56
56 Page 57 58
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 57 Section 8

Section 8. The disputed claims process
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 precertification:

Step Description

1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., 2101 East
Jefferson Street, Rockville, MD 20849, Attn: Member Services Appeals Unit; 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.

2 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.

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.

4 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, DC 20044-0436. 57
57 Page 58 59
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 58 Section 8

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.

5 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.

6 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 approval, then call us at
Monday through Friday at 301/ 468-6000 inside the Washington, DC metropolitan area or 800/ 777-7902
outside the Washington, DC metropolitan area. Our TDD is 301/ 816-6344. Weekends and holidays, please
call 703/ 359-7878 inside the Washington, DC metropolitan area or 800/ 777-7904 outside the Washington,
DC metropolitan area. Our weekend TDD numbers are 703/ 359-7616 or toll free at 800/ 700-4901. We will
expedite our review; or

(b) We denied your initial request for care or pre-authorization/ prior approval, 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. 58
58 Page 59 60
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 59 Section 9

Section 9. Coordinating benefits with other coverage
When you have other health You must tell us if you are covered or a family member is covered under
coverage 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 is the primary payer; it pays
benefits first. 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.) 59
59 Page 60 61
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 60 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
Then the primary payer is A. When either you --or your covered spouse --are age 65 or over and

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 when
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
services)

(for other
services)

6) Are a former Federal employee receiving Workers' Compensation
and the Office of Workers' Compensation Programs has determined
that you are unable to return to duty,

(except for claims
related to Workers'
Compensation)

B. When you --or a covered family member --have Medicare
based on end stage renal disease (ESRD) and

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 and
1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or .

b) Are an active employee .. .. 60
60 Page 61 62
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 61 Section 9

Medicare managed care plan 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+ Choice 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 will not waive our copayments and coinsurance for
your FEHB and Medicare coverage.

This Plan and another Plan's Medicare managed care plan: You 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.

Enrollment in Note: If you choose not to enroll in Medicare Part B, you can still be
Medicare Part B covered under the FEHB Program. We cannot require you to enroll in
Medicare.

TRICARE 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.

Workers' Compensation 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 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 similar agency pays its maximum benefits for your
treatment, we will cover your benefits. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first. 61
61 Page 62 63
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 62 Section 9

When other Government agencies We do not cover services and supplies when a local, State,
are responsible for your care or Federal Government agency directly or indirectly pays for them.

When others are responsible When you receive money to compensate you for medical or hospital care
for injuries 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. 62
62 Page 63 64
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 63 Section 10

Section 10. Definitions of terms we use in this brochure
Calendar year 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 Coinsurance is the percentage of our allowance that you must pay for your care.

Copayment A copayment is a fixed amount of money you pay when you receive covered services.

Covered services Care we provide benefits for, as described in this brochure.
Custodial care (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.

Deductible 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.

Experimental or
investigational services

A service, supply, item or drug that:
(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 available as the result of a written protocol that evaluates the
service's safety, toxicity, or efficacy; or
(4) is subject to the approval or review of an Institutional Review Board;
or
(5) requires an informed consent that describes the service as
experimental or investigational.

Group health coverage 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." 63
63 Page 64 65
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 64 Section 10

Medically necessary 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.

Our allowance 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/ We Us and we refer to Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.

You You refers to the enrollee and each covered family member. 64
64 Page 65 66
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 65 Section 11

Section 11. FEHB facts
Coverage information
No pre-existing condition We will not refuse to cover the treatment of a condition that you had
limitation before you enrolled in this Plan solely because you had the condition
before you enrolled.

Where you get information See www. opm. gov/ insure. Also, your employing or retirement office
about enrolling in the can answer your questions, and give you a Guide to Federal Employees
FEHB Program 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.

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for
for you and your family 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. 65
65 Page 66 67
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 66 Section 11

When benefits and The benefits in this brochure are effective on January 1. If you are new
premiums start 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.

Your medical and claims We will keep your medical and claims information confidential. Only
records are confidential 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 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

When FEHB coverage ends 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.

Spouse equity 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.

TCC 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.

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 66
66 Page 67 68
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 67 Section 11

Coverage and Former Spouse Enrollees, from your employing or
retirement office or from www. opm. gov/ insure.

Converting to You may convert to a non-FEHB individual policy if:
individual coverage 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.

Getting a Certificate of If you leave the FEHB Program, we will give you a Certificate of Group
Group Health Plan Coverage 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.

Inspector General advisory 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 us at 301/ 468-6000,
inside the Washington, DC metropolitan area or at 800/ 777-7902
outside the Washington, DC metropolitan area and explain the
situation. Our TDD telephone number is 301/ 816-6344,
If we do not resolve the issue, call THE HEALTH CARE FRAUD HOTLINE--202/ 418-3300 or write to: The United States Office of

Personnel Management, Office of the Inspector General Fraud
Hotline, 1900 E Street, NW, Room 6400, Washington, DC 20415.

Penalties for Fraud 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. 67
67 Page 68 69
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 68 Index

Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.
Accidental injury 46 Allergy tests 18
Alternative treatment 24 Ambulance 30, 33-35
Anesthesia 29, 31, 47 Autologous bone marrow
transplant 18, 29 Biopsies 26, 53
Blood and blood plasma 31-32 Breast cancer screening 15
Casts 31 Centers of excellence for
transplants 43 Changes for 2001 7
Chemotherapy 7, 18-19, 21, 41 Cholesterol tests 15
Coinsurance 5, 7-8, 12, 57, 61, 63-64
Colorectal cancer screening 15 Congenital anomalies 26-27
Contraceptive devices and drugs 41 Coordination of benefits 59
Covered providers 8 Crutches 22
Deaf and hearing impaired service 43
Deductible 12, 55, 63 Dental care 46
Diagnostic services 14-25 Disputed claims review 57-58
Donor expenses (transplants) 29 Dressings 24, 31, 42
Durable medical equipment (DME) 11, 22-24, 32
Educational classes and programs 25 Effective date of enrollment 65
Emergency 5-6, 8-9, 11, 34-35, 39-40, 44-45, 48, 53, 57, 63,
69 Experimental or investigational
23, 53, 56, 63 Eyeglasses 20-21
Family planning 17 Fecal occult blood test 15
Flexible benefits options 43, 69 General Exclusions 55
Hearing services 20

Home health services 23 Hospice care 32
Hospital 10, 14, 16, 22, 29-31, 34-35, 37, 44, 46-47, 53, 69
Immunizations 5, 15-16, 44 Infertility 11-12, 17-18, 42, 44
Inpatient Hospital Benefits 30 Insulin 41

Laboratory and pathological services 14
Magnetic Resonance Imagings (MRIs) 11, 14
Mail Order Prescription Drugs 39, 41, 70
Mammograms 15 Maternity Benefits 16
Medicaid 61-62 Medically necessary 64
Medicare 54, 59-60 Mental Conditions/ Substance
Abuse Benefits 36 Neurological testing 25
Newborn care 14, 16 Non-FEHB Benefits 12, 54
Nurse 8, 23, 31, 43, 63, 69 Licensed Practical Nurse 23
Nurse Anesthetist 31 Nurse Practitioner 8
Registered Nurse 23, 43 Nursery charges 16
Obstetrical care 16, 31 Occular Injury
Occupational therapy 11, 19 Oral and maxillofacial surgery 11,
28, 47 Orthopedic devices 21, 26
Ostomy and catheter supplies 24 Out-of-pocket expenses 12, 38,
54, 69 Oxygen 12, 22-23, 31-32
Pap test 14-15 Physical examination 5, 15-16
Physical therapy 11, 19 Precertification 11, 26, 30, 57
Preventive care, adult 15 Preventive care, children 16

Preventive services 5, 15-16, 18, 48, 54
Prior approval 11, 58 Prostate cancer screening 15
Prosthetic devices 21 Psychotherapy 38
Radiation therapy 7, 18, 21 Rehabilitation therapies
19-20, 37 Renal dialysis 18, 44, 59
Room and board 30, 32 Second surgical opinion 14
Services from other Kaiser Permanente Plans 6, 9,
34, 44-45, 55, 69 Skilled nursing facility care 10,
14, 19, 22, 24, 32 Smoking cessation 12, 25, 42
Speech therapy 11, 19 Splints 31
Sterilization procedures 17, 26-27
Subrogation 63 Substance abuse 5, 7-9,
36-38, 69 Surgery 7, 11, 16, 20-21, 26-
28, 30, 47
Anesthesia 29 Oral 28

Outpatient 27 Reconstructive 27
Syringes 41 Temporary continuation of
coverage 66-67 Transplants 11, 18, 28-29,
43-44, 70 Travel benefit 6, 8-9, 15,
44-45, 55, 69 Vision services 16, 20, 69
Well child care Wheelchairs 22-23
Workers' compensation 53, 60-61, 66
X-rays 14, 31, 52 24 hour nurse line 43, 69 68
68 Page 69 70
2001 Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc. 69 Summary

Summary of benefits for Kaiser Foundation Health Plan of the Mid-Atlantic
States, Inc. 2001

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 detail, 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 14

Services provided by a hospital:
Inpatient.............................................................................................
Outpatient..........................................................................................
Nothing
$10 per visit

30
31
Emergency benefits:
In-area..............................................................................................
Out-of-area ......................................................................................
$35 per visit
$35 per visit

35
35
Mental health and substance abuse treatment: ................................. Regular cost sharing 36
Prescription drugs ................................................................................. $7 per prescription if obtained at a
Plan medical office pharmacy;

$5 per prescription if obtained
through mail order

41

Dental Care ........................................................................................ Various copays based on
procedure rendered 46

Vision Care ........................................................................................ Refractions; $10 per office visit 20

Special features: Flexible benefits option; 24 hour nurse line; Services for deaf and hearing impaired;
Centers of excellence for transplants; Travel benefit; Services from other Kaiser Permanente Plans.
43

Protection against catastrophic costs
(your out-of-pocket maximum) .........................................................
Nothing after $1,500/ Self Only or
$3,000/ Family enrollment per
year

Some costs do not count toward
this protection

12 69
69 Page 70
2001 Rate Information for
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.

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 & 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
Enrollment Code
Gov't
Share
Your
Share
Gov't
Share
Your
Share
USPS
Share
Your
Share

Self Only E31 $79.32 $26.44 $171.86 $57.29 $93.86 $11.90
Self and Family E32 $195.82 $65.40 $424.28 $141.70 $231.17 $30.05 70

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