Kaiser Foundation Health Plan of Georgia, Inc.
http:// www. kp. org/ ga.
2001 A
Health Maintenance Organization
Serving: Atlanta, Georgia metropolitan area
Enrollment
in this Plan is limited; see page 5 for requirements.
Enrollment codes for this Plan:
F81 Self Only F82 Self and Family
Authorized for distribution by the:
RI 73-321
This Plan has excellent 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 Georgia, 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
.........................................................................................................
8
Primary
care...........................................................................................................................................
8
Specialty
care.........................................................................................................................................
9
Hospital care
........................................................................................................................................
10
Circumstances beyond our
control.............................................................................................................
10
Services requiring our prior approval
........................................................................................................
10
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........ 25
(c)
Services provided by a hospital or other facility, and ambulance
services...................................... 29
(d) Emergency services/
accidents
.........................................................................................................
33
(e) Mental health and substance abuse benefits
....................................................................................
35
(f) Prescription drug
benefits................................................................................................................
38
(g) Special features
...............................................................................................................................
41
(h) Dental
benefits.................................................................................................................................
44
(i) Non-FEHB benefits available to Plan
members..............................................................................
46 2
2 Page 3 4
2001 Kaiser Foundation Health Plan of Georgia, Inc
3 Table of Contents
Section 6. General exclusions --things we
don't
cover..............................................................................................
47
Section 7. Filing a claim for covered
services............................................................................................................
48
Medical, hospital, and drug
benefits.......................................................................................................
48
Deadline for filing your claim
................................................................................................................
48
When we need more information
...........................................................................................................
48
Section 8. The disputed claims
process......................................................................................................................
49
Section 9. Coordinating benefits with other
coverage................................................................................................
51
When you have other health coverage
......................................................................................................
51
What is Medicare?
...............................................................................................................................
51
The Original Medicare
Plan.................................................................................................................
51
Medicare managed care plan
...............................................................................................................
53
Enrollment in Medicare Part B
............................................................................................................
54
TRICARE..................................................................................................................................................
54
Workers'
Compensation............................................................................................................................
54
Medicaid
...................................................................................................................................................
54
When other Government agencies are responsible for your care
.............................................................. 54
When
others are responsible for
injuries...................................................................................................
54
Section 10. Definitions of terms we use in this
brochure...........................................................................................
55
Section 11. FEHB
facts..............................................................................................................................................
57
Coverage
information............................................................................................................................
57
No pre-existing condition
limitation...................................................................................................
57
Where you get information about enrolling in the FEHB
Program.................................................... 57
Types of
coverage available for you and your
family.........................................................................
57
When benefits and premiums
start......................................................................................................
58
Your medical and claims records are confidential
..............................................................................
58
When you retire
..................................................................................................................................
58
When you lose
benefits........................................................................................................................
58
When FEHB coverage
ends................................................................................................................
58
Spouse equity coverage
......................................................................................................................
58
Temporary Continuation of Coverage (TCC)
.....................................................................................
58
Converting to individual
coverage......................................................................................................
59
Getting a Certificate of Group Health Plan Coverage
........................................................................ 59
Inspector General advisory: Stop health care
fraud!...........................................................................
59
Penalties for
Fraud..............................................................................................................................
59
Index
...............................................................................................................................................................
60
Summary of benefits
...................................................................................................................................................
61
Rates…………………………………………………………………………………………………………..
Back cover 3
3 Page
4 5
2001 Kaiser Foundation Health Plan of Georgia, Inc. 4 Introduction/
Plain Language
Introduction
Kaiser Foundation Health Plan of
Georgia, Inc. Nine Piedmont Center
3495 Piedmont Road, NE Atlanta, Georgia
30305-1736
This brochure describes the benefits of Kaiser Foundation Health Plan of
Georgia, Inc. under our contract (CS 2163) 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 Georgia, Inc.
The plain language team
reorganized the brochure and the way we describe our benefits. When you compare
this Plan with other FEHB plans, you will find that the brochures have the same
format and similar information to make
comparisons easier.
If you have
comments or suggestions about how to improve this brochure, let us know.
Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov or write to
OPM at Insurance
Planning and Evaluation
Division, P. O. Box 436, Washington, DC 20044-0436. 4
4 Page 5 6
2001 Kaiser Foundation Health Plan of Georgia, 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 or coinsurance described in this brochure. When you receive
covered services from non-Plan
providers, such as emergency services or
services under our travel benefit, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not
because a particular provider is available. You cannot change plans because a
provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract
with us.
How we pay providers
We contract with the Southeast Permanente
Medical Group, Inc. and hospitals to provide the benefits in this brochure. Your
medical group physicians are paid in a number of ways, including salary,
capitation, per diem rates, case rates,
fee-for-service and incentive payments. Other Plan providers accept a
negotiated payment from us. You will only be responsible for your copayments or
coinsurance. If you would like further information about the way Kaiser
Permanente physicians are paid to provide or arrange medical and hospital
care for you, please call us at 404/ 261-2590.
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 Georgia, Inc., a Georgia not-for-profit
corporation, is a wholly owned subsidiary of Kaiser Foundation Health Plan, Inc.
We are 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.
In October 1995, Kaiser Permanente began operations in the State of Georgia.
Kaiser Permanente is one of the largest group practice health plans in Georgia.
We provide health care to more than 258,000 members in the
greater Atlanta
area.
In 2000, we received a three-year, full accreditation now known as
"Excellent Accreditation" from the National Committee for Quality
Assurance (NCQA).
All Kaiser Permanente affiliated hospitals are accredited by JCAHO, the
commission that sets nationally recognized health care standards for hospitals
and other health care organizations.
Kaiser Permanente reviews the
credentials – including licensing, education, training, experience, health
status, judgement, and office conditions – of physicians before they are
selected to participate in our medical care
program, and we review them on
an ongoing basis.
We credential Plan providers in accord with national
standards.
Plan physicians are members of American Specialty Boards or are
Board eligible. 5
5 Page
6 7
2001 Kaiser Foundation Health Plan
of Georgia, Inc. 6 Section 1
If you want more information about
us, call 404/ 365-0966, or write to: Kaiser Permanente, Member Services
Department, Nine Piedmont Center, 3495 Piedmont Road, NE, Atlanta, GA
30305-1736.
You may also contact us by visiting our website at www. kp. org/
ga.
Service Area
To enroll in this Plan, you must live or work in
our service area. This is where our providers practice. Our service area
includes these counties:
Bartow, Barrow, Butts, Cherokee, Clayton, Cobb, Coweta, DeKalb, Douglas,
Fayette, Forsyth, Fulton, Gwinnett, Hall, Henry, Newton, Paulding, Rockdale,
Spalding, and Walton County
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 42; and for emergency care obtained from any non-Plan
provider, as described on page 33. 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 you employment or retirement office. 6
6
Page 7 8
2001 Kaiser Foundation Health Plan of Georgia, 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. Your
mental health and substance abuse benefits have been changed to
reflect this
requirement.
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 our Member Service Department at 404/ 261-2590.
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 6. 1% for Self Only or 6. 2% for Self and Family.
Scoliosis
braces, formerly provided at a $200 copayment, are provided at a 20% copayment
like other external prosthetic and orthotic devices.
We cover extraction of teeth prior to radiation therapy treatment at a $10
copayment. Previously this benefit was not covered.
We cover allergy serum
at no charge. Previously this benefit was provided at a copayment of $50 per 6
month supply. 7
7 Page
8 9
2001 Kaiser Foundation Health Plan
of Georgia, 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 the
effective date of your enrollment, or if you need replacement cards, call our
Member
Service Department at 404/ 261-2590 (locally), 800/ 611-1811 (long
distance) or 800/ 255-0056 (TTY number).
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.
Plan providers
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 Southeast Permanente Medical Group, Inc. (Plan
physicians) an independent multi-specialty group of physicians
to provide or
arrange all necessary physician care. Plan physicians, nurse practitioners,
physician assistants, and other skilled medical personnel
working as medical
teams provide your health care services. Specialists consult with these medical
teams in determining your treatment. Plan
physicians refer patients to
community specialists when necessary. We also contract with American Dental Plan
(ADP) to provide or arrange
covered dental care.
We list Plan providers
in the provider directory, which we update periodically. The list is also on our
website at www. kp. org/ ga.
Plan facilities Plan facilities are hospitals and other facilities in
our service area that we contract with to provide covered services to our
members. Other
services, such as physical therapy, laboratory and X-ray, are
available at Plan facilities and other designated locations. Hospital care is
provided at
local community hospitals. We list these in the provider
directory, which we update periodically. The list is also on our website.
You must receive your health services at Plan facilities, except if you have
an emergency. If you are visiting another Kaiser Permanente
service area,
you may receive health care services at those Kaiser Permanente facilities.
Under the circumstances specified in this
brochure, you may receive
follow-up or continuing care while you travel anywhere.
What you must do to get It depends on the type of care you need.
First, you and each family covered care 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. Our website has information
about our
providers.
Primary care We require you to choose a
primary care physician when you enroll. Every member of your family should have
his or her own primary care
physician. If you do not select a primary care
physician upon enrollment, 8
8 Page 9 10
2001 Kaiser
Foundation Health Plan of Georgia, Inc. 9 Section 3
we will
assist you by identifying a physician in a medical center near your home and
including you in that physician's panel of patients. That
physician will be
listed in our records as your primary care physician until you make a selection
and inform us of your decision.
When choosing your primary care physician, keep in mind that your choice will
determine where you will receive specialty care. Your
primary care physician
has an established relationship with a specific group of specialty care
physicians with whom he or she works and trusts.
By referring only to a
select group of specialists, your primary care physician is better able to
ensure that you receive high-quality care.
You may select your primary care physician from the medical group or
affiliated community physicians. The medical group physicians provide
care
at Kaiser Permanente medical centers in our service area. An affiliated
community physician provides care in his or her own medical
office. Your
primary care physician can be a family practitioner, internist, or pediatrician.
Adults should select an internal medicine or
family practice physician.
Parents can choose a pediatric or family practice physician for their children,
or a family practice physician can be
selected for the entire family. To
learn how to choose or change a primary care physician, please call our Member
Services Department at
404/ 261-2590 (locally), 800/ 611-1811 (long
distance) or 800/ 255-0056 (TTY number).
If you wish to be treated by a physician at a Kaiser Permanente medical
center or by another affiliated community physician, you will need to
select
that individual as your new primary care physician before scheduling treatment.
If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.
Your
primary care physician will provide most of your health care, or give you a
referral to see a specialist.
Specialty care Your primary care physician will refer you to a
specialist for needed care. However, you may see obstetricians/ gynecologists,
dermatologists, and
ophthalmologists without a referral.
Here are other
things you should know about specialty care:
If you need to see a specialist
frequently because of a chronic, complex, or serious medical condition, your
primary care physician
will develop a treatment plan that allows you to see
your specialist for a certain number of visits without additional referrals.
Your primary
care physician will use our criteria when creating your
treatment plan.
If you are seeing a specialist when you enroll in our Plan,
talk to your primary care physician. Your primary care physician will decide
what treatment you need. If he or she decides to refer you to a specialist,
ask if you can see your current specialist. If your current
specialist does
not participate with us, you must receive treatment from a specialist who does.
Generally, we will not pay for you to see
a specialist who does not
participate with our Plan. 9
9 Page 10 11
2001 Kaiser
Foundation Health Plan of Georgia, Inc. 10 Section 3
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 and
you lose access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care, even
if it is beyond the 90 days.
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 404/ 261-2590. 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 Under certain extraordinary circumstances,
such as natural disasters, we control 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.
Services requiring our Your primary care physician has authority to
refer you for most services. prior approval 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. 10
10
Page 11 12
2001
Kaiser Foundation Health Plan of Georgia, Inc. 11 Section 3
We
call this review and approval process pre-authorization. Your physician must
obtain pre-authorization for the following services:
All inpatient hospital
care services Extended care/ skilled nursing facility services
Inpatient
mental health or substance abuse services Inpatient rehabilitation therapy
services or programs
Organ and tissue transplants Outpatient procedures and
services:
Knee arthroscopy Infertility procedures
Carpal tunnel surgery
Repair of nasal septum
Speech therapy Comprehensive outpatient
rehabilitation facility services
Home Health Care Hospice care
Durable
Medical Equipment Orthopedic and Prosthetic Devices
Circumcision (Pediatric
and adult) Plastic or reconstructive Surgery
Varicose Vein Stripping
Blepharoplasty
Spinal Cord Stimulation HBO Treatment
Pain management
Biofeedback
Intrathecal and epidural infusion pumps Any request for non-Plan
provider
Other services: Referrals to specific specialists and
recommendations for follow
up care 11
11
Page 12 13
2001
Kaiser Foundation Health Plan of Georgia, 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 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 your 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 and 20% of our allowance for durable
medical equipment.
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 $15 charge for
or coinsurance each bill sent for unpaid services.
Your out-of-pocket maximum After your copayments and coinsurance total
$2,000 per person or $5,000 for copayments and coinsurance per family
enrollment in any calendar year, you do not have to pay any
more for covered
services. However, copayments or coinsurance for the following services do not
count toward your out-of-pocket maximum, and
you must continue to pay
copayments or coinsurance for these services as described in this brochure:
prescription drugs durable medical equipment
external prosthetic and
orthotic devices the $25 charge for follow-up or continuing care
chiropractic services dental 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 Georgia, Inc.
13 Section 5
Section 5. Benefits --OVERVIEW
(See
page 7 for how our benefits changed this year and page 61 for a benefits
summary.)
NOTE: This benefits section is divided into
subsections. Please read the important things you should keep in mind at the
beginning of each subsection. Also read the General Exclusions in Section 6;
they apply to the benefits in the
following subsections. To obtain claims
forms, claims filing advice, or more information about our benefits, contact us
at 404/ 261-2590 or at our website at www. kp. org/ ga.
(a) Medical services and supplies provided by physicians and other health
care professionals............................. 14-24
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 ....................... 25-28
Surgical procedures
Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and
ambulance services..................................................... 29-32
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice
care Ambulance
(d) Emergency services/
accidents.........................................................................................................................
33-34
Emergency within our service area Emergency outside our service area
Ambulance
(e) Mental health and substance abuse
benefits....................................................................................................
35-37
(f) Prescription drug benefits
...............................................................................................................................
38-40
(g) Special features
...............................................................................................................................................
41-43
Flexible benefits option 24 hour nurse line
Services for deaf and hearing
impaired High risk pregnancies
Centers of excellence for transplants Travel
benefit
Services from other Kaiser Permanente Plans
(h) Dental benefits
................................................................................................................................................
44-45
(i) Non-FEHB benefits available to Plan members
..................................................................................................
46
Summary of benefits
...................................................................................................................................................
61 13
13 Page 14
15
2001 Kaiser Foundation Health Plan of Georgia,
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.
YOU MUST GET PRE-AUTHORIZATION FOR
SOME MEDICAL PROCEDURES. Please refer to the pre-authorization shown in Section
3 to be sure which services and
supplies require pre-authorization.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services You pay
Professional services of physicians and other health care professionals
In a physician's office
Initial examination of a newborn child covered
under a family enrollment
Office medical consultations
Second surgical opinion
In a Plan After
Hours Care Center
$10 per office visit
In any other urgent care center designated by the Plan $20 per visit
In a
skilled nursing facility
During a hospital stay
Nothing 14
14 Page 15 16
2001 Kaiser Foundation Health Plan of Georgia, Inc.
15 Section 5( a)
At home Nothing
Lab, X-ray, and other
diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Pathology
X-rays
Non-routine mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing
Preventive care, adult
Routine screenings, such as
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
Prostate Specific Antigen (PSA test) – one annually for men age 40 and
older
Routine pap test
Note: You pay only one copayment if you receive your
routine screening on the same day as your office visit.
$10 per office visit
Routine mammogram – covered for women age 35 and older, as follows:
From age 35 through 39, one during this five year period
From age 40
through 64, one every calendar year
At age 65 and older, one every two
consecutive calendar years
Note: In addition to routine screening, we cover
mammograms when medically necessary to diagnose or treat your illness.
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster
– once every 10 years, ages 19 and over (except as provided for under
Childhood immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
Nothing 15
15 Page
16 17
2001 Kaiser Foundation Health
Plan of Georgia, Inc. 16 Section 5( a)
Not covered:
Physical
exams required for:
Obtaining or continuing employment
Participating in employee programs
Insurance or licensing
Court order required for parole or probation
Attending
schools
Travel
All charges
Preventive care, children You pay
Childhood immunizations
recommended by the American Academy of Pediatrics
Well-child preventive care visits (up to 2 years of age)
Nothing
Examinations, such as:
Eye exams to determine the need for vision
correction
Ear exams to determine the need for hearing correction
Examinations done on the day of immunizations
Well-child care charges
for routine examinations, and care (over age 2)
$10 per office visit
Not covered:
Physical exams required for:
Obtaining or
continuing employment
Participating in employee programs
Insurance or licensing
Court order required for parole or
probation
Attending schools or camp
Travel
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.
Nothing 16
16 Page
17 18
2001 Kaiser Foundation Health
Plan of Georgia, Inc. 17 Section 5( a)
You may remain in the
hospital up to 48 hours after a regular delivery and 96 hours after a cesarean
delivery. Your Plan physician
will extend your inpatient stay if medically
necessary.
We cover routine nursery care of the newborn child during the
covered portion of the mother's maternity stay. We will cover other
care of an infant who requires non-routine treatment only if we cover the
infant under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Section 5( c) for hospital benefits and
Section 5(
b) for surgery benefits.
Not covered:
Routine sonograms to
determine fetal age, size, or sex
All charges
Family planning You pay
Family planning services, including:
Voluntary sterilization
Information on birth control
Note: We cover
surgically implanted contraceptives, injectable contraceptive drugs and
intrauterine devices (IUDs) under your
prescription drug benefit.
$10 per office visit
Not covered:
Reversal of voluntary surgical sterilization
Genetic counseling
All charges
Infertility services
Diagnosis and treatment of involuntary
infertility
Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
Fertility drugs
Note: We cover injectable fertility drugs under medical
benefits and oral fertility drugs under the prescription drug benefits.
50% of our allowance 17
17 Page 18 19
2001 Kaiser
Foundation Health Plan of Georgia, Inc. 18 Section 5( a)
Not covered:
Assisted reproductive technology (ART) procedures, such as:
in vitro fertilization
embryo transfer and GIFT
Services and supplies related to excluded ART procedures
Semen or eggs, and services and supplies related to their procurement
and storage
Cost of donor sperm
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 $10 per office visit
Allergy injections $5 per office visit
Allergy serum Nothing
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 are limited to those transplants listed under
Organ/ Tissue Transplants on page xx.
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.
Dialysis
Note: We waive office visit charges if you enroll in Medicare
Part B and assign your Medicare benefits to us.
$10 per office visit
Not covered:
Chemotherapy supported by a bone marrow transplant
or with stem cell support, for any diagnosis not listed as covered.
All
charges 18
18 Page
19 20
2001 Kaiser Foundation Health
Plan of Georgia, Inc. 19 Section 5( a)
Rehabilitative
therapies You pay
Two consecutive months of therapy per condition:
Physical therapy by qualified physical therapists to restore bodily function
when you have a total or partial loss of bodily function due
to illness or injury
Speech therapy by speech therapists to restore
speech when you have a total or partial loss of functional speech due to illness
or
injury
Occupational therapy by occupational therapists to assist you in
achieving and maintaining self-care and improved functioning in
other activities of daily life
Note: If you have not received 20 or more
outpatient visits within the two-month period that started with your first visit
to a therapist, we may
continue your therapy for up to 20 outpatient visits per therapy per
condition.
Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction, is provided for up to 12 weeks or 36 visits
$10 per office visit
Comprehensive outpatient rehabilitation facility services are provided up to
two months per condition. Outpatient rehabilitation,
including diagnostic
and restorative services, providing a program of physical, speech, occupational,
respiratory therapy, social and
psychological services, and other items and
services that are medically necessary for rehabilitation. The two month limit
applies
to all inpatient and outpatient comprehensive rehabilitation
services you may receive for the same condition.
$10 per office visit (nothing for inpatient service)
Not covered:
Long-term rehabilitative therapy
Exercise programs
Cognitive rehabilitation programs
Vocational rehabilitation programs
Therapies done
primarily for education purposes
All charges
Hearing services (testing, treatment, and supplies)
Hearing test
to determine the need for hearing correction
Hearing testing for children
through age 17 (see Preventive care, children)
$10 per office visit
Not covered:
All other hearing tests
Hearing aids,
tests to determine their effectiveness, and examinations for them
All charges 19
19 Page 20 21
2001 Kaiser
Foundation Health Plan of Georgia, Inc. 20 Section 5( a)
Vision services (testing, treatment, and supplies) You pay
Annual eye refractions for eyeglasses (to provide written lens
prescription) $15 per office visit
Diagnosis and treatment of diseases of the eye $10 per office visit
Not covered:
Corrective eyeglasses and frames or contact
lenses (including the examination and fitting of contact lenses)
Refractions for contact lenses
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery
Any eye
surgery solely for the purpose of correcting refractive defects of the eye, such
as nearsightedness (myopia), farsightedness
(hyperopia), and astigmatism
All charges
Foot care
Routine foot care when you are under active treatment
for a metabolic or peripheral vascular disease, such as diabetes.
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 of conditions of the
foot,
except as stated above
Treatment of weak, strained, or flat
feet or bunions or spurs; and of any instability, imbalance, or subluxation of
the foot (unless the
treatment is by open cutting surgery)
All charges
Orthopedic and prosthetic devices
External prosthetic and orthotic
devices, such as:
Artificial limbs and eyes; stump hose
Braces
Therapeutic shoes required for conditions associated with diabetes
Externally worn breast prostheses and surgical bras, including necessary
replacements, following a mastectomy
Scoliosis braces
Lenses following cataract removal
Corrective
orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ)
pain dysfunction syndrome
20% of our allowance 20
20 Page 21 22
2001 Kaiser
Foundation Health Plan of Georgia, Inc. 21 Section 5( a)
Internal
prosthetic devices, such as artificial joints, pacemakers, intraocula lens
following cataract removal, cochlear implants, and
surgically implanted
breast implant following mastectomy.
Note: See Section 5( b) for coverage of
the surgery to insert the device.
Nothing
Not covered:
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
Devices, equipment, supplies, and prosthetics related to the treatment of
sexual dysfunction
External and internally implanted hearing aids
Experimental or research equipment
All charges
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.
Covered items include:
Hospital beds
Wheelchairs, except motorized
Crutches
Walkers
Infant apnea monitors
Oxygen-dispensing
equipment
Oxygen
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.
20% of our allowance 21
21 Page 22 23
2001 Kaiser
Foundation Health Plan of Georgia, Inc. 22 Section 5( a)
Not covered:
Motorized wheel chairs
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
Electronic monitors of bodily
functions, except apnea monitors and blood glucose monitors
Disposable supplies
Replacement of lost equipment
Repair, 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
Spare or alternate use
equipment
Devices, equipment, supplies, and prosthetics for the
treatment of sexual dysfunction disorders
External and internally implanted hearing aids
Experimental or
research equipment
All charges
Home health services You pay
If you are homebound and reside in
the service area:
You may receive home health services of nurses and health
aides, physical or occupational therapists, and speech and language
pathologists
Services include oxygen therapy, intravenous therapy, and
medications
Note: Your Plan physician will periodically review the program for continuing
appropriateness and need.
Nothing 22
22 Page
23 24
2001 Kaiser Foundation Health
Plan of Georgia, Inc. 23 Section 5( a)
Not covered:
Nursing care requested by, or for the convenience of, the patient or
the patient's family
Nursing care primarily for hygiene, feeding, exercising, moving the
patient, homemaking, companionship, or giving oral medication
Custodial care
Care that the Medical Director of the
Medical Group or his/ her designee determines may be appropriately provided in a
Plan
facility, skilled nursing facility, or other facility we designate and we
provide or offer to provide that care in one of these facilities
Services outside our service area
All charges
Alternative treatments You pay
Chiropractic services up to 30
visits per calendar year, for the following services:
Evaluation and management
Routine chiropractic X-rays provided in the
chiropractor's office (not to exceed 4 views)
Chiropractic adjustments
Appropriate therapies (e. g. hot and cold packs)
not to exceed 2 per visits
Note: You may see a chiropractor without referral from your Plan physician.
Services must be provided from our list of Participating
Chiropractors.
Please contact us to get the list.
$10 per office visit 23
23 Page 24 25
2001 Kaiser
Foundation Health Plan of Georgia, Inc. 24 Section 5( a)
Not covered:
Vitamins and supplements
Vax-D
Structural
supports
Massage therapies
Maintenance/ preventative care
Acupuncture therapy
Physical, speech, and occupational
therapy provided by a chiropractor
Neurological testing, unless authorized by your primary care physician
Laboratory and pathology services, unless authorized by your primary
care physician
All charges
Educational classes and programs You pay
Training in self-care and
preventive care $10 per office visit
Health education publications and education about how to use our services and
supplies Nothing
General health education not addressed to a specific condition, as well as
Lamaze classes, weight control classes, and stop-smoking classes Charges vary ($
0 to $50)
Note: This information is a summary of services available. Please
call us at 404/ 261-2590 for availability and location of these classes. 24
24 Page 25 26
2001 Kaiser Foundation Health Plan of Georgia, Inc.
25 Section 5( b)
Section 5 (b). Surgical and anesthesia
services 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 do not have a 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.
YOU MUST GET PRE-AUTHORIZATION
FOR SOME SURGICAL PROCEDURES. Please refer to the pre-authorization shown in
Section 3 to be sure
which services and surgeries require pre-authorization.
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.).
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures You pay
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 prostethic devices. See Section 5( a) –
Orthopedic braces and prosthetic devices for coverage information
$10 per office visit for outpatient services
Nothing for inpatient
services
Voluntary sterilization (tubal ligation and vasectomy)
Norplant (a
surgically implanted contraceptive) and intrauterine devices (IUDs). Note:
Devices are covered under Section 5( a)
Treatment of burns
$10 per office visit for outpatient services
Nothing for inpatient
services 25
25 Page
26 27
2001 Kaiser Foundation Health
Plan of Georgia, Inc. 26 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:
the condition produced a major effect on the member's appearance; and
the condition can reasonably be expected to be corrected by such surgery.
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital
anomalies are protruding ear deformities, cleft lip, cleft palate, birthmarks,
web fingers, and toes.
Treatment of port wine stains on the face of members 18 years or younger
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; and
breast prostheses and surgical bras and replacements (see Prosthetic devices)
Note: If you need a mastectomy, you may choose to have this 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
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges 26
26 Page 27 28
2001 Kaiser
Foundation Health Plan of Georgia, Inc. 27 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 27
27 Page 28 29
2001 Kaiser
Foundation Health Plan of Georgia, Inc. 28 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
Autologous bone marrow transplants (autologous stem cell and peripheral stem
cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ
cell tumors
Limited Benefits -Treatment
for breast cancer, multiple myeloma, and epithelial ovarian cancer may be
provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved by
the Plan's medical director in accordance with the Plan's protocols
Note: We cover related medical and hospital expenses of the donor when we
cover your transplant.
$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 28
28 Page
29 30
2001 Kaiser Foundation Health
Plan of Georgia, Inc. 29 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 we cover them only when we
determine they are
medically necessary.
Plan physicians must provide or arrange your care
and you must be hospitalized in a Plan facility.
We do not have a calendar year deductible.
Be sure to read Section 4,
Your costs for covered services for valuable information about how cost
sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The
amounts listed below are for the charges billed by the facility (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 PRE-AUTHORIZATION FOR ALL NON-EMERGENCY INPATIENT HOSPITAL CARE
SERVICES. Please refer to the pre-authorization
shown in Section 3 to see
which services require pre-authorization.
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital You pay
Room
and board, such as:
Ward, semiprivate, or intensive care accommodations
General nursing care
Meals and special diets
Note: Your physician
may prescribe accommodations or private duty nursing care if is medically
necessary. If you want a private room
when it is not medically necessary, you pay the additional charge above the
semiprivate room rate.
Nothing 29
29 Page
30 31
2001 Kaiser Foundation Health
Plan of Georgia, Inc. 30 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.
The collection and storage of autologous blood for elective surgery is covered
when authorized by a Plan
physician
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including
nurse anesthetist services
Take-home items
Medical supplies, appliances,
medical equipment, and any covered items billed by a hospital for use at home
Note: You may receive covered hospital services for certain dental procedures
if a Plan physician determines you need to be hospitalized
for reasons
unrelated to the dental procedure. The conditions for which we will provide
hospitalization include hemophilia and heart
disease. The need for
anesthesia, by itself, is not such a condition.
Nothing
Not covered:
Personal comfort items, such as telephone,
television, barber services, guest meals, and beds
Private nursing care
Any inpatient dental procedures, except as
shown above and in Section 5( h) under dental benefits
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, blood plasma, and other biologicals
Blood and
blood plasma
Pre-surgical testing
Dressings, casts, and sterile tray
services
Medical supplies, including oxygen
Anesthetics and anesthesia
service
Nothing 30
30 Page
31 32
2001 Kaiser Foundation Health
Plan of Georgia, Inc. 31 Section 5( c)
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
Blood, blood products, and their administration
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 in an intermediate care facility
Custodial care
All charges
Hospice care
Supportive and palliative care for a terminally ill
member:
You must reside in the service area
Services are provided in the
home
Services are provided in a Plan approved hospice facility
Services
include inpatient care, outpatient care, and family counseling. A Plan physician
must certify that you have a terminal illness, with a
life expectancy of approximately six months or less.
Note: Hospice is a
program for caring for the terminally ill that emphasizes supportive services,
such as home care and pain control,
rather than curative care of the terminal illness. A person who is terminally
ill may elect to receive hospice benefits. These palliative
and supportive
services include nursing care, medical social services, physician services, and
short-term inpatient care for pain control and
acute and chronic symptom
management. We also provide counseling and bereavement services for the
individual and family members, and
therapy for purposes of symptom control
to enable the person to continue life with as little disruption as possible. If
you make a
hospice election, you are not entitled to receive other health
care services that are related to the terminal illness. If you have made a
hospice election, you may revoke that election at any time, and your
standard health benefits will be covered.
Nothing 31
31 Page
32 33
2001 Kaiser Foundation Health
Plan of Georgia, Inc. 32 Section 5( c)
Not covered:
Independent nursing
Homemaker services
All charges
Ambulance
Local professional ambulance service when ordered or
authorized by a Plan physician $50 per trip
Not covered:
Transports that we determine are not medically
necessary
All charges 32
32 Page 33 34
2001 Kaiser
Foundation Health Plan of Georgia, Inc. 33 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 do not have a 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
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 a medical emergency:
If you have a medical
emergency, dial 911 or go to the nearest emergency room.
Emergencies within our service area:
Emergency care is provided at
Plan Hospitals 24 hours a day, seven day a week. The location and phone number
of your nearest Kaiser Permanente hospital may be found in your FEHBP Facility
Guide.
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 the plan within 48 hours, unless it was
not reasonably possible to do so.
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
on the first working day following your admission, unless it was not reasonable
possible to notify the Plan within that time. If a Plan
physician believes
care can be better provided in a Plan hospital, then 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 Member Services Department
in the Atlanta area at 404/ 261-2590,
or from other areas at 800/ 611-1811. 33
33 Page 34 35
2001 Kaiser
Foundation Health Plan of Georgia, Inc. 34 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 an urgent care center
Emergency care in a hospital
emergency room
Note: Your copayment is waived if you are admitted to a
hospital.
$50 per visit
Not covered:
Elective care
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
Emergency care in a hospital emergency room
$50 per visit
Emergency care in a Kaiser Foundation hospital in another Kaiser Foundation
Health Plan service area
Note: See the Travel Benefit for coverage of
continuing or follow-up care.
The amount you would be charged if you were a
member in that service area
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 when medically
appropriate $50 per trip
Not covered:
Transportation by car,
taxi, bus, gurney van, wheelchair van, minivan, and any other type of
transportation, even if it is the only
way to travel to a facility
Transports we determine are not
medically necessary
All charges 34
34 Page 35 36
2001 Kaiser
Foundation Health Plan of Georgia, Inc. 35 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T
Parity
Beginning in 2001, all FEHBP plans' mental health and
substance benefits will achieve "parity" with other benefits. This
means that we will provide mental health and substance
abuse benefits differently than in the past.
When you get our approval
for services and follow a treatment plan we approve, cost-sharing and
limitations for Plan mental health and substance abuse benefits will be no
greater than for
similar benefits for other illnesses and conditions.
Here are some
important things to keep in mind about these benefits:
Please remember
that all benefits are subject to the definitions, limitations, and exclusions in
this brochure and we cover them only when we determine they are medically
necessary.
Plan physicians must provide or arrange your care.
We have no calendar
year deductible.
Be sure to read Section 4, Your costs for covered
services for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other
coverage, including with Medicare.
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. 35
35 Page 36 37
2001 Kaiser
Foundation Health Plan of Georgia, Inc. 36 Section 5( e)
Diagnosis and treatment of psychiatric, mental illness, or disorders of
children, adolescents, and adults. Services include:
Diagnostic evaluation
Crisis intervention and stabilization for acute episodes
Psychological
testing 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)
Rehabilitative care
Note: You may see an outpatient mental health or
substance abuse provider without a referral from your primary care physician.
See Section 3, How
you get care for information about services requiring our prior
approval.
Note: Your mental health or substance abuse 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 mental health and substance abuse care
Hospital alternative
services, such as partial hospitalization and intensive outpatient psychiatric
treatment programs
Note: All inpatient admissions and hospital alternative services treatment
programs require approval by a Plan physician.
Nothing
Not covered:
Care that is not clinically appropriate for the
treatment of your condition
Continued services if you do not
substantially follow your treatment plan
Services we have not
approved
Intelligence, IQ, aptitude ability, learning disorders, or
interest testing not necessary to determine the appropriate treatment of a
psychiatric condition
Evaluation or therapy on court order or as a condition of parole or
probation, or otherwise required by the criminal justice system, unless
determined by a Plan physician to be medically necessary and appropriate
Services that are custodial in nature
Services rendered or
billed by a school or a member of its staff
Services provided under a
federal, state, or local government program
Psychoanalysis or
psychotherapy credited toward earning a degree or furtherance of education or
training regardless of diagnosis or symptoms
All charges 36
36 Page 37 38
2001 Kaiser
Foundation Health Plan of Georgia, Inc. 37 Section 5( e)
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. 37
37 Page
38 39
2001 Kaiser Foundation Health
Plan of Georgia, Inc. 38 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 dentist must write the prescription.
Where you can obtain them. You may fill the prescription at a Plan
pharmacy or a Plan participating community pharmacy. It may be possible for you
to receive refills by mail at no
extra charge. Delivery may be made
available at an additional charge. Ask for details at a Plan Pharmacy. We pay a
higher level of benefits when you use a network pharmacy.
We use a formulary. We use a formulary, which is a listing of
preferred pharmaceutical substances and formulas that our physicians and
pharmacists consider to be the most safe, useful
and cost-effective ones
available. A team of Kaiser Permanente physicians and pharmacists independently
and objectively evaluates the scientific literature to identify the FDA-approved
drugs best suited to treat specific medical conditions. Coverage for
prescription drugs is limited to those drugs that are included on the Kaiser
Permanente 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. This formulary exception process
does not apply to your dentist. In order to be covered at your prescription drug
copayment all prescriptions written by your dentist
must be included on the
Kaiser Permanente formulary.
Unless otherwise specified by your Plan
physician or dentist, generic drugs may be used to fill a prescription. If you
request a brand name at Plan pharmacy or Plan participating community
pharmacy, you pay the cost difference between the generic and brand name
drugs, in addition to the applicable copayment.
If you would like information about whether a particular drug is included in
our drug formulary, or a list of our formulary drugs, please call our Member
Services Department, at 404/ 261-2590.
These are the dispensing
limitations. Up to the lesser of a 30 day supply or the standard
prescription amount of prescribed covered drugs and certain supplies. Drugs to
treat sexual
dysfunction have dispensing limitations. Contact us for
details.
When you have to file a claim. When you receive drugs from a
Plan pharmacy, you do not have to file a claim. For a covered out-of-area
emergency, you will need to file a claim when you
receive drugs from a non-Plan pharmacy.
Prescription drug benefits
begin on the next page. 38
38 Page 39 40
2001 Kaiser
Foundation Health Plan of Georgia, Inc. 39 Section 5( f)
Benefit Description You pay
Covered medications and supplies You
pay
We cover the following medications and supplies:
Drugs for which
a prescription is required by law
Diabetic supplies such as glucose test
strips (Chemstrip ® ), Dextrostix ® , sugar test tape, sugar test
tablets, acetone test tablets
Inhalers
Spacer devices
Compounded dermatological preparation
prepared by a pharmacist
Oral contraceptive drugs
Diaphragms
Growth
hormone therapy (GHT) – for treatment of children with Turner's syndrome
or classical growth hormone deficiency
$5 per prescription or refill if obtained at a Plan medical office
pharmacy
$11 per prescription or refill if obtained at a Plan
participating
community pharmacy
Insulin $5 per vial or refill if obtained at a Plan medical office pharmacy
$11 per vial or refill if obtained at a Plan participating community
pharmacy
Disposable needles and syringes for the administration of covered medications
Intravenous fluids and medications for home use
Amino acid-modified
products used to treat congenital errors of amino acid metabolism
Post-surgical immunosuppressant outpatient drugs required as a result of a
covered transplant
Nothing
Injectable contraceptives, including Norplant ® $180
Depo Provera
®
Other implanted time release drugs
Note: We do not refund any
portion of your copayment if you request removal of the implanted drug
time-release medication before the end of
its expected life.
$5 times the number of months the drug is expected to be effective, not
to exceed $200
Intrauterine devices $50 per device
Drugs for covered infertility
treatments 50% of our allowance
Drugs for sexual dysfunction
Note: Drugs
to treat sexual dysfunction have dispensing limitations.
50% of our
allowance 39
39 Page
40 41
2001 Kaiser Foundation Health
Plan of Georgia, Inc. 40 Section 5( f)
Not covered:
Drugs
and 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
out-of-area emergencies
Medical supplies such as dressings and
antiseptics
Drugs to enhance athletic performance
Drugs
related to non-covered infertility services
Contraceptive devices,
except diaphragms and intrauterine devices
Smoking cessation drugs
and medications, including nicotine patches
Drugs for non-covered services
Packaging of prescription
medications is limited to Plan standard packaging; special packaging is not
covered
Replacement of lost drugs and accessories
Infant formulas,
except for amino acid-modified products noted above
All charges 40
40 Page 41 42
2001 Kaiser
Foundation Health Plan of Georgia, Inc. 41 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
We review alternative benefits on an ongoing basis
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 404/ 365-0966 (locally) or 800/ 611-1811 (long
distance) and talk with a registered nurse who will discuss treatment options
and
answer your health questions.
Services for deaf and hearing impaired Our hearing and speech impaired
TYY number is: 800/ 255-0056.
High risk pregnancies Comprehensive Maternity Program. The goal is to
significantly reduce the incident of pre-term deliveries and low birth weight
babies by prompt interventions utilizing a multidisciplinary team approach.
All women receiving prenatal care are assessed at the first provider visit
(ideally during the first trimester) for factors associated with high-risk
pregnancy. Risk scoring systems are based on a combination of past medical
history (particularly reproductive history), current pregnancy
events,
personal habits during pregnancy, and demographic risks.
Although risk
scoring can identify some individuals at risk during pregnancy, no scoring
system is so effective that those at risk may be
safely ignored. Therefore,
ongoing assessment must be done for all patients for symptoms and risk factors
for pre-term birth.
We are not able to implement any aspect of our maternity benefits on a
"mandatory" basis. However, because copayments are waived for all
prenatal and one postnatal visit, we have a 99% compliance with the
recommended course of treatment. 41
41 Page 42 43
2001 Kaiser
Foundation Health Plan of Georgia, Inc. 42 Section 5( g)
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 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.
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 and 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. We deduct
this amount from the payment we make to you
We pay no more than $1200 each calendar year
For more information about
this benefit call the Travel Benefit Information Line at 800/ 390-3509
File claims as shown on page 48.
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) 42
42 Page 43 44
2001 Kaiser Foundation Health Plan of Georgia, Inc.
43 Section 5( g)
Services from other Kaiser Permanente
plans
When you visit 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
copayments or other charges imposed by the Plan you are visiting. If
the
Plan you are visiting has a benefit that differs 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 covered
if
you receive them 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 this Plan.
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 our
service area. 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 wish to obtain more information about the
benefits available to you from a Kaiser Permanente Plan in an area you visit,
please call our Member
Services Department at 404/ 261-2590 or 800/
611-1811. 43
43 Page
44 45
2001 Kaiser Foundation Health
Plan of Georgia, Inc. 44 Section 5( h)
Section 5 (h). Dental
benefits
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 pay them only when we
determine they are medically
necessary.
Plan dentists must provide or arrange your care. Call Member
Services for a list of participating dentists.
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
R T
A N
T
Dental Benefits
Accidental injury benefit You pay
We cover
restorative services and supplies necessary to promptly repair (but not replace)
sound natural
teeth. The need for these services must result from an
accidental injury.
50% of the first $1,000 of our allowance; all charges
thereafter
Other dental benefits You pay
We cover non-surgical treatment of
temporomandibular joint dysfunction (TMJ),
including splints and appliances
50% of the first $1,000 of our allowance per calendar year; all charges
thereafter
The following preventive dental services are covered when provided by a
participating Plan dentist:
Oral examinations twice a year
Dental
prophylaxis (cleaning) twice a year
Topical application of fluoride twice a
year
Bitewing X-ray twice a year
Full mouth series X-rays once every
three years
Note: You receive a 10% discount from the Plan dentist's usual
and customary fee schedule for all other
dental care.
$14 per office visit 44
44 Page 45 46
2001 Kaiser
Foundation Health Plan of Georgia, Inc. 45 Section 5( h)
General
anesthesia and associated hospital or ambulatory surgery facility charges in
conjunction
with dental care are covered for persons:
7 years of age or
younger
Who are developmentally disabled
Who are not able to have dental
care under local anesthesia due to a neurological or medically
compromising condition
Who have sustained extensive facial or dental
trauma
Nothing
Extraction of teeth to prepare the jaw for radiation treatment of neoplastic
disease $10 per office visit
Not covered
Other dental services
not specifically shown as covered
All charges 45
45 Page 46 47
2001 Kaiser Foundation Health Plan of Georgia, Inc.
46 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.
Expanded Dental Care
We are pleased to offer you and your family
expanded dental coverage through the American Dental Plan.
CompDent
Corporation offers you dental health maintenance organization benefits
administered by American Dental Plan (ADP). You must choose a primary care
dentist from the list of ADP dentists that is most convenient to you and
your family. With ADP you have no claim forms to worry about. ADP provides a
full range of services such as: preventive, restorative, endodontics,
periodontics, prosthetics, and orthodontics. Under this program, you pay a
copayment for all services which means a discount of approximately
seventy-five percent (75%) off all covered services.
Monthly Premium*
Self Only $ 11.00 Self & One Party $ 20.10
Self & Two or More $ 28.40
*These rates are effective January 1,
2001, through December 31, 2001
How To Enroll Please read the
enclosed flyer for a summary of the expanded dental plan. Use the postage paid
card attached to the
flyer to request enrollment information directly from
CompDent. If you would like more information call 888/ 340-2282 and identify
yourself as an Federal employee interested in the Kaiser Permanente/ ADP
Standard Option or High
Option Dental Plan.
You must pay for the
Standard Option or High Option by automatic monthly withdrawal from your
checking, savings, or credit union account on an annual charge to your
MasterCard or Visa.
Complementary and Alternative Medicine Program
As a Kaiser
Permanente member, you can enjoy access to our Complementary and Alternative
Medicine program, a unique program that offers discounted rates on a range of
chiropractic, acupuncture, acupressure and massage therapy
services. This
program entitles you to receive your chiropractic care at a discounted rate
after your covered 30 visits run out and other services not covered under your
chiropractic benefit described in Section 5( a). Kaiser Permanente
has
created this program in partnership with Guardian Care Alliance. In order to
receive the discount, you must choose from their designated list of providers.
For information and provider availability, visit the Guardian Care
Alliance
website at www. guardiancarealliance. com.
SelfWise Program
As a Kaiser Permanente member, you are
automatically enrolled in our SelfWise program. This program gives you
easy access to products and services you can use to be a safer and healthier
member of the community. Your
membership to SelfWise entitles you to
discounts on consumer health and safety merchandise, such as air purifiers,
smoke detectors, carbon monoxide detectors and fire extinguishers. You will also
have easy access to numerous
health-related programs and classes at no cost
or minimal cost to you; the absolute lowest rates for some of Atlanta's most
popular health clubs; discounts on vacation getaways; and substantial discounts
on many other services and
merchandise related to improving your health.
Note: Keep in mind that these programs are discount programs. They are not a
part of your FEHP benefits. 46
46 Page 47 48
2001 Kaiser
Foundation Health Plan of Georgia, Inc. 47 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. 47
47 Page 48 49
2001 Kaiser
Foundation Health Plan of Georgia, Inc. 48 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 drugs 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 404/ 261-2590.
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 Permanente Claims Administration
P. O. Box 190849 Atlanta, GA
31119-0849
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. 48
48 Page
49 50
2001 Kaiser Foundation Health
Plan of Georgia, Inc. 49 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
pre-authorization:
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 Georgia, Inc., Attention: Appeals Department, Nine Piedmont Center, 3495
Piedmont Road, NE, Atlanta GA 30305-1736; 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, D. C. 20044-0436. 49
49 Page 50 51
2001 Kaiser Foundation Health Plan of Georgia, Inc.
50 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 404/ 261-2590 and 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. 50
50
Page 51 52
2001
Kaiser Foundation Health Plan of Georgia, Inc. 51 Section 9
Section 9. Coordinating benefits with other coverage
When you
have other health coverage You must tell us if you are covered or a family
member is covered under another group health plan or have automobile insurance
that pays health
care expenses without regard to fault. This is called
"double coverage."
When you have double coverage, one plan 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 or 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.) 51
51 Page 52 53
2001 Kaiser Foundation Health Plan of Georgia, Inc.
52 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…………………………………………………
……….
b) Are an active
employee…………………………………………
……………………………...
52
52 Page 53 54
2001 Kaiser Foundation Health Plan of Georgia, Inc. 53 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
managed care plan, the following options are available to you:
This Plan and our Medicare managed care plan: You may enroll in our
Medicare managed care plan, known as Medicare+ Choice or Kaiser
Permanente
Senior Advantage, and also remain enrolled in our FEHB Plan. In this case, we
waive some of our copayments and coinsurance for
your FEHB and Medicare
coverage. If you would like information about our Medicare+ Choice plan, please
call 404/ 233-3700 (locally), 1-800-
232-4404 (long distance) and
1-800-255-0056 (TTY line). Your Kaiser Permanente Senior Advantage-FEHBP
benefits are:
Physician office visits: $5 copayment for physician/ specialist visit
Preventive care: $5 copayment per visit for most adult preventive
care services; no copayment for mammograms Routine physicals and hearing
exams: $5 copayment per visit
Outpatient mental health and substance
abuse: $5 copayment per visit
Prescriptions: $3 for each generic/
brand prescription obtained at a Plan medical
office pharmacy $9 for each
generic/ brand prescription obtained at a Plan
participating community
pharmacy Mail-order service available through the Plan at an additional
$2.50 postage/ handling charge Dialysis: no copayments
Durable
medical equipment: no copayments Orthopedic and prosthetic devices:
no copayments
Vision Services: $15 copayment for one routine eye
exam each year
$40 frame allowance for one frame every two years; $60
allowance for cosmetic contact lenses in lieu of eyeglasses once
every two
years
You will also enjoy: Health/ Wellness Education: $5 copayment
for disease-specific health
education classes (costs may vary for wellness classes) No deductibles and
virtually no paperwork
On-line access to health information and resources at
our award-winning members only website
Quarterly member communication in our
"Senior Outlook" magazine Customized Senior Advantage new member
orientation. 53
53 Page
54 55
2001 Kaiser Foundation Health
Plan of Georgia, Inc. 54 Section 9
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. 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. 54
54 Page
55 56
2001 Kaiser Foundation Health
Plan of Georgia, Inc. 55 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 whom, 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 We carefully evaluate whether
a particular therapy is safe and effective
or offers a reasonable degree of
promise with respect to improving health outcomes. The primary source of
evidence about health outcomes of any
intervention is peer-reviewed medical
or dental literature. When the service or supply, including a drug: (1) has not
been approved by the
FDA; or (2) is the subject of a new drug or new device
application on file with the FDA; or (3) is part of a Phase I or Phase II
clinical trial, as the
experimental or research arm of a Phase III clinical
trial; or is intended to evaluate the safety, toxicity, or efficacy of the
service; or (4) is available
as the result of a written protocol that
evaluates the service's safety, toxicity, or efficacy; or (5) is subject to the
approval or review of an
Institutional Review Board; or (6) requires an
informed consent that describes the service as experimental or investigational;
then this Plan
considers that service supply or drug to be experimental, and
not covered by the Plan.
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." 55
55 Page 56 57
2001 Kaiser Foundation Health Plan of Georgia, Inc.
56 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 Georgia,
Inc.
You You refers to the enrollee and each covered family member.
56
56 Page 57 58
2001 Kaiser Foundation Health Plan of Georgia, Inc.
57 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. 57
57 Page
58 59
2001 Kaiser Foundation Health
Plan of Georgia, Inc. 58 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 58
58 Page
59 60
2001 Kaiser Foundation Health
Plan of Georgia, Inc. 59 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 404/ 261-2590 and
explain the
situation. 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. 59
59 Page 60 61
2001 Kaiser Foundation Health Plan of Georgia, Inc.
60 Index
Index
Do not rely on this page; it is for
your convenience and does not explain your benefit coverage.
Accidental
injury 44 Allergy tests 18
Alternative treatment 23-24 Ambulance 32, 34
Anesthesia 28, 30, 40 Autologous bone marrow
transplant 18, 28
Biopsies 25
Blood and blood plasma 30 Breast cancer screening
Casts 30 Centers of excellence for
transplants 42 Changes for
2001 7
Chemotherapy 18 Cholesterol tests 15
Coinsurance 12, 55
Colorectal cancer screening 15
Congenital anomalies 25-26 Contraceptive
devices and drugs 17, 39
Coordination of benefits 51-54 Covered providers
5-8
Crutches 21 Deaf and hearing impaired
service 41 Deductible
12, 55
Dental care 44-46 Diagnostic services 14-15, 19, 30,
35-36
Disputed claims review 49-50
Donor expenses (transplants) 28 Dressings 30,
40
Durable medical equipment (DME) 12, 21-22, 31
Educational
classes and programs 24 Effective date of enrollment 58
Emergency 33-34
Experimental or investigational
47, 55 Eyeglasses 20, 53
Family
planning 17 Fecal occult blood test 15
Flexible benefits options 41
General Exclusions 47
Hearing services 19 Home health services
22-23
Hospice care 31-32 Hospital 10, 29-30
Immunizations 15-16
Infertility 17-18
Inpatient Hospital Benefits 29-30 Insulin 39
Laboratory and pathological services 15, 24
Magnetic
Resonance Imagings (MRIs) 15
Mail Order Prescription Drugs 38 Mammograms
15, 53
Maternity Benefits 16-17 Medicaid 54
Medically necessary 56
Medicare 51-54
Mental Conditions/ Substance Abuse Benefits 35-37
Neurological testing 24 Newborn care 17
Non-FEHB Benefits 46
Nurse
Licensed Practical Nurse Nurse Anesthetist 30
Nurse Practitioner 8
Registered Nurse 41
Nursery charges 17 Obstetrical care 16
Occupational therapy 19, 24 Ocular injury
Oral and maxillofacial surgery
27 Orthopedic devices 20-21
Out-of-pocket expenses 12 Oxygen 21
Pap
test 15 Physical examination 15-16
Physical therapy 19 Precertification
11
Preventive care, adult 15 Preventive care, children 16
Preventive
services 15-16 Prior approval 10-11
Prostate cancer screening 15 Prosthetic
devices 20
Psychotherapy 36 Radiation therapy 18
Rehabilitation
therapies 19 Renal dialysis 18, 51, 53
Room and board 29 Second
surgical opinion 14
Services from other Kaiser Permanente Plans 43
Skilled nursing facility care 31 Smoking cessation 24, 40
Speech therapy
19
Splints 30 Sterilization procedures 17
Subrogation 54 Substance abuse
35-37
Surgery 25-32 Anesthesia 28
Oral 27 Outpatient 30
Reconstructive 26 Syringes 39
Temporary continuation of coverage
58
Transplants 28 Travel benefit 42
Vision services 20 Well
child care 16
Wheelchairs 21 Workers' compensation 54
X-rays
15 24 hour nurse line 41 60
60 Page 61 62
2001 Kaiser
Foundation Health Plan of Georgia, Inc. 61 Summary
Summary of
benefits for Kaiser Foundation Health Plan of Georgia, 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
Nothing
29
30
Emergency benefits:
In-area.............................................................................................
Out-of-area
.....................................................................................
$50 per visit
$50 per visit
34
34
Mental health and substance abuse treatment:
................................. Regular cost sharing 35
Prescription drugs
................................................................................
$5 per prescription if obtained at a Plan medical office pharmacy;
$11 per prescription if obtained at a Plan participating community
pharmacy
38
Dental Care
.......................................................................................
Various copays based on procedure rendered 44
Vision Care
.......................................................................................
Refractions; $15 per office visit 20
Special features: Flexible benefits
option; 24 hour nurse line; Services for deaf and hearing impaired; High risk
pregnancies; Centers of excellence for transplants; Travel benefit; Services
from other Kaiser
Permanente Plans;
41
Protection against catastrophic costs (your out-of-pocket
maximum)......................................................... Nothing after
$2,000/ Self Only or $5,000/ Family enrollment per
year
Some costs do
not count toward this protection
12 61
61 Page
62 63
Notes 62
62 Page 63 64
Notes 63
63
Page 64
2001 Rate Information for
Kaiser Foundation Health Plan of Georgia, 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 F81 $72.57 $24.19 $157.24 $52.41 $85.87 $10.89
Self and
Family F82 $184.23 $61.41 $399.17 $133.05 $218. 01 $27.63 64