Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.
http://
www. kaiserpermanente. org
2002
A Health Maintenance Organization
Serving: Metropolitan Washington, DC Area and Metropolitan
Baltimore, Maryland Area
Enrollment in this Plan is limited. You must
live or work in our Geographic service area to enroll. See page 8 for
requirements.
Enrollment codes for this Plan:
E31 Self Only E32 Self and Family
RI 73-047
This Plan has commendable accreditation from the NCQA.
See the 2002
Guide for more
information on accreditation.
For changes
in benefits
see page 9 1
1 Page 2 3
2002 Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc. 2 Table of Contents
Table of
Contents
Introduction
.................................................................................................................................................................................
5
Plain
Language..................................................................................................................................................................................
5
Inspector General Advisory
............................................................................................................................................................
6
Section 1. Facts about this HMO
plan..........................................................................................................................................
7
How we pay providers
.................................................................................................................................................
7
Your
Rights....................................................................................................................................................................
7
Service
Area...................................................................................................................................................................
8
Section 2. How we change for
2002.............................................................................................................................................
9
Program-wide changes
................................................................................................................................................
9
Changes to this Plan
.....................................................................................................................................................
9
Section 3. How you get care
.......................................................................................................................................................
10
Identification
cards.....................................................................................................................................................
10
Where you get covered
care......................................................................................................................................
10
Plan
providers.......................................................................................................................................................
10
Plan facilities
........................................................................................................................................................
10
What you must do to get covered care
....................................................................................................................
11
Primary care
..........................................................................................................................................................
11
Specialty
care........................................................................................................................................................
11
Hospital care
.........................................................................................................................................................
12
Circumstances beyond our
control..........................................................................................................................
12
Services requiring our prior
approval......................................................................................................................
13
Section 4. Your costs for covered services
...............................................................................................................................
14
Copayments
..........................................................................................................................................................
14
Deductible
.............................................................................................................................................................
14
Coinsurance..........................................................................................................................................................
14
Fees when you fail to make your copayment or coinsurance
...................................................................... 14
Your catastrophic protection out-of-pocket maximum for copayments and
coinsurance ............................. 14
Section 5.
Benefits.........................................................................................................................................................................
15
Overview......................................................................................................................................................................
15
(a) Medical services and supplies provided by physicians and other health
care professionals ............. 16
(b) Surgical and anesthesia services
provided by physicians and other health care professionals ......... 28
(c)
Services provided by a hospital or other facility, and ambulance
services........................................... 32
(d) Emergency
services/ accidents
......................................................................................................................
36
(e) Mental health and substance abuse benefits
..............................................................................................
38
(f) Prescription drug
benefits..............................................................................................................................
41
(g) Special features
...............................................................................................................................................
45 2
2 Page 3 4
2002 Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc. 3 Table of Contents
Flexible benefits
option......................................................................................................................................
45
24 hour nurse line
................................................................................................................................................
45
Services for deaf and hearing
impaired............................................................................................................
45
Centers of excellence for transplants
...............................................................................................................
45
Travel
benefit........................................................................................................................................................
46
Services from other Kaiser Permanente
plans................................................................................................
47
(h) Dental
benefits.................................................................................................................................................
48
(i) Non-FEHB benefits available to Plan members
........................................................................................
57
Section 6. General exclusions – things we don't
cover...........................................................................................................
58
Section 7. Filing a claim for covered services
..........................................................................................................................
59
Medical, hospital, and drug
benefits........................................................................................................................
59
Deadline for filing your
claim...................................................................................................................................
59
When we need more
information.............................................................................................................................
59
Section 8. The disputed claims
process.....................................................................................................................................
60
Section 9. Coordinating benefits with other coverage
............................................................................................................
62
When you have other health
coverage....................................................................................................................
62
What is
Medicare?................................................................................................................................................
62
The Original Medicare Plan (Part A or Part
B)................................................................................................
62
Medicare managed care
plan...............................................................................................................................
65
If you do enroll in Medicare Part
B...................................................................................................................
66
If you do not enroll in Medicare Part A or Part B
...........................................................................................
66
TRICARE.....................................................................................................................................................................
66
Workers'
Compensation............................................................................................................................................
66
Medicaid
.......................................................................................................................................................................
66
When other Government agencies are responsible for your care
....................................................................... 66
When others are responsible for injuries
................................................................................................................
66
Section 10. Definitions of terms we use in this brochure
.......................................................................................................
67
Section 11. FEHB facts
................................................................................................................................................................
69
Coverage
information.............................................................................................................................................
69
No pre-existing condition
limitation.................................................................................................................
69
Where you get information about enrolling in the FEHB
Program............................................................ 69
Types of coverage available for you and your family
...................................................................................
69
When benefits and premiums start
...................................................................................................................
70
Your medical and claims records are
confidential.........................................................................................
70
When you
retire....................................................................................................................................................
70
When you lose benefits
.........................................................................................................................................
70
When FEHB coverage
ends...............................................................................................................................
70
Spouse equity
coverage......................................................................................................................................
70 3
3 Page 4 5
2002 Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc. 4 Table of Contents
Temporary
continuation of coverage
(TCC)...................................................................................................
70
Converting to individual
coverage....................................................................................................................
71
Getting a Certificate of Group Health Plan
Coverage...................................................................................
71
Long term care insurance is coming later in
2002.....................................................................................................................
72
Index
....................................................................................................................................................................................
73
Summary of benefits
......................................................................................................................................................................
74
Rates………………………………………………………………………………………………………….. Back cover 4
4 Page 5 6
2002 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 5
Introduction/ Plain Language/ Advisory
Introduction
Kaiser
Foundation Health Plan of the Mid-Atlantic States, Inc. 2101 East Jefferson
Street
Rockville, Maryland 20849
This brochure describes the benefits of
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., under our
contract (CS 1763) with the Office of Personnel Management (OPM), as authorized
by the Federal Employees Health
Benefits law. This brochure is the official
statement of benefits. No oral statement can modify or otherwise affect the
benefits, limitations, and exclusions of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for self and family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to
benefits that were available before January 1, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates
with each plan annually. Benefit changes are effective January 1, 2002, and
changes are summarized on page 9. Rates are shown at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible, and understandable to
the public. For instance,
Except for necessary technical terms, we use
common words. For instance, "you" means the enrollee or family
member; "we"
or "Plan" means Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.
We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is the
Office of Personnel Management. If we use
others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and
similar descriptions to help you compare
plans.
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/ insu re or e-mail us at fehbwebcomments@ opm. gov. You may
also write to OPM at
the Office of Personnel Management, Office of Insurance
Planning and Evaluation, 1900 E Street NW, Washington,
DC 20415. 5
5 Page 6 7
2002 Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc. 6 Introduction/ Plain Language/ Advisory
Inspector General Advisory
Stop health care fraud! Fraud
increases the cost of health care for everyone. If you suspect that a physician,
pharmacy, or hospital has charged you for services you did not receive,
billed you twice for the same service, or misrepresented any information, do
the following:
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 301/ 468-6000 inside the
Washington, DC metropolitan area or at 800/ 777-7902 outside the
Washington, DC metropolitan area, and explain the situation. Our TDD
telephone number is 301/ 816-6344.
If we do not resolve the issue, call or write
THE HEALTH CARE FRAUD
HOTLINE 202/ 418-3300
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. 6
6 Page 7 8
2002 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 7
Section 1
Section 1. Facts about this HMO plan
This Plan
is a health maintenance organization (HMO). We require you to see specific
physicians, hospitals and other
providers that contract with us. These Plan
providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care and immunizations, in
addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay the copayments and coinsurance described
in this brochure. When you receive emergency services or benefits from
non-Plan providers (while you travel) you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not
because a particular provider is available. You cannot change plans because a
provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract
with us.
How we pay providers
We pay the Mid-Atlantic Permanente Medical
Group, P. C., the Affiliated Primary Care Physician's Network (APCPN) located in
Baltimore, Maryland, APS Healthcare, Maryland Eye Care, Dental Benefit
Providers, and
contracted community specialists and ancillary providers to
provide your medical, surgical, mental health, substance abuse,
ophthalmological, optometry, and dental services. We contract with local
community hospitals to provide
hospitalization services. These Plan
providers accept a negotiated payment from us.
Your Rights
OPM requires that all FEHB plans provide certain
information to their FEHB members. You may
get information
about us, our networks, providers, and facilities. OPM's
FEHB website (www. opm. gov/ insure) lists the specific types of information
that we must make available to you. Some of the required information is listed
below.
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (Kaiser
Permanente), is a federally qualified Health Maintenance Organization.
This Plan is part of the Kaiser Permanente Medical Care Program, a group of
not-for-profit organizations and
contracting medical groups that serve over
8 million members nationwide.
Kaiser Permanente is a Maryland non-profit
corporation licensed in the Commonwealth of Virginia, the District of Columbia
and the state of Maryland.
Kaiser Permanente began delivering prepaid healthcare services to
Washington, DC residents in December 1972.
Kaiser Permanente presently
serves approximately 535,000 members in the Washington, DC and Baltimore,
Maryland metropolitan areas.
Kaiser Permanente credentials its Plan providers in accord with national
standards.
If you want more information, call us at 301/ 468-6000 inside the
Washington, DC metropolitan area or at 800/ 777-7902 outside the Washington, DC
metropolitan area. Our TDD telephone number is 301/ 816-6344. Write to us at
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., Attention:
Member Services Department, 2101 E.
Jefferson Street, Rockville, Maryland,
20852 or by fax at 301/ 816-6192. You may visit our website at http:// www.
kaiserpermanente. org or contact us by email at kponline. org. 7
7 Page 8 9
2002 Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc. 8 Section 1
Service Area
To
enroll in this Plan, you must live or work in our service area. This is where
our providers practice. Our service
area is:
The District of Columbia
The following Virginia counties:
Arlington
Fairfax
Loudoun
Prince William
The following Virginia cities:
Alexandria
Falls Church
Fairfax
Manassas
Manassas Park
The following Maryland counties:
Anne Arundel
Baltimore
Carroll
Harford
Howard
Montgomery
Prince Georges
Portions of the following Maryland counties, as indicated by the zip codes
below, are also within the service area:
Calvert – 20639, 20678, 20689,
20714, 20732, 20736, and 20754 zip codes only
Charles – 20601, 20602,
20603, 20604, 20612, 20616, 20617, 20637, 20640, 20643, 20646, 20658, 20675,
and 20695 zip codes only
Frederick – 21701, 21702, 21703, 21704,
21705, 21709, 21710, 21714, 21716, 21717, 21718, 21754, 21755, 21758, 21759,
21762, 21769, 21770, 21771, 21774, 21775, 21777, 21790, 21792, and 21793 zip
codes only
Baltimore City, MD
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 46;
and for emergency care obtained from any non-Plan provider, as described on
page 37. 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 live out of the area (for
example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with
affiliates in other areas. If you or a family
member move, you do not have to wait until Open Season to change plans.
Contact your employing or retirement
office. 8
8
Page 9 10
2002
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 9 Section
2
Section 2. How we change for 2002
Do not rely on these
change descriptions; this page is not an official statement of benefits. For
that, go to Section 5
Benefits. Also, we edited and clarified language
throughout the brochure; any language change not shown here is a clarification
that does not change benefits.
Program-wide changes
We removed the requirement that services
must be needed to restore functional speech from the speech therapy benefit.
Changes to this Plan
Your share of the non-Postal premium will
increase by 1.2% for Self Only or 1.1% for Self and Family.
We now lower
or waive many copayments if you also enroll in our Medicare Managed Care Plan.
See page 65 for details.
We clarified the Preventive care, adult benefit by removing the entry for
blood lead level testing for adults because it is a test more typically done for
children.
All primary care visits up to the age of 5 years will be
provided at no charge. Previously, we waived our copay only up to age 3.
We provide chemotherapy and radiation therapy at $10 per office visit.
Previously, we did not charge a copay for these services.
You pay $100 per
admission for all inpatient services. Previously, we did not charge a copay for
inpatient services.
We cover hearing aids for children through age 17. We
pay up to $1400 per hearing aid for each hearing impaired ear every 36 months.
Previously, we did not cover hearing aids.
You pay 20% of our allowance
for covered prosthetic devices. Previously, we provided these for $10 per item.
You pay 20% of our allowance for covered durable medical equipment (DME).
Previously, we provided DME for no charge.
Insulin pumps and their supplies require a payment of 20% of our allowance.
Previously, we did not charge a copayment for insulin pumps or supplies.
We increased your copayment for emergency care in a hospital emergency room
within our service area from $35 to $50 per visit.
We increased your
copayment for emergency care in a hospital emergency room outside our service
area from $35 to $50 per visit.
The prescription drug copayment changes
from $7 to $10 for generic drugs or $20 for brand-name drugs when
you fill
the prescription at a Plan pharmacy. You pay $8 for generic drugs or $18 for
brand-name drugs when you fill the prescription through our mail order delivery
system.
You pay 25% of our allowance for amino acid modified products. Previously,
we provided amino acid modified
products for no charge.
If you have Medicare Part B benefits, we now require that you assign your
Medicare Part B benefits to the Plan to receive covered services.
We no longer limit total blood cholesterol tests to certain age groups.
(Section 5( a))
We now cover certain intestinal transplants. (Section 5(
b))
We changed the address for sending disputed claims to OPM. 9
9 Page 10 11
2002 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 10
Section 3
Section 3. How you get care
Identification cards
We will send you an identification (ID) card when you enroll. You should
carry your ID card with you at all times. You must show it
whenever you
receive services from a Plan provider, or fill a
prescription at a Plan
pharmacy. Until you receive your ID card, use your copy of the health benefits
election form, SF-2809, your health
benefits enrollment confirmation (for annuitants), or your Employee
Express confirmation letter.
If you do not receive your ID card within 30 days after we have
received
your enrollment from your payroll office, or if you need replacement cards, call
us at 301/ 468-6000 inside the Washington, DC
metropolitan area or at 800/ 777-7902 outside the Washington, DC
metropolitan area. Our TDD telephone number is 301/ 816-6344.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments or coinsurance, and you will not
have to file claims,
except for emergency, urgent care services outside our
service area, and for covered services while you travel.
Plan providers Our Plan providers are physicians and other health
care professionals in our service area that we contract with to provide covered
services to our
members. We contract with the Mid-Atlantic Permanente
Medical Group, P. C. and the Affiliated Primary Care Physician Network
(APCPN) to provide primary care services and some specialty services.
Mid-Atlantic Permanente Medical Group is a multi-specialty physician group
practice with over 28 years of experience in providing services to
members of our Plan. Specialists in most major specialties are available
as part of the medical teams for consultation and treatment. Medical care is
provided through physicians, nurse practitioners and other
skilled medical personnel working as medical teams at Kaiser
Permanente
facilities. We contract with APS Healthcare in Baltimore, Maryland to provide
mental health and substance abuse services to
members, and with Maryland Eye Care and Dental Benefit Providers to
provide optometry, optical, and dental services to our members.
The Mid-Atlantic Permanente Medical Group, P. C. also contracts with
other specialists who may see you after you obtain a referral from your Plan
physician. The Affiliated Primary Care Physician Network,
located in Baltimore, Maryland is a group of independent primary care
physicians the Plan has contracted with to provide primary care services to
members. If your primary care physician, in consultation with you,
determines that you need to see a specialist, he or she will refer you to
one of our specialists.
Our Provider Directory lists the Plan providers, with locations and
phone
numbers. Directories are updated twice a year and are available at the time of
enrollment. However, our online Provider Directory is
updated monthly. Our website address is
http:// www. kaiserpermanente. org.
Plan facilities Plan facilities are hospitals and other facilities
in our service area that we contract with to provide covered services to our
members. Our Plan
physicians provide your health care at 25 Kaiser
Foundation Health Plan Medical Centers conveniently located throughout the
Washington,
DC and Baltimore, Maryland metropolitan areas. We also contract
with 10
10 Page 11
12
2002 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 11
Section 3
local community hospitals, Centers of Excellence and other
facilities, where you may get service after you receive a referral from a Plan
physician.
You must receive your health services at Plan facilities,
except if you have an emergency. We offer health care services at our Plan
Medical
Centers, Affiliated Primary Care Physician Network medical offices,
community hospitals and other selected locations throughout the
Washington,
DC, and Baltimore, Maryland metropolitan areas.
If you are visiting another
Kaiser Permanente service area, you may receive health care services at those
Kaiser Permanente facilities.
Under the circumstances specified in this
brochure you may receive follow-up or continuing care while you travel anywhere.
Our Provider Directory lists the Plan facilities. Directories are updated
twice a year and are available at the time of enrollment. However, our
online Provider Directory is updated monthly. Our website address is
http:// www. kaiserpermanente. org.
What you must do to get covered care It depends on the type of care
you need. First, you and each family member must choose a primary care
physician. This decision is
important since your primary care physician
provides or arranges for most of your health care.
To choose a primary care physician you can either select one from our
Provider Directory, or you can call us at 301/ 468-6000 inside the
Washington, DC metropolitan area or at 800/ 777-7902 outside the
Washington, DC metropolitan area. Our TDD telephone number is 301/ 816-6344.
We are happy to assist you in selecting a primary care
physician.
Primary care We require you to choose a primary care physician when
you enroll. Your primary care physician can be an internal medicine physician, a
pediatrician, or a family practice physician. Your primary care physician
will provide most of your health care, or give you a referral to
see a
specialist.
If you want to change primary care physicians or if your primary
care physician leaves the Plan, call us. We will help you select a new one.
Specialty care Your primary care physician will refer you to a
specialist for needed care. When you receive a referral from your primary care
physician,
you must return to the primary care physician after the
consultation, unless your primary care physician authorized a certain number of
visits
without additional referrals. The primary care physician must provide
or authorize all follow-up care. Do not go to the specialist for return
visits unless your primary care physician gives you a referral.
However, you may see a gynecologist, an optometrist, or our mental
health
and substance abuse Plan providers without a referral.
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex,
or serious medical condition, your primary care physician
will work with the
specialist, in consultation with you, to develop a treatment plan that allows
you to see your specialist for a certain
number of visits without additional
referrals. Your primary care
physician will use our criteria when creating
your treatment plan. 11
11 Page
12 13
2002 Kaiser Foundation Health
Plan of the Mid-Atlantic States, Inc. 12 Section 3
If you are
seeing a specialist when you enroll in our Plan, talk to
your primary care
physician. Your primary care physician will decide what treatment you need. If
he or she decides to refer you
to a specialist, ask if you can see your current specialist. If your
current specialist does not participate with us, you must receive treatment
from a specialist who does. Generally, we will not pay
for you to see a specialist who does not participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call
your primary care physician, who will arrange for you to see
another
specialist. You may receive services from your current specialist until we can
make arrangements for you to see someone
else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
—terminate our contract with your specialist for other than cause; or
—drop out of the Federal Employees Health Benefits (FEHB) Program and you
enroll in another FEHB plan; or
—reduce our service area and you enroll in
another FEHB plan,
you may be able to continue seeing your specialist for up
to 90 days after you receive notice of the change. Contact us, or if we drop out
of the Program, contact your new plan.
If you are in the second or third
trimester of pregnancy, you can
continue to see your specialist until the
end of your postpartum care, even if it is beyond the 90 days.
Hospital care Your Plan primary care physician or specialist will
make necessary hospital arrangements and supervise your care. This includes
admission
to a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our
Member Services department immediately at 301/ 468-6000 inside
the
Washington, DC metropolitan area or at 800/ 777-7902 outside the Washington, DC
metropolitan area. Our TDD telephone number is
301/ 816-6344.
If you are
new to the FEHB Program, we will arrange for you to receive care. If you changed
from another FEHB plan to us, your former plan
will pay for the hospital
stay until:
You are discharged, not merely moved to an alternative care
center;
or
The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan,
whichever happens first.
These provisions apply only to the benefits of
the hospitalized person.
Circumstances beyond our control Under
certain extraordinary circumstances, such as natural disasters, we may have to
delay your services or we may be unable to provide them.
In that case, we
will make all reasonable efforts to provide you with the necessary care. 12
12 Page 13 14
2002 Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc. 13 Section 3
Services requiring our
prior approval Your primary care physician has authority to refer you for
most services. For certain services, however, your physician must obtain
approval from us. Before giving approval, we consider if the service is
covered, medically necessary, and follows generally accepted medical
practice.
We call this review and approval process precertification. Your physician
must obtain precertification for the following services:
Acupuncture
All inpatient services, except maternity
Adenoids or tonsil removal
Breast surgery not associated with cancer
Carpal tunnel surgery
Chiropractic services
Clinical trials
Durable medical equipment
Gastric bypass surgery
Home health care
Hospice care
Hysterectomy
Infertility treatment
Infusion therapy
Injectable
medications
MRI
Nasal surgery
Occupational therapy
Oral
surgery
Organ transplants
Pain clinics
Physical therapy
Pulmonary therapy
Prosthetics
Reconstructive surgery
Sclerotherapy for varicose veins
Speech therapy
Spinal surgery not
associated with cancer
Sleep studies
Surgical procedures
Temporomandibular Joint surgery
Tubes in the ears
Requests for these services are made to your primary care physician just like
any other referral. Your primary care physician submits the
request, with
supporting documentation. It takes an average of 2 working days to process the
request. You should call your primary care
physician's office if you have
not been notified of the outcome of the
review within 5 working days. If
your request is not approved, you have a right to appeal by calling inside the
Washington, DC
Metropolitan area at 301/ 468-6000 or toll free at 800/ 777-7902. Our
TDD
is 301/ 816-6344. If you wish additional services, you must make the request to
your primary care physician.
Emergency services do not require precertification. However, you or your
family member must notify the Plan within 48 hours, or as soon as
is
reasonably possible. 13
13 Page
14 15
2002 Kaiser Foundation Health
Plan of the Mid-Atlantic States, Inc. 14 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, facility,
pharmacy, etc.,
when you receive services. Example: When you see your primary care physician,
you pay a copayment of $10 per office visit.
Deductible We do not have a deductible.
NOTE: If you change
plans during open season, you do not have to start a
new deductible under
your old plan between January 1 and the effective date of your new plan. If you
change plans at another time during the year,
you must begin a new deductible under 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, ovulation stimulants, weight
management drugs, smoking cessation drugs, and oxygen and equipment for home use
after the first three months.
Fees when you fail to If you do not pay your copayment or
coinsurance at the time you receive make your copayment services, we will
bill you. You will be required to pay a $10 charge for
or coinsurance
each bill sent for unpaid services.
Your catastrophic protection After your copayments and coinsurance
total $1,500 per person or $3,000 out-of-pocket maximum for per family
enrollment in any calendar year, you do not have to pay any
copayments
and coinsurance more for covered services. However, copayments for the
following services do not count toward your out-of-pocket maximum, and you must
continue to pay copayments and coinsurance for these services:
Prescription drugs
Chiropractic and acupuncture services
Dental
services
Follow-up and continuing care outside the service area
Infertility services
Any non-FEHB benefits
Be sure to keep accurate records of your copayments and coinsurance since you
are responsible for informing us when you reach the maximum. 14
14 Page 15 16
2002 Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc. 15 Section 5
Section 5. Benefits –
OVERVIEW
(See page 9 for how our benefits changed this year and
page 74 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to the
benefits in the
following subsections. To obtain claim forms, claim filing
advice, or more information about our benefits, contact us at 301/ 468-6000
inside the Washington, DC metropolitan area or at 800/ 777-7902 outside the
Washington, DC
metropolitan area. Our TDD telephone number is 301/ 816-6344.
You can also visit our website at
www. kaiserpermanente. org.
(a) Medical services and supplies provided by physicians and other health
care professionals ............................... 16-27
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
Physical and occupational therapies
Speech
therapy
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
Chiropractic
Alternative treatments
Educational classes
and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ........................... 28-31
Surgical procedures
Reconstructive surgery
Oral and maxillofacial
surgery
Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance
services............................................................. 32-35
Inpatient hospital
Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice
care
Ambulance (d) Emergency services/ accidents
.....................................................................................................
36-37
Emergency within our service area
Emergency outside our service area
Ambulance
(e) Mental health and substance abuse benefits
................................................................................................................
38-40
(f) Prescription drug
benefits................................................................................................................................................
41-44
(g) Special features
.................................................................................................................................................................
45-47
Flexible benefits option
24 hour nurse line
Services for deaf and
hearing impaired
Centers of excellence for transplants
Travel benefit
Services
from other Kaiser Permanente Plans
(h) Dental
benefits...................................................................................................................................................................
48-56
(i) Non-FEHB benefits available to Plan members
................................................................................................................
57
Summary of benefits
......................................................................................................................................................................
74 15
15 Page 16
17
2002 Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc. 16 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.
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.
We have no calendar year deductible.
Note: We waive the $10 charge if you enroll in our Medicare+ Choice Plan
and assign your Medicare benefits to the Plan.
I M
P O
R T
A N
T
Benefit Description You Pay
Diagnostic and treatment services
Professional services of physicians and other health care professionals
In a physician's office
In an urgent care center
Second
surgical opinion
$10 per office visit
Nothing for children 59 months and younger
During a hospital stay
In a skilled nursing facility
Note: See
Section 5 (c) for facility charges.
Nothing
At home (in the service area) Nothing
Lab, X-ray, and other diagnostic
tests
Tests, such as:
Blood tests
Urinalysis
Nonroutine pap smears
Pathology
X-rays
Non-routine mammograms
CAT scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing 16
16 Page
17 18
2002 Kaiser Foundation Health
Plan of the Mid-Atlantic States, Inc. 17 Section 5( a)
Preventive care, adult You Pay
Routine screenings, such as:
Total blood cholesterol
Colorectal cancer screening, including
—Fecal occult blood test
—Sigmoidoscopy -every five years starting at
age 50
$10 per office visit
Bone mass measurement for prevention, diagnosis and treatment of
osteoporosis
Prostate Specific Antigen -one annually for men age 40 and older
Chlamydia screenings – women under age 20 who are sexually
active and women
over age 20 with multiple risk factors
Routine pap smear
Note: You should consult with your physician to
determine what is
appropriate for you.
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
Note: You
pay only one copayment if you receive your routine
screening or immunization
on the same day as your office visit.
Routine mammogram – Covered for women age 35 and older, as follows:
From age 35 to 39, one during this five-year period
From age 40 to
64, one every calendar year
At age 65 and older, one every two consecutive
calendar years
Nothing
Not covered:
Physical exams required for:
Obtaining or
continuing employment
Participating in employee programs
Insurance or licensing
Court ordered for parole or probation
Attending schools
Travel
Travel immunizations
All charges 17
17 Page 18 19
2002 Kaiser
Foundation Health Plan of the Mid-Atlantic States, Inc. 18 Section 5( a)
Preventive care, children You Pay
Childhood immunizations
recommended by the American Academy of Pediatrics
Examinations, such as:
—Eye exams to determine the need for vision
correction
—Ear exams to determine the need for hearing correction
Nothing for primary care office visits for infancy through age 4
$10 per
office visit from age 5 up to age 22
Not covered:
Physical exams required for:
Obtaining or
continuing employment
Participating in employee programs
Insurance or licensing
Court ordered for parole or probation
Attending schools
Travel
Travel immunizations
All charges
Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some
things to keep in mind:
You do not need to precertify your normal
delivery.
You may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a cesarean delivery. Your inpatient stay
will be extended if medically necessary.
We cover routine nursery care
of the newborn child during the
covered portion of the mother's maternity
stay. We cover other care of an infant who requires non-routine treatment only
if the infant is
covered under a Self and Family enrollment.
We pay hospitalization and
surgeon services (delivery) the same as
for illness and injury. See Hospital
benefits (Section 5c) and Surgery benefits (Section 5b).
$10 for the first office visit to confirm pregnancy
Nothing once
pregnancy is confirmed through the post-partum
office visit 18
18 Page 19 20
2002 Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc. 19 Section 5( a)
Not covered:
Routine sonograms to determine fetal age, size, or sex
All charges
Family planning You Pay
Family planning services, including
counseling
Voluntary sterilization
Information on birth control
Genetic counseling
Note: We cover surgically implanted contraceptives,
injectable contraceptive drugs, intrauterine devices (IUDs), and diaphragms
under
the prescription drug benefit.
$10 per office visit
Not covered:
Reversal of voluntary surgical sterilization
All charges
Infertility services
Diagnosis and treatment of involuntary
infertility
Artificial insemination
—intravaginal insemination (IVI)
—intra-cervical insemination (ICI)
—intrauterine insemination (IUI)
Fertility Drugs
Note: We cover injectable fertility drugs under the
prescription drug
benefit.
50% of our allowance
In vitro fertilization, if:
—your oocytes are fertilized with your
spouse's sperm; and
—you and your spouse have a history of infertility of at
least 2 years duration as a result of endometriosis, exposure in utero to
diethylstilbestrol, commonly known as DES, blockage of, or surgical removal
of, one or both fallopian tubes (lateral or
bilateral salpingectomy, or
abnormal male factors, including oligospermia, contributing to the infertility;
and
—you have been unable to become pregnant through a less costly infertility
treatment for which coverage is available under the
Plan
50% of our allowance; Plan pays up to $100,000 in a Member's lifetime 19
19 Page 20 21
2002 Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc. 20 Section 5( a)
Not covered:
These
exclusions apply to fertile as well as infertile individuals or couples:
Assisted reproductive technology (ART) procedures, such as:
—embryo transfer
—gamete intrafallopian transfer (GIFT)
—zygote intrafallopian transfer (ZIFT)
Donor semen and
donor eggs, including retrieval of eggs
Storage and freezing of
eggs
Note: Infertility services are not available when either member of the
family has been voluntarily surgically sterilized.
All charges
Allergy care You Pay
Testing and treatment
Allergy
injection
Note: Allergy serum is covered in full as a part of the $10
copayment per office visit.
$10 per office visit
Not covered:
Provocative food testing
Sublingual
allergy desensitization
All charges
Treatment therapies
Respiratory and inhalation therapy
Intravenous IV/ Infusion Therapy – Home IV and antibiotic therapy
Note: We
cover growth hormone therapy (GHT) under the prescription drug benefit.
Qualified medical clinical trials that provide treatment for
life-threatening
conditions or for preventive, early detection, or treatment
studies of cancer for Phases I, II, III and IV
Dialysis – Hemodialysis and peritoneal dialysis
Chemotherapy and
radiation therapy
Note: We limit high dose chemotherapy in association with autologous bone
marrow transplants to those transplants listed under Organ/ tissue
transplants.
$10 per office visit 20
20 Page 21 22
2002 Kaiser
Foundation Health Plan of the Mid-Atlantic States, Inc. 21 Section 5( a)
Not covered:
Long term rehabilitative therapy
Cognitive therapy
Chemotherapy supported by a bone marrow
transplant or with stem cell support, for any diagnosis not listed as covered
Sleep therapy
Thermography and related services
All charges
Physical and occupational therapies You Pay
Inpatient Services –
up to 2 consecutive months of therapy per condition:
Physical therapy by a qualified Plan therapist in consultation with a Plan
physician to restore bodily function when you have a total or
partial loss
of bodily function due to illness or injury
Occupational therapy by a Plan
therapist in consultation with a Plan
physician to assist you in achieving
and maintaining self-care and improved functioning in other activities of daily
life
We provide inpatient multidisciplinary rehabilitation in a prescribed,
organized program in a plan facility or skilled nursing facility for up to
two consecutive months for all covered rehabilitation services and supplies
you may receive at different sites for the same condition
Note: This $100 charge is waived if you have been admitted directly from a
hospital inpatient stay.
$100 per admission
Outpatient physical and occupational therapy
We cover up to 40 office
visits or 90 days (whichever is greater) per condition of out-patient physical
therapy services
We cover up to 90 days per condition of out-patient occupational therapy
services
Habilitative services for children – from birth to age 19 for the
treatment of congenital and generic birth defects
We cover services to
help a child function age-appropriately within his or her environment and
enhance his or her functional ability
without an effective cure
$10 per visit
Not covered:
Long-term rehabilitative therapy
Exercise programs
Cognitive rehabilitation programs
Vocational rehabilitation programs
Therapies done primarily for
education purposes, except as may otherwise be covered above
Cardiac rehabilitation
All charges 21
21 Page 22 23
2002 Kaiser
Foundation Health Plan of the Mid-Atlantic States, Inc. 22 Section 5( a)
Speech therapy You pay
Inpatient Services – up to 2
consecutive months of therapy per condition:
Speech therapy by a Plan therapist in consultation with a Plan physician
when medically necessary
Note: This $100 charge is waived if you have been
admitted directly from a hospital inpatient stay.
$100 per admission
We cover up to 90 days per condition of outpatient speech therapy $10 per
outpatient visit
Not covered:
Speech therapy that is not medically
necessary such as:
Therapy for educational placement or other
educational purposes
Training or therapy to improve articulation in
the absence of injury, illness, or medical condition affecting articulation
Therapy for tongue thrust in the absence of swallowing problems
Voice therapy for occupation or performing arts
All charges
Hearing services (testing, treatment, and supplies)
Hearing
tests to determine the need for hearing correction $10 per office visit
Hearing aids for children under age 18 All charges in excess of $1400 for each
hearing impaired ear every 36
months
Not covered:
Hearing aids, tests to determine their
effectiveness, and examinations for them for all persons age 18 and over
All other hearing testing
All charges
Vision services (testing, treatment, and supplies)
Eye exam to
determine the need for vision correction
Annual eye refractions
Diagnosis and treatment of diseases of the eye
$10 per office visit
Eyeglass frames purchased at Plan Optical Shops
Eyeglass lenses
purchased at Plan Optical Shops
75% of our allowance 22
22 Page 23 24
2002 Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc. 23 Section 5( a)
Initial fitting for
contact lenses at a Plan facility
Insertion and removal of contact lens
training
Three months of follow-up office visits
Note: These services
are provided only in conjunction with obtaining
your first set of contact
lenses at a Plan Optical Shop.
85% of our allowance
Not covered:
Eye exercises and orthoptics
Radial
keratotomy and other refractive surgery
Eye surgery solely for the
purpose of correcting refractive defects of the eye, such as near-sightedness
(myopia), far-sightedness
(hyperopia), and astigmatism
Cosmetic contact lenses
Cost of eyewear not purchased at Plan facilities
Sunglasses without corrective lenses
All charges
Foot care You Pay
Routine foot care when you are under active
treatment for a metabolic or peripheral vascular disease
Note: See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$10 per office visit
Not covered:
Cutting, trimming, or removal of corns,
calluses, or the free edge of
toenails, and similar routine treatment for
conditions of the foot, except as stated above
Treatment of weak, strained, or flat feet or bunions or spurs; and of
any instability, imbalance, or subluxation of the foot (unless the
treatment
is by open cutting surgery)
All charges
Orthopedic and prosthetic devices
Externally worn breast
prostheses and surgical bras including necessary replacements following a
mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implants
following
mastectomy. Note: See Section 5( b) for coverage of the
surgery to insert
the device.
20% of our allowance
One hair prosthesis if your hair loss results from chemotherapy or
radiation treatment for cancer All charges in excess of $350 23
23 Page 24 25
2002 Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc. 24 Section 5( a)
Not covered:
Comfort, convenience, or luxury equipment or features
External
prosthetics and orthotics, such as braces, foot orthotics, artificial limbs, and
lenses following cataract removal
Devices, equipment, supplies, and prosthetics related to sexual
dysfunction
Orthopedic and corrective shoes
Arch
supports
Foot orthotics
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic
stockings, support hose and other supportive devices
All charges
Durable medical equipment (DME) You Pay
We cover prescribed DME
for home use for up to three months following:
An authorized hospital admission
An authorized skilled nursing
facility admission
An authorized rehabilitation facility admission
An authorized outpatient surgical procedure
Covered items include:
Hospital beds
Wheelchairs
Canes
Walkers
Portable
commodes
Crutches
Bilirubin lights and apnea monitors for infants up
to age 3 for a period not to exceed 6 months
Insulin pumps and supplies
20% of our allowance
Oxygen and equipment for home use
Note: Your Plan physician must
recertify your medical need for oxygen and equipment every 30 days.
20% of
our allowance for the first
three months; 50% of our allowance for every 30
days thereafter 24
24 Page
25 26
2002 Kaiser Foundation Health
Plan of the Mid-Atlantic States, Inc. 25 Section 5( a)
Asthmatic equipment (spacers, peak-flow meters, and nebulizers) for adults and
children, when purchased at a Plan pharmacy.
Note: We decide whether to rent
or purchase the equipment, and we select the vendor. We will repair the
equipment without charge, unless
the repair is due to loss or misuse. You
must return the equipment to us
or pay us the fair market price of the
equipment when it is no longer prescribed.
Spacers: $5 per spacer
Peak-Flow Meters: $10 per meter
Nebulizers:
$30 per nebulizer
Not covered:
Oxygen tents
Motorized wheelchairs
Comfort, convenience, or luxury equipment or features
Exercise or hygiene equipment
Non-medical items such as sauna
baths or elevators
Modifications to your home or car
Devices for testing blood or other body substances (glucose test strips are
covered under your prescription drug benefits)
Electronic monitors of bodily functions, except apnea monitors and blood
glucose monitors
Disposable supplies
Replacement of
lost equipment
Repairs, adjustments, or replacements necessitated
by misuse
More than one piece of durable medical equipment serving
essentially the same function, except for replacements other than
those necessitated by misuse or loss
Devices, equipment,
supplies, and prosthetics for the treatment of sexual dysfunction disorders
External and internally implanted hearing aids for all persons age 18
and over
Experimental or research equipment
Dental
appliances
All charges
Home health services You Pay
If you are homebound and reside in
the service area, we cover home
health care ordered by a Plan physician and
provided by a registered nurse, licensed practical nurse, licensed vocational
nurse, physical
therapist, occupational therapist, speech and language pathologist, or home
health aide
Services include oxygen therapy, intravenous therapy, and medications
Note: Your Plan physician will periodically review the home health program
for continuing appropriateness and medical need.
Nothing 25
25 Page
26 27
2002 Kaiser Foundation Health
Plan of the Mid-Atlantic States, Inc. 26 Section 5( a)
Not covered:
Nursing care requested by, or for the convenience of, the patient
or the patient's family
Custodial care
Homemaker services
Services
outside the service area
Home care primarily for personal
assistance that does not include a
medical component and is not diagnostic,
therapeutic, or rehabilitative
General maintenance care of colostomy, ileostomy, and ureterostomy
Medical supplies or dressings applied by you or a family caregiver
Care that a Plan physician determines may be provided in a Plan
facility or skilled nursing facility if we provide or offer to provide
that care in one of those facilities
Transportation and
delivery service costs of durable medical
equipment, medications, drugs,
medical supplies, and supplements to the home
Personal care items
All charges
Chiropractic You Pay
Chiropractic services, including spinal
manipulation of the neck and back, up to 20 visits per calendar year, for the
following services:
Evaluation and management
Routine chiropractic x-rays provided in the
chiropractor's office
Chiropractic adjustments
Adjunctive therapies
(e. g., hot and cold packs)
Educational materials
Note: You receive
these services when your Plan physician, in consultation with the Complementary
and Alternative Medicine Department, determines
that such care will result in improvement in your condition.
$15 per office visit 26
26 Page 27 28
2002 Kaiser
Foundation Health Plan of the Mid-Atlantic States, Inc. 27 Section 5( a)
Not covered:
Structural supports
Nutritional
supplements
All charges
Alternative treatments You Pay
Acupuncture services up to 20
visits per calendar year, for the following services:
Evaluation and management
Note: You receive these services when your
Plan physician, in consultation with the Complementary and Alternative Medicine
Department, determines that such care will result in improvement in
your
condition.
$15 per office visit
Not covered:
Herbal and nutritional supplements
All
charges
Educational classes and programs
Health education for conditions
such as diabetes, post-coronary, and nutritional counseling $10 per office visit
General health education classes such as Lamaze, weight control,
smoking cessation, and stress management.
Nominal fees ranging from $10
to
$50 per class
Not covered:
Educational classes and programs not offered
through this Plan
All charges 27
27 Page 28 29
2002 Kaiser
Foundation Health Plan of the Mid-Atlantic States, Inc. 28 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 are payable only when we
determine they are medically
necessary.
Plan physicians must provide or arrange your care.
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.
We have no calendar year
deductible.
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.).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL
PROCEDURES.
Please refer to the precertification information shown in Section 3 to be sure
which services require precertification and identify which surgeries require
precertification.
I M
P O
R T
A N
T
Benefit Description You Pay
Surgical procedures
A
comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative
care by the surgeon
Pre-surgical testing
Correction of amblyopia and
strabismus
Endoscopy procedures
Biopsy procedures
Removal of
tumors and cysts
Correction of congenital anomalies (see reconstructive
surgery)
Surgical treatment of morbid obesity --a condition in which an
individual weighs 100 pounds or 100% over his or her normal weight according
to current underwriting standards; eligible members must be
age 18 or over
Insertion of internal prosthetic devices. See Section 5(
a) – Orthopedic
and prosthetic devices for device coverage information.
Voluntary sterilization (tubal ligation and vasectomy)
Treatment of
burns
Insertion of Norplant (a surgically implanted contraceptive) and
intrauterine devices (IUDs). Note: We cover the cost of these devices
under the prescription drug benefit.
Nothing for professional services,
$10 per office visit for outpatient
services, or
$100 per inpatient admission 28
28 Page 29 30
2002 Kaiser
Foundation Health Plan of the Mid-Atlantic States, Inc. 29 Section 5( b)
Not covered:
Reversal of voluntary sterilization
Routine foot care; see Foot care
All charges
Reconstructive surgery You Pay
Surgery to correct a functional
defect
Surgery to correct a condition caused by injury or illness if:
—it produced a major effect on the member's appearance; and
—the
condition can reasonably be expected to be corrected by such surgery.
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of congenital
anomalies are protruding ear deformities, cleft lip, cleft
palate, birth marks, web fingers, and toes.
All stages of breast
reconstruction surgery following a mastectomy, such as:
—surgery to produce a symmetrical appearance on the other breast;
—treatment of any physical complications, such as lymphedemas; and
—breast prostheses and surgical bras and replacements (see Prosthetic
devices).
Note: If you need a mastectomy, you may choose to have the
procedure performed on an inpatient basis and remain in the hospital up to 48
hours
after the procedure.
Nothing for professional services,
$10 per office visit for outpatient
services, or
$100 per inpatient admission
Not covered:
Cosmetic surgery – any surgical procedure (or
any portion of a procedure) performed primarily to improve physical appearance
and/ or treat a mental condition through change in bodily form
Surgeries related to sex transformation
All charges 29
29 Page 30 31
2002 Kaiser
Foundation Health Plan of the Mid-Atlantic States, Inc. 30 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
Nothing for professional services,
$10 per office visit for outpatient
services, or
$100 per inpatient admission
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
Organ/ tissue transplants
Limited to:
Cornea
Heart
Heart/ Lung
Kidney
Kidney/ Pancreas
Liver
Lung:
Single -Double
Pancreas
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral
stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia, advanced Hodgkin's
lymphoma,
advanced non-Hodgkin's lymphoma, advanced neuroblastoma, testicular,
mediastinal, retroperitoneal and ovarian
germ cell tumors, breast cancer, multiple myeloma and epithelial ovarian
cancer
Intestinal transplants (small intestine) and the small intestine with the
liver or small intestine with multiple organs such as the liver,
stomach,
and pancreas
Nothing for professional services,
$10 per office visit for outpatient
services, or
$100 per inpatient admission 30
30 Page 31 32
2002 Kaiser
Foundation Health Plan of the Mid-Atlantic States, Inc. 31 Section 5( b)
After referral to a transplant facility, the following apply: unless
otherwise authorized by your physician, transplants are covered only at
institutions that we designate as "Centers of Excellence" for that
specific transplant. If your physician or the transplant facility determines
that you do not satisfy the criteria for receiving the
transplant, we will pay only for the covered services and supplies you
receive before you are notified of that determination.
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 for a living donor when
those expenses are directly related to your covered
transplant.
Not covered:
Donor screening tests and donor search expenses,
except screening blood tests and advanced testing performed for the actual donor
Implants of non-human or artificial organs
Transplants not
listed as covered
All charges
Anesthesia You Pay
Professional services provided in:
Hospital (inpatient)
Hospital outpatient department
Ambulatory
surgical center
Office
Nothing 31
31 Page
32 33
2002 Kaiser Foundation Health
Plan of the Mid-Atlantic States, Inc. 32 Section 5( c)
Section
5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and
exclusions in this brochure and are payable only when we determine they
are medically necessary.
Plan physicians must provide or arrange your care and you must be
hospitalized
in a Plan facility.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The
amounts listed below are for the charges billed by the facility (i. e., hospital
or surgical center) or ambulance service for your surgery or care. Any costs
associated with the professional charge (i. e., physicians, etc.) are covered
in Sections 5( a) or (b).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL
STAYS (except
for Maternity stays). Please refer to Section 3 to be sure which services
require precertification.
I M
P O
R T
A N
T
Benefit Description You Pay
Inpatient hospital
Room and board,
such as:
Ward, semiprivate, or intensive care accommodations
General
nursing care
Medically necessary special duty nursing
Meals and
special diets
Note: If you want a private room when it is not medically
necessary, you pay the additional charge above the semiprivate room rate.
$100 per admission 32
32 Page 33 34
2002 Kaiser
Foundation Health Plan of the Mid-Atlantic States, Inc. 33 Section 5( c)
Other hospital services and supplies, such as:
Operating,
recovery, maternity, and other treatment rooms
Prescribed drugs and
medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood and blood products
Blood or blood plasma, if
donated or replaced
Dressings, splints, plaster casts, and sterile tray
services
Medical supplies and equipment, including oxygen
Anesthetics and anesthesia services
Take home items
Hospitalization
for inpatient foot treatment
Note: You may receive covered medical hospital
services for certain dental procedures if a Plan physician determines that you
need to be
hospitalized for reasons unrelated to the dental procedure. The conditions
for which we will provide hospitalization include hemophilia
and heart
disease. The need for anesthesia, by itself, is not such a
condition.
$100 per admission
Not covered:
Custodial care
Non-covered
facilities
Personal comfort items, such as telephone, television,
barber services, guest meals, and beds
Private nursing care
Whole blood and packed red blood cells
not replaced by member
Any inpatient dental procedures
All charges
Outpatient hospital or ambulatory surgical center You Pay
Operating, recovery, and other treatment rooms
Prescribed drugs and
medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood and blood products
Blood and blood plasma,
if donated or replaced
Pre-surgical testing
Dressings, casts, and
sterile tray services
Medical supplies, including oxygen
Anesthetics
and anesthesia service
$10 per outpatient surgery 33
33 Page 34 35
2002 Kaiser
Foundation Health Plan of the Mid-Atlantic States, Inc. 34 Section 5( c)
Not covered:
Whole blood and packed red blood cells not
replaced by the member
All charges
Extended care benefits/ skilled nursing care facility benefits You Pay
Up to 100 days per calendar year when full-time skilled nursing care is
necessary and confinement in a skilled nursing facility is medically
appropriate. We cover the following:
Physician and nursing services
Room and board
Medical social services
Administration of
blood, blood products, and derivatives
Durable medical equipment
ordinarily furnished by a skilled nursing facility, including oxygen-dispensing
equipment and oxygen
Respiratory therapy
Biological supplies
Medical supplies
Note: We waive the $100 charge if you are admitted to an extended care or
skilled nursing facility directly from a hospital inpatient stay.
$100 per admission
Not covered:
Custodial care
Care in an
intermediate facility
All charges 34
34 Page 35 36
2002 Kaiser
Foundation Health Plan of the Mid-Atlantic States, Inc. 35 Section 5( c)
Hospice care You Pay
Supportive and palliative care for a
terminally ill member
You must reside in the service area
Services
are provided in your home, or
Services are provided in a Plan approved
hospice facility
Services include inpatient care, outpatient care, and
family counseling. A Plan physician must certify that you have a terminal
illness, with a life
expectancy of approximately six months or less.
Note: Hospice is a
program for caring for the terminally ill that
emphasizes supportive
services, such as home care and pain control, rather than curative care of the
terminal illness. A person
who is terminally ill may elect to receive hospice benefits. These
palliative and supportive services include nursing care, medical social
services, physician services, and short-term inpatient care
for pain control and acute and chronic symptom management. We also provide
counseling and bereavement services for the
individual and family members,
and therapy for purposes of
symptom control to enable the person to continue
life with as little disruption as possible. If you make a hospice election, you
are not
entitled to receive other health care services that are related to the
terminal illness. If you have made a hospice election, you may revoke that
election at any time, and your standard health benefits
will be covered.
Nothing
Not covered
Independent nursing
Homemaker services
All charges
Ambulance
Local professional ambulance service when medically
appropriate Nothing 35
35 Page
36 37
2002 Kaiser Foundation Health
Plan of the Mid-Atlantic States, Inc. 36 Section 5( d)
Section
5 (d). Emergency services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure.
We have no calendar year deductible.
Be sure to read Section 4,
Your costs for covered services, for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.
I M
P O
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 emergency:
In a life
threatening emergency-call the local emergency system (e. g., the local 911
telephone system). When the
operator answers, stay on the phone and answer
all questions. If you are not sure whether you are experiencing a medical
emergency, please contact our Emergency Line at 800/ 677-1112.
Emergencies within our service area:
Emergency care is provided at
Plan Hospitals 24 hours a day, seven days a week.
If you think you have a medical emergency condition and you cannot safely go
to a Plan Hospital, call 911 or go to the nearest hospital. Be sure to tell the
emergency room personnel that you are a Plan member so they can notify the
Plan. You or a family member must notify us within 48 hours, or as soon as
is reasonably possible, by calling
703/ 359-7878 inside the Washington, DC
metropolitan area or toll free 800/ 777-7904. Our TDD is 800/ 700-4901.
If you need to be hospitalized, the Plan must be notified within 48 hours or
on the first working day following your admission, unless it was not reasonably
possible to notify us within that time. If you are hospitalized in non-Plan
facilities and Plan physicians believe care can be better provided in a Plan
Hospital, we will transfer you when medically feasible, with any ambulance
charges covered in full.
Benefits are available for care from non-Plan providers in a medical
emergency only if delay in reaching a Plan provider
would result in death,
disability or significant jeopardy to your condition.
Emergencies outside our service area:
Benefits are available for
any medically necessary health service that is immediately required because of
injury or
unforeseen illness.
If you need to be hospitalized, the Plan must be notified within 48 hours or
as soon as is reasonably possible. If a Plan
physician believes care can be
better provided in a Plan Hospital, we will transfer you when medically
feasible, with any ambulance charges covered in full.
You may obtain emergency and urgent care services from Kaiser Permanente
medical facilities and providers when you are in the service area of another
Kaiser Permanente plan. The facilities will be listed in the local telephone
book under Kaiser Permanente. These numbers are available 24 hours a day,
seven days a week. You may also
obtain information about the location of
facilities by calling the Membership Services department at 301/ 468-6000 inside
the Washington, DC metropolitan area or at 800/ 777-7902 outside the Washington,
DC metropolitan area.
Our TDD telephone number is 301/ 816-6344. 36
36
Page 37 38
2002
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 37 Section
5( d)
Benefit Description You Pay
Emergency within our service
area
Emergency care at a physician's office
Emergency care at a
Plan urgent care center
$10 per visit
Emergency care in a hospital emergency room
Note: Your hospital
emergency room visit copayment is waived if you are admitted to a Plan Hospital.
Your $100 inpatient copay will apply.
$50 per visit
Not covered:
Elective care or non-emergency care
All
charges
Emergency outside our service area
Emergency care at a
physician's office
Emergency care at an urgent care center
$10 per
visit
Emergency care in a Kaiser Foundation hospital in another Kaiser Foundation
Health Plan service area
Emergency care in a non-Plan hospital emergency
room
Note: We waive your hospital emergency room visit copayment if you
are admitted to a Plan Hospital. Your $100 inpatient copay will apply. See
the Travel Benefit for coverage of continuing or follow-up care.
$50 per visit
Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could
have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full-term delivery of
a baby outside the service area
All charges
Ambulance
Professional ambulance service, including air ambulance,
when approved by the Plan.
Note: See Section 5( c) for non-emergency ambulance service.
Nothing 37
37 Page 38 39
2002 Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc. 38 Section 5( e)
Section 5 (e).
Mental health and substance abuse benefits
I M
P O
R T
A N
T
When you get our approval for services and follow a treatment plan we
approve, cost-sharing and limitations for Plan mental health and substance abuse
benefits will be no greater than for
similar benefits for other illnesses
and conditions.
Here are some important things to keep in mind about
these benefits:
Please remember that all benefits are subject to the
definitions, limitations, and exclusions
in this brochure and are payable
only when we determine they are clinically appropriate to treat your condition.
Plan physicians must provide or arrange your care.
We have no
calendar year deductible.
Be sure to read Section 4, Your costs for
covered services, for valuable information about how cost sharing works.
Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You Pay
Mental health and substance abuse benefits
We cover all diagnostic and treatment services recommended by a Plan
provider and contained in a treatment plan. The treatment plan may
include
services, drugs, and supplies described elsewhere in this brochure.
Note: We cover the services only when we determine that the care is
clinically appropriate to treat your condition, and only when you receive
the care as part of a treatment plan developed by a Plan provider.
Note:
OPM will base its review of disputes about treatment plans on the
treatment
plan's clinical appropriateness. OPM will generally not order us to pay or
provide one clinically appropriate treatment in favor of
another.
Your cost sharing responsibilities are no
greater than for other
illnesses or conditions 38
38 Page 39 40
2002 Kaiser
Foundation Health Plan of the Mid-Atlantic States, Inc. 39 Section 5( e)
Mental health and substance abuse benefits You pay
Diagnosis
and treatment of psychiatric conditions, mental illness, or disorders of
children, adolescents, and adults. Outpatient services
include:
Diagnostic evaluation
Crisis intervention and stabilization for acute
episodes
Psychological testing necessary to determine the appropriate
psychiatric treatment
Outpatient psychiatric treatment (including individual and group therapy
visits)
Medication evaluation and management
Diagnosis and treatment of alcoholism and drug abuse. Services include:
Detoxification (medical management of withdrawal from the substance)
Treatment and counseling (including individual and group therapy visits) as
part of intensive outpatient programs
Intensive day treatment
Methadone treatment
Note: You may see a Plan provider for outpatient
treatment without a referral from your primary care physician.
Note: Your Plan provider will develop a treatment plan to assist you in
improving or maintaining your condition and functional level, or to
prevent
relapse and will determine which diagnostic and treatment services are
appropriate for you.
$10 per office visit
Inpatient psychiatric care
Inpatient detoxification
Acute
inpatient substance abuse rehabilitation
Note: All inpatient admissions
and hospital alternative services treatment programs require approval by a Plan
physician. Inpatient services will only
be part of a treatment plan when services cannot be provided safely on an
outpatient basis or in a less intensive setting than an acute care hospital.
$100 per admission
Hospital alternative services, such as partial hospitalization and
intensive
outpatient psychiatric treatment programs
$10 per visit or
$100 per
admission if your treatment is more than 24
hours 39
39 Page
40 41
2002 Kaiser Foundation Health
Plan of the Mid-Atlantic States, Inc. 40 Section 5( e)
Mental
health and substance abuse benefits You pay
Not covered:
Care that is not clinically appropriate for the treatment of your condition
Services we have not approved
Intelligence, IQ, aptitude
ability, learning disabilities, or interest testing not necessary to determine
the appropriate treatment of a psychiatric
condition
Evaluation or therapy on court order or as a
condition of parole or probation, or otherwise required by the criminal justice
system, unless
determined by a Plan physician to be medically necessary and appropriate
Services that are custodial in nature
Marital, family, or
educational services
Services rendered or billed by a school or a
member of its staff
Services provided under a federal, state, or
local government program
Psychoanalysis or psychotherapy credited
toward earning a degree or furtherance of education or training regardless of
diagnosis or
symptoms that may be present
All charges
Limitation We may limit your benefits if you do not obtain a treatment
plan. 40
40 Page
41 42
2002 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 41
Section 5( f)
Section 5 (f). Prescription drug benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and we cover them only when we
determine they
are clinically appropriate to treat your condition.
We
have no calendar year deductible.
Be sure to read Section 4, Your costs
for covered services, for valuable information about how cost sharing works.
Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
There are important features you should be aware of. These include:
Who can write your prescription. A Plan physician or licensed
contracted dentist must write the prescription.
Where you can obtain
them. You must fill the prescription at a Plan pharmacy, or by mail for a
maintenance
medication. We will pay for prescriptions written by a non-Plan
physician and filled at a non-Plan pharmacy only when the prescription was given
during a hospital emergency room visit or an urgent care visit outside the
service
area.
We use a formulary. Our drug formulary is a list of prescribed drugs
and accessories that have been approved by our Pharmacy and Therapeutics
Committee for our Members. Unless otherwise specified by your Plan physician
or dentist, generic drugs may be used to fill prescriptions.
Our
Pharmacy and Therapeutics Committee, which is comprised of Plan physicians, Plan
providers, and our
pharmacists, selects prescription drugs and accessories
for the drug formulary based on a number of factors, including safety and
effectiveness as determined from a review of medical literature and research. In
addition, the
Committee sets dispensing limitations in accord with therapeutic guidelines
based on the medical literature and
research. The Pharmacy and Therapeutics'
Committee meets periodically to consider adding and removing prescribed drugs
and accessories on the formulary.
If you request a non-formulary drug – when your physician feels there is an
acceptable formulary alternative – you will be responsible for the full cost of
that drug.
However, if your Plan physician believes that a non-formulary
drug best treats your medical condition; a formulary drug has been ineffective
in the treatment of your medical condition; or a formulary drug causes or is
reasonably expected to cause a harmful reaction, then an exception process
is available to your Plan physician. In
that case, your standard
prescription drug copayment would apply.
If you would like information about whether a particular drug or accessory is
included in our drug formulary,
please visit us on line at www. kaiserpermanente. org, or call
our Member Services Department at 301/ 468-6000 inside the Washington, DC
metropolitan area or at 800/ 777-7902 outside the Washington, DC
metropolitan area.
Our TDD telephone number is 301/ 816-6344.
These are the dispensing limitations. We provide up to a 60-day
supply based upon (a) the prescribed dosage,
(b) the standard manufacturers
package size, and (c) specified dispensing limits. Maintenance medications may
be obtained for up to a 90-day supply when ordered through our mail order
program. 41
41 Page
42 43
2002 Kaiser Foundation Health
Plan of the Mid-Atlantic States, Inc. 42 Section 5( f)
Why
use generic drugs? Kaiser Permanente providers have successfully included
the use of generic drugs as
part of patient care without compromising
quality. Generic drugs offer a safe and economic way to meet your medication
needs. They are less expensive than brand name drugs -therefore you may reduce
your out-of-pocket
costs by choosing to use a generic drug. Generic drugs must contain the same
active ingredients and be equivalent
in strength and dosage to the original
brand name product. The U. S. Food and Drug Administration and also Kaiser
Permanente set criteria for the use of generic drugs to ensure that they meet
the same standards of purity,
strength and quality as brand-name drugs. They are expected to have the same
therapeutic effect as the brand
name product.
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. To file a claim, you should contact the Plan's Member Services
Department at 301/ 468-6000 inside
the Washington, DC metropolitan area or at 800/ 777-7902 outside the
Washington, DC metropolitan area and
obtain a claim form. Our TDD inside the
Washington, DC metropolitan area is 301/ 816-6344. A claim for reimbursement
must be submitted to the Plan within 12 months after you purchased the
prescribed drugs.
Prescription drug benefits begin on the next page 42
42 Page 43 44
2002 Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc. 43 Section 5( f)
Benefit Description
You Pay
Covered medications and supplies
We cover the following
medications and supplies prescribed by a Plan physician and obtained from a Plan
pharmacy or through our mail order
program:
Drugs for which a
physician's prescription is required by law
Disposable needles and
syringes for the administration of covered medications
Contraceptive drugs
Intrauterine devices (IUDs) and diaphragms
Implanted time-released drugs and injectable contraceptives, including
—Norplant
—Depo Provera
Self-injectable drugs, other than
ovulation stimulants
Self-administered chemotherapeutic drugs and oral
chemotherapeutic agents
Growth hormone therapy (GHT) -for treatment of children with
growth
hormone deficiency
Note: Compounded preparations must contain at least one ingredient requiring
a prescription.
$10 per prescription or refill for generic drugs or $20 per
prescription
or refill for brand-name
drugs if you get your prescription filled at a Plan
medical center pharmacy
$8 per prescription or refill for generic drugs or $18 per
prescription
or refill for brand-name drugs if you get your prescription
filled through
our mail order
delivery system
Post-surgical immunosuppressant outpatient drugs required as a
result
of a covered transplant
Intravenous fluids and medications for home use
Clinically administered chemotherapy drugs
Nothing
Amino acid modified products used to treat congenital errors of amino acid
metabolism (PKU) 25% of our allowance
Diabetic supplies when purchased at a
Plan pharmacy
Insulin (up to six (6) vials)
Disposable needles and
syringes (up to 3 boxes)
$10 per prescription or refill for generic drugs or
$20 per
prescription or refill for brand-name drugs if you get your prescription
filled at a Plan medical center pharmacy
Glucose test strips (six (6) boxes of 50 count) $10
Glucose meter $10
per meter
Replacement batteries
Control solutions
Lancets
$5 per package
$8 per package
$8 per package 43
43 Page 44 45
2002 Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc. 44 Section 5( f)
Covered medications
and supplies You pay
Smoking cessation products are provided for one
course of therapy per calendar year, when:
—prescribed by Plan provider
—you are in a formal smoking cessation
program
Weight management drugs for morbid obesity
Drugs for covered
infertility treatments
Drugs for sexual dysfunction
Note: Drugs to
treat sexual dysfunction have dispensing limitations. Please contact the Plan
for details.
50% of our allowance
Not covered:
Drugs or supplies for cosmetic purposes
Vitamins and nutritional supplements that can be purchased without
a prescription
Nonprescription drugs
Prescription drugs for which there is
a nonprescription equivalent available
Drugs obtained at a non-Plan pharmacy except for emergencies inside and
outside the service area
Medical supplies such as dressings and
antiseptics
Drugs to enhance athletic performance
Drugs related to non-covered infertility services
Drugs for
non-covered services
Dental prescriptions other than those prescribed for pain relief or
antibiotics
Replacement prescriptions necessitated by theft, loss, or damage
All drugs and accessories for the sole purpose of foreign travel
All charges 44
44 Page 45 46
2002 Kaiser
Foundation Health Plan of the Mid-Atlantic States, Inc. 45 Section 5( g)
Section 5 (g). Special features
Feature Description
Flexible benefits option Under the flexible benefits option, we
determine the most effective way to provide services.
We may identify
medically appropriate alternatives to traditional care and coordinate other
benefits as a less costly alternative benefit.
Alternative benefits are subject to our ongoing review.
By approving
an alternative benefit, we cannot guarantee you will get it in the future.
The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.
Our decision
to offer or withdraw alternative benefits is not subject to OPM review under the
disputed claims process.
24 hour nurse line For any of your health concerns, 24 hours a day, 7
days a week, you may call 703/ 359/ 7878 inside the Washington, DC metropolitan
area or
800/ 777-7904 outside the Washington, DC metropolitan area or call
our TDD at 703/ 359-7616 or 800/ 700-4901 and talk with a registered nurse
who will discuss treatment options and answer your health questions.
Services for deaf and hearing impaired For any of your health
concerns, 24 hours a day, 7 days a week, you may call 703/ 359-7616 inside the
Washington, DC metropolitan area or 800/ 700-4901 outside the Washington, DC
metropolitan area and talk with
a registered nurse who will discuss
treatment options and answer your health questions.
During regular business hours Monday through Friday, you may contact our
Member Services Department with any questions concerning the Plan and how to
obtain services by calling 301/ 816-6344.
Centers of excellence for transplants The Centers of Excellence
program began in Fall 1987. As new technologies proliferate and become the
standard of care, Kaiser Permanente refers members to contracted "centers of
excellence" for certain
specialized medical procedures.
We have
developed a national contract network of Centers of Excellence for organ
transplantation, which consists of medical facilities that have met
stringent criteria for quality care in specific procedures. A national
clinical
and administrative team has developed guidelines for site
selection, site visit protocol, volume and survival criteria for evaluation and
selection of
facilities. The institutions have a record of positive outcomes and
exceptional standards of quality. 45
45 Page 46 47
2002 Kaiser
Foundation Health Plan of the Mid-Atlantic States, Inc. 46 Section 5( g)
Travel benefit Kaiser Permanente's travel benefits for Federal
employees provide you with outpatient follow-up or continuing medical care when
you are outside your home service area by more than 100 miles or outside of
any other Kaiser Permanente service area. These benefits are in addition to
your emergency and urgent care benefits and include:
Outpatient follow-up care necessary to complete a course of treatment after
a covered emergency. Services include removal of stitches, a
catheter, or a
cast.
Outpatient continuing care for covered services for conditions
diagnosed
by a Kaiser Permanente health care provider or affiliated Plan
provider that have been treated within the previous 90 days. Services include
childhood immunizations, dialysis, or prescription drug monitoring.
You
pay $25 for each follow-up or continuing care office visit. This amount will be
deducted from the payment we make to you.
Your benefit is limited to $1200 each calendar year.
For more
information about this benefit call 800/ 390-3509.
File claims as shown on
page 59.
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 46
46 Page 47 48
2002 Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc. 47 Section 5( g)
Services from other
Kaiser Permanente
plans
When you are visiting in the service area of another Kaiser Permanente plan,
you are entitled to receive virtually all the benefits described in this
brochure at any Kaiser Permanente medical office or medical center. You
will have to pay the charges imposed by the Plan you are visiting. If the
Plan you are visiting has a benefit that is different from the benefits of this
Plan, you are not entitled to receive that benefit.
Some services covered by this Plan, such as artificial reproductive services
and the services of specialized rehabilitation facilities, will not be available
in other Kaiser Permanente service areas. If a benefit is limited to a
specific number of visits or days, you are entitled to receive only the
number of visits or days covered by the Plan in which you are enrolled.
If you are seeking routine, non-emergent, or non-urgent services, you
should call the Kaiser Permanente Membership Services Department in that
service area and request an appointment. You may obtain routine follow-up
or continuing care from these Plans, even when you have obtained the
original services in the service area of this Plan. If you require emergency
services as the result of unexpected or unforeseen illness that requires
immediate attention, you should go directly to the nearest Kaiser
Permanente facility to receive care.
At the time you register for services, you will be asked to pay the charges
required by the local Plan.
If you plan to travel to an area with another Kaiser Permanente plan, and
wish to obtain more information about the benefits available to you from
the
Kaiser Permanente plan, please call Membership Services at 301/ 468-
6000
inside the Washington, DC metropolitan area or at 800/ 777-7902 outside the
Washington, DC metropolitan area. Our TDD is 301/ 816-6344
inside the Washington, DC metropolitan area. 47
47
Page 48 49
2002
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 48 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 are payable only when we
determine they are medically necessary.
Plan dentists must provide or arrange your care.
We have no calendar
year deductible.
We cover hospitalization for dental procedures only when
a nondental physical impairment
exists which makes hospitalization necessary
to safeguard the health of the patient; we do not cover the dental procedure
except as described below.
Be sure to read Section 4, Your costs for covered services, for
valuable information about
how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
Dental Benefits You pay
Accidental injury benefit
We cover
restorative services and supplies necessary
to promptly repair (but not
replace) your sound natural teeth that you have injured as the result of an
external force (not chewing). A sound natural tooth is
one that has not
been weakened by existing dental pathology such as, decay or periodontal
disease, or
previously restored with a crown, inlay, onlay or
porcelain restoration,
or treatment by endodontics.
Note: You must start to receive services within 60 days of your accident and
complete them within 12
months of your accident. You are only covered for
the most cost effective procedure that will produce a
satisfactory result.
$10 per office visit, up to $2,000 per member per
accident
Not covered:
Injuries to non-sound natural teeth
Services required after the 12-month period
Services that are
needed, but did not start until later than 60 days after the accident
Services for teeth that have been so severely damaged that restoration
is impossible, in the
opinion of the Plan dental provider
Services for teeth that have been knocked-out
All charges 48
48 Page 49 50
2002 Kaiser
Foundation Health Plan of the Mid-Atlantic States, Inc. 49 Section 5( h)
Other dental benefits You pay
We cover general anesthesia and
associated hospital or ambulatory surgery facility charges in conjunction with
dental care provided by a fully accredited specialist in pediatric
dentistry, fully accredited specialist in oral and
maxillofacial surgery, or
a dentist for whom hospital privileges has been granted, for the following
members:
Children, 7 years of age or younger, who are developmentally disabled, for
whom a successful
result cannot be expected from dental care provided
under local anesthesia because of a physical, intellectual, or other
medically compromising
condition, for whom a superior result can be expected from dental care
provided under general anesthesia
Children, 17 years of age or younger, and extremely
uncooperative,
fearful, or uncommunicative with dental needs of such magnitude that treatment
should
not be delayed or deferred; and whom a lack of
treatment can be expected
to result in oral pain, infection, loss of teeth, or other increased oral or
dental morbidity
Adults, age 17 and older, whose medical condition
requires that dental service be performed in a hospital or ambulatory
surgical center for their
safety (e. g., heart disease and hemophilia)
$100 per inpatient admission
$10 per visit for outpatient services
Not covered:
The dentist's or specialist's professional
services
Dental care for temporal mandibular joint (TMJ) disorders
All charges 49
49 Page 50 51
2002 Kaiser
Foundation Health Plan of the Mid-Atlantic States, Inc. 50 Section 5( h)
Discounted Fee -Dental Benefits
Kaiser Permanente has entered
into an Agreement with Dental Benefit Providers, Inc. (" DBP"), under which DBP
will provide or arrange for the administration of covered dental services to you
through Participating Dental Providers.
All procedures listed in the following schedule of dental services and fees
are covered dental services. When you
receive any of the listed procedures
from a Participating Dental Provider, you will pay the fee listed next to the
procedure description for that service. The Participating Dental Provider has
agreed to accept that fee as payment in
full for that procedure. Neither Kaiser Permanente nor DBP are liable for
payment of these fees or for any fees incurred as the result of receipt of
non-covered dental services.
You will pay a fixed rate of $30 per office visit for procedures with an
"FC30" fee indication in the schedule below. We waive the $5 sterilization fee
for any office visit in which FC30 applies. "NB" indicates there is no benefit
available and you must pay the full cost of these services.
You may
select a Participating Dental Provider, who is a "general dentist," from whom
you will receive covered dental services. With a large network of general
dentists in our service area, you may select a general dentist from our
Dental Provider Directory for yourself and your family. You can obtain a
Dental Provider Directory by calling our Member Services Department at 301/
468-6000 inside the Washington, DC metropolitan area or at 800/ 777-7902
outside the Washington, DC metropolitan area. Our TDD is 301/ 816-6344.
Specialty care is also available should further covered services be
necessary; however, you must be referred to a
Participating Dental Provider
who is a specialist by your general dentist. Your discounted fees are slightly
higher for care received by a Participating Dental Provider who is a specialist.
Please refer to the following schedule of dental
services and fees for those discounted fees.
When a dental emergency
occurs outside our service area, Kaiser Permanente will reimburse you for the
reasonable
charges, less any discounted fee, upon proof of payment, not to
exceed $50 per incident. We cover emergency dental treatment required to
alleviate pain, bleeding, or swelling. If post-emergency care is required, you
must receive all
post-emergency care from your Participating Dental Provider.
The schedule for dental services and fees are:
Dental Benefits You Pay
ADA
CODE PROCEDURE NAME
TO
DENTIST
TO
SPECIALIST
Diagnostic Services
00120 Periodic Oral Exam (every 6 months) FC30
NB
00140 Ltd Oral Evaluation – Problem Focused FC30 NB
00150
Comprehensive Oral Examination FC30 NB
00210 Intraoral-Complete Series
Including Bitewings 34 37
00220 Intraoral-Periapical-First Film FC30 9
00230 Intraoral-Periapical-Each Additional Film FC30 9
00240 Intraoral
Occlusal Film FC30 9
00270 Bitewing-Single Film FC30 9
00272
Bitewing-Two Films FC30 9
00273 Bitewing – Three Films FC30 16
00274
Bitewing – Four Films FC30 25
00330 Panoramic Film 28 31
00460 Pulp
Vitality Tests FC30 16
00470 Diagnostic Casts FC30 NB
Preventive
Services
01110 Prophylaxis Adults (Every six months) FC30 NB
01120
Prophylaxis Child (Every six months) FC30 NB
01201 Topical Fluoride Incl
Proph <16 yrs every 6 mos FC30 NB
01203 Topical Fluoride Excl Proph
<16 yrs every 6 mos FC30 NB 50
50 Page 51 52
2002 Kaiser
Foundation Health Plan of the Mid-Atlantic States, Inc. 51 Section 5( h)
Dental Benefits You Pay
ADA CODE PROCEDURE NAME TO DENTIST TO
SPECIALIST
01330 Oral Hygiene Instruction FC30 NB
01351 Sealant –Per Tooth – To age
16 17 NB
01510 Space Maintainer – Fixed Unilateral 184 NB
01515 Space
Maintainer – Fixed Bilateral 184 NB
01520 Space Maintainer – Removable
Unilateral 226 NB
01525 Space Maintainer – Removable Bilateral 141 NB
01550 Recementation of Space Maintainer 21 NB
Restorative Services
02110 Amalgam – One Surface Primary 27 NB
02120 Amalgam – Two
Surfaces Primary 35 NB
02130 Amalgam – Three Surfaces Primary 39 NB
02131 Amalgam – Four or More Surfaces Primary 50 NB
02140 Amalgam – One
Surface Permanent 30 NB
02150 Amalgam – Two Surfaces Permanent 41 NB
02160 Amalgam – Three Surface Permanent 51 NB
02161 Amalgam – Four or
More Surfaces Permanent 60 NB
02330 Resin – One Surface Anterior 37 NB
02331 Resin – Two Surfaces Anterior 51 NB
02332 Resin –Three Surfaces
Anterior 52 NB
02335 Resin >3 Sur or Inv Incisal Angle Ant 66 NB
02385 Resin -One Surface, Posterior Permanent 35 NB
02386 Resin -Two
Surfaces, Posterior Permanent 56 NB
02387 Resin -3 or More Surfaces,
Posterior Permanent 70 NB
02510 Inlay-Metallic-One Surface 307 NB
02520
Inlay-Metallic-Two Surfaces 334 NB
02530 Inlay-Metallic-Three Surfaces 371
NB
02540 Onlay-Metallic-Per T In Add to Inlay 408 NB
02610
Inlay-Porcelain/ Ceramic-One Surface 498 NB
02620 Inlay-Porcelain/ Ceramic –
Two Surfaces 498 NB
02630 Inlay-Porcelain/ Ceramic – Three Surfaces 498 NB
02640 Onlay-Porc/ Ceramic-Per Tooth + Inlay 498 NB
02650 Inlay-Compos/
Resin-1 Surf (Lab Proc) 498 NB
02651 Inlay-Compos/ Resin-2 Surf (Lab Proc)
498 NB
02652 Inlay-Compos/ Resin-3 or More Surf (Lab) 498 NB
02710
Crown-Resin-Laboratory 235 NB
02740 Crown-Porcelain/ Ceramic Substrate 526
NB
02750 Crown-Porcelain Fused to Hi Noble Metal 531 NB
02751
Crown-Porcelain Fused to Predom Base Mental 472 NB
02752 Crown-Porcelain
Fused to Noble Metal 502 NB
02790 Crown-Full Cast High Noble Metal 510 NB
02791 Crown-Full Cast Predom Base Metal 442 NB
02792 Crown-Full Cast
Noble Metal 465 NB
02810 Crown-3/ 4 Cast Metallic 521 NB
02910 Recement
Inlay 34 NB
02920 Recement Crown 34 NB
02930 Prefab Stainl Stl
Crown-Prim Tooth 101 NB
02931 Prefab Stainl Stl Crown-Perm Tooth 106 NB
02932 Prefabricated Resin Crown 157 NB
02940 Sedative Fillings 34 NB
02950 Crown Buildup (Substructure) w/ pins 101 NB
02951 Pin Reten-Per
Tooth in Add to Rest 22 NB
02952 Cast Post & Core In Add to Crown 146 NB
02954 Prefab Post & Core in Add to Crown 129 NB 51
51 Page 52 53
2002 Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc. 52 Section 5( h)
Dental Benefits You
Pay
ADA CODE PROCEDURE NAME TO DENTIST TO SPECIALIST
02970 Temporary Crown (Fractured Tooth) 84 NB
02980 Crown Repair 84 NB
Endodontic Services
03110 Pulp Cap-Direct Excl Final Rest 22 NB
03120 Pulp Cap-Indirect Excl Final Rest 22 NB
03220 Therapeutic
Pulpotomy Exc Fin Rest 62 67
03310 RC Ther – Ant Exc Final Restoration 253
319
03320 RC Ther-Bicuspid Exc Final Restoration 294 496
03330 RC Ther –
Molar Exc Final Restoration 313 614
03346 Retreatment of Prev RC Ther
-Anterior NB 378
03347 Retreatment of Prev RC Ther -Bicuspid NB 584
03348 Retreatment of Prev RC Ther -Molar NB 732
03350 Apexification/
Recalc Per Trmt Visit 118 164
03410 Apicoectomy/ Periradicular Surg-Ant 148
381
03421 Apico/ perirad Surg-Bicus First Root 148 465
03425 Apico/
Perirad Srg-Molar First Root 148 487
03426 Apico/ Perirad Srg-Molar Ea Add
Root 49 185
06430 Retrograde Filling Per Root 104 196
03450 Root
Amputation-Per Root 104 252
03920 Hemisect W Rt Rem-Wo Root Canal Therapy
125 224
Periodontic Services
04210 Gingivectomy/
Gingivoplasty-Per Quad 222 297
04211 Gingivectomy/ Gingivoplasty-Per Tooth
59 90
04220 Ging Curettage Surg/ Quad-By Report 67 140
04240 Gingival
Flap Incl Rt Health Plan-Per Quad 222 381
04249 Crn Lengthn-Hard/ Soft
Tissue by Rep 260 358
04250 Muco-Gingival Surgery-Per Qdrant 260 370
04260 Oss Surg Inc Flap Ent, Grafts & Clos 371 661
04261 Osseous
Graft 185 330
04262 Osseous Graft Multiple 185 330
04268 Guid Tis Rgen
Inc Sur Re-Ent by Rep 358 358
04270 Pedicle Soft Tissue Graft Procedure 178
420
04271 Free Soft Tissue Graft & Donor Site 260 510
04320
Provisional Splinting – Intracoronal 106 130
04321 Provisional Splinting –
Extracoronal 74 134
04341 Perio Scaling/ Root Health Planing-Per Quad 71 140
04355 FM Debridmt before Comp Trmt 67 140
04910 Perio Maint After Active
Ther 45 67
Prosthetics -Removable
05110 Complete Denture – Upper
525 NB
05120 Complete Denture – Lower 525 NB
05130 Immediate Denture –
Upper 525 NB
05140 Immediate Denture – Lower 525 NB
05211 Upper Part
Dent-Resin Base Incl Clsp 381 NB
05212 Lower Part Dent-Resin Base Incl Clsp
470 NB
05213 Up Part Dent-Met Base, Res SDL Incl Clsp 567 NB
05214 Lo
Part Dent-Met Base, Res SDL Incl Clsp 567 NB
05281 Uni Part Dent-Met Base,
Cast Clsp 269 NB
05410 Adjust Dent-Comp or Part, Upr or Lwr 73 NB
05510
Repair Broken Complete Denture Base 56 NB
05520 Repl Miss/ Brkn T-Compl
Den-Ea T 45 NB
05610 Repair Acrylic Saddle or Base 56 NB
05620 Repair
Cast Framework 62 NB 52
52 Page
53 54
2002 Kaiser Foundation Health
Plan of the Mid-Atlantic States, Inc. 53 Section 5( h)
Dental
Benefits You Pay
ADA CODE PROCEDURE NAME TO DENTIST TO SPECIALIST
05630 Repair or Replace Broken Clasp 50 NB
05640 Replace Broken Teeth-Per
Tooth 50 NB
05650 Add Tooth to Existing Part Denture 73 NB
05660 Add
Clasp to Existing Part Denture 101 NB
05710 Rebase Dnt-Comp or Par, Upr or
Lower 196 NB
05730 Reline Dnt-Comp or Part, Chair 134 NB
05750 Reline
Dent-Comp or Part, Lab 148 NB
05820 Temp Part Stayplate-Upper or Lower 207
NB
05850 Tissue Conditioning Upper – Denture 50 NB
05851 Tissue
Conditioning Lower –Denture 56 NB
Prosthetics -Fixed
06210
Pontic-Cast High Noble Metal 525 NB
06211 Pontic-Cast Predom Base Metal 484
NB
06212 Pontic-Cast Noble Metal 459 NB
06240 Pontic-Porc Fused to Hi
Noble Metal 493 NB
06241 Pontic-Porc Fused to Predom Base Metal 431 NB
06242 Pontic-Porc Fused to Noble Metal 465 NB
06520 Inlay-Metallic-Two
Surfaces 353 NB
06530 Inlay-Metallic – 3 or More Surfaces 392 NB
06540
Only – Metallic Per Tooth + Inlay 431 NB
06545 Rtain-Cast Mtl For Acide Etch
Brdg 224 NB
06750 Crown-Porc Fused to Hi Noble Metal 504 NB
06751
Crown-Porc Fused to Predom Bse Metal 420 NB
06752 Crown-Porc Fused to Nobel
Metal 454 NB
06780 Crown-3/ 4 Cast High Noble Metal 476 NB
06790
Crown-Full Cast High Noble Metal 537 NB
06791 Crown-Full Cast Predom Base
Metal 478 NB
06792 Crown-Full Cast Noble Metal0 465 NB
06930 Recement
Bridge 39 NB
Oral Surgery
07110 Single Tooth 47 53
07120 Each Additional Tooth 41 47
07130 Root
Removal – Exposed Roots 28 39
07210 Surgical Removal of Erupted Tooth 59 106
07220 Rem Impacted Tooth-Soft Tissue 52 129
07230 Rem Impacted
Tooth-Part Bony 67 162
07240 Rem Impacted Tooth – Compl Bony 111 190
07250 Surg Rem Resid T Roots-Cutting Proc 59 106
07260 Oroantral Fistula
Closure 170 213
07270 Tooth Reimplantation 104 241
07280 Surg Expos Imp/
Unerup T-Ortho 125 207
07281 Surg Expos Imp/ Unerup T-Aid Erup 88 168
07285 Biopsy of Oral Tissue-Hard** 74 129
07286 Biopsy of Oral
Tissue-Soft** 74 112
07291 Transseptal Fiberotomy 34 34
07310 Alveolopl
In Conj w Extrac-Per Quad 59 118
07320 Alveolopl No Extract-Per Quad 74 134
07410 Rad Exc-Lesion to 1.25cm** 88 168
07420 Rad Exc-Lesion over
1.25cm** 141 286
07430 Exc Benign Tumor-Lesion to 1.25cm** 111 179
07431
Exc Benign Tumor-Lesion over 1.25cm** 140 281
07450 Rem Odont Cyc/ Tum-Les
to 1.25cm 105 170
07451 Rem Odont Cyst/ Tum-Les over 1.25cm 140 281 53
53 Page 54 55
2002 Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc. 54 Section 5( h)
Dental Benefits You
Pay
ADA CODE PROCEDURE NAME TO DENTIST TO SPECIALIST
07460 Rem NonOdont Cyst/ Tum-Les to 1.25cm 111 179
07461 Rem NonOdont
Cyst/ Tum-Les over 1.25cm 148 297
07470 Rem Exostosis-Maxilla or Mandible
193 280
07480 Part Ostectomy Gutter or Sauceriz 281 281
07510 I& D
Abscess-Intraoral Soft Tissue 59 78
07520 I& D Abscess-Extraoral
Soft-Tissue 59 78
07530 Rem Foreign Body/ Skn/ Subcut Areo Tissue 120 179
07550 Sequestrectomy for Osteomyelitis 162 162
07910 Suture Simple
Wounds up to 5cm 39 39
07911 Suture of Complex Wounds up to 5cm 78 78
07960 Frenectomy Frenec/ Frenot-Sep Proc 91 196
07970 Exc of
Hyperplastic Tissue-Per Arch 56 148
07971 Excision of Periocoronal Gingiva
67 95
Additional Procedures
09110 Palliative Treatment 28 NB
09210 Local Anesthesia 0 NB
09220 General Anesthesia-First 30 Minutes 74
185
09221 General Anesthesia-Each Add'l 15 Minutes 37 123
09230
Analgesia (per 30 Minutes) 17 22
09240 IV Sedation (per hour) 111 179
09310 Consult (No Add'l Procs Indicated) 45 49
09910 Appl Of
Desensitizing Med 28 28
09940 Occlusal Guards by Report 162 269
09951
Occlusal Adjustment – Limited 37 57
09952 Occlusal Adjustment-Complete 148
244
09980 Sterilization Surcharge (per visit) 5 5
09990 After Hours
Surcharge 25 25
09999 Broken Appointment Fee – Per Hour 15 15
Orthodontics – Per Case
08070 Orthodontic – Fully Banded 2 Yr.
Case -Transitional NB 2375
08080 Orthodontic – Fully Banded 2 Yr. Case
-Adolescent NB 2375
Limitations to dental services:
Full mouth X-rays and
panoramic X-rays are covered once every thirty-six (36) months, except when
taken for diagnosis of third molars, cysts, or neoplasms
Full mouth debridement (ADA Code 4355) is limited to once every
thirty-six (36) months
Perio Maintenance After Active Therapy (ADA
Code 04910) is limited to twice within twelve (12) months after Osseous Surgery
Denture relines for complete or partial conventional dentures are
included in the denture fee for the six (6)
month period following
insertion. Thereafter relines are covered once every twelve (12) months.
Sealants (ADA Code 01351) are limited to the first and second permanent
molars. Additionally, coverage is limited to members under age 16.
Root canal retreatment within one (1) year following the initial therapy
is the responsibility of the original treating Participating Dental Provider
(ADA Codes 3346, 3347, 3348)
Orthodontics coverage is limited to
treatment for a handicapping malocclusion, which is defined as an
occlusion
causing difficulty in chewing, speech or overall dental functioning. Coverage is
limited to two (2) years of active treatment per eligibile member per lifetime.
Patients must be banded by age 19. If Dental
Plan pays for interceptive therapy, minor tooth movement or other
orthodontic treatment prior to fully banded care, the Dental Plan payment for
inceptive therapy, minor tooth movement or other orthodontic
treatment will
be deducted from dental Plan's payment for fully banded care. 54
54 Page 55 56
2002 Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc. 55 Section 5( h)
Root planing or
scaling (ADA Code 4341) is covered once every six (6) months per quadrant.
Periodontal surgery of any type, including gingivectomy,
gingivoplasty, gingival curettage, gingival flap procedure, mucogingival
surgery, osseous surgery, pedicle graft, or free tissue graft is covered once
every
thirty-six (36) months per quadrant.
Osseous grafts are
covered once every thirty-six (36) months per quadrant or surgical site.
Replacement of crowns, bridges and fixed or removable prosthetic
appliances inserted prior to Dental Plan coverage is not covered until twelve
(12) months of continuous Dental Plan coverage have been achieved. If
loss of a tooth requires the addition of a clasp, pontic, and/ or
abutment( s) within this twelve-(12) month period, the plan will cover only the
procedures associated with the addition.
Not covered:
Services of dentists or other practitioners of
healing arts not associated with Kaiser Permanente and DBP
except upon
referral arranged by a Participating Dental Provider and authorized by us, or
when required in a covered emergency. Such excluded services mean any kind of
dental care and anything prescribed in
connection therewith.
Hospitalization for any dental
procedure, except as may otherwise be covered by the Plan
Any
cosmetic, beautifying, or elective procedure
Any procedure not
performed in a dental office setting
Experimental procedures,
implantations, or pharmacological regiments
Services for injuries
or conditions which are covered under Workers' Compensation or Employer's
Liability laws; services which are provided without cost to the Member by any
municipality, county, or
other political subdivision. This exclusion does not apply to any services
that are covered by Medicaid.
Replacement of denture, bridgework,
and/ or dental appliances previously supplied under this benefit, due to loss or
theft, or for any reason within sixty (60) months of initial insertion
Services which, in the opinion of the attending Participating Dental
Provider, are not necessary for the
member's dental health
Dental services pertaining, or related, to the Temporomandibular Joint
(TMJ), except when those services are included on the attached dental fee
schedule and are performed by the member's Participating Dental
Provider in that provider's office
Charges for failure to
keep a scheduled dental appointment. The charges are listed in the attached
dental fee schedule, and are charged by the general dentist and/ or specialist,
for each missed hour appointment
without twenty-four (24) hours notice.
Services of
Pedodontists and/ or Prosthodontists
Charges for second opinions,
unless previously authorized by the Plan
Occlusal guards are
excluded for any purpose other than habitual grinding
Procedures
requiring fixed prosthodontic restoration, which are necessary for complete oral
rehabilitation or reconstruction
Procedures relating to the change and maintenance of vertical dimension
or the restoration of occlusion
Dental lab fees for excisions and
biopsies. Procedures requiring lab fees are shown with asterisks ("**").
Drugs obtainable with or without a prescription (see your
prescription drug benefit as described in Section 5( f) for coverage of dental
prescriptions)
The setting of fractures or dislocations (see your medical and surgical
benefits as described in Sections 5( a) and 5( b) for coverage of these
services)
Treatment of malignancies, cysts or neoplasm or
congenital malformations. (see your medical and surgical benefits as described
in Sections 5( a) and 5( b) for coverage of these services) 55
55 Page 56 57
2002 Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc. 56 Section 5( h)
Dental expenses
incurred in connection with any dental procedure started prior to member's
eligibility with
Dental Plan. Examples: orthodontic work in progress, teeth
prepared for crowns, root canal therapy in progress.
Clinical situations that can be effectively treated by a less costly,
clinically acceptable alternative procedure
will be assigned a benefit based
on the less costly procedure, in accordance with the "Standards of Care"
established by DBP for its participating providers.
Placement of dental implants, implant-supported abutments and
prostheses.
Billing for incision and drainage (ADA Code 7510) is
excluded if the involved abscessed tooth is removed on the same date of service.
Placement of fixed bridgework solely for the purpose of achieving
periodontal stability.
Procedures not shown on the dental service
and fees listing 56
56 Page
57 58
2002 Kaiser Foundation Health
Plan of the Mid-Atlantic States, Inc. 57 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.
Medicare Prepaid
Plan Enrollment We offer Medicare recipients the opportunity to enroll in
our Plan through Medicare. Annuitants and former spouses
with FEHB coverage and Medicare Parts A and B may elect to either drop their
FEHB coverage and enroll in a
Medicare prepaid plan or remain enrolled in
the FEHB Program and simultaneously enroll in the Medicare prepaid plan when one
is available in their area. If you choose to disenroll from the FEHB Program you
may then later re-enroll in
the FEHB Program.
Most federal annuitants have Medicare Part A (hospital coverage). Those
without Medicare Part A may join this Medicare prepaid plan after they have
elected to purchase Medicare Part A in addition to continuing to pay for their
Part B premium. Before you drop your FEHB coverage and apply for coverage in
the Medicare prepaid plan, please
contact us at the numbers listed below
based on your residence:
The District of Columbia and the following cities and counties in
Virginia: Alexandria, Arlington, Fairfax, Fairfax City, Falls Church,
Loudoun, Manassas, Manassas Park, and Prince William, please call 800/ 281-8797.
The following cities and counties in the State of Maryland:
Baltimore, Baltimore City, Howard and the
following zip codes within
Anne Arundel County: 20794, 21060, 21076, 21077, 21090, 21108, 21122, 21144,
21146, 21226 and 21240, please call 800/ 203-2808.
The following counties in the State of Maryland: Montgomery, Prince
George's, and the following zip codes
within Charles County: 20601, 20602,
20603, 20604, 20612, 20616, 20617, 20637, 20640, 20643, 20646, 20658, 20675, and
20695, please call 800/ 229-5591.
Expanded Dental Benefits We are pleased to offer you a new choice of
dental coverage to supplement what is currently available to you through
the
FEHB program. This dental program is designed to enhance the level of dental
benefits that you currently receive. Your basic discounted dental coverage
through the Plan is not affected by this enhanced product offering. This new
supplemental coverage is through Delta Dental, a national dental provider,
and is only available to members of Kaiser Permanente.
Dental Premier, a table of allowances program, allows you to choose any
licensed dentist; however, discounted
pricing is available only through
Delta's provider network. After you satisfy a deductible, Delta will pay a
predetermined amount toward each covered service. You will not need to satisfy a
deductible toward covered
preventive services you receive. Delta Premier offers a full range of covered
services: diagnostic, preventive,
restorative, endodontics, periodontics,
oral surgery, and both fixed and removable prosthodontics. Orthodontic coverage
is not available. Covered services will be phased in over a three (3) year
period.
Delta Premier is only available to you if you are enrolled in Kaiser
Permanente's Plan for the FEHB. You do not need
to purchase this program to
receive the basic dental coverage included in the Plan. Payments will be made
directly to Delta. Payroll deduction is not available for this program.
How to Enroll: An enrollment form for Delta Premier is included in your
Kaiser Permanente enrollment kit. If you
would wish more information on
Delta Premier, please call Delta Dental at 800/ 932-0783.
Monthly Premiums: Self $18.45
Self and One Party $33.45 Family $52.45 57
57
Page 58 59
2002
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 58 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. 58
58 Page 59 60
2002 Kaiser
Foundation Health Plan of the Mid-Atlantic States, Inc. 59 Section 7
Section 7. Filing a claim for covered services
When you see
Plan physicians, receive services at Plan hospitals and facilities, or fill your
prescription drugs at Plan
pharmacies, you will not have to file claims.
Just present your identification card and pay your copayment or coinsurance.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these
providers bill us directly. Check with
the provider. If you need to file the claim, here is the process:
Medical, hospital, and drug In most cases, providers and facilities
file claims for you. Physicians benefits must file on the form HCFA-1500,
Health Insurance Claim Form.
Facilities will file on the UB-92 form. For
claims questions and assistance, call us at 301/ 468-6000 inside the Washington,
DC
metropolitan area or at 800/ 777-7902 outside the Washington, DC
metropolitan area. Our TDD telephone number is 301/ 816-6344.
When you must file a claim – such as for out-of-area care – submit it on the
HCFA-1500 or a claim form that includes the information shown
below. Bills and receipts should be itemized and show:
Covered member's
name and ID number;
Name and address of the physician or facility that
provided the
service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of
each service or supply;
The charge for each service or supply;
A
copy of the explanation of benefits, payments, or denial from any primary payer
– such as the Medicare Summary Notice (MSN); and
Receipts, if you paid for your services.
Submit your claims to:
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.
Attention: Claims Department
P. O. Box 6233
Rockville, Maryland
20849-6233
Deadline for filing your claim Send us all of the documents for your
claim as soon as possible. You must submit the claim by December 31 of the year
after the year you
received the service, unless timely filing was prevented
by administrative operations of Government or legal incapacity, provided the
claim was
submitted as soon as reasonably possible.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 59
59 Page
60 61
2002 Kaiser Foundation Health
Plan of the Mid-Atlantic States, Inc. 60 Section 8
Section 8.
The disputed claims process
Follow this Federal Employees Health
Benefits Program disputed claims process if you disagree with our decision on
your claim or request for services, drugs, or supplies – including a request
for precertification:
Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a)
Write to us within 6 months from the date of our decision; and
(b) Send your
request to us at: Kaiser Foundation Health Plan of the Mid-Atlantic States,
Inc., 2101 East Jefferson Street, Rockville, MD 20852, Attn: Member Services
Appeals Unit; and
(c) Include a statement about why you believe our initial decision was wrong,
based on specific benefit provisions in this brochure; and
(d) Include
copies of documents that support your claim, such as physicians' letters,
operative reports,
bills, medical records, and explanation of benefits (EOB)
forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or (b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy of
our request – go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days. If we do
not receive the information within 60 days, we will decide within 30 days of the
date the
information was due. We will base our decision on the information
we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter
upholding our initial decision; or
120 days after you first wrote to us
--if we did not answer that request in some way within 30 days; or
120
days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630.
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. 60
60 Page 61 62
2002 Kaiser
Foundation Health Plan of the Mid-Atlantic States, Inc. 61 Section 8
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
include 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 or from the year in which you were denied
precertification or prior
approval. 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
Monday through Friday at
301/ 468-6000 inside the Washington, DC metropolitan area or 800/ 777-7902
outside the Washington, DC metropolitan area. Our TDD is 301/ 816-6344. Weekends
and holidays, please
call 703/ 359-7878 inside the Washington, DC metropolitan area or 800/
777-7904 outside the Washington, DC metropolitan area. Our weekend TDD numbers
are 703/ 359-7616 or toll free at 800/ 700-4901. We will
expedite our
review; or
(b) We denied your initial request for care or pre-authorization/
prior approval, then:
If we expedite our review and maintain our denial,
we will inform OPM so that they can give your
claim expedited treatment too,
or
You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755
between 8 a. m. and 5 p. m. eastern time. 61
61
Page 62 63
2002
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 62 Section
9
Section 9. Coordinating benefits with other coverage
When you
have other health You must tell us if you are covered or a family member is
covered under coverage another group health plan or have automobile
insurance that pays health
care expenses without regard to fault. This is
called "double coverage."
When you have double coverage, one plan is the
primary payer; it pays benefits first. The other plan pays a reduced benefit as
the secondary
payer. We, like other insurers, determine which coverage is
primary according to the National Association of Insurance Commissioners'
Guidelines.
When we are the primary payer, we will pay the benefits
described in this brochure.
When we are the secondary payer, we will determine our allowance. After the
primary plan pays, we will pay what is left of our allowance, up
to our
regular benefit. We will not pay more than our allowance. If we are the
secondary payer, and you received your services from Plan
providers, we may
bill the primary carrier.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under 65
years of age.
People with End-Stage Renal Disease (permanent kidney
failure
requiring dialysis or a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A. If you or your spouse worked for at least 10 years in
Medicare-covered
employment, you should be able to qualify for premium-free
Part A insurance. (Someone who was a Federal employee on January 1, 1983 or
since automatically qualifies.) Otherwise, if you are age 65
or older, you may be able to buy it. Contact 1-800-MEDICARE for
more
information.
Part B (Medical Insurance). Most people pay monthly for Part B.
Generally, Part B premiums are withheld from your monthly Social Security
check or your retirement check.
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 (Original
Medicare) is available everywhere (Part A or Part B) in the United
States. It is the way everyone used to get Medicare benefits
and is the way
most people get their Medicare Part A and Part B benefits now. You may go to any
doctor, specialist, or hospital that accepts
Medicare. The Original Medicare
Plan pays its share and you pay your
share. Some things are not covered
under Original Medicare, like prescription drugs. 62
62 Page 63 64
2002 Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc. 63 Section 9
When you are enrolled in
Original Medicare along with this Plan, 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.) 63
63 Page 64 65
2002 Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc. 64 Section 9
The following chart
illustrates whether the Original Medicare Plan or this Plan should be the
primary payer for you according to your employment status and other factors
determined by Medicare. It is critical that you tell us if you or
a covered
family member has Medicare coverage so we can administer these requirements
correctly.
Primary Payer Chart
Then the primary payer is… A. When either you --or
your covered spouse --are age 65 or over and …
Original Medicare This Plan
1) Are an active employee with the
Federal government (including when you or a family member are eligible for
Medicare solely
because of a disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government when…
a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB
(Ask your employing office
which of these applies to you.)
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C. (or if
your
covered spouse is this type of judge),
5) Are enrolled in Part B only,
regardless of your employment status, (for Part B
services)
(for other services)
6) Are a former Federal employee receiving Workers' Compensation and the
Office of Workers' Compensation Programs has determined
that you are unable
to return to duty,
(except for claims related to Workers'
Compensation)
B. When you --or a covered family member --have Medicare
based on end stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD,
2) Have completed the 30-month ESRD coordination period and are still
eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to
ESRD after Medicare became
primary for you under another provision,
C. When you or a covered family member have FEHB and…
1) Are eligible for Medicare based on disability, and
a) Are an
annuitant, or
b) Are an active employee, or
c) Are a former spouse of an annuitant,
or
d) Are a former spouse of an active employee 64
64 Page 65 66
2002 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 65
Section 9
Medicare managed care plan If you are eligible for
Medicare, you may choose to enroll in and get your
Medicare benefits from
another type of Medicare+ Choice plan --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 provide all the benefits that Original
Medicare covers. Some cover extras, like prescription drugs. To learn
more about enrolling in a Medicare managed care plan, contact Medicare at
1-800-MEDICARE (1-800-633-4227) or at www.
medicare. gov.
If you enroll in a Medicare+ Choice plan, the following options are available
to you:
This Plan and our Medicare managed care plan: You may enroll
in our Medicare managed care plan, known as Medicare+ Choice or Kaiser
Permanente Senior Advantage, and also remain enrolled in our FEHB
Plan.
In this case, we have lowered or waived some of our copayments and coinsurance
for your FEHB and Medicare coverage. If you would
like information about our Medicare+ Choice plan, please call 301/
468-
6000 or 800/ 777-7902. Your Kaiser Permanente Senior Advantage-FEHBP
benefits that we lowered or waived are:
Physician Office Visits (both preventive and non-preventive): $0
Dialysis: $0
Voluntary sterilizations and family planning:
$0
Rehabilitative and Other Therapies: $0; unlimited number of
visits
as medically necessary
Cardiac Rehabilitation: $0
Comprehensive Outpatient
Rehabilitation Facility Services: $0
DME: $0 for all
Medicare-approved DME
Chiropractic Services and Acupuncture beyond what
is covered by Medicare: $0 up to 20 visits per modality per calendar year
Extended Care (i. e., Skilled Nursing Facility): $0 up to 100 days
per benefit period
Urgent Care Services: $0
Outpatient Substance Abuse
Rehabilitation: $0
Outpatient Mental Health Services: $0
Vision Services: $0 for eye examinations and refractions; covered up to
the Medicare-allowable amount for glasses after cataract surgery;
25% discount on eyeglass lenses and frames; 15% discount on initial purchase
of contact lenses
Hearing exams: $0 for routine and Medicare-covered hearing tests
Podiatry (medically necessary): $0
Blood transfusions:
$0
Blood and blood components: $0 if the blood is replaced;
otherwise you must replace the first three (3) pints or pay non-replacement fees
for whole blood; $0 for all blood products, except for hemophiliac factors
that are covered under the Prescription Drug benefit
Health Education Classes: $10-$ 20 for health education classes
Emergency Care in a hospital emergency room: $35
This Plan and another plan's Medicare managed care plan: You may
enroll in another plan's Medicare managed care plan and also remain 65
65 Page 66 67
2002 Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc. 66 Section 9
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. If you enroll in
a Medicare managed care plan, tell us. We
will need to know whether you are in the Original Medicare Plan or in a Medicare
managed care
plan so we can correctly coordinate benefits with Medicare.
Suspended
FEHB coverage to enroll in 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.
If you do enroll in If you enroll in Medicare Part B, we require you
to assign your Medicare
Medicare Part B Part B benefits to the Plan
for its services.
If you do not enroll in If you do not have one or both Parts of
Medicare, you can still be
Medicare Part A or Part B covered under
the FEHB Program. We will not require you to enroll in Medicare Part B, and if
you cannot get premium-free Part A, we will not
ask you to enroll in it.
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 illness 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 care. 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 for injuries hospital care for injuries or illness caused
by another person, you must
reimburse us for any expenses we paid. However,
we will cover the cost of treatment that exceeds the amount you received in the
settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation
procedures. 66
66 Page
67 68
2002 Kaiser Foundation Health
Plan of the Mid-Atlantic States, Inc. 67 Section 10
Section
10. Definitions of terms we use in this brochure
Calendar year January 1
through December 31 of the same year. For new enrollees, the calendar year
begins on the effective date of their enrollment and ends on
December 31 of
the same year.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services.
Covered services Care we provide benefits for, as described in this
brochure.
Custodial care (1) Assistance with activities of daily
living, for example, walking, getting in and out of bed, dressing, feeding,
toileting, and taking
medicine. (2) Care that can be performed safely and
effectively by people who, in order to provide the care, do not require medical
licenses
or certificates or the presence of a supervising licensed nurse.
Deductible A deductible is a fixed amount of covered expenses you must
incur for certain covered services and supplies before we start paying benefits
for
those services.
Durable medical equipment Durable medical
equipment (DME) is equipment that is 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.
Experimental or investigational services A service, supply, item or
drug that: (1) has not been approved by the FDA; or
(2) is the subject of a
new drug or new device application on file with the
FDA; or (3) is available
as the result of a written protocol that evaluates the
service's safety, toxicity, or efficacy; or
(4) is subject to the
approval or review of an Institutional Review Board; or
(5) requires an informed consent that describes the service as
experimental or investigational.
Group health coverage Health care benefits that are available as a
result of your employment, or the employment of your spouse, and that are
offered by an employer or
through membership in an employee organization.
Health care coverage
may be insured or indemnity coverage, self-insured or
self-funded coverage, or coverage through health maintenance organizations or
other
managed care plans. Health care coverage purchased through
membership in
an organization is also "group health coverage." 67
67
Page 68 69
2002
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 68 Section
10
Medically necessary All benefits need to be medically
necessary in order for them to be covered benefits. Generally, if your Plan
physician provides the service
in accord with the terms of this brochure, it
will be considered medically
necessary. However, some services are reviewed
in advance of your receiving them to determine if they are medically necessary.
When we
review a service to determine if it is medically necessary, a Plan
physician will evaluate what would happen to you if you do not receive the
service. If not receiving the service would adversely affect your
health, it will be considered medically necessary. The services must be a
medically appropriate course of treatment for your condition. If they are
not medically necessary, we will not cover the services. In case of
emergency services, the services that you received will be evaluated to
determine if they were medically necessary.
Our allowance The amount we use to determine your coinsurance. When
you receive services or supplies from Plan providers, it is the amount that we
set for
the services or supplies if we were to charge for them. When you
receive services from non-Plan providers, we determine the amount that we
believe is usual and customary for the service or supply, and compare it to
the charges. Our allowance is based upon the reasonableness of the
charges.
If the charges exceed what we believe is reasonable, you may
be responsible
for the excess over our allowance in addition to your coinsurance.
Us/ We Us and we refer to Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc.
You You refers to the enrollee and each
covered family member. 68
68 Page 69 70
2002 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 69
Section 11
Section 11. FEHB facts
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. 69
69 Page
70 71
2002 Kaiser Foundation Health
Plan of the Mid-Atlantic States, Inc. 70 Section 11
When
benefits and The benefits in this brochure are effective on January 1. If
you joined premiums start this Plan during Open Season, your coverage
begins on the first day of
your first pay period that starts on or after
January 1. Annuitants'
coverage and premiums begin on January 1. If you
joined at any other time during the year, your employing office will tell you
the effective
date of coverage.
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.
Temporary continuation If you leave Federal service, or if you lose
coverage because you no of coverage (TCC) 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, if
you lose your job, if you are a covered
dependent child and you turn 22
or marry, etc. 70
70 Page 71 72
2002 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 71
Section 11
You may not elect TCC if you are fired from your Federal
job due to gross misconduct.
Enrolling in TCC. Get the RI 79-27,
which describes TCC, and the RI 70-5, the Guide to Federal Employees Health
Benefits Plans for
Temporary Continuation of Coverage and Former Spouse
Enrollees,
from your employing or retirement office or from www. opm. gov/ insure . It explains what
you have to do to enroll.
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 The Health Insurance Portability and
Accountability Act of 1996 Group Health Plan Coverage (HIPAA) is a
Federal law that offers limited Federal protections for health
coverage availability and continuity to people who lose employer group
coverage. If you leave the FEHB Program, we will give you a Certificate
of
Group Health Plan Coverage that indicates how long you have been enrolled with
us. You can use this certificate when getting health
insurance or other
health care coverage. Your new plan must reduce or
eliminate waiting
periods, limitations, or exclusions for health related conditions based on the
information in the certificate, as long as you
enroll within 63 days of losing coverage under this Plan. If you have
been enrolled with us for less than 12 months, but were previously enrolled
in other FEHB plans, you may also request a certificate from
those plans.
For more information, get OPM pamphlet RI 79-27, Temporary
Continuation of Coverage (TCC) under the FEHB Program. See also the
FEHB
website ( www. opm. gov/ insure/ health);
refer to the "TCC and HIPAA" frequently asked question. These
highlight HIPAA rules, such
as the requirement that Federal employees
must exhaust any TCC
eligibility as one condition for guaranteed access to
individual health coverage under HIPAA, and have information about Federal and
State
agencies you can contact for more information. 71
71 Page 72 73
2002 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 72
Long Term Care Insurance
Long Term Care Insurance Is Coming Later
in 2002!
The Office of Personnel Management (OPM) will sponsor a
high-quality long term care insurance program effective
in October 2002. As
part of its educational effort, OPM asks you to consider these questions:
What is long term care It's insurance to help pay for long term care
services you may need
(LTC) insurance? if you can't take care of
yourself because of an extended illness or injury, or an age-related disease
such as Alzheimer's.
LTC insurance can provide broad, flexible benefits for nursing home
care, care in an assisted living facility, care in your home, adult day
care, hospice care, and more. LTC insurance can supplement care
provided by family members, reducing the burden you place on them.
I'm healthy. I won't need Welcome to the club!
long term
care. Or, will I? 76% of Americans believe they will never need long term
care, but the
facts are that about half of them will. And it's not just the
old folks. About 40% of people needing long term care are under age 65. They
may need chronic care due to a serious accident, a stroke, or
developing
multiple sclerosis, etc.
W e hope you will never need long term care, but
everyone should have a plan just in case. Many people now consider long term
care insurance
to be vital to their financial and retirement planning.
Is long term
care expensive? Yes, it can be very expensive. A year in a nursing home
can exceed
$50,000. Home care for only three 8-hour shifts a week can exceed
$20,000 a year. And that's before inflation!
Long term care can easily exhaust your savings. Long term care
insurance can protect your savings.
But won't my FEHB plan, Not FEHB. Look at the " Not covered"
blocks in sections 5( a) and 5( c)
Medicare or Medicaid cover of
your FEHB brochure. Health plans don't cover custodial care or a my long term
care? stay in an assisted living facility or a continuing need for a home
health
aide to help you get in and out of bed and with other activities of daily
living. Limited stays in skilled nursing facilities can be covered in some
circumstances.
Medicare only covers skilled nursing home care (the highest level of
nursing care) after a hospitalization for those who are blind, age 65 or
older or fully disabled. It also has a 100 day limit.
Medicaid covers long term care for those who meet their state's
poverty
guidelines, but has restrictions on covered services and where they can be
received. Long term care insurance can provide choices of
care and preserve your independence.
When will I get more information Employees will get more information
from their agencies during the on how to apply for this new LTC open
enrollment period in the late summer/ early fall of 2002.
insurance
coverage? Retirees will receive information at home.
How can I find
out more about the Our toll-free teleservice center will begin in
mid-2002. In the
program NOW? meantime, you can learn more about the
program on our website at www. opm. gov/
insure/ ltc.
Many FEHB enrollees think that their health plan and/ or Medicare will
cover their long-term care needs. Unfortunately, they are WRONG!
How are YOU planning to pay for the future custodial or chronic care you may
need?
You should consider buying long-term care insurance. 72
72 Page 73 74
2002 Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc. 73 Index
Index
Do not rely
on this page; it is for your convenience and may not show all pages where the
terms appear.
Accidental injury 48 Allergy tests 20
Alternative
treatment 27 Ambulance 35
Anesthesia 31 Autologous bone marrow
transplant 20 Biopsies 55
Blood and blood plasma 33 Breast cancer
screening 17
Casts 33 Centers of excellence for
transplants 45
Changes for 2002 9
Chemotherapy 20 Chiropractic 26
Cholesterol tests 9
Coinsurance 14
Colorectal cancer screening 17 Congenital anomalies 28
Contraceptive devices and drugs 43 Coordination of benefits 62
Covered
providers 10
Crutches 24 Deaf and hearing impaired
service 45 Deductible 14
Dental care 48 Diagnostic services 50
Disputed claims review 60 Donor expenses (transplants) 31
Dressings 33
Durable medical equipment
(DME) 24 Educational classes and programs
27
Effective date of enrollment 67 Emergency 36
Experimental or
investigational 67 Eyeglasses 22
Family planning 19 Fecal occult
blood test 17
Flexible benefits options 45 General Exclusions 58
Hearing
services 22 Home health services 25
Hospice care 35 Hospital 12
Immunizations 17 Infertility 19
Inpatient Hospital Benefits 32
Insulin 24
Laboratory and pathological services 16
Magnetic Resonance
Imagings (MRIs) 13
Mail Order Prescription Drugs 43 Mammograms 16
Maternity Benefits 18 Medicaid 66
Medically necessary 67 Medicare 62
Mental Conditions/ Substance Abuse Benefits 38
Neurological
testing 30 Newborn care 18
Non-FEHB Benefits 57 Nurse 10
Licensed
Practical Nurse 25 Nurse Anesthetist 28
Nurse Practitioner 10 Registered
Nurse 45
Nursery charges 18 Obstetrical care 18
Occular Injury 23
Occupational therapy 21
Oral and maxillofacial surgery 30 Orthopedic devices
23
Ostomy and catheter supplies 26 Out-of-pocket expenses 42
Oxygen 24
Pap test 16
Physical examination 17
Physical therapy 21 Precertification 13
Preventive care, adult 17
Preventive care, children 18
Preventive services 50 Prior approval 13
Prostate cancer screening 17 Prosthetic devices 23
Psychotherapy 40
Radiation therapy 20
Renal dialysis 64 Room and board 32
Second surgical opinion 16 Services from other Kaiser
Permanente
Plans 47 Skilled nursing facility care 16
Smoking cessation 44 Speech
therapy 22
Splints 33 Sterilization procedures 28
Subrogation 66
Substance abuse 38
Surgery 28 Anesthesia 31
Oral 53 Outpatient 33
Reconstructive 13 Syringes 43
Temporary continuation of
coverage 70
Transplants 30 Travel benefit 46
Treatment therapies 20
Vision services 22
Well child care 7 Wheelchairs 24
Workers' compensation 66 X-rays 16
24 hour nurse line 45
73
73 Page 74 75
2002 Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc. 74 Summary
Summary of benefits for
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. – 2002
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 16
Services provided by a hospital:
Inpatient.......................................................................................................
Outpatient....................................................................................................
$100 per admission
$10 per visit
32
33
Emergency benefits:
In-area
.........................................................................................................
Out-of-area
.................................................................................................
$50 per visit
$50 per visit
37
37
Mental health and substance abuse treatment:
...................................... Regular cost sharing 38
Prescription
drugs...........................................................................................
$10 per prescription or refill for
generic drugs or $20 per prescription or
refill for brand-name
drugs if you get your
prescription filled at a Plan medical center
pharmacy
$8 per prescription or refill for
generic drugs or $18 per prescription
or refill for brand-name
drugs if you get your
prescription filled through our mail order delivery
system
41
Dental
Care...................................................................................................
Various copays based on procedure rendered 48
Vision
Care...................................................................................................
Refractions; $10 per office visit 22
Special features: Flexible benefits
option; 24 hour nurse line; Services for deaf and hearing impaired;
Centers
of excellence for transplants; Travel benefit; Services from other Kaiser
Permanente Plans.
45
Protection against catastrophic costs (your out-of-pocket maximum)
................................................................ Nothing
after $1,500/ Self Only or $3,000/ Family enrollment per
year
Some costs
do not count toward this protection
14 74
74 Page
75 76
2002 Kaiser Foundation Health
Plan of the Mid-Atlantic States, Inc. 75 Notes
Notes 75
75 Page 76
2002 Rate Information for
Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc.
Non-Postal rates apply to most non-Postal enrollees. If you are in a
special enrollment category, refer to the FEHB Guide for that category or
contact the agency that maintains
your health benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees
should refer to the FEHB Guide for United States Postal Service Employees, RI
70-2. Different postal
rates apply and special FEHB guides are published
for Postal Service Nurses, 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 who are not career postal employees.
Refer to the applicable FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your
Share
Self Only E31 $80.29 $26.76 $173.96 $57.98 $95.01 $12.04
Self and
Family E32 $198.32 $66.10 $429.68 $143.23 $234.67 $29.75 76