Pages 1--36 from 1003-0006-01Feds-EOC 2nd

Kaiser Foundation Health Plan Inc
California Division 2000

A Health Maintenance Organization
Serving Northern Southern California service area
Enrollment in this Plan is limited see page 6 for requirements changes
For benefits 5
in see page

Enrollment code
591 Self only
592 Self and family

Enrollment code This Plan has commendable accreditation
621 Self only from the NCQA See the 2000 Guide for more information on NCQA
622 Self and family

Visit the OPM website at http www opm gov insure
and
our national website at http www kaiserpermanente org

Authorized for distribution by the
UNITED STATES OFFICE OF
PERSONNEL MANAGEMENT
RETIREMENT AND INSURANCE SERVICE

RI 73 003 1
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Kaiser Foundation Health Plan Inc California Division 2000
Table of contents

Introduction 3
Plain language 3
How to use this brochure 4
Section 1 Health Maintenance Organizations 5
Section 2 How we change for 2000 5
Section 3 How to get benefits 6
Section 4 What to do if we deny your claim or request for service 10
Section 5 Benefits 12
Section 6 General exclusions Things we don't cover 25
Section 7 Limitations Rules that affect your benefits 25
Section 8 FEHB facts 27
Department of Defense FEHB Demonstration Project 30
Inspector General advisory Stop health care fraud 32
Summary of benefits Inside back cover
Premiums Back cover

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Kaiser Foundation Health Plan Inc California Division 2000
Introduction

Kaiser Foundation Health Plan Inc California Division
1950 Franklin Oakland CA 94612 Northern Division
393 East Walnut Street Pasadena CA 91188 Southern Division

This brochure describes the benefits you can receive from Kaiser Foundation Health Plan Inc California Division under its contract
CS 1044 with the Office of Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB
law This brochure is the official statement of benefits on which you can rely A person enrolled in this Plan is 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

OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on
page 5 Premiums are listed at the end of this brochure

Plain language
The President and Vice President are making the Government's communication more responsive accessible and understandable
to the public by requiring agencies to use plain language Health Plan representatives and Office of Personnel Management staff have
worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary
technical terms you and other personal pronouns active voice and short sentences

We refer to Kaiser Foundation Health Plan Inc California Division as this Plan throughout this brochure even though in other
legal documents you will see a plan referred to as a carrier

These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not rewritten the Benefits section of this brochure You will find new benefits language next year

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Kaiser Foundation Health Plan Inc California Division 2000
How to use this brochure

This brochure has eight sections Each section has important information you should read If you want to compare this Plan's
benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to
make comparisons easier

1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs
and how they work

2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision
not to pay for your claim or to deny your request for a service

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find
information about non FEHB benefits

6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB facts Read this for information about the Federal Employees Health Benefits FEHB Program

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Kaiser Foundation Health Plan Inc California Division 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and
other providers that contract with us These providers coordinate your health care services The care you receive includes preventive
care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury

When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay
copayments and coinsurance listed in this brochure When you receive emergency services or follow up or continuing care under
this Plan's travel benefit you may have to submit claim forms

You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change
plans because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available
and or remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of
treatment

Section 2 How we change for 2000
Programwide changes To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care office visits

This year you have a right to more information about this Plan care management our networks
facilities and providers

If you have a chronic or disabling condition and your provider leaves the Plan at our request
you may continue to see your specialist for up to 90 days If your provider leaves the Plan and
you are in the second or third trimester of pregnancy you may be able to continue seeing your
OB GYN until the end of your postpartum care You have similar rights if this Plan leaves the
FEHB Program See Section 3 How to get benefits for more information

You may review and obtain copies of your medical records on request If you want copies of your
medical records ask your health care provider for them You may ask that a physician amend a
record that is not accurate not relevant or incomplete If the physician does not amend your
record you may add a brief statement to it If they do not provide you with your records call us
and we will assist you

Changes to this Plan Your share of the non Postal premium for code 59 will increase by 8 for Self Only or 7.9 for Self and Family

Your share of the high option premium for code 62 will increase by 5.0 for Self Only or 5.0 for Self and Family
The copay for primary care office visits will increase from 5 to 10 See page 12
Blood glucose monitors for diabetics will be covered with a 5 copay per prescription See page 13

The copay for emergency services will increase from 25 to 35 per visit See page 17
Non medical residential substance abuse care services that provide counseling and support services will be covered at a charge of 100 per admission Previously this benefit was limited

to Southern California service area members See page 20
Disposable needles and syringes needed for injecting covered prescribed drugs will be covered at a charge of 5 for up to a 90 day supply See page 21

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Kaiser Foundation Health Plan Inc California Division 2000
Section 3 How to get benefits

What is this Plan's To enroll in this Plan you must live or work in our service area This is where our providers service area practice Our service area is
These Northern California counties Alameda Contra Costa Marin Sacramento San Francisco
San Joaquin San Mateo Solano Stanislaus

These Northern California zip codes
Amador County 95640 95669
El Dorado County 95613 14 95619 95623 95633 35 95651 95664 95667 95672
95682 95762

Fresno County 93242 93602 93606 07 93609 93611 13 93616 93624 27 93630 31
93646 93648 52 93654 93656 57 93660 93662 93667 68 93675 93700 94 93844
93888

Kings County 93230 32
Madera County 93601 93604 93614 93637 39 93643 45 93653 93669
Mariposa County 93623
Napa County 94508 94515 94558 59 94562 94567 94573 74 94576 94581 94599
Placer County 95602 04 95648 95650 95658 95661 95663 95677 78 95681 95703
95722 95736 95746 47 95765

Santa Clara County 94022 24 94035 94039 43 94086 91 94301 99 95002 95008 09
95011 95013 16 95020 21 95026 95030 33 95035 38 95042 95044 95046 95050 57
95070 71 95101 99

Sonoma County 94922 23 94926 28 94931 94951 55 94972 94975 94999 95401 09
95416 95419 95421 95425 95430 31 95433 95436 95439 95441 42 95444 95446
95448 95450 95452 95462 95465 95471 73 95476 95486 87 95492

Sutter County 95622 95659 95668 95674 95676
Tulare County 93618 93666 93673
Yolo County 95605 95607 95612 95616 18 95645 95694 95 95697 98 95776
95798 99

Yuba County 95692 95903 95961

These Southern California zip codes 90000 099 90100 199 90200 299 90300 399
90400 499 90500 599 90600 699 90700 799 except 90704 90800 899 91000 099
91100 199 91200 299 91300 399 91400 499 91500 599 91600 699 91700 799
91800 899 91901 03 91808 17 91921 91931 33 91935 91941 47 91950 51 91962 63
91976 80 91990 91 92007 09 92014 92018 27 92029 30 92033 92037 40 92046 92049
92051 58 92064 65 92067 69 92071 72 92074 75 92079 92082 85 92090 93 92096
92100 199 92201 03 92210 11 92220 92223 92230 92234 36 92240 41 92252 56 92258
92260 64 92268 92270 92274 78 92282 92284 86 92292 92305 92307 08 92313 18
92320 22 92324 26 92329 92333 37 92339 41 92345 46 92350 92352 92354 92357 59
92369 92371 78 92382 92385 86 92391 94 92397 92399 92400 499 92500 532
92543 46 92548 92551 57 92562 64 92567 92570 72 92581 82 92595 96 92599
92600 699 92700 799 92800 899 93000 009 93010 12 93015 16 93022 93030 35 93040
93041 44 93060 61 93062 66 93093 93099 93203 93205 06 93215 16 93220 93222
93224 93225 93226 93238 93240 41 93243 93250 52 93261 93263 93268 93276 93280
93285 93287 93301 09 93311 13 93380 90 93501 02 93504 05 93510 93518 19
93531 32 93534 36 93539 93543 44 93550 53 93560 93561 93563 93581 93584 93586
93590 91 93599

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Kaiser Foundation Health Plan Inc California Division 2000
Section 3 How to get benefits continued

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 16
and for emergency care obtained from any non Plan provider as described on page 17 We will
not pay for any other health care services

If you or a covered family member move outside of our service area you can enroll in another
plan If your dependents permanently reside outside of the area you should consider enrolling in
another plan If you or a family member move you do not have to wait until Open Season to
change plans Contact your employment or retirement office

How much do I pay You must share the cost of some services This is called either a copayment a set dollar amount for services or coinsurance a set percentage of charges Please remember you must pay this amount when
you receive services If you do not pay at the time you receive your service you will be billed for
the service We also will bill you an additional 5 This charge will be added to each service for
which you did not pay

After you pay 1,500 in copayments or coinsurance for one family member or 3,000 for two or
more family members you do not have to make any further payments for certain services for the
rest of the year This is called a catastrophic limit However copayments or coinsurance for your
costs of prescription drugs dental services contraceptive devices cosmetic services chiropractic
services the 25 charges paid for follow up or continuing care and all mental conditions services
except the first 20 outpatient visits do not count toward these limits and you must continue to
pay for these services as described in this brochure

Be sure to keep accurate records of your copayments and coinsurance since you are responsible
for informing us when you reach the limits

Do I have to submit You normally won't have to submit claims to us unless you receive emergency services from a claims provider who doesn't contract with us or you receive follow up or continuing care under the
travel benefit If you file a claim please send us all of the documents we need to respond to your
claim as soon as possible You must submit claims by December 31 of the year after the year you
received the service Either OPM or we can extend this deadline if you show that circumstances
beyond your control prevented you from filing on time

Who provides my Kaiser Permanente offers comprehensive affordable health care at 30 Plan facilities conveniently health care located throughout the San Francisco Bay Sacramento Stockton and Fresno areas These
facilities include Medical Centers with full hospital facilities and Plan medical offices The
Southern California Service Area has 10 major Medical Centers and more than 90 medical offices
conveniently located throughout the Southern California area Health Plan contracts with The
Permanente Medical Group Inc the Southern California Permanente Medical Group and independent
multispecialty groups of physicians to provide or arrange all necessary physician care
for Plan members Medical care is provided through physicians nurse practitioners and other
skilled medical personnel working as medical teams at Kaiser Permanente facilities Specialists in
most major specialties are available as part of the medical teams for consultation and treatment
Other necessary medical care such as physical therapy and laboratory and x ray services is also
available at Kaiser Permanente facilities Plan doctors also arrange any necessary specialty care
Hospital care is available upon referral by a Plan doctor

You must receive your health care services at Plan facilities except if you have an emergency If
you are visiting another Kaiser Permanente service area you may receive health care services
at those Kaiser Permanente facilities This Plan also offers a benefit that will allow you to receive
follow up or continuing care while you travel anywhere

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Kaiser Foundation Health Plan Inc California Division 2000
Section 3 How to get benefits continued

Your primary care physician PCP either a family practitioner pediatrician gynecologist
or internist will coordinate most aspects of your health care including arranging for you to
receive services from a specialist This Plan will cover specialists services only when your
primary care physician refers you You also may receive mental health or optometry services
without a referral

The Plan's facilities directory lists the Plan's facilities and services with the locations and phone
numbers Directories are updated on a regular basis and are available at the time of enrollment or
upon request by calling our Member Services Call Center at 800 464 4000 Use your directory to

Receive more information about facility locations and services
Receive information about how to get established with a Plan physician
Notify the Plan of the primary care physician you choose If you need help choosing a PCP call
the Plan You may change your primary care physician at any time You are free to see other Plan
physicians if your primary care physician is not available and to receive care at other Kaiser
Permanente facilities

What do I do if my Call us We will help you select a new one primary care physician
leaves the Plan
What do I do if I need to Your primary care physician or specialist will make the necessary arrangements and continue to go into the hospital coordinate your care

What do I do if I'm in First call our Member Service Call Center at 800 464 4000 If you are new to the FEHB the hospital when I join Program we will arrange for you to receive care If you are currently in the FEHB Program and
this Plan are switching 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 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized

How do I get Your primary care physician will determine if you need care from a specialist and will refer you specialty care to the appropriate provider The referral will describe the services you will receive You should
return to your primary care physician after your consultation with the specialist If your specialist
recommends additional visits or services your primary care physician will review the recommendation
and authorize the visits or services as appropriate You should not go to a specialist unless
your primary care physician and your Plan have authorized the referral

If you need to see a specialist frequently because of a chronic complex or serious medical
condition your primary care physician will develop a treatment plan that allows you to see your
specialist for a specified number of visits You will not need to obtain additional referrals

What do I do if I Your primary care physician will decide what treatment you need If your primary care physician am seeing a specialist decides to refer you to a specialist ask if you can see your current specialist If your current
when I enroll 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

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Kaiser Foundation Health Plan Inc California Division 2000
Section 3 How to get benefits continued

What do I do if my Call your primary care physician who will arrange for you to see another specialist You may specialist leaves the Plan receive services from your current specialist until we can make arrangements for you to see
someone else
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to serious illness and my continue seeing your physician for up to 90 days after we notify you that we are terminating our
provider leaves the contract with the provider unless the termination is for cause If you are in the second or Plan or this Plan leaves third trimester of pregnancy you may continue to see your OB GYN provider until the end of
the Program your postpartum care
You may also be able to continue seeing your physician if this Plan drops out of the FEHB
Program and you enroll in a new FEHB plan Contact the new plan and explain that you have a
serious or chronic condition or are in your second or third trimester Your new plan will pay for
or provide your care for up to 90 days after you receive notice that your prior plan is leaving
the FEHB Program If you are in your second or third trimester your new plan will pay for the
OB GYN care you receive from your current physician until the end of your postpartum care

How do you authorize Your physician will make all necessary arrangements before sending you to a hospital referring medical services you to a specialist or recommending follow up care Before these arrangements can be made we
consider if the service is medically necessary to prevent diagnose or treat an illness or condition
We follow generally accepted medical practice in providing services to you

How do you decide if When the service or supply including a drug 1 has not been approved by the FDA or 2 is the a service is experimental subject of a new drug or new device application on file with the FDA or 3 is part of a Phase I
or investigational or Phase II clinical trial as the experimental or research arm of a Phase III clinical trial or is intended to evaluate the safety toxicity or efficacy of the service or 4 is available as the result
of a written protocol that evaluates the service's safety toxicity or efficacy or 5 is subject to
the approval or review of an Institutional Review Board or 6 requires an informed consent that
describes the service as experimental or investigational then this Plan considers that service
supply or drug to be experimental and not covered by the Plan This Plan and its Medical Group
carefully evaluate whether a particular therapy is safe and effective or offers a degree of promise
with respect to improving health outcomes The primary source of evidence about health outcomes
of any intervention is peer reviewed medical literature

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Kaiser Foundation Health Plan Inc California Division 2000
Section 4 What to do if we deny your claim or request for service

If we deny services or won't pay your claim you may ask us to reconsider our decision
Your request must

1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend
this time limit if you show that you were unable to make a timely request due to reasons beyond
your control

We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request
We must make a decision within 30 days after we receive the additional information If we do
not receive the requested information within 60 days we will make our decision based on the
information we already have

When may I ask OPM to You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal review a denial OPM will determine if we correctly applied the terms of our contract when we denied your claim
or request for service
What if I have a serious or Call us at 800 464 4000 and we will expedite our review life threatening condition
and you haven't responded to my request for service

If we expedite your review due to a serious medical condition and deny your claim we will
What if you have denied inform OPM so that they can give your claim expedited treatment too Alternatively you can call my request for care and OPM's health benefits Contract Division 3 at 202 606 0755 between 8 a m and 5 p m Serious

my condition is serious or or life threatening conditions are ones that may cause permanent loss of bodily functions or death life threatening if they are not treated as soon as possible

You must write to OPM and ask them to review our decision within 90 days after we uphold our
Are there other initial denial or refusal of service You may also ask OPM to review your claim if time limits

1 We do not answer your request within 30 days In this case OPM must receive your request
within 120 days of the date you asked us to reconsider your claim

2 You provided us with additional information we asked for and we did not answer within 30
days In this case OPM must receive your request within 120 days of the date we asked you for
additional information

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Kaiser Foundation Health Plan Inc California Division 2000
Section 4 What to do if we deny your claim or request for service continued

What do I send to OPM Your request must be complete or OPM will return it to you You must send the following information
1 A statement about why you believe our decision is wrong based on specific benefit provisions
in this brochure

2 Copies of documents that support your claim such as physicians letters operative reports
bills medical records and explanation of benefits EOB forms

3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply
to which claim

Who can make Those who have a legal right to file a disputed claim with OPM are the request
1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled
person's representative They must send a copy of the person's specific written consent with the
review request

Where should I mail my Send your request to Office of Personnel Management Office of Insurance Programs Contracts disputed claim to Division 3 P O Box 436 Washington D C 20044

What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our the Plan's denial 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 or supplies

What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base file a lawsuit its review on the record that was before OPM when OPM made its decision on your claim You
may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure
described above

Your records and Chapter 89 of Title 5 United States Code allows OPM to use the information it collects from the Privacy Act you and us to determine if our denial of your claim is correct The information OPM collects
during the review process becomes a permanent part of your disputed claims file and is subject to
the provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this
information to support the disputed claim decision If you file a lawsuit this information will
become part of the court record

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Kaiser Foundation Health Plan Inc California Division 2000
Section 5 Benefits Medical and surgical benefits

A comprehensive range of preventive diagnostic and treatment services is provided by Plan
physicians and other Plan providers This includes all necessary office and outpatient surgery visits
you pay a 10 per office visit copayment but nothing for ultraviolet light therapy treatment
visits laboratory tests and x rays Within the service area the home health services benefit is
provided as listed below and if in the judgment of the Plan physician such care is necessary and
appropriate you pay nothing for home health visits by nurses and health aides

The following services are included and are subject to the office visit copayment unless stated
otherwise

Preventive care including well baby care and periodic check ups All scheduled preventive Pediatric Department office visits for children from birth until age two will be provided at

no charge
Mammograms for women age 35 through 39 one mammogram during these five years for women age 40 through 49 one mammogram every one or two years for women age 50 through

64 one mammogram every year and for women age 65 and above one mammogram every two
years at no charge In addition to routine screening mammograms are covered when prescribed
by the physician to diagnose or treat your illness

Routine immunizations and boosters at no charge
Consultations by specialists
Diagnostic procedures such as laboratory tests and x rays
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan physician Following confirmation of pregnancy all medically necessary

Obstetrical Department prenatal visits and the first postpartum visit will be provided at no
charge The mother at her option may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a cesarean delivery Inpatient stays will be extended if medically
necessary If enrollment in the Plan is terminated during pregnancy benefits will not be provided
after coverage under the Plan has ended Ordinary nursery care of the newborn during the
covered portion of the mother's confinement for maternity will be covered under either a Self
Only or Self and Family enrollment other care of a newborn who requires definitive treatment
will be covered only if the newborn is covered under a Self and Family enrollment

Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including test and treatment materials such as allergy serum will be provided at no charge

Blood and blood products and the administration of blood no charge
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung kidney pancreas kidney simultaneous pancreas kidney liver and lung single or double transplants allogeneic donor bone marrow transplants autologous bone

marrow transplants autologous stem cell and peripheral stem cell support for the following
conditions acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's lymphoma
advanced non Hodgkin's lymphoma advanced neuroblastoma breast cancer multiple myeloma
epithelial ovarian cancer and testicular mediastinal retroperitoneal and ovarian germ cell
tumors Transplants are covered when approved by the Medical Group Related medical and
hospital expenses of the donor are covered

Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS 12 12
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Kaiser Foundation Health Plan Inc California Division 2000
Section 5 Benefits Medical and surgical benefits continued

Dialysis office visit charges will be waived if you enroll in Medicare Part B and assign your
Medicare benefits to the Plan

Chemotherapy and critical adjuncts respiratory therapy and radiation therapy
Cardiac rehabilitation following a heart transplant bypass surgery or myocardial infarction
Surgical treatment of morbid obesity
For members confined to their homes within the service area home health services of physicians
nurses and health aides and physical speech and occupational therapists including intravenous
fluids and medications at no charge when prescribed and directed by the Plan's Home
Health Committee which will periodically review the program for continuing appropriateness
and need

Visits to receive injections
Medical management of mental health conditions including drug therapy evaluation and
maintenance

All necessary medical or surgical care in a hospital or extended care facility from Plan physicians
and other Plan providers at no additional cost to you except as noted

If a member does not pay the applicable office visit charge at the time the services are provided
the member will be billed for the service The Plan shall collect an administrative charge of 5 for
every service for which payment was not made at the time the service was received These
charges will be included in the bill

Limited benefits Oral and maxillofacial surgery is provided for non dental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical procedures

occurring within or adjacent to the oral cavity or sinuses including but not limited to treatment
of fractures and excision of tumors and cysts All other procedures involving the teeth or intraoral
areas surrounding the teeth are not covered including shortening of the mandible or maxillae
for cosmetic purposes correction of malocclusion and any dental care involved in treatment of
temporomandibular joint TMJ pain dysfunction syndrome

Reconstructive surgery will be provided to correct a condition resulting from a functional defect
or from injury or surgery that has produced a major effect on the member's appearance and if the
condition can reasonably be expected to be corrected by such surgery A patient and their attending
physician may decide whether to have breast reconstruction surgery following a mastectomy and
whether surgery on the other breast is needed to produce a symmetrical appearance

Short term rehabilitative therapy physical speech and occupational is provided on an outpatient
or inpatient basis if significant improvement can be expected within two months you pay
10 per outpatient session and nothing for an inpatient session Speech therapy is limited to treatment
of certain speech impairments of organic origin Occupational therapy is limited to services
that assist the member to achieve and maintain self care and improved functioning in other activities
of daily living You may receive outpatient or inpatient therapy as part of a specialized therapy
program in a specialized rehabilitation facility for up to two months per condition you pay nothing

Durable medical equipment DME when intended to be used repeatedly and in the home is
covered Coverage is limited to the standard item of DME in accord with the Plan's formulary
guidelines that adequately meets the medical needs of the member Covered items include ostomy
and urological supplies and apnea monitors for newborns You pay nothing Blood glucose
monitors for diabetics are covered You pay 5 The following items are not covered comfort and
convenience equipment exercise and hygiene equipment disposable supplies electronic monitors
of the function of the heart or lungs devices to perform medical tests on blood or other bodily
substances or excretions dental appliances experimental or research equipment devices not
medical in nature such as sauna baths and elevators and modifications to the home or auto
chiropractic appliances except as specifically provided in the chiropractic benefit

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Kaiser Foundation Health Plan Inc California Division 2000
Section 5 Benefits Medical and surgical benefits continued

External prosthetic and orthotic devices and braces are covered You pay nothing Coverage
is provided for those FDA approved devices which are in general use and are required because of
a defect of form or function of a permanently inoperative or malfunctioning body part Lenses
following cataract removal breast protheses and surgical bras as well as their replacement are
covered Foot orthotics are not covered

Chiropractic services are provided through American Specialty Health Plans ASHP You will
have direct access to a participating ASHP chiropractor without the need to obtain a Plan physician
referral Participating chiropractors are listed in the ASHP Participating Provider Directory
Specific details of this chiropractic benefit are listed in the ASHP evidence of coverage disclosure
form You phone the ASHP chiropractor you have selected for an initial examination After the
initial examination and except for chiropractic emergency services your ASHP chiropractor is
responsible to obtain authorization from ASHP for any additional chiropractic services on your
behalf You pay 15 per office visit up to a maximum of 20 visits per calendar year When
necessary and prescribed by an ASHP chiropractor you may receive up to 50 of chiropractic
appliances per calendar year ASHP will not cover any chiropractic services if you were referred
through your Plan physician

Diagnosis and treatment of infertility is covered You pay 10 per office visit The following
types of artificial insemination are covered intravaginal insemination IVI intracervical insemination
ICI and intrauterine insemination IUI you pay 10 per office visit cost of donor
sperm and donor eggs and services related to their procurement and storage is not covered Other
assisted reproductive technology ART procedures such as in vitro fertilization gamete and
zygote intrafallopian transfer are not covered Infertility services are not available when either
member of the family has been voluntarily surgically sterilized Drugs used for covered infertility
treatments are provided under the Prescription Drug Benefit Drugs related to non covered
infertility treatments are not covered

What is not covered Physical examinations that are not necessary for medical reasons such as those required for

obtaining or continuing employment or insurance or governmental licensing
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
External and internally implanted hearing aids
Homemaker services
Long term rehabilitative therapy
Transplants not listed as covered
Any eye surgery solely for the purpose of correcting refractive defects of the eye such as nearsightedness myopia farsightedness hyperopia and astigmatism

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Kaiser Foundation Health Plan Inc California Division 2000
Section 5 Benefits Hospital extended care benefits

What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan physician You pay nothing All necessary services are

covered including
Semiprivate room accommodations when a Plan physician determines it is medically necessary the physician may prescribe private accommodations or private duty nursing care

Specialized care units such as intensive care or cardiac care units
Prescribed drugs and their administration blood and blood products and the administration of blood biologicals supplies and equipment ordinarily provided or arranged as part of

inpatient services
Extended care The Plan provides a comprehensive range of benefits for up to 100 days per benefit period when full time skilled nursing care is necessary and confinement in a skilled nursing facility is
medically appropriate A benefit period begins when a person enters a hospital or skilled nursing
facility and ends when a person has not been a patient in either a hospital or skilled nursing facility
for 60 consecutive days You pay nothing All necessary services are covered including

Bed board and general nursing care
Prescribed drugs and their administration biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan physician

Hospice care Supportive and palliative care for a terminally ill member is covered in the home You pay
nothing Services include inpatient and outpatient care and family counseling these services are
provided under the direction of a Plan physician who certifies that the patient is in the terminal
stages of illness with a life expectancy of approximately six months or less

Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan physician
You pay nothing

Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan physician determines there procedures
is a need for hospitalization for reasons totally unrelated to the dental procedure the Plan will
cover the hospitalization but not the cost of the professional dental services Conditions for which
hospitalization may be covered include hemophilia and heart disease the need for anesthesia
by itself is not such a condition

Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis detoxification
treatment of medical conditions and medical management of withdrawal symptoms acute
detoxification if the Plan physician determines that outpatient management is not medically
appropriate See page 20 for non medical substance abuse benefits

What is not covered Personal comfort items such as telephone and television
Custodial care and care in an intermediate care facility

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Kaiser Foundation Health Plan Inc California Division 2000
Section 5 Benefits Benefits available away from home

When you are outside the service area of this Plan you may still receive covered health care
services There are two types of coverage provided under your enrollment in this Plan

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 and from any Kaiser Permanente provider If the Plan you are visiting
has a charge that is different from the charges listed in this brochure you will have to pay the
charges imposed by the Plan you are visiting If the Kaiser Permanente Plan in the area 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
Member 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 an
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 copayment required under
your enrollment in 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 that Kaiser Permanente Plan please call the
Member Service Call Center at 800 464 4000

Benefits available while you travel
If you are outside the service area of this Plan by more than 100 miles or outside the service area
of any other Kaiser Permanente Plan the following health care services will be covered

Follow up care care necessary to complete a course of treatment following receipt of covered
out of plan emergency care or emergency care received from Plan facilities if the care would
otherwise be covered and is performed on an outpatient basis Examples of covered follow up
care include the removal of stitches a catheter or a cast

Continuing care care necessary to continue covered medical services normally obtained at Plan
facilities as long as care for the condition has been received at Plan facilities within the previous
90 days and the services would otherwise be covered Services must be performed on an outpatient
basis Services include scheduled well baby care prenatal visits medication monitoring blood
pressure monitoring and dialysis treatments The following services are not covered hospitalization
infertility treatments childbirth services and transplants Prescription drugs are not covered
However you may have prescriptions filled by mail through this Plan's Prescription Drug Benefit

If you have any questions about how to use these benefits call the Travel Benefit Information
Line at 800 390 3509 You may obtain the Travel Benefits for Federal Employees brochure by
calling this number You should pay the provider at the time you receive the service Submit a
claim to the Plan for the services on the Plan's Claim for Follow up Continuing Care Medical
Services Form with necessary supporting documentation Submit itemized bills and your receipts
to the Plan along with an explanation of the services and the identification information from your
ID card Submit claims to Kaiser Foundation Health Plan Inc Claims Department P O Box
12923 Oakland CA 94604 2923 if you reside in the Northern California service area or Kaiser
Foundation Health Plan Inc Claims Department P O Box 7102 Pasadena CA 91109 9880 if
you reside in the Southern California service area If the services are covered under this Travel
Benefit you will be reimbursed the reasonable charges for the care up to a maximum of 1,200
per calendar year You pay 25 for each follow up or continuing care visit This amount will be
deducted from the payment the Plan makes to you
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Kaiser Foundation Health Plan Inc California Division 2000
Section 5 Benefits Emergency benefits

What is a medical emergency
A medical emergency is the sudden and unexpected onset of a condition or 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 the Plan may
determine are medical emergencies what they all have in common is the need for quick action

Emergencies within the service area
If you are in an emergency situation call or go for treatment to the nearest Kaiser Permanente
Medical Center Emergency care is available through Kaiser Permanente 24 hours a day 7 days a
week The location and phone number of your nearest Kaiser Permanente facility may be found
in your FEHBP Facilities Guide

In an extreme emergency if you are unable to go to a Kaiser Permanente Medical Center
contact the local emergency system e g the 911 telephone system or go to the nearest hospital
emergency room Be sure to tell the emergency room personnel that you are a Kaiser Permanente
member so they can notify Kaiser Permanente You or a family member must notify the Plan
within 48 hours It is your responsibility to ensure that the Plan has been notified

If you need to be hospitalized in a non Plan facility 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
the Plan within that time If you are hospitalized in a non Plan facility Plan physicians will
arrange a transfer to a Plan hospital when medically feasible The Plan pays for any medically
necessary transportation

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

Plan pays Reasonable charges for emergency services to the extent the services would have
been covered if received from Plan providers

You pay 35 per hospital emergency room visit for emergency services that are covered benefits
of this Plan If the emergency results in admission to a hospital the charge is waived

Emergencies outside the service area
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 open
24 hours a day 7 days a week You may also obtain information about the location of facilities by
calling the Member Service Call Center at 800 464 4000

Benefits are available for any medically necessary health service that is immediately required
because of injury or unforeseen illness

If you need to be hospitalized the Plan must be notified within 48 hours or on the first working
day following your admission unless it was not reasonably possible to notify the Plan within that
time If you are hospitalized in a non Plan facility Plan physicians will arrange a transfer to a
Plan hospital when medically feasible The Plan pays for any medically necessary transportation

Plan pays Reasonable charges for emergency services to the extent the services would have
been covered if received from Plan providers

You pay 35 per hospital emergency room visit for emergency services that are covered
benefits of this Plan If the emergency results in admission to a hospital the charge is waived

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Kaiser Foundation Health Plan Inc California Division 2000
Section 5 Benefits Emergency benefits continued

What is covered Emergency care at a physician's office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital including physician services

Ambulance service approved by the Plan

What is not covered 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

Filing claims for non Plan providers With your authorization the Plan will pay benefits directly to the providers of your emergency
care upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim
form Submit claims to Kaiser Foundation Health Plan Inc Claims Department P O Box 12923
Oakland CA 94604 2923 if you reside in the Northern California service area or Kaiser
Foundation Health Plan Inc Claims Department P O Box 7102 Pasadena CA 91109 9880 if
you reside in the Southern California service area If you are required to pay for the services
submit itemized bills and your receipts to the Plan along with an explanation of the services and
the identification information from your ID card

Payment will be sent to you or the provider if you did not pay the bill unless the claim is
denied If it is denied you will receive notice of the decision including the reasons for the denial
and the provisions of the contract on which denial was based If you disagree with the Plan's
decision you may request reconsideration in accordance with the disputed claims procedure
described on page 10

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Kaiser Foundation Health Plan Inc California Division 2000
Section 5 Benefits Mental conditions Substance abuse benefits

What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis
and treatment of acute psychiatric conditions including the treatment of mental illness or disorders
Diagnostic evaluation
Psychological testing you pay 5 per visit These visits are not charged as mental health outpatient visits

Psychiatric treatment including individual and group therapy
Medical management visits including drug evaluation and maintenance You pay 5 per visit These visits are not charged as mental health outpatient visits

Hospitalization including inpatient professional services
Outpatient care Up to 40 outpatient visits to Plan physicians consultants or other psychiatric personnel each calendar year you pay 5 for each covered individual therapy visit 5 for each covered group
therapy visit all charges thereafter
If a member does not pay the applicable office visit charge at the time the services are provided
the member will be billed for the service The Plan shall collect an administrative charge of 5 for
every service for which payment was not made at the time the service was received These
charges will be included in the bill

Unless an appointment is canceled at least 24 hours in advance members must pay 20 for a
missed individual therapy appointment and 10 for a missed group therapy appointment

Inpatient care Up to 45 days of hospitalization each calendar year less one day for each two sessions of day and night care received or less one day for each three sessions of care received in an intensive
outpatient psychiatric treatment program you pay nothing for the first 45 days all charges
thereafter

Day and night care If in the professional judgment of a Plan physician a member would benefit from day care or night care services up to 90 sessions of such prescribed care are provided without charge each
calendar year However the number of such sessions is reduced by two for each day of hospitalization
for inpatient Mental Conditions services received during the calendar year Day and night
care sessions of no less than four and no more than 12 hour duration are provided in a hospitalbased
or residential program Such care includes all services of Plan physicians and mental health
professionals In addition the following services and supplies as prescribed by a Plan physician
are covered room and board psychiatric nursing care group therapy drugs and medical supplies

What is not covered
Care for psychiatric conditions that in the professional judgment of Plan physicians are not subject to significant improvement through relatively short term treatment

Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a Plan physician to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a short term psychiatric condition

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Kaiser Foundation Health Plan Inc California Division 2000
Section 5 Benefits Substance abuse

What is covered
This Plan provides medical and hospital services such as acute detoxification services for the
medical non psychiatric aspects of substance abuse including alcoholism and drug addiction
the same as for any other illness In addition the Plan provides

Inpatient care Short term recovery services including counseling and support You pay nothing Up to 60 days per calendar year maximum of 120 days in any five consecutive calendar years in
a non medical residential care facility that provides counseling and support services will be
provided when prescribed by a Plan physician you pay 100 per admission

Methadone treatment for a pregnant member at licensed treatment centers throughout the pregnancy and for two months after delivery You pay nothing

Outpatient care Treatment and counseling including the services to determine the need for specialized facilities
you pay 5 per visit 2 per group therapy session

If a member does not pay the applicable office visit charge at the time the services are provided
the member will be billed for the service The Plan shall collect an administrative charge of 5
for every service for which payment was not made at the time the service was received These
charges will be included in the bill

What is not covered Treatment that is not authorized by a Plan physician

Care in a specialized alcoholism drug abuse or drug addiction treatment center except as specifically noted above

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Kaiser Foundation Health Plan Inc California Division 2000
Section 5 Benefits Prescription drug benefits

Prescription drugs prescribed by Plan physicians or any dentist and obtained at a Plan pharmacy
will be dispensed for up to a 90 day supply You pay a 5 copayment per prescription or refill
Quantities in excess of a 90 day supply will be provided at Member Rates It may be possible for
you to receive refills by mail at no extra charge Delivery may be made available at an additional
charge Ask for details at a Plan pharmacy

The Plan uses a formulary to determine which prescribed drugs will be provided to members If
the physician specifically prescribes a non formulary drug because it is medically necessary the
non formulary drug will be covered If you request the non formulary drug when your physician
has prescribed a substitution the non formulary drug is not covered However you may purchase
the non formulary drug from a Plan pharmacy at prices charged to members for non covered drugs

The following drugs are provided at the 5 charge unless another charge is specifically
identified

Drugs for which a prescription is required by law
Oral contraceptive drugs diaphragms cervical caps and intrauterine devices
Implanted time release drugs You pay a one time payment equal to the 5 per prescription times one third the expected number of months the drug will be effective not to exceed

200 There will be no refund of any portion of these copayments if the implanted time release
medication is removed before the end of its expected life

Injectable contraceptives are provided up to a 90 day period of expected effectiveness you pay a one time copayment of 5 per injection

Insulin
Glucose test strips
Smoking cessation drugs Coverage is limited to one course of treatment per calendar year under the following conditions

1 the drug is prescribed by a Plan physician and
2 the member enrolls in a Plan approved behavioral intervention program

Disposable needles and syringes needed for injecting covered prescribed drugs

The Plan provides the following at no charge
Disposable needles and syringes needed for injecting covered prescribed drugs listed below
Amino acid modified products used in the treatment of inborn errors of amino acid metabolism PKU

Immunosuppressant drugs required after a covered transplant
Ostomy supplies
Intravenous fluids and medications for home use
Enteral elemental dietary formulas when used as primary therapy for divisional enteritis
Chemotherapy drugs

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Kaiser Foundation Health Plan Inc California Division 2000
Section 5 Benefits Prescription drug benefits continued

Limited benefits Drugs to treat sexual dysfunction have dispensing limitations You pay 50 percent of charges
Contact the Plan for details

What is not covered Drugs available without a prescription or for which there is a non prescription
equivalent available
Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Drugs related to non covered services including infertility services

Benefits Other benefits
Vision care
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases
of the eye eye refractions to provide a written lens prescription for eyeglasses but not for
contact lenses may be obtained from Plan providers You pay a 10 copayment per visit

What is not covered Corrective lenses or frames
Examinations for contact lenses or the fitting of contact lenses
Eye exercises

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Kaiser Foundation Health Plan Inc California Division 2000
Section 5 Benefits Other benefits continued

Special benefits for Medicare eligible enrollees
If you are enrolled in this Plan through the FEHBP have Medicare Part A coverage and have purchased
Part B coverage you also may enroll in the Kaiser Permanente Senior Advantage prgram

The Senior Advantage Program Plan provides all Medicare covered Part A and Part B benefits to
the Medicare beneficiary as well as some benefits not covered by Medicare It is an arrangement
between Medicare and this Plan in which Medicare pays a specific amount to this plan for each
Medicare beneficiary who enrolls in the Plan

Like your FEHBP enrollment in this Plan you are required to obtain your services from this
Plan's physicians and providers except for emergencies and out of area urgent care The
rules regarding enrollment in Kaiser Permanente Senior Advantage are fully explained in
Disclosure Form Evidence of Coverage for Senior Advantage Federal Members For a copy of
these rules please contact the Member Service Call Center at 800 464 4000

Following your enrollment in Kaiser Permanente Senior Advantage you will be entitled to
receive an enhanced benefits package that combines your FEHBP coverage with your Kaiser
Permanente Senior Advantage benefits

If you choose to enroll in Senior Advantage you will be responsible for paying the Part B premium
You must make an affirmative enrollment in Senior Advantage Information regarding enrollment
and disenrollment rules may be found in the Evidence of Coverage for Senior Advantage Federal
Members You will also continue to pay the employee share of the FEHBP premium

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Kaiser Foundation Health Plan Inc California Division 2000
Non FEHB benefits available to Plan Members The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made available
to all enrollees and family members of this Plan The cost of the benefits described on this page is not included in the Disclosure
Form FEHB premium and any charges for these services do not count toward any FEHB deductibles or out of pocket maximums These
benefits are not subject to the FEHB disputed claims procedure

Eyewear discount As a Kaiser Permanente FEHBP Member you and your eligible dependents will be able to purchase eyewear at significant savings
When you visit any of the California Division Health Plan Optical Departments you will receive 25 percent off the member rate for
frames and lenses and options such as no line bifocals and prescription and non prescription sunglasses You will also be able to receive
25 percent off the member rate for cosmetic contact lenses and the required lens fitting

Limitations Exclusions This discount will apply only to purchased eyewear under the FEHBP basic coverage The vision discount
may not be coordinated with any other Kaiser Permanente Health Plan vision benefit This discount will also not apply to any sale promotional
or packaged eyewear program or for any contact lens Extended Purchase Agreement which includes products purchased in
this Agreement

Expanded dental benefits Kaiser Permanente is pleased to offer Federal employees retirees and dependents a choice of dental coverages to supplement your medical plan

OPTION I DeltaCare DeltaCare offers dental health maintenance organization HMO benefits that are administered by PMI an affiliate of Delta Dental Plan
of California You select a dentist from the network of contracting DeltaCare dental offices that is most convenient for you and your family
With DeltaCare there are no claim forms to worry about DeltaCare also provides a full range of services that includes preventive
restorative endodontics periodontics prosthetics oral surgery and orthodontics Under this program the subscriber pays a specific
copayment for most covered services

OPTION II KPIC's Dental Plan KPIC's Dental Plan a table of allowances program allows you to select any licensed dentist After you satisfy a deductible KPIC's
Dental Plan will pay a predetermined amount that is specified in a table toward each covered service and you pay the remainder of the
fee You do not need to satisfy a deductible toward covered preventive services you receive KPIC's Dental Plan offers a full range of services
diagnostic preventive restorative endodontics periodontics oral surgery and both fixed and removable prosthodontics
Orthodontics is not available under the KPIC's Dental Plan

Monthly premium OPTION I OPTION II
DeltaCare KPIC's Dental Plan
Monthly Quarterly Monthly Premium Premium Premium

Self Only 8.25 24.75 19.90
Self One Party 13.80 41.39 35.40
Self Two or More 20.92 62.76 53.20

KPIC's Dental Plan and DeltaCare are available only if you enroll or are currently enrolled in the Kaiser Permanente Plan for FEHB
members You do not need to enroll in either dental plan if you choose not to However you must enroll in Kaiser Permanente to
participate in either the KPIC's Dental Plan or DeltaCare programs All subscribers who enroll in either dental program when eligible
must continue enrollment in the selected dental program until the next open enrollment period This does not apply if employment
is terminated

How to enroll Please use the enclosed postage paid card to send in your application If you would like more information on KPIC's Dental Plan please
call 800 933 9312 A Delta Dental representative will be able to assist you Monday through Friday 8 15 a m 4 30 p m For information
on DeltaCare please call 800 422 4234 where a Delta Dental representative will be able to assist you Monday through Friday 6 a m 6 p m

Payments for the KPIC's Dental Plan or DeltaCare programs will be made by automatic withdrawal from your checking savings or
credit union account

These rates are effective January 1 2000 through December 31 2000

Benefits on this page are not part of the FEHB contract

24 24
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Kaiser Foundation Health Plan Inc California Division 2000
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 or condition

We do not cover the following

Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan doctors or hospitals except for authorized referrals or emergencies and services received under the travel benefit see Emergency Benefits and Benefits Available Away

from Home
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and 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
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan

Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine
who is responsible for paying for medical services and we will coordinate the payments On
occasion you may need to file a Medicare claim form

If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain
enrolled with us

If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
Medicare Choice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a Medicare Choice plan 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

If you involuntarily lose coverage or move out of the Medicare Choice service area you may
re enroll in the FEHB Program at any time

If you do not have Medicare Part A or B you can still be covered under the FEHB Program and
your benefits will not be reduced We cannot require you to enroll in Medicare

For information on Medicare Choice plans contact your local Social Security Administration
SSA office or request it from SSA at 800 638 6833 For information on the Medicare Choice
plan offered by this Plan Kaiser Permanente Senior Advantage see page 23

Other group insurance coverage When anyone has coverage with us and with another group health plan it is called double
coverage You must tell us if you or a family member has double coverage You must also send
us documents about other insurance if we ask for them

When you have double coverage one plan is the primary payer it pays benefits first The
other plan is secondary it pays benefits next We decide which insurance is primary according
to the National Association of Insurance Commissioners Guidelines

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Kaiser Foundation Health Plan Inc California Division 2000
Section 7 Limitations Rules that affect your benefits continued

If we pay second we will determine what the reasonable charge for the benefit should be After
the first plan pays we will pay either what is left of the reasonable charge or our regular benefit
whichever is less We will not pay more than the reasonable charge If we are the secondary
payer we may be entitled to receive payment from your primary plan

We will always provide you with the benefits described in this brochure Remember even if you
do not file a claim with your other plan you must still tell us that you have double coverage

Circumstances beyond our control Under certain extraordinary circumstances we may have to delay your services or be unable to
provide them In that case we will make all reasonable efforts to provide you with necessary care

When others are responsible for injuries When you receive money to compensate you for medical or hospital care for injuries or illness
that another person caused you must reimburse us for whatever services we paid for 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

TRICARE TRICARE is the health care program for members eligible dependents and retirees of the
military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you
we are the primary payer See your TRICARE Health Benefits Advisor if you have questions
about TRICARE coverage

Workers compensation We do not cover services that

You need because of a workplace related disease or injury that the Office of Workers Compensation Programs OWCP or a similar Federal or State agency determine they must
provide
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 the OWCP or similar agency has paid its maximum benefits for your treatment we will
provide your benefits

Medicaid We pay first if both Medicaid and this Plan cover you

Other Government agencies We do not cover services and supplies that a local State or Federal Government agency directly
or indirectly pays for

If you have a malpractice claim If you have a malpractice claim because of services you did or did not receive from a
Plan provider it must go to binding arbitration Contact us about how to begin our binding
arbitration process

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Kaiser Foundation Health Plan Inc California Division 2000
Section 8 FEHB facts

You have a right OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the to information about right to information about your health plan its networks providers and facilities You can also
your HMO find out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website
http www opm gov insure lists the specific types of information that we must make available
to you

If you want specific information about us call 800 464 4000 or write to Kaiser Foundation
Health Plan Inc P O Box 23059 San Diego CA 92193 3059 You may also visit our website
http www kaiserpermanente org or e mail us at Callcenter webmail cal kaiperm org

Where do I get information Your employing or retirement office can answer your questions and give you a Guide to Federal about enrolling in the Employees Health Benefits Plans brochures for other plans and other materials you need to
FEHB Program 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
The next Open Season for enrollment
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

When are my benefits The benefits in this brochure are effective on January 1 If you are new to this Plan your and premiums effective coverage and premiums begin on the first day of your first pay period that starts on or after
January 1 Annuitants premiums begin January 1

What happens when When you retire you can usually stay in the FEHB Program Generally you must have been I retire 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 which is described later in this section

What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your coverage are available to unmarried dependent children under age 22 including any foster or stepchildren your employing
my family and me or retirement office authorizes coverage for Under certain circumstances you may also get 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 you give birth or add the child to your family The benefits and premiums for
your Self and Family enrollment begin on the first day of the pay period in which the child is
born or becomes an eligible family member

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

If you or one of your family members is enrolled in one FEHB plan that person may not be
enrolled in another FEHB plan

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Kaiser Foundation Health Plan Inc California Division 2000
Section 8 FEHB facts continued

Are my medical We will keep your medical and claims information confidential Only the following will and claims records have access to it
confidential 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
Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You can

also use an Employee Express confirmation letter
What if I paid a Your old plan's deductible continues until our coverage begins deductible under
my old plan

Pre existing conditions We will not refuse to cover the treatment of a condition that you or a family member had before you enrolled in this Plan solely because you had the condition before you enrolled

When you lose benefits
What happens You will receive an additional 31 days of coverage for no additional premium when if my enrollment in
Your enrollment ends unless you cancel your enrollment or this Plan ends

You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage

What is former If you are divorced from a Federal employee or annuitant you may not continue to get spouse coverage 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 more information about your
coverage choices

What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For
example you can receive TCC if you are not able to continue your FEHB enrollment after you
retire You may not elect TCC if you are fired from your Federal job due to gross misconduct

Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office

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Kaiser Foundation Health Plan Inc California Division 2000
Section 8 FEHB facts continued

Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32nd day after your regular coverage ends even if several months have passed

You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll in TCC If you leave Federal service your employing office will notify you of your right to enroll under TCC You must enroll within 60 days of leaving or receiving this notice whichever is later

Children You must notify your employing or retirement office within 60 days after your child is
no longer an eligible family member That office will send you information about enrolling in
TCC You must enroll your child within 60 days after they become eligible for TCC or receive
this notice whichever is later

Former spouses You or your former spouse must notify your employing or retirement office
within 60 days of one of these qualifying events

Divorce
Loss of spouse equity coverage within 36 months after the divorce

Your employing or retirement office will then send your former spouse information about
enrolling in TCC Your former spouse must enroll within 60 days after the event that qualifies
them for coverage or receiving the information whichever is later

Note Your child or former spouse loses TCC eligibility unless you or your former spouse
notify your employing or retirement office within the 60 day deadline

How can I convert to You may convert to an 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 if individual coverage is available
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

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Kaiser Foundation Health Plan Inc California Division 2000
Section 8 FEHB facts continued

How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage Certificate of Group that indicates how long you have been enrolled with us You can use this certificate when getting
Health Plan Coverage health insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations
or exclusions for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other
FEHB plans you may request a certificate from them as well

Department of Defense FEHB Demonstration Project
What is the Department of Defense DoD and FEHB Program Demonstration Project
The National Defense Authorization Act for 1999 Public Law 105 261 established the
DoD FEHBP Demonstration Project It allows some active and retired uniformed service members
and their dependents to enroll in the FEHB Program The demonstration will last for three
years beginning with the 1999 Open Season for the year 2000 Open Season enrollments will be
effective January 1 2000 DoD and OPM have set up some special procedures to successfully
implement the Demonstration Project noted below Otherwise the provisions described in this
brochure apply

Who is eligible DoD determines who is eligible to enroll in FEHB Generally you may enroll if
You are an active or retired uniformed service member and are eligible for Medicare
You are a dependent of an active or retired uniformed service member and are eligible for Medicare

You are a qualified former spouse of an active or retired uniformed service member and you have not remarried or
You are a survivor dependent of a deceased active or retired uniformed service member and
You live in one of the eight geographic demonstration areas
If you are eligible to enroll in a Plan under the regular Federal Employees Health Benefits
Program you are not eligible to enroll under the DoD FEHBP Demonstration Project

Where are the Dover AFB DE demonstration areas
Commonwealth of Puerto Rico
Fort Knox KY
Greensboro Winston Salem High Point NC
Dallas TX
Humboldt County CA
Naval Hospital Camp Pendleton CA
New Orleans LA

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Kaiser Foundation Health Plan Inc California Division 2000
Department of Defense FEHB Demonstration Project continued

When can I join Your first opportunity to enroll will be during the 1999 Open Season November 8 1999 through December 13 1999 Your coverage will begin January 1 2000 DoD has set up an Information
Processing Center IPC in Iowa to provide you with information about how to enroll IPC staff
will verify your eligibility and provide you with FEHB Program information plan brochures
enrollment instructions and forms The toll free phone number for the IPC is 877 DOD FEHB
877 363 3342

You may select coverage for yourself Self Only or for you and your family Self and Family
during the 1999 2000 and 2001 Open Seasons Your coverage will begin January 1 of the year
following the Open Season that you enrolled

If you become eligible for the DoD FEHBP Demonstration Project outside of Open Season
contact the IPC to find out how to enroll and when your coverage will begin

DoD has a website devoted to the Demonstration Project You can view information such as
their Marketing Beneficiary Education Plan Frequently Asked Questions demonstration area
locations and zip code lists at www tricare osd mil fehbp You can also view information about
the Demonstration Project including The 2000 Guide to Federal Employees Health Benefits
Plans Participating in the DoD FEHBP Demonstration Project on the OPM website at
www opm gov

Am I eligible for See Section 10 FEHB facts for information about TCC Under this Demonstration Project Temporary Continuation the only individual eligible for TCC is one who ceases to be eligible as a member of family
of Coverage TCC under your Self and Family enrollment This occurs when a child turns 22 for example or if you divorce and your spouse does not qualify to enroll as an unremarried former spouse
under title 10 United States Code For these individuals TCC begins the day after their
enrollment in the DoD FEHBP Demonstration Project ends TCC enrollment terminates
after 36 months or the end of the Demonstration Project whichever occurs first You your
child or another person must notify the IPC when a family member loses eligibility for
coverage under the DoD FEHBP Demonstration Project

TCC is not available if you move out of a DoD FEHBP Demonstration Project area you
cancel your coverage or your coverage is terminated for any reason TCC is not available
when the demonstration project ends

Do I have the 31 Day These provisions do not apply to the DoD FEHBP Demonstration Project Extension and Right to
Convert

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Kaiser Foundation Health Plan Inc California Division 2000
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 800 759 0584 for Northern California Service Area and 800 464 4000 for Southern California Service Area and explain the situation

If we do not resolve the issue call or write

THE HEALTH CARE FRAUD HOTLINE
202 418 3300

U S Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington D C 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 they

Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits
Your agency may also take administrative action against you

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Kaiser Foundation Health Plan Inc California Division 2000
Notes

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Kaiser Foundation Health Plan Inc California Division 2000
Notes

OPTION I OPTION II DeltaCare KPIC's Dental Plan
Monthly Quarterly Monthly Premium Premium Premium
Self Only 8.25 24.75 19.90
Self One Party 13.80 41.39 35.40
Self Two or More 20.92 62.76 53.20

KPIC's Dental Plan and DeltaCare are available only if you enroll or are currently enrolled in the
Kaiser Permanente Plan for FEHB members You do not need to enroll in either dental plan if you
choose not to However you must enroll in Kaiser Permanente to participate in either the KPIC's
Dental Plan or DeltaCare programs All subscribers who enroll in either dental program when
eligible must continue enrollment in the selected dental program until the next open enrollment
period This does not apply if employment is terminated

Please use the enclosed postage paid card to send in your application If you would like more
information on KPIC's Dental Plan please call 800 933 9312 A Delta Dental representative will
be able to assist you Monday through Friday 8 15 a m 4 30 p m For information on DeltaCare
please call 800 422 4234 where a Delta Dental representative will be able to assist you Monday
through Friday 6 a m 6 p m

Payments for the KPIC's Dental Plan or DeltaCare programs will be made by automatic withdrawal
from your checking savings or credit union account

These rates are effective January 1 2000 through December 31 2000

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Kaiser Foundation Health Plan Inc California Division 2000
Summary of benefits for Kaiser Foundation Health Plan Inc California Division 2000

Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions
set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or
change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the
cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE
FOLLOW UP AND CONTINUING CARE AND CARE RECEIVED FROM OTHER KAISER PERMANENTE PLANS ARE
COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN PHYSICIANS

Benefits Plan pays provides Page
Inpatient care
Hospital Comprehensive range of medical and surgical services without dollar or day limit
Includes in hospital physician care room and board general nursing care private room
and private nursing care if medically necessary diagnostic tests drugs and medical
supplies use of operating room intensive care and complete maternity care
You pay nothing 15

Extended care All necessary services up to 100 days per benefit period You pay nothing 15
Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 45 days of
inpatient care per year You pay nothing 19

Substance abuse Covered under Mental Conditions Benefit 20

Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care preventive care including well baby care periodic check ups
and routine immunizations laboratory tests and x rays complete maternity care
You pay 10 copayment per office visit and outpatient surgery visit 12

Home health care All necessary visits by nurses and health aides You pay nothing 15
Mental conditions Up to 40 outpatient visits per calendar year You pay a 5 copayment per individual
visit 5 per group therapy session 19

Substance abuse Treatment and counseling visits You pay a 5 copayment per individual visit 2.00
per group therapy session Mental conditions services are also covered as shown 20

Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay 35 copayment and all charges for non covered benefits 17

Prescription Drugs prescribed by your physician or dentist and obtained at a Plan pharmacy drugs You pay 5 per prescription unit or refill 21
Dental care No current benefit
Vision care Refractions You pay a 10 copayment per visit 22
Out of pocket Copayments are required for a few benefits however after your out of pocket expenses maximum reach a maximum of 1,500 per Self Only or 3,000 per Self and Family enrollment
per calendar year covered benefits will be provided at 100 This copayment maximum
does not include prescription drugs and other services listed on page 7 7

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Kaiser Foundation Health Plan Inc California Division 2000
x

2000 Rate Information for Kaiser Foundation Health Plan Inc California Division

Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB
Guide for that category or contact the agency that maintains your health benefits enrollment

Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates
referred to as Category A rates and Category B rates will apply for certain career employees If you are a career
postal employee but not a member of a special postal employment class refer to the category definitions in
The Guide to Federal Employees Health Benefits Plans for United States Postal Service Employees RI 70 2
to determine which rate applies to you

Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes
or associate members of any postal employee organization Such persons not subject to postal rates must refer to
the applicable Guide to Federal Employees Health Benefits Plans

Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share

Southern California
Self Only 621 69.83 23.27 151.29 50.43 82.63 10.47 82.63 10.47

Self and Family 622 161.39 53.79 349.67 116.55 190.97 24.21 190.97 24.21

Northern California
Self Only 591 65.00 21.67 140.84 46.95 76.92 9.75 76.92 9.75

Self and Family 592 155.18 51.72 336.21 112.07 183.62 23.28 183.62 23.28

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