Kaiser Foundation Health Plan Inc Hawaii Region 2000
A Health Maintanence Organization
Serving Hawaii
Enrollment in this Plan is limited see page 19 for requirements
Enrollment code
High Option
631 Self only
632 Self and family This Plan has accreditation from This Plan has accreditation from the JCAHO the NCQA with commendable status See the 2000 Guidefor more information on
Standard Option See the 2000 Guidefor more JCAHO information on NCQA
634 Self only
635 Self and family
Visit the OPM website at http www opm gov insure
and
This Plan's National website at http www kaiserpermanente org
Authorized for distribution by the
United States Office of Personnel Management
Retirement and Insurance
Table of Contents
Introduction
.2
Plain Language
.2
How to Use This Brochure
.2
Section 1 Health Maintenance Organizations
.3
Section 2 How We Change for 2000
.3
Section 3 How to Get Benefits
.4 5
Section 4 What to Do if We Deny Your Claim or Request for Service
.6 7
Section 5 Benefits
.8 17
Section 6 General Exclusions Things We Don't Cover
.17
Section 7 Limitations Rules That Affect Your Benefits
.18 19
Section 8 FEHB Facts
.19 21
Inspector General Advisory Stop Healthcare Fraud
.22
Summary of Benefits
.23 24
Premiums
Inside back cover
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Introduction
Kaiser Foundation Health Plan Inc Hawaii Region
711 Kapiolani Blvd Honolulu HI 96813
This brochure describes the benefits you can receive from Kaiser Foundation Health Plan Inc Hawaii Region under its contract CS
1060 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 3 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 Hawaii Region 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
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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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 preventative
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 when you receive services 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
Program Wide To keep your premiums as low as possible OPM has set a minimum copay of 10 for all primary Changes 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
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This
screening is for colorectal cancer
Changes to This Your share of the non postal high option premium will increase by 6.0 for Self Only or 6.0 for Plan Self and Family
Your share of the non postal standard option premium will increase by 2.1 for Self Only or 0.9
for Self and Family
The office visit charge for medical and surgical benefits has changed from 10 to 15 for the Standard Option
The office visit charge for medical and surgical benefits has changed from 7 to 10 for the High Option
Radiation therapy is provided at no charge for the High Option and at a 50 copay for the Standard Option
The short term rehabilitative therapy office visit charge has changed from 7 to 10 for the High Option
The short term rehabilitative therapy office visit charge has changed from 10 to 15 for the StandardOption
The office visit charge for diagnosis and treatment of infertility has changed from 10 to 15 for the Standard Option
The office visit charge for diagnosis and treatment of infertility has changed from 7 to 10 for the High Option
For emergency services received at a Plan facility you pay 25 per visit both options
The copay for prescription drugs has been increased to 7 both options
The maximum charge for implanted time release drugs and intrauterine devices changed from 200 to 250 both options
The office visit charge for vision care has changed from 10 to 15 for the Standard Option
3 The office visit charge for vision care has changed from 7 to 10 for the High Option
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Section 3 How to Get Benefits
What is This To enroll in this Plan you must live in our service area This is where our providers practice Our service Plan's Service area is
Area The Islands of Oahu Kauai Maui
The Island of Hawaii except zip codes 96718 96772 and 96777
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 11 and for emergency care obtained from any nonPlan
provider as described on page 12 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 employing
or retirement office
How much do You must share the cost of some services This is called either a copayment a set dollar amount or coinsurance I Pay for a set percentage of charges Please remember you must pay this amount when you receive services
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 15 This charge will be added to each service for which you did not pay
After you pay 1,000 in copayments or coinsurance for each family member or 3,000 for three 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 prescription drugs dental
services cosmetic services blood the 25 charges paid for follow up or continuing care and all mental
conditions substance abuse 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 You normally won't have to submit claims to us unless you receive emergency services from a non Plan Submit Claims provider 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 Kaiser Permanente offers comprehensive health care at 23 Plan facilities conveniently located on the Islands My Health of Oahu Kauai Maui and Hawaii and through specialists hospitals and other providers in the community
Care following an authorized referral Health Plan contracts with the Hawaii Permanente Medical Group an independent multi specialty group of physicians Plan physicians to provide or arrange all necessary
physiciancare for Plan members These physicians are members of American Specialty Boards or are Board eligible Medical care is provided through physicians nurse practitioners physician assistants 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 Services such as
physical therapy laboratory and X ray services are available at Kaiser Permanente facilities Plan physicians
can also arrange any necessary specialty care Hospital care is provided through the Plan at several local community hospitals Dental services are provided by Hawaii Dental Service
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 from 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
Your primary care physician either a family practitioner pediatrician 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 However a woman may see
her gynecologist without having to obtain a referral You may also receive vision care and mental health services without a referral
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Section 3 How to Get Benefits continued
Choose your primary care physician from this Plan's provider directory It lists Plan facilities and services available at each facility generally family practice pediatrics gynecology and internal medicine with their
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 Customer Service Center at 808 597 5955 on Oahu or 800 966 5955 on Kauai Maui or Hawaii If you want to receive care from a specific physician who is listed in the directory
call the physician to verify that he or she still participates with the Plan and is accepting new patients
What do I do if Call us We will help you select a new one My Primary
Care Physician Leaves the
Plan
What do I do if Your primary care physician or specialist will make the necessary arrangements and continue to supervise I Need to Go your care
into the Hospital
What do I do if First call our Customer Service Center at 808 597 5955 on Oahu or 800 966 5955 on Kauai Maui or I'm in the Hawaii If you are new to the FEHB Program we will arrange for you to receive care If you are currently
Hospital When in the FEHB Program and are switching to us your former plan will pay for the hospital stay until I Join This
Plan 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 He or she will obtain necessary Specialty Care authorizations from the Plan 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 has 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 Your primary care physician will obtain
Plan authorization for these visits
What do I do if Your primary care physician will decide what treatment you need If your primary care physician decides to I am Seeing a refer you to a specialist ask if you can see your current specialist If your current specialist does not participate
Specialist with us you must receive treatment from a specialist who does Generally we will not pay for you to see a When I Enroll specialist who does not participate with our Plan
What do I do if Call your primary care physician who will arrange for you to see another specialist You may receive services My Specialist from your current specialist until we can make arrangements for you to see someone else
Leaves the Plan
But What if I Please contact us if you believe your condition is chronic or disabling You may be able to continue seeing Have a Serious your physician for up to 90 days after we notify you that we are terminating our contract with the provider
Illness and My unless the termination is for cause If you are in the second or third trimester of pregnancy you may Provider continue to see your OB GYN until the end of your postpartum care
Leaves the Plan or You may also be able to continue seeing your physician if this Plan drops out of the FEHB Program and you
This Plan enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic condition Leaves the or are in your second or third trimester Your new plan will pay for or provide your care for up to 90 days
Program 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 5
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Section 3 How to Get Benefits continued
How do You Your physician will determine when you will be sent to a hospital or when to refer you to a specialist or Authorize whether to recommend follow up care Before this decision is made we consider if the service is medically
Medical necessary to prevent diagnose or treat an illness or condition We follow generally accepted medical practice Services in providing services to you
How do You When the service or supply including a drug 1 has not been approved by the FDA or 2 it is the subject Decide if a of a new drug or new device application on file with the FDA or 3 is part of a Phase I or Phase II clinical
Service is trial as the experimental or research arm of a Phase III clinical trial or is intended to evaluate the safety Experimental or toxicity or efficacy of the service or 4 is available as the result of a written protocol that evaluates the service's
Investigational 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
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 You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM will OPM to determine if we correctly applied the terms of our contract when we denied your claim or request for service
Review a Denial
What if I Have a Call us at 808 597 5955 on Oahu or 800 966 5955 on Kauai Maui or Hawaii and we will expedite our Serious or Life review
Threatening Condition and
You Haven't Responded to
My Request for Service
What if You Have If we expedite your review due to a serious medical condition and deny your claim we will inform OPM so that Denied My Request they can give your claim expedited treatment too Alternatively you can call OPM's Health Benefits Contract
for Care and My Division 3 at 202 606 0755 between 8 00 a m and 5 00 p m EST Serious or life threatening conditions are Condition is Serious ones that may cause permanent loss of bodily functions or death if they are not treated as soon as possible
or Life Threatening
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Section 4 What to do if We Deny Your Claim or Request for Service continued
Are There Other You must write to OPM and ask them to review our decision within 90 days after we uphold our initial denial Time Limits or refusal of service You may also ask OPM to review your claim if
1 We did 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 do 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
What do I Send Your request must be complete or OPM will return it to you You must send the following information to OPM
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 Send your request for review to Office of Personnel Management Office of Insurance Programs Contract Mail My OPM Division 3 P O Box 436 Washington D C 20044
Disputed Claim to
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our decision your Upholds the only recourse is to sue
Plan's Denial 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 Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its review if I File a Lawsuit 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 you and us to the Privacy Act 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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Section 5 Benefits
Medical and Surgical Benefits
A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other
Plan providers This includesall necessary office and outpatient surgery visits
High Option Standard Option You pay 10per visit You pay 15per visit
unless otherwise stated unless otherwise stated
For the following services
Preventive care including well baby care
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 In addition
to routine screening medically necessary mammograms to diagnose or treat your illness High Optionno
charge Standard Option 50 of charges
Routine immunizations and boosters no charge
Visits to primary care doctors and non physician providers and consults with specialist
Diagnostic procedures laboratory tests radiation therapy and X rays High Option you pay
nothing Standard Option you pay 50 of charges
Complete obstetrical maternity care for covered females including prenatal delivery and postnatal care by a Plan doctor office visit copays are waived for obstetrical care The mother at her option may
remain in the hospital up to 48 hours after a regular delivery and 96 hours after cesareandelivery
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 child during the covered portion of the mother's hospital 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 infant is covered under a Self and Family enrollment
Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye
Dialysis
Allergy testing and treatment All administered injections for testing and treating are covered without charge under the prescription drug benefit
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung kidney simultaneous pancreas kidney liver and lung single and 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 medastinal
retroperitoneal and ovarian germ cell tumors 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
Chemotherapy and respiratory therapy
Visits to receive injections Injectable drugs are covered under the Prescription Drug benefit
Surgical treatment of morbid obesity
For homebound members residing in the service area home health services of nurses social workers health aides physical occupational and speech therapists when prescribed by your Plan
doctor who will periodically review the program for continuing appropriateness and need
8 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Section 5 Benefits continued
Services of physicians and other health professionals in the hospital or extended care facility
Breast prostheses and surgical bras as well as their replacement
If a member does not pay the applicable office visit charge at the time the service is provided the member will be billed for the service The Plan will collect a 15 administrative charge for each service for which
payment was not made at the time the service was received The charge will be included in the bill
Limited Benefits Oral and maxillofacial surgery provided for nondental 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 limitedto treatment of fractures and excision of tumors and cysts All other procedures involving the teeth or intra oral areas surroundingthe teeth are not covered including
dental implants shortening of the mandible or maxillae for cosmetic purposes correction of malloclusion and
any dental care involved in treatment of temporomandibular joint TMJ pain dysfunction syndrome
Reconstructive surgery 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 her 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 provided on an inpatient or outpatient basis for up to two months per condition if significant improvement can be expected within two months you
pay 10 per outpatient visit under the High Option and 15 per outpatient visit under the Standard Option
and nothing for an inpatient visit Speech and language services are 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 Occupational therapy
supplies are not covered
Diagnosis and treatment of infertilityis covered you pay 10 per outpatient visit High Option and 15 per outpatient visit Standard Option Artificial intrauterine insemination IUI intravaginal insemination
IVI and intracervical insemination ICI are covered You pay 10 High Option and 15 Standard Option cost of donor sperm and donor eggs and services related to their procurement processing and storage
are not covered Other assisted reproductive technology ART procedures that enable a woman with otherwise
untreatable infertility to become pregnant through other artificial conception procedures such as embryo transfers are not covered Infertility services are not available when either member of the family has been
voluntarily surgically sterilized Drugs related to non covered infertility treatments are not covered Fertility
drugs are provided for covered infertility treatments under the Prescription Drug Benefit For females who qualify under Hawaii law one in vitro fertilization procedure per lifetime will be covered You pay 20 of
charges under either option
Blood limited to whole blood red cell products cryoprecipitates platelets plasma fresh frozen plasma and Rh immune globulin you pay 20 of charges both options Gamma globulin you pay nothing The
collection storage and processing of autologous blood is covered you pay 20 of charges both options
for covered scheduled surgery whether or not the units are used Donor directed units 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 attending school or camp or travel
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
External and internally implanted hearing aids
Homemaker services
Long term rehabilitative therapy
9 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Section 5 Benefits continued
Medical management of mental health conditions including drug therapy evaluation and maintenance
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
Chiropractic services
Orthopedic devices such as braces splints foot orthotics
Durable medical equipment such as wheelchairs and hospital beds
Prosthetic devices such as artificial limbs
Devices equipment supplies and prosthetics related to sexual dysfunction
House calls by doctors
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 doctor
High Option Standard Option You pay nothing You pay 10 of daily room rate charges
All necessary services are covered including
Semiprivate room accommodations when a Plan doctor determines it is medically necessary the
doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
Extended Care The Plan provides a comprehensive range of benefits for up to 100 days per benefit period when full time nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined
by a Plan doctor and approved by the Plan 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 hospitalor 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 doctor
Hospice Care Supportive and palliative care for a terminally ill member is covered in the home or a Plan approved hospice facility You pay nothing Services include inpatient and outpatient care and family counseling these services
are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages
of illness with a life expectancy of approximately six months or less
Ambulance Care Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor You pay 20 of charges both options
Limited Benefits
Inpatient Dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need for hospitalization Procedures 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
10 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Hospital Extended Care Benefits continued
Acute Inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis treatmentof Detoxification medical conditions and medical management of withdrawal symptoms acute detoxification if the Plan
doctor determines that outpatient management is not medically appropriate See pages X X for nonmedical
substance abuse benefits
What is not Covered Personal comfort items such as telephone and television
Custodial care or care in an intermediate care facility
Benefits Available away from Home
Services from Other When you are outside the service area of this Plan you may still receive covered health care services There Kaiser Permanente are two types of coverage provided under your enrollment in this Plan
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 availablein 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
or customer 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 unforeseenillness that
requires immediate attention you should go directly to the nearest Kaiser Permanente facility to receive care At the time you register for services you will be asked to pay the charges required by the local plan
Benefits Available If you plan to travel to an area with another Kaiser Permanente Plan and wish to obtain more information while You Travel about the benefits available to you from that Kaiser Permanente Plan please call the Customer Services
Center at 808 597 5955 or 800 966 5955
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 coveredand 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 3903509 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 andthe
identification information from your ID card as you would an emergency claim Claims should be submitted
to Affiliated Care 201 B Hamakua Drive Kailua Hawaii 96734 If the servicesare covered under this
11 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Benefits Available away from Homecontiued
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
Emergency Benefits
What is a Medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers Emergency your life or could result in serious injury or disability and requires immediate medical or surgicalcare
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
Emergency Services If you are in an emergency situation please call your Kaiser Permanente facility Emergency services are at a Plan Facility available from the Plan 24 hours a day seven days a week you pay 25
Emergency Services If you are unable to contact your Plan facility contact the local emergency system i e the 911 telephone at a Non Plan system or go to the nearest hospital emergency room Be sure to tell the emergency room personnel that you
Facility are a Plan member so they can notify the Plan If you or a family member is admitted to a non Plan facility you or a family member must notify the Plan within 48 hours by calling 808 834 9548 if you are not in
Hawaii call 800 227 0482 It is your responsibility to ensure that the Plan has been notified Benefitsare
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 Both Options 80 of usual and customary charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay Both Options 20 of all usual and customary charges from a non Plan provider for emergency services that are covered benefits of the Plan plus any additional charges which would have been required
if care had been rendered by the Plan
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 withinthat time
If you are hospitalized in non Plan facilities and Plan doctors believe care can be better providedin a Plan hospital you will be transferred when medically feasible Ambulance charges will be covered in full Air transportation
will be provided between Maui Kauai and Oahu or the island of Hawaii and Oahu when ordered
by a Plan doctor
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 listedin the local
telephone book under Kaiser Permanente
You may also obtain information about the location of facilities by calling the Plan's Customer Service
Center at 808 597 5955 or 800 966 5955
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 a Plan doctor believes care can be better provided in a Plan hospital you will be transferred when medically feasible with
any ambulance charges covered in full
Plan pays Both Options 80 of usual and customary charges for emergency and urgent care servicesto
12 the extent the services would have been covered if received from Plan providers
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Emergency Benefits continued
You pay Both Options 20 of all usual and customary charges from a non Plan provider for emergency and urgent care service which are covered benefits of this Plan
What is Covered Emergency care at a doctor's office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital including doctors 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 With your authorization the Plan will pay benefits directly to the providers of your emergency care upon Non Plan Providers receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form You should submit
claims forms to Affiliated Care 201 BHamakua Drive Kailua Hawaii 96734 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 6
Mental Conditions Substance Abuse Benefits
Mental Conditions 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
What is Covered Diagnostic evaluation
Psychological testing These visits are not charged as mental health outpatient visits
Psychiatric treatment including individual and group therapy
Medical management visits including drug evaluation and treatment These visits are not charged as mental
health outpatient visits
Hospitalization including inpatient professional services
Outpatient Care Visits to Plan doctors consultants or other psychiatric personnel each calendar year
High Option Standard Option You pay 7 per visit for visits 1 20 You pay 10per visit for visits 1 20
Under both options you pay all charges for all visits following the 20th visit
Additional After the 20 outpatient visits are exhausted each covered day of inpatient hospital services may also be Outpatient Care exchanged for two outpatient visits only if the Member's condition is such that the outpatient services would
reasonably preclude hospitalization
High Option Standard Option You pay 7per covered visit You pay 10per covered visit
If you do not pay any of the charges required for services at the time you receive the services you will be billed for those charges You will also be required to pay an administrative charge of 15 for each service
for which a bill is sent
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS 13
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Mental Conditions Substance Abuse Benefits continued
Inpatient Care Up to 30 days of hospitalization per calendar year Each inpatient day used reduces the number of day or night Residential care services available by two
Day Care Facility High Option Standard Option
You pay nothingfor first 30 days You pay 20 of the hospital room rate or day or night care for first 60 days for first 30 days 20 of charges for
charge all charges thereafter day or night care for first 60 days all charges thereafter
Day and Night Care If in the professional judgment of a Plan doctor a member would benefit from day care or night care services up to 60 sessions of such prescribed care are provided High Option You pay nothing Standard Option You
pay 20 of charges 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 hospital based or residential program Such care includes all services of Plan doctors and mental health professionals In addition the following
services and suppliesas prescribed by a Plan doctor 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 doctors 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 doctor to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a short term psychiatric condition
Substance Abuse
What is Covered This Plan provides medical and hospital services such as acute detoxification services for the medical nonpsychiatric aspects of substance abuse including alcoholism and drug addiction the same as for any other
illness or condition In addition the Plan provides
Outpatient Care Visits to Plan doctors consultants or other psychiatric personnel each calendar year
High Option Standard Option You pay 7per visit for visits 1 20 You pay 10per visit for visits 1 20
Under both options you pay all charges for all visits following the 20th visit
After the 20 outpatient visits are exhausted each covered day of inpatient hospital services may also be exchanged for two outpatient visits if the Member's condition is such the outpatient services would reasonably
preclude hospitalization
High Option Standard Option You pay 7per covered visit You pay 10per covered visit
If you do not pay any of the charges required for services at the time you receive the services you will be billed for those charges You will also be required to pay an administrative charge of 15 for each service for
which a bill is sent
Inpatient Care Up to 30 days of inpatient care or up to 60 days of day or night care for specialized residential treatment each Residential Day Care calendar year Each inpatientday used reduces the number of day care or night care services available by two
Facility and vice versa Inpatient substance abuse treatment is limited to two treatment episodes per lifetime You pay 20 of the cost for counseling and services for rehabilitation for the first 30 days of inpatient care or first
60 days of day or night care Both Options all charges thereafter
What is not Covered Treatment that is not authorized by a Plan doctor
Care in a specialized alcoholism drug abuse or drug addiction treatment center except as specifically noted above
Substance abuse treatment on court order or as a condition of parole or probation unless determined by a
Plan doctor to be necessary and appropriate
14 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Prescription Drug Benefits
What is Covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a one month supply one cycle of a contraceptive drug or 4 ounces of liquid drug You pay 7 per
prescription or refill both options It may be possible for you to receive refills by mail
The Plan uses a formulary to determine which prescribed drugs will be provided to members If the physician specifically prescribes a nonformulary drug because it is medically necessary the nonformulary drug will be
covered However you may purchase the nonformulary drug from a Plan pharmacy at regular retail prices
When generic substitution is permissible i e a generic drug is available and the prescribing doctor does not require the use of a name brand drug but you request the name brand drug you pay the price difference
between the generic and the name brand drug as well as the 7 charge per prescription unit or refill
For both options the following drugs are provided at the 7 charge unless another charge is specifically identified
Drugs for which a prescription is required by law
Oral and injectable contraceptive drugs You pay 7 per prescription times the expected number of months the medication will be effective
Diaphragms and cervical caps You pay 7 each
Implanted time release drugs and intrauterine devices IUD's You pay the 7 prescription charge times the expected number of months the medication will be effective not to exceed 250 There will be no refund
of any portion of the copayment if the implanted time release drug is removed before the end of its expected
lifetime and no refund of any portion of the copayment if the IUD is removed or spontaneously expulsed
Insulin
Disposable needles and syringes
Diabetes supplies limited to glucose strips control solutions for glucose meters lancets and insulin syringes
Amino acid modified products used in the treatment of inborn errors of amino acid metabolism PKU
Oral immunosuppressive drugs required after a transplant
Smoking cessation drugs including nicotine patches Coverage is limited to one course of treatment per
calendar year if
1 the drug is prescribed by a Plan doctor and
2 the member enrolls in and pays the fees for a Plan approved smoking cessation program
Intravenous fluids and medication for home use and some injectable drugs are covered under Medical
and Surgical Benefits
Limited Benefit Drugs and injections used to treat sexual dysfunction have dispensing limitations You pay 50 of charges Contact the Plan for details
What is not Covered Drugs available without a prescription or for which there is a nonprescription 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 for the treatment of non covered services including infertility services
15 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Other Benefits
The following dental services are covered when provided through Hawaii Dental Service
What is Covered Plan pays Plan pays
High Option Standard Option
Examinations once every 12 months 100 100
Bitewing x rays once every six months 100 100
Other x rays limited to one full 80 80 mouth series of x rays including bitewings
once every three years
Prophylaxis cleaning once every 80 80
12 months
Stannous Fluoride once every 12 months and for dependent children only 80 80
Palliative Treatment for relief of pain but not to cure 80 80
Plan pays the specified percentage of your dentist's Plan 75 fees or eligible fees whichever is lower
How to Use Visit your own dentist During your first appointment advise your dentist that you are covered by the Kaiser Your Dental Foundation Health Plan Federal Dental Care Program and present your HDS member identification card to
Program your dentist
Your dentist will perform an examination
If your dentist feels he she must perform procedures which may total 400 or more he she shall submit a
claim form to HDS before providing services
Upon HDS's approval your dentist will explain your treatment plan the dollar amount your dental benefits plan will cover and the amount you will pay
The benefits for covered services will be paid based upon your Plan 75 fees or eligible fees whichever is lower An eligible fee is the lowest fee a particular HDS Member Dentist agrees to charge a patient for a particular
service
An HDS Member Dentist's eligible fee for a particular procedure may be the same as lower or higher than the Plan 75 fee Any remaining balance between your dentist's eligible fee and the HDS payment amount
is your financial responsibility
Upon your approval your dentist will render services
Before you receive treatment discuss the total charges and your financial obligations with your dentist
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
High Option Standard Option You pay 10per visit You pay 15per visit
What is not Covered Corrective eyeglass lenses or frames
Examinations for contact lenses the fitting of contact lenses or contact lenses
Eye exercises
16 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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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 program
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 doctors and providers except for emergencies and out of area urgent care For information about Kaiser Permanente
Senior Advantage consult the Plan's Senior Advantage Evidence of Coverage for Group Members with
Medicare Benefits Please contact Kaiser Permanente Senior Advantage at 808 597 2010 on Oahu and 800 564 2010 on the Neighbor Islands
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 procedures may be found in the Senior Advantage Evidence of Coverage for Group Members You will also
continue to pay the employee share of the FEHBP premium
How to Obtain Benefits
Questions If you have a question concerning Plan benefits or how to arrange for care contact the Plan's Customer Service Center on Oahu at 808 597 5955 or on Maui the island of Hawaii or Kauai at 800 966 5955 or 808 834 9703
TDD or you may write to the Health Plan office at 711 Kapiolani Blvd Tower Bldg Suite 400 Honolulu
Hawaii 96813 You may also contact the Plan by fax at 808 597 5300 or at its website at http www kaiserpermanente org
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
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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 to pay 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 see page xx
Other Group When anyone has coverage with us and with another group health plan it is called double coverage You Insurance must tell us if you or a family member has double coverage You must also send us documents about other
Coverage 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
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 Under certain extraordinary circumstances we may have to delay your services or be unable to provide Beyond Our them In that case we will make all reasonable efforts to provide you with necessary care
Control
When Others When you receive money to compensate you for medical or hospital care for injuries or illness that another are Responsible person caused you must reimburse us for whatever services we paid for We will cover the cost of treatment
for Injuries 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 We do not cover services that Compensation
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
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Section 7 Limitations Rules That Affect Your Benefits continued
Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency directly or indirectly Agencies pays for
If You Have a If you have a malpractice claim because of services you did or did not receive from a plan provider it must Malpractice go to binding arbitration Contact us about how to begin our binding arbitration process
Claim
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 right to to Information information about your health plan its networks providers and facilities You can also find out about care
about Your HMO 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 808 597 5955 or write to Kaiser Foundation Health Plan Inc Hawaii Region 711 Kapiolani Blvd Honolulu HI 96813 You may also contact us by fax at 808 5975300
or visit our website at http www kaiserpermanente org
Where do I Get Your employing or retirement office can answer your questions and give you a Guide to Federal Employees Information about Health Benefits Plans brochures for other plans and other materials you need to make an informed decision
Enrolling in the about FEHB Program
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 The benefits in this brochure are effective on January 1 2000 If you are new to this plan your coverage and Benefits and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants premiums
Premiums begin January 1 Effective
What Happens When you retire you can usually stay in the FEHB Program Generally you must have been enrolled in the When I Retire 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 unmarried Coverage are dependent children under age 22 including any foster or step children your employing or retirement office
Available for Me authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years and My Family 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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Section 8 FEHB Facts continued
Are My Medical We will keep your medical and claims information confidential Only the following will have access to it and Claims
Records OPM this Plan and subcontractors when they administer this contract Confidential
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 We will not refuse to cover the treatment of a condition that you or a family member had before you enrolled Conditions in this Plan solely because you had the condition before you enrolled
When You Lose Benefits
What Happens if You will receive an additional 31 days of coverage for no additional premium when My Enrollment
in This Plan Ends Your enrollment ends unless you cancel your enrollment or
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 benefits under your Spouse Coverage 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
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
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Section 8 FEHB Facts continued
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 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 If you leave Federal service your employing office will notify you of your right to enroll under TCC You in TCC 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 which 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 You may convert to an individual policy if to 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
How Can I Get a Certificate of If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that indicates
Group Health Plan how long you have been enrolled with us You can use this certificate when getting health insurance or other Coverage 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
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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 808 597 5955 or 800 966 5955 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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Summary of Benefits for Kaiser Foundation Health Plan Inc Hawaii Region 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 DOCTORS
Benefits High Option pays provides Page
Inpatient care
Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital doctor 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 10
Extended care All necessary services up to 100 days per benefit period You pay nothing 10
Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care or up to 60 days of day or night care per year
You pay nothing 13 14
Substance abuse Up to 30 days or up to 60 days of day or night care services each calendar year in specialized treatment facility You pay 20 of
charges for first 30 days of inpatient care or up to 60 days of day or night care services all charges thereafter 14
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 per office visit 8 10
Home health care All necessary visits by nurses physical therapists and health aides You pay nothing per visit 8
Mental conditions Up to 20 outpatient visits per year You pay 7 per visit 13
Substance abuse Up to 20 outpatient visits per year You pay 7 per visit 14
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay 25 for services received at Plan facilities
You pay 20 of all reasonable and customary charges for emergency services received from a non plan provider 12 13
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay 7 per prescription unit or refill 15
Dental care Preventive dental care services You pay 20 of charges for most services 16
Vision care Both Options One refraction annually You pay 10 per visit 16
Out of pocket maximum Copayments are required for a few benefits however after your out of pocket expenses reach a maximum of 1,000 per Self Only
or 3,000 per Self and Family enrollment per calendar year covered benefits will be provided at 100 This copay maximum does not include
prescription drugs blood the 25 charge for follow up or continuing care
or dental services 4
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Summary of Benefits for Kaiser Foundation Health Plan Inc Hawaii Region 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 DOCTORS
Benefits Standard Option pays provides Page
Inpatient care
Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital doctor 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 10 of daily room rate charges 10
Extended care All necessary services up to 100 days per benefit period You pay nothing 10
Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care or up to 60 days of day or night care per year
You pay 20 of charges for first 30 days of inpatient care or up to 60 days of day or night care services all charges thereafter 13 14
Substance abuse Up to 30 days or up to 60 days of day or night care services each
calendar year in specialized treatment facility You pay 20 of charges for first 30 days of inpatient care or up to 60 days of day or
night care services all charges thereafter 14
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
complete maternity care You pay 15 per office visit 8 10
Home health care All necessary visits by nurses physical therapists and health aides You pay nothing per visit 8
Mental conditions Up to 20 outpatient visits per year You pay 10 per visit 13
Substance abuse Up to 20 outpatient visits per year You pay 10 per visit 14
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay 25 for services received at Plan facilities
You pay 20 of all reasonable and customary charges for emergency services received from a non plan provider 12 13
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay 7 per prescription unit or refill 15
Dental care Preventive dental care services You pay 20 of charges for most services 16
Vision care Both Options One refraction annually You pay 15 per visit 16
Out of pocket maximum Copayments are required for a few benefits however after your out of pocket expenses reach a maximum of 1,000 per Self Only
or 3,000 per Self and Family enrollment per calendar year covered benefits will be provided at 100 This copay maximum does not include
prescription drugs blood the 25 charge for follow up or continuing care
or dental services 4
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25
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2000 Rate Information for Kaiser Foundation Health Plan Inc
Non Postal ratesapply 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 ratesapply 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
Biweekly Monthly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share
Islands of Hawaii Maui Oahu Kauai
High Option 631 78.83 40.32 170.80 87.36 93.06 26.09 93.26 25.89
Self Only
High Option 632 175.97 80.20 381.27 173.77 207.74 48.43 201.02 55.15
Self Family
Islands of Hawaii Maui Oahu Kauai
Standard Option 634 74.87 24.95 162.21 54.07 88.59 11.23 88.59 11.23
Self Only
Standard Option 635 160.96 53.65 348.74 116.25 190.47 24.14 190.47 24.14
Self and Family
25 26