Kaiser Foundation 2000 Health Plan of Ohio
A Health Maintenance Organization
For changes
Serving Cleveland and Akron Ohio Metropolitan Areas in benefits see page 4
Enrollment in this Plan is limited see page 4 for requirements
Enrollment code 641 Self Only
642 Self and Family
This Plan has commendable accreditation
formerly called full accreditation
from the NCQA See the FEHB Guide
for more information on NCQA
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 73 017
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Kaiser Foundation Health Plan of Ohio 2000
Table of Contents
Page
Introduction 2
Plain language 2
How to use this brochure 3
Section 1 Health Maintenance Organizations 3
Section 2 How we change for 2000 4
Section 3 How to get benefits 4
Section 4 What to do if we deny your claim or request for service 8
Section 5 Benefits 10
Section 6 General exclusions Things we don't cover 21
Section 7 Limitations Rules that affect your benefits 21
Section 8 FEHB FACTS 23
Inspector General Advisory Stop Health Care Fraud 26
Summary of benefits Inside Back Cover
Premiums Back Cover
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Kaiser Foundation Health Plan of Ohio 2000
Introduction
Kaiser Foundation Health Plan of Ohio
North Point Tower
1001 Lakeside Avenue
Cleveland Ohio 44114
This brochure describes the benefits you can receive from Kaiser Foundation Health Plan of Ohio under its contract CS 1182 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 4 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 of Ohio 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 of Ohio 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
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
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Kaiser Foundation Health Plan of Ohio 2000
Section 2 How we change for 2000
Program wide To keep your premium 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 Plan Your share of the non postal premium will increase by 5.3 for Self Only or 12.3 for Self and Family
The primary care office visit copay will increase from 5 to 10 See page 10
Section 3 How to get benefits
What is this Plan's To enroll in this Plan you must live in our service area This is where our providers practice Our service area service area is
These counties in the Cleveland Ohio metropolitan area Cuyahoga Geauga Lake Lorain and Medina
These counties in the Akron Ohio metropolitan area Portage Stark Summit and Wayne
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 14 and for emergency care obtained from any non Plan provider as described on
page 15 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
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Kaiser Foundation Health Plan of Ohio 2000
Section 3 How to get benefits continued
How much do I You must share the cost of some services This is called either a copayment a set dollar amount pay for or coinsurance a set percentage of charges Please remember you must pay this amount when
services 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 4,052 in copayments or coinsurance for one family member or 12,156 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 prescription drugs or devices the 25 charge for follow up or continuing care outpatient
mental health services beyond the 20th visit inpatient mental health copayments if any reconstructive surgery durable medical equipment prosthetic devices orthotic appliances and
CORF Comprehensive Outpatient Rehabilitation Facility services 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 submit 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 Kaiser Permanente offers comprehensive health care at Plan facilities conveniently located my health
throughout the Cleveland and Akron metropolitan areas and through referral specialists care hospitals and other providers in the community Health Plan contracts with the Ohio Permanente
Medical Group an independent multi specialty group of more than 290 physicians Plan physicians to provide or arrange all necessary physician care for Plan members These Plan
physicians are members of American Specialty Boards or are Board eligible Plan physicians nurse practitioners physician assistants and other skilled medical personnel working as medical
teams provide your health care services Specialists consult with these medical teams in determining your treatment Plan physicians refer patients to community specialists when
necessary Other services such as laboratory and X ray are available at Plan facilities and other designated locations Hospital care is available through the Plan at several local community
hospitals
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 PCP 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 Plan obstetrician or Plan gynecologist without
having to obtain a referral You may also receive services for routine eye refractions outpatient mental health and outpatient alcohol and chemical dependency without a referral
Choose your primary care physician from this Plan's provider directory The directory which is updated on a regular basis lists the physicians addresses phone numbers and lets you know
whether the physician is accepting new patients To get a directory call our Customer Relations Representatives at 216 621 7100 or toll free at 800 686 7100 from anywhere within the United
States If you want to receive care from a specific physician who is listed in the directory call the Customer Relations Department to verify that he or she still participates with the Plan and is
accepting new patients
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Kaiser Foundation Health Plan of Ohio 2000
Section 3 How to get benefits continued
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 I need to Talk to your primary care physician If you need to be hospitalized your primary care physician go into
or specialist will make the necessary hospital arrangements and supervise your care the hospital
What do I do if First call our Customer Relations Representatives at 216 621 7100 or at 800 686 7100 If you I'm in the
are new to the FEHB Program we will arrange for you to receive care If you are currently in the hospital when I FEHB Program and are switching to us your former plan will pay for the hospital stay until
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
specialty care obtain necessary authorizations from the Plan The referral will describe either a specific service a treatment or series of treatments or be limited to a specific period of time 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 I Your primary care physician will decide what treatment you need If your primary care physician
am seeing a decides to refer you to a specialist ask if you can see your current specialist If your current
specialist when specialist does not participate with us you must receive treatment from a specialist who does
I enroll Generally we will not pay for you to see a 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
my specialist receive services from your current specialist until we can make arrangements for you to see
leaves the someone else
Plan
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Kaiser Foundation Health Plan of Ohio 2000
Section 3 How to get benefits continued
But what if I Please contact us if you believe your condition is chronic or disabling You may be able to
have a serious continue seeing your physician for up to 90 days after we notify you that we are terminating our
illness and my contract with the provider unless the termination is for cause If you are in the second or third
provider leaves trimester of pregnancy you may continue to see your OB GYN until the end of your postpartum
the Plan or this care
Plan leaves the You may also be able to continue seeing your physician if this Plan drops out of the FEHB
Program 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 Your primary care physician or specialist must obtain a precertification that the proposed
authorize treatment is a covered benefit and that the service is medically necessary to prevent diagnose or
medical treat an illness or condition before sending you to a hospital referring you to a specialist or
services recommending follow up care We follow generally accepted medical practice 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
decide if a the subject of a new drug or new device application on file with the FDA or 3 is part of a Phase
service is I or Phase II clinical trial as the experimental or research arm of a Phase III clinical trial or is
experimental or 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
investigational 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 of Ohio 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 You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal
OPM to review a OPM will determine if we correctly applied the terms of our contract when we denied your claim
denial or request for service
What if I have a Call us at 216 621 7100 or at 800 686 7100 and we will expedite our review
serious or lifethreatening
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
denied my inform OPM so that they can give your claim expedited treatment too Alternatively you can call
request for care OPM's health benefits Contract Division 3 at 202 606 0755 between 8 00 a m and 5 00 p m
and my condition Serious or life threatening conditions are ones that may cause permanent loss of bodily functions
is serious or lifethreatening or death if they are not treated as soon as possible
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our
time limits initial denial 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 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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Section 4 What to do if we deny your claim or request for service continued
What do I send to Your request must be complete or OPM will return it to you You must send the following
OPM 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 Send your request for review to Office of Personnel Management Office of Insurance
mail my disputed Programs Contracts Division 3 P O Box 436 Washington DC 20044
claim to
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our
upholds the decision your 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
if I 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 you
the Privacy Act 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 of Ohio 2000
Section 5 Benefits
Medical and Surgical Benefits
What is covered
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 office visit copay but no additional copay for laboratory test
and X rays Within the service area house calls will be provided if in the judgement of the Plan physician such care is necessary and appropriate you pay a 10 copay for a physician's house call for the first two calls only in any illness and nothing for home visits by
other health professionals
The following services are included
Preventive care including well baby care and periodic check ups
Mammograms are covered as follows 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 and above one mammogram every year In addition to routine
screening mammograms are covered when prescribed by the physician as medically necessary to diagnose or treat your illness
Routine immunizations and boosters
Consultations by specialist
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for covered females including prenatal visits delivery and postnatal care by a Plan physician Copays for prenatal office visits are waived 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 child 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 an infant 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
Allergy testing and treatment including testing and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung kidney kidney pancreas liver lung single or double and pancreas transplants allogenic 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
Dialysis office visit charges will be waived if you enroll in Medicare Part B and assign your Medicare benefits to the Plan
Chemotherapy radiation therapy and respiratory therapy
Surgical treatment of morbid obesity
Blood and blood products and the administration of blood
For homebound members residing in the service area home health services of health professionals including intravenous fluids and medications when prescribed by your Plan physician who will periodically review the program for continuing appropriateness and
need
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Section 5 Benefits continued
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
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 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
limited to treatment of fractures and excision of tumors and cysts All other procedures involving the teeth or intra oral 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 and dental services associated with medical treatment such as surgery and radiation treatment
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 basis for up to two consecutive months or 30 visits whichever is greater per condition if significant improvement can be expected within two months or 30 visits you
pay 10 per visit 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
Rehabilitation is provided on an inpatient or outpatient basis as part of a specialized multidisciplinary therapy program in an organized multidisciplinary program or facility approved by the Plan for up to two consecutive months per condition when in the judgment of the
Plan physician significant improvement can be expected within two months You pay nothing
Durable medical equipment is provided under Plan criteria as of January 1 of the prior year for home use on a rental or purchase basis at the Plan's discretion and obtained from sources designated by the Plan for use by the member during the period it is used as
prescribed including repair and replacements other than those necessitated by misuse or loss You pay nothing The following items are not covered electronic monitors of the function of the heart or lungs except apnea monitors for newborns and devices to perform
medical tests on blood or other bodily substances or excretions except blood glucose monitors for insulin dependent diabetics modification to the home or auto exercise and hygienic equipment experimental or research equipment self help devices not primarily
medical in nature and physician's equipment
Diagnosis and treatment of infertility is covered You pay 30 of charges The following type of artificial insemination is covered intrauterine insemination IUI you pay 30 of charges Services related to in vitro fertilization ovum transplants gamete and zygote
intrafallopian tube transfers the procurement and storage of donor eggs services that are experimental or investigational procedures for women who have evidence of ovarian failure and services for surrogate mothers who are not Plan members 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 services are not covered All prescribed drugs administered for the further evaluation or treatment of infertility are covered
you pay 50 of charges
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Kaiser Foundation Health Plan of Ohio 2000
Section 5 Benefits continued
External prosthetic and orthotic devices and braces are provided under Plan criteria as of January 1 of the prior year when prescribed by a Plan physician and obtained from sources designated by the Plan including replacements repair and adjustments other than those
necessitated by misuse or loss You pay nothing
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
Chiropractic services
Autologous or donor directed blood and related cost
Long term rehabilitative therapy
Transplants not listed as covered
Cardiac rehabilitation following a heart transplant bypass surgery or myocardial infarction
Any eye surgery solely for the purpose of correcting refractive defects of the eye such as nearsightedness myopia farsightedness hyperopia and astigmatism
Devices equipment supplies and prosthetics related to the treatment of sexual dysfunction
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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Kaiser Foundation Health Plan of Ohio 2000
Section 5 Benefits continued
Extended care
The Plan provides a comprehensive range of benefits for up to 100 days per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan physician and approved by the
Plan 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 the Plan physician
Hospice care
Supportive and palliative care for a terminally ill member is covered in the home You pay nothing Services include short term inpatient care limited to respite care and care for pain control and acute and chronic symptom management 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 50 per ambulance trip a round trip counts as one
Limited benefits
Inpatient dental procedures
Hospitalization for certain dental procedures is covered when a Plan physician determines there 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 detoxification
Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis 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 page17 for non medical 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
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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Kaiser Foundation Health Plan of Ohio 2000
Section 5 Benefits continued
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 Kaiser Permanente medical offices and medical centers and from Kaiser Permanente providers 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 transplants 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 days or visits you are entitled to receive only that number of days or visits 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 hospital to receive care
At the time you register for services you will be asked to pay the charge required by 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 please call the Customer Relations Department at 216 621 7100 or 800 686 7100
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 drug 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 Benefits 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 of Ohio Claims Department P O Box 5316 Cleveland Ohio 44101 9774 If the services are covered under this Travel Benefit you will be reimbursed the reasonable
charges for the care up to a maximum of 1200 per member 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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Kaiser Foundation Health Plan of Ohio 2000
Section 5 Benefits continued
Emergency Benefits
What is a medical emergency
A medical emergency is an injury or the sudden and unexpected onset of a condition 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 to the nearest Plan facility The emergency telephone numbers are Cleveland area Parma Medical Center 216 445 4900 Akron area 800 686 2240 These numbers are available 24 hours per day 7 days a week
In an extreme emergency 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 Plan member so they can notify the Plan You or a family member
must notify the Plan within 48 hours unless it was not reasonably possible to do so It is your responsibility to ensure that the Plan has been timely 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 non Plan facilities and Plan
physicians believe care can be better provided in a Plan designated hospital you will be transferred when medically feasible you pay 50 per ambulance trip You can notify the Plan by calling one of the following numbers In Cleveland call 216 445 4900 or toll free
800 686 2240 from anywhere in the United States
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 50 per hospital emergency room visit for emergency services that are covered benefits of this Plan If you are hospitalized the copayment 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 You may also
call the Customer Relations Department at the following phone number 800 686 7100
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 physician believes care can be better provided in a Plandesignated
hospital you will be transferred when medically feasible you pay 50 per ambulance trip
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 50 per hospital emergency room visit for emergency services that are covered benefits of this Plan
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Kaiser Foundation Health Plan of Ohio 2000
Section 5 Benefits continued
What is covered
Emergency care at a physician's office or an urgent care center
Ambulance service approved by the Plan you pay a 50 ambulance charge per trip
Emergency care as an outpatient or inpatient at a hospital including physicians services
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 unless the Plan determines that the Member was outside the service area because of circumstances beyond her control
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 of Ohio Claims
Department P O Box 5316 Cleveland Ohio 44101 9774 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 9
Mental Conditions Substance Abuse Benefits
Mental conditions
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
Psychiatric treatment including individual and group therapy
Medical management visits including drug evaluation and maintenance
Hospitalization including inpatient professional services
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Kaiser Foundation Health Plan of Ohio 2000
Section 5 Benefits continued
Outpatient care
Up to 20 outpatient visits to Plan physicians consultants or other psychiatric personnel each calendar year two group therapy visits may be substituted for one individual therapy visit You pay 5 per covered individual visit and 2.50 per covered group visit all charges
thereafter
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 5 for each service for which a bill is sent
Inpatient care
Up to 30 days of hospitalization each calendar year reduced by one day for each two sessions of day or night care and reduced by one day for each session of home psychiatric care up to a maximum of eight days You pay nothing for first 30 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 60 sessions of such prescribed care are provided each calendar year You pay nothing for 60 sessions all charges thereafter However the number of
sessions is reduced by two for each day of hospitalization for inpatient Mental Conditions services or by two for each session of home psychiatric care up to a maximum of 16 day or night care sessions 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 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
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 or condition In addition the Plan provides
Outpatient care
All necessary outpatient visits for follow up care and dependency counseling You pay 5 per visit for individual therapy and nothing for group therapy
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Kaiser Foundation Health Plan of Ohio 2000
Section 5 Benefits continued
Inpatient care
Up to two treatments per calendar year in a specialized facility which provides a non medical detoxification program You pay nothing
What is not covered
Treatment which is not authorized by a Plan physician
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 physician to be necessary and appropriate
Prescription Drug Benefits
What is covered
Prescription drugs prescribed by a Plan physician and obtained at a Plan pharmacy will be dispensed for up to a 31 day supply You pay 5 per prescription unit or refill 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
Drugs are prescribed by Plan physicians and dispensed in accordance with the Plan's drug formulary Non formulary drugs will be covered when prescribed by a Plan physician 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 and diaphragms
Contraceptive devices implanted time release drugs and injectable contraceptives For Norplant you pay a one time copayment of 180 per prescription For all other internally implanted time release drugs and injectable contraceptives you pay a one time
copayment equal to 5 per prescription times the expected number of months the device or drug will be effective not to exceed 200 There will be no refund of any portion of these copayments if the device or implanted time release drug is removed before the end of
its expected life For injectable contraceptives such as Depo provera you pay a one time copayment equal to the 5 per prescription copayment times the number of months the drug will be effective not to exceed the cost of the drug
Insulin
Glucose test strips
Drugs for covered infertility treatments You pay 50 of charges per prescription unit of refill
Certain antacids
Amino acid modified products used in the treatment of inborn errors of amino acid metabolism PKU
Disposable needles and syringes needed to inject covered prescribed medication
Intravenous fluids and prescribed drugs for home use some implantable drugs and some injectable drugs are covered under Medical and Surgical Benefits
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Kaiser Foundation Health Plan of Ohio 2000
Section 5 Benefits continued
Limited benefits
Drugs to treat sexual dysfunction have dispensing limitations You pay 50 of charges Contact the Plan for details
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 5 for each service for which a bill is sent
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 related to non covered infertility services
Smoking cessation drugs including nicotine patches
Drugs for non covered services
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 for eyeglasses to provide a written lens prescription may be obtained from Plan providers You pay 10 per visit
What is not covered
Corrective eyeglasses and frames or contact lenses
Examinations for contact lenses and the fitting of contact lenses
Refractions for contact lenses
Eye exercise
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Kaiser Foundation Health Plan of Ohio 2000
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor plan Contact us at 216 621 7100 or 800 686 7100 for guaranteed under the contract with the FEHB Program but are
information on the Medicare prepaid plan and the cost of that made available to all enrollees and family members of this enrollment
Plan The cost of the benefits described on this page is not If you are Medicare eligible and are interested in enrolling in a included in the FEHB premium and any charges for these
Medicare HMO sponsored by this Plan without dropping your services do not count toward any FEHB deductibles or out ofpocket enrollment in this Plan's FEHB plan call 216 621 7100 for
maximums These benefits are not subject to the FEHB information on the benefits available under the Medicare disputed claims procedure
HMO
VAPP Value Added Purchasing Plans Expanded Dental Benefits
Value Added Purchasing Plans VAPPs were developed to Kaiser Permanente is pleased to offer Federal employees provide members with lower prices on health related goods and
retirees and dependents a new choice of dental coverage to services that may not be covered by their basic or supplemental supplement what is currently available to you through the
health plans The Value Added Purchasing Plans use Kaiser Federal Employee Health Benefits Program The benefits of Permanente's ability to direct its members to vendors in
this program are designed to enhance the level of dental exchange for reduction in prices for those goods and services benefits Dental VAPP that you currently receive through
Members of Kaiser Permanente are eligible for substantial Kaiser Permanente Your Dental VAPP coverage through savings on the following goods and services
Kaiser Permanente is not affected by this enhanced product
Dental VAPP offering This new supplemental coverage is through Delta Dental a national dental provider and is only available to
Dental VAPP allows Members to purchase dental services at members of Kaiser Permanente favorable prices from selected community dentists Members
must use one of the Affiliated General Dentists participating in DeltaPremier Kaiser Permanente's Dental VAPP For a listing of Affiliated
DeltaPremier a table of allowances program allows you to General Dentists and a schedule of complete benefits call choose any licensed dentist however discounted pricing is
216 621 7100 or 800 686 7100 available only through Delta's provider network After you
Vision VAPP satisfy a deductible Delta will pay a predetermined amount toward each covered service You will not need to satisfy a
Vision VAPP entitles Kaiser Permanente members to special deductible toward covered preventive services you receive discounts on designated optical goods and services purchased
DeltaPremier offers a full range of covered services from quality vision care suppliers conveniently located diagnostic preventive restorative endodontics periodontics
throughout Northeast Ohio Members must obtain their oral surgery and both fixed and removable prosthodontics eyeglass examinations or refractions at Kaiser Permanente
Orthodontic coverage is not available Covered services will be Prescriptions must be filled at a participating optical provider phased in over a three year period
for members to receive discounts of 15 20 on designated optical goods and services For additional information contact
Monthly Premium Kaiser Permanente at 216 621 7100 or 800 686 7100
TO QUALIFY FOR DISCOUNTS AND SAVINGS ON Self 18.45 DENTAL AND VISION VAPPS MEMBERS MUST Self and One Party 33.45
PRESENT THEIR KAISER PERMANENTE IDENTIFICATION Family 52.45 CARD AT THE TIME OF SERVICE OR
PURCHASE DeltaPremier is only available to you if you are enrolled in
Medicare Prepaid Plan Enrollment Kaiser Permanente's Plan for FEHB If you enroll in DeltaPremier your payments will be made directly to Delta
This Plan offers Medicare recipients the opportunity to enroll Payroll deduction is not available for this program You do not in the Plan through Medicare As indicated on page 21 need to purchase this program to receive Kaiser Permanente
annuitants and former spouses with FEHB coverage and Dental VAPP coverage Medicare Part B may elect to drop their FEHB coverage and
enroll in a Medicare prepaid plan when one is available in their How to Enroll area They may then later reenroll in the FEHB Program Most
An enrollment form for DeltaPremier is included in your Federal annuitants have Medicare Part A Those without Kaiser Permanente enrollment kit If you would like more
Medicare part A may join this Medicare prepaid plan but will information on DeltaPremier please call Delta Dental at probably have to pay for hospital coverage in addition to the
800 932 0783 TDD 888 373 3582 Part B premium Before you join the Plan ask whether the Plan
covers hospital benefits and if so what you will have to pay Contact your retirement system for information on dropping
your FEHB enrollment and changing to a Medicare prepaid Benefits on this page are not part of the FEHB contract
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Kaiser Foundation Health Plan of Ohio 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
Other group When anyone has coverage with us and with another group health plan it is called double
insurance coverage You must tell us if you or a family member has double coverage You must also send us
coverage 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
21 National Association of Insurance Commissioners Guidelines
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Kaiser Foundation Health Plan of Ohio 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 Under certain extraordinary circumstances we may have to delay your services or be unable to
beyond our provide them In that case we will make all reasonable efforts to provide you with necessary
control care
When others When you receive money to compensate you for medical or hospital care for injuries or illness
are responsible that another person caused you must reimburse us for whatever services we provided or paid for
for injuries 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 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
Medicaid We pay first if both Medicaid and this Plan cover you
Other We do not cover services and supplies that a local State or Federal Government agency directly
Government or indirectly pays for
Agencies
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Kaiser Foundation Health Plan of Ohio 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 right to information about your health plan its networks providers and facilities You can also
about 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 216 621 7100 or write to Kaiser Foundation Health Plan of Ohio North Point Tower 1001 Lakeside Avenue Cleveland OH 44114 You may
also contact us by 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
information about Employees Health Benefits Plans brochures for other plans and other materials you need to
enrolling in the make an informed decision 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 If you are new to this plan your
benefits and coverage and premiums begin on the first day of your first pay period that starts on or after
premiums January 1 Annuitants premiums begin January 1
effective
What happens When you retire you can usually stay in the FEHB Program Generally you must have been
when 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 unmarried dependent children under age 22 including any stepchildren your employing or
available for my retirement office authorizes coverage for Under certain circumstances you may also get
family and me 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 of Ohio 2000
Section 8 FEHB FACTS continued
Are my medical We will keep your medical and claims information confidential Only the following will have
and claims access to it
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 We will send you an Identification ID card Use your copy of the Health Benefits Election
cards 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
conditions 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 benefits
spouse under your former spouse's enrollment But you may be eligible for your own FEHB coverage
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 of Ohio 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 If you leave Federal service your employing office will notify you of your right to enroll under
in TCC 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 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 You may convert to an individual policy if
convert to Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did
individual not pay your premium you cannot convert
coverage 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 If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage
Certificate of that indicates how long you have been enrolled with us You can use this certificate when getting
Group Health health insurance or other health care coverage You must arrange for the other coverage within 63
Plan 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
Coverage 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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Kaiser Foundation Health Plan of Ohio 2000
Inspector General Advisory Stop Health Care Fraud
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 216 621 7100 or 800 686 7100 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 of Ohio 2000
Notes
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Kaiser Foundation Health Plan of Ohio 2000
Notes
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Kaiser Foundation Health Plan of Ohio 2000
Notes
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Kaiser Foundation Health Plan of Ohio 2000
Summary of Benefits for Kaiser Foundation Health Plan of Ohio 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 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
care room and private nursing care if medically necessary diagnostic tests drugs and medical supplies use of operating room intensive care and complete maternity care
12 You pay nothing
Extended care All necessary services up to 100 days each calendar year You pay nothing 13
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient conditions care per year Two sessions of day or night care may be substituted for one day of
inpatient care and vice versa You pay nothing 16
Substance Two non medical detoxifications per calendar year in a specialized treatment facility abuse
you pay nothing Also covered under Mental conditions benefits 17
Outpatient Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care preventive care including well baby care periodic checkups
care and routine immunizations laboratory tests and X rays complete maternity care You pay 10 per office and outpatient surgery visit copays are waived for prenatal
office visits 10 per house call by a physician for the first two visits per illness 10
Home health All necessary visits by health care personnel You pay nothing 10 care
Mental Up to 20 outpatient individual therapy visits per year two group visits may be conditions substituted You pay 5 per individual visit and a 2.50 copay per group
visit 16
Substance All necessary outpatient visits for counseling you pay 5 per visit for individual abuse therapy and nothing for group therapy Also covered under Mental conditions
benefits 17
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay 50 for each emergency room visit received from Plan providers and
non Plan designated hospitals and any charges that are not covered by this Plan 15
Prescription drugs Drugs prescribed by a Plan physician and obtained at a Plan pharmacy You pay 5 per prescription unit or refill 18
Dental care No current benefit
Vision care Refractions for eyeglasses only You pay 5 per visit 19
Out of pocket maximum Copayments are required for a few benefits however after your out of pocket expenses reach a maximum of 4,052 per Self Only or 12,156 per Self and
Family enrollment per calendar year covered benefits will be provided at 100 This copayment maximum does not include the cost of prescription drugs outpatient
mental health services beyond the 20th visit inpatient mental health copayments if any copayments for contraceptive devices reconstructive surgery durable
medical equipment prosthetic devices orthotic appliances and CORF services 5
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Kaiser Foundation Health Plan of Ohio 2000
2000 Rate Information for
Kaiser Foundation Health Plan of Ohio
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 Gov't Your Gov't Your USPS Your USPS Your Enrollment Code Share Share Share Share Share Share Share Share
Self Only 641 70.22 23.41 152.15 50.72 83.10 10.53 83.10 10.53
Self and Family 642 172.32 57.45 373.41 124.47 203.94 25.85 201.02 28.77
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