KPS Health Plans 2000 Formerly Kitsap Physicians Service
A Prepaid Comprehensive Medical Plan
Serving Kitsap Mason and Jefferson Counties in Northwestern Washington
Enrollment in this Plan is limited see page 3 for requirements
Enrollment code
High Option
VT1 Self Only
VT2 Self and Family
Standard Option
VT4 Self Only
VT5 Self and Family
Visit the OPM website at http www opm gov insure
And
this Plan's website at http www kpshealthplans com
Authorized for distribution by the
United States Office of
Personnel Management
Retirement and Insurance
KPS Health Plans 2000
Table of Contents
Introduction
1
Plain language
1
How to use this brochure
1
Section 1 Health Maintenance Organizations
2
Section 2 How we change for 2000
2
Section 3 How to get benefits
3 5
Section 4 What to do if we deny your claim or request for service
5 6
Section 5 Benefits
7 15
Section 6 General exclusions Things we don't cover
16
Section 7 Limitations Rules that affect your benefits
16 17
Section 8 FEHB facts
18 20
Inspector General Advisory Stop Healthcare Fraud
20
Summary of benefits
Inside back cover
Premiums
Back cover
2
2
Page 3
4
KPS Health Plans 2000
Introduction KPS Health Plans 400
Warren Avenue P O Box 339 Bremerton Washington 98337
This brochure describes the benefits you can receive from KPS Health Plans under its contract CS1767 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 2 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 KPS Health Plans 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 re written 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 This Plan is also a Comprehensive Individual practice Prepaid Medical Plan Turn to this
section for a brief description of Comprehensive Individual practice Prepaid Medical Plans 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
KPS Health Plans 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other providers that contract with us These providers coordinate your health care services The care you
receive includes 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 you must pay copayments and coinsurance listed in this brochure When you receive emergency services 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
Comprehensive This Plan is a Comprehensive Individual practice Prepaid Medical Plan This means that we
Individual practice offer health services in whole or substantial part on a prepaid basis with professional services
Prepaid Medical Plans provided by individual physicians who agree under certain conditions approved by OPM to accept the payments provided by the Plan and the members cost sharing amounts as full
payment for covered services
Section 2 How we change for 2000
Program wide This year you have a right
to more information about this Plan care management our networks changes facilities and providers
If you have a chronic or disabling condition or are in the second or third trimester of pregnancy and your specialist provider leaves the Plan for reasons other than for cause you may continue to
see your specialist provider for up to 90 days or 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 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 Standard Option KPS Health Plans premium will increase by 10 0 for Self Only and 10.0 for Self and Family
Your share of the High Option KPS Health Plans premium will decrease by 17 1 for Self Only and 18.3 for Self and Family
The chemotherapy radiation and inhalation benefit has been split between the Medical and Surgical Benefits section and the Prescription Drug Benefit section The professional
services are covered under the Medical and Surgical Benefits Self administered drugs are covered under the Prescription Drug Benefit
The durable medical equipment benefit is now limited to a maximum Plan payment of 2,500 per member per year and a lifetime maximum of 50,000 per member
Cardiac rehabilitation for stable angina pectoris is provided for up to a maximum Plan payment of 500
Ambulance transportation has been clarified to indicate that it will be covered when it is medically necessary Air ambulance transportation is limited to 5,000 per trip
The Prescription Drug Benefit has been clarified to indicate that prescription drugs must be medically necessary to be covered Drugs that are not medically necessary will not be
covered
Compounded hormone replacement therapy is an excluded drug Drugs designated by the Pharmacy and Therapeutic Committee are excluded
The Plan now includes full mouth x rays once every 5 years and an emergency examination when determined necessary by the Plan
We have clarified that crowns are not a covered dental benefit Sound natural teeth are defined as those that do not have any restorations
KPS Health Plans 2000
Section 3 How to get benefits What is this Plan's To enroll with us you must
live in our service area This is where our providers practice Our service
service area area is the counties of Jefferson Kitsap and Mason in Northwest Washington
Ordinarily you must get your care from providers who contract with us If you receive care from nonPlan providers outside our service area we will pay only for emergency care We will not pay for any
other health care services Exception eligible dependent children away at school and members on temporary duty assignment outside our service area may receive benefits for other than emergency care
when arrangements are made with the Plan
If you or a covered family member move outside of our service area you can enroll in another plan If your dependents live out of the area you should consider enrolling in a fee for service plan or an HMO
that has agreements with affiliates in other areas
If you or a family member move you do not have to wait until Open Season to change plans Contact your employing or retirement office
How much do I pay for services You must share the cost of some services This is called either a deductible the amount you must pay
each year before the Plan starts paying benefits a copayment a set dollar amount or coinsurance a set percentage of charges Please remember you must pay this amount when you receive services except
for emergency care
Be sure to keep accurate records of your deductibles copayments and coinsurance since you are responsible for informing us when you reach the limits
Annual High Option Each family member must pay a deductible of 600 per year for the Prescription Drug Deductible Benefit
Standard Option You must pay a deductible of 100 for one family member or 200 for two or more family member This deductible is waived for accidental injuries
Copayments High Option Copayments are required for a few benefits However the Plan has established a and maximum amount of 600 per member per calendar year that you must pay for hospital copayments
Coinsurance Standard Option After you pay 2,000 in coinsurance for one family member or 2,000 for two or
more family members you do not have to make any further payments for certain services for the rest of the year This is called a catastrophic limit However copayments or coinsurance for your prescription
drugs dental services or services for which your coinsurance percentage level is greater than 20 percent i e services of non Plan providers allergy serum transplant costs in excess of 100,000 diagnosis
and treatment of infertility smoking cessation costs and costs for outpatient treatment of mental conditions substance abuse do not count toward these limits and you must continue to make these
payments
What If I If you are enrolled in Medicare Part B and Medicare is the primary payer this Plan will waive a the have copays deductible and coinsurance applicable to inpatient hospital care and to surgical and medical
Medicare care and b the coinsurance applicable to the Standard Option Prescription Drug Benefit when you use Part B as my generic or preferred drugs preferred drug lists are available from Plan pharmacists and Plan doctors
Primary However the High Option Prescription Drug Benefit deductible of 600 per member per year and 50 coverage coinsurance will still apply
Do I have to You normally won't have to submit claims to us unless you receive services from a provider who submit claims doesn't contract with us If you file a claim please send us all of the documents for your claim as soon
as possible You must submit claims by December 31 of the year after the year you received the service Either OPM or we can extend this deadline if you show that circumstances beyond your control
prevented you from filing on time
Who provides my The Plan emphasizes comprehensive medical and surgical care in Plan doctors offices and hospitals A health care Plan doctor is a participating Medical Doctor MD or Doctor of Osteopathy DO with KPS and
includes doctors participating in the KPS Northwest One and MultiPlan networks A Plan dentist is a participating dentist with KPS
For the purposes of a dependent child or member on temporary duty assignment residing outside the state of Washington a Plan doctor or Plan dentist is a MultiPlan provider If a MultiPlan provider is not
available in the dependent's or member's temporary county of residence then they may see any doctor or dentist practicing within the temporary county of residence at no penalty See What is this Plan's
Service Area
KPS Health Plans 2000
Section 3 How to get benefits continued
Who provides my The Plan arranges with doctors 579 primary care physicians and 617 specialists and hospitals 3 and
health care makes referrals to nonparticipating doctors to provide medical care for both the prevention of disease
continued and the treatment of serious illness
Role of a primary You are urged to choose a family doctor to assume primary responsibility for your care select a
care doctor pediatrician for your children have periodic checkups seek medical advice and get prompt attention at the first sign of illness If in the opinion of the Plan's medical director your utilization of covered
benefits appears to be excessive for proper medical care you may be required to designate a Plan doctor of your choice who will arrange for coordination of your medical care and for referrals to other providers
with the exception that a woman may see her Plan gynecologist for her annual routine examination without referral It is the responsibility of your doctor to obtain any necessary authorizations from the
Plan before referring you to a specialist or making arrangements for hospitalization
Choosing your The Plan's provider directory lists primary care doctors generally family practitioners pediatricians
doctor internists 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 the Customer Service Department at
360 478 6796 or toll free in Washington State 1 800 552 7114 You can also find out if your doctor participates with this Plan by calling this number If you are interested in receiving care from a specific
provider who is listed in the directory call the provider 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
doctor leaves the
Plan
What do I do if I Talk to your Plan doctor If you need to be hospitalized your primary care doctor or specialist will make
need to go into the the necessary hospital arrangements including Plan authorization and supervise your care Under the Mental Conditions inpatient benefit if your hospitalization extends from one year to the next and reaches
hospital or exceeds the covered benefit of 30 days you must be discharged before the new year's benefit of 30 days becomes available
What do I do if First call our customer service department at 360 478 6796 If you are new to the FEHB Program we
I'm in the hospital will arrange for you to receive care If you are currently in the FEHB Program and are switching to us
when I join this your former plan will pay for the hospital stay until
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 doctor will arrange your referral to a specialist
specialty care If you need to see a specialist frequently because of a chronic complex or serious medical condition your primary care physician will develop a treatment plan that allows you to see your specialist for a
certain number of visits without additional referrals Your primary care physician will use our criteria when creating your treatment plan and will obtain any necessary Plan authorization
What do I do if I Your primary care doctor will decide what treatment you need If they decide to refer you to a specialist
am seeing a ask if you can see your current specialist If your current specialist does not participate with us you must
specialist when receive treatment from a specialist who does Generally we will not pay for you to see a specialist who does not participate with our Plan
I enroll
What do I do if Call your primary care physician who will arrange for you to see another specialist You may receive
my specialist services from your current specialist for up to 90 days or until we can make arrangements for you to see
leaves the Plan someone else
KPS Health Plans 2000
Section 3 How to get benefits continued
But what if I have Please contact us if you believe your condition is chronic or disabling You may be able to continue
a serious illness seeing your provider for up to 90 days after we notify you that we are terminating our contract with the
and my provider provider unless the termination is for cause If you are in the second or third trimester of pregnancy
leaves the Plan or you may continue to see your OB GYN until the end of your postpartum care
this Plan leaves You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and
the Program 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 provider until the end of your postpartum care
How do you Your doctor must get our approval before sending you to a hospital referring you to a specialist or
authorize medical recommending follow up care Before giving approval we consider if the service is medically necessary
services and if it follows generally accepted medical practice
How do you A drug device or biological product is experimental or investigational if the drug device or biological
decide if a service product cannot be lawfully marketed without approval of the U S Food and Drug Administration FDA and approval for marketing has not been given at the time it is furnished
is experimental or
investigational An FDA approved drug device or biological product for use other than its intended purposes and labeled intentions or medical treatment or procedure is experimental or investigational if
1 reliable evidence shows that it is the subject of ongoing phase I II or III clinical trials or under study to determine its maximum tolerated dose its toxicity its safety or
2 reliable evidence shows that the consensus of opinion among experts regarding the drug device or biological product or medical treatment or procedure is that further studies or clinical trials are
necessary to determine its maximum tolerated dose its toxicity its safety its efficacy or its efficacy as compared with the standard means of treatment or diagnosis
Reliable evidence shall mean only published reports and articles in the authoritative medical and scientific literature the written protocol or protocols used by the treating facility or the protocol s of
another procedure or the written informed consent used by the treating facility or by another facility studying substantially the same drug device or medical treatment or procedure
FDA approved drugs devices or biological products used for their intended purposes and labeled indication and those that have received FDA approval subject to postmarketing approval clinical trials
and devices classified by the FDA as Category B Non experimental Investigational Devices are not considered experimental or investigational
Section 4 What to do if we deny your claim or request for service
If we deny services or your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that
you were unable to make a timely request due to reasons beyond your control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within
30 days after we receive the additional information If we do not receive the requested information within 60 days we will make
our decision based on the information we already have
When may I ask OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal
to review a denial OPM will determine if we correctly applied the terms of our contract when we denied your claim or request for service
KPS Health Plans 2000
Section 4 What to do if we deny your claim or request for service continued
What if I have a Call us 360 478 6796 and we will expedite our review
serious or life
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
denied my request for OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
care and my condition health benefits Contract Division II at 202 606 3818 between 8 a m and 5 p m Eastern Standard
is serious or life Time Serious or life threatening conditions are ones that may cause permanent loss of bodily
threatening functions or death if they are not treated as soon as possible
Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold our
limits initial denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request
within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30
days In this case OPM must receive your request within 120 days of the date we asked you
for additional information
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 Copies of all letters you sent us about the claim
3 Copies of all letters we sent you about the claim and 4 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 the Those who have a legal right to file a disputed claim with OPM are
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
What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our
the Plan's denial decision your only recourse is to sue
If you decide to sue you must file the suit against OPM in Federal court by December 31 of the
third year after the year in which you received the disputed services or supplies
What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its
file a lawsuit 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 the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you
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
KPS Health Plans 2000
Section 5 Benefits Help Us Control Costs
Outpatient Surgery Hospitalization is no longer necessary for many surgical and diagnostic procedures These procedures can be performed safely and less expensively on an outpatient basis without sacrificing quality care
Listed elective surgeries and diagnostic procedures must be performed in a hospital outpatient unit surgical center or Plan doctor's office These facilities are more convenient than a hospital because
surgery can be scheduled easily and quickly and the patient can return home sooner The cost of surgery is reduced because hospital room and board charges are eliminated
If circumstances indicate that it is medically necessary to perform a procedure on an inpatient basis full Plan benefits will be provided
If a procedure is performed on an inpatient basis when hospitalization is not medically necessary benefits for the surgical fee will be reduced by 20 and benefits for the hospital stay will be denied
No reduction in benefits will occur for emergency admissions
The following procedures must be performed on an outpatient basis
Biopsy procedures Hemorrhoid surgery Breast surgery minor However women Inguinal hernia surgery
who undergo mastectomies may at their Knee surgery option have this procedure performed on an Nose surgery
inpatient basis and remain in the hospital up Removal of bunions nails to 48 hours after the procedure Removal of cataracts
Diagnostic examination with scopes Removal of cysts ganglions and lesions hammertoes etc Sterilization procedures
Dilation and curettage D C Tendon bone and joint surgery of the hand Ear surgery minor and foot
Facial reconstruction surgery Tonsillectomy and adenoidectomy
Pre Admission Pre admission testing requires that necessary routine diagnostic tests be performed on an outpatient basis before you are hospitalized for elective non emergency care Tests must be performed within
Testing three days of the scheduled admission Failure to obtain testing prior to admission will result in a 20 reduction of benefits for the testing charges Pre admission testing is less expensive when done
on an out patient basis and is usually more convenient
When inpatient hospitalization is recommended for you ask your Plan doctor to schedule diagnostic tests on an outpatient basis within three days of admission Pre admission certification provides
advanced confirmation of benefits from the Plan before you are admitted to a hospital or skilled nursing facility
You and your Plan doctor must request pre admission certification before hospitalization This is a feature which allows you to know prior to hospitalization which services are considered medically
necessary and eligible for payment under this Plan If the hospitalization and treatment is not precertified the admitting physician's fees will be reduced by 20 and benefits for the hospital stay
will be reduced by 500
Pre Admission Pre admission certification authorizes inpatient hospital benefits and is valid for six months
Certification Approval for each admission or re admission is required The Plan will provide coverage only for the number of hospital days which have been pre certified If your hospital stay is extended due to complications your Plan doctor must obtain benefit authorization for the extension
After your Plan doctor notifies you that hospitalization or skilled nursing care is necessary ask your Plan doctor to obtain pre admission certification Written confirmation of the approved admission will be
sent to you by the Plan once certification is obtained If an emergency admission occurs have your attending physician and the hospital contact the Plan within 48 hours of admission or as soon as
reasonably possible to complete the certification process
Medical and Surgical Benefits
What is A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other
Covered Plan providers This includes all necessary office visits and within the Service Area house calls if in the judgement of the Plan doctor such care is necessary and appropriate
High Option You pay a 10 office visit copay but no additional copay for laboratory tests and X rays 15 copay for a doctor's house call nothing for visits by nurses and health aides
Standard Option You pay 20 of charges after a 100 per member deductible
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
KPS Health Plans 2000
Section 5 Benefits continued Medical and Surgical Benefits
continued
What is The following services are included
Covered Preventive care including well baby care and periodic check ups copays deductibles and coinsurance
continued are waived for well baby care up to age 3 Mammograms are covered as follows for women age 35 through age 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 mammograms are covered when prescribed by the doctor as medically necessary to diagnose or treat your illness
Routine immunizations and boosters copays deductibles and coinsurance are waived for immunizations through age 22
Consultations by specialists Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor The mother at her option may remain in the hospital up to 48 hours after a
regular delivery and 96 hours after a caesarean 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 hospital confinement for maternity will be covered under either a Self Only or
Self and Family enrollment copays and deductibles for the newborn child will be waived in this instance coinsurance will still be applied 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 allergy test materials you pay 50 of charges for allergy serum The insertion of internal prosthetic devices including the cost of the device such as pacemakers and
artificial joints
Cornea heart heart lung single double lung kidney and liver 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 testicular mediastinal retroperitoneal and ovarian germ cell tumors Transplants are covered when approved by the Medical Director Related medical and
hospital expenses of the donor are covered when the recipient is covered by this Plan You pay 50 of costs above the first 100,000 for all services associated with any listed transplant including any retransplant
within one year of the initial transplant
Mastectomy benefits include all stages of reconstruction of the breast on which the mastectomy was performed surgery and reconstruction of the other breast to produce a symmetrical appearance
prosthesis and treatment of physical complications of mastectomy including lymphedemas 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 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
Dialysis Chemotherapy radiation therapy and inhalation therapy All self administered drugs will be
administered through the Prescription Drug Benefit
Orthopedic devices such as braces prosthetic devices such as artificial limbs and external lenses following cataract removal and durable medical equipment such as wheelchairs and hospital beds
including colostomy supplies are provided up to a maximum Plan payment of 2,500 per year and a lifetime maximum of 50,000
Oxygen and the rental of related equipment Home health services of nurses health aides and medical social workers for up to two hours per visit
including intravenous fluids and medications when prescribed by your Plan doctor and approved by the Plan who will periodically review the program for continuing appropriateness and need
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers The Standard Option deductible and coinsurance apply
Non Plan For both options if you use the services of non Plan providers in the KPS Service Area payment will be
providers made to you of up to 75 of the KPS maximum Schedule of Allowances and you will be responsible for the difference between the provider's charges and the Plan's allowance All applicable copays deductibles and
coinsurance will be applied No coverage is provided for services of non Plan providers outside the KPS Service Area except for emergencies or Plan authorized referrals Elective surgery performed by a nonPlan
provider must be authorized in advance by the Plan's medical director
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
KPS Health Plans 2000
Section 5 Benefits continued
Medical and Surgical Benefits continued
Limited Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures
benefits for congenital defects such as cleft lip and cleft palate and for nondental 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 any dental care involved in
treatment of temporomandibular joint TMJ pain dysfunction syndrome
Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an 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
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to two consecutive months per condition if significant
improvement can be expected within two months you pay appropriate copays or deductible and coinsurance as stated on page 7 as for office visits 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 Room and board charges will be covered only if skilled nursing care is medically necessary and prior approval is obtained from the Plan's Medical Director
Diagnosis medical and surgical treatment and hospitalization of infertility is covered you pay 50 of covered charges The following types of artificial insemination are covered
intravaginal insemination IVI and intracervical insemination ICI you pay 50 of covered charges cost of donor sperm is not covered Fertility drugs are not covered Other assisted
reproductive technology ART procedures such as in vitro fertilization intrauterine insemination IUI and embryo transfer are not covered drugs for the treatment of infertility are
not covered
Cardiac rehabilitation following a heart transplant bypass surgery myocardial infarction or in cases of stable angina pectoris is provided for up to a maximum Plan payment of 500 you pay
all costs after the first 500
Smoking cessation The following services will be provided at 50 of charges when directly related to selected smoking cessation programs The services of a Plan doctor hospital
psychologist or licensed smoking cessation provider will be covered to a lifetime maximum of 150 per member Approved medications obtained at a Plan pharmacy will be covered under the
Prescription Drug Benefit to a lifetime maximum of 350 per member This benefit is not subject to the deductible No other benefits for smoking cessation are available
Morbid obesity Surgical treatment of morbid obesity including gastric bypass surgery or gastric stapling prior Plan approval is required you pay 50 of covered charges
Outpatient nutritional guidance counseling by a registered dietitian if the services are recommended by a Plan doctor for the following conditions diabetes cancer endocrine
conditions swallowing conditions after stroke hyperlipidemia Other conditions may be payable upon review by the Medical Director Coverage is NOT provided for weight control obesity or
surgical procedures for weight reduction The maximum benefit payable is 400 per member per year
Sleep disorders 8,000 lifetime maximum Must be approved by the Plan
a Sleep studies including polysomnograph multiple sleep latency tests continuous positive airway pressure CPAP studies and durable medical equipment and supplies will be
covered for the following sleep disorders when diagnosed and referred by a Plan doctor narcolepsy and sleep apnea syndrome such as obstructive upper airway and or central sleep
apnea Other conditions may be payable upon review by the Medical Director Sleep studies are limited to a lifetime maximum of 5,000 per member You pay 50 of covered charges
b Surgical treatment of the above listed sleep disorders will be limited to a lifetime maximum of 3,000 per member You pay 50 of covered charges
No other benefits will be provided for the purpose of studying monitoring and or treating sleep disorders
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
9
11
11
Page 12
13
KPS Health Plans 2000
Section 5 Benefits continued Medical and Surgical Benefits
continued
What is not Physical examinations and immunizations that are not necessary for medical reasons such as
covered those required for obtaining or continuing employment or insurance attending school or camp or travel or because a person works in an environment with a high risk of exposure
All treatment for obesity except for the surgical treatment of morbid obesity that may include gastric bypass surgery or gastric stapling
Treatment for impotence unless determined by the Plan to be medically necessary
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Hearing aids
Transplants not listed as covered
Foot orthotics
Chiropractic services
Homemaker services
Self help training programs or treatments which are designed to aid or improve one's self
Acupuncture naturopathy biofeedback massage therapy
Long term outpatient rehabilitative therapy
Palliative or cosmetic foot care treatment of subluxations of the foot flat foot conditions fallen arches chronic foot strain weak feet care of corns calluses toe nails and bunions except
capsular or bone surgery
Hospital Extended Care Benefits
What is covered 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
Hospital care High Option You pay a 200 copay per inpatient admission
Standard Option You pay 20 of charges after a 100 deductible
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 with no dollar or day limit when full time skilled 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 Extended care benefits require prior authorization by the Plan's Medical Director
High Option You pay nothing
Standard Option You pay 20 of charges after a 100 deductible
All necessary services are covered including
Bed board and general nursing care Drugs 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 Services include medical 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 There is a 5,000 maximum Plan payment per member per
calendar year
Ambulance Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor and when
service medically necessary Air ambulance benefits are limited to 5,000 per trip If however you are hospitalized in a non Plan facility and Plan doctors believe care can be provided in a Plan hospital
you will be transferred when medically feasible with any ambulance charges covered in full
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
KPS Health Plans 2000
Section 5 Benefits continued Limited Benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a
procedures 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 would be covered include hemophilia and heart disease the need for anesthesia by itself is not such a condition
What is not Personal comfort items such as telephone and television
Covered Custodial care rest cures domiciliary or convalescent care Inpatient hospice care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
Emergency Benefits
What is a A medical emergency is the sudden and unexpected onset of a condition or an injury that you
medical believe endangers your life or could result in serious injury or disability and requires immediate
emergency 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 If you are in an emergency situation please call your doctor In extreme emergencies if you are
within the unable to contact your doctor contact the local emergency system e g the 911 telephone system
service area 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 should notify the Plan
within 48 hours It is your responsibility to ensure that the Plan has been timely notified
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify the Plan within that
time If you are hospitalized in non Plan facilities and Plan doctors believe care can be better provided in a Plan hospital you will be transferred when medically feasible with any ambulance
charges covered in full
Benefits are available for care from non Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death disability or significant jeopardy to your condition
To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay High Option You pay a 25 copay per visit for emergency care services at an emergency room or urgent care center which are covered benefits of this Plan If the emergency results in
admission to a hospital inpatient services are subject to the hospital admission copay of 200 not applicable to accidental injury admissions and the emergency care copay is waived
Standard Option You pay 20 of charges after a 100 deductible for emergency care services at an emergency room or urgent care center which are covered benefits of this Plan
Emergencies outside Benefits are available for any medically necessary health service that is immediately required
the service area 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
To be covered by this Plan any follow up care recommended by non Plan providers must be
approved by the Plan or provided by Plan providers
KPS Health Plans 2000
Section 5 Benefits continued Emergency Benefits continued
Plan pays Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers
You pay High Option You pay a 25 copay per visit for emergency care services at an emergency room or urgent care center which are covered benefits of this Plan If the emergency results in admission to a
hospital inpatient services are subject to the hospital admission copay of 200 not applicable to accidental injury admissions and the emergency care copay is waived
Standard Option You pay 20 of charges after 100 deductible for emergency care services at an emergency room or urgent care center which are covered benefits of this Plan
What is covered Emergency care at a doctor's office or at an urgent care center Emergency care as an outpatient at a hospital including doctors services
Ambulance service approved by the Plan
What is not Elective care or nonemergency care
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 With your authorization the Plan will pay benefits directly to the providers of your emergency care
for non Plan upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If you are required to pay for the services submit itemized bills and your receipts to the Plan along with
providers 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 pages 5 6
Mental Conditions Substance Abuse Benefits
Mental All inpatient stays and outpatient visits must be pre authorized by the Plan You or your mental
conditions health provider must obtain pre authorization by calling 1 800 223 6114 before services are provided If pre authorization is not obtained payment for the services will be denied Note
Pre authorization is not required for treatment rendered by a state hospital when the member has been involuntarily committed
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 each hour of psychological testing counts as and is paid as one visit
maximum two per year
Psychiatric treatment including individual and group therapy Hospitalization including inpatient professional services
Outpatient care Under both options you pay 50 of charges
Inpatient care Up to 30 days of hospitalization each calendar year If a hospitalization extends from one contract year to the next and reaches or exceeds the covered benefit of 30 days the member must be discharged
before the new year's benefit of 30 days becomes available
High Option You pay nothing during the first 30 days all charges thereafter
Standard Option You pay 20 of charges after a 100 deductible during the first 30 days all charges thereafter
What is not Care for psychiatric conditions that in the professional judgment of the Plan are not subject to
covered 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 the Plan to be necessary and appropriate Psychological testing that is not medically necessary to determine the appropriated treatment of a
short term psychiatric condition Biofeedback self help stress management
Family or marital counseling Diagnosis or treatment of developmental delay speech delay or learning disabilities
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
12
14
14
Page 15
16
KPS Health Plans 2000
Section 5 Benefits continued Mental Conditions Substance Abuse
Benefits continued
Substance abuse All inpatient stays and outpatient visits must be pre authorized by the Plan You or your substance abuse provider must obtain pre authorization by calling 1 800 223 6114 before
services are provided If pre authorization is not obtained payment for the services will be denied
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 and to the extent shown below the services necessary for diagnosis and treatment
Outpatient care Under both options you pay 50 of charges
Inpatient care For both options the Plan pays up to 5,000 for substance abuse rehabilitation intermediate care programs per 24 month period in a Plan designated hospital or State approved center you pay all
charges in excess of 5,000
What is not Treatment that is not authorized by the Plan
covered Court ordered treatment for substance abuse unless determined by the Plan to be necessary and appropriate
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor that are medically necessary and obtained at a Plan pharmacy will be dispensed for up to a 31 day supply except certain
maintenance drugs approved by the Plan may be dispensed on a 3 month supply basis
High Option You pay a 600 deductible per member per year and 50 of charges thereafter
Standard Option You pay 20 of charges
Covered medications and accessories include
Drugs for which a prescription is required by law
Insulin with a copay coinsurance charge applied to each vial
Diabetic supplies including insulin syringes needles glucometers glucose test tablets and test tape Benedict's solution or equivalent and acetone test tablets
Prenatal vitamins during pregnancy
Disposable needles and syringes needed to inject covered prescribed medication
Growth hormones
Intravenous fluids and medication for home use implantable drugs and some injectable drugs are covered under Medical and Surgical Benefits
Drugs for the treatment of impotence when determined by the Plan to medically necessary to an annual maximum Plan payment of 500 per member
Oral and injectable contraceptive drugs contraceptive diaphragms intrauterine devices IUDs implanted time released contraceptives such as Norplant
Smoking cessation Under both Options approved medications obtained at a Plan pharmacy will be provided at 50 of charges when directly related to selected smoking cessation
programs to a lifetime maximum of 350 per member This benefit is not subject to the
deductible
What is not Drugs available without a prescription or for which there is a non prescription equivalent
covered available except certain over the counter substances approved by the Plan Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription except as specified above
Medical supplies such as dressings and antiseptics Drugs for the treatment of infertility
Drugs for cosmetic purposes Drugs to enhance athletic performance
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
13
15
15
Page 16
17
KPS Health Plans 2000
Section 5 Benefits continued Prescription Drug Benefits continued
What is not Implanted time release medications except those used for contraception such as Norplant
covered continued Drugs prescribed to treat any non covered service Drugs designated by the Plan Pharmacy and Therapeutics Committee which is made up of
Plan doctors and Plan pharmacists Compounded drugs for hormone replacement therapy
Drugs that are not medically necessary according to accepted medical dental or psychiatric practice as determined by the Plan
Other Benefits
Dental care
What is covered The following preventive and diagnostic dental services are covered when provided by Plan
Standard Option only dentists No deductible is required You pay 20 of charges
Preventive Diagnostic
dental care Full mouth X rays once every 5 years Bitewing X rays once a year
Oral exam once each 6 month period
Emergency Examination as determined by the Plan
Preventive
Prophylaxis cleaning once each 6 month period
Fluoride once each 6 month period to age 18
No coverage is provided for diagnostic or preventive care rendered by non Plan dentists within or
outside the KPS service area You will be reimbursed up to 80 of KPS Maximum Schedule of
Allowances for emergency services required when you are over 100 miles from home and a Plan
dentist is not available
Basic dental care The following basic dental services are covered when provided by participating Plan dentists A deductible of 25 per member 50 maximum per family per year is required for these services
You pay 20 of charges
Restorative
Restoration of carious decayed teeth to a state of functional accepta bility utilizing filling
materials such as amalgam silicate or plastic
Application of sealants for permanent molars and bicuspids only with a 3 year limitation per
surface to age 14
Oral Surgery
Removal of teeth and minor surgical procedures including surgical and non surgical extractions
preparation of the alveolar ridge and soft tissues of the mouth for insertion of dentures and
general anesthesia when administered in connection with covered oral surgery procedures
Periodontics
Surgical and non surgical procedures for treatment of the tissues supporting the teeth including
root planning subgingival curettage gingivectomy and minor adjustments to occlusion such as
smoothing ofteeth or reducing cusps
Endodontics
Procedures for pulpal and root canal therapy including pulp exposure treatment pulpotomy and
apicoectomy
Pedodontics
Space maintainers when used to maintain space only
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
KPS Health Plans 2000
Section 5 Benefits continued Other Benefits
continued
Dental care continued
What is not Appliances or restorations necessary to correct vertical dimensions or restore the occlusion
covered are not covered Crowns are not covered
Restorations on the same surface s of the same tooth are covered once in a two year period
Ridge extensions for insertion of dentures are not covered
General anesthesia is covered only when administered by a dentist in connection with a covered oral surgery procedure
Major surgical procedures e g mandibular osteotomy are not covered
Periodontal splinting and or crown and bridgework used in conjunction with periodontal splinting is not covered
Root planning and or subgingival curettage is covered once in a 12 month period
Root canal treatment on the same tooth is covered only once in a two year period
Replacement of a space maintainer previously covered by the Plan is not covered
Procedures appliances or restorations primarily for cosmetic purposes or nightguards including all charges for Orthodontic Services
Coverage for teeth missing or dental services started prior to the date the member enrolled in this Plan
Diagnosis of or treatment for temporomandibular joint TMJ disorders
Other dental services not shown as covered
Accidental Restorative services and supplies necessary to promptly repair but not replace sound natural
injury benefit teeth are covered Sound natural teeth are those that do not have any restoration The need for
both options these services must result from an accidental injury not biting or chewing occurring while the member is covered under the FEHB Program all services must be performed and completed
within 12 months of the date of the injury
High Option You pay nothing Standard Option You pay 20 of charges
Vision Care
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye this Plan provides an annual eye refraction including a written lens prescription for
but not including eyeglass lenses
High Option You pay a 10 office visit copay per visit
Standard Option You pay 20 of charges after a 100 deductible
For both options if you use the services of non Plan doctors in the KPS Service Area payment
will be made to you of up to 75 of the KPS maximum Schedule of Allowances and you will be
responsible for the difference between the provider's charges and the Plan's allowance All
applicable copays deductibles and coinsurance will be applied No coverage is provided for the
services of non Plan doctors outside the KPS Service Area except for emergencies or referrals
What is not Corrective lenses or frames
covered Eye exercises treatment of dyslexia visual analysis therapy training related to muscular imbalance of the eye and orthoptics
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
15
17
17
Page 18
19
KPS Health Plans 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 the Plan 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 as determined by the Plan Services not required according to accepted standards of medical dental or psychiatric practice as determined by the Plan
Care by non Plan providers when received outside the Plan's Service Area except for authorized referrals or emergencies see Emergency Benefits
Experimental or investigational procedures treatments drugs or devices as determined by the Plan 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
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 Medicare is the primary payer for you and or your covered dependent submit your claims or ask your
providers to submit your claims to Medicare first Claims for secondary benefits together with
Medicare's Explanation of Benefits form should be sent to this Plan after Medicare has paid its benefits
If Medicare is the secondary payer for you and or your covered dependent claims should be submitted
to this Plan first then to Medicare Be sure the claims include information about your employment or
end stage renal disease if appropriate
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 1 800 638 6833
KPS Health Plans 2000
Section 7 Limitations Rules that affect your benefits continued
Other group When anyone has coverage with us and with another group health plan it is called double coverage
insurance You must tell us if you or a family member has double coverage You must also send us documents
coverage about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan is
secondary it pays benefits next We decide which insurance is primary according to the National
Association of Insurance Commissioners Guidelines
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
are responsible another person caused you must reimburse us for whatever services we paid for We will cover the cost
for injuries 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 or
Government indirectly pays for
Agencies
If you have a If you have a malpractice claim because of services you did or did not receive from a plan provider it
malpractice must go to binding arbitration Contact us about how to begin our binding arbitration process
claim
KPS Health Plans 2000
Section 8 FEHB Facts
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the
information about right to information about your health plan its networks providers and facilities You can also
your Plan 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 www opm gov lists the specific types of information that we must make
available to you
If you want specific information about us call 360 478 6796 or write to KPS Health Plans P O
Box 339 Bremerton Washington 98337 You may also contact us by fax at 360 415 6514 or
visit our website at www kpshealthplans com
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 benefits The benefits in this brochure are effective on January 1 If you are new to this plan your
and premiums coverage and premiums begin on the first day of your first pay period that starts on or after
effective January 1 Annuitants premiums begin January 1
What happens when When you retire you can usually stay in the FEHB Program Generally you must have been
I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet this requirement you may be eligible for other forms of coverage such as Temporary
Continuation of Coverage which is described later in this section
What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your
coverage are unmarried dependent children under age 22 including any foster or step children your employing
available for me and or retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of self support
my family 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
Are my medical and We will keep your medical and claims information confidential Only the following will have
claims records access to it
confidential OPM this Plan and subcontractors when they administer this contract 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
KPS Health Plans 2000
Section 8 FEHB Facts continued
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 have solely
conditions 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 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 coverage under your former spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse equity law If you are recently divorced or are anticipating a divorce contact
your ex spouse's employing or retirement office to get more information about your coverage choices
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For
example you can receive TCC if you are not able to continue your FEHB enrollment after you retire You may not elect TCC if you are fired from your Federal job due to gross misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees
from your employing or retirement office
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 32 nd day after your regular coverage ends even if several months have
passed
You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits How do I enroll in If you leave Federal service your employing office will notify you of your right to enroll under
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
KPS Health Plans 2000
Section 8 FEHB Facts continued
How do I enroll in
Your employing or retirement office will then send your former spouse information about
TCC continued 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 Your coverage under TCC or the spouse equity law ends If you canceled your coverage or
coverage 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 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 Plan Coverage 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
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 360 478 6796 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
for
KPS
Health
Plans
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
ARE
COVERED
ONLY
WHEN
PROVIDED
OR
ARRANGED
BY
PLAN
DOCTORS
Benefits
High
Option
pays
provides
Page
Standard
Option
pays
provides
Page
Inpatient
Comprehensive
range
of
medical
and
surgical
services
without
dollar
or
day
Comprehensive
range
of
medical
and
surgical
services
without
dollar
or
day
care
limit
Includes
in
hospital
doctor
care
room
and
board
general
nursing
limit
Includes
in
hospital
doctor
care
room
and
board
general
nursing
care
private
room
and
private
nursing
care
if
medically
necessary
care
private
room
and
private
nursing
care
if
medically
necessary
diagnostic
tests
drugs
and
medical
supplies
use
of
operating
room
diagnostic
tests
drugs
and
medical
supplies
use
of
operating
room
intensive
care
and
complete
maternity
You
pay
200
per
admission
10
intensive
care
and
complete
maternity
You
pay
20
of
charges
10
Extended
care
All
necessary
services
no
dollar
or
day
limit
You
pay
nothing
10
All
necessary
services
no
dollar
or
day
limit
You
pay
20
of
charges
10
Mental
conditions
Diagnosis
and
treatment
of
acute
psychiatric
conditions
for
up
to
30
days
of
Diagnosis
and
treatment
of
acute
psychiatric
conditions
for
up
to
30
days
of
12
inpatient
care
per
year
You
pay
nothing
12
inpatient
care
per
year
You
pay
20
of
charges
Substance
abuse
Each
member
is
entitled
to
rehabilitative
benefits
of
5,000
per
24
month
Each
member
is
entitled
to
rehabilitative
benefits
of
5,000
per
24
month
period
13
period
13
Outpatient
Comprehensive
range
of
services
such
as
diagnosis
and
treatment
of
illness
Comprehensive
range
of
services
such
as
diagnosis
and
treatment
of
illness
care
or
injury
including
specialist's
care
preventive
care
including
well
baby
or
injury
including
specialist's
care
preventive
care
including
well
baby
care
periodic
check
ups
and
routine
immunizations
laboratory
tests
and
care
periodic
check
ups
and
routine
immunizations
not
subject
to
X
rays
complete
maternity
care
You
pay
a
10
copay
per
office
visit
a
deductible
laboratory
tests
and
X
rays
complete
maternity
care
You
pay
15
copay
per
home
visit
7
8
20
of
charges
7
8
Home
health
care
Services
by
nurses
health
aides
and
medical
social
workers
You
pay
Services
by
nurses
health
aides
and
medical
social
workers
You
pay
20
nothing
7
8
of
charges
7
8
Mental
conditions
No
visit
limits
if
you
access
care
through
the
Managed
Mental
Health
No
visit
limits
if
you
access
care
through
the
Managed
Mental
Health
12
Program
You
pay
50
of
charges
12
Program
You
pay
50
of
charges
Substance
abuse
No
visit
limits
if
you
access
care
through
the
Managed
Substance
Abuse
No
visit
limits
if
you
access
care
through
the
Managed
Substance
Abuse
13
Program
You
pay
50
of
charges
13
Program
You
pay
50
of
charges
Emergency
Reasonable
charges
for
services
and
supplies
required
because
of
a
medical
Reasonable
charges
for
services
and
supplies
required
because
of
medical
care
emergency
You
pay
25
copay
for
each
emergency
room
visit
and
any
emergency
You
pay
20
and
charges
for
each
emergency
room
visit
and
charges
for
services
that
are
not
covered
benefits
of
this
plan
11
12
any
charges
for
services
that
are
not
covered
benefits
of
this
Plan
11
12
Prescription
Drugs
prescribed
by
a
Plan
doctor
when
filled
at
a
Plan
pharmacy
You
Drugs
prescribed
by
a
Plan
doctor
when
filled
at
a
Plan
pharmacy
You
13
14
drugs
pay
50
of
costs
after
meeting
a
600
calendar
year
deductible
13
14
pay
20
of
charges
Dental
care
Accidental
injury
benefit
You
pay
nothing
15
Accidental
injury
benefit
you
pay
20
of
charges
Preventive
dental
care
you
pay
20
of
charges
no
deductible
required
Basic
dental
care
you
14
15
pay
20
of
charges
after
a
25
deductible
Vision
care
One
refraction
annually
You
pay
a
10
copay
per
office
visit
15
One
refraction
annually
You
pay
20
of
charges
15
Out of
pocket
Copayments
are
required
for
a
few
benefits
However
the
Plan
has
In
addition
to
the
deductible
coinsurance
is
required
for
most
benefits
maximum
established
a
maximum
amount
of
600
per
member
per
calendar
year
for
However
the
Plan
has
established
a
maximum
amount
of
2,000
per
person
hospital
copayments
3
2,000
per
family
per
calendar
year
of
total
coinsurance
charges
required
for
services
provided
or
arranged
by
the
Plan
This
coinsurance
maximum
does
not
include
costs
of
prescription
drugs
or
dental
services
3
These
benefits
are
subject
to
a
100
per
member
per
year
deductible
maximum
of
two
deductibles
per
Self
and
Family
2000 Rate Information for
Kitsap Physicians Service
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB Guide for that
category or contact the agency that maintains your health benefits enrollment
Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred to as
Category A rates and Category B rates will apply for certain career employees If you are a career postal employee but not a
member of a special postal employment class refer to the category definitions in The Guide to Federal Employees Health Benefits
Plans for United States Postal Service Employees RI 70 2 to determine which rate applies to you
Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or associate
members of any postal employee organization Such persons not subject to postal rates must refer to the applicable Guide to
Federal Employees Health Benefits Plans
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share
Kitsap Mason Jefferson Counties
High Option VT1 78.83 71.28 170.80 154.44 93.06 57.05 93.26 56.85
Self Only
High Option VT2 175.97 145.11 381.27 314.40 207.74 113.34 201.02 120.06
Self and Family
Kitsap Mason Jefferson Counties
Standard Option VT4 77.57 25.86 168.08 56.02 91.79 11.64 91.79 11.64
Self Only
Standard Option VT5 169.51 56.50 367.27 122.42 200.58 25.43 200.58 25.43
Self and Family
24