Kaiser Foundation
Health Plan of Kansas City Inc 2000 A Health Maintenance Organization
For changes benefits in
page 4 see
Serving Kansas City Metropolitan Area
Kansas and Missouri
Enrollment in this Plan is limited see page 5 for requirements
Enrollment code HA1 Self Only
HA2 Self and Family
This Plan has commendable accreditation
from the NCQA See the 2000 Guide
for more information on NCQA
Visit the OPM website at http www opm gov insure
and
our website at http www kaiserpermanente org
Authorized for distribution by the
United States Office of Personnel Management
Retirement and Insurance service
RI 73 128
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Kaiser Foundation Health Plan of Kansas City Inc 2000
Table of Contents
Introduction
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Plain language
2
How to use this brochure
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Section 1 Health Maintenance Organizations
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Section 2 How we change for 2000
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Section 3 How to get benefits
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Section 4 What to do if we deny your claim or request for service
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Section 5 Benefits
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Section 6 General exclusions Things we don't cover
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Section 7 Limitations Rules that affect your benefits
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Section 8 FEHB FACTS
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Inspector General Advisory Stop Healthcare Fraud
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Summary of benefits
Inside back cover
Premiums
Back cover
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Kaiser Foundation Health Plan of Kansas City Inc 2000
Introduction
Kaiser Foundation Health Plan of Kansas City Inc
10561 Barkley
Overland Park Kansas 66212
This brochure describes the benefits you can receive from Kaiser Foundation Health Plan of Kansas City Inc under its contract
CS 1948 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 Kansas City Inc 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 Kansas City Inc 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
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
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 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 Kansas City Inc 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 changes 10 for all primary care office visits
This year you have a right to more information about this Plan care management our networks
facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request you may
continue to see your specialist for up to 90 days If your provider leaves the Plan and you are in the
second or third trimester of pregnancy you may be able to continue seeing your OB GYN until the end
of your postpartum care You have similar rights if this Plan leaves the FEHB program See Section 3
How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your
medical records ask your health care provider for them You may ask that a physician amend a record
that is not accurate not relevant or incomplete If the physician does not amend your record you may
add a brief statement to it If they do not provide you with your records call us and we will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This
screening is for colorectal cancer
Changes to this Your share of the non postal premium will increase by 14.3 for Self Only or 14.3 Plan for Self and Family
The primary care office visit copay will increase from 5 to 10 See page 10
The copay for outpatient surgery obtained in a hospital or outpatient surgery center will increase from
5 to 50 See page 10
Pulmonary rehabilitation will be covered with a 50 copay See page 11
The short term rehabilitative therapy benefit no longer has a thirty visit limitation See page 11
Chiropractic visits will now be covered with a 15 copay per visit up to a maximum of 20 visits per
calendar year See page 11
This Plan will pay 100 up to the first 1,000 for durable medical equipment external prosthetic and
orthopedic devices per calendar year See page 12
The copay for prescription drugs will increase from 3 to 5 See page 18
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Kaiser Foundation Health Plan of Kansas City Inc 2000
Section 3 How to get benefits
What is this To enroll in this Plan you must live or work in our service area This is where our Plan's providers practice Our service area is
service area Kansas counties Johnson Leavenworth and Wyandotte
Missouri counties Cass Clay Jackson and Platte
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 16 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 con
sider enrolling in another plan If you or a family member move you do not have to wait
until Open Season to change plans Contact your employing or retirement office
How much You must share the cost of some services This is called either a copayment a set dollar amount do I 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 receiveyour service you will be billed for ice 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 2,000 in copayments or coinsurance for one family member or 4,500 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
cosmetic services extended care services durable medical equipment external prostheses and braces the
25 charges paid for follow up or continuing care chiropractic services dental care services and all mental
conditions services except the first 20 outpatient visits do not count toward these limits and you must
continue to pay for these services as described in this brochure
Be sure to keep accurate records of your copayments and coinsurance since you are responsible for
informing us when you reach the limits
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a provider submit claims 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
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Kaiser Foundation Health Plan of Kansas City Inc 2000
Section 3 How to get benefits continued
Who Kaiser Permanente offers comprehensive health care at six Plan facilities conveniently located provides my throughout the Kansas City metropolitan area and through referral specialists hospitals and other providers
health care in the community The Plan contracts with the Permanente Medical Group of Mid America P A an independent multi specialty group of physicians and with Lee's Summit Family Care Center Lee's Summit
Missouri to provide or arrange all necessary physician care for Plan members Medical care is provided
through doctors and other skilled medical personnel working as medical teams Specialists in most major
specialties are available as part of the medical teams for consultation and treatment These doctors are
members of American Specialty Boards or are Board Eligible Plan doctors also arrange for local referral
specialists to provide any necessary specialty physician care not directly available from Plan doctors Other
necessary medical services such as physical therapy and laboratory and X ray services are also available at
Plan facilities Hospital care is provided at 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 gynecologist without having to obtain a referral You may also receive mental health and optometry
services 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 Member Services at 913 642 2662 If you want to receive
care from a specific physician who is listed in the directory call Member Services to verify that he or she
still participates with the Plan and is accepting new patients
Notify the Plan of the primary care physician you choose If you need help choosing a primary care
physician call the Plan You may change your primary care physician by notifying the Plan at any time
You are free to see other Plan physicians if your primary care physician is not available and to receive care
at other Kaiser Permanente facilities
What do I do Call us We will help you select a new one if my primary
care physician
leaves the Plan
What do I do Your primary care physician or specialist will make the necessary arrangements and continue if I need to to supervise your care
go into the hospital
What do I do First call the Member Services Department at 913 642 2662 If you are new to the FEHB if I'm in the Program we will arrange for you to receive care If you are currently in the FEHB
hospital Program and are switching to us your former plan will pay for the hospital stay until when I join You are discharged not merely moved to an alternative care center or
this Plan 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
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Kaiser Foundation Health Plan of Kansas City Inc 2000
Section 3 How to get benefits continued
How do I get Your primary care physician will determine if you need care from a specialist He or she will obtain specialty necessary authorizations from the Plan The referral will describe the services you will receive You
care 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 Your primary care physician will decide what treatment you need If your primary care physician if I am decides to refer you to a specialist ask if you can see your current specialist If your current
seeing a specialist does not participate with us you must receive treatment from a specialist who does specialist Generally we will not pay for you to see a specialist who does not par ticipate with our Plan
when I enroll
What do I do Call your primary care physician who will arrange for you to see another specialist You may receive if my services from your current specialist until we can make arrangements for you to see someone else
specialist leaves the
Plan
But what if I Please contact us if you believe your condition is chronic or disabling You may be able to continue seeing have a your physician for up to 90 days after we notify you that we are terminating our contract with the provider
serious unless the termination is for cause If you are in the second or third trimester of pregnancy you may illness and continue to see your OB GYN until the end of your postpartum care
my provider leaves the You may also be able to continue seeing your physician if this Plan drops out of the FEHB Program and
Plan or this Plan you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic leaves the condition or are in your second or third trimester Your new plan will pay for or provide your care for up
Program 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 physician must get our approval before sending you to a hospital referring you to a specialist or authorize recommending follow up care Before giving approval we consider if the service is medically necessary
medical to prevent diagnose or treat an illness or condition We follow generally accepted medical practice in services providing services to you
How do you decide When the service or supply including a drug 1 has not been approved by the FDA or 2 is the subject if a service is of a new drug or new device application on file with the FDA or 3 is part of a Phase I or Phase II cliniexperimental
or cal trial as the experimental or research arm of a Phase III clinical trial or is intended to evaluate the investigational safety toxicity or efficacy of the service or 4 is available as the result of a written protocol that
evaluates the service's safety toxicity or efficacy or 5 is subject to the approval or review of an
Institutional Review Board or 6 requires an informed consent that describes the service as experimental
or investigational then this Plan considers that service supply or drug to be experimental and not covered
by the Plan This Plan and its Medical Group carefully evaluates 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 Kansas City Inc 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 OPM to review refusal OPM will determine if we correctly applied the terms of our contract when we
a denial denied your claim or request for service
What if I have a Call us at 913 642 2662 and we will expedite our review serious or life
threatening condition and
you haven't responded to
my request for service
What if you If we expedite your review due to a serious medical condition and deny your claim we have denied my will inform OPM so that they can give your claim expedited treatment too
request for care Alternatively you can call OPM's health benefits Contract Division 3 at 202 606 0755 and my between 8 00 a m and 5 00 p m Serious or life threatening conditions are ones that
condition is may cause permanent loss of bodily functions or death if they are not treated as soon as serious or life possible
threatening
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Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our initial denial time limits or refusal of service You may also ask OPM to review your claim if
1 We did not answer your request within 30 days In this case OPM must receive your request within 120
days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we 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 Your request must be complete or OPM will return it to you You must send the following to 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 Programs Contracts Division 3 P O Box 436 Washington D C 20044
disputed claim to
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with upholds the our 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 Federal law governs your lawsuit benefits and payment of benefits The Federal court apply if I file a will base its review on the record that was before OPM when OPM made its decision on
lawsuit 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 Chapter 89 of title 5 United States Code allows OPM to use the information it collects and the Privacy from you and us to determine if our denial of your claim is correct The informationOPM collects
Act during the review process becomes a permanent part of your disputed claims file and is subject to the provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this
information to support the disputed claim decision If you file a lawsuit this information will become
part of the court record
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Section 5 Benefits
Medical and Surgical Benefits
A comprehensive range of preventive diagnostic and treatment services is provided by Plan physicians and other Plan providers
This includes all necessary office and outpatient surgery visits you pay a 10 office visit copay and you pay 50 for each outpatient
surgery in a hospital or outpatient surgery center You pay 10 for each outpatient surgery in a medical office There is no
additional copay for laboratory and x rays You pay a 10 copay for all approved visits to a non Plan provider's office You pay
nothing for well child care visits well woman care visits routine pap smears and mammograms prenatal and postnatal care and
personal health appraisals 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 nothing for a physician's house call
Preventive care including well baby care and periodic check ups no charge
Personal health appraisals
Mammograms for women age 35 through 39 one mammogram during these five years for women age 40 through 49 one
mammogram every one or two years for women age 50 through 64 one mammogram every year and for women age 65 and
above one mammogram every two years at no charge In addition to routine screening medically necessary mammograms to
diagnose or treat your illness
Routine immunizations and boosters for children up to age 12 these are provided at no charge
Consultations with specialists
Diagnostic procedures such as laboratory tests and X rays no charge
Complete obstetrical maternity care for covered females including prenatal delivery and post natal care by a Plan physician at
no charge The mother at her option may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a
cesarean delivery Inpatient stays will be extended if medically necessary If enrollment in the Plan is terminated during
pregnancy benefits will not be provided after coverage under the Plan has ended Ordinary nursery care of the newborn 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 including diaphragms
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 prosthetics devices such as pacemakers and artificial joints
Cornea heart heart lung kidney simultaneous pancreas kidney liver and lung single and double transplants allogeneic
donor bone marrow transplants autologous bone marrow transplants autologous stem cell and peripheral stem cell support for
the following conditions acute lymphocytic on non lymphocytic leukemia advanced Hodgkin's lymphoma advanced non
Hodgkin's lymphoma advanced neuroblastoma breastcancer muliple myeloma epithelial ovarian cancer and testicular
mediastinal retroperitoneal and ovarian germ cell tumors Transplants are covered whenapproved by the Medical Group Related
medical and hospital expenses of thedonor 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 including colony stimulating drugs as required to maintain the
member's general condition during treatment
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided up to the level of
rehabilitation where cardiac monitoring is no longer medically necessary
Surgical treatment of morbid obesity
Home health services of nurses health aides and wound care supplies 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
Blood and blood products and the administration of blood no charge
Visits to receive injections
Initial lenses following cataract removal no charge
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
Pulmonary rehabilitation You pay a 50 copay per pulmonary incident in other words if someone has a pulmonary incident
and it requires them to make 10 trips for rehab they're only going to be responsible for paying 50 one time to cover the 10
visits
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
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 except as
covered on page 19
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 her attending physician may decide whether to have breast reconstruction surgery following a mastectomy and whether
surgery on the other breast is needed to produce a symmetrical appearance
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for two
consecutive months per condition if significant improvement can be expected within two months You pay 10 per outpatient
session and nothing for an inpatient session Speech therapy is limited to treatment of certain speech impairments of organic origin
Occupational therapy is limited to services that assist the member to achieve and maintain self care and improved functioning in
other activities of daily living You may receive inpatient therapy as part of a specialized therapy program in a specialized
rehabilitation facility for up to two consecutive months per condition You pay nothing
Diagnosis and treatment of infertility is covered you pay 50 of non member rates Artificial insemination is covered including
intracervical insemination ICI intrauterine insemination IUI and intravaginal insemination IVI you pay 50 of non member
rates per insemination procedure Cost of donor sperm and donor eggs and services related to their procurement and storage are not
covered Other assisted reproductive technology ART procedures such as in vitro fertilization gamete and zygote intrafallopian
transfer are not covered Infertility services are not available when either member of the family has been voluntarily surgically
sterilized Drugs used for covered infertility treatments are not covered Drugs related to non covered infertility treatments are not
covered
Chiropractic services Up to 20 visits per calendar year of self referred chiropractic services provided by Participating
Chiropractors Covered services include evaluation laboratory services and X rays and treatment of musculoskeletal disorders
You pay 15 per visit The following are not covered non neuroskeletal disorders vocational rehabilitation services thermography
transportation costs including ambulance prescription drugs vitamins minerals nutritional supplements or other similar type
products MRI or other types of diagnostic radiology
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Section 5 Benefits continued
Durable medical equipment and external prosthetic and orthopedic devices and braces are covered only when they are 1 able
to withstand repeated use 2 required to support or correct a defect of form or function or a permanently non functioning or
malfunctioning body part 3 primarily used as an alternative to surgery or to speed recovery following surgery and 4 in general
use before April 1 of the prior year Coverage includes orthopedic braces for scoliosis breast prostheses and surgical bras as well as
their replacement or equipment required as a part of acute primary care such as back braces rib belts slings and cervical collars
Purchase or rental is at the Plan's discretion You pay nothing up to the first 1,000 of charge and you pay all charges over and
above 1,000 per calendar year limit
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 attending school or camp or travel
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
External and internally implanted hearing aids
Homemaker services
Long term rehabilitative therapy
Transplants not listed as covered
Any eye surgery solely for the purpose of correcting refractive defects of the eye such as nearsightedness myopia
farsightedness hyperopia and astigmatism
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
Prescribed drugs and their administration blood and blood products and the administration of blood biologicals supplies and
equipment ordinarily provided or arranged as part of inpatient services
Extended care
The Plan provides a comprehensive range of benefits for up to 100 days per 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
Hospice care
Supportive and palliative care for a terminally ill member is covered in the home or Plan approved hospice facility You pay nothing
Services include inpatient and outpatient care and family counseling these services are provided under the direction of a Plan
physician who certifies that the patient is in the terminal stages of illness with a life expectancy of approximately six months or less
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Section 5 Benefits continued
Ambulance service
Benefits are provided for ambulance transportation ordered or authorized by a Plan physician You pay 50
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 page 18 for non medical substance abuse benefits
What is not covered
Personal comfort items such as telephone and television
Custodial care and care in an intermediate care facility
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Section 5 Benefits continued
Benefits Available Away From Home
When you are outside the service area of this Plan you may still receive covered health care services There are two types of
coverage provided under your enrollment in this Plan
Services From Other Kaiser Permanente Plans
When you are visiting in the service area of another Kaiser Permanente plan you are entitled to receive virtually all the benefits
described in this brochure at any Kaiser Permanente medical office or medical center and from any Kaiser Permanente provider If
the Plan you are visiting has a charge that is different from the charges listed in this brochure you will have to pay the
charges imposed by the Plan you are visiting If the Kaiser Permanente plan in the area you are visiting has a benefit that is
different from the benefits of this Plan you are not entitled to receive that benefit Some services covered by this Plan such as
artificial reproductive services and the services of specialized rehabilitation facilities will not be available in other Kaiser
Permanente service areas If a benefit is limited to a specific number of visits or days you are entitled to receive only the number
of visits or days covered by the Plan in which you are enrolled
If you are seeking routine non emergent or non urgent services you should call the Kaiser Permanente member services department
in that service area and request an appointment You may obtain routine follow up or continuing care from these plans even when
you have obtained the original services in the service area of this Plan If you require emergency services as the result of an
unexpected or unforeseen illness that requires immediate attention you should go directly to the nearest Kaiser Permanente facility
to receive care
At the time you register for services you will be asked to pay the charges required by the local plan
If you plan to travel to an area with another Kaiser Permanente plan and wish to obtain more information about the benefits available
to you from that Kaiser Permanente plan please call the Member Services Department at 913 642 2662 or outside the local calling
area call 800 726 5247
Benefits Available While You Travel
If you are outside the service area of this Plan by more than 100 miles or outside the service area of any other Kaiser Permanente
Plan the following health care services will be covered
Follow up care care necessary to complete a course of treatment following receipt of covered out of plan emergency care or
emergency care received from Plan facilities if the care would otherwise be covered and is performed on an outpatient basis
Examples of covered follow up care include the removal of stitches a catheter or a cast
Continuing care care necessary to continue covered medical services normally obtained at Plan facilities as long as care for the
condition has been received at Plan facilities within the previous 90 days and the services would otherwise be covered Services must
be performed on an outpatient basis Services include scheduled well baby care prenatal visits medication monitoring blood
pressure monitoring and dialysis treatments The following services are not covered hospitalization infertility treatments childbirth
services and transplants Prescription drugs are not covered However you may have most prescriptions filled by mail through this
Plan's Prescription Drug Benefit
If you have any questions about how to use these benefits call the Travel Benefit Information Line at 800 390 3509 You may obtain
the Travel Benefits for Federal Employees brochure by calling this number You should pay the provider at the time you receive the
service Submit a claim to the Plan 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 as you would an emergency claim Claims should be submitted to Kaiser Permanente
Member Claims P O Box 378044 Denver Colorado 80237 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 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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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 requiring 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 Medical Advice at 913 385 1155 or outside the local calling area 800 870 5711 Medical
Advice is open 24 hours a day 7 days a week
Urgent care is available at the Plan's Urgent Care Center located at the Overland Park Medical Office 10100 W 119th St Overland
Park Kansas and at Baptist Medical Office 6675 Holmes Road 4th and 5th Floors Kansas City Missouri
In an extreme emergency if you are unable to contact the Medical Advice line contact the local emergency system e g the 911
telephone system or go to the nearest hospital emergency room Be sure to tell the emergency room personnel that you are a Kaiser
Permanente member so they can notify Kaiser Permanente You or a family member must notify the Plan within 48 hours It is your
responsibility to ensure that the Plan has been notified
If you need to be hospitalized 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 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 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 at a Plan facility or 10 per urgent care center visit for emergency services that are
covered benefits of this Plan If the emergency room visit results in admission to a hospital the charge is waived
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Kaiser Foundation Health Plan of Kansas City Inc 2000
Section 5 Benefits continued
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
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 Plan
hospital you will be transferred when medically feasible with any ambulance charges covered in full
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 at a non Plan facility for emergency services that are covered benefits of this Plan
If the emergency results in admission to a hospital the charge is waived
What is covered
Emergency care at a physician's office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital including physician services
Ambulance service approved by the Plan You pay 50
What is not covered
Elective care or non emergency care except as specified in Benefits Available Away from Home
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area
Filing claims for non Plan providers
With your authorization the Plan will pay benefits directly to the providers of your emergency care upon receipt of their claims
Physician claims should be submitted on the HCFA 1500 claim form You should submit claim forms to Kaiser Permanente Member
Claims P O Box 378044 Denver Colorado 80237 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 8
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Kaiser Foundation Health Plan of Kansas City Inc 2000
Section 5 Benefits continued
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 You pay 20 for each hour of required diagnostic testing
Psychiatric treatment including individual and group therapy
Medical management visits including drug evaluation and maintenance You pay 10 per visit These visits are not charged as
mental health outpatient visits
Hospitalization including inpatient professional services
Outpatient care
Up to 40 visits to Plan physicians consultants or other psychiatric personnel each calendar year you pay nothing for the first visit
10 per visit for individual therapy sessions at visits 2 20 and 25 per visit for individual therapy visits 21 40 you pay 10 for all
group therapy visits In determining the number of visits two group therapy visits count as one individual therapy visit one
individual therapy visit counts as two group therapy visits
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
For the first 30 days of hospitalization each calendar year you pay nothing for days 31 through 45 you pay 50 of charges For
any additional days you pay all charges The number of covered inpatient days will be reduced by one for every two days of day
night care received
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 without charge each calendar year You pay 50 of charges for sessions 61 90 You pay all
charges thereafter However the number of such sessions is reduced by two for each day of hospitalization for inpatient Mental
Conditions services received during the calendar year Day and night care sessions of no less than four and no more than 12 hour
duration are provided in a hospital based or residential program Such care includes all services of Plan physicians and mental
health professionals In addition the following services and supplies as prescribed by a Plan physician are covered room and board
psychiatric nursing care group therapy drugs and medical supplies
What is not covered
Care for psychiatric conditions that in the professional judgment of Plan physicians are not subject to significant improvement
through relatively short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a Plan physician
to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a short term psychiatric condition
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Kaiser Foundation Health Plan of Kansas City Inc 2000
Section 5 Benefits continued
Substance abuse
What is covered
This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of
substance abuse including alcoholism and drug addiction the same as for any other illness In addition the Plan provides
Outpatient care
All necessary outpatient treatment visits You pay nothing for the first visit 20 per visit for all subsequent visits
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 or each service for which a bill is sent
Inpatient care
Up to 30 days of rehabilitative care from Plan providers if it is determined by a Plan physician that you are unresponsive to
outpatient treatment You pay nothing For any inpatient days in excess of thirty you pay all charges
What is not covered
Treatment that is not authorized by a Plan physician
Care in a specialized alcoholism drug abuse or drug addiction treatment center
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 Benefit
Prescription drugs prescribed by Plan or referral physicians or by general dentists or oral surgeons and obtained at a Plan pharmacy
will be dispensed for up to a 30 day supply You pay 5 per prescription or refill Maintenance drugs can be filled in a 60 day
supply you pay 10 It may be possible for you to receive refills by mail at no extra charge Ask for details at a Plan pharmacy
This Plan uses a formulary to determine which prescribed drugs will be provided to members If the physician specifically prescribes
a nonformulary drug because it is medically necessary the nonformulary drug will be covered If you request the nonformulary drug
when your physician has prescribed a substitution the nonformulary drug is not covered However you may purchase the
nonformulary 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
Contraceptive diaphragms
Implanted time release drugs You pay a one time payment equal to the 5 charge per prescription times the expected number of
months the drug will be effective not to exceed 200 The charge will be required even when the drug is injected in the
physician's office
Injectable contraceptives you pay a one time charge of 5 per injection times the expected number of months the drug will be
effective not to exceed 200 The charge for the drug applies when the contraceptive drug is injected during a medical office
visit
Insulin 5 per vial
Glucose test strips
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Kaiser Foundation Health Plan of Kansas City Inc 2000
Section 5 Benefits continued
The Plan provides the following at no charge
Disposable needles and syringes needed for injecting covered prescribed drugs
Any equipment necessary to use a prescribed drug
Amino acid modified products used in the treatment of inborn errors of amino acid metabolism PKU
Immunosuppressant drugs required after a covered transplant
Intravenous fluids and medications for home use
Enteral elemental dietary formulas when used as primary therapy for regional enteritis
Chemotherapy drugs
Oral contraceptives
Limited Benefits
Drugs to treat sexual dysfunction have dispensing limitations You pay 50 of charges Contact the Plan for details
What is not covered
Drugs available without a prescription or for which there is a nonprescription equivalent available
Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Drugs related to non covered services
Drugs related to infertility services
Smoking cessation drugs except for nicotine gum
OTHER BENEFITS
General Dentist
You Pay Restorative Services
Amalgam fillings silver plastic or composite 34 75
Inlay onlay 205 340
Crowns Stainless Steel cast or porcelain metal 130 450
PERIODONTIC SERVICES
Root Planning Per Quadrant 115
Occlusal Adjustment 50 230
ENDODONTIC SERVICES
Root Canals 240 420
ORAL SURGERY
Simple Extraction 45
Extractions Each Additional Tooth 40
Surgical Removal of Erupted Tooth 85
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Kaiser Foundation Health Plan of Kansas City Inc 2000
Section 5 Benefits continued
PROSTHETIC SERVICES
Dentures Complete upper or lower 460 495
Partial Dentures 405 505
Denture Relines 135 170
ORTHODONTIC SERVICES
Standard Fully Banded Case
available to members age 19 and under 2,750
Oral exams X rays prophylaxis cleaning of teeth every six months fluoride treatment and oral hygiene instruction are covered
with a 5 copayment per member per visit
This list of services and copayment ranges is a general summary and may vary depending on specific services required These
procedures are only available at participating general dental offices Should your general dentist refer you to an affiliated specialist
the charges may be higher If you have questions regarding specific covered services and corresponding copayments please contact
a Customer Service Representative at 800 445 9090
VISION CARE
What is covered
In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye eye refractions to
provide a written lens prescription for eyeglasses but not for contact lenses may be obtained from Plan providers You pay 10 per
visit
What is not covered
Eye exercises
Corrective eyeglasses and frames or contact lenses including the fitting of the lenses
Examination for prescription or contact lenses
Special Benefits for Medicare Eligible Enrollees
If you are enrolled in this Plan through the FEHBP have Medicare Part A coverage and have purchased Part B coverage you also
may enroll in the Kaiser Permanente Senior Advantage program
The Senior Advantage Program Plan provides all Medicare covered Part A and Part B benefits to the Medicare beneficiary as well as
some benefits not covered by Medicare It is an arrangement between Medicare and this Plan in which Medicare pays a specific
amount to this plan for each Medicare beneficiary who enrolls in the Plan
Like your FEHBP enrollment in this Plan you are required to obtain your services from this Plan's physicians and providers except
for emergencies and out of area urgent care The rules regarding enrollment in Kaiser Permanente Senior Advantage are fully
explained in the Certificate of Coverage for Senior Advantage Federal members For a copy of these rules please contact Member
Services at 913 642 2662 or 800 726 5247
Following your enrollment in Kaiser Permanente Senior Advantage you will be entitled to receive an enhanced benefits package that
combines your FEHBP coverage with your Kaiser Permanente Senior Advantage benefits
If you choose to enroll in Senior Advantage you will be responsible for paying the Part B premium You must make an affirmative
enrollment in Senior Advantage Refer to Certificate of Coverage for Senior Advantage Federal members for complete enrollment
and disenrollment rules You will also continue to pay the employee share of the FEHBP premium
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
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Kaiser Foundation Health Plan of Kansas City Inc 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless
your Plan physician determines it is medically necessary to prevent diagnose or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan doctors or hospitals except for authorized referrals or emergencies and services received under the travel
benefit see Emergency Benefits and Benefits Available Away from Home
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus
were carried to term or when the pregnancy is the result of an act of rape or incest
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On occasion you may
need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled
with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
Medicare Choice plan when one is available in your area For information on suspending your FEHB
enrollment and changing to a Medicare Choice plan contact your retirement office If you later want to
re enroll in the FEHB Program generally you may do so only at the next Open Season
If you involuntarily lose coverage or move out of the Medicare Choice service area you may re enroll
in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your
benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA
office or request it from SSA at 800 638 6833 For information on the Medicare Choice plan offered
by this Plan see page 20
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Kaiser Foundation Health Plan of Kansas City Inc 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 beyond our unable to provide them In that case we will make all reasonable efforts to provide you
control with necessary care
When others When you receive money to compensate you for medical or hospital care for injuries or illness that are another person caused you must reimburse us for whatever services we paid for We will cover the
responsible cost of treatment that exceeds the amount you received in the settlement If you do not seek for injuries 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
Worke rs 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 Government directly or indirectly pays for
Agencies
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Kaiser Foundation Health Plan of Kansas City Inc 2000
Section 8 FEHB FACTS
You have a OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right right to to information about your health plan its networks providers and facilities You can also find out about
information care management which includes medical practice guidelines disease management programs and how about your we determine if procedures are experimental or investigational OPM's website www opm gov insure
HMO lists the specific types of information that we must make available to you
If you want specific information about us call 913 642 2662 or 913 632 3696 TDD or write to Kaiser
Foundation Health Plan of Kansas City Inc Member Services 10561 Barkley Ste 200 Overland Park
Kansas 66212 You may also contact us by fax at 913 967 4630 or visit our website at
www kaiserpermanente org
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal information Employees Health Benefits Plans brochures for other plans and other materials you need to make
about enrolling an informed decision about in the 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 coverage benefits and and premiums begin on the first day of your first pay period that starts on or after January 1
premiums Annuitants premiums begin January 1 effective
What happens When you retire you can usually stay in the FEHB Program Generally you must have been enrolled when I retire 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 stepchildren your employing or
available for my retirement office authorizes coverage for Under certain circumstances you may also get coverage for a family and me 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 Kansas City Inc 2000
Section 8 FEHB FACTS continued
Are my medical We will keep your medical and claims information confidential Only the following will and claims have access to it
records confidential OPM this Plan and subcontractors when they administer this contract
This plan and appropriate third parties such as other insurance 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 cards Election Form SF 2809 or the OPM annuitant confirmation letter until you receive your
ID card You can also use an Employee Express confirmation letter
What if I paid Your old plan's deductible continues until our coverage begins a deductible
under my old plan
Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before you conditions enrolled in this Plan solely because you had the condition before you enrolled
When you lose benefits
What You will receive an additional 31 days of coverage for no additional premium when happens if Your enrollment ends unless you cancel your enrollment or
my You are a family member no longer eligible for coverage enrollment in
this Plan You may be eligible for former spouse coverage or Temporary Continuation of Coverage ends
What is If you are divorced from a Federal employee or annuitant you may not continue to get benefits under former your former spouse's enrollment But you may be eligible for your own FEHB coverage under the
spouse spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's coverage employing or retirement office to get more information about your coverage choices
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Kaiser Foundation Health Plan of Kansas City Inc 2000
Section 8 FEHB FACTS continued
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
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 If you leave Federal service your employing office will notify you of your right to enroll enroll in under TCC You must enroll within 60 days of leaving or receiving this notice whichever
TCC 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
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Kaiser Foundation Health Plan of Kansas City Inc 2000
Section 8 FEHB FACTS continued
How can I You may convert to an individual policy if convert to
individual Your coverage under TCC or the spouse equity law ends If you canceled your coverage coverage or did not pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is available You
must apply in writing to us within 31 days after you receive this notice However if you are a family
member who is losing coverage the employing or retirement office will not notify you You must apply in
writing to us within 31 days after you are no longer eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have to
answer questions about your health and we will not impose a waiting period or limit your coverage due to
pre existing conditions
How can I get If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that a Certificate indicates how long you have been enrolled with us You can use this certificate when getting health
of Group insurance or other health care coverage You must arrange for the other coverage within 63 days Health Plan of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions
Coverage for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other FEHB plans
you may request a certificate from them as well
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Kaiser Foundation Health Plan of Kansas City Inc 2000
Inspector General Advisory
Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has
charged you for services you did not receive billed you twice for the same service or misrepresented
any information do the following
Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 913 642 2662 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 Kansas City Inc 2000
Notes
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Kaiser Foundation Health Plan of Kansas City Inc 2000
Summary of Benefits for Kaiser Foundation Health Plan of Kansas City Inc 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
Benefit Plan pays provides Page
Inpatient care Hospital Comprehensive range of medical and surgical services without
dollar or day limit Includes in hospital physician care room and board
general nursing care private room and private nursing care if medically necessary diagnostic tests drugs and medical supplies use of operating
room intensive care and complete maternity care You pay nothing .12
Extended care All necessary services up to 100 days per calendar year You pay nothing .12
Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 45 days of inpatient care reduced by one day for every two sessions of day or
nightcare You pay nothing for the first 30 days 50 of charges for days 31 45 all charges thereafter .17
Substance abuse Up to 30 days of rehabilitative care per year You pay nothing .18
Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care preventive care including well baby
care periodic check ups and routine immunizations laboratory tests and X rays complete maternity care You pay a 10 copay per office visit
50 for each outpatient surgery in a hospital or outpatient surgery center nothing per house call by a physician .10
Home health care All necessary visits by nurses and health aides You pay nothing per visit .10
Mental conditions Up to 40 outpatient visits for individual therapy You pay nothing for the first visit 10 copay per visit for visits 2 20 and a 25 copay per visit for
visits 21 40 and all charges thereafter 17
Substance abuse All necessary outpatient visits You pay nothing for the first visit and 20 for each subsequent visit .18
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay 50 for services provided at Plan facilities
You pay 50 for services provided at non Plan facilities inside the service area and 50 for services provided outside the service area You pay 10
per urgent care center visit .15
Prescription drugs Drugs prescribed by a Plan physician and obtained at a Plan pharmacy You pay a 5 copay per prescription unit or refill .18
Dental care Accidental injury benefit You pay 50 of the first 1,000 in charges per injury and all charges thereafter Preventive dental care comprehensive
range of restorative prosthetic and other dental services You pay copays for these services .19
Vision care Refractions including prescriptions for eyeglasses You pay 10 per office visit .20
Out of pocket maximum Copayments are required for a few benefits however after your out of pocket expenses reach a maximum of 2,000 per Self Only or
4,500 per Self and Family enrollment per calendar year covered benefits will be provided at 100 This copay maximum does not include
prescription drugs or dental services Your out of pocket expenses for benefits under this Plan are limited to the stated copayment required for a
few benefits .5
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Kaiser Foundation Health Plan of Kansas City Inc 2000
2000 Rate Information for Kaiser Permanente
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 catefory definitions in The Guide to Federal Employees Health Benefits Plans for
the 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
memeber of any postal employee organization Such persons not subject to postal rates must refer to the applicable Guide to Federal
Employees Health Benefits plans
Non Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of Gov't Your Gov't Your USPS Your
Enrollment Code Share Share Share Share Share Share
Self Only HA1 60.10 20.03 130.22 43.40 71.12 9.01
Self and Family HA2 155.06 51.69 335.97 111.99 183.49 23.26
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