Pages 1--32 from Untitled

For
changes 5

in benefitssee page

Serving Atlanta Georgia metropolitan area
Enrollment in this plan is limited
see page 6 for requirements

Enrollment Code This Plan has Commendable
F81 Self Only accreditation from the NCQA See the 2000 Guide for more
F82 Self and Family information on NCQA

Visit the OPM website at http www opm gov insure
and
This Plan's National website at http www kaiserpermanente org

Authorized for distribution by the
UNITED STATES OFFICE OF
PERSONNEL MANAGEMENT
RETIREMENT AND INSURANCE SERVICE RI 73 086 1
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Kaiser Foundation Health Plan of Georgia Inc 2000
Table of Contents
Page
Introduction 4
Plain language 4
How to use this brochure .4
Section 1 Health Maintenance Organizations .5
Section 2 How we change for 2000 .5 6
Section 3 How to get benefits .6 9
Section 4 What to do if we deny your claim or request for service .9 11
Section 5 Benefits .11 22
Section 6 General exclusions Things we don't cover .23
Section 7 Limitations Rules that affect your benefits .23 24
Section 8 FEHB facts .25 28
Inspector General Advisory Stop Healthcare Fraud .29
Summary of benefits .30 31
Premiums Back Cover

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Kaiser Foundation Health Plan of Georgia Inc 2000
Introduction
Kaiser Foundation Health Plan of Georgia Inc
Nine Piedmont Center
3495 Piedmont Road NE
Atlanta GA 30305 1736

This brochure describes the benefits you can receive from Kaiser Foundation Health Plan of Georgia Inc under its contract CS2163
with the Office of Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This
brochure is the official statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described
in this brochure If you are enrolled for Self and Family coverage each eligible family member is also entitled to these benefits

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

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

We refer to Kaiser Foundation Health Plan of Georgia 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

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

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

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

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

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

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Kaiser Foundation Health Plan of Georgia Inc 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 or follow up or continuing care under this
Plan's travel benefit you may have to submit claim forms

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

Section 2 How We Change For 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary
changes care office visits

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

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

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

If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years
This screening is for colorectal cancer

Changes to Your share of the non postal premium will increase by 8.3 for Self Only or 8.3 for Self
this Plan and Family

The cardiac rehabilitation benefit will change from up to two consecutive months per acute
condition to 12 weeks or 36 visits per condition

The benefit limitations and exclusions for chiropractic services have been identified
The copay for external prosthetic and orthotic devices has been increased from no charge to 20
of charges This benefit has moved from What is covered to Limited benefits

The benefit coverage and limitations for durable medical equipment have been identified This
benefit has moved from What is covered to Limited benefits

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Kaiser Foundation Health Plan of Georgia Inc 2000
Section 2 How We Change For 2000 continued
The ambulance copay will increase from no charge to 50
The copay for urgent care has changed from 25 per visit to 20 per visit This copay applies to
visits to urgent care centers designated by the Plan Visits to the Plan's After Hours Offices will
be at the 10 office visit copay per visit

General anesthesia and associated hospital or ambulatory surgery facility charges in conjunction
with dental care will be covered for children age 7 and younger and for certain other individuals
under specific circumstances Previously this benefit was not covered

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 providers
Plan's service practice Our service area is
area Bartow County Barrow County Butts County Cherokee County Clayton County Cobb County

Coweta County DeKalb County Douglas County Fayette County Forsyth County Fulton
County Gwinnett County Hall County Henry County Newton County Paulding County
Rockdale County Spalding County and Walton County

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
15 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 consider enrolling in
another plan If you or a family member move you do not have to wait until Open Season to
change plans Contact your employing or retirement office

How much do You must share the cost of some services This is called either a copayment a set dollar amount
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 receive your service you will be billed for the service We also will bill you an additional 10 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 5,000 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 durable medical equipment external prosthetic and orthotic devices the 25
charge for follow up or continuing care chiropractic services or dental services do not count
toward these limits and you must continue to pay for these services as described in this brochure

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

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Kaiser Foundation Health Plan of Georgia Inc 2000
Section 3 How to get benefits continued
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a
submit claims provider who doesn't contract with us or you receive follow up or continuing care under the travel benefit If you file a claim please send us all of the documents we need to respond to your

claim as soon as possible You must submit claims by December 31 of the year after the year you
received the service Either OPM or we can extend this deadline if you show that circumstances
beyond your control prevented you from filing on time

Who provides Kaiser Permanente offers comprehensive health care at nine Plan medical centers conveniently
my health care located throughout the Atlanta metropolitan area and through referral specialists hospitals and other providers in the community This Plan contracts with The Southeast Permanente Medical

Group Inc an independent multi specialty group of physicians Plan physicians to provide or
arrange all necessary physician care Plan physicians are members of American Specialty Boards
or are Board eligible Plan physicians nurse practitioners physician assistants and other skilled
medical personnel working as medical teams provide your health care services Specialists consult
with these medical teams in determining your treatment Plan physicians refer patients to
community specialists when necessary Other services such as physical therapy and laboratory
and X ray are available at Plan facilities and other designated locations Hospital care is provided
at local community hospitals This Plan contracts with American Dental Plan ADP to
provide or arrange covered dental care

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

Your primary care physician either a family practitioner pediatrician or internist will coordinate
most aspects of your health care including arranging for you to receive services from
a specialist This Plan will cover specialists services only when your primary care physician
refers you However a woman may see her gynecologist without having to obtain a referral
You may also receive covered preventive dental services and accidental injury dental care
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 the Member Services
Department at 404 261 2590 If you want to receive care from a specific physician who is listed
in the directory call the physician to verify that he or she still participates with the Plan and is
accepting new patients

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

What do I do if my Call us We will help you select a new one
primary care physician
leaves the Plan

What do I do if I need Your primary care physician or specialist will make the necessary arrangements and continue to
to go into the hospital supervise your care

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Kaiser Foundation Health Plan of Georgia Inc 2000
Section 3 How to get benefits continued
What do I do if I'm First call our Member Services Department at 404 261 2590 If you are new to the FEHB
in the hospital when Program we will arrange for you to receive care If you are currently in the FEHB Program
I join this Plan and are switching to us your former plan will pay for the hospital stay until

You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first

These provisions only apply to the person who is hospitalized

How do I get Your primary care physician will determine if you need care from a specialist He or she will
specialty care obtain necessary authorizations from the Plan The referral will describe the services you will receive You should return to your primary care physician after your consultation with the specialist

If your specialist recommends additional visits or services your primary care physician
will review the recommendation and authorize the visits or services as appropriate You should
not go to a specialist unless your primary care physician and your Plan authorized the referral

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

What do I do if I Your primary care physician will decide what treatment you need If he or she decides to refer
am seeing a specialist you to a specialist ask if you can see your current specialist If your current specialist does not
when I enroll participate with us you must receive treatment from a specialist who does Generally we will not pay for you to see a specialist who does not participate with our Plan

What do I do if my Call your primary care physician who will arrange for you to see another specialist You may
specialist leaves the Plan receive services from your current specialist until we can make arrangements for you to see someone else

But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to continue
serious illness and my seeing your physician for up to 90 days after we notify you that we are terminating our contract
provider leaves the with the provider unless the termination is for cause If you are in the second or third
Plan or this Plan leaves trimester
the Program of pregnancy you may continue to see your OB GYN until the end of your postpartum care

You may also be able to continue seeing your physician if your plan drops out of the FEHB
Program and you enroll in a new FEHB plan Contact the new plan and explain that you have a
serious or chronic condition or are in your second or third trimester Your new plan will pay for
or provide your care for up to 90 days after you receive notice that your prior plan is leaving the
FEHB Program If you are in your second or third trimester your new plan will pay for the
OB GYN care you receive from your current physician until the end of your postpartum care
How do you authorize
medical services Your physician must get our approval before sending you to a hospital referring you to a specialist or recommending follow up care Before giving approval we consider if the service

is medically necessary to prevent diagnose or treat an illness or condition We follow generally
accepted medical practice in providing services to you

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Kaiser Foundation Health Plan of Georgia Inc 2000
Section 3 How to get benefits continued
How do you decide if a When the service or supply including a drug 1 has not been approved by the FDA or 2 is
service is experimental the subject of a new drug or new device application on file with the FDA or 3 is part of a
or investigational Phase I or Phase II clinical trial as the experimental or research arm of a Phase III clinical trial or is intended to evaluate the safety toxicity or efficacy of the service or 4 is available as the

result of a written protocol that evaluates the service's safety toxicity or efficacy or 5 is subject
to the approval or review of an Institutional Review Board or 6 requires an informed consent
that describes the service as experimental or investigational then this Plan considers that
service
supply or drug to be experimental and not covered by the Plan This Plan and its Medical Group
carefully evaluate whether a particular therapy is safe and effective or offers a degree of promise
with respect to improving health outcomes The primary source of evidence about health outcomes
of any intervention is peer reviewed medical literature

Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you
show that you were unable to make a timely request due to reasons beyond your control

We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information

If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30
days after we receive the additional information If we do not receive the requested information within 60 days we will make our
decision based on the information we already have
When may I ask OPM
to review a denial You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM will determine if we correctly applied the terms of our contract when we denied your claim

or request for service
What if I have a serious or
life threatening condition Call us at 404 261 2590 and we will expedite our review
and you haven't responded
to my request for service

What if you have denied
my request for care and If we expedite your review due to a serious medical condition and deny your claim we will
my condition is serious inform OPM so that they can give your claim expedited treatment too Alternatively you can call
or life threatening OPM's health benefits Contract Division 3 at 202 606 0755 between 8 00 a m and 5 00 p m Serious or life threatening conditions are ones that may cause permanent loss of bodily functions

or death if they are not treated as soon as possible

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Kaiser Foundation Health Plan of Georgia Inc 2000
Section 4 What to do if we deny your claim or request for service continued
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our
time limits initial denial or refusal of service You may also ask OPM to review your claim if

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

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

What do I send Your request must be complete or OPM will return it to you You must send the following
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 mail Send your request for review to
my disputed claim Office of Personnel Management
to OPM Office of Insurance Programs Contracts Division 3

P O Box 436
Washington D C 20044

What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our decision
the Plan's denial 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 Federal law governs your lawsuit benefits and payment of benefits The Federal court will base
if I file a lawsuit its review on the record that was before OPM when OPM made its decision on your claim You may recover only the amount of benefits in dispute

You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure
described above

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Kaiser Foundation Health Plan of Georgia Inc 2000
Section 4 What to do if we deny your claim or request for service continued
Your records and the Privacy Act
Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and us to determine if our denial of
your claim is correct The information OPM collects during the review process becomes a permanent part of your disputed claims
file and is subject to the provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this information to
support the disputed claim decision If you file a lawsuit this information will become part of the court record

Section 5 Benefits Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan physicians and other Plan providers This includes all necessary office and outpatient surgery
visits You pay 10 per office visit charge but no additional copay for laboratory tests and
X rays Within the service area house calls will be provided if in the judgment of the Plan
physician such care is necessary and appropriate you pay a 10 copay for a physician's house
call and nothing for home visits by physicians nurses and health aides

The following services are included
Preventive care including well baby care for children over 2 years of age and periodic
check ups

Mammograms are covered as follows for women age 35 through 39 one mammogram during
these five years for women age 40 through 49 one mammogram every one or two years for
women age 50 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 physician as medically necessary to diagnose or treat your illness

Routine immunizations and boosters you pay nothing
Visits to primary care physicians non physician providers and consultations with specialists
Diagnostic procedures such as laboratory tests and X rays You pay nothing
Complete obstetrical maternity care for covered females including all scheduled prenatal
delivery and postnatal care by a Plan physician The 10 copay is waived for maternity care
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 during the covered
portion of the mother's confinement for maternity will be covered under either a Self
Only
or Self and Family enrollment other care of a newborn who requires definitive treatment
will be covered only if the infant is covered under a Self and Family enrollment

Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including materials You pay 50 at the beginning of each
6 months of treatment for maintenance allergy serum preparations

The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung kidney simultaneous pancreas kidney liver and lung single and
double transplants allogeneic donor bone marrow transplants autologous bone marrow
transplants autologous stem cell and peripheral stem cell support for the following conditions
acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's lymphoma
advanced non Hodgkin's lymphoma advanced neuroblastoma breast cancer multiple

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS 11 11
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Kaiser Foundation Health Plan of Georgia Inc 2000
Section 5 Benefits Medical and Surgical Benefits continued
myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal and ovarian
germ cell tumors Transplants are covered when approved by the Medical Group Related
medical and hospital expenses of the donor are covered

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

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

Chemotherapy radiation therapy and respiratory therapy
Surgical treatment of morbid obesity
Home health services of nurses and health aides including intravenous fluids and medications
when prescribed by your Plan physician who will periodically review the program for
continuing appropriateness and need You pay nothing

Dressings casts catheters and catheter and ostomy supplies You pay nothing
Blood and blood products and the administration of blood
All necessary medical or surgical care in a hospital or extended care facility from Plan
physicians and other Plan providers at no additional cost to you except where noted

Medical management of mental health conditions including drug therapy evaluation and
maintenance

Visits to receive injections
Scheduled preventive office visits for children from birth to age 2 You pay nothing

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 10 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 Except as shown on page 20 under dental benefits all
other procedures involving the teeth or areas surrounding the teeth are not covered including
shortening of the mandible or maxillae for cosmetic purposes and correction of malocclusion

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 up to two months per condition if significant improvement can be expected
within two months You pay nothing for inpatient care and 10 per outpatient 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 Vocational rehabilitation is not covered

Diagnosis and treatment of infertility is covered you pay 50 of charges The following
types of artificial insemination are covered intravaginal insemination IVI intracervical insemination
ICI and intrauterine insemination IUI you pay 50 of charges cost of donor sperm
and donor eggs and services related to their procurement and storage is not covered Fertility
drugs are covered under the Prescription Drug Benefit Other assisted reproductive technology

12 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS 12
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Kaiser Foundation Health Plan of Georgia Inc 2000
Section 5 Benefits Medical and Surgical Benefits continued
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

Cardiac rehabilitation following a heart transplant bypass surgery or myocardial infarction is
provided concurrently with other short term therapy for up to 12 weeks or 36 visits per condition
if significant improvement can be expected You pay 10 per outpatient session and nothing
per inpatient session

Chiropractic services which are defined as manual manipulation of the spine to correct subluxation
demonstrated by X ray diagnosis of a Plan provider from sources designated by the Plan
are provided You pay 10 per visit for the first 30 visits in a calendar year you pay all charges
thereafter for any subsequent visits in the same calendar year Covered chiropractic services are
limited to evaluation and management routine chiropractic X rays provided in the chiropractor's
office not to exceed 4 views and appropriate therapies such as hot and cold packs not to
exceed 2 per visit All other chiropractic services vitamins and supplements Vax D structural
supports massage therapy maintenance or preventative care non acute medically necessary
treatment acupuncture therapy physical speech or occupational therapy neurological testing
and laboratory and pathology services at a chiropractor's office are not covered

External prosthetic and orthotic devices such as braces or therapeutic shoes required for conditions
associated with diabetes breast prostheses and surgical bras as well as their replacement
are covered You pay 200 for scoliosis braces Lenses following cataract removal are covered
For all other devices you pay 20 of charges Foot orthotics corrective shoes other than therapeutic
shoes required for conditions associated with diabetes dental prostheses devices and
appliances and prosthetics for the treatment of sexual dysfunction are not covered

Durable medical equipment when intended to be used repeatedly and in the home is covered
Coverage is limited to the standard item of durable medical equipment in accord with the Plan's
formulary guidelines that adequately meets the medical needs of the member You pay 20 of
charges The following items are not covered comfort and convenience equipment exercise and
hygiene equipment disposable supplies electronic monitors of the function of the heart or lungs
except apnea monitors for newborns and devices to perform medical tests on blood or other
bodily substances or excretions except blood glucose monitors for diabetics dental appliances
experimental or research equipment devices not medical in nature such as sauna baths and elevators
and modifications to the home or auto

What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance or governmental licensing

Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Homemaker services
External and internally implanted hearing aids
Transplants not listed as covered
Long term rehabilitative and cognitive therapy
Orthotic foot supports and inserts
Refractions for contact lenses
Corrective eyeglasses and frames or contact lenses including the fitting of the lenses
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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS 13 13
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Kaiser Foundation Health Plan of Georgia Inc 2000
Section 5 Benefits Hospital Extended Care Benefits
What is covered The Plan provides a comprehensive range of benefits with no dollar or day limit when you are Hospital care 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

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
Drugs and their administration biologicals supplies and equipment ordinarily provided or
arranged by the skilled nursing facility when prescribed by a Plan physician

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

Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan physician
You pay 50 per ambulance trip

Limited benefits Inpatient dental Hospitalization for certain dental procedures is covered when a Plan physician determines there

procedures is a need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the hospitalization but not the cost of the professional dental services Conditions for
which hospitalization would be covered include hemophilia and heart disease the need for
anesthesia by itself is not such a condition

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

See page 18 for nonmedical substance abuse benefits

What is not covered Personal comfort items such as telephone and television Custodial care rest cures domiciliary or convalescent care

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

When you are visiting in the service area of another Kaiser Permanente plan you are entitled to
receive virtually all the benefits described in this brochure at Kaiser Permanente medical offices
and medical centers and from Kaiser Permanente providers If the Plan you are visiting has a
charge that is different from the charges listed in this brochure you will have to pay the
charges imposed by the Plan you are visiting

14 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS 14
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Kaiser Foundation Health Plan of Georgia Inc 2000
Section 5 Benefits Hospital Extended Care Benefits continued
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 days or visits you are entitled to receive only the number of days or visits
covered by the Plan in which you are enrolled

If you are seeking routine non emergent or non urgent services you should call the Kaiser
Permanente member services department in that area and request an appointment You may
obtain routine follow up or continuing care from these Plans even when you have obtained the
original services in the service area of this Plan If you require emergency services as the result
of an unexpected or unforeseen illness that requires immediate attention you should go directly
to the nearest hospital to receive care

At the time you register for services you will be asked to pay the copayment required under your
enrollment in the local plan

If you plan to travel to an area with another Kaiser Permanente Plan and wish to obtain more
information about the benefits available to you please call the Member Services Department at
404 261 2590

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

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

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

If you have any questions about how to use these benefits call the Travel Benefit Information
line at 1 800 390 3509 You may obtain the travel benefits for Federal Employees brochure by
calling this number

You should pay the provider at the time you receive the service Submit a claim to the Plan for
the services on this Plan's Claim for Follow up Continuing Care Medical Form with necessary
supporting documentation Submit itemized bills and your receipts to the Plan along with an
explanation of the services and the identification information from your ID card Submit claims
to Kaiser Foundation Health Plan of Georgia Inc Claims Administration P O Box 190849
Atlanta GA 31119 0849 If the services are covered under this Travel Benefit you will be reimbursed
the reasonable charges for the care up to a maximum of 1,200 per calendar year You
pay 25 for each follow up or continuing care visit This amount will be deducted from the
payment the Plan makes to you

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS 15 15
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Kaiser Foundation Health Plan of Georgia Inc 2000
Section 5 Benefits Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you
emergency believe endangers your life or could result in serious injury or disability and requires immediate medical or surgical care Some problems are emergencies because if not treated promptly they

might become more serious examples include deep cuts and broken bones Others are emergencies
because they are potentially life threatening such as heart attacks strokes poisonings gunshot
wounds or sudden inability to breathe There are many other acute conditions that the Plan may
determine are medical emergencies what they all have in common is the need for quick action

Some situations may require prompt medical attention but are not or may not be an emergency
as described above Medical services to treat these situations are available to you at Kaiser
Permanente After Hours Offices or at Health Plan designated Urgent Care Centers

Emergencies within If you are in an emergency situation please call your Plan facility After office hours call
the service area 404 365 0966 If calling long distance call 1 800 611 1811

In extreme emergencies if you are unable to contact your physician or facility contact the local
emergency system e g the 911 telephone system or go to the nearest hospital emergency room
Be sure to tell the emergency room personnel that you are a Plan member so they can notify the
Plan You or a family member must notify the Plan within 48 hours unless it was not reasonably
possible to do so It is your responsibility to ensure that the Plan has been timely notified

If you need to be hospitalized 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 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 the 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 50 per hospital emergency room visit for emergency services that are covered benefits of this Plan and any additional copays which would have been required if the care had been rendered by
the Plan If the emergency results in admission to a hospital the emergency care copay is waived
20 per visit at an Urgent Care Center designated by the Plan for services that are covered
benefits of this Plan 10 per visit for each visit to the Plan's After Hours Offices

Emergencies outside You may obtain emergency and urgent care services from Kaiser Permanente medical facilities
the service area and providers when you are in the service area of another Kaiser Permanente plan The facilities will be listed in your FEHB Facilities Guide or the local telephone book under Kaiser

Permanente You may also call the Member Relations Department at the following phone
number 1 800 611 1811 This number is open 24 hours a day 7 days a week

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

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Kaiser Foundation Health Plan of Georgia Inc 2000
Section 5 Benefits Emergency Benefits continued
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

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 care services to the extent the services would have been covered if received from Plan providers

You pay 50 per hospital emergency room visit for emergency services that are covered benefits of this Plan and any additional copays which would have been required if the care had been rendered by
the Plan If the emergency results in admission to a hospital the emergency care copay is waived

What is covered Urgent Care at a physician's office Kaiser Permanente After Hours Office or Health Plan designated Urgent Care Center
Emergency care as an outpatient or inpatient at a hospital including physicians services
Ambulance service approved by the Plan You pay 50 per ambulance trip

What is not covered Elective care or nonemergency care
Emergency care provided outside the service area if the need for care could have been foreseen
before departing the service area

Medical and hospital costs resulting from a normal full term delivery of a baby outside the
service area

Filing Claims for With your authorization the Plan will pay benefits directly to the providers of your emergency
non Plan providers care upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form Submit claims to Kaiser Foundation Health Plan of Georgia Inc Claims Administration

P O Box 190849 Atlanta GA 31119 0849 If you are required to pay for the services submit
itemized bills and your receipts to the Plan along with an explanation of the services and the
identification information from your ID card Payment will be sent to you or the provider if you
did not pay the bill unless the claim is denied If it is denied you will receive notice of the
decision including the reasons for the denial and the provisions of the contract on which denial
was based If you disagree with the Plan's decision you may request reconsideration in accordance
with the disputed claims procedure described on page 9

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Kaiser Foundation Health Plan of Georgia Inc 2000
Section 5 Benefits Mental Conditions Substance Abuse Benefits
Mental Conditions To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including the treatment of mental illness or
disorders
What is covered Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Medical management visits including drug evaluation and maintenance
Hospitalization including inpatient professional services

Outpatient Care Outpatient visits to Plan physicians consultants or other psychiatric personnel each calendar year you pay nothing for visits 1 5 15 per visit for visits 6 40 and 50 of charges thereafter
for each visit in the same calendar year
Inpatient Care Inpatient days you pay nothing for the first 30 days of hospitalization each calendar year and 50 of charges thereafter for each day in the same calendar year

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 10 for each service for which a bill is sent

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

Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless
determined by a Plan physician to be necessary and appropriate

Psychological testing that is not medically necessary to determine the appropriate treatment of
a short term psychiatric condition

Substance Abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of substance abuse including alcoholism and drug addiction
the same as for any other illness In addition the Plan provides
Outpatient Care Up to 30 outpatient visits to Plan physicians consultants or other substance abuse specialists each calendar year for the treatment of alcohol or drug abuse when prescribed by a Plan physician
and provided at a designated facility and necessary aftercare visits when provided as part of
a covered program and prescribed by a Plan physician A visit may consist of an individual therapy
visit or up to a day visit to a specialized facility the Plan physician will determine the appropriate
type of visit You pay nothing for each covered visit all charges thereafter

Inpatient Care Inpatient treatment for the psychiatric aspects of substance abuse is limited to the inpatient mental conditions benefit listed above

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 10 for each service for which a bill is sent

What is not covered Treatment that is not authorized by a Plan physician
Inpatient treatment in a specialized treatment facility
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

18 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS 18
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Kaiser Foundation Health Plan of Georgia Inc 2000
Section 5 Benefits Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan physician or any dentist and obtained at a Plan pharmacy will be dispensed for up to a 30 day supply You pay 5 per prescription unit or refill if obtained at
a Plan medical office pharmacy and 11 if obtained at a Plan participating community pharmacy
It may be possible for you to receive refills by mail at no extra charge Delivery may be made
available at an additional charge Ask for details at a Plan pharmacy

The Plan uses a formulary to determine which prescribed drugs will be provided to members If
the physician specifically prescribes a 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 charge the 5 or 11 unless another charge is specifically
identified

Drugs for which a prescription is required by law
Oral contraceptive drugs contraceptive diaphragms and intrauterine devices
You pay 50 per intrauterine device

Implanted time release drugs and injectable contraceptives For Norplant you pay a one time
payment of 180 per prescription For other internally implanted time release drugs and
injectable contraceptives you pay a one time payment equal to 5 per prescription times the
expected number of months the drug or contraceptive will be effective not to exceed 200
There will be no refund of any portion of these copayments if the implanted time release drug or
contraceptive is removed before the end of its expected life

Insulin with a copay charge applied to each vial
Diabetic supplies limited to chemstrips glucose test tablets and test tape
and acetone test tablets

Drugs for covered infertility treatments You pay 50 per prescription unit of refill
Nasal and oral inhalers with a copay applied to each of the smallest standard package unit
and spacer devices with an additional copay for each device

Intravenous fluids and medication for home use are covered under Medical and Surgical
Benefits

Disposable needles and syringes needed for injecting prescribed drugs you pay nothing

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 10 for each service for which a bill is sent

Limited Benefit 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 infertility services
Contraceptive devices except diaphragms and intrauterine devices
Smoking cessation drugs and medication including nicotine patches
Drugs for non covered services

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS 19 19
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Kaiser Foundation Health Plan of Georgia Inc 2000
Section 5 Benefits Other Benefits
Dental Care The following preventive dental services are covered when provided by participating Plan dentists You pay 14 per visit

What is covered Oral examinations twice a year
Dental prophylaxis cleaning twice a year
Topical application of fluoride twice a year when prescribed by a Plan dentist
Bitewing X rays twice a year
Full mouth series X ray once every three years

You receive a 10 discount from the Plan dentist's usual and customary fee schedule for all
other dental care

Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound natural
benefit teeth are covered when provided by any dentist You pay 50 of the first 1,000 in charges per accidental injury and all charges thereafter

Non surgical Non surgical treatment of temporomandibular joint dysfunction TMJ including splints
treatment of and appliances is covered Services must be provided by participating Plan dentists
temporomandibular you pay 50 of the first 1,000 in charges per calendar year and all charges thereafter
joint dysfunction

General anesthesia General anesthesia and associated hospital or ambulatory surgery facility charges in conjunction
and associated facility with dental care are covered for persons
charges 7 years of age or younger

who are developmentally disabled
who are not able to have dental care under local anesthesia due to a neurological or
medically compromising condition and

who have sustained extensive facial or dental trauma

You pay nothing

What is not covered Other dental services not specifically shown as covered

Vision care
What is covered Eye refractions for eyeglasses to provide written lens prescription may be obtained from
Plan providers You pay 15 per visit

What is not covered Corrective eyeglasses and frames or contact lenses including the examination and fitting of contact lenses

Refractions for contact lenses
Eye exercise

20 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS 20
20 Page 21 22
Kaiser Foundation Health Plan of Georgia Inc 2000
Section 5 Benefits Special Benefits for Medicare Eligible Enrollees
If you are enrolled in this Plan through the FEHB have Medicare Part A coverage and have purchased Part B coverage you also
may enroll in the Kaiser Permanente Senior Advantage program

FEHB Senior Advantage Program provides all Medicare covered Part A and Part B benefits to the Medicare beneficiary all the
benefits you currently have under FEHB 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 enrollees in the Plan

Like your FEHB 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 Federal Employees Kaiser Permanente Senior Advantage packet For a copy of these rules please contact our
Medicare Department at 1 888 468 0100

Following your enrollment in Kaiser Permanente Senior Advantage you will be entitled to receive an enhanced benefits package
that combines your FEHB 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 complete and sign an
application to enroll in Senior Advantage You must also continue to pay the employee share of the FEHB premium You can return
to FEHB coverage alone at any time Your disenrollment will become effective the first day of the month after we receive your
completed Senior Advantage disenrollment form

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS 21 21
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Kaiser Foundation Health Plan of Georgia Inc 2000
Section 5 Benefits Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made
available to all enrollees and family members who are members of this Plan The cost of the benefits described on this page is not
included in the FEHB premium any charges for these services do not count toward any FEHB deductibles or out of pocket maximum
These benefits are not subject to the FEHB disputed claims procedures

These benefits are available only if you enroll or are currently enrolled in the Kaiser Permanente Plan for FEHB members You do
not need to enroll in either dental plan if you choose not to However you must enroll in Kaiser Permanente to participate in either
the Standard Option or High Options dental plans All subscribers who enroll in either dental program when eligible must continue
enrollment in the selected dental program until the next open enrollment period This does not apply if employment is terminated

Expanded Dental Kaiser Permanente is pleased to offer Federal employees retirees and dependents expanded dental
Benefits coverage through the American Dental Plan

CompDent Corporation offers dental health maintenance organization HMO benefits administered
by American Dental Plan ADP You must pre identify a primary care dentist from the list
of ADP dentists that is most convenient to you and your family With ADP there are no claim
forms to worry about ADP also provides a full range of services that includes preventative
restorative endodontics periodontics prosthetics and orthodontics Under this program the
subscriber pays a copayment for all service which means a discount of approximately seventyfive
percent 75 off all covered services

Monthly Premium Self Only 11.00 Self One Party 20.10
Self Two or More 28.40
These rates are effective January 1 2000 through December 31 2000

How to Enroll Please read the enclosed flyer for a summary of the expanded dental plan You can use the postage paid card attached to the flyer to request enrollment information directly from CompDent If you
would like more information call 888 340 2282 and identify yourself as an Federal employee interested
in the Kaiser Permanente ADP Standard Option or High Option dental plan
Payment for the Standard Option or High Option must be made by automatic monthly withdrawal
from your checking savings or credit union account or an annual charge to your MasterCard
or Visa

22 BENEFITS ON THIS PAGE ARE NOT PART OF THE FEHB CONTRACT 22
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Kaiser Foundation Health Plan of Georgia 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 1 800 638 6833 For information on the Medicare Choice
plan offered by this Plan see page 21

23 23
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Kaiser Foundation Health Plan of Georgia Inc 2000
Section 7 Limitations Rules that affect your benefits continued
Other Group Insurance When anyone has coverage with us and with another group health plan it is called double coverage
Coverage You must tell us if you or a family member has double coverage You must also send us documents about other insurance if we ask for them

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

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

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

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

When Others Are When you receive money to compensate you for medical or hospital care for injuries or illness
Responsible For that another person caused you must reimburse us for whatever services we paid for We will
Injuries cover the cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more information

contact us for our subrogation procedures

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

Workers We do not cover services that
Compensation You need because of a workplace related disease or injury that the Office of Workers

Compensation Programs OWCP or a similar Federal or State agency determine they
must provide

OWCP or a similar agency pays for through a third party injury settlement or other
similar proceeding that is based on a claim you filed under OWCP or similar laws

Once the OWCP or similar agency has paid its maximum benefits for your treatment we will
provide your benefits

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

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

24 24
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Kaiser Foundation Health Plan of Georgia Inc 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 HMO find out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's

website http www opm gov insure lists the specific types of information that we must make
available to you

If you want specific information about us call 404 261 2590 or write to Nine Piedmont Center
3495 Piedmont Road N E Atlanta GA 30305 1736 You may also contact us by fax at 404 364
4939 or visit our website at http www kaiserpermanente org

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

When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay
enter military service or retire

When your enrollment ends and
The next Open Season for enrollment

We don't determine who is eligible for coverage and in most cases cannot change your enrollment
status without information from your employing or retirement office

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

What happens when When you retire you can usually stay in the FEHB Program Generally you must have been
I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet this requirement you may be eligible for other forms of coverage such as Temporary

Continuation of Coverage which is described later in this section

What types of coverage Self Only coverage is for you alone Self and Family coverage is for you your spouse and your
are available for me unmarried dependent children under age 22 including any foster or step children your employing
and my family or retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of self support

If you have a Self Only enrollment you may change to a Self and Family enrollment if you
marry give birth or add a child to your family You may change your enrollment 31 days before
to 60 days after you give birth or add the child to your family The benefits and premiums for
your Self and Family enrollment begin on the first day of the pay period in which the child is
born or becomes an eligible family member

Your employing or retirement office will not notify you when a family member is no longer eligible
to receive health benefits nor will we Please tell us immediately when you add or remove
family members from your coverage for any reason including divorce

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

25 25
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Kaiser Foundation Health Plan of Georgia Inc 2000
Section 8 FEHB Facts continued
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

This Plan and appropriate third parties such as other insurance plans and the Office of
Workers Compensation Programs OWCP when coordinating benefit payments and
subrogating claims

Law enforcement officials when investigating and or prosecuting alleged civil or criminal
actions

OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your
identity or

OPM when reviewing a disputed claim or defending litigation about a claim

Information for
new members

Identification We will send you an Identification ID card Use your copy of the Health Benefits Election
Cards Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use an Employee Express confirmation letter

What if I paid a Your old plan's deductible continues until our coverage begins
deductible under
my old plan

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

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

You may be eligible for former spouse coverage or Temporary Continuation of Coverage

What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits
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

26 26
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Kaiser Foundation Health Plan of Georgia 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 administrative charge The government does
not share your costs

You receive another 31 day extension of coverage when your TCC enrollment ends
unless you cancel your TCC or stop paying the premium

You are not eligible for TCC if you can receive regular FEHB Program benefits

How do I enroll If you leave Federal service your employing office will notify you of your right to enroll under
in TCC TCC You must enroll within 60 days of leaving or receiving this notice whichever is later

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

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

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

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

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

27 27
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Kaiser Foundation Health Plan of Georgia Inc 2000
Section 8 FEHB Facts continued
How can I convert to You may convert to an individual policy if
individual coverage Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did

not pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law

If you leave Federal service your employing office will notify you if individual coverage is
available You must apply in writing to us within 31 days after you receive this notice However
if you are a family member who is losing coverage the employing or retirement office will not
notify you You must apply in writing to us within 31 days after you are no longer eligible for
coverage

Your benefits and rates will differ from those under the FEHB Program however you will not
have to answer questions about your health and we will not impose a waiting period or limit
your coverage due to pre existing conditions

How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage
Certificate of Group that indicates how long you have been enrolled with us You can use this certificate when getting
Health Plan Coverage health insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or

exclusions for health related conditions based on the information in the certificate

If you have been enrolled with us for less than 12 months but were previously enrolled in other
FEHB plans you may request a certificate from them as well

28 28
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Kaiser Foundation Health Plan of Georgia 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 404 261 2590 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 Georgia Inc 2000
Summary of Benefits for Kaiser Foundation Health Plan of Georgia 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

Benefits Plan pays provides Page
Inpatient Hospital Comprehensive range of medical and surgical services without dollar or day limit
Care 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 14

Extended Care All necessary services up to 100 days each calendar year You pay nothing 14
Mental Conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per year You pay nothing and 50 all charges thereafter for
each day in the same calendar year 18
Substance abuse Covered under mental conditions 18

Outpatient Comprehensive range of services such as diagnosis and treatment of illness or
Care injury including specialist's care preventive care including well baby care periodic check ups and routine immunizations laboratory tests and X rays

complete maternity care You pay 10 office visit copays are waived for
maternity care You pay 10 for each house call by a physician 11

Home health care All necessary visits by nurses and health aides You pay nothing 11
Mental Conditions You pay nothing for outpatient visits 1 5 15 per visit for visits 6 40 and 50 of all charges thereafter for each outpatient visit in a calendar year 18

Substance abuse Up to 30 outpatient visits per year in a treatment program
You pay nothing per visit 18

Emergency Reasonable charges for services and supplies required because of a medical
Care emergency You pay 50 for each emergency care visit any applicable Plan copayments in addition to the above and any charges for services that are not

covered by this Plan If the emergency results in admission to a hospital the
50 copayment is waived 16

Reasonable charges for services and supplies required because of treatment
received in a Kaiser Permanente After Hours Office or a Health Plan Designated
Urgent Care Center You pay 10 for each After Hours visit or 20 for each
Urgent Care visit and any charges for services that are not covered by this Plan 16

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Kaiser Foundation Health Plan of Georgia Inc 2000
Benefits Plan pays provides Page
Prescription Drugs prescribed by a Plan physician or dentist and obtained at a Plan pharmacy
Drugs You pay a 5 per prescription unit or refill obtained at a Plan medical office pharmacy and a 11 per prescription unit or refill obtained at a Plan participating

community Pharmacy 19

Dental Care Accidental injury benefit you pay 50 of the first 1,000 in charges per injury
and all charges thereafter Preventive dental care you pay 14 per visit
Non surgical treatment of TMJ dysfunction you pay 50 of the first 1,000
in charges per calendar year and all charges thereafter 20

Vision Care Eye refractions for eyeglasses you pay 15 per visit 20

Out of pocket Copayments are required for a few benefits however after your out of pocket
maximum expenses reach a maximum of 2,000 per Self Only or 5,000 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 6

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2000 Rate Information for
Kaiser Foundation Health Plan
of Georgia Inc
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 Postal Postal
Premium Premium A Premium B

Biweekly Monthly Biweekly Biweekly
Type of Gov't Your Gov't Your USPS Your USPS Your Enrollment Code Share Share Share Share Share Share Share Share

Self Only F81 68.37 22.79 148.13 49.38 80.90 10.26 80.90 10.26
Self Family F82 173.57 57.85 376.06 125.35 205.39 26.03 201.02 30.40

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