2002
A Health Maintenance Organization
Serving: Northern/
Southern California service areas
Enrollment in this Plan is limited.
You must live or work in our
Geographic service area to enroll. See pages 8
and 9 for requirements.
Enrollment codes for this Plan:
Northern California
591 Self Only
592 Self and Family
Southern California
621 Self Only 622 Self and Family
This Plan has excellent accreditation from the NCQA
in the Northern
California Service Area.
See the 2002 Guide for more information on NCQA.
This Plan has commendable accreditation from the
NCQA in the Southern
California Service Area.
See the 2002 Guide for more information on NCQA.
For
changes
in benefits,
see page 10.
RI 73-003 1
1 Page
2 3
Table of Contents
Introduction
.........................................................................................................................................................................
5
Plain
Language....................................................................................................................................................................
5
Inspector General Advisory
................................................................................................................................................
6
Section 1. Facts about this HMO
plan...............................................................................................................................
7
How we pay providers
......................................................................................................................................
7
Your Rights
.......................................................................................................................................................
7
Service
Area......................................................................................................................................................
8
Section 2. How we change for
2002................................................................................................................................
10
Program-wide changes
...................................................................................................................................
10
Changes to this Plan
.......................................................................................................................................
10
Section 3. How you get care
...........................................................................................................................................
11
Identification cards
.........................................................................................................................................
11
Where you get covered care
...........................................................................................................................
11
Plan
providers..............................................................................................................................................
11
Plan
facilities...............................................................................................................................................
11
What you must do to get covered
care...........................................................................................................
12
Primary care
................................................................................................................................................
12
Specialty care
..............................................................................................................................................
12
Hospital care
...............................................................................................................................................
13
Circumstances beyond our
control.................................................................................................................
13
Services requiring our prior
approval.............................................................................................................
13
Section 4. Your costs for covered services
......................................................................................................................
14
Copayments.................................................................................................................................................
14
Deductible
...................................................................................................................................................
14
Coinsurance.................................................................................................................................................
14
Fees when you fail to make your
copayment.............................................................................................
14
Your catastrophic protection out-of-pocket maximum for copayments and
coinsurance............................. 14
Section 5. Benefits
...........................................................................................................................................................
15
Overview.........................................................................................................................................................
15
(a) Medical services and supplies provided by physicians and other health
care professionals ............. 16
(b) Surgical and anesthesia services
provided by physicians and other health care professionals.......... 25
(c)
Services provided by a hospital or other facility, and ambulance
services........................................ 29
(d) Emergency services/
accidents
............................................................................................................
32
(e) Mental health and substance abuse benefits
......................................................................................
34
(f) Prescription drug
benefits...................................................................................................................
37
(g) Special
features...................................................................................................................................
40
2002 Kaiser Foundation Health Plan, Inc. 2 Table of Contents 2
2 Page 3 4
Flexible benefits
option.......................................................................................................................
40
Services from other Kaiser Permanente
Plans....................................................................................
40
Travel benefit
.......................................................................................................................................
41
24 hour nurse line
................................................................................................................................
41
Services for deaf and hearing impaired
..............................................................................................
41
Centers of excellence for transplants
..................................................................................................
41
(h) Dental benefits
........................................................................................................................................
42
(i) Non-FEHB benefits available to Plan members
....................................................................................
43
Section 6. General exclusions things we don't
cover...................................................................................................
44
Section 7. Filing a claim for covered services
................................................................................................................
45
Medical, hospital, and drug
benefits..............................................................................................................
45
Deadline for filing your
claim........................................................................................................................
45
When we need more
information...................................................................................................................
45
If you have a malpractice claim
.....................................................................................................................
45
Section 8. The disputed claims
process...........................................................................................................................
46
Section 9. Coordinating benefits with other coverage
....................................................................................................
48
When you have other health coverage
...........................................................................................................
48
What is Medicare?
......................................................................................................................................
48
The Original Medicare Plan (Part A or Part B)
.........................................................................................
48
Medicare managed care plan
......................................................................................................................
51
If you do enroll in Medicare Part B
...........................................................................................................
52
If you do not enroll in Medicare Part A or Part B
.....................................................................................
52
TRICARE
.......................................................................................................................................................
52
Workers'
Compensation..................................................................................................................................
52
Medicaid
.........................................................................................................................................................
52
When other Government agencies are responsible for your
care.................................................................. 53
When others are responsible for injuries
.......................................................................................................
53
Section 10. Definitions of terms we use in this
brochure.................................................................................................
54
Section 11. FEHB
facts......................................................................................................................................................
56
Coverage information
.....................................................................................................................................
56
No pre-existing condition limitation
..........................................................................................................
56
Where you get information about enrolling in the FEHB
Program.......................................................... 56
Types
of coverage available for you and your family
................................................................................
56
When benefits and premiums
start.............................................................................................................
57
Your medical and claims records are confidential
.....................................................................................
57
When you retire
..............................................................................................................................................
57
When you lose benefits
..................................................................................................................................
57
When FEHB coverage
ends........................................................................................................................
57
2002 Kaiser Foundation Health Plan, Inc. 3 Table of Contents 3
3 Page 4 5
Spouse equity
coverage...............................................................................................................................
57
Temporary continuation of coverage (TCC)
..............................................................................................
57
Converting to individual
coverage..............................................................................................................
58
Getting a Certificate of Group Health Plan
Coverage...................................................................................
58
Long term care insurance is coming later in
2002...........................................................................................................
59
Department of Defense/ FEHB Demonstration
Project....................................................................................................
60
Index
..................................................................................................................................................................................
62
Summary of
benefits.........................................................................................................................................................
63
Rates
....................................................................................................................................................................
Back cover
2002 Kaiser Foundation Health Plan, Inc. 4 Table of Contents 4
4 Page 5 6
Introduction
Kaiser Foundation Health Plan,
Inc., California Division
1950 Franklin Street, Oakland, CA 94612 (Northern
California)
393 East Walnut Street, Pasadena, CA 91188 (Southern California)
This brochure describes the benefits of Kaiser Foundation Health Plan, Inc.
California Division under our contract
(CS1044) with the Office of Personnel
Management (OPM), as authorized by the Federal Employees Health Benefits
law. This brochure is the official statement of benefits. No oral statement
can modify or otherwise affect the benefits,
limitations, and exclusions of
this brochure.
If you are enrolled in this Plan, you are 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. You do not have a
right to
benefits that were available before January 1, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2002, and
changes are summarized on page 63. Rates
are shown at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible,
and
understandable to the public. For instance,
Except for necessary technical terms, we use common words. For
instance, "you" means the enrollee or family
member; "we" or "Plan" means
Kaiser Foundation Health Plan, Inc.
We limit acronyms to ones you know. FEHB is the Federal Employees
Health Benefits Program. OPM is the
Office of Personnel Management. If we
use others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format
and similar descriptions to help you
compare plans.
If you have comments or suggestions about how to improve this brochure, let
us know. Visit OPM's "Rate Us"
feedback area at www. opm. gov/ insure or
e-mail us at fehbwebcomments@ opm. gov. You may also write to OPM at
the
Office of Personnel Management, Office of Insurance Planning and Evaluation,
1900 E Street NW, Washington,
DC 20415.
2002 Kaiser Foundation Health Plan, Inc. 5 Introduction/ Plain
Language/ Advisory 5
5 Page
6 7
Inspector General Advisory
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 eceive,
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 our Member Service Call
Center at 1-800-464-4000 and explain the situation.
If we do not resolve the issue, call or write
THE HEALTH CARE FRAUD
HOTLINE
202/ 418-3300
The United States Office of Personnel
Management
Office of the Inspector General Fraud Hotline
1900 E Street,
NW, Room 6400
Washington, DC 20415
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 the person tries to obtain services for someone who
is
not an eligible family member, or is no longer enrolled in the Plan and
tries to
obtain benefits. Your agency may also take administrative action
against you.
Penalties for Fraud
2002 Kaiser Foundation Health Plan, Inc. 6 Introduction/ Plain
Language/ Advisory
Stop health care fraud! 6
6 Page 7 8
Section 1. Facts
about this HMO plan
This Plan is a health maintenance organization
(HMO). We require you to see specific physicians, hospitals, and
other
providers that contract with us. These Plan providers coordinate your health
care services. HMOs emphasize
preventive care such as routine office visits,
physical exams, well-baby care, and immunizations, in addition to
treatment
for illness and injury. Our providers follow generally accepted medical practice
when prescribing any
course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay
the copayments and coinsurance
described in this brochure. When you receive emergency services from non-Plan
providers, 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.
How we pay providers
We contract with individual physicians,
medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers accept a negotiated payment from us, and you will only be
responsible for your copayments or
coinsurance.
Your Rights
OPM requires that all FEHB plans provide certain
information to their FEHB members. You may get information
about us, our
networks, providers, and facilities. OPM's FEHB Web site (www. opm. gov/ insure)
lists the specific types
of information that we must make available to you.
Some of the required information is listed below.
We are a federally qualified health maintenance organization, and we have
provided health care services to
Californians since the 1950s. Kaiser
Foundation Health Plan, Inc., is a California not-for-profit organization. This
Plan is part of the Kaiser Permanente Medical Care Program, a group of
not-for-profit organizations and contracting
medical groups that serve over
8 million members nationwide. Our Medical Groups, The Permanente Medical Group,
Inc., and the Southern California Permanente Medical Group, operate Plan
medical offices throughout California.
If you want more information about us, call 1-800-464-4000, or write to 1950
Franklin Street, Oakland, California
94612, or 393 East Walnut Street,
Pasadena, California 91188. You may visit our website at
www.
kaiserpermanente. org/ california, which lists the specific types of information
that we must make available to you.
2002 Kaiser Foundation Health Plan, Inc. 7 Section 1 7
7 Page 8 9
Service Area
To enroll in this Plan, you must
live or work in our service area. This is where our providers practice. Our
service
area is:
Northern California counties: Alameda; Contra Costa; Marin; Sacramento; San
Francisco; San Joaquin;
San Mateo; Solano; Stanislaus.
Portions of the following counties, as indicated by the zip codes below, are
also within the service area:
Amador County: 95640, 95669
El Dorado
County: 95613 14, 95619, 95623, 95633 35, 95651, 95664, 95667, 95672, 95682,
95762
Fresno County: 93242, 93602, 93606-07, 93609, 93611 13, 93616, 93624 27,
93630 31,
93646, 93648 52, 93654, 93656 57, 93660, 93662, 93667 68,
93675,
93701 12, 93714 18, 93720 22, 93724 29, 93740 41, 93744 45,
93747,
93750, 93755, 93759 62, 93764 65, 93771 80, 93782, 93784, 93786,
93790 94, 93844, 93888
Kings County: 93230 32
Madera County: 93601, 93604, 93614, 93637 39,
93643 45, 93653, 93669
Mariposa County: 93623
Napa County: 94503,
94508, 94515, 94558 59, 94562, 94567, 94573 74, 94576, 94581,
94599
Placer County: 95602 04, 95648, 95650, 95658, 95661, 95663, 95677 78,
95681, 95703,
95722, 95736, 95746 47, 95765
Santa Clara County: 94022 24, 94035, 94039 43, 94085 90, 94301 02, 94304
06, 94309 10,
95002, 95008 09, 95011, 95013 15, 95020** 21, 95026,
95030 33,
95035 38, 95042, 95044, 95046, 95050 56, 95070 71, 95101 03,
95106,
95108 42, 95148, 95150 61, 95164, 95170 73, 95190 94, 95196
** The Bells Station community, which lies within Gilroy zip code
95020,
is not in the service area
Sonoma County: 94922 23, 94926 28, 94931, 94951 55, 94972, 94975, 94999,
95401 09,
95416, 95419, 95421, 95425, 95430 31, 95433, 95436, 95439,
95441 42,
95444, 95446, 95448, 95450, 95452, 95462, 95465, 95471 73,
95476,
95486-87, 95492
Sutter County: 95659, 95668, 95674, 95676
Tulare County: 93618, 93666,
93673
Yolo County: 95605, 95607, 95612, 95616 18, 95645, 95691, 95694 95,
95697 98,
95776, 95798 99
Yuba County: 95692, 95903, 95961
2002 Kaiser Foundation Health Plan, Inc. 8 Section 1 8
8 Page 9 10
Southern California counties: Orange and Los Angeles
(except zip code 90704).
Portions of the following counties, as indicated by
the zip codes below, are also within the service area:
Imperial: 92275
Kern: 93203, 93205 06, 93215 16, 93220, 93222, 93224 26, 93238, 93240
41,
93243, 93250 52, 93263, 93268, 93276, 93280, 93285, 93287, 93301 09,
93311 13, 93380 90, 93501 02, 93504 05, 93518 19, 93531, 93560 61,
93581
Riverside: 91752, 92201 03, 92210 11, 92220, 92223, 92230, 92234 36,
92240 41,
92253 55, 92258, 92260 64, 92270, 92274, 92276, 92282, 92292,
92320,
92501 09, 92513 19, 92521 22, 92530 32, 92543 46, 92548, 92551
57,
92562 64, 92567, 92570 72, 92581 87, 92595 96, 92599, 92860, 92877
83
San Bernardino: 91701, 91708 10, 91729 30, 91737, 91739, 91743, 91758,
91761 64,
91784 86, 91798, 92252, 92256, 92268, 92277, 92278, 92284 86,
92305,
92307 08, 92313 18, 92321 22, 92324 26, 92329, 92333 37, 92339
41,
92345 46, 92350, 92352, 92354, 92357 59, 92369, 92371 78, 92382,
92385 86, 92391 94, 92397, 92399, 92401 08, 92410 15, 92418, 92420,
92423 24, 92427
San Diego: 91901 03, 91908 17, 91921, 91931 33, 91935, 91941 47, 91950
51,
91962 63, 91976 80, 91990, 92007 09, 92014, 92018 27, 92029 30,
92033, 92037 40, 92046, 92049, 92051 52, 92054 58, 92064 65, 92067
69, 92071 72, 92074 75, 92078 79, 92082 85, 92090 93, 92096, 92101
24, 92126 40, 92142 43, 92145, 92147, 92149 50, 92152 55, 92158 79,
92182, 92184, 92186 87, 92190 99
Tulare: 93261
Ventura: 91319 20, 91358 63, 91377, 93001 07, 93009,
93010 12, 93015 16,
93020 21, 93022, 93030 35, 93040, 93041 44, 93060
61, 93062 66,
93093, 93099
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 41; and for emergency care obtained
from any non-Plan provider, as described on
page 32. 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 live out of the area (for
example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with
affiliates in other areas. If you or a family
member move, you do not have
to wait until Open Season to change plans. Contact your employing or retirement
office.
2002 Kaiser Foundation Health Plan, Inc. 9 Section 1 9
9 Page 10 11
Section 2. How we change for 2002
Do not
rely on these change descriptions; this page is not an official statement of
benefits. For that, go to Section 5
Benefits. Also, we edited and clarified
language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.
Program-wide changes
We removed the requirement that services
must be needed to restore functional speech from the speech therapy
benefit.
Changes to this Plan
In Northern California your share of the
non-Postal premium will increase by 17.8% for Self Only or 17.7% for
Self
and Family.
In Southern California your share of the non-Postal premium will
increase by 18.6% for Self Only or 18.6% for
Self and Family.
We cover therapeutic contact lenses for the condition of aniridia at
no charge.
We increased the copayment for orthopedic and prosthetic
devices dispensed in a Plan medical office or
pharmacy, or by a vendor from
no charge to 20% of our allowance.
We increased the copayment for podiatric devices (including
footwear) to prevent or treat diabetes-related
complications when prescribed
by a Plan podiatrist, physiatrist, or orthopedist from no charge to 20% of our
allowance.
We increased the copayment for outpatient durable medical equipment
items for use in the home that are
dispensed in a Plan medical office or
pharmacy, or by a vendor from no charge to 20% of our allowance.
We increased the copayment for emergency services within and outside
our service area from $35 per visit to $50
per visit.
We increased the copayment for all covered emergency ambulance
transportation from no charge per trip to a $50
copayment per trip.
We increased the copayment for prescription drugs from $10 for all
drugs to $10 for generic drugs and $20 for
brand-name drugs. Also, if you
request a brand-name drug when your physician prescribes a generic drug, you
will pay full charges for that drug.
Certain contraceptives such as injectable and internally implanted,
time-release contraceptives and intrauterine
devices are now covered at no
charge when provided by a Plan medical office. Previously there was a $10
copayment.
We clarified the Preventive care, adult benefit by removing the
entry for blood lead level testing for adults
because it is a test more
typically done for children.
If you have Medicare Part B benefits, we now require that you assign
your Medicare Part B benefits to the Plan
to receive covered services.
We no longer limit total blood cholesterol tests to certain age
groups. (Section 5( a))
We now cover certain intestinal
transplants. (Section 5( b))
We changed the address for sending
disputed claims to OPM.
2002 Kaiser Foundation Health Plan, Inc. 10 Section 2 10
10 Page 11 12
Section 3. How you get care
We will send
you an identification (ID) card when you enroll. You
should carry your ID
card with you at all times. You must show it
whenever you receive services
from a Plan provider, or fill a prescription
at a Plan pharmacy. Until you
receive your ID card, use your copy of the
Health Benefits Election Form,
SF-2809, your health benefits enrollment
confirmation (for annuitants), or
your Employee Express confirmation
letter.
If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at our
Member Service Call Center at 1-800-464-4000.
You get care from "Plan providers" and "Plan facilities." You will only
pay copayments and/ or coinsurance, and you will not have to file claims.
Plan providers are physicians and other health care professionals in our
service area that we contract with to provide covered services to our
members. Health Plan contracts with The Permanente Medical Group,
Inc.,
the Southern California Permanente Medical Group, and
independent
multispecialty groups of physicians to provide or arrange all
necessary
physician care for Plan members. Medical care is provided
through
physicians, nurse practitioners, and other skilled medical
personnel working
as medical teams at Kaiser Permanente facilities. We
credential Plan
providers according to national standards. Specialists in
most major
specialties are available as part of the medical teams for
consultation and
treatment. Other necessary medical care, such as
physical therapy and
laboratory and X-ray services, is also available.
Plan physicians also
arrange any necessary specialty care.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.
Plan facilities are hospitals and other facilities in our service area that
we
contract with to provide covered services to our members. In Northern
California, Kaiser Permanente offers comprehensive, affordable health
care at 30 Plan facilities conveniently located throughout the San
Francisco Bay, Sacramento, Stockton, and Fresno areas. These facilities
include Medical Centers with full hospital facilities and Plan medical
offices. The Southern California service area has 10 major Medical
Centers and more than 90 medical offices conveniently located
throughout
the Southern California area.
The Plan's facility directory lists the Plan's facilities and services, with
the locations and phone numbers. Directories are updated on a regular
basis and are available at the time of enrollment or upon request by
calling our Member Service Call Center at 1-800-464-4000. You should
use
this directory to:
Receive more information about facility locations and services
Receive information about how to get established with a Plan
physician
Identification cards
Where you get covered care
Plan providers
Plan facilities
2002 Kaiser Foundation Health Plan, Inc. 11 Section 3 11
11 Page 12 13
You must receive your health 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 at
those Kaiser
Permanente facilities. Under the circumstances specified in
this
brochure, you may receive follow-up or continuing care while you travel
anywhere.
It depends on the type of care you need. First, you and each family
member must choose a primary care physician. This decision is
important
since your primary care physician provides or arranges for
most of your
health care.
Your primary care physician can be either a family practitioner,
pediatrician, gynecologist, or internist. Your primary care physician will
provide most of your health care, or give you a referral to see a
specialist.
Please 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 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.
If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.
Your primary care physician will refer you to a specialist for needed care.
When you receive a referral from your primary care physician, you must
return to the primary care physician after the consultation, unless your
primary care physician authorized a certain number of visits without
additional referrals. The primary care physician must provide or
authorize all follow-up care. Do not go to the specialist for return visits
unless your primary care physician gives you a referral. However, you
may see a gynecologist, an optometrist, or our mental health and
substance abuse Plan providers without a referral.
Here are other things you should know about specialty care:
If you need
to see a specialist frequently because of a chronic,
complex, or serious
medical condition, your primary care physician
will develop a treatment plan
that allows you to see your specialist for
a certain number of visits
without additional referrals. Your primary
care physician will use our
criteria when creating your treatment plan
(the physician may have to get an
authorization or approval
beforehand).
If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will decide
what
treatment you need. If he or she decides to refer you to a
specialist, ask
if you can see your current specialist. If your current
specialist does not
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.
If you are seeing a specialist and your specialist leaves the Plan, call
your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist
until
we can make arrangements for you to see someone else.
What you must do to get covered care
Primary care
Specialty care
2002 Kaiser Foundation Health Plan, Inc. 12 Section 3 12
12 Page 13 14
If you have a chronic or disabling condition
and lose access to your
specialist because we:
terminate our contract with your specialist for other than cause; or
drop out of the Federal Employees Health Benefits (FEHB)
Program and you
enroll in another FEHB plan; or
reduce our service area and you enroll in another FEHB plan,
you may be
able to continue seeing your specialist for up to 90 days
after you receive
notice of the change. Contact us, or if we drop out
of the Program, contact
your new plan.
If you are in the second or third trimester of pregnancy and you lose
access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care, even
if it is beyond the 90 days.
Your Plan primary care physician or specialist will make necessary
hospital arrangements and supervise your care. This includes admission
to a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call
our Member Service Call Center immediately at 1-800-464-4000. If you
are
new to the FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan 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 92 nd day after you become a member of this Plan,
whichever happens first.
These provisions apply only to the hospital
benefit of the hospitalized person.
Under certain extraordinary
circumstances, such as natural disasters, we
may have to delay your services
or we may be unable to provide them.
In that case, we will make all
reasonable efforts to provide you with the
necessary care.
Your primary care physician has authority to refer you for most services.
In certain cases your primary care physician can arrange for specialty
services through a process we call a referral. Your physician must write
a referral for services such as neurology, orthopedics, rheumatology,
endocrinology, and any service that will not be provided by Plan
physicians.
If a Plan physician determines that a referral for medical care is
necessary, those arrangements will be prepared in writing and in advance
of such medical care. If you receive care outside the Plan without a
referral, you will be responsible for those expenses. We encourage you
to participate in your medical care and discuss any questions about our
referral process with your primary care physician. If your request for
referral is denied, please contact our Member Service Call Center at
1-800-464-4000 or refer to Section 8 of this brochure.
Hospital care
Circumstances beyond our control
Services
requiring our prior approval
2002 Kaiser Foundation Health Plan, Inc. 13 Section 3 13
13 Page 14 15
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
A
copayment is a fixed amount of money you pay to the provider, facility,
pharmacy, etc., when you receive services. Example: When you see your
primary care physician, you pay a copayment of $10 per office visit.
We do not have a deductible.
NOTE: If you change plans during open
season, you do not have to start a
new deductible under your old plan
between January 1 and the effective
date of your new plan. If you change
plans at another time during the year,
you must begin a new deductible under
your new plan.
Coinsurance is the percentage of our allowance that you must pay for
certain services you receive. Example: In our Plan, you pay 50% of our
allowance for infertility services.
If you do not pay your copayment at the time you receive services, we
will bill you. You will be required to pay a $10 charge for each bill sent
for unpaid services.
After your copayments and coinsurance total $1,500 per person or
$3,000
per family enrollment in any calendar year, you do not have to pay
any more
for covered services. However, copayments or coinsurance for
the following
services do not count toward your out-of-pocket maximum.
You must continue
to pay copayments or coinsurance for these services:
Prescription drugs
Dental services
Contraceptive devices
Chiropractic services
The $25 charge paid for follow-up or continuing care
outside the
service area
Be sure to keep accurate records of your copayments and coinsurance,
since you are responsible for informing us when you reach the maximum.
Copayments
Deductible
Coinsurance
Fees when you fail to
make your copayment
Your catastrophic protection out-of-pocket maximum for
copayments and
coinsurance
2002 Kaiser Foundation Health Plan, Inc. 14 Section 4 14
14 Page 15 16
Section 5. Benefits OVERVIEW
(See
page 10 for how our benefits changed this year and page 63 for a benefits
summary.)
NOTE: This benefits section is divided into subsections. Please read
the important things you should keep in mind at
the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to the
benefits in the
following subsections. To obtain claims forms, claims filing
advice, or more information about our benefits, contact us
at 1-800-464-4000
or our website at www. kaiserpermanente. org/ california.
(a) Medical services and supplies provided by physicians and other health
care professionals ......................... 16 23
Diagnostic and
treatment services Hearing services (testing, treatment,
Lab, X-ray, and
other diagnostic tests and supplies)
Preventive care, adult Vision
services (testing, treatment,
Preventive care, children and supplies)
Maternity care Foot care
Family planning Orthopedic and
prosthetic devices
Infertility services Durable medical equipment (DME)
Allergy care Home health services
Treatment therapies
Chiropractic and alternative treatments
Physical and occupational
therapies Educational classes and programs
Speech therapy
(b) Surgical and anesthesia services provided by physicians and other health
care professionals...................... 25 27
Surgical procedures
Oral and maxillofacial surgery
Reconstructive surgery
Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance
services.................................................... 29 31
Inpatient hospital Extended care benefits/ skilled nursing care
Outpatient hospital or ambulatory facility benefits
surgical
center Hospice care
Ambulance
(d) Emergency services/ accidents
........................................................................................................................
32 33
Emergency within our service area Ambulance
Emergency outside our service area
(e) Mental health and substance abuse benefits
..................................................................................................
34 36
(f) Prescription drug
benefits...............................................................................................................................
37 39
(g) Special
features...............................................................................................................................................
40 41
Flexible benefits option 24 hour nurse line
Services from other Kaiser Permanente Plans Services for deaf and
hearing impaired
Travel benefit Centers of excellence for
transplants
(h) Dental
benefits......................................................................................................................................................
42
(i) Non-FEHB benefits available to Plan
members...................................................................................................
43
Summary of
benefits....................................................................................................................................................
63
2002 Kaiser Foundation Health Plan, Inc. 15 Section 5 15
15 Page 16 17
Here are some important things to keep in mind
about these benefits:
Please remember that all benefits are subject to
the definitions, limitations, and exclusions
in this brochure and we cover
them only when we determine they are medically necessary.
Plan physicians must provide or arrange your care.
We
have no calendar year deductible.
Be sure to read Section 4,
Your costs for covered services, for valuable information about
how
cost-sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
Note: Instead of a $10 charge, you pay only $5 if you enroll in our
Medicare+ Choice Plan
and assign your Medicare benefits to the Plan.
I M
P O
R T
A N
T
I M
P O
R T
A N
T
2002 Kaiser Foundation Health Plan, Inc. 16 Section 5( a)
Benefit description You pay
Diagnostic and treatment services
Professional services of physicians and other health care professionals
$10 per office visit
In a physician's office
In an
urgent care center
Second opinion within Plan
Consultations with specialists
During a hospital stay Nothing
In a skilled nursing
facility
Initial examination of a newborn child covered under a
family enrollment
At home Nothing
Section 5 (a). Medical services and supplies provided by physicians
and other health care professionals 16
16
Page 17 18
Lab,
X-ray, and other diagnostic tests You pay
Tests, such as: Nothing
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine mammograms
CAT scans/ MRI
Ultrasound
Electrocardiogram and EEG
Preventive care, adult
Routine screenings, such as: Nothing
Total blood cholesterol
Colorectal cancer screening, including
Fecal
occult blood test
Sigmoidoscopy every five years starting at age 50
Prostate Specific Antigen (PSA) test one annually for men age 40
and older
Routine pap test
Note: You should consult with your physician to
determine what is
appropriate for you.
Routine mammogram covered for women age 35 and older, as follows: Nothing
Age 35 through 39, one during this five-year period
Age 40 through
64, one every calendar year
At age 65 and older, once every two
consecutive calendar years
Note: In addition to routine screening, we cover
mammograms when
medically necessary to diagnose or treat your illness.
Routine immunizations, including but not limited to: Nothing
Tetanus-diphtheria (Td) booster once every 10 years, ages 19 and
over
(except as provided for under childhood immunizations)
Influenza/ Pneumococcal vaccines
Hepatitis vaccinations
2002 Kaiser Foundation Health Plan, Inc. 17 Section 5( a) 17
17 Page 18 19
Not covered: All charges
Physical exams
required for:
Obtaining or continuing employment
Insurance
Travel
Preventive care, children You pay
Well-child preventive care
visits (23 months and younger) Nothing
Childhood immunizations
recommended by the American Academy
of Pediatrics
Well-child care charges for routine examinations age 24 months and
$10 per office visit
older, such as:
Eye exams to determine the need for vision correction
Ear
exams to determine the need for hearing correction
Not covered: All charges
Physical exams required for:
Obtaining or continuing employment
Insurance
Maternity care
Complete maternity (obstetrical) care, such as:
Nothing
Prenatal care
Delivery
First
scheduled postnatal care visit
Note: Here are some things to keep in mind:
You may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a cesarean delivery. We will extend your
inpatient stay if medically necessary.
We cover routine nursery care of the newborn child during the
covered portion of the mother's maternity stay. We will cover other
care
of an infant who requires nonroutine treatment only if we cover
the infant
under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as
for illness and injury. See Section 5( c) for hospital benefits and
Section 5( b) for surgery benefits.
Not covered: All charges
Routine sonograms to
determine fetal age, size, or sex
2002 Kaiser Foundation Health Plan, Inc. 18 Section 5( a) 18
18 Page 19 20
Family planning You pay
Voluntary
sterilization $10 per office visit
Genetic counseling
Insertion of surgically implanted or injectable contraceptives
Note: The
following devices or contraceptives are provided at no
charge: intrauterine
devices (IUDs); implanted and injectable
contraceptives; and time release
contraceptives.
Note: We cover oral contraceptives, cervical caps, and diaphragms
under
the prescription drug benefit.
Not covered: All charges
Reversal of voluntary
surgical sterilization
Infertility services
Diagnosis and treatment of infertility, such
as: 50% of our allowance
Artificial insemination:
Intravaginal insemination (IVI)
Intracervical insemination (ICI)
Intrauterine insemination (IUI)
Note: We cover fertility drugs under the
prescription drug benefit.
Not covered: All charges
These exclusions apply to fertile as well as
infertile individuals or
couples:
Assisted reproductive technology (ART) procedures, such as:
In vitro fertilization
Embryo transfer and GIFT
Services and supplies related to excluded ART procedures
Cost of donor sperm and donor eggs and services related to their
procurement and storage
Allergy care
Allergy testing, treatment, and injections $3 per
office visit
Allergy serum Nothing
Not covered: All charges
Provocative food testing
Sublingual allergy
desensitization
2002 Kaiser Foundation Health Plan, Inc. 19 Section 5( a) 19
19 Page 20 21
Treatment therapies You pay
Chemotherapy
and radiation therapy Nothing for services provided by a
non-physician
provider
Note: We limit high-dose chemotherapy in association with autologous
bone-marrow transplants to those transplants listed under Organ/ Tissue
Transplants on page 28.
Intravenous (IV)/ Infusion therapy Home IV and antibiotic therapy
$10 for services
provided by a physician
Respiratory and inhalation therapy $10 per office visit
Growth hormone therapy (GHT)
Note: We cover human growth hormone under
the prescription drug
benefit.
Dialysis hemodialysis and peritoneal dialysis
Not covered: All charges
Chemotherapy supported by a
bone marrow transplant or with stem
cell support, for any diagnosis not
listed as covered
Physical and occupational therapies
We cover initial courses of
therapy for up to two months per condition $10 per outpatient visit
for:
Physical therapy by qualified physical therapists to restore bodily
Nothing for inpatient
function when you have a total or partial loss of
bodily function due
to illness or injury
Occupational therapy by occupational therapists to assist you in
achieving and maintaining self-care and improved functioning in
other
activities of daily life
Note: We provide subsequent courses of therapy for up to two months if
you show significant improvement in your condition.
Cardiac rehabilitation following a heart transplant, bypass surgery, or a
myocardial infarction.
Not covered: All charges
Long-term rehabilitative
therapy
Exercise programs
Speech therapy
We cover initial and subsequent courses of therapy
for up to two months
per condition for:
Speech therapy by speech therapists when medically necessary
Hearing services (testing, treatment, and supplies)
Hearing
testing $10 per office visit
2002 Kaiser Foundation Health Plan, Inc. 20 Section 5( a)
$10 per outpatient visit
Nothing for inpatient 20
20 Page 21 22
Not covered: All charges
Hearing aids
Hearing tests to determine the most
appropriate hearing aid
Vision services (testing, treatment, and supplies) You pay
Diagnosis and treatment of diseases of the eye $10 per office visit
Eye refractions to determine the need for vision correction and
provide
a prescription for eyeglasses
Therapeutic contact lenses for the condition of aniridia for up to two
Nothing
lenses per eye in a 12-month period
Not covered: All charges
Eyeglasses or contact lenses
(except for the condition of aniridia)
Eye exercises and
orthoptics
Radial keratotomy and other refractive surgery
Foot care
Routine foot care when you are under active treatment
for a metabolic $10 per office visit
or peripheral vascular disease, such as
diabetes
Not covered: All charges
Cutting, trimming, or removal
of corns, calluses, or the free edge of
toenails, and similar routine
treatment of conditions of the foot,
except as stated above
Treatment of weak, strained, or flat feet, or bunions or spurs;
and of
any instability, imbalance, or subluxation of the foot (unless the
treatment is by open cutting surgery)
Orthopedic and prosthetic devices
We cover internally implanted
FDA-approved devices, including but Nothing
not limited to:
Artificial joints
Pacemakers
Cochlear
implants
Intraocular implants following cataract removal
Surgically implanted breast implants following a mastectomy
Note: See
Section 5( b) for coverage of the surgery to insert the device.
2002 Kaiser Foundation Health Plan, Inc. 21 Section 5( a) 21
21 Page 22 23
We cover FDA-approved devices that are in general use
and are 20% of our allowance
required because of a defect in form or
function of a permanently
inoperative or malfunctioning body part, including
but not limited to:
Artificial limbs and eyes and stump hose
Externally
worn breast prostheses and surgical bras, including
necessary replacements,
following a mastectomy
Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome
Podiatric devices (including footwear) to prevent or treat
diabetes-related
complications when prescribed by a Plan podiatrist,
physiatrist, or orthopedist
Enteral formula for members who require tube feeding per Medicare
guidelines
Not covered: All charges
Comfort, convenience, or
luxury equipment or features
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses,
elastic stockings, support hose, and other
supportive devices
Shoes or arch supports, even if custom-made, except to treat
diabetes-related complications when prescribed by a Plan
podiatrist,
physiatrist, or orthopedist
Durable medical equipment (DME) You pay
During a covered stay in
a Plan hospital or skilled nursing facility Nothing
Ostomy and
urological supplies
We limit coverage to the standard item that meets your
medical needs
consistent with our Plan DME formulary guidelines.
2002 Kaiser Foundation Health Plan, Inc. 22 Section 5( a) 22
22 Page 23 24
For use in the home when intended to be used
repeatedly. Includes but 20% of our allowance
is not limited to:
Oxygen and oxygen dispensing equipment
Hospital beds
Wheelchairs including motorized when medically necessary
Crutches
Walkers
Blood glucose testing monitors
and related supplies
Insulin pumps
Infant apnea
monitors
Repairs and replacements resulting from normal use
We
limit coverage to the standard item that meets your medical needs
consistent
with our Plan DME formulary guidelines. We decide
whether to rent or
purchase the item, and choose the vendor.
Note: We only provide DME in the Plan's service area.
Not covered: All charges
Comfort, convenience, or
luxury equipment or features
Devices not medical in nature,
such as sauna baths, exercise and
hygiene equipment
Electronic monitors of the function of the heart or lungs, except
for
infant apnea monitors
Devices to perform medical tests on blood or other bodily
substances
or excretions, except diabetic testing equipment and supplies
Dental appliances
Experimental or research
equipment
Modifications to the home or auto
Home health services You pay
Home health care ordered by a Plan
physician and provided by a Nothing
registered nurse (RN), licensed
practical nurse (LPN), licensed
vocational nurse (LVN), or home health aide
Services include oxygen therapy, intravenous therapy, and
medications
Note: We only provide these services in the Plan's service area.
2002 Kaiser Foundation Health Plan, Inc. 23 Section 5( a) 23
23 Page 24 25
2002 Kaiser Foundation Health Plan, Inc. 24
Section 5( a)
Not covered: All charges
Nursing care
requested by, or for the convenience of, the patient or
the patient's family
Home care primarily for personal assistance that does not include
a
medical component and is not diagnostic, therapeutic, or
rehabilitative
Services outside of our service area
Chiropractic and alternative treatments You pay
Chiropractic
services covering the diagnosis or treatment of $15 per office visit
neuromusculoskeletal disorders limited to 20 visits per year. You can
access services in the following ways:
Chiropractic services are provided through American Specialty Health
Plans (ASHP). You will have direct access to a participating ASHP
chiropractor without the need to obtain a Plan physician referral.
Participating chiropractors are listed in the ASHP Participating Provider
Directory.
Specific details of this chiropractic benefit are listed in the ASHP
evidence of coverage/ disclosure form. You phone the ASHP
chiropractor
you have selected for an initial examination. After the
initial examination
and except for chiropractic emergency services, your
ASHP chiropractor is
responsible to obtain authorization from ASHP
for any additional
chiropractic services on your behalf. ASHP will not
cover any chiropractic
services if you were referred through your Plan
physician.
NOTE: When necessary and prescribed by an ASHP chiropractor, you
may
receive up to $50 of chiropractic appliances per calendar year.
Not covered: All charges
Naturopathic services
Hypnotherapy
Educational classes and programs
Education for specific
conditions Nothing
Health education publications Nothing
Educational classes for a wide variety of subjects that do not relate
Nominal charges
directly to specific conditions
Note: Call the Member Service Call Center at 1-800-464-4000 for
information on classes near you. 24
24 Page 25 26
Here are some
important things to keep in mind about these benefits:
Please remember
that all benefits are subject to the definitions, limitations, and
exclusions in this brochure and we cover them only when we determine they
are
medically necessary.
Plan physicians must provide or arrange your care.
We
have no calendar year deductible.
Be sure to read Section 4,
Your costs for covered services, for valuable information
about how
cost sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.
The amounts listed below are for the charges billed by a physician
or other health care
professional for your surgical care. Look in Section 5(
c) for charges associated with the
facility (i. e., hospital, surgical
center, etc.).
YOUR PHYSICIAN MUST GET A REFERRAL FOR SOME SURGICAL
PROCEDURES.
Please refer to the referral information shown in Section 3 to be sure
which
services require a referral and identify which surgeries require a referral.
I M
P O
R T
A N
T
I M
P O
R T
A N
T
2002 Kaiser Foundation Health Plan, Inc. 25 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians
and other health care professionals
Benefit description You pay
Surgical procedures
A
comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Treatment of
burns
Normal pre-and post-operative care by the surgeon
Pre-surgical testing
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies
(see reconstructive surgery)
Surgical treatment of morbid obesity
Voluntary sterilization (tubal ligation and vasectomy)
Insertion of internally implanted contraceptives and intrauterine
devices (IUDs)
Note: We cover contraceptive drugs and devices under the prescription
drug benefit.
Treatment for sexual dysfunction or inadequacy
Insertion of internal prosthetic devices. See Section 5( a)
Orthopedic
and prosthetic devices for device coverage information.
$10 per office visit when provided
on an outpatient basis
Nothing when provided on an
inpatient basis 25
25 Page 26 27
Not covered: All charges
Reversal of voluntary surgical sterilization
Routine
treatment of conditions of the foot
Reconstructive surgery You pay
Surgery to correct a functional
defect
Surgery to correct a condition caused by injury or illness
if:
the condition produced a major effect on the member's
appearance;
and
the condition can reasonably be expected to be corrected by such
surgery
Surgery to correct a condition that existed at or from birth and is
a
significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes
All stages of breast reconstruction surgery following a mastectomy,
such as:
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;
and
breast prostheses and surgical bras and replacements (see
Prosthetic
devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.
Not covered: All charges
Cosmetic surgery any
surgical procedure (or any portion of a
procedure) performed primarily to
improve physical appearance
through change in bodily form, except repair of
accidental injury
Surgeries related to sex transformation
2002 Kaiser Foundation Health Plan, Inc. 26 Section 5( b)
$10 per office visit when provided
on an outpatient basis
Nothing when provided on an
inpatient basis 26
26 Page 27 28
Oral and maxillofacial surgery You pay
Oral
surgical procedures, limited to:
Reduction of fractures or
dislocations of the jaw or facial bones
Surgical correction of
cleft lip, cleft palate, or severe functional
malocclusion
Removal of stones from salivary ducts
Excision of
leukoplakia or malignancies
Excision of cysts and incision of
abscesses when done as
independent procedures
Medical and surgical treatment of TMJ
Other surgical
procedures that do not involve the teeth or their
supporting structures
Not covered: All charges
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as
the periodontal membrane, gingiva, and alveolar bone)
2002 Kaiser Foundation Health Plan, Inc. 27 Section 5( b)
$10 per office visit when provided
on an outpatient basis
Nothing when provided on an
inpatient basis 27
27 Page 28 29
Organ/ tissue transplants You pay
Limited
to:
Cornea
Heart
Heart/ Lung
Kidney
Kidney/ Pancreas
Liver
Lung:
Single Double
Pancreas
Allogeneic (donor) bone marrow
transplants
Autologous bone marrow transplants (autologous stem
cell and
peripheral stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal,
retroperitoneal, and ovarian germ
cell tumors
Intestinal transplants (small intestine) and the small intestine
with
the liver or small intestine with multiple organs such as the liver,
stomach, and pancreas
Limited benefits Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved
by the Plan's medical director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor when
we
cover your transplant.
Not covered: All charges
Donor screening tests and
donor search expenses, except those
performed for the actual donor
Implants of non-human artificial organs
Transplants not listed as covered
Anesthesia
Professional services provided during a surgical
procedure Nothing
Hospital (inpatient)
Ambulatory
surgery center (outpatient)
2002 Kaiser Foundation Health Plan, Inc. 28 Section 5( b)
$10 per office visit when provided
on an outpatient basis
Nothing when provided on an
inpatient basis 28
28 Page 29 30
Here are some important things to keep in mind
about these benefits:
Please remember that all benefits are subject to
the definitions, limitations, and
exclusions in this brochure and we cover
them only when we determine they are
medically necessary.
Plan physicians must provide or arrange your care and you must be
hospitalized in a
Plan facility.
We have no calendar year deductible.
Be sure to read
Section 4, Your costs for covered services, for valuable information
about how cost-sharing works. Also read Section 9 about coordinating
benefits with
other coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility
(i. e., hospital or
surgical center) or ambulance service for your surgery
or care. Any costs associated
with the professional charge (i. e.,
physicians, etc.) are covered in Sections 5( a) or (b).
I M
P O
R T
A N
T
I M
P O
R T
A N
T
2002 Kaiser Foundation Health Plan, Inc. 29 Section 5( c)
Benefit description You pay
Section 5 (c). Services provided by a
hospital or other facility,
and ambulance services
Inpatient hospital
Room and board, such as Nothing
Ward, semiprivate, or intensive care accommodations
General
nursing care
Meals and special diets
Note: Your physician may
prescribe accommodation or private duty
nursing care if it is medically
necessary. If you want a private room
when it is not medically necessary,
you pay the additional charge above
the semiprivate room rate. 29
29 Page 30 31
Other hospital services and supplies, such as: Nothing
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and
X-rays
Administration of blood and blood products
Blood or blood plasma
Dressings, splints, casts, and sterile
tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Plan
physicians' and surgeons' services and supplies, including
consultation and
treatment by specialists
Take-home items
Note: You may receive covered hospital services
for certain dental
procedures if a Plan physician determines you need to be
hospitalized
for reasons unrelated to the dental procedure. The conditions
for which
we will provide hospitalization include hemophilia and heart
disease.
The need for anesthesia, by itself, is not such a condition.
Not covered: All charges
Custodial care and care in an
intermediate care facility
Personal comfort items, such as
barber services, guest meals, and
beds
Private nursing care unless medically necessary
Inpatient dental procedures
Outpatient hospital or ambulatory surgical center You pay
Operating, recovery, and other treatment rooms Nothing
Prescribed drugs and medicines
Dressings, casts, and sterile
trays
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies,
including oxygen
Anesthetics and anesthesia service
2002 Kaiser Foundation Health Plan, Inc. 30 Section 5( c) 30
30 Page 31 32
Extended care benefits/ skilled nursing care
facility benefits You pay
Up to 100 days per benefit period when you
need full-time skilled Nothing
nursing care. Your benefit period begins when
you enter a hospital or
skilled nursing facility and ends when you have not
been a patient in
either a hospital or skilled nursing facility for 60
consecutive days.
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
Not covered: All charges
Custodial care
Care in an intermediate care facility
Hospice care
Supportive and palliative care for a terminally ill
member: Nothing
You must reside in the service area
Services are provided in the home
Services are provided in a
Plan-approved hospice facility
Services include inpatient care, outpatient
care, and family counseling.
A Plan physician must certify that you have a
terminal illness, with a
life expectancy of approximately six months or
less.
Note: Hospice is a program for caring for the terminally ill that
emphasizes supportive services, such as home care and pain control,
rather than curative care of the terminal illness. A person who is
terminally ill may elect to receive hospice benefits. These palliative
and supportive services include nursing care, medical social services,
physician services, and short-term inpatient care for pain control and
acute and chronic symptom management. We also provide counseling
and
bereavement services for the individual and family members, and
therapy for
purposes of symptom control to enable the person to
continue life with as
little disruption as possible. If you make a hospice
election, you are not
entitled to receive other health care services that
are related to the
terminal illness. If you have made a hospice election,
you may revoke that
election at any time, and your standard health
benefits will be covered.
Ambulance
Professional ambulance service, including air ambulance,
when Nothing
medically appropriate
Not covered: All charges
Transports that we determine
are not medically necessary
2002 Kaiser Foundation Health Plan, Inc. 31 Section 5( c) 31
31 Page 32 33
Here are some important things to keep in mind
about these benefits:
Please remember that all benefits are subject to
the definitions, limitations, and exclusions
in this brochure and we cover
them only when we determine they are medically necessary.
We have no calendar year deductible.
Be sure to read
Section 4, Your costs for covered services, for valuable information
about
how cost-sharing works. Also read Section 9 about coordinating
benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe endangers
your life or could result in serious
injury or disability, and requires immediate medical or surgical care. Some
problems are emergencies because, if not treated promptly, they might become
more serious; examples include deep
cuts and broken bones. Others are
emergencies because they are potentially life-threatening, such as heart
attacks,
strokes, poisonings, gunshot wounds, or sudden inability to
breathe. There are many other acute conditions that we
may determine are
medical emergencies what they all have in common is the need for quick action.
What to do in case of emergency:
You are covered for medical
emergencies anywhere in the world. In a medical emergency, call 911. When the
operator answers, stay on the phone and answer all questions.
Emergencies within our service area:
Emergency care is provided at
Plan hospitals 24 hours a day, seven days a week. If you have a medical
emergency, go
to the closest Plan hospital. If you reasonably believe you
have a medical emergency condition and you cannot safely
go to a Plan
hospital, call 911 or go to the nearest hospital. If an ambulance comes, tell
the paramedics that the person
who needs help is a Kaiser Permanente member.
If you are within our service area, we will cover Out-of-Plan emergency care
only if you reasonably believe that going
to a Plan facility for treatment
will cause a delay resulting in permanent damage to your health. If you need to
be
hospitalized in a non-Plan facility, the Plan must be notified as soon as
reasonably possible. Call us toll free in
California at 1-800-772-3532. The
telephone number to call is also on your ID card. We will make arrangements for
necessary continued hospitalization or for transferring you to a designated
hospital.
Emergencies outside our service area:
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 as soon as
reasonably possible. If a Plan physician believes
care can be better
provided in a Plan hospital, we will transfer you when medically feasible.
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. These numbers are available 24 hours a day,
seven days a week. You may also obtain information
about the location of
facilities by calling 1-800-227-2415.
2002 Kaiser Foundation Health Plan, Inc. 32 Section 5( d)
Section 5 (d). Emergency services/ accidents 32
32 Page 33 34
Emergency within our service area
Emergency room visit for emergency services $50 per visit
Note: We waive
the $50 if you are admitted to the hospital.
Not covered: All charges
Elective care or
non-emergency care
Urgent care at a non-Plan urgent care
center
Emergency outside our service area
Emergency care as an outpatient
or inpatient at a hospital, including $50 per visit
physicians' services
Emergency room visit for emergency services
Emergency
care at an urgent care center
Emergency care in a Kaiser Foundation
hospital in another
Kaiser Foundation Health Plan service area
Note: See the "Travel Benefit" for coverage of continuing or follow-up
care.
Not covered: All charges
Elective care or nonemergency
care at non-Plan facilities
Ambulance
Professional ambulance service, including air ambulance,
when $50 per trip
medically appropriate
Not covered: All charges
Transports we determine are
not medically necessary
2002 Kaiser Foundation Health Plan, Inc. 33 Section 5( d)
Benefit description You pay
The amount you would be
charged if
you were a
member in that service
area 33
33
Page 34 35
When
you get our approval for services and follow a treatment plan we approve,
cost-sharing
and limitations for Plan mental health and substance abuse
benefits will be no greater than for
similar benefits for other illnesses
and conditions.
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions
in this brochure and we cover them only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
We
have no calendar year deductible.
Be sure to read Section 4,
Your costs for covered services, for valuable information about
how
cost sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
I M
P O
R T
A N
T
2002 Kaiser Foundation Health Plan, Inc. 34 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
Benefit
description You pay
Mental health and substance abuse benefits
We
cover all diagnostic and treatment services recommended by a Plan
provider
and contained in a treatment plan. The treatment plan may
include services,
drugs, and supplies described elsewhere in this
brochure.
Note: We cover the services only when we determine that the care is
clinically appropriate to treat your condition, and only when you receive
the care as part of a treatment plan developed by a Plan provider.
Note: OPM will base its review of disputes about treatment plans on the
treatment plan's clinical appropriateness. OPM will generally not order
us to pay or provide one clinically appropriate treatment in favor of
another.
Your cost sharing responsibilities
are no greater than for other
illnesses or conditions 34
34 Page 35 36
Mental health
and substance abuse benefits You pay
Diagnosis and treatment of
psychiatric conditions, mental illness, and $10 per office visit
mental
disorders. Services include:
Diagnostic evaluation
Treatment (including individual,
family, and group therapy visits)
Crisis intervention and
stabilization for acute episodes
Psychological testing that is
medically necessary to determine the
appropriate psychiatric treatment
Medication management and evaluation
Diagnosis and treatment of
alcoholism and drug abuse. Services include:
Treatment and
counseling (including individual, family, and group
therapy visits)
Outpatient detoxification (medical management of withdrawal from the
substance)
Note: You may see a Plan mental health or substance abuse provider for
outpatient treatment without a referral from your primary care
physician.
Note: Your Plan provider will develop a treatment plan to assist you in
improving or maintaining your condition and functional level, or to
prevent relapse and will determine which diagnostic and treatment
services are appropriate for you.
Inpatient psychiatric care Nothing
Hospital alternative
services, such as partial hospitalization and
intensive outpatient
psychiatric treatment programs
Inpatient substance abuse care and rehabilitation
Inpatient detoxification
Methadone treatment for a pregnant
woman throughout the pregnancy
and for two months after delivery
Note: All inpatient admissions and hospital alternative services
treatment programs require approval by a Plan physician.
Recovery services in a non-medical residential care facility $100 per stay
Note: All inpatient and alternative services treatment programs require
approval by a Plan physician.
2002 Kaiser Foundation Health Plan, Inc. 35 Section 5( e) 35
35 Page 36 37
2002 Kaiser Foundation Health Plan, Inc. 36
Section 5( e)
Mental health and substance abuse benefits You pay
Not covered: All charges
Care that is not
clinically appropriate for the treatment of your
condition
Services we have not approved
Intelligence,
IQ, aptitude ability, learning disorders, or interest testing
not necessary
to determine the appropriate treatment of a psychiatric
condition
Evaluation or therapy on court order or as a condition of parole
or
probation, or otherwise required by the criminal justice system, unless
determined by a Plan physician to be medically necessary and
appropriate
Services that are custodial in nature
Services rendered or billed by a school or a member of its staff
Services provided under a federal, state, or local
government program
Psychoanalysis or psychotherapy credited
toward earning a degree or
furtherance of education or training regardless
of diagnosis or
symptoms
Limitation We may limit your benefits if you do not obtain a treatment
plan. 36
36 Page
37 38
Here are some important things
to keep in mind about these benefits:
We cover prescribed drugs and
medications, as described in the chart beginning
on the next page.
Please remember that all benefits are subject to the definitions,
limitations, and
exclusions in this brochure and we cover them only when we
determine they are
medically necessary.
We have no calendar year deductible.
Be sure to read
Section 4, Your costs for covered services, for valuable
information
about how cost-sharing works. Also read Section 9 about
coordinating
benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
I M
P O
R T
A N
T
There are important features you should be aware of. These include:
Who can write your prescription. A Plan physician or any dentist
must write the prescription.
Drugs prescribed by dentists are not covered if
a Plan physician determines that they are not
medically necessary.
Where you can obtain them. You must fill the prescription at a Plan
pharmacy or another
pharmacy that we designate, or through our mail order
program.
We use a formulary. A formulary is a listing of preferred
pharmaceutical substances and
formulas. A team of Kaiser Permanente
physicians and pharmacists independently and objectively
evaluates the
scientific literature to identify the FDA-approved drugs best suited to treat
specific
medical conditions. The Plan uses this formulary to determine which
prescribed drugs will be
provided to members.
Our formulary includes a list of prescription drugs that have been approved
by our Pharmacy and
Therapeutics Committee. This committee, which is
comprised of Plan physicians and other Plan
providers, selects prescription
drugs for the formulary based on a number of factors, including
safety and
effectiveness as determined from a review of medical literature and research.
The
committee meets quarterly to consider adding and removing prescription
drugs on the formulary.
If you would like information about whether a
particular drug is included on our formulary, please
call the Member Service
Call Center at 1-800-464-4000.
If the physician specifically prescribes a non-formulary drug because it is
medically necessary, the
non-formulary drug will be covered. If you request
the non-formulary drug when your physician
has prescribed a substitution,
the non-formulary drug is not covered. However, you may purchase
the
non-formulary drug from a Plan pharmacy at prices charged to members for
non-covered drugs.
These are the dispensing limitations. We provide up to a 100-day
supply for most drugs, except
certain drugs that have a significant
potential for waste will be provided for up to a 30-day supply
in any 30-day
period. Please contact our Member Service Call Center at 1-800-464-4000 for the
current list of these drugs. Maintenance medications may be obtained for up
to a 100-day supply
when ordered through our mail-order program.
When you have to file a claim. When you receive drugs from a Plan
pharmacy, you do not have
to file a claim. For a covered out-of-area
emergency, you will need to file a claim when you
receive drugs from a
non-Plan pharmacy.
Prescription drug benefits begin on the next page.
2002 Kaiser Foundation Health Plan, Inc. 37 Section 5( f)
Section 5 (f). Prescription drug benefits 37
37 Page 38 39
2002 Kaiser Foundation Health Plan, Inc. 38
Section 5( f)
Benefit description You pay
Covered medications
and supplies
We cover the following medications and supplies prescribed
by a Plan Nothing
physician and obtained from a Plan pharmacy or through our
mail order
program:
Certain self-administered IV drugs and fluids requiring specific
types of parenteral infusion, and the supplies required for their
administration
Amino acid-modified products used to treat congenital errors of
amino acid metabolism
Diabetes urine-testing supplies
Vaccines and
immunizations approved for use by the Food and Drug
Administration
Elemental dietary enteral formula when used as a primary therapy
for regional enteritis
Drugs and medicines that by Federal law of the United States require
a physician's prescription for their purchase, except as excluded
below.
We also cover certain drugs that do not require a prescription
by law if
they are listed on our drug formulary.
Insulin
Certain insulin administration devices
Disposable needles and syringes for the administration of covered
medications
Smoking cessation drugs are covered for one course of treatment per
calendar year, but only if you participate in, and pay the cost of, a
Plan-approved behavioral intervention program
Oral contraceptives
Cervical caps and diaphragms
Infertility drugs 50% of
our allowance
Sexual dysfunction drugs
Episodic drugs will be
provided up to a maximum of 27 doses in
any 100-day period. Additional
prescribed doses during the same
100 days will be dispensed at our
allowance.
Maintenance drugs that require doses at regulated intervals
$10 per prescription for generic
drugs
$20 per prescription for brand-name
drugs
All charges if you request a brand-name
drug in place of a generic
drug
$10 per prescription for generic drugs
and $20 per prescription for
brand-name
drugs (up to a 3-cycle supply);
all charges if you request a
brand-name
drug in place of a generic drug
$20 per device 38
38 Page
39 40
Covered medications and supplies
You pay
Not covered: All charges
Drugs and
supplies for cosmetic purposes
Vitamins and nutritional
supplements that can be purchased without
a prescription
Nonprescription drugs, unless they are included in our drug
formulary
Medical supplies, such as dressings and antiseptics
Drugs to enhance athletic performance
2002 Kaiser Foundation Health Plan, Inc. 39 Section 5( f) 39
39 Page 40 41
Under the flexible benefits option, we determine the
most effective
way to provide services.
We may identify medically appropriate alternatives to traditional
care and coordinate other benefits as a less costly alternative
benefit.
Alternative benefits are subject to our ongoing review.
By approving an alternative benefit, we cannot guarantee you will
get it
in the future.
The decision to offer an alternative benefit is solely ours, and we
may withdraw it at any time and resume regular contract benefits.
Our decision to offer or withdraw alternative benefits is not
subject to OPM review under the disputed claims process.
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. You
will have to pay the charges imposed by the Plan you are visiting. If the
Plan 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 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
the Kaiser Permanente Plan, please call our Member Service Call Center
at 1-800-464-4000.
2002 Kaiser Foundation Health Plan, Inc. 40 Section 5( g)
Section 5 (g). Special features
Flexible benefits option
Services from other Kaiser Permanente Plans
Feature Description 40
40 Page 41 42
Kaiser
Permanente's travel benefits for federal employees provide you
with
outpatient follow-up or continuing medical care when you are
outside your
home service area by more than 100 miles or outside of
any other Kaiser
Permanente service area. These benefits are in
addition to your emergency
and urgent care benefits and include:
Outpatient follow-up care necessary to complete a course of
treatment after a covered emergency. Services include removal of
stitches, a catheter, or a cast.
Outpatient continuing care for conditions diagnosed by a Kaiser
Permanente health care provider or affiliated Plan provider that
have
been treated within the previous 90 days. Services include
childhood
immunizations, dialysis, or prescription drug
monitoring.
You pay $25 for each follow-up or continuing care office visit.
This amount will be deducted from the payment we make to you.
Your benefit is limited to $1,200 each calendar year.
For more
information about this benefit call 1-800-390-3509.
File claims as
shown on page 45.
The following are not included in your travel benefits
coverage:
Non emergency hospitalization
Infertility treatments
Medical and hospital costs
resulting from a normal full-term
delivery of a baby outside the service
area
Transplants
Prescription drugs
For any of your health concerns, 24 hours a day, 7 days a week, you
may
talk with a registered nurse who will discuss treatment options
and answer
your health questions. You can obtain an advice nurse
phone number for the
nearest Kaiser Permanente facility in the white
pages of your phone book
under "Kaiser Permanente".
We provide a TTY/ text telephone number 1-800-777-1370. Sign
language
services are also available.
Kaiser Permanente's National Transplant Network (NTN) was created
to
offer members greater choice of and access into Centers of
Excellence (COE)
that exceed minimum quality standards for
experience (based on volume of
cases and transplant team
composition), outcomes, and service (waiting time
and access to the
Center). The goal is to ensure that members are treated at
Centers
where optimal outcomes can be expected, measured, and managed.
Currently, the NTN contains 20 Centers that include 70 transplant
programs. Transplant services provided through the NTN are heart,
lung,
heart/ lung, liver, simultaneous kidney/ pancreas, pancreas, small
bowel,
and bone marrow/ stem cell (autologous and allogeneic).
2002 Kaiser Foundation Health Plan, Inc. 41 Section 5( g)
Travel benefit
24 hour nurse line
Services for deaf and hearing
impaired
Centers of excellence for transplants 41
41 Page 42 43
Here are some important things to keep in mind
about these benefits:
Please remember that all benefits are subject to
the definitions, limitations, and
exclusions in this brochure and are
payable only when we determine they are dentally
necessary.
We cover hospitalization for dental procedures at a Plan hospital we
designate only when
a non-dental physical impairment exists which makes
hospitalization necessary to
safeguard the health of the patient; we do not
cover the dental procedure except as
described below.
Be sure to read Section 4, Your costs for covered services,
for valuable information about
how cost-sharing works. Also read Section
9 about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
I M
P O
R T
A N
T
2002 Kaiser Foundation Health Plan, Inc. 42 Section 5( h)
Section 5 (h). Dental benefits
Dental benefits
We have no
dental benefits. 42
42 Page
43 44
Section 5 (i). Non-FEHB benefits
available to Plan members
The benefits on this page are not part of the
FEHB contract or premium, and you cannot file an FEHB disputed
claim
about them. Fees you pay for these services do not count toward FEHB
deductibles or out-of-pocket
maximums.
Eyewear discount
As a Kaiser Permanente FEHBP Member, you and your
eligible dependents will be able to purchase eyewear at
significant savings.
When you visit any of the California Division Health Plan Optical Departments,
you will receive
25 percent off our allowance for frames and lenses and
options such as no-line bifocals and prescription and non-prescription
sunglasses. You will also be able to receive 25 percent off our allowance
for cosmetic contact lenses and
the required lens fitting.
Limitations & exclusions: This discount will apply only to
purchased eyewear under the FEHBP basic coverage. The
vision discount may
not be coordinated with any other Kaiser Permanente Health Plan vision benefit.
This discount
will also not apply to any sale, promotional, or packaged
eyewear program or for any contact lens Extended Purchase
Agreement (which
includes products purchased in this Agreement).
Expanded dental benefits
Kaiser Permanente is pleased to offer
federal employees, retirees, and dependents a choice of dental coverages to
supplement your medical plan.
Option I/ Delta Care
DeltaCare offers dental health maintenance
organization (HMO) benefits that are administered by PMI, an affiliate of
Delta Dental Plan of California. You select a dentist from the network of
contracting DeltaCare dental offices that is
most convenient for you and
your family. With DeltaCare, there are no claim forms to worry about. DeltaCare
also
provides a full range of services that includes preventive,
restorative, endodontics, periodontics, prosthetics, oral
surgery, and
orthodontics. Under this program, the subscriber pays a specific copayment for
most covered services.
Option II/ KPIC's Dental Plan
KPIC's Dental Plan, a table of
allowances program, allows you to select any licensed dentist. After you satisfy
a
deductible, KPIC's Dental Plan will pay a predetermined amount that is
specified in a table toward each covered
service, and you pay the remainder
of the fee. You do not need to satisfy a deductible toward covered preventive
services you receive. KPIC's Dental Plan offers a full range of services;
diagnostic, preventive, restorative,
endodontics, periodontics, oral
surgery, and both fixed and removable prosthodontics. Orthodontics is not
available
under the KPIC's Dental Plan.
Monthly Premium* Option I/ Delta Care Option II/ KPIC's Dental Plan
Monthly Premium Quarterly Premium Monthly Premium
Self Only $ 9.01
$27.02 $23.21
Self & One Party $15.07 $45.21 $41.29
Self & Two
or More $22.85 $68.55 $62.06
KPIC's Dental Plan and DeltaCare 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. 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.
How to enroll
Please use the enclosed postage-paid card to send in
your application. If you would like more information on KPIC's
Dental Plan,
please call 1-800-933-9312. A Delta Dental representative will be able to assist
you Monday through
Friday, 6 a. m. to 6 p. m.
Payments for the KPIC's Dental Plan or DeltaCare programs will be made by
automatic withdrawal from your
checking, savings, or credit union account.
* These rates are effective January 1, 2002 through December 31, 2002.
2002 Kaiser Foundation Health Plan, Inc. 43 Section 5( i) 43
43 Page 44 45
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, disease, injury, or condition.
We do not cover the following:
Care by non-Plan providers except
for authorized referrals or emergencies (see Section 5( d)), services
under
the Travel Benefit (see Section 5( g)), and services received from other Kaiser
Permanente plans
(see Section 5( g));
Services, drugs, or supplies you receive while you are not enrolled
in this Plan;
Services, drugs, or supplies that are not medically
necessary;
Services, drugs, or supplies not required according to
accepted standards of medical, dental, or
psychiatric practice;
Experimental or investigational procedures, treatments, drugs, or
devices;
Services, drugs, or 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;
Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or
facility barred from the FEHB Program.
2002 Kaiser Foundation Health Plan, Inc. 44 Section 6 44
44 Page 45 46
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and
facilities, or fill your prescription drugs at Plan
pharmacies, you will not
have to file claims. Just present your identification card and pay your
copayment
or coinsurance.
You will only need to file a claim when you receive emergency services from
non-plan providers or when you use the
travel benefit. Sometimes these
providers bill us directly. Check with the provider. If you need to file the
claim, here
is the process:
In most cases, providers and facilities file claims for you.
Physicians
must file on the form HCFA-1500, Health Insurance
Claim Form. Facilities
will file on the UB-92 form. For claims
questions and assistance, call our
Member Service Call Center
at 1-800-464-4000.
When you must file a claim such as for out-of-area care
submit it on
the HCFA-1500 or a claim form that includes the
information shown below.
Bills and receipts should be itemized
and show:
Covered member's name and ID number;
Name and address of the
physician or facility that provided
the service or supply;
Dates you
received the services or supplies;
Diagnosis;
Type of each service
or supply;
The charge for each service or supply;
A copy of the
explanation of benefits, payments, or denial
from any primary payer such as
the Medicare Summary
Notice (MSN); and
Receipts, if you paid for your
services.
Submit your claims to:
Northern California service area: Southern
California service area:
Kaiser Foundation Health Plan, Inc. Kaiser
Foundation Health Plan, Inc.
Claims Department Claims Department
P. O.
Box 12923 P. O. Box 7102
Oakland, CA 94604-2923 Pasadena, CA 91109-9880
Send us all of the documents for your claim as soon as possible.
You must
submit the claim by December 31 of the year after the
year you received the
service, unless timely filing was prevented
by administrative operations of
government or legal incapacity,
provided the claim was submitted as soon as
reasonably possible.
Please reply promptly when we ask for additional information.
We may
delay processing or deny your claim if you do not respond.
If you have a malpractice claim because of services you did
receive, or
did not receive, from a Plan provider, you must
submit the claim to binding
arbitration. The Plan has the
information that describes the arbitration
process. Contact our
Member Service Call Center at 1-800-464-4000 for copies
of
our requirements. These will explain how you can begin the
binding
arbitration process.
2002 Kaiser Foundation Health Plan, Inc. 45 Section 7
Medical, hospital, and drug benefits
Deadline for filing your claim
When we need more information
If you have a malpractice claim 45
45 Page 46 47
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims
process if you disagree with our decision on
your claim or request for
services, drugs, or supplies including a request for a referral:
Ask us in writing to reconsider our initial decision. You must:
(a) Write
to us within six months from the date of our decision; and
(b) Send your
request to us at: Kaiser Permanente, Member Relations, P. O. Box 12983, Oakland,
CA
94604-2983; and
(c) Include a statement about why you believe our initial decision was wrong,
based on specific benefit
provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports,
bills, medical records, and explanation of
benefits (EOB) forms.
We have 30 days from the date we receive your request to:
(a) Pay the
claim (or, if applicable, arrange for the health care provider to give you the
care); or
(b) Write to you and maintain our denial go to step 4; or
(c)
Ask you or your provider for more information. If we ask your provider, we will
send you a copy of
our request go to step 3.
You or your provider must send the information so that we receive it within
60 days of our request. We will
then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30
days of the date the
information was due. We will base our decision on the
information we already have.
We will write to you with our decision.
If you do not agree with our decision, you may ask OPM to review it.
You
must write to OPM within:
90 days after the date of our letter
upholding our initial decision; or
120 days after you first wrote
to us if we did not answer that request in some way within 30 days; or
120 days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3,
1900 E Street, NW, Washington, DC
20415-3630.
2002 Kaiser Foundation Health Plan, Inc. 46 Section 8
Step Description
1
2
3
4 46
46 Page 47 48
Send OPM the
following information:
A statement about why you believe our
decision was wrong, based on specific benefit provisions in this
brochure;
Copies of documents that support your claim, such as physicians'
letters, operative reports, bills,
medical records, and explanation of
benefits (EOB) forms;
Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your
daytime phone number and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to
which claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your
representative, such as medical providers, must
include a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because
of reasons beyond your control.
OPM will review your disputed claim request and will use the information it
collects from you and us to
decide whether our decision is correct. OPM will
send you a final decision within 60 days. There are no
other administrative
appeals.
If you do not agree with OPM's decision, your only recourse is to sue. If you
decide to sue, you must file
the suit against OPM in federal court by
December 31 of the third year after the year in which you received
the
disputed services, drugs, or supplies or from the year in which you were denied
precertification or prior
approval. This is the only deadline that may not
be extended.
OPM may disclose the information it collects during the review process to
support their disputed claim
decision. This information will become part of
the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your
lawsuit, benefits, and payment of
benefits. The federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may
recover only the amount
of benefits in dispute.
NOTE: If you have a serious or life-threatening condition (one that
may cause permanent loss of bodily
functions or death if not treated as soon
as possible), and
(a) We haven't responded yet to your initial request for care or
preauthorization/ prior referral, then call us at 1-
800-464-4000 and we will
expedite our review; or
(b) We denied your initial request for care or a referral, then:
If we expedite our review and maintain our denial, we will inform OPM so
that they can give your
claim expedited treatment too, or
You can call OPM's Health Benefits Contracts Division 3 at (202) 606-0755
between 8 a. m. and 5 p. m.
eastern time.
2002 Kaiser Foundation Health Plan, Inc. 47 Section 8
5
6 47
47 Page
48 49
Section 9. Coordinating benefits
with other coverage
You must tell us if you are covered or a family
member is
covered under another group health plan or have automobile
insurance that pays health care expenses without regard to fault.
This
is called "double coverage."
When you have double coverage, one plan normally pays its
benefits in
full as the primary payer and the other plan pays a
reduced benefit as the
secondary payer. We, like other insurers,
determine which coverage is
primary according to the National
Association of Insurance Commissioners'
guidelines.
When we are the primary payer, we will pay the benefits
described in
this brochure.
When we are the secondary payer, we will determine our
allowance. After
the primary plan pays, we will pay what is left
of our allowance, up to our
regular benefit. We will not pay
more than our allowance. If we are the
secondary payer, and
you received your services from Plan providers, we may
bill the
primary carrier.
Medicare is a Health Insurance Program for:
People 65 years of age and
older.
Some people with disabilities, under 65 years of age.
People
with End-Stage Renal Disease (permanent kidney
failure requiring dialysis or
a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to
pay for Part A. If you or your spouse worked for at least 10
years in Medicare-covered employment, you should be able
to qualify for
premium-free Part A insurance. (Someone
who was a Federal employee on
January 1, 1983 or since
automatically qualifies.) Otherwise, if you are age
65 or
older, you may be able to buy it. Contact 1-800-
MEDICARE for more
information.
Part B (Medical Insurance). Most people pay monthly for
Part B.
Generally, Part B premiums are withheld from your
monthly Social Security
check or your retirement check.
If you are eligible for Medicare, you may have choices in how
you get
your health care. Medicare+ Choice is the term used to
describe the various
health plan choices available to Medicare
beneficiaries. The information in
the next few pages shows how
we coordinate benefits with Medicare, depending
on the type of
Medicare managed care plan you have.
The Original Medicare Plan (Original Medicare) is available
everywhere in
the United States. It is the way everyone used to
get Medicare benefits and
is the way most people get their
Medicare Part A and Part B benefits now.
You may go to any
doctor, specialist, or hospital that accepts Medicare. The
2002 Kaiser Foundation Health Plan, Inc. 48 Section 9
What is Medicare?
The Original Medicare Plan
(Part A or Part
B)
When you have other health coverage 48
48
Page 49 50
Original Medicare Plan pays its share and you pay your share.
Some
things are not covered under Original Medicare, like
prescription drugs.
When you are enrolled in Original Medicare along with this
Plan, you
still need to follow the rules in this brochure for us to
cover your care.
We will not waive any of our copayments.
(Primary payer chart begins on next page.)
2002 Kaiser Foundation Health Plan, Inc. 49 Section 9 49
49 Page 50 51
The following chart illustrates whether the
Original Medicare Plan or this Plan should be the primary payer for you
according to your employment status and other factors determined by
Medicare. It is critical that you tell us if you or
a covered family member
has Medicare coverage so we can administer these requirements correctly.
2002 Kaiser Foundation Health Plan, Inc. 50 Section 9
Primary payer chart
A. When either you, or your covered spouse,
are age 65 or over and Then the primary payer is
Original Medicare This
Plan
1) Are an active employee with the Federal government (including
when you or a family member are eligible for Medicare solely
because of
a disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government when
a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB,
(Ask your employing office
which of these applies to you.)
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax
Court judge who retired under Section 7447 of title 26, U. S. C. (or if
your covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status,
(for Part B (for other
services) services)
6) Are a former Federal employee receiving Workers' Compensation
and the
Office of Workers' Compensation Programs has determined (except for claims
that you are unable to return to duty, related to Workers'
Compensation)
B. When you, or a covered family member, have Medicare
based on end
stage renal disease (ESRD) and
1) Are within the first 30 months of eligibility to receive Part A
benefits solely because of ESRD,
2) Have completed the 30-month ESRD coordination period and are
still
eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to ESRD after Medicare became
primary
for you under another provision,
C. When you or a covered family member have FEHB and
1) Are
eligible for Medicare based on disability, and
a) Are an annuitant, or
b) Are an active employee, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee, 50
50 Page 51 52
If you are eligible for Medicare, you may choose to
enroll in and get your
Medicare benefits from another type of Medicare+
Choice plan a
Medicare managed care plan. These are health care choices
(like HMOs)
in some areas of the country. In most Medicare managed care
plans, you
can only go to doctors, specialists, or hospitals that are part
of the plan.
Medicare managed care plans provide all the benefits that
Original
Medicare covers. Some cover extras, like prescription drugs. To
learn
more about enrolling in a Medicare managed care plan, contact Medicare
at 1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This Plan and our Medicare managed care plan: You may enroll in
our Medicare managed care plan, known as Medicare+ Choice or Kaiser
Permanente Senior Advantage, and also remain enrolled in our FEHB
Plan.
In this case, we have lowered or waived some of our copayments
and
coinsurance for your FEHB and Medicare coverage. If you would
like
information about our Medicare+ Choice plan, please call 1-800-443-
0815.
Your Kaiser Permanente Senior Advantage-FEHBP benefits that
we lowered or
waived are:
Prescriptions: $5 for each generic/ formulary drug and $15 for each
brand name drug for up to a 100-day supply. The same prices apply
to
mail-order drugs.
Physician office visits: $5 for physician/ specialist office visits
Preventive services: $5
Routine physical and hearing
exams: $5 for one routine physical
and hearing exam each year
Immunizations: Pneumococcal pneumonia, flu, and Hepatitis B
vaccines provided at no charge
Urgently needed care: $5 for each visit to a Plan facility; $50 for
each visit to a non-Plan facility in or out of the Plan's service area;
Worldwide coverage
Vision services:
$5 for one routine eye exam each year
$80 frame allowance, for one frame every two years
Up to $124 allowance
for cosmetic contact lenses in lieu of
eyeglasses every 24 months
$0 for lenses, for one pair every two years
Dental services:
$0 for oral exams or X-rays
$15 for
cleanings, up to two office visits each year
No referral necessary for
network providers
Chiropractic services: Chiropractic care beyond what is covered by
Medicare, including:
$10 copayment for each office visit, up to 20 office visits each
year
No referral necessary for any network providers. Members must
use ASHP
Chiropractic providers
Medicare managed care plan
2002 Kaiser Foundation Health Plan, Inc. 51 Section 9 51
51 Page 52 53
You will also enjoy:
Health/ Wellness
Education: No copayments for disease-specific
health education classes
(costs may vary for wellness classes)
No deductibles and virtually no paperwork
On-line
access to health information and resources at our award-winning
members only
website
Quarterly member communication in our "Senior Outlook" magazine
You must use Kaiser Permanente Plan and affiliated providers and
continue
to pay Medicare premiums.
This Plan and another plan's Medicare managed care plan: You may
enroll in another plan's Medicare managed care plan and also remain
enrolled in our FEHB plan. We will still provide benefits when your
Medicare managed care plan is primary if you use our Plan providers, but
we will not waive or lower any of our copayments or coinsurance. If you
enroll in a Medicare managed care plan, tell us. We will need to know
whether you are in the Original Medicare Plan or in a Medicare managed
care plan so we can correctly coordinate benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care
plan:
If you are an annuitant or former spouse, you can suspend your
FEHB
coverage to enroll in a Medicare managed care plan, eliminating
your FEHB
premium. (OPM does not contribute to your Medicare
managed care plan
premium.) For information on suspending your
FEHB enrollment, 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 unless you
involuntarily lose coverage or move out of the
Medicare managed care service
area.
If you enroll in Medicare Part B, we require you to assign your Medicare
Part B benefits to the Plan for its services.
If you do not have one or both Parts of Medicare, you can still be
covered under the FEHB Program. We will not require you to enroll in
Medicare Part B, and if you cannot get premium-free Part A, we will not
ask you to enroll in it.
TRICARE is the health care program for eligible dependents of military
persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See
your
TRICARE Health Benefits Advisor if you have questions about
TRICARE
coverage.
We do not cover services that:
you need because of a
workplace-related illness or injury that the
Office of Workers' Compensation
Programs (OWCP) or a similar
Federal or State agency determines they must
provide; or
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 OWCP or similar agency pays its maximum benefits for your
treatment,
we will cover your care. You must use our providers.
When you have this Plan and Medicaid, we pay first.
2002 Kaiser Foundation Health Plan, Inc. 52 Section 9
Medicaid
If you do not enroll in
Medicare Part A or Part B
If you do enroll in Medicare
Part B
TRICARE
Worke rs ' compensation 52
52
Page 53 54
We do
not cover services and supplies when a local, State,
or Federal Government
agency directly or indirectly pays for them.
When you receive money to compensate you for medical or hospital care
for
injuries or illness caused by another person, you must reimburse us
for any
expenses we paid. However, we will cover the cost of treatment
that exceeds
the amount you received in the settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures.
2002 Kaiser Foundation Health Plan, Inc. 53 Section 9
When others are responsible for injuries
When other Government
agencies are responsible for your care 53
53
Page 54 55
Section 10. Definitions of terms we use in this brochure
January
1 through December 31 of the same year. For new enrollees, the
calendar year
begins on the effective date of their enrollment and ends on
December 31 of
the same year.
Coinsurance is the percentage of our allowance that you must pay for
your
care. See page 14.
A copayment is a fixed amount of money you pay when you receive
covered
services. See page 14.
Care we provide benefits for, as described in this brochure.
(1)
Assistance with activities of daily living, for example, walking,
getting in
and out of bed, dressing, feeding, toileting, and taking
medicine. (2) Care
that can be performed safely and effectively by
people who, in order to
provide the care, do not require medical licenses
or certificates or the
presence of a supervising licensed nurse.
A deductible is a fixed amount of covered expenses you must incur for
certain covered services and supplies before we start paying benefits for
those services. See page 14.
Durable medical equipment (DME) is equipment that is intended for
repeated use, medically necessary, primarily and customarily used to
serve a medical purpose, generally not useful to a person who is not ill or
injured, designed for prolonged use, appropriate for use in the home, and
serves a specific therapeutic purpose in the treatment of an illness or
injury.
We carefully evaluate whether a particular therapy is safe and effective
or offers a reasonable degree of promise with respect to improving health
outcomes. The primary source of evidence about health outcomes of any
intervention is peer-reviewed medical or dental literature. When the
service or supply, including a drug: (1) has not been approved by the
FDA; or (2) is the subject of a new drug or new device application on file
with the FDA; or (3) is part of a Phase I or Phase II clinical 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.
Health care benefits that are available as a result of your employment, or
the employment of your spouse, and that are offered by an employer or
through membership in an employee organization. Health care coverage
may
be insured or indemnity coverage, self-insured or self-funded
coverage, or
coverage through health maintenance organizations or other
managed care
plans. Health care coverage purchased through
membership in an organization
is also "group health coverage."
2002 Kaiser Foundation Health Plan, Inc. 54 Section 10
Coinsurance
Copayment
Covered services
Custodial care
Deductible
Durable medical equipment
Experimental or investigational services
Group health coverage
Calendar year 54
54 Page 55 56
All benefits need
to be medically necessary in order for them to be
covered benefits.
Generally, if your Plan physician provides the service
in accord with the
terms of this brochure, it will be considered medically
necessary. However,
some services are reviewed in advance of your
receiving them to determine if
they are medically necessary. When we
review a service to determine if it is
medically necessary, a Plan
physician will evaluate what would happen to you
if you do not receive
the service. If not receiving the service would
adversely affect your
health, it will be considered medically necessary. The
services must be a
medically appropriate course of treatment for your
condition. If they are
not medically necessary, we will not cover the
services. In case of
emergency services, the services that you received will
be evaluated to
determine if they were medically necessary.
The amount we use to determine your coinsurance. When you receive
services or supplies from Plan providers, it is the amount that we set for
the services or supplies if we were to charge for them. When you receive
services from non-Plan providers, we determine the amount that we
believe is usual and customary for the service or supply, and compare it
to the charges. Our allowance is based upon the reasonableness of the
charges. If the charges exceed what we believe is reasonable, you may
be
responsible for the excess over our allowance in addition to your
coinsurance.
Us and we refer to Kaiser Foundation Health Plan, Inc.
You refers to the
enrollee and each covered family member.
2002 Kaiser Foundation Health Plan, Inc. 55 Section 10
Medically necessary
Our allowance
Us/ We
Yo u 55
55 Page 56 57
Section 11. FEHB facts
We will not refuse
to cover the treatment of a condition that you had
before you enrolled in
this Plan solely because you had the condition
before you enrolled.
See www. opm. gov/ insure. Also, your employing or retirement office
can
answer your questions, and give you a Guide to Federal Employees
Health
Benefits Plans, brochures for other plans, and other materials you
need
to 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
When the next open
season for enrollment begins.
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.
Self Only coverage is for you alone. Self and Family coverage is for
you,
your spouse, and your unmarried dependent children under age 22,
including
any foster children or stepchildren your employing or
retirement office
authorizes coverage for. Under certain circumstances,
you may also continue
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 that event.
The Self and Family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When
you change to Self and Family because you marry, the change is effective
on the first day of the pay period that begins after your employing office
receives your enrollment form; benefits will not be available to your
spouse until you marry.
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, or when your child
under
age 22 marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan.
2002 Kaiser Foundation Health Plan, Inc. 56 Section 11
No pre-existing condition limitation
Where you can get information
about enrolling in the
FEHB Program
Types of coverage available for you and your family 56
56 Page 57 58
The benefits in this brochure are effective on January
1. If you joined
this Plan during Open Season, your coverage begins on the
first day of
your first pay period that starts on or after January 1.
Annuitants'
coverage and premiums begin on January 1. If you joined at any
other
time during the year, your employing office will tell you the
effective
date of coverage.
We will keep your medical and claims information confidential. Only
the
following will have access to it:
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.
When you retire, you can usually stay in the FEHB Program. Generally,
you
must have been 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
(TCC).
You will receive an additional 31 days of coverage, for no additional
premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary
Continuation
of Coverage.
If you are divorced from a Federal employee or annuitant, you may not
continue to get benefits 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 RI 70-5, the
Guide to
Federal Employees Health Benefits Plans for Temporary
Continuation of
Coverage and Former Spouse Enrollees, or other
information about your
coverage choices.
If you leave Federal service, or if you lose coverage because you no
longer qualify as a family member, you may be eligible for Temporary
Continuation of Coverage (TCC). For example, you can receive TCC if
you
are not able to continue your FEHB enrollment after you retire, if
you lose
your job, if you are a covered dependent child and you turn 22
or marry,
etc.
2002 Kaiser Foundation Health Plan, Inc. 57 Section 11
When you retire
When you lose benefits
When FEHB coverage ends
Spouse equity coverage
Temporary continuation of
coverage
(TCC)
When benefits and premiums start
Your medical and claims records are
confidential 57
57 Page
58 59
You may not elect TCC if you are
fired from your Federal job due to
gross misconduct.
Enrolling in TCC. 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 or from www. opm. gov/ insure.
It
explains what you have to do to enroll.
You may convert to a non-FEHB individual policy if:
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 of
your right to convert. 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.
The Health Insurance Portability and Accountability Act of 1996
(HIPAA)
is a Federal law that offers limited Federal protections for health
coverage
availability and continuity to people who lose employer group
coverage. If
you leave the FEHB Program, we will give you a Certificate
of Group Health
Plan Coverage that indicates how long you have been
enrolled with us. You
can use this certificate when getting health
insurance or other health care
coverage. Your new plan must reduce or
eliminate waiting periods,
limitations, or exclusions for health related
conditions based on the
information in the certificate, as long as you
enroll within 63 days of
losing coverage under this Plan. If you have
been enrolled with us for less
than 12 months, but were previously
enrolled in other FEHB plans, you may
also request a certificate from
those plans.
For more information, get OPM pamphlet RI 79-27, Temporary
Continuation
of Coverage (TCC) under the FEHB Program. See also the
FEHB website (www.
opm. gov/ insure/ health); refer to the "TCC and
HIPAA" frequently asked
question. These highlight HIPAA rules, such
as the requirement that Federal
employees must exhaust any TCC
eligibility as one condition for guaranteed
access to individual health
coverage under HIPAA, and have information about
Federal and State
agencies you can contact for more information.
2002 Kaiser Foundation Health Plan, Inc. 58 Section 11
Converting to individual
coverage
Getting a Certificate of Group Health Plan Coverage 58
58 Page 59 60
Long Term Care Insurance Is Coming Later in 2002!
The Office of Personnel Management (OPM) will sponsor a high-quality
long term care insurance program effective
in October 2002. As part of its
educational effort, OPM asks you to consider these questions:
It's insurance to help pay for long-term care services you may need
if
you can't take care of yourself because of an extended illness or
injury, or
an age-related disease such as Alzheimer's.
LTC insurance can provide
broad, flexible benefits for nursing home
care, care in an assisted living
facility, care in your home, adult day
care, hospice care, and more. LTC
insurance can supplement care
provided by family members, reducing the
burden you place on them.
Welcome to the club!
76% of Americans believe they will never need
long-term care, but the
facts are that about half of them will. And it's not
just the old folks.
About 40% of people needing long term care are under age
65. They
may need chronic care due to a serious accident, a stroke, or
developing multiple sclerosis, etc.
We hope you will never need long
term care, but everyone should have
a plan just in case. Many people now
consider long term care insurance
to be vital to their financial and
retirement planning.
Yes, it can be very expensive. A year in a nursing home can exceed
$50,000. Home care for only three 8-hour shifts a week can exceed
$20,000 a year. And that's before inflation!
Long-term care can easily
exhaust your savings. Long term care
insurance can protect your savings.
Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5(
c)
of your FEHB brochure. Health plans don't cover custodial care or a
stay in an assisted living facility or a continuing need for a home health
aide to help you get in and out of bed and with other activities of daily
living. Limited stays in skilled nursing facilities can be covered in
some circumstances.
Medicare only covers skilled nursing home care
(the highest level of
nursing care) after a hospitalization for those who
are blind, age 65 or
older or fully disabled. It also has a 100 day limit.
Medicaid covers long-term care for those who meet their state's
poverty guidelines, but has restrictions on covered services and where
they can be received. Long term care insurance can provide choices of
care and preserve your independence.
Employees will get more information from their agencies during the
LTC
open enrollment period in the late summer/ early fall of 2002.
Retirees
will receive information at home.
Our toll-free teleservice center will begin in mid-2002. In the
meantime, you can learn more about the program on our website at
www.
opm. gov/ insure/ ltc.
2002 Kaiser Foundation Health Plan, Inc. 59 Long Term Care
Insurance
I'm healthy. I won't need
long term care. Or, will I?
What is long term care
(LTC) insurance?
Is long term care expensive?
But won't my FEHB plan,
Medicare or
Medicaid cover
my long-term care?
When will I get more information
on how to apply for this new
insurance coverage?
How can I find out more about the
program NOW?
Many FEHB enrollees think that their health plan and/ or Medicare
will cover their long-term care needs.
Unfortunately, they are WRONG!
How are YOU planning to pay for the future custodial or chronic care
you may need?
You should consider buying long-term care insurance.
59
59 Page 60 61
Department of Defense/ FEHB Demonstration Project
The Department of Defense/ FEHB Demonstration Project allows some active
and
retired uniformed service members and their dependents to enroll in the
FEHB
Program. The demonstration will last for three years and began with the
1999
open season for the year 2000. Open season enrollments will be
effective January
1, 2002. DoD and OPM have set up some special procedures
to implement the
Demonstration Project, noted below. Otherwise, the
provisions described in this
brochure apply.
DoD determines who is eligible to enroll in the FEHB Program. Generally, you
may enroll if:
You are an active or retired uniformed service member and are eligible for
Medicare;
You are a dependent of an active or retired uniformed service member and
are
eligible for Medicare;
You are a qualified former spouse of an active or retired uniformed service
member and you have not remarried; or
You are a survivor dependent of a deceased active or retired uniformed
service member; and
You live in one of the geographic demonstration areas.
If you are eligible to enroll in a plan under the regular Federal Employees
Health
Benefits Program, you are not eligible to enroll under the DoD/ FEHBP
Demonstration Project.
Dover AFB, DE Commonwealth of Puerto Rico
Fort Knox, KY
Greensboro/ Winston Salem/ High Point, NC
Dallas, TX Humboldt County, CA
area
New Orleans, LA Naval Hospital, Camp Pendleton, CA
Adair
County, IA Coffee County, GA
You may enroll under the DoD/ FEHB Demonstration Project during the 2001
open season, November 12, 2001, through December 10, 2001. Your coverage
will begin January 1, 2002. DoD has set up an Information Processing Center
(IPC) in Iowa to provide you with information about how to enroll. IPC staff
will
verify your eligibility and provide you with FEHB Program information,
plan
brochures, enrollment instructions and forms. The toll-free phone
number for the
IPC is 1-877-DOD-FEHB (1-877-363-3342).
You may select coverage for yourself (Self Only) or for you and your family
(Self
and Family) during open season. Your coverage will begin January 1,
2002. If
you become eligible for the DoD/ FEHB Demonstration Project outside
of open
season, contact the IPC to find out how to enroll and when your
coverage will
begin.
DoD has a website devoted to the Demonstration Project. You can view
information such as their Marketing/ Beneficiary Education Plan, Frequently
Asked Questions, demonstration area locations, and zip code lists at
www. tricare. osd. mil/ fehbp. You can also view information about the
demonstration project, including "The 2002 Guide to Federal Employees Health
Benefits Plans Participating in the DoD/ FEHB Demonstration Project," on the
OPM website at www. opm. gov.
2002 Kaiser Foundation Health Plan, Inc. 60 DoD/ FEHB Demonstration
Project
Who is eligible
What is it?
The demonstration areas
When you can join 60
60 Page 61 62
See Section 11, FEHB Facts; it explains temporary
continuation of coverage
(TCC). Under this DoD/ FEHB Demonstration Project
the only individual eligible
for TCC is one who ceases to be eligible as a
"member of family" under your Self
and Family enrollment. This occurs when a
child turns 22, for example, or if you
divorce and your spouse does not
qualify to enroll as an unremarried former
spouse under title 10, United
States Code. For these individuals, TCC begins the
day after their
enrollment in the DoD/ FEHB Demonstration Project ends. TCC
enrollment
terminates after 36 months or the end of the Demonstration Project,
whichever occurs first. You, your child, or another person must notify the
IPC
when a family member loses eligibility for coverage under the DoD/ FEHB
Demonstration Project.
TCC is not available if you move out of a DoD/ FEHB Demonstration Project
area,
you cancel your coverage, or your coverage is terminated for any
reason. TCC is
not available when the demonstration project ends.
The 31-day extension of coverage and right to convert do not apply to the
DoD/ FEHB Demonstration Project.
2002 Kaiser Foundation Health Plan, Inc. 61 DoD/ FEHB Demonstration
Project
TCC eligibility
Other features 61
61
Page 62 63
Index
Do not rely on this page; it is for your convenience and
may not show all pages where the terms appear.
2002 Kaiser Foundation Health Plan, Inc. 62 Index
Accidental injury 26 Allergy tests 19
Alternative treatment
24
Ambulance 29, 31
Anesthesia 28
Autologous bone marrow
transplant 28
Biopsies 25 Blood and blood plasma 30
Breast cancer screening 17
Casts 30 Centers of excellence for
transplants 41
Changes for 2002 10
Chemotherapy 20
Chiropractic
24
Cholesterol tests 17
Coinsurance 14
Colorectal cancer screening
17
Congenital anomalies 26
Contraceptive devices and drugs 14,
19
Coordination of benefits 48
Covered providers 11
Crutches 23
Deaf and hearing impaired service 41
Deductible 14, 54
Dental care 42
Diagnostic services 16
Disputed
claims process 46
Donor expenses (transplants) 28
Dressings 30
Durable medical equipment
(DME) 22, 54
Educational classes
and programs 24 Effective date of enrollment 56
Emergency 32
Experimental or investigational 44, 54
Eyeglasses 21, 51
Family planning 19 Fecal occult blood test 17
Flexible benefits options 40
General Exclusions 44 Hearing
services 20
Home health services 23
Hospice care 31
Hospital 11, 13, 29, 32
Immunizations 17 Infertility 19
Inpatient Hospital Benefits 29
Insulin 38
Laboratory and pathological services 17
Magnetic Resonance
Imagings (MRIs) 17
Mail Order Prescription Drugs 37
Mammograms 17
Maternity Benefits 18
Medicaid 52
Medically necessary 16, 25, 29,
32,
34, 37, 55
Medicare 48
Mental Conditions/ Substance
Abuse
Benefits 34
Neurology 13 Newborn care 18
Non-FEHB Benefits 43
Nurse
Licensed Practical Nurse 23
Nurse
Anesthetist 30
Nurse Practitioner 11
Registered Nurse 23, 41
Nursery
charges 18
Obstetrical care 18 Occupational therapy 20
Ocular injury 21
Oral and maxillofacial surgery 27
Orthopedic devices
21
Ostomy and catheter supplies 22
Out-of-pocket expenses 14
Oxygen
23, 30
Pap test 17 Physical examination 18
Physical therapy 20
Precertification 47
Preventive care, adult 17
Preventive care, children 17
Preventive services 43, 51
Prior
approval 47
Prostate cancer screening 17
Prosthetic devices 21
Psychotherapy 36
Radiation therapy 20 Renal dialysis 20, 48
Room and board 29, 31
Second opinion 16 Services from other Kaiser
Permanente Plans 40
Skilled nursing facility care 13, 22,
31, 59
Smoking cessation 38
Speech therapy 20
Splints 30
Sterilization procedures 19, 25, 26
Subrogation 53, 57
Substance abuse 34, 35
Surgery 25
Anesthesia 28
Oral 27
Outpatient 25
Reconstructive 26
Syringes 38
Temporary
continuation of coverage 57, 58
Transplants 20, 28, 41
Treatment therapies 20
Travel benefit 41
Vision services 18, 21 Well child care 18
Wheelchairs 23
Workers' compensation 52
X-rays 17 24
hour nurse line 41 62
62 Page 63 64
Summary of
benefits for Kaiser Foundation Health Plan, Inc., California
Division 2002
Do not rely on this chart alone. All benefits are provided in full
unless indicated and are subject to the
definitions, limitations, and
exclusions in this brochure. On this page we summarize specific expenses we
cover;
for more detail, look inside.
If you want to enroll or change your enrollment in this Plan, be
sure to put the correct enrollment code from the
cover on your enrollment
form.
We only cover services provided or arranged by Plan physicians,
except in emergencies.
Benefits You Pay Page
Medical services
provided by physicians:
Diagnostic and treatment services provided
in the office . . . . . . . . . $10 per office visit 16
Services provided by a hospital:
Inpatient . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nothing 29
Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . Nothing 30
Emergency benefits:
In-area . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50 per visit 32
Out-of-area . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . $50 per visit 32
Mental health and substance abuse treatment: . . . . . . . . . . . . . . . .
. . . . Regular cost sharing 34
Prescription drugs . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . $10 per prescription for
generic 37
drugs; $20 per prescription for
brand-name drugs; all charges
if
you request a brand-name drug in
place of a generic drug
Dental Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . No benefit 42
Vision Care . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Refractions;
$10 per office visit 21
Special features: Flexible benefits option; Services
from other Kaiser Permanente Plans; Travel benefit; 40
24 hour nurse line;
Services for deaf and hearing impaired; Centers of excellence for transplants
Protection against catastrophic costs Nothing after $1,500/ Self Only or 14
(your out-of-pocket maximum) . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . $3,000/ Family enrollment per
year
Some costs do not count toward
this protection
2002 Kaiser Foundation Health Plan, Inc. 63 Summary 63
63 Page 64
2002
rate information for
Kaiser Foundation Health Plan, Inc., California
Division
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 career Postal Service employees. Most employees
should refer to the
FEHB Guide for United States Postal Service
Employees, RI 70-2. Different postal rates apply
and special FEHB guides
are published for Postal Service nurses and tool and die employees
(see RI
70-2B); and for Postal Service Inspectors and Office of Inspector General (OIG)
employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members
of any postal employee organization who are not career
postal employees. Refer to the
applicable FEHB Guide.
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
Northern California
Self only 591 $79.73 $26.58 $172.76 $57.58 $94.35
$11.96
Self and family 592 $190.34 $63.44 $412.40 $137.46 $225.23 $28.55
Southern California
Self only 621 $83.98 $27.99 $181.95 $60.65 $99.37
$12.60
Self and family 622 $194.08 $64.69 $420.50 $140.17 $229.66 $29.11
1034-0002-02 64