Kaiser Foundation Health Plan of the Northwest
http:// www. kp. org/ nw
2002
A
Health Maintenance Organization
Serving: Portland and Salem, Oregon
Vancouver and Longview, Washington
Enrollment in this Plan is limited. You must live or work in our
Geographic service area to enroll. See page 8 for requirements.
Enrollment codes for this Plan:
571 High Option Self Only 572 High
Option Self and Family
574 Standard Option Self Only 575 Standard Option
Self and Family
RI 73-004
This Plan has excellent
accreditation from the NCQA.
See the 2002
Guide for more
information on accreditation.
For changes
in benefits
see page 9 1
1 Page 2 3
2002 Kaiser Foundation Health Plan of the Northwest 2 Table of
Contents
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
.............................................................................................................................
9
Program-wide
changes.................................................................................................................................
9
Changes to this
Plan.....................................................................................................................................
9
Section 3. How you get care
......................................................................................................................................
10
Identification cards
....................................................................................................................................
10
Where you get covered
care.......................................................................................................................
10
Plan
providers......................................................................................................................................
10
Plan facilities
.......................................................................................................................................
10
What you must do to get covered
care.......................................................................................................
10
Primary care
........................................................................................................................................
11
Specialty care
......................................................................................................................................
11
Hospital
care........................................................................................................................................
12
Circumstances beyond our
control.............................................................................................................
12
Services requiring our prior approval
........................................................................................................
12
Section 4. Your costs for covered services
.................................................................................................................
13
Copayments.........................................................................................................................................
13
Deductible
...........................................................................................................................................
13
Coinsurance.........................................................................................................................................
13
Fees when you fail to make your copayment
......................................................................................
13
Your catastrophic protection out-of-pocket maximum
for copayments and coinsurance.......................... 13
Section 5.
Benefits......................................................................................................................................................
14
Overview....................................................................................................................................................
14
(a) Medical services and supplies provided by
physicians and other health care professionals ........... 15
(b) Surgical and anesthesia services provided by physicians and
other health care professionals........ 28
(c)
Services provided by a hospital or other facility, and ambulance services
..................................... 33
(d) Emergency
services/
accidents.........................................................................................................
37
(e) Mental health and substance abuse
benefits....................................................................................
40
(f) Prescription drug benefits
...............................................................................................................
43
(g) Special features
...............................................................................................................................
46 2
2 Page 3 4
2002 Kaiser Foundation Health Plan of the Northwest 3 Table of
Contents
Flexible benefits option
.......................................................................................................................
46
24 hour nurse line
................................................................................................................................
46
Services for deaf and hearing impaired
...............................................................................................
46
Language
interpretation.......................................................................................................................
46
High risk
pregnancies..........................................................................................................................
46
Centers of excellence for
transplants...................................................................................................
47
Travel benefit
......................................................................................................................................
47
Services from other Kaiser Permanente
Plans.....................................................................................
48
(h) Dental benefits
................................................................................................................................
49
(i) Non-FEHB benefits available to Plan
members..............................................................................
53
Section 6. General exclusions – things we don't
cover
...............................................................................................
54
Section 7. Filing a claim for covered services
............................................................................................................
55
Medical, hospital and drug benefits
...........................................................................................................
55
Deadline for filing your
claim....................................................................................................................
55
When we need more
information...............................................................................................................
55
Section 8. The disputed claims process
......................................................................................................................
56
Section 9. Coordinating benefits with other
coverage
................................................................................................
58
When you have other health coverage
.......................................................................................................
58
What is
Medicare?................................................................................................................................
58
The Original Medicare Plan (Part A or Part B)
....................................................................................
58
Medicare managed care plan
................................................................................................................
61
If you do enroll in Medicare Part
B......................................................................................................
62
If you do not enroll in Medicare Part A or Part B
................................................................................
62
TRICARE
..................................................................................................................................................
62
Workers' Compensation
............................................................................................................................
62
Medicaid
....................................................................................................................................................
62
When other Government agencies are responsible for
your care............................................................... 62
When others are responsible for
injuries....................................................................................................
62
Section 10. Definitions of terms we use in this
brochure
...........................................................................................
63
Section 11. FEHB
facts...............................................................................................................................................
65
Coverage
information.............................................................................................................................
65
No pre-existing condition
limitation....................................................................................................
65
Where you get information about enrolling in the
FEHB Program..................................................... 65
Types of coverage available for you and your family
......................................................................... 65
When benefits and premiums start
......................................................................................................
66
Your medical and claims records are
confidential...............................................................................
66
When you retire
...................................................................................................................................
66
When you lose benefits
..........................................................................................................................
66 3
3 Page 4 5
2002 Kaiser Foundation Health Plan of the Northwest 4 Table of
Contents
When FEHB coverage
ends.................................................................................................................
66
Spouse equity coverage
.......................................................................................................................
66
Temporary continuation of coverage (TCC)
.......................................................................................
66
Converting to individual coverage
......................................................................................................
67
Getting a Certificate of Group Health Plan Coverage
......................................................................... 67
Long term care insurance is coming later in
2002.......................................................................................................
68
Index............................................................................................................................................................................
69
Summary of
benefits....................................................................................................................................................
70
Rates…………………………………………………………………………………………………………..
Back cover 4
4 Page
5 6
2002 Kaiser Foundation Health Plan of the Northwest 5
Introduction/ Plain Language/ Advisory
Introduction
Kaiser
Foundation Health Plan of the Northwest
500 N. E. Multnomah Street, Suite
100
Portland, Oregon 97232-2099
This brochure describes the benefits of Kaiser Foundation Health Plan of the
Northwest under our contract (CS 1047)
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 9. 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 of the Northwest.
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 the
structure of 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. 5
5 Page 6 7
2002 Kaiser
Foundation Health Plan of the Northwest 6 Introduction/ Plain Language/
Advisory
Inspector General Advisory
Stop health care fraud!
Fraud increases the cost of health care for everyone. If you suspect that a
physician, pharmacy, or hospital has charged you for services you did not
receive,
billed you twice for the same service, or misrepresented any
information, do the following:
Call the provider and ask for an explanation. There may be an error.
If
the provider does not resolve the matter, call us from Portland at 503/
813-2000, or from other areas call 800/ 813-2000 or the TTY number
at 800/ 324-8007 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
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate anyone
who uses an ID card if 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. 6
6 Page 7 8
2002 Kaiser Foundation Health Plan of the Northwest 7 Section 1
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
Kaiser Foundation Health Plan of the
Northwest contracts with Northwest Permanente, P. C., to provide professional
health care services. Northwest Permanente physicians provide approximately
98% of primary care services and more
than 80% of specialty services to
members. We reimburse Northwest Permanente for these services through an
annually adjusted capitation rate, paid to the medical group as a whole. As
employees of Northwest Permanente,
individual physicians receive a salary.
Northwest Permanente uses approximately 97% of the base capitation payment
to pay physician salaries. An incentive compensation payment (ICP) of
approximately 3% of the base capitation
payment is at risk and is paid to
physicians based on a combination of patient satisfaction, quality, and
financial
results.
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 website (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. Kaiser
Foundation Health Plan of the Northwest is a
non-profit corporation. Kaiser
Permanente began offering medical services to workers and their families at
Grand
Coulee Dam in northeastern Washington and later the Kaiser shipyards
in Portland, Oregon and Vancouver,
Washington during World War II. When the
shipyards were closed in 1945, enrollment was opened to the
community. 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.
In 1995, Kaiser Permanente became the first HMO in Oregon and southwest
Washington to receive a three-year, full
accreditation from the National
Committee for Quality Assurance (NCQA). We were again awarded three-year, full
accreditation in 1998. In 2001, we were awarded the highest level of
accreditation, known as "Excellent
Accreditation." Excellent Accreditation
status is awarded to plans whose service and clinical quality meet or exceed
NCQA's rigorous requirements for consumer protection and quality
improvement, and whose HEDIS (Health Plan
Employer Data and Information Set)
results are in the highest range of national performance.
All Kaiser Permanente and affiliated hospitals are accredited by the Joint
Commission on Accreditation of Healthcare
Organizations (JCAHO).
All applicants for employment with Northwest Permanente P. C., or Permanente
Dental Associates must meet rigorous
Kaiser Permanente credentialing
standards. Once hired, they undergo periodic review by peers and hospital boards
to
assure their credentials are up to date and in order. 7
7 Page 8 9
2002 Kaiser Foundation Health Plan of the Northwest 8 Section 1
If you want more information about us, from Portland, call 503/
813-2000, or from other areas call 800/ 813-2000 or
our TTY numbers in
Oregon at 800/ 735-2900 and in Washington at 800/ 833-6388, or write to Kaiser
Foundation
Health Plan of the Northwest, 500 N. E. Multnomah Suite 100,
Portland, OR 97232. You may also visit our website at
www. kp. org/ nw.
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:
These Oregon counties: Columbia, Multnomah, Polk, Yamhill
And these
Oregon zip codes:
Benton County: 97330, 97331, 97333, 97339, 97370
Clackamas County: 97004, 97009, 97011, 97013, 97015, 97017, 97022-23, 97027,
97034-36, 97038, 97042, 97045,
97055, 97067-68, 97070, 97222, 97267-68
Linn County: 97321, 97335, 97355, 97358, 97360, 97374, 97389
Marion
County: 97002, 97020, 97026, 97032, 97071, 97137, 97301-3, 97305-14, 97325,
97352, 97359, 97362,
97375, 97381, 97383-85, 97392
Washington County: 97005-8, 97062, 97075-78, 97106, 97109, 97113, 97116-17,
97119, 97123-25, 97133, 97140,
97144, 97223-25, 97229, 97281, 97291
These Washington counties: Clark County
And these Washington zip codes:
Cowlitz County: 98581, 98603, 98609, 98611, 98616, 98625-26, 98632, 98645,
98649, 98674
Lewis County: 98591, 98593, 98596
Wahkiakum County: 98612,
98647
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 47 and for emergency care obtained
from any non-Plan provider, as described on
page 37. 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. 8
8 Page
9 10
2002 Kaiser Foundation Health
Plan of the Northwest 9 Section 2
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
Your share of the non-Postal premium will
increase by 2. 2% for Self Only or 0. 1% for Self and Family under the High
Option and will increase by 12.0% for Self Only or 12.0% for Self and Family
under the Standard Option.
We increased your office visit copayment from $12 to $15 for medical services
and supplies provided by physicians and other health care professionals
(Standard Option only).
We cover travel immunizations and medications.
We cover both the diagnosis and treatment of infertility at 50% of our
allowance for both the Standard and High Option.
We cover orthopedic and some prosthetic devices at 50% of our allowance for
both the Standard and High Option.
We cover durable medical equipment at 50%
of our allowance for both the Standard and High Option.
We waive your
non-plan emergency services copayment if you are admitted to a hospital directly
from the emergency room.
We increased the copayment for prescription drugs. For Standard Option, the
copayment changes from $15 for all drugs to $15 for generic drugs and $30 for
brand-name drugs. For High Option, the copayment changes from
$10 for all
drugs to $10 for generic drugs and $20 for brand-name drugs.
We cover
medications for foreign travel.
You pay $25, in addition to applicable
copayments, for emergency or urgent dental care received from a Plan dentist
during regular business hours, after hours, or on weekends (High Option only).
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. 9
9 Page 10 11
2002 Kaiser Foundation Health Plan of the Northwest
10 Section 3
Section 3. How you get care
Identification
cards 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 obtain 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 from
Portland at 503/ 813-2000, or from other areas call 800/ 813-2000 or
our
TTY numbers in Oregon at 800/ 735-2900 and in Washington at
800/ 833-6388.
Where you get covered care 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 The Plan contracts with Northwest Permanente, P. C. to
provide physician services. They practice in medical offices located within our
service
area. Permanente Dental Associates, an independent group of
dentists,
provides or arranges dental care for members of the High Option
plan.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.
Plan facilities Plan facilities are hospitals and other facilities in
our service area that we contract with to provide covered services to our
members. Medical
Centers, Medical Offices and Dental Offices are
conveniently located
throughout Portland and Salem, Oregon and Vancouver and
Longview-Kelso,
Washington. Inpatient care is available at Kaiser Sunnyside
Medical Center, Providence St. Vincent Medical Center, Providence
Portland Medical Center, Southwest Washington Medical Center, Salem
Hospital, St. John Medical Center, Doernbecher Children's Hospital (for
children only), and Legacy Emanuel Hospital and Health Center (for low
risk childbirth services). We list these in the provider directory, which
we update periodically. The list is also on our website.
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.
What you must do to get It depends on the type of care you need.
First, you and each family covered care 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. Our website has
information about our
providers. Membership Services can help you too, by
telling you who is
available and sharing information about them. To choose
or change a
primary care physician, call Membership Services from Portland
at
503/ 813-2000, or from other areas call 800/ 813-2000 or our TTY
numbers in Oregon at 800/ 735-2900 and in Washington at 800/ 833-6388. 10
10 Page 11 12
2002 Kaiser Foundation Health Plan of the Northwest
11 Section 3
Primary care Your primary care physician can
be a physician, nurse practitioner, or physician assistant in family practice,
internal medicine, or pediatrics.
Your primary care physician will provide
most of your health care, or
give you a referral to see a specialist.
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.
Specialty care 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, a
woman may see her obstetrician/ gynecologist without having to
obtain a
referral. You may also receive outpatient alcohol and drug
treatment,
cancer counseling, eye examinations, outpatient mental health,
chiropractic, occupational health, and social work services 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.
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.
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 11
11 Page 12 13
2002 Kaiser Foundation Health Plan of the Northwest
12 Section 3
continue to see your specialist until the end of
your postpartum care, even
if it is beyond the 90 days.
Hospital care 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 Membership
Services department immediately from Portland at
503/ 813-2000, or from
other areas call 800/ 813-2000 or our TTY
numbers in Oregon at 800/ 735-2900
and in Washington at 800/ 833-6388.
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 benefits of the hospitalized person.
Circumstances beyond our Under certain extraordinary circumstances,
such as natural disasters, we control 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.
Services requiring our Most care and service is not subject to
administrative prior authorization. prior approval Prior authorization is
required for select services such as care at skilled
nursing facilities,
home health and hospice services, referrals to non-Kaiser
Permanente
physicians, and transplants. Your primary care
physician will give a
referral for these services if they are medically
necessary. 12
12 Page 13 14
2002 Kaiser Foundation Health Plan of the Northwest
13 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments 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 if you are on the High Option Plan and
$15 per office
visit if you are on the Standard Plan. When you go in the
hospital, you pay
nothing under either Option.
Deductible 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.
And, if you change options in this Plan during the year, we will credit the
amount of covered expenses already applied toward the deductible of your
old option to the deductible of your new option.
Coinsurance 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.
Fees when you fail to If you do not pay your copayment at the time you
receive services, we make your copayment will bill you. You will be
required to pay a $6 charge for each bill sent for
unpaid services.
Your catastrophic protection After your copayments and coinsurance
total $600 per person or $1, 200 out-of-pocket maximum for per family
enrollment in any calendar year, you do not have to pay any
copayments and coinsurance more for covered services. However,
copayments for the following services do not count toward your out-of-pocket
maximum. You must
continue to pay copayments for these services under both
the High Option
and Standard Option.
Outpatient prescription drugs Contraceptive devices
Dental services
Corrective appliances and artificial aids
The $25 charges paid for follow-up
or continuing care when you are traveling out of our service area
Long-term
physical therapy and rehabilitation Eyeglasses and contact lenses
Health
education services
Be sure to keep accurate records of your copayments and
coinsurance since
you are responsible for informing us when you reach the
maximum. 13
13 Page
14 15
2002 Kaiser Foundation Health Plan of the Northwest 14 Section 5
Section 5. Benefits --OVERVIEW
(See page 9 for how our
benefits changed this year and page 70 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
from Portland at
503/ 813-2000, or from other areas call 800/
813-2000 or our TTY numbers in Oregon at 800/ 735-2900
and in Washington
at 800/ 833-6388 or at our website at www. kp. org/ nw.
(a) Medical services and supplies provided by physicians and other health
care professionals ............................ 15-27
Diagnostic and
treatment services Lab, X-ray, and other diagnostic tests
Preventive care,
adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Physical and
occupational therapies
Speech therapy
Hearing services (testing, treatment, and supplies)
Vision services
(testing, treatment, and supplies)
Foot care Orthopedic and prosthetic
devices
Durable medical equipment (DME) Home health services
Chiropractic Alternative treatments
Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals........................ 28-32
Surgical procedures
Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and
ambulance services...................................................... 33-36
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice
care Ambulance
(d) Emergency services/ accidents
.........................................................................................................................
37-39
Emergency within our service area Emergency outside our service area
Ambulance
(e) Mental health and substance abuse benefits
....................................................................................................
40-42
(f) Prescription drug
benefits................................................................................................................................
43-45
(g) Special
features................................................................................................................................................
46-48
Flexible benefits option 24 hour nurse line
Services for deaf and hearing
impaired Language interpretation
High risk pregnancies Centers of excellence
for transplants
Travel benefit Services from other Kaiser Permanente Plans
(h) Dental
benefits.................................................................................................................................................
49-52
(i) Non-FEHB benefits available to Plan members
...................................................................................................
53
Summary of
benefits...............................................................................................................................................
70-71 14
14 Page
15 16
2002 Kaiser Foundation Health
Plan of the Northwest 15 Section 5( a)
Section 5 (a). Medical
services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T
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: We waive the $10 charge 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
Benefit Description You pay
Diagnostic and treatment services You pay
-Standard Option You pay -High Option
Professional services of
physicians and other health
care professionals
In a physician's office
Office medical consultations
In a Plan urgent
care center
In a skilled nursing facility
Initial examination of a
newborn child covered under a family enrollment
Second surgical opinion
$15 per office visit $10 per office visit
Professional services of physicians and other health
care professionals
During a hospital stay
Nothing Nothing
At home Nothing Nothing 15
15 Page 16 17
2002 Kaiser
Foundation Health Plan of the Northwest 16 Section 5( a)
Lab,
X-ray, and other diagnostic tests You pay -Standard Option You pay -High Option
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine mammograms
CAT scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing Nothing
Preventive care, adult
Routine screenings, such as:
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 and medically
necessary for you.
Note: You will pay only one copayment if you
receive your routine
screening on the same day as
your office visit.
$15 per office visit $10 office visit
Routine mammogram – covered for women age 35
and older, as follows:
From age 35 through 39, one during this five year period
From age 40 through 64, one every calendar year
At age 65 and older, one
every two consecutive calendar years
Note: In addition to routine screening,
we cover
mammograms when medically necessary to
diagnose or treat your
illness.
Nothing Nothing 16
16 Page
17 18
2002 Kaiser Foundation Health
Plan of the Northwest 17 Section 5( a)
Routine immunizations and
boosters Nothing Nothing
Visits to receive injections $5 per office visit $5
per office visit
Injectable travel immunizations
Note: We cover oral
travel immunizations under
the prescription drug benefit.
$15 per office visit $10 per office visit
Not covered:
Physical exams required for:
Obtaining or continuing employment
Insurance
Attending schools
All charges All charges
Preventive care, children You pay – Standard Option You pay -High Option
Childhood immunizations recommended by the American Academy of
Pediatrics Nothing Nothing
Examinations, such as:
—Eye exams to determine the need for vision
correction
—Ear exams to determine the need for hearing
correction
—Examinations done on the day of
immunizations
Well-child care charges for routine examinations, immunizations, and care
$15 per office visit $10 per office visit
Injectable travel immunizations
Note: We cover oral travel immunizations
under
the prescription drug benefit.
$15 per office visit $10 per office visit
Not covered:
Physical exams required for:
Obtaining or continuing employment
Insurance
Could not
acquire words on page 20 Attending schools or camp
All charges All charges 17
17 Page 18 19
2002 Kaiser
Foundation Health Plan of the Northwest 18 Section 5( a)
Maternity care You pay -Standard Option You pay – High Option
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
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. Your physician 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 non-routine
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.
$15 per office visit $10 per office visit
Not covered:
Routine sonograms to determine fetal age, size, or
sex
All charges All charges
Family planning
Family planning services including counseling
Voluntary sterilization
Norplant (a surgically implanted contraceptive)
and intrauterine devices
(IUDs)
Note: In addition to the office visit copay for
surgical
procedures related to Norplant and IUDs,
we charge for the device according
to your
Prescription Drug benefit. Contraceptive drugs
and diaphragms
are also covered under your
Prescription Drug benefit.
$15 per office visit $10 per office visit
Not covered:
Reversal of voluntary surgical sterilization
Genetic counseling
All charges All charges 18
18 Page 19 20
2002 Kaiser
Foundation Health Plan of the Northwest 19 Section 5( a)
Infertility services You pay -Standard Option You pay -High Option
Diagnosis and treatment of involuntary infertility
including
artificial insemination limited to
intrauterine insemination (IUI)
50% of our allowance 50% of our allowance
Not covered:
These exclusions apply to fertile as well as
infertile individuals or couples:
Intravaginal insemination (IVI)
Intracervical insemination
(ICI)
Assisted reproductive technology (ART) procedures, such as:
—In vitro fertilization
—Embryo transfer and gamete
intrafallopian
transfer (GIFT)
Services and supplies related to excluded ART procedures
Cost of donor sperm and donor eggs and services related to their
procurement and
storage
Drugs used in the diagnosis and treatment
of infertility
All charges All charges
Allergy care
Testing and treatment $15 per office visit $10 per
office visit
Allergy injections $5 per office visit $5 per office visit
Allergy serum Nothing Nothing
Not covered:
Provocative
food testing
Sublingual allergy desensitization
All charges All charges 19
19 Page 20 21
20 Page 21 22
2002 Kaiser Foundation Health Plan of the Northwest
21 Section 5( a)
Not covered:
Speech therapy that is not
medically necessary
such as:
Therapy for educational placement or other educational purposes
Training or therapy to improve articulation in the absence of injury,
illness, or medical
condition affecting articulation
Therapy for
tongue thrust in the absence of swallowing problems
All charges All charges
Hearing services (testing, treatment, and supplies) You pay -Standard
Option You pay -High Option
Ear and hearing examinations to determine
the need for hearing correction
Hearing testing for children through age 17
(see Preventive care, children)
$15 per office visit $10 per office visit
Not covered:
All other hearing testing
Hearing aids
and supplies
All charges All charges
Vision services (testing, treatment, and supplies)
Diagnosis and
treatment of diseases of the eye
Eye refractions
$15 per office visit $10 per office visit
One pair of eyeglasses (regular lenses and designated frames), or designated
industrial
safety glasses
Medically indicated contact lenses for:
—Extremely high degrees of near or
farsightedness
—Distorted corneas which limit the best
visual acuity with glasses
—Visual error of the two eyes which are
greatly different in power
Note: You may select between the eyeglasses
lenses or the contact lenses.
You are not entitled
to both.
The cost of eyeglasses,
contact lenses, or industrial
safety glasses
less $25
The cost of contact lenses
less $25
Nothing
Nothing 21
21 Page 22 23
2002 Kaiser
Foundation Health Plan of the Northwest 22 Section 5( a)
You may
select non-medically indicated contact lenses instead of glasses The cost of
contact lenses less $25 The cost of contact lenses less a credit
equal to
the cost of
regular lenses and
designated frames
Eyeglasses and contact lens( es) after cataract surgery with intraocular lens
implant:
—Medically necessary intraocular lenses
—One pair of eyeglasses
(regular lenses and designated frames); or
—One pair of contact lenses
Nothing Nothing
Eyeglasses and contact lens( es) after cataract surgery not involving
intraocular lens implant:
—One pair of contact lenses and/ or one pair
of designated frames and regular lenses if
both must be worn at the same
time to
provide a significant improvement in
visual acuity or binocular
vision not
obtainable with regular lenses or contact
lens( es) alone
Nothing Nothing
What you should know:
Vision care benefits are provided to members
when prescribed by Plan physicians or
optometrists and provided at Plan
facilities and
optical departments.
Your vision care benefits for eyeglasses,
industrial safety glasses or
contact lenses renews
every two years from the date you last received
them.
If a significant change in correction occurs in one
or both eyes before
the two years has elapsed, we
cover regular lenses, designated safety lenses
or
medically necessary contact lenses instead of
glasses with the new
correction.
If you have selected non-medically necessary
contact lenses in lieu of
lenses and frames, and a
significant change in correction occurs in one or
both eyes before the two years has elasped, we
will cover replacement of
non-medically
necessary contact lenses.
The cost of the new lenses
less $25
The cost of new lenses
less a
credit equal to the
cost of regular lenses 22
22
Page 23 24
2002
Kaiser Foundation Health Plan of the Northwest 23 Section 5( a)
Not
covered:
Sunglasses, prescription or plain
Athletic safety
glasses
Photogrey, photosun, and tinted lenses
Two pairs
of lenses and frames in lieu of bifocals in the same frames
Repair or replacement of broken, lost, or stolen lenses or frames
Contacts having no refractive value
Fitting and routine
follow-up services for non-medically indicated contact lenses
Refractions for non-medically indicated contact lenses
Eye
exercises and orthoptics
Radial keratotomy, Photorefractive
Keratectomy and other refractive surgery
such as Lasik surgery and evaluations for
these procedures
Visual training
All charges All charges
Foot care You pay -Standard Option You pay -High Option
Routine
foot care when you are under active
treatment for a metabolic or peripheral
vascular
disease, such as diabetes
$15 per office visit $10 per office visit
Not covered:
Cutting, trimming or removal of corns, calluses,
or the free edge of toenails and
similar routine treatment of conditions of the
foot
Treatment of weak, strained or flat feet or bunions or spurs of any
instability, imbalance
or subluxation of the foot
All charges All charges 23
23 Page 24 25
2002 Kaiser
Foundation Health Plan of the Northwest 24 Section 5( a)
Orthopedic and prosthetic devices You pay -Standard Option You pay
-High Option
Externally worn breast prostheses and surgical bras,
including necessary
replacements, following a mastectomy
Internal
prosthetic devices, such as artificial joints, pacemakers, and surgically
implanted
breast implant following mastectomy. Note:
See Section 5( c) for payment
information and
Section 5( b) for coverage of the surgery to
insert the
device.
Corrective orthopedic appliances for nondental treatment of temporomandibular
joint (TMJ) pain dysfunction syndrome
Nothing Nothing
Maxillo-facial prosthetic devices to restore or
manage head and facial
structures that are
defective
20% of our allowance 20% of our allowance
When prescribed by a Plan physician, we cover
orthopedic and other
prosthetic devices not listed
above, including repairs, adjustments or
replacements other than those necessitated by
misuse or loss.
Note: We cover only those standard items that
are adequate to meet the
medical needs of the
member.
Note: Orthopedic and other prosthetic devices are
provided in accordance
with the Plan's DME
formulary and its guidelines.
50% of our allowance 50% of our allowance 24
24
Page 25 26
2002
Kaiser Foundation Health Plan of the Northwest 25 Section 5( a)
Not
covered:
Devices used primarily for cosmetic purposes that are not
necessary to control or eliminate
infection, pain, or restore functions such as
speech, swallowing, or
chewing
Artificial larynxes
Voice machines
Artificial hearts
Internally implanted insulin pumps
Dentures (except High
Option)
External and internally implanted hearing aids
Devices, equipment, supplies, and prosthetics related to the treatment of
sexual dysfunction
Orthopedic devices including corrective shoes
Arch supports
Foot orthotics
Heel pads and heel
cups
Lumbosacral supports
Corsets, trusses, elastic
stockings, support hose, and other supportive devices
All charges All charges
Durable medical equipment (DME) You pay -Standard Option You pay – High
Option
When prescribed by a Plan physician, we cover
or purchase, at
our option, durable medical
equipment intended to be used repeatedly and in
the home.
Necessary repairs, adjustments, and replacements
other than those
necessitated by misuse or loss
are also covered.
Note: We cover only those standard items that
are adequate to meet the
medical needs of the
member.
Note: DME-related supplies are provided in
accordance with the Plan's DME
formulary and
its guidelines.
Note: DME-related supplies for the treatment of
diabetes are covered
under your Prescription
Drug benefit.
50% of our allowance 50% of our allowance 25
25
Page 26 27
2002
Kaiser Foundation Health Plan of the Northwest 26 Section 5( a)
Home health services You pay -Standard Option You pay – High Option
If you are homebound and reside in the service
area:
You may receive home health services of nurses and health aides, physical or
occupational
therapists, and speech and language
pathologists, when prescribed by your
plan
physician, who will periodically review the
program for continuing
appropriateness and
need
Services include oxygen therapy, intravenous therapy, and medications
Nothing Nothing
Not covered:
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 our service area
All charges All charges
Chiropractic
Chiropractic services up to 20 visits per calendar
year
Services include evaluation and management, musculoskeletal treatments,
physical therapy
modalities such as hot and cold packs, and X-rays
Note: You must choose
the chiropractor from our
list of Participating Chiropractors. Contact us to
get the list. You may see a chiropractor without
referral from your Plan
physician.
$20 per office visit $15 per office visit
Not covered:
Non-neuroskeletal disorders
Vocational
rehabilitation services
Laboratory services; MRI or other type of
advanced diagnostic radiology
Durable medical equipment or supplies for use in the home
All charges All charges
Alternative treatments
No benefit All charges All charges
26
26 Page 27
28
2002 Kaiser Foundation Health Plan of the
Northwest 27 Section 5( a)
Education classes and programs You
pay -Standard Option You pay – High Option
No Benefit All charges All
charges 27
27 Page
28 29
2002 Kaiser Foundation Health
Plan of the Northwest 28 Section 5( b)
Section 5 (b). Surgical
and anesthesia services provided by physicians and other health care
professionals
I M
P O
R T
A N
T
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
PRE-AUTHORIZATION FOR SOME SURGICAL PROCEDURES. Please refer to the
pre-authorization shown in Section 3 to be sure
which services and surgeries require pre-authorization.
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures You pay – Standard
Option You pay -High Option
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
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 --a condition in which an individual
weighs 100
pounds or 100% over his or her normal
weight according to
current underwriting
standards; eligible members must be age 18
or over
Insertion of internal prosthetic devices. See Section 5( a) Orthopedic and
prosthetic
devices for coverage information
$15 per office visit for
outpatient services
Nothing for inpatient
services
$10 per office visit for
outpatient services
Nothing for inpatient
services 28
28 Page 29 30
2002 Kaiser
Foundation Health Plan of the Northwest 29 Section 5( b)
Voluntary sterilization (tubal ligation and vasectomy)
Norplant (a
surgically implanted contraceptive) and intrauterine devices
(IUDs).
Note: In addition to the office visit copay, we
charge the prescription
drug copayment for the
device.
Treatment of burns
$15 per office visit for
outpatient services
Nothing for inpatient
services
$10 per office visit for
outpatient services
Nothing for inpatient
services
Not covered:
Reversal of voluntary sterilization
All
charges All charges
Reconstructive surgery You pay – Standard Option You pay -High Option
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, birthmarks,
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 covered at no charge
(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.
$15 per office visit for
outpatient services
Nothing for inpatient
services
Nothing
$10 per office visit for
outpatient services
Nothing for inpatient
services
Nothing 29
29 Page
30 31
2002 Kaiser Foundation Health
Plan of the Northwest 30 Section 5( b)
Not covered:
Cosmetic surgery – any surgical procedure (or any portion of a
procedure) performed
primarily to improve physical appearance
through change in bodily form
Surgeries related to sex transformation
All charges All charges
Oral and maxillofacial surgery You pay -Standard Option You pay – High
Option
Oral surgical procedures, limited to:
Reduction of fractures
of the jaws 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
Other surgical procedures that do not involve the teeth or their supporting
structures
$15 per office visit for
outpatient services
Nothing for inpatient
services
$10 per office visit for
outpatient services
Nothing for inpatient
services
Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures
(such as the periodontal
membrane, gingiva, and alveolar bone)
All charges All charges 30
30 Page 31 32
2002 Kaiser
Foundation Health Plan of the Northwest 31 Section 5( b)
Organ/ tissue transplants You pay -Standard Option You pay -High
Option
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
Note: We cover related medical and hospital
expenses of the donor when we
cover your
transplant.
$15 per office visit for
outpatient services
Nothing for inpatient
services
$10 per office visit for
outpatient services
Nothing for inpatient
services
Not covered:
Donor screening tests and donor search expenses,
except those performed for the
actual donor
Implants of non-human or artificial organs
Transplants not listed as covered
All charges All charges 31
31 Page 32 33
2002 Kaiser
Foundation Health Plan of the Northwest 32 Section 5( b)
Anesthesia You pay -Standard Option You pay – High Option
Professional services provided in:
Hospital (inpatient)
Hospital
outpatient department
Ambulatory surgical center
Office
Nothing Nothing 32
32 Page
33 34
2002 Kaiser Foundation Health
Plan of the Northwest 33 Section 5( c)
Section 5 (c). Services
provided by a hospital or other facility, and ambulance services
I M
P O
R T
A N
T
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 Section
5( a) or (b).
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital You pay -Standard
Option You pay -High Option
Room and board, such as:
Ward,
semiprivate, or intensive care accommodations
General nursing care
Meals and special diets
NOTE: Your physician may
prescribe private
accommodations 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.
Nothing Nothing 33
33 Page
34 35
2002 Kaiser Foundation Health
Plan of the Northwest 34 Section 5( c)
Inpatient hospital You
pay -Standard Option You pay -High Option
Other hospital services and
supplies, such as:
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
Pre-surgical testing
Costs associated with blood donated by you for a
scheduled covered surgery
Dressings, splints, casts, and sterile tray services
Medical supplies and
equipment, including oxygen
Anesthetics, including nurse anesthetist services
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.
Nothing Nothing
Not covered:
Custodial care
Non-covered facilities,
Personal comfort items, such as telephone, television, barber
services, guest meals and
beds
Private nursing care
Any inpatient dental
procedures
All charges All charges 34
34 Page 35 36
2002 Kaiser
Foundation Health Plan of the Northwest 35 Section 5( c)
Outpatient hospital or ambulatory surgical center You pay -Standard
Option You pay -High Option
Operating, recovery, and other treatment
rooms
Prescribed drugs and medicines
Diagnostic laboratory tests,
X-rays, and pathology services
Administration of blood, and blood products
Blood and blood plasma
Costs associated with blood donated by you for a scheduled covered surgery
Dressings, casts, and sterile tray services
Medical supplies
Anesthetics and anesthesia service
Nothing Nothing
Not covered:
Collection, processing, and storage of blood
donated by donors designated by you or a family
member
All charges All charges
Extended care benefits/ skilled nursing care facility benefits
Up
to 100 days per calendar year when full-time
skilled nursing care is
necessary and confinement
in a skilled nursing facility is medically
appropriate. We cover the following:
Room, board, and general nursing care
Prescribed drugs and their
administration, biologicals, supplies, and equipment ordinarily
provided or arranged by the skilled nursing
facility
Nothing Nothing
Not covered:
Custodial care
Care in an intermediate
care facility
Personal comfort items such as telephone or television
All charges All charges 35
35 Page 36 37
2002 Kaiser
Foundation Health Plan of the Northwest 36 Section 5( c)
Hospice care You pay-StandardOption You pay -High Option
Supportive and palliative care for a terminally ill
member:
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
toCould not acquire words on page 37 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.
Nothing Nothing
Not covered:
Independent nursing
Homemaker services
All charges All charges
Ambulance
Local professional ambulance service when medically
appropriate $25 per transport $25 per transport
Not covered:
Transports that we determine are not medically
necessary
All charges All charges 36
36
Page 37 38
37 Page 38 39
2002 Kaiser Foundation Health Plan of the Northwest
38 Section 5( d)
Benefit Description You pay
Emergency
within our service area You pay-StandardOption You pay – High Option
Emergency care as an outpatient or inpatient at a
hospital,
including physicians'services
At a physician's office
At a Plan urgent care center
In a Plan
hospital emergency room
Note: We waive your copayment if you are
admitted to a Plan hospital.
$15 per visit
$15 per visit
$50 per visit
$10 per visit
$10 per visit
$50 per visit
Emergency care in a non-Plan hospital
emergency room or urgent care
center
$100 per visit $100 per visit
Not covered:
Elective care or non-emergency care
All
charges All charges
Emergency outside our service area
Emergency care as an outpatient
or inpatient at a
hospital, including physicians'services
At a physician's office
At an urgent care center
In a hospital
emergency room
In a Kaiser Foundation hospital in another Kaiser Foundation
Health Plan service area
$100 per visit
$100 per visit
$100 per visit
The amount you would
be charged if you were a
member in that service
area
$100 per visit
$100 per visit
$100 per visit
The amount you
would be charged if
you were a member
in that service area
Note: We waive your copayment if you are
admitted to a hospital.
Note: See the Travel Benefit for coverage of
continuing or follow-up
care.
Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care
could have been
foreseen before leaving the service area
Medical and hospital
costs resulting from a normal full-term delivery of a baby outside
the service area
All charges All charges 38
38 Page 39 40
2002 Kaiser
Foundation Health Plan of the Northwest 39 Section 5( d)
Ambulance You pay -Standard Option You pay – High Option
Professional ambulance service, including air
ambulance, when
medically appropriate. See
Section 5( c) for non-emergency service.
$25 per transport $25 per transport
Not covered:
Transports we determine are not medically
necessary
All charges All charges 39
39
Page 40 41
2002
Kaiser Foundation Health Plan of the Northwest 40 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T
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
Benefit Description You pay
Mental health and substance abuse benefits
You pay -Standard Option You pay – High Option
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
Your cost sharing
responsibilities are no
greater than for other
illnesses or conditions 40
40 Page 41 42
2002 Kaiser
Foundation Health Plan of the Northwest 41 Section 5( e)
Mental health and substance abuse benefits You pay -Standard Option
You pay – High Option
Diagnosis and treatment of psychiatric disorders,
mental illness or disorders of children, adolescents,
and adults.
Services include:
Diagnostic evaluation
Treatment services (including individual and group
therapy visits)
Crisis intervention and stabilization for acute episodes
Psychological
testing necessary to determine the appropriate psychiatric treatment
Medication evaluation and management
Diagnosis and treatment of chemical dependency.
Services include:
Detoxification (medical management of withdrawal from the substance)
Treatment and counseling (including individual and group therapy visits)
Note: Your mental health or substance abuse
provider will develop a
treatment plan to assist you
in improving or maintaining your condition and
functional level, or to prevent relapse.
Note: You may see a Plan outpatient mental health or
chemical dependency
provider without a referral
from your primary care physician.
$15 per office visit $10 per office visit
Inpatient psychiatric care
Inpatient care
Residential treatment
Note: All inpatient admissions and hospital
alternative services
treatment programs require pre-approval
by a Plan physician.
Nothing Nothing
Intensive outpatient psychiatric treatment programs
Note: These services
must be pre-approved by a Plan
physician.
$50 per day up to a
maximum of $250 per
episode or course of
treatment
$50 per day up to a
maximum of $250
per episode or
course of
treatment 41
41 Page
42 43
2002 Kaiser Foundation Health
Plan of the Northwest 42 Section 5( e)
Mental health and
substance abuse benefits You pay -Standard Option You pay – High Option
Not covered:
Care that is not clinically appropriate for
the treatment of your condition
Services we have not approved
Intelligence, IQ, aptitude
ability, 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
Marital, family, or
educational services
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
that
may be present
All charges All charges
Limitation We may limit your benefits if you do not obtain a treatment
plan. 42
42 Page
43 44
2002 Kaiser Foundation Health
Plan of the Northwest 43 Section 5( f)
Section 5 (f).
Prescription drug benefits
I M
P O
R T
A N
T
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
There are important features you
should be aware of. These include:
Who can write your prescription.
A Plan or referral physician, your primary care provider, or licensed
dentist must write the prescription.
Where you can obtain them. You must fill the prescription at a Plan
pharmacy, 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.
These preferred
drugs are included on our formulary. If your physician feels that a
non-formulary drug
is the most appropriate therapy to meet your individual
medical needs, your physician may make an
exception based on one of the
following:
1. You are intolerant of formulary alternatives.
2. You have experienced
treatment failure with formulary alternatives.
3. You are allergic to
formulary alternatives.
4. You are a new member currently using a
non-formulary drug. (A transition period is available
while new members
switch to the formulary alternative.)
5. The non-formulary drug is for a
dosage form or strength used in titrating a dose. (Titration is the
process
of gradually shifting a patient from one dosage level to another.)
These are the dispensing limitations. We provide up to a 30-day
supply. Maintenance medications may be obtained for up to a 90-day supply when
ordered through our mail order program.
Why use generic drugs? The generic name of a drug is its chemical
name; the name brand is the name under which the manufacturer advertises and
sells a drug. Under federal law, generic and name brand
drugs must meet the
same standards for safety, purity, strength, and effectiveness. Generic drugs
cost
you and your plan less money than a name-brand drug.
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. 43
43 Page
44 45
2002 Kaiser Foundation Health
Plan of the Northwest 44 Section 5( f)
Benefit Description You
pay
Covered medications and supplies You pay -Standard Option You pay -High
Option
We cover the following medications and supplies
prescribed by
a Plan physician and obtained from a Plan
pharmacy or through our mail order
program:
Drugs for which a prescription is required by law
Oral contraceptive
drugs
Insulin
Glucose test strips
Disposable needles and syringes
for administration of covered prescribed medications
Smoking cessation drugs and medication, including prescribed nicotine gum and
patches,
when used in conjunction with smoking cessation
programs
Chemotherapy
Certain over-the-counter medications prescribed by a Plan
physician and listed on the Plan's formulary
as the most appropriate treatment for a particular
condition
Diaphragms and cervical caps
Drugs for foreign travel
$15 per prescription or
refill for generic drugs
$30 per prescription or
refill for brand-name
drugs
$10 per prescription or
refill for generic drugs
$20 per prescription or
refill for brand-name
drugs
Intrauterine devices
Implanted time release drugs
Note: We do not
refund any portion of the copayment
if you request removal of the implanted
device or
time-release medication before the end of its expected
life.
$15 for generic drugs or
$30 for brand-name drugs
times the number of
months the device or
medication is expected to
be effective, or 50%
of
our allowance, whichever
is less up to $200
$10 for generic drugs or
$20 for brand-name
drugs times the number
of months the device or
medication is expected
to be effective, or
50%
of our allowance,
whichever is less up to
$200
Injectable contraceptives $15 for generic drugs or $30 for brand-name drugs
times the number of
months the medication is
expected to be
effective,
or 50% of our allowance,
whichever is less
$10 for generic drugs or
$20 for brand-name
drugs times the number
of months the
medication is expected
to be effective, or 50%
of
our allowance,
whichever is less 44
44 Page 45 46
2002 Kaiser
Foundation Health Plan of the Northwest 45 Section 5( f)
Covered medications and supplies You pay -Standard Option You pay
-High Option
Diabetic supplies such as external insulin pumps, infusion
devices, glucose monitors, and diabetic
foot care appliances
Drugs to
treat sexual dysfunction.
Note: These drugs have dispensing limitations.
Contact the Plan for details.
50% of our allowance 50% of our allowance
Amino acid modified products used in the treatment of inborn errors of amino
acid
metabolism (PKU)
Immunosuppressive drugs required after a
transplant
Intravenous fluids and medication for home
Nothing Nothing
Not covered:
Drugs available without a prescription or for
which there is a nonprescription equivalent
available, except those listed on the Plan's
formulary and prescribed
by a Plan physician
Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies
Vitamins and nutritional supplements that can be purchased without a
prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic
performance
Drugs used in the diagnosis and treatment of infertility
Drugs related to non-covered services
Drugs used for weight
management
All charges All charges 45
45 Page 46 47
2002 Kaiser
Foundation Health Plan of the Northwest 46 Section 5( g)
Section 5 (g). Special features
Feature Description
Flexible benefits option 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.
24 hour nurse line For any of your health concerns, 24 hours a day, 7
days a week, you may call from Portland at 503/ 813-2000, or from other areas
call
800/ 813-2000 or our TTY numbers in Oregon at 800/ 735-2900 and in
Washington at 800/ 833-6388, and talk with a registered nurse who
will
discuss treatment options and answer your health questions.
Services for deaf and hearing impaired We provide TTY/ text telephone
numbers -in Oregon at 800/ 735-2900 and in Washington at 800/ 833-6388. Sign
language services are also
available.
Language interpretation Interpreters are available to assist
non-English speaking members. Please see the listing in your Medical Directory.
High risk pregnancies Starring Health Babies was born August 1995 in
response to the need for a comprehensive program to prevent pre-term birth. Our
program
works with you to
Increase the gestational age of newborns and decrease our premature birth
rate though prevention and education.
Decrease the length of stay our infants require in the Neonatal Intensive
Care Unit due to premature birth.
Decrease the amount of time our high-risk
mothers need to spend in the hospital during their pregnancies by helping with
their care
at home.
All pregnant Kaiser Permanente members are screened
at their prenatal
appointments or at an urgent hospital visit. We enroll
those identified
as being high risk for pre-term labor and assign them to
their own case
manager. 46
46 Page 47 48
2002 Kaiser
Foundation Health Plan of the Northwest 47 Section 5( g)
Feature Description
Centers of excellence for transplants The
Centers of Excellence program began in Fall 1987. As new technologies
proliferate and become the standard of care, Kaiser
Permanente refers
members to contracted "centers of excellence" for
certain specialized
medical procedures.
We have developed a network of Centers of Excellence for organ
transplantation, which consists of medical facilities that have met
stringent criteria for quality care in specific procedures. A national
clinical and administrative team has developed guidelines for site
selection, site visit protocol, volume and survival criteria for evaluation
and selection of facilities. The institutions have a record of positive
outcomes and exceptional standards of quality.
Travel benefit 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 and 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 $1200 each calendar year.
For more information
about this benefit call 800/ 390-3509.
File claims as shown on page 55.
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 47
47 Page 48 49
2002 Kaiser Foundation Health Plan of the Northwest
48 Section 5( g)
Feature Description
Services from other
Kaiser Permanente
Plans
When you are visiting in the service area of another Kaiser Permanente
plan, you are entitled to receive virtually all the benefits described in
this
brochure at any Kaiser Permanente medical office or medical center. 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 this Plan.
If you are seeking routine, non-emergent, or non-urgent services, you
should call the Kaiser Permanente Membership 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. 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 Membership Services at
503/
813-2000 or 800/ 813-2000. 48
48 Page 49 50
2002 Kaiser
Foundation Health Plan of the Northwest 49 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T
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 dentally
necessary.
Plan dentists must provide or arrange your care.
We cover
hospitalization for dental procedures at a Plan hospital we designate subject to
pre-authorization 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.
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: You will have to pay $10 for
each missed appointment, unless you notify the dental
office in advance.
I M
P O
R T
A N
T
Dental Benefits
Service You pay -Standard Option You pay -High Option
Members who have elected the High Option Plan
will receive a
comprehensive range of dental
services as described below. All services must
be
prescribed by Plan dentists and provided at Plan
dental offices.
Note: These benefits are not covered under the
standard option. Members
covered under
Standard Option may use Kaiser Dental facilities
only as
appointment access permits.
No benefit See below
Diagnostic services and preventive care
including:
Routine oral examinations
X-rays
Routine teeth cleaning and topical
application of fluoride when prescribed by a Plan dentist,
but not more than two visits in any twelve-month
period
Prescribed space maintainers and habit appliances
All charges $10 per office visit 49
49
Page 50 51
2002
Kaiser Foundation Health Plan of the Northwest 50 Section 5( h)
Service You pay -Standard Option You pay -High Option
Basic
Restorative Services including basic restorative
services resulting from
accidental injury as follows:
Amalgam (silver) restorations in posterior teeth and anterior teeth
Synthetic (plastic, resin and glass ionomer) restorations in all primary
teeth, anterior teeth and
one-surface restorations of posterior permanent
teeth
Stainless steel or plastic crowns when amalgam or synthetic restorative
materials are not
professionally appropriate
If a member requests a procedure or material
in excess of that recommended by a Plan dentist, the
desired procedure or material may be provided
upon payment of charges
that reflect the
additional value of providing the procedure or
material, only if a Plan dentist agrees to perform
the service
Major Restorative Services as follows:
Placement of crowns, inlays, bridge pontics, or other cast metal restoration
when prescribed by a
Plan dentist
If a member requests a procedure or material in excess of
that recommended by a Plan dentist, the
desired procedure or material may be provided
upon payment of charges
that reflect the
additional value of providing the procedure or
material, only if a Plan dentist agrees to perform
the service
Note: We do not cover repair or replacement of
existing cast crowns,
inlays, bridge pontics, or
other cast metal restorations less than five
years
after the date of the most recent placement or
replacement.
All charges $10 per office visit plus
50% of our allowance
Oral Surgery Services as follows:
Diagnosis, evaluation, consultation,
and treatment for removal of teeth (including local anesthesia)
Minor surgical preparation of mouth for insertion of dentures
Surgical
treatment normally performed by a dentist for minor pathological conditions 50
50 Page 51 52
2002 Kaiser Foundation Health Plan of the Northwest
51 Section 5( h)
Service You pay -Standard Option You pay
-High Option
Periodontal Services as follows:
Diagnosis, evaluation,
consultation, and treatment for diseases of tissues supporting the teeth
including all follow-up cleaning visits
All charges $10 per office visit plus
50% of our allowance
Endodontic Services as follows:
Diagnosis, evaluation, consultation, and
treatment for root canal therapy
Prosthetics Appliances as follows:
Diagnosis, evaluation, consultation,
and treatment for removable prosthetics, including full or partial
dentures, relines, and rebases
Note: If the removable appliance cannot be
satisfactorily repaired or adjusted, then we cover a
new prosthetic
appliance only if the existing
appliance is more than 5 years old.
Emergency or Urgent Care
Note: This copayment applies for emergency or
urgent dental care received from a Plan dentist at
Plan dental offices.
Note: All other applicable copayments apply.
All charges $25 per office visit
Out-of-Area Emergency Care
Note: The Plan pays up to $100 for emergency
care
for relief of pain, acute infection, or hemorrhage, or
necessary
treatment (including local anesthesia and
pre-medication) due to injury.
All charges All charges
exceeding $100
Prescription Drugs
Covered under Prescription Drug benefits
Nitrous Oxide
Adults and children over 12 years of age
Children 12
years of age and under
All charges
All charges
$15 per occurrence
Nothing
Nightguards All charges 10% of our allowance 51
51 Page 52 53
2002 Kaiser Foundation Health Plan of the Northwest
52 Section 5( h)
Service You pay -Standard Option You pay
-High Option
Not covered:
Orthodontics
Dental
treatment for problems of the jaw joint, including temporomandibular joint
syndrome/
craniomandibular disorders; or other conditions
of the joint linking
the jaw bone and skull, and of
the complex of muscles, nerves, and other
tissues
related to that joint
Dental implants, including bone augmentation and the fixed or removable
prosthetic devices
attached to or covering the implants; and all
services and materials
relating to the placement
or removal of implants including, but not limited
to, diagnostic consultations, impressions, oral
surgery, and removal of
implants for cleaning;
and dental services related to post-operative
conditions or complications arising from implants
Restorative or reconstructive services for congenital or developmental
malformations
Full mouth reconstructions. This includes appliances, restoration, and
procedures needed to
alter vertical dimension or occlusion, or in
conjunction with alteration of vertical dimension
or occlusion or for
the purpose of splinting teeth
or correcting attrition or abrasion.
Cosmetic dental services, including replacement of cosmetic dental
restoration
Restoration replacement. Clinically acceptable restorations or material
will not be removed or
replaced with alternative materials unless a
pathological condition of the teeth exists
IV sedation
Genetic testing
Replacement of
pre-fabricated, non-cast crowns, including stainless steel crowns, which have
not
been placed by a Kaiser Permanente dentist
Replacement of
removable appliances or night guards which are lost or stolen within 5 years of
the date the member received the appliance
All charges All charges 52
52 Page 53 54
2002 Kaiser
Foundation Health Plan of the Northwest 53 Section 5( i)
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.
Classes to change your lifestyle and keep you healthy At Kaiser
Permanente, we actively encourage you to share responsibility for your health
care. Choices you make
every day, about what you eat and drink, whether you
exercise or smoke, how you handle stress, or whether you wear
a seat belt,
are tied directly to your health. They affect your chances of having a stroke or
a heart attack, getting
cancer, or being at risk for handicapping injuries.
We have developed a wide range of health education and health promotion
classes to help you stay healthy. You can
learn how to kick the smoking
habit for good, effectively manage your weight, improve personal and family
relationships, deal more effectively with a chronic health problem, have a
safe and healthy pregnancy, and much
more. Descriptions of the Non-Dieting
Weight Management and Freedom from Cigarettes classes are shown below.
Over
40 other classes are also offered. Class fees begin as low as $3 per member for
some classes.
Our classes are open to everyone, but we offer them at special reduced rates
to our members. If you would like to
enroll, you must fill out a
registration form. For the latest class catalog, call:
Health Education Membership Services
Portland 503/ 286-6816 Portland 503/
813-2000
8 am – 5 pm, Monday-Friday 8 am – 6 pm, Monday-Friday
Salem
503/ 316-2344 All other areas 800/ 813-2000
Washington 360/ 604-2070 8 am –
6 pm, Monday-Friday
Non-Dieting Weight Management Healthy Weight Kit is an interactive
guide to health weight management. It includes a resource guide, workbook, and
more!
Healthy Weight Kit Class is a 5-week program using the Healthy
Weight Kit.
Freedom from Diets is a 12-week program led by dieticians. It is
a lifestyle approach to weight management,
developed by Kaiser Permanente
researchers.
Freedom from Cigarettes The "cold turkey" approach to stop smoking or
chewing tobacco. Learn the latest and most effective techniques for
kicking
the smoking habit for good. Sessions include:
Relaxation techniques Understanding cigarette addiction
Practicing
effective ways to remain a non-smoker
Freedom from Cigarettes with
Temporary Drug Therapy These classes are designed to provide you with
techniques and support that will increase your chances for lifelong
freedom
from tobacco. The participants must be appropriate for this Program:
Drug
therapy has been proven to be most successfuCould not acquire words on page 56 l
when used in conjunction with a behavior change program. The
medication
treatment is a short-term aid for people committed to learning how to stop
smoking or chewing, and who
have been unsuccessful with other methods.
Your present pharmacy benefit provides coverage for smoking cessation drugs,
nicotine gum, and patches when used
in conjunction with this program.
Benefits on this page are not part of the FEHB contract. 53
53 Page 54 55
2002 Kaiser Foundation Health Plan of the Northwest
54 Section 6
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. 54
54 Page 55 56
2002 Kaiser
Foundation Health Plan of the Northwest 55 Section 7
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:
Medical, hospital, and drug In most cases, providers and facilities
file claims for you. Physicians benefits 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 us from Portland at 503/ 813-2000, or
from other areas
call 800/ 813-2000 or our TTY numbers in Oregon at 800/
735-2900 and
in Washington at 800/ 833-6388.
When you must file a claim – such as for out-of-area care – please
complete the Emergency Care Information (ECI) form and submit it with
the HCFA-1500 or a claim form that includes the information shown
below.
ECI forms may be obtained by calling us from Portland at
503/ 813-2000, or
from other areas call 800/ 813-2000 or our TTY
numbers in Oregon at 800/
735-2900 and in Washington at 800/ 833-6388.
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:
Claims Administration
Kaiser Foundation
Health Plan of the Northwest
500 N. E. Multnomah, Suite 100
Portland,
Oregon 97232-2099
Deadline for filing your claim 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.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 55
55 Page
56 57
56
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2002
Kaiser Foundation Health Plan of the Northwest 57 Section 8
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.
5 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.
6 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 approval, then call us from
Portland at 503/
813-2000, or from other areas call 800/ 813-2000 or our TTY numbers in Oregon at
800/ 735-2900 and in Washington at 800/ 833-6388 and we will expedite our
review; or
(b) We denied your initial request for care or pre-authorization/ prior
approval, 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. 57
57
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2002
Kaiser Foundation Health Plan of the Northwest 58 Section 9
Section 9. Coordinating benefits with other coverage
When you
have other health You must tell us if you are covered or a family member is
covered under coverage 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 is the
primary payer; it pays
benefits first. 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 payer 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.
What is Medicare? 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 The Original Medicare Plan (Original
Medicare) is available everywhere (Part A or Part B) 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
Original
Medicare Plan pays its share and you pay your share. Some things
are not
covered under Original Medicare, like prescription drugs. 58
58 Page 59 60
2002 Kaiser Foundation Health Plan of the Northwest
59 Section 9
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.) 59
59 Page 60 61
2002 Kaiser Foundation Health Plan of the Northwest
60 Section 9
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.
Primary Payer Chart
Then the primary payer is… A. When either you --or
your covered spouse --are age 65 or over and …
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
services)
(for other
services)
6) Are a former Federal employee receiving Workers' Compensation
and the
Office of Workers' Compensation Programs has determined
that you are unable
to return to duty,
(except for claims
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 60
60 Page 61 62
2002 Kaiser Foundation Health Plan of the Northwest 61 Section 9
Medicare managed care plan 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 waive or lower some of our copayments and
coinsurance for
your FEHB and Medicare coverage. If you would like
information about our
Medicare+ Choice plan, please call from Portland
503/ 813-2000 or from other
areas 800/ 813-2000 or our TTY numbers in
Oregon at 800/ 735-2900 and in
Washington at 800/ 833-6388. Your
Kaiser Permanente Senior Advantage-FEHBP
benefits that we lowered
or waived are:
Primary and Specialty care visits such as physical exams, allergy testing and
injections, respiratory therapy, radiation therapy, same-day
outpatient surgery, gynecological visits, hearing and vision
exams, and
manual manipulation of the spine: $0
Dialysis: $0
Hospital care: $0
Durable medical equipment: $0
Family planning: $0
Home health care: $0
Hospice care: $0
House
calls: $0
Medical social services: $0
Mental health and substance abuse:
inpatient and outpatient services (residential/ day treatment does have a
copay): $0
Physical, occupational and speech therapy, and rehabilitation services: $0
Prosthetic and orthotic devices, ostomy, and urological supplies: $0
Reconstructive therapy: $0
Skilled Nursing Facility care: up to 100 days
per benefit period: $0
Transplants: $0
Vision exams: $0 X-ray, lab
tests, and other special procedures: $0
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 lower or
waive any of our copayments or coinsurance. If you
enroll in a Medicare
managed care plan, tell us. We will need to know 61
61
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2002
Kaiser Foundation Health Plan of the Northwest 62 Section 9
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 If you enroll in Medicare Part B, we require
you to assign your Medicare Part B Part B benefits to the Plan for its
services.
If you do not enroll in If you do not have one or both Parts of
Medicare, you can still be Medicare Part A or Part B 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 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.
Workers' Compensation 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.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State, are responsible for your care or Federal Government
agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for medical or hospital care for injuries 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. 62
62 Page 63 64
2002 Kaiser
Foundation Health Plan of the Northwest 63 Section 10
Section
10. Definitions of terms we use in this brochure
Calendar year 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 Coinsurance is the percentage of our allowance that you
must pay for your care.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services.
Covered services Care we provide benefits for, as described in this
brochure.
Custodial care (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.
Deductible 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.
Durable medical equipment 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.
Experimental or investigational services 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.
Group health coverage 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." 63
63 Page 64 65
2002 Kaiser Foundation Health Plan of the Northwest
64 Section 10
Medically necessary 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.
Our allowance 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/ We Us and we refer to Kaiser Foundation Health Plan of the
Northwest.
You You refers to the enrollee and each covered family
member. 64
64 Page
65 66
2002 Kaiser Foundation Health Plan of the Northwest 65 Section 11
Section 11. FEHB facts
No pre-existing condition We will not
refuse to cover the treatment of a condition that you had limitation
before you enrolled in this Plan solely because you had the condition
before you enrolled.
Where you get information See www. opm. gov/ insure. Also, your employing
or retirement office about enrolling in the can answer your questions,
and give you a Guide to Federal Employees
FEHB Program 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.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for
for you and your family 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. 65
65 Page
66 67
2002 Kaiser Foundation Health
Plan of the Northwest 66 Section 11
When benefits and The
benefits in this brochure are effective on January 1. If you joined premiums
start 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.
Your medical and claims We will keep your medical and claims
information confidential. Only records are confidential 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 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).
When you lose benefits
When FEHB coverage ends 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.
Spouse equity 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.
Temporary continuation of If you leave Federal service, or if you lose
coverage because you no coverage (TCC) 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. 66
66 Page 67 68
2002 Kaiser Foundation Health Plan of the Northwest 67 Section 11
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.
Converting to You may convert to a non-FEHB individual policy if:
Individual Coverage
Your coverage under TCC or the spouse equity law
ends (if you canceled
your coverage or did not pay your premium, you cannot
convert);
You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If
you leave Federal service, your employing office will notify you 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. Conversion to an individual dental plan is
not available.
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.
Getting a Certificate of The Health Insurance Portability and
Accountability Act of 1996 Group Health Plan Coverage (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. 67
67 Page 68 69
2002 Kaiser Foundation Health Plan of the Northwest 68 Long Term
Care Insurance
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:
What is long term care It's insurance to help pay for long term care
services you may need (LTC) insurance? 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.
I'm healthy. I won't need Welcome to the club!
long term care.
Or, will I? 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.
Is long term care expensive? 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.
But won't my FEHB plan, Not FEHB. Look at the "Not covered"
blocks in sections 5( a) and 5( c) Medicare or Medicaid cover of your
FEHB brochure. Health plans don't cover custodial care or a
my long term
care? 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.
When will I get more information Employees will get more information
from their agencies during the on how to apply for this new LTC open
enrollment period in the late summer/ early fall of 2002.
insurance
coverage? Retirees will receive information at home.
How can I find
out more about the Our toll-free teleservice center will begin in mid-2002.
In the program NOW? meantime, you can learn more about the program on our
website at
www. opm. gov/ insure/
ltc.
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. 68
68 Page 69 70
2002 Kaiser Foundation Health Plan of the Northwest
69 Index
Index
Do not rely on this page; it is for
your convenience and may not show all pages where the terms appear.
Accidental injury 50 Allergy tests 19
Alternative treatment 26
Ambulance 39
Anesthesia 32 Autologous bone marrow
transplant 31
Biopsies 28 Blood and blood plasma 34
Breast cancer screening 16 Casts 28
Centers of excellence for
transplants 47
Changes for 2002 9 Chemotherapy 20
Chiropractic 26
Cholesterol tests 16
Coinsurance 63 Colorectal cancer screening 16
Congenital anomalies 28 Contraceptive devices and drugs 18
Coordination
of benefits 58 Covered providers 10
Deaf and hearing impaired service 46
Deductible 63 Dental care 49
Diagnostic services 16 Disputed claims review 56
Donor expenses
(transplants) 31 Dressings 34
Durable medical equipment (DME) 25
Educational classes and programs 53 Effective date of enrollment 66
Emergency 37 Experimental or investigational 63
Eyeglasses 21
Family planning 18 Fecal occult blood test 16
Flexible benefits options 46
General Exclusions 54
Hearing
services 21 Home health services 26
Hospice care 36 Hospital 33
Immunizations 17 Infertility 19
Inpatient Hospital Benefits 33
Insulin 44
Laboratory and pathological services 16
Magnetic Resonance
Imagings (MRIs) 16
Mail Order Prescription Drugs 43 Mammograms 16
Maternity Benefits 18 Medicaid 62
Medically necessary 64 Medicare 58
Mental Conditions/ Substance Abuse Benefits 40
Newborn care 18 Non-FEHB Benefits 53
Nursery charges 18
Obstetrical care 18 Occupational therapy 20
Oral and maxillofacial surgery 30 Orthopedic devices 24
Out-of-pocket
expenses 13 Oxygen 34
Pap test 16 Physical examination 16
Physical therapy 20
Prescription drugs 43
Preventive care, adult 16 Preventive care, children 17
Preventive
services 16 Prior approval 12
Prostate cancer screening 16 Prosthetic
devices 24
Psychotherapy 40
Radiation therapy 20 Renal dialysis
20
Room and board 33
Second surgical opinion 15 Services from other
Kaiser
Permanente Plans 48 Skilled nursing facility care 35
Smoking cessation 44
and 53 Speech therapy 20
Splints 34 Sterilization procedures 29
Subrogation 62 Substance abuse 40
Surgery 28
Anesthesia 32 Oral 30
Outpatient 35 Reconstructive 29
Syringes 44
Temporary continuation of coverage 66
Transplants 31 Travel benefit 47
Treatment therapies 20
Vision
services 21
Well child care 17 Workers' compensation 62
X-rays 16
24 hour nurse line 46 69
69 Page 70 71
2002 Kaiser Foundation Health Plan of the Northwest
70 Summary
Summary of benefits for Kaiser Foundation Health
Plan of the Northwest – Standard Option – 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................. $15 per office visit 15
Services provided by a hospital:
Inpatient............................................................................................
Outpatient
.........................................................................................
Nothing
Nothing
33
35
Emergency benefits:
In-area
.............................................................................................
Out-of-area
......................................................................................
$50 per visit
$100 per visit
38
38
Mental health and substance abuse treatment:
................................. Regular cost sharing 40
Prescription
drugs............................................................................
$15 per prescription or refill for generic drugs
$30 per prescription or refill for
brand-name drugs
44
Dental
Care.......................................................................................
No current benefit NA
Vision
Care.......................................................................................
Refractions; $15 per office visit 21
Special features: Flexible benefits
option; 24 hour nurse line; Services for deaf and hearing impaired;
Language
interpretation; High risk pregnancies; Centers of excellence for transplants;
Travel benefit;
Services from other Kaiser Permanente Plans
46
Protection against catastrophic costs
(your out-of-pocket maximum)
........................................................
Nothing
after $600/ Self Only or
$1200/ Family enrollment per year
Some costs do not count toward
this protection
13 70
70 Page
71 72
2002 Kaiser Foundation Health
Plan of the Northwest 71 Summary
Summary of benefits for
Kaiser Foundation Health Plan of the Northwest – High Option – 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 15
Services provided by a hospital:
Inpatient............................................................................................
Outpatient
.........................................................................................
Nothing
Nothing
33
35
Emergency benefits:
In-area
.............................................................................................
Out-of-area
......................................................................................
$50 per visit
$100 per visit
38
38
Mental health and substance abuse treatment:
................................. Regular cost sharing 40
Prescription
drugs............................................................................
$10 per prescription or refill for generic drugs
$20 per prescription or refill for
brand-name drugs
44
Dental
Care.......................................................................................
Various copays based on
procedure rendered
49
Vision
Care.......................................................................................
Refractions; $10 per office visit 21
Special features: Flexible benefits
option; 24 hour nurse line; Services for deaf and hearing impaired;
Language
interpretation; High risk pregnancies; Centers of excellence for transplants;
Travel benefit;
Services from other Kaiser Permanente Plans
46
Protection against catastrophic costs
(your out-of-pocket maximum)
........................................................
Nothing
after $600/ Self Only or
$1200/ Family enrollment per year
Some costs do not count toward
this protection
13 71
71 Page
72
2002 Rate Information for
Kaiser Foundation Health
Plan of the Northwest
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, 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 Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your
Share
High Option
Self Only 571 $97.86 $36.24 $212.03 $78.52 $115. 52 $18.58
High Option
Self and Family 572 $223.41 $84.34 $484.06 $182.73 $263.
75 $44.00
Standard Option
Self Only 574 $90.00 $30.00 $195.00 $65.00 $106. 50
$13.50
Standard Option
Self and Family 575 $206.55 $68.85 $447.53 $149.17
$244. 42 $30.98 72