Pages 1--72 from Kaiser Foundation Health Plan, Inc.-Hawaii Region

2002
A Health Maintenance Organization
Serving: Islands of Kauai, Maui, Oahu, and Hawaii (except for zip codes 96718, 96772, and 96777)

Enrollment in this Plan is limited. You must live in our Geographic service area to enroll. See page 8 for requirements.

This Plan has excellent
accreditation from the NCQA.
See the 2002 Guide for more
information on accreditation.

Enrollment codes for this Plan:
631 High Option Self Only 632 High Option Self and Family
634 Standard Option Self Only 635 Standard Option Self and Family

Authorized for distribution by the:
RI 73-005

For changes
in benefits
see page 9 1
1 Page 2 3
2
2 Page 3 4
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 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 ...................................................................................................... 11

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 .................................................................................................................. 14

Copayments.......................................................................................................................................... 14
Deductible ............................................................................................................................................ 14
Coinsurance.......................................................................................................................................... 14
Fees when you fail to make your copayment or coinsurance .............................................................. 14
Your catastrophic protection out-of-pocket maximum for copayments and coinsurance.......................... 14

Section 5. Benefits ...................................................................................................................................................... 15
Overview .................................................................................................................................................... 15
(a) Medical services and supplies provided by physicians and other health care professionals ........ 16
(b) Surgical and anesthesia services provided by physicians and other health care professionals .... 29
(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 .................................................................................. 39
(f) Prescription drug benefits .............................................................................................................. 42
(g) Special features .............................................................................................................................. 45 3
3 Page 4 5
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 3 Table of Contents

Services from other Kaiser Permanente Plans .................................................................................... 45
Interpretive services ............................................................................................................................ 45
24 hour advice line .............................................................................................................................. 45
Travel benefit ...................................................................................................................................... 46
Travel assistance .................................................................................................................................. 47
(h) Dental benefits ................................................................................................................................ 48

Section 6. General exclusions things we don't cover .............................................................................................. 50
Section 7. Filing a claim for covered services ............................................................................................................ 51
Medical, hospital, and drug benefits .......................................................................................................... 51
Deadline for filing your claim.................................................................................................................... 51
When we need more information .............................................................................................................. 51
If you have a malpractice claim ................................................................................................................ 52
Section 8. The disputed claims process ...................................................................................................................... 53
Section 9. Coordinating benefits with other coverage ................................................................................................ 55
When you have other health coverage........................................................................................................ 55

What is Medicare? .............................................................................................................................. 55
The Original Medicare Plan (Part A or Part B) .................................................................................. 55
Medicare managed care plan .............................................................................................................. 58
If you enroll in Medicare Part B.......................................................................................................... 59
If you do not enroll in Medicare Part A or Part B .............................................................................. 59
TRICARE .................................................................................................................................................. 59

Workers' Compensation.............................................................................................................................. 60
Medicaid .................................................................................................................................................... 60
When other Government agencies are responsible for your care .............................................................. 60
When others are responsible for injuries.................................................................................................... 60
Section 10. Definitions of terms we use in this brochure ............................................................................................ 61
Section 11. FEHB facts ................................................................................................................................................ 63
Coverage information ................................................................................................................................ 63

No pre-existing condition limitation.................................................................................................... 63
Where you get information about enrolling in the FEHB Program .................................................... 63
Types of coverage available for you and your family .......................................................................... 63
When benefits and premiums start ...................................................................................................... 64
Your medical and claims records are confidential .............................................................................. 64
When you retire.................................................................................................................................... 64
When you lose benefits .............................................................................................................................. 64

When FEHB coverage ends ................................................................................................................ 64
Spouse equity coverage........................................................................................................................ 64
Temporary Continuation of Coverage (TCC) ...................................................................................... 64 4
4 Page 5 6
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 4 Table of Contents

Converting to individual coverage .......................................................................................................... 65
Getting a Certificate of Group Health Plan Coverage ............................................................................ 65
Long term care insurance is coming later in 2002 ........................................................................................................ 66

Index .............................................................................................................................................................................. 67
Summary of benefits ...................................................................................................................................................... 68
Rates ................................................................................................................................................................ Back cover 5
5 Page 6 7
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 5 Introduction/ Plain Language/ Advisory

Introduction
Kaiser Foundation Health Plan, Inc., Hawaii Region
711 Kapiolani Boulevard
Honolulu, Hawaii 96813

This brochure describes the benefits of Kaiser Foundation Health Plan, Inc., Hawaii Region under our contract
(CS 1060) 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, Inc., Hawaii Region.

We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve this brochure, let us know. Visit OPM's "Rate Us"
feedback area at www.opm.gov/insure or e-mail us at fehbwebcomments@opm.gov. You may also write to OPM at
the Office of Personnel Management, Office of Insurance Planning and Evaluation, 1900 E Street NW, Washington,
DC 20415. 6
6 Page 7 8
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 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 at 808/432-5955 or 800/966-5955 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. 7
7 Page 8 9
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 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 plans benefits, not because a particular provider is available.
You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/or remain under contract with us.

How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. Plan
providers accept a negotiated payment from us, and you will only be responsible for your copayments or coinsurance.

Your Rights
OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information
about us, our networks, providers, and facilities. OPMs 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.

Non-profit group practice, federally qualified health maintenance organization
This Plan is part of the Kaiser Permanente Medical Care Program, a group of non-profit organizations and contracting medical groups that serve over 8 million members nationwide

44 years in existence
Our three entities Kaiser Foundation Health Plan, Inc., Kaiser Foundation Hospitals, and Hawaii Permanente Medical Group, Inc. (HPMG) work together to provide you with a full range of medical care, benefits, and

services
We credential Plan providers according to national standards
Our Moanalua Medical Center is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

If you want more information about us, call the Plans Customer Service Center on Oahu at 808/432-5955, or on
Kauai, Maui or Hawaii at 800/966-5955 or 808/432-7032 TTD, or write to the Health Plan office at 711 Kapiolani
Blvd., Tower Bldg., Suite 400, Honolulu, Hawaii 96813. You may also contact us by fax at 808/432-5300 or visit
our website at http://www.kaiserpermanente.org/hawaii. 8
8 Page 9 10
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 8 Section 1

Service Area
To enroll in this Plan, you must live in our service area. This is where our providers practice. Our service area is:
The Islands of Oahu, Kauai, Maui
The Island of Hawaii (except zip codes 96718, 96772, and 96777).

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 46; 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. 9
9 Page 10 11
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 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 decrease by 7% for Self Only or increase 2.3% for Self and Family under the High Option and will increase by 2.7% for Self Only or 2.7% for Self and Family under the Standard

Option.
We provide injectable travel immunizations for adults and children at 50% of our allowance for both High and Standard Options.

We provide up to 20 combined visits of chiropractic and acupuncture services at $10 per office visit for High Option and $15 per office visit for Standard Option.
We provide chiropractic appliances up to $50 per calendar year, for both High and Standard Options.
We provide Traditional Chinese Herbal Supplements at $5 per bottle up to $200 per member for both High and Standard Options.

We provide outpatient hospital or ambulatory surgical center services at $10 per surgery for High Option and $15 per surgery for Standard Option.
We provide emergency services within our service area at $25 per visit for both High and Standard Options.
We provide diabetes equipment (and supplies to operate the equipment) at 50% of our allowance for both High and Standard Options. Control solutions now require a 50% copay, rather than the $7 per prescription copay.

We provide oral travel immunizations for adults and children at $7 per prescription for both High and Standard Options.
A travel assistance benefit has been added that will provide you with assistance in locating hospitals, physicians, and other health care providers that would be responsive to your medical needs while you travel.
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. 10
10 Page 11 12
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 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 fill a prescription
at a Plan pharmacy. Until you receive your ID card, use your copy of the
Health Benefits Election Form, SF-2809, your health benefits enrollment
confirmation (for annuitants), or your Employee Express confirmation
letter.

If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at 808/432-
5955 on Oahu, or at 800/966-5955 on Kauai, Maui or Hawaii.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments and coinsurance. You will not have to file claims,
except for emergency, urgent care services outside our service area and
for covered services while you travel.

Plan providers Plan providers are physicians and other health care professionals in our
service area that we contract with to provide covered services to our
members. We contract with the Hawaii Permanente Medical Group, an
independent multi-specialty group of physicians ("Plan physicians"), to
provide or arrange all necessary physician care for you. These
physicians are members of American Specialty Boards or are Board
eligible. Your medical care is provided through physicians, nurse
practitioners, physician assistants, and other skilled medical personnel
working as medical teams at our facilities. Specialists in most major
specialties are available as part of the medical teams for consultation and
treatment. Services such as physical therapy, laboratory, and X-ray
services are available to you at our facilities. Plan physicians can also
arrange any necessary specialty care for you. Hospital care is provided to
you through the Kaiser Permanente Moanalua Medical Center on Oahu
and several local community hospitals on the Neighbor Islands. Dental
services are provided by Hawaii Dental Service.

We list Plan providers in the provider directory, which we update
periodically. The list is also on our website at
www.kaiserpermanente.org/hawaii.

Plan facilities Plan facilities are hospitals and other facilities in our service area that we
contract with to provide covered services to our members. We offer
comprehensive health care at 23 Plan facilities conveniently located on
the Islands of Oahu, Kauai, Maui and Hawaii; and through specialists,
hospitals and other providers in the community following an authorized
referral.

We list Plan facilities in our provider directory, which we update
periodically. The list is also on our website at
www.kaiserpermanente.org/hawaii.

You must receive your health care services at Plan facilities, except if
you have an emergency. If you are visiting another Kaiser Permanente
service area, you may receive health care services from those Kaiser
Permanente facilities. Your travel benefit allows you to receive follow-
up or continuing care while you travel anywhere. 11
11 Page 12 13
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 11 Section 3

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.
Choose your primary care physician from this Plans provider directory.
It lists Plan facilities and services available at each facility with their
locations and phone numbers. Directories are updated on a regular basis
and are available at the time of enrollment or upon request by calling our
Customer Service Center on Oahu at 808/432-5955, or on Kauai, Maui,
or Hawaii at 800/966-5955.

Primary care Your primary care physician can be a family practitioner, internist or
pediatrician. 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
and will obtain the necessary authorization. The referral will describe the
services you will receive. 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. If your specialist
recommends additional visits or services, your primary care physician
will review the recommendation and authorize the visits or services, as
appropriate. Do not go to the specialist for return visits unless your
primary care physician and Plan gives you a referral. A woman may see
her gynecologist without a referral. You may also receive vision care
and mental health and substance abuse 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 arrange for you to see your specialist. Your specialist will
develop a treatment plan for a certain number of visits without
additional referrals.

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: 12
12 Page 13 14
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 12 Section 3

terminate our contract with your specialist for other than cause; or
drop out of the Federal Employees Health Benefits (FEHB)
Program and you enroll in another FEHB plan; or

reduce our service area and you enroll in another FEHB plan,
you may be able to continue seeing your specialist for up to 90 days after
you receive notice of the change. Contact us, or if we drop out of the
Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose
access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care, even
if it is beyond the 90 days.

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 Customer Service Center immediately at 808/432-5955 on Oahu, or
on Kauai, Maui, or Hawaii at 800/966-5955. 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 Your primary care physician has authority to refer you for most services.
our prior approval For certain services, however, your physician must obtain approval from us. Before giving approval, we consider if the service is covered,

medically necessary, and follows generally accepted medical practice.
We call this review and approval process prior authorization. Your
physician must obtain approval for services which include, but are not
limited to: transplants, in vitro fertilization, hospice, referrals to facilities
outside of Hawaii, air ambulance to facilities outside of Hawaii, and care
delivered by a non-Plan physician. 13
13 Page 14 15
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 13 Section 3

Requests for these services are made to your primary care physician just
like any other referral. Your primary care physician submits the request,
with supporting documentation. If your request is not approved, you
have a right to appeal by calling 808/432-5955 on Oahu or 800/966-5955
on Kauai, Maui, or Hawaii. If you wish additional services, you must
make the request to your primary care physician.

Emergency services do not require prior authorization. However, you or
your family member must notify the Plan within 48 hours, or as soon as
is reasonably possible or your claim may be denied. 14
14 Page 15 16
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 14 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 (High Option) or $15
(Standard Option) per office visit.

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 20% of our
allowance for in vitro fertilization.

Fees when you fail to If you do not pay your copayment or coinsurance at the time you receive make your copayment services, we will bill you. You will be required to pay a $15 charge for
or coinsurance each bill sent for unpaid services.

Your catastrophic protection After your copayments and coinsurance total $1,000 per person or $3,000
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 and coinsurance for the following services do not count toward your out-of-pocket maximum, and

you must continue to pay copayments and coinsurance for these services:

Drugs and contraceptive devices
Diabetes equipment and supplies to operate the equipment
Dental services
Blood
$25 charges paid for follow-up or continuing care
Any non-FEHB benefits

Be sure to keep accurate records of your copayments and coinsurance since
you are responsible for informing us when you reach the maximum. 15
15 Page 16 17
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 15 Section 5

Section 5. Benefits -OVERVIEW
(See page 9 for how our benefits changed this year and pages 68 and 69 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at
the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact
us at 808/432-5955 on Oahu, or at 800/966-5955 on Kauai, Maui, or Hawaii or at our website at
http://www.kaiserpermanente.org/hawaii.

(a) Medical services and supplies provided by physicians and other health care professionals...............................16-28

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 ...........................29-32

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.................................................................................................. 37-38

Emergency within our service area
Emergency outside our service area
Ambulance

(e) Mental health and substance abuse benefits .......................................................................................................... 39-41
(f) Prescription drug benefits....................................................................................................................................... 42-44
(g) Special features ....................................................................................................................................................... 45-47
Services from other Kaiser Permanente Plans Travel benefit
Interpretive services Travel assistance
24 hour advice line

(h) Dental benefits ........................................................................................................................................................ 48-49
Summary of benefits ...................................................................................................................................................... 68-69 16
16 Page 17 18
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 16 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: You pay only $5 under our Standard Option and we waive the $10 charge under our High Option if you enroll in our Medicare+Choice Plan and assign your Medicare benefits

to the Plan.

I
M
P
O
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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 medical office
Initial examination of a newborn child covered under a family enrollment

Office medical consultations
Second surgical opinion

In an urgent care center

$15 per office visit $10 per office visit

During a hospital stay
In a skilled nursing facility (up to 100 days per benefit period)
Nothing Nothing

Not covered:
House calls by physicians
All charges All charges 17
17 Page 18 19
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 17 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

50% of charges Nothing

Preventive care, adult
Routine screenings, such as:
Total blood cholesterol
Fecal occult blood test
Prostate Specific Antigen (PSA test) -one annually for men age 40 and older

Routine pap test
Note: You should consult with your physician to
determine what is appropriate for you.

Routine mammogram covered for women age 35
and older, as follows:

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

50% of charges Nothing

Colorectal cancer screening, including
sigmoidoscopy screening -every five years
starting at age 50

Note: You should consult with your physician to
determine what is appropriate for you.

$15 per office visit $10 per office visit 18
18 Page 19 20
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 18 Section 5( a)

Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster once every 10 years, ages 19 and over (except as provided for

under Childhood immunizations)
Influenza/Pneumococcal vaccines, annually, age 65 and over

Nothing Nothing

Injectable travel immunizations
Note: You will also pay the office visit copayment
when you receive your immunization.

Note: We cover oral travel immunizations under the
prescription drug benefit.

50% of our allowance 50% of our allowance

Not covered:
Physical exams required for:
Obtaining or continuing employment
Insurance
Attending schools
Travel

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 through age 17 to determine the
need for vision correction

Ear exams through age 17 to determine the
need for hearing correction

Examinations done on the day of
immunizations (up to age 22)

Well-child care for routine examinations up to age 22

$15 per office visit $10 per office visit 19
19 Page 20 21
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 19 Section 5( a)

Injectable travel immunizations
Note: You will also pay the office visit copayment
when you receive your immunization.

Note: We cover oral travel immunizations under the
prescription drug benefit.

50% of our allowance 50% of our allowance

Not covered:
Physical exams required for:
Obtaining or continuing employment
Insurance
Attending schools and camp
Travel

All charges All charges

Maternity care You pay -Standard Option You pay -High Option
After confirmation of pregnancy, complete
maternity (obstetrical) care, such as:

Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:

You do not need to precertify your normal delivery.

You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a
cesarean delivery. We will extend your
inpatient stay if medically necessary.

We cover routine nursery care of the newborn child during the covered portion of the

mothers 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 page 34 for hospital benefits and page 29
for surgery benefits.

Nothing Nothing

Not covered:
Routine sonograms to determine fetal age, size, or sex
All charges All charges 20
20 Page 21 22
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 20 Section 5( a)

Family planning You pay -Standard Option You pay -High Option
A broad range of voluntary family planning
services, limited to:

Family planning services, including counseling

Voluntary sterilization
Surgically implanting contraceptives
Injection of contraceptive drugs
Insertion of intrauterine devices (IUDs)
Note: We cover contraceptive drugs and devices
under the prescription drug benefit.

$15 per office visit $10 per office visit

Not covered:
Reversal of voluntary surgical sterilization
Genetic counseling

All charges All charges

Infertility services
Diagnosis and treatment of involuntary infertility,
such as:

Artificial insemination:
Intravaginal insemination (IVI)
Intracervical insemination (ICI)
Intrauterine insemination (IUI)

$15 per office visit $10 per office visit

One in vitro fertilization (IVF) procedure per
lifetime (for females who qualify under Hawaii
law)

Note: We cover drugs used to treat involuntary
infertility and in vitro fertilization under the
prescription drug benefit, and laboratory tests
under the laboratory benefit.

20% of charges 20% of charges 21
21 Page 22 23
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 21 Section 5( a)

Not covered:
These exclusions apply to fertile as well as
infertile individuals or couples:

Assisted reproductive technology (ART) procedures, such as embryo transfer, GIFT,

and ZIFT
Services and supplies related to excluded ART procedures

Cost of donor sperm and donor egg and services related to their procurement,
processing, and storage
Infertility service when either member of the family has been voluntarily sterilized

All charges All charges

Allergy care You pay -Standard Option You pay -High Option
Testing and treatment
Allergy injection
$15 per office visit $10 per office visit

Allergy serum Nothing Nothing
Not covered:
Provocative food testing
Sublingual allergy desensitization

All charges All charges

Treatment therapies
Chemotherapy and radiation therapy
Note: We limit high dose chemotherapy in
association with autologous bone marrow
transplants to those transplants listed under
Organ/Tissue Transplants.

Respiratory and inhalation therapy
Dialysis
Intravenous (IV)/Infusion Therapy Home IV and antibiotic therapy

Growth hormone therapy (GHT)
Note: We cover GHT drugs under the
prescription drug benefit.

$15 per office visit $10 per office visit

Not covered:
Chemotherapy supported by a bone marrow transplant or with stem cell support, for any

diagnosis not listed as covered

All charges All charges 22
22 Page 23 24
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 22 Section 5( a)

Physical and occupational therapies You pay -Standard Option You pay -High Option
Up to two consecutive months of therapy per
condition if significant improvement can be
expected within that period:

Physical therapy by qualified physical therapists to restore bodily function when you

have a total or partial loss of bodily function
due to illness or injury

Occupational therapy by occupational therapists to assist you in achieving and

maintaining self-care and improved
functioning in other activities of daily life

$15 per outpatient visit
Nothing for inpatient
$10 per outpatient visit
Nothing for inpatient

Not covered:
Long-term physical therapy or occupational therapy

Exercise programs
Cardiac rehabilitation
Occupational therapy supplies

All charges All charges

Speech therapy
Up to two consecutive months of therapy per
condition:

Speech therapy by speech therapists when medically necessary

$15 per outpatient visit
Nothing for inpatient
$10 per outpatient visit
Nothing for inpatient

Not covered:
Speech therapy that is not medically necessary
such as:

Therapy for educational placement or other educational purposes

Training to improve fluency or modify dialect
Voice therapy for occupation or performing arts

Therapy supplies

All charges All charges

Hearing services (testing, treatment,
and supplies)

Hearing testing for adults to determine the need for hearing correction

Hearing testing for children through age 17
$15 per office visit $10 per office visit 23
23 Page 24 25
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 23 Section 5( a)

Not covered:
Hearing aids, testing, and examinations for them

All other hearing testing

All charges All charges

Vision services (testing, treatment, and
supplies)
You pay -Standard Option You pay -High Option

Diagnosis and treatment of diseases of the eye
Eye exam for children to determine the need for vision correction through age 17 (see page

18, Preventive care, children)
Eye refractions (for a written lens prescription for eyeglasses, but not for contact lenses)

$15 per office visit $10 per office visit

Not covered:
Eyeglasses
Contact lenses
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery such as lasik

All charges All charges

Foot care
No benefit, except for diabetes All charges All charges

Orthopedic and prosthetic devices
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: We cover surgery necessary to insert the
device.

Nothing Nothing 24
24 Page 25 26
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 24 Section 5( a)

Not covered:
Comfort, convenience, or luxury equipment or features

Orthopedic devices and corrective shoes
Braces and splints
Durable medical equipment
External prosthetic devices, except as listed above

Prosthetic devices and supplies related to sexual dysfunction
Arch supports
Foot orthotics
Take home items
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
Glucose meter (and control solutions)
External insulin pump
Supplies necessary to operate these items
Note: These items are covered only when
obtained through sources designated by the Plan

50% of our allowance 50% of our allowance

Not covered:
All other durable medical equipment
All charges All charges 25
25 Page 26 27
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 25 Section 5( a)

Home health services You pay -Standard Option You pay -High Option
Services ordered by a physician to homebound
members residing in the service area:

Nursing
Physical therapy, speech therapy, occupational
therapy

Medical social services and home health aide
when related to physical therapy, speech
therapy, or occupational therapy

Medical supplies included in the plan of care
Note: We cover IV therapy and medications under
the prescription drug benefit.

$15 per visit $10 per visit

Not covered:
Nursing care requested by you or your family for you or your family's convenience

Home care primarily for personal assistance
that does not include a medical component
and is not diagnostic, therapeutic, or
rehabilitative

Care that your physician determines can be appropriately provided in the medical office,

hospital, or skilled nursing facility
Prosthetics, durable medical equipment, supplies, and drugs (not part of home infusion

program)
Personal care items
Services outside our service areas

All charges All charges

Chiropractic
Up to a maximum of 20 combined chiropractic
and acupuncture visits per calendar year:

Chiropractic services for the treatment or diagnosis of neuromusculo-skeletal disorders

Adjunctive therapy as set forth in a treatment plan approved by the ASHN
X-rays
Note: Services must be performed by and received
from Participating Chiropractors of American
Specialty Health Networks (ASHN). Contact
Kaiser Permanente Customer Service at 808/432-
5955 on Oahu, and 800/966-5955 on Neighbor
Islands.

$15 per office visit $10 per office visit 26
26 Page 27 28
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 26 Section 5( a)

Chiropractic appliances when prescribed by a
participating chiropractor and authorized by ASHN.

Note: We pay no more than $50 per calendar
year. When the $50 maximum is reached, the
Member must pay the full retail price for all
chiropractic appliances for the remainder of the
calendar year.

All charges over $50 All charges over $50

Not covered:
Any services or treatment not authorized by ASHN, except for an initial examination

Services related to the chiropractic treatment that is performed or prescribed by a Plan
physician

All charges All charges

Alternative treatments You pay -Standard Option You pay -High Option
Up to a maximum of 20 combined chiropractic
and acupuncture visits per calendar year:

Acupuncture services for the treatment or diagnosis of neuromusculo-skeletal disorders,

nausea or pain syndromes
Adjunctive therapy as set forth in a treatment plan approved by the ASHN

Note: Services must be performed by and
received from Participating Acupuncturists of
American Specialty Health Networks (ASHN).
Contact Kaiser Permanente Customer Service at
808/432-5955 on Oahu, and 800/966-5955 on
Neighbor Islands.

$15 per office visit $10 per office visit

Traditional Chinese Herbal Supplements (TCHS)
which are recommended by a participating
acupuncturist, authorized by ASHN, and are
distributed through the ASHN mail order distribution
program.

Note: There is a $200 maximum which is based
upon the full retail price of the TCHS less the $5
copayment. When the $200 maximum is reached,
the Member must pay the full retail price for the
TCHS for the remainder of the calendar year.

$5 per bottle, or
All charges after we have
paid the $200 coverage
maximum

$5 per bottle, or
All charges after we have
paid the $200 coverage
maximum 27
27 Page 28 29
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 27 Section 5( a)

Not covered:
Any services or treatment not authorized by ASHN, except for an initial examination

Services related to the acupuncture treatment that is performed or prescribed by a Plan
physician
Other alternative treatments such as naturopathic services, hypnotherapy, and

biofeedback
All other forms of alternative treatment

All charges All charges

Educational classes and programs You pay -Standard Option You pay -High Option
Our Health Education Department and Lifestyle
Program offers a wide variety of classes to
members and the public. Participants can learn
how to take charge of their own health and well-
being, manage their chronic conditions, give up
unhealthy habits, and make positive, health
enhancing changes in their lifestyle.

Patient education classes, such as:
Cholesterol Classes
Living and Learning with Diabetes
Osteoporosis Group Education Clinic
Quit Smoking Program

$15 per visit $10 per visit

Lifestyle and health promotion classes, such as:
Body Conditioning
Iyengar Yoga
Prenatal/Post-Partum Exercise
55 Alive Mature Driving
Heart Saver (Basic CPR-Course A)
Childbirth Preparation/Lamaze Class
Couples Communication I
Parenting Patterns Workshop
Shapedown

Class fee varies from $10
to $85
Class fee varies from
$10 to $85 28
28 Page 29 30
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 28 Section 5( a)

Other classes (including support groups) such as:
Menopausal Years
Breastfeeding Your Baby
Mothers Share Group
New Sibling Class/Tour
Arthritis Support Group
H.O.P.I.N.G. (Helping Other Parents In Normal Grieving)

Stroke Club

Nothing Nothing

Smoking Cessation Program
Our nicotine dependence/smoking cessation
program offers self-help information, group
appointments, telephone counseling and support,
and monthly sessions. You must complete our
smoking cessation class to have your nicotine
replacement therapy medications covered under
the Prescription drug benefit.

$15 per class $10 per class 29
29 Page 30 31
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 29 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 PREAUTHORIZATION OF SOME SURGICAL PROCEDURES. Please refer to the pre-authorization information shown in Section 3 to

be sure which services require pre-authorization and identify which surgeries require pre-
authorization.

I M
P O
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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
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
Voluntary sterilization (tubal ligation or vasectomy)

Insertion of Norplant (a surgically implanted contraceptive) and intrauterine devices
(IUDs).
Note: We cover surgically implanted
contraceptives and intrauterine devices under the
prescription drug benefit.

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 30
30 Page 31 32
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 30 Section 5( b)

Surgical procedures You pay -Standard Option You pay -High Option
Endoscopy procedures
Biopsy procedures
50% of charges Nothing

Not covered:
Reversal of voluntary sterilization
Routine treatment of conditions of the foot

All charges All charges

Reconstructive surgery
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
members 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; webbed
fingers and toes.

All stages of breast reconstruction surgery following a mastectomy, such as:

surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas; and
breast prostheses and surgical bras and replacements (see Prosthetic devices).
Note: If you need a mastectomy, you may choose to
have the procedure performed on an inpatient basis
and remain in the hospital up to 48 hours after the
procedure.

$15 per office visit for
outpatient services

Nothing for inpatient
services

$10 per office visit for
outpatient services

Nothing for inpatient
services

Not covered:
Cosmetic surgery any surgical procedure (or any portion of a procedure) performed

primarily to improve physical appearance
through change in bodily form, and which will
not result in significant improvement in
physical function

Surgeries related to sex transformation

All charges All charges 31
31 Page 32 33
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 31 Section 5( c)

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)
Shortening of the mandible or maxillae for cosmetic purposes

Correction of malloclusion
Any dental care involved in treatment of temporomandibular joint (TMJ) pain

dysfunction syndrome

All charges All charges 32
32 Page 33 34
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 32 Section 5( c)

Organ/tissue transplants You pay -Standard Option You pay -High Option
Limited to:
Cornea
Heart
Heart/lung
Kidney
Simultaneous pancreas-kidney
Liver
Lung: Single Double
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 directly 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
Transportation, lodging, and living expenses

All charges All charges

Anesthesia
Professional services provided in:
Hospital (inpatient)
Hospital outpatient department
Ambulatory surgical center
Office

Nothing Nothing 33
33 Page 34 35
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 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 remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and we cover them only when we determine they are

medically necessary.
Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.

We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about

coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs

associated with the professional charge (i.e., physicians, etc.) are covered in
Sections 5(a) or (b).

I
M
P
O
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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.

10% of daily room rate
charges
Nothing 34
34 Page 35 36
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 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
Dressings, casts, and sterile trays
Medical supplies and equipment, including oxygen

Anesthetics, including nurse anesthetist services
Administration of blood and blood products
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. We do
not cover dental procedures

Nothing Nothing

Diagnostic laboratory tests and X-rays 50% of charges Nothing
Blood, limited to whole blood, red cell products, cryoprecipitates, platelets, plasma,
fresh frozen plasma, and Rh immune globulin
Collection, storage, and processing of autologous blood for covered scheduled

surgery whether or not the units are used

20% of charges 20% of charges

Not covered:
Donor directed units of blood
Custodial care
Non-covered facilities
Personal comfort items, such as telephone, television, barber services, guest meals, and

beds
Take home items
Private nursing care
Any inpatient dental procedures

All charges All charges 35
35 Page 36 37
Section 5( c)
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 35

Outpatient hospital or ambulatory
surgical center
You pay -Standard Option You pay -High Option

Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Dressings, casts, and sterile trays
Medical supplies, including oxygen
Anesthetics and anesthesia service
Administration of blood and blood products

Pre-surgical testing

$15 per surgery $10 per surgery

Diagnostic laboratory tests, X-rays, and pathology services 50% of charges Nothing
Blood, limited to whole blood, red cell products, cryoprecipitates, platelets, plasma,
fresh frozen plasma, and Rh immune globulin
Collection, storage and processing of autologous blood for covered scheduled

surgery whether or not the units are used

20% of charges 20% of charges

Not covered:
Donor directed units of blood
All charges All charges

Extended care benefits/skilled nursing care
facility benefits

Up to 100 days per benefit period when full time
care is necessary. A benefit period begins when
you enter a hospital or skilled nursing facility and
ends when you are not a patient in either a hospital
or skilled nursing facility for 60 consecutive days.

Services include:
Nursing care
Bed and board
Physical, occupational, and speech therapy
Medical social services
Prescribed drugs
Medical supplies

Nothing Nothing 36
36 Page 37 38
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 36 Section 5( c)

Not covered:
Custodial care
Personal comfort items, such as telephone, television, barber services, guest meals, and

beds

All charges All charges

Hospice care You pay -Standard Option You pay -High Option
If you are diagnosed with a terminal illness with
a life expectancy of six months or less, you may
elect hospice care.

Hospice care is supportive and palliative care
(including family counseling) for a terminally ill
member when provided by a Plan approved
licensed hospice.

Short-term inpatient care is limited to respite
care, care for pain control, and acute and chronic
symptom management.

Note: Hospice is a program for caring for the
terminally ill that emphasizes supportive services,
such as home care and pain control, rather than
curative care of the terminal illness. A person who
is terminally ill may elect to receive hospice
benefits. These palliative and supportive services
include nursing care, medical social services,
physician services, and short-term inpatient care for
pain control and acute and chronic symptom
management. We also provide counseling and
bereavement services for the individual and family
members, and therapy for purposes of symptom
control to enable the person to continue life with as
little disruption as possible. If you make a hospice
election, you are not entitled to receive other health
care services that are related to the terminal illness.
If you have made a hospice election, you may
revoke that election at any time, and your standard
health benefits will be covered.

Nothing Nothing

Not covered:
Independent nursing
Homemaker services

All charges All charges

Ambulance
Local professional ambulance service when medically appropriate 20% of charges 20% of charges

Not covered:
Transports that we determine are not medically necessary
All charges All charges 37
37 Page 38 39
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 37 Section 5( d)

Section 5 (d). Emergency services/accidents
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.

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.
We have no calendar year deductible.

I
M
P
O
R
T
A
N
T

What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your
life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems
are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and
broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes,
poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may
determine are medical emergencies what they all have in common is the need for quick action.

What to do in case of emergency:
In a life-threatening emergency, call 911. When the operator answers, stay on the phone and answer all questions.

Emergencies within our service area:
Emergency care is provided at Plan hospitals 24 hours a day, seven day a week. If you reasonably believe you have a
medical emergency condition and you cannot safely go to a Plan Hospital, call 911 or go to the nearest hospital. If an
ambulance comes, tell the paramedics that the person who needs help is a Kaiser Permanente member.

If you are admitted to a non-Plan facility, you or your family member must notify us within 48 hours, or as soon as
reasonably possible by calling the phone number on the back of your Kaiser Permanente membership card. This
must be done, or your claim for payment may be denied. We may arrange for your transfer to a Plan facility as soon
as it is medically appropriate to do so.

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan facility
would result in death, disability, or significant jeopardy to your condition. After an emergency in the service area,
follow-up and continuing care at a non-Plan facility are not covered.

Emergencies outside our service area:
Benefits are available for any medically necessary health service that is immediately required because of a sudden or
unforeseen injury or illness.

If you need to be hospitalized, the Plan must be notified within 48 hours, or as soon as reasonably possible. If a Plan
physician believes care can be better provided in a Plan hospital, we will transfer you when medically feasible.

You may obtain emergency and urgent care services from Kaiser Permanente medical facilities and providers when
you are in the service area of another Kaiser Permanente plan. The facilities will be listed in the local telephone
book under Kaiser Permanente. You may also obtain information about the location of facilities by calling the
Customer Service Center at 800/966-5955. 38
38 Page 39 40
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 38 Section 5( d)

Benefit Description You pay
Emergency within our service area You pay -Standard Option You pay -High Option
Emergency care at a physician's office
Emergency care at an urgent care center
Emergency care at a hospital, including physicians' services

$25 per visit $25 per visit

Not covered:
Elective care or non-emergency care
All charges All charges

Emergency outside our service area
At a non-Plan facility:
Emergency care at a physician's office
Emergency care at an urgent care center
Emergency care at a hospital, including physicians' services

20% of our allowance plus
any additional charges
which would be required if
you received your care
from the Plan

20% of our allowance
plus any additional
charges which would
be required if you
received your care
from the Plan

At a Plan facility:
Emergency care in a Kaiser Foundation Hospital in another Kaiser Foundation Health

Plan service area
Note: We cover continuing or follow-up care
under the Travel Benefit.

The amount you would be
charged if you were a
member in that service area

The amount you
would be charged if
you were a member
in that service area

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

Ambulance
Professional ambulance service (including air
ambulance) when medically appropriate.

Note: For non-emergency service, see page 36.

20% of charges 20% of charges

Not covered:
Transports we determine are not medically necessary
All charges All charges 39
39 Page 40 41
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 39 Section 5( e)

Section 5 (e). Mental health and substance abuse benefits
I
M
P
O
R
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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

clinically appropriate to treat your condition.
Plan physicians must provide or arrange for 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.

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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 plans 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, Inc.
Hawaii Region 40 Section 5( e)

Mental health and substance abuse
benefits You pay -Standard Option You pay -High Option

Diagnosis and treatment of psychiatric conditions,
mental illness, or disorders of children,
adolescents, and adults. Outpatient services
include:

Diagnostic evaluation
Crisis intervention and stabilization for acute episodes

Psychological testing necessary to determine appropriate psychiatric treatment
Psychiatric treatment (including individual and group therapy visits)
Medication evaluation and management

Diagnosis and treatment of alcoholism and drug
abuse. Outpatient services include:

Detoxification (the withdrawal process from physically-addictive drugs and/or alcohol

when withdrawal is likely to cause medical or
life-threatening complications)

Treatment and counseling (including individual and group therapy visits)

Note: You may see a Plan outpatient mental
health or substance abuse provider without a
referral from your primary care physician.

Note: Your Plan provider will develop a treatment
plan to assist you in improving or maintaining
your condition and functional level, or to prevent
relapse and will determine which diagnostic and
treatment services are appropriate for you.

$15 per office visit $10 per office visit

Inpatient psychiatric or substance abuse care
Hospital alternative services, such as partial hospitalization, day treatment, and intensive

outpatient psychiatric treatment programs
Day treatment programs for substance abuse
Note: All inpatient admissions, hospital
alternative services, and day treatment programs
require approval by a Plan physician.

10% of daily room charges Nothing 41
41 Page 42 43
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 41 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, learning disorders, or interest testing not necessary to

determine the appropriate treatment of a
psychiatric condition

Evaluation or therapy on court order or as a condition of parole or probation, or otherwise

required by the criminal justice system, unless
determined by a Plan physician to be
medically necessary and appropriate

Services that are custodial in nature
Services rendered or billed by a school or a member of its staff

Services provided under a federal, state, or local government program
Psychoanalysis or psychotherapy credited toward earning a degree or furtherance of
education or training regardless of diagnosis
or symptoms

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, Inc.
Hawaii Region 42 Section 5( f)

Section 5 (f). Prescription drug benefits
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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
clinically appropriate to treat your condition.
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.
We have no calendar year deductible.

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There are important features you should be aware of. These include:
Who can write your prescription. A Plan physician must write the prescription.
Where you can obtain them. You may fill the prescription and receive refills at a Plan pharmacy. The only drugs available through mail order are maintenance drugs.

Obtain mail order prescription forms at any Plan pharmacy, or call the Plans mail order pharmacy
at 808/432-5510, Monday -Friday, 8:30 A.M. to 5:00 P.M. You may purchase drugs through the
Plans mail order prescription service. Please mail your refill order before you are down to your last
10days supply. Allow one week to receive your medication for refillable orders. We do not deliver
the following drugs through mail order: narcotics, tranquilizers, bulky items, injectables, and
medication affected by temperature.

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. We use a formulary to determine
which drugs to prescribe to you. If the physician specifically prescribes a nonformulary drug
because it is medically necessary, the nonformulary drug will be covered.

When generic substitution is permissible (i.e. a generic drug is available and the prescribing
physician does not require the use of a name brand drug), but you request the name brand drug, you
pay the price difference between the generic and the name brand drug, as well as the $7 charge per
prescription unit or refill.

There are dispensing limitations. We provide up to a 30-day supply and one cycle of a contraceptive 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, Inc.
Hawaii Region 43 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 and medicines that require a physicians prescription

Disposable needles and syringes for the administration of covered medications
Diabetes supplies limited to glucose strips, lancets, and insulin syringes
Amino acid modified products used in the treatment of inborn errors of amino acid
metabolism (PKU)
Oral immunosuppressive drugs required after a transplant

Oral travel immunizations
Smoking cessation drugs, including nicotine patches. Coverage is limited to one course of

treatment per calendar year, if:
the drug is prescribed by a Plan physician; and

the member enrolls in and pays the fees for a Plan approved smoking cessation program
Insulin

$7 per prescription $7 per prescription

Contraceptives
Oral Contraceptives
$7 per cycle $7 per cycle

Diaphragms
Cervical caps

$7 each $7 each

Injectable contraceptive drugs (such as Depo-Provera) $7 times the expected number of months the
medication will be
effective

$7 times the expected
number of months the
medication will be
effective 44
44 Page 45 46
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 44 Section 5( f)

Covered medications and supplies You pay -Standard Option You pay -High Option
Intrauterine devices (IUD's)
Implanted time release contraceptive drugs (such as Norplant)

Note: We will not refund any portion of the
copayment if the IUD is removed or spontaneously
expulsed, or the implanted time release drug is
removed before the end of its lifetime.

$7 times the expected
number of months the
medication or device will
be effective, not to exceed
$250

$7 times the expected
number of months the
medication or device
will be effective, not
to exceed $250

Drugs to treat sexual dysfunction have dispensing limitations. Contact the Plan for
details.
50% of charges 50% of charges

Not covered:
Drugs related to non-covered services
Drugs obtained at a non-Plan pharmacy, except as part of a covered out-of-area

emergency
Drugs to enhance athletic performance
Drugs and supplies for cosmetic purposes
Vitamins and nutritional supplements that can be purchased without a prescription

Nonprescription drugs
Medical supplies (such as dressings and antiseptics), except as listed above

All charges All charges 45
45 Page 46 47
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 45 Section 5( g)

Section 5 (g). Special features
Feature Description

Services from other
Kaiser Permanente
Plans

When you visit 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 copayments or other charges imposed by the Plan you are visiting.
If the Plan you are visiting has a benefit that differs 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 covered
if you receive them 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 your Plan facility 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 our
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 wish to obtain more information about the benefits available to
you from a Kaiser Permanente Plan in an area you visit, please call our
Customer Service Center at 808/432-5955 on Oahu, or on Kauai,
Maui, or Hawaii at 800/966-5955.

Interpretive services If you need interpretive services during your visit, please ask an English-speaking friend or relative to call our Customer Service
Center at 808/432-5955 on Oahu or 800/966-5955 on neighbor
islands.

24 hour advice line For any of your health concerns, you may talk with a registered nurse 24 hours a day, 7 days a week, who will discuss your treatment options
and answer your health questions.
During clinic hours, you may call your clinic.
During after hours, you may call 808/432-7700 on Oahu or 800/467-
3011 on the other islands.

Hours of operation are:
Monday through Friday, 5 p.m. 8 a.m.
Noon, Saturday, through 8 a.m., Monday
Holidays, all day 46
46 Page 47 48
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 46 Section 5( g)

Travel benefit Kaiser Permanentes 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 covered services 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. We deduct this amount from the payment we make to you.

We pay no more than $1200 each calendar year.
For more information about this benefit call the Travel Benefit Information Line at 800/390-3509.

Claims should be submitted to Affiliated Care, Kaiser Foundation
Health Plan, Inc., 80 Mahalani Street, Wailuku, Hawaii 96793.

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, Inc.
Hawaii Region 47 Section 5( g)

Travel assistance In addition to the Kaiser Permanente travel benefit stated above, the Plan will provide travel and medical assistance for Federal members traveling
domestically and abroad. Services and products to assure access to
appropriate health care services and travel assistance while away from
home include:

Pre-trip information
Precertification assistance for inpatient hospital stays
Case management assistance
Translation services
Provider location assistance
Medical transport assistance
Emergency medication assistance
Lost document assistance
Emergency messaging
Lost baggage assistance

The cost for uninsured services will be paid by the member including
but not limited to: transportation costs, assistance for unattended
minors, repatriation of remains, lost document costs, and medical
evacuation.

Members who need assistance should contact World Access. If members
are travelling:

within the United States, Puerto Rico and the Virgin Islands, call toll free at 1-866-221-7870;

worldwide (outside US, Puerto Rico or Virgin Islands), call collect at 804-673-1497.
Both numbers are available 24 hours a day, 365 days a year. 48
48 Page 49 50
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 48 Section 5( h)

Section 5 (h). Dental benefits
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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 pay them only when we determine they are medically

necessary.
Plan dentists must provide or arrange your care.
We have no calendar year deductible.
We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of the

patient. We do not cover the dental procedure unless it is described below.

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Accidental injury benefit You pay -Standard Option You pay -High Option

We cover restorative services and supplies
necessary to promptly repair (but not replace) sound
natural teeth. The need for these services must
result from an accidental injury. Any other services
are provided as described below.

$15 per office visit $10 per office visit

Dental benefits
We cover dental benefits. You may choose your dentist and your out-of-pocket expenses will be based on your
dentists eligible fees and your plan benefits. During your first appointment, advise your dentist that you are covered
by the Kaiser Foundation Health Plan Federal Dental Care Program, and present your Hawaii Dental Service (HDS)
member identification card to your dentist.

If your dentist must perform procedures totaling $400 or more, your dentist must submit a claim form to HDS before
providing services to you. Upon HDSs approval, your dentist should explain your treatment plan, the dollar amount
your dental benefits plan will cover, and the amount you will pay before performing the services.

Before you receive treatment, you should discuss the total charges and your financial obligations with your dentist.
You are financially responsible for any remaining balance between your dentists eligible fee and the HDS payment.

Service You pay -Standard Option You pay -High Option
We cover diagnostic and preventive care services
when provided through Hawaii Dental Service:

Examinations once every calendar year
Bitewing X-rays twice every calendar year

Nothing Nothing

Other X-rays limited to one full mouth series of X-rays (including bitewings) once every three
years
Prophylaxis (cleaning) once every calendar year
Stannous fluoride once every calendar year and for dependent children only

Palliative treatment for relief of pain

20% of our allowance 20% of our allowance 49
49 Page 50 51
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 49 Section 5( h)

Service You pay -Standard Option You pay -High Option
Not covered:
Cos metic dental services
Pro sthodo ntic s ervices or d evices (including crowns
and bridg es) started prior to the date you became
eligible under this Program

Orthodontic ser vices
Den tal services not listed as covered

All charges All charges 50
50 Page 51 52
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 50 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. 51
51 Page 52 53
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 51 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. 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 at 808/243-6610 on Maui or 877/975-3805 on all other
islands.

When you must file a claim such as for out-of-area care submit it on
the HCFA-1500 or a claim form that includes the information shown
below. Bills and receipts should be itemized and show:

Covered members 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:
Affiliated Care -Claims Department
Kaiser Foundation Health Plan, Inc.
80 Mahalani Street
Wailuku, HI 96793

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. 52
52 Page 53 54
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 52 Section 7

If you have a malpractice claim If you have a malpractice claim because of services you did receive, or did not receive, from a Plan provider, you must submit the claim to
binding arbitration. The Plan has the information that describes the
arbitration process. Contact our Customer Service Center on Oahu at
808/432-5955, or on Kauai, Maui, or Hawaii at 800/966-5955 for copies
of our requirements. These will explain how you can begin the binding
arbitration process. 53
53 Page 54 55
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 53 Section 8

Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your claim or request for services, drugs, or supplies including a request for pre-authorization:

Step Description

1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: Regional Appeals Coordinator, Affiliated Care, Kaiser Foundation Health
Plan, Inc., 501 Alakawa Street, Honolulu, HI 96817; and

(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit
provisions in this brochure; and

(d) Include copies of documents that support your claim, such as physicians' letters, operative reports,
bills, medical records, and explanation of benefits (EOB) forms.

2 We have 30 days from the date we receive your request to: (a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of
our request go to step 3.

3 You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30 days of the date the
information was due. We will base our decision on the information we already have.

We will write to you with our decision.

4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us --if we did not answer that request in some way within 30 days; or
120 days after we asked for additional information.

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3,
1900 E Street, NW, Washington, D.C. 20415-3630.

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. 54
54 Page 55 56
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 54 Section 8

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 OPMs 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 at
the Expedited Review Hotline at 866/233-2851 and we will expedite our review; or

(b) We denied your initial request for care or preauthorization/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. 55
55 Page 56 57
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 55 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 normally pays its benefits in
full as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is
primary according to the National Association of Insurance
Commissioners' guidelines.

When we are the primary payer, we will pay the benefits described in this
brochure.

When we are the secondary payer, we will determine our allowance.
After the primary plan pays, we will pay what is left of our allowance, up
to our regular benefit. We will not pay more than our allowance. If we
are the secondary payer, and you received your services from Plan
providers, we may bill the primary carrier.

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. 56
56 Page 57 58
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 56 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.) 57
57 Page 58 59
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 57 Section 9

The following chart illustrates whether 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

A. When either you or your covered spouse are age 65 or over and Then the primary payer is
Original Medicare This Plan
________________________________________________ 1) Are an active employee with the Federal government (including

when you or a family member are eligible for Medicare solely
because of a disability), 3 ________________________________________________

2) Are an annuitant, 3 ________________________________________________
3) Are a reemployed annuitant with the Federal government when
a) The position is excluded from FEHB, or 3 ________________________________________________

b) The position is not excluded from FEHB 3
(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 3
your covered spouse is this type of judge), ________________________________________________

5) Are enrolled in Part B only, regardless of your employment status, 3 3
(for Part B (for other
services) services) ________________________________________________

6) Are a former Federal employee receiving Workers' Compensation 3
and the Office of Workers' Compensation Programs has determined (except for claims
that you are unable to return to duty, related to Workers'
Compensation) ________________________________________________

B. When you or a covered family member have Medicare
based on end stage renal disease (ESRD) and ________________________________________________

1) Are within the first 30 months of eligibility to receive Part A
benefits solely because of ESRD, 3 ________________________________________________

2) Have completed the 30-month ESRD coordination period and are
still eligible for Medicare due to ESRD, 3 ________________________________________________

3) Become eligible for Medicare due to ESRD after Medicare became
primary for you under another provision, 3 ________________________________________________

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 3 ________________________________________________

b) Are an active employee, or 3 ________________________________________________
c) Are a former spouse of an annuitant, or 3 ________________________________________________
d) Are a former spouse of an active employee 3 58
58 Page 59 60
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 58 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 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 808/432-2010
in Oahu and 800/564-2010 on Neighbor Islands. Your Kaiser
Permanente Senior Advantage-FEHBP benefits that we lowered or
waived are:

High Option
Office visits: $0 for physicians and other health professionals visits
Emergency care: $25 for each emergency visit
Preventive services visits: $0
Routine physical and hearing exams: $0 for each routine physical and hearing exam

Immunizations: Pneumoccoccal pneumonia, flu, and hepatitis B vaccines at no charge
Urgently needed care: $0 for each visit to a Plan facility
One routine eye exam each year: $0
Durable medical equipment: 20% copayment
External prosthetics: 20% copayment
Blood, blood transfusions, and blood products: $0
Dialysis: $0
Routine foot care: $0
Manual manipulation of the spine to correct subluxation: $0
Intraocular lens after cataract surgery: 20% copayment 59
59 Page 60 61
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 59 Section 9

Standard Option
Office visits: $5 copayment for physicians and other health professionals visits

Lab, X-ray, and diagnostic services: $0
Emergency care: $25 for each emergency visit
Preventive services visits: $5 copayment
Routine physical and hearing exams: $5 copayment for each routine physical and hearing exam

Immunizations: Pneumoccoccal pneumonia, flu, and hepatitis B vaccines at no charge
Urgently needed care: $5 copayment for each visit to a Plan facility
One routine eye exam each year: $5
Durable medical equipment: 20% copayment
External prosthetics: 20% copayment
Blood, blood transfusions, and blood products: $0
Dialysis: $0
Routine foot care: $5 copayment
Manual manipulation of the spine to correct subluxation: $5 copayment

Intraocular lens after cataract surgery -20% copayment
This Plan and another plans Medicare managed care plan: You
may enroll in another plans Medicare managed care plan and also
remain enrolled in our FEHB plan. We will still provide benefits when
your Medicare managed care plan is primary if you use our Plan
providers, but we will not waive or lower any of our copayments or
coinsurance. If you enroll in a Medicare managed care plan, tell us. We
will need to know whether you are in the Original Medicare Plan or in a
Medicare managed care plan so we can correctly coordinate benefits with
Medicare.

Suspended FEHB coverage to enroll in a Medicare managed care
plan: If you are an annuitant or former spouse, you can suspend your
FEHB coverage to enroll in a Medicare managed care plan, eliminating
your FEHB premium. (OPM does not contribute to your Medicare
managed care plan premium.) For information on suspending your
FEHB enrollment, contact your retirement office. If you later want to re-
enroll in the FEHB Program, generally you may do so only at the next
open season unless you involuntarily lose coverage or move out of the
Medicare managed care service area.

If you enroll in Medicare 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. 60
60 Page 61 62
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 60 Section 9

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. 61
61 Page 62 63
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 61 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.

Experimental or
investigational services We consider a service, supply or drug to be experimental 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
services 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.
We do not cover a service, supply, or drug that we consider experimental.

This Plan and our Medical Group carefully evaluate whether a particular
therapy is safe and effective or offers a degree of promise with respect to
improving health outcomes. The primary source of evidence about
health outcomes of any intervention is peer-reviewed medical literature.

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." 62
62 Page 63 64
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 62 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, Inc., Hawaii Region.
You You refers to the enrollee and each covered family member. 63
63 Page 64 65
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 63 Section 5( d)

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 dont 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. 64
64 Page 65 66
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 64 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 spouses 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-spouses 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. 65
65 Page 66 67
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 65 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.

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/archive/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. 66
66 Page 67 68
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 66 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 its 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 thats 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 states 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/archive/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. 67
67 Page 68 69
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 67 Index

Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.
Accidental injury 48
Allergy tests 21
Alternative treatment 26
Ambulance 36, 38
Anesthesia 32, 34
Autologous bone marrow
transplant 32
Biopsies 30
Blood and blood plasma 34, 35
Breast cancer screening 17
Casts 29, 34, 35
Changes for 2002 9
Chemotherapy 21
Chiropractic 25
Cholesterol tests 17
Coinsurance 10, 14, 61
Colorectal cancer screening 17
Congenital anomalies 29, 30
Contraceptive devices and drugs 43, 44
Coordination of benefits 55, 56
Covered providers 10, 11
Deaf and hearing impaired
service 7
Deductible 14, 61
Dental care 48
Diagnostic services 16, 17, 34, 35
Disputed claims review 53, 54
Donor expenses (transplants) 32
Dressings 34, 35
Durable medical equipment
(DME) 24, 25
Educational classes and programs 27
Effective date of enrollment 64
Emergency 37, 38
Experimental or investigational 50, 61
Eyeglasses 23
Family planning 20
Fecal occult blood test 17
General Exclusions 50
Hearing services 22, 23
Home health services 25
Hospice care 36
Hospital 12, 33, 34, 35
Immunizations 18, 19, 43
Infertility 20
Inpatient Hospital Benefits 33, 34
Insulin 43

Laboratory and pathological
services 17, 34, 35
Magnetic Resonance Imagings
(MRIs) 17
Mail Order Prescription Drugs 42
Mammograms 17
Maternity Benefits 19
Medicaid 60
Medically necessary 62
Medicare 55-59
Mental Conditions/ Substance
Abuse Benefits 39-41
Newborn care 16, 19
Nurse
Nurse Anesthetist 34
Nurse Practitioner 10
Registered Nurse 45
Nursery charges 19
Obstetrical care 19
Occupational therapy 22, 25
Oral and maxillofacial surgery 31
Orthopedic devices 23
Out-of-pocket expenses 14
Oxygen 34
Pap test 17
Physical examination 18, 19
Physical therapy 22, 25
Precertification 19, 47, 54
Preventive care, adult 17, 18
Preventive care, children 18, 19
Prior approval 12, 13
Prostate cancer screening 17
Prosthetic devices 23, 24
Psychotherapy 41
Radiation therapy 21
Renal dialysis 21
Room and board 33, 35
Second surgical opinion 16
Services from other Kaiser
Permanente Plans 45
Skilled nursing facility care 16, 35
Smoking cessation 28
Speech therapy 22, 25
Splints 24
Sterilization procedures 20
Subrogation 60
Substance abuse 39-41

Surgery 29-32, 35
Anesthesia 32, 34 Oral 31

Outpatient 29 Reconstructive 30
Syringes 43
Temporary continuation of
coverage 64, 65
Transplants 21, 31, 32, 46
Travel benefit 46
Treatment therapies 21
Vision services 23
Well child care 18
Workers' compensation 60
X-rays 17, 34, 35
24 hour nurse line 45 68
68 Page 69 70
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 68 Summary

Summary of benefits for Kaiser Foundation Health Plan, Inc. Hawaii Region 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 16 ________________________________________________________________________________________________

Services provided by a hospital:
Inpatient ............................................................................................ 10% of daily room rate charges 33
Outpatient ......................................................................................... $15 per office visit 35 ________________________________________________________________________________________________

Emergency benefits:
In-area ............................................................................................. $25 per visit 38
Out-of-area........................................................................................ 20% or our allowance 38 ________________________________________________________________________________________________

Mental health and substance abuse treatment: ........................................ Regular cost sharing 39 ________________________________________________________________________________________________
Prescription drugs .................................................................................... $7 per prescription 42 ________________________________________________________________________________________________
Dental Care ............................................................................................. Various copays based on 48
procedure rendered ________________________________________________________________________________________________

Vision Care ............................................................................................. $15 per office visit 23 ________________________________________________________________________________________________
Special features: Services from other Kaiser Permanente Plans; Interpretive Services; 24 hour advice line;
Travel benefit; Travel assistance 45 ________________________________________________________________________________________________

Protection against catastrophic costs Nothing after $1,000/ Self Only or
(your out-of-pocket maximum) ............................................................... $3,000/ Family enrollment per
year

Some costs do not count toward
this protection 14
________________________________________________ 69
69 Page 70 71
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 69 Summary

Summary of benefits for Kaiser Foundation Health Plan, Inc. Hawaii Region 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 16 ________________________________________________________________________________________________

Services provided by a hospital:
Inpatient ............................................................................................ Nothing 33
Outpatient ......................................................................................... $10 per office visit 35 ________________________________________________________________________________________________

Emergency benefits:
In-area ............................................................................................. $25 per visit 38
Out-of-area........................................................................................ 20% or our allowance 38 ________________________________________________________________________________________________

Mental health and substance abuse treatment: ........................................ Regular cost sharing 39 ________________________________________________________________________________________________
Prescription drugs .................................................................................... $7 per prescription 42 ________________________________________________________________________________________________
Dental Care ............................................................................................. Various copays based on 48
procedure rendered ________________________________________________________________________________________________

Vision Care ............................................................................................. $10 per visit 23 ________________________________________________________________________________________________
Special features: Services from other Kaiser Permanente Plans; Interpretive Services; 24 hour advice line;
Travel benefit; Travel assistance 45 ________________________________________________________________________________________________

Protection against catastrophic costs Nothing after $1,000/ Self Only or
(your out-of-pocket maximum) ............................................................... $3,000/ Family enrollment per
year

Some costs do not count toward
this protection 14
________________________________________________ 70
70 Page 71 72
2002 Kaiser Foundation Health Plan, Inc.
Hawaii Region 70 Notes

Notes 71
71 Page 72
2002 Rate Information for
Kaiser Foundation Health Plan, Inc., Hawaii Region
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 Gov't Your Gov't Your USPS Your
Enrollment Code Share Share Share Share Share Share ________________________________________________________________________________

________________________________________________ High Option

Self Only 631 $91.66 $30.55 $198.59 $66.20 $108.46 $13.75 ________________________________________________________________________________________________
High Option
Self and Family 632 $197.06 $65.69 $426.97 $142.32 $233.19 $29.56 ________________________________________________________________________________________________

Standard Option
Self Only 634 $69.96 $23.32 $151.58 $50.53 $82.79 $10.49 ________________________________________________________________________________________________

Standard Option
Self and Family 635 $150.41 $50.14 $325.90 $108.63 $177.99 $22.56 ________________________________________________________________________________________________ 72

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