Serving: Cleveland and Akron, Ohio Metropolitan Areas
Enrollment in this Plan is limited. You must live in our Geographic
service area to enroll. See page 8 for requirements.
Enrollment codes for this Plan:
641 Self Only 642 Self and Family
RI 73-017
Attach Your
Logo
This Plan has excellent accreditation from the NCQA.
See the 2002
Guide for more information on accreditation.
For changes in benefits
see page 9
1
1 Page 2 3
2002 Kaiser Foundation Health Plan of Ohio 2
Table of Contents
Table of Contents
Introduction
.................................................................................................................................................................
5
Plain Language
..............................................................................................................................................................
5
Inspector General
Advisory...........................................................................................................................................
6
Section 1. Facts about this HMO plan
..........................................................................................................................
7
How we pay providers
.................................................................................................................................
7
Your
Rights..................................................................................................................................................
7
Service Area
................................................................................................................................................
8
Section 2. How we change for
2002.............................................................................................................................
9
Program-wide
changes.................................................................................................................................
9
Changes to this
Plan.....................................................................................................................................
9
Section 3. How you get care
......................................................................................................................................
10
Identification cards
....................................................................................................................................
10
Where you get covered
care.......................................................................................................................
10
Plan
providers......................................................................................................................................
10
Plan facilities
.......................................................................................................................................
10
What you must do to get covered
care.......................................................................................................
10
Primary care
........................................................................................................................................
11
Specialty care
......................................................................................................................................
11
Hospital
care........................................................................................................................................
12
Circumstances beyond our
control.............................................................................................................
12
Services requiring our prior approval
........................................................................................................
12
Section 4. Your costs for covered services
.................................................................................................................
13
Copayments.........................................................................................................................................
13
Deductible
...........................................................................................................................................
13
Coinsurance.........................................................................................................................................
13
Fees when you fail to make your copayment or coinsurance
.............................................................. 13
Your
catastrophic protection out-of-pocket maximum for copayments and
coinsurance.......................... 13
Section 5.
Benefits......................................................................................................................................................
14
Overview
...................................................................................................................................................
14
(a) Medical services and supplies provided by physicians and other health
care professionals ........... 15
(b) Surgical and anesthesia services
provided by physicians and other health care professionals ....... 27
(c)
Services provided by a hospital or other facility, and ambulance services
..................................... 31
(d) Emergency services/
accidents.........................................................................................................
35
(e) Mental health and substance abuse
benefits....................................................................................
37
(f) Prescription drug benefits
...............................................................................................................
40
(g) Special features
...............................................................................................................................
43 2
2 Page 3 4
2002 Kaiser Foundation Health Plan of Ohio 3
Table of Contents
24 hour emergency advice
line............................................................................................................
43
Centers of excellence for
transplants...................................................................................................
43
Flexible benefits option
.......................................................................................................................
43
Services from other Kaiser Permanente
Plans.....................................................................................
44
Travel benefit
......................................................................................................................................
45
(h) Dental benefits
................................................................................................................................
46
(i) Non-FEHB benefits available to Plan
members..............................................................................
47
Section 6. General exclusions – things we don't cover
...............................................................................................
48
Section 7. Filing a claim for covered services
............................................................................................................
49
Medical, hospital, and drug benefits
..........................................................................................................
49
Deadline for filing your claim
...................................................................................................................
49
When we need more
information...............................................................................................................
49
Section 8. The disputed claims process
......................................................................................................................
50
Section 9. Coordinating benefits with other coverage
................................................................................................
52
When you have other health coverage
.......................................................................................................
52
What is
Medicare?................................................................................................................................
52
The Original Medicare Plan (Part A or Part B)
....................................................................................
52
Medicare managed care plan
................................................................................................................
55
If you do not enroll in Medicare Part A or Part B
................................................................................
55
TRICARE
..................................................................................................................................................
55
Workers' Compensation
............................................................................................................................
55
Medicaid....................................................................................................................................................
56
When other Government agencies are responsible for your
care............................................................... 56
When
others are responsible for
injuries....................................................................................................
56
Section 10. Definitions of terms we use in this brochure
...........................................................................................
57
Section 11. FEHB facts
..............................................................................................................................................
59
No pre-existing condition limitation
...................................................................................................
59
Where you get information about enrolling in the FEHB
Program..................................................... 59
Types of
coverage available for you and your family
......................................................................... 59
When benefits and premiums start
......................................................................................................
60
Your medical and claims records are confidential
..............................................................................
60
When you retire
...................................................................................................................................
60
When you lose benefits
..........................................................................................................................
60
When FEHB coverage
ends.................................................................................................................
60
Spouse equity coverage
.......................................................................................................................
60
Temporary continuation of coverage (TCC)
.......................................................................................
60
Converting to individual coverage
......................................................................................................
61
Getting a Certificate of Group Health Plan Coverage
......................................................................... 61 3
3 Page 4 5
2002 Kaiser Foundation Health Plan of Ohio 4
Table of Contents
Long term care insurance is coming later in
2002.......................................................................................................
62
Index............................................................................................................................................................................
63
Summary of
benefits....................................................................................................................................................
64
Rates………………………………………………………………………………………………………….. Back cover 4
4 Page 5 6
2002 Kaiser Foundation Health Plan of Ohio 5 Introduction/ Plain
Language/ Advisory
Introduction
Kaiser Foundation Health Plan
of Ohio North Point Tower
1001 Lakeside Avenue Cleveland, Ohio 44114
This brochure describes the benefits of Kaiser Foundation Health Plan of Ohio
under our contract (CS 1182) with the Office of Personnel Management (OPM), as
authorized by the Federal Employees Health Benefits law. This brochure
is
the official statement of benefits. No oral statement can modify or otherwise
affect the benefits, limitations, and exclusions of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to
benefits that were available before January 1, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates
with each plan annually. Benefit changes are effective January 1, 2002, and
changes are summarized on page 9. Rates are shown at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible, and understandable to
the public. For instance,
Except for necessary technical terms, we use common words. For instance,
"you" means the enrollee or family member; "we" or "Plan" means Kaiser
Foundation Health Plan of Ohio.
We limit acronyms to ones you know. FEHB is
the Federal Employees Health Benefits Program. OPM is the Office of Personnel
Management. If we use others, we tell you what they mean first.
Our brochure
and other FEHB plans' brochures have the same format and similar descriptions to
help you compare plans.
If you have comments or suggestions about how to
improve the structure of this brochure, let us know. Visit OPM's "Rate Us"
feedback area at www. opm. gov/ insure
or e-mail us at fehbwebcomments@
opm. gov. You may also write
to OPM at the Office of Personnel Management, Office of Insurance Planning and Evaluation, 1900
E Street NW, Washington, DC 20415. 5
5 Page 6 7
2002 Kaiser
Foundation Health Plan of Ohio 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 216/ 621-7100, or from
other areas call 800/ 686-7100 or the TTY number at 877/ 676-6677 and
explain the situation.
If we do not resolve the issue, call or write
THE HEALTH CARE FRAUD HOTLINE 202/ 418-3300
The United States
Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400 Washington, DC 20415
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate anyone who uses an ID
card if the person tries to obtain
services for someone who is not an eligible family member, or is no longer
enrolled in the Plan and tries to obtain benefits.
Your agency may also take
administrative action against you. 6
6 Page 7 8
2002 Kaiser Foundation Health Plan of Ohio 7 Section 1
Section 1. Facts about this HMO plan
This Plan is a health
maintenance organization (HMO). We require you to see specific physicians,
hospitals, and other providers that contract with us. These Plan providers
coordinate your health care services.
HMOs emphasize preventive care such as
routine office visits, physical exams, well-baby care, and immunizations, in
addition to treatment for illness and injury. Our providers follow generally
accepted medical practice when
prescribing any course of treatment.
When
you receive services from Plan providers, you will not have to submit claim
forms or pay bills. You only pay the copayments and coinsurance described in
this brochure. When you receive emergency services from non-Plan
providers, you may have to submit claim forms.
You should join an HMO
because you prefer the plan's benefits, not because a particular provider is
available. You cannot change plans because a provider leaves our Plan. We cannot
guarantee that any one physician,
hospital, or other provider will be available and/ or remain under
contract with us.
How we pay providers
Kaiser Foundation Health Plan
of Ohio contracts with a medical group, the Ohio Permanente Medical Group, Inc.
(Medical Group), for medical services. This organization may contract with other
organizations to provide services,
depending upon the area in which you
live. We reimburse the Medical Group for these services through an annually
adjusted capitation rate. This capitation payment is paid to the Medical Group
as a whole for physician services
provided or arranged by the Medical Group.
We also contract with other physicians and local community hospitals. These
Plan providers accept a negotiated payment from us.
Your Rights
OPM requires that all FEHB Plans provide certain
information to their FEHB members. You may get information about us, our
networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types
of information that we must make available to you. Some of the required
information is listed below.
Kaiser Foundation Health Plan of Ohio is a
federally qualified, not-for-profit health maintenance organization licensed to
provide prepaid health services to Ohio residents.
This Plan is part of the
Kaiser Permanente Medical Care Program, a group of not-for-profit organizations
and contracting medical groups that serve over 8 million members nationwide.
We began offering prepaid health services to members and their families in
1969. We presently serve over 160,000 members in the Cleveland and Akron
metropolitan areas.
All Kaiser Permanente and affiliated hospitals are
accredited by the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO).
All applicants for employment with the Ohio Permanente Medical
Group, Inc. must meet rigorous Kaiser Permanente credentialing standards. Once
hired, they undergo periodic review by peers and hospital boards to
assure
their credentials are up to date and in order. All Ohio Permanente Medical
Group, Inc. physicians must be Board Eligible in their specialty and must become
Board Certified within 5 years. At present, 94% are Board Certified. We
credential Plan providers every two years according to NCQA standards.
If you want more information about us, call 216/ 621-7100, or from other
areas call 800/ 686-7100 or the TTY number at 877/ 676-6677 or write to Kaiser
Foundation Health Plan of Ohio, North Point Tower, 1001 Lakeside Avenue,
Cleveland, Ohio 44114. You may also visit our website at www.
kaiserpermanente. org. 7
7 Page
8 9
2002 Kaiser Foundation Health Plan
of Ohio 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:
These counties in the Cleveland Metropolitan area:
Cuyahoga, Geauga, Lake, Lorain, and Medina.
These counties in the Akron
Metropolitan area: Portage, Stark, Summit and Wayne.
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 45; and for emergency care obtained from any non-Plan
provider, as described on page 35. We will not pay for any other health care
services.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your dependents live out of the area (for example, if
your child goes to college in another state), you should consider
enrolling
in a fee-for-service plan or an HMO that has agreements with affiliates in other
areas. If you or a family member move, you do not have to wait until Open Season
to change plans. Contact your employing or retirement
office. 8
8 Page 9 10
2002 Kaiser Foundation Health Plan of Ohio 9
Section 2
Section 2. How we change for 2002
Do not rely on
these change descriptions; this page is not an official statement of benefits.
For that, go to Section 5 Benefits. Also, we edited and clarified language
throughout the brochure; any language change not shown here is a
clarification that does not change benefits.
Program-wide changes
We removed the requirement that services must be needed to restore
functional speech from the speech therapy benefit.
Changes to this Plan
Your share of the non-Postal premium will
increase by 17.5% for Self Only or 17.5% for Self and Family.
We increased
the copayment for radiation therapy from no charge to $10 per visit.
We
increased the copayment for external prosthetics and orthotics from no charge to
20% of our allowance.
We increased the copayment for durable medical
equipment from no charge to 20% of our allowance.
We are now providing a
combination chiropractic and acupuncture benefit. You may have a maximum of 20
visits to chiropractors and acupuncturists. You must get these services through
American Specialty Health
Network. You pay $15 per visit.
We increased the copayment for substance
abuse group therapy from no charge to $5 per office visit.
We changed the
copayment for prescription drugs from $5 for all drugs to $5 per prescription or
refill for generic drugs and $15 per prescription or refill for brand-name
drugs.
We clarified the Preventive care, adult benefit by removing the entry for
blood lead level testing for adults because it is a test more typically done for
children.
If you have Medicare Part B benefits, we now require that you
assign your Medicare Part B benefits to the Plan to receive covered services.
We no longer limit total blood cholesterol tests to certain age groups.
(Section 5( a))
We now cover certain intestinal transplants. (Section 5( b))
We changed the address for sending disputed claims to OPM. 9
9 Page 10 11
2002 Kaiser Foundation Health Plan of Ohio 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
216/ 621-7100 or
800/ 686-7100.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments or coinsurance, and you will not
have to file claims.
Plan providers Plan providers are physicians and other health care
professionals in our service area who we contract with to provide covered
services to our
members. We contract with the Ohio Permanente Medical Group,
Inc. to provide physician services throughout the Cleveland and Akron
metropolitan areas. The Ohio Permanente Medical Group, Inc. has referral
relationships with other specialists within the community. You
are referred
to these specialists when necessary. In addition to the Ohio Permanente Medical
Group, Inc., we have affiliations with physician
networks throughout
Northeast Ohio to offer you greater access and choice.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website:
www. kaiserpermanente. org.
Plan facilities Kaiser Permanente offers comprehensive health care at
Plan facilities conveniently located throughout the Cleveland and Akron
metropolitan
areas and through referral specialists, hospitals, and other
providers in the community. Plan facilities are hospitals and other facilities
in our service
area that we contract with to provide covered services to our
members.
We list these facilities in the provider directory, which we update
periodically. To get a directory, call our Customer Relations Department
at
216/ 621-7100 or toll-free at 800/ 686-7100 from anywhere within the United
States. The list is also on our website:
www. kaiserpermanente. org.
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. Under
the circumstances specified in the brochure,
you may receive follow-up or
continuing care while you travel anywhere.
What you must do to get It depends on the type of care you need.
First, you and each family covered care member must choose a primary care
physician. This decision is
important since your primary care physician
provides or arranges for most of your health care. Choose your primary care
physician from our
provider directory. The directory lists the physicians'
addresses, phone numbers, and lets you know whether the physician is accepting
new 10
10 Page 11
12
2002 Kaiser Foundation Health Plan of Ohio
11 Section 3
patients. To choose or change a primary care
physician, call our Customer Relations Department at 216/ 621-7100 or 800/
686-7100.
Customer Relations can help you too, by telling you who is
available and sharing information about them.
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. When you receive a referral from your primary care
physician, you must
return to the primary care physician after the
consultation, unless your primary care physician authorized a certain number of
visits without
additional referrals. The primary care physician must provide
or authorize all follow-up care. Do not go to the specialist for return visits
unless your primary care physician gives you a referral. However, you may
receive services for routine eye refractions, chiropractic and
acupuncture
care, outpatient mental health, and outpatient alcohol and chemical dependency
without a referral. A woman may see her Plan
obstetrician or Plan
gynecologist without having to obtain a referral.
Here are other things you
should know about specialty care:
If you need to see a specialist frequently
because of a chronic, complex, or serious medical condition, your primary care
physician
will develop a treatment plan that allows you to see your
specialist for a certain number of visits without additional referrals. Your
primary care physician will use our criteria when creating your treatment
plan.
If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will
decide what
treatment you need. If he or she decides to refer you to a specialist, ask if
you can see your current specialist. If your
current specialist does not
participate with us, you must receive treatment from a specialist who does.
Generally, we will not pay for
you to see a specialist who does not
participate with our Plan.
If you are seeing a specialist and your
specialist leaves the Plan, call your primary care physician, who will arrange
for you to see another
specialist. You may receive services from your
current specialist until we can make arrangements for you to see someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
—terminate our contract with your specialist for
other than cause; or
—drop out of the Federal Employees Health Benefits
(FEHB) Program and you enroll in another FEHB plan; or
—reduce our service area and you enroll in another FEHB plan, 11
11 Page 12 13
2002 Kaiser Foundation Health Plan of Ohio 12
Section 3
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 Relations
Department immediately at 216/ 621-7100 or
800/ 686-7100. If you are new to
the FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for
the hospital stay until:
You are discharged, not merely moved to an
alternative care center; or
The day your benefits from your former plan run
out; or
The 92 nd day after you become a member of this Plan,
whichever
happens first.
These provisions apply only to the benefits of the
hospitalized person.
Circumstances beyond our Under certain extraordinary circumstances,
such as natural disasters, we control may have to delay your services or
we may be unable to provide them.
In that case, we will make all reasonable
efforts to provide you with the necessary care.
Services requiring our Your primary care physician has authority to
refer you for most services. 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 precertification. Your physician
must obtain precertification for services such as:
Hospital admissions
Referral to specialists
Recommendations for follow-up care Skilled Nursing
Care
Surgical Procedures
For a complete list of services requiring
preauthorization call our Customer Relations Department at 216/ 621-7100 or 800/
686-7100. If
services are not precertified they will not be covered. 12
12 Page 13 14
2002 Kaiser Foundation Health Plan of Ohio 13
Section 4
Section 4. Your costs for covered services
You
must share the cost of some services. You are responsible for:
Copayments
A copayment is a fixed amount of money you pay to the provider, facility,
pharmacy, etc., when you receive services. Example: When you see your
primary care physician, you pay a copayment of $10 per 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.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for certain services you receive. Example: In our Plan, you pay 30% of
our
allowance for infertility services.
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 $2,000 per person or $6,000 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 for the
following services do not count toward your out-of-pocket maximum and you must
continue to pay for these services as described in this brochure.
Outpatient prescription drugs Contraceptive devices
Dental services
Corrective appliances and artificial aids
Durable medical equipment The $25
charges paid for follow-up or continuing care
Reconstructive surgery
Multidisciplinary services
Extended care services 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. 13
13 Page 14 15
2002 Kaiser Foundation Health Plan of Ohio 14
Section 5
Section 5. Benefits --OVERVIEW
(See page 9
for how our benefits changed this year and page 64 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 216/ 621-7100 or
800/ 686-7100 or at our website at www. kaiserpermanente. org.
(a) Medical services and supplies provided by physicians and other health
care professionals ........................... 15-26
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........................ 27-30
Surgical procedures
Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and
ambulance services...................................................... 31-34
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice
care Ambulance
(d) Emergency services/ accidents
.........................................................................................................................
35-36
Emergency within our service area Emergency outside our service area
Ambulance
(e) Mental health and substance abuse benefits
....................................................................................................
37-39
(f) Prescription drug
benefits................................................................................................................................
40-42
(g) Special
features................................................................................................................................................
43-45
24-hour emergency advice line Centers of excellence for transplants
Flexible benefits option Services from other Kaiser Permanente Plans
Travel benefit
(h) Dental
benefits......................................................................................................................................................
46
(i) Non-FEHB benefits available to Plan members
...................................................................................................
47
Summary of
benefits....................................................................................................................................................
64 14
14 Page 15
16
2002 Kaiser Foundation Health Plan of Ohio
15 Section 5( a)
Section 5 (a). Medical services and supplies
provided by physicians and other health care professionals
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and we cover them only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have no calendar
year deductible.
Be sure to read Section 4, Your costs for covered
services, for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other
coverage, including with Medicare.
I
M
P
O
R
T
A
N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of
physicians and other health care professionals
In a physician's office
In ambulatory surgical centers
In urgent care centers
$10 per office visit
During a hospital stay
In a skilled nursing facility
Nothing
At home $10 for the first 2 visits (nothing thereafter)
Lab, X-ray,
and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine mammograms
CAT scans/ MRI
Ultrasound
Electrocardiogram and EEG
Note: We cover diagnostic services related to the evaluation and treatment of
infertility under our infertility services benefit.
Nothing 15
15 Page
16 17
2002 Kaiser Foundation Health
Plan of Ohio 16 Section 5( a)
Preventive care, adult You pay
Routine screenings, such as:
Total blood cholesterol
Colorectal
cancer screening, including
—Fecal occult blood test
—Sigmoidoscopy
-every five years starting at age 50
Nothing
Routine pap test
Prostate Specific Antigen (PSA test) -one annually for
men age 40 and older
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:
—Age
35 through 39, one during this five-year period
—Age 40 through 64, one
every calendar year
—At age 65 and older, once every two consecutive
calendar years
Routine immunizations and boosters
Note: You will still
pay $10 per visit for professional services of physicians and other health care
professionals.
Not covered:
Physical exams required for:
Obtaining or
continuing employment
Insurance
Governmental licensing
All charges
Preventive care, children
Childhood immunizations recommended by
the American Academy of Pediatrics
Note: You will still pay $10 per visit for professional services of
physicians and other health care professionals.
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 including routine examinations and immunizations
$10 per office visit 16
16 Page 17 18
2002 Kaiser
Foundation Health Plan of Ohio 17 Section 5( a)
Maternity care
You pay
Complete maternity (obstetrical) care, such as:
Prenatal
care
Delivery
Postnatal care
Note: We will waive your copayment for
prenatal care.
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. Your
inpatient stay
will be extended if medically necessary.
We pay hospitalization and
surgeon services (delivery) the same as for illness and injury. See Section 5(
c) for hospital benefits and
Section 5( b) for surgery benefits.
We cover routine nursery care of the
newborn child during the covered portion of the mother's maternity stay.
Note: We cover other care of an infant who requires non-routine treatment for
the first 31 days. The infant will only be covered beyond
the 31 days if the
infant is enrolled under a Self and Family enrollment.
$10 per office visit
Not covered:
Routine sonograms to determine fetal age, size, or
sex
All charges
Family planning
Voluntary sterilization
Family planning
services
Genetic counseling
Note: We cover surgically implanted
contraceptives, injectable contraceptive drugs, intrauterine devices (IUDs), and
diaphragms under
your prescription drug benefit.
$10 per office visit
Not covered:
Reversal of voluntary surgical sterilization
All charges
Infertility services You pay
Diagnosis and treatment of
infertility, such as:
Artificial insemination by intrauterine insemination
(IUI)
Note: You pay 30% of our allowance for inpatient hospital and lab and
X-ray procedures for the evaluation and treatment of involuntary
infertility.
30% of our allowance 17
17 Page 18 19
2002 Kaiser
Foundation Health Plan of Ohio 18 Section 5( a)
Infertility drugs
administered in the office
Note: We cover oral and injectable infertility
drugs under your prescription drug benefit.
50% of our allowance
Not covered:
These exclusions apply to fertile as well as infertile
individuals or couples:
Assisted reproductive technology (ART) procedures, such as:
—in
vitro fertilization
—embryo transfer and gamete intrafallopian
transfer( GIFT)
Services and supplies related to excluded ART
procedures
Intravaginal insemination (IVI)
Intracervical
insemination (ICI)
Ovum transplants
Zygote intrafallopian
transfer (ZIFT)
Services and supplies related to excluded services
Procurement and storage of donor eggs and semen
Procedures
for women who have evidence of ovarian failure
Procedures when either
member of the family has been voluntarily surgically sterilized
Services for surrogate mothers who are not Plan members
Services related to surrogate arrangements
All charges
Allergy care You pay
Testing and treatment
Allergy injection
$10 per office visit
Allergy serum Nothing 18
18 Page 19 20
2002 Kaiser
Foundation Health Plan of Ohio 19 Section 5( a)
Not covered:
Sublingual allergy densitization
All charges
Treatment therapies You pay
Chemotherapy
Radiation therapy
Dialysis – Hemodialysis and peritoneal dialysis at approved facilities
Growth hormone therapy
Note: Drugs for growth hormone therapy (GHT) are
covered under our prescription drug benefit. We cover home health dialysis under
our
home health services benefit.
$10 per office visit
Respiratory and inhalation therapy Nothing
Not covered:
Chemotherapy supported by a bone marrow transplant or with stem cell
support, for any diagnosis not listed as covered
All charges
Physical and occupational therapies
We cover two consecutive
months or 30 visits, whichever is greater, per condition for:
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 self-care and improved functioning in other activities of
daily life
$10 per outpatient visit
Nothing for inpatient
Multidisciplinary rehabilitation facility services are provided up to two
months per condition. Outpatient rehabilitation, including diagnostic
and
restorative services, providing a program of physical, speech, occupational,
respiratory therapy, social and psychological services, and
other items and
services that are medically necessary for rehabilitation. The two month limit
applies to all inpatient and outpatient
comprehensive rehabilitation
services you may receive for the same condition.
No charge
Not covered:
Long-term rehabilitative therapy
Cognitive rehabilitative therapy
Cardiac rehabilitation
All charges 19
19 Page 20 21
2002 Kaiser
Foundation Health Plan of Ohio 20 Section 5( a)
Speech therapy
You pay
We cover two consecutive months or 30 visits, whichever is
greater, per condition for:
Speech therapy by speech therapists when medically necessary
$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 or therapy to improve articulation in the absence of injury,
illness, or medical condition affecting articulation
Therapy for tongue thrust in the absence of swallowing problems
All charges
Hearing services (testing, treatment, and supplies)
Hearing tests
to determine the need for hearing correction $10 per office visit
Not
covered:
Hearing aids, examinations, and tests to determine their
effectiveness
All other hearing testing
All charges
Vision services (testing, treatment, and supplies)
Diagnosis and
treatment of diseases of the eye
Eye refractions
$10 per office visit
Not covered:
Corrective eyeglass lenses and frames
Contact lenses
Examinations for contact lenses and the
fitting of contact lenses
Refractions for contact lenses
Eye surgery solely for the purpose of correcting refractive defects
of the eye
Eye exercise and orthoptics
All charges
Foot care
Foot care when you are under active treatment for a
metabolic or peripheral vascular disease, such as diabetes, when prescribed by a
physician
$10 per office visit 20
20
Page 21 22
2002
Kaiser Foundation Health Plan of Ohio 21 Section 5( a)
Orthopedic and prosthetic devices You pay
Internal prosthetic
devices, such as:
Pacemakers
Artificial joints
Surgically implanted
breast implant following mastectomy
Nothing
External prosthetic and orthotic devices and braces are provided under Plan
criteria such as:
Breast prostheses and surgical bras, including necessary
replacements, following a mastectomy
Permanent lenses
Artificial limbs
Terminal devices
Braces
Appliances essential to the effective use of
artificial limbs or braces
External cardiac pacemakers
Corrective
orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ)
pain dysfunction syndrome
20% of our allowance
Not covered:
Comfort, convenience, or luxury equipment or
features
Corrective shoes
Arch supports
Foot
orthotics
Corsets, elastic stockings, garter belts, and other
nonrigid appliances
Replacement or repair of prosthetic or orthotic appliances because of
misuse or loss
Educational training in the use of the prosthetic
devices and orthotic appliances
Prosthetics related to the treatment
of sexual dysfunction
All charges 21
21 Page 22 23
2002 Kaiser
Foundation Health Plan of Ohio 22 Section 5( a)
Durable
medical equipment (DME) You pay
Rental or purchase, at our option, of
durable medical equipment provided under our criteria on January 1, 2001, is
covered when used in
your home (more than once), would not be of use to you
if you were not ill or injured, and when prescribed by your Plan physician.
Under this
benefit, we cover:
Hospital beds
Oxygen
Wheelchairs
Crutches
Walkers
Blood glucose monitors
Commodes
Note: We
cover repair and replacement not caused by misuse or loss.
20% of our allowance
Not covered:
Deluxe equipment such as motor driven wheelchairs
and beds, except when such deluxe features are necessary for the effective
treatment of your condition and required in order for you to operate the
equipment
Comfort, convenience, or luxury equipment or features
Physician's equipment
Exercise and hygienic equipment
Self help devices that are not medical in nature such as sauna baths
or elevators
Experimental or research equipment
Replacement or repair that
is needed due to misuse or loss
Devices equipment and supplies
related to the treatment of sexual dysfunction
Electronic monitors of the heart or lungs (except apnea monitors for
newborns)
Devices to perform medical tests on blood or other bodily
substances or excretions (except blood glucose monitors for insuling
dependent diabetics)
All charges 22
22 Page 23 24
2002 Kaiser
Foundation Health Plan of Ohio 23 Section 5( a)
Home health
services You pay
If you are homebound and reside within the service
area:
You may receive home health care ordered by a Plan physician and
provided by a registered nurse, practical nurse, licensed vocational
nurse, or home health aide
Services include oxygen therapy, intravenous
therapy and medications
Nothing
Home dialysis
—Hemodialysis
—Intermittent peritoneal dialysis
—Continuous ambulatory peritoneal dialysis
Intravenous (IV)/ Infusion
Therapy
Not covered:
Nursing care requested by, or for the convenience
of, the patient or the patient's family
Home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or rehabilitative
Services outside the service area
All charges 23
23 Page 24 25
2002 Kaiser
Foundation Health Plan of Ohio 24 Section 5( a)
Chiropractic
You pay
You may receive up to 20 visits for chiropractic and acupuncture
services. The total visit limit is 20 for any combination of chiropractic
or
acupuncture services.
Chiropractic services are provided through American
Specialty Health Network (ASHN). You will have direct access to a participating
ASHN
chiropractor without the need to obtain a Plan physician referral.
Participating chiropractors are listed in the ASHN Participating
Provider
Directory.
You phone the ASHN chiropractor you have selected for an
initial examination. After the initial examination, your ASHN chiropractor is
responsible for obtaining authorization from ASHN for any additional
chiropractic services on your behalf.
You may receive 20 visits for chiropractic services (in combination with
acupuncture services) for the treatment of neuromusculoskeletal
disorders.
Services include:
Examinations
Adjunctive chiropractic therapy such as
ultrasound, hot packs, cold packs, and electrical stimulation
Plain film X-rays and laboratory tests
Up to $50 for chiropractic
appliances
$15 per office visit
Not covered:
Any service that is not authorized or delivered by
participating providers
Hypnotherapy, behavior training, sleep therapy, and weight programs
Thermography
Any radiologic exam other than plain film
studies such as, magnetic resonance imaging, CAT scans, bone scans, nuclear
radiology
Education programs, non-medical self care or self help or any self-help
physical exercise training or any related diagnostic testing
Services
or treatments for pre-employment physicals or vocational rehabilitation
Adjunctive therapy not associated with spinal, muscle or joint
manipulation
All charges 24
24 Page 25 26
2002 Kaiser
Foundation Health Plan of Ohio 25 Section 5( a)
Alternative
treatments You pay
Biofeedback when administered by our mental health
department as part of a prescribed pain management program or a treatment plan
for other physical symptoms which are not responsive to the usual medical
treatment methods
$10 per office visit
You may receive up to 20 visits for acupuncture and chiropractic services.
The total visit limit is 20 for any combination of acupuncture
or
chiropractic services.
Acupuncture services are provided through American
Specialty Health Network (ASHN). You will have direct access to a participating
ASHN
acupuncturist without the need to obtain a Plan physician referral.
Participating acupuncturists are listed in the ASHN Participating
Provider Directory.
You phone the ASHN acupuncturist you have
selected for an initial examination. After the initial examination, your ASHN
acupuncturist is
responsible for obtaining authorization from ASHN for any additional
acupuncture services on your behalf.
You may receive 20 visits for acupuncture services (in combination with
chiropractic services) for the treatment of neuromusculoskeletal
disorders,
nausea, or pain syndromes. Services include:
Examinations
Adjunctive
acupuncture therapy such as acupressure, moxibustion, and cupping
Plain film X-rays and laboratory tests
$15 per office visit
Not covered:
Any service that is not authorized or delivered by
participating providers
Hypnotherapy, behavior training, sleep therapy, and weight programs
Thermography
Any radiologic exam other than plain film
studies such as, magnetic resonance imaging, CAT scans, bone scans, nuclear
radiology
Education programs, non-medical self care or self help or any self-help
physical exercise training or any related diagnostic testing
Services
or treatments for pre-employment physicals or vocational rehabilitation
Adjunctive therapy not associated with acupuncture
All
other forms of alternative treatment
All charges 25
25 Page 26 27
2002 Kaiser
Foundation Health Plan of Ohio 26 Section 5( a)
Educational
classes and programs You pay
Health education classes and specially
ordered materials Class fee varies
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:
Adult Asthma Management
Adult Chronic Obstructive Lung
Disease (COPD) Management
The Beat Goes On for heart patients
Diabetes
Challenge
Class fee varies
Lifestyle and health promotion classes, such as:
Pregnancy Basics
Weight Watchers ™/ Weight Management
Walkercise Workout
Class fee varies
Other classes (including support groups) such as:
Managing Menopause
Education in the appropriate use of the Plan
Health education
publications which tell you how to maintain physical and mental health and
prevent illness and injury
Class fee varies
Not covered:
All other educational programs and materials
All charges 26
26 Page
27 28
2002 Kaiser Foundation Health
Plan of Ohio 27 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 PRECERTIFICATION FOR ALL SURGICAL PROCEDURES. Please refer to the
precertification information shown in Section 3 to
be sure which surgeries require precertification.
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures
A
comprehensive range of services, such as:
Operative procedures
Treatment
of fractures, including casting
Normal pre-and post-operative care by the
surgeon
Pre-surgical testing
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Surgical treatment of morbid obesity --a condition in which an individual
weighs 100 pounds or 100% over ideal body weight
and/ or 200% of his or her ideal weight according to current underwriting
standards for 3 years; eligible members must be age
21-60 and meet our
medical criteria
Insertion of internal prosthetic devices. See Section 5( a)
-
Orthopedic and prosthetic devices for device coverage information
Voluntary sterilization (tubal ligation and vasectomy)
Norplant (a
surgically implanted contraceptive) and intrauterine devices (IUDs). Note:
Devices are covered under Section 5( a).
Treatment of burns
$10 per office visit for outpatient services
Nothing for inpatient
services 27
27 Page
28 29
2002 Kaiser Foundation Health
Plan of Ohio 28 Section 5( b)
Not covered:
Reversal of
voluntary sterilization
Routine foot care
All charges
Reconstructive surgery You pay
Surgery to correct a functional
defect
Surgery to correct a condition caused by injury or illness if:
—the condition produced a major effect on the member's appearance; and
—the condition can reasonably be expected to be corrected by such surgery.
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.
$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, except repair of accidental injury
Surgeries related to sex transformation
All charges
Oral and maxillofacial surgery
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 tumors
Other surgical procedures that
do not involve the teeth or their
supporting structures
$10 per office visit for outpatient services
Nothing for inpatient
services 28
28 Page
29 30
2002 Kaiser Foundation Health
Plan of Ohio 29 Section 5( b)
Not covered:
Correction of
malocclusion
Procedures that involve the teeth or their supporting
structures (such as the periodontal membrane, gingiva, and alveolar bone)
Dental care involved in treatment of temporomandibular joint (TMJ) pain
dysfunction syndrome
Dental services associated with medical
treatment such as surgery and radiation treatment
Oral implants and
transplants
All charges
Organ/ tissue transplants You pay
In order to receive a covered
transplant you must satisfy the criteria developed by us. Transplants are
limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single – Double
Pancreas
Allogeneic (donor) bone marrow
transplants
Autologous bone marrow transplants (autologous stem cell and
peripheral stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ
cell tumors
Intestinal transplants
(small intestine) and the small intestine with the liver or small intestine with
multiple organs such as the liver,
stomach, and pancreas
Limited Benefits -Treatment for breast cancer,
multiple myeloma, and epithelial ovarian cancer may be provided in an NCI-or
NIH-approved
clinical trial at a Plan-designated center of excellence and if approved by
the Plan's medical director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor when we
cover your transplant.
$10 per office visit for outpatient services
Nothing for inpatient
services 29
29 Page
30 31
2002 Kaiser Foundation Health
Plan of Ohio 30 Section 5( b)
Not covered:
Donor screening
tests and donor search expenses, except those performed for the actual donor
Implants of artificial or non-human organs
Transplants not
listed as covered
All charges
Anesthesia You pay
Professional services provided in:
Hospital
(inpatient)
Nothing
Professional services provided in:
Hospital outpatient department
Ambulatory surgical center
Office
$10 per office visit 30
30 Page 31 32
2002 Kaiser
Foundation Health Plan of Ohio 31 Section 5( c)
Section 5 (c).
Services provided by a hospital or other facility, and ambulance services
I
M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and we cover them only when we
determine they are
medically necessary.
Plan physicians must provide or arrange your care
and you must be hospitalized in a Plan facility.
We have no calendar year deductible.
Be sure to read Section 4, Your
costs for covered services, for valuable information about how cost sharing
works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The
amounts listed below are for the charges billed by the facility (i. e., hospital
or surgical center) or ambulance service for your surgery or care. Any costs
associated with the professional charge (i. e., physicians, etc.) are covered
in Section 5( a) or (b).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS (except for
Maternity stays). Please refer to Section 3 to be sure which
services
require precertification.
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as:
Ward, semiprivate, or intensive care accommodations
General
nursing care
Meals and special diets
Note: If you want a private room
when it is not medically necessary, you pay the additional charge above the
semiprivate room rate.
Note: We cover hospital services related to the treatment of infertility
under our infertility services benefit.
Nothing 31
31 Page
32 33
2002 Kaiser Foundation Health
Plan of Ohio 32 Section 5( c)
Inpatient hospital You pay
Other hospital services and supplies, such as:
Operating, recovery,
maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood
products
Blood and blood products
Dressings, splints, plaster casts, and
sterile tray services
Medical supplies, appliances, and equipment, including
oxygen
Anesthetics including nurse anesthetist services
Take-home items
Note: You may receive covered hospital services for certain dental
procedures if a Plan physician determines you need to be hospitalized for
reasons unrelated to the dental procedure. The conditions for which we will
provide hospitalization include hemophilia and heart disease. The
need for
anesthesia, by itself, is not such a condition. We do not cover the dental
procedures.
Nothing
Not covered:
Personal comfort items, such as telephone,
television, barber services, guest meals, and beds
Private nursing care
Custodial care
Non-covered
facilities, such as nursing homes, extended care facilities, and schools
Any inpatient dental procedures
All charges
Outpatient hospital or ambulatory surgical center
Operating,
recovery, and other treatment rooms
Prescribed drugs and medicines
Dressings, casts, and sterile trays
Diagnostic laboratory tests, X-rays,
and pathology services
Administration of blood and blood products
Pre-surgical testing
Medical supplies, including oxygen
Anesthetics
and anesthesia service
Nothing 32
32 Page
33 34
2002 Kaiser Foundation Health
Plan of Ohio 33 Section 5( c)
Extended care benefits/ skilled
nursing care facility benefits You pay
Up to 100 days per calendar year
When full-time skilled nursing care is necessary
Confinement in a
skilled nursing facility is medically appropriate
Services include:
Bed,
board, and general nursing care
Prescribed drugs and their administration,
biologicals, supplies, and equipment ordinarily provided or arranged by the
skilled nursing
facility
Nothing
Not covered:
Custodial care
Care in an intermediate
care facility
All charges
Hospice care
Supportive and palliative care for a terminally ill
member with a life expectancy of less than six months:
You must reside in the service area
Services are provided in the home
Services are provided in a Plan approved hospice facility
Services
include inpatient care, outpatient care, and family counseling. A Plan physician
must certify that you have a terminal illness, with a
life expectancy of approximately six months or less.
Note: Hospice is a
program for caring for the terminally ill that emphasizes supportive services,
such as home care and pain control,
rather than curative care of the terminal illness. A person who is terminally
ill may elect to receive hospice benefits. These palliative
and supportive
services include nursing care, medical social services, physician services, and
short-term inpatient care for pain control and
acute and chronic symptom
management. We also provide counseling and bereavement services for the
individual and family members, and
therapy for purposes of symptom control
to enable the person to continue life with as little disruption as possible. If
you make a hospice
election, you are not entitled to receive other health
care services that are related to the terminal illness. If you have made a
hospice election,
you may revoke that election at any time, and your
standard health benefits will be covered.
Nothing 33
33 Page
34 35
2002 Kaiser Foundation Health
Plan of Ohio 34 Section 5( c)
Not covered:
Independent
nursing
Homemaker services
All charges
Ambulance You pay
Local professional ambulance service when
medically necessary and ordered or authorized by a Plan physician $50 per trip
Not covered:
Transports that we determine are not medically
necessary
All charges 34
34 Page 35 36
2002 Kaiser
Foundation Health Plan of Ohio 35 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.
We have no calendar year deductible.
Be sure to read Section 4, Your
costs for covered services, for valuable information about how cost sharing
works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
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 or go to the nearest hospital emergency room. Be sure to tell the
emergency room personnel that you are a Plan member so they can notify us. You
or a family member must notify us within 48
hours unless it is not reasonable to do so. It is your responsibility to be
sure we have been timely notified.
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. However, if you reasonably
believe you can safely go to a Plan hospital, call us or
go to a Plan
Emergency Room. The emergency telephone numbers to call us are: Cleveland area
216/ 445-4900; Akron area 800/ 686-2240. These numbers are available 24 hours
per day, 7 days a week. You must return to us for
follow-up care after
emergency services are received within our service area.
If you are admitted
to a non-Plan facility, we must be notified within 48 hours or on the first
working day following your admission, unless it is not reasonably possible to
notify us within that time. If you are hospitalized in non-Plan
facilities
and our physicians believe care can be better provided in a Plan designated
hospital, you will be transferred when medically feasible. You can call us in
Cleveland at 216/ 445-4900 or toll free anywhere in the United States at
800/ 686-2240. Benefits are available for care from non-Plan providers in a
medical emergency only if delay in reaching us would result in death,
disability, or significant jeopardy to your condition.
Emergencies outside our service area:
If you are not near another
Kaiser Permanente facility you may seek care at any emergency room, urgent care
or physician's office for medically necessary health service that is immediately
required because of injury or
unforeseen illness.
If you need to be
hospitalized, you must notify us as soon as is 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 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 call our Customer Relations Department at
800/ 686-7100. See Travel Benefits Section 5( g) for follow up care received
outside the service area. 35
35 Page 36 37
2002 Kaiser
Foundation Health Plan of Ohio 36 Section 5( d)
Benefit
Description You pay
Emergency within our service area
Emergency care
as an outpatient or inpatient at a hospital, including physicians' services
At a physician's office
At a Plan urgent care center
$10 per visit
In a hospital emergency room
Note: We waive your copayment if you are
admitted to a hospital.
$50 per visit
Not covered:
Elective care or non-emergency care
All
charges
Emergency outside our service area
At a physician's office
At
an urgent care center
$10 per visit
In a hospital emergency room $50 per visit
In a Kaiser Foundation
hospital in another Kaiser Foundation Health Plan service area
Note: See the Travel Benefit for coverage of continuing or follow-up care. We
waive your copayment if you are admitted to a hospital.
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
Ambulance
Professional ambulance, air or ground service, when
medically appropriate
Note: See Section 5( c) for non-emergency service.
$50 per trip
Not covered:
Transports we determine are not medically
necessary
All charges 36
36 Page 37 38
2002 Kaiser
Foundation Health Plan of Ohio 37 Section 5( e)
Section 5 (e).
Mental health and substance abuse benefits
I M
P O
R T
A N
T
When you get our approval for services and follow a treatment plan we
approve, cost-sharing and limitations for Plan mental health and substance abuse
benefits will be no greater than for
similar benefits for other illnesses
and conditions.
Here are some important things to keep in mind about
these benefits:
Please remember that all benefits are subject to the
definitions, limitations, and exclusions in this brochure and we cover them only
when we determine they are clinically appropriate
to treat your condition.
Plan physicians must provide or arrange your
care.
We have no calendar year deductible.
Be sure to read Section 4,
Your costs for covered services, for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Mental health and substance abuse benefits
We cover all diagnostic and treatment services recommended by a Plan
provider and contained in a treatment plan. The treatment plan may
include
services, drugs, and supplies described elsewhere in this brochure.
Note: We cover the services only when we determine that the care is
clinically appropriate to treat your condition, and only when you receive
the care as part of a treatment plan developed by a Plan provider.
Note:
OPM will base its review of disputes about treatment plans on the treatment
plan's clinical appropriateness. OPM will generally not order
us to pay or
provide one clinically appropriate treatment in favor of another.
Your cost sharing responsibilities are no greater than for other
illnesses or conditions 37
37 Page 38 39
2002 Kaiser
Foundation Health Plan of Ohio 38 Section 5( e)
Mental health
and substance abuse benefits You pay
Diagnosis and treatment of
psychiatric conditions for children, adolescents, and adults. Services include:
Diagnostic evaluation
Treatment and counseling (including individual and
group therapy visits)
Crisis intervention and stabilization for acute episodes
Psychological
testing necessary to determine the appropriate psychiatric treatment
Diagnosis and treatment of alcoholism and drug abuse. Services include:
Detoxification (medical management of withdrawal from the substance)
Treatment and counseling (including individual and group therapy visits)
Note: You may see an outpatient mental health or substance abuse provider
without a referral from your primary care physician.
Note: Your mental
health or substance abuse provider will develop a treatment plan to assist you
in improving or maintaining your condition and
functional level, or to
prevent relapse and will determine which diagnostic and treatment services are
appropriate for you.
$10 per office visit for individual therapy
$5 per office visit for group
therapy
Medication evaluation and management $10 per office visit
Inpatient
psychiatric or substance abuse care
Hospital alternative services, such as
partial hospitalization, day and night care
Note: All inpatient admissions and hospital alternative services treatment
programs require approval by a Plan physician.
Nothing 38
38 Page
39 40
2002 Kaiser Foundation Health
Plan of Ohio 39 Section 5( e)
Mental health and substance
abuse benefits You pay
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
Limitation We may limit your benefits if you do not obtain a treatment
plan. 39
39 Page
40 41
2002 Kaiser Foundation Health
Plan of Ohio 40 Section 5( f)
Section 5 (f). Prescription drug
benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and we cover them only when we
determine they are
clinically appropriate to treat your condition.
We
have no calendar year deductible.
Be sure to read Section 4, Your costs
for covered services, for valuable information about how cost sharing works.
Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
There are important features you should be aware of. These include:
Who can write your prescription. A licensed Plan physician must write
the prescription.
Where you can obtain them. You may fill the
prescription at a Plan or affiliated pharmacy or get refills by mail.
We use a formulary. Drugs are prescribed by Plan Physicians and
dispensed according to our drug formulary. A formulary is a list 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. Non-formulary drugs will be covered when prescribed by a Plan
physician when the drug is medically necessary. If you request a non-formulary
drug when your
physician has prescribed a substitution, the non-formulary
drug is not covered. You may purchase the non-formulary drug from a Plan
pharmacy at prices charged to members for non-covered drugs.
These are the dispensing limitations. Prescription drugs will be
provided up to a 31-day supply or 62-day supply for mail order. We provide up to
a 31-day supply based upon (a) the prescribed dosage, (b)
the standard
manufacturers package size, and (c) specified dispensing limits. Certain drugs
for sexual dysfunction also have a dispensing limit less than a 31-day supply.
If you ask for a mail order
prescription too soon after the last one was
filled, the mail order pharmacy staff will send you a letter telling you it was
too soon to fill the prescription.
Why use generic drugs? The generic name of a drug is its chemical
name; the name brand is the name under which the manufacturer advertises and
sells a drug. Under federal law, generic and name brand
drugs must meet the
same standards for safety, purity, strength, and effectiveness. Generic drugs
cost you and your plan less money than a name-brand drug.
When you have to file a claim. When you receive drugs from a Plan
pharmacy, you do not have to file a claim. For a covered out-of-area emergency,
you will need to file a claim when you receive drugs
from a non-Plan
pharmacy.
Prescription drug benefits begin on the next page. 40
40 Page 41 42
2002 Kaiser Foundation Health Plan of Ohio 41
Section 5( f)
Benefit Description You pay
Covered medications
and supplies
We cover the following medications and supplies:
Drugs
for which a prescription is required by law
Insulin
Oral contraceptives
and diaphragms
Disposable needles and syringes for the administration of
insulin
Growth hormones
$5 per prescription or refill for generic drugs
$15 per prescription or
refill for brand-name drugs
Contraceptive devices, implanted time-release drugs, and injectable
contraceptives $5 times the number of months the generic contraceptive is
expected to
be effective. The most you will pay is $200.
$15 times the number of months the brand-name contraceptive is
expected
to be effective. The most you will pay is $200.
Infertility drugs
Drugs for sexual dysfunction
Note: Certain drugs to
treat sexual dysfunction have a dispensing limit of 8 tablets per month for a
single copay.
50% of our allowance 41
41 Page 42 43
2002 Kaiser
Foundation Health Plan of Ohio 42 Section 5( f)
Covered
medications and supplies You pay
Not covered:
Drugs and
supplies for cosmetic purposes
Vitamins and nutritional supplements
that can be purchased without a prescription
Nonprescription drugs
Prescriptions filled at non-Plan
pharmacies, except for out-of-area emergencies
Medical supplies such as dressings and antiseptics
Drugs to
enhance athletic performance
Drugs for non-covered services
Smoking cessation drugs including nicotine patches
Drugs
for the purpose of weight loss
Drugs and materials that require
administration by medical personnel or observation by medical personnel during
or after
administration
Replacement of lost or damaged prescriptions
Benzoyl peroxide products
All charges 42
42 Page 43 44
2002 Kaiser
Foundation Health Plan of Ohio 43 Section 5( g)
Section 5 (g).
Special features
Feature Description
24 hour emergency advice line 24 hours a day, 7 days a week, you may
call 800/ 686-2240 and talk with a registered nurse who will help you decide
your treatment options when you are not sure what to do.
Centers of excellence for transplants Kaiser Permanente, nationally,
has a National Transplant Network that contracts with transplant centers that
meet our requirements for excellence.
The Centers of Excellence program
began in Fall 1987. As new technologies proliferate and become the standard of
care, Kaiser
Permanente refers members to contracted "centers of excellence"
for certain specialized medical procedures.
We have developed a network of Centers of Excellence for organ
transplantation, which consists of medical facilities that have met
stringent criteria for quality care in specific procedures. A national
clinical and administrative team has developed guidelines for site
selection, site visit protocol, volume and survival criteria for evaluation
and selection of facilities. The institutions have a record of
positive
outcomes and exceptional standards of quality.
Flexible benefits option Under the flexible benefits option, we
determine the most effective way to provide services.
We may identify
medically appropriate alternatives to traditional care and coordinate other
benefits as a less costly alternative
benefit.
We review alternative benefits on an ongoing basis.
By
approving an alternative benefit, we cannot guarantee you will get it in the
future.
The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.
Our decision
to offer or withdraw alternative benefits is not subject to OPM review under the
disputed claims process. 43
43 Page 44 45
2002 Kaiser
Foundation Health Plan of Ohio 44 Section 5( g)
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 office visits or days, you are entitled to
receive only the number of visits or days covered by this Plan.
If you
are seeking routine, non-emergent, or non-urgent services, you should call the
Kaiser Permanente Membership Services department in
that service area and
request an appointment. You may obtain routine follow-up or continuing care from
these Plans, even when you have
obtained the original services in 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 Relations Department at 216/ 621-7100 or 800/
686-7100. 44
44 Page
45 46
2002 Kaiser Foundation Health
Plan of Ohio 45 Section 5( g)
Travel benefit Kaiser
Permanente's travel benefits for Federal employees provide you with outpatient
follow-up or continuing medical care when you are outside your home service area
by more than 100 miles and outside of
any other Kaiser Permanente service
area. These benefits are in addition to your emergency and urgent care benefits
and include:
Outpatient follow-up care necessary to complete a course of treatment after a
covered emergency. Services include removal of
stitches, a catheter, or a
cast.
Outpatient continuing care for 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 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 Kaiser Foundation Health Plan of Ohio, Claims
Department, P. O. Box 5316, Cleveland, Ohio,
44101-0309
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 45
45 Page 46 47
2002 Kaiser Foundation Health Plan of Ohio 46
Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R
T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and we pay them only when we
determine they are dentally necessary.
Plan dentists must provide or arrange your care.
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.
We have no calendar
year deductible.
Be sure to read Section 4, Your costs for covered
services, for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
Accidental injury benefit
Service You pay
No Benefit All
charges
Dental benefits
Service You pay
No Benefit All charges
46
46 Page 47
48
2002 Kaiser Foundation Health Plan of Ohio
47 Section 5( i)
Section 5 (i). Non-FEHB benefits available to
Plan members
The benefits on this page are not part of the FEHB contract
or premium, and you cannot file an FEHB disputed claim about them. Fees
you pay for these services do not count toward FEHB deductibles or out-of-pocket
maximums.
(VAPP) Value Added Purchasing Plans Value Added Purchasing Plans
(VAPPs) provide members with lower prices on health-related goods and services
that
may not be covered by their basic or supplemental health plans. The
Value Added Purchasing Plans use Kaiser Permanente's ability to direct its
members to vendors in exchange for reduction in prices for those goods and
services.
Members of Kaiser Permanente are eligible for substantial savings
on the following goods and services:
Dental VAPP Dental VAPP allows Members to purchase dental services at
favorable prices from selected community dentists.
Members must use one of
the Affiliated General Dentists participating in Kaiser Permanente's Dental
VAPP. For a list of Affiliated General Dentists and a schedule of complete
benefits, call 216/ 621-7100 or 800/ 686-7100.
Vision VAPP Vision VAPP entitles Kaiser Permanente members to special
discounts on designated optical goods and services
purchased from quality
vision care suppliers conveniently located throughout Northeast Ohio. Members
must obtain their eyeglass examinations or refractions at Kaiser Permanente.
Prescriptions must be filled at a participating optical
provider for members
to receive discounts of 15% -20% on designated optical goods and services. For
additional information, contact Kaiser Permanente at 216/ 621-7100 or 800/
686-7100.
TO QUALIFY FOR DISCOUNTS AND SAVINGS ON DENTAL AND VISION VAPPS,
MEMBERS MUST PRESENT THEIR KAISER PERMANENTE IDENTIFICATION CARD AT THE TIME OF
SERVICE OR
PURCHASE.
Expanded Dental Benefits In addition to your Dental VAPP coverage,
supplemental dental coverage is available to you through Delta Dental, a
national dental provider. Your Dental VAPP coverage through Kaiser
Permanente is not affected by this product offering.
DeltaPremier DeltaPremier allows you to choose any licensed dentist,
however, discounted pricing is available only through Delta's
provider
network. After you satisfy a deductible, Delta will pay a predetermined amount
toward each covered services. There is no deductible for covered preventive
services you receive. DeltaPremier offers a full range of
covered services:
diagnostic, preventive, restorative, endodontics, periodontics, oral surgery,
and both fixed and removable prosthodontics. Orthodontic coverage is not
available. Covered services will be phased in over a three
year period. Self
Self and One Party Family
Monthly Premiums $18.45 $33.45 $52.45
DeltaPremier is only available to you if you are enrolled in Kaiser
Permanente's Plan for FEHB. If you enroll in DeltaPremier, your payments will be
made directly to Delta. Payroll deduction is not available for this program. You
do not need to purchase this program to receive Kaiser Permanente Dental
VAPP coverage.
How to Enroll An enrollment form for DeltaPremier is included in your
Kaiser Permanente enrollment kit. If you would like more
information on
DeltaPremier, please call Delta Dental at 800/ 932-0783; TDD 888/ 373-3582. 47
47 Page 48 49
2002 Kaiser Foundation Health Plan of Ohio 48
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;
Services, drugs, or supplies you receive from a provider or facility barred
from the FEHB Program; or
Services required for (a) obtaining or maintaining
employment or participation in employee programs or (b) insurance or
governmental licensing. 48
48 Page 49 50
2002 Kaiser
Foundation Health Plan of Ohio 49 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 may 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 216/ 621-7100 or from other areas at
800/ 686-7100,
or the TTY number at 877/ 676-6677.
When you must file a
claim – such as for out-of-area care – submit it on HCFA-1500 or a claim form
that includes the information shown below.
Bills and receipts should be itemized and show:
Covered member's name and
ID number;
Name and address of the physician or facility that provided the
service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of each
service or supply;
The charge for each service or supply;
A copy of the
explanation of benefits, payments, or denial from any primary payer – such as
the Medicare Summary Notice (MSN); and
Receipts, if you paid for your services.
Submit your claims to:
Claims Administration
Kaiser Foundation Health Plan of Ohio P. O. Box 5316
Cleveland, OH
44101-0309
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. 49
49 Page
50 51
2002 Kaiser Foundation Health
Plan of Ohio 50 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: Customer Relations Department,
Kaiser Foundation Health Plan of Ohio, P. O. Box 5309, Cleveland, OH 44101-0309,
Attn: Member Advocate; 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, DC 20415-3630. 50
50 Page 51 52
2002 Kaiser Foundation Health Plan of Ohio 51
Section 8
Send OPM the following information:
A statement about
why you believe our decision was wrong, based on specific benefit provisions in
this brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies of
all letters we sent to you about the claim; and
Your daytime phone number
and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your representative, such as medical providers, must
include a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable
to meet the deadline because of reasons beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received the
disputed services, drugs, or supplies or from the year in which you were denied
precertification or prior
approval. This is the only deadline that may not
be extended.
OPM may disclose the information it collects during the review
process to support their disputed claim decision. This information will become
part of the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your lawsuit, benefits, and payment of benefits.
The Federal court will base its review on the record that was
before OPM
when OPM decided to uphold or overturn our decision. You may recover only the
amount of benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily functions or death if not treated as soon as
possible), and
(a) We haven't responded yet to your initial request for care
or preauthorization/ prior approval, then call us at 216/ 621-7100, or from
other areas call 800/ 686-7100 or the TTY number at 877/ 676-6677 and we will
expedite our review; or
(b) We denied your initial request for care or
pre-authorization/ prior approval, then:
If we expedite our review and
maintain our denial, we will inform OPM so that they can give your claim
expedited treatment too, or
You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755
between 8 a. m. and 5 p. m. eastern time. 51
51
Page 52 53
2002
Kaiser Foundation Health Plan of Ohio 52 Section 9
Section 9.
Coordinating benefits with other coverage
When you have other health You
must tell us if you are covered or a family member is covered under coverage
another group health plan or have automobile insurance that pays health
care expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan is the primary payer; it pays
benefits first. The other plan pays a reduced benefit as the secondary
payer. We, like other insurers, determine which coverage is primary
according to the National Association of Insurance Commissioners'
Guidelines.
When we are the primary payer, we will pay the benefits
described in this brochure.
When we are the secondary payer, we will determine our allowance. After the
primary payer plan pays, we will pay what is left of our
allowance, up to
our regular benefit. We will not pay more than our allowance. If we are the
secondary payer, and you received your services
from Plan providers, we may
bill the primary carrier.
What is Medicare? Medicare is a Health
Insurance Program for:
People 65 years of age and older. Some people with
disabilities, under 65 years of age.
People with End-Stage Renal Disease (permanent kidney failure requiring
dialysis or a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A. If you or your spouse worked for at least 10 years in
Medicare-covered
employment, you should be able to qualify for premium-free Part A insurance.
(Someone who was a Federal employee on January
1, 1983 or since
automatically qualifies.) Otherwise, if you are age 65 or older, you may be able
to buy it. Contact 1-800-MEDICARE for
more information.
Part B (Medical
Insurance). Most people pay monthly for Part B. Generally, Part B premiums are
withheld from your monthly Social
Security check or your retirement check.
If you are eligible for Medicare, you may have choices in how you get your
health care. Medicare+ Choice is the term used to describe the
various
health plan choices available to Medicare beneficiaries. The information in the
next few pages shows how we coordinate benefits
with Medicare, depending on
the type of Medicare managed care plan you have.
The Original Medicare Plan The Original Medicare Plan (Original
Medicare) is available everywhere (Part A or Part B) in the United
States. It is the way everyone used to get Medicare benefits
and is the way
most people get their Medicare Part A and Part B benefits now. You may go to any
doctor, specialist, or hospital that accepts
Medicare. The Original Medicare
Plan pays its share and you pay your share. Some things are not covered under
Original Medicare, like
prescription drugs. 52
52
Page 53 54
2002
Kaiser Foundation Health Plan of Ohio 53 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.) 53
53 Page 54 55
2002 Kaiser Foundation Health Plan of Ohio 54
Section 9
The following chart illustrates whether the Original
Medicare Plan or this Plan should be the primary payer for you according to
your employment status and other factors determined by Medicare. It is critical
that you tell us if you or
a covered family member has Medicare coverage so
we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is… A. When either you --or
your covered spouse --are age 65 or over and …
Original Medicare This Plan
1) Are an active employee with the
Federal government (including when you or a family member are eligible for
Medicare solely
because of a disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government when…
a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB
(Ask your employing office
which of these applies to you.)
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C. (or if
your
covered spouse is this type of judge),
5) Are enrolled in Part B only,
regardless of your employment status, (for Part B
services)
(for other services)
6) Are a former Federal employee receiving Workers' Compensation and the
Office of Workers' Compensation Programs has determined
that you are unable
to return to duty,
(except for claims related to Workers'
Compensation)
B. When you --or a covered family member --have Medicare
based on end stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD,
2) Have completed the 30-month ESRD coordination
period and are still eligible for Medicare due to ESRD,
3) Become eligible
for Medicare due to ESRD after Medicare became primary for you under another
provision,
C. When you or a covered family member have FEHB and…
1) Are eligible for Medicare based on disability, and
a) Are an
annuitant, or
b) Are an active employee, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee 54
54
Page 55 56
2002 Kaiser Foundation Health Plan of Ohio 55 Section 9
Medicare managed care plan If you are eligible for Medicare, you
may choose to enroll in and get your Medicare benefits from another type of
Medicare+ Choice plan --a
Medicare managed care plan. These are health care
choices (like HMOs) in some areas of the country. In most Medicare managed care
plans, you
can only go to doctors, specialists, or hospitals that are part
of the plan. Medicare managed care plans provide all the benefits that Original
Medicare covers. Some cover extras, like prescription drugs. To learn more
about enrolling in a Medicare managed care plan, contact Medicare
at
1-800-MEDICARE (1-800-633-4227) or at www.
medicare. gov.
If you enroll in a Medicare managed care plan, the
following options are available to you:
This Plan and our Medicare managed care plan: You may enroll in our
Medicare managed care plan, known as Medicare+ Choice, and also
remain
enrolled in our FEHB Plan. In this case, we will not waive our copayments and
coinsurance for your FEHB and Medicare coverage.
This Plan and another plan's Medicare managed care plan: You may
enroll in another plan's Medicare managed care plan and also remain
enrolled
in our FEHB plan. We will still provide benefits when your Medicare managed care
plan is primary if you use our Plan providers, but
we will not waive 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 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. However, we now require that you
assign your Medicare Part B benefits to the Plan for Plan services.
TRICARE TRICARE is the health care program for eligible dependents of
military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See your
TRICARE Health Benefits Advisor if you have questions about
TRICARE
coverage.
Workers' Compensation We do not cover services that:
You need
because of a workplace-related illness or injury that the Office of Workers'
Compensation Programs (OWCP) or a similar
Federal or State agency determines
they must provide; or OWCP or a similar agency pays for through a third party
injury
settlement or other similar proceeding that is based on a claim you
filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we
will cover your care. You must use our providers. 55
55 Page 56 57
2002 Kaiser Foundation Health Plan of Ohio 56
Section 9
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. 56
56 Page
57 58
2002 Kaiser Foundation Health
Plan of Ohio 57 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. See page 13.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 13.
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. See page 13.
Durable medical equipment Durable medical equipment (DME) is equipment
that is intended for repeated use, medically necessary, primarily and
customarily used to
serve a medical purpose, generally not useful to a
person who is not ill or injured, designed for prolonged use, appropriate for
use in the home, and
serves a specific therapeutic purpose in the treatment
of an illness or injury.
Experimental or investigational services We carefully evaluate whether
a particular therapy is safe and effective
or offers a reasonable degree of
promise with respect to improving health outcomes. The primary source of
evidence about health outcomes of any
intervention is peer-reviewed medical
or dental literature. When the service or supply, including a drug: (1) has not
been approved by the
FDA; or (2) is the subject of a new drug or new device
application on file with the FDA; or (3) is part of a Phase I or Phase II
clinical trial, as the
experimental or research arm of a Phase III clinical
trial; or is intended to evaluate the safety, toxicity, or efficacy of the
service; or (4) is available
as the result of a written protocol that
evaluates the service's safety, toxicity, or efficacy; or (5) is subject to the
approval or review of an
Institutional Review Board; or (6) requires an
informed consent that describes the service as experimental or investigational;
then this Plan
considers that service, supply, or drug to be experimental,
and not covered by the Plan.
Group health coverage Health care benefits that are available as a
result of your employment, or the employment of your spouse, and that are
offered by an employer or
through membership in an employee organization.
Health care coverage may be insured or indemnity coverage, self-insured or
self-funded
coverage, or coverage through health maintenance organizations
or other managed care plans. Health care coverage purchased through
membership in an organization is also "group health coverage." 57
57 Page 58 59
2002 Kaiser Foundation Health Plan of Ohio 58
Section 10
Medically necessary All benefits need to be
medically necessary in order for them to be covered benefits. Generally, if your
Plan physician provides the service
in accord with the terms of this
brochure, it will be considered medically necessary. However, some services are
reviewed in advance of your
receiving them to determine if they are
medically necessary. When we review a service to determine if it is medically
necessary, a Plan
physician will evaluate what would happen to you if you do
not receive the service. If not receiving the service would adversely affect
your
health, it will be considered medically necessary. The services must be
a medically appropriate course of treatment for your condition. If they are
not medically necessary, we will not cover the services. In case of
emergency services, the services that you received will be evaluated to
determine if they were medically necessary.
Our allowance The amount we use to determine your coinsurance. When
you receive services or supplies from Plan providers, it is the amount that we
set for
the services or supplies if we were to charge for them. When you
receive services from non-Plan providers, we determine the amount that we
believe is usual and customary for the service or supply, and compare it to
the charges. Our allowance is based upon the reasonableness of the
charges.
If the charges exceed what we believe is reasonable, you may be responsible for
the excess over our allowance in addition to your
coinsurance.
Us/ We Us and we refer to Kaiser Foundation Health Plan of Ohio.
You You refers to the enrollee and each covered family member. 58
58 Page 59 60
2002 Kaiser Foundation Health Plan of Ohio 59
Section 11
Section 11. FEHB facts
No pre-existing condition
We will not refuse to cover the treatment of a condition that you had
limitation before you enrolled in this Plan solely because you had the
condition
before you enrolled.
Where you get information See www.
opm. gov/ insure. Also, your employing or retirement office about enrolling
in the can answer your questions, and give you a Guide to Federal
Employees
FEHB Program Health Benefits Plans, brochures for other plans,
and other materials you need to make an informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for enrollment
begins.
We don't determine who is eligible for coverage and, in most cases,
cannot change your enrollment status without information from your
employing or retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for for you and your family you, your spouse, and
your unmarried dependent children under age 22,
including any foster
children or stepchildren your employing or retirement office authorizes coverage
for. Under certain circumstances,
you may also continue coverage for a
disabled child 22 years of age or older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You
may
change your enrollment 31 days before to 60 days after that event. The Self and
Family enrollment begins on the first day of the pay period
in which the
child is born or becomes an eligible family member. When you change to Self and
Family because you marry, the change is effective
on the first day of the
pay period that begins after your employing office receives your enrollment
form; benefits will not be available to your
spouse until you marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, however we will
send you a letter notifying you when a dependent reaches the age limit.
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. 59
59 Page
60 61
2002 Kaiser Foundation Health
Plan of Ohio 60 Section 11
When benefits and The benefits
in this brochure are effective on January 1. If you joined premiums start
this Plan during Open Season, your coverage begins on the first day of
your first pay period that starts on or after January 1. Annuitants'
coverage and premiums begin on January 1. If you joined at any other
time
during the year, your employing office will tell you the effective date of
coverage.
Your medical and claims We will keep your medical and claims
information confidential. Only records are confidential the following
will have access to it:
OPM, this Plan, and subcontractors when they
administer this contract;
This Plan and appropriate third parties, such as
other insurance plans and the Office of Workers' Compensation Programs (OWCP),
when
coordinating benefit payments and subrogating claims;
Law enforcement
officials when investigating and/ or prosecuting alleged civil or criminal
actions;
OPM and the General Accounting Office when conducting audits;
Individuals
involved in bona fide medical research or education that does not disclose your
identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years
of your Federal service. If you do not meet this requirement, you
may be eligible for other forms of coverage, such as temporary continuation of
coverage (TCC).
When you lose benefits
When FEHB coverage
ends You will receive an additional 31 days of coverage, for no additional
premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary Continuation of Coverage.
Spouse equity coverage If you are divorced from a Federal employee or
annuitant, you may not continue to get benefits under your former spouse's
enrollment. But, you
may be eligible for your own FEHB coverage under the
spouse equity law. If you are recently divorced or are anticipating a divorce,
contact
your ex-spouse's employing or retirement office to get RI 70-5, the
Guide to Federal Employees Health Benefits Plans for Temporary
Continuation of Coverage and Former Spouse Enrollees, or other
information about your coverage choices.
Temporary continuation of If you leave Federal service, or if you lose
coverage because you no coverage (TCC) longer qualify as a family member,
you may be eligible for Temporary
Continuation of Coverage (TCC). For
example, you can receive TCC if you are not able to continue your FEHB
enrollment after you retire, if
you lose your job, if you are a covered
dependent child and you turn 22 or marry, etc. 60
60
Page 61 62
2002
Kaiser Foundation Health Plan of Ohio 61 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/ health); refer to the "TCC and HIPAA" frequently asked questions.
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. 61
61 Page 62 63
2002 Kaiser Foundation Health Plan of Ohio 62
Long Term Care Insurance
Long Term Care Insurance Is Coming Later
in 2002!
The Office of Personnel Management (OPM) will sponsor a
high-quality long term care insurance program effective in October 2002. As part
of its educational effort, OPM asks you to consider these questions:
What
is long term care It's insurance to help pay for long term care services you
may need (LTC) insurance? if you can't take care of yourself because of
an extended illness or
injury, or an age-related disease such as
Alzheimer's. LTC insurance can provide broad, flexible benefits for nursing home
care, care in an assisted living facility, care in your home, adult day
care, hospice care, and more. LTC insurance can supplement care
provided by
family members, reducing the burden you place on them.
I'm healthy. I
won't need Welcome to the club! long term care. Or, will I? 76% of
Americans believe they will never need long term care, but the
facts are
that about half of them will. And it's not just the old folks. About 40% of
people needing long term care are under age 65. They
may need chronic care
due to a serious accident, a stroke, or developing multiple sclerosis, etc.
We hope you will never need long term care, but everyone should have a plan
just in case. Many people now consider long term care insurance
to be vital
to their financial and retirement planning.
Is long term care expensive?
Yes, it can be very expensive. A year in a nursing home can exceed $50,000.
Home care for only three 8-hour shifts a week can exceed
$20,000 a year. And
that's before inflation! Long term care can easily exhaust your savings. Long
term care
insurance can protect your savings.
But won't my FEHB
plan, Not FEHB. Look at the "Not covered" blocks in sections 5( a)
and 5( c) Medicare or Medicaid cover of your FEHB brochure. Health plans
don't cover custodial care or a
my long term care? stay in an
assisted living facility or a continuing need for a home health aide to help you
get in and out of bed and with other activities of daily
living. Limited
stays in skilled nursing facilities can be covered in some circumstances.
Medicare only covers skilled nursing home care (the highest level of nursing
care) after a hospitalization for those who are blind, age 65 or
older or
fully disabled. It also has a 100 day limit. Medicaid covers long term care for
those who meet their state's
poverty guidelines, but has restrictions on
covered services and where they can be received. Long term care insurance can
provide choices of
care and preserve your independence.
When will
I get more information Employees will get more information from their
agencies during the on how to apply for this new LTC open enrollment
period in the late summer/ early fall of 2002.
insurance coverage?
Retirees will receive information at home.
How can I find out more
about the Our toll-free teleservice center will begin in mid-2002. In the
program NOW? meantime, you can learn more about the program on our
website at
www. opm. gov/ insure/ ltc.
Many FEHB enrollees think that their health plan and/ or Medicare will cover
their long-term care needs. Unfortunately, they are WRONG!
How are
YOU planning to pay for the future custodial or chronic care you may need?
You should consider buying long-term care insurance. 62
62 Page 63 64
2002 Kaiser Foundation Health Plan of Ohio 63
Index
Index
Do not rely on this page; it is for your
convenience and does may not show all pages where the terms appear.
Accidental injury 35 Acupuncture 25
Allergy tests 18 Alternative
treatment 25
Ambulance 36 Anesthesia 30
Autologous bone marrow
transplant 29
Biopsies 27 Blood and blood plasma 32
Breast cancer
screening 16 Casts 32
Centers of excellence for transplants 43
Changes for 2002 9 Chemotherapy 19
Chiropractic 24 Cholesterol tests 16
Coinsurance 13 Colorectal cancer screening 16
Contraceptive devices and
drugs 41
Coordination of benefits 52 Covered providers 10
Crutches 22
Deductible 13
Dental care 46 Diagnostic services 15
Disputed claims
review 50 Donor expenses (transplants) 29
Dressings 32 Durable medical
equipment
(DME) 22 Educational classes and
programs 26 Effective
date of enrollment 60
Emergency 35 Experimental or investigational 57
Eyeglasses 20 Family planning 17
Fecal occult blood test 16
Flexible benefits options 43
General Exclusions 48 Hearing
services 20
Home health services 23 Hospice care 33
Hospital 32
Immunizations 16
Infertility 17 Inpatient Hospital Benefits 32
Insulin 41 Laboratory and pathological
services 15 Mail
Order Prescription
Drugs 40 Mammograms 15
Maternity Benefits 17
Medicaid 56
Medically necessary 58 Medicare 52
Mental Conditions/
Substance Abuse Benefits 37
Newborn care 17 Non-FEHB Benefits 47
Nurse
Anesthetist 32 Nursery charges 17
Obstetrical care 17 Occupational
therapy 19
Oral and maxillofacial surgery 28
Orthopedic devices 21
Out-of-pocket expenses 13
Oxygen 22 Pap test 16
Physical
examination 16 Physical therapy 19
Precertification 12 Preventive care,
adult 16
Preventive care, children 16 Preventive services 16
Prior
approval 12 Prostate cancer screening 16
Prosthetic devices 21 Psychotherapy
39
Radiation therapy 19 Renal dialysis 52
Room and board 31
Services from other Kaiser
Permanente Plans 44 Skilled nursing facility care
33
Smoking cessation 42 Speech therapy 20
Splints 32
Sterilization procedures 17 Subrogation 52
Substance abuse 37 Surgery 27
Anesthesia 30 Oral 28
Outpatient 32 Reconstructive 28
Syringes 44
Temporary continuation of
coverage 60 Transplants 29
Travel
benefit 45 Treatment therapies 19
Vision services 20 Well
child care 16
Wheelchairs 22 Workers' compensation 55
X-rays
15 24 hour nurse line 43 63
63 Page 64 65
2002 Kaiser
Foundation Health Plan of Ohio 64 Summary
Summary of benefits
for Kaiser Foundation Health Plan of Ohio – 2002
Do not rely on this
chart alone. All benefits are provided in full unless indicated and are
subject to the definitions, limitations, and exclusions in this brochure. On
this page we summarize specific expenses we cover;
for more detail, look
inside.
If you want to enroll or change your enrollment in this Plan, be
sure to put the correct enrollment code from the cover on your enrollment form.
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by
physicians:
Diagnostic and treatment services provided in the
office............ $10 per office visit 15
Services provided by a hospital:
Inpatient
......................................................................................
Outpatient
....................................................................................
Nothing
Nothing
31
32
Emergency benefits:
In-area
.........................................................................................
Out-of-area
..................................................................................
$50 per visit
$50 per visit
35
35
Mental health and substance abuse treatment:
................................. Regular cost sharing 37
Prescription drugs
............................................................................. $5
per prescription or refill for generic drugs
$15 per prescription or refill for brand-name drugs
40
Dental
Care.......................................................................................
No benefit 46
Vision
Care.......................................................................................
Refractions; $10 per office visit 20
Special features: 24 hour emergency
advice line; Centers of excellence for transplants; Flexible benefits option;
Services from other Kaiser Permanente Plans; Travel benefit 43
Protection against catastrophic costs (your out-of-pocket maximum)
........................................................ Nothing after
$2,000/ Self Only or $6,000/ Family enrollment per
year
Some costs do
not count toward this protection
13 64
64 Page
65 66
2002 Kaiser Foundation Health
Plan of Ohio 65 Notes
Notes 65
65 Page 66 67
2002 Kaiser Foundation Health Plan of Ohio 66
Notes
Notes 66
66 Page 67 68
2002 Kaiser
Foundation Health Plan of Ohio 67 Notes
Notes 67
67 Page 68
2002
Rate Information for Kaiser Foundation Health Plan of Ohio
Non-Postal rates
apply to most non-Postal enrollees. If you are in a special enrollment
category, refer to the FEHB Guide for that category or contact the agency
that maintains your health benefits
enrollment.
Postal rates
apply to career Postal Service employees. Most employees should refer to the
FEHB Guide for United States Postal Service Employees, RI 70-2. Different
postal rates apply and
special FEHB guides are published for Postal Service
Nurses, RI 70-2B; and for Postal Service Inspectors and Office of Inspector
General (OIG) employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal employee organization who are not career postal
employees. Refer to the applicable
FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your
Share
Self Only 641 $88.33 $29.44 $191.38 $63.79 $104. 52 $13.25
Self and
Family 642 $216.76 $72.25 $469.64 $156.55 $256. 50 $32.51 68