Page numbers referenced within this brochure apply only to the printed brochure

Kaiser Permanente - Northern California

www.kp.org/feds
Member Services Call Center 800-464-4000 (TTY:711)

2022



IMPORTANT:
  • Rates
  • Changes for 2022
  • Summary of Benefits
  • Accreditations
A Health Maintenance Organization
(High Option, Standard Option and Prosper)

This plan’s health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides. See page (Applies to printed brochure only) for details. This plan is accredited. See page (Applies to printed brochure only).

Serving:  Northern California service area

Enrollment in this Plan is limited. You must live or work in our
geographic service areas to enroll. See page 13 for requirements.

Enrollment codes for this Plan:
  591 High Option - Self Only
  593 High Option - Self Plus One
  592 High Option - Self and Family

  594 Standard Option - Self Only
  596 Standard Option - Self Plus One
  595 Standard Option - Self and Family

  KC1 Prosper - Self Only
  KC3 Prosper - Self Plus One
  KC2 Prosper - Self and Family

Special Notice: This Plan changed the name of the Basic Option to Prosper for 2022. See pages (Applies to printed brochure only) through (Applies to printed brochure only). 

Federal Employees Health Benefits Program seal
OPM Logo








Important Notice

Important Notice from Kaiser Foundation Health Plan, Inc., Northern California Region
About Our Prescription Drug Coverage and Medicare

The Office of Personnel Management (OPM) has determined that the Kaiser Foundation Health Plans Inc., Northern California Region's prescription drug coverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all plan participants and is considered Creditable Coverage. This means you do not need to enroll in Medicare Part D and pay extra for prescription drug coverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment as long as you keep your FEHB coverage.

However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will coordinate benefits with Medicare.

Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program.

Please be advised

If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that is at least as good as Medicare’s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1 percent per month for every month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug coverage, your premium will always be at least 19 percent higher than what many other people pay. You will have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the next Annual Coordinated Election Period (October 15 through December 7) to enroll in Medicare Part D.

Medicare’s Low-Income Benefits

For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA) online at www.socialsecurity.gov, or call the SSA at 800-772-1213, (TTY:  800-325-0778). 

You can get more information about Medicare prescription drug plans and the coverage offered in your area from these places:

  • Visit www.medicare.gov for personalized help.
  • Call 800-MEDICARE (800-633-4227), (TTY 877-486-2048).



Table of Contents

(Page numbers solely appear in the printed brochure)




Introduction

This brochure describes the benefits of Kaiser Permanente – Northern California under contract (CS1044-A) between  Kaiser Foundation Health Plan, Inc. Northern California Region and the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. Customer service may be reached at 800-464-4000 or through our website: www.kp.org. The address for Kaiser Permanente – Northern California administrative offices is:

Kaiser Foundation Health Plan, Inc. 1950 Franklin St., Oakland, CA  94612

This brochure is the official statement of benefits. No verbal statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus One or 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, 2022, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2022, and changes are summarized on page (Applies to printed brochure only). Rates are shown on the back cover of this brochure.




Plain Language

All FEHB brochures are written in plain language to make them easy to understand. Here are some examples:

  • Except for necessary technical terms, we use common words. For instance, “you” means the enrollee and each covered family member; “we” or "Plan" means Kaiser Foundation Health Plan, Inc., Northern California Region.
  • We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States Office of Personnel Management. If we use others, we tell you what they mean.
  • Our brochure and other FEHB plans’ brochures have the same format and similar descriptions to help you compare plans.



Stop Healthcare Fraud!

Fraud increases the cost of healthcare for everyone and increases your Federal Employees Health Benefits Program (FEHB) premium.

OPM’s Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud – Here are some things that you can do to prevent fraud:

  • Do not give your plan identification (ID) number over the phone or to people you do not know, except for your healthcare providers, authorized health benefits plan or OPM representative.
  • Let only the appropriate medical professionals review your medical record or recommend services.
  • Avoid using healthcare providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
  • Carefully review explanations of benefits (EOB) statements that you receive from us.
  • Periodically review your claim history for accuracy to ensure we have not been billed for services you did not receive.
  • Do not ask your doctor to make false entries on certificates, bills, or records in order to get us to pay for an item or service.
  • If you suspect that a provider 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 our Member Service Call Center at 800-464-4000 (TTY: 711) and explain the situation.
    • If we do not resolve the issue:


CALL - THE HEALTHCARE FRAUD HOTLINE
877-499-7295
OR go to www.opm.gov/our-inspector-general/hotline-to-report-fraud-waste-or-abuse/complaint-form/

The online reporting form is the desired method of reporting fraud in order to ensure accuracy, and a quicker response time.
You can also write to:
United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington, DC 20415-1100

  • Do not maintain, as a family member on your policy:
    • Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise)
    • Your child age 26 or over (unless they are disabled and incapable of self-support prior to age 26)
    • We may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.
  • If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under Temporary Continuation of Coverage (TCC).
  • Fraud or intentional misrepresentation of material fact is prohibited under the Plan. You can be prosecuted for fraud and your agency may take action against you. Examples of fraud include, falsifying a claim to obtain FEHB benefits, trying to or obtaining service or coverage for yourself or for someone else who is not eligible for coverage, or enrolling in the Plan when you are no longer eligible.
  • If your enrollment continues after you are no longer eligible for coverage (i.e., you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed by your provider for services received. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family member is no longer eligible to use your health insurance coverage.



Discrimination is Against the Law

Kaiser Foundation Health Plan, Inc. Northern California Region complies with all applicable Federal civil rights laws, including Title VII of the Civil Rights Act of 1964.

You can also file a civil rights complaint with the Office of Personnel Management by mail at:

Office of Personnel Management
Healthcare and Insurance
Federal Employee Insurance Operations
Attention: Assistant Director, FEIO
1900 E Street NW, Suite 3400-S
Washington, D.C. 20415-3610




Preventing Medical Mistakes

Medical mistakes continue to be a significant cause of preventable deaths within the United States. While death is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even additional treatments. Medical mistakes and their consequences also add significantly to the overall cost of healthcare. Hospitals and healthcare providers are being held accountable for the quality of care and reduction in medical mistakes by their accrediting bodies. You can also improve the quality and safety of your own healthcare and that of your family members by learning more about and understanding your risks. Take these simple steps:

1. Ask questions if you have doubts or concerns.

  • Ask questions and make sure you understand the answers.
  • Choose a doctor with whom you feel comfortable talking.
  • Take a relative or friend with you to help you take notes, ask questions and understand answers.

2. Keep and bring a list of all the medications you take.

  • Bring the actual medication or give your doctor and pharmacist a list of all the medications and dosages that you take, including non-prescription (over-the-counter) medications and nutritional supplements.
  • Tell your doctor and pharmacist about any drug, food, and other allergies you have, such as to latex.
  • Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your doctor or pharmacist says.
  • Make sure your medication is what the doctor ordered. Ask the pharmacist about your medication if it looks different than you expected.
  • Read the label and patient package insert when you get your medication, including all warnings and instructions.
  • Know how to use your medication. Especially note the times and conditions when your medication should and should not be taken.
  • Contact your doctor or pharmacist if you have any questions.
  • Understand both the generic and brand names of your medication. This helps ensure you do not receive double dosing from taking both a generic and a brand. It also helps prevent you from taking a medication to which you are allergic.

3. Get the results of any test or procedure.

  • Ask when and how you will get the results of tests or procedures. Will it be in person, by phone, mail, through the Plan or Provider’s portal?
  • Don’t assume the results are fine if you do not get them when expected. Contact your healthcare provider and ask for your results.
  • Ask what the results mean for your care.

4. Talk to your doctor about which hospital or clinic is best for your health needs.

  • Ask your doctor about which hospital or clinic has the best care and results for your condition if you have more than one hospital or clinic to choose from to get the healthcare you need.
  • Be sure you understand the instructions you get about follow-up care when you leave the hospital or clinic.

5. Make sure you understand what will happen if you need surgery.

  • Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.
  • Ask your doctor, “Who will manage my care when I am in the hospital?”
  • Ask your surgeon:
    • "Exactly what will you be doing?"
    • "About how long will it take?"
    • "What will happen after surgery?"
    • "How can I expect to feel during recovery?"
  • Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reactions to anesthesia, and any medications or nutritional supplements you are taking.

Patient Safety Links

For more information on patient safety, please visit:

  • www.jointcommission.org/speakup.aspx. The Joint Commission’s Speak Up™ patient safety program.

  • www.jointcommission.org/topics/patient_safety.aspx. The Joint Commission helps healthcare organizations to improve the quality and safety of the care they deliver.

  • www.ahrq.gov/patients-consumers/. The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality healthcare providers and improve the quality of care you receive.
  • www.bemedwise.org. The National Council on Patient Information and Education is dedicated to improving communication about the safe, appropriate use of medication.
  • www.leapfroggroup.org. The Leapfrog Group is active in promoting safe practices in hospital care.
  • www.ahqa.org. The American Health Quality Association represents organizations and healthcare professionals working to improve patient safety.

Preventable Healthcare Acquired Conditions (“Never Events”)

When you enter a Plan hospital for a covered service, you do not expect to leave with additional injuries, infections, or other serious conditions that occur during the course of your stay. Although some of these complications may not be avoidable, patients do suffer from injuries or illnesses that could have been prevented if doctors or the hospital had taken proper precautions. Errors in medical care that are clearly identifiable, preventable and serious in their consequences for patients, can indicate a significant problem in the safety and credibility of a healthcare facility. These conditions and errors are sometimes called “Never Events” or “Serious Reportable Events.” (See Section 10, Definitions of terms we use in this brochure).

We have a benefit payment policy that encourages Plan hospitals to reduce the likelihood of hospital-acquired conditions such as certain infections, severe bedsores, and fractures, and to reduce medical errors that should never happen. When such an event occurs, neither you nor your FEHB plan will incur costs to correct the medical error. If you are charged a cost share for a never event that occurs while you are receiving an inpatient covered service, or for treatment to correct a never event that occurred at a Plan provider, please notify us.




FEHB Facts

Coverage information




TermDefinition
  • No pre-existing condition limitation
We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled.
  • Minimum essential coverage (MEC)

Coverage under this plan qualifies as minimum essential coverage. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

  • Minimum value standard

Our health coverage meets the minimum value standard of 60% established by the ACA.  This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits.  The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure.

  • Where you can get information about enrolling in the FEHB Program

See www.opm.gov/healthcare-insurance for enrollment information as well as:

  • Information on the FEHB Program and plans available to you
  • A health plan comparison tool
  • A list of agencies that participate in Employee Express
  • A link to Employee Express
  • Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions, and give you brochures for other plans and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

  • 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
  • What happens when your enrollment ends
  • When the next Open Season for enrollment begins

We do not determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office. For information on your premium deductions, you must also contact your employing or retirement office.

Once enrolled in your FEHB Program Plan, you should contact your carrier directly for address updates and questions about your benefit coverage.

  • Types of coverage available for you and your family

Self Only coverage is only for the enrollee. Self Plus One coverage is for the enrollee and one eligible family member. Self and Family coverage is for the enrollee and one or more eligible family members. Family members include your spouse and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or 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 Plus One or 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 Plus One or 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 are married. We may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

Contact your carrier to obtain a Certificate of Creditable Coverage (COCC) or to add a dependent when there is already family Coverage.

Contact your employing or retirement office if you are changing from Self to Self Plus One or Self and Family or to add a newborn if you currently have a Self Only plan.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits, nor will we. Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26.

If you or one of your family members is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan.

If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a child - outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage.  For a complete list of QLEs, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events.  If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

  • Family member coverage

Family members covered under your Self and Family enrollment are your spouse (including your spouse by a valid common-law marriage from a state that recognizes common-law marriages) and children as described below.  A Self Plus One enrollment covers you and your spouse, or one eligible family member as described below.

Family members covered under your Self and Family enrollment are your spouse (including your spouse by valid common-law marriage if you reside in a state that recognizes common-law marriages) and children as described in the chart below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described in the chart below.

Natural children, adopted children, and stepchildren
Coverage: Natural children, adopted children, and stepchildren are covered until their 26th birthday.

Foster children
Coverage: Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information.

Children incapable of self-support
Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information.

Married children
Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday.

Children with or eligible for employer-provided health insurance
Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday.

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother's maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

 

  • Children’s Equity Act

OPM has implemented the Federal Employees Health Benefits Children’s Equity Act of 2000. This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows:

  • If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM
  • If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the same option of the same plan; or 
  • If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.

As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that does not serve the area in which your children live, unless you provide documentation that you have other coverage for the children.

If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect. Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child.  Contact your employing office for further information.

  • When benefits and premiums start
The benefits in this brochure are effective on January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2022 benefits of your prior plan or option. If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan's 2021 benefits until the effective date of your coverage with your new plan. 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.

If your enrollment continues after you are no longer eligible for coverage (i.e. you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid.  You may be billed for services received directly from your provider.  You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums.  It is your responsibility to know when you, or a family member, are no longer eligible to use your health insurance coverage.

  • 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




TermDefinition
  • 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.

Any person covered under the 31-day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60th day after the end of the 31-day temporary extension.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage (TCC), or a conversion policy (a non-FEHB individual policy).

  • Upon divorce

If you are divorced from a Federal employee, or annuitant, you may not continue to get benefits under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get information about your coverage choices.  You can also visit OPM’s website at www.opm.gov/healthcare-insurance/healthcare/plan-information/. We may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

  • Temporary Continuation of Coverage (TCC)

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). The Patient Protection and Affordable Care Act (ACA) did not eliminate TCC or change the TCC rules.  For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, if you are a covered dependent child and you turn 26, etc.

You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or retirement office or from www.opm.gov/healthcare-insurance. It explains what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a new kind of tax credit that lowers your monthly premiums. Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll. Finally, if you qualify for coverage under another group health plan (such as your spouse's plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHB Program coverage.

  • Converting to individual coverage

You may convert to a non-FEHB individual policy if:

  • Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert);
  • You decided not to receive coverage under TCC or the spouse equity law; or
  • You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal or Tribal service, your employing office will notify you of your right to convert. You must contact us in writing 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 contact us in writing 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, a waiting period will not be imposed, and your coverage will not be limited to pre-existing conditions.  When you contact us we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act's Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at 800-464-4000 (TTY: 711) or visit our website at www.kp.org/feds.

  • Health Insurance Marketplace

If you would like to purchase health insurance through the ACA's Health Insurance Marketplace, please visit www.HealthCare.gov.  This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.




Section 1. How This Plan Works

Kaiser Foundation Health Plan, Inc. (Plan) is a health maintenance organization (HMO). OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards. Kaiser Foundation Health Plan, Inc. Northern California Region holds the following accreditations: National Committee for Quality Assurance (NCQA. To learn more about this plan’s accreditation, please visit the following website: www.ncqa.org.

We require you to see specific physicians, hospitals, and other providers that contract with us. Our Plan providers coordinate your healthcare services. We are solely responsible for the selection of Plan providers in your area. Contact us for a copy of our most recent provider directory. We 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. We give you a choice of enrollment in a High Option, Standard Option or Prosper.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments, coinsurance and deductibles described in this brochure. When you receive emergency services or services covered under the travel benefit 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.

Questions regarding what protections apply may be directed to us at 800-464-4000. You can also read additional information from the U.S. Department of Health and Human Services at www.healthcare.gov.

General features of our High Option, Standard Option and Prosper

How we pay providers

We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure.  These Plan providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (copayments, coinsurance, deductibles, and no-covered services and supplies). 

Your rights and responsibilities

OPM requires that all FEHB plans provide certain information to their FEHB members.  You may get information about us, our networks, our providers, and our facilities.  OPM’s FEHB website (www.opm.gov/insurance-healthcare) lists the specific types of information that we must make available to you.  Some of the required information is listed below.

  • We are a health maintenance organization that has provided healthcare services to Californians since 1945.
  • This medical benefit plan is provided by Kaiser Foundation Health Plan, Inc. Medical and hospital services are provided through our integrated healthcare delivery organization known as Kaiser Permanente. Kaiser Permanente is composed of Kaiser Foundation Health Plan, Inc. (a not-for-profit organization), Kaiser Foundation Hospitals (a not-for-profit organization), and the Permanente Medical Group, Inc. (a for-profit California-based corporation) which operates Plan medical offices throughout Northern California.

You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. You can view the complete list of these rights and responsibilities by visiting our Kaiser Permanente Northern California website at www.kp.org/feds.  You can also contact us to request that we mail you a copy of that Notice.

If you want more information about us, call 800-464-4000, or write to Kaiser Foundation Health Plan, Inc., Customer Service Center, 1950 Franklin St., Oakland, CA, 94612. You may also visit our website at www.kp.org/feds.

By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI, visit our website at www.kp.org/feds to obtain our Notice of Privacy Practices. You can also contact us to request that we mail you a copy of that Notice.  

Language interpretation services

Language interpretation services are available to assist non-English speaking members. When you call Kaiser Permanente to make an appointment or talk with a medical advice nurse or member services representative, if you need an interpreter, we will provide language assistance.

Your medical and claims records are confidential

We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies.

Service Area

To enroll in this Plan, you must live or work in our service area. This is where our providers practice. Our service area counties are: 

Northern California counties:
Alameda, Contra Costa, Marin, Napa, Sacramento, San Francisco, San Joaquin, San Mateo, Santa Cruz, Solano, and Stanislaus are within our service area.

Portions of the following counties, as indicated by the ZIP codes below, are also within our service area:

  • Amador: 95640, 95669
  • El Dorado: 95613-14, 95619, 95623, 95633-35, 95651, 95664, 95667, 95672, 95682, 95762
  • Placer: 95602-04, 95610, 95626, 95648, 95650, 95658, 95661, 95663, 95668, 95677-78, 95681, 95692, 95703, 95722, 95736, 95746-47, 95765
  • Santa Clara: 94022-24, 94035, 94039-43, 94085-89, 94301-06, 94309, 94550, 95002, 95008-09, 95011, 95013-15, 95020-21, 95026, 95030-33, 95035-38, 95042, 95044, 95046, 95050-56, 95070-71, 95076, 95101-95103, 95106, 95108-13, 95115-36, 95138-41, 95148, 95150-61, 95164, 95170, 95172-73, 95190-94, 95196
  • Sonoma: 94515, 94922-23, 94926-28, 94931, 94951-55, 94972, 94975, 94999, 95401-07, 95409, 95416, 95419, 95421, 95425, 95430-31, 95433, 95436, 95439, 95441-42, 95444, 95446, 95448, 95450, 95452, 95462, 95465, 95471-73, 95476, 95486-87, 95492
  • Sutter: 95626, 95645, 95659, 95668, 95674, 95676, 95692, 95836-37
  • Yolo: 95605, 95607, 95612, 95615-18, 95645, 95691, 95694-95, 95697-98, 95776, 95798-99
  • Yuba: 95692, 95903, 95961

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 visiting member care from designated providers in that area. See Section 5(h), Special features, for more details. We also pay for certain follow-up services or continuing care services while you are traveling outside the service area, as described in Section 5(h); and for emergency care obtained from any non-Plan provider, as described in Section 5(d), Emergency services/accidents. We will not pay for any other healthcare services out of our service area unless the services have prior Plan approval.

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.




Section 2. Changes for 2022

Do not rely only on these change descriptions; this Section is not an official statement of benefits. For that, go to Section 5 Benefits Overview. 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

  • Effective in 2022, premium rates are the same for Non-Postal and Postal employees. See page (Applies to printed brochure only).

Changes to this Plan

  • This Plan changed the name of the Basic Option to Prosper for 2022. Any benefit changes to Prosper (formerly known as Basic Option) are listed below.

Changes to High Option, Standard Option and Prosper

  • Treatment therapies. We have listed the primary copay along with the specialty copay for cardiac rehabilitation following a qualifying event/condition. See page (Applies to printed brochure only).
  • Organ/tissue transplants. We have added coverage for dental services that are medically necessary prior to a transplant. See page (Applies to printed brochure only).
  • Reconstructive surgery. We have added coverage for facial hair removal and breast augmentation for gender reassignment surgery. See page (Applies to printed brochure only).
  • Fertility preservation. We have clarified that standard fertility preservation for iatrogenic infertility includes services such as retrieval of sperm and egg, cryopreservation and 1 year of storage. See page (Applies to printed brochure only).
  • Coordination of benefits. We changed how we coordinate benefits when we are secondary payor to Original Medicare. After Original Medicare pays as primary, we will pay what is left of our allowance, up to our regular benefit. You must pay cost-sharing described in this FEHB brochure. See page (Applies to printed brochure only).

Changes to High Option and Standard Option

  • Medicare Part B reimbursement. We have increased the reimbursement for Medicare Part B monthly premium from up to $125 to up to $250 per month for members enrolled in Senior Advantage 2. See page (Applies to printed brochure only).

Changes to High Option Only

  • Premium. Your share of the premium rate will decrease for Self Only, Self Plus One and Self and Family. See page (Applies to printed brochure only).
  • Diagnostic and treatment services at home. We have increased cost-sharing for professional services of physicians and other healthcare professionals at home from no charge to $15 per primary care visit and $25 for specialty care visits. See page (Applies to printed brochure only).
  • Ultraviolet light treatment equipment. We have reduced the cost-sharing for home ultraviolet light therapy equipment for home use from 20% of our allowance to no charge. See page (Applies to printed brochure only).
  • Prescription drugs. We have added coverage for weight management drugs. You will pay $10 for generic drugs, $40 for brand-name drugs, or $100 for specialty drugs per 30-day supply, on a formulary exception basis when deemed medically necessary by a plan provider. See page (Applies to printed brochure only).

Changes to Standard Option Only

  • Premium. Your share of the premium rate will decrease for Self Only, Self Plus One and Self and Family. See page (Applies to printed brochure only).
  • Diagnostic and treatment services at home. We have increased cost-sharing for professional services of physicians and other healthcare professionals at home from no charge to $30 per primary care visit and $40 for specialty care visits. See page (Applies to printed brochure only).
  • Ultraviolet light treatment equipment. We have reduced the cost-sharing for home ultraviolet light therapy equipment for home use from 50% of our allowance to no charge. See page (Applies to printed brochure only).
  • Prescription drugs. We have added coverage for weight management drugs. You will pay $15 for generic drugs, $50 for brand-name drugs, or $150 for specialty drugs per 30-day supply, on a formulary exception basis when deemed medically necessary by a plan provider. See page (Applies to printed brochure only).

Changes to Prosper Only

  • Premium. Your share of the premium rate will increase for Self Only, decrease for Self Plus One and increase for Self and Family. See page (Applies to printed brochure only). 
  • Diagnostic and treatment services at home. We have increased cost-sharing for professional services of physicians and other healthcare professionals at home from no charge to $25 per primary care visit and $35 for specialty care visits. See page (Applies to printed brochure only).
  • Ultraviolet light treatment equipment. We have reduced the cost-sharing for home ultraviolet light therapy equipment for home use from 50% of our allowance to no charge. See page (Applies to printed brochure only).
  • Prescription drugs. We have added coverage for weight management drugs. You will pay $15 for generic drugs, $60 for brand-name drugs, or $200 for specialty drugs per 30-day supply, on a formulary exception basis when deemed medically necessary by a plan provider. See page (Applies to printed brochure only).




Section 3. How You Get Care

TermDefinition

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. Providers may request photo identification together with your ID card to verify identity. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation letter (for annuitants), or your electronic enrollment system (such as 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  our Member Service Call Center at 800-464-4000 (TTY: 711). After registering on our website at www.kp.org/feds, you may also request replacement cards electronically.

Where you get covered care

You get care from “Plan providers” and “Plan facilities”. You will only pay cost-sharing as described in Section 4. Your Cost for Covered Services.

Balance billing protection

FEHB Carriers must have clauses in their plan provider agreements. These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the plan provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount. If a plan provider bills you for covered services over your normal cost share (deductible, copay, co-insurance), contact your Carrier to enforce the terms of its provider contract.

Plan providers

Plan providers are physicians and other healthcare professionals in our service area that we contract with to provide covered services to our members. We contract with The Permanente Medical Group, Inc. (Medical Group) to provide or arrange covered services for our members. Medical care is provided through physicians, nurse practitioners, physician assistants, and other skilled medical personnel. Specialists in most major specialties are available as part of the medical teams for consultation and treatment. We credential Plan providers according to national standards.

This plan recognizes that transsexual, transgender, and gender-nonconforming members require health care delivered by healthcare providers experienced in transgender health. While gender reassignment surgeons (benefit details found in Section 5(b)) and hormone therapy providers (benefit details found in Section 5(f)) play important roles in preventive care, you should see a primary care provider familiar with your overall health care needs. Benefits described in this brochure are available to all members meeting medical necessity guidelines. 

We list Plan providers in the provider directory, which we update periodically. Directories are available at the time of enrollment or upon request by calling our Member Service Call Center at 800-464-4000 (TTY: 711). The list is also on our website at www.kp.org/feds.

Plan facilities

Plan facilities are hospitals, medical offices, and other facilities in our service area that we own or contract with to provide covered services to our members. Kaiser Permanente offers comprehensive healthcare at Plan facilities conveniently located throughout our service areas.  

We list Plan facilities in the facility directory, with their locations and phone numbers. Directories are updated on a regular basis and are available at the time of enrollment or upon request by calling our Member Service Call Center at 800-464-4000
(TTY: 711).The list is also on our website at www.kp.org/feds.

You must receive your health services at Plan facilities, except if you have an emergency, authorized referral, or out-of-area urgent care. If you are visiting another Kaiser Permanente or allied plan service area, you may receive healthcare services at those Kaiser Permanente facilities. See Section 5(h), Special features, for more details. Under the circumstances specified in this brochure, you may receive follow-up or continuing care while you travel anywhere.

What you must do to get covered care

It depends on the type of care you need. First, you and each covered family member should choose a primary care physician. This decision is important since your primary care physician provides or arranges for most of your healthcare.

To choose or change your primary care physician, you can either select one from our Provider Directory, from our website, www.kp.org/feds, or you can call our Member Services Call Center at 800-464-4000 (TTY: 711).

Primary care

We encourage you to choose a primary care physician when you enroll. You may select a primary care physician from any of our available Plan providers who practice as generalists in these specialties: internal medicine, pediatrics, or family practice. If you do not select a primary care physician, one may be selected for you. You may choose any primary care Plan physician who is available to accept you.  Parents may choose a pediatrician as the Plan physician for their child. Your primary care physician will provide most of your healthcare, or give you a referral to see a specialist.

Please notify us of the primary care physician you choose. If you need help choosing a primary care physician, call us. You may change your primary care physician at any time. You are free to see other Plan physicians if your primary care physician is not available and to receive care at other Kaiser Permanente facilities.

Specialty care

Specialty care is care you receive from providers other than a primary care physician. When your primary care physician believes you may need specialty care, they will request authorization from the Plan to refer you to a specialist for an initial consultation and/or for a certain number of visits. If the Plan approves the referral, you may seek the initial consultation from the specialist to whom you were referred. You must then return to your primary care physician after the consultation, unless your referral authorizes a certain number of additional visits without the need to obtain another referral. The primary care physician must provide or obtain authorization for a specialist to provide all follow-up care. Do not go to the specialist for return visits unless your primary care physician gives you an approved referral. However, you may see Plan gynecologists, obstetricians, optometrists, audiologists, urologists (limited to vasectomies), and health education, or mental health and substance use disorder treatment providers without a referral. You may make appointments directly with these providers.

Here are some 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, in consultation with you and your attending specialist, may develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary care physician will use our criteria when creating your treatment plan (the physician may have to get an authorization or approval beforehand).
  • If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If they decide 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 approved services from your current specialist until we can make arrangements for you to see a Plan specialist.
  • If you have a chronic and disabling condition and lose access to your specialist because we:
    • terminate our contract with your specialist for a reason other than cause;
    • drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB plan; or 
    • reduce our service area and you enroll in another FEHB plan

you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the Program, contact your new plan.

If you are pregnant 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.  If you are being treated for a maternal mental health condition, you can continue to see your specialist for up to 12 months from the diagnosis or from the end of pregnancy, whichever occurs later.

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 hospitalized when your enrollment begins

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our Member Service Call Center immediately at 800-464-4000 (TTY: 711). If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

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;
  • the day your benefits from your former plan run out; or
  • the 92nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.

You need prior Plan approval for certain services

Your primary care physician arranges most referrals to specialists. For certain services your Plan physician must obtain approval from Medical Group. Before we approve a referral, we may consider if the service or item is medically necessary and meets other coverage requirements. We call this review and approval process “prior authorization”. Once the referral is approved, we will notify you that we have authorized your referral.

Your Plan physician must obtain prior authorization for:

  • Certain prescription medications as identified on our formulary
  • Durable medical equipment (DME)
  • Home health services (If your Plan Physician makes a written referral for at least eight continuous hours of home health nursing or other care, the Medical Group's designee Plan Physician or committee will authorize the Services if the designee determines that they are Medically Necessary and that they are not the types of Services that an unlicensed family member or other layperson could provide safely and effectively in the home setting after receiving appropriate training)
  • Organ/tissue transplants and related services
  • Orthopedic and prosthetic devices
  • Outpatient surgery and procedures
  • Gender reassignment surgery
  • Services or items from non-Plan providers or at non-Plan facilities (we cover these services and items only if they are not available from Plan providers)

To confirm if a referral has been approved for a service or item that requires prior authorization, please call our Member Service Call Center at 800-464-4000 (TTY: 711).

Prior authorization determinations are made based on the information available at the time the service or item is requested. We will not cover the service or item unless you are a Plan member on the date you receive the service or item.

Non-urgent care claims

For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. We will make our decision within 15 days of receipt of the pre-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

Urgent care claims

If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours. If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim. You will then have at least 48 hours to provide the required information. We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM.  Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 800-464-4000 (TTY: 711). You may also call OPM’s FEHB 3 at 202-606-0755 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care, call us at 800-464-4000 (TTY: 711). If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

Concurrent care claims

A concurrent care claim involves care provided over a period of time or over a number of treatments. We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends. If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

Emergency services/accidents and post-stabilization care

Emergency services do not require prior authorization. However, if you are admitted to a non-Kaiser Permanente facility, you or your family member must notify the Plan within 48 hours, or as soon as reasonably possible, or your claims may be denied.

You must obtain prior authorization from us for post-stabilization care you receive from non-Plan providers.

See Section 5(d), Emergency services/accidents for more information.

If your treatment needs to be extended

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

What happens when you do not follow the precertification rules If you or your Plan physician do not obtain prior authorization from us for services or items that require prior authorization, we will not pay any amount for those services or items and you may be liable for the full price of those services or items. This also includes any residual amounts, such as deductibles, copayments or coinsurance that are not covered or not paid by any other insurance plan you use to pay for those services or items.
Circumstances beyond our controlUnder extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care.
If you disagree with our pre-service claim decision

If you have a pre-service claim and you do not agree with our prior approval decision, you may request a review in accord with the procedures detailed below.

If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8.

To reconsider a non-urgent care claim

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.

In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to do one of the following:

1. Precertify your hospital stay or, if applicable, arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply.

2. Ask you or your provider for more information.

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.

3. Write to you and maintain our denial.

To reconsider an urgent care claim

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.

Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request. We will expedite the review process, which allows oral or written request for appeals and the exchange of information by phone, electronic mail, facsimile, or other expeditious methods.

To file an appeal with OPM

After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure.

The Federal Flexible Spending Account Program–FSAFEDS

  • Healthcare FSA (HCFSA)–Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you and your tax dependents, including adult children (through the end of the calendar year in which they turn 26).
  • FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans. This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.



Section 4. Your Cost for Covered Services

This is what you will pay out-of-pocket for covered care:



TermDefinition
Cost-sharing Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible, coinsurance, and copayments) for the covered care you receive.

Copayments

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services. The amount of copayment will depend upon whether you are enrolled in the High, Standard or Prosper, the type of provider, and the service or supply that you receive.

You pay a primary care provider copayment when you visit any primary care provider as described in Section 3, How you get care. You pay a specialist copayment when you receive care from a specialist as described in Section 3.

For example, for diagnostic and treatment services as described in Section 5(a):

  • Under the High Option, you pay a $15 copayment when you receive diagnostic and treatment services from a primary care provider or a $25 copayment when you receive diagnostic and treatment services from a specialty care provider.
  • Under the Standard Option, you pay a $30 copayment when you receive diagnostic and treatment services from a primary care provider or a $40 copayment when you receive diagnostic and treatment services from a specialty care provider.
  • Under Prosper, you pay a $25 copayment when you receive diagnostic and treatment services from a primary care provider and a $35 copayment when you receive diagnostic and treatment services from a specialty care provider.

The Plan may allow you to designate a specialist as the physician who provides most of your healthcare (including services that primary care physicians provide, such as referrals to specialists). If you choose to receive most of your healthcare from a physician designated as a specialist, the specialty care office visit copayment, rather than the primary care office visit copayment, will apply.

Deductible

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them.  Copayments do not count toward any deductible.

  • The High Option has no deductible.
  • The calendar year deductible is $100 per person under the Standard Option. Under a Self Plus One or Self and family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $200.
  • The calendar year deductible is $500 per person under Prosper. Under a Self Plus One or Self and family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $1,000.

Note: If you change plans during Open Season, you do not have to start a new deductible under your prior 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.

If you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option.

CoinsuranceCoinsurance is the percentage of our allowance that you must pay for certain services you receive. Example: In our Plan, you pay 50% of our allowance for infertility services.
Paying cost-sharing amounts

Cost-sharing is due when you receive the services, except for the following:

Before starting or continuing a course of infertility services, you may be required to pay one or more deposits toward some or the entire course of services. Any unused portion of your deposit will be returned to you. When a deposit is not required, before you can schedule an infertility procedure, you must pay the copayment or coinsurance for the procedure.

For items ordered in advance, you pay the copayment or coinsurance in effect on the order date (although we will not cover the item unless you still have plan coverage for it on the date you receive it) and you may be required to pay the copayment or coinsurance before the item is ordered.

Your catastrophic protection out-of-pocket maximum

After your cost-sharing total is $2,000 per person up to $4,000 per family enrollment (High Option) or $3,000 per person up to $6,000 per family enrollment (Standard Option) or $5,500 per person up to $11,000 per family enrollment (Prosper) in any calendar year, you do not have to pay any more for certain covered services. This includes any services required by group health plans to count toward the catastrophic protection out-of-pocket maximum by federal healthcare reform legislation (the Affordable Care Act and implementing regulations). 

Example: Your plan has a $2,000 per person up to $4,000 per family maximum out-of-pocket limit. If you or one of your covered family members has out-of-pocket qualified medical expenses of $2,000 in a calendar year, any cost-sharing for qualified medical expenses for that individual will be covered fully by your health plan for the remainder of the calendar year. With a family enrollment, the out-of-pocket maximum will be satisfied once two or more family members have out-of-pocket qualified medical expenses of $4,000 in a calendar year, and any cost–sharing for qualified medical expenses for all enrolled family members will be covered fully by your health plan for the reminder of the calendar year.

However, cost-sharing for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay cost-sharing for these services:

  • Chiropractic services
  • Dental services
  • Durable medical equipment, except the following items: blood glucose monitors and their supplies; infusion pumps and supplies to operate the pump; standard curved handle or quad cane and replacement supplies; standard or forearm crutches and replacement supplies; dry pressure pad for a mattress; nebulizer and supplies; peak flow meters; IV pole; bone stimulator; cervical traction (over door); and, phototherapy blankets for treatment of jaundice in newborns
  • Hearing aids
  • Infertility services and fertility drugs
  • Travel benefit

Be sure to keep accurate records and receipts of your cost-sharing, since you are responsible for informing us when you reach the maximum.

Carryover

If you changed to this Plan during Open Season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan’s catastrophic protection benefit during the prior year will be covered by your prior plan if they are for care you received in January before your effective date of coverage in this Plan. If you have already met your prior plan’s catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. If you have not met this expense level in full, your prior plan will first apply your covered out-of-pocket expenses until the prior year’s catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Your prior plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

Note: If you change options in this Plan during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your prior option to the catastrophic protection limit of your new option.

When Government facilities bill usFacilities of the Department of Veterans Affairs, the Department of Defense and the Indian Health Services are entitled to seek reimbursement from us for certain services and supplies they provide to you or a family member. They may not seek more than their governing laws allow. You may be responsible to pay for certain services and charges. Contact the government facility directly for more information.

Important notice about surprise billing - know your rights

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” under certain circumstances. A surprise bill is an unexpected bill you receive from a non-plan healthcare provider, facility, or air ambulance service for healthcare. Surprise bills can happen when you receive emergency care – when you have little or no say in the facility or provider from whom you receive care. They can also happen when you receive non-emergency services at plan facilities, but you receive some care from non-plan providers.

Balance billing happens when you receive a bill from the non-plan provider, facility, or air ambulance service for the difference between the non-plan provider's charge and the amount payable by your health plan.

Your health plan must comply with the NSA protections that hold you harmless from unexpected bills. 

In addition, your health plan adopts and complies with the surprise billing laws of California.

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.kp.org/feds or contact the health plan at 800-464-4000.




Section 5. High Option, Standard Option and Prosper Benefits (High Option, Standard Option and Prosper)

See page (Applies to printed brochure only) for how our benefits changed this year. Pages (Applies to printed brochure only) through (Applies to printed brochure only) are a benefits summary of each option. Make sure that you review the benefits that are available under the option in which you are enrolled.




(Page numbers solely appear in the printed brochure)




Section 5. High Option, Standard Option and Prosper Benefits Overview (High Option, Standard Option and Prosper)

This Plan offers High Option, Standard Option and Prosper. These benefit packages are described in Section 5. Make sure that you review the benefits that are available under the option in which you are enrolled.

The High Option, Standard Option and Prosper Section 5 is divided into subsections. Please read Important things you should keep in mind at the beginning of the subsections. Also read the general exclusions in Section 6, they apply to the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about High Option, Standard Option and Prosper benefits, contact us at 800-464-4000 (TTY: 711) or on our website at www.kp.org/feds.

Since 1945, Kaiser Foundation Health Plan, Inc., Northern California Region has offered quality integrated healthcare to the FEHB Program. Our delivery system offers convenient, comprehensive care all under one roof. You can come to almost any one of our medical facilities and see a primary care physician or specialist, fill prescriptions, have mammograms, complete lab work, get X-rays and more. Also, our sophisticated health technology gives you the opportunity 24 hours a day, 7 days a week to schedule appointments, send secure messages to your provider, refill prescriptions, or research medical conditions.

This Plan offers three options: the High Option, Standard Option and Prosper. All Options are designed to include preventive and acute care services provided by our Plan providers, but offer different levels of benefits and services for you to choose between to best fit your healthcare needs.

High Option

The High Option includes the most comprehensive benefits. Our FEHB High Option includes:

  • Primary care office visit copayment – $15
  • Specialty care office visit copayment – $25
  • Copayment on inpatient admissions – $250
  • Copayment for most adult preventive care services and immunizations provided at no charge
  • Drug cost-sharing – $10 for generic drugs, $40 for preferred and non-preferred brand name drugs, and $100 for specialty drugs per prescription or refill for up to a 30-day supply at a Plan pharmacy
  • Chiropractic office visit copayment – $15 for up to 20 visits per calendar year

Standard Option

We also offer a Standard Option. With the Standard Option your copayments (and coinsurance, if appropriate) may be higher than for the High Option, but the biweekly premium is lower. Specific benefits of our FEHB Standard Option include:

  • Calendar year deductible of $100 per person and $200 per family
  • Primary care office visit copayment $30
  • Specialty care office visit copayment $40
  • Copayment on inpatient admissions $500 after the deductible
  • Copayment for most adult preventive care services and immunizations provided at no charge
  • Drug cost-sharing $15 for generic drugs, $50 for preferred and non-preferred brand name drugs, and $150 for specialty drugs per prescription or refill for up to a 30-day supply at a Plan pharmacy
  • Chiropractic office visit copayment  $15 for up to 20 visits per calendar year

 

Prosper

We also offer Prosper. With Prosper your copayments (and coinsurance, if appropriate) may be higher than for the High Option, but the biweekly premium is lower. Specific benefits of FEHB Prosper include:

  • Calendar year deductible of $500 per person and $1,000 per family
  • Primary care office visit copayment  $25
  • Specialty care office visit copayment $35
  • Coinsurance on inpatient admissions 20% of our allowance after the deductible
  • Copayment for most adult preventive care services and immunizations provided at no charge
  • Drug cost-sharing – $15 for generic drugs, $60 for preferred and non-preferred brand name drugs, $200 per prescription for up to a 30-day supply at a Plan pharmacy
  • Chiropractic office visit copayment – $15 for up to 20 visits per calendar year

Please review this brochure carefully to learn which of our Kaiser Foundation Health Plan of California FEHB options is best for you. If you would like more information about our benefits, please contact us at 800-464-4000 (TTY: 711) or visit our website at www.kp.org.




Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals (High Option, Standard Option and Prosper)

Important things you should 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.
  • The calendar year deductible for the Standard Option is $100 per person ($200 per family). The calendar year deductible for Prosper is $500 per person ($1,000 per family). The calendar year deductible applies to some benefits in this Section. We added "after the deductible" when the calendar year deductible applies.
  • There is no deductible for the High Option.
  • Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • You pay one-half of the individual office visit copayment for certain group office visits, rounded down to the nearest dollar. You pay the primary care office visit copayment for visits with a non-physician specialist (such as nurse practitioners, physician assistants, optometrists, podiatrists and audiologists).
  • YOUR PROVIDER MUST GET PRIOR APPROVAL FOR SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.



Benefit Description : Diagnostic and treatment servicesHigh Option (You pay )Standard Option (You pay )Prosper (You pay )

Professional services of physicians and other healthcare professionals

  • In a physician’s office
  • Office medical consultations
  • Second surgical opinions
  • Advance care planning
  • At home

$15 per primary care office visit

$25 per specialty care office visit

$30 per primary care office visit

$40 per specialty care office visit

$25 per primary care office visit

$35 per specialty care office visit

Professional services of physicians and other healthcare professionals

  • During a hospital stay
  • In a skilled nursing facility
Nothing

Nothing after the deductible

20% of our allowance after the deductible

Benefit Description : Telehealth servicesHigh Option (You pay )Standard Option (You pay )Prosper (You pay )

Professional services of physicians and other healthcare professionals delivered through telehealth, such as:

  • Interactive video visits
  • Phone visits
  • Email

Note: Visits may be limited by provider type and/or location and benefit specific limitations, such as visit limits.

NothingNothingNothing
Benefit Description : Lab, X-ray, and other diagnostic testsHigh Option (You pay )Standard Option (You pay )Prosper (You pay )

Tests, such as:

  • Blood test
  • Urinalysis
  • Non-routine Pap test
  • Pathology
  • X-rays
  • Non-routine mammogram
  • Ultrasound
  • Electrocardiogram and EEG
  • Nuclear medicine
Nothing

$10 per office visit after the deductible

20% of our allowance after the deductible

  • Routine laboratory tests to monitor the effectiveness of dialysis

Nothing

Nothing after the deductible

Nothing after the deductible

  • CT/CAT scan
  • MRI 
  • PET scan
Nothing

$50 per procedure after the deductible

20% of our allowance after the deductible

  • Procedures requiring licensed staff to monitor your vital signs as you regain sensation after receiving drugs to reduce sensation or to minimize discomfort.
$50 per procedure

$200 per procedure after the deductible

20% of our allowance after the deductible

Benefit Description : Preventive care, adultHigh Option (You pay )Standard Option (You pay )Prosper (You pay )

Routine physical exam, including hearing exams to determine the need for hearing correction.

The following preventive services are covered at the time interval recommended at each of the links below:

  • Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV). For a complete list of immunizations visit the Centers for Disease Control (CDC) website at www.cdc.gov/vaccines/schedules
  • Screenings such as for breast cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer. For a complete list of A and B recommended screenings visit the U.S. Preventive Services Task Force (USPSTF) website at www.uspreventiveservicestaskforce.org/uspstf/
  • Individual counseling on prevention and reducing health risks
  • Well woman care such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of Well Women preventive care services please visit the Health and Human Services (HHS) website at www.healthcare.gov/preventive-care-women
  • Services such as routine prostate specific antigen (PSA) test and retinal photography screening.
  • We cover other preventive services required by federal healthcare reform legislation (the Affordable Care Act and implementing regulations) and additional services that we include in our preventive services benefit. For a complete list of Kaiser Permanente preventive services visit our website at www.kp.org/prevention
  • To build your personalized list of preventive services go to www.health.gov/myhealthfinder
Nothing

Nothing

Nothing

  • Routine mammogram covered for women
Nothing

Nothing

Nothing

  • Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule.

Nothing

Nothing

Nothing

Notes:

  • You may pay cost-sharing for any procedure, injection, diagnostic service, laboratory or X-ray service that is provided in conjunction with a routine physical exam and not included in the preventive recommended listing of services.
  • You should consult with your physician to determine what is appropriate for you.

Applies to this benefit

Applies to this benefit

Applies to this benefit

Not covered:

  • Physical exams required for:
    • Obtaining or continuing employment
    • Insurance or licensing
    • Participating in employee programs
    • Court ordered parole or probation

All charges

All charges

All charges

Benefit Description : Preventive care, childrenHigh Option (You pay )Standard Option (You pay )Prosper (You pay )
  • Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines visit https://brightfutures.aap.org
  • Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations visit the Centers for Disease Control (CDC) website at www.cdc.gov/vaccines/schedules/index.html
  • You can also find a complete list of A and B recommended preventive care services under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org/uspstf/
  • We cover other preventive services required by federal healthcare reform legislation (the Affordable Care Act and implementing regulations) and additional services that we include in our preventive services benefit. For a complete list of Kaiser Permanente preventive services visit our website at www.kp.org/prevention
  • To build your personalized list of preventive services go to https://health.gov/myhealthfinder
Nothing

Nothing

Nothing

Notes: 

  • You may pay cost-sharing for any procedure, injection, diagnostic service, laboratory or X-ray service that is provided in conjunction with a routine physical exam and not included in the preventive recommended listing of services.
  • Hearing screenings are provided by a primary care physician as part of a well-child care visit. For other hearing exams or tests, see Section 5(a), Diagnostic and treatment services or Section 5(a), Hearing services.

Applies to this benefit

Applies to this benefit

Not covered:

  • Physical exams required for:
    • Obtaining or continuing employment
    • Insurance or licensing
    • Participating in employee program 
    • Court ordered parole or probation
  • All other hearing testing, except as may be covered in Section 5(a), Diagnostic and treatment services and Section 5(a), Hearing services

All chargesAll chargesAll charges
Benefit Description : Maternity careHigh Option (You pay )Standard Option (You pay )Prosper (You pay )

Routine maternity (obstetrical) care, such as:

  • Prenatal care visit
  • Screening for gestational diabetes for pregnant women
  • First postpartum care visit
Nothing

Nothing

Nothing

  • Breastfeeding support, supplies and counseling for each birth

Note: We cover breastfeeding pumps and supplies under Durable Medical Equipment (DME). 

Nothing

Nothing

Nothing

  • Delivery
Nothing for inpatient professional delivery services

Nothing for inpatient professional delivery services after the deductible

20% of our allowance after the deductible

Notes:

  • Routine maternity care is covered after confirmation of pregnancy.
  • Your Plan provider does not have to obtain prior approval from us for your vaginal delivery. See Section 3, You need prior Plan approval for certain services, for prior approval guidelines.
  • We cover routine nursery care of the newborn during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment.
  • When a newborn requires definitive treatment during or after the mother's confinement, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.
  • We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
  • You pay cost-sharing for other services, including:
    • Diagnostic and treatment services for illness or injury received during a non-routine maternity care visit as described in this section.
    • Lab, X-ray and other diagnostic test (including ultrasounds), Durable medical equipment as described in this section.
    • Surgical services (including circumcision of an infant if performed after the mother's discharge from the hospital) as described in Section 5(b), Outpatient hospital or ambulatory surgical center.
    • Hospitalization (including room and board and delivery) as described in Section 5(c) Inpatient hospital.

Applies to this benefit

Applies to this benefit

Applies to this benefit

Benefit Description : Family planning High Option (You pay )Standard Option (You pay )Prosper (You pay )

A range of family planning services, limited to:

  • Surgically implanted contraceptive drugs
  • Injectable contraceptive drugs (such as Depo Provera)
  • Intrauterine devices (IUDs)
  • Family planning counseling
  • Contraceptives counseling

Notes:

  • Female voluntary sterilization (See Section 5(b), Surgical procedures)
  • We cover other contraceptive drugs, cervical caps, and diaphragms. See Section 5(f), Prescription drug benefits.
  • For surgical costs associated with family planning, see Section 5(b), Surgical procedures.
Nothing

Nothing

Nothing 

  • Genetic counseling

$15 per primary care office visit

$25 per specialty care office visit

$30 per primary care office visit

$40 per specialty care office visit

$25 per primary care office visit

$35 per specialty care office visit

Not covered:

  • Reversal of voluntary surgical sterilization
All chargesAll chargesAll charges
Benefit Description : Infertility servicesHigh Option (You pay )Standard Option (You pay )Prosper (You pay )

Diagnosis and treatment of infertility, such as:

  • Artificial insemination:
    • Intravaginal insemination (IVI)
    • Intracervical insemination (ICI)
    • Intrauterine insemination (IUI)
  • Semen analysis
  • Hysterosalpingogram
  • Hormone evaluation

Notes:

  • See Section 5(f), Prescription drug benefits, for coverage of fertility drugs
  • Infertility is the inability of an individual to conceive or produce conception during a period of 1 year if the female is age 35 or younger, or during a period of 6 months if the female is over the age of 35, or having a medical or other demonstrated condition that is recognized by a Plan physician as a cause of infertility.
  • Infertility services are covered for individuals over the age of 18. 
  • A Plan physician will determine the appropriate treatment and number of attempts for infertility treatment.
50% of our allowance

50% of our allowance

50% of our allowance

Standard fertility preservation for iatrogenic infertility, such as:

  • Retrieval of sperm and eggs
  • Cryopreservation
  • Storage for preserved specimen for 1 year after a covered preservation procedure even if your enrollment ends

Note: You pay cost-sharing for other services associated with fertility preservation for
iatrogenic infertility, including:

  • Lab, X-ray and other diagnostic tests, as
    described in Section 5(a)
  • Surgical services as described in Section
    5(b)
  • Outpatient hospital or ambulatory surgical
    center as described in Section 5(c)
  • Prescription drugs as described in Section
    5(f)

$25 per specialty care office visit

$40 per specialty care office visit

$35 per specialty care office visit

Not covered:

These exclusions apply to fertile as well as infertile individuals or couples:

  • Assisted reproductive technology (ART) procedures, including related services and supplies, such as: 
    • in vitro fertilization (IVF) 
    • embryo transfer, gamete intra-fallopian transfer (GIFT), and zygote intra-fallopian transfer (ZIFT)
  • Any charges associated with donor eggs,
    donor sperm or donor embryos
  • Any charges associated with cryopreservation, unless listed as covered above for iatrogenic infertility
  • Any charges associated with thawing and storage of frozen sperm, eggs and
    embryos, unless listed as covered above for iatrogenic infertility
  • Ovum transplants
  • Infertility services when either member of the family has been voluntarily, surgically sterilized
  • Services to reverse voluntary, surgically induced infertility
All chargesAll chargesAll charges
Benefit Description : Allergy careHigh Option (You pay )Standard Option (You pay )Prosper (You pay )
  • Testing and treatment
$25 per specialty care office visit

$40 per specialty care office visit

$35 per specialty care office visit

  • Injections
$5 per office visit

$5 per office visit after the deductible

$5 per office visit after the deductible

  • Serum
Nothing

Nothing after the deductible

Nothing after the deductible

Not covered:

  • Provocative food testing
  • Sublingual allergy desensitization
All chargesAll chargesAll charges
Benefit Description : Treatment therapiesHigh Option (You pay )Standard Option (You pay )Prosper (You pay )
  • Chemotherapy 

Note: High-dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Section 5(b), Organ/Tissue transplants.

  • Intravenous (IV)/Infusion therapy— Home IV and antibiotic therapy

$25 for services provided by a physician

Nothing for services provided by a non-physician provider

$40 for services provided by a physician

Nothing for services provided by a non-physician provider

$35 for services provided by a physician

Nothing for services provided by a non-physician provider

  • Cardiac rehabilitation following a qualifying event/condition

$15 per primary care office visit

$25 per specialty care office visit

$30 per primary care office visit

$40 per specialty care office visit

$25 per primary care office visit

$35 per specialty care office visit

  • Radiation therapy

$25 for services provided by a physician

Nothing for services provided by a non-physician provider

$40 for services provided by a physician

Nothing for services provided by a non-physician provider after the deductible

$35 for services provided by a physician

Nothing for services provided by a non-physician provider after the deductible

  • Respiratory and inhalation therapy

$25 per specialty care office visit

Nothing for services provided by a non-physician provider

$40 per specialty care office visit

$10 per office visit for services provided by a non-physician provider after the deductible

$35 per specialty care office visit

20% of our allowance for services provided by a non-physician provider after the deductible

  • Outpatient dialysis performed in a doctor’s office or facility - hemodialysis and peritoneal dialysis
$25 per specialty care office visit

$40 per specialty care office visit after the deductible

$35 per specialty care office visit after the deductible

  • One routine office visit per month with the multidisciplinary nephrology team
  • Ultraviolet light treatments
Nothing

Nothing

Nothing

  • Home dialysis – hemodialysis and peritoneal dialysis

Note: After you receive appropriate training at a dialysis facility we designate, we also cover equipment and medical supplies required for home hemodialysis and home peritoneal dialysis inside our service area. Coverage is limited to the standard item of equipment or supplies that adequately meets your medical needs. We decide whether to rent or purchase the equipment and supplies, and we select the vendor. You must return the equipment and any unused supplies to us or pay us the fair market price of the equipment and any unused supplies when we are no longer covering them.

Nothing

Nothing after the deductible

Nothing after the deductible

Notes:

  • Growth hormone is covered under the prescription drug benefit. See Section 5(f), Prescription drug benefits.
  • See Section 5(e), Professional services, for coverage of Applied Behavior Analysis (ABA).

Applies to this benefit

Applies to this benefit

Applies to this benefit

Benefit Description : Physical and occupational therapiesHigh Option (You pay )Standard Option (You pay )Prosper (You pay )
  • Physical habilitative and rehabilitative therapy by qualified physical therapists to attain or restore bodily function when you have a total or partial loss of bodily function due to illness or injury.
  • Occupational habilitative and rehabilitative therapy by occupational therapists to assist you in attaining or resuming self-care and improved functioning in other activities of daily life when you have a total or partial loss of bodily function due to illness or injury.
  • Multidisciplinary outpatient rehabilitation includes diagnostic and restorative services comprising a program of physical, speech, occupational, and respiratory therapy, as well as certain other items and services that are medically necessary for rehabilitation.

$15 per visit

$30 per visit after the deductible

$25 per visit after the deductible

Not covered:

  • Exercise programs
All chargesAll chargesAll charges
Benefit Description : Speech therapy High Option (You pay )Standard Option (You pay )Prosper (You pay )

Habilitative and rehabilitative for:

  • Visits to a speech therapist

$15 per visit

$30 per visit after the deductible

$25 per visit after the deductible

Not covered:

  • Services to treat social, behavioral, or cognitive delays in speech or language development, unless medically necessary.
All charges All charges All charges
Benefit Description : Hearing services (testing, treatment, and supplies)High Option (You pay )Standard Option (You pay )Prosper (You pay )
  • Hearing aids, including testing and examinations for them, for children through age 17
All charges in excess of $1,000 for each hearing impaired ear every 36 months

All charges in excess of $1,000 for each hearing impaired ear every 36 months

All charges in excess of $1,000 for each hearing impaired ear every 36 months

Notes:

  • We will cover hearing aids for both ears only if both aids are required to provide significant improvement that is not obtainable with only one hearing aid.
  • Coverage is limited to the types and models of hearing aids furnished by the provider or vendor we select.
  • For coverage of:
    • Hearing screenings, see Section 5(a), Preventive care, children and, for any other hearing testing, see Section 5(a), Diagnostic and treatment services.
    • Audible prescription reading and speech generating devices, see Section 5(a), Durable medical equipment.

Applies to this benefit

Applies to this benefit

Applies to this benefit

Not covered:

  • All other hearing testing, except as may be covered in Section 5(a), Diagnostic and treatment services and Section 5(a), Preventive care, children
  • Hearing aids, including testing and examinations for them, for all persons age 18 and over
  • Internally implanted hearing aids
  • Replacement parts and batteries, repair of hearing aids, and replacement of lost or broken hearing aids
All charges
All charges
All charges
Benefit Description : Vision services (testing, treatment, and supplies)High Option (You pay )Standard Option (You pay )Prosper (You pay )
  • Diagnosis and treatment of diseases of the eye

$15 per primary care office visit

$25 per specialty care office visit

$30 per primary care office visit

$40 per specialty care office visit

$25 per primary care office visit

$35 per specialty care office visit

  • Routine eye exam with a Plan optometrist to determine the need for vision correction and provide a prescription for eyeglasses
  • Therapeutic contact lenses for the condition of aniridia for up to two lenses per eye, per calendar year
  • Up to a total of six medically necessary aphakic contact replacement lenses per eye, per calendar year to treat aphakia (absence of the crystalline lens of the eye)
Nothing

Nothing

Nothing

Not covered:

  • Eyeglass lenses or frames 
  • Contact lenses, examinations for contact lenses or the fitting of contact lenses, except for the condition of aniridia or to treat aphakia
  • Eye surgery solely for the purpose of correcting refractive defects of the eye
All chargesAll chargesAll charges
Benefit Description : Foot careHigh Option (You pay )Standard Option (You pay )Prosper (You pay )
  • Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes

$15 per primary care office visit

$25 per specialty care office visit

$30 per primary care office visit

$40 per specialty care office visit

$25 per primary care office visit

$35 per specialty care office visit

Not covered:

  • Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
  • Treatment of weak, strained, or flat feet, or bunions or spurs; and of any instability, imbalance, or subluxation of the foot (unless the treatment is by open cutting surgery)
All chargesAll chargesAll charges
Benefit Description : Orthopedic and prosthetic devices High Option (You pay )Standard Option (You pay )Prosper (You pay )

External prosthetic and orthotic devices , such as:

  • Artificial limbs and eyes
  • Prosthetic sleeve or sock
  • Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy
  • Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
  • Ostomy and urological supplies that are consistent with our Plan Soft Goods Formulary guidelines
  • Podiatric devices (including footwear) to prevent or treat diabetes-related complications when prescribed by a Plan physician
  • Special footwear for foot disfigurement due to disease, injury, or developmental disability
  • Enteral formula for members who require tube feeding per Medicare guidelines
  • Tracheostomy tube and supplies
  • Enteral pump and supplies
  • External devices used for the treatment of sexual dysfunction
Nothing

Nothing

Nothing

Internal prosthetic devices, such as:

  • Artificial joints
  • Pacemakers
  • Cochlear implants
  • Osseointegrated external hearing devices
  • Surgically implanted breast implants following a mastectomy
  • Monofocal intraocular lenses following cataract removal
  • Repairs and replacements resulting from normal use

Note: See Section 5(b), Surgery benefits, for coverage of the surgery to insert the device and Section 5(c), Hospital benefits, for inpatient hospital benefits.

Nothing











Nothing after the deductible

 







Nothing after the deductible

Notes:

  • Orthopedic and prosthetic equipment or services must be prescribed by a Plan physician; obtained through sources designated by the Plan; and primarily and customarily used to serve a medical or therapeutic purpose in the treatment of an illness or injury.
  • We cover only those standard items that are adequate to meet the medical needs of the member.
  • For coverage of hearing aids, see Section 5(a), Hearing services.
  • See Section 3 How you get care for services that need prior Plan approval.

Applies to this benefit

Applies to this benefit

Applies to this benefit

Not covered:

  • Orthopedic and prosthetic devices and corrective shoes, except as described above
  • Foot orthotics and podiatric use devices, such as arch supports, heel pads and heel cups, except as described above
  • Multifocal intraocular lenses and intraocular lenses to correct astigmatism
  • Nonrigid supplies, such as elastic stockings and wigs
  • Lumbosacral supports
  • Corsets, trusses, elastic stockings, support hose, and other supportive devices
  • Comfort, convenience, or luxury equipment or features
  • Repairs, adjustments, or replacements due to misuse, theft or loss
All charges


All chargesAll charges
Benefit Description : Durable medical equipment (DME)High Option (You pay )Standard Option (You pay )Prosper (You pay )

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Covered items include:

  • Oxygen and oxygen dispensing equipment
  • Hospital beds
  • Wheelchairs, including motorized wheelchairs when medically necessary
  • Crutches
  • Walkers
  • Speech generating devices
  • Blood glucose monitors and related supplies
  • Insulin pumps
  • Infant apnea monitors
20% of our allowance

50% of our allowance

50% of our allowance

  • One breastfeeding pump and supplies per delivery, including equipment that is required for pump functionality
  • Ultraviolet light treatment equipment
Nothing

Nothing

Nothing

  • During a covered stay in a Plan hospital or skilled nursing facility

Nothing

Nothing after the deductible

20% of our allowance after the deductible

Notes:

  • Durable medical equipment (DME) is equipment that is prescribed by a Plan physician; obtained through sources designated by the Plan; consistent with our Plan DME formulary guidelines; intended for repeated use; primarily and customarily used to serve a medical or therapeutic purpose in the treatment of an illness or injury; designed for prolonged use; and appropriate for use in the home.
  • We cover only those standard items that are adequate to meet the medical needs of the member.
  • We may require you to return the equipment to us, or pay us the fair market price of the equipment, when it is no longer prescribed.
  • We only provide DME in the Plan's service areas, except we cover the following DME items if you live outside our service area when the item is dispensed at a Plan facility:
    • Standard curved handle cane
    • Standard crutches
    • For diabetes blood testing, blood glucose monitors and their supplies from a Plan Pharmacy
    • Insulin pumps and supplies to operate the pump (but not including insulin or any other drugs), after completion of training and education on the use of the pump
    • Nebulizers and their supplies for the treatment of pediatric asthma
    • Peak flow meters from a Plan Pharmacy
  • Diabetes urine-testing supplies and insulin-administration devices other than insulin pumps are covered under your prescription drug benefit. See Section 5(f), Prescription drug benefits.
  • See Section 3 How you get care for services that need prior Plan approval.

Applies to this benefit

Applies to this benefit

Applies to this benefit

Not covered:

  • Audible prescription reading devices
  • Comfort, convenience, or luxury equipment or features
  • Non-medical items such as sauna baths or elevators
  • Exercise and hygiene equipment
  • Electronic monitors of the heart, lungs, or other bodily functions, except for infant apnea monitors
  • Devices to perform medical testing of bodily fluids, excretions or substances, except diabetic blood testing equipment and supplies
  • Modifications to the home or vehicle
  • Dental appliances
  • More than one piece of durable medical equipment serving essentially the same function
  • Spare or alternate use equipment
  • Repairs, adjustments, or replacements due to misuse, theft or loss

All charges

All charges

All charges

Benefit Description : Home health servicesHigh Option (You pay )Standard Option (You pay )Prosper (You pay )
  • Home healthcare ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), physical or occupational therapist, speech therapist or home health aide
  • Services include oxygen therapy, intravenous therapy, and medications

Notes:

  • We only provide these services in the Plan's service areas.
  • The services are covered only if you are homebound and a Plan physician determines that it is feasible to maintain effective supervision and control of your care in your home.
  • Services of a home health aide must be part of covered home healthcare and home health aide services are not covered unless you are also getting covered home healthcare from a licensed provider that only a licensed provider can provide.
  • See Section 3 How you get care for services that need prior Plan approval.
Nothing

Nothing

Nothing

Not covered:

  • Nursing care requested by, or for the convenience of, the patient or the patient’s family
  • Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative
  • Custodial care
  • Personal care and hygiene items
  • Care of a type that an unlicensed family member or other layperson could provide safely and effectively in the home setting after receiving appropriate training. This care is excluded even if we would cover the care if it were provided by a qualified medical professional in a hospital or a skilled nursing facility.
All chargesAll chargesAll charges
Benefit Description : Chiropractic High Option (You pay )Standard Option (You pay )Prosper (You pay )

Up to 20 visits per calendar year, limited to:

  • Diagnosis and treatment of neuromusculoskeletal disorders
  • Laboratory tests and plain film X-rays associated with diagnosis and treatment

Notes:

  • You may only self-refer to a participating American Specialty Health (ASH) network chiropractor. The participating chiropractor must provide, arrange or prescribe your care and appliances.
  • Participating chiropractors are listed in the ASH Participating Provider Directory. For a list of ASH Participating Providers, call 800-678-9133.

$15 per visit

$15 per visit

$15 per visit

  • Chiropractic appliances
All charges over $50 per calendar year

All charges over $50 per calendar year

All charges over $50 per calendar year

Not covered:

  • Hypnotherapy, behavior training, sleep therapy and weight programs 
  • Thermography 
  • Any radiological exam other than plain film studies such as magnetic resonance imaging, CT scans, bone scans, nuclear radiology
  • Treatment for non-neuromusculoskeletal disorders, including adjunctive therapy
All chargesAll chargesAll charges
Benefit Description : Alternative treatmentsHigh Option (You pay )Standard Option (You pay )Prosper (You pay )
  • Acupuncture services, primarily for the treatment of chronic pain and nausea

$15 per visit

$30 per visit

$25 per visit

Not covered:

  • Massage therapy
All chargesAll chargesAll charges
Benefit Description : Educational classes and programsHigh Option (You pay )Standard Option (You pay )Prosper (You pay )

Health education classes including:

  • Tobacco cessation programs, including individual, group and phone counseling, prescribed over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco cessation.
  • Stress reduction
  • Chronic conditions, such as diabetes and asthma
  • Individual health education visits
  • Childhood obesity education

 Notes:

  • Please call your local Health Education department or Member Services at 800-464-4000 for information on classes near you.
  • See Section 5(f), Prescription drug benefits, for important information about coverage of tobacco cessation and other drugs.
Nothing

Nothing

Nothing




Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals (High Option, Standard Option and Prosper)

Important things you should 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 will also determine the most medically appropriate setting for provision of care. Consult with your physician to determine what is appropriate for you.
  • There is no deductible for the High Option.
  • The calendar year deductible for the Standard Option is $100 per person ($200 per family). The calendar year deductible for Prosper Option is $500 per person ($1,000 per family). The calendar year deductible applies to some benefits in this Section. We added "after the deductible” when the calendar year deductible applies.
  • Be sure to read Section 4, Your cost 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 cost-sharing listed below applies to services billed by a physician or other healthcare professional for your surgical care. See Section 5(a) for cost-sharing you pay for services performed during an office visit or 5(c) for cost-sharing you pay for services in an inpatient hospital, outpatient hospital or ambulatory surgical center facility.
  • YOUR PROVIDER MUST GET PRIOR APPROVAL FOR SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.



Benefit Description : Surgical proceduresHigh Option (You pay )Standard Option (You pay )Prosper (You pay )

A comprehensive range of services, such as:

  • Operative procedures
  • Treatment of fractures, including casting
  • Normal pre- and postoperative care by the surgeon
  • Correction of amblyopia and strabismus
  • Endoscopy procedures
  • Biopsy procedures
  • Removal of tumors and cysts
  • Correction of congenital anomalies (see Reconstructive surgery)
  • Male voluntary sterilization (e.g., vasectomy)
  • Treatment of burns
  • Insertion of other implanted time-release drugs

Notes:

  • We cover the cost of these drugs and devices under the prescription drug benefit (see Section 5(f)).
  • See Section 3, How you get care for services that need prior Plan approval.

Nothing

Nothing

Nothing, except 20% of our allowance after the deductible for physician services while in an outpatient hospital, ambulatory surgical center, or inpatient

  • Surgical treatment of morbid obesity (bariatric surgery). You must:
    • be 18 years of age or older; and 
    • have a Body Mass Index (BMI) greater than 40. If your BMI is 35 to 40, bariatric surgery may be covered if the Medical Group authorizes the services in accord with the Medical Group’s bariatric surgery referral guidelines. The guidelines may require that a significant comorbidity directly related to obesity be present, such as: moderate to severe sleep apnea, hypertension requiring medication, and diabetes; and
    • meet all other bariatric surgery referral guidelines, including but not limited to: nutritional, psychological, medical, and social readiness for surgery, and complete a Medical Group approved pre-surgical educational preparatory program regarding lifestyle changes necessary for long-term bariatric surgery success

Notes:

  • You should consult with your physician to determine what is appropriate for you.
  • A Plan physician, who is a specialist in bariatric care, must determine that the surgery is medically necessary.
  • If you live 50 miles or more from the facility to which you are referred for a covered bariatric surgery, we will reimburse you for certain authorized and documented travel and lodging expenses as follows if:
    • The Medical Group gives you prior written authorization for travel and lodging reimbursement and
    • You send us adequate documentation including receipts.
  • Reimbursement benefits are subject to certain limits. Please call our Member Services Call Center at 800-464-4000 for more information.

Nothing

Nothing

Nothing, except 20% of our allowance after the deductible for physician services while in an outpatient hospital, ambulatory surgical center, or inpatient

  • Female voluntary sterilization, including anesthesia and confirmation testing following tubal occlusion
  • Insertion of surgically implanted time-release contraceptive drugs and intrauterine devices (IUDs)
Nothing

Nothing

Nothing, except 20% of our allowance after the deductible for physician services while in an outpatient hospital, ambulatory surgical center, or inpatient

  • Surgical and any other procedures requiring licensed staff to monitor your vital signs as you regain sensation after receiving drugs to reduce sensation or to minimize discomfort.

Nothing

Nothing

Nothing, except 20% of our allowance after the deductible for physician services while in an outpatient hospital, ambulatory surgical center, or inpatient

  • Insertion of internal prosthetic devices. See Section 5(a) Orthopedic and prosthetic devices, for device coverage information.

Note: The following contraceptive devices and drugs are provided at no charge: intrauterine devices (IUDs), implanted time-release contraceptive drugs and injectable contraceptive drugs. We cover oral contraceptives, cervical caps, and diaphragms under the prescription drug benefit.

Nothing

Nothing

Nothing, except 20% of our allowance after the deductible for physician services while in an outpatient hospital, ambulatory surgical center, or inpatient

Not covered:

  • Reversal of voluntary surgical sterilization
  • Services for the promotion, prevention, or other treatment of hair loss or hair growth
  • Cosmetic surgery - any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form
All chargesAll chargesAll charges
Benefit Description : Reconstructive surgery High Option (You pay )Standard Option (You pay )Prosper (You pay )
  • Surgery to correct a functional defect
  • Surgery to correct a condition caused by injury or illness if:
    • the condition produced a major effect on the member’s appearance; and
    • the condition can reasonably be expected to be corrected by such surgery
  • Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers and toes
  • All stages of breast reconstruction surgery following a mastectomy, such as:
    • surgery and reconstruction on the other breast to produce a symmetrical appearance;
    • treatment of any physical complications, such as lymphedemas;
    • breast prostheses and surgical bras and replacements (see Prosthetic devices)
  • Gender reassignment surgery:
    • Assigned female at birth: hysterectomy, oophorectomy, metoidioplasty, phalloplasty, vaginectomy, scrotoplasty, erectile prosthesis, urethral extension, bilateral mastectomy with chest reconstruction, breast reduction
    • Assigned male at birth: penectomy, vaginoplasty, clitoroplasty, labiaplasty, orchiectomy, tracheal shave, breast augmentation, facial hair removal, facial feminization

Notes

  • 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.
  • We cover dental extractions, dental procedures necessary to prepare the mouth for an extraction and orthodontic services that are an integral part of reconstructive surgery for cleft palate, cleft lip, or other craniofacial anomalies associated with cleft palate.

Nothing

Nothing

Nothing, except 20% of our allowance after the deductible for physician services while in an outpatient hospital, ambulatory surgical center, or inpatient

  • Reconstructive surgical and any other procedures requiring licensed staff to monitor your vital signs as you regain sensation after receiving drugs to reduce sensation or to minimize discomfort.

Nothing

Nothing

Nothing, except 20% of our allowance after the deductible for physician services while in an outpatient hospital, ambulatory surgical center, or inpatient

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
  • Gender reassignment surgery not listed above
All chargesAll chargesAll charges
Benefit Description : Oral and maxillofacial surgery High Option (You pay )Standard Option (You pay )Prosper (You pay )

Oral surgical procedures, limited to:

  • Reduction of fractures of the jaw or facial bones
  • Surgical correction of cleft lip, cleft palate, or severe functional malocclusion
  • Removal of stones from salivary ducts
  • Excision of leukoplakia or malignancies
  • Excision of cysts and incision of abscesses when done as independent procedures
  • Medical and surgical treatment of temporomandibular joint (TMJ) disorder (non-dental); and
  • Other surgical procedures that do not involve the teeth or their supporting structures

Nothing

Nothing

Nothing, except 20% of our allowance after the deductible for physician services while in an outpatient hospital, ambulatory surgical center, or inpatient

  • Oral surgical procedures requiring licensed staff to monitor your vital signs as you regain sensation after receiving drugs to reduce sensation or to minimize discomfort.

Nothing

Nothing

Nothing

Not covered:

  • Oral implants and transplants
  • Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
  • Correction of any malocclusion not listed above
  • Dental services associated with medical treatment such as surgery, except for services related to accidental injury of teeth (See Section 5(g))
All chargesAll chargesAll charges
Benefit Description : Organ/tissue transplantsHigh Option (You pay )Standard Option (You pay )Prosper (You pay )

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan.  Refer to Section 3, How you get care for prior authorization procedures. Solid organ tissue transplants are limited to:

  • Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
  • Cornea
  • Heart
  • Heart/lung
  • Intestinal transplants
    • Isolated small intestine
    • Small intestine with the liver
    • Small intestine with multiple organs, such as the liver, stomach, and pancreas
  • Kidney
  • Kidney/pancreas
  • Liver
  • Lung: Single/bilateral/lobar
  • Pancreas

Nothing

Nothing

Nothing, except 20% of our allowance after the deductible for physician services while in an outpatient hospital, ambulatory surgical center, or inpatient

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Refer to Section 3 for prior authorization procedures.

  • Autologous tandem transplants for:
    • AL Amyloidosis
    • Multiple myeloma (de novo and treated)
    • Recurrent germ cell tumors (including testicular cancer)

Nothing

Nothing

Nothing, except 20% of our allowance after the deductible for physician services while in an outpatient hospital, ambulatory surgical center, or inpatient

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below:

  • Allogeneic transplants for:
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Acute myeloid leukemia
    • Advanced Myeloproliferative Disorders (MPDs)
    • Amyloidosis
    • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
    • Hemoglobinopathy
    • Marrow Failure and Related Disorders (i.e. Fanconi's, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
    • Myelodysplasia/Myelodysplastic syndromes
    • Paroxysmal Nocturnal Hemoglobinuria
    • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
    • Severe combined immunodeficiency
    • Severe or very severe aplastic anemia
    • Sickle cell anemia
    • X-linked lymphoproliferative syndrome
  • Autologous transplants for:
    • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
    • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Amyloidosis 
    • Multiple myeloma
    • Neuroblastoma
    • Testicular, mediastinal, retroperitoneal, and ovarian germ cell tumors

Nothing

Nothing

Nothing, except 20% of our allowance after the deductible for physician services while in an outpatient hospital, ambulatory surgical center, or inpatient

Limited benefits - The following autologous blood or bone marrow stem cell transplants may be provided in a National Cancer Institute (NCI) or National Institutes of Health (NIH)-approved clinical trial at a Plan-designated Center of Excellence. These limited benefits are not subject to medical necessity.

  • Advanced childhood kidney cancers
  • Advanced Ewing sarcoma
  • Aggressive non-Hodgkin's lymphomas
  • Breast cancer
  • Childhood rhabdomyosarcoma
  • Epithelial ovarian cancer
  • Mantle Cell (Non-Hodgkin's lymphoma)

Nothing

Nothing

Nothing, except 20% of our allowance after the deductible for physician services while in an outpatient hospital, ambulatory surgical center, or inpatient

Mini-transplants performed in a Clinical Trial Setting (non-myeloblative, reduced intensity conditioning).

  • Allogeneic transplants for:
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Acute myeloid leukemia
    • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced Myeloproliferative Disorders (MPDs)
    • Amyloidosis
    • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
    • Hemoglobinopathy
    • Marrow Failure and Related Disorders (i.e. Fanconi's, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
    • Myelodysplasia/Myelodysplastic syndromes
    • Paroxysmal Nocturnal Hemoglobinuria
    • Severe combined immunodeficiency
    • Severe or very severe aplastic anemia
  • Autologous transplants for:
    • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
    • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Amyloidosis  
    • Neuroblastoma

Nothing

Nothing

Nothing, except 20% of our allowance after the deductible for physician services while in an outpatient hospital, ambulatory surgical center, or inpatient

Transplant services requiring licensed staff to monitor your vital signs as you regain sensation after receiving drugs to reduce sensation or to minimize discomfort.

Nothing

Nothing

Nothing, except 20% of our allowance after the deductible for physician services while in an outpatient hospital, ambulatory surgical center, or inpatient

Notes:

  • We cover related medical and hospital expenses of the donor when we cover the recipient.
  • We cover donor screening tests for potential donors for solid organ transplants. We cover human leukocyte antigen (HLA) typing for potential donors for a bone marrow/stem cell transplant only for parents, children and siblings of the recipient.
  • We cover computerized national and international search expenses for prospective unrelated bone marrow/stem cell transplant donors conducted through the National Marrow Donor Program, and the testing of blood relatives of the recipient.
  • We cover medically necessary routine dental services required in preparation for a transplant. You pay cost-sharing listed in Section 5(a) for services performed during an office visit. Covered services may include a routine oral examination, cleaning (prophylaxis), extractions, and X-rays.
  • Please refer to Section 5(h), Special features, for information on our Centers of Excellence.
  • See Section 3 How you get care for services that need prior Plan approval.

Applies to this benefit

Applies to this benefit

Applies to this benefit

Not covered:

  • Donor screening tests and donor search expenses, except those listed above
  • Implants of non-human artificial organs
  • Transplants not listed as covered
All chargesAll chargesAll charges
Benefit Description : AnesthesiaHigh Option (You pay )Standard Option (You pay )Prosper (You pay )

Professional services provided in:

  • Hospital (inpatient)
  • Hospital outpatient department
  • Skilled nursing facility
  • Ambulatory surgery center
Nothing

Nothing

Nothing, except 20% of our allowance after the deductible for physician services while in an outpatient hospital, ambulatory, surgical center, or inpatient

  • Office

Nothing

Nothing

Nothing, except 20% of our allowance after the deductible for physician services while in an outpatient hospital, ambulatory, surgical center, or inpatient




Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services (High Option, Standard Option and Prosper)

Important things you should 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.
  • The calendar year deductible for the Standard Option is $100 per person ($200 per family). The calendar year deductible for Prosper is $500 per person ($1,000 per family). The calendar year deductible applies to some benefits in this Section. We added  “after the deductible” when the calendar year deductible applies.
  • There is no deductible for the High Option.
  • Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge (i.e., physicians, etc.) are covered in Sections 5(a) or (b).



Benefit Description : Inpatient hospitalHigh Option (You pay)Standard Option (You pay)Prosper (You pay)

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.

$250 per admission

$500 per admission after the deductible

20% of our allowance after the deductible

Other hospital services and supplies, such as:

  • Operating, recovery, maternity, and other treatment rooms
  • Prescribed drugs and medications
  • Diagnostic laboratory tests and X-rays
  • Blood and blood products
  • Dressings, splints, casts, and sterile tray services
  • Medical supplies and equipment, including oxygen
  • Anesthetics, including nurse anesthetist services

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 need for anesthesia, by itself, is not such a condition.

Nothing

Nothing after the deductible

20% of our allowance after the deductible

Not covered:

  • Custodial care and care in an intermediate care facility
  • Non-covered facilities, such as nursing homes
  • Personal comfort items, such as barber services, and guest meals and beds
  • Private nursing care, except when medically necessary
  • Inpatient dental procedures
All chargesAll chargesAll charges
Benefit Description : Outpatient hospital or ambulatory surgical centerHigh Option (You pay)Standard Option (You pay)Prosper (You pay)
  • Operating, recovery, and other treatment rooms
  • Prescribed drugs and medications
  • Lab, X-rays, and other diagnostic tests
  • Blood and blood products
  • Pre-surgical testing
  • Dressing, casts, and sterile tray services 
  • Medical supplies and equipment, including oxygen
  • Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.

$50 per admission

$200 per admission after the deductible

20% of our allowance after the deductible

Benefit Description : Skilled nursing care benefitsHigh Option (You pay)Standard Option (You pay)Prosper (You pay)

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

All necessary services are covered, including:

  • Room and board
  • General nursing care
  • Medical social services
  • Prescribed drugs, biological supplies, and equipment, including oxygen, ordinarily provided or arranged by the skilled nursing facility
Nothing

Nothing after the deductible

20% of our allowance after the deductible

Not covered:

  • Custodial care and care in an intermediate care facility
  • Personal comfort items, such as phone, television, barber services, and guest meals and beds
All chargesAll chargesAll charges
Benefit Description : Hospice careHigh Option (You pay)Standard Option (You pay)Prosper (You pay)

Supportive and palliative care for a terminally ill member:

  • The Services are provided inside our Service Area or inside California but within 15 miles or 30 minutes from our Service Area (including a friend's or relative's home even if you live there temporarily)
  • Services are provided in the home, when a Plan physician determines that it is feasible to maintain effective supervision and control of your care in your home.
  • Services include inpatient care under limited circumstances, outpatient care and family counseling. A Plan physician must certify that you have a terminal illness, with a life expectancy of approximately twelve months or less.

Nothing

Nothing

Nothing

Not covered:

  • Independent nursing (private duty nursing)

All charges

All chargesAll charges
Benefit Description : AmbulanceHigh Option (You pay)Standard Option (You pay)Prosper (You pay)
  • Local licensed ambulance service when medically necessary

Note: See Section 5(d) for emergency services.

$50 per trip

$150 per trip after the deductible

20% of our allowance after the deductible

Not covered:

  • Transportation by car, taxi, bus, gurney van, wheelchair van, and any other type of transportation (other than a licensed ambulance), even if it is the only way to travel to a Plan provider
All chargesAll chargesAll charges



Section 5(d). Emergency Services/Accidents (High Option, Standard Option and Prosper)

Important things you should 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.
  • The calendar year deductible for the Standard Option is $100 per person ($200 per family). The calendar year deductible for Prosper is $500 per person ($1,000 per family). The calendar year deductible applies to some benefits in this Section. We added “after the deductible” when the calendar year deductible applies.
  • There is no deductible for the High Option.
  • Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.



What is an 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. 
  • A psychiatric emergency is a mental disorder that manifests itself by acute symptoms of sufficient severity such that either you are in immediate danger to yourself or others, or you are not immediately able to provide for, or use, food, shelter, or clothing, due to the mental disorder.

Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies—what they all have in common is the need for quick action.




What to do in case of emergency:

You are covered for medical emergencies anywhere in the world. In a medical emergency, call 911 or go to the nearest hospital. If you call 911, when the operator answers, stay on the phone and answer all questions.

Emergencies within our service area:

If you think you have a medical emergency, call 911 or go to the nearest hospital. To better coordinate your emergency care, we recommend that you go to a Plan hospital if it is reasonable to do so considering your condition or symptoms. Please refer to Your Guidebook to Kaiser Permanente Services (Guidebook) for the location of Plan hospitals that provide emergency care.

Post-stabilization care is the services you receive after your treating physician determines that you are clinically stable. We cover post-stabilization care if a Plan provider provides it or if you obtain authorization from us to receive the care from a non-Plan provider.

When you are sick or injured, you may have an urgent care need. An urgent care need is one that requires prompt medical attention, but is not a medical emergency. If you think you may need urgent care, call the appropriate appointment or advice nurse number at a Plan facility. Please refer to the Guidebook for advice nurse and Plan facility phone numbers.

Emergencies outside our service area:

If you think you have a medical emergency, call 911 or go to the nearest hospital.

Post-stabilization care is the services you receive after your treating physician determines that you are clinically stable. We cover post-stabilization care if a Plan provider provides it or if you obtain authorization from us to receive the care from a non-Plan provider.

When you are sick or injured, you may have an urgent care need. An urgent care need is one that requires prompt medical attention, but is not a medical emergency. If you think you may need urgent care, call the appropriate appointment or advice nurse number at a Plan facility. Please refer to the Guidebook for advice nurse and Plan facility phone numbers. If you are temporarily outside the service area and have an urgent care need due to an unforeseen illness or injury, we cover the medically necessary services and supplies you receive from a non-Plan provider if we find that the services and supplies were necessary to prevent serious deterioration of your health and they could not be delayed until you returned to the service area.

You may obtain emergency and urgent care services from Kaiser Permanente medical facilities and providers when you are in the service area of another Kaiser Permanente plan. The facilities will be listed in the local phone book under “Kaiser Permanente”. These numbers are available 24 hours a day, seven days a week. You may also obtain information about the location of facilities by calling 800-227-2415.

How to Obtain Authorization

You must call us at 800-225-8883 (the phone number is also on your ID card) to:

  • Request authorization for post-stabilization care before you obtain the care from a non-Plan provider if it is reasonably possible to do so (otherwise, call us as soon as reasonably possible).
  • Notify us that you have been admitted to a non-Plan Hospital.

We understand that extraordinary circumstances can delay your ability to call us, for example, if you are unconscious or a young child without a parent or guardian. In these cases, you must call us as soon as it is reasonably possible. Please keep in mind that anyone can call us. We do not cover any care you receive from non-Plan providers after you’re clinically stable unless we authorize it, so if you don’t call us as soon as reasonably possible you increase the risk that you will have to pay for this care.




Benefit Description : Emergency within our service areaHigh Option (You pay )Standard Option (You pay )Prosper (You pay )
  • Urgent care at a Plan urgent care center
$15 per visit

$30 per visit

$25 per visit

  • Emergency room visits at a Plan hospital, including physicians’ services
  • Emergency care as an outpatient at a non-Plan hospital, including physicians’ services
  • Urgent care at a Plan emergency room 

Notes:

  • If you receive emergency care and then are transferred to observation care, you pay the emergency services cost-sharing. If you are admitted as an inpatient, we will waive your emergency room copayment (High and Standard Options) and you will pay your cost-sharing related to your inpatient hospital stay.
$100 per visit

$150 per visit after the deductible

20% of our allowance after the deductible

Not covered:

  • Elective care or non-emergency care (unless you receive prior authorization)
  • Urgent care at a non-Plan urgent care center
All chargesAll chargesAll charges
Benefit Description : Emergency outside our service areaHigh Option (You pay )Standard Option (You pay )Prosper (You pay )
  • Urgent care at an urgent care center
$15 per visit

$30 per visit

$25 per visit

  • Emergency care at an urgent care center
  • Emergency care as an outpatient at a hospital, including physicians’ services
  • Urgent care at an emergency room 

Note: See Section 5(h) for travel benefit coverage of continuing or follow-up care.

$100 per visit

$150 per visit after the deductible

20% of our allowance after the deductible

Not covered:

  • Elective care or non-emergency care at non-Plan facilities (unless you receive prior authorization)
All chargesAll chargesAll charges
Benefit Description : AmbulanceHigh Option (You pay )Standard Option (You pay )Prosper (You pay )

Licensed ambulance services are covered when:

  • Your treating physician determines that you must be transported to another facility because your emergency medical condition is not stabilized and the care you need is not available at the treating facility.
  • You are not already being treated, and a reasonable person would have believed that the medical condition was an emergency medical condition which required ambulance services.

Notes:

  • See Section 5(c) for non-emergency service.
  • Trip means any time an ambulance is summoned on your behalf.
$50 per trip

$150 per trip after the deductible

20% of our allowance after the deductible

Not covered:  

  • Transportation by car, taxi, bus, gurney van, wheelchair van, and any other type of transportation (other than a licensed ambulance or psychiatric transport van), even if it is the only way to travel to a provider or facility.
All chargesAll chargesAll charges



Section 5(e). Mental Health and Substance Use Disorder Benefits (High Option, Standard Option and Prosper)

Important things you should 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.
  • The calendar year deductible for the Standard Option is $100 per person ($200 per family). The calendar year deductible for Prosper is $500 per person ($1,000 per family). The calendar year deductible applies to some benefits in this Section. We added “after the deductible” when the calendar year deductible applies.
  • There is no deductible for the High Option.
  • Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • We will provide medical review criteria or reasons for treatment plan denials to enrollees, members or providers upon request or as otherwise required.We will provide medical review criteria or reasons for treatment plan denials to enrollees, members or providers upon request or as otherwise required.
  • 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 plan in favor of another.



Benefit Description : Professional servicesHigh Option (You pay )Standard Option (You pay )Prosper (You pay )

We cover professional services recommended by a Plan mental health or substance use disorder treatment provider that are covered services, drugs, and supplies described in this brochure.

Notes:

  • We cover the services only when we determine that the care is clinically appropriate to treat your condition.
  • 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 conditionsYour cost-sharing responsibilities are no greater than for other illnesses or conditionsYour cost-sharing responsibilities are no greater than for other illnesses or conditions

Diagnosis and treatment of psychiatric conditions, mental illness, or disorders. Services include:

  • Diagnostic evaluation
  • Treatment and counseling (including individual and group therapy visits)
  • Crisis intervention and stabilization for acute episodes
  • Psychological and neuropsychological testing that is medically necessary to determine the appropriate psychiatric treatment
  • Medication evaluation and management (pharmacotherapy)
  • Electroconvulsive therapy

$15 per individual office visit

$7 per group office visit

$30 per individual office visit

$15 per group office visit

$25 per individual office visit

$12 per group office visit

  • Applied Behavior Analysis (ABA) program for the treatment of autism spectrum disorder 

$15 per day

$30 per day

$25 per day

Diagnosis and treatment of substance use disorders. Services include:

  • Treatment and counseling (including individual, family, and group therapy visits)
  • Outpatient detoxification (medical management of withdrawal from the substance)

$15 per individual office visit

$5 per group office visit

$30 per individual office visit

$5 per group office visit

$25 per individual office visit

$5 per group office visit

Notes:

  • You may see a Plan mental health or substance use disorder treatment provider for outpatient services without a referral from your primary care physician. See Section 3, How you get care, for information about services requiring our prior approval.
  • Your Plan mental health or substance use disorder treatment 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.

Applies to this benefit

Applies to this benefit

Applies to this benefit

Benefit Description : DiagnosticsHigh Option (You pay )Standard Option (You pay )Prosper (You pay )
  • Outpatient diagnostic tests provided and billed by a licensed mental health and substance use disorder treatment practitioner
  • Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility

Your cost-sharing responsibilities are no greater than for other illness or condition. See Section 5(a) Lab, X-ray and other diagnostic tests. 

Your cost-sharing responsibilities are no greater than for other illness or condition. See Section 5(a) Lab, X-ray and other diagnostic tests. 

Your cost-sharing responsibilities are no greater than for other illness or condition. See Section 5(a) Lab, X-ray and other diagnostic tests. 

Benefit Description : Inpatient hospital or other covered facilityHigh Option (You pay )Standard Option (You pay )Prosper (You pay )
  • Inpatient psychiatric care
  • Inpatient substance use care

Note: All inpatient admissions require approval by a Plan mental health or substance use disorder treatment physician.

$250 per admission

$500 per admission after the deductible

20% of our allowance after the deductible

  • Psychiatric and substance use care in a residential treatment center

Note: Residential treatment programs require approval by a Plan mental health or substance use disorder treatment physician.

$100 per stay

$100 per stay after the deductible

20% of our allowance up to $100 per stay after the deductible

Benefit Description : Outpatient hospital or other covered facilityHigh Option (You pay )Standard Option (You pay )Prosper (You pay )
  • Hospital alternative services, such as partial hospitalization and intensive outpatient psychiatric treatment programs

Note: All hospital alternative services treatment programs require approval by a Plan mental health or substance use disorder treatment physician.

Nothing

Nothing after the deductible

20% of our allowance after the deductible

Benefit Description : Not coveredHigh Option (You pay )Standard Option (You pay )Prosper (You pay )

Not covered:

  • Care that is not clinically appropriate for the treatment of your condition
  • 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
  • Marital, family or educational services
  • Services rendered or billed by a school or a member of its staff
  • Services provided under a Federal, state, or local government program
  • Psychoanalysis or psychotherapy credited toward earning a degree or furtherance of education or training regardless of diagnosis or symptoms
All chargesAll chargesAll charges



Section 5(f). Prescription Drug Benefits (High Option, Standard Option and Prosper)

Important things you should keep in mind about these benefits:

  • We cover prescribed drugs and medications, as described in the chart beginning on the next page.
  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and we cover them only when we determine they are medically necessary.
  • We have no calendar year deductible.
  • Federal law prevents the pharmacy from accepting unused medications.
  • Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.



There are important features you should be aware of. These include:

  • Who can write your prescription. A licensed Plan provider or any dentist must prescribe your medication. Drugs prescribed by dentists are not covered if a Plan provider determines that they are not medically necessary. We cover prescriptions written by a non-Plan provider or filled at a non-Plan pharmacy only for emergencies or out-of-area urgent care.
  • Where you can obtain them. You must fill the prescription at a Plan pharmacy, another pharmacy that we designate, or through our mail order program for certain maintenance medication as specified below. You may be able to order refills from a Plan Pharmacy, our mail-order program or through our website at www.kp.org/rxrefill. A Plan Pharmacy or Your Guidebook can give you more information about obtaining refills, including the options available to you for obtaining refills. We cover prescriptions written by a non-Plan provider or filled at a non-Plan pharmacy only for covered emergencies as specified in Section 5(d), Emergency services/accidents. Plan members called to active military duty (or members in time of national emergency), who need to obtain prescribed medications, should contact our Member Service Call Center at 800-464-4000 (TTY: 711) for further information regarding dispensing limitations.
  • We use a formulary. The medications included in our drug formulary are chosen by a group of Kaiser Permanente physicians, pharmacists and other Plan providers known as the Pharmacy and Therapeutics Committee. The committee meets regularly to consider adding and removing prescription drugs on the drug formulary based on new information or drugs that become available. We describe any additional coverage requirements and limits in our FEHB formulary. These may include step therapy, prior authorization, quantity limits, drugs that can only be obtained at certain specialty pharmacies, or other requirements and limits described in our formulary.

We cover non-formulary drugs (those not listed on our drug formulary for your condition) prescribed by a Plan provider if they would otherwise be covered and a Plan provider determines that the drug is medically necessary. If you request the non-formulary drug when your Plan provider has prescribed a substitution, the non-formulary drug is not covered. However, you may purchase the non formulary drug from a Plan pharmacy at prices charged to members for non-covered drugs. For more information on our prescription drug FEHB formulary, visit www.kp.org/formulary, or call our Member Service Contact Center at 800-464-4000 (TTY: 711).

You pay applicable drug cost-sharing based on the tier a drug is in. Our drugs are categorized into four tiers:
    • Tier 1: Generic drugs. Generic drugs are produced and sold under their generic names after the patent of the brand-name drug expires. Although the price is usually lower, the quality of generic drugs is the same as brand-name drugs. Generic drugs are also just as effective as brand-name drugs. The Food and Drug Administration (FDA) requires that a generic drug contain the same active drug ingredient in the same amount as the brand-name drug.
    • Tier 2: Preferred brand-name drugs. Brand-name drugs are produced and sold under the original manufacturer's brand name. Preferred brand-name drugs are listed on our drug formulary.
    • Tier 3: Non-preferred brand-name drugs. Non-preferred brand-name drugs are not listed on our drug formulary and are not covered unless approved through the exception process.
    • Tier 4: Specialty drugs. Specialty drugs are high-cost drugs that are on our specialty drug list.

If our allowance for the drug, supply, or supplement is less than the copayment, you will pay the lesser amount. Items can change tier at any time, in accord with formulary guidelines, which may impact the cost-sharing you pay (for example, if a brand-name drug is added to the specialty drug list, you will pay the cost-sharing that applies to drugs on the specialty drug tier, not the cost-sharing for drugs on the brand-name drug tier).

  • These are the dispensing limitations. We provide up to a 30-day supply for most drugs when dispensed in a Plan pharmacy at one copayment.  We provide up to a 100-day supply for most drugs when dispensed in a Plan pharmacy for three copayments or through our mail order program for two copayments. For prescribed hormonal contraceptives, you may obtain up to a 12-month supply at a Plan pharmacy or through our mail-delivery program. We cover episodic drugs prescribed to treat sexual dysfunction disorders up to a maximum of 8 doses in any 30-day period or up to 27 doses in any 100-day period. When you are prescribed an oral or solid Schedule II drug (drugs with a high potential for abuse which may lead to severe psychological or physical dependence), you or the prescribing provider can request that the pharmacy dispense less than the prescribed amount.  Your cost-sharing will be prorated based on the amount of the drug that is dispensed. Most drugs can be mailed from our mail order pharmacy. Some drugs (for example, drugs that are extremely high cost, require special handling, have standard packaging or requested to be mailed outside the state of California) may not be eligible for mailing and/or mail order discount. The pharmacy may reduce the day supply dispensed to a 30-day supply in any 30-day period if the pharmacy determines that the item is in limited supply in the market or for specific drugs (your Plan pharmacy can tell you if a drug you take is one of these drugs).
  • A generic equivalent will be dispensed if it is available, unless your Plan provider specifically requires a brand-name drug. If you request a brand-name drug when a federally approved generic drug is available, and your Plan provider has not specified the brand-name drug must be dispensed, you have to pay the full cost of the brand-name drug.
  • Why use generic drugs? Typically generic drugs cost you and us less money than a brand-name drug. Under federal law, generic and brand-name drugs must meet the same standards for safety, purity, strength, and effectiveness.
  • When you do have to file a claim. You do not need to file a claim when you receive drugs from a Plan pharmacy. You have to file a claim when you receive drugs from a non-Plan pharmacy for a covered emergency as specified in Section 5(d), Emergency services/accidents. For information about how to file a claim, see Section 7, Filing a claim for covered services.



Benefit Description : Covered medications and suppliesHigh Option (You pay )Standard Option (You pay )Prosper (You pay )

We cover the following medications and supplies prescribed by a Plan physician or dentist and obtained from a Plan pharmacy or through our mail order program:

  • Certain self-administered IV drugs and fluids requiring specific types of parenteral infusion, and the supplies required for their administration
  • Hematopoietic agents for dialysis
  • Amino acid-modified products used to treat congenital errors of amino acid metabolism
  • Diabetes urine-testing supplies limited to ketone test strips, test tape and acetone test tablets, up to a 100-day supply
  • Elemental dietary enteral formula when used as a primary therapy for regional enteritis

Note: See Section 5(a), Durable medical equipment, for diabetes blood-testing equipment and supplies.

NothingNothingNothing
  • Drugs and medications that, by federal law, require a prescription for their purchase, except those listed as Not covered. We also cover certain drugs that do not require a prescription by law if they are listed on our drug formulary.
  • Insulin
  • Disposable needles and syringes for the administration of covered medications
  • Growth hormone
  • Drugs to treat gender dysphoria, including hormones and androgen blockers
  • Vaccines and immunizations approved for use by the Food and Drug Administration

Notes:

  • For information about mail order discounts, see “These are the dispensing limitations” in the introduction to Section 5(f)
  • The preferred or non-preferred brand name or specialty drug cost share will apply to compound drugs.
  • A compound drug is one in which two or more drugs or pharmaceutical agents are combined together. We limit coverage to products listed in our drug formulary and when one of the ingredients requires a prescription by law.

$10 for generic drugs, $40 for preferred and non-preferred brand name drugs, and $100 for specialty drugs per prescription or refill for up to a 30-day supply at a Plan pharmacy

All charges if you request a brand name drug in place of a generic drug

$15 for generic drugs, $50 for preferred and non-preferred brand name drugs, and $150 for specialty drugs per prescription or refill for up to a 30-day supply at a Plan pharmacy

All charges if you request a brand name drug in place of a generic drug

$15 for generic drugs, $60 for preferred and non-preferred brand name drugs, and $200 for specialty drugs per prescription or refill for up to a 30-day supply at a Plan pharmacy

All charges if you request a brand name drug in place of a generic drug

  • Prescribed tobacco cessation medications, including prescribed over-the-counter medications, approved by the FDA to treat tobacco dependence
NothingNothingNothing
  • Insulin administration devices, such as:
    • Disposable needles and syringes 
    • Pen delivery devices 
    • Visual aids required to ensure proper dosage (except eyewear)
Note: See Section 5(a), Durable medical equipment, for coverage of insulin pumps and supplies
Up to a 100-day supply at $10Up to a 100-day supply at $15Up to a 100-day supply at $15

Women’s contraceptive drugs and devices:

  • Oral contraceptives
  • Diaphragms and cervical caps
  • Topical contraceptives
  • Prescribed FDA approved over-the-counter women's contraceptives and devices

Nothing

All charges if you request a brand name drug in place of a generic drug

Nothing

All charges if you request a brand name drug in place of a generic drug

Nothing

All charges if you request a brand name drug in place of a generic drug

  • Fertility drugs
50% of our allowance50% of our allowance50% of our allowance
  • Sexual dysfunction drugs

Note: If a drug for which a prescription is required by law is excluded and we had been covering and providing it to you for a use approved by the FDA, we will continue to provide the drug upon payment of 50% of our allowance if a Plan physician continues to prescribe the drug for the same condition.

50% of our allowance up to a maximum of $50 for generic drugs;

50% of our allowance up to a maximum of $100 for preferred brand-name drugs

50% of our allowance up to a maximum of $50 for generic drugs;

50% of our allowance up to a maximum of $100 for preferred brand-name drugs

50% of our allowance up to a maximum of $50 for generic drugs;

50% of our allowance up to a maximum of $100 for preferred brand-name drugs

Not covered:

  • Drugs and supplies for cosmetic purposes
  • Drugs to enhance athletic performance
  • Prescriptions filled at a non-Plan pharmacy, except for emergencies as described in Section 5(d), Emergency services/accidents
  • Vitamins, nutritional and herbal supplements that can be purchased without a prescription, unless they are included in our drug formulary or listed as covered above. 
  • Nonprescription drugs, including prescription drugs for which there is a nonprescription equivalent available, unless
    listed as covered above.
  • Nonprescription drugs, unless they are included in our drug formulary or listed as covered above
  • Prescription drugs not on our drug formulary, unless approved through an exception process
  • Medical supplies, such as dressings and antiseptics, except as listed above
  • Drugs that shorten the duration of the common cold
  • Any requested packaging of drugs other than the dispensing pharmacy’s standard packaging
  • Replacement of lost, stolen or damaged prescription drugs and accessories
  • Drugs related to non-covered services
  • Drugs for the promotion, prevention, or other treatment of hair loss or growth
All charges      All chargesAll charges
Benefit Description : Preventive care medicationsHigh Option (You pay )Standard Option (You pay )Prosper (You pay )

The following are covered:

  • Aspirin to reduce the risk of heart attack
  • Oral fluoride for children to reduce the risk of tooth decay
  • Folic acid for women to reduce the risk of birth defects
  • Medication to reduce the risk of breast cancer

Note: Preventive medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a healthcare professional and filled by a Plan pharmacy. These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients. For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

NothingNothingNothing

Not covered:

  • Prescriptions filled at a non-Plan pharmacy, except for emergencies as described in Section 5(d), Emergency services/accidents
  • Vitamins, nutritional and herbal supplements that can be purchased without a prescription, unless they are included in our drug formulary or listed as covered above. 
  • Nonprescription drugs, unless they are included in our drug formulary or listed as covered above
  • Prescription drugs not on our drug formulary, unless approved through an exception process
  • Any requested packaging of drugs other than the dispensing pharmacy’s standard packaging
  • Replacement of lost, stolen or damaged prescription drugs and accessories
  • Drugs related to non-covered services

All charges

All charges

All charges




Section 5(g). Dental Benefits (High Option, Standard Option and Prosper)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, your FEHB Plan will be First/Primary payor of any Benefit payments and your FEDVIP Plan is secondary to your FEHB Plan. See Section 9, Coordinating benefits with other coverage.
  • We have no calendar year deductible.
  • We cover hospitalization for dental procedures at a Plan hospital we designate only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. See Section 5(c), Hospital benefits, for inpatient hospital benefits. We do not cover the dental procedure except as described below.
  • Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • No precertification is required for accidental injury to teeth. Accidental injury to teeth services may be obtained from a licensed dentist. Please submit claims for services related to accidental injury to teeth according to Section 7, Filing a claim for covered services, of this brochure.



Benefit Description : Accidental injury benefitHigh Option (You Pay)Standard Option (You Pay)Prosper (You Pay)

We cover restorative services and supplies necessary to promptly repair (but not replace) sound, natural teeth. The need for these services must result from an accidental injury.

  • damage is due to an accidental injury from trauma to the mouth from violent contact with an external object,
  • the tooth has not been restored previously, except in a proper manner, and
  • the tooth has not been weakened by decay, periodontal disease, or other existing dental pathology.

Note: Services will be covered only when provided within 72 hours following the accidental injury.

Nothing up to the benefit maximum of $500 of covered charges per accidental injury

All charges after reaching the benefit maximum of $500 per accidental injury

Nothing up to the benefit maximum of $500 of covered charges per accidental injury

All charges after reaching the benefit maximum of $500 per accidental injury

Nothing up to the benefit maximum of $500 of covered charges per accidental injury

All charges after reaching the benefit maximum of $500 per accidental injury

Not covered:

  • Services for conditions caused by an accidental injury occurring before your eligibility date.
All chargesAll chargesAll charges
Benefit Description : Dental benefitsHigh Option (You Pay)Standard Option (You Pay)Prosper (You Pay)

We have no other dental benefits.

All charges

All charges

All charges




Section 5(h). Wellness and Other Special Features (High Option, Standard Option and Prosper)

TermDefinition
Flexible benefits option

Under the flexible benefits option, we determine the most effective way to provide services. 

  • We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary. Until you sign and return the agreement, regular contract benefits will continue.
  • Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
  • By approving an alternative benefit, we do not guarantee you will get it in the future.
  • The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
  • If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.
  • Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claims process (see Section 8).
Centers of 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 nationally contracted 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.

Services for the deaf, hard of hearing or speech impaired

We provide a TTY/text phone number at: 711. Sign language services are also available.

Services from other Kaiser Permanente regions

When you visit a different Kaiser Foundation Health Plan service area, you can receive visiting member services from designated providers in that area. Visiting member services are subject to the terms, conditions and cost-sharing described in this FEHB brochure. Certain services are not covered as a visiting member.

For more information about receiving visiting member services, including provider and facility locations in other Kaiser Permanente service areas, please call our Away from Home Travel Line at 951-268-3900 or visit www.kp.org/travel.

Travel benefit

Kaiser Permanente’s travel benefits for Federal employees provide you with outpatient follow-up and/or continuing medical and mental health and substance use care when you are temporarily (for example, on a temporary work assignment or attending school) 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 services/accident 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 and treated within the previous 12 months by a Kaiser Permanente healthcare provider or affiliated Plan provider. Services include dialysis and prescription drug monitoring.

You pay $25 for each follow-up and/or continuing care office visit. This amount will be deducted from the reimbursement we make to you or to the provider. We limit our payment for this travel benefit to no more than $1,200 each calendar year. For more information about this benefit, call our Member Service Call Center at 800-464-4000 (TTY: 711). File claims as shown in Section 7.

The following are a few examples of services not included in your travel benefits coverage:

  • Nonemergency hospitalization
  • Infertility treatments
  • Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area
  • Durable medical equipment (DME)
  • Prescription drugs
  • Home health services

Rewards

Take steps to improve your well-being by completing the Kaiser Permanente Total Health Assessment and a healthy lifestyle program. FEHB subscribers and their enrolled spouses (age 18 and over) are eligible for the following rewards:

  • $50 for completing a confidential, online, Total Health Assessment (available in English or Spanish). You’ll get a picture of your overall health and a customized action plan with tips and resources to improve your well-being.
  • $25 for completing an online healthy lifestyle program of your choice. Personalized and self-paced, they can help you reduce stress, quit smoking, lose weight and more. You can complete as many of these online programs as you would like, but you will only earn a reward for one program completion.

You must accept the Wellness Program Agreement to be eligible to earn rewards. Please go to www.kp.org/feds to learn how to earn your reward and to view and track the status of your reward activities.

You must complete the Total Health Assessment and/or a healthy lifestyle program during the plan year. We will issue you a Kaiser Permanente Health Payment Card 4-6 weeks after you complete either activity. We will send each eligible member their own debit card.

You may use your Health Payment Card to pay for certain qualified medical expenses, such as:

  • Copayments for office visits, prescription drugs and other services at Kaiser Permanente or other providers
  • Prescription eyeglasses or contacts
  • Dental services
  • Over-the-counter medication for certain diseases
  • Other medical expenses, as permitted by the IRS

Please keep your card for use in the future. As you complete activities, we will add rewards to your card. We will not send you a new card until the card expires. Rewards you earn during this calendar year may be used until March 31 of the next calendar year. Funds are forfeited if you leave this plan.

For more information, please go to www.kp.org/feds. If you have questions about completing a Total Health Assessment or class, you may call us at 866-300-9867. If you have questions about your account balance or what expenses the Health Payment Card can be used for, you may call the phone number on the back of your Health Payment Card.




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 catastrophic protection out-of-pocket maximums. These programs and materials are the responsibility of the Plan, and all appeals must follow their guidelines. For additional information contact the Plan at 800-464-4000 (TTY: 711).

Dental plans - Delta Dental 800-933-9312

  • KPIC’s PPO Dental Insurance Plan (Plan ID 09874) lets you see any licensed dentist of your choice. Your out‑of‑pocket costs will usually be lowest if you visit a Delta Dental PPO™ Dentist (PPO Dentist). There are approximately 47,000 participating dentist locations in California. There is an annual deductible of $50 per person up to $150 per family and the maximum coverage annually is $1,000 per person. The plan covers a full range of services including diagnostic and preventative (no deductible), restorative, endodontics, periodontics, oral surgery and prosthodontics.
  • DeltaCare USA (Plan ID 71114) lets you select from more than 6,400 DeltaCare USA network dentists in California. You pay nothing or a copayment for most covered services. There is no deductible, no annual maximums (except for accidental injury) and no claim forms. DeltaCare USA provides a full range of services including diagnostic, preventive, restorative, endodontics, periodontics, oral surgery, prosthodontics and orthodontics.

 Visit www.kp.org/feds to download our dental programs brochure for details about premium, coverage and how to enroll.

Eyewear discount - www.kp2020.org

Kaiser Permanente High Option members get a 25% discount on eyeglasses, contacts and sunglasses at Vision Essentials by Kaiser Permanente. Some limits and exclusions apply.


Health classes and programs - www.kp.org/classes

You can sign up for wellness programs and classes designed to help you achieve your health goals. All sessions are taught by our team of experts who walk you through how to make actionable lifestyle changes.

Fitness deals - www.kp.org/exercise

  • ClassPass makes it easier for you to work out from anywhere. ClassPass partners with 30,000 gyms and studios around the world and offers a range of classes including yoga, dance, cardio, boxing, Pilates, boot camp, and more. You can get unlimited on-demand video workouts at no cost and reduced rates on livestream and in-person fitness classes.
  • Active&Fit Direct® network. As a Kaiser Permanente member, get access to more than 11,000 gyms with one membership. When Kaiser Permanente members sign up for an Active&Fit Direct gym membership, they can visit any of the 11,000 participating fitness centers in the nationwide Active&Fit Direct network.
  • ChooseHealthy® provides reduced rates on a variety of fitness, health, and wellness products. This includes activity trackers, workout apparel and exercise equipment.

Emotional Wellness or Coaching Apps - www.kp.org/selfcareapps

Kaiser Permanente provides wellness or coaching apps at no cost that can help you navigate life’s challenges and make small changes to improve your sleep, mood, relationships and more. Kaiser Permanente may add or remove apps from time to time without advance notice. Examples include:

  • Calm is an app for meditation and sleep designed to lower stress, reduce anxiety and more. Member can access great features at no cost including the Daily Calm (mindful theme each day), more than 100 guided medications, Sleep Stories (soothe you into deeper and better sleep) and video lessons on mindful movement and gentle stretching.
  • myStrength is a personalized program that helps you improve your awareness and change behaviors. You can explore interactive activities, in-the-moment coping tools, community support, and more.



Section 6. General Exclusions - Services, Drugs and Supplies We Do not Cover

The exclusions in this section apply to all benefits. There may be other exclusions and limitations listed in Section 5 of this brochure. Although we may list a specific service as a benefit, we will not cover it unless it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition. For information on obtaining prior approval for specific services, such as transplants, see Section 3, You need prior Plan approval for certain services.

We do not cover the following:

  • When a service is not covered, all services, drugs, or supplies related to the noncovered service are excluded from coverage, except services we would otherwise cover to treat complications of the noncovered service.
  • Fees associated with non-payment (including interest), missed appointments and special billing arrangements.
  • Care by non-Plan providers except for authorized referrals, emergencies, travel benefit, or services from other Kaiser Permanente plans (see “Emergency services/accidents and special features”).
  • Services, drugs, or supplies you receive while you are not enrolled in this Plan.
  • Services, drugs, or supplies 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 (see specifics regarding transplants).
  • 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 you receive without charge while in active military service.
  • Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.
  • Services or supplies we are prohibited from covering under the Federal law.



Section 7. Filing a Claim for Covered Services

This section primarily deals with post-service claims (claims for services, drugs or supplies you have already received). See
Section 3 for information on prior Plan approval and pre-service claims procedures (services, drugs or supplies requiring
prior Plan approval), including urgent care claims procedures.

When you see Plan providers, 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 a service from a non-Plan provider or at a non-Plan facility. This includes
services such as out-of-network emergency services, our-of-area urgent care and services covered under the travel benefit. 
Check with the provider to determine if they can bill us directly. Filing a claim does not guarantee payment. If you need to
file the claim, here is the process:




TermDefinition

Medical and hospital benefits

In most cases, providers and facilities file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form. Facilities will file on the UB-04 form. For claims questions and assistance, call our Member Service Call Center at 800-464-4000 (TTY: 711). 

 When you must file a claim - such as for services you receive outside the Plan’s service area - submit it on the CMS-1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show:

  • Covered member’s name, date of birth, address, phone number and ID number
  • Name and address of the provider 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
  • Follow-up services rendered out-of-area
  • A copy of the explanation of benefits, payments, or denial from any primary payor—such as the Medicare Summary Notice (MSN)
  • Receipts, if you paid for your services

Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills.

Submit your claims to:

Northern California service area:
Kaiser Foundation Health Plan, Inc.
Claims Department
P.O. Box 12923
Oakland, CA 94604-2923

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.

Post-Service Claims

We will notify you of our decision within 30 days after we receive your post-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you before the expiration of the original 30-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.

Authorized Representative

You may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions to us. For urgent care claims, we will permit a healthcare professional with knowledge of your medical condition to act as your authorized representative without your express consent. For the purposes of this section, we are also referring to your authorized representative when we refer to you.

Binding arbitration If you have any claim or dispute that is not governed by the Disputed Claims Process with OPM described in Section 8, then all such claims and disputes of any nature between you and the Plan, including but not limited to malpractice claims, shall be resolved by binding arbitration, subject to the Plan’s Arbitration procedures. For information that describes the arbitration process, contact our Member Service Call Center at 800-464-4000 for copies of our requirements. These will explain how you can begin the binding arbitration process.

Notice Requirements

If you live in a county where at least 10 percent of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language.  You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as phone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language.  The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the healthcare provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes




Section 8. The Disputed Claims Process

You may appeal directly to the Office of Personnel Management (OPM) if we do not follow required claims processes. For more information or to make an inquiry about situations in which you are entitled to immediately appeal to OPM, including additional requirements not listed in Sections 3, 7 and 8 of this brochure, please call Member Services at the phone number found on your ID card, Plan brochure, or Plan website.

Please follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your post-service claim (a claim where services, drugs or supplies have already been provided). In Section 3 If you disagree with our pre-service claim decision, we describe the process you need to follow if you have a claim for services, referrals, drugs or supplies that must have prior Plan approval, such as inpatient hospital admissions.

To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan documents under our control relating to your claim, including those that involve any expert review(s) of your claim.  To make your request, please contact our Customer Service Department by writing to us at: Kaiser Permanente, Special Services Unit, P.O. Box 23280, Oakland, CA 94623 or calling 800-464-4000.

Our reconsideration will take into account all comments, documents, records, and other information submitted by you relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination

When our initial decision is based (in whole or in part) on a medical judgment (i.e., medical necessity, experimental/investigational), we will consult with a healthcare professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who was not involved in making the initial decision.

Our reconsideration will not take into account the initial decision. The review will not be conducted by the same person, or their subordinate, who made the initial decision.

 We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual (such as a claims adjudicator or medical expert) based upon the likelihood that the individual will support the denial of benefits.




StepDescription
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: Kaiser Permanente, Special Services Unit, P.O. Box 23280, Oakland, CA 94623; and

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

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

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision. We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date. However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration. You may respond to that new evidence or rationale at the OPM review stage described in step 4.

2

In the case of a post-service claim, we have 30 days from the date we receive your request to:

a) Pay the claim or

b) Write to you and maintain our denial or

c) Ask you or your provider for more information.

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.

3

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: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 3, 1900 E Street NW, Washington, DC 20415-3630.

Send OPM the following information:

  • A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
  • Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
  • Copies of all letters you sent to us about the claim;
  • Copies of all letters we sent to you about the claim;
  • Your daytime phone number and the best time to call; and
  • Your email address, if you would like to receive OPM's decision via email. Please note that by providing your email address, you may receive OPM's decision more quickly.

Note: If you want OPM to review more than one claim, 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. However, for urgent care claims, a healthcare professional with knowledge of your medical condition may act as your authorized representative without your express consent.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

4

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to sue. If you decide to file a lawsuit, 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 file a lawsuit 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 you did not indicate that your claim was a claim for urgent care, then call us at 800-464-4000. We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal. You may call OPM’s FEHB 3 at 202-606-0755 between 8 a.m. and 5 p.m. Eastern Time.

Please remember that we do not make decisions about plan eligibility issues.  For example, we do not determine whether you or a dependent is covered under this Plan.  You must raise eligibility issues with your Agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant or the Office of Workers' Compensation Programs if you are receiving Workers' Compensation benefits.




Section 9. Coordinating Benefits with Medicare and Other Coverage

TermDefinition

When you have other health coverage

You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays healthcare expenses without regard to fault. This is called “double coverage”.

When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines. For more information on NAIC rules regarding the coordinating of benefits, visit our website at www.kp.org/feds.

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

When we are the secondary payor, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit, except Medicare-eligible members with Original Medicare as primary payor must pay cost-sharing described in this FEHB brochure (see Sections 4 and 5, members with Medicare should also see the Original Medicare Plan portion of this Section 9). We will not pay more than our allowance. If we are the secondary payor, and you received your services from Plan providers, we may bill the primary carrier.

  • TRICARE and CHAMPVA

TRICARE is the healthcare program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. IF TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) 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 under TRICARE or CHAMPVA.

  • Workers’ Compensation

We do not cover services that:

  • You (or a covered family member) 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.

  • Medicaid

When you have this Plan and Medicaid, we pay first.

Suspended FEHB coverage to enroll in Medicaid or a similar state-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these state programs, eliminating your FEHB 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 under the state program.

When other Government agencies are responsible for your care

We do not cover services and supplies when a local, state, or federal government agency directly or indirectly pays for them.

When third parties cause illness or injuries

When you receive money to compensate you for medical or hospital care for injuries or illness caused by another person, you must reimburse us for any expenses we paid. However, we will cover the cost of treatment that exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our subrogation procedures.

If you obtain a judgment or settlement from or on behalf of a third party who allegedly caused or is responsible for an injury or illness for which you received covered healthcare services or benefits (“Services”), you must pay us Charges for those Services. “Charges” are: 1) for Services that we pay the provider on a fee-for-service basis, the payments that we made for the Services; and 2) for all other Services, the charges in the provider’s schedule of charges for Services provided to Members less any cost share payments that you made to the provider. Our payments for Services in these circumstances are expressly conditioned on your agreement to comply with these provisions. You are still required to pay cost-sharing to the provider, even if a third party has allegedly caused or is responsible for the injury or illness for which you received Services.

You must also pay us Charges for such Services if you receive or are entitled to receive a recovery from any insurance for an injury or illness alleged to be based on a third party’s or your own fault, such as from uninsured or underinsured motorist coverage, automobile or premises medical payments coverage, or any other first party coverage. You must also pay us Charges for such Services if you receive or are entitled to receive recovery from any Workers' Compensation benefits.

To secure our rights, we will have a lien on and reimbursement right to the proceeds of any judgment or settlement you or we obtain. The proceeds of any judgment or settlement that you or we obtain shall first be applied to satisfy our lien, regardless of whether the total amount of the proceeds is less than the actual losses and damages you incurred. Our right to receive payment is not subject to reduction based on attorney fees or costs under the "common fund" doctrine and is fully enforceable regardless of whether you are "made whole" or fully compensated for the full amount of damages claimed.

We are entitled to full recovery regardless of whether any liability for payment is admitted by any person, entity or insurer.  We are entitled to full recovery regardless of whether the settlement or judgment received by you identifies the medical benefits provided or purports to allocate any portion of such settlement or judgment to payment of expenses other than medical expenses.  We are entitled to recover from any and all settlements, even those designated as for pain and suffering, non-economic damages and/or general damages only.

In order for us to determine the existence of any rights we may have and to satisfy those rights, you must complete and send us all consents, releases, authorizations, assignments, and other documents, including lien forms directing your attorney and any insurer to pay us directly. You may not agree to waive, release, or reduce our rights under this provision without our prior, written consent. You must cooperate in doing what is reasonably necessary to assist us with our right of recovery. You must notify us within 30 days of the date you or someone acting on your behalf notifies anyone, including an insurer or attorney, of your intention to pursue or investigate a claim to recover damages or obtain compensation due to your injury or illness. You must not take any action that may prejudice our right of recovery.

If your estate, parent, guardian, or conservator asserts a claim based on your injury or illness, that person or entity and any settlement or judgment recovered by that person or entity shall be subject to our liens and other rights to the same extent as if you had asserted the claim against the party. We may assign our rights to enforce our liens and other rights.

We have the option of becoming subrogated to all claims, causes of action, and other rights you may have against a third party or an insurer, government program, or other source of coverage for monetary damages, compensation, or indemnification on account of the injury or illness allegedly caused by the third party. We will be so subrogated as of the time we mail or deliver a written notice of our exercise of this option to you or your attorney, but we will be subrogated only to the extent of the total of Charges for the relevant Services.

Contact us if you need more information about recovery or subrogation.

Surrogacy Agreements

If you enter into a Surrogacy Agreement, you must reimburse us for covered services you receive related to conception, pregnancy, delivery, or postpartum care in connection with the Surrogacy Agreement, except that the amount you must pay will not exceed the payments or other compensation you and any other payee are entitled to receive under the Surrogacy Agreement. A "Surrogacy Agreement" is one in which a woman agrees to become pregnant and to surrender the baby (or babies) to another person or persons who intend to raise the child (or children), in exchange for payment or compensation for being a surrogate. The "Surrogacy Agreement" does not affect your obligation to pay your cost-sharing for services received, but we will credit any such payments toward the amount you must pay us under this paragraph. We will only cover charges incurred for any services when you have legal custody of the baby and when the baby is covered as a family member under your Self Plus One or Self and Family enrollment (the legal parents are financially responsible for any services that the baby receives).

By accepting services, you automatically assign to us your right to receive payments that are payable to you or any other payee under the Surrogacy Agreement, regardless of whether those payments are characterized as being for medical expenses. To secure our rights, we will also have a lien on those payments and on any escrow account, trust, or any other account that holds those payments. Those payments (and amounts in any escrow account, trust, or other account that holds those payments) shall first be applied to satisfy our lien. The assignment and our lien will not exceed the total amount of your obligation to us under the preceding paragraph.

Within 30 days after entering into a Surrogacy Agreement, you must send written notice of the Agreement, a copy of the Agreement, including the names, addresses, and phone numbers of all parties involved in the Agreement. You must send this information to:

Trover Solutions, Inc.
Kaiser Permanente Northern California Surrogacy Mailbox
9390 Bunsen Parkway
Louisville, KY  40220

You must complete and send us consents, releases, authorizations, lien forms, and other documents that are reasonably necessary for us to determine the existence of any rights we may have under this "Surrogacy Agreements" section and to satisfy those rights.

If your estate, parent, guardian, or conservator asserts a claim against a third party based on the Surrogacy Agreement, your estate, parent, guardian, or conservator and any settlement or judgment recovered by the estate, parent, guardian, or conservator shall be subject to our liens and other rights to the same extent as if you had asserted the claim against the third party. We may assign our rights to enforce our liens and other rights. 

When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) coverage

Some FEHB plans already cover some dental and vision services. When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage. FEDVIP coverage pays secondary to that coverage. When you enroll in a dental and/or vision plan on BENEFEDS.com or by phone at 877-888-3337, (TTY 877-889-5680), you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost.

Clinical trials

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application. 

We will cover routine care costs and may cover some extra care costs not provided by the clinical trial in accordance with Section 5 when Plan physicians provide or arrange for your care.

We encourage you to contact us to discuss specific services if you participate in a clinical trial.

  • Routine care costs are costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition whether the patient is in a clinical trial or is receiving standard therapy. We cover routine care costs not provided by the clinical trial.
  • Extra care costs are costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care. We cover some extra care costs not provided by the clinical trial. We encourage you to contact us to discuss coverage for specific services if you participate in a clinical trial.

The Plan does not cover research costs.

  • Research costs are costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This plan does not cover these costs.



TermDefinition

When you have Medicare

For more detailed information on "What is Medicare?" and "Should I Enroll in Medicare?" please contact Medicare at 800-MEDICARE (800-633-4227), (TTY 877-486-2048) or at www.medicare.gov.

  • The Original Medicare Plan (Part A or Part B)

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share.

All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary.  This is true whether or not they accept Medicare.

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.

Claims process when you have the Original Medicare Plan – You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payor, we process the claim first.

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 800-443-0815 (TTY: 711), 8 a.m. to 8 p.m., 7 days a week, or visit our website at www.kp.org/feds.

We do not waive any costs if the Original Medicare Plan is your primary payor.

  • If you enroll in Medicare Part B

If you enroll in Medicare Part B, we require you to assign your Medicare Part B benefits to the Plan for its services. Assigning your benefits means you give the Plan written permission to bill Medicare on your behalf for covered services you receive in network. You do not lose any benefits or entitlements as a result of assigning your Medicare Part B benefits.

  • Tell us about your Medicare coverage

You must tell us if you or a covered family member has Medicare coverage, and let us obtain information about services denied or paid under Medicare if we ask. You must also tell us about other coverage you or your covered family members may have, as this coverage may affect the primary/secondary status of this Plan and Medicare.

  • Medicare Part B Premium Reimbursement

We offer a plan designed to help High and Standard Option members with their Medicare Part B premium. This program is called, "Senior Advantage 2". For each month you are enrolled in Senior Advantage 2, have Medicare Parts A and B, or Part B only, and are enrolled in Senior Advantage for Federal Members, you will be reimbursed up to $250 of the Medicare Part B monthly premium you pay, including any amount added to your Part B premium for the Part B late enrollment penalty (LEP) or Income Related Monthly Adjustment Amount (IRMAA). In addition to reimbursing for the Part B monthly premium, we will cover additional benefits, including lower office visit copayments, urgent care and emergency care, plus additional coverage for additional benefits, such as hearing aids and the Silver&Fit fitness program.

You may enroll in this program if:

  • You enroll in the Plan's High or Standard Option
  • You have Medicare Parts A and B, or Medicare Part B only, and you enroll in Senior Advantage for Federal Members
  • The FEHB subscriber completes an additional application for enrollment in Senior Advantage 2

Reimbursements will begin on the first of the month following receipt of your additional application for enrollment in Senior Advantage 2 and verification of your Medicare Part B enrollment. During a calendar year, you may enroll in Senior Advantage 2 only once. If the FEHB subscriber enrolls in Senior Advantage 2, each family member who enrolls in Senior Advantage for Federal Members is required to participate in Senior Advantage 2. If, for any reason, you do not meet the enrollment requirements for Senior Advantage 2, you will no longer be eligible to participate in the program. Your reimbursements will end and your regular FEHB High or Standard Option benefits will resume. You may be required to repay any reimbursements paid to you in error.

To learn more about Senior Advantage 2 and how to enroll, call us at 855-366-9013, 8 a.m. to 8 p.m., 7 days a week, or visit our website at www.kp.org/feds. For TTY for the deaf, hard of hearing, or speech impaired, call 711. We will send you additional information and an additional application for enrollment in Senior Advantage 2.

  • Medicare Advantage (Part C)

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (800-633-4227)
(TTY: 877-486-2048
) or at www.medicare.gov.

If you enroll in a Medicare Advantage plan, the following options are available to you:

This Plan and our Medicare Advantage plan: We offer a Medicare Advantage plan known as Kaiser Permanente Senior Advantage for Federal Members. Senior Advantage for Federal Members enhances your FEHB coverage by lowering cost-sharing for some services and/or adding benefits. If you have Medicare Parts A and B, or Medicare Part B only, and you reside in our Medicare Advantage service area, you can enroll in Senior Advantage for Federal Members.  Enrolling in Senior Advantage for Federal Members does not change your FEHB premium. Your enrollment is in addition to your FEHB High Option, Standard Option or Prosper enrollment: however, your benefits will be provided under the Kaiser Permanente Senior Advantage for Federal Members plan and are subject to Medicare rules. If you are already a member of Senior Advantage for Federal Members and would like to understand your additional benefits in more detail, please refer to your Senior Advantage for Federal Members Evidence of Coverage. If you are considering enrolling in Senior Advantage for Federal Members, please call us at 800-443-0815 (TTY: 800-777-1370), 8 a.m. to 8 p.m., 7 days a week, or visit our website at www.kp.org/feds.

With Kaiser Permanente Senior Advantage for Federal Members, you’ll get more coverage, such as lower cost sharing and additional benefits. This 2022 benefit summary allows you to make a comparison of your choices:

Benefit Description: Deductible
High Option without Medicare you pay: None
High Option with Senior Advantage 1 you pay: None
High Option with Senior Advantage 2 you pay: None
Standard Option without Medicare you pay: $100
Standard Option with Senior Advantage 1 you pay: None
Standard Option with Senior Advantage 2 you pay: None
Prosper without Medicare you pay: $500 
Prosper with Senior Advantage you pay: None

Benefit Description: Primary Care
High Option without Medicare you pay: $15
High Option with Senior Advantage 1 you pay: $5
High Option with Senior Advantage 2 you pay: $10
Standard Option without Medicare you pay: $30
Standard Option with Senior Advantage 1 you pay: $15
Standard Option with Senior Advantage 2 you pay: $25
Prosper without Medicare you pay: $25 
Prosper with Senior Advantage you pay: $25

Benefit Description: Specialty Care
High Option without Medicare you pay: $25
High Option with Senior Advantage 1 you pay: $5
High Option with Senior Advantage 2 you pay: $10
Standard Option without Medicare you pay: $40
Standard Option with Senior Advantage 1 you pay: $15
Standard Option with Senior Advantage 2 you pay: $25
Prosper without Medicare you pay: $35 
Prosper with Senior Advantage you pay: $25

Benefit Description: Outpatient Surgery
High Option without Medicare you pay: $50
High Option with Senior Advantage 1 you pay: $5
High Option with Senior Advantage 2 you pay: $50
Standard Option without Medicare you pay: $200*
Standard Option with Senior Advantage 1 you pay: $15
Standard Option with Senior Advantage 2 you pay: $25
Prosper without Medicare you pay: 20%
Prosper with Senior Advantage you pay: $25

Benefit Description: Inpatient Hospital Care
High Option without Medicare you pay: $250
High Option with Senior Advantage 1 you pay: $100
High Option with Senior Advantage 2 you pay: $250
Standard Option without Medicare you pay: $500*
Standard Option with Senior Advantage 1 you pay: $250
Standard Option with Senior Advantage 2 you pay: $500
Prosper without Medicare you pay: 20%* 
Prosper with Senior Advantage you pay: $250 per day up to $1,000

Benefit Description: Additional Benefits Offered
High Option without Medicare: Not Applicable
High Option with Senior Advantage 1: Eyeglasses and contact lenses allowance, dental cleaning, home delivered meals, and transportation
High Option with Senior Advantage 2: Hearing aid allowance and Silver&Fit
Standard Option without Medicare: Not Applicable
Standard Option with Senior Advantage 1: Eyeglasses and contact lenses allowance and dental cleaning
Standard Option with Senior Advantage 2: Silver&Fit
Prosper without Medicare: Not Applicable
Prosper with Senior Advantage: Eyeglasses and contact lenses allowance

Benefit Description: Out-of-pocket (2x per family)
High Option without Medicare you pay: $2,000 per person
High Option with Senior Advantage 1 you pay: $2,000 per person
High Option with Senior Advantage 2 you pay: $2,000 per person
Standard Option without Medicare you pay: $3,000 per person
Standard Option with Senior Advantage 1 you pay: $2,000 per person
Standard Option with Senior Advantage 2 You pay: $2,000 per person
Prosper without Medicare you pay: $5,500 per person
Prosper with Senior Advantage you pay: $2,000 per person

Benefit Description: Part B Premium reimbursement
High Option without Medicare: $0
High Option with Senior Advantage 1: $0
High Option with Senior Advantage 2: Up to $250 monthly
Standard Option without Medicare: $0
Standard Option with Senior Advantage 1: $0
Standard Option with Senior Advantage 2: Up to $250 monthly
Prosper without Medicare: $0
Prosper with Senior Advantage: $0

*You pay the deductible, then cost-sharing.




TermDefinition

    

This is a summary of the features of the Kaiser Permanente Senior Advantage for Federal Members. As a Senior Advantage member, you are still entitled to coverage under the FEHB Program. All benefits are subject to the definitions, limitations, and exclusions set forth in this FEHB brochure and the Kaiser Permanente Senior Advantage for Federal Members Evidence of Coverage.

This Plan and another plan’s Medicare Advantage plan: You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area (if you use our Plan providers), however we will not waive any of our copayments, coinsurance, or deductibles. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage 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 Advantage plan’s service area.

  • Medicare prescription drug coverage (Part D)

When we are the primary payor, we process the claim first. If you enroll in another plan's Medicare Part D plan and we are the secondary payor, when you fill your prescription at a Plan pharmacy that is not owned and operated by Kaiser Permanente we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB plan. Our Kaiser Permanente owned and operated pharmacies will not consider another plan's Medicare Part D benefits. These Kaiser Permanente pharmacies will only provide your FEHB Kaiser Permanente benefits.

You will still need to follow the rules in this brochure for us to cover your care. We will only cover your prescription if it is written by a Plan provider and obtained at a Plan pharmacy or through our Plan mail service delivery program, except in an emergency or urgent care situation.

If you enroll in our Kaiser Permanente Senior Advantage for Federal Members plan, you will get all of the benefits of Medicare Part D plus additional drug benefits covered under your FEHB plan.




Primary Payor Chart

A. When you – or your covered spouse are age 65 or over and have Medicare and you...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have FEHB coverage on your own as an active employee
2) Have FEHB coverage on your own as an annuitant or through your spouse who is an annuitant
3) Have FEHB through your spouse who is an active employee
4) Are a reemployed annuitant with the Federal government and your position is excluded from the FEHB (your employing office will know if this is the case) and you are not covered under FEHB through your spouse under #3 above
5) Are a reemployed annuitant with the Federal government and your position is not excluded from the FEHB (your employing office will know if this is the case) and...
  • You have FEHB coverage on your own or through your spouse who is also an active employee
  • You have FEHB coverage through your spouse who is an annuitant
6) 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) and you are not covered under FEHB through your spouse under #3 above
7) Are enrolled in Part B only, regardless of your employment status ✓ for Part B services ✓ for other services
8) Are a Federal employee receiving Workers' Compensation ✓ *
9) Are a Federal employee receiving disability benefits for six months or more


B. When you or a covered family member...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have Medicare solely based on end stage renal disease (ESRD) and..
  • It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)
  • It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD
2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and...
  • This Plan was the primary payor before eligibility due to ESRD (for 30-month coordination period)
  • Medicare was the primary payor before eligibility due to ESRD
3) Have Temporary Continuation of Coverage(TCC) and...
  • Medicare based on age and disability
  • Medicare based on ESRD (for the 30-month coordination period)
  • Medicare based on ESRD (after the 30-month coordination period)


C. When either you or a covered family member are eligible for Medicare solely due to disability and you...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have FEHB coverage on your own as an active employee or through a family member who is an active employee
2) Have FEHB coverage on your own as an annuitant or through a family member who is an annuitant
D. When you are covered under the FEHB Spouse Equity provision as a former spouse

*Workers' Compensation is primary for claims related to your condition under Workers’ Compensation.




Section 10. Definitions of Terms We Use in This Brochure

TermDefinition
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.

Clinical trials cost categories

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application.

  • Routine care costs – costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition whether the patient is in a clinical trial or is receiving standard therapy.
  • Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care.
  • Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials.  This plan does not cover these costs.

Coinsurance

See Section 4, page (Applies to printed brochure only).

Copayment

See Section 4, page (Applies to printed brochure only).

Cost-sharing

See Section 4, page (Applies to printed brochure only).

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 medication. (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. Custodial care that lasts 90 days or more is sometimes known as long-term care.

Deductible

See Section 4, page (Applies to printed brochure only).

Experimental or investigational services

We do not cover a service, supply, item or drug that we consider experimental, except for the limited coverage specified in Section 9, Clinical trials. We consider a service, supply, item or drug to be experimental when the service, supply, item or 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.

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.  

Group health coverage

Healthcare 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. Healthcare coverage may be insured or indemnity coverage, self-insured or self-funded coverage, or coverage through health maintenance organizations or other managed care plans. Healthcare coverage purchased through membership in an organization is also “group health coverage”.

Healthcare professional

A physician or other healthcare professional licensed, accredited, or certified to perform specified health services consistent with state law.

Hospice care

Hospice is a program for caring for the terminally ill patient that emphasizes supportive services, such as home care and pain and symptom control, rather than curative care. If you make a hospice election, you are not entitled to receive other healthcare 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.

Medically necessaryAll 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 you 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.
Never event/serious reportable eventCertain Hospital Acquired Conditions, as defined by Medicare, including things like wrong-site surgeries, transfusion with the wrong blood type, pressure ulcers (bedsores), falls or trauma, and nosocomial infections (hospital-acquired infections) associated with surgeries or catheters, that are directly related to the provision of an inpatient covered service at a Plan provider.

Observation care

Hospital outpatient services you get while your physician decides whether to admit you as an inpatient or discharge you. You can get observation services in the emergency department or another area of the hospital.

Our allowance

Our allowance is the amount we use to determine our payment and your coinsurance for covered services. We determine our allowance as follows:

  • For services and items provided by Kaiser Permanente, the applicable charges in the Plan's schedule of Kaiser Permanente charges for services and items provided to Plan members. 
  • For services and items for which a provider (other than Kaiser Permanente) is compensated on a capitation basis, the charges in the schedule of charges that Kaiser Permanente negotiates with the capitated provider. 
  • For items obtained at a pharmacy owned and operated by Kaiser Permanente, the amount the pharmacy would charge a Plan member for the item if a Plan member's benefit plan did not cover the item. This amount is an estimate of: the cost of acquiring, storing, and dispensing drugs, the direct and indirect costs of providing Kaiser Permanente pharmacy services and items to Plan members, and the pharmacy program's contribution to the net revenue requirements of the Plan.  
  • For all other services and items, the payments that Kaiser Permanente makes for the services and items or, if Kaiser Permanente subtracts cost-sharing from its payment, the amount Kaiser Permanente would have paid if it did not subtract cost-sharing.

You should also see Important Notice About Surprise Billing – Know Your Rights in Section 4 that describes your protections against surprise billing under the No Surprises Act.

Post-service claimsAny claims that are not pre-service claims.  In other words, post-service claims are those claims where treatment has been performed and the claims have been sent to us in order to apply for benefits.
Pre-service claimsThose claims (1) that require precertification, prior approval, or a referral and (2) where failure to obtain precertification, prior approval, or a referral results in a reduction of benefits.
ReimbursementA carrier's pursuit of a recovery if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, and the terms of the carrier's health benefits plan require the covered individual, as a result of such payment, to reimburse the carrier Charges for Covered Services out of the payment to the extent of the Covered Services provided. The right of reimbursement is cumulative with and not exclusive of the right of subrogation.
SubrogationA carrier's pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier's health benefits plan.

Urgent care claims

A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts:

  • Waiting could seriously jeopardize your life or health;
  • Waiting could seriously jeopardize your ability to regain maximum function; or
  • In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Urgent care claims involve Pre-service claims and not Post-service claims. We will determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our Member Service Call Center at 800-464-4000. You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Us/WeUs and we refer to Kaiser Foundation Health Plan, Inc., Northern California Region.
You You refers to the enrollee and each covered family member.



Index

Do not rely on this page; it is for your convenience and may not show all the pages where the terms appear.




Index Entry
(Page numbers solely appear in the printed brochure)



Summary of Benefits for the High Option of Kaiser Permanente - Northern California - 2022

  • Do not rely on this chart alone. This is a summary. All benefits are subject to the definitions, limitations, and exclusions in this brochure. Before making a final decision, please read this FEHB brochure. You can also obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at www.kp.org/feds.
  • 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.

 




High Option BenefitsYou payPage

Medical services provided by physicians: Diagnostic and treatment services provided in the office

$15 per primary care office visit
$25 per specialty care office visit

(Applies to printed brochure only)

Services provided by a hospital: Inpatient

$250 per admission

(Applies to printed brochure only)

Services provided by a hospital: Outpatient

$50 per admission

(Applies to printed brochure only)

Emergency benefits:

$100 per visit

(Applies to printed brochure only)

Mental health and substance use disorder treatment:

Regular cost-sharing

(Applies to printed brochure only)

Prescription drugs:

$10 Generic; $40 preferred and non-preferred brand; $100 specialty

(Applies to printed brochure only)

Dental care:

No benefit

(Applies to printed brochure only)

Vision care: Eye exam

Nothing

(Applies to printed brochure only)

Special features: Flexible benefits option; Centers of Excellence; Services for the deaf, hard of hearing or speech impaired; Services from other Kaiser Permanente or allied plans; Travel benefit; Rewards.

See Section 5(h) for more information.

(Applies to printed brochure only)

Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum):

Nothing after $2,000/Self Only or $4,000/Family enrollment per year. Some costs do not count toward this protection.

(Applies to printed brochure only)




Summary of Benefits for the Standard Option of Kaiser Permanente - Northern California - 2022

  • Do not rely on this chart alone. This is a summary. All benefits are subject to the definitions, limitations, and exclusions in this brochure. Before making a final decision, please read this FEHB brochure. You can also obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at www.kp.org/feds.
  • 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.
  • Below, an asterisk (*) means the item may be subject to the calendar year deductible.



Standard Option BenefitsYou payPage

Calendar year deductible for covered services

$100 per person
$200 per family

(Applies to printed brochure only)

Medical services provided by physicians: Diagnostic and treatment services provided in the office

$30 per primary care office visit
$40 per specialty care office visit

(Applies to printed brochure only)

Services provided by a hospital:  Inpatient

$500 per admission*

(Applies to printed brochure only)

 Services provided by a hospital: Outpatient

$200 per admission*

(Applies to printed brochure only)

Emergency benefits:

$150 per visit*

(Applies to printed brochure only)

Mental health and substance use disorder treatment:

Regular cost-sharing

(Applies to printed brochure only)

Prescription drugs:

$15 generic; $50 preferred and non-preferred brand; $150 specialty

(Applies to printed brochure only)

Dental care:

No benefit

(Applies to printed brochure only)

Vision care: Eye exam

Nothing

(Applies to printed brochure only)

Special features: Flexible benefits option; Centers of Excellence; Services for the deaf, hard of hearing or speech impaired; Services from other Kaiser Permanente or allied plans; Travel benefit; Rewards.

See Section 5(h) for more information. 

(Applies to printed brochure only)

Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum):

Nothing after $3,000/Self Only or $6,000/Family enrollment per year. Some costs do not count toward this protection.

(Applies to printed brochure only)




Summary of Benefits for Prosper of Kaiser Permanente - Northern California - 2022

  • Do not rely on this chart alone. This is a summary. All benefits are subject to the definitions, limitations, and exclusions in this brochure. Before making a final decision, please read this FEHB brochure. You can also obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at www.kp.org/feds.
  • 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.
  • Below, an asterisk (*) means the item may be subject to the calendar year deductible.



Prosper BenefitsYou payPage

Calendar year deductible for covered services:

$500 per person
$1,000 per family

(Applies to printed brochure only)

Medical services provided by physicians: Diagnostic and treatment services provided in the office

$25 per primary care office visit
$35 per specialty care office visit

(Applies to printed brochure only)

Services provided by hospital: Inpatient

20% of our allowance*

(Applies to printed brochure only)

Services provided by hospital: Outpatient

20% of our allowance*

(Applies to printed brochure only)

 Emergency benefits: 

20% of our allowance*

(Applies to printed brochure only)

Mental health and substance use disorder treatment:

Regular cost-sharing

(Applies to printed brochure only)

Prescription drugs:

$15 generic; $60 preferred and non-preferred brand; $200 specialty

(Applies to printed brochure only)

Dental care:

No Benefit

(Applies to printed brochure only)

Vision care: Eye exam

Nothing

(Applies to printed brochure only)

Special features: Flexible benefits option; Centers of Excellence; Services for the deaf, hard of hearing or speech imparied; Services from other Kaiser Permanente or allied plans; Travel Benefit; Rewards.

See Section 5(h) for more information.

(Applies to printed brochure only)

Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum):

Nothing after $5,500/Self Only or $11,000/ Family enrollment per year. Some costs do not count toward this protection.

(Applies to printed brochure only)




2022 Rate Information for Kaiser Permanente - Northern California

To compare your FEHB health plan options please go to www.opm.gov/fehbcompare.

To review premium rates for all FEHB health plan options please go to www.opm.gov/FEHBpremiums or www.opm.gov/Tribalpremium.

Premiums for Tribal employees are shown under the Monthly Premium Rate column. The amount shown under employee contribution is the maximum you will pay. Your Tribal employer may choose to contribute a higher portion of your premium. Please contact your Tribal Benefits Officer for exact rates.




Type of EnrollmentEnrollment CodePremium Rate
BiWeekly
Gov't Share
Premium Rate
BiWeekly
Your Share
Premium Rate
Monthly
Gov't Share
Premium Rate
Monthly
Your Share
High Option Self Only591$244.86$217.74$530.53$471.77
High Option Self Plus One593$524.63$579.64$1,136.70$1,255.89
High Option Self and Family592$574.13$530.14$1,243.95$1,148.64
Standard Option Self Only594$244.86$131.24$530.53$284.35
Standard Option Self Plus One596$524.63$355.43$1,136.70$770.10
Standard Option Self and Family595$574.13$305.93$1,243.95$662.85
Type of EnrollmentEnrollment CodePremium Rate
BiWeekly
Gov't Share
Premium Rate
BiWeekly
Your Share
Premium Rate
Monthly
Gov't Share
Premium Rate
Monthly
Your Share
Prosper Self OnlyKC1$227.96$75.99$493.92$164.64
Prosper Self Plus OneKC3$524.63$186.61$1,136.70$404.32
Prosper Self and FamilyKC2$533.43$177.81$1,155.77$385.25