Kaiser Foundation Health Plan, Inc.
Northern California and
Southern California Regions
Kaiser Permanente
Senior Advantage (HMO)
with Part D
Evidence of Coverage for the University of California
Effective January 1, 2024
This document is available for free in Spanish. Please contact Member Services at 1-800-443-0815 for
additional information. (TTY users should call 711.) Hours are 8 a.m. to 8 p.m., 7 days a week.
Este documento está disponible de manera gratuita en español. Para obtener información adicional,
comuníquese con Servicio a los Miembros al 1-800-443-0815. (Los usuarios de la línea TTY deben
llamar al 711). El horario es de 8 a. m. a 8 p. m., los 7 días de la semana.
This document explains your benefits and rights. Use this document to understand about:
• Your cost sharing
• Your medical and prescription drug benefits
• How to file a complaint if you are not satisfied with a service or treatment
• How to contact us if you need further assistance
• Other protections required by Medicare law
.
TABLE OF CONTENTS
Benefit Highlights ................................................................................................................................................................ 1
Introduction .......................................................................................................................................................................... 3
About Kaiser Permanente ................................................................................................................................................. 3
Term of this EOC ............................................................................................................................................................. 4
Definitions ............................................................................................................................................................................ 4
Premiums, Eligibility, and Enrollment ............................................................................................................................... 11
Premiums ........................................................................................................................................................................ 11
Medicare Premiums ........................................................................................................................................................ 11
Who Is Eligible............................................................................................................................................................... 12
How to Enroll and When Coverage Begins.................................................................................................................... 14
How to Obtain Services ...................................................................................................................................................... 14
Routine Care ................................................................................................................................................................... 15
Urgent Care .................................................................................................................................................................... 15
Our Advice Nurses ......................................................................................................................................................... 15
Your Personal Plan Physician ........................................................................................................................................ 15
Getting a Referral ........................................................................................................................................................... 15
Travel and Lodging for Certain Services ....................................................................................................................... 17
Second Opinions ............................................................................................................................................................ 17
Contracts with Plan Providers ........................................................................................................................................ 17
Receiving Care Outside of Your Home Region Service Area ........................................................................................ 18
Your ID Card .................................................................................................................................................................. 18
Getting Assistance .......................................................................................................................................................... 19
Plan Facilities ..................................................................................................................................................................... 19
Provider Directory .......................................................................................................................................................... 19
Pharmacy Directory ........................................................................................................................................................ 19
Emergency Services and Urgent Care ................................................................................................................................ 19
Emergency Services ....................................................................................................................................................... 19
Urgent Care .................................................................................................................................................................... 20
Payment and Reimbursement ......................................................................................................................................... 21
Benefits and Your Cost Share ............................................................................................................................................ 21
Your Cost Share ............................................................................................................................................................. 22
Outpatient Care .............................................................................................................................................................. 24
Hospital Inpatient Services ............................................................................................................................................. 26
Ambulance Services ....................................................................................................................................................... 27
Bariatric Surgery ............................................................................................................................................................ 27
Dental Services ............................................................................................................................................................... 28
Dialysis Care .................................................................................................................................................................. 28
Durable Medical Equipment (“DME”) for Home Use ................................................................................................... 29
Fertility Services ............................................................................................................................................................ 31
Health Education ............................................................................................................................................................ 31
Hearing Services ............................................................................................................................................................ 32
Home Health Care .......................................................................................................................................................... 32
Home Medical Care Not Covered by Medicare for Members Who Live in Certain Counties (Advanced Care at
Home) .......................................................................................................................................................................... 33
Hospice Care .................................................................................................................................................................. 34
Mental Health Services .................................................................................................................................................. 35
Opioid Treatment Program Services .............................................................................................................................. 36
Ostomy, Urological, and Specialized Wound Care Supplies ......................................................................................... 36
Outpatient Imaging, Laboratory, and Other Diagnostic and Treatment Services ........................................................... 37
Outpatient Prescription Drugs, Supplies, and Supplements ........................................................................................... 37
Preventive Services ........................................................................................................................................................ 46
Prosthetic and Orthotic Devices ..................................................................................................................................... 47
Reconstructive Surgery .................................................................................................................................................. 48
Religious Nonmedical Health Care Institution Services ................................................................................................ 49
Services Associated with Clinical Trials ........................................................................................................................ 49
Skilled Nursing Facility Care ......................................................................................................................................... 50
Substance Use Disorder Treatment ................................................................................................................................ 50
Telehealth Visits ............................................................................................................................................................. 51
Transplant Services ........................................................................................................................................................ 52
Vision Services ............................................................................................................................................................... 52
Exclusions, Limitations, Coordination of Benefits, and Reductions .................................................................................. 54
Exclusions ...................................................................................................................................................................... 54
Limitations ..................................................................................................................................................................... 56
Coordination of Benefits ................................................................................................................................................ 56
Reductions ...................................................................................................................................................................... 57
Requests for Payment ......................................................................................................................................................... 59
Requests for Payment of Covered Services or Part D drugs .......................................................................................... 59
How to Ask Us to Pay You Back or to Pay a Bill You Have Received ......................................................................... 60
We Will Consider Your Request for Payment and Say Yes or No ................................................................................. 61
Other Situations in Which You Should Save Your Receipts and Send Copies to Us .................................................... 61
Your Rights and Responsibilities ....................................................................................................................................... 61
We must honor your rights and cultural sensitivities as a Member of our plan ............................................................. 61
You have some responsibilities as a Member of our plan .............................................................................................. 65
Coverage Decisions, Appeals, and Complaints .................................................................................................................. 66
What to Do if You Have a Problem or Concern ............................................................................................................. 66
Where To Get More Information and Personalized Assistance ..................................................................................... 66
To Deal with Your Problem, Which Process Should You Use? .................................................................................... 67
A Guide to the Basics of Coverage Decisions and Appeals ........................................................................................... 67
Your Medical Care: How to Ask for a Coverage Decision or Make an Appeal of a Coverage Decision ...................... 69
Your Part D Prescription Drugs: How to Ask for a Coverage Decision or Make an Appeal ......................................... 73
How to Ask Us to Cover a Longer Inpatient Hospital Stay if You Think You Are Being Discharged Too Soon ......... 78
How to Ask Us to Keep Covering Certain Medical Services if You Think Your Coverage Is Ending Too Soon ......... 81
Taking Your Appeal to Level 3 and Beyond .................................................................................................................. 85
How to Make a Complaint About Quality of Care, Waiting Times, Customer Service, or Other Concerns ................. 86
You can also tell Medicare about your complaint .......................................................................................................... 87
Additional Review .......................................................................................................................................................... 88
Binding Arbitration ........................................................................................................................................................ 88
Termination of Membership ............................................................................................................................................... 90
Termination Due to Loss of Eligibility .......................................................................................................................... 90
Termination of Agreement .............................................................................................................................................. 91
Disenrolling from Senior Advantage .............................................................................................................................. 91
Termination of Contract with the Centers for Medicare & Medicaid Services .............................................................. 92
Termination for Cause .................................................................................................................................................... 92
Termination for Nonpayment of Premiums .................................................................................................................... 92
Termination of a Product or all Products........................................................................................................................ 92
Payments after Termination ........................................................................................................................................... 92
Review of Membership Termination .............................................................................................................................. 92
Continuation of Membership .............................................................................................................................................. 92
Continuation of Group Coverage ................................................................................................................................... 93
Conversion from Group Membership to an Individual Plan .......................................................................................... 93
Miscellaneous Provisions ................................................................................................................................................... 94
Administration of Agreement ......................................................................................................................................... 94
Amendment of Agreement .............................................................................................................................................. 94
Applications and Statements .......................................................................................................................................... 94
Assignment ..................................................................................................................................................................... 94
Attorney and Advocate Fees and Expenses .................................................................................................................... 94
Claims Review Authority ............................................................................................................................................... 94
EOC Binding on Members ............................................................................................................................................. 94
Governing Law ............................................................................................................................................................... 94
Group and Members Not Our Agents ............................................................................................................................ 94
Newborns’ and Mothers’ Health Protection Act ............................................................................................................ 94
No Waiver ...................................................................................................................................................................... 94
Notices Regarding Your Coverage ................................................................................................................................. 94
Notice about Medicare Secondary Payer Subrogation Rights ........................................................................................ 95
Overpayment Recovery .................................................................................................................................................. 95
Public Policy Participation ............................................................................................................................................. 95
Telephone Access (TTY) ............................................................................................................................................... 95
Important Phone Numbers and Resources.......................................................................................................................... 95
Kaiser Permanente Senior Advantage ............................................................................................................................ 95
Medicare ......................................................................................................................................................................... 98
State Health Insurance Assistance Program ................................................................................................................... 98
Quality Improvement Organization ................................................................................................................................ 99
Social Security................................................................................................................................................................ 99
Medicaid ....................................................................................................................................................................... 100
Railroad Retirement Board ........................................................................................................................................... 100
Group Insurance or Other Health Insurance from an Employer ................................................................................... 100
Page 1
Benefit Highlights
Accumulation Period
The Accumulation Period for this plan is 1/1/24 through 12/31/24 (calendar year).
Plan Out-of-Pocket Maximum
For Services subject to the maximum, you will not pay any more Cost Share for the rest of the calendar year if the Copayments
and Coinsurance you pay for those Services add up to the following amount:
For any one Member ................................................................................ $1,500 per calendar year
Plan Deductible None
Plan Provider Office Visits
You Pay
Most Primary Care Visits and most Non-Physician Specialist Visits .........
$20 per visit
Most Physician Specialist Visits..................................................................
$20 per visit
Annual Wellness visit and the “Welcome to Medicare” preventive visit ....
No charge
Routine physical exams ...............................................................................
No charge
Routine eye exams with a Plan Optometrist ................................................
$20 per visit
Urgent care consultations, evaluations, and treatment.................................
$20 per visit
Physical, occupational, and speech therapy .................................................
$20 per visit
Telehealth Visits
You Pay
Primary Care Visits and Non-Physician Specialist Visits by interactive
video ..........................................................................................................
No charge
Physician Specialist Visits by interactive video ..........................................
No charge
Primary Care Visits and Non-Physician Specialist Visits by telephone ......
No charge
Physician Specialist Visits by telephone .....................................................
No charge
Outpatient Services
You Pay
Outpatient surgery and certain other outpatient procedures ........................
$100 per procedure
Allergy injections (including allergy serum) ...............................................
$3 per visit
Most immunizations (including the vaccine)...............................................
No charge
Most X-rays and laboratory tests .................................................................
No charge
Manual manipulation of the spine ...............................................................
$20 per visit
Hospitalization Services
You Pay
Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs ..
$250 per admission
Emergency Health Coverage
You Pay
Emergency Department visits ......................................................................
$65 per visit
Note: If you are admitted directly to the hospital as an inpatient for covered Services, you will pay the inpatient Cost Share
instead of the Emergency Department Cost Share (see “Hospitalization Services” for inpatient Cost Share).
Ambulance and Transportation Services
You Pay
Ambulance Services ....................................................................................
No charge
Prescription Drug Coverage
You Pay
Covered outpatient items in accord with our drug formulary guidelines:
Most generic items at a Plan Pharmacy ..................................................
$5 for up to a 30-day supply, $10 for a 31- to 60-day
supply, or $15 for a 61- to 100-day supply
Most generic refills through our mail-order service ...............................
$5 for up to a 30-day supply or $10 for a 31- to 100-
day supply
Most brand-name items at a Plan Pharmacy ..........................................
$25 for up to a 30-day supply, $50 for a 31- to 60-
day supply, or $75 for a 61- to 100-day supply
Most brand-name refills through our mail-order service ........................
$25 for up to a 30-day supply or $50 for a 31- to
100-day supply
Page 2
Durable Medical Equipment (DME)
You Pay
Covered durable medical equipment for home use as described in this
EOC ...........................................................................................................
No charge
Mental Health Services
You Pay
Inpatient psychiatric hospitalization ............................................................
$250 per admission
Individual outpatient mental health evaluation and treatment .....................
$20 per visit
Group outpatient mental health treatment ...................................................
$10 per visit
Substance Use Disorder Treatment
You Pay
Inpatient detoxification ................................................................................
$250 per admission
Individual outpatient substance use disorder evaluation and treatment .......
$20 per visit
Group outpatient substance use disorder treatment .....................................
$5 per visit
Home Health Services
You Pay
Home health care (part-time, intermittent) ..................................................
No charge
Other
You Pay
Eyeglasses or contact lenses every 24 months ............................................
Amount in excess of $150 Allowance
Hearing aid(s) every 36 months ...................................................................
Amount in excess of $2,500 Allowance per aid
Skilled Nursing Facility care (up to 100 days per benefit period) ...............
No charge
External prosthetic and orthotic devices as described in this EOC..............
No charge
Ostomy, urological, and wound care supplies .............................................
No charge
This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Share, out-of-
pocket maximums, exclusions, or limitations, nor does it list all benefits and Cost Share amounts. For a complete
explanation, refer to the “Benefits and Your Cost Share” and “Exclusions, Limitations, Coordination of Benefits, and
Reductions” sections.
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
Page 3
Introduction
Kaiser Foundation Health Plan, Inc. (Health Plan) has a
contract with the Centers for Medicare & Medicaid
Services as a Medicare Advantage Organization.
This contract provides Medicare Services (including
Medicare Part D prescription drug coverage) through
“Kaiser Permanente Senior Advantage
(HMO) with Part D” (Senior Advantage), except for
hospice care for Members with Medicare Part A, which
is covered under Original Medicare. Enrollment in this
Senior Advantage plan means that you are automatically
enrolled in Medicare Part D. Kaiser Permanente is an
HMO plan with a Medicare contract. Enrollment in
Kaiser Permanente depends on contract renewal.
This Evidence of Coverage (“EOC”) describes our
Senior Advantage health care coverage provided under
the Group Agreement (Agreement) between Health Plan
(Kaiser Foundation Health Plan, Inc. (“Health Plan”) and
the University of California (the entity with which
Health Plan has entered into the Agreement).
This EOC is part of the Agreement between Health Plan
and the University of California. The Agreement contains
additional terms such as Premiums, when coverage can
change, the effective date of coverage, and the effective
date of termination. The Agreement must be consulted to
determine the exact terms of coverage. A copy of the
Agreement is available from the University of California.
For benefits provided under any other program, refer to
that other plan’s evidence of coverage. For benefits
provided under any other program offered by the
University of California (for example, workers
compensation benefits), refer to the University of
California’s materials.
In this EOC, Health Plan is sometimes referred to as
“we” or “us.” Members are sometimes referred to as
“you.” Some capitalized terms have special meaning in
this EOC; please see the “Definitions” section for terms
you should know.
It is important to familiarize yourself with your coverage
by reading this EOC completely, so that you can take full
advantage of your Health Plan benefits. Also, if you have
special health care needs, please carefully read the
sections that apply to you.
About Kaiser Permanente
PLEASE READ THE FOLLOWING
INFORMATION SO THAT YOU WILL KNOW
FROM WHOM OR WHAT GROUP OF
PROVIDERS YOU MAY GET HEALTH CARE.
When you join Kaiser Permanente, you are enrolling in
one of two Health Plan Regions in California (either our
Northern California Region or Southern California
Region), which we call your “Home Region.” The
Service Area of each Region is described in the
“Definitions” section of this EOC. The coverage
information in this EOC applies when you obtain care in
your Home Region. When you visit the other California
Region, you may receive care as described in “Receiving
Care Outside of Your Home Region” in the “How to
Obtain Services” section.
Kaiser Permanente provides Services directly to our
Members through an integrated medical care program.
Health Plan, Plan Hospitals, and the Medical Group
work together to provide our Members with quality care.
Our medical care program gives you access to all of the
covered Services you may need, such as routine care
with your own personal Plan Physician, hospital
Services, laboratory and pharmacy Services, Emergency
Services, Urgent Care, and other benefits described in
this EOC. Plus, our health education programs offer you
great ways to protect and improve your health.
We provide covered Services to Members using Plan
Providers located in your Home Region Service Area,
which is described in the “Definitions” section. You
must receive all covered care from Plan Providers inside
your Home Region Service Area, except as described in
the sections listed below for the following Services:
• Authorized referrals as described under “Getting a
Referral” in the “How to Obtain Services” section
• Covered Services received outside of your Home
Region Service Area as described under “Receiving
Care Outside of Your Home Region Service Area” in
the “How to Obtain Services” section
• Emergency ambulance Services as described under
“Ambulance Services” in the “Benefits and Your Cost
Share” section
• Emergency Services, Post-Stabilization Care, and
Out-of-Area Urgent Care as described in the
“Emergency Services and Urgent Care” section
• Out-of-area dialysis care as described under “Dialysis
Care” in the “Benefits and Your Cost Share” section
• Prescription drugs from Non–Plan Pharmacies as
described under “Outpatient Prescription Drugs,
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
Page 4
Supplies, and Supplements” in the “Benefits and
Your Cost Share” section
• Routine Services associated with Medicare-approved
clinical trials as described under “Services Associated
with Clinical Trials” in the “Benefits and Your Cost
Share” section
Term of this EOC
This EOC is for the period January 1, 2024, through
December 31, 2024, unless amended. Benefits,
Copayments, and Coinsurance may change on January 1
of each year and at other times in accord with the
University of California’s Agreement with us. The
University of California can tell you whether this EOC is
still in effect and give you a current one if this EOC has
been amended.
Definitions
Some terms have special meaning in this EOC. When we
use a term with special meaning in only one section of
this EOC, we define it in that section. The terms in this
“Definitions” section have special meaning when
capitalized and used in any section of this EOC.
Accumulation Period: A period of time no greater than
12 consecutive months for purposes of accumulating
amounts toward any deductibles (if applicable) and out-
of-pocket maximums. The Accumulation Period for this
EOC is from 1/1/24 through 12/31/24.
Allowance: A specified credit amount that you can use
toward the cost of an item. If the cost of the item(s) or
Service(s) you select exceeds the Allowance, you will
pay the amount in excess of the Allowance, which does
not apply to the maximum out-of-pocket amount.
Catastrophic Coverage Stage: The stage in the Part D
drug benefit that begins when you (or other qualified
parties on your behalf) have spent $8,000 for Part D
covered drugs during the covered year. During this
payment stage, the plan pays the full cost for your
covered Part D drugs. You pay nothing. Note: This
amount may change every January 1 in accord with
Medicare requirements.
Centers for Medicare & Medicaid Services (CMS):
The federal agency that administers the Medicare
program.
Ancillary Coverage: Optional benefits such as
acupuncture, chiropractic, or dental coverage that may be
available to Members enrolled under this EOC. If your
plan includes Ancillary Coverage, this coverage will be
described in an amendment to this EOC or a separate
agreement from the issuer of the coverage.
Charges: “Charges” means the following:
• For Services provided by the Medical Group or
Kaiser Foundation Hospitals, the charges in Health
Plan’s schedule of Medical Group and Kaiser
Foundation Hospitals charges for Services provided
to Members
• For Services for which a provider (other than the
Medical Group or Kaiser Foundation Hospitals) 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 Member for the item if a 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 to
Members, and the pharmacy program’s contribution
to the net revenue requirements of Health Plan)
• For all other Services, the payments that Kaiser
Permanente makes for the Services or, if Kaiser
Permanente subtracts your Cost Share from its
payment, the amount Kaiser Permanente would have
paid if it did not subtract your Cost Share
Coinsurance: A percentage of Charges that you must
pay when you receive a covered Service under this EOC.
Complaint: The formal name for “making a complaint”
is “filing a grievance.” The complaint process is used
only for certain types of problems. This includes
problems related to quality of care, waiting times, and
the customer service you receive. It also includes
complaints if your plan does not follow the time periods
in the appeal process.
Comprehensive Formulary (Formulary or “Drug
List”): A list of Medicare Part D prescription drugs
covered by our plan. The drugs on this list are selected
by us with the help of doctors and pharmacists. The list
includes both brand-name and generic drugs.
Comprehensive Outpatient Rehabilitation Facility
(CORF): A facility that mainly provides rehabilitation
Services after an illness or injury, including physician’s
Services, physical therapy, social or psychological
Services, and outpatient rehabilitation.
Copayment: A specific dollar amount that you must pay
when you receive a covered Service under this EOC.
Note: The dollar amount of the Copayment can be $0 (no
charge).
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
Page 5
Cost Share: The amount you are required to pay for
covered Services. For example, your Cost Share may be
a Copayment or Coinsurance. If your coverage includes
a Plan Deductible and you receive Services that are
subject to the Plan Deductible, your Cost Share for those
Services will be Charges until you reach the Plan
Deductible.
Coverage Determination: An initial determination we
make about whether a Part D drug prescribed for you is
covered under Part D and the amount, if any, you are
required to pay for the prescription. In general, if you
bring your prescription for a Part D drug to a Plan
Pharmacy and the pharmacy tells you the prescription
isn’t covered by us, that isn’t a Coverage Determination.
You need to call or write us to ask for a formal decision
about the coverage. Coverage Determinations are called
“coverage decisions” in this EOC.
Dependent: A Member who meets the eligibility
requirements as a Dependent (for Dependent eligibility
requirements, see “Who Is Eligible” in the “Premiums,
Eligibility, and Enrollment” section).
Durable Medical Equipment (DME): Certain medical
equipment that is ordered by your doctor for medical
reasons. Examples include walkers, wheelchairs,
crutches, powered mattress systems, diabetic supplies, IV
infusion pumps, speech-generating devices, oxygen
equipment, nebulizers, or hospital beds ordered by a
provider for use in the home.
Emergency Medical Condition: A medical or mental
health condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) such that a
prudent layperson, with an average knowledge of health
and medicine, could reasonably expect the absence of
immediate medical attention to result in any of the
following:
• Serious jeopardy to the health of the individual or, in
the case of a pregnant woman, the health of the
woman or her unborn child
• Serious impairment to bodily functions
• Serious dysfunction of any bodily organ or part
A mental health condition is an emergency medical
condition when it meets the requirements of the
paragraph above, or when the condition manifests itself
by acute symptoms of sufficient severity such that either
of the following is true:
• The person is an immediate danger to themselves or
to others
• The person is immediately unable to provide for, or
use, food, shelter, or clothing, due to the mental
disorder
Emergency Services: Covered Services that are (1)
rendered by a provider qualified to furnish Emergency
Services; and (2) needed to treat, evaluate, or Stabilize an
Emergency Medical Condition such as:
• A medical screening exam that is within the
capability of the emergency department of a hospital,
including ancillary services (such as imaging and
laboratory Services) routinely available to the
emergency department to evaluate the Emergency
Medical Condition
• Within the capabilities of the staff and facilities
available at the hospital, Medically Necessary
examination and treatment required to Stabilize the
patient (once your condition is Stabilized, Services
you receive are Post Stabilization Care and not
Emergency Services)
EOC: This Evidence of Coverage document, including
any amendments, which describes the health care
coverage of “Kaiser Permanente Senior Advantage
(HMO) with Part D” under Health Plan’s Agreement
with the University of California.
“Extra Help”: A Medicare or state program to help
people with limited income and resources pay Medicare
prescription drug program costs, such as premiums,
deductibles, and coinsurance.
Family: A Subscriber and all of their Dependents.
Grievance: A type of complaint you make about our
plan, providers, or pharmacies, including a complaint
concerning the quality of your care. This does not
involve coverage or payment disputes.
Group: The entity with which Health Plan has entered
into the Agreement that includes this EOC.
Health Plan: Kaiser Foundation Health Plan, Inc., a
California nonprofit corporation. This EOC sometimes
refers to Health Plan as “we” or “us.”
Home Region: The Region where you enrolled (either
the Northern California Region or the Southern
California Region).
Income Related Monthly Adjustment Amount
(IRMAA): If your modified adjusted gross income as
reported on your IRS tax return from two years ago is
above a certain amount, you’ll pay the standard premium
amount and an Income Related Monthly Adjustment
Amount, also known as IRMAA. IRMAA is an extra
charge added to your premium. Less than 5% of people
with Medicare are affected, so most people will not pay a
higher premium.
Initial Enrollment Period: When you are first eligible
for Medicare, the period of time when you can sign up
for Medicare Part B. If you’re eligible for Medicare
when you turn 65, your Initial Enrollment Period is the
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
Page 6
7-month period that begins 3 months before the month
you turn 65, includes the month you turn 65, and ends 3
months after the month you turn 65.
Kaiser Permanente: Kaiser Foundation Hospitals (a
California nonprofit corporation), Health Plan, and the
Medical Group.
Medical Group: For Northern California Region
Members, The Permanente Medical Group, Inc., a for-
profit professional corporation, and for Southern
California Region Members, the Southern California
Permanente Medical Group, a for-profit professional
partnership.
Medically Necessary: A Service is Medically Necessary
if it is medically appropriate and required to prevent,
diagnose, or treat your condition or clinical symptoms in
accord with generally accepted professional standards of
practice that are consistent with a standard of care in the
medical community.
Medicare: The federal health insurance program for
people 65 years of age or older, some people under age
65 with certain disabilities, and people with End-Stage
Renal Disease (generally those with permanent kidney
failure who need dialysis or a kidney transplant). A
person enrolled in a Medicare Part D plan has Medicare
Part D by virtue of his or her enrollment in the Part D
plan (this EOC is for a Part D plan).
Medicare Advantage Organization: A public or private
entity organized and licensed by a state as a risk-bearing
entity that has a contract with the Centers for Medicare
& Medicaid Services to provide Services covered by
Medicare, except for hospice care covered by Original
Medicare. Kaiser Foundation Health Plan, Inc., is a
Medicare Advantage Organization.
Medicare Advantage Plan: Sometimes called Medicare
Part C. A plan offered by a private company that
contracts with Medicare to provide you with all your
Medicare Part A and Part B benefits. A Medicare
Advantage Plan can be (i) an HMO, (ii) a PPO, (iii) a
Private Fee-for-Service (PFFS) plan, or (iv) a Medicare
Medical Savings Account (MSA) plan. Besides choosing
from these types of plans, a Medicare Advantage HMO
or PPO plan can also be a Special Needs Plan (SNP). In
most cases, Medicare Advantage Plans also offer
Medicare Part D (prescription drug coverage). These
plans are called Medicare Advantage Plans with
Prescription Drug Coverage. This EOC is for a
Medicare Part D plan.
Medicare Health Plan: A Medicare Health Plan is
offered by a private company that contracts with
Medicare to provide Part A and Part B benefits to people
with Medicare who enroll in the plan. This term includes
all Medicare Advantage plans, Medicare Cost plans,
Demonstration/Pilot Programs, and Programs of All-
inclusive Care for the Elderly (PACE).
Medigap (Medicare Supplement Insurance) Policy:
Medicare supplement insurance sold by private insurance
companies to fill “gaps” in the Original Medicare plan
coverage. Medigap policies only work with the Original
Medicare plan. (A Medicare Advantage Plan is not a
Medigap policy.)
Member: A person who is eligible and enrolled under
this EOC, and for whom we have received applicable
Premiums. This EOC sometimes refers to a Member as
“you.”
Non-Physician Specialist Visits: Consultations,
evaluations, and treatment by non-physician specialists
(such as nurse practitioners, physician assistants,
optometrists, podiatrists, and audiologists).
Non–Plan Hospital: A hospital other than a Plan
Hospital.
Non–Plan Pharmacy: A pharmacy other than a Plan
Pharmacy. These pharmacies are also called “out-of-
network pharmacies.”
Non–Plan Physician: A physician other than a Plan
Physician.
Non–Plan Provider: A provider other than a Plan
Provider.
Non–Plan Psychiatrist: A psychiatrist who is not a Plan
Physician.
Non–Plan Skilled Nursing Facility: A Skilled Nursing
Facility other than a Plan Skilled Nursing Facility.
Organization Determination: An initial determination
we make about whether we will cover or pay for
Services that you believe you should receive. We also
make an Organization Determination when we provide
you with Services, or refer you to a Non–Plan Provider
for Services. Organization Determinations are called
“coverage decisions” in this EOC.
Original Medicare (“Traditional Medicare” or “Fee-
for-Service Medicare”): The Original Medicare plan is
the way many people get their health care coverage. It is
the national pay-per-visit program that lets you go to any
doctor, hospital, or other health care provider that
accepts Medicare. You must pay a deductible. Medicare
pays its share of the Medicare approved amount, and you
pay your share. Original Medicare has two parts: Part A
(Hospital Insurance) and Part B (Medical Insurance), and
is available everywhere in the United States and its
territories.
Out-of-Area Urgent Care: Medically Necessary
Services to prevent serious deterioration of your health
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
Page 7
resulting from an unforeseen illness or an unforeseen
injury if all of the following are true:
• You are temporarily outside your Home Region
Service Area
• A reasonable person would have believed that your
health would seriously deteriorate if you delayed
treatment until you returned to your Home Region
Service Area
Physician Specialist Visits: Consultations, evaluations,
and treatment by physician specialists, including
personal Plan Physicians who are not Primary Care
Physicians.
Plan Deductible: The amount you must pay under this
EOC in the calendar year for certain Services before we
will cover those Services at the applicable Copayment or
Coinsurance in that calendar year. Refer to the “Benefits
and Your Cost Share” section to learn whether your
coverage includes a Plan Deductible, the Services that
are subject to the Plan Deductible, and the Plan
Deductible amount.
Plan Facility: Any facility listed in the Provider
Directory on our website at kp.org/facilities. Plan
Facilities include Plan Hospitals, Plan Medical Offices,
and other facilities that we designate in the directory.
The directory is updated periodically. The availability of
Plan Facilities may change. If you have questions, please
call Member Services.
Plan Hospital: Any hospital listed in the Provider
Directory on our website at kp.org/facilities. In the
directory, some Plan Hospitals are listed as Kaiser
Permanente Medical Centers. The directory is updated
periodically. The availability of Plan Hospitals may
change. If you have questions, please call Member
Services.
Plan Medical Office: Any medical office listed in the
Provider Directory on our website at kp.org/facilities. In
the directory, Kaiser Permanente Medical Centers may
include Plan Medical Offices. The directory is updated
periodically. The availability of Plan Medical Offices
may change. If you have questions, please call Member
Services.
Plan Optical Sales Office: An optical sales office
owned and operated by Kaiser Permanente or another
optical sales office that we designate. Refer to the
Provider Directory on our website at kp.org/facilities for
locations of Plan Optical Sales Offices. In the directory,
Plan Optical Sales Offices may be called “Vision
Essentials.” The directory is updated periodically. The
availability of Plan Optical Sales Offices may change. If
you have questions, please call Member Services.
Plan Optometrist: An optometrist who is a Plan
Provider.
Plan Out-of-Pocket Maximum: The total amount of
Cost Share you must pay under this EOC in the calendar
year for certain covered Services that you receive in the
same calendar year. Refer to the “Benefits and Your Cost
Share” section to find your Plan Out-of-Pocket
Maximum amount and to learn which Services apply to
the Plan Out-of-Pocket Maximum.
Plan Pharmacy: A pharmacy owned and operated by
Kaiser Permanente or another pharmacy that we
designate. Refer to the Provider Directory on our website
at kp.org/facilities for locations of Plan Pharmacies. The
directory is updated periodically. The availability of Plan
Pharmacies may change. If you have questions, please
call Member Services.
Plan Physician: Any licensed physician who is a partner
or employee of the Medical Group, or any licensed
physician who contracts to provide Services to Members
(but not including physicians who contract only to
provide referral Services).
Plan Provider: A Plan Hospital, a Plan Physician, the
Medical Group, a Plan Pharmacy, or any other health
care provider that Health Plan designates as a Plan
Provider.
Plan Skilled Nursing Facility: A Skilled Nursing
Facility approved by Health Plan.
Post-Stabilization Care: Medically Necessary Services
related to your Emergency Medical Condition that you
receive in a hospital (including the Emergency
Department) after your treating physician determines that
this condition is Stabilized.
Premiums: The periodic amounts for your membership
under this EOC.
Preventive Services: Covered Services that prevent or
detect illness and do one or more of the following:
• Protect against disease and disability or further
progression of a disease
• Detect disease in its earliest stages before noticeable
symptoms develop
Primary Care Physicians: Generalists in internal
medicine, pediatrics, and family practice, and specialists
in obstetrics/gynecology whom the Medical Group
designates as Primary Care Physicians. Refer to the
Provider Directory on our website at kp.org for a list of
physicians that are available as Primary Care Physicians.
The directory is updated periodically. The availability of
Primary Care Physicians may change. If you have
questions, please call Member Services.
Primary Care Visits: Evaluations and treatment
provided by Primary Care Physicians and primary care
Plan Providers who are not physicians (such as nurse
practitioners).
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
Page 8
Provider Directory: A directory of Plan Physicians and
Plan Facilities in your Home Region. This directory is
available on our website at kp.org/directory. To obtain
a printed copy, call Member Services. The directory is
updated periodically. The availability of Plan Physicians
and Plan Facilities may change. If you have questions,
please call Member Services.
Real-Time Benefit Tool: A portal or computer
application in which enrollees can look up complete,
accurate, timely, clinically appropriate, enrollee-specific
formulary and benefit information. This includes cost-
sharing amounts, alternative formulary medications that
may be used for the same health condition as a given
drug, and coverage restrictions (prior authorization, step
therapy, quantity limits) that apply to alternative
medications.
Region: A Kaiser Foundation Health Plan organization
or allied plan that conducts a direct-service health care
program. Regions may change on January 1 of each year
and are currently the District of Columbia and parts of
Northern California, Southern California, Colorado,
Georgia, Hawaii, Maryland, Oregon, Virginia, and
Washington. For the current list of Region locations,
please visit our website at kp.org or call Member
Services.
Retiree: A former University Employee receiving
monthly benefits from a University-sponsored defined
benefit plan.
Serious Emotional Disturbance of a Child Under Age
18: A condition identified as a “mental disorder” in the
most recent edition of the Diagnostic and Statistical
Manual of Mental Disorders, other than a primary
substance use disorder or developmental disorder, that
results in behavior inappropriate to the child’s age
according to expected developmental norms, if the child
also meets at least one of the following three criteria:
• As a result of the mental disorder, (1) the child has
substantial impairment in at least two of the following
areas: self-care, school functioning, family
relationships, or ability to function in the community;
and (2) either (a) the child is at risk of removal from
the home or has already been removed from the
home, or (b) the mental disorder and impairments
have been present for more than six months or are
likely to continue for more than one year without
treatment
• The child displays psychotic features, or risk of
suicide or violence due to a mental disorder
• The child meets special education eligibility
requirements under Section 5600.3(a)(2)(C) of the
Welfare and Institutions Code
Service Area: The geographic area approved by the
Centers for Medicare & Medicaid Services within which
an eligible person may enroll in Senior Advantage. Note:
Subject to approval by the Centers for Medicare &
Medicaid Services, we may reduce or expand your Home
Region Service Area effective any January 1. ZIP codes
are subject to change by the U.S. Postal Service. Health
Plan has two Regions in California. As a Member, you
are enrolled in one of the two Regions (either our
Northern California Region or Southern California
Region), called your Home Region. This EOC describes
the coverage for both California Regions.
Northern California Region Service Area
The ZIP codes below for each county are in our Northern
California Service Area:
• All ZIP codes in Alameda County are inside our
Northern California Service Area: 94501–02, 94505,
94514, 94536–46, 94550–52, 94555, 94557, 94560,
94566, 94568, 94577–80, 94586–88, 94601–15,
94617–21, 94622–24, 94649, 94659–62, 94666,
94701–10, 94712, 94720, 95377, 95391
• The following ZIP codes in Amador County are
inside our Northern California Service Area: 95640,
95669
• All ZIP codes in Contra Costa County are inside our
Northern California Service Area: 94505–07, 94509,
94511, 94513–14, 94516–31, 94547–49, 94551,
94553, 94556, 94561, 94563–65, 94569–70, 94572,
94575, 94582–83, 94595–98, 94706–08, 94801–08,
94820, 94850
• The following ZIP codes in El Dorado County are
inside our Northern California Service Area: 95613–
14, 95619, 95623, 95633–35, 95651, 95664, 95667,
95672, 95682, 95762
• The following ZIP codes in Fresno County are inside
our Northern California Service Area: 93242, 93602,
93606–07, 93609, 93611–13, 93616, 93618–19,
93624–27, 93630–31, 93646, 93648–52, 93654,
93656–57, 93660, 93662, 93667–68, 93675, 93701–
12, 93714–18, 93720–30, 93737, 93740–41, 93744–
45, 93747, 93750, 93755, 93760–61, 93764–65,
93771–79, 93786, 93790–94, 93844, 93888
• The following ZIP codes in Kings County are inside
our Northern California Service Area: 93230, 93232,
93242, 93631, 93656
• The following ZIP codes in Madera County are inside
our Northern California Service Area: 93601–02,
93604, 93614, 93623, 93626, 93636–39, 93643–45,
93653, 93669, 93720
• All ZIP codes in Marin County are inside our
Northern California Service Area: 94901, 94903–04,
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
Page 9
94912–15, 94920, 94924–25, 94929–30, 94933,
94937–42, 94945–50, 94956–57, 94960, 94963–66,
94970–71, 94973–74, 94976–79
• The following ZIP codes in Mariposa County are
inside our Northern California Service Area: 93601,
93623, 93653
• All ZIP codes in Napa County are inside our Northern
California Service Area: 94503, 94508, 94515,
94558–59, 94562, 94567, 94573–74, 94576, 94581,
94599, 95476
• The following ZIP codes in Placer County are inside
our Northern California Service Area: 95602–04,
95610, 95626, 95648, 95650, 95658, 95661, 95663,
95668, 95677–78, 95681, 95703, 95722, 95736,
95746–47, 95765
• All ZIP codes in Sacramento County are inside our
Northern California Service Area: 94203–09, 94211,
94229–30, 94232, 94234–37, 94239–40, 94244–45,
94247–50, 94252, 94254, 94256–59, 94261–63,
94267–69, 94271, 94273–74, 94277–80, 94282–85,
94287–91, 94293–98, 94571, 95608–11, 95615,
95621, 95624, 95626, 95628, 95630, 95632, 95638–
39, 95641, 95652, 95655, 95660, 95662, 95670–71,
95673, 95678, 95680, 95683, 95690, 95693, 95741–
42, 95757–59, 95763, 95811–38, 95840–43, 95851–
53, 95860, 95864–67, 95894, 95899
• All ZIP codes in San Francisco County are inside our
Northern California Service Area: 94102–05, 94107–
12, 94114–34, 94137, 94139–47, 94151, 94158–61,
94163–64, 94172, 94177, 94188
• All ZIP codes in San Joaquin County are inside our
Northern California Service Area: 94514, 95201–15,
95219–20, 95227, 95230–31, 95234, 95236–37,
95240–42, 95253, 95258, 95267, 95269, 95296–97,
95304, 95320, 95330, 95336–37, 95361, 95366,
95376–78, 95385, 95391, 95632, 95686, 95690
• All ZIP codes in San Mateo County are inside our
Northern California Service Area: 94002, 94005,
94010–11, 94014–21, 94025–28, 94030, 94037–38,
94044, 94060–66, 94070, 94074, 94080, 94083,
94128, 94303, 94401–04, 94497
• The following ZIP codes in Santa Clara County are
inside our Northern California Service Area: 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
• All ZIP codes in Santa Cruz County are inside our
Northern California Service Area: 95001, 95003,
95005–07, 95010, 95017–19, 95033, 95041, 95060–
67, 95073, 95076–77
• All ZIP codes in Solano County are inside our
Northern California Service Area: 94503, 94510,
94512, 94533–35, 94571, 94585, 94589–92, 95616,
95618, 95620, 95625, 95687–88, 95690, 95694,
95696
• The following ZIP codes in Sonoma County are
inside our Northern California Service Area: 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
• All ZIP codes in Stanislaus County are inside our
Northern California Service Area: 95230, 95304,
95307, 95313, 95316, 95319, 95322–23, 95326,
95328–29, 95350–58, 95360–61, 95363, 95367–68,
95380–82, 95385–87, 95397
• The following ZIP codes in Sutter County are inside
our Northern California Service Area: 95626, 95645,
95659, 95668, 95674, 95676, 95692, 95836–37
• The following ZIP codes in Tulare County are inside
our Northern California Service Area: 93238, 93261,
93618, 93631, 93646, 93654, 93666, 93673
• The following ZIP codes in Yolo County are inside
our Northern California Service Area: 95605, 95607,
95612, 95615–18, 95645, 95691, 95694–95, 95697–
98, 95776, 95798–99
• The following ZIP codes in Yuba County are inside
our Northern California Service Area: 95692, 95903,
95961
Southern California Region Service Area
The ZIP codes below for each county are in our Southern
California Service Area:
• The following ZIP codes in Kern County are inside
our Southern California Service Area: 93203, 93205–
06, 93215–16, 93220, 93222, 93224–26, 93238,
93240–41, 93243, 93249–52, 93263, 93268, 93276,
93280, 93285, 93287, 93301–09, 93311–14, 93380,
93383–90, 93501–02, 93504–05, 93518–19, 93531,
93536, 93560–61, 93581
• The following ZIP codes in Los Angeles County are
inside our Southern California Service Area: 90001–
84, 90086–91, 90093–96, 90099, 90134, 90189,
90201–02, 90209–13, 90220–24, 90230–32, 90239–
42, 90245, 90247–51, 90254–55, 90260–67, 90270,
90272, 90274–75, 90277–78, 90280, 90290–96,
90301–12, 90401–11, 90501–10, 90601–10, 90623,
90630–31, 90637–40, 90650–52, 90660–62, 90670–
71, 90701–03, 90706–07, 90710–17, 90723, 90731–
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
Page 10
34, 90744–49, 90755, 90801–10, 90813–15, 90822,
90831–33, 90840, 90842, 90844, 90846–48, 90853,
90895, 91001, 91003, 91006–12, 91016–17, 91020–
21, 91023–25, 91030–31, 91040–43, 91046, 91066,
91077, 91101–10, 91114–18, 91121, 91123–26,
91129, 91182, 91184–85, 91188–89, 91199, 91201–
10, 91214, 91221–22, 91224–26, 91301–11, 91313,
91316, 91321–22, 91324–31, 91333–35, 91337,
91340–46, 91350–57, 91361–62, 91364–65, 91367,
91371–72, 91376, 91380–87, 91390, 91392–96,
91401–13, 91416, 91423, 91426, 91436, 91470,
91482, 91495–96, 91499, 91501–08, 91510, 91521–
23, 91526, 91601–12, 91614–18, 91702, 91706,
91711, 91714–16, 91722–24, 91731–35, 91740–41,
91744–50, 91754–56, 91759, 91765–73, 91775–76,
91778, 91780, 91788–93, 91801–04, 91896, 91899,
93243, 93510, 93532, 93534–36, 93539, 93543–44,
93550–53, 93560, 93563, 93584, 93586, 93590–91,
93599
• All ZIP codes in Orange County are inside our
Southern California Service Area: 90620–24, 90630–
33, 90638, 90680, 90720–21, 90740, 90742–43,
92602–07, 92609–10, 92612, 92614–20, 92623–30,
92637, 92646–63, 92672–79, 92683–85, 92688,
92690–94, 92697–98, 92701–08, 92711–12, 92728,
92735, 92780–82, 92799, 92801–09, 92811–12,
92814–17, 92821–23, 92825, 92831–38, 92840–46,
92850, 92856–57, 92859, 92861–71, 92885–87,
92899
• The following ZIP codes in Riverside County are
inside our Southern California Service Area: 91752,
92201–03, 92210–11, 92220, 92223, 92230, 92234–
36, 92240–41, 92247–48, 92253, 92255, 92258,
92260–64, 92270, 92276, 92282, 92320, 92324,
92373, 92399, 92501–09, 92513–14, 92516–19,
92521–22, 92530–32, 92543–46, 92548, 92551–57,
92562–64, 92567, 92570–72, 92581–87, 92589–93,
92595–96, 92599, 92860, 92877–83
• The following ZIP codes in San Bernardino County
are inside our Southern California Service Area:
91701, 91708–10, 91729–30, 91737, 91739, 91743,
91758–59, 91761–64, 91766, 91784–86, 92305,
92307–08, 92313–18, 92321–22, 92324–25, 92329,
92331, 92333–37, 92339–41, 92344–46, 92350,
92352, 92354, 92357–59, 92369, 92371–78, 92382,
92385–86, 92391–95, 92397, 92399, 92401–08,
92410–11, 92413, 92415, 92418, 92423, 92427,
92880
• The following ZIP codes in San Diego County are
inside our Southern California Service Area: 91901–
03, 91908–17, 91921, 91931–33, 91935, 91941–46,
91950–51, 91962–63, 91976–80, 91987, 92003,
92007–11, 92013–14, 92018–30, 92033, 92037–40,
92046, 92049, 92051–52, 92054–61, 92064–65,
92067–69, 92071–72, 92074–75, 92078–79, 92081–
86, 92088, 92091–93, 92096, 92101–24, 92126–32,
92134–40, 92142–43, 92145, 92147, 92149–50,
92152–55, 92158–61, 92163, 92165–79, 92182,
92186–87, 92191–93, 92195–99
• The following ZIP codes in Ventura County are
inside our Southern California Service Area: 90265,
91304, 91307, 91311, 91319–20, 91358–62, 91377,
93001–07, 93009–12, 93015–16, 93020–22, 93030–
36, 93040–44, 93060–66, 93094, 93099, 93252
For each ZIP code listed for a county, your Home Region
Service Area includes only the part of that ZIP code that
is in that county. When a ZIP code spans more than one
county, the part of that ZIP code that is in another county
is not inside your Home Region Service Area unless that
other county is listed above and that ZIP code is also
listed for that other county. If you have a question about
whether a ZIP code is in your Home Region Service
Area, please call Member Services. Also, the ZIP codes
listed above may include ZIP codes for Post Office boxes
and commercial rental mailboxes. A Post Office box or
rental mailbox cannot be used to determine whether you
meet the residence eligibility requirements for Senior
Advantage. Your permanent residence address must be
used to determine your Senior Advantage eligibility.
Services: Health care services or items (“health care”
includes both physical health care and mental health
care) and services to treat Serious Emotional Disturbance
of a Child Under Age 18 or Severe Mental Illness.
Severe Mental Illness: The following mental disorders:
schizophrenia, schizoaffective disorder, bipolar disorder
(manic-depressive illness), major depressive disorders,
panic disorder, obsessive-compulsive disorder, pervasive
developmental disorder or autism, anorexia nervosa, or
bulimia nervosa.
Skilled Nursing Facility: A facility that provides
inpatient skilled nursing care, rehabilitation services, or
other related health services and is licensed by the state
of California. The facility’s primary business must be the
provision of 24-hour-a-day licensed skilled nursing care.
The term “Skilled Nursing Facility” does not include
convalescent nursing homes, rest facilities, or facilities
for the aged, if those facilities furnish primarily custodial
care, including training in routines of daily living. A
“Skilled Nursing Facility” may also be a unit or section
within another facility (for example, a hospital) as long
as it continues to meet this definition.
Spouse: The person to whom the Subscriber is legally
married under applicable law. For the purposes of this
EOC, the term “Spouse” includes the Subscriber’s
domestic partner. “Domestic partners” are two people
who are registered and legally recognized as domestic
partners by California (if the University of California
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
Page 11
allows enrollment of domestic partners not legally
recognized as domestic partners by California, “Spouse”
also includes the Subscriber’s domestic partner who
meets the University of California’s eligibility
requirements for domestic partners).
Stabilize: To provide the medical treatment of the
Emergency Medical Condition that is necessary to
assure, within reasonable medical probability, that no
material deterioration of the condition is likely to result
from or occur during the transfer of the person from the
facility. With respect to a pregnant person who is having
contractions, when there is inadequate time to safely
transfer them to another hospital before delivery (or the
transfer may pose a threat to the health or safety of the
pregnant person or unborn child), “Stabilize” means to
deliver (including the placenta).
Subscriber: A Member who is eligible for membership
on their own behalf and not by virtue of Dependent
status and who meets the eligibility requirements as a
Subscriber (for Subscriber eligibility requirements, see
“Who Is Eligible” in the “Premiums, Eligibility, and
Enrollment” section).
Surrogacy Arrangement: An arrangement in which an
individual agrees to become pregnant and to surrender
the baby (or babies) to another person or persons who
intend to raise the child (or children), whether or not the
individual receives payment for being a surrogate. For
the purposes of this EOC, "Surrogacy Arrangements"
includes all types of surrogacy arrangements, including
traditional surrogacy arrangements and gestational
surrogacy arrangements.
Survivor: A deceased Employee's or Retiree's Family
Member receiving monthly benefits from a University-
sponsored defined benefit plan.
Telehealth Visits: Interactive video visits and scheduled
telephone visits between you and your provider.
Urgent Care: Medically Necessary Services for a
condition that requires prompt medical attention but is
not an Emergency Medical Condition.
Premiums, Eligibility, and
Enrollment
Premiums
Please contact the University of California’s benefits
administrator for information about your plan Premiums.
You must also continue to pay Medicare your monthly
Medicare premium.
If you do not have Medicare Part A, you may be eligible
to purchase Medicare Part A from Social Security. Please
contact Social Security for more information. If you get
Medicare Part A, this may reduce the amount you would
be expected to pay to the University of California, please
check with the University of California’s benefits
administrator.
Medicare Premiums
Medicare Part D premium due to income
Some members may be required to pay an extra charge,
known as the Part D Income Related Monthly
Adjustment Amount, also known as IRMAA. The extra
charge is figured out using your modified adjusted gross
income as reported on your IRS tax return from two
years ago. If this amount is above a certain amount,
you’ll pay the standard premium amount and the
additional IRMAA. For more information on the extra
amount you may have to pay based on your income, visit
https://www.medicare.gov.
If you have to pay an extra amount, Social Security, not
your Medicare plan, will send you a letter telling you
what that extra amount will be. The extra amount will be
withheld from your Social Security, Railroad Retirement
Board, or Office of Personnel Management benefit
check, no matter how you usually pay your plan
premium, unless your monthly benefit isn’t enough to
cover the extra amount owed. If your benefit check isn’t
enough to cover the extra amount, you will get a bill
from Medicare. You must pay the extra amount to the
government. If you do not pay the extra amount, you
will be disenrolled from the plan and lose
prescription drug coverage.
If you disagree about paying an extra amount, you can
ask Social Security to review the decision. To find out
more about how to do this, contact Social Security at
1-800-772-1213 (TTY users call 1-800-325-0778).
Medicare Part D late enrollment penalty
Some members are required to pay a Part D late
enrollment penalty. The Part D late enrollment penalty is
an additional premium that must be paid for Part D
coverage if at any time after your initial enrollment
period is over, there is a period of 63 days or more in a
row when you did not have Part D or other creditable
prescription drug coverage. “Creditable prescription drug
coverage” is coverage that meets Medicare’s minimum
standards since it is expected to pay, on average, at least
as much as Medicare’s standard prescription drug
coverage. The cost of the late enrollment penalty
depends on how long you went without Part D or other
creditable prescription drug coverage. You will have to
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
Page 12
pay this penalty for as long as you have Part D coverage.
The Part D late enrollment penalty is added to your plan
premium. The University of California or Health Plan
will inform you if the penalty applies to you.
You will not have to pay it if:
• You receive “Extra Help” from Medicare to pay for
your prescription drugs
• You have gone less than 63 days in a row without
creditable coverage
• You have had creditable drug coverage through
another source such as a former employer, union,
TRICARE, or Department of Veterans Affairs. Your
insurer or your human resources department will tell
you each year if your drug coverage is creditable
coverage. This information may be sent to you in a
letter or included in a newsletter from the plan. Keep
this information because you may need it if you join a
Medicare drug plan later
♦ any notice must state that you had “creditable”
prescription drug coverage that is expected to pay
as much as Medicare’s standard prescription drug
plan pays
♦ the following are not creditable prescription drug
coverage: prescription drug discount cards, free
clinics, and drug discount websites
Medicare determines the amount of the penalty. There
are three important things to note about this monthly Part
D late enrollment penalty:
• First, the penalty may change each year because the
average monthly premium can change each year
• Second, you will continue to pay a penalty every
month for as long as you are enrolled in a plan that
has Medicare Part D drug benefits, even if you
change plans
• Third, if you are under 65 and currently receiving
Medicare benefits, the Part D late enrollment penalty
will reset when you turn 65. After age 65, your Part D
late enrollment penalty will be based only on the
months that you don’t have coverage after your initial
enrollment period for aging into Medicare
If you disagree about your Part D late enrollment
penalty, you or your representative can ask for a
review. Generally, you must request this review within
60 days from the date on the first letter you receive
stating you have to pay a late enrollment penalty.
However, if you were paying a penalty before joining
our plan, you may not have another chance to request a
review of that late enrollment penalty.
Medicare’s “Extra Help” Program
Medicare provides “Extra Help” to pay prescription drug
costs for people who have limited income and resources.
Resources include your savings and stocks, but not your
home or car. If you qualify, you get help paying for any
Medicare drug plan’s monthly premium, and prescription
Copayments. This “Extra Help” also counts toward your
out-of-pocket costs.
People with limited income and resources may qualify
for “Extra Help.” If you automatically qualify for “Extra
Help,” Medicare will mail you a letter. You will not have
to apply. If you do not automatically qualify, you may be
able to get “Extra Help” to pay for your prescription drug
premiums and costs. To see if you qualify for getting
“Extra Help,” call:
• 1-800-MEDICARE (1-800-633-4227) (TTY users
call 1-877-486-2048), 24 hours a day, seven days a
week;
• The Social Security Office at 1-800-772-1213 (TTY
users call 1-800-325-0778), 8 a.m. to 7 p.m., Monday
through Friday (applications); or
• Your state Medicaid office (applications). See the
“Important Phone Numbers and Resources” section
for contact information
If you qualify for “Extra Help,” we will send you an
Evidence of Coverage Rider for People Who Get Extra
Help Paying for Prescription Drugs (also known as the
Low Income Subsidy Rider or the LIS Rider), that
explains your costs as a Member of our plan. If the
amount of your “Extra Help” changes during the year,
we will also mail you an updated Evidence of Coverage
Rider for People Who Get Extra Help Paying for
Prescription Drugs.
Who Is Eligible
To enroll and to continue enrollment, you must meet all
of the eligibility requirements described in this “Who Is
Eligible” section, including the University of California’s
eligibility requirements and your Home Region Service
Area eligibility requirements.
Group eligibility requirements
You must meet the University of California’s eligibility
requirements. The University of California is required to
inform Subscribers of its eligibility requirements.
The University establishes its own medical plan
eligibility, enrollment, and termination criteria based on
the University of California Group Insurance
Regulations and any corresponding Administrative
Supplements.
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
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Employees
Information pertaining to your eligibility, enrollment,
cancellation or termination of coverage and conversion
options can be found in the “Complete Guide to Your
UC Health Benefits.” A copy of this booklet is available
in the HR Forms & Publications section of UCnet
(ucnet.universityofcalifornia.edu). Additional
resources are also available in the Compensation and
Benefits section of UCnet to help you with your health
and welfare plan decisions.
Retirees
Information pertaining to your eligibility, enrollment,
cancellation, or termination of coverage and conversion
options can be found in the “Group Insurance Eligibility
Fact Sheet for Retirees.” A copy of this fact sheet is
available in the HR Forms & Publications section of
UCnet (ucnet.universityofcalifornia.edu). Additional
resources are also available in the Compensation and
Benefits section of UCnet to help you with your health
and welfare plan decisions.
Senior Advantage eligibility requirements
• You must have Medicare Part B
• You must be a United States citizen or lawfully
present in the United States
• Your Medicare coverage must be primary and the
University of California’s health care plan must be
secondary
• You may not be enrolled in another Medicare Health
Plan or Medicare prescription drug plan
Note: If you are enrolled in a Medicare plan and lose
Medicare eligibility, you may be able to enroll under the
University of California’s non-Medicare plan if that is
permitted by the University of California (please ask the
University of California for details).
Service Area eligibility requirements
When you join Kaiser Permanente, you are enrolling in
one of two Health Plan Regions in California (either our
Northern California Region or Southern California
Region), which we call your “Home Region.” The
Service Area of each Region is described in the
“Definitions” section.
You must live in your Home Region Service Area,
unless you have been continuously enrolled in Senior
Advantage since December 31, 1998, and lived outside
your Home Region Service Area during that entire time.
In which case, you may continue your membership
unless you move and are still outside your Home Region
Service Area. The “Definitions” section describes your
Home Region Service Area and how it may change.
Moving from your Home Region Service Area to our
other California Region Service Area. You must
complete a new Senior Advantage Election Form to
continue Senior Advantage coverage if you move from
your Home Region Service Area to the Service Area of
our other California Region (the Service Area of both
Regions are described in the “Definitions” section). To
get a Senior Advantage Election Form, please call
Member Services toll free at 1-800-443-0815 (TTY users
call 711) every day 8 a.m. to 8 p.m.
Moving outside our Northern and Southern
California Regions’ Service Areas. If you permanently
move outside our Northern and Southern California
Regions’ Service Areas, or you are temporarily absent
from your Home Region Service Area for a period of
more than six months in a row, you must notify us and
you cannot continue your Senior Advantage membership
under this EOC.
Send your notice to:
For Northern California Members:
Kaiser Foundation Health Plan, Inc.
California Service Center
P.O. Box 232400
San Diego, CA 92193
For Southern California Members:
Kaiser Foundation Health Plan, Inc.
California Service Center
P.O. Box 232407
San Diego, CA 92193
It is in your best interest to notify us as soon as possible
because until your Senior Advantage coverage is
officially terminated by the Centers for Medicare &
Medicaid Services, you will not be covered by us or
Original Medicare for any care you receive from Non–
Plan Providers, except as described in the sections listed
below for the following Services:
• Authorized referrals as described under “Getting a
Referral” in the “How to Obtain Services” section
• Covered Services received outside of your Home
Region Service Area as described under “Receiving
Care Outside of Your Home Region Service Area” in
the “How to Obtain Services” section
• Emergency ambulance Services as described under
“Ambulance Services” in the “Benefits and Your Cost
Share” section
• Emergency Services, Post-Stabilization Care, and
Out-of-Area Urgent Care as described in the
“Emergency Services and Urgent Care” section
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
Page 14
• Out-of-area dialysis care as described under “Dialysis
Care” in the “Benefits and Your Cost Share” section
• Prescription drugs from Non–Plan Pharmacies as
described under “Outpatient Prescription Drugs,
Supplies, and Supplements” in the “Benefits and
Your Cost Share” section
• Routine Services associated with Medicare-approved
clinical trials as described under “Services Associated
with Clinical Trials” in the “Benefits and Your Cost
Share” section
If you are not eligible to continue enrollment because
you move to the service area of another Region, please
contact the University of California to learn about the
University of California health care options. You may be
able to enroll in the service area of another Region
if there is an agreement between the University of
California and that Region, but the plan, including
coverage, premiums, and eligibility requirements, might
not be the same as under this EOC.
For more information about the service areas of the other
Regions, please call Member Services.
How to Enroll and When Coverage
Begins
The University of California is required to inform you
when you are eligible to enroll and what your effective
date of coverage is. If you are eligible to enroll as
described under “Who Is Eligible” in this “Premiums,
Eligibility, and Enrollment” section, enrollment is
permitted as described below and membership begins at
the beginning (12:00 a.m.) of the effective date of
coverage indicated below, except that:
• The University of California may have additional
requirements, which allow enrollment in other
situations
• The effective date of your Senior Advantage coverage
under this EOC must be confirmed by the Centers for
Medicare & Medicaid Services, as described under
“Effective date of Senior Advantage coverage” in this
“How to Enroll and When Coverage Begins” section
Effective date of Senior Advantage coverage
After we receive your completed Senior Advantage
Election Form, we will submit your enrollment request to
the Centers for Medicare & Medicaid Services for
confirmation and send you a notice indicating the
proposed effective date of your Senior Advantage
coverage under this EOC.
If the Centers for Medicare & Medicaid Services
confirms your Senior Advantage enrollment and
effective date, we will send you a notice that confirms
your enrollment and effective date. If the Centers for
Medicare & Medicaid Services tells us that you do not
have Medicare Part B coverage, we will notify you that
you will be disenrolled from Senior Advantage.
The effective date of Senior Advantage coverage for new
employees and their eligible family Dependents or newly
acquired Dependents, is determined by the University of
California, subject to confirmation by the Centers for
Medicare & Medicaid Services.
For more information about the University of
California’s enrollment rules, refer to the “Who Is
Eligible” section.
How to Obtain Services
As a Member, you are selecting our medical care
program to provide your health care. You must receive
all covered care from Plan Providers inside your Home
Region Service Area, except as described in the sections
listed below for the following Services:
• Authorized referrals as described under “Getting a
Referral” in this “How to Obtain Services” section
• Covered Services received outside of your Home
Region Service Area as described under “Receiving
Care Outside of Your Home Region Service Area” in
this “How to Obtain Services” section
• Emergency ambulance Services as described under
“Ambulance Services” in the “Benefits and Your Cost
Share” section
• Emergency Services, Post-Stabilization Care, and
Out-of-Area Urgent Care as described in the
“Emergency Services and Urgent Care” section
• Out-of-area dialysis care as described under “Dialysis
Care” in the “Benefits and Your Cost Share” section
• Prescription drugs from Non–Plan Pharmacies as
described under “Outpatient Prescription Drugs,
Supplies, and Supplements” in the “Benefits and
Your Cost Share” section
• Routine Services associated with Medicare-approved
clinical trials as described under “Services Associated
with Clinical Trials” in the “Benefits and Your Cost
Share” section
As a Member, you are enrolled in one of two Health Plan
Regions in California (either our Northern California
Region or Southern California Region), called your
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
Page 15
Home Region. The coverage information in this EOC
applies when you obtain care in your Home Region.
Our medical care program gives you access to all of the
covered Services you may need, such as routine care
with your own personal Plan Physician, hospital
Services, laboratory and pharmacy Services, Emergency
Services, Urgent Care, and other benefits described in
this EOC.
Routine Care
To request a non-urgent appointment, you can call your
local Plan Facility or request the appointment online. For
appointment phone numbers, refer to our Provider
Directory or call Member Services. To request an
appointment online, go to our website at kp.org.
Urgent Care
An Urgent Care need is one that requires prompt medical
attention but is not an Emergency Medical Condition.
If you think you may need Urgent Care, call the
appropriate appointment or advice phone number at a
Plan Facility. For phone numbers, refer to our Provider
Directory or call Member Services.
For information about Out-of-Area Urgent Care, refer to
“Urgent Care” in the “Emergency Services and Urgent
Care” section.
Our Advice Nurses
We know that sometimes it’s difficult to know what type
of care you need. That’s why we have telephone advice
nurses available to assist you. Our advice nurses are
registered nurses specially trained to help assess medical
symptoms and provide advice over the phone, when
medically appropriate. Whether you are calling for
advice or to make an appointment, you can speak to an
advice nurse. They can often answer questions about a
minor concern, tell you what to do if a Plan Medical
Office is closed, or advise you about what to do next,
including making a same-day Urgent Care appointment
for you if it’s medically appropriate. To reach an advice
nurse, refer to our Provider Directory or call Member
Services.
Your Personal Plan Physician
Personal Plan Physicians provide primary care and play
an important role in coordinating care, including hospital
stays and referrals to specialists.
We encourage you to choose a personal Plan Physician.
You may choose any available personal Plan Physician.
Parents may choose a pediatrician as the personal Plan
Physician for their child. Most personal Plan Physicians
are Primary Care Physicians (generalists in internal
medicine, pediatrics, or family practice, or specialists in
obstetrics/gynecology whom the Medical Group
designates as Primary Care Physicians). Some specialists
who are not designated as Primary Care Physicians but
who also provide primary care may be available as
personal Plan Physicians. For example, some specialists
in internal medicine and obstetrics/gynecology who are
not designated as Primary Care Physicians may be
available as personal Plan Physicians. However, if you
choose a specialist who is not designated as a Primary
Care Physician as your personal Plan Physician, the Cost
Share for a Physician Specialist Visit will apply to all
visits with the specialist except for Preventive Services
listed in the “Benefits and Your Cost Share” section.
To learn how to select or change to a different personal
Plan Physician, visit our website at kp.org, or call
Member Services. Refer to our Provider Directory for a
list of physicians that are available as Primary Care
Physicians. The directory is updated periodically. The
availability of Primary Care Physicians may change. If
you have questions, please call Member Services. You
can change your personal Plan Physician at any time for
any reason.
Getting a Referral
Referrals to Plan Providers
A Plan Physician must refer you before you can receive
care from specialists, such as specialists in surgery,
orthopedics, cardiology, oncology, dermatology, and
physical, occupational, and speech therapies. However,
you do not need a referral or prior authorization to
receive most care from any of the following Plan
Providers:
• Your personal Plan Physician
• Generalists in internal medicine, pediatrics, and
family practice
• Specialists in optometry, mental health Services,
substance use disorder treatment, and
obstetrics/gynecology
A Plan Physician must refer you before you can get care
from a specialist in urology except that you do not need a
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Page 16
referral to receive Services related to sexual or
reproductive health, such as a vasectomy.
Although a referral or prior authorization is not required
to receive most care from these providers, a referral may
be required in the following situations:
• The provider may have to get prior authorization for
certain Services in accord with “Medical Group
authorization procedure for certain referrals” in this
“Getting a Referral” section
• The provider may have to refer you to a specialist
who has a clinical background related to your illness
or condition
Standing referrals
If a Plan Physician refers you to a specialist, the referral
will be for a specific treatment plan. Your treatment plan
may include a standing referral if ongoing care from the
specialist is prescribed. For example, if you have a life-
threatening, degenerative, or disabling condition, you can
get a standing referral to a specialist if ongoing care from
the specialist is required.
Medical Group authorization procedure for
certain referrals
The following are examples of Services that require prior
authorization by the Medical Group for the Services to
be covered (“prior authorization” means that the Medical
Group must approve the Services in advance):
• Durable medical equipment
• Ostomy and urological supplies
• Services not available from Plan Providers
• Transplants
Utilization Management (“UM”) is a process that
determines whether a Service recommended by your
treating provider is Medically Necessary for you. Prior
authorization is a UM process that determines whether
the requested services are Medically Necessary before
care is provided. If it is Medically Necessary, then you
will receive authorization to obtain that care in a
clinically appropriate place consistent with the terms of
your health coverage. Decisions regarding requests for
authorization will be made only by licensed physicians
or other appropriately licensed medical professionals.
For the complete list of Services that require prior
authorization, and the criteria that are used to make
authorization decisions, please visit our website at
kp.org/UM or call Member Services to request a printed
copy. Refer to “Post-Stabilization Care” under
“Emergency Services” in the “Emergency Services and
Urgent Care” section for authorization requirements that
apply to Post-Stabilization Care from Non–Plan
Providers.
Additional information about prior authorization for
durable medical equipment, ostomy, urological, and
specialized wound care supplies. The prior
authorization process for durable medical equipment,
ostomy, urological, and specialized wound care supplies
includes the use of formulary guidelines. These
guidelines were developed by a multidisciplinary clinical
and operational work group with review and input from
Plan Physicians and medical professionals with clinical
expertise. The formulary guidelines are periodically
updated to keep pace with changes in medical
technology, Medicare guidelines, and clinical practice.
If your Plan Physician prescribes one of these items, they
will submit a written referral in accord with the UM
process described in this “Medical Group authorization
procedure for certain referrals” section. If the formulary
guidelines do not specify that the prescribed item is
appropriate for your medical condition, the referral will
be submitted to the Medical Group’s designee Plan
Physician, who will make an authorization decision as
described under “Medical Group’s decision time frames”
in this “Medical Group authorization procedure for
certain referrals” section.
Medical Group’s decision time frames. The applicable
Medical Group designee will make the authorization
decision within the time frame appropriate for your
condition, but no later than five business days after
receiving all of the information (including additional
examination and test results) reasonably necessary to
make the decision, except that decisions about urgent
Services will be made no later than 72 hours after receipt
of the information reasonably necessary to make the
decision. If the Medical Group needs more time to make
the decision because it doesn’t have information
reasonably necessary to make the decision, or because it
has requested consultation by a particular specialist, you
and your treating physician will be informed about the
additional information, testing, or specialist that is
needed, and the date that the Medical Group expects to
make a decision.
Your treating physician will be informed of the decision
within 24 hours after the decision is made. If the Services
are authorized, your physician will be informed of the
scope of the authorized Services. If the Medical Group
does not authorize all of the Services, Health Plan will
send you a written decision and explanation within two
business days after the decision is made. Any written
criteria that the Medical Group uses to make the decision
to authorize, modify, delay, or deny the request for
authorization will be made available to you upon request.
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
Page 17
If the Medical Group does not authorize all of the
Services requested and you want to appeal the decision,
you can file a grievance as described in the “Coverage
Decisions, Appeals, and Complaints” section.
For these referral Services, you pay the Cost Share
required for Services provided by a Plan Provider as
described in this EOC.
Travel and Lodging for Certain Services
The following are examples of when we will arrange or
provide reimbursement for certain travel and lodging
expenses in accord with our Travel and Lodging
Program Description:
• If Medical Group refers you to a provider that is more
than 50 miles from where you live for certain
specialty Services such as bariatric surgery, complex
thoracic surgery, transplant nephrectomy, or inpatient
chemotherapy for leukemia and lymphoma
• If Medical Group refers you to a provider that is
outside your Home Region Service Area for certain
specialty Services such as a transplant or transgender
surgery
• If you are outside of California and you need an
abortion on an emergency or urgent basis, and the
abortion can’t be obtained in a timely manner due to a
near total or total ban on health care providers’ ability
to provide such Services
For the complete list of specialty Services for which we
will arrange or provide reimbursement for travel and
lodging expenses, the amount of reimbursement,
limitations and exclusions, and how to request
reimbursement, refer to the Travel and Lodging Program
Description. The Travel and Lodging Program
Description is available online at kp.org/specialty-
care/travel-reimbursements or by calling Member
Services.
Second Opinions
If you want a second opinion, you can ask Member
Services to help you arrange one with a Plan Physician
who is an appropriately qualified medical professional
for your condition. If there isn’t a Plan Physician who is
an appropriately qualified medical professional for your
condition, Member Services will help you arrange a
consultation with a Non–Plan Physician for a second
opinion. For purposes of this “Second Opinions”
provision, an “appropriately qualified medical
professional” is a physician who is acting within their
scope of practice and who possesses a clinical
background, including training and expertise, related to
the illness or condition associated with the request for a
second medical opinion.
Here are some examples of when a second opinion may
be provided or authorized:
• Your Plan Physician has recommended a procedure
and you are unsure about whether the procedure is
reasonable or necessary
• You question a diagnosis or plan of care for a
condition that threatens substantial impairment or loss
of life, limb, or bodily functions
• The clinical indications are not clear or are complex
and confusing
• A diagnosis is in doubt due to conflicting test results
• The Plan Physician is unable to diagnose the
condition
• The treatment plan in progress is not improving your
medical condition within an appropriate period of
time, given the diagnosis and plan of care
• You have concerns about the diagnosis or plan of care
An authorization or denial of your request for a second
opinion will be provided in an expeditious manner, as
appropriate for your condition. If your request for a
second opinion is denied, you will be notified in writing
of the reasons for the denial and of your right to file a
grievance as described in the “Coverage Decisions,
Appeals, and Complaints” section.
For these referral Services, you pay the Cost Share
required for Services provided by a Plan Provider as
described in this EOC.
Contracts with Plan Providers
How Plan Providers are paid
Health Plan and Plan Providers are independent
contractors. Plan Providers are paid in a number of ways,
such as salary, capitation, per diem rates, case rates, fee
for service, and incentive payments. To learn more about
how Plan Physicians are paid to provide or arrange
medical and hospital Services for Members, please visit
our website at kp.org or call Member Services.
Financial liability
Our contracts with Plan Providers provide that you are
not liable for any amounts we owe. However, you may
have to pay the full price of noncovered Services you
obtain from Plan Providers or Non–Plan Providers.
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Page 18
When you are referred to a Plan Provider for covered
Services, you pay the Cost Share required for Services
from that provider as described in this EOC.
Termination of a Plan Provider’s contract and
completion of Services
If our contract with any Plan Provider terminates while
you are under the care of that provider, we will retain
financial responsibility for the covered Services you
receive from that provider until we make arrangements
for the Services to be provided by another Plan Provider
and notify you of the arrangements.
Completion of Services. If you are undergoing
treatment for specific conditions from a Plan Physician
(or certain other providers) when the contract with him
or her ends (for reasons other than medical disciplinary
cause, criminal activity, or the provider’s voluntary
termination), you may be eligible to continue receiving
covered care from the terminated provider for your
condition. The conditions that are subject to this
continuation of care provision are:
• Certain conditions that are either acute, or serious and
chronic. We may cover these Services for up to 90
days, or longer, if necessary for a safe transfer of care
to a Plan Physician or other contracting provider as
determined by the Medical Group
• A high-risk pregnancy or a pregnancy in its second or
third trimester. We may cover these Services through
postpartum care related to the delivery, or longer
if Medically Necessary for a safe transfer of care to a
Plan Physician as determined by the Medical Group
The Services must be otherwise covered under this EOC.
Also, the terminated provider must agree in writing to
our contractual terms and conditions and comply with
them for Services to be covered by us.
For the Services of a terminated provider, you pay the
Cost Share required for Services provided by a Plan
Provider as described in this EOC.
More information. For more information about this
provision, or to request the Services, please call Member
Services.
Receiving Care Outside of Your Home
Region Service Area
For information about your coverage when you are away
from home, visit our website at kp.org/travel. You can
also call the Away from Home Travel Line at
1-951-268-3900, 24 hours a day, seven days a week
(except closed holidays).
Receiving care in another Kaiser Permanente
service area
If you are visiting in another Kaiser Permanente service
area, you may receive certain covered Services from
designated providers in that other Kaiser Permanente
service area, subject to exclusions, limitations, prior
authorization or approval requirements, and reductions.
For more information about receiving covered Services
in another Kaiser Permanente service area, including
provider and facility locations, please visit kp.org/travel
or call our Away from Home Travel Line at 1-951-268-
3900, 24 hours a day, seven days a week (except closed
holidays).
Receiving care outside of any Kaiser
Permanente service area
If you are traveling outside of any Kaiser Permanente
service area, we cover Services as described in the
“Emergency Services and Urgent Care” section about
Emergency Services, Post-Stabilization Care, and Out-
of-Area Urgent Care and the “Benefits and Your Cost
Share” section about out-of-area dialysis care.
Your ID Card
Each Member’s Kaiser Permanente ID card has a
medical record number on it, which you will need when
you call for advice, make an appointment, or go to a
provider for covered care. When you get care, please
bring your Kaiser Permanente ID card and a photo ID.
Your medical record number is used to identify your
medical records and membership information. Your
medical record number should never change. Please call
Member Services if we ever inadvertently issue you
more than one medical record number or if you need to
replace your Kaiser Permanente ID card.
Your ID card is for identification only. To receive
covered Services, you must be a current Member.
Anyone who is not a Member will be billed as a non-
Member for any Services they receive. If you let
someone else use your ID card, we may keep your ID
card and terminate your membership as described under
“Termination for Cause” in the “Termination of
Membership” section.
Your Medicare card
Do NOT use your red, white, and blue Medicare card for
covered medical Services while you are a Member of this
plan. If you use your Medicare card instead of your
Senior Advantage membership card, you may have to
pay the full cost of medical services yourself. Keep your
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Page 19
Medicare card in a safe place. You may be asked to show
it if you need hospice services or participate in routine
research studies.
Getting Assistance
We want you to be satisfied with the health care you
receive from Kaiser Permanente. If you have any
questions or concerns, please discuss them with your
personal Plan Physician or with other Plan Providers
who are treating you. They are committed to your
satisfaction and want to help you with your questions.
Member Services
Member Services representatives can answer any
questions you have about your benefits, available
Services, and the facilities where you can receive care.
For example, they can explain the following:
• Your Health Plan benefits
• How to make your first medical appointment
• What to do if you move
• How to replace your Kaiser Permanente ID card
Many Plan Facilities have an office staffed with
representatives who can provide assistance if you need
help obtaining Services. At different locations, these
offices may be called Member Services, Patient
Assistance, or Customer Service. In addition, Member
Services representatives are available to assist you seven
days a week from 8 a.m. to 8 p.m. toll free at 1-800-443-
0815 or 711 (TTY for the deaf, hard of hearing, or
speech impaired). For your convenience, you can also
contact us through our website at kp.org.
Cost Share estimates
For information about estimates, see “Getting an
estimate of your Cost Share” under “Your Cost Share” in
the “Benefits and Your Cost Share” section.
Plan Facilities
Plan Medical Offices and Plan Hospitals are listed in the
Provider Directory for your Home Region. The directory
describes the types of covered Services that are available
from each Plan Facility, because some facilities provide
only specific types of covered Services. This directory is
available on our website at kp.org/facilities. To obtain a
printed copy, call Member Services. The directory is
updated periodically. The availability of Plan Facilities
may change. If you have questions, please call Member
Services.
At most of our Plan Facilities, you can usually receive all
of the covered Services you need, including specialty
care, pharmacy, and lab work. You are not restricted to a
particular Plan Facility, and we encourage you to use the
facility that will be most convenient for you:
• All Plan Hospitals provide inpatient Services and are
open 24 hours a day, seven days a week
• Emergency Services are available from Plan Hospital
Emergency Departments (for Emergency Department
locations, refer to our Provider Directory or call
Member Services)
• Same-day Urgent Care appointments are available at
many locations (for Urgent Care locations, refer to
our Provider Directory or call Member Services)
• Many Plan Medical Offices have evening and
weekend appointments
• Many Plan Facilities have a Member Services office
(for locations, refer to our Provider Directory or call
Member Services)
• Plan Pharmacies are located at most Plan Medical
Offices (refer to Kaiser Permanente Pharmacy
Directory for pharmacy locations)
Provider Directory
The Provider Directory lists our Plan Providers. It is
subject to change and periodically updated. If you don’t
have our Provider Directory, you can get a copy by
calling Member Services or by visiting our website at
kp.org/directory.
Pharmacy Directory
The Kaiser Permanente Pharmacy Directory lists the
locations of Plan Pharmacies, which are also called
“network pharmacies.” The pharmacy directory provides
additional information about obtaining prescription
drugs. It is subject to change and periodically updated.
If you don’t have the Kaiser Permanente Pharmacy
Directory, you can get a copy by calling Member
Services or by visiting our website at kp.org/directory.
Emergency Services and Urgent
Care
Emergency Services
If you have an Emergency Medical Condition, call 911
(where available) or go to the nearest Emergency
Department. You do not need prior authorization for
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Page 20
Emergency Services. When you have an Emergency
Medical Condition, we cover Emergency Services you
receive from Plan Providers or Non–Plan Providers
anywhere in the world.
Emergency Services are available from Plan Hospital
Emergency Departments 24 hours a day, seven days a
week.
Post-Stabilization Care
Post-Stabilization Care is Medically Necessary Services
related to your Emergency Medical Condition that you
receive in a hospital (including the Emergency
Department) after your treating physician determines that
your condition is Stabilized.
To request prior authorization, the Non–Plan Provider
must call 1-800-225-8883 or the notification phone
number on your Kaiser Permanente ID card before you
receive the care. We will discuss your condition with the
Non–Plan Provider. If we determine that you require
Post-Stabilization Care and that this care is part of your
covered benefits, we will authorize your care from the
Non–Plan Provider or arrange to have a Plan Provider (or
other designated provider) provide the care with the
treating physician’s concurrence. If we decide to have a
Plan Hospital, Plan Skilled Nursing Facility, or
designated Non–Plan Provider provide your care, we
may authorize special transportation services that are
medically required to get you to the provider. This may
include transportation that is otherwise not covered.
Be sure to ask the Non–Plan Provider to tell you what
care (including any transportation) we have authorized
because we will not cover unauthorized Post-
Stabilization Care or related transportation provided by
Non–Plan Providers. If you receive care from a Non–
Plan Provider that we have not authorized, you may have
to pay the full cost of that care if you are notified by the
Non–Plan Provider or us about your potential liability.
Your Cost Share
Your Cost Share for covered Emergency Services and
Post-Stabilization Care is described in the “Benefits and
Your Cost Share” section. Your Cost Share is the same
whether you receive the Services from a Plan Provider or
a Non–Plan Provider. For example:
• If you receive Emergency Services in the Emergency
Department of a Non–Plan Hospital, you pay the Cost
Share for an Emergency Department visit as
described under “Outpatient Care”
• If we gave prior authorization for inpatient Post-
Stabilization Care in a Non–Plan Hospital, you pay
the Cost Share for hospital inpatient care as described
under “Hospital Inpatient Care”
Urgent Care
Inside your Home Region Service Area
An Urgent Care need is one that requires prompt medical
attention but is not an Emergency Medical Condition.
If you think you may need Urgent Care, call the
appropriate appointment or advice phone number at a
Plan Facility. For appointment and advice phone
numbers, refer to our Provider Directory or call Member
Services.
In the event of unusual circumstances that delay or
render impractical the provision of Services under this
EOC (such as a major disaster, epidemic, war, riot, and
civil insurrection), we cover Urgent Care inside your
Home Region Service Area from a Non–Plan Provider.
Out-of-Area Urgent Care
If you need Urgent Care due to an unforeseen illness or
unforeseen injury, we cover Medically Necessary
Services to prevent serious deterioration of your health
from a Non–Plan Provider if all of the following are true:
• You receive the Services from Non–Plan Providers
while you are temporarily outside your Home Region
Service Area
• A reasonable person would have believed that your
health would seriously deteriorate if you delayed
treatment until you returned to your Home Region
Service Area
You do not need prior authorization for Out-of-Area
Urgent Care. We cover Out-of-Area Urgent Care you
receive from Non–Plan Providers if the Services would
have been covered under this EOC if you had received
them from Plan Providers.
We do not cover follow-up care from Non–Plan
Providers after you no longer need Urgent Care. To
obtain follow-up care from a Plan Provider, call the
appointment or advice phone number at a Plan Facility.
For phone numbers, refer to our Provider Directory or
call Member Services.
Your Cost Share
Your Cost Share for covered Urgent Care is the Cost
Share required for Services provided by Plan Providers
as described in this EOC. For example:
• If you receive an Urgent Care evaluation as part of
covered Out-of-Area Urgent Care from a Non–Plan
Provider, you pay the Cost Share for Urgent Care
consultations, evaluations, and treatment as described
under “Outpatient Care”
• If the Out-of-Area Urgent Care you receive includes
an X-ray, you pay the Cost Share for an X-ray as
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Page 21
described under “Outpatient Imaging, Laboratory, and
Other Diagnostic and Treatment Services” in addition
to the Cost Share for the Urgent Care evaluation
Note: If you receive Urgent Care in an Emergency
Department, you pay the Cost Share for an Emergency
Department visit as described under “Outpatient Care.”
Payment and Reimbursement
If you receive Emergency Services, Post-Stabilization
Care, or Urgent Care from a Non–Plan Provider as
described in this “Emergency Services and Urgent Care”
section, or emergency ambulance Services described
under “Ambulance Services” in the “Benefits and Your
Cost Share” section, ask the Non–Plan Provider to
submit a claim to us within 60 days or as soon as
possible, but no later than 15 months after receiving the
care (or up to 27 months according to Medicare rules, in
some cases). If the provider refuses to bill us, send us the
unpaid bill with a claim form. Also, if you receive
Services from a Plan Provider that are prescribed by a
Non–Plan Provider as part of covered Emergency
Services, Post-Stabilization Care, and Urgent Care (for
example, drugs), you may be required to pay for the
Services and file a claim. To request payment or
reimbursement, you must file a claim as described in the
“Requests for Payment” section.
We will reduce any payment we make to you or the
Non–Plan Provider by the applicable Cost Share. Also,
in accord with applicable law, we will reduce our
payment by any amounts paid or payable (or that in the
absence of this plan would have been payable) for the
Services under any insurance policy, or any other
contract or coverage, or any government program except
Medicaid.
Benefits and Your Cost Share
This section describes the Services that are covered
under this EOC.
Services are covered under this EOC as specifically
described in this EOC. Services that are not specifically
described in this EOC are not covered, except as required
by federal law. Services are subject to exclusions and
limitations described in the “Exclusions, Limitations,
Coordination of Benefits, and Reductions” section.
Except as otherwise described in this EOC, all of the
following conditions must be satisfied:
• You are a Member on the date that you receive the
Services
• The Services are Medically Necessary
• The Services are one of the following:
♦ Preventive Services
♦ health care items and services for diagnosis,
assessment, or treatment
♦ health education covered under “Health
Education” in this “Benefits and Your Cost Share”
section
♦ other health care items and services
♦ other services to treat Serious Emotional
Disturbance of a Child Under Age 18 or Severe
Mental Illness
• The Services are provided, prescribed, authorized, or
directed by a Plan Physician except for:
♦ covered Services received outside of your Home
Region Service Area, as described under
“Receiving Care Outside of Your Home Region
Service Area” in the “How to Obtain Services”
section
♦ drugs prescribed by dentists, as described under
“Outpatient Prescription Drugs, Supplies, and
Supplements” in this “Benefits and Your Cost
Share” section
♦ drugs prescribed by Non–Plan Psychiatrists, as
described under “Outpatient Prescription Drugs,
Supplies, and Supplements” in this “Benefits and
Your Cost Share” section
♦ emergency ambulance Services, as described
under “Ambulance Services” in this “Benefits and
Your Cost Share” section
♦ Emergency Services, Post-Stabilization Care, and
Out-of-Area Urgent Care, as described in the
“Emergency Services and Urgent Care” section
♦ eyeglasses and contact lenses prescribed by Non–
Plan Providers, as described under “Vision
Services” in this “Benefits and Your Cost Share”
section
♦ out-of-area dialysis care, as described under
“Dialysis Care” in this “Benefits and Your Cost
Share” section
♦ routine Services associated with Medicare-
approved clinical trials, as described under
“Services Associated with Clinical Trials” in this
“Benefits and Your Cost Share” section
♦ tests prescribed by Non–Plan Psychiatrists, as
described under “Outpatient Imaging, Laboratory,
and Other Diagnostic and Treatment Services” in
this “Benefits and Your Cost Share” section
• You receive the Services from Plan Providers inside
your Home Region Service Area, except for:
♦ authorized referrals, as described under “Getting a
Referral” in the “How to Obtain Services” section
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Page 22
♦ covered Services received outside of your Home
Region Service Area, as described under
“Receiving Care Outside of Your Home Region
Service Area” in the “How to Obtain Services”
section
♦ emergency ambulance Services, as described
under “Ambulance Services” in this “Benefits and
Your Cost Share” section
♦ Emergency Services, Post-Stabilization Care, and
Out-of-Area Urgent Care, as described in the
“Emergency Services and Urgent Care” section
♦ out-of-area dialysis care, as described under
“Dialysis Care” in this “Benefits and Your Cost
Share” section
♦ prescription drugs from Non–Plan Pharmacies, as
described under “Outpatient Prescription Drugs,
Supplies, and Supplements” in this “Benefits and
Your Cost Share” section
♦ routine Services associated with Medicare-
approved clinical trials, as described under
“Services Associated with Clinical Trials” in this
“Benefits and Your Cost Share” section
• The Medical Group has given prior authorization for
the Services, if required, as described under “Medical
Group authorization procedure for certain referrals”
in the “How to Obtain Services” section
Please also refer to:
• The “Emergency Services and Urgent Care” section
for information about how to obtain covered
Emergency Services, Post-Stabilization Care, and
Out-of-Area Urgent Care
• Our Provider Directory for the types of covered
Services that are available from each Plan Facility,
because some facilities provide only specific types of
covered Services
Your Cost Share
Your Cost Share is the amount you are required to pay
for covered Services. The Cost Share for covered
Services is listed in this EOC. For example, your Cost
Share may be a Copayment or Coinsurance. If your
coverage includes a Plan Deductible and you receive
Services that are subject to the Plan Deductible, your
Cost Share for those Services will be Charges until you
reach the Plan Deductible.
General rules, examples, and exceptions
Your Cost Share for covered Services will be the Cost
Share in effect on the date you receive the Services,
except as follows:
• If you are receiving covered hospital inpatient
Services on the effective date of this EOC, you pay
the Cost Share in effect on your admission date until
you are discharged if the Services were covered under
your prior Health Plan evidence of coverage and there
has been no break in coverage. However, if the
Services were not covered under your prior Health
Plan evidence of coverage, or if there has been a
break in coverage, you pay the Cost Share in effect on
the date you receive the Services
• For items ordered in advance, you pay the Cost Share
in effect on the order date (although we will not cover
the item unless you still have coverage for it on the
date you receive it) and you may be required to pay
the Cost Share when the item is ordered. For
outpatient prescription drugs, the order date is the
date that the pharmacy processes the order after
receiving all of the information they need to fill the
prescription
Payment toward your Cost Share (and when you may
be billed)
In most cases, your provider will ask you to make a
payment toward your Cost Share at the time you receive
Services. If you receive more than one type of Services
(such as primary care treatment and laboratory tests), you
may be required to pay separate Cost Share for each of
those Services. Keep in mind that your payment toward
your Cost Share may cover only a portion of your total
Cost Share for the Services you receive, and you will be
billed for any additional amounts that are due. The
following are examples of when you may be asked to
pay (or you may be billed for) Cost Share amounts in
addition to the amount you pay at check-in:
• You receive non-preventive Services during a
preventive visit. For example, you go in for a routine
physical exam, and at check-in you pay your Cost
Share for the preventive exam (your Cost Share may
be “no charge”). However, during your preventive
exam your provider finds a problem with your health
and orders non-preventive Services to diagnose your
problem (such as laboratory tests). You may be asked
to pay (or you will be billed for) your Cost Share for
these additional non-preventive diagnostic Services
• You receive diagnostic Services during a treatment
visit. For example, you go in for treatment of an
existing health condition, and at check-in you pay
your Cost Share for a treatment visit. However,
during the visit your provider finds a new problem
with your health and performs or orders diagnostic
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Page 23
Services (such as laboratory tests). You may be asked
to pay (or you will be billed for) your Cost Share for
these additional diagnostic Services
• You receive treatment Services during a diagnostic
visit. For example, you go in for a diagnostic exam,
and at check-in you pay your Cost Share for a
diagnostic exam. However, during the diagnostic
exam your provider confirms a problem with your
health and performs treatment Services (such as an
outpatient procedure). You may be asked to pay (or
you will be billed for) your Cost Share for these
additional treatment Services
• You receive Services from a second provider during
your visit. For example, you go in for a diagnostic
exam, and at check-in you pay your Cost Share for a
diagnostic exam. However, during the diagnostic
exam your provider requests a consultation with a
specialist. You may be asked to pay (or you will be
billed for) your Cost Share for the consultation with
the specialist
In some cases, your provider will not ask you to make a
payment at the time you receive Services, and you will
be billed for your Cost Share (for example, some
Laboratory Departments are not able to collect Cost
Shares).
When we send you a bill, it will list Charges for the
Services you received, payments and credits applied to
your account, and any amounts you still owe. Your
current bill may not always reflect your most recent
Charges and payments. Any Charges and payments that
are not on the current bill will appear on a future bill.
Sometimes, you may see a payment but not the related
Charges for Services. That could be because your
payment was recorded before the Charges for the
Services were processed. If so, the Charges will appear
on a future bill. Also, you may receive more than one bill
for a single outpatient visit or inpatient stay. For
example, you may receive a bill for physician services
and a separate bill for hospital services. If you don’t see
all the Charges for Services on one bill, they will appear
on a future bill. If we determine that you overpaid and
are due a refund, then we will send a refund to you
within four weeks after we make that determination.
If you have questions about a bill, please call the phone
number on the bill.
In some cases, a Non–Plan Provider may be involved in
the provision of covered Services at a Plan Facility or a
contracted facility where we have authorized you to
receive care. You are not responsible for any amounts
beyond your Cost Share for the covered Services you
receive at Plan Facilities or at contracted facilities where
we have authorized you to receive care. However, if the
provider does not agree to bill us, you may have to pay
for the Services and file a claim for reimbursement. For
information on how to file a claim, please see the
“Requests for Payment” section.
Primary Care Visits, Non-Physician Specialist Visits,
and Physician Specialist Visits. The Cost Share for a
Primary Care Visit applies to evaluations and treatment
provided by generalists in internal medicine, pediatrics,
or family practice, and by specialists in
obstetrics/gynecology whom the Medical Group
designates as Primary Care Physicians. Some physician
specialists provide primary care in addition to specialty
care but are not designated as Primary Care Physicians.
If you receive Services from one of these specialists, the
Cost Share for a Physician Specialist Visit will apply to
all consultations, evaluations, and treatment provided by
the specialist except for routine preventive counseling
and exams listed under “Preventive Services” in this
“Benefits and Your Cost Share” section. For example,
if your personal Plan Physician is a specialist in internal
medicine or obstetrics/gynecology who is not a Primary
Care Physician, you will pay the Cost Share for a
Physician Specialist Visit for all consultations,
evaluations, and treatment by the specialist except
routine preventive counseling and exams listed under
“Preventive Services” in this “Benefits and Your Cost
Share” section. The Non-Physician Specialist Visit Cost
Share applies to consultations, evaluations, and treatment
provided by non-physician specialists (such as nurse
practitioners, physician assistants, optometrists,
podiatrists, and audiologists).
Noncovered Services. If you receive Services that are
not covered under this EOC, you may have to pay the
full price of those Services. Payments you make for
noncovered Services do not apply to any deductible or
out-of-pocket maximum.
Getting an estimate of your Cost Share
If you have questions about the Cost Share for specific
Services that you expect to receive or that your provider
orders during a visit or procedure, please visit our
website at kp.org/memberestimates to use our cost
estimate tool or call Member Services.
• If you have a Plan Deductible and would like an
estimate for Services that are subject to the Plan
Deductible, please call 1-800-390-3507 (TTY users
call 711) Monday through Friday, 6 a.m. to 5 p.m.
• For all other Cost Share estimates, please call 1-800-
443-0815, 8 a.m. to 8 p.m., seven days a week (TTY
users should call 711)
Cost Share estimates are based on your benefits and the
Services you expect to receive. They are a prediction of
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Page 24
cost and not a guarantee of the final cost of Services.
Your final cost may be higher or lower than the estimate
since not everything about your care can be known in
advance.
Copayments and Coinsurance
The Copayment or Coinsurance you must pay for each
covered Service, after you meet any applicable
deductible, is described in this EOC.
Note: If Charges for Services are less than the
Copayment described in this EOC, you will pay the
lesser amount.
Plan Out-of-Pocket Maximum
There is a limit to the total amount of Cost Share you
must pay under this EOC in the calendar year for
covered Services that you receive in the same calendar
year. The Services that apply to the Plan Out-of-Pocket
Maximum are described under the “Payments that count
toward the Plan Out-of-Pocket Maximum” section
below. The limit is:
•
$1,500 per calendar year for any one Member
For Services subject to the Plan Out-of-Pocket
Maximum, you will not pay any more Cost Share during
the remainder of the calendar year, but every other
Member in your Family must continue to pay Cost Share
during the remainder of the calendar year until either he
or she reaches the $1,500 maximum for any one
Member.
Payments that count toward the Plan Out-of-Pocket
Maximum. Any amounts you pay for the following
Services apply toward the out-of-pocket maximum:
• Covered in-network Medicare Part A and Part B
Services
• Medicare Part B drugs (all other drugs do not apply)
• Residential treatment program Services covered in the
“Substance Use Disorder Treatment” and “Mental
Health Services” sections
Copayments and Coinsurance you pay for Services that
are not described above, do not apply to the out-of-
pocket maximum. For these Services, you must pay
Copayments or Coinsurance even if you have already
reached the out-of-pocket maximum. In addition:
• If your plan includes supplemental chiropractic or
acupuncture Services, or fitness benefit, described in
an amendment to this EOC, those Services do not
apply toward the maximum
• If your plan includes an Allowance for specific
Services (such as eyeglasses, contact lenses, or
hearing aids), any amounts you pay that exceed the
Allowance do not apply toward the maximum
Outpatient Care
We cover the following outpatient care subject to the
Cost Share indicated:
Office visits
• Primary Care Visits and Non-Physician Specialist
Visits that are not described elsewhere in this EOC: a
$20 Copayment per visit
• Physician Specialist Visits that are not described
elsewhere in this EOC: a $20 Copayment per visit
• Outpatient visits that are available as group
appointments that are not described elsewhere in this
EOC: a $10 Copayment per visit
• House calls by a Plan Physician (or a Plan Provider
who is a registered nurse) inside your Home Region
Service Area when care can best be provided in your
home as determined by a Plan Physician:
♦ Primary Care Visits and Non-Physician Specialist
Visits: a $20 Copayment per visit
♦ Physician Specialist Visits: a $20 Copayment per
visit
• Routine physical exams that are medically
appropriate preventive care in accord with generally
accepted professional standards of practice:
no charge
• Family planning counseling, or internally implanted
time-release contraceptives or intrauterine devices
(IUDs) and office visits related to their administration
and management: a $20 Copayment per visit
• After confirmation of pregnancy, the normal series of
regularly scheduled preventive prenatal care exams
and the first postpartum follow-up consultation and
exam: no charge
• Voluntary termination of pregnancy and related
Services: no charge
• Physical, occupational, and speech therapy in accord
with Medicare guidelines: a $20 Copayment per
visit
• Group and individual physical therapy prescribed by a
Plan Provider to prevent falls: no charge
• Physical, occupational, and speech therapy provided
in an organized, multidisciplinary rehabilitation day-
treatment program in accord with Medicare
guidelines: a $20 Copayment per day
• For Northern California Members, manual
manipulation of the spine to correct subluxation, in
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Page 25
accord with Medicare guidelines, is covered when
provided by a Plan Provider or a chiropractor
if authorized by a Plan Provider: a $20 Copayment
per visit. (For the list of participating ASH Plans
providers, please refer to your Provider Directory.)
For Southern California Members, manual
manipulation of the spine to correct subluxation, in
accord with Medicare guidelines, is covered by a
participating chiropractor of the American Specialty
Health Plans of California, Inc. (ASH Plans): a
$20 Copayment per visit. (A referral by a Plan
Physician is not required. For the list of participating
ASH Plans providers, refer to your Provider
Directory)
Acupuncture Services
• Acupuncture for chronic low back pain up to 12 visits
in 90 days, in accord with Medicare guidelines: a
$20 Copayment per visit. Chronic low back pain is
defined as follows:
♦ lasting 12 weeks or longer
♦ non-specific, in that it has no identifiable systemic
cause (i.e. not associated with metastatic,
inflammatory, infectious, disease, etc)
♦ not associated with surgery or pregnancy
• An additional eight sessions will be covered for those
patients demonstrating an improvement. No more
than 20 acupuncture treatments may be administered
annually. Treatment must be discontinued if the
patient is not improving or is regressing
• Acupuncture not covered by Medicare (typically
provided only for the treatment of nausea or as part of
a comprehensive pain management program for the
treatment of chronic pain): a $20 Copayment per
visit
Emergency Services and Urgent Care
• Urgent Care consultations, evaluations, and treatment:
a $20 Copayment per visit
• Emergency Department visits: a $65 Copayment per
visit
If you are admitted from the Emergency Department.
If you are admitted to the hospital as an inpatient for
covered Services (either within 24 hours for the same
condition or after an observation stay), then the Services
you received in the Emergency Department and
observation stay, if applicable, will be considered part of
your inpatient hospital stay. For the Cost Share for
inpatient care, refer to “Hospital Inpatient Services” in
this “Benefits and Your Cost Share” section. However,
the Emergency Department Cost Share does apply if you
are admitted for observation but are not admitted as an
inpatient.
Outpatient surgeries and procedures
• Outpatient surgery and outpatient procedures when
provided in an outpatient or ambulatory surgery
center or in a hospital operating room, or if it is
provided in any setting and a licensed staff member
monitors your vital signs as you regain sensation after
receiving drugs to reduce sensation or to minimize
discomfort: a $100 Copayment per procedure
• Any other outpatient surgery that does not require a
licensed staff member to monitor your vital signs as
described above: a $20 Copayment per procedure
• Any other outpatient procedures that do not require a
licensed staff member to monitor your vital signs as
described above: the Cost Share that would
otherwise apply for the procedure in this “Benefits
and Your Cost Share” section (for example, radiology
procedures that do not require a licensed staff
member to monitor your vital signs as described
above are covered under “Outpatient Imaging,
Laboratory, and Other Diagnostic and Treatment
Services”)
• Pre- and post-operative visits:
♦ Primary Care Visits and Non-Physician Specialist
Visits: a $20 Copayment per visit
♦ Physician Specialist Visits: a $20 Copayment per
visit
Administered drugs and products
Administered drugs and products are medications and
products that require administration or observation by
medical personnel. We cover these items when
prescribed by a Plan Provider, in accord with our drug
formulary guidelines, and they are administered to you in
a Plan Facility or during home visits.
We cover the following Services and their administration
in a Plan Facility at the Cost Share indicated:
• Whole blood, red blood cells, plasma, and platelets:
no charge
• Allergy antigens (including administration): a
$3 Copayment per visit
• Cancer chemotherapy drugs and adjuncts: no charge
• Drugs and products that are administered via
intravenous therapy or injection that are not for
cancer chemotherapy, including blood factor products
and biological products (“biologics”) derived from
tissue, cells, or blood: no charge
• Tuberculosis skin tests: no charge
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• All other administered drugs and products: no charge
We cover drugs and products administered to you during
a home visit at no charge.
Certain administered drugs are Preventive Services.
Refer to “Preventive Services” for information on
immunizations.
Note: Vaccines covered by Medicare Part D are not
covered under this “Outpatient Care” section (instead,
refer to “Outpatient Prescription Drugs, Supplies, and
Supplements” in this “Benefits and Your Cost Share”
section).
For the following Services, refer to these
sections
• Bariatric Surgery
• Dental Services
• Dialysis Care
• Durable Medical Equipment (“DME”) for Home Use
• Fertility Services
• Health Education
• Hearing Services
• Home Health Care
• Hospice Care
• Mental Health Services
• Ostomy, Urological, and Specialized Wound Care
Supplies
• Outpatient Imaging, Laboratory, and Other
Diagnostic and Treatment Services
• Outpatient Prescription Drugs, Supplies, and
Supplements
• Preventive Services
• Prosthetic and Orthotic Devices
• Reconstructive Surgery
• Services Associated with Clinical Trials
• Substance Use Disorder Treatment
• Transplant Services
• Vision Services
Hospital Inpatient Services
We cover the following inpatient Services in a Plan
Hospital, when the Services are generally and
customarily provided by acute care general hospitals
inside your Home Region Service Area:
• Room and board, including a private room
if Medically Necessary
• Specialized care and critical care units
• General and special nursing care
• Operating and recovery rooms
• Services of Plan Physicians, including consultation
and treatment by specialists
• Anesthesia
• Drugs prescribed in accord with our drug formulary
guidelines (for discharge drugs prescribed when you
are released from the hospital, refer to “Outpatient
Prescription Drugs, Supplies, and Supplements” in
this “Benefits and Your Cost Share” section)
• Radioactive materials used for therapeutic purposes
• Durable medical equipment and medical supplies
• Imaging, laboratory, and other diagnostic and
treatment Services, including MRI, CT, and PET
scans
• Whole blood, red blood cells, plasma, platelets, and
their administration
• Obstetrical care and delivery (including cesarean
section). Note: If you are discharged within 48 hours
after delivery (or within 96 hours if delivery is by
cesarean section), your Plan Physician may order a
follow-up visit for you and your newborn to take
place within 48 hours after discharge (for visits after
you are released from the hospital, please refer to
“Outpatient Care” in this “Benefits and Your Cost
Share” section)
• Physical, occupational, and speech therapy (including
treatment in an organized, multidisciplinary
rehabilitation program) in accord with Medicare
guidelines
• Respiratory therapy
• Medical social services and discharge planning
Your Cost Share. We cover hospital inpatient Services
at a $250 Copayment per admission.
For the following Services, refer to these
sections
• Bariatric surgical procedures (refer to “Bariatric
Surgery”)
• Dental procedures (refer to “Dental Services”)
• Dialysis care (refer to “Dialysis Care”)
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• Fertility Services related to diagnosis and treatment of
infertility, artificial insemination, or assisted
reproductive technology (refer to “Fertility Services”)
• Hospice care (refer to “Hospice Care”)
• Mental health Services (refer to “Mental Health
Services”)
• Prosthetics and orthotics (refer to “Prosthetic and
Orthotic Devices”)
• Reconstructive surgery Services (refer to
“Reconstructive Surgery”)
• Religious Nonmedical Health Care Institution
Services (refer to “Religious Nonmedical Health Care
Institution”)
• Services in connection with a clinical trial (refer to
“Services in Connection with a Clinical Trial”)
• Skilled inpatient Services in a Plan Skilled Nursing
Facility (refer to “Skilled Nursing Facility Care”)
• Substance use disorder treatment Services (refer to
“Substance Use Disorder Treatment”)
• Transplant Services (refer to “Transplant Services”)
Ambulance Services
Emergency
We cover Services of a licensed ambulance anywhere in
the world without prior authorization (including
transportation through the 911 emergency response
system where available) in the following situations:
• You reasonably believed that the medical condition
was an Emergency Medical Condition which required
ambulance Services
• 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
If you receive emergency ambulance Services that are
not ordered by a Plan Provider, you are not responsible
for any amounts beyond your Cost Share for covered
emergency ambulance Services. However, if the provider
does not agree to bill us, you may have to pay for the
Services and file a claim for reimbursement. For
information on how to file a claim, please see the
“Requests for Payment” section.
Nonemergency
Inside your Home Region Service Area, we cover
nonemergency ambulance Services in accord with
Medicare guidelines if a Plan Physician determines that
your condition requires the use of Services that only a
licensed ambulance can provide and that the use of other
means of transportation would endanger your health.
These Services are covered only when the vehicle
transports you to and from qualifying locations as
defined by Medicare guidelines.
Your Cost Share
You pay the following for covered ambulance Services:
• Emergency ambulance Services: no charge
• Nonemergency Services: no charge
Ambulance Services exclusions
• 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
Bariatric Surgery
We cover hospital inpatient Services related to bariatric
surgical procedures (including room and board, imaging,
laboratory, other diagnostic and treatment Services, and
Plan Physician Services) when performed to treat obesity
by modification of the gastrointestinal tract to reduce
nutrient intake and absorption, if all of the following
requirements are met:
• You complete the Medical Group–approved pre-
surgical educational preparatory program regarding
lifestyle changes necessary for long term bariatric
surgery success
• A Plan Physician who is a specialist in bariatric care
determines that the surgery is Medically Necessary
Your Cost Share. For covered Services related to
bariatric surgical procedures that you receive, you will
pay the Cost Share you would pay if the Services were
not related to a bariatric surgical procedure. For
example, see “Hospital Inpatient Services” in this
“Benefits and Your Cost Share” section for the Cost
Share that applies for hospital inpatient Services.
For the following Services, refer to these
sections
• Outpatient prescription drugs (refer to “Outpatient
Prescription Drugs, Supplies, and Supplements”)
• Outpatient administered drugs (refer to “Outpatient
Care”)
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Dental Services
Dental Services for radiation treatment
We cover services in accord with Medicare guidelines,
including dental evaluation, X-rays, fluoride treatment,
and extractions necessary to prepare your jaw for
radiation therapy of cancer in your head or neck if a Plan
Physician provides the Services or if the Medical Group
authorizes a referral to a dentist for those Services (as
described in “Medical Group authorization procedure for
certain referrals” under “Getting a Referral” in the “How
to Obtain Services” section).
Dental Services for transplants
We cover dental services that are Medically Necessary to
free the mouth from infection in order to prepare for a
transplant covered under "Transplant Services" in this
"Benefits" section, if a Plan Physician provides the
Services or if the Medical Group authorizes a referral to
a dentist for those Services (as described in "Medical
Group authorization procedure for certain referrals"
under "Getting a Referral" in the "How to Obtain
Services" section).
Dental anesthesia
For dental procedures at a Plan Facility, we provide
general anesthesia and the facility’s Services associated
with the anesthesia if all of the following are true:
• You are under age 7, or you are developmentally
disabled, or your health is compromised
• Your clinical status or underlying medical condition
requires that the dental procedure be provided in a
hospital or outpatient surgery center
• The dental procedure would not ordinarily require
general anesthesia
We do not cover any other Services related to the dental
procedure, such as the dentist’s Services, unless the
Service is covered in accord with Medicare guidelines or
for transplant services.
Your Cost Share
You pay the following for dental Services covered under
this “Dental Services” section:
• Non-Physician Specialist Visits with dentists for
Services covered under this “Dental Services”
section: a $20 Copayment per visit
• Physician Specialist Visits for Services covered under
this “Dental Services” section: a $20 Copayment per
visit
• Outpatient surgery and outpatient procedures when
provided in an outpatient or ambulatory surgery
center or in a hospital operating room, or if it is
provided in any setting and a licensed staff member
monitors your vital signs as you regain sensation after
receiving drugs to reduce sensation or to minimize
discomfort: a $100 Copayment per procedure
• Any other outpatient surgery that does not require a
licensed staff member to monitor your vital signs as
described above: a $20 Copayment per procedure
• Any other outpatient procedures that do not require a
licensed staff member to monitor your vital signs as
described above: the Cost Share that would
otherwise apply for the procedure in this “Benefits
and Your Cost Share” section (for example, radiology
procedures that do not require a licensed staff
member to monitor your vital signs as described
above are covered under “Outpatient Imaging,
Laboratory, and Other Diagnostic and Treatment
Services”)
• Hospital inpatient Services (including room and
board, drugs, imaging, laboratory, other diagnostic
and treatment Services, and Plan Physician Services):
a $250 Copayment per admission
For the following Services, refer to these
sections
• Office visits not described in this “Dental Services”
section (refer to “Outpatient Care”)
• Outpatient imaging, laboratory, and other diagnostic
and treatment Services (refer to “Outpatient Imaging,
Laboratory, and Other Diagnostic and Treatment
Services”)
• Outpatient prescription drugs (refer to “Outpatient
Prescription Drugs, Supplies, and Supplements”)
Dialysis Care
We cover acute and chronic dialysis Services if all of the
following requirements are met:
• You satisfy all medical criteria developed by the
Medical Group
• The facility is certified by Medicare
• A Plan Physician provides a written referral for your
dialysis treatment except for out-of-area dialysis care
We also cover hemodialysis and peritoneal home dialysis
(including equipment, training, and medical supplies).
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
supply when we are no longer covering them.
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Page 29
Out-of-area dialysis care
We cover dialysis (kidney) Services that you get at a
Medicare-certified dialysis facility when you are
temporarily outside your Home Region Service Area.
If possible, before you leave the Service Area, please let
us know where you are going so we can help arrange for
you to have maintenance dialysis while outside your
Home Region Service Area.
The procedure for obtaining reimbursement for out-of-
area dialysis care is described in the “Requests for
Payment” section.
Your Cost Share. You pay the following for these
covered Services related to dialysis:
• Equipment and supplies for home hemodialysis and
home peritoneal dialysis: no charge
• One routine outpatient visit per month with the
multidisciplinary nephrology team for a consultation,
evaluation, or treatment: no charge
• Hemodialysis and peritoneal dialysis treatment:
no charge
• Hospital inpatient Services (including room and
board, drugs, imaging, laboratory, and other
diagnostic and treatment Services, and Plan Physician
Services): a $250 Copayment per admission
For the following Services, refer to these
sections
• Durable medical equipment for home use (refer to
“Durable Medical Equipment (“DME”) for Home
Use”)
• Hospital inpatient Services (refer to “Hospital
Inpatient Services”)
• Office visits not described in this “Dialysis Care”
section (refer to “Outpatient Care”)
• Kidney disease education (refer to “Health
Education”)
• Outpatient laboratory (refer to “Outpatient Imaging,
Laboratory, and Other Diagnostic and Treatment
Services”)
• Outpatient prescription drugs (refer to “Outpatient
Prescription Drugs, Supplies, and Supplements”)
• Outpatient administered drugs (refer to “Outpatient
Care”)
• Telehealth Visits (refer to “Telehealth Visits”)
Dialysis care exclusions
• Comfort, convenience, or luxury equipment, supplies
and features
• Nonmedical items, such as generators or accessories
to make home dialysis equipment portable for travel
Durable Medical Equipment (“DME”) for
Home Use
DME coverage rules
DME for home use is an item that meets the following
criteria:
• The item is intended for repeated use
• The item is primarily and customarily used to serve a
medical purpose
• The item is generally useful only to an individual
with an illness or injury
• The item is appropriate for use in the home (or
another location used as your home as defined by
Medicare)
• The item is expected to last at least 3 years
For a DME item to be covered, all of the following
requirements must be met:
• Your EOC includes coverage for the requested DME
item
• A Plan Physician has prescribed the DME item for
your medical condition
• The item has been approved for you through the
Plan’s prior authorization process, as described in
“Medical Group authorization procedure for certain
referrals” under “Getting a Referral” in the “How to
Obtain Services” section
• The Services are provided inside your Home Region
Service Area
Coverage is limited to the standard item of equipment
that adequately meets your medical needs. We decide
whether to rent or purchase the equipment, and we select
the vendor.
DME for diabetes
We cover the following diabetes testing supplies and
equipment and insulin-administration devices if all of the
requirements described under “DME coverage rules” in
this “Durable Medical Equipment (“DME”) for Home
Use” section are met:
• Glucose monitors for diabetes testing and their
supplies (such as glucose monitor test strips, lancets,
and lancet devices)
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Page 30
• Insulin pumps and supplies to operate the pump
Your Cost Share. You pay the following for covered
DME for diabetes (including repair or replacement of
covered equipment):
• Glucose monitors for diabetes testing and their
supplies (such as glucose monitor test strips, lancets,
and lancet devices): no charge
• Insulin pumps and supplies to operate the pump:
no charge
Base DME Items
We cover Base DME Items (including repair or
replacement of covered equipment) if all of the
requirements described under “DME coverage rules” in
this “Durable Medical Equipment (“DME”) for Home
Use” section are met. “Base DME Items” means the
following items:
• Glucose monitors for diabetes blood testing and their
supplies (such as blood glucose monitor test strips,
lancets, and lancet devices)
• Bone stimulator
• Canes (standard curved handle or quad) and
replacement supplies
• Cervical traction (over door)
• Crutches (standard or forearm) and replacement
supplies
• Dry pressure pad for a mattress
• Infusion pumps (such as insulin pumps) and supplies
to operate the pump
• IV pole
• Nebulizer and supplies
• Phototherapy blankets for treatment of jaundice in
newborns
Your Cost Share. You pay the following for covered
Base DME Items: no charge.
Other covered DME items
If all of the requirements described under “DME
coverage rules” in this “Durable Medical Equipment
(“DME”) for Home Use” section are met, we cover the
following other DME items (including repair or
replacement of covered equipment):
• Bed accessories for a hospital bed when bed
extension is required
• Heel or elbow protectors to prevent or minimize
advanced pressure relief equipment use
• Iontophoresis device to treat hyperhidrosis when
antiperspirants are contraindicated and the
hyperhidrosis has created medical complications (for
example, skin infection) or preventing daily living
activities
• Nontherapeutic continuous glucose monitoring
devices and related supplies
• Peak flow meters
• Resuscitation bag if tracheostomy patient has
significant secretion management problems, needing
lavage and suction technique aided by deep breathing
via resuscitation bag
Your Cost Share. You pay the following for other
covered DME items: no charge.
Outside your Home Region Service Area
We do not cover most DME for home use outside your
Home Region Service Area. However, if you live outside
your Home Region Service Area, we cover the following
DME (subject to the Cost Share and all other coverage
requirements that apply to DME for home use inside
your Home Region Service Area) when the item is
dispensed at a Plan Facility:
• Blood glucose monitors for diabetes blood testing and
their supplies (such as blood glucose monitor test
strips, lancets, and lancet devices) from a Plan
Pharmacy
• Canes (standard curved handle)
• Crutches (standard)
• Nebulizers and their supplies for the treatment of
pediatric asthma
• Peak flow meters from a Plan Pharmacy
For the following Services, refer to these
sections
• Dialysis equipment and supplies required for home
hemodialysis and home peritoneal dialysis (refer to
“Dialysis Care”)
• Diabetes urine testing supplies and insulin-
administration devices other than insulin pumps (refer
to “Outpatient Prescription Drugs, Supplies, and
Supplements”)
• Durable medical equipment related to the terminal
illness for Members who are receiving covered
hospice care (refer to “Hospice Care”)
• Insulin and any other drugs administered with an
infusion pump (refer to “Outpatient Prescription
Drugs, Supplies, and Supplements”)
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Page 31
DME for home use exclusions
• Comfort, convenience, or luxury equipment or
features
• Dental appliances
• Items not intended for maintaining normal activities
of daily living, such as exercise equipment (including
devices intended to provide additional support for
recreational or sports activities)
• Hygiene equipment
• Nonmedical items, such as sauna baths or elevators
• Modifications to your home or car, unless covered in
accord with Medicare guidelines
• Devices for testing blood or other body substances
(except diabetes glucose monitors and their supplies)
• Electronic monitors of the heart or lungs except infant
apnea monitors
• Repair or replacement of equipment due to misuse
Fertility Services
“Fertility Services” means treatments and procedures to
help you become pregnant.
Before starting or continuing a course of fertility
Services, you may be required to pay initial and
subsequent deposits toward your Cost Share for some or
all of the entire course of Services, along with any past-
due fertility-related Cost Share. Any unused portion of
your deposit will be returned to you. When a deposit is
not required, you must pay the Cost Share for the
procedure, along with any past-due fertility-related Cost
Share, before you can schedule a fertility procedure.
Diagnosis and treatment of infertility
For purposes of this “Diagnosis and treatment of
infertility” section, “infertility” means not being able to
get pregnant or carry a pregnancy to a live birth after a
year or more of regular sexual relations without
contraception or having a medical or other demonstrated
condition that is recognized by a Plan Physician as a
cause of infertility. We cover the following:
• Services for the diagnosis and treatment of infertility
• Artificial insemination
You pay the following for covered infertility Services:
• Office visits: a $20 Copayment per visit
• Most outpatient surgery and outpatient procedures
when provided in an outpatient or ambulatory surgery
center or in a hospital operating room, or provided in
any setting where a licensed staff member monitors
your vital signs as you regain sensation after
receiving drugs to reduce sensation or to minimize
discomfort: a $20 Copayment per procedure
• Any other outpatient surgery that does not require a
licensed staff member to monitor your vital signs as
described above: a $20 Copayment per procedure
• Outpatient imaging: no charge
• Outpatient laboratory: no charge
• Outpatient administered drugs: no charge
• Hospital inpatient Services (including room and
board, imaging, laboratory, and other diagnostic and
treatment Services, and Plan Physician Services): a
$250 Copayment per admission
Note: Administered drugs and products are medications
and products that require administration or observation
by medical personnel. We cover these items when they
are prescribed by a Plan Provider, in accord with our
drug formulary guidelines, and they are administered to
you in a Plan Facility.
For the following Services, refer to these
sections
• Outpatient drugs, supplies, and supplements (refer to
“Outpatient Prescription Drugs, Supplies, and
Supplements”)
• Diagnostic Services provided by Plan Providers who
are not physicians, such as EKGs and EEGs (refer to
“Outpatient Imaging, Laboratory, and Other
Diagnostic and Treatment Services”)
Fertility Services exclusions
• Services to reverse voluntary, surgically induced
infertility
• Semen and eggs (and Services related to their
procurement and storage)
• Assisted reproductive technology Services, such as
ovum transplants, gamete intrafallopian transfer
(GIFT), in vitro fertilization (IVF), and zygote
intrafallopian transfer (ZIFT)
Health Education
We cover a variety of health education counseling,
programs, and materials that your personal Plan
Physician or other Plan Providers provide during a visit
covered under another part of this EOC.
We also cover a variety of health education counseling,
programs, and materials to help you take an active role in
protecting and improving your health, including
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Page 32
programs for tobacco cessation, stress management, and
chronic conditions (such as diabetes and asthma). Kaiser
Permanente also offers health education counseling,
programs, and materials that are not covered, and you
may be required to pay a fee.
For more information about our health education
counseling, programs, and materials, please contact a
Health Education Department or Member Services or go
to our website at kp.org.
Note: Our Health Education Department offers a
comprehensive self-management workshop to help
members learn the best choices in exercise, diet,
monitoring, and medications to manage and control
diabetes. Members may also choose to receive diabetes
self-management training from a program outside our
Plan that is recognized by the American Diabetes
Association (ADA) and approved by Medicare. Also, our
Health Education Department offers education to teach
kidney care and help members make informed decisions
about their care.
Your Cost Share. You pay the following for these
covered Services:
• Covered health education programs, which may
include programs provided online and counseling
over the phone: no charge
• Other covered individual counseling when the office
visit is solely for health education: a $20 Copayment
per visit
• Health education provided during an outpatient
consultation or evaluation covered in another part of
this EOC: no additional Cost Share beyond the
Cost Share required in that other part of this EOC
• Covered health education materials: no charge
Hearing Services
We cover the following:
• Hearing exams with an audiologist to determine the
need for hearing correction: a $20 Copayment per
visit
• Physician Specialist Visits to diagnose and treat
hearing problems: a $20 Copayment per visit
Hearing aids
We cover the following Services related to hearing aids:
• A $2,500 Allowance for each ear toward the purchase
price of a hearing aid (including fitting, counseling,
adjustment, cleaning, and inspection) every 36
months when prescribed by a Plan Physician or by a
Plan Provider who is an audiologist. 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. We will not
provide the Allowance if we have provided an
Allowance toward (or otherwise covered) a hearing
aid within the previous 36 months. Also, the
Allowance can only be used at the initial point of sale.
If you do not use all of your Allowance at the initial
point of sale, you cannot use it later
We select the provider or vendor that will furnish the
covered hearing aids. Coverage is limited to the types
and models of hearing aids furnished by the provider or
vendor.
For the following Services, refer to these
sections
• Services related to the ear or hearing other than those
described in this section, such as outpatient care to
treat an ear infection or outpatient prescription drugs,
supplies, and supplements (refer to the applicable
heading in this “Benefits and Your Cost Share”
section)
• Cochlear implants and osseointegrated hearing
devices (refer to “Prosthetic and Orthotic Devices”)
Hearing Services exclusions
• Internally implanted hearing aids
• Replacement parts and batteries, repair of hearing
aids, and replacement of lost or broken hearing aids
(the manufacturer warranty may cover some of these)
Home Health Care
“Home health care” means Services provided in the
home by nurses, medical social workers, home health
aides, and physical, occupational, and speech therapists.
We cover part-time or intermittent home health care in
accord with Medicare guidelines. Home health care
services are covered up to the number of visits and
length of time that are determined to be medically
necessary under the Member’s home health treatment
plan and no more than the limits established under
Medicare guidelines, only if all of the following are true:
• You are substantially confined to your home
• Your condition requires the Services of a nurse,
physical therapist, or speech therapist or continued
need for an occupational therapist (home health aide
Services are not covered unless you are also getting
covered home health care from a nurse, physical
therapist, occupational therapist, or speech therapist
that only a licensed provider can provide)
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Page 33
• A Plan Physician determines that it is feasible to
maintain effective supervision and control of your
care in your home and that the Services can be safely
and effectively provided in your home
• The Services are provided inside your Home Region
Service Area
Your Cost Share. We cover home health care Services
at no charge.
For the following Services, refer to these
sections
• Dialysis care (refer to “Dialysis Care”)
• Durable medical equipment (refer to “Durable
Medical Equipment (“DME”) for Home Use”)
• Ostomy, urological, and specialized wound care
supplies (refer to “Ostomy, Urological, and
Specialized Wound Care Supplies”)
• Outpatient drugs, supplies, and supplements (refer to
“Outpatient Prescription Drugs, Supplies, and
Supplements”)
• Outpatient physical, occupational, and speech therapy
visits (refer to “Outpatient Care”)
• Prosthetic and orthotic devices (refer to “Prosthetic
and Orthotic Devices”)
Home health care exclusions
• Care in the home if the home is not a safe and
effective treatment setting
Home Medical Care Not Covered by
Medicare for Members Who Live in
Certain Counties (Advanced Care at
Home)
We cover medical care in your home that is not
otherwise covered by Medicare when found medically
appropriate by a physician based on your health status to
provide you with an alternative to receiving acute care in
a hospital and post-acute care Services in the home to
support your recovery. Services in the home must be:
• Prescribed by a network hospitalist who has
determined that based on your health status, treatment
plan, and home setting that you can be treated safely
and effectively in the home
• Elected by you because you prefer to receive the care
described in your treatment plan in your home
Medically Home is our network provider and will
provide the following services and items in your home in
accord with your treatment plan for as long as they are
prescribed by a network hospitalist:
• Home visits by RNs, physical therapists, occupational
therapists, speech therapists, respiratory therapists,
nutritionist, home health aides, and other healthcare
professionals in accord with the home care treatment
plan and the provider's scope of practice and license
• Communication devices to allow you to contact
Medically Home's command center 24 hours a day,
7 days a week. This includes needed communication
technology to support reliable communication, and an
PERS alert device to contact Medically Home's
command center if you are unable to get to a phone
• The following equipment necessary to ensure that you
are monitored appropriately in your home: blood
pressure cuff/monitor, pulse oximeter, scale, and
thermometer
• Mobile imaging and tests such as X-rays, labs, and
EKGs
• The following safety items: shower stools, raised
toilet seats, grabbers, long handle shoehorn, and sock
aid
• Up to 21 meals per week while you are receiving
acute care in the home
In addition, for Medicare-covered services and items
listed below, the Cost-Sharing indicated elsewhere in this
EOC does not apply when the Services and items are
prescribed as part of your home treatment plan:
• Durable medical equipment
• Medical supplies
• Ambulance transportation to and from network
facilities when ambulance transport is Medically
Necessary
• Physician assistant and nurse practitioner house calls
or office visits
• The following Services at a Plan Facility if the
Services are part of your home treatment plan:
♦ Network Emergency Department visits associated
with this benefit
♦ Physical, speech, or occupational therapy office
visits
♦ X-rays, labs, ultrasounds, and EKGs
The cost-sharing indicated elsewhere in this EOC will
apply to all other Services and items that are not part of
your home treatment plan (for example, DME unrelated
to your home treatment plan) or are part of your home
treatment plan, but are not provided in your home except
as listed above. Note: For prescription drug Cost-Sharing
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Page 34
information, refer to the “Outpatient Prescription Drugs,
Supplies, and Supplements” section.
Hospice Care
Hospice care is a specialized form of interdisciplinary
health care designed to provide palliative care and to
alleviate the physical, emotional, and spiritual
discomforts of a Member experiencing the last phases of
life due to a terminal illness. It also provides support to
the primary caregiver and the Member’s family. A
Member who chooses hospice care is choosing to receive
palliative care for pain and other symptoms associated
with the terminal illness, but not to receive care to try to
cure the terminal illness. You may change your decision
to receive hospice care benefits at any time.
If you have Medicare Part A, you are eligible for the
hospice benefit when your doctor and the hospice
medical director have given you a terminal prognosis
certifying that you’re terminally ill and have six months
or less to live if your illness runs its normal course. You
may receive care from any Medicare-certified hospice
program. Our plan is obligated to help you find
Medicare-certified hospice programs in our plan's
Service Area, including those the MA organization owns,
controls, or has a financial interest in. Your hospice
doctor can be a Plan Provider or a Non–Plan Provider.
Covered Services include:
• Drugs for symptom control and pain relief
• Short-term respite care
• Home care
When you are admitted to a hospice you have the right to
remain in your plan; if you chose to remain in your plan,
you must continue to pay plan premiums.
For hospice services and for services that are covered
by Medicare Part A or B and are related to your
terminal prognosis: Original Medicare (rather than our
Plan) will pay your hospice provider for your hospice
services and any Part A and Part B services related to
your terminal condition. While you are in the hospice
program, your hospice provider will bill Original
Medicare for the services that Original Medicare pays
for. You will be billed Original Medicare cost-sharing.
For services that are covered by Medicare Part A or
B and are not related to your terminal prognosis:
If you need nonemergency, non–urgently needed
services that are covered under Medicare Part A or B and
that are not related to your terminal condition, your cost
for these services depends on whether you use a Plan
Provider and follow plan rules (such as if there is a
requirement to obtain prior authorization):
• If you obtain the covered services from a Plan
Provider and follow plan rules for obtaining service,
you only pay the Plan Cost Share amount
• If you obtain the covered services from a Non–Plan
Provider, you pay the cost sharing under Fee-for-
Service Medicare (Original Medicare)
For services that are covered by our Plan but are not
covered by Medicare Part A or B: We will continue to
cover Plan-covered Services that are not covered under
Part A or B whether or not they are related to your
terminal condition. You pay your Plan Cost Share
amount for these Services.
For drugs that may be covered by our plan’s Part D
benefit: If these drugs are unrelated to your terminal
hospice condition, you pay cost-sharing. If they are
related to your terminal hospice condition, then you pay
Original Medicare cost-sharing. Drugs are never covered
by both hospice and our plan at the same time. For more
information, please see “What if you’re in a Medicare-
certified hospice” in the “Outpatient Prescription Drugs,
Supplies, and Supplements” section.
Note: If you need non-hospice care (care that is not
related to your terminal prognosis), you should contact
us to arrange the services.
For more information about Original Medicare hospice
coverage, visit https://www.medicare.gov, and under
“Search Tools,” choose “Find a Medicare Publication” to
view or download the publication “Medicare Hospice
Benefits.” Or call 1-800-MEDICARE (1-800-633-4227)
(TTY users call 1-877-486-2048), 24 hours a day, seven
days a week.
Special note if you do not have Medicare Part A
We cover the hospice Services listed below at no charge
only if all of the following requirements are met:
• You are not entitled to Medicare Part A
• A Plan Physician has diagnosed you with a terminal
illness and determines that your life expectancy is 12
months or less
• The Services are provided inside your Home Region
Service Area (or inside California but within 15 miles
or 30 minutes from your Home Region Service Area
if you live outside your Home Region Service Area,
and you have been a Senior Advantage Member
continuously since before January 1, 1999, at the
same home address)
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• The Services are provided by a licensed hospice
agency that is a Plan Provider
• A Plan Physician determines that the Services are
necessary for the palliation and management of your
terminal illness and related conditions
If all of the above requirements are met, we cover the
following hospice Services, if necessary for your hospice
care:
• Plan Physician Services
• Skilled nursing care, including assessment,
evaluation, and case management of nursing needs,
treatment for pain and symptom control, provision of
emotional support to you and your family, and
instruction to caregivers
• Physical, occupational, and speech therapy for
purposes of symptom control or to enable you to
maintain activities of daily living
• Respiratory therapy
• Medical social services
• Home health aide and homemaker services
• Palliative drugs prescribed for pain control and
symptom management of the terminal illness for up to
a 100-day supply in accord with our drug formulary
guidelines. You must obtain these drugs from a Plan
Pharmacy. Certain drugs are limited to a maximum
30-day supply in any 30-day period (your Plan
Pharmacy can tell you if a drug you take is one of
these drugs)
• Durable medical equipment
• Respite care when necessary to relieve your
caregivers. Respite care is occasional short-term
inpatient Services limited to no more than five
consecutive days at a time
• Counseling and bereavement services
• Dietary counseling
We also cover the following hospice Services only
during periods of crisis when they are Medically
Necessary to achieve palliation or management of acute
medical symptoms:
• Nursing care on a continuous basis for as much as 24
hours a day as necessary to maintain you at home
• Short-term inpatient Services required at a level that
cannot be provided at home
Mental Health Services
We cover Services specified in this “Mental Health
Services” section only when the Services are for the
diagnosis or treatment of Mental Disorders. A “Mental
Disorder” is a mental health condition identified as a
“mental disorder” in the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text
Revision, as amended in the most recently issued edition,
(“DSM”) that results in clinically significant distress or
impairment of mental, emotional, or behavioral
functioning. We do not cover services for conditions that
the DSM identifies as something other than a “mental
disorder.” For example, the DSM identifies relational
problems as something other than a “mental disorder,” so
we do not cover services (such as couples counseling or
family counseling) for relational problems.
“Mental Disorders” include the following conditions:
• Severe Mental Illness of a person of any age
• Serious Emotional Disturbance of a Child Under Age
18
In addition to the Services described in this Mental
Health Services section, we also cover other Services
that are Medically Necessary to treat Serious Emotional
Disturbance of a Child Under Age 18 or Severe Mental
Illness, if the Medical Group authorizes a written referral
(as described in “Medical Group authorization procedure
for certain referrals” under “Getting a Referral” in the
“How to Obtain Services” section).
Outpatient mental health Services
We cover the following Services when provided by Plan
Physicians or other Plan Providers who are licensed
health care professionals acting within the scope of their
license:
• Individual and group mental health evaluation and
treatment
• Psychological testing when necessary to evaluate a
Mental Disorder
• Outpatient Services for the purpose of monitoring
drug therapy
Intensive psychiatric treatment programs
We cover the following intensive psychiatric treatment
programs at a Plan Facility, such as:
• Partial hospitalization
• Multidisciplinary treatment in an intensive outpatient
program
• Psychiatric observation for an acute psychiatric crisis
Your Cost Share. You pay the following for these
covered Services:
• Individual mental health evaluation and treatment: a
$20 Copayment per visit
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
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• Group mental health treatment: a $10 Copayment
per visit
• Partial hospitalization: no charge
• Other intensive psychiatric treatment programs:
no charge
Residential treatment
Inside your Home Region Service Area, we cover the
following Services when the Services are provided in a
licensed residential treatment facility that provides 24-
hour individualized mental health treatment, the Services
are generally and customarily provided by a mental
health residential treatment program in a licensed
residential treatment facility, and the Services are above
the level of custodial care:
• Individual and group mental health evaluation and
treatment
• Medical services
• Medication monitoring
• Room and board
• Drugs prescribed by a Plan Provider as part of your
plan of care in the residential treatment facility in
accord with our drug formulary guidelines if they are
administered to you in the facility by medical
personnel (for discharge drugs prescribed when you
are released from the residential treatment facility,
refer to “Outpatient Prescription Drugs, Supplies, and
Supplements” in this “Benefits and Your Cost Share”
section)
• Discharge planning
Your Cost Share. We cover residential mental health
treatment Services at no charge.
Inpatient psychiatric hospitalization
We cover care for acute psychiatric conditions in a
Medicare-certified psychiatric hospital.
Your Cost Share. We cover inpatient psychiatric
hospital Services at a $250 Copayment per admission.
For the following Services, refer to these
sections
• Outpatient drugs, supplies, and supplements (refer to
“Outpatient Prescription Drugs, Supplies, and
Supplements”)
• Outpatient laboratory (refer to “Outpatient Imaging,
Laboratory, and Other Diagnostic and Treatment
Services”)
• Telehealth Visits (refer to “Telehealth Visits”)
Opioid Treatment Program Services
Members with opioid use disorder (OUD) can receive
coverage of Services to treat OUD through an Opioid
Treatment Program (OTP) which includes the following
Services:
• U.S. Food and Drug Administration (FDA) approved
opioid agonist and antagonist medication-assisted
treatment (MAT) medications and the dispensing and
administration of MAT medications (if applicable)
• Substance use counseling
• Individual and group therapy
• Toxicology testing
• Intake activities
• Periodic assessments
• Medicare Part B clinically administered drugs
Your Cost Share: You pay the following for these
covered Services: no charge.
Ostomy, Urological, and Specialized
Wound Care Supplies
We cover ostomy, urological, and specialized wound
care supplies if the following requirements are met:
• A Plan Physician has prescribed ostomy, urological,
and specialized wound care supplies for your medical
condition
• The item has been approved for you through the
Plan’s prior authorization process, as described in
“Medical Group authorization procedure for certain
referrals” under “Getting a Referral” in the “How to
Obtain Services” section
• The Services are provided inside your Home Region
Service Area
Coverage is limited to the standard item of equipment
that adequately meets your medical needs. We decide
whether to rent or purchase the equipment, and we select
the vendor.
Your Cost Share: You pay the following for covered
ostomy, urological, and specialized wound care supplies:
no charge.
Ostomy, urological, and specialized wound care
supplies exclusions
• Comfort, convenience, or luxury equipment or
features
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
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Outpatient Imaging, Laboratory, and
Other Diagnostic and Treatment
Services
We cover the following Services at the Cost Share
indicated only when part of care covered under other
headings in this “Benefits and Your Cost Share” section.
The Services must be prescribed by a Plan Provider
except that we also cover laboratory tests and
electrocardiograms when prescribed by Non–Plan
Psychiatrists to treat mental health conditions unless a
Plan Physician determines that the Services are not
Medically Necessary:
• Complex imaging (other than preventive) such as CT
scans, MRIs, and PET scans: no charge
• Basic imaging Services, such as diagnostic and
therapeutic X-rays, mammograms, and ultrasounds:
no charge
• Nuclear medicine: no charge
• Routine preventive retinal photography screenings:
no charge
• Routine laboratory tests to monitor the effectiveness
of dialysis: no charge
• Hemoglobin (A1c) testing for diabetes, Low-Density
Lipoprotein (LDL) testing for heart disease,
International Normalized Ratio (INR) for persons
with liver disease or certain blood disorders, and
glucose quantitative blood tests not covered at $0
under Original Medicare: no charge
• All other laboratory tests (including tests for specific
genetic disorders for which genetic counseling is
available): no charge
• Diagnostic Services provided by Plan Providers who
are not physicians (such as EKGs and EEGs):
no charge
• Radiation therapy: no charge
• Ultraviolet light therapy treatments, including
ultraviolet light therapy equipment for home use, if
(1) the equipment has been approved for you through
the Plan's prior authorization process, as described in
"Medical Group authorization procedure for certain
referrals" under "Getting a Referral" in the "How to
Obtain Services" section and (2) the equipment is
provided inside your Home Region Service Area.
(Coverage for ultraviolet light therapy equipment is
limited to the standard item of equipment that
adequately meets your medical needs. We decide
whether to rent or purchase the equipment, and we
select the vendor. You must return the equipment to
us or pay us the fair market price of the equipment
when we are no longer covering it.): no charge
For the following Services, refer to these
sections
• Outpatient imaging and laboratory Services that are
Preventive Services, such as routine mammograms,
bone density scans, and laboratory screening tests
(refer to “Preventive Services”)
• Outpatient procedures that include imaging and
diagnostic Services (refer to "Outpatient surgeries and
procedures")
• Services related to diagnosis and treatment of
infertility, artificial insemination, or assisted
reproductive technology (“ART”) Services (refer to
“Fertility Services”)
Outpatient Imaging, Laboratory, and Other
Diagnostic and Treatment Services exclusions
• Ultraviolet light therapy comfort, convenience, or
luxury equipment or features
• Repair or replacement of ultraviolet light therapy
equipment due to misuse
Outpatient Prescription Drugs, Supplies,
and Supplements
We cover outpatient drugs, supplies, and supplements
specified in this “Outpatient Prescription Drugs,
Supplies, and Supplements” section when prescribed as
follows:
• Items prescribed by providers, within the scope of
their licensure and practice, and in accord with our
drug formulary guidelines
• Items prescribed by the following Non–Plan
Providers unless a Plan Physician determines that the
item is not Medically Necessary or the drug is for a
sexual dysfunction disorder:
♦ dentists if the drug is for dental care
♦ Non–Plan Physicians if the Medical Group
authorizes a written referral to the Non–Plan
Physician (in accord with “Medical Group
authorization procedure for certain referrals”
under “Getting a Referral” in the “How to Obtain
Services” section) and the drug, supply, or
supplement is covered as part of that referral
♦ Non–Plan Physicians if the prescription was
obtained as part of covered Emergency Services,
Post-Stabilization Care, or Out-of-Area Urgent
Care described in the “Emergency Services and
Urgent Care” section (if you fill the prescription at
a Plan Pharmacy, you may have to pay Charges
for the item and file a claim for reimbursement as
described in the “Requests for Payment” section)
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Page 38
♦ a Psychiatrist who is not a Plan Physician
prescribes the drug for mental health care
• The item meets the requirements of our applicable
drug formulary guidelines (our Medicare Part D
formulary or our formulary applicable to non
–Part D
items)
• You obtain the item at a Plan Pharmacy or through
our mail-order service, except as otherwise described
under “Certain items from Non–Plan Pharmacies” in
this “Outpatient Prescription Drugs, Supplies, and
Supplements” section. Refer to our Kaiser
Permanente Pharmacy Directory for the locations
of Plan Pharmacies in your area. Plan Pharmacies can
change without notice and if a pharmacy is no longer
a Plan Pharmacy, you must obtain covered items from
another Plan Pharmacy, except as otherwise described
under “Certain items from Non–Plan Pharmacies” in
this “Outpatient Prescription Drugs, Supplies, and
Supplements” section
• Your prescriber must either accept Medicare or file
documentation with the Centers for Medicare &
Medicaid Services showing that he or she is qualified
to write prescriptions, or your Part D claim will be
denied. You should ask your prescribers the next time
you call or visit if they meet this condition. If not,
please be aware it takes time for your prescriber to
submit the necessary paperwork to be processed
In addition to our plan’s Part D and medical benefits
coverage, if you have Medicare Part A, your drugs may
be covered by Original Medicare if you are in Medicare
hospice. For more information, please see “What
if you’re in a Medicare-certified hospice” in this
“Outpatient Prescription Drugs, Supplies, and
Supplements” section.
Obtaining refills by mail
Most refills are available through our mail-order service,
but there are some restrictions. A Plan Pharmacy, our
Kaiser Permanente Pharmacy Directory, or our
website at kp.org/refill can give you more information
about obtaining refills through our mail-order service.
Please check with your local Plan Pharmacy if you have
a question about whether your prescription can be
mailed. Items available through our mail-order service
are subject to change at any time without notice.
Certain items from Non–Plan Pharmacies
Generally, we cover drugs filled at a Non–Plan
Pharmacy only when you are not able to use a Plan
Pharmacy. If you cannot use a Plan Pharmacy, here are
the circumstances when we would cover prescriptions
filled at a Non–Plan Pharmacy.
• The drug is related to covered Emergency Services,
Post-Stabilization Care, or Out-of-Area Urgent Care
described in the “Emergency Services and Urgent
Care” section. Note: Prescription drugs prescribed
and provided outside of the United States and its
territories as part of covered Emergency Services or
Urgent Care are covered up to a 30-day supply in a
30-day period. These drugs are covered under your
medical benefits, and are not covered under Medicare
Part D. Therefore, payments for these drugs do not
count toward reaching the Part D Catastrophic
Coverage Stage
• For Medicare Part D covered drugs, the following are
additional situations when a Part D drug may be
covered:
♦ if you are traveling outside your Home Region
Service Area, but in the United States and its
territories, and you become ill or run out of your
covered Part D prescription drugs. We will cover
prescriptions that are filled at a Non–Plan
Pharmacy according to our Medicare Part D
formulary guidelines
♦ if you are unable to obtain a covered drug in a
timely manner inside your Home Region Service
Area because there is no Plan Pharmacy within a
reasonable driving distance that provides 24-hour
service. We may not cover your prescription if a
reasonable person could have purchased the drug
at a Plan Pharmacy during normal business hours
♦ if you are trying to fill a prescription for a drug
that is not regularly stocked at an accessible Plan
Pharmacy or available through our mail-order
pharmacy (including high-cost drugs)
♦ if you are not able to get your prescriptions from a
Plan Pharmacy during a disaster
In these situations, please check first with Member
Services to see if there is a Plan Pharmacy nearby.
You may be required to pay the difference between what
you pay for the drug at the Non–Plan Pharmacy and the
cost that we would cover at Plan Pharmacy.
Payment and reimbursement. If you go to a Non–Plan
Pharmacy for the reasons listed, you may have to pay the
full cost (rather than paying just your Copayment or
Coinsurance) when you fill your prescription. You may
ask us to reimburse you for our share of the cost by
submitting a request for reimbursement as described in
the “Requests for Payment” section. If we pay for the
drugs you obtained from a Non–Plan Pharmacy, you may
still pay more for your drugs than what you would have
paid if you had gone to a Plan Pharmacy because you
may be responsible for paying the difference between
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
Page 39
Plan Pharmacy Charges and the price that the Non–Plan
Pharmacy charged you.
What if you’re in a Medicare-certified hospice
If you have Medicare Part A, drugs are never covered by
both hospice and our plan at the same time. If you are
enrolled in Medicare hospice and require an anti-nausea,
laxative, pain medication, or antianxiety drug that is not
covered by your hospice because it is unrelated to your
terminal illness and related conditions, our plan must
receive notification from either the prescriber or your
hospice provider that the drug is unrelated before our
plan can cover the drug. To prevent delays in receiving
any unrelated drugs that should be covered by our plan,
you can ask your hospice provider or prescriber to make
sure we have the notification that the drug is unrelated
before you ask a pharmacy to fill your prescription.
In the event you either revoke your hospice election or
are discharged from hospice, our plan should cover all
your drugs. To prevent any delays at a pharmacy when
your Medicare hospice benefit ends, you should bring
documentation to the pharmacy to verify your revocation
or discharge. For more information about Medicare
Part D coverage and what you pay, please see “Medicare
Part D drugs” in this “Outpatient Prescription Drugs,
Supplies, and Supplements” section.
Medicare Part D drugs
Medicare Part D covers most outpatient prescription
drugs if they are sold in the United States and approved
for sale by the federal Food and Drug Administration.
Our Part D formulary includes drugs that can be covered
under Medicare Part D according to Medicare
requirements. Refer to our “Medicare Part D drug
formulary (2024 Comprehensive Formulary)” in this
“Outpatient Prescription Drugs, Supplies, and
Supplements” section for more information about this
formulary.
Cost Share for Medicare Part D drugs. Unless you
reach the Catastrophic Coverage Stage in a calendar
year, you will pay the following Cost Share for covered
Medicare Part D drugs:
• Generic drugs:
♦ a $5 Copayment for up to a 30-day supply, a
$10 Copayment for a 31- to 60-day supply, or a
$15 Copayment for a 61- to 100-day supply at a
Plan Pharmacy
♦ a $5 Copayment for up to a 30-day supply or a
$10 Copayment for a 31- to 100-day supply
through our mail-order service
• Brand-name and specialty drugs:
♦ a $25 Copayment for up to a 30-day supply, a
$50 Copayment for a 31- to 60-day supply, or a
$75 Copayment for a 61- to 100-day supply at a
Plan Pharmacy
♦ a $25 Copayment for up to a 30-day supply or a
$50 Copayment for a 31- to 100-day supply
through our mail-order service
• Injectable Part D vaccines: no charge
• Emergency contraceptive pills: no charge
• The following insulin-administration devices at a
$5 Copayment for up to a 30-day supply: needles,
syringes, alcohol swabs, and gauze
Catastrophic Coverage Stage. All Medicare
prescription drug plans include catastrophic coverage for
people with high drug costs. In order to qualify for
catastrophic coverage, you must spend $8,000 out-of-
pocket during 2024. When the total amount you have
paid for your Cost Share reaches $8,000, you pay
nothing for covered Part D drugs the remainder of the
calendar year.
Note: Each year, effective on January 1, the Centers for
Medicare & Medicaid Services may change coverage
thresholds that apply for the calendar year. We will
notify you in advance of any change to your coverage.
These payments are included in your out-of-pocket
costs. Your out-of-pocket costs include the payments
listed below (as long as they are for Part D covered drugs
and you followed the rules for drug coverage that are
explained in this “Outpatient Prescription Drugs,
Supplies, and Supplements” section):
• The amount you pay for drugs when you are in the
Initial Coverage Stage
• Any payments you made during this calendar year as
a member of a different Medicare prescription drug
plan before you joined our Plan
It matters who pays:
• If you make these payments yourself, they are
included in your out-of-pocket costs
• These payments are also included in your out-of-
pocket costs if they are made on your behalf by
certain other individuals or organizations. This
includes payments for your drugs made by a friend or
relative, by most charities, by AIDS drug assistance
programs, or by the Indian Health Service. Payments
made by Medicare’s Extra Help Program are also
included
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Page 40
These payments are not included in your out-of-
pocket costs. When you add up your out-of-pocket costs,
you are not allowed to include any of these types of
payments for prescription drugs:
• The amount you contribute, if any, toward the
University of California’s Premium
• Drugs you buy outside the United States and its
territories
• Drugs that are not covered by our Plan
• Drugs you get at an out-of-network pharmacy that do
not meet our Plan’s requirements for out-of-network
coverage
• Non-Part D drugs, including prescription drugs
covered by Part A or Part B and other drugs excluded
from coverage by Medicare
• Payments for your drugs that are made or funded by
group health plans, including employer health plans
• Payments for your drugs that are made by certain
insurance plans and government-funded health
programs such as TRICARE and Veterans Affairs
• Payments for your drugs made by a third-party with a
legal obligation to pay for prescription costs (for
example, Workers’ Compensation)
Reminder: If any other organization such as the ones
described above pays part or all of your out-of-pocket
costs for Part D drugs, you are required to tell our Plan.
Call Member Services to let us know (phone numbers are
on the cover of this EOC).
Keeping track of Medicare Part D drugs. The Part D
Explanation of Benefits is a document you will get for
each month you use your Part D prescription drug
coverage. The Part D Explanation of Benefits will tell
you the total amount you, or others on your behalf, have
spent on your prescription drugs and the total amount we
have paid for your prescription drugs. A Part D
Explanation of Benefits is also available upon request
from Member Services.
Medicare’s “Extra Help” Program
Medicare provides “Extra Help” to pay prescription drug
costs for people who have limited income and resources.
Resources include your savings and stocks, but not your
home or car. If you qualify, you get help paying for any
Medicare drug plan’s monthly premium, and prescription
Copayments. This “Extra Help” also counts toward your
out-of-pocket costs.
People with limited income and resources may qualify
for “Extra Help.” Some people automatically qualify for
“Extra Help” and don’t need to apply. Medicare mails a
letter to people who automatically qualify for “Extra
Help.”
You may be able to get “Extra Help” to pay for your
prescription drug premiums and costs. To see if you
qualify for getting “Extra Help,” call:
• 1-800-MEDICARE (1-800-633-4227) (TTY users
call 1-877-486-2048), 24 hours a day, seven days a
week;
• The Social Security Office at 1-800-772-1213 (TTY
users call 1-800-325-0778), 8 a.m. to 7 p.m., Monday
through Friday (applications); or
• Your state Medicaid office (applications). See the
“Important Phone Numbers and Resources” section
for contact information
If you believe you have qualified for “Extra Help” and
you believe that you are paying an incorrect Cost Share
amount when you get your prescription at a Plan
Pharmacy, our plan has established a process that allows
you either to request assistance in obtaining evidence of
your proper Cost Share level, or, if you already have the
evidence, to provide this evidence to us. If you aren’t
sure what evidence to provide us, please contact a Plan
Pharmacy or Member Services. The evidence is often a
letter from either your state Medicaid or Social Security
office that confirms you are qualified for Extra Help. The
evidence may also be state-issued documentation with
your eligibility information associated with Home and
Community-Based Services.
You or your appointed representative may need to
provide the evidence to a Plan Pharmacy when obtaining
covered Part D prescriptions so that we may charge you
the appropriate Cost Share amount until the Centers for
Medicare & Medicaid Services updates its records to
reflect your current status. Once the Centers for
Medicare & Medicaid Services updates its records, you
will no longer need to present the evidence to the Plan
Pharmacy. Please provide your evidence in one of the
following ways so we can forward it to the Centers for
Medicare & Medicaid Services for updating:
• Write to Kaiser Permanente at:
California Service Center
Attn: Best Available Evidence
P.O. Box 232407
San Diego, CA 92193-2407
• Fax it to 1-877-528-8579
• Take it to a Plan Pharmacy or your local Member
Services office at a Plan Facility
When we receive the evidence showing your Cost Share
level, we will update our system so that you can pay the
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
Page 41
correct Cost Share when you get your next prescription
at our Plan Pharmacy. If you overpay your Cost Share,
we will reimburse you. Either we will forward a check to
you in the amount of your overpayment or we will offset
future Cost Share. If our Plan Pharmacy hasn’t collected
a Cost Share from you and is carrying your Cost Share as
a debt owed by you, we may make the payment directly
to our Plan Pharmacy. If a state paid on your behalf, we
may make payment directly to the state. Please call
Member Services if you have questions.
If you qualify for “Extra Help,” we will send you an
Evidence of Coverage Rider for People Who Get
Extra Help Paying for Prescription Drugs (also known
as the Low Income Subsidy Rider or the LIS Rider), that
explains your costs as a Member of our plan. If the
amount of your “Extra Help” changes during the year,
we will also mail you an updated Evidence of Coverage
Rider for People Who Get Extra Help Paying for
Prescription Drugs.
Medicare Part D drug formulary (2024
Comprehensive Formulary)
Our Medicare Part D formulary is a list of covered drugs
selected by our plan in consultation with a team of health
care providers that represents the drug therapies believed
to be a necessary part of a quality treatment program.
Our formulary must meet requirements set by Medicare
and is approved by Medicare. Our formulary includes
drugs that can be covered under Medicare Part D
according to Medicare requirements. For a complete,
current listing of the Medicare Part D prescription drugs
we cover, please visit our website at kp.org/seniorrx or
call Member Services.
The presence of a drug on our formulary does not
necessarily mean that your Plan Physician will prescribe
it for a particular medical condition. Our drug formulary
guidelines allow you to obtain Medicare Part D
prescription drugs if a Plan Physician determines that
they are Medically Necessary for your condition. If you
disagree with your Plan Physician’s determination, refer
to “Your Part D Prescription Drugs: How to Ask for a
Coverage Decision or Make an Appeal” in the
“Coverage Decisions, Appeals, and Complaints” section.
Continuity drugs. If this EOC is amended to exclude a
drug that we have been covering and providing to you
under this EOC, we will continue to provide the drug if a
prescription is required by law and a Plan Physician
continues to prescribe the drug for the same condition
and for a use approved by the Federal Food and Drug
Administration.
About specialty drugs. Specialty drugs are high-cost
drugs that are on our specialty drug list. If your Plan
Physician prescribes more than a 30-day supply for an
outpatient drug, you may be able to obtain more than a
30-day supply at one time, up to the day supply limit for
that drug. However, most specialty drugs are limited to a
30-day supply in any 30-day period. Your Plan
Pharmacy can tell you if a drug you take is one of these
drugs.
Preferred generic and generic drugs listed in the
formulary will be subject to the generic drug Copayment
or Coinsurance listed under “Copayment and
Coinsurance for Medicare Part D drugs” in this
“Outpatient Prescription Drugs, Supplies, and
Supplements” section. Preferred and nonpreferred brand-
name drugs and specialty tier drugs listed in the
formulary will be subject to the brand-name Copayment
or Coinsurance listed under “Copayment and
Coinsurance for Medicare Part D drugs” in this
“Outpatient Prescription Drugs, Supplies, and
Supplements” section. Please note that sometimes a drug
may appear more than once on our 2024
Comprehensive Formulary. This is because different
restrictions or cost-sharing may apply based on factors
such as the strength, amount, or form of the drug
prescribed by your health care provider (for instance, 10
mg versus 100 mg; one per day versus two per day;
tablet versus liquid).
You can get updated information about the drugs our
plan covers by visiting our website at kp.org/seniorrx.
You may also call Member Services to find out if your
drug is on the formulary or to request an updated copy of
our formulary.
We may make certain changes to our formulary during
the year. Changes in the formulary may affect which
drugs are covered and how much you will pay when
filling your prescription. The kinds of formulary changes
we may make include:
• Adding or removing drugs from the formulary
• Adding prior authorizations or other restrictions on a
drug
If we remove drugs from the formulary or add prior
authorizations or restrictions on a drug, and you are
taking the drug affected by the change, you will be
permitted to continue receiving that drug at the same
level of Cost Share for the remainder of the calendar
year. However, if a brand-name drug is replaced with a
new generic drug, or our formulary is changed as a result
of new information on a drug’s safety or effectiveness,
you may be affected by this change. We will notify you
of the change at least 30 days before the date that the
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Page 42
change becomes effective or provide you with at least a
month’s supply at the Plan Pharmacy. This will give you
an opportunity to work with your physician to switch to a
different drug that we cover or request an exception. (If a
drug is removed from our formulary because the drug
has been recalled, we will not give 30 days’ notice before
removing the drug from the formulary. Instead, we will
remove the drug immediately and notify members taking
the drug about the change as soon as possible.)
If your drug isn’t listed on your copy of our formulary,
you should first check the formulary on our website,
which we update when there is a change. In addition, you
may call Member Services to be sure it isn’t covered.
If Member Services confirms that we don’t cover your
drug, you have two options:
• You may ask your Plan Physician if you can switch to
another drug that is covered by us
• You or your Plan Physician may ask us to make an
exception (a type of coverage determination) to cover
your Medicare Part D drug. See the “Coverage
Decisions, Complaints, and Appeals” section for
more information on how to request an exception
Transition policy. If you recently joined our plan, you
may be able to get a temporary supply of a Medicare
Part D drug you were previously taking that may not be
on our formulary or has other restrictions, during the first
90 days of your membership. Current members may also
be affected by changes in our formulary from one year to
the next. Members should talk to their Plan Physicians to
decide if they should switch to a different drug that we
cover or request a Part D formulary exception in order to
get coverage for the drug. Refer to our formulary or our
website, kp.org/seniorrx, for more information about
our Part D transition coverage.
Medicare Part D exclusions (non–Part D drugs). By
law, certain types of drugs are not covered by Medicare
Part D. If a drug is not covered by Medicare Part D, any
amounts you pay for that drug will not count toward
reaching the Catastrophic Coverage Stage. A Medicare
Prescription Drug Plan can’t cover a drug under
Medicare Part D in the following situations:
• The drug would be covered under Medicare Part A or
Part B
• Drug purchased outside the United States and its
territories
• Off-label uses (meaning for uses other than those
indicated on a drug’s label as approved by the federal
Food and Drug Administration) of a prescription
drug, except in cases where the use is supported by
certain reference books. Congress specifically listed
the reference books that list whether the off-label use
would be permitted. (These reference books are the
American Hospital Formulary Service Drug
Information and the DRUGDEX Information
System.) If the use is not supported by one of these
references, known as compendia, then the drug is
considered a non–Part D drug and cannot be covered
under Medicare Part D coverage
In addition, by law, certain types of drugs or categories
of drugs are not covered under Medicare Part D. These
drugs include:
• Nonprescription drugs (also called over-the-counter
drugs)
• Drugs when used to promote fertility
• Drugs when used for the relief of cough or cold
symptoms
• Drugs when used for cosmetic purposes or to promote
hair growth
• Prescription vitamins and mineral products, except
prenatal vitamins and fluoride preparations
• Drugs when used for the treatment of sexual or
erectile dysfunction
• Drugs when used for treatment of anorexia, weight
loss, or weight gain
• Outpatient drugs for which the manufacturer seeks to
require that associated tests or monitoring services be
purchased exclusively from the manufacturer as a
condition of sale
Note: In addition to the coverage provided under this
Medicare Part D plan, you also have coverage for non–
Part D drugs described under “Home infusion therapy,”
“Outpatient drugs covered by Medicare Part B,” “Certain
intravenous drugs, supplies, and supplements,” and
“Outpatient drugs, supplies, and supplements not
covered by Medicare” in this “Outpatient Prescription
Drugs, Supplies, and Supplements” section. If a drug is
not covered under Medicare Part D, refer to those
headings for information about your non–Part D drug
coverage.
Other prescription drug coverage. If you have
additional health care or drug coverage from another
plan, you must provide that information to our plan. The
information you provide helps us calculate how much
you and others have paid for your prescription drugs. In
addition, if you lose or gain additional health care or
prescription drug coverage, please call Member Services
to update your membership records.
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Home infusion therapy
We cover home infusion supplies and drugs at no charge
if all of the following are true:
• Your prescription drug is on our Medicare Part D
formulary
• We approved your prescription drug for home
infusion therapy
• Your prescription is written by a network provider
and filled at a network home-infusion pharmacy
Outpatient drugs covered by Medicare Part B
In addition to Medicare Part D drugs, we also cover the
limited number of outpatient prescription drugs that are
covered by Medicare Part B. The following are the types
of drugs that Medicare Part B covers:
• Drugs that usually aren’t self-administered by the
patient and are injected or infused while you are
getting physician, hospital outpatient, or ambulatory
surgical center services
• Drugs you take using durable medical equipment
(such as nebulizers) that were prescribed by a Plan
Physician
• Clotting factors you give yourself by injection if you
have hemophilia
• Immunosuppressive drugs, if Medicare paid for the
transplant (or a group plan was required to pay before
Medicare paid for it)
• Insulin furnished through an item of durable medical
equipment (such as a Medically Necessary insulin
pump)
• Injectable osteoporosis drugs, if you are homebound,
have a bone fracture that a doctor certifies was related
to post-menopausal osteoporosis, and cannot self-
administer the drug
• Antigens
• Certain oral anticancer drugs and antinausea drugs
• Certain drugs for home dialysis, including heparin,
the antidote for heparin when Medically Necessary,
topical anesthetics, and erythropoiesis-stimulating
agents (such as Epogen, Epoetin Alfa, Aranesp, or
Darbepoetin Alfa)
• Intravenous Immune Globulin for the home treatment
of primary immune deficiency diseases
Your Cost Share for Medicare Part B drugs. You pay
the following for Medicare Part B drugs:
• Generic drugs:
♦ a $5 Copayment for up to a 30-day supply, a
$10 Copayment for a 31- to 60-day supply, or a
$15 Copayment for a 61- to 100-day supply at a
Plan Pharmacy
♦ a $5 Copayment for up to a 30-day supply or a
$10 Copayment for a 31- to 100-day supply
through our mail-order service
• Brand-name drugs, specialty drugs, and compounded
products:
♦ a $25 Copayment for up to a 30-day supply, a
$50 Copayment for a 31- to 60-day supply, or a
$75 Copayment for a 61- to 100-day supply at a
Plan Pharmacy
♦ a $25 Copayment for up to a 30-day supply or a
$50 Copayment for a 31- to 100-day supply
through our mail-order service
Certain intravenous drugs, supplies, and
supplements
We cover certain self-administered intravenous drugs,
fluids, additives, and nutrients that require specific types
of parenteral-infusion (such as an intravenous or
intraspinal-infusion) at no charge for up to a 30-day
supply. In addition, we cover the supplies and equipment
required for the administration of these drugs at
no charge.
Outpatient drugs, supplies, and supplements
not covered by Medicare
If a drug, supply, or supplement is not covered by
Medicare Part B or D, we cover the following additional
items in accord with our non–Part D drug formulary:
• Drugs for which a prescription is required by law that
are not covered by Medicare Part B or D. We also
cover certain drugs that do not require a prescription
by law if they are listed on our drug formulary
applicable to non–Part D items
• Diaphragms, cervical caps, contraceptive rings, and
contraceptive patches
• Disposable needles and syringes needed for injecting
covered drugs, pen delivery devices, and visual aids
required to ensure proper dosage (except eyewear),
that are not covered by Medicare Part B or D
• Inhaler spacers needed to inhale covered drugs
• Ketone test strips and sugar or acetone test tablets or
tapes for diabetes urine testing
• FDA-approved medications for tobacco cessation,
including over-the-counter medications when
prescribed by a Plan Physician
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Page 44
Your Cost Share for other outpatient drugs, supplies,
and supplements not covered by Medicare. Your Cost
Share for these items is as follows:
• Generic items (that are not described elsewhere in this
EOC) at a Plan Pharmacy: a $5 Copayment for up to
a 30-day supply, a $10 Copayment for a 31- to 60-
day supply, or a $15 Copayment for a 61- to 100-
day supply
• Generic items (that are not described elsewhere in this
EOC) through our mail-order service: a
$5 Copayment for up to a 30-day supply or a
$10 Copayment for a 31- to 100-day supply
• Brand-name items, specialty drugs, and compounded
products (that are not described elsewhere in this
EOC) at a Plan Pharmacy: a $25 Copayment for up
to a 30-day supply, a $50 Copayment for a 31- to
60-day supply, or a $75 Copayment for a 61- to
100-day supply
• Brand-name items, specialty drugs, and compounded
products (that are not described elsewhere in this
EOC) through our mail-order service: a
$25 Copayment for up to a 30-day supply or a
$50 Copayment for a 31- to 100-day supply
• Drugs prescribed for the treatment of sexual
dysfunction disorders: 25 percent Coinsurance for
up to a 100-day supply
• Amino acid–modified products used to treat
congenital errors of amino acid metabolism (such as
phenylketonuria) and elemental dietary enteral
formula when used as a primary therapy for regional
enteritis: no charge for up to a 30-day supply
• Diabetes urine-testing supplies: no charge for up to a
100-day supply
• Tobacco cessation drugs: no charge. For over-the-
counter medications, we cover up to two 100-day
supplies per calendar year
Note: If Charges for the drug, supply, or supplement are
less than the Copayment, you will pay the lesser amount.
Non–Part D drug formulary. The non–Part D drug
formulary includes a list of drugs that our Pharmacy and
Therapeutics Committee has approved for our Members.
Our Pharmacy and Therapeutics Committee, which is
primarily composed of Plan Physicians, selects drugs for
the drug formulary based on a number of factors,
including safety and effectiveness as determined from a
review of medical literature. The Pharmacy and
Therapeutics Committee meets at least quarterly to
consider additions and deletions based on new
information or drugs that become available. To find out
which drugs are on the formulary for your plan, please
refer to the California Commercial HMO formulary on
our website at kp.org/formulary. The formulary also
discloses requirements or limitations that apply to
specific drugs, such as whether there is a limit on the
amount of the drug that can be dispensed and whether
the drug must be obtained at certain specialty
pharmacies. If you would like to request a copy of this
drug formulary, please call Member Services. Note: The
presence of a drug on the drug formulary does not
necessarily mean that it will be prescribed for a particular
medical condition.
Drug formulary guidelines allow you to obtain
nonformulary prescription drugs (those not listed on our
drug formulary for your condition) if they would
otherwise be covered and a Plan Physician determines
that they are Medically Necessary. If you disagree with
your Plan Physician’s determination that a nonformulary
prescription drug is not Medically Necessary, you may
file an appeal as described in the “Coverage Decisions,
Appeals, and Complaints” section. Also, our non–Part D
formulary guidelines may require you to participate in a
behavioral intervention program approved by the
Medical Group for specific conditions and you may be
required to pay for the program.
About specialty drugs. Specialty drugs are high-cost
drugs that are on our specialty drug list. If your Plan
Physician prescribes more than a 30-day supply for an
outpatient drug, you may be able to obtain more than a
30-day supply at one time, up to the day supply limit for
that drug. However, most specialty drugs are limited to a
30-day supply in any 30-day period. Your Plan
Pharmacy can tell you if a drug you take is one of these
drugs.
Manufacturer coupon program. For outpatient
prescription drugs or items that are covered under this
"Outpatient drugs, supplies, and supplements not covered
by Medicare" section and obtained at a Plan Pharmacy,
you may be able to use approved manufacturer coupons
as payment for the Cost Share that you owe, as allowed
under Health Plan's coupon program. You will owe any
additional amount if the coupon does not cover the entire
amount of your Cost Share for your prescription. Certain
health plan coverages are not eligible for coupons. You
can get more information regarding the Kaiser
Permanente coupon program rules and limitations at
kp.org/rxcoupons.
Drug utilization review
We conduct drug utilization reviews to make sure that
you are getting safe and appropriate care. These reviews
are especially important if you have more than one
doctor who prescribes your medications. We conduct
drug utilization reviews each time you fill a prescription
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Page 45
and on a regular basis by reviewing our records. During
these reviews, we look for medication problems such as:
• Possible medication errors
• Duplicate drugs that are unnecessary because you are
taking another drug to treat the same medical
condition
• Drugs that are inappropriate because of your age or
gender
• Possible harmful interactions between drugs you are
taking
• Drug allergies
• Drug dosage errors
• Unsafe amounts of opioid pain medications
If we identify a medication problem during our drug
utilization review, we will work with your doctor to
correct the problem.
Drug management program
We have a program that can help make sure our
members safely use their prescription opioid
medications, or other medications that are frequently
abused. This program is called a Drug Management
Program (DMP). If you use opioid medications that you
get from several doctors or pharmacies, we may talk to
your doctors to make sure your use is appropriate and
Medically Necessary. Working with your doctors, if we
decide you are at risk for misusing or abusing your
opioid or benzodiazepine medications, we may limit how
you can get those medications. The limitations may be:
• Requiring you to get all your prescriptions for opioid
or benzodiazepine medications from one pharmacy.
• Requiring you to get all your prescriptions for opioid
or benzodiazepine medications from one doctor.
• Limiting the amount of opioid or benzodiazepine
medications we will cover for you.
If we decide that one or more of these limitations should
apply to you, we will send you a letter in advance. The
letter will have information explaining the terms of the
limitations we think should apply to you. You will also
have an opportunity to tell us which doctors or
pharmacies you prefer to use. If you think we made a
mistake or you disagree with our determination that you
are at-risk for prescription drug abuse or the limitation,
you and your prescriber have the right to ask us for an
appeal. See the “Coverage Decisions, Appeals, and
Complaints” section for information about how to ask for
an appeal.
The DMP may not apply to you if you have certain
medical conditions, such as cancer, you are receiving
hospice, palliative, or end-of-life care, or you live in a
long-term care facility.
Medication therapy management program
We offer a medication therapy management program at
no additional cost to Members who have multiple
medical conditions, who are taking many prescription
drugs, and who have high drug costs. This program was
developed for us by a team of pharmacists and doctors.
We use this medication therapy management program to
help us provide better care for our members. For
example, this program helps us make sure that you are
using appropriate drugs to treat your medical conditions
and help us identify possible medication errors.
If you are selected to join a medication therapy
management program, we will send you information
about the specific program, including information about
how to access the program.
ID card at Plan Pharmacies
You must present your Kaiser Permanente ID card when
obtaining covered items from Plan Pharmacies, including
those that are not owned and operated by Kaiser
Permanente. If you do not have your ID card, the Plan
Pharmacy may require you to pay Charges for your
covered items, and you will have to file a claim for
reimbursement as described in the “Requests for
Payment” section.
Notes:
• If Charges for a covered item are less than the
Copayment, you will pay the lesser amount
• Durable medical equipment used to administer drugs,
such as diabetes insulin pumps (and their supplies)
and diabetes blood-testing equipment (and their
supplies) are not covered under this “Outpatient
Prescription Drugs, Supplies, and Supplements”
section (instead, refer to “Durable Medical Equipment
(“DME”) for Home Use” in this “Benefits and Your
Cost Share” section)
• Except for vaccines covered by Medicare Part D,
drugs administered to you in a Plan Medical Office or
during home visits are not covered under this
“Outpatient Prescription Drugs, Supplies, and
Supplements” section (instead, refer to “Outpatient
Care” in this “Benefits and Your Cost Share” section)
• Drugs covered during a covered stay in a Plan
Hospital or Skilled Nursing Facility are not covered
under this “Outpatient Prescription Drugs, Supplies,
and Supplements” section (instead, refer to “Hospital
Inpatient Care” and “Skilled Nursing Facility Care” in
this “Benefits and Your Cost Share” section)
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Outpatient prescription drugs, supplies, and
supplements limitations
Day supply limit. Plan Physicians determine the amount
of a drug or other item that is Medically Necessary for a
particular day supply for you. Upon payment of the Cost
Share specified in this “Outpatient Prescription Drugs,
Supplies, and Supplements” section, you will receive the
supply prescribed up to a 100-day supply in a 100-day
period. However, the Plan Pharmacy may reduce the day
supply dispensed to a 30-day supply in any 30-day
period at the Cost Share listed in this “Outpatient
Prescription Drugs, Supplies, and Supplements” section
if the Plan Pharmacy determines that the drug is in
limited supply in the market or a 31-day supply in any
31-day period if the item is dispensed by a long term care
facility’s pharmacy. Plan Pharmacies may also limit the
quantity dispensed as described under “Utilization
management.” If you wish to receive more than the
covered day supply limit, then the additional amount is
not covered and you must pay Charges for any
prescribed quantities that exceed the day supply limit.
The amount you pay for noncovered drugs does not
count toward reaching the Catastrophic Coverage Stage.
Utilization management. For certain items, we have
additional coverage requirements and limits that help
promote effective drug use and help us control drug plan
costs. Examples of these utilization management tools
are:
• Quantity limits: The Plan Pharmacy may reduce the
day supply dispensed at the Cost Share specified in
this “Outpatient Drugs, Supplies, and Supplements”
section to a 30-day supply or less in any 30-day
period for specific drugs. Your Plan Pharmacy can
tell you if a drug you take is one of these drugs. In
addition, we cover episodic drugs prescribed for the
treatment of sexual dysfunction up to a maximum of
eight doses in any 30-day period, up to 16 doses in
any 60-day period, or up to 27 doses in any 100-day
period. Also, when there is a shortage of a drug in the
marketplace and the amount of available supplies, we
may reduce the quantity of the drug dispensed
accordingly and charge one cost share
• Generic substitution: When there is a generic
version of a brand-name drug available, Plan
Pharmacies will automatically give you the generic
version, unless your Plan Physician has specifically
requested a formulary exception because it is
Medically Necessary for you to receive the brand-
name drug instead of the formulary alternative
Outpatient prescription drugs, supplies, and
supplements exclusions
• Any requested packaging (such as dose packaging)
other than the dispensing pharmacy’s standard
packaging
• Compounded products unless the active ingredient in
the compounded product is listed on one of our drug
formularies
• Drugs prescribed to shorten the duration of the
common cold
• Prescription drugs for which there is an over-the-
counter equivalent (the same active ingredient,
strength, and dosage form as the prescription drug).
This exclusion does not apply to:
♦ insulin
♦ over-the-counter tobacco cessation drugs and
contraceptive drugs
♦ an entire class of prescription drugs when one drug
within that class becomes available over-the-
counter
♦ drugs covered by Medicare Parts B or D
Preventive Services
We cover a variety of Preventive Services in accord with
Medicare guidelines. The list of Preventive Services is
subject to change by the Centers for Medicare &
Medicaid Services. These Preventive Services are subject
to all coverage requirements described in this “Benefits
and Your Cost Share” section and all provisions in the
“Exclusions, Limitations, Coordination of Benefits, and
Reductions” section. If you have questions about
Preventive Services, please call Member Services.
Note: If you receive any other covered Services that are
not Preventive Services during or subsequent to a visit
that includes Preventive Services on the list, you will pay
the applicable Cost Share for those other Services. For
example, if laboratory tests or imaging Services ordered
during a preventive office visit are not Preventive
Services, you will pay the applicable Cost Share for
those Services.
Your Cost Share. You pay the following for covered
Preventive Services:
• Abdominal aortic aneurysm screening prescribed
during the one-time “Welcome to Medicare”
preventive visit: no charge
• Annual Wellness visit: no charge
• Bone mass measurement: no charge
• Breast cancer screening (mammograms): no charge
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Page 47
• Cardiovascular disease risk reduction visit (therapy
for cardiovascular disease): no charge
• Cardiovascular disease testing: no charge
• Cervical and vaginal cancer screening: no charge
• Colorectal cancer screening, including flexible
sigmoidoscopies, colonoscopies, and fecal occult
blood tests: no charge
• Depression screening: no charge
• Diabetes screening, including fasting glucose tests:
no charge
• Diabetes self-management training: no charge
• Glaucoma screening: no charge
• HIV screening: no charge
• Immunizations (including the vaccine) covered by
Medicare Part B such as Hepatitis B, influenza,
pneumococcal, and COVID-19 vaccines that are
administered to you in a Plan Medical Office:
no charge
• Lung cancer screening: no charge
• Medical nutrition therapy for kidney disease and
diabetes: no charge
• Medicare diabetes prevention program: no charge
• Obesity screening and therapy to promote sustained
weight loss: no charge
• Prostate cancer screening exams, including digital
rectal exams and Prostate Specific Antigens (PSA)
tests: no charge
• Screening and counseling to reduce alcohol misuse:
no charge
• Screening for sexually transmitted infections (STIs)
and counseling to prevent STIs: no charge
• Smoking and tobacco use cessation (counseling to
stop smoking or tobacco use): no charge
• “Welcome to Medicare” preventive visit: no charge
Prosthetic and Orthotic Devices
Prosthetic and orthotic devices coverage rules
We cover the prosthetic and orthotic devices specified in
this “Prosthetic and Orthotic Devices” section if all of
the following requirements are met:
• The device is in general use, intended for repeated
use, and primarily and customarily used for medical
purposes
• The device is the standard device that adequately
meets your medical needs
• You receive the device from the provider or vendor
that we select
• The item has been approved for you through the
Plan’s prior authorization process, as described in
“Medical Group authorization procedure for certain
referrals” under “Getting a Referral” in the “How to
Obtain Services” section
• The Services are provided inside your Home Region
Service Area
Coverage includes fitting and adjustment of these
devices, their repair or replacement, and Services to
determine whether you need a prosthetic or orthotic
device. If we cover a replacement device, then you pay
the Cost Share that you would pay for obtaining that
device.
Base prosthetic and orthotic devices
If all of the requirements described under “Prosthetic and
orthotic coverage rules” in this “Prosthetics and Orthotic
Devices” section are met, we cover the items described
in this “Base prosthetic and orthotic devices” section.
Internally implanted devices. We cover prosthetic and
orthotic devices such as pacemakers, intraocular lenses,
cochlear implants, osseointegrated hearing devices, and
hip joints, in accord with Medicare guidelines, if they are
implanted during a surgery that we are covering under
another section of this “Benefits and Your Cost Share”
section. We cover these devices at no charge.
External devices. We cover the following external
prosthetic and orthotic devices at no charge:
• Prosthetics and orthotics in accord with Medicare
guidelines. These include, but are not limited to,
braces, prosthetic shoes, artificial limbs, and
therapeutic footwear for severe diabetes-related foot
disease in accord with Medicare guidelines
• Prosthetic devices and installation accessories to
restore a method of speaking following the removal
of all or part of the larynx (this coverage does not
include electronic voice-producing machines, which
are not prosthetic devices)
• After Medically Necessary removal of all or part of a
breast, prosthesis including custom-made prostheses
when Medically Necessary
• Podiatric devices (including footwear) to prevent or
treat diabetes-related complications when prescribed
by a Plan Physician or by a Plan Provider who is a
podiatrist
• Compression burn garments and lymphedema wraps
and garments
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Page 48
• Enteral formula for Members who require tube
feeding in accord with Medicare guidelines
• Enteral pump and supplies
• Tracheostomy tube and supplies
• Prostheses to replace all or part of an external facial
body part that has been removed or impaired as a
result of disease, injury, or congenital defect
Other covered prosthetic and orthotic devices
If all of the requirements described under “Prosthetic and
orthotic coverage rules” in this “Prosthetics and Orthotic
Devices” section are met, we cover the following items
described in this “Other covered prosthetic and orthotic
devices” section:
• Prosthetic devices required to replace all or part of an
organ or extremity, in accord with Medicare
guidelines
• Vacuum erection device for sexual dysfunction
• Certain surgical boots following surgery when
provided during an outpatient visit
• Orthotic devices required to support or correct a
defective body part, in accord with Medicare
guidelines
• Covered special footwear when custom made for foot
disfigurement due to disease, injury, or
developmental disability
Your Cost Share. You pay the following for other
covered prosthetic and orthotic devices: no charge.
For the following Services, refer to these
sections
• Eyeglasses and contact lenses, including contact
lenses to treat aniridia or aphakia (refer to “Vision
Services”)
• Eyewear following cataract surgery (refer to “Vision
Services”)
• Hearing aids other than internally implanted devices
described in this section (refer to “Hearing Services”)
• Injectable implants (refer to “Administered drugs and
products” under “Outpatient Care”)
Prosthetic and orthotic devices exclusions
• Dental appliances
• Nonrigid supplies not covered by Medicare, such as
elastic stockings and wigs, except as otherwise
described above in this “Prosthetic and Orthotic
Devices” section and the “Ostomy, Urological, and
Specialized Wound Care Supplies” section
• Comfort, convenience, or luxury equipment or
features
• Repair or replacement of device due to misuse
• Shoes, shoe inserts, arch supports, or any other
footwear, even if custom-made, except footwear
described above in this “Prosthetic and Orthotic
Devices” section for diabetes-related complications
and foot disfigurement
• Prosthetic and orthotic devices not intended for
maintaining normal activities of daily living
(including devices intended to provide additional
support for recreational or sports activities)
• Nonconventional intraocular lenses (IOLs) following
cataract surgery (for example, presbyopia-correcting
IOLs). You may request and we may provide
insertion of presbyopia-correcting IOLs or
astigmatism-correcting IOLs following cataract
surgery in lieu of conventional IOLs. However, you
must pay the difference between Charges for
nonconventional IOLs and associated services and
Charges for insertion of conventional IOLs following
cataract surgery
Reconstructive Surgery
We cover the following reconstructive surgery Services:
• Reconstructive surgery to correct or repair abnormal
structures of the body caused by congenital defects,
developmental abnormalities, trauma, infection,
tumors, or disease, if a Plan Physician determines that
it is necessary to improve function, or create a normal
appearance, to the extent possible
• Following Medically Necessary removal of all or part
of a breast, we cover reconstruction of the breast,
surgery and reconstruction of the other breast to
produce a symmetrical appearance, and treatment of
physical complications, including lymphedemas
Your Cost Share. You pay the following for covered
reconstructive surgery Services:
• Outpatient surgery and outpatient procedures when
provided in an outpatient or ambulatory surgery
center or in a hospital operating room, or if it is
provided in any setting and a licensed staff member
monitors your vital signs as you regain sensation after
receiving drugs to reduce sensation or to minimize
discomfort: a $100 Copayment per procedure
• Any other outpatient surgery that does not require a
licensed staff member to monitor your vital signs as
described above: a $20 Copayment per procedure
• Any other outpatient procedures that do not require a
licensed staff member to monitor your vital signs as
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Page 49
described above: the Cost Share that would
otherwise apply for the procedure in this “Benefits
and Your Cost Share” section (for example, radiology
procedures that do not require a licensed staff
member to monitor your vital signs as described
above are covered under “Outpatient Imaging,
Laboratory, and Other Diagnostic and Treatment
Services”)
• Hospital inpatient Services (including room and
board, drugs, imaging, laboratory, other diagnostic
and treatment Services, and Plan Physician Services):
a $250 Copayment per admission
For the following Services, refer to these
sections
• Office visits not described in this “Reconstructive
Surgery” section (refer to “Outpatient Care”)
• Outpatient imaging and laboratory (refer to
“Outpatient Imaging, Laboratory, and Other
Diagnostic and Treatment Services”)
• Outpatient prescription drugs (refer to “Outpatient
Prescription Drugs, Supplies, and Supplements”)
• Outpatient administered drugs (refer to “Outpatient
Care”)
• Prosthetics and orthotics (refer to “Prosthetic and
Orthotic Devices”)
• Telehealth Visits (refer to “Telehealth Visits”)
Reconstructive surgery exclusions
• Surgery that, in the judgment of a Plan Physician
specializing in reconstructive surgery, offers only a
minimal improvement in appearance
Religious Nonmedical Health Care
Institution Services
Care in a Medicare-certified Religious Nonmedical
Health Care Institution (RNHCI) is covered by our Plan
under certain conditions. Covered Services in an RNHCI
are limited to nonreligious aspects of care. To be eligible
for covered Services in a RNHCI, you must have a
medical condition that would allow you to receive
inpatient hospital or Skilled Nursing Facility care. You
may get Services furnished in the home, but only items
and Services ordinarily furnished by home health
agencies that are not RNHCIs. In addition, you must sign
a legal document that says you are conscientiously
opposed to the acceptance of “nonexcepted” medical
treatment. (“Excepted” medical treatment is a Service or
treatment that you receive involuntarily or that is
required under federal, state, or local law.
“Nonexcepted” medical treatment is any other Service or
treatment.) Your stay in the RNHCI is not covered by us
unless you obtain authorization (approval) in advance
from us.
Note: Covered Services are subject to the same
limitations and Cost Share required for Services provided
by Plan Providers as described in this “Benefits and Your
Cost Share” section.
Services Associated with Clinical Trials
If you participate in a Medicare-approved study, Original
Medicare pays most of the costs for the covered Services
you receive as part of the study. If you tell us that you
are in a qualified clinical trial, then you are only
responsible for the in-network cost-sharing for the
services in that trial. If you paid more, for example, if
you already paid the Original Medicare cost-sharing
amount, we will reimburse the difference between what
you paid and the in-network cost-sharing. However, you
will need to provide documentation to show us how
much you paid. When you are in a clinical research
study, you may stay enrolled in our plan and continue to
get the rest of your care (the care that is not related to the
study) through our plan.
If you want to participate in any Medicare-approved
clinical research study, you do not need to tell us or to
get approval from us or your Plan Provider. The
providers that deliver your care as part of the clinical
research study do not need to be part of our plan's
network of providers. Although you do not need to get
our plan's permission to be in a clinical research study,
we encourage you to notify us in advance when you
choose to participate in Medicare-qualified clinical trials.
If you participate in a study that Medicare has not
approved, you will be responsible for paying all costs for
your participation in the study.
Once you join a Medicare-approved clinical research
study, Original Medicare covers the routine items and
Services you receive as part of the study, including:
• Room and board for a hospital stay that Medicare
would pay for even if you weren’t in a study
• An operation or other medical procedure if it is part
of the research study
• Treatment of side effects and complications of the
new care
After Medicare has paid its share of the cost for these
Services, our plan will pay the difference between the
cost-sharing in Original Medicare and your Cost Share as
a Member of our plan. This means you will pay the same
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Page 50
amount for the Services you receive as part of the study
as you would if you received these Services from our
plan. However, you are required to submit
documentation showing how much cost sharing you
paid. Please see the “Requests for Payment” section for
more information for submitting requests for payment.
You can get more information about joining a clinical
research study by visiting the Medicare website to read
or download the publication “Medicare and Clinical
Research Studies.” (The publication is available at
https://www.medicare.gov.) You can also call
1-800-MEDICARE (1-800-633-4227), 24 hours a day,
seven days a week. TTY users call 1-877-486-2048.
Services associated with clinical trials
exclusions
When you are part of a clinical research study, neither
Medicare nor our plan will pay for any of the following:
• The new item or service that the study is testing,
unless Medicare would cover the item or service even
if you were not in a study
• Items or services provided only to collect data, and
not used in your direct health care
• Services that are customarily provided by the research
sponsors free of charge to enrollees in the clinical trial
• Items and services provided solely to determine trial
eligibility
Skilled Nursing Facility Care
Inside your Home Region Service Area, we cover up to
100 days per benefit period of skilled inpatient Services
in a Plan Skilled Nursing Facility and in accord with
Medicare guidelines. The skilled inpatient Services must
be customarily provided by a Skilled Nursing Facility,
and above the level of custodial or intermediate care.
A benefit period begins on the date you are admitted to a
hospital or Skilled Nursing Facility at a skilled level of
care (defined in accord with Medicare guidelines). A
benefit period ends on the date you have not been an
inpatient in a hospital or Skilled Nursing Facility,
receiving a skilled level of care, for 60 consecutive days.
A new benefit period can begin only after any existing
benefit period ends. A prior three-day stay in an acute
care hospital is not required. Note: If your Cost Share
changes during a benefit period, you will continue to pay
the previous Cost Share amount until a new benefit
period begins.
We cover the following Services:
• Physician and nursing Services
• Room and board
• Drugs prescribed by a Plan Physician as part of your
plan of care in the Plan Skilled Nursing Facility in
accord with our drug formulary guidelines if they are
administered to you in the Plan Skilled Nursing
Facility by medical personnel
• Durable medical equipment in accord with our prior
authorization procedure if Skilled Nursing Facilities
ordinarily furnish the equipment (refer to “Medical
Group authorization procedure for certain referrals”
under “Getting a Referral” in the “How to Obtain
Services” section)
• Imaging and laboratory Services that Skilled Nursing
Facilities ordinarily provide
• Medical social services
• Whole blood, red blood cells, plasma, platelets, and
their administration
• Medical supplies
• Physical, occupational, and speech therapy in accord
with Medicare guidelines
• Respiratory therapy
Your Cost Share. We cover these Skilled Nursing
Facility Services at no charge.
For the following Services, refer to these
sections
• Outpatient imaging, laboratory, and other diagnostic
and treatment Services (refer to “Outpatient Imaging,
Laboratory, and Other Diagnostic and Treatment
Services”)
Non–Plan Skilled Nursing Facility care
Generally, you will get your Skilled Nursing Facility
care from Plan Facilities. However, under certain
conditions listed below, you may be able to receive
covered care from a non–Plan facility, if the facility
accepts our Plan’s amounts for payment.
• A nursing home or continuing care retirement
community where you were living right before you
went to the hospital (as long as it provides Skilled
Nursing Facility care)
• A Skilled Nursing Facility where your spouse is
living at the time you leave the hospital
Substance Use Disorder Treatment
We cover Services specified in this “Substance Use
Disorder Treatment” section only when the Services are
for the preventive, diagnosis, or treatment of Substance
Use Disorders. A “Substance Use Disorder” is a
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Page 51
condition identified as a “substance use disorder” in the
most recently issued edition of the Diagnostic and
Statistical Manual of Mental Disorders (“DSM”).
Outpatient substance use disorder treatment
We cover the following Services for treatment of
substance use disorders:
• Day-treatment programs
• Individual and group substance use disorder
counseling
• Intensive outpatient programs
• Medical treatment for withdrawal symptoms
Your Cost Share. You pay the following for these
covered Services:
• Individual substance use disorder evaluation and
treatment: a $20 Copayment per visit
• Group substance use disorder treatment: a
$5 Copayment per visit
• Intensive outpatient and day-treatment programs: a
$5 Copayment per day
Residential treatment
Inside your Home Region Service Area, we cover the
following Services when the Services are provided in a
licensed residential treatment facility that provides 24-
hour individualized substance use disorder treatment, the
Services are generally and customarily provided by a
substance use disorder residential treatment program in a
licensed residential treatment facility, and the Services
are above the level of custodial care:
• Individual and group substance use disorder
counseling
• Medical services
• Medication monitoring
• Room and board
• Drugs prescribed by a Plan Provider as part of your
plan of care in the residential treatment facility in
accord with our drug formulary guidelines if they are
administered to you in the facility by medical
personnel (for discharge drugs prescribed when you
are released from the residential treatment facility,
refer to “Outpatient Prescription Drugs, Supplies, and
Supplements” in this “Benefits and Your Cost Share”
section)
• Discharge planning
Your Cost Share. We cover residential substance use
disorder treatment Services at a $100 Copayment per
admission.
Inpatient detoxification
We cover hospitalization in a Plan Hospital only for
medical management of withdrawal symptoms, including
room and board, Plan Physician Services, drugs,
dependency recovery Services, education, and
counseling.
Your Cost Share. We cover inpatient detoxification
Services at a $250 Copayment per admission.
For the following Services, refer to these
sections
• Outpatient laboratory (refer to “Outpatient Imaging,
Laboratory, and Other Diagnostic and Treatment
Services”)
• Outpatient self-administered drugs (refer to
“Outpatient Prescription Drugs, Supplies, and
Supplements”)
• Telehealth Visits (refer to “Telehealth Visits”)
Telehealth Visits
Telehealth Visits between you and your provider are
intended to make it more convenient for you to receive
covered Services, when a Plan Provider determines it is
medically appropriate for your medical condition. You
have the option of receiving these services either through
an in-person visit or via telehealth. You may receive
covered Services via Telehealth Visits, when available
and if the Services would have been covered under this
EOC if provided in person. If you choose to receive
Services via telehealth, then you must use a Plan
Provider that currently offers the service via telehealth.
We offer the following telehealth Services:
• Telehealth Services for monthly end-stage renal
disease--related visits for home dialysis members in a
hospital-based or critical access hospital-based renal
dialysis center, renal dialysis facility, or the
Member’s home
• Telehealth Services to diagnose, evaluate or treat
symptoms of a stroke, regardless of your location
• Telehealth services for members with a substance use
disorder or co-occurring mental health disorder,
regardless of their location
• Telehealth services for diagnosis, evaluation, and
treatment of mental health disorders if:
♦ you have an in-person visit within 6 months prior
to your first telehealth visit
♦ you have an in-person visit every 12 months while
receiving these telehealth services
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♦ exceptions can be made to the above for certain
circumstances
• Telehealth services for mental health visits provided
by Rural Health Clinics and Federally Qualified
Health Centers
• Virtual check-ins (for example, by phone or video
chat) with your doctor for 5-10 minutes if:
♦ you’re not a new patient, and
♦ the evaluation isn’t related to an office visit in the
past 7 days, and
♦ the evaluation doesn’t lead to an office visit within
24 hours or the soonest available appointment
• Evaluation of video and/or images you send to your
doctor, and interpretation and follow-up by your
doctor within 24 hours if:
♦ you’re not a new patient, and
♦ the check-in isn’t related to an office visit in the
past 7 days, and
♦ the check-in doesn’t lead to an office visit within
24 hours or the soonest available appointment
• Consultation your doctor has with other doctors by
phone, internet, or electronic health record
Your Cost Share. You pay the following types for
Telehealth Visits with Primary Care Physicians, Non-
Physician Specialists, and Physician Specialists:
• Interactive video visits: no charge
• Scheduled telephone visits: no charge
Transplant Services
We cover transplants of organs, tissue, or bone marrow
in accord with Medicare guidelines and if the Medical
Group provides a written referral for care to a transplant
facility as described in “Medical Group authorization
procedure for certain referrals” under “Getting a
Referral” in the “How to Obtain Services” section.
After the referral to a transplant facility, the following
applies:
• If either the Medical Group or the referral facility
determines that you do not satisfy its respective
criteria for a transplant, we will only cover Services
you receive before that determination is made
• Health Plan, Plan Hospitals, the Medical Group, and
Plan Physicians are not responsible for finding,
furnishing, or ensuring the availability of an organ,
tissue, or bone marrow donor
• In accord with our guidelines for Services for living
transplant donors, we provide certain donation-related
Services for a donor, or an individual identified by the
Medical Group as a potential donor, whether or not
the donor is a Member. These Services must be
directly related to a covered transplant for you, which
may include certain Services for harvesting the organ,
tissue, or bone marrow and for treatment of
complications. Please call Member Services for
questions about donor Services
Your Cost Share. For covered transplant Services that
you receive, you will pay the Cost Share you would pay
if the Services were not related to a transplant. For
example, see “Hospital Inpatient Services” in this
“Benefits and Your Cost Share” section for the Cost
Share that applies for hospital inpatient Services.
We provide or pay for donation-related Services for
actual or potential donors (whether or not they are
Members) in accord with our guidelines for donor
Services at no charge.
For the following Services, refer to these
sections
• Dental Services that are Medically Necessary to
prepare for a transplant (refer to “Dental Services”)
• Outpatient imaging and laboratory (refer to
“Outpatient Imaging, Laboratory, and Other
Diagnostic and Treatment Services”)
• Outpatient prescription drugs (refer to “Outpatient
Prescription Drugs, Supplies, and Supplements”)
• Outpatient administered drugs (refer to “Outpatient
Care”)
Vision Services
We cover the following:
• Routine eye exams with a Plan Optometrist to
determine the need for vision correction (including
dilation Services when Medically Necessary) and to
provide a prescription for eyeglass lenses: a
$20 Copayment per visit
• Physician Specialist Visits to diagnose and treat
injuries or diseases of the eye: a $20 Copayment per
visit
• Non-Physician Specialist Visits to diagnose and treat
injuries or diseases of the eye: a $20 Copayment per
visit
Optical Services
We cover the Services described in this “Optical
Services” section when received from Plan Medical
Offices or Plan Optical Sales Offices.
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The date we provide an Allowance toward (or otherwise
cover) an item described in this “Optical Services”
section is the date on which you order the item. For
example, if we last provided an Allowance toward an
item you ordered on May 1, 2022, and if we provide an
Allowance not more than once every 24 months for that
type of item, then we would not provide another
Allowance toward that type of item until on or after May
1, 2024. You can use the Allowances under this “Optical
Services” section only when you first order an item.
If you use part but not all of an Allowance when you first
order an item, you cannot use the rest of that Allowance
later.
Eyeglasses and contact lenses following cataract
surgery
We cover at no charge one pair of eyeglasses or contact
lenses (including fitting or dispensing) following each
cataract surgery that includes insertion of an intraocular
lens at Plan Medical Offices or Plan Optical Sales
Offices when prescribed by a physician or optometrist.
When multiple cataract surgeries are needed, and you do
not obtain eyeglasses or contact lenses between
procedures, we will only cover one pair of eyeglasses or
contact lenses after any surgery. If the eyewear you
purchase costs more than what Medicare covers for
someone who has Original Medicare (also known as
“Fee-for-Service Medicare”), you pay the difference.
Special contact lenses
We cover the following:
• For aniridia (missing iris), we cover up to two
Medically Necessary contact lenses per eye
(including fitting and dispensing) in any 12-month
period when prescribed by a Plan Physician or Plan
Optometrist: no charge
• In accord with Medicare guidelines, we cover
corrective lenses (including contact lens fitting and
dispensing) and frames (and replacements) for
Members who are aphakic (for example, who have
had a cataract removed but do not have an implanted
intraocular lens (IOL) or who have congenital
absence of the lens): no charge
• For other specialty contact lenses that will provide a
significant improvement in your vision not obtainable
with eyeglass lenses, we cover either one pair of
contact lenses (including fitting and dispensing) or an
initial supply of disposable contact lenses (up to six
months, including fitting and dispensing) in any 24
months at no charge
Eyeglasses and contact lenses
We provide a single $150 Allowance toward the
purchase price of any or all of the following not more
than once every 24 months when a physician or
optometrist prescribes an eyeglass lens (for eyeglass
lenses and frames) or contact lens (for contact lenses):
• Eyeglass lenses when a Plan Provider puts the lenses
into a frame
♦ we cover a clear balance lens when only one eye
needs correction
♦ we cover tinted lenses when Medically Necessary
to treat macular degeneration or retinitis
pigmentosa
• Eyeglass frames when a Plan Provider puts two lenses
(at least one of which must have refractive value) into
the frame
• Contact lenses, fitting, and dispensing
We will not provide the Allowance if we have provided
an Allowance toward (or otherwise covered) eyeglass
lenses or frames within the previous 24 months.
Replacement lenses
If you have a change in prescription of at least .50
diopter in one or both eyes within 12 months of the
initial point of sale of an eyeglass lens or contact lens
that we provided an Allowance toward (or otherwise
covered) we will provide an Allowance toward the
purchase price of a replacement item of the same type
(eyeglass lens, or contact lens, fitting, and dispensing)
for the eye that had the .50 diopter change. The
Allowance toward one of these replacement lenses is $30
for a single vision eyeglass lens or for a contact lens
(including fitting and dispensing) and $45 for a
multifocal or lenticular eyeglass lens.
For the following Services, refer to these
sections
• Services related to the eye or vision other than
Services covered under this “Vision Services”
section, such as outpatient surgery and outpatient
prescription drugs, supplies, and supplements (refer to
the applicable heading in this “Benefits and Your
Cost Share” section)
Vision Services exclusions
• Eyeglass or contact lens adornment, such as
engraving, faceting, or jeweling
• Items that do not require a prescription by law (other
than eyeglass frames), such as eyeglass holders,
eyeglass cases, and repair kits
• Lenses and sunglasses without refractive value,
except as described in this “Vision Services” section
• Low vision devices
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• Replacement of lost, broken, or damaged contact
lenses, eyeglass lenses, and frames
Exclusions, Limitations,
Coordination of Benefits, and
Reductions
Exclusions
The items and services listed in this “Exclusions” section
are excluded from coverage. These exclusions apply to
all Services that would otherwise be covered under this
EOC regardless of whether the services are within the
scope of a provider’s license or certificate. Additional
exclusions that apply only to a particular benefit are
listed in the description of that benefit in this EOC.
These exclusions or limitations do not apply to Services
that are Medically Necessary to treat Severe Mental
Illness or Serious Emotional Disturbance of a Child
Under Age 18.
Certain exams and Services
Routine physical exams and other Services that are not
Medically Necessary, such as when required (1) for
obtaining or maintaining employment or participation in
employee programs, (2) for insurance, credentialing or
licensing, (3) for travel, or (4) by court order or for
parole or probation.
Chiropractic Services
Chiropractic Services and the Services of a chiropractor,
except for manual manipulation of the spine as described
under “Outpatient Care” in the “Benefits and Your Cost
Share” section or unless you have coverage for
supplemental chiropractic Services as described in an
amendment to this EOC.
Cosmetic Services
Services that are intended primarily to change or
maintain your appearance, including cosmetic surgery
(surgery that is performed to alter or reshape normal
structures of the body in order to improve appearance),
except that this exclusion does not apply to any of the
following:
• Services covered under “Reconstructive Surgery” in
the “Benefits and Your Cost Share” section
• The following devices covered under “Prosthetic and
Orthotic Devices” in the “Benefits and Your Cost
Share” section: testicular implants implanted as part
of a covered reconstructive surgery, breast prostheses
needed after removal of all or part of a breast or
lumpectomy, and prostheses to replace all or part of
an external facial body part
Custodial care
Assistance with activities of daily living (for example:
walking, getting in and out of bed, bathing, dressing,
feeding, toileting, and taking medicine).
This exclusion does not apply to assistance with
activities of daily living that is provided as part of
covered hospice for Members who do not have Part A,
Skilled Nursing Facility, or hospital inpatient care.
Dental care
Dental care and dental X-rays, such as dental Services
following accidental injury to teeth, dental appliances,
dental implants, orthodontia, and dental Services
resulting from medical treatment such as surgery on the
jawbone and radiation treatment, except for Services
covered in accord with Medicare guidelines or under
“Dental Services” in the “Benefits and Your Cost Share”
section.
Disposable supplies
Disposable supplies for home use, such as bandages,
gauze, tape, antiseptics, dressings, Ace-type bandages,
and diapers, underpads, and other incontinence supplies.
This exclusion does not apply to disposable supplies
covered in accord with Medicare guidelines or under
“Durable Medical Equipment (“DME”) for Home Use,”
“Home Health Care,” “Hospice Care,” “Ostomy,
Urological, and Wound Care Supplies,” “Outpatient
Prescription Drugs, Supplies, and Supplements,” and
“Prosthetic and Orthotic Devices” in the “Benefits and
Your Cost Share” section.
Experimental or investigational Services
A Service is experimental or investigational if we, in
consultation with the Medical Group, determine that one
of the following is true:
• Generally accepted medical standards do not
recognize it as safe and effective for treating the
condition in question (even if it has been authorized
by law for use in testing or other studies on human
patients)
• It requires government approval that has not been
obtained when the Service is to be provided
Hair loss or growth treatment
Items and services for the promotion, prevention, or
other treatment of hair loss or hair growth.
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Intermediate care
Care in a licensed intermediate care facility. This
exclusion does not apply to Services covered under
“Durable Medical Equipment (“DME”) for Home Use,”
“Home Health Care,” and “Hospice Care” in the
“Benefits and Your Cost Share” section.
Items and services that are not health care items
and services
For example, we do not cover:
• Teaching manners and etiquette
• Teaching and support services to develop planning
skills such as daily activity planning and project or
task planning
• Items and services for the purpose of increasing
academic knowledge or skills
• Teaching and support services to increase intelligence
• Academic coaching or tutoring for skills such as
grammar, math, and time management
• Teaching you how to read, whether or not you have
dyslexia
• Educational testing
• Teaching art, dance, horse riding, music, play, or
swimming
• Teaching skills for employment or vocational
purposes
• Vocational training or teaching vocational skills
• Professional growth courses
• Training for a specific job or employment counseling
• Aquatic therapy and other water therapy, except when
ordered as part of a physical therapy program in
accord with Medicare guidelines
Items and services to correct refractive defects
of the eye
Items and services (such as eye surgery or contact lenses
to reshape the eye) for the purpose of correcting
refractive defects of the eye such as myopia, hyperopia,
or astigmatism.
Massage therapy
Massage therapy is not covered.
Oral nutrition and weight loss aids
Outpatient oral nutrition, such as dietary supplements,
herbal supplements, formulas, food, and weight loss aids.
This exclusion does not apply to any of the following:
• Amino acid–modified products and elemental dietary
enteral formula covered under “Outpatient
Prescription Drugs, Supplies, and Supplements” in
the “Benefits and Your Cost Share” section
• Enteral formula covered under “Prosthetic and
Orthotic Devices” in the “Benefits and Your Cost
Share” section
Residential care
Care in a facility where you stay overnight, except that
this exclusion does not apply when the overnight stay is
part of covered care in a hospital, a Skilled Nursing
Facility, inpatient respite care covered in the “Hospice
Care” section for Members who do not have Part A, or
residential treatment program Services covered in the
“Substance Use Disorder Treatment” and “Mental Health
Services” sections.
Routine foot care items and services
Routine foot care items and services, except for
Medically Necessary Services covered in accord with
Medicare guidelines.
Services not approved by the federal Food and
Drug Administration
Drugs, supplements, tests, vaccines, devices, radioactive
materials, and any other Services that by law require
federal Food and Drug Administration (“FDA”) approval
in order to be sold in the U.S., but are not approved by
the FDA. This exclusion applies to Services provided
anywhere, even outside the U.S., unless the Services are
covered under the “Emergency Services and Urgent
Care” section.
Services and items not covered by Medicare
Services and items that are not covered by Medicare,
including services and items that aren’t reasonable and
necessary, according to the standards of the Original
Medicare plan, unless these Services are otherwise listed
in this EOC as a covered Service.
Services performed by unlicensed people
Services that are performed safely and effectively by
people who do not require licenses or certificates by the
state to provide health care services and where the
Member’s condition does not require that the services be
provided by a licensed health care provider.
Services related to a noncovered Service
When a Service is not covered, all Services related to the
noncovered Service are excluded, except for Services we
would otherwise cover to treat complications of the
noncovered Service or if covered in accord with
Medicare guidelines. For example, if you have a
noncovered cosmetic surgery, we would not cover
Services you receive in preparation for the surgery or for
follow-up care. If you later suffer a life-threatening
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complication such as a serious infection, this exclusion
would not apply and we would cover any Services that
we would otherwise cover to treat that complication.
Surrogacy
Services for anyone in connection with a Surrogacy
Arrangement, except for otherwise-covered Services
provided to a Member who is a surrogate. Refer to
“Surrogacy Arrangements” under “Reductions” in this
“Exclusions, Limitations, Coordination of Benefits, and
Reductions” section for information about your
obligations to us in connection with a Surrogacy
Arrangement, including your obligations to reimburse us
for any Services we cover and to provide information
about anyone who may be financially responsible for
Services the baby (or babies) receive.
Travel and lodging expenses
Travel and lodging expenses, except as described in our
Travel and Lodging Program Description. The Travel
and Lodging Program Description is available online at
kp.org/specialty-care/travel-reimbursements or by
calling Member Services.
Limitations
We will make a good faith effort to provide or arrange
for covered Services within the remaining availability of
facilities or personnel in the event of unusual
circumstances that delay or render impractical the
provision of Services under this EOC, such as a major
disaster, epidemic, war, riot, civil insurrection, disability
of a large share of personnel at a Plan Facility, complete
or partial destruction of facilities, and labor dispute.
Under these circumstances, if you have an Emergency
Medical Condition, call 911 or go to the nearest
emergency department as described under “Emergency
Services” in the “Emergency Services and Urgent Care”
section, and we will provide coverage and
reimbursement as described in that section.
Additional limitations that apply only to a particular
benefit are listed in the description of that benefit in this
EOC.
Coordination of Benefits
If you have other medical or dental coverage, it is
important to use your other coverage in combination
with your coverage as a Senior Advantage Member to
pay for the care you receive. This is called “coordination
of benefits” because it involves coordinating all of the
health benefits that are available to you. Using all of the
coverage you have helps keep the cost of health care
more affordable for everyone.
You must tell us if you have other health care coverage,
and let us know whenever there are any changes in your
additional coverage. The types of additional coverage
that you might have include the following:
• Coverage that you have from an employer’s group
health care coverage for employees or retirees, either
through yourself or your spouse
• Coverage that you have under workers’ compensation
because of a job-related illness or injury, or under the
Federal Black Lung Program
• Coverage you have for an accident where no-fault
insurance or liability insurance is involved
• Coverage you have through Medicaid
• Coverage you have through the “TRICARE for Life”
program (veteran’s benefits)
• Coverage you have for dental insurance or
prescription drugs
• “Continuation coverage” you have through COBRA
(COBRA is a law that requires employers with 20 or
more employees to let employees and their
dependents keep their group health coverage for a
time after they leave their group health plan under
certain conditions)
When you have additional health care coverage, how we
coordinate your benefits as a Senior Advantage Member
with your benefits from your other coverage depends on
your situation. With coordination of benefits, you will
often get your care as usual from Plan Providers, and the
other coverage you have will simply help pay for the
care you receive. In other situations, such as benefits that
we don’t cover, you may get your care outside of our
plan directly through your other coverage.
In general, the coverage that pays its share of your bills
first is called the “primary payer.” Then the other
company or companies that are involved (called the
“secondary payers”) each pay their share of what is left
of your bills. Often your other coverage will settle its
share of payment directly with us and you will not have
to be involved. However, if payment owed to us is sent
directly to you, you are required under Medicare law to
give this payment to us. When you have additional
coverage, whether we pay first or second, or at all,
depends on what type or types of additional coverage
you have and the rules that apply to your situation. Many
of these rules are set by Medicare. Some of them take
into account whether you have a disability or have end-
stage renal disease, or how many employees are covered
by an employer’s group plan.
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If you have additional health coverage, please call
Member Services to find out which rules apply to your
situation, and how payment will be handled.
Reductions
Employer responsibility
For any Services that the law requires an employer to
provide, we will not pay the employer, and, when we
cover any such Services, we may recover the value of the
Services from the employer.
Government agency responsibility
For any Services that the law requires be provided only
by or received only from a government agency, we will
not pay the government agency, and, when we cover any
such Services, we may recover the value of the Services
from the government agency.
Injuries or illnesses alleged to be caused by
third parties
Third parties who cause you injury or illness (and/or
their insurance companies) usually must pay first before
Medicare or our plan. Therefore, we are entitled to
pursue these primary payments. If you obtain a judgment
or settlement from or on behalf of a third party who
allegedly caused an injury or illness for which you
received covered Services, you must ensure we receive
reimbursement for those Services. Note: This “Injuries or
illnesses alleged to be caused by third parties” section
does not affect your obligation to pay your Cost Share
for these Services.
To the extent permitted or required by law, we shall be
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.
To secure our rights, we will have a lien and
reimbursement rights to the proceeds of any judgment or
settlement you or we obtain against a third party that
results in any settlement proceeds or judgment, from
other types of coverage that include but are not limited
to: liability, uninsured motorist, underinsured motorist,
personal umbrella, workers’ compensation, personal
injury, medical payments and all other first party types.
The proceeds of any judgment or settlement that you or
we obtain shall first be applied to satisfy our lien,
regardless of whether you are made whole and regardless
of whether the total amount of the proceeds is less than
the actual losses and damages you incurred. We are not
required to pay attorney fees or costs to any attorney
hired by you to pursue your damages claim. If you
reimburse us without the need for legal action, we will
allow a procurement cost discount. If we have to pursue
legal action to enforce its interest, there will be no
procurement discount.
Within 30 days after submitting or filing a claim or legal
action against a third party, you must send written notice
of the claim or legal action to:
For Northern California Home Region Members:
Equian
Kaiser Permanente - Northern California Region
Subrogation Mailbox
P.O. Box 36380
Louisville, KY 40233
Fax: 1-502-214-1137
For Southern California Home Region Members:
The Rawlings Group
Subrogation Mailbox
P.O. Box 2000
LaGrange, KY 40031
Fax: 1-502-753-7064
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, the third
party, and the third party’s liability insurer to pay us
directly. You may not agree to waive, release, or reduce
our rights under this provision without our prior, written
consent.
If your estate, parent, guardian, or conservator asserts a
claim against a third party based on your injury or
illness, 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.
Surrogacy Arrangements
If you enter into a Surrogacy Arrangement and you or
any other payee are entitled to receive payments or other
compensation under the Surrogacy Arrangement, you
must reimburse us for covered Services you receive
related to conception, pregnancy, delivery, or postpartum
care in connection with that arrangement (“Surrogacy
Health Services”) to the maximum extent allowed under
California Civil Code Section 3040. Note: This
“Surrogacy Arrangements” section does not affect your
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obligation to pay your Cost Share for these Services.
After you surrender a baby to the legal parents, you are
not obligated to reimburse us for any Services that the
baby receives (the legal parents are financially
responsible for any Services that the baby receives).
By accepting Surrogacy Health Services, you
automatically assign to us your right to receive payments
that are payable to you or any other payee under the
Surrogacy Arrangement, 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
Arrangement, you must send written notice of the
arrangement, including all of the following information:
• Names, addresses, and phone numbers of the other
parties to the arrangement
• Names, addresses, and phone numbers of any escrow
agent or trustee
• Names, addresses, and phone numbers of the intended
parents and any other parties who are financially
responsible for Services the baby (or babies) receive,
including names, addresses, and phone numbers for
any health insurance that will cover Services that the
baby (or babies) receive
• A signed copy of any contracts and other documents
explaining the arrangement
• Any other information we request in order to satisfy
our rights
You must send this information to:
For Northern California Home Region Members:
Equian
Kaiser Permanente – Northern California Region
Surrogacy Mailbox
P.O. Box 36380
Louisville, KY 40233
Fax: 1-502-214-1137
For Southern California Home Region Members:
The Rawlings Group
Surrogacy Mailbox
P.O. Box 2000
LaGrange, KY 40031
Fax: 1-502-753-7064
You must complete and send us all 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
Arrangements” section and to satisfy those rights. You
may not agree to waive, release, or reduce our rights
under this “Surrogacy Arrangements” section without
our prior, written consent.
If your estate, parent, guardian, or conservator asserts a
claim against another party based on the Surrogacy
Arrangement, 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 other party. We
may assign our rights to enforce our liens and other
rights.
If you have questions about your obligations under this
provision, please call Member Services.
U.S. Department of Veterans Affairs
For any Services for conditions arising from military
service that the law requires the Department of Veterans
Affairs to provide, we will not pay the Department of
Veterans Affairs, and when we cover any such Services
we may recover the value of the Services from the
Department of Veterans Affairs.
Workers’ compensation or employer’s liability
benefits
Workers’ compensation usually must pay first before
Medicare or our plan. Therefore, we are entitled to
pursue primary payments under workers’ compensation
or employer’s liability law. You may be eligible for
payments or other benefits, including amounts received
as a settlement (collectively referred to as “Financial
Benefit”), under workers’ compensation or employer’s
liability law. We will provide covered Services even if it
is unclear whether you are entitled to a Financial Benefit,
but we may recover the value of any covered Services
from the following sources:
• From any source providing a Financial Benefit or
from whom a Financial Benefit is due
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Page 59
• From you, to the extent that a Financial Benefit is
provided or payable or would have been required to
be provided or payable if you had diligently sought to
establish your rights to the Financial Benefit under
any workers’ compensation or employer’s liability
law
Requests for Payment
Requests for Payment of Covered
Services or Part D drugs
If you pay our share of the cost of your covered
services or Part D drugs, or if you receive a bill,
you can ask us for payment
Sometimes when you get medical care or a Part D drug,
you may need to pay the full cost. Other times, you may
find that you have paid more than you expected under
the coverage rules of our plan. In these cases, you can
ask us to pay you back (paying you back is often called
“reimbursing” you). It is your right to be paid back by
our plan whenever you’ve paid more than your share of
the cost for medical services or Part D drugs that are
covered by our plan. There may be deadlines that you
must meet to get paid back.
There may also be times when you get a bill from a
provider for the full cost of medical care you have
received or possibly for more than your share of cost
sharing as discussed in this document. First try to
resolve the bill with the provider. If that does not
work, send the bill to us instead of paying it. We will
look at the bill and decide whether the services should
be covered. If we decide they should be covered, we
will pay the provider directly. If we decide not to pay
it, we will notify the provider. You should never pay
more than plan-allowed cost sharing. If this provider is
contracted, you still have the right to treatment.
Here are examples of situations in which you may need
to ask us to pay you back or to pay a bill you have
received:
When you’ve received emergency, urgent, or dialysis
care from a Non–Plan Provider. Outside the service
area, you can receive emergency or urgently needed
services from any provider, whether or not the provider
is a Plan Provider. In these cases:
• You are only responsible for paying your share of the
cost for emergency or urgently needed services.
Emergency providers are legally required to provide
emergency care. If you pay the entire amount yourself
at the time you receive the care, ask us to pay you
back for our share of the cost. Send us the bill, along
with documentation of any payments you have made
• You may get a bill from the provider asking for
payment that you think you do not owe. Send us this
bill, along with documentation of any payments you
have already made
♦ if the provider is owed anything, we will pay the
provider directly
♦ if you have already paid more than your share of
the cost of the service, we will determine how
much you owed and pay you back for our share of
the cost
When a Plan Provider sends you a bill you think you
should not pay. Plan Providers should always bill us
directly and ask you only for your share of the cost. But
sometimes they make mistakes and ask you to pay more
than your share.
• You only have to pay your Cost Share amount when
you get covered Services. We do not allow providers
to add additional separate charges, called balance
billing. This protection (that you never pay more than
your Cost Share amount) applies even if we pay the
provider less than the provider charges for a service,
and even if there is a dispute and we don’t pay certain
provider charges
• Whenever you get a bill from a Plan Provider that you
think is more than you should pay, send us the bill.
We will contact the provider directly and resolve the
billing problem
• If you have already paid a bill to a Plan Provider, but
you feel that you paid too much, send us the bill along
with documentation of any payment you have made
and ask us to pay you back the difference between the
amount you paid and the amount you owed under our
plan
If you are retroactively enrolled in our plan.
Sometimes a person’s enrollment in our plan is
retroactive. (This means that the first day of their
enrollment has already passed. The enrollment date may
even have occurred last year.) If you were retroactively
enrolled in our plan and you paid out-of-pocket for any
of your covered Services or Part D drugs after your
enrollment date, you can ask us to pay you back for our
share of the costs. You will need to submit paperwork
such as receipts and bills for us to handle the
reimbursement.
When you use a Non–Plan Pharmacy to get a
prescription filled. If you go to a Non–Plan, the
pharmacy may not be able to submit the claim directly to
us. When that happens, you will have to pay the full cost
of your prescription.
Save your receipt and send a copy to us when you ask us
to pay you back for our share of the cost. Remember that
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Page 60
we only cover out of network pharmacies in limited
circumstances.
When you pay the full cost for a prescription because
you don’t have your plan membership card with you.
If you do not have your plan membership card with you,
you can ask the pharmacy to call us or to look up your
plan enrollment information. However, if the pharmacy
cannot get the enrollment information they need right
away, you may need to pay the full cost of the
prescription yourself.
Save your receipt and send a copy to us when you ask us
to pay you back for our share of the cost.
When you pay the full cost for a prescription in other
situations. You may pay the full cost of the prescription
because you find that the drug is not covered for some
reason.
• For example, the drug may not be on our 2024
Comprehensive Formulary; or it could have a
requirement or restriction that you didn’t know about
or don’t think should apply to you. If you decide to
get the drug immediately, you may need to pay the
full cost for it
• Save your receipt and send a copy to us when you ask
us to pay you back. In some situations, we may need
to get more information from your doctor in order to
pay you back for our share of the cost
When you pay copayments under a drug
manufacturer patient assistance program. If you get
help from, and pay copayments under, a drug
manufacturer patient assistance program outside our
plan’s benefit, you may submit a paper claim to have
your out-of-pocket expense count toward qualifying you
for catastrophic coverage.
• Save your receipt and send a copy to us
All of the examples above are types of coverage
decisions. This means that if we deny your request for
payment, you can appeal our decision. The “Coverage
Decisions, Appeals, and Complaints” section has
information about how to make an appeal.
How to Ask Us to Pay You Back or to
Pay a Bill You Have Received
You may request us to pay you back by sending us a
request in writing. If you send a request in writing, send
your bill and documentation of any payment you have
made. It’s a good idea to make a copy of your bill and
receipts for your records. You must submit your claim to
us within 12 months (for Part C medical claims) and
within 36 months (for Part D drug claims) of the date
you received the service, item, or drug.
To make sure you are giving us all the information we
need to make a decision, you can fill out our claim form
to make your request for payment. You don’t have to use
the form, but it will help us process the information
faster. You can file a claim to request payment by:
To file a claim, this is what you need to do:
• Completing and submitting our electronic form at
(kp.org) and upload supporting documentation
• Either download a copy of the form from our website
(kp.org) or call Member Services and ask them to
send you the form. Mail the completed form to our
Claims Department address listed below
• If you are unable to get the form, you can file your
request for payment by sending us the following
information to our Claims Department address listed
below:
♦ a statement with the following information:
– your name (member/patient name) and
medical/health record number
– the date you received the services
– where you received the services
– who provided the services
– why you think we should pay for the services
– your signature and date signed. (If you want
someone other than yourself to make the
request, we will also need a completed
“Appointment of Representative” form, which
is available at kp.org)
♦ a copy of the bill, your medical record(s) for these
services, and your receipt if you paid for the
services
• Mail your request for payment of medical care
together with any bills or paid receipts to us at this
address:
For Northern California Home Region Members:
Kaiser Permanente
Claims Administration - NCAL
P.O. Box 12923
Oakland, CA 94604-2923
For Southern California Home Region Members:
Kaiser Permanente
Claims Administration - SCAL
P.O. Box 7004
Downey, CA 90242-7004
To request payment of a Part D drug that was prescribed
by a Plan Provider and obtained from a Plan Pharmacy,
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
Page 61
write to the address below. For all other Part D requests,
send your request to the address above.
Kaiser Foundation Health Plan, Inc.
Medicare Part D Unit
P.O. Box 23170
Oakland, CA 94623-0170
We Will Consider Your Request for
Payment and Say Yes or No
We check to see whether we should cover the
service or Part D drug and how much we owe
When we receive your request for payment, we will let
you know if we need any additional information from
you. Otherwise, we will consider your request and make
a coverage decision.
• If we decide that the medical care or Part D drug is
covered and you followed all the rules, we will pay
for our share of the cost. If you have already paid for
the service or Part D drug, we will mail your
reimbursement of our share of the cost to you. If you
have not paid for the service or Part D drug yet, we
will mail the payment directly to the provider
• If we decide that the medical care or Part D drug is
not covered, or you did not follow all the rules, we
will not pay for our share of the cost. We will send
you a letter explaining the reasons why we are not
sending the payment and your right to appeal that
decision
If we tell you that we will not pay for all or part of
the medical care or Part D drug, you can make
an appeal
If you think we have made a mistake in turning down
your request for payment or the amount we are paying,
you can make an appeal. If you make an appeal, it means
you are asking us to change the decision we made when
we turned down your request for payment.
The appeals process is a formal process with detailed
procedures and important deadlines. For the details about
how to make this appeal, go to the “Coverage Decisions,
Appeals, and Complaints” section.
Other Situations in Which You Should
Save Your Receipts and Send Copies to
Us
In some cases, you should send copies of your
receipts to us to help us track your out-of-
pocket drug costs
There are some situations when you should let us know
about payments you have made for your covered Part D
prescription drugs. In these cases, you are not asking us
for payment. Instead, you are telling us about your
payments so that we can calculate your out-of-pocket
costs correctly. This may help you to qualify for the
Catastrophic Coverage Stage more quickly.
Here is one situation when you should send us copies of
receipts to let us know about payments you have made
for your drugs:
• When you get a drug through a patient assistance
program offered by a drug manufacturer. Some
members are enrolled in a patient assistance program
offered by a drug manufacturer that is outside our
plan benefits. If you get any drugs through a program
offered by a drug manufacturer, you may pay a
copayment to the patient assistance program
♦ save your receipt and send a copy to us so that we
can have your out-of-pocket expenses count
toward qualifying you for the Catastrophic
Coverage Stage
♦ note: Because you are getting your drug through
the patient assistance program and not through our
plan’s benefits, we will not pay for any share of
these drug costs. But sending a copy of the receipt
allows us to calculate your out-of-pocket costs
correctly and may help you qualify for the
Catastrophic Coverage Stage more quickly
Since you are not asking for payment in the case
described above, this situation is not considered a
coverage decision. Therefore, you cannot make an appeal
if you disagree with our decision.
Your Rights and Responsibilities
We must honor your rights and cultural
sensitivities as a Member of our plan
We must provide information in a way that
works for you and consistent with your cultural
sensitivities (in languages other than English,
Braille, large print, or CD)
Our plan is required to ensure that all services, both
clinical and non-clinical, are provided in a culturally
competent manner and are accessible to all enrollees,
including those with limited English proficiency, limited
reading skills, hearing incapacity, or those with diverse
cultural and ethnic backgrounds. Examples of how our
plan may meet these accessibility requirements include,
but are not limited to: provision of translator services,
interpreter services, teletypewriters, or TTY (text
telephone or teletypewriter phone) connection.
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Page 62
Our plan has free interpreter services available to answer
questions from non-English-speaking members. This
document is available in Spanish by calling Member
Services. We can also give you information in braille,
large print, or CD at no cost if you need it. We are
required to give you information about our plan’s
benefits in a format that is accessible and appropriate for
you. To get information from us in a way that works for
you, please call Member Services.
Our plan is required to give female enrollees the option
of direct access to a women’s health specialist within the
network for women’s routine and preventive health care
services.
If providers in our network for a specialty are not
available, it is our responsibility to locate specialty
providers outside the network who will provide you with
the necessary care. In this case, you will only pay in-
network cost sharing. If you find yourself in a situation
where there are no specialists in our network that cover a
service you need, call us for information on where to go
to obtain this service at in-network cost-sharing.
If you have any trouble getting information from our
plan in a format that is accessible and appropriate for
you, seeing a women’s health specialist, or finding a
network specialist, please call to file a grievance with
Member Services. You may also file a complaint with
Medicare by calling 1-800-MEDICARE (1-800-633-
4227) or directly with the Office for Civil Rights 1-800-
368-1019 or TTY 1-800-537-7697.
Debemos proporcionar la información de un
modo adecuado para usted y conforme a su
sensibilidad cultural (en idiomas distintos al
inglés, en letra grande, en braille o en CD)
Nuestro plan está obligado a garantizar que todos los
servicios, tanto clínicos como no clínicos, se
proporcionen de una manera culturalmente competente y
que sean accesibles para todas las personas inscritas,
incluidas las que tienen un dominio limitado del inglés,
capacidades limitadas para leer, una incapacidad auditiva
o diversos antecedentes culturales y étnicos. Algunos
ejemplos de cómo nuestro plan puede cumplir estos
requisitos de accesibilidad incluyen, entre otros,
proporcionar servicios de traducción, servicios de
interpretación, de teletipo o TTY (teléfono de texto o
teletipo).
Nuestro plan tiene servicios de interpretación disponibles
para responder las preguntas de los miembros que no
hablan inglés. Este documento está disponible en español
llamando a Servicio a los Miembros. También podemos
darle información en letra grande, braille o en CD sin
costo si la necesita. Tenemos la obligación de darle
información acerca de los beneficios de nuestro plan en
un formato que sea accesible y adecuado para usted. Para
obtener información de una forma que se adapte a sus
necesidades, llame a Servicio a los Miembros.
Nuestro plan está obligado a ofrecer a las mujeres
inscritas la opción de acceder directamente a un
especialista en salud femenina dentro de la red para los
servicios de atención médica preventiva y de rutina para
la mujer.
Si los proveedores de nuestra red para una especialidad
no están disponibles, es nuestra responsabilidad buscar
proveedores fuera de la red que le proporcionen la
atención necesaria. En este caso, usted solo pagará el
costo compartido dentro de la red. Si se encuentra en una
situación en la que no hay especialistas dentro de nuestra
red que cubran el servicio que necesita, llámenos para
recibir información sobre a dónde acudir para obtener
este servicio con un costo compartido dentro de la red.
Si tiene algún problema para obtener información de
nuestro plan en un formato que sea accesible y adecuado
para usted, para ver a un especialista en salud femenina o
para encontrar un especialista de la red, llame a Servicio
a los Miembros para presentar una queja. También puede
presentar una queja ante Medicare, llamando al 1-800-
MEDICARE (1-800-633-4227) o directamente en la
Oficina de Derechos Civiles al 1-800-368-1019 o TTY
1-800-537-7697.
We must ensure that you get timely access to
your covered services and Part D drugs
You have the right to choose a primary care provider
(PCP) in our network to provide and arrange for your
covered services. You also have the right to go to a
women’s health specialist (such as a gynecologist), a
mental health services provider, and an optometrist
without a referral, as well as other providers described in
the “How to Obtain Services” section.
You have the right to get appointments and covered
services from our network of providers within a
reasonable amount of time. This includes the right to get
timely services from specialists when you need that care.
You also have the right to get your prescriptions filled or
refilled at any of our network pharmacies without long
delays.
If you think that you are not getting your medical care or
Part D drugs within a reasonable amount of time, “How
to make a complaint about quality of care, waiting times,
customer service, or other concerns” in the “Coverage
Decisions, Appeals, and Complaints” section tells you
what you can do.
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We must protect the privacy of your personal
health information
Federal and state laws protect the privacy of your
medical records and personal health information. We
protect your personal health information as required by
these laws.
• Your personal health information includes the
personal information you gave us when you enrolled
in our plan as well as your medical records and other
medical and health information
• You have rights related to your information and
controlling how your health information is used. We
give you a written notice, called a Notice of Privacy
Practices, that tells you about these rights and
explains how we protect the privacy of your health
information
How do we protect the privacy of your health
information?
• We make sure that unauthorized people don’t see or
change your records
• Except for the circumstances noted below, if we
intend to give your health information to anyone who
isn’t providing your care or paying for your care, we
are required to get written permission from you or by
someone you have given legal power to make
decisions for you first
• Your health information is shared with the University
of California only with your authorization or as
otherwise permitted by law
• There are certain exceptions that do not require us to
get your written permission first. These exceptions
are allowed or required by law
♦ we are required to release health information to
government agencies that are checking on quality
of care
♦ because you are a Member of our plan through
Medicare, we are required to give Medicare your
health information, including information about
your Part D prescription drugs. If Medicare
releases your information for research or other
uses, this will be done according to federal statutes
and regulations; typically, this requires that
information that uniquely identifies you not be
shared
You can see the information in your records and
know how it has been shared with others
You have the right to look at your medical records held
by our plan, and to get a copy of your records. We are
allowed to charge you a fee for making copies. You also
have the right to ask us to make additions or corrections
to your medical records. If you ask us to do this, we will
work with your health care provider to decide whether
the changes should be made.
You have the right to know how your health information
has been shared with others for any purposes that are not
routine.
If you have questions or concerns about the privacy of
your personal health information, please call Member
Services.
We must give you information about our plan,
our Plan Providers, and your covered services
As a Member of our plan, you have the right to get
several kinds of information from us.
If you want any of the following kinds of information,
please call Member Services:
• Information about our plan. This includes, for
example, information about our plan’s financial
condition
• Information about our network providers and
pharmacies
♦ you have the right to get information about the
qualifications of the providers and pharmacies in
our network and how we pay the providers in our
network
• Information about your coverage and the rules
you must follow when using your coverage
♦ the “How to Obtain Services” and “Benefits and
Your Cost Share” sections provide information
regarding medical services
♦ the “Outpatient Prescription Drugs, Supplies, and
Supplements” in the “Benefits and Your Cost
Share” section provides information about
coverage for certain drugs
♦ if you have questions about the rules or
restrictions, please call Member Services
• Information about why something is not covered
and what you can do about it
♦ the “Coverage Decisions, Appeals, and
Complaints” section provides information on
asking for a written explanation on why a medical
service or Part D drug is not covered, or if your
coverage is restricted
♦ the “Coverage Decisions, Appeals, and
Complaints” section also provides information on
asking us to change a decision, also called an
appeal
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We must support your right to make decisions
about your care
You have the right to know your treatment options
and participate in decisions about your health care
You have the right to get full information from your
doctors and other health care providers when you go for
medical care. Your providers must explain your medical
condition and your treatment choices in a way that you
can understand.
You also have the right to participate fully in decisions
about your health care. To help you make decisions with
your doctors about what treatment is best for you, your
rights include the following:
• To know about all of your choices. You have the
right to be told about all of the treatment options that
are recommended for your condition, no matter what
they cost or whether they are covered by our plan. It
also includes being told about programs our plan
offers to help members manage their medications and
use drugs safely
• To know about the risks. You have the right to be
told about any risks involved in your care. You must
be told in advance if any proposed medical care or
treatment is part of a research experiment. You
always have the choice to refuse any experimental
treatments
• The right to say “no.” You have the right to refuse
any recommended treatment. This includes the right
to leave a hospital or other medical facility, even
if your doctor advises you not to leave. You also have
the right to stop taking your medication. Of course,
if you refuse treatment or stop taking a medication,
you accept full responsibility for what happens to
your body as a result
You have the right to give instructions about what is
to be done if you are not able to make medical
decisions for yourself
Sometimes people become unable to make health care
decisions for themselves due to accidents or serious
illness. You have the right to say what you want to
happen if you are in this situation. This means that,
if you want to, you can:
• Fill out a written form to give someone the legal
authority to make medical decisions for you if you
ever become unable to make decisions for yourself
• Give your doctors written instructions about how you
want them to handle your medical care if you become
unable to make decisions for yourself
The legal documents that you can use to give your
directions in advance of these situations are called
advance directives. There are different types of advance
directives and different names for them. Documents
called living will and power of attorney for health care
are examples of advance directives.
If you want to use an advance directive to give your
instructions, here is what to do:
• Get the form. You can get an advance directive, a
form from your lawyer, from a social worker, or from
some office supply stores. You can sometimes get
advance directive forms from organizations that give
people information about Medicare. You can also
contact Member Services to ask for the forms
• Fill it out and sign it. Regardless of where you get
this form, keep in mind that it is a legal document.
You should consider having a lawyer help you
prepare it
• Give copies to appropriate people. You should give
a copy of the form to your doctor and to the person
you name on the form who can make decisions for
you if you can’t. You may want to give copies to
close friends or family members. Keep a copy at
home
If you know ahead of time that you are going to be
hospitalized, and you have signed an advance directive,
take a copy with you to the hospital.
• The hospital will ask you whether you have signed an
advance directive form and whether you have it with
you
• If you have not signed an advance directive form, the
hospital has forms available and will ask if you want
to sign one
Remember, it is your choice whether you want to fill
out an advance directive (including whether you want
to sign one if you are in the hospital). According to law,
no one can deny you care or discriminate against you
based on whether or not you have signed an advance
directive.
What if your instructions are not followed?
If you have signed an advance directive, and you believe
that a doctor or hospital did not follow the instructions in
it, you may file a complaint with the Quality
Improvement Organization listed in the “Important
Phone Numbers and Resources” section.
You have the right to make complaints and to
ask us to reconsider decisions we have made
If you have any problems, concerns, or complaints and
need to request coverage, or make an appeal, the
“Coverage Decisions, Appeals, and Complaints” section
of this document tells you what you can do.
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Whatever you do—ask for a coverage decision, make an
appeal, or make a complaint—we are required to treat
you fairly.
What can you do if you believe you are being
treated unfairly or your rights are not being
respected?
If it is about discrimination, call the Office for Civil
Rights
If you believe you have been treated unfairly, your
dignity has not been recognized, or your rights have not
been respected due to your race, disability, religion, sex,
health, ethnicity, creed (beliefs), age, sexual orientation,
or national origin, you should call the Department of
Health and Human Services’ Office for Civil Rights at
1-800-368-1019 (TTY users call 1-800-537-7697) or call
your local Office for Civil Rights.
Is it about something else?
If you believe you have been treated unfairly or your
rights have not been respected, and it’s not about
discrimination, you can get help dealing with the
problem you are having:
• You can call Member Services
• You can call the State Health Insurance Assistance
Program. For details, go to the “Important Phone
Numbers and Resources” section
• Or you can call Medicare at 1-800-MEDICARE
(1-800-633-4227), 24 hours a day, seven days a week
(TTY 1-877-486-2048)
How to get more information about your rights
There are several places where you can get more
information about your rights:
• You can call Member Services
• You can call the State Health Insurance Assistance
Program. For details, go to the “Important Phone
Numbers and Resources” section
• You can contact Medicare:
♦ you can visit the Medicare website to read or
download the publication Medicare Rights &
Protections. (The publication is available at
https://www.medicare.gov/Pubs/pdf/11534-
Medicare-Rights-and-Protections.pdf)
♦ or you can call 1-800-MEDICARE (1-800-633-
4227), 24 hours a day, seven days a week (TTY
1-877-486-2048)
Information about new technology assessments
Rapidly changing technology affects health care and
medicine as much as any other industry. To determine
whether a new drug or other medical development has
long-term benefits, our plan carefully monitors and
evaluates new technologies for inclusion as covered
benefits. These technologies include medical procedures,
medical devices, and new drugs.
You can make suggestions about rights and
responsibilities
As a Member of our plan, you have the right to make
recommendations about the rights and responsibilities
included in this section. Please call Member Services
with any suggestions.
You have some responsibilities as a
Member of our plan
Things you need to do as a Member of our plan are listed
below. If you have any questions, please call Member
Services.
• Get familiar with your covered services and the
rules you must follow to get these covered services.
Use this EOC to learn what is covered for you and the
rules you need to follow to get your covered services
♦ the “How to Obtain Services” and “Benefits and
Your Cost Share” sections give details about your
medical services
♦ the “Outpatient Prescription Drugs, Supplies, and
Supplements” in the “Benefits and Your Cost
Share” section gives details about your Part D
prescription drug coverage
• If you have any other health insurance coverage or
prescription drug coverage in addition to our plan,
you are required to tell us.
♦ the “Exclusion, Limitations, Coordination of
Benefits, and Reductions” section tells you about
coordinating these benefits
• Tell your doctor and other health care providers
that you are enrolled in our plan. Show your plan
membership card whenever you get your medical care
or Part D drugs
• Help your doctors and other providers help you by
giving them information, asking questions, and
following through on your care
♦ to help get the best care, tell your doctors and
other health care providers about your health
problems. Follow the treatment plans and
instructions that you and your doctors agree upon
♦ make sure your doctors know all of the drugs you
are taking, including over-the-counter drugs,
vitamins, and supplements
♦ if you have any questions, be sure to ask and get
an answer you can understand
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• Be considerate. We expect all our members to
respect the rights of other patients. We also expect
you to act in a way that helps the smooth running of
your doctor’s office, hospitals, and other offices
• Pay what you owe. As a plan member, you are
responsible for these payments:
♦ you must continue to pay a premium for your
Medicare Part B to remain a Member of our plan
♦ for most of your Services or Part D drugs covered
by our plan, you must pay your share of the cost
when you get the Service or Part D drug
♦ if you are required to pay the extra amount for
Part D because of your yearly income, you must
continue to pay the extra amount directly to the
government to remain a Member of our plan
• If you move within your Home Region Service
Area, we need to know so we can keep your
membership record up-to-date and know how to
contact you
• If you move outside of your plan’s Service Area,
you cannot remain a member of our plan
• If you move, it is also important to tell Social
Security (or the Railroad Retirement Board)
Coverage Decisions, Appeals, and
Complaints
What to Do if You Have a Problem or
Concern
This section explains two types of processes for handling
problems and concerns:
• For some problems, you need to use the process for
coverage decisions and appeals
• For other problems, you need to use the process for
making complaints, also called grievances
Both of these processes have been approved by
Medicare. Each process has a set of rules, procedures,
and deadlines that must be followed by you and us.
The guide under “To Deal with Your Problem, Which
Process Should You Use?” in this “Coverage Decisions,
Appeals, and Complaints” section will help you identify
the right process to use and what you should do.
Hospice care
If you have Medicare Part A, your hospice care is
covered by Original Medicare and it is not covered under
this EOC. Therefore, any complaints related to the
coverage of hospice care must be resolved directly with
Medicare and not through any complaint or appeal
procedure discussed in this EOC. Medicare complaint
and appeal procedures are described in the Medicare
handbook Medicare & You, which is available from your
local Social Security office, at
https://www.medicare.gov, or by calling toll free 1-800-
MEDICARE (1-800-633-4227) (TTY users call 1-877-
486-2048), 24 hours a day, seven days a week. If you do
not have Medicare Part A, Original Medicare does not
cover hospice care. Instead, we will provide hospice
care, and any complaints related to hospice care are
subject to this “Coverage Decisions, Appeals, and
Complaints” section.
What about the legal terms?
There are legal terms for some of the rules, procedures,
and types of deadlines explained in this “Coverage
Decisions, Appeals, and Complaints” section. Many of
these terms are unfamiliar to most people and can be
hard to understand.
To make things easier, this section:
• Uses simpler words in place of certain legal terms.
For example, this section generally says making a
complaint rather than filing a grievance, coverage
decision rather than organization determination or
coverage determination, or at-risk determination, and
independent review organization instead of
Independent Review Entity.
• It also uses abbreviations as little as possible.
However, it can be helpful, and sometimes quite
important, for you to know the correct legal terms.
Knowing which terms to use will help you communicate
more accurately to get the right help or information for
your situation. To help you know which terms to use, we
include legal terms when we give the details for handling
specific types of situations.
Where To Get More Information and
Personalized Assistance
We are always available to help you. Even if you have a
complaint about our treatment of you, we are obligated
to honor your right to complain. Therefore, you should
always reach out to Member Services for help. But in
some situations you may also want help or guidance
from someone who is not connected with us. Below are
two entities that can assist you.
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State Health Insurance Assistance Program
(SHIP)
Each state has a government program with trained
counselors. The program is not connected with us or with
any insurance company or health plan. The counselors at
this program can help you understand which process you
should use to handle a problem you are having. They can
also answer your questions, give you more information,
and offer guidance on what to do.
The services of SHIP counselors are free. You will find
phone numbers and website URLs in the “Important
Phone Numbers and Resources” section.
Medicare
You can also contact Medicare to get help. To contact
Medicare:
• You can call 1-800-MEDICARE (1-800-633-4227),
24 hours a day, seven days a week (TTY 1-877-486-
2048)
• You can also visit the Medicare website
(https://www.medicare.gov)
To Deal with Your Problem, Which
Process Should You Use?
If you have a problem or concern, you only need to read
the parts of this section that apply to your situation. The
guide that follows will help.
Is your problem or concern about your benefits or
coverage?
This includes problems about whether medical care
(medical items, services and/or Part B prescription
drugs) are covered or not, the way they are covered, and
problems related to payment for medical care
• Yes. Go on to “A Guide to the Basics of Coverage
Decisions and Appeals”
• No. Skip ahead to “How to Make a Complaint About
Quality of Care, Waiting Times, Customer Service, or
Other Concerns”
A Guide to the Basics of Coverage
Decisions and Appeals
Asking for coverage decisions and making
appeals—the big picture
Coverage decisions and appeals deal with problems
related to your benefits and coverage for your medical
care (services, items and Part B prescription drugs,
including payment). To keep things simple, we generally
refer to medical items, services and Medicare Part B
prescription drugs as medical care. You use the coverage
decision and appeals process for issues such as whether
something is covered or not, and the way in which
something is covered.
Asking for coverage decisions prior to receiving
benefits
A coverage decision is a decision we make about your
benefits and coverage or about the amount we will pay
for your medical care. For example, if your Plan
Physician refers you to a medical specialist not inside the
network, this referral is considered a favorable coverage
decision unless either your Plan Physician can show that
you received a standard denial notice for this medical
specialist, or the EOC makes it clear that the referred
service is never covered under any condition. You or
your doctor can also contact us and ask for a coverage
decision, if your doctor is unsure whether we will cover a
particular medical service or refuses to provide medical
care you think that you need. In other words, if you want
to know if we will cover a medical care before you
receive it, you can ask us to make a coverage decision
for you.
We are making a coverage decision for you whenever we
decide what is covered for you and how much we pay. In
some cases, we might decide medical care is not covered
or is no longer covered by Medicare for you. If you
disagree with this coverage decision, you can make an
appeal.
Making an appeal
If we make a coverage decision, whether before or after a
benefit is received, and you are not satisfied, you can
appeal the decision. An appeal is a formal way of asking
us to review and change a coverage decision we have
made. Under certain circumstances, which we discuss
later, you can request an expedited or fast appeal of a
coverage decision. Your appeal is handled by different
reviewers than those who made the original decision.
When you appeal a decision for the first time, this is
called a Level 1 appeal. In this appeal, we review the
coverage decision we have made to check to see if we
were properly following the rules. When we have
completed the review, we give you our decision.
In limited circumstances, a request for a Level 1 appeal
will be dismissed, which means we won’t review the
request. Examples of when a request will be dismissed
include if the request is incomplete, if someone makes
the request on your behalf but isn’t legally authorized to
do so or if you ask for your request to be withdrawn. If
we dismiss a request for a Level 1 appeal, we will send a
notice explaining why the request was dismissed and
how to ask for a review of the dismissal.
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Page 68
If we say no to all or part of your Level 1 appeal for
medical care, your appeal will automatically go on to a
Level 2 appeal conducted by an independent review
organization that is not connected to us.
• You do not need to do anything to start a Level 2
appeal. Medicare rules require we automatically send
your appeal for medical care to Level 2 if we do not
fully agree with your Level 1 appeal
• See “Step-by-step: How a Level 2 appeal is done” of
this chapter for more information about Level 2
appeals
• For Part D drug appeals, if we say no to all or part of
your appeal you will need to ask for a Level 2 appeal.
Part D appeals are discussed further in “Your Part D
Prescription Drugs: How to Ask for a Coverage
Decision or Make an Appeal” of this section)
If you are not satisfied with the decision at the Level 2
appeal, you may be able to continue through additional
levels of appeal. (“Taking Your Appeal to Level 3 and
Beyond” in this section explains the Level 3, 4, and 5
appeals processes).
How to get help when you are asking for a
coverage decision or making an appeal
Here are resources if you decide to ask for any kind of
coverage decision or appeal a decision:
• You can call us at Member Services
• You can get free help from your State Health
Insurance Assistance Program
• Your doctor can make a request for you. If your
doctor helps with an appeal past Level 2, they will
need to be appointed as your representative. Please
call Member Services and ask for the Appointment
of Representative form. (The form is also available
on Medicare’s website at
https://www.cms.gov/Medicare/CMS-Forms/
CMS-Forms/downloads/cms1696.pdf or on our
website at kp.org)
♦ for medical care or Medicare Part B prescription
drugs, your doctor can request a coverage decision
or a Level 1 appeal on your behalf. If your appeal
is denied at Level 1, it will be automatically
forwarded to Level 2
♦ for Part D prescription drugs, your doctor or other
prescriber can request a coverage decision or a
Level 1 appeal on your behalf. If your Level 1
appeal is denied, your doctor or prescriber can
request a Level 2 appeal
• You can ask someone to act on your behalf. If you
want to, you can name another person to act for you
as your representative to ask for a coverage decision
or make an appeal
♦ if you want a friend, relative, or other person to be
your representative, call Member Services and ask
for the Appointment of Representative form. (The
form is also available on Medicare’s website at
https://www.cms.gov/Medicare/CMS-Forms/
CMS-Forms/downloads/cms1696.pdf or on our
website at kp.org.) The form gives that person
permission to act on your behalf. It must be signed
by you and by the person whom you would like to
act on your behalf. You must give us a copy of the
signed form
♦ while we can accept an appeal request without the
form, we cannot begin or complete our review
until we receive it. If we do not receive the form
within 44 calendar days after receiving your
appeal request (our deadline for making a decision
on your appeal), your appeal request will be
dismissed. If this happens, we will send you a
written notice explaining your right to ask the
independent review organization to review our
decision to dismiss your appeal.
• You also have the right to hire a lawyer. You may
contact your own lawyer, or get the name of a lawyer
from your local bar association or other referral
service. There are also groups that will give you free
legal services if you qualify. However, you are not
required to hire a lawyer to ask for any kind of
coverage decision or appeal a decision
Which section gives the details for your
situation?
There are four different situations that involve coverage
decisions and appeals. Since each situation has different
rules and deadlines, we give the details for each one in a
separate section:
• “Your Medical Care: How to Ask for a Coverage
Decision or Make an Appeal of a Coverage Decision”
• “Your Part D Prescription Drugs: How to Ask for a
Coverage Decision or Make an Appeal”
• “How to Ask Us to Cover a Longer Inpatient Hospital
Stay if You Think the Doctor Is Discharging You Too
Soon”
• “How to Ask Us to Keep Covering Certain Medical
Services if You Think Your Coverage is Ending Too
Soon” (applies only to these services: home health
care, Skilled Nursing Facility care, and
Comprehensive Outpatient Rehabilitation Facility
(CORF) services)
If you’re not sure which section you should be using,
please call Member Services. You can also get help or
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
Page 69
information from government organizations such as your
SHIP.
Your Medical Care: How to Ask for a
Coverage Decision or Make an Appeal
of a Coverage Decision
This section tells what to do if you have
problems getting coverage for medical care or
if you want us to pay you back for our share of
the cost of your care
This section is about your benefits for medical care.
These benefits are described in the “Benefits and Your
Cost Share” section. In some cases, different rules apply
to a request for a Medicare Part B prescription drug. In
those cases, we will explain how the rules for Medicare
Part B prescription drugs are different from the rules for
medical items and services.
This section tells you what you can do if you are in any
of the following situations:
• You are not getting certain medical care you want,
and you believe that this is covered by our plan. Ask
for a coverage decision
• We will not approve the medical care your doctor or
other medical provider wants to give you, and you
believe that this care is covered by our plan. Ask for
a coverage decision
• You have received medical care that you believe
should be covered by our plan, but we have said we
will not pay for this care. Make an appeal
• You have received and paid for medical care that you
believe should be covered by our plan, and you want
to ask us to reimburse you for this care. Send us the
bill
• You are being told that coverage for certain medical
care you have been getting that we previously
approved will be reduced or stopped, and you believe
that reducing or stopping this care could harm your
health. Make an appeal
Note: If the coverage that will be stopped is for hospital
Services, home health care, Skilled Nursing Facility care,
or Comprehensive Outpatient Rehabilitation Facility
(CORF) services, you need to read “How to Ask Us to
Cover a Longer Inpatient Hospital Stay if You Think the
Doctor Is Discharging You Too Soon” and “How to Ask
Us to Keep Covering Certain Medical Services if You
Think Your Coverage is Ending Too Soon” of this
section. Special rules apply to these types of care.
Step-by-step: How to ask for a coverage
decision
When a coverage decision involves your medical care, it
is called an organization determination. A fast
coverage decision is called an expedited determination.
Step 1: Decide if you need a standard coverage
decision or a fast coverage decision.
A standard coverage decision is usually made within 14
days or 72 hours for Part B drugs. A fast coverage
decision is generally made within 72 hours, for medical
services, or 24 hours for Part B drugs. In order to get a
fast coverage decision, you must meet two requirements:
♦ you may only ask for coverage for medical items
and/or services not requests for payment for items
and/or services already received
♦ you can get a fast coverage decision only if using
the standard deadlines could cause serious harm to
your health or hurt your ability to function
• If your doctor tells us that your health requires a fast
coverage decision, we will automatically agree to
give you a fast coverage decision
• If you ask for a fast coverage decision on your own,
without your doctor’s support, we will decide whether
your health requires that we give you a fast coverage
decision. If we do not approve a fast coverage
decision, we will send you a letter that:
♦ explains that we will use the standard deadlines
♦ explains if your doctor asks for the fast coverage
decision, we will automatically give you a fast
coverage decision
♦ explains that you can file a fast complaint about
our decision to give you a standard coverage
decision instead of the fast coverage decision you
requested
Step 2: Ask our plan to make a coverage decision
or fast coverage decision
• Start by calling, writing, or faxing our plan to make
your request for us to authorize or provide coverage
for the medical care you want. You, your doctor, or
your representative can do this. The “Important Phone
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Numbers and Resources” section has contact
information
Step 3: We consider your request for medical care
coverage and give you our answer
For standard coverage decisions, we use the standard
deadlines.
This means we will give you an answer within 14
calendar days after we receive your request for a medical
item or service. If your request is for a Medicare Part B
prescription drug, we will give you an answer within 72
hours after we receive your request.
♦ however, if you ask for more time, or if we need
more information that may benefit you, we can
take up to 14 more days if your request is for a
medical item or service. If we take extra days, we
will tell you in writing. We can’t take extra time to
make a decision if your request is for a Medicare
Part B prescription drug
♦ if you believe we should not take extra days, you
can file a fast complaint. We will give you an
answer to your complaint as soon as we make the
decision. (The process for making a complaint is
different from the process for coverage decisions
and appeals. See “How to Make a Complaint
About Quality of Care, Waiting Times, Customer
Service, or Other Concerns” of this section for
information on complaints.)
For fast coverage decisions, we use an expedited time
frame.
A fast coverage decision means we will answer within 72
hours if your request is for a medical item or service. If
your request is for a Medicare Part B prescription drug,
we will answer within 24 hours.
♦ however, if you ask for more time, or if we need
more information that may benefit you we can
take up to 14 more days. If we take extra days, we
will tell you in writing. We can’t take extra time to
make a decision if your request is for a Medicare
Part B prescription drug
♦ if you believe we should not take extra days, you
can file a fast complaint. See “How to Make a
Complaint About Quality of Care, Waiting Times,
Customer Service, or Other Concerns” of this
section for information on complaints.) We will
call you as soon as we make the decision.
♦ if we do not give you our answer within 72 hours
(or if there is an extended time period, by the end
of that period), or within 24 hours if your request
is for a Medicare Part B prescription drug, you
have the right to appeal. “Step-by-step: How to
make a Level 1 Appeal” below tells you how to
make an appeal
♦ If our answer is no to part or all of what you
requested, we will send you a written statement
that explains why we said no
Step 4: If we say no to your request for coverage
for medical care, you can appeal
• If we say no, you have the right to ask us to
reconsider this decision by making an appeal. This
means asking again to get the medical care coverage
you want. If you make an appeal, it means you are
going on to Level 1 of the appeals process
Step-by-step: How to make a Level 1 appeal
An appeal to our plan about a medical care coverage
decision is called a plan reconsideration. A fast appeal
is also called an expedited reconsideration.
Step 1: Decide if you need a standard appeal or a
fast appeal
A standard appeal is usually made within 30 days or
7 days for Part B drugs. A fast appeal is generally
made within 72 hours.
• If you are appealing a decision we made about
coverage for care that you have not yet received, you
and/or your doctor will need to decide if you need a
fast appeal. If your doctor tells us that your health
requires a fast appeal, we will give you a fast appeal
• The requirements for getting a fast appeal are the
same as those for getting a fast coverage decision in
“Your Medical Care: How to Ask for a Coverage
Decision or Make an Appeal” of this section
Step 2: Ask our plan for an appeal or a fast appeal
• If you are asking for a standard appeal, submit your
standard appeal in writing. You may also ask for an
appeal by calling us. The “Important Phone Numbers
and Resources” section has contact information
• If you are asking for a fast appeal, make your appeal
in writing or call us. The “Important Phone Numbers
and Resources” section has contact information
• You must make your appeal request within 60
calendar days from the date on the written notice we
sent to tell you our answer on the coverage decision.
If you miss this deadline and have a good reason for
missing it, explain the reason your appeal is late when
you make your appeal. We may give you more time
to make your appeal. Examples of good cause may
include a serious illness that prevented you from
contacting us or if we provided you with incorrect or
incomplete information about the deadline for
requesting an appeal
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• You can ask for a copy of the information regarding
your medical decision. You and your doctor may add
more information to support your appeal. We are
allowed to charge a fee for copying and sending this
information to you
Step 3: We consider your appeal and we give you
our answer
• When we are reviewing your appeal, we take a
careful look at all of the information. We check to see
if we were following all the rules when we said no to
your request
• We will gather more information if needed possibly
contacting you or your doctor
Deadlines for a fast appeal
• For fast appeals, we must give you our answer within
72 hours after we receive your appeal. We will give
you our answer sooner if your health requires us to
♦ however, if you ask for more time, or if we need
more information that may benefit you, we can
take up to 14 more days if your request is for a
medical item or service. If we take extra days, we
will tell you in writing. We can’t take extra time if
your request is for a Medicare Part B prescription
drug
♦ if we do not give you an answer within 72 hours
(or by the end of the extended time period if we
took extra days), we are required to automatically
send your request on to Level 2 of the appeals
process, where it will be reviewed by an
independent review organization. “Step-by-Step:
How a Level 2 Appeal is Done” explains the Level
2 appeal process
• If our answer is yes to part or all of what you
requested, we must authorize or provide the coverage
we have agreed to provide within 72 hours after we
receive your appeal
• If our answer is no to part or all of what you
requested, we will send you our decision in writing
and automatically forward your appeal to the
independent review organization for a Level 2 appeal.
The independent review organization will notify you
in writing when it receives your appeal
Deadlines for a standard appeal
• For standard appeals, we must give you our answer
within 30 calendar days after we receive your appeal.
If your request is for a Medicare Part B prescription
drug you have not yet received, we will give you our
answer within 7 calendar days after we receive your
appeal. We will give you our decision sooner if your
health condition requires us to
♦ however, if you ask for more time, or if we need
more information that may benefit you, we can
take up to 14 more calendar days if your request is
for a medical item or service. If we take extra
days, we will tell you in writing. We can’t take
extra time to make a decision if your request is for
a Medicare Part B prescription drug
♦ if you believe we should not take extra days, you
can file a fast complaint. When you file a fast
complaint, we will give you an answer to your
complaint within 24 hours. (See “How to Make a
Complaint About Quality of Care, Waiting Times,
Customer Service, or Other Concerns” in this
“Coverage Decisions, Appeals, and Complaints”
section)
♦ if we do not give you an answer by the deadline
(or by the end of the extended time period), we
will send your request to a Level 2 appeal, where
an independent review organization will review
the appeal. Later in this section, we talk about this
review organization and explain the Level 2
appeal process
• If our answer is yes to part or all of what you
requested, we must authorize or provide the coverage
within 30 calendar days if your request is for a
medical item or service, or within 7 calendar days if
your request is for a Medicare Part B prescription
drug
• If our plan says no to part or all of what your appeal,
we will automatically send your appeal to the
independent review organization for a Level 2 appeal
Step-by-step: How a Level 2 appeal is done
The formal name for the independent review
organization is the Independent Review Entity. It is
sometimes called the IRE.
The independent review organization is an independent
organization hired by Medicare. It is not connected with
us and is not a government agency. This organization
decides whether the decision we made is correct or if it
should be changed. Medicare oversees its work.
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Step 1: The independent review organization
reviews your appeal
• We will send the information about your appeal to
this organization. This information is called your case
file. You have the right to ask us for a copy of your
case file. We are allowed to charge you a fee for
copying and sending this information to you
• You have a right to give the independent review
organization additional information to support your
appeal
• Reviewers at the independent review organization
will take a careful look at all of the information
related to your appeal
If you had a fast appeal at Level 1, you will also have
a fast appeal at Level 2
• For the fast appeal, the review organization must give
you an answer to your Level 2 appeal within 72 hours
of when it receives your appeal
• However, if your request is for a medical item or
service and the independent review organization
needs to gather more information that may benefit
you, it can take up to 14 more calendar days. The
independent review organization can’t take extra time
to make a decision if your request is for a Medicare
Part B prescription drug
If you had a standard appeal at Level 1, you will also
have a standard appeal at Level 2
• For the standard appeal, if your request is for a
medical item or service, the review organization must
give you an answer to your Level 2 appeal within 30
calendar days of when it receives your appeal. If your
request is for a Medicare Part B prescription drug, the
review organization must give you an answer to your
Level 2 appeal within 7 calendar days of when it
receives your appeal
• However, if your request is for a medical item or
service and the independent review organization
needs to gather more information that may benefit
you, it can take up to 14 more calendar days. The
independent review organization can’t take extra time
to make a decision if your request is for a Medicare
Part B prescription drug
Step 2: The independent review organization gives
you their answer
The independent review organization will tell you its
decision in writing and explain the reasons for it.
• If the review organization says yes to part or all of a
request for a medical item or service, we must
authorize the medical care coverage within 72 hours
or provide the service within 14 calendar days after
we receive the decision from the review organization
for standard requests. For expedited requests, we have
72 hours from the date we receive the decision from
the review organization
• If the review organization says yes to part or all of a
request for a Medicare Part B prescription drug, we
must authorize or provide the Medicare Part B
prescription drug within 72 hours after we receive the
decision from the review organization for standard
requests. For expedited requests, we have 24 hours
from the date we receive the decision from the review
organization
• If this organization says no to part or all of your
appeal, it means they agree with us that your request
(or part of your request) for coverage for medical care
should not be approved. (This is called upholding the
decision or turning down your appeal)
• In this care, the independent review organization will
send you a letter:
♦ explaining its decision
♦ notifying you of the right to a Level 3 appeal if the
dollar value of the medical care coverage meets a
certain minimum. The written notice you get from
the independent review organization will tell you
the dollar amount you must meet to continue the
appeals process
Step 3: If your case meets the requirements, you
choose whether you want to take your appeal
further
• There are three additional levels in the appeals
process after Level 2 (for a total of five levels of
appeal). If you want to go to a Level 3 appeal the
details on how to do this are in the written notice you
get after your Level 2 appeal
• The Level 3 appeal is handled by an Administrative
Law Judge or attorney adjudicator. “Taking Your
Appeal to Level 3 and Beyond” in this “Coverage
Decisions, Appeals, and Complaints” section explains
the Levels 3, 4, and 5 appeals processes
What if you are asking us to pay you for our
share of a bill you have received for medical
care?
The “Requests for Payment” section describes when you
may need to ask for reimbursement or to pay a bill you
have received from a provider. It also tells you how to
send us the paperwork that asks us for payment.
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Asking for reimbursement is asking for a
coverage decision from us
If you send us the paperwork asking for reimbursement,
you are asking for a coverage decision. To make this
decision, we will check to see if the medical care you
paid for is covered. We will also check to see if you
followed all the rules for using your coverage for
medical care.
• If we say yes to your request: If the medical care is
covered and you followed all the rules, we will send
you the payment for our share of the cost within 60
calendar days after we receive your request. If you
haven’t paid for the medical care, we will send the
payment directly to the provider
• If we say no to your request: If the medical care is not
covered, or you did not follow all the rules, we will
not send payment. Instead, we will send you a letter
that says we will not pay for the medical care and the
reasons why
If you do not agree with our decision to turn you down,
you can make an appeal. If you make an appeal, it means
you are asking us to change the coverage decision we
made when we turned down your request for payment.
To make this appeal, follow the process for appeals that
we describe in “Step-by-step: How to make a Level 1
Appeal.” For appeals concerning reimbursement, please
note:
• We must give you our answer within 60 calendar days
after we receive your appeal. If you are asking us to
pay you back for medical care you have already
received and paid for yourself, you are not allowed to
ask for a fast appeal
• If the independent review organization decides we
should pay, we must send you or the provider the
payment within 30 calendar days. If the answer to
your appeal is yes at any stage of the appeals process
after Level 2, we must send the payment you
requested to you or to the provider within 60 calendar
days
Your Part D Prescription Drugs: How to
Ask for a Coverage Decision or Make an
Appeal
What to do if you have problems getting a Part D
drug or you want us to pay you back for a Part D
drug
Your benefits include coverage for many prescription
drugs. To be covered, the drug must be used for a
medically accepted indication. (A “medically accepted
indication” is a use of the drug that is either approved by
the Food and Drug Administration or supported by
certain reference books.) For details about Part D drugs,
rules, restrictions, and costs, please see “Outpatient
Prescription Drugs, Supplies, and Supplements” in the
“Benefits and Your Cost Share” section. This section is
about your Part D drugs only. To keep things simple,
we generally say drug in the rest of this section, instead
of repeating covered outpatient prescription drug or
Part D drug every time. We also use the term “Drug
List” instead of List of Covered Drugs or 2024
Comprehensive Formulary.
• If you do not know if a drug is covered or if you meet
the rules, you can ask us. Some drugs require that you
get approval from us before we will cover it
• If your pharmacy tells you that your prescription
cannot be filled as written, the pharmacy will give
you a written notice explaining how to contact us to
ask for a coverage decision
Part D coverage decisions and appeals
An initial coverage decision about your Part D drugs is
called a coverage determination.
A coverage decision is a decision we make about your
benefits and coverage or about the amount we will pay
for your drugs. This section tells what you can do if you
are in any of the following situations:
• Asking us to cover a Part D drug that is not on our
2024 Comprehensive Formulary. Ask for an
exception
• Asking us to waive a restriction on our plan’s
coverage for a drug (such as limits on the amount of
the drug you can get). Ask for an exception
• Asking to pay a lower cost-sharing amount for a
covered drug on a higher cost-sharing tier. Ask for an
exception
• Asking us to get pre-approval for a drug. Ask for a
coverage decision
• Pay for a prescription drug you already bought. Ask
us to pay you back
If you disagree with a coverage decision we have made,
you can appeal our decision.
This section tells you both how to ask for coverage
decisions and how to request an appeal.
What is an exception?
Asking for coverage of a drug that is not on the Drug
List is sometimes called asking for a formulary
exception.
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Asking for removal of a restriction on coverage for a
drug is sometimes called asking for a formulary
exception.
If a drug is not covered in the way you would like it to be
covered, you can ask us to make an exception. An
exception is a type of coverage decision.
For us to consider your exception request, your doctor or
other prescriber will need to explain the medical reasons
why you need the exception approved. Here are two
examples of exceptions that you or your doctor or other
prescriber can ask us to make:
• Covering a Part D drug for you that is not on our
“Drug List.” If we agree to cover a drug that is not on
the “Drug List,” you will need to pay the Cost Share
amount that applies to drugs in the brand-name drug
tier. You cannot ask for an exception to the
Copayment or Coinsurance amount we require you to
pay for the drug
• Removing a restriction for a covered Part D drug.
“Outpatient Prescription Drugs, Supplies, and
Supplements” in the “Benefits and Your Cost Share”
section describes the extra rules or restrictions that
apply to certain drugs on our “Drug List.” If we agree
to make an exception and waive a restriction for you,
you can ask for an exception to the Copayment or
Coinsurance amount we require you to pay for the
Part D drug
Important things to know about asking for
Part D exceptions
Your doctor must tell us the medical reasons
Your doctor or other prescriber must give us a statement
that explains the medical reasons for requesting a Part D
exception. For a faster decision, include this medical
information from your doctor or other prescriber when
you ask for the exception.
Typically, our “Drug List” includes more than one drug
for treating a particular condition. These different
possibilities are called alternative drugs. If an
alternative drug would be just as effective as the drug
you are requesting and would not cause more side effects
or other health problems, we will generally not approve
your request for an exception. If you ask us for a tiering
exception, we will generally not approve your request for
an exception unless all the alternative drugs in the lower
cost-sharing tier(s) won’t work as well for you or are
likely to cause an adverse reaction or other harm.
We can say yes or no to your request
• If we approve your request for a Part D exception, our
approval usually is valid until the end of the plan
year. This is true as long as your doctor continues to
prescribe the drug for you and that drug continues to
be safe and effective for treating your condition
• If we say no to your request, you can ask for another
review by making an appeal
Step-by-step: How to ask for a coverage
decision, including a Part D exception
A fast coverage decision is called an expedited coverage
determination.
Step 1: Decide if you need a standard coverage
decision or a fast coverage decision
Standard coverage decisions are made within 72 hours
after we receive your doctor's statement. Fast coverage
decisions are made within 24 hours after we receive
your doctor's statement.
If your health requires it, ask us to give you a fast
coverage decision. To get a fast coverage decision, you
must meet two requirements:
• You must be asking for a drug you have not yet
received. (You cannot ask for a fast coverage decision
to be paid back for a drug you have already bought)
• Using the standard deadlines could cause serious
harm to your health or hurt your ability to function
• If your doctor or other prescriber tells us that
your health requires a fast coverage decision, we
will automatically give you a fast coverage decision
• If you ask for a fast coverage decision on your
own, without your doctor's or prescriber's support, we
will decide whether your health requires that we give
you a fast coverage decision. If we do not approve a
fast coverage decision, we will send you a letter that:
♦ explains that we will use the standard deadlines
♦ explains if your doctor or other prescriber asks for
the fast coverage decision, we will automatically
give you a fast coverage decision
♦ tells you how you can file a fast complaint about
our decision to give you a standard coverage
decision instead of the fast coverage decision you
requested. We will answer your complaint within
24 hours of receipt
Step 2: Request a standard coverage decision or a
fast coverage decision
Start by calling, writing, or faxing OptumRx Prior
Authorization Member Services Desk to make your
request for us to authorize or provide coverage for the
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medical care you want. You can also access the coverage
decision process through our website. We must accept
any written request, including a request submitted on the
CMS Model Coverage Determination Request form,
which is available on our website. “How to contact us
when you are asking for a coverage decision about your
Part D prescription drugs” in the “Important Phone
Numbers and Resources” section has contact
information. To assist us in processing your request,
please be sure to include your name, contact information,
and information identifying which denied claim is being
appealed.
You, or your doctor (or other prescriber), or your
representative can do this. You can also have a lawyer
act on your behalf. “How to Get Help When You are
Asking for a Coverage Decision or Making an Appeal”
of this section tells how you can give written permission
to someone else to act as your representative.
• If you are requesting a Part D exception, provide the
supporting statement which is the medical reasons for
the exception. Your doctor or other prescriber can fax
or mail the statement to us. Or your doctor or other
prescriber can tell us on the phone and follow up by
faxing or mailing a written statement if necessary
Step 3: We consider your request and we give you
our answer
Deadlines for a fast coverage decision
• We must generally give you our answer within 24
hours after we receive your request.
♦ for exceptions, we will give you our answer within
24 hours after we receive your doctor’s supporting
statement. We will give you our answer sooner
if your health requires us to
♦ if we do not meet this deadline, we are required to
send your request to Level 2 of the appeals
process, where it will be reviewed by an
independent review organization
• If our answer is yes to part or all of what you
requested, we must provide the coverage we have
agreed to provide within 24 hours after we receive
your request or doctor’s statement supporting your
request
• If our answer is no to part or all of what you
requested, we will send you a written statement that
explains why we said no. We will also tell you how
you can appeal
Deadlines for a standard coverage decision about a
Part D drug you have not yet received
• We must generally give you our answer within 72
hours after we receive your request
♦ for exceptions, we will give you our answer within
72 hours after we receive your doctor’s supporting
statement. We will give you our answer sooner
if your health requires us to
♦ if we do not meet this deadline, we are required to
send your request on to Level 2 of the appeals
process, where it will be reviewed by an
independent review organization
• If our answer is yes to part or all of what you
requested, we must provide the coverage we have
agreed to provide within 72 hours after we receive
your request or doctor’s statement supporting your
request
• If our answer is no to part or all of what you
requested, we will send you a written statement that
explains why we said no. We will also tell you how
you can appeal
Deadlines for a standard coverage decision about
payment for a drug you have already bought
• We must give you our answer within 14 calendar days
after we receive your request
♦ if we do not meet this deadline, we are required to
send your request to Level 2 of the appeals
process, where it will be reviewed by an
independent review organization
• If our answer is yes to part or all of what you
requested, we are also required to make payment to
you within 14 calendar days after we receive your
request
• If our answer is no to part or all of what you
requested, we will send you a written statement that
explains why we said no. We will also tell you how
you can appeal
Step 4: If we say no to your coverage request, you
decide if you want to make an appeal
If we say no, you have the right to ask us to reconsider
this decision by making an appeal. This means asking
again to get the drug coverage you want. If you make an
appeal, it means you are going to Level 1 of the appeals
process.
Step-by-step: How to make a Level 1 appeal
An appeal to our plan about a Part D drug coverage
decision is called a plan redetermination. A fast appeal
is also called an expedited redetermination.
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Page 76
Step 1: Decide if you need a standard appeal or a
fast appeal
A standard appeal is usually made within 7 days. A
fast appeal is generally made within 72 hours. If your
health requires it, ask for a fast appeal
• If you are appealing a decision we made about a drug
you have not yet received, you and your doctor or
other prescriber will need to decide if you need a fast
appeal
• The requirements for getting a “fast appeal” are the
same as those for getting a fast coverage decision in
“Step-by-step: How to ask for a coverage decision,
including a Part D exception” of this section
Step 2: You, your representative, doctor, or other
prescriber must contact us and make your Level 1
appeal. If your health requires a quick response,
you must ask for a fast appeal
• For standard appeals, submit a written request.
“Important Phone Numbers and Resources” has
contact information
• For fast appeals either submit your appeal in writing
or call us at 1-800-443-0815. “Important Phone
Numbers and Resources” has contact information
• We must accept any written request, including a
request submitted on the CMS Model Coverage
Determination Request Form, which is available on
our website. Please be sure to include your name,
contact information, and information regarding your
claim to assist us in processing your request
• You must make your appeal request within 60
calendar days from the date on the written notice we
sent to tell you our answer on the coverage decision.
If you miss this deadline and have a good reason for
missing it, explain the reason your appeal is late when
you make your appeal. We may give you more time
to make your appeal. Examples of good cause may
include a serious illness that prevented you from
contacting us or if we provided you with incorrect or
incomplete information about the deadline for
requesting an appeal
• You can ask for a copy of the information in your
appeal and add more information. You and your
doctor may add more information to support your
appeal. We are allowed to charge a fee for copying
and sending this information to you
Step 3: We consider your appeal and we give you
our answer
• When we are reviewing your appeal, we take another
careful look at all of the information about your
coverage request. We check to see if we were
following all the rules when we said no to your
request. We may contact you or your doctor or other
prescriber to get more information
Deadlines for a fast appeal
• For fast appeals, we must give you our answer within
72 hours after we receive your appeal. We will give
you our answer sooner if your health requires us to
♦ if we do not give you an answer within 72 hours,
we are required to send your request on to Level 2
of the appeals process, where it will be reviewed
by an independent review organization
• If our answer is yes to part or all of what you
requested, we must provide the coverage we have
agreed to provide within 72 hours after we receive
your appeal
• If our answer is no to part or all of what you
requested, we will send you a written statement that
explains why we said no and how you can appeal our
decision
Deadlines for a standard appeal for a drug you have
not yet received
• For standard appeals, we must give you our answer
within 7 calendar days after we receive your appeal.
We will give you our decision sooner if you have not
received the drug yet and your health condition
requires us to do so
♦ if we do not give you a decision within 7 calendar
days, we are required to send your request on to
Level 2 of the appeals process, where it will be
reviewed by an independent review organization
• If our answer is yes to part or all of what you
requested, we must provide the coverage as quickly as
your health requires, but no later than 7 calendar days
after we receive your appeal
• If our answer is no to part or all of what you
requested, we will send you a written statement that
explains why we said no and how you can appeal our
decision
Deadlines for a standard appeal about payment for a
drug you have already bought
• We must give you our answer within 14 calendar days
after we receive your request
♦ If we do not meet this deadline, we are required to
send your request to Level 2 of the appeals
process, where it will be reviewed by an
independent review organization
• If our answer is yes to part or all of what you
requested, we are also required to make payment to
you within 30 calendar days after we receive your
request
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Page 77
• If our answer is no to part or all of what you
requested, we will send you a written statement that
explains why we said no. We will also tell you how
you can appeal our decision
Step 4: If we say no to your appeal, you decide
if you want to continue with the appeals process
and make another appeal
• If you decide to make another appeal, it means your
appeal is going on to Level 2 of the appeals process
Step-by-step: How to make a Level 2 appeal
The formal name for the independent review
organization is the Independent Review Entity. It is
sometimes called the IRE.
The independent review organization is an
independent organization hired by Medicare. It is not
connected with us and is not a government agency. This
organization decides whether the decision we made is
correct or if it should be changed. Medicare oversees its
work.
Step 1: You (or your representative or your doctor
or other prescriber) must contact the independent
review organization and ask for a review of your
case
• If we say no to your Level 1 appeal, the written notice
we send you will include instructions on how to make
a Level 2 appeal with the independent review
organization. These instructions will tell who can
make this Level 2 appeal, what deadlines you must
follow, and how to reach the review organization. If,
however, we did not complete our review within the
applicable timeframe, or make an unfavorable
decision regarding at-risk determination under our
drug management program, we will automatically
forward your claim to the IRE
• We will send the information about your appeal to
this organization. This information is called your case
file. You have the right to ask us for a copy of your
case file. We are allowed to charge you a fee for
copying and sending this information to you
• You have a right to give the independent review
organization additional information to support your
appeal
Step 2: The independent review organization
reviews your appeal
Reviewers at the independent review organization will
take a careful look at all of the information related to
your appeal.
Deadlines for fast appeal
• If your health requires it, ask the independent review
organization for a fast appeal
• If the organization agrees to give you a fast appeal,
the organization must give you an answer to your
Level 2 appeal within 72 hours after it receives your
appeal request
Deadlines for standard appeal
• For standard appeals, the review organization must
give you an answer to your Level 2 appeal within 7
calendar days after it receives your appeal if it is for a
drug you have not yet received. If you are requesting
that we pay you back for a drug you have already
bought, the review organization must give you an
answer to your Level 2 appeal within 14 calendar
days after it receives your request
Step 3: The independent review organization give
you their answer
For fast appeals:
• If the independent review organization says yes to
part or all of what you requested, we must provide the
drug coverage that was approved by the review
organization within 24 hours after we receive the
decision from the review organization
For standard appeals:
• If the independent review organization says yes to
part or all of your request for coverage, we must
provide the drug coverage that was approved by the
review organization within 72 hours after we receive
the decision from the review organization
• If the independent review organization says yes to
part or all of your request to pay you back for a drug
you already bought, we are required to send payment
to you within 30 calendar days after we receive the
decision from the review organization
What if the review organization says no to your
appeal?
If this organization says no to your appeal, it means the
organization agrees with our decision not to approve
your request (or part of your request.) (This is called
upholding the decision. It is also called turning down
your appeal.) In this case, the independent review
organization will send you a letter:
• Explaining its decision
• Notifying you of the right to a Level 3 appeal if the
dollar value of the drug coverage you are requesting
meets a certain minimum. If the dollar value of the
drug coverage you are requesting is too low, you
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Page 78
cannot make another appeal and the decision at Level
2 is final
• Telling you the dollar value that must be in dispute to
continue with the appeals process
Step 4: If your case meets the requirements, you
choose whether you want to take your appeal
further
• There are three additional levels in the appeals
process after Level 2 (for a total of five levels of
appeal)
• If you want to go on to a Level 3 appeal the details on
how to do this are in the written notice you get after
your Level 2 appeal decision
• The Level 3 appeal is handled by an Administrative
Law Judge or attorney adjudicator. “Taking Your
Appeal to Level 3 and Beyond” tells more about
Levels 3, 4, and 5 of the appeals process
How to Ask Us to Cover a Longer
Inpatient Hospital Stay if You Think You
Are Being Discharged Too Soon
When you are admitted to a hospital, you have the right
to get all of your covered hospital Services that are
necessary to diagnose and treat your illness or injury.
During your covered hospital stay, your doctor and the
hospital staff will be working with you to prepare for the
day when you will leave the hospital. They will help
arrange for care you may need after you leave.
• The day you leave the hospital is called your
discharge date
• When your discharge date is decided, your doctor or
the hospital staff will tell you
• If you think you are being asked to leave the hospital
too soon, you can ask for a longer hospital stay and
your request will be considered
During your inpatient hospital stay, you will get
a written notice from Medicare that tells about
your rights
Within two days of being admitted to the hospital, you
will be given a written notice called An Important
Message from Medicare About Your Rights. Everyone
with Medicare gets a copy of this notice If you do not get
the notice from someone at the hospital (for example, a
caseworker or nurse), ask any hospital employee for it.
If you need help, please call Member Services or 1-800-
MEDICARE (1-800-633-4227), 24 hours a day, seven
days a week (TTY 1-877-486-2048).
• Read this notice carefully and ask questions if you
don’t understand it. It tells you:
♦ your right to receive Medicare-covered services
during and after your hospital stay, as ordered by
your doctor. This includes the right to know what
these services are, who will pay for them, and
where you can get them
♦ your right to be involved in any decisions about
your hospital stay
♦ where to report any concerns you have about the
quality of your hospital Services
♦ your right to request an immediate review of the
decision to discharge you if you think you are
being discharged from the hospital too soon. This
is a formal, legal way to ask for a delay in your
discharge date so that we will cover your hospital
care for a longer time
• You will be asked to sign the written notice to
show that you received it and understand your
rights
♦ you or someone who is acting on your behalf will
be asked to sign the notice
♦ signing the notice shows only that you have
received the information about your rights. The
notice does not give your discharge date. Signing
the notice does not mean you are agreeing on a
discharge date
• Keep your copy of the notice handy so you will have
the information about making an appeal (or reporting
a concern about quality of care) if you need it
♦ if you sign the notice more than two days before
your discharge date, you will get another copy
before you are scheduled to be discharged
♦ to look at a copy of this notice in advance, you can
call Member Services or 1-800-MEDICARE
(1-800-633-4227) (TTY users call 1-877-486-
2048), 24 hours a day, seven days a week. You
can also see the notice online at
https://www.cms.gov/Medicare/Medicare-
General-
Information/BNI/HospitalDischargeAppealNoti
ces.html
Step-by-step: How to make a Level 1 appeal to
change your hospital discharge date
If you want to ask for your inpatient hospital
services to be covered by us for a longer time, you
will need to use the appeals process to make this
request. Before you start, understand what you need
to do and what the deadlines are.
• Follow the process
• Meet the deadlines
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• Ask for help if you need it. If you have questions or
need help at any time, please call Member Services.
Or call your State Health Insurance Assistance
Program, a government organization that provides
personalized assistance
During a Level 1 appeal, the Quality Improvement
Organization reviews your appeal. It checks to see
if your planned discharge date is medically appropriate
for you.
The Quality Improvement Organization is a group of
doctors and other health care professionals paid by the
federal government to check on and help improve the
quality of care for people with Medicare. This includes
reviewing hospital discharge dates for people with
Medicare. These experts are not part of our plan.
Step 1: Contact the Quality Improvement
Organization for your state and ask for an
immediate review of your hospital discharge. You
must act quickly
How can you contact this organization?
• The written notice you received (An Important
Message from Medicare About Your Rights) tells you
how to reach this organization. Or find the name,
address, and phone number of the Quality
Improvement Organization for your state in the
“Important Phone Numbers and Resources” section
Act quickly
• To make your appeal, you must contact the Quality
Improvement Organization before you leave the
hospital and no later than midnight the day of your
discharge
♦ if you meet this deadline, you may stay in the
hospital after your discharge date without paying
for it while you wait to get the decision from the
Quality Improvement Organization
♦ if you do not meet this deadline, and you decide to
stay in the hospital after your planned discharge
date, you may have to pay all of the costs for
hospital Services you receive after your planned
discharge date
• If you miss the deadline for contacting the Quality
Improvement Organization and you still wish to
appeal, you must make an appeal directly to our plan
instead. For details about this other way to make your
appeal, see “What if you miss the deadline for making
your Level 1 appeal?”
Once you request an immediate review of your hospital
discharge, the Quality Improvement Organization will
contact us. By noon of the day after we are contacted, we
will give you a Detailed Notice of Discharge. This notice
gives your planned discharge date and explains in detail
the reasons why your doctor, the hospital, and we think it
is right (medically appropriate) for you to be discharged
on that date.
You can get a sample of the Detailed Notice of
Discharge by calling Member Services or 1-800-
MEDICARE (1-800-633-4227) 24 hours a day, seven
days a week (TTY users call 1-877-486-2048). Or you
can see a sample notice online at
https://www.cms.gov/Medicare/Medicare-General-
Information/BNI/HospitalDischargeAppealNotices.ht
ml
Step 2: The Quality Improvement Organization
conducts an independent review of your case
• Health professionals at the Quality Improvement
Organization (the reviewers) will ask you (or your
representative) why you believe coverage for the
services should continue. You don’t have to prepare
anything in writing, but you may do so if you wish
• The reviewers will also look at your medical
information, talk with your doctor, and review
information that the hospital and we have given to
them
• By noon of the day after the reviewers told us of your
appeal, you will get a written notice from us that
gives you your planned discharge date. This notice
also explains in detail the reasons why your doctor,
the hospital, and we think it is right (medically
appropriate) for you to be discharged on that date
Step 3: Within one full day after it has all the
needed information, the Quality Improvement
Organization will give you its answer to your appeal
What happens if the answer is yes?
• If the review organization says yes, we must keep
providing your covered inpatient hospital services for
as long as these services are medically necessary
• You will have to keep paying your share of the costs
(such as Cost Share, if applicable). In addition, there
may be limitations on your covered hospital services
What happens if the answer is no?
• If the review organization says no, they are saying
that your planned discharge date is medically
appropriate. If this happens, our coverage for your
inpatient hospital services will end at noon on the day
after the Quality Improvement Organization gives
you its answer to your appeal
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• If the review organization says no to your appeal and
you decide to stay in the hospital, then you may have
to pay the full cost of hospital Services you receive
after noon on the day after the Quality Improvement
Organization gives you its answer to your appeal
Step 4: If the answer to your Level 1 appeal is no,
you decide if you want to make another appeal
• If the Quality Improvement Organization has said no
to your appeal, and you stay in the hospital after your
planned discharge date, then you can make another
appeal. Making another appeal means you are going
on to Level 2 of the appeals process
Step-by-step: How to make a Level 2 appeal to
change your hospital discharge date
During a Level 2 appeal, you ask the Quality
Improvement Organization to take another look at their
decision on your first appeal. If the Quality Improvement
Organization turns down your Level 2 appeal, you may
have to pay the full cost for your stay after your planned
discharge date.
Step 1: Contact the Quality Improvement
Organization again and ask for another review
• You must ask for this review within 60 calendar days
after the day the Quality Improvement Organization
said no to your Level 1 appeal. You can ask for this
review only if you stay in the hospital after the date
that your coverage for the care ended
Step 2: The Quality Improvement Organization
does a second review of your situation
• Reviewers at the Quality Improvement Organization
will take another careful look at all of the information
related to your appeal
Step 3: Within 14 calendar days of receipt of your
request for a Level 2 appeal, the reviewers will
decide on your appeal and tell you their decision
If the review organization says yes
• We must reimburse you for our share of the costs of
hospital Services you have received since noon on the
day after the date your first appeal was turned down
by the Quality Improvement Organization. We must
continue providing coverage for your inpatient
hospital Services for as long as it is medically
necessary
• You must continue to pay your share of the costs, and
coverage limitations may apply
If the review organization says no
• It means they agree with the decision they made on
your Level 1 appeal. This is called upholding the
decision
• The notice you get will tell you in writing what you
can do if you wish to continue with the review
process
Step 4: If the answer is no, you will need to decide
whether you want to take your appeal further by
going on to Level 3
• There are three additional levels in the appeals
process after Level 2 (for a total of five levels of
appeal). If you want to go to a Level 3 appeal, the
details on how to do this are in the written notice you
get after your Level 2 appeal decision
• The Level 3 appeal is handled by an Administrative
Law Judge or attorney adjudicator. The “Taking Your
Appeal to Level 3 and Beyond” section tells you more
about Levels 3, 4, and 5 of the appeals process
What if you miss the deadline for making your
Level 1 appeal to change your hospital
discharge date?
A fast review (or fast appeal) is also called an expedited
appeal.
You can appeal to us instead
As explained above, you must act quickly to start your
Level 1 appeal of your hospital discharge date. If you
miss the deadline for contacting the Quality Review
Organization, there is another way to make your appeal.
If you use this other way of making your appeal, the first
two levels of appeal are different.
Step-by-step: How to make a Level 1 alternate
appeal
Step 1: Contact us and ask for a fast review
• Ask for a fast review. This means you are asking us
to give you an answer using the fast deadlines rather
than the standard deadlines. The “Important Phone
Numbers and Resources” section has contact
information
Step 2: We do a fast review of your planned
discharge date, checking to see if it was medically
appropriate
• During this review, we take a look at all of the
information about your hospital stay. We check to see
if your planned discharge date was medically
appropriate. We will see if the decision about when
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Page 81
you should leave the hospital was fair and followed
all the rules
Step 3: We give you our decision within 72 hours
after you ask for a fast review
• If we say yes to your appeal, it means we have agreed
with you that you still need to be in the hospital after
the discharge date. We will keep providing your
covered inpatient hospital services for as long as they
are medically necessary. It also means that we have
agreed to reimburse you for our share of the costs of
care you have received since the date when we said
your coverage would end. (You must pay your share
of the costs, and there may be coverage limitations
that apply)
• If we say no to your appeal, we are saying that your
planned discharge date was medically appropriate.
Our coverage for your inpatient hospital services ends
as of the day we said coverage would end
• If you stayed in the hospital after your planned
discharge date, then you may have to pay the full
cost of hospital Services you received after the
planned discharge date
Step 4: If we say no to your appeal, your case will
automatically be sent on to the next level of the
appeals process
Step-by-step: Level 2 alternate appeal process
The formal name for the independent review
organization is the Independent Review Entity. It is
sometimes called the IRE.
The independent review organization is an independent
organization hired by Medicare. It is not connected with
our plan and is not a government agency. This
organization decides whether the decision we made is
correct or if it should be changed. Medicare oversees its
work.
Step 1: We will automatically forward your case to
the independent review organization
We are required to send the information for your Level 2
appeal to the independent review organization within 24
hours of when we tell you that we are saying no to your
first appeal. (If you think we are not meeting this
deadline or other deadlines, you can make a complaint.
“How to Make a Complaint About Quality of Care,
Waiting Times, Customer Service, or Other Concerns” in
this “Coverage Decisions, Appeals, and Complaints”
section tells you how to make a complaint.)
Step 2: The independent review organization does
a fast review of your appeal. The reviewers give
you an answer within 72 hours
• Reviewers at the independent review organization
will take a careful look at all of the information
related to your appeal of your hospital discharge
• If this organization says yes to your appeal, then we
must pay you back for our share of the costs of
hospital Services you received since the date of your
planned discharge. We must also continue our plan’s
coverage of your inpatient hospital services for as
long as it is medically necessary. You must continue
to pay your share of the costs. If there are coverage
limitations, these could limit how much we would
reimburse or how long we would continue to cover
your services
• If this organization says no to your appeal, it means
they agree that your planned hospital discharge date
was medically appropriate
♦ the written notice you get from the independent
review organization will tell how to start a Level 3
appeal with the review process which is handled
by an Administrative Law Judge or attorney
adjudicator
Step 3: If the independent review organization turns
down your appeal, you choose whether you want to
take your appeal further
• There are three additional levels in the appeals
process after Level 2 (for a total of five levels of
appeal). If reviewers say no to your Level 2 appeal,
you decide whether to accept their decision or go on
to Level 3 appeal
• “Taking Your Appeal to Level 3 and Beyond” in this
“Coverage Decisions, Appeals, and Complaints”
section tells you more about Levels 3, 4, and 5 of the
appeals process
How to Ask Us to Keep Covering Certain
Medical Services if You Think Your
Coverage Is Ending Too Soon
Home health care, Skilled Nursing Facility care,
and Comprehensive Outpatient Rehabilitation
Facility (CORF) services
When you are getting covered home health services,
Skilled Nursing Facility care, or rehabilitation care
(Comprehensive Outpatient Rehabilitation Facility),
you have the right to keep getting your services for that
type of care for as long as the care is needed to diagnose
and treat your illness or injury.
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Page 82
When we decide it is time to stop covering any of the
three types of care for you, we are required to tell you in
advance. When your coverage for that care ends, we will
stop paying our share of the cost for your care.
If you think we are ending the coverage of your care too
soon, you can appeal our decision. This section tells you
how to ask for an appeal.
We will tell you in advance when your coverage
will be ending
The Notice of Medicare Non-Coverage tells how you
can request a fast-track appeal. Requesting a fast-track
appeal is a formal, legal way to request a change to our
coverage decision about when to stop your care.
• You receive a notice in writing at least two days
before our plan is going to stop covering your care.
The notice tells you:
♦ the date when we will stop covering the care for
you
♦ how to request a fast-track appeal to request us to
keep covering your care for a longer period of
time
• You, or someone who is acting on your behalf, will
be asked to sign the written notice to show that
you received it. Signing the notice shows only that
you have received the information about when your
coverage will stop. Signing it does not mean you
agree with the plan’s decision to stop care
Step-by-step: How to make a Level 1 appeal to
have our plan cover your care for a longer time
If you want to ask us to cover your care for a longer
period of time, you will need to use the appeals
process to make this request. Before you start,
understand what you need to do and what the
deadlines are.
• Follow the process
• Meet the deadlines
• Ask for help if you need it. If you have questions or
need help at any time, please call Member Services.
Or call your State Health Insurance Assistance
Program, a government organization that provides
personalized assistance
During a Level 1 appeal, the Quality Improvement
Organization reviews your appeal. It decides if the end
date for your care is medically appropriate.
The Quality Improvement Organization is a group of
doctors and other health care experts who are paid by the
federal government to check on and help improve the
quality of care for people with Medicare. This includes
reviewing plan decisions about when it’s time to stop
covering certain kinds of medical care. These experts are
not part of our plan.
Step 1: Make your Level 1 appeal: contact the
Quality Improvement Organization and ask for a
fast-track appeal. You must act quickly
How can you contact this organization?
• The written notice you received (Notice of Medicare
Non-Coverage) tells you how to reach this
organization. Or find the name, address, and phone
number of the Quality Improvement Organization for
your state in the “Important Phone Numbers and
Resources” section
Act quickly
• You must contact the Quality Improvement
Organization to start your appeal by noon of the day
before the effective date on the Notice of Medicare
Non-Coverage
• If you miss the deadline for contacting the Quality
Improvement Organization, and you still wish to file
an appeal, you must make an appeal directly to us
instead. For details about this other way to make your
appeal, see “Step-by-step: How to make a Level 2
appeal to have our plan cover your care for a longer
time”
Step 2: The Quality Improvement Organization
conducts an independent review of your case
The Detailed Explanation of Non-Coverage provides
details on reasons for ending coverage.
What happens during this review?
• Health professionals at the Quality Improvement
Organization (the reviewers) will ask you or your
representative why you believe coverage for the
services should continue. You don’t have to prepare
anything in writing, but you may do so if you wish
• The review organization will also look at your
medical information, talk with your doctor, and
review information that our plan has given to them
• By the end of the day the reviewers tell us of your
appeal, you will get the Detailed Explanation of
Non-Coverage from us that explains in detail our
reasons for ending our coverage for your services.
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Page 83
Step 3: Within one full day after they have all the
information they need, the reviewers will tell you
their decision
What happens if the reviewers say yes?
• If the reviewers say yes to your appeal, then we must
keep providing your covered services for as long as it
is medically necessary
• You will have to keep paying your share of the costs
(such as Cost Share, if applicable). There may be
limitations on your covered services
What happens if the reviewers say no?
• If the reviewers say no, then your coverage will end
on the date we have told you
• If you decide to keep getting the home health care, or
Skilled Nursing Facility care, or Comprehensive
Outpatient Rehabilitation Facility (CORF) services
after this date when your coverage ends, then you will
have to pay the full cost of this care yourself
Step 4: If the answer to your Level 1 appeal is no,
you decide if you want to make another appeal
• If reviewers say no to your Level 1 appeal, and you
choose to continue getting care after your coverage
for the care has ended, then you can make a Level 2
appeal
Step-by-step: How to make a Level 2 appeal to
have our plan cover your care for a longer time
During a Level 2 appeal, you ask the Quality
Improvement Organization to take another look at the
decision on your first appeal. If the Quality Improvement
Organization turns down your Level 2 appeal, you may
have to pay the full cost for your home health care, or
Skilled Nursing Facility care, or Comprehensive
Outpatient Rehabilitation Facility (CORF) services after
the date when we said your coverage would end.
Step 1: Contact the Quality Improvement
Organization again and ask for another review
• You must ask for this review within 60 days after the
day when the Quality Improvement Organization said
no to your Level 1 appeal. You can ask for this
review only if you continued getting care after the
date that your coverage for the care ended
Step 2: The Quality Improvement Organization
does a second review of your situation
Reviewers at the Quality Improvement Organization will
take another careful look at all of the information related
to your appeal
Step 3: Within 14 days of receipt of your appeal
request, reviewers will decide on your appeal and
tell you their decision
What happens if the review organization says yes?
• We must reimburse you for our share of the costs of
care you have received since the date when we said
your coverage would end. We must continue
providing coverage for the care for as long as it is
medically necessary
• You must continue to pay your share of the costs and
there may be coverage limitations that apply
What happens if the review organization says no?
• It means they agree with the decision we made to
your Level 1 appeal
• The notice you get will tell you in writing what you
can do if you wish to continue with the review
process. It will give you the details about how to go
on to the next level of appeal, which is handled by an
Administrative Law Judge or attorney adjudicator
Step 4: If the answer is no, you will need to decide
whether you want to take your appeal further
• There are three additional levels of appeal after Level
2, for a total of five levels of appeal. If you want to go
on to a Level 3 appeal, the details on how to do this
are in the written notice you get after your Level 2
appeal decision
• The Level 3 appeal is handled by an Administrative
Law Judge or attorney adjudicator. “Taking Your
Appeal to Level 3 and Beyond” in this “Coverage
Decisions, Appeals, and Complaints” section tells you
more about Levels 3, 4, and 5 of the appeals process
What if you miss the deadline for making your
Level 1 appeal?
You can appeal to us instead
As explained above, you must act quickly to contact the
Quality Improvement Organization to start your first
appeal (within a day or two, at the most). If you miss the
deadline for contacting this organization, there is another
way to make your appeal. If you use this other way of
making your appeal, the first two levels of appeal are
different.
Step-by-step: How to make a Level 1 alternate
appeal
A fast review (or fast appeal) is also called an expedited
appeal.
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Page 84
Step 1: Contact us and ask for a fast review
• Ask for a fast review. This means you are asking us
to give you an answer using the fast deadlines rather
than the standard deadlines. The “Important Phone
Numbers and Resources” section has contact
information
Step 2: We do a fast review of the decision we
made about when to end coverage for your services
• During this review, we take another look at all of the
information about your case. We check to see if we
were following all the rules when we set the date for
ending our plan’s coverage for services you were
receiving
Step 3: We give you our decision within 72 hours
after you ask for a fast review
• If we say yes to your appeal, it means we have agreed
with you that you need services longer, and will keep
providing your covered services for as long as it is
medically necessary. It also means that we have
agreed to reimburse you for our share of the costs of
care you have received since the date when we said
your coverage would end. (You must pay your share
of the costs and there may be coverage limitations
that apply)
• If we say no to your appeal, then your coverage will
end on the date we told you and we will not pay any
share of the costs after this date
• If you continued to get home health care, or Skilled
Nursing Facility care, or Comprehensive Outpatient
Rehabilitation Facility (CORF) services after the date
when we said your coverage would end, then you will
have to pay the full cost of this care
Step 4: If we say no to your fast appeal, your case
will automatically go on to the next level of the
appeals process
The formal name for the independent review
organization is the Independent Review Entity. It is
sometimes called the IRE.
Step-by-step: Level 2 alternate appeal process
During the Level 2 Appeal, the independent review
organization reviews the decision we made to your fast
appeal. This organization decides whether the decision
should be changed. The independent review
organization is an independent organization that is
hired by Medicare. This organization is not connected
with our plan and it is not a government agency. This
organization is a company chosen by Medicare to handle
the job of being the independent review organization.
Medicare oversees its work.
Step 1: We will automatically forward your case to
the independent review organization
We are required to send the information for your Level 2
appeal to the independent review organization within 24
hours of when we tell you that we are saying no to your
first appeal. (If you think we are not meeting this
deadline or other deadlines, you can make a complaint.
“How to Make a Complaint About Quality of Care,
Waiting Times, Customer Service, or Other Concerns” in
this “Coverage Decisions, Appeals, and Complaints”
section tells how to make a complaint.)
Step 2: The independent review organization does
a fast review of your appeal. The reviewers give
you an answer within 72 hours
• Reviewers at the independent review organization
will take a careful look at all of the information
related to your appeal
• If this organization says yes to your appeal, then we
must pay you back for our share of the costs of care
you have received since the date when we said your
coverage would end. We must also continue to cover
the care for as long as it is medically necessary. You
must continue to pay your share of the costs. If there
are coverage limitations, these could limit how much
we would reimburse or how long we would continue
to cover your services
• If this organization says no to your appeal, it means
they agree with the decision our plan made to your
first appeal and will not change it
♦ the notice you get from the independent review
organization will tell you in writing what you can
do if you wish to go on to a Level 3 appeal
Step 3: If the independent review organization says
no to your appeal, you choose whether you want to
take your appeal further
• There are three additional levels of appeal after Level
2, for a total of five levels of appeal. If you want to go
on to a Level 3 appeal, the details on how to do this
are in the written notice you get after your Level 2
appeal decision
• A Level 3 appeal is reviewed by an Administrative
Law Judge or attorney adjudicator. “Taking Your
Appeal to Level 3 and Beyond” in this “Coverage
Decisions, Appeals, and Complaints” section tells you
more about Levels 3, 4, and 5 of the appeals process
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Taking Your Appeal to Level 3 and
Beyond
Levels of Appeal 3, 4, and 5 for Medical Service
Requests
This section may be appropriate for you if you have
made a Level 1 appeal and a Level 2 appeal, and both of
your appeals have been turned down.
If the dollar value of the item or medical service you
have appealed meets certain minimum levels, you may
be able to go on to additional levels of appeal. If the
dollar value is less than the minimum level, you cannot
appeal any further. The written response you receive to
your Level 2 appeal will explain how to make a Level 3
appeal.
For most situations that involve appeals, the last three
levels of appeal work in much the same way. Here is
who handles the review of your appeal at each of these
levels.
Level 3 appeal: An Administrative Law Judge or
an attorney adjudicator who works for the
federal government will review your appeal and
give you an answer
• If the Administrative Law Judge or attorney
adjudicator says yes to your appeal, the appeals
process may or may not be over. Unlike a decision
at a Level 2 appeal, we have the right to appeal a
Level 3 decision that is favorable to you. If we decide
to appeal, it will go to a Level 4 appeal
♦ if we decide not to appeal, we must authorize or
provide you with the medical care within 60
calendar days after receiving the Administrative
Law Judge’s or attorney adjudicator’s decision
♦ if we decide to appeal the decision, we will send
you a copy of the Level 4 appeal request with any
accompanying documents. We may wait for the
Level 4 appeal decision before authorizing or
providing the medical care in dispute
• If the Administrative Law Judge or attorney
adjudicator says no to your appeal, the appeals
process may or may not be over
♦ if you decide to accept this decision that turns
down your appeal, the appeals process is over
♦ if you do not want to accept the decision, you can
continue to the next level of the review process.
The notice you get will tell you what to do for a
Level 4 appeal
Level 4 appeal: The Medicare Appeals Council
(Council) will review your appeal and give you
an answer. The Council is part of the federal
government
• If the answer is yes, or if the Council denies our
request to review a favorable Level 3 appeal
decision, the appeals process may or may not be
over. Unlike a decision at Level 2, we have the right
to appeal a Level 4 decision that is favorable to you.
We will decide whether to appeal this decision to
Level 5
♦ if we decide not to appeal the decision, we must
authorize or provide you with the medical care
within 60 calendar days after receiving the
Council’s decision
♦ if we decide to appeal the decision, we will let you
know in writing
• If the answer is no or if the Council denies the
review request, the appeals process may or may
not be over
♦ if you decide to accept this decision that turns
down your appeal, the appeals process is over
♦ if you do not want to accept the decision, you may
be able to continue to the next level of the review
process. If the Council says no to your appeal, the
notice you get will tell you whether the rules allow
you to go on to a Level 5 appeal and how to
continue with a Level 5 appeal
Level 5 appeal: A judge at the Federal District
Court will review your appeal
• A judge will review all of the information and decide
yes or no to your request. This is a final answer.
There are no more appeal levels after the Federal
District Court
Appeal Levels 3, 4, and 5 for Part D Drug
Requests
This section may be appropriate for you if you have
made a Level 1 appeal and a Level 2 appeal, and both of
your appeals have been turned down.
If the value of the Part D drug you have appealed meets a
certain dollar amount, you may be able to go on to
additional levels of appeal. If the dollar amount is less,
you cannot appeal any further. The written response you
receive to your Level 2 appeal will explain whom to
contact and what to do to ask for a Level 3 appeal.
For most situations that involve appeals, the last three
levels of appeal work in much the same way. Here is
who handles the review of your appeal at each of these
levels.
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Page 86
Level 3 appeal: An Administrative Law Judge or
an attorney adjudicator who works for the
federal government will review your appeal and
give you an answer
• If the answer is yes, the appeals process is over. We
must authorize or provide the drug coverage that was
approved by the Administrative Law Judge or
attorney adjudicator within 72 hours (24 hours for
expedited appeals) or make payment no later than 30
calendar days after we receive the decision
• If the answer is no, the appeals process may or may
not be over
♦ If you decide to accept this decision that turns
down your appeal, the appeals process is over
♦ If you do not want to accept the decision, you can
continue to the next level of the review process.
The notice you get will tell you what to do for a
Level 4 appeal
Level 4 appeal: The Medicare Appeals Council
(Council) will review your appeal and give you
an answer. The Council is part of the federal
government
• If the answer is yes, the appeals process is over. We
must authorize or provide the drug coverage that was
approved by the Council within 72 hours (24 hours
for expedited appeals) or make payment no later than
30 calendar days after we receive the decision
• If the answer is no, the appeals process may or may
not be over
♦ if you decide to accept this decision that turns
down your appeal, the appeals process is over
♦ if you do not want to accept the decision, you may
be able to continue to the next level of the review
process. If the Council says no to your appeal or
denies your request to review the appeal, the
notice will tell you whether the rules allow you to
go on to a Level 5 appeal. It will also tell you
whom to contact and what to do next if you choose
to continue with your appeal
Level 5 appeal: A judge at the Federal District
Court will review your appeal
• A judge will review all of the information and decide
yes or no to your request. This is a final answer.
There are no more appeal levels after the Federal
District Court
How to Make a Complaint About Quality
of Care, Waiting Times, Customer
Service, or Other Concerns
What kinds of problems are handled by the
complaint process?
The complaint process is only used for certain types of
problems. This includes problems related to quality of
care, waiting times, and customer service. Here are
examples of the kinds of problems handled by the
complaint process:
• Quality of your medical care
♦ are you unhappy with the quality of care you have
received (including care in the hospital)?
• Respecting your privacy
♦ did someone not respect your right to privacy or
share confidential information?
• Disrespect, poor customer service, or other
negative behaviors
♦ has someone been rude or disrespectful to you?
♦ are you unhappy with our Member Services?
♦ do you feel you are being encouraged to leave our
plan?
• Waiting times
♦ are you having trouble getting an appointment, or
waiting too long to get it?
♦ have you been kept waiting too long by doctors,
pharmacists, or other health professionals? Or by
Member Services or other staff at our plan?
– Examples include waiting too long on the
phone, in the waiting or exam room, or getting
a prescription
• Cleanliness
♦ are you unhappy with the cleanliness or condition
of a clinic, hospital, or doctor’s office?
• Information you get from our plan
♦ did we fail to give you a required notice?
♦ is our written information hard to understand?
Timeliness (these types of complaints are all
related to the timeliness of our actions related to
coverage decisions and appeals)
If you have asked for a coverage decision or made an
appeal, and you think that we are not responding quickly
enough, you can make a complaint about our slowness.
Here are examples:
• You asked us for a “fast coverage decision” or a “fast
appeal,” and we have said no, you can make a
complaint
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Page 87
• You believe we are not meeting the deadlines for
coverage decisions or appeals; you can make a
complaint
• You believe we are not meeting deadlines for
covering or reimbursing you for certain medical
services or Part D drugs that were approved; you can
make a complaint
• You believe we failed to meet required deadlines for
forwarding your case to the independent review
organization; you can make a complaint
Step-by-step: making a complaint
• A complaint is also called a grievance
• Making a complaint is also called filing a grievance
• Using the process for complaints is also called
using the process for filing a grievance
• A fast complaint is also called an expedited
grievance
Step 1: Contact us promptly – either by phone or in
writing
• Usually calling Member Services is the first step.
If there is anything else you need to do, Member
Services will let you know
• If you do not wish to call (or you called and were not
satisfied), you can put your complaint in writing and
send it to us. If you put your complaint in writing, we
will respond to you in writing. We will also respond
in writing when you make a complaint by phone
if you request a written response or your complaint is
related to quality of care
• If you have a complaint, we will try to resolve your
complaint over the phone. If we cannot resolve your
complaint over the phone, we have a formal
procedure to review your complaints. Your grievance
must explain your concern, such as why you are
dissatisfied with the services you received. Please see
the “Important Phone Numbers and Resources”
section for whom you should contact if you have a
complaint
♦ you must submit your grievance to us (orally or in
writing) within 60 calendar days of the event or
incident. We must address your grievance as
quickly as your health requires, but no later than
30 calendar days after receiving your complaint.
We may extend the time frame to make our
decision by up to 14 calendar days if you ask for
an extension, or if we justify a need for additional
information and the delay is in your best interest
♦ you can file a fast grievance about our decision not
to expedite a coverage decision or appeal, or if we
extend the time we need to make a decision about
a coverage decision or appeal. We must respond to
your fast grievance within 24 hours
• The deadline for making a complaint is 60 calendar
days from the time you had the problem you want to
complain about
Step 2: We look into your complaint and give you
our answer
• If possible, we will answer you right away. If you
call us with a complaint, we may be able to give you
an answer on the same phone call
• Most complaints are answered within 30 calendar
days. If we need more information and the delay is in
your best interest or if you ask for more time, we can
take up to 14 more calendar days (44 calendar days
total) to answer your complaint. If we decide to take
extra days, we will tell you in writing
• If you are making a complaint because we denied
your request for a fast coverage decision or a fast
appeal, we will automatically give you a fast
complaint. If you have a fast complaint, it means we
will give you an answer within 24 hours
• If we do not agree with some or all of your
complaint or don’t take responsibility for the problem
you are complaining about, we will include our
reasons in the response to you
You can also make complaints about quality of
care to the Quality Improvement Organization
When your complaint is about quality of care, you also
have two extra options:
• You can make your complaint directly to the
Quality Improvement Organization. The Quality
Improvement Organization is a group of practicing
doctors and other health care experts paid by the
federal government to check and improve the care
given to Medicare patients. The “Important Phone
Numbers and Resources” section has contact
information
• Or you can make your complaint to both the
Quality Improvement Organization and us at the
same time
You can also tell Medicare about your
complaint
You can submit a complaint about our plan directly to
Medicare. To submit a complaint to Medicare, go to
https://www.medicare.gov/MedicareComplaintForm/
home.aspx. You may also call 1-800-MEDICARE
(1-800-633-4227). TTY/TDD users should call 1-877-
486-2048.
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Additional Review
You may have certain additional rights if you remain
dissatisfied after you have exhausted our internal claims
and appeals procedure, and if applicable, external
review:
• If the University of California’s benefit plan is subject
to the Employee Retirement Income Security Act
(ERISA), you may file a civil action under section
502(a) of ERISA. To understand these rights, you
should check with the University of California or
contact the Employee Benefits Security
Administration (part of the U.S. Department of
Labor) at 1-866-444-EBSA (1-866-444-3272)
• If the University of California’s benefit plan is not
subject to ERISA (for example, most state or local
government plans and church plans), you may have a
right to request review in state court
Binding Arbitration
For all claims subject to this “Binding Arbitration”
section, both Claimants and Respondents give up the
right to a jury or court trial and accept the use of binding
arbitration. Insofar as this “Binding Arbitration” section
applies to claims asserted by Kaiser Permanente Parties,
it shall apply retroactively to all unresolved claims that
accrued before the effective date of this EOC. Such
retroactive application shall be binding only on the
Kaiser Permanente Parties.
Scope of arbitration
Any dispute shall be submitted to binding arbitration if
all of the following requirements are met:
• The claim arises from or is related to an alleged
violation of any duty incident to or arising out of or
relating to this EOC or a Member Party’s relationship
to Kaiser Foundation Health Plan, Inc. (“Health
Plan”), including any claim for medical or hospital
malpractice (a claim that medical services or items
were unnecessary or unauthorized or were
improperly, negligently, or incompetently rendered),
for premises liability, or relating to the coverage for,
or delivery of, services or items, irrespective of the
legal theories upon which the claim is asserted
• The claim is asserted by one or more Member Parties
against one or more Kaiser Permanente Parties or by
one or more Kaiser Permanente Parties against one or
more Member Parties
• Governing law does not prevent the use of binding
arbitration to resolve the claim
Members enrolled under this EOC thus give up their
right to a court or jury trial, and instead accept the use of
binding arbitration except that the following types of
claims are not subject to binding arbitration:
• Claims within the jurisdiction of the Small Claims
Court
• Claims subject to a Medicare appeal procedure as
applicable to Kaiser Permanente Senior Advantage
Members
• Claims that cannot be subject to binding arbitration
under governing law
As referred to in this “Binding Arbitration” section,
“Member Parties” include:
• A Member
• A Member’s heir, relative, or personal representative
• Any person claiming that a duty to them arises from a
Member’s relationship to one or more Kaiser
Permanente Parties
“Kaiser Permanente Parties” include:
• Kaiser Foundation Health Plan, Inc.
• Kaiser Foundation Hospitals
• The Permanente Medical Group, Inc.
• Southern California Permanente Medical Group
• The Permanente Federation, LLC
• The Permanente Company, LLC
• Any Southern California Permanente Medical Group
or The Permanente Medical Group physician
• Any individual or organization whose contract with
any of the organizations identified above requires
arbitration of claims brought by one or more Member
Parties
• Any employee or agent of any of the foregoing
“Claimant” refers to a Member Party or a Kaiser
Permanente Party who asserts a claim as described
above. “Respondent” refers to a Member Party or a
Kaiser Permanente Party against whom a claim is
asserted.
Rules of Procedure
Arbitrations shall be conducted according to the Rules
for Kaiser Permanente Member Arbitrations Overseen
by the Office of the Independent Administrator (“Rules
of Procedure”) developed by the Office of the
Independent Administrator in consultation with Kaiser
Permanente and the Arbitration Oversight Board. Copies
of the Rules of Procedure may be obtained from Member
Services.
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Page 89
Initiating arbitration
Claimants shall initiate arbitration by serving a Demand
for Arbitration. The Demand for Arbitration shall include
the basis of the claim against the Respondents; the
amount of damages the Claimants seek in the arbitration;
the names, addresses, and phone numbers of the
Claimants and their attorney, if any; and the names of all
Respondents. Claimants shall include in the Demand for
Arbitration all claims against Respondents that are based
on the same incident, transaction, or related
circumstances.
Serving demand for arbitration
Health Plan, Kaiser Foundation Hospitals, The
Permanente Medical Group, Inc., Southern California
Permanente Medical Group, The Permanente Federation,
LLC, and The Permanente Company, LLC, shall be
served with a Demand for Arbitration by mailing the
Demand for Arbitration addressed to that Respondent in
care of:
For Northern California Home Region Members:
Kaiser Foundation Health Plan, Inc.
Legal Department, Professional & Public Liability
1 Kaiser Plaza, 19th Floor
Oakland, CA 94612
For Southern California Home Region Members:
Kaiser Foundation Health Plan, Inc.
Legal Department, Professional & Public Liability
393 E. Walnut St.
Pasadena, CA 91188
Service on that Respondent shall be deemed completed
when received. All other Respondents, including
individuals, must be served as required by the California
Code of Civil Procedure for a civil action.
Filing fee
The Claimants shall pay a single, nonrefundable filing
fee of $150 per arbitration payable to “Arbitration
Account” regardless of the number of claims asserted in
the Demand for Arbitration or the number of Claimants
or Respondents named in the Demand for Arbitration.
Any Claimant who claims extreme hardship may request
that the Office of the Independent Administrator waive
the filing fee and the neutral arbitrator’s fees and
expenses. A Claimant who seeks such waivers shall
complete the Fee Waiver Form and submit it to the
Office of the Independent Administrator and
simultaneously serve it upon the Respondents. The Fee
Waiver Form sets forth the criteria for waiving fees and
is available by calling Member Services.
Number of arbitrators
The number of arbitrators may affect the Claimants’
responsibility for paying the neutral arbitrator’s fees and
expenses (see the Rules of Procedure).
If the Demand for Arbitration seeks total damages of
$200,000 or less, the dispute shall be heard and
determined by one neutral arbitrator, unless the parties
otherwise agree in writing after a dispute has arisen and a
request for binding arbitration has been submitted that
the arbitration shall be heard by two party arbitrators and
one neutral arbitrator. The neutral arbitrator shall not
have authority to award monetary damages that are
greater than $200,000.
If the Demand for Arbitration seeks total damages of
more than $200,000, the dispute shall be heard and
determined by one neutral arbitrator and two party
arbitrators, one jointly appointed by all Claimants and
one jointly appointed by all Respondents. Parties who are
entitled to select a party arbitrator may agree to waive
this right. If all parties agree, these arbitrations will be
heard by a single neutral arbitrator.
Payment of arbitrators’ fees and expenses
Health Plan will pay the fees and expenses of the neutral
arbitrator under certain conditions as set forth in the
Rules of Procedure. In all other arbitrations, the fees and
expenses of the neutral arbitrator shall be paid one-half
by the Claimants and one-half by the Respondents.
If the parties select party arbitrators, Claimants shall be
responsible for paying the fees and expenses of their
party arbitrator and Respondents shall be responsible for
paying the fees and expenses of their party arbitrator.
Costs
Except for the aforementioned fees and expenses of the
neutral arbitrator, and except as otherwise mandated by
laws that apply to arbitrations under this “Binding
Arbitration” section, each party shall bear the party’s
own attorneys’ fees, witness fees, and other expenses
incurred in prosecuting or defending against a claim
regardless of the nature of the claim or outcome of the
arbitration.
General provisions
A claim shall be waived and forever barred if (1) on the
date the Demand for Arbitration of the claim is served,
the claim, if asserted in a civil action, would be barred as
to the Respondent served by the applicable statute of
limitations, (2) Claimants fail to pursue the arbitration
claim in accord with the Rules of Procedure with
reasonable diligence, or (3) the arbitration hearing is not
commenced within five years after the earlier of (a) the
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Page 90
date the Demand for Arbitration was served in accord
with the procedures prescribed herein, or (b) the date of
filing of a civil action based upon the same incident,
transaction, or related circumstances involved in the
claim. A claim may be dismissed on other grounds by the
neutral arbitrator based on a showing of a good cause. If
a party fails to attend the arbitration hearing after being
given due notice thereof, the neutral arbitrator may
proceed to determine the controversy in the party’s
absence.
The California Medical Injury Compensation Reform
Act of 1975 (including any amendments thereto),
including sections establishing the right to introduce
evidence of any insurance or disability benefit payment
to the patient, the limitation on recovery for non-
economic losses, and the right to have an award for
future damages conformed to periodic payments, shall
apply to any claims for professional negligence or any
other claims as permitted or required by law.
Arbitrations shall be governed by this “Binding
Arbitration” section, Section 2 of the Federal Arbitration
Act, and the California Code of Civil Procedure
provisions relating to arbitration that are in effect at the
time the statute is applied, together with the Rules of
Procedure, to the extent not inconsistent with this
“Binding Arbitration” section. In accord with the rule
that applies under Sections 3 and 4 of the Federal
Arbitration Act, the right to arbitration under this
“Binding Arbitration” section shall not be denied, stayed,
or otherwise impeded because a dispute between a
Member Party and a Kaiser Permanente Party involves
both arbitrable and nonarbitrable claims or because one
or more parties to the arbitration is also a party to a
pending court action with another party that arises out of
the same or related transactions and presents a possibility
of conflicting rulings or findings.
Termination of Membership
The University of California is required to inform the
Subscriber of the date your membership terminates. Your
membership termination date is the first day you are not
covered (for example, if your termination date is January
1, 2025, your last minute of coverage was at 11:59 p.m.
on December 31, 2024). When a Subscriber’s
membership ends, the memberships of any Dependents
end at the same time. You will be billed as a non-
Member for any Services you receive after your
membership terminates. Health Plan and Plan Providers
have no further liability or responsibility under this EOC
after your membership terminates, except:
• As provided under “Payments after Termination” in
this “Termination of Membership” section
• If you are receiving covered Services as an acute care
hospital inpatient on the termination date, we will
continue to cover those hospital Services (but not
physician Services or any other Services) until you
are discharged
Until your membership terminates, you remain a Senior
Advantage Member and must continue to receive your
medical care from us, except as described in the
“Emergency Services and Urgent Care” section about
Emergency Services, Post-Stabilization Care, and Out-
of-Area Urgent Care and the “Benefits and Your Cost
Share” section about out-of-area dialysis care.
Note: If you enroll in another Medicare Health Plan or a
prescription drug plan, your Senior Advantage
membership will terminate as described under
“Disenrolling from Senior Advantage” in this
“Termination of Membership” section.
Termination Due to Loss of Eligibility
If you no longer meet the eligibility requirements
described under “Who Is Eligible” in the “Premiums,
Eligibility, and Enrollment” section the University of
California will notify you of the date that your
membership will end. Your membership termination date
is the first day you are not covered. For example, if your
termination date is January 1, 2025, your last minute of
coverage was at 11:59 p.m. on December 31, 2024.
For information about termination procedures, contact
the person who handles benefits at your location (or the
University's Customer Service Center if you are a
Retiree) or refer to the “Who is Eligible” section.
Also, we will terminate your Senior Advantage
membership on the last day of the month if you:
• Are temporarily absent from your Home Region
Service Area for more than six months in a row
• Permanently move from your Home Region Service
Area
• No longer have Medicare Part B
• Enroll in another Medicare Health Plan (for example,
a Medicare Advantage Plan or a Medicare
prescription drug plan). The Centers for Medicare &
Medicaid Services will automatically terminate your
Senior Advantage membership when your enrollment
in the other plan becomes effective
• Are not a U.S. citizen or lawfully present in the
United States. The Centers for Medicare & Medicaid
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Page 91
Services will notify us if you are not eligible to
remain a Member on this basis. We must disenroll
you if you do not meet this requirement
In addition, if you are required to pay the extra Part D
amount because of your income and you do not pay it,
Medicare will disenroll you from our Senior Advantage
Plan and you will lose prescription drug coverage.
Note: If you lose eligibility for Senior Advantage due to
any of these circumstances, you may be eligible to
transfer your membership to another Kaiser Permanente
plan offered by the University of California. Please
contact the University of California for information.
Termination of Agreement
If the University of California’s Agreement with us
terminates for any reason, your membership ends on the
same date. The University of California is required to
notify Subscribers in writing if its Agreement with us
terminates.
Disenrolling from Senior Advantage
You may terminate (disenroll from) your Senior
Advantage membership at any time. However, before
you request disenrollment, please check with the
University of California to determine if you are able to
continue the University of California membership.
If you request disenrollment during the University of
California’s open enrollment, your disenrollment
effective date is determined by the date your written
request is received by us and the date the University of
California coverage ends. The effective date will not be
earlier than the first day of the following month after we
receive your written request, and no later than three
months after we receive your request.
If you request disenrollment at a time other than the
University of California’s open enrollment, your
disenrollment effective date will be the first day of the
month following our receipt of your disenrollment
request.
You may request disenrollment by calling toll free
1-800-MEDICARE/1-800-633-4227 (TTY users call
1-877-486-2048), 24 hours a day, seven days a week, or
sending written notice to the following address:
For Northern California Members:
Kaiser Foundation Health Plan, Inc.
California Service Center
P.O. Box 232400
San Diego, CA 92193-2400
For Southern California Members:
Kaiser Foundation Health Plan, Inc.
California Service Center
P.O. Box 232407
San Diego, CA 92193-2407
Other Medicare Health Plans. If you want to enroll in
another Medicare Health Plan or a Medicare prescription
drug plan, you should first confirm with the other plan
and the University of California that you are able to
enroll. Your new plan or the University of California will
tell you the date when your membership in the new plan
begins and your Senior Advantage membership will end
on that same day (your disenrollment date).
The Centers for Medicare & Medicaid Services will let
us know if you enroll in another Medicare Health Plan,
so you will not need to send us a disenrollment request.
Original Medicare. If you request disenrollment from
Senior Advantage and you do not enroll in another
Medicare Health Plan, you will automatically be enrolled
in Original Medicare when your Senior Advantage
membership terminates (your disenrollment date). On
your disenrollment date, you can start using your red,
white, and blue Medicare card to get services under
Original Medicare. You will not get anything in writing
that tells you that you have Original Medicare after you
disenroll. If you choose Original Medicare and you want
to continue to get Medicare Part D prescription drug
coverage, you will need to enroll in a prescription drug
plan.
If you receive Extra Help from Medicare to pay for your
prescription drugs, and you switch to Original Medicare
and do not enroll in a separate Medicare Part D
prescription drug plan, Medicare may enroll you in a
drug plan, unless you have opted out of automatic
enrollment.
Note: If you disenroll from Medicare prescription drug
coverage and go without creditable prescription drug
coverage for 63 or more days in a row, you may need to
pay a Part D late enrollment penalty if you join a
Medicare drug plan later.
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
Page 92
Termination of Contract with the
Centers for Medicare & Medicaid
Services
If our contract with the Centers for Medicare & Medicaid
Services to offer Senior Advantage terminates, your
Senior Advantage membership will terminate on the
same date. We will send you advance written notice and
advise you of your health care options. Also, you may be
eligible to transfer your membership to another Kaiser
Permanente plan offered by the University of California.
Termination for Cause
We may terminate your membership by sending you
advance written notice if you commit one of the
following acts:
• If you continuously behave in a way that is disruptive,
to the extent that your continued enrollment seriously
impairs our ability to arrange or provide medical care
for you or for our other members. We cannot make
you leave our Senior Advantage Plan for this reason
unless we get permission from Medicare first
• If you let someone else use your Plan membership
card to get medical care. We cannot make you leave
our Senior Advantage Plan for this reason unless we
get permission from Medicare first. If you are
disenrolled for this reason, the Centers for Medicare
& Medicaid Services may refer your case to the
Inspector General for additional investigation
• You commit theft from Health Plan, from a Plan
Provider, or at a Plan Facility
• You intentionally misrepresent membership status or
commit fraud in connection with your obtaining
membership. We cannot make you leave our Senior
Advantage Plan for this reason unless we get
permission from Medicare first
• If you become incarcerated (go to prison)
• You knowingly falsify or withhold information about
other parties that provide reimbursement for your
prescription drug coverage
If we terminate your membership for cause, you will not
be allowed to enroll in Health Plan in the future until you
have completed a Member Orientation and have signed a
statement promising future compliance. We may report
fraud and other illegal acts to the authorities for
prosecution.
Termination for Nonpayment of
Premiums
If we do not receive Premiums for your Family, we may
terminate the memberships of everyone in your Family.
Termination of a Product or all Products
We may terminate a particular product or all products
offered in the group market as permitted or required by
law. If we discontinue offering a particular product in the
group market, we will terminate just the particular
product by sending you written notice at least 90 days
before the product terminates. If we discontinue offering
all products in the group market, we may terminate the
University of California’s Agreement by sending you
written notice at least 180 days before the Agreement
terminates.
Payments after Termination
If we terminate your membership for cause or for
nonpayment, we will:
• Refund any amounts we owe for Premiums paid after
the termination date
• Pay you any amounts we have determined that we
owe you for claims during your membership in
accord with the “Requests for Payment” section. We
will deduct any amounts you owe Health Plan or Plan
Providers from any payment we make to you
Review of Membership Termination
If you believe that we terminated your Senior Advantage
membership because of your ill health or your need for
care, you may file a complaint as described in the
“Coverage Decisions, Appeals, and Complaints” section.
Continuation of Membership
If your membership under this Senior Advantage EOC
ends, you may be eligible to continue Health Plan
membership without a break in coverage. You may be
able to continue Group coverage under this Senior
Advantage EOC as described under “Continuation of
Group Coverage.” Also, you may be able to continue
membership under an individual plan as described under
“Conversion from Group Membership to an Individual
Plan.” If at any time you become entitled to continuation
of Group coverage, please examine your coverage
options carefully before declining this coverage.
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
Page 93
Individual plan premiums and coverage will be different
from the premiums and coverage under the University of
California plan.
Continuation of Group Coverage
COBRA
You may be able to continue your coverage under this
Senior Advantage EOC for a limited time after you
would otherwise lose eligibility, if required by the
federal Consolidated Omnibus Budget Reconciliation
Act (“COBRA”). COBRA applies to most employees
(and most of their covered family Dependents) of most
employers with 20 or more employees.
If the University of California is subject to COBRA and
you are eligible for COBRA coverage, in order to enroll,
you must submit a COBRA election form to the
University of California within the COBRA election
period. Please ask the University of California for details
about COBRA coverage, such as how to elect coverage,
how much you must pay for coverage, when coverage
and Premiums may change, and where to send your
Premium payments.
As described in “Conversion from Group Membership to
an Individual Plan” in this “Continuation of
Membership” section, you may be able to convert to an
individual (nongroup) plan if you don’t apply for
COBRA coverage, or if you enroll in COBRA and your
COBRA coverage ends.
Coverage for a disabling condition
If you became Totally Disabled while you were a
Member under the University of California’s Agreement
with us and while the Subscriber was employed by the
University of California, and the University of
California’s Agreement with us terminates and is not
renewed, we will cover Services for your totally
disabling condition until the earliest of the following
events occurs:
• 12 months have elapsed since the University of
California’s Agreement with us terminated
• You are no longer Totally Disabled
• The University of California’s Agreement with us is
replaced by another group health plan without
limitation as to the disabling condition
Your coverage will be subject to the terms of this EOC,
including Cost Share, but we will not cover Services for
any condition other than your totally disabling condition.
For Subscribers and adult Dependents, “Totally
Disabled” means that, in the judgment of a Medical
Group physician, an illness or injury is expected to result
in death or has lasted or is expected to last for a
continuous period of at least 12 months, and makes the
person unable to engage in any employment or
occupation, even with training, education, and
experience.
For Dependent children, “Totally Disabled” means that,
in the judgment of a Medical Group physician, an illness
or injury is expected to result in death or has lasted or is
expected to last for a continuous period of at least 12
months and the illness or injury makes the child unable
to substantially engage in any of the normal activities of
children in good health of like age.
To request continuation of coverage for your disabling
condition, you must call Member Services within 30
days after the University of California’s Agreement with
us terminates.
Conversion from Group Membership to
an Individual Plan
After the University of California notifies us to terminate
the University of California membership, we will send a
termination letter to the Subscriber’s address of record.
The letter will include information about options that
may be available to you to remain a Health Plan
Member.
Kaiser Permanente Conversion Plan
If you want to remain a Health Plan Member, one option
that may be available is our Senior Advantage Individual
Plan. You may be eligible to enroll in our individual plan
if you no longer meet the eligibility requirements
described under “Who Is Eligible” in the “Premiums,
Eligibility, and Enrollment” section. Individual plan
coverage begins when the University of California
coverage ends. The premiums and coverage under our
individual plan are different from those under this EOC
and will include Medicare Part D prescription drug
coverage.
However, if you are no longer eligible for Senior
Advantage and Group coverage, you may be eligible to
convert to our non-Medicare individual plan, called
“Kaiser Permanente Individual−Conversion Plan.” You
may be eligible to enroll in our Individual−Conversion
Plan if we receive your enrollment application within 63
days of the date of our termination letter or of your
membership termination date (whichever date is later).
You may not be eligible to convert if your membership
ends for the reasons stated under “Termination for
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
Page 94
Cause” or “Termination of Agreement” in the
“Termination of Membership” section.
Miscellaneous Provisions
Administration of Agreement
We may adopt reasonable policies, procedures, and
interpretations to promote orderly and efficient
administration of the University of California’s
Agreement, including this EOC.
Amendment of Agreement
The University of California’s Agreement with us will
change periodically. If these changes affect this EOC, the
University of California is required to inform you in
accord with applicable law and the University of
California’s Agreement.
Applications and Statements
You must complete any applications, forms, or
statements that we request in our normal course of
business or as specified in this EOC.
Assignment
You may not assign this EOC or any of the rights,
interests, claims for money due, benefits, or obligations
hereunder without our prior written consent.
Attorney and Advocate Fees and
Expenses
In any dispute between a Member and Health Plan, the
Medical Group, or Kaiser Foundation Hospitals, each
party will bear its own fees and expenses, including
attorneys’ fees, advocates’ fees, and other expenses.
Claims Review Authority
We are responsible for determining whether you are
entitled to benefits under this EOC and we have the
discretionary authority to review and evaluate claims that
arise under this EOC. We conduct this evaluation
independently by interpreting the provisions of this EOC.
We may use medical experts to help us review claims.
EOC Binding on Members
By electing coverage or accepting benefits under this
EOC, all Members legally capable of contracting, and
the legal representatives of all Members incapable of
contracting, agree to all provisions of this EOC.
Governing Law
Except as preempted by federal law, this EOC will be
governed in accord with California law and any
provision that is required to be in this EOC by state or
federal law shall bind Members and Health Plan whether
or not set forth in this EOC.
Group and Members Not Our Agents
Neither the University of California nor any Member is
the agent or representative of Health Plan.
Newborns’ and Mothers’ Health
Protection Act
Group health plans and health insurance issuers generally
may not, under Federal law, restrict benefits for any
hospital length of stay in connection with childbirth for
the mother or newborn child to less than 48 hours
following a vaginal delivery, or less than 96 hours
following a cesarean section. However, Federal law
generally does not prohibit the mother’s or newborn’s
attending provider, after consulting with the mother,
from discharging the mother or her newborn earlier than
48 hours (or 96 hours as applicable). In any case, plans
and issuers may not, under Federal law, require that a
provider obtain authorization from the plan or the
insurance issuer for prescribing a length of stay not in
excess of 48 hours (or 96 hours).
Coverage for Services described above is subject to all
provisions of this EOC.
No Waiver
Our failure to enforce any provision of this EOC will not
constitute a waiver of that or any other provision, or
impair our right thereafter to require your strict
performance of any provision.
Notices Regarding Your Coverage
Our notices to you will be sent to the most recent address
we have for the Subscriber. The Subscriber is responsible
for notifying us of any change in address. Subscribers
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
Page 95
who move should call Member Services and Social
Security toll free at 1-800-772-1213 (TTY users call
1-800-325-0778) as soon as possible to give us their new
address. If a Member does not reside with the Subscriber,
or needs to have confidential information sent to an
address other than the Subscriber’s address, they should
contact Member Services to discuss alternate delivery
options.
Note: When we tell the University of California about
changes to this EOC or provide the University of
California other information that affects you, the
University of California is required to notify the
Subscriber within 30 days after receiving the information
from us. The Subscriber is also responsible for notifying
Group of any change in contact information.
Notice about Medicare Secondary Payer
Subrogation Rights
We have the right and responsibility to collect for
covered Medicare services for which Medicare is not the
primary payer. According to CMS regulations at 42 CFR
sections 422.108 and 423.462, Kaiser Permanente Senior
Advantage, as a Medicare Advantage Organization, will
exercise the same rights of recovery that the Secretary
exercises under CMS regulations in subparts B through
D of part 411 of 42 CFR and the rules established in this
section supersede any state laws.
Overpayment Recovery
We may recover any overpayment we make for Services
from anyone who receives such an overpayment or from
any person or organization obligated to pay for the
Services.
Public Policy Participation
The Kaiser Foundation Health Plan, Inc., Board of
Directors establishes public policy for Health Plan. A list
of the Board of Directors is available on our website at
kp.org or from Member Services. If you would like to
provide input about Health Plan public policy for
consideration by the Board, please send written
comments to:
Kaiser Foundation Health Plan, Inc.
Office of Board and Corporate Governance
Services
One Kaiser Plaza, 19th Floor
Oakland, CA 94612
Telephone Access (TTY)
If you use a text telephone device (TTY, also known as
TDD) to communicate by phone, you can use the
California Relay Service by calling 711.
Important Phone Numbers and
Resources
Kaiser Permanente Senior Advantage
How to contact our plan’s Member Services
For assistance, please call or write to our plan’s Member
Services. We will be happy to help you.
Member Services – contact information
Call 1-800-443-0815
Calls to this number are free.
Seven days a week, 8 a.m. to 8 p.m.
Member Services also has free language
interpreter services available for non-English
speakers.
TTY 711
Calls to this number are free.
Seven days a week, 8 a.m. to 8 p.m.
Write Your local Member Services office (see the
Provider Directory for locations).
Website kp.org
You can also visit
kp.org/universityofcalifornia for more
information about Kaiser Permanente and your
University of California plan.
How to contact us when you are asking for a
coverage decision or making an appeal or
complaint about your Services
• A coverage decision is a decision we make about your
benefits and coverage or about the amount we will
pay for your medical services
• An appeal is a formal way of asking us to review and
change a coverage decision we have made
• You can make a complaint about us or one of our
network providers, including a complaint about the
quality of your care. This type of complaint does not
involve coverage or payment disputes
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
Page 96
For more information about asking for coverage
decisions or making appeals or complaints about your
medical care, see the “Coverage Decisions, Appeals, and
Complaints” section.
Coverage decisions, appeals, or complaints for
Services – contact information
Call 1-800-443-0815
Calls to this number are free.
Seven days a week, 8 a.m. to 8 p.m.
If your coverage decision, appeal, or complaint
qualifies for a fast decision as described in the
“Coverage Decisions, Appeals, and
Complaints” section, call the Expedited Review
Unit at 1-888-987-7247, 8:30 a.m. to 5 p.m.,
Monday through Saturday.
TTY 711
Calls to this number are free.
Seven days a week, 8 a.m. to 8 p.m.
Fax If your coverage decision, appeal, or complaint
qualifies for a fast decision, fax your request to
our Expedited Review Unit at 1-888-987-2252.
Write For a standard coverage decision or
complaint, write to your local Member Services
office (see the Provider Directory for
locations).
For a standard appeal, write to the address
shown on the denial notice we send you.
If your coverage decision, appeal, or complaint
qualifies for a fast decision, write to:
Kaiser Permanente
Expedited Review Unit
P.O. Box 1809
Pleasanton, CA 94566
Medicare Website. You can submit a complaint about
our Plan directly to Medicare. To submit an online
complaint to Medicare, go to
https://www.medicare.gov/MedicareComplaintForm/
home.aspx.
How to contact us when you are asking for a
coverage decision about your Part D
prescription drugs
• A coverage decision is a decision we make about your
benefits and coverage or about the amount we will
pay for your prescription drugs covered under the
Part D benefit included in your plan
For more information about asking for coverage
decisions about your Part D prescription drugs, see
the “Coverage Decisions, Appeals, and Complaints”
section.
Coverage decisions for Part D prescription
drugs – contact information
For Northern California Home Region Members:
Call 1-877-645-1282
For Southern California Home Region Members:
Call 1-888-791-7213
Calls to this number are free.
Seven days a week, 8 a.m. to 8 p.m.
TTY 711
Calls to this number are free.
Seven days a week, 8 a.m. to 8 p.m.
Fax 1-844-403-1028
Write OptumRx
c/o Prior Authorization
P.O. Box 2975
Mission, KS 66201
Website kp.org
How to contact us when you are making an
appeal about your Part D prescription drugs
• An appeal is a formal way of asking us to review and
change a coverage decision we have made
For more information about making appeals about
your Part D prescription drugs, see the “Coverage
Decisions, Appeals, and Complaints” section. You
may call us if you have questions about our appeals
process.
Appeals for Part D prescription drugs – contact
information
Call 1-866-206-2973
Calls to this number are free.
Seven days a week, 8:30 a.m. to 5 p.m.
TTY 711
Calls to this number are free.
Seven days a week, 8 a.m. to 8 p.m.
Fax 1-866-206-2974
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
Page 97
Write Kaiser Permanente
Medicare Part D Unit
P.O. Box 1809
Pleasanton, CA 94566
Website kp.org
How to contact us when you are making a
complaint about your Part D prescription drugs
You can make a complaint about us or one of our
network pharmacies, including a complaint about the
quality of your care. This type of complaint does not
involve coverage or payment disputes. (If your problem
is about our plan’s coverage or payment, you should look
at the section above about requesting coverage decisions
or making appeals.) For more information about making
a complaint about your Part D prescription drugs, see the
“Coverage Decisions, Appeals, and Complaints” section.
Complaints for Part D prescription drugs –
contact information
Call 1-800-443-0815
Calls to this number are free.
Seven days a week, 8 a.m. to 8 p.m.
If your complaint qualifies for a fast decision,
call the Part D Unit at 1-866-206-2973, 8:30
a.m. to 5 p.m., Monday through Friday. See the
“Coverage Decisions, Appeals, and
Complaints” section to find out if your issue
qualifies for a fast decision.
TTY 711
Calls to this number are free.
Seven days a week, 8 a.m. to 8 p.m.
Fax If your complaint qualifies for a fast review, fax
your request to our Part D Unit at 1-866-206-
2974.
Write For a standard complaint, write to your local
Member Services office (see the Provider
Directory for locations).
If your complaint qualifies for a fast decision,
write to:
Kaiser Permanente
Medicare Part D Unit
P.O. Box 1809
Pleasanton, CA 94566
Medicare Website. You can submit a complaint about
our plan directly to Medicare. To submit an online
complaint to Medicare, go to
https://www.medicare.gov/MedicareComplaintForm/
home.aspx.
Where to send a request asking us to pay for
our share of the cost for Services or a Part D
drug you have received
If you have received a bill or paid for services (such as a
provider bill) that you think we should pay for, you may
need to ask us for reimbursement or to pay the provider
bill. See the “Requests for Payment” section.
Note: If you send us a payment request and we deny any
part of your request, you can appeal our decision. See the
“Coverage Decisions, Appeals, and Complaints” section
for more information.
Payment Requests – contact information
Call 1-800-443-0815
Calls to this number are free.
Seven days a week, 8 a.m. to 8 p.m.
Note: If you are requesting payment of a Part D
drug that was prescribed by a Plan Provider and
obtained from a Plan Pharmacy, call our Part D
unit at 1-866-206-2973, 8:30 a.m. to 5 p.m.,
Monday through Friday.
TTY 711
Calls to this number are free.
Seven days a week, 8 a.m. to 8 p.m.
For Northern California Home Region Members:
Write For medical care:
Kaiser Permanente
Claims Department
P.O. Box 12923
Oakland, CA 94604-2923
For Southern California Home Region Members:
Write For medical care:
Kaiser Permanente
Claims Department
P.O. Box 7004
Downey, CA 90242-7004
For Part D drugs:
If you are requesting payment of a Part D drug
that was prescribed and provided by a Plan
Provider, you can fax your request to 1-866-
206-2974 or mail it to:
Kaiser Permanente
Medicare Part D Unit
P.O. Box 1809
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
Page 98
Pleasanton, CA 94566
Website kp.org
Medicare
How to get help and information directly from
the federal Medicare program
Medicare is the federal health insurance program for
people 65 years of age or older, some people under age
65 with disabilities, and people with end-stage renal
disease (permanent kidney failure requiring dialysis or a
kidney transplant). The federal agency in charge of
Medicare is the Centers for Medicare & Medicaid
Services (sometimes called CMS). This agency contracts
with Medicare Advantage organizations, including our
plan.
Medicare – contact information
Call 1-800-MEDICARE or 1-800-633-4227
Calls to this number are free. 24 hours a day,
seven days a week.
TTY 1-877-486-2048
This number requires special telephone
equipment and is only for people who have
difficulties with hearing or speaking. Calls to
this number are free.
Website https://www.Medicare.gov
This is the official government website for Medicare. It
gives you up-to-date information about Medicare and
current Medicare issues. It also has information about
hospitals, nursing homes, physicians, home health
agencies, and dialysis facilities. It includes documents
you can print directly from your computer. You can also
find Medicare contacts in your state.
The Medicare website also has detailed information
about your Medicare eligibility and enrollment options
with the following tools:
Medicare Eligibility Tool: Provides Medicare eligibility
status information.
Medicare Plan Finder: Provides personalized
information about available Medicare prescription drug
plans, Medicare Health Plans, and Medigap (Medicare
Supplement Insurance) policies in your area. These tools
provide an estimate of what your out-of-pocket costs
might be in different Medicare plans.
You can also use the website to tell Medicare about any
complaints you have about our plan.
Tell Medicare about your complaint: You can submit
a complaint about our plan directly to Medicare. To
submit a complaint to Medicare, go to
https://www.medicare.gov/MedicareComplaintForm/
home.aspx. Medicare takes your complaints seriously
and will use this information to help improve the quality
of the Medicare program.
If you don’t have a computer, your local library or senior
center may be able to help you visit this website using its
computer. Or, you can call Medicare and tell them what
information you are looking for. They will find the
information on the website and review the information
with you. You can call Medicare at 1-800-MEDICARE
(1-800-633-4227) (TTY users call 1-877-486-2048), 24
hours a day, 7 days a week.
State Health Insurance Assistance
Program
Free help, information, and answers to your
questions about Medicare
The State Health Insurance Assistance Program (SHIP)
is a government program with trained counselors in
every state. In California, the State Health Insurance
Assistance Program is called the Health Insurance
Counseling and Advocacy Program (HICAP).
HICAP is an independent (not connected with any
insurance company or health plan) state program that
gets money from the federal government to give free
local health insurance counseling to people with
Medicare.
HICAP counselors can help you understand your
Medicare rights, help you make complaints about your
Services or treatment, and help you straighten out
problems with your Medicare bills. HICAP counselors
can also help you with Medicare questions or problems
and help you understand your Medicare plan choices and
answer questions about switching plans.
Method to access SHIP and other resources:
• Visit https://www.shiphelp.org
• Click on SHIP Locator in middle of page
• Select your state from the list. This will take you
to a page with phone numbers and resources
specific to your state
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
Page 99
Health Insurance Counseling and Advocacy
Program (California’s State Health Insurance
Assistance Program) – contact information
Call 1-800-434-0222
Calls to this number are free.
TTY 711
Write Your HICAP office for your county.
Website www.aging.ca.gov/HICAP/
Quality Improvement Organization
Paid by Medicare to check on the quality of care
for people with Medicare
There is a designated Quality Improvement Organization
for serving Medicare beneficiaries in each state. For
California, the Quality Improvement Organization is
called Livanta.
Livanta has a group of doctors and other health care
professionals who are paid by Medicare to check on and
help improve the quality of care for people with
Medicare. Livanta is an independent organization. It is
not connected with our plan.
You should contact Livanta in any of these situations:
• You have a complaint about the quality of care you
have received
• You think coverage for your hospital stay is ending
too soon
• You think coverage for your home health care,
Skilled Nursing Facility care, or Comprehensive
Outpatient Rehabilitation Facility (CORF) services
are ending too soon
Livanta (California’s Quality Improvement
Organization) – contact information
Call 1-877-588-1123
Calls to this number are free. Monday through
Friday, 9 a.m. to 5 p.m Weekends and holidays
11 a.m. to 3 p.m.
TTY 1-855-887-6668
This number requires special telephone
equipment and is only for people who have
difficulties with hearing or speaking.
Write Livanta
BFCC – QIO Program
10820 Guilford Road, Suite 202
Annapolis Junction, MD 20701–1105
Website www.livantaqio.com/en
Social Security
Social Security is responsible for determining eligibility
and handling enrollment for Medicare. U.S. citizens and
lawful permanent residents who are 65 or older, or who
have a disability or end stage renal disease and meet
certain conditions, are eligible for Medicare. If you are
already getting Social Security checks, enrollment into
Medicare is automatic. If you are not getting Social
Security checks, you have to enroll in Medicare. To
apply for Medicare, you can call Social Security or visit
your local Social Security office.
Social Security is also responsible for determining who
has to pay an extra amount for their Part D drug coverage
because they have a higher income. If you got a letter
from Social Security telling you that you have to pay the
extra amount and have questions about the amount or
if your income went down because of a life-changing
event, you can call Social Security to ask for
reconsideration.
If you move or change your mailing address, it is
important that you contact Social Security to let them
know.
Social Security – contact information
Call 1-800-772-1213
Calls to this number are free. Available 8 a.m.
to 7 p.m., Monday through Friday.
You can use Social Security’s automated
telephone services and get recorded information
24 hours a day.
TTY 1-800-325-0778
This number requires special telephone
equipment and is only for people who have
difficulties with hearing or speaking. Calls to
this number are free. Available 8 a.m. to 7 p.m.,
Monday through Friday.
Website www.ssa.gov
Member Service: toll free 1-800-443-0815 (TTY users call 711) seven days a week, 8 a.m.–8 p.m.
Page 100
Medicaid
A joint federal and state program that helps with
medical costs for some people with limited
income and resources
Medicaid is a joint federal and state government program
that helps with medical costs for certain people with
limited incomes and resources. Some people with
Medicare are also eligible for Medicaid.
In addition, there are programs offered through Medicaid
that help people with Medicare pay their Medicare costs,
such as their Medicare premiums. These “Medicare
Savings Programs” help people with limited income and
resources save money each year:
• Qualified Medicare Beneficiary (QMB): Helps pay
Medicare Part A and Part B premiums, and other Cost
Share. Some people with QMB are also eligible for
full Medicaid benefits (QMB+)
• Specified Low-Income Medicare Beneficiary
(SLMB): Helps pay Part B premiums. Some people
with SLMB are also eligible for full Medicaid
benefits (SLMB+)
• Qualifying Individual (QI): Helps pay Part B
premiums
• Qualified Disabled & Working Individuals
(QDWI): Helps pay Part A premiums
To find out more about Medicaid and its programs,
contact Medi-Cal.
Medi-Cal (California’s Medicaid program) –
contact information
Call 1-800-430-4263
Calls to this number are free. Monday through
Friday, 8 a.m. to 6 p.m.
TTY 1-800-430-7077
This number requires special telephone
equipment and is only for people who have
difficulties with hearing or speaking.
Write CA Department of Health Care Services
Health Care Options
P.O. Box 989009
West Sacramento, CA 95798-9850
Website http://www.healthcareoptions.dhcs.ca.gov/
Railroad Retirement Board
The Railroad Retirement Board is an independent federal
agency that administers comprehensive benefit programs
for the nation’s railroad workers and their families.
If you have questions regarding your benefits from the
Railroad Retirement Board, contact the agency.
If you receive your Medicare through the Railroad
Retirement Board, it is important that you let them know
if you move or change your mailing address.
Railroad Retirement Board – contact information
Call 1-877-772-5772
Calls to this number are free. If you press “0,”
you may speak with an RRB representative
from 9 a.m. to 3:30 p.m., Monday, Tuesday,
Thursday, and Friday, and from 9 a.m. to 12
p.m. on Wednesday.
If you press “1,” you may access the automated
RRB HelpLine and recorded information 24
hours a day, including weekends and holidays.
TTY 1-312-751-4701
This number requires special telephone
equipment and is only for people who have
difficulties with hearing or speaking. Calls to
this number are not free.
Website rrb.gov/
Group Insurance or Other Health
Insurance from an Employer
If you have any questions about your employer-
sponsored Group plan, please contact the University of
California’s benefits administrator. You can ask about
your employer or retiree health benefits, any
contributions toward the Group’s premium, eligibility,
and enrollment periods.
If you have other prescription drug coverage through
your (or your spouse’s) employer or retiree group, please
contact that group’s benefits administrator. The benefits
administrator can help you determine how your current
prescription drug coverage will work with our plan.
1126306860 CA
June 2023
Notice of Nondiscrimination
Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate
on the basis of race, color, national origin, age, disability, or sex. Kaiser Permanente does not
exclude people or treat them differently because of race, color, national origin, age, disability,
or sex. We also:
• Provide no cost aids and services to people with disabilities to communicate effectively
with us, such as:
ο Qualified sign language interpreters.
ο Written information in other formats, such as large print, audio, and accessible
electronic formats.
• Provide no cost language services to people whose primary language is not English,
such as:
ο Qualified interpreters.
ο Information written in other languages.
If you need these services, call Member Services at 1-800-443-0815 (TTY 711),
8 a.m. to 8 p.m., seven days a week.
If you believe that Kaiser Permanente has failed to provide these services or discriminated in
another way on the basis of race, color, national origin, age, disability, or sex, you can file a
grievance with our Civil Rights Coordinator by writing to One Kaiser Plaza, 12th Floor, Suite 1223,
Oakland, CA 94612 or calling Member Services at the number listed above. You can file a
grievance by mail or phone. If you need help filing a grievance, our Civil Rights Coordinator is
available to help you. You can also file a civil rights complaint with the U.S. Department of Health
and Human Services, Office for Civil Rights electronically through the Office for Civil Rights
Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone
at: U.S. Department of Health and Human Services, 200 Independence Avenue SW.,
Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Form Approved
OMB# 0938-1421
Form CMS-10802
(Expires 12/31/25)
Y0043_N00036258_C
Multi-Language Insert
Multi-language Interpreter Services
English: We have free interpreter services to answer any questions you
may have about our health or drug plan. To get an interpreter, just call us
at 1-800-443-0815 (TTY 711). Someone who speaks English/Language can help
you. This is a free service.
Spanish: Tenemos servicios de intérprete sin costo alguno para responder
cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos.
Para hablar con un intérprete, por favor llame al 1-800-443-0815 (TTY 711). Alguien
que hable español le podrá ayudar. Este es un servicio gratuito.
Chinese Mandarin: 我们提供免费的翻译服务，帮助您解答关于健康或药物保险的任何疑 问。
如果您需要此翻译服务，请致电 1-800-443-0815 (TTY 711)。我们的中文工作人员很乐意帮助
您。 这是一项免费服务。
Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問，為此我們提供免費的翻譯 服
務。如需翻譯服務，請致電 1-800-443-0815 (TTY 711)。我們講中文的人員將樂意為您提供幫
助。這 是一項免費服務。
Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot
ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o
panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa
1-800-443-0815 (TTY 711). Maaari kayong tulungan ng isang nakakapagsalita ng
Tagalog. Ito ay libreng serbisyo.
French: Nous proposons des services gratuits d'interprétation pour répondre à
toutes vos questions relatives à notre régime de santé ou d'assurance-
médicaments. Pour accéder au service d'interprétation, il vous suffit de nous
appeler au 1-800-443-0815 (TTY 711). Un interlocuteur parlant Français pourra vous
aider. Ce service est gratuit.
Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về
chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin
gọi 1-800-443-0815 (TTY 711) sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là
dịch vụ miễn phí .
German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu
unserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie
unter 1-800-443-0815 (TTY 711). Man wird Ihnen dort auf Deutsch weiterhelfen.
Dieser Service ist kostenlos.
Form Approved
OMB# 0938-1421
Form CMS-10802
(Expires 12/31/25)
1140823727
June 2023
Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를
제공하고 있습니다. 통역 서비스를 이용하려면 전화 1-800-443-0815 (TTY 711) 번으로 문의해
주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다.
Russian: Если у вас возникнут вопросы относительно страхового или
медикаментного плана, вы можете воспользоваться нашими бесплатными
услугами переводчиков. Чтобы воспользоваться услугами переводчика,
позвоните нам по телефону 1-800-443-0815 (TTY 711). Вам окажет помощь
сотрудник, который говорит по-pусски. Данная услуга бесплатная.
:Arabic
1-800-443-0815 (TTY 711)
.
Hindi:
, 1-800-443-0815 (TTY 711)
Italian: È disponibile un servizio di interpretariato gratuito per rispondere a
eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete,
contattare il numero 1-800-443-0815 (TTY 711). Un nostro incaricato che parla
Italianovi fornirà l'assistenza necessaria. È un servizio gratuito.
Portuguese: Dispomos de serviços de interpretação gratuitos para responder a
qualquer questão que tenha acerca do nosso plano de saúde ou de medicação.
Para obter um intérprete, contacte-nos através do número 1-800-443-0815 (TTY 711).
Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é
gratuito.
French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta
genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis
rele nou nan 1-800-443-0815 (TTY 711). Yon moun ki pale Kreyòl kapab ede w. Sa a
se yon sèvis ki gratis.
Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który
pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania
leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy
zadzwonić pod numer 1-800-443-0815 (TTY 711). Ta usługa jest bezpłatna.
Japanese: 当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするため
に、無料の通訳サービスがありますございます。通訳をご用命になるには、
1-800-443-0815 (TTY 711) にお電話ください。日本語を話す人 者 が支援いたします。これ
は無料のサー ビスです。
