Evidence of Coverage - City of Palm Springs
Transcript Of Evidence of Coverage - City of Palm Springs
Evidence of Coverage
Effective January 1, 2022
Kaiser Permanente Basic Plan
Health Maintenance Organization (HMO)
Contracted by the CalPERS Board of Administration Under the Public Employees’ Medical & Hospital Care Act (PEMHCA)
TABLE OF CONTENTS
Benefit Changes for Current Year........................................................................................................................................ 1 Copayments or Coinsurance Summary ................................................................................................................................ 1
Accumulation Period........................................................................................................................................................ 1 Deductible(s) and Out-of-Pocket Maximum(s)................................................................................................................ 1 Copayments or Coinsurance Summary Tables by Benefit ............................................................................................... 1 Introduction ........................................................................................................................................................................ 19 About Kaiser Permanente................................................................................................................................................19 Term of this EOC ............................................................................................................................................................20 Definitions.......................................................................................................................................................................... 20 Premiums, Eligibility, and Enrollment............................................................................................................................... 26 Premiums ........................................................................................................................................................................26 Eligibility ........................................................................................................................................................................26 How to Obtain Services ..................................................................................................................................................... 26 Routine Care ...................................................................................................................................................................27 Urgent Care .....................................................................................................................................................................27 Not Sure What Kind of Care You Need? ........................................................................................................................27 Your Personal Plan Physician .........................................................................................................................................27 Getting a Referral ............................................................................................................................................................28 Second Opinions .............................................................................................................................................................31 Contracts with Plan Providers .........................................................................................................................................31 Receiving Care Outside of Your Home Region ..............................................................................................................31 Your ID Card ..................................................................................................................................................................32 Timely Access to Care ....................................................................................................................................................32 Getting Assistance...........................................................................................................................................................32 Plan Facilities ..................................................................................................................................................................... 33 Emergency Services and Urgent Care................................................................................................................................ 34 Emergency Services ........................................................................................................................................................34 Urgent Care .....................................................................................................................................................................34 Payment and Reimbursement..........................................................................................................................................35 Benefits .............................................................................................................................................................................. 35 Your Copayments and Coinsurance ................................................................................................................................36 Administered Drugs and Products...................................................................................................................................39 Ambulance Services........................................................................................................................................................39 Bariatric Surgery .............................................................................................................................................................40 Behavioral Health Treatment for Autism Spectrum Disorder .........................................................................................40 Dental and Orthodontic Services.....................................................................................................................................41 Dialysis Care ...................................................................................................................................................................42 Durable Medical Equipment (“DME”) for Home Use ....................................................................................................43 Emergency and Urgent Care Visits .................................................................................................................................44 Family Planning Services................................................................................................................................................44 Fertility Services .............................................................................................................................................................45 Health Education .............................................................................................................................................................45 Hearing Services .............................................................................................................................................................46 Home Health Care...........................................................................................................................................................46 Hospice Care ...................................................................................................................................................................47 Hospital Inpatient Care ...................................................................................................................................................47 Injury to Teeth.................................................................................................................................................................48 Mental Health Services ...................................................................................................................................................48 Office Visits ....................................................................................................................................................................49
Ostomy and Urological Supplies.....................................................................................................................................49 Outpatient Imaging, Laboratory, and Other Diagnostic and Treatment Services............................................................49 Outpatient Prescription Drugs, Supplies, and Supplements ............................................................................................50 Outpatient Surgery and Outpatient Procedures ...............................................................................................................53 Preventive Services .........................................................................................................................................................54 Prosthetic and Orthotic Devices ......................................................................................................................................54 Reconstructive Surgery ...................................................................................................................................................55 Rehabilitative and Habilitative Services .........................................................................................................................56 Services in Connection with a Clinical Trial...................................................................................................................56 Skilled Nursing Facility Care ..........................................................................................................................................57 Substance Use Disorder Treatment .................................................................................................................................58 Telehealth Visits..............................................................................................................................................................58 Transplant Services .........................................................................................................................................................58 Vision Services for Adult Members ................................................................................................................................59 Vision Services for Pediatric Members...........................................................................................................................60 Exclusions, Limitations, Coordination of Benefits, and Reductions.................................................................................. 61 Exclusions .......................................................................................................................................................................61 Limitations ......................................................................................................................................................................63 Coordination of Benefits .................................................................................................................................................63 Reductions .......................................................................................................................................................................64 Post-Service Claims and Appeals ...................................................................................................................................... 66 Who May File .................................................................................................................................................................66 Supporting Documents....................................................................................................................................................67 Initial Claims ...................................................................................................................................................................67 Appeals............................................................................................................................................................................68 External Review ..............................................................................................................................................................69 Additional Review ..........................................................................................................................................................69 Dispute Resolution ............................................................................................................................................................. 69 Grievances .......................................................................................................................................................................69 Independent Review Organization for Non-Formulary Prescription Drug Requests ......................................................72 Department of Managed Health Care Complaints ..........................................................................................................73 Independent Medical Review (“IMR”) ...........................................................................................................................73 Appeal Procedure Following Disposition of Health Plan’s Grievance Process ..............................................................74 Office of Civil Rights Complaints...................................................................................................................................76 Additional Review ..........................................................................................................................................................76 Binding Arbitration .........................................................................................................................................................76 Termination of Membership............................................................................................................................................... 78 Termination Due to Loss of Eligibility ...........................................................................................................................79 Termination of Agreement ..............................................................................................................................................79 Termination for Cause.....................................................................................................................................................79 Termination of a Product or all Products ........................................................................................................................79 Payments after Termination ............................................................................................................................................79 State Review of Membership Termination......................................................................................................................79 Continuation of Membership ............................................................................................................................................. 80 Continuation of Group Coverage ....................................................................................................................................80 Leave of Absence ............................................................................................................................................................83 Continuation of Coverage under an Individual Plan .......................................................................................................83 Miscellaneous Provisions ................................................................................................................................................... 84 Administration of Agreement ..........................................................................................................................................84 Advance Directives .........................................................................................................................................................84 Amendment of Agreement ..............................................................................................................................................84 Applications and Statements ...........................................................................................................................................84
Assignment ......................................................................................................................................................................84 Attorney and Advocate Fees and Expenses.....................................................................................................................84 Claims Review Authority................................................................................................................................................84 EOC Binding on Members ..............................................................................................................................................84 Governing Law................................................................................................................................................................84 Group and Members Not Our Agents .............................................................................................................................84 No Waiver .......................................................................................................................................................................84 Notices Regarding Your Coverage..................................................................................................................................85 Overpayment Recovery...................................................................................................................................................85 Privacy Practices .............................................................................................................................................................85 Public Policy Participation ..............................................................................................................................................85 Helpful Information ........................................................................................................................................................... 86 How to Obtain this EOC in Other Formats .....................................................................................................................86 Provider Directory...........................................................................................................................................................86 Online Tools and Resources............................................................................................................................................86 How to Reach Us ............................................................................................................................................................86 Payment Responsibility...................................................................................................................................................87 Chiropractic Services and Acupuncture Services Benefit Highlights ................................................................................ 91 Introduction ........................................................................................................................................................................ 93 Definitions.......................................................................................................................................................................... 93 ASH Participating Providers .............................................................................................................................................. 94 How to Obtain Services ..................................................................................................................................................94 Covered Services................................................................................................................................................................ 95 Office Visits ....................................................................................................................................................................95 Laboratory Tests and X-rays ...........................................................................................................................................96 Chiropractic Supports and Appliances ............................................................................................................................96 Second Opinions .............................................................................................................................................................96 Emergency and Urgent Services Covered Under this Amendment.................................................................................96 Exclusions .......................................................................................................................................................................... 97 Customer Service ............................................................................................................................................................... 97 Grievances.......................................................................................................................................................................... 97
Benefit Changes for Current Year
The following is a summary of the most important coverage changes and clarifications that we have made to this Basic Plan 2022 EOC. Please read this EOC for the complete text of these changes, as well as changes not listed in the summary below.
Please refer to the "Benefits" section in this EOC for benefit descriptions. Please refer to the “Copayments or Coinsurance Summary” for the amount Members must pay for covered benefits. Benefits are also subject to the "Emergency Services and Urgent Care" and the "Exclusions, Limitations, Coordination of Benefits, and Reductions" sections in this EOC.
Durable Medical Equipment Please note that effective January 1, 2021, the following changes to the “Durable Medical Equipment (“DME”) for home use” benefit will apply: • Peak flow meters, and blood glucose monitors and their associated testing supplies will no longer be subject to any Plan
Deductible in nongrandfathered plans. This is pursuant to IRS Notice 19-45, which allows, but does not require, health plans to provide additional items and services outside of a deductible to individuals diagnosed with specified chronic conditions. Peak flow meters are now listed as a separate line item in the “Durable Medical Equipment (“DME”) for home use” copayments or coinsurance table in the “Copayments or Coinsurance Summary” section of all EOCs. Previously, peak flow meters were categorized under “Other Base DME.”
Mental Health Services and Substance Use Disorder Treatment (SB 855) We have made the following changes in accordance with state law:
• Under “Definitions,” we have added a separate definition of “Medically Necessary” for mental health and substance use disorder Services
• Under “Mental Health Services,” we have revised EOC language to reflect expanded coverage of mental health conditions
• Under “Substance Use Disorder Treatment,” we have revised EOC language to reflect expanded coverage of substance use disorders
• Under “Behavioral Health Treatment for Autism Spectrum Disorder,” “Mental Health Services,” and “Substance Use Disorder Treatment,” we have clarified that when we are not able to offer an appointment within geographic and timely access standards, we will offer to refer the Member to a Non-Plan Provider
• Under “Exclusions,” we have clarified that the exclusions and limitations do not apply to Services that are Medically Necessary to treat covered mental health conditions or substance use disorders
• Throughout the EOC, we have removed references to “Severe Emotional Disturbance of a Child Under Age 18” and “Severe Mental Illness,” as SB 855 expands the coverage requirement to include coverage for the diagnosis and treatment of mental health and substance use disorders that fall under any of the diagnostic categories included in the most recent edition of the International Classification of Diseases or the Diagnostic and Statistical Manual of Mental Disorders
• Throughout the EOC, we have changed the terminology “pervasive developmental disorder or autism” to “autism spectrum disorder”
Preventive Services In the “Preventive Services” section, we have made the following changes for clarity:
• Simplified introductory language
• Added language explaining that certain preventive items listed on our website may not be covered in grandfathered plans
Prosthetics and Orthotics In the “Prosthetic and Orthotic Devices” section, we have replaced the word “mastectomy” with the phrase “removal of all or part of a breast,” to align with terminology used elsewhere in the EOC. This is not a change in coverage.
Copayments or Coinsurance Summary
This “Copayments or Coinsurance Summary” is part of your Evidence of Coverage (EOC) and is meant to explain the amount you will pay for covered Services under this plan. It does not provide a full description of your benefits. For a full description of your benefits, including any limitations and exclusions, please read this entire EOC, including any amendments, carefully.
Accumulation Period
The Accumulation Period for this plan is January 1 through December 31.
Deductible(s) and Out-of-Pocket Maximum(s)
For Services that apply to the Plan Out-of-Pocket Maximum or the Drug Out-of-Pocket Maximum, you will not pay any
more Copayments or Coinsurance for the rest of the Accumulation Period once you have reached the amounts listed below.
Amounts Per Accumulation Period
Self-Only Coverage
Family Coverage
(a Family of one Member) Each Member in a Family
of two or more Members
Family Coverage Entire Family of two or
more Members
Plan Deductible
None
None
None
Drug Deductible
None
None
None
Plan Out-of-Pocket Maximum (“OOPM”)
$1,500
$1,500
$3,000
Drug Out-of-Pocket Maximum (“OOPM”)
$7,200
$7,200
$14,400
Copayments or Coinsurance Summary Tables by Benefit
How to read the Copayments or Coinsurance summary tables Each table below explains the Copayments or Coinsurance for a category of benefits. Specific Services related to the benefit are described in the first column of each table. For a detailed description of coverage for a particular benefit, please refer to the same benefit heading in the “Benefits” section of this EOC.
• Copayment / Coinsurance. This column describes the Copayments or Coinsurance you will pay for Services after you have met your Plan Deductible or Drug Deductible, if applicable. (Please see the “Deductible(s) and Out-ofPocket Maximum(s)” section above to determine if your plan includes deductibles.) If the Services are not covered in your plan, this column will read “Not covered.” If we provide an Allowance that you can use toward the cost of the Services, this column will include the Allowance.
• Subject to Deductible. This column explains whether the Copayments or Coinsurance you pay for Services is subject to a Plan Deductible or Drug Deductible. If the Services are subject to a deductible, you will pay Charges for those Services until you have met your deductible. If the Services are subject to a deductible, there will be a “✔” or “●” in this column, depending on which deductible applies (“✔” for Plan Deductible, “●” for Drug Deductible). If the Services do not apply to a deductible, or if your plan does not include a deductible, this column will be blank. For a more detailed explanation of deductibles, please refer to “Plan Deductible” and “Drug Deductible” in the “Benefits” section of this EOC.
• OOPM. This column explains whether the Copayments or Coinsurance you pay for Services counts toward the Plan Out-of-Pocket Maximum (“Plan OOPM”) or Drug Out-of-Pocket Maximum (“Drug OOPM”) after you have met any applicable deductible. If the Services count toward the Plan OOPM, there will be a “✔” in this column. If the Services count toward the Drug OOPM, there will be a “⬛” in this column. If the Services do not count toward the Plan OOPM or Drug OOPM, this column will be blank. For a more detailed explanation of the Plan OOPM and Drug OOPM, please refer to the “Plan Out-of-Pocket Maximum” and “Drug Out-of-Pocket Maximum” headings in the “Benefits” section of this EOC.
2022 Kaiser Permanente Basic Plan
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Administered drugs and products Description of Services
Copayment / Coinsurance
Whole blood, red blood cells, plasma, and platelets
No charge
Allergy antigens (including administration)
No charge
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
All other administered drugs and products
No charge
Drugs and products administered to you during a home visit Ambulance Services Description of Services
No charge
Copayment / Coinsurance
Emergency ambulance Services
No charge
Nonemergency ambulance and psychiatric transport van Services
No charge
Behavioral health treatment for autism spectrum disorder Description of Services
Copayment / Coinsurance
Covered Services
$15 per day
Dialysis care Description of Services
Copayment / Coinsurance
Equipment and supplies for home hemodialysis and home peritoneal No charge dialysis
One routine outpatient visit per month with the multidisciplinary nephrology team for a consultation, evaluation, or treatment
No charge
2022 Kaiser Permanente Basic Plan
Subject to Deductible
OOPM
✔
✔
✔
✔
✔ ✔
Subject to Deductible
OOPM
✔
✔
Subject to Deductible
OOPM
✔
Subject to Deductible
OOPM
✔
✔
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Description of Services
Copayment / Coinsurance
Subject to Deductible
OOPM
Hemodialysis and peritoneal dialysis treatment at a Plan Facility
No charge
Durable Medical Equipment (“DME”) for home use Description of Services
Copayment / Coinsurance
Blood glucose monitors for diabetes blood testing and their supplies No charge
✔
Subject to Deductible
OOPM
✔
Peak flow meters
No charge
✔
Insulin pumps and supplies to operate the pump
No charge
✔
Other Base DME Items as described in this EOC
No charge
✔
Supplemental DME items as described in this EOC
No charge
Retail-grade breast pumps
No charge
✔
Hospital-grade breast pumps Emergency and Urgent Care visits
Description of Services Emergency Department visits
No charge
Copayment / Coinsurance $50 per visit
✔
Subject to Deductible
OOPM
✔
Urgent Care visits
$15 per visit
✔
Note: If you are admitted to the hospital as an inpatient from the Emergency Department, the Emergency Department visits Copayments or Coinsurance above does not apply. Instead, the Services you received in the Emergency Department, including any observation stay, if applicable, will be considered part of your inpatient hospital stay. Also, if you are held for an observation stay for covered Services but not admitted to the hospital as an inpatient, then the Services you received in the Emergency Department will be considered part of your observation stay and the inpatient hospital Copayments or Coinsurance will apply. For the Copayments or Coinsurance for inpatient care, please refer to “Hospital inpatient care” in this “Copayments or Coinsurance Summary.”
2022 Kaiser Permanente Basic Plan
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Family planning Services Description of Services
Copayment / Coinsurance
Family planning counseling
No charge
Injectable contraceptives, internally implanted time-release contraceptives or intrauterine devices (“IUDs”) and office visits related to their administration and management
Female sterilization procedures if performed in an ambulatory surgery center or in a hospital operating room
All other female sterilization procedures
No charge No charge No charge
Male sterilization procedures if performed in an ambulatory surgery center or in a hospital operating room
$15 per procedure
All other male sterilization procedures
$15 per visit
Termination of pregnancy Fertility Services Diagnosis and treatment of infertility
Description of Services Office visits
$15 per procedure
Copayment / Coinsurance 50% Coinsurance
Outpatient surgery and outpatient procedures (including imaging and diagnostic Services) when performed in an ambulatory surgery center or in a hospital operating room, or any setting where a licensed staff member monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or minimize discomfort
50% Coinsurance
Any other outpatient surgery that does not require a licensed staff member to monitor your vital signs as described above
50% Coinsurance
Outpatient imaging
50% Coinsurance
Outpatient laboratory
50% Coinsurance
Outpatient diagnostic Services
50% Coinsurance
Subject to Deductible
OOPM
✔
✔
✔ ✔ ✔ ✔ ✔
Subject to Deductible
OOPM
2022 Kaiser Permanente Basic Plan
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Description of Services Outpatient administered drugs
Copayment / Coinsurance
50% Coinsurance
Hospital inpatient care (including room and board, drugs, imaging, laboratory, other diagnostic and treatment Services, and Plan Physician Services)
50% Coinsurance
Artificial insemination Description of Services
Copayment / Coinsurance
Office visits
50% Coinsurance
Outpatient surgery and outpatient procedures (including imaging and diagnostic Services) when performed in an ambulatory surgery center or in a hospital operating room, or any setting where a licensed staff member monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or minimize discomfort
50% Coinsurance
Any other outpatient surgery that does not require a licensed staff member to monitor your vital signs as described above
Outpatient imaging
50% Coinsurance 50% Coinsurance
Outpatient laboratory
50% Coinsurance
Outpatient diagnostic Services
50% Coinsurance
Outpatient administered drugs
50% Coinsurance
Hospital inpatient care (including room and board, drugs, imaging, laboratory, other diagnostic and treatment Services, and Plan Physician Services)
50% Coinsurance
Assisted reproductive technology (“ART”) Services Description of Services
Copayment / Coinsurance
Assisted reproductive technology (“ART”) Services such as invitro fertilization (“IVF”), gamete intra-fallopian transfer (“GIFT”), or zygote intrafallopian transfer (“ZIFT”)
Not covered
Subject to Deductible
OOPM
Subject to Deductible
OOPM
Subject to Deductible
OOPM
2022 Kaiser Permanente Basic Plan
Page 5
Effective January 1, 2022
Kaiser Permanente Basic Plan
Health Maintenance Organization (HMO)
Contracted by the CalPERS Board of Administration Under the Public Employees’ Medical & Hospital Care Act (PEMHCA)
TABLE OF CONTENTS
Benefit Changes for Current Year........................................................................................................................................ 1 Copayments or Coinsurance Summary ................................................................................................................................ 1
Accumulation Period........................................................................................................................................................ 1 Deductible(s) and Out-of-Pocket Maximum(s)................................................................................................................ 1 Copayments or Coinsurance Summary Tables by Benefit ............................................................................................... 1 Introduction ........................................................................................................................................................................ 19 About Kaiser Permanente................................................................................................................................................19 Term of this EOC ............................................................................................................................................................20 Definitions.......................................................................................................................................................................... 20 Premiums, Eligibility, and Enrollment............................................................................................................................... 26 Premiums ........................................................................................................................................................................26 Eligibility ........................................................................................................................................................................26 How to Obtain Services ..................................................................................................................................................... 26 Routine Care ...................................................................................................................................................................27 Urgent Care .....................................................................................................................................................................27 Not Sure What Kind of Care You Need? ........................................................................................................................27 Your Personal Plan Physician .........................................................................................................................................27 Getting a Referral ............................................................................................................................................................28 Second Opinions .............................................................................................................................................................31 Contracts with Plan Providers .........................................................................................................................................31 Receiving Care Outside of Your Home Region ..............................................................................................................31 Your ID Card ..................................................................................................................................................................32 Timely Access to Care ....................................................................................................................................................32 Getting Assistance...........................................................................................................................................................32 Plan Facilities ..................................................................................................................................................................... 33 Emergency Services and Urgent Care................................................................................................................................ 34 Emergency Services ........................................................................................................................................................34 Urgent Care .....................................................................................................................................................................34 Payment and Reimbursement..........................................................................................................................................35 Benefits .............................................................................................................................................................................. 35 Your Copayments and Coinsurance ................................................................................................................................36 Administered Drugs and Products...................................................................................................................................39 Ambulance Services........................................................................................................................................................39 Bariatric Surgery .............................................................................................................................................................40 Behavioral Health Treatment for Autism Spectrum Disorder .........................................................................................40 Dental and Orthodontic Services.....................................................................................................................................41 Dialysis Care ...................................................................................................................................................................42 Durable Medical Equipment (“DME”) for Home Use ....................................................................................................43 Emergency and Urgent Care Visits .................................................................................................................................44 Family Planning Services................................................................................................................................................44 Fertility Services .............................................................................................................................................................45 Health Education .............................................................................................................................................................45 Hearing Services .............................................................................................................................................................46 Home Health Care...........................................................................................................................................................46 Hospice Care ...................................................................................................................................................................47 Hospital Inpatient Care ...................................................................................................................................................47 Injury to Teeth.................................................................................................................................................................48 Mental Health Services ...................................................................................................................................................48 Office Visits ....................................................................................................................................................................49
Ostomy and Urological Supplies.....................................................................................................................................49 Outpatient Imaging, Laboratory, and Other Diagnostic and Treatment Services............................................................49 Outpatient Prescription Drugs, Supplies, and Supplements ............................................................................................50 Outpatient Surgery and Outpatient Procedures ...............................................................................................................53 Preventive Services .........................................................................................................................................................54 Prosthetic and Orthotic Devices ......................................................................................................................................54 Reconstructive Surgery ...................................................................................................................................................55 Rehabilitative and Habilitative Services .........................................................................................................................56 Services in Connection with a Clinical Trial...................................................................................................................56 Skilled Nursing Facility Care ..........................................................................................................................................57 Substance Use Disorder Treatment .................................................................................................................................58 Telehealth Visits..............................................................................................................................................................58 Transplant Services .........................................................................................................................................................58 Vision Services for Adult Members ................................................................................................................................59 Vision Services for Pediatric Members...........................................................................................................................60 Exclusions, Limitations, Coordination of Benefits, and Reductions.................................................................................. 61 Exclusions .......................................................................................................................................................................61 Limitations ......................................................................................................................................................................63 Coordination of Benefits .................................................................................................................................................63 Reductions .......................................................................................................................................................................64 Post-Service Claims and Appeals ...................................................................................................................................... 66 Who May File .................................................................................................................................................................66 Supporting Documents....................................................................................................................................................67 Initial Claims ...................................................................................................................................................................67 Appeals............................................................................................................................................................................68 External Review ..............................................................................................................................................................69 Additional Review ..........................................................................................................................................................69 Dispute Resolution ............................................................................................................................................................. 69 Grievances .......................................................................................................................................................................69 Independent Review Organization for Non-Formulary Prescription Drug Requests ......................................................72 Department of Managed Health Care Complaints ..........................................................................................................73 Independent Medical Review (“IMR”) ...........................................................................................................................73 Appeal Procedure Following Disposition of Health Plan’s Grievance Process ..............................................................74 Office of Civil Rights Complaints...................................................................................................................................76 Additional Review ..........................................................................................................................................................76 Binding Arbitration .........................................................................................................................................................76 Termination of Membership............................................................................................................................................... 78 Termination Due to Loss of Eligibility ...........................................................................................................................79 Termination of Agreement ..............................................................................................................................................79 Termination for Cause.....................................................................................................................................................79 Termination of a Product or all Products ........................................................................................................................79 Payments after Termination ............................................................................................................................................79 State Review of Membership Termination......................................................................................................................79 Continuation of Membership ............................................................................................................................................. 80 Continuation of Group Coverage ....................................................................................................................................80 Leave of Absence ............................................................................................................................................................83 Continuation of Coverage under an Individual Plan .......................................................................................................83 Miscellaneous Provisions ................................................................................................................................................... 84 Administration of Agreement ..........................................................................................................................................84 Advance Directives .........................................................................................................................................................84 Amendment of Agreement ..............................................................................................................................................84 Applications and Statements ...........................................................................................................................................84
Assignment ......................................................................................................................................................................84 Attorney and Advocate Fees and Expenses.....................................................................................................................84 Claims Review Authority................................................................................................................................................84 EOC Binding on Members ..............................................................................................................................................84 Governing Law................................................................................................................................................................84 Group and Members Not Our Agents .............................................................................................................................84 No Waiver .......................................................................................................................................................................84 Notices Regarding Your Coverage..................................................................................................................................85 Overpayment Recovery...................................................................................................................................................85 Privacy Practices .............................................................................................................................................................85 Public Policy Participation ..............................................................................................................................................85 Helpful Information ........................................................................................................................................................... 86 How to Obtain this EOC in Other Formats .....................................................................................................................86 Provider Directory...........................................................................................................................................................86 Online Tools and Resources............................................................................................................................................86 How to Reach Us ............................................................................................................................................................86 Payment Responsibility...................................................................................................................................................87 Chiropractic Services and Acupuncture Services Benefit Highlights ................................................................................ 91 Introduction ........................................................................................................................................................................ 93 Definitions.......................................................................................................................................................................... 93 ASH Participating Providers .............................................................................................................................................. 94 How to Obtain Services ..................................................................................................................................................94 Covered Services................................................................................................................................................................ 95 Office Visits ....................................................................................................................................................................95 Laboratory Tests and X-rays ...........................................................................................................................................96 Chiropractic Supports and Appliances ............................................................................................................................96 Second Opinions .............................................................................................................................................................96 Emergency and Urgent Services Covered Under this Amendment.................................................................................96 Exclusions .......................................................................................................................................................................... 97 Customer Service ............................................................................................................................................................... 97 Grievances.......................................................................................................................................................................... 97
Benefit Changes for Current Year
The following is a summary of the most important coverage changes and clarifications that we have made to this Basic Plan 2022 EOC. Please read this EOC for the complete text of these changes, as well as changes not listed in the summary below.
Please refer to the "Benefits" section in this EOC for benefit descriptions. Please refer to the “Copayments or Coinsurance Summary” for the amount Members must pay for covered benefits. Benefits are also subject to the "Emergency Services and Urgent Care" and the "Exclusions, Limitations, Coordination of Benefits, and Reductions" sections in this EOC.
Durable Medical Equipment Please note that effective January 1, 2021, the following changes to the “Durable Medical Equipment (“DME”) for home use” benefit will apply: • Peak flow meters, and blood glucose monitors and their associated testing supplies will no longer be subject to any Plan
Deductible in nongrandfathered plans. This is pursuant to IRS Notice 19-45, which allows, but does not require, health plans to provide additional items and services outside of a deductible to individuals diagnosed with specified chronic conditions. Peak flow meters are now listed as a separate line item in the “Durable Medical Equipment (“DME”) for home use” copayments or coinsurance table in the “Copayments or Coinsurance Summary” section of all EOCs. Previously, peak flow meters were categorized under “Other Base DME.”
Mental Health Services and Substance Use Disorder Treatment (SB 855) We have made the following changes in accordance with state law:
• Under “Definitions,” we have added a separate definition of “Medically Necessary” for mental health and substance use disorder Services
• Under “Mental Health Services,” we have revised EOC language to reflect expanded coverage of mental health conditions
• Under “Substance Use Disorder Treatment,” we have revised EOC language to reflect expanded coverage of substance use disorders
• Under “Behavioral Health Treatment for Autism Spectrum Disorder,” “Mental Health Services,” and “Substance Use Disorder Treatment,” we have clarified that when we are not able to offer an appointment within geographic and timely access standards, we will offer to refer the Member to a Non-Plan Provider
• Under “Exclusions,” we have clarified that the exclusions and limitations do not apply to Services that are Medically Necessary to treat covered mental health conditions or substance use disorders
• Throughout the EOC, we have removed references to “Severe Emotional Disturbance of a Child Under Age 18” and “Severe Mental Illness,” as SB 855 expands the coverage requirement to include coverage for the diagnosis and treatment of mental health and substance use disorders that fall under any of the diagnostic categories included in the most recent edition of the International Classification of Diseases or the Diagnostic and Statistical Manual of Mental Disorders
• Throughout the EOC, we have changed the terminology “pervasive developmental disorder or autism” to “autism spectrum disorder”
Preventive Services In the “Preventive Services” section, we have made the following changes for clarity:
• Simplified introductory language
• Added language explaining that certain preventive items listed on our website may not be covered in grandfathered plans
Prosthetics and Orthotics In the “Prosthetic and Orthotic Devices” section, we have replaced the word “mastectomy” with the phrase “removal of all or part of a breast,” to align with terminology used elsewhere in the EOC. This is not a change in coverage.
Copayments or Coinsurance Summary
This “Copayments or Coinsurance Summary” is part of your Evidence of Coverage (EOC) and is meant to explain the amount you will pay for covered Services under this plan. It does not provide a full description of your benefits. For a full description of your benefits, including any limitations and exclusions, please read this entire EOC, including any amendments, carefully.
Accumulation Period
The Accumulation Period for this plan is January 1 through December 31.
Deductible(s) and Out-of-Pocket Maximum(s)
For Services that apply to the Plan Out-of-Pocket Maximum or the Drug Out-of-Pocket Maximum, you will not pay any
more Copayments or Coinsurance for the rest of the Accumulation Period once you have reached the amounts listed below.
Amounts Per Accumulation Period
Self-Only Coverage
Family Coverage
(a Family of one Member) Each Member in a Family
of two or more Members
Family Coverage Entire Family of two or
more Members
Plan Deductible
None
None
None
Drug Deductible
None
None
None
Plan Out-of-Pocket Maximum (“OOPM”)
$1,500
$1,500
$3,000
Drug Out-of-Pocket Maximum (“OOPM”)
$7,200
$7,200
$14,400
Copayments or Coinsurance Summary Tables by Benefit
How to read the Copayments or Coinsurance summary tables Each table below explains the Copayments or Coinsurance for a category of benefits. Specific Services related to the benefit are described in the first column of each table. For a detailed description of coverage for a particular benefit, please refer to the same benefit heading in the “Benefits” section of this EOC.
• Copayment / Coinsurance. This column describes the Copayments or Coinsurance you will pay for Services after you have met your Plan Deductible or Drug Deductible, if applicable. (Please see the “Deductible(s) and Out-ofPocket Maximum(s)” section above to determine if your plan includes deductibles.) If the Services are not covered in your plan, this column will read “Not covered.” If we provide an Allowance that you can use toward the cost of the Services, this column will include the Allowance.
• Subject to Deductible. This column explains whether the Copayments or Coinsurance you pay for Services is subject to a Plan Deductible or Drug Deductible. If the Services are subject to a deductible, you will pay Charges for those Services until you have met your deductible. If the Services are subject to a deductible, there will be a “✔” or “●” in this column, depending on which deductible applies (“✔” for Plan Deductible, “●” for Drug Deductible). If the Services do not apply to a deductible, or if your plan does not include a deductible, this column will be blank. For a more detailed explanation of deductibles, please refer to “Plan Deductible” and “Drug Deductible” in the “Benefits” section of this EOC.
• OOPM. This column explains whether the Copayments or Coinsurance you pay for Services counts toward the Plan Out-of-Pocket Maximum (“Plan OOPM”) or Drug Out-of-Pocket Maximum (“Drug OOPM”) after you have met any applicable deductible. If the Services count toward the Plan OOPM, there will be a “✔” in this column. If the Services count toward the Drug OOPM, there will be a “⬛” in this column. If the Services do not count toward the Plan OOPM or Drug OOPM, this column will be blank. For a more detailed explanation of the Plan OOPM and Drug OOPM, please refer to the “Plan Out-of-Pocket Maximum” and “Drug Out-of-Pocket Maximum” headings in the “Benefits” section of this EOC.
2022 Kaiser Permanente Basic Plan
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Administered drugs and products Description of Services
Copayment / Coinsurance
Whole blood, red blood cells, plasma, and platelets
No charge
Allergy antigens (including administration)
No charge
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
All other administered drugs and products
No charge
Drugs and products administered to you during a home visit Ambulance Services Description of Services
No charge
Copayment / Coinsurance
Emergency ambulance Services
No charge
Nonemergency ambulance and psychiatric transport van Services
No charge
Behavioral health treatment for autism spectrum disorder Description of Services
Copayment / Coinsurance
Covered Services
$15 per day
Dialysis care Description of Services
Copayment / Coinsurance
Equipment and supplies for home hemodialysis and home peritoneal No charge dialysis
One routine outpatient visit per month with the multidisciplinary nephrology team for a consultation, evaluation, or treatment
No charge
2022 Kaiser Permanente Basic Plan
Subject to Deductible
OOPM
✔
✔
✔
✔
✔ ✔
Subject to Deductible
OOPM
✔
✔
Subject to Deductible
OOPM
✔
Subject to Deductible
OOPM
✔
✔
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Description of Services
Copayment / Coinsurance
Subject to Deductible
OOPM
Hemodialysis and peritoneal dialysis treatment at a Plan Facility
No charge
Durable Medical Equipment (“DME”) for home use Description of Services
Copayment / Coinsurance
Blood glucose monitors for diabetes blood testing and their supplies No charge
✔
Subject to Deductible
OOPM
✔
Peak flow meters
No charge
✔
Insulin pumps and supplies to operate the pump
No charge
✔
Other Base DME Items as described in this EOC
No charge
✔
Supplemental DME items as described in this EOC
No charge
Retail-grade breast pumps
No charge
✔
Hospital-grade breast pumps Emergency and Urgent Care visits
Description of Services Emergency Department visits
No charge
Copayment / Coinsurance $50 per visit
✔
Subject to Deductible
OOPM
✔
Urgent Care visits
$15 per visit
✔
Note: If you are admitted to the hospital as an inpatient from the Emergency Department, the Emergency Department visits Copayments or Coinsurance above does not apply. Instead, the Services you received in the Emergency Department, including any observation stay, if applicable, will be considered part of your inpatient hospital stay. Also, if you are held for an observation stay for covered Services but not admitted to the hospital as an inpatient, then the Services you received in the Emergency Department will be considered part of your observation stay and the inpatient hospital Copayments or Coinsurance will apply. For the Copayments or Coinsurance for inpatient care, please refer to “Hospital inpatient care” in this “Copayments or Coinsurance Summary.”
2022 Kaiser Permanente Basic Plan
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Family planning Services Description of Services
Copayment / Coinsurance
Family planning counseling
No charge
Injectable contraceptives, internally implanted time-release contraceptives or intrauterine devices (“IUDs”) and office visits related to their administration and management
Female sterilization procedures if performed in an ambulatory surgery center or in a hospital operating room
All other female sterilization procedures
No charge No charge No charge
Male sterilization procedures if performed in an ambulatory surgery center or in a hospital operating room
$15 per procedure
All other male sterilization procedures
$15 per visit
Termination of pregnancy Fertility Services Diagnosis and treatment of infertility
Description of Services Office visits
$15 per procedure
Copayment / Coinsurance 50% Coinsurance
Outpatient surgery and outpatient procedures (including imaging and diagnostic Services) when performed in an ambulatory surgery center or in a hospital operating room, or any setting where a licensed staff member monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or minimize discomfort
50% Coinsurance
Any other outpatient surgery that does not require a licensed staff member to monitor your vital signs as described above
50% Coinsurance
Outpatient imaging
50% Coinsurance
Outpatient laboratory
50% Coinsurance
Outpatient diagnostic Services
50% Coinsurance
Subject to Deductible
OOPM
✔
✔
✔ ✔ ✔ ✔ ✔
Subject to Deductible
OOPM
2022 Kaiser Permanente Basic Plan
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Description of Services Outpatient administered drugs
Copayment / Coinsurance
50% Coinsurance
Hospital inpatient care (including room and board, drugs, imaging, laboratory, other diagnostic and treatment Services, and Plan Physician Services)
50% Coinsurance
Artificial insemination Description of Services
Copayment / Coinsurance
Office visits
50% Coinsurance
Outpatient surgery and outpatient procedures (including imaging and diagnostic Services) when performed in an ambulatory surgery center or in a hospital operating room, or any setting where a licensed staff member monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or minimize discomfort
50% Coinsurance
Any other outpatient surgery that does not require a licensed staff member to monitor your vital signs as described above
Outpatient imaging
50% Coinsurance 50% Coinsurance
Outpatient laboratory
50% Coinsurance
Outpatient diagnostic Services
50% Coinsurance
Outpatient administered drugs
50% Coinsurance
Hospital inpatient care (including room and board, drugs, imaging, laboratory, other diagnostic and treatment Services, and Plan Physician Services)
50% Coinsurance
Assisted reproductive technology (“ART”) Services Description of Services
Copayment / Coinsurance
Assisted reproductive technology (“ART”) Services such as invitro fertilization (“IVF”), gamete intra-fallopian transfer (“GIFT”), or zygote intrafallopian transfer (“ZIFT”)
Not covered
Subject to Deductible
OOPM
Subject to Deductible
OOPM
Subject to Deductible
OOPM
2022 Kaiser Permanente Basic Plan
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