CCC Workbook 2013 - FINAL.pdf - Cherry Creek School District

CHERRY CREEK
BENEFITS
July 1, 2013 – June 30, 2014
Cherry Creek Schools

CHERRY CREEK SCHOOL DISTRICT EMPLOYEE BENEFITS
BENEFITS DESIGNED TO MEET YOUR NEEDS
PERSONALIZED BENEFIT PROGRAM FOR EMPLOYEES OF
CHERRY CREEK SCHOOL DISTRICT
All plans effective July 1, 2013
We are proud to provide the Cherry Creek Choice benefit program to our
employees. Through its life, health, and disability insurance coverage, the program
offers valuable protection to you and your family.
The program you are offered as an employee of Cherry Creek School District is
considered to be one of the finest benefit programs in Colorado.
This workbook describes the benefit program available to eligible employees of
Cherry Creek School District. The program allows you to choose among a variety
of benefit options and to determine how your benefit dollars are spent.
This workbook
• Explains your choices for each plan.
• Provides information about eligibility and how to enroll.
• Helps you make the benefit decisions that are right for you.
Employee Self-Service Online Enrollment
• Is used to enroll in the plans of your choice.
The information contained in this workbook is a guide - the benefit decisions are
yours.
NOTE: This is not intended as a complete benefit description of all coverage.
The Cherry Creek group policies govern all coverage, and contain all terms,
covenants and conditions of coverage.
3

TABLE OF CONTENTS
AN INTRODUCTION
What is Cherry Creek Choice? ....................................................................................... 5
Overview of the Choices ............................................................................................... 6
ENROLLMENT PERIODS & ELIGIBILITY PROVISIONS
Enrollment Periods ................................................................................................... 7-11
• New Employee .................................................................................................................................. 8
• Annual Open Enrollment .................................................................................................................. 8
• Special Enrollment (Changes in Status) ............................................................................................ 9
Eligibility Provisions ..................................................................................................... 10
Tax Elecons for Premiums ......................................................................................... 11
MEDICAL PLAN DESIGNS
All Medical Plans .................................................................................................... 12-21
• Medical Plan Overview (Plan Summary) ........................................................................................ 14
• Medical Plan Choices ...................................................................................................................... 15
• Parcipang Hospitals .................................................................................................................... 15
• Arbitraon Agreement ................................................................................................................... 16
Frequently Asked Quesons .................................................................................. 17-19
Important Telephone Numbers ............................................................................................................. 20
Kaiser Permanente Catastrophic DHMO .............................................................. 21-32
• How the Catastrophic DHMO Works .............................................................................................. 22
• Summary of Benefits & Coverage (SBC) for Catastrophic DHMO ............................................. 23-32
Kaiser Permanente DHMO .................................................................................... 33-44
• How the DHMO Works ................................................................................................................... 34
• Summary of Benefits & Coverage (SBC) for DHMO .................................................................. 35-44
Kaiser Permanente Added Choice Triple Opon .................................................. 45-59
• How the Added Choice Triple Opon Works ............................................................................. 46-49
• Summary of Benefits & Coverage (SBC) for Triple Opon ........................................................ 50-61
Kaiser Plan Limitaons & Exclusions ................................................................................................. 62-64
DENTAL PLAN DESIGNS
All Dental Plans ...................................................................................................... 65-70
Dental Summary .......................................................................................................... 70
VISION PLAN DESIGN
VSP Plan .................................................................................................................. 71-73
HEALTHCARE & DEPENDENT CARE FLEIXBLE SPENDING ACCOUNTS
24 Hour Flex Guide ................................................................................................. 74-80
VOLUNTARY LIFE INSURANCE
Voluntary Life Insurance Plan Informaon ............................................................ 81-90
CONTACT INFORMATION ........................................................................................... 92
4

AN INTRODUCTION
WHAT IS CHERRY CREEK CHOICE?
• Cherry Creek Choice is the benefit program for eligible employees of Cherry
Creek School District.
• Cherry Creek Choice is a cafeteria benefits plan which offers you choices of
benefits. A cafeteria benefits plan enables you to choose plans with varying
costs that fit the needs of you and your family.
WHAT CHOICE OF BENEFITS DO I HAVE?
You may make choices in these plans:
• Medical Coverage
• Dental Coverage
• Vision Coverage
• Health Care Reimbursement Plan
• Dependent Care Assistance Plan
• Voluntary Life
• Voluntary Accidental Death & Dismemberment (AD&D)
Plans which are part of this program, and are provided to eligible employees at no
cost are:
• Basic Life Insurance/AD&D
• Long Term Disability
(Refer to separate policy information for Basic Life Insurance & LTD)
5

DHMO Catastrophic DHMO Added Choice
Triple Option
PPO Plus
Premier
MEDICAL OPTIONS
Kaiser Permanente
DENTAL OPTIONS
Delta Dental
Preferred Provider
Option
VISION OPTIONS
VSP
6
Exclusive Provider
Option
Opt for Coverage Waive Coverage
FLEX ACCOUNTS OPTIONS
RPS / 24 Hour Flex
Waive Coverage -
Must provide proof of
other group coverage
Waive Coverage
Health Care Reimbursement Plan Dependent Care Assistance Plan
“No Cost” Coverage for eligible
employees :
Life/AD&D—CIGNA
Long Term Disability—Standard

Enrollment Periods
And
Eligibility Provisions
7

NEW EMPLOYEE ENROLLMENT
ENROLLMENT PERIODS
• All benefit eligible employees will receive an enrollment packet through e-mail
via your Outlook account. If you do not receive a packet contact your manager.
• The benefit choices you make take effect the first day of the month following
31 days of continuous employment if you are a new hire.
• You may enroll in benefits until 31 days past your effective date. If you exceed
that time frame you will need to wait until open enrollment.
• Benefits are current month. This means:
• District contributions for eligible employees will be provided when you
become eligible for benefits to use towards payment for coverage if you
enroll.
• Payroll deductions to pay for coverage are current month. (i.e. June
paycheck deduction to pay for coverage in June).
ANNUAL OPEN ENROLLMENT
• Open Enrollment is held annually for all benefit eligible employees in Cherry
Creek School District during the months of April and/or May with a benefit effective
date of July 1 st .
• You cannot change your decisions during the plan year unless you have a status
change.
• The plan year is from July 1 st through June 30 th . The premiums for renewed
plans will be effective in July for all employee groups.
8

Change in Status & Special Enrollment Rules
As a participant in the Benefit Cafeteria Plan, you are entitled to revoke your prior benefits election and
enter into a new election in the event of certain changes in status. The change in your benefits election
must be due to and be consistent with the change in status. The change must be acceptable under the regulations
issued by the Department of Treasury.
A change must be made within thirty-one days of the change of status.
Change in Marital Status
• Change in legal marital status including marriage, death of the spouse, divorce, legal separation or
annulment.
Change in Number of Dependents
• Change in the number of dependents including birth, adoption, and placement for adoption or death of a
dependent, permanent legal guardianship. This includes dropping ineligible dependents who reach the
maximum age limit for dependent status (i.e., age 26 for medical or age 24 for vision & dental).
Changes in Spouse, Domestic Partner or Dependent’s Eligibility under an Employer’s Plan
• Change in dependent status in satisfying or ceasing to satisfy the eligibility requirements of the
plan, such as change in marital status.
• Gain or loss of Medicaid or Medicare entitlement.
• Entitlement to COBRA.
• Special Requirements relating to the Family and Medical Leave Act (FMLA).
Change in Employment Status that Changes Eligibility Status
• Change of employment status, such as termination or commencement of employment by the employee,
spouse or dependent.
• Change in work schedule, such as a reduction or increase in hours of employment by the employee,
spouse or dependent, including a switch between part-time and full-time, a strike or lockout, a change
in worksite, or commencement or return from an unpaid leave of absence.
• Change in eligibility due to change in residency of the employee, spouse or dependent.
Change in Cost or Coverage
• Significant cost increase in your coverage or your dependent’s coverage.
• Significant curtailment of your coverage or your dependent’s coverage.
• Addition or elimination of benefit package option under your or your dependent’s employer’s plan.
• Change in coverage or open enrollment of spouse or dependent under other employer’s plan provided
that the employee, spouse or dependent elects coverage under the dependent’s plan.
Cost or Coverage change of status not applicable for health care reimbursement or dependent care
assistance accounts.
Applicable for Dependent Care Assistance Accounts only:
• Change in dependent care provider.
• Change in dependent care costs.
9

WHO IS ELIGIBLE?
Eligible Employees:
ELIGIBILITY PROVISIONS
You are eligible for Cherry Creek Choice if you are a regular employee working
50 percent of a full-time contract in an eligible employee group. For more information
of eligibility see our website: http://www.cherrycreekschools.org/
HumanResources/Employees/Pages/Benefit-Information.aspx on the links for district
contribution and benefit eligibility for Licensed or Classified Employees.
Eligible dependents include:
• Your legal spouse, common law spouse (must sign common law affidavit) or samesex
domestic partner.
• For dental and vision insurance an unmarried child of the employee, or domestic
partner (with domestic partner enrollment) through the end of the calendar year in
which the child becomes age 19 or age 24 if the child is a full time student.
• For medical insurance and the Healthcare Reimbursement Account, an eligible child
is defined as a child of the employee through the end of the month in which the
child turns age 26. (For Health Care Reimbursement Account see tax dependency
rules for domestic partner and their children).
• “Child” indicates your dependent children. This definition includes: natural children,
stepchildren, legally adopted children, a child placed for adoption, children of
domestic partner (with domestic partner enrollment) or children under “permanent”
court-appointed legal guardianship. With the exception of legal guardianship, dependent
children do not have to reside in the household of the subscriber. Cherry
Creek requires proof of such relationships (legal adoption papers, legal custody papers,
etc.) that the dependent qualifies for coverage. NOTE: Foster children are not
considered eligible dependents and may not be enrolled.
• An unmarried child who is 26 years of age or older incapable of self-support because
of mental incompetence or severe physical handicap as certified by a physician and
by the insurance carriers.
You may enroll your eligible dependents in some of the plans that you are enrolled in
and are not required to enroll them in all of your plans. Dependents must be enrolled in
the same plan type as you are - for example: You can not be enrolled in Kaiser Triple
Option and have your dependents in Kaiser DHMO. You do not have to go to the same
providers. If you do not enroll all of your eligible dependents now, you may do so at
future open enrollments only (unless a special enrollment event occurs). See Change in
Status Section for details on special enrollments.
10

PRE-TAX CONTRIBUTIONS
TAX ELECTIONS FOR PREMIUMS
If the benefit plans you select cost more than the District’s monthly contribution, you may
contribute benefit dollars out of your paycheck with pre-tax dollars for these plans:
• Medical Coverage
• Dental Coverage
• Vision Coverage
• Health Care Reimbursement Plan
• Dependent Care Assistance Plan
• Voluntary Life
• Voluntary Accidental Death - Dismemberment (AD&D)
Cherry Creek will automatically default your tax selection to a pre-tax basis. You pay no
federal or state income, Medicare, or PERA taxes on your pre-tax contributions.
AFTER-TAX CONTRIBUTIONS
When you approach the final four years before retirement, PERA recommends that if your
benefit selections exceed your district contribution, you may wish to change your status to
after-tax. The amount that exceeds the district contribution is taken directly out of your salary
and when deducted on a pre-tax basis, this reduces the earnings reported to PERA and
lowers your highest average salary. If your premium totals are less than the district contribution,
this will not affect your PERA earnings and may only be contributed on a pre-tax
basis.
Please contact PERA if you have questions related to your highest average salary. An employee
may elect to have medical, dental, vision, voluntary life and voluntary AD&D premiums
on an after tax basis. You cannot participate in the Healthcare Reimbursement
or Dependent Care on an after-tax basis.
Once elected, this selection will continue for the full plan year. A change can only be
made during open enrollment or as the result of an eligible status change.
11

Medical Plan
Designs
12

ALL MEDICAL PLANS
Cherry Creek Choice offers three medical plan options through Kaiser Permanente. You may also choose
to waive coverage under a medical plan but only if you submit evidence that you are covered under another
group medical insurance plan, such as through your spouse’s employer. Each medical option is priced
separately to reflect the benefits of the plan. Each medical plan option is described in detail on the pages
that follow.
CHOICES – THE MEDICAL PLAN OPTIONS ARE:
• Kaiser Permanente Catastrophic DHMO
The Catastrophic DHMO saves you money in premium by including high deductibles and
coinsurance while still offering co-pays for office visits and prescriptions. The Catastrophic
DHMO plan requires you to access care from Kaiser facilities/providers. You may make appointments
directly with your PCP or Specialist. While you may self-refer to a Specialist, Kaiser
Permanente encourages coordinating overall care with your PCP.
• Kaiser Permanente DHMO
The DHMO plan has a lower deductible and co-insurance than the Catastrophic DHMO plan.
The plan requires you to access care from Kaiser facilities/providers. You may make appointments
directly with your PCP, or with a Specialist. While you may self-refer to a Specialist,
Kaiser Permanente encourages coordinating your overall care with your PCP.
• Kaiser Permanente Added Choice Triple Option
The Added Choice Triple Option allows you to choose to access care from Kaiser facilities/
providers or Private Healthcare Systems (PHCS) facilities/providers inside and outside of Colorado
or any other facility/provider. Benefit levels vary based on the facilities/providers accessed.
Co-pays for preventive care apply to tier three. Prescriptions are available outside of
the Kaiser Permanente formulary.
• No Coverage
You may choose to waive all medical coverage only if you submit evidence that you are covered
under another group medical insurance plan by providing a copy of a current ID card that
includes the group name and effective date of benefits.
If you waive all medical coverage at this time, you will not have another opportunity to
enroll for medical coverage until the next enrollment period, unless you qualify for special
enrollment.
PARTICIPATING HOSPITALS AND DOCTORS
The medical plan choices offered vary by the type and level of benefits available, but there are also
important differences having to do with your choice of medical care providers. Kaiser
Permanente has specific lists of participating hospitals, doctors/facilities, and other medical care
providers. For the most current information, you may review these lists on-line at:
• Kaiser Catastrophic DHMO & Kaiser DHMO - www.kp.org
• Kaiser Added Choice Triple Option – www.phcs.com (locally and nationally)
Please note Centura Facilities are not in the PHCS network. Colorado State law requires an
Access Plan describing Kaiser Permanente’s network of providers and services be available.
To obtain a copy, call Customer Service at 303-338-3800.
15

ALL MEDICAL PLANS (continued)
ARBITRATION
By enrolling in Kaiser Permanente, you agree to have all disputes and/or claims for money damages
exceeding the Small Claims Court limit in Colorado, including issues of medical malpractice, decided
by neutral arbitration rather than by a jury or court trial.
MISCELLANEOUS
Affordable Care Act requires carriers to make available a Summary of Benefits & Coverage, (SBC)
which is intended to facilitate comparison of health plans. The SBC must be provided the first day of
open enrollment and with enrollment or application materials for newly eligible employees.
Point-of-Service benefits are underwritten by the Kaiser Permanente Insurance Company, a
subsidiary of Kaiser Foundation Health Plan.
This is only a summary. It does not fully describe you health care coverage. For complete details on
your coverage, including exclusions and plan terms, please refer to your employer’s Service Agreement
and the Kaiser Permanente Insurance Company (KPIC) Group Policy and Certificate of Insurance.
The Service Agreement and KPIC Group Policy are the legally binding documents between Kaiser
Foundation Health Plan of Colorado, KPIC and its members. In the event of ambiguity and/or conflict
between this summary and/or the Service Agreement and KPIC Group Policy, the Service Agreement
and the KPIC Group Policy shall control.
16

ENROLLMENT FREQUENTLY ASKED QUESTIONS
HOW DO YOU CHOOSE THE OPTION THAT’S RIGHT FOR YOU?
The medical plan that is right for you will not necessarily be the medical plan that is right for
your co-worker. The medical plan options offer ranges of benefits and costs.
WHAT CAN I AFFORD TO SPEND EACH MONTH FOR A MEDICAL PLAN?
Only you can determine this based on the District’s contributions, the other benefits you want
to purchase, and your own budget. It may be more economical to choose a lower cost plan,
and only pay co-payments or deductibles if you actually use the plan.
IF MY CHILD ATTENDS COLLEGE OUT OF THE AREA, WILL THEIR CARE BE
COVERED UNDER ALL OF THE PLANS?
The Kaiser Permanente DHMOs have an Out of Area Student benefit, which allows for fulltime
college student dependents who attend a college or vocational school outside of any Kaiser
Permanente service area with coverage @ 80% of the charges for routine and follow-up
care, up to an annual maximum of $1,200. The Kaiser Permanente Added Choice Triple Option
provides coverage for those college student dependents attending school outside of the
Kaiser Permanente service area through Tier 2 (PHCS Providers), and Tier 3 (any licensed
provider), at the applicable co-pays and coinsurance. Any college student dependent enrolled
in either the Kaiser Permanente DHMO or Added Choice Triple Option, who attends school
in another Kaiser Permanente service area outside of Colorado, will have visiting member
benefits, and can obtain routine and follow-up care at any Kaiser Permanente facility.
WHICH PLANS WILL PROVIDE THE BEST PREVENTIVE CARE BENEFITS?
Because of Health Care Reform, you will not pay anything for a preventive care visit in either
of the DHMO plans or the first two tiers of the Added Choice Triple Option plan. However,
tier three of the Added Choice Triple Option Plan does require a co-pay and preventive services
are limited.
IF I CHOOSE TO WAIVE MEDICAL COVERAGE, CAN I GET BACK INTO THE
PLAN AT ANOTHER DATE?
You must wait to enroll until the next annual enrollment period, unless you are eligible for
special enrollment in which case you may enroll within 31 days of that change. The effective
date must be the date when the previous coverage ended.
17

ENROLLMENT FREQUENTLY ASKED QUESTIONS (continued)
WHAT ARE THE MAJOR DIFFERENCES BETWEEN THE
HEALTH PLANS?
Kaiser Catastrophic DHMO & Kaiser DHMO vs. Added Choice Triple Option
• Kaiser physicians are employed by Colorado Medical Group.
• Members must seek care at Kaiser facilities for DHMO benefits and for Option 1 of the
Added Choice Triple Option in-network benefits. Other facilities/hospitals may be used in
life threatening urgent and emergency situations.
• In Kaiser’s Added Choice Triple Option you may choose from three provider “tier options”.
Option 1: The Kaiser DHMO facilities/providers offer the least amount of out-of-pocket
expense. Option 2: PHCS facilities/providers are available with an even higher out-ofpocket
expense. Option 3: You may see any provider anywhere with a higher out-of-pocket
expenses. At each point of service you are free to choose any of the provider options listed.
The member is responsible for satisfying the deductible for benefits with a coinsurance for
all other services. (See Summary of Benefits & Coverage form for more details).
• St. Joseph’s and Good Samaritan are the primary hospitals contracted with Kaiser Permanente
DHMO in the Denver/Boulder areas. After hours emergency care can be obtained at
any licensed facility. After hours urgent care are at Lutheran or Swedish. There are other
Kaiser Permanente facilities that provide after hours care, you can find these facilities on
their website at www.kp.org.
• With the exception of the out-of-area student benefit, Kaiser’s DHMO has no coverage outside
the DHMO service area unless it is urgent or emergency care.
HOW DO I ACCESS MENTAL HEALTH AND SUBSTANCE ABUSE SER-
VICES?
As a member of any Kaiser medical plan you have access to four Mental Health Facilities and
two Substance Abuse Facilities in Kaiser’s network for most of your mental health / substance
abuse needs. To obtain services you do not need a referral. Simply call one of the facilities
listed below:
Baseline Mental Health
580 Mohawk Drive
Boulder, CO 80302
303-554-5200
Execuve Center Mental Health
4851 Independence St., Suite 270
Wheat Ridge, CO 80033
303-467-5850
Highline Center Mental Health and Chemical Dependency
10350 E. Dakota Avenue
Denver, CO 80231
303-367-2800
Hidden Lake Mental Health and Chemical Dependency
7701 Sheridan Blvd.
Westminster, CO 80003
303-650-3900
18

ENROLLMENT FREQUENTLY ASKED QUESTIONS (continued)
DO I HAVE TO USE KAISER FACILITIES FOR MENTAL HEALTH / SUBSTANCE
ABUSE EVEN IF I AM ON THE ADDED CHOICE TRIPLE OPTION?
As a member of the Kaiser Added Choice Triple Option plan you can access the facilities listed
above for the lowest cost. You can use any licensed facility for inpatient and outpatient care,
but benefits will be paid according to lower out-of-network or PHCS benefits.
HOW DO I ACCESS ALTERNATIVE CARE SERVICES?
For other services such as acupuncture or chiropractic care please contact Kaiser for participating
providers. These services are not covered under the schedule of benefits, but may be available
at a reduced fee.
HOW DO I ACCESS THE EYE EXAMINATION BENEFIT?
You can have an annual eye exam with applicable co-pay as a part of your Kaiser Permanente
benefit package. The eye examination benefit does not include the cost of eyeglasses, contact
lenses or contact lens fittings. Contact lens exams are available at an additional charge. A referral
from a primary care physician is not required. Simply call the Kaiser Permanente optical
department of your choice and make an appointment.
DOES KAISER OFFER ANY OTHER SERVICES?
Kaiser Permanente offers a variety of courses, webinars for everything from weight loss, smoking
cessation, yoga classes, parenting classes and more for all Kaiser members and nonmembers.
Health Education Webinars
Kaiser Permanente Webinars offer "live" interactive learning with a professional health expert
and coach. View the presentation through your computer's web browser and listen through your
phone or computer headset. Most Webinars are free to Kaiser Permanente members and
non-members. Below is a link to view upcoming and pre-recorded classes and to register:
https://www.signup4.net/Public/ap.aspx?EID=20113952E%20
Can I attend these Webinars with my Smartphone?
Yes, if you have a 4G phone (Examples: I-Phone, I-Pad, or Android)
* You will be alerted to download the WebEx application
Health Education Courses (On-site courses offered at Kaiser facilities and hospitals)
Kaiser Permanente offers many health education courses at several of their facilities for a cost
for all members and non-members. For a listing of their courses please visit their website at:
https://healthy.kaiserpermanente.org/health/care/consumer/health-wellness/programs-classes/
classes you will be directed to select your region and city to find the course closest to you.
19

IMPORTANT KAISER PHONE NUMBERS
Kaiser Permanente appointments/medical advice 303-338-4545
Point-of-Service Internal Referral 303-743-5330
This number is for use by your Out-of-
Plan provider to refer you to a Kaiser
Permanente specialist or for a diagnostic
test requiring an appointment.
Pre-certification for Out-of-Plan Services 1-800-448-9776
PHCS 1-866-680-7427
To locate a network provider contact
PHCS or visit their Web site at
www.phcs.com 24 hours a day (select
PPO network when searching).
20

Kaiser Permanente
Catastrophic DHMO
21

KAISER PERMANENTE CATASTROPHIC DHMO
The Kaiser Permanente Catastrophic DHMO plan emphasizes preventive health and pays office
visits and prescriptions in full after required co-payments. For the DHMO benefit, care must be
obtained from participating Kaiser Permanente providers/medical offices, unless there is an
emergency, in which case you visit the nearest emergency room. In addition to the rich benefits
offered by the District, classes offered in the Kaiser Permanente quarterly magazine, Partners
In Health, are offered at no charge to Cherry Creek School District members (with the exception
of some weight loss and smoking cessation classes.)
ACCESS TO CARE
With Kaiser Catastrophic DHMO, you do not need to select a Primary Care Physician (PCP),
but Kaiser Permanente encourages you to do so. You do need to go to a Kaiser facility to obtain
care. You can view the most current Physician directory on-line at www.kp.org. If you are
enrolling for the first time, enter the information as requested on the enrollment form included
in your enrollment packet.
If you have any questions regarding choosing a Kaiser Facility, please call Kaiser’s Customer
Service at 303-338-3800.
When you arrive for your appointment, have your ID card and co-payment with you.
If you choose to go to a non-Kaiser facility without obtaining a referral from a Kaiser Permanente
physician, you will be responsible for all of the charges for all services rendered,
including Hospital care.
Regardless of where an emergency occurs, it is always covered under DHMO benefits. Check
your Summary of Benefits & Coverage for DHMO emergency room coinsurance, ambulance
coinsurance, and hospital coinsurance.
CHANGING DOCTORS
With Kaiser you may change doctors at your choice. You simply need to request or make an
appointment with a different physician.
PARTICIPATING HOSPITALS & DOCTORS
A directory of all Kaiser providers (including specialists) can be accessed
on-line at www.kp.org.
22

Kaiser Permanente DHMO
33

KAISER PERMANENTE DHMO
The Kaiser Permanente DHMO stresses preventive care and preventive visits are covered
100%. Other visits or diagnostic services may be subject to co-pays, deductibles and/or coinsurance.
For the DHMO benefit, care must be obtained from participating Kaiser providers/
facilities.
ACCESS TO CARE
With Kaiser DHMO, you do not need to select a Primary Care Physician (PCP), but Kaiser
Permanente encourages you to do so. You do need to go to a Kaiser facility to obtain care.
You can view the most current Physician directory on-line at www.kp.org. If you are enrolling
for the first time, enter the information as requested on the enrollment form included in your
enrollment packet.
If you have any questions regarding choosing a Kaiser Facility, please call Kaiser’s Customer
Service at 303-338-3800.
When you arrive for your appointment, have your ID card and co-payment with you.
If you choose to go to a non-Kaiser facility without obtaining a referral from a Kaiser Permanente
physician, you will be responsible for all of the charges for all services rendered,
including Hospital care.
Regardless of where an emergency occurs, it is always covered under DHMO benefits. Check
your Summary of Benefits & Coverage (SBC) Form for DHMO emergency room co-insurance,
ambulance co-insurance, and hospital co-insurance.
CHANGING DOCTORS
With Kaiser you may change doctors at your choice. You simply need to request or make an
appointment with a different physician.
PARTICIPATING HOSPITALS & DOCTORS
A directory of all Kaiser providers (including specialists) can be accessed on-line at
www.kp.org.
34

Kaiser Permanente
Added Choice
Triple Option
45

Kaiser Permanente Added Choice Triple Option
If you choose the Added Choice Triple Option plan, you will receive full access to the Kaiser
Permanente Health Care System as well as access to the PHCS Preferred Provider Networks
and any other provider. Please see your Summary of Benefits & Coverage (SBC) on the following
pages for information concerning how your plan benefits are structured in all three tiers of
the plan:
• Option 1/Tier 1 - Kaiser Permanente
• Option 2/Tier 2 – Private Healthcare Systems (PHCS) inside and outside of Colorado.
• Option 3/Tier 3 - Any licensed provider in any location in the United States.
You will have less out-of-pocket expense when you access Kaiser Permanente services. You
may choose from primary care physicians in Family Practice, Internal Medicine, or Pediatrics.
One co-payment will cover your provider visit. However any procedures performed during the
visit will be subject to the deductible and co-insurance. Kaiser Permanente also have an extensive
network of specialty physicians.
How Added Choice Triple Option Works
If you choose to see a PHCS provider, you will be charged an office visit co-payment for your
office visit. You will be subject to a deductible and coinsurance for any services billed in addition
to the office visit, including laboratory samples sent from the provider’s office (see Laboratory
and Imaging for more information).
If you choose to see a PHCS or non-affiliated provider, you will reduce your out-of-pocket expenses
by bringing requests for services from your physician to a Kaiser Permanente medical
office. Added Choice Triple Option is designed to save you money by allowing you to continue
to see your non-Kaiser Permanente physician, yet come into Kaiser Permanente for pharmacy,
laboratory, and X-ray services.
Prescriptions
• Prescriptions for medications that are on the Kaiser Permanente Formulary may be
filled at any Kaiser Permanente pharmacy. You may request refills by using the
phone-in pharmacy refill service or online at www.kp.org. They’ll also mail your
medications to you at no extra charge, which can save you a trip.
• If you have questions about Kaiser Permanente’s drug formulary or need to transfer
existing prescriptions to Kaiser Permanente, please call the Clinical Pharmacy Call
Center at 303-338-4503. Please identify that you are a Added Choice Triple Option
member when calling.
• Prescriptions for medications not on the Kaiser Permanente Formulary may be filled
at any MedImpact Pharmacy for the applicable co-payment on the PHCS (preferred
provider) Option. In Colorado, MedImpact Pharmacies are found at:
Long’s King Soopers Medicine Shoppes
Safeway Walgreens Albertsons
City Market K-Mart Target
46

Kaiser Permanente Added Choice Triple Option (Continued)
Laboratory work
• You may bring orders for routine laboratory work from your outside provider to any Kaiser
Permanente medical office. There is no charge for this service. Just go directly to the lab
in the Kaiser Permanente office with the order from your Tier 2 or Tier 3 physician. Results
will be returned to your doctor’s office by fax, telephone, or mail.
Imaging (subject to deductible, co-pays and/or co-insurance - See page 14)
• You may also take orders for routine X-ray studies to any Kaiser Permanente medical
office. You may take the order directly to the Radiology
Department. A report will be returned to your doctor’s office.
• MRIs, CT, and PET studies may have higher costs. Appointments are required for these
studies.
• MRIs, PET, CT, bone density studies, and other studies must be completed at the
Franklin Medical Offices and will require an appointment.
• MRIs ordered by non-Kaiser Permanente providers always require precertification.
Call 1-800-448-9776.
• After pre-certification is obtained, ask your provider to call the referral line at 303-
743-5330. When the request for referral comes to Kaiser Permanente, they will call
you to make an appointment.
• Orders for other studies such as ultrasound, bone density studies and mammograms also
require appointments and referrals. Your provider’s office should refer you by calling
303-743-5330. A referral will be put on the Kaiser Permanente internal system and a fax
will be sent to the proper department. They will send a letter to you verifying the referral
and providing a phone number for you to make your appointment.
• Mammograms will only be covered at the Kaiser Permanente level of benefits if provided
at a Kaiser Permanente Medical Office.
Specialty referrals
• When using a PHCS or non-preferred provider, you may access the Kaiser Permanente
system to see a specialist without a referral from a Kaiser Permanente primary care physician.
This benefit can often allow you to access treatment at a much lower cost than the
deductible/coinsurance benefits of the 2nd and 3rd tiers of the Added Choice Triple Option
Plan. You will receive your care from a Kaiser Permanente board-certified specialist.
• Ask your PHCS or non-preferred provider to call the referral line at 303‑743‑5330. Your
provider will leave the information concerning your needs and the referral will be put on
their system.
• The appointment request will be faxed to the appropriate department.
• A letter will be sent to you verifying the referral and providing a telephone number to call
and make an appointment.
47

Hospitalization
Kaiser Permanente Added Choice Triple Option (Continued)
• You may be admitted to any hospital your provider chooses. PHCS hospitals will be less expensive
than nonaffiliated hospitals. Pre-certification is required.
• For pre-certification, your doctor must call 1-800-448-9776.
• If a Kaiser Permanente provider admits you to a Kaiser Permanente hospital, your in-plan DHMO
hospital benefits will apply.
Pre-certification for PHCS and Out-of-Network Procedures
Pre-certification is required for:
• Hospital admission, including pre-admission testing
• Any procedure performed at a non-Kaiser Permanente outpatient surgery facility (colonoscopy,
sigmoidoscopy and other diagnostic tests included)
• Prenatal care (call within the first trimester, if possible)
• MRIs. The test cannot be performed at Kaiser Permanente until a pre-certification is obtained.
• Skilled nursing facility admission
Your benefit will be reduced by an additional 20%, after the deductible, if pre-certification is not obtained.
Other information
Certain services are covered only in Option 1/Tier 1 (inside Kaiser Permanente). These include:
• With the exception of prosthetic arms and legs, Durable Medical Equipment, including oxygen.
Your provider may manage your care, but you must obtain your durable medical supplies
(including oxygen) from Kaiser’s contracted vendors. For information call Customer Service at
303-338-3800.
• Dialysis is performed at Presbyterian-St. Luke’s.
• Skilled nursing facility care must be arranged through Kaiser Permanente.
• All Emergency claims are paid by Kaiser Permanente.
Claims
You or your provider should mail claims to: Kaiser Permanente Added Choice Claims,
P.O. Box 370897, Denver, CO 80237-0897
Emergencies
• In the event of a life threatening emergency, call 911.
• Regardless of where an emergency occurs, it is always covered under DHMO benefits. Check
your Summary of Benefits & Coverage (SBC) for DHMO emergency room co-payments, ambulance
co-payments, and hospital co-payments. Your emergency room co-payment is waived if
you are admitted as an inpatient.
• Kaiser Permanente contracts with several hospitals in the Denver/Boulder area.
• If time permits, please go to the nearest contracted hospitals: Exempla St. Joseph Hospital,
Exempla Good Samaritan, Lutheran Medical Center, or Swedish Medical Center.
48

Kaiser Permanente Added Choice Triple Option (Continued)
Important telephone numbers for Added Choice Triple Option members:
Emergency 911
To check on a claim 1-800-382-4661
Kaiser Permanente Customer Service 303-338-3800
(TTY 303-338-3820)
Clinical Pharmacy Call Center 303-338-4503
Use this number for questions about formulary medications and to transition prescriptions
to Kaiser Permanente.
Please tell them when you call that you are an Added Choice Triple Option
member.
49

Limitaons for In-Plan Benefits
The following is a paral list of limitaons under this Plan:
Prescribed diabec supplies dispensed at In-Plan pharmacies are provided at the applicable
co-payment · Insulin pumps and insulin pump supplies are provided for Type 1 diabetes, at
the applicable co-payment, when clinical guidelines are met. Pumps and supplies must be
obtained from a Kaiser Permanente designated provider · Prosthec arms and legs are covered
as a base benefit for the applicable co-payment ·Transplants will be covered in accordance
with the Evidence of Coverage only if they are deemed to be medically necessary by a
Kaiser Permanente physician and meet the clinical requirements of the facility where they
are performed · Bone marrow transplants associated with high dose chemotherapy for solid
ssue tumors, other than autologous stem cell and peripheral stem cell support, for germ
cell tumors and neuroblastoma in children are not covered · Bone marrow transplants for
aplasc anemia, leukemia, severe combined immunodeficiency disease, Wisko-Aldrich syndrome
and other bone marrow transplants are covered · Pancreas alone transplants are limited
to paents without renal problems · Injectable hormone for treatment of prostate cancer
is provided with a 20 percent charge · Covered inferlity services including laboratory
tests and X-rays for inferlity or arficial concepon are provided with a 50 percent charge ·
Oxygen for use in conjuncon with DME is provided upon payment of 20 percent of member
charges with no annual benefit maximum · Oxygen will be covered when traveling outside
the service area. To qualify for coverage, members must have a pre-exisng oxygen order
and must use the Kaiser Permanente designated vendor · Services for long-term rehabilita-
on are not covered; however, short-term (up to two months per condion per contract
year) physical, occupaonal, and speech therapy are covered in an appropriate inpaent or
outpaent seng as determined by a Kaiser Permanente physician · Speech therapy not
medically necessary is not covered, except for treatment for speech impairments due to injury
or illness · Occupaonal therapy is limited to treatment to achieve and maintain improved
self-care and other customary acvies of daily living · Medically necessary physical,
occupaonal and speech therapy for the care and treatment of congenital defects and birth
abnormalies are covered for children up to age 5 · Chemical dependency rehabilitaon services
in a specialized facility are not covered; however, evaluaon and referral for such services
are covered · Non-preferred drugs are not covered unless a non-preferred drug has
been specifically prescribed and authorized through the non-preferred drug process · Genec
tesng is not covered unless determined to be medically appropriate and meets criteria
established by the Medical Group.
Exclusions for In-Plan benefits
The following is a paral list of exclusions under this Plan:
Condions covered by Workers’ Compensaon or Employer’s Liability · Condions arising
from military service · Custodial or homemaker care · Care more appropriately provided in a
Plan or Skilled Nursing Facility · Intermediate level care · Mental health services on court order,
to be used in court proceedings or as a condion of parole or probaon · Mental health
services for organic brain syndromes · Evaluaons for any purpose other than mental health
treatment · Residenal care · Cosmec services intended primarily to change or maintain
your appearance · Dental services and dental X-rays including dental services
62

following injury to teeth; dental appliances; dental implants; orthodona; dental services
associated with surgery on the jawbone and radiaon therapy · Physical examinaons for
insurance, employment, licensing, parcipaon in employee programs, disability or on court
order or required for parole or probaon · Roune foot care that is not medically necessary ·
Alternave medical services unless purchased as a supplemental benefit · Services to reverse
voluntary surgically induced inferlity · All services related to sexual reassignment surgery ·
All services and supplies (other than arficial inseminaon) related to concepon by arficial
means, prescripon drugs related to such services, and donor semen and donor eggs used
for such services, such as, but not limited to: in vitro ferlizaon, ovum transplants, gamete
intra fallopian transfer and zygote intra fallopian transfer. The exclusions apply to ferle as
well as inferle individuals or couples · Surrogacy arrangements · Experimental or invesga-
onal services · All services for eye surgery to correct refracve defects · Arficial aids and
correcve appliances · Eye examinaons for cosmec contact lenses · Transportaon other
than a licensed ambulance · Maintenance physical, occupaonal and speech therapy · Nonhuman
and arficial organs and their implantaon · Condions alleged to be caused by another
party for which amounts are collected from or on behalf of a third party · Services provided
or arranged by criminal jusce instuons unless covered as Out-of-Plan emergency
services · Any health care procedure not generally and customarily available in the service
area · Special educaon and related counseling and therapy for learning deficiencies and behavioral
problems · All services necessary for an excluded service that would otherwise be
covered.
Limitaons and Exclusions for Out-of-Plan benefits
No payment will be made under any benefit of the group policy for expenses incurred in connecon
with the following, unless specifically stated otherwise in the group policy.
Charges in excess of the maximum allowable charge · Charges for non-emergency care in an
emergency care seng · Weekend admission charges for non-emergency care hospital services
Confinement, treatment, services, or supplies which are not medically necessary · Injury
or sickness for which the covered person has or had a right to payment under any workers’
compensaon or similar law · Injury or sickness for which the law requires the covered
person to maintain alternave insurance, bonding, or third party coverage · Injury or sickness
arising out of or in the course of past or current work for pay, profit, or gain, unless
workers’ compensaon or benefits under similar law are not required or available · Injury or
sickness contracted while on duty with any military, naval, or air force of any country or internaonal
organizaon · Treatment, services, or supplies provided by the covered person;
the covered person’s spouse; or a person who resides in the covered person’s home · Confinement,
treatment, services or supplies received where care is provided at government
expense · Dental care and dental X-rays; dental appliances; orthodona; and dental services
resulng from medical treatment, including surgery on the jawbone and radiaon treatment
· Cosmec services, plasc surgery or other services that are indicated primarily to improve
the covered person’s appearance and will not result in significant improvement
63

in physical funcon · Sex transformaon, or surgery or treatment related to sexual dysfunc-
on · Non-prescripon drugs or medicines; vitamins, nutrients and food supplements even if
prescribed or administered by a physician · Any treatment, procedure, drug, or equipment or
device which KPIC determines to be experimental or invesgaonal · Special educaon and
related counseling or therapy, or care for learning deficiencies or behavioral problems · Services
or supplies rendered for the treatment of obesity · Treatment of craniumandibular and
temporomandibular joint disorders · Confinement, treatment, services or supplies that are
required: only by a court of law; or only for insurance, travel, employment, school, camp,
government licensing, or similar purposes · Personal comfort items such as telephones, radios,
televisions, or grooming devices · Custodial care · Care in accordance with the aending
physician’s orders · Hearing exams, hearing therapy, or hearing aids · Services of a private
duty nurse in a hospital, skilled nursing facility or other licensed medical facility · Outpaent
private duty nursing services · Acupuncture; biofeedback; massage therapy; or hypnotherapy
· Health educaon · Medical social services · Living expenses or transportaon, except as
provided for under covered services · Second surgical opinions, unless required under the
Medical Review Program · Roune adult physicals · Eye refracons, orthopcs, glasses, contact
lenses or the fing of glasses or contact lenses; radial keratotomy or any other surgical
procedure to treat a refracve error of the eye, unless the treatment is medically necessary ·
Reversal of sterilizaon · Services provided in the home other than covered services provided
through a Home Health Agency or related to Hospice Care services · Durable medical
equipment · Braces and prosthecs · Acquision cost of any organ or bodily element · Transplants
· Treatment for inferlity · Maintenance therapy for rehabilitaon · Treatment, services
and supplies in connecon with inpaent or outpaent alcoholism · Treatment, services
and supplies in connecon with inpaent mental illness · Treatment and services covered
under Medicare or other governmental programs, except Medicaid · Treatment and
services covered under any state or federal worker’s compensaon, employers liability or
occupaonal disease law, or any motor vehicle no-fault law · Treatment and services provided
in a government hospital.
Disrupon of Services
Kaiser Permanente will use its best efforts to provide or arrange for your health care needs
in the event of unusual circumstances that delay or render impraccal the provision of Services,
such as major disaster, epidemic, war, riot, civil insurrecon, disability of a large share
of personnel at a Plan Facility, complete or paral destrucon of facilies, and labor disputes
not involving Health Plan, Kaiser Foundaon Hospitals, or Medical Group. However, Health
Plan, Kaiser Foundaon Hospitals, Medical Group, and Medical Group Physicians will not
have any liability for any delay or failure in providing covered Services. In the case of a labor
dispute involving Health Plan, Hospitals or Medical Group, we may postpone care unl the
dispute is resolved if delaying your care is safe and will not result in harmful health consequences.
Kaiser Permanente Point-of-Service Products are not Federally Qualified.
64

Dental
Plan
65
Designs

Vision Plan Design
71

Voluntary Life
Plan Design
81

Kaiser Permanente
Added Choice Triple Option
Customer Service
Delta Dental of Colorado
Customer Service
PPO Plus Premier Plan (#1108)
PPO Plan (#1726)
EPO Plan (#7094)
CARRIER CONTACT INFO
Vision Service Providers (VSP)
Customer Service
24 Hour Flex
Help Center
Customer Service
Cigna
Group Life Insurance (# FLX50878)
Group Basic AD&D (# OK980170)
Voluntary Life Insurance (# FLX50878)
Voluntary AD&D (# OK980171)
92
www.kp.org
www.phcs.com
303-338-3800
www.deltadentalco.com
1-800-610-0201
Providers: Premier Network
Providers: PPO Network
Providers: PPO Network
www.vsp.com
1-800-877-7195
www.24hourflex.com
303-369-7886
1-800-651-4855
Customer Service
1-800-732-1603