Disclosure form and evidence of coverage - Kaiser Permanente ...

TABLE OF CONTENTS FOR EOC #1
2013 Group Agreement Summary of Changes and Clarifications .......................................................................................... 4
Changes to the Group Agreement, including EOC documents ......................................................................................... 4
Clarifications to the Group Agreement, including EOC documents ................................................................................ 4
2013 University of California Specific Summary of Benefit Changes ................................................................................... 6
Benefit Highlights ................................................................................................................................................................... 7
Introduction ............................................................................................................................................................................. 9
Term of this Evidence of Coverage .................................................................................................................................. 9
About Kaiser Permanente................................................................................................................................................. 9
Definitions ............................................................................................................................................................................. 10
Premiums, Eligibility, and Enrollment .................................................................................................................................. 15
Premiums ........................................................................................................................................................................15
Medicare premiums .........................................................................................................................................................15
Who Is Eligible ...............................................................................................................................................................16
When You Can Enroll and When Coverage Begins........................................................................................................17
How to Obtain Services ........................................................................................................................................................ 18
Routine Care ...................................................................................................................................................................18
Urgent Care .....................................................................................................................................................................18
Our Advice Nurses ..........................................................................................................................................................18
Your Personal Plan Physician .........................................................................................................................................19
Getting a Referral ............................................................................................................................................................19
Second Opinions .............................................................................................................................................................20
Contracts with Plan Providers .........................................................................................................................................21
Visiting Other Regions ....................................................................................................................................................21
Your ID Card ..................................................................................................................................................................21
Getting Assistance ...........................................................................................................................................................22
Plan Facilities ........................................................................................................................................................................ 22
Plan Hospitals and Plan Medical Offices ........................................................................................................................22
Your Guidebook to Kaiser Permanente Services (Your Guidebook) ...............................................................................26
Provider Directory ...........................................................................................................................................................26
Pharmacy Directory ........................................................................................................................................................27
Emergency Services and Urgent Care ................................................................................................................................... 27
Emergency Services ........................................................................................................................................................27
Urgent Care .....................................................................................................................................................................28
Payment and Reimbursement ..........................................................................................................................................28
Benefits and Cost Sharing ..................................................................................................................................................... 28
Cost Sharing ....................................................................................................................................................................29
Preventive Care Services .................................................................................................................................................31
Outpatient Care ...............................................................................................................................................................32
Hospital Inpatient Care ...................................................................................................................................................33
Ambulance Services ........................................................................................................................................................34
Bariatric Surgery .............................................................................................................................................................34
Chemical Dependency Services ......................................................................................................................................35
Dental Services for Radiation Treatment and Dental Anesthesia ...................................................................................36
Dialysis Care ...................................................................................................................................................................36
Durable Medical Equipment for Home Use ....................................................................................................................37
Health Education .............................................................................................................................................................38
Hearing Services .............................................................................................................................................................38
Home Health Care ...........................................................................................................................................................39
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