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

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Chemical dependency Services exclusion • Services in a specialized facility for alcoholism, drug abuse, or drug addiction except as otherwise described in this "Chemical Dependency Services" section Dental Services for Radiation Treatment and Dental Anesthesia Dental Services for radiation treatment We cover services in accord with Medicare guidelines, including dental evaluation, X-rays, fluoride treatment, and extractions necessary to prepare your jaw for radiation therapy of cancer in your head or neck if a Plan Physician provides the Services or if the Medical Group authorizes a referral to a dentist (as described in "Medical Group authorization procedure for certain referrals" under "Getting a Referral" in the "How to Obtain Services" section). Dental anesthesia For dental procedures at a Plan Facility, we provide general anesthesia and the facility's Services associated with the anesthesia if all of the following are true: • You are under age 7, or you are developmentally disabled, or your health is compromised • Your clinical status or underlying medical condition requires that the dental procedure be provided in a hospital or outpatient surgery center • The dental procedure would not ordinarily require general anesthesia We do not cover any other Services related to the dental procedure, such as the dentist's Services, unless the Service is covered in accord with Medicare guidelines. Cost Sharing for dental Services for radiation treatment and dental anesthesia You pay the following for dental Services covered under this "Dental Services for Radiation Treatment and Dental Anesthesia" section: • Hospital inpatient care: a $250 Copayment per admission • Outpatient consultations, exams, and treatment: a $20 Copayment per visit • Outpatient surgery: a $100 Copayment per procedure if it is provided in an outpatient or ambulatory surgery center or in a hospital operating room, or if it is provided in any setting and a licensed staff member monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or to minimize discomfort. Any other outpatient surgery is covered at a $20 Copayment per procedure • Outpatient procedures (other than surgery): a $100 Copayment per procedure if a licensed staff member monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or to minimize discomfort. All outpatient procedures that do not require a licensed staff member to monitor your vital signs as described above are covered at the Cost Sharing that would otherwise apply for the procedure in this "Benefits and Cost Sharing" section (for example, radiology procedures that do not require a licensed staff member to monitor your vital signs as described above are covered under "Outpatient Imaging, Laboratory, and Special Procedures") Services not covered under this "Dental Services for Radiation Treatment and Dental Anesthesia" section Coverage for the following Services is described under these headings in this "Benefits and Cost Sharing" section: • Outpatient prescription drugs (refer to "Outpatient Prescription Drugs, Supplies, and Supplements") Dialysis Care We cover acute and chronic dialysis Services if all of the following requirements are met: • You satisfy all medical criteria developed by the Medical Group • The facility is certified by Medicare • A Plan Physician provides a written referral for your dialysis treatment except for out-of-area dialysis care We also cover hemodialysis and peritoneal home dialysis (including equipment, training, and medical supplies). Out-of-area dialysis care We cover dialysis (kidney) Services that you get at a Medicare-certified dialysis facility when you are temporarily outside our Service Area. If possible, before you leave the Service Area, please let us know where you are going so we can help arrange for you to have maintenance dialysis while outside our Service Area. The procedure for obtaining reimbursement for out-ofarea dialysis care is described in the "Requests for Payment" section. Page 36
Member Service Contact Center: toll free 1-800-443-0815 (TTY users call 711) seven days a week 8 a.m.–8 p.m. You pay the following for these covered Services related to dialysis: • Inpatient dialysis care: a $250 Copayment per admission • One routine outpatient visit per month with the multidisciplinary nephrology team for a consultation, exam, or treatment: no charge • Hemodialysis treatment: no charge • All other outpatient consultations, exams, and treatment: a $20 Copayment per visit Services not covered under this "Dialysis Care" section Coverage for the following Services is described under these headings in this "Benefits and Cost Sharing" section: • Durable medical equipment for home use (refer to "Durable Medical Equipment for Home Use") • Kidney disease education (refer to "Health Education") • Outpatient laboratory (refer to "Outpatient Imaging, Laboratory, and Special Procedures") • Outpatient prescription drugs (refer to "Outpatient Prescription Drugs, Supplies, and Supplements") • Outpatient administered drugs (refer to "Outpatient Care") Dialysis Care exclusions • Comfort, convenience, or luxury equipment, supplies and features • Nonmedical items, such as generators or accessories to make home dialysis equipment portable for travel Durable Medical Equipment for Home Use We cover durable medical equipment for use in your home (or another location used as your home as defined by Medicare) in accord with our durable medical equipment formulary and Medicare guidelines. Durable medical equipment for home use is an item that is intended for repeated use, primarily and customarily used to serve a medical purpose, generally not useful to a person who is not ill or injured, and appropriate for use in the home. Coverage is limited to the standard item of equipment that adequately meets your medical needs. We decide whether to rent or purchase the equipment, and we select the vendor. Durable medical equipment for diabetes The following diabetes blood-testing supplies and equipment and insulin-administration devices are covered under this "Durable Medical Equipment for Home Use" section: • Blood glucose monitors and their supplies (such as blood glucose monitor test strips, lancets, and lancet devices) • Insulin pumps and supplies to operate the pump Cost sharing for durable medical equipment You pay the following for covered durable medical equipment (including repair or replacement of covered equipment): • Blood glucose monitors and their supplies (such as blood glucose monitor test strips, lancets, and lancet devices): no charge • External sexual dysfunction devices: no charge • Insulin pumps and supplies to operate the pump: no charge • All other covered durable medical equipment: no charge About our durable medical equipment formulary Our durable medical equipment formulary includes the list of durable medical equipment that is covered by Medicare or has been approved by our Durable Medical Equipment Formulary Executive Committee for our Members. Our durable medical equipment formulary was developed by a multidisciplinary clinical and operational work group with review and input from Plan Physicians and medical professionals with durable medical equipment expertise (for example: physical, respiratory, and enterostomal therapists and home health). A multidisciplinary Durable Medical Equipment Formulary Executive Committee is responsible for reviewing and revising the durable medical equipment formulary. Our durable medical equipment formulary is periodically updated to keep pace with changes in medical technology, Medicare guidelines, and clinical practice. To find out whether a particular item is included in our durable medical equipment formulary, please call our Member Service Contact Center. Our formulary guidelines allow you to obtain nonformulary durable medical equipment (equipment not listed on our durable medical equipment formulary for your condition) if the equipment would otherwise be covered and the Medical Group determines that it is Medically Necessary as described in "Medical Group authorization procedure for certain referrals" under "Getting a Referral" in the "How to Obtain Services" section. E O C 1 Page 37
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