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

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Hospice Care ...................................................................................................................................................................39 Infertility Services ...........................................................................................................................................................41 Mental Health Services ...................................................................................................................................................41 Ostomy and Urological Supplies .....................................................................................................................................42 Outpatient Imaging, Laboratory, and Special Procedures ...............................................................................................42 Outpatient Prescription Drugs, Supplies, and Supplements ............................................................................................43 Prosthetic and Orthotic Devices ......................................................................................................................................51 Reconstructive Surgery ...................................................................................................................................................52 Religious Nonmedical Health Care Institution Services .................................................................................................52 Routine Services Associated with Clinical Trials ...........................................................................................................53 Skilled Nursing Facility Care ..........................................................................................................................................53 Transgender Surgery .......................................................................................................................................................54 Transplant Services .........................................................................................................................................................55 Vision Services................................................................................................................................................................55 Exclusions, Limitations, Coordination of Benefits, and Reductions ..................................................................................... 57 Exclusions .......................................................................................................................................................................57 Limitations ......................................................................................................................................................................59 Coordination of Benefits .................................................................................................................................................59 Reductions .......................................................................................................................................................................60 Requests for Payment ............................................................................................................................................................ 62 Requests for Payment of Covered Services or Part D drugs ...........................................................................................62 How to Ask Us to Pay You Back or to Pay a Bill You Have Received ..........................................................................63 We Will Consider Your Request for Payment and Say Yes or No ..................................................................................64 Other Situations in Which You Should Save Your Receipts and Send Copies to Us .....................................................64 Coverage Decisions, Appeals, and Complaints ..................................................................................................................... 65 What to Do if You Have a Problem or Concern .............................................................................................................65 You Can Get Help from Government Organizations That Are Not Connected with Us ................................................65 To Deal with Your Problem, Which Process Should You Use? .....................................................................................66 A Guide to the Basics of Coverage Decisions and Appeals ............................................................................................66 Your Medical Care: How to Ask for a Coverage Decision or Make an Appeal .............................................................67 Your Part D Prescription Drugs: How to Ask for a Coverage Decision or Make an Appeal ..........................................73 How to Ask Us to Cover a Longer Inpatient Hospital Stay if You Think the Doctor Is Discharging You Too Soon ....78 How to Ask Us to Keep Covering Certain Medical Services if You Think Your Coverage Is Ending Too Soon ..........83 Taking Your Appeal to Level 3 and Beyond...................................................................................................................87 How to Make a Complaint About Quality of Care, Waiting Times, Customer Service, or Other Concerns ..................88 You can also tell Medicare about your complaint ...........................................................................................................90 Additional Review ..........................................................................................................................................................90 Binding Arbitration .........................................................................................................................................................90 Termination of Membership .................................................................................................................................................. 93 Termination Due to Loss of Eligibility ...........................................................................................................................93 Termination of Agreement ..............................................................................................................................................93 Disenrolling from Senior Advantage ..............................................................................................................................93 Termination of Contract with the Centers for Medicare & Medicaid Services ...............................................................94 Termination for Cause .....................................................................................................................................................94 Termination for Nonpayment of Premiums ....................................................................................................................95 Termination of a Product or all Products ........................................................................................................................95 Payments after Termination ............................................................................................................................................95 Review of Membership Termination ..............................................................................................................................95 Continuation of Membership ................................................................................................................................................ 95 Continuation of Group Coverage ....................................................................................................................................95 Conversion from Group Membership to an Individual Plan ...........................................................................................96 Miscellaneous Provisions ...................................................................................................................................................... 96 Page 2
Important Phone Numbers and Resources ............................................................................................................................ 98 Kaiser Permanente Senior Advantage .............................................................................................................................98 Medicare........................................................................................................................................................................100 State Health Insurance Assistance Program ..................................................................................................................101 Quality Improvement Organization...............................................................................................................................101 Social Security ..............................................................................................................................................................102 Medicaid........................................................................................................................................................................102 Railroad Retirement Board............................................................................................................................................103 Group Insurance or Other Health Insurance from an Employer....................................................................................103 Evidence of Coverage Addendum ....................................................................................................................................... 103 Eligibility ......................................................................................................................................................................103 Enrollment .....................................................................................................................................................................106 Termination of Coverage ..............................................................................................................................................109 Page 3
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Multi-language Interpreter Services
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Disclosure form and evidence of coverage - Kaiser Permanente ...

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