Disclosure form and evidence of coverage - Kaiser Permanente ...
Disclosure form and evidence of coverage - Kaiser Permanente ...
Disclosure form and evidence of coverage - Kaiser Permanente ...
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accord with our drug <strong>form</strong>ulary guidelines if they are<br />
administered to you in the Plan Skilled Nursing<br />
Facility by medical personnel<br />
• Durable medical equipment in accord with our<br />
durable medical equipment <strong>form</strong>ulary <strong>and</strong> Medicare<br />
guidelines if Skilled Nursing Facilities ordinarily<br />
furnish the equipment<br />
• Imaging <strong>and</strong> laboratory Services that Skilled Nursing<br />
Facilities ordinarily provide<br />
• Medical social services<br />
• Blood, blood products, <strong>and</strong> their administration<br />
• Medical supplies<br />
• Physical, occupational, <strong>and</strong> speech therapy in accord<br />
with Medicare guidelines<br />
• Respiratory therapy<br />
Services not covered under this "Skilled<br />
Nursing Facility Care" section<br />
Coverage for the following Services is described under<br />
these headings in this "Benefits <strong>and</strong> Cost Sharing"<br />
section:<br />
• Outpatient imaging, laboratory, <strong>and</strong> special<br />
procedures (refer to "Outpatient Imaging, Laboratory,<br />
<strong>and</strong> Special Procedures")<br />
Non–Plan Skilled Nursing Facility care<br />
Generally, you will get your Skilled Nursing Facility<br />
care from Plan Facilities. However, under certain<br />
conditions listed below, you may be able to receive<br />
covered care from a non–Plan facility, if the facility<br />
accepts our Plan's amounts for payment.<br />
• A nursing home or continuing care retirement<br />
community where you were living right before you<br />
went to the hospital (as long as it provides Skilled<br />
Nursing Facility care)<br />
• A Skilled Nursing Facility where your spouse is<br />
living at the time you leave the hospital<br />
Transgender Surgery<br />
We cover genital surgery <strong>and</strong> mastectomy to treat gender<br />
dysphoria if Medical Group authorizes the surgery in<br />
accord with "Medical Group authorization procedure for<br />
certain referrals" under "Getting a Referral" in the "How<br />
to Obtain Services" section.<br />
There is a lifetime maximum <strong>of</strong> $75,000 per Member for<br />
the covered transgender surgery Services. We will<br />
calculate accumulation toward the lifetime maximum by<br />
adding up the Charges for covered transgender surgical<br />
Services (<strong>and</strong> authorized travel <strong>and</strong> lodging), less any<br />
Cost Sharing that you paid for those Services. The<br />
lifetime maximum applies to the following:<br />
• All Services covered under this "Transgender<br />
Surgery" section<br />
• All related travel <strong>and</strong> lodging we cover in accord with<br />
our travel <strong>and</strong> lodging guidelines. (Our travel <strong>and</strong><br />
lodging guidelines are available from our Member<br />
Service Contact Center.)<br />
• Any transgender surgery Services <strong>and</strong> related travel<br />
<strong>and</strong> lodging we covered under any other <strong>evidence</strong> <strong>of</strong><br />
<strong>coverage</strong> <strong>of</strong>fered by your Group<br />
You pay the following for these covered transgender<br />
surgical Services:<br />
• Outpatient consultations, exams, <strong>and</strong> treatment: a<br />
$20 Copayment per visit<br />
• Outpatient surgery: a $100 Copayment per<br />
procedure if it is provided in an outpatient or<br />
ambulatory surgery center or in a hospital operating<br />
room, or if it is provided in any setting <strong>and</strong> a licensed<br />
staff member monitors your vital signs as you regain<br />
sensation after receiving drugs to reduce sensation or<br />
to minimize discomfort. Any other outpatient surgery<br />
is covered at a $20 Copayment per procedure<br />
• Outpatient procedures (other than surgery): a<br />
$100 Copayment per procedure if a licensed staff<br />
member monitors your vital signs as you regain<br />
sensation after receiving drugs to reduce sensation or<br />
to minimize discomfort. All outpatient procedures<br />
that do not require a licensed staff member to monitor<br />
your vital signs as described above are covered at the<br />
Cost Sharing that would otherwise apply for the<br />
procedure in this "Benefits <strong>and</strong> Cost Sharing"<br />
section (for example, radiology procedures that do<br />
not require a licensed staff member to monitor your<br />
vital signs as described above are covered under<br />
"Outpatient Imaging, Laboratory, <strong>and</strong> Special<br />
Procedures")<br />
• Hospital inpatient care (including room <strong>and</strong> board,<br />
drugs, <strong>and</strong> Plan Physician Services): a<br />
$250 Copayment per admission<br />
Services not covered under this "Transgender<br />
Surgery" section<br />
Coverage for the following Services is described under<br />
these headings in this "Benefits <strong>and</strong> Cost Sharing"<br />
section:<br />
• Outpatient prescription drugs (refer to "Outpatient<br />
Prescription Drugs, Supplies, <strong>and</strong> Supplements")<br />
• Outpatient administered drugs (refer to "Outpatient<br />
Care")<br />
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