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

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accord with our drug formulary guidelines if they are administered to you in the Plan Skilled Nursing Facility by medical personnel • Durable medical equipment in accord with our durable medical equipment formulary and Medicare guidelines if Skilled Nursing Facilities ordinarily furnish the equipment • Imaging and laboratory Services that Skilled Nursing Facilities ordinarily provide • Medical social services • Blood, blood products, and their administration • Medical supplies • Physical, occupational, and speech therapy in accord with Medicare guidelines • Respiratory therapy Services not covered under this "Skilled Nursing Facility Care" section Coverage for the following Services is described under these headings in this "Benefits and Cost Sharing" section: • Outpatient imaging, laboratory, and special procedures (refer to "Outpatient Imaging, Laboratory, and Special Procedures") Non–Plan Skilled Nursing Facility care Generally, you will get your Skilled Nursing Facility care from Plan Facilities. However, under certain conditions listed below, you may be able to receive covered care from a non–Plan facility, if the facility accepts our Plan's amounts for payment. • A nursing home or continuing care retirement community where you were living right before you went to the hospital (as long as it provides Skilled Nursing Facility care) • A Skilled Nursing Facility where your spouse is living at the time you leave the hospital Transgender Surgery We cover genital surgery and mastectomy to treat gender dysphoria if Medical Group authorizes the surgery in accord with "Medical Group authorization procedure for certain referrals" under "Getting a Referral" in the "How to Obtain Services" section. There is a lifetime maximum of $75,000 per Member for the covered transgender surgery Services. We will calculate accumulation toward the lifetime maximum by adding up the Charges for covered transgender surgical Services (and authorized travel and lodging), less any Cost Sharing that you paid for those Services. The lifetime maximum applies to the following: • All Services covered under this "Transgender Surgery" section • All related travel and lodging we cover in accord with our travel and lodging guidelines. (Our travel and lodging guidelines are available from our Member Service Contact Center.) • Any transgender surgery Services and related travel and lodging we covered under any other evidence of coverage offered by your Group You pay the following for these covered transgender surgical Services: • 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") • Hospital inpatient care (including room and board, drugs, and Plan Physician Services): a $250 Copayment per admission Services not covered under this "Transgender Surgery" 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") • Outpatient administered drugs (refer to "Outpatient Care") Page 54
Member Service Contact Center: toll free 1-800-443-0815 (TTY users call 711) seven days a week 8 a.m.–8 p.m. • Prosthetics and orthotics (refer to "Prosthetic and Orthotic Devices") • Psychological counseling (refer to "Mental Health Services") • Outpatient imaging and laboratory (refer to "Outpatient Imaging, Laboratory, and Special Procedures") Transgender surgery exclusion • Surgical procedures (other than mastectomy or genital surgery) such as breast augmentation, reduction of the Adam's apple, or facial feminization surgery Transplant Services We cover transplants of organs, tissue, or bone marrow in accord with Medicare guidelines and if the Medical Group provides a written referral for care to a transplant facility as described in "Medical Group authorization procedure for certain referrals" under "Getting a Referral" in the "How to Obtain Services" section. After the referral to a transplant facility, the following applies: • If either the Medical Group or the referral facility determines that you do not satisfy its respective criteria for a transplant, we will only cover Services you receive before that determination is made • Health Plan, Plan Hospitals, the Medical Group, and Plan Physicians are not responsible for finding, furnishing, or ensuring the availability of an organ, tissue, or bone marrow donor • In accord with our guidelines for Services for living transplant donors, we provide certain donation-related Services for a donor, or an individual identified by the Medical Group as a potential donor, whether or not the donor is a Member. These Services must be directly related to a covered transplant for you, which may include certain Services for harvesting the organ, tissue, or bone marrow and for treatment of complications. Our guidelines for donor Services are available by calling our Member Service Contact Center For covered transplant Services that you receive, you will pay the Cost Sharing you would pay if the Services were not related to a transplant. For example, see "Hospital Inpatient Care" in this "Benefits and Cost Sharing" section for the Cost Sharing that applies for hospital inpatient care. We provide or pay for donation-related Services for actual or potential donors (whether or not they are Members) in accord with our guidelines for donor Services at no charge. Services not covered under this "Transplant Services" section Coverage for the following Services is described under these headings in this "Benefits and Cost Sharing" section: • Outpatient imaging and 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") Vision Services We cover the following: • Glaucoma screenings in accord with Medicare guidelines and eye exams for refraction to determine the need for vision correction and to provide a prescription for eyeglass lenses: a $20 Copayment per visit Optical Services We cover the Services described in this "Optical Services" section at Plan Medical Offices or Plan Optical Sales Offices. The date we provide an Allowance toward (or otherwise cover) an item described in this "Optical Services" section is the date on which you order the item. For example, if we last provided an Allowance toward an item you ordered on May 1, 2011, and if we provide an Allowance not more than once every 24 months for that type of item, then we would not provide another Allowance toward that type of item until on or after May 1, 2013. You can use the Allowances under this "Optical Services" section only when you first order an item. If you use part but not all of an Allowance when you first order an item, you cannot use the rest of that Allowance later. E O C 1 Page 55
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Disclosure form and evidence of coverage - Kaiser Permanente ...

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