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

often get your care as usual from Plan Providers, and the
other coverage you have will simply help pay for the
care you receive. In other situations, such as benefits that
we don't cover, you may get your care outside of our
Plan directly through your other coverage.
In general, the coverage that pays its share of your bills
first is called the "primary payer." Then the other
company or companies that are involved (called the
"secondary payers") each pay their share of what is left
of your bills. Often your other coverage will settle its
share of payment directly with us and you will not have
to be involved. However, if payment owed to us is sent
directly to you, you are required under Medicare law to
give this payment to us. When you have additional
coverage, whether we pay first or second, or at all,
depends on what type or types of additional coverage
you have and the rules that apply to your situation. Many
of these rules are set by Medicare. Some of them take
into account whether you have a disability or have endstage
renal disease, or how many employees are covered
by an employer's group plan.
If you have additional health coverage, please call our
Member Service Contact Center to find out which rules
apply to your situation, and how payment will be
handled.
Reductions
Employer responsibility
For any Services that the law requires an employer to
provide, we will not pay the employer, and, when we
cover any such Services, we may recover the value of the
Services from the employer.
Government agency responsibility
For any Services that the law requires be provided only
by or received only from a government agency, we will
not pay the government agency, and, when we cover any
such Services, we may recover the value of the Services
from the government agency.
Injuries or illnesses alleged to be caused by
third parties
Third parties who cause you injury or illness (and/or
their insurance companies) usually must pay first before
Medicare or our Plan. Therefore, we are entitled to
pursue these primary payments. If you obtain a judgment
or settlement from or on behalf of a third party who
allegedly caused an injury or illness for which you
received covered Services, you must pay us Charges for
those Services, except that the amount you must pay will
not exceed the maximum amount allowed under
California Civil Code Section 3040. Note: This "Injuries
or illnesses alleged to be caused by third parties" section
does not affect your obligation to pay Cost Sharing for
these Services, but we will credit any such payments
toward the amount you must pay us under this section.
To the extent permitted or required by law, we have the
option of becoming subrogated to all claims, causes of
action, and other rights you may have against a third
party or an insurer, government program, or other source
of coverage for monetary damages, compensation, or
indemnification on account of the injury or illness
allegedly caused by the third party. We will be so
subrogated as of the time we mail or deliver a written
notice of our exercise of this option to you or your
attorney, but we will be subrogated only to the extent of
the total of Charges for the relevant Services.
To secure our rights, we will have a lien on the proceeds
of any judgment or settlement you or we obtain against a
third party. The proceeds of any judgment or settlement
that you or we obtain shall first be applied to satisfy our
lien, regardless of whether the total amount of the
proceeds is less than the actual losses and damages you
incurred.
Within 30 days after submitting or filing a claim or legal
action against a third party, you must send written notice
of the claim or legal action to:
Northern California Region Members:
Healthcare Recoveries, Inc.
Subrogation Mailbox
9390 Bunsen Parkway
Louisville, KY 40220
Southern California Region Members:
The Rawlings Group
Subrogation Mailbox
P.O. Box 2000
LaGrange, KY 40031
In order for us to determine the existence of any rights
we may have and to satisfy those rights, you must
complete and send us all consents, releases,
authorizations, assignments, and other documents,
including lien forms directing your attorney, the third
party, and the third party's liability insurer to pay us
directly. You may not agree to waive, release, or reduce
our rights under this provision without our prior, written
consent.
If your estate, parent, guardian, or conservator asserts a
claim against a third party based on your injury or
illness, your estate, parent, guardian, or conservator and
any settlement or judgment recovered by the estate,
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