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

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Your coverage will be subject to the terms of this Evidence of Coverage, including Cost Sharing, but we will not cover Services for any condition other than your totally disabling condition. For Subscribers and adult Dependents, "Totally Disabled" means that, in the judgment of a Medical Group physician, an illness or injury is expected to result in death or has lasted or is expected to last for a continuous period of at least 12 months and makes the person unable to engage in any employment or occupation, even with training, education, and experience. For Dependent children, "Totally Disabled" means that, in the judgment of a Medical Group physician, an illness or injury is expected to result in death or has lasted or is expected to last for a continuous period of at least 12 months and the illness or injury makes the child unable to substantially engage in any of the normal activities of children in good health of like age. To request continuation of coverage for your disabling condition, you must call our Member Service Contact Center within 30 days after the University of California's Agreement with us terminates. Conversion from Group Membership to an Individual Plan After the University of California notifies us to terminate your Group membership, we will send a termination letter to the Subscriber's address of record. The letter will include information about options that may be available to you to remain a Health Plan Member. Kaiser Permanente Conversion Plan If you want to remain a Health Plan Member, one option that may be available is our Senior Advantage Individual Plan. You may be eligible to enroll in our individual plan if you no longer meet the eligibility requirements described under "Who Is Eligible" in the "Premiums, Eligibility, and Enrollment" section. Individual plan coverage begins when your Group coverage ends. The premiums and coverage under our individual plan are different from those under this Evidence of Coverage and will include Medicare Part D prescription drug coverage. However, if you are no longer eligible for Senior Advantage and Group coverage, you may be eligible to convert to our non-Medicare individual plan, called "Kaiser Permanente Individual−Conversion Plan." You may be eligible to enroll in our Individual−Conversion Plan if we receive your enrollment application within 63 days of the date of our termination letter or of your membership termination date (whichever date is later). You may not be eligible to convert if your membership ends for the reasons stated under "Termination for Cause" or "Termination of Agreement" in the "Termination of Membership" section. For information about converting your membership or about other individual plans, call our Member Service Contact Center. Miscellaneous Provisions Administration of Agreement We may adopt reasonable policies, procedures, and interpretations to promote orderly and efficient administration of the University of California's Agreement, including this Evidence of Coverage. Advance directives The California Health Care Decision Law offers several ways for you to control the kind of health care you will receive if you become very ill or unconscious, including the following: • A Power of Attorney for Health Care lets you name someone to make health care decisions for you when you cannot speak for yourself. It also lets you write down your own views on life support and other treatments • Individual health care instructions let you express your wishes about receiving life support and other treatment. You can express these wishes to your doctor and have them documented in your medical chart, or you can put them in writing and have that included in your medical chart To learn more about advance directives, including how to obtain forms, contact the Member Services Department at a Plan Facility. You can also refer to Your Guidebook for more information about advance directives. If you have signed an advance directive, and you believe that a doctor or hospital did not follow the instructions in it, you may file a complaint with the California Department of Managed Care toll free at 1-800-HMO- 2219 (or 1-877-688-9891 for TTY users). Agreement binding on Members By electing coverage or accepting benefits under this Evidence of Coverage, all Members legally capable of contracting, and the legal representatives of all Members Page 96
Member Service Contact Center: toll free 1-800-443-0815 (TTY users call 711) seven days a week 8 a.m.–8 p.m. incapable of contracting, agree to all provisions of this Evidence of Coverage. Amendment of Agreement The University of California's Agreement with us will change periodically. If these changes affect this Evidence of Coverage, the University of California is required to inform you in accord with applicable law and the University of California's Agreement. Applications and statements You must complete any applications, forms, or statements that we request in our normal course of business or as specified in this Evidence of Coverage. Assignment You may not assign this Evidence of Coverage or any of the rights, interests, claims for money due, benefits, or obligations hereunder without our prior written consent. Attorney and advocate fees and expenses In any dispute between a Member and Health Plan, the Medical Group, or Kaiser Foundation Hospitals, each party will bear its own fees and expenses, including attorneys' fees, advocates' fees, and other expenses. Claims review authority We are responsible for determining whether you are entitled to benefits under this Evidence of Coverage and we have the discretionary authority to review and evaluate claims that arise under this Evidence of Coverage. We conduct this evaluation independently by interpreting the provisions of this Evidence of Coverage. We may use medical experts to help us review claims. Governing law Except as preempted by federal law, this Evidence of Coverage will be governed in accord with California law and any provision that is required to be in this Evidence of Coverage by state or federal law shall bind Members and Health Plan whether or not set forth in this Evidence of Coverage. Group and Members not our agents Neither the University of California nor any Member is the agent or representative of Health Plan. Information about new technology assessments Rapidly changing technology affects health care and medicine as much as any other industry. To determine whether a drug or other medical development has longterm benefits, our plan carefully monitors and evaluates new technologies for inclusion as covered benefits. These technologies include medical procedures, medical devices, and new medications. No waiver Our failure to enforce any provision of this Evidence of Coverage will not constitute a waiver of that or any other provision, or impair our right thereafter to require your strict performance of any provision. Nondiscrimination We do not discriminate on the basis of age, race, ethnicity, color, national origin, cultural background, ancestry, language, religion, sex, gender, gender identity, gender expression, sexual orientation, marital status, physical or mental disability, health status, claims experience, medical history, genetic information, evidence of insurability, or geographic location within the Service Area. Notices Our notices to you will be sent to the most recent address we have for the Subscriber. The Subscriber is responsible for notifying us of any change in address. Subscribers who move should call our Member Service Contact Center and Social Security toll free at 1-800-772-1213 (TTY users call 1-800-325-0778) as soon as possible to give us their new address. If a Member does not reside with the Subscriber, he or she should contact our Member Service Contact Center to discuss alternate delivery options. Note: When we tell the University of California about changes to this Evidence of Coverage or provide your Group other information that affects you, the University of California is required to notify the Subscriber within 30 days after receiving the information from us. Notice about Medicare Secondary Payer subrogation rights We have the right and responsibility to collect for covered Medicare services for which Medicare is not the primary payer. According to CMS regulations at 42 CFR sections 422.108 and 423.462, Kaiser Permanente Senior Advantage, as a Medicare Advantage Organization, will exercise the same rights of recovery that the Secretary exercises under CMS regulations in subparts B through D of part 411 of 42 CFR and the rules established in this section supersede any state laws. Other Evidence of Coverage formats You can request a copy of this Evidence of Coverage in an alternate format (Braille, audio, electronic text file, or large print) by calling our Member Service Contact Center. Overpayment recovery We may recover any overpayment we make for Services from anyone who receives such an overpayment or from E O C 1 Page 97
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Disclosure form and evidence of coverage - Kaiser Permanente ...

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