HELPFUL INFORMATION ADDED CHOICE TRIPLE OPTION PLANS

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1 HELPFUL INFORMATION ADDED CHOICE TRIPLE OPTION PLANS PLEASE KEEP THIS IMPORTANT INFORMATION WELCOME TO KAISER PERMANENTE With our Added Choice Triple Option Plan, you can choose from three provider options to obtain the health care that best meet your needs. You can select our traditional HMO coverage; visit a physician in one of our preferred provider networks, Mountain Medical Affiliates (MMA) or CCN (outside of Colorado); or seek care from any other licensed health care provider. OPTION 1 In-Plan Services are provided within Kaiser Permanente-owned medical offices. When you choose this option, you ll have lower out-of-pocket costs and you ll enjoy the convenience of receiving most care in one location, the same way our traditional HMO members do. You may see Kaiser Permanente physicians in family practice, internal medicine, pediatrics, and Ob/Gyn without a referral. You may also get referrals to a large number of Kaiser Permanente specialists. OPTION 2 Mountain Medical Affiliates (MMA) / CCN When you choose this option, you may visit a participating physician or hospital from one of Colorado s preferred provider networks, Mountain Medical Affiliates (MMA), or if you re traveling or living outside of Colorado, you may also choose a CCN provider anywhere in the United States. When using an MMA network provider, you ll pay a copayment for most office visits. You ll have a deductible to meet and will pay coinsurance for hospitalization and other services, such as laboratory tests and X-rays. However, for greater convenience and cost savings, you can bring your laboratory and X-ray orders from any licensed physician to a Kaiser Permanente medical office. All test results will be sent to your MMA or CCN provider.

2 OPTION 3 Out-of-Plan For added convenience, you have the option to seek care from any other licensed provider or hospital that is not part of Kaiser Permanente, MMA, or CCN. When doing so, you will make your own financial arrangements with those providers and you ll submit claim forms for reimbursement. Once you have satisfied your calendar-year deductible, you ll pay the remaining percentage, which is called coinsurance. The amount of coinsurance you pay each calendar year is limited to your out-of-pocket maximum. ACCESSING SERVICES IN-PLAN (OPTION 1) Medical office visits At Kaiser Permanente, the choice is yours. You may choose from any of our medical offices, conveniently located throughout the Denver, Boulder, and Longmont areas. In addition, you may see physicians who specialize in internal medicine, family practice, pediatrics, Ob/Gyn, mental health, and chemical dependency, without receiving referrals from your personal physician. Choice is important and that s why you select your own personal physician. Choosing your personal physician is simple. To find out how, please refer to the Member Resource Guide included in your enrollment materials, visit our Web site at kaiserpermanente. org, or call Customer Service at and one of our representatives will be happy to assist you. At Kaiser Permanente, we realize that your time is valuable. That s why each of our medical offices offers X-rays, laboratory, and pharmacy services in one convenient location. The following is a partial list of services are provided to you for the applicable copayment: Doctor appointments Eye exams for glasses Short-term physical, occupational, and speech therapy Allergy tests, injections, and treatment materials Routine laboratory tests and diagnostic X-rays are provided at no charge Alternative medicine and health education classes Kaiser Permanente is committed to helping you to thrive by addressing all your health care needs. We realize no two people, or no two conditions, are exactly the same and that different conditions sometimes call for different approaches. That s why we offer you access to alternative methods of treatment and preventive techniques. Our Centers for Complementary Medicine (CCM) provides you with a variety of alternative treatments with experts in such fields as acupuncture, chiropractic, and massage therapy. CCM also provides classes in mind-body medicine where you can harness the power of your own mind to help you reduce stress and the physical and psychological symptoms of such things as chronic pain, anxiety, and depression. Fees for CCM services are competitive with the market. For more information or to schedule an appointment, please call the Boulder Medical Office at or the Smoky Hill Medical Office at

3 To help you lead a healthier life, Kaiser Permanente also offers a wide range of health education classes on rotating schedules and locations. Classes, which range in cost from free-of-charge to a nominal registration fee, deal with specific topics under a variety of categories including chronic conditions, diabetes, health and wellness, heart health, parenting, social support, stress management, tobacco cessation, women s health, weight management, and fitness. Registration is required for all classes and the deadline for registration is five (5) days before a class begins. For more information on classes, locations, and any applicable registration fees, call Scheduled hospitalization Coverage is provided at the applicable coinsurance level for inpatient hospitalization at Exempla Saint Joseph Hospital, The Children s Hospital, Exempla Good Samaritan Medical Center*, or Boulder Community Hospital*, and Boulder Community Foothills Hospital* when you are admitted by a Kaiser Permanente physician. Coverage includes: Professional services of physicians and health care professionals Operating room X-rays, laboratory tests, and other diagnostic services Intensive care Room and board (semi-private) Prescribed drugs and medicines Blood, blood products, and their administration Short-term physical, occupational, and speech therapy (* As of December 31, 2004 our contract with Boulder Community Hospital and Boulder Community Foothills Hospital will end and we will begin admitting patients to our new plan hospital, Exempla Good Samaritan Medical Center as of January 1, 2005.) Urgent and after-hours care What is an urgent need? An urgent care need is one that requires prompt medical attention, usually within 24 to 48 hours, but is not an emergency life- or limb-threatening medical condition. Examples of urgent care situations include: backache, coughs, earaches, minor injuries, sore throat, upper respiratory symptoms, frequent urination or burning sensation when urinating. We make every effort to schedule a same-day appointment for you with your primary care physician whenever you need urgent care. For daytime appointments, Monday through Friday, call the Appointments and Medical Advice Line at from 7 a.m. to 7 p.m. TTY for the deaf and hard of hearing is The earliest appointments are scheduled at 8:00 a.m., and the latest at 5:45 p.m. We also offer after-hours and weekend care, without an appointment, at some locations for an after-hours copayment that is typically higher than the regular office visit copayment, but less than a visit to an emergency room. Hours and locations for after-hours care are subject to change. Please call at the time of need to confirm current hours and locations for after-hours care. 3

4 Emergency care and emergency hospitalization What is an emergency? A medical emergency is when you reasonably believe that your health is in serious danger when every second counts. A medical emergency includes severe pain, bad injury, a serious illness, or a medical condition that is quickly getting much worse. Examples of emergencies are poisonings, fractures, severe cuts or burns, suspected heart attacks, severe asthma attacks, or severe abdominal pains. In a life- or limb-threatening emergency, please dial 911 or go immediately to the nearest emergency room. If time and safety permit, you can go to Exempla Saint Joseph Hospital, The Children s Hospital, Boulder Community Hospital,* Boulder Community Foothills Hospital,* or Exempla Good Samaritan Medical Center,* where Kaiser Permanente physicians, with immediate access to your medical records, can provide prompt care. In addition, Kaiser Permanente has contracted for emergency care services at Lutheran Medical Center, Swedish Medical Center, and Sky Ridge Medical Center. If you re admitted to one of these contracted emergency care hospitals or to an out-of-plan hospital following an emergency room visit, please call us personally or have someone else do so on your behalf as soon as possible at , so we may assist in coordinating your care and reducing your risk of incurring noncovered inpatient charges. When you are outside the Kaiser Permanente service area or in other circumstances when it is not reasonable to be treated by a Kaiser Permanente provider, costs of urgent and emergency care by an outside provider are covered. (*As of December 31, 2004 our contract with Boulder Community Hospital and Boulder Community Foothills Hospital will end and we will begin admitting patients to our new Plan hospital, Exempla Good Samaritan Medical Center as of January 1, 2005.) Prescriptions and prescription refills Getting a prescription filled is easy. Pharmacies, located in each medical office, also have 24-hour refill telephone numbers and mail-in refill services. You can purchase over-the-counter products there as well. You can also receive your prescriptions by mail, postage free, by calling And for even greater convenience, try ordering refills online at kaiserpermanente.org. Optical You may obtain optical services including exams, custom fittings, frames, and contact lenses at competitive prices from any Kaiser Permanente Optical Department. Routine eye exams for glasses are covered at the applicable copayment. Other optical services are provided at competitive prices. ACCESSING SERVICES OUT-OF-PLAN How Added Choice works (Option 2 and 3) If you choose to see an MMA provider, you will be charged an office visit copayment for your office visit. You will be subject to a deductible and coinsurance for any services billed in addition to the office visit, including laboratory samples sent from the provider s office. Please see laboratory and imaging sections for more information. 4

5 If you choose to see an MMA or a non-affiliated provider, you will reduce your out-of-pocket expenses by bringing requests for services from your physician to a Kaiser Permanente medical office. Added Choice Triple Option is designed to save you money by allowing you to continue to see your non-kaiser Permanente physician, yet take advantage of lower costs with Kaiser Permanente s pharmacy, laboratory, and X-ray services. Prescriptions and prescription refills Prescriptions for medications that are on the Kaiser Permanente Health Plan Drug Formulary may be filled at any Kaiser Permanente pharmacy. You may request refills at pharmacies located at the medical office closest to you. Each pharmacy offers a 24-hour refill phone number and mail-in refill services. You can also receive refills by mail at no extra charge by calling our mail order pharmacy at You may also order refills online at kaiserpermanente.org to be picked up at the medical office pharmacy closest to you. We ll also mail your medications to you at no extra charge, which can save you a trip. If you have questions about Kaiser Permanente s drug formulary or need to transfer existing prescriptions to Kaiser Permanente, please call our Clinical Pharmacy Call Center at Please identify yourself as a Triple Option member when calling. Prescriptions for medications not on the Kaiser Permanente Formulary may be filled at any MedImpact Pharmacy for the applicable PPO copayment. In Colorado, MedImpact Pharmacies can be found at: Long s King Soopers Medicine Shoppes Safeway Walgreens Albertsons City Market Kmart Target Laboratory work You may bring orders for routine laboratory work from your outside provider to any Kaiser Permanente medical office. You may take the order directly to the lab and results will be returned to your doctor s office by fax, telephone, or mail. Imaging You may also take orders for routine X-ray studies to any Kaiser Permanente medical office. Check in at the front desk and then take the order directly to the Radiology Department. A report will be returned to your doctor s office. MRIs, CT, and PET studies are performed for the applicable coinsurance amount and will also apply toward your deductible. Appointments are required for these studies. MRIs, PET, CT, bone density studies, and other studies must be completed at our Franklin Medical Offices and will require an appointment. MRIs ordered by non-kaiser Permanente providers always require precertification. Call After precertification is obtained, ask your provider to call our Referral Line at When the request for referral comes to Kaiser Permanente, we will call you to make an appointment. 5

6 Orders for other studies such as ultrasound, bone density studies, and mammograms also require appointments and referrals. Your provider s office should refer you by calling the Referral Line at A referral will be put on the Kaiser Permanente internal system and a fax will be sent to the proper department. We will send a letter to you verifying the referral and providing a phone number for you to make your appointment. Specialty referrals When you use an MMA or non-preferred provider for your primary care, you may access the Kaiser Permanente system to see a specialist without a referral from a Kaiser Permanente primary care physician. This benefit can often allow you to access treatment at a much lower cost than the deductible/coinsurance benefits of the second and third tiers of the Added Choice Triple Option Plan. You will receive your care from a board-certified specialist at Kaiser Permanente. Ask your MMA or non-preferred provider to call the Referral Line at Your provider will leave the information concerning your needs and the referral will be put on our system. The appointment request will be faxed to the appropriate department and a letter will be sent to you verifying the referral and providing a telephone number to call and make an appointment. Scheduled hospitalization You may be admitted to any hospital your provider chooses. MMA hospitals will be less expensive than nonaffiliated hospitals. Precertification is required. For precertification, your doctor must call If a Kaiser Permanente provider admits you to a Kaiser Permanente hospital, your in-plan HMO hospital benefits will apply. Precertification for MMA and out-of-network procedures Precertification is required for: Hospital admission, including pre-admission testing Any procedure performed at a non-kaiser Permanente outpatient surgery facility (colonoscopy, sigmoidoscopy, and other diagnostic tests included) Prenatal care (call within the first trimester, if possible) MRIs this test cannot be performed at Kaiser Permanente until a precertification is obtained. Skilled nursing facility admission Your benefit will be reduced by 20 percent if precertification is not obtained. 6

7 OTHER INFORMATION Certain services are covered only when you seek care inside Kaiser Permanente. These include: Durable Medical Equipment (DME), including oxygen. Your provider may manage your care, but you must obtain your durable medical supplies (including oxygen) from our contracted vendors. For information call Customer Service at Dialysis is performed at Presbyterian-St.Luke s. Skilled nursing facility care must be arranged through Kaiser Permanente. Emergency claims are paid by Kaiser Permanente. CLAIMS You or your provider should mail claims to: Kaiser Permanente Added Choice Claims P.O. Box Denver, CO To check on a claim, call the Claims Center at EMERGENCY CARE AND EMERGENCY HOSPITALIZATIONS In the event of a life- or limb-threatening emergency, call 911 or go to the nearest emergency room. If time and safety permit, you can go to the nearest plan hospital or contracted emergency care hospital. Plan hospitals include Exempla St. Joseph Hospital, The Children s Hospital, Boulder Community Hospital*, and Boulder Community Foothills Hospital*, as well as Exempla Good Samaritan Medical Center*. Contracted emergency care hospitals include Lutheran Medical Center, Sky Ridge Medical Center, and Swedish Medical Center. Consult the Member Resource Guide for hospital locations. Regardless of where an emergency occurs, it is always covered under HMO benefits. Check your Health Plan Description Form for HMO emergency room copayments, ambulance copayments, and hospital copayments. Your emergency room copayment is waived if you are admitted as an inpatient. (* As of December 31, 2004 our contract with Boulder Community Hospital and Boulder Community Foothills Hospital will end and we will begin admitting patients to our new plan hospital, Exempla Good Samaritan Medical Center as of January 1, 2005.) 7

8 IMPORTANT TELEPHONE NUMBERS FOR ADDED CHOICE MEMBERS (Whenever you call Kaiser Permanente, please let us know that you are a Triple Option member.) Emergency Claims address: Kaiser Permanente Added Choice Claims P.O. Box Denver, CO To check on a claim Kaiser Permanente Customer Service (8 a.m. 5 p.m., Monday Friday) TTY Kaiser Permanente Appointments/Medical Advice Line (7 a.m. 7 p.m., Monday Friday) TTY (After hours: answering service available) Clinical Pharmacy Call Center (8 a.m. 6 p.m., Monday Friday) TTY (8 a.m. noon, Saturday) Point-of-service internal referral This number is for use by your out-of-plan provider to refer you to a Kaiser Permanente specialist or for a diagnostic test requiring an appointment. Precertification for out-of-plan services Mountain Medical Affiliates (MMA) If you live or are traveling inside Colorado and need to locate a provider, contact MMA toll-free or visit their Web site at mmanetwork.com 24 hours a day. CCN If you live or are traveling outside of Colorado and need to locate a provider, contact CCN toll-free or visit their Web site at ccnusa.com 24 hours a day. Relay Colorado When a TTY number is not specifically listed for a service, provider, or location, please use your TTY equipment to contact Relay Colorado and provide them with the number you want to reach. 8

9 LIMITATIONS FOR IN-PLAN BENEFITS The following is a partial list of limitations under this plan: Prescribed diabetic supplies dispensed at in-plan pharmacies are provided at the applicable copayment Insulin pumps and insulin pump supplies are provided for type 1 diabetes, at the applicable copayment, when clinical guidelines are met. Pumps and supplies must be obtained from a Kaiser Permanente designated provider Prosthetic arms and legs are covered as a base benefit for the applicable copayment Transplants will be covered in accordance with the Evidence of Coverage only if they are deemed to be medically necessary by a Kaiser Permanente physician and meet the clinical requirements of the facility where they are performed Bone marrow transplants associated with high dose chemotherapy for solid tissue tumors, other than autologous stem cell and peripheral stem cell support, for germ cell tumors and neuroblastoma in children are not covered Bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease, Wiskott-Aldrich syndrome and other bone marrow transplants are covered Pancreas alone transplants are limited to patients without renal problems Injectable hormone for treatment of prostate cancer is provided with a 20 percent charge Covered infertility services including laboratory tests and X-rays for infertility or artificial conception are provided with a 50 percent charge Oxygen for use in conjunction with DME is provided upon payment of 20 percent of member charges with no annual benefit maximum Oxygen will be covered when traveling outside the service area. To qualify for coverage, members must have a pre-existing oxygen order and must use the Kaiser Permanente designated vendor Services for long-term rehabilitation are not covered; however, short-term (up to two months or 20 visits per condition per contract year) physical, occupational, and speech therapy are covered in an appropriate inpatient or outpatient setting as determined by a Kaiser Permanente physician Speech therapy not medically necessary is not covered, except for treatment for speech impairments due to injury or illness Occupational therapy is limited to treatment to achieve and maintain improved self-care and other customary activities of daily living Medically necessary physical, occupational and speech therapy for the care and treatment of congenital defects and birth abnormalities are covered for children up to age 5 Chemical dependency rehabilitation services in a specialized facility are not covered; however, evaluation and referral for such services are covered Nonpreferred drugs are not covered unless a non-preferred drug has been specifically prescribed and authorized through the non-preferred drug process Genetic testing is not covered unless determined to be medically appropriate and meets criteria established by the Medical Group. Kaiser Permanente will use its best efforts to provide or arrange for your health care needs in the event of unusual circumstances that delay or render impractical the provision of Services, such as major disaster, epidemic, war, riot, civil insurrection, disability of a large share of personnel at a Plan Facility, complete or partial destruction of facilities, and labor disputes not involving Health Plan, Kaiser Foundation Hospitals, or Medical Group. However, Health Plan, Kaiser Foundation Hospitals, Medical Group, and Medical Group Physicians will not have any liability for any delay or failure in providing covered Services. In the case of a labor dispute involving Health Plan, Hospitals or Medical Group, we may postpone care until the dispute is resolved if delaying your care is safe and will not result in harmful health consequences. 9

10 EXCLUSIONS FOR IN-PLAN BENEFITS The following is a partial list of limitations under this plan: Conditions covered by Workers Compensation or Employer s Liability Conditions arising from military service Custodial or homemaker care Care more appropriately provided in a Plan or Skilled Nursing Facility Intermediate level care Mental health services on court order, to be used in court proceedings or as a condition of parole or probation Mental health services for organic brain syndromes Evaluations for any purpose other than mental health treatment Residential care Cosmetic services intended primarily to change or maintain your appearance Dental services and dental X-rays including dental services following injury to teeth; dental appliances; dental implants; orthodontia; dental services associated with surgery on the jawbone and radiation therapy Physical examinations for insurance, employment, licensing, participation in employee programs, disability or on court order or required for parole or probation Routine foot care that is not medically necessary Alternative medical services unless purchased as a supplemental benefit Services to reverse voluntary surgically induced infertility All services related to sexual reassignment surgery All services and supplies (other than artificial insemination) related to conception by artificial means, prescription drugs related to such services, and donor semen and donor eggs used for such services, such as, but not limited to: in vitro fertilization, ovum transplants, gamete intra fallopian transfer and zygote intra fallopian transfer. The exclusions apply to fertile as well as infertile individuals or couples Surrogacy arrangements Experimental or investigational services All services for eye surgery to correct refractive defects Artificial aids and corrective appliances Eye examinations for cosmetic contact lenses Transportation other than a licensed ambulance Maintenance physical, occupational and speech therapy Non-human and artificial organs and their implantation Conditions alleged to be caused by another party for which amounts are collected from or on behalf of a third party Services provided or arranged by criminal justice institutions unless covered as Out-of-Plan emergency services Any health care procedure not generally and customarily available in the service area Special education and related counseling and therapy for learning deficiencies and behavioral problems All services necessary for an excluded service that would otherwise be covered. LIMITATIONS AND EXCLUSIONS FOR OUT-OF-PLAN BENEFITS No payment will be made under any benefit of the group policy for expenses incurred in connection with the following, unless specifically stated otherwise in the group policy. Charges in excess of the maximum allowable charge Charges for non-emergency care in an emergency care setting Weekend admission charges for non-emergency care hospital services Confinement, treatment, services, or supplies which are not medically necessary Injury or sickness for which the covered person has or had a right to payment under any workers compensation or similar law Injury or sickness for which the law requires the covered person to maintain alternative insurance, bonding, or third party coverage Injury or sickness arising out of or in the course of past or current work for pay, profit, or gain, unless workers compensation or benefits under similar law are not required or available Injury or sickness contracted while on duty with any military, naval, or air force of any country or international organization Treatment, services, or supplies provided by the covered person; the covered person s spouse; or a person who resides in the covered person s home Confinement, treatment, services or supplies received where care is provided at government expense Dental care and dental X- 10

11 rays; dental appliances; orthodontia; and dental services resulting from medical treatment, including surgery on the jawbone and radiation treatment Cosmetic services, plastic surgery or other services that are indicated primarily to improve the covered person s appearance and will not result in significant improvement in physical function Sex transformation, or surgery or treatment related to sexual dysfunction Non-prescription drugs or medicines; vitamins, nutrients and food supplements even if prescribed or administered by a physician Any treatment, procedure, drug, or equipment or device which KPIC determines to be experimental or investigational Special education and related counseling or therapy, or care for learning deficiencies or behavioral problems Services or supplies rendered for the treatment of obesity Treatment of craniomandibular and temporomandibular joint disorders Confinement, treatment, services or supplies that are required: only by a court of law; or only for insurance, travel, employment, school, camp, government licensing, or similar purposes Personal comfort items such as telephones, radios, televisions, or grooming devices Custodial care Care in accordance with the attending physician s orders Hearing exams, hearing therapy, or hearing aids Services of a private duty nurse in a hospital, skilled nursing facility or other licensed medical facility Outpatient private duty nursing services Acupuncture; biofeedback; massage therapy; or hypnotherapy Health education Medical social services Living expenses or transportation, except as provided for under covered services Second surgical opinions, unless required under the Medical Review Program Routine adult physicals Eye refractions, orthoptics, glasses, contact lenses or the fitting of glasses or contact lenses; radial keratotomy or any other surgical procedure to treat a refractive error of the eye, unless the treatment is medically necessary Reversal of sterilization Services provided in the home other than covered services provided through a Home Health Agency or related to Hospice Care services Durable medical equipment Braces and prosthetics Acquisition cost of any organ or bodily element Transplants Treatment for infertility Maintenance therapy for rehabilitation Treatment, services and supplies in connection with inpatient or outpatient alcoholism Treatment, services and supplies in connection with inpatient mental illness Treatment and services covered under Medicare or other governmental programs, except Medicaid Treatment and services covered under any state or federal worker s compensation, employers liability or occupational disease law, or any motor vehicle no-fault law Treatment and services provided in a government hospital. continued on back 11

12 This is not a federally qualified health benefit plan. ARBITRATION: Except for Small Claims Court cases and claims arising under Section 502(a)(1)(B) of the Employee Retirement Income Security Act (ERISA) or covered under the Colorado Health Care Availability Act, section , any dispute between Members, their heirs, or other associated parties on the one hand and Health Plan, its health care providers, or other associated parties on the other hand, for alleged violation of any duty arising from your membership in Health Plan, must be decided through binding arbitration. This includes claims for premises liability, or relating to the coverage for, or delivery of, services or times, regardless of legal theory. Both sides give up all rights to a jury or court trial, and both sides are responsible for certain costs associated with binding arbitration. Colorado State law requires an Access Plan describing Kaiser Permanente s network of providers and services be available. To obtain a copy, call Customer Service at Colorado State law requires carriers to make available a Colorado Health Plan Description Form, which is intended to facilitate comparison of health plans. The form must be provided automatically within three (3) business days to a potential policyholder who has expressed interest in a particular plan. The carrier also must provide the form, upon oral or written request, within three (3) business days, to any person who is interested in coverage under or who is covered by a health benefit plan of the carrier. Point-of-Service benefits are underwritten by the Kaiser Permanente Insurance Company, a subsidiary of Kaiser Foundation Health Plan. This is only a summary. It does not fully describe you health care coverage. For complete details on your coverage which is effective January 1, 2005, including exclusions and plan terms, please refer to your Evidence of Coverage and the Kaiser Permanente Insurance Company (KPIC) Group Policy and Certificate of Insurance. The Evidence of Coverage and KPIC Group Policy are the legally binding documents between Kaiser Foundation Health Plan of Colorado, KPIC and its members. In the event of ambiguity and/or conflict between this summary and/or the Evidence of Coverage and KPIC Group Policy, the Evidence of Coverage and the KPIC Group Policy shall control. 05-D-HITOP 2004, Kaiser Permanente Recycled Paper