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Home My WebLink AboutAgreement A-23-657 with Kaiser Permanente.pdf Agreement No. 23-657 Kaiser Permanente Health Plan Contract Printing Instruction Sheet Contract: 6043 34-1.34 Group Size:L Contract Type:HPREN Document Release Type: FULL Date: 10/21/2023 Region:NCR Contract Party Distribution Date Copies Name and Address PURCHASER 10/21/2023 1 HOLLIS MAGILL DIRECTOR OF HUMAN RESOURCES SJVIA-CO OF FRESNO(SAN JOAQUIN VALLEY INSU 2220 TULARE ST FL 14 FRESNO,CA 93721-2122 Contract Party Distribution Date Copies Name and Address CONSULTANT 10/21/2023 1 PETER P MEILAK HUB INTERNATIONAL INSURANCE SERVICES INC 4695 MACARTHUR CT STE 600 NEWPORT BEACH,CA 92660-1861 Agreement No. 23-657 0411 KAISER PERMAN EWE. October 20,2023 HOLLIS MAGILL,DIRECTOR OF HUMAN RESOURCES COUNTY OF FRESNO,RETIREE 2220 TULARE ST FL 14 FRESNO,CA 93721-2122 Re:Renewal Group Agreement for Group ID#604334 Renewal effective date: 01/01/2024 Dear HOLLIS MAGILL, We value being your health care partner,and look forward to continuing to work with you to provide your subscribers with quality care well into the future. Enclosed,please find the new Group Agreement between COUNTY OF FRESNO,RETIREE and Kaiser Foundation Health Plan,Inc.,Northern California Region,for the contract period January 1,2024,through December 31,2024.For a summary of the most important changes,see the enclosed 2024 Notice.Review these documents carefully and keep the Group Agreement for your records.Also,be sure to sign and return the copy of the Agreement Signature Page provided with the Group Agreement. If your group doesn't want to renew the Group Agreement,you'll need to give us advance written notice,as described under "Termination on Notice"in the"Termination of Agreement"section of your Group Agreement. Your new monthly rate See the"Calculating Premiums"section of the enclosed Group Agreement for your new premium rate,which will start January 1,2024. Your premium rates may have been affected by a variety of factors,including: • The periodic adjustment of base rates,resulting from changes in the costs of delivering care • Changes in your group's size or demographics • Changes to the risk characteristics of your group • Your group's actual claims experience,depending on your group size If you have any questions or need enrollment or enrollee materials for your subscribers,please contact your Kaiser Permanente account manager,Dorrenda Thomas,at 559-448-3753. If you receive the Group Agreement or enrollment materials in electronic form,you are not authorized to modify or alter in any way the text or the formatting of these documents.If you post the electronic documents on your intranet site,you must do so in such a way so as to permit your subscribers to download and print a complete and accurate copy of the materials.Please refer to the Group Agreement for details about these requirements. Thank you for continuing to offer Kaiser Permanente to your subscribers. COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: I Version:34 Sincerely, 1 Thomas A.Curtin Jr. Senior Vice President,Commercial Group Lines of Business cc: PETER P MEILAK COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: I Version:34 Agreement Signature Page Acceptance of Agreement Group acknowledges acceptance of this Agreement by signing the Signature Page and returning it to Health Plan.If Group does not return it to Health Plan,Group will be deemed as having accepted this Agreement if Group pays Health Plan any amount toward Premiums. Group may not change this Agreement by adding or deleting words,and any such addition or deletion is void.Health Plan might not respond to any changes or comments submitted on or with this Signature Page.Group may not construe Health Plan's lack of response to any submitted changes or comments to imply acceptance.If Group wishes to change anything in this Agreement,Group must contact its Health Plan account manager.Health Plan will issue a new Agreement or amendment if Health Plan and Group agree on any changes. Binding Arbitration As more fully set forth in the arbitration provision in the applicable Evidence of Coverage,disputes between Members, their heirs,relatives,or associated parties(on the one hand)and Health Plan,Kaiser Permanente health care providers,or other associated parties(on the other hand)for alleged violation of any duty arising out of or related to this Agreement, including any claim for medical or hospital malpractice(a claim that medical services or items were unnecessary or unauthorized or were improperly,negligently,or incompetently rendered),for premises liability,or relating to the coverage for,or delivery of,services or items pursuant to this Agreement,irrespective of legal theory, must be decided by binding arbitration and not by lawsuit or resort to court process,except as applicable law provides for judicial review of arbitration proceedings.Members enrolled under this Agreement thus give up their right to a court or jury trial,and instead accept the use of binding arbitration as specified in the applicable Evidence of Coverage except that the following types of claims are not subject to binding arbitration: • Claims within the jurisdiction of the Small Claims Court • Claims subject to a Medicare appeals procedure as applicable to Kaiser Permanente Senior Advantage Members • Claims that cannot be subject to binding arbitration under governing law Signatures Kaiser Foundation Health Plan,Inc.,Northern California Region "-1-L a. 9�k- — Thomas A.Curtin Jr. Authorized officer Senior Vice President,Commercial Group Lines of Business October 20,2023 COUNTY OF FRESNO,RETIREE uth ri td Gt up officer signature Sal Quintero,Chairman �-2- —l 02 -a oa 3 Print name and title Date Please keep this copy of the signature page with your Agreement.An extra copy is included in your contract package to sign and return: • By mail:Kaiser Permanente,California Service Center,P.O.Box 23448,San Diego,CA 92193-3448. • By fax: 1-855-355-5334 ATTEST: BERNICE E.SEIDEL Clerk of the Board of Supervisors County of Fresno, of alifornia By Deputy COUNTY OF FRESNO,RETIREE Group 1D:604334 Contract: I Version:34 Effective: 1/1/24-12/31/24 Date:October 20,2023 Helpful information about disclosures that Group must make The Group is required to provide certain disclosures about its group health plan to employees and dependents: • As described in your Group Agreement,Group must notify subscribers and dependents about changes to coverage and provide an Evidence of Coverage(EOC). • If Group's group health plan is subject to Affordable Care Act(ACA)mandates,Group must provide any required ACA notices. • If Group's group health plan is subject to ERISA,Group's plan administrator must provide a Summary Plan Description.In addition,Groups may have additional reporting and disclosure obligations under ERISA.These additional requirements are the Group's responsibility.For more information on your group health plan's obligations under ERISA,we recommend that you seek the advice of your own legal counsel.You may also find general information at dol.gov/agencies/ebsa.A handy Reporting and Disclosure Guide for Employee Benefit Plans is also available on that website. In addition,the EOCs that are part of your Group Agreement provide certain notices as described in this document. The information in this document applies to commercial group coverage offered by Health Plan in its Northern and Southern California Regions(it does not apply to Medicare coverage,the Federal Employees Health Benefit Plan,or self-funded coverage). This document is not legal advice. Group should consult its own legal counsel for specific guidance related to its group health plan requirements. Disclosures required by the ACA The EOCs include the following notices required by the ACA: • Grandfathered status: In EOCs for grandfathered coverage,a notice of grandfathered status is provided in the"Cost Share Summary"section. • Choice of provider.A notice about designating a Plan Primary Care Physician(including a pediatrician for a child)is provided under"Your Personal Plan Physician"in the"How to Obtain Services"section. • Access to Plan obstetricians and gynecologists.A notice that prior authorization is not required to receive care from obstetricians and gynecologists is provided under"Getting a Referral"in the"How to Obtain Services"section. • Claims procedure.The procedure for post-service claims is explained in the"Post-Service Claims and Appeals" section.The procedure for all other requests for payment and services is explained in the"Dispute Resolution"section. The"Dispute Resolution"section says that binding arbitration is not required when governing law prevents the use of binding arbitration. • Nondiscrimination.A nondiscrimination notice and language assistance taglines are provided with the EOC. SPD Disclosures required by ERISA The Employee Retirement Income Security Act(ERISA)is a federal law that sets minimum standards for employee welfare benefit plans,which includes group health plans,and is established by private employers and employee organizations(for example,unions).The plan administrator of an employee welfare benefit plan is responsible for development and distribution of a Summary Plan Description (SPD)to plan participants and beneficiaries.The plan administrator is an employee or designee of the employer or union plan sponsor.Health Plan underwrites group coverage that plan sponsors make available,but Health Plan is neither the"ERISA plan"nor the"plan administrator"of the group health plan. The plan administrator of a group health plan may satisfy the Group's ERISA disclosure obligations by incorporating the EOC into the Group's SPD by reference.However,the EOC by itself does not satisfy the disclosure requirements under ERISA.If a disclosure required under ERISA is not in the EOC,or if the plan administrator chooses to not incorporate the EOC in the SPD,the plan administrator must provide the disclosure in the Group's SPD.If there are discrepancies between COUNTY OF FRESNO,RETIREE Purchaser ID:604334 Contract: 1 Version:34 Page 1 the description of Kaiser Permanente HMO-covered group health plan benefits appearing in the Group's SPD and those reflected in the EOC, the benefit description appearing in Kaiser Permanente's EOC will control. The chart below identifies certain key ERISA disclosure requirements and whether those disclosures are in the EOC.It is intended for use as a reference tool;however,it is the plan administrator's responsibility to verify that the Group's SPD satisfies all ERISA disclosure requirements.For more information about ERISA,visit the Department of Labor website at dol.2ov/agencies/ebsa. SPD Disclosure Requirement Evidence of Coverage(EOC) Eligibility The EOC does not explain in detail Group's eligibility requirements(a summary of Health Plan eligibility requirements appears in the"Premiums,Eligibility,and Enrollment"section).The plan administrator must include Group's specific eligibility information in the Group's SPD. Special enrollment,including: The EOC explains special enrollment rights in"How to Enroll and When Coverage • Special enrollment due to new Begins"in the"Premiums,Eligibility and Enrollment"section.The plan dependents administrator is required to document that plan participants and beneficiaries have • Special enrollment due to loss of been informed of these rights. other coverage The EOC does not describe the procedures governing qualified medical child support • Special enrollment due to order(QMCSO)determinations or state that plan participants and beneficiaries can eligibility for premium assistance obtain,without charge,a copy of those procedures from the plan administrator.The • Special enrollment due to court plan administrator should include this information in the Group's SPD. or administrative order • Special enrollment due to reemployment after military service • Otherspecial enrollment events Michelle's law(student status and Michelle's law establishes that dependent children who are under the dependent child eligibility) age limit of the group health plan eligibility rules meet the eligibility age requirement whether or not they are attending school.Therefore,Health Plan provides a notice about student leaves of absence only in EOCs where the dependent child age limit is higher for a student than the non-student.If the student age limit is higher,the notice appears in the"Who Is Eligible"section under"Eligibility as a Dependent." COUNTY OF FRESNO,RETIREE Purchaser ID:604334 Contract: 1 Version:34 Page 2 SPD Disclosure Requirement Evidence of Coverage(EOC) Description of coverage,including: Under ERISA,a Group's SPD may provide only a general description of plan • Cost sharing benefits as long as the SPD references a detailed schedule of benefits and incorporates it by reference.That detailed schedule of benefits can be the Health Plan • Exclusions and limitations EOC,which offers a clear description of the benefits and the rules for obtaining those • Prior authorization requirements benefits.If the plan administrator chooses to incorporate the EOC by reference into • Provider network the Group's SPD,the Group may satisfy the ERISA coverage disclosure requirements by including the following text without changes as the introduction to • Claims procedure the benefit chart in the Group's SPD: "This benefit chart provides summary information only.It does not fully describe your benefit coverage.For details on your benefit coverage,please refer to your Kaiser Foundation Health Plan,Inc. (Health Plan)Evidence of Coverage.The Health Plan Evidence of Coverage is the binding document between Health Plan and its members. As a condition of coverage,a Health Plan physician must determine that any requested services and items are medically necessary to prevent,diagnose,or treat a medical condition.Generally,requested services and items must be provided, prescribed,authorized,or directed by a Health Plan provider.Except as otherwise noted in the Health Plan Evidence of Coverage,you must receive the requested services and items from a Health Plan-designated provider inside the Health Plan Service Area in which you are enrolled. For details on the benefit and claims review and adjudication procedures,please refer to the Health Plan Evidence of Coverage." Newborns' and Mothers'Health Health Plan covers hospital lengths of stay following childbirth for mothers and Protection Act(Newborn Act) newborns in accord with the Newborn Act.To assist the plan administrator in complying with the ERISA notice requirement,a Newborn Act notice is included under"ERISA notices"in the"Miscellaneous Provisions"section of the EOC. Women's Health and Cancer Rights Health Plan covers mastectomy and reconstructive surgery and related services as Act(WHCRA) required by WHCRA. To assist the plan administrator in complying with the ERISA notice requirement,a WHCRA notice is included under"ERISA notices"in the "Miscellaneous Provisions"section of the EOC. ERISA rights The EOC does not include a statement of ERISA rights.The plan administrator should include this information in the Group's SPD. COBRA The EOC states that continuation health care coverage under federal COBRA or under state continuation coverage laws may be available following termination of group health coverage.If your employee benefit plan offers COBRA continuation coverage,your plan administrator is responsible for administration of this coverage (for example,your plan administrator is responsible for providing all notices related to continuation coverage,eligibility,and participation). COUNTY OF FRESNO,RETIREE Purchaser ID:604334 Contract: 1 Version:34 Page 3 SPD Disclosure Requirement Evidence of Coverage(EOC) Information about the employee Health Plan does not collect this information from groups and cannot include it in the benefit plan and how it is EOC. The plan administrator must include this information in the Group's SPD. administered,such as: • Name of the plan • Name and address of the entity maintaining the plan • Employer identification number, plan number,type of plan,and how it is administered • The plan administrator's authority to terminate the plan or amend benefits,circumstances that may trigger ineligibility, denial,or reduction of benefits, and rights upon termination of plan or amendment of benefits COUNTY OF FRESNO,RETIREE Purchaser ID:604334 Contract: 1 Version:34 Page 4 2024 Group Agreement Summary of Changes and Clarifications Notice Effective January 1, 2024, through December 31, 2024 Kaiser Foundation Health Plan,Inc.,Northern California Region("Health Plan")is renewing your Group's Group Agreement("Agreement'),including the Evidence of Coverage("EOC')documents,effective January 1,2024(your Group's"Anniversary Date")by sending COUNTY OF FRESNO,RETIREE("Group")this "Group Agreement Summary of Changes and Clarifications Notice"("Notice')in accord with the"Term of Agreement and Renewal"section of your Agreement.This Notice includes a summary of the changes and clarifications that will be effective when your Agreement is renewed on the Anniversary Date,unless a different effective date is stated.Unless otherwise indicated,the changes and clarifications described here apply to each type of coverage that will be effective upon renewal of your Agreement.If you have not already received your renewal contract("2024 Agreement"),please contact your broker or Health Plan account manager to obtain a copy.If your Group does not wish to renew your Agreement,your Group must give us advance written notice in accord with"Termination on Notice"in the"Termination of Agreement"section of your Agreement. In certain circumstances,this summary may also include changes that we made to your Agreement during the 2023 plan year through an amendment.This summary does not include minor changes and clarifications that Health Plan is making to improve the readability of the Agreement or any changes we are making at your Group's request.In addition to the changes and clarifications listed below,Health Plan will also make any changes required by law or by any state or federal agency. The"Calculating Premiums"section of this Notice includes the Premiums that will be applicable to your Agreement upon renewal. Note: Some capitalized terms in this Notice have special meaning.Please see the"Definitions"section of the applicable EOC document in your Agreement for terms you should know.In this Notice"Medicare EOCs"means Kaiser Permanente Senior Advantage EOCs,and"non-Medicare EOCs"means all EOCs other than Senior Advantage EOCs. 2024 Agreement If you have not already received your 2024 Agreement and your Group wants to make changes to benefits or Cost Share, please request them before your Anniversary Date.You will then receive your 2024 Agreement shortly after you tell your Health Plan account manager about changes your Group wants to make.If you don't wish to make changes to benefits or Cost Share,you don't need to do anything to renew your Agreement.We will provide your Group with its 2024 Agreement within 60 days after your Anniversary Date.If you would like to receive it sooner,please contact your Health Plan account manager. We will provide the 2024 Agreement to your Group online unless you have asked us to mail your Group a printed 2024 Agreement.When we provide the 2024 Agreement online,we will mail your Group a notice to let you know when the 2024 Agreement is available to view and download. Please keep in mind that unless your Group notifies us to make changes to benefits or Cost Share,your 2024 Agreement, including the EOC documents,will reflect the same benefits and Cost Share information as your current Agreement, subject to the changes described in this Notice. Global Changes to the Agreement, including EOC documents 988 Crisis Services (AB 988) For consistency with state law effective January 1,2023,we have updated the "Services from Non-Plan Providers" section under "Behavioral Health Treatment for Autism Spectrum Disorder," "Mental Health Services,"and "Substance Use Disorder Treatment"in non-Medicare EOCs to explain that we cover behavioral health crisis services provided to an enrollee by a 988 center, mobile crisis team, or other provider of behavioral health crisis services, regardless of whether the service is provided in-network or out-of-network, without prior authorization. COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:34 Date:October 20,2023 Page I Abortion and Abortion-Related Services (SB 245) In accordance with state law effective January 1,2023, Cost Share for abortion and abortion-related Services is no charge in all plans(except that these Services are subject to the Plan Deductible in HSA-Qualified High Deductible Health Plans).In conjunction with this change, in non-Medicare EOCs we have restructured the "Family Planning Services" section, and changed the name of this section to "Reproductive Health Services." CARE Courts (SB 1338) For consistency with state law effective January 1,2023,we have added a new section titled "CARE Plans"to the "Cost Share Summary"section of non-Medicare EOCs to explain that we cover health care services required under a court- approved Community Assistance,Recovery, and Empowerment("CARE')plan at no cost and without prior authorization, with the exception ofprescription drugs. Contraceptive Equity(SB 523) For consistency with state law effective January 1,2023,we have expanded contraceptive coverage to all enrollees.In accord with this change, we have made the following changes: • Removed the limitation that contraceptives are `for women"from the "Contraceptive drugs and devices"table in the "Cost Share Summary"section of non-Medicare EOCs • Added language clarifying how enrollees may obtain a 365-day supply of contraceptives under `Day supply limit"in the "Outpatient Prescription Drugs, Supplies, and Supplements"section of non-Medicare EOCs For consistency with state law effective January 1,2024: • We have removed the verbiage "when prescribed by a Plan Provider"from the "Contraceptive Drugs and Devices" table in the "Cost Share Summary"section of non-Medicare EOCs,for consistency with other tables in the Cost Share Summary.Drugs still require a prescription, as specified in the "Outpatient Prescription Drugs, Supplies, and Supplements"section, except for over-the-counter contraceptives • Sterilization Services for Members assigned male at birth will be covered at no charge for non-grandfathered plans Contraceptive Gel In accord with ACA FAQ part 51,we added a disclosure to the "Contraceptive drugs and devices"table in the "Cost Share Summary"section of non-Medicare EOCs that we cover contraceptive gel, which is a new type of contraceptive. Home-Delivered Meals in Medicare EOCs Due to a change in policy, if your plan includes meals delivered to the home immediately following discharge from a network hospital as an inpatient due to congestive heart failure, home-delivered meals will no longer be covered. If your plan includes meals delivered to the home immediately following discharge from a network hospital or skilled nursing facility as an inpatient, a referral will no longer be required. Medicare Part D Outpatient Prescription Drug Coverage In accordance with the Centers for Medicare&Medicaid Services requirements, in Medicare EOCs with Part D coverage, the Senior Advantage Medicare Part D Catastrophic Coverage Stage threshold is increasing from$7,400 to $8,000 for calendar year 2024.In addition, the Part D Cost Sharing in the Catastrophic Stage is decreasing to$0. If your drug plan includes a Coverage Gap Stage, the Initial Coverage Stage threshold is increasing from$4,660 to$5,030 for calendar year 2024. Mental Health Services and Substance Use Disorder Treatment Cost Share for Certain Plans To meet Mental Health Parity and Addiction Equity Act("MHPAEA')requirements, Cost Share for the following services will be "no charge,"subject to the Plan Deductible(if applicable)for certain non-Medicare plans: • Behavioral health treatment for autism spectrum disorder • Partial hospitalization and other intensive psychiatric treatment programs under "Mental health Services" COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:34 Date:October 20,2023 Page 2 • Intensive outpatient and day-treatment programs under "Substance Use Disorder Treatment" The impacted plans have Plan ID 16320 or 12696(p16320 or p12696). You can find your plan's Plan ID on the back of the cover page of your EOC. No Surprises Act We have made the following changes to non-Medicare EOCs for the purpose of compliance with the federal No Surprises Act: • Throughout EOCs, we have added the term "independent freestanding emergency department,"and used more general language to refer to the facilities at which post-stabilization care may be provided • Under `Definitions,"we have updated the definition of"Charges"to include the recognized amount under the No Surprises Act • Under `Definitions,"we have updated the definition of"Emergency Services"to include post-stabilization care that is considered emergency care under federal law • Under `Definitions,"we have updated the definition of"Post-Stabilization Care"by moving a portion of the text previously printing under "Post-Stabilization Care"in the "Emergency Services and Urgent Care"section into this definition • Under `Post-Stabilization Care"in the "Emergency Services and Urgent Care"section, we have explained when post- stabilization care may be considered emergency care, and that a member may consent to waive balance billing protections under the No Surprises Act • Under `Payment and Reimbursement"in the "Emergency Services and Urgent Care"section, we have deleted the word "Emergency"to align with currentpolicy. This policy also covers Post-Stabilization Care and Out-of-Area Urgent Care as described earlier in the paragraph Post-Stabilization Care To reflect a new arrangement with Cigna Payer Solutions,under "Post-Stabilization Care"in the `Emergency and Urgent Care"section of the EOC, we have revised language to describe the circumstances under which Cigna Payer Solutions is responsible for authorizing any necessary post-stabilization care.In accord with this change, we have also added two new defined terms to the "Definitions"section of non-Medicare EOCs: "Cigna PPO Network"and "Kaiser Permanente State." Reproductive Health Equity(AB 2134) For consistency with state law effective January 1,2023,under "Outpatient prescription drugs, supplies and supplements exclusions"and "Reproductive health Services exclusions"in religious employer non-Medicare EOCs that do not include coverage for contraception, we have added a notice stating that additional services may be available through the California Reproductive Health Equity Program. Silver&Fit®Healthy Aging and Exercise Program Premium Fitness Network Due to a change in policy,if your plan includes the Silver&Fit®Healthy Aging and Exercise Program,effective January 1,2024, we have added an expanded network of select fitness centers that are not in the Silver&Fit standard fitness network.Members will have access to these select fitness centers and studio choices in addition to the standard network fitness centers.Initiation fees may be applicable at some select fitness centers in this expanded network. Global Clarifications to the Agreement, including EOC documents Authorized Officer Under"Notices"in large group Agreements,and on the Agreement signature page in all Agreements,we have updated the authorized officer who signs Agreements for our California regions to Thomas A. Curtin Jr.In conjunction with this change,we have also updated the address for Group to send notices to Health Plan in large group Agreements. COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:34 Date:October 20,2023 Page 3 Deductibles and Out-of-Pocket Maximums In the"Cost Share Summary"section of non-Medicare EOCs,we have made the following change for clarity: • When we provide an allowance for supplemental hearing aids or eyewear,the Cost Share Summary will say that those services don't apply to the out-of-pocket maximum because there is never any out-of-pocket cost for covered Services • When pediatric eyewear is covered at no charge,the Cost Share Summary will say that those services don't apply to the out-of-pocket maximum because there is never any out-of-pocket cost for covered Services Drug Tiers We have revised the description of drug coverage for clarity.In the"Cost Share Summary"section of non-Medicare EOCs, we now refer to the tiers as"Tier 1,""Tier 2,"and"Tier 4"to align with how tiers are presented in the drug formulary.We have revised the definition of these tiers under"About the drug formulary"in the"Outpatient Drugs,Supplies,and Supplements"section for consistency with the descriptions used in the drug formulary.Also in that section,we have revised the"Day supply limit"and"About the drug formulary"sections to align with similar disclosures in the drug formulary. Gender Inclusivity Throughout EOCs,we have made several changes for the purpose of gender inclusivity,including the following: • Changed the term"breast pump"to"milk pump"and changed"breastfeeding supplies"to"lactation supplies" • Changed sterilization language to reference gender assigned at birth • Eliminated other unnecessary gendered references These changes are for clarity and do not have an impact on the scope of services that are covered or the people who may obtain services. Infertility Definition In the"Definitions"section of EOCs,we have added the defined term"Infertility."This definition replaces the definition that previously appeared under"Diagnosis and treatment of infertility"in the"Fertility Services"section.This is a clarification to EOC language only and does not affect coverage under the plan. Insufficient Funds Fee Under"Premiums"in the"Premiums,Eligibility,and Enrollment"section of EOCs where retirees pay premiums directly to Kaiser Permanente,and under"Cal-COBRA enrollment and Premiums"in the"Continuation of Group Coverage"section of other EOCs,we have removed the exact dollar amounts charged for returned checks and insufficient funds.Additionally, some billing departments do not impose this fee,so we have changed"will"to"may"in these sections.If the billing fee applies,it will be disclosed on the monthly bill. Newborn Coverage Under"If you have a baby"in the"Who is Eligible"section of EOCs,we have removed language stating that the automatic coverage period for a newborn would be terminated if the newborn was enrolled in another plan,to align with operational practice.Enrollment in another plan would not affect the 31-day period of automatic coverage for a baby.This is a clarification to EOC language only and does not reflect a change in practice. Nonduplication Agreement We have added a new section to Group Agreements entitled"Nonduplication Agreement"which outlines the responsibilities we have agreed to undertake for the purpose of complying with the federal regulations related to Transparency in Coverage,Prescription Drug and Health Care Cost reporting,and the No Surprises Act.A group may satisfy its obligations with respect to certain reporting and other transparency activities by entering into a written agreement with a group health plan to perform such activities. POS Contract Option Under"Calculating Premiums"in Agreements for large group coverage,we have defined"POS Plan contract option"for clarity. COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:34 Date:October 20,2023 Page 4 Premium Due Date Under"Cal-COBRA enrollment and Premiums"and"Termination for nonpayment of Cal-COBRA premiums"in group EOCs,we have clarified that premium payments for the upcoming month of coverage are due on the last day of the preceding month. Premium Payments In the"Definitions,""Premiums,Eligibility,and Enrollment,""Termination for Nonpayment of Premiums,"and "Payments after Termination"sections of Medicare EOCs,we have revised specific references about who pays the premiums,which can vary depending on the arrangement with Group. Reductions Under"Injuries or illnesses alleged to be caused by other parties"in the"Reductions"section of EOCs,we have clarified the sources from we may obtain judgment or settlement proceeds to secure our right to reimbursement for Services provided when another party allegedly caused an injury or illness.This is a clarification to EOC language only and does not reflect a change in practice. Telehealth Visits (AB 457) For consistency with state law effective January 1,2022,under"Telehealth Visits"in the"Benefits"section of non- Medicare EOCs,we have clarified that Members are not required to use Telehealth Visits and may choose to receive in- person services instead.We have also clarified that if a Member visits a Plan Provider that offers Services exclusively through a telehealth technology platform and has no physical location at which they can receive Services,they may access their medical record of the Telehealth Visit and,unless they object,such information will be added to their Health Plan electronic medical record and shared with their Primary Care Physician. Travel and Lodging We have moved the"Travel and lodging for certain referrals"section of EOCs from the"Getting a Referral"section into a separate section,and changed the heading to"Travel and Lodging for Certain Services."This is because some services that qualify for travel and lodging do not require a referral.Additionally,we have added a bullet point to the list of examples of when we may arrange or provide reimbursement for certain travel and lodging expenses that reads"If you are outside of California and you need an abortion on an emergency or urgent basis,and the abortion can't be obtained in a timely manner due to a near total or total ban on health care providers' ability to provide such Services."These changes do not constitute changes in policy,but clarifications in the EOC. Weight Loss Aids We have updated the heading"Oral nutrition"in the"Exclusions"section to read"Oral nutrition and weight loss aids." This paragraph was revised for clarity only;weight loss aids were already listed in this exclusion.Weight loss aids are weight loss programs and do not include weight loss drugs. Calculating Premiums To calculate the amount of Full Premiums that apply to a Family(a Subscriber and all of their Dependents): 1. If this Agreement includes more than one contract option,determine the coverage(EOCs and contract options)that apply to each Member in the Family(for example,Traditional Plan and any Ancillary Coverage). 2. Determine the family role type and Medicare status of each Member(for family role types,please see the"Definitions" section of the EOC for the definition of Subscriber,Dependent,and Spouse). 3. Identify the Premiums for each Member for each EOC and contract option(including contract options issued through a separate contract)based on the family role type and Medicare status of each Member: • Premiums for coverage issued under this Agreement appear in the Premium tables below. • If this Agreement includes a POS Plan contract option(a contract option with one tier underwritten by Health Plan and two tiers underwritten by Kaiser Permanente Insurance Company),the amounts shown below for the POS Plan (for Large Groups)product includes premiums for the Health Plan and Kaiser Permanente Insurance Company portions of Group's POS Plan coverage,and Group submits payment for this coverage as part of Full Premium. COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:34 Date:October 20,2023 Page 5 • If Ancillary Coverage has been issued under a separate contract and Premiums for that coverage are not listed in the Premium tables below,refer to that contract for Premiums. This Ancillary Coverage is part of the contract options selected by Group,and Group submits payment for this Ancillary Coverage as part of Full Premium. 4. Add the amounts of Premiums for each Member together to arrive at the total,Full Premiums required for the Family. Monthly Premiums for Kaiser Permanente Traditional HMO Plan — EOC # 1 TRADITIONAL PLAN HIGH-HIGH OPTION Members under age 65 who are not eligible for Medicare Family role type Premiums Subscriber $1,765.40 Spouse $1,482.94 1 st child without Spouse $953.32 1st child with Spouse $918.00 Each additional Dependent $0.00 Members under age 65 who are eligible for or have Medicare Part A only Family role type Premiums Subscriber $1,765.40 Spouse $1,482.94 1 st child without Spouse $953.32 1st child with Spouse $918.00 Each additional Dependent $0.00 Members under age 65 who are eligible for or have Medicare Part B only Family role type Premiums Subscriber $1,765.40 Spouse $1,482.94 1 st child without Spouse $953.32 1st child with Spouse $918.00 Each additional Dependent $0.00 Members under age 65 who are eligible for or have Medicare Parts A&B Family role type Premiums Subscriber $1,765.40 Spouse $1,482.94 l st child without Spouse $953.32 1st child with Spouse $918.00 Each additional Dependent $0.00 Members under age 65 who are enrolled in another carrier's Medicare Risk product Family role type Premiums Subscriber $1,846.31 Spouse $1,846.31 1st child without Spouse $1,846.31 1 st child with Spouse $1,846.31 Each additional Dependent $1,846.31 COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: I Version:34 Date:October 20,2023 Page 6 Members under age 65 when Medicare is secondary Family role type Premiums Subscriber $1,765.40 Spouse $1,482.94 1st child without Spouse $953.32 1st child with Spouse $918.00 Each additional Dependent $0.00 Members age 65 and over whose Medicare eligibility is unknown Family role type Premiums Subscriber $1,846.31 Spouse $1,846.31 1 st child without Spouse $1,846.31 1st child with Spouse $1,846.31 Each additional Dependent $1,846.31 Members age 65 and over who are eligible for or have Medicare Part A only Family role type Premiums Subscriber $1,435.66 Spouse $1,435.66 1st child without Spouse $1,435.66 1st child with Spouse $1,435.66 Each additional Dependent $1,435.66 Members age 65 and over who are eligible for or have Medicare Part B only Family role type Premiums Subscriber $1,846.31 Spouse $1,846.31 1st child without Spouse $1,846.31 1 st child with Spouse $1,846.31 Each additional Dependent $1,846.31 Members age 65 and over who are eligible for or have Medicare Parts A&B Family role type Premiums Subscriber $1,435.66 Spouse $1,435.66 1st child without Spouse $1,435.66 1 st child with Spouse $1,435.66 Each additional Dependent $1,435.66 Members age 65 and over who are enrolled in another carrier's Medicare Risk product Family role type Premiums Subscriber $1,846.31 Spouse $1,846.31 1st child without Spouse $1,846.31 1st child with Spouse $1,846.31 Each additional Dependent $1,846.31 COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: I Version:34 Date:October 20,2023 Page 7 Members age 65 and over when Medicare is secondary Family role type Premiums Subscriber $1,765.40 Spouse $1,482.94 1st child without Spouse $953.32 1st child with Spouse $918.00 Each additional Dependent $0.00 Note: Members who are"eligible for"Medicare Part A or B are those who would qualify for Medicare Part A or B coverage if they applied for it. Members who"have"Medicare Part A or B are those who have been granted Medicare Part A or B coverage.Medicare Part A provides inpatient coverage and Part B provides outpatient coverage. Monthly Premiums for Kaiser Permanente Senior Advantage (HMO) with Part D — EOC #2 SENIOR ADVANTAGE HIGH-HIGH OPTION Family role type Medicare Parts A&B Medicare Part B only Subscriber $316.17 $626.17 1 st Dependent $316.17 $626.17 2nd Dependent $316.17 $626.17 Each additional Dependent $316.17 $626.17 Monthly Premiums for American Specialty Health Plans Chiropractic Plan — EOC #3 CHIROPRACTIC BENEFIT-HIGH OPTION Family role type Premiums Subscriber $1.83 Spouse $1.54 1 st child without Spouse $0.99 1 st child with Spouse $0.95 Monthly Premiums for Kaiser Permanente Senior Advantage (HMO) with Part D — EOC #4 SENIOR ADVANTAGE-LOW OPTION Family role type Medicare Parts A&B Medicare Part B only Subscriber $250.46 $560.46 1st Dependent $250.46 $560.46 2nd Dependent $250.46 $560.46 Each additional Dependent $250.46 $560.46 Monthly Premiums for Kaiser Permanente Traditional HMO Plan — EOC # 5 TRADITIONAL PLAN-LOW OPTION Members under age 65 who are not eligible for Medicare Family role type Premiums Subscriber $1,765.40 COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: I Version:34 Date:October 20,2023 Page 8 Family role type Premiums Spouse $1,482.94 1st child without Spouse $953.32 1st child with Spouse $918.00 Each additional Dependent $0.00 Members under age 65 who are eligible for or have Medicare Part A only Family role type Premiums Subscriber $1,765.40 Spouse $1,482.94 1 st child without Spouse $953.32 1st child with Spouse $918.00 Each additional Dependent $0.00 Members under age 65 who are eligible for or have Medicare Part B only Family role type Premiums Subscriber $1,765.40 Spouse $1,482.94 1 st child without Spouse $953.32 1 st child with Spouse $918.00 Each additional Dependent $0.00 Members under age 65 who are eligible for or have Medicare Parts A&B Family role type Premiums Subscriber $1,765.40 Spouse $1,482.94 1st child without Spouse $953.32 1 st child with Spouse $918.00 Each additional Dependent $0.00 Members under age 65 who are enrolled in another carrier's Medicare Risk product Family role type Premiums Subscriber $1,846.31 Spouse $1,846.31 1st child without Spouse $1,846.31 1 st child with Spouse $1,846.31 Each additional Dependent $1,846.31 Members under age 65 when Medicare is secondary Family role type Premiums Subscriber $1,765.40 Spouse $1,482.94 1st child without Spouse $953.32 1 st child with Spouse $918.00 Each additional Dependent $0.00 Members age 65 and over whose Medicare eligibility is unknown Family role type Premiums Subscriber $1,846.31 COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: I Version:34 Date:October 20,2023 Page 9 Family role type Premiums Spouse $1,846.31 1st child without Spouse $1,846.31 1st child with Spouse $1,846.31 Each additional Dependent $1,846.31 Members age 65 and over who are eligible for or have Medicare Part A only Family role type Premiums Subscriber $1,435.66 Spouse $1,435.66 1 st child without Spouse $1,435.66 1st child with Spouse $1,435.66 Each additional Dependent $1,435.66 Members age 65 and over who are eligible for or have Medicare Part B only Family role type Premiums Subscriber $1,846.31 Spouse $1,846.31 1 st child without Spouse $1,846.31 1st child with Spouse $1,846.31 Each additional Dependent $1,846.31 Members age 65 and over who are eligible for or have Medicare Parts A&B Family role type Premiums Subscriber $1,435.66 Spouse $1,435.66 1st child without Spouse $1,435.66 1 st child with Spouse $1,435.66 Each additional Dependent $1,435.66 Members age 65 and over who are enrolled in another carrier's Medicare Risk product Family role type Premiums Subscriber $1,846.31 Spouse $1,846.31 1st child without Spouse $1,846.31 1 st child with Spouse $1,846.31 Each additional Dependent $1,846.31 Members age 65 and over when Medicare is secondary Family role type Premiums Subscriber $1,765.40 Spouse $1,482.94 1st child without Spouse $953.32 1 st child with Spouse $918.00 Each additional Dependent $0.00 Note: Members who are"eligible for"Medicare Part A or B are those who would qualify for Medicare Part A or B coverage if they applied for it.Members who"have"Medicare Part A or B are those who have been granted Medicare Part A or B coverage.Medicare Part A provides inpatient coverage and Part B provides outpatient coverage. COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: I Version:34 Date:October 20,2023 Page 10 Monthly Premiums for Chiropractic Services and Silver&Fit® Healthy Aging and Exercise Program — EOC # 7 SLVRFIT CHIRO NCR-HIGH OPTION Family role type Premiums Subscriber $1.83 Spouse $1.54 1 st child without Spouse $0.99 1st child with Spouse $0.95 Monthly Premiums for Chiropractic Services and Silver&Fit® Healthy Aging and Exercise Program — EOC # 8 NCR SLVRFIT CHIRO-LOW OPTION Family role type Premiums Subscriber $1.83 Spouse $1.54 1 st child without Spouse $0.99 1st child with Spouse $0.95 Monthly Premiums for American Specialty Health Plans Chiropractic Plan — EOC #9 HMO CHIRO ACN NCR-LOW OPTION Family role type Premiums Subscriber $1.83 Spouse $1.54 1st child without Spouse $0.99 1 st child with Spouse $0.95 COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: I Version:34 Date:October 20,2023 Page I I Enrollment Unit Chart M Contract name: COUNTY OF FRESNO,RETIREE Group ID: 604334 Contract: 1 The charts below describe how the coverage your Group has purchased(called contract options)are organized into administrative groupings(called enrollment units)for the purposes of enrollment and billing.Please keep this document handy for future reference as the information it contains will be helpful when reporting membership changes. An Evidence of Coverage(EOC)for each Health Plan coverage that your Group has purchased is incorporated into the enclosed Group Agreement(the EOC number is the same as the contract option number).If your Group has purchased non- Health Plan coverage(such as dental coverage),the carrier(s)for the applicable coverage will send its agreement to your Group under separate cover. Contract option:A unique contract option name and number exists for each coverage option that you offer to your Members.For example,if you offer the same benefits to all of your Members,but have different eligibility rules for different segments of your membership,you will have a separate contract option for each coverage option. Enrollment unit:An enrollment unit is a grouping of contract options for a specific segment of your Member population for enrollment and billing purposes.If there are contract options only available to a specific segment of your Member population,then there will be a distinct enrollment unit for that segment.If your Member population is billed separately, there will be a separate enrollment unit(or billing unit)for each segment.Note:An enrollment unit may also be referred to as a subgroup. The following are the enrollment units associated with this contract: Enrollment unit number: 0 Enrollment unit name: COUNTY OF FRESNO,RETIREE HI Billing contact: Brittany Simmons Contract Option Product name Contract option name I Kaiser Permanente Traditional HMO Plan TRADITIONAL PLAN HIGH-HIGH OPTION 2 Kaiser Permanente Senior Advantage SENIOR ADVANTAGE HIGH-HIGH (HMO)with Part D OPTION 3 American Specialty Health Plans Chiropractic CHIROPRACTIC BENEFIT-HIGH OPTION Plan 7 Chiropractic Services and Silver&Fit®Healthy SLVRFIT CHIRO NCR-HIGH OPTION Aging and Exercise Program Enrollment unit number: 1 Enrollment unit name: COUNTY OF FRESNO,RETIRE LOW Billing contact:Brittany Simmons Contract Option Product name Contract option name 4 Kaiser Permanente Senior Advantage SENIOR ADVANTAGE-LOW OPTION (HMO)with Part D 5 Kaiser Permanente Traditional HMO Plan TRADITIONAL PLAN-LOW OPTION 8 Chiropractic Services and Silver&Fit®Healthy NCR SLVRFIT CHIRO-LOW OPTION Aging and Exercise Program 9 American Specialty Health Plans Chiropractic HMO CHIRO ACN NCR-LOW OPTION Plan COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Date:October 20,2023 Page 1 Enrollment unit number: 8500 Enrollment unit name: COUNTY OF FRESNO,RETIREE/LIS REFUNDS Billing contact:Brittany Simmons Contract Option Product name Contract option name I Kaiser Permanente Traditional HMO Plan TRADITIONAL PLAN HIGH-HIGH OPTION 2 Kaiser Permanente Senior Advantage SENIOR ADVANTAGE HIGH-HIGH (HMO)with Part D OPTION 3 American Specialty Health Plans Chiropractic CHIROPRACTIC BENEFIT-HIGH OPTION Plan 7 Chiropractic Services and Silver&Fit®Healthy SLVRFIT CHIRO NCR-HIGH OPTION Aging and Exercise Program COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Date:October 20,2023 Page 2 �1Ai% KAISER PERMANEWE® Kaiser Foundation Health Plan, Inc. Northern California Region A nonprofit corporation Group Agreement for COUNTY OF FRESNO, RETIREE Group ID: 604334 Contract: 1 Version: 34 January 1,2024,through December 31, 2024 TABLE OF CONTENTS Introduction............................................................................................................................................................................I Health Plan and Other Ancillary Products.........................................................................................................................I Term of Agreement and Renewal...........................................................................................................................................1 Termof Agreement.............................................................................................................................................................I Renewal..............................................................................................................................................................................2 Amendmentof Agreement......................................................................................................................................................2 Amendments Effective on your Group's Anniversary Date..............................................................................................2 Amendments Related to Government Approval................................................................................................................2 Amendment Due to Medicare Changes..............................................................................................................................2 Amendment Due to Tax or Other Charges.........................................................................................................................2 OtherAmendments.............................................................................................................................................................3 Acceptanceof Amendments...............................................................................................................................................3 Terminationof Agreement......................................................................................................................................................3 Terminationon Notice........................................................................................................................................................3 Termination Due to Nonacceptance of Amendments........................................................................................................4 Terminationfor Nonpayment.............................................................................................................................................4 Termination for Fraud or Intentionally Furnishing Incorrect or Incomplete Information.................................................4 Termination for Violation of Contribution or Participation Requirements........................................................................5 Termination for Discontinuance of a Product or all Products within a Market.................................................................5 Contribution and Participation Requirements........................................................................................................................5 MiscellaneousProvisions.......................................................................................................................................................6 Assignment.........................................................................................................................................................................6 AttorneyFees and Costs.....................................................................................................................................................6 Confidential Information about Health Plan or its Affiliates.............................................................................................6 ContractProviders..............................................................................................................................................................7 Delegationof Claims Review.............................................................................................................................................7 EnrollmentApplication Requirements...............................................................................................................................7 Grandfathered Health Plan Coverage.................................................................................................................................7 GoverningLaw...................................................................................................................................................................8 NonduplicationAgreement................................................................................................................................................8 MemberInformation..........................................................................................................................................................8 NoWaiver..........................................................................................................................................................................9 Notices................................................................................................................................................................................9 OpenEnrollment................................................................................................................................................................9 Other Group coverage that covers Essential Health Benefits..........................................................................................10 Reporting Membership Changes and Retroactivity.........................................................................................................10 Representation Regarding Waiting Periods.....................................................................................................................11 Rightto Examine Records................................................................................................................................................I I Social Security and Tax Identification Numbers.............................................................................................................11 Premiums..............................................................................................................................................................................I I Due Date and Payment of Premiums...............................................................................................................................11 NewMembers..................................................................................................................................................................11 MembershipTermination.................................................................................................................................................12 PremiumRebates..............................................................................................................................................................12 Medicare...........................................................................................................................................................................12 Subscriber Contributions for Medicare Part C and Part D Coverage...............................................................................13 CalculatingPremiums......................................................................................................................................................14 Monthly Premiums for Kaiser Permanente Traditional HMO Plan—EOC# 1.............................................................14 Monthly Premiums for Kaiser Permanente Senior Advantage(HMO)with Part D—EOC#2....................................16 Monthly Premiums for American Specialty Health Plans Chiropractic Plan—EOC#3..............................................17 Monthly Premiums for Kaiser Permanente Senior Advantage(HMO)with Part D—EOC#4....................................17 Monthly Premiums for Kaiser Permanente Traditional HMO Plan—EOC#5.............................................................17 Monthly Premiums for Chiropractic Services and Silver&Fit®Healthy Aging and Exercise Program—EOC#7.....19 Monthly Premiums for Chiropractic Services and Silver&Fit®Healthy Aging and Exercise Program—EOC#8.....20 Monthly Premiums for American Specialty Health Plans Chiropractic Plan—EOC#9..............................................20 AgreementSignature Page....................................................................................................................................................21 Acceptanceof Agreement.................................................................................................................................................21 BindingArbitration..........................................................................................................................................................21 Signatures.........................................................................................................................................................................21 Introduction This Group Agreement(Agreement),including the Evidence of Coverage(EOC)and other documents listed below under "Health Plan and Other Ancillary Products,"the group application that Group submitted to Health Plan,and any amendments to any of them,all of which are incorporated into this Agreement by reference,constitute the contract between Kaiser Foundation Health Plan,Inc.,(Health Plan)and COUNTY OF FRESNO,RETIREE(Group). If Group has applied for Ancillary Coverage through Health Plan,provided under a separate contract,it is the intent of Group and Health Plan that coverage under this Agreement and those other contract(s)be treated as one package of benefits for the purposes of term,renewal,termination and payment of Premiums. In consideration of timely payment of Premium,Health Plan will provide or arrange for covered Services to Members in accord with the documents listed below under"Health Plan and Other Ancillary Products." Health Plan and Other Ancillary Products Health Plan products, including Ancillary Coverage offered by Health Plan Product name Contract option name for product EOC# Kaiser Permanente Traditional HMO Plan TRADITIONAL PLAN HIGH-HIGH OPTION 1 Kaiser Permanente Senior Advantage(HMO)with Part D SENIOR ADVANTAGE HIGH-HIGH 2 OPTION American Specialty Health Plans Chiropractic Plan CHIROPRACTIC BENEFIT-HIGH OPTION 3 Kaiser Permanente Senior Advantage(HMO)with Part D SENIOR ADVANTAGE-LOW OPTION 4 Kaiser Permanente Traditional HMO Plan TRADITIONAL PLAN-LOW OPTION 5 Chiropractic Services and Silver&Fit®Healthy Aging and SLVRFIT CHIRO NCR-HIGH OPTION 7 Exercise Program Chiropractic Services and Silver&Fit®Healthy Aging and NCR SLVRFIT CHIRO-LOW OPTION 8 Exercise Program American Specialty Health Plans Chiropractic Plan HMO CHIRO ACN NCR-LOW OPTION 9 Pediatric dental coverage Not applicable Other Ancillary Coverage Not applicable In this Agreement, some capitalized terms have special meaning;please see the"Definitions"section in the EOC documents for definitions of terms that are used in EOC documents and this Agreement. Term of Agreement and Renewal Term of Agreement Unless terminated as set forth in the"Termination of Agreement'section,this Agreement is effective from January 1,2024, through December 31,2024. COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:34 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 1 Renewal This Agreement does not automatically renew.If Group complies with all of the terms of this Agreement,Health Plan will provide prior written notice of any offer to renew the Agreement,in a timely manner consistent with applicable state and federal requirements,by doing one of the following: • Providing Group with a new Group Agreement to become effective immediately after termination of this Agreement • Extending the term of this Agreement and making other changes pursuant to"Amendments Effective on your Group's Anniversary Date"in the"Amendment of Agreement"section • Sending Group a renewal notice,which will include a summary of changes to this Agreement that will become effective immediately after termination of this Agreement.The new Group Agreement will incorporate the changes summarized in the renewal notice.Health Plan will send Group the new Group Agreement after Group confirms it wants to make additional changes or 60 days after Group's Anniversary Date,if Group does not confirm If Group does not want to renew the Agreement,Group must give Health Plan written notice as described under "Termination on Notice"or"Termination due to Nonacceptance of Amendments"in the"Termination of Agreement" section. Note:Your Group's Anniversary Date is January 1. Amendment of Agreement Amendments Effective on your Group's Anniversary Date Upon 60 days prior written notice to Group,Health Plan may extend the term of this Agreement and make other changes by amending this Agreement effective January 1 (the Anniversary Date). Amendments Related to Government Approval If Health Plan notified Group that Health Plan had not received all necessary governmental approvals related to this Agreement,Health Plan may amend this Agreement by giving written notice to Group after receiving all necessary governmental approvals.Any such government-approved provisions go into effect on January 1,2024(unless the government requires a later effective date). Amendment Due to Medicare Changes Health Plan contracts on a calendar year basis with the Centers for Medicare&Medicaid Services(CMS)to offer Kaiser Permanente Senior Advantage.Health Plan may amend this Agreement to change any Kaiser Permanente Senior Advantage EOCs and Premiums effective January 1,2025 (unless the federal government requires or allows a different effective date). The amendment may include an increase or decrease in Premiums and benefits(including Member Cost Sharing and any Medicare Part D coverage level thresholds).Health Plan will give Group written notice of any such amendment. In addition,Health Plan may amend this Agreement at any time by giving written notice to Group,in order to increase any benefits of any Medicare product approved by the Centers for Medicare&Medicaid Services(CMS). Amendment Due to Tax or Other Charges If a government agency or other taxing authority imposes or increases a tax or other charge(other than a tax on or measured by net income)upon Health Plan or Plan Providers(or any of their activities),then upon 60 days prior written notice, Health Plan may increase Group's Premiums to include Group's share of the new or increased tax or charge. Group's share COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:34 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 2 will be determined by dividing the number of Members enrolled through Group by the total number of members enrolled in Health Plan's Northern California Region. Other Amendments Health Plan may amend this Agreement at any time by giving written notice to Group,in order to address any law or regulatory requirement,which may include an increase in Premiums to reflect an increase in costs to Health Plan or Plan Providers(Health Plan will give Group 60 days prior written notice of any increase in Premiums or reduction in benefits). Acceptance of Amendments All amendments are deemed accepted by Group unless Group gives Health Plan written notice of nonacceptance within 15 days after the date of Health Plan's amendment notice,in which case this Agreement will terminate pursuant to "Termination due to Nonacceptance of Amendments"in the"Termination of Agreement"section. Termination of Agreement J This Agreement will terminate under any of the conditions listed below.All rights to benefits under this Agreement end on the termination date,except as expressly provided in the"Termination of Membership"or"Continuation of Membership" sections of an Evidence of Coverage.The termination date is the first day when this Agreement is no longer in effect(for example,if the termination date is January 1,2025,the last minute this Agreement was in effect was at 11:59 p.m.on December 31,2024). If Health Plan terminates this Agreement, Health Plan will give Group written notice.In the case of"Termination for Nonpayment,""Termination for Fraud or Intentionally Furnishing Incorrect or Incomplete Information,"and"Termination for Discontinuance of a Product or all Products within a Market,"Health Plan will provide both advance notice of the termination in addition to a final notice of termination.Within five business days of receipt of an advance or final notice of termination,Group will mail to each Subscriber a legible copy of the notice and will give Health Plan proof of that mailing and of the date thereof. Termination on Notice If Group has Kaiser Permanente Senior Advantage Members If Group has Senior Advantage Members enrolled under this Agreement at the time Health Plan receives written notice from Group that it is terminating this Agreement,Group may terminate this Agreement effective as of the Anniversary Date by giving prior written notice to Health Plan at least 30 days prior to the Anniversary Date,except that the termination will be effective on the first of the month following the Anniversary Date if the Anniversary Date is not the first of the month. Group remains responsible for remitting all amounts payable relating to this Agreement,including Premiums,for the period through the termination date. If Group does not have Kaiser Permanente Senior Advantage Members If Group does not have Senior Advantage Members enrolled under this Agreement at the time Health Plan receives written notice from Group that it is terminating this Agreement,Group may terminate this Agreement effective as of the Anniversary Date by giving prior written notice to Health Plan at least 15 days prior to the Anniversary Date,except that termination will be effective on the first of the month following the Anniversary Date if the Anniversary Date is not the first of the month.Group remains responsible for remitting all amounts payable relating to this Agreement,including Premiums,for the period through the termination date. COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:34 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 3 Termination Due to Nonacceptance of Amendments All amendments are deemed accepted by Group unless Group gives Health Plan written notice of nonacceptance within 15 days after the date of Health Plan's amendment notice and Group remits all amounts payable related to this Agreement, including Premiums,for the period prior to the amendment effective date,in which case this Agreement will terminate on the following date,as applicable: • In the case of amendments described in the"Amendment of Agreement"section under"Amendments Related to Government Approval"and"Amendments Due to Medicare Changes,"and amendments described under"Other Amendments"that do not require 60 days notice by Health Plan,if Group has Kaiser Permanente Senior Advantage Members enrolled under this Agreement at the time Health Plan receives written notice of nonacceptance,the termination date will be first of the month following 30 days after Health Plan receives written notice of nonacceptance • In all other cases,the termination date will be the day before the effective date of the amendment Termination for Nonpayment Premiums are due for the Full Premium owed as described in the"Premiums"section.If Health Plan does not receive the required Premium payment for all coverage issued under this Agreement on or before the due date,we will send a notice of nonpayment to Group as described under"Notices"in the"Miscellaneous Provisions"section.This notice will include the following information: • A statement that we have not received Full Premium payment and that we will terminate this Agreement for nonpayment if we do not receive the required Premiums by the specified date • The amount of Premiums that are due If we do not receive the required Premiums when due,the Agreement will terminate and all coverage issued under the Agreement will end on the date specified in the notice of nonpayment,which will be at least 30 days after the date of the notice.The Agreement will remain in effect during this grace period,but upon termination Group will be responsible for paying all past due Premiums,including the Premiums for this grace period. We will mail a termination notice to Group as described under"Notices"in the"Miscellaneous Provisions"section if we do not receive Full Premium payment within 30 days after the date of the notice of nonreceipt of payment. If Group has Kaiser Permanente Senior Advantage Members enrolled under this Agreement at the time Health Plan gives written notice to Group,Health Plan may terminate this Agreement effective on one date with respect to Members other than Senior Advantage Members and effective on a later date with respect to Senior Advantage Members,in order to comply with CMS termination notice requirements. Termination for Fraud or Intentionally Furnishing Incorrect or Incomplete Information If Group commits fraud or intentionally furnishes incorrect or incomplete material information to Health Plan,Health Plan may terminate this Agreement by giving advance written notice to Group,and Group is liable for all unpaid Premiums up to the termination date. If Group has Kaiser Permanente Senior Advantage Members enrolled under this Agreement at the time Health Plan gives written notice to Group,Health Plan may terminate this Agreement effective on one date with respect to Members other than Senior Advantage Members and effective on a later date with respect to Senior Advantage Members,in order to comply with CMS termination notice requirements. COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:34 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 4 Termination for Violation of Contribution or Participation Requirements If Group fails to comply with Health Plan's participation or contribution requirements(including those discussed in the "Contribution and Participation Requirements"section),Health Plan may terminate this Agreement by giving advance written notice to Group,and Group is liable for all unpaid Premiums up to the termination date. If Group has Kaiser Permanente Senior Advantage Members enrolled under this Agreement at the time Health Plan gives written notice to Group,Health Plan may terminate this Agreement effective on one date with respect to Members other than Senior Advantage Members and effective on a later date with respect to Senior Advantage Members,in order to comply with CMS termination notice requirements. Termination for Discontinuance of a Product or all Products within a Market Grandfathered products Health Plan may terminate a particular product or all products offered in a small or large group market as permitted or required by law.If Health Plan discontinues offering a particular grandfathered product in a market,Health Plan may terminate this Agreement with respect to that product upon 90 days prior written notice to Group.Health Plan will offer Group another product that it makes available to groups in the small or large group market,as applicable.If Health Plan discontinues offering all products to groups in a small or large group market,as applicable,Health Plan may terminate this Agreement upon 180 days prior written notice to Group and Health Plan will not offer any other product to Group.A "product"is a combination of benefits and services that is defined by a distinct Evidence of Coverage. All other products Health Plan may terminate a particular product or all products offered in the group market as permitted or required by law. If Health Plan discontinues offering a particular product(other than a grandfathered product)in the group market,Health Plan may terminate this Agreement with respect to that product upon 90 days prior written notice to Group.Health Plan will offer Group another product that it makes available in the group market.If Health Plan discontinues offering all products in the group market,Health Plan may terminate this Agreement upon 180 days prior written notice to Group and Health Plan will not offer any other product to Group.A"product"is a combination of benefits and services that is defined by a distinct Evidence of Coverage. Contribution and Participation Requirements No change in Group's contribution or participation requirements listed below is effective for purposes of this Agreement unless Health Plan consents in writing.As a condition to consenting to Group's revised contribution and participation requirements,Health Plan may require Group to agree to amend the Premiums,benefits,or other provisions of this Agreement. Group must: • Ensure that: ♦ all Subscribers live or work inside the Service Area applicable to their coverage when they enroll(except that Group must ensure that Subscribers live inside the Service Area applicable to their coverage when they enroll if Group chooses not to have a"live or work"eligibility rule,and that Kaiser Permanente Senior Advantage Members live inside the Service Area applicable to their coverage when they enroll in Senior Advantage and thereafter) ♦ at least one employee,proprietor,or partner who lives or works inside the Service Area is eligible to enroll as a Subscriber • Meet all applicable legal and contractual requirements,such as: ♦ meet all Health Plan requirements set forth in the"Rate Assumptions and Requirements"section of the Rate Proposal document(Group's Health Plan account manager can provide Group with a copy of the Rate Proposal if Group does not have one) COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:34 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 5 ♦ offer enrollment in accord with eligibility requirements in state law(for example,domestic partners must be eligible if married spouses are eligible and disabled dependents must be eligible if dependent children are eligible) Miscellaneous Provisions Assignment Health Plan may assign this Agreement.Group may not assign this Agreement or any of the rights,interests,claims for money due,benefits,or obligations hereunder without Health Plan's prior written consent. This Agreement shall be binding on the successors and permitted assignees of Health Plan and Group. Attorney Fees and Costs If Health Plan or Group institutes legal action against the other to collect any sums owed under this Agreement,the party that substantially prevails will be reimbursed for its reasonable litigation expenses,including attorneys' fees,by the other parry. Confidential Information about Health Plan or its Affiliates For the purposes of this"Confidential Information about Health Plan or its Affiliates"section,"Confidential Information" means any oral,written,or electronic information concerning Health Plan or its affiliates,if the information either is marked"confidential"or is by its nature proprietary or non-public,except that it does not include any of the following: • Information that is or becomes available to the public other than as a result of disclosure by Group or its employees, advisors,or representatives • Information that was available to Group or within its knowledge before Health Plan disclosed it to Group • Information that becomes available to Group from a source other than Health Plan,but only if that source is not bound by a confidentiality agreement with Health Plan If Group receives any Confidential Information,it will use that information only to evaluate Health Plan and actual or proposed group agreements with Health Plan. Group will ensure that the information is not disclosed to anyone other than a limited number of Group's employees and advisors,and only to the extent necessary in connection with the evaluation of Health Plan and actual or proposed group agreements with Health Plan.Group will inform any such employees and advisors that the information is confidential and that they must treat it confidentially. Upon Health Plan's request Group will promptly return to Health Plan all Confidential Information,and will destroy any other copies and any notes or other Group documents about the information. If Group is requested or required(by oral questions,interrogatories,request for information or documents,subpoena,civil investigative demand,or similar process)to disclose any Confidential Information,Group will give Health Plan prompt notice of the request or requirement,and Group will cooperate with Health Plan in seeking to legally avoid the disclosure. If,in the absence of a protective order,Group is legally compelled,in the opinion of its counsel,to disclose any of the information,Health Plan either will seek and obtain appropriate protective orders against the disclosure or will be deemed to waive Group's compliance with the provisions of this"Confidential Information about Health Plan or its Affiliates" section to the extent necessary to satisfy the request or requirement. Group understands(and will inform any employees and advisors who receive Confidential Information)that United States securities laws prohibit anyone who has material non-public information about a company from buying or selling that company's securities in reliance upon that information or from communicating the information to any other person or entity under circumstances in which it is reasonably foreseeable that the person or entity is likely to buy or sell that company's COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:34 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 6 securities in reliance upon the information.Group agrees that it and its affiliates,associates,employees,agents,and advisors will not rely on any Confidential Information in directly or indirectly buying or selling any Health Plan securities. Monetary damages would not be a sufficient remedy for any breach or threatened breach of this"Confidential Information about Health Plan or its Affiliates"section.Health Plan will be entitled to equitable relief by way of injunction or specific performance if Group or any of its officers,directors,employees,attorneys,accountants,agents,advisors,or representatives breach,or threaten to breach,any of the provisions of this"Confidential Information about Health Plan or its Affiliates"section. Group's obligations under this"Confidential Information about Health Plan or its Affiliates"section will continue indefinitely and will survive the termination or expiration of this Agreement. Contract Providers Health Plan will give Group written notice within a reasonable time of any termination or breach of contract by,or inability to perform of,any health care provider that contracts with Health Plan if Group may be materially and adversely affected thereby. Delegation of Claims Review Group delegates to Health Plan the discretion to determine whether a Member is entitled to benefits under this Agreement. In making these determinations,Health Plan has discretionary authority to review claims in accord with the procedures contained in this Agreement and to construe this Agreement to determine whether the Member is entitled to benefits.If coverage under an EOC is subject to the Employee Retirement Income Security Act(ERISA)claims procedure regulation (29 CFR 2560.503-1),Health Plan is a"named claims fiduciary"to review claims under that EOC. Enrollment Application Requirements Group must use enrollment application forms that are provided by Health Plan.If Group wants to use a different form or system for enrolling Members,Group must obtain Health Plan's prior approval of the form or system.Other forms and systems include a"universal"enrollment application form,interactive voice recording(IVR)enrollment system,or intranet online enrollment system.All forms and systems must meet Health Plan requirements for enrolling Members,including disclosure of binding arbitration in accord with Section 1363.1 of the California Health and Safety Code and other applicable law.Group must retain documentation of each Member's acceptance of the use of binding arbitration indefinitely,and upon request,must be able to produce documentation relating to a specific Member to Health Plan at any time.In the event that the contract between Health Plan and Group terminates or Group is unable to comply with this document retention requirement,Group must transfer possession of all such documentation to Health Plan in a mutually agreeable manner. Group's Health Plan account manager can provide Group with Health Plan's current requirements for enrollment application forms and systems. Grandfathered Health Plan Coverage For any coverage identified in an EOC as a"grandfathered health plan"under the Patient Protection and Affordable Care Act and regulations,Group must immediately inform Health Plan if this coverage does not meet(or no longer meets)the requirements for grandfathered status including but not limited to any change in its contribution rate to the cost of any grandfathered health plans during the plan year.Group represents that,for any coverage identified as a"grandfathered health plan"in the applicable EOC,Group has not decreased its contribution rate more than five percent(5%)for any rate tier for such grandfathered health plan when compared to the contribution rate in effect on March 23,2010 for the same plan.Health Plan will rely on Group's representation in issuing and continuing any and all grandfathered health plan coverage. COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:34 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 7 Governing Law Except as preempted by federal law,this Agreement will be governed in accord with California law and any provision that is required to be in this Agreement by state or federal law,shall bind Group and Health Plan whether or not set forth in this Agreement. Nonduplication Agreement Health Plan agrees to undertake performance of the following regulatory requirements,and Group may rely on Health Plan's performance in order to satisfy its obligation to perform the same activities with respect to the health plan coverages issued to Group by Health Plan: • Preparation and publication of machine-readable files on a public website for in-network rates and billed charges and allowed amounts for out-of-network providers in the required form and manner as set forth in applicable regulations and any sub-regulatory guidance • Provision of an internet,self-service tool as well as paper reports and telephone assistance to provide personalized estimates of cost sharing for 500 shoppable services beginning on January 1,2023,and for all covered services as of January 1,2024 as set forth in applicable regulations and any sub-regulatory guidance • Annual reporting of prescription drug and health care costs reporting required to be furnished in accordance with applicable regulations and any sub-regulatory guidance • Publication of a consumer notice regarding federal and,when applicable,any state legal requirements related to balance billing by non-participating providers in accordance with applicable regulations and any sub-regulatory guidance • Annual reporting of data related to the provision and cost of air ambulance services for 2022 and 2023 in the required form and manner as set forth in applicable regulations and any sub-regulatory guidance • Annual submission of a Gag Clause Prohibition Compliance Attestation in the required form and manner as set forth in applicable regulations,if any,and sub-regulatory guidance Member Information Group will inform Members and prospective Members of eligibility requirements for Subscribers and Dependents and when coverage becomes effective and terminates. When Health Plan notifies Group about changes to this Agreement or provides Group other information that affects Members,Group will disseminate the information to Members by the next regular communication to them,but in no event later than 30 days after Group receives the information. For each Health Plan coverage included in this Agreement,Health Plan will provide Group with the following disclosures for Group to distribute in accord with applicable laws("Member Materials"): • A Disclosure Form(DF)for each non-Medicare coverage.Group will provide DFs(or combined EOC/DFs)to Subscribers and potential Subscribers when the coverage is offered • A Summary of Benefits and Coverage(SBC)for each non-Medicare coverage other than retiree plans with fewer than two current employees.Group will provide electronic or paper SBCs to Members and potential Members to the extent required by law,except that Health Plan will provide SBCs to Members who make a request to Health Plan • Pre-enrollment materials that CMS requires for Kaiser Permanente Senior Advantage coverage,which are available upon request from Health Plan.Group will provide these materials to potential Members before they enroll in Senior Advantage coverage • An EOC for each non-Medicare coverage. Group will provide EOCs(or combined EOC/DFs)to Subscribers,except that Health Plan will provide EOCs(or combined EOC/DFs)to Members and potential Members who make a request to Health Plan COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:34 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 8 If Group receives the Agreement or Member Materials in electronic form,Group is not authorized to modify or alter in any way the text or the formatting of the electronic Agreement or Member Materials. Health Plan assumes no responsibility for any changes in text or formatting that may occur in the Agreement or Member Materials after they are provided to Group.If Group posts the electronic Agreement or Member Materials on its intranet site,it shall do so in such a way so as to permit employees of Group to download and print a complete and accurate copy of the Agreement or Member Materials. In the event Health Plan reasonably concludes that Group is either using the electronic Agreement or Member Materials in a manner not permitted by this Agreement or is not providing Subscribers with access to the Member Materials in accord with applicable laws,then Health Plan will print copies of the Agreement or Member Materials and Group will cooperate with Health Plan to ensure that printed copies of the Agreement or Member Materials are provided in a timely manner to all employees of Group enrolled with Health Plan.Group agrees to reimburse Health Plan for the reasonable cost of printing and delivering the Agreement or Member Materials. No Waiver Health Plan's failure to enforce any provision of this Agreement will not constitute a waiver of that or any other provision, or impair Health Plan's right thereafter to require Group's strict performance of any provision. Notices Notices must be sent to the addresses listed below.Health Plan or Group may change its addresses for notices by giving written notice to the other.All notices are deemed given when delivered in person or deposited in a U.S.Postal Service receptacle for the collection of U.S.mail. Notices from Health Plan to Group must be sent to: HOLLIS MAGILL,DIRECTOR OF HUMAN RESOURCES COUNTY OF FRESNO,RETIREE 2220 TULARE ST FL 14 FRESNO,CA 93721-2122 If Group has chosen to receive group agreements electronically through Health Plan's website at kp.or2/yourcontract, Health Plan will send a notice to Group at the address listed above when a group agreement has been posted to that website. Note:When Health Plan sends Group a new(renewed)Agreement,Health Plan will enclose a summary of changes that discusses the changes Health Plan has made to the Group Agreement.If Group wants information about changes before receiving the Agreement,Group may request advance information from their Health Plan account manager.Also,if Group designates a third party in writing(for example,"Broker of Record"statements),Health Plan may send the advance information to the third party rather than to Group(unless Group requests a copy too). Notices from Group to Health Plan must be sent to: Kaiser Permanente 1 Kaiser Plaza Oakland,CA 94612 Attn: Thomas A. Curtin Jr., Senior Vice President,Commercial Group Lines of Business Open Enrollment Group must hold an annual open enrollment period during which all eligible people,in accord with state law,may enroll in Health Plan or in any other health care plan available through Group.Also,Group must not hold open enrollment for 2025 until Group receives its 2025 group agreement Premium and coverage information from Health Plan.If Group holds the COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:34 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 9 open enrollment without receiving 2025 group agreement Premium and coverage information,Health Plan may change Premiums and coverage(including benefits and Cost Sharing)when it offers to renew Group's Agreement as described under"Renewal"in the"Term of Agreement and Renewal"section. Other Group coverage that covers Essential Health Benefits For each non-grandfathered non-Medicare Health Plan coverage,except for any retiree-only coverage,Group must do all of the following if Group provides Health Plan Members with other medical or dental coverage(for example,separate pharmacy coverage)that covers any Essential Health Benefits: • Notify Health Plan of the out-of-pocket maximum(OOPM)that applies to the Essential Health Benefits in each of the other medical or dental coverage. • Ensure that the sum of the OOPM in Health Plan's coverage plus the OOPMs that apply to Essential Health Benefits in all of the other medical and dental coverage does not exceed the annual limitation on cost sharing described in 45 CFR 156.130. Reporting Membership Changes and Retroactivity Group must report membership changes(including sending appropriate membership forms)within the time limit for retroactive changes and in accord with any applicable"rescission"provisions of the Patient Protection and Affordable Care Act and regulations.Except for Senior Advantage membership terminations discussed below,the time limit for retroactive membership changes is the calendar month when Health Plan's California Service Center receives Group's notification of the change plus the previous 2 months. Representation regarding communication of membership changes Group represents that its communication regarding membership changes to Health Plan is accurate.Group and its representative are bound by all membership data,including any changes or updates that it,or its representative,submits to Health Plan via any medium,electronic or otherwise,including but not limited to the following: • Electronic data submissions regarding enrollment and eligibility • Health Plan approved online tool for submission of data • Paper enrollments submitted through postal mail or fax Health Plan's Administrative Handbook includes the details about how to report membership changes.Group's Health Plan account manager can provide Group with an Administrative Handbook if Group does not have one. Involuntary Kaiser Permanente Senior Advantage Membership Terminations Group must give Health Plan's California Service Center 30 days'prior written notice of Senior Advantage involuntary membership terminations.An involuntary membership termination is a termination that is not in response to a disenrollment notice issued by CMS to Health Plan or received by Health Plan directly from a Member(these events are usually in response to a Member's request for disenrollment to CMS because the Member has enrolled in another Medicare health plan or wants Original Medicare coverage or has lost Medicare eligibility). The membership termination date is the first of the month following 30 days after the date when Health Plan's California Service Center receives a Senior Advantage membership termination notice unless Group specifies a later termination date.For example,if Health Plan's California Service Center receives a termination notice on March 5 for a Senior Advantage Member,the earliest termination date is May 1 and Group is required to pay applicable Premiums for the months of March and April. Voluntary Kaiser Permanente Senior Advantage Membership Terminations If Health Plan's California Service Center receives a disenrollment notice from CMS or a membership termination request from the Member,the membership termination date will be in accord with CMS requirements. COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:34 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 10 Representation Regarding Waiting Periods By entering into this Agreement,Group hereby represents that Group does not impose a waiting period exceeding 90 days on employees who meet Group's eligibility requirements.For purposes of this requirement,a"waiting period"is the period that must pass before coverage for an individual who is otherwise eligible to enroll in non-Medicare coverage under the terms of a group health plan can become effective in accord with the waiting period requirements in the Patient Protection and Affordable Care Act and regulations. In addition,Group represents that eligibility data provided by the Group to Health Plan will include coverage effective dates for Group's employees that correctly account for eligibility in compliance with the waiting period requirements in the Patient Protection and Affordable Care Act and regulations and will not exceed the waiting period established by Group. For example,if the hire date of an otherwise-eligible employee is January 19,the waiting period begins on January 19 and the effective date of coverage cannot be any later than April 19.Note: If the effective date of your Group's coverage is always on the first day of the month,in this example the effective date cannot be any later than April 1. Right to Examine Records Upon reasonable notice,Health Plan may examine Group's records with respect to contribution and participation requirements,eligibility,and payments under this Agreement. Social Security and Tax Identification Numbers Within 60 days after Health Plan sends Group a written request,Group will send Health Plan a list of all Members covered under this Agreement,along with the following: • The Social Security number of the Member • The tax identification number of the employer of the Subscriber in the Member's Family • Any other information that Health Plan is required by law to collect Premiums Only Members for whom Health Plan(or its designee)has received the Full Premium payment as described below are entitled to coverage under this Agreement,and then only for the period for which Health Plan(or its designee)has received required Premium payment.Group is responsible for paying Premiums,except that Members who have Cal-COBRA coverage under an EOC that is included in this Agreement are responsible for paying Premiums for Cal-COBRA coverage. Due Date and Payment of Premiums The payment due date for each enrollment unit(or subgroup)associated with Group will be reflected on the monthly membership invoice if applicable to Group(if not applicable,then as specified in writing by Health Plan).If Group does not pay Full Premiums by the first of the coverage month,the Premiums may include an additional administrative charge upon renewal."Full Premiums"means 100 percent of monthly Premiums for all of the coverage issued to each enrolled Member,as set forth under"Calculating Premiums"in this"Premiums"section. New Members Premiums are payable for the entire month for a new Member whose coverage effective date falls between the first day of the month and the fifteenth day of the month.No Premiums are due for the month for a new Member whose coverage becomes effective after the fifteenth day of that month. COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:34 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 11 Note: Membership begins at the beginning(12:00 a.m.)of the effective date of coverage. Membership Termination Premiums are payable for the entire month for Members whose last day of coverage is on or after the sixteenth day of that month.No Premiums are due for the month for a Member whose last day of coverage is before the sixteenth day of that month. Note: The membership termination date is the first day a Member is not covered(for example,if the termination date is January 1,2025,the last minute of coverage was at 11:59 p.m. on December 31,2024). Involuntary Kaiser Permanente Senior Advantage Membership Terminations Group must give Health Plan's California Service Center 30 days'prior written notice of Senior Advantage involuntary membership terminations.An involuntary membership termination is a termination that is not in response to a disenrollment notice issued by CMS to Health Plan or received by Health Plan directly from a Member(these events are usually in response to a Member's request for disenrollment to CMS because the Member has enrolled in another Medicare health plan or wants Original Medicare coverage or has lost Medicare eligibility). The membership termination date is the first of the month following 30 days after the date when Health Plan's California Service Center receives a Senior Advantage membership termination notice unless Group specifies a later termination date.For example,if Health Plan's California Service Center receives a termination notice on March 5 for a Senior Advantage Member,the earliest termination date is May 1 and Group is required to pay applicable Premiums for the months of March and April. Voluntary Kaiser Permanente Senior Advantage Membership Terminations If Health Plan's California Service Center receives a disenrollment notice from CMS or a membership termination request from the Member,the membership termination date will be in accord with CMS requirements. Premium Rebates If state or federal law requires Health Plan to rebate premiums from this or any earlier contract year and Health Plan rebates premiums to Group,Group represents that Group will use that rebate for the benefit of Members,in a manner consistent with the requirements of the Public Health Service Act and the Affordable Care Act and if applicable with the obligations of a fiduciary under the Employee Retirement Income Security Act(ERISA). Medicare Medicare as primary coverage For Members who are(or the subscriber in the family is)retired,age 65 or over,and eligible for Medicare as primary coverage,Premiums are based on the assumption that Health Plan or its designee will receive Medicare payments for Medicare-covered services provided to Members whose Medicare coverage is primary.If a Member age 65 or over is(or becomes)eligible for Medicare as primary coverage and is not for any reason enrolled through Group under a Kaiser Permanente Senior Advantage EOC(including inability to enroll under that EOC because they do not meet the plan's eligibility requirements,the plan is not available through Group,or the plan is closed to enrollment),Group must pay the Premiums listed below for the EOC under which the Member is enrolled that apply to Members age 65 or over who are not enrolled through Group under one of Health Plan's Medicare plans. If a Member age 65 or over who is eligible for Medicare as primary coverage and enrolled under a Kaiser Permanente Senior Advantage EOC is no longer eligible for that plan,Health Plan may transfer the Member's membership to one of Group's plans that does not require Members to have Medicare,and Group must pay the Premiums listed below for the EOC under which the Member is enrolled that apply to Members age 65 or over who are not enrolled through Group under one of Health Plan's Medicare plans. COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:34 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 12 Medicare as secondary coverage Medicare is the primary coverage except when federal law requires that Group's health care coverage be primary and Medicare coverage be secondary.Members entitled to Medicare when Medicare is secondary by law are subject to the same Premiums and receive the same benefits as Members who are under age 65 and not eligible for Medicare.In addition, Members for whom Medicare is secondary who meet the Kaiser Permanente Senior Advantage eligibility requirements may also enroll in the Senior Advantage plan under this Agreement that is applicable when Medicare is secondary.These Members receive the benefits and coverage described in both the EOC for the non-Medicare plan(the plan that does not require Members to have Medicare)and the Senior Advantage EOC that is applicable when Medicare is secondary. Subscriber Contributions for Medicare Part C and Part D Coverage Medicare Part C coverage This"Medicare Part C coverage"section applies to Group's Kaiser Permanente Senior Advantage coverage. Group's Senior Advantage Premiums include the Medicare Part C premium for coverage of items and services covered under Parts A and B of Medicare,and supplemental benefits.Group may determine how much it will require Subscribers to contribute toward the Medicare Part C premium for each Senior Advantage Member in the Subscriber's Family,subject to the following restrictions: • If Group requires different contribution amounts for different classes of Senior Advantage Members for the Medicare Part C premium,then Group agrees to the following: ♦ any such differences in classes of Members are reasonable and based on objective business criteria,such as years of service,business location,and job category ♦ Group will not require different Subscriber contributions toward the Medicare Part C premium for Members within the same class • Group will not require Subscribers to pay a contribution for Medicare Part C coverage for a Senior Advantage Member that exceeds the Medicare Part C Premium for items and services covered under Parts A and B of Medicare,and supplemental benefits.As applicable,Health Plan will pass through monthly payments received from CMS(the monthly payments described in 42 C.F.R.422.304(a))to reduce the amount the Member contributes toward the Medicare Part C premium Medicare Part D coverage This"Medicare Part D coverage"section applies only to Group's Kaiser Permanente Senior Advantage coverage that includes Medicare Part D prescription drug coverage.Group's Senior Advantage Premiums include the Medicare Part D premium.Group may determine how much it will require Subscribers to contribute toward the Medicare Part D premium for each Senior Advantage Member in the Subscriber's Family,subject to the following restrictions: • If Group requires different contribution amounts for different classes of Senior Advantage Members for the Medicare Part D premium,then Group agrees to the following: ♦ any such differences in classes of Members are reasonable and based on objective business criteria,such as years of service,business location,and job category,and are not based on eligibility for the Medicare Part D Low Income Subsidy(the subsidies described in 42 C.F.R. Section 423 Subpart P,which are offered by the Medicare program to certain low-income Medicare beneficiaries enrolled in Medicare Part D,and which reduce the Medicare beneficiaries'Medicare Part D premiums and/or Medicare Part D cost-sharing amounts) ♦ Group will not require different Subscriber contributions toward the Medicare Part D premium for Members within the same class • Group will not require Subscribers to pay a contribution for prescription drug coverage for a Senior Advantage Member that exceeds the Premium for prescription drug coverage(including the Medicare Part D premium).The Group will pass through direct subsidy payments received from CMS to reduce the amount the Member contributes toward the Medicare Part D premium • Health Plan will credit Group with any Low Income Subsidy amounts that Health Plan receives from CMS for Group's Members,and Health Plan will identify those Members for Group as required by CMS.For those Members,Group will first credit the Low Income Subsidy amount toward the Subscriber's contribution for that Member's Senior Advantage Premium for the same month,and will then apply any remaining portion of the Member's Low Income Subsidy toward COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:34 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 13 the portion of the Senior Advantage Premium that Group pays on behalf of that Member for that month.If Group is unable to reduce the Subscriber's contribution before the Subscriber makes the contribution,Group shall,consistent with CMS guidance,refund the Low Income Subsidy amount to the Subscriber(up to the amount of the Subscriber Premium contribution for the Member for that month)within 45 days after the date Health Plan receives the Low Income Subsidy amount from CMS.Health Plan reserves the right to periodically require Group to certify that Group is either reducing Subscribers'monthly Premium contributions or refunding the Low Income Subsidy amounts to Subscribers in accord with CMS guidance • For any Members who are eligible for the Low Income Subsidy,if the amount of that Low Income Subsidy is less than the Member's contribution for the Medicare Part D premium,then Group should inform the Member of the financial consequences of the Member's enrolling in the Member's current coverage,as compared to enrolling in another Medicare Part D plan with a monthly premium equal to or less than the Low Income Subsidy amount Late Enrollment Penalty If any Members are subject to the Medicare Part D late enrollment penalty,Premiums for those Members will increase to include the amount of the penalty. Calculating Premiums To calculate the amount of Full Premiums that apply to a Family(a Subscriber and all of their Dependents): 1. If this Agreement includes more than one contract option,determine the coverage(EOCs and contract options)that apply to each Member in the Family(for example,Traditional Plan and any Ancillary Coverage). 2. Determine the family role type and Medicare status of each Member(for family role types,please see the"Definitions" section of the EOC for the definition of Subscriber,Dependent,and Spouse). 3. Identify the Premiums for each Member for each EOC and contract option(including contract options issued through a separate contract)based on the family role type and Medicare status of each Member: • Premiums for coverage issued under this Agreement appear in the Premium tables below. • If this Agreement includes a POS Plan contract option(a contract option with one tier underwritten by Health Plan and two tiers underwritten by Kaiser Permanente Insurance Company),the amounts shown below for the POS Plan (for Large Groups)product includes premiums for the Health Plan and Kaiser Permanente Insurance Company portions of Group's POS Plan coverage,and Group submits payment for this coverage as part of Full Premium. • If Ancillary Coverage has been issued under a separate contract and Premiums for that coverage are not listed in the Premium tables below,refer to that contract for Premiums. This Ancillary Coverage is part of the contract options selected by Group,and Group submits payment for this Ancillary Coverage as part of Full Premium. 4. Add the amounts of Premiums for each Member together to arrive at the total,Full Premiums required for the Family. Monthly Premiums for Kaiser Permanente Traditional HMO Plan — EOC # 1 TRADITIONAL PLAN HIGH-HIGH OPTION Members under age 65 who are not eligible for Medicare Family role type Premiums Subscriber $1,765.40 Spouse $1,482.94 1st child without Spouse $953.32 1st child with Spouse $918.00 Each additional Dependent $0.00 Members under age 65 who are eligible for or have Medicare Part A only Family role type Premiums Subscriber $1,765.40 Spouse $1,482.94 COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:34 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 14 Family role type Premiums 1 st child without Spouse $953.32 1st child with Spouse $918.00 Each additional Dependent $0.00 Members under age 65 who are eligible for or have Medicare Part B only Family role type Premiums Subscriber $1,765.40 Spouse $1,482.94 1 st child without Spouse $953.32 1 st child with Spouse $918.00 Each additional Dependent $0.00 Members under age 65 who are eligible for or have Medicare Parts A&B Family role type Premiums Subscriber $1,765.40 Spouse $1,482.94 1st child without Spouse $953.32 1 st child with Spouse $918.00 Each additional Dependent $0.00 Members under age 65 who are enrolled in another carrier's Medicare Risk product Family role type Premiums Subscriber $1,846.31 Spouse $1,846.31 1st child without Spouse $1,846.31 l st child with Spouse $1,846.31 Each additional Dependent $1,846.31 Members under age 65 when Medicare is secondary Family role type Premiums Subscriber $1,765.40 Spouse $1,482.94 1st child without Spouse $953.32 1 st child with Spouse $918.00 Each additional Dependent $0.00 Members age 65 and over whose Medicare eligibility is unknown Family role type Premiums Subscriber $1,846.31 Spouse $1,846.31 1 st child without Spouse $1,846.31 1st child with Spouse $1,846.31 Each additional Dependent $1,846.31 Members age 65 and over who are eligible for or have Medicare Part A only Family role type Premiums Subscriber $1,435.66 COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: I Version:34 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 15 Family role type Premiums Spouse $1,435.66 1st child without Spouse $1,435.66 1st child with Spouse $1,435.66 Each additional Dependent $1,435.66 Members age 65 and over who are eligible for or have Medicare Part B only Family role type Premiums Subscriber $1,846.31 Spouse $1,846.31 1 st child without Spouse $1,846.31 1st child with Spouse $1,846.31 Each additional Dependent $1,846.31 Members age 65 and over who are eligible for or have Medicare Parts A&B Family role type Premiums Subscriber $1,435.66 Spouse $1,435.66 1 st child without Spouse $1,435.66 1st child with Spouse $1,435.66 Each additional Dependent $1,435.66 Members age 65 and over who are enrolled in another carrier's Medicare Risk product Family role type Premiums Subscriber $1,846.31 Spouse $1,846.31 l st child without Spouse $1,846.31 1 st child with Spouse $1,846.31 Each additional Dependent $1,846.31 Members age 65 and over when Medicare is secondary Family role type Premiums Subscriber $1,765.40 Spouse $1,482.94 1st child without Spouse $953.32 1 st child with Spouse $918.00 Each additional Dependent $0.00 Note: Members who are"eligible for"Medicare Part A or B are those who would qualify for Medicare Part A or B coverage if they applied for it.Members who"have"Medicare Part A or B are those who have been granted Medicare Part A or B coverage.Medicare Part A provides inpatient coverage and Part B provides outpatient coverage. Monthly Premiums for Kaiser Permanente Senior Advantage (HMO) with Part D — EOC #2 SENIOR ADVANTAGE HIGH-HIGH OPTION Family role type Medicare Parts A&B Medicare Part B only Subscriber $316.17 $626.17 COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: I Version:34 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 16 Family role type Medicare Parts A&B Medicare Part B only 1st Dependent $316.17 $626.17 2nd Dependent $316.17 $626.17 Each additional Dependent $316.17 $626.17 Monthly Premiums for American Specialty Health Plans Chiropractic Plan — EOC #3 CHIROPRACTIC BENEFIT-HIGH OPTION Family role type Premiums Subscriber $1.83 Spouse $1.54 1 st child without Spouse $0.99 1 st child with Spouse $0.95 Monthly Premiums for Kaiser Permanente Senior Advantage (HMO) with Part D — EOC #4 SENIOR ADVANTAGE-LOW OPTION Family role type Medicare Parts A&B Medicare Part B only Subscriber $250.46 $560.46 1st Dependent $250.46 $560.46 2nd Dependent $250.46 $560.46 Each additional Dependent 1 $250.46 1 $560.46 Monthly Premiums for Kaiser Permanente Traditional HMO Plan — EOC # 5 TRADITIONAL PLAN-LOW OPTION Members under age 65 who are not eligible for Medicare Family role type Premiums Subscriber $1,765.40 Spouse $1,482.94 1st child without Spouse $953.32 1 st child with Spouse $918.00 Each additional Dependent $0.00 Members under age 65 who are eligible for or have Medicare Part A only Family role type Premiums Subscriber $1,765.40 Spouse $1,482.94 1st child without Spouse $953.32 1 st child with Spouse $918.00 Each additional Dependent $0.00 Members under age 65 who are eligible for or have Medicare Part B only Family role type Premiums Subscriber $1,765.40 Spouse $1,482.94 COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: I Version:34 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 17 Family role type Premiums 1 st child without Spouse $953.32 1st child with Spouse $918.00 Each additional Dependent $0.00 Members under age 65 who are eligible for or have Medicare Parts A&B Family role type Premiums Subscriber $1,765.40 Spouse $1,482.94 1 st child without Spouse $953.32 1 st child with Spouse $918.00 Each additional Dependent $0.00 Members under age 65 who are enrolled in another carrier's Medicare Risk product Family role type Premiums Subscriber $1,846.31 Spouse $1,846.31 1st child without Spouse $1,846.31 1 st child with Spouse $1,846.31 Each additional Dependent $1,846.31 Members under age 65 when Medicare is secondary Family role type Premiums Subscriber $1,765.40 Spouse $1,482.94 1 st child without Spouse $953.32 l st child with Spouse $918.00 Each additional Dependent $0.00 Members age 65 and over whose Medicare eligibility is unknown Family role type Premiums Subscriber $1,846.31 Spouse $1,846.31 1st child without Spouse $1,846.31 1st child with Spouse $1,846.31 Each additional Dependent $1,846.31 Members age 65 and over who are eligible for or have Medicare Part A only Family role type Premiums Subscriber $1,435.66 Spouse $1,435.66 1 st child without Spouse $1,435.66 1st child with Spouse $1,435.66 Each additional Dependent $1,435.66 Members age 65 and over who are eligible for or have Medicare Part B only Family role type Premiums Subscriber $1,846.31 COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: I Version:34 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 18 Family role type Premiums Spouse $1,846.31 1st child without Spouse $1,846.31 1st child with Spouse $1,846.31 Each additional Dependent $1,846.31 Members age 65 and over who are eligible for or have Medicare Parts A&B Family role type Premiums Subscriber $1,435.66 Spouse $1,435.66 1 st child without Spouse $1,435.66 1st child with Spouse $1,435.66 Each additional Dependent $1,435.66 Members age 65 and over who are enrolled in another carrier's Medicare Risk product Family role type Premiums Subscriber $1,846.31 Spouse $1,846.31 1 st child without Spouse $1,846.31 1st child with Spouse $1,846.31 Each additional Dependent $1,846.31 Members age 65 and over when Medicare is secondary Family role type Premiums Subscriber $1,765.40 Spouse $1,482.94 l st child without Spouse $953.32 1 st child with Spouse $918.00 Each additional Dependent $0.00 Note: Members who are"eligible for"Medicare Part A or B are those who would qualify for Medicare Part A or B coverage if they applied for it.Members who"have"Medicare Part A or B are those who have been granted Medicare Part A or B coverage.Medicare Part A provides inpatient coverage and Part B provides outpatient coverage. Monthly Premiums for Chiropractic Services and Silver&Fit® Healthy Aging and Exercise Program — EOC # 7 SLVRFIT CHIRO NCR-HIGH OPTION Family role type Premiums Subscriber $1.83 Spouse $1.54 1 st child without Spouse $0.99 1st child with Spouse $0.95 COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: I Version:34 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 19 Monthly Premiums for Chiropractic Services and Silver&Fit® Healthy Aging and Exercise Program — EOC # 8 NCR SLVRFIT CHIRO-LOW OPTION Family role type Premiums Subscriber $1.83 Spouse $1.54 1 st child without Spouse $0.99 1st child with Spouse $0.95 Monthly Premiums for American Specialty Health Plans Chiropractic Plan — EOC #9 HMO CHIRO ACN NCR-LOW OPTION Family role type Premiums Subscriber $1.83 Spouse $1.54 1st child without Spouse $0.99 1 st child with Spouse $0.95 COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: I Version:34 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 20 Agreement Signature Page Acceptance of Agreement Group acknowledges acceptance of this Agreement by signing the Signature Page and returning it to Health Plan.If Group does not return it to Health Plan,Group will be deemed as having accepted this Agreement if Group pays Health Plan any amount toward Premiums. Group may not change this Agreement by adding or deleting words,and any such addition or deletion is void.Health Plan might not respond to any changes or comments submitted on or with this Signature Page.Group may not construe Health Plan's lack of response to any submitted changes or comments to imply acceptance.If Group wishes to change anything in this Agreement,Group must contact its Health Plan account manager.Health Plan will issue a new Agreement or amendment if Health Plan and Group agree on any changes. Binding Arbitration As more fully set forth in the arbitration provision in the applicable Evidence of Coverage,disputes between Members, their heirs,relatives,or associated parties(on the one hand)and Health Plan,Kaiser Permanente health care providers,or other associated parties(on the other hand)for alleged violation of any duty arising out of or related to this Agreement, including any claim for medical or hospital malpractice(a claim that medical services or items were unnecessary or unauthorized or were improperly,negligently,or incompetently rendered),for premises liability,or relating to the coverage for,or delivery of,services or items pursuant to this Agreement,irrespective of legal theory,must be decided by binding arbitration and not by lawsuit or resort to court process,except as applicable law provides for judicial review of arbitration proceedings.Members enrolled under this Agreement thus give up their right to a court or jury trial,and instead accept the use of binding arbitration as specified in the applicable Evidence of Coverage except that the following types of claims are not subject to binding arbitration: • Claims within the jurisdiction of the Small Claims Court • Claims subject to a Medicare appeals procedure as applicable to Kaiser Permanente Senior Advantage Members • Claims that cannot be subject to binding arbitration under governing law Signatures Kaiser Foundation Health Plan,Inc.,Northern California Region a. pk- Thomas A.Curtin Jr. Authorized officer Senior Vice President,Commercial Group Lines of Business October 20,2023 COUNTY OF FRESNO,RETIREE Authorized Group officer signature Print name and title Date Please keep this copy of the signature page with your Agreement.An extra copy is included in your contract package to sign and return: • By mail:Kaiser Permanente,California Service Center,P.O.Box 23448,San Diego,CA 92193-3448. • By fax: 1-855-355-5334 COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:34 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 21 00 NO"71 KAISER PERMANEWEe Kaiser Foundation Health Plan, Inc. Northern California Region A nonprofit corporation EOC #1 - Kaiser Permanente Traditional HMO Plan Evidence of Coverage for COUNTY OF FRESNO, RETIREE Group ID: 604334 Contract: 1 Version: 34 EOC Number: 1 January 1,2024, through December 31, 2024 Member Services 24 hours a day, seven days a week(except closed holidays) 1-800-464-4000 (TTY users call 711) kp.org coaccum NGF ACA p103 TABLE OF CONTENTS FOR EOC #1 CostShare Summary..............................................................................................................................................................1 AccumulationPeriod..........................................................................................................................................................1 Deductibles and Out-of-Pocket Maximums.......................................................................................................................1 Cost Share Summary Tables by Benefit.............................................................................................................................1 CAREPlan.......................................................................................................................................................................18 Introduction..........................................................................................................................................................................19 AboutKaiser Permanente.................................................................................................................................................19 Termof this EOC.............................................................................................................................................................19 Definitions............................................................................................................................................................................19 Premiums,Eligibility,and Enrollment.................................................................................................................................25 Premiums..........................................................................................................................................................................25 WhoIs Eligible.................................................................................................................................................................25 How to Enroll and When Coverage Begins.....................................................................................................................28 Howto Obtain Services........................................................................................................................................................30 RoutineCare.....................................................................................................................................................................30 UrgentCare......................................................................................................................................................................30 NotSure What Kind of Care You Need?.........................................................................................................................31 YourPersonal Plan Physician..........................................................................................................................................31 Gettinga Referral.............................................................................................................................................................31 Travel and Lodging for Certain Services.........................................................................................................................34 SecondOpinions...............................................................................................................................................................34 Contractswith Plan Providers..........................................................................................................................................34 Receiving Care Outside of Your Home Region Service Area.........................................................................................35 YourID Card....................................................................................................................................................................35 TimelyAccess to Care.....................................................................................................................................................35 GettingAssistance............................................................................................................................................................36 PlanFacilities.......................................................................................................................................................................36 Emergency Services and Urgent Care..................................................................................................................................37 EmergencyServices.........................................................................................................................................................37 UrgentCare......................................................................................................................................................................38 Paymentand Reimbursement...........................................................................................................................................39 Benefits.................................................................................................................................................................................39 YourCost Share...............................................................................................................................................................40 AdministeredDrugs and Products....................................................................................................................................43 AmbulanceServices.........................................................................................................................................................43 BariatricSurgery..............................................................................................................................................................43 Behavioral Health Treatment for Autism Spectrum Disorder..........................................................................................44 Dental and Orthodontic Services......................................................................................................................................45 DialysisCare....................................................................................................................................................................46 Durable Medical Equipment("DME")for Home Use.....................................................................................................47 EmergencyServices and Urgent Care..............................................................................................................................48 FertilityServices...............................................................................................................................................................48 Fertility Preservation Services for latrogenic Infertility..................................................................................................49 HealthEducation..............................................................................................................................................................49 HearingServices...............................................................................................................................................................49 HomeHealth Care............................................................................................................................................................50 HospiceCare....................................................................................................................................................................50 HospitalInpatient Services...............................................................................................................................................51 Injuryto Teeth..................................................................................................................................................................52 MentalHealth Services....................................................................................................................................................52 OfficeVisits.....................................................................................................................................................................53 Ostomyand Urological Supplies......................................................................................................................................53 Outpatient Imaging,Laboratory,and Other Diagnostic and Treatment Services............................................................53 Outpatient Prescription Drugs, Supplies,and Supplements.............................................................................................54 Outpatient Surgery and Outpatient Procedures................................................................................................................57 PreventiveServices..........................................................................................................................................................57 Prostheticand Orthotic Devices.......................................................................................................................................58 ReconstructiveSurgery....................................................................................................................................................59 Rehabilitative and Habilitative Services..........................................................................................................................59 Reproductive Health Services..........................................................................................................................................60 Services in Connection with a Clinical Trial....................................................................................................................60 SkilledNursing Facility Care...........................................................................................................................................61 Substance Use Disorder Treatment..................................................................................................................................62 TelehealthVisits...............................................................................................................................................................62 TransplantServices..........................................................................................................................................................63 VisionServices for Adult Members.................................................................................................................................63 Vision Services for Pediatric Members............................................................................................................................64 Exclusions,Limitations,Coordination of Benefits,and Reductions...................................................................................65 Exclusions........................................................................................................................................................................65 Limitations........................................................................................................................................................................68 Coordinationof Benefits..................................................................................................................................................68 Reductions........................................................................................................................................................................69 Post-Service Claims and Appeals.........................................................................................................................................70 WhoMay File...................................................................................................................................................................71 SupportingDocuments.....................................................................................................................................................71 InitialClaims....................................................................................................................................................................72 Appeals.............................................................................................................................................................................73 ExternalReview...............................................................................................................................................................73 AdditionalReview............................................................................................................................................................74 DisputeResolution...............................................................................................................................................................74 Grievances........................................................................................................................................................................74 Independent Review Organization for Non-Formulary Prescription Drug Requests......................................................76 Department of Managed Health Care Complaints...........................................................................................................77 Independent Medical Review("IMR")............................................................................................................................77 Officeof Civil Rights Complaints....................................................................................................................................78 AdditionalReview............................................................................................................................................................78 BindingArbitration..........................................................................................................................................................78 Terminationof Membership.................................................................................................................................................81 Termination Due to Loss of Eligibility............................................................................................................................81 Terminationof Agreement................................................................................................................................................81 Terminationfor Cause......................................................................................................................................................81 Termination of a Product or all Products.........................................................................................................................81 Paymentsafter Termination.............................................................................................................................................81 State Review of Membership Termination......................................................................................................................81 Continuationof Membership................................................................................................................................................82 Continuationof Group Coverage.....................................................................................................................................82 Continuation of Coverage under an Individual Plan........................................................................................................84 MiscellaneousProvisions.....................................................................................................................................................85 Administrationof Agreement...........................................................................................................................................85 AdvanceDirectives..........................................................................................................................................................85 Amendmentof Agreement................................................................................................................................................85 Applicationsand Statements............................................................................................................................................85 Assignment.......................................................................................................................................................................85 Attorney and Advocate Fees and Expenses.....................................................................................................................85 ClaimsReview Authority.................................................................................................................................................85 EOCBinding on Members...............................................................................................................................................86 ERISANotices.................................................................................................................................................................86 GoverningLaw.................................................................................................................................................................86 Group and Members Not Our Agents..............................................................................................................................86 NoWaiver........................................................................................................................................................................86 Notices Regarding Your Coverage...................................................................................................................................86 OverpaymentRecovery....................................................................................................................................................86 PrivacyPractices..............................................................................................................................................................86 PublicPolicy Participation...............................................................................................................................................87 HelpfulInformation..............................................................................................................................................................87 How to Obtain this EOC in Other Formats......................................................................................................................87 ProviderDirectory............................................................................................................................................................87 Online Tools and Resources.............................................................................................................................................87 Document Delivery Preferences.......................................................................................................................................88 Howto Reach Us..............................................................................................................................................................88 PaymentResponsibility....................................................................................................................................................89 Cost Share Summary This"Cost Share Summary"is part of your Evidence of Coverage(EOC)and is meant to explain the amount you will pay for covered Services under this plan.It does not provide a full description of your benefits.For a full description of your benefits, including any limitations and exclusions,please read this entire EOC,including any amendments,carefully. Accumulation Period The Accumulation Period for this plan is January I through December 31. Deductibles and Out-of-Pocket Maximums For Services that apply to the Plan Out-of-Pocket Maximum,you will not pay any more Cost Share for the rest of the Accumulation Period once you have reached the amounts listed below. If your Group's plan changes during an Accumulation Period,your deductibles and out-of-pocket maximums may increase or decrease,which may change the total amount you must accumulate to reach the deductibles or out-of-pocket maximums during that Accumulation Period. Self-Only Coverage Family Coverage Family Coverage Amounts Per Accumulation Period Each Member in a Family Entire Family of two or (a Family of one Member) of two or more Members more Members Plan Deductible None None None Drug Deductible None None None Plan Out-of-Pocket Maximum("OOPM") $1,500 $1,500 $3,000 Cost Share Summary Tables by Benefit How to read the Cost Share summary tables Each table below explains the Cost Share for a category of benefits. Specific Services related to the benefit are described in the first column of each table.For a detailed description of coverage for a particular benefit,refer to the same benefit heading in the`Benefits"section of this EOC. • Copayment/Coinsurance.This column describes the Cost Share you will pay for Services after you have met your Plan Deductible or Drug Deductible,if applicable.(Please see the"Deductibles and Out-of-Pocket Maximums" section above to determine if your plan includes deductibles.)If the Services are not covered in your plan,this column will read"Not covered."If we provide an Allowance that you can use toward the cost of the Services,this column will include the Allowance. • Subject to Deductible.This column explains whether the Cost Share you pay for Services is subject to a Plan Deductible or Drug Deductible. If the Services are subject to a deductible,you will pay Charges for those Services until you have met your deductible.If the Services are subject to a deductible,there will be a"✓"or"D"in this column,depending on which deductible applies("✓"for Plan Deductible,"D"for Drug Deductible).If the Services do not apply to a deductible,or if your plan does not include a deductible,this column will be blank.For a more detailed explanation of deductibles,refer to"Plan Deductible"and"Drug Deductible"in the"Benefits"section of this EOC. • Applies to OOPM.This column explains whether the Cost Share you pay for Services counts toward the Plan Out- of-Pocket Maximum("OOPM")after you have met any applicable deductible.If the Services count toward the Plan OOPM,there will be a"✓"in this column.If the Services do not count toward the Plan OOPM,this column will be blank.For a more detailed explanation of the Plan OOPM,refer to"Plan Out-of-Pocket Maximum"heading in the "Benefits"section of this EOC. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#1 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 1 Administered drugs and products Copayment/ Subject to Applies to Description of Administered Drugs and Products Services Coinsurance Deductible OOPM Whole blood,red blood cells,plasma,and platelets No charge Allergy antigens(including administration) $3 per visit Cancer chemotherapy drugs and adjuncts No charge Drugs and products that are administered via intravenous therapy or No charge injection that are not for cancer chemotherapy,including blood factor ✓ products and biological products("biologics")derived from tissue, cells,or blood All other administered drugs and products No charge Drugs and products administered to you during a home visit No charge Ambulance Services Copayment/ Subject to Applies to Description of Ambulance Services Coinsurance Deductible OOPM Emergency ambulance Services $50 per trip Nonemergency ambulance and psychiatric transport van Services $50 per trip Behavioral health treatment for autism spectrum disorder Copayment/ Subject to Applies to Description of Behavioral Health Treatment Services Coinsurance Deductible OOPM Covered Services No charge Dialysis care Copayment/ Subject to Applies to Description of Dialysis Care Services Coinsurance Deductible OOPM Equipment and supplies for home hemodialysis and home peritoneal No charge It dialysis One routine outpatient visit per month with the multidisciplinary No charge It nephrology team for a consultation,evaluation,or treatment Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#1 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 2 Copayment/ Subject to Applies to Description of Dialysis Care Services Coinsurance Deductible OOPM Hemodialysis and peritoneal dialysis treatment at a Plan Facility $15 per visit ,/ Durable Medical Equipment("DME")for home use Copayment/ Subject to Applies to Description of DME Services Coinsurance Deductible OOPM Blood glucose monitors for diabetes blood testing and their supplies 20%Coinsurance Peak flow meters 20%Coinsurance Insulin pumps and supplies to operate the pump 20%Coinsurance Other Base DME Items as described in this EOC 20%Coinsurance Supplemental DME items as described in this EOC 20%Coinsurance Retail-grade milk pumps No charge Hospital-grade milk pumps No charge Emergency Services and Urgent Care Copayment/ Subject to Applies to Description of Emergency Services and Urgent Care Coinsurance Deductible OOPM Emergency department visits $100 per visit Urgent Care visits $15 per visit Note:If you are admitted to the hospital as an inpatient from the emergency department,the emergency department visits Cost Share above does not apply.Instead,the Services you received in the emergency department,including any observation stay,if applicable,will be considered part of your hospital inpatient stay.For the Cost Share for inpatient Services,refer to "Hospital inpatient Services"in this"Cost Share Summary."The emergency department Cost Share does apply if you are admitted for observation but are not admitted as an inpatient. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#1 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 3 Fertility Services Diagnosis and treatment of Infertility Copayment/ Subject to Applies to Description of Diagnosis and Treatment of Infertility Services Coinsurance Deductible OOPM Office visits $15 per visit Outpatient surgery and outpatient procedures(including imaging and $15 per procedure diagnostic Services)when performed in an outpatient or ambulatory surgery center or in a hospital operating room,or any setting where a licensed staff member monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or minimize discomfort Any other outpatient surgery that does not require a licensed staff $15 per procedure member to monitor your vital signs as described above Outpatient imaging No charge Outpatient laboratory No charge Outpatient administered drugs No charge Hospital inpatient Services(including room and board,drugs, No charge imaging,laboratory,other diagnostic and treatment Services,and Plan Physician Services) Artificial insemination Copayment/ Subject to Applies to Description of Artificial Insemination Services Coinsurance Deductible OOPM Office visits $15 per visit Outpatient surgery and outpatient procedures(including imaging and $15 per procedure diagnostic Services)when performed in an outpatient or ambulatory surgery center or in a hospital operating room,or any setting where a licensed staff member monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or minimize discomfort Any other outpatient surgery that does not require a licensed staff $15 per procedure member to monitor your vital signs as described above Outpatient imaging No charge Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#1 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 4 Copayment/ Subject to Applies to Description of Artificial Insemination Services Coinsurance Deductible OOPM Outpatient laboratory No charge Outpatient administered drugs No charge Hospital inpatient Services(including room and board,drugs, No charge imaging,laboratory,other diagnostic and treatment Services,and Plan Physician Services) Assisted reproductive technology("ART')Services Copayment/ Subject to Applies to Description of ART Services Coinsurance Deductible OOPM Assisted reproductive technology("ART")Services such as invitro Not covered fertilization("IVF"),gamete intra-fallopian transfer("GIFT"),or zygote intrafallopian transfer("ZIFT") Health education Copayment/ Subject to Applies to Description of Health Education Services Coinsurance Deductible OOPM Covered health education programs,which may include programs No charge ✓ provided online and counseling over the phone Individual counseling during an office visit related to tobacco No charge ✓ cessation Individual counseling during an office visit related to diabetes No charge ✓ management Other covered individual counseling when the office visit is solely for No charge ✓ health education Covered health education materials No charge Hearing Services Copayment/ Subject to Applies to Description of Hearing Services Coinsurance Deductible OOPM Hearing exams with an audiologist to determine the need for hearing $15 per visit It correction Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#1 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 5 Copayment/ Subject to Applies to Description of Hearing Services Coinsurance Deductible OOPM Physician Specialist Visits to diagnose and treat hearing problems $15 per visit ,/ Hearing aids,including,fitting,counseling,adjustment,cleaning,and We provide a$1,000 inspection Allowance for each ear every 36 months Home health care Copayment/ Subject to Applies to Description of Home Health Care Services Coinsurance Deductible OOPM Home health care Services(100 visits per Accumulation Period) No charge Hospice care Copayment/ Subject to Applies to Description of Hospice Care Services Coinsurance Deductible OOPM Hospice Services No charge Hospital inpatient Services Copayment/ Subject to Applies to Description of Hospital Inpatient Services Coinsurance Deductible OOPM Hospital inpatient stays No charge Injury to teeth Copayment/ Subject to Applies to Description of Injury to Teeth Services Coinsurance Deductible OOPM Accidental injury to teeth Not covered Mental health Services Copayment/ Subject to Applies to Description of Mental Health Services Coinsurance Deductible OOPM Inpatient mental health hospital stays No charge Individual mental health evaluation and treatment $15 per visit Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#1 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 6 Copayment/ Subject to Applies to Description of Mental Health Services Coinsurance Deductible OOPM Group mental health treatment $7 per visit Partial hospitalization No charge Other intensive psychiatric treatment programs No charge Residential mental health treatment Services No charge Office visits Copayment/ Subject to Applies to Description of Office Visit Services Coinsurance Deductible OOPM Primary Care Visits and Non-Physician Specialist Visits that are not $15 per visit ✓ described elsewhere in this"Cost Share Summary" Physician Specialist Visits that are not described elsewhere in this $15 per visit "Cost Share Summary" Group appointments that are not described elsewhere in this"Cost $7 per visit ✓ Share Summary" Acupuncture Services $15 per visit Ostomy and urological supplies Copayment/ Subject to Applies to Description of Ostomy and Urological Services Coinsurance Deductible OOPM Ostomy and urological supplies as described in this EOC No charge Outpatient imaging, laboratory, and other diagnostic and treatment Services Description of Outpatient Imaging,Laboratory,and Other Diagnostic Copayment/ Subject to Applies to and Treatment Services Coinsurance Deductible OOPM Complex imaging(other than preventive)such as CT scans,MRIs, No charge ✓ and PET scans Basic imaging Services,such as diagnostic and therapeutic X-rays, No charge ✓ mammograms,and ultrasounds Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#1 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 7 Description of Outpatient Imaging,Laboratory,and Other Diagnostic Copayment/ Subject to Applies to and Treatment Services Coinsurance Deductible OOPM Nuclear medicine No charge Routine retinal photography screenings No charge Routine laboratory tests to monitor the effectiveness of dialysis No charge All other laboratory tests(including tests for specific genetic No charge ✓ disorders for which genetic counseling is available) Diagnostic Services provided by Plan Providers who are not No charge ✓ physicians(such as EKGs and EEGs) Radiation therapy No charge Ultraviolet light treatments(including ultraviolet light therapy No charge equipment as described in this EOC) Outpatient prescription drugs, supplies, and supplements If the"Cost Share at a Plan Pharmacy"column in this section provides Cost Share for a 30-day supply and your Plan Physician prescribes more than this,you may be able to obtain more than a 30-day supply at one time up to the day supply limit for that drug.Applicable Cost Share will apply.For example,two 30-day copayments may be due when picking up a 60-day prescription,three copayments may be due when picking up a 100-day prescription at the pharmacy. Most items Cost Share Cost Share Subject to Applies to Description of Most Items at a Plan Pharmacy by Mail Deductible OOPM Items on Tier 1 not described elsewhere in $10 for up to a 30-day $20 for up to a 100-day ✓ this"Cost Share Summary" supply supply Items on Tier 2 not described elsewhere in $20 for up to a 30-day $40 for up to a 100-day ✓ this"Cost Share Summary" supply supply Items on Tier 4 not described elsewhere in $20 for up to a 30-day Availability for mail this"Cost Share Summary" supply order varies by item. ✓ Talk to your local pharmacy Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#1 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 8 Base drugs,supplies, and supplements Description of Base Drugs, Supplies and Cost Share Cost Share Subject to Applies to Supplements at a Plan Pharmacy by Mail Deductible OOPM Hematopoietic agents for dialysis No charge for up to a Not available ✓ 30-day supply Elemental dietary enteral formula when No charge for up to a Not available used as a primary therapy for regional 30-day supply ✓ enteritis All other items on Tier 1 as described in $10 for up to a 30-day Availability for mail this EOC supply order varies by item. ✓ Talk to your local pharmacy All other items on Tier 2 as described in $20 for up to a 30-day Availability for mail this EOC supply order varies by item. ✓ Talk to your local pharmacy All other items on Tier 4 as described in $20 for up to a 30-day Availability for mail this EOC supply order varies by item. ✓ Talk to your local pharmacy Anticancer drugs and certain critical adjuncts following a diagnosis of cancer Description of Anticancer Drugs and Cost Share Cost Share Subject to Applies to Certain Critical Adjuncts at a Plan Pharmacy by Mail Deductible OOPM Oral anticancer drugs on Tier 1 $10 for up to a 30-day Availability for mail supply order varies by item. ✓ Talk to your local pharmacy Oral anticancer drugs on Tier 2 $20 for up to a 30-day Availability for mail supply order varies by item. ✓ Talk to your local pharmacy Oral anticancer drugs on Tier 4 $20 for up to a 30-day Availability for mail supply order varies by item. ✓ Talk to your local pharmacy Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#1 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 9 Description of Anticancer Drugs and Cost Share Cost Share Subject to Applies to Certain Critical Adjuncts at a Plan Pharmacy by Mail Deductible OOPM Non-oral anticancer drugs on Tier 1 $10 for up to a 30-day Availability for mail supply order varies by item. ✓ Talk to your local pharmacy Non-oral anticancer drugs on Tier 2 $20 for up to a 30-day Availability for mail supply order varies by item. ✓ Talk to your local pharmacy Non-oral anticancer drugs on Tier 4 $20 for up to a 30-day Availability for mail supply order varies by item. ✓ Talk to your local pharmacy Home infusion drugs Cost Share Cost Share Subject to Applies to Description of Home Infusion Drugs at a Plan Pharmacy by Mail Deductible OOPM Home infusion drugs No charge for up to a Not available ✓ 30-day supply Supplies necessary for administration of No charge No charge ✓ home infusion drugs Home infusion drugs are self-administered intravenous drugs,fluids,additives,and nutrients that require specific types of parenteral-infusion,such as an intravenous or intraspinal-infusion. Diabetes supplies and amino acid—modified products Description of Diabetes Supplies and Cost Share Cost Share Subject to Applies to Amino Acid—Modified Products at a Plan Pharmacy by Mail Deductible OOPM Amino acid—modified products used to No charge for up to a Not available treat congenital errors of amino acid 30-day supply ✓ metabolism(such as phenylketonuria) Ketone test strips and sugar or acetone test No charge for up to a Not available ✓ tablets or tapes for diabetes urine testing 100-day supply Insulin-administration devices:pen $10 for up to a 100-day Availability for mail delivery devices,disposable needles and supply order varies by item. ✓ syringes,and visual aids required to Talk to your local ensure proper dosage(except eyewear) pharmacy Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#1 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 10 For drugs related to the treatment of diabetes(for example,insulin),and for continuous insulin delivery devices that use disposable items such as patches or pods,refer to the"Most items"table above.For insulin pumps,refer to the"Durable Medical Equipment("DME")for home use"table above. Contraceptive drugs and devices Description of Contraceptive Drugs and Cost Share Cost Share Subject to Applies to Devices at a Plan Pharmacy by Mail Deductible OOPM The following hormonal contraceptive No charge for up to a No charge for up to a items on Tier 1: 365-day supply 365-day supply • Rings Rings are not available ✓ for mail order • Patches • Oral contraceptives The following contraceptive items on No charge for up to a Not available Tier 1: 100-day supply • Spermicide ✓ • Sponges • Contraceptive gel The following hormonal contraceptive No charge for up to a No charge for up to a items on Tier 2: 365-day supply 365-day supply • Rings Rings are not available ✓ for mail order • Patches • Oral contraceptives The following contraceptive items on No charge for up to a Not available Tier 2: 100-day supply • Spermicide ✓ • Sponges • Contraceptive gel Emergency contraception No charge Not available ✓ Diaphragms,cervical caps,and up to a 30- No charge Not available ✓ day supply of condoms Certain preventive items Cost Share Cost Share Subject to Applies to Description of Certain Preventive Items at a Plan Pharmacy by Mail Deductible OOPM Items on our Preventive Services list on No charge for up to a Not available our website at ku.om/prevention when 100-day supply ✓ prescribed by a Plan Provider Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#1 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 11 Fertility and sexual dysfunction drugs Description of Fertility and Sexual Cost Share Cost Share Subject to Applies to Dysfunction Drugs at a Plan Pharmacy by Mail Deductible OOPM Drugs on Tier 1 prescribed to treat $10 for up to a 30-day $20 for up to a 100-day Infertility or in connection with covered supply supply artificial insemination Services Drugs on Tier 2 and Tier 4 prescribed to $20 for up to a 30-day $40 for up to a 100-day treat Infertility or in connection with supply supply covered artificial insemination Services Drugs on Tier 1 prescribed in connection Not covered Not covered with covered assisted reproductive technology("ART") Services Drugs on Tier 2 and Tier 4 prescribed in Not covered Not covered connection with covered assisted reproductive technology("ART") Services Drugs on Tier 1 prescribed for sexual 50%Coinsurance(not to 50%Coinsurance(not to dysfunction disorders exceed$50)for up to a exceed$50)for up to a ✓ 100-day supply 100-day supply Drugs on Tier 2 and Tier 4 prescribed for 50%Coinsurance(not to 50%Coinsurance(not to sexual dysfunction disorders exceed$100)for up to a exceed$100)for up to a ✓ 100-day supply 100-day supply Outpatient surgery and outpatient procedures Copayment/ Subject to Applies to Description of Outpatient Surgery and Outpatient Procedure Services Coinsurance Deductible OOPM Outpatient surgery and outpatient procedures(including imaging and $15 per procedure diagnostic Services)when provided in an outpatient or ambulatory surgery center or in a hospital operating room,or any setting where a ✓ licensed staff member monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or minimize discomfort Any other outpatient surgery that does not require a licensed staff $15 per procedure ✓ member to monitor your vital signs as described above Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#1 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 12 Preventive Services Copayment/ Subject to Applies to Description of Preventive Services Coinsurance Deductible OOPM Routine physical exams,including well-woman,postpartum follow- No charge ✓ up,and preventive exams for Members age 2 and older Well-child preventive exams for Members through age 23 months No charge ✓ Normal series of regularly scheduled preventive prenatal care exams No charge ✓ after confirmation of pregnancy Immunizations(including the vaccine)administered to you in a Plan No charge ✓ Medical Office Tuberculosis skin tests No charge ✓ Screening and counseling Services when provided during a routine No charge physical exam or a well-child preventive exam,such as obesity counseling,routine vision and hearing screenings,alcohol and ✓ substance abuse screenings,health education,depression screening, and developmental screenings to diagnose and assess potential developmental delays Screening colonoscopies No charge ✓ Screening flexible sigmoidoscopies No charge ✓ Routine imaging screenings such as mammograms No charge ✓ Bone density CT scans No charge ✓ Bone density DEXA scans No charge ✓ Routine laboratory tests and screenings,such as cancer screening No charge tests,sexually transmitted infection("STI")tests,cholesterol ✓ screening tests,and glucose tolerance tests Other laboratory screening tests,such as fecal occult blood tests and No charge ✓ hepatitis B screening tests Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#1 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 13 Prosthetic and orthotic devices Copayment/ Subject to Applies to Description of Prosthetic and Orthotic Device Services Coinsurance Deductible OOPM Internally implanted prosthetic and orthotic devices as described in No charge ✓ this EOC External prosthetic and orthotic devices as described in this EOC No charge Supplemental prosthetic and orthotic devices as described in this No charge ✓ EOC Rehabilitative and habilitative Services Copayment/ Subject to Applies to Description of Rehabilitative and Habilitative Services Coinsurance Deductible OOPM Individual outpatient physical,occupational,and speech therapy $15 per visit Group outpatient physical,occupational,and speech therapy $7 per visit Physical,occupational,and speech therapy provided in an organized, $15 per day ✓ multidisciplinary rehabilitation day-treatment program Reproductive Health Services Family planning Services Copayment/ Subject to Applies to Description of Family Planning Services Coinsurance Deductible OOPM Family planning counseling No charge Injectable contraceptives,internally implanted time-release No charge contraceptives or intrauterine devices("IUDs")and office visits ✓ related to their insertion,removal,and management when provided to prevent pregnancy Sterilization procedures for Members assigned female at birth if No charge performed in an outpatient or ambulatory surgery center or in a hospital operating room All other sterilization procedures for Members assigned female at No charge ✓ birth Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#1 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 14 Copayment/ Subject to Applies to Description of Family Planning Services Coinsurance Deductible OOPM Sterilization procedures for Members assigned male at birth if No charge performed in an outpatient or ambulatory surgery center or in a hospital operating room All other sterilization procedures for Members assigned male at birth No charge Abortion and abortion-related Services Copayment/ Subject to Applies to Description of abortion and abortion-related Services Coinsurance Deductible OOPM Surgical abortion No charge Prescription drugs,in accord with our drug formulary guidelines No charge Other abortion-related Services No charge Skilled nursing facility care Copayment/ Subject to Applies to Description of Skilled Nursing Facility Care Services Coinsurance Deductible OOPM Skilled nursing facility Services up to 100 days per benefit period* No charge 1/ *A benefit period begins on the date you are admitted to a hospital or Skilled Nursing Facility at a skilled level of care.A benefit period ends on the date you have not been an inpatient in a hospital or Skilled Nursing Facility,receiving a skilled level of care,for 60 consecutive days.A new benefit period can begin only after any existing benefit period ends.A prior three-day stay in an acute care hospital is not required. Substance use disorder treatment Copayment/ Subject to Applies to Description of Substance Use Disorder Treatment Services Coinsurance Deductible OOPM Inpatient detoxification No charge Individual substance use disorder evaluation and treatment $15 per visit Group substance use disorder treatment $5 per visit Intensive outpatient and day-treatment programs No charge Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#1 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 15 Copayment/ Subject to Applies to Description of Substance Use Disorder Treatment Services Coinsurance Deductible OOPM Residential substance use disorder treatment No charge Telehealth visits Interactive video visits Copayment/ Subject to Applies to Description of Interactive Video Visit Services Coinsurance Deductible OOPM Primary Care Visits and Non-Physician Specialist Visits No charge Physician Specialist Visits No charge Scheduled telephone visits Copayment/ Subject to Applies to Description of Scheduled Telephone Visit Services Coinsurance Deductible OOPM Primary Care Visits and Non-Physician Specialist Visits No charge Physician Specialist Visits No charge Vision Services for Adult Members Copayment/ Subject to Applies to Description of Vision Services for Adult Members Coinsurance Deductible OOPM Routine eye exams with a Plan Optometrist to determine the need for No charge ✓ vision correction and to provide a prescription for eyeglass lenses Physician Specialist Visits to diagnose and treat injuries or diseases $15 per visit ✓ of the eye Non-Physician Specialist Visits to diagnose and treat injuries or $15 per visit ✓ diseases of the eye Aniridia lenses:up to two Medically Necessary contact lenses per eye No charge ✓ (including fitting and dispensing)in any 12-month period Aphakia lenses:up to six Medically Necessary aphakic contact lenses No charge ✓ per eye(including fitting and dispensing)in any 12-month period Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#1 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 16 Copayment/ Subject to Applies to Description of Vision Services for Adult Members Coinsurance Deductible OOPM Specialty contact lenses(other than aniridia and aphakia lenses)that No charge after optical will provide a significant improvement in vision not obtainable with Allowance applied eyeglass lenses: either one pair of contact lenses(including fitting and dispensing)or an initial supply of disposable contact lenses(up to six months,including fitting and dispensing)in any 24-month period Eyeglasses and contact lenses as described in this EOC We provide a$175 Allowance every 24 months Replacement lenses if there has been a change in prescription of at We provide a$30 least.50 diopter in one or both eyes within 12 months of the initial Allowance for a single point of sale of an eyeglass lens or contact lens that we provided an vision eyeglass lens or Allowance toward(or otherwise covered) contact lens,a$45 Allowance for a multifocal or lenticular eyeglass lens Low vision devices(including fitting and dispensing) Not covered Vision Services for Pediatric Members Copayment/ Subject to Applies to Description of Vision Services for Pediatric Members Coinsurance Deductible OOPM Routine eye exams with a Plan Optometrist to determine the need for No charge ✓ vision correction and to provide a prescription for eyeglass lenses Physician Specialist Visits to diagnose and treat injuries or diseases $15 per visit ✓ of the eye Non-Physician Specialist Visits to diagnose and treat injuries or $15 per visit ✓ diseases of the eye Aniridia lenses:up to two Medically Necessary contact lenses per eye No charge ✓ (including fitting and dispensing)in any 12-month period Aphakia lenses:up to six Medically Necessary aphakic contact lenses No charge ✓ per eye(including fitting and dispensing)in any 12-month period Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#1 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 17 Copayment/ Subject to Applies to Description of Vision Services for Pediatric Members Coinsurance Deductible OOPM Specialty contact lenses(other than aniridia and aphakia lenses)that No charge after optical will provide a significant improvement in vision not obtainable with Allowance applied eyeglass lenses: either one pair of contact lenses(including fitting and dispensing)or an initial supply of disposable contact lenses(up to six months,including fitting and dispensing)in any 24-month period Eyeglasses and contact lenses as described in this EOC We provide a$175 Allowance every 24 months Replacement lenses if there has been a change in prescription of at No charge least.50 diopter in one or both eyes within 12 months of the initial point of sale of an eyeglass lens or contact lens that we provided an Allowance toward(or otherwise covered) Low vision devices(including fitting and dispensing) Not covered CARE Plan The California Community Assistance,Recovery,and Empowerment("CARE")Act established a system for individuals with severe mental illness to be evaluated and given a treatment plan developed by a county behavioral health agency ("CARE Plan").If a Member has a court-approved CARE Plan,we cover the Services required under that plan when provided by Plan Providers or non-Plan Providers at no charge,with the exception of prescription drugs.Prescription drugs required under a court-approved CARE Plan are subject to the same Cost Share as drugs prescribed by Plan Providers,as described in this Cost Share Summary,and are also subject to prior authorization by Health Plan.To inform us that you have a court-approved CARE Plan,please call Member Services. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#1 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 18 Introduction coverage information in this EOC applies when you obtain care in your Home Region.When you visit the This Evidence of Coverage("EOC")describes the health other California Region,you may receive care as described in"Receiving Care Outside of Your Home care coverage of this Kaiser Permanente Traditional Region Service Area"in the"How to Obtain Services" HMO Plan provided under the Group Agreement section. ("Agreement")between Kaiser Foundation Health Plan, Inc. ("Health Plan")and the entity with which Health Plan has entered into the Agreement(your"Group"). Kaiser Permanente provides Services directly to our Members through an integrated medical care program. Health Plan,Plan Hospitals,and the Medical Group This EOC is part of the Agreement between work together to provide our Members with quality care. Health Plan and your Group. The Agreement Our medical care program gives you access to all of the contains additional terms such as Premiums, covered Services you may need,such as routine care when coverage can change, the effective date with your own personal Plan Physician,hospital of coverage, and the effective date of Services,laboratory and pharmacy Services,Emergency Services,Urgent Care,and other benefits described in termination. The Agreement must be consulted this EOC.Plus,our health education programs offer you to determine the exact terms of coverage. A great ways to protect and improve your health. copy of the Agreement is available from your Group. We provide covered Services to Members using Plan Providers located in our Service Area,which is described Once enrolled in other coverage made available through in the"Definitions"section.You must receive all Health Plan,that other plan's evidence of coverage covered care from Plan Providers inside our Service cannot be cancelled without cancelling coverage under Area,except as described in the sections listed below for this EOC,unless the change is made during open the following Services: enrollment or a special enrollment period. • Authorized referrals as described under"Getting a Referral"in the"How to Obtain Services"section For benefits provided under any other program offered • Covered Services received outside of your Home by your Group(for example,workers compensation Region Service Area as described under"Receiving benefits),refer to your Group's materials. Care Outside of Your Home Region Service Area"in the"How to Obtain Services"section In this EOC,Health Plan is sometimes referred to as "we"or"us."Members are sometimes referred to as • Emergency ambulance Services as described under "you."Some capitalized terms have special meaning in "Ambulance Services"in the"Benefits"section this EOC;please see the"Definitions"section for terms . Emergency Services,Post-Stabilization Care,and you should know. Out-of-Area Urgent Care as described in the "Emergency Services and Urgent Care"section It is important to familiarize yourself with your coverage . Hospice care as described under"Hospice Care"in by reading this EOC completely,so that you can take full the"Benefits"section advantage of your Health Plan benefits.Also,if you have special health care needs,please carefully read the sections that apply to you. Term of this EOC This EOC is for the period January 1,2024,through About Kaiser Permanente December 31,2024,unless amended.Your Group can tell you whether this EOC is still in effect and give you a PLEASE READ THE FOLLOWING current one if this EOC has expired or been amended. INFORMATION SO THAT YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS YOU MAY GET HEALTH CARE. Definitions r When you join Kaiser Permanente,you are enrolling in one of two Health Plan Regions in California(either our Some terms have special meaning in this EOC.When we Northern California Region or Southern California use a term with special meaning in only one section of Region),which we call your"Home Region."The this EOC,we define it in that section.The terms in this Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 19 "Definitions"section have special meaning when • For all other Services received from Non-Plan capitalized and used in any section of this EOC. Providers(including Post-Stabilization Services that Accumulation Period:A period of time no greater than are not Emergency Services under federal law),the 12 consecutive months for purposes of accumulating amount(1)required to be paid pursuant to state law, amounts toward any deductibles(if applicable),out-of- when it is applicable,or federal law,or(2)in the pocket maximums,and benefit limits.For example,the event that neither state or federal law prohibiting Accumulation Period may be a calendar year or contract balance billing apply,then the amount agreed to by year.The Accumulation Period for this EOC is from the Non-Plan Provider and Health Plan or,absent January 1 through December 31. such an agreement,the usual,customary and reasonable rate for those services as determined by Allowance:A specified amount that you can use toward Health Plan based on objective criteria the purchase price of an item.If the price of the items • For all other Services,the payments that Kaiser you select exceeds the Allowance,you will pay the Permanente makes for the Services or,if Kaiser amount in excess of the Allowance(and that payment will not apply toward any deductible or out-of-pocket Permanente subtracts your Cost Share from its payment,the amount Kaiser Permanente would have maximum). paid if it did not subtract your Cost Share Ancillary Coverage: Optional benefits such as acupuncture,chiropractic,or dental coverage that may be Cigna PPO Network: The Cigna PPO Network refers to available to Members enrolled under this EOC. If your the health care providers(doctors,hospitals,specialists) plan includes Ancillary Coverage,this coverage will be contracted as part of a shared administration network described in an amendment to this EOC or a separate arrangement called Cigna PPO for Shared agreement from the issuer of the coverage. Administration. Charges: "Charges"means the following: Cigna is an independent company and not affiliated with • For Services provided by the Medical Group or Kaiser Foundation Health Plan,Inc.,and its subsidiary Kaiser Foundation Hospitals,the charges in Health health plans.Access to the Cigna PPO Network is Plan's schedule of Medical Group and Kaiser available through Cigna's contractual relationship with Foundation Hospitals charges for Services provided the Kaiser Permanente health plans.The Cigna PPO to Members Network is provided exclusively by or through operating • For Services for which a provider(other than the subsidiaries of Cigna Corporation,including Cigna Medical Group or Kaiser Foundation Hospitals)is Health and Life Insurance Company.The Cigna name, compensated on a capitation basis,the charges in the logo,and other Cigna marks are owned by Cigna schedule of charges that Kaiser Permanente Intellectual Property,Inc. negotiates with the capitated provider Coinsurance:A percentage of Charges that you must • For items obtained at a pharmacy owned and operated pay when you receive a covered Service under this EOC. by Kaiser Permanente,the amount the pharmacy Copayment:A specific dollar amount that you must pay would charge a Member for the item if a Member's when you receive a covered Service under this EOC. benefit plan did not cover the item(this amount is an Note: The dollar amount of the Copayment can be$0 estimate of:the cost of acquiring,storing,and (no charge). dispensing drugs,the direct and indirect costs of providing Kaiser Permanente pharmacy Services to Cost Share:The amount you are required to pay for Members,and the pharmacy program's contribution covered Services.For example,your Cost Share may be to the net revenue requirements of Health Plan) a Copayment or Coinsurance.If your coverage includes a • For air ambulance Services received from Non-Plan Plan Deductible and you receive Services that are subject Providers when you have an Emergency Medical to the Plan Deductible,your Cost Share for those Condition,the amount required to be paid by Health Services will be Charges until you reach the Plan Plan pursuant to federal law Deductible. Similarly,if your coverage includes a Drug Deductible,and you receive Services that are subject to • For other Emergency Services received from Non- the Drug Deductible,your Cost Share for those Services Plan Providers(including Post-Stabilization Care that will be Charges until you reach the Drug Deductible. constitutes Emergency Services under federal law), the amount required to be paid by Health Plan Dependent:A Member who meets the eligibility pursuant to state law,when it is applicable,or federal requirements as a Dependent(for Dependent eligibility requirements,see"Who Is Eligible"in the"Premiums, law Eligibility,and Enrollment"section). Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 20 Disclosure Form("DF"):A summary of coverage for Stabilization Care"in the"Emergency Services" prospective Members.For some products,the DF is section combined with the evidence of coverage. EOC: This Evidence of Coverage document,including Drug Deductible: The amount you must pay under this any amendments,which describes the health care EOC in the Accumulation Period for certain drugs, coverage of"Kaiser Permanente Traditional HMO Plan" supplies,and supplements before we will cover those under Health Plan's Agreement with your Group. Services at the applicable Copayment or Coinsurance in Family:A Subscriber and all of their Dependents. that Accumulation Period.Refer to the"Cost Share Summary"section to learn whether your coverage Group: The entity with which Health Plan has entered includes a Drug Deductible,the Services that are subject into the Agreement that includes this EOC. to the Drug Deductible,and the Drug Deductible Health Plan:Kaiser Foundation Health Plan,Inc.,a amount. California nonprofit corporation.Health Plan is a health Emergency Medical Condition:A medical condition care service plan licensed to offer health care coverage manifesting itself by acute symptoms of sufficient by the Department of Managed Health Care.This EOC severity(including severe pain)such that you reasonably sometimes refers to Health Plan as"we"or"us." believed that the absence of immediate medical attention Home Region: The Region where you enrolled(either would result in any of the following: the Northern California Region or the Southern • Placing the person's health(or,with respect to a California Region). pregnant person,the health of the pregnant person or unborn child)in serious jeopardy Infertility:A person's inability to conceive a pregnancy or carry a pregnancy to live birth either as an individual • Serious impairment to bodily functions or with their partner;or,a Plan Physician's determination • Serious dysfunction of any bodily organ or part of Infertility,based on a patient's medical,sexual,and reproductive history,age,physical findings,diagnostic A mental health condition is an Emergency Medical testing,or any combination of those factors. Condition when it meets the requirements of the paragraph above,or when the condition manifests itself Kaiser Permanente:Kaiser Foundation Hospitals(a by acute symptoms of sufficient severity such that either California nonprofit corporation),Health Plan,and the of the following is true: Medical Group. • The person is an immediate danger to themself or to Kaiser Permanente State: California,Colorado,District others of Columbia,Georgia,Hawaii,Maryland,Oregon, • The person is immediately unable to provide for,or Virginia,and Washington. use,food,shelter,or clothing,due to the mental Medical Group: The Permanente Medical Group,Inc.,a disorder for-profit professional corporation. Emergency Services:All of the following with respect Medically Necessary:For Services related to mental to an Emergency Medical Condition: health or substance use disorder treatment,a Service is • A medical screening exam that is within the Medically Necessary if it is addressing your specific capability of the emergency department of a hospital needs,for the purpose of preventing,diagnosing,or or an independent freestanding emergency treating an illness,injury,condition,or its symptoms, department,including ancillary services(such as including minimizing the progression of that illness, imaging and laboratory Services)routinely available injury,condition,or its symptoms,in a manner that is all to the emergency department to evaluate the of the following: Emergency Medical Condition • In accordance with the generally accepted standards • Within the capabilities of the staff and facilities of mental health and substance use disorder care available at the facility,Medically Necessary • Clinically appropriate in terms of type,frequency, examination and treatment required to Stabilize the extent,site,and duration patient(once your condition is Stabilized, Services • Not primarily for the economic benefit of the health you receive are Post-Stabilization Care and not care service plan and subscribers or for the Emergency Services) convenience of the patient,treating physician,or • Post-Stabilization Care furnished by a Non-Plan other health care provider Provider is covered as Emergency Services when For all other Services,a Service is Medically Necessary federal law applies,as described under Post- if it is medically appropriate and required to prevent, Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 21 diagnose,or treat your condition or clinical symptoms in Services that are subject to the Plan Deductible,and the accord with generally accepted professional standards of Plan Deductible amount. practice that are consistent with a standard of care in the Plan Facility:Any facility listed in the Provider medical community. Directory on our website at kp.org/facilities.Plan Medicare: The federal health insurance program for Facilities include Plan Hospitals,Plan Medical Offices, people 65 years of age or older,some people under age and other facilities that we designate in the directory. 65 with certain disabilities,and people with end-stage The directory is updated periodically.The availability of renal disease(generally those with permanent kidney Plan Facilities may change.If you have questions,please failure who need dialysis or a kidney transplant). call Member Services. Member:A person who is eligible and enrolled under Plan Hospital:Any hospital listed in the Provider this EOC,and for whom we have received applicable Directory on our website at kp.org/facilities.In the Premiums.This EOC sometimes refers to a Member as directory,some Plan Hospitals are listed as Kaiser "you." Permanente Medical Centers.The directory is updated Non-Physician Specialist Visits: Consultations, periodically.The availability of Plan Hospitals may evaluations,and treatment by non-physician specialists change.If you have questions,please call Member (such as nurse practitioners,physician assistants, Services. optometrists,podiatrists,and audiologists).For Services Plan Medical Office:Any medical office listed in the described under"Dental and Orthodontic Services"in Provider Directory on our website at kp.org/facilities.In the`Benefits"section,non-physician specialists include the directory,Kaiser Permanente Medical Centers may dentists and orthodontists. include Plan Medical Offices.The directory is updated Non—Plan Hospital:A hospital other than a Plan periodically.The availability of Plan Medical Offices Hospital. may change.If you have questions,please call Member Services. Non—Plan Physician:A physician other than a Plan Plan Optical Sales Office:An optical sales office Physician. owned and operated by Kaiser Permanente or another Non—Plan Provider:A provider other than a Plan optical sales office that we designate.Refer to the Provider. Provider Directory on our website at kp.org/facilities for Non—Plan Psychiatrist:A psychiatrist who is not a Plan locations of Plan Optical Sales Offices.In the directory, Physician. Plan Optical Sales Offices may be called"Vision Essentials."The directory is updated periodically.The Out-of-Area Urgent Care:Medically Necessary availability of Plan Optical Sales Offices may change.If Services to prevent serious deterioration of your(or your you have questions,please call Member Services. unborn child's)health resulting from an unforeseen Plan Optometrist:An optometrist who is a Plan illness,unforeseen injury,or unforeseen complication of Provider. an existing condition(including pregnancy)if all of the following are true: Plan Out-of-Pocket Maximum: The total amount of • You are temporarily outside our Service Area Cost Share you must pay under this EOC in the Accumulation Period for certain covered Services that • A reasonable person would have believed that your you receive in the same Accumulation Period.Refer to (or your unborn child's)health would seriously the"Cost Share Summary"section to find your Plan Out- deteriorate if you delayed treatment until you returned of-Pocket Maximum amount and to learn which Services to our Service Area apply to the Plan Out-of-Pocket Maximum. Physician Specialist Visits: Consultations,evaluations, Plan Pharmacy:A pharmacy owned and operated by and treatment by physician specialists,including Kaiser Permanente or another pharmacy that we personal Plan Physicians who are not Primary Care designate.Refer to the Provider Directory on our website Physicians. at kp.org/facilities for locations of Plan Pharmacies.The Plan Deductible: The amount you must pay under this directory is updated periodically.The availability of Plan EOC in the Accumulation Period for certain Services Pharmacies may change.If you have questions,please before we will cover those Services at the applicable call Member Services. Copayment or Coinsurance in that Accumulation Period. Plan Physician:Any licensed physician who is an Refer to the"Cost Share Summary"section to learn employee of the Medical Group,or any licensed whether your coverage includes a Plan Deductible,the physician who contracts to provide Services to Members Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 22 (but not including physicians who contract only to available on our website at kp.m/facilities.To obtain a provide referral Services). printed copy,call Member Services.The directory is Plan Provider:A Plan Hospital,a Plan Physician,the updated periodically.The availability of Plan Physicians Medical Group,a Plan Pharmacy,or any other health and Plan Facilities may change.If you have questions, care provider that Health Plan designates as a Plan please call Member Services. Provider. Region:A Kaiser Foundation Health Plan organization Plan Skilled Nursing Facility:A Skilled Nursing or allied plan that conducts a direct-service health care Facility approved by Health Plan. program.Regions may change on January 1 of each year and are currently the District of Columbia and parts of Post-Stabilization Care: Medically Necessary Services Northern California,Southern California,Colorado, related to your Emergency Medical Condition that you Georgia,Hawaii,Idaho,Maryland,Oregon,Virginia, receive in a hospital(including the emergency and Washington.For the current list of Region locations, department),an independent freestanding emergency please visit our website at ku.org or call Member department,or a skilled nursing facility after your Services. treating physician determines that this condition is Service Area: The ZIP codes below for each county are Stabilized.Post-Stabilization Care also includes durable in our Service Area: medical equipment covered under this EOC,if it is Medically Necessary after discharge from an emergency • All ZIP codes in Alameda County are inside our department and related to the same Emergency Medical Northern California Service Area: 94501-02,94505, Condition.For more information about durable medical 94514,94536-46,94550-52,94555,94557,94560, equipment covered under this EOC,see"Durable 94566,94568,94577-80,94586-88,94601-15, Medical Equipment("DME")for Home Use"in the 94617-21,94622-24,94649,94659-62,94666, "Benefits"section. 94701-10,94712,94720,95377,95391 Premiums: The periodic amounts that your Group is • The following ZIP codes in Amador County are responsible for paying for your membership under this inside our Northern California Service Area: 95640, EOC, except that you are responsible for paying 95669 Premiums if you have Cal-COBRA coverage."Full . All ZIP codes in Contra Costa County are inside our Premiums"means 100 percent of Premiums for all of the Northern California Service Area: 94505-07,94509, coverage issued to each enrolled Member,as set forth in 94511,94513-14,94516-31,94547-49,94551, the"Premiums"section of Health Plan's Agreement with 94553,94556,94561,94563-65,94569-70,94572, your Group. 94575,94582-83,94595-98,94706-08,94801-08, Preventive Services: Covered Services that prevent or 94820,94850 detect illness and do one or more of the following: • The following ZIP codes in El Dorado County are • Protect against disease and disability or further inside our Northern California Service Area: 95613- progression of a disease 14,95619,95623,95633-35,95651,95664,95667, 95672,95682,95762 • Detect disease in its earliest stages before noticcablc symptoms develop • The following ZIP codes in Fresno County are inside our Northern California Service Area: 93242,93602, Primary Care Physicians: Generalists in internal 93606-07,93609,93611-13,93616,93618-19, medicine,pediatrics,and family practice,and specialists 93624-27,93630-31,93646,93648-52,93654, in obstetrics/gynecology whom the Medical Group 93656-57,93660,93662,93667-68,93675,93701- designates as Primary Care Physicians.Refer to the 12,93714-18,93720-30,93737,93740-41,93744-45, Provider Directory on our website at ky.org/facilities for 93747,93750,93755,93760-61,93764-65,93771- a list of physicians that are available as Primary Care 79,93786,93790-94,93844,93888 Physicians. The directory is updated periodically.The • The following ZIP codes in Kings County are inside availability of Primary Care Physicians may change.If you have questions,please call Member Services. our Northern California Service Area: 93230,93232, 93242,93631,93656 Primary Care Visits:Evaluations and treatment • The following ZIP codes in Madera County are inside provided by Primary Care Physicians and primary care our Northern California Service Area: 93601-02, Plan Providers who are not physicians(such as nurse 93604,93614,93623,93626,93636-39,93643-45, practitioners). 93653,93669,93720 Provider Directory:A directory of Plan Physicians and • All ZIP codes in Marin County are inside our Plan Facilities in your Home Region.This directory is Northern California Service Area: 94901,94903-04, Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 23 94912-15,94920,94924-25,94929-30,94933, 95005-7,95010,95017-19,95033,95041,95060-67, 94937-42,94945-50,94956-57,94960,94963-66, 95073,95076-77 94970-71,94973-74,94976-79 • All ZIP codes in Solano County are inside our • The following ZIP codes in Mariposa County are Northern California Service Area: 94503,94510, inside our Northern California Service Area: 93 60 1, 94512,94533-35,94571,94585,94589-92,95616, 93623,93653 95618,95620,95625,95687-88,95690,95694, • All ZIP codes in Napa County are inside our Northern 95696 California Service Area: 94503,94508,94515, • The following ZIP codes in Sonoma County are 94558-59,94562,94567,94573-74,94576,94581, inside our Northern California Service Area: 94515, 94599,95476 94922-23,94926-28,94931,94951-55,94972, • The following ZIP codes in Placer County are inside 94975,94999,95401-07,95409,95416,95419, our Northern California Service Area: 95602-04, 95421,95425,95430-31,95433,95436,95439, 95610,95626,95648,95650,95658,95661,95663, 95441-42,95444,95446,95448,95450,95452, 95668,95677-78,95681,95703,95722,95736, 95462,95465,95471-73,95476,95486-87,95492 95746-47,95765 • All ZIP codes in Stanislaus County are inside our • All ZIP codes in Sacramento County are inside our Northern California Service Area: 95230,95304, Northern California Service Area: 94203-09,94211, 95307,95313,95316,95319,95322-23,95326, 94229-30,94232,94234-37,94239-40,94244-45, 95328-29,95350-58,95360-61,95363,95367-68, 94247-50,94252,94254,94256-59,94261-63, 95380-82,95385-87,95397 94267-69,94271,94273-74,94277-80,94282-85, • The following ZIP codes in Sutter County are inside 94287-91,94293-98,94571,95608-11,95615, our Northern California Service Area: 95626,95645, 95621,95624,95626,95628,95630,95632,95638- 95659,95668,95674,95676,95692,95836-7 39,95641,95652,95655,95660,95662,95670-71, • The following ZIP codes in Tulare County are inside 95673,95678,95680,95683,95690,95693,95741- our Northern California Service Area: 93618,93631, 42,95757-59,95763,95811-38,95840-43,95851-53, 93646,93654,93666,93673 95860,95864-67,95894,95899 • The following ZIP codes in Yolo County are inside • All ZIP codes in San Francisco County are inside our our Northern California Service Area: 95605,95607, Northern California Service Area: 94102-05,94107- 95612,95615-18,95645,95691,95694-95,95697- 12,94114-34,94137,94139-47,94151,94158-61, 98,95776,95798-99 94163-64,94172,94177,94188 • The following ZIP codes in Yuba County are inside • All ZIP codes in San Joaquin County are inside our our Northern California Service Area: 95692,95903, Northern California Service Area: 94514,95201-15, 95961 95219-20,95227,95230-31,95234,95236-37, 95240-42,95253,95258,95267,95269,95296-97, For each ZIP code listed for a county,our Service Area 95304,95320,95330,95336-37,95361,95366, includes only the part of that ZIP code that is in that 95376-78,95385,95391,95632,95686,95690 county.When a ZIP code spans more than one county, • All ZIP codes in San Mateo County are inside our the part of that ZIP code that is in another county is not Northern California Service Area: 94002,94005, inside our Service Area unless that other county is listed 94010-11,94014-21,94025-28,94030,94037-38, above and that ZIP code is also listed for that other 94044,94060-66,94070,94074,94080,94083, county. 94128,94303,94401-04,94497 If you have a question about whether a ZIP code is in our • The following ZIP codes in Santa Clara County are Service Area,please call Member Services. inside our Northern California Service Area: 94022- Note:We may expand our Service Area at any time by 24,94035,94039-43,94085-89,94301-06,94309, giving written notice to your Group.ZIP codes are 94550,95002,95008-09,95011,95013-15,95020- subject to change by the U.S.Postal Service. 21 95026 95030-33 95035-38 95042 95044 95046,95050-56,95070-71,95076,95101,95103, Services:Health care services or items("health care" 95106,95108-13,95115-36,95138-41,95148, includes physical health care,mental health care,and 95150-61,95164,95170,95172-73,95190-94,95196 substance use disorder treatment),and behavioral health treatment covered under"Behavioral Health Treatment • All ZIP codes in Santa Cruz County are inside our for Autism Spectrum Disorder"in the"Benefits"section. Northern California Service Area: 95001,95003, Skilled Nursing Facility:A facility that provides inpatient skilled nursing care,rehabilitation services,or Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 24 other related health services and is licensed by the state Premiums, Eligibility, a n d of California.The facility's primary business must be the provision of24-hour-a-day licensed skilled nursing care. Enrollment The term"Skilled Nursing Facility"does not include convalescent nursing homes,rest facilities,or facilities Premiums for the aged,if those facilities furnish primarily custodial care,including training in routines of daily living.A Your Group is responsible for paying Full Premiums, "Skilled Nursing Facility"may also be a unit or section except that you are responsible for paying Full Premiums within another facility(for example,a hospital)as long as described in the"Continuation of Membership" as it continues to meet this definition. section if you have Cal-COBRA coverage under this EOC.If you are responsible for any contribution to the Spouse: The person to whom the Subscriber is legally Premiums that your Group pays,your Group will tell you married under applicable law.For the purposes of this the amount,when Premiums are effective,and how to EOC,the term"Spouse"includes the Subscriber's pay your Group(through payroll deduction,for domestic partner."Domestic partners"are two people example). who are registered and legally recognized as domestic partners by California(if your Group allows enrollment of domestic partners not legally recognized as domestic Who Is Eligible partners by California,"Spouse"also includes the Subscriber's domestic partner who meets your Group's To enroll and to continue enrollment,you must meet all eligibility requirements for domestic partners). of the eligibility requirements described in this"Who Is Eligible"section,including your Group's eligibility Stabilize: To provide the medical treatment of the requirements and our Service Area eligibility Emergency Medical Condition that is necessary to requirements. assure,within reasonable medical probability,that no material deterioration of the condition is likely to result Group eligibility requirements from or occur during the transfer of the person from the facility.With respect to a pregnant person who is having You must meet your Group's eligibility requirements, contractions,when there is inadequate time to safely such as the minimum number of hours that employees transfer them to another hospital before delivery(or the must work.Your Group is required to inform Subscribers transfer may pose a threat to the health or safety of the of its eligibility requirements. pregnant person or unborn child),"Stabilize"means to deliver(including the placenta). Service Area eligibility requirements The"Definitions"section describes our Service Area and Subscriber:A Member who is eligible for membership how it may change. on their own behalf and not by virtue of Dependent status and who meets the eligibility requirements as a Subscribers must live or work inside our Service Area at Subscriber(for Subscriber eligibility requirements,see the time they enroll.If after enrollment the Subscriber no "Who Is Eligible"in the"Premiums,Eligibility,and longer lives or works inside our Service Area,the Enrollment"section). Subscriber can continue membership unless(1)they live Surrogacy Arrangement:An arrangement in which an inside or move to the service area of another Region and individual agrees to become pregnant and to surrender do not work inside our Service Area,or(2)your Group the baby(or babies)to another person or persons who does not allow continued enrollment of Subscribers who intend to raise the child(or children),whether or not the do not live or work inside our Service Area. individual receives payment for being a surrogate.For the purposes of this EOC, "Surrogacy Arrangements" Dependent children of the Subscriber or of the includes all types of surrogacy arrangements,including Subscriber's Spouse may live anywhere inside or outside traditional surrogacy arrangements and gestational our Service Area.Other Dependents may live anywhere, surrogacy arrangements. except that they are not eligible to enroll or to continue Telehealth Visits:Interactive video visits and scheduled enrollment if they live in or move to the service area of another Region. telephone visits between you and your provider. Urgent Care: Medically Necessary Services for a If you are not eligible to continue enrollment because condition that requires prompt medical attention but is you live in or move to the service area of another not an Emergency Medical Condition. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 25 Region,please contact your Group to learn about your ♦ children placed with you for adoption Group health care options: ♦ foster children if you or your Spouse have the • Regions outside California.You may be able to legal authority to direct their care enroll in the service area of another Region if there is ♦ children for whom you or your Spouse is the an agreement between your Group and that Region, court-appointed guardian(or was when the child but the plan,including coverage,premiums,and reached age 18) eligibility requirements,might not be the same as . Children whose parent is a Dependent child under under this EOC your family coverage(including adopted children and • Southern California Region's service area.Your children placed with your Dependent child for Group may have an arrangement with us that permits adoption or foster care),if they meet all of the membership in the Southern California Region,but following requirements: the plan,including coverage,premiums,and ♦ they are not married and do not have a domestic eligibility requirements,might not be the same as partner(for the purposes of this requirement only, under this EOC.All terms and conditions in your "domestic partner"means someone who is application for enrollment in the Northern California registered and legally recognized as a domestic Region,including the Arbitration Agreement,will partner by California) continue to apply if the Subscriber does not submit a ♦ they meet the requirements described under"Age new enrollment form limit of Dependent children" For more information about the service areas of the other ♦ they receive all of their support and maintenance Regions,please call Member Services. from you or your Spouse ♦ they permanently reside with you or your Spouse Eligibility as a Subscriber You may be eligible to enroll and continue enrollment as If you have a baby a Subscriber if you are: If you have a baby while enrolled under this EOC,the • An employee of your Group baby is not automatically enrolled in this plan.The Subscriber must request enrollment of the baby as • A proprietor or partner of your Group described under"Special enrollment"in the"How to • Otherwise entitled to coverage under a trust Enroll and When Coverage Begins"section below.If the agreement,retirement benefit program,or Subscriber does not request enrollment within this employment contract(unless the Internal Revenue special enrollment period,the baby will only be covered Service considers you self-employed) under this plan for 31 days(including the date of birth). Eligibility as a Dependent Age limit of Dependent children Children must be under age 26 as of the effective date of Enrolling a Dependent this EOC to enroll as a Dependent under your plan. Dependent eligibility is subject to your Group's eligibility requirements,which are not described in this Dependent children are eligible to remain on the plan EOC.You can obtain your Group's eligibility through the end of the month in which they reach the age requirements directly from your Group.If you are a limit. Subscriber under this EOC and if your Group allows enrollment of Dependents,Health Plan allows the Dependent children of the Subscriber or Spouse following persons to enroll as your Dependents under (including adopted children and children placed with you this EOC: for adoption,but not including children placed with you • Your Spouse for foster care)who reach the age limit may continue • Your or your Spouse's Dependent children,who meet coverage under this EOC if all of the following the requirements described under"Age limit of conditions are met: Dependent children,"if they are any of the following: • They meet all requirements to be a Dependent except ♦ biological children for the age limit ♦ stepchildren • Your Group permits enrollment of Dependents ♦ adopted children • They are incapable of self-sustaining employment because of a physically-or mentally-disabling injury, Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 26 illness,or condition that occurred before they reached a subscriber under a Kaiser Permanente Medicare plan the age limit for Dependents offered by your Group(please ask your Group about • They receive 50 percent or more of their support and your membership options).All of your dependents who maintenance from you or your Spouse are enrolled under this or any other non-Medicare evidence of coverage offered by your Group must be • If requested,you give us proof of their incapacity and enrolled under the same non-Medicare evidence of dependency within 60 days after receiving our request coverage.A"non-Medicare"evidence of coverage is one (see"Disabled Dependent certification"below in this that does not require members to have Medicare. "Eligibility as a Dependent"section) Persons barred from enrolling Disabled Dependent certification You cannot enroll if you have had your entitlement to Proof may be required for a Dependent to be eligible to receive Services through Health Plan terminated for continue coverage as a disabled Dependent.If we request cause. it,the Subscriber must provide us documentation of the dependent's incapacity and dependency as follows: Members with Medicare and retirees • If the child is a Member,we will send the Subscriber This EOC is not intended for most Medicare a notice of the Dependent's membership termination beneficiaries and some Groups do not offer coverage to due to loss of eligibility at least 90 days before the retirees.If,during the term of this EOC,you are(or date coverage will end due to reaching the age limit. become)eligible for Medicare or you retire,please ask The Dependent's membership will terminate as your Group about your membership options as follows: described in our notice unless the Subscriber provides • If a Subscriber who has Medicare Part B retires and us documentation of the Dependent's incapacity and the Subscriber's Group has a Kaiser Permanente dependency within 60 days of receipt of our notice Senior Advantage plan for retirees,the Subscriber and we determine that the Dependent is eligible as a should enroll in the plan if eligible disabled dependent.If the Subscriber provides us this documentation in the specified time period and we do • If the Subscriber has dependents who have Medicare not make a determination about eligibility before the and your Group has a Kaiser Permanente Senior termination date,coverage will continue until we Advantage plan(or of one our other plans that require make a determination.If we determine that the members to have Medicare),the Subscriber may be Dependent does not meet the eligibility requirements able to enroll them as dependents under that plan as a disabled dependent,we will notify the Subscriber • If the Subscriber retires and your Group does not that the Dependent is not eligible and let the offer coverage to retirees,you may be eligible to Subscriber know the membership termination date.If continue membership as described in the we determine that the Dependent is eligible as a "Continuation of Membership"section disabled dependent,there will be no lapse in • If federal law requires that your Group's health care coverage.Also,starting two years after the date that the Dependent reached the age limit,the Subscriber coverage be primary and Medicare coverage be must provide us documentation of the Dependent's secondary,your coverage under this EOC will be the incapacity and dependency annually within 60 days same as it would be if you had not become eligible for after we request it so that we can determine if the Medicare.However,you may also be eligible to Dependent continues to be eligible as a disabled enroll in Kaiser Permanente Senior Advantage through your Group if you have Medicare Part B dependent •• If the child is not a Member because you are changing If you are(or become)eligible for Medicare and arein a class of beneficiaries for which your Group's coverage,you must give us proof,within 60 days after we request it,of the child's incapacity and health care coverage is secondary to Medicare,you dependency as well as proof of the child's coverage should consider enrollment in Kaiser Permanente under your prior coverage.In the future,you must Senior Advantage through your Group if you are provide proof of the child's continued incapacity and eligible dependency within 60 days after you receive our • If none of the above applies to you and you are request,but not more frequently than annually eligible for Medicare or you retire,please ask your Group about your membership options If the Subscriber is enrolled under a Kaiser Permanente Medicare plan Note:If you are enrolled in a Medicare plan and lose The dependent eligibility rules described in the Medicare eligibility,you may be able to enroll under this "Eligibility as a Dependent"section also apply if you are Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 27 EOC if permitted by your Group(please ask your Group under"Who Is Eligible"in this"Premiums,Eligibility, for details). and Enrollment"section,enrollment is permitted as described below and membership begins at the beginning When Medicare is primary (12:00 a.m.)of the effective date of coverage indicated Your Group's Premiums may increase if you are(or below,except that your Group may have additional become)eligible for Medicare Part A or B as primary requirements,which allow enrollment in other situations. coverage,and you are not enrolled through your Group in Kaiser Permanente Senior Advantage for any reason If you are eligible to be a Dependent under this EOC but (even if you are not eligible to enroll or the plan is not the subscriber in your family is enrolled under a Kaiser available to you). Permanente Senior Advantage evidence of coverage offered by your Group,the rules for enrollment of When Medicare is secondary Dependents in this"How to Enroll and When Coverage Medicare is the primary coverage except when federal Begins"section apply,not the rules for enrollment of law requires that your Group's health care coverage be dependents in the subscriber's evidence of coverage. primary and Medicare coverage be secondary.Members who have Medicare when Medicare is secondary by law New employees are subject to the same Premiums and receive the same When your Group informs you that you are eligible to benefits as Members who are under age 65 and do not enroll as a Subscriber,you may enroll yourself and any have Medicare.In addition,any such Member for whom eligible Dependents by submitting a Health Plan— Medicare is secondary by law and who meets the approved enrollment application to your Group within 31 eligibility requirements for the Kaiser Permanente Senior days. Advantage plan applicable when Medicare is secondary may also enroll in that plan if it is available. These Effective date of coverage Members receive the benefits and coverage described in The effective date of coverage for new employees and this EOC and the Kaiser Permanente Senior Advantage their eligible family Dependents is determined by your evidence of coverage applicable when Medicare is Group in accord with waiting period requirements in secondary. state and federal law.Your Group is required to inform the Subscriber of the date your membership becomes Medicare late enrollment penalties effective.For example,if the hire date of an otherwise- If you become eligible for Medicare Part B and do not eligible employee is January 19,the waiting period enroll,Medicare may require you to pay a late begins on January 19 and the effective date of coverage enrollment penalty if you later enroll in Medicare Part B. cannot be any later than April 19.Note: If the effective However,if you delay enrollment in Part B because you date of your Group's coverage is always on the first day or your spouse are still working and have coverage of the month,in this example the effective date cannot be through an employer group health plan,you may not any later than April 1. have to pay the penalty.Also,if you are(or become) eligible for Medicare and go without creditable Open enrollment prescription drug coverage(drug coverage that is at least You may enroll as a Subscriber(along with any eligible as good as the standard Medicare Part D prescription Dependents),and existing Subscribers may add eligible drug coverage)for a continuous period of 63 days or Dependents,by submitting a Health Plan—approved more,you may have to pay a late enrollment penalty if enrollment application to your Group during your you later sign up for Medicare prescription drug Group's open enrollment period.Your Group will let you coverage.If you are(or become)eligible for Medicare, know when the open enrollment period begins and ends your Group is responsible for informing you about and the effective date of coverage. whether your drug coverage under this EOC is creditable prescription drug coverage at the times required by the Special enrollment Centers for Medicare&Medicaid Services and upon If you do not enroll when you are first eligible and later your request. want to enroll,you can enroll only during open enrollment unless one of the following is true: How to Enroll and When Coverage • You become eligible because you experience a Begins qualifying event(sometimes called a"triggering event")as described in this"Special enrollment" Your Group is required to inform you when you are section eligible to enroll and what your effective date of coverage is.If you are eligible to enroll as described Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 28 • You did not enroll in any coverage offered by your California),Children's Health Insurance Program Group when you were first eligible and your Group coverage,or Medi-Cal Access Program coverage does not give us a written statement that verifies you ♦ reaching a lifetime maximum on all benefits signed a document that explained restrictions about enrolling in the future.The effective date of an Note:If you are enrolling yourself as a Subscriber along enrollment resulting from this provision is no later with at least one eligible Dependent,only one of you than the first day of the month following the date your must meet the requirements stated above. Group receives a Health Plan—approved enrollment or change of enrollment application from the Subscriber To request enrollment,the Subscriber must submit a Health Plan—approved enrollment or change of Special enrollment due to new Dependents enrollment application to your Group within 30 days You may enroll as a Subscriber(along with eligible after loss of other coverage,except that the timeframe for Dependents),and existing Subscribers may add eligible submitting the application is 60 days if you are Dependents,within 30 days after marriage,establishment requesting enrollment due to loss of eligibility for of domestic partnership,birth,adoption,placement for coverage through Covered California,Medicaid, adoption,or placement for foster care by submitting to Children's Health Insurance Program,or Medi-Cal your Group a Health Plan—approved enrollment Access Program coverage.The effective date of an application. enrollment resulting from loss of other coverage is no later than the first day of the month following the date The effective date of an enrollment resulting from your Group receives an enrollment or change of marriage or establishment of domestic partnership is no enrollment application from the Subscriber. later than the first day of the month following the date your Group receives an enrollment application from the Special enrollment due to court or administrative order Subscriber.Enrollments due to birth,adoption, Within 30 days after the date of a court or administrative placement for adoption,or placement for foster care are order requiring a Subscriber to provide health care effective on the date of birth,date of adoption,or the coverage for a Spouse or child who meets the eligibility date you or your Spouse have newly assumed a legal requirements as a Dependent,the Subscriber may add the right to control health care. Spouse or child as a Dependent by submitting to your Group a Health Plan—approved enrollment or change of Special enrollment due to loss of other coverage enrollment application. You may enroll as a Subscriber(along with any eligible Dependents),and existing Subscribers may add eligible The effective date of coverage resulting from a court or Dependents,if all of the following are true: administrative order is the first of the month following • The Subscriber or at least one of the Dependents had the date we receive the enrollment request,unless your other coverage when they previously declined all Group specifies a different effective date(if your Group coverage through your Group specifies a different effective date,the effective date • The loss of the other coverage is due to one of the cannot be earlier than the date of the order). following: Special enrollment due to eligibility for premium ♦ exhaustion of COBRA coverage assistance ♦ termination of employer contributions for non- You may enroll as a Subscriber(along with eligible COBRA coverage Dependents),and existing Subscribers may add eligible ♦ loss of eligibility for non-COBRA coverage,but Dependents,if you or a dependent become eligible for not termination for cause or termination from an premium assistance through the Medi-Cal program. individual(nongroup)plan for nonpayment.For Premium assistance is when the Medi-Cal program pays example,this loss of eligibility may be due to legal all or part of premiums for employer group coverage for separation or divorce,moving out of the plan's a Medi-Cal beneficiary.To request enrollment in your service area,reaching the age limit for dependent Group's health care coverage,the Subscriber must children,or the subscriber's death,termination of submit a Health Plan—approved enrollment or change of employment,or reduction in hours of employment enrollment application to your Group within 60 days ♦ loss of eligibility(but not termination for cause) after you or a dependent become eligible for premium for coverage through Covered California, assistance.Please contact the California Department of Medicaid coverage(known as Medi-Cal in Health Care Services to find out if premium assistance is available and the eligibility requirements. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 29 Special enrollment due to reemployment after military How to Obtain Services service If you terminated your health care coverage because you As a Member,you are selecting our medical care were called to active duty in the military service,you program to provide your health care.You must receive may be able to reenroll in your Group's health plan if all covered care from Plan Providers inside our Service required by state or federal law.Please ask your Group Area,except as described in the sections listed below for for more information. the following Services: Other special enrollment events • Authorized referrals as described under"Getting a You may enroll as a Subscriber(along with any eligible Referral"in this"How to Obtain Services"section Dependents)if you or your Dependents were not • Covered Services received outside of your Home previously enrolled,and existing Subscribers may add Region Service Area as described under"Receiving eligible Dependents not previously enrolled,if any of the Care Outside of Your Home Region Service Area"in following are true: this"How to Obtain Services"section • You lose employment for a reason other than gross • Emergency ambulance Services as described under misconduct "Ambulance Services"in the"Benefits"section • Your employment hours are reduced • Emergency Services,Post-Stabilization Care,and • You are a Dependent of someone who becomes Out-of-Area Urgent Care as described in the entitled to Medicare "Emergency Services and Urgent Care"section • You become divorced or legally separated • Hospice care as described under"Hospice Care"in the"Benefits"section • You are a Dependent of someone who dies • A Health Benefit Exchange(such as Covered Our medical care program gives you access to all of the California)determines that one of the following covered Services you may need,such as routine care occurred because of misconduct on the part of a non- with your own personal Plan Physician,hospital Exchange entity that provided enrollment assistance Services,laboratory and pharmacy Services,Emergency or conducted enrollment activities: Services,Urgent Care,and other benefits described in ♦ a qualified individual was not enrolled in a this EOC. qualified health plan ♦ a qualified individual was not enrolled in the Routine Care qualified health plan that the individual selected ♦ a qualified individual is eligible for,but is not If you need the following Services,you should schedule receiving,advance payments of the premium tax an appointment: credit or cost share reductions • Preventive Services To request special enrollment,you must submit a Health • Periodic follow-up care(regularly scheduled follow- Plan-approved enrollment application to your Group up care,such as visits to monitor a chronic condition) within 30 days after loss of other coverage.You may be • Other care that is not Urgent Care required to provide documentation that you have experienced a qualifying event.Membership becomes To request a non-urgent appointment,you can call your effective either on the first day of the next month(for local Plan Facility or request the appointment online.For applications that are received by the fifteenth day of a appointment phone numbers,refer to our Provider month)or on the first day of the month following the Directory or call Member Services.To request an next month(for applications that are received after the appointment online,go to our website at ku.org. fifteenth day of a month). Note:If you are enrolling as a Subscriber along with at Urgent Care least one eligible Dependent,only one of you must meet An Urgent Care need is one that requires prompt medical one of the requirements stated above. attention but is not an Emergency Medical Condition.If you think you may need Urgent Care,call the appropriate appointment or advice phone number at a Plan Facility.For phone numbers,refer to our Provider Directory or call Member Services. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 30 For information about Out-of-Area Urgent Care,refer to visits with the specialist except for routine preventive "Urgent Care"in the"Emergency Services and Urgent visits listed under"Preventive Services"in the Care"section. "Benefits"section. To learn how to select or change to a different personal Not Sure What Kind of Care You Need? Plan Physician,visit our website at ky.org or call Sometimes it's difficult to know what kind of care you Member Services.Refer to our Provider Directory for a need,so we have licensed health care professionals list of physicians that are available as Primary Care available to assist you by phone 24 hours a day,seven Physicians. The directory is updated periodically.The days a week.Here are some of the ways they can help availability of Primary Care Physicians may change.If you have questions,please call Member Services.You you: can change your personal Plan Physician at any time for • They can answer questions about a health concern, any reason. and instruct you on self-care at home if appropriate • They can advise you about whether you should get Getting a Referral medical care,and how and where to get care(for example,if you are not sure whether your condition is Referrals to Plan Providers an Emergency Medical Condition,they can help you A Plan Physician must refer you before you can receive decide whether you need Emergency Services or care from specialists,such as specialists in surgery, Urgent Care,and how and where to get that care) orthopedics,cardiolog y,gy,oncology,dermatology,and • They can tell you what to do if you need care and a physical,occupational,and speech therapies.Also,a Plan Medical Office is closed or you are outside our Plan Physician must refer you before you can get care Service Area from Qualified Autism Service Providers covered under "Behavioral Health Treatment for Autism Spectrum You can reach one of these licensed health care Disorder"in the`Benefits"section.However,you do not professionals by calling the appointment or advice phone need a referral or prior authorization to receive most care number(for phone numbers,refer to our Provider from any of the following Plan Providers: Directory or call Member Services).When you call,a • Your personal Plan Physician trained support person may ask you questions to help • Generalists in internal medicine,pediatrics,and determine how to direct your call. family practice • Specialists in optometry,mental health Services, Your Personal Plan Physician substance use disorder treatment,and Personal Plan Physicians provide primary care and play obstetrics/gynecology an important role in coordinating care,including hospital stays and referrals to specialists. A Plan Physician must refer you before you can get care from a specialist in urology except that you do not need a We encourage you to choose a personal Plan Physician. referral to receive Services related to sexual or You may choose any available personal Plan Physician. reproductive health,such as a vasectomy. Parents may choose a pediatrician as the personal Plan Physician for their child.Most personal Plan Physicians Although a referral or prior authorization is not required are Primary Care Physicians(generalists in internal to receive most care from these providers,a referral may medicine,pediatrics,or family practice,or specialists in be required in the following situations: obstetrics/gynecology whom the Medical Group • The provider may have to get prior authorization for designates as Primary Care Physicians). Some specialists certain Services in accord with"Medical Group who are not designated as Primary Care Physicians but authorization procedure for certain referrals"in this who also provide primary care may be available as "Getting a Referral"section personal Plan Physicians.For example,some specialists • The provider may have to refer you to a specialist in internal medicine and obstetrics/gynecology who are who has a clinical background related to your illness not designated as Primary Care Physicians may be or condition available as personal Plan Physicians.However,if you choose a specialist who is not designated as a Primary Standing referrals Care Physician as your personal Plan Physician,the Cost If a Plan Physician refers you to a specialist,the referral Share for a Physician Specialist Visit will apply to all will be for a specific treatment plan.Your treatment plan Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 31 may include a standing referral if ongoing care from the If your Plan Physician prescribes one of these items,they specialist is prescribed.For example,if you have a life- will submit a written referral in accord with the UM threatening,degenerative,or disabling condition,you can process described in this"Medical Group authorization get a standing referral to a specialist if ongoing care from procedure for certain referrals"section.If the formulary the specialist is required. guidelines do not specify that the prescribed item is appropriate for your medical condition,the referral will Medical Group authorization procedure for be submitted to the Medical Group's designee Plan certain referrals Physician,who will make an authorization decision as The following are examples of Services that require prior described under"Medical Group's decision time frames" authorization by the Medical Group for the Services to in this"Medical Group authorization procedure for be covered("prior authorization"means that the Medical certain referrals"section. Group must approve the Services in advance): • Durable medical equipment Medical Group's decision time frames The applicable Medical Group designee will make the • Ostomy and urological supplies authorization decision within the time frame appropriate • Services not available from Plan Providers for your condition,but no later than five business days • Transplants after receiving all of the information(including additional examination and test results)reasonably necessary to make the decision,except that decisions Utilization Management("UM")is a process that about urgent Services will be made no later than 72 determines whether a Service recommended by your hours after receipt of the information reasonably treating provider is Medically Necessary for you.Prior necessary to make the decision.If the Medical Group authorization is a UM process that determines whether needs more time to make the decision because it doesn't the requested services are Medically Necessary before have information reasonably necessary to make the care is provided.If it is Medically Necessary,then you decision,or because it has requested consultation by a will receive authorization to obtain that care in a particular specialist,you and your treating physician will clinically appropriate place consistent with the terms of be informed about the additional information,testing,or your health coverage.Decisions regarding requests for specialist that is needed,and the date that the Medical authorization will be made only by licensed physicians Group expects to make a decision. or other appropriately licensed medical professionals. Your treating physician will be informed of the decision For the complete list of Services that require prior within 24 hours after the decision is made.If the Services authorization,and the criteria that are used to make are authorized,your physician will be informed of the authorization decisions,please visit our website at scope of the authorized Services.If the Medical Group kp.oru/UM or call Member Services to request a printed does not authorize all of the Services,Health Plan will copy. send you a written decision and explanation within two business days after the decision is made.Any written Refer to"Post-Stabilization Care"under"Emergency criteria that the Medical Group uses to make the decision Services"in the"Emergency Services and Urgent Care" to authorize,modify,delay,or deny the request for section for authorization requirements that apply to Post- authorization will be made available to you upon request. Stabilization Care from Non—Plan Providers. If the Medical Group does not authorize all of the Additional information about prior authorization for Services requested and you want to appeal the decision, durable medical equipment and ostomy and urological you can file a grievance as described under"Grievances" supplies in the"Dispute Resolution"section. The prior authorization process for durable medical equipment and ostomy and urological supplies includes For these referral Services,you pay the Cost Share the use of formulary guidelines.These guidelines were required for Services provided by a Plan Provider as developed by a multidisciplinary clinical and operational described in this EOC. work group with review and input from Plan Physicians and medical professionals with clinical expertise.The Completion of Services from Non—Plan formulary guidelines are periodically updated to keep Providers pace with changes in medical technology and clinical practice. New Member If you are currently receiving Services from a Non—Plan Provider in one of the cases listed below under Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 32 "Eligibility"and your prior plan's coverage of the • Children under age 3.We may cover completion of provider's Services has ended or will end when your these Services until the earlier of(1) 12 months from coverage with us becomes effective,you may be eligible the child's effective date of coverage if the child is a for limited coverage of that Non—Plan Provider's new Member,(2) 12 months from the termination Services. date of the terminated provider,or(3)the child's third birthday Terminated provider • Surgery or another procedure that is documented as If you are currently receiving covered Services in one of part of a course of treatment and has been the cases listed below under`Eligibility"from a Plan recommended and documented by the provider to Hospital or a Plan Physician(or certain other providers) occur within 180 days of your effective date of when our contract with the provider ends(for reasons coverage if you are a new Member or within 180 days other than medical disciplinary cause or criminal of the termination date of the terminated provider activity),you may be eligible for limited coverage of that terminated provider's Services. To qualify for this completion of Services coverage,all Eligibility of the following requirements must be met: The cases that are subject to this completion of Services • Your Health Plan coverage is in effect on the date you provision are: receive the Services • Acute conditions,which are medical conditions that • For new Members,your prior plan's coverage of the involve a sudden onset of symptoms due to an illness, provider's Services has ended or will end when your injury,or other medical problem that requires prompt coverage with us becomes effective medical attention and has a limited duration.We may • You are receiving Services in one of the cases listed cover these Services until the acute condition ends above from a Non—Plan Provider on your effective • Serious chronic conditions until the earlier of(1) 12 date of coverage if you are a new Member,or from months from your effective date of coverage if you the terminated Plan Provider on the provider's are a new Member,(2) 12 months from the termination date termination date of the terminated provider,or(3)the • For new Members,when you enrolled in Health Plan, first day after a course of treatment is complete when you did not have the option to continue with your it would be safe to transfer your care to a Plan previous health plan or to choose another plan Provider,as determined by Kaiser Permanente after (including an out-of-network option)that would cover consultation with the Member and Non—Plan Provider the Services of your current Non—Plan Provider and consistent with good professional practice. . The provider agrees to our standard contractual terms Serious chronic conditions are illnesses or other and conditions,such as conditions pertaining to medical conditions that are serious,if one of the payment and to providing Services inside our Service following is true about the condition: Area(the requirement that the provider agree to ♦ it persists without full cure providing Services inside our Service Area doesn't ♦ it worsens over an extended period of time apply if you were receiving covered Services from the ♦ it requires ongoing treatment to maintain provider outside our Service Area when the remission or prevent deterioration provider's contract terminated) • Pregnancy and immediate postpartum care.We may • The Services to be provided to you would be covered cover these Services for the duration of the pregnancy Services under this EOC if provided by a Plan and immediate postpartum care Provider • Mental health conditions in pregnant Members that • You request completion of Services within 30 days occur,or can impact the Member,during pregnancy (or as soon as reasonably possible)from your or during the postpartum period including,but not effective date of coverage if you are a new Member limited to,postpartum depression.We may cover or from the termination date of the Plan Provider completion of these Services for up to 12 months from the mental health diagnosis or from the end of For completion of Services,you pay the Cost Share pregnancy,whichever occurs later required for Services provided by a Plan Provider as described in this EOC. • Terminal illnesses,which are incurable or irreversible illnesses that have a high probability of causing death within a year or less.We may cover completion of these Services for the duration of the illness Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 33 More information Here are some examples of when a second opinion may For more information about this provision,or to request be provided or authorized: the Services or a copy of our"Completion of Covered • Your Plan Physician has recommended a procedure Services"policy,please call Member Services. and you are unsure about whether the procedure is reasonable or necessary Travel and Lodging for Certain Services • You question a diagnosis or plan of care for a condition that threatens substantial impairment or loss The following are examples of when we will arrange or of life,limb,or bodily functions provide reimbursement for certain travel and lodging . The clinical indications are not clear or are complex expenses in accord with our Travel and Lodging and confusing Program Description: • If Medical Group refers you to a provider that is more • A diagnosis is in doubt due to conflicting test results than 50 miles from where you live for certain • The Plan Physician is unable to diagnose the specialty Services such as bariatric surgery,complex condition thoracic surgery,transplant nephrectomy,or inpatient . The treatment plan in progress is not improving your chemotherapy for leukemia and lymphoma medical condition within an appropriate period of • If Medical Group refers you to a provider that is time,given the diagnosis and plan of care outside our Service Area for certain specialty Services . You have concerns about the diagnosis or plan of care such as a transplant or transgender surgery • If you are outside of California and you need an An authorization or denial of your request for a second abortion on an emergency or urgent basis,and the opinion will be provided in an expeditious manner,as abortion can't be obtained in a timely manner due to a appropriate for your condition.If your request for a near total or total ban on health care providers' ability second opinion is denied,you will be notified in writing to provide such Services of the reasons for the denial and of your right to file a grievance as described under"Grievances"in the For the complete list of specialty Services for which we "Dispute Resolution"section. will arrange or provide reimbursement for travel and lodging expenses,the amount of reimbursement, For these referral Services,you pay the Cost Share limitations and exclusions,and how to request required for Services provided by a Plan Provider as reimbursement,refer to the Travel and Lodging Program described in this EOC. Description.The Travel and Lodging Program Description is available online at ku.org/suecialty- care/travel-reimbursements or by calling Member Contracts with Plan Providers Services. How Plan Providers are paid Health Plan and Plan Providers are independent Second Opinions contractors.Plan Providers are paid in a number of ways, such as salary,capitation,per diem rates,case rates,fee If you want a second opinion,you can ask Member for service,and incentive payments. To learn more about Services to help you arrange one with a Plan Physician how Plan Physicians are paid to provide or arrange who is an appropriately qualified medical professional medical and hospital Services for Members,please visit for your condition.If there isn't a Plan Physician who is our website at kp.org or call Member Services. an appropriately qualified medical professional for your condition,Member Services will help you arrange a Financial liability consultation with a Non—Plan Physician for a second Our contracts with Plan Providers provide that you are opinion.For purposes of this"Second Opinions" not liable for any amounts we owe.However,you may provision,an"appropriately qualified medical have to pay the full price of noncovered Services you professional"is a physician who is acting within their obtain from Plan Providers or Non—Plan Providers. scope of practice and who possesses a clinical background,including training and expertise,related to When you are referred to a Plan Provider for covered the illness or condition associated with the request for a Services,you pay the Cost Share required for Services second medical opinion. from that provider as described in this EOC. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 34 Termination of a Plan Provider's contract Your ID Card If our contract with any Plan Provider terminates while you are under the care of that provider,we will retain Each Member's Kaiser Permanente ID card has a financial responsibility for the covered Services you medical record number on it,which you will need when receive from that provider until we make arrangements you call for advice,make an appointment,or go to a for the Services to be provided by another Plan Provider provider for covered care.When you get care,please and notify you of the arrangements.You may be eligible bring your ID card and a photo ID.Your medical record to receive Services from a terminated provider;refer to number is used to identify your medical records and "Completion of Services from Non—Plan Providers" membership information.Your medical record number under"Getting a Referral"in this"How to Obtain should never change.Please call Member Services if we Services"section. ever inadvertently issue you more than one medical record number or if you need to replace your ID card. Provider groups and hospitals If you are assigned to a provider group or hospital whose Your ID card is for identification only.To receive contract with us terminates,or if you live within 15 miles covered Services,you must be a current Member. of a hospital whose contract with us terminates,we will Anyone who is not a Member will be billed as a non- give you written notice at least 60 days before the Member for any Services they receive.If you let termination(or as soon as reasonably possible). someone else use your ID card,we may keep your ID card and terminate your membership as described under "Termination for Cause"in the"Termination of Receiving Care Outside of Your Home Membership"section. Region Service Area For information about your coverage when you are away Timely Access to Care from home,visit our website at kky.orE/travel.You can Standards for appointment availability also call the Away from Home Travel Line at 1-951-268-3900 24 hours a day,seven days a week The California Department of Managed Health Care (except closed holidays). ("DMHC")developed the following standards for appointment availability. This information can help you Receiving care in another Kaiser Permanente know what to expect when you request an appointment. service area • Urgent care appointment:within 48 hours If you are visiting in another Kaiser Permanente service . Routine(non-urgent)primary care appointment area,you may receive certain covered Services from (including adult/internal medicine,pediatrics,and designated providers in that other Kaiser Permanente family medicine):within 10 business days service area,subject to exclusions,limitations,prior . Routine(non-urgent)specialty care appointment with authorization or approval requirements,and reductions. For more information about receiving covered Services a physician:within 15 business days in another Kaiser Permanente service area,including • Routine(non-urgent)mental health care or substance provider and facility locations,please visit kp.orz/travel use disorder treatment appointment with a practitioner or call our Away from Home Travel Line at 1-951-268- other than a physician:within 10 business days 3900 24 hours a day,seven days a week(except closed . Follow-up(non-urgent)mental health care or holidays). substance use disorder treatment appointment with a practitioner other than a physician,for those For covered Services you receive in another Kaiser undergoing a course of treatment for an ongoing Permanente service area,you pay the Cost Share mental health or substance use disorder condition: required for Services provided by a Plan Provider inside within 10 business days our Service Area as described in this EOC. If you prefer to wait for a later appointment that will Receiving care outside of any Kaiser better fit your schedule or to see the Plan Provider of Permanente service area your choice,we will respect your preference.In some If you are traveling outside of any Kaiser Permanente cases,your wait may be longer than the time listed if a service area,we cover Emergency Services and Urgent licensed health care professional decides that a later Care as described in the"Emergency Services and appointment won't have a negative effect on your health. Urgent Care"section. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 35 The standards for appointment availability do not apply 24 hours a day,seven days a week(except to Preventive Services.Your Plan Provider may closed holidays) recommend a specific schedule for Preventive Services, Visit Member Services office at a Plan Facility(for depending on your needs.Except as specified above for addresses,refer to our Provider Directory or mental health care and substance use disorder treatment, call Member Services) the standards also do not apply to periodic follow-up care for ongoing conditions or standing referrals to Write Member Services office at a Plan Facility(for specialists. addresses,refer to our Provider Directory or call Member Services) Timely access to telephone assistance Website kp•Org DMHC developed the following standards for answering telephone questions: Cost Share estimates • For telephone advice about whether you need to get For information about estimates,see"Getting an care and where to get care:within 30 minutes,24 estimate of your Cost Share"under"Your Cost Share"in hours a day,seven days a week the"Benefits"section. • For general questions:within 10 minutes during normal business hours Plan Facilities Interpreter services If you need interpreter services when you call us or when Plan Medical Offices and Plan Hospitals are listed in the you get covered Services,please let us know.Interpreter Provider Directory for your Home Region.The directory services,including sign language,are available during all describes the types of covered Services that are available business hours at no cost to you.For more information from each Plan Facility,because some facilities provide on the interpreter services we offer,please call Member only specific types of covered Services.This directory is Services. available on our website at kp.or2/facilities.To obtain a printed copy,call Member Services.The directory is Getting Assistance updated periodically.The availability of Plan Facilities may change.If you have questions,please call Member We want you to be satisfied with the health care you Services. receive from Kaiser Permanente.If you have any questions or concerns,please discuss them with your At most of our Plan Facilities,you can usually receive all personal Plan Physician or with other Plan Providers of the covered Services you need,including specialty who are treating you.They are committed to your care,pharmacy,and lab work.You are not restricted to a satisfaction and want to help you with your questions. particular Plan Facility,and we encourage you to use the facility that will be most convenient for you: Member Services • All Plan Hospitals provide inpatient Services and are Member Services representatives can answer any open 24 hours a day,seven days a week questions you have about your benefits,available • Emergency Services are available from Plan Hospital Services,and the facilities where you can receive care. emergency departments(for emergency department For example,they can explain the following: locations,refer to our Provider Directory or call • Your Health Plan benefits Member Services) • How to make your first medical appointment • Same-day Urgent Care appointments are available at • What to do if you move many locations(for Urgent Care locations,refer to our Provider Directory or call Member Services) • How to replace your Kaiser Permanente ID card • Many Plan Medical Offices have evening and You can reach Member Services in the following ways: weekend appointments • Many Plan Facilities have a Member Services office Call 1-800-464-4000(English and more than 150 (for locations,refer to our Provider Directory or call languages using interpreter services) Member Services) 1-800-788-0616(Spanish) 1-800-757-7585(Chinese dialects) TTY users call 711 Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 36 Note: State law requires evidence of coverage documents • Post-Stabilization Care authorization at a Cigna to include the following notice: PPO Network facility outside of a Kaiser Some hospitals and other providers do not Permanente State: If you are outside of a Kaiser Permanente state and you were treated at a Cigna provide one or more of the following services PPO Network facility for an Emergency Medical that may be covered under your plan Condition,Cigna Payer Solutions is responsible for contract and that you or your family authorizing any Post-Stabilization Care. member might need: family planning; • Post-Stabilization Care authorization from other contraceptive services,including emergency Non-Plan Providers(including Cigna PPO contraception; sterilization, including tubal Network facilities inside a Kaiser Permanente State): To request prior authorization,the Non—Plan ligation at the time of labor and delivery; Provider must call 1-800-225-8883 or the notification infertility treatments; or abortion. You phone number on your Kaiser Permanente ID card should obtain more information before you before you receive the care.We will discuss your enroll. Call your prospective doctor, medical condition with the Non-Plan Provider.If we group, independent practice association, or determine that you require Post-Stabilization Care and that this care is part of your covered benefits,we clinic, or call Kaiser Permanente Member will authorize your care from the Non—Plan Provider Services,to ensure that you can obtain the or arrange to have a Plan Provider(or other health care services that you need. designated provider)provide the care.If we decide to have a Plan Hospital,Plan Skilled Nursing Facility,or Please be aware that if a Service is covered but not designated Non—Plan Provider provide your care,we available at a particular Plan Facility,we will make it may authorize special transportation services that are available to you at another facility. medically required to get you to the provider. This may include transportation that is otherwise not covered. Emergency Services and Urgent Be sure to ask the Non—Plan Provider to tell you what Care care(including any transportation)we have authorized because we will not cover Post- Emergency Services Stabilization Care or related transportation provided by Non—Plan Providers that has not been authorized. If you have an Emergency Medical Condition,call 911 If you receive care from a Non—Plan Provider that we (where available)or go to the nearest emergency have not authorized,you may have to pay the full cost department.You do not need prior authorization for of that care.If you are admitted to a Non—Plan Emergency Services.When you have an Emergency Hospital or independent freestanding emergency Medical Condition,we cover Emergency Services you department,please notify us as soon as possible by receive from Plan Providers or Non—Plan Providers calling 1-800-225-8883 or the notification phone anywhere in the world. number on your ID card. Emergency Services are available from Plan Hospital When you receive Post-Stabilization Care from a Non- emergency departments 24 hours a day,seven days a Plan Provider that is not a Cigna PPO Network week. provider outside of California After you receive Emergency Services from non-Plan Post-Stabilization Care Providers and your condition is Stabilized,Post- Stabilization Care is considered Emergency Services When you receive Post-Stabilization Care from allon- under federal law if either of the following are true: Plan Provider inside of California,or from a Cigna PPO Network facility outside of a Kaiser Permanente • Your treating physician determines that you are not State able to travel using nonemergency transportation to When you receive Emergency Services,we cover Post- an available Plan Provider located within a reasonable Stabilization Care from a Non—Plan Provider only if travel distance,taking into account your medical prior authorization for the care is obtained as described condition;or below,or if otherwise required by applicable law("prior • Your treating physician,using appropriate medical authorization"means that the Services must be approved judgment,determines that you are not in a condition in advance). Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 37 to receive,and/or to provide consent to,the Non-Plan Plan Facility.For appointment and advice phone Provider's notice and consent form,in accordance numbers,refer to our Provider Directory or call Member with applicable state informed consent law Services. If the Post-Stabilization Care is considered Emergency Out-of-Area Urgent Care Services under the criteria above,prior authorization for If you need Urgent Care due to an unforeseen illness, Post-Stabilization Care at a Non-Plan Provider will not unforeseen injury,or unforeseen complication of an be required. existing condition(including pregnancy),we cover Medically Necessary Services to prevent serious If the Post-Stabilization Care is not considered deterioration of your(or your unborn child's)health Emergency Services,the Services are not covered unless from a Non—Plan Provider if all of the following are true: you have received prior authorization from Health Plan • You receive the Services from Non—Plan Providers as described under"Post-Stabilization Care authorization while you are temporarily outside our Service Area from other Non-Plan Providers(including Cigna PPO Network facilities inside a Kaiser Permanente State)" • A reasonable person would have believed that your above.Non-Plan Providers outside of California may (or your unborn child's)health would seriously provide notice and seek your consent to waive your deteriorate if you delayed treatment until you returned balance billing protections under the federal No to our Service Area Surprises Act,if such consent is permissible under applicable state informed consent law.If you consent to You do not need prior authorization for Out-of-Area waive your balance billing protections and receive Urgent Care.We cover Out-of-Area Urgent Care you Services from the Non-Plan Provider,you will have to receive from Non—Plan Providers if the Services would pay the full cost of the Services. have been covered under this EOC if you had received them from Plan Providers. Your Cost Share Your Cost Share for covered Emergency Services and To obtain follow-up care from a Plan Provider,call the Post-Stabilization Care is described in the"Cost Share appointment or advice phone number at a Plan Facility. Summary"section of this EOC.Your Cost Share is the For phone numbers,refer to our Provider Directory or same whether you receive the Services from a Plan call Member Services.We do not cover follow-up care Provider or a Non—Plan Provider.For example: from Non—Plan Providers after you no longer need • If you receive Emergency Services in the emergency Urgent Care,except for durable medical equipment covered under this EOC.For more information about department of a Non—Plan Hospital,you pay the Cost durable medical equipment covered under this EOC,see Share for an emergency department visit as described "Durable Medical Equipment("DME")for Home Use" in the"Cost Share Summary"under"Emergency in the"Benefits"section.If you require durable medical Services and Urgent Care" equipment related to your Urgent Care after receiving • If we gave prior authorization for inpatient Post- Out-of-Area Urgent Care,your provider must obtain Stabilization Care in a Non—Plan Hospital,you pay prior authorization as described under"Getting a the Cost Share for hospital inpatient Services as Referral"in the"How to Obtain Services"section. described in the"Cost Share Summary"under "Hospital inpatient Services" Your Cost Share • If we gave prior authorization for durable medical Your Cost Share for covered Urgent Care is the Cost equipment after discharge from a Non—Plan Hospital, Share required for Services provided by Plan Providers you pay the Cost Share for durable medical as described in the"Cost Share Summary"section of this equipment as described in the"Cost Share Summary" EOC.For example: under"Durable Medical Equipment("DME")for • If you receive an Urgent Care evaluation as part of home use" covered Out-of-Area Urgent Care from a Non—Plan Provider,you pay the Cost Share for Urgent Care consultations,evaluations,and treatment as described Urgent Care in the"Cost Share Summary"under"Emergency Inside our Service Area Services and Urgent Care" An Urgent Care need is one that requires prompt medical • If the Out-of-Area Urgent Care you receive includes attention but is not an Emergency Medical Condition.If an X-ray,you pay the Cost Share for an X-ray as you think you may need Urgent Care,call the described in the"Cost Share Summary"under appropriate appointment or advice phone number at a "Outpatient imaging,laboratory,and other diagnostic Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 38 and treatment Services,"in addition to the Cost Share • The Services are one of the following: for the Urgent Care evaluation ♦ Preventive Services • If we gave prior authorization for durable medical ♦ health care items and services for diagnosis, equipment provided as part of Out-of-Area Urgent assessment,or treatment Care,you pay the Cost Share for durable medical ♦ health education covered under"Health equipment as described in the"Cost Share Summary" Education"in this"Benefits"section under"Durable Medical Equipment("DME")for ♦ other health care items and services home use" • The Services are provided,prescribed,authorized,or Note:If you receive Urgent Care in an emergency directed by a Plan Physician,except for: department,you pay the Cost Share for an emergency ♦ covered Services received outside of your Home department visit as described in the"Cost Share Region Service Area,as described under Summary"under"Emergency Services and Urgent "Receiving Care Outside of Your Home Region Care." Service Area"in the"How to Obtain Services" section Payment and Reimbursement ♦ drugs prescribed by dentists,as described under "Outpatient Prescription Drugs,Supplies,and If you receive Emergency Services,Post-Stabilization Supplements"below Care,or Out-of-Area Urgent Care from a Non—Plan ♦ emergency ambulance Services,as described Provider as described in this"Emergency Services and under"Ambulance Services"below Urgent Care"section,or emergency ambulance Services ♦ Emergency Services,Post-Stabilization Care,and described under"Ambulance Services"in the"Benefits" Out-of-Area Urgent Care,as described in the section,you are not responsible for any amounts beyond "Emergency Services and Urgent Care"section your Cost Share for covered Services.However,if the Non— provider does not agree to bill us,you may have to pay ♦ eyeglasses and contact lenses prescribed by Non— for the Services and file a claim for reimbursement.Also, Plan Providers,as described under"Vision you maybe required to pay and file a claim for any Services for Adult Members"and"Vision Services prescribed by a Non—Plan Provider as part of Services for Pediatric Members"below covered Emergency Services,Post-Stabilization Care, • You receive the Services from Plan Providers inside and Out-of-Area Urgent Care even if you receive the our Service Area,except for: Services from a Plan Provider,such as a Plan Pharmacy. ♦ authorized referrals,as described under"Getting a Referral"in the"How to Obtain Services"section For information on how to file a claim,please see the ♦ covered Services received outside of your Home "Post-Service Claims and Appeals"section. Region Service Area,as described under "Receiving Care Outside of Your Home Region Service Area"in the"How to Obtain Services" Benefits section ♦ emergency ambulance Services,as described This section describes the Services that are covered under"Ambulance Services"below under this EOC. ♦ Emergency Services,Post-Stabilization Care,and Out-of-Area Urgent Care,as described in the Services are covered under this EOC as specifically "Emergency Services and Urgent Care"section described in this EOC. Services that are not specifically ♦ hospice care,as described under"Hospice Care" described in this EOC are not covered,except as required below by state or federal law. Services are subject to exclusions and limitations described in the"Exclusions,Limitations, • The Medical Group has given prior authorization for Coordination of Benefits,and Reductions"section. the Services,if required,as described under"Medical Except as otherwise described in this EOC,all of the Group authorization procedure for certain referrals" following conditions must be satisfied: in the"How to Obtain Services"section • You are a Member on the date that you receive the Please also refer to: Services • The"Emergency Services and Urgent Care"section • The Services are Medically Necessary for information about how to obtain covered Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 39 Emergency Services,Post-Stabilization Care,and "Who Is Eligible"in the"Premiums,Eligibility,and Out-of-Area Urgent Care Enrollment"section,the parent or guardian of the • Our Provider Directory for the types of covered newborn must pay the Cost Share indicated in the"Cost Services that are available from each Plan Facility, Share Summary"section of this EOC for any Services because some facilities provide only specific types of that the newborn receives,whether or not the newborn is covered Services enrolled.When the"Cost Share Summary"indicates the Services are subject to the Plan Deductible,the Cost Share for those Services will be Charges if the newborn Your Cost Share has not met the Plan Deductible. Your Cost Share is the amount you are required to pay Payment toward your Cost Share(and when you may for covered Services.For example,your Cost Share may be billed) be a Copayment or Coinsurance. In most cases,your provider will ask you to make a payment toward your Cost Share at the time you receive If your coverage includes a Plan Deductible and you Services.If you receive more than one type of Services receive Services that are subject to the Plan Deductible, (such as a routine physical maintenance exam and your Cost Share for those Services will be Charges until laboratory tests),you may be required to pay separate you reach the Plan Deductible. Similarly,if your Cost Share for each of those Services.Keep in mind that coverage includes a Drug Deductible,and you receive your payment toward your Cost Share may cover only a Services that are subject to the Drug Deductible,your portion of your total Cost Share for the Services you Cost Share for those Services will be Charges until you receive,and you will be billed for any additional reach the Drug Deductible. amounts that are due.The following are examples of when you may be asked to pay(or you may be billed for) Refer to the"Cost Share Summary"section of this EOC Cost Share amounts in addition to the amount you pay at for the amount you will pay for Services. check-in: • You receive non-preventive Services during a General rules, examples, and exceptions preventive visit.For example,you go in for a routine Your Cost Share for covered Services will be the Cost physical maintenance exam,and at check-in you pay Share in effect on the date you receive the Services, your Cost Share for the preventive exam(your Cost except as follows: Share may be"no charge").However,during your • If you are receiving covered hospital inpatient or preventive exam your provider finds a problem with Skilled Nursing Facility Services on the effective date your health and orders non-preventive Services to of this EOC,you pay the Cost Share in effect on your diagnose your problem(such as laboratory tests).You admission date until you are discharged if the may be asked to pay(or you will be billed for)your Services were covered under your prior Health Plan Cost Share for these additional non-preventive evidence of coverage and there has been no break in diagnostic Services coverage.However,if the Services were not covered • You receive diagnostic Services during a treatment under your prior Health Plan evidence of coverage,or visit.For example,you go in for treatment of an if there has been a break in coverage,you pay the existing health condition,and at check-in you pay Cost Share in effect on the date you receive the your Cost Share for a treatment visit.However, Services during the visit your provider finds a new problem • For items ordered in advance,you pay the Cost Share with your health and performs or orders diagnostic in effect on the order date(although we will not cover Services(such as laboratory tests).You may be asked the item unless you still have coverage for it on the to pay(or you will be billed for)your Cost Share for date you receive it)and you may be required to pay these additional diagnostic Services the Cost Share when the item is ordered.For • You receive treatment Services during a diagnostic outpatient prescription drugs,the order date is the visit.For example,you go in for a diagnostic exam, date that the pharmacy processes the order after and at check-in you pay your Cost Share for a receiving all of the information they need to fill the diagnostic exam.However,during the diagnostic prescription exam your provider confirms a problem with your health and performs treatment Services(such as an Cost Share for Services received by newborn children outpatient procedure).You may be asked to pay(or of a Member you will be billed for)your Cost Share for these During the 31 days of automatic coverage for newborn additional treatment Services children described under"If you have a baby"under Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 40 • You receive Services from a second provider during Primary Care Visits,Non-Physician Specialist Visits, your visit.For example,you go in for a diagnostic and Physician Specialist Visits exam,and at check-in you pay your Cost Share for a The Cost Share for a Primary Care Visit applies to diagnostic exam.However,during the diagnostic evaluations and treatment provided by generalists in exam your provider requests a consultation with a internal medicine,pediatrics,or family practice,and by specialist.You may be asked to pay(or you will be specialists in obstetrics/gynecology whom the Medical billed for)your Cost Share for the consultation with Group designates as Primary Care Physicians. Some the specialist physician specialists provide primary care in addition to specialty care but are not designated as Primary Care In some cases,your provider will not ask you to make a Physicians.If you receive Services from one of these payment at the time you receive Services,and you will specialists,the Cost Share for a Physician Specialist Visit be billed for your Cost Share(for example,some will apply to all consultations,evaluations,and treatment Laboratory Departments are not able to collect Cost provided by the specialist except for routine preventive Share,or your Plan Provider is not able to collect Cost counseling and exams listed under"Preventive Services" Share,if any,for Telehealth Visits you receive at home). in this`Benefits"section.For example,if your personal Plan Physician is a specialist in internal medicine or When we send you a bill,it will list Charges for the obstetrics/gynecology who is not a Primary Care Services you received,payments and credits applied to Physician,you will pay the Cost Share for a Physician your account,and any amounts you still owe.Your Specialist Visit for all consultations,evaluations,and current bill may not always reflect your most recent treatment by the specialist except routine preventive Charges and payments.Any Charges and payments that counseling and exams listed under"Preventive Services" are not on the current bill will appear on a future bill. in this`Benefits"section.The Non-Physician Specialist Sometimes,you may see a payment but not the related Visit Cost Share applies to consultations,evaluations, Charges for Services. That could be because your and treatment provided by non-physician specialists payment was recorded before the Charges for the (such as nurse practitioners,physician assistants, Services were processed.If so,the Charges will appear optometrists,podiatrists,and audiologists). on a future bill.Also,you may receive more than one bill for a single outpatient visit or inpatient stay.For Noncovered Services example,you may receive a bill for physician services If you receive Services that are not covered under this and a separate bill for hospital services.If you don't see EOC,you may have to pay the full price of those all the Charges for Services on one bill,they will appear Services.Payments you make for noncovered Services on a future bill.If we determine that you overpaid and do not apply to any deductible or out-of-pocket are due a refund,then we will send a refund to you maximum. within four weeks after we make that determination.If you have questions about a bill,please call the phone Benefit limits number on the bill. Some benefits may include a limit on the number of visits,days,treatment cycles,or dollar amount that will In some cases,a Non—Plan Provider may be involved in be covered under your plan during a specified time the provision of covered Services at a Plan Facility or a period.If a benefit includes a limit,this will be indicated contracted facility where we have authorized you to in the"Cost Share Summary"section of this EOC. The receive care.You are not responsible for any amounts time period associated with a benefit limit may not be the beyond your Cost Share for the covered Services you same as the term of this EOC.We will count all Services receive at Plan Facilities or at contracted facilities where you receive during the benefit limit period toward the we have authorized you to receive care.However,if the benefit limit,including Services you received under a provider does not agree to bill us,you may have to pay prior Health Plan EOC(as long as you have continuous for the Services and file a claim for reimbursement.For coverage with Health Plan).Note:We will not count information on how to file a claim,please see the"Post- Services you received under a prior Health Plan EOC Service Claims and Appeals"section. when you first enroll in individual plan coverage or a new employer group's plan,when you move from group Please refer to the"Emergency Services and Urgent to individual plan coverage(or vice versa),or when you Care"section for more information about when you may received Services under a Kaiser Permanente Senior be billed for Emergency Services,Post-Stabilization Advantage evidence of coverage.If you are enrolled in Care,and Out-of-Area Urgent Care. the Kaiser Permanente POS Plan,refer to your KPIC Certificate of Insurance and Schedule of Coverage for benefit limits that apply to your separate indemnity Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 41 coverage provided by the Kaiser Permanente Insurance If you are a Member in a Family of two or more Company("KPIC"). Members,you reach the Plan Out-of-Pocket Maximum either when you reach the maximum for any one Getting an estimate of your Cost Share Member,or when your Family reaches the Family If you have questions about the Cost Share for specific maximum.For example,suppose you have reached the Services that you expect to receive or that your provider Plan Out-of-Pocket Maximum for any one Member.For orders during a visit or procedure,please visit our Services subject to the Plan Out-of-Pocket Maximum, website at kp.org/memberestimates to use our cost you will not pay any more Cost Share during the estimate tool or call Member Services. remainder of the Accumulation Period,but every other • If you have a Plan Deductible and would like an Member in your Family must continue to pay Cost Share estimate for Services that are subject to the Plan during the remainder of the Accumulation Period until Deductible,please call 1-800-390-3507(TTY users either they reach the maximum for any one Member or call 711)Monday through Friday 6 a.m.to 5 p.m. your Family reaches the Family maximum. Refer to the"Cost Share Summary"section of this Payments that count toward the Plan Out-of-Pocket EOC to find out if you have a Plan Deductible Maximum • For all other Cost Share estimates,please call 1-800- Any payments you make toward the Plan Deductible or 464-4000(TTY users call 711)24 hours a day,seven Drug Deductible,if applicable,apply toward the days a week(except closed holidays) maximum. Cost Share estimates are based on your benefits and the Most Copayments and Coinsurance you pay for covered Services you expect to receive.They are a prediction of Services apply to the maximum,however some may not. cost and not a guarantee of the final cost of Services. To find out whether a Copayment or Coinsurance for a Your final cost may be higher or lower than the estimate covered Service will apply to the maximum refer to the since not everything about your care can be known in "Cost Share Summary"section of this EOC. advance. If your plan includes pediatric dental Services described Drug Deductible in a Pediatric Dental Services Amendment to this EOC, This EOC does not include a Drug Deductible. those Services will apply toward the maximum.If your plan has a Pediatric Dental Services Amendment,it will Plan Deductible be attached to this EOC,and it will be listed in the This EOC does not include a Plan Deductible. EOC's Table of Contents. Copayments and Coinsurance Accrual toward deductibles and out-of-pocket The Copayment or Coinsurance you must pay for each maximums covered Service,after you meet any applicable To see how close you are to reaching your deductibles,if deductible,is described in this EOC. any,and out-of-pocket maximums,use our online Out- of-Pocket Summary tool at kp.org or call Member Note:If Charges for Services are less than the Services.We will provide you with accrual balance Copayment described in this EOC,you will pay the information for every month that you receive Services lesser amount,subject to any applicable deductible or until you reach your individual out-of-pocket maximums out-of-pocket maximum. or your Family reaches the Family out-of-pocket maximums. Plan Out-of-Pocket Maximum There is a limit to the total amount of Cost Share you We will provide accrual balance information by mail must pay under this EOC in the Accumulation Period for unless you have opted to receive notices electronically. covered Services that you receive in the same You can change your document delivery preferences at Accumulation Period. The Services that apply to the Plan any time at kp.org or by calling Member Services. Out-of-Pocket Maximum are described under the "Payments that count toward the Plan Out-of-Pocket Maximum"section below.Refer to the"Cost Share Summary"section of this EOC for your applicable Plan Out-of-Pocket Maximum amounts. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 42 Administered Drugs and Products Nonemergency Inside our Service Area,we cover nonemergency Administered drugs and products are medications and ambulance and psychiatric transport van Services if a products that require administration or observation by Plan Physician determines that your condition requires medical personnel,such as: the use of Services that only a licensed ambulance(or • Whole blood,red blood cells,plasma,and platelets psychiatric transport van)can provide and that the use of • Allergy antigens(including administration) other means of transportation would endanger your health.These Services are covered only when the vehicle • Cancer chemotherapy drugs and adjuncts transports you to or from covered Services. • Drugs and products that are administered via intravenous therapy or injection that are not for Ambulance Services exclusions cancer chemotherapy,including blood factor products • Transportation by car,taxi,bus,gurney van, and biological products("biologics")derived from wheelchair van,and any other type of transportation tissue,cells,or blood (other than a licensed ambulance or psychiatric • Other administered drugs and products transport van),even if it is the only way to travel to a Plan Provider We cover these items when prescribed by a Plan Provider,in accord with our drug formulary guidelines, Bariatric Surgery and they are administered to you in a Plan Facility or during home visits. We cover hospital inpatient Services related to bariatric surgical procedures(including room and board,imaging, Certain administered drugs are Preventive Services. laboratory,other diagnostic and treatment Services,and Refer to"Reproductive Health Services"for information Plan Physician Services)when performed to treat obesity about administered contraceptives and refer to by modification of the gastrointestinal tract to reduce "Preventive Services"for information on immunizations. nutrient intake and absorption,if all of the following requirements are met: Ambulance Services • You complete the Medical Group—approved pre- surgical educational preparatory program regarding Emergency lifestyle changes necessary for long term bariatric We cover Services of a licensed ambulance anywhere in surgery success the world without prior authorization(including • A Plan Physician who is a specialist in bariatric care transportation through the 911 emergency response determines that the surgery is Medically Necessary system where available)in the following situations: • You reasonably believed that the medical condition For covered Services related to bariatric surgical was an Emergency Medical Condition which required procedures that you receive,you will pay the Cost Share ambulance Services you would pay if the Services were not related to a • Your treating physician determines that you must be bariatric surgical procedure.For example, see"Hospital transported to another facility because your inpatient Services"in the"Cost Share Summary"section Emergency Medical Condition is not Stabilized and of this EOC for the Cost Share that applies for hospital the care you need is not available at the treating inpatient Services. facility For the following Services, refer to these If you receive emergency ambulance Services that are sections not ordered by a Plan Provider,you are not responsible • Outpatient prescription drugs(refer to"Outpatient for any amounts beyond your Cost Share for covered Prescription Drugs,Supplies,and Supplements") emergency ambulance Services.However,if the provider • Outpatient administered drugs(refer to"Administered does not agree to bill us,you may have to pay for the Drugs and Products") Services and file a claim for reimbursement.For information on how to file a claim,please see the"Post- Service Claims and Appeals"section. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 43 Behavioral Health Treatment for Autism • "Qualified Autism Service Paraprofessional"means Spectrum Disorder an unlicensed and uncertified individual who meets all of the following criteria: The following terms have special meaning when ♦ is supervised by a Qualified Autism Service capitalized and used in this"Behavioral Health Provider or Qualified Autism Service Professional Treatment for Autism Spectrum Disorder"section: at a level of clinical supervision that meets • "Qualified Autism Service Provider"means a professionally recognized standards of practice provider who has the experience and competence to ♦ provides treatment and implements Services design,supervise,provide,or administer treatment for pursuant to a treatment plan developed and autism spectrum disorder and is either of the approved by the Qualified Autism Service following: Provider ♦ a person who is certified by a national entity(such ♦ meets the education and training qualifications as the Behavior Analyst Certification Board)with described in Section 54342 of Title 17 of the a certification that is accredited by the National California Code of Regulations Commission for Certifying Agencies ♦ has adequate education,training,and experience, ♦ a person licensed in California as a physician, as certified by a Qualified Autism Service physical therapist,occupational therapist, Provider or an entity or group that employs psychologist,marriage and family therapist, Qualified Autism Service Providers educational psychologist,clinical social worker, ♦ is employed by the Qualified Autism Service professional clinical counselor,speech-language Provider or an entity or group that employs pathologist,or audiologist Qualified Autism Service Providers responsible • "Qualified Autism Service Professional"means an for the autism treatment plan individual who meets all of the following criteria: ♦ provides behavioral health treatment,which may We cover behavioral health treatment for autism include clinical case management and case spectrum disorder(including applied behavior analysis supervision under the direction and supervision of and evidence-based behavior intervention programs)that a qualified autism service provider develops or restores,to the maximum extent practicable, the functioning of a person with autism spectrum ♦ is supervised by a Qualified Autism Service disorder and that meets all of the following criteria: Provider ♦ provides treatment pursuant to a treatment plan • The Services are provided inside our Service Area developed and approved by the Qualified Autism • The treatment is prescribed by a Plan Physician,or is Service Provider developed by a Plan Provider who is a psychologist ♦ is a behavioral health treatment provider who • The treatment is provided under a treatment plan meets the education and experience qualifications prescribed by a Plan Provider who is a Qualified described in Section 54342 of Title 17 of the Autism Service Provider California Code of Regulations for an Associate • The treatment is administered by a Plan Provider who Behavior Analyst,Behavior Analyst,Behavior Management Assistant,Behavior Management is one of the following: Consultant,or Behavior Management Program ♦ a Qualified Autism Service Provider ♦ has training and experience in providing Services ♦ a Qualified Autism Service Professional for autism spectrum disorder pursuant to Division supervised by the Qualified Autism Service 4.5(commencing with Section 4500)of the Provider Welfare and Institutions Code or Title 14 ♦ a Qualified Autism Service Paraprofessional (commencing with Section 95000)of the supervised by a Qualified Autism Service Provider Government Code or Qualified Autism Service Professional ♦ is employed by the Qualified Autism Service • The treatment plan has measurable goals over a Provider or an entity or group that employs specific timeline that is developed and approved by Qualified Autism Service Providers responsible the Qualified Autism Service Provider for the for the autism treatment plan Member being treated • The treatment plan is reviewed no less than once every six months by the Qualified Autism Service Provider and modified whenever appropriate Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 44 • The treatment plan requires the Qualified Autism "Hospital Inpatient Services"and"Skilled Nursing Service Provider to do all of the following: Facility Care") ♦ describe the Member's behavioral health • Outpatient drugs,supplies,and supplements(refer to impairments to be treated "Outpatient Prescription Drugs,Supplies,and ♦ design an intervention plan that includes the Supplements") service type,number of hours,and parent • Outpatient laboratory(refer to"Outpatient Imaging, participation needed to achieve the plan's goal and Laboratory,and Other Diagnostic and Treatment objectives,and the frequency at which the Services") Member's progress is evaluated and reported • Outpatient physical,occupational,and speech therapy ♦ provide intervention plans that utilize evidence- visits(refer to"Rehabilitative and Habilitative based practices,with demonstrated clinical Services") efficacy in treating autism spectrum disorder • Services to diagnose autism spectrum disorder and ♦ discontinue intensive behavioral intervention Services to develop and revise the treatment plan Services when the treatment goals and objectives (refer to"Mental Health Services") are achieved or no longer appropriate • The treatment plan is not used for either of the following: Dental and Orthodontic Services ♦ for purposes of providing(or for the We do not cover most dental and orthodontic Services reimbursement of)respite care,day care,or under this EOC,but we do cover some dental and educational services orthodontic Services as described in this"Dental and ♦ to reimburse a parent for participating in the Orthodontic Services"section. treatment program For covered dental and orthodontic procedures that you We also cover behavioral health treatment that meets the may receive,you will pay the Cost Share you would pay same criteria to treat mental health conditions other than if the Services were not related to dental and orthodontic autism spectrum disorder when behavioral health Services.For example,see"Hospital inpatient Services" treatment is clinically indicated. in the"Cost Share Summary"section of this EOC for the Cost Share that applies for hospital inpatient Services. Services from Non-Plan Providers If we are not able to offer an appointment with a Plan Dental Services for radiation treatment Provider within required geographic and timely access We cover dental evaluation,X-rays,fluoride treatment, standards,we will offer to refer you to a Non-Plan and extractions necessary to prepare your jaw for Provider(as described in"Medical Group authorization radiation therapy of cancer in your head or neck if a Plan procedure for certain referrals"under"Getting a Physician provides the Services or if the Medical Group Referral"in the"How to Obtain Services"section). authorizes a referral to a dentist for those Services(as described in"Medical Group authorization procedure for Additionally,we cover Services provided by a 988 certain referrals"under"Getting a Referral"in the"How center,mobile crisis team,or other provider of to Obtain Services"section). behavioral health crisis services(collectively,"988 Services")for medically necessary treatment of a mental Dental Services for transplants health or substance use disorder without prior We cover dental services that are Medically Necessary to authorization,as required by state law. free the mouth from infection in order to prepare for a transplant covered under"Transplant Services"in this For these referral Services and 988 Services,you pay the "Benefits" section,if a Plan Physician provides the Cost Share required for Services provided by a Plan Services or if the Medical Group authorizes a referral to Provider as described in this EOC. a dentist for those Services(as described in"Medical Group authorization procedure for certain referrals" For the following Services, refer to these under"Getting a Referral"in the"How to Obtain sections Services" section). • Behavioral health treatment for autism spectrum disorder provided during a covered stay in a Plan Hospital or Skilled Nursing Facility(refer to Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 45 Dental anesthesia Dialysis Care For dental procedures at a Plan Facility,we provide general anesthesia and the facility's Services associated We cover acute and chronic dialysis Services if all of the with the anesthesia if all of the following are true: following requirements are met: • You are under age 7,or you are developmentally • The Services are provided inside our Service Area disabled,or your health is compromised • You satisfy all medical criteria developed by the • Your clinical status or underlying medical condition Medical Group and by the facility providing the requires that the dental procedure be provided in a dialysis hospital or outpatient surgery center • A Plan Physician provides a written referral for care • The dental procedure would not ordinarily require at the facility general anesthesia After you receive appropriate training at a dialysis We do not cover any other Services related to the dental facility we designate,we also cover equipment and procedure,such as the dentist's Services. medical supplies required for home hemodialysis and home peritoneal dialysis inside our Service Area. Dental and orthodontic Services for cleft palate Coverage is limited to the standard item of equipment or We cover dental extractions,dental procedures necessary supplies that adequately meets your medical needs.We to prepare the mouth for an extraction,and orthodontic decide whether to rent or purchase the equipment and Services,if they meet all of the following requirements: supplies,and we select the vendor.You must return the equipment and any unused supplies to us or pay us the • The Services are an integral part of a reconstructive fair market price of the equipment and any unused surgery for cleft palate that we are covering under supply when we are no longer covering them. "Reconstructive Surgery"in this"Benefits"section ("cleft palate"includes cleft palate,cleft lip,or other For the following Services, refer to these craniofacial anomalies associated with cleft palate) sections • A Plan Provider provides the Services or the Medical • Durable medical equipment for home use(refer to Group authorizes a referral to a Non—Plan Provider "Durable Medical Equipment("DME")for Home who is a dentist or orthodontist(as described in Use") "Medical Group authorization procedure for certain referrals"under"Getting a Referral"in the"How to • Hospital inpatient Services(refer to"Hospital Obtain Services"section) Inpatient Services") • Office visits not described in the"Dialysis Care" For the following Services, refer to these section(refer to"Office Visits") sections • Outpatient laboratory(refer to"Outpatient Imaging, • Accidental injury to teeth(refer to"Injury to Teeth") Laboratory,and Other Diagnostic and Treatment • Office visits not described in the"Dental and Services") Orthodontic Services"section(refer to"Office • Outpatient prescription drugs(refer to"Outpatient Visits") Prescription Drugs,Supplies,and Supplements") • Outpatient imaging,laboratory,and other diagnostic • Outpatient administered drugs(refer to"Administered and treatment Services(refer to"Outpatient Imaging, Drugs and Products") Laboratory,and Other Diagnostic and Treatment • Telehealth Visits(refer to"Telehealth Visits") Services") • Outpatient administered drugs(refer to"Administered Dialysis care exclusions Drugs and Products"),except that we cover outpatient . Comfort convenience or lux equipment, lies administered drugs under"Dental anesthesia"in this supplies and features "Dental and Orthodontic Services"section • Nonmedical items,such as generators or accessories • Outpatient prescription drugs(refer to"Outpatient to make home dialysis equipment portable for travel Prescription Drugs,Supplies,and Supplements") • Telehealth Visits(refer to"Telehealth Visits") Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 46 Durable Medical Equipment ("DME") for • Infusion pumps(such as insulin pumps)and supplies Home Use to operate the pump DME coverage rules • IV pole DME for home use is an item that meets the following • Nebulizer and supplies criteria: • Peak flow meters • The item is intended for repeated use • Phototherapy blankets for treatment of jaundice in • The item is primarily and customarily used to serve a newborns medical purpose Supplemental DME items • The item is generally useful only to an individual We cover DME that is not described under"Base DME with an illness or injury Items"or"Lactation supplies,"including repair and • The item is appropriate for use in the home replacement of covered equipment,if all of the requirements described under"DME coverage rules"in For a DME item to be covered,all of the following this"Durable Medical Equipment("DME")for Home requirements must be met: Use"section are met. • Your EOC includes coverage for the requested DME Lactation supplies item We cover one retail-grade milk pump(also known as a • A Plan Physician has prescribed the DME item for breast pump)per pregnancy and associated supplies,as your medical condition listed on our website at kp.m/prevention.We will • The item has been approved for you through the decide whether to rent or purchase the item and we Plan's prior authorization process,as described in choose the vendor.We cover this pump for convenience "Medical Group authorization procedure for certain purposes. The pump is not subject to prior authorization referrals"under"Getting a Referral"in the"How to requirements. Obtain Services"section • The Services are provided inside our Service Area If you or your baby has a medical condition that requires the use of a milk pump,we cover a hospital-grade milk Coverage is limited to the standard item of equipment pump and the necessary supplies to operate it,in accord that adequately meets your medical needs.We decide with the coverage rules described under"DME coverage whether to rent or purchase the equipment,and we select rules"in this"Durable Medical Equipment("DME")for the vendor.You must return the equipment to us or pay Home Use section. us the fair market price of the equipment when we are no Outside our Service Area longer covering it. We do not cover most DME for home use outside our Base DME Items Service Area.However,if you live outside our Service We cover Base DME Items(including repair or Area,we cover the following DME(subject to the Cost replacement of covered equipment)if all of the Share and all other coverage requirements that apply to requirements described under"DME coverage rules"in DME for home use inside our Service Area)when the this"Durable Medical Equipment("DME")for Home item is dispensed at a Plan Facility: Use"section are met."Base DME Items"means the • Blood glucose monitors for diabetes blood testing and following items: their supplies(such as blood glucose monitor test • Blood glucose monitors for diabetes blood testing and strips,lancets,and lancet devices)from a Plan their supplies(such as blood glucose monitor test Pharmacy strips,lancets,and lancet devices) • Canes(standard curved handle) • Bone stimulator • Crutches(standard) • Canes(standard curved handle or quad)and • Insulin pumps and supplies to operate the pump,after replacement supplies completion of training and education on the use of the • Cervical traction(over door) PUMP • Nebulizers and their supplies for the treatment of • Crutches(standard or forearm)and replacement pediatric asthma supplies • Dry pressure pad for a mattress • Peak flow meters from a Plan Pharmacy Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 47 For the following Services, refer to these For the following Services, refer to these sections sections • Dialysis equipment and supplies required for home • Abortion and abortion-related Services(refer to hemodialysis and home peritoneal dialysis(refer to "Reproductive Health Services") "Dialysis Care") • Diabetes urine testing supplies and insulin- Fertility Services administration devices other than insulin pumps(refer to"Outpatient Prescription Drugs, Supplies,and "Fertility Services"means treatments and procedures to Supplements") help you become pregnant. • Durable medical equipment related to an Emergency Medical Condition or Urgent Care episode(refer to Before starting or continuing a course of fertility "Post-Stabilization Care"and"Out-of-Area Urgent Services,you may be required to pay initial and Care") subsequent deposits toward your Cost Share for some or • Durable medical equipment related to the terminal all of the entire course of Services,along with any past- illness for Members who are receiving covered due fertility-related Cost Share.Any unused portion of hospice care(refer to"Hospice Care") your deposit will be returned to you.When a deposit is not required,you must pay the Cost Share for the • Insulin and any other drugs administered with an procedure,along with any past-due fertility-related Cost infusion pump(refer to"Outpatient Prescription Share,before you can schedule a fertility procedure. Drugs, Supplies,and Supplements") Diagnosis and treatment of Infertility DME for home use exclusions We cover the following Services for the diagnosis and • Comfort,convenience,or luxury equipment or treatment of Infertility: features except for retail-grade milk pumps as • Office visits described under"Lactation supplies"in this"Durable • Outpatient surgery and outpatient procedures Medical Equipment("DME")for Home Use"section • Items not intended for maintaining normal activities • Outpatient imaging and laboratory Services of daily living,such as exercise equipment(including • Outpatient administered drugs that require devices intended to provide additional support for administration or observation by medical personnel. recreational or sports activities) We cover these items when they are prescribed by a • Hygiene equipment Plan Provider,in accord with our drug formulary guidelines,and they are administered to you in a Plan • Nonmedical items,such as sauna baths or elevators Facility • Modifications to your home or car • Hospital inpatient stay directly related to diagnosis • Devices for testing blood or other body substances and treatment of Infertility (except diabetes blood glucose monitors and their supplies) Artificial insemination • Electronic monitors of the heart or lungs except infant We cover the following Services for artificial apnea monitors insemination: • Repair or replacement of equipment due to loss,theft, • Office visits or misuse • Outpatient surgery and outpatient procedures • Outpatient imaging and laboratory Services Emergency Services and Urgent Care • Outpatient administered drugs that require administration or observation by medical personnel. We cover the following Services: We cover these items when they are prescribed by a • Emergency department visits Plan Provider,in accord with our drug formulary guidelines,and they are administered to you in a Plan • Urgent Care consultations,evaluations,and treatment Facility • Hospital inpatient stays directly related to diagnosis and treatment of Infertility Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 48 Assisted reproductive technology ("ART") We also cover a variety of health education counseling, Services programs,and materials to help you take an active role in ART Services such as in vitro fertilization("IVF"), protecting and improving your health,including gamete intra-fallopian transfer("GIFT"),or zygote programs for tobacco cessation,stress management,and intrafallopian transfer("ZIFT")are not covered under chronic conditions(such as diabetes and asthma).Kaiser this EOC. Permanente also offers health education counseling, programs,and materials that are not covered,and you For the following Services, refer to these may be required to pay a fee. sections For more information about our health education • Fertility preservation Services for iatrogenic counseling,programs,and materials,please contact a Infertility(refer to"Fertility Preservation Services for Health Education Department or Member Services or go Iatrogenic Infertility") to our website at ky.m. • Diagnostic Services provided by Plan Providers who are not physicians,such as EKGs and EEGs(refer to "Outpatient Imaging,Laboratory,and Other Hearing Services Diagnostic and Treatment Services") We cover the following: • Outpatient drugs,supplies,and supplements(refer to "Outpatient Prescription Drugs,Supplies,and • Hearing exams with an audiologist to determine the need for hearing correction Supplements") • Physician Specialist Visits to diagnose and treat Fertility Services exclusions hearing problems • Services to reverse voluntary,surgically induced Hearing aids Infertility We provide an Allowance for each ear toward the • Semen and eggs(and Services related to their purchase price of a hearing aid(including fitting, procurement and storage) counseling,adjustment,cleaning,and inspection)when • ART Services,such as ovum transplants,GIFT,IVF, prescribed by a Plan Physician or by a Plan Provider who and ZIFT is an audiologist.We will cover hearing aids for both ears only if both aids are required to provide significant improvement that is not obtainable with only one hearing Fertility Preservation Services for aid.We will not provide the Allowance if we have Iatrogenic Infertility provided an Allowance toward(or otherwise covered)a hearing aid within the previous 36 months.Also,the Standard fertility preservation Services are covered for Allowance can only be used at the initial point of sale.If Members undergoing treatment or receiving covered you do not use all of your Allowance at the initial point Services that may directly or indirectly cause iatrogenic of sale,you cannot use it later.Refer to"Hearing Infertility.Fertility preservation Services do not include Services"in the"Cost Share Summary"section of this diagnosis or treatment of Infertility. EOC for your Allowance amount. For covered fertility preservation Services that you We select the provider or vendor that will furnish the receive,you will pay the Cost Share you would pay if the covered hearing aids.Coverage is limited to the types Services were not related to fertility preservation.For and models of hearing aids furnished by the provider or example,see"Outpatient surgery and outpatient vendor. procedures"in the"Cost Share Summary"section of this EOC for the Cost Share that applies for outpatient For the following Services, refer to these procedures. sections • Routine hearing screenings when performed as part of Health Education a routine physical maintenance exam(refer to We cover a variety of health education counseling, "Preventive Services") programs,and materials that your personal Plan • Services related to the ear or hearing other than those Physician or other Plan Providers provide during a visit described in this section,such as outpatient care to covered under another part of this EOC. treat an ear infection or outpatient prescription drugs, Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 49 supplies,and supplements(refer to the applicable visit.For example,if a nurse comes to your home for heading in this"Benefits"section) three hours and then leaves,that counts as two visits. • Cochlear implants and osseointegrated hearing Also,each person providing Services counts toward devices(refer to"Prosthetic and Orthotic Devices") these visit limits.For example,if a home health aide and a nurse are both at your home during the same two hours, Hearing Services exclusions that counts as two visits. • Internally implanted hearing aids For the following Services, refer to these • Replacement parts and batteries,repair of hearing sections aids,and replacement of lost or broken hearing aids • Behavioral health treatment for autism spectrum (the manufacturer warranty may cover some of these) disorder(refer to"Behavioral Health Treatment for Autism Spectrum Disorder") Home Health Care • Dialysis care(refer to"Dialysis Care") • Durable medical equipment(refer to"Durable "Home health care"means Services provided in the Medical Equipment("DME")for Home Use") home by nurses,medical social workers,home health aides,and physical,occupational,and speech therapists. • Ostomy and urological supplies(refer to"Ostomy and Urological Supplies") We cover home health care only if all of the following • Outpatient drugs,supplies,and supplements(refer to are true: "Outpatient Prescription Drugs,Supplies,and • You are substantially confined to your home(or a Supplements") friend's or relative's home) • Outpatient physical,occupational,and speech therapy • Your condition requires the Services of a nurse, visits(refer to"Rehabilitative and Habilitative physical therapist,occupational therapist,or speech Services") therapist(home health aide Services are not covered • Prosthetic and orthotic devices(refer to"Prosthetic unless you are also getting covered home health care and Orthotic Devices") from a nurse,physical therapist,occupational therapist,or speech therapist that only a licensed Home health care exclusions provider can provide) • Care of a type that an unlicensed family member or • A Plan Physician determines that it is feasible to other layperson could provide safely and effectively maintain effective supervision and control of your in the home setting after receiving appropriate care in your home and that the Services can be safely training.This care is excluded even if we would cover and effectively provided in your home the care if it were provided by a qualified medical • The Services are provided inside our Service Area professional in a hospital or a Skilled Nursing Facility • Care in the home if the home is not a safe and We cover only part-time or intermittent home health effective treatment setting care,as follows: • Up to two hours per visit for visits by a nurse, Hospice Care medical social worker,or physical,occupational,or speech therapist,and up to four hours per visit for Hospice care is a specialized form of interdisciplinary visits by a home health aide health care designed to provide palliative care and to • Up to three visits per day(counting all home health alleviate the physical,emotional,and spiritual visits) discomforts of a Member experiencing the last phases of • Up to 100 visits per Accumulation Period(counting life due to a terminal illness.It also provides support to all home health visits) the primary caregiver and the Member's family.A Member who chooses hospice care is choosing to receive palliative care for pain and other symptoms associated Note:If a visit by a nurse,medical social worker,or with the terminal illness,but not to receive care to try to physical,occupational,or speech therapist lasts longer cure the terminal illness.You may change your decision than two hours,then each additional increment of two to receive hospice care benefits at any time. hours counts as a separate visit.If a visit by a home health aide lasts longer than four hours,then each additional increment of four hours counts as a separate Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 50 We cover the hospice Services listed below only if all of Necessary to achieve palliation or management of acute the following requirements are met: medical symptoms: • A Plan Physician has diagnosed you with a terminal • Nursing care on a continuous basis for as much as 24 illness and determines that your life expectancy is 12 hours a day as necessary to maintain you at home months or less • Short-term inpatient Services required at a level that • The Services are provided inside our Service Area or cannot be provided at home inside California but within 15 miles or 30 minutes from our Service Area(including a friend's or relative's home even if you live there temporarily) Hospital Inpatient Services • The Services are provided by a licensed hospice We cover the following inpatient Services in a Plan agency that is a Plan Provider Hospital,when the Services are generally and • A Plan Physician determines that the Services are customarily provided by acute care general hospitals necessary for the palliation and management of your inside our Service Area: terminal illness and related conditions • Room and board,including a private room if Medically Necessary If all of the above requirements are met,we cover the following hospice Services,if necessary for your hospice • Specialized care and critical care units care: • General and special nursing care • Plan Physician Services • Operating and recovery rooms • Skilled nursing care,including assessment, • Services of Plan Physicians,including consultation evaluation,and case management of nursing needs, and treatment by specialists treatment for pain and symptom control,provision of • Anesthesia emotional support to you and your family,and instruction to caregivers • Drugs prescribed in accord with our drug formulary guidelines(for discharge drugs prescribed when you • Physical,occupational,and speech therapy for are released from the hospital,refer to"Outpatient purposes of symptom control or to enable you to Prescription Drugs,Supplies,and Supplements"in maintain activities of daily living this"Benefits"section) • Respiratory therapy • Radioactive materials used for therapeutic purposes • Medical social services • Durable medical equipment and medical supplies • Home health aide and homemaker services • Imaging,laboratory,and other diagnostic and • Palliative drugs prescribed for pain control and treatment Services,including MRI,CT,and PET symptom management of the terminal illness for up to scans a 100-day supply in accord with our drug formulary • Whole blood,red blood cells,plasma,platelets,and guidelines.You must obtain these drugs from a Plan their administration Pharmacy.Certain drugs are limited to a maximum 30-day supply in any 30-day period(your Plan • Obstetrical care and delivery(including cesarean Pharmacy can tell you if a drug you take is one of section).Note:If you are discharged within 48 hours these drugs) after delivery(or within 96 hours if delivery is by cesarean section),your Plan Physician may order a • Durable medical equipment follow-up visit for you and your newborn to take • Respite care when necessary to relieve your place within 48 hours after discharge(for visits after caregivers.Respite care is occasional short-term you are released from the hospital,refer to"Office inpatient Services limited to no more than five Visits"in this"Benefits"section) consecutive days at a time • Behavioral health treatment that is Medically • Counseling and bereavement services Necessary to treat mental health conditions that fall • Dietary counseling under any of the diagnostic categories listed in the mental and behavioral disorders chapter of the most recent edition of the International Classification of We also cover the following hospice Services only Diseases or that are listed in the most recent version during periods of crisis when they are Medically of the Diagnostic and Statistical Manual of Mental Disorders Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 51 • Respiratory therapy categories listed in the mental and behavioral disorders • Physical,occupational,and speech therapy(including chapter of the most recent edition of the International treatment in our organized,multidisciplinary Classification of Diseases or that is listed in the most rehabilitation program) recent version of the Diagnostic and Statistical Manual of Mental Disorders. • Medical social services and discharge planning Outpatient mental health Services For the following Services, refer to these We cover the following Services when provided by Plan sections Physicians or other Plan Providers who are licensed • Abortion and abortion-related Services(refer to health care professionals acting within the scope of their "Reproductive Health Services") license: • Bariatric surgical procedures(refer to`Bariatric • Individual and group mental health evaluation and Surgery") treatment • Dental and orthodontic procedures(refer to"Dental • Psychological testing when necessary to evaluate a and Orthodontic Services") Mental Health Condition • Dialysis care(refer to"Dialysis Care") • Outpatient Services for the purpose of monitoring • Fertility preservation Services for iatrogenic drug therapy Infertility(refer to"Fertility Preservation Services for Iatrogenic Infertility") Intensive psychiatric treatment programs We cover intensive psychiatric treatment programs at a • Services related to diagnosis and treatment of Plan Facility,such as: Infertility,artificial insemination,or assisted reproductive technology(refer to"Fertility Services") • Partial hospitalization • Hospice care(refer to"Hospice Care") • Multidisciplinary treatment in an intensive outpatient program • Mental health Services(refer to"Mental Health • Psychiatric observation for an acute psychiatric crisis Services") • Prosthetics and orthotics(refer to"Prosthetic and Residential treatment Orthotic Devices") Inside our Service Area,we cover the following Services • Reconstructive surgery Services(refer to when the Services are provided in a licensed residential "Reconstructive Surgery") treatment facility that provides 24-hour individualized • Services in connection with a clinical trial(refer to mental health treatment,the Services are generally and "Services in Connection with a Clinical Trial") customarily provided by a mental health residential treatment program in a licensed residential treatment • Skilled inpatient Services in a Plan Skilled Nursing facility,and the Services are above the level of custodial Facility(refer to"Skilled Nursing Facility Care") care: • Substance use disorder treatment Services(refer to • Individual and group mental health evaluation and "Substance Use Disorder Treatment") treatment • Transplant Services(refer to"Transplant Services") • Medical services • Medication monitoring Iniury to Teeth • Room and board Services for accidental injury to teeth are not covered • Social services under this EOC. • Drugs prescribed by a Plan Provider as part of your plan of care in the residential treatment facility in Mental Health Services accord with our drug formulary guidelines if they are administered to you in the facility by medical We cover Services specified in this"Mental Health personnel(for discharge drugs prescribed when you Services"section only when the Services are for the are released from the residential treatment facility, prevention,diagnosis,or treatment of Mental Health refer to"Outpatient Prescription Drugs, Supplies,and Conditions.A"Mental Health Condition"is a mental Supplements"in this"Benefits"section) health condition that falls under any of the diagnostic • Discharge planning Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 52 Inpatient psychiatric hospitalization For the following Services, refer to these We cover inpatient psychiatric hospitalization in a Plan sections Hospital. Coverage includes room and board,drugs,and . Abortion and abortion-related Services(refer to Services of Plan Physicians and other Plan Providers "Reproductive Health Services") who are licensed health care professionals acting within the scope of their license. Ostomy and Urological Supplies Services from Non-Plan Providers If we are not able to offer an appointment with a Plan We cover ostomy and urological supplies if the Provider within required geographic and timely access following requirements are met: standards,we will offer to refer you to a Non-Plan • A Plan Physician has prescribed ostomy and Provider(as described in"Medical Group authorization urological supplies for your medical condition procedure for certain referrals"under"Getting a • The item has been approved for you through the Referral"in the"How to Obtain Services"section). Plan's prior authorization process,as described in Additionally,we cover Services provided by a 988 "Medical Group authorization procedure for certain referrals"under"Getting a Referral"in the"How to center,mobile crisis team,or other provider of Obtain Services"section behavioral health crisis services(collectively,"988 Services")for medically necessary treatment of a mental • The Services are provided inside our Service Area health or substance use disorder without prior authorization,as required by state law. Coverage is limited to the standard item of equipment that adequately meets your medical needs.We decide For these referral Services and 988 Services,you pay the whether to rent or purchase the equipment,and we select Cost Share required for Services provided by a Plan the vendor. Provider as described in this EOC. Ostomy and urological supplies exclusions For the following Services, refer to these . Comfort,convenience,or luxury equipment or sections features • Outpatient drugs,supplies,and supplements(refer to "Outpatient Prescription Drugs,Supplies,and Supplements") Outpatient Imaging, Laboratory, and Other Diagnostic and Treatment • Outpatient laboratory(refer to"Outpatient Imaging, Laboratory,and Other Diagnostic and Treatment Services Services") We cover the following Services only when part of care • Telehealth Visits(refer to"Telehealth Visits") covered under other headings in this"Benefits"section. The Services must be prescribed by a Plan Provider. Office Visits • Complex imaging(other than preventive)such as CT scans,MRIs,and PET scans We cover the following: • Basic imaging Services,such as diagnostic and • Primary Care Visits and Non-Physician Specialist therapeutic X-rays,mammograms,and ultrasounds Visits • Nuclear medicine • Physician Specialist Visits • Routine retinal photography screenings • Group appointments • Laboratory tests,including tests to monitor the • Acupuncture Services(typically provided only for the effectiveness of dialysis and tests for specific genetic treatment of nausea or as part of a comprehensive disorders for which genetic counseling is available pain management program for the treatment of • Diagnostic Services provided by Plan Providers who chronic pain) are not physicians(such as EKGs and EEGs) • House calls by a Plan Physician(or a Plan Provider • Radiation therapy who is a registered nurse)inside our Service Area • Ultraviolet light treatments,including ultraviolet light when care can best be provided in your home as determined by a Plan Physician therapy equipment for home use,if(1)the equipment has been approved for you through the Plan's prior Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 53 authorization process,as described in"Medical Group ♦ Non—Plan Physicians if the Medical Group authorization procedure for certain referrals"under authorizes a written referral to the Non—Plan "Getting a Referral"in the"How to Obtain Services" Physician(in accord with"Medical Group section and(2)the equipment is provided inside our authorization procedure for certain referrals" Service Area. (Coverage for ultraviolet light therapy under"Getting a Referral"in the"How to Obtain equipment is limited to the standard item of Services"section)and the drug,supply,or equipment that adequately meets your medical needs. supplement is covered as part of that referral We decide whether to rent or purchase the equipment, ♦ Non—Plan Physicians if the prescription was and we select the vendor.You must return the obtained as part of covered Emergency Services, equipment to us or pay us the fair market price of the Post-Stabilization Care,or Out-of-Area Urgent equipment when we are no longer covering it.) Care described in the"Emergency Services and Urgent Care"section(if you fill the prescription at For the following Services, refer to these a Plan Pharmacy,you may have to pay Charges sections for the item and file a claim for reimbursement as • Abortion and abortion-related Services(refer to described under"Payment and Reimbursement"in "Reproductive Health Services") the"Emergency Services and Urgent Care" • Outpatient imaging and laboratory Services that are section) Preventive Services,such as routine mammograms, How to obtain covered items bone density scans,and laboratory screening tests (refer to"Preventive Services") You must obtain covered items at a Plan Pharmacy or through our mail-order service unless you obtain the item • Outpatient procedures that include imaging and as part of covered Emergency Services,Post- diagnostic Services(refer to"Outpatient Surgery and Stabilization Care,or Out-of-Area Urgent Care described Outpatient Procedures") in the"Emergency Services and Urgent Care"section. • Services related to diagnosis and treatment of Infertility,artificial insemination,or assisted For the locations of Plan Pharmacies,refer to our reproductive technology("ART")Services(refer to Provider Directory or call Member Services. "Fertility Services") Refills Outpatient Imaging, Laboratory, and Other You may be able to order refills at a Plan Pharmacy, Diagnostic and Treatment Services exclusions through our mail-order service,or through our website at • Ultraviolet light therapy comfort,convenience,or kp.oryJrxrefill.A Plan Pharmacy can give you more luxury equipment or features information about obtaining refills,including the options available to you for obtaining refills.For example,a few • Repair or replacement of ultraviolet light therapy Plan Pharmacies don't dispense refills and not all drugs equipment due to loss,theft,or misuse can be mailed through our mail-order service.Please check with a Plan Pharmacy if you have a question about Outpatient Prescription Drugs, Supplies, Whether your prescription can be mailed or obtained at a Plan Pharmacy.Items available through our mail-order and Supplements service are subject to change at any time without notice. We cover outpatient drugs,supplies,and supplements Day supply limit specified in this"Outpatient Prescription Drugs, The prescribing physician or dentist determines how Supplies,and Supplements"section,in accord with our much of a drug,supply,item,or supplement to prescribe. drug formulary guidelines,subject to any applicable For purposes of day supply coverage limits,Plan exclusions or limitations under this EOC.We cover Physicians determine the amount of an item that items described in this section when prescribed as constitutes a Medically Necessary 30-or 100-day supply follows: (or 365-day supply if the item is a hormonal • Items prescribed by Plan Providers,within the scope contraceptive)for you.Upon payment of the Cost Share of their licensure and practice specified in the"Outpatient prescription drugs,supplies, • Items prescribed by the following Non—Plan and supplements"section of the"Cost Share Summary," Providers: you will receive the supply prescribed up to the day ♦ Dentists if the drug is for dental care supply limit specified in this section or in the drug formulary for your plan(see About the drug formulary" below).The maximum you may receive at one time of a Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 54 covered item,other than a hormonal contraceptive,is Formulary exception process either one 30-day supply in a 30-day period or one 100- Drug formulary guidelines allow you to obtain a non- day supply in a 100-day period.If you wish to receive formulary prescription drug(those not listed on our drug more than the covered day supply limit,then you must formulary for your condition)if it would otherwise be pay Charges for any prescribed quantities that exceed the covered by your plan,as described above,and it is day supply limit. Medically Necessary.If you disagree with a Health Plan determination that a non-formulary prescription drug is If your plan includes coverage for hormonal not covered,you may file a grievance as described in the contraceptives,the maximum you may receive at one "Dispute Resolution"section. time of contraceptive drugs is a 365-day supply.To obtain a 365-day supply,talk to your prescribing Continuity drugs provider.Refer to the"Cost Share Summary"section of If this EOC is amended to exclude a drug that we have this EOC to find out if your plan includes coverage for been covering and providing to you under this EOC,we hormonal contraceptives. will continue to provide the drug if a prescription is required by law and a Plan Physician continues to If your plan includes coverage for sexual dysfunction prescribe the drug for the same condition and for a use drugs,the maximum you may receive at one time of approved by the Federal Food and Drug Administration. episodic drugs prescribed for the treatment of sexual dysfunction disorders is eight doses in any 30-day period About drug tiers or up to 27 doses in any 100-day period.Refer to the Drugs on the drug formulary for your plan are "Cost Share Summary"section of this EOC to find out if categorized into tiers as described in the table below(the your plan includes coverage for sexual dysfunction formulary doesn't have a Tier 3).Refer to"About the cgs• drug formulary"above for details about the formulary for your plan.Your Cost Share for covered items may The pharmacy may reduce the day supply dispensed at vary based on the tier.Refer to"Outpatient prescription the Cost Share specified in the"Outpatient prescription drugs,supplies,and supplements"in the"Cost Share drugs,supplies,and supplements"section of the"Cost Summary"section of this EOC for Cost Share for items Share Summary"for any drug to a 30-day supply in any covered under this section.Refer to the formulary for the 30-day period if the pharmacy determines that the item is definition of"generic drug"and"brand-name drug." in limited supply in the market or for specific drugs (your Plan Pharmacy can tell you if a drug you take is one of these drugs). Drug Tier Description About the drug formulary Tier 1 Most generic drugs,supplies and The drug formulary includes a list of drugs that our supplements(also includes certain Pharmacy and Therapeutics Committee has approved for brand-name drugs,supplies,and our Members.Our Pharmacy and Therapeutics supplements) Committee,which is primarily composed of Plan Physicians and pharmacists,selects drugs for the drug formulary based on several factors,including safety and Tier 2 Most brand-name drugs,supplies, and supplements(also includes effectiveness as determined from a review of medical certain generic drugs,supplies,and literature.The drug formulary is updated monthly based supplements) on new information or new drugs that become available. To find out which drugs are on the formulary for your plan,please refer to the California Commercial HMO Tier 4 High-cost brand-name generic formulary on our website at ky.org/formulary.The drugs,supplies,and supplements lements formulary also discloses requirements or limitations that apply to specific drugs,such as whether there is a limit When a drug is not on the formulary,you pay the same on the amount of the drug that can be dispensed and Cost Share as you would for a formulary drug,when whether the drug must be obtained at certain specialty approved through the formulary exception process pharmacies.If you would like to request a copy of this described above(your Plan Pharmacy will tell you which drug formulary,please call Member Services.Note:The drug tier Cost Share applies). presence of a drug on the drug formulary does not necessarily mean that it will be prescribed for a particular medical condition. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 55 General rules about coverage and your Cost • On your next visit to a Kaiser Permanente pharmacy, Share ask our staff how you can have your prescriptions We cover the following outpatient drugs,supplies,and mailed to you supplements as described in this"Outpatient Prescription Drugs, Supplies,and Supplements"section: Note:Restrictions and limitations apply.For example, • Drugs for which a prescription is required by law.We not all drugs can be mailed and we cannot mail drugs to also cover certain over-the-counter drugs and items all states. (drugs and items that do not require a prescription by law)if they are listed on our drug formulary and Manufacturer coupon program prescribed by a Plan Physician,except a prescription For outpatient prescription drugs or items that are is not required for over-the-counter contraceptives covered under this"Outpatient Prescription Drugs, Supplies,and Supplements" section and obtained at a • Disposable needles and syringes needed for injecting Plan Pharmacy,you maybe able to use approved covered drugs and supplements manufacturer coupons as payment for the Cost Share that • Inhaler spacers needed to inhale covered drugs you owe,as allowed under Health Plan's coupon program.You will owe any additional amount if the Note: coupon does not cover the entire amount of your Cost • If Charges for the drug,supply,or supplement are less Share for your prescription.When you use an approved than the Copayment,you will pay the lesser amount, coupon for payment of your Cost Share,the coupon subject to any applicable deductible or out-of-pocket amount and any additional payment that you make will accumulate to your out-of-pocket maximum if maximum applicable.Refer to the"Cost Share Summary" section • Items can change tier at any time,in accord with of this EOC to find your applicable out-of-pocket formulary guidelines,which may impact your Cost maximum amount and to learn which drugs and items Share(for example,if a brand-name drug is added to apply to the maximum. Certain health plan coverages are the specialty drug list,you will pay the Cost Share not eligible for coupons.You can get more information that applies to drugs on the specialty drugs tier(Tier regarding the Kaiser Permanente coupon program rules 4),not the Cost Share for drugs on the brand drugs and limitations at kp.org/rxcoupons. tier(Tier 2)) Base drugs,supplies,and supplements Schedule H drugs Cost Share for the following items may be different than You or the prescribing provider can request that the other drugs,supplies,and supplements.Refer to"Base pharmacy dispense less than the prescribed amount of a drugs,supplies,and supplements"in the"Cost Share covered oral,solid dosage form of a Schedule II drug Summary"section of this EOC: (your Plan Pharmacy can tell you if a drug you take is • Certain drugs for the treatment of life-threatening one of these drugs).Your Cost Share will be prorated ventricular arrhythmia based on the amount of the drug that is dispensed.If the pharmacy does not prorate your Cost Share,we will send • Drugs for the treatment of tuberculosis you a refund for the difference. • Elemental dietary enteral formula when used as a primary therapy for regional enteritis Mail-order service Prescription refills can be mailed within 3 to 5 days at no • Hematopoietic agents for dialysis extra cost for standard U.S.postage.The appropriate • Hematopoietic agents for the treatment of anemia in Cost Share(according to your drug coverage)will apply chronic renal insufficiency and must be charged to a valid credit card. • Human growth hormone for long-term treatment of pediatric patients with growth failure from lack of You may request mail-order service in the following adequate endogenous growth hormone secretion ways: • Immunosuppressants and ganciclovir and ganciclovir • To order online,visit kp.org/rxrefill(you can register prodrugs for the treatment of cytomegalovirus when for a secure account at ky.org/registernow)or use prescribed in connection with a transplant the KP app from your smartphone or other mobile • Phosphate binders for dialysis patients for the device treatment of hyperphosphatemia in end stage renal • Call the pharmacy phone number highlighted on your disease prescription label and select the mail delivery option Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 56 For the following Services, refer to these Outpatient Surgery and Outpatient sections Procedures • Drugs prescribed for abortion or abortion-related Services(refer to"Reproductive Health Services") We cover the following outpatient care Services: • Administered contraceptives(refer to"Reproductive • Outpatient surgery Health Services") • Outpatient procedures(including imaging and • Diabetes blood-testing equipment and their supplies, diagnostic Services)when provided in an outpatient and insulin pumps and their supplies(refer to or ambulatory surgery center or in a hospital "Durable Medical Equipment("DME")for Home operating room,or in any setting where a licensed Use") staff member monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or • Drugs covered during a covered stay in a Plan to minimize discomfort Hospital or Skilled Nursing Facility(refer to "Hospital Inpatient Services"and"Skilled Nursing For the following Services, refer to these Facility Care") sections • Drugs prescribed for pain control and symptom • Fertility preservation Services for iatrogenic management of the terminal illness for Members who Infertility(refer to"Fertility Preservation Services for are receiving covered hospice care(refer to"Hospice Iatrogenic Infertility") Care") • Outpatient procedures(including imaging and • Durable medical equipment used to administer drugs diagnostic Services)that do not require a licensed (refer to Durable Medical Equipment("DME")for staff member to monitor your vital signs(refer to the Home Use") section that would otherwise apply for the procedure; • Outpatient administered drugs that are not for example,for radiology procedures that do not contraceptives(refer to"Administered Drugs and require a licensed staff member to monitor your vital Products") signs,refer to"Outpatient Imaging,Laboratory,and Other Diagnostic and Treatment Services") Outpatient prescription drugs, supplies, and supplements exclusions Preventive Services • Any requested packaging(such as dose packaging) other than the dispensing pharmacy's standard We cover a variety of Preventive Services,as listed on packaging our website at kp.ora/prevention,including the • Compounded products unless the drug is listed on our following: drug formulary or one of the ingredients requires a • Services recommended by the United States prescription by law Preventive Services Task Force with rating of"A"or • Drugs prescribed to shorten the duration of the "B."The complete list of these services can be found common cold at uspreventiveservicestaskforce.org • Prescription drugs for which there is an over-the- • Immunizations recommended by the Advisory counter equivalent(the same active ingredient, Committee on Immunization Practices of the Centers strength,and dosage form as the prescription drug). for Disease Control and Prevention.The complete list This exclusion does not apply to: of recommended immunizations can be found at ♦ insulin cdc.gov/vaccines/schedules ♦ over-the-counter drugs covered under"Preventive • Preventive services recommended by the Health Services"in this"Benefits"section(this includes Resources and Services Administration and tobacco cessation drugs and contraceptive drugs) incorporated into the Affordable Care Act.The complete list of these services can be found at ♦ an entire class of prescription drugs when one drug hrsa.gov/womens-guidelines within that class becomes available over-the- counter The list of Preventive Services recommended by the • All drugs,supplies,and supplements related to above organizations is subject to change.These assisted reproductive technology("ART")Services Preventive Services are subject to all coverage requirements described in this"Benefits"section and all Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 57 provisions in the"Exclusions,Limitations,Coordination referrals"under"Getting a Referral"in the"How to of Benefits,and Reductions"section. Obtain Services"section •If you are enrolled in a grandfathered plan,certain The Services are provided inside our Service Area preventive items listed on our website,such as over-the- Coverage includes fitting and adjustment of these counter drugs,may not be covered.Refer to the"Certain devices their or repair replacement,and Services to preventive items"table in the"Cost Share Summary" p determine whether you need a prosthetic or orthotic section of this EOC for coverage information.If you device.If we cover a replacement device,then you pay have questions about Preventive Services,please call the Cost Share that you would pay for obtaining that Member Services. device. Note:Preventive Services help you stay healthy,before Base prosthetic and orthotic devices you have symptoms.If you have symptoms,you may If all of the requirements described under"Prosthetic and need other care,such as diagnostic or treatment Services. orthotic coverage rules"in this"Prosthetics and Orthotic If you receive any other covered Services that are not Devices"section are met,we cover the items described Preventive Services before,during,or after a visit that in this"Base prosthetic and orthotic devices"section. includes Preventive Services,you will pay the applicable Cost Share for those other Services.For example,if laboratory tests or imaging Services ordered during a Internally implanted devices preventive office visit are not Preventive Services,you We cover prosthetic and orthotic devices such as will pay the applicable Cost Share for those Services. pacemakers,intraocular lenses,cochlear implants, osseointegrated hearing devices,and hip joints,if they For the following Services, refer to these are implanted during a surgery that we are covering sections under another section of this"Benefits"section. • Milk pumps and lactation supplies(refer to"Lactation External devices supplies"under"Durable Medical Equipment We cover the following external prosthetic and orthotic ("DME")for Home Use") devices: • Health education programs(refer to"Health • Prosthetic devices and installation accessories to Education") restore a method of speaking following the removal • Outpatient drugs,supplies,and supplements that are of all or part of the larynx(this coverage does not Preventive Services(refer to"Outpatient Prescription include electronic voice-producing machines,which Drugs, Supplies,and Supplements") are not prosthetic devices) • Family planning counseling,consultations,and • After Medically Necessary removal of all or part of a sterilization Services(refer to"Reproductive Health breast: Services") ♦ prostheses,including custom-made prostheses when Medically Necessary Prosthetic and Orthotic Devices ♦ up to three brassieres required to hold a prosthesis in any 12-month period Prosthetic and orthotic devices coverage rules • Podiatric devices(including footwear)to prevent or We cover the prosthetic and orthotic devices specified in treat diabetes-related complications when prescribed this"Prosthetic and Orthotic Devices"section if all of by a Plan Physician or by a Plan Provider who is a the following requirements are met: podiatrist • The device is in general use,intended for repeated • Compression burn garments and lymphedema wraps use,and primarily and customarily used for medical and garments purposes • Enteral formula for Members who require tube • The device is the standard device that adequately feeding in accord with Medicare guidelines meets your medical needs • Enteral pump and supplies • You receive the device from the provider or vendor • Tracheostomy tube and supplies that we select • The item has been approved for you through the • Prostheses to replace all or part of an external facial Plan's prior authorization process,as described in body part that has been removed or impaired as a "Medical Group authorization procedure for certain result of disease,injury,or congenital defect Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 58 Supplemental prosthetic and orthotic devices • Following Medically Necessary removal of all or part If all of the requirements described under"Prosthetic and of a breast,we cover reconstruction of the breast, orthotic coverage rules"in this"Prosthetics and Orthotic surgery and reconstruction of the other breast to Devices"section are met,we cover the following items: produce a symmetrical appearance,and treatment of • Prosthetic devices required to replace all or part of an physical complications,including lymphedemas organ or extremity,but only if they also replace the function of the organ or extremity For covered Services related to reconstructive surgery that you receive,you will pay the Cost Share you would • Rigid and semi-rigid orthotic devices required to pay if the Services were not related to reconstructive support or correct a defective body part surgery.For example,see"Hospital inpatient Services" in the"Cost Share Summary"section of this EOC for the For the following Services, refer to these Cost Share that applies for hospital inpatient Services, sections and see"Outpatient surgery and outpatient procedures" • Eyeglasses and contact lenses,including contact in the"Cost Share Summary"for the Cost Share that lenses to treat aniridia or aphakia(refer to"Vision applies for outpatient surgery. Services for Adult Members"and"Vision Services for Pediatric Members") For the following Services, refer to these sections • Hearing aids other than internally implanted devices described in this section(refer to"Hearing Services") • Dental and orthodontic Services that are an integral part of reconstructive surgery for cleft palate(refer to • Injectable implants(refer to"Administered Drugs and "Dental and Orthodontic Services") Products") • Office visits not described in the"Reconstructive Prosthetic and orthotic devices exclusions Surgery"section(refer to"Office Visits") • Multifocal intraocular lenses and intraocular lenses to • Outpatient imaging and laboratory(refer to correct astigmatism "Outpatient Imaging,Laboratory,and Other • Nonrigid supplies,such as elastic stockings and wigs, Diagnostic and Treatment Services") except as otherwise described above in this • Outpatient prescription drugs(refer to"Outpatient "Prosthetic and Orthotic Devices"section Prescription Drugs,Supplies,and Supplements") • Comfort,convenience,or luxury equipment or • Outpatient administered drugs(refer to"Administered features Drugs and Products") • Repair or replacement of device due to loss,theft,or • Prosthetics and orthotics refer to"Prosthetic and misuse Orthotic Devices") • Shoes,shoe inserts,arch supports,or any other • Telehealth Visits(refer to"Telehealth Visits") footwear,even if custom-made,except footwear described above in this"Prosthetic and Orthotic Reconstructive surgery exclusions Devices"section for diabetes-related complications • Surgery that,in the judgment of a Plan Physician • Prosthetic and orthotic devices not intended for specializing in reconstructive surgery,offers only a maintaining normal activities of daily living minimal improvement in appearance (including devices intended to provide additional support for recreational or sports activities) Rehabilitative and Habilitative Services Reconstructive Surgery We cover the Services described in this"Rehabilitative and Habilitative Services"section if all of the following We cover the following reconstructive surgery Services: requirements are met: • Reconstructive surgery to correct or repair abnormal • The Services are to address a health condition structures of the body caused by congenital defects, • The Services are to help you keep,learn,or improve developmental abnormalities,trauma,infection, skills and functioning for daily living tumors,or disease,if a Plan Physician determines that • you receive the Services at a Plan Facility unless a it is necessary to improve function,or create a normal appearance,to the extent possible Plan Physician determines that it is Medically Necessary for you to receive the Services in another location Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 59 We cover the following Services: Abortion and abortion-related Services • Individual outpatient physical,occupational,and We cover the following Services: speech therapy • Surgical abortion • Group outpatient physical,occupational,and speech • Prescription drugs,in accord with our drug formulary therapy guidelines • Physical,occupational,and speech therapy provided • Abortion-related Services in an organized,multidisciplinary rehabilitation day- treatment program For the following Services, refer to these sections For the following Services, refer to these • Fertility preservation Services for iatrogenic sections Infertility(refer to"Fertility Preservation Services for • Behavioral health treatment for autism spectrum Iatrogenic Infertility") disorder(refer to"Behavioral Health Treatment for • Services to diagnose or treat Infertility(refer to Autism Spectrum Disorder") "Fertility Services") • Home health care(refer to"Home Health Care") • Office visits related to injectable contraceptives, • Durable medical equipment(refer to"Durable internally implanted time-release contraceptives or Medical Equipment("DME")for Home Use") intrauterine devices("IUDs")when provided for • Ostomy and urological supplies(refer to"Ostomy and medical reasons other than to prevent pregnancy Urological Supplies") (refer to"Office Visits") • Prosthetic and orthotic devices(refer to"Prosthetic • Outpatient administered drugs that are not and Orthotic Devices") contraceptives(refer to"Administered Drugs and • Physical,occupational,and speech therapy provided Products") during a covered stay in a Plan Hospital or Skilled • Outpatient laboratory and imaging services associated Nursing Facility(refer to"Hospital Inpatient with family planning services(refer to"Outpatient Services"and"Skilled Nursing Facility Care") Imaging,Laboratory,and Other Diagnostic and Treatment Services") Rehabilitative and habilitative Services • Outpatient contraceptive drugs and devices(refer to exclusions "Outpatient Prescription Drugs, Supplies,and • Items and services that are not health care items and Supplements") services(for example,respite care,day care, • Outpatient surgery and outpatient procedures when recreational care,residential treatment,social provided for medical reasons other than to prevent services,custodial care,or education services of any pregnancy(refer to"Outpatient Surgery and kind,including vocational training) Outpatient Procedures") Reproductive Health Services Reproductive health Services exclusions • Reversal of voluntary sterilization Family planning Services We cover the following Services when provided for family planning purposes: Services in Connection with a Clinical • Family planning counseling Trial • Injectable contraceptives,internally implanted time- We cover Services you receive in connection with a release contraceptives or intrauterine devices clinical trial if all of the following requirements are met: ("IUDs")and office visits related to their insertion, • We would have covered the Services if they were not removal,and management when provided to prevent related to a clinical trial pregnancy • You are eligible to participate in the clinical trial • Sterilization procedures for Members assigned female according to the trial protocol with respect to at birth treatment of cancer or other life-threatening condition • Sterilization procedures for Members assigned male (a condition from which the likelihood of death is at birth probable unless the course of the condition is Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 60 interrupted),as determined in one of the following of this EOC for the Cost Share that applies for hospital ways: inpatient Services. ♦ a Plan Provider makes this determination ♦ you provide us with medical and scientific Services in connection with a clinical trial information establishing this determination exclusions • If any Plan Providers participate in the clinical trial • The investigational Service and will accept you as a participant in the clinical • Services that are provided solely to satisfy data trial,you must participate in the clinical trial through collection and analysis needs and are not used in your a Plan Provider unless the clinical trial is outside the clinical management state where you live • The clinical trial is an Approved Clinical Trial Skilled Nursing Facility Care "Approved Clinical Trial"means a phase I,phase II, Inside our Service Area,we cover skilled inpatient phase III,or phase IV clinical trial related to the Services in a Plan Skilled Nursing Facility.The skilled prevention,detection,or treatment of cancer or other inpatient Services must be customarily provided by a life-threatening condition,and that meets one of the Skilled Nursing Facility,and above the level of custodial following requirements: or intermediate care. • The study or investigation is conducted under an investigational new drug application reviewed by the We cover the following Services: U.S.Food and Drug Administration • Physician and nursing Services • The study or investigation is a drug trial that is • Room and board exempt from having an investigational new drug • Drugs prescribed by a Plan Physician as part of your application plan of care in the Plan Skilled Nursing Facility in • The study or investigation is approved or funded by at accord with our drug formulary guidelines if they are least one of the following: administered to you in the Plan Skilled Nursing ♦ the National Institutes of Health Facility by medical personnel ♦ the Centers for Disease Control and Prevention • Durable medical equipment in accord with our prior ♦ the Agency for Health Care Research and Quality authorization procedure if Skilled Nursing Facilities ♦ the Centers for Medicare&Medicaid Services ordinarily furnish the equipment(refer to"Medical Group authorization procedure for certain referrals" ♦ a cooperative group or center of any of the above under"Getting a Referral"in the"How to Obtain entities or of the Department of Defense or the Services"section) Department of Veterans Affairs • Imaging and laboratory Services that Skilled Nursing ♦ a qualified non-governmental research entity Facilities ordinarily provide identified in the guidelines issued by the National Institutes of Health for center support grants • Medical social services ♦ the Department of Veterans Affairs or the • Whole blood,red blood cells,plasma,platelets,and Department of Defense or the Department of their administration Energy,but only if the study or investigation has . Medical supplies been reviewed and approved though a system of peer review that the U.S. Secretary of Health and • Behavioral health treatment that is Medically Human Services determines meets all of the Necessary to treat mental health conditions that fall following requirements: (1)It is comparable to the under any of the diagnostic categories listed in the National Institutes of Health system of peer review mental and behavioral disorders chapter of the most of studies and investigations and(2)it assures recent edition of the International Classification of unbiased review of the highest scientific standards Diseases or that are listed in the most recent version by qualified people who have no interest in the of the Diagnostic and Statistical Manual of Mental outcome of the review Disorders • Physical,occupational,and speech therapy For covered Services related to a clinical trial,you will • Respiratory therapy pay the Cost Share you would pay if the Services were not related to a clinical trial.For example,see"Hospital inpatient Services"in the"Cost Share Summary"section Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 61 For the following Services, refer to these personnel(for discharge drugs prescribed when you sections are released from the residential treatment facility, • Outpatient imaging,laboratory,and other diagnostic refer to"Outpatient Prescription Drugs, Supplies,and and treatment Services(refer to"Outpatient Imaging, Supplements"in this"Benefits"section) Laboratory,and Other Diagnostic and Treatment • Discharge planning Services") • Outpatient physical,occupational,and speech therapy Inpatient detoxification (refer to"Rehabilitative and Habilitative Services") We cover hospitalization in a Plan Hospital only for medical management of withdrawal symptoms,including room and board,Plan Physician Services,drugs, Substance Use Disorder Treatment dependency recovery Services,education,and counseling. We cover Services specified in this"Substance Use Disorder Treatment"section only when the Services are Services from Non-Plan Providers for the prevention,diagnosis,or treatment of Substance If we are not able to offer an appointment with a Plan Use Disorders.A"Substance Use Disorder"is a Provider within required geographic and timely access substance use disorder that falls under any of the standards,we will offer to refer you to a Non-Plan diagnostic categories listed in the mental and behavioral Provider(as described in"Medical Group authorization disorders chapter of the most recent edition of the procedure for certain referrals"under"Getting a International Classification of Diseases or that is listed Referral'in the"How to Obtain Services"section). in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders. Additionally,we cover Services provided by a 988 center,mobile crisis team,or other provider of Outpatient substance use disorder treatment behavioral health crisis services(collectively,"988 We cover the following Services for treatment of Services")for medically necessary treatment of a mental substance use disorders: health or substance use disorder without prior • Day-treatment programs authorization,as required by state law. • Individual and group substance use disorder For these referral Services and 988 Services,you pay the counseling Cost Share required for Services provided by a Plan • Intensive outpatient programs Provider as described in this EOC. • Medical treatment for withdrawal symptoms For the following Services, refer to these Residential treatment sections Inside our Service Area,we cover the following Services • Outpatient laboratory(refer to"Outpatient Imaging, when the Services are provided in a licensed residential Laboratory,and Other Diagnostic and Treatment treatment facility that provides 24-hour individualized Services") substance use disorder treatment,the Services are • Outpatient self-administered drugs(refer to generally and customarily provided by a substance use "Outpatient Prescription Drugs,Supplies,and disorder residential treatment program in a licensed Supplements") residential treatment facility,and the Services are above the level of custodial care: • Telehealth Visits(refer to"Telehealth Visits") • Individual and group substance use disorder counseling Telehealth Visits • Medical services Telehealth Visits are intended to make it more • Medication monitoring convenient for you to receive covered Services,when a • Room and board Plan Provider determines it is medically appropriate for your medical condition.You may receive covered • Social services Services via Telehealth Visits,when available and if the • Drugs prescribed by a Plan Provider as part of your Services would have been covered under this EOC if plan of care in the residential treatment facility in provided in person.You are not required to use accord with our drug formulary guidelines if they are Telehealth Visits,and you may choose to receive in- administered to you in the facility by medical person Services from a Plan Provider instead. Some Plan Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 62 Providers offer Services exclusively through a telehealth donors(whether or not they are Members)in accord with technology platform and have no physical location at our guidelines for donor Services at no charge. which you can receive Services.If you receive covered Services from these Plan Providers,you may access your For the following Services, refer to these medical record of the Telehealth Visit and,unless you sections object,such information will be added to your Health • Dental Services that are Medically Necessary to Plan electronic medical record and shared with your prepare for a transplant(refer to"Dental and Primary Care Physician. Orthodontic Services") We cover the following types of Telehealth Visits with • Outpatient imaging and laboratory(refer to Primary Care Physicians,Non-Physician Specialists,and "Outpatient Imaging,Laboratory,and Other Physician Specialists: Diagnostic and Treatment Services") • Interactive video visits • Outpatient prescription drugs(refer to"Outpatient • Scheduled telephone visits Prescription Drugs,Supplies,and Supplements") • Outpatient administered drugs(refer to"Administered Drugs and Products") Transplant Services We cover transplants of organs,tissue,or bone marrow if Vision Services for Adult Members the Medical Group provides a written referral for care to a transplant facility as described in"Medical Group For the purpose of this"Vision Services for Adult authorization procedure for certain referrals"under Members"section,an"Adult Member"is a Member who "Getting a Referral"in the"How to Obtain Services" is age 19 or older and is not a Pediatric Member,as section. defined under"Vision Services for Pediatric Members" in this"Benefits"section.For example,if you turn 19 on After the referral to a transplant facility,the following June 25,you will be an Adult Member starting July 1. applies: • If either the Medical Group or the referral facility We cover the following for Adult Members: determines that you do not satisfy its respective • Routine eye exams with a Plan Optometrist to criteria for a transplant,we will only cover Services determine the need for vision correction(including you receive before that determination is made dilation Services when Medically Necessary)and to • Health Plan,Plan Hospitals,the Medical Group,and provide a prescription for eyeglass lenses Plan Physicians are not responsible for finding, • Physician Specialist Visits to diagnose and treat furnishing,or ensuring the availability of an organ, injuries or diseases of the eye tissue,or bone marrow donor • Non-Physician Specialist Visits to diagnose and treat • In accord with our guidelines for Services for living injuries or diseases of the eye transplant donors,we provide certain donation-related Services for a donor,or an individual identified by the Optical Services Medical Group as a potential donor,whether or not We cover the Services described in this"Optical the donor is a Member. These Services must be Services"section when received from Plan Medical directly related to a covered transplant for you,which Offices or Plan Optical Sales Offices. may include certain Services for harvesting the organ, tissue,or bone marrow and for treatment of The date we provide an Allowance toward(or otherwise complications.Please call Member Services for cover)an item described in this"Optical Services" questions about donor Services section is the date on which you order the item.For example,if we last provided an Allowance toward an For covered transplant Services that you receive,you item you ordered on May 1,2022,and if we provide an will pay the Cost Share you would pay if the Services Allowance not more than once every 24 months for that were not related to a transplant.For example,see type of item,then we would not provide another "Hospital inpatient Services"in the"Cost Share Allowance toward that type of item until on or after May Summary"section of this EOC for the Cost Share that 1,2024.You can use the Allowances under this"Optical applies for hospital inpatient Services.We provide or pay Services"section only when you first order an item.If for donation-related Services for actual or potential you use part but not all of an Allowance when you first Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 63 order an item,you cannot use the rest of that Allowance covered)we will provide an Allowance toward the later. purchase price of a replacement item of the same type (eyeglass lens,or contact lens,fitting,and dispensing) Special contact lenses for the eye that had the.50 diopter change.Refer to We cover the following: "Vision Services for Adult Members"in the"Cost Share • For aniridia(missing iris),we cover up to two Summary"section of this EOC for your Allowanceamount. Medically Necessary contact lenses per eye (including fitting and dispensing)in any 12-month Low vision devices period when prescribed by a Plan Physician or Plan Optometrist Low vision devices(including fitting and dispensing)are not covered under this EOC. • For aphakia(absence of the crystalline lens of the eye),we cover up to six Medically Necessary aphakic For the following Services, refer to these contact lenses per eye(including fitting and sections dispensing)in any 12-month period when prescribed by a Plan Physician or Plan Optometrist • Routine vision screenings when performed as part of a routine physical exam(refer to"Preventive • For other specialty contact lenses that will provide a Services") significant improvement in your vision not obtainable with eyeglass lenses,we cover either one pair of • Services related to the eye or vision other than contact lenses(including fitting and dispensing)or an Services covered under this"Vision Services for initial supply of disposable contact lenses(up to six Adult Members"section,such as outpatient surgery months,including fitting and dispensing)in any 24- and outpatient prescription drugs,supplies,and month period supplements(refer to the applicable heading in this "Benefits"section) Eyeglasses and contact lenses Vision Services for Adult Members exclusions We provide a single Allowance toward the purchase price of any or all of the following not more than once • Eyeglass or contact lens adornment,such as every 24 months when a physician or optometrist engraving,faceting,or jeweling prescribes an eyeglass lens(for eyeglass lenses and • Items that do not require a prescription by law(other frames)or contact lens(for contact lenses).Refer to than eyeglass frames),such as eyeglass holders, "Vision Services for Adult Members"in the"Cost Share eyeglass cases,and repair kits Summary"section of this EOC for your Allowance amount. • Lenses and sunglasses without refractive value, • Eyeglass lenses when a Plan Provider puts the lenses except as described in this"Vision Services for Adult Members section into a frame ♦ we cover a clear balance lens when only one eye • Low vision devices needs correction • Replacement of lost,broken,or damaged contact ♦ we cover tinted lenses when Medically Necessary lenses,eyeglass lenses,and frames to treat macular degeneration or retinitis pigmentosa Vision Services for Pediatric Members • Eyeglass frames when a Plan Provider puts two lenses (at least one of which must have refractive value)into For the purpose of this"Vision Services for Pediatric the frame Members"section,a"Pediatric Member"is a Member • Contact lenses,fitting,and dispensing from birth through the end of the month of their 19th birthday.For example,if you turn 19 on June 25,you We will not provide the Allowance if we have provided will be an Adult Member starting July 1 and your last an Allowance toward(or otherwise covered)eyeglass minute as a Pediatric Member will be 11:59 p.m. on June lenses or frames within the previous 24 months. 30. Replacement lenses We cover the following for Pediatric Members: If you have a change in prescription of at least.50 • Routine eye exams with a Plan Optometrist to diopter in one or both eyes within 12 months of the determine the need for vision correction(including initial point of sale of an eyeglass lens or contact lens that we provided an Allowance toward(or otherwise Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 64 dilation Services when Medically Necessary)and to We will not provide the Allowance if we have provided provide a prescription for eyeglass lenses an Allowance toward(or otherwise covered)eyeglass • Physician Specialist Visits to diagnose and treat lenses or frames within the previous 24 months. injuries or diseases of the eye Replacement lenses • Non-Physician Specialist Visits to diagnose and treat If you have a change in prescription of at least.50 injuries or diseases of the eye diopter in one or both eyes at least 12 months after the date we dispensed eyeglass lenses of the type described Optical Services in this"Vision Services for Pediatric Members"section, We cover the Services described in this"Optical we will cover a replacement Regular Eyeglass Lens for Services"section when received from Plan Medical the eye that had the.50 diopter change. Offices or Plan Optical Sales Offices. Low vision devices Special contact lenses Low vision devices(including fitting and dispensing)are We cover the following: not covered under this EOC. • For aniridia(missing iris),we cover up to two Medically Necessary contact lenses per eye For the following Services, refer to these (including fitting and dispensing)in any 12-month sections period when prescribed by a Plan Physician or Plan • Routine vision screenings when performed as part of Optometrist a routine physical exam(refer to"Preventive • For aphakia(absence of the crystalline lens of the Services") eye),we cover up to six Medically Necessary aphakic • Services related to the eye or vision other than contact lenses per eye(including fitting and Services covered under this"Vision Services for dispensing)in any 12-month period when prescribed Pediatric Members"section,such as outpatient by a Plan Physician or Plan Optometrist surgery and outpatient prescription drugs,supplies, • For other specialty contact lenses that will provide a and supplements(refer to the applicable heading in significant improvement in your vision not obtainable this"Benefits"section) with eyeglass lenses,we cover either one pair of contact lenses(including fitting and dispensing)or an Vision Services for Pediatric Members initial supply of disposable contact lenses(up to six exclusions months,including fitting and dispensing)in any 24- • Eyeglass or contact lens adornment,such as month period engraving,faceting,or jeweling Eyeglasses and contact lenses • Items that do not require a prescription by law(other We provide a single Allowance toward the purchase than eyeglass frames),such as eyeglass holders, price of any or all of the following not more than once eyeglass cases,and repair kits every 24 months when a physician or optometrist • Lenses and sunglasses without refractive value, prescribes an eyeglass lens(for eyeglass lenses and except as described in this"Vision Services for frames)or contact lens(for contact lenses).Refer to Pediatric Members"section "Vision Services for Pediatric Members"in the"Cost • Low vision devices Share Summary"section of this EOC for your Allowance amount. • Replacement of lost,broken,or damaged contact • Eyeglass lenses when a Plan Provider puts the lenses lenses,eyeglass lenses,and frames into a frame ♦ we cover a clear balance lens when only one eye EXClUSIOnS, Limitations, needs correction ♦ we cover tinted lenses when Medically Necessary Coordination of Benefits, and to treat macular degeneration or retinitis Reductions pigmentosa • Eyeglass frames when a Plan Provider puts two lenses Exclusions (at least one of which must have refractive value)into the frame The items and services listed in this"Exclusions"section • Contact lenses,fitting,and dispensing are excluded from coverage.These exclusions apply to Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 65 all Services that would otherwise be covered under this orthodontists,dental Services following accidental injury EOC regardless of whether the services are within the to teeth,and dental Services resulting from medical scope of a provider's license or certificate.These treatment such as surgery on the jawbone and radiation exclusions or limitations do not apply to Services that are treatment. Medically Necessary to treat mental health conditions or substance use disorders that fall under any of the This exclusion does not apply to the following Services: diagnostic categories listed in the mental and behavioral • Services covered under"Dental and Orthodontic disorders chapter of the most recent edition of the Services"in the"Benefits"section International Classification of Diseases or that are listed in the most recent version of the Diagnostic and • Service described under"Injury to Teeth"in the Statistical Manual of Mental Disorders. "Benefits"section • Pediatric dental Services described in a Pediatric Certain exams and Services Dental Services Amendment to this EOC,if any.If Routine physical exams and other Services that are not your plan has a Pediatric Dental Services Medically Necessary,such as when required(1)for Amendment,it will be attached to this EOC,and it obtaining or maintaining employment or participation in will be listed in the EOC's Table of Contents employee programs,(2)for insurance,credentialing or licensing,(3)for travel,or(4)by court order or for Disposable supplies parole or probation. Disposable supplies for home use,such as bandages, gauze,tape,antiseptics,dressings,Ace-type bandages, Chiropractic Services and diapers,underpads,and other incontinence supplies. Chiropractic Services and the Services of a chiropractor, unless you have coverage for supplemental chiropractic This exclusion does not apply to disposable supplies Services as described in an amendment to this EOC. covered under"Durable Medical Equipment("DME") for Home Use,""Home Health Care,""Hospice Care," Cosmetic Services "Ostomy and Urological Supplies,"and"Outpatient Services that are intended primarily to change or Prescription Drugs,Supplies,and Supplements"in the maintain your appearance,including cosmetic surgery "Benefits"section. (surgery that is performed to alter or reshape normal structures of the body in order to improve appearance), Experimental or investigational Services except that this exclusion does not apply to any of the A Service is experimental or investigational if we,in following: consultation with the Medical Group,determine that one • Services covered under"Reconstructive Surgery"in of the following is true: the"Benefits"section • Generally accepted medical standards do not • The following devices covered under"Prosthetic and recognize it as safe and effective for treating the Orthotic Devices"in the"Benefits"section:testicular condition in question(even if it has been authorized implants implanted as part of a covered reconstructive by law for use in testing or other studies on human surgery,breast prostheses needed after removal of all patients) or part of a breast,and prostheses to replace all or part • It requires government approval that has not been of an external facial body part obtained when the Service is to be provided Custodial care This exclusion does not apply to any of the following: Assistance with activities of daily living(for example: • Experimental or investigational Services when an walking,getting in and out of bed,bathing,dressing, investigational application has been filed with the feeding,toileting,and taking medicine). federal Food and Drug Administration("FDA")and the manufacturer or other source makes the Services This exclusion does not apply to assistance with available to you or Kaiser Permanente through an activities of daily living that is provided as part of FDA-authorized procedure,except that we do not covered hospice,Skilled Nursing Facility,or hospital cover Services that are customarily provided by inpatient Services. research sponsors free of charge to enrollees in a Dental and orthodontic Services clinical trial or other investigational treatment protocol Dental and orthodontic Services such as X-rays, . Services covered under"Services in Connection with appliances,implants, Services provided by dentists or a Clinical Trial"in the"Benefits"section Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 66 Refer to the"Dispute Resolution"section for information refractive defects of the eye such as myopia,hyperopia, about Independent Medical Review related to denied or astigmatism. requests for experimental or investigational Services. Massage therapy Hair loss or growth treatment Massage therapy,except that this exclusion does not Items and services for the promotion,prevention,or apply to therapy Services that are part of a physical other treatment of hair loss or hair growth. therapy treatment plan and covered under"Home Health Care,""Hospice Services,""Hospital Inpatient Intermediate care Services,""Rehabilitative and Habilitative Services,"or Care in a licensed intermediate care facility. This "Skilled Nursing Facility Care"in the"Benefits"section. exclusion does not apply to Services covered under "Durable Medical Equipment("DME")for Home Use," Oral nutrition and weight loss aids "Home Health Care,"and"Hospice Care"in the Outpatient oral nutrition,such as dietary supplements, "Benefits"section. herbal supplements,formulas,food,and weight loss aids. Items and services that are not health care items This exclusion does not apply to any of the following: and services • Amino acid—modified products and elemental dietary For example,we do not cover: enteral formula covered under"Outpatient • Teaching manners and etiquette Prescription Drugs,Supplies,and Supplements"in • Teaching and support services to develop planning the`Benefits"section skills such as daily activity planning and project or • Enteral formula covered under"Prosthetic and task planning Orthotic Devices"in the`Benefits"section • Items and services for the purpose of increasing Residential care academic knowledge or skills Care in a facility where you stay overnight,except that • Teaching and support services to increase intelligence this exclusion does not apply when the overnight stay is • Academic coaching or tutoring for skills such as part of covered care in a hospital,a Skilled Nursing grammar,math,and time management Facility,or inpatient respite care covered in the"Hospice • Teaching you how to read,whether or not you have Care"section. dyslexia Routine foot care items and services • Educational testing Routine foot care items and services that are not • Teaching art,dance,horse riding,music,play or Medically Necessary. swimming • Teaching skills for employment or vocational Services not approved by the federal Food and purposes Drug Administration Drugs,supplements,tests,vaccines,devices,radioactive • Vocational training or teaching vocational skills materials,and any other Services that by law require • Professional growth courses federal Food and Drug Administration("FDA")approval • Training for a specific job or employment counseling in order to be sold in the U.S.but are not approved by the FDA.This exclusion applies to Services provided • Aquatic therapy and other water therapy,except that anywhere,even outside the U.S. this exclusion for aquatic therapy and other water therapy does not apply to therapy Services that are This exclusion does not apply to any of the following: part of a physical therapy treatment plan and covered • Services covered under the"Emergency Services and under"Home Health Care,""Hospice Services," Urgent Care"section that you receive outside the U.S. "Hospital Inpatient Services,""Rehabilitative and Habilitative Services,"or"Skilled Nursing Facility • Experimental or investigational Services when an Care"in the"Benefits"section investigational application has been filed with the FDA and the manufacturer or other source makes the Items and services to correct refractive defects Services available to you or Kaiser Permanente of the eye through an FDA-authorized procedure,except that we Items and services(such as eye surgery or contact lenses do not cover Services that are customarily provided to reshape the eye)for the purpose of correcting by research sponsors free of charge to enrollees in a Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 67 clinical trial or other investigational treatment provision of Services under this EOC,such as a major protocol disaster,epidemic,war,riot,civil insurrection,disability • Services covered under"Services in Connection with of a large share of personnel at a Plan Facility,complete a Clinical Trial"in the"Benefits"section or partial destruction of facilities,and labor dispute. Under these circumstances,if you have an Emergency Refer to the"Dispute Resolution"section for information Medical Condition,call 911 or go to the nearest about Independent Medical Review related to denied emergency department as described under"Emergency requests for experimental or investigational Services. Services"in the"Emergency Services and Urgent Care" section,and we will provide coverage and Services performed by unlicensed people reimbursement as described in that section. Services that are performed safely and effectively by people who do not require licenses or certificates by the Coordination of Benefits state to provide health care services and where the Member's condition does not require that the services be The Services covered under this EOC are subject to provided by a licensed health care provider. coordination of benefits rules. Services related to a noncovered Service Coverage other than Medicare coverage When a Service is not covered,all Services related to the If you have medical or dental coverage under another noncovered Service are excluded, except for Services we plan that is subject to coordination of benefits,we will would otherwise cover to treat complications of the coordinate benefits with the other coverage under the noncovered Service.For example,if you have a coordination of benefits rules of the California noncovered cosmetic surgery,we would not cover Department of Managed Health Care.Those rules are Services you receive in preparation for the surgery or for incorporated into this EOC. follow-up care.If you later suffer a life-threatening complication such as a serious infection,this exclusion If both the other coverage and we cover the same would not apply and we would cover any Services that Service,the other coverage and we will see that up to we would otherwise cover to treat that complication. 100 percent of your covered medical expenses are paid for that Service.The coordination of benefits rules Surrogacy determine which coverage pays first,or is"primary,"and Services for anyone in connection with a Surrogacy which coverage pays second,or is"secondary."The Arrangement,except for otherwise-covered Services secondary coverage may reduce its payment to take into provided to a Member who is a surrogate.Refer to account payment by the primary coverage.You must "Surrogacy Arrangements"under"Reductions"in this give us any information we request to help us coordinate "Exclusions,Limitations,Coordination of Benefits,and benefits. Reductions"section for information about your obligations to us in connection with a Surrogacy If your coverage under this EOC is secondary,we may Arrangement,including your obligations to reimburse us be able to establish a Benefit Reserve Account for you. for any Services we cover and to provide information You may draw on the Benefit Reserve Account during a about anyone who may be financially responsible for calendar year to pay for your out-of-pocket expenses for Services the baby(or babies)receive. Services that are partially covered by either your other coverage or us during that calendar year.If you are Travel and lodging expenses entitled to a Benefit Reserve Account,we will provide Travel and lodging expenses,except as described in our you with detailed information about this account. Travel and Lodging Program Description.The Travel and Lodging Program Description is available online at If you have any questions about coordination of benefits, kp.ora/specialty-care/travel-reimbursements or by please call Member Services. calling Member Services. Medicare coverage If you have Medicare coverage,we will coordinate Limitations benefits with the Medicare coverage under Medicare rules.Medicare rules determine which coverage pays We will make a good faith effort to provide or arrange first,or is"primary,"and which coverage pays second, for covered Services within the remaining availability of or is"secondary."You must give us any information we facilities or personnel in the event of unusual request to help us coordinate benefits.Please call circumstances that delay or render impractical the Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 68 Member Services to find out which Medicare rules apply the total amount of the proceeds is less than the actual to your situation,and how payment will be handled. losses and damages you incurred. Within 30 days after submitting or filing a claim or legal Reductions action against another party,you must send written Employer responsibility notice of the claim or legal action to: For any Services that the law requires an employer to Equian provide,we will not pay the employer,and when we Kaiser Permanente-Northern California Region cover any such Services we may recover the value of the Subrogation Mailbox Services from the employer. P.O.Box 36380 Louisville,KY 40233 Government agency responsibility Fax: 1-502-214-1137 For any Services that the law requires be provided only In order for us to determine the existence of any rights by or received only from a government agency,we will we may have and to satisfy those rights,you must not pay the government agency,and when we cover any complete and send us all consents,releases, such Services we may recover the value of the Services authorizations,assignments,and other documents, from the government agency. including lien forms directing your attorney,the other party,and the other party's liability insurer to pay us Injuries or illnesses alleged to be caused by directly.You may not agree to waive,release,or reduce other parties our rights under this provision without our prior,written If you obtain a judgment or settlement from or on behalf consent. of another party who allegedly caused an injury or illness for which you received covered Services,you must If your estate,parent,guardian,or conservator asserts a reimburse us to the maximum extent allowed under claim against another party based on your injury or California Civil Code Section 3040. The reimbursement illness,your estate,parent,guardian,or conservator and due to us is not limited by or subject to the Plan Out-of- any settlement or judgment recovered by the estate, Pocket Maximum.Note: This"Injuries or illnesses parent,guardian,or conservator shall be subject to our alleged to be caused by other parties"section does not liens and other rights to the same extent as if you had affect your obligation to pay your Cost Share for these asserted the claim against the other party.We may assign Services. our rights to enforce our liens and other rights. To the extent permitted or required by law,we have the If you have Medicare,Medicare law may apply with option of becoming subrogated to all claims,causes of respect to Services covered by Medicare. action,and other rights you may have against another party or an insurer,government program,or other source Some providers have contracted with Kaiser Permanente of coverage for monetary damages,compensation,or to provide certain Services to Members at rates that are indemnification on account of the injury or illness typically less than the fees that the providers ordinarily allegedly caused by the other party.We will be so charge to the general public("General Fees").However, subrogated as of the time we mail or deliver a written these contracts may allow the providers to recover all or notice of our exercise of this option to you or your a portion of the difference between the fees paid by attorney. Kaiser Permanente and their General Fees by means of a lien claim under California Civil Code Sections 3045.1- To secure our rights,we will have a lien and 3045.6 against a judgment or settlement that you receive reimbursement rights to the proceeds of any judgment or from or on behalf of another party.For Services the settlement you or we obtain(1)against another party, provider furnished,our recovery and the provider's and/or(2)from other types of coverage or sources of recovery together will not exceed the provider's General payment that include but are not limited to: liability, Fees. uninsured motorist,underinsured motorist,personal umbrella,workers'compensation,and/or personal injury Surrogacy Arrangements coverages,any other types of medical payments and all other first party types of coverages or sources of If you enter into a Surrogacy Arrangement and you or any other payee are entitled to receive payments or other payment.The proceeds of any judgment or settlement compensation under the Surrogacy Arrangement,you that you or we obtain and/or payments that you receive must reimburse us for covered Services you receive shall first be applied to satisfy our lien,regardless of related to conception,pregnancy,delivery,or postpartum whether you are made whole and regardless of whether Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 69 care in connection with that arrangement("Surrogacy Arrangements"section and to satisfy those rights.You Health Services")to the maximum extent allowed under may not agree to waive,release,or reduce our rights California Civil Code Section 3040.Note: This under this"Surrogacy Arrangements"section without "Surrogacy Arrangements"section does not affect your our prior,written consent. obligation to pay your Cost Share for these Services. After you surrender a baby to the legal parents,you are If your estate,parent,guardian,or conservator asserts a not obligated to reimburse us for any Services that the claim against another party based on the Surrogacy baby receives(the legal parents are financially Arrangement,your estate,parent,guardian,or responsible for any Services that the baby receives). conservator and any settlement or judgment recovered by the estate,parent,guardian,or conservator shall be By accepting Surrogacy Health Services,you subject to our liens and other rights to the same extent as automatically assign to us your right to receive payments if you had asserted the claim against the other party.We that are payable to you or any other payee under the may assign our rights to enforce our liens and other Surrogacy Arrangement,regardless of whether those rights. payments are characterized as being for medical expenses.To secure our rights,we will also have a lien If you have questions about your obligations under this on those payments and on any escrow account,trust,or provision,please call Member Services. any other account that holds those payments. Those payments(and amounts in any escrow account,trust,or U.S. Department of Veterans Affairs other account that holds those payments)shall first be For any Services for conditions arising from military applied to satisfy our lien.The assignment and our lien service that the law requires the Department of Veterans will not exceed the total amount of your obligation to us Affairs to provide,we will not pay the Department of under the preceding paragraph. Veterans Affairs,and when we cover any such Services we may recover the value of the Services from the Within 30 days after entering into a Surrogacy Department of Veterans Affairs. Arrangement,you must send written notice of the arrangement,including all of the following information: Workers' compensation or employer's liability • Names,addresses,and phone numbers of the other benefits parties to the arrangement You may be eligible for payments or other benefits, • Names,addresses,and phone numbers of any escrow including amounts received as a settlement(collectively agent or trustee referred to as"Financial Benefit"),under workers' compensation or employer's liability law.We will • Names,addresses,and phone numbers of the intended provide covered Services even if it is unclear whether parents and any other parties who are financially you are entitled to a Financial Benefit,but we may responsible for Services the baby(or babies)receive, recover the value of any covered Services from the including names,addresses,and phone numbers for following sources: any health insurance that will cover Services that the • From any source providing a Financial Benefit or baby(or babies)receive from whom a Financial Benefit is due • A signed copy of any contracts and other documents • From you,to the extent that a Financial Benefit is explaining the arrangement provided or payable or would have been required to • Any other information we request in order to satisfy be provided or payable if you had diligently sought to our rights establish your rights to the Financial Benefit under any workers' compensation or employer's liability You must send this information to: law Equian Kaiser Permanente-Northern California Region Surrogacy Mailbox Post-Service Claims and Appeals P.O.Box 36380 Louisville,KY 40233 Fax: 1-502-214-1137 This"Post-Service Claims and Appeals"section explains how to file a claim for payment or reimbursement for You must complete and send us all consents,releases, Services that you have already received.Please use the authorizations,lien forms,and other documents that are procedures in this section in the following situations: reasonably necessary for us to determine the existence of • You have received Emergency Services,Post- any rights we may have under this"Surrogacy Stabilization Care,Out-of-Area Urgent Care,or Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 70 emergency ambulance Services from a Non—Plan Supporting Documents Provider and you want us to pay for the Services • You have received Services from a Non—Plan You can request payment or reimbursement orally or in Provider that we did not authorize(other than writing.Your request for payment or reimbursement,and Emergency Services,Post-Stabilization Care,Out-of- any related documents that you give us,constitute your Area Urgent Care,or emergency ambulance Services) claim. and you want us to pay for the Services Claim forms for Emergency Services, Post- • You want to appeal a denial of an initial claim for Stabilization Care, Out-of-Area Urgent Care, and payment emergency ambulance Services To file a claim in writing for Emergency Services,Post- Please follow the procedures under"Grievances"in the Stabilization Care,Out-of-Area Urgent Care,or "Dispute Resolution"section in the following situations: emergency ambulance Services,please use our claim • You want us to cover Services that you have not yet form.You can obtain a claim form in the following received ways: • You want us to continue to cover an ongoing course • By visiting our website at kmorg of covered treatment • In person from any Member Services office at a Plan • You want to appeal a written denial of a request for Facility and from Plan Providers(for addresses,refer Services that require prior authorization(as described to our Provider Directory or call Member Services) under"Medical Group authorization procedure for • By calling Member Services at 1-800-464-4000(TTY certain referrals") users call 711) Who May File Claims forms for all other Services To file a claim in writing for all other Services,you may The following people may file claims: use our grievance form.You can obtain this form in the • You may file for yourself following ways: • You can ask a friend,relative,attorney,or any other • By visiting our website at kp.org individual to file a claim for you by appointing them • In person from any Member Services office at a Plan in writing as your authorized representative Facility and from Plan Providers(for addresses,refer to our Provider Directory or call Member Services) • A parent may file for their child under age 18,except that the child must appoint the parent as authorized • By calling Member Services at 1-800-464-4000(TTY representative if the child has the legal right to control users call 711) release of information that is relevant to the claim • A court-appointed guardian may file for their ward, Other supporting information except that the ward must appoint the court-appointed When you file a claim,please include any information guardian as authorized representative if the ward has that clarifies or supports your position.For example,if the legal right to control release of information that is you have paid for Services,please include any bills and relevant to the claim receipts that support your claim.To request that we pay a Non—Plan Provider for Services,include any bills from • A court-appointed conservator may file for their the Non—Plan Provider.If the Non—Plan Provider states conservatee that they will file the claim,you are still responsible for • An agent under a currently effective health care making sure that we receive everything we need to proxy,to the extent provided under state law,may file process the request for payment.When appropriate,we for their principal will request medical records from Plan Providers on your behalf.If you tell us that you have consulted with a Non— Authorized representatives must be appointed in writing Plan Provider and are unable to provide copies of using either our authorization form or some other form of relevant medical records,we will contact the provider to written notification.The authorization form is available request a copy of your relevant medical records.We will from the Member Services office at a Plan Facility,on ask you to provide us a written authorization so that we our website at kp.org,or by calling Member Services. can request your records. Your written authorization must accompany the claim. You must pay the cost of anyone you hire to represent or If you want to review the information that we have help you. collected regarding your claim,you may request,and we Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 71 will provide without charge,copies of all relevant possible after you receive the Services,you must file documents,records,and other information.You also your claim in one of the following ways: have the right to request any diagnosis and treatment • By delivering your claim to a Member Services office codes and their meanings that are the subject of your at a Plan Facility(for addresses,refer to our Provider claim.To make a request,you should follow the steps in Directory or call Member Services) the written notice sent to you about your claim. • By mailing your claim to a Member Services office at a Plan Facility(for addresses,refer to our Provider Initial Claims Directory or call Member Services) To request that we pay a provider(or reimburse you)for • By calling Member Services at 1-800-464-4000(TTY Services that you have already received,you must file a users call 711) claim.If you have any questions about the claims • By visiting our website at kp•org process,please call Member Services. Please call Member Services if you need help filing your Submitting a claim for Emergency Services, claim. Post-Stabilization Care, Out-of-Area Urgent Care, and emergency ambulance Services After we receive your claim You may file a claim(request for We will send you an acknowledgment letter within five payment/reimbursement): days after we receive your claim. • By visiting Ikp.org,completing an electronic form and uploading supporting documentation; After we review your claim,we will respond as follows: • By mailing a paper form that can be obtained by • If we have all the information we need we will send visiting kp•org or calling Member Services;or you a written decision within 30 days after we receive • If you are unable access the electronic form(or obtain your claim.We may extend the time for making a decision for an additional 15 days if circumstances the paper form),by mailing the minimum amount of beyond our control delay our decision,if we notify information we need to process your claim: you within 30 days after we receive your claim ♦ Member/Patient Name and Medical/Health Record . If we need more information,we will ask you for the Number information before the end of the initial 30-day ♦ The date you received the Services decision period.We will send our written decision no ♦ Where you received the Services later than 15 days after the date we receive the ♦ Who provided the Services additional information.If we do not receive the ♦ Why you think we should pay for the Services necessary information within the timeframe specified in our letter,we will make our decision based on the ♦ A copy of the bill,your medical record(s)for these information we have within 15 days after the end of Services,and your receipt if you paid for the that timeframe Services If we pay any part of your claim,we will subtract Mailing address to submit your claim to Kaiser applicable Cost Share from any payment we make to you Permanente: or the Non—Plan Provider.You are not responsible for any amounts beyond your Cost Share for covered Kaiser Permanente Emergency Services.If we deny your claim(if we do not Claims Administration-NCAL agree to pay for all the Services you requested other than P.O.Box 12923 the applicable Cost Share),our letter will explain why Oakland,CA 94604-2923 we denied your claim and how you can appeal. Please call Member Services if you need help filing your If you later receive any bills from the Non—Plan Provider claim. for covered Services(other than bills for your Cost Share),please call Member Services for assistance. Submitting a claim for all other Services If you have received Services from a Non—Plan Provider that we did not authorize(other than Emergency Services,Post-Stabilization Care,Out-of-Area Urgent Care,or emergency ambulance Services),then as soon as Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 72 Appeals believe support your claim.If we asked for additional information and you did not provide it before we made Claims for Emergency Services, Post- our initial decision about your claim,then you may still Stabilization Care, Out-of-Area Urgent Care, or send us the additional information so that we may emergency ambulance Services from a Non— include it as part of our review of your appeal.Please Plan Provider send all additional information to the address or fax If we did not decide fully in your favor and you want to mentioned in your denial letter. appeal our decision,you may submit your appeal in one of the following ways: Also,you may give testimony in writing or by phone. • By mailing your appeal to the Claims Department at Please send your written testimony to the address the following address: mentioned in our acknowledgment letter,sent to you within five days after we receive your appeal.To arrange Kaiser Foundation Health Plan,Inc. to give testimony by phone,you should call the phone Special Services Unit P.O.Box 23280 number mentioned in our acknowledgment letter. Oakland,CA 94623 We will add the information that you provide through • By calling Member Services at 1-800-464-4000(TTY testimony or other means to your appeal file and we will users call 711) review it without regard to whether this information was • By visiting our website at kp•org filed or considered in our initial decision regarding your request for Services.You have the right to request any Claims for Services from a Non—Plan Provider diagnosis and treatment codes and their meanings that that we did not authorize (other than Emergency are the subject of your claim. Services, Post-Stabilization Care, Out-of-Area Urgent Care, or emergency ambulance Services) We will share any additional information that we collect If we did not decide fully in your favor and you want to in the course of our review and we will send it to you.If appeal our decision,you may submit your appeal in one we believe that your request should not be granted, of the following ways: before we issue our final decision letter,we will also • By visiting our website at kp•org share with you any new or additional reasons for that decision.We will send you a letter explaining the • By mailing your appeal to any Member Services additional information and/or reasons. Our letters about office at a Plan Facility(for addresses,refer to our additional information and new or additional rationales Provider Directory or call Member Services) will tell you how you can respond to the information • In person at any Member Services office at a Plan provided if you choose to do so.If you do not respond Facility or any Plan Provider(for addresses,refer to before we must issue our final decision letter,that our Provider Directory or call Member Services) decision will be based on the information in your appeal • By calling Member Services at 1-800-464-4000(TTY file. users call 711) We will send you a resolution letter within 30 days after When you file an appeal,please include any information we receive your appeal.If we do not decide in your that clarifies or supports your position.If you want to favor,our letter will explain why and describe your review the information that we have collected regarding further appeal rights. your claim,you may request,and we will provide without charge,copies of all relevant documents, External Review records,and other information.To make a request,you should call Member Services. You must exhaust our internal claims and appeals procedures before you may request external review Additional information regarding a claim for unless we have failed to comply with the claims and Services from a Non—Plan Provider that we did appeals procedures described in this"Post-Service not authorize (other than Emergency Services, Claims and Appeals"section.For information about the Post-Stabilization Care, Out-of-Area Urgent external review process,see"Independent Medical Care, or emergency ambulance Services) Review("IMR")"in the"Dispute Resolution"section. If we initially denied your request,you must file your appeal within 180 days after the date you received our denial letter.You may send us information including comments,documents,and medical records that you Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 73 Additional Review • You were told that Services are not covered and you believe that the Services should be covered You may have certain additional rights if you remain • You want us to continue to cover an ongoing course dissatisfied after you have exhausted our internal claims of covered treatment and appeals procedure,and if applicable,external review: • You are dissatisfied with how long it took to get • If your Group's benefit plan is subject to the Services,including getting an appointment,in the Employee Retirement Income Security Act waiting room,or in the exam room ("ERISA"),you may file a civil action under section • You want to report unsatisfactory behavior by 502(a)of ERISA.To understand these rights,you providers or staff,or dissatisfaction with the condition should check with your Group or contact the of a facility Employee Benefits Security Administration(part of • You believe you have faced discrimination from the U.S.Department of Labor)at 1-866-444-EBSA providers, staff,or Health Plan (1-866-444-3272) • We terminated your membership and you disagree • If your Group's benefit plan is not subject to ERISA with that termination (for example,most state or local government plans and church plans),you may have a right to request Who may file review in state court The following people may file a grievance: • You may file for yourself Dispute Resolution • You can ask a friend,relative,attorney,or any other individual to file a grievance for you by appointing We are committed to providing you with quality care and them in writing as your authorized representative with a timely response to your concerns.You can discuss • A parent may file for their child under age 18,except your concerns with our Member Services representatives that the child must appoint the parent as authorized at most Plan Facilities,or you can call Member Services. representative if the child has the legal right to control release of information that is relevant to the grievance Grievances • A court-appointed guardian may file for their ward, except that the ward must appoint the court-appointed This"Grievances"section describes our grievance guardian as authorized representative if the ward has procedure.A grievance is any expression of the legal right to control release of information that is dissatisfaction expressed by you or your authorized relevant to the grievance representative through the grievance process.If you want • A court-appointed conservator may file for their to make a claim for payment or reimbursement for conservatee Services that you have already received from a Non—Plan • An agent under a currently effective health care Provider,please follow the procedure in the"Post- proxy,to the extent provided under state law,may file Service Claims and Appeals"section. for their principal Here are some examples of reasons you might file a • Your physician may act as your authorized grievance: representative with your verbal consent to request an urgent grievance as described under"Urgent • You are not satisfied with the quality of care you procedure"in this"Grievances"section received • You received a written denial of Services that require Authorized representatives must be appointed in writing prior authorization from the Medical Group and you using either our authorization form or some other form of want us to cover the Services written notification.The authorization form is available • You received a written denial for a second opinion or from the Member Services office at a Plan Facility,on we did not respond to your request for a second our website at kp•org,or by calling Member Services. opinion in an expeditious manner,as appropriate for Your written authorization must accompany the your condition grievance.You must pay the cost of anyone you hire to • Your treating physician has said that Services are not represent or help you. Medically Necessary and you want us to cover the Services Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 74 How to file we will provide without charge,copies of all relevant You can file a grievance orally or in writing.Your documents,records,and other information. To make a grievance must explain your issue,such as the reasons request,you should call Member Services. why you believe a decision was in error or why you are dissatisfied with the Services you received. Urgentprocedure If you want us to consider your grievance on an urgent Standard Procedure basis,please tell us that when you file your grievance. To file a grievance electronically,use the grievance form Note:Urgent is sometimes referred to as"exigent."If on kp•org. exigent circumstances exist,your grievance may be reviewed using the urgent procedure described in this To file a grievance orally,call Member Services toll free section. at 1-800-464-4000(TTY users call 711). You must file your urgent grievance in one of the To file a grievance in writing,please use our grievance following ways: form,which is available on kp.org under"Forms& • By calling our Expedited Review Unit toll free at Publications,"in person from any Member Services 1-888-987-7247(TTY users call 711) office at a Plan Facility,or from Plan Providers(for addresses,refer to our Provider Directory or call Member • By mailing a written request to: Services).You can submit the form in the following Kaiser Foundation Health Plan,Inc. ways: Expedited Review Unit • In person at any Member Services office at a Plan P.O.Box 1809 Facility Pleasanton, 09CA 94566 • By faxing a written request to our Expedited Review Fa• mail to any Member Services office at a Plan Unit toll free at 1-888-987-2252 Facility • By visiting a Member Services office at a Plan You must file your grievance within 180 days following Facility(for addresses,refer to our Provider Directory the incident or action that is subject to your or call Member Services) dissatisfaction.You may send us information including • By completing the grievance form on our website at comments,documents,and medical records that you ky.m believe support your grievance. We will decide whether your grievance is urgent or non- Please call Member Services if you need help filing a urgent unless your attending health care provider tells us grievance. your grievance is urgent.If we determine that your grievance is not urgent,we will use the procedure If your grievance involves a request to obtain a non- described under"Standard procedure"in this formulary prescription drug,we will notify you of our "Grievances"section.Generally,a grievance is urgent decision within 72 hours.If we do not decide in your only if one of the following is true: favor,our letter will explain why and describe your • Using the standard procedure could seriously further appeal rights.For information on how to request jeopardize your life,health,or ability to regain a review by an independent review organization,see maximum function "Independent Review Organization for Non-Formulary Prescription Drug Requests"in this"Dispute Resolution" • Using the standard procedure would,in the opinion of section. a physician with knowledge of your medical condition,subject you to severe pain that cannot be For all other grievances,we will send you an adequately managed without extending your course of acknowledgment letter within five days after we receive covered treatment your grievance.We will send you a resolution letter • A physician with knowledge of your medical within 30 days after we receive your grievance.If you condition determines that your grievance is urgent are requesting Services,and we do not decide in your • You have received Emergency Services but have not favor,our letter will explain why and describe your further appeal rights. been discharged from a facility and your request involves admissions,continued stay,or other health If you want to review the information that we have care Services collected regarding your grievance,you may request,and Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 75 • You are undergoing a current course of treatment We will send you a letter explaining the additional using a non-formulary prescription drug and your information and/or reasons. Our letters about additional grievance involves a request to refill a non-formulary information and new or additional rationales will tell you prescription drug how you can respond to the information provided if you choose to do so.If your grievance is urgent,the For most grievances that we respond to on an urgent information will be provided to you orally and followed basis,we will give you oral notice of our decision as in writing.If you do not respond before we must issue soon as your clinical condition requires,but no later than our final decision letter,that decision will be based on 72 hours after we received your grievance.We will send the information in your grievance file. you a written confirmation of our decision within three days after we received your grievance. Additional information regarding appeals of written denials for Services that require prior authorization If your grievance involves a request to obtain a non- You must file your appeal within 180 days after the date formulary prescription drug and we respond to your you received our denial letter. request on an urgent basis,we will notify you of our decision within 24 hours of your request.For information You have the right to request any diagnosis and on how to request a review by an independent review treatment codes and their meanings that are the subject of organization,see"Independent Review Organization for your appeal. Non-Formulary Prescription Drug Requests"in this "Dispute Resolution"section. Also,you may give testimony in writing or by phone. Please send your written testimony to the address If we do not decide in your favor,our letter will explain mentioned in our acknowledgment letter.To arrange to why and describe your further appeal rights. give testimony by phone,you should call the phone number mentioned in our acknowledgment letter. Note:If you have an issue that involves an imminent and serious threat to your health(such as severe pain or We will add the information that you provide through potential loss of life,limb,or major bodily function),you testimony or other means to your appeal file and we will can contact the California Department of Managed consider it in our decision regarding your appeal. Health Care at any time at 1-888-466-2219(TDD 1-877- 688-9891)without first filing a grievance with us. We will share any additional information that we collect in the course of our review and we will send it to you.If If you want to review the information that we have we believe that your request should not be granted, collected regarding your grievance,you may request,and before we issue our decision letter,we will also share we will provide without charge,copies of all relevant with you any new or additional reasons for that decision. documents,records,and other information. To make a We will send you a letter explaining the additional request,you should call Member Services. information and/or reasons. Our letters about additional information and new or additional rationales will tell you Additional information regarding pre-service requests how you can respond to the information provided if you for Medically Necessary Services choose to do so.If your appeal is urgent,the information You may give testimony in writing or by phone.Please will be provided to you orally and followed in writing.If send your written testimony to the address mentioned in you do not respond before we must issue our final our acknowledgment letter.To arrange to give testimony decision letter,that decision will be based on the by phone,you should call the phone number mentioned information in your appeal file. in our acknowledgment letter. We will add the information that you provide through Independent Review Organization for testimony or other means to your grievance file and we Non-Formulary Prescription Drug will consider it in our decision regarding your pre- Requests service request for Medically Necessary Services. If you filed a grievance to obtain a non-formulary We will share any additional information that we collect prescription drug and we did not decide in your favor, in the course of our review and we will send it to you.If you may submit a request for a review of your grievance we believe that your request should not be granted, by an independent review organization("IRO").You before we issue our decision letter,we will also share must submit your request for IRO review within 180 with you any new or additional reasons for that decision. days of the receipt of our decision letter. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 76 You must file your request for IRO review in one of the services. The department also has a toll-free telephone following ways: number(1-888-466-2219)and a TDD line • By calling our Expedited Review Unit toll free at (1-877-688-9891)for the hearing and speech 1-888-987-7247(TTY users call 711) impaired. The department's Internet website • By mailing a written request to: www.dmhc.ca.20V has complaint forms,IMR Kaiser Foundation Health Plan,Inc. application forms and instructions online. Expedited Review Unit P.O.Box 1809 Independent Medical Review ("IMR") Pleasanton,CA 94566 • By faxing a written request to our Expedited Review Except as described in this"Independent Medical Unit toll free at 1-888-987-2252 Review("IMR")"section,you must exhaust our internal grievance procedure before you may request independent • By visiting a Member Services office at a Plan medical review unless we have failed to comply with the Facility(for addresses,refer to our Provider Directory grievance procedure described under"Grievances"in or call Member Services) this"Dispute Resolution"section.If you qualify,you or • By completing the grievance form on our website at your authorized representative may have your issue kp•or2 reviewed through the IMR process managed by the California Department of Managed Health Care For urgent IRO reviews,we will forward to you the ("DMHC").The DMHC determines which cases qualify independent reviewer's decision within 24 hours.For for IMR.This review is at no cost to you.If you decide non-urgent requests,we will forward the independent not to request an IMR,you may give up the right to reviewer's decision to you within 72 hours.If the pursue some legal actions against us. independent reviewer does not decide in your favor,you may submit a complaint to the Department of Managed You may qualify for IMR if all of the following are true: Health Care,as described under"Department of • One of these situations applies to you: Managed Health Care Complaints"in this"Dispute Resolution"section.You may also submit a request for ♦ you have a recommendation from a provider an Independent Medical Review as described under requesting Medically Necessary Services "Independent Medical Review"in this"Dispute ♦ you have received Emergency Services, Resolution"section. emergency ambulance Services,or Urgent Care from a provider who determined the Services to be Medically Necessary Department of Managed Health Care ♦ you have been seen by a Plan Provider for the Complaints diagnosis or treatment of your medical condition The California Department of Managed Health Care is • Your request for payment or Services has been responsible for regulating health care service plans.If denied,modified,or delayed based in whole or in part you have a grievance against your health plan,you on a decision that the Services are not Medically should first telephone your health plan toll free at Necessary 1-800-464-4000 (TTY users call 711)and use your • You have filed a grievance and we have denied it or health plan's grievance process before contacting the we haven't made a decision about your grievance department.Utilizing this grievance procedure does not within 30 days(or three days for urgent grievances). prohibit any potential legal rights or remedies that may The DMHC may waive the requirement that you first be available to you.If you need help with a grievance file a grievance with us in extraordinary and involving an emergency,a grievance that has not been compelling cases,such as severe pain or potential loss satisfactorily resolved by your health plan,or a grievance of life,limb,or major bodily function. If we have that has remained unresolved for more than 30 days,you denied your grievance,you must submit your request may call the department for assistance.You may also be for an IMR within six months of the date of our eligible for an Independent Medical Review(IMR).If written denial.However,the DMHC may accept your you are eligible for IMR,the IMR process will provide request after six months if they determine that an impartial review of medical decisions made by a circumstances prevented timely submission health plan related to the medical necessity of a proposed service or treatment,coverage decisions for treatments You may also qualify for IMR if the Service you that are experimental or investigational in nature and requested has been denied on the basis that it is payment disputes for emergency or urgent medical Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 77 experimental or investigational as described under Note:You can request IMR for experimental or "Experimental or investigational denials." investigational denials at any time without first filing a grievance with us. If the DMHC determines that your case is eligible for IMR,it will ask us to send your case to the DMHC's IMR organization.The DMHC will promptly notify you Office of Civil Rights Complaints of its decision after it receives the IMR organization's If you believe that you have been discriminated against determination.If the decision is in your favor,we will by a Plan Provider or by us because of your race,color, contact you to arrange for the Service or payment. national origin,disability,age,sex(including sex Experimental or investigational denials stereotyping and gender identity),or religion,you may file a complaint with the Office of Civil Rights in the If we deny a Service because it is experimental or United States Department of Health and Human Services investigational,we will send you our written explanation OCR"). within three days after we received your request.We will explain why we denied the Service and provide You may file your complaint with the OCR within 180 additional dispute resolution options.Also,we will days of when you believe the act of discrimination provide information about your right to request occurred.However,the OCR may accept your request Independent Medical Review if we had the following after six months if they determine that circumstances information when we made our decision: prevented timely submission.For more information on • Your treating physician provided us a written the OCR and how to file a complaint with the OCR,go statement that you have a life-threatening or seriously to hhs.gov/civil-rights. debilitating condition and that standard therapies have not been effective in improving your condition,or that standard therapies would not be appropriate,or Additional Review that there is no more beneficial standard therapy we cover than the therapy being requested."Life- You may have certain additional rights if you remain threatening"means diseases or conditions where the dissatisfied after you have exhausted our internal claims likelihood of death is high unless the course of the and appeals procedure,and if applicable,external disease is interrupted,or diseases or conditions with review: potentially fatal outcomes where the end point of • If your Group's benefit plan is subject to the clinical intervention is survival. "Seriously Employee Retirement Income Security Act debilitating"means diseases or conditions that cause ("ERISA"),you may file a civil action under section major irreversible morbidity 502(a)of ERISA.To understand these rights,you • If your treating physician is a Plan Physician,they should check with your Group or contact the recommended a treatment,drug,device,procedure,or Employee Benefits Security Administration(part of other therapy and certified that the requested therapy the U.S.Department of Labor)at 1-866-444-EBSA is likely to be more beneficial to you than any (1-866-444-3272) available standard therapies and included a statement • If your Group's benefit plan is not subject to ERISA of the evidence relied upon by the Plan Physician in (for example,most state or local government plans certifying their recommendation and church plans),you may have a right to request • You(or your Non—Plan Physician who is a licensed, review in state court and either a board-certified or board-eligible, physician qualified in the area of practice appropriate Binding Arbitration to treat your condition)requested a therapy that, based on two documents from the medical and For all claims subject to this"Binding Arbitration" scientific evidence,as defined in California Health section,both Claimants and Respondents give up the and Safety Code Section 1370.4(d),is likely to be right to a jury or court trial and accept the use of binding more beneficial for you than any available standard arbitration.Insofar as this"Binding Arbitration"section therapy.The physician's certification included a applies to claims asserted by Kaiser Permanente Parties, statement of the evidence relied upon by the it shall apply retroactively to all unresolved claims that physician in certifying their recommendation.We do accrued before the effective date of this EOC. Such not cover the Services of the Non—Plan Provider retroactive application shall be binding only on the Kaiser Permanente Parties. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 78 Scope of arbitration • Any Southern California Permanente Medical Group Any dispute shall be submitted to binding arbitration if or The Permanente Medical Group physician all of the following requirements are met: • Any individual or organization whose contract with • The claim arises from or is related to an alleged any of the organizations identified above requires violation of any duty incident to or arising out of or arbitration of claims brought by one or more Member relating to this EOC or a Member Party's relationship Parties to Kaiser Foundation Health Plan,Inc. ("Health • Any employee or agent of any of the foregoing Plan"),including any claim for medical or hospital malpractice(a claim that medical services or items "Claimant"refers to a Member Party or a Kaiser were unnecessary or unauthorized or were Permanente Party who asserts a claim as described improperly,negligently,or incompetently rendered), above."Respondent"refers to a Member Party or a for premises liability,or relating to the coverage for, Kaiser Permanente Party against whom a claim is or delivery of,services or items,irrespective of the asserted. legal theories upon which the claim is asserted • The claim is asserted by one or more Member Parties Rules of Procedure against one or more Kaiser Permanente Parties or by Arbitrations shall be conducted according to the Rules one or more Kaiser Permanente Parties against one or for Kaiser Permanente Member Arbitrations Overseen more Member Parties by the Office of the Independent Administrator("Rules • Governing law does not prevent the use of binding of Procedure")developed by the Office of the arbitration to resolve the claim Independent Administrator in consultation with Kaiser Permanente and the Arbitration Oversight Board. Copies Members enrolled under this EOC thus give up their of the Rules of Procedure may be obtained from Member right to a court or jury trial,and instead accept the use of Services. binding arbitration except that the following types of claims are not subject to binding arbitration: Initiating arbitration Claimants shall initiate arbitration by serving a Demand • Claims within the jurisdiction of the Small Claims for Arbitration. The Demand for Arbitration shall include Court the basis of the claim against the Respondents;the • Claims subject to a Medicare appeal procedure as amount of damages the Claimants seek in the arbitration; applicable to Kaiser Permanente Senior Advantage the names,addresses,and phone numbers of the Members Claimants and their attorney,if any;and the names of all • Claims that cannot be subject to binding arbitration Respondents. Claimants shall include in the Demand for under governing law Arbitration all claims against Respondents that are based on the same incident,transaction,or related As referred to in this`Binding Arbitration"section, circumstances. "Member Parties"include: Serving Demand for Arbitration • A Member Health Plan,Kaiser Foundation Hospitals,The • A Member's heir,relative,or personal representative Permanente Medical Group,Inc., Southern California • Any person claiming that a duty to them arises from a Permanente Medical Group,The Permanente Federation, Member's relationship to one or more Kaiser LLC,and The Permanente Company,LLC,shall be Permanente Parties served with a Demand for Arbitration by mailing the Demand for Arbitration addressed to that Respondent in "Kaiser Permanente Parties"include: care o£ • Kaiser Foundation Health Plan,Inc. Kaiser Foundation Health Plan,Inc. Legal Department,Professional&Public Liability • Kaiser Foundation Hospitals 1 Kaiser Plaza, 191h Floor • The Permanente Medical Group,Inc. Oakland,CA 94612 • Southern California Permanente Medical Group Service on that Respondent shall be deemed completed • The Permanente Federation,LLC when received.All other Respondents,including • The Permanente Company,LLC individuals,must be served as required by the California Code of Civil Procedure for a civil action. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 79 Filing fee Costs The Claimants shall pay a single,nonrefundable filing Except for the aforementioned fees and expenses of the fee of$150 per arbitration payable to"Arbitration neutral arbitrator,and except as otherwise mandated by Account"regardless of the number of claims asserted in laws that apply to arbitrations under this"Binding the Demand for Arbitration or the number of Claimants Arbitration"section,each party shall bear the party's or Respondents named in the Demand for Arbitration. own attorneys' fees,witness fees,and other expenses incurred in prosecuting or defending against a claim Any Claimant who claims extreme hardship may request regardless of the nature of the claim or outcome of the that the Office of the Independent Administrator waive arbitration. the filing fee and the neutral arbitrator's fees and expenses.A Claimant who seeks such waivers shall General provisions complete the Fee Waiver Form and submit it to the A claim shall be waived and forever barred if(1)on the Office of the Independent Administrator and date the Demand for Arbitration of the claim is served, simultaneously serve it upon the Respondents.The Fee the claim,if asserted in a civil action,would be barred as Waiver Form sets forth the criteria for waiving fees and to the Respondent served by the applicable statute of is available by calling Member Services. limitations,(2)Claimants fail to pursue the arbitration claim in accord with the Rules of Procedure with Number of arbitrators reasonable diligence,or(3)the arbitration hearing is not The number of arbitrators may affect the Claimants' commenced within five years after the earlier of(a)the responsibility for paying the neutral arbitrator's fees and date the Demand for Arbitration was served in accord expenses(see the Rules of Procedure). with the procedures prescribed herein,or(b)the date of filing of a civil action based upon the same incident, If the Demand for Arbitration seeks total damages of transaction,or related circumstances involved in the $200,000 or less,the dispute shall be heard and claim.A claim may be dismissed on other grounds by the determined by one neutral arbitrator,unless the parties neutral arbitrator based on a showing of a good cause.If otherwise agree in writing after a dispute has arisen and a a party fails to attend the arbitration hearing after being request for binding arbitration has been submitted that given due notice thereof,the neutral arbitrator may the arbitration shall be heard by two party arbitrators and proceed to determine the controversy in the party's one neutral arbitrator.The neutral arbitrator shall not absence. have authority to award monetary damages that are greater than$200,000. The California Medical Injury Compensation Reform Act of 1975(including any amendments thereto), If the Demand for Arbitration seeks total damages of including sections establishing the right to introduce more than$200,000,the dispute shall be heard and evidence of any insurance or disability benefit payment determined by one neutral arbitrator and two party to the patient,the limitation on recovery for non- arbitrators,one jointly appointed by all Claimants and economic losses,and the right to have an award for one jointly appointed by all Respondents.Parties who are future damages conformed to periodic payments,shall entitled to select a party arbitrator may agree to waive apply to any claims for professional negligence or any this right.If all parties agree,these arbitrations will be other claims as permitted or required by law. heard by a single neutral arbitrator. Arbitrations shall be governed by this"Binding Payment of arbitrators'fees and expenses Arbitration"section, Section 2 of the Federal Arbitration Health Plan will pay the fees and expenses of the neutral Act,and the California Code of Civil Procedure arbitrator under certain conditions as set forth in the provisions relating to arbitration that are in effect at the Rules of Procedure.In all other arbitrations,the fees and time the statute is applied,together with the Rules of expenses of the neutral arbitrator shall be paid one-half Procedure,to the extent not inconsistent with this by the Claimants and one-half by the Respondents. "Binding Arbitration"section.In accord with the rule that applies under Sections 3 and 4 of the Federal If the parties select party arbitrators,Claimants shall be Arbitration Act,the right to arbitration under this responsible for paying the fees and expenses of their "Binding Arbitration"section shall not be denied,stayed, party arbitrator and Respondents shall be responsible for or otherwise impeded because a dispute between a paying the fees and expenses of their party arbitrator. Member Party and a Kaiser Permanente Party involves both arbitrable and nonarbitrable claims or because one or more parties to the arbitration is also a party to a pending court action with another party that arises out of Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 80 the same or related transactions and presents a possibility • Giving us incorrect or incomplete material of conflicting rulings or findings. information.For example,you have entered into a Surrogacy Arrangement and you fail to send us the information we require under"Surrogacy Termination of Membership Arrangements"under"Reductions"in the "Exclusions,Limitations,Coordination of Benefits, and Reductions"section Your Group is required to inform the Subscriber of the date your membership terminates.Your membership • Failing to notify us of changes in family status or termination date is the first day you are not covered(for Medicare coverage that may affect your eligibility or example,if your termination date is January 1,2025, benefits your last minute of coverage was at 11:59 p.m.on December 31,2024).When a Subscriber's membership If we terminate your membership for cause,you will not ends,the memberships of any Dependents end at the be allowed to enroll in Health Plan in the future.We may same time.You will be billed as a non-Member for any also report criminal fraud and other illegal acts to the Services you receive after your membership terminates. authorities for prosecution. Health Plan and Plan Providers have no further liability or responsibility under this EOC after your membership terminates,except as provided under"Payments after Termination of a Product or all Products Termination"in this"Termination of Membership" We may terminate a particular product or all products section. offered in the group market as permitted or required by law. If we discontinue offering a particular product in the Termination Due to Loss of Eligibility group market,we will terminate just the particular product by sending you written notice at least 90 days If you no longer meet the eligibility requirements before the product terminates.If we discontinue offering described under"Who Is Eligible"in the"Premiums, all products in the group market,we may terminate your Eligibility,and Enrollment"section,your Group will Group's Agreement by sending you written notice at notify you of the date that your membership will end. least 180 days before the Agreement terminates. Your membership termination date is the first day you are not covered.For example,if your termination date is January 1,2025,your last minute of coverage was at Payments after Termination 11:59 p.m. on December 31,2024. If we terminate your membership for cause or for nonpayment,we will: Termination of Agreement • Refund any amounts we owe your Group for Premiums paid after the termination date If your Group's Agreement with us terminates for any • pay you any amounts we have determined that we reason,your membership ends on the same date.Your Group is required to notify Subscribers in writing if its owe you for claims during your membership in Agreement with us terminates. accord with the"Emergency Services and Urgent Care"and"Dispute Resolution"sections Termination for Cause We will deduct any amounts you owe Health Plan or Plan Providers from any payment we make to you. If you intentionally commit fraud in connection with membership,Health Plan,or a Plan Provider,we may terminate your membership by sending written notice to State Review of Membership the Subscriber;termination will be effective 30 days Termination from the date we send the notice. Some examples of fraud include: If you believe that we have terminated your membership because of your ill health or your need for care,you may • Misrepresenting eligibility information about you or a request a review of the termination by the California Dependent Department of Managed Health Care(please see • Presenting an invalid prescription or physician order "Department of Managed Health Care Complaints"in • Misusing a Kaiser Permanente ID card(or letting the"Dispute Resolution"section). someone else use it) Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 81 Continuation of Membership coverage effective the date your COBRA coverage ends if all of the following are true: If your membership under this EOC ends,you may be • Your effective date of COBRA coverage was on or eligible to continue Health Plan membership without a after January 1,2003 break in coverage.You may be able to continue Group . You have exhausted the time limit for COBRA coverage under this EOC as described under coverage and that time limit was 18 or 29 months "Continuation of Group Coverage."Also,you may be able to continue membership under an individual plan as • You do not have Medicare described under"Continuation of Coverage under an Individual Plan."If at any time you become entitled to You must request an enrollment application by calling continuation of Group coverage,please examine your Member Services within 60 days of the date of when coverage options carefully before declining this your COBRA coverage ends. coverage.Individual plan premiums and coverage will be different from the premiums and coverage under your Cal-COBRA enrollment and Premiums Group plan. Within 10 days of your request for an enrollment application,we will send you our application,which will include Premium and billing information.You must Continuation of Group Coverage return your completed application within 63 days of the COBRA date of our termination letter or of your membership termination date(whichever date is later). You may be able to continue your coverage under this EOC for a limited time after you would otherwise lose If we approve your enrollment application,we will send eligibility,if required by the federal Consolidated you billing information within 30 days after we receive Omnibus Budget Reconciliation Act("COBRA"). your application.You must pay Full Premiums within 45 COBRA applies to most employees(and most of their days after the date we issue the bill.The first Premium covered family Dependents)of most employers with 20 payment will include coverage from your Cal-COBRA or more employees. effective date through our current billing cycle.You must send us the Premium payment by the due date on If your Group is subject to COBRA and you are eligible the bill to be enrolled in Cal-COBRA. for COBRA coverage,in order to enroll you must submit a COBRA election form to your Group within the After that first payment,your Premium payment for the COBRA election period.Please ask your Group for upcoming coverage month is due on the last day of the details about COBRA coverage,such as how to elect preceding month. The Premiums will not exceed 110 coverage,how much you must pay for coverage,when percent of the applicable Premiums charged to a coverage and Premiums may change,and where to send similarly situated individual under the Group benefit plan your Premium payments. except that Premiums for disabled individuals after 18 months of COBRA coverage will not exceed 150 percent If you enroll in COBRA and exhaust the time limit for instead of 110 percent.Returned checks or insufficient COBRA coverage,you may be able to continue Group funds on electronic payments may be subject to a fee. coverage under state law as described under"Cal- COBRA"in this"Continuation of Group Coverage" If you have selected Ancillary Coverage provided under section. any other program,the Premium for that Ancillary Coverage will be billed together with required Premiums Cal-COBRA for coverage under this EOC.Full Premiums will then If you are eligible for coverage under the California also include Premium for Ancillary Coverage. This Continuation Benefits Replacement Act("Cal- means if you do not pay the Full Premiums owed by the COBRA"),you can continue coverage as described in due date,we may terminate your membership under this this"Cal-COBRA"section if you apply for coverage in EOC and any Ancillary Coverage,as described in the compliance with Cal-COBRA law and pay applicable "Termination for nonpayment of Cal-COBRA Premiums. Premiums"section. Eligibility and effective date of coverage for Cal- Changes to Cal-COBRA coverage and Premiums COBRA after COBRA Your Cal-COBRA coverage is the same as for any If your group is subject to COBRA and your COBRA similarly situated individual under your Group's coverage ends,you may be able to continue Group Agreement,and your Cal-COBRA coverage and Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 82 Premiums will change at the same time that coverage or Kaiser Foundation Health Plan,Inc. Premiums change in your Group's Agreement.Your California Service Center Group's coverage and Premiums will change on the P.O.Box 23127 renewal date of its Agreement(January 1),and may also San Diego,CA 92193-3127 change at other times if your Group's Agreement is amended.Your monthly invoice will reflect the current Termination for nonpayment of Cal-COBRA Premiums Premiums that are due for Cal-COBRA coverage, If you do not pay Full Premiums by the due date,we may including any changes.For example,if your Group terminate your membership as described in this makes a change that affects Premiums retroactively,the "Termination for nonpayment of Cal-COBRA amount we bill you will be adjusted to reflect the Premiums"section.If you intend to terminate your retroactive adjustment in Premiums.Your Group can tell membership,be sure to notify us as described under you whether this EOC is still in effect and give you a "How you may terminate your Cal-COBRA coverage"in current one if this EOC has expired or been amended. this"Cal-COBRA"section,as you will be responsible You can also request one from Member Services. for any Premiums billed to you unless you let us know before the first of the coverage month that you want us to Cal-COBRA open enrollment or termination of another terminate your coverage. health plan If you previously elected Cal-COBRA coverage through Your Premium payment for the upcoming coverage another health plan available through your Group,you month is due on the last day of the preceding month.If may be eligible to enroll in Kaiser Permanente during we do not receive Full Premium payment by the due your Group's annual open enrollment period,or if your date,we will send a notice of nonreceipt of payment to Group terminates its agreement with the health plan you the Subscriber's address of record.You will have a 30- are enrolled in.You will be entitled to Cal-COBRA day grace period to pay the required Premiums before we coverage only for the remainder,if any,of the coverage terminate your Cal-COBRA coverage for nonpayment. period prescribed by Cal-COBRA.Please ask your The notice will state when the grace period begins and Group for information about health plans available to when the memberships of the Subscriber and all you either at open enrollment or if your Group terminates Dependents will terminate if the required Premiums are a health plan's agreement. not paid.Your coverage will continue during this grace period.If we do not receive Full Premium payment by In order for you to switch from another health plan and the end of the grace period,we will mail a termination continue your Cal-COBRA coverage with us,we must notice to the Subscriber's address of record.After receive your enrollment application during your Group's termination of your membership for nonpayment of Cal- open enrollment period,or within 63 days of receiving COBRA Premiums,you are still responsible for paying the Group's termination notice described under"Group all amounts due,including Premiums for the grace responsibilities."To request an application,please call period. Member Services.We will send you our enrollment application and you must return your completed Reinstatement of your membership after termination application before open enrollment ends or within 63 for nonpayment of Cal-COBRA Premiums days of receiving the termination notice described under If we terminate your membership for nonpayment of "Group responsibilities."If we approve your enrollment Premiums,we will permit reinstatement of your application,we will send you billing information within membership three times during any 12-month period if 30 days after we receive your application.You must pay we receive the amounts owed within 15 days of the date the bill within 45 days after the date we issue the bill. of the Termination Notice.We will not reinstate your You must send us the Premium payment by the due date membership if you do not obtain reinstatement of your on the bill to be enrolled in Cal-COBRA. terminated membership within the required 15 days,or if we terminate your membership for nonpayment of How you may terminate your Cal-COBRA coverage Premiums more than three times in a 12-month period. You may terminate your Cal-COBRA coverage by sending written notice,signed by the Subscriber,to the Termination of Cal-COBRA coverage address below.Your membership will terminate at 11:59 Cal-COBRA coverage continues only upon payment of p.m.on the last day of the month in which we receive applicable monthly Premiums to us at the time we your notice.Also,you must include with your notice all specify,and terminates on the earliest of: amounts payable related to your Cal-COBRA coverage, . The date your Group's Agreement with us terminates including Premiums,for the period prior to your (you may still be eligible for Cal-COBRA through termination date. another Group health plan) Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 83 • The date you get Medicare Employment and Reemployment Rights Act • The date your coverage begins under any other group ("USERRA").You must submit a USERRA election health plan that does not contain any exclusion or form to your Group within 60 days after your call to limitation with respect to any pre-existing condition active duty.Please contact your Group to find out how to you may have(or that does contain such an exclusion elect USERRA coverage and how much you must pay or limitation,but it has been satisfied) your Group. • The date that is 36 months after your original Coverage for a Disabling Condition COBRA effective date(under this or any other plan) If you became Totally Disabled while you were a • The date your membership is terminated for Member under your Group's Agreement with us and nonpayment of Premiums as described under while the Subscriber was employed by your Group,and "Termination for nonpayment of Cal-COBRA your Group's Agreement with us terminates and is not Premiums"in this"Continuation of Membership" renewed,we will cover Services for your totally section disabling condition until the earliest of the following events occurs: Note:If the Social Security Administration determined • 12 months have elapsed since your Group's that you were disabled at any time during the first 60 Agreement with us terminated days of COBRA coverage,you must notify your Group within 60 days of receiving the determination from • You are no longer Totally Disabled Social Security.Also,if Social Security issues a final • Your Group's Agreement with us is replaced by determination that you are no longer disabled in the 35th another group health plan without limitation as to the or 36th month of Group continuation coverage,your Cal- disabling condition COBRA coverage will end the later o£ (1)expiration of 36 months after your original COBRA effective date,or Your coverage will be subject to the terms of this EOC, (2)the first day of the first month following 31 days after including Cost Share,but we will not cover Services for Social Security issued its final determination.You must any condition other than your totally disabling condition. notify us within 30 days after you receive Social Security's final determination that you are no longer For Subscribers and adult Dependents,"Totally disabled. Disabled"means that,in the judgment of a Medical Group physician,an illness or injury is expected to result Group responsibilities in death or has lasted or is expected to last for a If your Group's agreement with a health plan is continuous period of at least 12 months,and makes the terminated,your Group is required to provide written person unable to engage in any employment or notice at least 30 days before the termination date to the occupation,even with training,education,and persons whose Cal-COBRA coverage is terminating. experience. This notice must inform Cal-COBRA beneficiaries that they can continue Cal-COBRA coverage by enrolling in For Dependent children,"Totally Disabled"means that, any health benefit plan offered by your Group.It must in the judgment of a Medical Group physician,an illness also include information about benefits,premiums, or injury is expected to result in death or has lasted or is payment instructions,and enrollment forms(including expected to last for a continuous period of at least 12 instructions on how to continue Cal-COBRA coverage months and the illness or injury makes the child unable under the new health plan).Your Group is required to to substantially engage in any of the normal activities of send this information to the person's last known address, children in good health of like age. as provided by the prior health plan.Health Plan is not obligated to provide this information to qualified To request continuation of coverage for your disabling beneficiaries if your Group fails to provide the notice. condition,you must call Member Services within 30 These persons will be entitled to Cal-COBRA coverage days after your Group's Agreement with us terminates. only for the remainder,if any,of the coverage period prescribed by Cal-COBRA. Continuation of Coverage under an USERRA Individual Plan If you are called to active duty in the uniformed services, you may be able to continue your coverage under this If you want to remain a Health Plan member when your EOC for a limited time after you would otherwise lose Group coverage ends,you might be able to enroll in one eligibility,if required by the federal Uniformed Services of our Kaiser Permanente for Individuals and Families Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 84 plans.The premiums and coverage under our individual chart,or you can put them in writing and have that plan coverage are different from those under this EOC. included in your medical chart If you want your individual plan coverage to be effective To learn more about advance directives,including how when your Group coverage ends,you must submit your to obtain forms and instructions,contact the Member application within the special enrollment period for Services office at a Plan Facility.For more information enrolling in an individual plan due to loss of other about advance directives,refer to our website at kp.orQ coverage.Otherwise,you will have to wait until the next or call Member Services. annual open enrollment period. To request an application to enroll directly with us, Amendment of Agreement please go to buykp.or or call Member Services.For information about plans that are available through Your Group's Agreement with us will change Covered California,see"Covered California"below. periodically.If these changes affect this EOC,your Group is required to inform you in accord with Covered California applicable law and your Group's Agreement. U.S.citizens or legal residents of the U.S.can buy health care coverage from Covered California.This is Applications and Statements California's health benefit exchange("the Exchange"). You may apply for help to pay for premiums and You must complete any applications,forms,or copayments but only if you buy coverage through statements that we request in our normal course of Covered California.This financial assistance may be business or as specified in this EOC. available if you meet certain income guidelines.To learn more about coverage that is available through Covered California,visit CoveredCA.com or call Covered Assignment California at 1-800-300-1506(TTY users call 711). You may not assign this EOC or any of the rights, interests,claims for money due,benefits,or obligations hereunder without our prior written consent. Miscellaneous Provisions Attorney and Advocate Fees and Administration of Agreement Expenses We may adopt reasonable policies,procedures,and In any dispute between a Member and Health Plan,the interpretations to promote orderly and efficient Medical Group,or Kaiser Foundation Hospitals,each administration of your Group's Agreement, including this party will bear its own fees and expenses,including EOC. attorneys' fees,advocates' fees,and other expenses. Advance Directives Claims Review Authority The California Health Care Decision Law offers several We are responsible for determining whether you are ways for you to control the kind of health care you will entitled to benefits under this EOC and we have the receive if you become very ill or unconscious,including discretionary authority to review and evaluate claims that the following: arise under this EOC.We conduct this evaluation • A Power of Attorney for Health Care lets you name independently by interpreting the provisions of this EOC. someone to make health care decisions for you when We may use medical experts to help us review claims.If you cannot speak for yourself.It also lets you write coverage under this EOC is subject to the Employee down your own views on life support and other Retirement Income Security Act("ERISA")claims treatments procedure regulation(29 CFR 2560.503-1),then we are a • Individual health care instructions let you express "named claims fiduciary"to review claims under thisEOC. your wishes about receiving life support and other treatment.You can express these wishes to your doctor and have them documented in your medical Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 85 EOC Binding on Members federal law shall bind Members and Health Plan whether or not set forth in this EOC. By electing coverage or accepting benefits under this EOC,all Members legally capable of contracting,and the legal representatives of all Members incapable of Group and Members Not Our Agents contracting,agree to all provisions of this EOC. Neither your Group nor any Member is the agent or representative of Health Plan. ERISA Notices This"ERISA Notices"section applies only if your No Waiver Group's health benefit plan is subject to the Employee Retirement Income Security Act("ERISA").We provide Our failure to enforce any provision of this EOC will not these notices to assist ERISA-covered groups in constitute a waiver of that or any other provision,or complying with ERISA.Coverage for Services described impair our right thereafter to require your strict in these notices is subject to all provisions of this EOC. performance of any provision. Newborns' and Mothers' Health Protection Act Notices Regarding Your Coverage Group health plans and health insurance issuers generally may not,under Federal law,restrict benefits for any Our notices to you will be sent to the most recent address hospital length of stay in connection with childbirth for we have for the Subscriber.The Subscriber is responsible the birthing person or newborn child to less than 48 for notifying us of any change in address. Subscribers hours following a vaginal delivery,or less than 96 hours who move should call Member Services as soon as following a cesarean section.However,Federal law possible to give us their new address.If a Member does generally does not prohibit the birthing person's or not reside with the Subscriber,or needs to have newborn's attending provider,after consulting with the confidential information sent to an address other than the birthing person,from discharging the birthing person or Subscriber's address,they should call Member Services their newborn earlier than 48 hours(or 96 hours as to discuss alternate delivery options. applicable).In any case,plans and issuers may not,under Federal law,require that a provider obtain authorization Note:When we tell your Group about changes to this from the plan or the insurance issuer for prescribing a EOC or provide your Group other information that length of stay not in excess of 48 hours(or 96 hours). affects you,your Group is required to notify the Subscriber within 30 days(or five days if we terminate Women's Health and Cancer Rights Act your Group's Agreement)after receiving the information If you have had or are going to have a mastectomy,you from us.The Subscriber is also responsible for notifying may be entitled to certain benefits under the Women's Group of any change in contact information. Health and Cancer Rights Act.For individuals receiving mastectomy-related benefits,coverage will be provided in a manner determined in consultation with the Overpayment Recovery attending physician and the patient,for all stages of reconstruction of the breast on which the mastectomy We may recover any overpayment we make for Services was performed,surgery and reconstruction of the other from anyone who receives such an overpayment or from breast to produce a symmetrical appearance,prostheses, any person or organization obligated to pay for the and treatment of physical complications of the Services. mastectomy,including lymphedemas.These benefits will be provided subject to the same Cost Share applicable to Privacy Practices other medical and surgical benefits provided under this plan. Kaiser Permanente will protect the privacy of your protected health information. We also Governing Law require contracting providers to protect your Except as preempted by federal law,this EOC will be protected health information. Your protected governed in accord with California law and any health information is individually-identifiable provision that is required to be in this EOC by state or information(oral, written, or electronic) about your health, health care services you receive, or Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 86 payment for your health care. You may call Member Services. You can also End the generally see and receive copies of your notice at a Plan Facility or on our website at protected health information, correct or update ky.org. your protected health information, and ask us for an accounting of certain disclosures of your Public Policy Participation protected health information. The Kaiser Foundation Health Plan,Inc.,Board of You can request delivery of confidential Directors establishes public policy for Health Plan.A list communication to a location other than your of the Board of Directors is available on our website at about.kp.om or from Member Services.If you would usual address or by a means of delivery other like to provide input about Health Plan public policy for than the usual means. You may request consideration by the Board,please send written confidential communication by completing a comments to: confidential communication request form, which is available on kp•om under"Request Kaiser Foundation Health Plan,Inc. for confidential communications forms."Your Office of Board and Corporate Governance Services One Kaiser Plaza, 19th Floor request for confidential communication will be Oakland,CA 94612 valid until you submit a revocation or a new request for confidential communication. If you have questions,please call Member Services. Helpful Information We may use or disclose your protected health How to Obtain this EOC in Other information for treatment, health research, Formats payment, and health care operations purposes, such as measuring the quality of Services. We You can request a copy of this EOC in an alternate are sometimes required by law to give format(Braille,audio,electronic text file,or large print) by calling Member Services. protected health information to others, such as government agencies or in judicial actions. In addition,protected health information is shared Provider Directory with your Group only with your authorization Refer to the Provider Directory for your Home Region or as otherwise permitted by law. for the following information: • A list of Plan Physicians We will not use or disclose your protected The location of Plan Facilities and the types of health information for any other purpose covered Services that are available from each facility without your(or your representative's) written Hours of operation authorization, except as described in our Notice of Privacy Practices (see below). Giving us • Appointments and advice phone numbers authorization is at your discretion. This directory is available on our website at kp.org.To obtain a printed copy,call Member Services.The This is only a brief summary of some of our directory is updated periodically.The availability of Plan key privacy practices. OUR NOTICE OF Physicians and Plan Facilities may change.If you have PRIVACYPRACTICES, WHICH PROVIDES questions,please call Member Services. ADDITIONAL INFORMATION ABOUT OUR PRIVACY PRACTICES AND YOUR Online Tools and Resources RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION, IS AVAILABLE Here are some tools and resources available on our AND WILL BE FURNISHED TO YOU website at kp.org: UPON REQUEST. To request a copy, please • How to use our Services and make appointments Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 87 • Tools you can use to email your doctor's office,view 24 hours a day,seven days a week(except test results,refill prescriptions,and schedule routine closed holidays) appointments Visit Member Services office at a Plan Facility(for • Health education resources addresses,refer to our Provider Directory or • Preventive care guidelines call Member Services) • Member rights and responsibilities Write Member Services office at a Plan Facility(for addresses,refer to our Provider Directory or You can also access tools and resources using the KP call Member Services) app on your smartphone or other mobile device. Website kp.org Estimates, bills, and statements Document Delivery Preferences For the following concerns,please call us at the number Many Health Plan documents are available below: electronically,such as bills,statements,and notices.If • If you have questions about a bill you prefer to get documents in electronic format,go to • To find out how much you have paid toward your kp•or,a or call Member Services.You can change Plan Deductible(if applicable)or Plan Out-of-Pocket delivery preference at any time. To get a copy of a specific Heath Plan document in printed format,call Maximum Member Services. • To get an estimate of Charges for Services that are subject to the Plan Deductible(if applicable) How to Reach Us Call 1-800-464-4000(TTY users call 711) Appointments 24 hours a day,seven days a week(except closed holidays) If you need to make an appointment,please call us or visit our website: Website kp.ors!/memberestimates Call The appointment phone number at a Plan Away from Home Travel Line Facility(for phone numbers,refer to our If you have questions about your coverage when you are Provider Directory or call Member Services) away from home: Website kp.or2 for routine(non-urgent)appointments Call 1-951-268-3900 with your personal Plan Physician or another Primary Care Physician 24 hours a day,seven days a week(except closed holidays) Not sure what kind of care you need? Website kp.orp-/travel If you need advice on whether to get medical care,or how and when to get care,we have licensed health care Authorization for Post-Stabilization Care professionals available to assist you by phone 24 hours a To request prior authorization for Post-Stabilization Care day,seven days a week: as described under"Emergency Services"in the Call The appointment or advice phone number at a "Emergency Services and Urgent Care"section: Plan Facility(for phone numbers,refer to our Call 1-800-225-8883 or the notification phone Provider Directory or call Member Services) number on your Kaiser Permanente ID card Member Services (TTY users call 711) If you have questions or concerns about your coverage, 24 hours a day,seven days a week how to obtain Services,or the facilities where you can receive care,you can reach us in the following ways: Help with claim forms for Emergency Services, Post-Stabilization Care, Out-of-Area Urgent Call 1-800-464-4000(English and more than 150 Care, and emergency ambulance Services languages using interpreter services) If you need a claim form to request payment or 1-800-788-0616(Spanish) reimbursement for Services described in the"Emergency 1-800-757-7585(Chinese dialects) Services and Urgent Care"section or under"Ambulance TTY users call 711 Services"in the`Benefits"section,or if you need help Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 88 completing the form,you can reach us by calling or by • You are responsible for paying your Cost Share for visiting our website. covered Services(refer to the"Cost Share Summary" Call 1-800-464-4000(TTY users call 711) section) 24 hours a day,seven days a week(except • If you receive Emergency Services,Post-Stabilization closed holidays) Care,or Out-of-Area Urgent Care from a Non—Plan Provider,or if you receive emergency ambulance Website kmorg Services,you must pay the provider and file a claim for reimbursement unless the provider agrees to bill Submitting claims for Emergency Services, us(refer to"Payment and Reimbursement"in the Post-Stabilization Care, Out-of-Area Urgent "Emergency Services and Urgent Care"section) Care, and emergency ambulance Services . If you receive Services from Non—Plan Providers that If you need to submit a completed claim form for we did not authorize(other than Emergency Services, Services described in the"Emergency Services and Post-Stabilization Care,Out-of-Area Urgent Care,or Urgent Care"section or under"Ambulance Services"in emergency ambulance Services)and you want us to the"Benefits"section,or if you need to submit other pay for the care,you must submit a grievance(refer to information that we request about your claim,send it to "Grievances"in the"Dispute Resolution"section) our Claims Department: • If you have coverage with another plan or with Write Kaiser Permanente Medicare,we will coordinate benefits with the other Claims Administration-NCAL coverage(refer to"Coordination of Benefits"in the P.O.Box 12923 "Exclusions,Limitations,Coordination of Benefits, Oakland,CA 94604-2923 and Reductions"section) • In some situations you or another party may be Text telephone access ("TTY") responsible for reimbursing us for covered Services If you use a text telephone device("TTY,"also known as (refer to"Reductions"in the"Exclusions, "TDD")to communicate by phone,you can use the Limitations,Coordination of Benefits,and California Relay Service by calling 711. Reductions"section) Interpreter services • You must pay the full price for noncovered Services If you need interpreter services when you call us or when you get covered Services,please let us know.Interpreter services,including sign language,are available during all business hours at no cost to you.For more information on the interpreter services we offer,please call Member Services. Payment Responsibility This"Payment Responsibility"section briefly explains who is responsible for payments related to the health care coverage described in this EOC.Payment responsibility is more fully described in other sections of the EOC as described below: • Your Group is responsible for paying Premiums, except that you are responsible for paying Premiums if you have COBRA or Cal-COBRA(refer to "Premiums"in the"Premiums,Eligibility,and Enrollment"section and"COBRA"and "Cal-COBRA"under"Continuation of Group Coverage"in the"Continuation of Membership" section) • Your Group may require you to contribute to Premiums(your Group will tell you the amount and how to pay) Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#1 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 89 FM EEMMEEE E F1 anguage Assistance Chinese:1,MA7)c, V)c24/1,Hi17p7 f4t%6 Services Fhf A AA"A M,It 4_40 2r,M 7�4 At-RVIrn*h AMA 7 7c, t7�24 English: Language assistance /1,Fk�Jz� ;CPLrfT'W'�-p�1-800-757-7585 rU**P�4 (fi is available at no cost to you, 24 hours a day, 7 days a week. �_,�A ci A.)&L51y fly Le L,,! L,,,L,:,;I L 3&I �:�cS�&'�s�`�L,y L-'!�jl�j a��S�I.s,o�j�.i c� You can request interpreter 9 .. UL services materials translated 24 —' 9� "�ly,��y J� cSlA,9,vCLLu.ul Aa)dXsA ,3,7 into your language, or in e-)L-,!> (TTY) ICU yam --Lz 1-800-464-4000 .�,.� alternative formats. You can �lz 711 also request auxiliary aids and Hindi:fWT f*R 977 47� T ,ffq 47 24 ft, Tm7*m-�7f rfkff ti 31m7T-� *t# r* devices at our facilities. �r f�17,f<T f *ffm-�r 4�fl 141 N t;ft r Just call us at 1-800-464-4000, *"'7'-qT �r ft�T u TT 7Tc tI 3M7 7ft 4 RT4**i 24 hours a day, 7 days a week *f47*3T;jfttT-171 9T�tI z7*zff (closed .holiday s) TTY users 1-800-464-4000 7T,fk,7*24#:�, 9-97 47 M�ff fk-'�r ( -q-0 fkff 4-,T TTTr t)Tlff T:�I TTY call 711. 7117T Tf;Fr 77ti ;et ;oaUl L� hh o A s a I a,� `I�lA�:Arabic Hmong:Muaj kec pab txhais lus pub dawb rau koj, � � ' . .�s=� ass► .� 91 Jk17�Us a��91 all a�y,11 a o v .GtSAL,� �I�>,I 24 teev ib hnub twg,7 hnub ib lim tiam twg.Koj thov l� Lsslyo s j�19 aal al ul�cL w L dl,st;< ,�yl tau cov kev pab txhais lus,muab cov ntaub ntawv nQUI_)I-)A L,6 1-800-464-4000,j P L,6 1-4 cJL—'1I ss• txhais ua koj hom lus,los yog ua lwm hom.Koj kuj thov tau lwm yam kev pab thiab khoom siv hauv peb tej (711)��I FYI tsev hauj lwm.Tsuas hu rau 1-800-464-4000,24 teev ib hnub twg,7 hnub ib lim tiam twg(cov hnub caiv kaw). Armenian: Qhq 4wpnil L wbq&wp ogtinLlalnLh Cov neeg siv TTY hu 711. tnpwLlwilptlhL thgo hwpgnLt[' opp 24 duit[, w w 7 0 `7hnt w n h whwti h Japanese: ��Z d�, 2 F laLt p p k p it p ul Q L puibuignp lawpgifLuhAi hwnwlnLlalndihtip,Qhp Lhgtjntj lawpgt[whqwb llwt[wj1pbuipwhpwl�1i Miw�wt�nq ulwtnpwutntjwh hlnLlahp:'TnLp hwh Z 6Z: l Z lltupnrl hp jubilphLoduihi ui4 oghnLlalnthhhp h -t "Nl Ot tz 6f l To :8'- 6-- 1-800-464-4000 uwpphp L1hp hwuLnwuinLlalnLhbhpnttl: - 'Rwpgwulhu gwtigwhwphp L[hq 1-800-464-4000 hhnw nuwhwt[w n o 24 dwd, w w 7 op TTY 1 — 711 6� a <�� o � p �� pLt 2 F lap (innb ophpbb*u14 k):TTY-hg ogtngn1jtihpU ulhtnp k qtu igwhwphli 711: Khmer: G 2 UJn-I€n iI iI n c�n[G[�w Iis n I� PUS Navajo:Doo bik'6 asinilaag66 saad bee ata'hane'bee 24 [f31bnbULDIG 7[t;Mb9PUf€i.SgIM-1 akae'elyeednich'i' gq'at'&,t'aaalahj}'jiWod66 Finw GIcif€ISI€ISitHnf5n MUII inftni[d n im sun tl'6e'go aad66 tsosts'iji gq'at'6.Ata'hane'yidiikil, naaltsoos t'aa Dinh bizaad bee bik'i' ashchiigo,6i IffS IS�G'flail€iSl 62i fSG'fli €IS Iia, [��n`1 doodago hane'bee didiits'iiligii yidiikil.Hane'bee H n n w G[€d hJ 2 fS n i Il.fln2'1 i G S PUS 21 n bik'i' di'diitiiligii d66 bee hane' didiits'iiligii €IS f3 UfJf!n-nI11219—nIt)IUr RU,t)Nhal-WI 1 ct J d bina'idilkidgo yidiikil.Koji hodiilnih 1-800-464-4000, f ii12[ii�SiiS�lfan[PUSS -nI91nJ2 1-8004644000 t'aa alahj}',jtigo d66 tl'6e'go aad66 tsosts'iji gq'at'6. M 2 24 Ith O M I U PUS[G 7 [d Q O f3 PUS€V P tS (Dahodilzing6ne' doo nida'anish dago 6i da'deelkaal). (fS w[t!U ftfl ) H n V TTY IW[[U 2 711`1 TTY chodayool'inigii koj}dahalne' 711. Korean: $°� "�R' A)7,"1 1 A]'V°) (11(�-71 ] Punjabi: trV f-7t B-JFH cam, ftl?5 i�24 W�, TU3 is AIHI TRV- 01- °}t' T 'OJ�) gr+. -1°}i 7ft�_ ;e�> aUlt F�ft Q 14T8 El u4I �fta �&}j w 101 L1 -71ii rll-�Jl zVz� , > zsfa o All PI 4R z $-1500 IU 'OIJ 6=LI 4 Li al A A '4F� c�Fi�, r�T fdF7 44 fed H'Ll3 1-800-464-4000 $(o gar°d ErF fjaia Tpt 1-800-464-4000 �, fET i�24 W , T� TTY 44,71It1 711. i� 7 fe 5c ( T;�.Trt f�5c 14 UtT 4) -�5 awl TTY Laotian: 2T @4 t T Td25-,�-rg 711 ` 75 gdTl cc7i6°w, c)zt7laC) 24 �OFa)g, 7 61)c�3�)tncJ. t!)�)I) Russian:Mbi 6ecrmaTHo o6ecneHt4saem Bac ycJryramH q�to��, 2tnccucanv rlepesoAa 24 Haca B cyTKH,7 AMA B HeAeJHo.Bbi moxcew Z9wc_uwJ )Z�20gt i�w' 1f7 I)SUCCUU01). BOCHOJIb3OBaTbCA 110MOI11b10 yCTHOTO HepeBOALIHKa, cc:Dv qutnaI) 3anpOCHTb HepeBOA marepHaiiOB Ha CBOH A31E.IK HJIH c 3anpOCHTb HX B OAHOM H3 a IbTepxaTHBHbIX CpopMaTOB. C7�qqc�C)JZvT�7JL)�9��`�e9`�1ile79�CeS��C7.lil�`�00cS0�Ctn MbI TwoRe moweM rIOMOgb BaM C BcriomoraTeJIbHbIMH �n wonc&)tn 1-800-464-4000, nt-noc) 24 `ole`J)q, 7 CpeACTBaMH H aJIbTepHaTHBHbIMH I opMaramH.rIpocTO O7Jc»')tnO (tsc��I�t�ric i°��). c�?1� �€I TTY Ftn 1-103BoHHTe Ham no Tenet oHy 1-800-464-4000,KoTopbH3 711. AocTyneH 24 Haca B cyTKH,7 AHeA B HeAeino(Kpome ripa3AHMHUX AHeI3).r1OJIb3OBaTeJIH JH HHH TTY moryT Mien:Mbenc nzoih liouh wang-henh tengx nzie faan 3BOHHTb no Homepy 711. waac bun muangx maiv zuqc cuotv zinh nyaanh meih, yietc hnoi mbenc maaih 24 norm ziangh hoc,yietc Spanish: Tenemos disponible asistencia en su idioma norm liv baaiz mbenc maaih 7 hnoi.Meih se haih tov sin ningun costo para usted 24 horas al dia,7 dias a la heuc tengx lorx faan waac mienh tengx faan waac bun semana.Puede solicitar los servicios de un int6rprete, muangx,dorh nyungc horngh jaa-sic mingh faan benx que los materiales se traduzcan a su idioma o en meih nyei waac,a'fai liouh ginv longc benx haaix hoc formatos alternativos.Tambi6n puede solicitar recursos para discapacidades en nuestros centros de atenci6n. sou-guv daan yaac dugv. Meih tort haih tov longc Solo llame al 1-800-788-0616,24 horas al dia,7 dias a benx wuotc ginc jaa-dorngx tengx aengx caux jaa-sic la semana(excepto los dias festivos).Los usuarios de nzie bun yiem njiec zorc goux baengc zingh gorn TTY,deben llamar al 711. zangc. Kungx douc waac mingh lorx taux yie mbuo yiem njiec naaiv 1-800-464-4000,yietc hnoi mbenc Tagalog:May magagamit na tulong sa wika nang wala maaih 24 norm ziangh hoc,yietc norm liv baaiz mbenc kang babayaran,24 na oras bawat araw,7 araw bawat maaih 7 hnoi.(hnoi-gec se guon gorn zangc oc). linggo. Maaari kang humingi ng mga serbisyo ng TTY nyei mienh nor douc waac lorx 711. tagasalin sa wika,mga babasahin na isinalin sa iyong wika o sa raga alternatibong format.Maaari ka ring humiling ng raga karagdagang tulong at device sa aming raga pasilidad.Tawagan lamang kami sa 1-800-464-4000,24 na oras bawat araw,7 araw bawat linggo(sarado sa raga pista opisyal).Ang mga gumagamit ng TTY ay maaaring tumawag sa 711. Thai: 24 4-)IN4 7 ijolz3'vsn-i5�-i3j 661�s76e7flsf 1511�Ydt1 ll�1RJe7Sk1€L6 MgAU51JLLIJIJd)Ul1 hl€Llc�'l7J"15€1RJoo�l f15€1.66Ls�ddhl5e�S8J e�Rf"J LI LY�f�e��G1Y 1k1L6€Iv5f1"15 6Y�k1Jl7J2tJfl6l9e1�e1R1e7S151 601FI6V-M-1 VW- l 1-800-464-4000 viaom 24 4ilw 7 iu�io i1�I�vi(FJtI!JLl JLlVftl(lSlRffllS) '$ff TTY lsklwi 711 Ukrainian:IIocnyrH nepexnaAaua HaAaloTbcsl 6e3KOHITOBHO,I[LnOA06OBO,7 AHIB Ha TH)KAeHb.BH Mo)KeTe 3po6HTH 3anHT Ha nOcnyrH yCHoro nepeKnaAana,oTpHMaHHSI MaTepianiB y IlepeK.naAi MOBOIO,AKOIO BOJIOAIew,a60 B anbTepHaTHBHHX ( opMaTaX.TaKO)K BH MO)KeTe 3po6HTH 3anHT Ha oTpHMaHHsi AorloMi)KHHx 3aco6iB i npHCTPOYB y 3aKnaAax Haiuoi Mepe)Ki KoMnaxiH.IIpoCTo 3aTene( oHyfte HaM 3a HOMepOM 1-800-4644000. MH npauloeMo uinoAo6OBO,7 AHiB Ha THxcgeHE, (KpiM CB31TKOB14x Axis).HoMep Anse KopHCTysaHi TeneTaMia:711. Vietnamese:Dich vu th6ng dich duac dung cap mien phi cho quy vi 24 gi&moi ngay,7 ngay trong tuan.Quy vi c6 the yeu cau dich vu th6ng dich,tai lieu phien dich ra ng6n ngiz ctila quy vi hoac tai lieu bang nhieu hinh third khac.Quy vi dung co the yeu cau cac phuong tien trg gilip va thiet bi bo tra tai cac ca so ciia chlmg t6i. Quy vi chi can goi cho chimg t6i tai so 1-800-464-4000, 24 gia moi ngay,7 ngay trong tuan(trir cac ngay le). Nguai dung TTY xin goi 711. Nondiscrimination Notice Discrimination is against the law. Kaiser Permanente follows State and Federal civil rights laws. Kaiser Permanente does not unlawfully discriminate, exclude people, or treat them differently because of age, race, ethnic group identification, color, national origin, cultural background, ancestry, religion, sex, gender, gender identity, gender expression, sexual orientation, marital status, physical or mental disability, medical condition, source of payment, genetic information, citizenship, primary language, or immigration status. Kaiser Permanente provides the following services: • No-cost aids and services to people with disabilities to help them communicate better with us, such as: ♦ Qualified sign language interpreters ♦ Written information in other formats (braille, large print, audio, accessible electronic formats, and other formats) • No-cost language services to people whose primary language is not English, such as: ♦ Qualified interpreters ♦ Information written in other languages If you need these services, call our Member Service Contact Center at 1-800-464-4000 (TTY 711), 24 hours a day, 7 days a week(except closed holidays). If you cannot hear or speak well, please call 711. Upon request, this document can be made available to you in braille, large print, audiocassette, or electronic form. To obtain a copy in one of these alternative formats, or another format, call our Member Service Contact Center and ask for the format you need. How to file a grievance with Kaiser Permanente You can file a discrimination grievance with Kaiser Permanente if you believe we have failed to provide these services or unlawfully discriminated in another way. Please refer to your Evidence of Coverage or Certificate of Insurance for details. You may also speak with a Member Services representative about the options that apply to you. Please call Member Services if you need help filing a grievance. You may submit a discrimination grievance in the following ways: • By phone: Call Member Services at 1 800-464-4000 (TTY 711) 24 hours a day, 7 days a week(except closed holidays) • By mail: Call us at 1 800-464-4000 (TTY 711) and ask to have a form sent to you • In person: Fill out a Complaint or Benefit Claim/Request form at a member services office located at a Plan Facility(go to your provider directory at kp.org/facilities for addresses) • Online: Use the online form on our website at kp.org You may also contact the Kaiser Permanente Civil Rights Coordinators directly at the addresses below: Attn: Kaiser Permanente Civil Rights Coordinator Member Relations Grievance Operations P.O. Box 939001 San Diego CA 92193 How to file a grievance with the California Department of Health Care Services Office of Civil Rights (For Medi-Cal Beneficiaries Only) You can also file a civil rights complaint with the California Department of Health Care Services Office of Civil Rights in writing,by phone or by email: • By phone: Call DHCS Office of Civil Rights at 916-440-7370 (TTY 711) • By mail: Fill out a complaint form or send a letter to: Deputy Director, Office of Civil Rights Department of Health Care Services Office of Civil Rights P.O. Box 997413, MS 0009 Sacramento, CA 95899-7413 Complaint forms are available at: http://www.dhcs.ca.gov/Pages/Language_Access.aspx • Online: Send an email to CivilRights@dhcs.ca.gov How to file a grievance with the U.S. Department of Health and Human Services Office of Civil Rights You can file a discrimination complaint with the U.S. Department of Health and Human Services Office for Civil Rights. You can file your complaint in writing,by phone, or online: • By phone: Call 1-800-368-1019 (TTY 711 or 1-800-537-7697) • By mail: Fill out a complaint form or send a letter to: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 Complaint forms are available at: http:www.hhs.gov/ocr/office/file/index.html • Online: Visit the Office of Civil Rights Complaint Portal at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsL Aviso de no discriminacion La discriminacion es ilegal. Kaiser Permanente cumple con las leyes de los derechos civiles federales y estatales. Kaiser Permanente no discrimina ilicitamente, excluye ni trata a ninguna persona de forma distinta por motivos de edad, raza, identificacion de grupo etnico, color,pais de origen, antecedentes culturales, ascendencia, religion, sexo, genero, identidad de genero, expresion de genero, orientacion sexual, estado civil, discapacidad fisica o mental, condicion medica, fuente de pago, informacion genetica, ciudadania, lengua materna o estado migratorio. Kaiser Permanente ofrece los siguientes servicios: • Ayuda y servicios sin costo a personas con discapacidades para que puedan comunicarse mejor con nosotros, como to siguiente: ♦ interpretes calificados de lenguaje de sefias, ♦ informacion escrita en otros formatos (braille, impresion en letra grande, audio, formatos electronicos accesibles y otros formatos). • Servicios de idiomas sin costo a las personas cuya lengua materna no es el ingles, como: ♦ interpretes calificados, ♦ informacion escrita en otros idiomas. Si necesita nuestros servicios, llame a nuestra Central de Llamadas de Servicio a los Miembros al 1-800-464-4000 (TTY 711) las 24 horas del dia, los 7 dias de la semana(excepto los dias festivos). Si tiene deficiencias auditivas o del habla, llame al 711. Este documento estara disponible en braille, letra grande, casete de audio o en formato electronico a solicitud. Para obtener una copia en uno de estos formatos alternativos o en otro formato, llame a nuestra Central de Llamadas de Servicio a los Miembros y solicite el formato que necesita. C6mo presentar una queja ante Kaiser Permanente Usted puede presentar una queja por discriminacion ante Kaiser Permanente si siente que no le hemos ofrecido estos servicios o to hemos discriminado ilicitamente de otra forma. Consulte su Evidencia de Cobertura (Evidence of Coverage) o Certificado de Seguro (Certificate of Insurance) para obtener mas informacion. Tambien puede hablar con un representante de Servicio a los Miembros sobre las opciones que se apliquen a su caso. Llame a Servicio a los Miembros si necesita ayuda para presentar una queja. Puede presentar una queja por discriminacion de las siguientes maneras: • Por telkfono: llame a Servicio a los Miembros al 1 800-464-4000 (TTY 711), las 24 horas del dia, los 7 dias de la semana(excepto los dias festivos). • Por correo postal: llamenos al 1 800-464-4000 (TTY 711)y pida que se le envie un formulario. • En persona: Ilene un formulario de Queja o reclamaci6n/solicitud de beneficios en una oficina de Servicio a los Miembros ubicada en un centro del plan(consulte su directorio de proveedores en kp.org/facilities [cambie el idioma a espanol] para obtener las direcciones). • En linea: utilice el formulario en linea en nuestro sitio web en kp.org/espanol. Tambien puede comunicarse directamente con el coordinador de derechos civiles(Civil Rights Coordinator)de Kaiser Permanente a la siguiente direcci6n: Attn: Kaiser Permanente Civil Rights Coordinator Member Relations Grievance Operations P.O. Box 939001 San Diego CA 92193 C6mo presentar una queja ante la Oficina de Derechos Civiles del Departamento de Servicios de Atenci6n Medica de California (Solo para beneficiarios de Medi-Cal) Tambien puede presentar una queja sobre derechos civiles ante la Oficina de Derechos Civiles (Office of Civil Rights) del Departamento de Servicios de Atenci6n Medica de California (California Department of Health Care Services)por escrito,por telefono o por correo electr6nico: • Por telefono: llame a la Oficina de Derechos Civiles del Departamento de Servicios de Atenci6n Medica(Department of Health Care Services,DHCS)al 916-440-7370(TTY 711). • Por correo postal: Ilene un formulario de queja o envie una carta a: Deputy Director, Office of Civil Rights Department of Health Care Services Office of Civil Rights P.O. Box 997413, MS 0009 Sacramento, CA 95899-7413 Los formularios de queja estan disponibles en: http://www.dhcs.ca.gov/Pages/Language_Access.aspx (en ingles). • En linea: envie un correo electr6nico a CivilRights@dhcs.ca.gov. C6mo presentar una queja ante la Oficina de Derechos Civiles del Departamento de Salud y Servicios Humanos de los EE. UU. Puede presentar una queja por discriminaci6n ante la Oficina de Derechos Civiles del Departamento de Salud y Servicios Humanos de EE. UU. (U.S. Department of Health and Human Services). Puede presentar su queja por escrito,por telefono o en linea: • Por telefono: flame al 1-800-368-1019 (TTY 711 o al 1-800-537-7697). • Por correo postal: Ilene un formulario de queja o envie una carta a: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 Los formularios de quejas estan disponibles en http://www.hhs.gov/ocr/office/file/index.html (en ingles). • En linea: visite el Portal de quejas de la Oficina de Derechos Civiles en: https:Hocrportal.hhs.gov/ocr/portal/lobby.jsf(en ingles). LE , j ( jTT ° KaiserPermanenteJ'f`f �yNl� �'J� > ° Kaiser Permanente Q 7 j - rFTW9 n JS f ,NP. TL Wi g , Ift T 9 Kaiser PermanentetHt-- f&A- : • Q f-9-f-AAaaa Qf-9LIaTA Ir ape r=—1 � t�Z ' A� T Qul-800-464-4000 (TTY 711) u a77 ' 15)Q24/jA4 (�nfl Q ap Q Q ' A' 1 at711 ° JLA-mv )[ J -AM)IMC7 JNX tfcljnKaiser PermanentelQV jj:,:�Cp7Kaiser Permanente R-,—*RWkH)j IND (Evidence of Coverage) A (q,yMR)J)) (Certificate of Insurance) W,,J A ' ° Z-ftoTU fu7 f A 9�A'-' tft p p�Affl-A R�, fA-rfi ° ZA • RIBIB : JTMptl 800-464-4000 (TTY 711) N 7) t)�24/]\H4 (R-I fP!El ,g, • h��y5 : T pt��l 800-464-44\000 (Ty{T�Y 711)g h�� a{ yy ,err fx ryFya T�; q� • I%4��" 'IJ--��I\��.p�"�-� I ASz�L�I-I'7 B�/J�� /��i� J�W F��a/T p�� kp.org/facilities��i��;��J(„� ��,�j;��j�th��) L,,R,t@A4 @Kaiser PermanenteP�)ri-S y q �ttiiL T : Attn: Kaiser Permanente Civil Rights Coordinator Member Relations Grievance Operations P.O. Box 939001 San Diego CA 92193 (%FPMedi-Cal@ `,k) @-LEA no o R)Vva nffi� �a • !R@ TT ZRpt916-440-7370 (TTY 711) (DHCS) Deputy Director, Office of Civil Rights Department of Health Care Services Office of Civil Rights P.O. Box 997413, MS 0009 Sacramento, CA 95899-7413 L%r@ �MM--�-http://www.dhcs.ca.gov/Pages/Language_Access.aspxgA@1RVtK� • : 4,;'�-@ � �@-,�FCivilRights@dhcs.ca.gov �G��I JT��Y`liJ��.�/•I/•��J7J A�� T/JT/L`��WI��I��X R� � �['`��.c%.L.�LW � �Q��G��W�SZ • 115 IT4A&1-800-368-1019 (TTY 711�1-800-537-7697) U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 http:www.hhs.gov/ocr/office/file/index.htmlgRT4��p�t-,'- https://ocrportal.hhs.gov/ocr/portal/lobby.j sf Thong Bao Khong Phan Biet floi X6, Phan biet doi xu la trai v&i phap luat. Kaiser Permanente tuan thu cac luat dan quyen cua Tieu Bang va Lien Bang. Kaiser Permanente khong phan biet doi xu trai phap luat, loai trir hay doi xir khac biet voi nglrori nao do vi ly do tuoi tac, chang toc, nhan dang nhom sac toc, mau da, nguon goc quoc gia, nen tang van hoa, to tien, ton giao, gioi tinh, nhan dang gibi tinh, cach the hien gioi tinh, khuynh huong gioi tinh, tinh trang hon nhan, tinh trang khuyet tat ve the chat hoac tinh than, benh trang, nguon thanh town, thong tin di truyen, quyen cong dan, ngon ngir me de hoac tinh trang nhap cu. Kaiser Permanente cung cap cac dich vu sau: • Phuong tien ho trq va dich vu mien phi cho nguoi khuyet tat de giup ho giao tiep hieu qua hon voi chang toi, chang han nhu: ♦ Thong dich vien ngon ngir ky hieu du trinh do ♦ Thong tin bang van ban theo cac dinh dang khac (cha not braille, ban in kho chic l&n, am thanh, dinh dang dien Ur de truy cap va cac dinh dang khac) • Dich vu ngon ngir mien phi cho nhfmg nguai co ngon ngir chinh khong phai la tieng Anh, chang han nhu: ♦ Thong dich vien du trinh do ♦ Thong tin dugc trinh bay bang cac ngon nga khac Neu quy vi can nhimg dich vu nay, xin goi den Trung Tam Lien Lac ban Dich Vu Hoi Vien cua chang toi theo so 1-800-464-4000 (TTY 711), 24 gi&trong ngay, 7 ngay trong tuan(dong cua ngay le). Neu quy vi khong the not hay nghe ro,vui long goi 711 . Theo yeu cau, tai lieu nay co the dugc cung cap cho quy vi du6i dang chic not braille,ban in kho chic lon, bang thu am hay dang dien td. De lay mot ban sao theo mot trong nhftg dinh dang thay the nay hay dinh dang khac, xin goi den Trung Tam Lien Lac ban Dich Vu Hoi Vien cua chang toi va yeu cau dinh dang ma quy vi can. Cach de trinh phan nan v6'i Kaiser Permanente Quy vi co the de trinh phan nan ve phan biet doi xir voi Kaiser Permanente neu quy vi tin rang chang toi da khong cung cap nhung dich vu nay hay phan biet doi xir trai phap luat theo cach khac. Vui long tham khao Chung Tie Bao Hiem (Evidence of Coverage) hay Chung Nhan Bdo Hiem (Certificate of Insurance) cua quy vi de biet them chi tiet. Quy vi cung co the not chuyen voi nhan vien ban Dich Vu Hoi Vien ve nhirng lira chon ap dung cho quy vi. Vui long goi den ban Dich Vu Hoi Vien neu quy vi can dugc trq giiip de de trinh phan nan. Quy vi co the de trinh phan nan ve phan biet doi Vr bang cac cach sau day: • Qua dien thoah Goi den ban Dich Vu Hoi Vien theo so 1-800-464-4000 (TTY 711) 24 gi6 trong ngay, 7 ngay trong tuan(dong cua ngay le) • Qua thu tin: Goi chang toi then so 1-800-464-4000 (TTY 711)va yeu cau gui mau don cho quy vi • Trurc tiep: Hoan tat mau don Than Phien hay Yeu Cau Thanh Toan/Yeu Cau Quyen Lqi tai van ph6ng dich vu hoi vien o mot Ca Sa Thu6c Chuong Trinh (truy cap danh muc nha cung cap cua quy vi tai kp.org/facilities de biet dia chi) • Truc tuyen: Sfr dung mau don true tuyen tren trang mang cua chfing t6i tai kp.org Quy vi cung co the lien he trtrc tiep voi Dieu Ph6i Vien Dan Quyen cua Kaiser Permanente theo dia chi duoi clay: Attn: Kaiser Permanente Civil Rights Coordinator Member Relations Grievance Operations P.O. Box 939001 San Diego CA 92193 Cach de" trinh phan nan voi Van Phong Dan Quyen Ban Dich Vu Y Te California (Danh Rieng Cho Ngzr6z Thu Hurting Medi-Cal) Quy vi cung c6 the d6 trinh than phien ve dan quyen voi Van Phong Dan Quyen Ban Dich Vu Y Te California bang van ban, qua dien thoai hay qua email: • Qua dien thoai: Goi den Van Phong Dan Quyen Ban Dich Vu Y Te (Department of Health Care Services, DHCS)theo so 916-440-7370 (TTY 711) • Qua thu tin: Dien mau don than phien va hay gfri thu den: Deputy Director, Office of Civil Rights Department of Health Care Services Office of Civil Rights P.O. Box 997413, MS 0009 Sacramento, CA 95899-7413 Mau don than phien hien c6 tai: http://www.dhcs.ca.gov/Pages/Language_Access.aspx • Trurc tuyen: Gfri email den CivilRights@dhcs.ca.gov Cach de trinh phan nan v61 Van Phong Dan Quyen cua Bo Y Te va Dich Vu Nhan Sinh Hoa Ky. Quy vi cung c6 quyen de trinh than phien ve phan biet d6i xfr voi Van Phong Dan Quyen cua Bo Y Te va Dich Vu Nhan Sinh Hoa Ky. Quy vi c6 the de trinh than phien bang van ban, qua dien thoai hoac truc tuyen: • Qua dien thoai: Goi 1-800-368-1019 (TTY 711 hay 1-800-537-7697) • Qua thu tin: Dien mau don than phien va hay gui thu den: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 Mau don than phien hien c6 tai http:www.hhs.gov/ocr/office/file/index.html • Trurc tuyen: Truy cap Cong Thong Tin Than Phien cua Van Phong Dan Quyen tai: https:Hocrportal.hhs.gov/ocr/portal/lobby.jsL 00 NO"71 KAISER PERMANEWEe Kaiser Foundation Health Plan, Inc. Northern California Region A nonprofit corporation and a Medicare Advantage Organization EOC #2 - Kaiser Permanente Senior Advantage (HMO) with Part D Evidence of Coverage for COUNTY OF FRESNO, RETIREE Group ID: 604334 Contract: 1 Version: 34 EOC Number: 2 January 1,2024,through December 31, 2024 Member Services Seven days a week, 8 a.m.-8 p.m. 1-800-443-0815 (TTY users call 711) kp.or� This document is available for free in Spanish. Please contact Member Services at 1-800-443-0815 for additional information. (TTY users should call 711.)Hours are 8 a.m. to 8 p.m., 7 days a week. Este documento estd disponible de manera gratuita en espanol. Para obtener informacion adicional, comuniquese con Servicio a los Miembros al 1-800-443-0815. (Los usuarios de la linea TTYdeben llamar al 711). El horario es de 8 a. m. a 8 p. m., los 7 dias de la semana. This document explains your benefits and rights. Use this document to understand about: • Your cost sharing • Your medical and prescription drug benefits • How to file a complaint if you are not satisfied with a service or treatment • How to contact us if you need further assistance • Other protections required by Medicare law TABLE OF CONTENTS FOR EOC #2 BenefitHighlights..................................................................................................................................................................1 Introduction............................................................................................................................................................................3 AboutKaiser Permanente...................................................................................................................................................3 Termof this EOC...............................................................................................................................................................3 Definitions..............................................................................................................................................................................4 Premiums,Eligibility,and Enrollment.................................................................................................................................10 Premiums..........................................................................................................................................................................10 MedicarePremiums..........................................................................................................................................................10 WhoIs Eligible.................................................................................................................................................................11 How to Enroll and When Coverage Begins.....................................................................................................................13 Howto Obtain Services........................................................................................................................................................15 RoutineCare.....................................................................................................................................................................16 UrgentCare......................................................................................................................................................................16 OurAdvice Nurses...........................................................................................................................................................16 YourPersonal Plan Physician..........................................................................................................................................16 Gettinga Referral.............................................................................................................................................................16 Travel and Lodging for Certain Services.........................................................................................................................18 SecondOpinions...............................................................................................................................................................18 Contractswith Plan Providers..........................................................................................................................................18 Receiving Care Outside of Your Home Region Service Area.........................................................................................19 YourID Card....................................................................................................................................................................19 GettingAssistance............................................................................................................................................................20 PlanFacilities.......................................................................................................................................................................20 ProviderDirectory............................................................................................................................................................20 PharmacyDirectory..........................................................................................................................................................20 Emergency Services and Urgent Care..................................................................................................................................21 EmergencyServices.........................................................................................................................................................21 UrgentCare......................................................................................................................................................................21 Paymentand Reimbursement...........................................................................................................................................22 Benefitsand Your Cost Share..............................................................................................................................................22 YourCost Share...............................................................................................................................................................23 OutpatientCare.................................................................................................................................................................25 HospitalInpatient Services...............................................................................................................................................27 AmbulanceServices.........................................................................................................................................................28 BariatricSurgery..............................................................................................................................................................28 DentalServices.................................................................................................................................................................29 DialysisCare....................................................................................................................................................................29 Durable Medical Equipment("DME")for Home Use.....................................................................................................30 FertilityServices...............................................................................................................................................................32 HealthEducation..............................................................................................................................................................33 HearingServices...............................................................................................................................................................33 Home-Delivered Meals....................................................................................................................................................33 HomeHealth Care............................................................................................................................................................34 Home Medical Care Not Covered by Medicare for Members Who Live in Certain Counties(Advanced Care at Home).............................................................................................................................................................................34 HospiceCare....................................................................................................................................................................35 MentalHealth Services....................................................................................................................................................36 Opioid Treatment Program Services................................................................................................................................37 Ostomy,Urological,and Specialized Wound Care Supplies...........................................................................................38 Outpatient Imaging,Laboratory,and Other Diagnostic and Treatment Services............................................................38 Outpatient Prescription Drugs, Supplies,and Supplements.............................................................................................39 Over-the-Counter(OTC)Health and Wellness................................................................................................................47 PreventiveServices..........................................................................................................................................................47 Prostheticand Orthotic Devices.......................................................................................................................................48 ReconstructiveSurgery....................................................................................................................................................49 Religious Nonmedical Health Care Institution Services..................................................................................................50 Services Associated with Clinical Trials..........................................................................................................................50 SkilledNursing Facility Care...........................................................................................................................................51 Substance Use Disorder Treatment..................................................................................................................................52 TelehealthVisits...............................................................................................................................................................52 TransplantServices..........................................................................................................................................................53 TransportationServices....................................................................................................................................................53 VisionServices.................................................................................................................................................................54 Exclusions,Limitations,Coordination of Benefits,and Reductions...................................................................................55 Exclusions........................................................................................................................................................................55 Limitations........................................................................................................................................................................57 Coordinationof Benefits..................................................................................................................................................58 Reductions........................................................................................................................................................................58 Requestsfor Payment...........................................................................................................................................................60 Requests for Payment of Covered Services or Part D drugs............................................................................................60 How to Ask Us to Pay You Back or to Pay a Bill You Have Received...........................................................................61 We Will Consider Your Request for Payment and Say Yes or No...................................................................................62 Other Situations in Which You Should Save Your Receipts and Send Copies to Us......................................................62 YourRights and Responsibilities.........................................................................................................................................63 We must honor your rights and cultural sensitivities as a Member of our plan...............................................................63 You have some responsibilities as a Member of our plan................................................................................................67 Coverage Decisions,Appeals,and Complaints....................................................................................................................67 What to Do if You Have a Problem or Concern..............................................................................................................67 Where To Get More Information and Personalized Assistance.......................................................................................68 To Deal with Your Problem,Which Process Should You Use?......................................................................................68 A Guide to the Basics of Coverage Decisions and Appeals.............................................................................................68 Your Medical Care:How to Ask for a Coverage Decision or Make an Appeal of a Coverage Decision.......................70 Your Part D Prescription Drugs:How to Ask for a Coverage Decision or Make an Appeal..........................................74 How to Ask Us to Cover a Longer Inpatient Hospital Stay if You Think You Are Being Discharged Too Soon..........79 How to Ask Us to Keep Covering Certain Medical Services if You Think Your Coverage Is Ending Too Soon..........83 Taking Your Appeal to Level 3 and Beyond...................................................................................................................86 How to Make a Complaint About Quality of Care,Waiting Times,Customer Service,or Other Concerns..................88 You can also tell Medicare about your complaint............................................................................................................89 AdditionalReview............................................................................................................................................................89 BindingArbitration..........................................................................................................................................................89 Terminationof Membership.................................................................................................................................................91 Termination Due to Loss of Eligibility............................................................................................................................92 Terminationof Agreement................................................................................................................................................92 Disenrolling from Senior Advantage...............................................................................................................................92 Termination of Contract with the Centers for Medicare&Medicaid Services...............................................................93 Terminationfor Cause......................................................................................................................................................93 Termination for Nonpayment of Premiums.....................................................................................................................93 Termination of a Product or all Products.........................................................................................................................93 Paymentsafter Termination.............................................................................................................................................93 Review of Membership Termination...............................................................................................................................94 Continuationof Membership................................................................................................................................................94 Continuationof Group Coverage.....................................................................................................................................94 Conversion from Group Membership to an Individual Plan............................................................................................94 MiscellaneousProvisions.....................................................................................................................................................95 Administrationof Agreement...........................................................................................................................................95 Amendmentof Agreement................................................................................................................................................95 Applicationsand Statements............................................................................................................................................95 Assignment.......................................................................................................................................................................95 Attorney and Advocate Fees and Expenses.....................................................................................................................95 ClaimsReview Authority.................................................................................................................................................95 EOCBinding on Members...............................................................................................................................................95 ERISANotices.................................................................................................................................................................95 GoverningLaw.................................................................................................................................................................96 Groupand Members Not Our Agents..............................................................................................................................96 NoWaiver........................................................................................................................................................................96 Notices Regarding Your Coverage...................................................................................................................................96 Notice about Medicare Secondary Payer Subrogation Rights.........................................................................................96 OverpaymentRecovery....................................................................................................................................................96 PublicPolicy Participation...............................................................................................................................................96 TelephoneAccess(TTY).................................................................................................................................................97 Important Phone Numbers and Resources...........................................................................................................................97 Kaiser Permanente Senior Advantage..............................................................................................................................97 Medicare...........................................................................................................................................................................99 State Health Insurance Assistance Program...................................................................................................................100 Quality Improvement Organization................................................................................................................................100 SocialSecurity................................................................................................................................................................100 Medicaid.........................................................................................................................................................................101 RailroadRetirement Board.............................................................................................................................................101 Group Insurance or Other Health Insurance from an Employer....................................................................................102 Benefit Highlights Accumulation Period The Accumulation Period for this plan is 1/1/24 through 12/31/24(calendar year). Plan Out-of-Pocket Maximum For Services subject to the maximum,you will not pay any more Cost Share for the rest of the calendar year if the Copayments and Coinsurance you pay for those Services add up to the following amount: For any one Member.................................................................................$1,000 per calendar year Plan Deductible None Plan Provider Office Visits You Pay Most Primary Care Visits and most Non-Physician Specialist Visits.......... $15 per visit Most Physician Specialist Visits................................................................... $15 per visit Annual Wellness visit and the"Welcome to Medicare"preventive visit.... No charge Routine physical exams................................................................................ No charge Routine eye exams with a Plan Optometrist................................................. $15 per visit Urgent care consultations,evaluations,and treatment................................. $15 per visit Physical,occupational,and speech therapy.................................................. $15 per visit Telehealth Visits You Pay Primary Care Visits and Non-Physician Specialist Visits by interactive video........................................................................................................... No charge Physician Specialist Visits by interactive video........................................... No charge Primary Care Visits and Non-Physician Specialist Visits by telephone...... No charge Physician Specialist Visits by telephone...................................................... No charge Outpatient Services You Pay Outpatient surgery and certain other outpatient procedures......................... $50 per procedure Allergy injections(including allergy serum)................................................ $3 per visit Most immunizations(including the vaccine)............................................... No charge Most X-rays and laboratory tests.................................................................. No charge Manual manipulation of the spine................................................................ $15 per visit Hospitalization Services You Pay Room and board,surgery,anesthesia,X-rays,laboratory tests,and drugs.. No charge Emergency Health Coverage You Pay Emergency Department visits....................................................................... $50 per visit Note:If you are admitted directly to the hospital as an inpatient for covered Services,you will pay the inpatient Cost Share instead of the Emergency Department Cost Share(see"Hospitalization Services"for inpatient Cost Share). Ambulance and Transportation Services You Pay AmbulanceServices..................................................................................... $100 per trip Other transportation Services when provided by our designated No charge for up to 24 one-way trips(50 miles per transportation provider as described in this EOC....................................... trip)per calendar year Prescription Drug Coverage You Pay Covered outpatient items in accord with our drug formulary guidelines: Most generic items.................................................................................. $5 for up to a 100-day supply Most brand-name items........................................................................... $20 for up to a 100-day supply Durable Medical Equipment(DME) You Pay Covered durable medical equipment for home use as described in this EOC............................................................................................................. 20 percent Coinsurance Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 1 Mental Health Services You Pay Inpatient psychiatric hospitalization............................................................. No charge Individual outpatient mental health evaluation and treatment...................... $15 per visit Group outpatient mental health treatment.................................................... $7 per visit Substance Use Disorder Treatment You Pay Inpatient detoxification................................................................................. No charge Individual outpatient substance use disorder evaluation and treatment....... $15 per visit Group outpatient substance use disorder treatment...................................... $5 per visit Home Health Services You Pay Home health care(part-time,intermittent)................................................... No charge Other You Pay Eyeglasses or contact lenses every 24 months............................................. Amount in excess of$175 Allowance Hearing aid(s)every 36 months.................................................................... Amount in excess of$1,000 Allowance per aid Skilled Nursing Facility care(up to 100 days per benefit period)................ No charge External prosthetic and orthotic devices as described in this EOC.............. 20 percent Coinsurance Ostomy,urological,and wound care supplies.............................................. 20 percent Coinsurance Meals delivered to your home immediately following discharge from a No charge up to three meals per day in a Plan Hospital or Skilled Nursing Facility as an inpatient........................... consecutive four-week period,once per calendar year Over-the-Counter(OTC)Health and Wellness items obtained through our catalog......................................................................................................... No charge up to a quarterly benefit of$70 This is a summary of the most frequently asked-about benefits. This chart does not explain benefits,Cost Share,out-of- pocket maximums,exclusions,or limitations,nor does it list all benefits and Cost Share amounts.For a complete explanation,refer to the"Benefits and Your Cost Share"and"Exclusions,Limitations,Coordination of Benefits,and Reductions"sections. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 2 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Introduction FROM WHOM OR WHAT GROUP OF PROVIDERS YOU MAY GET HEALTH CARE. Kaiser Foundation Health Plan,Inc. (Health Plan)has a contract with the Centers for Medicare&Medicaid Kaiser Permanente provides Services directly to our Services as a Medicare Advantage Organization. Members through an integrated medical care program. Health Plan,Plan Hospitals,and the Medical Group This contract provides Medicare Services(including work together to provide our Members with quality care. Medicare Part D prescription drug coverage)through Our medical care program gives you access to all of the "Kaiser Permanente Senior Advantage covered Services you may need,such as routine care (HMO)with Part D"(Senior Advantage),except for with your own personal Plan Physician,hospital hospice care for Members with Medicare Part A,which Services,laboratory and pharmacy Services,Emergency is covered under Original Medicare.Enrollment in this Services,Urgent Care,and other benefits described in Senior Advantage plan means that you are automatically this EOC.Plus,our health education programs offer you enrolled in Medicare Part D.Kaiser Permanente is an great ways to protect and improve your health. HMO plan with a Medicare contract.Enrollment in Kaiser Permanente depends on contract renewal. We provide covered Services to Members using Plan Providers located in our Service Area,which is described This Evidence of Coverage("EOC")describes our in the"Definitions"section.You must receive all Senior Advantage health care coverage provided under covered care from Plan Providers inside our Service the Group Agreement(Agreement)between Health Plan Area,except as described in the sections listed below for (Kaiser Foundation Health Plan,Inc. ("Health Plan")and the following Services: your Group(the entity with which Health Plan has • Authorized referrals as described under"Getting a entered into the Agreement). Referral"in the"How to Obtain Services"section • Covered Services received outside of your Home This EOC is part of the Agreement between Health Plan Region Service Area as described under"Receiving and your Group.The Agreement contains additional Care Outside of Your Home Region Service Area"in terms such as Premiums,when coverage can change,the the"How to Obtain Services"section effective date of coverage,and the effective date of • Emergency ambulance Services as described under termination.The Agreement must be consulted to determine the exact terms of coverage.A copy of the "Ambulance Services"in the"Benefits and Your Cost Agreement is available from your Group. Share"section • Emergency Services,Post-Stabilization Care,and For benefits provided under any other program,refer to Out-of-Area Urgent Care as described in the that other plan's evidence of coverage.For benefits "Emergency Services and Urgent Care"section provided under any other program offered by your Group • Out-of-area dialysis care as described under"Dialysis (for example,workers compensation benefits),refer to Care"in the"Benefits and Your Cost Share"section your Group's materials. • Prescription drugs from Non—Plan Pharmacies as In this EOC,Health Plan is sometimes referred to as described under"Outpatient Prescription Drugs, "we"or"us."Members are sometimes referred to as Supplies,and Supplements"in the"Benefits and "you."Some capitalized terms have special meaning in Your Cost Share"section this EOC;please see the"Definitions"section for terms • Routine Services associated with Medicare-approved you should know. clinical trials as described under"Services Associated with Clinical Trials"in the"Benefits and Your Cost It is important to familiarize yourself with your coverage Share"section by reading this EOC completely,so that you can take full advantage of your Health Plan benefits.Also,if you have special health care needs,please carefully read the Term of this EOC sections that apply to you. This EOC is for the period January 1,2024,through December 31,2024,unless amended.Benefits, About Kaiser Permanente Copayments,and Coinsurance may change on January 1 of each year and at other times in accord with your PLEASE READ THE FOLLOWING Group's Agreement with us.Your Group can tell you INFORMATION SO THAT YOU WILL KNOW Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 3 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. whether this EOC is still in effect and give you a current benefit plan did not cover the item(this amount is an one if this EOC has been amended. estimate of:the cost of acquiring,storing,and dispensing drugs,the direct and indirect costs of providing Kaiser Permanente pharmacy Services to Definitions . Members,and the pharmacy program's contribution to the net revenue requirements of Health Plan) Some terms have special meaning in this EOC.When we use a term with special meaning in only one section of • For all other Services,the payments that Kaiser this EOC,we define it in that section.The terms in this Permanente makes for the Services or,if Kaiser "Definitions"section have special meaning when Permanente subtracts your Cost Share from its capitalized and used in any section of this EOC. payment,the amount Kaiser Permanente would have paid if it did not subtract your Cost Share Accumulation Period:A period of time no greater than 12 consecutive months for purposes of accumulating Coinsurance:A percentage of Charges that you must amounts toward any deductibles(if applicable)and out- pay when you receive a covered Service under this EOC. of-pocket maximums. The Accumulation Period for this Complaint: The formal name for"making a complaint" EOC is from 1/l/24 through 12/31/24. is"filing a grievance."The complaint process is used Allowance:A specified credit amount that you can use only for certain types of problems.This includes toward the cost of an item.If the cost of the item(s)or problems related to quality of care,waiting times,and Service(s)you select exceeds the Allowance,you will the customer service you receive.It also includes pay the amount in excess of the Allowance,which does complaints if your plan does not follow the time periods not apply to the maximum out-of-pocket amount. in the appeal process. Catastrophic Coverage Stage:The stage in the Part D Comprehensive Formulary(Formulary or"Drug drug benefit that begins when you(or other qualified List"):A list of Medicare Part D prescription drugs parties on your behalf)have spent$8,000 for Part D covered by our plan.The drugs on this list are selected covered drugs during the covered year.During this by us with the help of doctors and pharmacists.The list payment stage,the plan pays the full cost for your includes both brand-name and generic drugs. covered Part D drugs.You pay nothing.Note:This Comprehensive Outpatient Rehabilitation Facility amount may change every January 1 in accord with (CORF):A facility that mainly provides rehabilitation Medicare requirements. Services after an illness or injury,including physician's Centers for Medicare&Medicaid Services(CMS): Services,physical therapy,social or psychological The federal agency that administers the Medicare Services,and outpatient rehabilitation. program. Copayment:A specific dollar amount that you must pay Ancillary Coverage: Optional benefits such as when you receive a covered Service under this EOC. acupuncture,chiropractic,or dental coverage that may be Note: The dollar amount of the Copayment can be$0(no available to Members enrolled under this EOC. If your charge). plan includes Ancillary Coverage,this coverage will be Cost Share:The amount you are required to pay for described in an amendment to this EOC or a separate covered Services.For example,your Cost Share may be agreement from the issuer of the coverage. a Copayment or Coinsurance. If your coverage includes Charges: "Charges"means the following: a Plan Deductible and you receive Services that are subject to the Plan Deductible,your Cost Share for those • For Services provided by the Medical Group or Services will be Charges until you reach the Plan Kaiser Foundation Hospitals,the charges in Health Deductible. Plan's schedule of Medical Group and Kaiser Foundation Hospitals charges for Services provided Coverage Determination:An initial determination we to Members make about whether a Part D drug prescribed for you is covered under Part D and the amount,if any,you are • For Services for which a provider(other than the required to pay for the prescription.In general,if you Medical Group or Kaiser Foundation Hospitals)is bring your prescription for a Part D drug to a Plan compensated on a capitation basis,the charges in the pharmacy and the pharmacy tells you the prescription schedule of charges that Kaiser Permanente isn't covered by us,that isn't a Coverage Determination. negotiates with the capitated provider You need to call or write us to ask for a formal decision • For items obtained at a pharmacy owned and operated about the coverage.Coverage Determinations are called by Kaiser Permanente,the amount the pharmacy "coverage decisions"in this EOC. would charge a Member for the item if a Member's Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 4 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Dependent:A Member who meets the eligibility coverage of"Kaiser Permanente Senior Advantage requirements as a Dependent(for Dependent eligibility (HMO)with Part D"under Health Plan's Agreement requirements,see"Who Is Eligible"in the"Premiums, with your Group. Eligibility,and Enrollment"section). "Extra Help":A Medicare or state program to help Durable Medical Equipment(DME): Certain medical people with limited income and resources pay Medicare equipment that is ordered by your doctor for medical prescription drug program costs,such as premiums, reasons.Examples include walkers,wheelchairs, deductibles,and coinsurance. crutches,powered mattress systems,diabetic supplies,IV Family:A Subscriber and all of their Dependents. infusion pumps,speech-generating devices,oxygen equipment,nebulizers,or hospital beds ordered by a Grievance:A type of complaint you make about our provider for use in the home. plan,providers,or pharmacies,including a complaint Emergency Medical Condition:A medical or mental concerning the quality of your care. This does not health condition manifesting itself by acute symptoms of involve coverage or payment disputes. sufficient severity(including severe pain)such that a Group: The entity with which Health Plan has entered prudent layperson,with an average knowledge of health into the Agreement that includes this EOC. and medicine,could reasonably expect the absence of Health Plan:Kaiser Foundation Health Plan,Inc.,a immediate medical attention to result in any of the following: California nonprofit corporation.This EOC sometimes refers to Health Plan as"we"or"us." • Serious jeopardy to the health of the individual or,in Home Region: The Region where you enrolled(either the case of a pregnant woman,the health of the the Northern California Region or the Southern woman or her unborn child California Region). • Serious impairment to bodily functions Income Related Monthly Adjustment Amount • Serious dysfunction of any bodily organ or part (IRMAA):If your modified adjusted gross income as A mental health condition is an emergency medical reported on your IRS tax return from two years ago is condition when it meets the requirements of the above a certain amount,you'll pay the standard premium paragraph above,or when the condition manifests itself amount and an Income Related Monthly Adjustment by acute symptoms of sufficient severity such that either Amount,also known as IRMAA.IRMAA is an extra of the following is true: charge added to your premium.Less than 5%of people • The person is an immediate danger to themselves or with Medicare are affected,so most people will not pay a to others higher premium. • The person is immediately unable to provide for,or Initial Enrollment Period:When you are first eligible use,food,shelter,or clothing,due to the mental for Medicare,the period of time when you can sign up disorder for Medicare Part B.If you're eligible for Medicare when you turn 65,your Initial Enrollment Period is the Emergency Services: Covered Services that are(1) 7-month period that begins 3 months before the month rendered by a provider qualified to furnish Emergency you turn 65,includes the month you turn 65,and ends 3 Services;and(2)needed to treat,evaluate,or Stabilize an months after the month you turn 65. Emergency Medical Condition such as: Kaiser Permanente:Kaiser Foundation Hospitals(a • A medical screening exam that is within the California nonprofit corporation),Health Plan,and the capability of the emergency department of a hospital, Medical Group. including ancillary services(such as imaging and laboratory Services)routinely available to the Medical Group: The Permanente Medical Group,Inc.,a emergency department to evaluate the Emergency for-profit professional corporation. Medical Condition Medically Necessary:A Service is Medically Necessary • Within the capabilities of the staff and facilities if it is medically appropriate and required to prevent, available at the hospital,Medically Necessary diagnose,or treat your condition or clinical symptoms in examination and treatment required to Stabilize the accord with generally accepted professional standards of patient(once your condition is Stabilized, Services practice that are consistent with a standard of care in the you receive are Post Stabilization Care and not medical community. Emergency Services) Medicare: The federal health insurance program for EOC: This Evidence of Coverage document,including people 65 years of age or older,some people under age any amendments,which describes the health care 65 with certain disabilities,and people with End-Stage Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 5 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Renal Disease(generally those with permanent kidney Non—Plan Physician:A physician other than a Plan failure who need dialysis or a kidney transplant).A Physician. person enrolled in a Medicare Part D plan has Medicare Non—Plan Provider:A provider other than a Plan Part D by virtue of his or her enrollment in the Part D Provider. plan(this EOC is for a Part D plan). Medicare Advantage Organization:A public or private Non—Plan Psychiatrist:A psychiatrist who is not a Plan entity organized and licensed by a state as a risk-bearing Physician. entity that has a contract with the Centers for Medicare Non—Plan Skilled Nursing Facility:A Skilled Nursing &Medicaid Services to provide Services covered by Facility other than a Plan Skilled Nursing Facility. Medicare,except for hospice care covered by Original Organization Determination:An initial determination Medicare.Kaiser Foundation Health Plan,Inc.,is a we make about whether we will cover or pay for Medicare Advantage Organization. Services that you believe you should receive.We also Medicare Advantage Plan: Sometimes called Medicare make an Organization Determination when we provide Part C.A plan offered by a private company that you with Services,or refer you to a Non—Plan Provider contracts with Medicare to provide you with all your for Services. Organization Determinations are called Medicare Part A and Part B benefits.A Medicare "coverage decisions"in this EOC. Advantage Plan can be(i)an HMO,(ii)a PPO,(iii)a Original Medicare("Traditional Medicare"or"Fee- Private Fee-for-Service(PFFS)plan,or(iv)a Medicare for-Service Medicare"):The Original Medicare plan is Medical Savings Account(MSA)plan.Besides choosing the way many people get their health care coverage.It is from these types of plans,a Medicare Advantage HMO or PPO plan can also be a Special Needs Plan(SNP).In the national pay-per-visit program that lets you go to any most cases,Medicare Advantage Plans also offer doctor,hospital,or other health care provider that Medicare Part D(prescription drug coverage).These accepts Medicare.You must pay a deductible.Medicare plans are called Medicare Advantage Plans with pays its share of the Medicare approved amount,and you Prescription Drug Coverage.This EOC is fora pay your share.Original Medicare has two parts:Part A Medicare Part D plan. (Hospital Insurance)and Part B(Medical Insurance),and is available everywhere in the United States and its Medicare Health Plan:A Medicare Health Plan is territories. offered by a private company that contracts with Out-of-Area Urgent Care:Medically Necessary Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan.This term includes Services to prevent serious deterioration of your health all Medicare Advantage plans,Medicare Cost plans, resulting from an unforeseen illness or an unforeseen Demonstration/Pilot Programs,and Programs of All- injury if all of the following are true: inclusive Care for the Elderly(PACE). • You are temporarily outside our Service Area Medigap(Medicare Supplement Insurance)Policy: • A reasonable person would have believed that your Medicare supplement insurance sold by private insurance health would seriously deteriorate if you delayed companies to fill"gaps"in the Original Medicare plan treatment until you returned to our Service Area coverage.Medigap policies only work with the Original Physician Specialist Visits: Consultations,evaluations, Medicare plan.(A Medicare Advantage Plan is not a and treatment by physician specialists,including Medigap policy.) personal Plan Physicians who are not Primary Care Member:A person who is eligible and enrolled under Physicians. this EOC,and for whom we have received applicable Plan Deductible:The amount you must pay under this Premiums.This EOC sometimes refers to a Member as EOC in the calendar year for certain Services before we "you." will cover those Services at the applicable Copayment or Non-Physician Specialist Visits: Consultations, Coinsurance in that calendar year.Refer to the"Benefits evaluations,and treatment by non-physician specialists and Your Cost Share"section to learn whether your (such as nurse practitioners,physician assistants, coverage includes a Plan Deductible,the Services that optometrists,podiatrists,and audiologists). are subject to the Plan Deductible,and the Plan Deductible amount. Non—Plan Hospital:A hospital other than a Plan Hospital. Plan Facility:Any facility listed in the Provider Directory on our website at kn.org/facilities.Plan Non—Plan Pharmacy:A pharmacy other than a Plan Facilities include Plan Hospitals,Plan Medical Offices, Pharmacy.These pharmacies are also called"out-of- and other facilities that we designate in the directory. network pharmacies." The directory is updated periodically.The availability of Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 6 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Plan Facilities may change.If you have questions,please Plan Skilled Nursing Facility:A Skilled Nursing call Member Services. Facility approved by Health Plan. Plan Hospital:Any hospital listed in the Provider Post-Stabilization Care: Medically Necessary Services Directory on our website at kp.org/facilities.In the related to your Emergency Medical Condition that you directory, some Plan Hospitals are listed as Kaiser receive in a hospital(including the Emergency Permanente Medical Centers.The directory is updated Department)after your treating physician determines that periodically.The availability of Plan Hospitals may this condition is Stabilized. change.If you have questions,please call Member Premiums: The periodic amounts for your membership Services. under this EOC. Plan Medical Office:Any medical office listed in the Preventive Services: Covered Services that prevent or Provider Directory on our website at kp.org/facilities.In detect illness and do one or more of the following: the directory,Kaiser Permanente Medical Centers may include Plan Medical Offices.The directory is updated • Protect against disease and disability or further periodically.The availability of Plan Medical Offices progression of a disease may change.If you have questions,please call Member . Detect disease in its earliest stages before noticeable Services. symptoms develop Plan Optical Sales Office:An optical sales office Primary Care Physicians: Generalists in internal owned and operated by Kaiser Permanente or another medicine,pediatrics,and family practice,and specialists optical sales office that we designate.Refer to the in obstetrics/gynecology whom the Medical Group Provider Directory on our website at kky.org/facilities for designates as Primary Care Physicians.Refer to the locations of Plan Optical Sales Offices.In the directory, Provider Directory on our website at kp.org for a list of Plan Optical Sales Offices may be called"Vision physicians that are available as Primary Care Physicians. Essentials."The directory is updated periodically.The The directory is updated periodically.The availability of availability of Plan Optical Sales Offices may change.If Primary Care Physicians may change.If you have you have questions,please call Member Services. questions,please call Member Services. Plan Optometrist:An optometrist who is a Plan Primary Care Visits:Evaluations and treatment Provider. provided by Primary Care Physicians and primary care Plan Out-of-Pocket Maximum: The total amount of Plan Providers who are not physicians(such as nurse Cost Share you must pay under this EOC in the calendar practitioners). year for certain covered Services that you receive in the Provider Directory:A directory of Plan Physicians and same calendar year.Refer to the"Benefits and Your Cost Plan Facilities in your Home Region.This directory is Share"section to find your Plan Out-of-Pocket available on our website at ky.org/directory.To obtain Maximum amount and to learn which Services apply to a printed copy,call Member Services.The directory is the Plan Out-of-Pocket Maximum. updated periodically.The availability of Plan Physicians Plan Pharmacy:A pharmacy owned and operated by and Plan Facilities may change.If you have questions, Kaiser Permanente or another pharmacy that we please call Member Services. designate.Refer to the Provider Directory on our website Real-Time Benefit Tool:A portal or computer at ky.org/facilities for locations of Plan Pharmacies.The application in which enrollees can look up complete, directory is updated periodically.The availability of Plan accurate,timely,clinically appropriate,enrollee-specific Pharmacies may change.If you have questions,please formulary and benefit information.This includes cost- call Member Services. sharing amounts,alternative formulary medications that Plan Physician:Any licensed physician who is an may be used for the same health condition as a given employee of the Medical Group,or any licensed drug,and coverage restrictions(prior authorization,step physician who contracts to provide Services to Members therapy,quantity limits)that apply to alternative (but not including physicians who contract only to medications. provide referral Services). Region:A Kaiser Foundation Health Plan organization Plan Provider:A Plan Hospital,a Plan Physician,the or allied plan that conducts a direct-service health care Medical Group,a Plan Pharmacy,or any other health program.Regions may change on January 1 of each year care provider that Health Plan designates as a Plan and are currently the District of Columbia and parts of Provider. Northern California,Southern California,Colorado, Georgia,Hawaii,Maryland,Oregon,Virginia,and Washington.For the current list of Region locations, Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 7 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. please visit our website at kp•org or call Member • The following ZIP codes in Fresno County are inside Services. our Northern California Service Area: 93242,93602, Serious Emotional Disturbance of a Child Under Age 93606-07,93609,93611-13,93616,93618-19, 18:A condition identified as a"mental disorder"in the 93624-27,93630-31,93646,93648-52,93654, most recent edition of the Diagnostic and Statistical 93656-57,93660,93662,93667-68,93675,93701- Manual of Mental Disorders,other than a primary 12,93714-18,93720-30,93737,93740-41,93744- substance use disorder or developmental disorder,that 45,93747,93750,93755,93760-61,93764-65, results in behavior inappropriate to the child's age 93771-79,93786,93790-94,93844,93888 according to expected developmental norms,if the child • The following ZIP codes in Kings County are inside also meets at least one of the following three criteria: our Northern California Service Area: 93230,93232, • As a result of the mental disorder,(1)the child has 93242,93631,93656 substantial impairment in at least two of the following • The following ZIP codes in Madera County are inside areas: self-care,school functioning,family our Northern California Service Area: 93601-02, relationships,or ability to function in the community; 93604,93614,93623,93626,93636-39,93643-45, and(2)either(a)the child is at risk of removal from 93653,93669,93720 the home or has already been removed from the • All ZIP codes in Marin County are inside our home,or(b)the mental disorder and impairments Northern California Service Area: 94901,94903-04, have been present for more than six months or are 94912-15,94920,94924-25,94929-30,94933, likely to continue for more than one year without 94937-42,94945-50,94956-57,94960,94963-66, treatment 94970-71,94973-74,94976-79 • The child displays psychotic features,or risk of • The following ZIP codes in Mariposa County are suicide or violence due to a mental disorder inside our Northern California Service Area: 93 60 1, • The child meets special education eligibility 93623,93653 requirements under Section 5600.3(a)(2)(C)of the • All ZIP codes in Napa County are inside our Northern Welfare and Institutions Code California Service Area: 94503,94508,94515, Service Area: The geographic area approved by the 94558-59,94562,94567,94573-74,94576,94581, Centers for Medicare&Medicaid Services within which 94599,95476 an eligible person may enroll in Senior Advantage.Note: • The following ZIP codes in Placer County are inside Subject to approval by the Centers for Medicare& our Northern California Service Area: 95602-04, Medicaid Services,we may reduce or expand our Service 95610,95626,95648,95650,95658,95661,95663, Area effective any January 1.ZIP codes are subject to 95668,95677-78,95681,95703,95722,95736, change by the U.S.Postal Service.The ZIP codes below 95746-47,95765 for each county are in our Service Area: • All ZIP codes in Sacramento County are inside our • All ZIP codes in Alameda County are inside our Northern California Service Area: 94203-09,94211, Northern California Service Area: 94501-02,94505, 94229-30,94232,94234-37,94239-40,94244-45, 94514,94536-46,94550-52,94555,94557,94560, 94247-50,94252,94254,94256-59,94261-63, 94566,94568,94577-80,94586-88,94601-15, 94267-69,94271,94273-74,94277-80,94282-85, 94617-21,94622-24,94649,94659-62,94666, 94287-91,94293-98,94571,95608-11,95615, 94701-10,94712,94720,95377,95391 95621,95624,95626,95628,95630,95632,95638- • The following ZIP codes in Amador County are 39,95641,95652,95655,95660,95662,95670-71, inside our Northern California Service Area: 95640, 95673,95678,95680,95683,95690,95693,95741- 95669 42,95757-59,95763,95811-38,95840-43,95851- • All ZIP codes in Contra Costa County are inside our 53,95860,95864-67,95894,95899 Northern California Service Area: 94505-07,94509, • All ZIP codes in San Francisco County are inside our 94511,94513-14,94516-31,94547-49,94551, Northern California Service Area: 94102-05,94107- 94553,94556,94561,94563-65,94569-70,94572, 12,94114-34,94137,94139-47,94151,94158-61, 94575,94582-83,94595-98,94706-08,94801-08, 94163-64,94172,94177,94188 94820,94850 • All ZIP codes in San Joaquin County are inside our • The following ZIP codes in El Dorado County are Northern California Service Area: 94514,95201-15, inside our Northern California Service Area: 95613- 95219-20,95227,95230-31,95234,95236-37, 14,95619,95623,95633-35,95651,95664,95667, 95240-42,95253,95258,95267,95269,95296-97, 95672,95682,95762 Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 8 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. 95304,95320,95330,95336-37,95361,95366, For each ZIP code listed for a county,our Service Area 95376-78,95385,95391,95632,95686,95690 includes only the part of that ZIP code that is in that • All ZIP codes in San Mateo County are inside our county.When a ZIP code spans more than one county, Northern California Service Area: 94002,94005, the part of that ZIP code that is in another county is not 94010-11,94014-21,94025-28,94030,94037-38, inside our Service Area unless that other county is listed 94044,94060-66,94070,94074,94080,94083, above and that ZIP code is also listed for that other 94128,94303,94401-04,94497 county.If you have a question about whether a ZIP code is in our Service Area,please call Member Services. • The following ZIP codes in Santa Clara County are Also,the ZIP codes listed above may include ZIP codes inside our Northern California Service Area: 94022- for Post Office boxes and commercial rental mailboxes. 24,94035,94039-43,94085-89,94301-06,94309, A Post Office box or rental mailbox cannot be used to 94550,95002,95008-09,95011,95013-15,95020- determine whether you meet the residence eligibility 21,95026,95030-33,95035-38,95042,95044, requirements for Senior Advantage.Your permanent 95046,95050-56,95070-71,95076,95101,95103, residence address must be used to determine your Senior 95106,95108-13,95115-36,95138-41,95148, Advantage eligibility. 95150-61,95164,95170,95172-73,95190-94, 95196 Services:Health care services or items("health care" • All ZIP codes in Santa Cruz County are inside our includes both physical health care and mental health care)and services to treat Serious Emotional Disturbance Northern California Service Area: 95001,95003, of a Child Under Age 18 or Severe Mental Illness. 95005-07,95010,95017-19,95033,95041,95060- 67,95073,95076-77 Severe Mental Illness:The following mental disorders: • All ZIP codes in Solano County are inside our schizophrenia,schizoaffective disorder,bipolar disorder (manic-depressive illness),major depressive disorders, Northern California Service Area: 94503,94510, panic disorder,obsessive-compulsive disorder,pervasive 94512,94533-35,94571,94585,94589-92,95616, developmental disorder or autism,anorexia nervosa,or 95618,95620,95625,95687-88,95690,95694, bulimia nervosa. 95696 • The following ZIP codes in Sonoma County are Skilled Nursing Facility:A facility that provides inside our Northern California Service Area: 94515, inpatient skilled nursing care,rehabilitation services,or 94922-23,94926-28,94931,94951-55,94972, other related health services and is licensed by the state 94975,94999,95401-07,95409,95416,95419, of California.The facility's primary business must be the 95421 95425 95430-31 95433 95436 95439 provision of 24-hour-a-day licensed skilled nursing care. 95441-42,95444,95446,95448,95450,95452, The term"Skilled Nursing Facility"does not include 95462,95465,95471-73,95476,95486-87,95492 convalescent nursing homes,rest facilities,or facilities for the aged,if those facilities furnish primarily custodial • All ZIP codes in Stanislaus County are inside our care,including training in routines of daily living.A Northern California Service Area: 95230,95304, "Skilled Nursing Facility"may also be a unit or section 95307,95313,95316,95319,95322-23,95326, within another facility(for example,a hospital)as long 95328-29,95350-58,95360-61,95363,95367-68, as it continues to meet this definition. 95380-82,95385-87,95397 Spouse: The person to whom the Subscriber is legally • The following ZIP codes in Sutter County are inside married under applicable law.For the purposes of this our Northern California Service Area: 95626,95645, EOC,the term"Spouse"includes the Subscriber's 95659,95668,95674,95676,95692,95836-37 domestic partner."Domestic partners"are two people • The following ZIP codes in Tulare County are inside who are registered and legally recognized as domestic our Northern California Service Area: 93238,93261, partners by California(if your Group allows enrollment 93618,93631,93646,93654,93666,93673 of domestic partners not legally recognized as domestic partners by California,"Spouse"also includes the • The following ZIP codes in Yolo County are inside Subscriber's domestic partner who meets your Group's our Northern California Service Area: 95605,95607,95612,95615-18,95645,95691,95694-95,95697- eligibility requirements for domestic partners). 98,95776,95798-99 Stabilize: To provide the medical treatment of the • The following ZIP codes in Yuba County are inside Emergency Medical Condition that is necessary to our Northern California Service Area: 95692,95903, assure,within reasonable medical probability,that no 95961 material deterioration of the condition is likely to result from or occur during the transfer of the person from the facility.With respect to a pregnant person who is having Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 9 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. contractions,when there is inadequate time to safely years ago.If this amount is above a certain amount, transfer them to another hospital before delivery(or the you'll pay the standard premium amount and the transfer may pose a threat to the health or safety of the additional IRMAA.For more information on the extra pregnant person or unborn child),"Stabilize"means to amount you may have to pay based on your income,visit deliver(including the placenta). haws://www.medicare.2ov. Subscriber:A Member who is eligible for membership If you have to pay an extra amount, Social Security,not on their own behalf and not by virtue of Dependent your Medicare plan,will send you a letter telling you status and who meets the eligibility requirements as a what that extra amount will be.The extra amount will be Subscriber(for Subscriber eligibility requirements,see withheld from your Social Security,Railroad Retirement "Who Is Eligible"in the"Premiums,Eligibility,and Board,or Office of Personnel Management benefit Enrollment"section). check,no matter how you usually pay your plan Surrogacy Arrangement:An arrangement in which an premium,unless your monthly benefit isn't enough to individual agrees to become pregnant and to surrender cover the extra amount owed.If your benefit check isn't the baby(or babies)to another person or persons who enough to cover the extra amount,you will get a bill intend to raise the child(or children),whether or not the from Medicare.You must pay the extra amount to the individual receives payment for being a surrogate.For government.If you do not pay the extra amount,you the purposes of this EOC, "Surrogacy Arrangements" will be disenrolled from the plan and lose includes all types of surrogacy arrangements,including prescription drug coverage. traditional surrogacy arrangements and gestational surrogacy arrangements. If you disagree about paying an extra amount,you can ask Social Security to review the decision.To find out Telehealth Visits:Interactive video visits and scheduled more about how to do this,contact Social Security at telephone visits between you and your provider. 1-800-772-1213(TTY users call 1-800-325-0778). Urgent Care: Medically Necessary Services for a condition that requires prompt medical attention but is Medicare Part D late enrollment penalty not an Emergency Medical Condition. Some members are required to pay a Part D late enrollment penalty.The Part D late enrollment penalty is an additional premium that must be paid for Part D coverage if at any time after your initial enrollment Premiums, Eligibility, and period is over,there is a period of 63 days or more in a Enrollment row when you did not have Part D or other creditable prescription drug coverage."Creditable prescription drug coverage"is coverage that meets Medicare's minimum Premiums standards since it is expected to pay,on average,at least as much as Medicare's standard prescription drug Please contact your Group's benefits administrator for coverage.The cost of the late enrollment penalty information about your plan Premiums.You must also depends on how long you went without Part D or other continue to pay Medicare your monthly Medicare creditable prescription drug coverage.You will have to premium. pay this penalty for as long as you have Part D coverage. The Part D late enrollment penalty is added to your plan If you do not have Medicare Part A,you may be eligible premium.Your Group or Health Plan will inform you if to purchase Medicare Part A from Social Security.Please the penalty applies to you. contact Social Security for more information.If you get Medicare Part A,this may reduce the amount you would You will not have to pay it if: be expected to pay to your Group,please check with . You receive"Extra Help"from Medicare to pay for your Group's benefits administrator. your prescription drugs • You have gone less than 63 days in a row without Medicare Premiums creditable coverage Medicare Part D premium due to income • You have had creditable drug coverage through Some members may be required to pay an extra charge, another source such as a former employer,union, known as the Part D Income Related Monthly TRICARE,or Department of Veterans Affairs.Your Adjustment Amount,also known as IRMAA.The extra insurer or your human resources department will tell charge is figured out using your modified adjusted gross you each year if your drug coverage is creditable c income as reported on your IRS tax return from two overage.This information may be sent to you in a Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 10 Member Service:toll free 1-800-443-0815(TTY users call 711)seven days a week, 8 a.m.-8 p.m. letter or included in a newsletter from the plan.Keep • 1-800-MEDICARE(1-800-633-4227)(TTY users this information because you may need it if you join a call 1-877-486-2048),24 hours a day,seven days a Medicare drug plan later week; ♦ any notice must state that you had"creditable" • The Social Security Office at 1-800-772-1213(TTY prescription drug coverage that is expected to pay users call 1-800-325-0778), 8 a.m.to 7 p.m.,Monday as much as Medicare's standard prescription drug through Friday(applications);or plan pays • Your state Medicaid office(applications). See the ♦ the following are not creditable prescription drug "Important Phone Numbers and Resources"section coverage:prescription drug discount cards,free for contact information clinics,and drug discount websites Medicare determines the amount of the penalty.There If you qualify for"Extra Help,"we will send you an are three important things to note about this monthly Part Evidence of Coverage Rider for People Who Get Extra D late enrollment penalty: Help Paying for Prescription Drugs(also known as the Low Income Subsidy Rider or the LIS Rider),that • First,the penalty may change each year because the explains your costs as a Member of our plan.If the average monthly premium can change each year amount of your"Extra Help"changes during the year, • Second,you will continue to pay a penalty every we will also mail you an updated Evidence of Coverage month for as long as you are enrolled in a plan that Rider for People Who Get Extra Help Paying for has Medicare Part D drug benefits,even if you Prescription Drugs. change plans • Third,if you are under 65 and currently receiving Who Is Eli i1ble Medicare benefits,the Part D late enrollment penalty To enroll and to continue enrollment,you must meet all will reset when you turn 65.After age 65,your Part D of the eligibility requirements described in this"Who Is late enrollment penalty will be based only on the Eligible"section,including your Group's eligibility months that you don't have coverage after your initial enrollment period for aging into Medicare requirements and your Home Region Service Area eligibility requirements. If you disagree about your Part D late enrollment penalty,you or your representative can ask for a Group eligibility requirements review. Generally,you must request this review within You must meet your Group's eligibility requirements. 60 days from the date on the first letter you receive Your Group is required to inform Subscribers of its stating you have to pay a late enrollment penalty. eligibility requirements. However,if you were paying a penalty before joining our plan,you may not have another chance to request a Senior Advantage eligibility requirements review of that late enrollment penalty. • You must have Medicare Part B Medicare's "Extra Help" Program • You must be a United States citizen or lawfully Medicare provides"Extra Help"to pay prescription drug present in the United States costs for people who have limited income and resources. • Your Medicare coverage must be primary and your Resources include your savings and stocks,but not your Group's health care plan must be secondary home or car.If you qualify,you get help paying for any • You may not be enrolled in another Medicare Health Medicare drug plan's monthly premium,and prescription Plan or Medicare prescription drug plan Copayments.This"Extra Help"also counts toward your out-of-pocket costs. Note:If you are enrolled in a Medicare plan and lose Medicare eligibility,you may be able to enroll under People with limited income and resources may qualify your Group's non-Medicare plan if that is permitted by for"Extra Help."If you automatically qualify for"Extra your Group(please ask your Group for details). Help,"Medicare will mail you a letter.You will not have to apply.If you do not automatically qualify,you may be able to get"Extra Help"to pay for your prescription drug Service Area eligibility requirements premiums and costs.To see if you qualify for getting "Extra Help,"call: You must live in our Service Area,unless you have been continuously enrolled in Senior Advantage since December 31, 1998,and lived outside our Service Area during that entire time.In which case,you may continue Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 11 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. your membership unless you move and are still outside options.You may be able to enroll in the service area of your Home Region Service Area. The"Definitions" another Region if there is an agreement between your section describes our Service Area and how it may Group and that Region,but the plan,including coverage, change. premiums,and eligibility requirements,might not be the same as under this EOC. Moving outside your Home Region Service Area. If you permanently move outside your Home Region For more information about the service areas of the other Service Area,or you are temporarily absent from your Regions,please call Member Services. Home Region Service Area for a period of more than six months in a row,you must notify us and you cannot Eligibility as a Subscriber continue your Senior Advantage membership under this You may be eligible to enroll and continue enrollment as EOC. a Subscriber if you are: Send your notice to: • An employee of your Group • A proprietor or partner of your Group Kaiser Foundation Health Plan,Inc. • Otherwise entitled to coverage under a trust California Service Center P.O.Box 232400 agreement,retirement benefit program,or San Diego,CA 92193 employment contract(unless the Internal Revenue Service considers you self-employed) It is in your best interest to notify us as soon as possible Eligibility as a Dependent because until your Senior Advantage coverage is officially terminated by the Centers for Medicare& Enrolling as a Dependent Medicaid Services,you will not be covered by us or Dependent eligibility is subject to your Group's Original Medicare for any care you receive from Non— eligibility requirements,which are not described in this Plan Providers,except as described in the sections listed EOC.You can obtain your Group's eligibility below for the following Services: requirements directly from your Group.If you are a • Authorized referrals as described under"Getting a Subscriber under this EOC and if your Group allows Referral"in the"How to Obtain Services"section enrollment of Dependents,Health Plan allows the following persons to enroll as your Dependents under • Covered Services received outside of your Home this EOC if they meet all of the other requirements Region Service Area as described under"Receiving described under"Senior Advantage eligibility Care Outside of Your Home Region Service Area"in requirements,"and"Service Area eligibility the"How to Obtain Services"section requirements"in this"Who Is Eligible"section: • Emergency ambulance Services as described under • Your Spouse "Ambulance Services"in the"Benefits and Your Cost Share"section • Your or your Spouse's Dependent children,who meet the requirements described under"Age limit of • Emergency Services,Post-Stabilization Care,and Dependent children,"if they are any of the following: Out-of-Area Urgent Care as described in the ♦ biological children "Emergency Services and Urgent Care"section ♦ stepchildren • Out-of-area dialysis care as described under"Dialysis ♦ adopted children Care"in the"Benefits and Your Cost Share"section • Prescription drugs from Non—Plan Pharmacies as ♦ children placed with you for adoption described under"Outpatient Prescription Drugs, ♦ foster children if you or your Spouse have the Supplies,and Supplements"in the"Benefits and legal authority to direct their care Your Cost Share"section ♦ children for whom you or your Spouse is the • Routine Services associated with Medicare-approved court-appointed guardian(or was when the child clinical trials as described under"Services Associated reached age 18) with Clinical Trials"in the"Benefits and Your Cost • Children whose parent is a Dependent child under Share"section your family coverage(including adopted children and children placed with your Dependent child for If you are not eligible to continue enrollment because you move to the service area of another Region,please contact your Group to learn about your Group health care Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 12 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. adoption or foster care)if they meet all of the us documentation of the Dependent's incapacity and following requirements: dependency within 60 days of receipt of our notice ♦ they are not married and do not have a domestic and we determine that the Dependent is eligible as a partner(for the purposes of this requirement only, disabled dependent.If the Subscriber provides us this "domestic partner"means someone who is documentation in the specified time period and we do registered and legally recognized as a domestic not make a determination about eligibility before the partner by California) termination date,coverage will continue until we ♦ they meet the requirements described under"Age make a determination.If we determine that the limit of Dependent children" Dependent does not meet the eligibility requirements as a disabled dependent,we will notify the Subscriber ♦ they receive all of their support and maintenance that the Dependent is not eligible and let the from you or your Spouse Subscriber know the membership termination date. ♦ they permanently reside with you or your Spouse If we determine that the Dependent is eligible as a disabled dependent,there will be no lapse in Age limit of Dependent children coverage.Also,starting two years after the date that Children must be under age 26 as of the effective date of the Dependent reached the age limit,the Subscriber this EOC to enroll as a Dependent under your plan. must provide us documentation of the Dependent's incapacity and dependency annually within 60 days Dependent children are eligible to remain on the plan after we request it so that we can determine if the through the end of the month in which they reach the age Dependent continues to be eligible as a disabled limit. dependent • If the child is not a Member because you are changing Dependent children of the Subscriber or Spouse coverage,you must give us proof,within 60 days (including adopted children and children placed with you after we request it,of the child's incapacity and for adoption,but not including children placed with you dependency as well as proof of the child's coverage for foster care)who reach the age limit may continue under your prior coverage.In the future,you must coverage under this EOC if all of the following provide proof of the child's continued incapacity and conditions are met: dependency within 60 days after you receive our • They meet all requirements to be a Dependent except request,but not more frequently than annually for the age limit Dependents not eligible to enroll under a Senior • Your Group permits enrollment of Dependents Advantage plan.If you have dependents who do not • They are incapable of self-sustaining employment have Medicare Part B coverage or for some other reason because of a physically-or mentally-disabling injury, are not eligible to enroll under this EOC,you may be illness,or condition that occurred before they reached able to enroll them as your dependents under a non- the age limit for Dependents Medicare plan offered by your Group.Please contact • They receive 50 percent or more of their support and your Group for details,including eligibility and benefit maintenance from you or your Spouse information,and to request a copy of the non-Medicare plan document. • If requested,you give us proof of their incapacity and dependency within 60 days after receiving our request (see"Disabled Dependent certification"below in this How to Enroll and When Coverage "Eligibility as a Dependent"section) Begins Disabled Dependent certification Your Group is required to inform you when you are Proof may be required for a Dependent to be eligible to eligible to enroll and what your effective date of continue coverage as a disabled Dependent.If we request coverage is.If you are eligible to enroll as described it,the Subscriber must provide us documentation of the under"Who Is Eligible"in this"Premiums,Eligibility, dependent's incapacity and dependency as follows: and Enrollment"section,enrollment is permitted as • If the child is a Member,we will send the Subscriber described below and membership begins at the beginning a notice of the Dependent's membership termination (12:00 a.m.)of the effective date of coverage indicated below,except that: due to loss of eligibility at least 90 days before the date coverage will end due to reaching the age limit. • Your Group may have additional requirements,which The Dependent's membership will terminate as allow enrollment in other situations described in our notice unless the Subscriber provides Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 13 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • The effective date of your Senior Advantage coverage Group open enrollment under this EOC must be confirmed by the Centers for You may enroll as a Subscriber(along with any eligible Medicare&Medicaid Services,as described under Dependents),and existing Subscribers may add eligible "Effective date of Senior Advantage coverage"in this Dependents,by submitting a Health Plan—approved "How to Enroll and When Coverage Begins"section enrollment application,and a Senior Advantage Election Form for each person to your Group during your Group's If you are a Subscriber under this EOC and you have open enrollment period.Your Group will let you know dependents who do not have Medicare Part B coverage or when the open enrollment period begins and ends and the for some other reason are not eligible to enroll under this effective date of coverage,which is subject to EOC,you may be able to enroll them as your dependents confirmation by the Centers for Medicare&Medicaid under a non-Medicare plan offered by your Group.Please Services. contact your Group for details,including eligibility and benefit information,and to request a copy of the non- Special enrollment Medicare plan document. If you do not enroll when you are first eligible and later want to enroll,you can enroll only during open If you are eligible to be a Dependent under this EOC but the enrollment unless one of the following is true: subscriber in your family is enrolled under a non-Medicare . You become eligible because you experience a plan offered by your Group,the subscriber must follow the qualifying event(sometimes called a"triggering rules applicable to Subscribers who are enrolling Dependents in this"How to Enroll and When Coverage event")as described in this"Special enrollment" section Begins"section. • You did not enroll in any coverage offered by your Effective date of Senior Advantage coverage Group when you were first eligible and your Group After we receive your completed Senior Advantage does not give us a written statement that verifies you Election Form,we will submit your enrollment request to signed a document that explained restrictions about the Centers for Medicare&Medicaid Services for enrolling in the future. Subject to confirmation by the confirmation and send you a notice indicating the Centers for Medicare&Medicaid Services,the proposed effective date of your Senior Advantage effective date of an enrollment resulting from this coverage under this EOC. provision is no later than the first day of the month following the date your Group receives a Health If the Centers for Medicare&Medicaid Services Plan—approved enrollment or change of enrollment confirms your Senior Advantage enrollment and application,and a Senior Advantage Election Form effective date,we will send you a notice that confirms for each person,from the Subscriber your enrollment and effective date.If the Centers for Medicare&Medicaid Services tells us that you do not Special enrollment due to new Dependents.You may have Medicare Part B coverage,we will notify you that enroll as a Subscriber(along with eligible Dependents), you will be disenrolled from Senior Advantage. and existing Subscribers may add eligible Dependents, within 30 days after marriage,establishment of domestic New employees partnership,birth,adoption,placement for adoption,or When your Group informs you that you are eligible to placement for foster care by submitting to your Group a enroll as a Subscriber,you may enroll yourself and any Health Plan—approved enrollment application,and a eligible Dependents by submitting a Health Plan— Senior Advantage Election Form for each person. approved enrollment application,and a Senior Advantage Election Form for each person,to your Group Subject to confirmation by the Centers for Medicare& within 31 days. Medicaid Services,the effective date of an enrollment resulting from marriage or establishment of domestic Effective date of Senior Advantage coverage.The partnership is no later than the first day of the month effective date of Senior Advantage coverage for new following the date your Group receives an enrollment employees and their eligible family Dependents or newly application,and a Senior Advantage Election Form for acquired Dependents,is determined by your Group, each person,from the Subscriber. Subject to subject to confirmation by the Centers for Medicare& confirmation by the Centers for Medicare&Medicaid Medicaid Services. Services,enrollments due to birth,adoption,placement for adoption,or placement for foster care are effective on the date of birth,date of adoption,or the date you or your Spouse have newly assumed a legal right to control health care. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 14 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Special enrollment due to loss of other coverage.You submitting to your Group a Health Plan—approved may enroll as a Subscriber(along with any eligible enrollment or change of enrollment application,and a Dependents),and existing Subscribers may add eligible Senior Advantage Election Form for each person. Dependents,if all of the following are true: • The Subscriber or at least one of the Dependents had Subject to confirmation by the Centers for Medicare& other coverage when they previously declined all Medicaid Services,the effective date of coverage coverage through your Group resulting from a court or administrative order is the first of the month following the date we receive the • The loss of the other coverage is due to one of the enrollment request,unless your Group specifies a following: different effective date(if your Group specifies a ♦ exhaustion of COBRA coverage different effective date,the effective date cannot be ♦ termination of employer contributions for non- earlier than the date of the order). COBRA coverage ♦ loss of eligibility for non-COBRA coverage,but Special enrollment due to eligibility for premium not termination for cause or termination from an assistance.You may enroll as a Subscriber(along with individual(nongroup)plan for nonpayment.For eligible Dependents),and existing Subscribers may add example,this loss of eligibility may be due to legal eligible Dependents,if you or a dependent become separation or divorce,moving out of the plan's eligible for premium assistance through the Medi-Cal service area,reaching the age limit for dependent program.Premium assistance is when the Medi-Cal children,or the subscriber's death,termination of program pays all or part of premiums for employer group employment,or reduction in hours of employment coverage for a Medi-Cal beneficiary. To request enrollment in your Group's health care coverage,the ♦ loss of eligibility(but not termination for cause) Subscriber must submit a Health Plan—approved for coverage through Covered California, enrollment or change of enrollment application,and a Medicaid coverage(known as Medi-Cal in Senior Advantage Election Form for each person,to your California),Children's Health Insurance Program Group within 60 days after you or a dependent become coverage,or Medi-Cal Access Program coverage eligible for premium assistance.Please contact the ♦ reaching a lifetime maximum on all benefits California Department of Health Care Services to find out if premium assistance is available and the eligibility Note: If you are enrolling yourself as a Subscriber along requirements. with at least one eligible Dependent,only one of you must meet the requirements stated above. Special enrollment due to reemployment after military service.If you terminated your health care To request enrollment,the Subscriber must submit a coverage because you were called to active duty in the Health Plan—approved enrollment or change of military service,you may be able to reenroll in your enrollment application,and a Senior Advantage Election Group's health plan if required by state or federal law. Form for each person,to your Group within 30 days after Please ask your Group for more infonnation. loss of other coverage,except that the timeframe for submitting the application is 60 days if you are requesting enrollment due to loss of eligibility for How to Obtain Services coverage through Covered California,Medicaid, Children's Health Insurance Program,or Medi-Cal Access Program coverage. Subject to confirmation by As a Member,you are selecting our medical care the Centers for Medicare&Medicaid Services,the program to provide your health care.You must receive effective date of an enrollment resulting from loss of all covered care from Plan Providers inside our Service other coverage is no later than the first day of the month Area,except as described in the sections listed below for following the date your Group receives an enrollment or the following Services: change of enrollment application,and Senior Advantage • Authorized referrals as described under"Getting a Election Form for each person,from the Subscriber. Referral"in this"How to Obtain Services"section • Covered Services received outside of your Home Special enrollment due to court or administrative Region Service Area as described under"Receiving order.Within 31 days after the date of a court or Care Outside of Your Home Region Service Area"in administrative order requiring a Subscriber to provide this"How to Obtain Services"section health care coverage for a Spouse or child who meets the eligibility requirements as a Dependent,the Subscriber may add the Spouse or child as a Dependent by Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 15 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Emergency ambulance Services as described under medically appropriate.Whether you are calling for "Ambulance Services"in the"Benefits and Your Cost advice or to make an appointment,you can speak to an Share"section advice nurse.They can often answer questions about a • Emergency Services,Post-Stabilization Care,and minor concern,tell you what to do if a Plan Medical Out-of-Area Urgent Care as described in the Office is closed,or advise you about what to do next, "Emergency Services and Urgent Care"section including making a same-day Urgent Care appointment for you if it's medically appropriate.To reach an advice • Out-of-area dialysis care as described under"Dialysis nurse,refer to our Provider Directory or call Member Care"in the"Benefits and Your Cost Share"section Services. • Prescription drugs from Non—Plan Pharmacies as described under"Outpatient Prescription Drugs, Your Personal Plan Physician Supplies,and Supplements"in the"Benefits and Your Cost Share"section Personal Plan Physicians provide primary care and play • Routine Services associated with Medicare-approved an important role in coordinating care,including hospital clinical trials as described under"Services Associated stays and referrals to specialists. with Clinical Trials"in the"Benefits and Your Cost Share"section We encourage you to choose a personal Plan Physician. You may choose any available personal Plan Physician. Our medical care program gives you access to all of the Parents may choose a pediatrician as the personal Plan covered Services you may need,such as routine care Physician for their child.Most personal Plan Physicians with your own personal Plan Physician,hospital are Primary Care Physicians(generalists in internal Services,laboratory and pharmacy Services,Emergency medicine,pediatrics,or family practice,or specialists in Services,Urgent Care,and other benefits described in obstetrics/gynecology whom the Medical Group this EOC. designates as Primary Care Physicians). Some specialists who are not designated as Primary Care Physicians but who also provide primary care may be available as Routine Care personal Plan Physicians.For example,some specialists in internal medicine and obstetrics/gynecology who are To request anon-urgent appointment,you can call your not designated as Primary Care Physicians maybe local Plan Facility or request the appointment online.For available as personal Plan Physicians.However,if you appointment phone numbers,refer to our Provider choose a specialist who is not designated as a Primary Directory or call Member Services.To request an Care Physician as your personal Plan Physician,the Cost appointment online,go to our website at kp•org. Share for a Physician Specialist Visit will apply to all visits with the specialist except for Preventive Services Urgent Care listed in the"Benefits and Your Cost Share"section. An Urgent Care need is one that requires prompt medical To learn how to select or change to a different personal attention but is not an Emergency Medical Condition. Plan Physician,visit our website at kp.org,or call If you think you may need Urgent Care,call the Member Services.Refer to our Provider Directory for a appropriate appointment or advice phone number at a list of physicians that are available as Primary Care Plan Facility.For phone numbers,refer to our Provider Physicians. The directory is updated periodically.The Directory or call Member Services. availability of Primary Care Physicians may change.If you have questions,please call Member Services.You For information about Out-of-Area Urgent Care,refer to can change your personal Plan Physician at any time for "Urgent Care"in the"Emergency Services and Urgent any reason. Care"section. Getting a Referral Our Advice Nurses Referrals to Plan Providers We know that sometimes it's difficult to know what type A Plan Physician must refer you before you can receive of care you need.That's why we have telephone advice care from specialists,such as specialists in surgery, nurses available to assist you.Our advice nurses are orthopedics,cardiology,oncology,dermatology,and registered nurses specially trained to help assess medical physical,occupational,and speech therapies.However, symptoms and provide advice over the phone,when you do not need a referral or prior authorization to Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 16 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. receive most care from any of the following Plan clinically appropriate place consistent with the terms of Providers: your health coverage.Decisions regarding requests for • Your personal Plan Physician authorization will be made only by licensed physicians or other appropriately licensed medical professionals. • Generalists in internal medicine,pediatrics,and family practice For the complete list of Services that require prior • Specialists in optometry,mental health Services, authorization,and the criteria that are used to make substance use disorder treatment,and authorization decisions,please visit our website at obstetrics/gynecology ky.ora/UM or call Member Services to request a printed copy.Refer to"Post-Stabilization Care"under A Plan Physician must refer you before you can get care "Emergency Services"in the"Emergency Services and from a specialist in urology except that you do not need a Urgent Care"section for authorization requirements that referral to receive Services related to sexual or apply to Post-Stabilization Care from Non—Plan reproductive health,such as a vasectomy. Providers. Although a referral or prior authorization is not required Additional information about prior authorization for to receive most care from these providers,a referral may durable medical equipment,ostomy,urological,and be required in the following situations: specialized wound care supplies.The prior • The provider may have to get prior authorization for authorization process for durable medical equipment, ostomy,urological,and specialized wound care supplies certain Services in accord with"Medical Group includes the use of formulary guidelines.These authorization procedure for certain referrals"in this guidelines were developed by a multidisciplinary clinical "Getting a Referral"section and operational work group with review and input from • The provider may have to refer you to a specialist Plan Physicians and medical professionals with clinical who has a clinical background related to your illness expertise.The formulary guidelines are periodically or condition updated to keep pace with changes in medical technology,Medicare guidelines,and clinical practice. Standing referrals If a Plan Physician refers you to a specialist,the referral If your Plan Physician prescribes one of these items,they will be for a specific treatment plan.Your treatment plan will submit a written referral in accord with the UM may include a standing referral if ongoing care from the process described in this"Medical Group authorization specialist is prescribed.For example,if you have a life- procedure for certain referrals"section.If the formulary threatening,degenerative,or disabling condition,you can guidelines do not specify that the prescribed item is get a standing referral to a specialist if ongoing care from appropriate for your medical condition,the referral will the specialist is required. be submitted to the Medical Group's designee Plan Physician,who will make an authorization decision as Medical Group authorization procedure for described under"Medical Group's decision time frames" certain referrals in this"Medical Group authorization procedure for The following are examples of Services that require prior certain referrals"section. authorization by the Medical Group for the Services to be covered("prior authorization"means that the Medical Medical Group's decision time frames.The applicable Group must approve the Services in advance): Medical Group designee will make the authorization • Durable medical equipment decision within the time frame appropriate for your condition,but no later than five business days after • Ostomy and urological supplies receiving all of the information(including additional • Services not available from Plan Providers examination and test results)reasonably necessary to make the decision,except that decisions about urgent • Transplants Services will be made no later than 72 hours after receipt of the information reasonably necessary to make the Utilization Management("UM")is a process that decision.If the Medical Group needs more time to make determines whether a Service recommended by your the decision because it doesn't have information treating provider is Medically Necessary for you.Prior reasonably necessary to make the decision,or because it authorization is a UM process that determines whether has requested consultation by a particular specialist,you the requested services are Medically Necessary before and your treating physician will be informed about the care is provided.If it is Medically Necessary,then you additional information,testing,or specialist that is will receive authorization to obtain that care in a Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 17 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. needed,and the date that the Medical Group expects to Second Opinions make a decision. If you want a second opinion,you can ask Member Your treating physician will be informed of the decision Services to help you arrange one with a Plan Physician within 24 hours after the decision is made.If the Services who is an appropriately qualified medical professional are authorized,your physician will be informed of the for your condition. If there isn't a Plan Physician who is scope of the authorized Services.If the Medical Group an appropriately qualified medical professional for your does not authorize all of the Services,Health Plan will condition,Member Services will help you arrange a send you a written decision and explanation within two consultation with a Non—Plan Physician for a second business days after the decision is made.Any written opinion.For purposes of this"Second Opinions" criteria that the Medical Group uses to make the decision provision,an"appropriately qualified medical to authorize,modify,delay,or deny the request for professional"is a physician who is acting within their authorization will be made available to you upon request. scope of practice and who possesses a clinical background,including training and expertise,related to If the Medical Group does not authorize all of the the illness or condition associated with the request for a Services requested and you want to appeal the decision, second medical opinion. you can file a grievance as described in the"Coverage Decisions,Appeals,and Complaints"section. Here are some examples of when a second opinion may be provided or authorized: For these referral Services,you pay the Cost Share • Your Plan Physician has recommended a procedure required for Services provided by a Plan Provider as and you are unsure about whether the procedure is described in this EOC. reasonable or necessary • You question a diagnosis or plan of care for a Travel and Lodging for Certain Services condition that threatens substantial impairment or loss of life,limb,or bodily functions The following are examples of when we will arrange or • The clinical indications are not clear or are complex provide reimbursement for certain travel and lodging and confusing expenses in accord with our Travel and Lodging • A diagnosis is in doubt due to conflicting test results Program Description: • The Plan Physician is unable to diagnose the • If Medical Group refers you to a provider that is more condition than 50 miles from where you live for certain • The treatment plan in progress is not improving your specialty Services such as bariatric surgery,complex medical condition within an appropriate period of thoracic surgery,transplant nephrectomy,or inpatient time,given the diagnosis and plan of care chemotherapy for leukemia and lymphoma • If Medical Group refers you to a provider that is • You have concerns about the diagnosis or plan of care outside our Service Area for certain specialty Services An authorization or denial of your request for a second such as a transplant or transgender surgery opinion will be provided in an expeditious manner,as • If you are outside of California and you need an appropriate for your condition.If your request for a abortion on an emergency or urgent basis,and the second opinion is denied,you will be notified in writing abortion can't be obtained in a timely manner due to a of the reasons for the denial and of your right to file a near total or total ban on health care providers' ability grievance as described in the"Coverage Decisions, to provide such Services Appeals,and Complaints"section. For the complete list of specialty Services for which we For these referral Services,you pay the Cost Share will arrange or provide reimbursement for travel and required for Services provided by a Plan Provider as lodging expenses,the amount of reimbursement, described in this EOC. limitations and exclusions,and how to request reimbursement,refer to the Travel and Lodging Program Description.The Travel and Lodging Program Contracts with Plan Providers Description is available online at kn.org/specialty- How Plan Providers are paid care/travel-reimbursements or by calling Member Services. Health Plan and Plan Providers are independent contractors.Plan Providers are paid in a number of ways, such as salary,capitation,per diem rates,case rates,fee Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 18 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. for service,and incentive payments. To learn more about More information.For more information about this how Plan Physicians are paid to provide or arrange provision,or to request the Services,please call Member medical and hospital Services for Members,please visit Services. our website at kp.org or call Member Services. Financial liability Receiving Care Outside of Your Home Our contracts with Plan Providers provide that you are Region Service Area not liable for any amounts we owe.However,you may have to pay the full price of noncovered Services you For information about your coverage when you are away from home,visit our website at kp.orE/travel.You can obtain from Plan Providers or Non—Plan Providers. also call the Away from Home Travel Line at When you are referred to a Plan Provider for covered 1-951-268-3900,24 hours a day,seven days a week Services,you pay the Cost Share required for Services (except closed holidays). from that provider as described in this EOC. Receiving care in another Kaiser Permanente Termination of a Plan Provider's contract and service area completion of Services If you are visiting in another Kaiser Permanente service If our contract with any Plan Provider terminates while area,you may receive certain covered Services from you are under the care of that provider,we will retain designated providers in that other Kaiser Permanente financial responsibility for the covered Services you service area,subject to exclusions,limitations,prior receive from that provider until we make arrangements authorization or approval requirements,and reductions. for the Services to be provided by another Plan Provider For more information about receiving covered Services and notify you of the arrangements. in another Kaiser Permanente service area,including provider and facility locations,please visit kp.orz/travel Completion of Services.If you are undergoing or call our Away from Home Travel Line at 1-951-268- treatment for specific conditions from a Plan Physician 3900,24 hours a day,seven days a week(except closed (or certain other providers)when the contract with him holidays). or her ends(for reasons other than medical disciplinary Receiving care outside of any Kaiser cause,criminal activity,or the provider's voluntary Permanente service area termination),you may be eligible to continue receiving covered care from the terminated provider for your If you are traveling outside of any Kaiser Permanente condition.The conditions that are subject to this service area,we cover Services as described in the continuation of care provision are: "Emergency Services and Urgent Care"section about Emergency Services,Post-Stabilization Care,and Out- • Certain conditions that are either acute,or serious and of-Area Urgent Care and the"Benefits and Your Cost chronic.We may cover these Services for up to 90 Share"section about out-of-area dialysis care. days,or longer,if necessary for a safe transfer of care to a Plan Physician or other contracting provider as determined by the Medical Group Your ID Card • A high-risk pregnancy or a pregnancy in its second or Each Member's Kaiser Permanente ID card has a third trimester.We may cover these Services through medical record number on it,which you will need when postpartum care related to the delivery,or longer you call for advice,make an appointment,or go to a if Medically Necessary for a safe transfer of care to a provider for covered care.When you get care,please Plan Physician as determined by the Medical Group bring your Kaiser Permanente ID card and a photo ID. Your medical record number is used to identify your The Services must be otherwise covered under this EOC. medical records and membership information.Your Also,the terminated provider must agree in writing to medical record number should never change.Please call our contractual terms and conditions and comply with Member Services if we ever inadvertently issue you them for Services to be covered by us. more than one medical record number or if you need to replace your Kaiser Permanente ID card. For the Services of a terminated provider,you pay the Cost Share required for Services provided by a Plan Your ID card is for identification only.To receive Provider as described in this EOC. covered Services,you must be a current Member. Anyone who is not a Member will be billed as a non- Member for any Services they receive.If you let Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 19 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. someone else use your ID card,we may keep your ID Plan Facilities card and terminate your membership as described under "Termination for Cause"in the"Termination of Plan Medical Offices and Plan Hospitals are listed in the Membership"section. Provider Directory for your Home Region.The directory Your Medicare card describes the types of covered Services that are available from each Plan Facility,because some facilities provide Do NOT use your red,white,and blue Medicare card for only specific types of covered Services.This directory is covered medical Services while you are a Member of this available on our website at kp.org/facilities.To obtain a plan.If you use your Medicare card instead of your printed copy,call Member Services.The directory is Senior Advantage membership card,you may have to updated periodically.The availability of Plan Facilities pay the full cost of medical services yourself.Keep your may change.If you have questions,please call Member Medicare card in a safe place.You may be asked to show Services. it if you need hospice services or participate in routine research studies. At most of our Plan Facilities,you can usually receive all of the covered Services you need,including specialty Getting Assistance care,pharmacy,and lab work.You are not restricted to a particular Plan Facility,and we encourage you to use the We want you to be satisfied with the health care you facility that will be most convenient for you: receive from Kaiser Permanente.If you have any . All Plan Hospitals provide inpatient Services and are questions or concerns,please discuss them with your open 24 hours a day,seven days a week personal Plan Physician or with other Plan Providers • Emergency Services are available from Plan Hospital who are treating you.They are committed to your satisfaction and want to help you with your questions. Emergency Departments(for Emergency Department locations,refer to our Provider Directory or call Member Services Member Services) Member Services representatives can answer any • Same-day Urgent Care appointments are available at questions you have about your benefits,available many locations(for Urgent Care locations,refer to Services,and the facilities where you can receive care. our Provider Directory or call Member Services) For example,they can explain the following: . Many Plan Medical Offices have evening and • Your Health Plan benefits weekend appointments • How to make your first medical appointment • Many Plan Facilities have a Member Services office (for locations,refer to our Provider Directory or call • What to do if you move Member Services) • How to replace your Kaiser Permanente ID card . Plan Pharmacies are located at most Plan Medical Offices(refer to Kaiser Permanente Pharmacy Many Plan Facilities have an office staffed with Directory for pharmacy locations) representatives who can provide assistance if you need help obtaining Services.At different locations,these offices may be called Member Services,Patient Provider Directory Assistance,or Customer Service.In addition,Member Services representatives are available to assist you seven The Provider Directory lists our Plan Providers.It is days a week from 8 a.m.to 8 p.m.toll free at 1-800-443- subject to change and periodically updated.If you don't 0815 or 711 (TTY for the deaf,hard of hearing,or have our Provider Directory,you can get a copy by speech impaired).For your convenience,you can also calling Member Services or by visiting our website at contact us through our website at kp.org. kp.org/directory. Cost Share estimates For information about estimates,see"Getting an Pharmacy Directory estimate of your Cost Share"under"Your Cost Share"in The Kaiser Permanente Pharmacy Directory lists the the"Benefits and Your Cost Share"section. locations of Plan Pharmacies,which are also called "network pharmacies."The pharmacy directory provides additional information about obtaining prescription drugs.It is subject to change and periodically updated. If you don't have the Kaiser Permanente Pharmacy Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 20 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Directory,you can get a copy by calling Member Your Cost Share Services or by visiting our website at kp.org/directory. Your Cost Share for covered Emergency Services and Post-Stabilization Care is described in the"Benefits and Your Cost Share"section.Your Cost Share is the same Emergency Services and Urgent whether you receive the Services from a Plan Provider or Care a Non—Plan Provider.For example: • If you receive Emergency Services in the Emergency Department of a Non—Plan Hospital,you pay the Cost Emergency Services Share for an Emergency Department visit as described under"Outpatient Care" If you have an Emergency Medical Condition,call 911 . If we gave prior authorization for inpatient Post- (where available)or go to the nearest Emergency Stabilization Care in a Non—Plan Hospital,you pay Department.You do not need prior authorization for the Cost Share for hospital inpatient care as described Emergency Services.When you have an Emergency under"Hospital Inpatient Care" Medical Condition,we cover Emergency Services you receive from Plan Providers or Non—Plan Providers anywhere in the world. Urgent Care Emergency Services are available from Plan Hospital Inside your Home Region Service Area Emergency Departments 24 hours a day,seven days a An Urgent Care need is one that requires prompt medical week. attention but is not an Emergency Medical Condition. If you think you may need Urgent Care,call the Post-Stabilization Care appropriate appointment or advice phone number at a Post-Stabilization Care is Medically Necessary Services Plan Facility.For appointment and advice phone related to your Emergency Medical Condition that you numbers,refer to our Provider Directory or call Member receive in a hospital(including the Emergency Services. Department)after your treating physician determines that your condition is Stabilized. In the event of unusual circumstances that delay or render impractical the provision of Services under this To request prior authorization,the Non—Plan Provider EOC(such as a major disaster,epidemic,war,riot,and must call 1-800-225-8883 or the notification phone civil insurrection),we cover Urgent Care inside our number on your Kaiser Permanente ID card before you Service Area from a Non—Plan Provider. receive the care.We will discuss your condition with the Non—Plan Provider.If we determine that you require Out-of-Area Urgent Care Post-Stabilization Care and that this care is part of your If you need Urgent Care due to an unforeseen illness or covered benefits,we will authorize your care from the unforeseen injury,we cover Medically Necessary Non—Plan Provider or arrange to have a Plan Provider(or Services to prevent serious deterioration of your health other designated provider)provide the care with the from a Non—Plan Provider if all of the following are true: treating physician's concurrence.If we decide to have a . You receive the Services from Non—Plan Providers Plan Hospital,Plan Skilled Nursing Facility,or while you are temporarily outside our Service Area designated Non—Plan Provider provide your care,we may authorize special transportation services that are • A reasonable person would have believed that your medically required to get you to the provider.This may health would seriously deteriorate if you delayed include transportation that is otherwise not covered. treatment until you returned to our Service Area Be sure to ask the Non—Plan Provider to tell you what You do not need prior authorization for Out-of-Area care(including any transportation)we have authorized Urgent Care.We cover Out-of-Area Urgent Care you because we will not cover unauthorized Post- receive from Non—Plan Providers if the Services would Stabilization Care or related transportation provided by have been covered under this EOC if you had received Non—Plan Providers.If you receive care from a Non— them from Plan Providers. Plan Provider that we have not authorized,you may have to pay the full cost of that care if you are notified by the We do not cover follow-up care from Non—Plan Non—Plan Provider or us about your potential liability. Providers after you no longer need Urgent Care.To obtain follow-up care from a Plan Provider,call the appointment or advice phone number at a Plan Facility. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 21 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. For phone numbers,refer to our Provider Directory or Benefits and Your Cost Share call Member Services. This section describes the Services that are covered Your Cost Share under this EOC. Your Cost Share for covered Urgent Care is the Cost Services are covered under this EOC as specifically Share required for Services provided by Plan Providers described in this EOC. Services that are not specifically as described in this EOC.For example: described in this EOC are not covered,except as required • If you receive an Urgent Care evaluation as part of by federal law. Services are subject to exclusions and covered Out-of-Area Urgent Care from a Non—Plan limitations described in the"Exclusions,Limitations, Provider,you pay the Cost Share for Urgent Care Coordination of Benefits,and Reductions"section. consultations,evaluations,and treatment as described Except as otherwise described in this EOC,all of the under"Outpatient Care" following conditions must be satisfied: • If the Out-of-Area Urgent Care you receive includes • You are a Member on the date that you receive the an X-ray,you pay the Cost Share for an X-ray as Services described under"Outpatient Imaging,Laboratory,and • The Services are Medically Necessary Other Diagnostic and Treatment Services"in addition to the Cost Share for the Urgent Care evaluation • The Services are one of the following: ♦ Preventive Services Note: If you receive Urgent Care in an Emergency ♦ health care items and services for diagnosis, Department,you pay the Cost Share for an Emergency assessment,or treatment Department visit as described under"Outpatient Care." ♦ health education covered under"Health Education"in this`Benefits and Your Cost Share" Payment and Reimbursement section ♦ other health care items and services If you receive Emergency Services,Post-Stabilization ♦ other services to treat Serious Emotional Care,or Urgent Care from a Non—Plan Provider as Disturbance of a Child Under Age 18 or Severe described in this"Emergency Services and Urgent Care" Mental Illness section,or emergency ambulance Services described under"Ambulance Services"in the"Benefits and Your • The Services are provided,prescribed,authorized,or Cost Share"section,ask the Non—Plan Provider to directed by a Plan Physician except for: submit a claim to us within 60 days or as soon as ♦ covered Services received outside of your Home possible,but no later than 15 months after receiving the Region Service Area,as described under care(or up to 27 months according to Medicare rules,in "Receiving Care Outside of Your Home Region some cases).If the provider refuses to bill us,send us the Service Area"in the"How to Obtain Services" unpaid bill with a claim form.Also,if you receive section Services from a Plan Provider that are prescribed by a ♦ drugs prescribed by dentists,as described under Non—Plan Provider as part of covered Emergency "Outpatient Prescription Drugs,Supplies,and Services,Post-Stabilization Care,and Urgent Care(for Supplements"in this"Benefits and Your Cost example,drugs),you may be required to pay for the Share"section Services and file a claim.To request payment or ♦ emergency ambulance Services,as described reimbursement,you must file a claim as described in the under"Ambulance Services"in this"Benefits and "Requests for Payment"section. Your Cost Share"section We will reduce any payment we make to you or the ♦ Emergency Services,Post-Stabilization Care,and Non—Plan Provider by the applicable Cost Share.Also, Out-of-Area Urgent Care,as described in the in accord with applicable law,we will reduce our "Emergency Services and Urgent Care"section payment by any amounts paid or payable(or that in the ♦ eyeglasses and contact lenses prescribed by Non— absence of this plan would have been payable)for the Plan Providers,as described under"Vision Services under any insurance policy,or any other Services"in this`Benefits and Your Cost Share" contract or coverage,or any government program except section Medicaid. ♦ out-of-area dialysis care,as described under "Dialysis Care"in this"Benefits and Your Cost Share"section Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 22 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. ♦ routine Services associated with Medicare- Services that are subject to the Plan Deductible,your approved clinical trials,as described under Cost Share for those Services will be Charges until you "Services Associated with Clinical Trials"in this reach the Plan Deductible. "Benefits and Your Cost Share"section • You receive the Services from Plan Providers inside General rules, examples, and exceptions our Service Area,except for: Your Cost Share for covered Services will be the Cost ♦ authorized referrals,as described under"Getting a Share in effect on the date you receive the Services, Referral"in the"How to Obtain Services"section except as follows: ♦ covered Services received outside of your Home • If you are receiving covered hospital inpatient Region Service Area,as described under Services on the effective date of this EOC,you pay "Receiving Care Outside of Your Home Region the Cost Share in effect on your admission date until Service Area"in the"How to Obtain Services" you are discharged if the Services were covered under section your prior Health Plan evidence of coverage and there ♦ emergency ambulance Services,as described has been no break in coverage.However,if the Services were not covered under your prior Health under"Ambulance Services"in this"Benefits and Plan evidence of coverage,or if there has been a Your Cost Share"section break in coverage,you pay the Cost Share in effect on ♦ Emergency Services,Post-Stabilization Care,and the date you receive the Services Out-of-Area Urgent Care,as described in the . For items ordered in advance,you pay the Cost Share Emergency Services and Urgent Care section in effect on the order date(although we will not cover ♦ out-of-area dialysis care,as described under the item unless you still have coverage for it on the "Dialysis Care"in this"Benefits and Your Cost date you receive it)and you may be required to pay Share"section the Cost Share when the item is ordered.For ♦ prescription drugs from Non—Plan Pharmacies,as outpatient prescription drugs,the order date is the described under"Outpatient Prescription Drugs, date that the pharmacy processes the order after Supplies,and Supplements"in this"Benefits and receiving all of the information they need to fill the Your Cost Share"section prescription ♦ routine Services associated with Medicare- approved clinical trials,as described under Payment toward your Cost Share(and when you may "Services Associated with Clinical Trials"in this be billed) "Benefits and Your Cost Share"section In most cases,your provider will ask you to make a • The Medical Group has given prior authorization for payment toward your Cost Share at the time you receive the Services,if required,as described under"Medical Services.If you receive more than one type of Services Group authorization procedure for certain referrals" (such as primary care treatment and laboratory tests),you in the"How to Obtain Services"section may be required to pay separate Cost Share for each of those Services.Keep in mind that your payment toward your Cost Share may cover only a portion of your total Please also refer to: Cost Share for the Services you receive,and you will be • The"Emergency Services and Urgent Care"section billed for any additional amounts that are due.The for information about how to obtain covered following are examples of when you may be asked to Emergency Services,Post-Stabilization Care,and pay(or you may be billed for)Cost Share amounts in Out-of-Area Urgent Care addition to the amount you pay at check-in: • Our Provider Directory for the types of covered • You receive non-preventive Services during a Services that are available from each Plan Facility, preventive visit.For example,you go in for a routine because some facilities provide only specific types of physical exam,and at check-in you pay your Cost covered Services Share for the preventive exam(your Cost Share may be"no charge").However,during your preventive exam your provider finds a problem with your health Your Cost Share and orders non-preventive Services to diagnose your Your Cost Share is the amount you are required to pay problem(such as laboratory tests).You may be asked for covered Services.The Cost Share for covered to pay(or you will be billed for)your Cost Share for Services is listed in this EOC.For example,your Cost these additional non-preventive diagnostic Services Share may be a Copayment or Coinsurance.If your • You receive diagnostic Services during a treatment coverage includes a Plan Deductible and you receive visit.For example,you go in for treatment of an Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 23 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. existing health condition,and at check-in you pay receive care.You are not responsible for any amounts your Cost Share for a treatment visit.However, beyond your Cost Share for the covered Services you during the visit your provider finds a new problem receive at Plan Facilities or at contracted facilities where with your health and performs or orders diagnostic we have authorized you to receive care.However,if the Services(such as laboratory tests).You may be asked provider does not agree to bill us,you may have to pay to pay(or you will be billed for)your Cost Share for for the Services and file a claim for reimbursement.For these additional diagnostic Services information on how to file a claim,please see the • You receive treatment Services during a diagnostic "Requests for Payment"section. visit.For example,you go in for a diagnostic exam, and at check-in you pay your Cost Share fora Primary Care Visits,Non-Physician Specialist Visits, diagnostic exam.However,during the diagnostic and Physician Specialist Visits.The Cost Share for a exam your provider confirms a problem with your Primary Care Visit applies to evaluations and treatment health and performs treatment Services(such as an provided by generalists in internal medicine,pediatrics, outpatient procedure).You may be asked to pay(or or family practice,and by specialists in you will be billed for)your Cost Share for these obstetrics/gynecology whom the Medical Group additional treatment Services designates as Primary Care Physicians. Some physician specialists provide primary care in addition to specialty • You receive Services from a second provider during care but are not designated as Primary Care Physicians. your visit.For example,you go in for a diagnostic If you receive Services from one of these specialists,the exam,and at check-in you pay your Cost Share for a Cost Share for a Physician Specialist Visit will apply to diagnostic exam.However,during the diagnostic all consultations,evaluations,and treatment provided by exam your provider requests a consultation with a the specialist except for routine preventive counseling specialist.You may be asked to pay(or you will be and exams listed under"Preventive Services"in this billed for)your Cost Share for the consultation with "Benefits and Your Cost Share"section.For example, the specialist if your personal Plan Physician is a specialist in internal medicine or obstetrics/gynecology who is not a Primary In some cases,your provider will not ask you to make a Care Physician,you will pay the Cost Share for a payment at the time you receive Services,and you will Physician Specialist Visit for all consultations, be billed for your Cost Share(for example,some evaluations,and treatment by the specialist except Laboratory Departments are not able to collect Cost routine preventive counseling and exams listed under Shares). "Preventive Services"in this`Benefits and Your Cost Share"section.The Non-Physician Specialist Visit Cost When we send you a bill,it will list Charges for the Share applies to consultations,evaluations,and treatment Services you received,payments and credits applied to provided by non-physician specialists(such as nurse your account,and any amounts you still owe.Your practitioners,physician assistants,optometrists, current bill may not always reflect your most recent podiatrists,and audiologists). Charges and payments.Any Charges and payments that are not on the current bill will appear on a future bill. Noncovered Services.If you receive Services that are Sometimes,you may see a payment but not the related not covered under this EOC,you may have to pay the Charges for Services. That could be because your full price of those Services.Payments you make for payment was recorded before the Charges for the noncovered Services do not apply to any deductible or Services were processed.If so,the Charges will appear out-of-pocket maximum. on a future bill.Also,you may receive more than one bill for a single outpatient visit or inpatient stay.For Getting an estimate of your Cost Share example,you may receive a bill for physician services If you have questions about the Cost Share for specific and a separate bill for hospital services.If you don't see Services that you expect to receive or that your provider all the Charges for Services on one bill,they will appear orders during a visit or procedure,please visit our on a future bill.If we determine that you overpaid and website at kp.ore/memberestimates to use our cost are due a refund,then we will send a refund to you estimate tool or call Member Services. within four weeks after we make that determination. If you have questions about a bill,please call the phone • If you have a Plan Deductible and would like an number on the bill. estimate for Services that are subject to the Plan Deductible,please call 1-800-390-3507(TTY users In some cases,a Non—Plan Provider may be involved in call 711)Monday through Friday,6 a.m.to 5 p.m. the provision of covered Services at a Plan Facility or a contracted facility where we have authorized you to Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 24 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • For all other Cost Share estimates,please call 1-800- Copayments or Coinsurance even if you have already 443-0815,8 a.m.to 8 p.m.,seven days a week(TTY reached the out-of-pocket maximum.In addition: users should call 711) • If your plan includes supplemental chiropractic or acupuncture Services,or fitness benefit,described in Cost Share estimates are based on your benefits and the an amendment to this EOC,those Services do not Services you expect to receive.They are a prediction of apply toward the maximum cost and not a guarantee of the final cost of Services. Your final cost may be higher or lower than the estimate • If your plan includes an Allowance for specific since not everything about your care can be known in Services(such as eyeglasses,contact lenses,or hearing aids),any amounts you pay that exceed the advance. Allowance do not apply toward the maximum Copayments and Coinsurance The Copayment or Coinsurance you must pay for each Outpatient Care covered Service,after you meet any applicable deductible,is described in this EOC. We cover the following outpatient care subject to the Cost Share indicated: Note: If Charges for Services are less than the Copayment described in this EOC,you will pay the Office visits lesser amount. . Primary Care Visits and Non-Physician Specialist Plan Out-of-Pocket Maximum Visits that are not described elsewhere in this EOC: a $15 Copayment per visit There is a limit to the total amount of Cost Share you Specialist Visits that are not described• Physician S must pay under this EOC in the calendar year for y p covered Services that you receive in the same calendar elsewhere in this EOC: a$15 Copayment per visit year.The Services that apply to the Plan Out-of-Pocket • Outpatient visits that are available as group Maximum are described under the"Payments that count appointments that are not described elsewhere in this toward the Plan Out-of-Pocket Maximum"section EOC: a$7 Copayment per visit below.The limit is: • House calls by a Plan Physician(or a Plan Provider • $1,000 per calendar year for any one Member who is a registered nurse)inside our Service Area when care can best be provided in your home as For Services subject to the Plan Out-of-Pocket determined by a Plan Physician: Maximum,you will not pay any more Cost Share during ♦ Primary Care Visits and Non-Physician Specialist the remainder of the calendar year,but every other Visits: a$15 Copayment per visit Member in your Family must continue to pay Cost Share ♦ Physician Specialist Visits: a$15 Copayment per during the remainder of the calendar year until either he visit or she reaches the$1,000 maximum for any one Member. • Routine physical exams that are medically appropriate preventive care in accord with generally Payments that count toward the Plan Out-of-Pocket accepted professional standards of practice: Maximum.Any amounts you pay for the following ac charge Services apply toward the out-of-pocket maximum: no • Family planning counseling,or internally implanted • Covered in-network Medicare Part A and Part B time-release contraceptives or intrauterine devices Services (IUDs)and office visits related to their administration • Medicare Part B drugs(all other drugs do not apply) and management: a$15 Copayment per visit • Residential treatment program Services covered in the • After confirmation of pregnancy,the normal series of "Substance Use Disorder Treatment"and"Mental regularly scheduled preventive prenatal care exams Health Services"sections and the first postpartum follow-up consultation and Copayments and Coinsurance you pay for Services that exam: a$15 Copayment per visit are not described above,do not apply to the out-of- • Voluntary termination of pregnancy and related pocket maximum.For these Services,you must pay Services: no charge • Physical,occupational,and speech therapy in accord with Medicare guidelines: a$15 Copayment per visit Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 25 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Group and individual physical therapy prescribed by a are admitted for observation but are not admitted as an Plan Provider to prevent falls: no charge inpatient. • Physical,occupational,and speech therapy provided Outpatient surgeries and procedures in an organized,multidisciplinary rehabilitation day- treatment program in accord with Medicare • Outpatient surgery and outpatient procedures when guidelines: a$15 Copayment per day provided in an outpatient or ambulatory surgery • Manual manipulation of the spine to correct center or in a hospital operating room,or if it is subluxation,in accord with Medicare guidelines,is provided in any setting and a licensed staff member covered when provided by a Plan Provider or a monitors your vital signs as you regain sensation after chiropractor when referred by a Plan Provider: a receiving drugs to reduce sensation or to minimize $15 Copayment per visit. (For the list of discomfort: a$50 Copayment per procedure participating ASH Plans providers,please refer to • Any other outpatient surgery that does not require a your Provider Directory) licensed staff member to monitor your vital signs as described above: a$15 Copayment per procedure Acupuncture Services • Any other outpatient procedures that do not require a • Acupuncture for chronic low back pain up to 12 visits licensed staff member to monitor your vital signs as in 90 days,in accord with Medicare guidelines: a described above: the Cost Share that would $15 Copayment per visit. Chronic low back pain is otherwise apply for the procedure in this"Benefits defined as follows: and Your Cost Share"section(for example,radiology ♦ lasting 12 weeks or longer procedures that do not require a licensed staff member to monitor your vital signs as described ♦ non-specific,in that it has no identifiable systemic above are covered under"Outpatient Imaging, cause(i.e.not associated with metastatic, Laboratory,and Other Diagnostic and Treatment inflammatory,infectious,disease,etc) Services") ♦ not associated with surgery or pregnancy . Pre-and post-operative visits: • An additional eight sessions will be covered for those ♦ Primary Care Visits and Non-Physician Specialist patients demonstrating an improvement.No more Visits: a$15 Copayment per visit than 20 acupuncture treatments may be administered annually.Treatment must be discontinued if the ♦ Physician Specialist Visits: a$15 Copayment per patient is not improving or is regressing visit • Acupuncture not covered by Medicare(typically Administered drugs and products provided only for the treatment of nausea or as part of Administered drugs and products are medications and a comprehensive pain management program for the products that require administration or observation by treatment of chronic pain): a$15 Copayment per medical personnel.We cover these items when visit prescribed by a Plan Provider,in accord with our drug Emergency Services and Urgent Care formulary guidelines,and they are administered to you in a Plan Facility or during home visits. • Urgent Care consultations,evaluations,and treatment: a$15 Copayment per visit We cover the following Services and their administration • Emergency Department visits: a$50 Copayment per in a Plan Facility at the Cost Share indicated: visit • Whole blood,red blood cells,plasma,and platelets: no charge If you are admitted from the Emergency Department. • Allergy antigens(including administration): a If you are admitted to the hospital as an inpatient for $3 Copayment per visit covered Services(either within 24 hours for the same condition or after an observation stay),then the Services • Cancer chemotherapy drugs and adjuncts: no charge you received in the Emergency Department and • Drugs and products that are administered via observation stay,if applicable,will be considered part of intravenous therapy or injection that are not for your inpatient hospital stay.For the Cost Share for cancer chemotherapy,including blood factor products inpatient care,refer to"Hospital Inpatient Services"in and biological products("biologics")derived from this"Benefits and Your Cost Share"section.However, tissue,cells,or blood: no charge the Emergency Department Cost Share does apply if you . Tuberculosis skin tests: no charge Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 26 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • All other administered drugs and products: no charge Hospital Inpatient Services We cover drugs and products administered to you during We cover the following inpatient Services in a Plan a home visit at no charge. Hospital,when the Services are generally and customarily provided by acute care general hospitals Certain administered drugs are Preventive Services. inside our Service Area: Refer to"Preventive Services"for information on • Room and board,including a private room immunizations. if Medically Necessary Note:Vaccines covered by Medicare Part D are not • Specialized care and critical care units covered under this"Outpatient Care"section(instead, • General and special nursing care refer to"Outpatient Prescription Drugs, Supplies,and • Operating and recovery rooms Supplements"in this"Benefits and Your Cost Share" • Services of Plan Physicians,including consultation section). and treatment by specialists For the following Services, refer to these • Anesthesia sections • Drugs prescribed in accord with our drug formulary • Bariatric Surgery guidelines(for discharge drugs prescribed when you • Dental Services are released from the hospital,refer to"Outpatient Prescription Drugs,Supplies,and Supplements"in • Dialysis Care this"Benefits and Your Cost Share"section) • Durable Medical Equipment("DME")for Home Use • Radioactive materials used for therapeutic purposes • Fertility Services • Durable medical equipment and medical supplies • Health Education • Imaging,laboratory,and other diagnostic and • Hearing Services treatment Services,including MRI,CT,and PET scans • Home-Delivered Meals • Whole blood,red blood cells,plasma,platelets,and • Home Health Care their administration • Hospice Care • Obstetrical care and delivery(including cesarean • Mental Health Services section).Note:If you are discharged within 48 hours • Ostomy,Urological,and Specialized Wound Care after delivery(or within 96 hours if delivery is by Supplies cesarean section),your Plan Physician may order a follow-up visit for you and your newborn to take • Outpatient Imaging,Laboratory,and Other place within 48 hours after discharge(for visits after Diagnostic and Treatment Services you are released from the hospital,please refer to • Outpatient Prescription Drugs, Supplies,and "Outpatient Care"in this"Benefits and Your Cost Supplements Share"section) • Preventive Services • Physical,occupational,and speech therapy(including treatment in an organized,multidisciplinary • Prosthetic and Orthotic Devices rehabilitation program)in accord with Medicare • Reconstructive Surgery guidelines • Services Associated with Clinical Trials • Respiratory therapy • Substance Use Disorder Treatment • Medical social services and discharge planning • Transplant Services Your Cost Share.We cover hospital inpatient Services • Transportation Services at no charge. • Vision Services For the following Services, refer to these sections • Bariatric surgical procedures(refer to"Bariatric Surgery") Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 27 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Dental procedures(refer to"Dental Services") Nonemergency • Dialysis care(refer to"Dialysis Care") Inside our Service Area,we cover nonemergency ambulance Services in accord with Medicare guidelines • Fertility Services related to diagnosis and treatment of if a Plan Physician determines that your condition infertility,artificial insemination,or assisted requires the use of Services that only a licensed reproductive technology(refer to"Fertility Services") ambulance can provide and that the use of other means • Hospice care(refer to"Hospice Care") of transportation would endanger your health. These • Mental health Services(refer to"Mental Health Services are covered only when the vehicle transports Services") you to and from qualifying locations as defined by Medicare guidelines. • Prosthetics and orthotics(refer to"Prosthetic and Orthotic Devices") Your Cost Share • Reconstructive surgery Services(refer to You pay the following for covered ambulance Services: "Reconstructive Surgery") • Emergency ambulance Services: a$100 Copayment • Religious Nonmedical Health Care Institution per trip Services(refer to"Religious Nonmedical Health Care • Nonemergency Services: a$100 Copayment per Institution") trip • Services in connection with a clinical trial(refer to "Services in Connection with a Clinical Trial") Ambulance Services exclusions • Skilled inpatient Services in a Plan Skilled Nursing • Transportation by car,taxi,bus,gurney van, Facility(refer to"Skilled Nursing Facility Care") wheelchair van,and any other type of transportation • Substance use disorder treatment Services(refer to (other than a licensed ambulance),even if it is the "Substance Use Disorder Treatment") only way to travel to a Plan Provider,except as otherwise covered under"Transportation Services"in • Transplant Services(refer to"Transplant Services") this section Ambulance Services Bariatric Surgery Emergency We cover hospital inpatient Services related to bariatric We cover Services of a licensed ambulance anywhere in surgical procedures(including room and board,imaging, the world without prior authorization(including laboratory,other diagnostic and treatment Services,and transportation through the 911 emergency response Plan Physician Services)when performed to treat obesity system where available)in the following situations: by modification of the gastrointestinal tract to reduce • You reasonably believed that the medical condition nutrient intake and absorption,if all of the following was an Emergency Medical Condition which required requirements are met: ambulance Services • You complete the Medical Group—approved pre- • Your treating physician determines that you must be surgical educational preparatory program regarding transported to another facility because your lifestyle changes necessary for long term bariatric Emergency Medical Condition is not Stabilized and surgery success the care you need is not available at the treating . A Plan Physician who is a specialist in bariatric care facility determines that the surgery is Medically Necessary If you receive emergency ambulance Services that are Your Cost Share.For covered Services related to not ordered by a Plan Provider,you are not responsible bariatric surgical procedures that you receive,you will for any amounts beyond your Cost Share for covered pay the Cost Share you would pay if the Services were emergency ambulance Services.However,if the provider not related to a bariatric surgical procedure.For does not agree to bill us,you may have to pay for the example,see"Hospital Inpatient Services"in this Services and file a claim for reimbursement.For "Benefits and Your Cost Share"section for the Cost information on how to file a claim,please see the Share that applies for hospital inpatient Services. "Requests for Payment"section. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 28 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. For the following Services, refer to these Your Cost Share sections You pay the following for dental Services covered under • Outpatient prescription drugs(refer to"Outpatient this"Dental Services"section: Prescription Drugs,Supplies,and Supplements") • Non-Physician Specialist Visits with dentists for • Outpatient administered drugs(refer to"Outpatient Services covered under this"Dental Services" Care") section: a$15 Copayment per visit • Physician Specialist Visits for Services covered under this"Dental Services"section: a$15 Copayment per Dental Services visit Dental Services for radiation treatment • Outpatient surgery and outpatient procedures when We cover services in accord with Medicare guidelines, provided in an outpatient or ambulatory surgery including dental evaluation,X-rays,fluoride treatment, center or in a hospital operating room,or if it is and extractions necessary to prepare your jaw for provided in any setting and a licensed staff member radiation therapy of cancer in your head or neck if a Plan monitors your vital signs as you regain sensation after Physician provides the Services or if the Medical Group receiving drugs to reduce sensation or to minimize authorizes a referral to a dentist for those Services(as discomfort: a$50 Copayment per procedure described in"Medical Group authorization procedure for • Any other outpatient surgery that does not require a certain referrals"under"Getting a Referral"in the"How licensed staff member to monitor your vital signs as to Obtain Services"section). described above: a$15 Copayment per procedure Dental Services for transplants • Any other outpatient procedures that do not require a We cover dental services that are Medically Necessary to licensed staff member to monitor your vital signs as described above: the Cost Share that would free the mouth from infection in order to prepare for a otherwise apply for the procedure in this"Benefits transplant covered under"Transplant Services"in this and Your Cost Share"section(for example,radiology "Benefits" section,if a Plan Physician provides the procedures that do not require a licensed staff Services or if the Medical Group authorizes a referral to member to monitor your vital signs as described a dentist for those Services(as described in"Medical above are covered under"Outpatient Imaging, Group authorization procedure for certain referrals" Laboratory,and Other Diagnostic and Treatment under"Getting a Referral"in the"How to Obtain Services") Services" section). • Hospital inpatient Services(including room and Dental anesthesia board,drugs,imaging,laboratory,other diagnostic For dental procedures at a Plan Facility,we provide and treatment Services,and Plan Physician Services): general anesthesia and the facility's Services associated no charge with the anesthesia if all of the following are true: For the following Services, refer to these • You are under age 7,or you are developmentally sections disabled,or your health is compromised • Office visits not described in this"Dental Services" • Your clinical status or underlying medical condition section(refer to"Outpatient Care") requires that the dental procedure be provided in a hospital or outpatient surgery center • Outpatient imaging,laboratory,and other diagnostic and treatment Services(refer to"Outpatient Imaging, • The dental procedure would not ordinarily require Laboratory,and Other Diagnostic and Treatment general anesthesia Services") We do not cover any other Services related to the dental • Outpatient prescription drugs(refer to"Outpatient procedure,such as the dentist's Services,unless the Prescription Drugs,Supplies,and Supplements") Service is covered in accord with Medicare guidelines or for transplant services. Dialysis Care We cover acute and chronic dialysis Services if all of the following requirements are met: • You satisfy all medical criteria developed by the Medical Group Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 29 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • The facility is certified by Medicare • Outpatient laboratory(refer to"Outpatient Imaging, • A Plan Physician provides a written referral for your Laboratory,and Other Diagnostic and Treatment dialysis treatment except for out-of-area dialysis care Services") • Outpatient prescription drugs(refer to"Outpatient We also cover hemodialysis and peritoneal home dialysis Prescription Drugs,Supplies,and Supplements") (including equipment,training,and medical supplies). • Outpatient administered drugs(refer to"Outpatient Coverage is limited to the standard item of equipment or Care") supplies that adequately meets your medical needs.We . Telehealth Visits(refer to"Telehealth Visits") decide whether to rent or purchase the equipment and supplies,and we select the vendor.You must return the equipment and any unused supplies to us or pay us the Dialysis care exclusions fair market price of the equipment and any unused • Comfort,convenience,or luxury equipment,supplies supply when we are no longer covering them. and features Out-of-area dialysis care • Nonmedical items,such as generators or accessories We cover dialysis(kidney)Services that you get at a to make home dialysis equipment portable for travel Medicare-certified dialysis facility when you are temporarily outside our Service Area.If possible,before Durable Medical Equipment ("DME") for you leave the Service Area,please let us know where Home Use you are going so we can help arrange for you to have maintenance dialysis while outside our Service Area. DME coverage rules DME for home use is an item that meets the following The procedure for obtaining reimbursement for out-of- criteria: area dialysis care is described in the"Requests for • The item is intended for repeated use Payment"section. • The item is primarily and customarily used to serve a Your Cost Share.You pay the following for these medical purpose covered Services related to dialysis: . The item is generally useful only to an individual • Equipment and supplies for home hemodialysis and with an illness or injury home peritoneal dialysis: no charge • The item is appropriate for use in the home(or • One routine outpatient visit per month with the another location used as your home as defined by multidisciplinary nephrology team for a consultation, Medicare) evaluation,or treatment: no charge • The item is expected to last at least 3 years • Hemodialysis and peritoneal dialysis treatment: no charge For a DME item to be covered,all of the following • Hospital inpatient Services(including room and requirements must be met: board,drugs,imaging,laboratory,and other • Your EOC includes coverage for the requested DME diagnostic and treatment Services,and Plan Physician item Services): no charge • A Plan Physician has prescribed the DME item for For the following Services, refer to these your medical condition sections • The item has been approved for you through the Plan's prior authorization process,as described in • Durable medical equipment for home use(refer to "Medical Group authorization procedure for certain "Durable Medical Equipment("DME")for Home referrals"under"Getting a Referral"in the"How to „) se Obtain Services"section • Hospital inpatient Services(refer to"Hospital • The Services are provided inside our Service Area Inpatient Services") • Office visits not described in this"Dialysis Care" Coverage is limited to the standard item of equipment section(refer to"Outpatient Care") that adequately meets your medical needs.We decide • Kidney disease education(refer to"Health whether to rent or purchase the equipment,and we select Education") the vendor. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 30 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. DME for diabetes ("DME")for Home Use"section are met,we cover the We cover the following diabetes testing supplies and following other DME items(including repair or equipment and insulin-administration devices if all of the replacement of covered equipment): requirements described under"DME coverage rules"in • Bed accessories for a hospital bed when bed this"Durable Medical Equipment("DME")for Home extension is required Use"section are met: • Heel or elbow protectors to prevent or minimize • Glucose monitors for diabetes testing and their advanced pressure relief equipment use supplies(such as glucose monitor test strips,lancets, • Iontophoresis device to treat hyperhidrosis when and lancet devices) antiperspirants are contraindicated and the • Insulin pumps and supplies to operate the pump hyperhidrosis has created medical complications(for example,skin infection)or preventing daily living Your Cost Share.You pay the following for covered activities DME for diabetes(including repair or replacement of • Nontherapeutic continuous glucose monitoring covered equipment): devices and related supplies • Glucose monitors for diabetes testing and their • Peak flow meters supplies(such as glucose monitor test strips,lancets, and lancet devices): no charge • Resuscitation bag if tracheostomy patient has • Insulin pumps and supplies to operate the pump: significant secretion management problems,needing 20 percent Coinsurance lavage and suction technique aided by deep breathing via resuscitation bag Base DME Items We cover Base DME Items(including repair or Your Cost Share.You pay the following for other replacement of covered equipment)if all of the covered DME items: 20 percent Coinsurance,except requirements described under"DME coverage rules"in peak flow meters are covered at: no charge. this"Durable Medical Equipment("DME")for Home Outside our Service Area Use"section are met."Base DME Items"means the following items: We do not cover most DME for home use outside our Service Area.However,if you live outside our Service • Glucose monitors for diabetes blood testing and their Area,we cover the following DME(subject to the Cost supplies(such as blood glucose monitor test strips, Share and all other coverage requirements that apply to lancets,and lancet devices) DME for home use inside our Service Area)when the • Bone stimulator item is dispensed at a Plan Facility: • Canes(standard curved handle or quad)and • Blood glucose monitors for diabetes blood testing and replacement supplies their supplies(such as blood glucose monitor test Cervical traction(over door) strips,lancets,and lancet devices)from a Plan • Pharmacy • Crutches(standard or forearm)and replacement . Canes(standard curved handle) supplies • Dry pressure pad for a mattress • Crutches(standard) • Nebulizers and their supplies for the treatment of • Infusion pumps(such as insulin pumps)and supplies pediatric asthma to operate the pump • 1V pole • Peak flow meters from a Plan Pharmacy • Nebulizer and supplies For the following Services, refer to these • Phototherapy blankets for treatment of jaundice in sections newborns • Dialysis equipment and supplies required for home hemodialysis and home peritoneal dialysis(refer to Your Cost Share.You pay the following for covered "Dialysis Care") Base DME Items: 20 percent Coinsurance. • Diabetes urine testing supplies and insulin- Other covered DME items administration devices other than insulin pumps(refer to"Outpatient Prescription Drugs, Supplies,and If all of the requirements described under"DME Supplements") coverage rules"in this"Durable Medical Equipment Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 31 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Durable medical equipment related to the terminal You pay the following for covered infertility Services: illness for Members who are receiving covered • Office visits: a$15 Copayment per visit hospice care(refer to"Hospice Care") • Most outpatient surgery and outpatient procedures • Insulin and any other drugs administered with an when provided in an outpatient or ambulatory surgery infusion pump(refer to"Outpatient Prescription center or in a hospital operating room,or provided in Drugs, Supplies,and Supplements") any setting where a licensed staff member monitors your vital signs as you regain sensation after DME for home use exclusions receiving drugs to reduce sensation or to minimize • Comfort,convenience,or luxury equipment or discomfort: a$15 Copayment per procedure features • Any other outpatient surgery that does not require a • Dental appliances licensed staff member to monitor your vital signs as • Items not intended for maintaining normal activities described above: a$15 Copayment per procedure of daily living,such as exercise equipment(including • Outpatient imaging: no charge devices intended to provide additional support for • Outpatient laboratory: no charge recreational or sports activities) • Outpatient administered drugs: no charge • Hygiene equipment • Hospital inpatient Services(including room and • Nonmedical items,such as sauna baths or elevators board,imaging,laboratory,and other diagnostic and • Modifications to your home or car,unless covered in treatment Services,and Plan Physician Services): accord with Medicare guidelines no charge • Devices for testing blood or other body substances (except diabetes glucose monitors and their supplies) Note:Administered drugs and products are medications and products that require administration or observation • Electronic monitors of the heart or lungs except infant by medical personnel.We cover these items when they apnea monitors are prescribed by a Plan Provider,in accord with our • Repair or replacement of equipment due to misuse drug formulary guidelines,and they are administered to you in a Plan Facility. Fertility Services For the following Services, refer to these sections "Fertility Services"means treatments and procedures to help you become pregnant. • Outpatient drugs,supplies,and supplements(refer to "Outpatient Prescription Drugs,Supplies,and Before starting or continuing a course of fertility Supplements") Services,you may be required to pay initial and • Diagnostic Services provided by Plan Providers who subsequent deposits toward your Cost Share for some or are not physicians,such as EKGs and EEGs(refer to all of the entire course of Services,along with any past- "Outpatient Imaging,Laboratory,and Other due fertility-related Cost Share.Any unused portion of Diagnostic and Treatment Services") your deposit will be returned to you.When a deposit is not required,you must pay the Cost Share for the Fertility Services exclusions procedure,along with any past-due fertility-related Cost • Services to reverse voluntary,surgically induced Share,before you can schedule a fertility procedure. infertility Diagnosis and treatment of infertility • Semen and eggs(and Services related to their For purposes of this"Diagnosis and treatment of procurement and storage) infertility"section,"infertility"means not being able to • Assisted reproductive technology Services,such as get pregnant or carry a pregnancy to a live birth after a ovum transplants,gamete intrafallopian transfer year or more of regular sexual relations without (GIFT),in vitro fertilization(IVF),and zygote contraception or having a medical or other demonstrated intrafallopian transfer(ZIFT) condition that is recognized by a Plan Physician as a cause of infertility.We cover the following: • Services for the diagnosis and treatment of infertility • Artificial insemination Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 32 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Health Education • Physician Specialist Visits to diagnose and treat hearing problems: a$15 Copayment per visit We cover a variety of health education counseling, programs,and materials that your personal Plan Hearing aids Physician or other Plan Providers provide during a visit We cover the following Services related to hearing aids: covered under another part of this EOC. • A$1,000 Allowance for each ear toward the purchase We also cover a variety of health education counseling, price of a hearing aid(including fitting,counseling, programs,and materials to help you take an active role in adjustment,cleaning,and inspection)every 36 protecting and improving your health,including months when prescribed by a Plan Physician or by a programs for tobacco cessation,stress management,and Plan Provider who is an audiologist.We will cover chronic conditions(such as diabetes and asthma).Kaiser hearing aids for both ears only if both aids are Permanente also offers health education counseling, required to provide significant improvement that is programs,and materials that are not covered,and you not obtainable with only one hearing aid.We will not may be required to pay a fee. provide the Allowance if we have provided an Allowance toward(or otherwise covered)a hearing aid within the previous 36 months.Also,the For more information about our health education Allowance can only be used at the initial point of sale. counseling,programs,and materials,please contact a If you do not use all of your Allowance at the initial Health Education Department or Member Services or go point of sale,you cannot use it later to our website at kp.oru. Note: Our Health Education Department offers a We select the provider or vendor that will furnish the comprehensive self-management workshop to help covered hearing aids.Coverage is limited to the types members learn the best choices in exercise,diet, and models of hearing aids furnished by the provider or monitoring,and medications to manage and control vendor. diabetes.Members may also choose to receive diabetes For the following Services, refer to these self-management training from a program outside our sections Plan that is recognized by the American Diabetes Association(ADA)and approved by Medicare.Also,our • Services related to the ear or hearing other than those Health Education Department offers education to teach described in this section,such as outpatient care to kidney care and help members make informed decisions treat an ear infection or outpatient prescription drugs, about their care. supplies,and supplements(refer to the applicable heading in this"Benefits and Your Cost Share" Your Cost Share.You pay the following for these section) covered Services: • Cochlear implants and osseointegrated hearing • Covered health education programs,which may devices(refer to"Prosthetic and Orthotic Devices") include programs provided online and counseling over the phone: no charge Hearing Services exclusions • Other covered individual counseling when the office • Internally implanted hearing aids visit is solely for health education: a$15 Copayment . Replacement parts and batteries,repair of hearing per visit aids,and replacement of lost or broken hearing aids • Health education provided during an outpatient (the manufacturer warranty may cover some of these) consultation or evaluation covered in another part of this EOC: no additional Cost Share beyond the Cost Share required in that other part of this EOC Home-Delivered Meals • Covered health education materials: no charge Immediately following discharge from a Plan Hospital or Skilled Nursing Facility as an inpatient,we cover up to three meals per day in a consecutive four-week period, Hearing Services once per calendar year as follows: We cover the following: • When you are discharged from a Plan Hospital or • Hearing exams with an audiologist to determine the Skilled Nursing Facility,the meal delivery vendor need for hearing correction: a$15 Copayment per will contact you to review your meal options and visit arrange meal delivery to your home in California.In most cases,the meals must be initiated within 30 days Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 33 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. of discharge.You can contact Member Services if • Durable medical equipment(refer to"Durable you have any questions about your meals coverage Medical Equipment("DME")for Home Use") • In addition to meals for general health,there are • Ostomy,urological,and specialized wound care menus to support specific conditions and diets supplies(refer to"Ostomy,Urological,and Specialized Wound Care Supplies") Your Cost Share.We cover home-delivered meals at . Outpatient drugs,supplies,and supplements(refer to no charge. "Outpatient Prescription Drugs,Supplies,and Home-delivered meals exclusions Supplements") We will not cover meals if more than 30 days have • Outpatient physical,occupational,and speech therapy passed since your discharge(except in limited visits(refer to"Outpatient Care") circumstances)or if you are discharged as follows: • Prosthetic and orthotic devices(refer to"Prosthetic • To another facility that provides meals(for example, and Orthotic Devices") inpatient rehabilitation) Home health care exclusions • From a Non-Plan Hospital or Skilled Nursing Facility,Hospital Observation,Outpatient Surgery,or • Care in the home if the home is not a safe and effective treatment setting Emergency Department • To a home outside of California Home Medical Care Not Covered by Home Health Care Medicare for Members Who Live in Certain Counties (Advanced Care at "Home health care"means Services provided in the Home home by nurses,medical social workers,home health aides,and physical,occupational,and speech therapists. We cover medical care in your home that is not We cover part-time or intermittent home health care in otherwise covered by Medicare when found medically accord with Medicare guidelines.Home health care appropriate by a physician based on your health status to services are covered up to the number of visits and provide you with an alternative to receiving acute care in length of time that are determined to be medically a hospital and post-acute care Services in the home to necessary under the Member's home health treatment support your recovery. Services in the home must be: plan and no more than the limits established under . Prescribed by a network hospitalist who has Medicare guidelines,only if all of the following are true: determined that based on your health status,treatment • You are substantially confined to your home plan,and home setting that you can be treated safely • Your condition requires the Services of a nurse, and effectively in the home physical therapist,or speech therapist or continued • Elected by you because you prefer to receive the care need for an occupational therapist(home health aide described in your treatment plan in your home Services are not covered unless you are also getting covered home health care from a nurse,physical Medically Home is our network provider and will therapist,occupational therapist,or speech therapist provide the following services and items in your home in that only a licensed provider can provide) accord with your treatment plan for as long as they are • A Plan Physician determines that it is feasible to prescribed by a network hospitalist: maintain effective supervision and control of your • Home visits by RNs,physical therapists,occupational care in your home and that the Services can be safely therapists,speech therapists,respiratory therapists, and effectively provided in your home nutritionist,home health aides,and other healthcare • The Services are provided inside our Service Area professionals in accord with the home care treatment plan and the provider's scope of practice and license Your Cost Share.We cover home health care Services • Communication devices to allow you to contact at no charge. Medically Home's command center 24 hours a day, 7 days a week.This includes needed communication For the following Services, refer to these technology to support reliable communication,and an sections PERS alert device to contact Medically Home's • Dialysis care(refer to"Dialysis Care") command center if you are unable to get to a phone Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 34 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • The following equipment necessary to ensure that you cure the terminal illness.You may change your decision are monitored appropriately in your home:blood to receive hospice care benefits at any time. pressure cuff/monitor,pulse oximeter,scale,and thermometer If you have Medicare Part A,you are eligible for the • Mobile imaging and tests such as X-rays,labs,and hospice benefit when your doctor and the hospice EKGs medical director have given you a terminal prognosis certifying that you're terminally ill and have six months • The following safety items: shower stools,raised or less to live if your illness runs its normal course.You toilet seats,grabbers,long handle shoehorn,and sock may receive care from any Medicare-certified hospice aid program.Our plan is obligated to help you find • Up to 21 meals per week while you are receiving Medicare-certified hospice programs in our plan's acute care in the home Service Area,including those the MA organization owns, controls,or has a financial interest in.Your hospice In addition,for Medicare-covered services and items doctor can be a Plan Provider or a Non—Plan Provider. listed below,the Cost-Sharing indicated elsewhere in this Covered Services include: EOC does not apply when the Services and items are • Drugs for symptom control and pain relief prescribed as part of your home treatment plan: • Short-term respite care • Durable medical equipment • Home care • Medical supplies • Ambulance transportation to and from network When you are admitted to a hospice you have the right to facilities when ambulance transport is Medically remain in your plan;if you chose to remain in your plan, Necessary you must continue to pay plan premiums. • Physician assistant and nurse practitioner house calls For hospice services and for services that are covered or office visits by Medicare Part A or B and are related to your • The following Services at a Plan Facility if the terminal prognosis: Original Medicare(rather than our Services are part of your home treatment plan: Plan)will pay your hospice provider for your hospice ♦ Network Emergency Department visits associated services and any Part A and Part B services related to with this benefit your terminal condition.While you are in the hospice ♦ Physical,speech,or occupational therapy office program,your hospice provider will bill Original visits Medicare for the services that Original Medicare pays ♦ X-rays,labs,ultrasounds,and EKGs for.You will be billed Original Medicare cost-sharing. For services that are covered by Medicare Part A or The cost-sharing indicated elsewhere in this EOC will Band are not related to your terminal prognosis: apply to all other Services and items that are not part of If you need nonemergency,non—urgently needed your home treatment plan(for example,DME unrelated services that are covered under Medicare Part A or B and to your home treatment plan)or are part of your home that are not related to your terminal condition,your cost treatment plan,but are not provided in your home except for these services depends on whether you use a Plan as listed above.Note:For prescription drug Cost-Sharing Provider and follow plan rules(such as if there is a information,refer to the"Outpatient Prescription Drugs, requirement to obtain prior authorization): Supplies,and Supplements"section. • If you obtain the covered services from a Plan Provider and follow plan rules for obtaining service, Hospice Care you only pay the Plan Cost Share amount Hospice care is a specialized form of interdisciplinary • If you obtain the covered services from a Non—Plan health care designed to provide palliative care and to Provider,you pay the cost sharing under Fee-for- alleviate the physical,emotional,and spiritual Service Medicare(Original Medicare) discomforts of a Member experiencing the last phases of life due to a terminal illness.It also provides support to For services that are covered by our Plan but are not the primary caregiver and the Member's family.A covered by Medicare Part A or B:We will continue to Member who chooses hospice care is choosing to receive cover Plan-covered Services that are not covered under palliative care for pain and other symptoms associated Part A or B whether or not they are related to your with the terminal illness,but not to receive care to try to terminal condition.You pay your Plan Cost Share amount for these Services. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 35 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. For drugs that may be covered by our plan's Part D • Physical,occupational,and speech therapy for benefit:If these drugs are unrelated to your terminal purposes of symptom control or to enable you to hospice condition,you pay cost-sharing.If they are maintain activities of daily living related to your terminal hospice condition,then you pay . Respiratory therapy Original Medicare cost-sharing.Drugs are never covered by both hospice and our plan at the same time.For more • Medical social services information,please see"What if you're in a Medicare- . Home health aide and homemaker services certified hospice"in the"Outpatient Prescription Drugs, Supplies,and Supplements"section. • Palliative drugs prescribed for pain control and symptom management of the terminal illness for up to Note: If you need non-hospice care(care that is not a 100-day supply in accord with our drug formulary related to your terminal prognosis),you should contact guidelines.You must obtain these drugs from a Plan us to arrange the services. Pharmacy.Certain drugs are limited to a maximum 30-day supply in any 30-day period(your Plan For more information about Original Medicare hospice Pharmacy can tell you if a drug you take is one of coverage,visit https://www.medicare.i!ov,and under these drugs) "Search Tools,"choose"Find a Medicare Publication"to • Durable medical equipment view or download the publication"Medicare Hospice . Respite care when necessary to relieve your Benefits."Or call 1-800-MEDICARE(1-800-633-4227) caregivers.Respite care is occasional short-term (TTY users call 1-877-486-2048),24 hours a day,seven inpatient Services limited to no more than five days a week. consecutive days at a time Special note if you do not have Medicare Part A • Counseling and bereavement services We cover the hospice Services listed below at no charge • Dietary counseling only if all of the following requirements are met: • You are not entitled to Medicare Part A We also cover the following hospice Services only during periods of crisis when they are Medically • A Plan Physician has diagnosed you with a terminal Necessary to achieve palliation or management of acute illness and determines that your life expectancy is 12 medical symptoms: months or less . Nursing care on a continuous basis for as much as 24 • The Services are provided inside our Service Area(or hours a day as necessary to maintain you at home inside California but within 15 miles or 30 minutes . Short-term inpatient Services required at a level that from our Service Area if you live outside our Service Area,and you have been a Senior Advantage Member cannot be provided at home continuously since before January 1, 1999,at the same home address) Mental Health Services • The Services are provided by a licensed hospice agency that is a Plan Provider We cover Services specified in this"Mental Health • A Plan Physician determines that the Services are Services"section only when the Services are for the diagnosis or treatment of Mental Disorders.A"Mental necessary for the palliation and management of your Disorder"is a mental health condition identified as a terminal illness and related conditions "mental disorder"in the Diagnostic and Statistical Manual of Mental Disorders,Fourth Edition, Text If all of the above requirements are met,we cover the Revision,as amended in the most recently issued edition, following hospice Services,if necessary for your hospice (`DSM')that results in clinically significant distress or care: impairment of mental,emotional,or behavioral • Plan Physician Services functioning.We do not cover services for conditions that • Skilled nursing care,including assessment, the DSM identifies as something other than a"mental evaluation,and case management of nursing needs, disorder. For example,the DSM identifies relational treatment for pain and symptom control,provision of problems as something other than a mental disorder, so emotional support to you and your family,and we do not cover services(such as couples counseling or instruction to caregivers family counseling)for relational problems. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 36 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. "Mental Disorders"include the following conditions: facility,and the Services are above the level of custodial • Severe Mental Illness of a person of any age care: • Serious Emotional Disturbance of a Child Under Age • Individual and group mental health evaluation and 18 treatment • Medical services In addition to the Services described in this Mental . Medication monitoring Health Services section,we also cover other Services that are Medically Necessary to treat Serious Emotional • Room and board Disturbance of a Child Under Age 18 or Severe Mental . Drugs prescribed by a Plan Provider as part of your Illness,if the Medical Group authorizes a written referral plan of care in the residential treatment facility in (as described in"Medical Group authorization procedure accord with our drug formulary guidelines if they are for certain referrals"under"Getting a Referral"in the administered to you in the facility by medical "How to Obtain Services"section). personnel(for discharge drugs prescribed when you are released from the residential treatment facility, Outpatient mental health Services refer to"Outpatient Prescription Drugs, Supplies,and We cover the following Services when provided by Plan Supplements"in this"Benefits and Your Cost Share" Physicians or other Plan Providers who are licensed section) health care professionals acting within the scope of their . Discharge planning license: • Individual and group mental health evaluation and Your Cost Share.We cover residential mental health treatment treatment Services at no charge. • Psychological testing when necessary to evaluate a Inpatient psychiatric hospitalization Mental Disorder • Outpatient Services for the purpose of monitoring We cover care for acute psychiatric conditions in a drug therapy Medicare-certified psychiatric hospital. Your Cost Share.We cover inpatient psychiatric Intensive psychiatric treatment programs hospital Services at no charge. We cover the following intensive psychiatric treatment programs at a Plan Facility,such as: For the following Services, refer to these • Partial hospitalization sections • Multidisciplinary treatment in an intensive outpatient • Outpatient drugs,supplies,and supplements(refer to program "Outpatient Prescription Drugs,Supplies,and • Psychiatric observation for an acute psychiatric crisis Supplements") • Outpatient laboratory(refer to"Outpatient Imaging, Your Cost Share.You pay the following for these Laboratory,and Other Diagnostic and Treatment covered Services: Services") • Individual mental health evaluation and treatment: a • Telehealth Visits(refer to"Telehealth Visits") $15 Copayment per visit • Group mental health treatment: a$7 Copayment per Opioid Treatment Program Services visit • Partial hospitalization: no charge Members with opioid use disorder(OUD)can receive coverage of Services to treat OUD through an Opioid • Other intensive psychiatric treatment programs: Treatment Program(OTP)which includes the following no charge Services: Residential treatment • U.S.Food and Drug Administration(FDA)approved Inside our Service Area,we cover the following Services opioid agonist and antagonist medication-assisted when the Services are provided in a licensed residential treatment(MAT)medications and the dispensing and treatment facility that provides 24-hour individualized administration of MAT medications(if applicable) mental health treatment,the Services are generally and • Substance use counseling customarily provided by a mental health residential . Individual and group therapy treatment program in a licensed residential treatment Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 37 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Toxicology testing • Nuclear medicine: no charge • Intake activities • Routine preventive retinal photography screenings: • Periodic assessments no charge • Medicare Part B clinically administered drugs • Routine laboratory tests to monitor the effectiveness of dialysis: no charge Your Cost Share:You pay the following for these • Hemoglobin(Alc)testing for diabetes,Low-Density covered Services: no charge. Lipoprotein(LDL)testing for heart disease, International Normalized Ratio(INR)for persons with liver disease or certain blood disorders,and Ostomy, Urological, and Specialized glucose quantitative blood tests not covered at$0 Wound Care Supplies under Original Medicare: no charge We cover ostomy,urological,and specialized wound • All other laboratory tests(including tests for specific genetic disorders for which genetic counseling is care supplies if the following requirements are met: available): no charge • A Plan Physician has prescribed ostomy,urological, • Diagnostic Services provided by Plan Providers who and specialized wound care supplies for your medical condition are not physicians(such as EKGs and EEGs): no charge • The item has been approved for you through the Plan's prior authorization process,as described in • Radiation therapy: no charge "Medical Group authorization procedure for certain • Ultraviolet light therapy treatments,including referrals"under"Getting a Referral"in the"How to ultraviolet light therapy equipment for home use,if Obtain Services"section (1)the equipment has been approved for you through • The Services are provided inside our Service Area the Plan's prior authorization process,as described in "Medical Group authorization procedure for certain referrals"under"Getting a Referral"in the"How to Coverage is limited to the standard item of equipment Obtain Services" section and(2)the equipment is that adequately meets your medical needs.We decide provided inside your Home Region Service Area. whether to rent or purchase the equipment,and we select (Coverage for ultraviolet light therapy equipment is the vendor. limited to the standard item of equipment that adequately meets your medical needs.We decide Your Cost Share:You pay the following for covered whether to rent or purchase the equipment,and we ostomy,urological,and specialized wound care supplies: select the vendor.You must return the equipment to 20 percent Coinsurance. us or pay us the fair market price of the equipment Ostomy, urological, and specialized wound care when we are no longer covering it.): no charge supplies exclusions For the following Services, refer to these • Comfort,convenience,or luxury equipment or sections features • Outpatient imaging and laboratory Services that are Preventive Services,such as routine mammograms, Outpatient Imaging, Laboratory, and bone density scans,and laboratory screening tests Other Diagnostic and Treatment (refer to"Preventive Services") Services • Outpatient procedures that include imaging and diagnostic Services(refer to"Outpatient surgeries and We cover the following Services at the Cost Share procedures") indicated only when part of care covered under other • Services related to diagnosis and treatment of headings in this"Benefits and Your Cost Share"section. infertility,artificial insemination,or assisted The Services must be prescribed by a Plan Provider: reproductive technology("ART")Services(refer to • Complex imaging(other than preventive)such as CT "Fertility Services") scans,MRIs,and PET scans: no charge • Basic imaging Services,such as diagnostic and therapeutic X-rays,mammograms,and ultrasounds: no charge Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 38 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Outpatient Imaging, Laboratory, and Other this"Outpatient Prescription Drugs, Supplies,and Diagnostic and Treatment Services exclusions Supplements"section • Ultraviolet light therapy comfort,convenience,or • Your prescriber must either accept Medicare or file luxury equipment or features documentation with the Centers for Medicare& • Repair or replacement of ultraviolet light therapy Medicaid Services showing that he or she is qualified equipment due to misuse to write prescriptions,or your Part D claim will be denied.You should ask your prescribers the next time you call or visit if they meet this condition. If not, Outpatient Prescription Drugs, Supplies, please be aware it takes time for your prescriber to and Supplements submit the necessary paperwork to be processed We cover outpatient drugs,supplies,and supplements In addition to our plan's Part D and medical benefits specified in this"Outpatient Prescription Drugs, coverage,if you have Medicare Part A,your drugs may Supplies,and Supplements"section when prescribed as be covered by Original Medicare if you are in Medicare follows: hospice.For more information,please see"What • Items prescribed by providers,within the scope of if you're in a Medicare-certified hospice"in this "Outpatient Prescription Drugs,Supplies,and their licensure and practice,and in accord with our Supplements"section. drug formulary guidelines • Items prescribed by the following Non—Plan Obtaining refills by mail Providers unless a Plan Physician determines that the Most refills are available through our mail-order service, item is not Medically Necessary or the drug is for a but there are some restrictions.A Plan Pharmacy,our sexual dysfunction disorder: Kaiser Permanente Pharmacy Directory,or our ♦ dentists if the drug is for dental care website at ko.org/refill can give you more information ♦ Non—Plan Physicians if the Medical Group about obtaining refills through our mail-order service. authorizes a written referral to the Non—Plan Please check with your local Plan Pharmacy if you have Physician(in accord with"Medical Group a question about whether your prescription can be authorization procedure for certain referrals" mailed.Items available through our mail-order service under"Getting a Referral"in the"How to Obtain are subject to change at any time without notice. Services"section)and the drug,supply,or supplement is covered as part of that referral Certain items from Non—Plan Pharmacies ♦ Non—Plan Physicians if the prescription was Generally,we cover drugs filled at a Non—Plan obtained as part of covered Emergency Services, Pharmacy only when you are not able to use a Plan Post-Stabilization Care,or Out-of-Area Urgent Pharmacy.If you cannot use a Plan Pharmacy,here are Care described in the"Emergency Services and the circumstances when we would cover prescriptions Urgent Care"section(if you fill the prescription at filled at a Non—Plan Pharmacy. a Plan Pharmacy,you may have to pay Charges • The drug is related to covered Emergency Services, for the item and file a claim for reimbursement as Post-Stabilization Care,or Out-of-Area Urgent Care described in the"Requests for Payment"section) described in the"Emergency Services and Urgent • The item meets the requirements of our applicable Care"section.Note:Prescription drugs prescribed drug formulary guidelines(our Medicare Part D and provided outside of the United States and its formulary or our formulary applicable to non—Part D territories as part of covered Emergency Services or Urgent Care are covered up to a 30-day supply in a items) 30-day period.These drugs are covered under your • You obtain the item at a Plan Pharmacy or through medical benefits,and are not covered under Medicare our mail-order service,except as otherwise described Part D.Therefore,payments for these drugs do not under"Certain items from Non—Plan Pharmacies"in count toward reaching the Part D Catastrophic this"Outpatient Prescription Drugs, Supplies,and Coverage Stage Supplements"section.Refer to our Kaiser • For Medicare Part D covered drugs,the following are Permanente Pharmacy Directory for the locations additional situations when a Part D drug may be of Plan Pharmacies in your area.Plan Pharmacies can covered: change without notice and if a pharmacy is no longer a Plan Pharmacy,you must obtain covered items from ♦ if you are traveling outside your Home Region another Plan Pharmacy,except as otherwise described Service Area,but in the United States and its territories,and you become ill or run out of your under"Certain items from Non—Plan Pharmacies"in Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 39 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. covered Part D prescription drugs.We will cover your drugs.To prevent any delays at a pharmacy when prescriptions that are filled at a Non—Plan your Medicare hospice benefit ends,you should bring Pharmacy according to our Medicare Part D documentation to the pharmacy to verify your revocation formulary guidelines or discharge.For more information about Medicare ♦ if you are unable to obtain a covered drug in a Part D coverage and what you pay,please see"Medicare timely manner inside your Home Region Service Part D drugs"in this"Outpatient Prescription Drugs, Area because there is no Plan Pharmacy within a Supplies,and Supplements"section. reasonable driving distance that provides 24-hour service.We may not cover your prescription if a Medicare Part D drugs reasonable person could have purchased the drug Medicare Part D covers most outpatient prescription at a Plan Pharmacy during normal business hours drugs if they are sold in the United States and approved ♦ if you are trying to fill a prescription for a drug for sale by the federal Food and Drug Administration. that is not regularly stocked at an accessible Plan Our Part D formulary includes drugs that can be covered Pharmacy or available through our mail-order under Medicare Part D according to Medicare pharmacy(including high-cost drugs) requirements.Refer to our"Medicare Part D drug formulary(2024 Comprehensive Formulary)"in this ♦ if you are not able to get your prescriptions from a °Outpatient Prescription Drugs,Supplies,and Plan Pharmacy during a disaster Supplements"section for more information about this In these situations,please check first with Member formulary. Services to see if there is a Plan Pharmacy nearby. Cost Share for Medicare Part D drugs.Unless you You may be required to pay the difference between what reach the Catastrophic Coverage Stage in a calendar you pay for the drug at the Non—Plan Pharmacy and the year,you will pay the following Cost Share for covered cost that we would cover at Plan Pharmacy. Medicare Part D drugs: Payment and reimbursement.If you go to a Non—Plan • Generic drugs: a$5 Copayment for up to a 100-day Pharmacy for the reasons listed,you may have to pay the supply full cost(rather than paying just your Copayment or • Brand-name and specialty drugs: a$20 Copayment Coinsurance)when you fill your prescription.You may for up to a 100-day supply ask us to reimburse you for our share of the cost by • Injectable Part D vaccines: no charge submitting a request for reimbursement as described in the"Requests for Payment"section.If we pay for the • Emergency contraceptive pills: no charge drugs you obtained from a Non—Plan Pharmacy,you may • The following insulin-administration devices at a still pay more for your drugs than what you would have $5 Copayment for up to a 100-day supply:needles, paid if you had gone to a Plan Pharmacy because you syringes,alcohol swabs,and gauze may be responsible for paying the difference between Plan Pharmacy Charges and the price that the Non Plan Catastrophic Coverage Stage.All Medicare Pharmacy charged you. prescription drug plans include catastrophic coverage for people with high drug costs.In order to qualify for What if you're in aMedicare-certified hospice catastrophic coverage,you must spend$8,000 out-of- If you have Medicare Part A,drugs are never covered by pocket during 2024.When the total amount you have both hospice and our plan at the same time.If you are paid for your Cost Share reaches$8,000,you pay enrolled in Medicare hospice and require an anti-nausea, nothing for covered Part D drugs the remainder of the laxative,pain medication,or antianxiety drug that is not calendar year. covered by your hospice because it is unrelated to your terminal illness and related conditions,our plan must Note:Each year,effective on January 1,the Centers for receive notification from either the prescriber or your Medicare&Medicaid Services may change coverage hospice provider that the drug is unrelated before our thresholds that apply for the calendar year.We will plan can cover the drug.To prevent delays in receiving notify you in advance of any change to your coverage. any unrelated drugs that should be covered by our plan, you can ask your hospice provider or prescriber to make These payments are included in your out-of-pocket sure we have the notification that the drug is unrelated costs.Your out-of-pocket costs include the payments before you ask a pharmacy to fill your prescription. listed below(as long as they are for Part D covered drugs and you followed the rules for drug coverage that are In the event you either revoke your hospice election or are discharged from hospice,our plan should cover all Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 40 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. explained in this"Outpatient Prescription Drugs, Keeping track of Medicare Part D drugs.The Part D Supplies,and Supplements"section): Explanation of Benefits is a document you will get for • The amount you pay for drugs when you are in the each month you use your Part D prescription drug Initial Coverage Stage coverage.The Part D Explanation of Benefits will tell you the total amount you,or others on your behalf,have • Any payments you made during this calendar year as spent on your prescription drugs and the total amount we a member of a different Medicare prescription drug have paid for your prescription drugs.A Part D plan before you joined our Plan Explanation of Benefits is also available upon request from Member Services. It matters who pays: • If you make these payments yourself,they are Medicare's "Extra Help" Program included in your out-of-pocket costs Medicare provides"Extra Help"to pay prescription drug • These payments are also included in your out-of- costs for people who have limited income and resources. pocket costs if they are made on your behalf by Resources include your savings and stocks,but not your certain other individuals or organizations.This home or car.If you qualify,you get help paying for any includes payments for your drugs made by a friend or Medicare drug plan's monthly premium,and prescription relative,by most charities,by AIDS drug assistance Copayments.This"Extra Help"also counts toward your programs,or by the Indian Health Service.Payments out-of-pocket costs. made by Medicare's Extra Help Program are also included People with limited income and resources may qualify for"Extra Help."Some people automatically qualify for These payments are not included in your out-of- "Extra Help"and don't need to apply.Medicare mails a letter to people who automatically qualify for"Extra pocket costs.When you add up your out-of-pocket costs, Help." you are not allowed to include any of these types of payments for prescription drugs: You may be able to get"Extra Help"to pay for your • The amount you contribute,if any,toward your prescription drug premiums and costs.To see if you group's Premium qualify for getting"Extra Help,"call: • Drugs you buy outside the United States and its • 1-800-MEDICARE(1-800-633-4227)(TTY users territories call 1-877-486-2048),24 hours a day,seven days a • Drugs that are not covered by our Plan week; • Drugs you get at an out-of-network pharmacy that do • The Social Security Office at 1-800-772-1213(TTY not meet our Plan's requirements for out-of-network users call 1-800-325-0778), 8 a.m.to 7 p.m.,Monday coverage through Friday(applications);or • Non-Part D drugs,including prescription drugs • Your state Medicaid office(applications). See the covered by Part A or Part B and other drugs excluded "Important Phone Numbers and Resources"section from coverage by Medicare for contact information • Payments for your drugs that are made or funded by group health plans,including employer health plans If you believe you have qualified for"Extra Help"and you believe that you are paying an incorrect Cost Share • Payments for your drugs that are made by certain amount when you get your prescription at a Plan insurance plans and government-funded health Pharmacy,our plan has established a process that allows programs such as TRICARE and Veterans Affairs you either to request assistance in obtaining evidence of • Payments for your drugs made by a third-party with a your proper Cost Share level,or,if you already have the legal obligation to pay for prescription costs(for evidence,to provide this evidence to us.If you aren't example,Workers' Compensation) sure what evidence to provide us,please contact a Plan Pharmacy or Member Services.The evidence is often a Reminder: If any other organization such as the ones letter from either your state Medicaid or Social Security described above pays part or all of your out-of-pocket office that confirms you are qualified for Extra Help.The costs for Part D drugs,you are required to tell our Plan. evidence may also be state-issued documentation with Call Member Services to let us know(phone numbers are your eligibility information associated with Home and on the cover of this EOC). Community-Based Services. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 41 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. You or your appointed representative may need to we cover,please visit our website at ku.oru/seniorrx or provide the evidence to a Plan Pharmacy when obtaining call Member Services. covered Part D prescriptions so that we may charge you the appropriate Cost Share amount until the Centers for The presence of a drug on our formulary does not Medicare&Medicaid Services updates its records to necessarily mean that your Plan Physician will prescribe reflect your current status. Once the Centers for it for a particular medical condition. Our drug formulary Medicare&Medicaid Services updates its records,you guidelines allow you to obtain Medicare Part D will no longer need to present the evidence to the Plan prescription drugs if a Plan Physician determines that Pharmacy.Please provide your evidence in one of the they are Medically Necessary for your condition.If you following ways so we can forward it to the Centers for disagree with your Plan Physician's determination,refer Medicare&Medicaid Services for updating: to"Your Part D Prescription Drugs:How to Ask for a • Write to Kaiser Permanente at: Coverage Decision or Make an Appeal"in the California Service Center "Coverage Decisions,Appeals,and Complaints"section. Attn:Best Available Evidence P.O.Box 232407 Continuity drugs.If this EOC is amended to exclude a San Diego,CA 92193-2407 drug that we have been covering and providing to you under this EOC,we will continue to provide the drug if a • Fax it to 1-877-528-8579 prescription is required by law and a Plan Physician • Take it to a Plan Pharmacy or your local Member continues to prescribe the drug for the same condition Services office at a Plan Facility and for a use approved by the Federal Food and Drug Administration. When we receive the evidence showing your Cost Share level,we will update our system so that you can pay the About specialty drugs. Specialty drugs are high-cost correct Cost Share when you get your next prescription drugs that are on our specialty drug list.If your Plan at our Plan Pharmacy.If you overpay your Cost Share, Physician prescribes more than a 30-day supply for an we will reimburse you.Either we will forward a check to outpatient drug,you may be able to obtain more than a you in the amount of your overpayment or we will offset 30-day supply at one time,up to the day supply limit for future Cost Share.If our Plan Pharmacy hasn't collected that drug.However,most specialty drugs are limited to a a Cost Share from you and is carrying your Cost Share as 30-day supply in any 30-day period.Your Plan a debt owed by you,we may make the payment directly Pharmacy can tell you if a drug you take is one of these to our Plan Pharmacy.If a state paid on your behalf,we drugs. may make payment directly to the state.Please call Member Services if you have questions. Preferred generic and generic drugs listed in the formulary will be subject to the generic drug Copayment If you qualify for"Extra Help,"we will send you an or Coinsurance listed under"Copayment and Evidence of Coverage Rider for People Who Get Coinsurance for Medicare Part D drugs"in this Extra Help Paying for Prescription Drugs(also known "Outpatient Prescription Drugs,Supplies,and as the Low Income Subsidy Rider or the LIS Rider),that Supplements"section.Preferred and nonpreferred brand- explains your costs as a Member of our plan.If the name drugs and specialty tier drugs listed in the amount of your"Extra Help"changes during the year, formulary will be subject to the brand-name Copayment we will also mail you an updated Evidence of Coverage or Coinsurance listed under"Copayment and Rider for People Who Get Extra Help Paying for Coinsurance for Medicare Part D drugs"in this Prescription Drugs. "Outpatient Prescription Drugs,Supplies,and Supplements"section.Please note that sometimes a drug Medicare Part D drug formulary(2024 may appear more than once on our 2024 Comprehensive Formulary) Comprehensive Formulary.This is because different Our Medicare Part D formulary is a list of covered drugs restrictions or cost-sharing may apply based on factors selected by our plan in consultation with a team of health such as the strength,amount,or form of the drug care providers that represents the drug therapies believed prescribed by your health care provider(for instance, 10 to be a necessary part of a quality treatment program. mg versus 100 mg;one per day versus two per day; Our formulary must meet requirements set by Medicare tablet versus liquid). and is approved by Medicare.Our formulary includes drugs that can be covered under Medicare Part D You can get updated information about the drugs our according to Medicare requirements.For a complete, plan covers by visiting our website at kv.org/seniorrx. current listing of the Medicare Part D prescription drugs You may also call Member Services to find out if your Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 42 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. drug is on the formulary or to request an updated copy of cover or request a Part D formulary exception in order to our formulary. get coverage for the drug.Refer to our formulary or our website,k%org/seniorrx,for more information about We may make certain changes to our formulary during our Part D transition coverage. the year. Changes in the formulary may affect which drugs are covered and how much you will pay when Medicare Part D exclusions(non—Part D drugs).By filling your prescription.The kinds of formulary changes law,certain types of drugs are not covered by Medicare we may make include: Part D.If a drug is not covered by Medicare Part D,any • Adding or removing drugs from the formulary amounts you pay for that drug will not count toward reaching the Catastrophic Coverage Stage.A Medicare • Adding prior authorizations or other restrictions on a Prescription Drug Plan can't cover a drug under drug Medicare Part D in the following situations: If we remove drugs from the formulary or add prior • The drug would be covered under Medicare Part A or authorizations or restrictions on a drug,and you are Part B taking the drug affected by the change,you will be • Drug purchased outside the United States and its permitted to continue receiving that drug at the same territories level of Cost Share for the remainder of the calendar . Off-label uses(meaning for uses other than those year.However,if a brand-name drug is replaced with a indicated on a drug's label as approved by the federal new generic drug,or our formulary is changed as a result Food and Drug Administration)of a prescription of new information on a drug's safety or effectiveness, drug,except in cases where the use is supported by you may be affected by this change.We will notify you certain reference books.Congress specifically listed of the change at least 30 days before the date that the the reference books that list whether the off-label use change becomes effective or provide you with at least a would be permitted. (These reference books are the month's supply at the Plan Pharmacy.This will give you American Hospital Formulary Service Drug an opportunity to work with your physician to switch to a Information and the DRUGDEX Information different drug that we cover or request an exception. (If a System.)If the use is not supported by one of these drug is removed from our formulary because the drug references,known as compendia,then the drug is has been recalled,we will not give 30 days'notice before considered a non—Part D drug and cannot be covered removing the drug from the formulary.Instead,we will under Medicare Part D coverage remove the drug immediately and notify members taking the drug about the change as soon as possible.) In addition,by law,certain types of drugs or categories of drugs are not covered under Medicare Part D.These If your drug isn't listed on your copy of our formulary, drugs include: you should first check the formulary on our website, which we update when there is a change.In addition,you • Nonprescription drugs(also called over-the-counter may call Member Services to be sure it isn't covered. drugs) If Member Services confirms that we don't cover your . Drugs when used to promote fertility drug,you have two options: . Drugs when used for the relief of cough or cold • You may ask your Plan Physician if you can switch to symptoms another drug that is covered by us . Drugs when used for cosmetic purposes or to promote • You or your Plan Physician may ask us to make an hair growth exception(a type of coverage determination)to cover . Prescription vitamins and mineral products,except your Medicare Part D drug. See the"Coverage prenatal vitamins and fluoride preparations Decisions,Complaints,and Appeals"section for more information on how to request an exception • Drugs when used for the treatment of sexual or erectile dysfunction Transition policy.If you recently joined our plan,you . Drugs when used for treatment of anorexia,weight may be able to get a temporary supply of a Medicare loss,or weight gain Part D drug you were previously taking that may not be . Outpatient drugs for which the manufacturer seeks to on our formulary or has other restrictions,during the first 90 days of your membership.Current members may also require that associated tests or monitoring services be be affected by changes in our formulary from one year to purchased exclusively from the manufacturer as a the next.Members should talk to their Plan Physicians to condition of sale decide if they should switch to a different drug that we Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 43 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Note:In addition to the coverage provided under this • Injectable osteoporosis drugs,if you are homebound, Medicare Part D plan,you also have coverage for non— have a bone fracture that a doctor certifies was related Part D drugs described under"Home infusion therapy," to post-menopausal osteoporosis,and cannot self- "Outpatient drugs covered by Medicare Part B,""Certain administer the drug intravenous drugs,supplies,and supplements,"and • Antigens "Outpatient drugs,supplies,and supplements not covered by Medicare"in this"Outpatient Prescription • Certain oral anticancer drugs and antinausea drugs Drugs, Supplies,and Supplements"section.If a drug is • Certain drugs for home dialysis,including heparin, not covered under Medicare Part D,refer to those the antidote for heparin when Medically Necessary, headings for information about your non—Part D drug topical anesthetics,and erythropoiesis-stimulating coverage. agents(such as Epogen®,Epoetin Alfa,Aranesp®,or Darbepoetin Alfa) Other prescription drug coverage.If you have • Intravenous Immune Globulin for the home treatment additional health care or drug coverage from another plan,you must provide that information to our plan. The of primary immune deficiency diseases information you provide helps us calculate how much you and others have paid for your prescription drugs.In Your Cost Share for Medicare Part B drugs.You pay addition,if you lose or gain additional health care or the following for Medicare Part B drugs: prescription drug coverage,please call Member Services • Generic drugs: a$5 Copayment for up to a 100-day to update your membership records. supply • Brand-name drugs,specialty drugs,and compounded Home infusion therapy products: a$20 Copayment for up to a 100-day We cover home infusion supplies and drugs at no charge supply if all of the following are true: • Your prescription drug is on our Medicare Part D Certain intravenous drugs, supplies, and formulary supplements • We approved your prescription drug for home We cover certain self-administered intravenous drugs, infusion therapy fluids,additives,and nutrients that require specific types of parenteral-infusion(such as an intravenous or • Your prescription is written by a network provider intraspinal-infusion)at no charge for up to a 30-day and filled at a network home-infusion pharmacy supply.In addition,we cover the supplies and equipment required for the administration of these drugs at Outpatient drugs covered by Medicare Part B no charge. In addition to Medicare Part D drugs,we also cover the limited number of outpatient prescription drugs that are Outpatient drugs, supplies, and supplements covered by Medicare Part B.The following are the types not covered by Medicare of drugs that Medicare Part B covers: If a drug,supply,or supplement is not covered by • Drugs that usually aren't self-administered by the Medicare Part B or D,we cover the following additional patient and are injected or infused while you are items in accord with our non—Part D drug formulary: getting physician,hospital outpatient,or ambulatory • Drugs for which a prescription is required by law that surgical center services are not covered by Medicare Part B or D.We also • Drugs you take using durable medical equipment cover certain drugs that do not require a prescription (such as nebulizers)that were prescribed by a Plan by law if they are listed on our drug formulary Physician applicable to non—Part D items • Clotting factors you give yourself by injection if you • Diaphragms,cervical caps,contraceptive rings,and have hemophilia contraceptive patches • Immunosuppressive drugs,if Medicare paid for the • Disposable needles and syringes needed for injecting transplant(or a group plan was required to pay before covered drugs,pen delivery devices,and visual aids Medicare paid for it) required to ensure proper dosage(except eyewear), • Insulin furnished through an item of durable medical that are not covered by Medicare Part B or D equipment(such as a Medically Necessary insulin • Inhaler spacers needed to inhale covered drugs pump) Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 44 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Ketone test strips and sugar or acetone test tablets or necessarily mean that it will be prescribed for a particular tapes for diabetes urine testing medical condition. • FDA-approved medications for tobacco cessation, including over-the-counter medications when Drug formulary guidelines allow you to obtain prescribed by a Plan Physician nonformulary prescription drugs(those not listed on our drug formulary for your condition)if they would Your Cost Share for other outpatient drugs,supplies, otherwise be covered and a Plan Physician determines and supplements not covered by Medicare.Your Cost that they are Medically Necessary.If you disagree with Share for these items is as follows: your Plan Physician's determination that a nonformulary prescription drug is not Medically Necessary,you may • Generic items(that are not described elsewhere in this file an appeal as described in the"Coverage Decisions, EOC): a$5 Copayment for up to a 100-day supply Appeals,and Complaints"section.Also,our non—Part D • Brand-name items,specialty drugs,and compounded formulary guidelines may require you to participate in a products(that are not described elsewhere in this behavioral intervention program approved by the EOC): a$20 Copayment for up to a 100-day Medical Group for specific conditions and you may be supply required to pay for the program. • Drugs prescribed for the treatment of sexual About specialty drugs. Specialty drugs are high-cost dysfunction disorders:25 percent Coinsurance for drugs that are on our specialty drug list.If your Plan up to a 100-day supply Physician prescribes more than a 30-day supply for an • Amino acid—modified products used to treat outpatient drug,you may be able to obtain more than a congenital errors of amino acid metabolism(such as 30-day supply at one time,up to the day supply limit for phenylketonuria)and elemental dietary enteral that drug.However,most specialty drugs are limited to a formula when used as a primary therapy for regional 30-day supply in any 30-day period.Your Plan enteritis: no charge for up to a 30-day supply Pharmacy can tell you if a drug you take is one of these • Diabetes urine-testing supplies:no charge for up to a drugs. 100-day supply Manufacturer coupon program.For outpatient • Tobacco cessation drugs: no charge.For over-the- prescription drugs or items that are covered under this counter medications,we cover up to two 100-day "Outpatient drugs,supplies,and supplements not covered supplies per calendar year by Medicare" section and obtained at a Plan Pharmacy, you may be able to use approved manufacturer coupons Note:If Charges for the drug,supply,or supplement are as payment for the Cost Share that you owe,as allowed less than the Copayment,you will pay the lesser amount. under Health Plan's coupon program.You will owe any additional amount if the coupon does not cover the entire Non—Part D drug formulary.The non—Part D drug amount of your Cost Share for your prescription. Certain formulary includes a list of drugs that our Pharmacy and health plan coverages are not eligible for coupons.You Therapeutics Committee has approved for our Members. can get more information regarding the Kaiser Our Pharmacy and Therapeutics Committee,which is Permanente coupon program rules and limitations at primarily composed of Plan Physicians,selects drugs for ky.or2/rxcoupons. the drug formulary based on a number of factors, including safety and effectiveness as determined from a Drug utilization review review of medical literature.The Pharmacy and We conduct drug utilization reviews to make sure that Therapeutics Committee meets at least quarterly to you are getting safe and appropriate care.These reviews consider additions and deletions based on new are especially important if you have more than one information or drugs that become available.To find out doctor who prescribes your medications.We conduct which drugs are on the formulary for your plan,please drug utilization reviews each time you fill a prescription refer to the California Commercial HMO formulary on and on a regular basis by reviewing our records.During our website at kp.org/formulary.The formulary also these reviews,we look for medication problems such as: discloses requirements or limitations that apply to specific drugs,such as whether there is a limit on the • Possible medication errors amount of the drug that can be dispensed and whether • Duplicate drugs that are unnecessary because you are the drug must be obtained at certain specialty taking another drug to treat the same medical pharmacies.If you would like to request a copy of this condition drug formulary,please call Member Services.Note:The presence of a drug on the drug formulary does not Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 45 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Drugs that are inappropriate because of your age or drugs,and who have high drug costs.This program was gender developed for us by a team of pharmacists and doctors. • Possible harmful interactions between drugs you are We use this medication therapy management program to taking help us provide better care for our members.For example,this program helps us make sure that you are • Drug allergies using appropriate drugs to treat your medical conditions • Drug dosage errors and help us identify possible medication errors. • Unsafe amounts of opioid pain medications If you are selected to join a medication therapy management program,we will send you information If we identify a medication problem during our drug about the specific program,including information about utilization review,we will work with your doctor to how to access the program. correct the problem. ID card at Plan Pharmacies Drug management program You must present your Kaiser Permanente ID card when We have a program that can help make sure our obtaining covered items from Plan Pharmacies,including members safely use their prescription opioid those that are not owned and operated by Kaiser medications,or other medications that are frequently Permanente.If you do not have your ID card,the Plan abused.This program is called a Drug Management Pharmacy may require you to pay Charges for your Program(DMP).If you use opioid medications that you covered items,and you will have to file a claim for get from several doctors or pharmacies,we may talk to reimbursement as described in the"Requests for your doctors to make sure your use is appropriate and Payment"section. Medically Necessary.Working with your doctors,if we decide you are at risk for misusing or abusing your Notes: opioid or benzodiazepine medications,we may limit how you can get those medications.The limitations may be: • If Charges for a covered item are less than the • Requiring you to get all your prescriptions for opioid Copayment,you will pay the lesser amount or benzodiazepine medications from one pharmacy. • Durable medical equipment used to administer drugs, • Requiring you to get all your prescriptions for opioid such as diabetes insulin pumps(and their supplies) or benzodiazepine medications from one doctor. and diabetes blood-testing equipment(and their supplies)are not covered under this"Outpatient • Limiting the amount of opioid or benzodiazepine Prescription Drugs,Supplies,and Supplements" medications we will cover for you. section(instead,refer to"Durable Medical Equipment ("DME")for Home Use"in this"Benefits and Your If we decide that one or more of these limitations should Cost Share"section) apply to you,we will send you a letter in advance.The letter will have information explaining the terms of the • Except for vaccines covered by Medicare Part D, limitations we think should apply to you.You will also drugs administered to you in a Plan Medical Office or have an opportunity to tell us which doctors or during home visits are not covered under this pharmacies you prefer to use.If you think we made a "Outpatient Prescription Drugs,Supplies,and mistake or you disagree with our determination that you Supplements"section(instead,refer to"Outpatient are at-risk for prescription drug abuse or the limitation, Care"in this"Benefits and Your Cost Share"section) you and your prescriber have the right to ask us for an • Drugs covered during a covered stay in a Plan appeal. See the"Coverage Decisions,Appeals,and Hospital or Skilled Nursing Facility are not covered Complaints"section for information about how to ask for under this"Outpatient Prescription Drugs, Supplies, an appeal. and Supplements"section(instead,refer to"Hospital Inpatient Care"and"Skilled Nursing Facility Care"in The DMP may not apply to you if you have certain this"Benefits and Your Cost Share"section) medical conditions,such as cancer,you are receiving hospice,palliative,or end-of-life care,or you live in a Outpatient prescription drugs, supplies, and long-term care facility. supplements limitations Day supply limit.Plan Physicians determine the amount Medication therapy management program of a drug or other item that is Medically Necessary for a We offer a medication therapy management program at particular day supply for you.Upon payment of the Cost no additional cost to Members who have multiple Share specified in this"Outpatient Prescription Drugs, medical conditions,who are taking many prescription Supplies,and Supplements"section,you will receive the Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 46 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. supply prescribed up to a 100-day supply in a 100-day • Prescription drugs for which there is an over-the- period.However,the Plan Pharmacy may reduce the day counter equivalent(the same active ingredient, supply dispensed to a 30-day supply in any 30-day strength,and dosage form as the prescription drug). period at the Cost Share listed in this"Outpatient This exclusion does not apply to: Prescription Drugs,Supplies,and Supplements"section ♦ insulin if the Plan Pharmacy determines that the drug is in limited supply in the market or a 31-day supply in any ♦ over-the-counter tobacco cessation drugs and 31-day period if the item is dispensed by a long term care contraceptive drugs facility's pharmacy.Plan Pharmacies may also limit the ♦ an entire class of prescription drugs when one drug quantity dispensed as described under"Utilization within that class becomes available over-the- management."If you wish to receive more than the counter covered day supply limit,then the additional amount is ♦ drugs covered by Medicare Parts B or D not covered and you must pay Charges for any prescribed quantities that exceed the day supply limit. The amount you pay for noncovered drugs does not Over-the-Counter (OTC) Health and count toward reaching the Catastrophic Coverage Stage. Wellness Utilization management.For certain items,we have We cover OTC items listed in our OTC catalog for free additional coverage requirements and limits that help home delivery at no charge.You may order OTC items promote effective drug use and help us control drug plan up to the$70 quarterly benefit limit.Each order must be costs.Examples of these utilization management tools at least$25.Your order may not exceed your quarterly are: benefit limit.Any unused portion of the quarterly benefit limit doesn't carry forward to the next quarter.(Your • Quantity limits: The Plan Pharmacy may reduce the benefit limit resets on January 1,April 1,July 1,and day supply dispensed at the Cost Share specified in October this"Outpatient Drugs, Supplies,and Supplements" section to a 30-day supply or less in any 30-day To view our catalog and place an order online,please period for specific drugs.Your Plan Pharmacy can visit kky.orE/otc/ca.You may place an order over the tell you if a drug you take is one of these drugs.In phone or request a printed catalog be mailed to you by addition,we cover episodic drugs prescribed for the calling 1-833-569-2360(TTY 711),7 a.m.to 6 p.m. treatment of sexual dysfunction up to a maximum of PST,Monday through Friday. eight doses in any 30-day period,up to 16 doses in any 60-day period,or up to 27 doses in any 100-day period.Also,when there is a shortage of a drug in the preventive Services marketplace and the amount of available supplies,we may reduce the quantity of the drug dispensed We cover a variety of Preventive Services in accord with accordingly and charge one cost share Medicare guidelines.The list of Preventive Services is • Generic substitution:When there is a generic subject to change by the Centers for Medicare& version of a brand-name drug available,Plan Medicaid Services.These Preventive Services are subject Pharmacies will automatically give you the generic to all coverage requirements described in this`Benefits version,unless your Plan Physician has specifically and Your Cost Share"section and all provisions in the requested a formulary exception because it is "Exclusions,Limitations,Coordination of Benefits,and Medically Necessary for you to receive the brand- Reductions"section.If you have questions about name drug instead of the formulary alternative Preventive Services,please call Member Services. Outpatient prescription drugs, supplies, and Note:If you receive any other covered Services that are supplements exclusions not Preventive Services during or subsequent to a visit that includes Preventive Services on the list,you will pay • Any requested packaging(such as dose packaging) the applicable Cost Share for those other Services.For other than the dispensing pharmacy's standard example,if laboratory tests or imaging Services ordered packaging during a preventive office visit are not Preventive • Compounded products unless the active ingredient in Services,you will pay the applicable Cost Share for the compounded product is listed on one of our drug those Services. formularies • Drugs prescribed to shorten the duration of the common cold Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 47 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Your Cost Share.You pay the following for covered Prosthetic and Orthotic Devices Preventive Services: • Abdominal aortic aneurysm screening prescribed Prosthetic and orthotic devices coverage rules during the one-time"Welcome to Medicare" We cover the prosthetic and orthotic devices specified in preventive visit: no charge this"Prosthetic and Orthotic Devices"section if all of the following requirements are met: • Annual Wellness visit: no charge • The device is in general use,intended for repeated • Bone mass measurement: no charge use,and primarily and customarily used for medical • Breast cancer screening(mammograms): no charge purposes • Cardiovascular disease risk reduction visit(therapy • The device is the standard device that adequately for cardiovascular disease): no charge meets your medical needs • Cardiovascular disease testing: no charge • You receive the device from the provider or vendor • Cervical and vaginal cancer screening: no charge that we select • The item has been approved for you through the • Colorectal cancer screening,including flexible Plan's prior authorization process,as described in blood tests: no c colonoscopies,and fecal occult "Medical Group authorization procedure for certain blood tests: no charge referrals"under"Getting a Referral"in the"How to • Depression screening: no charge Obtain Services"section • Diabetes screening,including fasting glucose tests: • The Services are provided inside our Service Area no charge • Diabetes self-management training: no charge Coverage includes fitting and adjustment of these devices,their repair or replacement,and Services to • Glaucoma screening: no charge determine whether you need a prosthetic or orthotic • HIV screening: no charge device.If we cover a replacement device,then you pay • Immunizations(including the vaccine)covered by the Cost Share that you would pay for obtaining that Medicare Part B such as Hepatitis B,influenza, device. pneumococcal,and COVID-19 vaccines that are administered to you in a Plan Medical Office: Base prosthetic and orthotic devices no charge If all of the requirements described under"Prosthetic and • Lung cancer screening: no charge orthotic coverage rules"in this"Prosthetics and Orthotic Devices section are met,we cover the items described • Medical nutrition therapy for kidney disease and in this"Base prosthetic and orthotic devices"section. diabetes: no charge • Medicare diabetes prevention program: no charge Internally implanted devices.We cover prosthetic and orthotic devices such as pacemakers,intraocular lenses, • Obesity screening and therapy to promote sustained cochlear implants,osseointegrated hearing devices,and weight loss:no charge hip joints,in accord with Medicare guidelines,if they are • Prostate cancer screening exams,including digital implanted during a surgery that we are covering under rectal exams and Prostate Specific Antigens(PSA) another section of this"Benefits and Your Cost Share" tests: no charge section.We cover these devices at no charge. • Screening and counseling to reduce alcohol misuse: External devices.We cover the following external no charge prosthetic and orthotic devices at 20 percent • Screening for sexually transmitted infections(STIs) Coinsurance: and counseling to prevent STIs: no charge • Prosthetics and orthotics in accord with Medicare • Smoking and tobacco use cessation(counseling to guidelines. These include,but are not limited to, stop smoking or tobacco use): no charge braces,prosthetic shoes,artificial limbs,and • "Welcome to Medicare"preventive visit: no charge therapeutic footwear for severe diabetes-related foot disease in accord with Medicare guidelines • Prosthetic devices and installation accessories to restore a method of speaking following the removal of all or part of the larynx(this coverage does not Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 48 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. include electronic voice-producing machines,which Prosthetic and orthotic devices exclusions are not prosthetic devices) . Dental appliances • After Medically Necessary removal of all or part of a • Nonrigid supplies not covered by Medicare,such as breast,prosthesis including custom-made prostheses elastic stockings and wigs,except as otherwise when Medically Necessary described above in this"Prosthetic and Orthotic • Podiatric devices(including footwear)to prevent or Devices"section and the"Ostomy,Urological,and treat diabetes-related complications when prescribed Specialized Wound Care Supplies"section by a Plan Physician or by a Plan Provider who is a • Comfort,convenience,or luxury equipment or podiatrist features • Compression burn garments and lymphedema wraps . Repair or replacement of device due to misuse and garments • Shoes,shoe inserts,arch supports,or any other • Enteral formula for Members who require tube footwear,even if custom-made,except footwear feeding in accord with Medicare guidelines described above in this"Prosthetic and Orthotic • Enteral pump and supplies Devices"section for diabetes-related complications • Tracheostomy tube and supplies • Prosthetic and orthotic devices not intended for • Prostheses to replace all or part of an external facial maintaining normal activities of daily living body part that has been removed or impaired as a (including devices intended to provide additional result of disease,injury,or congenital defect support for recreational or sports activities) • Nonconventional intraocular lenses(IOLs)following Other covered prosthetic and orthotic devices cataract surgery(for example,presbyopia-correcting If all of the requirements described under"Prosthetic and IOLs).You may request and we may provide orthotic coverage rules"in this"Prosthetics and Orthotic insertion of presbyopia-correcting IOLs or Devices"section are met,we cover the following items astigmatism-correcting IOLs following cataract described in this"Other covered prosthetic and orthotic surgery in lieu of conventional IOLs.However,you devices"section: must pay the difference between Charges for • Prosthetic devices required to replace all or part of an nonconventional IOLs and associated services and organ or extremity,in accord with Medicare Charges for insertion of conventional IOLs following guidelines cataract surgery • Vacuum erection device for sexual dysfunction • Certain surgical boots following surgery when Reconstructive Surgery provided during an outpatient visit We cover the following reconstructive surgery Services: • Orthotic devices required to support or correct a . Reconstructive surgery to correct or repair abnormal defective body part,in accord with Medicare structures of the body caused by congenital defects, guidelines developmental abnormalities,trauma,infection, tumors,or disease,if a Plan Physician determines that Your Cost Share.You pay the following for other it is necessary to improve function,or create a normal covered prosthetic and orthotic devices: 20 percent appearance,to the extent possible Coinsurance. • Following Medically Necessary removal of all or part For the following Services, refer to these of a breast,we cover reconstruction of the breast, sections surgery and reconstruction of the other breast to produce a symmetrical appearance,and treatment of • Eyeglasses and contact lenses,including contact physical complications,including lymphedemas lenses to treat aniridia or aphakia(refer to"Vision Services") Your Cost Share.You pay the following for covered • Eyewear following cataract surgery(refer to"Vision reconstructive surgery Services: Services") • Outpatient surgery and outpatient procedures when • Hearing aids other than internally implanted devices provided in an outpatient or ambulatory surgery described in this section(refer to"Hearing Services") center or in a hospital operating room,or if it is provided in any setting and a licensed staff member • Injectable implants(refer to"Administered drugs and monitors your vital signs as you regain sensation after products"under"Outpatient Care") Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 49 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. receiving drugs to reduce sensation or to minimize and Services ordinarily furnished by home health discomfort: a$50 Copayment per procedure agencies that are not RNHCIs.In addition,you must sign • Any other outpatient surgery that does not require a a legal document that says you are conscientiously licensed staff member to monitor your vital signs as opposed to the acceptance of"nonexcepted"medical described above: a$15 Copayment per procedure treatment.("Excepted"medical treatment is a Service or treatment that you receive involuntarily or that is • Any other outpatient procedures that do not require a required under federal,state,or local law. licensed staff member to monitor your vital signs as "Nonexcepted"medical treatment is any other Service or described above: the Cost Share that would treatment.)Your stay in the RNHCI is not covered by us otherwise apply for the procedure in this"Benefits unless you obtain authorization(approval)in advance and Your Cost Share"section(for example,radiology from us. procedures that do not require a licensed staff member to monitor your vital signs as described Note: Covered Services are subject to the same above are covered under"Outpatient Imaging, limitations and Cost Share required for Services provided Laboratory,and Other Diagnostic and Treatment by Plan Providers as described in this"Benefits and Your Services") Cost Share"section. • Hospital inpatient Services(including room and board,drugs,imaging,laboratory,other diagnostic and treatment Services,and Plan Physician Services): Services Associated with Clinical Trials no charge If you participate in a Medicare-approved study,Original For the following Services, refer to these Medicare pays most of the costs for the covered Services sections you receive as part of the study.If you tell us that you are in a qualified clinical trial,then you are only • Office visits not described in this"Reconstructive responsible for the in-network cost-sharing for the Surgery"section(refer to"Outpatient Care") services in that trial.If you paid more,for example,if • Outpatient imaging and laboratory(refer to you already paid the Original Medicare cost-sharing "Outpatient Imaging,Laboratory,and Other amount,we will reimburse the difference between what Diagnostic and Treatment Services") you paid and the in-network cost-sharing.However,you will need to provide documentation to show us how • Outpatient prescription drugs(refer to"Outpatient much you paid.When you are in a clinical research Prescription Drugs,Supplies,and Supplements") study,you may stay enrolled in our plan and continue to • Outpatient administered drugs(refer to"Outpatient get the rest of your care(the care that is not related to the Care") study)through our plan. • Prosthetics and orthotics(refer to"Prosthetic and If you want to participate in any Medicare-approved Orthotic Devices") clinical research study,you do not need to tell us or to • Telehealth Visits(refer to"Telehealth Visits") get approval from us or your Plan Provider.The providers that deliver your care as part of the clinical Reconstructive surgery exclusions research study do not need to be part of our plan's • Surgery that,in the judgment of a Plan Physician network of providers.Although you do not need to get specializing in reconstructive surgery,offers only a our plan's permission to be in a clinical research study, minimal improvement in appearance we encourage you to notify us in advance when you choose to participate in Medicare-qualified clinical trials. Religious Nonmedical Health Care If you participate in a study that Medicare has not Institution Services approved,you will be responsible for paying all costs for your participation in the study. Care in a Medicare-certified Religious Nonmedical Health Care Institution(RNHCI)is covered by our Plan Once you join a Medicare-approved clinical research under certain conditions.Covered Services in an RNHCI study,Original Medicare covers the routine items and are limited to nonreligious aspects of care.To be eligible Services you receive as part of the study,including: for covered Services in a RNHCI,you must have a . Room and board for a hospital stay that Medicare medical condition that would allow you to receive would pay for even if you weren't in a study inpatient hospital or Skilled Nursing Facility care.You may get Services furnished in the home,but only items Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 50 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • An operation or other medical procedure if it is part A new benefit period can begin only after any existing of the research study benefit period ends.A prior three-day stay in an acute • Treatment of side effects and complications of the care hospital is not required.Note:If your Cost Share new care changes during a benefit period,you will continue to pay the previous Cost Share amount until a new benefit After Medicare has paid its share of the cost for these period begins. Services,our plan will pay the difference between the cost-sharing in Original Medicare and your Cost Share as We cover the following Services: a Member of our plan.This means you will pay the same • Physician and nursing Services amount for the Services you receive as part of the study • Room and board as you would if you received these Services from our plan.However,you are required to submit • Drugs prescribed by a Plan Physician as part of your documentation showing how much cost sharing you plan of care in the Plan Skilled Nursing Facility in paid.Please see the"Requests for Payment"section for accord with our drug formulary guidelines if they are more information for submitting requests for payment. administered to you in the Plan Skilled Nursing Facility by medical personnel You can get more information about joining a clinical • Durable medical equipment in accord with our prior research study by visiting the Medicare website to read authorization procedure if Skilled Nursing Facilities or download the publication"Medicare and Clinical ordinarily furnish the equipment(refer to"Medical Research Studies."(The publication is available at Group authorization procedure for certain referrals" htti)s://www.medicare.2ov.)You can also call under"Getting a Referral"in the"How to Obtain 1-800-MEDICARE(1-800-633-4227),24 hours a day, Services"section) seven days a week.TTY users call 1-877-486-2048. . Imaging and laboratory Services that Skilled Nursing Services associated with clinical trials Facilities ordinarily provide exclusions • Medical social services When you are part of a clinical research study,neither • Whole blood,red blood cells,plasma,platelets,and Medicare nor our plan will pay for any of the following: their administration • The new item or service that the study is testing, • Medical supplies unless Medicare would cover the item or service even . Physical,occupational,and speech therapy in accord if you were not in a study with Medicare guidelines • Items or services provided only to collect data,and • Respiratory therapy not used in your direct health care • Services that are customarily provided by the research Your Cost Share.We cover these Skilled Nursing sponsors free of charge to enrollees in the clinical trial Facility Services at no charge. • Items and services provided solely to determine trial eligibility For the following Services, refer to these sections • Outpatient imaging,laboratory,and other diagnostic Skilled Nursing Facility Care and treatment Services(refer to"Outpatient Imaging, Inside our Service Area,we cover up to 100 days per Laboratory,and Other Diagnostic and Treatment benefit period of skilled inpatient Services in a Plan Services") Skilled Nursing Facility and in accord with Medicare guidelines.The skilled inpatient Services must be Non—Plan Skilled Nursing Facility care customarily provided by a Skilled Nursing Facility,and Generally,you will get your Skilled Nursing Facility above the level of custodial or intermediate care. care from Plan Facilities.However,under certain conditions listed below,you may be able to receive A benefit period begins on the date you are admitted to a covered care from a non—Plan facility,if the facility hospital or Skilled Nursing Facility at a skilled level of accepts our Plan's amounts for payment. care(defined in accord with Medicare guidelines).A • A nursing home or continuing care retirement benefit period ends on the date you have not been an community where you were living right before you inpatient in a hospital or Skilled Nursing Facility, went to the hospital(as long as it provides Skilled receiving a skilled level of care,for 60 consecutive days. Nursing Facility care) Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 51 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • A Skilled Nursing Facility where your spouse is are released from the residential treatment facility, living at the time you leave the hospital refer to"Outpatient Prescription Drugs, Supplies,and Supplements"in this"Benefits and Your Cost Share" section) Substance Use Disorder Treatment . Discharge planning We cover Services specified in this"Substance Use Disorder Treatment"section only when the Services are Your Cost Share.We cover residential substance use for the preventive,diagnosis,or treatment of Substance disorder treatment Services at no charge. Use Disorders.A"Substance Use Disorder"is a condition identified as a"substance use disorder"in the Inpatient detoxification most recently issued edition of the Diagnostic and We cover hospitalization in a Plan Hospital only for Statistical Manual of Mental Disorders("DSM"). medical management of withdrawal symptoms,including room and board,Plan Physician Services,drugs, Outpatient substance use disorder treatment dependency recovery Services,education,and We cover the following Services for treatment of counseling. substance use disorders: Your Cost Share.We cover inpatient detoxification • Day-treatment programs Services at no charge. • Individual and group substance use disorder counseling For the following Services, refer to these • Intensive outpatient programs sections • Medical treatment for withdrawal symptoms • Outpatient laboratory(refer to"Outpatient Imaging, Laboratory,and Other Diagnostic and Treatment Your Cost Share.You pay the following for these Services") covered Services: • Outpatient self-administered drugs(refer to • Individual substance use disorder evaluation and "Outpatient Prescription Drugs,Supplies,and treatment: a$15 Copayment per visit Supplements") • Group substance use disorder treatment: a • Telehealth Visits(refer to"Telehealth Visits") $5 Copayment per visit • Intensive outpatient and day-treatment programs: a Telehealth Visits $5 Copayment per day Telehealth Visits between you and your provider are Residential treatment intended to make it more convenient for you to receive Inside our Service Area,we cover the following Services covered Services,when a Plan Provider determines it is when the Services are provided in a licensed residential medically appropriate for your medical condition.You treatment facility that provides 24-hour individualized have the option of receiving these services either through substance use disorder treatment,the Services are an in-person visit or via telehealth.You may receive generally and customarily provided by a substance use covered Services via Telehealth Visits,when available disorder residential treatment program in a licensed and if the Services would have been covered under this residential treatment facility,and the Services are above EOC if provided in person.If you choose to receive the level of custodial care: Services via telehealth,then you must use a Plan Provider that currently offers the service via telehealth. • Individual and group substance use disorder We offer the following telehealth Services: counseling • Telehealth Services for monthly end-stage renal • Medical services disease--related visits for home dialysis members in a • Medication monitoring hospital-based or critical access hospital-based renal • Room and board dialysis center,renal dialysis facility,or the Member's home • Drugs prescribed by a Plan Provider as part of your • Telehealth Services to diagnose,evaluate or treat plan of care in the residential treatment facility in symptoms of a stroke,regardless of your location accord with our drug formulary guidelines if they are administered to you in the facility by medical personnel(for discharge drugs prescribed when you Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 52 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Telehealth services for members with a substance use After the referral to a transplant facility,the following disorder or co-occurring mental health disorder, applies: regardless of their location • If either the Medical Group or the referral facility • Telehealth services for diagnosis,evaluation,and determines that you do not satisfy its respective treatment of mental health disorders if: criteria for a transplant,we will only cover Services ♦ you have an in-person visit within 6 months prior you receive before that determination is made to your first telehealth visit • Health Plan,Plan Hospitals,the Medical Group,and ♦ you have an in-person visit every 12 months while Plan Physicians are not responsible for finding, receiving these telehealth services furnishing,or ensuring the availability of an organ, ♦ exceptions can be made to the above for certain tissue,or bone marrow donor circumstances • In accord with our guidelines for Services for living • Telehealth services for mental health visits provided transplant donors,we provide certain donation-related by Rural Health Clinics and Federally Qualified Services for a donor,or an individual identified by the Health Centers Medical Group as a potential donor,whether or not the donor is a Member.These Services must be • Virtual check-ins(for example,by phone or video directly related to a covered transplant for you,which chat)with your doctor for 5-10 minutes if: may include certain Services for harvesting the organ, ♦ you're not a new patient,and tissue,or bone marrow and for treatment of ♦ the evaluation isn't related to an office visit in the complications.Please call Member Services for past 7 days,and questions about donor Services ♦ the evaluation doesn't lead to an office visit within Your Cost Share.For covered transplant Services that 24 hours or the soonest available appointment you receive,you will pay the Cost Share you would pay • Evaluation of video and/or images you send to your if the Services were not related to a transplant.For doctor,and interpretation and follow-up by your example,see"Hospital Inpatient Services"in this doctor within 24 hours if. "Benefits and Your Cost Share"section for the Cost ♦ you're not a new patient,and Share that applies for hospital inpatient Services. ♦ the check-in isn't related to an office visit in the past 7 days,and We provide or pay for donation-related Services for ♦ the check-in doesn't lead to an office visit within actual or potential donors(whether or not they are 24 hours or the soonest available appointment Members)in accord with our guidelines for donor Services at no charge. • Consultation your doctor has with other doctors by phone,internet,or electronic health record For the following Services, refer to these sections Your Cost Share.You pay the following types for . Dental Services that are Medically Necessary to Telehealth Visits with Primary Care Physicians,Non- prepare for a transplant(refer to"Dental Services") Physician Specialists,and Physician Specialists: • Outpatient imaging and laboratory(refer to • Interactive video visits: no charge "Outpatient Imaging,Laboratory,and Other • Scheduled telephone visits: no charge Diagnostic and Treatment Services") • Outpatient prescription drugs(refer to"Outpatient Transplant Services Prescription Drugs,Supplies,and Supplements") • Outpatient administered drugs(refer to"Outpatient We cover transplants of organs,tissue,or bone marrow Care") 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 Transportation Services procedure for certain referrals"under"Getting a Referral"in the"How to Obtain Services"section. We cover transportation up to 24 one-way trips(50 miles per trip)per calendar year,if you meet the following conditions: Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 53 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • You are traveling to and from a network provider Vision Services when provided by our designated transportation provider.Each stop will count towards one trip We cover the following: • The ride is for Services covered under this EOC • Routine eye exams with a Plan Optometrist to determine the need for vision correction(including For trips greater than 50 miles,you will need an approval dilation Services when Medically Necessary)and to from a provider indicating medical necessity to travel to provide a prescription for eyeglass lenses: a a location beyond this limit. $15 Copayment per visit • Physician Specialist Visits to diagnose and treat To request non-medical transportation(rideshare, injuries or diseases of the eye: a$15 Copayment per taxi,or private transportation),please call our visit transportation provider at 1-877-930-1477(TTY 711), Monday through Friday,5:00 a.m.to 6:00 p.m.You may • Non-Physician Specialist Visits to diagnose and treat also create an account with our transportation vendor and injuries or diseases of the eye: a$15 Copayment per schedule rides online at medicaltrip.net or via their visit mobile app. Optical Services If you need to use non-emergency medical We cover the Services described in this"Optical transportation(wheelchair van or gurney van) Services"section when received from Plan Medical because you physically or medically are not able to get to Offices or Plan Optical Sales Offices. your medical appointment by non-medical transportation (rideshare,taxi,or private transportation),please call The date we provide an Allowance toward(or otherwise 1-833-226-6760(TTY 711),Monday through Friday, cover)an item described in this"Optical Services" 9:00 a.m.to 5:00 p.m. section is the date on which you order the item.For example,if we last provided an Allowance toward an Call at least three business days before your appointment item you ordered on May 1,2022,and if we provide an or as soon as you can when you have an urgent Allowance not more than once every 24 months for that appointment.Please have all of the following when you type of item,then we would not provide another call: Allowance toward that type of item until on or after May • Your Kaiser Permanente ID card 1,2024.You can use the Allowances under this"Optical • The date and time of your medical appointments Services"section only when you first order an item. • The address of where you need to be picked up and If you use part but not all of an Allowance when you first the address of where you are going order an item,you cannot use the rest of that Allowance later. • If you will need a return trip • If someone will be traveling with you(for example,a Eyeglasses and contact lenses following cataract parent/legal guardian or caregiver) surgery We cover at no charge one pair of eyeglasses or contact Your Cost Share:You pay the following for covered lenses(including fitting or dispensing)following each transportation: no charge. cataract surgery that includes insertion of an intraocular lens at Plan Medical Offices or Plan Optical Sales For the following Services, refer to this section Offices when prescribed by a physician or optometrist. When multiple cataract surgeries are needed,and you do • Emergency and non-emergency ambulance Services not obtain eyeglasses or contact lenses between (refer to"Ambulance Services") procedures,we will only cover one pair of eyeglasses or contact lenses after any surgery.If the eyewear you Transportation Services exclusion purchase costs more than what Medicare covers for Transportation will not be provided if: someone who has Original Medicare(also known as • The ride is not for a service covered under this EOC "Fee-for-Service Medicare"),you pay the difference. Special contact lenses We cover the following: • For aniridia(missing iris),we cover up to two Medically Necessary contact lenses per eye (including fitting and dispensing)in any 12-month Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 54 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. period when prescribed by a Plan Physician or Plan For the following Services, refer to these Optometrist: no charge sections • In accord with Medicare guidelines,we cover • Services related to the eye or vision other than corrective lenses(including contact lens fitting and Services covered under this"Vision Services" dispensing)and frames(and replacements)for section,such as outpatient surgery and outpatient Members who are aphakic(for example,who have prescription drugs,supplies,and supplements(refer to had a cataract removed but do not have an implanted the applicable heading in this"Benefits and Your intraocular lens(IOL)or who have congenital Cost Share"section) absence of the lens):no charge • For other specialty contact lenses that will provide a Vision Services exclusions significant improvement in your vision not obtainable • Eyeglass or contact lens adornment,such as with eyeglass lenses,we cover either one pair of engraving,faceting,or jeweling contact lenses(including fitting and dispensing)or an • Items that do not require a prescription by law(other initial supply of disposable contact lenses(up to six than eyeglass frames),such as eyeglass holders, months,including fitting and dispensing)in any 24 eyeglass cases,and repair kits months at no charge • Lenses and sunglasses without refractive value, Eyeglasses and contact lenses except as described in this"Vision Services"section We provide a single$175 Allowance toward the • Low vision devices purchase price of any or all of the following not more . Replacement of lost,broken,or damaged contact than once every 24 months when a physician or optometrist prescribes an eyeglass lens(for eyeglass lenses,eyeglass lenses,and frames lenses and frames)or contact lens(for contact lenses): • Eyeglass lenses when a Plan Provider puts the lenses into a frame Exclusions, Limitations, ♦ we cover a clear balance lens when only one eye Coordination of Benefits, and needs correction Reductions ♦ we cover tinted lenses when Medically Necessary to treat macular degeneration or retinitis pigmentosa Exclusions • Eyeglass frames when a Plan Provider puts two lenses The items and services listed in this"Exclusions"section (at least one of which must have refractive value)into are excluded from coverage.These exclusions apply to the frame all Services that would otherwise be covered under this • Contact lenses,fitting,and dispensing EOC regardless of whether the services are within the scope of a provider's license or certificate.Additional We will not provide the Allowance if we have provided exclusions that apply only to a particular benefit are an Allowance toward(or otherwise covered)eyeglass listed in the description of that benefit in this EOC. lenses or frames within the previous 24 months. These exclusions or limitations do not apply to Services that are Medically Necessary to treat Severe Mental Replacement lenses Illness or Serious Emotional Disturbance of a Child If you have a change in prescription of at least.50 Under Age 18. diopter in one or both eyes within 12 months of the initial point of sale of an eyeglass lens or contact lens Certain exams and Services that we provided an Allowance toward(or otherwise Routine physical exams and other Services that are not covered)we will provide an Allowance toward the Medically Necessary,such as when required(1)for purchase price of a replacement item of the same type obtaining or maintaining employment or participation in (eyeglass lens,or contact lens,fitting,and dispensing) employee programs,(2)for insurance,credentialing or for the eye that had the.50 diopter change.The licensing,(3)for travel,or(4)by court order or for Allowance toward one of these replacement lenses is$30 parole or probation. for a single vision eyeglass lens or for a contact lens (including fitting and dispensing)and$45 for a Chiropractic Services multifocal or lenticular eyeglass lens. Chiropractic Services and the Services of a chiropractor, except for manual manipulation of the spine as described Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 55 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. under"Outpatient Care"in the"Benefits and Your Cost "Prosthetic and Orthotic Devices"in the"Benefits and Share"section or unless you have coverage for Your Cost Share"section. supplemental chiropractic Services as described in an amendment to this EOC. Experimental or investigational Services A Service is experimental or investigational if we,in Cosmetic Services consultation with the Medical Group,determine that one Services that are intended primarily to change or of the following is true: maintain your appearance,including cosmetic surgery . Generally accepted medical standards do not (surgery that is performed to alter or reshape normal recognize it as safe and effective for treating the structures of the body in order to improve appearance), condition in question(even if it has been authorized except that this exclusion does not apply to any of the by law for use in testing or other studies on human following: patients) • Services covered under"Reconstructive Surgery"in . It requires government approval that has not been the"Benefits and Your Cost Share"section obtained when the Service is to be provided • The following devices covered under"Prosthetic and Orthotic Devices"in the"Benefits and Your Cost Hair loss or growth treatment Share"section:testicular implants implanted as part Items and services for the promotion,prevention,or of a covered reconstructive surgery,breast prostheses other treatment of hair loss or hair growth. needed after removal of all or part of a breast or lumpectomy,and prostheses to replace all or part of Intermediate care an external facial body part Care in a licensed intermediate care facility.This exclusion does not apply to Services covered under Custodial care "Durable Medical Equipment("DME")for Home Use," Assistance with activities of daily living(for example: "Home Health Care,"and"Hospice Care"in the walking,getting in and out of bed,bathing,dressing, "Benefits and Your Cost Share"section. feeding,toileting,and taking medicine). Items and services that are not health care items This exclusion does not apply to assistance with and services activities of daily living that is provided as part of For example,we do not cover: covered hospice for Members who do not have Part A, Skilled Nursing Facility,or hospital inpatient care. • Teaching manners and etiquette • Teaching and support services to develop planning Dental care skills such as daily activity planning and project or Dental care and dental X-rays,such as dental Services task planning following accidental injury to teeth,dental appliances, • Items and services for the purpose of increasing dental implants,orthodontia,and dental Services academic knowledge or skills resulting from medical treatment such as surgery on the • Teaching and support services to increase intelligence jawbone and radiation treatment,except for Services covered in accord with Medicare guidelines or under • Academic coaching or tutoring for skills such as "Dental Services"in the"Benefits and Your Cost Share" grammar,math,and time management section. • Teaching you how to read,whether or not you have Disposable supplies dyslexia Disposable supplies for home use,such as bandages, • Educational testing gauze,tape,antiseptics,dressings,Ace-type bandages, • Teaching art,dance,horse riding,music,play,or and diapers,underpads,and other incontinence supplies. swimming This exclusion does not apply to disposable supplies • Teaching skills for employment or vocational purposes covered in accord with Medicare guidelines or under "Durable Medical Equipment("DME")for Home Use," • Vocational training or teaching vocational skills "Home Health Care,""Hospice Care,""Ostomy, • Professional growth courses Urological,and Wound Care Supplies,""Outpatient • Training for a specific job or employment counseling Prescription Drugs,Supplies,and Supplements,"and Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 56 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Aquatic therapy and other water therapy,except when Services and items not covered by Medicare ordered as part of a physical therapy program in Services and items that are not covered by Medicare, accord with Medicare guidelines including services and items that aren't reasonable and necessary,according to the standards of the Original Items and services to correct refractive defects Medicare plan,unless these Services are otherwise listed of the eye in this EOC as a covered Service. Items and services(such as eye surgery or contact lenses to reshape the eye)for the purpose of correcting Services performed by unlicensed people refractive defects of the eye such as myopia,hyperopia, Services that are performed safely and effectively by or astigmatism. people who do not require licenses or certificates by the state to provide health care services and where the Massage therapy Member's condition does not require that the services be Massage therapy is not covered. provided by a licensed health care provider. Oral nutrition and weight loss aids Services related to a noncovered Service Outpatient oral nutrition,such as dietary supplements, When a Service is not covered,all Services related to the herbal supplements,formulas,food,and weight loss aids. noncovered Service are excluded, except for Services we would otherwise cover to treat complications of the This exclusion does not apply to any of the following: noncovered Service or if covered in accord with Medicare guidelines.For example,if you have a • Amino acid—modified products and elemental dietary noncovered cosmetic surgery,we would not cover enteral formula covered under"Outpatient Services you receive in preparation for the surgery or for Prescription Drugs,Supplies,and Supplements"in follow-up care.If you later suffer alife-threatening the"Benefits and Your Cost Share"section complication such as a serious infection,this exclusion • Enteral formula covered under"Prosthetic and would not apply and we would cover any Services that Orthotic Devices"in the"Benefits and Your Cost we would otherwise cover to treat that complication. Share"section Surrogacy Residential care Services for anyone in connection with a Surrogacy Care in a facility where you stay overnight,except that Arrangement,except for otherwise-covered Services this exclusion does not apply when the overnight stay is provided to a Member who is a surrogate.Refer to part of covered care in a hospital,a Skilled Nursing "Surrogacy Arrangements"under"Reductions"in this Facility,inpatient respite care covered in the"Hospice "Exclusions,Limitations,Coordination of Benefits,and Care"section for Members who do not have Part A,or Reductions"section for information about your residential treatment program Services covered in the obligations to us in connection with a Surrogacy "Substance Use Disorder Treatment"and"Mental Health Arrangement,including your obligations to reimburse us Services"sections. for any Services we cover and to provide information about anyone who may be financially responsible for Routine foot care items and services Services the baby(or babies)receive. Routine foot care items and services,except for Medically Necessary Services covered in accord with Travel and lodging expenses Medicare guidelines. Travel and lodging expenses,except as described in our Travel and Lodging Program Description.The Travel Services not approved by the federal Food and and Lodging Program Description is available online at Drug Administration kp.or2/specialty-care/travel-reimbursements or by Drugs,supplements,tests,vaccines,devices,radioactive calling Member Services. materials,and any other Services that by law require federal Food and Drug Administration("FDA")approval in order to be sold in the U.S.,but are not approved by Limitations the FDA.This exclusion applies to Services provided We will make a good faith effort to provide or arrange anywhere,even outside the U.S.,unless the Services are covered under the"Emergency Services and Urgent for covered Services within the remaining availability of Care"section. facilities or personnel in the event of unusual circumstances that delay or render impractical the provision of Services under this EOC,such as a major Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 57 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. disaster,epidemic,war,riot,civil insurrection,disability your situation.With coordination of benefits,you will of a large share of personnel at a Plan Facility,complete often get your care as usual from Plan Providers,and the or partial destruction of facilities,and labor dispute. other coverage you have will simply help pay for the Under these circumstances,if you have an Emergency care you receive.In other situations,such as benefits that Medical Condition,call 911 or go to the nearest we don't cover,you may get your care outside of our emergency department as described under"Emergency plan directly through your other coverage. Services"in the"Emergency Services and Urgent Care" section,and we will provide coverage and In general,the coverage that pays its share of your bills reimbursement as described in that section. first is called the"primary payer."Then the other company or companies that are involved(called the Additional limitations that apply only to a particular "secondary payers")each pay their share of what is left benefit are listed in the description of that benefit in this of your bills.Often your other coverage will settle its EOC. 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 Coordination of Benefits give this payment to us.When you have additional coverage,whether we pay first or second,or at all, If you have other medical or dental coverage,it is depends on what type or types of additional coverage important to use your other coverage in combination you have and the rules that apply to your situation.Many with your coverage as a Senior Advantage Member to of these rules are set by Medicare. Some of them take pay for the care you receive.This is called"coordination into account whether you have a disability or have end- ofbenefits"because it involves coordinating all of the stage renal disease,or how many employees are covered health benefits that are available to you.Using all of the by an employer's group plan. coverage you have helps keep the cost of health care more affordable for everyone. If you have additional health coverage,please call Member Services to find out which rules apply to your You must tell us if you have other health care coverage, situation,and how payment will be handled. and let us know whenever there are any changes in your additional coverage.The types of additional coverage that you might have include the following: Reductions • Coverage that you have from an employer's group health care coverage for employees or retirees,either Employer responsibility through yourself or your spouse For any Services that the law requires an employer to provide,we will not pay the employer,and,when we • Coverage that you have under workers' compensation cover any such Services,we may recover the value of the because of a job-related illness or injury,or under the Services from the employer. Federal Black Lung Program • Coverage you have for an accident where no-fault Government agency responsibility insurance or liability insurance is involved For any Services that the law requires be provided only • Coverage you have through Medicaid by or received only from a government agency,we will not pay the government agency,and,when we cover any • Coverage you have through the"TRICARE for Life" such Services,we may recover the value of the Services program(veteran's benefits) from the government agency. • Coverage you have for dental insurance or prescription drugs Injuries or illnesses alleged to be caused by • "Continuation coverage"you have through COBRA third parties (COBRA is a law that requires employers with 20 or Third parties who cause you injury or illness(and/or more employees to let employees and their their insurance companies)usually must pay first before dependents keep their group health coverage for a Medicare or our plan.Therefore,we are entitled to time after they leave their group health plan under pursue these primary payments.If you obtain a judgment certain conditions) or settlement from or on behalf of a third party who allegedly caused an injury or illness for which you When you have additional health care coverage,how we received covered Services,you must ensure we receive coordinate your benefits as a Senior Advantage Member reimbursement for those Services.Note:This"Injuries or with your benefits from your other coverage depends on illnesses alleged to be caused by third parties"section Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 58 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. does not affect your obligation to pay your Cost Share illness,your estate,parent,guardian,or conservator and for these Services. any settlement or judgment recovered by the estate, parent,guardian,or conservator shall be subject to our To the extent permitted or required by law,we shall be liens and other rights to the same extent as if you had subrogated to all claims,causes of action,and other asserted the claim against the third party.We may assign rights you may have against a third party or an insurer, our rights to enforce our liens and other rights. government program,or other source of coverage for monetary damages,compensation,or indemnification on Surrogacy Arrangements account of the injury or illness allegedly caused by the If you enter into a Surrogacy Arrangement and you or third party.We will be so subrogated as of the time we any other payee are entitled to receive payments or other mail or deliver a written notice of our exercise of this compensation under the Surrogacy Arrangement,you option to you or your attorney. must reimburse us for covered Services you receive related to conception,pregnancy,delivery,or postpartum To secure our rights,we will have a lien and care in connection with that arrangement("Surrogacy reimbursement rights to the proceeds of any judgment or Health Services")to the maximum extent allowed under settlement you or we obtain against a third party that California Civil Code Section 3040.Note: This results in any settlement proceeds or judgment,from "Surrogacy Arrangements"section does not affect your other types of coverage that include but are not limited obligation to pay your Cost Share for these Services. to: liability,uninsured motorist,underinsured motorist, After you surrender a baby to the legal parents,you are personal umbrella,workers' compensation,personal not obligated to reimburse us for any Services that the injury,medical payments and all other first party types. baby receives(the legal parents are financially The proceeds of any judgment or settlement that you or responsible for any Services that the baby receives). we obtain shall first be applied to satisfy our lien, regardless of whether you are made whole and regardless By accepting Surrogacy Health Services,you of whether the total amount of the proceeds is less than automatically assign to us your right to receive payments the actual losses and damages you incurred.We are not that are payable to you or any other payee under the required to pay attorney fees or costs to any attorney Surrogacy Arrangement,regardless of whether those hired by you to pursue your damages claim.If you payments are characterized as being for medical reimburse us without the need for legal action,we will expenses.To secure our rights,we will also have a lien allow a procurement cost discount.If we have to pursue on those payments and on any escrow account,trust,or legal action to enforce its interest,there will be no any other account that holds those payments. Those procurement discount. payments(and amounts in any escrow account,trust,or other account that holds those payments)shall first be Within 30 days after submitting or filing a claim or legal applied to satisfy our lien.The assignment and our lien action against a third party,you must send written notice will not exceed the total amount of your obligation to us of the claim or legal action to: under the preceding paragraph. Equian Within 30 days after entering into a Surrogacy Kaiser Permanente-Northern California Region Subrogation Mailbox Arrangement,you must send written notice of the P.O.Box 36380 arrangement,including all of the following information: Louisville,KY 40233 • Names,addresses,and phone numbers of the other Fax: 1-502-214-1137 parties to the arrangement • Names,addresses,and phone numbers of any escrow In order for us to determine the existence of any rights agent or trustee we may have and to satisfy those rights,you must . Names,addresses,and phone numbers of the intended complete and send us all consents,releases, parents and any other parties who are financially authorizations,assignments,and other documents, responsible for Services the baby(or babies)receive, including lien forms directing your attorney,the third including names,addresses,and phone numbers for party,and the third party's liability insurer to pay us any health insurance that will cover Services that the directly.You may not agree to waive,release,or reduce baby(or babies)receive our rights under this provision without our prior,written . A signed copy of any contracts and other documents consent. explaining the arrangement If your estate,parent,guardian,or conservator asserts a • Any other information we request in order to satisfy claim against a third party based on your injury or our rights Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 59 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. You must send this information to: • From you,to the extent that a Financial Benefit is Equian provided or payable or would have been required to be provided or payable if you had diligently sought to Kaiser Perma —Northern California Region establish your rights to the Financial Benefit under Surrogacy Mailbox any workers' compensation or employer's liability P.O.Box 36380 law Louisville,KY 40233 Fax: 1-502-214-1137 You must complete and send us all consents,releases, Requests for Payment authorizations,lien forms,and other documents that are reasonably necessary for us to determine the existence of any rights we may have under this"Surrogacy Requests for Payment of Covered Arrangements"section and to satisfy those rights.You Services or Part D drugs may not agree to waive,release,or reduce our rights under this"Surrogacy Arrangements"section without If you pay our share of the cost of your covered our prior,written consent. services or Part D drugs, or if you receive a bill, you can ask us for payment If your estate,parent,guardian,or conservator asserts a Sometimes when you get medical care or a Part D drug, claim against another party based on the Surrogacy you may need to pay the full cost.Other times,you may Arrangement,your estate,parent,guardian,or find that you have paid more than you expected under conservator and any settlement or judgment recovered by the coverage rules of our plan.In these cases,you can the estate,parent,guardian,or conservator shall be ask us to pay you back(paying you back is often called subject to our liens and other rights to the same extent as "reimbursing"you).It is your right to be paid back by if you had asserted the claim against the other party.We our plan whenever you've paid more than your share of may assign our rights to enforce our liens and other the cost for medical services or Part D drugs that are rights. covered by our plan.There may be deadlines that you must meet to get paid back. If you have questions about your obligations under this There may also be times when you get a bill from a provision,please call Member Services. provider for the full cost of medical care you have received or possibly for more than your share of cost U.S. Department of Veterans Affairs sharing as discussed in this document.First try to For any Services for conditions arising from military resolve the bill with the provider.If that does not service that the law requires the Department of Veterans work,send the bill to us instead of paying it.We will Affairs to provide,we will not pay the Department of look at the bill and decide whether the services should Veterans Affairs,and when we cover any such Services be covered.If we decide they should be covered,we we may recover the value of the Services from the will pay the provider directly.If we decide not to pay Department of Veterans Affairs. it,we will notify the provider.You should never pay more than plan-allowed cost sharing.If this provider is Workers' compensation or employer's liability contracted,you still have the right to treatment. benefits Here are examples of situations in which you may need Workers' compensation usually must pay first before to ask us to pay you back or to pay a bill you have Medicare or our plan.Therefore,we are entitled to received: pursue primary payments under workers' compensation or employer's liability law.You may be eligible for When you've received emergency,urgent,or dialysis payments or other benefits,including amounts received care from a Non—Plan Provider.Outside the service as a settlement(collectively referred to as"Financial area,you can receive emergency or urgently needed Benefit"),under workers' compensation or employer's services from any provider,whether or not the provider liability law.We will provide covered Services even if it is a Plan Provider.In these cases: is unclear whether you are entitled to a Financial Benefit, You are only responsible for paying your share of the but we may recover the value of any covered Services from the following sources: cost for emergency or urgently needed services. Emergency providers are legally required to provide • From any source providing a Financial Benefit or emergency care.If you pay the entire amount yourself from whom a Financial Benefit is due at the time you receive the care,ask us to pay you Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 60 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. back for our share of the cost. Send us the bill,along we only cover out of network pharmacies in limited with documentation of any payments you have made circumstances. • You may get a bill from the provider asking for When you pay the full cost for a prescription because payment that you think you do not owe. Send us this you don't have your plan membership card with you. bill,along with documentation of any payments you If you do not have your plan membership card with you, have already made you can ask the pharmacy to call us or to look up your ♦ if the provider is owed anything,we will pay the plan enrollment information.However,if the pharmacy provider directly cannot get the enrollment information they need right ♦ if you have already paid more than your share of away,you may need to pay the full cost of the the cost of the service,we will determine how prescription yourself. much you owed and pay you back for our share of Save your receipt and send a copy to us when you ask us the cost to pay you back for our share of the cost. When a Plan Provider sends you a bill you think you When you pay the full cost for a prescription in other should not pay.Plan Providers should always bill us situations.You may pay the full cost of the prescription directly and ask you only for your share of the cost.But because you find that the drug is not covered for some sometimes they make mistakes and ask you to pay more reason. than your share. • For example,the drug may not be on our 2024 • You only have to pay your Cost Share amount when Comprehensive Formulary;or it could have a you get covered Services.We do not allow providers requirement or restriction that you didn't know about to add additional separate charges,called balance or don't think should apply to you.If you decide to billing.This protection(that you never pay more than get the drug immediately,you may need to pay the your Cost Share amount)applies even if we pay the full cost for it provider less than the provider charges for a service, • Save your receipt and send a copy to us when you ask and even if there is a dispute and we don't pay certain us to pay you back.In some situations,we may need provider charges to get more information from your doctor in order to • Whenever you get a bill from a Plan Provider that you pay you back for our share of the cost think is more than you should pay,send us the bill. When you pay copayments under a drug We will contact the provider directly and resolve the manufacturer patient assistance program.If you get billing problem help from,and pay copayments under,a drug manufacturer patient assistance program outside our • If you have already paid a bill to a Plan Provider,but plan's benefit,you may submit a paper claim to have you feel that you paid too much,send us the bill along your out-of-pocket expense count toward qualifying you with documentation of any payment you have made and ask us to pay you back the difference between the for catastrophic coverage. amount you paid and the amount you owed under our • Save your receipt and send a copy to us plan If you are retroactively enrolled in our plan. All of the examples above are types of coverage Sometimes a person's enrollment in our plan is decisions.This means that if we deny your request for retroactive. (This means that the first day of their payment,you can appeal our decision.The"Coverage enrollment has already passed.The enrollment date may Decisions,Appeals,and Complaints"section has even have occurred last year.)If you were retroactively information about how to make an appeal. enrolled in our plan and you paid out-of-pocket for any of your covered Services or Part D drugs after your How to Ask Us to Pay You Back or to enrollment date,you can ask us to pay you back for our share of the costs.You will need to submit paperwork Pay a Bill You Have Received such as receipts and bills for us to handle the You may request us to pay you back by sending us a reimbursement. request in writing.If you send a request in writing,send When you use a Non—Plan Pharmacy to get a your bill and documentation of any payment you have prescription filled.If you go to a Non—Plan,the made.It's a good idea to make a copy of your bill and pharmacy may not be able to submit the claim directly to receipts for your records.You must submit your claim to us.When that happens,you will have to pay the full cost us within 12 months(for Part C medical claims)and of your prescription. within 36 months(for Part D drug claims)of the date you received the service,item,or drug. Save your receipt and send a copy to us when you ask us to pay you back for our share of the cost.Remember that Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 61 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. To make sure you are giving us all the information we We Will Consider Your Request for need to make a decision,you can fill out our claim form Payment and Say Yes or No to make your request for payment.You don't have to use the form,but it will help us process the information We check to see whether we should cover the faster.You can file a claim to request payment by: service or Part D drug and how much we owe When we receive your request for payment,we will let To file a claim,this is what you need to do: you know if we need any additional information from • Completing and submitting our electronic form at you.Otherwise,we will consider your request and make k .or and upload supporting documentation a coverage decision. • Either download a copy of the form from our website • If we decide that the medical care or Part D drug is (kD.oro or call Member Services and ask them to covered and you followed all the rules,we will pay send you the form.Mail the completed form to our for our share of the cost.If you have already paid for Claims Department address listed below the service or Part D drug,we will mail your • If you are unable to get the form,you can file your reimbursement of our share of the cost to you.If you have not paid for the service or Part D drug yet,we request for payment by sending us the following will mail the payment directly to the provider information to our Claims Department address listed below: • If we decide that the medical care or Part D drug is ♦ a statement with the following information: not covered,or you did not follow all the rules,we will not pay for our share of the cost.We will send — your name(member/patient name)and you a letter explaining the reasons why we are not medical/health record number sending the payment and your right to appeal that — the date you received the services decision — where you received the services — who provided the services If we tell you that we will not pay for all or part of the medical care or Part D drug,you can make — why you think we should pay for the services an appeal — your signature and date signed. (If you want If you think we have made a mistake in turning down someone other than yourself to make the your request for payment or the amount we are paying, request,we will also need a completed you can make an appeal.If you make an appeal,it means "Appointment of Representative"form,which you are asking us to change the decision we made when is available at kp.org) we turned down your request for payment. ♦ a copy of the bill,your medical record(s)for these services,and your receipt if you paid for the The appeals process is a formal process with detailed services procedures and important deadlines.For the details about • Mail your request for payment of medical care how to make this appeal,go to the"Coverage Decisions, together with any bills or paid receipts to us at this Appeals,and Complaints"section. address: KaiserPermanente Other Situations in Which You Should Claims Administration-NCAL Save Your Receipts and Send Copies to P.O.Box 12923 Oakland,CA 94604-2923 US In some cases, you should send copies of your To request payment of a Part D drug that was prescribed receipts to us to help us track your out-of- by a Plan Provider and obtained from a Plan Pharmacy, pocket drug costs write to the address below.For all other Part D requests, There are some situations when you should let us know send your request to the address above. about payments you have made for your covered Part D Kaiser Foundation Health Plan,Inc. prescription drugs.In these cases,you are not asking us Medicare Part D Unit for payment.Instead,you are telling us about your P.O.Box 23170 payments so that we can calculate your out-of-pocket Oakland,CA 94623-0170 costs correctly.This may help you to qualify for the Catastrophic Coverage Stage more quickly. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 62 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Here is one situation when you should send us copies of benefits in a format that is accessible and appropriate for receipts to let us know about payments you have made you.To get information from us in a way that works for for your drugs: you,please call Member Services. • When you get a drug through a patient assistance program offered by a drug manufacturer. Some Our plan is required to give female enrollees the option members are enrolled in a patient assistance program of direct access to a women's health specialist within the offered by a drug manufacturer that is outside our network for women's routine and preventive health care plan benefits.If you get any drugs through a program services. offered by a drug manufacturer,you may pay a copayment to the patient assistance program If providers in our network for a specialty are not ♦ save your receipt and send a copy to us so that we available,it is our responsibility to locate specialty can have your out-of-pocket expenses count providers outside the network who will provide you with toward qualifying you for the Catastrophic the necessary care.In this case,you will only pay in- Coverage Stage network cost sharing.If you find yourself in a situation where there are no specialists in our network that cover a ♦ note:Because you are getting your drug through service you need,call us for information on where to go the patient assistance program and not through our to obtain this service at in-network cost-sharing. plan's benefits,we will not pay for any share of these drug costs.But sending a copy of the receipt If you have any trouble getting information from our allows us to calculate your out-of-pocket costs plan in a format that is accessible and appropriate for correctly and may help you qualify for the you,seeing a women's health specialist,or finding a Catastrophic Coverage Stage more quickly network specialist,please call to file a grievance with Member Services.You may also file a complaint with Since you are not asking for payment in the case Medicare by calling 1-800-MEDICARE(1-800-633- described above,this situation is not considered a 4227)or directly with the Office for Civil Rights 1-800- coverage decision.Therefore,you cannot make an appeal 368-1019 or TTY 1-800-537-7697. if you disagree with our decision. Debemos proporcionar la informaci6n de un modo adecuado para usted y conforme a su Your Rights and Responsibilities sensibilidad cultural (en idiomas distintos al ingl6s, en letra grande, en braille o en CD) Nuestro plan esta obligado a garantizar que todos los We must honor your rights and cultural servicios,tanto clinicos como no clinicos,se sensitivities as a Member of our plan proporcionen de una manera culturalmente competente y que Sean accesibles para todas las personas inscritas, We must provide information in a way that incluidas las que tienen un dominio limitado del ingl6s, works for you and consistent with your cultural capacidades limitadas para leer,una incapacidad auditiva sensitivities (in languages other than English, o diversos antecedentes culturales y 6tnicos.Algunos Braille, large print, or CD) ejemplos de c6mo nuestro plan puede cumplir estos Our plan is required to ensure that all services,both requisitos de accesibilidad incluyen,entre otros, clinical and non-clinical,are provided in a culturally proporcionar servicios de traducci6n,servicios de competent manner and are accessible to all enrollees, interpretaci6n,de teletipo o TTY(tel6fono de texto o including those with limited English proficiency,limited teletipo). reading skills,hearing incapacity,or those with diverse cultural and ethnic backgrounds.Examples of how our Nuestro plan tiene servicios de interpretacidn disponibles plan may meet these accessibility requirements include, Para responder las preguntas de los miembros que no but are not limited to:provision of translator services, hablan ingl6s.Este documento esta disponible en espaiiol interpreter services,teletypewriters,or TTY(text llamando a Servicio a los Miembros.Tambidn podemos telephone or teletypewriter phone)connection. darle informacidn en Tetra grande,braille o en CD sin costo si la necesita.Tenemos la obligaci6n de darle Our plan has free interpreter services available to answer informacion acerca de los beneficios de nuestro plan en questions from non-English-speaking members.This un formato que sea accesible y adecuado para usted.Para document is available in Spanish by calling Member obtener informati6n de una forma que se adapte a sus Services.We can also give you information in braille, necesidades,llame a Servicio a los Miembros. large print,or CD at no cost if you need it.We are required to give you information about our plan's Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 63 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Nuestro plan esta obligado a ofrecer a las mujeres protect your personal health information as required by inscritas la opci6n de acceder directamente a un these laws. especialista en salud femenina dentro de la red para los • Your personal health information includes the servicios de atenci6n m6dica preventiva y de rutina para personal information you gave us when you enrolled la mujer. in our plan as well as your medical records and other Si los proveedores de nuestra red para una especialidad medical and health information no estan disponibles,es nuestra responsabilidad buscar • You have rights related to your information and proveedores fuera de la red que le proporcionen la controlling how your health information is used.We atenci6n necesaria.En este caso,usted solo pagara el give you a written notice,called a Notice of Privacy costo compartido dentro de la red. Si se encuentra en una Practices,that tells you about these rights and situaci6n en la que no hay especialistas dentro de nuestra explains how we protect the privacy of your health red que cubran el servicio que necesita,llamenos para information recibir informacion sobre a d6nde acudir para obtener este servicio con un costo compartido dentro de la red. How do we protect the privacy of your health Si tiene algun problema para obtener informaci6n de information? nuestro plan en un formato que sea accesible y adecuado • We make sure that unauthorized people don't see or para usted,para ver a un especialista en salud femenina o change your records para encontrar un especialista de la red,llame a Servicio • Except for the circumstances noted below,if we a los Miembros para presentar una queja.Tambien puede intend to give your health information to anyone who presentar una queja ante Medicare,llamando al 1-800- isn't providing your care or paying for your care,we MEDICARE(1-800-633-4227)o directamente en la are required to get written permission from you or by Oficina de Derechos Civiles al 1-800-368-1019 o TTY someone you have given legal power to make 1-800-537-7697. decisions for you first We must ensure that you get timely access to • Your health information is shared with your Group your covered services and Part D drugs only with your authorization or as otherwise permitted by law You have the right to choose a primary care provider(PCP)in our network to provide and arrange for your . There are certain exceptions that do not require us to covered services.You also have the right to go to a get your written permission first.These exceptions women's health specialist(such as a gynecologist),a are allowed or required by law mental health services provider,and an optometrist ♦ we are required to release health information to without a referral,as well as other providers described in government agencies that are checking on quality the"How to Obtain Services"section. of care ♦ because you are a Member of our plan through You have the right to get appointments and covered Medicare,we are required to give Medicare your services from our network of providers within a health information,including information about reasonable amount of time. This includes the right to get your Part D prescription drugs.If Medicare timely services from specialists when you need that care. releases your information for research or other You also have the right to get your prescriptions filled or uses,this will be done according to federal statutes refilled at any of our network pharmacies without long and regulations;typically,this requires that delays. information that uniquely identifies you not be shared If you think that you are not getting your medical care or Part D drugs within a reasonable amount of time,"How You can see the information in your records and to make a complaint about quality of care,waiting times, know how it has been shared with others customer service,or other concerns"in the"Coverage You have the right to look at your medical records held Decisions,Appeals,and Complaints"section tells you by our plan,and to get a copy of your records.We are what you can do. allowed to charge you a fee for making copies.You also have the right to ask us to make additions or corrections We must protect the privacy of your personal to your medical records.If you ask us to do this,we will health information work with your health care provider to decide whether Federal and state laws protect the privacy of your the changes should be made. medical records and personal health information.We Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 64 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. You have the right to know how your health information medical care.Your providers must explain your medical has been shared with others for any purposes that are not condition and your treatment choices in a way that you routine. can understand. If you have questions or concerns about the privacy of You also have the right to participate fully in decisions your personal health information,please call Member about your health care.To help you make decisions with Services. your doctors about what treatment is best for you,your rights include the following: We must give you information about our plan, To know about all of your choices.You have the our Plan Providers, and your covered services right to be told about all of the treatment options that As a Member of our plan,you have the right to get are recommended for your condition,no matter what several kinds of information from us. they cost or whether they are covered by our plan.It also includes being told about programs our plan If you want any of the following kinds of information, offers to help members manage their medications and please call Member Services: use drugs safely • Information about our plan.This includes,for • To know about the risks.You have the right to be example,information about our plan's financial told about any risks involved in your care.You must condition be told in advance if any proposed medical care or • Information about our network providers and treatment is part of a research experiment.You pharmacies always have the choice to refuse any experimental ♦ you have the right to get information about the treatments qualifications of the providers and pharmacies in • The right to say"no."You have the right to refuse our network and how we pay the providers in our any recommended treatment.This includes the right network to leave a hospital or other medical facility,even • Information about your coverage and the rules if your doctor advises you not to leave.You also have you must follow when using your coverage the right to stop taking your medication.Of course, ♦ the"How to Obtain Services"and`Benefits and if you refuse treatment or stop taking a medication, Your Cost Share"sections provide information you accept full responsibility for what happens to regarding medical services your body as a result ♦ the"Outpatient Prescription Drugs,Supplies,and You have the right to give instructions about what is Supplements"in the`Benefits and Your Cost to be done if you are not able to make medical Share"section provides information about decisions for yourself coverage for certain drugs Sometimes people become unable to make health care ♦ if you have questions about the rules or decisions for themselves due to accidents or serious restrictions,please call Member Services illness.You have the right to say what you want to • Information about why something is not covered happen if you are in this situation.This means that, and what you can do about it if you want to,you can: ♦ the"Coverage Decisions,Appeals,and . Fill out a written form to give someone the legal Complaints"section provides information on authority to make medical decisions for you if you asking for a written explanation on why a medical ever become unable to make decisions for yourself service or Part D drug is not covered,or if your . Give your doctors written instructions about how you coverage is restricted want them to handle your medical care if you become ♦ the"Coverage Decisions,Appeals,and unable to make decisions for yourself Complaints"section also provides information on asking us to change a decision,also called an The legal documents that you can use to give your appeal directions in advance of these situations are called advance directives.There are different types of advance We must support your right to make decisions directives and different names for them.Documents about your care called living will and power of attorney for health care You have the right to know your treatment options are examples of advance directives. and participate in decisions about your health care You have the right to get full information from your doctors and other health care providers when you go for Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 65 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. If you want to use an advance directive to give your What can you do if you believe you are being instructions,here is what to do: treated unfairly or your rights are not being • Get the form.You can get an advance directive,a respected? form from your lawyer,from a social worker,or from If it is about discrimination,call the Office for Civil some office supply stores.You can sometimes get Rights advance directive forms from organizations that give If you believe you have been treated unfairly,your people information about Medicare.You can also dignity has not been recognized,or your rights have not contact Member Services to ask for the forms been respected due to your race,disability,religion,sex, • Fill it out and sign it.Regardless of where you get health,ethnicity,creed(beliefs),age,sexual orientation, this form,keep in mind that it is a legal document. or national origin,you should call the Department of You should consider having a lawyer help you Health and Human Services' Office for Civil Rights at prepare it 1-800-368-1019(TTY users call 1-800-537-7697)or call • Give copies to appropriate people.You should give your local Office for Civil Rights. a copy of the form to your doctor and to the person you name on the form who can make decisions for Is it about something else? you if you can't.You may want to give copies to If you believe you have been treated unfairly or your close friends or family members.Keep a copy at rights have not been respected,and it's not about home discrimination,you can get help dealing with the problem you are having: If you know ahead of time that you are going to be • You can call Member Services hospitalized,and you have signed an advance directive, • You can call the State Health Insurance Assistance take a copy with you to the hospital. Program.For details,go to the"Important Phone • The hospital will ask you whether you have signed an Numbers and Resources"section advance directive form and whether you have it with • Or you can call Medicare at 1-800-MEDICARE you (1-800-633-4227),24 hours a day,seven days a week • If you have not signed an advance directive form,the (TTY 1-877-486-2048) hospital has forms available and will ask if you want to sign one How to get more information about your rights There are several places where you can get more Remember,it is your choice whether you want to fill information about your rights: out an advance directive(including whether you want • You can call Member Services to sign one if you are in the hospital).According to law, • You can call the State Health Insurance Assistance no one can deny you care or discriminate against you Program.For details,go to the"Important Phone based on whether or not you have signed an advance Numbers and Resources"section directive. • You can contact Medicare: What if your instructions are not followed? ♦ you can visit the Medicare website to read or If you have signed an advance directive,and you believe download the publication Medicare Rights& that a doctor or hospital did not follow the instructions in Protections.(The publication is available at it,you may file a complaint with the Quality htti)s://www.medicare.p-ov/Pubs/i)df/11534- Improvement Organization listed in the"Important Medicare-Rights-and-Protections.pdf) Phone Numbers and Resources"section. ♦ or you can call 1-800-MEDICARE(1-800-633- 4227),24 hours a day,seven days a week(TTY You have the right to make complaints and to 1-877-486-2048) ask us to reconsider decisions we have made If you have any problems,concerns,or complaints and Information about new technology assessments need to request coverage,or make an appeal,the Rapidly changing technology affects health care and "Coverage Decisions,Appeals,and Complaints"section medicine as much as any other industry.To determine of this document tells you what you can do. whether a new drug or other medical development has long-term benefits,our plan carefully monitors and Whatever you do—ask for a coverage decision,make an evaluates new technologies for inclusion as covered appeal,or make a complaint—we are required to treat benefits.These technologies include medical procedures, you fairly. medical devices,and new drugs. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 66 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. You can make suggestions about rights and • Pay what you owe.As a plan member,you are responsibilities responsible for these payments: As a Member of our plan,you have the right to make ♦ you must continue to pay a premium for your recommendations about the rights and responsibilities Medicare Part B to remain a Member of our plan included in this section.Please call Member Services ♦ for most of your Services or Part D drugs covered with any suggestions. by our plan,you must pay your share of the cost when you get the Service or Part D drug You have some responsibilities as a ♦ if you are required to pay the extra amount for Member of our plan Part D because of your yearly income,you must continue to pay the extra amount directly to the Things you need to do as a Member of our plan are listed government to remain a Member of our plan below.If you have any questions,please call Member • If you move within your Home Region Service Services. Area,we need to know so we can keep your • Get familiar with your covered services and the membership record up-to-date and know how to rules you must follow to get these covered services. contact you Use this EOC to learn what is covered for you and the • If you move outside of your plan's Service Area, rules you need to follow to get your covered services you cannot remain a member of our plan ♦ the"How to Obtain Services"and"Benefits and • If you move,it is also important to tell Social Your Cost Share"sections give details about your Security(or the Railroad Retirement Board) medical services ♦ the"Outpatient Prescription Drugs,Supplies,and Supplements"in the"Benefits and Your Cost Share"section gives details about your Part D Coverage Decisions, Appeals, and prescription drug coverage Complaints • If you have any other health insurance coverage or prescription drug coverage in addition to our plan, What to Do if You Have a Problem or you are required to tell us. ♦ Concern the"Exclusion,Limitations,Coordination of Benefits,and Reductions"section tells you about This section explains two types of processes for handling coordinating these benefits problems and concerns: • Tell your doctor and other health care providers • For some problems,you need to use the process for that you are enrolled in our plan.Show your plan coverage decisions and appeals membership card whenever you get your medical care . For other problems,you need to use the process for or Part D drugs making complaints,also called grievances • Help your doctors and other providers help you by giving them information,asking questions,and Both of these processes have been approved by following through on your care Medicare.Each process has a set of rules,procedures, ♦ to help get the best care,tell your doctors and and deadlines that must be followed by you and us. other health care providers about your health problems.Follow the treatment plans and The guide under"To Deal with Your Problem,Which instructions that you and your doctors agree upon Process Should You Use?"in this"Coverage Decisions, ♦ make sure your doctors know all of the drugs you Appeals,and Complaints"section will help you identify are taking,including over-the-counter drugs, the right process to use and what you should do. vitamins,and supplements ♦ if you have any questions,be sure to ask and get Hospice care an answer you can understand If you have Medicare Part A,your hospice care is covered by Original Medicare and it is not covered under • Be considerate.We expect all our members to this EOC.Therefore,any complaints related to the respect the rights of other patients.We also expect coverage of hospice care must be resolved directly with you to act in a way that helps the smooth running of Medicare and not through any complaint or appeal your doctor's office,hospitals,and other offices procedure discussed in this EOC.Medicare complaint and appeal procedures are described in the Medicare Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 67 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. handbook Medicare&You,which is available from your also answer your questions,give you more information, local Social Security office,at and offer guidance on what to do. https://www.medicare.aov,or by calling toll free 1-800- MEDICARE(1-800-633-4227)(TTY users call 1-877- The services of SHIP counselors are free.You will find 486-2048),24 hours a day,seven days a week.If you do phone numbers and website URLs in the"Important not have Medicare Part A,Original Medicare does not Phone Numbers and Resources"section. cover hospice care.Instead,we will provide hospice care,and any complaints related to hospice care are Medicare subject to this"Coverage Decisions,Appeals,and You can also contact Medicare to get help. To contact Complaints"section. Medicare: What about the legal terms? • You can call 1-800-MEDICARE(1-800-633-4227), There are legal terms for some of the rules,procedures, 24 hours a day,seven days a week(TTY 1-877-486- 2048) and types of deadlines explained in this"Coverage Decisions,Appeals,and Complaints"section.Many of • You can also visit the Medicare website these terms are unfamiliar to most people and can be (https://www.medicare.2ov) hard to understand. To make things easier,this section: To Deal with Your Problem, Which Process Should You Use? • Uses simpler words in place of certain legal terms. For example,this section generally says making a If you have a problem or concern,you only need to read complaint rather than filing a grievance,coverage the parts of this section that apply to your situation.The decision rather than organization determination or guide that follows will help. coverage determination,or at-risk determination,and independent review organization instead of Is your problem or concern about your benefits or Independent Review Entity. coverage? • It also uses abbreviations as little as possible. This includes problems about whether medical care (medical items,services and/or Part B prescription drugs)are covered or not,the way they are covered,and However,it can be helpful,and sometimes quite problems related to payment for medical care important,for you to know the correct legal terms. Knowing which terms to use will help you communicate • Yes.Go on to"A Guide to the Basics of Coverage more accurately to get the right help or information for Decisions and Appeals" your situation.To help you know which terms to use,we • No. Skip ahead to"How to Make a Complaint About include legal terms when we give the details for handling Quality of Care,Waiting Times,Customer Service,or specific types of situations. Other Concerns" Where To Get More Information and A Guide to the Basics of Coverage Personalized Assistance Decisions and Appeals We are always available to help you.Even if you have a Asking for coverage decisions and making complaint about our treatment of you,we are obligated appeals—the big picture to honor your right to complain. Therefore,you should Coverage decisions and appeals deal with problems always reach out to Member Services for help.But in related to your benefits and coverage for your medical some situations you may also want help or guidance care(services,items and Part B prescription drugs, from someone who is not connected with us.Below are including payment).To keep things simple,we generally two entities that can assist you. refer to medical items,services and Medicare Part B prescription drugs as medical care.You use the coverage State Health Insurance Assistance Program decision and appeals process for issues such as whether (SHIP) something is covered or not,and the way in which Each state has a government program with trained something is covered. counselors.The program is not connected with us or with any insurance company or health plan.The counselors at this program can help you understand which process you should use to handle a problem you are having.They can Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 68 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Asking for coverage decisions prior to receiving Level 2 appeal conducted by an independent review benefits organization that is not connected to us. A coverage decision is a decision we make about your • You do not need to do anything to start a Level 2 benefits and coverage or about the amount we will pay appeal.Medicare rules require we automatically send for your medical care.For example,if your Plan your appeal for medical care to Level 2 if we do not Physician refers you to a medical specialist not inside the fully agree with your Level 1 appeal network,this referral is considered a favorable coverage decision unless either your Plan Physician can show that • See"Step-by-step:How a Level 2 appeal is done"of you received a standard denial notice for this medical this chapter for more information about Level 2 specialist,or the EOC makes it clear that the referred appeals service is never covered under any condition.You or • For Part D drug appeals,if we say no to all or part of your doctor can also contact us and ask for a coverage your appeal you will need to ask for a Level 2 appeal. decision,if your doctor is unsure whether we will cover a Part D appeals are discussed further in"Your Part D particular medical service or refuses to provide medical Prescription Drugs:How to Ask for a Coverage care you think that you need.In other words,if you want Decision or Make an Appeal"of this section) to know if we will cover a medical care before you receive it,you can ask us to make a coverage decision If you are not satisfied with the decision at the Level 2 for you. appeal,you may be able to continue through additional levels of appeal.("Taking Your Appeal to Level 3 and We are making a coverage decision for you whenever we Beyond"in this section explains the Level 3,4,and 5 decide what is covered for you and how much we pay.In appeals processes). some cases,we might decide medical care is not covered or is no longer covered by Medicare for you.If you How to get help when you are asking for a disagree with this coverage decision,you can make an coverage decision or making an appeal appeal. Here are resources if you decide to ask for any kind of Making an appeal coverage decision or appeal a decision: If we make a coverage decision,whether before or after a • You can call us at Member Services benefit is received,and you are not satisfied,you can • You can get free help from your State Health appeal the decision.An appeal is a formal way of asking Insurance Assistance Program us to review and change a coverage decision we have • Your doctor can make a request for you.If your made.Under certain circumstances,which we discuss doctor helps with an appeal past Level 2,they will later,you can request an expedited or fast appeal of a need to be appointed as your representative.Please coverage decision.Your appeal is handled by different call Member Services and ask for the Appointment reviewers than those who made the original decision. of Representative form.(The form is also available on Medicare's website at When you appeal a decision for the first time,this is https://www.cros.zov[Medicare/CMS-Forms/ called a Level 1 appeal.In this appeal,we review the CMS-Forms/downloads/cros1696.pdf or on our coverage decision we have made to check to see if we website at k .or were properly following the rules.When we have ♦ for medical care or Medicare Part B prescription completed the review,we give you our decision. drugs,your doctor can request a coverage decision or a Level 1 appeal on your behalf.If your appeal In limited circumstances,a request for a Level 1 appeal is denied at Level 1,it will be automaticallyforwarded to Level will be dismissed,which means we won't review the request.Examples of when a request will be dismissed ♦ for Part D prescription drugs,your doctor or other include if the request is incomplete,if someone makes prescriber can request a coverage decision or a the request on your behalf but isn't legally authorized to Level 1 appeal on your behalf.If your Level 1 do so or if you ask for your request to be withdrawn.If appeal is denied,your doctor or prescriber can we dismiss a request for a Level 1 appeal,we will send a request a Level 2 appeal notice explaining why the request was dismissed and • You can ask someone to act on your behalf.If you how to ask for a review of the dismissal. want to,you can name another person to act for you If we say no to all or part of your Level 1 appeal for medical care,your appeal will automatically go on to a Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 69 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. as your representative to ask for a coverage decision information from government organizations such as your or make an appeal SHIP. ♦ if you want a friend,relative,or other person to be your representative,call Member Services and ask for the Appointment of Representative form. (The Your Medical Care: How to Ask for a form is also available on Medicare's website at Coverage Decision or Make an Appeal httns://www.cros.2ov/Medicare/CMS-Forms/ of a Coverage Decision CMS-Forms/downloads/cros1696.ndf or on our website at kp.org.)The form gives that person This section tells what to do if you have permission to act on your behalf.It must be signed problems getting coverage for medical care or by you and by the person whom you would like to if you want pay you back for our share of act on your behalf.You must give us a copy of the the cost of your care signed form This section is about your benefits for medical care. ♦ while we can accept an appeal request without the These benefits are described in the"Benefits and Your form,we cannot begin or complete our review Cost Share"section.In some cases,different rules apply until we receive it.If we do not receive the form to a request for a Medicare Part B prescription drug.In within 44 calendar days after receiving your those cases,we will explain how the rules for Medicare appeal request(our deadline for making a decision Part B prescription drugs are different from the rules for on your appeal),your appeal request will be medical items and services. dismissed.If this happens,we will send you a written notice explaining your right to ask the This section tells you what you can do if you are in any independent review organization to review our of the following situations: decision to dismiss your appeal. . You are not getting certain medical care you want, • You also have the right to hire a lawyer.You may and you believe that this is covered by our plan.Ask contact your own lawyer,or get the name of a lawyer for a coverage decision from your local bar association or other referral • We will not approve the medical care your doctor or service.There are also groups that will give you free other medical provider wants to give you,and you legal services if you qualify.However,you are not believe that this care is covered by our plan.Ask for required to hire a lawyer to ask for any kind of a coverage decision coverage decision or appeal a decision . You have received medical care that you believe Which section gives the details for your should be covered by our plan,but we have said we situation? will not pay for this care.Make an appeal There are four different situations that involve coverage • You have received and paid for medical care that you decisions and appeals. Since each situation has different believe should be covered by our plan,and you want rules and deadlines,we give the details for each one in a to ask us to reimburse you for this care. Send us the separate section: bill • Your Medical Care:How to Ask for a Coverage • You are being told that coverage for certain medical Decision or Make an Appeal of a Coverage Decision" care you have been getting that we previously approved will be reduced or stopped,and you believe • "Your Part D Prescription Drugs:How to Ask for a that reducing or stopping this care could harm your Coverage Decision or Make an Appeal" health.Make an appeal • "How to Ask Us to Cover a Longer Inpatient Hospital Note: If the coverage that will be stopped is for hospital Stay if You Think the Doctor Is Discharging You Too Services,home health care,Skilled Nursing Facility care, Soon" or Comprehensive Outpatient Rehabilitation Facility • "How to Ask Us to Keep Covering Certain Medical (CORF)services,you need to read"How to Ask Us to Services if You Think Your Coverage is Ending Too Cover a Longer Inpatient Hospital Stay if You Think the Soon"(applies only to these services:home health Doctor Is Discharging You Too Soon"and"How to Ask care,Skilled Nursing Facility care,and Us to Keep Covering Certain Medical Services if You Comprehensive Outpatient Rehabilitation Facility Think Your Coverage is Ending Too Soon"of this (CORF)services) section. Special rules apply to these types of care. If you're not sure which section you should be using, please call Member Services.You can also get help or Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 70 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Step-by-step: How to ask for a coverage Numbers and Resources"section has contact decision information When a coverage decision involves your medical care,it is called an organization determination.A fast Step 3: We consider your request for medical care coverage decision is called an expedited determination. coverage and give you our answer Step 1: Decide if you need a standard coverage For standard coverage decisions,we use the standard deadlines. decision or a fast coverage decision. A standard coverage decision is usually made within 14 This means we will give you an answer within 14 days or 72 hours for Part B drugs.A fast coverage calendar days after we receive your request for a medical decision is generally made within 72 hours,for medical item or service.If your request is for a Medicare Part B services,or 24 hours for Part B drugs.In order to get a prescription drug,we will give you an answer within 72 fast coverage decision,you must meet two requirements: hours after we receive your request. ♦ you may only ask for coverage for medical items ♦ however,if you ask for more time,or if we need and/or services not requests for payment for items more information that may benefit you,we can and/or services already received take up to 14 more days if your request is for a medical item or service.If we take extra days,we ♦ you can get a fast coverage decision only if using will tell you in writing.We can't take extra time to the standard deadlines could cause serious harm to make a decision if your request is for a Medicare your health or hurt your ability to function Part B prescription drug • If your doctor tells us that your health requires a fast ♦ if you believe we should not take extra days,you coverage decision,we will automatically agree to can file a fast complaint.We will give you an give you a fast coverage decision answer to your complaint as soon as we make the • If you ask for a fast coverage decision on your own, decision. (The process for making a complaint is without your doctor's support,we will decide whether different from the process for coverage decisions your health requires that we give you a fast coverage and appeals. See"How to Make a Complaint decision.If we do not approve a fast coverage About Quality of Care,Waiting Times,Customer decision,we will send you a letter that: Service,or Other Concerns"of this section for ♦ explains that we will use the standard deadlines information on complaints.) ♦ explains if your doctor asks for the fast coverage For fast coverage decisions,we use an expedited time decision,we will automatically give you a fast frame. coverage decision ♦ explains that you can file a fast complaint about A fast coverage decision means we will answer within 72 our decision to give you a standard coverage hours if your request is for a medical item or service.If decision instead of the fast coverage decision you your request is for a Medicare Part B prescription drug, requested we will answer within 24 hours. Step 2: Ask our plan to make a coverage decision ♦ however,if you ask for more time,or if we need or fast coverage decision more information that may benefit you we can take up to 14 more days.If we take extra days,we • Start by calling,writing,or faxing our plan to make will tell you in writing.We can't take extra time to your request for us to authorize or provide coverage make a decision if your request is for a Medicare for the medical care you want.You,your doctor,or Part B prescription drug your representative can do this.The"Important Phone ♦ if you believe we should not take extra days,you can file a fast complaint. See"How to Make a Complaint About Quality of Care,Waiting Times, Customer Service,or Other Concerns"of this section for information on complaints.)We will call you as soon as we make the decision. ♦ if we do not give you our answer within 72 hours (or if there is an extended time period,by the end of that period),or within 24 hours if your request is for a Medicare Part B prescription drug,you have the right to appeal."Step-by-step:How to Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 71 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. make a Level 1 Appeal"below tells you how to • You can ask for a copy of the information regarding make an appeal your medical decision.You and your doctor may add ♦ If our answer is no to part or all of what you more information to support your appeal.We are requested,we will send you a written statement allowed to charge a fee for copying and sending this that explains why we said no information to you Step 4: If we say no to your request for coverage Step 3: We consider your appeal and we give you for medical care, you can appeal our answer • If we say no,you have the right to ask us to • When we are reviewing your appeal,we take a reconsider this decision by making an appeal.This careful look at all of the information.We check to see means asking again to get the medical care coverage if we were following all the rules when we said no to you want.If you make an appeal,it means you are your request going on to Level 1 of the appeals process • We will gather more information if needed possibly contacting you or your doctor Step-by-step: How to make a Level 1 appeal An appeal to our plan about a medical care coverage Deadlines for a fast appeal decision is called a plan reconsideration.A fast appeal • For fast appeals,we must give you our answer within is also called an expedited reconsideration. 72 hours after we receive your appeal.We will give Step 1: Decide if you need a standard appeal or a you our answer sooner if your health requires us to fast appeal ♦ however,if you ask for more time,or if we need more information that may benefit you,we can A standard appeal is usually made within 30 days or take up to 14 more days if your request is for a 7 days for Part B drugs.A fast appeal is generally medical item or service.If we take extra days,we made within 72 hours. will tell you in writing.We can't take extra time if • If you are appealing a decision we made about your request is for a Medicare Part B prescription coverage for care that you have not yet received,you drug and/or your doctor will need to decide if you need a ♦ if we do not give you an answer within 72 hours fast appeal.If your doctor tells us that your health (or by the end of the extended time period if we requires a fast appeal,we will give you a fast appeal took extra days),we are required to automatically • The requirements for getting a fast appeal are the send your request on to Level 2 of the appeals same as those for getting a fast coverage decision in process,where it will be reviewed by an "Your Medical Care:How to Ask for a Coverage independent review organization. "Step-by-Step: Decision or Make an Appeal"of this section How a Level 2 Appeal is Done"explains the Level 2 appeal process Step 2: Ask our plan for an appeal or a fast appeal • If our answer is yes to part or all of what you • If you are asking for a standard appeal,submit your requested,we must authorize or provide the coverage standard appeal in writing.You may also ask for an we have agreed to provide within 72 hours after we appeal by calling us.The"Important Phone Numbers receive your appeal and Resources"section has contact information • If our answer is no to part or all of what you • If you are asking for a fast appeal,make your appeal requested,we will send you our decision in writing in writing or call us.The"Important Phone Numbers and automatically forward your appeal to the and Resources"section has contact information independent review organization for a Level 2 appeal. The independent review organization will notify you • You must make your appeal request within 60 in writing when it receives your appeal calendar days from the date on the written notice we sent to tell you our answer on the coverage decision. If you miss this deadline and have a good reason for missing it,explain the reason your appeal is late when you make your appeal.We may give you more time to make your appeal.Examples of good cause may include a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 72 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Deadlines for a standard appeal Step 1: The independent review organization • For standard appeals,we must give you our answer reviews your appeal within 30 calendar days after we receive your appeal. . We will send the information about your appeal to If your request is for a Medicare Part B prescription this organization.This information is called your case drug you have not yet received,we will give you our file.You have the right to ask us for a copy of your answer within 7 calendar days after we receive your case file.We are allowed to charge you a fee for appeal.We will give you our decision sooner if your copying and sending this information to you health condition requires us to . You have a right to give the independent review ♦ however,if you ask for more time,or if we need organization additional information to support your more information that may benefit you,we can appeal take up to 14 more calendar days if your request is for a medical item or service.If we take extra • Reviewers at the independent review organization days,we will tell you in writing.We can't take will take a careful look at all of the information extra time to make a decision if your request is for related to your appeal a Medicare Part B prescription drug ♦ if you believe we should not take extra days,you If you had a fast appeal at Level 1,you will also have can file a fast complaint.When you file a fast a fast appeal at Level 2 complaint,we will give you an answer to your • For the fast appeal,the review organization must give complaint within 24 hours.(See"How to Make a you an answer to your Level 2 appeal within 72 hours Complaint About Quality of Care,Waiting Times, of when it receives your appeal Customer Service,or Other Concerns"in this • However,if your request is for a medical item or "Coverage Decisions,Appeals,and Complaints" service and the independent review organization section) needs to gather more information that may benefit ♦ if we do not give you an answer by the deadline you,it can take up to 14 more calendar days.The (or by the end of the extended time period),we independent review organization can't take extra time will send your request to a Level 2 appeal,where to make a decision if your request is for a Medicare an independent review organization will review Part B prescription drug the appeal.Later in this section,we talk about this review organization and explain the Level 2 If you had a standard appeal at Level 1,you will also appeal process have a standard appeal at Level 2 • If our answer is yes to part or all of what you • For the standard appeal,if your request is for a requested,we must authorize or provide the coverage medical item or service,the review organization must within 30 calendar days if your request is for a give you an answer to your Level 2 appeal within 30 medical item or service,or within 7 calendar days if calendar days of when it receives your appeal.If your your request is for a Medicare Part B prescription request is for a Medicare Part B prescription drug,the drug review organization must give you an answer to your • If our plan says no to part or all of what your appeal, Level 2 appeal within 7 calendar days of when it we will automatically send your appeal to the receives your appeal independent review organization for a Level 2 appeal • However,if your request is for a medical item or service and the independent review organization Step-by-step: How a Level 2 appeal is done needs to gather more information that may benefit The formal name for the independent review you,it can take up to 14 more calendar days.The organization is the Independent Review Entity.It is independent review organization can't take extra time sometimes called the IRE. to make a decision if your request is for a Medicare Part B prescription drug The independent review organization is an independent organization hired by Medicare.It is not connected with Step 2: The independent review organization gives us and is not a government agency.This organization you their answer decides whether the decision we made is correct or if it The independent review organization will tell you its should be changed.Medicare oversees its work. decision in writing and explain the reasons for it. • If the review organization says yes to part or all of a request for a medical item or service,we must authorize the medical care coverage within 72 hours Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 73 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. or provide the service within 14 calendar days after Asking for reimbursement is asking for a we receive the decision from the review organization coverage decision from us for standard requests.For expedited requests,we have If you send us the paperwork asking for reimbursement, 72 hours from the date we receive the decision from you are asking for a coverage decision.To make this the review organization decision,we will check to see if the medical care you • If the review organization says yes to part or all of a paid for is covered.We will also check to see if you request for a Medicare Part B prescription drug,we followed all the rules for using your coverage for must authorize or provide the Medicare Part B medical care. prescription drug within 72 hours after we receive the • If we say yes to your request:If the medical care is decision from the review organization for standard covered and you followed all the rules,we will send requests.For expedited requests,we have 24 hours you the payment for our share of the cost within 60 from the date we receive the decision from the review calendar days after we receive your request.If you organization haven't paid for the medical care,we will send the • If this organization says no to part or all of your payment directly to the provider appeal,it means they agree with us that your request • If we say no to your request: If the medical care is not (or part of your request)for coverage for medical care covered,or you did not follow all the rules,we will should not be approved. (This is called upholding the not send payment.Instead,we will send you a letter decision or turning down your appeal) that says we will not pay for the medical care and the • In this care,the independent review organization will reasons why send you a letter: ♦ explaining its decision If you do not agree with our decision to turn you down, you can make an appeal.If you make an appeal,it means ♦ notifying you of the right to a Level appeal if the you are asking us to change the coverage decision we dollar value of the medical care coverage meets a made when we turned down your request for payment. certain minimum.The written notice you get from the independent review organization will tell you To make this appeal,follow the process for appeals that the dollar amount you must meet to continue the we describe in"Step-by-step:How to make a Level 1 appeals process Appeal."For appeals concerning reimbursement,please Step 3: If your case meets the requirements, you note: choose whether you want to take your appeal • We must give you our answer within 60 calendar days further after we receive your appeal.If you are asking us to • There are three additional levels in the appeals pay you back for medical care you have already process after Level(for a total of five levels of received and paid for yourself,you are not allowed to ask for a fast appeal appeal).If you want to go to a Level 3 appeal the details on how to do this are in the written notice you • If the independent review organization decides we get after your Level 2 appeal should pay,we must send you or the provider the • The Level 3 appeal is handled by an Administrative payment within 30 calendar days.If the answer to Law Judge or attorney adjudicator."Taking Your your appeal is yes at any stage of the appeals process Appeal to Level 3 and Beyond"in this"Coverage after Level 2,we must send the payment you Decisions,Appeals,and Complaints"section explains requested to you or to the provider within 60 calendar the Levels 3,4,and 5 appeals processes days What if you are asking us to pay you for our Your Part D Prescription Drugs: How to share of a bill you have received for medical Ask for a Coverage Decision or Make an care? The"Requests for Payment"section describes when you Appeal may need to ask for reimbursement or to pay a bill you What to do if you have problems getting a Part D have received from a provider.It also tells you how to drug or you want us to pay you back for a Part D send us the paperwork that asks us for payment. drug Your benefits include coverage for many prescription drugs.To be covered,the drug must be used for a medically accepted indication.(A"medically accepted indication"is a use of the drug that is either approved by Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 74 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. the Food and Drug Administration or supported by Asking for removal of a restriction on coverage for a certain reference books.)For details about Part D drugs, drug is sometimes called asking for a formulary rules,restrictions,and costs,please see"Outpatient exception. Prescription Drugs,Supplies,and Supplements"in the "Benefits and Your Cost Share"section. This section is If a drug is not covered in the way you would like it to be about your Part D drugs only.To keep things simple, covered,you can ask us to make an exception.An we generally say drug in the rest of this section,instead exception is a type of coverage decision. of repeating covered outpatient prescription drug or Part D drug every time.We also use the term"Drug For us to consider your exception request,your doctor or List"instead of List of Covered Drugs or 2024 other prescriber will need to explain the medical reasons Comprehensive Formulary. why you need the exception approved.Here are two • If you do not know if a drug is covered or if you meet examples of exceptions that you or your doctor or other the rules,you can ask us. Some drugs require that you prescriber can ask us to make: get approval from us before we will cover it • Covering a Part D drug for you that is not on our • If your pharmacy tells you that your prescription "Drug List."If we agree to cover a drug that is not on cannot be filled as written,the pharmacy will give the"Drug List,"you will need to pay the Cost Share you a written notice explaining how to contact us to amount that applies to drugs in the brand-name drug ask for a coverage decision tier.You cannot ask for an exception to the Copayment or Coinsurance amount we require you to Part D coverage decisions and appeals pay for the drug An initial coverage decision about your Part D drugs is • Removing a restriction for a covered Part D drug. called a coverage determination. "Outpatient Prescription Drugs,Supplies,and Supplements"in the"Benefits and Your Cost Share" A coverage decision is a decision we make about your section describes the extra rules or restrictions that benefits and coverage or about the amount we will pay apply to certain drugs on our"Drug List."If we agree for your drugs.This section tells what you can do if you to make an exception and waive a restriction for you, are in any of the following situations: you can ask for an exception to the Copayment or • Asking us to cover a Part D drug that is not on our Coinsurance amount we require you to pay for the 2024 Comprehensive Formulary.Ask for an Part D drug exception • Asking us to waive a restriction on our plan's Important things to know about asking for Part D exceptions coverage for a drug(such as limits on the amount of the drug you can get).Ask for an exception Your doctor must tell us the medical reasons • Asking to pay a lower cost-sharing amount for a Your doctor or other prescriber must give us a statement covered drug on a higher cost-sharing tier.Ask for an that explains the medical reasons for requesting a Part D exception exception.For a faster decision,include this medical • Asking us to get pre-approval for a drug.Ask for a information from your doctor or other prescriber when coverage decision you ask for the exception. • Pay for a prescription drug you already bought.Ask Typically,our"Drug List"includes more than one drug us to pay you back for treating a particular condition.These different possibilities are called alternative drugs.If an If you disagree with a coverage decision we have made, alternative drug would be just as effective as the drug you can appeal our decision. you are requesting and would not cause more side effects or other health problems,we will generally not approve This section tells you both how to ask for coverage your request for an exception.If you ask us for a tiering decisions and how to request an appeal. exception,we will generally not approve your request for an exception unless all the alternative drugs in the lower What is an exception? cost-sharing tier(s)won't work as well for you or are Asking for coverage of a drug that is not on the Drug likely to cause an adverse reaction or other harm. List is sometimes called asking for a formulary exception. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 75 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. We can say yes or no to your request medical care you want.You can also access the coverage • If we approve your request for a Part D exception,our decision process through our website.We must accept approval usually is valid until the end of the plan any written request,including a request submitted on the year.This is true as long as your doctor continues to CMS Model Coverage Determination Request form, which is available on our website. How to contact us prescribe the drug for you and that drug continues to when you are asking for a coverage decision about your be safe and effective for treating your condition part D prescription drugs"in the"Important Phone • If we say no to your request,you can ask for another Numbers and Resources"section has contact review by making an appeal information.To assist us in processing your request, please be sure to include your name,contact information, Step-by-step: How to ask for a coverage and information identifying which denied claim is being decision, including a Part D exception appealed. A fast coverage decision is called an expedited coverage You,or your doctor(or other prescriber),or your determination. representative can do this.You can also have a lawyer act on your behalf."How to Get Help When You are Step 1: Decide if you need a standard coverage Asking for a Coverage Decision or Making an Appeal" decision or a fast coverage decision of this section tells how you can give written permission Standard coverage decisions are made within 72 hours to someone else to act as your representative. after we receive your doctor's statement.Fast coverage • If you are requesting a Part D exception,provide the decisions are made within 24 hours after we receive supporting statement which is the medical reasons for your doctor's statement. the exception.Your doctor or other prescriber can fax If your health requires it,ask us to give you a fast or mail the statement to us.Or your doctor or other coverage decision.To get a fast coverage decision,you prescriber can tell us on the phone and follow up by must meet two requirements: faxing or mailing a written statement if necessary • You must be asking for a drug you have not yet Step 3: We consider your request and we give you received. (You cannot ask for a fast coverage decision our answer to be paid back for a drug you have already bought) • Using the standard deadlines could cause serious Deadlines for a fast coverage decision harm to your health or hurt your ability to function • We must generally give you our answer within 24 • If your doctor or other prescriber tells us that hours after we receive your request. your health requires a fast coverage decision,we ♦ for exceptions,we will give you our answer within will automatically give you a fast coverage decision 24 hours after we receive your doctor's supporting • If you ask for a fast coverage decision on your statement.We will give you our answer sooner own,without your doctor's or prescriber's support,we if your health requires us to will decide whether your health requires that we give ♦ if we do not meet this deadline,we are required to you a fast coverage decision.If we do not approve a send your request to Level 2 of the appeals fast coverage decision,we will send you a letter that: process,where it will be reviewed by an ♦ explains that we will use the standard deadlines independent review organization ♦ explains if your doctor or other prescriber asks for • If our answer is yes to part or all of what you the fast coverage decision,we will automatically requested,we must provide the coverage we have give you a fast coverage decision agreed to provide within 24 hours after we receive ♦ tells you how you can file a fast complaint about your request or doctor's statement supporting your our decision to give you a standard coverage request decision instead of the fast coverage decision you • If our answer is no to part or all of what you requested.We will answer your complaint within requested,we will send you a written statement that 24 hours of receipt explains why we said no.We will also tell you how you can appeal Step 2: Request a standard coverage decision or a fast coverage decision Deadlines for a standard coverage decision about a Part D drug you have not yet received Start by calling,writing,or faxing OptumRx Prior Authorization Member Services Desk to make your request for us to authorize or provide coverage for the Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 76 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • We must generally give you our answer within 72 Step 1: Decide if you need a standard appeal or a hours after we receive your request fast appeal ♦ for exceptions,we will give you our answer within A standard appeal is usually made within 7 days.A 72 hours after we receive your doctor's supporting fast appeal is generally made within 72 hours.If your statement.We will give you our answer sooner health requires it,ask for a fast appeal if your health requires us to ♦ if we do not meet this deadline,we are required to • If you are appealing a decision we made about a drug send your request on to Level 2 of the appeals you have not yet received,you and your doctor or process,where it will be reviewed by an other prescriber will need to decide if you need a fast independent review organization appeal • If our answer is yes to part or all of what you • The requirements for getting a"fast appeal"are the requested,we must provide the coverage we have same as those for getting a fast coverage decision in agreed to provide within 72 hours after we receive "Step-by-step:How to ask for a coverage decision, your request or doctor's statement supporting your including a Part D exception"of this section request • If our answer is no to part or all of what you Step 2: You, your representative, doctor, or other requested,we will send you a written statement that prescriber must contact us and make your Level 1 explains why we said no.We will also tell you how appeal. If your health requires a quick response, you can appeal you must ask for a fast appeal • For standard appeals,submit a written request. Deadlines for a standard coverage decision about "Important Phone Numbers and Resources"has payment for a drug you have already bought contact information • We must give you our answer within 14 calendar days • For fast appeals either submit your appeal in writing after we receive your request or call us at 1-800-443-0815."Important Phone Numbers and Resources"has contact information ♦ if we do not meet this deadline,we are required to send your request to Level 2 of the appeals • We must accept any written request,including a process,where it will be reviewed by an request submitted on the CMS Model Coverage independent review organization Determination Request Form,which is available on our website.Please be sure to include your name, • If our answer is yes to part or all of what you contact information,and information regarding your requested,we are also required to make payment to claim to assist us in processing your request you within 14 calendar days after we receive your • You must make your appeal request within 60 request calendar days from the date on the written notice we • If our answer is no to part or all of what you sent to tell you our answer on the coverage decision. requested,we will send you a written statement that If you miss this deadline and have a good reason for explains why we said no.We will also tell you how missing it,explain the reason your appeal is late when you can appeal you make your appeal.We may give you more time to make your appeal.Examples of good cause may Step 4: If we say no to your coverage request, you include a serious illness that prevented you from decide if you want to make an appeal contacting us or if we provided you with incorrect or incomplete information about the deadline for If we say no,you have the right to ask us to reconsider requesting an appeal this decision by making an appeal.This means asking again to get the drug coverage you want.If you make an • You can ask for a copy of the information in your appeal,it means you are going to Level 1 of the appeals appeal and add more information.You and your process. doctor may add more information to support your appeal.We are allowed to charge a fee for copying Step-by-step: How to make a Level 1 appeal and sending this information to you An appeal to our plan about a Part D drug coverage decision is called a plan redetermination.A fast appeal Step 3: We consider your appeal and we give you is also called an expedited redetermination. our answer • When we are reviewing your appeal,we take another careful look at all of the information about your coverage request.We check to see if we were Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 77 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. following all the rules when we said no to your • If our answer is no to part or all of what you request.We may contact you or your doctor or other requested,we will send you a written statement that prescriber to get more information explains why we said no.We will also tell you how you can appeal our decision Deadlines for a fast appeal • For fast appeals,we must give you our answer within Step 4: If we say no to your appeal, you decide 72 hours after we receive your appeal.We will give if you want to continue with the appeals process you our answer sooner if your health requires us to and make another appeal ♦ if we do not give you an answer within 72 hours, • If you decide to make another appeal,it means your we are required to send your request on to Level 2 appeal is going on to Level 2 of the appeals process of the appeals process,where it will be reviewed by an independent review organization Step-by-step: How to make a Level 2 appeal • If our answer is yes to part or all of what you The formal name for the independent review requested,we must provide the coverage we have organization is the Independent Review Entity.It is agreed to provide within 72 hours after we receive sometimes called the IRE. your appeal The independent review organization is an • If our answer is no to part or all of what you independent organization hired by Medicare.It is not requested,we will send you a written statement that connected with us and is not a government agency.This explains why we said no and how you can appeal our organization decides whether the decision we made is decision correct or if it should be changed.Medicare oversees its Deadlines for a standard appeal for a drug you have Fork. not yet received • For standard appeals,we must give you our answer Step 1: You (or your representative or your doctor within 7 calendar days after we receive your appeal. or other prescriber) must contact the independent We will give you our decision sooner if you have not review organization and ask for a review of your received the drug yet and your health condition case requires us to do so • If we say no to your Level 1 appeal,the written notice ♦ if we do not give you a decision within 7 calendar we send you will include instructions on how to make days,we are required to send your request on to a Level 2 appeal with the independent review Level 2 of the appeals process,where it will be organization. These instructions will tell who can reviewed by an independent review organization make this Level 2 appeal,what deadlines you must follow,and how to reach the review organization.If, • If our answer is yes to part or all of what you however,we did not complete our review within the requested,we must provide the coverage as quickly as applicable timeframe,or make an unfavorable your health requires,but no later than 7 calendar days decision regarding at-risk determination under our after we receive your appeal drug management program,we will automatically • If our answer is no to part or all of what you forward your claim to the IRE requested,we will send you a written statement that • We will send the information about your appeal to explains why we said no and how you can appeal our this organization.This information is called your case decision file.You have the right to ask us for a copy of your Deadlines for a standard appeal about payment for a case file.We are allowed to charge you a fee for drug you have already bought copying and sending this information to you • We must give you our answer within 14 calendar days • You have a right to give the independent review after we receive your request organization additional information to support your ♦ If we do not meet this deadline,we are required to appeal send your request to Level 2 of the appeals Step 2: The independent review organization process,where it will be reviewed by an reviews your appeal independent review organization • If our answer is yes to part or all of what you Reviewers at the independent review organization will requested,we are also required to make payment to take a careful look at all of the information related to you within 30 calendar days after we receive your your appeal. request Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 78 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Deadlines for fast appeal cannot make another appeal and the decision at Level • If your health requires it,ask the independent review 2 is final organization for a fast appeal • Telling you the dollar value that must be in dispute to • If the organization agrees to give you a fast appeal, continue with the appeals process the organization must give you an answer to your Level 2 appeal within 72 hours after it receives your Step 4: If your case meets the requirements, you appeal request choose whether you want to take your appeal further Deadlines for standard appeal • There are three additional levels in the appeals • For standard appeals,the review organization must process after Level 2(for a total of five levels of give you an answer to your Level 2 appeal within 7 appeal) calendar days after it receives your appeal if it is for a • If you want to go on to a Level 3 appeal the details on drug you have not yet received.If you are requesting how to do this are in the written notice you get after that we pay you back for a drug you have already your Level 2 appeal decision bought,the review organization must give you an • The Level 3 appeal is handled by an Administrative answer to your Level 2 appeal within 14 calendar days after it receives your request Law Judge or attorney adjudicator."Taking Your Appeal to Level 3 and Beyond"tells more about Step 3: The independent review organization give Levels 3,4,and 5 of the appeals process you their answer For fast appeals: How to Ask Us to Cover a Longer • If the independent review organization says yes to Inpatient Hospital Stay if You Think You part or all of what you requested,we must provide the Are Being Discharged Too Soon drug coverage that was approved by the review When you are admitted to a hospital,you have the right organization within 24 hours after we receive the to get all of your covered hospital Services that are decision from the review organization necessary to diagnose and treat your illness or injury. For standard appeals: • If the independent review organization says yes to During your covered hospital stay,your doctor and the part or all of your request for coverage,we must hospital staff will be working with you to prepare for the provide the drug coverage that was approved by the day when you will leave the hospital.They will help review organization within 72 hours after we receive arrange for care you may need after you leave. the decision from the review organization • The day you leave the hospital is called your • If the independent review organization says yes to discharge date part or all of your request to pay you back for a drug • When your discharge date is decided,your doctor or you already bought,we are required to send payment the hospital staff will tell you to you within 30 calendar days after we receive the . If you think you are being asked to leave the hospital decision from the review organization too soon,you can ask for a longer hospital stay and What if the review organization says no to your your request will be considered appeal? During your inpatient hospital stay, you will get If this organization says no to your appeal,it means the a written notice from Medicare that tells about organization agrees with our decision not to approve your rights your request(or part of your request.)(This is called Within two days of being admitted to the hospital,you upholding the decision.It is also called turning down will be given a written notice called An Important your appeal.)In this case,the independent review Message from Medicare About Your Rights. Everyone organization will send you a letter: with Medicare gets a copy of this notice If you do not get • Explaining its decision the notice from someone at the hospital(for example,a caseworker or nurse),ask any hospital employee for it. • Notifying you of the right to a Level 3 appeal if the If you need help,please call Member Services or 1-800- dollar value of the drug coverage you are requesting MEDICARE(1-800-633-4227),24 hours a day,seven meets a certain minimum.If the dollar value of the days a week(TTY 1-877-486-2048). drug coverage you are requesting is too low,you Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 79 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Read this notice carefully and ask questions if you • Ask for help if you need it.If you have questions or don't understand it.It tells you: need help at any time,please call Member Services. ♦ your right to receive Medicare-covered services Or call your State Health Insurance Assistance during and after your hospital stay,as ordered by Program,a government organization that provides your doctor. This includes the right to know what personalized assistance these services are,who will pay for them,and where you can get them During a Level 1 appeal,the Quality Improvement ♦ your right to be involved in any decisions about Organization reviews your appeal.It checks to see your hospital stay if your planned discharge date is medically appropriate ♦ where to report any concerns you have about the for you. quality of your hospital Services The Quality Improvement Organization is a group of ♦ your right to request an immediate review of the doctors and other health care professionals paid by the decision to discharge you if you think you are federal government to check on and help improve the being discharged from the hospital too soon. This quality of care for people with Medicare.This includes is a formal,legal way to ask for a delay in your reviewing hospital discharge dates for people with discharge date so that we will cover your hospital Medicare.These experts are not part of our plan. care for a longer time • You will be asked to sign the written notice to Step 1: Contact the Quality Improvement show that you received it and understand your Organization for your state and ask for an rights immediate review of your hospital discharge. You ♦ you or someone who is acting on your behalf will must act quickly be asked to sign the notice How can you contact this organization? ♦ signing the notice shows only that you have . The written notice you received(An Important received the information about your rights.The Message from Medicare About Your Rights)tells you notice does not give your discharge date. Signing how to reach this organization.Or find the name, the notice does not mean you are agreeing on a discharge date address,and phone number of the Quality Improvement Organization for your state in the • Keep your copy of the notice handy so you will have "Important Phone Numbers and Resources"section the information about making an appeal(or reporting a concern about quality of care)if you need it Act quickly ♦ if you sign the notice more than two days before . To make your appeal,you must contact the Quality your discharge date,you will get another copy Improvement Organization before you leave the before you are scheduled to be discharged hospital and no later than midnight the day of your ♦ to look at a copy of this notice in advance,you can discharge call Member Services or 1-800-MEDICARE ♦ if you meet this deadline,you may stay in the (1-800-633-4227)(TTY users call 1-877-486- hospital after your discharge date without paying 2048),24 hours a day,seven days a week.You for it while you wait to get the decision from the can also see the notice online at Quality Improvement Organization htti)s://www.cms.2ov/Medicare/Medicare- eneral- ♦ if you do not meet this deadline,and you decide to G I General- stay in the hospital after your planned discharge ces.html date,you may have to pay all of the costs for hospital Services you receive after your planned Step-by-step: How to make a Level 1 appeal to discharge date change your hospital discharge date • If you miss the deadline for contacting the Quality If you want to ask for your inpatient hospital Improvement Organization and you still wish to services to be covered by us for a longer time,you appeal,you must make an appeal directly to our plan will need to use the appeals process to make this instead.For details about this other way to make your request.Before you start,understand what you need appeal,see"What if you miss the deadline for making to do and what the deadlines are. your Level 1 appeal?" Once you request an immediate review of your hospital • Follow the process discharge,the Quality Improvement Organization will • Meet the deadlines contact us.By noon of the day after we are contacted,we Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 80 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. will give you a Detailed Notice of Discharge.This notice • If the review organization says no to your appeal and gives your planned discharge date and explains in detail you decide to stay in the hospital,then you may have the reasons why your doctor,the hospital,and we think it to pay the full cost of hospital Services you receive is right(medically appropriate)for you to be discharged after noon on the day after the Quality Improvement on that date. Organization gives you its answer to your appeal You can get a sample of the Detailed Notice of Step 4: If the answer to your Level 1 appeal is no, Discharge by calling Member Services or 1-800- you decide if you want to make another appeal MEDICARE(1-800-633-4227)24 hours a day,seven • If the Quality Improvement Organization has said no days a week(TTY users call 1-877-486-2048).Or you to your appeal,and you stay in the hospital after your can see a sample notice online at planned discharge date,then you can make another https://www.cros.2ov/Medicare/Medicare-General- appeal.Making another appeal means you are going Information/BNI/HospitalDischarueAppealNotices.ht on to Level 2 of the appeals process ml Step-by-step: How to make a Level 2 appeal to Step 2: The Quality Improvement Organization change your hospital discharge date conducts an independent review of your case During a Level 2 appeal,you ask the Quality • Health professionals at the Quality Improvement Improvement Organization to take another look at their Organization(the reviewers)will ask you(or your decision on your first appeal.If the Quality Improvement representative)why you believe coverage for the Organization turns down your Level 2 appeal,you may services should continue.You don't have to prepare have to pay the full cost for your stay after your planned anything in writing,but you may do so if you wish discharge date. • The reviewers will also look at your medical information,talk with your doctor,and review Step 1: Contact the Quality Improvement information that the hospital and we have given to Organization again and ask for another review them • You must ask for this review within 60 calendar days • By noon of the day after the reviewers told us of your after the day the Quality Improvement Organization appeal,you will get a written notice from us that said no to your Level 1 appeal.You can ask for this gives you your planned discharge date.This notice review only if you stay in the hospital after the date also explains in detail the reasons why your doctor, that your coverage for the care ended the hospital,and we think it is right(medically appropriate)for you to be discharged on that date Step 2: The Quality Improvement Organization does a second review of your situation Step 3: Within one full day after it has all the Reviewers at the Quality Improvement Organization needed information, the Quality Improvement will take another careful look at all of the information Organization will give you its answer to your appeal related to your appeal What happens if the answer is yes? Step 3: Within 14 calendar days of receipt of your • If the review organization says yes,we must keep request for a Level 2 appeal, the reviewers will providing your covered inpatient hospital services for decide on your appeal and tell you their decision as long as these services are medically necessary If the review organization says yes • You will have to keep paying your share of the costs • We must reimburse you for our share of the costs of (such as Cost Share,if applicable).In addition,there hospital Services you have received since noon on the may be limitations on your covered hospital services day after the date your first appeal was turned down What happens if the answer is no? by the Quality Improvement Organization.We must continue providing coverage for your inpatient • If the review organization says no,they are saying hospital Services for as long as it is medically that your planned discharge date is medically necessary appropriate.If this happens,our coverage for your . You must continue to pay your share of the costs,and inpatient hospital services will end at noon on the day after the Quality Improvement Organization gives coverage limitations may apply you its answer to your appeal Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 81 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. If the review organization says no you should leave the hospital was fair and followed • It means they agree with the decision they made on all the rules your Level 1 appeal.This is called upholding the Step 3: We give you our decision within 72 hours decision after you ask for a fast review • The notice you get will tell you in writing what you . If we say yes to your appeal,it means we have agreed can do if you wish to continue with the review process with you that you still need to be in the hospital after the discharge date.We will keep providing your Step 4: If the answer is no, you will need to decide covered inpatient hospital services for as long as they whether you want to take your appeal further by are medically necessary.It also means that we have going on to Level 3 agreed to reimburse you for our share of the costs of care you have received since the date when we said • There are three additional levels in the appeals your coverage would end. (You must pay your share process after Level 2(for a total of five levels of of the costs,and there may be coverage limitations appeal).If you want to go to a Level 3 appeal,the that apply) details on how to do this are in the written notice you • If we say no to your appeal,we are saying that your get after your Level 2 appeal decision planned discharge date was medically appropriate. • The Level 3 appeal is handled by an Administrative Our coverage for your inpatient hospital services ends Law Judge or attorney adjudicator.The"Taking Your as of the day we said coverage would end Appeal to Level 3 and Beyond"section tells you more . If you stayed in the hospital after your planned about Levels 3,4,and 5 of the appeals process discharge date,then you may have to pay the full What if you miss the deadline for making your cost of hospital Services you received after the Level 1 appeal to change your hospital planned discharge date discharge date? Step 4: If we say no to your appeal, your case will A fast review(or fast appeal)is also called an expedited automatically be sent on to the next level of the appeal. appeals process You can appeal to us instead As explained above,you must act quickly to start your Step-by-step: Level 2 alternate appeal process Level 1 appeal of your hospital discharge date.If you The formal name for the independent review miss the deadline for contacting the Quality Review organization is the Independent Review Entity.It is Organization,there is another way to make your appeal. sometimes called the IRE. If you use this other way of making your appeal,the first two levels of appeal are different. The independent review organization is an independent organization hired by Medicare.It is not connected with Step-by-step: How to make a Level 1 alternate our plan and is not a government agency.This appeal organization decides whether the decision we made is correct or if it should be changed.Medicare oversees its Step 1: Contact us and ask for a fast review work. • Ask for a fast review.This means you are asking us Step 1: We will automatically forward your case to to give you an answer using the fast deadlines rather the independent review organization than the standard deadlines.The"Important Phone Numbers and Resources"section has contact We are required to send the information for your Level information appeal to the independent review organization within 24 hours of when we tell you that we are saying no to your Step 2: We do a fast review of your planned first appeal. (If you think we are not meeting this discharge date, checking to see if it was medically deadline or other deadlines,you can make a complaint. appropriate "How to Make a Complaint About Quality of Care, Waiting Times,Customer Service,or Other Concerns"in • During this review,we take a look at all of the this"Coverage Decisions,Appeals,and Complaints" information about your hospital stay.We check to see section tells you how to make a complaint.) if your planned discharge date was medically appropriate.We will see if the decision about when Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 82 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Step 2: The independent review organization does When we decide it is time to stop covering any of the a fast review of your appeal. The reviewers give three types of care for you,we are required to tell you in you an answer within 72 hours advance.When your coverage for that care ends,we will • Reviewers at the independent review organization stop paying our share of the cost for your care. will take a careful look at all of the information If you think we are ending the coverage of your care too related to your appeal of your hospital discharge soon,you can appeal our decision.This section tells you • If this organization says yes to your appeal,then we how to ask for an appeal. must pay you back for our share of the costs of hospital Services you received since the date of your We will tell you in advance when your coverage planned discharge.We must also continue our plan's will be ending coverage of your inpatient hospital services for as The Notice of Medicare Non-Coverage tells how you long as it is medically necessary.You must continue can request a fast-track appeal.Requesting a fast-track to pay your share of the costs.If there are coverage appeal is a formal,legal way to request a change to our limitations,these could limit how much we would coverage decision about when to stop your care. reimburse or how long we would continue to cover . You receive a notice in writing at least two days your services before our plan is going to stop covering your care. • If this organization says no to your appeal,it means The notice tells you: they agree that your planned hospital discharge date ♦ the date when we will stop covering the care for was medically appropriate you ♦ the written notice you get from the independent ♦ how to request a fast-track appeal to request us to review organization will tell how to start a Level 3 keep covering your care for a longer period of appeal with the review process which is handled time by an Administrative Law Judge or attorney . You,or someone who is acting on your behalf,will adjudicator be asked to sign the written notice to show that Step 3: If the independent review organization turns you received it.Signing the notice shows only that down your appeal, you choose whether you want to you have received the information about when your take your appeal further coverage will stop. Signing it does not mean you • There are three additional levels in the appeals agree with the plan's decision to stop care process after Level 2(for a total of five levels of Step-by-step: How to make a Level 1 appeal to appeal).If reviewers say no to your Level 2 appeal, have our plan cover your care for a longer time you decide whether to accept their decision or go on If you want to ask us to cover your care for a longer to Level 3 appeal period of time,you will need to use the appeals • "Taking Your Appeal to Level 3 and Beyond"in this process to make this request.Before you start, "Coverage Decisions,Appeals,and Complaints" understand what you need to do and what the section tells you more about Levels 3,4,and 5 of the deadlines are. appeals process . Follow the process • Meet the deadlines How to Ask Us to Keep Covering Certain e Ask for help if you need it.If you have questions or Medical Services if You Think Your need help at any time,please call Member Services. Coverage Is Ending Too Soon Or call your State Health Insurance Assistance Program,a government organization that provides Home health care, Skilled Nursing Facility care, personalized assistance and Comprehensive Outpatient Rehabilitation Facility (CORF) services During a Level 1 appeal,the Quality Improvement Organization reviews your appeal.It decides if the end When you are getting covered home health services, date for your care is medically appropriate. Skilled Nursing Facility care,or rehabilitation care (Comprehensive Outpatient Rehabilitation Facility), The Quality Improvement Organization is a group of you have the right to keep getting your services for that doctors and other health care experts who are paid by the type of care for as long as the care is needed to diagnose federal government to check on and help improve the and treat your illness or injury. quality of care for people with Medicare.This includes Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 83 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. reviewing plan decisions about when it's time to stop Step 3: Within one full day after they have all the covering certain kinds of medical care.These experts are information they need, the reviewers will tell you not part of our plan. their decision Step 1: Make your Level 1 appeal: contact the What happens if the reviewers say yes? Quality Improvement Organization and ask for a • If the reviewers say yes to your appeal,then we must fast-track appeal. You must act quickly keep providing your covered services for as long as it How can you contact this organization? is medically necessary • You will have to keep paying your share of the costs • The written notice you received(Notice of Medicare (such as Cost Share,if applicable). There may be Non-Coverage)tells you how to reach this limitations on your covered services organization. Or find the name,address,and phone number of the Quality Improvement Organization for What happens if the reviewers say no? your state in the"Important Phone Numbers and Resources"section • If the reviewers say no,then your coverage will end on the date we have told you Act quickly • If you decide to keep getting the home health care,or • You must contact the Quality Improvement Skilled Nursing Facility care,or Comprehensive Organization to start your appeal by noon of the day Outpatient Rehabilitation Facility(CORF)services before the effective date on the Notice of Medicare after this date when your coverage ends,then you will Non-Coverage have to pay the full cost of this care yourself • If you miss the deadline for contacting the Quality Step 4: If the answer to your Level 1 appeal is no, Improvement Organization,and you still wish to file you decide if you want to make another appeal an appeal,you must make an appeal directly to us instead.For details about this other way to make your • If reviewers say no to your Level 1 appeal,and you appeal,see"Step-by-step:How to make a Level 2 choose to continue getting care after your coverage appeal to have our plan cover your care for a longer for the care has ended,then you can make a Level 2 time" appeal Step 2: The Quality Improvement Organization Step-by-step: How to make a Level 2 appeal to conducts an independent review of your case have our plan cover your care for a longer time The Detailed Explanation of Non-Coverage provides During a Level 2 appeal,you ask the Quality details on reasons for ending coverage. Improvement Organization to take another look at the decision on your first appeal.If the Quality Improvement What happens during this review? Organization turns down your Level 2 appeal,you may have to pay the full cost for your home health care,or • Health professionals at the Quality Improvement Skilled Nursing Facility care,or Comprehensive Organization(the reviewers)will ask you or your Outpatient Rehabilitation Facility(CORE)services after representative why you believe coverage for the the date when we said your coverage would end. services should continue.You don't have to prepare anything in writing,but you may do so if you wish Step 1: Contact the Quality Improvement • The review organization will also look at your Organization again and ask for another review medical information,talk with your doctor,and . You must ask for this review within 60 days after the review information that our plan has given to them day when the Quality Improvement Organization said • By the end of the day the reviewers tell us of your no to your Level 1 appeal.You can ask for this appeal,you will get the Detailed Explanation of review only if you continued getting care after the Non-Coverage from us that explains in detail our date that your coverage for the care ended reasons for ending our coverage for your services. Step 2: The Quality Improvement Organization does a second review of your situation Reviewers at the Quality Improvement Organization will take another careful look at all of the information related to your appeal Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 84 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Step 3: Within 14 days of receipt of your appeal Step 1: Contact us and ask for a fast review request, reviewers will decide on your appeal and Ask for a fast review.This means you are asking us tell you their decision to give you an answer using the fast deadlines rather What happens if the review organization says yes? than the standard deadlines.The"Important Phone • We must reimburse you for our share of the costs of Numbers and Resources"section has contactinformation care you have received since the date when we said your coverage would end.We must continue Step 2: We do a fast review of the decision we providing coverage for the care for as long as it is made about when to end coverage for your services medically necessary • During this review,we take another look at all of the • You must continue to pay your share of the costs and information about your case.We check to see if we there may be coverage limitations that apply were following all the rules when we set the date for What happens if the review organization says no? ending our plan's coverage for services you were • It means they agree with the decision we made to receiving your Level 1 appeal Step 3: We give you our decision within 72 hours • The notice you get will tell you in writing what you after you ask for a fast review can do if you wish to continue with the review • If we say yes to your appeal,it means we have agreed process.It will give you the details about how to go on to the next level of appeal,which is handled by an with you that you need services longer,and will keep Administrative Law Judge or attorney adjudicator providing your covered services for as long as it is medically necessary.It also means that we have Step 4: If the answer is no, you will need to decide agreed to reimburse you for our share of the costs of whether you want to take your appeal further care you have received since the date when we said your coverage would end. (You must pay your share • There are three additional levels of appeal after Level of the costs and there may be coverage limitations 2,for a total of five levels of appeal.If you want to go that apply) on to a Level 3 appeal,the details on how to do this . If we say no to your appeal,then your coverage will are in the written notice you get after your Level 2 appeal decision end on the date we told you and we will not pay any share of the costs after this date • The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator."Taking Your • If you continued to get home health care,or Skilled Appeal to Level 3 and Beyond"in this"Coverage Nursing Facility care,or Comprehensive Outpatient Decisions,Appeals,and Complaints"section tells you Rehabilitation Facility(CORF)services after the date more about Levels 3,4,and 5 of the appeals process when we said your coverage would end,then you will have to pay the full cost of this care What if you miss the deadline for making your Level 1 appeal? Step 4: If we say no to your fast appeal, your case will automatically go on to the next level of the You can appeal to us instead appeals process As explained above,you must act quickly to contact the The formal name for the independent review Quality Improvement Organization to start your first organization is the Independent Review Entity.It is appeal(within a day or two,at the most).If you miss the sometimes called the IRE. deadline for contacting this organization,there is another way to make your appeal.If you use this other way of Step-by-step: Level 2 alternate appeal process making your appeal,the first two levels of appeal are During the Level 2 Appeal,the independent review different. organization reviews the decision we made to your fast appeal.This organization decides whether the decision Step-by-step: How to make a Level 1 alternate should be changed. The independent review appeal organization is an independent organization that is A fast review(or fast appeal)is also called an expedited hired by Medicare.This organization is not connected appeal. with our plan and it is not a government agency.This organization is a company chosen by Medicare to handle the job of being the independent review organization. Medicare oversees its work. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 85 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Step 1: We will automatically forward your case to Taking Your Appeal to Level 3 and the independent review organization Beyond We are required to send the information for your Level 2 appeal to the independent review organization within 24 Levels of Appeal 3, 4, and 5 for Medical Service hours of when we tell you that we are saying no to your Requests first appeal. (If you think we are not meeting this This section may be appropriate for you if you have deadline or other deadlines,you can make a complaint. made a Level I appeal and a Level 2 appeal,and both of "How to Make a Complaint About Quality of Care, your appeals have been turned down. Waiting Times,Customer Service,or Other Concerns"in this"Coverage Decisions,Appeals,and Complaints" If the dollar value of the item or medical service you section tells how to make a complaint.) have appealed meets certain minimum levels,you may be able to go on to additional levels of appeal.If the Step 2: The independent review organization does dollar value is less than the minimum level,you cannot a fast review of your appeal. The reviewers give appeal any further. The written response you receive to you an answer within 72 hours your Level 2 appeal will explain how to make a Level 3 • Reviewers at the independent review organization appeal. will take a careful look at all of the information For most situations that involve appeals,the last three related to your appeal levels of appeal work in much the same way.Here is • If this organization says yes to your appeal,then we who handles the review of your appeal at each of these must pay you back for our share of the costs of care levels. you have received since the date when we said your coverage would end.We must also continue to cover Level 3 appeal: An Administrative Law Judge or the care for as long as it is medically necessary.You an attorney adjudicator who works for the must continue to pay your share of the costs.If there federal government will review your appeal and are coverage limitations,these could limit how much give you an answer we would reimburse or how long we would continue • If the Administrative Law Judge or attorney to cover your services adjudicator says yes to your appeal,the appeals • If this organization says no to your appeal,it means process may or may not be over.Unlike a decision they agree with the decision our plan made to your at a Level 2 appeal,we have the right to appeal a first appeal and will not change it Level 3 decision that is favorable to you.If we decide ♦ the notice you get from the independent review to appeal,it will go to a Level 4 appeal organization will tell you in writing what you can ♦ if we decide not to appeal,we must authorize or do if you wish to go on to a Level 3 appeal provide you with the medical care within 60 calendar days after receiving the Administrative Step 3: If the independent review organization says Law Judge's or attorney adjudicator's decision no to your appeal, you choose whether you want to ♦ if we decide to appeal the decision,we will send take your appeal further you a copy of the Level 4 appeal request with any • There are three additional levels of appeal after Level accompanying documents.We may wait for the 2,for a total of five levels of appeal.If you want to go Level 4 appeal decision before authorizing or on to a Level 3 appeal,the details on how to do this providing the medical care in dispute are in the written notice you get after your Level 2 • If the Administrative Law Judge or attorney appeal decision adjudicator says no to your appeal,the appeals • A Level 3 appeal is reviewed by an Administrative process may or may not be over Law Judge or attorney adjudicator."Taking Your ♦ if you decide to accept this decision that turns Appeal to Level 3 and Beyond"in this"Coverage down your appeal,the appeals process is over Decisions,Appeals,and Complaints"section tells you ♦ if you do not want to accept the decision,you can more about Levels 3,4,and 5 of the appeals process continue to the next level of the review process. The notice you get will tell you what to do for a Level 4 appeal Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 86 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Level 4 appeal: The Medicare Appeals Council Level 3 appeal: An Administrative Law Judge or (Council)will review your appeal and give you an attorney adjudicator who works for the an answer. The Council is part of the federal federal government will review your appeal and government give you an answer • If the answer is yes,or if the Council denies our • If the answer is yes,the appeals process is over.We request to review a favorable Level 3 appeal must authorize or provide the drug coverage that was decision,the appeals process may or may not be approved by the Administrative Law Judge or over.Unlike a decision at Level 2,we have the right attorney adjudicator within 72 hours(24 hours for to appeal a Level 4 decision that is favorable to you. expedited appeals)or make payment no later than 30 We will decide whether to appeal this decision to calendar days after we receive the decision Level 5 • If the answer is no,the appeals process may or may ♦ if we decide not to appeal the decision,we must not be over authorize or provide you with the medical care ♦ If you decide to accept this decision that turns within 60 calendar days after receiving the down your appeal,the appeals process is over Council's decision ♦ If you do not want to accept the decision,you can ♦ if we decide to appeal the decision,we will let you continue to the next level of the review process. know in writing The notice you get will tell you what to do for a • If the answer is no or if the Council denies the Level 4 appeal review request,the appeals process may or may not be over Level 4 appeal: The Medicare Appeals Council ♦ if you decide to accept this decision that turns (Council)will review your appeal and give you down your appeal,the appeals process is over an answer. The Council is part of the federal ♦ if you do not want to accept the decision,you may government be able to continue to the next level of the review • If the answer is yes,the appeals process is over.We process.If the Council says no to your appeal,the must authorize or provide the drug coverage that was notice you get will tell you whether the rules allow approved by the Council within 72 hours(24 hours you to go on to a Level 5 appeal and how to for expedited appeals)or make payment no later than continue with a Level 5 appeal 30 calendar days after we receive the decision • If the answer is no,the appeals process may or may Level 5 appeal: A judge at the Federal District not be over Court will review your appeal ♦ if you decide to accept this decision that turns • A judge will review all of the information and decide down your appeal,the appeals process is over yes or no to your request.This is a final answer. ♦ if you do not want to accept the decision,you may There are no more appeal levels after the Federal be able to continue to the next level of the review District Court process.If the Council says no to your appeal or denies your request to review the appeal,the Appeal Levels 3, 4, and 5 for Part D Drug notice will tell you whether the rules allow you to Requests go on to a Level 5 appeal.It will also tell you This section may be appropriate for you if you have whom to contact and what to do next if you choose made a Level 1 appeal and a Level 2 appeal,and both of to continue with your appeal your appeals have been turned down. Level 5 appeal: A judge at the Federal District If the value of the Part D drug you have appealed meets a Court will review your appeal certain dollar amount,you may be able to go on to A judge will review all of the information and decide additional levels of appeal.If the dollar amount is less, yes or no to your request.This is a final answer. you cannot appeal any further.The written response you There are no more appeal levels after the Federal receive to your Level 2 appeal will explain whom to District Court contact and what to do to ask for a Level 3 appeal. For most situations that involve appeals,the last three levels of appeal work in much the same way.Here is who handles the review of your appeal at each of these levels. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 87 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. How to Make a Complaint About Quality • You believe we are not meeting the deadlines for of Care, Waiting Times, Customer coverage decisions or appeals;you can make a Service, or Other Concerns complaint • You believe we are not meeting deadlines for covering or reimbursing you for certain medical What kinds of problems are handled by the services or Part D drugs that were approved;you can complaint process? make a complaint The complaint process is only used for certain types of • You believe we failed to meet required deadlines for problems.This includes problems related to quality of forwarding your case to the independent review care,waiting times,and customer service.Here are organization;you can make a complaint examples of the kinds of problems handled by the complaint process: Step-by-step: making a complaint • Quality of your medical care • A complaint is also called a grievance ♦ are you unhappy with the quality of care you have • Making a complaint is also called filing a grievance received(including care in the hospital)? • Using the process for complaints is also called • Respecting your privacy using the process for filing a grievance ♦ did someone not respect your right to privacy or • A fast complaint is also called an expedited share confidential information? grievance • Disrespect,poor customer service,or other negative behaviors Step 1: Contact us promptly—either by phone or in ♦ has someone been rude or disrespectful to you? writing ♦ are you unhappy with our Member Services? • Usually calling Member Services is the first step. ♦ do you feel you are being encouraged to leave our If there is anything else you need to do,Member plan? Services will let you know • Waiting times • If you do not wish to call(or you called and were not ♦ are you having trouble getting an appointment,or satisfied),you can put your complaint in writing and waiting too long to get it? send it to us.If you put your complaint in writing,we will respond to you in writing.We will also respond ♦ have you been kept waiting too long by doctors, in writing when you make a complaint by phone pharmacists,or other health professionals?Or by if you request a written response or your complaint is Member Services or other staff at our plan? related to quality of care — Examples include waiting too long on the . If you have a complaint,we will try to resolve your phone,in the waiting or exam room,or getting complaint over the phone.If we cannot resolve your a prescription complaint over the phone,we have a formal • Cleanliness procedure to review your complaints.Your grievance ♦ are you unhappy with the cleanliness or condition must explain your concern,such as why you are of a clinic,hospital,or doctor's office? dissatisfied with the services you received.Please see the"Important Phone Numbers and Resources" • Information you get from our plan section for whom you should contact if you have a ♦ did we fail to give you a required notice? complaint ♦ is our written information hard to understand? ♦ you must submit your grievance to us(orally or in writing)within 60 calendar days of the event or Timeliness (these types of complaints are all incident.We must address your grievance as related to the timeliness of our actions related to quickly as your health requires,but no later than coverage decisions and appeals) 30 calendar days after receiving your complaint. If you have asked for a coverage decision or made an We may extend the time frame to make our appeal,and you think that we are not responding quickly decision by up to 14 calendar days if you ask for enough,you can make a complaint about our slowness. an extension,or if we justify a need for additional Here are examples: information and the delay is in your best interest • You asked us for a"fast coverage decision"or a"fast ♦ you can file a fast grievance about our decision not appeal,"and we have said no,you can make a to expedite a coverage decision or appeal,or if we complaint extend the time we need to make a decision about Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 88 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. a coverage decision or appeal.We must respond to Additional Review your fast grievance within 24 hours • The deadline for making a complaint is 60 calendar You may have certain additional rights if you remain days from the time you had the problem you want to dissatisfied after you have exhausted our internal claims complain about and appeals procedure,and if applicable,external review: Step 2: We look into your complaint and give you If your Group's benefit plan is subject to the our answer Employee Retirement Income Security Act(ERISA), • If possible,we will answer you right away.If you you may file a civil action under section 502(a)of call us with a complaint,we may be able to give you ERISA.To understand these rights,you should check an answer on the same phone call with your Group or contact the Employee Benefits Security Administration(part of the U.S.Department • Most complaints are answered within 30 calendar of Labor)at 1-866-444-EBSA(1-866-444-3272) days.If we need more information and the delay is in . If your Group's benefit plan is not subject to ERISA your best interest or if you ask for more time,we can take up to 14 more calendar days(44 calendar days (for example,most state or local government plans total)to answer your complaint.If we decide to take and church plans),you may have a right to request review in state court extra days,we will tell you in writing • If you are making a complaint because we denied your request for a fast coverage decision or a fast Binding Arbitration appeal,we will automatically give you a fast complaint.If you have a fast complaint,it means we For all claims subject to this"Binding Arbitration" will give you an answer within 24 hours section,both Claimants and Respondents give up the • If we do not agree with some or all of your right to a jury or court trial and accept the use of binding arbitration.Insofar as this Binding Arbitration section complaint or don't take responsibility for the problem applies to claims asserted by Kaiser Permanente Parties, you are complaining about,we will include our it shall apply retroactively to all unresolved claims that reasons in the response to you accrued before the effective date of this EOC. Such retroactive application shall be binding only on the You can also make complaints about quality of Kaiser Permanente Parties. care to the Quality Improvement Organization When your complaint is about quality of care,you also Scope of arbitration have two extra options: Any dispute shall be submitted to binding arbitration if • You can make your complaint directly to the all of the following requirements are met: Quality Improvement Organization. The Quality . The claim arises from or is related to an alleged Improvement Organization is a group of practicing violation of any duty incident to or arising out of or doctors and other health care experts paid by the relating to this EOC or a Member Party's relationship federal government to check and improve the care to Kaiser Foundation Health Plan,Inc. ("Health given to Medicare patients.The"Important Phone Plan"),including any claim for medical or hospital Numbers and Resources"section has contact malpractice(a claim that medical services or items information were unnecessary or unauthorized or were • Or you can make your complaint to both the improperly,negligently,or incompetently rendered), Quality Improvement Organization and us at the for premises liability,or relating to the coverage for, same time or delivery of,services or items,irrespective of the legal theories upon which the claim is asserted • The claim is asserted by one or more Member Parties You can also tell Medicare about your against one or more Kaiser Permanente Parties or by complaint one or more Kaiser Permanente Parties against one or You can submit a complaint about our plan directly to more Member Parties Medicare.To submit a complaint to Medicare,go to • Governing law does not prevent the use of binding https://www.medicare.zov[MedicareComplaintForm/ arbitration to resolve the claim home.aspx.You may also call 1-800-MEDICARE (1-800-633-4227).TTY/TDD users should call 1-877- Members enrolled under this EOC thus give up their 486-2048. right to a court or jury trial,and instead accept the use of Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 89 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. binding arbitration except that the following types of Initiating arbitration claims are not subject to binding arbitration: Claimants shall initiate arbitration by serving a Demand • Claims within the jurisdiction of the Small Claims for Arbitration. The Demand for Arbitration shall include Court the basis of the claim against the Respondents;the amount of damages the Claimants seek in the arbitration; • Claims subject to a Medicare appeal procedure as the names,addresses,and phone numbers of the applicable to Kaiser Permanente Senior Advantage Claimants and their attorney,if any;and the names of all Members Respondents. Claimants shall include in the Demand for • Claims that cannot be subject to binding arbitration Arbitration all claims against Respondents that are based under governing law on the same incident,transaction,or related circumstances. As referred to in this"Binding Arbitration"section, "Member Parties"include: Serving demand for arbitration • A Member Health Plan,Kaiser Foundation Hospitals,The Permanente Medical Group,Inc., Southern California • A Member's heir,relative,or personal representative Permanente Medical Group,The Permanente Federation, • Any person claiming that a duty to them arises from a LLC,and The Permanente Company,LLC,shall be Member's relationship to one or more Kaiser served with a Demand for Arbitration by mailing the Permanente Parties Demand for Arbitration addressed to that Respondent in care of: "Kaiser Permanente Parties"include: Kaiser Foundation Health Plan,Inc. • Kaiser Foundation Health Plan,Inc. Legal Department,Professional&Public Liability • Kaiser Foundation Hospitals 1 Kaiser Plaza, 19th FloorOakland,CA 94612 • The Permanente Medical Group,Inc. • Southern California Permanente Medical Group Service on that Respondent shall be deemed completed • The Permanente Federation,LLC when received.All other Respondents,including individuals,must be served as required by the California • The Permanente Company,LLC Code of Civil Procedure for a civil action. • Any Southern California Permanente Medical Group or The Permanente Medical Group physician Filing fee The Claimants shall pay a single,nonrefundable filing • Any individual or organization whose contract with fee of$150 per arbitration payable to"Arbitration any of the organizations identified above requires Account"regardless of the number of claims asserted in arbitration of claims brought by one or more Member the Demand for Arbitration or the number of Claimants Parties or Respondents named in the Demand for Arbitration. • Any employee or agent of any of the foregoing Any Claimant who claims extreme hardship may request "Claimant"refers to a Member Party or a Kaiser that the Office of the Independent Administrator waive Permanente Party who asserts a claim as described the filing fee and the neutral arbitrator's fees and above."Respondent"refers to a Member Party or a expenses.A Claimant who seeks such waivers shall Kaiser Permanente Party against whom a claim is complete the Fee Waiver Form and submit it to the asserted. Office of the Independent Administrator and simultaneously serve it upon the Respondents.The Fee Rules of Procedure Waiver Form sets forth the criteria for waiving fees and Arbitrations shall be conducted according to the Rules is available by calling Member Services. for Kaiser Permanente Member Arbitrations Overseen by the Office of the Independent Administrator("Rules Number of arbitrators of Procedure")developed by the Office of the The number of arbitrators may affect the Claimants' Independent Administrator in consultation with Kaiser responsibility for paying the neutral arbitrator's fees and Permanente and the Arbitration Oversight Board. Copies expenses(see the Rules of Procedure). of the Rules of Procedure may be obtained from Member Services. If the Demand for Arbitration seeks total damages of $200,000 or less,the dispute shall be heard and determined by one neutral arbitrator,unless the parties Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 90 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. otherwise agree in writing after a dispute has arisen and a proceed to determine the controversy in the party's request for binding arbitration has been submitted that absence. the arbitration shall be heard by two party arbitrators and one neutral arbitrator.The neutral arbitrator shall not The California Medical Injury Compensation Reform have authority to award monetary damages that are Act of 1975(including any amendments thereto), greater than$200,000. including sections establishing the right to introduce evidence of any insurance or disability benefit payment If the Demand for Arbitration seeks total damages of to the patient,the limitation on recovery for non- more than$200,000,the dispute shall be heard and economic losses,and the right to have an award for determined by one neutral arbitrator and two party future damages conformed to periodic payments,shall arbitrators,one jointly appointed by all Claimants and apply to any claims for professional negligence or any one jointly appointed by all Respondents.Parties who are other claims as permitted or required by law. entitled to select a party arbitrator may agree to waive this right.If all parties agree,these arbitrations will be Arbitrations shall be governed by this"Binding heard by a single neutral arbitrator. Arbitration"section, Section 2 of the Federal Arbitration Act,and the California Code of Civil Procedure Payment of arbitrators' fees and expenses provisions relating to arbitration that are in effect at the Health Plan will pay the fees and expenses of the neutral time the statute is applied,together with the Rules of arbitrator under certain conditions as set forth in the Procedure,to the extent not inconsistent with this Rules of Procedure.In all other arbitrations,the fees and "Binding Arbitration"section.In accord with the rule expenses of the neutral arbitrator shall be paid one-half that applies under Sections 3 and 4 of the Federal by the Claimants and one-half by the Respondents. Arbitration Act,the right to arbitration under this "Binding Arbitration"section shall not be denied,stayed, If the parties select party arbitrators,Claimants shall be or otherwise impeded because a dispute between a responsible for paying the fees and expenses of their Member Party and a Kaiser Permanente Party involves party arbitrator and Respondents shall be responsible for both arbitrable and nonarbitrable claims or because one paying the fees and expenses of their party arbitrator. or more parties to the arbitration is also a party to a pending court action with another party that arises out of Costs the same or related transactions and presents a possibility Except for the aforementioned fees and expenses of the of conflicting rulings or findings. neutral arbitrator,and except as otherwise mandated by laws that apply to arbitrations under this"Binding Arbitration"section,each party shall bear the party's Termination of Membership own attorneys' fees,witness fees,and other expenses incurred in prosecuting or defending against a claim Your Group is required to inform the Subscriber of the regardless of the nature of the claim or outcome of the date your membership terminates.Your membership arbitration. termination date is the first day you are not covered(for General provisions example,if your termination date is January 1,2025, your last minute of coverage was at 11:59 p.m.on A claim shall be waived and forever barred if(1)on the December 31,2024).When a Subscriber's membership date the Demand for Arbitration of the claim is served, ends,the memberships of any Dependents end at the the claim,if asserted in a civil action,would be barred as same time.You will be billed as a non-Member for any to the Respondent served by the applicable statute of Services you receive after your membership terminates. limitations,(2)Claimants fail to pursue the arbitration Health Plan and Plan Providers have no further liability claim in accord with the Rules of Procedure with or responsibility under this EOC after your membership reasonable diligence,or(3)the arbitration hearing is not terminates,except: commenced within five years after the earlier of(a)the date the Demand for Arbitration was served in accord • As provided under"Payments after Termination"in with the procedures prescribed herein,or(b)the date of this"Termination of Membership"section filing of a civil action based upon the same incident, • If you are receiving covered Services as an acute care transaction,or related circumstances involved in the hospital inpatient on the termination date,we will claim.A claim may be dismissed on other grounds by the continue to cover those hospital Services(but not neutral arbitrator based on a showing of a good cause.If physician Services or any other Services)until you a party fails to attend the arbitration hearing after being are discharged given due notice thereof,the neutral arbitrator may Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 91 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Until your membership terminates,you remain a Senior Termination of Agreement Advantage Member and must continue to receive your medical care from us,except as described in the If your Group's Agreement with us terminates for any "Emergency Services and Urgent Care"section about reason,your membership ends on the same date.Your Emergency Services,Post-Stabilization Care,and Out- Group is required to notify Subscribers in writing if its of-Area Urgent Care and the"Benefits and Your Cost Agreement with us terminates. Share"section about out-of-area dialysis care. Note:If you enroll in another Medicare Health Plan or a Disenrolling from Senior Advantage prescription drug plan,your Senior Advantage You may terminate(disenroll from)your Senior membership will terminate as described under Advantage membership at any time.However,before "Disenrolling from Senior Advantage"in this you request disenrollment,please check with your Group "Termination of Membership"section. to determine if you are able to continue your Group membership. Termination Due to Loss of Eligibility If you request disenrollment during your Group's open If you no longer meet the eligibility requirements enrollment,your disenrollment effective date is described under"Who Is Eligible"in the"Premiums, determined by the date your written request is received Eligibility,and Enrollment"section your Group will by us and the date your Group coverage ends.The notify you of the date that your membership will end. effective date will not be earlier than the first day of the Your membership termination date is the first day you following month after we receive your written request, are not covered.For example,if your termination date is and no later than three months after we receive your January 1,2025,your last minute of coverage was at request. 11:59 p.m. on December 31,2024. If you request disenrollment at a time other than your Also,we will terminate your Senior Advantage Group's open enrollment,your disenrollment effective membership on the last day of the month if you: date will be the first day of the month following our • Are temporarily absent from our Service Area for receipt of your disenrollment request. more than six months in a row You may request disenrollment by calling toll free • Permanently move from our Service Area 1-800-MEDICARE/1-800-633-4227(TTY users call • No longer have Medicare Part B 1-877-486-2048),24 hours a day,seven days a week,or • Enroll in another Medicare Health Plan(for example, sending written notice to the following address: a Medicare Advantage Plan or a Medicare Kaiser Foundation Health Plan,Inc. prescription drug plan).The Centers for Medicare& California Service Center Medicaid Services will automatically terminate your P.O.Box 232400 Senior Advantage membership when your enrollment San Diego,CA 92193-2400 in the other plan becomes effective • Are not a U.S. citizen or lawfully present in the Other Medicare Health Plans.If you want to enroll in United States.The Centers for Medicare&Medicaid another Medicare Health Plan or a Medicare prescription Services will notify us if you are not eligible to drug plan,you should first confirm with the other plan remain a Member on this basis.We must disenroll and your Group that you are able to enroll.Your new you if you do not meet this requirement plan or your Group will tell you the date when your membership in the new plan begins and your Senior In addition,if you are required to pay the extra Part D Advantage membership will end on that same day(your amount because of your income and you do not pay it, disenrollment date). Medicare will disenroll you from our Senior Advantage Plan and you will lose prescription drug coverage. The Centers for Medicare&Medicaid Services will let us know if you enroll in another Medicare Health Plan, Note: If you lose eligibility for Senior Advantage due to so you will not need to send us a disenrollment request. any of these circumstances,you may be eligible to transfer your membership to another Kaiser Permanente Original Medicare.If you request disenrollment from plan offered by your Group.Please contact your Group Senior Advantage and you do not enroll in another for information. Medicare Health Plan,you will automatically be enrolled Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 92 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. in Original Medicare when your Senior Advantage • You commit theft from Health Plan,from a Plan membership terminates(your disenrollment date).On Provider,or at a Plan Facility your disenrollment date,you can start using your red, • You intentionally misrepresent membership status or white,and blue Medicare card to get services under commit fraud in connection with your obtaining Original Medicare.You will not get anything in writing membership.We cannot make you leave our Senior that tells you that you have Original Medicare after you Advantage Plan for this reason unless we get disenroll.If you choose Original Medicare and you want permission from Medicare first to continue to get Medicare Part D prescription drug coverage,you will need to enroll in a prescription drug • If you become incarcerated(go to prison) plan. • You knowingly falsify or withhold information about other parties that provide reimbursement for your If you receive Extra Help from Medicare to pay for your prescription drug coverage prescription drugs,and you switch to Original Medicare and do not enroll in a separate Medicare Part D If we terminate your membership for cause,you will not prescription drug plan,Medicare may enroll you in a be allowed to enroll in Health Plan in the future until you drug plan,unless you have opted out of automatic have completed a Member Orientation and have signed a enrollment. statement promising future compliance.We may report fraud and other illegal acts to the authorities for Note: If you disenroll from Medicare prescription drug prosecution. coverage and go without creditable prescription drug coverage for 63 or more days in a row,you may need to pay a Part D late enrollment penalty if you join a Termination for Nonpayment of Medicare drug plan later. Premiums If we do not receive Premiums for your Family,we may Termination of Contract with the terminate the memberships of everyone in your Family. Centers for Medicare & Medicaid Services Termination of a Product or all Products If our contract with the Centers for Medicare&Medicaid Services to offer Senior Advantage terminates,your We may terminate a particular product or all products Senior Advantage membership will terminate on the offered in the group market as permitted or required by same date.We will send you advance written notice and law.If we discontinue offering a particular product in the advise you of your health care options.Also,you maybe group market,we will terminate just the particular product by sending you written notice at least 90 days eligible to transfer your membership to another Kaiser Permanente plan offered by your Group. before the product terminates.If we discontinue offering all products in the group market,we may terminate your Group's Agreement by sending you written notice at Termination for Cause least 180 days before the Agreement terminates. We may terminate your membership by sending you advance written notice if you commit one of the Payments after Termination following acts: If we terminate your membership for cause or for • If you continuously behave in a way that is disruptive, nonpayment,we will: to the extent that your continued enrollment seriously impairs our ability to arrange or provide medical care • Refund any amounts we owe for Premiums paid after for you or for our other members.We cannot make the termination date you leave our Senior Advantage Plan for this reason • Pay you any amounts we have determined that we unless we get permission from Medicare first owe you for claims during your membership in • If you let someone else use your Plan membership accord with the"Requests for Payment"section.We card to get medical care.We cannot make you leave will deduct any amounts you owe Health Plan or Plan our Senior Advantage Plan for this reason unless we Providers from any payment we make to you get permission from Medicare first.If you are disenrolled for this reason,the Centers for Medicare &Medicaid Services may refer your case to the Inspector General for additional investigation Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 93 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Review of Membership Termination while the Subscriber was employed by your Group,and your Group's Agreement with us terminates and is not If you believe that we terminated your Senior Advantage renewed,we will cover Services for your totally membership because of your ill health or your need for disabling condition until the earliest of the following care,you may file a complaint as described in the events occurs: "Coverage Decisions,Appeals,and Complaints"section. . 12 months have elapsed since your Group's Agreement with us terminated • You are no longer Totally Disabled Continuation of Membership . Your Group's Agreement with us is replaced by If your membership under this Senior Advantage EOC another group health plan without limitation as to the ends,you may be eligible to continue Health Plan disabling condition membership without a break in coverage.You may be able to continue Group coverage under this Senior Your coverage will be subject to the terms of this EOC, Advantage EOC as described under"Continuation of including Cost Share,but we will not cover Services for Group Coverage."Also,you may be able to continue any condition other than your totally disabling condition. membership under an individual plan as described under "Conversion from Group Membership to an Individual For Subscribers and adult Dependents,"Totally Plan."If at any time you become entitled to continuation Disabled"means that,in the judgment of a Medical of Group coverage,please examine your coverage Group physician,an illness or injury is expected to result options carefully before declining this coverage. in death or has lasted or is expected to last for a Individual plan premiums and coverage will be different continuous period of at least 12 months,and makes the from the premiums and coverage under your Group plan. person unable to engage in any employment or occupation,even with training,education,and experience. Continuation of Group Coverage For Dependent children,"Totally Disabled"means that, COBRA in the judgment of a Medical Group physician,an illness You may be able to continue your coverage under this or injury is expected to result in death or has lasted or is Senior Advantage EOC for a limited time after you expected to last for a continuous period of at least 12 would otherwise lose eligibility,if required by the months and the illness or injury makes the child unable federal Consolidated Omnibus Budget Reconciliation to substantially engage in any of the normal activities of Act("COBRA"). COBRA applies to most employees children in good health of like age. (and most of their covered family Dependents)of most employers with 20 or more employees. To request continuation of coverage for your disabling condition,you must call Member Services within 30 If your Group is subject to COBRA and you are eligible days after your Group's Agreement with us terminates. for COBRA coverage,in order to enroll,you must submit a COBRA election form to your Group within the COBRA election period.Please ask your Group for Conversion from Group Membership to details about COBRA coverage,such as how to elect an Individual Plan coverage,how much you must pay for coverage,when coverage and Premiums may change,and where to send After your Group notifies us to terminate your Group your Premium payments. membership,we will send a termination letter to the Subscriber's address of record.The letter will include As described in"Conversion from Group Membership to information about options that may be available to you to an Individual Plan"in this"Continuation of remain a Health Plan Member. Membership"section,you may be able to convert to an individual(nongroup)plan if you don't apply for Kaiser Permanente Conversion Plan COBRA coverage,or if you enroll in COBRA and your If you want to remain a Health Plan Member,one option COBRA coverage ends. that may be available is our Senior Advantage Individual Plan.You may be eligible to enroll in our individual plan Coverage for a disabling condition if you no longer meet the eligibility requirements If you became Totally Disabled while you were a described under"Who Is Eligible"in the"Premiums, Member under your Group's Agreement with us and Eligibility,and Enrollment"section.Individual plan Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 94 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. coverage begins when your Group coverage ends.The Attorney and Advocate Fees and premiums and coverage under our individual plan are Expenses different from those under this EOC and will include Medicare Part D prescription drug coverage. In any dispute between a Member and Health Plan,the Medical Group,or Kaiser Foundation Hospitals,each However,if you are no longer eligible for Senior party will bear its own fees and expenses,including Advantage and Group coverage,you may be eligible to attorneys' fees,advocates' fees,and other expenses. convert to our non-Medicare individual plan,called "Kaiser Permanente Individual—Conversion Plan."You may be eligible to enroll in our Individual—Conversion Claims Review Authority Plan if we receive your enrollment application within 63 days of the date of our termination letter or of your We are responsible for determining whether you are membership termination date(whichever date is later). entitled to benefits under this EOC and we have the discretionary authority to review and evaluate claims that You may not be eligible to convert if your membership arise under this EOC.We conduct this evaluation independently by interpreting the provisions of this EOC. ends for the reasons stated under"Termination for We may use medical experts to help us review claims. Cause"or"Termination of Agreement"in the If coverage under this EOC is subject to the Employee "Termination of Membership"section. Retirement Income Security Act("ERISA")claims procedure regulation(29 CFR 2560.503-1),then we are a "named claims fiduciary"to review claims under this Miscellaneous Provisions EOC. Administration of Agreement EOC Binding on Members We may adopt reasonable policies,procedures,and By electing coverage or accepting benefits under this interpretations to promote orderly and efficient EOC,all Members legally capable of contracting,and administration of your Group's Agreement,including this the legal representatives of all Members incapable of EOC. contracting,agree to all provisions of this EOC. Amendment of Agreement ERISA Notices Your Group's Agreement with us will change This"ERISA Notices"section applies only if your periodically.If these changes affect this EOC,your Group's health benefit plan is subject to the Employee Group is required to inform you in accord with Retirement Income Security Act("ERISA").We provide applicable law and your Group's Agreement. these notices to assist ERISA-covered groups in complying with ERISA.Coverage for Services described in these notices is subject to all provisions of this EOC. Applications and Statements Newborns' and Mothers' Health Protection Act You must complete any applications,forms,or Group health plans and health insurance issuers generally statements that we request in our normal course of may not,under Federal law,restrict benefits for any business or as specified in this EOC. hospital length of stay in connection with childbirth for the birthing person or newborn child to less than 48 Assignment hours following a vaginal delivery,or less than 96 hours following a cesarean section.However,Federal law You may not assign this EOC or any of the rights, generally does not prohibit the birthing person's or interests,claims for money due,benefits,or obligations newborn's attending provider,after consulting with the hereunder without our prior written consent. birthing person,from discharging the birthing person or their newborn earlier than 48 hours(or 96 hours as applicable).In any case,plans and issuers may not,under Federal law,require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours(or 96 hours). Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 95 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Women's Health and Cancer Rights Act Subscriber within 30 days after receiving the information If you have had or are going to have a mastectomy,you from us.The Subscriber is also responsible for notifying may be entitled to certain benefits under the Women's Group of any change in contact information. Health and Cancer Rights Act.For individuals receiving mastectomy-related benefits,coverage will be provided in a manner determined in consultation with the Notice about Medicare Secondary Paver attending physician and the patient,for all stages of Subrogation Rights reconstruction of the breast on which the mastectomy was performed,surgery and reconstruction of the other We have the right and responsibility to collect for breast to produce a symmetrical appearance,prostheses, covered Medicare services for which Medicare is not the and treatment of physical complications of the primary payer.According to CMS regulations at 42 CFR mastectomy,including lymphedemas.These benefits will sections 422.108 and 423.462,Kaiser Permanente Senior be provided subject to the same Cost Share applicable to Advantage,as a Medicare Advantage Organization,will other medical and surgical benefits provided under this exercise the same rights of recovery that the Secretary plan. 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. Governing Law Except as preempted by federal law,this EOC will be Overpayment Recovery governed in accord with California law and any provision that is required to be in this EOC by state or We may recover any overpayment we make for Services federal law shall bind Members and Health Plan whether from anyone who receives such an overpayment or from or not set forth in this EOC. any person or organization obligated to pay for the Services. Group and Members Not Our Agents Public Policy Participation Neither your Group nor any Member is the agent or representative of Health Plan. The Kaiser Foundation Health Plan,Inc.,Board of Directors establishes public policy for Health Plan.A list of the Board of Directors is available on our website at No Waiver ku•ore or from Member Services.If you would like to provide input about Health Plan public policy for Our failure to enforce any provision of this EOC will not consideration by the Board,please send written constitute a waiver of that or any other provision,or comments to: impair our right thereafter to require your strict Kaiser Foundation Health Plan,Inc. performance of any provision. Office of Board and Corporate Governance Services Notices Regarding Your Coverage One Kaiser Plaza, 19th Floor Oakland,CA 94612 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 Member Services 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, or needs to have confidential information sent to an address other than the Subscriber's address,they should contact Member Services to discuss alternate delivery options. Note:When we tell your Group about changes to this EOC or provide your Group other information that affects you,your Group is required to notify the Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 96 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Telephone Access (TTY) Coverage decisions, appeals, or complaints for Services—contact information If you use a text telephone device(TTY,also known as TDD)to communicate by phone,you can use the Call 1-800-443-0815 California Relay Service by calling 711. Calls to this number are free. Seven days a week,8 a.m.to 8 p.m. Important Phone Numbers and If your coverage decision,appeal,or complaint qualifies for a fast decision as described in the Resources "Coverage Decisions,Appeals,and Complaints"section,call the Expedited Review Unit at 1-888-987-7247,8:30 a.m.to 5 p.m., Kaiser Permanente Senior Advantaqe Monday through Saturday. How to contact our plan's Member Services TTY 711 For assistance,please call or write to our plan's Member Calls to this number are free. Services.We will be happy to help you. Seven days a week,8 a.m.to 8 p.m. Member Services—contact information Fax If your coverage decision,appeal,or complaint Call 1-800-443-0815 qualifies for a fast decision,fax your request to Calls to this number are free. our Expedited Review Unit at 1-888-987-2252. Write For a standard coverage decision or Seven days a week,8 a.m.to 8 p.m. complaint,write to your local Member Services Member Services also has free language office(see the Provider Directory for interpreter services available for non-English locations). speakers. For a standard appeal,write to the address TTY 711 shown on the denial notice we send you. Calls to this number are free. If your coverage decision,appeal,or complaint qualifies for a fast decision,write to: Seven days a week,8 a.m.to 8 p.m. Kaiser Permanente Write Your local Member Services office(see the Expedited Review Unit Provider Directory for locations). P.O.Box 1809 Pleasanton,CA 94566 Website ky.or2 Medicare Website.You can submit a complaint about How to contact us when you are asking for a our Plan directly to Medicare. To submit an online coverage decision or making an appeal or complaint to Medicare,go to complaint about your Services https://www.medicare.2ov/MedicareComplaintForm/ home.aspx. • A coverage decision is a decision we make about your benefits and coverage or about the amount we will How to contact us when you are asking for a pay for your medical services coverage decision about your Part D • An appeal is a formal way of asking us to review and prescription drugs change a coverage decision we have made • A coverage decision is a decision we make about your • You can make a complaint about us or one of our benefits and coverage or about the amount we will network providers,including a complaint about the pay for your prescription drugs covered under the quality of your care.This type of complaint does not Part D benefit included in your plan involve coverage or payment disputes For more information about asking for coverage For more information about asking for coverage decisions about your Part D prescription drugs,see decisions or making appeals or complaints about your the"Coverage Decisions,Appeals,and Complaints" medical care,see the"Coverage Decisions,Appeals,and section. Complaints"section. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 97 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Coverage decisions for Part D prescription is about our plan's coverage or payment,you should look drugs—contact information at the section above about requesting coverage decisions or making appeals.)For more information about making Call 1-877-645-1282 a complaint about your Part D prescription drugs,see the Calls to this number are free. "Coverage Decisions,Appeals,and Complaints"section. Seven days a week, 8 a.m.to 8 p.m. Complaints for Part D prescription drugs— TTY 711 contact information Calls to this number are free. Call 1-800-443-0815 Seven days a week,8 a.m.to 8 p.m. Calls to this number are free. Fax 1-844-403-1028 Seven days a week,8 a.m.to 8 p.m. Write OptumRx If your complaint qualifies for a fast decision, c/o Prior Authorization call the Part D Unit at 1-866-206-2973,8:30 P.O.Box 2975 a.m.to 5 p.m.,Monday through Friday. See the Mission,KS 66201 "Coverage Decisions,Appeals,and Website kmore Complaints"section to find out if your issue qualifies for a fast decision. How to contact us when you are making an TTY 711 appeal about your Part D prescription drugs Calls to this number are free. • An appeal is a formal way of asking us to review and change a coverage decision we have made Seven days a week,8 a.m.to 8 p.m. For more information about making appeals about Fax If your complaint qualifies for a fast review,fax your Part D prescription drugs,see the"Coverage your request to our Part D Unit at 1-866-206- Decisions,Appeals,and Complaints"section.You 2974. may call us if you have questions about our appeals process. Write For a standard complaint,write to your local Member Services office(see the Provider Appeals for Part D prescription drugs—contact Directory for locations). information If your complaint qualifies for a fast decision, Call 1-866-206-2973 write to: Kaiser Permanente Calls to this number are free. Medicare Part D Unit Seven days a week,8:30 a.m.to 5 p.m. P.O.Box 1809 TTY 711 Pleasanton,CA 94566 Medicare Website.You can submit a complaint about Calls to this number are free. our plan directly to Medicare.To submit an online Seven days a week,8 a.m.to 8 p.m. complaint to Medicare,go to https://www.medicare.2ov[MedicareC omplaintForm/ Fax 1-866-206-2974 home.aspx. Write Kaiser Permanente Medicare Part D Unit Where to send a request asking us to pay for P.O.Box 1809 our share of the cost for Services or a Part D Pleasanton,CA 94566 drug you have received Website ky.or2 If you have received a bill or paid for services(such as a provider bill)that you think we should pay for,you may How to contact us when you are making a need to ask us for reimbursement or to pay the provider complaint about your Part D prescription drugs bill. See the"Requests for Payment"section. You can make a complaint about us or one of our network pharmacies,including a complaint about the Note:If you send us a payment request and we deny any quality of your care.This type of complaint does not part of your request,you can appeal our decision. See the involve coverage or payment disputes. (If your problem Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 98 Member Service:toll free 1-800-443-0815(TTY users call 711)seven days a week, 8 a.m.-8 p.m. "Coverage Decisions,Appeals,and Complaints"section Medicare—contact information for more information. Call 1-800-MEDICARE or 1-800-633-4227 Payment Requests—contact information Calls to this number are free.24 hours a day, Call 1-800-443-0815 seven days a week. Calls to this number are free. TTY 1-877-486-2048 Seven days a week,8 a.m.to 8 p.m. This number requires special telephone equipment and is only for people who have Note:If you are requesting payment of a Part D difficulties with hearing or speaking. Calls to drug that was prescribed by a Plan Provider and this number are free. obtained from a Plan Pharmacy,call our Part D Website https://www.Medicare.gov unit at 1-866-206-2973,8:30 a.m.to 5 p.m., Monday through Friday. This is the official government website for Medicare.It TTY 711 gives you up-to-date information about Medicare and Calls to this number are free. current Medicare issues.It also has information about hospitals,nursing homes,physicians,home health Seven days a week,8 a.m.to 8 p.m. agencies,and dialysis facilities.It includes documents Write For medical care: you can print directly from your computer.You can also find Medicare contacts in your state. Kaiser Permanente Claims Department The Medicare website also has detailed information P.O.Box 12923 about your Medicare eligibility and enrollment options Oakland,CA 94604-2923 with the following tools: For Part D drugs: Medicare Eligibility Tool:Provides Medicare eligibility If you are requesting payment of a Part D drug status information. that was prescribed and provided by a Plan Provider,you can fax your request to 1-866- Medicare Plan Finder:Provides personalized 206-2974 or mail it to: information about available Medicare prescription drug Kaiser Permanente plans,Medicare Health Plans,and Medigap(Medicare Medicare Part D Unit Supplement Insurance)policies in your area.These tools P.O.Box 1809 provide an estimate of what your out-of-pocket costs Pleasanton,CA 94566 might be in different Medicare plans. Website kp.org You can also use the website to tell Medicare about any complaints you have about our plan. Medicare Tell Medicare about your complaint:You can submit How to get help and information directly from a complaint about our plan directly to Medicare.To the federal Medicare program submit a complaint to Medicare,go to Medicare is the federal health insurance program for htus://www.medicare.gov/MedicareComplaintForm/ people 65 years of age or older,some people under age home.aspx.Medicare takes your complaints seriously 65 with disabilities,and people with end-stage renal and will use this information to help improve the quality disease(permanent kidney failure requiring dialysis or a of the Medicare program. kidney transplant).The federal agency in charge of Medicare is the Centers for Medicare&Medicaid If you don't have a computer,your local library or senior Services(sometimes called CMS).This agency contracts center may be able to help you visit this website using its with Medicare Advantage organizations,including our computer.Or,you can call Medicare and tell them what plan. information you are looking for.They will find the information on the website and review the information with you.You can call Medicare at 1-800-MEDICARE (1-800-633-4227)(TTY users call 1-877-486-2048),24 hours a day,7 days a week. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 99 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. State Health Insurance Assistance Livanta has a group of doctors and other health care Program professionals who are paid by Medicare to check on and help improve the quality of care for people with Free help, information, and answers to your Medicare.Livanta is an independent organization.It is questions about Medicare not connected with our plan. The State Health Insurance Assistance Program(SHIP) is a government program with trained counselors in You should contact Livanta in any of these situations: every state.In California,the State Health Insurance • You have a complaint about the quality of care you Assistance Program is called the Health Insurance have received Counseling and Advocacy Program(HICAP). . You think coverage for your hospital stay is ending HICAP is an independent(not connected with any too soon insurance company or health plan)state program that • You think coverage for your home health care, gets money from the federal government to give free Skilled Nursing Facility care,or Comprehensive local health insurance counseling to people with Outpatient Rehabilitation Facility(CORF)services Medicare. are ending too soon HICAP counselors can help you understand your Livanta (California's Quality Improvement Medicare rights,help you make complaints about your Organization)—contact information Services or treatment,and help you straighten out Call 1-877-588-1123 problems with your Medicare bills.HICAP counselors can also help you with Medicare questions or problems Calls to this number are free.Monday through and help you understand your Medicare plan choices and Friday,9 a.m.to 5 p.m Weekends and holidays answer questions about switching plans. 11 a.m.to 3 p.m. TTY 1-855-887-6668 Method to access SHIP and other resources: • Visit https://www.shiphelp.org This number requires special telephone equipment and is only for people who have • Click on SHIP Locator in middle of page difficulties with hearing or speaking. • Select your state from the list.This will take you Write Livanta to a page with phone numbers and resources BFCC—QIO Program specific to your state 10820 Guilford Road,Suite 202 Annapolis Junction,MD 20701-1105 Health Insurance Counseling and Advocacy Website www.livantaciio.com/en Program (California's State Health Insurance Assistance Program)—contact information Call 1-800-434-0222 Social Security Calls to this number are free. Social Security is responsible for determining eligibility TTY 711 and handling enrollment for Medicare.U.S.citizens and lawful permanent residents who are 65 or older,or who Write Your HICAP office for your county. have a disability or end stage renal disease and meet Website www.a2in2.ca.2ov/HICAP/ certain conditions,are eligible for Medicare.If you are already getting Social Security checks,enrollment into Medicare is automatic.If you are not getting Social Quality Improvement Organization Security checks,you have to enroll in Medicare.To apply for Medicare,you can call Social Security or visit Paid by Medicare to check on the quality of care your local Social Security office. for people with Medicare There is a designated Quality Improvement Organization Social Security is also responsible for determining who for serving Medicare beneficiaries in each state.For has to pay an extra amount for their Part D drug coverage California,the Quality Improvement Organization is because they have a higher income.If you got a letter called Livanta. from Social Security telling you that you have to pay the extra amount and have questions about the amount or if your income went down because of a life-changing Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 100 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. event,you can call Social Security to ask for To find out more about Medicaid and its programs, reconsideration. contact Medi-Cal. If you move or change your mailing address,it is Medi-Cal (California's Medicaid program)— important that you contact Social Security to let them contact information know. Call 1-800-430-4263 Social Security—contact information Calls to this number are free.Monday through Call 1-800-772-1213 Friday,8 a.m.to 6 p.m. Calls to this number are free.Available 8 a.m. TTY 1-800-430-7077 to 7 p.m.,Monday through Friday. This number requires special telephone You can use Social Security's automated equipment and is only for people who have telephone services and get recorded information difficulties with hearing or speaking. 24 hours a day. Write CA Department of Health Care Services TTY 1-800-325-0778 Health Care Options P.O.Box 989009 This number requires special telephone West Sacramento,CA 95798-9850 equipment and is only for people who have Website http://www.healthcareoptions.dhes.ca.gov/ difficulties with hearing or speaking. Calls to this number are free.Available 8 a.m.to 7 p.m., Monday through Friday. Railroad Retirement Board Website www.ssa.gov The Railroad Retirement Board is an independent federal agency that administers comprehensive benefit programs Medicaid for the nation's railroad workers and their families. If you have questions regarding your benefits from the A joint federal and state program that helps with Railroad Retirement Board,contact the agency. medical costs for some people with limited income and resources If you receive your Medicare through the Railroad Medicaid is a joint federal and state government program Retirement Board,it is important that you let them know that helps with medical costs for certain people with if you move or change your mailing address. limited incomes and resources. Some people with Medicare are also eligible for Medicaid. Railroad Retirement Board—contact information In addition,there are programs offered through Medicaid Call 1-877-772-5772 that help people with Medicare pay their Medicare costs, Calls to this number are free.If you press"0," such as their Medicare premiums.These"Medicare you may speak with an RRB representative Savings Programs"help people with limited income and from 9 a.m.to 3:30 p.m.,Monday,Tuesday, resources save money each year: Thursday,and Friday,and from 9 a.m.to 12 • Qualified Medicare Beneficiary(QMB):Helps pay p.m.on Wednesday. Medicare Part A and Part B premiums,and other Cost If you press"1,"you may access the automated Share. Some people with QMB are also eligible for RRB HelpLine and recorded information 24 full Medicaid benefits(QMB+) hours a day,including weekends and holidays. • Specified Low-Income Medicare Beneficiary TTY 1-312-751-4701 (SLMB):Helps pay Part B premiums. Some people with SLMB are also eligible for full Medicaid This number requires special telephone benefits(SLMB+) equipment and is only for people who have difficulties with hearing or speaking. Calls to • Qualifying Individual(QI):Helps pay Part B this number are not free. premiums Website rrb.gov/ • Qualified Disabled&Working Individuals (QDWI):Helps pay Part A premiums Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 101 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Group Insurance or Other Health Insurance from an Employer If you have any questions about your employer- sponsored Group plan,please contact your Group's benefits administrator.You can ask about your employer or retiree health benefits,any contributions toward the Group's premium,eligibility,and enrollment periods. If you have other prescription drug coverage through your(or your spouse's)employer or retiree group,please contact that group's benefits administrator.The benefits administrator can help you determine how your current prescription drug coverage will work with our plan. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#2 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 102 Notice of Nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Permanente does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also: • Provide no cost aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters. o Written information in other formats, such as large print, audio, and accessible electronic formats. • Provide no cost language services to people whose primary language is not English, such as: o Qualified interpreters. o Information written in other languages. If you need these services, call Member Services at 1-800-443-0815 (TTY 711), 8 a.m. to 8 p.m., seven days a week. If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator by writing to One Kaiser Plaza, 12th Floor, Suite 1223, Oakland, CA 94612 or calling Member Services at the number listed above. You can file a grievance by mail or phone. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.htmi. ' KAISER PERMANEWE® 1126306860 CA June 2023 Form Approved OMB# 0938-1421 Multi-Language Insert Multi-language Interpreter Services English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-800-443-0815 (TTY 711). Someone who speaks English/Language can help you. This is a free service. Spanish: Tenemos servicios de interprete sin costo alguno pars responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un interprete, por favor Ilame al 1-800-443-0815 (TTY 711). Alguien que hable espanol le podra ayudar. Este es un servicio gratuito. Chinese Mandarin: �i] T1i �� m��J1� TI �1T7 Ip7o M4R k All i+V*, i*GAF, 1-800-443-0815 (TTY 711)0 Chinese Cantonese: 9�Y_fRfr1n, I -�AIMI-ftf,9 b"o UATWL 1-800-443-0815 (TTY 711)0 Ma X2 �r� � o Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa 1-800-443-0815 (TTY 711). Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. French: Nous proposons des services gratuits d'interpretation pour repondre a toutes vos questions relatives a notre regime de sante ou d'assurance- medicaments. Pour acceder au service d'interpretation, it vous suffit de nous appeler au 1-800-443-0815 (TTY 711). Un interlocuteur parlant Frangais pourra vous cider. Ce service est gratuit. Vietnamese: Chung toi co dich vu thong dich mien phi de tra Idi cac c3u hoi ve chLrdng sLYc khoe va chLrdng trinh thuoc men. Neu qui vi can thong dich vien xin goi 1-800-443-0815 (TTY 711) se co nh3n vien not tieng Viet giup dd qui vi. flay la dich vu mien phi . German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- and Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-800-443-0815 (TTY 711). Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Form CMS-10802 F50*111 KAISER PERMANEWE, (Expires 12/31/25) Y0043_N00036258_C Form Approved OMB# 0938-1421 Korean: oA}L I Ada fL -V-AaOil oN E�ela�} T� a 011 A] HIL I o o}� IV �}. o ��l dl o }�� 1-800-443-0815 (TTY 711) V1 0 L 914 Russian: ECJIVI y BaC B03HMKHYT BOnpOCbl OTHOCMTeJlbHO CTpaXOBOro mnm megMKaMeHTHOro nJlaHa, Bbl moweTe BOcnOJlb3OBaTbCA Hawmmm 6ecnJlaTHbIMM yCJlyramL4 nepeBOALIMKOB. LlT06bI Bocnonb30BaTbCq yCJlyram" nepeBOALI"Ka, n03BOHMTe Ham no TeneCpOHy 1-800-443-0815 (TTY 711). Bam OKaweT nOMOLL4b COTpy,gHMK, KOTOpblV rOBOPMT no-pyCCKVI. ,QaHHaq yCnyra 6ecnnaTHaA. 1-3 J�� -9I d,,�I�, �I SI L.Jc a�I�JJ �li�Li cJl s,�l �yA11 Arabic P� .1-800-443-0815 (TTY 711) Lrl,-- 13.E JL--�T s c>J 'cs,-O Lr�-- cis� H i nd i: of f-ff-dT-4ft T-cF Z[ft# 3JTQ f45t Ift-f%�-� r�-6�TTf JWT -q T#T�-Jq�t. IZW-g T Wcf qTT4-4�f�T, Zf-iF# 1-800-443-0815 (TTY 711) W q5t q?r� f-�3ftf art TriT&-qR Twmt. zF,5 7c-F ijwr#aT . Italian: E disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare it numero 1-800-443-0815 (TTY 711). Un nostro incaricato the parla Italianovi fornira I'assistenza necessaria. E un servizio gratuito. Portuguese: Dispomos de servigos de interpretagao gratuitos para responder a qualquer questao que tenha acerca do nosso plano de saude ou de medicagao. Para obter um interprete, contacte-nos atraves do numero 1-800-443-0815 (TTY 711). Ira encontrar alguem que fale o idioma Portugues para o ajudar. Este servigo e gratuito. French Creole: Nou genyen sevis entepret gratis you reponn tout kesyon ou to genyen konsenan plan medikal oswa dwog nou an. Pou jwenn you entepret, jis rele nou nan 1-800-443-0815 (TTY 711). Yon moun ki pale Kreyol kapab ede w. Sa a se you sevis ki gratis. Polish: Umo2liwiamy bezpkatne skorzystanie z uskug tkumacza ustnego, ktory pomo2e w uzyskaniu odpowiedzi na temat planu zdrowotnego Iub dawkowania lekow. Aby skorzystac z pomocy t+umacza znajacego jgzyk polski, nale2y zadzwonic pod numer 1-800-443-0815 (TTY 711). Ta uskuga jest bezpkatna. Japanese: �'iYto)1 IA RFAf A LjV- Q -7 Mlt 7.,�N1A : �3 t 76 L'V) 1-800-443-0815 (TTY 711) 6` �3 7-FE-1-Au , o L L I to fL 6t I'M f4 a)-t t:� 7, Z't Form CMS-10802 (Expires 12/31/25) 1140823727 June 2023 00 NO"71 KAISER PERMANEWEe Kaiser Foundation Health Plan, Inc. Northern California Region EOC #3 - Chiropractic Services Amendment of the Kaiser Foundation Health Plan, Inc. Evidence of Coverage for COUNTY OF FRESNO, RETIREE Group ID: 604334 Contract: 1 Version: 34 EOC Number: 3 January 1,2024,through December 31, 2024 ASH Plans Customer Service Department Monday through Friday, 5 a.m. to 6 p.m. 1-800-678-9133 (TTY users call 711)toll free ashlink.com/ash/kp TABLE OF CONTENTS FOR EOC #3 BenefitHighlights..................................................................................................................................................................1 Introduction............................................................................................................................................................................2 Definitions..............................................................................................................................................................................2 ASHParticipating Providers..................................................................................................................................................3 Howto Obtain Services......................................................................................................................................................3 CoveredServices....................................................................................................................................................................3 OfficeVisits.......................................................................................................................................................................4 LaboratoryTests and X-rays..............................................................................................................................................4 Chiropractic Supports and Appliances...............................................................................................................................4 SecondOpinions.................................................................................................................................................................4 Emergency and Urgent Services Covered Under this Amendment...................................................................................5 Exclusions..............................................................................................................................................................................5 CustomerService...................................................................................................................................................................5 Grievances..............................................................................................................................................................................6 Benefit Highlights _ We cover the Services described below,subject to exclusions described in the"Exclusions"section,only if all of the following conditions are satisfied: • You are a Member on the date that you receive the Services • ASH Plans has determined that the Services are Medically Necessary,except as described in this Amendment • You receive the Services from ASH Participating Providers or other licensed providers that ASH contracts to provide covered care,except as described in this Amendment Professional Services(ASH Participating Provider office visits) You Pay Chiropractic office visits(up to a total of 30 visits per 12-month period).. $10 per visit Other You Pay X-rays and laboratory tests that are covered Chiropractic Services............ No charge Chiropractic supports and appliances.......................................................... Amounts in excess of the$50 Allowance This is a summary of the most frequently asked-about benefits.This chart does not explain benefits,Cost Share,out-of- pocket maximums,exclusions,or limitations,nor does it list all benefits and Cost Share amounts.For a complete explanation,refer to the"Covered Services"and"Exclusions"sections. Introduction ASH Plans:American Specialty Health Plans of California,Inc.,a California corporation. This document amends your Kaiser Foundation Health Plan,Inc.(Health Plan)EOC to add coverage Chiropractic Services: Chiropractic services include for Chiropractic Services as described in this spinal and extremity manipulation and adjunctive Chiropractic Services Amendment("Amendment"). therapies such as ultrasound,therapeutic exercise,or All provisions of the EOC apply to coverage described in electrical muscle stimulation,when provided during the this document except for the following sections: same course of treatment and in conjunction with chiropractic manipulative services,and other services • "How to Obtain Services"(except that the provided or prescribed by a chiropractor(including "Completion of Services from Non—Plan Providers" laboratory tests,X-rays,and chiropractic supports and section,or for Kaiser Permanente Senior Advantage appliances)for the treatment of your Musculoskeletal Members,the"Termination of a Plan Provider's and Related Disorder. contract and completion of Services"section,does apply to coverage described in this document) Emergency Chiropractic Services: Covered • "Plan Facilities" Chiropractic Services provided for the treatment of a • "Emergency Services and Urgent Care" Musculoskeletal and Related Disorder which manifests itself by acute symptoms of sufficient severity(including • "Benefits" severe pain)such that you could expect the absence of immediate Chiropractic Services to result in serious Kaiser Foundation Health Plan,Inc. contracts with jeopardy to your health or body functions or organs. American Specialty Health Plans of California,Inc. ("ASH Plans")to make the network of ASH Musculoskeletal and Related Disorders: Conditions Participating Providers available to you. with signs and symptoms related to the nervous, muscular,and/or skeletal systems.Musculoskeletal and When you need chiropractic care,you have direct access Related Disorders are conditions typically categorized as to more than 3,400 licensed chiropractors in California. structural,degenerative,or inflammatory disorders;or You can obtain covered Services from any ASH biomechanical dysfunction of the joints of the body Participating Provider without a referral from a Plan and/or related components of the muscle or skeletal Physician.Your Cost Share is due when you receive systems(muscles,tendons,fascia,nerves, covered Services. ligaments/capsules,discs and synovial structures)and related manifestations or conditions. Definitions 14pr, Non—Participating Provider:A provider other than an ASH Participating Provider. In addition to the terms defined in the"Definitions" Treatment Plan: The course of treatment for your section of your Health Plan EOC,the following terms, Musculoskeletal and Related Disorder,which may when capitalized and used in any part of this include laboratory tests,X-rays,chiropractic supports Amendment,have the following meanings: and appliances,and a specific number of visits for chiropractic manipulations(adjustments)and adjunctive ASH Participating Provider:A chiropractor who is therapies that are Medically Necessary Chiropractic licensed to provide chiropractic services in California Services for you. and who has a contract with ASH Plans to provide Medically Necessary Chiropractic Services to you.A list of ASH Participating Providers is available on the ASH Urgent Chiropractic Services: Chiropractic Services Plans website at ashlink.com/ash/kaisercamedicare for that meet all of the following requirements: Kaiser Permanente Senior Advantage Members,or • They are necessary to prevent serious deterioration of ashlink.com/ash/ku for all other Members,or from the your health resulting from an unforeseen illness, ASH Plans Customer Service Department toll free at injury,or complication of an existing condition, 1-800-678-9133(TTY users call 711).The list of ASH including pregnancy Participating Providers is subject to change at any time, • They cannot be delayed until you return to the Service without notice.If you have questions,please call the Area ASH Plans Customer Service Department. Group ID:604334 American Specialty Health Plans Chiropractic Plan Contract: 1 Version:34 EOC'#3 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 2 ASH Participating Providers will be informed of the scope of the authorized Services. If ASH Plans does not authorize all of the Services,ASH PLEASE READ THE FOLLOWING Plans will send you a written decision and explanation, INFORMATION SO YOU WILL KNOW FROM including the rationale for the decision and the criteria WHOM OR WHAT GROUP OF PROVIDERS used to make the decision,within two business days after HEALTH CARE MAY BE OBTAINED. the decision is made.The letter will also include information about your appeal rights,which are described in the"Coverage Decisions,Appeals,and ASH Plans contracts with ASH Participating Providers Complaints"section of your Health Plan EOC for Kaiser and other licensed providers to provide the Services permanente Senior Advantage Members,and"Dispute covered under this Amendment(including laboratory Resolution"section of your Health Plan EOC for all tests,X-rays,and chiropractic supports and appliances). other Members.Any written criteria that ASH Plans uses You must receive Services covered under this to make the decision to authorize,modify,delay,or deny Amendment from an ASH Participating Provider or the request for authorization will be made available to another licensed provider with which ASH contracts to you upon request.If you have questions or concerns, provide covered care,except for Services covered under please contact ASH Plans or Kaiser Permanente as "Emergency and Urgent Services Covered Under this described under"Customer Service"in this Amendment. Amendment"in the"Covered Services"section and Services that are not available from contracted providers and that are authorized in advance by ASH Plans. Covered Services How to Obtain Services We cover the Services listed in this"Covered Services" To obtain Services covered under this Amendment call section,subject to exclusions described in the an ASH Participating Provider to schedule an initial "Exclusions"section,only if all of the following examination.If additional Services are required after the conditions are satisfied: initial examination,verification that the Services are • You are a Member on the date that you receive the Medically Necessary may be required,as described Services under"Decision time frames"below.Your ASH . ASH Plans has determined that the Services are Participating Provider will request any required medical Medically Necessary,except for: necessity determinations.An ASH Plans clinician in the same or similar specialty as the provider of Services ♦ the initial examination described under"Office under review will determine whether the Services are or Visits"in this"Covered Services"section were Medically Necessary Services. ♦ Services covered under"Emergency and Urgent Services Covered Under this Amendment"in this Decision time frames "Covered Services"section The ASH Plans' clinician will make the authorization • You receive the Services from ASH Participating decision within the time frame appropriate for your Providers or other licensed providers with which condition,but no later than five business days after ASH contracts to provide covered care,except for: receiving all of the information(including additional ♦ Services covered under"Emergency and Urgent examination and test results)reasonably necessary to Services Covered Under this Amendment"in this make the decision,except that decisions about urgent "Covered Services"section Services will be made no later than 72 hours after receipt of the information reasonably necessary to make the ♦ Services that are not available from ASH decision.If ASH Plans needs more time to make the Participating Providers or other licensed providers decision because it doesn't have information reasonably with which ASH contracts to provide covered care necessary to make the decision,or because it has and that are authorized in advance by ASH Plans requested consultation by a particular specialist,you and your ASH Participating Provider will be informed in When you receive covered Services,you must pay the writing about the additional information,testing,or Cost Share listed in this"Covered Services"section.If specialist that is needed,and the date that ASH Plans you receive Services that are not covered under this expects to make a decision. Amendment,you maybe liable for the full price of those Services. Your ASH Participating Provider will be informed of the decision within 24 hours after the decision is made.If the Services are authorized,your ASH Participating Provider Group ID:604334 American Specialty Health Plans Chiropractic Plan Contract: 1 Version:34 EOC'#3 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 3 Note:If Charges for Services are less than the Laboratory Tests and X-rays Copayment described in this"Covered Services"section, you will pay the lesser amount. We cover Medically Necessary laboratory tests and X- rays when prescribed as part of covered chiropractic care The Cost Share you pay for Services covered under this described under"Office Visits"in this"Covered Amendment does not apply toward any Plan Deductible Services"section at no charge when an ASH or Plan Out-of-Pocket Maximum described in your Participating Provider provides the Services or refers you Health Plan EOC. to another licensed provider with which ASH contracts to provide covered Services. If you have questions about your Cost Share for specific Services that you are scheduled to receive or that your provider orders during a visit or procedure,please call Chiropractic Supports and Appliances the ASH Plans Customer Service Department toll free at We provide a$50 Allowance per 12-month period 1-800-678-9133(TTY users call 711)weekdays from 5 toward the ASH Plans fee schedule price for chiropractic a.m.to 6 p.m. appliances listed in this paragraph when the item is prescribed and provided to you by an ASH Participating If you are a Kaiser Permanente Senior Advantage Provider as part of covered chiropractic care described Member,refer to your Health Plan EOC for information under"Office Visits"in this"Covered Services"section. about the chiropractic Services that we cover in accord If the price of the items in the ASH Plans fee schedule with Medicare guidelines,which are separate from the exceeds$50(the Allowance),you will pay the amount in Services covered under this Amendment. excess of$50(and that payment does not apply toward the Plan Out-of-Pocket Maximum described in your Office Visits Health Plan EOC).Covered chiropractic appliances are limited to: elbow supports,back supports(thoracic), We cover the following: cervical collars,cervical pillows,heel lifts,hot or cold packs,lumbar braces and supports,lumbar cushions, • Initial chiropractic examination:An examination orthotics,wrist supports,rib belts,home traction units performed by an ASH Participating Provider to (cervical or lumbar),ankle braces,knee braces,rib determine the nature of your problem(and,if supports,and wrist braces. appropriate,to prepare a Treatment Plan),and to provide Medically Necessary Chiropractic Services, which may include an adjustment and adjunctive Second Opinions therapy.We cover an initial examination only if you have not already received covered Chiropractic You may request a second opinion in regard to covered Services from an ASH Participating Provider in the Services by contacting another ASH Participating same 12-month period for your Musculoskeletal and Provider.Your visit to another ASH Participating Related Disorder Provider for a second opinion generally will count • Subsequent chiropractic office visits: Subsequent toward any visit limit,if applicable.An ASH ASH Participating Provider office visits for Participating Provider may also request a second opinion Chiropractic Services that are determined to be in regard to covered Services by referring you to another Medically Necessary by an ASH Plans clinician. ASH Participating Provider in the same or similar These subsequent office visits may include an specialty.When you are referred by an ASH adjustment,adjunctive therapy,and a re-examination Participating Provider to another ASH Participating to assess the need to continue,extend,or change a Provider for a second opinion,your visit to the other Treatment Plan ASH Participating Provider will not count toward any visit limit,if applicable.An authorization or denial of your request for a second opinion will be provided in an Each office visit counts toward any visit limit,if expeditious manner,as appropriate for your condition.If applicable. your request for a second opinion is denied,you will be notified in writing of the reasons for the denial,and of You pay the following for these covered Services(up to your right to file a grievance as described under 30 visits per 12 month period): a$10 Copayment per "Grievances"in this Amendment. visit Group ID:604334 American Specialty Health Plans Chiropractic Plan Contract: 1 Version:34 EOC'#3 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 4 Emergency and Urgent Services • Thermography Covered Under this Amendment • Experimental or investigational Services.If coverage for a Service is denied because it is experimental or We cover Emergency Chiropractic Services and Urgent investigational and you want to appeal the denial, Chiropractic Services provided by an ASH Participating refer to your Health Plan EOC for information about Provider or a Non—Participating Provider at a the appeal process $10 Copayment per visit.We do not cover follow-up or continuing care from a Non-Participating Provider unless • CT scans,MRIs,PET scans,bone scans,nuclear ASH Plans has authorized the Services in advance.Also, medicine,and any other type of diagnostic imaging or we do not cover Services from a Non-Participating radiology other than X-rays covered under the Provider that ASH Plans determines are not Emergency "Covered Services"section of this Amendment Chiropractic Services or Urgent Chiropractic Services. • Ambulance and other transportation • Education programs,non-medical self-care or self- How to file a Claim help,any self-help physical exercise training,and any As soon as possible after receiving Emergency related diagnostic testing Chiropractic Services or Urgent Chiropractic Services, you must file an ASH Plans claim form.To request a • Services for pre-employment physicals or vocational claim form or for more information,please call ASH rehabilitation Plans toll free at 1-800-678-9133(TTY users call 711)or . Drugs and medicines,including non-legend or visit the ASH Plans website at ashlink.com.You must proprietary drugs and medicines send the completed claim form to: • Services you receive outside the state of California, ASH Plans except for Services covered under"Emergency and P.O.Box 509002 Urgent Services Covered Under this Amendment"in San Diego,CA 92150-9002 the"Covered Services"section • Hospital services,anesthesia,manipulation under anesthesia,and related services Exclusions • Dietary and nutritional supplements,such as vitamins, minerals,herbs,herbal products,injectable The items and services listed in this"Exclusions"section supplements,and similar products are excluded from coverage under this Amendment. . Massage therapy (Note: Some items and services listed in this "Exclusions"section maybe covered Services under • Maintenance care(services provided to Members your Health Plan EOC.Please refer to your Health Plan whose treatment records indicate that they have EOC for details.)These exclusions apply to all Services reached maximum therapeutic benefit) that would otherwise be covered under this Amendment regardless of whether the services are within the scope of a provider's license or certificate: Customer Service i • Services provided by a chiropractor that are not within the scope of licensure for a chiropractor If you have a question or concern regarding the Services licensed in California you received from an ASH Participating Provider or any • Adjunctive therapy not associated with spinal, other licensed provider with which ASH contracts to muscle,or joint manipulations provide covered Services,you may call the ASH Plans Customer Service Department toll free at 1-800-678- • Air conditioners,air purifiers,therapeutic mattresses, 9133(TTY users call 711)weekdays from 5 a.m.to 6 chiropractic appliances,durable medical equipment, p.m.,or write ASH Plans at: supplies,devices,appliances,and any other item except those listed as covered under"Chiropractic ASH Plans Supports and Appliances"in the"Covered Services" Customer Service Department section of this Amendment P.O.Box 509002 • Services for asthma or addiction,such as nicotine San Diego,CA 92150-9002 addiction • Hypnotherapy,behavior training,sleep therapy,and weight programs Group ID:604334 American Specialty Health Plans Chiropractic Plan Contract: 1 Version:34 EOC'#3 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 5 Grievances You can file a grievance with Kaiser Permanente regarding any issue.Your grievance must explain your issue,such as the reasons why you believe a decision was in error or why you are dissatisfied about Services you received.If you are a Kaiser Permanente Senior Advantage Member,you may submit your grievance orally or in writing to Kaiser Permanente as described in the"Coverage Decisions,Appeals,and Complaints" section of your Health Plan EOC. Otherwise,you may submit your grievance orally or in writing to Kaiser Permanente as described in the"Dispute Resolution" section of your Health Plan EOC. Group ID:604334 American Specialty Health Plans Chiropractic Plan Contract: 1 Version:34 EOC'#3 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 6 00 NO"71 KAISER PERMANEWEe Kaiser Foundation Health Plan, Inc. Northern California Region A nonprofit corporation and a Medicare Advantage Organization EOC #4 - Kaiser Permanente Senior Advantage (HMO) with Part D Evidence of Coverage for COUNTY OF FRESNO, RETIREE Group ID: 604334 Contract: 1 Version: 34 EOC Number: 4 January 1,2024,through December 31, 2024 Member Services Seven days a week, 8 a.m.-8 p.m. 1-800-443-0815 (TTY users call 711) kp.or� This document is available for free in Spanish. Please contact Member Services at 1-800-443-0815 for additional information. (TTY users should call 711.)Hours are 8 a.m. to 8 p.m., 7 days a week. Este documento estd disponible de manera gratuita en espanol. Para obtener informacion adicional, comuniquese con Servicio a los Miembros al 1-800-443-0815. (Los usuarios de la linea TTYdeben llamar al 711). El horario es de 8 a. m. a 8 p. m., los 7 dias de la semana. This document explains your benefits and rights. Use this document to understand about: • Your cost sharing • Your medical and prescription drug benefits • How to file a complaint if you are not satisfied with a service or treatment • How to contact us if you need further assistance • Other protections required by Medicare law TABLE OF CONTENTS FOR EOC #4 BenefitHighlights..................................................................................................................................................................1 Introduction............................................................................................................................................................................3 AboutKaiser Permanente...................................................................................................................................................3 Termof this EOC...............................................................................................................................................................3 Definitions..............................................................................................................................................................................4 Premiums,Eligibility,and Enrollment.................................................................................................................................10 Premiums..........................................................................................................................................................................10 MedicarePremiums..........................................................................................................................................................10 WhoIs Eligible.................................................................................................................................................................11 How to Enroll and When Coverage Begins.....................................................................................................................13 Howto Obtain Services........................................................................................................................................................15 RoutineCare.....................................................................................................................................................................16 UrgentCare......................................................................................................................................................................16 OurAdvice Nurses...........................................................................................................................................................16 YourPersonal Plan Physician..........................................................................................................................................16 Gettinga Referral.............................................................................................................................................................16 Travel and Lodging for Certain Services.........................................................................................................................18 SecondOpinions...............................................................................................................................................................18 Contractswith Plan Providers..........................................................................................................................................18 Receiving Care Outside of Your Home Region Service Area.........................................................................................19 YourID Card....................................................................................................................................................................19 GettingAssistance............................................................................................................................................................20 PlanFacilities.......................................................................................................................................................................20 ProviderDirectory............................................................................................................................................................20 PharmacyDirectory..........................................................................................................................................................20 Emergency Services and Urgent Care..................................................................................................................................21 EmergencyServices.........................................................................................................................................................21 UrgentCare......................................................................................................................................................................21 Paymentand Reimbursement...........................................................................................................................................22 Benefitsand Your Cost Share..............................................................................................................................................22 YourCost Share...............................................................................................................................................................23 OutpatientCare.................................................................................................................................................................25 HospitalInpatient Services...............................................................................................................................................27 AmbulanceServices.........................................................................................................................................................28 BariatricSurgery..............................................................................................................................................................28 DentalServices.................................................................................................................................................................29 DialysisCare....................................................................................................................................................................29 Durable Medical Equipment("DME")for Home Use.....................................................................................................30 FertilityServices...............................................................................................................................................................32 HealthEducation..............................................................................................................................................................33 HearingServices...............................................................................................................................................................33 Home-Delivered Meals....................................................................................................................................................33 HomeHealth Care............................................................................................................................................................34 Home Medical Care Not Covered by Medicare for Members Who Live in Certain Counties(Advanced Care at Home).............................................................................................................................................................................34 HospiceCare....................................................................................................................................................................35 MentalHealth Services....................................................................................................................................................36 Opioid Treatment Program Services................................................................................................................................37 Ostomy,Urological,and Specialized Wound Care Supplies...........................................................................................38 Outpatient Imaging,Laboratory,and Other Diagnostic and Treatment Services............................................................38 Outpatient Prescription Drugs, Supplies,and Supplements.............................................................................................39 Over-the-Counter(OTC)Health and Wellness................................................................................................................48 PreventiveServices..........................................................................................................................................................48 Prostheticand Orthotic Devices.......................................................................................................................................48 ReconstructiveSurgery....................................................................................................................................................50 Religious Nonmedical Health Care Institution Services..................................................................................................50 Services Associated with Clinical Trials..........................................................................................................................51 SkilledNursing Facility Care...........................................................................................................................................51 Substance Use Disorder Treatment..................................................................................................................................52 TelehealthVisits...............................................................................................................................................................53 TransplantServices..........................................................................................................................................................53 TransportationServices....................................................................................................................................................54 VisionServices.................................................................................................................................................................54 Exclusions,Limitations,Coordination of Benefits,and Reductions...................................................................................56 Exclusions........................................................................................................................................................................56 Limitations........................................................................................................................................................................58 Coordinationof Benefits..................................................................................................................................................58 Reductions........................................................................................................................................................................59 Requestsfor Payment...........................................................................................................................................................60 Requests for Payment of Covered Services or Part D drugs............................................................................................60 How to Ask Us to Pay You Back or to Pay a Bill You Have Received...........................................................................62 We Will Consider Your Request for Payment and Say Yes or No...................................................................................62 Other Situations in Which You Should Save Your Receipts and Send Copies to Us......................................................63 YourRights and Responsibilities.........................................................................................................................................63 We must honor your rights and cultural sensitivities as a Member of our plan...............................................................63 You have some responsibilities as a Member of our plan................................................................................................67 Coverage Decisions,Appeals,and Complaints....................................................................................................................68 What to Do if You Have a Problem or Concern..............................................................................................................68 Where To Get More Information and Personalized Assistance.......................................................................................68 To Deal with Your Problem,Which Process Should You Use?......................................................................................68 A Guide to the Basics of Coverage Decisions and Appeals.............................................................................................69 Your Medical Care:How to Ask for a Coverage Decision or Make an Appeal of a Coverage Decision.......................70 Your Part D Prescription Drugs:How to Ask for a Coverage Decision or Make an Appeal..........................................75 How to Ask Us to Cover a Longer Inpatient Hospital Stay if You Think You Are Being Discharged Too Soon..........80 How to Ask Us to Keep Covering Certain Medical Services if You Think Your Coverage Is Ending Too Soon..........83 Taking Your Appeal to Level 3 and Beyond...................................................................................................................86 How to Make a Complaint About Quality of Care,Waiting Times,Customer Service,or Other Concerns..................88 You can also tell Medicare about your complaint............................................................................................................89 AdditionalReview............................................................................................................................................................89 BindingArbitration..........................................................................................................................................................90 Terminationof Membership.................................................................................................................................................92 Termination Due to Loss of Eligibility............................................................................................................................92 Terminationof Agreement................................................................................................................................................92 Disenrolling from Senior Advantage...............................................................................................................................92 Termination of Contract with the Centers for Medicare&Medicaid Services...............................................................93 Terminationfor Cause......................................................................................................................................................93 Termination for Nonpayment of Premiums.....................................................................................................................94 Termination of a Product or all Products.........................................................................................................................94 Paymentsafter Termination.............................................................................................................................................94 Review of Membership Termination...............................................................................................................................94 Continuationof Membership................................................................................................................................................94 Continuationof Group Coverage.....................................................................................................................................94 Conversion from Group Membership to an Individual Plan............................................................................................95 MiscellaneousProvisions.....................................................................................................................................................95 Administrationof Agreement...........................................................................................................................................95 Amendmentof Agreement................................................................................................................................................95 Applicationsand Statements............................................................................................................................................95 Assignment.......................................................................................................................................................................95 Attorney and Advocate Fees and Expenses.....................................................................................................................95 ClaimsReview Authority.................................................................................................................................................95 EOCBinding on Members...............................................................................................................................................96 ERISANotices.................................................................................................................................................................96 GoverningLaw.................................................................................................................................................................96 Groupand Members Not Our Agents..............................................................................................................................96 NoWaiver........................................................................................................................................................................96 Notices Regarding Your Coverage...................................................................................................................................96 Notice about Medicare Secondary Payer Subrogation Rights.........................................................................................96 OverpaymentRecovery....................................................................................................................................................96 PublicPolicy Participation...............................................................................................................................................97 TelephoneAccess(TTY).................................................................................................................................................97 Important Phone Numbers and Resources...........................................................................................................................97 Kaiser Permanente Senior Advantage..............................................................................................................................97 Medicare...........................................................................................................................................................................99 State Health Insurance Assistance Program...................................................................................................................100 Quality Improvement Organization................................................................................................................................100 SocialSecurity................................................................................................................................................................101 Medicaid.........................................................................................................................................................................101 RailroadRetirement Board.............................................................................................................................................101 Group Insurance or Other Health Insurance from an Employer....................................................................................102 Benefit Highlights Accumulation Period The Accumulation Period for this plan is 1/1/24 through 12/31/24(calendar year). Plan Out-of-Pocket Maximum For Services subject to the maximum,you will not pay any more Cost Share for the rest of the calendar year if the Copayments and Coinsurance you pay for those Services add up to the following amount: For any one Member.................................................................................$1,000 per calendar year Plan Deductible None Plan Provider Office Visits You Pay Most Primary Care Visits and most Non-Physician Specialist Visits.......... $25 per visit Most Physician Specialist Visits................................................................... $25 per visit Annual Wellness visit and the"Welcome to Medicare"preventive visit.... No charge Routine physical exams................................................................................ No charge Routine eye exams with a Plan Optometrist................................................. $25 per visit Urgent care consultations,evaluations,and treatment................................. $25 per visit Physical,occupational,and speech therapy.................................................. $25 per visit Telehealth Visits You Pay Primary Care Visits and Non-Physician Specialist Visits by interactive video........................................................................................................... No charge Physician Specialist Visits by interactive video........................................... No charge Primary Care Visits and Non-Physician Specialist Visits by telephone...... No charge Physician Specialist Visits by telephone...................................................... No charge Outpatient Services You Pay Outpatient surgery and certain other outpatient procedures......................... $25 per procedure Allergy injections(including allergy serum)................................................ $3 per visit Most immunizations(including the vaccine)............................................... No charge Most X-rays and laboratory tests.................................................................. No charge Manual manipulation of the spine................................................................ $20 per visit Hospitalization Services You Pay Room and board,surgery,anesthesia,X-rays,laboratory tests,and drugs.. $250 per admission Emergency Health Coverage You Pay Emergency Department visits....................................................................... $75 per visit Note:If you are admitted directly to the hospital as an inpatient for covered Services,you will pay the inpatient Cost Share instead of the Emergency Department Cost Share(see"Hospitalization Services"for inpatient Cost Share). Ambulance and Transportation Services You Pay AmbulanceServices..................................................................................... $100 per trip Other transportation Services when provided by our designated No charge for up to 24 one-way trips(50 miles per transportation provider as described in this EOC....................................... trip)per calendar year Prescription Drug Coverage You Pay Covered outpatient items in accord with our drug formulary guidelines: Most generic items at a Plan Pharmacy................................................... $10 for up to a 30-day supply,$20 for a 31-to 60- day supply,or$30 for a 6 1-to 100-day supply Most generic refills through our mail-order service................................ $10 for up to a 30-day supply or$20 for a 3 1-to 100-day supply Most brand-name items at a Plan Pharmacy........................................... $25 for up to a 30-day supply,$50 for a 3 1-to 60- day supply,or$75 for a 6 1-to 100-day supply Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 1 Prescription Drug Coverage You Pay Most brand-name refills through our mail-order service........................ $25 for up to a 30-day supply or$50 for a 3 1-to 100-day supply Durable Medical Equipment(DME) You Pay Covered durable medical equipment for home use as described in this EOC............................................................................................................. 20 percent Coinsurance Mental Health Services You Pay Inpatient psychiatric hospitalization............................................................. $250 per admission Individual outpatient mental health evaluation and treatment...................... $25 per visit Group outpatient mental health treatment.................................................... $12 per visit Substance Use Disorder Treatment You Pay Inpatient detoxification................................................................................. $250 per admission Individual outpatient substance use disorder evaluation and treatment....... $25 per visit Group outpatient substance use disorder treatment...................................... $5 per visit Home Health Services You Pay Home health care(part-time,intermittent)................................................... No charge Other You Pay Eyeglasses or contact lenses every 24 months............................................. Amount in excess of$175 Allowance Hearing aid(s)every 36 months.................................................................... Amount in excess of$1,000 Allowance per aid Skilled Nursing Facility care(up to 100 days per benefit period)................ No charge External prosthetic and orthotic devices as described in this EOC.............. 20 percent Coinsurance Ostomy,urological,and wound care supplies.............................................. 20 percent Coinsurance Meals delivered to your home immediately following discharge from a No charge up to three meals per day in a Plan Hospital or Skilled Nursing Facility as an inpatient........................... consecutive four-week period,once per calendar year Over-the-Counter(OTC)Health and Wellness items obtained through our catalog......................................................................................................... No charge up to a quarterly benefit of$70 This is a summary of the most frequently asked-about benefits.This chart does not explain benefits,Cost Share,out-of- pocket maximums,exclusions,or limitations,nor does it list all benefits and Cost Share amounts.For a complete explanation,refer to the"Benefits and Your Cost Share"and"Exclusions,Limitations,Coordination of Benefits,and Reductions"sections. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 2 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Introduction FROM WHOM OR WHAT GROUP OF PROVIDERS YOU MAY GET HEALTH CARE. Kaiser Foundation Health Plan,Inc. (Health Plan)has a contract with the Centers for Medicare&Medicaid Kaiser Permanente provides Services directly to our Services as a Medicare Advantage Organization. Members through an integrated medical care program. Health Plan,Plan Hospitals,and the Medical Group This contract provides Medicare Services(including work together to provide our Members with quality care. Medicare Part D prescription drug coverage)through Our medical care program gives you access to all of the "Kaiser Permanente Senior Advantage covered Services you may need,such as routine care (HMO)with Part D"(Senior Advantage),except for with your own personal Plan Physician,hospital hospice care for Members with Medicare Part A,which Services,laboratory and pharmacy Services,Emergency is covered under Original Medicare.Enrollment in this Services,Urgent Care,and other benefits described in Senior Advantage plan means that you are automatically this EOC.Plus,our health education programs offer you enrolled in Medicare Part D.Kaiser Permanente is an great ways to protect and improve your health. HMO plan with a Medicare contract.Enrollment in Kaiser Permanente depends on contract renewal. We provide covered Services to Members using Plan Providers located in our Service Area,which is described This Evidence of Coverage("EOC")describes our in the"Definitions"section.You must receive all Senior Advantage health care coverage provided under covered care from Plan Providers inside our Service the Group Agreement(Agreement)between Health Plan Area,except as described in the sections listed below for (Kaiser Foundation Health Plan,Inc. ("Health Plan")and the following Services: your Group(the entity with which Health Plan has • Authorized referrals as described under"Getting a entered into the Agreement). Referral"in the"How to Obtain Services"section • Covered Services received outside of your Home This EOC is part of the Agreement between Health Plan Region Service Area as described under"Receiving and your Group.The Agreement contains additional Care Outside of Your Home Region Service Area"in terms such as Premiums,when coverage can change,the the"How to Obtain Services"section effective date of coverage,and the effective date of • Emergency ambulance Services as described under termination.The Agreement must be consulted to determine the exact terms of coverage.A copy of the "Ambulance Services"in the"Benefits and Your Cost Agreement is available from your Group. Share"section • Emergency Services,Post-Stabilization Care,and For benefits provided under any other program,refer to Out-of-Area Urgent Care as described in the that other plan's evidence of coverage.For benefits "Emergency Services and Urgent Care"section provided under any other program offered by your Group • Out-of-area dialysis care as described under"Dialysis (for example,workers compensation benefits),refer to Care"in the"Benefits and Your Cost Share"section your Group's materials. • Prescription drugs from Non—Plan Pharmacies as In this EOC,Health Plan is sometimes referred to as described under"Outpatient Prescription Drugs, "we"or"us."Members are sometimes referred to as Supplies,and Supplements"in the"Benefits and "you."Some capitalized terms have special meaning in Your Cost Share"section this EOC;please see the"Definitions"section for terms • Routine Services associated with Medicare-approved you should know. clinical trials as described under"Services Associated with Clinical Trials"in the"Benefits and Your Cost It is important to familiarize yourself with your coverage Share"section by reading this EOC completely,so that you can take full advantage of your Health Plan benefits.Also,if you have special health care needs,please carefully read the Term of this EOC sections that apply to you. This EOC is for the period January 1,2024,through December 31,2024,unless amended.Benefits, About Kaiser Permanente Copayments,and Coinsurance may change on January 1 of each year and at other times in accord with your PLEASE READ THE FOLLOWING Group's Agreement with us.Your Group can tell you INFORMATION SO THAT YOU WILL KNOW Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 3 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. whether this EOC is still in effect and give you a current benefit plan did not cover the item(this amount is an one if this EOC has been amended. estimate of:the cost of acquiring,storing,and dispensing drugs,the direct and indirect costs of providing Kaiser Permanente pharmacy Services to Definitions . Members,and the pharmacy program's contribution to the net revenue requirements of Health Plan) Some terms have special meaning in this EOC.When we use a term with special meaning in only one section of • For all other Services,the payments that Kaiser this EOC,we define it in that section.The terms in this Permanente makes for the Services or,if Kaiser "Definitions"section have special meaning when Permanente subtracts your Cost Share from its capitalized and used in any section of this EOC. payment,the amount Kaiser Permanente would have paid if it did not subtract your Cost Share Accumulation Period:A period of time no greater than 12 consecutive months for purposes of accumulating Coinsurance:A percentage of Charges that you must amounts toward any deductibles(if applicable)and out- pay when you receive a covered Service under this EOC. of-pocket maximums. The Accumulation Period for this Complaint: The formal name for"making a complaint" EOC is from 1/l/24 through 12/31/24. is"filing a grievance."The complaint process is used Allowance:A specified credit amount that you can use only for certain types of problems.This includes toward the cost of an item.If the cost of the item(s)or problems related to quality of care,waiting times,and Service(s)you select exceeds the Allowance,you will the customer service you receive.It also includes pay the amount in excess of the Allowance,which does complaints if your plan does not follow the time periods not apply to the maximum out-of-pocket amount. in the appeal process. Catastrophic Coverage Stage:The stage in the Part D Comprehensive Formulary(Formulary or"Drug drug benefit that begins when you(or other qualified List"):A list of Medicare Part D prescription drugs parties on your behalf)have spent$8,000 for Part D covered by our plan.The drugs on this list are selected covered drugs during the covered year.During this by us with the help of doctors and pharmacists.The list payment stage,the plan pays the full cost for your includes both brand-name and generic drugs. covered Part D drugs.You pay nothing.Note:This Comprehensive Outpatient Rehabilitation Facility amount may change every January 1 in accord with (CORF):A facility that mainly provides rehabilitation Medicare requirements. Services after an illness or injury,including physician's Centers for Medicare&Medicaid Services(CMS): Services,physical therapy,social or psychological The federal agency that administers the Medicare Services,and outpatient rehabilitation. program. Copayment:A specific dollar amount that you must pay Ancillary Coverage: Optional benefits such as when you receive a covered Service under this EOC. acupuncture,chiropractic,or dental coverage that may be Note: The dollar amount of the Copayment can be$0(no available to Members enrolled under this EOC. If your charge). plan includes Ancillary Coverage,this coverage will be Cost Share:The amount you are required to pay for described in an amendment to this EOC or a separate covered Services.For example,your Cost Share may be agreement from the issuer of the coverage. a Copayment or Coinsurance. If your coverage includes Charges: "Charges"means the following: a Plan Deductible and you receive Services that are subject to the Plan Deductible,your Cost Share for those • For Services provided by the Medical Group or Services will be Charges until you reach the Plan Kaiser Foundation Hospitals,the charges in Health Deductible. Plan's schedule of Medical Group and Kaiser Foundation Hospitals charges for Services provided Coverage Determination:An initial determination we to Members make about whether a Part D drug prescribed for you is covered under Part D and the amount,if any,you are • For Services for which a provider(other than the required to pay for the prescription.In general,if you Medical Group or Kaiser Foundation Hospitals)is bring your prescription for a Part D drug to a Plan compensated on a capitation basis,the charges in the pharmacy and the pharmacy tells you the prescription schedule of charges that Kaiser Permanente isn't covered by us,that isn't a Coverage Determination. negotiates with the capitated provider You need to call or write us to ask for a formal decision • For items obtained at a pharmacy owned and operated about the coverage.Coverage Determinations are called by Kaiser Permanente,the amount the pharmacy "coverage decisions"in this EOC. would charge a Member for the item if a Member's Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 4 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Dependent:A Member who meets the eligibility coverage of"Kaiser Permanente Senior Advantage requirements as a Dependent(for Dependent eligibility (HMO)with Part D"under Health Plan's Agreement requirements,see"Who Is Eligible"in the"Premiums, with your Group. Eligibility,and Enrollment"section). "Extra Help":A Medicare or state program to help Durable Medical Equipment(DME): Certain medical people with limited income and resources pay Medicare equipment that is ordered by your doctor for medical prescription drug program costs,such as premiums, reasons.Examples include walkers,wheelchairs, deductibles,and coinsurance. crutches,powered mattress systems,diabetic supplies,IV Family:A Subscriber and all of their Dependents. infusion pumps,speech-generating devices,oxygen equipment,nebulizers,or hospital beds ordered by a Grievance:A type of complaint you make about our provider for use in the home. plan,providers,or pharmacies,including a complaint Emergency Medical Condition:A medical or mental concerning the quality of your care. This does not health condition manifesting itself by acute symptoms of involve coverage or payment disputes. sufficient severity(including severe pain)such that a Group: The entity with which Health Plan has entered prudent layperson,with an average knowledge of health into the Agreement that includes this EOC. and medicine,could reasonably expect the absence of Health Plan:Kaiser Foundation Health Plan,Inc.,a immediate medical attention to result in any of the following: California nonprofit corporation.This EOC sometimes refers to Health Plan as"we"or"us." • Serious jeopardy to the health of the individual or,in Home Region: The Region where you enrolled(either the case of a pregnant woman,the health of the the Northern California Region or the Southern woman or her unborn child California Region). • Serious impairment to bodily functions Income Related Monthly Adjustment Amount • Serious dysfunction of any bodily organ or part (IRMAA):If your modified adjusted gross income as A mental health condition is an emergency medical reported on your IRS tax return from two years ago is condition when it meets the requirements of the above a certain amount,you'll pay the standard premium paragraph above,or when the condition manifests itself amount and an Income Related Monthly Adjustment by acute symptoms of sufficient severity such that either Amount,also known as IRMAA.IRMAA is an extra of the following is true: charge added to your premium.Less than 5%of people • The person is an immediate danger to themselves or with Medicare are affected,so most people will not pay a to others higher premium. • The person is immediately unable to provide for,or Initial Enrollment Period:When you are first eligible use,food,shelter,or clothing,due to the mental for Medicare,the period of time when you can sign up disorder for Medicare Part B.If you're eligible for Medicare when you turn 65,your Initial Enrollment Period is the Emergency Services: Covered Services that are(1) 7-month period that begins 3 months before the month rendered by a provider qualified to furnish Emergency you turn 65,includes the month you turn 65,and ends 3 Services;and(2)needed to treat,evaluate,or Stabilize an months after the month you turn 65. Emergency Medical Condition such as: Kaiser Permanente:Kaiser Foundation Hospitals(a • A medical screening exam that is within the California nonprofit corporation),Health Plan,and the capability of the emergency department of a hospital, Medical Group. including ancillary services(such as imaging and laboratory Services)routinely available to the Medical Group: The Permanente Medical Group,Inc.,a emergency department to evaluate the Emergency for-profit professional corporation. Medical Condition Medically Necessary:A Service is Medically Necessary • Within the capabilities of the staff and facilities if it is medically appropriate and required to prevent, available at the hospital,Medically Necessary diagnose,or treat your condition or clinical symptoms in examination and treatment required to Stabilize the accord with generally accepted professional standards of patient(once your condition is Stabilized, Services practice that are consistent with a standard of care in the you receive are Post Stabilization Care and not medical community. Emergency Services) Medicare: The federal health insurance program for EOC: This Evidence of Coverage document,including people 65 years of age or older,some people under age any amendments,which describes the health care 65 with certain disabilities,and people with End-Stage Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 5 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Renal Disease(generally those with permanent kidney Non—Plan Physician:A physician other than a Plan failure who need dialysis or a kidney transplant).A Physician. person enrolled in a Medicare Part D plan has Medicare Non—Plan Provider:A provider other than a Plan Part D by virtue of his or her enrollment in the Part D Provider. plan(this EOC is for a Part D plan). Medicare Advantage Organization:A public or private Non—Plan Psychiatrist:A psychiatrist who is not a Plan entity organized and licensed by a state as a risk-bearing Physician. entity that has a contract with the Centers for Medicare Non—Plan Skilled Nursing Facility:A Skilled Nursing &Medicaid Services to provide Services covered by Facility other than a Plan Skilled Nursing Facility. Medicare,except for hospice care covered by Original Organization Determination:An initial determination Medicare.Kaiser Foundation Health Plan,Inc.,is a we make about whether we will cover or pay for Medicare Advantage Organization. Services that you believe you should receive.We also Medicare Advantage Plan: Sometimes called Medicare make an Organization Determination when we provide Part C.A plan offered by a private company that you with Services,or refer you to a Non—Plan Provider contracts with Medicare to provide you with all your for Services. Organization Determinations are called Medicare Part A and Part B benefits.A Medicare "coverage decisions"in this EOC. Advantage Plan can be(i)an HMO,(ii)a PPO,(iii)a Original Medicare("Traditional Medicare"or"Fee- Private Fee-for-Service(PFFS)plan,or(iv)a Medicare for-Service Medicare"):The Original Medicare plan is Medical Savings Account(MSA)plan.Besides choosing the way many people get their health care coverage.It is from these types of plans,a Medicare Advantage HMO or PPO plan can also be a Special Needs Plan(SNP).In the national pay-per-visit program that lets you go to any most cases,Medicare Advantage Plans also offer doctor,hospital,or other health care provider that Medicare Part D(prescription drug coverage).These accepts Medicare.You must pay a deductible.Medicare plans are called Medicare Advantage Plans with pays its share of the Medicare approved amount,and you Prescription Drug Coverage.This EOC is fora pay your share.Original Medicare has two parts:Part A Medicare Part D plan. (Hospital Insurance)and Part B(Medical Insurance),and is available everywhere in the United States and its Medicare Health Plan:A Medicare Health Plan is territories. offered by a private company that contracts with Out-of-Area Urgent Care:Medically Necessary Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan.This term includes Services to prevent serious deterioration of your health all Medicare Advantage plans,Medicare Cost plans, resulting from an unforeseen illness or an unforeseen Demonstration/Pilot Programs,and Programs of All- injury if all of the following are true: inclusive Care for the Elderly(PACE). • You are temporarily outside our Service Area Medigap(Medicare Supplement Insurance)Policy: • A reasonable person would have believed that your Medicare supplement insurance sold by private insurance health would seriously deteriorate if you delayed companies to fill"gaps"in the Original Medicare plan treatment until you returned to our Service Area coverage.Medigap policies only work with the Original Physician Specialist Visits: Consultations,evaluations, Medicare plan.(A Medicare Advantage Plan is not a and treatment by physician specialists,including Medigap policy.) personal Plan Physicians who are not Primary Care Member:A person who is eligible and enrolled under Physicians. this EOC,and for whom we have received applicable Plan Deductible:The amount you must pay under this Premiums.This EOC sometimes refers to a Member as EOC in the calendar year for certain Services before we "you." will cover those Services at the applicable Copayment or Non-Physician Specialist Visits: Consultations, Coinsurance in that calendar year.Refer to the"Benefits evaluations,and treatment by non-physician specialists and Your Cost Share"section to learn whether your (such as nurse practitioners,physician assistants, coverage includes a Plan Deductible,the Services that optometrists,podiatrists,and audiologists). are subject to the Plan Deductible,and the Plan Deductible amount. Non—Plan Hospital:A hospital other than a Plan Hospital. Plan Facility:Any facility listed in the Provider Directory on our website at kn.org/facilities.Plan Non—Plan Pharmacy:A pharmacy other than a Plan Facilities include Plan Hospitals,Plan Medical Offices, Pharmacy.These pharmacies are also called"out-of- and other facilities that we designate in the directory. network pharmacies." The directory is updated periodically.The availability of Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 6 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Plan Facilities may change.If you have questions,please Plan Skilled Nursing Facility:A Skilled Nursing call Member Services. Facility approved by Health Plan. Plan Hospital:Any hospital listed in the Provider Post-Stabilization Care: Medically Necessary Services Directory on our website at kp.org/facilities.In the related to your Emergency Medical Condition that you directory, some Plan Hospitals are listed as Kaiser receive in a hospital(including the Emergency Permanente Medical Centers.The directory is updated Department)after your treating physician determines that periodically.The availability of Plan Hospitals may this condition is Stabilized. change.If you have questions,please call Member Premiums: The periodic amounts for your membership Services. under this EOC. Plan Medical Office:Any medical office listed in the Preventive Services: Covered Services that prevent or Provider Directory on our website at kp.org/facilities.In detect illness and do one or more of the following: the directory,Kaiser Permanente Medical Centers may include Plan Medical Offices.The directory is updated • Protect against disease and disability or further periodically.The availability of Plan Medical Offices progression of a disease may change.If you have questions,please call Member . Detect disease in its earliest stages before noticeable Services. symptoms develop Plan Optical Sales Office:An optical sales office Primary Care Physicians: Generalists in internal owned and operated by Kaiser Permanente or another medicine,pediatrics,and family practice,and specialists optical sales office that we designate.Refer to the in obstetrics/gynecology whom the Medical Group Provider Directory on our website at kky.org/facilities for designates as Primary Care Physicians.Refer to the locations of Plan Optical Sales Offices.In the directory, Provider Directory on our website at kp.org for a list of Plan Optical Sales Offices may be called"Vision physicians that are available as Primary Care Physicians. Essentials."The directory is updated periodically.The The directory is updated periodically.The availability of availability of Plan Optical Sales Offices may change.If Primary Care Physicians may change.If you have you have questions,please call Member Services. questions,please call Member Services. Plan Optometrist:An optometrist who is a Plan Primary Care Visits:Evaluations and treatment Provider. provided by Primary Care Physicians and primary care Plan Out-of-Pocket Maximum: The total amount of Plan Providers who are not physicians(such as nurse Cost Share you must pay under this EOC in the calendar practitioners). year for certain covered Services that you receive in the Provider Directory:A directory of Plan Physicians and same calendar year.Refer to the"Benefits and Your Cost Plan Facilities in your Home Region.This directory is Share"section to find your Plan Out-of-Pocket available on our website at ky.org/directory.To obtain Maximum amount and to learn which Services apply to a printed copy,call Member Services.The directory is the Plan Out-of-Pocket Maximum. updated periodically.The availability of Plan Physicians Plan Pharmacy:A pharmacy owned and operated by and Plan Facilities may change.If you have questions, Kaiser Permanente or another pharmacy that we please call Member Services. designate.Refer to the Provider Directory on our website Real-Time Benefit Tool:A portal or computer at ky.org/facilities for locations of Plan Pharmacies.The application in which enrollees can look up complete, directory is updated periodically.The availability of Plan accurate,timely,clinically appropriate,enrollee-specific Pharmacies may change.If you have questions,please formulary and benefit information.This includes cost- call Member Services. sharing amounts,alternative formulary medications that Plan Physician:Any licensed physician who is an may be used for the same health condition as a given employee of the Medical Group,or any licensed drug,and coverage restrictions(prior authorization,step physician who contracts to provide Services to Members therapy,quantity limits)that apply to alternative (but not including physicians who contract only to medications. provide referral Services). Region:A Kaiser Foundation Health Plan organization Plan Provider:A Plan Hospital,a Plan Physician,the or allied plan that conducts a direct-service health care Medical Group,a Plan Pharmacy,or any other health program.Regions may change on January 1 of each year care provider that Health Plan designates as a Plan and are currently the District of Columbia and parts of Provider. Northern California,Southern California,Colorado, Georgia,Hawaii,Maryland,Oregon,Virginia,and Washington.For the current list of Region locations, Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 7 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. please visit our website at kp•org or call Member • The following ZIP codes in Fresno County are inside Services. our Northern California Service Area: 93242,93602, Serious Emotional Disturbance of a Child Under Age 93606-07,93609,93611-13,93616,93618-19, 18:A condition identified as a"mental disorder"in the 93624-27,93630-31,93646,93648-52,93654, most recent edition of the Diagnostic and Statistical 93656-57,93660,93662,93667-68,93675,93701- Manual of Mental Disorders,other than a primary 12,93714-18,93720-30,93737,93740-41,93744- substance use disorder or developmental disorder,that 45,93747,93750,93755,93760-61,93764-65, results in behavior inappropriate to the child's age 93771-79,93786,93790-94,93844,93888 according to expected developmental norms,if the child • The following ZIP codes in Kings County are inside also meets at least one of the following three criteria: our Northern California Service Area: 93230,93232, • As a result of the mental disorder,(1)the child has 93242,93631,93656 substantial impairment in at least two of the following • The following ZIP codes in Madera County are inside areas: self-care,school functioning,family our Northern California Service Area: 93601-02, relationships,or ability to function in the community; 93604,93614,93623,93626,93636-39,93643-45, and(2)either(a)the child is at risk of removal from 93653,93669,93720 the home or has already been removed from the • All ZIP codes in Marin County are inside our home,or(b)the mental disorder and impairments Northern California Service Area: 94901,94903-04, have been present for more than six months or are 94912-15,94920,94924-25,94929-30,94933, likely to continue for more than one year without 94937-42,94945-50,94956-57,94960,94963-66, treatment 94970-71,94973-74,94976-79 • The child displays psychotic features,or risk of • The following ZIP codes in Mariposa County are suicide or violence due to a mental disorder inside our Northern California Service Area: 93 60 1, • The child meets special education eligibility 93623,93653 requirements under Section 5600.3(a)(2)(C)of the • All ZIP codes in Napa County are inside our Northern Welfare and Institutions Code California Service Area: 94503,94508,94515, Service Area: The geographic area approved by the 94558-59,94562,94567,94573-74,94576,94581, Centers for Medicare&Medicaid Services within which 94599,95476 an eligible person may enroll in Senior Advantage.Note: • The following ZIP codes in Placer County are inside Subject to approval by the Centers for Medicare& our Northern California Service Area: 95602-04, Medicaid Services,we may reduce or expand our Service 95610,95626,95648,95650,95658,95661,95663, Area effective any January 1.ZIP codes are subject to 95668,95677-78,95681,95703,95722,95736, change by the U.S.Postal Service.The ZIP codes below 95746-47,95765 for each county are in our Service Area: • All ZIP codes in Sacramento County are inside our • All ZIP codes in Alameda County are inside our Northern California Service Area: 94203-09,94211, Northern California Service Area: 94501-02,94505, 94229-30,94232,94234-37,94239-40,94244-45, 94514,94536-46,94550-52,94555,94557,94560, 94247-50,94252,94254,94256-59,94261-63, 94566,94568,94577-80,94586-88,94601-15, 94267-69,94271,94273-74,94277-80,94282-85, 94617-21,94622-24,94649,94659-62,94666, 94287-91,94293-98,94571,95608-11,95615, 94701-10,94712,94720,95377,95391 95621,95624,95626,95628,95630,95632,95638- • The following ZIP codes in Amador County are 39,95641,95652,95655,95660,95662,95670-71, inside our Northern California Service Area: 95640, 95673,95678,95680,95683,95690,95693,95741- 95669 42,95757-59,95763,95811-38,95840-43,95851- • All ZIP codes in Contra Costa County are inside our 53,95860,95864-67,95894,95899 Northern California Service Area: 94505-07,94509, • All ZIP codes in San Francisco County are inside our 94511,94513-14,94516-31,94547-49,94551, Northern California Service Area: 94102-05,94107- 94553,94556,94561,94563-65,94569-70,94572, 12,94114-34,94137,94139-47,94151,94158-61, 94575,94582-83,94595-98,94706-08,94801-08, 94163-64,94172,94177,94188 94820,94850 • All ZIP codes in San Joaquin County are inside our • The following ZIP codes in El Dorado County are Northern California Service Area: 94514,95201-15, inside our Northern California Service Area: 95613- 95219-20,95227,95230-31,95234,95236-37, 14,95619,95623,95633-35,95651,95664,95667, 95240-42,95253,95258,95267,95269,95296-97, 95672,95682,95762 Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 8 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. 95304,95320,95330,95336-37,95361,95366, For each ZIP code listed for a county,our Service Area 95376-78,95385,95391,95632,95686,95690 includes only the part of that ZIP code that is in that • All ZIP codes in San Mateo County are inside our county.When a ZIP code spans more than one county, Northern California Service Area: 94002,94005, the part of that ZIP code that is in another county is not 94010-11,94014-21,94025-28,94030,94037-38, inside our Service Area unless that other county is listed 94044,94060-66,94070,94074,94080,94083, above and that ZIP code is also listed for that other 94128,94303,94401-04,94497 county.If you have a question about whether a ZIP code is in our Service Area,please call Member Services. • The following ZIP codes in Santa Clara County are Also,the ZIP codes listed above may include ZIP codes inside our Northern California Service Area: 94022- for Post Office boxes and commercial rental mailboxes. 24,94035,94039-43,94085-89,94301-06,94309, A Post Office box or rental mailbox cannot be used to 94550,95002,95008-09,95011,95013-15,95020- determine whether you meet the residence eligibility 21,95026,95030-33,95035-38,95042,95044, requirements for Senior Advantage.Your permanent 95046,95050-56,95070-71,95076,95101,95103, residence address must be used to determine your Senior 95106,95108-13,95115-36,95138-41,95148, Advantage eligibility. 95150-61,95164,95170,95172-73,95190-94, 95196 Services:Health care services or items("health care" • All ZIP codes in Santa Cruz County are inside our includes both physical health care and mental health care)and services to treat Serious Emotional Disturbance Northern California Service Area: 95001,95003, of a Child Under Age 18 or Severe Mental Illness. 95005-07,95010,95017-19,95033,95041,95060- 67,95073,95076-77 Severe Mental Illness:The following mental disorders: • All ZIP codes in Solano County are inside our schizophrenia,schizoaffective disorder,bipolar disorder (manic-depressive illness),major depressive disorders, Northern California Service Area: 94503,94510, panic disorder,obsessive-compulsive disorder,pervasive 94512,94533-35,94571,94585,94589-92,95616, developmental disorder or autism,anorexia nervosa,or 95618,95620,95625,95687-88,95690,95694, bulimia nervosa. 95696 • The following ZIP codes in Sonoma County are Skilled Nursing Facility:A facility that provides inside our Northern California Service Area: 94515, inpatient skilled nursing care,rehabilitation services,or 94922-23,94926-28,94931,94951-55,94972, other related health services and is licensed by the state 94975,94999,95401-07,95409,95416,95419, of California.The facility's primary business must be the 95421 95425 95430-31 95433 95436 95439 provision of 24-hour-a-day licensed skilled nursing care. 95441-42,95444,95446,95448,95450,95452, The term"Skilled Nursing Facility"does not include 95462,95465,95471-73,95476,95486-87,95492 convalescent nursing homes,rest facilities,or facilities for the aged,if those facilities furnish primarily custodial • All ZIP codes in Stanislaus County are inside our care,including training in routines of daily living.A Northern California Service Area: 95230,95304, "Skilled Nursing Facility"may also be a unit or section 95307,95313,95316,95319,95322-23,95326, within another facility(for example,a hospital)as long 95328-29,95350-58,95360-61,95363,95367-68, as it continues to meet this definition. 95380-82,95385-87,95397 Spouse: The person to whom the Subscriber is legally • The following ZIP codes in Sutter County are inside married under applicable law.For the purposes of this our Northern California Service Area: 95626,95645, EOC,the term"Spouse"includes the Subscriber's 95659,95668,95674,95676,95692,95836-37 domestic partner."Domestic partners"are two people • The following ZIP codes in Tulare County are inside who are registered and legally recognized as domestic our Northern California Service Area: 93238,93261, partners by California(if your Group allows enrollment 93618,93631,93646,93654,93666,93673 of domestic partners not legally recognized as domestic partners by California,"Spouse"also includes the • The following ZIP codes in Yolo County are inside Subscriber's domestic partner who meets your Group's our Northern California Service Area: 95605,95607,95612,95615-18,95645,95691,95694-95,95697- eligibility requirements for domestic partners). 98,95776,95798-99 Stabilize: To provide the medical treatment of the • The following ZIP codes in Yuba County are inside Emergency Medical Condition that is necessary to our Northern California Service Area: 95692,95903, assure,within reasonable medical probability,that no 95961 material deterioration of the condition is likely to result from or occur during the transfer of the person from the facility.With respect to a pregnant person who is having Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 9 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. contractions,when there is inadequate time to safely years ago.If this amount is above a certain amount, transfer them to another hospital before delivery(or the you'll pay the standard premium amount and the transfer may pose a threat to the health or safety of the additional IRMAA.For more information on the extra pregnant person or unborn child),"Stabilize"means to amount you may have to pay based on your income,visit deliver(including the placenta). haws://www.medicare.2ov. Subscriber:A Member who is eligible for membership If you have to pay an extra amount, Social Security,not on their own behalf and not by virtue of Dependent your Medicare plan,will send you a letter telling you status and who meets the eligibility requirements as a what that extra amount will be.The extra amount will be Subscriber(for Subscriber eligibility requirements,see withheld from your Social Security,Railroad Retirement "Who Is Eligible"in the"Premiums,Eligibility,and Board,or Office of Personnel Management benefit Enrollment"section). check,no matter how you usually pay your plan Surrogacy Arrangement:An arrangement in which an premium,unless your monthly benefit isn't enough to individual agrees to become pregnant and to surrender cover the extra amount owed.If your benefit check isn't the baby(or babies)to another person or persons who enough to cover the extra amount,you will get a bill intend to raise the child(or children),whether or not the from Medicare.You must pay the extra amount to the individual receives payment for being a surrogate.For government.If you do not pay the extra amount,you the purposes of this EOC, "Surrogacy Arrangements" will be disenrolled from the plan and lose includes all types of surrogacy arrangements,including prescription drug coverage. traditional surrogacy arrangements and gestational surrogacy arrangements. If you disagree about paying an extra amount,you can ask Social Security to review the decision.To find out Telehealth Visits:Interactive video visits and scheduled more about how to do this,contact Social Security at telephone visits between you and your provider. 1-800-772-1213(TTY users call 1-800-325-0778). Urgent Care: Medically Necessary Services for a condition that requires prompt medical attention but is Medicare Part D late enrollment penalty not an Emergency Medical Condition. Some members are required to pay a Part D late enrollment penalty.The Part D late enrollment penalty is an additional premium that must be paid for Part D coverage if at any time after your initial enrollment Premiums, Eligibility, and period is over,there is a period of 63 days or more in a Enrollment row when you did not have Part D or other creditable prescription drug coverage."Creditable prescription drug coverage"is coverage that meets Medicare's minimum Premiums standards since it is expected to pay,on average,at least as much as Medicare's standard prescription drug Please contact your Group's benefits administrator for coverage.The cost of the late enrollment penalty information about your plan Premiums.You must also depends on how long you went without Part D or other continue to pay Medicare your monthly Medicare creditable prescription drug coverage.You will have to premium. pay this penalty for as long as you have Part D coverage. The Part D late enrollment penalty is added to your plan If you do not have Medicare Part A,you may be eligible premium.Your Group or Health Plan will inform you if to purchase Medicare Part A from Social Security.Please the penalty applies to you. contact Social Security for more information.If you get Medicare Part A,this may reduce the amount you would You will not have to pay it if: be expected to pay to your Group,please check with . You receive"Extra Help"from Medicare to pay for your Group's benefits administrator. your prescription drugs • You have gone less than 63 days in a row without Medicare Premiums creditable coverage Medicare Part D premium due to income • You have had creditable drug coverage through Some members may be required to pay an extra charge, another source such as a former employer,union, known as the Part D Income Related Monthly TRICARE,or Department of Veterans Affairs.Your Adjustment Amount,also known as IRMAA.The extra insurer or your human resources department will tell charge is figured out using your modified adjusted gross you each year if your drug coverage is creditable c income as reported on your IRS tax return from two overage.This information may be sent to you in a Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 10 Member Service:toll free 1-800-443-0815(TTY users call 711)seven days a week, 8 a.m.-8 p.m. letter or included in a newsletter from the plan.Keep • 1-800-MEDICARE(1-800-633-4227)(TTY users this information because you may need it if you join a call 1-877-486-2048),24 hours a day,seven days a Medicare drug plan later week; ♦ any notice must state that you had"creditable" • The Social Security Office at 1-800-772-1213(TTY prescription drug coverage that is expected to pay users call 1-800-325-0778), 8 a.m.to 7 p.m.,Monday as much as Medicare's standard prescription drug through Friday(applications);or plan pays • Your state Medicaid office(applications). See the ♦ the following are not creditable prescription drug "Important Phone Numbers and Resources"section coverage:prescription drug discount cards,free for contact information clinics,and drug discount websites Medicare determines the amount of the penalty.There If you qualify for"Extra Help,"we will send you an are three important things to note about this monthly Part Evidence of Coverage Rider for People Who Get Extra D late enrollment penalty: Help Paying for Prescription Drugs(also known as the Low Income Subsidy Rider or the LIS Rider),that • First,the penalty may change each year because the explains your costs as a Member of our plan.If the average monthly premium can change each year amount of your"Extra Help"changes during the year, • Second,you will continue to pay a penalty every we will also mail you an updated Evidence of Coverage month for as long as you are enrolled in a plan that Rider for People Who Get Extra Help Paying for has Medicare Part D drug benefits,even if you Prescription Drugs. change plans • Third,if you are under 65 and currently receiving Who Is Eli i1ble Medicare benefits,the Part D late enrollment penalty To enroll and to continue enrollment,you must meet all will reset when you turn 65.After age 65,your Part D of the eligibility requirements described in this"Who Is late enrollment penalty will be based only on the Eligible"section,including your Group's eligibility months that you don't have coverage after your initial enrollment period for aging into Medicare requirements and your Home Region Service Area eligibility requirements. If you disagree about your Part D late enrollment penalty,you or your representative can ask for a Group eligibility requirements review. Generally,you must request this review within You must meet your Group's eligibility requirements. 60 days from the date on the first letter you receive Your Group is required to inform Subscribers of its stating you have to pay a late enrollment penalty. eligibility requirements. However,if you were paying a penalty before joining our plan,you may not have another chance to request a Senior Advantage eligibility requirements review of that late enrollment penalty. • You must have Medicare Part B Medicare's "Extra Help" Program • You must be a United States citizen or lawfully Medicare provides"Extra Help"to pay prescription drug present in the United States costs for people who have limited income and resources. • Your Medicare coverage must be primary and your Resources include your savings and stocks,but not your Group's health care plan must be secondary home or car.If you qualify,you get help paying for any • You may not be enrolled in another Medicare Health Medicare drug plan's monthly premium,and prescription Plan or Medicare prescription drug plan Copayments.This"Extra Help"also counts toward your out-of-pocket costs. Note:If you are enrolled in a Medicare plan and lose Medicare eligibility,you may be able to enroll under People with limited income and resources may qualify your Group's non-Medicare plan if that is permitted by for"Extra Help."If you automatically qualify for"Extra your Group(please ask your Group for details). Help,"Medicare will mail you a letter.You will not have to apply.If you do not automatically qualify,you may be able to get"Extra Help"to pay for your prescription drug Service Area eligibility requirements premiums and costs.To see if you qualify for getting "Extra Help,"call: You must live in our Service Area,unless you have been continuously enrolled in Senior Advantage since December 31, 1998,and lived outside our Service Area during that entire time.In which case,you may continue Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 11 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. your membership unless you move and are still outside options.You may be able to enroll in the service area of your Home Region Service Area. The"Definitions" another Region if there is an agreement between your section describes our Service Area and how it may Group and that Region,but the plan,including coverage, change. premiums,and eligibility requirements,might not be the same as under this EOC. Moving outside your Home Region Service Area. If you permanently move outside your Home Region For more information about the service areas of the other Service Area,or you are temporarily absent from your Regions,please call Member Services. Home Region Service Area for a period of more than six months in a row,you must notify us and you cannot Eligibility as a Subscriber continue your Senior Advantage membership under this You may be eligible to enroll and continue enrollment as EOC. a Subscriber if you are: Send your notice to: • An employee of your Group • A proprietor or partner of your Group Kaiser Foundation Health Plan,Inc. • Otherwise entitled to coverage under a trust California Service Center P.O.Box 232400 agreement,retirement benefit program,or San Diego,CA 92193 employment contract(unless the Internal Revenue Service considers you self-employed) It is in your best interest to notify us as soon as possible Eligibility as a Dependent because until your Senior Advantage coverage is officially terminated by the Centers for Medicare& Enrolling as a Dependent Medicaid Services,you will not be covered by us or Dependent eligibility is subject to your Group's Original Medicare for any care you receive from Non— eligibility requirements,which are not described in this Plan Providers,except as described in the sections listed EOC.You can obtain your Group's eligibility below for the following Services: requirements directly from your Group.If you are a • Authorized referrals as described under"Getting a Subscriber under this EOC and if your Group allows Referral"in the"How to Obtain Services"section enrollment of Dependents,Health Plan allows the following persons to enroll as your Dependents under • Covered Services received outside of your Home this EOC if they meet all of the other requirements Region Service Area as described under"Receiving described under"Senior Advantage eligibility Care Outside of Your Home Region Service Area"in requirements,"and"Service Area eligibility the"How to Obtain Services"section requirements"in this"Who Is Eligible"section: • Emergency ambulance Services as described under • Your Spouse "Ambulance Services"in the"Benefits and Your Cost Share"section • Your or your Spouse's Dependent children,who meet the requirements described under"Age limit of • Emergency Services,Post-Stabilization Care,and Dependent children,"if they are any of the following: Out-of-Area Urgent Care as described in the ♦ biological children "Emergency Services and Urgent Care"section ♦ stepchildren • Out-of-area dialysis care as described under"Dialysis ♦ adopted children Care"in the"Benefits and Your Cost Share"section • Prescription drugs from Non—Plan Pharmacies as ♦ children placed with you for adoption described under"Outpatient Prescription Drugs, ♦ foster children if you or your Spouse have the Supplies,and Supplements"in the"Benefits and legal authority to direct their care Your Cost Share"section ♦ children for whom you or your Spouse is the • Routine Services associated with Medicare-approved court-appointed guardian(or was when the child clinical trials as described under"Services Associated reached age 18) with Clinical Trials"in the"Benefits and Your Cost • Children whose parent is a Dependent child under Share"section your family coverage(including adopted children and children placed with your Dependent child for If you are not eligible to continue enrollment because you move to the service area of another Region,please contact your Group to learn about your Group health care Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 12 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. adoption or foster care)if they meet all of the us documentation of the Dependent's incapacity and following requirements: dependency within 60 days of receipt of our notice ♦ they are not married and do not have a domestic and we determine that the Dependent is eligible as a partner(for the purposes of this requirement only, disabled dependent.If the Subscriber provides us this "domestic partner"means someone who is documentation in the specified time period and we do registered and legally recognized as a domestic not make a determination about eligibility before the partner by California) termination date,coverage will continue until we ♦ they meet the requirements described under"Age make a determination.If we determine that the limit of Dependent children" Dependent does not meet the eligibility requirements as a disabled dependent,we will notify the Subscriber ♦ they receive all of their support and maintenance that the Dependent is not eligible and let the from you or your Spouse Subscriber know the membership termination date. ♦ they permanently reside with you or your Spouse If we determine that the Dependent is eligible as a disabled dependent,there will be no lapse in Age limit of Dependent children coverage.Also,starting two years after the date that Children must be under age 26 as of the effective date of the Dependent reached the age limit,the Subscriber this EOC to enroll as a Dependent under your plan. must provide us documentation of the Dependent's incapacity and dependency annually within 60 days Dependent children are eligible to remain on the plan after we request it so that we can determine if the through the end of the month in which they reach the age Dependent continues to be eligible as a disabled limit. dependent • If the child is not a Member because you are changing Dependent children of the Subscriber or Spouse coverage,you must give us proof,within 60 days (including adopted children and children placed with you after we request it,of the child's incapacity and for adoption,but not including children placed with you dependency as well as proof of the child's coverage for foster care)who reach the age limit may continue under your prior coverage.In the future,you must coverage under this EOC if all of the following provide proof of the child's continued incapacity and conditions are met: dependency within 60 days after you receive our • They meet all requirements to be a Dependent except request,but not more frequently than annually for the age limit Dependents not eligible to enroll under a Senior • Your Group permits enrollment of Dependents Advantage plan.If you have dependents who do not • They are incapable of self-sustaining employment have Medicare Part B coverage or for some other reason because of a physically-or mentally-disabling injury, are not eligible to enroll under this EOC,you may be illness,or condition that occurred before they reached able to enroll them as your dependents under a non- the age limit for Dependents Medicare plan offered by your Group.Please contact • They receive 50 percent or more of their support and your Group for details,including eligibility and benefit maintenance from you or your Spouse information,and to request a copy of the non-Medicare plan document. • If requested,you give us proof of their incapacity and dependency within 60 days after receiving our request (see"Disabled Dependent certification"below in this How to Enroll and When Coverage "Eligibility as a Dependent"section) Begins Disabled Dependent certification Your Group is required to inform you when you are Proof may be required for a Dependent to be eligible to eligible to enroll and what your effective date of continue coverage as a disabled Dependent.If we request coverage is.If you are eligible to enroll as described it,the Subscriber must provide us documentation of the under"Who Is Eligible"in this"Premiums,Eligibility, dependent's incapacity and dependency as follows: and Enrollment"section,enrollment is permitted as • If the child is a Member,we will send the Subscriber described below and membership begins at the beginning a notice of the Dependent's membership termination (12:00 a.m.)of the effective date of coverage indicated below,except that: due to loss of eligibility at least 90 days before the date coverage will end due to reaching the age limit. • Your Group may have additional requirements,which The Dependent's membership will terminate as allow enrollment in other situations described in our notice unless the Subscriber provides Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 13 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • The effective date of your Senior Advantage coverage Group open enrollment under this EOC must be confirmed by the Centers for You may enroll as a Subscriber(along with any eligible Medicare&Medicaid Services,as described under Dependents),and existing Subscribers may add eligible "Effective date of Senior Advantage coverage"in this Dependents,by submitting a Health Plan—approved "How to Enroll and When Coverage Begins"section enrollment application,and a Senior Advantage Election Form for each person to your Group during your Group's If you are a Subscriber under this EOC and you have open enrollment period.Your Group will let you know dependents who do not have Medicare Part B coverage or when the open enrollment period begins and ends and the for some other reason are not eligible to enroll under this effective date of coverage,which is subject to EOC,you may be able to enroll them as your dependents confirmation by the Centers for Medicare&Medicaid under a non-Medicare plan offered by your Group.Please Services. contact your Group for details,including eligibility and benefit information,and to request a copy of the non- Special enrollment Medicare plan document. If you do not enroll when you are first eligible and later want to enroll,you can enroll only during open If you are eligible to be a Dependent under this EOC but the enrollment unless one of the following is true: subscriber in your family is enrolled under a non-Medicare . You become eligible because you experience a plan offered by your Group,the subscriber must follow the qualifying event(sometimes called a"triggering rules applicable to Subscribers who are enrolling Dependents in this"How to Enroll and When Coverage event")as described in this"Special enrollment" section Begins"section. • You did not enroll in any coverage offered by your Effective date of Senior Advantage coverage Group when you were first eligible and your Group After we receive your completed Senior Advantage does not give us a written statement that verifies you Election Form,we will submit your enrollment request to signed a document that explained restrictions about the Centers for Medicare&Medicaid Services for enrolling in the future. Subject to confirmation by the confirmation and send you a notice indicating the Centers for Medicare&Medicaid Services,the proposed effective date of your Senior Advantage effective date of an enrollment resulting from this coverage under this EOC. provision is no later than the first day of the month following the date your Group receives a Health If the Centers for Medicare&Medicaid Services Plan—approved enrollment or change of enrollment confirms your Senior Advantage enrollment and application,and a Senior Advantage Election Form effective date,we will send you a notice that confirms for each person,from the Subscriber your enrollment and effective date.If the Centers for Medicare&Medicaid Services tells us that you do not Special enrollment due to new Dependents.You may have Medicare Part B coverage,we will notify you that enroll as a Subscriber(along with eligible Dependents), you will be disenrolled from Senior Advantage. and existing Subscribers may add eligible Dependents, within 30 days after marriage,establishment of domestic New employees partnership,birth,adoption,placement for adoption,or When your Group informs you that you are eligible to placement for foster care by submitting to your Group a enroll as a Subscriber,you may enroll yourself and any Health Plan—approved enrollment application,and a eligible Dependents by submitting a Health Plan— Senior Advantage Election Form for each person. approved enrollment application,and a Senior Advantage Election Form for each person,to your Group Subject to confirmation by the Centers for Medicare& within 31 days. Medicaid Services,the effective date of an enrollment resulting from marriage or establishment of domestic Effective date of Senior Advantage coverage.The partnership is no later than the first day of the month effective date of Senior Advantage coverage for new following the date your Group receives an enrollment employees and their eligible family Dependents or newly application,and a Senior Advantage Election Form for acquired Dependents,is determined by your Group, each person,from the Subscriber. Subject to subject to confirmation by the Centers for Medicare& confirmation by the Centers for Medicare&Medicaid Medicaid Services. Services,enrollments due to birth,adoption,placement for adoption,or placement for foster care are effective on the date of birth,date of adoption,or the date you or your Spouse have newly assumed a legal right to control health care. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 14 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Special enrollment due to loss of other coverage.You submitting to your Group a Health Plan—approved may enroll as a Subscriber(along with any eligible enrollment or change of enrollment application,and a Dependents),and existing Subscribers may add eligible Senior Advantage Election Form for each person. Dependents,if all of the following are true: • The Subscriber or at least one of the Dependents had Subject to confirmation by the Centers for Medicare& other coverage when they previously declined all Medicaid Services,the effective date of coverage coverage through your Group resulting from a court or administrative order is the first of the month following the date we receive the • The loss of the other coverage is due to one of the enrollment request,unless your Group specifies a following: different effective date(if your Group specifies a ♦ exhaustion of COBRA coverage different effective date,the effective date cannot be ♦ termination of employer contributions for non- earlier than the date of the order). COBRA coverage ♦ loss of eligibility for non-COBRA coverage,but Special enrollment due to eligibility for premium not termination for cause or termination from an assistance.You may enroll as a Subscriber(along with individual(nongroup)plan for nonpayment.For eligible Dependents),and existing Subscribers may add example,this loss of eligibility may be due to legal eligible Dependents,if you or a dependent become separation or divorce,moving out of the plan's eligible for premium assistance through the Medi-Cal service area,reaching the age limit for dependent program.Premium assistance is when the Medi-Cal children,or the subscriber's death,termination of program pays all or part of premiums for employer group employment,or reduction in hours of employment coverage for a Medi-Cal beneficiary. To request enrollment in your Group's health care coverage,the ♦ loss of eligibility(but not termination for cause) Subscriber must submit a Health Plan—approved for coverage through Covered California, enrollment or change of enrollment application,and a Medicaid coverage(known as Medi-Cal in Senior Advantage Election Form for each person,to your California),Children's Health Insurance Program Group within 60 days after you or a dependent become coverage,or Medi-Cal Access Program coverage eligible for premium assistance.Please contact the ♦ reaching a lifetime maximum on all benefits California Department of Health Care Services to find out if premium assistance is available and the eligibility Note: If you are enrolling yourself as a Subscriber along requirements. with at least one eligible Dependent,only one of you must meet the requirements stated above. Special enrollment due to reemployment after military service.If you terminated your health care To request enrollment,the Subscriber must submit a coverage because you were called to active duty in the Health Plan—approved enrollment or change of military service,you may be able to reenroll in your enrollment application,and a Senior Advantage Election Group's health plan if required by state or federal law. Form for each person,to your Group within 30 days after Please ask your Group for more infonnation. loss of other coverage,except that the timeframe for submitting the application is 60 days if you are requesting enrollment due to loss of eligibility for How to Obtain Services coverage through Covered California,Medicaid, Children's Health Insurance Program,or Medi-Cal Access Program coverage. Subject to confirmation by As a Member,you are selecting our medical care the Centers for Medicare&Medicaid Services,the program to provide your health care.You must receive effective date of an enrollment resulting from loss of all covered care from Plan Providers inside our Service other coverage is no later than the first day of the month Area,except as described in the sections listed below for following the date your Group receives an enrollment or the following Services: change of enrollment application,and Senior Advantage • Authorized referrals as described under"Getting a Election Form for each person,from the Subscriber. Referral"in this"How to Obtain Services"section • Covered Services received outside of your Home Special enrollment due to court or administrative Region Service Area as described under"Receiving order.Within 31 days after the date of a court or Care Outside of Your Home Region Service Area"in administrative order requiring a Subscriber to provide this"How to Obtain Services"section health care coverage for a Spouse or child who meets the eligibility requirements as a Dependent,the Subscriber may add the Spouse or child as a Dependent by Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 15 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Emergency ambulance Services as described under medically appropriate.Whether you are calling for "Ambulance Services"in the"Benefits and Your Cost advice or to make an appointment,you can speak to an Share"section advice nurse.They can often answer questions about a • Emergency Services,Post-Stabilization Care,and minor concern,tell you what to do if a Plan Medical Out-of-Area Urgent Care as described in the Office is closed,or advise you about what to do next, "Emergency Services and Urgent Care"section including making a same-day Urgent Care appointment for you if it's medically appropriate.To reach an advice • Out-of-area dialysis care as described under"Dialysis nurse,refer to our Provider Directory or call Member Care"in the"Benefits and Your Cost Share"section Services. • Prescription drugs from Non—Plan Pharmacies as described under"Outpatient Prescription Drugs, Your Personal Plan Physician Supplies,and Supplements"in the"Benefits and Your Cost Share"section Personal Plan Physicians provide primary care and play • Routine Services associated with Medicare-approved an important role in coordinating care,including hospital clinical trials as described under"Services Associated stays and referrals to specialists. with Clinical Trials"in the"Benefits and Your Cost Share"section We encourage you to choose a personal Plan Physician. You may choose any available personal Plan Physician. Our medical care program gives you access to all of the Parents may choose a pediatrician as the personal Plan covered Services you may need,such as routine care Physician for their child.Most personal Plan Physicians with your own personal Plan Physician,hospital are Primary Care Physicians(generalists in internal Services,laboratory and pharmacy Services,Emergency medicine,pediatrics,or family practice,or specialists in Services,Urgent Care,and other benefits described in obstetrics/gynecology whom the Medical Group this EOC. designates as Primary Care Physicians). Some specialists who are not designated as Primary Care Physicians but who also provide primary care may be available as Routine Care personal Plan Physicians.For example,some specialists in internal medicine and obstetrics/gynecology who are To request anon-urgent appointment,you can call your not designated as Primary Care Physicians maybe local Plan Facility or request the appointment online.For available as personal Plan Physicians.However,if you appointment phone numbers,refer to our Provider choose a specialist who is not designated as a Primary Directory or call Member Services.To request an Care Physician as your personal Plan Physician,the Cost appointment online,go to our website at kp•org. Share for a Physician Specialist Visit will apply to all visits with the specialist except for Preventive Services Urgent Care listed in the"Benefits and Your Cost Share"section. An Urgent Care need is one that requires prompt medical To learn how to select or change to a different personal attention but is not an Emergency Medical Condition. Plan Physician,visit our website at kp.org,or call If you think you may need Urgent Care,call the Member Services.Refer to our Provider Directory for a appropriate appointment or advice phone number at a list of physicians that are available as Primary Care Plan Facility.For phone numbers,refer to our Provider Physicians. The directory is updated periodically.The Directory or call Member Services. availability of Primary Care Physicians may change.If you have questions,please call Member Services.You For information about Out-of-Area Urgent Care,refer to can change your personal Plan Physician at any time for "Urgent Care"in the"Emergency Services and Urgent any reason. Care"section. Getting a Referral Our Advice Nurses Referrals to Plan Providers We know that sometimes it's difficult to know what type A Plan Physician must refer you before you can receive of care you need.That's why we have telephone advice care from specialists,such as specialists in surgery, nurses available to assist you.Our advice nurses are orthopedics,cardiology,oncology,dermatology,and registered nurses specially trained to help assess medical physical,occupational,and speech therapies.However, symptoms and provide advice over the phone,when you do not need a referral or prior authorization to Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 16 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. receive most care from any of the following Plan clinically appropriate place consistent with the terms of Providers: your health coverage.Decisions regarding requests for • Your personal Plan Physician authorization will be made only by licensed physicians or other appropriately licensed medical professionals. • Generalists in internal medicine,pediatrics,and family practice For the complete list of Services that require prior • Specialists in optometry,mental health Services, authorization,and the criteria that are used to make substance use disorder treatment,and authorization decisions,please visit our website at obstetrics/gynecology ky.ora/UM or call Member Services to request a printed copy.Refer to"Post-Stabilization Care"under A Plan Physician must refer you before you can get care "Emergency Services"in the"Emergency Services and from a specialist in urology except that you do not need a Urgent Care"section for authorization requirements that referral to receive Services related to sexual or apply to Post-Stabilization Care from Non—Plan reproductive health,such as a vasectomy. Providers. Although a referral or prior authorization is not required Additional information about prior authorization for to receive most care from these providers,a referral may durable medical equipment,ostomy,urological,and be required in the following situations: specialized wound care supplies.The prior • The provider may have to get prior authorization for authorization process for durable medical equipment, ostomy,urological,and specialized wound care supplies certain Services in accord with"Medical Group includes the use of formulary guidelines.These authorization procedure for certain referrals"in this guidelines were developed by a multidisciplinary clinical "Getting a Referral"section and operational work group with review and input from • The provider may have to refer you to a specialist Plan Physicians and medical professionals with clinical who has a clinical background related to your illness expertise.The formulary guidelines are periodically or condition updated to keep pace with changes in medical technology,Medicare guidelines,and clinical practice. Standing referrals If a Plan Physician refers you to a specialist,the referral If your Plan Physician prescribes one of these items,they will be for a specific treatment plan.Your treatment plan will submit a written referral in accord with the UM may include a standing referral if ongoing care from the process described in this"Medical Group authorization specialist is prescribed.For example,if you have a life- procedure for certain referrals"section.If the formulary threatening,degenerative,or disabling condition,you can guidelines do not specify that the prescribed item is get a standing referral to a specialist if ongoing care from appropriate for your medical condition,the referral will the specialist is required. be submitted to the Medical Group's designee Plan Physician,who will make an authorization decision as Medical Group authorization procedure for described under"Medical Group's decision time frames" certain referrals in this"Medical Group authorization procedure for The following are examples of Services that require prior certain referrals"section. authorization by the Medical Group for the Services to be covered("prior authorization"means that the Medical Medical Group's decision time frames.The applicable Group must approve the Services in advance): Medical Group designee will make the authorization • Durable medical equipment decision within the time frame appropriate for your condition,but no later than five business days after • Ostomy and urological supplies receiving all of the information(including additional • Services not available from Plan Providers examination and test results)reasonably necessary to make the decision,except that decisions about urgent • Transplants Services will be made no later than 72 hours after receipt of the information reasonably necessary to make the Utilization Management("UM")is a process that decision.If the Medical Group needs more time to make determines whether a Service recommended by your the decision because it doesn't have information treating provider is Medically Necessary for you.Prior reasonably necessary to make the decision,or because it authorization is a UM process that determines whether has requested consultation by a particular specialist,you the requested services are Medically Necessary before and your treating physician will be informed about the care is provided.If it is Medically Necessary,then you additional information,testing,or specialist that is will receive authorization to obtain that care in a Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 17 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. needed,and the date that the Medical Group expects to Second Opinions make a decision. If you want a second opinion,you can ask Member Your treating physician will be informed of the decision Services to help you arrange one with a Plan Physician within 24 hours after the decision is made.If the Services who is an appropriately qualified medical professional are authorized,your physician will be informed of the for your condition. If there isn't a Plan Physician who is scope of the authorized Services.If the Medical Group an appropriately qualified medical professional for your does not authorize all of the Services,Health Plan will condition,Member Services will help you arrange a send you a written decision and explanation within two consultation with a Non—Plan Physician for a second business days after the decision is made.Any written opinion.For purposes of this"Second Opinions" criteria that the Medical Group uses to make the decision provision,an"appropriately qualified medical to authorize,modify,delay,or deny the request for professional"is a physician who is acting within their authorization will be made available to you upon request. scope of practice and who possesses a clinical background,including training and expertise,related to If the Medical Group does not authorize all of the the illness or condition associated with the request for a Services requested and you want to appeal the decision, second medical opinion. you can file a grievance as described in the"Coverage Decisions,Appeals,and Complaints"section. Here are some examples of when a second opinion may be provided or authorized: For these referral Services,you pay the Cost Share • Your Plan Physician has recommended a procedure required for Services provided by a Plan Provider as and you are unsure about whether the procedure is described in this EOC. reasonable or necessary • You question a diagnosis or plan of care for a Travel and Lodging for Certain Services condition that threatens substantial impairment or loss of life,limb,or bodily functions The following are examples of when we will arrange or • The clinical indications are not clear or are complex provide reimbursement for certain travel and lodging and confusing expenses in accord with our Travel and Lodging • A diagnosis is in doubt due to conflicting test results Program Description: • The Plan Physician is unable to diagnose the • If Medical Group refers you to a provider that is more condition than 50 miles from where you live for certain • The treatment plan in progress is not improving your specialty Services such as bariatric surgery,complex medical condition within an appropriate period of thoracic surgery,transplant nephrectomy,or inpatient time,given the diagnosis and plan of care chemotherapy for leukemia and lymphoma • If Medical Group refers you to a provider that is • You have concerns about the diagnosis or plan of care outside our Service Area for certain specialty Services An authorization or denial of your request for a second such as a transplant or transgender surgery opinion will be provided in an expeditious manner,as • If you are outside of California and you need an appropriate for your condition.If your request for a abortion on an emergency or urgent basis,and the second opinion is denied,you will be notified in writing abortion can't be obtained in a timely manner due to a of the reasons for the denial and of your right to file a near total or total ban on health care providers' ability grievance as described in the"Coverage Decisions, to provide such Services Appeals,and Complaints"section. For the complete list of specialty Services for which we For these referral Services,you pay the Cost Share will arrange or provide reimbursement for travel and required for Services provided by a Plan Provider as lodging expenses,the amount of reimbursement, described in this EOC. limitations and exclusions,and how to request reimbursement,refer to the Travel and Lodging Program Description.The Travel and Lodging Program Contracts with Plan Providers Description is available online at kn.org/specialty- How Plan Providers are paid care/travel-reimbursements or by calling Member Services. Health Plan and Plan Providers are independent contractors.Plan Providers are paid in a number of ways, such as salary,capitation,per diem rates,case rates,fee Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 18 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. for service,and incentive payments. To learn more about More information.For more information about this how Plan Physicians are paid to provide or arrange provision,or to request the Services,please call Member medical and hospital Services for Members,please visit Services. our website at kp.org or call Member Services. Financial liability Receiving Care Outside of Your Home Our contracts with Plan Providers provide that you are Region Service Area not liable for any amounts we owe.However,you may have to pay the full price of noncovered Services you For information about your coverage when you are away from home,visit our website at kp.orE/travel.You can obtain from Plan Providers or Non—Plan Providers. also call the Away from Home Travel Line at When you are referred to a Plan Provider for covered 1-951-268-3900,24 hours a day,seven days a week Services,you pay the Cost Share required for Services (except closed holidays). from that provider as described in this EOC. Receiving care in another Kaiser Permanente Termination of a Plan Provider's contract and service area completion of Services If you are visiting in another Kaiser Permanente service If our contract with any Plan Provider terminates while area,you may receive certain covered Services from you are under the care of that provider,we will retain designated providers in that other Kaiser Permanente financial responsibility for the covered Services you service area,subject to exclusions,limitations,prior receive from that provider until we make arrangements authorization or approval requirements,and reductions. for the Services to be provided by another Plan Provider For more information about receiving covered Services and notify you of the arrangements. in another Kaiser Permanente service area,including provider and facility locations,please visit kp.orz/travel Completion of Services.If you are undergoing or call our Away from Home Travel Line at 1-951-268- treatment for specific conditions from a Plan Physician 3900,24 hours a day,seven days a week(except closed (or certain other providers)when the contract with him holidays). or her ends(for reasons other than medical disciplinary Receiving care outside of any Kaiser cause,criminal activity,or the provider's voluntary Permanente service area termination),you may be eligible to continue receiving covered care from the terminated provider for your If you are traveling outside of any Kaiser Permanente condition.The conditions that are subject to this service area,we cover Services as described in the continuation of care provision are: "Emergency Services and Urgent Care"section about Emergency Services,Post-Stabilization Care,and Out- • Certain conditions that are either acute,or serious and of-Area Urgent Care and the"Benefits and Your Cost chronic.We may cover these Services for up to 90 Share"section about out-of-area dialysis care. days,or longer,if necessary for a safe transfer of care to a Plan Physician or other contracting provider as determined by the Medical Group Your ID Card • A high-risk pregnancy or a pregnancy in its second or Each Member's Kaiser Permanente ID card has a third trimester.We may cover these Services through medical record number on it,which you will need when postpartum care related to the delivery,or longer you call for advice,make an appointment,or go to a if Medically Necessary for a safe transfer of care to a provider for covered care.When you get care,please Plan Physician as determined by the Medical Group bring your Kaiser Permanente ID card and a photo ID. Your medical record number is used to identify your The Services must be otherwise covered under this EOC. medical records and membership information.Your Also,the terminated provider must agree in writing to medical record number should never change.Please call our contractual terms and conditions and comply with Member Services if we ever inadvertently issue you them for Services to be covered by us. more than one medical record number or if you need to replace your Kaiser Permanente ID card. For the Services of a terminated provider,you pay the Cost Share required for Services provided by a Plan Your ID card is for identification only.To receive Provider as described in this EOC. covered Services,you must be a current Member. Anyone who is not a Member will be billed as a non- Member for any Services they receive.If you let Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 19 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. someone else use your ID card,we may keep your ID Plan Facilities card and terminate your membership as described under "Termination for Cause"in the"Termination of Plan Medical Offices and Plan Hospitals are listed in the Membership"section. Provider Directory for your Home Region.The directory Your Medicare card describes the types of covered Services that are available from each Plan Facility,because some facilities provide Do NOT use your red,white,and blue Medicare card for only specific types of covered Services.This directory is covered medical Services while you are a Member of this available on our website at kp.org/facilities.To obtain a plan.If you use your Medicare card instead of your printed copy,call Member Services.The directory is Senior Advantage membership card,you may have to updated periodically.The availability of Plan Facilities pay the full cost of medical services yourself.Keep your may change.If you have questions,please call Member Medicare card in a safe place.You may be asked to show Services. it if you need hospice services or participate in routine research studies. At most of our Plan Facilities,you can usually receive all of the covered Services you need,including specialty Getting Assistance care,pharmacy,and lab work.You are not restricted to a particular Plan Facility,and we encourage you to use the We want you to be satisfied with the health care you facility that will be most convenient for you: receive from Kaiser Permanente.If you have any . All Plan Hospitals provide inpatient Services and are questions or concerns,please discuss them with your open 24 hours a day,seven days a week personal Plan Physician or with other Plan Providers • Emergency Services are available from Plan Hospital who are treating you.They are committed to your satisfaction and want to help you with your questions. Emergency Departments(for Emergency Department locations,refer to our Provider Directory or call Member Services Member Services) Member Services representatives can answer any • Same-day Urgent Care appointments are available at questions you have about your benefits,available many locations(for Urgent Care locations,refer to Services,and the facilities where you can receive care. our Provider Directory or call Member Services) For example,they can explain the following: . Many Plan Medical Offices have evening and • Your Health Plan benefits weekend appointments • How to make your first medical appointment • Many Plan Facilities have a Member Services office (for locations,refer to our Provider Directory or call • What to do if you move Member Services) • How to replace your Kaiser Permanente ID card . Plan Pharmacies are located at most Plan Medical Offices(refer to Kaiser Permanente Pharmacy Many Plan Facilities have an office staffed with Directory for pharmacy locations) representatives who can provide assistance if you need help obtaining Services.At different locations,these offices may be called Member Services,Patient Provider Directory Assistance,or Customer Service.In addition,Member Services representatives are available to assist you seven The Provider Directory lists our Plan Providers.It is days a week from 8 a.m.to 8 p.m.toll free at 1-800-443- subject to change and periodically updated.If you don't 0815 or 711 (TTY for the deaf,hard of hearing,or have our Provider Directory,you can get a copy by speech impaired).For your convenience,you can also calling Member Services or by visiting our website at contact us through our website at kp.org. kp.org/directory. Cost Share estimates For information about estimates,see"Getting an Pharmacy Directory estimate of your Cost Share"under"Your Cost Share"in The Kaiser Permanente Pharmacy Directory lists the the"Benefits and Your Cost Share"section. locations of Plan Pharmacies,which are also called "network pharmacies."The pharmacy directory provides additional information about obtaining prescription drugs.It is subject to change and periodically updated. If you don't have the Kaiser Permanente Pharmacy Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 20 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Directory,you can get a copy by calling Member Your Cost Share Services or by visiting our website at kp.org/directory. Your Cost Share for covered Emergency Services and Post-Stabilization Care is described in the"Benefits and Your Cost Share"section.Your Cost Share is the same Emergency Services and Urgent whether you receive the Services from a Plan Provider or Care a Non—Plan Provider.For example: • If you receive Emergency Services in the Emergency Department of a Non—Plan Hospital,you pay the Cost Emergency Services Share for an Emergency Department visit as described under"Outpatient Care" If you have an Emergency Medical Condition,call 911 . If we gave prior authorization for inpatient Post- (where available)or go to the nearest Emergency Stabilization Care in a Non—Plan Hospital,you pay Department.You do not need prior authorization for the Cost Share for hospital inpatient care as described Emergency Services.When you have an Emergency under"Hospital Inpatient Care" Medical Condition,we cover Emergency Services you receive from Plan Providers or Non—Plan Providers anywhere in the world. Urgent Care Emergency Services are available from Plan Hospital Inside your Home Region Service Area Emergency Departments 24 hours a day,seven days a An Urgent Care need is one that requires prompt medical week. attention but is not an Emergency Medical Condition. If you think you may need Urgent Care,call the Post-Stabilization Care appropriate appointment or advice phone number at a Post-Stabilization Care is Medically Necessary Services Plan Facility.For appointment and advice phone related to your Emergency Medical Condition that you numbers,refer to our Provider Directory or call Member receive in a hospital(including the Emergency Services. Department)after your treating physician determines that your condition is Stabilized. In the event of unusual circumstances that delay or render impractical the provision of Services under this To request prior authorization,the Non—Plan Provider EOC(such as a major disaster,epidemic,war,riot,and must call 1-800-225-8883 or the notification phone civil insurrection),we cover Urgent Care inside our number on your Kaiser Permanente ID card before you Service Area from a Non—Plan Provider. receive the care.We will discuss your condition with the Non—Plan Provider.If we determine that you require Out-of-Area Urgent Care Post-Stabilization Care and that this care is part of your If you need Urgent Care due to an unforeseen illness or covered benefits,we will authorize your care from the unforeseen injury,we cover Medically Necessary Non—Plan Provider or arrange to have a Plan Provider(or Services to prevent serious deterioration of your health other designated provider)provide the care with the from a Non—Plan Provider if all of the following are true: treating physician's concurrence.If we decide to have a . You receive the Services from Non—Plan Providers Plan Hospital,Plan Skilled Nursing Facility,or while you are temporarily outside our Service Area designated Non—Plan Provider provide your care,we may authorize special transportation services that are • A reasonable person would have believed that your medically required to get you to the provider.This may health would seriously deteriorate if you delayed include transportation that is otherwise not covered. treatment until you returned to our Service Area Be sure to ask the Non—Plan Provider to tell you what You do not need prior authorization for Out-of-Area care(including any transportation)we have authorized Urgent Care.We cover Out-of-Area Urgent Care you because we will not cover unauthorized Post- receive from Non—Plan Providers if the Services would Stabilization Care or related transportation provided by have been covered under this EOC if you had received Non—Plan Providers.If you receive care from a Non— them from Plan Providers. Plan Provider that we have not authorized,you may have to pay the full cost of that care if you are notified by the We do not cover follow-up care from Non—Plan Non—Plan Provider or us about your potential liability. Providers after you no longer need Urgent Care.To obtain follow-up care from a Plan Provider,call the appointment or advice phone number at a Plan Facility. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 21 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. For phone numbers,refer to our Provider Directory or Benefits and Your Cost Share call Member Services. This section describes the Services that are covered Your Cost Share under this EOC. Your Cost Share for covered Urgent Care is the Cost Services are covered under this EOC as specifically Share required for Services provided by Plan Providers described in this EOC. Services that are not specifically as described in this EOC.For example: described in this EOC are not covered,except as required • If you receive an Urgent Care evaluation as part of by federal law. Services are subject to exclusions and covered Out-of-Area Urgent Care from a Non—Plan limitations described in the"Exclusions,Limitations, Provider,you pay the Cost Share for Urgent Care Coordination of Benefits,and Reductions"section. consultations,evaluations,and treatment as described Except as otherwise described in this EOC,all of the under"Outpatient Care" following conditions must be satisfied: • If the Out-of-Area Urgent Care you receive includes • You are a Member on the date that you receive the an X-ray,you pay the Cost Share for an X-ray as Services described under"Outpatient Imaging,Laboratory,and • The Services are Medically Necessary Other Diagnostic and Treatment Services"in addition to the Cost Share for the Urgent Care evaluation • The Services are one of the following: ♦ Preventive Services Note: If you receive Urgent Care in an Emergency ♦ health care items and services for diagnosis, Department,you pay the Cost Share for an Emergency assessment,or treatment Department visit as described under"Outpatient Care." ♦ health education covered under"Health Education"in this`Benefits and Your Cost Share" Payment and Reimbursement section ♦ other health care items and services If you receive Emergency Services,Post-Stabilization ♦ other services to treat Serious Emotional Care,or Urgent Care from a Non—Plan Provider as Disturbance of a Child Under Age 18 or Severe described in this"Emergency Services and Urgent Care" Mental Illness section,or emergency ambulance Services described under"Ambulance Services"in the"Benefits and Your • The Services are provided,prescribed,authorized,or Cost Share"section,ask the Non—Plan Provider to directed by a Plan Physician except for: submit a claim to us within 60 days or as soon as ♦ covered Services received outside of your Home possible,but no later than 15 months after receiving the Region Service Area,as described under care(or up to 27 months according to Medicare rules,in "Receiving Care Outside of Your Home Region some cases).If the provider refuses to bill us,send us the Service Area"in the"How to Obtain Services" unpaid bill with a claim form.Also,if you receive section Services from a Plan Provider that are prescribed by a ♦ drugs prescribed by dentists,as described under Non—Plan Provider as part of covered Emergency "Outpatient Prescription Drugs,Supplies,and Services,Post-Stabilization Care,and Urgent Care(for Supplements"in this"Benefits and Your Cost example,drugs),you may be required to pay for the Share"section Services and file a claim.To request payment or ♦ emergency ambulance Services,as described reimbursement,you must file a claim as described in the under"Ambulance Services"in this"Benefits and "Requests for Payment"section. Your Cost Share"section We will reduce any payment we make to you or the ♦ Emergency Services,Post-Stabilization Care,and Non—Plan Provider by the applicable Cost Share.Also, Out-of-Area Urgent Care,as described in the in accord with applicable law,we will reduce our "Emergency Services and Urgent Care"section payment by any amounts paid or payable(or that in the ♦ eyeglasses and contact lenses prescribed by Non— absence of this plan would have been payable)for the Plan Providers,as described under"Vision Services under any insurance policy,or any other Services"in this`Benefits and Your Cost Share" contract or coverage,or any government program except section Medicaid. ♦ out-of-area dialysis care,as described under "Dialysis Care"in this"Benefits and Your Cost Share"section Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 22 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. ♦ routine Services associated with Medicare- Services that are subject to the Plan Deductible,your approved clinical trials,as described under Cost Share for those Services will be Charges until you "Services Associated with Clinical Trials"in this reach the Plan Deductible. "Benefits and Your Cost Share"section • You receive the Services from Plan Providers inside General rules, examples, and exceptions our Service Area,except for: Your Cost Share for covered Services will be the Cost ♦ authorized referrals,as described under"Getting a Share in effect on the date you receive the Services, Referral"in the"How to Obtain Services"section except as follows: ♦ covered Services received outside of your Home • If you are receiving covered hospital inpatient Region Service Area,as described under Services on the effective date of this EOC,you pay "Receiving Care Outside of Your Home Region the Cost Share in effect on your admission date until Service Area"in the"How to Obtain Services" you are discharged if the Services were covered under section your prior Health Plan evidence of coverage and there ♦ emergency ambulance Services,as described has been no break in coverage.However,if the Services were not covered under your prior Health under"Ambulance Services"in this"Benefits and Plan evidence of coverage,or if there has been a Your Cost Share"section break in coverage,you pay the Cost Share in effect on ♦ Emergency Services,Post-Stabilization Care,and the date you receive the Services Out-of-Area Urgent Care,as described in the . For items ordered in advance,you pay the Cost Share Emergency Services and Urgent Care section in effect on the order date(although we will not cover ♦ out-of-area dialysis care,as described under the item unless you still have coverage for it on the "Dialysis Care"in this"Benefits and Your Cost date you receive it)and you may be required to pay Share"section the Cost Share when the item is ordered.For ♦ prescription drugs from Non—Plan Pharmacies,as outpatient prescription drugs,the order date is the described under"Outpatient Prescription Drugs, date that the pharmacy processes the order after Supplies,and Supplements"in this"Benefits and receiving all of the information they need to fill the Your Cost Share"section prescription ♦ routine Services associated with Medicare- approved clinical trials,as described under Payment toward your Cost Share(and when you may "Services Associated with Clinical Trials"in this be billed) "Benefits and Your Cost Share"section In most cases,your provider will ask you to make a • The Medical Group has given prior authorization for payment toward your Cost Share at the time you receive the Services,if required,as described under"Medical Services.If you receive more than one type of Services Group authorization procedure for certain referrals" (such as primary care treatment and laboratory tests),you in the"How to Obtain Services"section may be required to pay separate Cost Share for each of those Services.Keep in mind that your payment toward your Cost Share may cover only a portion of your total Please also refer to: Cost Share for the Services you receive,and you will be • The"Emergency Services and Urgent Care"section billed for any additional amounts that are due.The for information about how to obtain covered following are examples of when you may be asked to Emergency Services,Post-Stabilization Care,and pay(or you may be billed for)Cost Share amounts in Out-of-Area Urgent Care addition to the amount you pay at check-in: • Our Provider Directory for the types of covered • You receive non-preventive Services during a Services that are available from each Plan Facility, preventive visit.For example,you go in for a routine because some facilities provide only specific types of physical exam,and at check-in you pay your Cost covered Services Share for the preventive exam(your Cost Share may be"no charge").However,during your preventive exam your provider finds a problem with your health Your Cost Share and orders non-preventive Services to diagnose your Your Cost Share is the amount you are required to pay problem(such as laboratory tests).You may be asked for covered Services.The Cost Share for covered to pay(or you will be billed for)your Cost Share for Services is listed in this EOC.For example,your Cost these additional non-preventive diagnostic Services Share may be a Copayment or Coinsurance.If your • You receive diagnostic Services during a treatment coverage includes a Plan Deductible and you receive visit.For example,you go in for treatment of an Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 23 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. existing health condition,and at check-in you pay receive care.You are not responsible for any amounts your Cost Share for a treatment visit.However, beyond your Cost Share for the covered Services you during the visit your provider finds a new problem receive at Plan Facilities or at contracted facilities where with your health and performs or orders diagnostic we have authorized you to receive care.However,if the Services(such as laboratory tests).You may be asked provider does not agree to bill us,you may have to pay to pay(or you will be billed for)your Cost Share for for the Services and file a claim for reimbursement.For these additional diagnostic Services information on how to file a claim,please see the • You receive treatment Services during a diagnostic "Requests for Payment"section. visit.For example,you go in for a diagnostic exam, and at check-in you pay your Cost Share fora Primary Care Visits,Non-Physician Specialist Visits, diagnostic exam.However,during the diagnostic and Physician Specialist Visits.The Cost Share for a exam your provider confirms a problem with your Primary Care Visit applies to evaluations and treatment health and performs treatment Services(such as an provided by generalists in internal medicine,pediatrics, outpatient procedure).You may be asked to pay(or or family practice,and by specialists in you will be billed for)your Cost Share for these obstetrics/gynecology whom the Medical Group additional treatment Services designates as Primary Care Physicians. Some physician specialists provide primary care in addition to specialty • You receive Services from a second provider during care but are not designated as Primary Care Physicians. your visit.For example,you go in for a diagnostic If you receive Services from one of these specialists,the exam,and at check-in you pay your Cost Share for a Cost Share for a Physician Specialist Visit will apply to diagnostic exam.However,during the diagnostic all consultations,evaluations,and treatment provided by exam your provider requests a consultation with a the specialist except for routine preventive counseling specialist.You may be asked to pay(or you will be and exams listed under"Preventive Services"in this billed for)your Cost Share for the consultation with "Benefits and Your Cost Share"section.For example, the specialist if your personal Plan Physician is a specialist in internal medicine or obstetrics/gynecology who is not a Primary In some cases,your provider will not ask you to make a Care Physician,you will pay the Cost Share for a payment at the time you receive Services,and you will Physician Specialist Visit for all consultations, be billed for your Cost Share(for example,some evaluations,and treatment by the specialist except Laboratory Departments are not able to collect Cost routine preventive counseling and exams listed under Shares). "Preventive Services"in this`Benefits and Your Cost Share"section.The Non-Physician Specialist Visit Cost When we send you a bill,it will list Charges for the Share applies to consultations,evaluations,and treatment Services you received,payments and credits applied to provided by non-physician specialists(such as nurse your account,and any amounts you still owe.Your practitioners,physician assistants,optometrists, current bill may not always reflect your most recent podiatrists,and audiologists). Charges and payments.Any Charges and payments that are not on the current bill will appear on a future bill. Noncovered Services.If you receive Services that are Sometimes,you may see a payment but not the related not covered under this EOC,you may have to pay the Charges for Services. That could be because your full price of those Services.Payments you make for payment was recorded before the Charges for the noncovered Services do not apply to any deductible or Services were processed.If so,the Charges will appear out-of-pocket maximum. on a future bill.Also,you may receive more than one bill for a single outpatient visit or inpatient stay.For Getting an estimate of your Cost Share example,you may receive a bill for physician services If you have questions about the Cost Share for specific and a separate bill for hospital services.If you don't see Services that you expect to receive or that your provider all the Charges for Services on one bill,they will appear orders during a visit or procedure,please visit our on a future bill.If we determine that you overpaid and website at kp.ore/memberestimates to use our cost are due a refund,then we will send a refund to you estimate tool or call Member Services. within four weeks after we make that determination. If you have questions about a bill,please call the phone • If you have a Plan Deductible and would like an number on the bill. estimate for Services that are subject to the Plan Deductible,please call 1-800-390-3507(TTY users In some cases,a Non—Plan Provider may be involved in call 711)Monday through Friday,6 a.m.to 5 p.m. the provision of covered Services at a Plan Facility or a contracted facility where we have authorized you to Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 24 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • For all other Cost Share estimates,please call 1-800- Copayments or Coinsurance even if you have already 443-0815,8 a.m.to 8 p.m.,seven days a week(TTY reached the out-of-pocket maximum.In addition: users should call 711) • If your plan includes supplemental chiropractic or acupuncture Services,or fitness benefit,described in Cost Share estimates are based on your benefits and the an amendment to this EOC,those Services do not Services you expect to receive.They are a prediction of apply toward the maximum cost and not a guarantee of the final cost of Services. Your final cost may be higher or lower than the estimate • If your plan includes an Allowance for specific since not everything about your care can be known in Services(such as eyeglasses,contact lenses,or hearing aids),any amounts you pay that exceed the advance. Allowance do not apply toward the maximum Copayments and Coinsurance The Copayment or Coinsurance you must pay for each Outpatient Care covered Service,after you meet any applicable deductible,is described in this EOC. We cover the following outpatient care subject to the Cost Share indicated: Note: If Charges for Services are less than the Copayment described in this EOC,you will pay the Office visits lesser amount. . Primary Care Visits and Non-Physician Specialist Plan Out-of-Pocket Maximum Visits that are not described elsewhere in this EOC: a $25 Copayment per visit There is a limit to the total amount of Cost Share you Specialist Visits that are not described• Physician S must pay under this EOC in the calendar year for y p covered Services that you receive in the same calendar elsewhere in this EOC: a$25 Copayment per visit year.The Services that apply to the Plan Out-of-Pocket • Outpatient visits that are available as group Maximum are described under the"Payments that count appointments that are not described elsewhere in this toward the Plan Out-of-Pocket Maximum"section EOC: a$12 Copayment per visit below.The limit is: • House calls by a Plan Physician(or a Plan Provider • $1,000 per calendar year for any one Member who is a registered nurse)inside our Service Area when care can best be provided in your home as For Services subject to the Plan Out-of-Pocket determined by a Plan Physician: Maximum,you will not pay any more Cost Share during ♦ Primary Care Visits and Non-Physician Specialist the remainder of the calendar year,but every other Visits: a$25 Copayment per visit Member in your Family must continue to pay Cost Share ♦ Physician Specialist Visits: a$25 Copayment per during the remainder of the calendar year until either he visit or she reaches the$1,000 maximum for any one Member. • Routine physical exams that are medically appropriate preventive care in accord with generally Payments that count toward the Plan Out-of-Pocket accepted professional standards of practice: Maximum.Any amounts you pay for the following ac charge Services apply toward the out-of-pocket maximum: no • Family planning counseling,or internally implanted • Covered in-network Medicare Part A and Part B time-release contraceptives or intrauterine devices Services (IUDs)and office visits related to their administration • Medicare Part B drugs(all other drugs do not apply) and management: a$25 Copayment per visit • Residential treatment program Services covered in the • After confirmation of pregnancy,the normal series of "Substance Use Disorder Treatment"and"Mental regularly scheduled preventive prenatal care exams Health Services"sections and the first postpartum follow-up consultation and Copayments and Coinsurance you pay for Services that exam: a$5 Copayment per visit are not described above,do not apply to the out-of- • Voluntary termination of pregnancy and related pocket maximum.For these Services,you must pay Services: no charge • Physical,occupational,and speech therapy in accord with Medicare guidelines: a$25 Copayment per visit Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 25 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Group and individual physical therapy prescribed by a are admitted for observation but are not admitted as an Plan Provider to prevent falls: no charge inpatient. • Physical,occupational,and speech therapy provided Outpatient surgeries and procedures in an organized,multidisciplinary rehabilitation day- treatment program in accord with Medicare • Outpatient surgery and outpatient procedures when guidelines: a$25 Copayment per day provided in an outpatient or ambulatory surgery • Manual manipulation of the spine to correct center or in a hospital operating room,or if it is subluxation,in accord with Medicare guidelines,is provided in any setting and a licensed staff member covered when provided by a Plan Provider or a monitors your vital signs as you regain sensation after chiropractor when referred by a Plan Provider: a receiving drugs to reduce sensation or to minimize $20 Copayment per visit. (For the list of discomfort: a$25 Copayment per procedure participating ASH Plans providers,please refer to • Any other outpatient surgery that does not require a your Provider Directory) licensed staff member to monitor your vital signs as described above: a$25 Copayment per procedure Acupuncture Services • Any other outpatient procedures that do not require a • Acupuncture for chronic low back pain up to 12 visits licensed staff member to monitor your vital signs as in 90 days,in accord with Medicare guidelines: a described above: the Cost Share that would $25 Copayment per visit. Chronic low back pain is otherwise apply for the procedure in this"Benefits defined as follows: and Your Cost Share"section(for example,radiology ♦ lasting 12 weeks or longer procedures that do not require a licensed staff member to monitor your vital signs as described ♦ non-specific,in that it has no identifiable systemic above are covered under"Outpatient Imaging, cause(i.e.not associated with metastatic, Laboratory,and Other Diagnostic and Treatment inflammatory,infectious,disease,etc) Services") ♦ not associated with surgery or pregnancy . Pre-and post-operative visits: • An additional eight sessions will be covered for those ♦ Primary Care Visits and Non-Physician Specialist patients demonstrating an improvement.No more Visits: a$25 Copayment per visit than 20 acupuncture treatments may be administered annually.Treatment must be discontinued if the ♦ Physician Specialist Visits: a$25 Copayment per patient is not improving or is regressing visit • Acupuncture not covered by Medicare(typically Administered drugs and products provided only for the treatment of nausea or as part of Administered drugs and products are medications and a comprehensive pain management program for the products that require administration or observation by treatment of chronic pain): a$25 Copayment per medical personnel.We cover these items when visit prescribed by a Plan Provider,in accord with our drug Emergency Services and Urgent Care formulary guidelines,and they are administered to you in a Plan Facility or during home visits. • Urgent Care consultations,evaluations,and treatment: a$25 Copayment per visit We cover the following Services and their administration • Emergency Department visits: a$75 Copayment per in a Plan Facility at the Cost Share indicated: visit • Whole blood,red blood cells,plasma,and platelets: no charge If you are admitted from the Emergency Department. • Allergy antigens(including administration): a If you are admitted to the hospital as an inpatient for $3 Copayment per visit covered Services(either within 24 hours for the same condition or after an observation stay),then the Services • Cancer chemotherapy drugs and adjuncts: no charge you received in the Emergency Department and • Drugs and products that are administered via observation stay,if applicable,will be considered part of intravenous therapy or injection that are not for your inpatient hospital stay.For the Cost Share for cancer chemotherapy,including blood factor products inpatient care,refer to"Hospital Inpatient Services"in and biological products("biologics")derived from this"Benefits and Your Cost Share"section.However, tissue,cells,or blood: no charge the Emergency Department Cost Share does apply if you . Tuberculosis skin tests: no charge Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 26 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • All other administered drugs and products: no charge Hospital Inpatient Services We cover drugs and products administered to you during We cover the following inpatient Services in a Plan a home visit at no charge. Hospital,when the Services are generally and customarily provided by acute care general hospitals Certain administered drugs are Preventive Services. inside our Service Area: Refer to"Preventive Services"for information on • Room and board,including a private room immunizations. if Medically Necessary Note:Vaccines covered by Medicare Part D are not • Specialized care and critical care units covered under this"Outpatient Care"section(instead, • General and special nursing care refer to"Outpatient Prescription Drugs, Supplies,and • Operating and recovery rooms Supplements"in this"Benefits and Your Cost Share" • Services of Plan Physicians,including consultation section). and treatment by specialists For the following Services, refer to these • Anesthesia sections • Drugs prescribed in accord with our drug formulary • Bariatric Surgery guidelines(for discharge drugs prescribed when you • Dental Services are released from the hospital,refer to"Outpatient Prescription Drugs,Supplies,and Supplements"in • Dialysis Care this"Benefits and Your Cost Share"section) • Durable Medical Equipment("DME")for Home Use • Radioactive materials used for therapeutic purposes • Fertility Services • Durable medical equipment and medical supplies • Health Education • Imaging,laboratory,and other diagnostic and • Hearing Services treatment Services,including MRI,CT,and PET scans • Home-Delivered Meals • Whole blood,red blood cells,plasma,platelets,and • Home Health Care their administration • Hospice Care • Obstetrical care and delivery(including cesarean • Mental Health Services section).Note:If you are discharged within 48 hours • Ostomy,Urological,and Specialized Wound Care after delivery(or within 96 hours if delivery is by Supplies cesarean section),your Plan Physician may order a follow-up visit for you and your newborn to take • Outpatient Imaging,Laboratory,and Other place within 48 hours after discharge(for visits after Diagnostic and Treatment Services you are released from the hospital,please refer to • Outpatient Prescription Drugs, Supplies,and "Outpatient Care"in this"Benefits and Your Cost Supplements Share"section) • Preventive Services • Physical,occupational,and speech therapy(including treatment in an organized,multidisciplinary • Prosthetic and Orthotic Devices rehabilitation program)in accord with Medicare • Reconstructive Surgery guidelines • Services Associated with Clinical Trials • Respiratory therapy • Substance Use Disorder Treatment • Medical social services and discharge planning • Transplant Services Your Cost Share.We cover hospital inpatient Services • Transportation Services at a$250 Copayment per admission. • Vision Services For the following Services, refer to these sections • Bariatric surgical procedures(refer to"Bariatric Surgery") Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 27 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Dental procedures(refer to"Dental Services") Nonemergency • Dialysis care(refer to"Dialysis Care") Inside our Service Area,we cover nonemergency ambulance Services in accord with Medicare guidelines • Fertility Services related to diagnosis and treatment of if a Plan Physician determines that your condition infertility,artificial insemination,or assisted requires the use of Services that only a licensed reproductive technology(refer to"Fertility Services") ambulance can provide and that the use of other means • Hospice care(refer to"Hospice Care") of transportation would endanger your health. These • Mental health Services(refer to"Mental Health Services are covered only when the vehicle transports Services") you to and from qualifying locations as defined by Medicare guidelines. • Prosthetics and orthotics(refer to"Prosthetic and Orthotic Devices") Your Cost Share • Reconstructive surgery Services(refer to You pay the following for covered ambulance Services: "Reconstructive Surgery") • Emergency ambulance Services: a$100 Copayment • Religious Nonmedical Health Care Institution per trip Services(refer to"Religious Nonmedical Health Care • Nonemergency Services: a$100 Copayment per Institution") trip • Services in connection with a clinical trial(refer to "Services in Connection with a Clinical Trial") Ambulance Services exclusions • Skilled inpatient Services in a Plan Skilled Nursing • Transportation by car,taxi,bus,gurney van, Facility(refer to"Skilled Nursing Facility Care") wheelchair van,and any other type of transportation • Substance use disorder treatment Services(refer to (other than a licensed ambulance),even if it is the "Substance Use Disorder Treatment") only way to travel to a Plan Provider,except as otherwise covered under"Transportation Services"in • Transplant Services(refer to"Transplant Services") this section Ambulance Services Bariatric Surgery Emergency We cover hospital inpatient Services related to bariatric We cover Services of a licensed ambulance anywhere in surgical procedures(including room and board,imaging, the world without prior authorization(including laboratory,other diagnostic and treatment Services,and transportation through the 911 emergency response Plan Physician Services)when performed to treat obesity system where available)in the following situations: by modification of the gastrointestinal tract to reduce • You reasonably believed that the medical condition nutrient intake and absorption,if all of the following was an Emergency Medical Condition which required requirements are met: ambulance Services • You complete the Medical Group—approved pre- • Your treating physician determines that you must be surgical educational preparatory program regarding transported to another facility because your lifestyle changes necessary for long term bariatric Emergency Medical Condition is not Stabilized and surgery success the care you need is not available at the treating . A Plan Physician who is a specialist in bariatric care facility determines that the surgery is Medically Necessary If you receive emergency ambulance Services that are Your Cost Share.For covered Services related to not ordered by a Plan Provider,you are not responsible bariatric surgical procedures that you receive,you will for any amounts beyond your Cost Share for covered pay the Cost Share you would pay if the Services were emergency ambulance Services.However,if the provider not related to a bariatric surgical procedure.For does not agree to bill us,you may have to pay for the example,see"Hospital Inpatient Services"in this Services and file a claim for reimbursement.For "Benefits and Your Cost Share"section for the Cost information on how to file a claim,please see the Share that applies for hospital inpatient Services. "Requests for Payment"section. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 28 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. For the following Services, refer to these Your Cost Share sections You pay the following for dental Services covered under • Outpatient prescription drugs(refer to"Outpatient this"Dental Services"section: Prescription Drugs,Supplies,and Supplements") • Non-Physician Specialist Visits with dentists for • Outpatient administered drugs(refer to"Outpatient Services covered under this"Dental Services" Care") section: a$25 Copayment per visit • Physician Specialist Visits for Services covered under this"Dental Services"section: a$25 Copayment per Dental Services visit Dental Services for radiation treatment • Outpatient surgery and outpatient procedures when We cover services in accord with Medicare guidelines, provided in an outpatient or ambulatory surgery including dental evaluation,X-rays,fluoride treatment, center or in a hospital operating room,or if it is and extractions necessary to prepare your jaw for provided in any setting and a licensed staff member radiation therapy of cancer in your head or neck if a Plan monitors your vital signs as you regain sensation after Physician provides the Services or if the Medical Group receiving drugs to reduce sensation or to minimize authorizes a referral to a dentist for those Services(as discomfort: a$25 Copayment per procedure described in"Medical Group authorization procedure for • Any other outpatient surgery that does not require a certain referrals"under"Getting a Referral"in the"How licensed staff member to monitor your vital signs as to Obtain Services"section). described above: a$25 Copayment per procedure Dental Services for transplants • Any other outpatient procedures that do not require a We cover dental services that are Medically Necessary to licensed staff member to monitor your vital signs as described above: the Cost Share that would free the mouth from infection in order to prepare for a otherwise apply for the procedure in this"Benefits transplant covered under"Transplant Services"in this and Your Cost Share"section(for example,radiology "Benefits" section,if a Plan Physician provides the procedures that do not require a licensed staff Services or if the Medical Group authorizes a referral to member to monitor your vital signs as described a dentist for those Services(as described in"Medical above are covered under"Outpatient Imaging, Group authorization procedure for certain referrals" Laboratory,and Other Diagnostic and Treatment under"Getting a Referral"in the"How to Obtain Services") Services" section). • Hospital inpatient Services(including room and Dental anesthesia board,drugs,imaging,laboratory,other diagnostic For dental procedures at a Plan Facility,we provide and treatment Services,and Plan Physician Services): general anesthesia and the facility's Services associated a$250 Copayment per admission with the anesthesia if all of the following are true: For the following Services, refer to these • You are under age 7,or you are developmentally sections disabled,or your health is compromised • Office visits not described in this"Dental Services" • Your clinical status or underlying medical condition section(refer to"Outpatient Care") requires that the dental procedure be provided in a hospital or outpatient surgery center • Outpatient imaging,laboratory,and other diagnostic and treatment Services(refer to"Outpatient Imaging, • The dental procedure would not ordinarily require Laboratory,and Other Diagnostic and Treatment general anesthesia Services") We do not cover any other Services related to the dental • Outpatient prescription drugs(refer to"Outpatient procedure,such as the dentist's Services,unless the Prescription Drugs,Supplies,and Supplements") Service is covered in accord with Medicare guidelines or for transplant services. Dialysis Care We cover acute and chronic dialysis Services if all of the following requirements are met: • You satisfy all medical criteria developed by the Medical Group Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 29 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • The facility is certified by Medicare • Outpatient laboratory(refer to"Outpatient Imaging, • A Plan Physician provides a written referral for your Laboratory,and Other Diagnostic and Treatment dialysis treatment except for out-of-area dialysis care Services") • Outpatient prescription drugs(refer to"Outpatient We also cover hemodialysis and peritoneal home dialysis Prescription Drugs,Supplies,and Supplements") (including equipment,training,and medical supplies). • Outpatient administered drugs(refer to"Outpatient Coverage is limited to the standard item of equipment or Care") supplies that adequately meets your medical needs.We . Telehealth Visits(refer to"Telehealth Visits") decide whether to rent or purchase the equipment and supplies,and we select the vendor.You must return the equipment and any unused supplies to us or pay us the Dialysis care exclusions fair market price of the equipment and any unused • Comfort,convenience,or luxury equipment,supplies supply when we are no longer covering them. and features Out-of-area dialysis care • Nonmedical items,such as generators or accessories We cover dialysis(kidney)Services that you get at a to make home dialysis equipment portable for travel Medicare-certified dialysis facility when you are temporarily outside our Service Area.If possible,before Durable Medical Equipment ("DME") for you leave the Service Area,please let us know where Home Use you are going so we can help arrange for you to have maintenance dialysis while outside our Service Area. DME coverage rules DME for home use is an item that meets the following The procedure for obtaining reimbursement for out-of- criteria: area dialysis care is described in the"Requests for • The item is intended for repeated use Payment"section. • The item is primarily and customarily used to serve a Your Cost Share.You pay the following for these medical purpose covered Services related to dialysis: . The item is generally useful only to an individual • Equipment and supplies for home hemodialysis and with an illness or injury home peritoneal dialysis: no charge • The item is appropriate for use in the home(or • One routine outpatient visit per month with the another location used as your home as defined by multidisciplinary nephrology team for a consultation, Medicare) evaluation,or treatment: no charge • The item is expected to last at least 3 years • Hemodialysis and peritoneal dialysis treatment: no charge For a DME item to be covered,all of the following • Hospital inpatient Services(including room and requirements must be met: board,drugs,imaging,laboratory,and other • Your EOC includes coverage for the requested DME diagnostic and treatment Services,and Plan Physician item Services): a$250 Copayment per admission • A Plan Physician has prescribed the DME item for For the following Services, refer to these your medical condition sections • The item has been approved for you through the Plan's prior authorization process,as described in • Durable medical equipment for home use(refer to "Medical Group authorization procedure for certain "Durable Medical Equipment("DME")for Home referrals"under"Getting a Referral"in the"How to „) se Obtain Services"section • Hospital inpatient Services(refer to"Hospital • The Services are provided inside our Service Area Inpatient Services") • Office visits not described in this"Dialysis Care" Coverage is limited to the standard item of equipment section(refer to"Outpatient Care") that adequately meets your medical needs.We decide • Kidney disease education(refer to"Health whether to rent or purchase the equipment,and we select Education") the vendor. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 30 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. DME for diabetes ("DME")for Home Use"section are met,we cover the We cover the following diabetes testing supplies and following other DME items(including repair or equipment and insulin-administration devices if all of the replacement of covered equipment): requirements described under"DME coverage rules"in • Bed accessories for a hospital bed when bed this"Durable Medical Equipment("DME")for Home extension is required Use"section are met: • Heel or elbow protectors to prevent or minimize • Glucose monitors for diabetes testing and their advanced pressure relief equipment use supplies(such as glucose monitor test strips,lancets, • Iontophoresis device to treat hyperhidrosis when and lancet devices) antiperspirants are contraindicated and the • Insulin pumps and supplies to operate the pump hyperhidrosis has created medical complications(for example,skin infection)or preventing daily living Your Cost Share.You pay the following for covered activities DME for diabetes(including repair or replacement of • Nontherapeutic continuous glucose monitoring covered equipment): devices and related supplies • Glucose monitors for diabetes testing and their • Peak flow meters supplies(such as glucose monitor test strips,lancets, and lancet devices): no charge • Resuscitation bag if tracheostomy patient has • Insulin pumps and supplies to operate the pump: significant secretion management problems,needing 20 percent Coinsurance lavage and suction technique aided by deep breathing via resuscitation bag Base DME Items We cover Base DME Items(including repair or Your Cost Share.You pay the following for other replacement of covered equipment)if all of the covered DME items: 20 percent Coinsurance,except requirements described under"DME coverage rules"in peak flow meters are covered at: no charge. this"Durable Medical Equipment("DME")for Home Outside our Service Area Use"section are met."Base DME Items"means the following items: We do not cover most DME for home use outside our Service Area.However,if you live outside our Service • Glucose monitors for diabetes blood testing and their Area,we cover the following DME(subject to the Cost supplies(such as blood glucose monitor test strips, Share and all other coverage requirements that apply to lancets,and lancet devices) DME for home use inside our Service Area)when the • Bone stimulator item is dispensed at a Plan Facility: • Canes(standard curved handle or quad)and • Blood glucose monitors for diabetes blood testing and replacement supplies their supplies(such as blood glucose monitor test Cervical traction(over door) strips,lancets,and lancet devices)from a Plan • Pharmacy • Crutches(standard or forearm)and replacement . Canes(standard curved handle) supplies • Dry pressure pad for a mattress • Crutches(standard) • Nebulizers and their supplies for the treatment of • Infusion pumps(such as insulin pumps)and supplies pediatric asthma to operate the pump • 1V pole • Peak flow meters from a Plan Pharmacy • Nebulizer and supplies For the following Services, refer to these • Phototherapy blankets for treatment of jaundice in sections newborns • Dialysis equipment and supplies required for home hemodialysis and home peritoneal dialysis(refer to Your Cost Share.You pay the following for covered "Dialysis Care") Base DME Items: 20 percent Coinsurance. • Diabetes urine testing supplies and insulin- Other covered DME items administration devices other than insulin pumps(refer to"Outpatient Prescription Drugs, Supplies,and If all of the requirements described under"DME Supplements") coverage rules"in this"Durable Medical Equipment Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 31 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Durable medical equipment related to the terminal You pay the following for covered infertility Services: illness for Members who are receiving covered • Office visits: a$25 Copayment per visit hospice care(refer to"Hospice Care") • Most outpatient surgery and outpatient procedures • Insulin and any other drugs administered with an when provided in an outpatient or ambulatory surgery infusion pump(refer to"Outpatient Prescription center or in a hospital operating room,or provided in Drugs, Supplies,and Supplements") any setting where a licensed staff member monitors your vital signs as you regain sensation after DME for home use exclusions receiving drugs to reduce sensation or to minimize • Comfort,convenience,or luxury equipment or discomfort: a$25 Copayment per procedure features • Any other outpatient surgery that does not require a • Dental appliances licensed staff member to monitor your vital signs as • Items not intended for maintaining normal activities described above: a$25 Copayment per procedure of daily living,such as exercise equipment(including • Outpatient imaging: no charge devices intended to provide additional support for • Outpatient laboratory: no charge recreational or sports activities) • Outpatient administered drugs: no charge • Hygiene equipment • Hospital inpatient Services(including room and • Nonmedical items,such as sauna baths or elevators board,imaging,laboratory,and other diagnostic and • Modifications to your home or car,unless covered in treatment Services,and Plan Physician Services): a accord with Medicare guidelines $250 Copayment per admission • Devices for testing blood or other body substances (except diabetes glucose monitors and their supplies) Note:Administered drugs and products are medications and products that require administration or observation • Electronic monitors of the heart or lungs except infant by medical personnel.We cover these items when they apnea monitors are prescribed by a Plan Provider,in accord with our • Repair or replacement of equipment due to misuse drug formulary guidelines,and they are administered to you in a Plan Facility. Fertility Services For the following Services, refer to these sections "Fertility Services"means treatments and procedures to help you become pregnant. • Outpatient drugs,supplies,and supplements(refer to "Outpatient Prescription Drugs,Supplies,and Before starting or continuing a course of fertility Supplements") Services,you may be required to pay initial and • Diagnostic Services provided by Plan Providers who subsequent deposits toward your Cost Share for some or are not physicians,such as EKGs and EEGs(refer to all of the entire course of Services,along with any past- "Outpatient Imaging,Laboratory,and Other due fertility-related Cost Share.Any unused portion of Diagnostic and Treatment Services") your deposit will be returned to you.When a deposit is not required,you must pay the Cost Share for the Fertility Services exclusions procedure,along with any past-due fertility-related Cost • Services to reverse voluntary,surgically induced Share,before you can schedule a fertility procedure. infertility Diagnosis and treatment of infertility • Semen and eggs(and Services related to their For purposes of this"Diagnosis and treatment of procurement and storage) infertility"section,"infertility"means not being able to • Assisted reproductive technology Services,such as get pregnant or carry a pregnancy to a live birth after a ovum transplants,gamete intrafallopian transfer year or more of regular sexual relations without (GIFT),in vitro fertilization(IVF),and zygote contraception or having a medical or other demonstrated intrafallopian transfer(ZIFT) condition that is recognized by a Plan Physician as a cause of infertility.We cover the following: • Services for the diagnosis and treatment of infertility • Artificial insemination Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 32 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Health Education • Physician Specialist Visits to diagnose and treat hearing problems: a$25 Copayment per visit We cover a variety of health education counseling, programs,and materials that your personal Plan Hearing aids Physician or other Plan Providers provide during a visit We cover the following Services related to hearing aids: covered under another part of this EOC. • A$1,000 Allowance for each ear toward the purchase We also cover a variety of health education counseling, price of a hearing aid(including fitting,counseling, programs,and materials to help you take an active role in adjustment,cleaning,and inspection)every 36 protecting and improving your health,including months when prescribed by a Plan Physician or by a programs for tobacco cessation,stress management,and Plan Provider who is an audiologist.We will cover chronic conditions(such as diabetes and asthma).Kaiser hearing aids for both ears only if both aids are Permanente also offers health education counseling, required to provide significant improvement that is programs,and materials that are not covered,and you not obtainable with only one hearing aid.We will not may be required to pay a fee. provide the Allowance if we have provided an Allowance toward(or otherwise covered)a hearing aid within the previous 36 months.Also,the For more information about our health education Allowance can only be used at the initial point of sale. counseling,programs,and materials,please contact a If you do not use all of your Allowance at the initial Health Education Department or Member Services or go point of sale,you cannot use it later to our website at kp.oru. Note: Our Health Education Department offers a We select the provider or vendor that will furnish the comprehensive self-management workshop to help covered hearing aids.Coverage is limited to the types members learn the best choices in exercise,diet, and models of hearing aids furnished by the provider or monitoring,and medications to manage and control vendor. diabetes.Members may also choose to receive diabetes For the following Services, refer to these self-management training from a program outside our sections Plan that is recognized by the American Diabetes Association(ADA)and approved by Medicare.Also,our • Services related to the ear or hearing other than those Health Education Department offers education to teach described in this section,such as outpatient care to kidney care and help members make informed decisions treat an ear infection or outpatient prescription drugs, about their care. supplies,and supplements(refer to the applicable heading in this"Benefits and Your Cost Share" Your Cost Share.You pay the following for these section) covered Services: • Cochlear implants and osseointegrated hearing • Covered health education programs,which may devices(refer to"Prosthetic and Orthotic Devices") include programs provided online and counseling over the phone: no charge Hearing Services exclusions • Other covered individual counseling when the office • Internally implanted hearing aids visit is solely for health education: a$25 Copayment . Replacement parts and batteries,repair of hearing per visit aids,and replacement of lost or broken hearing aids • Health education provided during an outpatient (the manufacturer warranty may cover some of these) consultation or evaluation covered in another part of this EOC: no additional Cost Share beyond the Cost Share required in that other part of this EOC Home-Delivered Meals • Covered health education materials: no charge Immediately following discharge from a Plan Hospital or Skilled Nursing Facility as an inpatient,we cover up to three meals per day in a consecutive four-week period, Hearing Services once per calendar year as follows: We cover the following: • When you are discharged from a Plan Hospital or • Hearing exams with an audiologist to determine the Skilled Nursing Facility,the meal delivery vendor need for hearing correction: a$25 Copayment per will contact you to review your meal options and visit arrange meal delivery to your home in California.In most cases,the meals must be initiated within 30 days Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 33 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. of discharge.You can contact Member Services if • Durable medical equipment(refer to"Durable you have any questions about your meals coverage Medical Equipment("DME")for Home Use") • In addition to meals for general health,there are • Ostomy,urological,and specialized wound care menus to support specific conditions and diets supplies(refer to"Ostomy,Urological,and Specialized Wound Care Supplies") Your Cost Share.We cover home-delivered meals at . Outpatient drugs,supplies,and supplements(refer to no charge. "Outpatient Prescription Drugs,Supplies,and Home-delivered meals exclusions Supplements") We will not cover meals if more than 30 days have • Outpatient physical,occupational,and speech therapy passed since your discharge(except in limited visits(refer to"Outpatient Care") circumstances)or if you are discharged as follows: • Prosthetic and orthotic devices(refer to"Prosthetic • To another facility that provides meals(for example, and Orthotic Devices") inpatient rehabilitation) Home health care exclusions • From a Non-Plan Hospital or Skilled Nursing Facility,Hospital Observation,Outpatient Surgery,or • Care in the home if the home is not a safe and effective treatment setting Emergency Department • To a home outside of California Home Medical Care Not Covered by Home Health Care Medicare for Members Who Live in Certain Counties (Advanced Care at "Home health care"means Services provided in the Home home by nurses,medical social workers,home health aides,and physical,occupational,and speech therapists. We cover medical care in your home that is not We cover part-time or intermittent home health care in otherwise covered by Medicare when found medically accord with Medicare guidelines.Home health care appropriate by a physician based on your health status to services are covered up to the number of visits and provide you with an alternative to receiving acute care in length of time that are determined to be medically a hospital and post-acute care Services in the home to necessary under the Member's home health treatment support your recovery. Services in the home must be: plan and no more than the limits established under . Prescribed by a network hospitalist who has Medicare guidelines,only if all of the following are true: determined that based on your health status,treatment • You are substantially confined to your home plan,and home setting that you can be treated safely • Your condition requires the Services of a nurse, and effectively in the home physical therapist,or speech therapist or continued • Elected by you because you prefer to receive the care need for an occupational therapist(home health aide described in your treatment plan in your home Services are not covered unless you are also getting covered home health care from a nurse,physical Medically Home is our network provider and will therapist,occupational therapist,or speech therapist provide the following services and items in your home in that only a licensed provider can provide) accord with your treatment plan for as long as they are • A Plan Physician determines that it is feasible to prescribed by a network hospitalist: maintain effective supervision and control of your • Home visits by RNs,physical therapists,occupational care in your home and that the Services can be safely therapists,speech therapists,respiratory therapists, and effectively provided in your home nutritionist,home health aides,and other healthcare • The Services are provided inside our Service Area professionals in accord with the home care treatment plan and the provider's scope of practice and license Your Cost Share.We cover home health care Services • Communication devices to allow you to contact at no charge. Medically Home's command center 24 hours a day, 7 days a week.This includes needed communication For the following Services, refer to these technology to support reliable communication,and an sections PERS alert device to contact Medically Home's • Dialysis care(refer to"Dialysis Care") command center if you are unable to get to a phone Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 34 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • The following equipment necessary to ensure that you cure the terminal illness.You may change your decision are monitored appropriately in your home:blood to receive hospice care benefits at any time. pressure cuff/monitor,pulse oximeter,scale,and thermometer If you have Medicare Part A,you are eligible for the • Mobile imaging and tests such as X-rays,labs,and hospice benefit when your doctor and the hospice EKGs medical director have given you a terminal prognosis certifying that you're terminally ill and have six months • The following safety items: shower stools,raised or less to live if your illness runs its normal course.You toilet seats,grabbers,long handle shoehorn,and sock may receive care from any Medicare-certified hospice aid program.Our plan is obligated to help you find • Up to 21 meals per week while you are receiving Medicare-certified hospice programs in our plan's acute care in the home Service Area,including those the MA organization owns, controls,or has a financial interest in.Your hospice In addition,for Medicare-covered services and items doctor can be a Plan Provider or a Non—Plan Provider. listed below,the Cost-Sharing indicated elsewhere in this Covered Services include: EOC does not apply when the Services and items are • Drugs for symptom control and pain relief prescribed as part of your home treatment plan: • Short-term respite care • Durable medical equipment • Home care • Medical supplies • Ambulance transportation to and from network When you are admitted to a hospice you have the right to facilities when ambulance transport is Medically remain in your plan;if you chose to remain in your plan, Necessary you must continue to pay plan premiums. • Physician assistant and nurse practitioner house calls For hospice services and for services that are covered or office visits by Medicare Part A or B and are related to your • The following Services at a Plan Facility if the terminal prognosis: Original Medicare(rather than our Services are part of your home treatment plan: Plan)will pay your hospice provider for your hospice ♦ Network Emergency Department visits associated services and any Part A and Part B services related to with this benefit your terminal condition.While you are in the hospice ♦ Physical,speech,or occupational therapy office program,your hospice provider will bill Original visits Medicare for the services that Original Medicare pays ♦ X-rays,labs,ultrasounds,and EKGs for.You will be billed Original Medicare cost-sharing. For services that are covered by Medicare Part A or The cost-sharing indicated elsewhere in this EOC will Band are not related to your terminal prognosis: apply to all other Services and items that are not part of If you need nonemergency,non—urgently needed your home treatment plan(for example,DME unrelated services that are covered under Medicare Part A or B and to your home treatment plan)or are part of your home that are not related to your terminal condition,your cost treatment plan,but are not provided in your home except for these services depends on whether you use a Plan as listed above.Note:For prescription drug Cost-Sharing Provider and follow plan rules(such as if there is a information,refer to the"Outpatient Prescription Drugs, requirement to obtain prior authorization): Supplies,and Supplements"section. • If you obtain the covered services from a Plan Provider and follow plan rules for obtaining service, Hospice Care you only pay the Plan Cost Share amount Hospice care is a specialized form of interdisciplinary • If you obtain the covered services from a Non—Plan health care designed to provide palliative care and to Provider,you pay the cost sharing under Fee-for- alleviate the physical,emotional,and spiritual Service Medicare(Original Medicare) discomforts of a Member experiencing the last phases of life due to a terminal illness.It also provides support to For services that are covered by our Plan but are not the primary caregiver and the Member's family.A covered by Medicare Part A or B:We will continue to Member who chooses hospice care is choosing to receive cover Plan-covered Services that are not covered under palliative care for pain and other symptoms associated Part A or B whether or not they are related to your with the terminal illness,but not to receive care to try to terminal condition.You pay your Plan Cost Share amount for these Services. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 35 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. For drugs that may be covered by our plan's Part D • Physical,occupational,and speech therapy for benefit:If these drugs are unrelated to your terminal purposes of symptom control or to enable you to hospice condition,you pay cost-sharing.If they are maintain activities of daily living related to your terminal hospice condition,then you pay . Respiratory therapy Original Medicare cost-sharing.Drugs are never covered by both hospice and our plan at the same time.For more • Medical social services information,please see"What if you're in a Medicare- . Home health aide and homemaker services certified hospice"in the"Outpatient Prescription Drugs, Supplies,and Supplements"section. • Palliative drugs prescribed for pain control and symptom management of the terminal illness for up to Note: If you need non-hospice care(care that is not a 100-day supply in accord with our drug formulary related to your terminal prognosis),you should contact guidelines.You must obtain these drugs from a Plan us to arrange the services. Pharmacy.Certain drugs are limited to a maximum 30-day supply in any 30-day period(your Plan For more information about Original Medicare hospice Pharmacy can tell you if a drug you take is one of coverage,visit https://www.medicare.i!ov,and under these drugs) "Search Tools,"choose"Find a Medicare Publication"to • Durable medical equipment view or download the publication"Medicare Hospice . Respite care when necessary to relieve your Benefits."Or call 1-800-MEDICARE(1-800-633-4227) caregivers.Respite care is occasional short-term (TTY users call 1-877-486-2048),24 hours a day,seven inpatient Services limited to no more than five days a week. consecutive days at a time Special note if you do not have Medicare Part A • Counseling and bereavement services We cover the hospice Services listed below at no charge • Dietary counseling only if all of the following requirements are met: • You are not entitled to Medicare Part A We also cover the following hospice Services only during periods of crisis when they are Medically • A Plan Physician has diagnosed you with a terminal Necessary to achieve palliation or management of acute illness and determines that your life expectancy is 12 medical symptoms: months or less . Nursing care on a continuous basis for as much as 24 • The Services are provided inside our Service Area(or hours a day as necessary to maintain you at home inside California but within 15 miles or 30 minutes . Short-term inpatient Services required at a level that from our Service Area if you live outside our Service Area,and you have been a Senior Advantage Member cannot be provided at home continuously since before January 1, 1999,at the same home address) Mental Health Services • The Services are provided by a licensed hospice agency that is a Plan Provider We cover Services specified in this"Mental Health • A Plan Physician determines that the Services are Services"section only when the Services are for the diagnosis or treatment of Mental Disorders.A"Mental necessary for the palliation and management of your Disorder"is a mental health condition identified as a terminal illness and related conditions "mental disorder"in the Diagnostic and Statistical Manual of Mental Disorders,Fourth Edition, Text If all of the above requirements are met,we cover the Revision,as amended in the most recently issued edition, following hospice Services,if necessary for your hospice (`DSM')that results in clinically significant distress or care: impairment of mental,emotional,or behavioral • Plan Physician Services functioning.We do not cover services for conditions that • Skilled nursing care,including assessment, the DSM identifies as something other than a"mental evaluation,and case management of nursing needs, disorder. For example,the DSM identifies relational treatment for pain and symptom control,provision of problems as something other than a mental disorder, so emotional support to you and your family,and we do not cover services(such as couples counseling or instruction to caregivers family counseling)for relational problems. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 36 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. "Mental Disorders"include the following conditions: facility,and the Services are above the level of custodial • Severe Mental Illness of a person of any age care: • Serious Emotional Disturbance of a Child Under Age • Individual and group mental health evaluation and 18 treatment • Medical services In addition to the Services described in this Mental . Medication monitoring Health Services section,we also cover other Services that are Medically Necessary to treat Serious Emotional • Room and board Disturbance of a Child Under Age 18 or Severe Mental . Drugs prescribed by a Plan Provider as part of your Illness,if the Medical Group authorizes a written referral plan of care in the residential treatment facility in (as described in"Medical Group authorization procedure accord with our drug formulary guidelines if they are for certain referrals"under"Getting a Referral"in the administered to you in the facility by medical "How to Obtain Services"section). personnel(for discharge drugs prescribed when you are released from the residential treatment facility, Outpatient mental health Services refer to"Outpatient Prescription Drugs, Supplies,and We cover the following Services when provided by Plan Supplements"in this"Benefits and Your Cost Share" Physicians or other Plan Providers who are licensed section) health care professionals acting within the scope of their . Discharge planning license: • Individual and group mental health evaluation and Your Cost Share.We cover residential mental health treatment treatment Services at no charge. • Psychological testing when necessary to evaluate a Inpatient psychiatric hospitalization Mental Disorder • Outpatient Services for the purpose of monitoring We cover care for acute psychiatric conditions in a drug therapy Medicare-certified psychiatric hospital. Your Cost Share.We cover inpatient psychiatric Intensive psychiatric treatment programs hospital Services at a$250 Copayment per admission. We cover the following intensive psychiatric treatment programs at a Plan Facility,such as: For the following Services, refer to these • Partial hospitalization sections • Multidisciplinary treatment in an intensive outpatient • Outpatient drugs,supplies,and supplements(refer to program "Outpatient Prescription Drugs,Supplies,and • Psychiatric observation for an acute psychiatric crisis Supplements") • Outpatient laboratory(refer to"Outpatient Imaging, Your Cost Share.You pay the following for these Laboratory,and Other Diagnostic and Treatment covered Services: Services") • Individual mental health evaluation and treatment: a • Telehealth Visits(refer to"Telehealth Visits") $25 Copayment per visit • Group mental health treatment: a$12 Copayment Opioid Treatment Program Services per visit • Partial hospitalization: no charge Members with opioid use disorder(OUD)can receive coverage of Services to treat OUD through an Opioid • Other intensive psychiatric treatment programs: Treatment Program(OTP)which includes the following no charge Services: Residential treatment • U.S.Food and Drug Administration(FDA)approved Inside our Service Area,we cover the following Services opioid agonist and antagonist medication-assisted when the Services are provided in a licensed residential treatment(MAT)medications and the dispensing and treatment facility that provides 24-hour individualized administration of MAT medications(if applicable) mental health treatment,the Services are generally and • Substance use counseling customarily provided by a mental health residential . Individual and group therapy treatment program in a licensed residential treatment Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 37 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Toxicology testing • Nuclear medicine: no charge • Intake activities • Routine preventive retinal photography screenings: • Periodic assessments no charge • Medicare Part B clinically administered drugs • Routine laboratory tests to monitor the effectiveness of dialysis: no charge Your Cost Share:You pay the following for these • Hemoglobin(Alc)testing for diabetes,Low-Density covered Services: no charge. Lipoprotein(LDL)testing for heart disease, International Normalized Ratio(INR)for persons with liver disease or certain blood disorders,and Ostomy, Urological, and Specialized glucose quantitative blood tests not covered at$0 Wound Care Supplies under Original Medicare: no charge We cover ostomy,urological,and specialized wound • All other laboratory tests(including tests for specific genetic disorders for which genetic counseling is care supplies if the following requirements are met: available): no charge • A Plan Physician has prescribed ostomy,urological, • Diagnostic Services provided by Plan Providers who and specialized wound care supplies for your medical condition are not physicians(such as EKGs and EEGs): no charge • The item has been approved for you through the Plan's prior authorization process,as described in • Radiation therapy: no charge "Medical Group authorization procedure for certain • Ultraviolet light therapy treatments,including referrals"under"Getting a Referral"in the"How to ultraviolet light therapy equipment for home use,if Obtain Services"section (1)the equipment has been approved for you through • The Services are provided inside our Service Area the Plan's prior authorization process,as described in "Medical Group authorization procedure for certain referrals"under"Getting a Referral"in the"How to Coverage is limited to the standard item of equipment Obtain Services" section and(2)the equipment is that adequately meets your medical needs.We decide provided inside your Home Region Service Area. whether to rent or purchase the equipment,and we select (Coverage for ultraviolet light therapy equipment is the vendor. limited to the standard item of equipment that adequately meets your medical needs.We decide Your Cost Share:You pay the following for covered whether to rent or purchase the equipment,and we ostomy,urological,and specialized wound care supplies: select the vendor.You must return the equipment to 20 percent Coinsurance. us or pay us the fair market price of the equipment Ostomy, urological, and specialized wound care when we are no longer covering it.): no charge supplies exclusions For the following Services, refer to these • Comfort,convenience,or luxury equipment or sections features • Outpatient imaging and laboratory Services that are Preventive Services,such as routine mammograms, Outpatient Imaging, Laboratory, and bone density scans,and laboratory screening tests Other Diagnostic and Treatment (refer to"Preventive Services") Services • Outpatient procedures that include imaging and diagnostic Services(refer to"Outpatient surgeries and We cover the following Services at the Cost Share procedures") indicated only when part of care covered under other • Services related to diagnosis and treatment of headings in this"Benefits and Your Cost Share"section. infertility,artificial insemination,or assisted The Services must be prescribed by a Plan Provider: reproductive technology("ART")Services(refer to • Complex imaging(other than preventive)such as CT "Fertility Services") scans,MRIs,and PET scans: no charge • Basic imaging Services,such as diagnostic and therapeutic X-rays,mammograms,and ultrasounds: no charge Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 38 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Outpatient Imaging, Laboratory, and Other this"Outpatient Prescription Drugs, Supplies,and Diagnostic and Treatment Services exclusions Supplements"section • Ultraviolet light therapy comfort,convenience,or • Your prescriber must either accept Medicare or file luxury equipment or features documentation with the Centers for Medicare& • Repair or replacement of ultraviolet light therapy Medicaid Services showing that he or she is qualified equipment due to misuse to write prescriptions,or your Part D claim will be denied.You should ask your prescribers the next time you call or visit if they meet this condition. If not, Outpatient Prescription Drugs, Supplies, please be aware it takes time for your prescriber to and Supplements submit the necessary paperwork to be processed We cover outpatient drugs,supplies,and supplements In addition to our plan's Part D and medical benefits specified in this"Outpatient Prescription Drugs, coverage,if you have Medicare Part A,your drugs may Supplies,and Supplements"section when prescribed as be covered by Original Medicare if you are in Medicare follows: hospice.For more information,please see"What • Items prescribed by providers,within the scope of if you're in a Medicare-certified hospice"in this "Outpatient Prescription Drugs,Supplies,and their licensure and practice,and in accord with our Supplements"section. drug formulary guidelines • Items prescribed by the following Non—Plan Obtaining refills by mail Providers unless a Plan Physician determines that the Most refills are available through our mail-order service, item is not Medically Necessary or the drug is for a but there are some restrictions.A Plan Pharmacy,our sexual dysfunction disorder: Kaiser Permanente Pharmacy Directory,or our ♦ dentists if the drug is for dental care website at ko.org/refill can give you more information ♦ Non—Plan Physicians if the Medical Group about obtaining refills through our mail-order service. authorizes a written referral to the Non—Plan Please check with your local Plan Pharmacy if you have Physician(in accord with"Medical Group a question about whether your prescription can be authorization procedure for certain referrals" mailed.Items available through our mail-order service under"Getting a Referral"in the"How to Obtain are subject to change at any time without notice. Services"section)and the drug,supply,or supplement is covered as part of that referral Certain items from Non—Plan Pharmacies ♦ Non—Plan Physicians if the prescription was Generally,we cover drugs filled at a Non—Plan obtained as part of covered Emergency Services, Pharmacy only when you are not able to use a Plan Post-Stabilization Care,or Out-of-Area Urgent Pharmacy.If you cannot use a Plan Pharmacy,here are Care described in the"Emergency Services and the circumstances when we would cover prescriptions Urgent Care"section(if you fill the prescription at filled at a Non—Plan Pharmacy. a Plan Pharmacy,you may have to pay Charges • The drug is related to covered Emergency Services, for the item and file a claim for reimbursement as Post-Stabilization Care,or Out-of-Area Urgent Care described in the"Requests for Payment"section) described in the"Emergency Services and Urgent • The item meets the requirements of our applicable Care"section.Note:Prescription drugs prescribed drug formulary guidelines(our Medicare Part D and provided outside of the United States and its formulary or our formulary applicable to non—Part D territories as part of covered Emergency Services or Urgent Care are covered up to a 30-day supply in a items) 30-day period.These drugs are covered under your • You obtain the item at a Plan Pharmacy or through medical benefits,and are not covered under Medicare our mail-order service,except as otherwise described Part D.Therefore,payments for these drugs do not under"Certain items from Non—Plan Pharmacies"in count toward reaching the Part D Catastrophic this"Outpatient Prescription Drugs, Supplies,and Coverage Stage Supplements"section.Refer to our Kaiser • For Medicare Part D covered drugs,the following are Permanente Pharmacy Directory for the locations additional situations when a Part D drug may be of Plan Pharmacies in your area.Plan Pharmacies can covered: change without notice and if a pharmacy is no longer a Plan Pharmacy,you must obtain covered items from ♦ if you are traveling outside your Home Region another Plan Pharmacy,except as otherwise described Service Area,but in the United States and its territories,and you become ill or run out of your under"Certain items from Non—Plan Pharmacies"in Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 39 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. covered Part D prescription drugs.We will cover your drugs.To prevent any delays at a pharmacy when prescriptions that are filled at a Non—Plan your Medicare hospice benefit ends,you should bring Pharmacy according to our Medicare Part D documentation to the pharmacy to verify your revocation formulary guidelines or discharge.For more information about Medicare ♦ if you are unable to obtain a covered drug in a Part D coverage and what you pay,please see"Medicare timely manner inside your Home Region Service Part D drugs"in this"Outpatient Prescription Drugs, Area because there is no Plan Pharmacy within a Supplies,and Supplements"section. reasonable driving distance that provides 24-hour service.We may not cover your prescription if a Medicare Part D drugs reasonable person could have purchased the drug Medicare Part D covers most outpatient prescription at a Plan Pharmacy during normal business hours drugs if they are sold in the United States and approved ♦ if you are trying to fill a prescription for a drug for sale by the federal Food and Drug Administration. that is not regularly stocked at an accessible Plan Our Part D formulary includes drugs that can be covered Pharmacy or available through our mail-order under Medicare Part D according to Medicare pharmacy(including high-cost drugs) requirements.Refer to our"Medicare Part D drug formulary(2024 Comprehensive Formulary)"in this ♦ if you are not able to get your prescriptions from a °Outpatient Prescription Drugs,Supplies,and Plan Pharmacy during a disaster Supplements"section for more information about this In these situations,please check first with Member formulary. Services to see if there is a Plan Pharmacy nearby. Cost Share for Medicare Part D drugs.Unless you You may be required to pay the difference between what reach the Catastrophic Coverage Stage in a calendar you pay for the drug at the Non—Plan Pharmacy and the year,you will pay the following Cost Share for covered cost that we would cover at Plan Pharmacy. Medicare Part D drugs: Payment and reimbursement.If you go to a Non—Plan • Generic drugs: Pharmacy for the reasons listed,you may have to pay the ♦ a$10 Copayment for up to a 30-day supply,a full cost(rather than paying just your Copayment or $20 Copayment for a 31-to 60-day supply,or a Coinsurance)when you fill your prescription.You may $30 Copayment for a 61-to 100-day supply at a ask us to reimburse you for our share of the cost by Plan Pharmacy submitting a request for reimbursement as described in ♦ a$10 Copayment for up to a 30-day supply or a the"Requests for Payment"section.If we pay for the $20 Copayment for a 31-to 100-day supply drugs you obtained from a Non—Plan Pharmacy,you may through our mail-order service still pay more for your drugs than what you would have . Brand-name and specialty drugs: paid if you had gone to a Plan Pharmacy because you may be responsible for paying the difference between ♦ a$25 Copayment for up to a 30-day supply,a Plan Pharmacy Charges and the price that the Non Plan $50 Copayment for a 31-to 60-day supply,or a Pharmacy charged you. $75 Copayment for a 61-to 100-day supply at a Plan Pharmacy What if you're in a Medicare-certified hospice ♦ a$25 Copayment for up to a 30-day supply or a If you have Medicare Part A,drugs are never covered by $50 Copayment for a 31-to 100-day supply both hospice and our plan at the same time.If you are through our mail-order service enrolled in Medicare hospice and require an anti-nausea, • Injectable Part D vaccines: no charge laxative,pain medication,or antianxiety drug that is not covered by your hospice because it is unrelated to your • Emergency contraceptive pills: no charge terminal illness and related conditions,our plan must . The following insulin-administration devices at a receive notification from either the prescriber or your $10 Copayment for up to a 30-day supply:needles, hospice provider that the drug is unrelated before our syringes,alcohol swabs,and gauze plan can cover the drug.To prevent delays in receiving any unrelated drugs that should be covered by our plan, Catastrophic Coverage Stage.All Medicare you can ask your hospice provider or prescriber to make prescription drug plans include catastrophic coverage for sure we have the notification that the drug is unrelated people with high drug costs.In order to qualify for before you ask a pharmacy to fill your prescription. catastrophic coverage,you must spend$8,000 out-of- pocket during 2024.When the total amount you have In the event you either revoke your hospice election or paid for your Cost Share reaches$8,000,you pay are discharged from hospice,our plan should cover all Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 40 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. nothing for covered Part D drugs the remainder of the • Payments for your drugs that are made by certain calendar year. insurance plans and government-funded health programs such as TRICARE and Veterans Affairs Note:Each year,effective on January 1,the Centers for . Payments for your drugs made by a third-party with a Medicare&Medicaid Services may change coverage legal obligation to pay for prescription costs(for thresholds that apply for the calendar year.We will example,Workers' Compensation) notify you in advance of any change to your coverage. Reminder: If any other organization such as the ones These payments are included in your out-of-pocket described above pays part or all of your out-of-pocket costs.Your out-of-pocket costs include the payments costs for Part D drugs,you are required to tell our Plan. listed below(as long as they are for Part D covered drugs Call Member Services to let us know(phone numbers are and you followed the rules for drug coverage that are on the cover of this EOC). explained in this"Outpatient Prescription Drugs, Supplies,and Supplements"section): Keeping track of Medicare Part D drugs.The Part D • The amount you pay for drugs when you are in the Explanation of Benefits is a document you will get for Initial Coverage Stage each month you use your Part D prescription drug • Any payments you made during this calendar year as coverage.The Part D Explanation of Benefits will tell a member of a different Medicare prescription drug you the total amount you,or others on your behalf,have plan before you joined our Plan spent on your prescription drugs and the total amount we have paid for your prescription drugs.A Part D It matters who pays: Explanation of Benefits is also available upon request from Member Services. • If you make these payments yourself,they are included in your out-of-pocket costs Medicare's "Extra Help" Program • These payments are also included in your out-of- Medicare provides"Extra Help"to pay prescription drug pocket costs if they are made on your behalf by costs for people who have limited income and resources. certain other individuals or organizations.This Resources include your savings and stocks,but not your includes payments for your drugs made by a friend or home or car.If you qualify,you get help paying for any relative,by most charities,by AIDS drug assistance Medicare drug plan's monthly premium,and prescription programs,or by the Indian Health Service.Payments Copayments. This"Extra Help"also counts toward your made by Medicare's Extra Help Program are also out-of-pocket costs. included People with limited income and resources may qualify These payments are not included in your out-of- for"Extra Help."Some people automatically qualify for pocket costs.When you add up your out-of-pocket costs, "Extra Help"and don't need to apply.Medicare mails a you are not allowed to include any of these types of letter to people who automatically qualify for"Extra payments for prescription drugs: Help." • The amount you contribute,if any,toward your group's Premium You may be able to get"Extra Help"to pay for your prescription drug premiums and costs. To see if you • Drugs you buy outside the United States and its qualify for getting"Extra Help,"call: territories • 1-800-MEDICARE(1-800-633-4227)(TTY users • Drugs that are not covered by our Plan call 1-877-486-2048),24 hours a day,seven days a • Drugs you get at an out-of-network pharmacy that do week; not meet our Plan's requirements for out-of-network . The Social Security Office at 1-800-772-1213(TTY coverage users call 1-800-325-0778), 8 a.m.to 7 p.m.,Monday • Non-Part D drugs,including prescription drugs through Friday(applications);or covered by Part A or Part B and other drugs excluded . Your state Medicaid office(applications). See the from coverage by Medicare "Important Phone Numbers and Resources"section • Payments for your drugs that are made or funded by for contact information group health plans,including employer health plans If you believe you have qualified for"Extra Help"and you believe that you are paying an incorrect Cost Share amount when you get your prescription at a Plan Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 41 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Pharmacy,our plan has established a process that allows Medicare Part D drug formulary (2024 you either to request assistance in obtaining evidence of Comprehensive Formulary) your proper Cost Share level,or,if you already have the Our Medicare Part D formulary is a list of covered drugs evidence,to provide this evidence to us.If you aren't selected by our plan in consultation with a team of health sure what evidence to provide us,please contact a Plan care providers that represents the drug therapies believed Pharmacy or Member Services.The evidence is often a to be a necessary part of a quality treatment program. letter from either your state Medicaid or Social Security Our formulary must meet requirements set by Medicare office that confirms you are qualified for Extra Help. The and is approved by Medicare.Our formulary includes evidence may also be state-issued documentation with drugs that can be covered under Medicare Part D your eligibility information associated with Home and according to Medicare requirements.For a complete, Community-Based Services. current listing of the Medicare Part D prescription drugs we cover,please visit our website at kp.or2/seniorrx or You or your appointed representative may need to call Member Services. provide the evidence to a Plan Pharmacy when obtaining covered Part D prescriptions so that we may charge you The presence of a drug on our formulary does not the appropriate Cost Share amount until the Centers for necessarily mean that your Plan Physician will prescribe Medicare&Medicaid Services updates its records to it for a particular medical condition. Our drug formulary reflect your current status. Once the Centers for guidelines allow you to obtain Medicare Part D Medicare&Medicaid Services updates its records,you prescription drugs if a Plan Physician determines that will no longer need to present the evidence to the Plan they are Medically Necessary for your condition.If you Pharmacy.Please provide your evidence in one of the disagree with your Plan Physician's determination,refer following ways so we can forward it to the Centers for to"Your Part D Prescription Drugs:How to Ask for a Medicare&Medicaid Services for updating: Coverage Decision or Make an Appeal"in the • Write to Kaiser Permanente at: "Coverage Decisions,Appeals,and Complaints"section. California Service Center Attn:Best Available Evidence Continuity drugs.If this EOC is amended to exclude a P.O.Box 232407 drug that we have been covering and providing to you San Diego,CA 92193-2407 under this EOC,we will continue to provide the drug if a prescription is required by law and a Plan Physician • Fax it to 1-877-528-8579 continues to prescribe the drug for the same condition • Take it to a Plan Pharmacy or your local Member and for a use approved by the Federal Food and Drug Services office at a Plan Facility Administration. When we receive the evidence showing your Cost Share About specialty drugs. Specialty drugs are high-cost level,we will update our system so that you can pay the drugs that are on our specialty drug list.If your Plan correct Cost Share when you get your next prescription Physician prescribes more than a 30-day supply for an at our Plan Pharmacy.If you overpay your Cost Share, outpatient drug,you may be able to obtain more than a we will reimburse you.Either we will forward a check to 30-day supply at one time,up to the day supply limit for you in the amount of your overpayment or we will offset that drug.However,most specialty drugs are limited to a future Cost Share.If our Plan Pharmacy hasn't collected 30-day supply in any 30-day period.Your Plan a Cost Share from you and is carrying your Cost Share as Pharmacy can tell you if a drug you take is one of these a debt owed by you,we may make the payment directly drugs. to our Plan Pharmacy.If a state paid on your behalf,we may make payment directly to the state.Please call Preferred generic and generic drugs listed in the Member Services if you have questions. formulary will be subject to the generic drug Copayment or Coinsurance listed under"Copayment and If you qualify for"Extra Help,"we will send you an Coinsurance for Medicare Part D drugs"in this Evidence of Coverage Rider for People Who Get "Outpatient Prescription Drugs,Supplies,and Extra Help Paying for Prescription Drugs(also known Supplements"section.Preferred and nonpreferred brand- as the Low Income Subsidy Rider or the LIS Rider),that name drugs and specialty tier drugs listed in the explains your costs as a Member of our plan.If the formulary will be subject to the brand-name Copayment amount of your"Extra Help"changes during the year, or Coinsurance listed under"Copayment and we will also mail you an updated Evidence of Coverage Coinsurance for Medicare Part D drugs"in this Rider for People Who Get Extra Help Paying for "Outpatient Prescription Drugs,Supplies,and Prescription Drugs. Supplements"section.Please note that sometimes a drug Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 42 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. may appear more than once on our 2024 Decisions,Complaints,and Appeals"section for Comprehensive Formulary.This is because different more information on how to request an exception restrictions or cost-sharing may apply based on factors such as the strength,amount,or form of the drug Transition policy.If you recently joined our plan,you prescribed by your health care provider(for instance, 10 may be able to get a temporary supply of a Medicare mg versus 100 mg;one per day versus two per day; Part D drug you were previously taking that may not be tablet versus liquid). on our formulary or has other restrictions,during the first 90 days of your membership.Current members may also You can get updated information about the drugs our be affected by changes in our formulary from one year to plan covers by visiting our website at k%orE/seniorrx. the next.Members should talk to their Plan Physicians to You may also call Member Services to find out if your decide if they should switch to a different drug that we drug is on the formulary or to request an updated copy of cover or request a Part D formulary exception in order to our formulary. get coverage for the drug.Refer to our formulary or our website,ku.org/seniorrx,for more information about We may make certain changes to our formulary during our Part D transition coverage. the year. Changes in the formulary may affect which drugs are covered and how much you will pay when Medicare Part D exclusions(non—Part D drugs).By filling your prescription.The kinds of formulary changes law,certain types of drugs are not covered by Medicare we may make include: Part D.If a drug is not covered by Medicare Part D,any • Adding or removing drugs from the formulary amounts you pay for that drug will not count toward reaching the Catastrophic Coverage Stage.A Medicare • Adding prior authorizations or other restrictions on a Prescription Drug Plan can't cover a drug under drug Medicare Part D in the following situations: If we remove drugs from the formulary or add prior • The drug would be covered under Medicare Part A or authorizations or restrictions on a drug,and you are Part B taking the drug affected by the change,you will be • Drug purchased outside the United States and its permitted to continue receiving that drug at the same territories level of Cost Share for the remainder of the calendar . Off-label uses(meaning for uses other than those year.However,if a brand-name drug is replaced with a indicated on a drug's label as approved by the federal new generic drug,or our formulary is changed as a result Food and Drug Administration)of a prescription of new information on a drug's safety or effectiveness, drug,except in cases where the use is supported by you may be affected by this change.We will notify you certain reference books.Congress specifically listed of the change at least 30 days before the date that the the reference books that list whether the off-label use change becomes effective or provide you with at least a would be permitted. (These reference books are the month's supply at the Plan Pharmacy.This will give you American Hospital Formulary Service Drug an opportunity to work with your physician to switch to a Information and the DRUGDEX Information different drug that we cover or request an exception. (If a System.)If the use is not supported by one of these drug is removed from our formulary because the drug references,known as compendia,then the drug is has been recalled,we will not give 30 days'notice before considered a non—Part D drug and cannot be covered removing the drug from the formulary.Instead,we will under Medicare Part D coverage remove the drug immediately and notify members taking the drug about the change as soon as possible.) In addition,by law,certain types of drugs or categories of drugs are not covered under Medicare Part D.These If your drug isn't listed on your copy of our formulary, drugs include: you should first check the formulary on our website, which we update when there is a change.In addition,you • Nonprescription drugs(also called over-the-counter may call Member Services to be sure it isn't covered. drugs) If Member Services confirms that we don't cover your • Drugs when used to promote fertility drug,you have two options: . Drugs when used for the relief of cough or cold • You may ask your Plan Physician if you can switch to symptoms another drug that is covered by us • Drugs when used for cosmetic purposes or to promote • You or your Plan Physician may ask us to make an hair growth exception(a type of coverage determination)to cover . Prescription vitamins and mineral products,except your Medicare Part D drug. See the"Coverage prenatal vitamins and fluoride preparations Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 43 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Drugs when used for the treatment of sexual or • Clotting factors you give yourself by injection if you erectile dysfunction have hemophilia • Drugs when used for treatment of anorexia,weight • Immunosuppressive drugs,if Medicare paid for the loss,or weight gain transplant(or a group plan was required to pay before • Outpatient drugs for which the manufacturer seeks to Medicare paid for it) require that associated tests or monitoring services be • Insulin furnished through an item of durable medical purchased exclusively from the manufacturer as a equipment(such as a Medically Necessary insulin condition of sale pump) • Injectable osteoporosis drugs,if you are homebound, Note: In addition to the coverage provided under this have a bone fracture that a doctor certifies was related Medicare Part D plan,you also have coverage for non— to post-menopausal osteoporosis,and cannot self- Part D drugs described under"Home infusion therapy," administer the drug "Outpatient drugs covered by Medicare Part B,""Certain intravenous drugs,supplies,and supplements,"and • Antigens "Outpatient drugs,supplies,and supplements not • Certain oral anticancer drugs and antinausea drugs covered by Medicare"in this"Outpatient Prescription • Certain drugs for home dialysis,including heparin, Drugs, Supplies,and Supplements"section.If a drug is not covered under Medicare Part D,refer to those the antidote for heparin when Medically Necessary, headings for information about your non—Part D drug topical anesthetics,and erythropoiesis-stimulating coverage. agents(such as Epogen®,Epoetin Alfa,Aranesp®,or Darbepoetin Alfa) Other prescription drug coverage.If you have • Intravenous Immune Globulin for the home treatment additional health care or drug coverage from another of primary immune deficiency diseases plan,you must provide that information to our plan. The information you provide helps us calculate how much Your Cost Share for Medicare Part B drugs.You pay you and others have paid for your prescription drugs.In the following for Medicare Part B drugs: addition,if you lose or gain additional health care or . Generic drugs: prescription drug coverage,please call Member Services to update your membership records. ♦ a$10 Copayment for up to a 30-day supply,a $20 Copayment for a 31-to 60-day supply,or a Home infusion therapy $30 Copayment for a 61-to 100-day supply at a We cover home infusion supplies and drugs at no charge Plan Pharmacy if all of the following are true: ♦ a$10 Copayment for up to a 30-day supply or a $20 Copayment for a 31-to 100-day supply • Your prescription drug is on our Medicare Part D through our mail-order service formulary • Brand-name drugs,specialty drugs,and compounded • We approved your prescription drug for home products: infusion therapy ♦ a$25 Copayment for up to a 30-day supply,a • Your prescription is written by a network provider $50 Copayment for a 31-to 60-day supply,or a and filled at a network home-infusion pharmacy $75 Copayment for a 61-to 100-day supply at a Plan Pharmacy Outpatient drugs covered by Medicare Part B ♦ a$25 Copayment for up to a 30-day supply or a In addition to Medicare Part D drugs,we also cover the $50 Copayment for a 31-to 100-day supply limited number of outpatient prescription drugs that are through our mail-order service covered by Medicare Part B.The following are the types of drugs that Medicare Part B covers: Certain intravenous drugs, supplies, and • Drugs that usually aren't self-administered by the supplements patient and are injected or infused while you are We cover certain self-administered intravenous drugs, getting physician,hospital outpatient,or ambulatory fluids,additives,and nutrients that require specific types surgical center services of parenteral-infusion(such as an intravenous or • Drugs you take using durable medical equipment intraspinal-infusion)at no charge for up to a 30-day (such as nebulizers)that were prescribed by a Plan supply.In addition,we cover the supplies and equipment Physician required for the administration of these drugs at no charge. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 44 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Outpatient drugs, supplies, and supplements phenylketonuria)and elemental dietary enteral not covered by Medicare formula when used as a primary therapy for regional If a drug,supply,or supplement is not covered by enteritis: no charge for up to a 30-day supply Medicare Part B or D,we cover the following additional • Diabetes urine-testing supplies:no charge for up to a items in accord with our non—Part D drug formulary: 100-day supply • Drugs for which a prescription is required by law that • Tobacco cessation drugs: no charge.For over-the- are not covered by Medicare Part B or D.We also counter medications,we cover up to two 100-day cover certain drugs that do not require a prescription supplies per calendar year by law if they are listed on our drug formulary applicable to non—Part D items Note:If Charges for the drug,supply,or supplement are • Diaphragms,cervical caps,contraceptive rings,and less than the Copayment,you will pay the lesser amount. contraceptive patches • Disposable needles and syringes needed for injecting Non—Part D drug formulary.The non—Part D drug covered drugs,pen delivery devices,and visual aids formulary includes a list of drugs that our Pharmacy and required to ensure proper dosage(except eyewear), Therapeutics Committee has approved for our Members. that are not covered by Medicare Part B or D Our Pharmacy and Therapeutics Committee,which is primarily composed of Plan Physicians,selects drugs for • Inhaler spacers needed to inhale covered drugs the drug formulary based on a number of factors, • Ketone test strips and sugar or acetone test tablets or including safety and effectiveness as determined from a tapes for diabetes urine testing review of medical literature.The Pharmacy and Therapeutics Committee meets at least quarterly to • FDA-approved medications for tobacco cessation, consider additions and deletions based on new including over-the-counter medications when information or drugs that become available.To find out prescribed by a Plan Physician which drugs are on the formulary for your plan,please refer to the California Commercial HMO formulary on Your Cost Share for other outpatient drugs,supplies, our website at kn.orE/formulary.The formulary also and supplements not covered by Medicare.Your Cost discloses requirements or limitations that apply to Share for these items is as follows: specific drugs,such as whether there is a limit on the • Generic items(that are not described elsewhere in this amount of the drug that can be dispensed and whether EOC)at a Plan Pharmacy: a$10 Copayment for up the drug must be obtained at certain specialty to a 30-day supply,a$20 Copayment for a 31-to pharmacies.If you would like to request a copy of this 60-day supply,or a$30 Copayment for a 61-to drug formulary,please call Member Services.Note:The 100-day supply presence of a drug on the drug formulary does not • Generic items(that are not described elsewhere in this necessarily mean that it will be prescribed for a particular EOC)through our mail-order service: a medical condition. $10 Copayment for up to a 30-day supply or a $20 Copayment fora 31-to 100-day supply Drug formulary guidelines allow you to obtain nonformulary prescription drugs(those not listed on our • Brand-name items,specialty drugs,and compounded drug formulary for your condition)if they would products(that are not described elsewhere in this otherwise be covered and a Plan Physician determines EOC)at a Plan Pharmacy: a$25 Copayment for up that they are Medically Necessary.If you disagree with to a 30-day supply,a$50 Copayment for a 31-to your Plan Physician's determination that a nonformulary 60-day supply,or a$75 Copayment for a 61-to prescription drug is not Medically Necessary,you may 100-day supply file an appeal as described in the"Coverage Decisions, • Brand-name items,specialty drugs,and compounded Appeals,and Complaints"section.Also,our non—Part D products(that are not described elsewhere in this formulary guidelines may require you to participate in a EOC)through our mail-order service: a behavioral intervention program approved by the $25 Copayment for up to a 30-day supply or a Medical Group for specific conditions and you may be $50 Copayment for a 31-to 100-day supply required to pay for the program. • Drugs prescribed for the treatment of sexual dysfunction disorders:25 percent Coinsurance for About specialty drugs. Specialty drugs are high-cost up to a 100-day supply drugs that are on our specialty drug list.If your Plan Physician prescribes more than a 30-day supply for an • Amino acid—modified products used to treat outpatient drug,you may be able to obtain more than a congenital errors of amino acid metabolism(such as 30-day supply at one time,up to the day supply limit for Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 45 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. that drug.However,most specialty drugs are limited to a opioid or benzodiazepine medications,we may limit how 30-day supply in any 30-day period.Your Plan you can get those medications. The limitations may be: Pharmacy can tell you if a drug you take is one of these • Requiring you to get all your prescriptions for opioid drugs. or benzodiazepine medications from one pharmacy. Manufacturer coupon program.For outpatient • Requiring you to get all your prescriptions for opioid prescription drugs or items that are covered under this or benzodiazepine medications from one doctor. "Outpatient drugs,supplies,and supplements not covered • Limiting the amount of opioid or benzodiazepine by Medicare" section and obtained at a Plan Pharmacy, medications we will cover for you. you may be able to use approved manufacturer coupons as payment for the Cost Share that you owe,as allowed If we decide that one or more of these limitations should under Health Plan's coupon program.You will owe any apply to you,we will send you a letter in advance.The additional amount if the coupon does not cover the entire letter will have information explaining the terms of the amount of your Cost Share for your prescription. Certain limitations we think should apply to you.You will also health plan coverages are not eligible for coupons.You have an opportunity to tell us which doctors or can get more information regarding the Kaiser pharmacies you prefer to use.If you think we made a Permanente coupon program rules and limitations at mistake or you disagree with our determination that you kp.org/rxcoupons. are at-risk for prescription drug abuse or the limitation, you and your prescriber have the right to ask us for an Drug utilization review appeal. See the"Coverage Decisions,Appeals,and We conduct drug utilization reviews to make sure that Complaints"section for information about how to ask for you are getting safe and appropriate care.These reviews an appeal. are especially important if you have more than one doctor who prescribes your medications.We conduct The DMP may not apply to you if you have certain drug utilization reviews each time you fill a prescription medical conditions,such as cancer,you are receiving and on a regular basis by reviewing our records.During hospice,palliative,or end-of-life care,or you live in a these reviews,we look for medication problems such as: long-term care facility. • Possible medication errors Medication therapy management program • Duplicate drugs that are unnecessary because you are We offer a medication therapy management program at taking another drug to treat the same medical no additional cost to Members who have multiple condition medical conditions,who are taking many prescription • Drugs that are inappropriate because of your age or drugs,and who have high drug costs.This program was gender developed for us by a team of pharmacists and doctors. We use this medication therapy management program to • Possible harmful interactions between drugs you are help us provide better care for our members.For taking example,this program helps us make sure that you are • Drug allergies using appropriate drugs to treat your medical conditions • Drug dosage errors and help us identify possible medication errors. • Unsafe amounts of opioid pain medications If you are selected to join a medication therapy management program,we will send you information If we identify a medication problem during our drug about the specific program,including information about utilization review,we will work with your doctor to how to access the program. correct the problem. ID card at Plan Pharmacies Drug management program You must present your Kaiser Permanente ID card when We have a program that can help make sure our obtaining covered items from Plan Pharmacies,including members safely use their prescription opioid those that are not owned and operated by Kaiser medications,or other medications that are frequently Permanente.If you do not have your ID card,the Plan abused.This program is called a Drug Management Pharmacy may require you to pay Charges for your Program(DMP).If you use opioid medications that you covered items,and you will have to file a claim for get from several doctors or pharmacies,we may talk to reimbursement as described in the"Requests for your doctors to make sure your use is appropriate and Payment"section. Medically Necessary.Working with your doctors,if we decide you are at risk for misusing or abusing your Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 46 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Notes: Utilization management.For certain items,we have • If Charges for a covered item are less than the additional coverage requirements and limits that help Copayment,you will pay the lesser amount promote effective drug use and help us control drug plan costs.Examples of these utilization management tools • Durable medical equipment used to administer drugs, arc: such as diabetes insulin pumps(and their supplies) . Quantity limits: The Plan Pharmacy may reduce the and diabetes blood-testing equipment(and their supplies)are not covered under this"Outpatient day supply dispensed at the Cost Share specified in Prescription Drugs,Supplies,and Supplements" this"Outpatient Drugs, Supplies,and Supplements" section(instead,refer to"Durable Medical Equipment section to a 30-day supply or less in any 30-day ("DME")for Home Use"in this"Benefits and Your period for specific drugs.Your Plan Pharmacy can Cost Share"section) tell you if a drug you take is one of these drugs.In addition,we cover episodic drugs prescribed for the • Except for vaccines covered by Medicare Part D, treatment of sexual dysfunction up to a maximum of drugs administered to you in a Plan Medical Office or eight doses in any 30-day period,up to 16 doses in during home visits are not covered under this any 60-day period,or up to 27 doses in any 100-day "Outpatient Prescription Drugs,Supplies,and period.Also,when there is a shortage of a drug in the Supplements"section(instead,refer to"Outpatient marketplace and the amount of available supplies,we Care"in this"Benefits and Your Cost Share"section) may reduce the quantity of the drug dispensed • Drugs covered during a covered stay in a Plan accordingly and charge one cost share Hospital or Skilled Nursing Facility are not covered • Generic substitution:When there is a generic under this"Outpatient Prescription Drugs, Supplies, version of a brand-name drug available,Plan and Supplements"section(instead,refer to"Hospital Pharmacies will automatically give you the generic Inpatient Care"and"Skilled Nursing Facility Care"in version,unless your Plan Physician has specifically this"Benefits and Your Cost Share"section) requested a formulary exception because it is Medically Necessary for you to receive the brand- Outpatient prescription drugs, supplies, and name drug instead of the formulary alternative supplements limitations Day supply limit.Plan Physicians determine the amount Outpatient prescription drugs, supplies, and of a drug or other item that is Medically Necessary for a supplements exclusions particular day supply for you.Upon payment of the Cost • Any requested packaging(such as dose packaging) Share specified in this"Outpatient Prescription Drugs, other than the dispensing pharmacy's standard Supplies,and Supplements"section,you will receive the packaging supply prescribed up to a 100-day supply in a 100-day period.However,the Plan Pharmacy may reduce the day • Compounded products unless the active ingredient in supply dispensed to a 30-day supply in any 30-day the compounded product is listed on one of our drug period at the Cost Share listed in this"Outpatient formularies Prescription Drugs,Supplies,and Supplements"section • Drugs prescribed to shorten the duration of the if the Plan Pharmacy determines that the drug is in common cold limited supply in the market or a 31-day supply in any 31-day period if the item is dispensed by a long term care • Prescription drugs for which there is an over-the- facility's pharmacy.Plan Pharmacies may also limit the counter equivalent(the same active ingredient, quantity dispensed as described under"Utilization strength,and dosage form as the prescription drug). management."If you wish to receive more than the This exclusion does not apply to: covered day supply limit,then the additional amount is ♦ insulin not covered and you must pay Charges for any ♦ over-the-counter tobacco cessation drugs and prescribed quantities that exceed the day supply limit. contraceptive drugs The amount you pay for noncovered drugs does not ♦ an entire class of prescription drugs when one drug count toward reaching the Catastrophic Coverage Stage. within that class becomes available over-the- counter ♦ drugs covered by Medicare Parts B or D Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 47 Member Service:toll free 1-800-443-0815(TTY users call 711)seven days a week, 8 a.m.-8 p.m. Over-the-Counter (OTC) Health and • Colorectal cancer screening,including flexible Wellness sigmoidoscopies,colonoscopies,and fecal occult blood tests: no charge We cover OTC items listed in our OTC catalog for free . Depression screening: no charge home delivery at no charge.You may order OTC items • Diabetes screening,including fasting glucose tests: up to the$70 quarterly benefit limit.Each order must be at least$25.Your order may not exceed your quarterly no charge benefit limit.Any unused portion of the quarterly benefit . Diabetes self-management training: no charge limit doesn't carry forward to the next quarter.(Your . Glaucoma screening: no charge benefit limit resets on January 1,April 1,July 1,and October 1). • HIV screening: no charge • Immunizations(including the vaccine)covered by To view our catalog and place an order online,please Medicare Part B such as Hepatitis B,influenza, visit kp.org/otc/ca.You may place an order over the pneumococcal,and COVID-19 vaccines that are phone or request a printed catalog be mailed to you by administered to you in a Plan Medical Office: calling 1-833-569-2360(TTY 711),7 a.m.to 6 p.m. no charge PST,Monday through Friday. . Lung cancer screening: no charge • Medical nutrition therapy for kidney disease and Preventive Services diabetes: no charge We cover a variety of Preventive Services in accord with • Medicare diabetes prevention program: no charge Medicare guidelines.The list of Preventive Services is • Obesity screening and therapy to promote sustained subject to change by the Centers for Medicare& weight loss:no charge Medicaid Services.These Preventive Services are subject . Prostate cancer screening exams,including digital to all coverage requirements described in this"Benefits and Your Cost Share"section and all provisions in the rectal exams and Prostate Specific Antigens(PSA) "Exclusions,Limitations,Coordination of Benefits,and tests: no charge Reductions"section.If you have questions about • Screening and counseling to reduce alcohol misuse: Preventive Services,please call Member Services. no charge • Screening for sexually transmitted infections(STIs) Note:If you receive any other covered Services that are and counseling to prevent STIs: no charge not Preventive Services during or subsequent to a visit that includes Preventive Services on the list,you will pay • Smoking and tobacco use cessation(counseling to the applicable Cost Share for those other Services.For stop smoking or tobacco use): no charge example,if laboratory tests or imaging Services ordered • "Welcome to Medicare"preventive visit:no charge during a preventive office visit are not Preventive Services,you will pay the applicable Cost Share for those services. Prosthetic and Orthotic Devices Your Cost Share.You pay the following for covered Prosthetic and orthotic devices coverage rules Preventive Services: We cover the prosthetic and orthotic devices specified in this"Prosthetic and Orthotic Devices"section if all of • Abdominal aortic aneurysm screening prescribed the following requirements are met: during the one-time"Welcome to Medicare" • The device is in general use,intended for repeated preventive visit: no charge use,and primarily and customarily used for medical • Annual Wellness visit: no charge purposes • Bone mass measurement: no charge . The device is the standard device that adequately • Breast cancer screening(mammograms): no charge meets your medical needs • Cardiovascular disease risk reduction visit(therapy • You receive the device from the provider or vendor for cardiovascular disease): no charge that we select • Cardiovascular disease testing: no charge • The item has been approved for you through the Plan's prior authorization process,as described in • Cervical and vaginal cancer screening: no charge "Medical Group authorization procedure for certain Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 48 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. referrals"under"Getting a Referral"in the"How to • Prostheses to replace all or part of an external facial Obtain Services"section body part that has been removed or impaired as a • The Services are provided inside our Service Area result of disease,injury,or congenital defect Coverage includes fitting and adjustment of these Other covered prosthetic and orthotic devices devices,their repair or replacement,and Services to If all of the requirements described under"Prosthetic and determine whether you need a prosthetic or orthotic orthotic coverage rules"in this"Prosthetics and Orthotic device.If we cover a replacement device,then you pay Devices"section are met,we cover the following items the Cost Share that you would pay for obtaining that described in this"Other covered prosthetic and orthotic device. devices"section: • Prosthetic devices required to replace all or part of an Base prosthetic and orthotic devices organ or extremity,in accord with Medicare If all of the requirements described under"Prosthetic and guidelines orthotic coverage rules"in this"Prosthetics and Orthotic • Vacuum erection device for sexual dysfunction Devices"section are met,we cover the items described in this"Base prosthetic and orthotic devices"section. • Certain surgical boots following surgery when provided during an outpatient visit Internally implanted devices.We cover prosthetic and • Orthotic devices required to support or correct a orthotic devices such as pacemakers,intraocular lenses, defective body part,in accord with Medicare cochlear implants,osseointegrated hearing devices,and guidelines hip joints,in accord with Medicare guidelines,if they are implanted during a surgery that we are covering under Your Cost Share.You pay the following for other another section of this"Benefits and Your Cost Share" covered prosthetic and orthotic devices:20 percent section.We cover these devices at no charge. Coinsurance. External devices.We cover the following external For the following Services, refer to these prosthetic and orthotic devices at 20 percent sections Coinsurance: • Eyeglasses and contact lenses,including contact • Prosthetics and orthotics in accord with Medicare lenses to treat aniridia or aphakia(refer to"Vision guidelines. These include,but are not limited to, Services") braces,prosthetic shoes,artificial limbs,and • Eyewear following cataract surgery(refer to"Vision therapeutic footwear for severe diabetes-related foot disease in accord with Medicare guidelines Services") • Hearing aids other than internally implanted devices • Prosthetic devices and installation accessories to described in this section(refer to"Hearing Services") restore a method of speaking following the removal of all or part of the larynx(this coverage does not • Injectable implants(refer to"Administered drugs and include electronic voice-producing machines,which products"under"Outpatient Care") are not prosthetic devices) • After Medically Necessary removal of all or part of a Prosthetic and orthotic devices exclusions breast,prosthesis including custom-made prostheses • Dental appliances when Medically Necessary • Nonrigid supplies not covered by Medicare,such as • Podiatric devices(including footwear)to prevent or elastic stockings and wigs,except as otherwise treat diabetes-related complications when prescribed described above in this"Prosthetic and Orthotic by a Plan Physician or by a Plan Provider who is a Devices"section and the"Ostomy,Urological,and podiatrist Specialized Wound Care Supplies"section • Compression burn garments and lymphedema wraps • Comfort,convenience,or luxury equipment or and garments features • Enteral formula for Members who require tube • Repair or replacement of device due to misuse feeding in accord with Medicare guidelines • Shoes,shoe inserts,arch supports,or any other • Enteral pump and supplies footwear,even if custom-made,except footwear • Tracheostomy tube and supplies described above in this"Prosthetic and Orthotic Devices"section for diabetes-related complications Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 49 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Prosthetic and orthotic devices not intended for • Hospital inpatient Services(including room and maintaining normal activities of daily living board,drugs,imaging,laboratory,other diagnostic (including devices intended to provide additional and treatment Services,and Plan Physician Services): support for recreational or sports activities) a$250 Copayment per admission • Nonconventional intraocular lenses(IOLs)following For the following Services, refer to these cataract surgery(for example,presbyopia-correcting IOLs).You may request and we may provide sections insertion of presbyopia-correcting IOLs or • Office visits not described in this"Reconstructive astigmatism-correcting IOLs following cataract Surgery"section(refer to"Outpatient Care") surgery in lieu of conventional IOLs.However,you . Outpatient imaging and laboratory(refer to must pay the difference between Charges for "Outpatient Imaging,Laboratory,and Other nonconventional IOLs and associated services and Diagnostic and Treatment Services") Charges for insertion of conventional IOLs following cataract surgery • Outpatient prescription drugs(refer to"Outpatient Prescription Drugs,Supplies,and Supplements") • Outpatient administered drugs(refer to"Outpatient Reconstructive Surgery Care") We cover the following reconstructive surgery Services: • Prosthetics and orthotics(refer to"Prosthetic and • Reconstructive surgery to correct or repair abnormal Orthotic Devices") structures of the body caused by congenital defects, • Telehealth Visits(refer to"Telehealth Visits") developmental abnormalities,trauma,infection, tumors,or disease,if a Plan Physician determines that Reconstructive surgery exclusions it is necessary to improve function,or create a normal • Surgery that,in the judgment of a Plan Physician appearance,to the extent possible specializing in reconstructive surgery,offers only a • Following Medically Necessary removal of all or part minimal improvement in appearance of a breast,we cover reconstruction of the breast, surgery and reconstruction of the other breast to produce a symmetrical appearance,and treatment of Religious Nonmedical Health Care physical complications,including lymphedemas Institution Services Your Cost Share.You pay the following for covered Care in a Medicare-certified Religious Nonmedical reconstructive surgery Services: Health Care Institution(RNHCI)is covered by our Plan • Outpatient surgery and outpatient procedures when under certain conditions.Covered Services in an RNHCI are limited to nonreligious aspects of care.To be eligible provided in an outpatient or ambulatory surgery for covered Services in a RNHCI,you must have a center or in a hospital operating room,or if it is medical condition that would allow you to receive provided in any setting and a licensed staff member inpatient hospital or Skilled Nursing Facility care.You monitors your vital signs as you regain sensation after may get Services furnished in the home,but only items receiving drugs to reduce sensation or to minimize and Services ordinarily furnished by home health discomfort: a$25 Copayment per procedure agencies that are not RNHCIs.In addition,you must sign • Any other outpatient surgery that does not require a a legal document that says you are conscientiously licensed staff member to monitor your vital signs as opposed to the acceptance of"nonexcepted"medical described above: a$25 Copayment per procedure treatment.("Excepted"medical treatment is a Service or • Any other outpatient procedures that do not require a treatment that you receive involuntarily or that is licensed staff member to monitor your vital signs as required under federal,state,or local law. described above: the Cost Share that would "Nonexcepted"medical treatment is any other Service or otherwise apply for the procedure in this`Benefits treatment.)Your stay in the RNHCI is not covered by us and Your Cost Share"section(for example,radiology unless you obtain authorization(approval)in advance procedures that do not require a licensed staff from us. member to monitor your vital signs as described above are covered under"Outpatient Imaging, Note: Covered Services are subject to the same Laboratory,and Other Diagnostic and Treatment limitations and Cost Share required for Services provided Services") by Plan Providers as described in this"Benefits and Your Cost Share"section. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 50 Member Service:toll free 1-800-443-0815(TTY users call 711)seven days a week, 8 a.m.-8 p.m. Services Associated with Clinical Trials or download the publication"Medicare and Clinical Research Studies."(The publication is available at If you participate in a Medicare-approved study,Original httns://www.medicare.aov.)You can also call Medicare pays most of the costs for the covered Services 1-800-MEDICARE(1-800-633-4227),24 hours a day, you receive as part of the study.If you tell us that you seven days a week.TTY users call 1-877-486-2048. are in a qualified clinical trial,then you are only responsible for the in-network cost-sharing for the Services associated with clinical trials services in that trial.If you paid more,for example,if exclusions you already paid the Original Medicare cost-sharing When you are part of a clinical research study,neither amount,we will reimburse the difference between what Medicare nor our plan will pay for any of the following: you paid and the in-network cost-sharing.However,you will need to provide documentation to show us how • The new item or service that the study is testing, much you paid.When you are in a clinical research unless Medicare would cover the item or service even study,you may stay enrolled in our plan and continue to if you were not in a study get the rest of your care(the care that is not related to the • Items or services provided only to collect data,and study)through our plan. not used in your direct health care • Services that are customarily provided by the research If you want to participate in any Medicare-approved sponsors free of charge to enrollees in the clinical trial clinical research study,you do not need to tell us or to get approval from us or your Plan Provider.The • Items and services provided solely to determine trial providers that deliver your care as part of the clinical eligibility research study do not need to be part of our plan's network of providers.Although you do not need to get Skilled Nursing Facility Care our plan's permission to be in a clinical research study, we encourage you to notify us in advance when you Inside our Service Area,we cover up to 100 days per choose to participate in Medicare-qualified clinical trials. benefit period of skilled inpatient Services in a Plan Skilled Nursing Facility and in accord with Medicare If you participate in a study that Medicare has not guidelines.The skilled inpatient Services must be approved,you will be responsible for paying all costs for customarily provided by a Skilled Nursing Facility,and your participation in the study. above the level of custodial or intermediate care. Once you join a Medicare-approved clinical research A benefit period begins on the date you are admitted to a study,Original Medicare covers the routine items and hospital or Skilled Nursing Facility at a skilled level of Services you receive as part of the study,including: care(defined in accord with Medicare guidelines).A • Room and board for a hospital stay that Medicare benefit period ends on the date you have not been an would pay for even if you weren't in a study inpatient in a hospital or Skilled Nursing Facility, • An operation or other medical procedure if it is part receiving a skilled level of care,for 60 consecutive days. A new benefit period can begin only after any existing of the research study benefit period ends.A prior three-day stay in an acute • Treatment of side effects and complications of the care hospital is not required.Note:If your Cost Share new care changes during a benefit period,you will continue to pay the previous Cost Share amount until a new benefit After Medicare has paid its share of the cost for these period begins. Services,our plan will pay the difference between the cost-sharing in Original Medicare and your Cost Share as We cover the following Services: a Member of our plan.This means you will pay the same . Physician and nursing Services amount for the Services you receive as part of the study as you would if you received these Services from our • Room and board plan.However,you are required to submit • Drugs prescribed by a Plan Physician as part of your documentation showing how much cost sharing you plan of care in the Plan Skilled Nursing Facility in paid.Please see the"Requests for Payment"section for accord with our drug formulary guidelines if they are more information for submitting requests for payment. administered to you in the Plan Skilled Nursing Facility by medical personnel You can get more information about joining a clinical . Durable medical equipment in accord with our prior research study by visiting the Medicare website to read authorization procedure if Skilled Nursing Facilities Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 51 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. ordinarily furnish the equipment(refer to"Medical • Individual and group substance use disorder Group authorization procedure for certain referrals" counseling under"Getting a Referral"in the"How to Obtain • Intensive outpatient programs Services"section) • Imaging and laboratory Services that Skilled Nursing • Medical treatment for withdrawal symptoms Facilities ordinarily provide Your Cost Share.You pay the following for these • Medical social services covered Services: • Whole blood,red blood cells,plasma,platelets,and • Individual substance use disorder evaluation and their administration treatment: a$25 Copayment per visit • Medical supplies • Group substance use disorder treatment: a • Physical,occupational,and speech therapy in accord $5 Copayment per visit with Medicare guidelines • Intensive outpatient and day-treatment programs: a • Respiratory therapy $5 Copayment per day Your Cost Share.We cover these Skilled Nursing Residential treatment Facility Services at no charge. Inside our Service Area,we cover the following Services when the Services are provided in a licensed residential For the following Services, refer to these treatment facility that provides 24-hour individualized sections substance use disorder treatment,the Services are • Outpatient imaging,laboratory,and other diagnostic generally and customarily provided by a substance use disorder residential treatment program in a licensed and treatment Services(refer to"Outpatient Imaging, residential treatment facility,and the Services are above Laboratory,and Other Diagnostic and Treatment the level of custodial care: Services") • Individual and group substance use disorder Non—Plan Skilled Nursing Facility care counseling Generally,you will get your Skilled Nursing Facility • Medical services care from Plan Facilities.However,under certain • Medication monitoring conditions listed below,you may be able to receive covered care from a non—Plan facility,if the facility • Room and board accepts our Plan's amounts for payment. • Drugs prescribed by a Plan Provider as part of your • A nursing home or continuing care retirement plan of care in the residential treatment facility in community where you were living right before you accord with our drug formulary guidelines if they are went to the hospital(as long as it provides Skilled administered to you in the facility by medical Nursing Facility care) personnel(for discharge drugs prescribed when you • A Skilled Nursing Facility where your spouse is are released from the residential treatment facility, refer to Outpatient Prescription Drugs, Supplies,and living at the time you leave the hospital Supplements"in this"Benefits and Your Cost Share" section) Substance Use Disorder Treatment • Discharge planning We cover Services specified in this"Substance Use Your Cost Share.We cover residential substance use Disorder Treatment"section only when the Services are disorder treatment Services at no charge. for the preventive,diagnosis,or treatment of Substance Use Disorders.A"Substance Use Disorder"is a Inpatient detoxification condition identified as a"substance use disorder"in the We cover hospitalization in a Plan Hospital only for most recently issued edition of the Diagnostic and medical management of withdrawal symptoms,including Statistical Manual of Mental Disorders("DSM"). room and board,Plan Physician Services,drugs, dependency recovery Services,education,and Outpatient substance use disorder treatment counseling. We cover the following Services for treatment of substance use disorders: Your Cost Share.We cover inpatient detoxification • Day-treatment programs Services at a$250 Copayment per admission. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 52 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. For the following Services, refer to these ♦ the evaluation doesn't lead to an office visit within sections 24 hours or the soonest available appointment • Outpatient laboratory(refer to"Outpatient Imaging, • Evaluation of video and/or images you send to your Laboratory,and Other Diagnostic and Treatment doctor,and interpretation and follow-up by your Services") doctor within 24 hours if: • Outpatient self-administered drugs(refer to ♦ you're not a new patient,and "Outpatient Prescription Drugs, Supplies,and ♦ the check-in isn't related to an office visit in the Supplements") past 7 days,and • Telehealth Visits(refer to"Telehealth Visits") ♦ the check-in doesn't lead to an office visit within 24 hours or the soonest available appointment Telehealth Visits • Consultation your doctor has with other doctors by phone,internet,or electronic health record Telehealth Visits between you and your provider are intended to make it more convenient for you to receive Your Cost Share.You pay the following types for covered Services,when a Plan Provider determines it is Telehealth Visits with Primary Care Physicians,Non- medically appropriate for your medical condition.You Physician Specialists,and Physician Specialists: have the option of receiving these services either through • Interactive video visits: no charge an in-person visit or via telehealth.You may receive • Scheduled telephone visits: no charge covered Services via Telehealth Visits,when available and if the Services would have been covered under this EOC if provided in person.If you choose to receive Transplant Services Services via telehealth,then you must use a Plan Provider that currently offers the service via telehealth. We cover transplants of organs,tissue,or bone marrow We offer the following telehealth Services: in accord with Medicare guidelines and if the Medical • Telehealth Services for monthly end-stage renal Group provides a written referral for care to a transplant disease--related visits for home dialysis members in a facility as described in"Medical Group authorization hospital-based or critical access hospital-based renal procedure for certain referrals"under"Getting a dialysis center,renal dialysis facility,or the Referral"in the"How to Obtain Services"section. Member's home • Telehealth Services to diagnose,evaluate or treat After the referral to a transplant facility,the following symptoms of a stroke,regardless of your location applies: • If either the Medical Group or the referral facility • Telehealth services for members with a substance use determines that you do not satisfy its respective disorder or co-occurring mental health disorder, criteria for a transplant,we will only cover Services regardless of their location you receive before that determination is made • Telehealth services for diagnosis,evaluation,and • Health Plan,Plan Hospitals,the Medical Group,and treatment of mental health disorders if: Plan Physicians are not responsible for finding, ♦ you have an in-person visit within 6 months prior furnishing,or ensuring the availability of an organ, to your first telehealth visit tissue,or bone marrow donor ♦ you have an in-person visit every 12 months while • In accord with our guidelines for Services for living receiving these telehealth services transplant donors,we provide certain donation-related ♦ exceptions can be made to the above for certain Services for a donor,or an individual identified by the circumstances Medical Group as a potential donor,whether or not • Telehealth services for mental health visits provided the donor is a Member. These Services must be by Rural Health Clinics and Federally Qualified directly related to a covered transplant for you,which Health Centers may include certain Services for harvesting the organ, tissue,or bone marrow and for treatment of • Virtual check-ins(for example,by phone or video complications.Please call Member Services for chat)with your doctor for 5-10 minutes if: questions about donor Services ♦ you're not a new patient,and ♦ the evaluation isn't related to an office visit in the Your Cost Share.For covered transplant Services that past 7 days,and you receive,you will pay the Cost Share you would pay if the Services were not related to a transplant.For Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 53 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. example,see"Hospital Inpatient Services"in this appointment.Please have all of the following when you "Benefits and Your Cost Share"section for the Cost call: Share that applies for hospital inpatient Services. . Your Kaiser Permanente ID card We provide or pay for donation-related Services for • The date and time of your medical appointments actual or potential donors(whether or not they are • The address of where you need to be picked up and Members)in accord with our guidelines for donor the address of where you are going Services at no charge. . If you will need a return trip For the following Services, refer to these • If someone will be traveling with you(for example,a sections parent/legal guardian or caregiver) • Dental Services that are Medically Necessary to Your Cost Share:You pay the following for covered prepare for a transplant(refer to"Dental Services") transportation: no charge. • Outpatient imaging and laboratory(refer to "Outpatient Imaging,Laboratory,and Other For the following Services, refer to this section Diagnostic and Treatment Services") • Emergency and non-emergency ambulance Services • Outpatient prescription drugs(refer to"Outpatient (refer to"Ambulance Services") Prescription Drugs,Supplies,and Supplements") • Outpatient administered drugs(refer to"Outpatient Transportation Services exclusion Care") Transportation will not be provided if: • The ride is not for a service covered under this EOC Transportation Services We cover transportation up to 24 one-way trips(50 miles Vision Services per trip)per calendar year,if you meet the following We cover the following: conditions: • Routine eye exams with a Plan Optometrist to • You are traveling to and from a network provider determine the need for vision correction(including when provided by our designated transportation dilation Services when Medically Necessary)and to provider.Each stop will count towards one trip provide a prescription for eyeglass lenses: a • The ride is for Services covered under this EOC $25 Copayment per visit • Physician Specialist Visits to diagnose and treat For trips greater than 50 miles,you will need an approval injuries or diseases of the eye: a$25 Copayment per from a provider indicating medical necessity to travel to visit a location beyond this limit. . Non-Physician Specialist Visits to diagnose and treat To request non-medical transportation(rideshare, injuries or diseases of the eye: a$25 Copayment per taxi,or private transportation),please call our visit transportation provider at 1-877-930-1477(TTY 711), Monday through Friday,5:00 a.m.to 6:00 p.m.You may Optical Services also create an account with our transportation vendor and We cover the Services described in this"Optical schedule rides online at medicaltrip.net or via their Services"section when received from Plan Medical mobile app. Offices or Plan Optical Sales Offices. If you need to use non-emergency medical The date we provide an Allowance toward(or otherwise transportation(wheelchair van or gurney van) cover)an item described in this"Optical Services" because you physically or medically are not able to get to section is the date on which you order the item.For your medical appointment by non-medical transportation example,if we last provided an Allowance toward an (rideshare,taxi,or private transportation),please call item you ordered on May 1,2022,and if we provide an 1-833-226-6760(TTY 711),Monday through Friday, Allowance not more than once every 24 months for that 9:00 a.m.to 5:00 p.m. type of item,then we would not provide another Allowance toward that type of item until on or after May Call at least three business days before your appointment 1,2024.You can use the Allowances under this or or as soon as you can when you have an urgent Services"section only when you first order an item. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 54 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. If you use part but not all of an Allowance when you first ♦ we cover tinted lenses when Medically Necessary order an item,you cannot use the rest of that Allowance to treat macular degeneration or retinitis later. pigmentosa • Eyeglass frames when a Plan Provider puts two lenses Eyeglasses and contact lenses following cataract (at least one of which must have refractive value)into surgery the frame We cover at no charge one pair of eyeglasses or contact lenses(including fitting or dispensing)following each • Contact lenses,fitting,and dispensing cataract surgery that includes insertion of an intraocular lens at Plan Medical Offices or Plan Optical Sales We will not provide the Allowance if we have provided Offices when prescribed by a physician or optometrist. an Allowance toward(or otherwise covered)eyeglass When multiple cataract surgeries are needed,and you do lenses or frames within the previous 24 months. not obtain eyeglasses or contact lenses between procedures,we will only cover one pair of eyeglasses or Replacement lenses contact lenses after any surgery.If the eyewear you If you have a change in prescription of at least.50 purchase costs more than what Medicare covers for diopter in one or both eyes within 12 months of the someone who has Original Medicare(also known as initial point of sale of an eyeglass lens or contact lens "Fee-for-Service Medicare"),you pay the difference. that we provided an Allowance toward(or otherwise covered)we will provide an Allowance toward the Special contact lenses purchase price of a replacement item of the same type We cover the following: (eyeglass lens,or contact lens,fitting,and dispensing) for the eye that had the.50 diopter change. The • For aniridia(missing iris),we cover up to two Allowance toward one of these replacement lenses is$30 Medically Necessary contact lenses per eye for a single vision eyeglass lens or for a contact lens (including fitting and dispensing)in any 12-month (including fitting and dispensing)and$45 for a period when prescribed by a Plan Physician or Plan multifocal or lenticular eyeglass lens. Optometrist: no charge • In accord with Medicare guidelines,we cover For the following Services, refer to these corrective lenses(including contact lens fitting and sections dispensing)and frames(and replacements)for Services related to the eye or vision other than Members who are aphakic(for example,who have • Services covered under this"Vision Services" had a cataract removed but do not have an implanted section,such as outpatient surgery and outpatient intraocular lens(IOL)or who have congenital prescription drugs,rescri tion s' pplies supplies, supplements refer to the applicable h absence of the lens):no charge e and ppeading in this Benefits and Your • For other specialty contact lenses that will provide a Cost Share"section) significant improvement in your vision not obtainable with eyeglass lenses,we cover either one pair of Vision Services exclusions contact lenses(including fitting and dispensing)or an • Eyeglass or contact lens adornment,such as initial supply of disposable contact lenses(up to six engraving,faceting,or jeweling months,including fitting and dispensing)in any 24 months at no charge • Items that do not require a prescription by law(other than eyeglass frames),such as eyeglass holders, Eyeglasses and contact lenses eyeglass cases,and repair kits We provide a single$175 Allowance toward the • Lenses and sunglasses without refractive value, purchase price of any or all of the following not more except as described in this"Vision Services"section than once every 24 months when a physician or • Low vision devices optometrist prescribes an eyeglass lens(for eyeglass lenses and frames)or contact lens(for contact lenses): • Replacement of lost,broken,or damaged contact • Eyeglass lenses when a Plan Provider puts the lenses lenses,eyeglass lenses,and frames into a frame ♦ we cover a clear balance lens when only one eye needs correction Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 55 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Exclusions, Limitations, Custodial care Coordination of Benefits, and Assistance with activities of daily living(for example: walking,getting in and out of bed,bathing,dressing, Reductions feeding,toileting,and taking medicine). This exclusion does not apply to assistance with Exclusions activities of daily living that is provided as part of covered hospice for Members who do not have Part A, The items and services listed in this"Exclusions"section Skilled Nursing Facility,or hospital inpatient care. are excluded from coverage.These exclusions apply to all Services that would otherwise be covered under this Dental care EOC regardless of whether the services are within the scope of a provider's license or certificate.Additional Dental care and dental X-rays,such as dental Services exclusions that apply only to a particular benefit are following accidental injury to teeth,dental appliances, listed in the description of that benefit in this EOC. dental implants,orthodontia,and dental Services These exclusions or limitations do not apply to Services resulting from medical treatment such as surgery on the that are Medically Necessary to treat Severe Mental jawbone and radiation treatment,except for Services Illness or Serious Emotional Disturbance of a Child covered in accord with Medicare guidelines or under Under Age 18. "Dental Services"in the"Benefits and Your Cost Share" section. Certain exams and Services Routine physical exams and other Services that are not Disposable supplies Medically Necessary,such as when required(1)for Disposable supplies for home use,such as bandages, obtaining or maintaining employment or participation in gauze,tape,antiseptics,dressings,Ace-type bandages, employee programs,(2)for insurance,credentialing or and diapers,underpads,and other incontinence supplies. licensing,(3)for travel,or(4)by court order or for parole or probation. This exclusion does not apply to disposable supplies covered in accord with Medicare guidelines or under Chiropractic Services "Durable Medical Equipment("DME")for Home Use," Chiropractic Services and the Services of a chiropractor, "Home Health Care,""Hospice Care,""Ostomy, except for manual manipulation of the spine as described Urological,and Wound Care Supplies, Outpatient under"Outpatient Care"in the"Benefits and Your Cost Prescription Drugs,Supplies,and Supplements,"and Share"section or unless you have coverage for "Prosthetic and Orthotic Devices"in the"Benefits and supplemental chiropractic Services as described in an Your Cost Share"section. amendment to this EOC. Experimental or investigational Services Cosmetic Services A Service is experimental or investigational if we,in Services that are intended primarily to change or consultation with the Medical Group,determine that one maintain your appearance,including cosmetic surgery of the following is true: (surgery that is performed to alter or reshape normal • Generally accepted medical standards do not structures of the body in order to improve appearance), recognize it as safe and effective for treating the except that this exclusion does not apply to any of the condition in question(even if it has been authorized following: by law for use in testing or other studies on human • Services covered under"Reconstructive Surgery"in patients) the"Benefits and Your Cost Share"section • It requires government approval that has not been • The following devices covered under"Prosthetic and obtained when the Service is to be provided Orthotic Devices"in the"Benefits and Your Cost Hair loss or growth treatment Share"section:testicular implants implanted as part of a covered reconstructive surgery,breast prostheses Items and services for the promotion,prevention,or needed after removal of all or part of a breast or other treatment of hair loss or hair growth. lumpectomy,and prostheses to replace all or part of an external facial body part Intermediate care Care in a licensed intermediate care facility. This exclusion does not apply to Services covered under "Durable Medical Equipment("DME")for Home Use," Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 56 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. "Home Health Care,"and"Hospice Care"in the • Enteral formula covered under"Prosthetic and "Benefits and Your Cost Share"section. Orthotic Devices"in the"Benefits and Your Cost Share"section Items and services that are not health care items and services Residential care For example,we do not cover: Care in a facility where you stay overnight,except that • Teaching manners and etiquette this exclusion does not apply when the overnight stay is part of covered care in a hospital,a Skilled Nursing • Teaching and support services to develop planning Facility,inpatient respite care covered in the"Hospice skills such as daily activity planning and project or Care"section for Members who do not have Part A,or task planning residential treatment program Services covered in the • Items and services for the purpose of increasing "Substance Use Disorder Treatment"and"Mental Health academic knowledge or skills Services"sections. • Teaching and support services to increase intelligence Routine foot care items and services • Academic coaching or tutoring for skills such as Routine foot care items and services,except for grammar,math,and time management Medically Necessary Services covered in accord with • Teaching you how to read,whether or not you have Medicare guidelines. dyslexia Services not approved by the federal Food and • Educational testing Drug Administration • Teaching art,dance,horse riding,music,play,or Drugs,supplements,tests,vaccines,devices,radioactive swimming materials,and any other Services that by law require • Teaching skills for employment or vocational federal Food and Drug Administration("FDA")approval purposes in order to be sold in the U.S.,but are not approved by the FDA.This exclusion applies to Services provided • Vocational training or teaching vocational skills anywhere,even outside the U.S.,unless the Services are • Professional growth courses covered under the"Emergency Services and Urgent • Training for a specific job or employment counseling Care"section. • Aquatic therapy and other water therapy,except when Services and items not covered by Medicare ordered as part of a physical therapy program in Services and items that are not covered by Medicare, accord with Medicare guidelines including services and items that aren't reasonable and Items and services to correct refractive defects necessary,according to the standards of the Original of the eye Medicare plan,unless these Services are otherwise listed in this EOC as a covered Service. Items and services(such as eye surgery or contact lenses to reshape the eye)for the purpose of correcting Services performed by unlicensed people refractive defects of the eye such as myopia,hyperopia, Services that are performed safely and effectively by or astigmatism. people who do not require licenses or certificates by the Massage therapy state to provide health care services and where the Member's condition does not require that the services be Massage therapy is not covered. provided by a licensed health care provider. Oral nutrition and weight loss aids Services related to a noncovered Service Outpatient oral nutrition,such as dietary supplements, When a Service is not covered,all Services related to the herbal supplements,formulas,food,and weight loss aids. noncovered Service are excluded, except for Services we would otherwise cover to treat complications of the This exclusion does not apply to any of the following: noncovered Service or if covered in accord with • Amino acid—modified products and elemental dietary Medicare guidelines.For example,if you have a enteral formula covered under"Outpatient noncovered cosmetic surgery,we would not cover Prescription Drugs,Supplies,and Supplements"in Services you receive in preparation for the surgery or for the"Benefits and Your Cost Share"section follow-up care.If you later suffer a life-threatening complication such as a serious infection,this exclusion Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 57 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. would not apply and we would cover any Services that You must tell us if you have other health care coverage, we would otherwise cover to treat that complication. and let us know whenever there are any changes in your additional coverage.The types of additional coverage Surrogacy that you might have include the following: Services for anyone in connection with a Surrogacy . Coverage that you have from an employer's group Arrangement,except for otherwise-covered Services health care coverage for employees or retirees,either provided to a Member who is a surrogate.Refer to through yourself or your spouse "Surrogacy Arrangements"under"Reductions"in this "Exclusions,Limitations,Coordination of Benefits,and • Coverage that you have under workers' compensation Reductions"section for information about your because of ajob-related illness or injury,or under the obligations to us in connection with a Surrogacy Federal Black Lung Program Arrangement,including your obligations to reimburse us • Coverage you have for an accident where no-fault for any Services we cover and to provide information insurance or liability insurance is involved about anyone who may be financially responsible for • Coverage you have through Medicaid Services the baby(or babies)receive. • Coverage you have through the"TRICARE for Life" Travel and lodging expenses program(veteran's benefits) Travel and lodging expenses,except as described in our • Coverage you have for dental insurance or Travel and Lodging Program Description.The Travel prescription drugs and Lodging Program Description is available online at . "Continuation coverage"you have through COBRA kp.or2/specialty-care/travel-reimbursements or by (COBRA is a law that requires employers with 20 or calling Member Services. more employees to let employees and their dependents keep their group health coverage for a Limitations time after they leave their group health plan under certain conditions) We will make a good faith effort to provide or arrange for covered Services within the remaining availability of When you have additional health care coverage,how we facilities or personnel in the event of unusual coordinate your benefits as a Senior Advantage Member circumstances that delay or render impractical the with your benefits from your other coverage depends on provision of Services under this EOC,such as a major your situation.With coordination of benefits,you will disaster,epidemic,war,riot,civil insurrection,disability often get your care as usual from Plan Providers,and the of a large share of personnel at a Plan Facility,complete other coverage you have will simply help pay for the or partial destruction of facilities,and labor dispute. care you receive.In other situations,such as benefits that Under these circumstances,if you have an Emergency we don't cover,you may get your care outside of our Medical Condition,call 911 or go to the nearest plan directly through your other coverage. emergency department as described under"Emergency Services"in the"Emergency Services and Urgent Care" In general,the coverage that pays its share of your bills section,and we will provide coverage and first is called the"primary payer."Then the other reimbursement as described in that section. company or companies that are involved(called the "secondary payers")each pay their share of what is left Additional limitations that apply only to a particular of your bills.Often your other coverage will settle its benefit are listed in the description of that benefit in this share of payment directly with us and you will not have EOC. 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 Coordination of Benefits coverage,whether we pay first or second,or at all, depends on what type or types of additional coverage If you have other medical or dental coverage,it is you have and the rules that apply to your situation.Many important to use your other coverage in combination of these rules are set by Medicare. Some of them take with your coverage as a Senior Advantage Member to into account whether you have a disability or have end- pay for the care you receive.This is called"coordination stage renal disease,or how many employees are covered of benefits"because it involves coordinating all of the by an employer's group plan. health benefits that are available to you.Using all of the coverage you have helps keep the cost of health care more affordable for everyone. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 58 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. If you have additional health coverage,please call the actual losses and damages you incurred.We are not Member Services to find out which rules apply to your required to pay attorney fees or costs to any attorney situation,and how payment will be handled. hired by you to pursue your damages claim.If you reimburse us without the need for legal action,we will allow a procurement cost discount.If we have to pursue Reductions legal action to enforce its interest,there will be no Employer responsibility procurement discount. For any Services that the law requires an employer to Within 30 days after submitting or filing a claim or legal provide,we will not pay the employer,and,when we action against a third party,you must send written notice cover any such Services,we may recover the value of the of the claim or legal action to: Services from the employer. Equian Government agency responsibility Kaiser Permanente-Northern California Region For any Services that the law requires be provided only Subrogation Mailbox by or received only from a government agency,we will P.O.Box 36380 not pay the government agency,and,when we cover any Louisville,KY 40233 such Services,we may recover the value of the Services Fax: 1-502-214-1137 from the government agency. In order for us to determine the existence of any rights Injuries or illnesses alleged to be caused by we may have and to satisfy those rights,you must third parties complete and send us all consents,releases, Third parties who cause you injury or illness(and/or authorizations,assignments,and other documents, their insurance companies)usually must pay first before including lien forms directing your attorney,the third Medicare or our plan.Therefore,we are entitled to party,and the third party's liability insurer to pay us pursue these primary payments.If you obtain a judgment directly.You may not agree to waive,release,or reduce or settlement from or on behalf of a third party who our rights under this provision without our prior,written allegedly caused an injury or illness for which you consent. received covered Services,you must ensure we receive reimbursement for those Services.Note:This"Injuries or If your estate,parent,guardian,or conservator asserts a illnesses alleged to be caused by third parties"section claim against a third party based on your injury or does not affect your obligation to pay your Cost Share illness,your estate,parent,guardian,or conservator and for these Services. any settlement or judgment recovered by the estate, parent,guardian,or conservator shall be subject to our To the extent permitted or required by law,we shall be liens and other rights to the same extent as if you had subrogated to all claims,causes of action,and other asserted the claim against the third party.We may assign rights you may have against a third party or an insurer, our rights to enforce our liens and other rights. government program,or other source of coverage for monetary damages,compensation,or indemnification on Surrogacy Arrangements account of the injury or illness allegedly caused by the If you enter into a Surrogacy Arrangement and you or third party.We will be so subrogated as of the time we any other payee are entitled to receive payments or other mail or deliver a written notice of our exercise of this compensation under the Surrogacy Arrangement,you option to you or your attorney. must reimburse us for covered Services you receive related to conception,pregnancy,delivery,or postpartum To secure our rights,we will have a lien and care in connection with that arrangement("Surrogacy reimbursement rights to the proceeds of any judgment or Health Services")to the maximum extent allowed under settlement you or we obtain against a third party that California Civil Code Section 3040.Note: This results in any settlement proceeds or judgment,from "Surrogacy Arrangements"section does not affect your other types of coverage that include but are not limited obligation to pay your Cost Share for these Services. to: liability,uninsured motorist,underinsured motorist, After you surrender a baby to the legal parents,you are personal umbrella,workers' compensation,personal not obligated to reimburse us for any Services that the injury,medical payments and all other first party types. baby receives(the legal parents are financially The proceeds of any judgment or settlement that you or responsible for any Services that the baby receives). we obtain shall first be applied to satisfy our lien, regardless of whether you are made whole and regardless By accepting Surrogacy Health Services,you of whether the total amount of the proceeds is less than automatically assign to us your right to receive payments Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 59 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. that are payable to you or any other payee under the if you had asserted the claim against the other party.We Surrogacy Arrangement,regardless of whether those may assign our rights to enforce our liens and other payments are characterized as being for medical rights. expenses.To secure our rights,we will also have a lien on those payments and on any escrow account,trust,or If you have questions about your obligations under this any other account that holds those payments.Those provision,please call Member Services. payments(and amounts in any escrow account,trust,or other account that holds those payments)shall first be U.S. Department of Veterans Affairs applied to satisfy our lien.The assignment and our lien For any Services for conditions arising from military will not exceed the total amount of your obligation to us service that the law requires the Department of Veterans under the preceding paragraph. Affairs to provide,we will not pay the Department of Veterans Affairs,and when we cover any such Services Within 30 days after entering into a Surrogacy we may recover the value of the Services from the Arrangement,you must send written notice of the Department of Veterans Affairs. arrangement,including all of the following information: • Names,addresses,and phone numbers of the other Workers' compensation or employer's liability parties to the arrangement benefits • Names,addresses,and phone numbers of any escrow Workers' compensation usually must pay first before agent or trustee Medicare or our plan.Therefore,we are entitled to pursue primary payments under workers' compensation • Names,addresses,and phone numbers of the intended or employer's liability law.You may be eligible for parents and any other parties who are financially payments or other benefits,including amounts received responsible for Services the baby(or babies)receive, as a settlement(collectively referred to as"Financial including names,addresses,and phone numbers for Benefit"),under workers' compensation or employer's any health insurance that will cover Services that the liability law.We will provide covered Services even if it baby(or babies)receive is unclear whether you are entitled to a Financial Benefit, • A signed copy of any contracts and other documents but we may recover the value of any covered Services explaining the arrangement from the following sources: • Any other information we request in order to satisfy • From any source providing a Financial Benefit or our rights from whom a Financial Benefit is due • From you,to the extent that a Financial Benefit is You must send this information to: provided or payable or would have been required to Equian be provided or payable if you had diligently sought to Kaiser Permanente—Northern California Region establish your rights to the Financial Benefit under Surrogacy Mailbox any workers' compensation or employer's liability P.O.Box 36380 law Louisville,KY 40233 Fax: 1-502-214-1137 Requests for Payment You must complete and send us all consents,releases, authorizations,lien forms,and other documents that are reasonably necessary for us to determine the existence of Requests for Payment of Covered any rights we may have under this"Surrogacy Services or Part D drugs Arrangements"section and to satisfy those rights.You may not agree to waive,release,or reduce our rights If you pay our share of the cost of your covered under this"Surrogacy Arrangements"section without services or Part D drugs, or if you receive a bill, our prior,written consent. you can ask us for payment Sometimes when you get medical care or a Part D drug, If your estate,parent,guardian,or conservator asserts a you may need to pay the full cost. Other times,you may claim against another party based on the Surrogacy find that you have paid more than you expected under Arrangement,your estate,parent,guardian,or the coverage rules of our plan.In these cases,you can conservator and any settlement or judgment recovered by ask us to pay you back(paying you back is often called the estate,parent,guardian,or conservator shall be "reimbursing"you).It is your right to be paid back by subject to our liens and other rights to the same extent as our plan whenever you've paid more than your share of Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 60 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. the cost for medical services or Part D drugs that are and even if there is a dispute and we don't pay certain covered by our plan.There may be deadlines that you provider charges must meet to get paid back. • Whenever you get a bill from a Plan Provider that you There may also be times when you get a bill from a think is more than you should pay,send us the bill. provider for the full cost of medical care you have We will contact the provider directly and resolve the received or possibly for more than your share of cost billing problem sharing as discussed in this document.First try to • If you have already paid a bill to a Plan Provider,but resolve the bill with the provider.If that does not you feel that you paid too much,send us the bill along work,send the bill to us instead of paying it.We will with documentation of any payment you have made look at the bill and decide whether the services should and ask us to pay you back the difference between the be covered.If we decide they should be covered,we amount you paid and the amount you owed under our will pay the provider directly.If we decide not to pay plan it,we will notify the provider.You should never pay more than plan-allowed cost sharing.If this provider is If you are retroactively enrolled in our plan. contracted,you still have the right to treatment. Sometimes a person's enrollment in our plan is retroactive. (This means that the first day of their Here are examples of situations in which you may need enrollment has already passed.The enrollment date may to ask us to pay you back or to pay a bill you have even have occurred last year.)If you were retroactively received: enrolled in our plan and you paid out-of-pocket for any of your covered Services or Part D drugs after your When you've received emergency,urgent,or dialysis enrollment date,you can ask us to pay you back for our care from a Non—Plan Provider.Outside the service share of the costs.You will need to submit paperwork area,you can receive emergency or urgently needed such as receipts and bills for us to handle the services from any provider,whether or not the provider reimbursement. is a Plan Provider.In these cases: When you use a Non—Plan Pharmacy to get a • You are only responsible for paying your share of the prescription filled.If you go to a Non—Plan,the cost for emergency or urgently needed services. pharmacy may not be able to submit the claim directly to Emergency providers are legally required to provide us.When that happens,you will have to pay the full cost emergency care.If you pay the entire amount yourself of your prescription. at the time you receive the care,ask us to pay you back for our share of the cost. Send us the bill,along Save your receipt and send a copy to us when you ask us with documentation of an payments have made to pay you back for our share of the cost.Remember that y p you we only cover out of network pharmacies in limited • You may get a bill from the provider asking for circumstances. payment that you think you do not owe. Send us this When you pay the full cost for a prescription because bill,along with documentation of any payments you you don't have your plan membership card with you. have already made If you do not have your plan membership card with you, ♦ if the provider is owed anything,we will pay the you can ask the pharmacy to call us or to look up your provider directly plan enrollment information.However,if the pharmacy ♦ if you have already paid more than your share of cannot get the enrollment information they need right the cost of the service,we will determine how away,you may need to pay the full cost of the much you owed and pay you back for our share of prescription yourself. the cost Save your receipt and send a copy to us when you ask us When a Plan Provider sends you a bill you think you to pay you back for our share of the cost. should not pay.Plan Providers should always bill us When you pay the full cost for a prescription in other directly and ask you only for your share of the cost.But situations.You may pay the full cost of the prescription sometimes they make mistakes and ask you to pay more because you find that the drug is not covered for some than your share. reason. • You only have to pay your Cost Share amount when • For example,the drug may not be on our 2024 you get covered Services.We do not allow providers Comprehensive Formulary;or it could have a to add additional separate charges,called balance requirement or restriction that you didn't know about billing.This protection(that you never pay more than or don't think should apply to you.If you decide to your Cost Share amount)applies even if we pay the get the drug immediately,you may need to pay the provider less than the provider charges for a service, full cost for it Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 61 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Save your receipt and send a copy to us when you ask — where you received the services us to pay you back.In some situations,we may need — who provided the services to get more information from your doctor in order to — why you think we should pay for the services pay you back for our share of the cost — your signature and date signed. (If you want When you pay copayments under a drug someone other than yourself to make the manufacturer patient assistance program.If you get request,we will also need a completed help from,and pay copayments under,a drug "Appointment of Representative"form,which manufacturer patient assistance program outside our is available at kn.org) plan's benefit,you may submit a paper claim to have your out-of-pocket expense count toward qualifying you ♦ a copy of the bill,your medical record(s)for these for catastrophic coverage. services,and your receipt if you paid for the services • Save your receipt and send a copy to us • Mail your request for payment of medical care All of the examples above are types of coverage together with any bills or paid receipts to us at this decisions.This means that if we deny your request for address: payment,you can appeal our decision.The"Coverage Kaiser Permanente Decisions,Appeals,and Complaints"section has Claims Administration-NCAL information about how to make an appeal. P.O.Box 12923 Oakland,CA 94604-2923 How to Ask Us to Pay You Back or to To request payment of a Part D drug that was prescribed Pay a Bill You Have Received by a Plan Provider and obtained from a Plan Pharmacy, write to the address below.For all other Part D requests, You may request us to pay you back by sending us a send your request to the address above. request in writing.If you send a request in writing,send Kaiser Foundation Health Plan,Inc. your bill and documentation of any payment you have Medicare Part D Unit made.It's a good idea to make a copy of your bill and P.O.Box 23170 receipts for your records.You must submit your claim to Oakland,CA 94623-0170 us within 12 months(for Part C medical claims)and within 36 months(for Part D drug claims)of the date you received the service,item,or drug. We Will Consider Your Request for Payment and Say Yes or No To make sure you are giving us all the information we need to make a decision,you can fill out our claim form We check to see whether we should cover the to make your request for payment.You don't have to use service or Part D drug and how much we owe the form,but it will help us process the information When we receive your request for payment,we will let faster.You can file a claim to request payment by: you know if we need any additional information from you.Otherwise,we will consider your request and make To file a claim,this is what you need to do: a coverage decision. • Completing and submitting our electronic form at • If we decide that the medical care or Part D drug is k .or and upload supporting documentation covered and you followed all the rules,we will pay for our share of the cost.If you have already paid for • Either download a copy of the form from our website the service or Part D drug,we will mail your k .or or call Member Services and ask them to reimbursement of our share of the cost to you.If you send you the form.Mail the completed form to our have not paid for the service or Part D drug yet,we Claims Department address listed below will mail the payment directly to the provider • If you are unable to get the form,you can file your • If we decide that the medical care or Part D drug is request for payment by sending us the following not covered,or you did not follow all the rules,we information to our Claims Department address listed will not pay for our share of the cost.We will send below: you a letter explaining the reasons why we are not ♦ a statement with the following information: sending the payment and your right to appeal that — your name(member/patient name)and decision medical/health record number — the date you received the services Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 62 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. If we tell you that we will not pay for all or part of coverage decision.Therefore,you cannot make an appeal the medical care or Part D drug, you can make if you disagree with our decision. an appeal If you think we have made a mistake in turning down your request for payment or the amount we are paying, Your Rights and Responsibilities you can make an appeal.If you make an appeal,it means you are asking us to change the decision we made when we turned down your request for payment. We must honor your rights and cultural The appeals process is a formal process with detailed sensitivities as a Member of our plan procedures and important deadlines.For the details about We must provide information in a way that how to make this appeal,go to the"Coverage Decisions, works for you and consistent with your cultural Appeals,and Complaints"section. sensitivities (in languages other than English, Braille, large print, or CD) Other Situations in Which You Should Our plan is required to ensure that all services,both clinical and non-clinical,are provided in a culturally Save Your Receipts and Send Copies to competent manner and are accessible to all enrollees, Us including those with limited English proficiency,limited reading skills,hearing incapacity,or those with diverse In some cases, you should send copies of your cultural and ethnic backgrounds.Examples of how our receipts to us to help us track your out-of- plan may meet these accessibility requirements include, pocket drug costs but are not limited to:provision of translator services, There are some situations when you should let us know interpreter services,teletypewriters,or TTY(text about payments you have made for your covered Part D telephone or teletypewriter phone)connection. prescription drugs.In these cases,you are not asking us for payment.Instead,you are telling us about your Our plan has free interpreter services available to answer payments so that we can calculate your out-of-pocket questions from non-English-speaking members.This costs correctly.This may help you to qualify for the document is available in Spanish by calling Member Catastrophic Coverage Stage more quickly. Services.We can also give you information in braille, large print,or CD at no cost if you need it.We are Here is one situation when you should send us copies of required to give you information about our plan's receipts to let us know about payments you have made benefits in a format that is accessible and appropriate for for your drugs: you.To get information from us in a way that works for • When you get a drug through a patient assistance you,please call Member Services. program offered by a drug manufacturer. Some members are enrolled in a patient assistance program Our plan is required to give female enrollees the option offered by a drug manufacturer that is outside our of direct access to a women's health specialist within the plan benefits.If you get any drugs through a program network for women's routine and preventive health care offered by a drug manufacturer,you may pay a services. copayment to the patient assistance program ♦ save your receipt and send a copy to us so that we If providers in our network for a specialty are not can have your out-of-pocket expenses count available,it is our responsibility to locate specialty toward qualifying you for the Catastrophic providers outside the network who will provide you with Coverage Stage the necessary care.In this case,you will only pay in- ♦ note:Because you are getting your drug through network cost sharing.If you find yourself in a situation the patient assistance program and not through our where there are no specialists in our network that cover a plan's benefits,we will not pay for any share of service you need,call us for information on where to go these drug costs.But sending a copy of the receipt to obtain this service at in-network cost-sharing. allows us to calculate your out-of-pocket costs correctly and may help you qualify for the If you have any trouble getting information from our Catastrophic Coverage Stage more quickly plan in a format that is accessible and appropriate for you,seeing a women's health specialist,or finding a Since you are not asking for payment in the case network specialist,please call to file a grievance with described above,this situation is not considered a Member Services.You may also file a complaint with Medicare by calling 1-800-MEDICARE(1-800-633- Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 63 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. 4227)or directly with the Office for Civil Rights 1-800- We must ensure that you get timely access to 368-1019 or TTY 1-800-537-7697. your covered services and Part D drugs You have the right to choose a primary care provider Debemos proporcionar la informaci6n de un (PCP)in our network to provide and arrange for your modo adecuado para usted y conforme a su covered services.You also have the right to go to a sensibilidad cultural (en idiomas distintos al women's health specialist(such as a gynecologist),a ingl6s, en letra grande, en braille o en CD) mental health services provider,and an optometrist Nuestro plan esta obligado a garantizar que todos los without a referral,as well as other providers described in servicios,tanto clinicos como no clinicos,se the"How to Obtain Services"section. proporcionen de una manera culturalmente competente y que Sean accesibles para todas las personas inscritas, You have the right to get appointments and covered incluidas las que tienen un domino limitado del ingl6s, services from our network of providers within a capacidades limitadas para leer,una incapacidad auditiva reasonable amount of time. This includes the right to get o diversos antecedentes culturales y 6tnicos.Algunos timely services from specialists when you need that care. ejemplos de c6mo nuestro plan puede cumplir estos You also have the right to get your prescriptions filled or requisitos de accesibilidad incluyen,entre otros, refilled at any of our network pharmacies without long proporcionar servicios de traducci6n,servicios de delays. interpretaci6n,de teletipo o TTY(tel&fono de texto o teletipo). If you think that you are not getting your medical care or Nuestro plan tiene servicios de interpretaci6n disponibles Part D drugs within a reasonable amount of time,"How para responder las preguntas de los miembros que no to make a complaint about quality of care,waiting times, hablan ingl6s.Este documento esta disponible en espaiiol customer service,or other concerns"in the"Coverage llamando a Servicio a los Miembros.Tambi6n podemos Decisions,Appeals,and Complaints"section tells you darle informaci6n en letra grande,braille o en CD sin what you can do. costo si la necesita.Tenemos la obligaci6n de darle e informaci6n acerca de los beneficios de nuestro plan en h must protect the privacy of your personal un formato que sea accesible y adecuado para usted.Para health information obtener informaci6n de una forma que se adapte a sus Federal and state laws protect the privacy of your necesidades,llame a Servicio a los Miembros. medical records and personal health information.We protect your personal health information as required by Nuestro plan esta obligado a ofrecer a las mujeres these laws. inscritas la opci6n de acceder directamente a un • Your personal health information includes the especialista en salud femenina dentro de la red para los personal information you gave us when you enrolled servicios de atenci6n m6dica preventiva y de rutina para in our plan as well as your medical records and other la mujer. medical and health information Si los proveedores de nuestra red para una especialidad . You have rights related to your information and no estan disponibles,es nuestra responsabilidad buscar controlling how your health information is used.We proveedores fuera de la red que le proporcionen la give you a written notice,called a Notice of Privacy atenci6n necesaria.En este caso,usted solo pagara el Practices,that tells you about these rights and costo compartido dentro de la red. Si se encuentra en una explains how we protect the privacy of your health situaci6n en la que no hay especialistas dentro de nuestra information red que cubran el servicio que necesita,llamenos para recibir informaci6n sobre a d6nde acudir para obtener How do we protect the privacy of your health este servicio con un costo compartido dentro de la red. information? Si tiene algun problema para obtener informaci6n de • We make sure that unauthorized people don't see or nuestro plan en un formato que sea accesible y adecuado change your records para usted,para ver a un especialista en salud femenina o . Except for the circumstances noted below,if we para encontrar un especialista de la red,llame a Servicio intend to give your health information to anyone who a los Miembros para presentar una queja.Tambi6n puede isn't providing your care or paying for your care,we presentar una queja ante Medicare,llamando al 1-800- are required to get written permission from you or by MEDICARE(1-800-633-4227)o directamente en la someone you have given legal power to make Oficina de Derechos Civiles al 1-800-368-1019 o TTY decisions for you first 1-800-537-7697. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 64 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Your health information is shared with your Group • Information about your coverage and the rules only with your authorization or as otherwise you must follow when using your coverage permitted by law ♦ the"How to Obtain Services"and`Benefits and • There are certain exceptions that do not require us to Your Cost Share"sections provide information get your written permission first.These exceptions regarding medical services are allowed or required by law ♦ the"Outpatient Prescription Drugs,Supplies,and ♦ we are required to release health information to Supplements"in the`Benefits and Your Cost government agencies that are checking on quality Share"section provides information about of care coverage for certain drugs ♦ because you are a Member of our plan through ♦ if you have questions about the rules or Medicare,we are required to give Medicare your restrictions,please call Member Services health information,including information about • Information about why something is not covered your Part D prescription drugs.If Medicare and what you can do about it releases your information for research or other ♦ the"Coverage Decisions,Appeals,and uses,this will be done according to federal statutes Complaints"section provides information on and regulations;typically,this requires that asking for a written explanation on why a medical information that uniquely identifies you not be service or Part D drug is not covered,or if your shared coverage is restricted ♦ the"Coverage Decisions,Appeals,and You can see the information in your records and Complaints"section also provides information on know how it has been shared with others asking us to change a decision,also called an You have the right to look at your medical records held appeal by our plan,and to get a copy of your records.We are allowed to charge you a fee for making copies.You also We must support your right to make decisions have the right to ask us to make additions or corrections about your care to your medical records.If you ask us to do this,we will work with your health care provider to decide whether You have the right to know your treatment options the changes should be made. and participate in decisions about your health care You have the right to get full information from your You have the right to know how your health information doctors and other health care providers when you go for has been shared with others for any purposes that are not medical care.Your providers must explain your medical routine. condition and your treatment choices in a way that you can understand. If you have questions or concerns about the privacy of your personal health information,please call Member You also have the right to participate fully in decisions Services. about your health care.To help you make decisions with your doctors about what treatment is best for you,your We must give you information about our plan, rights include the following: our Plan Providers, and your covered services . To know about all of your choices.You have the As a Member of our plan,you have the right to get right to be told about all of the treatment options that several kinds of information from us. are recommended for your condition,no matter what they cost or whether they are covered by our plan.It If you want any of the following kinds of information, also includes being told about programs our plan please call Member Services: offers to help members manage their medications and • Information about our plan.This includes,for use drugs safely example,information about our plan's financial • To know about the risks.You have the right to be condition told about any risks involved in your care.You must • Information about our network providers and be told in advance if any proposed medical care or pharmacies treatment is part of a research experiment.You ♦ you have the right to get information about the always have the choice to refuse any experimental qualifications of the providers and pharmacies in treatments our network and how we pay the providers in our • The right to say"no."You have the right to refuse network any recommended treatment.This includes the right to leave a hospital or other medical facility,even Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 65 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. if your doctor advises you not to leave.You also have • If you have not signed an advance directive form,the the right to stop taking your medication.Of course, hospital has forms available and will ask if you want if you refuse treatment or stop taking a medication, to sign one you accept full responsibility for what happens to your body as a result Remember,it is your choice whether you want to fill out an advance directive(including whether you want You have the right to give instructions about what is to sign one if you are in the hospital).According to law, to be done if you are not able to make medical no one can deny you care or discriminate against you decisions for yourself based on whether or not you have signed an advance Sometimes people become unable to make health care directive. decisions for themselves due to accidents or serious illness.You have the right to say what you want to What if your instructions are not followed? happen if you are in this situation.This means that, If you have signed an advance directive,and you believe if you want to,you can: that a doctor or hospital did not follow the instructions in • Fill out a written form to give someone the legal it,you may file a complaint with the Quality authority to make medical decisions for you if you Improvement Organization listed in the"Important ever become unable to make decisions for yourself Phone Numbers and Resources"section. • Give your doctors written instructions about how you You have the right to make complaints and to want them to handle your medical care if you become ask us to reconsider decisions we have made unable to make decisions for yourself If you have any problems,concerns,or complaints and The legal documents that you can use to give your need to request coverage,or make an appeal,the directions in advance of these situations are called "Coverage Decisions,Appeals,and Complaints"section advance directives.There are different types of advance of this document tells you what you can do. directives and different names for them.Documents called living will and power of attorney for health care Whatever you do—ask for a coverage decision,make an are examples of advance directives. appeal,or make a complaint—we are required to treat you fairly. If you want to use an advance directive to give your instructions,here is what to do: What can you do if you believe you are being treated unfairly or your rights are not being • Get the form.You can get an advance directive,a respected? form from your lawyer,from a social worker,or from some office supply stores.You can sometimes get If it is about discrimination,call the Office for Civil advance directive forms from organizations that give Rights people information about Medicare.You can also If you believe you have been treated unfairly,your contact Member Services to ask for the forms dignity has not been recognized,or your rights have not • Fill it out and sign it.Regardless of where you get been respected due to your race,disability,religion,sex, this form,keep in mind that it is a legal document. health,ethnicity,creed(beliefs),age,sexual orientation, You should consider having a lawyer help you or national origin,you should call the Department of prepare it Health and Human Services' Office for Civil Rights at 1-800-368-1019(TTY users call 1-800-537-7697)or call • Give copies to appropriate people.You should give your local Office for Civil Rights. a copy of the form to your doctor and to the person you name on the form who can make decisions for Is it about something else? you if you can't.You may want to give copies to If you believe you have been treated unfairly or your close friends or family members.Keep a copy at rights have not been respected,and it's not about home discrimination,you can get help dealing with the problem you are having: If you know ahead of time that you are going to be • You can call Member Services hospitalized,and you have signed an advance directive, take a copy with you to the hospital. • You can call the State Health Insurance Assistance Program.For details,go to the"Important Phone • The hospital will ask you whether you have signed an Numbers and Resources"section advance directive form and whether you have it with you Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 66 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Or you can call Medicare at 1-800-MEDICARE Share"section gives details about your Part D (1-800-633-4227),24 hours a day,seven days a week prescription drug coverage (TTY 1-877-486-2048) . If you have any other health insurance coverage or How to get more information about your rights prescription drug coverage in addition to our plan, There are several places where you can get more you are required to tell us. information about your rights: ♦ the"Exclusion,Limitations,Coordination of Benefits,and Reductions"section tells you about • You can call Member Services coordinating these benefits • You can call the State Health Insurance Assistance Program.For details,go to the"Important Phone • Tell your doctor and other health care providers Numbers and Resources"section that you are enrolled in our plan.Show your plan membership card whenever you get your medical care • You can contact Medicare: or Part D drugs ♦ you can visit the Medicare website to read or download the publication Medicare Rights& • Help your doctors and other providers help you by Protections.(The publication is available at giving them information,asking questions,and htti)s://www.medicare.2ov/Pubs/i)df/11534- following through on your care Medicare-Rights-and-Protections.udf) ♦ to help get the best care,tell your doctors and ♦ or you can call 1-800-MEDICARE(1-800-633- other health care providers about your health 4227),24 hours a day,seven days a week(TTY problems.Follow the treatment plans and 1-877-486-2048) instructions that you and your doctors agree upon ♦ make sure your doctors know all of the drugs you Information about new technology assessments are taking,including over-the-counter drugs, Rapidly changing technology affects health care and vitamins,and supplements medicine as much as any other industry.To determine ♦ if you have any questions,be sure to ask and get whether a new drug or other medical development has an answer you can understand long-term benefits,our plan carefully monitors and . Be considerate.We expect all our members to evaluates new technologies for inclusion as covered respect the rights of other patients.We also expect benefits.These technologies include medical procedures, you to act in a way that helps the smooth running of medical devices,and new drugs. your doctor's office,hospitals,and other offices You can make suggestions about rights and • Pay what you owe.As a plan member,you are responsibilities responsible for these payments: As a Member of our plan,you have the right to make ♦ you must continue to pay a premium for your recommendations about the rights and responsibilities Medicare Part B to remain a Member of our plan included in this section.Please call Member Services ♦ for most of your Services or Part D drugs covered with any suggestions. by our plan,you must pay your share of the cost when you get the Service or Part D drug ♦ if you are required to pay the extra amount for You have some responsibilities as a Part D because of your yearly income,you must Member of our plan continue to pay the extra amount directly to the government to remain a Member of our plan Things you need to do as a Member of our plan are listed below.If you have any questions,please call Member • If you move within your Home Region Service Services. Area,we need to know so we can keep your membership record up-to-date and know how to • Get familiar with your covered services and the contact you rules you must follow to get these covered services. Use this EOC to learn what is covered for you and the • If you move outside of your plan's Service Area, rules you need to follow to get your covered services you cannot remain a member of our plan ♦ the"How to Obtain Services"and"Benefits and • If you move,it is also important to tell Social Your Cost Share"sections give details about your Security(or the Railroad Retirement Board) medical services ♦ the"Outpatient Prescription Drugs,Supplies,and Supplements"in the"Benefits and Your Cost Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 67 Member Service:toll free 1-800-443-0815(TTY users call 711)seven days a week, 8 a.m.-8 p.m. Coverage Decisions, Appeals, and coverage determination,or at-risk determination,and Complaints independent review organization instead of Independent Review Entity. • It also uses abbreviations as little as possible. What to Do if You Have a Problem or Concern However,it can be helpful,and sometimes quite important,for you to know the correct legal terms. This section explains two types of processes for handling Knowing which terms to use will help you communicate problems and concerns: more accurately to get the right help or information for • For some problems,you need to use the process for your situation.To help you know which terms to use,we include legal terms when we give the details for handling coverage decisions and appeals specific types of situations. • For other problems,you need to use the process for making complaints,also called grievances Where To Get More Information and Both of these processes have been approved by Personalized Assistance Medicare.Each process has a set of rules,procedures, and deadlines that must be followed by you and us. We are always available to help you.Even if you have a complaint about our treatment of you,we are obligated The guide under"To Deal with Your Problem,Which to honor your right to complain. Therefore,you should Process Should You Use?"in this"Coverage Decisions, always reach out to Member Services for help.But in Appeals,and Complaints"section will help you identify some situations you may also want help or guidance the right process to use and what you should do. from someone who is not connected with us.Below are two entities that can assist you. Hospice care If you have Medicare Part A,your hospice care is State Health Insurance Assistance Program covered by Original Medicare and it is not covered under (SHIP) this EOC.Therefore,any complaints related to the Each state has a government program with trained coverage of hospice care must be resolved directly with counselors. The program is not connected with us or with Medicare and not through any complaint or appeal any insurance company or health plan.The counselors at procedure discussed in this EOC.Medicare complaint this program can help you understand which process you and appeal procedures are described in the Medicare should use to handle a problem you are having.They can handbook Medicare&You,which is available from your also answer your questions,give you more information, local Social Security office,at and offer guidance on what to do. httys://www.medicare.2ov,or by calling toll free 1-800- MEDICARE(1-800-633-4227)(TTY users call 1-877- The services of SHIP counselors are free.You will find 486-2048),24 hours a day,seven days a week.If you do phone numbers and website URLs in the"Important not have Medicare Part A,Original Medicare does not Phone Numbers and Resources"section. cover hospice care.Instead,we will provide hospice care,and any complaints related to hospice care are Medicare subject to this"Coverage Decisions,Appeals,and You can also contact Medicare to get help.To contact Complaints"section. Medicare: • You can call 1-800-MEDICARE(1-800-633-4227), What about the legal terms? 24 hours a day,seven days a week(TTY 1-877-486- There are legal terms for some of the rules,procedures, 2048) and types of deadlines explained in this"Coverage . You can also visit the Medicare website Decisions,Appeals,and Complaints"section.Many of these terms are unfamiliar to most people and can be (https://www.medicare.gov) hard to understand. To Deal with Your Problem, Which To make things easier,this section: Process Should You Use? • Uses simpler words in place of certain legal terms. For example,this section generally says making a If you have a problem or concern,you only need to read complaint rather than filing a grievance,coverage the parts of this section that apply to your situation.The decision rather than organization determination or guide that follows will help. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 68 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Is your problem or concern about your benefits or Making an appeal coverage? If we make a coverage decision,whether before or after a This includes problems about whether medical care benefit is received,and you are not satisfied,you can (medical items,services and/or Part B prescription appeal the decision.An appeal is a formal way of asking drugs)are covered or not,the way they are covered,and us to review and change a coverage decision we have problems related to payment for medical care made.Under certain circumstances,which we discuss later,you can request an expedited or fast appeal of a • Yes.Go to A Guide to the Basics of Coverage coverage decision.Your appeal is handled by different Decisionss and Appeals" reviewers than those who made the original decision. • No. Skip ahead to"How to Make a Complaint About Quality of Care,Waiting Times,Customer Service,or When you appeal a decision for the first time,this is Other Concerns" called a Level 1 appeal.In this appeal,we review the coverage decision we have made to check to see if we A Guide to the Basics of Coverage were properly following the rules.When we have Decisions and Appeals completed the review,we give you our decision. Asking for coverage decisions and making In limited circumstances,a request for a Level 1 appeal appeals—the big picture will be dismissed,which means we won't review the Coverage decisions and appeals deal with problems request.Examples of when a request will be dismissed related to your benefits and coverage for your medical include if the request is incomplete,if someone makes care(services,items and Part B prescription drugs, the request on your behalf but isn't legally authorized to including payment).To keep things simple,we generally do so or if you ask for your request to be withdrawn.If refer to medical items,services and Medicare Part B we dismiss a request for a Level 1 appeal,we will send a prescription drugs as medical care.You use the coverage notice explaining why the request was dismissed and decision and appeals process for issues such as whether how to ask for a review of the dismissal. something is covered or not,and the way in which something is covered. If we say no to all or part of your Level 1 appeal for Asking for coverage decisions prior to receiving medical care,your appeal will automatically go on to a benefits Level 2 appeal conducted by an independent review A coverage decision is a decision we make about your organization that is not connected to us. benefits and coverage or about the amount we will pay • You do not need to do anything to start a Level 2 for your medical care.For example,if your Plan appeal.Medicare rules require we automatically send Physician refers you to a medical specialist not inside the your appeal for medical care to Level 2 if we do not network,this referral is considered a favorable coverage fully agree with your Level 1 appeal decision unless either your Plan Physician can show that you received a standard denial notice for this medical • See"Step-by-step:How a Level appeal is done"of specialist,or the EOC makes it clear that the referred this chapter for more information about Level service is never covered under any condition.You or appeals your doctor can also contact us and ask for a coverage • For Part D drug appeals,if we say no to all or part of decision,if your doctor is unsure whether we will cover a your appeal you will need to ask for a Level 2 appeal. particular medical service or refuses to provide medical Part D appeals are discussed further in"Your Part D care you think that you need.In other words,if you want Prescription Drugs: How to Ask for a Coverage to know if we will cover a medical care before you Decision or Make an Appeal"of this section) receive it,you can ask us to make a coverage decision for you. If you are not satisfied with the decision at the Level 2 appeal,you may be able to continue through additional We are making a coverage decision for you whenever we levels of appeal.("Taking Your Appeal to Level 3 and decide what is covered for you and how much we pay.In Beyond"in this section explains the Level 3,4,and 5 some cases,we might decide medical care is not covered appeals processes). or is no longer covered by Medicare for you.If you disagree with this coverage decision,you can make an appeal. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 69 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. How to get help when you are asking for a from your local bar association or other referral coverage decision or making an appeal service.There are also groups that will give you free Here are resources if you decide to ask for any kind of legal services if you qualify.However,you are not coverage decision or appeal a decision: required to hire a lawyer to ask for any kind of You can call us at Member Services coverage decision or appeal a decision • • You can get free help from your State Health Which section gives the details for your Insurance Assistance Program situation? • Your doctor can make a request for you.If your There are four different situations that involve coverage doctor helps with an appeal past Level 2,they will decisions and appeals. Since each situation has different need to be appointed as your representative.Please rules and deadlines,we give the details for each one in a call Member Services and ask for the Appointment separate section: of Representative form.(The form is also available • "Your Medical Care:How to Ask for a Coverage on Medicare's website at Decision or Make an Appeal of a Coverage Decision" https://www.cms.zov[Medicare/CMS-Forms/ CMS-Forms/downloads/cros1696.pdf or on our • "four Part D Prescription Drugs:How to Ask for a website at kp.or2 Coverage Decision or Make an Appeal" ♦ for medical care or Medicare Part B prescription • "How to Ask Us to Cover a Longer Inpatient Hospital drugs,your doctor can request a coverage decision Stay if You Think the Doctor Is Discharging You Too or a Level 1 appeal on your behalf.If your appeal Soon" is denied at Level 1,it will be automatically . "How to Ask Us to Keep Covering Certain Medical forwarded to Level 2 Services if You Think Your Coverage is Ending Too ♦ for Part D prescription drugs,your doctor or other Soon"(applies only to these services:home health prescriber can request a coverage decision or a care,Skilled Nursing Facility care,and Level 1 appeal on your behalf If your Level 1 Comprehensive Outpatient Rehabilitation Facility appeal is denied,your doctor or prescriber can (CORF)services) request a Level 2 appeal • You can ask someone to act on your behalf.If you If you're not sure which section you should be using, want to,you can name another person to act for you please call Member Services.You can also get help or as your representative to ask for a coverage decision information from government organizations such as your or make an appeal SHIP. ♦ if you want a friend,relative,or other person to be your representative,call Member Services and ask Your Medical Care: How to Ask for a for the Appointment of Representative form. (The Coverage Decision or Make an Appeal form is also available on Medicare's website at httys://www.cros.2ov/Medicare/CMS-Forms/ of a Coverage Decision CMS-Forms/downloads/cros1696.pdf or on our This section tells what to do if you have website at kp.or2.)The form gives that person problems getting coverage for medical care or permission to act on your behalf.It must be signed if you want us to pay you back for our share of by you and by the person whom you would like to the cost of your care act on your behalf.You must give us a copy of the This section is about your benefits for medical care. signed form These benefits are described in the"Benefits and Your ♦ while we can accept an appeal request without the Cost Share"section.In some cases,different rules apply form,we cannot begin or complete our review to a request for a Medicare Part B prescription drug.In until we receive it.If we do not receive the form those cases,we will explain how the rules for Medicare within 44 calendar days after receiving your Part B prescription drugs are different from the rules for appeal request(our deadline for making a decision medical items and services. on your appeal),your appeal request will be dismissed.If this happens,we will send you a This section tells you what you can do if you are in any written notice explaining your right to ask the of the following situations: independent review organization to review our decision to dismiss your appeal. • You are not getting certain medical care you want, and you believe that this is covered by our plan.Ask • You also have the right to hire a lawyer.You may for a coverage decision contact your own lawyer,or get the name of a lawyer Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 70 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • We will not approve the medical care your doctor or decision.If we do not approve a fast coverage other medical provider wants to give you,and you decision,we will send you a letter that: believe that this care is covered by our plan.Ask for ♦ explains that we will use the standard deadlines a coverage decision ♦ explains if your doctor asks for the fast coverage • You have received medical care that you believe decision,we will automatically give you a fast should be covered by our plan,but we have said we coverage decision will not pay for this care.Make an appeal ♦ explains that you can file a fast complaint about • You have received and paid for medical care that you our decision to give you a standard coverage believe should be covered by our plan,and you want decision instead of the fast coverage decision you to ask us to reimburse you for this care. Send us the requested bill • You are being told that coverage for certain medical Step 2: Ask our plan to make a coverage decision or fast coverage decision care you have been getting that we previously approved will be reduced or stopped,and you believe • Start by calling,writing,or faxing our plan to make that reducing or stopping this care could harm your your request for us to authorize or provide coverage health.Make an appeal for the medical care you want.You,your doctor,or Note: If the coverage that will be stopped is for hospital your representative can do this.The"Important Phone Services,home health care,Skilled Nursing Facility care, Numbers and Resources"section has contact or Comprehensive Outpatient Rehabilitation Facility information (CORF)services,you need to read"How to Ask Us to Cover a Longer Inpatient Hospital Stay if You Think the Step 3: We consider your request for medical care Doctor Is Discharging You Too Soon"and"How to Ask coverage and give you our answer Us to Keep Covering Certain Medical Services if You For standard coverage decisions,we use the standard Think Your Coverage is Ending Too Soon"of this deadlines. section. Special rules apply to these types of care. This means we will give you an answer within 14 Step-by-step: How to ask for a coverage calendar days after we receive your request for a medical decision item or service.If your request is for a Medicare Part B When a coverage decision involves your medical care,it prescription drug,we will give you an answer within 72 is called an organization determination.A fast hours after we receive your request. coverage decision is called an expedited determination. ♦ however,if you ask for more time,or if we need Step 1: Decide if you need a standard coverage more information that may benefit you,we can decision or a fast coverage decision. take up to 14 more days if your request is for a medical item or service.If we take extra days,we A standard coverage decision is usually made within 14 will tell you in writing.We can't take extra time to days or 72 hours for Part B drugs.A fast coverage make a decision if your request is for a Medicare decision is generally made within 72 hours,for medical Part B prescription drug services,or 24 hours for Part B drugs.In order to get a ♦ if you believe we should not take extra days,you fast coverage decision,you must meet two requirements: can file a fast complaint.We will give you an ♦ you may only ask for coverage for medical items answer to your complaint as soon as we make the and/or services not requests for payment for items decision. (The process for making a complaint is and/or services already received different from the process for coverage decisions ♦ you can get a fast coverage decision only if using and appeals. See"How to Make a Complaint About Quality of Care,Waiting Times,Customer the standard deadlines could cause serious harm to Service,or Other Concerns"of this section for your health or hurt your ability to function information on complaints.) • If your doctor tells us that your health requires a fast coverage decision,we will automatically agree to For fast coverage decisions,we use an expedited time give you a fast coverage decision frame. • If you ask for a fast coverage decision on your own, without your doctor's support,we will decide whether A fast coverage decision means we will answer within 72 your health requires that we give you a fast coverage hours if your request is for a medical item or service.If your request is for a Medicare Part B prescription drug, we will answer within 24 hours. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 71 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. ♦ however,if you ask for more time,or if we need Step 2: Ask our plan for an appeal or a fast appeal more information that may benefit you we can . If you are asking for a standard appeal,submit your take up to 14 more days.If we take extra days,we will tell you in writing.We can't take extra time to standard appeal in writing.You may also ask for an make a decision if your request is for a Medicare appeal by calling us.The"Important Phone Numbers and Resources"section has contact information Part B prescription drug ♦ if you believe we should not take extra days,you • If you are asking for a fast appeal,make your appeal can file a fast complaint. See"How to Make a in writing or call us.The"Important Phone Numbers Complaint About Quality of Care,Waiting Times, and Resources"section has contact information Customer Service,or Other Concerns"of this • You must make your appeal request within 60 section for information on complaints.)We will calendar days from the date on the written notice we call you as soon as we make the decision. sent to tell you our answer on the coverage decision. ♦ if we do not give you our answer within 72 hours If you miss this deadline and have a good reason for (or if there is an extended time period,by the end missing it,explain the reason your appeal is late when of that period),or within 24 hours if your request you make your appeal.We may give you more time is for a Medicare Part B prescription drug,you to make your appeal.Examples of good cause may have the right to appeal."Step-by-step:How to include a serious illness that prevented you from make a Level 1 Appeal"below tells you how to contacting us or if we provided you with incorrect or make an appeal incomplete information about the deadline for ♦ If our answer is no to part or all of what you requesting an appeal requested,we will send you a written statement • You can ask for a copy of the information regarding that explains why we said no your medical decision.You and your doctor may add more information to support your appeal.We are Step 4: If we say no to your request for coverage allowed to charge a fee for copying and sending this for medical care, you can appeal information to you • If we say no,you have the right to ask us to reconsider this decision by making an appeal.This Step 3: We consider your appeal and we give you means asking again to get the medical care coverage our answer you want.If you make an appeal,it means you are • When we are reviewing your appeal,we take a going on to Level 1 of the appeals process careful look at all of the information.We check to see if we were following all the rules when we said no to Step-by-step: How to make a Level 1 appeal your request An appeal to our plan about a medical care coverage • We will gather more information if needed possibly decision is called a plan reconsideration.A fast appeal contacting you or your doctor is also called an expedited reconsideration. Step 1: Decide if you need a standard appeal or a Deadlines for a fast appeal fast appeal • For fast appeals,we must give you our answer within 72 hours after we receive your appeal.We will give A standard appeal is usually made within 30 days or you our answer sooner if your health requires us to 7 days for Part B drugs.A fast appeal is generally made within 72 hours. ♦ however,if you ask for more time,or if we need more information that may benefit you,we can • If you are appealing a decision we made about take up to 14 more days if your request is for a coverage for care that you have not yet received,you medical item or service.If we take extra days,we and/or your doctor will need to decide if you need a will tell you in writing.We can't take extra time if fast appeal.If your doctor tells us that your health your request is for a Medicare Part B prescription requires a fast appeal,we will give you a fast appeal drug • The requirements for getting a fast appeal are the ♦ if we do not give you an answer within 72 hours same as those for getting a fast coverage decision in (or by the end of the extended time period if we "Your Medical Care:How to Ask for a Coverage took extra days),we are required to automatically Decision or Make an Appeal"of this section send your request on to Level 2 of the appeals process,where it will be reviewed by an independent review organization. "Step-by-Step: Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 72 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. How a Level 2 Appeal is Done"explains the Level Step-by-step: How a Level 2 appeal is done 2 appeal process The formal name for the independent review • If our answer is yes to part or all of what you organization is the Independent Review Entity.It is requested,we must authorize or provide the coverage sometimes called the IRE. we have agreed to provide within 72 hours after we receive your appeal The independent review organization is an independent • If our answer is no to part or all of what you organization hired by Medicare.It is not connected with us and is not a government agency. This organization requested,we will send you our decision in writing decides whether the decision we made is correct or if it and automatically forward your appeal to the should be changed.Medicare oversees its work. independent review organization for a Level 2 appeal. The independent review organization will notify you Step 1: The independent review organization in writing when it receives your appeal reviews your appeal Deadlines for a standard appeal • We will send the information about your appeal to • For standard appeals,we must give you our answer this organization.This information is called your case within 30 calendar days after we receive your appeal. file.You have the right to ask us for a copy of your If your request is for a Medicare Part B prescription case file.We are allowed to charge you a fee for drug you have not yet received,we will give you our copying and sending this information to you answer within 7 calendar days after we receive your • You have a right to give the independent review appeal.We will give you our decision sooner if your organization additional information to support your health condition requires us to appeal ♦ however,if you ask for more time,or if we need • Reviewers at the independent review organization more information that may benefit you,we can will take a careful look at all of the information take up to 14 more calendar days if your request is related to your appeal for a medical item or service.If we take extra days,we will tell you in writing.We can't take If you had a fast appeal at Level 1,you will also have extra time to make a decision if your request is for a fast appeal at Level 2 a Medicare Part B prescription drug • For the fast appeal,the review organization must give ♦ if you believe we should not take extra days,you you an answer to your Level 2 appeal within 72 hours can file a fast complaint.When you file a fast of when it receives your appeal complaint,we will give you an answer to your complaint within 24 hours.(See"How to Make a • However,if your request is for a medical item or Complaint About Quality of Care,Waiting Times, service and the independent review organization Customer Service,or Other Concerns"in this needs to gather more information that may benefit "Coverage Decisions,Appeals,and Complaints" you,it can take up to 14 more calendar days.The section) independent review organization can't take extra time ♦ if we do not give you an answer by the deadline to make a decision if your request is for a Medicare (or by the end of the extended time period),we Part B prescription drug will send your request to a Level 2 appeal,where If you had a standard appeal at Level 1,you will also an independent review organization will review have a standard appeal at Level 2 the appeal.Later in this section,we talk about this review organization and explain the Level 2 • For the standard appeal,if your request is for a appeal process medical item or service,the review organization must • If our answer is yes to part or all of what you give you an answer to your Level 2 appeal within 30 requested,we must authorize or provide the coverage calendar days of when it receives your appeal.If your within 30 calendar days if your request is for a request is for a Medicare Part B prescription drug,the medical item or service,or within 7 calendar days if review organization must give you an answer to your your request is for a Medicare Part B prescription Level 2 appeal within 7 calendar days of when it drug receives your appeal • If our plan says no to part or all of what your appeal, • However,if your request is for a medical item or we will automatically send your appeal to the service and the independent review organization needs to gather more information that may benefit independent review organization for a Level appeal you,it can take up to 14 more calendar days.The independent review organization can't take extra time Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 73 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. to make a decision if your request is for a Medicare What if you are asking us to pay you for our Part B prescription drug share of a bill you have received for medical care? Step 2: The independent review organization gives The"Requests for Payment"section describes when you you their answer may need to ask for reimbursement or to pay a bill you The independent review organization will tell you its have received from a provider.It also tells you how to decision in writing and explain the reasons for it. send us the paperwork that asks us for payment. • If the review organization says yes to part or all of a Asking for reimbursement is asking for a request for a medical item or service,we must coverage decision from us authorize the medical care coverage within 72 hours or provide the service within 14 calendar days after If you send us the paperwork asking for reimbursement, we receive the decision from the review organization you are asking for a coverage decision.To make this for standard requests.For expedited requests,we have decision,we will check to see if the medical care you 72 hours from the date we receive the decision from paid for is covered.We will also check to see if you the review organization followed all the rules for using your coverage for medical care. • If the review organization says yes to part or all of a . If we say yes to your request:If the medical care is request for a Medicare Part B prescription drug,we must authorize or provide the Medicare Part B covered and you followed all the rules,we will send prescription drug within 72 hours after we receive the you the payment for our share of the cost within 60 decision from the review organization for standard calendar days after we receive your request.If you requests.For expedited requests,we have 24 hours haven't paid for the medical care,we will send the from the date we receive the decision from the review payment directly to the provider organization • If we say no to your request: If the medical care is not • If this organization says no to part or all of your covered,or you did not follow all the rules,we will appeal,it means they agree with us that your request not send payment.Instead,we will send you a letter (or part of your request)for coverage for medical care that says we will not pay for the medical care and the should not be approved. (This is called upholding the reasons why decision or turning down your appeal) If you do not agree with our decision to turn you down, • In this care,the independent review organization will you can make an appeal.If you make an appeal,it means send you a letter: you are asking us to change the coverage decision we ♦ explaining its decision made when we turned down your request for payment. ♦ notifying you of the right to a Level 3 appeal if the dollar value of the medical care coverage meets a To make this appeal,follow the process for appeals that certain minimum.The written notice you get from we describe in"Step-by-step:How to make a Level 1 the independent review organization will tell you Appeal."For appeals concerning reimbursement,please the dollar amount you must meet to continue the note: appeals process • We must give you our answer within 60 calendar days after we receive your appeal.If you are asking us to Step 3: If your case meets the requirements, you pay you back for medical care you have already choose whether you want to take your appeal received and paid for yourself,you are not allowed to further ask for a fast appeal • There are three additional levels in the appeals • If the independent review organization decides we process after Level 2(for a total of five levels of should pay,we must send you or the provider the appeal).If you want to go to a Level 3 appeal the payment within 30 calendar days.If the answer to details on how to do this are in the written notice you your appeal is yes at any stage of the appeals process get after your Level 2 appeal after Level 2,we must send the payment you • The Level 3 appeal is handled by an Administrative requested to you or to the provider within 60 calendar Law Judge or attorney adjudicator."Taking Your days Appeal to Level 3 and Beyond"in this"Coverage Decisions,Appeals,and Complaints"section explains the Levels 3,4,and 5 appeals processes Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 74 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Your Part D Prescription Drugs: How to • Asking us to cover a Part D drug that is not on our Ask for a Coverage Decision or Make an 2024 Comprehensive Formulary.Ask for an Appeal exception • Asking us to waive a restriction on our plan's What to do if you have problems getting a Part D coverage for a drug(such as limits on the amount of drug or you want us to pay you back for a Part D the drug you can get).Ask for an exception drug • Asking to pay a lower cost-sharing amount for a Your benefits include coverage for many prescription covered drug on a higher cost-sharing tier.Ask for an drugs.To be covered,the drug must be used for a exception medically accepted indication.(A"medically accepted indication"is a use of the drug that is either approved by • Asking us to get pre-approval for a drug.Ask for a the Food and Drug Administration or supported by coverage decision certain reference books.)For details about Part D drugs, . Pay for a prescription drug you already bought.Ask rules,restrictions,and costs,please see"Outpatient us to pay you back Prescription Drugs,Supplies,and Supplements"in the "Benefits and Your Cost Share"section. This section is If you disagree with a coverage decision we have made, about your Part D drugs only.To keep things simple, you can appeal our decision. we generally say drug in the rest of this section,instead of repeating covered outpatient prescription drug or This section tells you both how to ask for coverage Part D drug every time.We also use the term"Drug decisions and how to request an appeal. List"instead of List of Covered Drugs or 2024 Comprehensive Formulary. What is an exception? • If you do not know if a drug is covered or if you meet Asking for coverage of a drug that is not on the Drug the rules,you can ask us. Some drugs require that you List is sometimes called asking for a formulary get approval from us before we will cover it exception. • If your pharmacy tells you that your prescription Asking for removal of a restriction on coverage for a cannot be filled as written,the pharmacy will give drug is sometimes called asking for a formulary you a written notice explaining how to contact us to exception. ask for a coverage decision If a drug is not covered in the way you would like it to be Part D coverage decisions and appeals covered,you can ask us to make an exception.An An initial coverage decision about your Part D drugs is exception is a type of coverage decision. called a coverage determination. For us to consider your exception request,your doctor or A coverage decision is a decision we make about your other prescriber will need to explain the medical reasons benefits and coverage or about the amount we will pay why you need the exception approved.Here are two for your drugs.This section tells what you can do if you examples of exceptions that you or your doctor or other are in any of the following situations: prescriber can ask us to make: • Covering a Part D drug for you that is not on our "Drug List."If we agree to cover a drug that is not on the"Drug List,"you will need to pay the Cost Share amount that applies to drugs in the brand-name drug tier.You cannot ask for an exception to the Copayment or Coinsurance amount we require you to pay for the drug • Removing a restriction for a covered Part D drug. "Outpatient Prescription Drugs,Supplies,and Supplements"in the"Benefits and Your Cost Share" section describes the extra rules or restrictions that apply to certain drugs on our"Drug List."If we agree to make an exception and waive a restriction for you, you can ask for an exception to the Copayment or Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 75 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Coinsurance amount we require you to pay for the • If your doctor or other prescriber tells us that Part D drug your health requires a fast coverage decision,we will automatically give you a fast coverage decision Important things to know about asking for • If you ask for a fast coverage decision on your Part D exceptions own,without your doctor's or prescriber's support,we Your doctor must tell us the medical reasons will decide whether your health requires that we give Your doctor or other prescriber must give us a statement you a fast coverage decision.If we do not approve a that explains the medical reasons for requesting a Part D fast coverage decision,we will send you a letter that: exception.For a faster decision,include this medical ♦ explains that we will use the standard deadlines information from your doctor or other prescriber when ♦ explains if your doctor or other prescriber asks for you ask for the exception. the fast coverage decision,we will automatically give you a fast coverage decision Typically,our"Drug List"includes more than one drug ♦ tells you how you can file a fast complaint about for treating a particular condition.These different our decision to give you a standard coverage possibilities are called alternative drugs.If an decision instead of the fast coverage decision you alternative drug would be just as effective as the drug requested.We will answer your complaint within you are requesting and would not cause more side effects 24 hours of receipt or other health problems,we will generally not approve your request for an exception.If you ask us for a tiering Step 2: Request a standard coverage decision or a exception,we will generally not approve your request for fast coverage decision an exception unless all the alternative drugs in the lower cost-sharing tier(s)won't work as well for you or are Start by calling,writing,or faxing OptumRx Prior likely to cause an adverse reaction or other harm. Authorization Member Services Desk to make your request for us to authorize or provide coverage for the We can say yes or no to your request medical care you want.You can also access the coverage • If we approve your request for a Part D exception,our decision process through our website.We must accept any written request,including a request submitted on the approval usually is valid until the end of the plan CMS Model Coverage Determination Request form, year.This is true as long as your doctor continues to which is available on our website."How to contact us prescribe the drug for you and that drug continues to when you are asking for a coverage decision about your be safe and effective for treating your condition Part D prescription drugs"in the"Important Phone • If we say no to your request,you can ask for another Numbers and Resources"section has contact review by making an appeal information.To assist us in processing your request, please be sure to include your name,contact information, Step-by-step: How to ask for a coverage and information identifying which denied claim is being decision, including a Part D exception appealed. A fast coverage decision is called an expedited coverage You,or your doctor(or other prescriber),or your determination. representative can do this.You can also have a lawyer act on your behalf."How to Get Help When You are Step 1: Decide if you need a standard coverage Asking for a Coverage Decision or Making an Appeal" decision or a fast coverage decision of this section tells how you can give written permission Standard coverage decisions are made within 72 hours to someone else to act as your representative. after we receive your doctor's statement.Fast coverage • If you are requesting a Part D exception,provide the decisions are made within 24 hours after we receive supporting statement which is the medical reasons for your doctor's statement. the exception.Your doctor or other prescriber can fax If your health requires it,ask us to give you a fast or mail the statement to us.Or your doctor or other coverage decision.To get a fast coverage decision,you prescriber can tell us on the phone and follow up by must meet two requirements: faxing or mailing a written statement if necessary • You must be asking for a drug you have not yet received. (You cannot ask for a fast coverage decision to be paid back for a drug you have already bought) • Using the standard deadlines could cause serious harm to your health or hurt your ability to function Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 76 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Step 3: We consider your request and we give you Deadlines for a standard coverage decision about our answer payment for a drug you have already bought Deadlines for a fast coverage decision • We must give you our answer within 14 calendar days after we receive your request • We must generally give you our answer within 24 hours after we receive your request. ♦ if we do not meet this deadline,we are required to send your request to Level 2 of the appeals ♦ for exceptions,we will give you our answer within process,where it will be reviewed by an 24 hours after we receive your doctor's supporting independent review organization statement.We will give you our answer sooner . If our answer is yes to part or all of what you if your health requires us to requested,we are also required to make payment to ♦ if we do not meet this deadline,we are required to you within 14 calendar days after we receive your send your request to Level 2 of the appeals request process,where it will be reviewed by an independent review organization • If our answer is no to part or all of what you requested,we will send you a written statement that • If our answer is yes to part or all of what you explains why we said no.We will also tell you how requested,we must provide the coverage we have agreed to provide within 24 hours after we receive you can appeal your request or doctor's statement supporting your Step 4: If we say no to your coverage request, you request decide if you want to make an appeal • If our answer is no to part or all of what you requested,we will send you a written statement that If we say no,you have the right to ask us to reconsider explains why we said no.We will also tell you how this decision by making an appeal.This means asking you can appeal again to get the drug coverage you want.If you make an appeal,it means you are going to Level 1 of the appeals Deadlines for a standard coverage decision about a process. Part D drug you have not yet received Step-by-step: How to make a Level 1 appeal • We must generally give you our answer within 72 An appeal to our plan about a Part D drug coverage hours after we receive your request decision is called a plan redetermination.A fast appeal ♦ for exceptions,we will give you our answer within is also called an expedited redetermination. 72 hours after we receive your doctor's supporting statement.We will give you our answer sooner Step 1: Decide if you need a standard appeal or a if your health requires us to fast appeal ♦ if we do not meet this deadline,we are required to A standard appeal is usually made within 7 days.A send your request on to Level 2 of the appeals fast appeal is generally made within 72 hours.If your process,where it will be reviewed by an health requires it,ask for a fast appeal independent review organization • If our answer is yes to part or all of what you • If you are appealing a decision we made about a drug requested,we must provide the coverage we have you have not yet received,you and your doctor or agreed to provide within 72 hours after we receive other prescriber will need to decide if you need a fast your request or doctor's statement supporting your appeal request • The requirements for getting a"fast appeal"are the • If our answer is no to part or all of what you same as those for getting a fast coverage decision in requested,we will send you a written statement that "Step-by-step:How to ask for a coverage decision, explains why we said no.We will also tell you how including a Part D exception"of this section you can appeal Step 2: You, your representative, doctor, or other prescriber must contact us and make your Level 1 appeal. If your health requires a quick response, you must ask for a fast appeal • For standard appeals,submit a written request. "Important Phone Numbers and Resources"has contact information Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 77 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • For fast appeals either submit your appeal in writing Deadlines for a standard appeal for a drug you have or call us at 1-800-443-0815."Important Phone not yet received Numbers and Resources"has contact information • For standard appeals,we must give you our answer • We must accept any written request,including a within 7 calendar days after we receive your appeal. request submitted on the CMS Model Coverage We will give you our decision sooner if you have not Determination Request Form,which is available on received the drug yet and your health condition our website.Please be sure to include your name, requires us to do so contact information,and information regarding your ♦ if we do not give you a decision within 7 calendar claim to assist us in processing your request days,we are required to send your request on to • You must make your appeal request within 60 Level 2 of the appeals process,where it will be calendar days from the date on the written notice we reviewed by an independent review organization sent to tell you our answer on the coverage decision. • If our answer is yes to part or all of what you If you miss this deadline and have a good reason for requested,we must provide the coverage as quickly as missing it,explain the reason your appeal is late when your health requires,but no later than 7 calendar days you make your appeal.We may give you more time to make your appeal.Examples of good cause may after we receive your appeal include a serious illness that prevented you from • If our answer is no to part or all of what you contacting us or if we provided you with incorrect or requested,we will send you a written statement that incomplete information about the deadline for explains why we said no and how you can appeal our requesting an appeal decision • You can ask for a copy of the information in your Deadlines for a standard appeal about payment for a appeal and add more information.You and your drug you have already bought doctor may add more information to support your appeal.We are allowed to charge a fee for copying • We must give you our answer within 14 calendar days and sending this information to you after we receive your request ♦ If we do not meet this deadline,we are required to Step 3: We consider your appeal and we give you send your request to Level 2 of the appeals our answer process,where it will be reviewed by an • When we are reviewing your appeal,we take another independent review organization careful look at all of the information about your • If our answer is yes to part or all of what you coverage request.We check to see if we were requested,we are also required to make payment to following all the rules when we said no to your you within 30 calendar days after we receive your request.We may contact you or your doctor or other request prescriber to get more information • If our answer is no to part or all of what you requested,we will send you a written statement that Deadlines for a fast appeal explains why we said no.We will also tell you how • For fast appeals,we must give you our answer within you can appeal our decision 72 hours after we receive your appeal.We will give you our answer sooner if your health requires us to Step 4: If we say no to your appeal, you decide ♦ if we do not give you an answer within 72 hours, if you want to continue with the appeals process we are required to send your request on to Level 2 and make another appeal of the appeals process,where it will be reviewed • If you decide to make another appeal,it means your by an independent review organization appeal is going on to Level 2 of the appeals process • If our answer is yes to part or all of what you requested,we must provide the coverage we have Step-by-step: How to make a Level 2 appeal agreed to provide within 72 hours after we receive The formal name for the independent review your appeal organization is the Independent Review Entity. It is • If our answer is no to part or all of what you sometimes called the IRE. requested,we will send you a written statement that The independent review organization is an explains why we said no and how you can appeal our independent organization hired by Medicare.It is not decision connected with us and is not a government agency.This organization decides whether the decision we made is Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 78 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. correct or if it should be changed.Medicare oversees its Step 3: The independent review organization give work. you their answer For fast appeals: Step 1: You (or your representative or your doctor or other prescriber) must contact the independent • If the independent review organization says yes to review organization and ask for a review of your part or all of what you requested,we must provide the case drug coverage that was approved by the review organization within 24 hours after we receive the • If we say no to your Level I appeal,the written notice decision from the review organization we send you will include instructions on how to make a Level 2 appeal with the independent review For standard appeals: organization. These instructions will tell who can • If the independent review organization says yes to make this Level 2 appeal,what deadlines you must part or all of your request for coverage,we must follow,and how to reach the review organization.If, provide the drug coverage that was approved by the however,we did not complete our review within the review organization within 72 hours after we receive applicable timeframe,or make an unfavorable the decision from the review organization decision regarding at-risk determination under our drug management program,we will automatically • If the independent review organization says yes to forward your claim to the IRE part or all of your request to pay you back for a drug you already bought,we are required to send payment • We will send the information about your appeal to to you within 30 calendar days after we receive the this organization.This information is called your case decision from the review organization file.You have the right to ask us for a copy of your case file.We are allowed to charge you a fee for What if the review organization says no to your copying and sending this information to you appeal? • You have a right to give the independent review If this organization says no to your appeal,it means the organization additional information to support your organization agrees with our decision not to approve appeal your request(or part of your request.)(This is called upholding the decision.It is also called turning down Step 2: The independent review organization your appeal.)In this case,the independent review reviews your appeal organization will send you a letter: Reviewers at the independent review organization will • Explaining its decision take a careful look at all of the information related to your appeal. • Notifying you of the right to a Level 3 appeal if the dollar value of the drug coverage you are requesting Deadlines for fast appeal meets a certain minimum.If the dollar value of the drug coverage you are requesting is too low,you • If your health requires it,ask the independent review cannot make another appeal and the decision at Level organization for a fast appeal 2 is final • If the organization agrees to give you a fast appeal, • Telling you the dollar value that must be in dispute to the organization must give you an answer to your continue with the appeals process Level 2 appeal within 72 hours after it receives your appeal request Step 4: If your case meets the requirements, you Deadlines for standard appeal choose whether you want to take your appeal further • For standard appeals,the review organization must give you an answer to your Level appeal within 7 • There are three additional levels in the appeals calendar days after it receives your appeal if it is fora process after Level (for a total of five levels of drug you have not yet received.If you are requesting appeal) that we pay you back for a drug you have already • If you want to go on to a Level 3 appeal the details on bought,the review organization must give you an how to do this are in the written notice you get after answer to your Level 2 appeal within 14 calendar your Level 2 appeal decision days after it receives your request • The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator."Taking Your Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 79 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Appeal to Level 3 and Beyond"tells more about • You will be asked to sign the written notice to Levels 3,4,and 5 of the appeals process show that you received it and understand your rights How to Ask Us to Cover a Longer ♦ you or someone who is acting on your behalf will Inpatient Hospital Stay if You Think You be asked to sign the notice ♦ signing the notice shows only that you have Are Being Discharged Too Soon received the information about your rights.The When you are admitted to a hospital,you have the right notice does not give your discharge date. Signing to get all of your covered hospital Services that are the notice does not mean you are agreeing on a necessary to diagnose and treat your illness or injury. discharge date • Keep your copy of the notice handy so you will have During your covered hospital stay,your doctor and the the information about making an appeal(or reporting hospital staff will be working with you to prepare for the a concern about quality of care)if you need it day when you will leave the hospital.They will help ♦ if you sign the notice more than two days before arrange for care you may need after you leave. your discharge date,you will get another copy • The day you leave the hospital is called your before you are scheduled to be discharged discharge date ♦ to look at a copy of this notice in advance,you can • When your discharge date is decided,your doctor or call Member Services or 1-800-MEDICARE (1-800-633-4227)(TTY users call 1-877-486- the hospital staff will tell you 2048),24 hours a day,seven days a week.You • If you think you are being asked to leave the hospital can also see the notice online at too soon,you can ask for a longer hospital stay and https://www.cros.zov[Medicare/Medicare- your request will be considered General- InformationBNI/HospitalDischarEeAppealNoti During your inpatient hospital stay,you will get ces.html a written notice from Medicare that tells about your rights Step-by-step: How to make a Level 1 appeal to Within two days of being admitted to the hospital,you change your hospital discharge date will be given a written notice called An Important If you want to ask for your inpatient hospital Message from Medicare About Your Rights. Everyone services to be covered by us for a longer time,you with Medicare gets a copy of this notice If you do not get will need to use the appeals process to make this the notice from someone at the hospital(for example,a request.Before you start,understand what you need caseworker or nurse),ask any hospital employee for it. to do and what the deadlines are. If you need help,please call Member Services or 1-800- MEDICARE(1-800-633-4227),24 hours a day,seven • Follow the process days a week(TTY 1-877-486-2048). • Meet the deadlines • Read this notice carefully and ask questions if you • Ask for help if you need it.If you have questions or don't understand it.It tells you: need help at any time,please call Member Services. ♦ your right to receive Medicare-covered services Or call your State Health Insurance Assistance during and after your hospital stay,as ordered by Program,a government organization that provides your doctor. This includes the right to know what personalized assistance these services are,who will pay for them,and where you can get them During a Level 1 appeal,the Quality Improvement ♦ your right to be involved in any decisions about Organization reviews your appeal.It checks to see your hospital stay if your planned discharge date is medically appropriate ♦ where to report any concerns you have about the for you. quality of your hospital Services ♦ your right to request an immediate review of the The Quality Improvement Organization is a group of decision to discharge you if you think you are doctors and other health care professionals paid by the being discharged from the hospital too soon.This federal government to check on and help improve the is a formal,legal way to ask for a delay in your quality of care for people with Medicare.This includes discharge date so that we will cover your hospital reviewing hospital discharge dates for people with care for a longer time Medicare.These experts are not part of our plan. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 80 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Step 1: Contact the Quality Improvement Step 2: The Quality Improvement Organization Organization for your state and ask for an conducts an independent review of your case immediate review of your hospital discharge. You Health professionals at the Quality Improvement must act quickly Organization(the reviewers)will ask you(or your How can you contact this organization? representative)why you believe coverage for the services should continue.You don't have to prepare • The written notice you received(An Important anything in writing,but you may do so if you wish Message from Medicare About Your Rights)tells you how to reach this organization.Or find the name, • The reviewers will also look at your medical address,and phone number of the Quality information,talk with your doctor,and review Improvement Organization for your state in the information that the hospital and we have given to "Important Phone Numbers and Resources"section them • By noon of the day after the reviewers told us of your Act quickly appeal,you will get a written notice from us that • To make your appeal,you must contact the Quality gives you your planned discharge date.This notice Improvement Organization before you leave the also explains in detail the reasons why your doctor, hospital and no later than midnight the day of your the hospital,and we think it is right(medically discharge appropriate)for you to be discharged on that date ♦ if you meet this deadline,you may stay in the Step 3: Within one full day after it has all the hospital after your discharge date without paying needed information, the Quality Improvement for it while you wait to get the decision from the Organization will give you its answer to your appeal Quality Improvement Organization ♦ if you do not meet this deadline,and you decide to What happens if the answer is yes? stay in the hospital after your planned discharge • If the review organization says yes,we must keep date,you may have to pay all of the costs for hospital Services you receive after your planned providing your covered inpatient hospital services for as long as these services are medically necessary discharge date • If you miss the deadline for contacting the Quality • You will have to keep paying your share of the costs Improvement Organization and you still wish to (such as Cost Share,if applicable). In addition,there appeal,you must make an appeal directly to our plan may be limitations on your covered hospital services instead.For details about this other way to make your appeal,see"What if you miss the deadline for making What happens if the answer is no? your Level 1 appeal?" • If the review organization says no,they are saying Once you request an immediate review of your hospital that your planned discharge date is medically discharge,the Quality Improvement Organization will appropriate.If this happens,our coverage for your contact us.By noon of the day after we are contacted,we inpatient hospital services will end at noon on the day will give you a Detailed Notice of Discharge.This notice after the Quality Improvement Organization gives gives your planned discharge date and explains in detail you its answer to your appeal the reasons why your doctor,the hospital,and we think it • If the review organization says no to your appeal and is right(medically appropriate)for you to be discharged you decide to stay in the hospital,then you may have on that date. to pay the full cost of hospital Services you receive after noon on the day after the Quality Improvement You can get a sample of the Detailed Notice of Organization gives you its answer to your appeal Discharge by calling Member Services or 1-800- MEDICARE(1-800-633-4227)24 hours a day,seven Step 4: If the answer to your Level 1 appeal is no, days a week(TTY users call 1-877-486-2048).Or you you decide if you want to make another appeal can see a sample notice online at • If the Quality Improvement Organization has said no htti)s://www.cros.2ov[Medicare/Medicare-General- to your appeal,and you stay in the hospital after your Information/BNI/HospitalDischargeAppealNotices.ht planned discharge date,then you can make another ml appeal.Making another appeal means you are going on to Level 2 of the appeals process Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 81 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Step-by-step: How to make a Level 2 appeal to details on how to do this are in the written notice you change your hospital discharge date get after your Level 2 appeal decision During a Level 2 appeal,you ask the Quality • The Level 3 appeal is handled by an Administrative Improvement Organization to take another look at their Law Judge or attorney adjudicator.The"Taking Your decision on your first appeal.If the Quality Improvement Appeal to Level 3 and Beyond"section tells you more Organization turns down your Level 2 appeal,you may about Levels 3,4,and 5 of the appeals process have to pay the full cost for your stay after your planned discharge date. What if you miss the deadline for making your Level 1 appeal to change your hospital Step 1: Contact the Quality Improvement discharge date? Organization again and ask for another review You must ask for this review within 60 calendar days A fast review(or fast appeal)is also called an expedited • after the day the Quality Improvement Organization appeal. said no to your Level 1 appeal.You can ask for this You can appeal to us instead review only if you stay in the hospital after the date As explained above,you must act quickly to start your that your coverage for the care ended Level 1 appeal of your hospital discharge date.If you miss the deadline for contacting the Quality Review Step 2: The Quality Improvement Organization Organization,there is another way to make your appeal. does a second review of your situation If you use this other way of making your appeal,the first • Reviewers at the Quality Improvement Organization two levels of appeal are different. will take another careful look at all of the information related to your appeal Step-by-step: How to make a Level 1 alternate appeal Step 3: Within 14 calendar days of receipt of your request for a Level 2 appeal, the reviewers will Step 1: Contact us and ask for a fast review decide on your appeal and tell you their decision • Ask for a fast review.This means you are asking us If the review organization says yes to give you an answer using the fast deadlines rather than the standard deadlines.The"Important Phone • We must reimburse you for our share of the costs of Numbers and Resources"section has contact hospital Services you have received since noon on the information day after the date your first appeal was turned down by the Quality Improvement Organization.We must Step 2: We do a fast review of your planned continue providing coverage for your inpatient discharge date, checking to see if it was medically hospital Services for as long as it is medically appropriate necessary • You must continue to pay your share of the costs,and • During this review,we take a look at all of the coverage limitations may apply information about your hospital stay.We check to see if your planned discharge date was medically appropriate.We will see if the decision about when If the review organization says no you should leave the hospital was fair and followed • It means they agree with the decision they made on all the rules your Level 1 appeal.This is called upholding the decision Step 3: We give you our decision within 72 hours • The notice you get will tell you in writing what you after you ask for a fast review can do if you wish to continue with the review • If we say yes to your appeal,it means we have agreed process with you that you still need to be in the hospital after the discharge date.We will keep providing your Step 4: If the answer is no, you will need to decide covered inpatient hospital services for as long as they whether you want to take your appeal further by are medically necessary.It also means that we have going on to Level 3 agreed to reimburse you for our share of the costs of • There are three additional levels in the appeals care you have received since the date when we said process after Level 2(for a total of five levels of your coverage would end.(You must pay your share appeal).If you want to go to a Level 3 appeal,the of the costs,and there may be coverage limitations that apply) Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 82 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • If we say no to your appeal,we are saying that your • If this organization says no to your appeal,it means planned discharge date was medically appropriate. they agree that your planned hospital discharge date Our coverage for your inpatient hospital services ends was medically appropriate as of the day we said coverage would end ♦ the written notice you get from the independent • If you stayed in the hospital after your planned review organization will tell how to start a Level 3 discharge date,then you may have to pay the full appeal with the review process which is handled cost of hospital Services you received after the by an Administrative Law Judge or attorney planned discharge date adjudicator Step 4: If we say no to your appeal, your case will Step 3: If the independent review organization turns automatically be sent on to the next level of the down your appeal, you choose whether you want to appeals process take your appeal further • There are three additional levels in the appeals Step-by-step: Level 2 alternate appeal process process after Level 2(for a total of five levels of The formal name for the independent review appeal).If reviewers say no to your Level 2 appeal, organization is the Independent Review Entity.It is you decide whether to accept their decision or go on sometimes called the IRE. to Level 3 appeal • "Taking Your Appeal to Level 3 and Beyond"in this The independent review organization is an independent "Coverage Decisions,Appeals,and Complaints" organization hired by Medicare.It is not connected with section tells you more about Levels 3,4,and 5 of the our plan and is not a government agency.This appeals process organization decides whether the decision we made is correct or if it should be changed.Medicare oversees its work. How to Ask Us to Keep Covering Certain Medical Services if You Think Your Step 1: We will automatically forward your case to Coverage Is Ending Too Soon the independent review organization We are required to send the information for your Level 2 Home health care, Skilled Nursing Facility care, appeal to the independent review organization within 24 and Comprehensive Outpatient Rehabilitation hours of when we tell you that we are saying no to your Facility (CORF) services first appeal.(If you think we are not meeting this deadline or other deadlines,you can make a complaint. When you are getting covered home health services, "How to Make a Complaint About Quality of Care, Skilled Nursing Facility care,or rehabilitation care Waiting Times,Customer Service,or Other Concerns"in (Comprehensive Outpatient Rehabilitation Facility), this"Coverage Decisions,Appeals,and Complaints" you have the right to keep getting your services for that section tells you how to make a complaint.) type of care for as long as the care is needed to diagnose and treat your illness or injury. Step 2: The independent review organization does a fast review of your appeal. The reviewers give When we decide it is time to stop covering any of the you an answer within 72 hours three types of care for you,we are required to tell you in advance.When your coverage for that care ends,we will • Reviewers at the independent review organization stop paying our share of the cost for your care. will take a careful look at all of the information related to your appeal of your hospital discharge If you think we are ending the coverage of your care too • If this organization says yes to your appeal,then we soon,you can appeal our decision.This section tells you must pay you back for our share of the costs of how to ask for an appeal. hospital Services you received since the date of your planned discharge.We must also continue our plan's We will tell you in advance when your coverage coverage of your inpatient hospital services for as will be ending long as it is medically necessary.You must continue The Notice of Medicare Non-Coverage tells how you to pay your share of the costs.If there are coverage can request a fast-track appeal.Requesting a fast-track limitations,these could limit how much we would appeal is a formal,legal way to request a change to our reimburse or how long we would continue to cover coverage decision about when to stop your care. your services Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 83 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • You receive a notice in writing at least two days Act quickly before our plan is going to stop covering your care. • You must contact the Quality Improvement The notice tells you: Organization to start your appeal by noon of the day ♦ the date when we will stop covering the care for before the effective date on the Notice of Medicare you Non-Coverage ♦ how to request a fast-track appeal to request us to . If you miss the deadline for contacting the Quality keep covering your care for a longer period of Improvement Organization,and you still wish to file time an appeal,you must make an appeal directly to us • You,or someone who is acting on your behalf,will instead.For details about this other way to make your be asked to sign the written notice to show that appeal,see"Step-by-step:How to make a Level 2 you received it.Signing the notice shows only that appeal to have our plan cover your care for a longer you have received the information about when your time" coverage will stop. Signing it does not mean you agree with the plan's decision to stop care Step 2: The Quality Improvement Organization conducts an independent review of your case Step-by-step: How to make a Level 1 appeal to The Detailed Explanation of Non-Coverage provides have our plan cover your care for a longer time details on reasons for ending coverage. If you want to ask us to cover your care for a longer period of time,you will need to use the appeals What happens during this review? process to make this request.Before you start, . Health professionals at the Quality Improvement understand what you need to do and what the Organization(the reviewers)will ask you or your deadlines are. representative why you believe coverage for the • Follow the process services should continue.You don't have to prepare Meet the deadlines anything in writing,but you may do so if you wish • • Ask for help if you need it.If you have questions or • The review organization will also look at your need help at any time,please call Member Services. medical information,talk with your doctor,and Or call your State Health Insurance Assistance review information that our plan has given to them Program,a government organization that provides • By the end of the day the reviewers tell us of your personalized assistance appeal,you will get the Detailed Explanation of Non-Coverage from us that explains in detail our During a Level 1 appeal,the Quality Improvement reasons for ending our coverage for your services. Organization reviews your appeal.It decides if the end date for your care is medically appropriate. Step 3: Within one full day after they have all the information they need, the reviewers will tell you The Quality Improvement Organization is a group of their decision doctors and other health care experts who are paid by the What happens if the reviewers say yes? federal government to check on and help improve the quality of care for people with Medicare.This includes • If the reviewers say yes to your appeal,then we must reviewing plan decisions about when it's time to stop keep providing your covered services for as long as it covering certain kinds of medical care.These experts are is medically necessary not part of our plan. • You will have to keep paying your share of the costs (such as Cost Share,if applicable).There may be Step 1: Make your Level 1 appeal: contact the limitations on your covered services Quality Improvement Organization and ask for a fast-track appeal. You must act quickly What happens if the reviewers say no? How can you contact this organization? • If the reviewers say no,then your coverage will end • The written notice you received(Notice of Medicare on the date we have told you Non-Coverage)tells you how to reach this • If you decide to keep getting the home health care,or organization. Or find the name,address,and phone Skilled Nursing Facility care,or Comprehensive number of the Quality Improvement Organization for Outpatient Rehabilitation Facility(CORF)services your state in the"Important Phone Numbers and after this date when your coverage ends,then you will Resources"section have to pay the full cost of this care yourself Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 84 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Step 4: If the answer to your Level 1 appeal is no, Step 4: If the answer is no, you will need to decide you decide if you want to make another appeal whether you want to take your appeal further • If reviewers say no to your Level 1 appeal,and you • There are three additional levels of appeal after Level choose to continue getting care after your coverage 2,for a total of five levels of appeal.If you want to go for the care has ended,then you can make a Level 2 on to a Level 3 appeal,the details on how to do this appeal are in the written notice you get after your Level 2 appeal decision Step-by-step: How to make a Level 2 appeal to • The Level 3 appeal is handled by an Administrative have our plan cover your care for a longer time Law Judge or attorney adjudicator."Taking Your During a Level 2 appeal,you ask the Quality Appeal to Level 3 and Beyond"in this"Coverage Improvement Organization to take another look at the Decisions,Appeals,and Complaints"section tells you decision on your first appeal.If the Quality Improvement more about Levels 3,4,and 5 of the appeals process Organization turns down your Level 2 appeal,you may have to pay the full cost for your home health care,or What if you miss the deadline for making your Skilled Nursing Facility care,or Comprehensive Level 1 appeal? Outpatient Rehabilitation Facility(CORF)services after the date when we said your coverage would end. You can appeal to us instead As explained above,you must act quickly to contact the Step 1: Contact the Quality Improvement Quality Improvement Organization to start your first Organization again and ask for another review appeal(within a day or two,at the most).If you miss the • You must ask for this review within 60 days after the deadline for contacting this organization,there is another day when the Quality Improvement Organization said way to make your appeal.If you use this other way of no to your Level I appeal.You can ask for this making your appeal,the first two levels of appeal are review only if you continued getting care after the different. date that your coverage for the care ended Step-by-step: How to make a Level 1 alternate Step 2: The Quality Improvement Organization appeal does a second review of your situation A fast review(or fast appeal)is also called an expedited Reviewers at the Quality Improvement Organization will appeal. take another careful look at all of the information related to your appeal Step 1: Contact us and ask for a fast review Step 3: Within 14 days of receipt of your appeal • Ask for a fast review.This means you are asking us request, reviewers will decide on your appeal and to give you an answer using the fast deadlines rather tell you their decision than the standard deadlines.The"Important Phone Numbers and Resources"section has contact What happens if the review organization says yes? information • We must reimburse you for our share of the costs of Step 2: We do a fast review of the decision we care you have received since the date when we said made about when to end coverage for your services your coverage would end.We must continue providing coverage for the care for as long as it is • During this review,we take another look at all of the medically necessary information about your case.We check to see if we • You must continue to pay your share of the costs and were following all the rules when we set the date for there maybe coverage limitations that apply ending our plan's coverage for services you were receiving What happens if the review organization says no? • It means they agree with the decision we made to Step 3: We give you our decision within 72 hours your Level 1 appeal after you ask for a fast review • If we say yes to your appeal,it means we have agreed • The notice you get will tell you in writing what you with you that you need services longer,and will keep can do if you wish to continue with the review process.It will give you the details about how to go providing your covered services for as long as it is on to the next level of appeal,which is handled by an medically necessary.It also means that we have Administrative Law Judge or attorney adjudicator agreed to reimburse you for our share of the costs of care you have received since the date when we said Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 85 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. your coverage would end. (You must pay your share the care for as long as it is medically necessary.You of the costs and there may be coverage limitations must continue to pay your share of the costs.If there that apply) are coverage limitations,these could limit how much • If we say no to your appeal,then your coverage will we would reimburse or how long we would continue end on the date we told you and we will not pay any to cover your services share of the costs after this date • If this organization says no to your appeal,it means • If you continued to get home health care,or Skilled they agree with the decision our plan made to your Nursing Facility care,or Comprehensive Outpatient first appeal and will not change it Rehabilitation Facility(CORF)services after the date ♦ the notice you get from the independent review when we said your coverage would end,then you will organization will tell you in writing what you can have to pay the full cost of this care do if you wish to go on to a Level 3 appeal Step 4: If we say no to your fast appeal, your case Step 3: If the independent review organization says will automatically go on to the next level of the no to your appeal, you choose whether you want to appeals process take your appeal further The formal name for the independent review • There are three additional levels of appeal after Level organization is the Independent Review Entity.It is 2,for a total of five levels of appeal.If you want to go sometimes called the IRE. on to a Level 3 appeal,the details on how to do this are in the written notice you get after your Level 2 Step-by-step: Level 2 alternate appeal process appeal decision During the Level 2 Appeal,the independent review • A Level 3 appeal is reviewed by an Administrative organization reviews the decision we made to your fast Law Judge or attorney adjudicator."Taking Your appeal.This organization decides whether the decision Appeal to Level 3 and Beyond"in this"Coverage should be changed. The independent review Decisions,Appeals,and Complaints"section tells you organization is an independent organization that is more about Levels 3,4,and 5 of the appeals process hired by Medicare.This organization is not connected with our plan and it is not a government agency.This organization is a company chosen by Medicare to handle Taking Your Appeal to Level 3 and the job of being the independent review organization. Beyond Medicare oversees its work. Levels of Appeal 3, 4, and 5 for Medical Service Step 1: We will automatically forward your case to Requests the independent review organization This section may be appropriate for you if you have We are required to send the information for your Level 2 made a Level 1 appeal and a Level 2 appeal,and both of appeal to the independent review organization within 24 your appeals have been turned down. hours of when we tell you that we are saying no to your first appeal. (If you think we are not meeting this If the dollar value of the item or medical service you deadline or other deadlines,you can make a complaint. have appealed meets certain minimum levels,you may "How to Make a Complaint About Quality of Care, be able to go on to additional levels of appeal.If the Waiting Times,Customer Service,or Other Concerns"in dollar value is less than the minimum level,you cannot this"Coverage Decisions,Appeals,and Complaints" appeal any further.The written response you receive to section tells how to make a complaint.) your Level 2 appeal will explain how to make a Level 3 appeal. Step 2: The independent review organization does a fast review of your appeal. The reviewers give For most situations that involve appeals,the last three you an answer within 72 hours levels of appeal work in much the same way.Here is who handles the review of your appeal at each of these • Reviewers at the independent review organization levels. will take a careful look at all of the information related to your appeal • If this organization says yes to your appeal,then we must pay you back for our share of the costs of care you have received since the date when we said your coverage would end.We must also continue to cover Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 86 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Level 3 appeal: An Administrative Law Judge or process.If the Council says no to your appeal,the an attorney adjudicator who works for the notice you get will tell you whether the rules allow federal government will review your appeal and you to go on to a Level 5 appeal and how to give you an answer continue with a Level 5 appeal • If the Administrative Law Judge or attorney adjudicator says yes to your appeal,the appeals Level 5 appeal: A judge at the Federal District process may or may not be over.Unlike a decision Court will review your appeal at a Level 2 appeal,we have the right to appeal a • A judge will review all of the information and decide Level 3 decision that is favorable to you.If we decide yes or no to your request.This is a final answer. to appeal,it will go to a Level 4 appeal There are no more appeal levels after the Federal ♦ if we decide not to appeal,we must authorize or District Court provide you with the medical care within 60 calendar days after receiving the Administrative Appeal Levels 3, 4, and 5 for Part D Drug Law Judge's or attorney adjudicator's decision Requests ♦ if we decide to appeal the decision,we will send This section may be appropriate for you if you have you a copy of the Level 4 appeal request with any made a Level 1 appeal and a Level 2 appeal,and both of accompanying documents.We may wait for the your appeals have been turned down. Level 4 appeal decision before authorizing or providing the medical care in dispute If the value of the Part D drug you have appealed meets a • If the Administrative Law Judge or attorney certain dollar amount,you may be able to go on to adjudicator says no to your appeal,the appeals additional levels of appeal.If the dollar amount is less, process may or may not be over you cannot appeal any further.The written response you receive to your Level 2 appeal will explain whom to ♦ if you decide to accept this decision that turns contact and what to do to ask for a Level appeal. down your appeal,the appeals process is over ♦ if you do not want to accept the decision,you can For most situations that involve appeals,the last three continue to the next level of the review process. levels of appeal work in much the same way.Here is The notice you get will tell you what to do for a who handles the review of your appeal at each of these Level 4 appeal levels. Level 4 appeal: The Medicare Appeals Council Level 3 appeal: An Administrative Law Judge or (Council)will review your appeal and give you an attorney adjudicator who works for the an answer. The Council is part of the federal federal government will review your appeal and government give you an answer • If the answer is yes,or if the Council denies our • If the answer is yes,the appeals process is over.We request to review a favorable Level 3 appeal must authorize or provide the drug coverage that was decision,the appeals process may or may not be approved by the Administrative Law Judge or over.Unlike a decision at Level 2,we have the right attorney adjudicator within 72 hours(24 hours for to appeal a Level 4 decision that is favorable to you. expedited appeals)or make payment no later than 30 We will decide whether to appeal this decision to calendar days after we receive the decision Level 5 • If the answer is no,the appeals process may or may ♦ if we decide not to appeal the decision,we must not be over authorize or provide you with the medical care within 60 calendar days after receiving the ♦ If you decide to accept this decision that turns Council's decision down your appeal,the appeals process is over ♦ if we decide to appeal the decision,we will let you ♦ If you do not want to accept the decision,you can know in writing continue to the next level of the review process. The notice you get will tell you what to do for a • If the answer is no or if the Council denies the Level 4 appeal review request,the appeals process may or may not be over ♦ if you decide to accept this decision that turns down your appeal,the appeals process is over ♦ if you do not want to accept the decision,you may be able to continue to the next level of the review Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 87 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Level 4 appeal: The Medicare Appeals Council ♦ do you feel you are being encouraged to leave our (Council)will review your appeal and give you plan? an answer. The Council is part of the federal . Waiting times government • If the answer is yes,the appeals process is over.We ♦ are you having trouble getting an appointment,or must authorize or provide the drug coverage that was waiting too long to get it? approved by the Council within 72 hours(24 hours ♦ have you been kept waiting too long by doctors, for expedited appeals)or make payment no later than pharmacists,or other health professionals?Or by 30 calendar days after we receive the decision Member Services or other staff at our plan? Examples include waiting too long on the • If the answer is no,the appeals process may or may phone,in the waiting or exam room,or getting not be over ♦ if you decide to accept this decision that turns a prescription down your appeal,the appeals process is over • Cleanliness ♦ if you do not want to accept the decision,you may ♦ are you unhappy with the cleanliness or condition be able to continue to the next level of the review of a clinic,hospital,or doctor's office? process.If the Council says no to your appeal or • Information you get from our plan denies your request to review the appeal,the ♦ did we fail to give you a required notice? notice will tell you whether the rules allow you to g ♦ is our written information hard to understand? o on to a Level 5 appeal.It will also tell you whom to contact and what to do next if you choose to continue with your appeal Timeliness (these types of complaints are all related to the timeliness of our actions related to Level 5 appeal: A judge at the Federal District coverage decisions and appeals) Court will review your appeal If you have asked for a coverage decision or made an appeal,and you think that we are not responding quickly • A judge will review all of the information and decide enough,you can make a complaint about our slowness. yes or no to your request.This is a final answer. Here are examples: There are no more appeal levels after the Federal • You asked us for a"fast coverage decision"or a"fast District Court appeal,"and we have said no,you can make a complaint How to Make a Complaint About Quality • You believe we are not meeting the deadlines for of Care, Waiting Times, Customer coverage decisions or appeals;you can make a Service, or Other Concerns complaint • You believe we are not meeting deadlines for What kinds of problems are handled by the covering or reimbursing you for certain medical complaint process? services or Part D drugs that were approved;you can The complaint process is only used for certain types of make a complaint problems.This includes problems related to quality of • You believe we failed to meet required deadlines for care,waiting times,and customer service.Here are forwarding your case to the independent review examples of the kinds of problems handled by the organization;you can make a complaint complaint process: Step-by-step: making a complaint • Quality of your medical care • A complaint is also called a grievance ♦ are you unhappy with the quality of care you have received(including care in the hospital)? • Making a complaint is also called filing a grievance • Respecting your privacy • Using the process for complaints is also called ♦ did someone not respect your right to privacy or using the process for filing a grievance share confidential information? • A fast complaint is also called an expedited • Disrespect,poor customer service,or other grievance negative behaviors ♦ has someone been rude or disrespectful to you? ♦ are you unhappy with our Member Services? Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 88 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Step 1: Contact us promptly—either by phone or in complaint.If you have a fast complaint,it means we writing will give you an answer within 24 hours • Usually calling Member Services is the first step. • If we do not agree with some or all of your If there is anything else you need to do,Member complaint or don't take responsibility for the problem Services will let you know you are complaining about,we will include our • If you do not wish to call(or you called and were not reasons in the response to you satisfied),you can put your complaint in writing and send it to us.If you put your complaint in writing,we You can also make complaints about quality of will respond to you in writing.We will also respond care to the Quality Improvement Organization in writing when you make a complaint by phone When your complaint is about quality of care,you also if you request a written response or your complaint is have two extra options: related to quality of care • You can make your complaint directly to the • If you have a complaint,we will try to resolve your Quality Improvement Organization. The Quality complaint over the phone.If we cannot resolve your Improvement Organization is a group of practicing complaint over the phone,we have a formal doctors and other health care experts paid by the procedure to review your complaints.Your grievance federal government to check and improve the care must explain your concern,such as why you are given to Medicare patients.The"Important Phone dissatisfied with the services you received.Please see Numbers and Resources"section has contact the"Important Phone Numbers and Resources" information section for whom you should contact if you have a . Or you can make your complaint to both the complaint Quality Improvement Organization and us at the ♦ you must submit your grievance to us(orally or in same time writing)within 60 calendar days of the event or incident.We must address your grievance as quickly as your health requires,but no later than You can also tell Medicare about your 30 calendar days after receiving your complaint. complaint We may extend the time frame to make our decision by up to 14 calendar days if you ask for You can submit a complaint about our plan directly to an extension,or if we justify a need for additional Medicare.To submit a complaint to Medicare,go to information and the delay is in your best interest https://www.medicare.2ov[MedicareComplaintForm/ ♦ you can file a fast grievance about our decision not home.aspx.You may also call 1-800-MEDICARE to expedite a coverage decision or appeal,or if we (1-800-633-4227).TTY/TDD users should call 1-877- extend the time we need to make a decision about 486-2048. a coverage decision or appeal.We must respond to your fast grievance within 24 hours Additional Review • The deadline for making a complaint is 60 calendar days from the time you had the problem you want to You may have certain additional rights if you remain complain about dissatisfied after you have exhausted our internal claims and appeals procedure,and if applicable,external Step 2: We look into your complaint and give you review: our answer • If your Group's benefit plan is subject to the • If possible,we will answer you right away.If you Employee Retirement Income Security Act(ERISA), call us with a complaint,we may be able to give you you may file a civil action under section 502(a)of an answer on the same phone call ERISA.To understand these rights,you should check • Most complaints are answered within 30 calendar with your Group or contact the Employee Benefits days.If we need more information and the delay is in Security Administration(part of the U.S.Department your best interest or if you ask for more time,we can of Labor)at 1-866-444-EBSA(1-866-444-3272) take up to 14 more calendar days(44 calendar days • If your Group's benefit plan is not subject to ERISA total)to answer your complaint.If we decide to take (for example,most state or local government plans extra days,we will tell you in writing and church plans),you may have a right to request • If you are making a complaint because we denied review in state court your request for a fast coverage decision or a fast appeal,we will automatically give you a fast Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 89 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Binding Arbitration "Kaiser Permanente Parties"include: For all claims subject to this"Binding Arbitration" • Kaiser Foundation Health Plan,Inc. section,both Claimants and Respondents give up the • Kaiser Foundation Hospitals right to a jury or court trial and accept the use of binding • The Permanente Medical Group,Inc. arbitration.Insofar as this"Binding Arbitration"section applies to claims asserted by Kaiser Permanente Parties, • Southern California Permanente Medical Group it shall apply retroactively to all unresolved claims that • The Permanente Federation,LLC accrued before the effective date of this EOC. Such • The Permanente Company,LLC retroactive application shall be binding only on the Kaiser Permanente Parties. • Any Southern California Permanente Medical Group or The Permanente Medical Group physician Scope of arbitration • Any individual or organization whose contract with Any dispute shall be submitted to binding arbitration if any of the organizations identified above requires all of the following requirements are met: arbitration of claims brought by one or more Member • The claim arises from or is related to an alleged Parties violation of any duty incident to or arising out of or • Any employee or agent of any of the foregoing relating to this EOC or a Member Party's relationship to Kaiser Foundation Health Plan,Inc. ("Health "Claimant"refers to a Member Party or a Kaiser Plan"),including any claim for medical or hospital Permanente Party who asserts a claim as described malpractice(a claim that medical services or items above."Respondent"refers to a Member Party or a were unnecessary or unauthorized or were Kaiser Permanente Party against whom a claim is improperly,negligently,or incompetently rendered), asserted. for premises liability,or relating to the coverage for, or delivery of,services or items,irrespective of the Rules of Procedure legal theories upon which the claim is asserted Arbitrations shall be conducted according to the Rules • The claim is asserted by one or more Member Parties for Kaiser Permanente Member Arbitrations Overseen against one or more Kaiser Permanente Parties or by by the Office of the Independent Administrator("Rules one or more Kaiser Permanente Parties against one or of Procedure")developed by the Office of the more Member Parties Independent Administrator in consultation with Kaiser • Governing law does not prevent the use of binding Permanente and the Arbitration Oversight Board. Copies arbitration to resolve the claim of the Rules of Procedure may be obtained from Member Services. Members enrolled under this EOC thus give up their Initiating arbitration right to a court or jury trial,and instead accept the use of binding arbitration except that the following types of Claimants shall initiate arbitration by serving a Demand claims are not subject to binding arbitration: for Arbitration. The Demand for Arbitration shall include the basis of the claim against the Respondents;the • Claims within the jurisdiction of the Small Claims amount of damages the Claimants seek in the arbitration; Court the names,addresses,and phone numbers of the • Claims subject to a Medicare appeal procedure as Claimants and their attorney,if any;and the names of all applicable to Kaiser Permanente Senior Advantage Respondents. Claimants shall include in the Demand for Members Arbitration all claims against Respondents that are based • Claims that cannot be subject to binding arbitration on the same incident,transaction,or relatedcircumstances. under governing law Serving demand for arbitration As referred to in this"Binding Arbitration"section, Health Plan,Kaiser Foundation Hospitals,The "Member Parties"include: Permanente Medical Group,Inc., Southern California • A Member Permanente Medical Group,The Permanente Federation, • A Member's heir,relative,or personal representative LLC,and The Permanente Company,LLC,shall be served with a Demand for Arbitration by mailing the • Any person claiming that a duty to them arises from a Demand for Arbitration addressed to that Respondent in Member's relationship to one or more Kaiser care of: Permanente Parties Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 90 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Kaiser Foundation Health Plan,Inc. expenses of the neutral arbitrator shall be paid one-half Legal Department,Professional&Public Liability by the Claimants and one-half by the Respondents. 1 Kaiser Plaza, 19th Floor Oakland,CA 94612 If the parties select party arbitrators,Claimants shall be responsible for paying the fees and expenses of their Service on that Respondent shall be deemed completed party arbitrator and Respondents shall be responsible for when received.All other Respondents,including paying the fees and expenses of their party arbitrator. individuals,must be served as required by the California Code of Civil Procedure for a civil action. Costs Except for the aforementioned fees and expenses of the Filing fee neutral arbitrator,and except as otherwise mandated by The Claimants shall pay a single,nonrefundable filing laws that apply to arbitrations under this"Binding fee of$150 per arbitration payable to"Arbitration Arbitration"section,each party shall bear the party's Account"regardless of the number of claims asserted in own attorneys' fees,witness fees,and other expenses the Demand for Arbitration or the number of Claimants incurred in prosecuting or defending against a claim or Respondents named in the Demand for Arbitration. regardless of the nature of the claim or outcome of the arbitration. Any Claimant who claims extreme hardship may request that the Office of the Independent Administrator waive General provisions the filing fee and the neutral arbitrator's fees and A claim shall be waived and forever barred if(1)on the expenses.A Claimant who seeks such waivers shall date the Demand for Arbitration of the claim is served, complete the Fee Waiver Form and submit it to the the claim,if asserted in a civil action,would be barred as Office of the Independent Administrator and to the Respondent served by the applicable statute of simultaneously serve it upon the Respondents.The Fee limitations,(2)Claimants fail to pursue the arbitration Waiver Form sets forth the criteria for waiving fees and claim in accord with the Rules of Procedure with is available by calling Member Services. reasonable diligence,or(3)the arbitration hearing is not commenced within five years after the earlier of(a)the Number of arbitrators date the Demand for Arbitration was served in accord The number of arbitrators may affect the Claimants' with the procedures prescribed herein,or(b)the date of responsibility for paying the neutral arbitrator's fees and filing of a civil action based upon the same incident, expenses(see the Rules of Procedure). transaction,or related circumstances involved in the claim.A claim may be dismissed on other grounds by the If the Demand for Arbitration seeks total damages of neutral arbitrator based on a showing of a good cause.If $200,000 or less,the dispute shall be heard and a party fails to attend the arbitration hearing after being determined by one neutral arbitrator,unless the parties given due notice thereof,the neutral arbitrator may otherwise agree in writing after a dispute has arisen and a proceed to determine the controversy in the party's request for binding arbitration has been submitted that absence. the arbitration shall be heard by two party arbitrators and one neutral arbitrator.The neutral arbitrator shall not The California Medical Injury Compensation Reform have authority to award monetary damages that are Act of 1975(including any amendments thereto), greater than$200,000. including sections establishing the right to introduce evidence of any insurance or disability benefit payment If the Demand for Arbitration seeks total damages of to the patient,the limitation on recovery for non- more than$200,000,the dispute shall be heard and economic losses,and the right to have an award for determined by one neutral arbitrator and two party future damages conformed to periodic payments,shall arbitrators,one jointly appointed by all Claimants and apply to any claims for professional negligence or any one jointly appointed by all Respondents.Parties who are other claims as permitted or required by law. entitled to select a party arbitrator may agree to waive this right.If all parties agree,these arbitrations will be Arbitrations shall be governed by this"Binding heard by a single neutral arbitrator. Arbitration"section, Section 2 of the Federal Arbitration Act,and the California Code of Civil Procedure Payment of arbitrators'fees and expenses provisions relating to arbitration that are in effect at the Health Plan will pay the fees and expenses of the neutral time the statute is applied,together with the Rules of arbitrator under certain conditions as set forth in the Procedure,to the extent not inconsistent with this Rules of Procedure.In all other arbitrations,the fees and "Binding Arbitration"section.In accord with the rule Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 91 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. that applies under Sections 3 and 4 of the Federal Your membership termination date is the first day you Arbitration Act,the right to arbitration under this are not covered.For example,if your termination date is "Binding Arbitration"section shall not be denied,stayed, January 1,2025,your last minute of coverage was at or otherwise impeded because a dispute between a 11:59 p.m. on December 31,2024. Member Party and a Kaiser Permanente Parry involves both arbitrable and nonarbitrable claims or because one Also,we will terminate your Senior Advantage or more parties to the arbitration is also a party to a membership on the last day of the month if you: pending court action with another party that arises out of . Are temporarily absent from our Service Area for the same or related transactions and presents a possibility more than six months in a row of conflicting rulings or findings. • Permanently move from our Service Area • No longer have Medicare Part B Termination of Membership • Enroll in another Medicare Health Plan(for example, a Medicare Advantage Plan or a Medicare Your Group is required to inform the Subscriber of the prescription drug plan).The Centers for Medicare& date your membership terminates.Your membership Medicaid Services will automatically terminate your termination date is the first day you are not covered(for Senior Advantage membership when your enrollment example,if your termination date is January 1,2025, in the other plan becomes effective your last minute of coverage was at 11:59 p.m.on . Are not a U.S. citizen or lawfully present in the December 31,2024).When a Subscriber's membership United States.The Centers for Medicare&Medicaid ends,the memberships of any Dependents end at the Services will notify us if you are not eligible to same time.You will be billed as a non-Member for any remain a Member on this basis.We must disenroll Services you receive after your membership terminates. you if you do not meet this requirement Health Plan and Plan Providers have no further liability or responsibility under this EOC after your membership In addition,if you are required to pay the extra Part D terminates,except: amount because of your income and you do not pay it, • As provided under"Payments after Termination"in Medicare will disenroll you from our Senior Advantage this"Termination of Membership"section Plan and you will lose prescription drug coverage. • If you are receiving covered Services as an acute care hospital inpatient on the termination date,we will Note:If you lose eligibility for Senior Advantage due to continue to cover those hospital Services(but not any of these circumstances,you may be eligible to physician Services or any other Services)until you transfer your membership to another Kaiser Permanente are discharged plan offered by your Group.Please contact your Group for information. Until your membership terminates,you remain a Senior Advantage Member and must continue to receive your Termination of Agreement medical care from us,except as described in the "Emergency Services and Urgent Care"section about If your Group's Agreement with us terminates for any Emergency Services,Post-Stabilization Care,and Out- reason,your membership ends on the same date.Your of-Area Urgent Care and the"Benefits and Your Cost Group is required to notify Subscribers in writing if its Share"section about out-of-area dialysis care. Agreement with us terminates. Note:If you enroll in another Medicare Health Plan or a prescription drug plan,your Senior Advantage Disenrolling from Senior Advantage membership will terminate as described under "Disenrolling from Senior Advantage"in this You may terminate(disenroll from)your Senior "Termination of Membership"section. Advantage membership at any time.However,before you request disenrollment,please check with your Group to determine if you are able to continue your Group Termination Due to Loss of Eligibility membership. If you no longer meet the eligibility requirements If you request disenrollment during your Group's open described under"Who Is Eligible"in the"Premiums, enrollment,your disenrollment effective date is Eligibility,and Enrollment"section your Group will determined by the date your written request is received notify you of the date that your membership will end. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 92 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. by us and the date your Group coverage ends.The Note: If you disenroll from Medicare prescription drug effective date will not be earlier than the first day of the coverage and go without creditable prescription drug following month after we receive your written request, coverage for 63 or more days in a row,you may need to and no later than three months after we receive your pay a Part D late enrollment penalty if you join a request. Medicare drug plan later. If you request disenrollment at a time other than your Group's open enrollment,your disenrollment effective Termination of Contract with the date will be the first day of the month following our Centers for Medicare & Medicaid receipt of your disenrollment request. Services You may request disenrollment by calling toll free If our contract with the Centers for Medicare&Medicaid 1-800-MEDICARE/1-800-633-4227(TTY users call Services to offer Senior Advantage terminates,your 1-877-486-2048),24 hours a day,seven days a week,or Senior Advantage membership will terminate on the sending written notice to the following address: same date.We will send you advance written notice and advise you of your health care options.Also,you may be Kaiser Foundation Health Plan,Inc. eligible to transfer your membership to another Kaiser California Service Center Permanente plan offered by your Group. P.O.Box 232400 San Diego,CA 92193-2400 Termination for Cause Other Medicare Health Plans.If you want to enroll in another Medicare Health Plan or a Medicare prescription We may terminate your membership by sending you drug plan,you should first confirm with the other plan advance written notice if you commit one of the and your Group that you are able to enroll.Your new following acts: plan or your Group will tell you the date when your • If you continuously behave in a way that is disruptive, membership in the new plan begins and your Senior to the extent that your continued enrollment seriously Advantage membership will end on that same day(your impairs our ability to arrange or provide medical care disenrollment date). for you or for our other members.We cannot make you leave our Senior Advantage Plan for this reason The Centers for Medicare&Medicaid Services will let unless we get permission from Medicare first us know if you enroll in another Medicare Health Plan, • If you let someone else use your Plan membership so you will not need to send us a disenrollment request. card to get medical care.We cannot make you leave our Senior Advantage Plan for this reason unless we Original Medicare.If you request disenrollment from get permission from Medicare first.If you are Senior Advantage and you do not enroll in another disenrolled for this reason,the Centers for Medicare Medicare Health Plan,you will automatically be enrolled &Medicaid Services may refer your case to the in Original Medicare when your Senior Advantage Inspector General for additional investigation membership terminates(your disenrollment date).On • You commit theft from Health Plan,from a Plan your disenrollment date,you can start using your red, white,and blue Medicare card to get services under Provider,or at a Plan Facility Original Medicare.You will not get anything in writing • You intentionally misrepresent membership status or that tells you that you have Original Medicare after you commit fraud in connection with your obtaining disenroll.If you choose Original Medicare and you want membership.We cannot make you leave our Senior to continue to get Medicare Part D prescription drug Advantage Plan for this reason unless we get coverage,you will need to enroll in a prescription drug permission from Medicare first plan. • If you become incarcerated(go to prison) If you receive Extra Help from Medicare to pay for your • You knowingly falsify or withhold information about prescription drugs,and you switch to Original Medicare other parties that provide reimbursement for your and do not enroll in a separate Medicare Part D prescription drug coverage prescription drug plan,Medicare may enroll you in a drug plan,unless you have opted out of automatic If we terminate your membership for cause,you will not enrollment. be allowed to enroll in Health Plan in the future until you have completed a Member Orientation and have signed a statement promising future compliance.We may report Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 93 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. fraud and other illegal acts to the authorities for of Group coverage,please examine your coverage prosecution. options carefully before declining this coverage. Individual plan premiums and coverage will be different Termination for Nonpayment of from the premiums and coverage under your Group plan. Premiums Continuation of Group Coverage If we do not receive Premiums for your Family,we may terminate the memberships of everyone in your Family. COBRA You may be able to continue your coverage under this Senior Advantage EOC for a limited time after you Termination of a Product or all Products would otherwise lose eligibility,if required by the federal Consolidated Omnibus Budget Reconciliation We may terminate a particular product or all products Act("COBRA"). COBRA applies to most employees offered in the group market as permitted or required by (and most of their covered family Dependents)of most law.If we discontinue offering a particular product in the employers with 20 or more employees. group market,we will terminate just the particular product by sending you written notice at least 90 days If your Group is subject to COBRA and you are eligible before the product terminates.If we discontinue offering for COBRA coverage,in order to enroll,you must all products in the group market,we may terminate your submit a COBRA election form to your Group within the Group's Agreement by sending you written notice at COBRA election period.Please ask your Group for least 180 days before the Agreement terminates. details about COBRA coverage,such as how to elect coverage,how much you must pay for coverage,when Payments after Termination coverage and Premiums may change,and where to send your Premium payments. If we terminate your membership for cause or for nonpayment,we will: As described in"Conversion from Group Membership to an Individual Plan"in this"Continuation of • Refund any amounts we owe for Premiums paid after Membership"section,you may be able to convert to an the termination date individual(nongroup)plan if you don't apply for • Pay you any amounts we have determined that we COBRA coverage,or if you enroll in COBRA and your owe you for claims during your membership in COBRA coverage ends. accord with the"Requests for Payment"section.We will deduct any amounts you owe Health Plan or Plan Coverage for a disabling condition Providers from any payment we make to you If you became Totally Disabled while you were a Member under your Group's Agreement with us and Review of Membership Termination while the Subscriber was employed by your Group,and your Group's Agreement with us terminates and is not If you believe that we terminated your Senior Advantage renewed,we will cover Services for your totally membership because of your ill health or your need for disabling condition until the earliest of the following care,you may file a complaint as described in the events occurs: "Coverage Decisions,Appeals,and Complaints"section. • 12 months have elapsed since your Group's Agreement with us terminated • You are no longer Totally Disabled Continuation of Membership • Your Group's Agreement with us is replaced by another group health plan without limitation as to the If your membership under this Senior Advantage EOC disabling condition ends,you may be eligible to continue Health Plan membership without a break in coverage.You may be Your coverage will be subject to the terms of this EOC, able to continue Group coverage under this Senior including Cost Share,but we will not cover Services for Advantage EOC as described under"Continuation of any condition other than your totally disabling condition. Group Coverage."Also,you may be able to continue membership under an individual plan as described under For Subscribers and adult Dependents,"Totally "Conversion from Group Membership to an Individual Disabled"means that,in the judgment of a Medical Plan."If at any time you become entitled to continuation Group physician,an illness or injury is expected to result Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 94 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. in death or has lasted or is expected to last for a Miscellaneous Provisions continuous period of at least 12 months,and makes the person unable to engage in any employment or occupation,even with training,education,and Administration of Agreement experience. We may adopt reasonable policies,procedures,and For Dependent children,"Totally Disabled"means that, interpretations to promote orderly and efficient in the judgment of a Medical Group physician,an illness administration of your Group's Agreement,including this or injury is expected to result in death or has lasted or is EOC. 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 Amendment of Agreement children in good health of like age. Your Group's Agreement with us will change periodically.If these changes affect this EOC,your To request continuation of coverage for your disabling Group is required to inform you in accord with condition,you must call Member Services within 30 applicable law and your Group's Agreement. days after your Group's Agreement with us terminates. Conversion from Group Membership to Applications and Statements an Individual Plan You must complete any applications,forms,or statements that we request in our normal course of After your Group notifies us to terminate your Group business or as specified in this EOC. 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 Assignment remain a Health Plan Member. You may not assign this EOC or any of the rights, Kaiser Permanente Conversion Plan interests,claims for money due,benefits,or obligations If you want to remain a Health Plan Member,one option hereunder without our prior written consent. that may be available is our Senior Advantage Individual Plan.You may be eligible to enroll in our individual plan Attorney and Advocate Fees and if you no longer meet the eligibility requirements described under"Who Is Eligible"in the"Premiums, Expenses Eligibility,and Enrollment"section.Individual plan In any dispute between a Member and Health Plan,the coverage begins when your Group coverage ends.The Medical Group,or Kaiser Foundation Hospitals,each premiums and coverage under our individual plan are different from those under this EOC and will include party will bear its own fees and expenses,including attorneys' fees,advocates' fees,and other expenses. Medicare Part D prescription drug coverage. However,if you are no longer eligible for Senior Claims Review Authority Advantage and Group coverage,you may be eligible to convert to our non-Medicare individual plan,called We are responsible for determining whether you are "Kaiser Permanente Individual—Conversion Plan."You entitled to benefits under this EOC and we have the may be eligible to enroll in our Individual—Conversion discretionary authority to review and evaluate claims that Plan if we receive your enrollment application within 63 arise under this EOC.We conduct this evaluation days of the date of our termination letter or of your independently by interpreting the provisions of this EOC. membership termination date(whichever date is later). We may use medical experts to help us review claims. If coverage under this EOC is subject to the Employee You may not be eligible to convert if your membership Retirement Income Security Act("ERISA")claims ends for the reasons stated under"Termination for procedure regulation(29 CFR 2560.503-1),then we are a Cause"or"Termination of Agreement"in the "named claims fiduciary"to review claims under this "Termination of Membership"section. EOC. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 95 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. EOC Binding on Members federal law shall bind Members and Health Plan whether or not set forth in this EOC. By electing coverage or accepting benefits under this EOC,all Members legally capable of contracting,and the legal representatives of all Members incapable of Group and Members Not Our Agents contracting,agree to all provisions of this EOC. Neither your Group nor any Member is the agent or representative of Health Plan. ERISA Notices This"ERISA Notices"section applies only if your No Waiver Group's health benefit plan is subject to the Employee Retirement Income Security Act("ERISA").We provide Our failure to enforce any provision of this EOC will not these notices to assist ERISA-covered groups in constitute a waiver of that or any other provision,or complying with ERISA.Coverage for Services described impair our right thereafter to require your strict in these notices is subject to all provisions of this EOC. performance of any provision. Newborns' and Mothers' Health Protection Act Notices Regarding Your Coverage Group health plans and health insurance issuers generally may not,under Federal law,restrict benefits for any Our notices to you will be sent to the most recent address hospital length of stay in connection with childbirth for we have for the Subscriber.The Subscriber is responsible the birthing person or newborn child to less than 48 for notifying us of any change in address. Subscribers hours following a vaginal delivery,or less than 96 hours who move should call Member Services and Social following a cesarean section.However,Federal law Security toll free at 1-800-772-1213(TTY users call generally does not prohibit the birthing person's or 1-800-325-0778)as soon as possible to give us their new newborn's attending provider,after consulting with the address.If a Member does not reside with the Subscriber, birthing person,from discharging the birthing person or or needs to have confidential information sent to an their newborn earlier than 48 hours(or 96 hours as address other than the Subscriber's address,they should applicable).In any case,plans and issuers may not,under contact Member Services to discuss alternate delivery Federal law,require that a provider obtain authorization options. from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours(or 96 hours). Note:When we tell your Group about changes to this EOC or provide your Group other information that Women's Health and Cancer Rights Act affects you,your Group is required to notify the If you have had or are going to have a mastectomy,you Subscriber within 30 days after receiving the information may be entitled to certain benefits under the Women's from us.The Subscriber is also responsible for notifying Health and Cancer Rights Act.For individuals receiving Group of any change in contact information. mastectomy-related benefits,coverage will be provided in a manner determined in consultation with the attending physician and the patient,for all stages of Notice about Medicare Secondary Payer reconstruction of the breast on which the mastectomy Subrogation Rights was performed,surgery and reconstruction of the other breast to produce a symmetrical appearance,prostheses, We have the right and responsibility to collect for and treatment of physical complications of the covered Medicare services for which Medicare is not the mastectomy,including lymphedemas.These benefits will primary payer.According to CMS regulations at 42 CFR be provided subject to the same Cost Share applicable to sections 422.108 and 423.462,Kaiser Permanente Senior other medical and surgical benefits provided under this Advantage,as a Medicare Advantage Organization,will plan. 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 Governing Law section supersede any state laws. Except as preempted by federal law,this EOC will be governed in accord with California law and any Overpayment Recovery provision that is required to be in this EOC by state or We may recover any overpayment we make for Services from anyone who receives such an overpayment or from Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 96 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. any person or organization obligated to pay for the How to contact us when you are asking for a Services. coverage decision or making an appeal or complaint about your Services Public Policy Participation • A coverage decision is a decision we make about your benefits and coverage or about the amount we will The Kaiser Foundation Health Plan,Inc.,Board of pay for your medical services Directors establishes public policy for Health Plan.A list • An appeal is a formal way of asking us to review and of the Board of Directors is available on our website at change a coverage decision we have made ku.ore or from Member Services.If you would like to . You can make a complaint about us or one of our provide input about Health Plan public policy for consideration by the Board,please send written network providers,including a complaint about the quality of your care.This type of complaint does not comments to: Kaiser Foundation Health Plan,Inc. involve coverage or payment disputes Office of Board and Corporate Governance Services For more information about asking for coverage One Kaiser Plaza, 19th Floor decisions or making appeals or complaints about your Oakland,CA 94612 medical care,see the"Coverage Decisions,Appeals,and Complaints"section. Telephone Access (TTY) Coverage decisions, appeals, or complaints for Services—contact information If you use a text telephone device(TTY,also known as TDD)to communicate by phone,you can use the Call 1-800-443-0815 California Relay Service by calling 711. Calls to this number are free. Seven days a week,8 a.m.to 8 p.m. Important Phone Numbers and If your coverage decision,appeal,or complaint qualifies for a fast decision as described in the Resources "Coverage Decisions,Appeals,and Complaints"section,call the Expedited Review Unit at 1-888-987-7247,8:30 a.m.to 5 p.m., Kaiser Permanente Senior Advantage Monday through Saturday. How to contact our plan's Member Services TTY 711 For assistance,please call or write to our plan's Member Calls to this number are free. Services.We will be happy to help you. Seven days a week,8 a.m.to 8 p.m. Member Services—contact information Fax If your coverage decision,appeal,or complaint Call 1-800-443-0815 qualifies for a fast decision,fax your request to Calls to this number are free. our Expedited Review Unit at 1-888-987-2252. Write For a standard coverage decision or Seven days a week,8 a.m.to 8 p.m. complaint,write to your local Member Services Member Services also has free language office(see the Provider Directory for interpreter services available for non-English locations). speakers. For a standard appeal,write to the address TTY 711 shown on the denial notice we send you. Calls to this number are free. If your coverage decision,appeal,or complaint qualifies for a fast decision,write to: Seven days a week,8 a.m.to 8 p.m. Kaiser Permanente Write Your local Member Services office(see the Expedited Review Unit Provider Directory for locations). P.O.Box 1809 Pleasanton,CA 94566 Website kp•or Medicare Website.You can submit a complaint about our Plan directly to Medicare. To submit an online Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 97 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. complaint to Medicare,go to Appeals for Part D prescription drugs—contact htti)s://www.medicare.2ov/MedicareComplaintForm/ information home.aspx. Call 1-866-206-2973 How to contact us when you are asking for a Calls to this number are free. coverage decision about your Part D Seven days a week, 8:30 a.m. to 5 p.m. prescription drugs • A coverage decision is a decision we make about your TTY 711 benefits and coverage or about the amount we will Calls to this number are free. pay for your prescription drugs covered under the Part D benefit included in your plan Seven days a week,8 a.m.to 8 p.m. Fax 1-866-206-2974 For more information about asking for coverage Write Kaiser Permanente decisions about your Part D prescription drugs,see Medicare Part D Unit the"Coverage Decisions,Appeals,and Complaints" P.O.Box 1809 section. Pleasanton,CA 94566 Coverage decisions for Part D prescription Website kn•ore drugs—contact information How to contact us when you are making a Call 1-877-645-1282 complaint about your Part D prescription drugs Calls to this number are free. You can make a complaint about us or one of our network pharmacies,including a complaint about the Seven days a week,8 a.m.to 8 p.m. quality of your care.This type of complaint does not TTY 711 involve coverage or payment disputes. (If your problem is about our plan's coverage or payment,you should look Calls to this number are free. at the section above about requesting coverage decisions Seven days a week,8 a.m.to 8 p.m. or making appeals.)For more information about making a complaint about your Part D prescription drugs,see the Fax 1-844-403-1028 "Coverage Decisions,Appeals,and Complaints"section. Write OptumRx c/o Prior Authorization Complaints for Part D prescription drugs— P.O.Box 2975 contact information Mission,KS 66201 Call 1-800-443-0815 Website kp.or Calls to this number are free. How to contact us when you are making an Seven days a week, 8 a.m.to 8 p.m. appeal about your Part D prescription drugs If your complaint qualifies for a fast decision, • An appeal is a formal way of asking us to review and call the Part D Unit at 1-866-206-2973,8:30 change a coverage decision we have made a.m.to 5 p.m.,Monday through Friday. See the "Coverage Decisions,Appeals,and For more information about making appeals about Complaints"section to find out if your issue your Part D prescription drugs,see the"Coverage qualifies for a fast decision. Decisions,Appeals,and Complaints"section.You may call us if you have questions about our appeals TTY 711 process. Calls to this number are free. Seven days a week, 8 a.m.to 8 p.m. Fax If your complaint qualifies for a fast review,fax your request to our Part D Unit at 1-866-206- 2974. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 98 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Write For a standard complaint,write to your local Provider,you can fax your request to 1-866- Member Services office(see the Provider 206-2974 or mail it to: Directory for locations). Kaiser Permanente If your complaint qualifies for a fast decision, Medicare Part D Unit write to: P.O.Box 1809 Kaiser Permanente Pleasanton,CA 94566 Medicare Part D Unit Website kp•org P.O.Box 1809 Pleasanton,CA 94566 Medicare Website.You can submit a complaint about Medicare our plan directly to Medicare.To submit an online How to get help and information directly from complaint to Medicare,go to the federal Medicare program https://www.medicare.gov[MedicareComplaintForm home.aspx. Medicare is the federal health insurance program for people 65 years of age or older,some people under age Where to send a request asking us to pay for 65 with disabilities,and people with end-stage renal our share of the cost for Services or a Part D disease(permanent kidney failure requiring dialysis or a drug you have received kidney transplant).The federal agency in charge of Medicare is the Centers for Medicare&Medicaid If you have received a bill or paid for services(such as a Services(sometimes called CMS).This agency contracts Provider bill)that you think we should pay for,you may with Medicare Advantage organizations,including our need to ask us for reimbursement or to pay the provider plan. bill. See the"Requests for Payment"section. Medicare—contact information Note:If you send us a payment request and we deny any part of your request,you can appeal our decision. See the Call 1-800-MEDICARE or 1-800-633-4227 "Coverage Decisions,Appeals,and Complaints"section Calls to this number are free.24 hours a day, for more information. seven days a week. Payment Requests—contact information TTY 1-877-486-2048 Call 1-800-443-0815 This number requires special telephone equipment and is only for people who have Calls to this number are free. difficulties with hearing or speaking. Calls to Seven days a week,8 a.m.to 8 p.m. this number are free. Note:If you are requesting payment of a Part D Website httys://www.Medicare.gov drug that was prescribed by a Plan Provider and obtained from a Plan Pharmacy,call our Part D This is the official government website for Medicare.It unit at 1-866-206-2973,8:30 a.m.to 5 p.m., gives you up-to-date information about Medicare and Monday through Friday. current Medicare issues.It also has information about TTY 711 hospitals,nursing homes,physicians,home health agencies,and dialysis facilities.It includes documents Calls to this number are free. you can print directly from your computer.You can also find Medicare contacts in your state. Seven days a week, 8 a.m.to 8 p.m. Write For medical care: The Medicare website also has detailed information Kaiser Permanente about your Medicare eligibility and enrollment options Claims Department with the following tools: P.O.Box 12923 Medicare Eligibility Tool:Provides Medicare eligibility Oakland,CA 94604-2923 status information. For Part D drugs: If you are requesting payment of a Part D drug Medicare Plan Finder:Provides personalized that was prescribed and provided by a Plan information about available Medicare prescription drug plans,Medicare Health Plans,and Medigap(Medicare Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 99 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Supplement Insurance)policies in your area.These tools • Select your state from the list.This will take you provide an estimate of what your out-of-pocket costs to a page with phone numbers and resources might be in different Medicare plans. specific to your state You can also use the website to tell Medicare about any Health Insurance Counseling and Advocacy complaints you have about our plan. Program (California's State Health Insurance Assistance Program)—contact information Tell Medicare about your complaint:You can submit a complaint about our plan directly to Medicare.To Call 1-800-434-0222 submit a complaint to Medicare,go to Calls to this number are free. https://www.medicare.i!ov[MedicareComplaintForm/ TTY 711 home.aspx.Medicare takes your complaints seriously and will use this information to help improve the quality Write Your HICAP office for your county. of the Medicare program. Website www.aging.ca.gov/HICAP/ If you don't have a computer,your local library or senior center may be able to help you visit this website using its Quality Improvement Organization computer.Or,you can call Medicare and tell them what information you are looking for.They will find the Paid by Medicare to check on the quality of care information on the website and review the information for people with Medicare with you.You can call Medicare at 1-800-MEDICARE There is a designated Quality Improvement Organization (1-800-633-4227)(TTY users call 1-877-486-2048),24 for serving Medicare beneficiaries in each state.For hours a day,7 days a week. California,the Quality Improvement Organization is called Livanta. State Health Insurance Assistance Livanta has a group of doctors and other health care Program professionals who are paid by Medicare to check on and Free help, information, and answers to your help improve the quality of care for people with questions about Medicare Medicare.Livanta is an independent organization.It is The State Health Insurance Assistance Program(SHIP) not connected with our plan. is a government program with trained counselors in You should contact Livanta in any of these situations: every state.In California,the State Health Insurance Assistance Program is called the Health Insurance • You have a complaint about the quality of care you Counseling and Advocacy Program(HICAP). have received • You think coverage for your hospital stay is ending HICAP is an independent(not connected with any too soon insurance company or health plan)state program that . You think coverage for your home health care, gets money from the federal government to give free local health insurance counseling to people with Skilled Nursing Facility care,or Comprehensive Medicare. Outpatient Rehabilitation Facility(CORF)services are ending too soon HICAP counselors can help you understand your Livanta (California's Quality Improvement Medicare rights,help you make complaints about your Organization)—contact information Services or treatment,and help you straighten out problems with your Medicare bills.HICAP counselors Call 1-877-588-1123 can also help you with Medicare questions or problems and help you understand your Medicare plan choices and Calls to this number are free.Monday through answer questions about switching plans. Friday,9 a.m.to 5 p.m Weekends and holidays 11 a.m.to 3 p.m. Method to access SHIP and other resources: TTY 1-855-887-6668 • Visit https://www.shiphelp.or2 This number requires special telephone • Click on SHIP Locator in middle of page equipment and is only for people who have difficulties with hearing or speaking. Write Livanta Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 100 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. BFCC—QIO Program Medicaid 10820 Guilford Road,Suite 202 Annapolis Junction,MD 20701-1105 A joint federal and state program that helps with medical costs for some people with limited Website www.livantagio.com/en income and resources Medicaid is a joint federal and state government program Social Security that helps with medical costs for certain people with limited incomes and resources. Some people with Social Security is responsible for determining eligibility Medicare are also eligible for Medicaid. and handling enrollment for Medicare.U.S.citizens and lawful permanent residents who are 65 or older,or who In addition,there are programs offered through Medicaid have a disability or end stage renal disease and meet that help people with Medicare pay their Medicare costs, certain conditions,are eligible for Medicare.If you are such as their Medicare premiums.These"Medicare already getting Social Security checks,enrollment into Savings Programs"help people with limited income and Medicare is automatic.If you are not getting Social resources save money each year: Security checks,you have to enroll in Medicare.To . Qualified Medicare Beneficiary(QMB):Helps pay apply for Medicare,you can call Social Security or visit Medicare Part A and Part B premiums,and other Cost your local Social Security office. Share. Some people with QMB are also eligible for Social Security is also responsible for determining who full Medicaid benefits(QMB+) has to pay an extra amount for their Part D drug coverage • Specified Low-Income Medicare Beneficiary because they have a higher income.If you got a letter (SLMB):Helps pay Part B premiums. Some people from Social Security telling you that you have to pay the with SLMB are also eligible for full Medicaid extra amount and have questions about the amount or benefits(SLMB+) if your income went down because of a life-changing • Qualifying Individual(QI):Helps pay Part B event,you can call Social Security to ask for premiums reconsideration. . Qualified Disabled&Working Individuals If you move or change your mailing address,it is (QDWI):Helps pay Part A premiums important that you contact Social Security to let them To find out more about Medicaid and its programs, know. contact Medi-Cal. Social Security—contact information Medi-Cal (California's Medicaid program)— Call 1-800-772-1213 contact information Calls to this number are free.Available 8 a.m. Call 1-800-430-4263 to 7 p.m.,Monday through Friday. Calls to this number are free.Monday through You can use Social Security's automated Friday,8 a.m.to 6 p.m. telephone services and get recorded information TTY 1-800-430-7077 24 hours a day. TTY 1-800-325-0778 This number requires special telephone equipment and is only for people who have This number requires special telephone difficulties with hearing or speaking. equipment and is only for people who have Write CA Department of Health Care Services difficulties with hearing or speaking. Calls to Health Care Options this number are free.Available 8 a.m.to 7 p.m., P.O.Box 989009 Monday through Friday. West Sacramento,CA 95798-9850 Website www.ssa.gov Website http://www.healtheareoptions.dhcs.ca.gov/ Railroad Retirement Board The Railroad Retirement Board is an independent federal agency that administers comprehensive benefit programs Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 101 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. for the nation's railroad workers and their families. If you have questions regarding your benefits from the Railroad Retirement Board,contact the agency. If you receive your Medicare through the Railroad Retirement Board,it is important that you let them know if you move or change your mailing address. Railroad Retirement Board—contact information Call 1-877-772-5772 Calls to this number are free.If you press"0," you may speak with an RRB representative from 9 a.m.to 3:30 p.m.,Monday,Tuesday, Thursday,and Friday,and from 9 a.m.to 12 p.m.on Wednesday. If you press"1,"you may access the automated RRB HelpLine and recorded information 24 hours a day,including weekends and holidays. TTY 1-312-751-4701 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are not free. Website rrb•2ov/ Group Insurance or Other Health Insurance from an Employer If you have any questions about your employer- sponsored Group plan,please contact your Group's benefits administrator.You can ask about your employer or retiree health benefits,any contributions toward the Group's premium,eligibility,and enrollment periods. If you have other prescription drug coverage through your(or your spouse's)employer or retiree group,please contact that group's benefits administrator.The benefits administrator can help you determine how your current prescription drug coverage will work with our plan. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:34 EOC'#4 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 102 Notice of Nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Permanente does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also: • Provide no cost aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters. o Written information in other formats, such as large print, audio, and accessible electronic formats. • Provide no cost language services to people whose primary language is not English, such as: o Qualified interpreters. o Information written in other languages. If you need these services, call Member Services at 1-800-443-0815 (TTY 711), 8 a.m. to 8 p.m., seven days a week. If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator by writing to One Kaiser Plaza, 12th Floor, Suite 1223, Oakland, CA 94612 or calling Member Services at the number listed above. You can file a grievance by mail or phone. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.htmi. ' KAISER PERMANEWE® 1126306860 CA June 2023 Form Approved OMB# 0938-1421 Multi-Language Insert Multi-language Interpreter Services English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-800-443-0815 (TTY 711). Someone who speaks English/Language can help you. This is a free service. Spanish: Tenemos servicios de interprete sin costo alguno pars responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un interprete, por favor Ilame al 1-800-443-0815 (TTY 711). Alguien que hable espanol le podra ayudar. Este es un servicio gratuito. Chinese Mandarin: �i] T1i �� m��J1� TI �1T7 Ip7o M4R k All i+V*, i*GAF, 1-800-443-0815 (TTY 711)0 Chinese Cantonese: 9�Y_fRfr1n, I -�AIMI-ftf,9 b"o UATWL 1-800-443-0815 (TTY 711)0 Ma X2 �r� � o Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa 1-800-443-0815 (TTY 711). Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. French: Nous proposons des services gratuits d'interpretation pour repondre a toutes vos questions relatives a notre regime de sante ou d'assurance- medicaments. Pour acceder au service d'interpretation, it vous suffit de nous appeler au 1-800-443-0815 (TTY 711). Un interlocuteur parlant Frangais pourra vous cider. Ce service est gratuit. Vietnamese: Chung toi co dich vu thong dich mien phi de tra Idi cac c3u hoi ve chLrdng sLYc khoe va chLrdng trinh thuoc men. Neu qui vi can thong dich vien xin goi 1-800-443-0815 (TTY 711) se co nh3n vien not tieng Viet giup dd qui vi. flay la dich vu mien phi . German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- and Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-800-443-0815 (TTY 711). Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Form CMS-10802 F50*111 KAISER PERMANEWE, (Expires 12/31/25) Y0043_N00036258_C Form Approved OMB# 0938-1421 Korean: oA}L I Ada fL -V-AaOil oN E�ela�} T� a 011 A] HIL I o o}� IV �}. o ��l dl o }�� 1-800-443-0815 (TTY 711) V1 0 L 914 Russian: ECJIVI y BaC B03HMKHYT BOnpOCbl OTHOCMTeJlbHO CTpaXOBOro mnm megMKaMeHTHOro nJlaHa, Bbl moweTe BOcnOJlb3OBaTbCA Hawmmm 6ecnJlaTHbIMM yCJlyramL4 nepeBOALIMKOB. LlT06bI Bocnonb30BaTbCq yCJlyram" nepeBOALI"Ka, n03BOHMTe Ham no TeneCpOHy 1-800-443-0815 (TTY 711). Bam OKaweT nOMOLL4b COTpy,gHMK, KOTOpblV rOBOPMT no-pyCCKVI. ,QaHHaq yCnyra 6ecnnaTHaA. 1-3 J�� -9I d,,�I�, �I SI L.Jc a�I�JJ �li�Li cJl s,�l �yA11 Arabic P� .1-800-443-0815 (TTY 711) Lrl,-- 13.E JL--�T s c>J 'cs,-O Lr�-- cis� H i nd i: of f-ff-dT-4ft T-cF Z[ft# 3JTQ f45t Ift-f%�-� r�-6�TTf JWT -q T#T�-Jq�t. IZW-g T Wcf qTT4-4�f�T, Zf-iF# 1-800-443-0815 (TTY 711) W q5t q?r� f-�3ftf art TriT&-qR Twmt. zF,5 7c-F ijwr#aT . Italian: E disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare it numero 1-800-443-0815 (TTY 711). Un nostro incaricato the parla Italianovi fornira I'assistenza necessaria. E un servizio gratuito. Portuguese: Dispomos de servigos de interpretagao gratuitos para responder a qualquer questao que tenha acerca do nosso plano de saude ou de medicagao. Para obter um interprete, contacte-nos atraves do numero 1-800-443-0815 (TTY 711). Ira encontrar alguem que fale o idioma Portugues para o ajudar. Este servigo e gratuito. French Creole: Nou genyen sevis entepret gratis you reponn tout kesyon ou to genyen konsenan plan medikal oswa dwog nou an. Pou jwenn you entepret, jis rele nou nan 1-800-443-0815 (TTY 711). Yon moun ki pale Kreyol kapab ede w. Sa a se you sevis ki gratis. Polish: Umo2liwiamy bezpkatne skorzystanie z uskug tkumacza ustnego, ktory pomo2e w uzyskaniu odpowiedzi na temat planu zdrowotnego Iub dawkowania lekow. Aby skorzystac z pomocy t+umacza znajacego jgzyk polski, nale2y zadzwonic pod numer 1-800-443-0815 (TTY 711). Ta uskuga jest bezpkatna. Japanese: �'iYto)1 IA RFAf A LjV- Q -7 Mlt 7.,�N1A : �3 t 76 L'V) 1-800-443-0815 (TTY 711) 6` �3 7-FE-1-Au , o L L I to fL 6t I'M f4 a)-t t:� 7, Z't Form CMS-10802 (Expires 12/31/25) 1140823727 June 2023 00 NO"71 KAISER PERMANEWEe Kaiser Foundation Health Plan, Inc. Northern California Region A nonprofit corporation EOC #5 - Kaiser Permanente Traditional HMO Plan Evidence of Coverage for COUNTY OF FRESNO, RETIREE Group ID: 604334 Contract: 1 Version: 34 EOC Number: 5 January 1,2024, through December 31, 2024 Member Services 24 hours a day, seven days a week(except closed holidays) 1-800-464-4000 (TTY users call 711) kp.org coaccum NGF ACA p103 TABLE OF CONTENTS FOR EOC #5 CostShare Summary..............................................................................................................................................................1 AccumulationPeriod..........................................................................................................................................................1 Deductibles and Out-of-Pocket Maximums.......................................................................................................................1 Cost Share Summary Tables by Benefit.............................................................................................................................1 CAREPlan.......................................................................................................................................................................18 Introduction..........................................................................................................................................................................19 AboutKaiser Permanente.................................................................................................................................................19 Termof this EOC.............................................................................................................................................................19 Definitions............................................................................................................................................................................19 Premiums,Eligibility,and Enrollment.................................................................................................................................25 Premiums..........................................................................................................................................................................25 WhoIs Eligible.................................................................................................................................................................25 How to Enroll and When Coverage Begins.....................................................................................................................28 Howto Obtain Services........................................................................................................................................................30 RoutineCare.....................................................................................................................................................................30 UrgentCare......................................................................................................................................................................30 NotSure What Kind of Care You Need?.........................................................................................................................31 YourPersonal Plan Physician..........................................................................................................................................31 Gettinga Referral.............................................................................................................................................................31 Travel and Lodging for Certain Services.........................................................................................................................34 SecondOpinions...............................................................................................................................................................34 Contractswith Plan Providers..........................................................................................................................................34 Receiving Care Outside of Your Home Region Service Area.........................................................................................35 YourID Card....................................................................................................................................................................35 TimelyAccess to Care.....................................................................................................................................................35 GettingAssistance............................................................................................................................................................36 PlanFacilities.......................................................................................................................................................................36 Emergency Services and Urgent Care..................................................................................................................................37 EmergencyServices.........................................................................................................................................................37 UrgentCare......................................................................................................................................................................38 Paymentand Reimbursement...........................................................................................................................................39 Benefits.................................................................................................................................................................................39 YourCost Share...............................................................................................................................................................40 AdministeredDrugs and Products....................................................................................................................................43 AmbulanceServices.........................................................................................................................................................43 BariatricSurgery..............................................................................................................................................................43 Behavioral Health Treatment for Autism Spectrum Disorder..........................................................................................44 Dental and Orthodontic Services......................................................................................................................................45 DialysisCare....................................................................................................................................................................46 Durable Medical Equipment("DME")for Home Use.....................................................................................................47 EmergencyServices and Urgent Care..............................................................................................................................48 FertilityServices...............................................................................................................................................................48 Fertility Preservation Services for latrogenic Infertility..................................................................................................49 HealthEducation..............................................................................................................................................................49 HearingServices...............................................................................................................................................................49 HomeHealth Care............................................................................................................................................................50 HospiceCare....................................................................................................................................................................50 HospitalInpatient Services...............................................................................................................................................51 Injuryto Teeth..................................................................................................................................................................52 MentalHealth Services....................................................................................................................................................52 OfficeVisits.....................................................................................................................................................................53 Ostomyand Urological Supplies......................................................................................................................................53 Outpatient Imaging,Laboratory,and Other Diagnostic and Treatment Services............................................................53 Outpatient Prescription Drugs, Supplies,and Supplements.............................................................................................54 Outpatient Surgery and Outpatient Procedures................................................................................................................57 PreventiveServices..........................................................................................................................................................57 Prostheticand Orthotic Devices.......................................................................................................................................58 ReconstructiveSurgery....................................................................................................................................................59 Rehabilitative and Habilitative Services..........................................................................................................................59 Reproductive Health Services..........................................................................................................................................60 Services in Connection with a Clinical Trial....................................................................................................................60 SkilledNursing Facility Care...........................................................................................................................................61 Substance Use Disorder Treatment..................................................................................................................................62 TelehealthVisits...............................................................................................................................................................62 TransplantServices..........................................................................................................................................................63 VisionServices for Adult Members.................................................................................................................................63 Vision Services for Pediatric Members............................................................................................................................64 Exclusions,Limitations,Coordination of Benefits,and Reductions...................................................................................65 Exclusions........................................................................................................................................................................65 Limitations........................................................................................................................................................................68 Coordinationof Benefits..................................................................................................................................................68 Reductions........................................................................................................................................................................69 Post-Service Claims and Appeals.........................................................................................................................................70 WhoMay File...................................................................................................................................................................71 SupportingDocuments.....................................................................................................................................................71 InitialClaims....................................................................................................................................................................72 Appeals.............................................................................................................................................................................73 ExternalReview...............................................................................................................................................................73 AdditionalReview............................................................................................................................................................74 DisputeResolution...............................................................................................................................................................74 Grievances........................................................................................................................................................................74 Independent Review Organization for Non-Formulary Prescription Drug Requests......................................................76 Department of Managed Health Care Complaints...........................................................................................................77 Independent Medical Review("IMR")............................................................................................................................77 Officeof Civil Rights Complaints....................................................................................................................................78 AdditionalReview............................................................................................................................................................78 BindingArbitration..........................................................................................................................................................78 Terminationof Membership.................................................................................................................................................81 Termination Due to Loss of Eligibility............................................................................................................................81 Terminationof Agreement................................................................................................................................................81 Terminationfor Cause......................................................................................................................................................81 Termination of a Product or all Products.........................................................................................................................81 Paymentsafter Termination.............................................................................................................................................81 State Review of Membership Termination......................................................................................................................81 Continuationof Membership................................................................................................................................................82 Continuationof Group Coverage.....................................................................................................................................82 Continuation of Coverage under an Individual Plan........................................................................................................84 MiscellaneousProvisions.....................................................................................................................................................85 Administrationof Agreement...........................................................................................................................................85 AdvanceDirectives..........................................................................................................................................................85 Amendmentof Agreement................................................................................................................................................85 Applicationsand Statements............................................................................................................................................85 Assignment.......................................................................................................................................................................85 Attorney and Advocate Fees and Expenses.....................................................................................................................85 ClaimsReview Authority.................................................................................................................................................85 EOCBinding on Members...............................................................................................................................................86 ERISANotices.................................................................................................................................................................86 GoverningLaw.................................................................................................................................................................86 Group and Members Not Our Agents..............................................................................................................................86 NoWaiver........................................................................................................................................................................86 Notices Regarding Your Coverage...................................................................................................................................86 OverpaymentRecovery....................................................................................................................................................86 PrivacyPractices..............................................................................................................................................................86 PublicPolicy Participation...............................................................................................................................................87 HelpfulInformation..............................................................................................................................................................87 How to Obtain this EOC in Other Formats......................................................................................................................87 ProviderDirectory............................................................................................................................................................87 Online Tools and Resources.............................................................................................................................................87 Document Delivery Preferences.......................................................................................................................................88 Howto Reach Us..............................................................................................................................................................88 PaymentResponsibility....................................................................................................................................................89 Cost Share Summary This"Cost Share Summary"is part of your Evidence of Coverage(EOC)and is meant to explain the amount you will pay for covered Services under this plan.It does not provide a full description of your benefits.For a full description of your benefits, including any limitations and exclusions,please read this entire EOC,including any amendments,carefully. Accumulation Period The Accumulation Period for this plan is January I through December 31. Deductibles and Out-of-Pocket Maximums For Services that apply to the Plan Out-of-Pocket Maximum,you will not pay any more Cost Share for the rest of the Accumulation Period once you have reached the amounts listed below. If your Group's plan changes during an Accumulation Period,your deductibles and out-of-pocket maximums may increase or decrease,which may change the total amount you must accumulate to reach the deductibles or out-of-pocket maximums during that Accumulation Period. Self-Only Coverage Family Coverage Family Coverage Amounts Per Accumulation Period Each Member in a Family Entire Family of two or (a Family of one Member) of two or more Members more Members Plan Deductible None None None Drug Deductible None None None Plan Out-of-Pocket Maximum("OOPM") $1,500 $1,500 $3,000 Cost Share Summary Tables by Benefit How to read the Cost Share summary tables Each table below explains the Cost Share for a category of benefits. Specific Services related to the benefit are described in the first column of each table.For a detailed description of coverage for a particular benefit,refer to the same benefit heading in the`Benefits"section of this EOC. • Copayment/Coinsurance.This column describes the Cost Share you will pay for Services after you have met your Plan Deductible or Drug Deductible,if applicable.(Please see the"Deductibles and Out-of-Pocket Maximums" section above to determine if your plan includes deductibles.)If the Services are not covered in your plan,this column will read"Not covered."If we provide an Allowance that you can use toward the cost of the Services,this column will include the Allowance. • Subject to Deductible.This column explains whether the Cost Share you pay for Services is subject to a Plan Deductible or Drug Deductible. If the Services are subject to a deductible,you will pay Charges for those Services until you have met your deductible.If the Services are subject to a deductible,there will be a"✓"or"D"in this column,depending on which deductible applies("✓"for Plan Deductible,"D"for Drug Deductible).If the Services do not apply to a deductible,or if your plan does not include a deductible,this column will be blank.For a more detailed explanation of deductibles,refer to"Plan Deductible"and"Drug Deductible"in the"Benefits"section of this EOC. • Applies to OOPM.This column explains whether the Cost Share you pay for Services counts toward the Plan Out- of-Pocket Maximum("OOPM")after you have met any applicable deductible.If the Services count toward the Plan OOPM,there will be a"✓"in this column.If the Services do not count toward the Plan OOPM,this column will be blank.For a more detailed explanation of the Plan OOPM,refer to"Plan Out-of-Pocket Maximum"heading in the "Benefits"section of this EOC. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#5 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 1 Administered drugs and products Copayment/ Subject to Applies to Description of Administered Drugs and Products Services Coinsurance Deductible OOPM Whole blood,red blood cells,plasma,and platelets No charge Allergy antigens(including administration) $3 per visit Cancer chemotherapy drugs and adjuncts No charge Drugs and products that are administered via intravenous therapy or No charge injection that are not for cancer chemotherapy,including blood factor ✓ products and biological products("biologics")derived from tissue, cells,or blood All other administered drugs and products No charge Drugs and products administered to you during a home visit No charge Ambulance Services Copayment/ Subject to Applies to Description of Ambulance Services Coinsurance Deductible OOPM Emergency ambulance Services $50 per trip Nonemergency ambulance and psychiatric transport van Services $50 per trip Behavioral health treatment for autism spectrum disorder Copayment/ Subject to Applies to Description of Behavioral Health Treatment Services Coinsurance Deductible OOPM Covered Services No charge Dialysis care Copayment/ Subject to Applies to Description of Dialysis Care Services Coinsurance Deductible OOPM Equipment and supplies for home hemodialysis and home peritoneal No charge It dialysis One routine outpatient visit per month with the multidisciplinary No charge It nephrology team for a consultation,evaluation,or treatment Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#5 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 2 Copayment/ Subject to Applies to Description of Dialysis Care Services Coinsurance Deductible OOPM Hemodialysis and peritoneal dialysis treatment at a Plan Facility $15 per visit ,/ Durable Medical Equipment("DME")for home use Copayment/ Subject to Applies to Description of DME Services Coinsurance Deductible OOPM Blood glucose monitors for diabetes blood testing and their supplies 20%Coinsurance Peak flow meters 20%Coinsurance Insulin pumps and supplies to operate the pump 20%Coinsurance Other Base DME Items as described in this EOC 20%Coinsurance Supplemental DME items as described in this EOC 20%Coinsurance Retail-grade milk pumps No charge Hospital-grade milk pumps No charge Emergency Services and Urgent Care Copayment/ Subject to Applies to Description of Emergency Services and Urgent Care Coinsurance Deductible OOPM Emergency department visits $100 per visit Urgent Care visits $15 per visit Note:If you are admitted to the hospital as an inpatient from the emergency department,the emergency department visits Cost Share above does not apply.Instead,the Services you received in the emergency department,including any observation stay,if applicable,will be considered part of your hospital inpatient stay.For the Cost Share for inpatient Services,refer to "Hospital inpatient Services"in this"Cost Share Summary."The emergency department Cost Share does apply if you are admitted for observation but are not admitted as an inpatient. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#5 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 3 Fertility Services Diagnosis and treatment of Infertility Copayment/ Subject to Applies to Description of Diagnosis and Treatment of Infertility Services Coinsurance Deductible OOPM Office visits $15 per visit Outpatient surgery and outpatient procedures(including imaging and $15 per procedure diagnostic Services)when performed in an outpatient or ambulatory surgery center or in a hospital operating room,or any setting where a licensed staff member monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or minimize discomfort Any other outpatient surgery that does not require a licensed staff $15 per procedure member to monitor your vital signs as described above Outpatient imaging No charge Outpatient laboratory No charge Outpatient administered drugs No charge Hospital inpatient Services(including room and board,drugs, No charge imaging,laboratory,other diagnostic and treatment Services,and Plan Physician Services) Artificial insemination Copayment/ Subject to Applies to Description of Artificial Insemination Services Coinsurance Deductible OOPM Office visits $15 per visit Outpatient surgery and outpatient procedures(including imaging and $15 per procedure diagnostic Services)when performed in an outpatient or ambulatory surgery center or in a hospital operating room,or any setting where a licensed staff member monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or minimize discomfort Any other outpatient surgery that does not require a licensed staff $15 per procedure member to monitor your vital signs as described above Outpatient imaging No charge Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#5 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 4 Copayment/ Subject to Applies to Description of Artificial Insemination Services Coinsurance Deductible OOPM Outpatient laboratory No charge Outpatient administered drugs No charge Hospital inpatient Services(including room and board,drugs, No charge imaging,laboratory,other diagnostic and treatment Services,and Plan Physician Services) Assisted reproductive technology("ART')Services Copayment/ Subject to Applies to Description of ART Services Coinsurance Deductible OOPM Assisted reproductive technology("ART")Services such as invitro Not covered fertilization("IVF"),gamete intra-fallopian transfer("GIFT"),or zygote intrafallopian transfer("ZIFT") Health education Copayment/ Subject to Applies to Description of Health Education Services Coinsurance Deductible OOPM Covered health education programs,which may include programs No charge ✓ provided online and counseling over the phone Individual counseling during an office visit related to tobacco No charge ✓ cessation Individual counseling during an office visit related to diabetes No charge ✓ management Other covered individual counseling when the office visit is solely for No charge ✓ health education Covered health education materials No charge Hearing Services Copayment/ Subject to Applies to Description of Hearing Services Coinsurance Deductible OOPM Hearing exams with an audiologist to determine the need for hearing $15 per visit It correction Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#5 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 5 Copayment/ Subject to Applies to Description of Hearing Services Coinsurance Deductible OOPM Physician Specialist Visits to diagnose and treat hearing problems $15 per visit ,/ Hearing aids,including,fitting,counseling,adjustment,cleaning,and We provide a$1,000 inspection Allowance for each ear every 36 months Home health care Copayment/ Subject to Applies to Description of Home Health Care Services Coinsurance Deductible OOPM Home health care Services(100 visits per Accumulation Period) No charge Hospice care Copayment/ Subject to Applies to Description of Hospice Care Services Coinsurance Deductible OOPM Hospice Services No charge Hospital inpatient Services Copayment/ Subject to Applies to Description of Hospital Inpatient Services Coinsurance Deductible OOPM Hospital inpatient stays No charge Injury to teeth Copayment/ Subject to Applies to Description of Injury to Teeth Services Coinsurance Deductible OOPM Accidental injury to teeth Not covered Mental health Services Copayment/ Subject to Applies to Description of Mental Health Services Coinsurance Deductible OOPM Inpatient mental health hospital stays No charge Individual mental health evaluation and treatment $15 per visit Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#5 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 6 Copayment/ Subject to Applies to Description of Mental Health Services Coinsurance Deductible OOPM Group mental health treatment $7 per visit Partial hospitalization No charge Other intensive psychiatric treatment programs No charge Residential mental health treatment Services No charge Office visits Copayment/ Subject to Applies to Description of Office Visit Services Coinsurance Deductible OOPM Primary Care Visits and Non-Physician Specialist Visits that are not $15 per visit ✓ described elsewhere in this"Cost Share Summary" Physician Specialist Visits that are not described elsewhere in this $15 per visit "Cost Share Summary" Group appointments that are not described elsewhere in this"Cost $7 per visit ✓ Share Summary" Acupuncture Services $15 per visit Ostomy and urological supplies Copayment/ Subject to Applies to Description of Ostomy and Urological Services Coinsurance Deductible OOPM Ostomy and urological supplies as described in this EOC No charge Outpatient imaging, laboratory, and other diagnostic and treatment Services Description of Outpatient Imaging,Laboratory,and Other Diagnostic Copayment/ Subject to Applies to and Treatment Services Coinsurance Deductible OOPM Complex imaging(other than preventive)such as CT scans,MRIs, No charge ✓ and PET scans Basic imaging Services,such as diagnostic and therapeutic X-rays, No charge ✓ mammograms,and ultrasounds Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#5 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 7 Description of Outpatient Imaging,Laboratory,and Other Diagnostic Copayment/ Subject to Applies to and Treatment Services Coinsurance Deductible OOPM Nuclear medicine No charge Routine retinal photography screenings No charge Routine laboratory tests to monitor the effectiveness of dialysis No charge All other laboratory tests(including tests for specific genetic No charge ✓ disorders for which genetic counseling is available) Diagnostic Services provided by Plan Providers who are not No charge ✓ physicians(such as EKGs and EEGs) Radiation therapy No charge Ultraviolet light treatments(including ultraviolet light therapy No charge equipment as described in this EOC) Outpatient prescription drugs, supplies, and supplements If the"Cost Share at a Plan Pharmacy"column in this section provides Cost Share for a 30-day supply and your Plan Physician prescribes more than this,you may be able to obtain more than a 30-day supply at one time up to the day supply limit for that drug.Applicable Cost Share will apply.For example,two 30-day copayments may be due when picking up a 60-day prescription,three copayments may be due when picking up a 100-day prescription at the pharmacy. Most items Cost Share Cost Share Subject to Applies to Description of Most Items at a Plan Pharmacy by Mail Deductible OOPM Items on Tier 1 not described elsewhere in $10 for up to a 30-day $20 for up to a 100-day ✓ this"Cost Share Summary" supply supply Items on Tier 2 not described elsewhere in $20 for up to a 30-day $40 for up to a 100-day ✓ this"Cost Share Summary" supply supply Items on Tier 4 not described elsewhere in $20 for up to a 30-day Availability for mail this"Cost Share Summary" supply order varies by item. ✓ Talk to your local pharmacy Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#5 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 8 Base drugs,supplies, and supplements Description of Base Drugs, Supplies and Cost Share Cost Share Subject to Applies to Supplements at a Plan Pharmacy by Mail Deductible OOPM Hematopoietic agents for dialysis No charge for up to a Not available ✓ 30-day supply Elemental dietary enteral formula when No charge for up to a Not available used as a primary therapy for regional 30-day supply ✓ enteritis All other items on Tier 1 as described in $10 for up to a 30-day Availability for mail this EOC supply order varies by item. ✓ Talk to your local pharmacy All other items on Tier 2 as described in $20 for up to a 30-day Availability for mail this EOC supply order varies by item. ✓ Talk to your local pharmacy All other items on Tier 4 as described in $20 for up to a 30-day Availability for mail this EOC supply order varies by item. ✓ Talk to your local pharmacy Anticancer drugs and certain critical adjuncts following a diagnosis of cancer Description of Anticancer Drugs and Cost Share Cost Share Subject to Applies to Certain Critical Adjuncts at a Plan Pharmacy by Mail Deductible OOPM Oral anticancer drugs on Tier 1 $10 for up to a 30-day Availability for mail supply order varies by item. ✓ Talk to your local pharmacy Oral anticancer drugs on Tier 2 $20 for up to a 30-day Availability for mail supply order varies by item. ✓ Talk to your local pharmacy Oral anticancer drugs on Tier 4 $20 for up to a 30-day Availability for mail supply order varies by item. ✓ Talk to your local pharmacy Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#5 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 9 Description of Anticancer Drugs and Cost Share Cost Share Subject to Applies to Certain Critical Adjuncts at a Plan Pharmacy by Mail Deductible OOPM Non-oral anticancer drugs on Tier 1 $10 for up to a 30-day Availability for mail supply order varies by item. ✓ Talk to your local pharmacy Non-oral anticancer drugs on Tier 2 $20 for up to a 30-day Availability for mail supply order varies by item. ✓ Talk to your local pharmacy Non-oral anticancer drugs on Tier 4 $20 for up to a 30-day Availability for mail supply order varies by item. ✓ Talk to your local pharmacy Home infusion drugs Cost Share Cost Share Subject to Applies to Description of Home Infusion Drugs at a Plan Pharmacy by Mail Deductible OOPM Home infusion drugs No charge for up to a Not available ✓ 30-day supply Supplies necessary for administration of No charge No charge ✓ home infusion drugs Home infusion drugs are self-administered intravenous drugs,fluids,additives,and nutrients that require specific types of parenteral-infusion,such as an intravenous or intraspinal-infusion. Diabetes supplies and amino acid—modified products Description of Diabetes Supplies and Cost Share Cost Share Subject to Applies to Amino Acid—Modified Products at a Plan Pharmacy by Mail Deductible OOPM Amino acid—modified products used to No charge for up to a Not available treat congenital errors of amino acid 30-day supply ✓ metabolism(such as phenylketonuria) Ketone test strips and sugar or acetone test No charge for up to a Not available ✓ tablets or tapes for diabetes urine testing 100-day supply Insulin-administration devices:pen $10 for up to a 100-day Availability for mail delivery devices,disposable needles and supply order varies by item. ✓ syringes,and visual aids required to Talk to your local ensure proper dosage(except eyewear) pharmacy Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#5 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 10 For drugs related to the treatment of diabetes(for example,insulin),and for continuous insulin delivery devices that use disposable items such as patches or pods,refer to the"Most items"table above.For insulin pumps,refer to the"Durable Medical Equipment("DME")for home use"table above. Contraceptive drugs and devices Description of Contraceptive Drugs and Cost Share Cost Share Subject to Applies to Devices at a Plan Pharmacy by Mail Deductible OOPM The following hormonal contraceptive No charge for up to a No charge for up to a items on Tier 1: 365-day supply 365-day supply • Rings Rings are not available ✓ for mail order • Patches • Oral contraceptives The following contraceptive items on No charge for up to a Not available Tier 1: 100-day supply • Spermicide ✓ • Sponges • Contraceptive gel The following hormonal contraceptive No charge for up to a No charge for up to a items on Tier 2: 365-day supply 365-day supply • Rings Rings are not available ✓ for mail order • Patches • Oral contraceptives The following contraceptive items on No charge for up to a Not available Tier 2: 100-day supply • Spermicide ✓ • Sponges • Contraceptive gel Emergency contraception No charge Not available ✓ Diaphragms,cervical caps,and up to a 30- No charge Not available ✓ day supply of condoms Certain preventive items Cost Share Cost Share Subject to Applies to Description of Certain Preventive Items at a Plan Pharmacy by Mail Deductible OOPM Items on our Preventive Services list on No charge for up to a Not available our website at ku.om/prevention when 100-day supply ✓ prescribed by a Plan Provider Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#5 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 11 Fertility and sexual dysfunction drugs Description of Fertility and Sexual Cost Share Cost Share Subject to Applies to Dysfunction Drugs at a Plan Pharmacy by Mail Deductible OOPM Drugs on Tier 1 prescribed to treat $10 for up to a 30-day $20 for up to a 100-day Infertility or in connection with covered supply supply artificial insemination Services Drugs on Tier 2 and Tier 4 prescribed to $20 for up to a 30-day $40 for up to a 100-day treat Infertility or in connection with supply supply covered artificial insemination Services Drugs on Tier 1 prescribed in connection Not covered Not covered with covered assisted reproductive technology("ART") Services Drugs on Tier 2 and Tier 4 prescribed in Not covered Not covered connection with covered assisted reproductive technology("ART") Services Drugs on Tier 1 prescribed for sexual 50%Coinsurance(not to 50%Coinsurance(not to dysfunction disorders exceed$50)for up to a exceed$50)for up to a ✓ 100-day supply 100-day supply Drugs on Tier 2 and Tier 4 prescribed for 50%Coinsurance(not to 50%Coinsurance(not to sexual dysfunction disorders exceed$100)for up to a exceed$100)for up to a ✓ 100-day supply 100-day supply Outpatient surgery and outpatient procedures Copayment/ Subject to Applies to Description of Outpatient Surgery and Outpatient Procedure Services Coinsurance Deductible OOPM Outpatient surgery and outpatient procedures(including imaging and $15 per procedure diagnostic Services)when provided in an outpatient or ambulatory surgery center or in a hospital operating room,or any setting where a ✓ licensed staff member monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or minimize discomfort Any other outpatient surgery that does not require a licensed staff $15 per procedure ✓ member to monitor your vital signs as described above Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#5 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 12 Preventive Services Copayment/ Subject to Applies to Description of Preventive Services Coinsurance Deductible OOPM Routine physical exams,including well-woman,postpartum follow- No charge ✓ up,and preventive exams for Members age 2 and older Well-child preventive exams for Members through age 23 months No charge ✓ Normal series of regularly scheduled preventive prenatal care exams No charge ✓ after confirmation of pregnancy Immunizations(including the vaccine)administered to you in a Plan No charge ✓ Medical Office Tuberculosis skin tests No charge ✓ Screening and counseling Services when provided during a routine No charge physical exam or a well-child preventive exam,such as obesity counseling,routine vision and hearing screenings,alcohol and ✓ substance abuse screenings,health education,depression screening, and developmental screenings to diagnose and assess potential developmental delays Screening colonoscopies No charge ✓ Screening flexible sigmoidoscopies No charge ✓ Routine imaging screenings such as mammograms No charge ✓ Bone density CT scans No charge ✓ Bone density DEXA scans No charge ✓ Routine laboratory tests and screenings,such as cancer screening No charge tests,sexually transmitted infection("STI")tests,cholesterol ✓ screening tests,and glucose tolerance tests Other laboratory screening tests,such as fecal occult blood tests and No charge ✓ hepatitis B screening tests Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#5 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 13 Prosthetic and orthotic devices Copayment/ Subject to Applies to Description of Prosthetic and Orthotic Device Services Coinsurance Deductible OOPM Internally implanted prosthetic and orthotic devices as described in No charge ✓ this EOC External prosthetic and orthotic devices as described in this EOC No charge Supplemental prosthetic and orthotic devices as described in this No charge ✓ EOC Rehabilitative and habilitative Services Copayment/ Subject to Applies to Description of Rehabilitative and Habilitative Services Coinsurance Deductible OOPM Individual outpatient physical,occupational,and speech therapy $15 per visit Group outpatient physical,occupational,and speech therapy $7 per visit Physical,occupational,and speech therapy provided in an organized, $15 per day ✓ multidisciplinary rehabilitation day-treatment program Reproductive Health Services Family planning Services Copayment/ Subject to Applies to Description of Family Planning Services Coinsurance Deductible OOPM Family planning counseling No charge Injectable contraceptives,internally implanted time-release No charge contraceptives or intrauterine devices("IUDs")and office visits ✓ related to their insertion,removal,and management when provided to prevent pregnancy Sterilization procedures for Members assigned female at birth if No charge performed in an outpatient or ambulatory surgery center or in a hospital operating room All other sterilization procedures for Members assigned female at No charge ✓ birth Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#5 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 14 Copayment/ Subject to Applies to Description of Family Planning Services Coinsurance Deductible OOPM Sterilization procedures for Members assigned male at birth if No charge performed in an outpatient or ambulatory surgery center or in a hospital operating room All other sterilization procedures for Members assigned male at birth No charge Abortion and abortion-related Services Copayment/ Subject to Applies to Description of abortion and abortion-related Services Coinsurance Deductible OOPM Surgical abortion No charge Prescription drugs,in accord with our drug formulary guidelines No charge Other abortion-related Services No charge Skilled nursing facility care Copayment/ Subject to Applies to Description of Skilled Nursing Facility Care Services Coinsurance Deductible OOPM Skilled nursing facility Services up to 100 days per benefit period* No charge 1/ *A benefit period begins on the date you are admitted to a hospital or Skilled Nursing Facility at a skilled level of care.A benefit period ends on the date you have not been an inpatient in a hospital or Skilled Nursing Facility,receiving a skilled level of care,for 60 consecutive days.A new benefit period can begin only after any existing benefit period ends.A prior three-day stay in an acute care hospital is not required. Substance use disorder treatment Copayment/ Subject to Applies to Description of Substance Use Disorder Treatment Services Coinsurance Deductible OOPM Inpatient detoxification No charge Individual substance use disorder evaluation and treatment $15 per visit Group substance use disorder treatment $5 per visit Intensive outpatient and day-treatment programs No charge Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#5 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 15 Copayment/ Subject to Applies to Description of Substance Use Disorder Treatment Services Coinsurance Deductible OOPM Residential substance use disorder treatment No charge Telehealth visits Interactive video visits Copayment/ Subject to Applies to Description of Interactive Video Visit Services Coinsurance Deductible OOPM Primary Care Visits and Non-Physician Specialist Visits No charge Physician Specialist Visits No charge Scheduled telephone visits Copayment/ Subject to Applies to Description of Scheduled Telephone Visit Services Coinsurance Deductible OOPM Primary Care Visits and Non-Physician Specialist Visits No charge Physician Specialist Visits No charge Vision Services for Adult Members Copayment/ Subject to Applies to Description of Vision Services for Adult Members Coinsurance Deductible OOPM Routine eye exams with a Plan Optometrist to determine the need for No charge ✓ vision correction and to provide a prescription for eyeglass lenses Physician Specialist Visits to diagnose and treat injuries or diseases $15 per visit ✓ of the eye Non-Physician Specialist Visits to diagnose and treat injuries or $15 per visit ✓ diseases of the eye Aniridia lenses:up to two Medically Necessary contact lenses per eye No charge ✓ (including fitting and dispensing)in any 12-month period Aphakia lenses:up to six Medically Necessary aphakic contact lenses No charge ✓ per eye(including fitting and dispensing)in any 12-month period Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#5 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 16 Copayment/ Subject to Applies to Description of Vision Services for Adult Members Coinsurance Deductible OOPM Specialty contact lenses(other than aniridia and aphakia lenses)that No charge after optical will provide a significant improvement in vision not obtainable with Allowance applied eyeglass lenses: either one pair of contact lenses(including fitting and dispensing)or an initial supply of disposable contact lenses(up to six months,including fitting and dispensing)in any 24-month period Eyeglasses and contact lenses as described in this EOC We provide a$175 Allowance every 24 months Replacement lenses if there has been a change in prescription of at We provide a$30 least.50 diopter in one or both eyes within 12 months of the initial Allowance for a single point of sale of an eyeglass lens or contact lens that we provided an vision eyeglass lens or Allowance toward(or otherwise covered) contact lens,a$45 Allowance for a multifocal or lenticular eyeglass lens Low vision devices(including fitting and dispensing) Not covered Vision Services for Pediatric Members Copayment/ Subject to Applies to Description of Vision Services for Pediatric Members Coinsurance Deductible OOPM Routine eye exams with a Plan Optometrist to determine the need for No charge ✓ vision correction and to provide a prescription for eyeglass lenses Physician Specialist Visits to diagnose and treat injuries or diseases $15 per visit ✓ of the eye Non-Physician Specialist Visits to diagnose and treat injuries or $15 per visit ✓ diseases of the eye Aniridia lenses:up to two Medically Necessary contact lenses per eye No charge ✓ (including fitting and dispensing)in any 12-month period Aphakia lenses:up to six Medically Necessary aphakic contact lenses No charge ✓ per eye(including fitting and dispensing)in any 12-month period Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#5 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 17 Copayment/ Subject to Applies to Description of Vision Services for Pediatric Members Coinsurance Deductible OOPM Specialty contact lenses(other than aniridia and aphakia lenses)that No charge after optical will provide a significant improvement in vision not obtainable with Allowance applied eyeglass lenses: either one pair of contact lenses(including fitting and dispensing)or an initial supply of disposable contact lenses(up to six months,including fitting and dispensing)in any 24-month period Eyeglasses and contact lenses as described in this EOC We provide a$175 Allowance every 24 months Replacement lenses if there has been a change in prescription of at No charge least.50 diopter in one or both eyes within 12 months of the initial point of sale of an eyeglass lens or contact lens that we provided an Allowance toward(or otherwise covered) Low vision devices(including fitting and dispensing) Not covered CARE Plan The California Community Assistance,Recovery,and Empowerment("CARE")Act established a system for individuals with severe mental illness to be evaluated and given a treatment plan developed by a county behavioral health agency ("CARE Plan").If a Member has a court-approved CARE Plan,we cover the Services required under that plan when provided by Plan Providers or non-Plan Providers at no charge,with the exception of prescription drugs.Prescription drugs required under a court-approved CARE Plan are subject to the same Cost Share as drugs prescribed by Plan Providers,as described in this Cost Share Summary,and are also subject to prior authorization by Health Plan.To inform us that you have a court-approved CARE Plan,please call Member Services. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC#5 Effective: 1/1/24-12/31/24 Date:October 20,2023 Page 18 Introduction coverage information in this EOC applies when you obtain care in your Home Region.When you visit the This Evidence of Coverage("EOC")describes the health other California Region,you may receive care as described in"Receiving Care Outside of Your Home care coverage of this Kaiser Permanente Traditional Region Service Area"in the"How to Obtain Services" HMO Plan provided under the Group Agreement section. ("Agreement")between Kaiser Foundation Health Plan, Inc. ("Health Plan")and the entity with which Health Plan has entered into the Agreement(your"Group"). Kaiser Permanente provides Services directly to our Members through an integrated medical care program. Health Plan,Plan Hospitals,and the Medical Group This EOC is part of the Agreement between work together to provide our Members with quality care. Health Plan and your Group. The Agreement Our medical care program gives you access to all of the contains additional terms such as Premiums, covered Services you may need,such as routine care when coverage can change, the effective date with your own personal Plan Physician,hospital of coverage, and the effective date of Services,laboratory and pharmacy Services,Emergency Services,Urgent Care,and other benefits described in termination. The Agreement must be consulted this EOC.Plus,our health education programs offer you to determine the exact terms of coverage. A great ways to protect and improve your health. copy of the Agreement is available from your Group. We provide covered Services to Members using Plan Providers located in our Service Area,which is described Once enrolled in other coverage made available through in the"Definitions"section.You must receive all Health Plan,that other plan's evidence of coverage covered care from Plan Providers inside our Service cannot be cancelled without cancelling coverage under Area,except as described in the sections listed below for this EOC,unless the change is made during open the following Services: enrollment or a special enrollment period. • Authorized referrals as described under"Getting a Referral"in the"How to Obtain Services"section For benefits provided under any other program offered • Covered Services received outside of your Home by your Group(for example,workers compensation Region Service Area as described under"Receiving benefits),refer to your Group's materials. Care Outside of Your Home Region Service Area"in the"How to Obtain Services"section In this EOC,Health Plan is sometimes referred to as "we"or"us."Members are sometimes referred to as • Emergency ambulance Services as described under "you."Some capitalized terms have special meaning in "Ambulance Services"in the"Benefits"section this EOC;please see the"Definitions"section for terms . Emergency Services,Post-Stabilization Care,and you should know. Out-of-Area Urgent Care as described in the "Emergency Services and Urgent Care"section It is important to familiarize yourself with your coverage . Hospice care as described under"Hospice Care"in by reading this EOC completely,so that you can take full the"Benefits"section advantage of your Health Plan benefits.Also,if you have special health care needs,please carefully read the sections that apply to you. Term of this EOC This EOC is for the period January 1,2024,through About Kaiser Permanente December 31,2024,unless amended.Your Group can tell you whether this EOC is still in effect and give you a PLEASE READ THE FOLLOWING current one if this EOC has expired or been amended. INFORMATION SO THAT YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS YOU MAY GET HEALTH CARE. Definitions r When you join Kaiser Permanente,you are enrolling in one of two Health Plan Regions in California(either our Some terms have special meaning in this EOC.When we Northern California Region or Southern California use a term with special meaning in only one section of Region),which we call your"Home Region."The this EOC,we define it in that section.The terms in this Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 19 "Definitions"section have special meaning when • For all other Services received from Non-Plan capitalized and used in any section of this EOC. Providers(including Post-Stabilization Services that Accumulation Period:A period of time no greater than are not Emergency Services under federal law),the 12 consecutive months for purposes of accumulating amount(1)required to be paid pursuant to state law, amounts toward any deductibles(if applicable),out-of- when it is applicable,or federal law,or(2)in the pocket maximums,and benefit limits.For example,the event that neither state or federal law prohibiting Accumulation Period may be a calendar year or contract balance billing apply,then the amount agreed to by year.The Accumulation Period for this EOC is from the Non-Plan Provider and Health Plan or,absent January 1 through December 31. such an agreement,the usual,customary and reasonable rate for those services as determined by Allowance:A specified amount that you can use toward Health Plan based on objective criteria the purchase price of an item.If the price of the items • For all other Services,the payments that Kaiser you select exceeds the Allowance,you will pay the Permanente makes for the Services or,if Kaiser amount in excess of the Allowance(and that payment will not apply toward any deductible or out-of-pocket Permanente subtracts your Cost Share from its payment,the amount Kaiser Permanente would have maximum). paid if it did not subtract your Cost Share Ancillary Coverage: Optional benefits such as acupuncture,chiropractic,or dental coverage that may be Cigna PPO Network: The Cigna PPO Network refers to available to Members enrolled under this EOC. If your the health care providers(doctors,hospitals,specialists) plan includes Ancillary Coverage,this coverage will be contracted as part of a shared administration network described in an amendment to this EOC or a separate arrangement called Cigna PPO for Shared agreement from the issuer of the coverage. Administration. Charges: "Charges"means the following: Cigna is an independent company and not affiliated with • For Services provided by the Medical Group or Kaiser Foundation Health Plan,Inc.,and its subsidiary Kaiser Foundation Hospitals,the charges in Health health plans.Access to the Cigna PPO Network is Plan's schedule of Medical Group and Kaiser available through Cigna's contractual relationship with Foundation Hospitals charges for Services provided the Kaiser Permanente health plans.The Cigna PPO to Members Network is provided exclusively by or through operating • For Services for which a provider(other than the subsidiaries of Cigna Corporation,including Cigna Medical Group or Kaiser Foundation Hospitals)is Health and Life Insurance Company.The Cigna name, compensated on a capitation basis,the charges in the logo,and other Cigna marks are owned by Cigna schedule of charges that Kaiser Permanente Intellectual Property,Inc. negotiates with the capitated provider Coinsurance:A percentage of Charges that you must • For items obtained at a pharmacy owned and operated pay when you receive a covered Service under this EOC. by Kaiser Permanente,the amount the pharmacy Copayment:A specific dollar amount that you must pay would charge a Member for the item if a Member's when you receive a covered Service under this EOC. benefit plan did not cover the item(this amount is an Note: The dollar amount of the Copayment can be$0 estimate of:the cost of acquiring,storing,and (no charge). dispensing drugs,the direct and indirect costs of providing Kaiser Permanente pharmacy Services to Cost Share:The amount you are required to pay for Members,and the pharmacy program's contribution covered Services.For example,your Cost Share may be to the net revenue requirements of Health Plan) a Copayment or Coinsurance.If your coverage includes a • For air ambulance Services received from Non-Plan Plan Deductible and you receive Services that are subject Providers when you have an Emergency Medical to the Plan Deductible,your Cost Share for those Condition,the amount required to be paid by Health Services will be Charges until you reach the Plan Plan pursuant to federal law Deductible. Similarly,if your coverage includes a Drug Deductible,and you receive Services that are subject to • For other Emergency Services received from Non- the Drug Deductible,your Cost Share for those Services Plan Providers(including Post-Stabilization Care that will be Charges until you reach the Drug Deductible. constitutes Emergency Services under federal law), the amount required to be paid by Health Plan Dependent:A Member who meets the eligibility pursuant to state law,when it is applicable,or federal requirements as a Dependent(for Dependent eligibility requirements,see"Who Is Eligible"in the"Premiums, law Eligibility,and Enrollment"section). Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 20 Disclosure Form("DF"):A summary of coverage for Stabilization Care"in the"Emergency Services" prospective Members.For some products,the DF is section combined with the evidence of coverage. EOC: This Evidence of Coverage document,including Drug Deductible: The amount you must pay under this any amendments,which describes the health care EOC in the Accumulation Period for certain drugs, coverage of"Kaiser Permanente Traditional HMO Plan" supplies,and supplements before we will cover those under Health Plan's Agreement with your Group. Services at the applicable Copayment or Coinsurance in Family:A Subscriber and all of their Dependents. that Accumulation Period.Refer to the"Cost Share Summary"section to learn whether your coverage Group: The entity with which Health Plan has entered includes a Drug Deductible,the Services that are subject into the Agreement that includes this EOC. to the Drug Deductible,and the Drug Deductible Health Plan:Kaiser Foundation Health Plan,Inc.,a amount. California nonprofit corporation.Health Plan is a health Emergency Medical Condition:A medical condition care service plan licensed to offer health care coverage manifesting itself by acute symptoms of sufficient by the Department of Managed Health Care.This EOC severity(including severe pain)such that you reasonably sometimes refers to Health Plan as"we"or"us." believed that the absence of immediate medical attention Home Region: The Region where you enrolled(either would result in any of the following: the Northern California Region or the Southern • Placing the person's health(or,with respect to a California Region). pregnant person,the health of the pregnant person or unborn child)in serious jeopardy Infertility:A person's inability to conceive a pregnancy or carry a pregnancy to live birth either as an individual • Serious impairment to bodily functions or with their partner;or,a Plan Physician's determination • Serious dysfunction of any bodily organ or part of Infertility,based on a patient's medical,sexual,and reproductive history,age,physical findings,diagnostic A mental health condition is an Emergency Medical testing,or any combination of those factors. Condition when it meets the requirements of the paragraph above,or when the condition manifests itself Kaiser Permanente:Kaiser Foundation Hospitals(a by acute symptoms of sufficient severity such that either California nonprofit corporation),Health Plan,and the of the following is true: Medical Group. • The person is an immediate danger to themself or to Kaiser Permanente State: California,Colorado,District others of Columbia,Georgia,Hawaii,Maryland,Oregon, • The person is immediately unable to provide for,or Virginia,and Washington. use,food,shelter,or clothing,due to the mental Medical Group: The Permanente Medical Group,Inc.,a disorder for-profit professional corporation. Emergency Services:All of the following with respect Medically Necessary:For Services related to mental to an Emergency Medical Condition: health or substance use disorder treatment,a Service is • A medical screening exam that is within the Medically Necessary if it is addressing your specific capability of the emergency department of a hospital needs,for the purpose of preventing,diagnosing,or or an independent freestanding emergency treating an illness,injury,condition,or its symptoms, department,including ancillary services(such as including minimizing the progression of that illness, imaging and laboratory Services)routinely available injury,condition,or its symptoms,in a manner that is all to the emergency department to evaluate the of the following: Emergency Medical Condition • In accordance with the generally accepted standards • Within the capabilities of the staff and facilities of mental health and substance use disorder care available at the facility,Medically Necessary • Clinically appropriate in terms of type,frequency, examination and treatment required to Stabilize the extent,site,and duration patient(once your condition is Stabilized, Services • Not primarily for the economic benefit of the health you receive are Post-Stabilization Care and not care service plan and subscribers or for the Emergency Services) convenience of the patient,treating physician,or • Post-Stabilization Care furnished by a Non-Plan other health care provider Provider is covered as Emergency Services when For all other Services,a Service is Medically Necessary federal law applies,as described under Post- if it is medically appropriate and required to prevent, Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 21 diagnose,or treat your condition or clinical symptoms in Services that are subject to the Plan Deductible,and the accord with generally accepted professional standards of Plan Deductible amount. practice that are consistent with a standard of care in the Plan Facility:Any facility listed in the Provider medical community. Directory on our website at kp.org/facilities.Plan Medicare: The federal health insurance program for Facilities include Plan Hospitals,Plan Medical Offices, people 65 years of age or older,some people under age and other facilities that we designate in the directory. 65 with certain disabilities,and people with end-stage The directory is updated periodically.The availability of renal disease(generally those with permanent kidney Plan Facilities may change.If you have questions,please failure who need dialysis or a kidney transplant). call Member Services. Member:A person who is eligible and enrolled under Plan Hospital:Any hospital listed in the Provider this EOC,and for whom we have received applicable Directory on our website at kp.org/facilities.In the Premiums.This EOC sometimes refers to a Member as directory,some Plan Hospitals are listed as Kaiser "you." Permanente Medical Centers.The directory is updated Non-Physician Specialist Visits: Consultations, periodically.The availability of Plan Hospitals may evaluations,and treatment by non-physician specialists change.If you have questions,please call Member (such as nurse practitioners,physician assistants, Services. optometrists,podiatrists,and audiologists).For Services Plan Medical Office:Any medical office listed in the described under"Dental and Orthodontic Services"in Provider Directory on our website at kp.org/facilities.In the`Benefits"section,non-physician specialists include the directory,Kaiser Permanente Medical Centers may dentists and orthodontists. include Plan Medical Offices.The directory is updated Non—Plan Hospital:A hospital other than a Plan periodically.The availability of Plan Medical Offices Hospital. may change.If you have questions,please call Member Services. Non—Plan Physician:A physician other than a Plan Plan Optical Sales Office:An optical sales office Physician. owned and operated by Kaiser Permanente or another Non—Plan Provider:A provider other than a Plan optical sales office that we designate.Refer to the Provider. Provider Directory on our website at kp.org/facilities for Non—Plan Psychiatrist:A psychiatrist who is not a Plan locations of Plan Optical Sales Offices.In the directory, Physician. Plan Optical Sales Offices may be called"Vision Essentials."The directory is updated periodically.The Out-of-Area Urgent Care:Medically Necessary availability of Plan Optical Sales Offices may change.If Services to prevent serious deterioration of your(or your you have questions,please call Member Services. unborn child's)health resulting from an unforeseen Plan Optometrist:An optometrist who is a Plan illness,unforeseen injury,or unforeseen complication of Provider. an existing condition(including pregnancy)if all of the following are true: Plan Out-of-Pocket Maximum: The total amount of • You are temporarily outside our Service Area Cost Share you must pay under this EOC in the Accumulation Period for certain covered Services that • A reasonable person would have believed that your you receive in the same Accumulation Period.Refer to (or your unborn child's)health would seriously the"Cost Share Summary"section to find your Plan Out- deteriorate if you delayed treatment until you returned of-Pocket Maximum amount and to learn which Services to our Service Area apply to the Plan Out-of-Pocket Maximum. Physician Specialist Visits: Consultations,evaluations, Plan Pharmacy:A pharmacy owned and operated by and treatment by physician specialists,including Kaiser Permanente or another pharmacy that we personal Plan Physicians who are not Primary Care designate.Refer to the Provider Directory on our website Physicians. at kp.org/facilities for locations of Plan Pharmacies.The Plan Deductible: The amount you must pay under this directory is updated periodically.The availability of Plan EOC in the Accumulation Period for certain Services Pharmacies may change.If you have questions,please before we will cover those Services at the applicable call Member Services. Copayment or Coinsurance in that Accumulation Period. Plan Physician:Any licensed physician who is an Refer to the"Cost Share Summary"section to learn employee of the Medical Group,or any licensed whether your coverage includes a Plan Deductible,the physician who contracts to provide Services to Members Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 22 (but not including physicians who contract only to available on our website at kp.m/facilities.To obtain a provide referral Services). printed copy,call Member Services.The directory is Plan Provider:A Plan Hospital,a Plan Physician,the updated periodically.The availability of Plan Physicians Medical Group,a Plan Pharmacy,or any other health and Plan Facilities may change.If you have questions, care provider that Health Plan designates as a Plan please call Member Services. Provider. Region:A Kaiser Foundation Health Plan organization Plan Skilled Nursing Facility:A Skilled Nursing or allied plan that conducts a direct-service health care Facility approved by Health Plan. program.Regions may change on January 1 of each year and are currently the District of Columbia and parts of Post-Stabilization Care: Medically Necessary Services Northern California,Southern California,Colorado, related to your Emergency Medical Condition that you Georgia,Hawaii,Idaho,Maryland,Oregon,Virginia, receive in a hospital(including the emergency and Washington.For the current list of Region locations, department),an independent freestanding emergency please visit our website at ku.org or call Member department,or a skilled nursing facility after your Services. treating physician determines that this condition is Service Area: The ZIP codes below for each county are Stabilized.Post-Stabilization Care also includes durable in our Service Area: medical equipment covered under this EOC,if it is Medically Necessary after discharge from an emergency • All ZIP codes in Alameda County are inside our department and related to the same Emergency Medical Northern California Service Area: 94501-02,94505, Condition.For more information about durable medical 94514,94536-46,94550-52,94555,94557,94560, equipment covered under this EOC,see"Durable 94566,94568,94577-80,94586-88,94601-15, Medical Equipment("DME")for Home Use"in the 94617-21,94622-24,94649,94659-62,94666, "Benefits"section. 94701-10,94712,94720,95377,95391 Premiums: The periodic amounts that your Group is • The following ZIP codes in Amador County are responsible for paying for your membership under this inside our Northern California Service Area: 95640, EOC, except that you are responsible for paying 95669 Premiums if you have Cal-COBRA coverage."Full . All ZIP codes in Contra Costa County are inside our Premiums"means 100 percent of Premiums for all of the Northern California Service Area: 94505-07,94509, coverage issued to each enrolled Member,as set forth in 94511,94513-14,94516-31,94547-49,94551, the"Premiums"section of Health Plan's Agreement with 94553,94556,94561,94563-65,94569-70,94572, your Group. 94575,94582-83,94595-98,94706-08,94801-08, Preventive Services: Covered Services that prevent or 94820,94850 detect illness and do one or more of the following: • The following ZIP codes in El Dorado County are • Protect against disease and disability or further inside our Northern California Service Area: 95613- progression of a disease 14,95619,95623,95633-35,95651,95664,95667, 95672,95682,95762 • Detect disease in its earliest stages before noticcabic symptoms develop • The following ZIP codes in Fresno County are inside our Northern California Service Area: 93242,93602, Primary Care Physicians: Generalists in internal 93606-07,93609,93611-13,93616,93618-19, medicine,pediatrics,and family practice,and specialists 93624-27,93630-31,93646,93648-52,93654, in obstetrics/gynecology whom the Medical Group 93656-57,93660,93662,93667-68,93675,93701- designates as Primary Care Physicians.Refer to the 12,93714-18,93720-30,93737,93740-41,93744-45, Provider Directory on our website at ky.org/facilities for 93747,93750,93755,93760-61,93764-65,93771- a list of physicians that are available as Primary Care 79,93786,93790-94,93844,93888 Physicians. The directory is updated periodically.The • The following ZIP codes in Kings County are inside availability of Primary Care Physicians may change.If you have questions,please call Member Services. our Northern California Service Area: 93230,93232, 93242,93631,93656 Primary Care Visits:Evaluations and treatment • The following ZIP codes in Madera County are inside provided by Primary Care Physicians and primary care our Northern California Service Area: 93601-02, Plan Providers who are not physicians(such as nurse 93604,93614,93623,93626,93636-39,93643-45, practitioners). 93653,93669,93720 Provider Directory:A directory of Plan Physicians and • All ZIP codes in Marin County are inside our Plan Facilities in your Home Region.This directory is Northern California Service Area: 94901,94903-04, Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 23 94912-15,94920,94924-25,94929-30,94933, 95005-7,95010,95017-19,95033,95041,95060-67, 94937-42,94945-50,94956-57,94960,94963-66, 95073,95076-77 94970-71,94973-74,94976-79 • All ZIP codes in Solano County are inside our • The following ZIP codes in Mariposa County are Northern California Service Area: 94503,94510, inside our Northern California Service Area: 93 60 1, 94512,94533-35,94571,94585,94589-92,95616, 93623,93653 95618,95620,95625,95687-88,95690,95694, • All ZIP codes in Napa County are inside our Northern 95696 California Service Area: 94503,94508,94515, • The following ZIP codes in Sonoma County are 94558-59,94562,94567,94573-74,94576,94581, inside our Northern California Service Area: 94515, 94599,95476 94922-23,94926-28,94931,94951-55,94972, • The following ZIP codes in Placer County are inside 94975,94999,95401-07,95409,95416,95419, our Northern California Service Area: 95602-04, 95421,95425,95430-31,95433,95436,95439, 95610,95626,95648,95650,95658,95661,95663, 95441-42,95444,95446,95448,95450,95452, 95668,95677-78,95681,95703,95722,95736, 95462,95465,95471-73,95476,95486-87,95492 95746-47,95765 • All ZIP codes in Stanislaus County are inside our • All ZIP codes in Sacramento County are inside our Northern California Service Area: 95230,95304, Northern California Service Area: 94203-09,94211, 95307,95313,95316,95319,95322-23,95326, 94229-30,94232,94234-37,94239-40,94244-45, 95328-29,95350-58,95360-61,95363,95367-68, 94247-50,94252,94254,94256-59,94261-63, 95380-82,95385-87,95397 94267-69,94271,94273-74,94277-80,94282-85, • The following ZIP codes in Sutter County are inside 94287-91,94293-98,94571,95608-11,95615, our Northern California Service Area: 95626,95645, 95621,95624,95626,95628,95630,95632,95638- 95659,95668,95674,95676,95692,95836-7 39,95641,95652,95655,95660,95662,95670-71, • The following ZIP codes in Tulare County are inside 95673,95678,95680,95683,95690,95693,95741- our Northern California Service Area: 93618,93631, 42,95757-59,95763,95811-38,95840-43,95851-53, 93646,93654,93666,93673 95860,95864-67,95894,95899 • The following ZIP codes in Yolo County are inside • All ZIP codes in San Francisco County are inside our our Northern California Service Area: 95605,95607, Northern California Service Area: 94102-05,94107- 95612,95615-18,95645,95691,95694-95,95697- 12,94114-34,94137,94139-47,94151,94158-61, 98,95776,95798-99 94163-64,94172,94177,94188 • The following ZIP codes in Yuba County are inside • All ZIP codes in San Joaquin County are inside our our Northern California Service Area: 95692,95903, Northern California Service Area: 94514,95201-15, 95961 95219-20,95227,95230-31,95234,95236-37, 95240-42,95253,95258,95267,95269,95296-97, For each ZIP code listed for a county,our Service Area 95304,95320,95330,95336-37,95361,95366, includes only the part of that ZIP code that is in that 95376-78,95385,95391,95632,95686,95690 county.When a ZIP code spans more than one county, • All ZIP codes in San Mateo County are inside our the part of that ZIP code that is in another county is not Northern California Service Area: 94002,94005, inside our Service Area unless that other county is listed 94010-11,94014-21,94025-28,94030,94037-38, above and that ZIP code is also listed for that other 94044,94060-66,94070,94074,94080,94083, county. 94128,94303,94401-04,94497 If you have a question about whether a ZIP code is in our • The following ZIP codes in Santa Clara County are Service Area,please call Member Services. inside our Northern California Service Area: 94022- Note:We may expand our Service Area at any time by 24,94035,94039-43,94085-89,94301-06,94309, giving written notice to your Group.ZIP codes are 94550,95002,95008-09,95011,95013-15,95020- subject to change by the U.S.Postal Service. 21 95026 95030-33 95035-38 95042 95044 95046,95050-56,95070-71,95076,95101,95103, Services:Health care services or items("health care" 95106,95108-13,95115-36,95138-41,95148, includes physical health care,mental health care,and 95150-61,95164,95170,95172-73,95190-94,95196 substance use disorder treatment),and behavioral health treatment covered under"Behavioral Health Treatment • All ZIP codes in Santa Cruz County are inside our for Autism Spectrum Disorder"in the"Benefits"section. Northern California Service Area: 95001,95003, Skilled Nursing Facility:A facility that provides inpatient skilled nursing care,rehabilitation services,or Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 24 other related health services and is licensed by the state Premiums, Eligibility, a n d of California.The facility's primary business must be the provision of24-hour-a-day licensed skilled nursing care. Enrollment The term"Skilled Nursing Facility"does not include convalescent nursing homes,rest facilities,or facilities Premiums for the aged,if those facilities furnish primarily custodial care,including training in routines of daily living.A Your Group is responsible for paying Full Premiums, "Skilled Nursing Facility"may also be a unit or section except that you are responsible for paying Full Premiums within another facility(for example,a hospital)as long as described in the"Continuation of Membership" as it continues to meet this definition. section if you have Cal-COBRA coverage under this EOC.If you are responsible for any contribution to the Spouse: The person to whom the Subscriber is legally Premiums that your Group pays,your Group will tell you married under applicable law.For the purposes of this the amount,when Premiums are effective,and how to EOC,the term"Spouse"includes the Subscriber's pay your Group(through payroll deduction,for domestic partner."Domestic partners"are two people example). who are registered and legally recognized as domestic partners by California(if your Group allows enrollment of domestic partners not legally recognized as domestic Who Is Eligible partners by California,"Spouse"also includes the Subscriber's domestic partner who meets your Group's To enroll and to continue enrollment,you must meet all eligibility requirements for domestic partners). of the eligibility requirements described in this"Who Is Eligible"section,including your Group's eligibility Stabilize: To provide the medical treatment of the requirements and our Service Area eligibility Emergency Medical Condition that is necessary to requirements. assure,within reasonable medical probability,that no material deterioration of the condition is likely to result Group eligibility requirements from or occur during the transfer of the person from the facility.With respect to a pregnant person who is having You must meet your Group's eligibility requirements, contractions,when there is inadequate time to safely such as the minimum number of hours that employees transfer them to another hospital before delivery(or the must work.Your Group is required to inform Subscribers transfer may pose a threat to the health or safety of the of its eligibility requirements. pregnant person or unborn child),"Stabilize"means to deliver(including the placenta). Service Area eligibility requirements The"Definitions"section describes our Service Area and Subscriber:A Member who is eligible for membership how it may change. on their own behalf and not by virtue of Dependent status and who meets the eligibility requirements as a Subscribers must live or work inside our Service Area at Subscriber(for Subscriber eligibility requirements,see the time they enroll.If after enrollment the Subscriber no "Who Is Eligible"in the"Premiums,Eligibility,and longer lives or works inside our Service Area,the Enrollment"section). Subscriber can continue membership unless(1)they live Surrogacy Arrangement:An arrangement in which an inside or move to the service area of another Region and individual agrees to become pregnant and to surrender do not work inside our Service Area,or(2)your Group the baby(or babies)to another person or persons who does not allow continued enrollment of Subscribers who intend to raise the child(or children),whether or not the do not live or work inside our Service Area. individual receives payment for being a surrogate.For the purposes of this EOC, "Surrogacy Arrangements" Dependent children of the Subscriber or of the includes all types of surrogacy arrangements,including Subscriber's Spouse may live anywhere inside or outside traditional surrogacy arrangements and gestational our Service Area.Other Dependents may live anywhere, surrogacy arrangements. except that they are not eligible to enroll or to continue Telehealth Visits:Interactive video visits and scheduled enrollment if they live in or move to the service area of another Region. telephone visits between you and your provider. Urgent Care: Medically Necessary Services for a If you are not eligible to continue enrollment because condition that requires prompt medical attention but is you live in or move to the service area of another not an Emergency Medical Condition. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 25 Region,please contact your Group to learn about your ♦ children placed with you for adoption Group health care options: ♦ foster children if you or your Spouse have the • Regions outside California.You may be able to legal authority to direct their care enroll in the service area of another Region if there is ♦ children for whom you or your Spouse is the an agreement between your Group and that Region, court-appointed guardian(or was when the child but the plan,including coverage,premiums,and reached age 18) eligibility requirements,might not be the same as . Children whose parent is a Dependent child under under this EOC your family coverage(including adopted children and • Southern California Region's service area.Your children placed with your Dependent child for Group may have an arrangement with us that permits adoption or foster care),if they meet all of the membership in the Southern California Region,but following requirements: the plan,including coverage,premiums,and ♦ they are not married and do not have a domestic eligibility requirements,might not be the same as partner(for the purposes of this requirement only, under this EOC.All terms and conditions in your "domestic partner"means someone who is application for enrollment in the Northern California registered and legally recognized as a domestic Region,including the Arbitration Agreement,will partner by California) continue to apply if the Subscriber does not submit a ♦ they meet the requirements described under"Age new enrollment form limit of Dependent children" For more information about the service areas of the other ♦ they receive all of their support and maintenance Regions,please call Member Services. from you or your Spouse ♦ they permanently reside with you or your Spouse Eligibility as a Subscriber You may be eligible to enroll and continue enrollment as If you have a baby a Subscriber if you are: If you have a baby while enrolled under this EOC,the • An employee of your Group baby is not automatically enrolled in this plan.The Subscriber must request enrollment of the baby as • A proprietor or partner of your Group described under"Special enrollment"in the"How to • Otherwise entitled to coverage under a trust Enroll and When Coverage Begins"section below.If the agreement,retirement benefit program,or Subscriber does not request enrollment within this employment contract(unless the Internal Revenue special enrollment period,the baby will only be covered Service considers you self-employed) under this plan for 31 days(including the date of birth). Eligibility as a Dependent Age limit of Dependent children Children must be under age 26 as of the effective date of Enrolling a Dependent this EOC to enroll as a Dependent under your plan. Dependent eligibility is subject to your Group's eligibility requirements,which are not described in this Dependent children are eligible to remain on the plan EOC.You can obtain your Group's eligibility through the end of the month in which they reach the age requirements directly from your Group.If you are a limit. Subscriber under this EOC and if your Group allows enrollment of Dependents,Health Plan allows the Dependent children of the Subscriber or Spouse following persons to enroll as your Dependents under (including adopted children and children placed with you this EOC: for adoption,but not including children placed with you • Your Spouse for foster care)who reach the age limit may continue • Your or your Spouse's Dependent children,who meet coverage under this EOC if all of the following the requirements described under"Age limit of conditions are met: Dependent children,"if they are any of the following: • They meet all requirements to be a Dependent except ♦ biological children for the age limit ♦ stepchildren • Your Group permits enrollment of Dependents ♦ adopted children • They are incapable of self-sustaining employment because of a physically-or mentally-disabling injury, Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 26 illness,or condition that occurred before they reached a subscriber under a Kaiser Permanente Medicare plan the age limit for Dependents offered by your Group(please ask your Group about • They receive 50 percent or more of their support and your membership options).All of your dependents who maintenance from you or your Spouse are enrolled under this or any other non-Medicare evidence of coverage offered by your Group must be • If requested,you give us proof of their incapacity and enrolled under the same non-Medicare evidence of dependency within 60 days after receiving our request coverage.A"non-Medicare"evidence of coverage is one (see"Disabled Dependent certification"below in this that does not require members to have Medicare. "Eligibility as a Dependent"section) Persons barred from enrolling Disabled Dependent certification You cannot enroll if you have had your entitlement to Proof may be required for a Dependent to be eligible to receive Services through Health Plan terminated for continue coverage as a disabled Dependent.If we request cause. it,the Subscriber must provide us documentation of the dependent's incapacity and dependency as follows: Members with Medicare and retirees • If the child is a Member,we will send the Subscriber This EOC is not intended for most Medicare a notice of the Dependent's membership termination beneficiaries and some Groups do not offer coverage to due to loss of eligibility at least 90 days before the retirees.If,during the term of this EOC,you are(or date coverage will end due to reaching the age limit. become)eligible for Medicare or you retire,please ask The Dependent's membership will terminate as your Group about your membership options as follows: described in our notice unless the Subscriber provides • If a Subscriber who has Medicare Part B retires and us documentation of the Dependent's incapacity and the Subscriber's Group has a Kaiser Permanente dependency within 60 days of receipt of our notice Senior Advantage plan for retirees,the Subscriber and we determine that the Dependent is eligible as a should enroll in the plan if eligible disabled dependent.If the Subscriber provides us this documentation in the specified time period and we do • If the Subscriber has dependents who have Medicare not make a determination about eligibility before the and your Group has a Kaiser Permanente Senior termination date,coverage will continue until we Advantage plan(or of one our other plans that require make a determination.If we determine that the members to have Medicare),the Subscriber may be Dependent does not meet the eligibility requirements able to enroll them as dependents under that plan as a disabled dependent,we will notify the Subscriber • If the Subscriber retires and your Group does not that the Dependent is not eligible and let the offer coverage to retirees,you may be eligible to Subscriber know the membership termination date.If continue membership as described in the we determine that the Dependent is eligible as a "Continuation of Membership"section disabled dependent,there will be no lapse in • If federal law requires that your Group's health care coverage.Also,starting two years after the date that the Dependent reached the age limit,the Subscriber coverage be primary and Medicare coverage be must provide us documentation of the Dependent's secondary,your coverage under this EOC will be the incapacity and dependency annually within 60 days same as it would be if you had not become eligible for after we request it so that we can determine if the Medicare.However,you may also be eligible to Dependent continues to be eligible as a disabled enroll in Kaiser Permanente Senior Advantage through your Group if you have Medicare Part B dependent •• If the child is not a Member because you are changing If you are(or become)eligible for Medicare and arein a class of beneficiaries for which your Group's coverage,you must give us proof,within 60 days after we request it,of the child's incapacity and health care coverage is secondary to Medicare,you dependency as well as proof of the child's coverage should consider enrollment in Kaiser Permanente under your prior coverage.In the future,you must Senior Advantage through your Group if you are provide proof of the child's continued incapacity and eligible dependency within 60 days after you receive our • If none of the above applies to you and you are request,but not more frequently than annually eligible for Medicare or you retire,please ask your Group about your membership options If the Subscriber is enrolled under a Kaiser Permanente Medicare plan Note:If you are enrolled in a Medicare plan and lose The dependent eligibility rules described in the Medicare eligibility,you may be able to enroll under this "Eligibility as a Dependent"section also apply if you are Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 27 EOC if permitted by your Group(please ask your Group under"Who Is Eligible"in this"Premiums,Eligibility, for details). and Enrollment"section,enrollment is permitted as described below and membership begins at the beginning When Medicare is primary (12:00 a.m.)of the effective date of coverage indicated Your Group's Premiums may increase if you are(or below,except that your Group may have additional become)eligible for Medicare Part A or B as primary requirements,which allow enrollment in other situations. coverage,and you are not enrolled through your Group in Kaiser Permanente Senior Advantage for any reason If you are eligible to be a Dependent under this EOC but (even if you are not eligible to enroll or the plan is not the subscriber in your family is enrolled under a Kaiser available to you). Permanente Senior Advantage evidence of coverage offered by your Group,the rules for enrollment of When Medicare is secondary Dependents in this"How to Enroll and When Coverage Medicare is the primary coverage except when federal Begins"section apply,not the rules for enrollment of law requires that your Group's health care coverage be dependents in the subscriber's evidence of coverage. primary and Medicare coverage be secondary.Members who have Medicare when Medicare is secondary by law New employees are subject to the same Premiums and receive the same When your Group informs you that you are eligible to benefits as Members who are under age 65 and do not enroll as a Subscriber,you may enroll yourself and any have Medicare.In addition,any such Member for whom eligible Dependents by submitting a Health Plan— Medicare is secondary by law and who meets the approved enrollment application to your Group within 31 eligibility requirements for the Kaiser Permanente Senior days. Advantage plan applicable when Medicare is secondary may also enroll in that plan if it is available. These Effective date of coverage Members receive the benefits and coverage described in The effective date of coverage for new employees and this EOC and the Kaiser Permanente Senior Advantage their eligible family Dependents is determined by your evidence of coverage applicable when Medicare is Group in accord with waiting period requirements in secondary. state and federal law.Your Group is required to inform the Subscriber of the date your membership becomes Medicare late enrollment penalties effective.For example,if the hire date of an otherwise- If you become eligible for Medicare Part B and do not eligible employee is January 19,the waiting period enroll,Medicare may require you to pay a late begins on January 19 and the effective date of coverage enrollment penalty if you later enroll in Medicare Part B. cannot be any later than April 19.Note: If the effective However,if you delay enrollment in Part B because you date of your Group's coverage is always on the first day or your spouse are still working and have coverage of the month,in this example the effective date cannot be through an employer group health plan,you may not any later than April 1. have to pay the penalty.Also,if you are(or become) eligible for Medicare and go without creditable Open enrollment prescription drug coverage(drug coverage that is at least You may enroll as a Subscriber(along with any eligible as good as the standard Medicare Part D prescription Dependents),and existing Subscribers may add eligible drug coverage)for a continuous period of 63 days or Dependents,by submitting a Health Plan—approved more,you may have to pay a late enrollment penalty if enrollment application to your Group during your you later sign up for Medicare prescription drug Group's open enrollment period.Your Group will let you coverage.If you are(or become)eligible for Medicare, know when the open enrollment period begins and ends your Group is responsible for informing you about and the effective date of coverage. whether your drug coverage under this EOC is creditable prescription drug coverage at the times required by the Special enrollment Centers for Medicare&Medicaid Services and upon If you do not enroll when you are first eligible and later your request. want to enroll,you can enroll only during open enrollment unless one of the following is true: How to Enroll and When Coverage • You become eligible because you experience a Begins qualifying event(sometimes called a"triggering event")as described in this"Special enrollment" Your Group is required to inform you when you are section eligible to enroll and what your effective date of coverage is.If you are eligible to enroll as described Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 28 • You did not enroll in any coverage offered by your California),Children's Health Insurance Program Group when you were first eligible and your Group coverage,or Medi-Cal Access Program coverage does not give us a written statement that verifies you ♦ reaching a lifetime maximum on all benefits signed a document that explained restrictions about enrolling in the future.The effective date of an Note:If you are enrolling yourself as a Subscriber along enrollment resulting from this provision is no later with at least one eligible Dependent,only one of you than the first day of the month following the date your must meet the requirements stated above. Group receives a Health Plan—approved enrollment or change of enrollment application from the Subscriber To request enrollment,the Subscriber must submit a Health Plan—approved enrollment or change of Special enrollment due to new Dependents enrollment application to your Group within 30 days You may enroll as a Subscriber(along with eligible after loss of other coverage,except that the timeframe for Dependents),and existing Subscribers may add eligible submitting the application is 60 days if you are Dependents,within 30 days after marriage,establishment requesting enrollment due to loss of eligibility for of domestic partnership,birth,adoption,placement for coverage through Covered California,Medicaid, adoption,or placement for foster care by submitting to Children's Health Insurance Program,or Medi-Cal your Group a Health Plan—approved enrollment Access Program coverage.The effective date of an application. enrollment resulting from loss of other coverage is no later than the first day of the month following the date The effective date of an enrollment resulting from your Group receives an enrollment or change of marriage or establishment of domestic partnership is no enrollment application from the Subscriber. later than the first day of the month following the date your Group receives an enrollment application from the Special enrollment due to court or administrative order Subscriber.Enrollments due to birth,adoption, Within 30 days after the date of a court or administrative placement for adoption,or placement for foster care are order requiring a Subscriber to provide health care effective on the date of birth,date of adoption,or the coverage for a Spouse or child who meets the eligibility date you or your Spouse have newly assumed a legal requirements as a Dependent,the Subscriber may add the right to control health care. Spouse or child as a Dependent by submitting to your Group a Health Plan—approved enrollment or change of Special enrollment due to loss of other coverage enrollment application. You may enroll as a Subscriber(along with any eligible Dependents),and existing Subscribers may add eligible The effective date of coverage resulting from a court or Dependents,if all of the following are true: administrative order is the first of the month following • The Subscriber or at least one of the Dependents had the date we receive the enrollment request,unless your other coverage when they previously declined all Group specifies a different effective date(if your Group coverage through your Group specifies a different effective date,the effective date • The loss of the other coverage is due to one of the cannot be earlier than the date of the order). following: Special enrollment due to eligibility for premium ♦ exhaustion of COBRA coverage assistance ♦ termination of employer contributions for non- You may enroll as a Subscriber(along with eligible COBRA coverage Dependents),and existing Subscribers may add eligible ♦ loss of eligibility for non-COBRA coverage,but Dependents,if you or a dependent become eligible for not termination for cause or termination from an premium assistance through the Medi-Cal program. individual(nongroup)plan for nonpayment.For Premium assistance is when the Medi-Cal program pays example,this loss of eligibility may be due to legal all or part of premiums for employer group coverage for separation or divorce,moving out of the plan's a Medi-Cal beneficiary.To request enrollment in your service area,reaching the age limit for dependent Group's health care coverage,the Subscriber must children,or the subscriber's death,termination of submit a Health Plan—approved enrollment or change of employment,or reduction in hours of employment enrollment application to your Group within 60 days ♦ loss of eligibility(but not termination for cause) after you or a dependent become eligible for premium for coverage through Covered California, assistance.Please contact the California Department of Medicaid coverage(known as Medi-Cal in Health Care Services to find out if premium assistance is available and the eligibility requirements. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 29 Special enrollment due to reemployment after military How to Obtain Services service If you terminated your health care coverage because you As a Member,you are selecting our medical care were called to active duty in the military service,you program to provide your health care.You must receive may be able to reenroll in your Group's health plan if all covered care from Plan Providers inside our Service required by state or federal law.Please ask your Group Area,except as described in the sections listed below for for more information. the following Services: Other special enrollment events • Authorized referrals as described under"Getting a You may enroll as a Subscriber(along with any eligible Referral"in this"How to Obtain Services"section Dependents)if you or your Dependents were not • Covered Services received outside of your Home previously enrolled,and existing Subscribers may add Region Service Area as described under"Receiving eligible Dependents not previously enrolled,if any of the Care Outside of Your Home Region Service Area"in following are true: this"How to Obtain Services"section • You lose employment for a reason other than gross • Emergency ambulance Services as described under misconduct "Ambulance Services"in the"Benefits"section • Your employment hours are reduced • Emergency Services,Post-Stabilization Care,and • You are a Dependent of someone who becomes Out-of-Area Urgent Care as described in the entitled to Medicare "Emergency Services and Urgent Care"section • You become divorced or legally separated • Hospice care as described under"Hospice Care"in the"Benefits"section • You are a Dependent of someone who dies • A Health Benefit Exchange(such as Covered Our medical care program gives you access to all of the California)determines that one of the following covered Services you may need,such as routine care occurred because of misconduct on the part of a non- with your own personal Plan Physician,hospital Exchange entity that provided enrollment assistance Services,laboratory and pharmacy Services,Emergency or conducted enrollment activities: Services,Urgent Care,and other benefits described in ♦ a qualified individual was not enrolled in a this EOC. qualified health plan ♦ a qualified individual was not enrolled in the Routine Care qualified health plan that the individual selected ♦ a qualified individual is eligible for,but is not If you need the following Services,you should schedule receiving,advance payments of the premium tax an appointment: credit or cost share reductions • Preventive Services To request special enrollment,you must submit a Health • Periodic follow-up care(regularly scheduled follow- Plan-approved enrollment application to your Group up care,such as visits to monitor a chronic condition) within 30 days after loss of other coverage.You may be • Other care that is not Urgent Care required to provide documentation that you have experienced a qualifying event.Membership becomes To request a non-urgent appointment,you can call your effective either on the first day of the next month(for local Plan Facility or request the appointment online.For applications that are received by the fifteenth day of a appointment phone numbers,refer to our Provider month)or on the first day of the month following the Directory or call Member Services.To request an next month(for applications that are received after the appointment online,go to our website at ku.org. fifteenth day of a month). Note:If you are enrolling as a Subscriber along with at Urgent Care least one eligible Dependent,only one of you must meet An Urgent Care need is one that requires prompt medical one of the requirements stated above. attention but is not an Emergency Medical Condition.If you think you may need Urgent Care,call the appropriate appointment or advice phone number at a Plan Facility.For phone numbers,refer to our Provider Directory or call Member Services. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 30 For information about Out-of-Area Urgent Care,refer to visits with the specialist except for routine preventive "Urgent Care"in the"Emergency Services and Urgent visits listed under"Preventive Services"in the Care"section. "Benefits"section. To learn how to select or change to a different personal Not Sure What Kind of Care You Need? Plan Physician,visit our website at ky.org or call Sometimes it's difficult to know what kind of care you Member Services.Refer to our Provider Directory for a need,so we have licensed health care professionals list of physicians that are available as Primary Care available to assist you by phone 24 hours a day,seven Physicians. The directory is updated periodically.The days a week.Here are some of the ways they can help availability of Primary Care Physicians may change.If you have questions,please call Member Services.You you: can change your personal Plan Physician at any time for • They can answer questions about a health concern, any reason. and instruct you on self-care at home if appropriate • They can advise you about whether you should get Getting a Referral medical care,and how and where to get care(for example,if you are not sure whether your condition is Referrals to Plan Providers an Emergency Medical Condition,they can help you A Plan Physician must refer you before you can receive decide whether you need Emergency Services or care from specialists,such as specialists in surgery, Urgent Care,and how and where to get that care) orthopedics,cardiolog y,gy,oncology,dermatology,and • They can tell you what to do if you need care and a physical,occupational,and speech therapies.Also,a Plan Medical Office is closed or you are outside our Plan Physician must refer you before you can get care Service Area from Qualified Autism Service Providers covered under "Behavioral Health Treatment for Autism Spectrum You can reach one of these licensed health care Disorder"in the`Benefits"section.However,you do not professionals by calling the appointment or advice phone need a referral or prior authorization to receive most care number(for phone numbers,refer to our Provider from any of the following Plan Providers: Directory or call Member Services).When you call,a • Your personal Plan Physician trained support person may ask you questions to help • Generalists in internal medicine,pediatrics,and determine how to direct your call. family practice • Specialists in optometry,mental health Services, Your Personal Plan Physician substance use disorder treatment,and Personal Plan Physicians provide primary care and play obstetrics/gynecology an important role in coordinating care,including hospital stays and referrals to specialists. A Plan Physician must refer you before you can get care from a specialist in urology except that you do not need a We encourage you to choose a personal Plan Physician. referral to receive Services related to sexual or You may choose any available personal Plan Physician. reproductive health,such as a vasectomy. Parents may choose a pediatrician as the personal Plan Physician for their child.Most personal Plan Physicians Although a referral or prior authorization is not required are Primary Care Physicians(generalists in internal to receive most care from these providers,a referral may medicine,pediatrics,or family practice,or specialists in be required in the following situations: obstetrics/gynecology whom the Medical Group • The provider may have to get prior authorization for designates as Primary Care Physicians). Some specialists certain Services in accord with"Medical Group who are not designated as Primary Care Physicians but authorization procedure for certain referrals"in this who also provide primary care may be available as "Getting a Referral"section personal Plan Physicians.For example,some specialists • The provider may have to refer you to a specialist in internal medicine and obstetrics/gynecology who are who has a clinical background related to your illness not designated as Primary Care Physicians may be or condition available as personal Plan Physicians.However,if you choose a specialist who is not designated as a Primary Standing referrals Care Physician as your personal Plan Physician,the Cost If a Plan Physician refers you to a specialist,the referral Share for a Physician Specialist Visit will apply to all will be for a specific treatment plan.Your treatment plan Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 31 may include a standing referral if ongoing care from the If your Plan Physician prescribes one of these items,they specialist is prescribed.For example,if you have a life- will submit a written referral in accord with the UM threatening,degenerative,or disabling condition,you can process described in this"Medical Group authorization get a standing referral to a specialist if ongoing care from procedure for certain referrals"section.If the formulary the specialist is required. guidelines do not specify that the prescribed item is appropriate for your medical condition,the referral will Medical Group authorization procedure for be submitted to the Medical Group's designee Plan certain referrals Physician,who will make an authorization decision as The following are examples of Services that require prior described under"Medical Group's decision time frames" authorization by the Medical Group for the Services to in this"Medical Group authorization procedure for be covered("prior authorization"means that the Medical certain referrals"section. Group must approve the Services in advance): • Durable medical equipment Medical Group's decision time frames The applicable Medical Group designee will make the • Ostomy and urological supplies authorization decision within the time frame appropriate • Services not available from Plan Providers for your condition,but no later than five business days • Transplants after receiving all of the information(including additional examination and test results)reasonably necessary to make the decision,except that decisions Utilization Management("UM")is a process that about urgent Services will be made no later than 72 determines whether a Service recommended by your hours after receipt of the information reasonably treating provider is Medically Necessary for you.Prior necessary to make the decision.If the Medical Group authorization is a UM process that determines whether needs more time to make the decision because it doesn't the requested services are Medically Necessary before have information reasonably necessary to make the care is provided.If it is Medically Necessary,then you decision,or because it has requested consultation by a will receive authorization to obtain that care in a particular specialist,you and your treating physician will clinically appropriate place consistent with the terms of be informed about the additional information,testing,or your health coverage.Decisions regarding requests for specialist that is needed,and the date that the Medical authorization will be made only by licensed physicians Group expects to make a decision. or other appropriately licensed medical professionals. Your treating physician will be informed of the decision For the complete list of Services that require prior within 24 hours after the decision is made.If the Services authorization,and the criteria that are used to make are authorized,your physician will be informed of the authorization decisions,please visit our website at scope of the authorized Services.If the Medical Group kp.oru/UM or call Member Services to request a printed does not authorize all of the Services,Health Plan will copy. send you a written decision and explanation within two business days after the decision is made.Any written Refer to"Post-Stabilization Care"under"Emergency criteria that the Medical Group uses to make the decision Services"in the"Emergency Services and Urgent Care" to authorize,modify,delay,or deny the request for section for authorization requirements that apply to Post- authorization will be made available to you upon request. Stabilization Care from Non—Plan Providers. If the Medical Group does not authorize all of the Additional information about prior authorization for Services requested and you want to appeal the decision, durable medical equipment and ostomy and urological you can file a grievance as described under"Grievances" supplies in the"Dispute Resolution"section. The prior authorization process for durable medical equipment and ostomy and urological supplies includes For these referral Services,you pay the Cost Share the use of formulary guidelines.These guidelines were required for Services provided by a Plan Provider as developed by a multidisciplinary clinical and operational described in this EOC. work group with review and input from Plan Physicians and medical professionals with clinical expertise.The Completion of Services from Non—Plan formulary guidelines are periodically updated to keep Providers pace with changes in medical technology and clinical practice. New Member If you are currently receiving Services from a Non—Plan Provider in one of the cases listed below under Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 32 "Eligibility"and your prior plan's coverage of the • Children under age 3.We may cover completion of provider's Services has ended or will end when your these Services until the earlier of(1) 12 months from coverage with us becomes effective,you may be eligible the child's effective date of coverage if the child is a for limited coverage of that Non—Plan Provider's new Member,(2) 12 months from the termination Services. date of the terminated provider,or(3)the child's third birthday Terminated provider • Surgery or another procedure that is documented as If you are currently receiving covered Services in one of part of a course of treatment and has been the cases listed below under`Eligibility"from a Plan recommended and documented by the provider to Hospital or a Plan Physician(or certain other providers) occur within 180 days of your effective date of when our contract with the provider ends(for reasons coverage if you are a new Member or within 180 days other than medical disciplinary cause or criminal of the termination date of the terminated provider activity),you may be eligible for limited coverage of that terminated provider's Services. To qualify for this completion of Services coverage,all Eligibility of the following requirements must be met: The cases that are subject to this completion of Services • Your Health Plan coverage is in effect on the date you provision are: receive the Services • Acute conditions,which are medical conditions that • For new Members,your prior plan's coverage of the involve a sudden onset of symptoms due to an illness, provider's Services has ended or will end when your injury,or other medical problem that requires prompt coverage with us becomes effective medical attention and has a limited duration.We may • You are receiving Services in one of the cases listed cover these Services until the acute condition ends above from a Non—Plan Provider on your effective • Serious chronic conditions until the earlier of(1) 12 date of coverage if you are a new Member,or from months from your effective date of coverage if you the terminated Plan Provider on the provider's are a new Member,(2) 12 months from the termination date termination date of the terminated provider,or(3)the • For new Members,when you enrolled in Health Plan, first day after a course of treatment is complete when you did not have the option to continue with your it would be safe to transfer your care to a Plan previous health plan or to choose another plan Provider,as determined by Kaiser Permanente after (including an out-of-network option)that would cover consultation with the Member and Non—Plan Provider the Services of your current Non—Plan Provider and consistent with good professional practice. . The provider agrees to our standard contractual terms Serious chronic conditions are illnesses or other and conditions,such as conditions pertaining to medical conditions that are serious,if one of the payment and to providing Services inside our Service following is true about the condition: Area(the requirement that the provider agree to ♦ it persists without full cure providing Services inside our Service Area doesn't ♦ it worsens over an extended period of time apply if you were receiving covered Services from the ♦ it requires ongoing treatment to maintain provider outside our Service Area when the remission or prevent deterioration provider's contract terminated) • Pregnancy and immediate postpartum care.We may • The Services to be provided to you would be covered cover these Services for the duration of the pregnancy Services under this EOC if provided by a Plan and immediate postpartum care Provider • Mental health conditions in pregnant Members that • You request completion of Services within 30 days occur,or can impact the Member,during pregnancy (or as soon as reasonably possible)from your or during the postpartum period including,but not effective date of coverage if you are a new Member limited to,postpartum depression.We may cover or from the termination date of the Plan Provider completion of these Services for up to 12 months from the mental health diagnosis or from the end of For completion of Services,you pay the Cost Share pregnancy,whichever occurs later required for Services provided by a Plan Provider as described in this EOC. • Terminal illnesses,which are incurable or irreversible illnesses that have a high probability of causing death within a year or less.We may cover completion of these Services for the duration of the illness Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 33 More information Here are some examples of when a second opinion may For more information about this provision,or to request be provided or authorized: the Services or a copy of our"Completion of Covered • Your Plan Physician has recommended a procedure Services"policy,please call Member Services. and you are unsure about whether the procedure is reasonable or necessary Travel and Lodging for Certain Services • You question a diagnosis or plan of care for a condition that threatens substantial impairment or loss The following are examples of when we will arrange or of life,limb,or bodily functions provide reimbursement for certain travel and lodging . The clinical indications are not clear or are complex expenses in accord with our Travel and Lodging and confusing Program Description: • If Medical Group refers you to a provider that is more • A diagnosis is in doubt due to conflicting test results than 50 miles from where you live for certain • The Plan Physician is unable to diagnose the specialty Services such as bariatric surgery,complex condition thoracic surgery,transplant nephrectomy,or inpatient . The treatment plan in progress is not improving your chemotherapy for leukemia and lymphoma medical condition within an appropriate period of • If Medical Group refers you to a provider that is time,given the diagnosis and plan of care outside our Service Area for certain specialty Services . You have concerns about the diagnosis or plan of care such as a transplant or transgender surgery • If you are outside of California and you need an An authorization or denial of your request for a second abortion on an emergency or urgent basis,and the opinion will be provided in an expeditious manner,as abortion can't be obtained in a timely manner due to a appropriate for your condition.If your request for a near total or total ban on health care providers' ability second opinion is denied,you will be notified in writing to provide such Services of the reasons for the denial and of your right to file a grievance as described under"Grievances"in the For the complete list of specialty Services for which we "Dispute Resolution"section. will arrange or provide reimbursement for travel and lodging expenses,the amount of reimbursement, For these referral Services,you pay the Cost Share limitations and exclusions,and how to request required for Services provided by a Plan Provider as reimbursement,refer to the Travel and Lodging Program described in this EOC. Description.The Travel and Lodging Program Description is available online at ku.org/suecialty- care/travel-reimbursements or by calling Member Contracts with Plan Providers Services. How Plan Providers are paid Health Plan and Plan Providers are independent Second Opinions contractors.Plan Providers are paid in a number of ways, such as salary,capitation,per diem rates,case rates,fee If you want a second opinion,you can ask Member for service,and incentive payments. To learn more about Services to help you arrange one with a Plan Physician how Plan Physicians are paid to provide or arrange who is an appropriately qualified medical professional medical and hospital Services for Members,please visit for your condition.If there isn't a Plan Physician who is our website at kp.org or call Member Services. an appropriately qualified medical professional for your condition,Member Services will help you arrange a Financial liability consultation with a Non—Plan Physician for a second Our contracts with Plan Providers provide that you are opinion.For purposes of this"Second Opinions" not liable for any amounts we owe.However,you may provision,an"appropriately qualified medical have to pay the full price of noncovered Services you professional"is a physician who is acting within their obtain from Plan Providers or Non—Plan Providers. scope of practice and who possesses a clinical background,including training and expertise,related to When you are referred to a Plan Provider for covered the illness or condition associated with the request for a Services,you pay the Cost Share required for Services second medical opinion. from that provider as described in this EOC. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 34 Termination of a Plan Provider's contract Your ID Card If our contract with any Plan Provider terminates while you are under the care of that provider,we will retain Each Member's Kaiser Permanente ID card has a financial responsibility for the covered Services you medical record number on it,which you will need when receive from that provider until we make arrangements you call for advice,make an appointment,or go to a for the Services to be provided by another Plan Provider provider for covered care.When you get care,please and notify you of the arrangements.You may be eligible bring your ID card and a photo ID.Your medical record to receive Services from a terminated provider;refer to number is used to identify your medical records and "Completion of Services from Non—Plan Providers" membership information.Your medical record number under"Getting a Referral"in this"How to Obtain should never change.Please call Member Services if we Services"section. ever inadvertently issue you more than one medical record number or if you need to replace your ID card. Provider groups and hospitals If you are assigned to a provider group or hospital whose Your ID card is for identification only.To receive contract with us terminates,or if you live within 15 miles covered Services,you must be a current Member. of a hospital whose contract with us terminates,we will Anyone who is not a Member will be billed as a non- give you written notice at least 60 days before the Member for any Services they receive.If you let termination(or as soon as reasonably possible). someone else use your ID card,we may keep your ID card and terminate your membership as described under "Termination for Cause"in the"Termination of Receiving Care Outside of Your Home Membership"section. Region Service Area For information about your coverage when you are away Timely Access to Care from home,visit our website at kky.orE/travel.You can Standards for appointment availability also call the Away from Home Travel Line at 1-951-268-3900 24 hours a day,seven days a week The California Department of Managed Health Care (except closed holidays). ("DMHC")developed the following standards for appointment availability. This information can help you Receiving care in another Kaiser Permanente know what to expect when you request an appointment. service area • Urgent care appointment:within 48 hours If you are visiting in another Kaiser Permanente service . Routine(non-urgent)primary care appointment area,you may receive certain covered Services from (including adult/internal medicine,pediatrics,and designated providers in that other Kaiser Permanente family medicine):within 10 business days service area,subject to exclusions,limitations,prior . Routine(non-urgent)specialty care appointment with authorization or approval requirements,and reductions. For more information about receiving covered Services a physician:within 15 business days in another Kaiser Permanente service area,including • Routine(non-urgent)mental health care or substance provider and facility locations,please visit kp.orz/travel use disorder treatment appointment with a practitioner or call our Away from Home Travel Line at 1-951-268- other than a physician:within 10 business days 3900 24 hours a day,seven days a week(except closed . Follow-up(non-urgent)mental health care or holidays). substance use disorder treatment appointment with a practitioner other than a physician,for those For covered Services you receive in another Kaiser undergoing a course of treatment for an ongoing Permanente service area,you pay the Cost Share mental health or substance use disorder condition: required for Services provided by a Plan Provider inside within 10 business days our Service Area as described in this EOC. If you prefer to wait for a later appointment that will Receiving care outside of any Kaiser better fit your schedule or to see the Plan Provider of Permanente service area your choice,we will respect your preference.In some If you are traveling outside of any Kaiser Permanente cases,your wait may be longer than the time listed if a service area,we cover Emergency Services and Urgent licensed health care professional decides that a later Care as described in the"Emergency Services and appointment won't have a negative effect on your health. Urgent Care"section. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 35 The standards for appointment availability do not apply 24 hours a day,seven days a week(except to Preventive Services.Your Plan Provider may closed holidays) recommend a specific schedule for Preventive Services, Visit Member Services office at a Plan Facility(for depending on your needs.Except as specified above for addresses,refer to our Provider Directory or mental health care and substance use disorder treatment, call Member Services) the standards also do not apply to periodic follow-up care for ongoing conditions or standing referrals to Write Member Services office at a Plan Facility(for specialists. addresses,refer to our Provider Directory or call Member Services) Timely access to telephone assistance Website kp•Org DMHC developed the following standards for answering telephone questions: Cost Share estimates • For telephone advice about whether you need to get For information about estimates,see"Getting an care and where to get care:within 30 minutes,24 estimate of your Cost Share"under"Your Cost Share"in hours a day,seven days a week the"Benefits"section. • For general questions:within 10 minutes during normal business hours Plan Facilities Interpreter services If you need interpreter services when you call us or when Plan Medical Offices and Plan Hospitals are listed in the you get covered Services,please let us know.Interpreter Provider Directory for your Home Region.The directory services,including sign language,are available during all describes the types of covered Services that are available business hours at no cost to you.For more information from each Plan Facility,because some facilities provide on the interpreter services we offer,please call Member only specific types of covered Services.This directory is Services. available on our website at kp.or2/facilities.To obtain a printed copy,call Member Services.The directory is Getting Assistance updated periodically.The availability of Plan Facilities may change.If you have questions,please call Member We want you to be satisfied with the health care you Services. receive from Kaiser Permanente.If you have any questions or concerns,please discuss them with your At most of our Plan Facilities,you can usually receive all personal Plan Physician or with other Plan Providers of the covered Services you need,including specialty who are treating you.They are committed to your care,pharmacy,and lab work.You are not restricted to a satisfaction and want to help you with your questions. particular Plan Facility,and we encourage you to use the facility that will be most convenient for you: Member Services • All Plan Hospitals provide inpatient Services and are Member Services representatives can answer any open 24 hours a day,seven days a week questions you have about your benefits,available • Emergency Services are available from Plan Hospital Services,and the facilities where you can receive care. emergency departments(for emergency department For example,they can explain the following: locations,refer to our Provider Directory or call • Your Health Plan benefits Member Services) • How to make your first medical appointment • Same-day Urgent Care appointments are available at • What to do if you move many locations(for Urgent Care locations,refer to our Provider Directory or call Member Services) • How to replace your Kaiser Permanente ID card • Many Plan Medical Offices have evening and You can reach Member Services in the following ways: weekend appointments • Many Plan Facilities have a Member Services office Call 1-800-464-4000(English and more than 150 (for locations,refer to our Provider Directory or call languages using interpreter services) Member Services) 1-800-788-0616(Spanish) 1-800-757-7585(Chinese dialects) TTY users call 711 Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 36 Note: State law requires evidence of coverage documents • Post-Stabilization Care authorization at a Cigna to include the following notice: PPO Network facility outside of a Kaiser Some hospitals and other providers do not Permanente State: If you are outside of a Kaiser Permanente state and you were treated at a Cigna provide one or more of the following services PPO Network facility for an Emergency Medical that may be covered under your plan Condition,Cigna Payer Solutions is responsible for contract and that you or your family authorizing any Post-Stabilization Care. member might need: family planning; • Post-Stabilization Care authorization from other contraceptive services,including emergency Non-Plan Providers(including Cigna PPO contraception; sterilization, including tubal Network facilities inside a Kaiser Permanente State): To request prior authorization,the Non—Plan ligation at the time of labor and delivery; Provider must call 1-800-225-8883 or the notification infertility treatments; or abortion. You phone number on your Kaiser Permanente ID card should obtain more information before you before you receive the care.We will discuss your enroll. Call your prospective doctor, medical condition with the Non-Plan Provider.If we group, independent practice association, or determine that you require Post-Stabilization Care and that this care is part of your covered benefits,we clinic, or call Kaiser Permanente Member will authorize your care from the Non—Plan Provider Services,to ensure that you can obtain the or arrange to have a Plan Provider(or other health care services that you need. designated provider)provide the care.If we decide to have a Plan Hospital,Plan Skilled Nursing Facility,or Please be aware that if a Service is covered but not designated Non—Plan Provider provide your care,we available at a particular Plan Facility,we will make it may authorize special transportation services that are available to you at another facility. medically required to get you to the provider. This may include transportation that is otherwise not covered. Emergency Services and Urgent Be sure to ask the Non—Plan Provider to tell you what Care care(including any transportation)we have authorized because we will not cover Post- Emergency Services Stabilization Care or related transportation provided by Non—Plan Providers that has not been authorized. If you have an Emergency Medical Condition,call 911 If you receive care from a Non—Plan Provider that we (where available)or go to the nearest emergency have not authorized,you may have to pay the full cost department.You do not need prior authorization for of that care.If you are admitted to a Non—Plan Emergency Services.When you have an Emergency Hospital or independent freestanding emergency Medical Condition,we cover Emergency Services you department,please notify us as soon as possible by receive from Plan Providers or Non—Plan Providers calling 1-800-225-8883 or the notification phone anywhere in the world. number on your ID card. Emergency Services are available from Plan Hospital When you receive Post-Stabilization Care from a Non- emergency departments 24 hours a day,seven days a Plan Provider that is not a Cigna PPO Network week. provider outside of California After you receive Emergency Services from non-Plan Post-Stabilization Care Providers and your condition is Stabilized,Post- Stabilization Care is considered Emergency Services When you receive Post-Stabilization Care from allon- under federal law if either of the following are true: Plan Provider inside of California,or from a Cigna PPO Network facility outside of a Kaiser Permanente • Your treating physician determines that you are not State able to travel using nonemergency transportation to When you receive Emergency Services,we cover Post- an available Plan Provider located within a reasonable Stabilization Care from a Non—Plan Provider only if travel distance,taking into account your medical prior authorization for the care is obtained as described condition;or below,or if otherwise required by applicable law("prior • Your treating physician,using appropriate medical authorization"means that the Services must be approved judgment,determines that you are not in a condition in advance). Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 37 to receive,and/or to provide consent to,the Non-Plan Plan Facility.For appointment and advice phone Provider's notice and consent form,in accordance numbers,refer to our Provider Directory or call Member with applicable state informed consent law Services. If the Post-Stabilization Care is considered Emergency Out-of-Area Urgent Care Services under the criteria above,prior authorization for If you need Urgent Care due to an unforeseen illness, Post-Stabilization Care at a Non-Plan Provider will not unforeseen injury,or unforeseen complication of an be required. existing condition(including pregnancy),we cover Medically Necessary Services to prevent serious If the Post-Stabilization Care is not considered deterioration of your(or your unborn child's)health Emergency Services,the Services are not covered unless from a Non—Plan Provider if all of the following are true: you have received prior authorization from Health Plan • You receive the Services from Non—Plan Providers as described under"Post-Stabilization Care authorization while you are temporarily outside our Service Area from other Non-Plan Providers(including Cigna PPO Network facilities inside a Kaiser Permanente State)" • A reasonable person would have believed that your above.Non-Plan Providers outside of California may (or your unborn child's)health would seriously provide notice and seek your consent to waive your deteriorate if you delayed treatment until you returned balance billing protections under the federal No to our Service Area Surprises Act,if such consent is permissible under applicable state informed consent law.If you consent to You do not need prior authorization for Out-of-Area waive your balance billing protections and receive Urgent Care.We cover Out-of-Area Urgent Care you Services from the Non-Plan Provider,you will have to receive from Non—Plan Providers if the Services would pay the full cost of the Services. have been covered under this EOC if you had received them from Plan Providers. Your Cost Share Your Cost Share for covered Emergency Services and To obtain follow-up care from a Plan Provider,call the Post-Stabilization Care is described in the"Cost Share appointment or advice phone number at a Plan Facility. Summary"section of this EOC.Your Cost Share is the For phone numbers,refer to our Provider Directory or same whether you receive the Services from a Plan call Member Services.We do not cover follow-up care Provider or a Non—Plan Provider.For example: from Non—Plan Providers after you no longer need • If you receive Emergency Services in the emergency Urgent Care,except for durable medical equipment covered under this EOC.For more information about department of a Non—Plan Hospital,you pay the Cost durable medical equipment covered under this EOC,see Share for an emergency department visit as described "Durable Medical Equipment("DME")for Home Use" in the"Cost Share Summary"under"Emergency in the"Benefits"section.If you require durable medical Services and Urgent Care" equipment related to your Urgent Care after receiving • If we gave prior authorization for inpatient Post- Out-of-Area Urgent Care,your provider must obtain Stabilization Care in a Non—Plan Hospital,you pay prior authorization as described under"Getting a the Cost Share for hospital inpatient Services as Referral"in the"How to Obtain Services"section. described in the"Cost Share Summary"under "Hospital inpatient Services" Your Cost Share • If we gave prior authorization for durable medical Your Cost Share for covered Urgent Care is the Cost equipment after discharge from a Non—Plan Hospital, Share required for Services provided by Plan Providers you pay the Cost Share for durable medical as described in the"Cost Share Summary"section of this equipment as described in the"Cost Share Summary" EOC.For example: under"Durable Medical Equipment("DME")for • If you receive an Urgent Care evaluation as part of home use" covered Out-of-Area Urgent Care from a Non—Plan Provider,you pay the Cost Share for Urgent Care consultations,evaluations,and treatment as described Urgent Care in the"Cost Share Summary"under"Emergency Inside our Service Area Services and Urgent Care" An Urgent Care need is one that requires prompt medical • If the Out-of-Area Urgent Care you receive includes attention but is not an Emergency Medical Condition.If an X-ray,you pay the Cost Share for an X-ray as you think you may need Urgent Care,call the described in the"Cost Share Summary"under appropriate appointment or advice phone number at a "Outpatient imaging,laboratory,and other diagnostic Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 38 and treatment Services,"in addition to the Cost Share • The Services are one of the following: for the Urgent Care evaluation ♦ Preventive Services • If we gave prior authorization for durable medical ♦ health care items and services for diagnosis, equipment provided as part of Out-of-Area Urgent assessment,or treatment Care,you pay the Cost Share for durable medical ♦ health education covered under"Health equipment as described in the"Cost Share Summary" Education"in this"Benefits"section under"Durable Medical Equipment("DME")for ♦ other health care items and services home use" • The Services are provided,prescribed,authorized,or Note:If you receive Urgent Care in an emergency directed by a Plan Physician,except for: department,you pay the Cost Share for an emergency ♦ covered Services received outside of your Home department visit as described in the"Cost Share Region Service Area,as described under Summary"under"Emergency Services and Urgent "Receiving Care Outside of Your Home Region Care." Service Area"in the"How to Obtain Services" section Payment and Reimbursement ♦ drugs prescribed by dentists,as described under "Outpatient Prescription Drugs,Supplies,and If you receive Emergency Services,Post-Stabilization Supplements"below Care,or Out-of-Area Urgent Care from a Non—Plan ♦ emergency ambulance Services,as described Provider as described in this"Emergency Services and under"Ambulance Services"below Urgent Care"section,or emergency ambulance Services ♦ Emergency Services,Post-Stabilization Care,and described under"Ambulance Services"in the"Benefits" Out-of-Area Urgent Care,as described in the section,you are not responsible for any amounts beyond "Emergency Services and Urgent Care"section your Cost Share for covered Services.However,if the Non— provider does not agree to bill us,you may have to pay ♦ eyeglasses and contact lenses prescribed by Non— for the Services and file a claim for reimbursement.Also, Plan Providers,as described under"Vision you maybe required to pay and file a claim for any Services for Adult Members"and"Vision Services prescribed by a Non—Plan Provider as part of Services for Pediatric Members"below covered Emergency Services,Post-Stabilization Care, • You receive the Services from Plan Providers inside and Out-of-Area Urgent Care even if you receive the our Service Area,except for: Services from a Plan Provider,such as a Plan Pharmacy. ♦ authorized referrals,as described under"Getting a Referral"in the"How to Obtain Services"section For information on how to file a claim,please see the ♦ covered Services received outside of your Home "Post-Service Claims and Appeals"section. Region Service Area,as described under "Receiving Care Outside of Your Home Region Service Area"in the"How to Obtain Services" Benefits section ♦ emergency ambulance Services,as described This section describes the Services that are covered under"Ambulance Services"below under this EOC. ♦ Emergency Services,Post-Stabilization Care,and Out-of-Area Urgent Care,as described in the Services are covered under this EOC as specifically "Emergency Services and Urgent Care"section described in this EOC. Services that are not specifically ♦ hospice care,as described under"Hospice Care" described in this EOC are not covered,except as required below by state or federal law. Services are subject to exclusions and limitations described in the"Exclusions,Limitations, • The Medical Group has given prior authorization for Coordination of Benefits,and Reductions"section. the Services,if required,as described under"Medical Except as otherwise described in this EOC,all of the Group authorization procedure for certain referrals" following conditions must be satisfied: in the"How to Obtain Services"section • You are a Member on the date that you receive the Please also refer to: Services • The"Emergency Services and Urgent Care"section • The Services are Medically Necessary for information about how to obtain covered Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 39 Emergency Services,Post-Stabilization Care,and "Who Is Eligible"in the"Premiums,Eligibility,and Out-of-Area Urgent Care Enrollment"section,the parent or guardian of the • Our Provider Directory for the types of covered newborn must pay the Cost Share indicated in the"Cost Services that are available from each Plan Facility, Share Summary"section of this EOC for any Services because some facilities provide only specific types of that the newborn receives,whether or not the newborn is covered Services enrolled.When the"Cost Share Summary"indicates the Services are subject to the Plan Deductible,the Cost Share for those Services will be Charges if the newborn Your Cost Share has not met the Plan Deductible. Your Cost Share is the amount you are required to pay Payment toward your Cost Share(and when you may for covered Services.For example,your Cost Share may be billed) be a Copayment or Coinsurance. In most cases,your provider will ask you to make a payment toward your Cost Share at the time you receive If your coverage includes a Plan Deductible and you Services.If you receive more than one type of Services receive Services that are subject to the Plan Deductible, (such as a routine physical maintenance exam and your Cost Share for those Services will be Charges until laboratory tests),you may be required to pay separate you reach the Plan Deductible. Similarly,if your Cost Share for each of those Services.Keep in mind that coverage includes a Drug Deductible,and you receive your payment toward your Cost Share may cover only a Services that are subject to the Drug Deductible,your portion of your total Cost Share for the Services you Cost Share for those Services will be Charges until you receive,and you will be billed for any additional reach the Drug Deductible. amounts that are due.The following are examples of when you may be asked to pay(or you may be billed for) Refer to the"Cost Share Summary"section of this EOC Cost Share amounts in addition to the amount you pay at for the amount you will pay for Services. check-in: • You receive non-preventive Services during a General rules, examples, and exceptions preventive visit.For example,you go in for a routine Your Cost Share for covered Services will be the Cost physical maintenance exam,and at check-in you pay Share in effect on the date you receive the Services, your Cost Share for the preventive exam(your Cost except as follows: Share may be"no charge").However,during your • If you are receiving covered hospital inpatient or preventive exam your provider finds a problem with Skilled Nursing Facility Services on the effective date your health and orders non-preventive Services to of this EOC,you pay the Cost Share in effect on your diagnose your problem(such as laboratory tests).You admission date until you are discharged if the may be asked to pay(or you will be billed for)your Services were covered under your prior Health Plan Cost Share for these additional non-preventive evidence of coverage and there has been no break in diagnostic Services coverage.However,if the Services were not covered • You receive diagnostic Services during a treatment under your prior Health Plan evidence of coverage,or visit.For example,you go in for treatment of an if there has been a break in coverage,you pay the existing health condition,and at check-in you pay Cost Share in effect on the date you receive the your Cost Share for a treatment visit.However, Services during the visit your provider finds a new problem • For items ordered in advance,you pay the Cost Share with your health and performs or orders diagnostic in effect on the order date(although we will not cover Services(such as laboratory tests).You may be asked the item unless you still have coverage for it on the to pay(or you will be billed for)your Cost Share for date you receive it)and you may be required to pay these additional diagnostic Services the Cost Share when the item is ordered.For • You receive treatment Services during a diagnostic outpatient prescription drugs,the order date is the visit.For example,you go in for a diagnostic exam, date that the pharmacy processes the order after and at check-in you pay your Cost Share for a receiving all of the information they need to fill the diagnostic exam.However,during the diagnostic prescription exam your provider confirms a problem with your health and performs treatment Services(such as an Cost Share for Services received by newborn children outpatient procedure).You may be asked to pay(or of a Member you will be billed for)your Cost Share for these During the 31 days of automatic coverage for newborn additional treatment Services children described under"If you have a baby"under Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 40 • You receive Services from a second provider during Primary Care Visits,Non-Physician Specialist Visits, your visit.For example,you go in for a diagnostic and Physician Specialist Visits exam,and at check-in you pay your Cost Share for a The Cost Share for a Primary Care Visit applies to diagnostic exam.However,during the diagnostic evaluations and treatment provided by generalists in exam your provider requests a consultation with a internal medicine,pediatrics,or family practice,and by specialist.You may be asked to pay(or you will be specialists in obstetrics/gynecology whom the Medical billed for)your Cost Share for the consultation with Group designates as Primary Care Physicians. Some the specialist physician specialists provide primary care in addition to specialty care but are not designated as Primary Care In some cases,your provider will not ask you to make a Physicians.If you receive Services from one of these payment at the time you receive Services,and you will specialists,the Cost Share for a Physician Specialist Visit be billed for your Cost Share(for example,some will apply to all consultations,evaluations,and treatment Laboratory Departments are not able to collect Cost provided by the specialist except for routine preventive Share,or your Plan Provider is not able to collect Cost counseling and exams listed under"Preventive Services" Share,if any,for Telehealth Visits you receive at home). in this`Benefits"section.For example,if your personal Plan Physician is a specialist in internal medicine or When we send you a bill,it will list Charges for the obstetrics/gynecology who is not a Primary Care Services you received,payments and credits applied to Physician,you will pay the Cost Share for a Physician your account,and any amounts you still owe.Your Specialist Visit for all consultations,evaluations,and current bill may not always reflect your most recent treatment by the specialist except routine preventive Charges and payments.Any Charges and payments that counseling and exams listed under"Preventive Services" are not on the current bill will appear on a future bill. in this`Benefits"section.The Non-Physician Specialist Sometimes,you may see a payment but not the related Visit Cost Share applies to consultations,evaluations, Charges for Services. That could be because your and treatment provided by non-physician specialists payment was recorded before the Charges for the (such as nurse practitioners,physician assistants, Services were processed.If so,the Charges will appear optometrists,podiatrists,and audiologists). on a future bill.Also,you may receive more than one bill for a single outpatient visit or inpatient stay.For Noncovered Services example,you may receive a bill for physician services If you receive Services that are not covered under this and a separate bill for hospital services.If you don't see EOC,you may have to pay the full price of those all the Charges for Services on one bill,they will appear Services.Payments you make for noncovered Services on a future bill.If we determine that you overpaid and do not apply to any deductible or out-of-pocket are due a refund,then we will send a refund to you maximum. within four weeks after we make that determination.If you have questions about a bill,please call the phone Benefit limits number on the bill. Some benefits may include a limit on the number of visits,days,treatment cycles,or dollar amount that will In some cases,a Non—Plan Provider may be involved in be covered under your plan during a specified time the provision of covered Services at a Plan Facility or a period.If a benefit includes a limit,this will be indicated contracted facility where we have authorized you to in the"Cost Share Summary"section of this EOC. The receive care.You are not responsible for any amounts time period associated with a benefit limit may not be the beyond your Cost Share for the covered Services you same as the term of this EOC.We will count all Services receive at Plan Facilities or at contracted facilities where you receive during the benefit limit period toward the we have authorized you to receive care.However,if the benefit limit,including Services you received under a provider does not agree to bill us,you may have to pay prior Health Plan EOC(as long as you have continuous for the Services and file a claim for reimbursement.For coverage with Health Plan).Note:We will not count information on how to file a claim,please see the"Post- Services you received under a prior Health Plan EOC Service Claims and Appeals"section. when you first enroll in individual plan coverage or a new employer group's plan,when you move from group Please refer to the"Emergency Services and Urgent to individual plan coverage(or vice versa),or when you Care"section for more information about when you may received Services under a Kaiser Permanente Senior be billed for Emergency Services,Post-Stabilization Advantage evidence of coverage.If you are enrolled in Care,and Out-of-Area Urgent Care. the Kaiser Permanente POS Plan,refer to your KPIC Certificate of Insurance and Schedule of Coverage for benefit limits that apply to your separate indemnity Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 41 coverage provided by the Kaiser Permanente Insurance If you are a Member in a Family of two or more Company("KPIC"). Members,you reach the Plan Out-of-Pocket Maximum either when you reach the maximum for any one Getting an estimate of your Cost Share Member,or when your Family reaches the Family If you have questions about the Cost Share for specific maximum.For example,suppose you have reached the Services that you expect to receive or that your provider Plan Out-of-Pocket Maximum for any one Member.For orders during a visit or procedure,please visit our Services subject to the Plan Out-of-Pocket Maximum, website at kp.org/memberestimates to use our cost you will not pay any more Cost Share during the estimate tool or call Member Services. remainder of the Accumulation Period,but every other • If you have a Plan Deductible and would like an Member in your Family must continue to pay Cost Share estimate for Services that are subject to the Plan during the remainder of the Accumulation Period until Deductible,please call 1-800-390-3507(TTY users either they reach the maximum for any one Member or call 711)Monday through Friday 6 a.m.to 5 p.m. your Family reaches the Family maximum. Refer to the"Cost Share Summary"section of this Payments that count toward the Plan Out-of-Pocket EOC to find out if you have a Plan Deductible Maximum • For all other Cost Share estimates,please call 1-800- Any payments you make toward the Plan Deductible or 464-4000(TTY users call 711)24 hours a day,seven Drug Deductible,if applicable,apply toward the days a week(except closed holidays) maximum. Cost Share estimates are based on your benefits and the Most Copayments and Coinsurance you pay for covered Services you expect to receive.They are a prediction of Services apply to the maximum,however some may not. cost and not a guarantee of the final cost of Services. To find out whether a Copayment or Coinsurance for a Your final cost may be higher or lower than the estimate covered Service will apply to the maximum refer to the since not everything about your care can be known in "Cost Share Summary"section of this EOC. advance. If your plan includes pediatric dental Services described Drug Deductible in a Pediatric Dental Services Amendment to this EOC, This EOC does not include a Drug Deductible. those Services will apply toward the maximum.If your plan has a Pediatric Dental Services Amendment,it will Plan Deductible be attached to this EOC,and it will be listed in the This EOC does not include a Plan Deductible. EOC's Table of Contents. Copayments and Coinsurance Accrual toward deductibles and out-of-pocket The Copayment or Coinsurance you must pay for each maximums covered Service,after you meet any applicable To see how close you are to reaching your deductibles,if deductible,is described in this EOC. any,and out-of-pocket maximums,use our online Out- of-Pocket Summary tool at kp.org or call Member Note:If Charges for Services are less than the Services.We will provide you with accrual balance Copayment described in this EOC,you will pay the information for every month that you receive Services lesser amount,subject to any applicable deductible or until you reach your individual out-of-pocket maximums out-of-pocket maximum. or your Family reaches the Family out-of-pocket maximums. Plan Out-of-Pocket Maximum There is a limit to the total amount of Cost Share you We will provide accrual balance information by mail must pay under this EOC in the Accumulation Period for unless you have opted to receive notices electronically. covered Services that you receive in the same You can change your document delivery preferences at Accumulation Period. The Services that apply to the Plan any time at kp.org or by calling Member Services. Out-of-Pocket Maximum are described under the "Payments that count toward the Plan Out-of-Pocket Maximum"section below.Refer to the"Cost Share Summary"section of this EOC for your applicable Plan Out-of-Pocket Maximum amounts. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 42 Administered Drugs and Products Nonemergency Inside our Service Area,we cover nonemergency Administered drugs and products are medications and ambulance and psychiatric transport van Services if a products that require administration or observation by Plan Physician determines that your condition requires medical personnel,such as: the use of Services that only a licensed ambulance(or • Whole blood,red blood cells,plasma,and platelets psychiatric transport van)can provide and that the use of • Allergy antigens(including administration) other means of transportation would endanger your health.These Services are covered only when the vehicle • Cancer chemotherapy drugs and adjuncts transports you to or from covered Services. • Drugs and products that are administered via intravenous therapy or injection that are not for Ambulance Services exclusions cancer chemotherapy,including blood factor products • Transportation by car,taxi,bus,gurney van, and biological products("biologics")derived from wheelchair van,and any other type of transportation tissue,cells,or blood (other than a licensed ambulance or psychiatric • Other administered drugs and products transport van),even if it is the only way to travel to a Plan Provider We cover these items when prescribed by a Plan Provider,in accord with our drug formulary guidelines, Bariatric Surgery and they are administered to you in a Plan Facility or during home visits. We cover hospital inpatient Services related to bariatric surgical procedures(including room and board,imaging, Certain administered drugs are Preventive Services. laboratory,other diagnostic and treatment Services,and Refer to"Reproductive Health Services"for information Plan Physician Services)when performed to treat obesity about administered contraceptives and refer to by modification of the gastrointestinal tract to reduce "Preventive Services"for information on immunizations. nutrient intake and absorption,if all of the following requirements are met: Ambulance Services • You complete the Medical Group—approved pre- surgical educational preparatory program regarding Emergency lifestyle changes necessary for long term bariatric We cover Services of a licensed ambulance anywhere in surgery success the world without prior authorization(including • A Plan Physician who is a specialist in bariatric care transportation through the 911 emergency response determines that the surgery is Medically Necessary system where available)in the following situations: • You reasonably believed that the medical condition For covered Services related to bariatric surgical was an Emergency Medical Condition which required procedures that you receive,you will pay the Cost Share ambulance Services you would pay if the Services were not related to a • Your treating physician determines that you must be bariatric surgical procedure.For example, see"Hospital transported to another facility because your inpatient Services"in the"Cost Share Summary"section Emergency Medical Condition is not Stabilized and of this EOC for the Cost Share that applies for hospital the care you need is not available at the treating inpatient Services. facility For the following Services, refer to these If you receive emergency ambulance Services that are sections not ordered by a Plan Provider,you are not responsible • Outpatient prescription drugs(refer to"Outpatient for any amounts beyond your Cost Share for covered Prescription Drugs,Supplies,and Supplements") emergency ambulance Services.However,if the provider • Outpatient administered drugs(refer to"Administered does not agree to bill us,you may have to pay for the Drugs and Products") Services and file a claim for reimbursement.For information on how to file a claim,please see the"Post- Service Claims and Appeals"section. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 43 Behavioral Health Treatment for Autism • "Qualified Autism Service Paraprofessional"means Spectrum Disorder an unlicensed and uncertified individual who meets all of the following criteria: The following terms have special meaning when ♦ is supervised by a Qualified Autism Service capitalized and used in this"Behavioral Health Provider or Qualified Autism Service Professional Treatment for Autism Spectrum Disorder"section: at a level of clinical supervision that meets • "Qualified Autism Service Provider"means a professionally recognized standards of practice provider who has the experience and competence to ♦ provides treatment and implements Services design,supervise,provide,or administer treatment for pursuant to a treatment plan developed and autism spectrum disorder and is either of the approved by the Qualified Autism Service following: Provider ♦ a person who is certified by a national entity(such ♦ meets the education and training qualifications as the Behavior Analyst Certification Board)with described in Section 54342 of Title 17 of the a certification that is accredited by the National California Code of Regulations Commission for Certifying Agencies ♦ has adequate education,training,and experience, ♦ a person licensed in California as a physician, as certified by a Qualified Autism Service physical therapist,occupational therapist, Provider or an entity or group that employs psychologist,marriage and family therapist, Qualified Autism Service Providers educational psychologist,clinical social worker, ♦ is employed by the Qualified Autism Service professional clinical counselor,speech-language Provider or an entity or group that employs pathologist,or audiologist Qualified Autism Service Providers responsible • "Qualified Autism Service Professional"means an for the autism treatment plan individual who meets all of the following criteria: ♦ provides behavioral health treatment,which may We cover behavioral health treatment for autism include clinical case management and case spectrum disorder(including applied behavior analysis supervision under the direction and supervision of and evidence-based behavior intervention programs)that a qualified autism service provider develops or restores,to the maximum extent practicable, the functioning of a person with autism spectrum ♦ is supervised by a Qualified Autism Service disorder and that meets all of the following criteria: Provider ♦ provides treatment pursuant to a treatment plan • The Services are provided inside our Service Area developed and approved by the Qualified Autism • The treatment is prescribed by a Plan Physician,or is Service Provider developed by a Plan Provider who is a psychologist ♦ is a behavioral health treatment provider who • The treatment is provided under a treatment plan meets the education and experience qualifications prescribed by a Plan Provider who is a Qualified described in Section 54342 of Title 17 of the Autism Service Provider California Code of Regulations for an Associate • The treatment is administered by a Plan Provider who Behavior Analyst,Behavior Analyst,Behavior Management Assistant,Behavior Management is one of the following: Consultant,or Behavior Management Program ♦ a Qualified Autism Service Provider ♦ has training and experience in providing Services ♦ a Qualified Autism Service Professional for autism spectrum disorder pursuant to Division supervised by the Qualified Autism Service 4.5(commencing with Section 4500)of the Provider Welfare and Institutions Code or Title 14 ♦ a Qualified Autism Service Paraprofessional (commencing with Section 95000)of the supervised by a Qualified Autism Service Provider Government Code or Qualified Autism Service Professional ♦ is employed by the Qualified Autism Service • The treatment plan has measurable goals over a Provider or an entity or group that employs specific timeline that is developed and approved by Qualified Autism Service Providers responsible the Qualified Autism Service Provider for the for the autism treatment plan Member being treated • The treatment plan is reviewed no less than once every six months by the Qualified Autism Service Provider and modified whenever appropriate Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 44 • The treatment plan requires the Qualified Autism "Hospital Inpatient Services"and"Skilled Nursing Service Provider to do all of the following: Facility Care") ♦ describe the Member's behavioral health • Outpatient drugs,supplies,and supplements(refer to impairments to be treated "Outpatient Prescription Drugs,Supplies,and ♦ design an intervention plan that includes the Supplements") service type,number of hours,and parent • Outpatient laboratory(refer to"Outpatient Imaging, participation needed to achieve the plan's goal and Laboratory,and Other Diagnostic and Treatment objectives,and the frequency at which the Services") Member's progress is evaluated and reported • Outpatient physical,occupational,and speech therapy ♦ provide intervention plans that utilize evidence- visits(refer to"Rehabilitative and Habilitative based practices,with demonstrated clinical Services") efficacy in treating autism spectrum disorder • Services to diagnose autism spectrum disorder and ♦ discontinue intensive behavioral intervention Services to develop and revise the treatment plan Services when the treatment goals and objectives (refer to"Mental Health Services") are achieved or no longer appropriate • The treatment plan is not used for either of the following: Dental and Orthodontic Services ♦ for purposes of providing(or for the We do not cover most dental and orthodontic Services reimbursement of)respite care,day care,or under this EOC,but we do cover some dental and educational services orthodontic Services as described in this"Dental and ♦ to reimburse a parent for participating in the Orthodontic Services"section. treatment program For covered dental and orthodontic procedures that you We also cover behavioral health treatment that meets the may receive,you will pay the Cost Share you would pay same criteria to treat mental health conditions other than if the Services were not related to dental and orthodontic autism spectrum disorder when behavioral health Services.For example,see"Hospital inpatient Services" treatment is clinically indicated. in the"Cost Share Summary"section of this EOC for the Cost Share that applies for hospital inpatient Services. Services from Non-Plan Providers If we are not able to offer an appointment with a Plan Dental Services for radiation treatment Provider within required geographic and timely access We cover dental evaluation,X-rays,fluoride treatment, standards,we will offer to refer you to a Non-Plan and extractions necessary to prepare your jaw for Provider(as described in"Medical Group authorization radiation therapy of cancer in your head or neck if a Plan procedure for certain referrals"under"Getting a Physician provides the Services or if the Medical Group Referral"in the"How to Obtain Services"section). authorizes a referral to a dentist for those Services(as described in"Medical Group authorization procedure for Additionally,we cover Services provided by a 988 certain referrals"under"Getting a Referral"in the"How center,mobile crisis team,or other provider of to Obtain Services"section). behavioral health crisis services(collectively,"988 Services")for medically necessary treatment of a mental Dental Services for transplants health or substance use disorder without prior We cover dental services that are Medically Necessary to authorization,as required by state law. free the mouth from infection in order to prepare for a transplant covered under"Transplant Services"in this For these referral Services and 988 Services,you pay the "Benefits" section,if a Plan Physician provides the Cost Share required for Services provided by a Plan Services or if the Medical Group authorizes a referral to Provider as described in this EOC. a dentist for those Services(as described in"Medical Group authorization procedure for certain referrals" For the following Services, refer to these under"Getting a Referral"in the"How to Obtain sections Services" section). • Behavioral health treatment for autism spectrum disorder provided during a covered stay in a Plan Hospital or Skilled Nursing Facility(refer to Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 45 Dental anesthesia Dialysis Care For dental procedures at a Plan Facility,we provide general anesthesia and the facility's Services associated We cover acute and chronic dialysis Services if all of the with the anesthesia if all of the following are true: following requirements are met: • You are under age 7,or you are developmentally • The Services are provided inside our Service Area disabled,or your health is compromised • You satisfy all medical criteria developed by the • Your clinical status or underlying medical condition Medical Group and by the facility providing the requires that the dental procedure be provided in a dialysis hospital or outpatient surgery center • A Plan Physician provides a written referral for care • The dental procedure would not ordinarily require at the facility general anesthesia After you receive appropriate training at a dialysis We do not cover any other Services related to the dental facility we designate,we also cover equipment and procedure,such as the dentist's Services. medical supplies required for home hemodialysis and home peritoneal dialysis inside our Service Area. Dental and orthodontic Services for cleft palate Coverage is limited to the standard item of equipment or We cover dental extractions,dental procedures necessary supplies that adequately meets your medical needs.We to prepare the mouth for an extraction,and orthodontic decide whether to rent or purchase the equipment and Services,if they meet all of the following requirements: supplies,and we select the vendor.You must return the equipment and any unused supplies to us or pay us the • The Services are an integral part of a reconstructive fair market price of the equipment and any unused surgery for cleft palate that we are covering under supply when we are no longer covering them. "Reconstructive Surgery"in this"Benefits"section ("cleft palate"includes cleft palate,cleft lip,or other For the following Services, refer to these craniofacial anomalies associated with cleft palate) sections • A Plan Provider provides the Services or the Medical • Durable medical equipment for home use(refer to Group authorizes a referral to a Non—Plan Provider "Durable Medical Equipment("DME")for Home who is a dentist or orthodontist(as described in Use") "Medical Group authorization procedure for certain referrals"under"Getting a Referral"in the"How to • Hospital inpatient Services(refer to"Hospital Obtain Services"section) Inpatient Services") • Office visits not described in the"Dialysis Care" For the following Services, refer to these section(refer to"Office Visits") sections • Outpatient laboratory(refer to"Outpatient Imaging, • Accidental injury to teeth(refer to"Injury to Teeth") Laboratory,and Other Diagnostic and Treatment • Office visits not described in the"Dental and Services") Orthodontic Services"section(refer to"Office • Outpatient prescription drugs(refer to"Outpatient Visits") Prescription Drugs,Supplies,and Supplements") • Outpatient imaging,laboratory,and other diagnostic • Outpatient administered drugs(refer to"Administered and treatment Services(refer to"Outpatient Imaging, Drugs and Products") Laboratory,and Other Diagnostic and Treatment • Telehealth Visits(refer to"Telehealth Visits") Services") • Outpatient administered drugs(refer to"Administered Dialysis care exclusions Drugs and Products"),except that we cover outpatient . Comfort convenience or lux equipment, lies administered drugs under"Dental anesthesia"in this supplies and features "Dental and Orthodontic Services"section • Nonmedical items,such as generators or accessories • Outpatient prescription drugs(refer to"Outpatient to make home dialysis equipment portable for travel Prescription Drugs,Supplies,and Supplements") • Telehealth Visits(refer to"Telehealth Visits") Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 46 Durable Medical Equipment ("DME") for • Infusion pumps(such as insulin pumps)and supplies Home Use to operate the pump DME coverage rules • IV pole DME for home use is an item that meets the following • Nebulizer and supplies criteria: • Peak flow meters • The item is intended for repeated use • Phototherapy blankets for treatment of jaundice in • The item is primarily and customarily used to serve a newborns medical purpose Supplemental DME items • The item is generally useful only to an individual We cover DME that is not described under"Base DME with an illness or injury Items"or"Lactation supplies,"including repair and • The item is appropriate for use in the home replacement of covered equipment,if all of the requirements described under"DME coverage rules"in For a DME item to be covered,all of the following this"Durable Medical Equipment("DME")for Home requirements must be met: Use"section are met. • Your EOC includes coverage for the requested DME Lactation supplies item We cover one retail-grade milk pump(also known as a • A Plan Physician has prescribed the DME item for breast pump)per pregnancy and associated supplies,as your medical condition listed on our website at kp.m/prevention.We will • The item has been approved for you through the decide whether to rent or purchase the item and we Plan's prior authorization process,as described in choose the vendor.We cover this pump for convenience "Medical Group authorization procedure for certain purposes. The pump is not subject to prior authorization referrals"under"Getting a Referral"in the"How to requirements. Obtain Services"section • The Services are provided inside our Service Area If you or your baby has a medical condition that requires the use of a milk pump,we cover a hospital-grade milk Coverage is limited to the standard item of equipment pump and the necessary supplies to operate it,in accord that adequately meets your medical needs.We decide with the coverage rules described under"DME coverage whether to rent or purchase the equipment,and we select rules"in this"Durable Medical Equipment("DME")for the vendor.You must return the equipment to us or pay Home Use section. us the fair market price of the equipment when we are no Outside our Service Area longer covering it. We do not cover most DME for home use outside our Base DME Items Service Area.However,if you live outside our Service We cover Base DME Items(including repair or Area,we cover the following DME(subject to the Cost replacement of covered equipment)if all of the Share and all other coverage requirements that apply to requirements described under"DME coverage rules"in DME for home use inside our Service Area)when the this"Durable Medical Equipment("DME")for Home item is dispensed at a Plan Facility: Use"section are met."Base DME Items"means the • Blood glucose monitors for diabetes blood testing and following items: their supplies(such as blood glucose monitor test • Blood glucose monitors for diabetes blood testing and strips,lancets,and lancet devices)from a Plan their supplies(such as blood glucose monitor test Pharmacy strips,lancets,and lancet devices) • Canes(standard curved handle) • Bone stimulator • Crutches(standard) • Canes(standard curved handle or quad)and • Insulin pumps and supplies to operate the pump,after replacement supplies completion of training and education on the use of the • Cervical traction(over door) PUMP • Nebulizers and their supplies for the treatment of • Crutches(standard or forearm)and replacement pediatric asthma supplies • Dry pressure pad for a mattress • Peak flow meters from a Plan Pharmacy Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 47 For the following Services, refer to these For the following Services, refer to these sections sections • Dialysis equipment and supplies required for home • Abortion and abortion-related Services(refer to hemodialysis and home peritoneal dialysis(refer to "Reproductive Health Services") "Dialysis Care") • Diabetes urine testing supplies and insulin- Fertility Services administration devices other than insulin pumps(refer to"Outpatient Prescription Drugs, Supplies,and "Fertility Services"means treatments and procedures to Supplements") help you become pregnant. • Durable medical equipment related to an Emergency Medical Condition or Urgent Care episode(refer to Before starting or continuing a course of fertility "Post-Stabilization Care"and"Out-of-Area Urgent Services,you may be required to pay initial and Care") subsequent deposits toward your Cost Share for some or • Durable medical equipment related to the terminal all of the entire course of Services,along with any past- illness for Members who are receiving covered due fertility-related Cost Share.Any unused portion of hospice care(refer to"Hospice Care") your deposit will be returned to you.When a deposit is not required,you must pay the Cost Share for the • Insulin and any other drugs administered with an procedure,along with any past-due fertility-related Cost infusion pump(refer to"Outpatient Prescription Share,before you can schedule a fertility procedure. Drugs, Supplies,and Supplements") Diagnosis and treatment of Infertility DME for home use exclusions We cover the following Services for the diagnosis and • Comfort,convenience,or luxury equipment or treatment of Infertility: features except for retail-grade milk pumps as • Office visits described under"Lactation supplies"in this"Durable • Outpatient surgery and outpatient procedures Medical Equipment("DME")for Home Use"section • Items not intended for maintaining normal activities • Outpatient imaging and laboratory Services of daily living,such as exercise equipment(including • Outpatient administered drugs that require devices intended to provide additional support for administration or observation by medical personnel. recreational or sports activities) We cover these items when they are prescribed by a • Hygiene equipment Plan Provider,in accord with our drug formulary guidelines,and they are administered to you in a Plan • Nonmedical items,such as sauna baths or elevators Facility • Modifications to your home or car • Hospital inpatient stay directly related to diagnosis • Devices for testing blood or other body substances and treatment of Infertility (except diabetes blood glucose monitors and their supplies) Artificial insemination • Electronic monitors of the heart or lungs except infant We cover the following Services for artificial apnea monitors insemination: • Repair or replacement of equipment due to loss,theft, • Office visits or misuse • Outpatient surgery and outpatient procedures • Outpatient imaging and laboratory Services Emergency Services and Urgent Care • Outpatient administered drugs that require administration or observation by medical personnel. We cover the following Services: We cover these items when they are prescribed by a • Emergency department visits Plan Provider,in accord with our drug formulary guidelines,and they are administered to you in a Plan • Urgent Care consultations,evaluations,and treatment Facility • Hospital inpatient stays directly related to diagnosis and treatment of Infertility Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 48 Assisted reproductive technology ("ART") We also cover a variety of health education counseling, Services programs,and materials to help you take an active role in ART Services such as in vitro fertilization("IVF"), protecting and improving your health,including gamete intra-fallopian transfer("GIFT"),or zygote programs for tobacco cessation,stress management,and intrafallopian transfer("ZIFT")are not covered under chronic conditions(such as diabetes and asthma).Kaiser this EOC. Permanente also offers health education counseling, programs,and materials that are not covered,and you For the following Services, refer to these may be required to pay a fee. sections For more information about our health education • Fertility preservation Services for iatrogenic counseling,programs,and materials,please contact a Infertility(refer to"Fertility Preservation Services for Health Education Department or Member Services or go Iatrogenic Infertility") to our website at ky.m. • Diagnostic Services provided by Plan Providers who are not physicians,such as EKGs and EEGs(refer to "Outpatient Imaging,Laboratory,and Other Hearing Services Diagnostic and Treatment Services") We cover the following: • Outpatient drugs,supplies,and supplements(refer to "Outpatient Prescription Drugs,Supplies,and • Hearing exams with an audiologist to determine the need for hearing correction Supplements") • Physician Specialist Visits to diagnose and treat Fertility Services exclusions hearing problems • Services to reverse voluntary,surgically induced Hearing aids Infertility We provide an Allowance for each ear toward the • Semen and eggs(and Services related to their purchase price of a hearing aid(including fitting, procurement and storage) counseling,adjustment,cleaning,and inspection)when • ART Services,such as ovum transplants,GIFT,IVF, prescribed by a Plan Physician or by a Plan Provider who and ZIFT is an audiologist.We will cover hearing aids for both ears only if both aids are required to provide significant improvement that is not obtainable with only one hearing Fertility Preservation Services for aid.We will not provide the Allowance if we have Iatrogenic Infertility provided an Allowance toward(or otherwise covered)a hearing aid within the previous 36 months.Also,the Standard fertility preservation Services are covered for Allowance can only be used at the initial point of sale.If Members undergoing treatment or receiving covered you do not use all of your Allowance at the initial point Services that may directly or indirectly cause iatrogenic of sale,you cannot use it later.Refer to"Hearing Infertility.Fertility preservation Services do not include Services"in the"Cost Share Summary"section of this diagnosis or treatment of Infertility. EOC for your Allowance amount. For covered fertility preservation Services that you We select the provider or vendor that will furnish the receive,you will pay the Cost Share you would pay if the covered hearing aids.Coverage is limited to the types Services were not related to fertility preservation.For and models of hearing aids furnished by the provider or example,see"Outpatient surgery and outpatient vendor. procedures"in the"Cost Share Summary"section of this EOC for the Cost Share that applies for outpatient For the following Services, refer to these procedures. sections • Routine hearing screenings when performed as part of Health Education a routine physical maintenance exam(refer to We cover a variety of health education counseling, "Preventive Services") programs,and materials that your personal Plan • Services related to the ear or hearing other than those Physician or other Plan Providers provide during a visit described in this section,such as outpatient care to covered under another part of this EOC. treat an ear infection or outpatient prescription drugs, Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 49 supplies,and supplements(refer to the applicable visit.For example,if a nurse comes to your home for heading in this"Benefits"section) three hours and then leaves,that counts as two visits. • Cochlear implants and osseointegrated hearing Also,each person providing Services counts toward devices(refer to"Prosthetic and Orthotic Devices") these visit limits.For example,if a home health aide and a nurse are both at your home during the same two hours, Hearing Services exclusions that counts as two visits. • Internally implanted hearing aids For the following Services, refer to these • Replacement parts and batteries,repair of hearing sections aids,and replacement of lost or broken hearing aids • Behavioral health treatment for autism spectrum (the manufacturer warranty may cover some of these) disorder(refer to"Behavioral Health Treatment for Autism Spectrum Disorder") Home Health Care • Dialysis care(refer to"Dialysis Care") • Durable medical equipment(refer to"Durable "Home health care"means Services provided in the Medical Equipment("DME")for Home Use") home by nurses,medical social workers,home health aides,and physical,occupational,and speech therapists. • Ostomy and urological supplies(refer to"Ostomy and Urological Supplies") We cover home health care only if all of the following • Outpatient drugs,supplies,and supplements(refer to are true: "Outpatient Prescription Drugs,Supplies,and • You are substantially confined to your home(or a Supplements") friend's or relative's home) • Outpatient physical,occupational,and speech therapy • Your condition requires the Services of a nurse, visits(refer to"Rehabilitative and Habilitative physical therapist,occupational therapist,or speech Services") therapist(home health aide Services are not covered • Prosthetic and orthotic devices(refer to"Prosthetic unless you are also getting covered home health care and Orthotic Devices") from a nurse,physical therapist,occupational therapist,or speech therapist that only a licensed Home health care exclusions provider can provide) • Care of a type that an unlicensed family member or • A Plan Physician determines that it is feasible to other layperson could provide safely and effectively maintain effective supervision and control of your in the home setting after receiving appropriate care in your home and that the Services can be safely training.This care is excluded even if we would cover and effectively provided in your home the care if it were provided by a qualified medical • The Services are provided inside our Service Area professional in a hospital or a Skilled Nursing Facility • Care in the home if the home is not a safe and We cover only part-time or intermittent home health effective treatment setting care,as follows: • Up to two hours per visit for visits by a nurse, Hospice Care medical social worker,or physical,occupational,or speech therapist,and up to four hours per visit for Hospice care is a specialized form of interdisciplinary visits by a home health aide health care designed to provide palliative care and to • Up to three visits per day(counting all home health alleviate the physical,emotional,and spiritual visits) discomforts of a Member experiencing the last phases of • Up to 100 visits per Accumulation Period(counting life due to a terminal illness.It also provides support to all home health visits) the primary caregiver and the Member's family.A Member who chooses hospice care is choosing to receive palliative care for pain and other symptoms associated Note:If a visit by a nurse,medical social worker,or with the terminal illness,but not to receive care to try to physical,occupational,or speech therapist lasts longer cure the terminal illness.You may change your decision than two hours,then each additional increment of two to receive hospice care benefits at any time. hours counts as a separate visit.If a visit by a home health aide lasts longer than four hours,then each additional increment of four hours counts as a separate Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 50 We cover the hospice Services listed below only if all of Necessary to achieve palliation or management of acute the following requirements are met: medical symptoms: • A Plan Physician has diagnosed you with a terminal • Nursing care on a continuous basis for as much as 24 illness and determines that your life expectancy is 12 hours a day as necessary to maintain you at home months or less • Short-term inpatient Services required at a level that • The Services are provided inside our Service Area or cannot be provided at home inside California but within 15 miles or 30 minutes from our Service Area(including a friend's or relative's home even if you live there temporarily) Hospital Inpatient Services • The Services are provided by a licensed hospice We cover the following inpatient Services in a Plan agency that is a Plan Provider Hospital,when the Services are generally and • A Plan Physician determines that the Services are customarily provided by acute care general hospitals necessary for the palliation and management of your inside our Service Area: terminal illness and related conditions • Room and board,including a private room if Medically Necessary If all of the above requirements are met,we cover the following hospice Services,if necessary for your hospice • Specialized care and critical care units care: • General and special nursing care • Plan Physician Services • Operating and recovery rooms • Skilled nursing care,including assessment, • Services of Plan Physicians,including consultation evaluation,and case management of nursing needs, and treatment by specialists treatment for pain and symptom control,provision of • Anesthesia emotional support to you and your family,and instruction to caregivers • Drugs prescribed in accord with our drug formulary guidelines(for discharge drugs prescribed when you • Physical,occupational,and speech therapy for are released from the hospital,refer to"Outpatient purposes of symptom control or to enable you to Prescription Drugs,Supplies,and Supplements"in maintain activities of daily living this"Benefits"section) • Respiratory therapy • Radioactive materials used for therapeutic purposes • Medical social services • Durable medical equipment and medical supplies • Home health aide and homemaker services • Imaging,laboratory,and other diagnostic and • Palliative drugs prescribed for pain control and treatment Services,including MRI,CT,and PET symptom management of the terminal illness for up to scans a 100-day supply in accord with our drug formulary • Whole blood,red blood cells,plasma,platelets,and guidelines.You must obtain these drugs from a Plan their administration Pharmacy.Certain drugs are limited to a maximum 30-day supply in any 30-day period(your Plan • Obstetrical care and delivery(including cesarean Pharmacy can tell you if a drug you take is one of section).Note:If you are discharged within 48 hours these drugs) after delivery(or within 96 hours if delivery is by cesarean section),your Plan Physician may order a • Durable medical equipment follow-up visit for you and your newborn to take • Respite care when necessary to relieve your place within 48 hours after discharge(for visits after caregivers.Respite care is occasional short-term you are released from the hospital,refer to"Office inpatient Services limited to no more than five Visits"in this"Benefits"section) consecutive days at a time • Behavioral health treatment that is Medically • Counseling and bereavement services Necessary to treat mental health conditions that fall • Dietary counseling under any of the diagnostic categories listed in the mental and behavioral disorders chapter of the most recent edition of the International Classification of We also cover the following hospice Services only Diseases or that are listed in the most recent version during periods of crisis when they are Medically of the Diagnostic and Statistical Manual of Mental Disorders Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 51 • Respiratory therapy categories listed in the mental and behavioral disorders • Physical,occupational,and speech therapy(including chapter of the most recent edition of the International treatment in our organized,multidisciplinary Classification of Diseases or that is listed in the most rehabilitation program) recent version of the Diagnostic and Statistical Manual of Mental Disorders. • Medical social services and discharge planning Outpatient mental health Services For the following Services, refer to these We cover the following Services when provided by Plan sections Physicians or other Plan Providers who are licensed • Abortion and abortion-related Services(refer to health care professionals acting within the scope of their "Reproductive Health Services") license: • Bariatric surgical procedures(refer to`Bariatric • Individual and group mental health evaluation and Surgery") treatment • Dental and orthodontic procedures(refer to"Dental • Psychological testing when necessary to evaluate a and Orthodontic Services") Mental Health Condition • Dialysis care(refer to"Dialysis Care") • Outpatient Services for the purpose of monitoring • Fertility preservation Services for iatrogenic drug therapy Infertility(refer to"Fertility Preservation Services for Iatrogenic Infertility") Intensive psychiatric treatment programs We cover intensive psychiatric treatment programs at a • Services related to diagnosis and treatment of Plan Facility,such as: Infertility,artificial insemination,or assisted reproductive technology(refer to"Fertility Services") • Partial hospitalization • Hospice care(refer to"Hospice Care") • Multidisciplinary treatment in an intensive outpatient program • Mental health Services(refer to"Mental Health • Psychiatric observation for an acute psychiatric crisis Services") • Prosthetics and orthotics(refer to"Prosthetic and Residential treatment Orthotic Devices") Inside our Service Area,we cover the following Services • Reconstructive surgery Services(refer to when the Services are provided in a licensed residential "Reconstructive Surgery") treatment facility that provides 24-hour individualized • Services in connection with a clinical trial(refer to mental health treatment,the Services are generally and "Services in Connection with a Clinical Trial") customarily provided by a mental health residential treatment program in a licensed residential treatment • Skilled inpatient Services in a Plan Skilled Nursing facility,and the Services are above the level of custodial Facility(refer to"Skilled Nursing Facility Care") care: • Substance use disorder treatment Services(refer to • Individual and group mental health evaluation and "Substance Use Disorder Treatment") treatment • Transplant Services(refer to"Transplant Services") • Medical services • Medication monitoring Iniury to Teeth • Room and board Services for accidental injury to teeth are not covered • Social services under this EOC. • Drugs prescribed by a Plan Provider as part of your plan of care in the residential treatment facility in Mental Health Services accord with our drug formulary guidelines if they are administered to you in the facility by medical We cover Services specified in this"Mental Health personnel(for discharge drugs prescribed when you Services"section only when the Services are for the are released from the residential treatment facility, prevention,diagnosis,or treatment of Mental Health refer to"Outpatient Prescription Drugs, Supplies,and Conditions.A"Mental Health Condition"is a mental Supplements"in this"Benefits"section) health condition that falls under any of the diagnostic • Discharge planning Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 52 Inpatient psychiatric hospitalization For the following Services, refer to these We cover inpatient psychiatric hospitalization in a Plan sections Hospital. Coverage includes room and board,drugs,and . Abortion and abortion-related Services(refer to Services of Plan Physicians and other Plan Providers "Reproductive Health Services") who are licensed health care professionals acting within the scope of their license. Ostomy and Urological Supplies Services from Non-Plan Providers If we are not able to offer an appointment with a Plan We cover ostomy and urological supplies if the Provider within required geographic and timely access following requirements are met: standards,we will offer to refer you to a Non-Plan • A Plan Physician has prescribed ostomy and Provider(as described in"Medical Group authorization urological supplies for your medical condition procedure for certain referrals"under"Getting a • The item has been approved for you through the Referral"in the"How to Obtain Services"section). Plan's prior authorization process,as described in Additionally,we cover Services provided by a 988 "Medical Group authorization procedure for certain referrals"under"Getting a Referral"in the"How to center,mobile crisis team,or other provider of Obtain Services"section behavioral health crisis services(collectively,"988 Services")for medically necessary treatment of a mental • The Services are provided inside our Service Area health or substance use disorder without prior authorization,as required by state law. Coverage is limited to the standard item of equipment that adequately meets your medical needs.We decide For these referral Services and 988 Services,you pay the whether to rent or purchase the equipment,and we select Cost Share required for Services provided by a Plan the vendor. Provider as described in this EOC. Ostomy and urological supplies exclusions For the following Services, refer to these . Comfort,convenience,or luxury equipment or sections features • Outpatient drugs,supplies,and supplements(refer to "Outpatient Prescription Drugs,Supplies,and Supplements") Outpatient Imaging, Laboratory, and Other Diagnostic and Treatment • Outpatient laboratory(refer to"Outpatient Imaging, Laboratory,and Other Diagnostic and Treatment Services Services") We cover the following Services only when part of care • Telehealth Visits(refer to"Telehealth Visits") covered under other headings in this"Benefits"section. The Services must be prescribed by a Plan Provider. Office Visits • Complex imaging(other than preventive)such as CT scans,MRIs,and PET scans We cover the following: • Basic imaging Services,such as diagnostic and • Primary Care Visits and Non-Physician Specialist therapeutic X-rays,mammograms,and ultrasounds Visits • Nuclear medicine • Physician Specialist Visits • Routine retinal photography screenings • Group appointments • Laboratory tests,including tests to monitor the • Acupuncture Services(typically provided only for the effectiveness of dialysis and tests for specific genetic treatment of nausea or as part of a comprehensive disorders for which genetic counseling is available pain management program for the treatment of • Diagnostic Services provided by Plan Providers who chronic pain) are not physicians(such as EKGs and EEGs) • House calls by a Plan Physician(or a Plan Provider • Radiation therapy who is a registered nurse)inside our Service Area • Ultraviolet light treatments,including ultraviolet light when care can best be provided in your home as determined by a Plan Physician therapy equipment for home use,if(1)the equipment has been approved for you through the Plan's prior Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 53 authorization process,as described in"Medical Group ♦ Non—Plan Physicians if the Medical Group authorization procedure for certain referrals"under authorizes a written referral to the Non—Plan "Getting a Referral"in the"How to Obtain Services" Physician(in accord with"Medical Group section and(2)the equipment is provided inside our authorization procedure for certain referrals" Service Area. (Coverage for ultraviolet light therapy under"Getting a Referral"in the"How to Obtain equipment is limited to the standard item of Services"section)and the drug,supply,or equipment that adequately meets your medical needs. supplement is covered as part of that referral We decide whether to rent or purchase the equipment, ♦ Non—Plan Physicians if the prescription was and we select the vendor.You must return the obtained as part of covered Emergency Services, equipment to us or pay us the fair market price of the Post-Stabilization Care,or Out-of-Area Urgent equipment when we are no longer covering it.) Care described in the"Emergency Services and Urgent Care"section(if you fill the prescription at For the following Services, refer to these a Plan Pharmacy,you may have to pay Charges sections for the item and file a claim for reimbursement as • Abortion and abortion-related Services(refer to described under"Payment and Reimbursement"in "Reproductive Health Services") the"Emergency Services and Urgent Care" • Outpatient imaging and laboratory Services that are section) Preventive Services,such as routine mammograms, How to obtain covered items bone density scans,and laboratory screening tests (refer to"Preventive Services") You must obtain covered items at a Plan Pharmacy or through our mail-order service unless you obtain the item • Outpatient procedures that include imaging and as part of covered Emergency Services,Post- diagnostic Services(refer to"Outpatient Surgery and Stabilization Care,or Out-of-Area Urgent Care described Outpatient Procedures") in the"Emergency Services and Urgent Care"section. • Services related to diagnosis and treatment of Infertility,artificial insemination,or assisted For the locations of Plan Pharmacies,refer to our reproductive technology("ART")Services(refer to Provider Directory or call Member Services. "Fertility Services") Refills Outpatient Imaging, Laboratory, and Other You may be able to order refills at a Plan Pharmacy, Diagnostic and Treatment Services exclusions through our mail-order service,or through our website at • Ultraviolet light therapy comfort,convenience,or kp.oryJrxrefill.A Plan Pharmacy can give you more luxury equipment or features information about obtaining refills,including the options available to you for obtaining refills.For example,a few • Repair or replacement of ultraviolet light therapy Plan Pharmacies don't dispense refills and not all drugs equipment due to loss,theft,or misuse can be mailed through our mail-order service.Please check with a Plan Pharmacy if you have a question about Outpatient Prescription Drugs, Supplies, Whether your prescription can be mailed or obtained at a Plan Pharmacy.Items available through our mail-order and Supplements service are subject to change at any time without notice. We cover outpatient drugs,supplies,and supplements Day supply limit specified in this"Outpatient Prescription Drugs, The prescribing physician or dentist determines how Supplies,and Supplements"section,in accord with our much of a drug,supply,item,or supplement to prescribe. drug formulary guidelines,subject to any applicable For purposes of day supply coverage limits,Plan exclusions or limitations under this EOC.We cover Physicians determine the amount of an item that items described in this section when prescribed as constitutes a Medically Necessary 30-or 100-day supply follows: (or 365-day supply if the item is a hormonal • Items prescribed by Plan Providers,within the scope contraceptive)for you.Upon payment of the Cost Share of their licensure and practice specified in the"Outpatient prescription drugs,supplies, • Items prescribed by the following Non—Plan and supplements"section of the"Cost Share Summary," Providers: you will receive the supply prescribed up to the day ♦ Dentists if the drug is for dental care supply limit specified in this section or in the drug formulary for your plan(see About the drug formulary" below).The maximum you may receive at one time of a Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 54 covered item,other than a hormonal contraceptive,is Formulary exception process either one 30-day supply in a 30-day period or one 100- Drug formulary guidelines allow you to obtain a non- day supply in a 100-day period.If you wish to receive formulary prescription drug(those not listed on our drug more than the covered day supply limit,then you must formulary for your condition)if it would otherwise be pay Charges for any prescribed quantities that exceed the covered by your plan,as described above,and it is day supply limit. Medically Necessary.If you disagree with a Health Plan determination that a non-formulary prescription drug is If your plan includes coverage for hormonal not covered,you may file a grievance as described in the contraceptives,the maximum you may receive at one "Dispute Resolution"section. time of contraceptive drugs is a 365-day supply.To obtain a 365-day supply,talk to your prescribing Continuity drugs provider.Refer to the"Cost Share Summary"section of If this EOC is amended to exclude a drug that we have this EOC to find out if your plan includes coverage for been covering and providing to you under this EOC,we hormonal contraceptives. will continue to provide the drug if a prescription is required by law and a Plan Physician continues to If your plan includes coverage for sexual dysfunction prescribe the drug for the same condition and for a use drugs,the maximum you may receive at one time of approved by the Federal Food and Drug Administration. episodic drugs prescribed for the treatment of sexual dysfunction disorders is eight doses in any 30-day period About drug tiers or up to 27 doses in any 100-day period.Refer to the Drugs on the drug formulary for your plan are "Cost Share Summary"section of this EOC to find out if categorized into tiers as described in the table below(the your plan includes coverage for sexual dysfunction formulary doesn't have a Tier 3).Refer to"About the cgs• drug formulary"above for details about the formulary for your plan.Your Cost Share for covered items may The pharmacy may reduce the day supply dispensed at vary based on the tier.Refer to"Outpatient prescription the Cost Share specified in the"Outpatient prescription drugs,supplies,and supplements"in the"Cost Share drugs,supplies,and supplements"section of the"Cost Summary"section of this EOC for Cost Share for items Share Summary"for any drug to a 30-day supply in any covered under this section.Refer to the formulary for the 30-day period if the pharmacy determines that the item is definition of"generic drug"and"brand-name drug." in limited supply in the market or for specific drugs (your Plan Pharmacy can tell you if a drug you take is one of these drugs). Drug Tier Description About the drug formulary Tier 1 Most generic drugs,supplies and The drug formulary includes a list of drugs that our supplements(also includes certain Pharmacy and Therapeutics Committee has approved for brand-name drugs,supplies,and our Members.Our Pharmacy and Therapeutics supplements) Committee,which is primarily composed of Plan Physicians and pharmacists,selects drugs for the drug formulary based on several factors,including safety and Tier 2 Most brand-name drugs,supplies, and supplements(also includes effectiveness as determined from a review of medical certain generic drugs,supplies,and literature.The drug formulary is updated monthly based supplements) on new information or new drugs that become available. To find out which drugs are on the formulary for your plan,please refer to the California Commercial HMO Tier 4 High-cost brand-name generic formulary on our website at ky.org/formulary.The drugs,supplies,and supplements lements formulary also discloses requirements or limitations that apply to specific drugs,such as whether there is a limit When a drug is not on the formulary,you pay the same on the amount of the drug that can be dispensed and Cost Share as you would for a formulary drug,when whether the drug must be obtained at certain specialty approved through the formulary exception process pharmacies.If you would like to request a copy of this described above(your Plan Pharmacy will tell you which drug formulary,please call Member Services.Note:The drug tier Cost Share applies). presence of a drug on the drug formulary does not necessarily mean that it will be prescribed for a particular medical condition. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 55 General rules about coverage and your Cost • On your next visit to a Kaiser Permanente pharmacy, Share ask our staff how you can have your prescriptions We cover the following outpatient drugs,supplies,and mailed to you supplements as described in this"Outpatient Prescription Drugs, Supplies,and Supplements"section: Note:Restrictions and limitations apply.For example, • Drugs for which a prescription is required by law.We not all drugs can be mailed and we cannot mail drugs to also cover certain over-the-counter drugs and items all states. (drugs and items that do not require a prescription by law)if they are listed on our drug formulary and Manufacturer coupon program prescribed by a Plan Physician,except a prescription For outpatient prescription drugs or items that are is not required for over-the-counter contraceptives covered under this"Outpatient Prescription Drugs, Supplies,and Supplements" section and obtained at a • Disposable needles and syringes needed for injecting Plan Pharmacy,you maybe able to use approved covered drugs and supplements manufacturer coupons as payment for the Cost Share that • Inhaler spacers needed to inhale covered drugs you owe,as allowed under Health Plan's coupon program.You will owe any additional amount if the Note: coupon does not cover the entire amount of your Cost • If Charges for the drug,supply,or supplement are less Share for your prescription.When you use an approved than the Copayment,you will pay the lesser amount, coupon for payment of your Cost Share,the coupon subject to any applicable deductible or out-of-pocket amount and any additional payment that you make will accumulate to your out-of-pocket maximum if maximum applicable.Refer to the"Cost Share Summary" section • Items can change tier at any time,in accord with of this EOC to find your applicable out-of-pocket formulary guidelines,which may impact your Cost maximum amount and to learn which drugs and items Share(for example,if a brand-name drug is added to apply to the maximum. Certain health plan coverages are the specialty drug list,you will pay the Cost Share not eligible for coupons.You can get more information that applies to drugs on the specialty drugs tier(Tier regarding the Kaiser Permanente coupon program rules 4),not the Cost Share for drugs on the brand drugs and limitations at kp.org/rxcoupons. tier(Tier 2)) Base drugs,supplies,and supplements Schedule H drugs Cost Share for the following items may be different than You or the prescribing provider can request that the other drugs,supplies,and supplements.Refer to"Base pharmacy dispense less than the prescribed amount of a drugs,supplies,and supplements"in the"Cost Share covered oral,solid dosage form of a Schedule II drug Summary"section of this EOC: (your Plan Pharmacy can tell you if a drug you take is • Certain drugs for the treatment of life-threatening one of these drugs).Your Cost Share will be prorated ventricular arrhythmia based on the amount of the drug that is dispensed.If the pharmacy does not prorate your Cost Share,we will send • Drugs for the treatment of tuberculosis you a refund for the difference. • Elemental dietary enteral formula when used as a primary therapy for regional enteritis Mail-order service Prescription refills can be mailed within 3 to 5 days at no • Hematopoietic agents for dialysis extra cost for standard U.S.postage.The appropriate • Hematopoietic agents for the treatment of anemia in Cost Share(according to your drug coverage)will apply chronic renal insufficiency and must be charged to a valid credit card. • Human growth hormone for long-term treatment of pediatric patients with growth failure from lack of You may request mail-order service in the following adequate endogenous growth hormone secretion ways: • Immunosuppressants and ganciclovir and ganciclovir • To order online,visit kp.org/rxrefill(you can register prodrugs for the treatment of cytomegalovirus when for a secure account at ky.org/registernow)or use prescribed in connection with a transplant the KP app from your smartphone or other mobile • Phosphate binders for dialysis patients for the device treatment of hyperphosphatemia in end stage renal • Call the pharmacy phone number highlighted on your disease prescription label and select the mail delivery option Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 56 For the following Services, refer to these Outpatient Surgery and Outpatient sections Procedures • Drugs prescribed for abortion or abortion-related Services(refer to"Reproductive Health Services") We cover the following outpatient care Services: • Administered contraceptives(refer to"Reproductive • Outpatient surgery Health Services") • Outpatient procedures(including imaging and • Diabetes blood-testing equipment and their supplies, diagnostic Services)when provided in an outpatient and insulin pumps and their supplies(refer to or ambulatory surgery center or in a hospital "Durable Medical Equipment("DME")for Home operating room,or in any setting where a licensed Use") staff member monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or • Drugs covered during a covered stay in a Plan to minimize discomfort Hospital or Skilled Nursing Facility(refer to "Hospital Inpatient Services"and"Skilled Nursing For the following Services, refer to these Facility Care") sections • Drugs prescribed for pain control and symptom • Fertility preservation Services for iatrogenic management of the terminal illness for Members who Infertility(refer to"Fertility Preservation Services for are receiving covered hospice care(refer to"Hospice Iatrogenic Infertility") Care") • Outpatient procedures(including imaging and • Durable medical equipment used to administer drugs diagnostic Services)that do not require a licensed (refer to Durable Medical Equipment("DME")for staff member to monitor your vital signs(refer to the Home Use") section that would otherwise apply for the procedure; • Outpatient administered drugs that are not for example,for radiology procedures that do not contraceptives(refer to"Administered Drugs and require a licensed staff member to monitor your vital Products") signs,refer to"Outpatient Imaging,Laboratory,and Other Diagnostic and Treatment Services") Outpatient prescription drugs, supplies, and supplements exclusions Preventive Services • Any requested packaging(such as dose packaging) other than the dispensing pharmacy's standard We cover a variety of Preventive Services,as listed on packaging our website at kp.ora/prevention,including the • Compounded products unless the drug is listed on our following: drug formulary or one of the ingredients requires a • Services recommended by the United States prescription by law Preventive Services Task Force with rating of"A"or • Drugs prescribed to shorten the duration of the "B."The complete list of these services can be found common cold at uspreventiveservicestaskforce.org • Prescription drugs for which there is an over-the- • Immunizations recommended by the Advisory counter equivalent(the same active ingredient, Committee on Immunization Practices of the Centers strength,and dosage form as the prescription drug). for Disease Control and Prevention.The complete list This exclusion does not apply to: of recommended immunizations can be found at ♦ insulin cdc.gov/vaccines/schedules ♦ over-the-counter drugs covered under"Preventive • Preventive services recommended by the Health Services"in this"Benefits"section(this includes Resources and Services Administration and tobacco cessation drugs and contraceptive drugs) incorporated into the Affordable Care Act.The complete list of these services can be found at ♦ an entire class of prescription drugs when one drug hrsa.gov/womens-guidelines within that class becomes available over-the- counter The list of Preventive Services recommended by the • All drugs,supplies,and supplements related to above organizations is subject to change.These assisted reproductive technology("ART")Services Preventive Services are subject to all coverage requirements described in this"Benefits"section and all Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 57 provisions in the"Exclusions,Limitations,Coordination referrals"under"Getting a Referral"in the"How to of Benefits,and Reductions"section. Obtain Services"section •If you are enrolled in a grandfathered plan,certain The Services are provided inside our Service Area preventive items listed on our website,such as over-the- Coverage includes fitting and adjustment of these counter drugs,may not be covered.Refer to the"Certain devices their or repair replacement,and Services to preventive items"table in the"Cost Share Summary" p determine whether you need a prosthetic or orthotic section of this EOC for coverage information.If you device.If we cover a replacement device,then you pay have questions about Preventive Services,please call the Cost Share that you would pay for obtaining that Member Services. device. Note:Preventive Services help you stay healthy,before Base prosthetic and orthotic devices you have symptoms.If you have symptoms,you may If all of the requirements described under"Prosthetic and need other care,such as diagnostic or treatment Services. orthotic coverage rules"in this"Prosthetics and Orthotic If you receive any other covered Services that are not Devices"section are met,we cover the items described Preventive Services before,during,or after a visit that in this"Base prosthetic and orthotic devices"section. includes Preventive Services,you will pay the applicable Cost Share for those other Services.For example,if laboratory tests or imaging Services ordered during a Internally implanted devices preventive office visit are not Preventive Services,you We cover prosthetic and orthotic devices such as will pay the applicable Cost Share for those Services. pacemakers,intraocular lenses,cochlear implants, osseointegrated hearing devices,and hip joints,if they For the following Services, refer to these are implanted during a surgery that we are covering sections under another section of this"Benefits"section. • Milk pumps and lactation supplies(refer to"Lactation External devices supplies"under"Durable Medical Equipment We cover the following external prosthetic and orthotic ("DME")for Home Use") devices: • Health education programs(refer to"Health • Prosthetic devices and installation accessories to Education") restore a method of speaking following the removal • Outpatient drugs,supplies,and supplements that are of all or part of the larynx(this coverage does not Preventive Services(refer to"Outpatient Prescription include electronic voice-producing machines,which Drugs, Supplies,and Supplements") are not prosthetic devices) • Family planning counseling,consultations,and • After Medically Necessary removal of all or part of a sterilization Services(refer to"Reproductive Health breast: Services") ♦ prostheses,including custom-made prostheses when Medically Necessary Prosthetic and Orthotic Devices ♦ up to three brassieres required to hold a prosthesis in any 12-month period Prosthetic and orthotic devices coverage rules • Podiatric devices(including footwear)to prevent or We cover the prosthetic and orthotic devices specified in treat diabetes-related complications when prescribed this"Prosthetic and Orthotic Devices"section if all of by a Plan Physician or by a Plan Provider who is a the following requirements are met: podiatrist • The device is in general use,intended for repeated • Compression burn garments and lymphedema wraps use,and primarily and customarily used for medical and garments purposes • Enteral formula for Members who require tube • The device is the standard device that adequately feeding in accord with Medicare guidelines meets your medical needs • Enteral pump and supplies • You receive the device from the provider or vendor • Tracheostomy tube and supplies that we select • The item has been approved for you through the • Prostheses to replace all or part of an external facial Plan's prior authorization process,as described in body part that has been removed or impaired as a "Medical Group authorization procedure for certain result of disease,injury,or congenital defect Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 58 Supplemental prosthetic and orthotic devices • Following Medically Necessary removal of all or part If all of the requirements described under"Prosthetic and of a breast,we cover reconstruction of the breast, orthotic coverage rules"in this"Prosthetics and Orthotic surgery and reconstruction of the other breast to Devices"section are met,we cover the following items: produce a symmetrical appearance,and treatment of • Prosthetic devices required to replace all or part of an physical complications,including lymphedemas organ or extremity,but only if they also replace the function of the organ or extremity For covered Services related to reconstructive surgery that you receive,you will pay the Cost Share you would • Rigid and semi-rigid orthotic devices required to pay if the Services were not related to reconstructive support or correct a defective body part surgery.For example,see"Hospital inpatient Services" in the"Cost Share Summary"section of this EOC for the For the following Services, refer to these Cost Share that applies for hospital inpatient Services, sections and see"Outpatient surgery and outpatient procedures" • Eyeglasses and contact lenses,including contact in the"Cost Share Summary"for the Cost Share that lenses to treat aniridia or aphakia(refer to"Vision applies for outpatient surgery. Services for Adult Members"and"Vision Services for Pediatric Members") For the following Services, refer to these sections • Hearing aids other than internally implanted devices described in this section(refer to"Hearing Services") • Dental and orthodontic Services that are an integral part of reconstructive surgery for cleft palate(refer to • Injectable implants(refer to"Administered Drugs and "Dental and Orthodontic Services") Products") • Office visits not described in the"Reconstructive Prosthetic and orthotic devices exclusions Surgery"section(refer to"Office Visits") • Multifocal intraocular lenses and intraocular lenses to • Outpatient imaging and laboratory(refer to correct astigmatism "Outpatient Imaging,Laboratory,and Other • Nonrigid supplies,such as elastic stockings and wigs, Diagnostic and Treatment Services") except as otherwise described above in this • Outpatient prescription drugs(refer to"Outpatient "Prosthetic and Orthotic Devices"section Prescription Drugs,Supplies,and Supplements") • Comfort,convenience,or luxury equipment or • Outpatient administered drugs(refer to"Administered features Drugs and Products") • Repair or replacement of device due to loss,theft,or • Prosthetics and orthotics refer to"Prosthetic and misuse Orthotic Devices") • Shoes,shoe inserts,arch supports,or any other • Telehealth Visits(refer to"Telehealth Visits") footwear,even if custom-made,except footwear described above in this"Prosthetic and Orthotic Reconstructive surgery exclusions Devices"section for diabetes-related complications • Surgery that,in the judgment of a Plan Physician • Prosthetic and orthotic devices not intended for specializing in reconstructive surgery,offers only a maintaining normal activities of daily living minimal improvement in appearance (including devices intended to provide additional support for recreational or sports activities) Rehabilitative and Habilitative Services Reconstructive Surgery We cover the Services described in this"Rehabilitative and Habilitative Services"section if all of the following We cover the following reconstructive surgery Services: requirements are met: • Reconstructive surgery to correct or repair abnormal • The Services are to address a health condition structures of the body caused by congenital defects, • The Services are to help you keep,learn,or improve developmental abnormalities,trauma,infection, skills and functioning for daily living tumors,or disease,if a Plan Physician determines that • you receive the Services at a Plan Facility unless a it is necessary to improve function,or create a normal appearance,to the extent possible Plan Physician determines that it is Medically Necessary for you to receive the Services in another location Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 59 We cover the following Services: Abortion and abortion-related Services • Individual outpatient physical,occupational,and We cover the following Services: speech therapy • Surgical abortion • Group outpatient physical,occupational,and speech • Prescription drugs,in accord with our drug formulary therapy guidelines • Physical,occupational,and speech therapy provided • Abortion-related Services in an organized,multidisciplinary rehabilitation day- treatment program For the following Services, refer to these sections For the following Services, refer to these • Fertility preservation Services for iatrogenic sections Infertility(refer to"Fertility Preservation Services for • Behavioral health treatment for autism spectrum Iatrogenic Infertility") disorder(refer to"Behavioral Health Treatment for • Services to diagnose or treat Infertility(refer to Autism Spectrum Disorder") "Fertility Services") • Home health care(refer to"Home Health Care") • Office visits related to injectable contraceptives, • Durable medical equipment(refer to"Durable internally implanted time-release contraceptives or Medical Equipment("DME")for Home Use") intrauterine devices("IUDs")when provided for • Ostomy and urological supplies(refer to"Ostomy and medical reasons other than to prevent pregnancy Urological Supplies") (refer to"Office Visits") • Prosthetic and orthotic devices(refer to"Prosthetic • Outpatient administered drugs that are not and Orthotic Devices") contraceptives(refer to"Administered Drugs and • Physical,occupational,and speech therapy provided Products") during a covered stay in a Plan Hospital or Skilled • Outpatient laboratory and imaging services associated Nursing Facility(refer to"Hospital Inpatient with family planning services(refer to"Outpatient Services"and"Skilled Nursing Facility Care") Imaging,Laboratory,and Other Diagnostic and Treatment Services") Rehabilitative and habilitative Services • Outpatient contraceptive drugs and devices(refer to exclusions "Outpatient Prescription Drugs, Supplies,and • Items and services that are not health care items and Supplements") services(for example,respite care,day care, • Outpatient surgery and outpatient procedures when recreational care,residential treatment,social provided for medical reasons other than to prevent services,custodial care,or education services of any pregnancy(refer to"Outpatient Surgery and kind,including vocational training) Outpatient Procedures") Reproductive Health Services Reproductive health Services exclusions • Reversal of voluntary sterilization Family planning Services We cover the following Services when provided for family planning purposes: Services in Connection with a Clinical • Family planning counseling Trial • Injectable contraceptives,internally implanted time- We cover Services you receive in connection with a release contraceptives or intrauterine devices clinical trial if all of the following requirements are met: ("IUDs")and office visits related to their insertion, • We would have covered the Services if they were not removal,and management when provided to prevent related to a clinical trial pregnancy • You are eligible to participate in the clinical trial • Sterilization procedures for Members assigned female according to the trial protocol with respect to at birth treatment of cancer or other life-threatening condition • Sterilization procedures for Members assigned male (a condition from which the likelihood of death is at birth probable unless the course of the condition is Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 60 interrupted),as determined in one of the following of this EOC for the Cost Share that applies for hospital ways: inpatient Services. ♦ a Plan Provider makes this determination ♦ you provide us with medical and scientific Services in connection with a clinical trial information establishing this determination exclusions • If any Plan Providers participate in the clinical trial • The investigational Service and will accept you as a participant in the clinical • Services that are provided solely to satisfy data trial,you must participate in the clinical trial through collection and analysis needs and are not used in your a Plan Provider unless the clinical trial is outside the clinical management state where you live • The clinical trial is an Approved Clinical Trial Skilled Nursing Facility Care "Approved Clinical Trial"means a phase I,phase II, Inside our Service Area,we cover skilled inpatient phase III,or phase IV clinical trial related to the Services in a Plan Skilled Nursing Facility.The skilled prevention,detection,or treatment of cancer or other inpatient Services must be customarily provided by a life-threatening condition,and that meets one of the Skilled Nursing Facility,and above the level of custodial following requirements: or intermediate care. • The study or investigation is conducted under an investigational new drug application reviewed by the We cover the following Services: U.S.Food and Drug Administration • Physician and nursing Services • The study or investigation is a drug trial that is • Room and board exempt from having an investigational new drug • Drugs prescribed by a Plan Physician as part of your application plan of care in the Plan Skilled Nursing Facility in • The study or investigation is approved or funded by at accord with our drug formulary guidelines if they are least one of the following: administered to you in the Plan Skilled Nursing ♦ the National Institutes of Health Facility by medical personnel ♦ the Centers for Disease Control and Prevention • Durable medical equipment in accord with our prior ♦ the Agency for Health Care Research and Quality authorization procedure if Skilled Nursing Facilities ♦ the Centers for Medicare&Medicaid Services ordinarily furnish the equipment(refer to"Medical Group authorization procedure for certain referrals" ♦ a cooperative group or center of any of the above under"Getting a Referral"in the"How to Obtain entities or of the Department of Defense or the Services"section) Department of Veterans Affairs • Imaging and laboratory Services that Skilled Nursing ♦ a qualified non-governmental research entity Facilities ordinarily provide identified in the guidelines issued by the National Institutes of Health for center support grants • Medical social services ♦ the Department of Veterans Affairs or the • Whole blood,red blood cells,plasma,platelets,and Department of Defense or the Department of their administration Energy,but only if the study or investigation has . Medical supplies been reviewed and approved though a system of peer review that the U.S. Secretary of Health and • Behavioral health treatment that is Medically Human Services determines meets all of the Necessary to treat mental health conditions that fall following requirements: (1)It is comparable to the under any of the diagnostic categories listed in the National Institutes of Health system of peer review mental and behavioral disorders chapter of the most of studies and investigations and(2)it assures recent edition of the International Classification of unbiased review of the highest scientific standards Diseases or that are listed in the most recent version by qualified people who have no interest in the of the Diagnostic and Statistical Manual of Mental outcome of the review Disorders • Physical,occupational,and speech therapy For covered Services related to a clinical trial,you will • Respiratory therapy pay the Cost Share you would pay if the Services were not related to a clinical trial.For example,see"Hospital inpatient Services"in the"Cost Share Summary"section Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 61 For the following Services, refer to these personnel(for discharge drugs prescribed when you sections are released from the residential treatment facility, • Outpatient imaging,laboratory,and other diagnostic refer to"Outpatient Prescription Drugs, Supplies,and and treatment Services(refer to"Outpatient Imaging, Supplements"in this"Benefits"section) Laboratory,and Other Diagnostic and Treatment • Discharge planning Services") • Outpatient physical,occupational,and speech therapy Inpatient detoxification (refer to"Rehabilitative and Habilitative Services") We cover hospitalization in a Plan Hospital only for medical management of withdrawal symptoms,including room and board,Plan Physician Services,drugs, Substance Use Disorder Treatment dependency recovery Services,education,and counseling. We cover Services specified in this"Substance Use Disorder Treatment"section only when the Services are Services from Non-Plan Providers for the prevention,diagnosis,or treatment of Substance If we are not able to offer an appointment with a Plan Use Disorders.A"Substance Use Disorder"is a Provider within required geographic and timely access substance use disorder that falls under any of the standards,we will offer to refer you to a Non-Plan diagnostic categories listed in the mental and behavioral Provider(as described in"Medical Group authorization disorders chapter of the most recent edition of the procedure for certain referrals"under"Getting a International Classification of Diseases or that is listed Referral'in the"How to Obtain Services"section). in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders. Additionally,we cover Services provided by a 988 center,mobile crisis team,or other provider of Outpatient substance use disorder treatment behavioral health crisis services(collectively,"988 We cover the following Services for treatment of Services")for medically necessary treatment of a mental substance use disorders: health or substance use disorder without prior • Day-treatment programs authorization,as required by state law. • Individual and group substance use disorder For these referral Services and 988 Services,you pay the counseling Cost Share required for Services provided by a Plan • Intensive outpatient programs Provider as described in this EOC. • Medical treatment for withdrawal symptoms For the following Services, refer to these Residential treatment sections Inside our Service Area,we cover the following Services • Outpatient laboratory(refer to"Outpatient Imaging, when the Services are provided in a licensed residential Laboratory,and Other Diagnostic and Treatment treatment facility that provides 24-hour individualized Services") substance use disorder treatment,the Services are • Outpatient self-administered drugs(refer to generally and customarily provided by a substance use "Outpatient Prescription Drugs,Supplies,and disorder residential treatment program in a licensed Supplements") residential treatment facility,and the Services are above the level of custodial care: • Telehealth Visits(refer to"Telehealth Visits") • Individual and group substance use disorder counseling Telehealth Visits • Medical services Telehealth Visits are intended to make it more • Medication monitoring convenient for you to receive covered Services,when a • Room and board Plan Provider determines it is medically appropriate for your medical condition.You may receive covered • Social services Services via Telehealth Visits,when available and if the • Drugs prescribed by a Plan Provider as part of your Services would have been covered under this EOC if plan of care in the residential treatment facility in provided in person.You are not required to use accord with our drug formulary guidelines if they are Telehealth Visits,and you may choose to receive in- administered to you in the facility by medical person Services from a Plan Provider instead. Some Plan Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 62 Providers offer Services exclusively through a telehealth donors(whether or not they are Members)in accord with technology platform and have no physical location at our guidelines for donor Services at no charge. which you can receive Services.If you receive covered Services from these Plan Providers,you may access your For the following Services, refer to these medical record of the Telehealth Visit and,unless you sections object,such information will be added to your Health • Dental Services that are Medically Necessary to Plan electronic medical record and shared with your prepare for a transplant(refer to"Dental and Primary Care Physician. Orthodontic Services") We cover the following types of Telehealth Visits with • Outpatient imaging and laboratory(refer to Primary Care Physicians,Non-Physician Specialists,and "Outpatient Imaging,Laboratory,and Other Physician Specialists: Diagnostic and Treatment Services") • Interactive video visits • Outpatient prescription drugs(refer to"Outpatient • Scheduled telephone visits Prescription Drugs,Supplies,and Supplements") • Outpatient administered drugs(refer to"Administered Drugs and Products") Transplant Services We cover transplants of organs,tissue,or bone marrow if Vision Services for Adult Members the Medical Group provides a written referral for care to a transplant facility as described in"Medical Group For the purpose of this"Vision Services for Adult authorization procedure for certain referrals"under Members"section,an"Adult Member"is a Member who "Getting a Referral"in the"How to Obtain Services" is age 19 or older and is not a Pediatric Member,as section. defined under"Vision Services for Pediatric Members" in this"Benefits"section.For example,if you turn 19 on After the referral to a transplant facility,the following June 25,you will be an Adult Member starting July 1. applies: • If either the Medical Group or the referral facility We cover the following for Adult Members: determines that you do not satisfy its respective • Routine eye exams with a Plan Optometrist to criteria for a transplant,we will only cover Services determine the need for vision correction(including you receive before that determination is made dilation Services when Medically Necessary)and to • Health Plan,Plan Hospitals,the Medical Group,and provide a prescription for eyeglass lenses Plan Physicians are not responsible for finding, • Physician Specialist Visits to diagnose and treat furnishing,or ensuring the availability of an organ, injuries or diseases of the eye tissue,or bone marrow donor • Non-Physician Specialist Visits to diagnose and treat • In accord with our guidelines for Services for living injuries or diseases of the eye transplant donors,we provide certain donation-related Services for a donor,or an individual identified by the Optical Services Medical Group as a potential donor,whether or not We cover the Services described in this"Optical the donor is a Member. These Services must be Services"section when received from Plan Medical directly related to a covered transplant for you,which Offices or Plan Optical Sales Offices. may include certain Services for harvesting the organ, tissue,or bone marrow and for treatment of The date we provide an Allowance toward(or otherwise complications.Please call Member Services for cover)an item described in this"Optical Services" questions about donor Services section is the date on which you order the item.For example,if we last provided an Allowance toward an For covered transplant Services that you receive,you item you ordered on May 1,2022,and if we provide an will pay the Cost Share you would pay if the Services Allowance not more than once every 24 months for that were not related to a transplant.For example,see type of item,then we would not provide another "Hospital inpatient Services"in the"Cost Share Allowance toward that type of item until on or after May Summary"section of this EOC for the Cost Share that 1,2024.You can use the Allowances under this"Optical applies for hospital inpatient Services.We provide or pay Services"section only when you first order an item.If for donation-related Services for actual or potential you use part but not all of an Allowance when you first Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 63 order an item,you cannot use the rest of that Allowance covered)we will provide an Allowance toward the later. purchase price of a replacement item of the same type (eyeglass lens,or contact lens,fitting,and dispensing) Special contact lenses for the eye that had the.50 diopter change.Refer to We cover the following: "Vision Services for Adult Members"in the"Cost Share • For aniridia(missing iris),we cover up to two Summary"section of this EOC for your Allowanceamount. Medically Necessary contact lenses per eye (including fitting and dispensing)in any 12-month Low vision devices period when prescribed by a Plan Physician or Plan Optometrist Low vision devices(including fitting and dispensing)are not covered under this EOC. • For aphakia(absence of the crystalline lens of the eye),we cover up to six Medically Necessary aphakic For the following Services, refer to these contact lenses per eye(including fitting and sections dispensing)in any 12-month period when prescribed by a Plan Physician or Plan Optometrist • Routine vision screenings when performed as part of a routine physical exam(refer to"Preventive • For other specialty contact lenses that will provide a Services") significant improvement in your vision not obtainable with eyeglass lenses,we cover either one pair of • Services related to the eye or vision other than contact lenses(including fitting and dispensing)or an Services covered under this"Vision Services for initial supply of disposable contact lenses(up to six Adult Members"section,such as outpatient surgery months,including fitting and dispensing)in any 24- and outpatient prescription drugs,supplies,and month period supplements(refer to the applicable heading in this "Benefits"section) Eyeglasses and contact lenses Vision Services for Adult Members exclusions We provide a single Allowance toward the purchase price of any or all of the following not more than once • Eyeglass or contact lens adornment,such as every 24 months when a physician or optometrist engraving,faceting,or jeweling prescribes an eyeglass lens(for eyeglass lenses and • Items that do not require a prescription by law(other frames)or contact lens(for contact lenses).Refer to than eyeglass frames),such as eyeglass holders, "Vision Services for Adult Members"in the"Cost Share eyeglass cases,and repair kits Summary"section of this EOC for your Allowance amount. • Lenses and sunglasses without refractive value, • Eyeglass lenses when a Plan Provider puts the lenses except as described in this"Vision Services for Adult Members section into a frame ♦ we cover a clear balance lens when only one eye • Low vision devices needs correction • Replacement of lost,broken,or damaged contact ♦ we cover tinted lenses when Medically Necessary lenses,eyeglass lenses,and frames to treat macular degeneration or retinitis pigmentosa Vision Services for Pediatric Members • Eyeglass frames when a Plan Provider puts two lenses (at least one of which must have refractive value)into For the purpose of this"Vision Services for Pediatric the frame Members"section,a"Pediatric Member"is a Member • Contact lenses,fitting,and dispensing from birth through the end of the month of their 19th birthday.For example,if you turn 19 on June 25,you We will not provide the Allowance if we have provided will be an Adult Member starting July 1 and your last an Allowance toward(or otherwise covered)eyeglass minute as a Pediatric Member will be 11:59 p.m. on June lenses or frames within the previous 24 months. 30. Replacement lenses We cover the following for Pediatric Members: If you have a change in prescription of at least.50 • Routine eye exams with a Plan Optometrist to diopter in one or both eyes within 12 months of the determine the need for vision correction(including initial point of sale of an eyeglass lens or contact lens that we provided an Allowance toward(or otherwise Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 64 dilation Services when Medically Necessary)and to We will not provide the Allowance if we have provided provide a prescription for eyeglass lenses an Allowance toward(or otherwise covered)eyeglass • Physician Specialist Visits to diagnose and treat lenses or frames within the previous 24 months. injuries or diseases of the eye Replacement lenses • Non-Physician Specialist Visits to diagnose and treat If you have a change in prescription of at least.50 injuries or diseases of the eye diopter in one or both eyes at least 12 months after the date we dispensed eyeglass lenses of the type described Optical Services in this"Vision Services for Pediatric Members"section, We cover the Services described in this"Optical we will cover a replacement Regular Eyeglass Lens for Services"section when received from Plan Medical the eye that had the.50 diopter change. Offices or Plan Optical Sales Offices. Low vision devices Special contact lenses Low vision devices(including fitting and dispensing)are We cover the following: not covered under this EOC. • For aniridia(missing iris),we cover up to two Medically Necessary contact lenses per eye For the following Services, refer to these (including fitting and dispensing)in any 12-month sections period when prescribed by a Plan Physician or Plan • Routine vision screenings when performed as part of Optometrist a routine physical exam(refer to"Preventive • For aphakia(absence of the crystalline lens of the Services") eye),we cover up to six Medically Necessary aphakic • Services related to the eye or vision other than contact lenses per eye(including fitting and Services covered under this"Vision Services for dispensing)in any 12-month period when prescribed Pediatric Members"section,such as outpatient by a Plan Physician or Plan Optometrist surgery and outpatient prescription drugs,supplies, • For other specialty contact lenses that will provide a and supplements(refer to the applicable heading in significant improvement in your vision not obtainable this"Benefits"section) with eyeglass lenses,we cover either one pair of contact lenses(including fitting and dispensing)or an Vision Services for Pediatric Members initial supply of disposable contact lenses(up to six exclusions months,including fitting and dispensing)in any 24- • Eyeglass or contact lens adornment,such as month period engraving,faceting,or jeweling Eyeglasses and contact lenses • Items that do not require a prescription by law(other We provide a single Allowance toward the purchase than eyeglass frames),such as eyeglass holders, price of any or all of the following not more than once eyeglass cases,and repair kits every 24 months when a physician or optometrist • Lenses and sunglasses without refractive value, prescribes an eyeglass lens(for eyeglass lenses and except as described in this"Vision Services for frames)or contact lens(for contact lenses).Refer to Pediatric Members"section "Vision Services for Pediatric Members"in the"Cost • Low vision devices Share Summary"section of this EOC for your Allowance amount. • Replacement of lost,broken,or damaged contact • Eyeglass lenses when a Plan Provider puts the lenses lenses,eyeglass lenses,and frames into a frame ♦ we cover a clear balance lens when only one eye EXClUSIOnS, Limitations, needs correction ♦ we cover tinted lenses when Medically Necessary Coordination of Benefits, and to treat macular degeneration or retinitis Reductions pigmentosa • Eyeglass frames when a Plan Provider puts two lenses Exclusions (at least one of which must have refractive value)into the frame The items and services listed in this"Exclusions"section • Contact lenses,fitting,and dispensing are excluded from coverage.These exclusions apply to Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 65 all Services that would otherwise be covered under this orthodontists,dental Services following accidental injury EOC regardless of whether the services are within the to teeth,and dental Services resulting from medical scope of a provider's license or certificate.These treatment such as surgery on the jawbone and radiation exclusions or limitations do not apply to Services that are treatment. Medically Necessary to treat mental health conditions or substance use disorders that fall under any of the This exclusion does not apply to the following Services: diagnostic categories listed in the mental and behavioral • Services covered under"Dental and Orthodontic disorders chapter of the most recent edition of the Services"in the"Benefits"section International Classification of Diseases or that are listed in the most recent version of the Diagnostic and • Service described under"Injury to Teeth"in the Statistical Manual of Mental Disorders. "Benefits"section • Pediatric dental Services described in a Pediatric Certain exams and Services Dental Services Amendment to this EOC,if any.If Routine physical exams and other Services that are not your plan has a Pediatric Dental Services Medically Necessary,such as when required(1)for Amendment,it will be attached to this EOC,and it obtaining or maintaining employment or participation in will be listed in the EOC's Table of Contents employee programs,(2)for insurance,credentialing or licensing,(3)for travel,or(4)by court order or for Disposable supplies parole or probation. Disposable supplies for home use,such as bandages, gauze,tape,antiseptics,dressings,Ace-type bandages, Chiropractic Services and diapers,underpads,and other incontinence supplies. Chiropractic Services and the Services of a chiropractor, unless you have coverage for supplemental chiropractic This exclusion does not apply to disposable supplies Services as described in an amendment to this EOC. covered under"Durable Medical Equipment("DME") for Home Use,""Home Health Care,""Hospice Care," Cosmetic Services "Ostomy and Urological Supplies,"and"Outpatient Services that are intended primarily to change or Prescription Drugs,Supplies,and Supplements"in the maintain your appearance,including cosmetic surgery "Benefits"section. (surgery that is performed to alter or reshape normal structures of the body in order to improve appearance), Experimental or investigational Services except that this exclusion does not apply to any of the A Service is experimental or investigational if we,in following: consultation with the Medical Group,determine that one • Services covered under"Reconstructive Surgery"in of the following is true: the"Benefits"section • Generally accepted medical standards do not • The following devices covered under"Prosthetic and recognize it as safe and effective for treating the Orthotic Devices"in the"Benefits"section:testicular condition in question(even if it has been authorized implants implanted as part of a covered reconstructive by law for use in testing or other studies on human surgery,breast prostheses needed after removal of all patients) or part of a breast,and prostheses to replace all or part • It requires government approval that has not been of an external facial body part obtained when the Service is to be provided Custodial care This exclusion does not apply to any of the following: Assistance with activities of daily living(for example: • Experimental or investigational Services when an walking,getting in and out of bed,bathing,dressing, investigational application has been filed with the feeding,toileting,and taking medicine). federal Food and Drug Administration("FDA")and the manufacturer or other source makes the Services This exclusion does not apply to assistance with available to you or Kaiser Permanente through an activities of daily living that is provided as part of FDA-authorized procedure,except that we do not covered hospice,Skilled Nursing Facility,or hospital cover Services that are customarily provided by inpatient Services. research sponsors free of charge to enrollees in a Dental and orthodontic Services clinical trial or other investigational treatment protocol Dental and orthodontic Services such as X-rays, . Services covered under"Services in Connection with appliances,implants, Services provided by dentists or a Clinical Trial"in the"Benefits"section Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 66 Refer to the"Dispute Resolution"section for information refractive defects of the eye such as myopia,hyperopia, about Independent Medical Review related to denied or astigmatism. requests for experimental or investigational Services. Massage therapy Hair loss or growth treatment Massage therapy,except that this exclusion does not Items and services for the promotion,prevention,or apply to therapy Services that are part of a physical other treatment of hair loss or hair growth. therapy treatment plan and covered under"Home Health Care,""Hospice Services,""Hospital Inpatient Intermediate care Services,""Rehabilitative and Habilitative Services,"or Care in a licensed intermediate care facility. This "Skilled Nursing Facility Care"in the"Benefits"section. exclusion does not apply to Services covered under "Durable Medical Equipment("DME")for Home Use," Oral nutrition and weight loss aids "Home Health Care,"and"Hospice Care"in the Outpatient oral nutrition,such as dietary supplements, "Benefits"section. herbal supplements,formulas,food,and weight loss aids. Items and services that are not health care items This exclusion does not apply to any of the following: and services • Amino acid—modified products and elemental dietary For example,we do not cover: enteral formula covered under"Outpatient • Teaching manners and etiquette Prescription Drugs,Supplies,and Supplements"in • Teaching and support services to develop planning the`Benefits"section skills such as daily activity planning and project or • Enteral formula covered under"Prosthetic and task planning Orthotic Devices"in the`Benefits"section • Items and services for the purpose of increasing Residential care academic knowledge or skills Care in a facility where you stay overnight,except that • Teaching and support services to increase intelligence this exclusion does not apply when the overnight stay is • Academic coaching or tutoring for skills such as part of covered care in a hospital,a Skilled Nursing grammar,math,and time management Facility,or inpatient respite care covered in the"Hospice • Teaching you how to read,whether or not you have Care"section. dyslexia Routine foot care items and services • Educational testing Routine foot care items and services that are not • Teaching art,dance,horse riding,music,play or Medically Necessary. swimming • Teaching skills for employment or vocational Services not approved by the federal Food and purposes Drug Administration Drugs,supplements,tests,vaccines,devices,radioactive • Vocational training or teaching vocational skills materials,and any other Services that by law require • Professional growth courses federal Food and Drug Administration("FDA")approval • Training for a specific job or employment counseling in order to be sold in the U.S.but are not approved by the FDA.This exclusion applies to Services provided • Aquatic therapy and other water therapy,except that anywhere,even outside the U.S. this exclusion for aquatic therapy and other water therapy does not apply to therapy Services that are This exclusion does not apply to any of the following: part of a physical therapy treatment plan and covered • Services covered under the"Emergency Services and under"Home Health Care,""Hospice Services," Urgent Care"section that you receive outside the U.S. "Hospital Inpatient Services,""Rehabilitative and Habilitative Services,"or"Skilled Nursing Facility • Experimental or investigational Services when an Care"in the"Benefits"section investigational application has been filed with the FDA and the manufacturer or other source makes the Items and services to correct refractive defects Services available to you or Kaiser Permanente of the eye through an FDA-authorized procedure,except that we Items and services(such as eye surgery or contact lenses do not cover Services that are customarily provided to reshape the eye)for the purpose of correcting by research sponsors free of charge to enrollees in a Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 67 clinical trial or other investigational treatment provision of Services under this EOC,such as a major protocol disaster,epidemic,war,riot,civil insurrection,disability • Services covered under"Services in Connection with of a large share of personnel at a Plan Facility,complete a Clinical Trial"in the"Benefits"section or partial destruction of facilities,and labor dispute. Under these circumstances,if you have an Emergency Refer to the"Dispute Resolution"section for information Medical Condition,call 911 or go to the nearest about Independent Medical Review related to denied emergency department as described under"Emergency requests for experimental or investigational Services. Services"in the"Emergency Services and Urgent Care" section,and we will provide coverage and Services performed by unlicensed people reimbursement as described in that section. Services that are performed safely and effectively by people who do not require licenses or certificates by the Coordination of Benefits state to provide health care services and where the Member's condition does not require that the services be The Services covered under this EOC are subject to provided by a licensed health care provider. coordination of benefits rules. Services related to a noncovered Service Coverage other than Medicare coverage When a Service is not covered,all Services related to the If you have medical or dental coverage under another noncovered Service are excluded, except for Services we plan that is subject to coordination of benefits,we will would otherwise cover to treat complications of the coordinate benefits with the other coverage under the noncovered Service.For example,if you have a coordination of benefits rules of the California noncovered cosmetic surgery,we would not cover Department of Managed Health Care.Those rules are Services you receive in preparation for the surgery or for incorporated into this EOC. follow-up care.If you later suffer a life-threatening complication such as a serious infection,this exclusion If both the other coverage and we cover the same would not apply and we would cover any Services that Service,the other coverage and we will see that up to we would otherwise cover to treat that complication. 100 percent of your covered medical expenses are paid for that Service.The coordination of benefits rules Surrogacy determine which coverage pays first,or is"primary,"and Services for anyone in connection with a Surrogacy which coverage pays second,or is"secondary."The Arrangement,except for otherwise-covered Services secondary coverage may reduce its payment to take into provided to a Member who is a surrogate.Refer to account payment by the primary coverage.You must "Surrogacy Arrangements"under"Reductions"in this give us any information we request to help us coordinate "Exclusions,Limitations,Coordination of Benefits,and benefits. Reductions"section for information about your obligations to us in connection with a Surrogacy If your coverage under this EOC is secondary,we may Arrangement,including your obligations to reimburse us be able to establish a Benefit Reserve Account for you. for any Services we cover and to provide information You may draw on the Benefit Reserve Account during a about anyone who may be financially responsible for calendar year to pay for your out-of-pocket expenses for Services the baby(or babies)receive. Services that are partially covered by either your other coverage or us during that calendar year.If you are Travel and lodging expenses entitled to a Benefit Reserve Account,we will provide Travel and lodging expenses,except as described in our you with detailed information about this account. Travel and Lodging Program Description.The Travel and Lodging Program Description is available online at If you have any questions about coordination of benefits, kp.ora/specialty-care/travel-reimbursements or by please call Member Services. calling Member Services. Medicare coverage If you have Medicare coverage,we will coordinate Limitations benefits with the Medicare coverage under Medicare rules.Medicare rules determine which coverage pays We will make a good faith effort to provide or arrange first,or is"primary,"and which coverage pays second, for covered Services within the remaining availability of or is"secondary."You must give us any information we facilities or personnel in the event of unusual request to help us coordinate benefits.Please call circumstances that delay or render impractical the Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 68 Member Services to find out which Medicare rules apply the total amount of the proceeds is less than the actual to your situation,and how payment will be handled. losses and damages you incurred. Within 30 days after submitting or filing a claim or legal Reductions action against another party,you must send written Employer responsibility notice of the claim or legal action to: For any Services that the law requires an employer to Equian provide,we will not pay the employer,and when we Kaiser Permanente-Northern California Region cover any such Services we may recover the value of the Subrogation Mailbox Services from the employer. P.O.Box 36380 Louisville,KY 40233 Government agency responsibility Fax: 1-502-214-1137 For any Services that the law requires be provided only In order for us to determine the existence of any rights by or received only from a government agency,we will we may have and to satisfy those rights,you must not pay the government agency,and when we cover any complete and send us all consents,releases, such Services we may recover the value of the Services authorizations,assignments,and other documents, from the government agency. including lien forms directing your attorney,the other party,and the other party's liability insurer to pay us Injuries or illnesses alleged to be caused by directly.You may not agree to waive,release,or reduce other parties our rights under this provision without our prior,written If you obtain a judgment or settlement from or on behalf consent. of another party who allegedly caused an injury or illness for which you received covered Services,you must If your estate,parent,guardian,or conservator asserts a reimburse us to the maximum extent allowed under claim against another party based on your injury or California Civil Code Section 3040. The reimbursement illness,your estate,parent,guardian,or conservator and due to us is not limited by or subject to the Plan Out-of- any settlement or judgment recovered by the estate, Pocket Maximum.Note: This"Injuries or illnesses parent,guardian,or conservator shall be subject to our alleged to be caused by other parties"section does not liens and other rights to the same extent as if you had affect your obligation to pay your Cost Share for these asserted the claim against the other party.We may assign Services. our rights to enforce our liens and other rights. To the extent permitted or required by law,we have the If you have Medicare,Medicare law may apply with option of becoming subrogated to all claims,causes of respect to Services covered by Medicare. action,and other rights you may have against another party or an insurer,government program,or other source Some providers have contracted with Kaiser Permanente of coverage for monetary damages,compensation,or to provide certain Services to Members at rates that are indemnification on account of the injury or illness typically less than the fees that the providers ordinarily allegedly caused by the other party.We will be so charge to the general public("General Fees").However, subrogated as of the time we mail or deliver a written these contracts may allow the providers to recover all or notice of our exercise of this option to you or your a portion of the difference between the fees paid by attorney. Kaiser Permanente and their General Fees by means of a lien claim under California Civil Code Sections 3045.1- To secure our rights,we will have a lien and 3045.6 against a judgment or settlement that you receive reimbursement rights to the proceeds of any judgment or from or on behalf of another party.For Services the settlement you or we obtain(1)against another party, provider furnished,our recovery and the provider's and/or(2)from other types of coverage or sources of recovery together will not exceed the provider's General payment that include but are not limited to: liability, Fees. uninsured motorist,underinsured motorist,personal umbrella,workers'compensation,and/or personal injury Surrogacy Arrangements coverages,any other types of medical payments and all other first party types of coverages or sources of If you enter into a Surrogacy Arrangement and you or any other payee are entitled to receive payments or other payment.The proceeds of any judgment or settlement compensation under the Surrogacy Arrangement,you that you or we obtain and/or payments that you receive must reimburse us for covered Services you receive shall first be applied to satisfy our lien,regardless of related to conception,pregnancy,delivery,or postpartum whether you are made whole and regardless of whether Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 69 care in connection with that arrangement("Surrogacy Arrangements"section and to satisfy those rights.You Health Services")to the maximum extent allowed under may not agree to waive,release,or reduce our rights California Civil Code Section 3040.Note: This under this"Surrogacy Arrangements"section without "Surrogacy Arrangements"section does not affect your our prior,written consent. obligation to pay your Cost Share for these Services. After you surrender a baby to the legal parents,you are If your estate,parent,guardian,or conservator asserts a not obligated to reimburse us for any Services that the claim against another party based on the Surrogacy baby receives(the legal parents are financially Arrangement,your estate,parent,guardian,or responsible for any Services that the baby receives). conservator and any settlement or judgment recovered by the estate,parent,guardian,or conservator shall be By accepting Surrogacy Health Services,you subject to our liens and other rights to the same extent as automatically assign to us your right to receive payments if you had asserted the claim against the other party.We that are payable to you or any other payee under the may assign our rights to enforce our liens and other Surrogacy Arrangement,regardless of whether those rights. payments are characterized as being for medical expenses.To secure our rights,we will also have a lien If you have questions about your obligations under this on those payments and on any escrow account,trust,or provision,please call Member Services. any other account that holds those payments. Those payments(and amounts in any escrow account,trust,or U.S. Department of Veterans Affairs other account that holds those payments)shall first be For any Services for conditions arising from military applied to satisfy our lien.The assignment and our lien service that the law requires the Department of Veterans will not exceed the total amount of your obligation to us Affairs to provide,we will not pay the Department of under the preceding paragraph. Veterans Affairs,and when we cover any such Services we may recover the value of the Services from the Within 30 days after entering into a Surrogacy Department of Veterans Affairs. Arrangement,you must send written notice of the arrangement,including all of the following information: Workers' compensation or employer's liability • Names,addresses,and phone numbers of the other benefits parties to the arrangement You may be eligible for payments or other benefits, • Names,addresses,and phone numbers of any escrow including amounts received as a settlement(collectively agent or trustee referred to as"Financial Benefit"),under workers' compensation or employer's liability law.We will • Names,addresses,and phone numbers of the intended provide covered Services even if it is unclear whether parents and any other parties who are financially you are entitled to a Financial Benefit,but we may responsible for Services the baby(or babies)receive, recover the value of any covered Services from the including names,addresses,and phone numbers for following sources: any health insurance that will cover Services that the • From any source providing a Financial Benefit or baby(or babies)receive from whom a Financial Benefit is due • A signed copy of any contracts and other documents • From you,to the extent that a Financial Benefit is explaining the arrangement provided or payable or would have been required to • Any other information we request in order to satisfy be provided or payable if you had diligently sought to our rights establish your rights to the Financial Benefit under any workers' compensation or employer's liability You must send this information to: law Equian Kaiser Permanente-Northern California Region Surrogacy Mailbox Post-Service Claims and Appeals P.O.Box 36380 Louisville,KY 40233 Fax: 1-502-214-1137 This"Post-Service Claims and Appeals"section explains how to file a claim for payment or reimbursement for You must complete and send us all consents,releases, Services that you have already received.Please use the authorizations,lien forms,and other documents that are procedures in this section in the following situations: reasonably necessary for us to determine the existence of • You have received Emergency Services,Post- any rights we may have under this"Surrogacy Stabilization Care,Out-of-Area Urgent Care,or Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 70 emergency ambulance Services from a Non—Plan Supporting Documents Provider and you want us to pay for the Services • You have received Services from a Non—Plan You can request payment or reimbursement orally or in Provider that we did not authorize(other than writing.Your request for payment or reimbursement,and Emergency Services,Post-Stabilization Care,Out-of- any related documents that you give us,constitute your Area Urgent Care,or emergency ambulance Services) claim. and you want us to pay for the Services Claim forms for Emergency Services, Post- • You want to appeal a denial of an initial claim for Stabilization Care, Out-of-Area Urgent Care, and payment emergency ambulance Services To file a claim in writing for Emergency Services,Post- Please follow the procedures under"Grievances"in the Stabilization Care,Out-of-Area Urgent Care,or "Dispute Resolution"section in the following situations: emergency ambulance Services,please use our claim • You want us to cover Services that you have not yet form.You can obtain a claim form in the following received ways: • You want us to continue to cover an ongoing course • By visiting our website at kmorg of covered treatment • In person from any Member Services office at a Plan • You want to appeal a written denial of a request for Facility and from Plan Providers(for addresses,refer Services that require prior authorization(as described to our Provider Directory or call Member Services) under"Medical Group authorization procedure for • By calling Member Services at 1-800-464-4000(TTY certain referrals") users call 711) Who May File Claims forms for all other Services To file a claim in writing for all other Services,you may The following people may file claims: use our grievance form.You can obtain this form in the • You may file for yourself following ways: • You can ask a friend,relative,attorney,or any other • By visiting our website at kp.org individual to file a claim for you by appointing them • In person from any Member Services office at a Plan in writing as your authorized representative Facility and from Plan Providers(for addresses,refer to our Provider Directory or call Member Services) • A parent may file for their child under age 18,except that the child must appoint the parent as authorized • By calling Member Services at 1-800-464-4000(TTY representative if the child has the legal right to control users call 711) release of information that is relevant to the claim • A court-appointed guardian may file for their ward, Other supporting information except that the ward must appoint the court-appointed When you file a claim,please include any information guardian as authorized representative if the ward has that clarifies or supports your position.For example,if the legal right to control release of information that is you have paid for Services,please include any bills and relevant to the claim receipts that support your claim.To request that we pay a Non—Plan Provider for Services,include any bills from • A court-appointed conservator may file for their the Non—Plan Provider.If the Non—Plan Provider states conservatee that they will file the claim,you are still responsible for • An agent under a currently effective health care making sure that we receive everything we need to proxy,to the extent provided under state law,may file process the request for payment.When appropriate,we for their principal will request medical records from Plan Providers on your behalf.If you tell us that you have consulted with a Non— Authorized representatives must be appointed in writing Plan Provider and are unable to provide copies of using either our authorization form or some other form of relevant medical records,we will contact the provider to written notification.The authorization form is available request a copy of your relevant medical records.We will from the Member Services office at a Plan Facility,on ask you to provide us a written authorization so that we our website at kp.org,or by calling Member Services. can request your records. Your written authorization must accompany the claim. You must pay the cost of anyone you hire to represent or If you want to review the information that we have help you. collected regarding your claim,you may request,and we Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 71 will provide without charge,copies of all relevant possible after you receive the Services,you must file documents,records,and other information.You also your claim in one of the following ways: have the right to request any diagnosis and treatment • By delivering your claim to a Member Services office codes and their meanings that are the subject of your at a Plan Facility(for addresses,refer to our Provider claim.To make a request,you should follow the steps in Directory or call Member Services) the written notice sent to you about your claim. • By mailing your claim to a Member Services office at a Plan Facility(for addresses,refer to our Provider Initial Claims Directory or call Member Services) To request that we pay a provider(or reimburse you)for • By calling Member Services at 1-800-464-4000(TTY Services that you have already received,you must file a users call 711) claim.If you have any questions about the claims • By visiting our website at kp•org process,please call Member Services. Please call Member Services if you need help filing your Submitting a claim for Emergency Services, claim. Post-Stabilization Care, Out-of-Area Urgent Care, and emergency ambulance Services After we receive your claim You may file a claim(request for We will send you an acknowledgment letter within five payment/reimbursement): days after we receive your claim. • By visiting Ikp.org,completing an electronic form and uploading supporting documentation; After we review your claim,we will respond as follows: • By mailing a paper form that can be obtained by • If we have all the information we need we will send visiting kp•org or calling Member Services;or you a written decision within 30 days after we receive • If you are unable access the electronic form(or obtain your claim.We may extend the time for making a decision for an additional 15 days if circumstances the paper form),by mailing the minimum amount of beyond our control delay our decision,if we notify information we need to process your claim: you within 30 days after we receive your claim ♦ Member/Patient Name and Medical/Health Record . If we need more information,we will ask you for the Number information before the end of the initial 30-day ♦ The date you received the Services decision period.We will send our written decision no ♦ Where you received the Services later than 15 days after the date we receive the ♦ Who provided the Services additional information.If we do not receive the ♦ Why you think we should pay for the Services necessary information within the timeframe specified in our letter,we will make our decision based on the ♦ A copy of the bill,your medical record(s)for these information we have within 15 days after the end of Services,and your receipt if you paid for the that timeframe Services If we pay any part of your claim,we will subtract Mailing address to submit your claim to Kaiser applicable Cost Share from any payment we make to you Permanente: or the Non—Plan Provider.You are not responsible for any amounts beyond your Cost Share for covered Kaiser Permanente Emergency Services.If we deny your claim(if we do not Claims Administration-NCAL agree to pay for all the Services you requested other than P.O.Box 12923 the applicable Cost Share),our letter will explain why Oakland,CA 94604-2923 we denied your claim and how you can appeal. Please call Member Services if you need help filing your If you later receive any bills from the Non—Plan Provider claim. for covered Services(other than bills for your Cost Share),please call Member Services for assistance. Submitting a claim for all other Services If you have received Services from a Non—Plan Provider that we did not authorize(other than Emergency Services,Post-Stabilization Care,Out-of-Area Urgent Care,or emergency ambulance Services),then as soon as Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 72 Appeals believe support your claim.If we asked for additional information and you did not provide it before we made Claims for Emergency Services, Post- our initial decision about your claim,then you may still Stabilization Care, Out-of-Area Urgent Care, or send us the additional information so that we may emergency ambulance Services from a Non— include it as part of our review of your appeal.Please Plan Provider send all additional information to the address or fax If we did not decide fully in your favor and you want to mentioned in your denial letter. appeal our decision,you may submit your appeal in one of the following ways: Also,you may give testimony in writing or by phone. • By mailing your appeal to the Claims Department at Please send your written testimony to the address the following address: mentioned in our acknowledgment letter,sent to you within five days after we receive your appeal.To arrange Kaiser Foundation Health Plan,Inc. to give testimony by phone,you should call the phone Special Services Unit P.O.Box 23280 number mentioned in our acknowledgment letter. Oakland,CA 94623 We will add the information that you provide through • By calling Member Services at 1-800-464-4000(TTY testimony or other means to your appeal file and we will users call 711) review it without regard to whether this information was • By visiting our website at kp•org filed or considered in our initial decision regarding your request for Services.You have the right to request any Claims for Services from a Non—Plan Provider diagnosis and treatment codes and their meanings that that we did not authorize (other than Emergency are the subject of your claim. Services, Post-Stabilization Care, Out-of-Area Urgent Care, or emergency ambulance Services) We will share any additional information that we collect If we did not decide fully in your favor and you want to in the course of our review and we will send it to you.If appeal our decision,you may submit your appeal in one we believe that your request should not be granted, of the following ways: before we issue our final decision letter,we will also • By visiting our website at kp•org share with you any new or additional reasons for that decision.We will send you a letter explaining the • By mailing your appeal to any Member Services additional information and/or reasons. Our letters about office at a Plan Facility(for addresses,refer to our additional information and new or additional rationales Provider Directory or call Member Services) will tell you how you can respond to the information • In person at any Member Services office at a Plan provided if you choose to do so.If you do not respond Facility or any Plan Provider(for addresses,refer to before we must issue our final decision letter,that our Provider Directory or call Member Services) decision will be based on the information in your appeal • By calling Member Services at 1-800-464-4000(TTY file. users call 711) We will send you a resolution letter within 30 days after When you file an appeal,please include any information we receive your appeal.If we do not decide in your that clarifies or supports your position.If you want to favor,our letter will explain why and describe your review the information that we have collected regarding further appeal rights. your claim,you may request,and we will provide without charge,copies of all relevant documents, External Review records,and other information.To make a request,you should call Member Services. You must exhaust our internal claims and appeals procedures before you may request external review Additional information regarding a claim for unless we have failed to comply with the claims and Services from a Non—Plan Provider that we did appeals procedures described in this"Post-Service not authorize (other than Emergency Services, Claims and Appeals"section.For information about the Post-Stabilization Care, Out-of-Area Urgent external review process,see"Independent Medical Care, or emergency ambulance Services) Review("IMR")"in the"Dispute Resolution"section. If we initially denied your request,you must file your appeal within 180 days after the date you received our denial letter.You may send us information including comments,documents,and medical records that you Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 73 Additional Review • You were told that Services are not covered and you believe that the Services should be covered You may have certain additional rights if you remain • You want us to continue to cover an ongoing course dissatisfied after you have exhausted our internal claims of covered treatment and appeals procedure,and if applicable,external review: • You are dissatisfied with how long it took to get • If your Group's benefit plan is subject to the Services,including getting an appointment,in the Employee Retirement Income Security Act waiting room,or in the exam room ("ERISA"),you may file a civil action under section • You want to report unsatisfactory behavior by 502(a)of ERISA.To understand these rights,you providers or staff,or dissatisfaction with the condition should check with your Group or contact the of a facility Employee Benefits Security Administration(part of • You believe you have faced discrimination from the U.S.Department of Labor)at 1-866-444-EBSA providers, staff,or Health Plan (1-866-444-3272) • We terminated your membership and you disagree • If your Group's benefit plan is not subject to ERISA with that termination (for example,most state or local government plans and church plans),you may have a right to request Who may file review in state court The following people may file a grievance: • You may file for yourself Dispute Resolution • You can ask a friend,relative,attorney,or any other individual to file a grievance for you by appointing We are committed to providing you with quality care and them in writing as your authorized representative with a timely response to your concerns.You can discuss • A parent may file for their child under age 18,except your concerns with our Member Services representatives that the child must appoint the parent as authorized at most Plan Facilities,or you can call Member Services. representative if the child has the legal right to control release of information that is relevant to the grievance Grievances • A court-appointed guardian may file for their ward, except that the ward must appoint the court-appointed This"Grievances"section describes our grievance guardian as authorized representative if the ward has procedure.A grievance is any expression of the legal right to control release of information that is dissatisfaction expressed by you or your authorized relevant to the grievance representative through the grievance process.If you want • A court-appointed conservator may file for their to make a claim for payment or reimbursement for conservatee Services that you have already received from a Non—Plan • An agent under a currently effective health care Provider,please follow the procedure in the"Post- proxy,to the extent provided under state law,may file Service Claims and Appeals"section. for their principal Here are some examples of reasons you might file a • Your physician may act as your authorized grievance: representative with your verbal consent to request an urgent grievance as described under"Urgent • You are not satisfied with the quality of care you procedure"in this"Grievances"section received • You received a written denial of Services that require Authorized representatives must be appointed in writing prior authorization from the Medical Group and you using either our authorization form or some other form of want us to cover the Services written notification.The authorization form is available • You received a written denial for a second opinion or from the Member Services office at a Plan Facility,on we did not respond to your request for a second our website at kp•org,or by calling Member Services. opinion in an expeditious manner,as appropriate for Your written authorization must accompany the your condition grievance.You must pay the cost of anyone you hire to • Your treating physician has said that Services are not represent or help you. Medically Necessary and you want us to cover the Services Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 74 How to file we will provide without charge,copies of all relevant You can file a grievance orally or in writing.Your documents,records,and other information. To make a grievance must explain your issue,such as the reasons request,you should call Member Services. why you believe a decision was in error or why you are dissatisfied with the Services you received. Urgentprocedure If you want us to consider your grievance on an urgent Standard Procedure basis,please tell us that when you file your grievance. To file a grievance electronically,use the grievance form Note:Urgent is sometimes referred to as"exigent."If on kp•org. exigent circumstances exist,your grievance may be reviewed using the urgent procedure described in this To file a grievance orally,call Member Services toll free section. at 1-800-464-4000(TTY users call 711). You must file your urgent grievance in one of the To file a grievance in writing,please use our grievance following ways: form,which is available on kp.org under"Forms& • By calling our Expedited Review Unit toll free at Publications,"in person from any Member Services 1-888-987-7247(TTY users call 711) office at a Plan Facility,or from Plan Providers(for addresses,refer to our Provider Directory or call Member • By mailing a written request to: Services).You can submit the form in the following Kaiser Foundation Health Plan,Inc. ways: Expedited Review Unit • In person at any Member Services office at a Plan P.O.Box 1809 Facility Pleasanton, 09CA 94566 • By faxing a written request to our Expedited Review Fa• mail to any Member Services office at a Plan Unit toll free at 1-888-987-2252 Facility • By visiting a Member Services office at a Plan You must file your grievance within 180 days following Facility(for addresses,refer to our Provider Directory the incident or action that is subject to your or call Member Services) dissatisfaction.You may send us information including • By completing the grievance form on our website at comments,documents,and medical records that you ky.m believe support your grievance. We will decide whether your grievance is urgent or non- Please call Member Services if you need help filing a urgent unless your attending health care provider tells us grievance. your grievance is urgent.If we determine that your grievance is not urgent,we will use the procedure If your grievance involves a request to obtain a non- described under"Standard procedure"in this formulary prescription drug,we will notify you of our "Grievances"section.Generally,a grievance is urgent decision within 72 hours.If we do not decide in your only if one of the following is true: favor,our letter will explain why and describe your • Using the standard procedure could seriously further appeal rights.For information on how to request jeopardize your life,health,or ability to regain a review by an independent review organization,see maximum function "Independent Review Organization for Non-Formulary Prescription Drug Requests"in this"Dispute Resolution" • Using the standard procedure would,in the opinion of section. a physician with knowledge of your medical condition,subject you to severe pain that cannot be For all other grievances,we will send you an adequately managed without extending your course of acknowledgment letter within five days after we receive covered treatment your grievance.We will send you a resolution letter • A physician with knowledge of your medical within 30 days after we receive your grievance.If you condition determines that your grievance is urgent are requesting Services,and we do not decide in your • You have received Emergency Services but have not favor,our letter will explain why and describe your further appeal rights. been discharged from a facility and your request involves admissions,continued stay,or other health If you want to review the information that we have care Services collected regarding your grievance,you may request,and Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 75 • You are undergoing a current course of treatment We will send you a letter explaining the additional using a non-formulary prescription drug and your information and/or reasons. Our letters about additional grievance involves a request to refill a non-formulary information and new or additional rationales will tell you prescription drug how you can respond to the information provided if you choose to do so.If your grievance is urgent,the For most grievances that we respond to on an urgent information will be provided to you orally and followed basis,we will give you oral notice of our decision as in writing.If you do not respond before we must issue soon as your clinical condition requires,but no later than our final decision letter,that decision will be based on 72 hours after we received your grievance.We will send the information in your grievance file. you a written confirmation of our decision within three days after we received your grievance. Additional information regarding appeals of written denials for Services that require prior authorization If your grievance involves a request to obtain a non- You must file your appeal within 180 days after the date formulary prescription drug and we respond to your you received our denial letter. request on an urgent basis,we will notify you of our decision within 24 hours of your request.For information You have the right to request any diagnosis and on how to request a review by an independent review treatment codes and their meanings that are the subject of organization,see"Independent Review Organization for your appeal. Non-Formulary Prescription Drug Requests"in this "Dispute Resolution"section. Also,you may give testimony in writing or by phone. Please send your written testimony to the address If we do not decide in your favor,our letter will explain mentioned in our acknowledgment letter.To arrange to why and describe your further appeal rights. give testimony by phone,you should call the phone number mentioned in our acknowledgment letter. Note:If you have an issue that involves an imminent and serious threat to your health(such as severe pain or We will add the information that you provide through potential loss of life,limb,or major bodily function),you testimony or other means to your appeal file and we will can contact the California Department of Managed consider it in our decision regarding your appeal. Health Care at any time at 1-888-466-2219(TDD 1-877- 688-9891)without first filing a grievance with us. We will share any additional information that we collect in the course of our review and we will send it to you.If If you want to review the information that we have we believe that your request should not be granted, collected regarding your grievance,you may request,and before we issue our decision letter,we will also share we will provide without charge,copies of all relevant with you any new or additional reasons for that decision. documents,records,and other information. To make a We will send you a letter explaining the additional request,you should call Member Services. information and/or reasons. Our letters about additional information and new or additional rationales will tell you Additional information regarding pre-service requests how you can respond to the information provided if you for Medically Necessary Services choose to do so.If your appeal is urgent,the information You may give testimony in writing or by phone.Please will be provided to you orally and followed in writing.If send your written testimony to the address mentioned in you do not respond before we must issue our final our acknowledgment letter.To arrange to give testimony decision letter,that decision will be based on the by phone,you should call the phone number mentioned information in your appeal file. in our acknowledgment letter. We will add the information that you provide through Independent Review Organization for testimony or other means to your grievance file and we Non-Formulary Prescription Drug will consider it in our decision regarding your pre- Requests service request for Medically Necessary Services. If you filed a grievance to obtain a non-formulary We will share any additional information that we collect prescription drug and we did not decide in your favor, in the course of our review and we will send it to you.If you may submit a request for a review of your grievance we believe that your request should not be granted, by an independent review organization("IRO").You before we issue our decision letter,we will also share must submit your request for IRO review within 180 with you any new or additional reasons for that decision. days of the receipt of our decision letter. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 76 You must file your request for IRO review in one of the services. The department also has a toll-free telephone following ways: number(1-888-466-2219)and a TDD line • By calling our Expedited Review Unit toll free at (1-877-688-9891)for the hearing and speech 1-888-987-7247(TTY users call 711) impaired. The department's Internet website • By mailing a written request to: www.dmhc.ca.20V has complaint forms,IMR Kaiser Foundation Health Plan,Inc. application forms and instructions online. Expedited Review Unit P.O.Box 1809 Independent Medical Review ("IMR") Pleasanton,CA 94566 • By faxing a written request to our Expedited Review Except as described in this"Independent Medical Unit toll free at 1-888-987-2252 Review("IMR")"section,you must exhaust our internal grievance procedure before you may request independent • By visiting a Member Services office at a Plan medical review unless we have failed to comply with the Facility(for addresses,refer to our Provider Directory grievance procedure described under"Grievances"in or call Member Services) this"Dispute Resolution"section.If you qualify,you or • By completing the grievance form on our website at your authorized representative may have your issue kp•or2 reviewed through the IMR process managed by the California Department of Managed Health Care For urgent IRO reviews,we will forward to you the ("DMHC").The DMHC determines which cases qualify independent reviewer's decision within 24 hours.For for IMR.This review is at no cost to you.If you decide non-urgent requests,we will forward the independent not to request an IMR,you may give up the right to reviewer's decision to you within 72 hours.If the pursue some legal actions against us. independent reviewer does not decide in your favor,you may submit a complaint to the Department of Managed You may qualify for IMR if all of the following are true: Health Care,as described under"Department of • One of these situations applies to you: Managed Health Care Complaints"in this"Dispute Resolution"section.You may also submit a request for ♦ you have a recommendation from a provider an Independent Medical Review as described under requesting Medically Necessary Services "Independent Medical Review"in this"Dispute ♦ you have received Emergency Services, Resolution"section. emergency ambulance Services,or Urgent Care from a provider who determined the Services to be Medically Necessary Department of Managed Health Care ♦ you have been seen by a Plan Provider for the Complaints diagnosis or treatment of your medical condition The California Department of Managed Health Care is • Your request for payment or Services has been responsible for regulating health care service plans.If denied,modified,or delayed based in whole or in part you have a grievance against your health plan,you on a decision that the Services are not Medically should first telephone your health plan toll free at Necessary 1-800-464-4000 (TTY users call 711)and use your • You have filed a grievance and we have denied it or health plan's grievance process before contacting the we haven't made a decision about your grievance department.Utilizing this grievance procedure does not within 30 days(or three days for urgent grievances). prohibit any potential legal rights or remedies that may The DMHC may waive the requirement that you first be available to you.If you need help with a grievance file a grievance with us in extraordinary and involving an emergency,a grievance that has not been compelling cases,such as severe pain or potential loss satisfactorily resolved by your health plan,or a grievance of life,limb,or major bodily function. If we have that has remained unresolved for more than 30 days,you denied your grievance,you must submit your request may call the department for assistance.You may also be for an IMR within six months of the date of our eligible for an Independent Medical Review(IMR).If written denial.However,the DMHC may accept your you are eligible for IMR,the IMR process will provide request after six months if they determine that an impartial review of medical decisions made by a circumstances prevented timely submission health plan related to the medical necessity of a proposed service or treatment,coverage decisions for treatments You may also qualify for IMR if the Service you that are experimental or investigational in nature and requested has been denied on the basis that it is payment disputes for emergency or urgent medical Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 77 experimental or investigational as described under Note:You can request IMR for experimental or "Experimental or investigational denials." investigational denials at any time without first filing a grievance with us. If the DMHC determines that your case is eligible for IMR,it will ask us to send your case to the DMHC's IMR organization.The DMHC will promptly notify you Office of Civil Rights Complaints of its decision after it receives the IMR organization's If you believe that you have been discriminated against determination.If the decision is in your favor,we will by a Plan Provider or by us because of your race,color, contact you to arrange for the Service or payment. national origin,disability,age,sex(including sex Experimental or investigational denials stereotyping and gender identity),or religion,you may file a complaint with the Office of Civil Rights in the If we deny a Service because it is experimental or United States Department of Health and Human Services investigational,we will send you our written explanation OCR"). within three days after we received your request.We will explain why we denied the Service and provide You may file your complaint with the OCR within 180 additional dispute resolution options.Also,we will days of when you believe the act of discrimination provide information about your right to request occurred.However,the OCR may accept your request Independent Medical Review if we had the following after six months if they determine that circumstances information when we made our decision: prevented timely submission.For more information on • Your treating physician provided us a written the OCR and how to file a complaint with the OCR,go statement that you have a life-threatening or seriously to hhs.gov/civil-rights. debilitating condition and that standard therapies have not been effective in improving your condition,or that standard therapies would not be appropriate,or Additional Review that there is no more beneficial standard therapy we cover than the therapy being requested."Life- You may have certain additional rights if you remain threatening"means diseases or conditions where the dissatisfied after you have exhausted our internal claims likelihood of death is high unless the course of the and appeals procedure,and if applicable,external disease is interrupted,or diseases or conditions with review: potentially fatal outcomes where the end point of • If your Group's benefit plan is subject to the clinical intervention is survival. "Seriously Employee Retirement Income Security Act debilitating"means diseases or conditions that cause ("ERISA"),you may file a civil action under section major irreversible morbidity 502(a)of ERISA.To understand these rights,you • If your treating physician is a Plan Physician,they should check with your Group or contact the recommended a treatment,drug,device,procedure,or Employee Benefits Security Administration(part of other therapy and certified that the requested therapy the U.S.Department of Labor)at 1-866-444-EBSA is likely to be more beneficial to you than any (1-866-444-3272) available standard therapies and included a statement • If your Group's benefit plan is not subject to ERISA of the evidence relied upon by the Plan Physician in (for example,most state or local government plans certifying their recommendation and church plans),you may have a right to request • You(or your Non—Plan Physician who is a licensed, review in state court and either a board-certified or board-eligible, physician qualified in the area of practice appropriate Binding Arbitration to treat your condition)requested a therapy that, based on two documents from the medical and For all claims subject to this"Binding Arbitration" scientific evidence,as defined in California Health section,both Claimants and Respondents give up the and Safety Code Section 1370.4(d),is likely to be right to a jury or court trial and accept the use of binding more beneficial for you than any available standard arbitration.Insofar as this"Binding Arbitration"section therapy.The physician's certification included a applies to claims asserted by Kaiser Permanente Parties, statement of the evidence relied upon by the it shall apply retroactively to all unresolved claims that physician in certifying their recommendation.We do accrued before the effective date of this EOC. Such not cover the Services of the Non—Plan Provider retroactive application shall be binding only on the Kaiser Permanente Parties. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 78 Scope of arbitration • Any Southern California Permanente Medical Group Any dispute shall be submitted to binding arbitration if or The Permanente Medical Group physician all of the following requirements are met: • Any individual or organization whose contract with • The claim arises from or is related to an alleged any of the organizations identified above requires violation of any duty incident to or arising out of or arbitration of claims brought by one or more Member relating to this EOC or a Member Party's relationship Parties to Kaiser Foundation Health Plan,Inc. ("Health • Any employee or agent of any of the foregoing Plan"),including any claim for medical or hospital malpractice(a claim that medical services or items "Claimant"refers to a Member Party or a Kaiser were unnecessary or unauthorized or were Permanente Party who asserts a claim as described improperly,negligently,or incompetently rendered), above."Respondent"refers to a Member Party or a for premises liability,or relating to the coverage for, Kaiser Permanente Party against whom a claim is or delivery of,services or items,irrespective of the asserted. legal theories upon which the claim is asserted • The claim is asserted by one or more Member Parties Rules of Procedure against one or more Kaiser Permanente Parties or by Arbitrations shall be conducted according to the Rules one or more Kaiser Permanente Parties against one or for Kaiser Permanente Member Arbitrations Overseen more Member Parties by the Office of the Independent Administrator("Rules • Governing law does not prevent the use of binding of Procedure")developed by the Office of the arbitration to resolve the claim Independent Administrator in consultation with Kaiser Permanente and the Arbitration Oversight Board. Copies Members enrolled under this EOC thus give up their of the Rules of Procedure may be obtained from Member right to a court or jury trial,and instead accept the use of Services. binding arbitration except that the following types of claims are not subject to binding arbitration: Initiating arbitration Claimants shall initiate arbitration by serving a Demand • Claims within the jurisdiction of the Small Claims for Arbitration. The Demand for Arbitration shall include Court the basis of the claim against the Respondents;the • Claims subject to a Medicare appeal procedure as amount of damages the Claimants seek in the arbitration; applicable to Kaiser Permanente Senior Advantage the names,addresses,and phone numbers of the Members Claimants and their attorney,if any;and the names of all • Claims that cannot be subject to binding arbitration Respondents. Claimants shall include in the Demand for under governing law Arbitration all claims against Respondents that are based on the same incident,transaction,or related As referred to in this`Binding Arbitration"section, circumstances. "Member Parties"include: Serving Demand for Arbitration • A Member Health Plan,Kaiser Foundation Hospitals,The • A Member's heir,relative,or personal representative Permanente Medical Group,Inc., Southern California • Any person claiming that a duty to them arises from a Permanente Medical Group,The Permanente Federation, Member's relationship to one or more Kaiser LLC,and The Permanente Company,LLC,shall be Permanente Parties served with a Demand for Arbitration by mailing the Demand for Arbitration addressed to that Respondent in "Kaiser Permanente Parties"include: care o£ • Kaiser Foundation Health Plan,Inc. Kaiser Foundation Health Plan,Inc. Legal Department,Professional&Public Liability • Kaiser Foundation Hospitals 1 Kaiser Plaza, 191h Floor • The Permanente Medical Group,Inc. Oakland,CA 94612 • Southern California Permanente Medical Group Service on that Respondent shall be deemed completed • The Permanente Federation,LLC when received.All other Respondents,including • The Permanente Company,LLC individuals,must be served as required by the California Code of Civil Procedure for a civil action. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 79 Filing fee Costs The Claimants shall pay a single,nonrefundable filing Except for the aforementioned fees and expenses of the fee of$150 per arbitration payable to"Arbitration neutral arbitrator,and except as otherwise mandated by Account"regardless of the number of claims asserted in laws that apply to arbitrations under this"Binding the Demand for Arbitration or the number of Claimants Arbitration"section,each party shall bear the party's or Respondents named in the Demand for Arbitration. own attorneys' fees,witness fees,and other expenses incurred in prosecuting or defending against a claim Any Claimant who claims extreme hardship may request regardless of the nature of the claim or outcome of the that the Office of the Independent Administrator waive arbitration. the filing fee and the neutral arbitrator's fees and expenses.A Claimant who seeks such waivers shall General provisions complete the Fee Waiver Form and submit it to the A claim shall be waived and forever barred if(1)on the Office of the Independent Administrator and date the Demand for Arbitration of the claim is served, simultaneously serve it upon the Respondents.The Fee the claim,if asserted in a civil action,would be barred as Waiver Form sets forth the criteria for waiving fees and to the Respondent served by the applicable statute of is available by calling Member Services. limitations,(2)Claimants fail to pursue the arbitration claim in accord with the Rules of Procedure with Number of arbitrators reasonable diligence,or(3)the arbitration hearing is not The number of arbitrators may affect the Claimants' commenced within five years after the earlier of(a)the responsibility for paying the neutral arbitrator's fees and date the Demand for Arbitration was served in accord expenses(see the Rules of Procedure). with the procedures prescribed herein,or(b)the date of filing of a civil action based upon the same incident, If the Demand for Arbitration seeks total damages of transaction,or related circumstances involved in the $200,000 or less,the dispute shall be heard and claim.A claim may be dismissed on other grounds by the determined by one neutral arbitrator,unless the parties neutral arbitrator based on a showing of a good cause.If otherwise agree in writing after a dispute has arisen and a a party fails to attend the arbitration hearing after being request for binding arbitration has been submitted that given due notice thereof,the neutral arbitrator may the arbitration shall be heard by two party arbitrators and proceed to determine the controversy in the party's one neutral arbitrator.The neutral arbitrator shall not absence. have authority to award monetary damages that are greater than$200,000. The California Medical Injury Compensation Reform Act of 1975(including any amendments thereto), If the Demand for Arbitration seeks total damages of including sections establishing the right to introduce more than$200,000,the dispute shall be heard and evidence of any insurance or disability benefit payment determined by one neutral arbitrator and two party to the patient,the limitation on recovery for non- arbitrators,one jointly appointed by all Claimants and economic losses,and the right to have an award for one jointly appointed by all Respondents.Parties who are future damages conformed to periodic payments,shall entitled to select a party arbitrator may agree to waive apply to any claims for professional negligence or any this right.If all parties agree,these arbitrations will be other claims as permitted or required by law. heard by a single neutral arbitrator. Arbitrations shall be governed by this"Binding Payment of arbitrators'fees and expenses Arbitration"section, Section 2 of the Federal Arbitration Health Plan will pay the fees and expenses of the neutral Act,and the California Code of Civil Procedure arbitrator under certain conditions as set forth in the provisions relating to arbitration that are in effect at the Rules of Procedure.In all other arbitrations,the fees and time the statute is applied,together with the Rules of expenses of the neutral arbitrator shall be paid one-half Procedure,to the extent not inconsistent with this by the Claimants and one-half by the Respondents. "Binding Arbitration"section.In accord with the rule that applies under Sections 3 and 4 of the Federal If the parties select party arbitrators,Claimants shall be Arbitration Act,the right to arbitration under this responsible for paying the fees and expenses of their "Binding Arbitration"section shall not be denied,stayed, party arbitrator and Respondents shall be responsible for or otherwise impeded because a dispute between a paying the fees and expenses of their party arbitrator. Member Party and a Kaiser Permanente Party involves both arbitrable and nonarbitrable claims or because one or more parties to the arbitration is also a party to a pending court action with another party that arises out of Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 80 the same or related transactions and presents a possibility • Giving us incorrect or incomplete material of conflicting rulings or findings. information.For example,you have entered into a Surrogacy Arrangement and you fail to send us the information we require under"Surrogacy Termination of Membership Arrangements"under"Reductions"in the "Exclusions,Limitations,Coordination of Benefits, and Reductions"section Your Group is required to inform the Subscriber of the date your membership terminates.Your membership • Failing to notify us of changes in family status or termination date is the first day you are not covered(for Medicare coverage that may affect your eligibility or example,if your termination date is January 1,2025, benefits your last minute of coverage was at 11:59 p.m.on December 31,2024).When a Subscriber's membership If we terminate your membership for cause,you will not ends,the memberships of any Dependents end at the be allowed to enroll in Health Plan in the future.We may same time.You will be billed as a non-Member for any also report criminal fraud and other illegal acts to the Services you receive after your membership terminates. authorities for prosecution. Health Plan and Plan Providers have no further liability or responsibility under this EOC after your membership terminates,except as provided under"Payments after Termination of a Product or all Products Termination"in this"Termination of Membership" We may terminate a particular product or all products section. offered in the group market as permitted or required by law. If we discontinue offering a particular product in the Termination Due to Loss of Eligibility group market,we will terminate just the particular product by sending you written notice at least 90 days If you no longer meet the eligibility requirements before the product terminates.If we discontinue offering described under"Who Is Eligible"in the"Premiums, all products in the group market,we may terminate your Eligibility,and Enrollment"section,your Group will Group's Agreement by sending you written notice at notify you of the date that your membership will end. least 180 days before the Agreement terminates. Your membership termination date is the first day you are not covered.For example,if your termination date is January 1,2025,your last minute of coverage was at Payments after Termination 11:59 p.m. on December 31,2024. If we terminate your membership for cause or for nonpayment,we will: Termination of Agreement • Refund any amounts we owe your Group for Premiums paid after the termination date If your Group's Agreement with us terminates for any • pay you any amounts we have determined that we reason,your membership ends on the same date.Your Group is required to notify Subscribers in writing if its owe you for claims during your membership in Agreement with us terminates. accord with the"Emergency Services and Urgent Care"and"Dispute Resolution"sections Termination for Cause We will deduct any amounts you owe Health Plan or Plan Providers from any payment we make to you. If you intentionally commit fraud in connection with membership,Health Plan,or a Plan Provider,we may terminate your membership by sending written notice to State Review of Membership the Subscriber;termination will be effective 30 days Termination from the date we send the notice. Some examples of fraud include: If you believe that we have terminated your membership because of your ill health or your need for care,you may • Misrepresenting eligibility information about you or a request a review of the termination by the California Dependent Department of Managed Health Care(please see • Presenting an invalid prescription or physician order "Department of Managed Health Care Complaints"in • Misusing a Kaiser Permanente ID card(or letting the"Dispute Resolution"section). someone else use it) Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 81 Continuation of Membership coverage effective the date your COBRA coverage ends if all of the following are true: If your membership under this EOC ends,you may be • Your effective date of COBRA coverage was on or eligible to continue Health Plan membership without a after January 1,2003 break in coverage.You may be able to continue Group . You have exhausted the time limit for COBRA coverage under this EOC as described under coverage and that time limit was 18 or 29 months "Continuation of Group Coverage."Also,you may be able to continue membership under an individual plan as • You do not have Medicare described under"Continuation of Coverage under an Individual Plan."If at any time you become entitled to You must request an enrollment application by calling continuation of Group coverage,please examine your Member Services within 60 days of the date of when coverage options carefully before declining this your COBRA coverage ends. coverage.Individual plan premiums and coverage will be different from the premiums and coverage under your Cal-COBRA enrollment and Premiums Group plan. Within 10 days of your request for an enrollment application,we will send you our application,which will include Premium and billing information.You must Continuation of Group Coverage return your completed application within 63 days of the COBRA date of our termination letter or of your membership termination date(whichever date is later). You may be able to continue your coverage under this EOC for a limited time after you would otherwise lose If we approve your enrollment application,we will send eligibility,if required by the federal Consolidated you billing information within 30 days after we receive Omnibus Budget Reconciliation Act("COBRA"). your application.You must pay Full Premiums within 45 COBRA applies to most employees(and most of their days after the date we issue the bill.The first Premium covered family Dependents)of most employers with 20 payment will include coverage from your Cal-COBRA or more employees. effective date through our current billing cycle.You must send us the Premium payment by the due date on If your Group is subject to COBRA and you are eligible the bill to be enrolled in Cal-COBRA. for COBRA coverage,in order to enroll you must submit a COBRA election form to your Group within the After that first payment,your Premium payment for the COBRA election period.Please ask your Group for upcoming coverage month is due on the last day of the details about COBRA coverage,such as how to elect preceding month. The Premiums will not exceed 110 coverage,how much you must pay for coverage,when percent of the applicable Premiums charged to a coverage and Premiums may change,and where to send similarly situated individual under the Group benefit plan your Premium payments. except that Premiums for disabled individuals after 18 months of COBRA coverage will not exceed 150 percent If you enroll in COBRA and exhaust the time limit for instead of 110 percent.Returned checks or insufficient COBRA coverage,you may be able to continue Group funds on electronic payments may be subject to a fee. coverage under state law as described under"Cal- COBRA"in this"Continuation of Group Coverage" If you have selected Ancillary Coverage provided under section. any other program,the Premium for that Ancillary Coverage will be billed together with required Premiums Cal-COBRA for coverage under this EOC.Full Premiums will then If you are eligible for coverage under the California also include Premium for Ancillary Coverage. This Continuation Benefits Replacement Act("Cal- means if you do not pay the Full Premiums owed by the COBRA"),you can continue coverage as described in due date,we may terminate your membership under this this"Cal-COBRA"section if you apply for coverage in EOC and any Ancillary Coverage,as described in the compliance with Cal-COBRA law and pay applicable "Termination for nonpayment of Cal-COBRA Premiums. Premiums"section. Eligibility and effective date of coverage for Cal- Changes to Cal-COBRA coverage and Premiums COBRA after COBRA Your Cal-COBRA coverage is the same as for any If your group is subject to COBRA and your COBRA similarly situated individual under your Group's coverage ends,you may be able to continue Group Agreement,and your Cal-COBRA coverage and Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 82 Premiums will change at the same time that coverage or Kaiser Foundation Health Plan,Inc. Premiums change in your Group's Agreement.Your California Service Center Group's coverage and Premiums will change on the P.O.Box 23127 renewal date of its Agreement(January 1),and may also San Diego,CA 92193-3127 change at other times if your Group's Agreement is amended.Your monthly invoice will reflect the current Termination for nonpayment of Cal-COBRA Premiums Premiums that are due for Cal-COBRA coverage, If you do not pay Full Premiums by the due date,we may including any changes.For example,if your Group terminate your membership as described in this makes a change that affects Premiums retroactively,the "Termination for nonpayment of Cal-COBRA amount we bill you will be adjusted to reflect the Premiums"section.If you intend to terminate your retroactive adjustment in Premiums.Your Group can tell membership,be sure to notify us as described under you whether this EOC is still in effect and give you a "How you may terminate your Cal-COBRA coverage"in current one if this EOC has expired or been amended. this"Cal-COBRA"section,as you will be responsible You can also request one from Member Services. for any Premiums billed to you unless you let us know before the first of the coverage month that you want us to Cal-COBRA open enrollment or termination of another terminate your coverage. health plan If you previously elected Cal-COBRA coverage through Your Premium payment for the upcoming coverage another health plan available through your Group,you month is due on the last day of the preceding month.If may be eligible to enroll in Kaiser Permanente during we do not receive Full Premium payment by the due your Group's annual open enrollment period,or if your date,we will send a notice of nonreceipt of payment to Group terminates its agreement with the health plan you the Subscriber's address of record.You will have a 30- are enrolled in.You will be entitled to Cal-COBRA day grace period to pay the required Premiums before we coverage only for the remainder,if any,of the coverage terminate your Cal-COBRA coverage for nonpayment. period prescribed by Cal-COBRA.Please ask your The notice will state when the grace period begins and Group for information about health plans available to when the memberships of the Subscriber and all you either at open enrollment or if your Group terminates Dependents will terminate if the required Premiums are a health plan's agreement. not paid.Your coverage will continue during this grace period.If we do not receive Full Premium payment by In order for you to switch from another health plan and the end of the grace period,we will mail a termination continue your Cal-COBRA coverage with us,we must notice to the Subscriber's address of record.After receive your enrollment application during your Group's termination of your membership for nonpayment of Cal- open enrollment period,or within 63 days of receiving COBRA Premiums,you are still responsible for paying the Group's termination notice described under"Group all amounts due,including Premiums for the grace responsibilities."To request an application,please call period. Member Services.We will send you our enrollment application and you must return your completed Reinstatement of your membership after termination application before open enrollment ends or within 63 for nonpayment of Cal-COBRA Premiums days of receiving the termination notice described under If we terminate your membership for nonpayment of "Group responsibilities."If we approve your enrollment Premiums,we will permit reinstatement of your application,we will send you billing information within membership three times during any 12-month period if 30 days after we receive your application.You must pay we receive the amounts owed within 15 days of the date the bill within 45 days after the date we issue the bill. of the Termination Notice.We will not reinstate your You must send us the Premium payment by the due date membership if you do not obtain reinstatement of your on the bill to be enrolled in Cal-COBRA. terminated membership within the required 15 days,or if we terminate your membership for nonpayment of How you may terminate your Cal-COBRA coverage Premiums more than three times in a 12-month period. You may terminate your Cal-COBRA coverage by sending written notice,signed by the Subscriber,to the Termination of Cal-COBRA coverage address below.Your membership will terminate at 11:59 Cal-COBRA coverage continues only upon payment of p.m.on the last day of the month in which we receive applicable monthly Premiums to us at the time we your notice.Also,you must include with your notice all specify,and terminates on the earliest of: amounts payable related to your Cal-COBRA coverage, . The date your Group's Agreement with us terminates including Premiums,for the period prior to your (you may still be eligible for Cal-COBRA through termination date. another Group health plan) Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 83 • The date you get Medicare Employment and Reemployment Rights Act • The date your coverage begins under any other group ("USERRA").You must submit a USERRA election health plan that does not contain any exclusion or form to your Group within 60 days after your call to limitation with respect to any pre-existing condition active duty.Please contact your Group to find out how to you may have(or that does contain such an exclusion elect USERRA coverage and how much you must pay or limitation,but it has been satisfied) your Group. • The date that is 36 months after your original Coverage for a Disabling Condition COBRA effective date(under this or any other plan) If you became Totally Disabled while you were a • The date your membership is terminated for Member under your Group's Agreement with us and nonpayment of Premiums as described under while the Subscriber was employed by your Group,and "Termination for nonpayment of Cal-COBRA your Group's Agreement with us terminates and is not Premiums"in this"Continuation of Membership" renewed,we will cover Services for your totally section disabling condition until the earliest of the following events occurs: Note:If the Social Security Administration determined • 12 months have elapsed since your Group's that you were disabled at any time during the first 60 Agreement with us terminated days of COBRA coverage,you must notify your Group within 60 days of receiving the determination from • You are no longer Totally Disabled Social Security.Also,if Social Security issues a final • Your Group's Agreement with us is replaced by determination that you are no longer disabled in the 35th another group health plan without limitation as to the or 36th month of Group continuation coverage,your Cal- disabling condition COBRA coverage will end the later o£ (1)expiration of 36 months after your original COBRA effective date,or Your coverage will be subject to the terms of this EOC, (2)the first day of the first month following 31 days after including Cost Share,but we will not cover Services for Social Security issued its final determination.You must any condition other than your totally disabling condition. notify us within 30 days after you receive Social Security's final determination that you are no longer For Subscribers and adult Dependents,"Totally disabled. Disabled"means that,in the judgment of a Medical Group physician,an illness or injury is expected to result Group responsibilities in death or has lasted or is expected to last for a If your Group's agreement with a health plan is continuous period of at least 12 months,and makes the terminated,your Group is required to provide written person unable to engage in any employment or notice at least 30 days before the termination date to the occupation,even with training,education,and persons whose Cal-COBRA coverage is terminating. experience. This notice must inform Cal-COBRA beneficiaries that they can continue Cal-COBRA coverage by enrolling in For Dependent children,"Totally Disabled"means that, any health benefit plan offered by your Group.It must in the judgment of a Medical Group physician,an illness also include information about benefits,premiums, or injury is expected to result in death or has lasted or is payment instructions,and enrollment forms(including expected to last for a continuous period of at least 12 instructions on how to continue Cal-COBRA coverage months and the illness or injury makes the child unable under the new health plan).Your Group is required to to substantially engage in any of the normal activities of send this information to the person's last known address, children in good health of like age. as provided by the prior health plan.Health Plan is not obligated to provide this information to qualified To request continuation of coverage for your disabling beneficiaries if your Group fails to provide the notice. condition,you must call Member Services within 30 These persons will be entitled to Cal-COBRA coverage days after your Group's Agreement with us terminates. only for the remainder,if any,of the coverage period prescribed by Cal-COBRA. Continuation of Coverage under an USERRA Individual Plan If you are called to active duty in the uniformed services, you may be able to continue your coverage under this If you want to remain a Health Plan member when your EOC for a limited time after you would otherwise lose Group coverage ends,you might be able to enroll in one eligibility,if required by the federal Uniformed Services of our Kaiser Permanente for Individuals and Families Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 84 plans.The premiums and coverage under our individual chart,or you can put them in writing and have that plan coverage are different from those under this EOC. included in your medical chart If you want your individual plan coverage to be effective To learn more about advance directives,including how when your Group coverage ends,you must submit your to obtain forms and instructions,contact the Member application within the special enrollment period for Services office at a Plan Facility.For more information enrolling in an individual plan due to loss of other about advance directives,refer to our website at kp.orQ coverage.Otherwise,you will have to wait until the next or call Member Services. annual open enrollment period. To request an application to enroll directly with us, Amendment of Agreement please go to buykp.or or call Member Services.For information about plans that are available through Your Group's Agreement with us will change Covered California,see"Covered California"below. periodically.If these changes affect this EOC,your Group is required to inform you in accord with Covered California applicable law and your Group's Agreement. U.S.citizens or legal residents of the U.S.can buy health care coverage from Covered California.This is Applications and Statements California's health benefit exchange("the Exchange"). You may apply for help to pay for premiums and You must complete any applications,forms,or copayments but only if you buy coverage through statements that we request in our normal course of Covered California.This financial assistance may be business or as specified in this EOC. available if you meet certain income guidelines.To learn more about coverage that is available through Covered California,visit CoveredCA.com or call Covered Assignment California at 1-800-300-1506(TTY users call 711). You may not assign this EOC or any of the rights, interests,claims for money due,benefits,or obligations hereunder without our prior written consent. Miscellaneous Provisions Attorney and Advocate Fees and Administration of Agreement Expenses We may adopt reasonable policies,procedures,and In any dispute between a Member and Health Plan,the interpretations to promote orderly and efficient Medical Group,or Kaiser Foundation Hospitals,each administration of your Group's Agreement, including this party will bear its own fees and expenses,including EOC. attorneys' fees,advocates' fees,and other expenses. Advance Directives Claims Review Authority The California Health Care Decision Law offers several We are responsible for determining whether you are ways for you to control the kind of health care you will entitled to benefits under this EOC and we have the receive if you become very ill or unconscious,including discretionary authority to review and evaluate claims that the following: arise under this EOC.We conduct this evaluation • A Power of Attorney for Health Care lets you name independently by interpreting the provisions of this EOC. someone to make health care decisions for you when We may use medical experts to help us review claims.If you cannot speak for yourself.It also lets you write coverage under this EOC is subject to the Employee down your own views on life support and other Retirement Income Security Act("ERISA")claims treatments procedure regulation(29 CFR 2560.503-1),then we are a • Individual health care instructions let you express "named claims fiduciary"to review claims under thisEOC. your wishes about receiving life support and other treatment.You can express these wishes to your doctor and have them documented in your medical Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 85 EOC Binding on Members federal law shall bind Members and Health Plan whether or not set forth in this EOC. By electing coverage or accepting benefits under this EOC,all Members legally capable of contracting,and the legal representatives of all Members incapable of Group and Members Not Our Agents contracting,agree to all provisions of this EOC. Neither your Group nor any Member is the agent or representative of Health Plan. ERISA Notices This"ERISA Notices"section applies only if your No Waiver Group's health benefit plan is subject to the Employee Retirement Income Security Act("ERISA").We provide Our failure to enforce any provision of this EOC will not these notices to assist ERISA-covered groups in constitute a waiver of that or any other provision,or complying with ERISA.Coverage for Services described impair our right thereafter to require your strict in these notices is subject to all provisions of this EOC. performance of any provision. Newborns' and Mothers' Health Protection Act Notices Regarding Your Coverage Group health plans and health insurance issuers generally may not,under Federal law,restrict benefits for any Our notices to you will be sent to the most recent address hospital length of stay in connection with childbirth for we have for the Subscriber.The Subscriber is responsible the birthing person or newborn child to less than 48 for notifying us of any change in address. Subscribers hours following a vaginal delivery,or less than 96 hours who move should call Member Services as soon as following a cesarean section.However,Federal law possible to give us their new address.If a Member does generally does not prohibit the birthing person's or not reside with the Subscriber,or needs to have newborn's attending provider,after consulting with the confidential information sent to an address other than the birthing person,from discharging the birthing person or Subscriber's address,they should call Member Services their newborn earlier than 48 hours(or 96 hours as to discuss alternate delivery options. applicable).In any case,plans and issuers may not,under Federal law,require that a provider obtain authorization Note:When we tell your Group about changes to this from the plan or the insurance issuer for prescribing a EOC or provide your Group other information that length of stay not in excess of 48 hours(or 96 hours). affects you,your Group is required to notify the Subscriber within 30 days(or five days if we terminate Women's Health and Cancer Rights Act your Group's Agreement)after receiving the information If you have had or are going to have a mastectomy,you from us.The Subscriber is also responsible for notifying may be entitled to certain benefits under the Women's Group of any change in contact information. Health and Cancer Rights Act.For individuals receiving mastectomy-related benefits,coverage will be provided in a manner determined in consultation with the Overpayment Recovery attending physician and the patient,for all stages of reconstruction of the breast on which the mastectomy We may recover any overpayment we make for Services was performed,surgery and reconstruction of the other from anyone who receives such an overpayment or from breast to produce a symmetrical appearance,prostheses, any person or organization obligated to pay for the and treatment of physical complications of the Services. mastectomy,including lymphedemas.These benefits will be provided subject to the same Cost Share applicable to Privacy Practices other medical and surgical benefits provided under this plan. Kaiser Permanente will protect the privacy of your protected health information. We also Governing Law require contracting providers to protect your Except as preempted by federal law,this EOC will be protected health information. Your protected governed in accord with California law and any health information is individually-identifiable provision that is required to be in this EOC by state or information(oral, written, or electronic) about your health, health care services you receive, or Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 86 payment for your health care. You may call Member Services. You can also End the generally see and receive copies of your notice at a Plan Facility or on our website at protected health information, correct or update ky.org. your protected health information, and ask us for an accounting of certain disclosures of your Public Policy Participation protected health information. The Kaiser Foundation Health Plan,Inc.,Board of You can request delivery of confidential Directors establishes public policy for Health Plan.A list communication to a location other than your of the Board of Directors is available on our website at about.kp.om or from Member Services.If you would usual address or by a means of delivery other like to provide input about Health Plan public policy for than the usual means. You may request consideration by the Board,please send written confidential communication by completing a comments to: confidential communication request form, which is available on kp•om under"Request Kaiser Foundation Health Plan,Inc. for confidential communications forms."Your Office of Board and Corporate Governance Services One Kaiser Plaza, 19th Floor request for confidential communication will be Oakland,CA 94612 valid until you submit a revocation or a new request for confidential communication. If you have questions,please call Member Services. Helpful Information We may use or disclose your protected health How to Obtain this EOC in Other information for treatment, health research, Formats payment, and health care operations purposes, such as measuring the quality of Services. We You can request a copy of this EOC in an alternate are sometimes required by law to give format(Braille,audio,electronic text file,or large print) by calling Member Services. protected health information to others, such as government agencies or in judicial actions. In addition,protected health information is shared Provider Directory with your Group only with your authorization Refer to the Provider Directory for your Home Region or as otherwise permitted by law. for the following information: • A list of Plan Physicians We will not use or disclose your protected The location of Plan Facilities and the types of health information for any other purpose covered Services that are available from each facility without your(or your representative's) written Hours of operation authorization, except as described in our Notice of Privacy Practices (see below). Giving us • Appointments and advice phone numbers authorization is at your discretion. This directory is available on our website at kp.org.To obtain a printed copy,call Member Services.The This is only a brief summary of some of our directory is updated periodically.The availability of Plan key privacy practices. OUR NOTICE OF Physicians and Plan Facilities may change.If you have PRIVACYPRACTICES, WHICH PROVIDES questions,please call Member Services. ADDITIONAL INFORMATION ABOUT OUR PRIVACY PRACTICES AND YOUR Online Tools and Resources RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION, IS AVAILABLE Here are some tools and resources available on our AND WILL BE FURNISHED TO YOU website at kp.org: UPON REQUEST. To request a copy, please • How to use our Services and make appointments Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 87 • Tools you can use to email your doctor's office,view 24 hours a day,seven days a week(except test results,refill prescriptions,and schedule routine closed holidays) appointments Visit Member Services office at a Plan Facility(for • Health education resources addresses,refer to our Provider Directory or • Preventive care guidelines call Member Services) • Member rights and responsibilities Write Member Services office at a Plan Facility(for addresses,refer to our Provider Directory or You can also access tools and resources using the KP call Member Services) app on your smartphone or other mobile device. Website kp.org Estimates, bills, and statements Document Delivery Preferences For the following concerns,please call us at the number Many Health Plan documents are available below: electronically,such as bills,statements,and notices.If • If you have questions about a bill you prefer to get documents in electronic format,go to • To find out how much you have paid toward your kp•or,a or call Member Services.You can change Plan Deductible(if applicable)or Plan Out-of-Pocket delivery preference at any time. To get a copy of a specific Heath Plan document in printed format,call Maximum Member Services. • To get an estimate of Charges for Services that are subject to the Plan Deductible(if applicable) How to Reach Us Call 1-800-464-4000(TTY users call 711) Appointments 24 hours a day,seven days a week(except closed holidays) If you need to make an appointment,please call us or visit our website: Website kp.ors!/memberestimates Call The appointment phone number at a Plan Away from Home Travel Line Facility(for phone numbers,refer to our If you have questions about your coverage when you are Provider Directory or call Member Services) away from home: Website kp.or2 for routine(non-urgent)appointments Call 1-951-268-3900 with your personal Plan Physician or another Primary Care Physician 24 hours a day,seven days a week(except closed holidays) Not sure what kind of care you need? Website kp.orp-/travel If you need advice on whether to get medical care,or how and when to get care,we have licensed health care Authorization for Post-Stabilization Care professionals available to assist you by phone 24 hours a To request prior authorization for Post-Stabilization Care day,seven days a week: as described under"Emergency Services"in the Call The appointment or advice phone number at a "Emergency Services and Urgent Care"section: Plan Facility(for phone numbers,refer to our Call 1-800-225-8883 or the notification phone Provider Directory or call Member Services) number on your Kaiser Permanente ID card Member Services (TTY users call 711) If you have questions or concerns about your coverage, 24 hours a day,seven days a week how to obtain Services,or the facilities where you can receive care,you can reach us in the following ways: Help with claim forms for Emergency Services, Post-Stabilization Care, Out-of-Area Urgent Call 1-800-464-4000(English and more than 150 Care, and emergency ambulance Services languages using interpreter services) If you need a claim form to request payment or 1-800-788-0616(Spanish) reimbursement for Services described in the"Emergency 1-800-757-7585(Chinese dialects) Services and Urgent Care"section or under"Ambulance TTY users call 711 Services"in the`Benefits"section,or if you need help Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 88 completing the form,you can reach us by calling or by • You are responsible for paying your Cost Share for visiting our website. covered Services(refer to the"Cost Share Summary" Call 1-800-464-4000(TTY users call 711) section) 24 hours a day,seven days a week(except • If you receive Emergency Services,Post-Stabilization closed holidays) Care,or Out-of-Area Urgent Care from a Non—Plan Provider,or if you receive emergency ambulance Website kmorg Services,you must pay the provider and file a claim for reimbursement unless the provider agrees to bill Submitting claims for Emergency Services, us(refer to"Payment and Reimbursement"in the Post-Stabilization Care, Out-of-Area Urgent "Emergency Services and Urgent Care"section) Care, and emergency ambulance Services . If you receive Services from Non—Plan Providers that If you need to submit a completed claim form for we did not authorize(other than Emergency Services, Services described in the"Emergency Services and Post-Stabilization Care,Out-of-Area Urgent Care,or Urgent Care"section or under"Ambulance Services"in emergency ambulance Services)and you want us to the"Benefits"section,or if you need to submit other pay for the care,you must submit a grievance(refer to information that we request about your claim,send it to "Grievances"in the"Dispute Resolution"section) our Claims Department: • If you have coverage with another plan or with Write Kaiser Permanente Medicare,we will coordinate benefits with the other Claims Administration-NCAL coverage(refer to"Coordination of Benefits"in the P.O.Box 12923 "Exclusions,Limitations,Coordination of Benefits, Oakland,CA 94604-2923 and Reductions"section) • In some situations you or another party may be Text telephone access ("TTY") responsible for reimbursing us for covered Services If you use a text telephone device("TTY,"also known as (refer to"Reductions"in the"Exclusions, "TDD")to communicate by phone,you can use the Limitations,Coordination of Benefits,and California Relay Service by calling 711. Reductions"section) Interpreter services • You must pay the full price for noncovered Services If you need interpreter services when you call us or when you get covered Services,please let us know.Interpreter services,including sign language,are available during all business hours at no cost to you.For more information on the interpreter services we offer,please call Member Services. Payment Responsibility This"Payment Responsibility"section briefly explains who is responsible for payments related to the health care coverage described in this EOC.Payment responsibility is more fully described in other sections of the EOC as described below: • Your Group is responsible for paying Premiums, except that you are responsible for paying Premiums if you have COBRA or Cal-COBRA(refer to "Premiums"in the"Premiums,Eligibility,and Enrollment"section and"COBRA"and "Cal-COBRA"under"Continuation of Group Coverage"in the"Continuation of Membership" section) • Your Group may require you to contribute to Premiums(your Group will tell you the amount and how to pay) Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:34 EOC'#5 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 89 FM EEMMEEE E F1 anguage Assistance Chinese:1,MA7)c, V)c24/1,Hi17p7 f4t%6 Services Fhf A AA"A M,It 4_40 2r,M 7�4 At-RVIrn*h AMA 7 7c, t7�24 English: Language assistance /1,Fk�Jz� ;CPLrfT'W'�-p�1-800-757-7585 rU**P�4 (fi is available at no cost to you, 24 hours a day, 7 days a week. �_,�A ci A.)&L51y fly Le L,,! L,,,L,:,;I L 3&I �:�cS�&'�s�`�L,y L-'!�jl�j a��S�I.s,o�j�.i c� You can request interpreter 9 .. UL services materials translated 24 —' 9� "�ly,��y J� cSlA,9,vCLLu.ul Aa)dXsA ,3,7 into your language, or in e-)L-,!> (TTY) ICU yam --Lz 1-800-464-4000 .�,.� alternative formats. You can �lz 711 also request auxiliary aids and Hindi:fWT f*R 977 47� T ,ffq 47 24 ft, Tm7*m-�7f rfkff ti 31m7T-� *t# r* devices at our facilities. �r f�17,f<T f *ffm-�r 4�fl 141 N t;ft r Just call us at 1-800-464-4000, *"'7'-qT �r ft�T u TT 7Tc tI 3M7 7ft 4 RT4**i 24 hours a day, 7 days a week *f47*3T;jfttT-171 9T�tI z7*zff (closed .holiday s) TTY users 1-800-464-4000 7T,fk,7*24#:�, 9-97 47 M�ff fk-'�r ( -q-0 fkff 4-,T TTTr t)Tlff T:�I TTY call 711. 7117T Tf;Fr 77ti ;et ;oaUl L� hh o A s a I a,� `I�lA�:Arabic Hmong:Muaj kec pab txhais lus pub dawb rau koj, � � ' . .�s=� ass► .� 91 Jk17�Us a��91 all a�y,11 a o v .GtSAL,� �I�>,I 24 teev ib hnub twg,7 hnub ib lim tiam twg.Koj thov l� Lsslyo s j�19 aal al ul�cL w L dl,st;< ,�yl tau cov kev pab txhais lus,muab cov ntaub ntawv nQUI_)I-)A L,6 1-800-464-4000,j P L,6 1-4 cJL—'1I ss• txhais ua koj hom lus,los yog ua lwm hom.Koj kuj thov tau lwm yam kev pab thiab khoom siv hauv peb tej (711)��I FYI tsev hauj lwm.Tsuas hu rau 1-800-464-4000,24 teev ib hnub twg,7 hnub ib lim tiam twg(cov hnub caiv kaw). Armenian: Qhq 4wpnil L wbq&wp ogtinLlalnLh Cov neeg siv TTY hu 711. tnpwLlwilptlhL thgo hwpgnLt[' opp 24 duit[, w w 7 0 `7hnt w n h whwti h Japanese: ��Z d�, 2 F laLt p p k p it p ul Q L puibuignp lawpgifLuhAi hwnwlnLlalndihtip,Qhp Lhgtjntj lawpgt[whqwb llwt[wj1pbuipwhpwl�1i Miw�wt�nq ulwtnpwutntjwh hlnLlahp:'TnLp hwh Z 6Z: l Z lltupnrl hp jubilphLoduihi ui4 oghnLlalnthhhp h -t "Nl Ot tz 6f l To :8'- 6-- 1-800-464-4000 uwpphp L1hp hwuLnwuinLlalnLhbhpnttl: - 'Rwpgwulhu gwtigwhwphp L[hq 1-800-464-4000 hhnw nuwhwt[w n o 24 dwd, w w 7 op TTY 1 — 711 6� a <�� o � p �� pLt 2 F lap (innb ophpbb*u14 k):TTY-hg ogtngn1jtihpU ulhtnp k qtu igwhwphli 711: Khmer: G 2 UJn-I€n iI iI n c�n[G[�w Iis n I� PUS Navajo:Doo bik'6 asinilaag66 saad bee ata'hane'bee 24 [f31bnbULDIG 7[t;Mb9PUf€i.SgIM-1 akae'elyeednich'i' gq'at'&,t'aaalahj}'jiWod66 Finw GIcif€ISI€ISitHnf5n MUII inftni[d n im sun tl'6e'go aad66 tsosts'iji gq'at'6.Ata'hane'yidiikil, naaltsoos t'aa Dinh bizaad bee bik'i' ashchiigo,6i IffS IS�G'flail€iSl 62i fSG'fli €IS Iia, [��n`1 doodago hane'bee didiits'iiligii yidiikil.Hane'bee H n n w G[€d hJ 2 fS n i Il.fln2'1 i G S PUS 21 n bik'i' di'diitiiligii d66 bee hane' didiits'iiligii €IS f3 UfJf!n-nI11219—nIt)IUr RU,t)Nhal-WI 1 ct J d bina'idilkidgo yidiikil.Koji hodiilnih 1-800-464-4000, f ii12[ii�SiiS�lfan[PUSS -nI91nJ2 1-8004644000 t'aa alahj}',jtigo d66 tl'6e'go aad66 tsosts'iji gq'at'6. M 2 24 Ith O M I U PUS[G 7 [d Q O f3 PUS€V P tS (Dahodilzing6ne' doo nida'anish dago 6i da'deelkaal). (fS w[t!U ftfl ) H n V TTY IW[[U 2 711`1 TTY chodayool'inigii koj}dahalne' 711. Korean: $°� "�R' A)7,"1 1 A]'V°) (11(�-71 ] Punjabi: trV f-7t B-JFH cam, ftl?5 i�24 W�, TU3 is AIHI TRV- 01- °}t' T 'OJ�) gr+. -1°}i 7ft�_ ;e�> aUlt F�ft Q 14T8 El u4I �fta �&}j w 101 L1 -71ii rll-�Jl zVz� , > zsfa o All PI 4R z $-1500 IU 'OIJ 6=LI 4 Li al A A '4F� c�Fi�, r�T fdF7 44 fed H'Ll3 1-800-464-4000 °(o�6rOd SrT). ErF fjaia Tpt 1-800-464-4000 �, fET i�24 W , T� TTY 44,71It1 711. i� 7 fe 5c ( T;�.Trt f�5c 14 UtT 4) -�5 awl TTY Laotian: 2T @4 t T Td25-,�-rg 711 ` 75 gdTl cc7i6°w, c)zt7laC) 24 �OFa)g, 7 61)c�3�)tncJ. t!)�)I) Russian:Mbi 6ecrmaTHo o6ecneHt4saem Bac ycJryramH q�to��, 2tnccucanv rlepesoAa 24 Haca B cyTKH,7 AMA B HeAeJHo.Bbi moxcew Z9wc_uwJ )Z�20gt i�w' 1f7 I)SUCCUU01). BOCHOJIb3OBaTbCA 110MOI11b10 yCTHOTO HepeBOALIHKa, cc:Dv qutnaI) 3anpOCHTb HepeBOA marepHaiiOB Ha CBOH A31E.IK HJIH c 3anpOCHTb HX B OAHOM H3 a IbTepxaTHBHbIX CpopMaTOB. C7�qqc�C)JZvT�7JL)�9��`�e9`�1ile79�CeS��C7.lil�`�00cS0�Ctn MbI TwoRe moweM rIOMOgb BaM C BcriomoraTeJIbHbIMH �n wonc&)tn 1-800-464-4000, nt-noc) 24 `ole`J)q, 7 CpeACTBaMH H aJIbTepHaTHBHbIMH I opMaramH.rIpocTO O7Jc»')tnO (tsc��I�t�ric i°��). c�?1� �€I TTY Ftn 1-103BoHHTe Ham no Tenet oHy 1-800-464-4000,KoTopbH3 711. AocTyneH 24 Haca B cyTKH,7 AHeA B HeAeino(Kpome ripa3AHMHUX AHeI3).r1OJIb3OBaTeJIH JH HHH TTY moryT Mien:Mbenc nzoih liouh wang-henh tengx nzie faan 3BOHHTb no Homepy 711. waac bun muangx maiv zuqc cuotv zinh nyaanh meih, yietc hnoi mbenc maaih 24 norm ziangh hoc,yietc Spanish: Tenemos disponible asistencia en su idioma norm liv baaiz mbenc maaih 7 hnoi.Meih se haih tov sin ningun costo para usted 24 horas al dia,7 dias a la heuc tengx lorx faan waac mienh tengx faan waac bun semana.Puede solicitar los servicios de un int6rprete, muangx,dorh nyungc horngh jaa-sic mingh faan benx que los materiales se traduzcan a su idioma o en meih nyei waac,a'fai liouh ginv longc benx haaix hoc formatos alternativos.Tambi6n puede solicitar recursos para discapacidades en nuestros centros de atenci6n. sou-guv daan yaac dugv. Meih tort haih tov longc Solo llame al 1-800-788-0616,24 horas al dia,7 dias a benx wuotc ginc jaa-dorngx tengx aengx caux jaa-sic la semana(excepto los dias festivos).Los usuarios de nzie bun yiem njiec zorc goux baengc zingh gorn TTY,deben llamar al 711. zangc. Kungx douc waac mingh lorx taux yie mbuo yiem njiec naaiv 1-800-464-4000,yietc hnoi mbenc Tagalog:May magagamit na tulong sa wika nang wala maaih 24 norm ziangh hoc,yietc norm liv baaiz mbenc kang babayaran,24 na oras bawat araw,7 araw bawat maaih 7 hnoi.(hnoi-gec se guon gorn zangc oc). linggo. Maaari kang humingi ng mga serbisyo ng TTY nyei mienh nor douc waac lorx 711. tagasalin sa wika,mga babasahin na isinalin sa iyong wika o sa raga alternatibong format.Maaari ka ring humiling ng raga karagdagang tulong at device sa aming raga pasilidad.Tawagan lamang kami sa 1-800-464-4000,24 na oras bawat araw,7 araw bawat linggo(sarado sa raga pista opisyal).Ang mga gumagamit ng TTY ay maaaring tumawag sa 711. Thai: 24 4-)IN4 7 ijolz3'vsn-i5�-i3j 661�s76e7flsf 1511�Ydt1 ll�1RJe7Sk1€L6 MgAU51JLLIJIJd)Ul1 hl€Llc�'l7J"15€1RJoo�l f15€1.66Ls�ddhl5e�S8J e�Rf"J LI LY�f�e��G1Y 1k1L6€Iv5f1"15 6Y�k1Jl7J2tJfl6l9e1�e1R1e7S151 601FI6V-M-1 VW- l 1-800-464-4000 viaom 24 4ilw 7 iu�io i1�I�vi(FJtI!JLl JLlVftl(lSlRffllS) '$ff TTY lsklwi 711 Ukrainian:IIocnyrH nepexnaAaua HaAaloTbcsl 6e3KOHITOBHO,I[LnOA06OBO,7 AHIB Ha TH)KAeHb.BH Mo)KeTe 3po6HTH 3anHT Ha nOcnyrH yCHoro nepeKnaAana,oTpHMaHHSI MaTepianiB y IlepeK.naAi MOBOIO,AKOIO BOJIOAIew,a60 B anbTepHaTHBHHX ( opMaTaX.TaKO)K BH MO)KeTe 3po6HTH 3anHT Ha oTpHMaHHsi AorloMi)KHHx 3aco6iB i npHCTPOYB y 3aKnaAax Haiuoi Mepe)Ki KoMnaxiH.IIpoCTo 3aTene( oHyfte HaM 3a HOMepOM 1-800-4644000. MH npauloeMo uinoAo6OBO,7 AHiB Ha THxcgeHE, (KpiM CB31TKOB14x Axis).HoMep Anse KopHCTysaHi TeneTaMia:711. Vietnamese:Dich vu th6ng dich duac dung cap mien phi cho quy vi 24 gi&moi ngay,7 ngay trong tuan.Quy vi c6 the yeu cau dich vu th6ng dich,tai lieu phien dich ra ng6n ngiz ctila quy vi hoac tai lieu bang nhieu hinh third khac.Quy vi dung co the yeu cau cac phuong tien trg gilip va thiet bi bo tra tai cac ca so ciia chlmg t6i. Quy vi chi can goi cho chimg t6i tai so 1-800-464-4000, 24 gia moi ngay,7 ngay trong tuan(trir cac ngay le). Nguai dung TTY xin goi 711. Nondiscrimination Notice Discrimination is against the law. Kaiser Permanente follows State and Federal civil rights laws. Kaiser Permanente does not unlawfully discriminate, exclude people, or treat them differently because of age, race, ethnic group identification, color, national origin, cultural background, ancestry, religion, sex, gender, gender identity, gender expression, sexual orientation, marital status, physical or mental disability, medical condition, source of payment, genetic information, citizenship, primary language, or immigration status. Kaiser Permanente provides the following services: • No-cost aids and services to people with disabilities to help them communicate better with us, such as: ♦ Qualified sign language interpreters ♦ Written information in other formats (braille, large print, audio, accessible electronic formats, and other formats) • No-cost language services to people whose primary language is not English, such as: ♦ Qualified interpreters ♦ Information written in other languages If you need these services, call our Member Service Contact Center at 1-800-464-4000 (TTY 711), 24 hours a day, 7 days a week(except closed holidays). If you cannot hear or speak well, please call 711. Upon request, this document can be made available to you in braille, large print, audiocassette, or electronic form. To obtain a copy in one of these alternative formats, or another format, call our Member Service Contact Center and ask for the format you need. How to file a grievance with Kaiser Permanente You can file a discrimination grievance with Kaiser Permanente if you believe we have failed to provide these services or unlawfully discriminated in another way. Please refer to your Evidence of Coverage or Certificate of Insurance for details. You may also speak with a Member Services representative about the options that apply to you. Please call Member Services if you need help filing a grievance. You may submit a discrimination grievance in the following ways: • By phone: Call Member Services at 1 800-464-4000 (TTY 711) 24 hours a day, 7 days a week(except closed holidays) • By mail: Call us at 1 800-464-4000 (TTY 711) and ask to have a form sent to you • In person: Fill out a Complaint or Benefit Claim/Request form at a member services office located at a Plan Facility(go to your provider directory at kp.org/facilities for addresses) • Online: Use the online form on our website at kp.org You may also contact the Kaiser Permanente Civil Rights Coordinators directly at the addresses below: Attn: Kaiser Permanente Civil Rights Coordinator Member Relations Grievance Operations P.O. Box 939001 San Diego CA 92193 How to file a grievance with the California Department of Health Care Services Office of Civil Rights (For Medi-Cal Beneficiaries Only) You can also file a civil rights complaint with the California Department of Health Care Services Office of Civil Rights in writing,by phone or by email: • By phone: Call DHCS Office of Civil Rights at 916-440-7370 (TTY 711) • By mail: Fill out a complaint form or send a letter to: Deputy Director, Office of Civil Rights Department of Health Care Services Office of Civil Rights P.O. Box 997413, MS 0009 Sacramento, CA 95899-7413 Complaint forms are available at: http://www.dhcs.ca.gov/Pages/Language_Access.aspx • Online: Send an email to CivilRights@dhcs.ca.gov How to file a grievance with the U.S. Department of Health and Human Services Office of Civil Rights You can file a discrimination complaint with the U.S. Department of Health and Human Services Office for Civil Rights. You can file your complaint in writing,by phone, or online: • By phone: Call 1-800-368-1019 (TTY 711 or 1-800-537-7697) • By mail: Fill out a complaint form or send a letter to: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 Complaint forms are available at: http:www.hhs.gov/ocr/office/file/index.html • Online: Visit the Office of Civil Rights Complaint Portal at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsL Aviso de no discriminacion La discriminacion es ilegal. Kaiser Permanente cumple con las leyes de los derechos civiles federales y estatales. Kaiser Permanente no discrimina ilicitamente, excluye ni trata a ninguna persona de forma distinta por motivos de edad, raza, identificacion de grupo etnico, color,pais de origen, antecedentes culturales, ascendencia, religion, sexo, genero, identidad de genero, expresion de genero, orientacion sexual, estado civil, discapacidad fisica o mental, condicion medica, fuente de pago, informacion genetica, ciudadania, lengua materna o estado migratorio. Kaiser Permanente ofrece los siguientes servicios: • Ayuda y servicios sin costo a personas con discapacidades para que puedan comunicarse mejor con nosotros, como to siguiente: ♦ interpretes calificados de lenguaje de sefias, ♦ informacion escrita en otros formatos (braille, impresion en letra grande, audio, formatos electronicos accesibles y otros formatos). • Servicios de idiomas sin costo a las personas cuya lengua materna no es el ingles, como: ♦ interpretes calificados, ♦ informacion escrita en otros idiomas. Si necesita nuestros servicios, llame a nuestra Central de Llamadas de Servicio a los Miembros al 1-800-464-4000 (TTY 711) las 24 horas del dia, los 7 dias de la semana(excepto los dias festivos). Si tiene deficiencias auditivas o del habla, llame al 711. Este documento estara disponible en braille, letra grande, casete de audio o en formato electronico a solicitud. Para obtener una copia en uno de estos formatos alternativos o en otro formato, llame a nuestra Central de Llamadas de Servicio a los Miembros y solicite el formato que necesita. C6mo presentar una queja ante Kaiser Permanente Usted puede presentar una queja por discriminacion ante Kaiser Permanente si siente que no le hemos ofrecido estos servicios o to hemos discriminado ilicitamente de otra forma. Consulte su Evidencia de Cobertura (Evidence of Coverage) o Certificado de Seguro (Certificate of Insurance) para obtener mas informacion. Tambien puede hablar con un representante de Servicio a los Miembros sobre las opciones que se apliquen a su caso. Llame a Servicio a los Miembros si necesita ayuda para presentar una queja. Puede presentar una queja por discriminacion de las siguientes maneras: • Por telkfono: llame a Servicio a los Miembros al 1 800-464-4000 (TTY 711), las 24 horas del dia, los 7 dias de la semana(excepto los dias festivos). • Por correo postal: llamenos al 1 800-464-4000 (TTY 711)y pida que se le envie un formulario. • En persona: Ilene un formulario de Queja o reclamaci6n/solicitud de beneficios en una oficina de Servicio a los Miembros ubicada en un centro del plan(consulte su directorio de proveedores en kp.org/facilities [cambie el idioma a espanol] para obtener las direcciones). • En linea: utilice el formulario en linea en nuestro sitio web en kp.org/espanol. Tambien puede comunicarse directamente con el coordinador de derechos civiles(Civil Rights Coordinator)de Kaiser Permanente a la siguiente direcci6n: Attn: Kaiser Permanente Civil Rights Coordinator Member Relations Grievance Operations P.O. Box 939001 San Diego CA 92193 C6mo presentar una queja ante la Oficina de Derechos Civiles del Departamento de Servicios de Atenci6n Medica de California (Solo para beneficiarios de Medi-Cal) Tambien puede presentar una queja sobre derechos civiles ante la Oficina de Derechos Civiles (Office of Civil Rights) del Departamento de Servicios de Atenci6n Medica de California (California Department of Health Care Services)por escrito,por telefono o por correo electr6nico: • Por telefono: llame a la Oficina de Derechos Civiles del Departamento de Servicios de Atenci6n Medica(Department of Health Care Services,DHCS)al 916-440-7370(TTY 711). • Por correo postal: Ilene un formulario de queja o envie una carta a: Deputy Director, Office of Civil Rights Department of Health Care Services Office of Civil Rights P.O. Box 997413, MS 0009 Sacramento, CA 95899-7413 Los formularios de queja estan disponibles en: http://www.dhcs.ca.gov/Pages/Language_Access.aspx (en ingles). • En linea: envie un correo electr6nico a CivilRights@dhcs.ca.gov. C6mo presentar una queja ante la Oficina de Derechos Civiles del Departamento de Salud y Servicios Humanos de los EE. UU. Puede presentar una queja por discriminaci6n ante la Oficina de Derechos Civiles del Departamento de Salud y Servicios Humanos de EE. UU. (U.S. Department of Health and Human Services). Puede presentar su queja por escrito,por telefono o en linea: • Por telefono: flame al 1-800-368-1019 (TTY 711 o al 1-800-537-7697). • Por correo postal: Ilene un formulario de queja o envie una carta a: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 Los formularios de quejas estan disponibles en http://www.hhs.gov/ocr/office/file/index.html (en ingles). • En linea: visite el Portal de quejas de la Oficina de Derechos Civiles en: https:Hocrportal.hhs.gov/ocr/portal/lobby.jsf(en ingles). LE , j ( jTT ° KaiserPermanenteJ'f`f �yNl� �'J� > ° Kaiser Permanente Q 7 j - rFTW9 n JS f ,NP. TL Wi g , Ift T 9 Kaiser PermanentetHt-- f&A- : • Q f-9-f-AAaaa Qf-9LIaTA Ir ape r=—1 � t�Z ' A� T Qul-800-464-4000 (TTY 711) u a77 ' 15)Q24/jA4 (�nfl Q ap Q Q ' A' 1 at711 ° JLA-mv )[ J -AM)IMC7 JNX tfcljnKaiser PermanentelQV jj:,:�Cp7Kaiser Permanente R-,—*RWkH)j IND (Evidence of Coverage) A (q,yMR)J)) (Certificate of Insurance) W,,J A ' ° Z-ftoTU fu7 f A 9�A'-' tft p p�Affl-A R�, fA-rfi ° ZA • RIBIB : JTMptl 800-464-4000 (TTY 711) N 7) t)�24/]\H4 (R-I fP!El ,g, • h��y5 : T pt��l 800-464-44\000 (Ty{T�Y 711)g h�� a{ yy ,err fx ryFya T�; q� • I%4��" 'IJ--��I\��.p�"�-� I ASz�L�I-I'7 B�/J�� /��i� J�W F��a/T p�� kp.org/facilities��i��;��J(„� ��,�j;��j�th��) L,,R,t@A4 @Kaiser PermanenteP�)ri-S y q �ttiiL T : Attn: Kaiser Permanente Civil Rights Coordinator Member Relations Grievance Operations P.O. Box 939001 San Diego CA 92193 (%FPMedi-Cal@ `,k) @-LEA no o R)Vva nffi� �a • !R@ TT ZRpt916-440-7370 (TTY 711) (DHCS) Deputy Director, Office of Civil Rights Department of Health Care Services Office of Civil Rights P.O. Box 997413, MS 0009 Sacramento, CA 95899-7413 L%r@ �MM--�-http://www.dhcs.ca.gov/Pages/Language_Access.aspxgA@1RVtK� • : 4,;'�-@ � �@-,�FCivilRights@dhcs.ca.gov �G��I JT��Y`liJ��.�/•I/•��J7J A�� T/JT/L`��WI��I��X R� � �['`��.c%.L.�LW � �Q��G��W�SZ • 115 IT4A&1-800-368-1019 (TTY 711�1-800-537-7697) U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 http:www.hhs.gov/ocr/office/file/index.htmlgRT4��p�t-,'- https://ocrportal.hhs.gov/ocr/portal/lobby.j sf Thong Bao Khong Phan Biet floi X6, Phan biet doi xu la trai v&i phap luat. Kaiser Permanente tuan thu cac luat dan quyen cua Tieu Bang va Lien Bang. Kaiser Permanente khong phan biet doi xu trai phap luat, loai trir hay doi xir khac biet voi nglrori nao do vi ly do tuoi tac, chang toc, nhan dang nhom sac toc, mau da, nguon goc quoc gia, nen tang van hoa, to tien, ton giao, gioi tinh, nhan dang gibi tinh, cach the hien gioi tinh, khuynh huong gioi tinh, tinh trang hon nhan, tinh trang khuyet tat ve the chat hoac tinh than, benh trang, nguon thanh town, thong tin di truyen, quyen cong dan, ngon ngir me de hoac tinh trang nhap cu. Kaiser Permanente cung cap cac dich vu sau: • Phuong tien ho trq va dich vu mien phi cho nguoi khuyet tat de giup ho giao tiep hieu qua hon voi chang toi, chang han nhu: ♦ Thong dich vien ngon ngir ky hieu du trinh do ♦ Thong tin bang van ban theo cac dinh dang khac (cha not braille, ban in kho chic l&n, am thanh, dinh dang dien Ur de truy cap va cac dinh dang khac) • Dich vu ngon ngir mien phi cho nhfmg nguai co ngon ngir chinh khong phai la tieng Anh, chang han nhu: ♦ Thong dich vien du trinh do ♦ Thong tin dugc trinh bay bang cac ngon nga khac Neu quy vi can nhimg dich vu nay, xin goi den Trung Tam Lien Lac ban Dich Vu Hoi Vien cua chang toi theo so 1-800-464-4000 (TTY 711), 24 gi&trong ngay, 7 ngay trong tuan(dong cua ngay le). Neu quy vi khong the not hay nghe ro,vui long goi 711 . Theo yeu cau, tai lieu nay co the dugc cung cap cho quy vi du6i dang chic not braille,ban in kho chic lon, bang thu am hay dang dien td. De lay mot ban sao theo mot trong nhftg dinh dang thay the nay hay dinh dang khac, xin goi den Trung Tam Lien Lac ban Dich Vu Hoi Vien cua chang toi va yeu cau dinh dang ma quy vi can. Cach de trinh phan nan v6'i Kaiser Permanente Quy vi co the de trinh phan nan ve phan biet doi xir voi Kaiser Permanente neu quy vi tin rang chang toi da khong cung cap nhung dich vu nay hay phan biet doi xir trai phap luat theo cach khac. Vui long tham khao Chung Tie Bao Hiem (Evidence of Coverage) hay Chung Nhan Bdo Hiem (Certificate of Insurance) cua quy vi de biet them chi tiet. Quy vi cung co the not chuyen voi nhan vien ban Dich Vu Hoi Vien ve nhirng lira chon ap dung cho quy vi. Vui long goi den ban Dich Vu Hoi Vien neu quy vi can dugc trq giiip de de trinh phan nan. Quy vi co the de trinh phan nan ve phan biet doi Vr bang cac cach sau day: • Qua dien thoah Goi den ban Dich Vu Hoi Vien theo so 1-800-464-4000 (TTY 711) 24 gi6 trong ngay, 7 ngay trong tuan(dong cua ngay le) • Qua thu tin: Goi chang toi then so 1-800-464-4000 (TTY 711)va yeu cau gui mau don cho quy vi • Trurc tiep: Hoan tat mau don Than Phien hay Yeu Cau Thanh Toan/Yeu Cau Quyen Lqi tai van ph6ng dich vu hoi vien o mot Ca Sa Thu6c Chuong Trinh (truy cap danh muc nha cung cap cua quy vi tai kp.org/facilities de biet dia chi) • Truc tuyen: Sfr dung mau don true tuyen tren trang mang cua chfing t6i tai kp.org Quy vi cung co the lien he trtrc tiep voi Dieu Ph6i Vien Dan Quyen cua Kaiser Permanente theo dia chi duoi clay: Attn: Kaiser Permanente Civil Rights Coordinator Member Relations Grievance Operations P.O. Box 939001 San Diego CA 92193 Cach de" trinh phan nan voi Van Phong Dan Quyen Ban Dich Vu Y Te California (Danh Rieng Cho Ngzr6z Thu Hurting Medi-Cal) Quy vi cung c6 the d6 trinh than phien ve dan quyen voi Van Phong Dan Quyen Ban Dich Vu Y Te California bang van ban, qua dien thoai hay qua email: • Qua dien thoai: Goi den Van Phong Dan Quyen Ban Dich Vu Y Te (Department of Health Care Services, DHCS)theo so 916-440-7370 (TTY 711) • Qua thu tin: Dien mau don than phien va hay gfri thu den: Deputy Director, Office of Civil Rights Department of Health Care Services Office of Civil Rights P.O. Box 997413, MS 0009 Sacramento, CA 95899-7413 Mau don than phien hien c6 tai: http://www.dhcs.ca.gov/Pages/Language_Access.aspx • Trurc tuyen: Gfri email den CivilRights@dhcs.ca.gov Cach de trinh phan nan v61 Van Phong Dan Quyen cua Bo Y Te va Dich Vu Nhan Sinh Hoa Ky. Quy vi cung c6 quyen de trinh than phien ve phan biet d6i xfr voi Van Phong Dan Quyen cua Bo Y Te va Dich Vu Nhan Sinh Hoa Ky. Quy vi c6 the de trinh than phien bang van ban, qua dien thoai hoac truc tuyen: • Qua dien thoai: Goi 1-800-368-1019 (TTY 711 hay 1-800-537-7697) • Qua thu tin: Dien mau don than phien va hay gui thu den: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 Mau don than phien hien c6 tai http:www.hhs.gov/ocr/office/file/index.html • Trurc tuyen: Truy cap Cong Thong Tin Than Phien cua Van Phong Dan Quyen tai: https:Hocrportal.hhs.gov/ocr/portal/lobby.jsL 00 NO"71 KAISER PERMANEWEe Kaiser Foundation Health Plan, Inc. Northern California Region EOC #7 - Combined Chiropractic Services and Silver&Fit® Healthy Aging and Exercise Program Amendment of the Kaiser Foundation Health Plan, Inc. Evidence of Coverage for COUNTY OF FRESNO, RETIREE Group ID: 604334 Contract: 1 Version: 34 EOC Number: 7 January 1,2024, through December 31,2024 ASH Plans Customer Service Department Monday through Friday, 5 a.m. to 6 p.m. 1-800-678-9133 (TTY users call 711)toll free ashlink.com/ash/kp Silver&Fit Customer Service Monday through Friday, 5 a.m.to 6 p.m 1-877-750-2746 (TTY 711) kp.org/silverandfit This document is available for free in Spanish. Please contact Member Services at 1-800-443-0815 for additional information. (TTY users should call 711.)Hours are 8 a.m. to 8 p.m., 7 days a week. Este documento estd disponible de manera gratuita en espanol. Para obtener informacion adicional, comuniquese con Servicio a los Miembros al 1-800-443-0815. (Los usuarios de la linea TTYdeben llamar al 711). El horario es de 8 a. m. a 8 p. m., los 7 dias de la semana. TABLE OF CONTENTS FOR EOC #7 Chiropractic Services Benefit Highlights...............................................................................................................................1 Silver&Fit®Healthy Aging and Exercise Program Benefit Highlights................................................................................1 Introduction............................................................................................................................................................................2 ChiropracticServices.............................................................................................................................................................3 Definitions..............................................................................................................................................................................3 ASHParticipating Providers..................................................................................................................................................3 Howto Obtain Services......................................................................................................................................................4 CoveredServices....................................................................................................................................................................4 OfficeVisits.......................................................................................................................................................................5 LaboratoryTests and X-rays..............................................................................................................................................5 ChiropracticSupports and Appliances...............................................................................................................................5 SecondOpinions.................................................................................................................................................................5 Emergency and Urgent Services Covered Under this Amendment...................................................................................5 Exclusions..............................................................................................................................................................................6 CustomerService...................................................................................................................................................................6 Grievances..............................................................................................................................................................................6 Silver&Fit®Healthy Aging and Exercise Program...............................................................................................................8 CoveredServices................................................................................................................................................................8 Chiropractic Services Benefit Highlights _ We cover the Services described below,subject to exclusions described in the"Exclusions"section,only if all of the following conditions are satisfied: • You are a Member on the date that you receive the Services • ASH Plans has determined that the Services are Medically Necessary,except as described in this Amendment • You receive the Services from ASH Participating Providers or other licensed providers that ASH contracts to provide covered care,except as described in this Amendment Professional Services(ASH Participating Provider office visits) You Pay Chiropractic office visits(up to a total of 30 visits per 12-month period).. $15 per visit Other You Pay X-rays and laboratory tests that are covered Chiropractic Services............ No charge Chiropractic supports and appliances.......................................................... Amounts in excess of the$50 Allowance This is a summary of the most frequently asked-about benefits.This chart does not explain benefits,Cost Share,out-of- pocket maximums,exclusions,or limitations,nor does it list all benefits and Cost Share amounts.For a complete explanation,refer to the"Covered Services"and"Exclusions"sections. Silver&Fit® Healthy Aging and Exercise Program Benefit Highlights Fitness Facility You Pay Participating Silver&Fit basic fitness facility membership......................... No charge Home Fitness Program You Pay One Home Fitness Kit per calendar year in addition to a basic fitness membership................................................................................................ No charge This chart does not explain benefits.For a complete explanation,refer to the"Covered Services"in the"Silver&Fit® Healthy Aging and Exercise Program"section. Introduction This document amends your Kaiser Foundation Health Plan,Inc.(Health Plan)EOC to add coverage for Chiropractic Services and the Silver&Fit Program as described in this Combined Chiropractic Services and Silver&Fit®Healthy Aging and Exercise Program Amendment("Amendment"). Group ID:604334 Chiropractic Services and Silver&Fit®Healthy Aging and Exercise Program Contract: 1 Version:34 EOC'#7 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 2 Chiropractic Services therapies such as ultrasound,therapeutic exercise,or electrical muscle stimulation,when provided during the All provisions of the EOC apply to coverage described in same course of treatment and in conjunction with this document except for the following sections: chiropractic manipulative services,and other services provided or prescribed by a chiropractor(including • "How to Obtain Services"(except that the laboratory tests,X-rays,and chiropractic supports and "Completion of Services from Non—Plan Providers" appliances)for the treatment of your Musculoskeletal section,or for Kaiser Permanente Senior Advantage and Related Disorder. Members,the"Termination of a Plan Provider's contract and completion of Services"section,does Emergency Chiropractic Services: Covered apply to coverage described in this document) Chiropractic Services provided for the treatment of a • "Plan Facilities" Musculoskeletal and Related Disorder which manifests itself by acute symptoms of sufficient severity(including • "Emergency Services and Urgent Care" severe pain)such that you could expect the absence of • "Benefits" immediate Chiropractic Services to result in serious jeopardy to your health or body functions or organs. Kaiser Foundation Health Plan,Inc. contracts with American Specialty Health Plans of California,Inc. Musculoskeletal and Related Disorders: Conditions ("ASH Plans")to make the network of ASH with signs and symptoms related to the nervous, Participating Providers available to you. muscular,and/or skeletal systems.Musculoskeletal and Related Disorders are conditions typically categorized as When you need chiropractic care,you have direct access structural,degenerative,or inflammatory disorders;or to more than 3,400 licensed chiropractors in California. biomechanical dysfunction of the joints of the body You can obtain covered Services from any ASH and/or related components of the muscle or skeletal Participating Provider without a referral from a Plan systems(muscles,tendons,fascia,nerves, Physician.Your Cost Share is due when you receive ligaments/capsules,discs and synovial structures)and covered Services. related manifestations or conditions. Non—Participating Provider:A provider other than an Definitions ASH Participating Provider. Treatment Plan: The course of treatment for your In addition to the terms defined in the"Definitions" Musculoskeletal and Related Disorder,which may section of your Health Plan EOC,the following terms, include laboratory tests,X-rays,chiropractic supports when capitalized and used in any part of this and appliances,and a specific number of visits for Amendment,have the following meanings: chiropractic manipulations(adjustments)and adjunctive therapies that are Medically Necessary Chiropractic ASH Participating Provider:A chiropractor who is Services for you. licensed to provide chiropractic services in California and who has a contract with ASH Plans to provide Urgent Chiropractic Services: Chiropractic Services Medically Necessary Chiropractic Services to you.A list that meet all of the following requirements: of ASH Participating Providers is available on the ASH Plans website at ashlink.com/ash/kaisercamedicare for • They are necessary to prevent serious deterioration of Kaiser Permanente Senior Advantage Members,or your health resulting from an unforeseen illness, ashlink.com/ash/ki)for all other Members,or from the injury,or complication of an existing condition, ASH Plans Customer Service Department toll free at including pregnancy 1-800-678-9133(TTY users call 711).The list of ASH • They cannot be delayed until you return to the Service Participating Providers is subject to change at any time, Area without notice.If you have questions,please call the ASH Plans Customer Service Department. ASH Plans:American Specialty Health Plans of ASH Participating Providers California,Inc.,a California corporation. PLEASE READ THE FOLLOWING Chiropractic Services: Chiropractic services include INFORMATION SO YOU WILL KNOW FROM spinal and extremity manipulation and adjunctive Group ID:604334 Chiropractic Services and Silver&Fit®Healthy Aging and Exercise Program Contract: 1 Version:34 EOC'#7 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 3 WHOM OR WHAT GROUP OF PROVIDERS used to make the decision,within two business days after HEALTH CARE MAY BE OBTAINED. the decision is made.The letter will also include information about your appeal rights,which are ASH Plans contracts with ASH Participating Providers described in the"Coverage Decisions,Appeals,and and other licensed providers to provide the Services Complaints"section of your Health Plan EOC for Kaiser covered under this Amendment(including laboratory Permanente Senior Advantage Members,and"Dispute tests,X-rays,and chiropractic supports and appliances). Resolution"section of your Health Plan EOC for all You must receive Services covered under this other Members.Any written criteria that ASH Plans uses Amendment from an ASH Participating Provider or to make the decision to authorize,modify,delay,or deny another licensed provider with which ASH contracts to the request for authorization will be made available to provide covered care,except for Services covered under you upon request.If you have questions or concerns, "Emergency and Urgent Services Covered Under this please contact ASH Plans or Kaiser Permanente as Amendment"in the"Covered Services"section and described under"Customer Service"in this Amendment. Services that are not available from contracted providers and that are authorized in advance by ASH Plans. Covered Services How to Obtain Services We cover the Services listed in this"Covered Services" To obtain Services covered under this Amendment call section,subject to exclusions described in the an ASH Participating Provider to schedule an initial "Exclusions"section,only if all of the following examination.If additional Services are required after the conditions are satisfied: initial examination,verification that the Services are . You are a Member on the date that you receive the Medically Necessary may be required,as described Services under"Decision time frames"below.Your ASH Participating Provider will request any required medical • ASH Plans has determined that the Services are necessity determinations.An ASH Plans clinician in the Medically Necessary,except for: same or similar specialty as the provider of Services ♦ the initial examination described under"Office under review will determine whether the Services are or Visits"in this"Covered Services"section were Medically Necessary Services. ♦ Services covered under"Emergency and Urgent Services Covered Under this Amendment"in this Decision time frames "Covered Services"section The ASH Plans' clinician will make the authorization . You receive the Services from ASH Participating decision within the time frame appropriate for your condition,but no later than five business days after Providers or other licensed providers with which receiving all of the information(including additional ASH contracts to provide covered care,except for: examination and test results)reasonably necessary to ♦ Services covered under"Emergency and Urgent make the decision,except that decisions about urgent Services Covered Under this Amendment"in this Services will be made no later than 72 hours after receipt "Covered Services"section of the information reasonably necessary to make the ♦ Services that are not available from ASH decision.If ASH Plans needs more time to make the Participating Providers or other licensed providers decision because it doesn't have information reasonably with which ASH contracts to provide covered care necessary to make the decision,or because it has and that are authorized in advance by ASH Plans requested consultation by a particular specialist,you and your ASH Participating Provider will be informed in When you receive covered Services,you must pay the writing about the additional information,testing,or Cost Share listed in this"Covered Services"section.If specialist that is needed,and the date that ASH Plans you receive Services that are not covered under this expects to make a decision. Amendment,you may be liable for the full price of those Services. Your ASH Participating Provider will be informed of the decision within 24 hours after the decision is made.If the Note:If Charges for Services are less than the Services are authorized,your ASH Participating Provider Copayment described in this"Covered Services"section, will be informed of the scope of the authorized Services. you will pay the lesser amount. If ASH Plans does not authorize all of the Services,ASH Plans will send you a written decision and explanation, The Cost Share you pay for Services covered under this including the rationale for the decision and the criteria Amendment does not apply toward any Plan Deductible Group ID:604334 Chiropractic Services and Silver&Fit®Healthy Aging and Exercise Program Contract: 1 Version:34 EOC'#7 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 4 or Plan Out-of-Pocket Maximum described in your to another licensed provider with which ASH contracts Health Plan EOC. to provide covered Services. If you have questions about your Cost Share for specific Services that you are scheduled to receive or that your Chiropractic Supports and Appliances provider orders during a visit or procedure,please call We provide a$50 Allowance per 12-month period the ASH Plans Customer Service Department toll free at toward the ASH Plans fee schedule price for chiropractic 1-800-678-9133(TTY users call 711)weekdays from 5 a.m.to 6 p.m. appliances listed in this paragraph when the item is prescribed and provided to you by an ASH Participating Provider as part of covered chiropractic care described If you are a Kaiser Permanente Senior Advantage under"Office Visits"in this"Covered Services"section. Member,refer to your Health Plan EOC for information If the price of the items in the ASH Plans fee schedule about the chiropractic Services that we cover in accord exceeds$50(the Allowance),you will pay the amount in with Medicare guidelines,which are separate from the excess of$50(and that payment does not apply toward Services covered under this Amendment. the Plan Out-of-Pocket Maximum described in your Health Plan EOC). Covered chiropractic appliances are Office Visits limited to: elbow supports,back supports(thoracic), cervical collars,cervical pillows,heel lifts,hot or cold We cover the following: packs,lumbar braces and supports,lumbar cushions, orthotics,wrist supports,rib belts,home traction units • Initial chiropractic examination:An examination (cervical or lumbar),ankle braces,knee braces,rib performed by an ASH Participating Provider to supports,and wrist braces. determine the nature of your problem(and,if appropriate,to prepare a Treatment Plan),and to provide Medically Necessary Chiropractic Services, Second Opinions which may include an adjustment and adjunctive therapy.We cover an initial examination only if you You may request a second opinion in regard to covered have not already received covered Chiropractic Services by contacting another ASH Participating Services from an ASH Participating Provider in the Provider.Your visit to another ASH Participating same 12-month period for your Musculoskeletal and Provider for a second opinion generally will count Related Disorder toward any visit limit,if applicable.An ASH • Subsequent chiropractic office visits: Subsequent Participating Provider may also request a second opinion ASH Participating Provider office visits for in regard to covered Services by referring you to another Chiropractic Services that are determined to be ASH Participating Provider in the same or similar Medically Necessary by an ASH Plans clinician. specialty.When you are referred by an ASH These subsequent office visits may include an Participating Provider to another ASH Participating adjustment,adjunctive therapy,and a re-examination Provider for a second opinion,your visit to the other to assess the need to continue,extend,or change a ASH Participating Provider will not count toward any Treatment Plan visit limit,if applicable.An authorization or denial of your request for a second opinion will be provided in an Each office visit counts toward any visit limit,if expeditious manner,as appropriate for your condition.If applicable. your request for a second opinion is denied,you will be notified in writing of the reasons for the denial,and of You pay the following for these covered Services(up to your right to file a grievance as described under 30 visits per 12 month period): a$15 Copayment per "Grievances"in this Amendment. visit Emergency and Urgent Services Laboratory Tests and X-rays Covered Under this Amendment We cover Medically Necessary laboratory tests and X- We cover Emergency Chiropractic Services and Urgent rays when prescribed as part of covered chiropractic care Chiropractic Services provided by an ASH Participating described under"Office Visits"in this"Covered Provider or a Non—Participating Provider at a Services"section at no charge when an ASH $15 Copayment per visit.We do not cover follow-up or Participating Provider provides the Services or refers you continuing care from a Non-Participating Provider unless ASH Plans has authorized the Services in advance.Also, Group ID:604334 Chiropractic Services and Silver&Fit®Healthy Aging and Exercise Program Contract: 1 Version:34 EOC'#7 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 5 we do not cover Services from a Non-Participating radiology other than X-rays covered under the Provider that ASH Plans determines are not Emergency "Covered Services"section of this Amendment Chiropractic Services or Urgent Chiropractic Services. • Ambulance and other transportation How to file a claim • Education programs,non-medical self-care or self- As soon as possible after receiving Emergency help,any self-help physical exercise training,and any Chiropractic Services or Urgent Chiropractic Services, related diagnostic testing you must file an ASH Plans claim form.To request a • Services for pre-employment physicals or vocational claim form or for more information,please call ASH rehabilitation Plans toll free at 1-800-678-9133(TTY users call 711)or • Drugs and medicines,including non-legend or visit the ASH Plans website at ashlink.com.You must proprietary drugs and medicines send the completed claim form to: • Services you receive outside the state of California, ASH Plans except for Services covered under"Emergency and P.O.Box 509002 Urgent Services Covered Under this Amendment"in San Diego,CA 92150-9002 the"Covered Services"section • Hospital services,anesthesia,manipulation under anesthesia,and related services Exclusions . Dietary and nutritional supplements,such as vitamins, minerals,herbs,herbal products,injectable The items and services listed in this"Exclusions"section supplements,and similar products are excluded from coverage under this Amendment. • Massage therapy (Note: Some items and services listed in this "Exclusions"section may be covered Services under • Maintenance care(services provided to Members your Health Plan EOC.Please refer to your Health Plan whose treatment records indicate that they have EOC for details.)These exclusions apply to all Services reached maximum therapeutic benefit) that would otherwise be covered under this Amendment regardless of whether the services are within the scope of a provider's license or certificate: Customer Service i • Services provided by a chiropractor that are not within the scope of licensure for a chiropractor If you have a question or concern regarding the Services licensed in California you received from an ASH Participating Provider or any • Adjunctive therapy not associated with spinal, other licensed provider with which ASH contracts to muscle,or joint manipulations provide covered Services,you may call the ASH Plans • Air conditioners,air purifiers,therapeutic mattresses, Customer Service Department toll free at 1-800-678- chiropractic appliances,durable medical equipment, 9133(TTY users call 711)weekdays from 5 a.m.to 6 supplies,devices,appliances,and any other item p.m.,or write ASH Plans at: except those listed as covered under"Chiropractic ASH Plans Supports and Appliances"in the"Covered Services" Customer Service Department section of this Amendment P.O.Box 509002 • Services for asthma or addiction,such as nicotine San Diego,CA 92150-9002 addiction • Hypnotherapy,behavior training,sleep therapy,and weight programs Grievances _ • Thermography You can file a grievance with Kaiser Permanente • Experimental or investigational Services.If coverage regarding any issue.Your grievance must explain your for a Service is denied because it is experimental or issue, such as the reasons why you believe a decision investigational and you want to appeal the denial, was in error or why you are dissatisfied about Services refer to your Health Plan EOC for information about you received.If you are a Kaiser Permanente Senior the appeal process Advantage Member,you may submit your grievance • CT scans,MRIs,PET scans,bone scans,nuclear orally or in writing to Kaiser Permanente as described in medicine,and any other type of diagnostic imaging or the"Coverage Decisions,Appeals,and Complaints" Group ID:604334 Chiropractic Services and Silver&Fit®Healthy Aging and Exercise Program Contract: 1 Version:34 EOC'#7 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 6 section of your Health Plan EOC Otherwise,you may submit your grievance orally or in writing to Kaiser Permanente as described in the"Dispute Resolution" section of your Health Plan EOC. Group ID:604334 Chiropractic Services and Silver&Fit®Healthy Aging and Exercise Program Contract: 1 Version:34 EOC'#7 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 7 Silver&Fit® Healthy Aging and • If you would like to work out at home,you can select Exercise Program one Home Fitness Kit per calendar year. There are many Home Fitness Kits to choose from,including Wearable Fitness Tracker,Pilates,Strength,Swim, The Silver&Fit program is provided by American Walking/Trekking,and Yoga Kit options.Kits are Specialty Health Fitness,Inc.,a subsidiary of American subject to change and once selected cannot be Specialty Health Incorporated(ASH). Silver&Fit is a exchanged federally registered trademark of ASH and used with ♦ to pick your kit,please visit kmorg/silverandfit or permission herein.Participating fitness centers and call Silver&Fit customer service fitness chains may vary by location and are subject to change. • Access to Silver&Fit online services at kp.m/silverandfit that provide on-demand workout videos,Workout Plans,the Well-Being Club,a Covered Services newsletter,and other helpful features.The Well- Being Club enhanced feature of the Silver&Fit The Silver&Fit program includes the following at no website allows members the opportunity to view charge: customized resources as well as attend live-streaming • You can join a participating Silver&Fit fitness center classes and events and take advantage of the services that are included in the fitness center's basic membership(for example, For more information about the Silver&Fit program and use of fitness center equipment or instructor-led the list of participating fitness centers and home kits, classes that do not require an additional fee).If you visit kp.or2/silverandfit or call Silver&Fit customer sign-up for a Silver&Fit fitness center membership, service at 1-877-750-2746(TTY 711),Monday through the following applies: Friday,5 a.m.to 6 p.m. (PST). ♦ the fitness center provides facility and equipment orientation ♦ services offered by fitness centers vary by location.Any nonstandard fitness center service that typically requires an additional fee is not included in your basic fitness center membership through the Silver&Fit program(for example, court fees or personal trainer services) — Silver&Fit Premium fitness network covers an expanded network of select fitness centers that are not in the Silver&Fit standard fitness network.Members have the option to access these select fitness centers and studio choices at additional costs from the standard network fitness centers.Initiation fees may be applicable at some select fitness centers in this expanded network ♦ to join a participating Silver&Fit fitness center, register through kp.ore/silverandfit and select a participating fitness center.Members who select a Premium fitness center location will need to pay their nonrefundable membership fee(s).You can then print or download your"Welcome Letter," which includes your Silver&Fit card with fitness ID number to provide to the selected fitness center ♦ once you join,you can switch to another participating Silver&Fit fitness center once a month and your change will be effective the first of the following month(you may need to complete a new membership agreement at the fitness center) Group ID:604334 Chiropractic Services and Silver&Fit®Healthy Aging and Exercise Program Contract: 1 Version:34 EOC'#7 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 8 00 NO"71 KAISER PERMANEWEe Kaiser Foundation Health Plan, Inc. Northern California Region EOC #8 - Combined Chiropractic Services and Silver&Fit® Healthy Aging and Exercise Program Amendment of the Kaiser Foundation Health Plan, Inc. Evidence of Coverage for COUNTY OF FRESNO, RETIREE Group ID: 604334 Contract: 1 Version: 34 EOC Number: 8 January 1,2024, through December 31,2024 ASH Plans Customer Service Department Monday through Friday, 5 a.m. to 6 p.m. 1-800-678-9133 (TTY users call 711)toll free ashlink.com/ash/kp Silver&Fit Customer Service Monday through Friday, 5 a.m.to 6 p.m 1-877-750-2746 (TTY 711) kp.org/silverandfit This document is available for free in Spanish. Please contact Member Services at 1-800-443-0815 for additional information. (TTY users should call 711.)Hours are 8 a.m. to 8 p.m., 7 days a week. Este documento estd disponible de manera gratuita en espanol. Para obtener informacion adicional, comuniquese con Servicio a los Miembros al 1-800-443-0815. (Los usuarios de la linea TTYdeben llamar al 711). El horario es de 8 a. m. a 8 p. m., los 7 dias de la semana. TABLE OF CONTENTS FOR EOC #8 Chiropractic Services Benefit Highlights...............................................................................................................................1 Silver&Fit®Healthy Aging and Exercise Program Benefit Highlights................................................................................1 Introduction............................................................................................................................................................................2 ChiropracticServices.............................................................................................................................................................3 Definitions..............................................................................................................................................................................3 ASHParticipating Providers..................................................................................................................................................3 Howto Obtain Services......................................................................................................................................................4 CoveredServices....................................................................................................................................................................4 OfficeVisits.......................................................................................................................................................................5 LaboratoryTests and X-rays..............................................................................................................................................5 ChiropracticSupports and Appliances...............................................................................................................................5 SecondOpinions.................................................................................................................................................................5 Emergency and Urgent Services Covered Under this Amendment...................................................................................5 Exclusions..............................................................................................................................................................................6 CustomerService...................................................................................................................................................................6 Grievances..............................................................................................................................................................................6 Silver&Fit®Healthy Aging and Exercise Program...............................................................................................................8 CoveredServices................................................................................................................................................................8 Chiropractic Services Benefit Highlights _ We cover the Services described below,subject to exclusions described in the"Exclusions"section,only if all of the following conditions are satisfied: • You are a Member on the date that you receive the Services • ASH Plans has determined that the Services are Medically Necessary,except as described in this Amendment • You receive the Services from ASH Participating Providers or other licensed providers that ASH contracts to provide covered care,except as described in this Amendment Professional Services(ASH Participating Provider office visits) You Pay Chiropractic office visits(up to a total of 30 visits per 12-month period).. $15 per visit Other You Pay X-rays and laboratory tests that are covered Chiropractic Services............ No charge Chiropractic supports and appliances.......................................................... Amounts in excess of the$50 Allowance This is a summary of the most frequently asked-about benefits.This chart does not explain benefits,Cost Share,out-of- pocket maximums,exclusions,or limitations,nor does it list all benefits and Cost Share amounts.For a complete explanation,refer to the"Covered Services"and"Exclusions"sections. Silver&Fit® Healthy Aging and Exercise Program Benefit Highlights Fitness Facility You Pay Participating Silver&Fit basic fitness facility membership......................... No charge Home Fitness Program You Pay One Home Fitness Kit per calendar year in addition to a basic fitness membership................................................................................................ No charge This chart does not explain benefits.For a complete explanation,refer to the"Covered Services"in the"Silver&Fit® Healthy Aging and Exercise Program"section. Introduction This document amends your Kaiser Foundation Health Plan,Inc.(Health Plan)EOC to add coverage for Chiropractic Services and the Silver&Fit Program as described in this Combined Chiropractic Services and Silver&Fit®Healthy Aging and Exercise Program Amendment("Amendment"). Group ID:604334 Chiropractic Services and Silver&Fit®Healthy Aging and Exercise Program Contract: 1 Version:34 EOC'#8 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 2 Chiropractic Services therapies such as ultrasound,therapeutic exercise,or electrical muscle stimulation,when provided during the All provisions of the EOC apply to coverage described in same course of treatment and in conjunction with this document except for the following sections: chiropractic manipulative services,and other services provided or prescribed by a chiropractor(including • "How to Obtain Services"(except that the laboratory tests,X-rays,and chiropractic supports and "Completion of Services from Non—Plan Providers" appliances)for the treatment of your Musculoskeletal section,or for Kaiser Permanente Senior Advantage and Related Disorder. Members,the"Termination of a Plan Provider's contract and completion of Services"section,does Emergency Chiropractic Services: Covered apply to coverage described in this document) Chiropractic Services provided for the treatment of a • "Plan Facilities" Musculoskeletal and Related Disorder which manifests itself by acute symptoms of sufficient severity(including • "Emergency Services and Urgent Care" severe pain)such that you could expect the absence of • "Benefits" immediate Chiropractic Services to result in serious jeopardy to your health or body functions or organs. Kaiser Foundation Health Plan,Inc. contracts with American Specialty Health Plans of California,Inc. Musculoskeletal and Related Disorders: Conditions ("ASH Plans")to make the network of ASH with signs and symptoms related to the nervous, Participating Providers available to you. muscular,and/or skeletal systems.Musculoskeletal and Related Disorders are conditions typically categorized as When you need chiropractic care,you have direct access structural,degenerative,or inflammatory disorders;or to more than 3,400 licensed chiropractors in California. biomechanical dysfunction of the joints of the body You can obtain covered Services from any ASH and/or related components of the muscle or skeletal Participating Provider without a referral from a Plan systems(muscles,tendons,fascia,nerves, Physician.Your Cost Share is due when you receive ligaments/capsules,discs and synovial structures)and covered Services. related manifestations or conditions. Non—Participating Provider:A provider other than an Definitions ASH Participating Provider. Treatment Plan: The course of treatment for your In addition to the terms defined in the"Definitions" Musculoskeletal and Related Disorder,which may section of your Health Plan EOC,the following terms, include laboratory tests,X-rays,chiropractic supports when capitalized and used in any part of this and appliances,and a specific number of visits for Amendment,have the following meanings: chiropractic manipulations(adjustments)and adjunctive therapies that are Medically Necessary Chiropractic ASH Participating Provider:A chiropractor who is Services for you. licensed to provide chiropractic services in California and who has a contract with ASH Plans to provide Urgent Chiropractic Services: Chiropractic Services Medically Necessary Chiropractic Services to you.A list that meet all of the following requirements: of ASH Participating Providers is available on the ASH Plans website at ashlink.com/ash/kaisercamedicare for • They are necessary to prevent serious deterioration of Kaiser Permanente Senior Advantage Members,or your health resulting from an unforeseen illness, ashlink.com/ash/ki)for all other Members,or from the injury,or complication of an existing condition, ASH Plans Customer Service Department toll free at including pregnancy 1-800-678-9133(TTY users call 711).The list of ASH • They cannot be delayed until you return to the Service Participating Providers is subject to change at any time, Area without notice.If you have questions,please call the ASH Plans Customer Service Department. ASH Plans:American Specialty Health Plans of ASH Participating Providers California,Inc.,a California corporation. PLEASE READ THE FOLLOWING Chiropractic Services: Chiropractic services include INFORMATION SO YOU WILL KNOW FROM spinal and extremity manipulation and adjunctive Group ID:604334 Chiropractic Services and Silver&Fit®Healthy Aging and Exercise Program Contract: 1 Version:34 EOC'#8 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 3 WHOM OR WHAT GROUP OF PROVIDERS used to make the decision,within two business days after HEALTH CARE MAY BE OBTAINED. the decision is made.The letter will also include information about your appeal rights,which are ASH Plans contracts with ASH Participating Providers described in the"Coverage Decisions,Appeals,and and other licensed providers to provide the Services Complaints"section of your Health Plan EOC for Kaiser covered under this Amendment(including laboratory Permanente Senior Advantage Members,and"Dispute tests,X-rays,and chiropractic supports and appliances). Resolution"section of your Health Plan EOC for all You must receive Services covered under this other Members.Any written criteria that ASH Plans uses Amendment from an ASH Participating Provider or to make the decision to authorize,modify,delay,or deny another licensed provider with which ASH contracts to the request for authorization will be made available to provide covered care,except for Services covered under you upon request.If you have questions or concerns, "Emergency and Urgent Services Covered Under this please contact ASH Plans or Kaiser Permanente as Amendment"in the"Covered Services"section and described under"Customer Service"in this Amendment. Services that are not available from contracted providers and that are authorized in advance by ASH Plans. Covered Services How to Obtain Services We cover the Services listed in this"Covered Services" To obtain Services covered under this Amendment call section,subject to exclusions described in the an ASH Participating Provider to schedule an initial "Exclusions"section,only if all of the following examination.If additional Services are required after the conditions are satisfied: initial examination,verification that the Services are . You are a Member on the date that you receive the Medically Necessary may be required,as described Services under"Decision time frames"below.Your ASH Participating Provider will request any required medical • ASH Plans has determined that the Services are necessity determinations.An ASH Plans clinician in the Medically Necessary,except for: same or similar specialty as the provider of Services ♦ the initial examination described under"Office under review will determine whether the Services are or Visits"in this"Covered Services"section were Medically Necessary Services. ♦ Services covered under"Emergency and Urgent Services Covered Under this Amendment"in this Decision time frames "Covered Services"section The ASH Plans' clinician will make the authorization . You receive the Services from ASH Participating decision within the time frame appropriate for your condition,but no later than five business days after Providers or other licensed providers with which receiving all of the information(including additional ASH contracts to provide covered care,except for: examination and test results)reasonably necessary to ♦ Services covered under"Emergency and Urgent make the decision,except that decisions about urgent Services Covered Under this Amendment"in this Services will be made no later than 72 hours after receipt "Covered Services"section of the information reasonably necessary to make the ♦ Services that are not available from ASH decision.If ASH Plans needs more time to make the Participating Providers or other licensed providers decision because it doesn't have information reasonably with which ASH contracts to provide covered care necessary to make the decision,or because it has and that are authorized in advance by ASH Plans requested consultation by a particular specialist,you and your ASH Participating Provider will be informed in When you receive covered Services,you must pay the writing about the additional information,testing,or Cost Share listed in this"Covered Services"section.If specialist that is needed,and the date that ASH Plans you receive Services that are not covered under this expects to make a decision. Amendment,you may be liable for the full price of those Services. Your ASH Participating Provider will be informed of the decision within 24 hours after the decision is made.If the Note:If Charges for Services are less than the Services are authorized,your ASH Participating Provider Copayment described in this"Covered Services"section, will be informed of the scope of the authorized Services. you will pay the lesser amount. If ASH Plans does not authorize all of the Services,ASH Plans will send you a written decision and explanation, The Cost Share you pay for Services covered under this including the rationale for the decision and the criteria Amendment does not apply toward any Plan Deductible Group ID:604334 Chiropractic Services and Silver&Fit®Healthy Aging and Exercise Program Contract: 1 Version:34 EOC'#8 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 4 or Plan Out-of-Pocket Maximum described in your to another licensed provider with which ASH contracts Health Plan EOC. to provide covered Services. If you have questions about your Cost Share for specific Services that you are scheduled to receive or that your Chiropractic Supports and Appliances provider orders during a visit or procedure,please call We provide a$50 Allowance per 12-month period the ASH Plans Customer Service Department toll free at toward the ASH Plans fee schedule price for chiropractic 1-800-678-9133(TTY users call 711)weekdays from 5 a.m.to 6 p.m. appliances listed in this paragraph when the item is prescribed and provided to you by an ASH Participating Provider as part of covered chiropractic care described If you are a Kaiser Permanente Senior Advantage under"Office Visits"in this"Covered Services"section. Member,refer to your Health Plan EOC for information If the price of the items in the ASH Plans fee schedule about the chiropractic Services that we cover in accord exceeds$50(the Allowance),you will pay the amount in with Medicare guidelines,which are separate from the excess of$50(and that payment does not apply toward Services covered under this Amendment. the Plan Out-of-Pocket Maximum described in your Health Plan EOC). Covered chiropractic appliances are Office Visits limited to: elbow supports,back supports(thoracic), cervical collars,cervical pillows,heel lifts,hot or cold We cover the following: packs,lumbar braces and supports,lumbar cushions, orthotics,wrist supports,rib belts,home traction units • Initial chiropractic examination:An examination (cervical or lumbar),ankle braces,knee braces,rib performed by an ASH Participating Provider to supports,and wrist braces. determine the nature of your problem(and,if appropriate,to prepare a Treatment Plan),and to provide Medically Necessary Chiropractic Services, Second Opinions which may include an adjustment and adjunctive therapy.We cover an initial examination only if you You may request a second opinion in regard to covered have not already received covered Chiropractic Services by contacting another ASH Participating Services from an ASH Participating Provider in the Provider.Your visit to another ASH Participating same 12-month period for your Musculoskeletal and Provider for a second opinion generally will count Related Disorder toward any visit limit,if applicable.An ASH • Subsequent chiropractic office visits: Subsequent Participating Provider may also request a second opinion ASH Participating Provider office visits for in regard to covered Services by referring you to another Chiropractic Services that are determined to be ASH Participating Provider in the same or similar Medically Necessary by an ASH Plans clinician. specialty.When you are referred by an ASH These subsequent office visits may include an Participating Provider to another ASH Participating adjustment,adjunctive therapy,and a re-examination Provider for a second opinion,your visit to the other to assess the need to continue,extend,or change a ASH Participating Provider will not count toward any Treatment Plan visit limit,if applicable.An authorization or denial of your request for a second opinion will be provided in an Each office visit counts toward any visit limit,if expeditious manner,as appropriate for your condition.If applicable. your request for a second opinion is denied,you will be notified in writing of the reasons for the denial,and of You pay the following for these covered Services(up to your right to file a grievance as described under 30 visits per 12 month period): a$15 Copayment per "Grievances"in this Amendment. visit Emergency and Urgent Services Laboratory Tests and X-rays Covered Under this Amendment We cover Medically Necessary laboratory tests and X- We cover Emergency Chiropractic Services and Urgent rays when prescribed as part of covered chiropractic care Chiropractic Services provided by an ASH Participating described under"Office Visits"in this"Covered Provider or a Non—Participating Provider at a Services"section at no charge when an ASH $15 Copayment per visit.We do not cover follow-up or Participating Provider provides the Services or refers you continuing care from a Non-Participating Provider unless ASH Plans has authorized the Services in advance.Also, Group ID:604334 Chiropractic Services and Silver&Fit®Healthy Aging and Exercise Program Contract: 1 Version:34 EOC'#8 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 5 we do not cover Services from a Non-Participating radiology other than X-rays covered under the Provider that ASH Plans determines are not Emergency "Covered Services"section of this Amendment Chiropractic Services or Urgent Chiropractic Services. • Ambulance and other transportation How to file a claim • Education programs,non-medical self-care or self- As soon as possible after receiving Emergency help,any self-help physical exercise training,and any Chiropractic Services or Urgent Chiropractic Services, related diagnostic testing you must file an ASH Plans claim form.To request a • Services for pre-employment physicals or vocational claim form or for more information,please call ASH rehabilitation Plans toll free at 1-800-678-9133(TTY users call 711)or • Drugs and medicines,including non-legend or visit the ASH Plans website at ashlink.com.You must proprietary drugs and medicines send the completed claim form to: • Services you receive outside the state of California, ASH Plans except for Services covered under"Emergency and P.O.Box 509002 Urgent Services Covered Under this Amendment"in San Diego,CA 92150-9002 the"Covered Services"section • Hospital services,anesthesia,manipulation under anesthesia,and related services Exclusions . Dietary and nutritional supplements,such as vitamins, minerals,herbs,herbal products,injectable The items and services listed in this"Exclusions"section supplements,and similar products are excluded from coverage under this Amendment. • Massage therapy (Note: Some items and services listed in this "Exclusions"section may be covered Services under • Maintenance care(services provided to Members your Health Plan EOC.Please refer to your Health Plan whose treatment records indicate that they have EOC for details.)These exclusions apply to all Services reached maximum therapeutic benefit) that would otherwise be covered under this Amendment regardless of whether the services are within the scope of a provider's license or certificate: Customer Service i • Services provided by a chiropractor that are not within the scope of licensure for a chiropractor If you have a question or concern regarding the Services licensed in California you received from an ASH Participating Provider or any • Adjunctive therapy not associated with spinal, other licensed provider with which ASH contracts to muscle,or joint manipulations provide covered Services,you may call the ASH Plans • Air conditioners,air purifiers,therapeutic mattresses, Customer Service Department toll free at 1-800-678- chiropractic appliances,durable medical equipment, 9133(TTY users call 711)weekdays from 5 a.m.to 6 supplies,devices,appliances,and any other item p.m.,or write ASH Plans at: except those listed as covered under"Chiropractic ASH Plans Supports and Appliances"in the"Covered Services" Customer Service Department section of this Amendment P.O.Box 509002 • Services for asthma or addiction,such as nicotine San Diego,CA 92150-9002 addiction • Hypnotherapy,behavior training,sleep therapy,and weight programs Grievances _ • Thermography You can file a grievance with Kaiser Permanente • Experimental or investigational Services.If coverage regarding any issue.Your grievance must explain your for a Service is denied because it is experimental or issue, such as the reasons why you believe a decision investigational and you want to appeal the denial, was in error or why you are dissatisfied about Services refer to your Health Plan EOC for information about you received.If you are a Kaiser Permanente Senior the appeal process Advantage Member,you may submit your grievance • CT scans,MRIs,PET scans,bone scans,nuclear orally or in writing to Kaiser Permanente as described in medicine,and any other type of diagnostic imaging or the"Coverage Decisions,Appeals,and Complaints" Group ID:604334 Chiropractic Services and Silver&Fit®Healthy Aging and Exercise Program Contract: 1 Version:34 EOC'#8 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 6 section of your Health Plan EOC Otherwise,you may submit your grievance orally or in writing to Kaiser Permanente as described in the"Dispute Resolution" section of your Health Plan EOC. Group ID:604334 Chiropractic Services and Silver&Fit®Healthy Aging and Exercise Program Contract: 1 Version:34 EOC'#8 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 7 Silver&Fit® Healthy Aging and • If you would like to work out at home,you can select Exercise Program one Home Fitness Kit per calendar year. There are many Home Fitness Kits to choose from,including Wearable Fitness Tracker,Pilates,Strength,Swim, The Silver&Fit program is provided by American Walking/Trekking,and Yoga Kit options.Kits are Specialty Health Fitness,Inc.,a subsidiary of American subject to change and once selected cannot be Specialty Health Incorporated(ASH). Silver&Fit is a exchanged federally registered trademark of ASH and used with ♦ to pick your kit,please visit kmorg/silverandfit or permission herein.Participating fitness centers and call Silver&Fit customer service fitness chains may vary by location and are subject to change. • Access to Silver&Fit online services at kp.m/silverandfit that provide on-demand workout videos,Workout Plans,the Well-Being Club,a Covered Services newsletter,and other helpful features.The Well- Being Club enhanced feature of the Silver&Fit The Silver&Fit program includes the following at no website allows members the opportunity to view charge: customized resources as well as attend live-streaming • You can join a participating Silver&Fit fitness center classes and events and take advantage of the services that are included in the fitness center's basic membership(for example, For more information about the Silver&Fit program and use of fitness center equipment or instructor-led the list of participating fitness centers and home kits, classes that do not require an additional fee).If you visit kp.or2/silverandfit or call Silver&Fit customer sign-up for a Silver&Fit fitness center membership, service at 1-877-750-2746(TTY 711),Monday through the following applies: Friday,5 a.m.to 6 p.m. (PST). ♦ the fitness center provides facility and equipment orientation ♦ services offered by fitness centers vary by location.Any nonstandard fitness center service that typically requires an additional fee is not included in your basic fitness center membership through the Silver&Fit program(for example, court fees or personal trainer services) — Silver&Fit Premium fitness network covers an expanded network of select fitness centers that are not in the Silver&Fit standard fitness network.Members have the option to access these select fitness centers and studio choices at additional costs from the standard network fitness centers.Initiation fees may be applicable at some select fitness centers in this expanded network ♦ to join a participating Silver&Fit fitness center, register through kp.ore/silverandfit and select a participating fitness center.Members who select a Premium fitness center location will need to pay their nonrefundable membership fee(s).You can then print or download your"Welcome Letter," which includes your Silver&Fit card with fitness ID number to provide to the selected fitness center ♦ once you join,you can switch to another participating Silver&Fit fitness center once a month and your change will be effective the first of the following month(you may need to complete a new membership agreement at the fitness center) Group ID:604334 Chiropractic Services and Silver&Fit®Healthy Aging and Exercise Program Contract: 1 Version:34 EOC'#8 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 8 00 NO"71 KAISER PERMANEWEe Kaiser Foundation Health Plan, Inc. Northern California Region EOC #9 - Chiropractic Services Amendment of the Kaiser Foundation Health Plan, Inc. Evidence of Coverage for COUNTY OF FRESNO, RETIREE Group ID: 604334 Contract: 1 Version: 34 EOC Number: 9 January 1,2024,through December 31, 2024 ASH Plans Customer Service Department Monday through Friday, 5 a.m. to 6 p.m. 1-800-678-9133 (TTY users call 711)toll free ashlink.com/ash/kp TABLE OF CONTENTS FOR EOC #9 BenefitHighlights..................................................................................................................................................................1 Introduction............................................................................................................................................................................2 Definitions..............................................................................................................................................................................2 ASHParticipating Providers..................................................................................................................................................3 Howto Obtain Services......................................................................................................................................................3 CoveredServices....................................................................................................................................................................3 OfficeVisits.......................................................................................................................................................................4 LaboratoryTests and X-rays..............................................................................................................................................4 Chiropractic Supports and Appliances...............................................................................................................................4 SecondOpinions.................................................................................................................................................................4 Emergency and Urgent Services Covered Under this Amendment...................................................................................5 Exclusions..............................................................................................................................................................................5 CustomerService...................................................................................................................................................................5 Grievances..............................................................................................................................................................................6 Benefit Highlights _ We cover the Services described below,subject to exclusions described in the"Exclusions"section,only if all of the following conditions are satisfied: • You are a Member on the date that you receive the Services • ASH Plans has determined that the Services are Medically Necessary,except as described in this Amendment • You receive the Services from ASH Participating Providers or other licensed providers that ASH contracts to provide covered care,except as described in this Amendment Professional Services(ASH Participating Provider office visits) You Pay Chiropractic office visits(up to a total of 30 visits per 12-month period).. $10 per visit Other You Pay X-rays and laboratory tests that are covered Chiropractic Services............ No charge Chiropractic supports and appliances.......................................................... Amounts in excess of the$50 Allowance This is a summary of the most frequently asked-about benefits.This chart does not explain benefits,Cost Share,out-of- pocket maximums,exclusions,or limitations,nor does it list all benefits and Cost Share amounts.For a complete explanation,refer to the"Covered Services"and"Exclusions"sections. Introduction ASH Plans:American Specialty Health Plans of California,Inc.,a California corporation. This document amends your Kaiser Foundation Health Plan,Inc.(Health Plan)EOC to add coverage Chiropractic Services: Chiropractic services include for Chiropractic Services as described in this spinal and extremity manipulation and adjunctive Chiropractic Services Amendment("Amendment"). therapies such as ultrasound,therapeutic exercise,or All provisions of the EOC apply to coverage described in electrical muscle stimulation,when provided during the this document except for the following sections: same course of treatment and in conjunction with chiropractic manipulative services,and other services • "How to Obtain Services"(except that the provided or prescribed by a chiropractor(including "Completion of Services from Non—Plan Providers" laboratory tests,X-rays,and chiropractic supports and section,or for Kaiser Permanente Senior Advantage appliances)for the treatment of your Musculoskeletal Members,the"Termination of a Plan Provider's and Related Disorder. contract and completion of Services"section,does apply to coverage described in this document) Emergency Chiropractic Services: Covered • "Plan Facilities" Chiropractic Services provided for the treatment of a • "Emergency Services and Urgent Care" Musculoskeletal and Related Disorder which manifests itself by acute symptoms of sufficient severity(including • "Benefits" severe pain)such that you could expect the absence of immediate Chiropractic Services to result in serious Kaiser Foundation Health Plan,Inc. contracts with jeopardy to your health or body functions or organs. American Specialty Health Plans of California,Inc. ("ASH Plans")to make the network of ASH Musculoskeletal and Related Disorders: Conditions Participating Providers available to you. with signs and symptoms related to the nervous, muscular,and/or skeletal systems.Musculoskeletal and When you need chiropractic care,you have direct access Related Disorders are conditions typically categorized as to more than 3,400 licensed chiropractors in California. structural,degenerative,or inflammatory disorders;or You can obtain covered Services from any ASH biomechanical dysfunction of the joints of the body Participating Provider without a referral from a Plan and/or related components of the muscle or skeletal Physician.Your Cost Share is due when you receive systems(muscles,tendons,fascia,nerves, covered Services. ligaments/capsules,discs and synovial structures)and related manifestations or conditions. Definitions 14pr, Non—Participating Provider:A provider other than an ASH Participating Provider. In addition to the terms defined in the"Definitions" Treatment Plan: The course of treatment for your section of your Health Plan EOC,the following terms, Musculoskeletal and Related Disorder,which may when capitalized and used in any part of this include laboratory tests,X-rays,chiropractic supports Amendment,have the following meanings: and appliances,and a specific number of visits for chiropractic manipulations(adjustments)and adjunctive ASH Participating Provider:A chiropractor who is therapies that are Medically Necessary Chiropractic licensed to provide chiropractic services in California Services for you. and who has a contract with ASH Plans to provide Medically Necessary Chiropractic Services to you.A list of ASH Participating Providers is available on the ASH Urgent Chiropractic Services: Chiropractic Services Plans website at ashlink.com/ash/kaisercamedicare for that meet all of the following requirements: Kaiser Permanente Senior Advantage Members,or • They are necessary to prevent serious deterioration of ashlink.com/ash/ku for all other Members,or from the your health resulting from an unforeseen illness, ASH Plans Customer Service Department toll free at injury,or complication of an existing condition, 1-800-678-9133(TTY users call 711).The list of ASH including pregnancy Participating Providers is subject to change at any time, • They cannot be delayed until you return to the Service without notice.If you have questions,please call the Area ASH Plans Customer Service Department. Group ID:604334 American Specialty Health Plans Chiropractic Plan Contract: 1 Version:34 EOC'#9 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 2 ASH Participating Providers will be informed of the scope of the authorized Services. If ASH Plans does not authorize all of the Services,ASH PLEASE READ THE FOLLOWING Plans will send you a written decision and explanation, INFORMATION SO YOU WILL KNOW FROM including the rationale for the decision and the criteria WHOM OR WHAT GROUP OF PROVIDERS used to make the decision,within two business days after HEALTH CARE MAY BE OBTAINED. the decision is made.The letter will also include information about your appeal rights,which are described in the"Coverage Decisions,Appeals,and ASH Plans contracts with ASH Participating Providers Complaints"section of your Health Plan EOC for Kaiser and other licensed providers to provide the Services permanente Senior Advantage Members,and"Dispute covered under this Amendment(including laboratory Resolution"section of your Health Plan EOC for all tests,X-rays,and chiropractic supports and appliances). other Members.Any written criteria that ASH Plans uses You must receive Services covered under this to make the decision to authorize,modify,delay,or deny Amendment from an ASH Participating Provider or the request for authorization will be made available to another licensed provider with which ASH contracts to you upon request.If you have questions or concerns, provide covered care,except for Services covered under please contact ASH Plans or Kaiser Permanente as "Emergency and Urgent Services Covered Under this described under"Customer Service"in this Amendment. Amendment"in the"Covered Services"section and Services that are not available from contracted providers and that are authorized in advance by ASH Plans. Covered Services How to Obtain Services We cover the Services listed in this"Covered Services" To obtain Services covered under this Amendment call section,subject to exclusions described in the an ASH Participating Provider to schedule an initial "Exclusions"section,only if all of the following examination.If additional Services are required after the conditions are satisfied: initial examination,verification that the Services are • You are a Member on the date that you receive the Medically Necessary may be required,as described Services under"Decision time frames"below.Your ASH . ASH Plans has determined that the Services are Participating Provider will request any required medical Medically Necessary,except for: necessity determinations.An ASH Plans clinician in the same or similar specialty as the provider of Services ♦ the initial examination described under"Office under review will determine whether the Services are or Visits"in this"Covered Services"section were Medically Necessary Services. ♦ Services covered under"Emergency and Urgent Services Covered Under this Amendment"in this Decision time frames "Covered Services"section The ASH Plans' clinician will make the authorization • You receive the Services from ASH Participating decision within the time frame appropriate for your Providers or other licensed providers with which condition,but no later than five business days after ASH contracts to provide covered care,except for: receiving all of the information(including additional ♦ Services covered under"Emergency and Urgent examination and test results)reasonably necessary to Services Covered Under this Amendment"in this make the decision,except that decisions about urgent "Covered Services"section Services will be made no later than 72 hours after receipt of the information reasonably necessary to make the ♦ Services that are not available from ASH decision.If ASH Plans needs more time to make the Participating Providers or other licensed providers decision because it doesn't have information reasonably with which ASH contracts to provide covered care necessary to make the decision,or because it has and that are authorized in advance by ASH Plans requested consultation by a particular specialist,you and your ASH Participating Provider will be informed in When you receive covered Services,you must pay the writing about the additional information,testing,or Cost Share listed in this"Covered Services"section.If specialist that is needed,and the date that ASH Plans you receive Services that are not covered under this expects to make a decision. Amendment,you maybe liable for the full price of those Services. Your ASH Participating Provider will be informed of the decision within 24 hours after the decision is made.If the Services are authorized,your ASH Participating Provider Group ID:604334 American Specialty Health Plans Chiropractic Plan Contract: 1 Version:34 EOC'#9 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 3 Note:If Charges for Services are less than the Laboratory Tests and X-rays Copayment described in this"Covered Services"section, you will pay the lesser amount. We cover Medically Necessary laboratory tests and X- rays when prescribed as part of covered chiropractic care The Cost Share you pay for Services covered under this described under"Office Visits"in this"Covered Amendment does not apply toward any Plan Deductible Services"section at no charge when an ASH or Plan Out-of-Pocket Maximum described in your Participating Provider provides the Services or refers you Health Plan EOC. to another licensed provider with which ASH contracts to provide covered Services. If you have questions about your Cost Share for specific Services that you are scheduled to receive or that your provider orders during a visit or procedure,please call Chiropractic Supports and Appliances the ASH Plans Customer Service Department toll free at We provide a$50 Allowance per 12-month period 1-800-678-9133(TTY users call 711)weekdays from 5 toward the ASH Plans fee schedule price for chiropractic a.m.to 6 p.m. appliances listed in this paragraph when the item is prescribed and provided to you by an ASH Participating If you are a Kaiser Permanente Senior Advantage Provider as part of covered chiropractic care described Member,refer to your Health Plan EOC for information under"Office Visits"in this"Covered Services"section. about the chiropractic Services that we cover in accord If the price of the items in the ASH Plans fee schedule with Medicare guidelines,which are separate from the exceeds$50(the Allowance),you will pay the amount in Services covered under this Amendment. excess of$50(and that payment does not apply toward the Plan Out-of-Pocket Maximum described in your Office Visits Health Plan EOC).Covered chiropractic appliances are limited to: elbow supports,back supports(thoracic), We cover the following: cervical collars,cervical pillows,heel lifts,hot or cold packs,lumbar braces and supports,lumbar cushions, • Initial chiropractic examination:An examination orthotics,wrist supports,rib belts,home traction units performed by an ASH Participating Provider to (cervical or lumbar),ankle braces,knee braces,rib determine the nature of your problem(and,if supports,and wrist braces. appropriate,to prepare a Treatment Plan),and to provide Medically Necessary Chiropractic Services, which may include an adjustment and adjunctive Second Opinions therapy.We cover an initial examination only if you have not already received covered Chiropractic You may request a second opinion in regard to covered Services from an ASH Participating Provider in the Services by contacting another ASH Participating same 12-month period for your Musculoskeletal and Provider.Your visit to another ASH Participating Related Disorder Provider for a second opinion generally will count • Subsequent chiropractic office visits: Subsequent toward any visit limit,if applicable.An ASH ASH Participating Provider office visits for Participating Provider may also request a second opinion Chiropractic Services that are determined to be in regard to covered Services by referring you to another Medically Necessary by an ASH Plans clinician. ASH Participating Provider in the same or similar These subsequent office visits may include an specialty.When you are referred by an ASH adjustment,adjunctive therapy,and a re-examination Participating Provider to another ASH Participating to assess the need to continue,extend,or change a Provider for a second opinion,your visit to the other Treatment Plan ASH Participating Provider will not count toward any visit limit,if applicable.An authorization or denial of your request for a second opinion will be provided in an Each office visit counts toward any visit limit,if expeditious manner,as appropriate for your condition.If applicable. your request for a second opinion is denied,you will be notified in writing of the reasons for the denial,and of You pay the following for these covered Services(up to your right to file a grievance as described under 30 visits per 12 month period): a$10 Copayment per "Grievances"in this Amendment. visit Group ID:604334 American Specialty Health Plans Chiropractic Plan Contract: 1 Version:34 EOC'#9 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 4 Emergency and Urgent Services • Thermography Covered Under this Amendment • Experimental or investigational Services.If coverage for a Service is denied because it is experimental or We cover Emergency Chiropractic Services and Urgent investigational and you want to appeal the denial, Chiropractic Services provided by an ASH Participating refer to your Health Plan EOC for information about Provider or a Non—Participating Provider at a the appeal process $10 Copayment per visit.We do not cover follow-up or continuing care from a Non-Participating Provider unless • CT scans,MRIs,PET scans,bone scans,nuclear ASH Plans has authorized the Services in advance.Also, medicine,and any other type of diagnostic imaging or we do not cover Services from a Non-Participating radiology other than X-rays covered under the Provider that ASH Plans determines are not Emergency "Covered Services"section of this Amendment Chiropractic Services or Urgent Chiropractic Services. • Ambulance and other transportation • Education programs,non-medical self-care or self- How to file a Claim help,any self-help physical exercise training,and any As soon as possible after receiving Emergency related diagnostic testing Chiropractic Services or Urgent Chiropractic Services, you must file an ASH Plans claim form.To request a • Services for pre-employment physicals or vocational claim form or for more information,please call ASH rehabilitation Plans toll free at 1-800-678-9133(TTY users call 711)or . Drugs and medicines,including non-legend or visit the ASH Plans website at ashlink.com.You must proprietary drugs and medicines send the completed claim form to: • Services you receive outside the state of California, ASH Plans except for Services covered under"Emergency and P.O.Box 509002 Urgent Services Covered Under this Amendment"in San Diego,CA 92150-9002 the"Covered Services"section • Hospital services,anesthesia,manipulation under anesthesia,and related services Exclusions • Dietary and nutritional supplements,such as vitamins, minerals,herbs,herbal products,injectable The items and services listed in this"Exclusions"section supplements,and similar products are excluded from coverage under this Amendment. . Massage therapy (Note: Some items and services listed in this "Exclusions"section maybe covered Services under • Maintenance care(services provided to Members your Health Plan EOC.Please refer to your Health Plan whose treatment records indicate that they have EOC for details.)These exclusions apply to all Services reached maximum therapeutic benefit) that would otherwise be covered under this Amendment regardless of whether the services are within the scope of a provider's license or certificate: Customer Service i • Services provided by a chiropractor that are not within the scope of licensure for a chiropractor If you have a question or concern regarding the Services licensed in California you received from an ASH Participating Provider or any • Adjunctive therapy not associated with spinal, other licensed provider with which ASH contracts to muscle,or joint manipulations provide covered Services,you may call the ASH Plans Customer Service Department toll free at 1-800-678- • Air conditioners,air purifiers,therapeutic mattresses, 9133(TTY users call 711)weekdays from 5 a.m.to 6 chiropractic appliances,durable medical equipment, p.m.,or write ASH Plans at: supplies,devices,appliances,and any other item except those listed as covered under"Chiropractic ASH Plans Supports and Appliances"in the"Covered Services" Customer Service Department section of this Amendment P.O.Box 509002 • Services for asthma or addiction,such as nicotine San Diego,CA 92150-9002 addiction • Hypnotherapy,behavior training,sleep therapy,and weight programs Group ID:604334 American Specialty Health Plans Chiropractic Plan Contract: 1 Version:34 EOC'#9 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 5 Grievances You can file a grievance with Kaiser Permanente regarding any issue.Your grievance must explain your issue,such as the reasons why you believe a decision was in error or why you are dissatisfied about Services you received.If you are a Kaiser Permanente Senior Advantage Member,you may submit your grievance orally or in writing to Kaiser Permanente as described in the"Coverage Decisions,Appeals,and Complaints" section of your Health Plan EOC. Otherwise,you may submit your grievance orally or in writing to Kaiser Permanente as described in the"Dispute Resolution" section of your Health Plan EOC. Group ID:604334 American Specialty Health Plans Chiropractic Plan Contract: 1 Version:34 EOC'#9 Effective: 1/l/24-12/31/24 Date:October 20,2023 Page 6