Also see: Medical Insurance Health Net HealthNet PPO  

Description The Kaiser Permanente Health Maintenance Organization (HMO) is available only to employees and their eligible dependents living within the Kaiser zip code service areas of Los Angeles, Orange, Riverside, San Bernardino, San Diego, Kern and Ventura Counties. Certain outlying zip codes within the County are not eligible for coverage through Kaiser Permanente.  Please contact Kaiser Permanente's customer service number to verify that you are in an eligible service area. How the Plan Works Kaiser Permanente providers (e.g., physicians, hospitals, etc.) contract exclusively with Kaiser Permanente facilities around the country. You have access to virtually full-service, unlimited medical care at little or no additional cost.  However, you must use Kaiser Permanente's physicians, hospitals and other approved health care providers. Otherwise, you will not be eligible to receive benefits, except in a life-threatening situation, such as an out-of-area urgent or emergency situation. The County has also contracted for premiums to cover durable medical equipment. See the durable medical equipment insert located in your materials from Kaiser Permanente for specific benefit information. Co-payments For most routine care, you pay $10. For other services, co-payments may range from $5 to $100. Deductible Under Kaiser Permanente, you pay no deductible and your out-of-pocket annual expenses are limited to $1,500 per person or $3,000 per family. Hospitalization Kaiser Permanente will coordinate all non-emergency admissions. Emergency Care If you think you have an emergency medical condition and cannot safely go to a Plan hospital, call 911 or go to the nearest hospital. Please see your Evidence of Coverage for more details on your coverage and benefits. Out-of-Area Care If you need medical care and cannot get to a Kaiser Permanente facility, call the 800 number on the back of your ID card for guidance. Claim Forms Under Kaiser Permanente, you do not have to file claim forms except for out-of-area urgent or emergency care. How to Enroll Enrolling in the plan is easy. Ask your payroll clerk for an enrollment packet.  New employees must enroll within 31 days of hire into an eligible position during the first week of hire into an eligible position.  Current employees can add or change coverage only during the annual open enrollment period or if you experience a qualifying event. Refer to the Employee Benefits Guide for more details. Call Kaiser Permanente's Member Services at (800) 464-4000 if you:   · Have a benefits question · Need a member identification (ID) card · Have an eligibility question · Have a claims question · Want to file a grievance   What's Covered Kaiser Permanente benefits include routine checkups, physicals, vision exams, hearing exams, pediatric checkups and health education to help keep you and your family healthy.  The Mental Health Parity Law (AB88) requires coverage for the diagnosis and medically necessary treatment services for severe mental illness of a person of any age. Coverage must be provided for these mental health services in the same way that other medical conditions are covered (e.g., same co-payments and limits). The nine specific diagnoses identified as severe mental illnesses are: Schizophrenia, Schizoaffective Disorder, Bipolar Disorder (Manic- Depressive Disorder), Major Depressive Disorder, Panic Disorder, Obsessive-Compulsive Disorder, Pervasive Development Disorder or Autism, Anorexia Nervosa and Bulimia Nervosa.  Coverage under the plan will terminate on the earliest of the conditions listed below.  Termination will be effective on the date indicated in the official plan document: · Your employment terminates · The Group Agreement terminates · You are no longer eligible for County benefits · You become covered under another health plan or under any other plan offered in connection with the County   What's Not Covered Service in this section means any treatment, therapeutic or diagnostic procedure, drug, equipment, or device. When a service is excluded, all other services that are necessary for the excluded service, and that would otherwise be a covered benefit, are also excluded. The following are excluded from your Kaiser Permanente coverage: · All services and supplies (other than artificial insemination) related to conception by artificial means, such as, but not limited to: ovum transplants; gamete intra-fallopian transfer (GIFT); donor semen or eggs, and services and supplies related to their procurement and storage; in vitro fertilization (IVF); zygote intra-fallopian transfer (ZIFT) · Any eye surgery solely for the purpose of correcting refractive defects of the eye, such as nearsightedness (myopia), farsightedness (hyperopia), and astigmatism · Care for conditions arising from military service that are reasonably available from the Veterans Administration · Care in an intermediate care facility · Chiropractic services and supplies · Comfort, convenience, or luxury equipment or features · Custodial care · Dental care and dental X-rays · Drugs, supplies, and supplements needed in connection with a service not covered · Durable medical equipment used to administer drugs (covered only as described in the Kaiser Permanente materials) · Durable medical equipment for comfort, convenience, or luxury equipment or features; exercise or hygiene equipment; dental appliances; non-medical items such as sauna baths or elevators; modifications to your home or car; devices for testing blood substances, except blood glucose monitors for diabetics; electronic monitors of the heart or lungs except infant apnea monitors · Experimental or investigational services · Hearing aids or tests to determine their efficacy · Physical examinations related to employment, insurance, licensing, court orders, parole, or probation · Home health services and supplies do not include custodial care, homemaker services and supplies or care that the home health committee determines may be appropriately provided in a plan medical office, plan hospital, or skilled nursing facility and Kaiser Permanente provides or offers to provide that care in one of these facilities · Living and transportation expenses for any person, including the Member, for transplantation of organs · Mental health services and supplies after diagnosis for conditions that, in the professional judgment of a plan physician or other plan mental health professional, are not subject to significant improvement through relatively short-term therapy; these excluded conditions include chronic psychosis, chronic organic brain syndrome, intractable personality disorders, and mental retardation; Kaiser Permanente covers visits for the purpose of monitoring outpatient drug therapy for these conditions, but Kaiser Permanente does not cover outpatient drugs unless they are covered under the drugs, supplies, and supplements section of the plan document; services and supplies for patients who, in the judgment of a plan physician or other plan mental health professional, are seeking services and supplies for other than therapeutic purposes;  psychological testing for ability, aptitude, intelligence, or interest - Plastic surgery or other cosmetic services and supplies, except those specifically listed in the reconstructive surgery section of the plan document that are primarily intended to improve your appearance, or will not result in significant improvement in physical function · Routine foot care services and supplies that are not medically necessary · Services and supplies that an employer is required by law to provide · Services and supplies that a government agency is required by law to provide · Services and supplies not available in the Kaiser Permanente service area · Services and supplies related to sexual reassignment · Services and supplies covered by Worker's Kaiser Permanente will provide a referral to these facilities for non-covered services and supplies; services will be discontinued if the Member becomes disruptive or physically abusive · Services and supplies to reverse voluntary, surgically induced infertility · Specific prosthetic and orthotic devices including: eyeglasses and contact lenses; hearing aids; dental appliances; non-rigid supplies, such as elastic stockings and wigs; comfort, convenience, or luxury equipment or features; electronic voice-producing machines; shoes or arch supports, even if custom-made, except as specifically stated in the prosthetic and orthotic devices section of the plan document · Services and supplies related to nonhuman or artificial organs and their implantation · Tests to determine an appropriate hearing aid · Transportation by car, taxi, bus, gurney van, wheelchair van, minivan, and any other type of transportation (other than a licensed ambulance), even if it is the only way to travel to a Kaiser Permanente provider Limitations · Coverage for sexual dysfunction drugs is limited to 50% of the retail drug cost · Occupational therapy is limited to treatment to achieve and maintain improved self-care and other customary activities of daily living; speech therapy is limited to treatment for speech impairments of specific organic origin and treatment of articulation disorders due to congenital abnormalities of the palate · In the event of unusual circumstances that delay or render impractical the provision of services and supplies, such as major disaster, epidemic, civil insurrection, disability of a large share of personnel, or labor disputes not involving Kaiser Permanente, Kaiser Permanente will use their best efforts to provide or arrange for all of their Members' health care; however, Kaiser Permanente will not be liable for any delay or failure in providing services; in the case of a labor Compensation or an employee's liability law · Services related to conception, pregnancy, or delivery in connection with a surrogacy arrangement; a surrogacy arrangement is one in which a woman agrees to become pregnant and to surrender the baby to another person or persons who intend to raise the child · Services and supplies in a specialized facility for alcoholism, drug abuse, or drug addiction except as specifically stated in the alcohol and drug dependency benefits section of the plan; in appropriate cases, dispute involving Kaiser Permanente, nonemergency care may be postponed until after the dispute is resolved · Some Members may refuse to accept treatments that are recommended by the plan physician for a particular condition; if you refuse to accept a treatment recommended by your plan physician, and he or she advises you that there is no professionally acceptable alternative, you may get a second opinion from another plan physician; if you refuse to accept a recommended treatment from either plan physician, Kaiser Permanente has no further responsibility to provide any alternative treatment you may request Reductions · Benefits are reduced by any benefits that a Member is entitled to under Medicare except when Medicare is secondary payor by law · If you become ill or injured through the fault of a third party and you collect any money from the third party or from his or her insurance company, you must reimburse Kaiser Permanente for any services and supplies Kaiser Permanente covers for that injury or illness; alternatively, Kaiser Permanente may file a claim against the third party on their own behalf for the value of the services and supplies Kaiser Permanente covers for that injury or illness · Kaiser Permanente will seek reimbursement from the medical expense provisions of any motor vehicle insurance covering you, and any liability insurance that provides payment for injuries or illness to you; you must submit to Kaiser Permanente all consents, releases, and other documents necessary for Kaiser Permanente to obtain payment   How to Get in Touch with Kaiser Permanente Please call Member Services, available seven days a week from 7:00 a.m. to 7:00 p.m., at 1-800-464-4000, or go to Kaiser Permanente's web site at www.kp.org for more information.