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CITY OF SAN BERrGRDINO - REQUEST ~R COUNCIL ACTION
Dept:
Personnel
January 31, 1989
REC'O _ JttWect. Resolution authorizing the execution
. AD . ufF of agreement with Kaiser Foundation Health
1989 FEB 28 AM 9: l:lan, Inc. relating to change in rates
I >1ffective January 1, 1989. 'ft2,f;
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From:
Gordon R. Johnson
Director of Personnel
Date:
Synopsis of Previous Council action:
Kaiser Foundation Health Plan, Inc. has been offered to
city employees since 1973, and extended annually by the
Council.
Racommended motion:
Approve the resolution to authorize the execution
of the Kaiser Foundation Health Plan, Inc., relating
to change in rates effective January 1, 1989.
~ek
, S~ture
Contact person: Gordon R. Johnson
Phone: 5161
Supporting data attached: Yes
Ward:
FUNDING REQUIREMENTS:
Amount: No additional cost.
Source: (Acct. No.! Existing budgets.
(Acct. Description)
Finance:
0~ tJ~
Council Notes:
75-0262
Agenda Item No 1'1
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CITY OF SAN BERNGlDINO - REQUEST.... COUNCIL ACTION
STAFF REPORT
The City is currently transitioning into the PERS Medical and
Hospital Care Act. This is being accomplished by bargaining
units and will be completed as of February 1, 1989. To
afford those employees of the bargaining units not yet under
PERS continued coverage, the City's self-insured health plan
with Kaiser Permanente requires renewal. The 1989 rates for
the Kaiser Health Plan are as follows:
Kaiser Health Plan
Employee
Onlv
Two Person
Coveraae
Familv
Rates Effective 1/1/89
1988 Rates
$100.46
$ 91. 32
.$200.92
$182.62
$284.50
$258.60
The new rates represent an approximate increase of 10.0%.
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RESOLUTION NO..
RESOLUTION OF THE CITY OF SAN BERNARDINO AUTHORIUNG THE
EXECUTION OF AN AMENDMENT TO THE AGREEMENT WITH KAISER
FOUNDATION HEALTH PLAN, INC., RELATING TO A CHANGE IN RATES,
EFFECTIVE JANUARY 1, 1989.
BE IT RESOLVED BY THE MAYOR AND COMMON COUNCIL OF THE
CITY OF SAN BERNARDINO AS FOLLOWS:
\' SECTION 1. The Director of Personnel of the City of San
Bernardino is hereby authorized and directed to execute on
Ibeha1f of said City an amended agreement with Kaiser Founda-
tion Health Plan, Inc., relating to a change in rates effec-
tive January 1, 1989, affecting the City's Group Health Plan,
copy of which amendment is on file in the Personnel Depart-
mente
I HEREBY CERTIFY that the foregoing resolution was, duly
adopted by the Mayor and Common Council of the City of San
Bernardino at a
meeting thereof, held on
the
day of
, 1989, by the following
vote, to wit:
AYES:
Counc il Member s
NAYS:
ABSENT:
City Clerk
27
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28 Page 1
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AMENDMENT TO THE AGREEMENT W'ITH
PLAN, INC., RELATING TO A CHANGE
1, 1989.
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KAISER FOUNDATION HEALTH
IN RATES, EFFECTIVE JANUARY
The foregoing resolution is hereby approved this ____
day of
, 1989.
Mayor of the City .of San Bernardino
Approved as to form and legal content:
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KAISER FOUNDATION HEALTH PLAN, INC.
Southern California Region
1989 Group Medical and Hospital Service Agreement
Format and Language Changes
Generic language changes are made in the following sections of the 1989 Group
Medical and Hospital Service Agreements:
Section 1: The Service Area definition has been divided into two sections - the
"Southern Cal Hornia Section" and the "Bakersfield Section".
Section 2-A(1): For Service Agreements using standard eligibility language. the
Subscriber eligibility is changed to indicate that individuals must work a
minimum of 17~ hours per week. This change is due to Section 89-Welfare Benefit
Nondiscrimination Rules.
Section 2-A(2)(c): Family Dependent el igibil ity of "other unmarried dependent
persons" hlls been changed to require the Subscriber or Subscriber's spouse to be
the court-appointed guardian.
Section 2-A(4)(b): A clarification has been made to this Section to show that a
Member loses continuation coverage (COBRA) upon entitlement to Medicare.
Section 6-A(9): The podiatry exclusion
exclusion .for services of a podiatrist.
Care services continue to be excluded.
has been rewritten to remove the
Routine. non-medically necessary foot
Section 8-A & B: The addresses for initiating clllims and arbitration
proceedings have been changed.
Section 11-0: This Section has been rewri tten for clarification.
Section ll-E: This Sect ion has been rewritten for clarification.
Section l1-L: The first paragraph describing Home Health Services has beeTl
changed to introduce both the Home Health Services and Hospice Care belh:!fits.
Section I1-M: Recovery services tor alcohol and drug dependency has been added.
Section 11-5: The copayment requirement h)r Emergency Services received from
"nil-Plan providers has been increased to 50ia of the first $200 of charges. This
copaymellt is appLicable for services received either witllin the Service Area or
'""ithin 30 miles of the Member's home if the Member lives 'outside the 'Service
Area.
" definicion of Reasonable and Customary Charges has been added.
,\ 12-mnnch claims submissillll I imitation hdS bet.'1l auded.
Section 12-0: This Sect i \)11 has been rewr i tten lor cLarification. /~
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Section 12-E: This Sect i l\ll has been rcwr i ttell i.nr clarification.
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Section 12-L: The first paragraph describing Home Health Services has been
changed to introduce both the Home Health Services and Hospice Care benefits.
Section 12-M: Recovery services for alcohol and drug dependency has been added.
Section 12-S: A definition of Reasonable and Customary Charges has been added.
The following sections have been revised to establish uniformity among the
Kaiser Permanente Regions across the nation. There are no material changes:
Section 4 - "Rates and Payment"
Section 7 - "Conversion and Transferll
The following changes are due to The Medicare Catastrophic Coverage Act:
Section 1: The Spell of Illness definition has been deleted.
Section 11-K: The Extended Care Services benefit for Medicare Members and Part
A Members has been expanded to 150 days per calendar year. The benefit for
non-Medicare Members remains at 100 days per calendar year.
Section 11-L: The 2tO day Medicare limitation for Hospice Care has been
deleted.
Section 12-B: The "Spell of Illness" blood deductible has been changed to a
"calendar year" deductible.
. Section 12-K:
been expanded
is greater.
The Extended Care Services benefit for Health Pledge Members has
to 150 days per calendar year, or per period of illness. whichever
Section 12-L:
deleted.
The 210 day Medicare limitation for Hospice Care has been
The following two section changes are not generic but affect only those groups
which offer the Supplemental Prescription Drug Benefit and/or the Supplemental
Vision Benefit, Level 11:
Section 11-F: The prescription drug benefit has been expanded to cover
prescriptions written by dentists.
An exclusion (or drugs and medications used for cosmetic purposes has b~en
added.
Section 11-T: The Vision 11 frame allowance applicable in calendar year lq/lq
will be increased from $37.00 to $3q.OO.
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TABLE OF CONTEMTS
1989
Section
Subject
DefiDitians
1.
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1{I1BJhl1itJ, Enrollment ADd ec:.verll(e
A. Eligibility
(1) Subscribers
(2) Family Dependents
(3) Health Pledge Member
(4) Continuation Coverage
Ineligible Persons
B. Enrollment
(1) Newly Eligible Persons
(2) Open Enrollment Period
Limitation on Enrollment
C. Effective Date of Coverage
(1) Newly Eligible Persons
(2) Newborn
(3) Open Enrollment Period
D. Termination Date of Coverage
3. Belatians Amoag PerU. Affected By Agreement
4. Bates ADd PaJIDents
A. Periodic Payment Schedule
Basic Rate Structure
Variables to Basic Rate Structure
Imposition of Tax or License Fees
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B _ Other Charges
C. Medicare
(1) Medicare Payments
(2) Special Provision for Members Entitled to Medicare Benefits
(3) Other Coverage - Health Pledge Members
D. Employer Contribution
E. Coordination of Benefits (If Applicable)
5. ServiceB ADd Benefits
A. Within the Service Area
Choice of Physician and Hospital
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B. Outside the Service Area
6. BI..llltoi'llll8, LimitatiCIIIS And B.eduetiCIIIS
A.
Exclusions
(1) Employer or Governmental Responsibility
(2) Non-Covered Inpatient Care
(3) Cosmetic Services
(4) Dental Care
(5) Certain Physical Examinations
(6) Experimental or Investigational Services
(7) Procedures Not Generally and Customarily Provided
(8) . Voluntary Infertility
(9) Podiatry
(10) Chiropractic
(11) Durable Bquipment
(12) Blood
(13) Artificial Organs
(14) Sex Change
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B; Limitations
(1) Unusual Circumstances
(2) Refusal to Accept Treatment
(3) Alcohol and Drug Dependency
(4) Rehabilitation
(5) Psychiatric Conditions
(6) Corrective Appliances and Artificial Aids
C. . Reductions
(1) Injuries or illnesses Caused by Third Parties
'I. Conversion And Transfer
A. Conversion to Non-Group Enrollment
B. Change of Residence
(1) All Members Except Health Pledge Members
(2) Health Pledge Members
8. Arbitration Of Claims
9. Term And Termination
A. Term of Agreement
B. Termination
(1) Termination of Agreement
(2) Termination of Specific Members
(3) Return of Prorata Portion of Monthly Payment in
Certain Cases
(4) Opportunity for Review of Certain Terminations by
Commissioner of Corporations
(5) Termination of Risk Contract With Health Care
Financing Administration ("HCFA")
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C. Amendment
10. ~'-a n._. ProvilIlOll8
A. Acceptance of Agreement
B. Agreement Binding on Members
C. Applications and Statements
D. Identification Cards
E. Right to Examine Records
P. Notice of Certain Events
G. Goveming Law .
H. Administration of Agreement
I. Member Information
J. Notices
L. ERISA Information (If Applicable)
M. . Hold-Harmless Agreement (If Applicable)
11. s-fitslilbedule
A. Medical Care In Hospital, Office And Skilled Nursing Pacility
(1) Care While Hospitalized
(2) Care in Medical Offices or Emergency Departments
(3) Care in Skilled Nursing Pacility
B. Hospital Care
C. Home Visits
D. Diagnostic Procedures: Diagnostic X-Ray, Laboratory And
Special Procedures
E. Therapeutic Procedures
(1) Physical Therapy
Inhalation Therapy
Occupational Therapy
(2) Speech Therapy
(3) Rehabilitation
(4) Therapeutic X.-Rays and Therapeutic Nuclear Medicine Procedures
(5) Orthoptic and Dermatological Black Light Treatments
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F. Prescribed Medications, Immunizations And Dressing And Casts
(1) Prescribed Medications and Items
(2) .Immunizations
(3) Dressings and Casts
(4) Amino Acid Modified Products
(5) Immunosuppressive Drugs
G. Ambulance Service
H. Family Planning And Infertility
(1) Family Planning
(2) Infertility
I. Reconstructive Surgery And Prosthetic Devices Following
Mastectomy
J. Hemodialysis And Organ Transplants
K. Extended Care Services
(1) Members Who Are Not Medicare Members or
Part A Members
(2) Members Who Are Medicare Members or
Part A Members
L. Home Health Services And Hospice Care
(1) Home Health Services
(a) Members Who Are Not Medicare Members, Part A
Members or Part B Members
(b) Members Who Are Medicare Members, Part A
Members or Part B Members
Durable Equipment for Medicare Members
(2) Hospice Care
Limitation
M. Treatment For Alcohol And Drug Dependency
(1) Inpatient Care for Withdrawal
(2) Outpatient Services
. (3) Exclusions
N. Mental Health Services
(1) Outpatient Services
(2) Day and Night Care Services
(3) Inpatient Services
(4) Psychological Testing
(5) Exclusions and Limitations
O. Medical Social Services
P. Health Education
Q.
Payment In Lieu Of Service Benefits
Service Benefits In Other Health Plan Regions
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S. Emergency Services Received From Providers Not Contracting
With Health Plan
(1) Emergency Services
(2) . Reductions for Other Benefits and Copayments
(3) Payment
(4) Continuing or Follow-Up Treatment
(5) Notification and Claims
(6) Releases and Assignments
(7) Right of Recovery
T. Corrective Lenses And Eyeglasses (If Applicable)
(1) Services and Benefits
(2) Exclusions
U. Hearing Aids (If Applicable)
(1) Services and Benefits
(2) Exclusions
V. Orthotic And Prosthetic Devices And Durable Medical
Equipment (If Applicable)
12. Beoefit Sebedu1e Por ReIIlth Pledge Members
A. Medical Care In Hospital, Office And Skilled Nursing Facility
(1) Care While Hospitalized
(2) Care in Medical Offices or Emergency Departments
(3) Care in Skilled Nursing Facility
B. Hospital Care
C. Home Visits
D. Diagnostic Procedures: Diagnostic X-Ray, Laboratory And
Special Procedures
E. Therapeutic Procedures
(1) Physical Therapy
Inhalation Therapy
Occupational Therapy
(2) Speech Therapy
(3) Therapeutic X-Rays and Therapeutic Nuclear
Medicine Procedures
(4) Orthoptic and Dermatological Black Light Treatments
F. Prescribed Medications, Immunizations And Dressings And Casts
(1) Prescribed Medications and Items
(2) Immunizations
(3) Dressings and Casts
(4) Amino Acid Modified Products
(5) Immunosuppressive Drugs
G. Ambulance Service
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H. Family Planning And Infertility
(1) Family Planning
(2) Infertility
L. Reconstructive Surgery And Prosthetic Devices following
Mastectomy
J. Hemodialysis And Organ Transplants
K. Extended Care Services
L. Home Health Services And Hospice Care
(1) Home Health Services
(2) Hospice Care
M. Treatment For Alcohol And Drug Dependency
(1) Inpatient Care for Withdrawal
(2) Outpatient Services
(3) Exclusions
N. Mental Health Services
(1) Outpatient Services
(2) Day and Night Care Services
(3) Inpatient Services
(4) Psychological Testing
(5) Exclusions
O. Medical Social Services
P. Health Education
Q. Payment In Lieu Of Service Benefits
R. Service Benefits In Other Health Plan Regions
S. Emergency Care Or Urgent Care Received From Providers
Not Contracting With Health Plan
(1) Emergency Care or Urgent Care
(2) Continuing or FollOW-Up Treatment
(3) Notification and Claims
(4) Releases and Assignments
(5) Right of Recovery
T. Corrective Lenses And Eyeglasses (If Applicable)
U. Hearing Aids (If Applicable)
v. Durable Medical Equipment, Corrective Appliances And
Artificial Aids
13. Sipature PlIp And Effective Date
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KAISER FOUNDATION HEALTH PLAN, INC.
A Nonprofit Corporation
Southern California Region
GROUP MEDICAL AND HOSPITAL SERVICE AGREEMENT
INTRODUCTION
This Service Agreement has been entered into between Kaiser Foundation Health Plan
Incorporated, a California nonprofit corporation, herein called "Health Plan", and
CITY OF SAN BERNARDINO, herein called "Group".
Health Plan, in consideration of the monthly payments to be paid to Health Plan by
Group and in consideration of the Supplemental Charges to be paid by or on behalf of
Members, agrees to arrange necessary Medical and Hospital Services and other benefits
as specified in Section 11 or Section 12, as applicable for eligible persons who en-
roll hereunder, in accord with the terms, conditions, limitations and exclusions of
this Service Agreement.
INTERPRETATION OF AGREEMENT
In order to provide the advantages of integrated medical services and facilities,
Health Plan arranges and provides services directly rather than paying for services
provided by others. The interpretation of this Agreement is guided by the direct
service nature of the Health Plan program.
1. DEFIN ITlONS
As used in this Agreement and all Benefit Schedules and any amendments hereto, the
terms in boldface type, when capitalized, have the meanings shown below:
A. Extended Care Services: Skilled inpatient services that are: (i) medically
necessary; (ii) ordered by a Physician; (iii) customarily provided by Skilled Nurs-
ing Facilities; and (iv) above the level of custodial, convalescent, intermediate or
domiciliary care.
B. Family Dependent: Any person (i) who meets all applicable eligibility
requirements of Section 2; (ii) who is enrolled hereunder; and (iii) for whom the
prepayment required by Section 4 has been received by Health Plan.
C. Family Unit: A Subscriber and all of his or her Family Dependents.
D. Health Plan: Kaiser Foundation Health Plan, Inc., a California nonprofit cor-
poration.
E. Health Plan Region:
dation Health Plan, Inc.,
care program.
Each of the specific geographic areas where Kaiser Foun-
or s related organization conducts a direct service health
F. Hospital: Any hospital in the Service Area to which a Member is admitted to
receive Hospital Services pursuant to arrangements made by a Physician. A current
list of Hospitals may be obtained from any Health Plan office.
G. Hospital Services: Except as expressly limited or excluded by this Agreement,
those medically necessary services for registered bed patients that are: (i) general-
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,ly and customarily provided by acute care general hospitals in Southern California;
and (ii) prescribed, directed or authorized by the Attending Physician.
H. Kedical Group: Southern California Permanente Medical Group.
I. Kedical Office: Any outpatient treatment facility staffed by Medical Group. A
current list of Medical Offices may be obtained from any Health Plan office.
J. Kedical Services: Except as.expressly limited or excluded by this Agreement,
those medically necessary professional services of physicians, other health pro-
fessionals, and paramedical personnel, that are: (i) generally and customarily provi-
ded in Southern California; and (ii) performed, prescribed, or directed by the Atten-
ding Physician.
K. Kedicare: The Federal Health Insurance for the Aged and Disabled Act.
L. Kember: Any Subscriber or Family Dependent; Medicare Kember: Any Member enti-
tled to benefits under both parts of Medicare who has assigned Part B benefits to
Health Plan, except Members described in Section 4-C of this Agreement; Part A Kem-
ber: Any Member entitled to benefits under Part A of Medicare only, except Members
described in Section 4-C of this Agreement; Part B Kember: Any Member entitled to
benefits under Part B of Medicare only, who has assigned Part B benefits to Health
Plan, except Members. described in Section 4-C of this Agreement; Health Pledge Kem-
ber: Any Member entitled to benefits under both Parts of Medicare or under Part B of
Medicare who meets the eligibility requirements of Section 2-A(3) of this Agreement,
except Members described in Section 4-C of this Agreement.
K. Non-Kember Rates: The chsrges in the applicable schedule of charges maintained
by Medical Group or Hospitals for services provided to patients who are not Members.
N. Physician: Any doctor of medicine associated with or engaged by Medical Group;
Attending Physician: The Physician primarily responsible for the csre of a Member
with respect to any particular injury or illness.
O. Service Area:
Southern Cslifornia Section. The Service Area is that portion of Los Angeles,
Orange, Riverside, San Bernardino, San Diego, and Ventura counties within the follow-
ing zip codes: 90000-99, 90101-99, 90200-99, 90300-99, 90400-99, 90500-99, 90600-99,
90700-99, except 90704, 90800-99, 91000-99, 91100-99, 91200-99, 91300-99, 91400-99,
91500-99, 91600-99, 91700-99, 91800-99, 92001-2, 92006-14, 92016-7, 92019-22,
92024-7, 92031-2, 92035-8, 92040-2, 92044-5, 92047-8, 92050, 92053-4, 92056, 92062-5,
92067-71, 92073, 92075, 92077-8, 92080, 92082-4, 92093, 92100~99, 92220, 92223,
92305, 92307-8, 92313-8, 92320-2, 92324-6, 92330, 92333-7, 92339-41, 92343-6, 92348,
92352-4, 92356, 92358-60, 92362, 92367, 92369-74, 92376, 92378, 92380-3, 92385-8,
92391-2, 92395-7, 92399, 92400-99, 92500-99, 92600-99, 92700-99, 92800-99, 93010-1,
93015, 93021, 93040, 93060, 93062-6, 93510, 93532, 93534-6, 93539, 93543-4, 93550,
93551, 93553, 93563.
Bakersfield Section. The Service Area is that portion of Kern and Tulare coun-
ties within the following zip codes: 93203, 93205-6, 93215, 93217, 93220, 93224,
93226, 93238, 93240-1, 93250-2, 93261, 93263, 93268, 93276, 93280, 93285, 93287,
93301-9, 93311-13, 93380, 93385-9, 93518, 93531, 93561.
P. Skilled Nursing Facility: An institution (or a distinct part of an
institution) which: (i) provides 24-hour-a-day licensed nursing care; (ii) has in
effect a transfer agreement with one or more hospitals; (iii) is primarily engsged in
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.providing skilled nursing care as a part of an ongoing therapeutic regimen; (iv) is
licensed under applicable state law; and (v) has been approved in writing by Medical
Group.
Q. Subscriber: A person (i) who meets all applicable eligibility requirements of
Section 2; (ii) who is enrolled hereunder; and (iii) for whom the prepayment required
by Section 4 has been received by Health Plan.
R. Supp18lllentalCharges: Those amounts that Members must pay when they receive
covered services that are not fully prepaid.
2. ELIGIBILITY, ENROLLMENT AND COVERAGE
A. Eligibility. Individuals are accepted tor enrollment and continuing coverage
only if they meet all eligibility requirements established by Group and all appli-
cable requirements set forth below. At original enrollment, individuals must reside
in that portion of the Service Area which Health Plan designated as open for enroll-
ment.
(1) Subscribers. To be a Subscriber, a person on his or her own behalf and not
by virtue of dependency status, must be either:
(a) An employee of Group employed to work a minimum of 17-1/2 hours per
week; or
(b) Entitled to coverage under a trust agreement or employment contract,
except that no change in Group's eligibility or participation requirements is
effective for purposes of this Agreement unless Health Plan consents.
(2) Family Dependents. To be a Family Dependent a person must be:
(a) The Subscriber's spouse; or
(b) A dependent child of the Subscriber or the Subscriber's spouse and
either:
(i) Unmarried and under age 19; or
(ii) Over age 19 and incapable of self-sustaining employment by reason of
mental retardation or physical handicap incurred prior to age 19 and chiefly
dependent upon the Subscriber or the Subscriber's spouse for support and
maintenance, with proof of incapacity and dependency furnished annually if
requested by Health Plan; or
(c) Any other unmarried dependent person under age 19 (i) entirely suppor-
ted by the Subscriber or the Subscriber's spouse. (ii) permanently residing in
the Subscriber's household and, (iii) for whom the Subscriber or Subscriber's
spouse is (or was before the person's 18th birthday) the court-appointed guard-
ian. However. a child who meets the qualifications set forth above and whose
parent is a Family Dependent is eligible for coverage without court-appointed
guardianship as long as the parent is eligible for coverage as a Family Depen-
dent.
(3) Health Pledge Member. To be a Health Pledge Member, a person must:
(a) Meet the requirements in Section 2-A(l) or 2-A(2);
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(b) Be enrolled under the risk contract between Health Plan and the Health
Care Financing Administration ("HCFA");
(c) Not have end-stage renal disease at the time of enrollment (unless the
person is currently enrolled under any other Group or Individual Medical and
Hospital Service Agreement);
(d) Not be receiving Medicare hospice benefits at the time of enrollment;
and
(e) Reside in the Service Area (unless the person is currently enrolled
under any other Group or Individual Medical and Hospital Service Agreement).
(4) Continuation Coverage.
(a) If Group has 20 or more employees, a Member who would otherwise lose
coverage may continue uninterrupted coverage hereunder upon arrangement with
Group in compliance with the Consolidated Omnibus Budget Reconciliation Act of
1985 and related statutes (collectively "COBRA"), and upon payment of applica-
ble monthly charges to Group, if:
(i) The Member's coverage is through a Subscriber who dies, divorces or
legally separates, or becomes entitled to Medicare benefits; or
(ii) The Member is a dependent child who ceases to qualify'under Section
2-A(2)(b); or
(iii) The Member is a Subscriber, or the Member's coverage is through a
Subscriber, whose employment terminates (other than for gross misconduct) or
whose hours of employment are reduced.
(b) Coverage under this
applicable monthly charges
terminates on the earlier of:
Section 2-A(4)
to Group at
continues
the time
only upon payment of
specified by Group, and
(i) Termination of this Agreement.
(ii) Coverage of the Member under any other group health plan or entitle-
ment to Medicare.
(iii) Expiration of 36
tion 2-A(4)(a)(i) or (ii).
calendar months after an event descr\bed in Sec-
,
(iv) Expiration of 18 calendar months after an eytnt described in Section
2-A(4 )(a)(iii).
(c) A Member who is a retiree or the spouse or dependent of a retiree may
continue coverage hereunder if (a) Group has more than 20 employees and (b) the
Member would otherwise lose coverage hereunder within one year of the date a
proceeding under Title 11 of the United States Code is commenced with respect
to Group. Coverage under this Section 2-A(4) continues only upon payment of
applicable monthly charges to Group at the time' specified by Group. The terms
and conditions of this coverage are governed by COBRA.
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Health Plan may terminate any Member enrolled under this Section 2-A(4) for
fwhom Health Plan does not receive payment when due.
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Ineligible Persons. No person is eligible to enroll hereunder if the person or
any other person in his or her Family Unit has had Health Plan coverage terminated
under this or any other Health Plan Medical and Hospital Service Agreement for any
reason specified in Section 9-B(2).
B. Enrollment. Group will (1) offer coverage under this Agreement to all eligible
persons on conditions no less favorable than those for any alternate health care plan
available through Group, and (2) have an open enrollment period at least once a year
during which all eligible persons are offered a choice of enrollment under this
Agreement or any alternate health care plan av~ilable through Group.
(1) Newly Eligible Persons. A person who newly attains eligibility to become a
Subscriber may enroll by submitting an enrollment application to Group within 30
days. If Group has a probationary period during which a new employee is not
eligible to become a Subscriber, the enrollment application must be submitted to
Group within 30 days after the probationary period ends. If Subscriber desires
to enroll the persons then eligible to become the Subscriber's Family Dependents,
they must be enrolled at the same time.
Any person who thereafter newly attains eligibility to become a Family Depen-
dent, such as a new spouse or newborn child, may be enrolled by Subscriber's sub-
mitting a change of enrollment form to Group within 30 days. A newborn child of a
Family Dependent other than the Subscriber's spouse may be enrolled hereunder only
if the newborn child is eligible under Section 2-A(2)(c); if not eligible under
Section 2-A(2)(c), the newborn may be enrolled under an Individual Service Agree-
ment by submitting an application within 30 days of birth.
(2) Open Enrollment Period. There shall be an Open Enrollment Period between
November 01 - November 30 each year.
Eligible persons not enrolled when newly eligible may only be enrolled as Sub-
cribers and Family Dependents by submitting an enrollment application to Group
during the open enrollment period.
Limitation on Enrollment. If Health Plan determines that it is necessary to limit
enrollment of additional Members in order to maintain a suitable level of Medical or
Hospital Services to Members, Health Plan may limit enrollment (except for .newborns
or newly adopted children) as it deems appropriate notwithstanding the eligibility
and enrollment provisions of this Section 2 or any other provision of this Agreement.
C. Effective Date of Coverage.
(1) Newly Eligible Persons. Coverage for every newly eligible and enrolled per-
son except a newborn or adopted child is effective on the first day of the month
following receipt of the enrollment card. An eligible and enrolled adopted child
is covered from the date placed in the custody of the adoptive parents..
(2) Newborn. Coverage for a newborn child is provided from birth during the
Member mother's confinement or during the calendar month of birth, whichever is
greater; for coverage thereafter the newborn must be enrolled in accord with
Section 2-B(I).
Group 66-00
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(3) Open Enrollment Period. Coverage for persons enrolled during the open en-
rollment period November 01 - November 30 is effective January 01.
D. Subject to the provisions of Section 9, a person who is a Member hereunder
on the first day of a month is covered for the entire month.
3. RELATIONS AMONG PARTIES AFFECTED BY AGREEMENT
The relationships between Health Plan and Medical Group arid between Health. Plan
and Hospitals are those of independent contractors. Physicians and Hospitals are not
agents or employees of Health Plan. Neither Health Plan nor any employee of Health
Plan is an employee or agent of Hospitals or Medical Group or any Physician.
Physicians maintain the physician-patient r~lationship with Members and are solely.
responsible to Members for all Medical Services. Hospitals maintain the hospital-
patient relationship with Members and are solely responsible to Members. for all. Hos-
pital Services.
Patient-identifying information from the medical records of Members and
patient-identifying information received by Physicians or Hospitals incident to the
physician-patient relationship or hospital-patient relationship is kept. confidential
and is not disclosed without the Member's prior consent, except for use by Health
Plan, Hospitals, or Medical Group or Physicians related to (i) administering this
Agreement; (ii) complying with government requirements; and (iii) bona fide research
or education.
Neither Group nor any Member is the agent or representative of Health Plan.
Neither Group nor any Member is liable for any act or omission of (i) Health Plan,
.its agents or employees; (ii) Medical Group; (iii) any Physician; (iv) Hospitals; or
(v) any other person or organization with which Health Plan has made or hereafter
makes arrangements for performance of services under this Agreement.
The contracts between Health Plan and Medical Group and between Health Plan and
Hospitals provide that Members are not liable for any amounts owed Medical Group or
Hospitals by Health Plan. However, a Member may be liable for the cost of any
services obtained from a non-contracting provider if Health Plan fails to pay that
provider.
4. RATES AND PAYMENT
A. Periodic Payment Schedule.
for each Subscriber and his or her
last day of the preceding month:
Group shall pay Health Plan the following amounts
Family Dependents for each month on or before the
Basic Rate Structure
Subscriber only
Subscriber with one Family Dependent
Subscriber with two or more Family Dependents
$ 100.46
$ 200.92
$ 2114.50
Variables to lIasic Rate Structure:
Health Pledge Member
For each Member (up to 2 per Family Unit) entitled to
benefits under Part A and enrolled in Part B of Medicare:
.
.
.
Group 66-00
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0
Subtract $ 45.98
Subtract $ 45.98
B of
A of
Add $ 36.09
Subscriber
Subscriber's spouse or child
For each Member age 65 or older, enrolled in Part
Medicare, but not entitled to benefits under Part
Medicare:
Medicare "M" Member
For each Member (up to 2 per Family Unit) entitled to ben-
efits under both Parts A and B of Medicare, for whom an
assignment of Part B benefits to Health Plan is in effect
(except for Members living outside the Service Area):
Subscriber
Subscriber's spouse or child
Subtract $
Subtract $
35.98
35.98
For each Member age 65 or older (a) entitled to benefits
under Part A of Medicare and for whom no assignment of
Medicare Part B benefits to Health Plan is in effect, or
(b) who disenro11s from Health Pledge, or (c) who is en-
rolled in Part B of Medicare after 7/1/87, but not
entitled to benefits under Part A and lives outside the
Service Area
Add $
38.30
For each Member age 65 or older who has become a Member of
another Medicare Risk Program: Add
$ 200.67
These amounts are called the "Base Payment". A state or other taxing authority
may impose upon Health Plan a tax or other fee that was not in effect when this
Agreement was first entered into or last renewed, and which is levied upon or
measured by the Base Payment, by Health Plan's gross receipts, by Health Plan's
membership, or any.combination of these. If such a tax or fee is imposed, or if any
such existing tax or fee is increased, beginning on the effective date thereof
Group will pay Health Plan an amount with, and in addition to, the Base Payment.
This additional amount shall be the Group's prorated share of such tax, fee, or
increase.
Only Members for whom Health Plan has received the appropriate payment are enti-
tled to coverage under this Agreement, ana then only for the period to which the pay-
ment applies.
B. Other Charges. In addition, Members must pay for or arrange for payment of
amounts they owe Health Plan, Hospitals or Medical Group.
C. Medicare
(1) Medicare Payments.
Payments owed by Members or Group under this Agreement are based on the assumption
that Health Plan, Hospitals, Medical Group or their designees will receive and re-
tain Medicare payments for services provided to Members entitled to Medica~e bene-
fits. Each such Member must complete and submit to Health Plan all consents, re-
leases, assignments and other documents necessary for Health Plan, Hospitals, .Me-
dical Group or their designees to obtain and retain Medicare payments. Any Member
who fails to do so miJt pay for services at Non-Member Rates.
Group 66-00
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(2) Special Provision for Members Entitled to Medicare Benefits.
Under federal law, employed Members and their Family Dependents who are entitled
to Medicare benefits may elect, or may be. required, to have Group's health plan
as their primary health care coverage. Such Members, and Members with end stage
renal disease whose Medicare benefits provide secondary coverage, are subject to
the same rates and receive the same benefits under this Agreement as Members under
65 who are not entitled to Medicare benefits.
(3) Other Coverage - Health Pledge Members.
When Medicare by law is secondary payer, benefits otherwise provided under this
Agreement for Health Pledge Members are red~ced by all ~unts paid or payable, or
which in the absence of this Agreement would be payable, 'under any insurance poli-
cy or any other contract. Members must complete and submit to Health Plan all
consents, releases, assignments and other documents necessary for Health Plan tOI
obtain or assure such payment. A Member who fails to do so must pay for services
at Non-Member Rates.
D. Employer Contribution. Employer contribution shall be determined by Group, but
in no case will be less than one-half the rate required for a single Subscriber.
5. SERVICES AND BENEFITS
Subject to all terms and provisions of this Agreement, Members receive services
and other benefits as follows:
A. Within the Service Area. Members receive the services and other benefits
specified in the applicable Benefit Schedule(s) when provided, prescribed or directed
by Physicians.
Choice of Physician and Hospital. Within the Service Area, covered services are
available only from Medical Group, Hospitals and in Skilled Nursing Facilities.
Neither Health Plan, Hospitals, Medical Group nor any Physician has any liability or
obligation for any service or benefit sought or received by any Member from any other
doctor, hospital, skilled nursing facility, person, institution, or organization,
unless such services are covered under Sections 11-Q or 11-5, or Sections 12-Q or
12-5 of the applicable Benefit Schedule(s).
B. Outside the Service Area. Members receive benefits under Sections.11-R and
11-5, or Sections 12-R and 12-5 of the applicable Benefit Schedule(s).
6. EXCLUSIONS, LIMITATIONS, AND REDUCTIONS
A. Exclusions. The following are excluded from the coverage of this Agreement:
(1) Employer or Governmental Responsibility.
\
(a) Financial responsibility for services and other benefits provided or
arranged by Health Plan for any illness, injury or condition for which, or as a
result of which, a payment or any other benefit, including amounts received in
settlement of claims therefor ("Financial Benefit") is provided pursuant to
.,
Group 66-00
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any federal, state, county or municipal workers' compensation or employer's
liability law or other legislation of similar purpose or import.
(b) Services for any illness, injury or condition for which, or as a result
of which, a service benefit, including amounts received in settlement of
claims therefor ("Service Benefit") is provided or is required to be pro-
vided by the Veterans Administration for military service-connected disa-
bilities, as defined by the Veterans Administration, when such care is reason-
ably available to the Member. This exclusion does not apply to Health Pledge
Members .
(c) Services and financial responsibility for services for any illness,
injury or condition which law requires be provided only by or received only
from a federal, state, county, municipal or other governmental agency.
If there is reasonable doubt whether any Financial Benefit is available
because of illness, injury or condition pursuant to any workers' compensation or
employer's liability law, and if the Member seeks diligently to establish his or
her rights to Financial Benefits, then services that otherwise would be provided
under this Agreement will be provided, except that the value of such services, at
Non-Member Rates, is recoverable by Health Plan or its nominee from any person,
organization or agency providing Financial Benefits or from whom Financial
Benefits are due, or from the Member, to the extent that monetary Benefits are
provided or payable or would have been required to be provided if the Member had
diligently sought to establish his or her rights to such Financial Benefits. ..
(2) Non-Covered Inpatient Care. Custodial care, domiciliary care, convalescent
care, care in an intermediate care facility and any other inpatient care which is
not medically required and specifically covered by this Service Agreement.
(3) Cosmetic Services. Plastic surgery or other services which are indicated
primarily for cosmetic purposes, except as provided in Sections ll-I and l2-I.
(4) Dental Care. Dental
teeth. This exclusion does
Medicare.
care and dental X-rays,
not apply to medically
including care for injury to .
necessary care covered by
(5) Certain Physical Examinations. Physical examinations and related services
required for obtaining or continuing employment, insurance or governmental licens-
ing.
(6) Experimental or Investigational Services. Any treatment pr9,cedure, drug or
drug usage, facility or facility usage, equipment or equipment usage; device or
device usage, or supplies . (each of which is hereafter called a' "Service") which
Health Plan, after consultation with Medical Group, determines to be experimental
or investigational. A Service is experimental or investigational if:
(a) The Service is not recognized in accord with generaliy accepted medical
standards as being safe and effective for use in the treatment of the condi-
tion in question, whether or not the Service is authorized by law for use in
testing or other studies on human patients; or
(b) The Service requires approval by any governmental authority prior to use
where such approval has not been granted when the Service is to be rendered.
(7) Procedures Not Generally and Customarily Provided.
I
Anybealth care pro-
Group 66-00
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cedure not generally and customarily provided in Southern California, unless it is
generally accepted medical practice to refer patients outside of Southern Califor-
nia for such procedures.
(8) Voluntary Infertility. Services to reverse voluntary, surgically induced
infertility.
(9) Podiatry. Routine, non-medically necessary foot care services.
(10) Chiropractic. Chiropractic services and services of a chiropractor, except
that manual manipulation of the spine to correct subluxation that can be
demonstrated by x-ray is covered when x-ray diagnosis and manual manipulation are
performed by .a Physician.
(11) Durable Equipment. Durable medical equipment, such as oxygen dispensing
equipment, hospital beds, and wheelchairs used in the Member's home (including an
institution used as his or her home) except that Medicare Members and Part B
Members have the benefits as set forth in Section ll-L and Health Pledge Members
have the benefits as set forth in Section l2-V.
(12) Blood. Blood, except as specified in Sections 11-B and 12-B.
(13) Artificial Organs. Artificial organs and their implantation are excluded.
(14) Sex Change. All services related to sex changes.
B. Limitations. The rights of Members and obligations of Health Plan, Hospitals,
Medical Group and Physicians under this Agreement are subject to the following
limitations:
(1) Unusual Circumstances. If, due to unusual circumstances, such as (a) com-
plete or partial destruction of facilities, war, riot, civil insurrection, labor
disputes not involving Health Plan, Hospitals or Medical Group, major disaster,
disability of a significant part of Hospital or Medical Group personnel, epidemic,
or similar causes, .or (b) labor disputes involving Health Plan, Hospitals or Medi-
cal Group, the rendition or provision of services and other benefits covered under
this Agreement is delayed or rendered impractical, Hospitals, Medical Group and
Physicians will, within the limitation of available facilities and personnel, use
their best efforts to provide services and other benefits covered under this
Agreement, but with regard to (a), neither Health Plan, Hospitals, Medical Group
nor any Physician shall have any liability or obligation on account of such delay
or such failure to provide services or other benefits, and with regard to (b), the
provision of non-emergent care may be deferred until after resolution of the labor
dispute. .
(2) Refusal to Accept Treatment. Certain Members may, for personal reasons, re-
fuse to accept procedures or treatment recommended by Physicians. Physicians may
regard such refusal as incompatible with the continuance of a satisfactory physi-
cian-patient relationship and as obstructing the providing of proper medical care.
Physicians use their best efforts to render all necessary and appropriate.profes-
sional services in a manner compatible with a Member's wishes, insofar as this can
be done consistently with the Physician's judgment regarding proper medical prac-
tice. If a Member refuses to follow a recommended treatment or procedure, and the
Physician believes that no professionally acceptable alternative exists, the Mem-
ber is so advised. If the Member still refuses to follow the recommended treatment
or procedure, then neither Medical Group, Hospitals, Health Plan nor any Physician
Group 66-00
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has any further responsibility to provide care for the condition under treatment.
(3) Alcohol and Drug Dependency. Services' for alcohol and drug dependency are
provided only in accord with Sections ll-M and l2-M.
(4) Rehabilitation. Rehabilitative treatment is provided only in accord with
Sections ll-E and l2-E.
(S) Psychiatric Conditions. Mental health services, including any treatment for
mental illness or disorders, or drug-induced mental condition, are provided only
in accord with Sections ll-N and l2-N.
(6) Corrective Appliances and Artificial Aids. Corrective appliances and arti-
ficial aids such as braces, prosthetic devi~es, hearing aids, corrective lenses
and eyeglasses are limited to:
(a) permanent internally implanted prosthetic devices,such as cardiac pace-
makers and hip joints, which are not experimental and are generally and custom-
arily available in Southern California.
(b) prosthetic devices as provided in Sections 11-1 and 12-1.
(c) post-cataract surgery lenses covered by Medicare, which are provided
without charge to Medicare Members and Part B Members.
(d) for Health Pledge Members, additional benefits are provided as set
forth in Section l2-V.
C. Reductions. The benefits of Members are subject to the following reductions:
(1) Injuries or Illnesses Caused or Alleged to be Caused by Third Parties.
Members are required to pay for Services, as follows:
(a) Services Rendered at Facilities Contracting with Health Plan. If any
injury or illness is caused or alleged to be caused by any act or omission of a
third party, services and other benefits are furnished or arranged by
Physicians and Hospitals at Non-Member Rates. Payment of these charges is the
Member's responsibility, except that the Member is not required to pay any
portion of such charges which is in excess of the total amount that the Member
(or his or her estate, parent or legal guardian) receives from or on behalf of
the third party on account of such acts or omissions, whether by settlement or
judgment. Payment shall be made from the proceeds of the settlement or
judgment, and Health Plan (or its designee) shall have a lien on the settlement
or judgment for that purpose. At Health Plan's (or its designee's) request the
Member (or his or her estate, parent or legal guardian) shall execute a lien
formes) directing his or her attorney or the third party to make payments
directly to Health Plan (or to its designee).
(b) Emergency Services Received at Facilities Not Contracting with Health
Plan. If any injury or illness is caused or alleged to be caused by any act or
omission of a third party, payments under Sections ll-S and l2-S are made' for
the services of physicians, hospitals and other providers not contracting with
Health Plan; however, the Member must reimburse Health Plan for any amount paid
by Health Plan up to the total amount that the Member (or his or her estate,
parent or legal guardian) receives from or on behalf of the third party on
account of such acts or omissions, whether by settlement or judgment.
Group 66-00
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Reimbursement is the Member's responsibility and shall be made from the
proceeds of the settlement or judgment, and Health Plan (or its designee) shall
have a lien on the settlement or judgment for that purpose. At Health Plan's
request the Member (or his or her estate, parent or legal guardian) shall
execute a lien formes) directing his or her attorney or the third party to make
payments directly to Health Plan (or to its designee).
The provisions of this Section 6-C(1) apply even if the total
Member's recovery on account of the third party's conduct
Member's actual damages.
amount of the
is less than the
The Member further agrees that he or she (or his or her estate, parent or legal
guardian) will notify Health Plan of any actual or potential claim or legal
action which the Member anticipates br~nging or has brought against any third
party arising from the alleged acts or omissions not later than 30 days
subsequent to submitting or filing a claim or legal action against the third
party.
7. CONVERSION AND TRANSFER
A. Conversion to Non-Group Membership. A person who ceases to qualify as a Member
under this Agreement for any reason except termination of membership under' Section 9
may convert to non-group membership within 31 days after ceasing to qualify. Non-
group membership begins when membership under this Agreement ends.
B. Change of Residence.
(1) All Members except Health Pledge Members. A Member who moves to an area
not within a Health Plan Region may continue Health Plan membership under this
Agreement if the Member continues to meet the other applicable eligibility re-
quirements of Section 2. However, the only benefits covered outside the SerVice
Area are those specified in Sections ll-R and ll-S of the applicable Benefit Sche-
dule(s).
A Member who moves to another Health Plan Region and who
membership must promptly enroll as a Member in the new Region.
coverage may not be available in the new Region.
wishes to maintain
However, identical
A Member may obtain benefits under Sections 11-R and 11-S of the applicable
Benefit Schedule(s) while in another Health Plan Region. However, a Member has
no right to benefits in the new Region after residing there for more than 90 days,
unless the member: (a) has enrolled as a Member in the new Region; or (b) demon-
strates, by prior application to Health Plan, that his or her stay in the new Re-
gion for a period longer than 90 days is "temporary", and Health Plan approves in
writing.
(2) Health Pledge Members. A Health Pledge Member who permanently moves to an
area not within a Health Plan Region may not continue to be a Health Pledge Mem-
ber. (Medicare regulations define "a permanent move" as being out of the Service
Area for more than 90 consecutive days.) Such a Member must give Health Plan
written notice of the move. The Member may continue membership as a Medicare Mem-
ber or a Part B Member, as appropriate. Such membership begins when membership as
a Health Pledge Member ends. However, the only benefits which such a Medicare
Member or Part B Member has outside the Service Area are those specified in Sec-
tions ll-R-and ll-S of the applicable Benefit Schedule(s). If such a Medicare
Group 66-00
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Member or Part B Member later
tify Health Plan and may be
maintain membership.
moves back into the Service Area the Member must no-
required to re-enroll as a Health Pledge Member to
A Member who permanently moves to another Health Plan Region and who wishes to
maintain membership must promptly enroll as a Member in the new Region. However,
identical coverage may not be available in the new Region.
8. ARBITRATION OF CLAIMS
A. Initiating a Claim. Any claim which arises from alleged violation of any duty
incident to or arising out of this Agreement, irrespective of the legal theories upon
which the claim is asserted, including any claim for medical or hospital negligence,
(1) Against one or more of the following ("Respondent"):
(a) Health Plan,
(b) Hospitals,
(c) Medical Group,
(d) Any Physician, or
(e) Any employee or agent of the foregoing,
(2) By a Member, a Member's heir or personal representative, or by a person
claiming that a duty to him or her arises from a Member's relationship with one or
more Respondents ("Claimant"),
(3) For any damage or relief, except for claims solely for monetary damages
within the jurisdictional limit of the Small Claims Court,
shall be submitted to binding arbitration.
Claimant shall initiate the claim by serving at least one Respondent with notice
of the nature' of the claim and a demand for arbitration. Claimant shall serve all
Respondents reasonably servable, and the arbitrators shall have jurisdiction only
over Respondents actually served. The notice and demand must be served in the fol-
lowing manner: Natural persons and all other Respondents must be served by registered
letter, postage prepaid, addressed to Respondent in care of Kaiser Foundation, Health
Plan, Inc., Legal Department, 393 East Walnut Street, Pasadena, California 91188-8401.
B. Initiating Arbitration Proceedings. Within 30 days after initial service on a
Respondent, Claimant and Respondent each shall designate an arbitrator and give writ-
ten notice of such designation to the other, and Claimant shall forward a check for
$150 made payable to Kaiser Foundation Health Plan, Inc., Legal Department, 393 ,East
Walnut Street, Pasadena, California 91188-8401. This $150 will be deposited with
Respondent's check for $150 in a special account maintained by Bank of America Na-
tional Trust and Savings Association, 1850 Gateway Boulevard, Concord, California
94520. These funds provide the initial funds to pay the fees of the neutral arbitra-
tor and expenses of arbitration as approved by him or her, which fees and expenses
shall be borne equally by the parties. "Expenses of arbitration" does not include
counselor witness fees or other expenses incurred by a party for his or her own
benefit. Said account shall be replenished from time to time as directed by the neu-
tral arbitrator. Within 30 days after these notices have been given and payments
Group 66-00
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.made, the two arbitrators so selected shall select a neutral arbitrator and give no-
tice of the selection to Claimant and all Respondents served, and the three arbitra-
tors shall hold a hearing within a reasonable time thereafter. Except where other-
wise agreed to by the parties, arbitration shall be held at a time and place designa-
ted by the neutral arbitrator in a county where an alleged wrongful act occured.
C. General Provisions. All claims based upon the same incident, transaction or
related circumstances shall be arbitrated in one proceeding and all Respondents duly
served in connection therewith shall be parties. A claim shall be waived and forever
barred if (1) on the date notice thereof is received, the claim, if asserted in a
civil action, would be barred by the applicable California statute of limitations, or
(2) the Claimant fails to pursue the arbitration claim in accord with procedures
prescribed herein with reasonable diligence. All notices or other papers required to
be served or convenient in the conduct of arbitration proceedings following the
initial service shall be served'by mailing the same, postage prepaid, to such address
as each party gives for this purpose. With respect to any matter not herein
expressly provided for, the arbitration shall be governed by California Code of Civil
Procedure provisions relating to arbitration. The California Medical Injury
Compensation Reform Act of 1975 (including any amendments thereto), including, but
not limited to, sections establishing the right to introduce evidence of any
insurance or disability benefit payable to the patient, the limitation on recovery
for non-economic losses, and the right to have an award for future damages conformed
to periodic payments, shall apply to any claims for professional negligence.
D. Special Provision For Health Pledge Members. For Health Pledge Members, the
provisions of this Section 8 apply only to claims asserted on account of death,
mental disturbance or bodily injury arising from rendition or failure to render
services under this Agreement, irrespective of the legal theory upon which the claim
is asserted.
9. TERM AND TERMINATION
A. Term.
This Agreement continues in effect from the effective date stated on the last page
of this Agreement to January 01, 1990, and from year to year thereafter, subject
to Health Plan or Group terminating this Agreement pursuant to Section 9B.
B. Termination.
Except as specifically provided in this paragraph, all rights to services and oth-
er benefits hereunder terminate as of the effective date of termination.
(1) Termination of Agreement.
This Agreement may be terminated as follows:
(a) Termination on Notice.
by giving written notice to
January 1 ("Anniversary Date").
Either party may terminate this Agreement
the other at least 90 days 'prior to any
(b) Nonpayment. If Group fails to make any past due monthly paylllent within
15 days after notice to Group of the amount payable, then Health Plan may ter-
minate this Agreement by written notice effective immediately upon written no-
tice.
(c) Discontinuance or Partial Discontinuance of Health Plan Operations and
Group 66-00
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Services. If Health Plan's governing Board determines that Health Plan would be
unable or it would be impractical to continue providing or arranging any or all
benefits and services being provided or arranged pursuant to this Agreement,
then Health Plan may terminate this Agreement upon 30 days written notice to
Group, and neither Health Plan, Hospitals, Medical Group, nor any Physician
shall have any further liability or responsibility, except for benefits refer-
red to in Section 9(B)(1)(d), by reason of or pursuant to this Agreement after
the effective date of such termination.
(d) Continued Coverage for Disabled Kembers. If this Agreement is termi-
nated, any totally disabled Member who became totally disabled after December
31, 1977, and while enrolled as a Member under this Agreement, except
Subscribers or their Family Dependents who became totally disabled. after the
Subscriber's employment with Group terminated, shall, subject to all
limitations and restrictions of this Agreement,. including payment of Sup-
plemental Charges, be covered for the disabling condition for (a) 12 months,
or (b) until no longer totally disabled, or (c) until this Agreement is re-
placed by another group health benefits arrangement providing benefits similar
to those provided hereunder (if such other arrangement is without limitation
as to the disabling condition), whichever occurs first. A person is totally
disabled if he or she (a) has any medically determinable physical or mental im-
pairment that (i) can be expected to result in death, or (ii) has lasted or can
be expected to last for a . continuous period of not less than 12 months, and
(iii) renders the individual unable to engage in any substantial gainful acti-
vity,. or (b) is (i) age 55 or older, and (ii) unable, by reason of legal blind-
ness, to engage in substantial gainful activity requiring skills or abilities
comparable to those of any gainful activity in which he or she previously en-
gaged with some regularity over a substantial period of time.
(2) Termination of Specific Kembers.
(a) Termination for Cause. If Hospitals or Medical Group, after reasonable
efforts to establish and maintain a satisfactory hospital-patient or physician-
patient relationship with any Member, are unable to do so, then the rights of
the Member and all other Members of the Family Unit may be terminated on not
less than 15 days written notice to Subscriber. Termination of Health Pledge
Members is subject to approval by HCFA.
(b) Nonpayment. If a Member fails to pay any amount owed by the Member to
Health Plan, Hospitals or Medical Group within 15 days after notice to the Fa-
mily Unit Subscriber of the amount due, then Health Plan may terminate the
rights of the Member and all other Members of the Family Unit effective immedi-
ately upon written notice and their rights may be reinstated only by payment of
the amounts due and by renewed application and re-enrollment in accord with
Section 2-B(2).
(c) Furnishing Incorrect or Incomplete Information. Members warrant that all
information contained in applications, questionnaires, forms or statements sub-
mitted to Health Plan incident to enrollment under this Agreement or the admi-
nistration hereof is true, correct and complete. Members agree to advise Health
Plan of any change in family or Medicare coverage status that affects eligibil-
ity for membership. If a Member knowingly furnishes incorrect or incomplete in-
formation or subsequently fails to inform Health Plan of changes of eligibility
status of dependents, then the rights of the Member and all other Members of
the Family Unit may be terminated effective immediately upon Written notice.
Group 66-00
Page 15
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(d) Kisuse of Identification Card. If any Member permits the use of his or
her or any other Member's Health Plan identification card by any other person,
or uses another person's card, the card may be retained by Health Plan, and all
rights of the Member and all other Members of the Family Unit may be terminated
effective immediately upon written notice.
(3) Return of Prorata Portion of Konthly Payment in Certain Cases. If the
rights of a Member hereunder are terminated under Section 9(B)(2), prepayments re-
ceived on account of the terminated Member or Members applicable to periods after
the effective date of termination, plus amounts due on claims, if any, less any
amounts due to Health Plan, Hospitals or Medical Group, are refunded within thirty
days and neither Health Plan, Hospitals, Medical Group nor any Physician has any
further liability or responsibility under this Agreement.
(4) Opportunity for Review of Certain Terminations by Commissioner of Corpora-
tions. A Member who alleges that his or her rights hereunder were terminated or
not renewed because of a Member's health status or requirements for health care
services, may request a review of the terminstion by the Commissioner of Corpora-
tions. Section 1365 (b) of the Knox-Keene Act provides as follows:
"(b) An enrollee or subscriber who alleges that an enrollment or subscrip.
tion has been cancelled or not renewed because of the enrollee's or subscri-
. ber's health status or requirement for health care services may request a re-
view by the commissioner. If the commissioner determines that a proper com-
plaint exists under the provisions of this section, the commissioner shall no-
tify the plan. Within 15 days after receipt of such notice, the plan shall ei-
ther request a hearing or reinstate the enrollee or subscriber. If, after
hearing, the commissioner determines that the cancellation or failure to renew
is contrary to subdivision (a), the commissioner shall order the plan to rein-
state the enrollee or subscriber. A reinstatement pursuant to this subdivision
shall be retroactive to the time of cancellation or failure to renew and the
plan shall be liable for the expenses incurred by the subscriber or enrollee
for covered health care services from the date of cancellation or nonrenewal to
and including the date of reinstatement."
(5) Termination of Risk Contract with Health Care Financing A~inistration
("HCFA") . If the risk contract between Health Plan and HCFA which provides for
prospective payment of all or part of the services covered for Health Pledge
Members is terminated, Health Pledge Members may continue their enrollment in this
Agreement as Medicare Members or Part B Members, as appropriate, effective
upon termination of the risk contract with HCFA.
C. Amendment
Health Plan may amend this Service Agreement with respect to.any matter, including
rates, effective as of any Anniversary Date by mailing a postage prepaid notice of
the amendments to Group at its sddress of record with Health Plan at lesst 90 days
before the Anniversary Date. All amendments are deemed aCCepted by Group Unless Group
gives Health Plan written notice of non-acceptance at least 30 days before the Anni-
versary Date, in which event this Service Agreement and all rights to services and
other benefits terminate on the Anniversary Date.
10. MISCELLANEOUS PROVISIONS
A. Acceptance of Agreement. Group may accept this Agreement either by execution
of the acceptance provided on the last page of this Service Agreement or by making
payment to Health Plan pursuant to Section 4-A hereof, and such acceptance renders
all terms and provisions hereof binding on Health Plan and Group.
Group 66-00 Page 16
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B. Agreement Binding on Kembers. By this Agreement, Group makes Health Plan cov-
erage available to persons who are eligible. However, this Agreement is subject to
amendment, modification or termination in accord with any provision hereof or by mu-
tual agreement between Health Plan and Group without the consent or concurrence of
Kembers. By electing medical and hospital coverage pursuant to this Agreement, or ac-
cepting benefits hereunder, all Members legally capable of contracting, and the legal
representatives of all Members incapable of contracting, agree to all terms, condi-
tions and provisions hereof.
C. Applicatioils and Statements. Members or applicants for membership shall
complete and submit to Health Plan such applications, or other forms or statements as
Health Plan may reasonably request.
D. Identification Cards. Cards issued by Health Plan to Members pursuant to this
Agreement are for identification only. Possession of a Health Plan identification
card confers no rights to services or other benefits under this Agreement. To be en-
titled to such services or benefits the holder of the card must, in fact, be a Member
on whose behalf all applicable charges under this Agreement have been paid. Any per-
son receiving services or other benefits to which he or she is not then entitled pur-
suant to the provisions of this Agreement is chargeable therefor at Non-Member Rates.
E. Right to Examine Records.
pertinent records, with respect
ment.
Health Plan at reasonable times may examine Group's
to eligibility and monthly payments under this Agree-
F. Notice of Certain Events. Health Plan shall give Group written notice within a .
reasonable time of any termination or breach of contract by, or inability to perform
of, Hospitals or Medical Group or any other person with whom Health Plan has a con-
tract to provide services and benefits hereunder, if Group may be materially and ad-
versely affected thereby.
In the event that the contract between Health Plan and Hospitals, Medical Group or
any other contracting provider is terminated while a Member is under the care of such
provider, Health Plan will retain financial responsibility for such care, in excess
of any applicable supplemental charges. Such responsibility shall continue until the
services being rendered are completed, or until Health Plan makes provision for the
assumption of such services by another provider and so notifies Subscriber, whichever
occurs first.
G. Governing Law. Health Plan is subject to the requirements of Chapter 2.2 of
Division 2 of the California Health and Safety Code and of Subchapter 5.5 of Chapter
3 of Title 10 of the California Administrative Code, and any provision required to be
in this Service Agreement by either of the above shall bind Health Plan whether or
not set forth herein.
H. Administration of Agreement.
cedures, rules and interpretations
this Agreement.
Health Plan may adopt reasonable policies, pro-
to promote orderly and efficient administration of
t
I. Kember Information. Group shall inform Subscribers (1) of the periodic charges
applicable to their coverage; (2) of conditions of eligibility regarding Subscribers
and Family Dependents; and (3) when coverage becomes effective and terminates.
J. Notices. Any notice under this Agreement may be given by United States mail,
postage prepaid, addressed as follows:
Group 66-00
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If To Health Plan:
Health Plan Manager
Kaiser Foundation Health Plan, Inc.
393 East Walnut Street
Pasadena, California 91188
If To A Member:
To the latest address provided for the Member on enrollment or change of ad-
dress forms actually delivered to Health Plan.
If to Group:
To the address indicated on the last page of this Agreement.
A person designated as Group Representative on the last page of this Agreement or
otherwise designated by Group by notice to Health Plan, shall disseminate notice to
Subscribers by the next regular communication to them, but in no event later than 30
days after receipt thereof, .of all matters (of which Group Representative receives
notice from Health Plan) to which a reasonable person would attach importance in de-
termining the action to be taken upon the matter.
11. BENEFIT SCHEDULE
Subject to all terms, conditions, limitations and exclusions herein, Members are
entitled to the Medical and Hospital Services and other benefits set forth in this
Section, upon payment of specified Supplemental Charges or Non-Member rates. These
services and benefits are available only if and to the extent that they are provided,
prescribed or directed by a Physician, and unless otherwise specifically provided,
received at a Hospital or Medical Office.
Benefits hereunder include and are not in addition to Medicare benefits, except
for Members entitled to Medicare benefits who elect the Group's health plan as
primary coverage described in Section 4-C(2).
A. MEDICAL CARE IN HOSPITAL, OFFICE AND SKILLED NURSING FACILITY
Except for Medical Services specifically described in other parts of this Section
II, Medical Services are provided as follows.
(1) Care While Hospitalized. During prescribed hospitalization specified in
Section ll-B, Medical Services, including surgical procedures, obstetrical care,
anesthesia and consultation with and treatment by specialists, are provided with-
out charge.
(2) Care in Medical Offices or Emergency Departments.
(a) Diagnosis and Treatment. Medical Services, including surgical pro-
cedures, obstetrical care, eye examinations for corrective lenses, ear examina-
tions to determine the need for hearing correction, and consultation with and
treatment by specialists, are provided without charge.
(b) Preventive Services. Medical Services for health maintenance, including
physical checkups, are provided without charge.
Group 66-00
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Exclusion. Physical examinations required for obtaining or continuing em-
ployment, insurance or governmental licensing are not covered.
(3) Care in Skilled Nursing Facility. Medical Services, to the extent practica-
ble within the limitations of the equipment and staff of the Skilled Nursing Faci-
lity, are provided without charge while the Member is admitted to the Facility as
a registered bed patient.
B. HOSPITAL CARE
When prescribed, the following Hospital Services are provided without charge: room
and board; general nursing care; services and supplies; use of operating room; pri-
vate room; intensive care room and related ho~pital services; special diet; special
duty nursing; medications as specified in Section Il-F,.and medical supplies.
Diagnostic x-rays and laboratory tests are provided in accord with Section Il-D,
and physical therapy, inhalation therapy, occupational therapy,. speech therapy and
rehabilitation services, are provided in accord with Section 11-E.
Blood used in blood transfusions is provided without charge,. if blood is replaced
at a blood bank designated by Medical Group in accord with the blood bank's require-
ments. Health Plan may charge Non-Member Rates for.blood which is not replaced; ex-
cept (i) no charge is made for blood covered under Medicare, and (ii) a Member is not
charged for blood if (a) any Member of the Family Unit donated blood within the pre-
ceding 12 months, or (b) no Member of the Family Unit meets the medical criteria for
blood donors.
C. HOME VISITS
Necessary home visits by Physicians to supervise services provided under Section
11-L, and by visiting nurses when prescribed by a Physician, are provided within the
Service Area without charge.
D. DIAGNOSTIC PROCEDURES: DIAGNOSTIC X-RAY, LABORATORY AND SPECIAL
PROCEDURES.
All prescribed diagnostic x-rays and laboratory tests, special procedures, ser-
vices and materials are provided without charge.
E. THERAPEUTIC PROCEDURES
(1) Physical Therapy, Inhalation Therapy, Occupational Therapy.
(a) While Hospitalized, in a Skilled Nursing Facility, and While Receiving
Home Health Services. During hospitalization specified in Section 11-B, while
receiving Extended Care Services in a Skilled Nursing Facility specified in
Section ll-K, and while receiving Home Health Services specified in Section
11-L, prescribed physical therapy, inhalation therapy and occupational therapy
are provided without charge. Physical therapy and occupational therapy are
limited to treatment for conditions (including acute phases of chronic condi-
tions) which in the judgment of the Attending Physician are subject to continu-
ing significant improvement within a period of two months.
(b) In Medical Offices. Prescribed physical therapy, inhalation therapy and
occupational therapy are prOVided at Medical Offices without charge. Physical
Group 66-00
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therapy and occupational therapy are limited to treatment for conditions (in-
cludina acute phases of chronic conditions) which in the judgment of the Atten-
dina Ph~sician are subject to continuing significant improvement within a peri-
od of two months.
(b) In Medical Offices. Prescribed speech therapy as described in Section
ll-E (2)(a) above is provided at Medical Offices without charge to Part B Mem-
bers and Medicare Members and is provided at a charge of $5.00 per visit to
other Members.
(3) Rehabilitation. When, in the judgment of the Attendina Physician, signif-
icant ,improvement in function is achievable within a period of two months, up to
two months per condition under this or any other Health Plan Service Agreement
(including renewals) of a prescribed inpatient rehabilitation program are
provided in a Hospital or Skilled Nursing Facility without charge, except ~
diagnostic x-rays and laboratory tests are provided in accord with Section II-D.
(4) Therapeutic X-Rays and Therapeutic Nuclear Medicine Procedures.
(a) While Hospitalized. During hospitalization specified in Section ll-B,
prescribed therapeutic x-rays and therapeutic nuclear medicine procedures are
provided without charge.
(b) In Medical Offices. Prescribed therapeutic x-rays and therapeutic nu.
clear medicine procedures are provided at Medical Offices without charge.
Radiation therapy is provided by the specialized Regional ,Radiation Therapy
Service at the Los Angeles Medical Center.
(5) Orthoptic and Dermatological Black Light Treatments. Prescribed orthoptic
and dermatological black light treatments are provided in Medical offices without
charge.
F. PRESCRIBED MEDICATIONS, IMMUNIZATIONS, AND DRESSINGS AND CASTS
(1) Prescribed Medications and Items.
(a) Administered to Members.
(i) While Hospitalized. During hospitalization specified in Section ll-B,
all prescribed medications, injectables, radioactive materials used for
therapeutic purposes, and allergy test materials and allergy treatment ma-
terials are provided without charge.
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(ii) In Medical Offices, Emergency Departments and on Home Visits. All
prescribed injectable medications (including immune serums) which were
developed and in general use for specific diseases on April I of the year
immediately preceding the year in which this Agreement was entered into or
last renewed; chemotherapy medications generally available in Southern Cali-
fornia when prescribed for the treatment of cancer; and allergy test and
treatment materials administered in Medical Offices, at Hospital emergency
rooms and on home visits are provided without charge.
Prescribed injectable medications (including immune serums) which were
not developed or in general use for specific diseases as of April 1 of the
preceding year administered in Medical Offices, at Hospital emergency
departments and on home visits are provided without charge to Medicare
Members and,Part B Members and upon p~yment of a reasonable charge to other
members.
Intravenous fluids and medications, additives and nutrients administered
therewith are provided without charge when administered and are furnished
without charge at pharmacies in Hospitals and designated Medical Offices
when prescribed by a Physician for self-administration.
(b) Purchased by Members.
Members are provided up to a 100 day supply of covered medications and ac-
cessories at a charge of $2.50 for each prescription (except that if the regu-
lar charge is less than $2.50, members pay the regular charge), and any excess
over a 100 day supply at a reasonable charge. Each prescription refill is pro-
vided on the same basis as the original prescription. If requested and legally
permissible, refills are mailed upon prepayment of applicable charges.
The following medications and accessories are covered only when prescribed
by Physicians and dentists and obtained at pharmacies in Hospitals and desig-
nated Medical Offices or, in Kern County, at a designated pharmacy in the Ser-
vice Area. The locations and scheduled hours of operation of these pharmacies
are provided to Group on request.
(i) Drugs for which a prescription is required by law.
(ii) Additional drugs and accessories.
(A) Insulin
(B) The following diabetic supplies:
(a) Insulin syringes and needles
(b) Glucose test tablets
(c) Glucose test tape
(d) Acetone test tablets
(C) Compounded dermatological preparations which must be prepared by a
pharmacist in accord with a Physician's prescription.
(D) Antacids
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(E) For Members with enterostomies and urinary diversions, the fol-
lowing ostomy supplies and equipment: appliances, adhesives, skin bar-
riers, skin care items, belts and clamps, and internal and appliance deo-
dorants.
Exclusion. Drugs and medications when used for cosmetic purposes.
(2) Imaunizations. Immunizations (including immune serums, human origin) avail-
able in Southern California which were developed and in general use for specific
diseases on April 1 of the year immediately preceding the year in which this
Agreement became effective or was last renewed are provided without ch.rge. Immu-
nizations available in Southern California which were developed or put in general
use for specific diseases after April 1 of the year immediately preceding the year
in which this Agreement becomes effective or was last renewed and unexpected mass
immunizations are provided at 50 percent of Non-Member Rates.
(3) Dressings and Casts. During hospitalization specified in Section 11-B, and
at Medical Offices, Hospital emergency departments, and on home visits, prescribed
dressings and casts are provided without charge.
(4) Amino Acid Modified Products. Amino acid modified products used in the
treatment of inborn errors of amino acid metabolism when prescribed by a Physician
for inborn aminoacidopathy are provided without charge during the child's hospi-
talization, and are furnished without charge at pharmacies in Hospitals and desig-
nated Medical Offices for self-administered use.
(5) Immunosuppressive Drugs. Immunosuppressive drugs developed and in general
use on' April 1 of the year immediately preceding the year in which this Agreement
became effective or was last renewed are furnished without charge at pharmacies in
Hospitals and designated Medical Offices when prescribed by a Physician following
a covered transplant.
G. AMBULANCE SERVICE
Necessary ambulance service is provided without charge within the Service Area if
ordered or approved by a Physician.
H. FAMILY PLANNING AND INFERTILITY
(1) Family Planning. Family planning counseling, including pre-abortion and
post-abortion counseling and information on birth control, is . provided upon
payment of the registration charge, if any, specified in Section 11-A(2).
Diagnostic x-rays and laboratory tests are provided in accord with Section 11-D.
Contraceptive devices are provided at reasonable charges. Contraceptive drugs are
provided in accord with Section 11-F.
(2) Infertility. Medical Services for diagnosis and treatment of involuntary
infertility are provided upon payment of the registration charge, if any,
specified in Section 11-A(2). Diagnostic x-rays and laboratory tests are provided
in accord with Section 11-D, and medications are provided in accord with Section
11-F.
Exclusions.
The following are not covered:
(a) the cost of donor semen.
Group 66-00
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(b) Services, other than artificial insemination, related to conception
by artificial means, including, but not limited to, in vitro fertiliza-
tion and ovum transplants.
I. RECONSTRUCTIVE SURGERY AND PROSTHETIC DEVICES FOLLOWING MASTECTOMY
If all or part of a breast is surgically removed for medically necessary reasons,
reconstructive surgery and a prosthetic device incident to the mastectomy are provi-
ded subject to the payment of applicable Supplemental Charges, if any. A Physician
determines whether reconstructive surgery is medically feasible and the extent to
which further reconstructive surgery is necessary.
Medical Group will designate the source from which external prostheses are to be
obtained. Replacement will be made when prostheses are no longer functional. Custom
made prostheses will be provided when necessary.
J. HEMODIALYSIS AND ORGAN TRANSPLANTS
(1) Hemodialysis. Subject to the terms and conditions in this Section Il-J,
Medical and Hospital Services for hemodialysis for acute renal disease are
provided in accord with this Section 11 and for chronic renal disease .are provided
without charge. Medical Group determines whether a condition is chronic or acute.
Hemodialysis for chronic conditions is provided only in facilities approved for
participation in the Medicare program. Equipment, training and medical supplies
required for home dialysis, are provided without charge.
(2) Organ Transplants. Subject to the terms and conditions in this Section
Il-J, Medical and Hospital Services for covered organ transplants are provided in
accord with this Section 11. Reasonable medical and hospital expenses of the donor
or prospective donor directly related to the transplant are covered in full.
(3) Related Prescription Drugs. Prescribed post-surgical immunosuppressive
outpatient drugs required as a result of a covered transplant are provided in
accord with Section Il-F(S).
(4) Terms and Conditions. Covered services and benefits are provided only in
accord with the following terms and conditions:
(a) Medical Group determines that the Member satisfies medical criteria
developed by Medical Group for receiving the services.
(b) Medical Group provides a written referral for care to a transplant or
hemodialysis facility selected by Medical Group from a list of facilities it
has approved.
(c) If, after referral, either Medical Group or the medical staff of the
referral facility determines that the Member does not satisfy its respective
criteria for the services involved, Health Plan's obligation under this Section
ll-J is limited to paying for covered services provided prior to such determi-
nation.
(d) Neither Health Plan, Medical Group nor Physicians undertake to provide a'
donor or a donor organ or to assure the availability of a donor or of a donor
organ or the availability or capacity of referral facilities for organ trans.
Group 66-00
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plants approved by Medical Group.
(e) Except for medically necessary ambulance service provided in accord
with Section ll-G, neither transportation nor living expenses are covered for
the Member, for his or her family, or for a donor.
K. EXTENDED CARE SERVICES
(1) Kambers Who Are Not Kedicare Kembers or Part A Kembers. During each cal-
endar year, up to 100 days of prescribed Extended Care Services are provided or
arranged at approved Skilled Nursing Facilities, except that the number of days of
care is reduced and offset by the number of days of Extended Care Services that
the Member received under any other Health Plan Service Agreement during the
same calendar year.
(2) Kembers Who Are Kedicare Members or Part A Members. During each calendar
year, up to 150 days of prescribed Extended Care Services are provided or arranged
at approved Skilled Nursing Facilities, except that the number of days of care is
reduced and offset by all days of Extended Care Services covered in whole or in
part by Medicare that the Member receives which were not prescribed or directed
by a Physician or which were received from facilities not approved in writing by
Medical Group and by the number of days of Extended Care Services that the Member
received under any other Health Plan Service Agreement during the same calendar
year.
Extended Care Services include nursing care, bed and board, physical, occupation-
al, and speech therapy, medical social services, prescribed drugs and medications and
medical supplies, appliances and equipment ordinarily furnished by the Skilled Nurs-
ing Facility.
Diagnostic x-rays and laboratory tests are provided in accord with Section ll-D
and physical therapy, inhalation therapy, occupational therapy, speech therapy and
rehabilitation services, are provided in accord with Section II-E. Other covered Ex-
tended Care Services are provided without charge.
L. HOME HEALTH SERVICES AND HOSPICE CARE
Benefits under
available only
tain effective
this Section ll-L are provided within the
if the Attending Physician determines that it
supervision and control of the Member's care.
Service Area and are
is feasible to main-
(1) Home Health Services.
(a) Members Who Are Not Medicare Members, Part A Kembers or Part B Members.
Home health services are limited to services of registered nurses and home
health aides on a part-time or intermittent basis, and services of a medical
social worker as prescribed or directed by the Attending Physician, and are
provided without charge. Physical therapy, inhalation therapy, occupational
therapy, and speech therapy are provided in accord with Section II-E.
(b) Members Who Are Medicare Members, Part A Members or Part B Members. All
home health services (as defined in Medicare) that are covered in whole or in
part under Medicare and that are prescribed or directed by the Attending
Physician, are provided without charge.
Durable Equipment for Medicare Members. Durable medical equipment used in a
Group 66-00
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Member's home (including an institution used as his or her home) covered in whole
or in part under Medicare is provided without charge to Medicare Members and Part
B Members for the same period that partial or full reimbursement therefor is
available under Medicare.
(2) Hospice Care. Members who are diagnosed as having a terminal illness with
a life expectancy of six months or less may elect hospice care for such illness
instead of traditional services covered under this Service Agreement and by
Medicare. Care is provided by licensed hospices approved for participation in the
Medicare program and approved by Medical Group. While a hospice election is in
effect, covered care for the terminal illness is provided without charge. Such
care includes the following services and other. benefits when ordered by the Atten-
ding Physician and the hospice care team:
(a) nursing care;
(b) physical or
pathology;
occupational therapy or therapy for
speech-language
(c) medical social services;
(d) home health aide and homemaker services;
(e) medical supplies, drugs and appliances;
(f) physician services;
(g) short-term inpatient care, including respite care and care for pain
control and acute and chronic symptom management;
(h) counseling and bereavement services; and
(i) services of volunteers.
Limitation. Members who elect hospice care under this provision are not enti-
tled to any other benefits under this Sarvice Agreement or under Medicare for the
terminal ilness while the hospice election is in effect.
M. TREATMENT FOR ALCOHOL AND DRUG DEPENDENCY
Subject to the exclusions set forth in this Section ll-M, and to the Supplemental
Charges, if any, set forth in Section II, the care described herein is provided for
alcohol and/or drug dependency:
(1) Inpatient Care for Withdrawal. Prescribed Hospital Services for the medical
management of the signs and symptoms attendant to the withdrawal process. Recov.
ery services for the dependency, including education and counseling, are provided
when prescribed by a Physician.
(2) Outpatient Services. Diagnosis and prescribed treatment and counseling and
services for the medical management of the signs and symptoms attendant to the
withdrawal process are provided in Medical Offices.
(3) Exclusions. The following services are not provided:
(a) Methadone maintenance.
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(b) Continuation in a course of counseling for patients who are disruptive
or physically abusive.
N. MENTAL HEALTH SERVICES
Mental Health services specified in this Section ll-N are limited to evaluation,
crisis intervention and treatment -for acute psychiatric conditions which, in the
judpent of the Attending Physician, are subject to significant improvement through
relatively short-term therapy.
Calendar year maximums include-the number of outpatient visits, days of inpatient
mental health services and sessions of day care or night care services received dur-
ing the same calendar year under any other Heafth Plan Service Agreement.
(1) Outpatient Mental Health Services. All services of Physicians and mental
health professionals, as performed, prescribed or directed by the Attending Physi-
cian, including diagnostic evaluation and psychiatric treatment, including indivi-
dual therapy and group therapy, are provided at Medical -Offices without charge to
Medicare Members for the first 20 visits each calendar year and at a $5.00 charge
thereafter, and to all other Members upon payment of a $10.00 registration charge
per visit for the first twenty visits during each calendar year, and at Non-Member
Rates thereafter. A charge is made for each broken appointment unless Medical
Group's procedures for cancelling appointments are complied with.
(2) Day Care and Night Care Services. If, in the professional judgment of the
Attending Physician, a Member would benefit from day care or night care mental
health services, up to 28 sessions of prescribed care and, for Medicare Members
Part A Members and Part B Members, additional sessions of day care or night
care paid for in whole or in part by Medicare, are provided without charge each
calendar year at facilities designated by Health Plan, and an additional 62
sessions of care are provided during the calendar year at 25% of Non-Member
Rates, except that this benefit is reduced by two sessions for each day of
hospitalization for psychiatric conditions received by the Member pursuant to
Section ll-N(3) during the calendar year. Each fully prepaid day of hospitaliza-
tion received pursuant to Section ll-N(3) exhausts two fully prepaid sessions of
day or night care under this Section ll-N(2). Day care and night care include all
services of Physicians and mental health professionals and the following s-ervices
and supplies prescribed by a Physician: psychiatric nursing care, group therapy,
occupational therapy, drug therapy, shock therapy, medications and supplies.
(3) Inpatient Mental Health Services. If, in the professional judgment of- the
Attending Physician, a Member requires short-term inpatient mental health ser-
vices, up to 14 days of Hospital Services, and,for Medicare Members and Part A
Members additional days of Hospital Services paid for in whole or in part under
Medicare, are provided without charge each calendar year at facilities designated
by Health Plan, and an additional 31 days of care are provided each
calendar year at 25% of Non-Member Rates, except that this benefit is reduced by
one day for each two sessions of day care or night care received by the Member
pursuant to Section ll-N(2) during the calendar year. Each fully prepaid
session of day care or night care received pursuant to Section ll-N(2)
exhausts one-half fully prepaid day of hospitalization under this Section ll-N(3).
Hospital Services include all services of Physicians
sionals and the following services as prescribed by a
psychiatric nursing care, group therapy, shock therapy,
and mental health profes.
Physician: Board and room,
drug therapy, medications
Group 66-00
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;- and supplies while the Member is confined as a registered bed patient in. a Hospi-
tal.
(4) Psychological Testing. If, in the professional judgment of the Attending
Physician, a Member requires psychological testing, prescribed tests are provided
without charge. Court-ordered testing, and testing for ability, aptitude, intelli-
gence or interest., are not covered.
(5) Exclusions and Limitations. The following services are not covered:
(a) Mental health services for the following conditions after diagnosis if,
in the professional judgment of the Attending Physician, they would not be
responsive to therapeutic management:
(i) Chronic psychosis, except that acute episodes due to a chronic psy-
chotic condition are covered if the Member has been cooperative and has re-
sponded favorably to an ongoing treatment plan.
(ii) Care for organic psychosis.
(iii) Intractable personality disorders.
(b) Mental health services for mental retardation after diagnosis.
(c) Services on court order or as a condition of parole or probation, unless
determined by a Physician to be necessary and appropriate.
O. MEDICAL SOCIAL SERVICES
Medical social services are provided without charge at Hospitals and Medical Of-
fices. Medical social services include hospital discharge planning, social services
counseling and referrals for services not covered under this Agreement.
P. HEALTH EDUCATION
Health education services for specific conditions, such as diabetic counseling,
post-coronary counseling and nutritional counseling, are provided upon payment of the
.registration charge, if any, specified in Section Il-A(2).
When
dition,
payment
available, general health education services not addressed to a specific con-
such as weight control classes and anti-smoking classes, are provided upon
of a reasonable charge.
Education in the appropriate use of Health Plan's services, and printed health ed-
ucation materials published by Health Plan which contain instructions on achieving
and maintaining physical and mental health and on preventing illness and injury, are
provided without charge. Recorded health education programs are provided at cost.
Q. PAYMENT IN LIEU OF SERVICE BENEFITS
If, in the professional judgment of Medical Group, a Member requires Medical or
Hospital Services covered by this Agreement which require skills not available within
Medical Group or facilities not available in Hospitals and Medical Offices, and Medi-
cal Group determines that it would be in the best interests of the Member to obtain
care from another source, then, upon written referral by Medical Group, payment, in
lieu of service benefits hereunder, is made for prescribed services within the cover-
age of this Agreement. Referrals may be made to sources outside of the Service Area.
Group 66-00
Page 27
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o
Jlembers must pay Supplemental Charges that would be due if the services received un-
der this Section ll-Q were received from Physicians, Hospitals or Medical Offices.
R. SERVICE BENEFITS IN OTHER HEALTH PLAN REGIONS
If a Member is temporarily in another Health Plan Region the Member may obtain
hospital and medical services from physi~ians and hospitals that have a contractual
arrangement with Health Plan or a related organization.
A description of Regions in which Health Plan, either directly or through related
. organizations, conducts direct-service medical and hospital care programs and a list
of their facilities may be obtained at the Health Plan office.
Services and Supplemental Charges are those prevailing in each Region for the
Health Plan coverage generally provided there, that is most nearly comparable to the
Member's coverage in the Southern California Region.
S. EMERGENCY SERVICES RECEIVED FROM PROVIDERS NOT CONTRACTING WITH
HEALTH PLAN
(1) Emergency Services. This Section ll-S defines and limits Health Plan's ob-
ligation to pay for Emergency Services that a Member receives from a physician,
hospital or other provider not contracting with Health Plan. Health Plan
determines whether, and in what amount, claims made under this Section are paid.
The term "Emergency Services" means medically necessary health services that are:
(a) generally available and customarily provided to patients residing in Southern
California, (b) covered under this Service Agreement, and (c) immediately required
because of unforeseen illness or injury.
(2) Reductions for Other Benefits and Copayments. The amount otherwise payable
is reduced by Other Benefits and Copayments.
(a) Other Benefits means all amounts paid or payable, or which in the ab-
sence of this Agreement would be payable, for the Emergency Services in ques-
tion, under any insurance policy or contract, or any other contract,. or any
governmental program except Medicaid. If the Member notifies Health Plan that
Other Benefits equal in amount to the charges for Emergency Services have not
been paid within a reasonable period of time, Health Plan will pay for Emergen-
cy Services in accord with this Section 11-S if the Member (1) assigns all Oth-
er Benefits to Health Plan, (2) agrees to cooperate fully with Health Plan in
obtaining Other Benefits, and (3) allows Health Plan to obtain confirmation
from any person regarding Other Benefits. Any person claiming benefits under
this Section shall furnish Health Plan with such information as may be neces.
sary to implement these provisions.
Reimbursement for Emergency Services required because of an act or omission
of a third party is subject to the conditions stated in Section 6-C(1).
(b) Copayments means the sum of (i) the amount of Supplemental Charges that
would be due if Emergency Services were received from Physicians or Hospitals
or at Medical Offices, (ii) the amount charged for Emergency Services which is
in excess of the Reasonable and Customary Charges for such services; and (iii)
if Emergency Services are obtained within the Service Area or within 30 miles
of the home of a Member who resides outside the Service Area, 50% of the first
$200 after Other Benefits and the amounts under (b) (i) and (b) (ii) have been
deducted. For Medicare Members, copayments are limited to (i) and (ii). "Rea-
Group 66-00
Page 28
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;;
sonable and Customary Charge" means a charge which (a) bears a reasonable rela-
tionship to the covered care, service or supply rendered by a non-contracting
provider as determined by current community standards, and (b) is no more than
the customary charge made by the non-contracting provider for that service or
supply.
(3) Payment. Subject to the foregoing limitations:
(a) Within the Service Area. Health Plan will pay for Emergency Services re-
ceived within the Service Area from providers not contracting with Health Plan
if:
(i) Receipt of the Emergency Services from Physicians or Hospitals or at
Medical Offices would have entailed a delay resulting in death, serious di-
sability or significant jeopardy to the Member's condition; or
(ii) Receipt of Emergency Services from a physician, hospital or other
provider not contracting with Health Plan was beyond the control of the
Member and the Member's immediate family.
(b) Outside the
received outside
Plan if:
Service Area. Health Plan will pay for Emergency Services
the Service Area from providers not contracting with Health
(i) A Member who resides in the Service Area becomes ill or is injured
while outside the Service Area. Covered benefits include Emergency Services
for unexpected premature delivery, but not for normal delivery (after 8
months gestation), unless Health Plan determines that the Member was outside
the Service Area because of circumstances beyond her control or because of
extreme personal emergency.
(ii) A Member who resides outside the Service area:
(A) becomes ill or is injured while more than 30 miles from the Mem-
ber's home and receives Emergency Services more than 30 miles from the
Member's home; covered benefits include Emergency Services for unexpected
premature delivery, but not for normal delivery (after 8 months gesta-
tion) unless Health Plan determines that the Member was more than 30
miles from her home because of circumstances beyond her control or be-
cause of extreme personal emergency, or
(B) receives Emergency Services, other than for delivery, less than 30
miles from the Members's home if:
(a) Emergency Services were needed to prevent death, serious disa-
bility or significant jeopardy to the Member's condition and it would
have been unreasonable to expect the Member to obtain such services
from Physicians or Hospitals or at Medical Offices; or
(b) Receipt of Emergency Services from a physician, hospital, or
other provider not contracting with Health Plan was beyond the control
of the Member and the Member's immediate family.
(4) Continuing or Follow-up Treatment. Continuing or follow-up treatment from
providers not contracting with Health Plan is not covered under this Section ll-S,
except that Health Plan at its option may continue inpatient care coverage in lieu
Group 66-00
Page 29
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'"
-
,
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,
... of transferring the Member. Payment is limited to Emergency Services required be-
fore the Member can, without medically harmful consequences, be transported to a
Hospital or Medical Office in the Service Area, or, if the Member is near another
Health Plan Region, to a contracting hospital or medical office in the other
Health Plan Region. If the Member obtains prior approval from Health Plan or a
Physician in the Service Area or in the nearest other Health Plan Region, covered
benefits include necessary ambulance service or other special transportation ar-
rangements when medically required to transport the Member to a Hospital or Med-
ical Office in the Service Area or to a contracting hospital or medical office in
the nearest other Health Plan Region for continuing or follow-up treatment.
(5) Notification and Claims. Any Member receiving hospital Emergency Services
within the scope of this Section ll-S must notify the Health Plan office within 48
hours after care is commenced. No claim pur~uant to this Section ll-S is allowed
unless a complete application for payment, on forms provided by Health Plan, is
filed with the Health Plan office within 60 days after the first Emergency Service
for which payment is requested. The 48 hour and 60 day notice requirements are not
applied if notice is given as soon as reasonably possible. In no event will a
claim be allowed unless Health Plan has received a complete application for pay-
ment within 12 months after the Emergency Service is received.
(6) Releases and Assignments. Each Member claiming reimbursement hereunder
shall complete and submit to Health Plan such consents, releases, assignments and
other documents as Health Plan may reasonably request for the purpose of determin-
ing the applicability of and implementing this Section ll-S.
(7) Right of Recovery. Any overpayment hereunder may be
Plan from any person to whom the payment was made, or from
or organization which is obligated to pay for the Emergency
recovered by Health
any insurance company
Services.
Group 66-00
Page 30
~~
';'d... 0
Ex.cut.d .t P...d.... CaUforni. to take eff.ct .. of JIUlU.rj 01.
o
1919
D.t.: D.c.-b.r IS. 1988
KAISER FOUNDATION HEALTH PLAN, INC.
A C.liforni. nonprofit corpor.tion
By
~t-" fj..t-~
Authoriz.d R.pr...nt.tiv.
KAISER FOUNDATION HEALTH PLAN. INC.
South.rn C.liforni. R.aion
CITY OF SAN BERNARDINO
300 NORTH 0 ST
SAN BERNARDINO. CA
92418
Attn: GORDON R. JOHNSON. PERSONNEL OIR.
Accepted .................. 19 e... ...
By
/);1\__
IA/'
Group R.pr....t.tiv.
CITY OF SAN BERNARDINO
By
Group Repr....t.tiv.
cm OF SAN BERNARDINO
ATTEST:
H..lth PIIUl Copy
Pi.... return to:
City Clerk
KAISER FOUNDATION HEALTH PLAN, INC.
ATTN: CONTRACTS UNIT, 6TH FLOOR, 393 EAST WALNUT STREET
PASADENA, CALIFORNIA 91188-8325
Approved as to form and 1e9a1 content:
1989 .~
Group 66-00 By: ~ g,...4~
/c ty Arney e." ~""I
Pea. 32