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C11 ! OF SAN BERNARM_O - REQUL ,T FOR COUNCIL AC' ON From: Roger DeFratis 3utije�t: gesa�ui on authorizing the execution of agreement with Kaiser Foundation Health Dept: Personnel Plan, Inc. relating to change in Rates effective January 1, 1988. Date: 1-8-88 gn Synopsis of Previous Council action: Kaiser Foundation Health Plan, Inc. has been offered to City employees since 1973, and extended annually by the Council . Recommended motion: Adopt resolution Signature Contact person: Roger DeFratis Phone: 5008 Supporting data attached: Yes Ward: FUNDING REQUIREMENTS: Amount: no additional cost Source: existing budgets _ Finance: Council Notes: C17 , OF SAN BERNARDIL , - REQUE, T FOR COUNCIL ACT 3N STAFF REPORT The City, at present, offers employees a choice of the Kaiser Health Plan or the City' s self-insured health program. In October of each year, the payment rates are reviewed and revised for upcoming calendar to be effective on January 1, of each year. The 1988 rates for the Kaiser Health Plan are as follows: Two Person Family Kaiser Health Plan Employee Only Coverage Coverage Rates-Effective 1-1-88 $91. 32 $182 . 62 $258 . 60 Current 1987 Rates $86. 68 $173 . 34 $245.46 The new rates represent an approximate increase of 6. 0%. The additional cost will be paid by the employees who select the Kaiser Plan as stipulated in the various existing Memorandums of Understanding for the respective bargaining units. There are no other changes to existing agreement. The Insurance Committee has been conferred with and are in full support and agreement with the plan design. *Current Cafeteria Benefit contribution by the City. Fire Safety $96.80 for employee only/$163 . 36 for em- loyee with dependent(s) Police Safety $80. 00 for employee only/$135. 00 for em- ployee with dependent(s) General Unit $105. 00 for employee only/$180. 00 for em- ployee with dependent(s) Mid-Mgmt $200. 00 for employee with or without de- pendent(s) Management/ $360. 12 for employee with or without de- Confidential pendent(s) i 1 RESOLUTION NO. 2 3 RESOLUTION OF THE CITY OF SAN BERNARDINO AUTHORIZING THE EXECUTION OF AN AMENDMENT TO THE AGREEMENT WITH KAISER 4 FOUNDATION HEALTH PLAN, INC. , RELATING TO A CHANGE IN RATES, EFFECTIVE JANUARY 1, 1988. 5 BE IT RESOLVED BY THE MAYOR AND COMMON COUNCIL OF THE � 6 CITY OF SAN BERNARDINO AS FOLLOWS: 7 SECTION 1. The Director of Personnel of the City of San 8 Bernardino is hereby authorized and directed to execute on 9 behalf of said City an amended agreement with Kaiser Founda- 10 tion Health Plan, Inc. , relating to a change in rates effec- 11 tive January 1, 1988, affecting the City's Group Health Plan. 12 The new rate structure is called out in Section 4-A of the 13 amended agreement. Other minor amendments to the agreement 14 are called out in Exhibit A, attached hereto and incorporated 15 by reference. 16 I HEREBY CERTIFY that the foregoing resolution was duly 17 adopted by the Mayor and Common Council of the City of San 181 Bernardino at a _ meeting thereof, held on 19I the _ day of 1988, by the following 20 vote, to wit: 21 AYES: Council Members 22 --- — — — 23 NAYS: __ ------- -- - - 24 ABSENT: 25 26 City Clerk 27 (Continued) 28 PAGE 1 13 JAN 1988 t The foregoing resolution is hereby approved this 1 day of 1988. 2 3 Mayor of the City of San Bernardino 4 5 Approved as to form and legal content: 6 ` 7 City Attorney 8 � 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 n ��II Illy Kaiser Foundation Health Plan, Inc. Southern California Region 1988 Group Medical and Hospital Service Agreement 0 KAISER FOUNDATION HEALTH PLAN, INC. Southern California Region 1988 Group Medical and Hospital Service Agreement Format and Language Changes The format of our Service Agreement has been changed to incorporate Health Pledge benefits (our new Medicare Program) and related provisions. Minor changes have been made to Sections 1- 10 and a new Benefit Schedule for Health Pledge Members has been added as Section 12. Additional generic language changes have been made in the following sections of the 1988 Group Medical and Hospital Service Agreements: Section 2-A(3) : The COBRA continuation coverage provision has been modified to allow for continued coverage for certain retirees and dependents of a Group that files a bankruptcy proceeding, required as a result of the 1986 OBRA legislation. Section 4-A: The Rates and Payment section has been expanded to include rates for Health Pledge members. Section 4-B: This section has been revised to show that the limit on Supplemental Charges for Basic Health Services for the calendar year 1988 is $1, 000. 00 per member and $2, 830. 00 per Family Unit of three or more members. Section 4-C (2) : This section has been changed to remove the "over age 65" reference to Medicare Members, required as a result of the 1986 OBRA legislation. Section 6-A(11) : The durable equipment exclusion has been changed to update the term "oxygen tents" to "oxygen dispensing equipment" . Section 9-B: A clarification has been made to this section to show that Subscribers or dependents who became totally disabled after the Subscriber ' s employment with Group terminates are not eligible for coverage under this provision. Section 11: The second paragraph has been changed to remove the "over age 65" reference to Medicare Members, required as a result of the 1986 OBRA legislation. EXHIBIT A Section 11-S: The first paragraph has been modified to clarify that Health Plan determines whether and in what amount claims made under the Emergency Services section are paid . The fifth paragraph has been changed to show that Medicare Members are not subject to the copayment of 50% of the first $100. The following sections have been revised to establish uniformity among the Raiser Permanente Regions across the nation. There are no material changes: Section 1 - "Definitions" (The definitions have been alphabetized) . Section 3 - "Relations Among Parties Affected by Agreement" . Section 5 - "Services and Benefits" . The following two section changes are not generic but affect only those groups which offer the Coordination of Benefits Program and/or the Supplemental Vision Benefit, Level II: Section 4-E: This provision has been extensively revised to incorporate the COB NAIC model language. Section 11-T: The Vision II frame allowance applicable in calendar year 1988 will be increased from $35. 00 to $37. 00. A 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. r 1 . DEFINITIONS 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: Each of the specific geographic areas where Kaiser Foun- dation Health Plan, Inc. , or a related organization conducts a direct service health care program. 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- Group 66-00 Page 1 ly and customarily provided by acute care general hospitals in Southern California; and (ii) prescribed, directed or authorized by the Attending Physician. H. Medical Group: Southern California Permanente Medical Group. I. Medical Office: Any outpatient treatment facility staffed by Medical Group. A current list of Medical Offices may be obtained from any Health Plan office. J. Medical 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. Medicare: The Federal Health Insurance for the Aged and Disabled Act. L. Member: Any Subscriber or Family Dependent; Medicare Member: 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 Mem- ber: Any Member entitled to benefits under Part A of Medicare only, except Members described in Section 4-C of this Agreement; Part B Member: 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 Mem- 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. M. Non-Member Rates: The charges 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 care of a Member with respect to any particular injury or illness. 0. Service Area: The Service Area is that portion of Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, and Ventura counties within the following 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, 92007-8, 92009, 92010-2, 92013, 92014, 92016-7, 92019, 92020-2, 92024-7, 92031-2, 92035, 92036, 92037-38, 92040-1, 92042, 92044, 92045, 92047-8, 92050, 92053-4, 92056, 92062-5, 92067-71, 920735 92075, 92077-8, 92080, 92082-3, 92084, 92093, 92100-99, 92220, 92223, 92305, 92307-92308, 92314-8, 92320-2, 92324-6, 92329-30, 92333, 92334, 92335, 92336, 92339-41, 92343-6, 92348, 92352-4, 92356, 92358-60, 92362, 92367, 92369-74, 92376, 92378, 92380-2, 92383, 92385-6, 92388, 92391-2, 92395-7, 92399, 92400-99, 92500-99, 92600-99, 92700-99, 92800-99, 93010-11, 93015, 93021, 93040, 93060, 93062-6, 93203, 93205-6, 93215, 93217, 93220, 93224, 932265 932385 93240-1, 93250-2, 93261, 93263, 93268, 93276, 93280, 93285, 93287, 93301-9, 93311-13, 93380, 93385-9, 93510, 93518, 93531-2, 93534-5, 93539, 93543-4, 93550, 93551, 93553, 93561, 93563. 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 engaged in 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. e_...... 44-nn pa 00 9 Q. Spell of Illness: The same meaning as in Medicare. A spell of illness begins when a person enters a hospital or skilled nursing facility. A spell of illness ends when the person has not been a patient in either a hospital or skilled nursing facility for 60 consecutive days. R. 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. S. Supplemental Charges: 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 for 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 20 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 entirely supported by the Subscriber or the Subscriber's spouse and permanently residing in the Sub- scriber's household. (3) Health Pledge Member. To be a Health Pledge Member, a person must: (a) Meet the requirements in Section 2-A(1) or 2-A(2) ; (b) Be enrolled under the risk contract between Health Plan and the Health Care Financing Administration ("HCFA") ; Group 66-00 Page 3 (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) . Enrollment in Health Pledge in Kern County is subject to final approval by the Health Care Financing Administration. (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 Section 2-A(4) continues only upon payment of applicable monthly charges to Group at the time specified by Group, and terminates on the earlier of: (i) Termination of this Agreement. (ii) Coverage of the Member under any other group health plan or Medi- care. (iii) Expiration of 36 calendar months after an event described in Sec- tion 2-A(4)(a)(i) or (ii) . (iv) Expiration of 18 calendar months after an event 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. Health Plan may terminate any Member enrolled under this Section 2-A(4) for Grouv 66-00 Page 4 whom Health Plan does not receive payment when due. Ineligible Persons. No person is eligible to enroll hereunder if the person or any cther 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 available 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 24(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(1) . (3) Open Enrollment Period. Coverage for persons enrolled during the open en- Grouv 66-00 Page 5 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 and 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 relationship with Members and Physicians 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 Hospital 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. Group shall remit to Health Plan on behalf of each Subscriber and his or her Family Dependents for each month on or before the last day of the preceding month the following amounts: Basic Rate Structure Subscriber only $ 91.32 Subscriber with one Family Dependent $ 182.62 Subscriber with two or more Family Dependents $ 258.60 Variables to Basic 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: Subscriber Subtract $ 41.20 Group 66-00 Page 6 Subscriber's spouse or child Subtract $ 41. 18 For each Member age 65 or older, enrolled in Part B of Medicare, but not entitled to benefits under Part A of Medicare: Add $ 43.72 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 (ex-cept for Members living outside the Service Area) : 31.20 Subscriber Subtract $ Subscriber's spouse or child Subtract $ 31.18 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 disenrolls from Health Pledge, or (c) who is en- rolled in Part B of Medicare, but not entitled to benefits under Part A and lives outside the Service Area. Add $ 36.98 For each Member age 65 or older who has become a Member of another Medicare Risk Program: Add $ 170.90 These amounts are called the "Base Payment". If a state or any other taxing au- thority imposes upon Health Plan a tax or license fee which is levied upon or meas- ured by the Base Payment or by Health Plan's gross receipts or any portion of either, then Health Plan may amend this Agreement with respect to rates to increase the Base Payment by an amount sufficient to cover the Group's prorated share of all such taxes or license fees rounded to the nearest cent, effective as of the date stated in the notice, which shall not be earlier than the date of imposition of such tax or license, by mailing a postage prepaid notice of the amendment to Group at its address of record with Health Plan at least 30 days before the effective date of the amendment. Only Members for whom the stipulated payment is received by Health Plan are enti- tled to Medical and Hospital Services hereunder, and then only for the period for which such payment is received. B. Other Charges. In addition, Members must pay for or arrange for payment of Sup- plemental Charges and other amounts they owe Health Plan, Hospitals and Medical Group_ Limits on Supplemental Charges. After a Member (or Family Unit) demonstrates that the Member (or Family Unit) has paid Supplemental Charges for Basic Health Services received during a calendar year which total the Member (or Family Unit) limit on such Supplemental Charges established by Health Plan for that calendar year, no additional Supplemental Charges are made to the Member (or Family Unit) for such services during the remainder of the calendar year. The limit for any calendar year will not exceed Health Plan's annual charge for fully prepaid Basic Health Services established ef- fective January 1 of the calendar year. Health Plan will notify Group prior to Janu- ary 1 of each year of the limit on Supplemental Charges under this paragraph for the ensuing calendar year. Group 66-00 Page 7 For the calendar year 1988 the limit on Supplemental Charges is $1,000.00 per Member but not more than an aggregate of $2,830.00 for a Family Unit of 3 or more Members. "Basic Health Services" for determining this limit on Supplemental Charges are the benefits covered in Section 11, Parts A,C,D,E,F(2) ,L,M,B, except blood; H, except contraceptive drugs and devices and infertility medications; the first 20 out-patient visits specified in Section 11-N and Sections ll-Q, 11-R, and 11-S, except for care which is not otherwise a Basic Health Service under this paragraph. Payments made by the Member or on his behalf for non-covered services or due as a result of Section 6-C or 11-S-(2) (a) are not Supplemental Charges for Basic Health Services. C. Medicare (1) Medicare Payments. Payments required hereunder are established on the assumption that Medicare payments for services provided to Members hereunder will be received by Health Plan or the provider of services entitled thereto. Therefore, all sums payable on behalf of Members pursuant to Medicare for services provided pur- suant to this Agreement are payable to and retained by either Health Plan or the provider of services entitled thereto, and each Member entitled to any Medicare benefits shall complete and submit to Health Plan all consents, releases, assignments and other documents reasonably requested by Health Plan in order to obtain or assure such payment. Any Member who fails to do so must pay for services received at Non-Member Rates. (2) Special Provision for Members Entitled to Medicare Benefits Who Elect the Group's Health Plan as Primary Coverage. Members who are entitled to Medicare benefits but who elect to have the Group's health plan as their primary health coverage pursuant to the applicable provisions of Federal law, and Members with end-stage renal disease whose Medicare benefits are secondary, will be considered, for purposes of rates and benefits under this Agreement, Members under age 65 who are not entitled to Medicare benefits. 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-S, or Sections 12-Q or 12-S of the applicable Benefit Schedule(s) . r.rn,rn 66-00 Page 8 s low B. Outside the Service Area. Members receive benefits under Sections 11-R and 11-S, or Sections 12-R and 12-S 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 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 ti©n-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 11-I and 12-I. (4) Dental Care. Dental care and dental X-rays, including care for injury to teeth. This exclusion does not apply to medically necessary care covered by Medicare. (5) Certain Physical Examinations. Physical examinations and related services required for obtaining or continuing employment, insurance or governmental licens- ing. Group 66-00 Page 9 (6) Experimental or Investigational Services. Any treatment procedure, drug or drug usage, facility or facility usage, equipment or equipment usage, device or de-ice 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 generally 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. Any health care pro- 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; services of a podiatrist. This exclusion does not apply to medically necessary foot care provided by Physicians. (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 11-L and Health Pledge Members have the benefits as set forth in Section 12-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 Group 66-00 Page 10 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 prcvision 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- sicnal 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 has any further responsibility to provide care for the condition under treatment. (3) Alcohol and Drug Dependency. Services for alcohol and drug dependency are prcvided only in accord with Sections 11-M and 12-M. (4) Rehabilitation. Rehabilitative treatment is provided only in accord with Sections 11-E and 12-E. (5) 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 11-N and 12-N. (6) Corrective Appliances and Artificial Aids. Corrective appliances and arti- ficial aids such as braces, prosthetic devices, 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-I and 12-I. (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 12-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 Group 66-00 Page 11 (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 form(s) 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 11-5 and 12-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. 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 form(s) 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 amount of the Member's recovery on account of the third party's conduct is less than the Member's actual damages. 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 bringing 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. (2) Other Coverage - Health Pledge Members. The benefits otherwise provided under this Agreement are reduced by all amounts paid or payable, or which in the absence of this Agreement would be payable, under any insurance policy or contract, or any other contract, in instances when Medicare is by law secondary payor. Members shall complete and submit to Health Plan all consents, releases, assignments and other documents reasonably requested by Health Plan in order to obtain or assure such payment. A Member who fails to do so must pay for services at Non-Member Rates. 7. CONVERSION AND TRANSFER A. Conversion to Non-Group Enrollment. If any person ceases to qualify as a Member for any reason other than termination of membership rights pursuant to Section 9, then said person may, within thirty-one days after termination of said rights,convert to non-group membership effective as of the date of such termination. B. Change of Residence. (1) All Members except Health Pledge Members. Members who move from the Southern California Region to any geographical area not served by Health Plan may, if they desire, continue their Health Plan coverage. However, the only benefits provided outside the Service Area are those specified in Sections 11-R and 11-S. "Members who move to another Health Plan Region must promptly apply to a Health Plan office in such Region to transfer their Membership. No right to service benefits under Sections 11-R and 11-S exists in another Health Plan Region after a Member has resided in such Region more than 90 days, unless the Member, by prior application to Health Plan, demonstrates special circumstances under which a longer period is "temporary" and the Member's continuing status of temporary residence is confirmed in writing by Health Plan. (2) Health Pledge Members. Members who permanently move to any geographic area not within a Kaiser Foundation Health Plan Region may not continue enrollment as Health Pledge Members. (Medicare regulations define a "permanent move" as being out of the Service Area for more than 90 consecutive days. ) Such Members must provide Health Plan with written notice of the move. Members may continue enrollment in this Agreement as Medicare Members or Part B Members, as appropriate, effective the first day of the first month following the date Health Plan receives notice of the move, except that the only benefits available outside the Service Area are those specified in Sections 11-R and 11-S of the applicable Benefit Schedule. Members who continue enrollment and subsequently move back to the Service Area must re-enroll as Health Pledge Members when an opening is available. Members who permanently move to another Kaiser Foundation Health Plan Region must promptly apply to a Health Plan office in that Region to transfer their membership. However, identical coverage may not be available in another Health Plan 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 must be served as in a California civil action, and any other Respondent must be served by registered letter, postage prepaid, addressed to Respondent in care of Health Plan at the address provided in Section 10-J. 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 each shall deposit $150.00 in a spe- cial account maintained by Bank of America National Trust and Savings Association, Wilshire-Robertson Branch, 8760 Wilshire Boulevard, Los Angeles, California 90211, to provide the initial funds to pay the fees of the neutral arbitrator 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 counsel or 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 neutral arbitrator. Within 30 days after these notices have been given and payments made, the two arbitrators so select- ed shall select a neutral arbitrator and give notice of the selection to Claimant and all Respondents served, and the three arbitrators shall hold a hearing within a rea- sonable time thereafter. Except where otherwise agreed to by the parties, arbitration shall be held at a time and place designated by the neutral arbitrator in a county where an alleged wrongful act occurred. 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 ... ,�.r.,. v..- .mac-. ......a...._.�.. .o...._ ..r..�...-.�-.....__ ....... �_..........� �._ ... ._... .. ._.. .._ A. Term. This Agreement continues in effect from the effective date stated on the last page of this Agreement to January 01, 1989, 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. Either party may terminate this Agreement by giving written notice to the other at least 90 days prior to any January 1 ("Anniversary Date") . (b) Nonpayment. If Group fails to make any past due monthly payment 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 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 Members. 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 terminates, 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 Members. (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. (d) Misuse 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 Monthly 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 termination 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 Administration ("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 Me=bers is terminated, Health Pledge Members may continue their enrollment in this Agreement as Medicare Members or Part B Members, as appropriate, effective uoon 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 address of record with Health Plan at least 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. B. Agreement Binding on Members. 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 Members. 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. Applications 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 .-hose 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. Health Plan at reasonable times may examine Group's pertinent records, with respect to eligibility and monthly payments under this Agree- ment. 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. .. .... D 1 7 In the event that the contract between Health Plan and Hospitals, Medical Group or any o=her 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 :'itle 10 of the California Administrative Code, and any provision required to be in t!is Service Agreement by either of the above shall bind Health Plan whether or not set forth herein. H. Administration of Agreement. Health Plan may adopt reasonable policies, pro- cedures, rules and interpretations to promote orderly and efficient administration of this `greement. I. Member Information. Group shall inform Subscribers (1) of the periodic charges appli=able 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: 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. -1 __ n___ 1 Q Benefits hereunder include and are not in addition to Medicare benefits, except for "_embers 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 11, Medical Services are provided as follows. (1) Care While Hospitalized. During prescribed hospitalization specified in Section 11-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. 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 hospital services; special diet; special duty nursing; medications as specified in Section 11-F, and medical supplies. Diagnostic tests and procedures are provided in accord with Section 11-D, and the- rapeutic procedures, including speech therapy and rehabilitative services, are pro- vided 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. .. 11 __ n..__ in D. DIAGNOSTIC TESTS AND PROCEDURES When prescribed, the following diagnostic tests and procedures are provided with- out charge: diagnostic laboratory tests including cytology examinations and venereal disease tests, diagnostic X-rays, diagnostic nuclear medicine procedures including radioisotopes used therewith, sonograms, pulmonary function studies, cardiovascular studies, audiologic function studies, electroencephalograms, electrocardiograms, elect:omyograms and other diagnostic studies using electrostimulation or electronic equipment or producing recordings, tracings, images or similar readings. E. THERAPEUTIC PROCEDURES (1) Except when provided under Section 11-E(5) during an inpatient stay primar- ly to receive rehabilitative services, prescribed physical therapy, occupational therapy, and inhalation therapy are provided without charge while receiving Hospi- tal Services under Section 11-B, Extended Care Services under Section 11-K, and Home Health Services under Section 11-L and when received in Medical Offices. Re- habilitative services, physical therapy and occupational therapy treatment are lisited to treatment for conditions (including acute phases of chronic conditions) which in the judgment of the Attending Physician are subject to continuing sig- nificant improvement within a period of two months. (2) Prescribed radiotherapy and therapeutic nuclear medicine procedures includ- ing radioisotopes used therewith are provided without charge while receiving Hos- pital Services under Section 11-B and in Medical Offices. Radiation therapy is provided by the specialized Regional Radiation Therapy Service at the Los Angeles Medical Center. (3) Prescribed orthoptic treatments and dermatological black light treatments are provided without charge in Medical Offices. (4) Except when provided under Section 11-E(5) during an inpatient stay primar- ilv to receive rehabilitative services, speech therapy is provided for (a) treat- ment for speech impairments of specific organic origin, which in the judgment of the Attending Physician are subject to continuing significant improvement within a period of two months and, (b) treatment of articulation disorders due to con- genital abnormalities of the palate. Prescribed speech therapy is provided on a group or individual basis without charge while receiving Hospital Services under Section 11-B, Extended Care Ser- vices under Section 11-K, and Home Health Services under Section 11-L. For cov- ered visits which are provided in Medical Offices, no charge is made to Part B Members and Medicare Members, and a charge of $5.00 per visit is made to other Members. (5) When, in the judgment of the Attending Physician, significant improvement in function is achievable within a period of 2 months, up to 2 months per condi- tion 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. F. PRESCRIBED MEDICATIONS, IMMUNIZATIONS, AND DRESSINGS AND CASTS (1) Prescribed Medications and Items. �_....� cc-nn Paoo In (a) Administered to Members. (i) While Hospitalized. During hospitalization specified in Section 11-B, all prescribed medications, injectables, radioactive materials used for therapeutic purposes, and allergy test materials and allergy treatment ma- terials are provided without charge. (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 1 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 payment 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 obtained at pharmacies in Hospitals and designated Medical Offices or, in Kern County, at a designated pharmacy in the Service 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 (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. (2) Immunizations. 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 charge. Immu- nisations 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 i=unizations are provided at 50 percent of Non-Member Rates. (3) Dressings and Casts . During hospitalization specified in Section 11B, 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 fcr 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 Hcspitals 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 past-abortion counseling and information on birth control, is provided upon payment of the registration charge, if any, specified in Section 11-A(2) . Diagnostic tests and procedures 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 tests and procedures are provided in accord with Section 11-D, and medications are provided in accord with Section 11-_. Exclusions. The following are not covered: (a) the cost of sperm. (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 11-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 11-J, Medical and Hospital services for covered organ transplants are provided in accord with this Section 11. Reasonable medical and hospital expenes 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 11-F(5) . (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 11-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- plants approved by Medical Group. (e) Except for medically necessary ambulance service provided in accord with Section 11-G, neither transportation nor living expenses are covered for the Member, for his or her family, or for a donor. K. EXTENDED CARE SERVICES During each calendar 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 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, occupational, and speech therapy, medical social services, prescribed drugs and medications and medical supplies, appliances and equipment ordinarily furnished by the Skilled Nursing Facility. Diagnostic tests and procedures are provided in accord with Section 11-D and therapeutic procedures, including speech therapy and rehabilitative services, are provided in accord with Section 11-E. Other covered Extended Care Services are provided without charge. L. HOME HEALTH SERVICES AND HOSPICE CARE (1) Home Health Services. Benefits under this Section 11-L are provided within the Service Area and are available only if the Attending Physician determines that it is feasible to maintain effective supervision and control of the Member's care. (a) Members Who Are Not Medicare Members, Part A Members 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. Inhalation therapy, physical therapy, occupational therapy, and speech therapy are provided in accord with Section 11-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 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 in writing 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 Attending Physician and the hospice care team: (a) nursing care; (b) physical or occupational therapy or therapy for speech-language pathology; (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 for Members Entitled to Medicare Benefits. Members entitled to Medicare Benefits who elect hospice care under this provision are entitled to hospice coverage for up to 210 days in licensed hospices approved for participation in the Medicare Program and approved by Medical Group. While the election is in effect, such Members are not entitled to any other benefits under this Service Agreement or under Medicare for the terminal illness. M. TREATMENT FOR ALCOHOL AND DRUG DEPENDENCY Subject to the exclusions set forth in this Section 11-M, and to the Supplemental Charges, if any, set forth in Section 11, the care described herein is provided for alcohol and/or drug dependency: (1) Inpatient Care for Withdrawal. Prescribed Hospital Services for the medical —nagement of the signs and symptoms attendant to the withdrawal process. (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. (b) Continuation in a course of counseling for patients who are disruptive or physically abusive. N. MENTAL HEALTH SERVICES s � Mental Health services specified in this Section 11-N are limited to evaluation, crisis intervention and acute psychiatric conditions which, in the judgment 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 Health 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 patient pursuant to Section 11-N(3) during the calendar year. Each fully prepaid day of hospitaliza- tion received pursuant to Section 11-N(3) exhausts two fully prepaid sessions of day or night care under this Section 11-N(2) . Day care and night care include all services of Physicians and mental health professionals and the following services 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 patient pursuant to Section 11-N(2) during the calendar year. Each fully prepaid session of day care or night care received pursuant to Section 11-N(2) exhausts one-half fully prepaid day of hospitalization under this Section 11-N(3) . Hospital Services include all services of Physicians and mental health profes- sionals and the following services as prescribed by a Physician: Board and room, psychiatric nursing care, group therapy, shock therapy, drug therapy, medications and supplies while the patient 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 I �.��•�.N i. .. � � �.\.r\.. ...a:.\�i.�.:i.u._.ti-.. l ..Y .r r .. .........i..r..... .... ....... � • .....r..r r..-•........... -..... .. • � . without charge. Court-ordered testing, and testing for ability, aptitude, intelli- gence or interest, are not covered. (S) 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 patient 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) Psychiatric therapy on court order or as a condition of parole or proba- tion, 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 11-A(2) . %hen available, general health education services not addressed to a specific con- dition, such as weight control classes and anti-smoking classes, are provided upon payment 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. Members must pay Supplemental Charges that would be due if the services received un- der this Section 11-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 physicians 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 11-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. Services" means medically necessary health services that are: (a) generally avail- able and customarily provided to patients residing in Southern California, (b) covered under this Service Agreement, and (c) immediately required because of un- foreseen 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 reasonable charges for such services, and (iii) if Emergency Ser- vices are obtained within the Service Area or within 30 air miles of the home of a Member who resides outside the Service Area, 50% of the first $100 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) . (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 Service Area. Health Plan will pay for Emergency Services received outside the Service Area from providers not contracting with Health Plan if: (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 air miles from the Member's home and receives Emergency Services more than 30 air miles from the Member's home; covered benefits include Emergency Services for unex- pected premature delivery, but not for normal delivery (after 8 months gestation) unless Health Plan determines that the Member was more than 30 air miles from her home because of circumstances beyond her control or because 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 11-S, except that Health Plan at its option may continue inpatient care coverage in lieu 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 Phcsician in the Service Area or in the nearest other Health Plan Region, covered benefits include necessary ambulance service or other special transportation ar- raagements when medically required to transport the Member to a Hospital or Med- ic-=l 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 11-5 must notify the Health Plan office within 48 hc-:rs after care is commenced. No claim pursuant to this Section 11-5 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. (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 11-S. (7) Right of Recovery. Any overpayment hereunder may be recovered by Health Plan from any person to whom the payment was made, or from any insurance company or organization which is obligated to pay for the Emergency Services. Executed at Pasadena, California to take effect as of January 01, 1988 Date: December 15, 1987 KAISER FOUNDATION HEALTH PLAN, INC. A California nonprofit corporation By Authorized Representative KAISER FOUNDATION HEALTH PLAN, INC. Southern California Region CITY OF SAN BERNARDINO 300 NORTH D ST SAN BERNARDINO, CA 92418 Attn: MS. M. J. PERLICK, PERS DIR Accepted . . . . . . . . . . . . . . . . . . 19. . . . . . By Group Representative CITY OF SAN BERNARDINO By Group Representative CITY OF SAN BERNARDINO Group Copy Please retain for your records 12. BENEFIT SCHEDULE FOR HEALTH PLEDGE MEMBERS The following Medical and Hospital Services and other benefits apply only to Health Pledge Members. These benefits are supplemented by the benefits set forth in Section 11-F(1)(b) , Section 11-M(3), (4) and (5), and Sections 11-T and 11-U, if applicable. 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. These services and benefits are available only if and to the extent that they are provided, prescribed and direc- ted by-a Physician, and unless otherwise specifically provided, received at a Hos- pital or Medical Office. Benefits hereunder include and are not in addition to Medicare Benefits. A. MEDICAL CARE IN HOSPITAL, OFFICE AND SKILLED NURSING FACILITY Except for Medical Services specifically described in other parts of this Section 12, Medical Services are provided as follows. (1) Care While Hospitalized. During prescribed hospitalization specified in Section 12-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. 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 a Skilled Nursing Faci- lity are provided without charge while the Member is admitted to a Skilled Nursing 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 hospital services; special diet; special duty nursing; medications as specified in Section 12-F, and medical supplies. Diagnostic tests and procedures are provided in accord with Section 12-D, and the- rapeutic procedures, including speech therapy and rehabilitative services, are pro- vided in accord with Section 12-E. Blood used in blood transfusions is provided without charge, if blood is replaced a a blood bank designated bf--ledical Group accord with the blood bank'r requirements. Health Plan may charge Non-Member Ratts for the first three pints of blood or its equivalent in packed red cells per Spell of Illness if blood is not replaced in accord with the blood bank's requirements. C. HOME VISITS Necessary home visits by Physicians to supervise services provided under Section 12-L, and by visiting nurses when prescribed by a Physician, are provided within the Service Area without charge. D. DIAGNOSTIC TESTS AND PROCEDURES When prescribed, the following diagnostic tests and procedures are provided with- out charge: diagnostic laboratory tests including cytology examinations and venereal disease tests, diagnostic X-rays, diagnostic nuclear medicine procedures including radioisotopes used therewith, sonograms, pulmonary function studies, cardiovascular studies, audiologic function studies, electroencephalograms, electrocardiograms, electromyograms and other diagnostic studies using electrostimulation or electronic equipment or producing recordings, tracings, images or similar readings. E. THERAPEUTIC PROCEDURES (1) Prescribed physical therapy, occupational therapy, and inhalation therapy are provided without charge while receiving Hospital Services under Section 12-B, Extended Care Services under Section 12-K, and Home Health Services under Section 12-L and when received in Medical Offices. Rehabilitative services, physical therapy and occupational therapy treatment are limited to treatment for conditions (including acute phases of ckzonic conditions) which in the judgment of the Attending Physician are subject af, continuing significant improvement within a reasonable and generally predictable period. (2) Prescribed radiotherapy and therapeutic nuclear medicine procedures includ- ing radioisotopes used therewith are provided without charge while receiving Hos- pital Services under Section 12-B and in Medical Offices. Radiation therapy is provided by the specialized Regional Radiation Therapy Service at the Los Angeles Medical Center. ; (3) Prescribed orthoptic treatments and dermatological black light treatments are provided without charge in Medical Offices. (4) Speech therapy is provided for (a) treatment for speech impairments of specific organic origin, which in the judgment of the Attending Physician are subject to continuing significant improvement within a reasonable and generally predictable period-and, (b) treatment of articulation disorders due to congenital abnormalities of the palate. Prescribed speech therapy is provided on a group or individual basis without charge while receiving Hospital Services under Section 12-B, Extended Care Services under Section 12-K, Home Health Services under Section 12-L, and when received in Medical Offices. 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 12-B, all prescribed medications, injectables, radioactive materials used for therapeutic purposes, and allergy test materials and allergy treatment ma- terials are provided without charge. (ii) In Medical Offices, Emergency Departments, and on Home Visits. All prescribed medications, injectables, allergy test materials and allergy treatment materials administered at Medical Offices, at Hospital emergency departments, and on home visits are provided without charge. Chemotherapy medications and radioisotopes generally available in Southern California when prescribed by a Physician for treatment of cancer; and intravenous fluids and medications and additives and nutrients administered therewith, when prescribed by a Physician for out-patient or self-administered use, are provided without charge. Self-administered covered items will be furnished at pharmacies in Hospitals and designated Medical Offices. (b) Purchased by Members. Drugs and medications purchased by Members are provided in accord with Section 11-F(1)(b) . (2) Immunizations. 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 charge. 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 SO percent of Non-Member Rates. (3) Dressings and Casts. During hospitalization specified in Section 12-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. (S) 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 Medically necessary ambulance service is provided without charge 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 without charge. Diagnostic tests and procedures are provided in accord with Section 12-D. Contraceptive devices are provided at reasonable charges. Contraceptive drugs are provided in accord with Section 12-F. (2) Infertility. Medical Services for diagnosis and treatment of involuntary infertilitv are provided without charge. Diagnostic tests and procedures are pro- Section 12-F. Exclusions. The following are not covered: (a) the cost of sperm. (b) Services, other than artificial insemination, related to conception by artificial means, including, but not limited to, in vitro fertiliza- tion and ovum transplants. 1. 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 without charge. A Physician determines whether reconstructive surgery is med- ically 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 12-J, Medical and Hospital Services for hemodialysis for acute and chronic renal disease are provided in accord with this Section 12. Medical Group determines whether a condition is chronic or acute. Hemodialysis for chronic conditions is provided only in facililties approved for participation in the Medicare program. Equip- ment, training and medical supplies required for home dialysis are provided with- out charge. — (2) Organ Transplants. Subject to the terms and conditions in this Section 12-J, Medical and Hospital services for covered organ transplants are provided in accord with this Section 12. Reasonable medical and hospital expenses of the do- nor 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 12-F(5). (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 12-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- plants approved by Medical Group. (e) Except for medically necessary ambulance service provided in accord with Section 12-G, neither transportation nor living expenses are covered for the Member, for his or her family, or for a donor. K. EXTENDED CARE SERVICES Up to 100 days of prescribed Extended Care Services, per Spell of Illness as cov- ered by Medicare or per calendar year, whichever is greater, are provided or arranged without charge at approved Skilled Nursing Facilities. Extended Care Services . include nursing care, bed and board, physical, occupational, and speech therapy, medical social services, preseribed .drugs and medications and medical supplies, appliances and equipment ordinarily furnished by the Skilled Nursing Facility. Diagnostic tests and procedures are provided in accord with Section 12-D and therapeutic procedures, including speech therapy and rehabilitative services., are provided in accord with Section 12-E. L. HOME HEALTH SERVICES AND HOSPICE CARE (1) Rome Health Services. Benefits under this Section 12-L are available only if the Attending Physician determines that it is feasible to maintain effective supervision and control of the Member's care. Medicare-covered home health services that are prescribed or directed by the Attending Physician are provided by Medicare-certified home health agencies without charge. (2) Hospice Care. Members who are diagnosed as having a terminal illness with a life expectancy of six months or less may elect home-based hospice care for such illness for up to 210 days instead of the traditional services covered under this Service Agreement and by Medicare. Care is provided by licensed hospices approved by Medical Group and HCFA. While a hospice election is in effect, covered care for the terminal illness is provided without charge. Such care includes the fol- lowing services and other benefits when ordered by the Attending Physician and the hospice care team: (a) nursing care; (b) physical or occupational therapy or therapy for speech-language pathology; (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 entitled to any other benefits under this Agreement or under Medicare for the terminal illness while the hospice election is in effect. M. TREATMENT FOR ALCOHOL AND DRUG DEPENDENCY Subject to the exclusions set forth in this Section 12-M, the care described here- in is provided without charge 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. (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. (b) Continuation in a course of counseling for patients who are disruptive or physically abusive. If the Member is enrolled through a Group with the supplemental benefit for Residential-Care, benefits are provided in accord with Section 11-M(3) , (4) and (5). N. MENTAL HEALTH SERVICES 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 .Health Plan Service Agreement. (1) Outpatient Mental Health Services. All services of Physicians and mental health professionals, as performed, prescribed or directed by the Attending Physician, including diagnostic evaluation and psychiatric treatment, including individual therapy and group therapy, are provided at Medical Offices without charge for the first 20 visits each calendar year and at a $5.00 charge 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 90 sessions of prescribed care for acute conditions, are provided without charge each calendar year at facilities designated by Health Plan, except that this benefit is reduced by two sessions for each day of hospitalization for psychiatric conditions received by the Member pursuant to Section 12-N(3) during the calendar year. Day and night care include all services of physicians and mental health professionals and the following services and supplies prescribed by a Physician: psychiatric nursing care, group therapy, occupational therapy, shock therapy, medications and supplies. (3) Inpatient Mental Health Services. If, in the professional judgment of the Attending Physician, a Member requires inpatient mental health services, up to 190 days of Hospital Services per lifetime for acute conditions are provided in accord with Medicare and subject to applicable Medicare copayments in a Medicare-certified psychiatric facility, except that the number of days is reduced by one day for each day of inpatient mental health services previously covered by Medicare. Thereafter, up to 45 days of Hospital Services for acute conditions are provided without charge each calendar year at facilities designated by Health Plan, except that this benefit is reduced by one day for each two sessions of day care or night care received by the patient pursuant to Section 12-N(2) during the calendar year. Hospital Services include all services of Physicians and mental health profes- sionals and the following services as prescribed by a Physician: Board and room, psychiatric nursing care, group therapy, shock therapy, drug therapy, medications and supplies while the patient 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. The following services are excluded except when covered by Med- icare: (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 patient 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) Psychiatric therapy on court order or as a condition of parole or proba- tion, 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 without charge. Vhen available, general health education services not addressed to a specific con- dition, such as weight control classes and anti-smoking classes, are provided upon payment 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 ;pital Services covered by thin greement which . uire skills not available with' r—dical Group or facilities not a.�ilable 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. Members must pay Supplemental Charges that would be due if the services received un- der this Section 12-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 physicians 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 CARE OR URGENT CARE RECEIVED FROM PROVIDERS NOT CONTRACTING WITH HEALTH PLAN (1) Emergency Care or Urgent Care. This Section defines and limits Health Plan's obligation to pay for Emergency Care or Urgent Care 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 Care" means: (a) care needed immediately because of sudden injury or illness; and (b) the time required to reach a Hospital or Medical Office would mean risk of permanent damage to the Member's health; and (c) transfer to a Hospital or Medical Office is precluded because of serious risk to the Member's health, or is unreasonable due to the distance involved and the nature of the Member's condition. The term "Urgent Care" means: (a) care resulting from an unforeseen illness or injury when the Member is temporarily away from the Service Area; and (b) care is required to prevent serious deterioration of the Member's health; and (c) the care cannot be delayed until the Member's return to the Service Area. The amount otherwise payable is reduced by the amount of Supplemental Charges that would be due if Emergency Care or Urgent Care were received from Physicians or Hospitals or at Medical Offices, and is subject to all of the exclusions, limitations and reductions set forth in this Agreement. (i) Within the Service Area. Subject to the foregoing limitations, Health t Plan will pay all reasonable charges for Emergency Care received within the Service Area from providers not contracting with Health Plan. (ii) Outside the Service Area. (A) Members Who Reside Within the Service Area. Subject to the foregoing limitations, Health Plan will pay all reasonable charges for Emergency Care or Urgent Care received outside the Service Area from providers not contracting with Health Plan. Covered benefits include Emergency Care or Urgent Care for unexpected premature delivery but not for normal delivery, unless Health Plan determines that the Member was outside the Service Area because of circumstances beyond her control. (fl) Members Who Reside Outside the Service Area. (a) Illness -or Injuries More than 30 Air Miles From the Member's Home. Subject to the foregoing limitations, if a Member becomes ill or is injured while more than 30 air miles from the Member's home and receives Emergency Care or Urgent Care more than 30 air miles from the Member's home, Health Plan will pay all reasonable charges for Emergency Care or Urgent Care received outside the Service Area from providers not contracting with Health Plan. Covered benefits include Emergency Care or Urgent Care for unexpected premature delivery but not for normal delivery, unless Health Plan determines that the Member was more than 30 air miles from her home because of circumstances beyond her control. (b) Illness or Injuries Less Than 30 Air Miles From the Member's Home. Subject to the foregoing limitations, if a Member becomes ill or is injured while less than 30 air miles from the Member's home, Health Plan will pay all reasonable charges for Emergency Care, other than for delivery, received from providers not contracting with Health Plan. (2) Continuing or Follow-up Treatment. Continuing or follow-up treatment is not covered. Payment is limited to Emergency Care or Urgent Care required before the Member can, without medically harmful consequences , be transferred to a Hospital or Medical Office in the Service Area, or, if the Member is near another Health Plan Region, be transferred to a contracting hospital or medical office in the other Health Plan Region. A decision to transfer a Member to a Hospital or Medical Office specified in this paragraph is made at Health Plan's discretion. 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 the cost of necessary ambulance service or other special transportation arrangements medically required to transport the Member to a Hospital or Medical 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. (3) Notification and Claims . Any Member receiving hospital services within the scope of this Section 12-5 should notify the Health Plan office within 48 hours after care is commenced. A complete claim for payment, on forms provided by Health Plan, should be filed with the Health Plan office within. 60 days after the first 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. (4) 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 determining the applicability of and implementing this Section 12-5. s I� (5) Right of Recovery. Any overpayment hereunder may be recovered by Health Plan from any person to whom the payment was made, or from any insurance company or organ- ization which is obligated to pay for the Emergency Care or Urgent Care. T. CORRECTIVE LENSES AND EYEGLASSES If the Member is enrolled through a Group with the supplemental benefit for corrective lenses and eyeglasses, benefits are provided in accord with Section 11-T. U. HEARING AIDS If the Member is enrolled through a Group with the supplemental benefit for hearing aids, benefits are-provided in accord with Section 11-U. V. DURABLE MEDICAL EQUIPMENT, CORRECTIVE APPLIANCES AND ARTIFICIAL AIDS When prescribed by the Attending Physician, medical equipment covered under pedicare, and corrective appliances and artificial aids covered under Medicare, are provided without charge.