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CIT~OF SAN BERNARDI~ - REQUEU FOR COUNCIL AC1~N
From:
Mary Jane Perlick,
Personnel Director
Personnel
ftEC'D.- ADMIN, OFF, Subject:
\98') OCT ?l\ P;', 3: 211
Resolution authorizing the execution of
agreement with Kaiser Foundation Health
Plan, Inc. relating to change in Rates
effective January 1, 1986.
Dept:
Date: October 21, 1935
Synopsis of Previous Council action:
On December 4, 1984, the current Kasier Foundation Health Plan, Inc., and rates were
approved with an effective date of January 1, 1985.
Recommended motion:
Approve the resolution to authorize the execution of the Kaiser Foundation Health
Plan, Inc., relating to change in rates effective January 1, 1986.
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Signatu re
Contact person: ~lary Jane Perl ick
Phone: x~l 111
Supporting 1ata attached: 'Jf's
Ward: N/A
FUNDING REQUIREMENTS:
Amount: no additional cost Source: e
Finance:
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Council Notes:
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CITY OF SAN BERNARDIWo -
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REQU~T FOR COUNCIL AcfioN
STAFF REPORT
The City, at present, offers employees a choice the Kaiser Health Plan and
the Cityls self-insured health program. In October of each year, the payment
rates are reviewed and revised for the upcoming calendar to be effective on
January 1. The 1986 rates for the Kaiser Health Plan are as follows:
Rates-Effective 1-1-86
Employee Only
$83.49
$75.26
Two Person
Coverage
Family
Coverage
Kaiser Health Plan
Current 1985 Rates
$166,98
$150.50
$235,44
$213,10
The new rates r~present an approximate increase of 11.0%, 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.*
The coverage has been amended to include a prescription drug benefit where
the member can Durchase medicine at the maximum cost of $2.50 per prescription.
Also the mental health coverage was changed to where the member pays a maximum
charge of $10.00 for the first twenty mental health visits. All other coverages
remain the same as presently exist,
The Insurance Committee has been conferred with and are in full support and
agreement with the plan design,
*Current health plan contribution levels
Fire Safety - $80/135.00 mo (Cafeteria Plan)
Police Safety - $80/135.00 mo(Cafeteria Plan)
General Unit - $53.05 Employee/$111.42 with dependents
Mid-Mgmt - $57.24 employee/$120.75 with dependents
Management/Confidential - $158.06 mo (Cafeteria Plan)
RCD/hg
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RESOLUTION NO '___ ____,___________
RESOLUTION OF THE CITY OF SAN BERNARDINO AUTHORIZING THE
XECUTION OF AN AMENDMENT TO THE AGREEMENT WITH KAISER
OUNDATION HEALTH PLAN, INC., RELATING TO A CHANGE IN RATES,
FFECTIVE JANUARY 1, 1986.
BE IT RESOLVED BY THE MAYOR AND COMMON COUNCIL OF THE
ITY OF SAN BERNARDINO AS FOLLOWS:
SECTION 1. The Director of Personnel of the City of San
ernardino is hereby authorized and directed to execute on
ehalf of said City an amendment to the agreement with Kaiser
oundation Health Plan, Inc., relating to a change in rates
ffective January 1,1986, affecting the City's Group Health
lan, a copy of which amendment is on file in the Personnel
epartment.
I HEREBY CERTIFY that the foregoing resolution was duly
dopted by the Mayor and Common Council of the City of San
ernardino at an __________________ meeting thereof, held
n the
day of ________________, 1985, by the fol-
owing vote, to wit:
AYES:
Council Members
NAYS:
ABSENT:
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City Clerk
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The foregoing resolution is hereby approved this ____
ay of _______________, 1985.
pproved as to form:
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d-c~J~rc!!tt:Ji.,.~~,
C~ty Attorney
Mayor of the City of San Bernardino
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I~SER PERMANENTE
Kaiser Foundation Health Plan. Inc,
Southern California Region
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October 10, 1985
City of San Bernardino
300 North D Street
San Bernardino, CA 92418
Attn: Ms. M. J. Perlick, Personnel Director
This is to advise you of the dues rates and of other contractual changes which will
be effective in 1986. Our overall community rate increase for basic coverage in
1986 is 5.9\ Depending on your group's level of coverage, however, your dues rates
may have increased at a slightly higher or lower rate. This is because there are
differences in the percentage increase for certain supplemental benefits.
We are pleased to tell you that in 1986 we will be increasing our physician an~ non-
physician staffing to further improve our members' access to care. Also during the
coming year, a number of new medical facilities will be available to our members.
We are particularly excited about the opening of the new 200-bed Woodland Hills
Medical Center. In addition to this major medical center, several new medical
offices will be open and available to our members in the following areas: Temple
City, Riverside, Garden Grove, Point Loma, Escondido and Car1sbad.
Over the last two years, our expenses for emergency services provided to our members
at non-Kaiser Permanente facilities have been increaSing rapidly. In response, we
are actively working with local community hospitals to better coordinate emergency
care they provide to our members. This includes improving our systems to monitor
and transfer members back to our hospitals when medically possible and working
toward more cost-effective payment arrangements. We feel that these strategies will
provide more coordinated and cost-effective care to our members.
The following rates will be effective January I, 1986
The monthly rates will be:
Basic Rate Structure
Subscriber only
Subscriber with one Family Dependent
Subscriber with two or more Family Dependents
$ 83.49
$ 166.98
$ 236.44
Variables to Basic Rate Structure
For each Member age 65 or older for whom no
assignment of Medicare Part B benefits to
Health Plan is in effect
Add $ 30.29
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For each Member (up to 2 per Family Unit)
entitled to benefi ts under both Parts A and B
of Medicare, for whom an assignment of Part B
benefits to Health Plan is in effect:
Subscr iber
Subscriber's spouse or child
Subtract $
Subtract $
30.66
30.66
Variables to the Basic Rate Structure are Medicare adjustments and do not apply when
Medicare benefits are secondary to employer plan benefits pursuant to applicable
provisions of Federal law.
All contractual changes, inClUding the changes required by the Federal government,
as so indicated, are summarized in the enclosure which has been prepared to assist
you in identifying generic changes between your current Service Agreement and the
1986 Service Agreement. The enclosure does not identify any changes which are,
unique to your group, such as mutually agreed upon changes in benefits or revisions
to eligibility provisions.
Additionally, as requested, Mental Health Program has been changed, from 12 to 13,
and Prescription Drug Program 13 has been added.
A revised Service Agreement incorporating these changes is enclosed. After your
review, please sign the Health Plan copy of the signature page and return it to my
attention for our records. Please retain the Service Agreement itself for your
records.
Please do not hesitate to contact your Health Plan Representative if you have any
questions.
Very truly yours,
(:',
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Sharon Flaherty
Vice President and Health Plan Manager
Southern California Region
Enclosures
Group 66-00
cc: Dean Kemp
David Root
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KAISER FOUNDATION HEALTH PLAN, INC.
Southern California Region
1986 Group Medical and Hospital Service Agreement
Generic Language Changes
Generic language changes are made in the following sections of
the 1986 Group Medical and Hospital Service Agreements:
Section l-B: This is a minor change indicating that each Health
plan Region operates in a specific geographic area.
Section l-N has been revised to define the Service Area in terms
of zip codes. The actual geographic area encompassed is
approximately the same under the new description as it was under
the 1985 contract. This change is made in the interest of making
it easier for groups, members, prospective members, and Kaiser
permanente staff to readily determine whether or not any given
location is within or outside of the Service Area by using the
zip code which is a commonly used and generally known reference.
Section 2-A: The first paragraph of Section 2-A has been revised
to indicate that at the time of original enrollment, individuals
must reside within that portion of the Service Area which Health
plan has designated as open for enrollment. This area is
designated by the zip code listing which appears on the
application and enrollment cards furnished by Health Plan.
Section 2-C: This section now specifies that coverage for the
newborn child is provided during the mother's confinement. This
previously was specified as part of the maternity care benefit.
The provisions have not been changed.
Section 4-A: There are two cha~ges to Section 4-A:
Except where precluded as a result of TEFRA or DEFRA, Medicare-
related adjustments are made to the basic rate structure. The
language used to indicate to which Members these adjustments
apply, has been simplified and clarified.
The second change clarifies that if a taxing authority imposes
certain taxes or license fees upon us, the associated rate
increase for each group will be sufficient to cover each group's
prorata share of such tax or license fees.
Section 4-B: This section has been revised to show that the
limit on Supplemental Charges for Basic Health Services for the
calendar year 1986 is $900 per Member and $2,600 per Family Unit
of three or more Members. The list of Basic Health Services
subject to this limit has been revised to include occupational
therapy and speech therapy which the Federal Office of Health
Maintenance Organizations (OHMO) has categorized as basic health
services.
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Section 4-C: In anticipation of possible Congressional action,
which would require that employer benefits be primary to Medicare
benerits for active employees and their spouses, regardless of
age, Section 4-C(2) has been changed to remove the upper age
limit. The upper age limit will remain 69 unless Federal law
changes, in which case the upper age limit, if any, will be that
specified in the law.
Section 6-A(I): The section has been rearranged and subsection
(c) has been written to make it clear that the exclusion applies
only when the care is required by law to be provided only by or
received only from the indicated public agencies.
Section 6-A(7): At the request of OHMO, this section has been
rewritten to indicate more clearly that this exclusion does not
apply when it is the generally accepted medical practice to refer
patients outside of Southern California for procedures.
Section 6-A (9) :
OHMO to clarify
not excluded.
This exclusion has been modified as required by
that medically necessary foot care services are
Section 6-C(2): This is a TEFRA-related correction to recognize
those Members whose Medicare benefits are not integrated with
Health Plan benefits.
Section 10-J: This change reflects the move of. the Health Plan's
Southern California Regional Office from 4747 Sunset Boulevard,
Los Angeles to 393 East Walnut Street, Pasadena, California'"
91188.
Section II-A: This section has been changed to indicate that the
medical services for pregnancy are covered on the same basis as
for other conditions. Specifically, the office visit registration
charge, if any, will apply to ~~stetrica1 care visits just as it
does to other medical office visits.
Section Il-E: OHMO requires that our Service Agreement language
reflect the HMO requirement for coverage of rehabilitative
services by specifying that services are available for two months
when significant improvement is expected within a period of two
months. Subsections (1) and (5) of this section are revised
accordingly.
In order to assure that the two months' coverage requirement is
satisfied for speech therapy, Subsection (4) has also been
changed to eliminate the reference to the 30 visit limitation.
In addition, the $5.00 copayment for speech therapy visits
provided to Members who are inpatients has been eliminated.
Section Il-F(2): This change, also required by OHMO, provides
that immunizations which were developed and put in use for
specific diseases after April 1 of the year preceding the year in
which this Agreement becomes effective or was last renewed and
unexpected mass immunizations will be covered at 50% of non-
member rates.
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Section 11-8: Section 11-H now addresses only family planning
and infertility care. Pregnancy related services will be
provided in accordance with the sections relating to the
applicable services. There is no substantive change.
Section 11-1: At the request of OHMO, this section has been
modified to provide that post-mastectomy reconstructive surgery
and prosthetic device coverage will be provided without regard to
the date of the mastectomy.
Section 11-J has been revised to indicate that kidney transplants
are provided only in facilities approved for participation in the
Medicare Program. In addition, written referral to dialysis
facilities by Medical Group has been included in subsection (4)
and the reference to Southern California has been deleted.
Section 11-M: As a result of OHMO review, the exclusions in this
section have been revised to eliminate the specific exclusion of
home visits and to clarify that only counseling and not treatment
for medical problems may be discontinued for disruptive and
physically abusive patients.
Section 11-N: This section is modified as a result of OHMO's
requirement that we--specify that the mental health services
include evaluation and crisis intervention. OHMO also required
that we indicate that otherwise covered mental health treatment
will not be excluded on the basis that it was being sought as a
result of court order or as a condition of probation or parole,
if a physician determines that such treatment would be necessary
and appropriate.
Section 11-Q: This section has been modified to indicate that
referrals may be made to sources outside of the Service Area.
This would occur primarily when covered services were not
available within the Service Area and it would be customary
practice in the community to refer patients needing such services
to facilities outside of Southern California.
Section 11-R: In order to eliminate the need for frequent
revisions as Health Plan expands to new Regions, we have changed
the second paragraph to indicate that a description of such
Regions and a list of their facilities may be obtained at the
Health Plan Office.
Section 11-T: This is not a generic change but affects only
those groups which offer the supplemental Vision Benefit, level
II, and indicates that the frame allowance applicable in calendar
year 1986 will be increased from $33.00 to $34.00. For those
groups which offer the supplemental Vision Benefit, level I, the
frame allowance remains $20.00.
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I<AlSER PERMANENTE
Kaiser Foundation Health Plan, Inc.
Southern California Region
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1986
Group Medical
and Hospital Service
Agreement
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'!'ABLE OF UJl'f.a.DIL'I.LO
1986
Section
Subject
1.
Definitions
2.
Bligibility, Bnrollaent and Coverage
A. Eligibility
(1) Subscribers
(2) Family Dependents
Ineligible Persons
B. Enrollment
(1) Newly Eligible Persons
(2) Open Enrollment Period
Limitation on Enrollment
C. Effective Date of Coverage
(1) Newly Eligible Persons
(2) Newborn
(3) Open Enrollment Period
D. Termination Date of Coverage
3. Relations ~g Parties Affected By Agr~t
4.
Rates
A.
and Payaent
Periodic Payment Schedule
Basic Rate Structure
Variables to Basic Rate Structure
Imposition of Tax or License Fees
B. Other Charges
Limits on Supplemental Charges
C. Medicare
(1) Medicare Payments
(2) Special Provision for Members Ages 65 and over Who Elect
Group's Health Plan As Primary
D. Employer Contribution
E. Coordination of Benefits (If Applicable)
5. Services and Benefits
A. Within the Service Area
Choice of Physician and Hospital
B. Outside the Service Area
6. Exclusions, Liaitations and Reductions
A. Exclusions
(1) Employer or Governmental Responsibility
(2) Non-Covered Inpatient Care
(3) Cosmetic Services
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Section
Subject
(4) Dental Care
(5) Certain Physical Examinations
(6) Experimental or Investigational Procedures
(7) Procedures Not Generally and Customarily Available
(8) Voluntary Infertility
(9) Podiatry
(10) Chiropractic
(11) Durable Equipment
(12) Blood
(13) Organ Transplants
(14) Sex Change
B. Limitations
(1) Unusual Circumstances
(2) Refusal to Accept Treatment
(3) Alcohol and Drug Dependency
(4) Rehabilitation
(5) Psychiatric Conditions
(6) Corrective Appliances and Artifical Aids
C. Reductions
(1) Injuries or Illnesses Caused By Third Parties
(2) Medicare
7. Conversion and Transfer
A. Conversion to Non-Group Enrollment
B. Change of Residence
8. Arbitration of Claims
9. Ter. and Ter.ination
A. Term of Agreement
B. Termination
(1) Termination of Agreement
(2) Termination of Specific Members
(3) Return of prorata Portion of Monthly Payment
in Certain Cases
(4) Opportunity For Review of Certain Terminations
By Commissioner of Corporations
C, Amendment
10. Miscellaneous Provisions
A. Acceptance of Agreement
B. Agreement Binding on Members
C. Applications, Statements and Questionnaires
D. Identification Cards
E. Right to Examine Records
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Section
Subject
F. Notice of Certain Events
G. Governing Law
H. Administration of Agreement
I. Member Information
J. Notices
L. ERISA Information (If Applicable)
M. Hold-Harmless Agreement (If Applicable)
11. Benefit Schedule
A. Medical Care In Hospital, Office and Skilled Nursing Facility
(1) Care While Hospitalized
(2) Care In Medical Offices or Emergency Departments
(3) Care In Skilled Nursing Facility
B. Hospital Care
c. Home Visits
D. Diagnostic Tests and Procedures
E. Therapeutic Procedures
(1) Physical Therapy
Occupational Therapy
Inhalation Therapy
(2) Radiotherapy
Therapeutic Nuclear Medicine
(3) Orthoptic and Black Light Treatments
(4) Speech Therapy
(5) Inpatient Rehabilitation
F. Prescribed Medications, Immunizations and Dressings and Casts
(1) Prescribed Medications and Items
(2) Immunizations
(3) Dressings and Casts
(4) Amino Acid Modified Products
(5) Immunosuppressive Drugs
G. Ambulance Service
H.
Family
(1)
(2)
Planning and Infertility
Family Planning
Infertili ty
I. Reconstructive Surgery and Prosthetic Devices Following Mastectomy
J. Hemodialysis and Kidney Transplants; Liver Transplants
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Section
Subject
K. Extended Care Services
(2)
Health Services
Members Who Are Not Medicare Members, Part A Members or
Part B Members
Members Who Are Medicare Members, Part A Members or Part
B Members
Durable Equipment For Medicare Members
L.
Home
(1)
M. Treatment For Alcohol and Drug Dependency
(1) Inpatient Care for Withdrawal
(2) Outpatient Services
(3) Exclusions
N.
Mental
(1)
(2)
(3)
(4)
(5)
Health Services
Outpatient Services
Day and Night Care Services
Inpatient Services
Psychological Testing
Exclusions and Limitations
O. Medical Social Services
P. Health Education
Q. Payment In Lieu of Service Benefits
R. Service Benefits In Other Health Plan Regions
S. Emergency Services Received From Providers Not
Contracting With Health Plan
(1) Emergency Services
(2) Reductions for Other Benefits and Copayments
(3) Payment
(4) Continuing or Follow-Up Treatment
(5) Notification and Claims
(6) Releases and Assignments
(7) Right of Recovery
T. Corrective Lenses and Eyeglasses (If Applicable)
(1) Services and Benefits
(2) Exclusions
U.
Hearing
(1)
(2)
Aids (If Applicable)
Services and Benefits
Exclusions
V. Orthotic and Prosthetic Devices and Durable Medical Equipment
(If Applicable)
12. Signature Page and Effective Date
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KAISER FOUNDATION HEALTH PLAN, INC.
A Nonprofit Corporation
Southern California Region
GROUP MEDICAL AND HOSPITAL SERVICE AGREEMENT
INTRODUCTION
This Service Agreement has been entered into between Kaiser Foundation Health Plan
Incorporated, a California nonprofit corporation, herein called "Health Plan", and
CITY OF SAN BERNARDINO, herein called "Group".
Health Plan, in consideration of the monthly payments to be paid to Health Plan by
Group and in consideration of the Supplemental Charges to be paid by or on behalf of
Members, agrees to arrange necessary Medical and Hospital Services and other benefits
as specified in Section 11 for eligible persons who enroll 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 and hospital facilities
and of group medical practice, Health Plan operates on a direct-service rather than
indemnity basis. The interpretation of this Agreement is guided by the direct-service
nature of the Health Plan program.
1. DEFIN IT IONS
As used in this Agreement and all attached schedules or prov1s1ons modifying this
Service Agreement, the terms in boldface type, when capitalized, have the meanings
shown:
A. Health Plan:
poration organized
v ices.
Kaiser Foundation Health Plan, Inc., a California nonprofit cor-
for the primary purpose of arranging Medical and Hospital Ser-
B. Health Plan Region: A specific geographical area in which a direct-service
health care program is conducted by Health Plan or a related organization.
C. Subscriber: A person who meets all applicable eligibility requirements of Sec-
tion 2 and is enrolled hereunder, and for whom the prepayment required by Section 4
has been received by Health Plan.
D. Family Dependent: Any person who meets all applicable eligibility requirements
of Section 2 and is enrolled hereunder and for whom the prepayment required by Sec-
tion 4 has been received by Health Plan.
E. Family Unit: A Subscriber and all his or her Family Dependents.
F. 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 for Members described in Section 4-C(2) of this Service Agreement;
Part A Member: Any Member entitled to benefits under Part A of Medicare, except
for Members described in Section 4-C(2) of this Service Agreement; Part B Member:
Any Member entitled to benefits under Part B of Medicare, who has assigned Part B
benefits to Health Plan, except for Members described in Section 4-C(2).
Group 66-00
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G. Medical Group: Any group of medical doctors or any medical doctor that has
contracted with Health Plan to render Medical Services.
H. 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.
I. Hospital: Any hospital in the Southern California Region with respect to which
Health Plan maintains contractual arrangements for Hospital Services. A current list
of such Hospitals may be obtained from any Health Plan office.
J. Medical
Region which
obtained from
Office: Any outpatient
is staffed by Medical
any Health Plan office.
treatment facility in the Southern California
Group. A current list of Medical Offices may be
K. Medical Services: Except as expressly limited or excluded by this Agreement,
those medically necessary professional services of physicians and surgeons, other
health professionals and paramedical personnel, including medical, diagnostic, thera-
peutic and preventive services which are (1) generally and customarily provided in
Southern California and (2) performed, prescribed, or directed by the Attending Phy-
sician.
L. Hospital Services: Except as expressly limited or excluded by this Agreement,
those medically necessary services for registered bed patients which are (1) general-
ly and customarily provided by acute general hospitals in Southern Californa and (2)
prescribed, directed or authorized by the Attending Physician.
M. Non-Member Rates:
maintained by Medical
not Members.
The charges set forth in the applicable schedule of charges
Group or Hospitals for services provided to patients who are
N. Service Area: The Service Area is that portion of Los Angeles, Orange, River-
side, San Bernardino, San Diego and Ventura counties within the following zip codes
as constituted on April 1, 1985: 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,
92010-2, 92014, 92016-7, 92020-2, 92024-7, 92031-2, 92035, 92036, 92037-38, 92040-1,
92045, 92047-8, 92050, 92053-4, 92056, 92062-5, 92067-71, 92073, 92075, 92077-8,
92080, 92082-3, 92093, 92100-99, 92220, 92223, 92305, 92307, 92314-8, 92320-2,
92324-6, 92329-30, 92333, 92335, 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, 93510, 93532, 93534-35, 93539, 93543-4, 93550, 93553,
93563.
O. Medicare: The Federal Health Insurance for the Aged and Disabled Act.
P. Skilled Nursing Facility: A licensed institution (or a distinct part of an in-
stitution) which (1) provides 24 hour a day licensed nursing care; (2) has in effect
a transfer agreement with one or more hospitals; (3) is primarily engaged in provid-
ing skilled nursing care and related services to inpatients who require medical or
nursing care as part of an ongoing therapeutic regimen; and (4) has been approved in
writing by Medical Group.
Q. Extended Care Services: Skilled inpatient services which are (i) medically
necessary, (ii) ordered by an Attending Physician, (iii) customarily provided by
Group 66-00
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Skilled Nursing Facilities, and (iv) above the level of custodial, convalescent,
intermediate, or domiciliary care.
R. Supplemental Charges: Those amounts,if any, which must be paid by Members when
they receive covered services not fully prepaid hereunder.
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 Groupls 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 Subscriberls 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.
Ineligible Persons. No person is eligible to enroll hereunder if the person or
any other person in his or her Family Unit has had Health Plan coverage terminated
under this or any other Health Plan Medical and Hospital Service Agreement for any
reason specified in Section 9-B.
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
Subscriber may enroll by submitting an enrollment application to Group
become a
within 30
Group 66-00
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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 Subscriberls 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 Subscriberls sub-
mitting a change of enrollment form to Group within 30 days. A newborn child of a
Family Dependent other than the Subscriberls spouse may be enrolled hereunder only
if the newborn child is eligible under Section 2-A(2)(c); if not eligible under
Section 2-A(2)(c), the newborn may be enrolled under an Individual Service Agree-
ment by submitting an application within 30 days of birth.
(2) Open Enrollment Period. There shall be an Open Enrollment Period between
December 01 - December 15 each year.
Eligible persons not enrolled when newly
cribers and Family Dependents by submitting
during the open enrollment period.
eligible may only be enrolled as Sub-
an enrollment application to Group
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-
rollment period December 01 - December 15 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 relationship between Health Plan and Medical Group and between Health Plan and
Hospitals is an independent contractor relationship; Physicians and Hospitals are not
agents or employees of Health Plan, nor is Health Plan or any employee of Health
Plan, an employee or agent of Hospitals or Medical Group or any Physician.
Physicians maintain the physician-patient relationship with Members and are solely
responsible to Members for all Medical Services. Hospitals maintain the hospital-
patient relationship with Members and are solely responsible to Members for all Hos-
pital Services.
Group 66-00
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Patient-identifying information from the medical records of Members and patient-
identifying information received by Physicians or Hospitals incident to the
physician-patient or hospital-patient relationship is kept confidential and is not
disclosed without the prior consent of the Member, except (i) for internal use by
Health Plan, Hospitals or Medical Group in bona fide medical research or education,
or for use in the administration of this Agreement, and (ii) to comply with govern-
ment requirements established by law.
Neither Group nor any Member is the agent or representative of Health Plan, and
neither is liable for any acts or omissions of Health Plan, its agents or employees,
or of Medical Group, any Physician, or Hospitals, or 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 Health Plan and Hospitals
provide that Members shall not be liable for any amounts owed Medical Group or Hospi-
tals by Health Plan. However, should Health Plan fail to pay a non-contracting pro-
vider the Member may be liable for the cost of any such services received by him.
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
Subscriber with one Family Dependent
Subscriber with two or more Family Dependents
$ 83.49
$ 166.98
$ 236.44
Variables to Basic Rate Structure
For each Member age 65 or older, for whom no assignment of
Medicare Part B benefits to Health Plan is in effect
Add
$ 30.29
For each ~Iember (up to 2 per Family Unit) entitled to bene-
fits under both Parts A and B of Medicare, for whom an as-
signment of Part B benefits to Health Plan is in effect:
Subscriber
Subscriber's spouse or child
Subtract
Subtract
$
$
30.66
30.66
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 Planls 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 Groupls 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 ~Iembers for whom the stipulated payment is received by Health Plan
tIed to Hedical and Hospital Services hereunder, and then only for the
which such payment is received.
are enti-
period for
Group 66-00
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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 Planls annual charge for fully prepaid Basic Health Services established ef-
fective January I 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.
For the calendar year 1986 the limit on Supplemental Charges is $900.00 per Member
but not more than an aggregate of $2,600.00 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 11-Q, 11-R, and ll-S, except for care
which is not otherwise a Basic Health Service under this paragraph.
Payments
result of
Services.
made by the Member or on his behalf for non-covered services or due as a
Section 6-C or 11-S-(2)(a) are not Supplemental Charges for Basic Health
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 Ages 65 and Over Who Elect the Group's Health
Plan as Primary Coverage.
~Iembers ages 65 and over who are entitled to Medicare benefits but who elect
to have the Groupls health plan as their primary health coverage pursuant to
the applicable provisions of Federal law 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
Group 66-00
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Subject to all terms and provisions of this Agreement, Members
receive services and other benefits as follows:
are entitled to
A. Within the Service Area, Within
ceive the services and other benefits
scribed or directed by Physicians.
the Service Area, Members are entitled to re-
specified in Section 11 when provided, pre-
Choice,of Physician and Hospital. Within the Service Area, covered services are
available only from Medical Group, Hospitals and in Skilled Nursing Facilities, and
neither Health Plan, Hospitals, Medical Group nor any Physician has any liability or
obligation on account of any service or benefit sought or received by any Member from
any other doctor, hospital or skilled nursing facility, or other person, institution,
or organization unless (1) prior special arrangements are made by a Physician and
confirmed by written referral from Medical Group or (2) such services are covered un-
der Section ll-S(l)(a).
B. Outside the Service Area. While outside the Service Area, Members may have be-
nefits under Sections ll-R and ll-S(l)(b).
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 ('IFinancial 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.
(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
employerls liability law, and if the Member seeks diligently to establish his or
her rights to Financial Benefits, then services that otherwise would be provided
under this Agreement will be provided, except that the value of such services, at
Non-Member Rates, is recoverable by Health Plan or its nominee from any person,
organization or agency providing Financial Benefits or from whom Financial
Benefits are due, or from the Member, to the extent that monetary Benefits are
provided or payable or would have been required to be provided if the Member had
diligently sought to establish his or her rights to such Financial Benefits.
(2) Non-Covered Inpatient Care. Custodial care, domiciliary care, convalescent
Group 66-00 Page 7
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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 Section II-I.
(4) Dental Care. Dental care and dental X-rays, including care for injury to
teeth.
(5) Certain Physical Examinations. Physical examinations and related services
required for obtaining or continuing employment, insurance or governmental licens-
ing.
(6) Experimental or Investigational Services, Any treatment procedure, drug or
drug usage, facility or facility usage, equipment or equipment usage, device or
device usage, or supplies (each of which is hereafter called a "Service") which
Health Plan, after consultation with Medical Group, determines to be experimental
or investi.gational. 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 Available. 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.
(10) Chiropractic. Chiropractic services and services of a chiropractor.
(11) Durable Equipment. Durable medical equipment, such as oxygen tents, hos-
pital beds, and wheelchairs used in the Memberls home (including an institution
used as his or her home) except that Medicare Members and Part B Members have the
benefits as set forth in Section ll-L.
(12) Blood. Blood, except as specified in Section II-B.
(13) Organ Transplants. Organ
plants and liver transplants for
pursuant to Section llJ.
transplants are excluded,except for kidney trans-
children with biliary atresia, which are provided
(14) Sex Change, All services
related to sex changes.
B. Limitations.
Medical Group and
limitations:
The rights of Members and
Physicians under this
obligations of Health Plan, Hospitals,
Agreement are subject to the following
Group 66-00
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(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 Nedical Group, major disaster,
disability of a significant part of Hospital or Medical Group personnel, epidemic,
or similar causes, or (b) labor disputes involving Health Plan, Hospitals or Medi-
cal Group, the rendition or provision of services and other benefits covered under
this Agreement is delayed or rendered impractical, Hospitals, Medical Group and
Physicians will, within the limitation of available facilities and personnel, use
their best efforts to provide services and other benefits covered under this
Agreement, but with regard to (a), neither Health Plan, Hospitals, Medical Group
nor any Physician shall have any liability or obligation on account of such delay
or such failure to provide services or other benefits, and with regard to (b), the
provision of non-emergent care may be deferred until after resolution of the labor
dispute.
(2) Refusal to Accept Treatment. Certain Members may, for personal reasons, re-
fuse to accept procedures or treatment recommended by Physicians. Physicians may
regard such refusal as incompatible with the continuance of a satisfactory physi-
cian-patient relationship and as obstructing the providing of proper medical care.
Physicians use their best efforts to render all necessary and appropriate profes-
sional services in a manner compatible with a Member's wishes, insofar as this can
be done consistently with the Physician's judgment regarding proper medical prac-
tice. If a Member refuses to follow a recommended treatment or procedure, and the
Physician believes that no professionally acceptable alternative exists, the Mem-
ber is so advised. If the Member still refuses to follow the recommended treatment
or procedure, then neither Medical Group, Hospitals, Health Plan nor any Physician
has any further responsibility to provide care for the condition under treatment.
(3) Alcohol and Drug Dependency. Services for alcohol and drug dependency are
provided only in accord with Section II-M.
(4) Rehabilitation, Rehabilitative treatment is provided only in accord with
Section ll-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 Section II-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 Section II-I.
(c) post-cataract surgery lenses covered by Medicare, which are provided
without charge to Medicare Members and Part B Members.
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,
Group 66-00
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(a) Services Received at Facilities Contracting with Health Plan. If an in-
jury 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 Physi-
cians 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 are in excess of the total amount of any settle-
ment or judgment the Member, his or her estate, parent or legal guardian re-
ceives from or on behalf of the third party on account of such injury or
illness.
(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 Section Il-S are made for the ser-
vices of physicians, hospitals and other providers not contracting with Health
Plan; however, the Member must reimburse Health Plan for any amounts paid by
Health Plan up to the amount of any settlement or judgment the Member, his or
her estate, parent or legal guardian receives from or on behalf of the third
party on account of such injury or illness. Health Plan may condition payment
upon execution by the Member, his or her estate, parent or legal guardian of an
agreement (i) to reimburse Health Plan accordingly, and (ii) directing his or
her attorney to make payments directly to Health Plan.
The provisions of this Section 6-C(I) apply even
covery on account of the injury or illness is less
if the total amount of the re-
than the Memberls actual loss.
(2) Medicare. Benefits are reduced by any benefits to which a Medicare Member,
Part A Member or Part B Member is entitled under Medicare.
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. 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 II-R and II-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 II-R and I1-S exists in another Health
plan Region after a Member has resided in such Region more than 90 days, unless the
Member, ~y prior application to Health Plan, demonstrates special circumstances
under whith a longer period is "temporary" and the Member's continuing status of
temporary! residence is confirmed in writing by Health Plan.
8. ARBITRATION OF CLAIMS
A. Initiating a Claim. Any claim arising from alleged violation of a legal duty
incident to this Agreement shall be submitted to binding arbitration if the claim is
asserted:
(1) by a ~lember, or by a ~lemberls heir or personal representative ("Claimant")
Group 66-,00
Page 10
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(2) On account of death, mental disturbance or bodily injury arIsIng from ren-
dition or failure to render services under this Agreement, irrespective of the le-
gal theory upon which the claim is asserted;
(3) For monetary damages exceeding the jurisdictional limit of the Small Claims
Court; and
(4) Against one or more of the following ("Respondent"):
(a) Health Plan,
(b) Hospitals,
(c) Medical Group,
(d) Any Physician, or
(e) Any employee of the foregoing.
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 counselor witness fees or
other expenses incurred by a party for his or her own benefit. Said account shall be
replenished from time to time as directed by the 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 the 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 ini-
tial 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.
Group 66-00
Page 11
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9, TERM AND TERMINATION
A, Term.
This Agreement continues in effect from the effective date stated on the last page
of this Agreement to January 01, 1987, 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 benefitsihereunder terminate as of the effective date of termination.
(1) Termination of Agreement. This Agreement may be terminated as follows:
(a) Termination on Notice.
by giving written notice to
January 1 ("Anniversary Date").
Either party
the other at
may terminate
leas t 60 days
this Agreement
prior to any
(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 Planls governing Board determines that Health Plan woul~ 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 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
Group 66-00
Page 12
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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.
(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 Memberls 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
Group 66-00
Page 13
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and including the date of reinstatement."
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 60 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, Statements, and Questionnaires. Members or applicants for mem-
bership shall complete and submit to Health Plan such applications, medical review
questionnaires, or other forms or statements as Health Plan may reasonably request.
D. Identification Cards. Cards issued by Health Plan to Members pursuant to this
Agreement are for identification only. Possession of a Health Plan identification
card confers no rights to services or other benefits under this Agreement. To be en-
titled to such services or benefits the holder of the card must, in fact, be a Member
on whose behalf all applicable charges under this Agreement have been paid. Any per-
son receiving services or other benefits to which he or she is not then entitled pur-
suant to the provisions of this Agreement is chargeable therefor at Non-Member Rates.
E. Right to Examine Records.
pertinent records, with respect
ment.
Health Plan at reasonable times may examine Group's
to eligibility and monthly payments under this Agree-
F. Notice of Certain Events. Health Plan shall give Group written notice within a
reasonable time of any termination or breach of contract by, or inability to perform
of, Hospitals or Hedical Group or any other person with whom Health Plan has a con-
tract to provide services and benefits hereunder, if Group may be materially and ad-
versely affected thereby.
In the event that the contract between Health Plan and Hospitals, Medical Group or
any other contracting provider is terminated while a Hember 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.
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G. Governing Law. Health Plan is subject to the requirements of Chapter 2.2 of
Division 2 of the California Health and Safety Code and of Subchapter 5.5 of Chapter
3 of Title 10 of the California Administrative Code, and any provision required to be
in this Service Agreement by either of the above shall bind Health Plan whether or
not set forth herein.
H. Administration of Agreement. Health Plan may adopt reasonable policies, pro-
cedures, rules and interpretations to promote orderly and efficient administration of
this Agreement.
I. Member Information, Group shall inform Subscribers (1) of the periodic charges
applicable to their coverage; (2) of conditions of eligibility regarding Subscribers
and Family Dependents; and (3) when coverage becomes effective and terminates.
J. Notices. Any notice under this Agreement may be given by United States mail,
postage prepaid, addressed as follows:
If To Health Plan:
Health Plan Manager
Kaiser Foundation Health Plan, Inc.
393 East Walnut Street
Pasadena, California 91188
If To A Member:
To the latest address provided for the Member on enrollment or change of ad-
dress forms actually delivered to Health Plan.
If to Group:
To the address indicated on the last page of this Agreement.
A person designated as Group Representative on the last page of this Agreement or
otherwise designated by Group by notice to Health Plan, shall disseminate notice to
Subscribers by the next regular communication to them, but in no event later than 30
days after receipt thereof, of all matters (of which Group Representative receives
notice from Health Plan) to which a reasonable person would attach importance in de-
termining the action to be taken upon the matter.
11. BENEFIT SCHEDULE
Subject to all terms, conditions, limitations and exclusions herein, Members are
entitled to the Medical and Hospital Services and other benefits set forth in this
Section, upon payment of specified Supplemental Charges or Non-Member rates. These
services and benefits are available only if and to the extent that they are provided,
prescribed or directed by a Physician, and unless otherwise specifically provided,
received at a Hospital or Medical Office.
Benefits hereunder include and are not in addition to Medicare Benefits, except
for Members ages 65-69 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.
Group 66-00 Page 15
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(1) Care While Hospitalized. During prescribed hospitalization specified in
Section II-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 Il-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 bankls 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
11-L, and by visiting nurses when prescribed by a Physician,
Service Area without charge.
provided under Section
are provided within the
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, c~rdiovascular
studies, audiologic function studies, electroencephalograms, electrocardiograms,
electromyograms and other diagnostic studies using electrostimu1ation or electronic
equipment or producing recordings, tracings, images or similar readings.
Group 66-00 Page 16
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E. THERAPEUTIC PROCEDURES
(1) Except when provided under Section II-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 II-B, Extended Care Services under Section II-K, and
Home Health Services under Section II-L and when received in ~Iedical Offices. Re-
habilitative services, physical therapy and occupational therapy treatment are
limited 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 lI-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 lI-E(5) during an inpatient stay primar-
ily 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 II-B, Extended Care Ser-
vices under Section II-K, and Home Health Services under Section Il-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.
(a) Administered to Members.
(i) While Hospitalized. During hospitalization specified in Section lI-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
Group 66-00
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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. 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-
Group 66-00
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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-
nizations available in Southern California which were developed or put in general
use for specific diseases after April 1 of the year immediately preceding the year
in which this Agreement becomes effective or was last renewed and unexpected mass
immunizations are provided at 50 percent of Non-Member Rates.
(3) Dressings and Casts. During hospitalization specified in Section lIB, 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 childls hospi-
talization, and are furnished without charge at pharmacies in Hospitals and desig-
nated Medical Offices for self-administered use.
(5) Immunosuppressive Drugs. Immunosuppressive drugs developed and in general
use on April 1 of the year immediately preceding the year in which this Agreement
became effective or was last renewed are furnished without charge at pharmacies in
Hospitals and designated Medical Offices when prescribed by a Physician following
a covered transplant.
G. AMBULANCE SERVICE
Necessary ambulance service is provided without charge within the Service Area if
ordered or approved by a Physician.
H. FAMILY PLANNING AND INFERTILITY
(1) Family Planning. Family planning counseling, including pre-abortion and
post-abortion counseling and information on birth control, is provided upon
payment of the registration charge, if any, specified in Section Il-A(2).
Diagnostic tests and procedures are provided in accord with Section II-D.
Contraceptive devices are provided at reasonable charges. Contraceptive drugs are
provided in accord with Section II-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 ll-A(2). Diagnostic tests and procedures are provided in
accord with Section II-D, and medications are provided in accord with Section
ll-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.
I. RECONSTRUCTIVE SURGERY AND PROSTHETIC DEVICES FOLLOWING MASTECTOMY
Group 66-00
Page 19
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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
obtained. Replacement will be made when prostheses are no longer functional.
made prostheses will be provided when necessary.
to be
Custom
J. HEMODIALYSIS AND KIDNEY TRANSPLANTS; LIVER TRANSPLANTS
(1) Hemodialysis and Kidney Transplants. Subject to the terms and conditions
in this Section 11-J:
(a) 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 chro-
nic or acute. Hemodialysis for chronic conditions is provided only in facili-
ties approved for participation in the Medicare program. Equipment,
training and medical supplies required for home dialysis, are provided without
charge.
(b) Medical and Hospital Services for kidney transplants and the directly
related reasonable medical and hospital expenses of a donor or prospective
donor are covered in full. Kidney transplants are provided only in facilities
approved for participation in the Medicare Program.
(2) Liver Transplants for Children with Biliary Atresia. Subject to the terms
and conditions in paragraph (4) of this provision:
(a) Medical and Hospital Services for liver transplants for children with
biliary atresia are provided in accord with this Section 11; and
(b) Costs directly related to obtaining the donor liver are covered in full.
(3) Related Prescription
outpatient drugs required
accord with Section 11-F(S).
Drugs. Prescribed post-surgical immunosuppressive
as a result of a covered transplant are provided in
(4) Terms and Conditions. Covered services and benefits are provided only in
accord with the following terms and conditions:
(a) Medical Group must determine that the procedure represents the safest
and most effective method of treatment.
(b) Medical Group must provide a written referral for
facilities or dialysis facilities which have been approved
care to transplant
by Medical Group.
(c) If, after referral, either Medical Group or the medical staff of the
referral facility determines that the Member does not satisfy its criteria for
the service involved, Health Planls obligation is limited to paying for covered
services provided prior to such determination.
(d) Neither Health Plan, Medical Group nor Physicians undertake to provide a
Group 66-00
Page 20
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donor or a donor organ or to assure the availability of a donor or of a
organ or the availability or capacity of referral facilities for organ
plants approved by Medical Group.
donor
trans-
(e) Except for medically necessary ambulance service provided in accord
with Section ll-G, neither transportation nor living expenses are covered for
the Member, for his or her family, or for a donor.
K. EXTENDED CARE SERVICES
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 ll-D and
therapeutic procedures, including speech therapy and rehabilitative services, are
provided in accord with Section II-E. Other covered Extended Care Services are
provided without charge.
L. HOME HEALTH SERVICES
Benefits under this Section ll-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.
(1) 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 II-E.
(2) 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
Memberls 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.
M. TREATMENT FOR ALCOHOL AND DRUG DEPENDENCY
Subject to the exclusions set forth in this Section M, and to
Charges, if any, set forth in Section 11, the care described herein
alcohol and/or drug dependency:
Group 66-00
the Supplemental
is provided for
Page 21
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(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 ~ledical 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
Mental Health services specified in this Section ll-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 ~Iembers 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 Il-N(3) during the calendar year. Each fully prepaid day of hospitaliza-
tion received pursuant to Section II-N(3) exhausts two fully prepaid sessions of
day or night care under this Section II-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
Group 66-00
Page 22
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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 II-N(2) during the calendar year. Each fully prepaid
session of day care or night care received pursuant to Section II-N(2)
exhausts one-half fully prepaid day of hospitalization under this Section II-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
Physician, a Member requires psychological testing, prescribed
without charge. Court-ordered testing, and testing for ability,
gence or interest, are not covered.
of the Attending
tests are provided
aptitude, intelli-
(5) Exclusions and Limitations. The following services are not covered:
(a) Mental health services for the following conditions after diagnosis if,
in the professional judgment of the Attending Physician, they would not be
responsive to therapeutic management:
(i) Chronic psychosis, except that acute episodes due to a chronic psy-
chotic condition are covered if the 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
fices. Medical social services include hospital
counseling and referrals for services not covered
charge at Hospitals and Medical Of-
discharge planning, social services
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 ll-A(2).
When
clition,
payment
available, general health education services not addressed to a
such as weight control classes and anti-smoking classes, are
of a reasonable charge.
specific con-
provided upon
Education in the appropriate use of Health Planls 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.
Group 66-00 Page 23
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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 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
organizations, conducts direct-service medical and hospital care programs and
of their facilities may be obtained at the Health Plan office.
related
a list
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
Memberls coverage in the Southern California Region.
S. EMERGENCY SERVICES RECEIVED FROM PROVIDERS NOT CONTRACTING WITH
HEALTH PLAN
(1) Emergency Services. This Section Il-S defines and limits Health Planls ob-
ligation to pay for Emergency Services that a Member receives from a physician,
hospital or other provider not contracting with Health Plan. The term "Emergency
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 ll-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(I).
Group 66-00
Page 24
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(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.
(3) Payment. Subject to the foregoing limitations:
(a)
ceived
if:
Within the Service Area.
within the Service Area
Health Plan will pay for Emergency Services re-
from providers not contracting with Health Plan
(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 Memberls immediate family.
(b) Outside the
received outside
Plan if:
Service Area. Health Plan will pay for Emergency Services
the Service Area from providers not contracting with Health
(i) A Member who resides in the Service Area becomes ill or is injured
while outside the Service Area. Covered benefits include Emergency Services
for unexpected premature delivery, but not for normal delivery (after 8
months gestation), unless Health Plan determines that the Member was outside
the Service Area because of circumstances beyond her control or because of
extreme personal emergency.
(ii) A Member who resides outside the Service area:
(A) becomes ill or is injured while more than 30 air miles from the
Hember'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 Memberls immediate family.
Group 66-00
Page 25
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(4) Continuing or Follow-up Treatment. Continuing or follow-up treatment from
providers not contracting with Health Plan is not covered under this Section 11-8,
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
Physician in the Service Area or in the nearest other Health Plan Region, covered
benefits include necessary ambulance service or other special transportation ar-
rangements when medically required to transport the Member to a Hospital or Med-
ical Office in the Service Area or to a contracting hospital or medical office in
the nearest other Health Plan Region for continuing or follow-up treatment.
(5) Notification and Claims. Any Member receiving hospital Emergency Services
within the scope of this Section ll-S must notify the Health Plan office within 48
hours after care is commenced. No claim pursuant to this Section ll-S is allowed
unless a complete application for payment, on forms provided by Health Plan, is
filed with the Health Plan office within 60 days after the first Emergency Service
for which payment is requested. The 48 hour and 60 day notice requirements are not
applied if notice is given as scon 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 ll-S.
(7) Right of Recovery. Any overpayment hereunder may be recovered by
Plan from any person to whom the payment was made, or from any insurance
or organization which is obligated to pay for the Emergency Services.
Health
company
Group 66-00
Page 26
'-
"
.....,
Executed at Pasadena, California to take effect as of January 01, 1986
Date: October 07, 1985
KAISER FOUNDATION HEALTH PLAN, INC.
A California nonprofit corporation
~
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cr
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
Group 66-00
...J
Page 27