Pages 1--32 from Fed RI-47 NEW R8N

Kaiser Foundation Health Plan
Kaiser Foundation Health Plan of the Mid Atlantic States Inc of the Mid Atlantic States Inc 2000

A Health Maintenance Organization

For changesin benefitssee
page
5

Serving Metropolitan Washington DC Area and Metropolitan Baltimore Maryland Area
Enrollment in this Plan is limited see page 6 for requirements
Enrollment code
E31 Self only
E32 Self and family

This Plan has commendable accreditation
from the NCQA See the 2000 Guide for more
information on NCQA

Service area Services from Plan providers are available only in the area described on page 4 5

Visit the OPM website at http www opm gov insure
and
our National website at http www kaiserpermanente org

Important Notice A copay will apply to office visits and outpatient surgery visits
Authorized for distribution by the
United States
Office of Personnel Management
Retirement and Insurance Service

RI 73 047 1
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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Table of Contents
Introduction 3
Plain language 3
How to use this brochure 4
Section 1 Health Maintenance Organizations 5
Section 2 How we change for 2000 5
Section 3 How to get benefits 6
Section 4 What to do if we deny your claim or request for service 8
Section 5 Benefits 10
Section 6 General exclusions Things we don't cover 23
Section 7 Limitations Rules that affect your benefits 23
Section 8 FEHB Facts 24
Inspector General Advisory Stop Health Care Fraud 28
Summary of Benefits 31
Premiums 32

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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Introduction
Kaiser Foundation Health Plan of the Mid Atlantic States Inc
2101 East Jefferson Street
Rockville MD 20849

This brochure describes the benefits you can receive from Kaiser Foundation Health Plan of the Mid Atlantic States Inc under its
contract CS 1763 with the Office of Personnel Management OPM as authorized by the Federal Employees Health Benefits
FEHB law This brochure is the official statement of benefits on which you can rely A person enrolled in this Plan is entitled to
the benefits described in this brochure If you are enrolled for Self and Family coverage each eligible family member is also
entitled to these benefits

OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on
page 5 Premiums are listed at the end of this brochure

Plain language
The President and Vice President are making the Government's communication more responsive accessible and understandable to
the public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have
worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary
technical terms you and other personal pronouns active voice and short sentences

We refer to Kaiser Foundation Health Plan of the Mid Atlantic States Inc as this Plan throughout this brochure even though in
other legal documents you will see a plan referred to as a carrier

These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more
understandable

We have not rewritten the Benefits section of this brochure You will find new benefits language next year

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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's
benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to
make comparisons easier

1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs
and how they work

2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our
decision not to pay for your claim or to deny your request for a service

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find
information about non FEHB benefits

6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB FACTS Read this for information about the Federal Employees Health Benefits FEHB Program

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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Section 1 Health Maintenance Organizations
Health Maintenance Organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other providers that contract with us These providers coordinate your health care services The care you receive includes
preventative care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury

When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay copayments and coinsurance listed in this brochure When you receive emergency services or follow up or continuing care under
this Plan's travel benefit you may have to submit claim forms
You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change plans because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available

and or remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment

Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all
changes primary care office visits This year you have a right to more information about this Plan care management our

networks facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request you may continue to see your specialist for up to 90 days If your provider leaves the Plan and

you are in the second or third trimester of pregnancy you may be able to continue seeing your OB GYN until the end of your postpartum care You have similar rights if this Plan leaves the
FEHB program See Section 3 How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your medical records ask your health care provider for them You may ask that a physician

amend a record that is not accurate not relevant or incomplete If the physician does not amend your record you may add a brief statement to it If they do not provide you with your
records call us and we will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This screening is for colorectal cancer

Changes to this Your share of the non postal premium will increase by 7.7 for Self Only or 5.1 for Self and
Plan Family The primary care office visit copay will increase from 5 to 10 See page 10

The copayment for chemotherapy radiation therapy and inhalation therapy visits will decrease from 5 to no charge per visit See page 11
Coverage for durable medical equipment DME will increase This Plan now covers various items of DME at specified copays See page 12
Short term outpatient rehabilitative therapy visits will increase from up to two consecutive months per condition to up to 40 visits or 90 days whichever is greater per condition Speech
and occupational therapy will increase to up to 90 days per condition See page 11
Contraceptive drugs devices and implants will be covered at the standard prescription drug copay amount See page 17

The copay for disposable needles and syringes needed for injecting covered prescribed drugs and self administered chemotherapeutic drugs and oral chemotherapeutic agents will increase
from 0 to 7 See page 17
Smoking cessation drugs will be covered with a 50 copay based on the average wholesale price See page 17

Anti obesity drugs will be covered with a 50 copay based on the average wholesale price See page 17

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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Section 2 How we change for 2000 continued
The copay for ovulation stimulants will increase from 25 to 50 of the average wholesale price See page 17
This Plan now provides coverage for drugs prescribed for acute conditions through its Mail Order program at a 5 copay per prescription or refill See page 17

Section 3 How to get benefits
What is this To enroll in this Plan you must live or work in our service area This is where our providers
Plan's service practice Our service area is
area The District of Columbia

Montgomery Prince George's Baltimore Carroll Hartford Howard and Anne Arundel Counties in Maryland the City of Baltimore the following Maryland zip codes

Charles County 20601 20602 20603 20604 20612 20616 20617 20637 20640 20646 20658 20675 20695 Calvert County 20639 20689 20714 20732 20736
20754 Frederick County 21702 21705 21709 21710 21714 21716 21717 21718 21754 21755 21758 21762 21769 21770 21774 21777 21790 21793

The cities of Alexandria Fairfax Falls Church Manassas Manassas Park in Virginia Arlington Fairfax Loudoun and Prince William Counties in Virginia
Ordinarily you must get your care from physicians hospitals and other providers who contract with us However we are part of the Kaiser Permanente Medical Care Program and if you are
visiting another Kaiser Permanente Service area you can receive the benefits of this Plan at any other Kaiser Permanente facility We also pay for follow up services or continuing care
services while you are traveling outside the service area as described on page 13 14 and for emergency care obtained from any provider as described on page 13 14 We will not pay for
any other health care services
If you or a covered family member move outside of our service area you can enroll in another plan If your dependents live out of the area you should consider enrolling in another plan If

you or a family member move you do not have to wait until Open Season to change plans Contact your employment or retirement office

How much do You must share the cost of some services This is called either a copayment a set dollar
I pay for amount or coinsurance a set percentage of charges Please remember you must pay this
services amount when you receive services If you do not pay at the time you receive your service you will be billed for the service We also will bill you an additional 10 This charge will be

added to each service for which you did not pay

After you pay 1,500 in copayments or coinsurance for one family member or 3,000 for two or more family members you do not have to make any further payments for certain services

for the rest of the year This is called a catastrophic limit However copayments or coinsurance for your prescription drugs chiropractic and acupuncture services dental and the
25 charge paid for follow up or continuing care do not count toward these limits and you must continue to pay for these services as described in this brochure

Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when you reach the limits

Do I have to You normally won't have to submit claims to us unless you receive emergency services from a
submit claims provider who doesn't contract with us or you receive follow up or continuing care under the travel benefit If you file a claim please send us all of the documents we need to respond to

your claim as soon as possible You must submit claims by December 31 of the year after the year you received the service Either OPM or we can extend this deadline if you show that

circumstances beyond your control prevented you from filing on time
Who provides Kaiser Foundation Health Plan of the Mid Atlantic States Inc is a Federally qualified Health
my health care Maintenance Organization The Plan has been delivering prepaid health services to Washington D C area residents since December 1972 Presently it serves nearly 550,000

members in the Washington D C and Baltimore Maryland metropolitan areas

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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Section 3 How to get benefits continued
This Plan offers comprehensive health care at Plan Medical Centers community hospitals and other designated locations conveniently located throughout the Washington D C and
Baltimore Maryland metropolitan areas Health Plan contracts with the Mid Atlantic Permanente Medical Group P C Plan physicians an independent multi specialty group of
physicians to provide or arrange all necessary physician care for Plan members These Plan physicians are members of American Specialty Boards or are Board eligible Plan physicians
nurse practitioners physician assistants and other skilled medical personnel working as medical teams provide your health care services Specialists consult with these medical teams
in determining your treatment Plan physicians refer patients to community specialists when necessary Other services such as physical therapy and laboratory and X ray are available at
Plan facilities and other designated locations Hospital care is provided at local community hospitals

You must receive your health care services at Plan facilities except if you have an emergency If you are visiting another Kaiser Permanente service area you may receive health care
services from those Kaiser Permanente facilities This Plan also offers a benefit that will allow you to receive follow up or continuing care while you travel anywhere

Your primary care physician PCP either a family practitioner pediatrician or internist will coordinate most aspects of your health care including arranging for you to receive services
from a specialist This Plan will cover specialists services only when your primary care physician refers you However a woman may see her gynecologist without having to obtain a
referral You may also receive mental conditions and substance abuse conditions services eye examinations and refractions without a referral

Choose your PCP from this Plan's provider directory The directory which is updated on a regular basis lists the physicians addresses and phone numbers and lets you know whether
the physician is accepting new patients To get a directory call the Member Services Department at 301 468 6000 or 800 777 7902 If you want to receive care from a specific
physician who is listed in the directory call the physician to verify that he or she still participates with the Plan and is accepting new patients

What do I do if Call us We will help you select a new one
my primary care
physician leaves
the Plan

What do I do if Your primary care physician or specialist will make the necessary arrangements and continue
I need to go into to supervise your care
the hospital

What do I do if First call our Member Services Department at 301 468 6000 or 800 777 7902 If you are
I'm in the new to the FEHB Program we will arrange for you to receive care If you are currently in the
hospital when I FEHB Program and are switching to us your former plan will pay for the hospital stay until
join this Plan You are discharged not merely moved to an alternative care center or The day your benefits from your former plan run out or

The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized

How do I get Your primary care physician will determine if you need care from a specialist He or she will
specialty care obtain necessary authorizations from the Plan The referral will describe the services you will receive You should return to your primary care physician after your consultation with the

specialist If your specialist recommends additional visits or services your primary care physician will review the recommendation and authorize the visits or services as appropriate

You should not go to a specialist unless your primary care physician and your Plan has authorized the referral

If you need to see a specialist frequently because of a chronic complex or serious medical condition your primary care physician will develop a treatment plan that allows you to see

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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Section 3 How to get benefits continued
your specialist for a specified number of visits You will not need to obtain additional referrals Your primary care physician will obtain Plan authorization for these visits
What do I do Your primary care physician will decide what treatment you need If your primary care
if I am seeing a physician decides to refer you to a specialist ask if you can see your current specialist If your
specialist when current specialist does not participate with us you must receive treatment from a specialist who does Generally we will not pay for you to see a specialist who does not participate with
I enroll our Plan

Call your primary care physician who will arrange for you to see another specialist You may receive services from your current specialist until we can make arrangements for you to see

someone else
But what if I have a serious illness and my provider leaves the Plan or this Plan leaves the Program

Please contact us if you believe your condition is chronic or disabling You may be able to continue seeing your physician for up to 90 days after we notify you that we are terminating
our contract with the provider unless the termination is for cause If you are in the second or third trimester of pregnancy you may continue to see your OB GYN until the end of your
postpartum care
What do I do You may also be able to continue seeing your physician if this Plan drops out of the FEHB
if my specialist Program and you enroll in a new FEHB plan Contact the new plan and explain that you have
leaves the Plan a serious or chronic condition or are in your second or third trimester Your new plan will pay for or provide your care for up to 90 days after you receive notice that your prior plan is
leaving the FEHB Program If you are in your second or third trimester your new plan will pay for the OB GYN care you receive from your current physician until the end of your

postpartum care
How do you Your physician must get our approval before sending you to a hospital referring you to a
authorize specialist or recommending follow up care Before giving approval we consider if the service
medical is medically necessary to prevent diagnose or treat an illness or condition We follow generally accepted medical practice in providing services to you
services

How do you When the service or supply including a drug 1 has not been approved by the FDA or 2 is
decide if a the subject of a new drug or new device application on file with the FDA or 3 is part of a
service is Phase I or Phase II clinical trial as the experimental or research arm of a Phase III clinical trial or is intended to evaluate the safety toxicity or efficacy of the service or 4 is available
experimental or as the result of a written protocol that evaluates the service's safety toxicity or efficacy or 5
investigational is subject to the approval or review of an Institutional Review Board or 6 requires an informed consent that describes the service as experimental or investigational then this Plan

considers that service supply or drug to be experimental and not covered by the Plan This Plan and its Medical Group carefully evaluate whether a particular therapy is safe and effective

or offers a degree of promise with respect to improving health outcomes The primary source of evidence about health outcomes of any intervention is peer reviewed medical literature

Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you
were unable to make a timely request due to reasons beyond your control

We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim

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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Section 4 What to do if we deny your claim or request for service continued
3 Arrange for a health care provider to give you the service or
4 Ask for more information

If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30
days after we receive the additional information If we do not receive the requested information within 60 days we will make our
decision based on the information we already have

When may I ask OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or
to review a denial refusal OPM will determine if we correctly applied the terms of our contract when we denied your claim or request for service

What if I have a serious Call us at 301 468 6000 or 800 777 7902 and we will expedite our review
or life threatening
condition and you
haven't responded to my
request for service

What if you have If we expedite your review due to a serious medical condition and deny your claim we will
denied my request for inform OPM so that they can also give your claim expedited treatment Alternatively you can
care and my condition call OPM's health benefits Contract Division 3 at 202 606 0755 between 8 00 a m and 5 00 p m Serious or life threatening conditions are ones that may cause permanent loss of bodily
is serious or life functions or death if they are not treated as soon as possible
threatening

Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold
time limits our initial denial or refusal of service You may also ask OPM to review your claim if

1 We did not answer your request within 30 days In this case OPM must receive your
request within 120 days of the date you asked us to reconsider your claim

2 You provided us with additional information we asked for and we did not answer within 30
days In this case OPM must receive your request within 120 days of the date we asked
you for additional information

What do I send to Your request must be complete or OPM will return it to you You must send the following
OPM information
1 A statement about why you believe our decision is wrong based on specific benefit
provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports
bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call

If you want OPM to review different claims you must clearly identify which documents apply
to which claim

Who can make Those who have a legal right to file a disputed claim with OPM are
the request 1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled
person's representative They must send a copy of the person's specific written consent with
the review request

Where should I Send your request for review to Office of Personnel Management Office of Insurance
mail my disputed Programs Contracts Division 3 P O Box 436 Washington D C 20044
claim to

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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Section 4 What to do if we deny your claim or request for service continued
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our
upholds the decision your only recourse is to sue
Plan's denial If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services or supplies

What laws apply Federal law governs your lawsuit benefits and payment of benefits The Federal court will
if I file a lawsuit base its review on the record that was before OPM when OPM made its decision on your claim You may recover only the amount of benefits in dispute

You or a person acting on your behalf may not sue to recover benefits on a claim for
treatment services supplies or drugs covered by us until you have completed the OPM review
procedure described above

Your records and Chapter 89 United States Code allows OPM to use the information it collects from you and us
the Privacy Act to determine if our denial of your claim is correct The information OPM collects during the review process becomes a permanent part of your disputed claims file and is subject to the

provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this
information to support the disputed claim decision If you file a lawsuit this information will
become part of the court record

Section 5 Benefits
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan physicians and other Plan providers This includes all necessary office and outpatient surgery
visits You pay a 10 per office visit charge for the following
Preventive care including office visits for children over 3 years of age Pediatric visits for children up to age 3 are provided at no charge

Mammograms are covered as follows for women age 35 through 39 one mammogram during these five years for women age 40 through 49 one mammogram every one or two
years for women age 50 through 64 one mammogram every year and for women age 65 and above one mammogram every two years at no charge In addition to routine screening
mammograms are covered when prescribed by the physician as medically necessary to diagnose or treat your illness
Routine immunizations and boosters Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays at no charge Complete obstetrical maternity care for all covered females including prenatal delivery
and post natal care by a Plan physician Copays are waived for scheduled prenatal visits and the first post partum visit The mother at her option may remain in the hospital up to 48
hours after a regular delivery and 96 hours after a caesarean delivery Inpatient stays will be extended if medically necessary If enrollment in the Plan is terminated during pregnancy
benefits will not be provided after coverage under the Plan has ended Ordinary nursery care of the newborn child during the covered portion of the mother's hospital confinement for
maternity will be covered under either a Self Only or Self and Family enrollment other care of an infant who requires definitive treatment will be covered only if the infant is covered
under a Self and Family enrollment Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye Allergy testing and treatment including testing and treatment materials such as allergy
serum The insertion of covered internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung kidney simultaneous pancreas kidney liver and lung single and double transplants allogeneic donor bone marrow transplants
autologous bone marrow transplants autologous stem cell and peripheral stem cell support for the following conditions acute lymphocytic on non lymphocytic leukemia advanced
Hodgkin's lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma breast

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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Section 5 Medical and Surgical Benefits continued
cancer multiple myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal and ovarian germ cell tumors Transplant services are not available for
ovarian carcinoma Transplants are covered when approved by the Medical Group Related medical and hospital expenses of the donor are covered
Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure
Dialysis office visit charges will be waived if you enroll in Medicare Part B and assign your Medicare benefits to the Plan
Chemotherapy radiation and inhalation therapy at no charge Surgical treatment of morbid obesity
Prosthetic devices breast protheses and surgical bras as well as their replacement Home health services of physicians nurses and health aides including intravenous fluids and
medications when prescribed by your Plan physician who will periodically review the program for continuing appropriateness and need at no charge
Medical management of mental health conditions including drug therapy evaluation and maintenance
Medical food and low protein modified food products for the treatment of inherited metabolic disease will be covered if the medical food and low protein modified food
products are a prescribed and pre authorized as medically necessary for the therapeutic treatment of inherited metabolic diseases and b administered under the direction of a
physician at no charge Medically necessary foot care
All necessary medical or surgical care in a hospital or extended care facility from Plan physicians and other plan providers

If you do not pay any of the charges required for services at the time you receive the services you will be billed for those charges You will also be required to pay an administrative charge
of 10 for each service for which a bill is sent
Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical

procedures occurring within or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures and excision of tumors and cysts All other procedures involving the

teeth or intra oral areas surrounding the teeth are not covered except as shown on page 18 under Dental care including shortening of the mandible or maxillae for cosmetic purposes
correction of malocclusion and any dental care involved in treatment of temporolmandibular joint TMJ or temporalmandibular pain dysfunction syndrome

Cleft lip and Cleft palate Coverage shall include benefits for inpatient or outpatient expenses arising from orthodontics oral surgery and orthologic audiological and speech language
treatment for the management of the birth defect cleft lip or cleft palate or both
General Anesthesia for Dental Care General anesthesia and associated hospital or ambulatory services for dental care provided to children under the age of 7 or children with

developmental disabilities when a successful result could not be expected from the use of local anesthesia Coverage is also provided for children under age 17 who are extremely
uncooperative fearful or uncommunicative and for whom lack of treatment can be expected to result in oral pain infection loss of teeth or other morbidity Coverage is also provided for
adults age 17 and older when the member's medical condition necessitates that the dental services be performed in a hospital or ambulatory surgical center for the safety of the member
e g heart disease hemophilia Coverage is not provided for the professional dental component

Qualified Medical Clinical Trials Clinical trials that provide treatment for life threatening conditions or for prevention early detection and treatment studies of cancer Treatment or
studies are being conducted in a Phase I II III or IV clinical trial for cancer or Phase II III or IV clinical trial for any other life threatening condition Coverage may be provided for a
Phase I clinical trial for these conditions on a case by case basis
Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from injury or surgery that has produced a major effect on the member's appearance

and if the condition can reasonably be expected to be corrected by such surgery A patient and their attending physician may decide whether to have breast reconstruction surgery following a
mastectomy and whether surgery on the other breast is needed to produce a symmetrical appearance

Short term rehabilitative physical therapy is provided for up to 40 visits or 90 days whichever is greater if significant improvement can be expected within the 40 visits or 90

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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Section 5 Medical and Surgical Benefits continued
days you pay 10 per visit Speech and occupational therapy is provided for up to 90 days if significant improvement can be expected within 90 days you pay 10 per visit Speech
therapy is limited to treatment of certain speech impairments of organic origin Occupational therapy is limited to services that assist the member to achieve and maintain self care and
improved functioning in other activities of daily living You may receive outpatient or inpatient therapy as part of a specialized therapy program in a specialized rehabilitation facility for up to
two months per condition you pay nothing
Diagnosis and treatment of infertility is covered you pay 50 of non member rates The following types of artificial insemination are covered intravaginal insemination IVI

intracervical insemination ICI and intrauterine insemination IUI you pay cost of donor sperm and donor eggs and services related to their procurement and storage are not covered
Other assisted reproductive technology ART procedures such as in vitro fertilization gamete and zygote intrafallopian transfer are not covered Infertility services are not available when
either member of the family has been voluntarily surgically sterilized Drugs used for covered infertility treatments are provided under the Prescription Drug Benefit Drugs related to noncovered
infertility treatments are not covered
Durable Medical Equipment DME Rental or purchase of Medicare approved durable medical equipment for use in the member's home will be provided for up to three months at no

charge following a an authorized hospital confinement b an authorized confinement in a sub acute facility c an authorized confinement in a specialized rehabilitation facility and d
an authorized outpatient surgical procedure This Plan will determine whether the equipment will be rented or purchased Bilirubin lights for home use and apnea monitors for infants up to
age 3 will be provided for a period not to exceed 6 months you pay nothing Oxygen and oxygen equipment for home use is provided when the need for the oxygen and equipment
meets Medicare guidelines and is prescribed by a Plan Provider you pay nothing for the first three months 50 of non member rates for each additional authorized month Liquid oxygen
and oxygen tents are not covered Equipment used for adult and pediatric asthmatics such as spacers peak flow meters and nebulizers will be provided when purchased at a Plan
Pharmacy you pay 5 per spacer 10 per peak flow meter and 30 per nebulizer
Alternative therapy services Chiropractic and acupuncture services will be provided as a component of the Plan's complementary and alternative medicine services when your primary

care physician in consultation with the Plan's Complementary and Alternative Medicine
Department determines that such care is appropriate The services will be covered only when
medical improvement can be reasonably expected to occur Chiropractic and acupuncture
services are provided for up to 20 visits per therapy per calendar year You pay 15 per visit

Blood Products including gamma globulin and anti hemophiliac factors

What is not Physical examinations that are not necessary for medical reasons such as those required for
covered obtaining or continuing employment or insurance or government licensing Reversal of voluntary surgically induced sterility

Surgery primarily for cosmetic purposes
External and internally implanted hearing aids
Homemaker services
Long term rehabilitative therapy
Transplants not listed as covered
Any eye surgery solely for the purpose of correcting refractive defects of the eye such as
nearsightedness myopia farsightedness hyperopia and astigmatism
Orthopedic and prosthetic devices such as braces foot orthotics artificial limbs and lenses
following cataract removal
Devices equipment supplies and prosthetics related to sexual dysfunction
Cardiac rehabilitation
Whole blood and packed red blood cells

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS 12 12
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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Hospital Extended Care Benefits
What is covered The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan physician You pay nothing All necessary services are
covered including
Hospital care Semiprivate room accommodations when a Plan physician determines it is medically necessary the physician may prescribe private accommodations or private duty nursing care

Specialized care units such as intensive care or cardiac care units Prescribed drugs and their administration blood products and the administration of blood
biologicals supplies and equipment ordinarily provided or arranged as part of inpatient services

Extended care The Plan provides a comprehensive range of benefits for up to 100 days per calendar year
when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate You pay nothing All necessary services are covered including

Bed board and general nursing care Prescribed drugs and their administration biologicals supplies and equipment ordinarily
provided or arranged by the skilled nursing facility
Hospice care Supportive and palliative care for a terminally ill member is covered in the home You pay
nothing Services include short term inpatient and outpatient care and family counseling these services are provided under the direction of a Plan physician who certifies that the patient is in

the terminal stages of illness with a life expectancy of approximately six months or less
Ambulance Benefits are provided for ambulance transportation ordered or authorized by a Plan physician
service You pay nothing

Limited benefits

Inpatient dental Hospitalization for certain dental procedures is covered when a Plan physician determines there
procedures is a need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the hospitalization and anesthesiology cost but not the cost of the professional dental

services Conditions for which hospitalization may be covered include hemophilia and heart disease the need for anesthesia by itself is not such a condition

Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care
detoxification diagnosis treatment of medical conditions and medical management of withdrawal symptoms acute detoxification if the Plan physician determines that outpatient management is not

medically appropriate See page 16 for nonmedical substance abuse benefits
What is not Personal comfort items such as telephone and television
covered Custodial care or care in an intermediate care facility Whole blood and packed red blood cells

Benefits Available Away From Home
Services From When you are outside the service area of this Plan you may still receive covered health care
Other Kaiser services There are two types of coverage provided under your enrollment in this Plan
Permanente Plans When you are visiting in the service area of another Kaiser Permanente plan you are entitled to receive virtually all the benefits described in this brochure at any Kaiser Permanente

medical office or medical center and from any Kaiser Permanente provider If the Plan you are visiting has a charge that is different from the charges listed in this brochure you will have to
pay the charges imposed by the Plan you are visiting If the Kaiser Permanente plan in the area you are visiting has a benefit that is different from the benefits of this Plan you are not
entitled to receive that benefit Some services covered by this Plan such as artificial reproductive services and the services of specialized rehabilitation facilities will not be
available in other Kaiser Permanente service areas If a benefit is limited to a specific number of visits or days you are entitled to receive only the number of visits or days covered by the
Plan in which you are enrolled

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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Benefits Available Away From Home continued
If you are seeking routine non emergency or non urgent services you should call the Kaiser Permanente member services department in that service area and request an appointment You
may obtain routine follow up or continuing care from these Plans even when you have obtained the original services in the service area of this Plan If you require emergency
services as the result of an unexpected or unforeseen illness that requires immediate attention you should go directly to the nearest Kaiser Permanente facility to receive care

At the time you register for services you will be asked to pay the copayment required under your enrollment in this plan
If you plan to travel to an area with another Kaiser Foundation Health Plan and wish to obtain more information about the benefits available to you from that Kaiser Foundation Health Plan
please call the Member Services Office at 310 468 6000 in the Washington D C area or 800 777 7902 in the Baltimore Maryland area

Benefits Available While You Travel
If you are outside the service area of this Plan by more than 100 miles or outside the service area of any other Kaiser Permanente Plan the following health care services will be covered
Follow up care care necessary to complete a course of treatment following receipt of covered out of plan emergency care or emergency care received from Plan facilities if the
care would otherwise be covered and is performed on an outpatient basis Examples of
covered follow up care include the removal of stitches a catheter or a cast

Continuing care care necessary to continue covered medical services normally obtained at Plan facilities as long as care for the condition has been received at Plan facilities within the

previous 90 days and the services would otherwise be covered Services must be performed on
an outpatient basis Services include scheduled well baby care prenatal visits medication
monitoring blood pressure monitoring and dialysis treatments The following services are not
covered hospitalization infertility treatments childbirth services and transplants Prescription
drugs are not covered However you may have prescriptions filled by mail through this Plan's
Prescription Drug Benefit

If you have any questions about how to use these benefits call the Travel Benefit Information Line at 800 390 3509 You may obtain the Travel Benefits for Federal Employees brochure by

calling this number You should pay the provider at the time you receive the service Submit a claim to the Plan for the services on this Plan's Claim for Follow up Continuing Care Medical
Form with necessary supporting documentation Submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification information from your
ID card Submit claims to Kaiser Foundation Health Plan of the Mid Atlantic States Inc P O Box 6233 Rockville Maryland 20849 6233 If the services are covered under this Travel
Benefit you will be reimbursed the reasonable charges for the care up to a maximum of 1200 per calendar year You pay 25 for each follow up or continuing care visit This amount
will be deducted from the payment the Plan makes to you

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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that
emergency requires immediate medical or surgical attention Some problems are emergencies because if not treated promptly they might become more serious examples include deep cuts and broken

bones Others are emergencies because they are potentially life threatening such as heart attacks strokes poisonings gunshot wounds or sudden inability to breathe There are many

other acute conditions that the Plan may determine are medical emergencies What they all have in common is the need for quick action

Emergencies within If you are in an emergency situation please call the Plan's 24 hour emergency number
the service area 800 677 1112 Emergency care is available through Kaiser Permanente 24 hours a day 7 days a week

In extreme emergencies if you are unable to contact your physician contact the local emergency system e g the 911 telephone system or go to the nearest hospital emergency
room Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan You or a family member must notify the Plan within 48 hours It is your
responsibility to ensure that the Plan has been notified
If you need to be hospitalized in a non Plan facility the Plan must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to

notify the Plan within that time If you are hospitalized in non Plan facilities and Plan physicians believe care can be better provided in a Plan hospital you will be transferred when
medically feasible with any ambulance charges covered in full
Benefits are available for care from non Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death disability or significant jeopardy to your

condition
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers

You pay 35 per hospital emergency room visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the charge is waived
Emergencies You may obtain emergency and urgent care services from Kaiser Permanente medical facilities
outside the and providers when you are in the service area of another Kaiser Permanente plan The
service area facilities will be listed in the local telephone book under Kaiser Permanente You may also obtain information about these facilities by calling 301 468 6000

Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness

If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify the Plan
within that time If a Plan physician believes care can be better provided in a Plan hospital you will be transferred when medically feasible with any ambulance charges covered in full

Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 35 per hospital emergency room visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the charge is waived

What is covered Emergency care at a physician's office or an urgent care center Emergency care as an outpatient or inpatient at a hospital including physicians services
Ambulance service approved by the Plan
What is not Emergency care provided outside the service area if the need for care could have been
covered foreseen before leaving the service area Medical and hospital costs resulting from a normal full term delivery of a baby outside the

service area
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency
non plan providers care upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form Submit claims to Kaiser Foundation Health Plan of the Mid Atlantic States Inc

P O Box 6233 Rockville Maryland 20849 6233 If you are required to pay for the services submit itemized bills and your receipts to the Plan along with an explanation of the services

and the identification information from your ID card

15 15
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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Emergency Benefits continued
Payment will be sent to you or the provider if you did not pay the bill unless the claim is denied If it is denied you will receive notice of the decision including the reasons for the
denial and the provisions of the contract on which denial was based If you disagree with the Plan's decision you may request reconsideration in accordance with the disputed claims
procedure described on page 8

Mental Conditions Substance Abuse Benefits
Mental conditions
What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including the treatment of mental illness or

disorders
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Medical management visits including drug evaluation methadone treatment and
maintenance
Hospitalization including inpatient professional services

Outpatient care Unlimited visits to Plan physicians consultants or other psychiatric personnel each calendar year you pay nothing for the 1st through 5th visits thereafter you pay 10 for an individual

visit and 5 for group visits 6 through 20 then 30 for an individual visit and 5 for group
visits for the remainder of the calendar year

If you do not pay any of the charges required for services at the time you receive the services
you will be billed for those charges You will also be required to pay an administrative charge
of 10 for each service for which a bill is sent

Inpatient care Unlimited number of days each calendar year you pay nothing
What is not Care for psychiatric conditions that in the professional judgment of Plan physicians are not
covered subject to significant improvement through relatively short term treatment Psychiatric evaluation or therapy on court order or as a condition of parole or probation

unless determined by a Plan physician to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment
of a short term psychiatric condition Substance abuse

What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of substance abuse including alcoholism and drug addiction
the same as for any other illness or condition and to the extent shown below the services
necessary for diagnosis and treatment

Outpatient care Outpatient visits to Plan providers for treatment you pay nothing for each visit
Inpatient care Acute detoxification the Plan provides unlimited number of days for rehabilitative services in a hospital or specialized facility you pay nothing

What is not Treatment that is not authorized by a Plan physician
covered Substance abuse treatment on court order or as a condition of parole or probation unless determined by a Plan physician to be necessary and appropriate

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS 16 16
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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral physician and obtained at a Plan pharmacy will be dispensed for up to a 90 day supply based upon the prescribed dosage and standard
manufacturer's package size You pay 7 per prescription unit or refill for drugs purchased at a
Plan pharmacy You can obtain drugs prescribed for acute conditions at 5 per prescription or
refill if obtained through the Plan's Mail Order program

Dental prescriptions are limited to formulary products for pain relief and antibiotics only
This Plan uses a formulary to determine which prescribed drugs will be provided to members
If the physician specifically prescribes a nonformulary drug because it is medically necessary
the nonformulary drug will be covered If you request the nonformulary drug when your
physician has prescribed a substitution the nonformulary drug is not covered However you
may purchase the nonformulary drug from a Plan pharmacy at prices charged to members for
non covered drugs

The following drugs are provided at the 7 charge unless another charge is specifically
identified

Drugs for which a prescription is required by law
Oral contraceptive drugs diaphragms and intrauterine devices
Implanted time released drugs
Injectable contraceptive drugs
Insulin
Diabetic test strips
Self injectable drugs other than ovulation stimulants you pay 7 per prescribed therapeutic
course of treatment
Ovulation stimulants you pay 50 of the average wholesale price
Anti obesity drugs you pay 50 of the average wholesale price
Smoking cessation drugs when enrolled in a formal smoking cessation program you pay
50 of the average wholesale price
Disposable needles and syringes needed for injecting covered prescribed drugs
Self administered chemotherapeutic drugs and oral chemotherapeutic agents

If you do not pay any of the charges required for services at the time you receive the services
you will be billed for those charges You will also be required to pay an administrative charge
of 10 for each service for which a bill is sent

The Plan provides the following at no charge
Amino acid modified products used in the treatment of inborn errors of amino acid
metabolism PKU
Immunosuppressant drugs required after a covered transplant
Intravenous fluids and medications for home use
Chemotherapy drugs

Limited Benefits Drugs to treat sexual dysfunction have dispensing limitations you pay 50 of charges Contact the Plan for details

What is not Drugs available without a prescription or for which there is a nonprescription equivalent
covered available Drugs obtained at a non Plan pharmacy except for out of area emergencies

Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Drugs related to non covered services including infertility services

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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Other Benefits
Dental care The following dental services are covered when provided by participating Plan general dentists You pay copayments when services are performed by a general dentist Services of a specialist
can only be received by referral from a Plan general dentist Higher copayments may apply for services received from a specialist

Preventative and diagnostic services
Initial and periodic examinations bitewing X rays cleaning of teeth prophylaxis every six months topical fluoride treatments and preventive care training You pay a 30 copayment per

member per visit
Schedule of dental services and fees

Area Procedure General Specialist Area Procedure General Specialist
Code Name Dentist Dentist Code Name Dentist Dentist

00120 Periodic Oral Exam Every 6 Months Fc30 Nb 02610 Inlay Porcelain Ceramic One Surface 498 Nb
00140 Ltd Oral Evaluation Problem Focused Fc30 Nb 02620 Inlay Porcelain Ceramic 2 Surfaces 498 Nb
00150 Comprehensive Oral Evaluation Fc30 Nb 02630 Inlay Porcelain Ceramic 3 Surfaces 498 Nb
00210 Intraoral Compl Ser Incl Bitewings 34 37 02640 Onlay Porc Ceramic Per Tooth 498 Nb
00220 Intraoral Periapical First Film Fc30 9 02650 Inlay Compos Resin 1 Surf Lab Proc 498 Nb
00230 Intraoral Periapical Each Add Film Fc30 9 02651 Inlay Compos Resin 2 Surf Lab Proc 498 Nb
00240 Intraoral Occlusal Film Fc30 9 02652 Inlay Compos Resin 3 Or More Surf Lab 498 Nb
00270 Bitewing Single Film Fc30 9 02710 Crown Resin Laboratory 235 Nb
00272 Bitewings Two Films Fc30 9 02740 Crown Porcelain Ceramic Substrate 526 Nb
00273 Bitewings Three Films Fc30 16 02750 Crwn Prc Fused To Hi Noble Mtl 531 Nb
00274 Bitewings Four Films Fc30 25 02751 Crwn Prc Fused To Pred Bas Mtl 472 Nb
00330 Panoramic Film 28 31 02752 Crwn Porc Fused To Noble Mtl 502 Nb
00460 Pulp Vitality Tests Fc30 16 02790 Crown Full Cast High Noble Metal 510 Nb
00470 Diagnostic Casts Fc30 Nb 02791 Crown Full Cast Predom Base Metal 442 Nb

02792 Crown Full Cast Noble Metal 465 Nb Preventive
02810 Crown 3 4 Cast Metallic 521 Nb 01110 Prophylaxis Adults Every 6 Months Fc30 Nb
02910 Recement Inlay 34 Nb 01120 Prophylaxis Child Every 6 Months Fc30 Nb
02920 Recement Crown 34 Nb 01201 Top Flor Incl Prop Age 16 Every 6 Mos Fc30 Nb
02930 Prefab Stainl Stl Crwn Prim Tooth 101 Nb 01203 Top Flor Excl Prop Age 16 Every 6 Mos Fc30 Nb
02931 Prefab Stainl Stl Crwn Perm Tooth 106 Nb 01330 Oral Hygiene Instruction Fc30 Nb
02932 Prefabricated Resin Crown 157 Nb 01351 Sealant Per Tooth To Age 16 Note D 17 Nb
02940 Sedative Fillings 34 Nb 01510 Space Maintainer Fixed Unilateral 184 Nb
02950 Crown Buildup Substructure W Pins 101 Nb 01515 Space Maintainer Fixed Bilateral 184 Nb
02951 Pin Reten Per Tooth In Add To Rest 22 Nb 01520 Space Maintainer Remov Unilateral 226 Nb
02952 Cast Post Core In Add To Crown 146 Nb 01525 Space Maintainer Remov Bilateral 141 Nb
02954 Prefab Post Core In Add To Crown 129 Nb 01550 Recementation Of Space Maintainer 21 Nb
02970 Temporary Crown Fractured Tooth 84 Nb
02980 Crown Repair 84 Nb Restorative

02110 Amalgam One Surface Primary 27 Nb Endodontics
02120 Amalgam Two Surfaces Primary 35 Nb 03110 Pulp Cap Direct Excl Final Rest 22 Nb
02130 Amalgam Three Surfaces Primary 39 Nb 03120 Pulp Cap Indirect Excl Final Rest 22 Nb
02131 Amalgam 4 Or More Surfaces Primary 50 Nb 03220 Therapeutic Pulpotomy Exc Fin Rest 62 67
02140 Amalgam One Surface Permanent 30 Nb 03310 Rc Ther Ant Exc Final Restoration 253 319
02150 Amalgam Two Surfaces Permanent 41 Nb 03320 Rc Ther Bicuspid Exc Final Restorat 294 496
02160 Amalgam Three Surfaces Permanent 51 Nb 03330 Rc Ther Molar Exc Final Restoration 313 614
02161 Amalgam Four Or More Surfaces Perm 60 Nb 03350 Apexification Recalc Per Trmt Visit 118 164
02330 Resin One Surface Anterior 37 Nb 03410 Apicoectomy Periradicular Surg Ant 148 381
02331 Resin Two Surfaces Anterior 51 Nb 03421 Apico Perirad Surg Bicus First Root 148 465
02332 Resin Three Surfaces Anterior 52 Nb 03425 Apico Perirad Surg Molar First Root 148 487
02335 Res 3 Sur Or Inv Incisal Angle Ant 66 Nb 03426 Apico Perirad Srg Molar Ea Add Root 49 185
02510 Inlay Metallic One Surface 307 Nb 03430 Retrograde Filling Per Root 104 196
02520 Inlay Metallic Two Surfaces 334 Nb 03450 Root Amputation Per Root 104 252
02530 Inlay Metallic Three Surfaces 371 Nb 03920 Hemisect W Rt Rem Wo Rt Canal Therapy125 224
02540 Onlay Metallic 3 Or More Surfaces 408 Nb

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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Other Benefits continued
Area Procedure General Specialist Area Procedure General Specialist Code Name Dentist Dentist Code Name Dentist Dentist
Periodontics 06545 Rtain Cast Mtl For Acid Etch Brdg 224 Nb
04210 Gingivectomy Gingivoplasty Per Quad 222 297 06750 Crown Porc Fused To Hi Noble Metal 504 Nb
04211 Gingivectomy Gingivoplasty Per Tth 59 90 06751 Crown Porc Fused To Predom Base Mtl 420 Nb
04220 Ging Curettage Surg Quad By Report 67 140 06752 Crown Porc Fused To Noble Metal 454 Nb
04240 Gingival Flap Incl Rt Plan Per Quad 222 381 06780 Crown 3 4 Cast High Noble Metal 476 Nb
04249 Crn Lengthn Hard Soft Tissue By Rep 260 358 06790 Crown Full Cast High Noble Metal 537 Nb
04250 Muco Gingival Surgery Per Qdrant 260 370 06791 Crown Full Cast Predom Base Metal 478 Nb
04260 Oss Surg Inc Flap Ent Grfts Clos 371 661 06792 Crown Full Cast Noble Metal 465 Nb
04261 Osseous Graft 185 330 06930 Recement Bridge 39 Nb
04262 Osseous Graft Multiple 185 330
04268 Guid Tis Rgen Inc Sur Re Ent By Rep 358 358 Oral Surgery
04270 Pedicle Soft Tissue Graft Procedure 178 420 07110 Single Tooth 47 53
04271 Free Soft Tissue Gft Donor Site 260 510 07120 Each Additional Tooth 41 47
04320 Provisional Splinting Intracoronal 106 130 07130 Root Removal Exposed Roots 28 39
04321 Provisional Splinting Extracoronal 74 134 07210 Surgical Removal Of Erupted Tooth 59 106
04341 Perio Scaling Root Planing Per Quad 71 140 07220 Rem Impacted Tooth Soft Tissue 52 129
04355 Fm Debridmt Before Comp Trmt Note A 67 140 07230 Rem Impacted Tooth Part Bony 67 162
04910 Perio Maint After Active Ther Note B 45 67 07240 Rem Impacted Tooth Compl Bony 111 190
07250 Surg Rem Resid T Roots Cutting Proc 59 106
Prosthetics Removable 07260 Oroantral Fistula Closure 170 213
05110 Complete Denture Upper 525 Nb 07270 Tooth Reimplantation 104 241
05120 Complete Denture Lower 525 Nb 07280 Surg Expos Imp Unerup T Ortho 125 207
05130 Immediate Denture Upper 525 Nb 07281 Surg Expos Imp Unerup T Aid Erup 88 168
05140 Immediate Denture Lower 525 Nb 07285 Biopsy Of Oral Tissue Hard 74 129
05211 Upper Part Dent Resin Base Incl Clsp 381 Nb 07286 Biopsy Of Oral Tissue Soft 74 112
05212 Lower Part Dent Resin Base Incl Clsp 470 Nb 07291 Transseptal Fiberotomy 34 34
05213 Up Part Dent Met Base Res Sdl Incl Clsp 567 Nb 07310 Alveolopl In Conj W Extrac Per Quad 59 118
05214 Lo Part Dent Met Base Res Sdl Incl Clsp 567 Nb 07320 Alveolopl No Extract Per Quad 74 134
05281 Uni Part Dent Met Base Cast Clsp 269 Nb 07410 Rad Exc Lesion To 1.25cm 88 168
05410 Adjust Dent Comp Or Part Upr Or Lwr 73 Nb 07420 Rad Exc Lesion Over 1.25cm 141 286
05510 Repair Broken Complete Denture Base 56 Nb 07430 Exc Benign Tumor Lesion To 1.25cm 111 179
05520 Repl Miss Brkn T Compl Dent Ea T 45 Nb 07431 Exc Ben Tunor Lesion Over 1.25cm 140 281
05610 Repair Acrylic Saddle Or Base 56 Nb 07450 Rem Odont Cyst Tum Les To 1.25cm 105 170
05620 Repair Cast Framework 62 Nb 07451 Rem Odont Cyst Tum Les 1.25cm 140 281
05630 Repair Or Replace Broken Clasp 50 Nb 07460 Rem Nonodont Cyst Tum Les To 1.25cm 111 179
05640 Replace Broken Teeth Per Tooth 50 Nb 07461 Rem Nonodont Cyst Tum Les 1.25cm 148 297
05650 Add Tooth To Existing Part Denture 73 Nb 07470 Rem Exostosis Maxilla Or Mandible 193 280
05660 Add Clasp To Existing Part Denture 101 Nb 07480 Part Ostectomy Gutter Or Sauceriz 281 281
05710 Rebase Dnt Comp Or Par Upr Or Lower 196 Nb 07510 I D Abscess Intraoral Soft Tissue 59 78
05730 Reline Dnt Comp Or Part Chair Note C 134 Nb 07520 I D Abscess Extraoral Soft Tissue 59 78
05750 Reline Dent Comp Or Part Lab Note C 148 Nb 07530 Rem Frn Bdy Skn Subcut Areo Tissue 120 179
05820 Interim Part Dentures Upr Or Lower 207 Nb 07550 Sequestrectomy For Osteomyelitis 162 162
05850 Tissue Conditioning Maxillary 50 Nb 07910 Suture Simple Wounds Up To 5cm 39 39
05851 Tissue Conditioning Mandibular 56 Nb 07911 Suture Of Complex Wounds Up To 5cm 78 78
07960 Frenectomy Frenec Frenot Sep Proc 91 196
Prosthetics Fixed 07970 Exc Of Hyperplastic Tissue Per Arch 56 148
06210 Pontic Cast High Noble Metal 525 Nb 07971 Excision Of Pericoronal Gingiva 67 95
06211 Pontic Cast Predom Base Metal 484 Nb
06212 Pontic Cast Noble Metal 459 Nb Orthodontics
06240 Pont Porc Fused To Hi Noble Mtl 493 Nb 08070 Orthodontic Fully Banded 2 Yr Case Nb 2375
06241 Pont Porc Fused To Pred Bs Mtl 431 Nb Transitional
06242 Pont Porc Fused To Noble Metal 465 Nb 08080 Orthodontic Fully Banded 2 Yr Case Nb 2375
06520 Inlay Metallic Two Surfaces 353 Nb Adolescent
06530 Inlay Metallic 3 Or More Surfaces 392 Nb
06540 Onlay Metallic 3 Or More Surfaces 431 Nb

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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Other Benefits continued
Area Procedure General Specialist Area Procedure General Specialist Code Name Dentist Dentist Code Name Dentist Dentist

Additional Procedures 09910 Appl Of Desensitizing Med 28 28
09110 Palliative Treatment 28 Nb 09940 Occlusal Guards By Report 162 269
09210 Local Anesthesia 0 Nb 09951 Occlusal Adjustment Limited 37 57
09220 General Anesthesia First 30 Minutes 74 185 09952 Occlusal Adjustment Complete 148 244
09221 Gen'l Anesthesia Each Add'l 15 Min 37 123 09980 Sterilization Surcharge 5 5
09230 Analgesia 17 22 09990 After Hours Surcharge 25 25
09240 Iv Sedation 111 179 09999 Broken Appointmt Fee Per Half Hour 15 15
09310 Consult No Add'l Procs Indicated 45 49

Footnotes
Lab Fees For Excisions And Biopsies Are To Be Paid By The Patient
Orthodontic Benefits Are For Ages 19 And Under Adult Orthodontics Is Not Covered Treatment Beyond 24 Months Is The
Responsibility Of The Patient Orthodontic Treatment Related To Tmj Dysfunction Is Not Covered

NOTE Procedures Not Shown Are Not Covered By The Dental Plan Fees Quoted In The General Dentist Column Apply Only
When Performed By Your Participating General Dentist If Specialty Care Is Required Your General Dentist Can Refer You To A
Participating Specialist Procedures Performed By A Participating Specialist Where Available Are Discounted Off Area Usual
And Customary Rates These Discounted Fees Are Listed In The Specialist Column Procedures Performed Without A Referral Or
By A Non Participating Specialist Are Not Covered

Fc30 Patient Pays A Fixed Fee Of 30 Per Visit For Any Diagnostic Preventive Visit In Which Exam Cleaning Or
X Ray Procedures Except When Codes 0210 Complete Series And 0330 Panoramic Are Performed The 5
Sterilization Fee Cannot Be Charged For Any Visit In Which The Fc30 Applies

Nb No Benefit Not A Covered Procedure
Note A Procedure 4355 Full Mouth Debridement Limited To Once Per 36 Months
Note B Procedure 04910 Periodontal Maintenance After Active Therapy Limited To Twice Within 12 Months After
Osseous Surgery

Note C Procedures 05730 05750 Reline Dentures Limited To Once Per 36 Mos
Note D Coverage For Sealants Ada Code 1351 Is Limited To The First And Second Permanent Molars
Additionally Coverage Is Limited To Patients Under Age 16

There will be a 25 surcharge for covered dental services provided after hours and a 15 broken appointment fee
applies to each one half hour of scheduled appointment time For a complete listing of participating Plan dentists
please call the Kaiser Permanente Dental Plan in the Washington area 301 986 5600 1 800 638 8847 in the
Baltimore area or call the Plan's Member Services Department

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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Other Benefits continued
Accidental injury benefit Restorative services and supplies necessary to promptly repair but not replace sound natural teeth are covered up to a maximum benefit amount per accident of 2,000 A sound natural
tooth is one that has not been weakened by existing dental pathology such as decay or
periodontal disease one that has been previously restored by a crown inlay onlay porcelain
restoration or treatment by endodontics The need for these services must result from an
accidental injury from an external force not chewing The accident must be reported to a
Plan provider within 72 hours of the event Services must be provided within the 12 month
period immediately following the injury and must start within 60 days of the accident You
must pay 10 per office visit Coverage under this benefit is for the most cost effective
procedure that in the opinion of the Plan dental provider would produce a satisfactory result
No benefits will be available to replace teeth that have been knocked out or that have been so
severely damaged that in the opinion of the Plan dental provider restoration is impossible

What is not Hospitalization for dental procedures except as covered under Hospital Extended Care
covered Benefits Limited benefits
Replacement of dentures or bridge work due to loss or theft or accidental injury
Dental procedures or services for cosmetic purposes
Other dental services not shown as covered
Laboratory fees for biopsies and excisions
Fully banded orthodontics for members ages 20 and over
Vision care

What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye this Plan provides certain vision care benefits from Plan providers

Routine eye examinations including lens prescription for eyeglasses You pay 10 per
examination

Eyeglasses including frames and lenses and the initial fitting and purchase of contact lenses
You pay all charges less 25 off the usual and customary charges on all purchases of eyeglass lenses and frames and less 15 off the usual and customary charge on the cost of

the initial fitting and purchase of contact lenses Members may apply the above discounts to
purchases of lenses and frames as often as they wish

What is not covered If you do not pay any of the charges required for services at the time you receive the services you will be billed for those charges You will also be required to pay an administrative charge

of 10 for each service for which a bill is sent
Eye exercises
Cost of eyewear not purchased at Plan facilities

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS 21 21
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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
NON FEHB Benefits Available To Plan Members
The Benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made available to all enrollees and family members who are members of this Plan The cost of the benefits described on this
page is not included in the FEHB premium any charges for these services do not count toward any FEHB deductibles out ofpocket maximum copay charges etc These benefits are not subject to the FEHB disputed claims procedure

Medicare Prepaid Plan This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare
Enrollment As indicated on Page 23 annuitants and former spouses with FEHB coverage and Medicare Parts A B may elect to either drop their FEHB coverage and enroll in a Medicare prepaid

plan or remain enrolled in the FEHB Program and simultaneously enroll in the Medicare Prepaid plan when one is available in their area Those members who choose to disenroll

from the FEHB Program may then later re enroll in the FEHB Program
Most Federal annuitants have Medicare Part A hospital coverage Those without Medicare Part A may join this Medicare prepaid plan after they have elected to purchase Medicare Part

A in addition to continuing to pay their Part B premium Before you drop your FEHB coverage and apply for coverage in the Medicare Prepaid plan please contact us so we may
help you determine your Medicare A B eligibility
If you are interested in dropping your FEHB enrollment please contact your retirement system for more information For information on the Medicare Prepaid Plan please contact us at the

numbers listed below based on your residence
The District of Columbia and the following cities and counties in Virginia Alexandria Arlington Fairfax Fairfax City Falls Church Loudoun Manassas Manassas Park Prince

William please call 800 281 8797 The following cities and counties in the State of Maryland Baltimore Baltimore City and
the following zip codes within Anne Arundel county 20794 21060 21076 21077 21090 21108 21122 21144 21146 21226 and 21240 please call 800 203 2808
The following counties in the State of Maryland Montgomery Prince George's and the following zip codes within Charles county 20601 20602 20603 20604 20612 20616
20617 20637 20640 20643 20646 20658 20675 and 20695 please call 800 229 5591
Expanded Dental Kaiser Permanente is pleased to offer Federal employees retirees and dependents a new
Benefits choice of dental coverage to supplement what is currently available to you through the Federal Employee Health Benefits Program This program is designed to enhance the level of dental

benefits that you currently receive through Kaiser Permanente Your basic discounted dental coverage through Kaiser Permanente is not affected by this enhanced product offering This

new supplemental coverage is through Delta Dental a national dental provider and is only available to members of Kaiser Permanente

Delta Premier
Delta Premier a table of allowances program allows you to choose any licensed dentists however discounted pricing is available only through Delta's provider network After you

satisfy a deductible Delta will pay a predetermined amount toward each covered service You will not need to satisfy a deductible toward covered preventive services you receive Delta
Premier offers a full range of covered services diagnostic preventive restorative endodontics periodontics oral surgery and both fixed and removable prosthodontics
Orthodontic coverage is not available Covered services will be phased in over a three year period

Monthly Premium Self 18.45
Self and One Party 33.45 Family 52.45

Delta Premier is only available to you if you are enrolled in Kaiser Permanente's Plan for FEHB You do not need to purchase this program to receive the basic dental coverage
included in the plan Payments will be made directly to Delta Payroll deduction is not available for this program

How to Enroll
An enrollment form for Delta Premier is included in your Kaiser Permanente enrollment kit If you would like more information on Delta Premier please call Delta Dental at

800 932 0783
Benefits on this page are not part of the FEHB contract

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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless your Plan physician determines it is medically necessary
to prevent diagnose or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary Services not required according to accepted standards of medical dental or psychiatric

practice Care by non Plan doctors or hospitals except for authorized referrals or emergencies and
services received under the travel benefit see Emergency Benefits and Benefits Available Away from Home and Benefits Available While You Travel
Experimental or investigational procedures treatments drugs or devices Procedures services drugs and supplies related to abortions except when the life of the
mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest
Procedures services drugs and supplies related to sex transformations Services or supplies you receive from a provider or facility barred from the FEHB Program
and Expenses you incurred while you were not enrolled in this Plan

Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the
payments On occasion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain
enrolled with us

If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
Medicare Choice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If
you later want to re enroll in the FEHB Program generally you may do so only at the next
Open Season

If you involuntarily lose coverage or move out of the Medicare Choice service area you may
re enroll in the FEHB Program at any time

If you do not have Medicare Part A or B you can still be covered under the FEHB Program
and your benefits will not be reduced We cannot require you to enroll in Medicare

Other group For information on Medicare Choice plans contact your local Social Security Administration
insurance SSA office or request it from SSA at 800 638 6833
coverage When anyone has coverage with us and with another group health plan it is called double
coverage You must tell us if you or a family member has double coverage You must also
send us documents about other insurance if we ask for them

When you have double coverage one plan is the primary payer it pays benefits first The
other plan is secondary it pays benefits next We decide which insurance is primary according
to the National Association of Insurance Commissioners Guidelines

If we pay second we will determine what the reasonable charge for the benefit should be
After the first plan pays we will pay either what is left of the reasonable charge or our regular
benefit whichever is less We will not pay more than the reasonable charge If we are the
secondary payer we may be entitled to receive payment from your primary plan

We will always provide you with the benefits described in this brochure Remember even if
you do not file a claim with your other plan you must still tell us that you have double
coverage

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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Section 7 Limitations Rules that affect your benefits continued
Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to
beyond our control provide them In that case we will make all reasonable efforts to provide you with necessary care

When others When you receive money to compensate you for medical or hospital care for injuries or illness
are responsible that another person caused you must reimburse us for whatever services we paid for We will
for injuries cover the cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more

information contact us for our subrogation procedures

TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover
you we are the primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage

Workers compensation We do not cover services that
You need because of a workplace related disease or injury that the Office of Workers Compensation Programs OWCP or a similar Federal or State agency determine they must

provide OWCP or a similar agency pays for through a third party injury settlement or other similar
proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provide your benefits

Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency
Agencies directly or indirectly pays for

Section 8 FEHB Facts
You have a right OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you
to information the right to information about your health plan its networks providers and facilities You can
about your HMO also find out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or

investigational OPM's website http www opm gov insure lists the specific types of information that we must make available to you

If you want specific information about us call 301 468 6000 or write to Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2101 E Jefferson St P O Box 6103 Rockville
MD 20849 6103 You may also contact us by fax at 301 816 7482 or visit our website at http www kaiserpermanente org or by email at kaiseronline org

Where do I get Your employing or retirement office can answer your questions and give you a Guide to
information about Federal Employees Health Benefits Plans brochures for other plans and other materials you
enrolling in the need to make an informed decision about
FEHB Program When you may change your enrollment How you can cover your family members

What happens when you transfer to another Federal agency go on leave without pay enter military service or retire

When your enrollment ends and The next Open Season for enrollment

We don't determine who is eligible for coverage and in most cases cannot change your enrollment status without information from your employment or retirement office
When are my benefits The benefits in this brochure are effective on January 1 If you are new to this plan your
and premiums effective coverage and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants premiums begin January 1

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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Section 8 FEHB Facts continued
What happens When you retire you can usually stay in the FEHB Program Generally you must have been
when I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet this requirement you may be eligible for other forms of coverage such as Temporary

Continuation of Coverage which is described later in this section
What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and
coverage are your unmarried dependent children under age 22 including any foster or step children your
available for my employment or retirement office authorizes coverage for Under certain circumstances you
family and me may also get coverage for a disabled child 22 years of age or older who is incapable of selfsupport

If you have a Self Only enrollment you may change to a Self and Family enrollment if you
marry give birth or add a child to your family You may change your enrollment 31 days
before to 60 days after you give birth or add a child to your family The benefits and premiums
for your Self and Family enrollment begin on the first day of the pay period in which the child
is born or becomes an eligible family member

Your employment or retirement office will not notify you when a family member is no longer
eligible to receive health benefits nor will we Please tell us immediately when you add or
remove family members from your coverage for any reason including divorce

If you or one of your family members is enrolled in one FEHB plan that person may not be
enrolled in another FEHB plan

Are my medical We will keep your medical and claims information confidential Only the following will have
and claims access to it
records OPM this Plan and subcontractors when they administer this contract
confidential This plan and appropriate third parties such as other insurance plans and the Office of Workers Compensation Programs OWCP when coordinating benefit payments and

subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal
actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your
identity or
OPM when reviewing a disputed claim or defending litigation about a claim

Information for new members Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election
Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You
can also use an Employee Express confirmation letter

What if I paid a Your old plan's deductible continues until our coverage begins
deductible under
my old plan

Pre existing We will not refuse to cover the treatment of a condition that you or a family member had
conditions before you enrolled in this Plan solely because you had the condition before you enrolled

When you lose benefits What happens You will receive an additional 31 days of coverage for no additional premium when
if my enrollment in
this Plan ends Your enrollment ends unless you cancel your enrollment or You are a family member no longer eligible for coverage

You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits
spouse coverage under your former spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse equity law If you are recently divorced or are anticipating a divorce contact

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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Section 8 FEHB Facts continued
your ex spouse's employment or retirement office to get more information about your coverage
choices

What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For

example you can receive TCC if you are not able to continue your FEHB enrollment after you
retire You may not elect TCC if you are fired from your Federal job due to gross misconduct

Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees
Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees
from your employment or retirement office

Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employment office delay processing your request you still have to pay
premiums from the 32nd day after your regular coverage ends even if several months have
passed
You pay the total premium and generally a 2 percent administrative charge The
government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless
you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits

How do I enroll in If you leave Federal service your employment office will notify you of your right to enroll
TCC under TCC You must enroll within 60 days of leaving or receiving this notice whichever is later

Children You must notify your employment or retirement office within 60 days after your
child is no longer an eligible family member That office will send you information about
enrolling in TCC You must enroll your child within 60 days after they become eligible for
TCC or receive this notice whichever is later

Former spouses You or your former spouse must notify your employment or retirement
office within 60 days of one of these qualifying events

Divorce
Loss of spouse equity coverage within 36 months after the divorce

Your employment or retirement office will then send your former spouse information
about enrolling in TCC Your former spouse must enroll within 60 days after the event
which qualifies them for coverage or receiving the information whichever is later

Note Your child or former spouse loses TCC eligibility unless you or your former spouse
notify your employing or retirement office within the 60 day deadline

How can I convert to You may convert to an individual policy if
individual coverage Your coverage under TCC or the spouse equity law ends If you canceled your coverage or

did not pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law

If you leave Federal service your employment office will notify you if individual coverage is
available You must apply in writing to us within 31 days after you receive this notice
However if you are a family member who is losing coverage the employment or retirement
office will not notify you You must apply in writing to us within 31 days after you are no
longer eligible for coverage

Your benefits and rates will differ from those under the FEHB Program however you will not
have to answer questions about your health and we will not impose a waiting period or limit
your coverage due to pre existing conditions

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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Section 8 FEHB Facts continued
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage
Certificate of Group that indicates how long you have been enrolled with us You can use this certificate when
Health Plan Coverage getting health insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods

limitations or exclusions for health related conditions based on the information in the
certificate

If you have been enrolled with us for less than 12 months but were previously enrolled in
other FEHB plans you may request a certificate from them as well

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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you
for services you did not receive billed you twice for the same service or misrepresented any information do the following

Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 503 813 2000 and explain the situation
If we do not resolve the issue call or write

THE HEALTH CARE FRAUD HOTLINE 202 418 3300
U S Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington D C 20415

Penalties for Fraud
Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the Inspector General
may investigate anyone who uses an ID card if they

Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits

Your payroll agency may also take administrative action against you

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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Notes

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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Notes

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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Summary of Benefits for Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions
set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or
change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the
cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY
CARE FOLLOW UP AND CONTINUING CARE AND CARE RECEIVED FROM OTHER KAISER PERMANENTE PLANS ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN PHYSICIANS

Benefits Plan pays provides Page
Inpatient care Hospital care Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital physician care room and board general nursing
care private room and private nursing care if medically necessary diagnostic
tests drugs and medical supplies use of operating room intensive care and
complete maternity care You pay nothing 13

Extended care All necessary services for up to 100 days per calendar year You pay nothing 13
Mental conditions Diagnosis and treatment of acute psychiatric conditions for unlimited number of days of inpatient care per calendar year You pay nothing .16

Substance abuse Inpatient rehabilitation services You pay nothing for unlimited number of days in a hospital or specialized facility per calendar year 16

Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care preventive care including well baby
care periodic check ups and routine immunizations laboratory tests and
X rays complete maternity care You pay 10 per office visit nothing per
house call by a physician 10 12

Home health care All necessary visits by nurses and health aides You pay nothing per visit 11
Mental conditions Unlimited visits per year You pay nothing for the first five visits then 10 for individual visits and 5 for group visits 6 20 then 30 for individual visits

and 5 for group visits for the remainder of the year 16
Substance abuse Outpatient counseling and treatment you pay nothing 16

Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay 35 per emergency room visit except for services that

are not covered benefits of this Plan 15 16
Prescription drugs Drugs prescribed by a Plan physician and obtained at a Plan pharmacy You pay 7 per prescription unit or refill 17

Dental care Accidental injury benefit you pay 10 per visit Preventive dental care comprehensive range of restorative orthodontic and other services Yo u
pay copays for these services 18 21
Vision care Refractions including lens prescription You pay 10 per examination Eyeglasses including frames and lenses and the initial fitting and

purchase of contact lenses See page 21 21
Out of pocket maximum Copayments will not be required for the remainder of the calendar year after your out of pocket expenses for services provided or arranged by

the Plan reach 1500 per Self Only enrollment or 3000 per Self and
Family enrollment 6

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Kaiser Foundation Health Plan of the Mid Atlantic States Inc 2000
2000 Rate Information for
Kaiser Foundation Health Plan of the Mid Atlantic States Inc

Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB
Guide for that category or contact the agency that maintains your health benefits enrollment

Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred
to as Category A rates and Category B rates will apply for certain career employees If you are a career postal
employee but not a member of a special postal employment class refer to the category definitions in The Guide to
Federal Employees Health Benefits Plans for United States Postal Service Employees RI 70 2 to determine which
rate applies to you

Postal rates do not apply to non career Postal employees postal retirees certain special postal employment classes or
associate members of any postal employee organization Such persons not subject to postal rates must refer to the
applicable Guide to Federal Employees Health Benefits Plans

Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly

Type of Gov't Your Gov't Your USPS Your USPS Your
Enrollment Code Share Share Share Share Share Share Share Share

Self Only E31 70.50 23.50 152.75 50.92 83.43 10.57 83.43 10.57
Self and Family E32 174.30 58.10 377.65 125.88 206.26 26.14 201.02 31.38

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