BENEFITS AND SERVICES

THE BENEFITS AND SERVICES YOUR COVERAGE PROVIDES ARE EXPLAINED ON THE BENEFIT CHART IN THE BACK OF THIS BOOKLET. THESE BENEFITS INCLUDE, BUT ARE NOT IN ADDITION TO, MEDICARE BENEFITS. YOUR GROUP'S ADDITIONAL BENEFITS (IF ANY) ARE INCLUDED IN THIS BOOKLET IMMEDIATELY PRECEDING YOUR BENEFIT CHART. THE FACT THAT A PHYSICIAN MAY PRESCRIBE, PROVIDE OR DIRECT A SERVICE DOES NOT AUTOMATICALLY MAKE THE SERVICE A COVERED BENEFIT

ADDITIONAL BENEFIT INFORMATION

House Calls. Medical Group Physicians will make house calls within the Service Area only when they decide that necessary care can best be provided in your home. There is no charge for such house calls.

Reconstructive Surgery. Kaiser Permanente covers reconstructive surgery that will result in significant improvement in physical function, or that will correct significant disfigurement resulting from an injury or medically necessary surgery or is performed incident to a covered mastectomy.

Home Health Services. Members Not Entitled to Medicare Benefits. Covered services are provided in your home only when they can be safely and effectively provided there and are prescribed by a Plan Physician. There is no charge for these visits. We will not provide custodial care or homemaker care in your home. We will not provide care in your home if a Plan Physician determines that the care can be appropriately provided in a Medical Office, designated Hospital or skilled nursing facility and we provide, or offer to provide, the care in one of these settings.

Members Entitled to Medicare Benefits. All home health services as defined by Medicare that are prescribed or directed by a Plan Physician are provided at no charge.

Hospice Care. If you are diagnosed as having a terminal illness with a life expectancy of six months or less, you may elect to receive hospice care for the terminal illness. You pay the Supplemental Charge, if any, listed on the Benefit Chart.

If you elect to receive hospice care, you will not receive additional benefits for the terminal illness. However, you may continue to receive Plan benefits for conditions other than the terminal illness. Hospice care includes the following services and other benefits when prescribed by a Plan Physician and the hospice care team and received from a licensed hospice approved in writing by Medical Group:

1. nursing care;

2. physical, respiratory, occupational or speech therapy;

3. medical social services;

4. home health aide and homemaker services;

5. medical supplies, drugs, biologicals and appliances;

6. physician services;

7. short-term inpatient care, including respite care and care for pain control and acute and chronic symptom management;

8. counseling and bereavement services; and

9. services of volunteers.

Extended Care Services Provided in a Skilled Nursing Facility. Extended care services include nursing care, bed and board, medical social services, prescribed drugs and biological supplies, laboratory services, x-ray, medical supplies and equipment ordinarily furnished by a skilled nursing facility.

A skilled nursing facility is an institution that provides skilled nursing care 24 hours a day, is licensed under applicable state law, and is approved in writing by Medical Group and by Medicare.

Members Not Entitled to Part A Medicare Benefit s. During each calendar year, up to 100 days of prescribed extended care services are provided or arranged at approved skilled nursing facilities at no charge.

Members Entitled to Part A of Medicare. Up to 100 days of prescribed extended care services per Medicare benefit period are provided or arranged at approved skilled nursing facilities at no charge. A

Medicare benefit period begins when you enter a hospital or skilled nursing facility and ends when you have not been a patient in either a hospital or skilled nursing facility for 60 consecutive days.

Treatment for Substance Abuse. Medical and hospital services for alcohol and drug detoxification are covered in the same way as for other medical conditions. Detoxification is the process of removing toxic substances from the body. Outpatient rehabilitation for treatment of alcohol and drug abuse is covered when referred by a Medical Group Physician. Kaiser Permanente will pay 50% up to a maximum benefit of $650 per 12-month period only if you complete the prescribed program.

If your Group has purchased additional coverage for alcohol and drug rehabilitation, you will find an explanation of that benefit preceding your Benefit Chart.

Mental health services required in conjunction with treatment for alcoholism or drug dependency are provided in accord with mental health services described below.

Basic Mental Health Benefit. Mental health services of Medical Group Physicians and mental health professionals include evaluation and services for conditions which, in the judgment of a Plan Physician, would be responsive to therapeutic management.

• Outpatient Mental Health Services - You may pay a Supplemental Charge for each of the first ten visits per calendar year. This charge, if any, is on your Benefit Chart. You may pay a Supplemental Charge of $25 for each additional medically necessary visit per calendar year. This charge, if any, is on your Benefit Chart. If you are a Medicare member or a Part B member, you pay the Supplemental Charge listed on your Benefit Chart for each of the first 20 visits each calendar year and $25 per visit thereafter. Services include diagnostic evaluation, individual therapy, and psychiatrically oriented child and teenage guidance counseling.

You pay the Supplemental Charge, if any on your Benefit Chart for each group therapy visit. If you are a Medicare member or a Part B member, you pay a Supplemental Charge of $5 per visit.

You pay the Supplemental Charge, if any, on your Benefit Chart for each visit to monitor outpatient drug therapy. If you are a Medicare member or a Part B member, you pay a Supplemental Charge of $5 per visit. These visits are not charged against the mental health benefit.

• Inpatient Mental Health Services for Members Not Entitled to Benefits Under Part A of Medicare - Your inpatient mental health benefit provides up to 45 days of hospital care per member during each calendar year in a facility designated by Medical Group. The first 20 days are provided without charge and at 50% of Non-Member Rates for the 21st through the 45th day. Services include services of Physicians and mental health professionals, room and board, psychiatric nursing care, group therapy, electric shock therapy, occupational therapy, drug therapy and medical supplies.
• Inpatient Mental Health Services for Members Entitled to Benefits Under Part A of Medicare Your inpatient mental health benefit includes up to 190 lifetime days of Hospital Services in a Medicare-certified psychiatric facility without charge. These 190 lifetime days are reduced by one day for each day of inpatient mental health services previously covered by Medicare. When you have used all lifetime days, up to 45 days of Hospital Services are provided each calendar year without charge in a Medicare-certified psychiatric facility. These 45 days are reduced by one day for each two sessions of day care or night care received (see below). Services include services of Physicians and mental health professionals, room and board, psychiatric nursing care, group therapy, electric shock therapy, occupational therapy, drug therapy and medical supplies.
• Day Care and Night Care - If a Medical Group Physician prescribes it, you can receive two sessions of day care or night care instead of one day of hospital care up to the limit of your inpatient mental health benefit. Up to 40 sessions of prescribed care are provided without charge each calendar year. Thereafter, up to an additional 50 sessions of prescribed care are provided at 50% of Non-Member Rates each calendar year. These sessions must be at a facility designated by Medical Group. Such care includes the services of Physicians and other mental health professionals. Coverage also includes room and board, psychiatric nursing care, group therapy, electric shock therapy, occupational therapy, drug therapy and medical supplies.

You will find a description of the exclusions and limitations of your mental health coverage on page 1. If your Group has purchased alternate mental health coverage, you will find a description of it preceding your Benefit Chart.

Health Education. We provide health education appointments to support understanding of chronic diseases such as diabetes and hypertension. We also teach self-care on numerous topics including stress management and nutrition. For each visit, you pay the office visit charge, if any, shown on your Benefit Chart.

When available, health education classes, such as weight control classes or smoking cessation classes are provided upon payment of a reasonable fee.

There is no charge for new member programs that teach you how to use our services or for brochures that teach you how to stay healthy.

Durable Medical Equipment. Durable medical equipment such as wheelchairs, hospital beds, oxygen dispensing equipment and oxygen used in your home (including an institution used as your home) that are covered under Medicare are provided to Medicare members and Part B members upon payment of 20% of Medicare-approved charges when prescribed by a Medical Group Physician and obtained from sources designated by Kaiser Permanente. When use is no longer prescribed by a Physician, durable medical equipment must be returned or you must pay the fair market price, established by Kaiser Permanente, for the equipment. For all other members who are not Medicare members or Part B members, oxygen dispensing equipment and oxygen used in your home are covered upon payment of 20% of member charges. All other items of durable medical equipment are NOT COVERED.

If your Group has purchased additional coverage for durable medical equipment, you will find an explanation of that benefit preceding your Benefit Chart.

Prosthetic Devices. We provide coverage for prosthetic devices as follows:

• Prosthetic devices that are covered under Medicare and prescribed by a Medical Group Physician and obtained from sources designated by Kaiser Permanente to Medicare members and Part B members upon payment of 20% of Medicare-approved charges. For all other members who are not Medicare members or Part B members, prosthetic devices are NOT COVERED.
• Internally implanted devices for functional purposes, such as pacemakers and hip joints, are covered without charge.
• If you undergo mastectomy, you may receive prosthetic devices if you are a member when the mastectomy occurs. (This limitation does not apply to Medicare members or Part B members.) Medical Group will designate the source from which external prostheses can be obtained. Replacement will be made when a prosthesis is no longer functional; custom-made prostheses will be provided when necessary. You pay 20% of member charges for an external breast prosthesis.
• Prosthetic devices, such as obturators and speech and feeding appliances, required for treatment of cleft lip or cleft palate in newborn members are covered without charge when prescribed by a Medical Group Physician and obtained from sources designated by Kaiser Permanente.
• Other prosthetic devices are NOT COVERED.

Your Medical Group Physician may provide the services necessary to determine your need for prosthetic devices and help you make arrangements to obtain such equipment at a reasonable rate.

Orthotic Devices. You may receive certain orthotic devices, including fitting and adjustment of braces, at a charge of 20% of member charges when prescribed by a Medical Group Physician. The orthotic devices must be obtained from a provider or vendor selected by Kaiser Permanente.

Orthotic devices covered under this benefit are devices prescribed for treatment of scoliosis and other devices that meet each of the following criteria:

• Are medically approved and in general use on April 1, 1996, and
• Are required to support or correct a defect of form or function or a permanently non-functioning or malfunctioning body part, and
• Are used as an alternative to surgery or to speed recovery from surgery, and
• Are able to withstand repeated use, and
• Are not useful in the absence of an injury or illness.

Devices NOT COVERED under this benefit include:

• Dental braces, orthotic devices for podiatric use and arch support, braces for aid in sports activities, corsets and other non-rigid appliances;
• Braces normally used as an aid for chronic conditions, including but not limited to chronic back pain, polio, multiple sclerosis and spina bifida;
• Experimental and research braces.

The repair or replacement of orthotic devices will be provided at a charge of 20% of member charges unless necessitated by misuse. Kaiser Permanente may repair or replace a device at its option.

If your Group has purchased additional coverage for orthotic devices, you will find an explanation of that benefit preceding your Benefit Chart.

Examination for Eyeglasses; Eyeglasses and Contact Lenses. We provide eye refractions for lenses or eyeglasses (which include the written lens prescription). You may pay a Supplemental Charge for the Medical Office visit. This charge, if any, is on your Benefit Chart. Corrective lenses, eyeglasses, frames, and contact lenses (including the fitting of contact lenses) are NOT COVERED except as covered by Medicare. If your Group has purchased additional optical coverage, you will find an explanation of that benefit preceding your Benefit Chart.

Hearing Tests and Hearing Aids. We provide hearing tests, including tests to determine the need for hearing correction. You may pay a Supplemental Charge for the Medical Office visit. This charge, if any, is on your Benefit Chart. Hearing aids and tests to determine their efficacy are NOT COVERED.

If your Group has purchased additional coverage for hearing aids, you will find an explanation of that benefit preceding your Benefit Chart.

Prescription Drugs. Drugs administered in the hospital or during a covered visit, including allergy testing and treatment materials and injections, are provided without charge. Only drugs and materials that require administration by medical personnel or observation by medical personnel during self- administration are covered at the time of an outpatient visit. Outpatient drugs may be purchased at Health Plan pharmacies. If your Group has purchased additional coverage for prescription drugs, you will find an explanation of that benefit preceding your Benefit Chart.

For Medicare Members , the following drugs are provided at no charge when prescribed by a Physician: 1) drugs necessary for effective use of some prescribed items of durable medical equipment; 2) these oral drugs when used to treat cancer: cyclophosphamide, etoposide, melphalan and methotrexate; 3) epoetin for certain home dialysis patients; and 4) blood clotting factors for some hemophilia patients.

Drugs for Treatment of Prostate Cancer. LH-RH agonists (such as Lupron Depot injections) prescribed for hormonal treatment of prostate cancer are provided at a Supplemental Charge of 20% of member charges, unless a Physician determines no clinically equivalent alternative therapy exists.

Post-Surgical Immunosuppresive Drugs. Prescribed post-surgical immunosuppressive drugs required after a covered transplant are provided without charge.

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NAVIGATION

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Introduction | Benefit Changes | How to Use | Definitions | How Your Plan Works | Who Is Eligible | When Coverage Starts | Benefits And Services | Referrals and Restrictions on Choice of Providers | Emergency Services | Urgent Care | Health Plan's Appeals Procedure | Special Claims Procedures for Medicare Members | General Provisions | Binding Arbitration | Coordination Of currentbenefits | Medicare | What Is Not Covered | When Coverage Stops | Continuation Of Coverage | Customer Satisfaction Procedure | Service Information | Statement Of Financial Condition | Important Phone Numbers | Local Designated Hospitals | Supplemental Benefits | Benefit Chart

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Website for Kaiser of Colorado

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Denver Public Schools
Employee Benefits Department
900 Grant Street, Room 502
Denver, Colorado 80203
(303) 764-3371