Third Party Liability.
The benefits of this Plan do not apply to treatment of injury or illness claimed to be caused by any act or omission of a third party. Kaiser Permanente will provide necessary care, but you must reimburse Kaiser Permanente any amounts you collect from or on behalf of the third party for the cost of any treatment paid by or through Kaiser Permanente up to the amount you collect, regardless of whether you have been fully compensated for your injuries or damages. If you ( or Kaiser Permanente, at its election) make a good faith attempt to collect from the third party and fail, Kaiser Permanente will cancel all charges, except Supplemental Charges, for the care received at Plan facilities.
Motor Vehicle Accidents Covered by No Fault Insurance.
The benefits of this Plan do not apply to that portion of medical, rehabilitation and hospital expenses for injury, illness or disease arising out of a motor vehicle accident which is covered under "no fault" motor vehicle insurance. This uncovered amount will include up to a combined total of the first $100,000 of medical and rehabilitation costs, although rehabilitation costs alone cannot exceed $50,000 (as the terms "medical" and "rehabilitation" are defined and implemented in the Colorado No Fault Act). You will be charged Non-Member Rates for such services. You must provide Kaiser Permanente with assignments or other documents to enable Kaiser Permanente to obtain reimbursement from the "no fault" insurer responsible for payment. If you cooperate in assisting Kaiser Permanente in obtaining reimbursement from the "no fault" insurer in this manner, and Kaiser Permanente is then unable to recover any portion or all of those charges, that portion of the charges for services which is not reimbursed by the "no fault" insurer is canceled, except applicable Supplemental Charges.
What If You Fail to Purchase the Required No Fault Coverage on Your Own Automobile?
The benefits of this Plan will not be available to you to the extent of minimum benefits required by the "no fault" law for medical, rehabilitation and hospital expenses for injuries suffered by you while operating or riding in a motor vehicle registered and licensed for operation on the public highways of Colorado under the following circumstances: (1) if you own the accident vehicle, and you fail to purchase "no fault" insurance for that vehicle; or (2) if you do not own the accident vehicle, but you do own any other motor vehicle which is supposed to be registered and licensed for operation on the public highways of Colorado, and you fail to purchase "no fault" insurance for that vehicle. If you do not own the accident vehicle, and if you do not own another motor vehicle which is supposed to be registered and licensed for operation on the public highways of Colorado, then this limitation of benefits under this Plan does not apply to you. If this limitation of benefits does apply to you, then you will be responsible for payment of up to a combined total of the first $100,000 of medical and rehabilitation costs, although rehabilitation costs alone cannot exceed $50,000 (as the terms "medical" and "rehabilitation" are defined and implemented in the Colorado No Fault Act).
Kaiser Permanente may adopt reasonable policies, procedures, rules and interpretations that govern your Group's coverage. Kaiser Permanente and your Group can mutually change the terms of group coverage without your consent. If Kaiser Permanente makes a favorable exception to the terms and conditions of group coverage, Kaiser Permanente is not required to make the same or similar exceptions in the future. Neither you nor your Group may assign any rights or obligations under your Group's coverage without Kaiser Permanente's written consent.
If Kaiser Permanente successfully sues to collect sums you owe under group coverage, you must pay collection costs, including legal fees.
Services In Another Kaiser Permanente Service Area.
If you are temporarily visiting any other Kaiser Permanente service area for fewer than 90 days, you may obtain medical and hospital services at Kaiser Permanente facilities in the areas listed below. Benefits and Supplemental Charges in other Regions may not be identical to those provided in the Colorado Region. Transplants and services for infertility are provided or arranged only in or by the Colorado Region. Contact the Information Center for a copy of the Visiting Member brochure that lists medical offices and designated hospitals for all 12 Kaiser Permanente Regions.
The Atlanta area.
On the islands of Oahu, Maui and Hawaii.
Kansas City, Kansas and Kansas City, Missouri.
The Washington, D.C. area; the Baltimore, Maryland area; and the Arlington, Virginia area.
The Hartford and Stamford, Connecticut areas; Westchester County, New York; and the Amherst, Massachusetts area.
The Portland-Salem, Oregon area; and the Vancouver-Longview-Kelso, Washington areas.
The Raleigh-Durham-Chapel Hill and Charlotte areas.
The San Francisco Bay, Stockton, Fresno and Sacramento areas.
The Cleveland/Akron areas.
The Los Angeles, San Diego and Bakersfield areas.
The Dallas-Fort Worth area.
If You Move.
If you move permanently to another Health Plan's service area, you must promptly apply to the Kaiser Permanente office in that service area to transfer your membership. Your right to Out-of-Plan emergency benefits in another Kaiser Permanente's service area ends after you have lived there more than 90 days unless you receive prior written authorization for continuation of your benefits from your Colorado Health Plan.
If, after enrollment, you move out of our Service Area to an area not served by any Kaiser Permanente Region, you may continue your coverage with us. However, under such membership, the only benefits available to you outside our Service Area are those described in "Outside the Service Area" on page 8. It may be to your advantage to switch your coverage to another health insurance carrier that can provide coverage for both your routine and emergency health care needs.
Limit on Supplemental Charges.
To reduce your out-of-pocket costs for health care, we limit the amount you must pay in Supplemental Charges each calendar year for certain BASIC SERVICES such as:
Medical services provided in hospitals, medical offices, emergency rooms and on house calls.
The first 20 outpatient mental health visits.
Short-term physical therapy, speech therapy and occupational therapy.
Supplemental Charges for NON-BASIC SERVICES AND SUPPLIES that do not count toward your limit include items such as prescription drugs, contraceptive devices, eyeglasses, orthopedic braces, hospitalization for mental health conditions or residential care for substance abuse.
Each year we determine the limits on Supplemental Charges for the following calendar year. The 1997 limit is $1,000 per individual or $3,000 per family.
When you have paid either the individual or the family limit on Supplemental Charges, you will not be required to pay any additional Supplemental Charges for basic health services for the remainder of the calendar year. It is your responsibility to request and keep receipts for such charges and to send the original receipts by certified mail or bring them to the Patient Accounting Department as proof that your Supplemental Charges limit has been reached. Your exemption from further payment of Supplemental Charges is effective only from the date that you present proof of eligibility until the end of the calendar year in which the exemption occurred.
Supplemental Charges (and other charges, for example, charges for non-covered services) are due when you receive the services to which they are attached.
We will charge you an administrative billing fee of $10.00 if any amount owed to Kaiser Permanente is not paid at the time of the office visit. This applies only to outpatient visits at Kaiser Permanente facilities.