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KAISER PERMANENTE HMO MEDICAL PLAN
SUMMARY PLAN DESCRIPTION
January 2004
TABLE OF CONTENTS
- INTRODUCTION
SECTION 1 - ELIGIBILITY REQUIREMENTS
- A.
- Employee
- B.
- Dependent
- C.
- Duplicate Coverage
- D.
- Retiree
- E.
- Scientific Visitor
- F.
- Foreign Scientific and Student Visitors
- G.
- Employees on Leaves of Absence
- H.
- Staff Reduction
- I.
- COBRA Eligibility
- J.
- Waiting Period
- K.
- Employees on Long-Term Disability
SECTION 2 - ENROLLMENT
- A.
- Enrollment Procedures
- B.
- Enrollment Eligibility Date
- C.
- Transfer from Another UCAR Plan
- D.
- Declining Coverage
- E.
- Changing Your Medical Coverage
- F.
- Loss of Coverage
SECTION 3 - EFFECTIVE DATE OF COVERAGE
- A.
- Effective Date
- B.
- Eligibility Status Change
SECTION 4 - MEDICAL BENEFITS
- PART ONE - KAISER PERMANENTE PLAN MEMBER HANDBOOK
- A.
- Your Plan Sponsor
- B.
- Your Membership Identification Card
- PERSONAL PRIMARY CARE PHYSICIAN
- A.
- Your Kaiser Permanente Physician
- B.
- Referrals to Specialists
- C.
- Inpatient Hospital Care
- APPOINTMENTS
- A.
- To Make Appointments
- B.
- Routine Appointments
- C.
- Same Day Appointments
- D.
- Medical Emergencies
- E.
- Mental Health/Chemical Dependency Services
- F.
- Appointments With Specialists
- G.
- To Arrange for Hospital Care
- H.
- To Access Other Services
- I.
- Prescription Drugs
- YOUR RIGHTS AND RESPONSIBILITIES
- FINANCIAL RESPONSIBILITIES
- A.
- Copayments
- B.
- Lifetime Maximum
- C.
- If You Should Receive a Bill
- NOTIFICATION OF CHANGES
- YOUR QUESTIONS AND CONCERNS ARE IMPORTANT
- EMERGENCY SERVICES AND PROCEDURES
- A.
- Emergencies Within the Service Area
- B.
- Emergencies Outside the Service Area
- PART TWO - PLAN PROVISIONS
- A.
- Copayment Schedule Benefits
- Inpatient Services
- Mental Health
- Drug and Alcohol Rehabilitation
- Prescription Drug Coverage
- B.
- Description of Benefits
- Physician Services
- Hospital and Related Services
- Inpatient Services
- Outpatient Services
- Maternity Services
- Mental Health Services
- Treatment for Alcoholism, Drug Abuse and Drug Addiction
- Drug and Alcohol Rehabilitation
- Prescription Drugs
- Immunizations
- Miscellaneous Health Services
- C.
- Exclusions
- D.
- Limitations
- E.
- Termination of Individual Coverage
- SECTION 5 - CONTINUATION AND CONVERSION
- PART ONE - CONTINUATION OF BENEFITS REQUIRED UNDER FEDERAL LAW (COBRA)
- A.
- Qualifying Events
- B.
- Notification Requirements and Election Period
- C.
- Premium Payment
- D.
- End of Continuation
- E.
- Extended Coverage Period for Disabled Persons
- F.
- Retirees
- PART TWO - CONVERSION
- A.
- In-Area Conversion
- B.
- Out-of-Area Conversion
- SECTION 6 - COORDINATION OF BENEFITS
- A.
- Effect on Benefits
- B.
- Plans Considered for COB
- C.
- Order of Benefit Determination
- D.
- Operation of COB
- SECTION 7 - THIRD PARTY REIMBURSEMENT
- A.
- Injuries or Illnesses Caused or Alleged to be Caused by Third Parties
- SECTION 8 - GENERAL INFORMATION
- A.
- Claims Procedures
- B.
- Member Satisfaction Procedure
- C.
- Charge for Service or Purchase
- D.
- Workers' Compensation
- E.
- Binding Arbitration
- F.
- Statements
- G.
- Relationships Between Parties
- H.
- Records
- I.
- Examination of Covered Persons
- J.
- Conformity With Statutes
- K.
- Right to Modify, Amend or Terminate Plan
- L.
- Return of Over Payment
- SECTION 9 - DEFINITIONS
- SECTION 10 - ERISA
- INTRODUCTION
- Election of this Plan
- The University Corporation for Atmospheric Research (UCAR) offers three medical options and one dental plan to Eligible Persons.
- Your options include:
- Option I, which is an Exclusive Provider Organization (HMO),
- Option II, which is a Preferred Provider Organization (PPO),
- Option IV, which is a Health Maintenance Organization (HMO).
- This Summary Plan Description explains the benefits available under Option IV, the UCAR HMO medical Plan.
- You will be asked to complete an enrollment form when first eligible and to re-enroll annually in the option of your choice.
- A Participant can add or delete Dependents throughout the year if a qualified change of family status occurs.
- Summary of Coverage
- This handbook contains a summary of the Coverage and rules applicable to the Kaiser Permanente HMO - Option IV of UCAR's medical Plan. In the case of any discrepancies between this handbook and the HMO contract, the provisions in the HMO contract will govern. The description of the program given here is for general information only and should not be relied upon as accurately defining all benefits or all limitations on such benefits. The applicable benefits, conditions and limitations are those set forth in the master policy and the booklets issued to the individual employee.
- The benefits described in this handbook are sponsored by UCAR. Kaiser Permanente underwrites and insures the benefits for medical Option IV.
- All covered dependents must live in a Kaiser Permanente service area.
- A complete description of the HMO contract is on file at the office of UCAR in Boulder, Colorado and can be inspected by Participants at any time during normal business hours.
- Employee Contributions
- Coverage for Participants is Contributory. Coverage for Dependents of a Participant is also Contributory.
UCAR and the Participant share the cost of this plan. To participate in the plan, an Employee or Retiree must make contributions toward the cost of Employee or Retiree coverage and Dependent coverage. After September 30, 2008, the cost of Retiree coverage will be fully paid by Retirees. Employment at Will - This handbook is provided to help Participants understand the UCAR benefit programs. Nothing contained herein should be construed as a contract of employment nor as a guarantee of continued employment.
Defined Terms - Throughout this handbook, certain terms begin with a capital letter. These terms are defined in SECTION 9 - DEFINITIONS.
January 2004 |
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