HomeMy WebLinkAboutKaiser Foundation Health Plan; 1983-01-01;, I _- - . --. .
KAISER PERNlANENTE Kaiser Foundation Health Plan, Inc.
Southern California Region
- .-,
KAISER FOUNDATION HEALTH PLAN, INC.
A Nonprofit Corporation
Southern California Region
GROUP MEDICAL AND HOSPITAL SERVICE AGREEMENT
INTRODUCTION
This Service Agreement has been entered into between Kaiser Foundation Health Plan
Incorporated, a California nonprofit corporation, herein called "Health Plan", and
CITY OF CARLSBAD, herein called l(Groupfl.
Health Plan, in consideration of the monthly payments to be paid to Health Plan by
Group and in consideration of the Supplemental Charges to be paid by or on behalf of
Members, agrees to arrange necessary Medical and Hospital Services and other benefits
as specified in Section 11 for eligible persons who enrol1 hereunder, in accord with
the terms, conditions, limitations and exclusions of this Service Agreement.
INTERPRETATION OF AGREEMENT
In order to provide the advantages of integrated medical and hospital facilities
and of group medical practice, Health Plan operates on a direct-service rather than
indemnity basis. The interpretation of this Agreement is guided by the direct-service
nature of the Health Plan program.
1. DEFINITIONS
As used in this Agreement and all attached schedules or provisions modifying this
Service Agreement, the terms in boldface type, when capitalized, have the meanings
shown:
A. Health Plan: Kaiser Foundation Health Plan, Inc., a California nonprofit cor-
poration organized for the primary purpose of arranging Medical and Hospital Ser-
vices.
B. Health Plan Region: Any geographical area in which a direct-service health
care program is conducted by Health Plan or a related organization.
C. Subscriber: A person who meets all applicable eligibility requirements of Sec-
tion 2 and is enrolled hereunder, and for whom the prepayment required by Section 4
has been received by Health Plan.
D. Family Dependent: Any person who meets all applicable eligibility requirements
of Section 2 and is enrolled hereunder and for whom the prepayment required by Sec-
tion 4 has been received by Health Plan.
E. Family Unit: A Subscriber and all his or her Family Dependents.
F. Member: Any Subscriber or Family Dependent; Medicare Member: Any Member enti-
tled to benefits under both parts of Medicare who has assigned Part B benefits to
Health Plan; Part A Member: Any Member entitled to benefits under Part A of Medi-
care; Part B Member: Any Member entitled to benefits under Part B of Medicare who has
assigned Part B benefits to Health Plan.
Page 1 Group 4329-00
G. Medical Group: Any group of medical doctors or any medical doctor that has
contracted with Health Plan to render Medical Services.
H. Physician: Any doctor of medicine associated with or engaged by Medical Group;
Attending Physician: The Physician primarily responsible for the care of a Member
with respect to any particular injury or illness.
I. Hospital: Any hospital in the Southern California Region with respect to which
Health Plan maintains contractual arrangements for Hospital Services. A current list
of such Hospitals may be obtained from any Health Plan office.
J. Medical Office: Any outpatient treatment facility in the Southern California
Region which is staffed by Medical Group. A current list of Medical Offices may be
obtained from any Health Plan office.
K. Medical Services: Except as expressly limited or excluded by this Agreement,
those medically necessary professional services of physicians and surgeons, other
health professionals and paramedical personnel, including medical, diagnostic, thera-
peutic and preventive services which are (1) generally and customarily provided in
Southern California and (2) performed, prescribed, or directed by the Attending Phy-
sician.
L. Hospital Services: Except as expressly limited or excluded by this Agreement,
those medically necessary services for registered bed patients which are (1) general-
ly and customarily provided by acute general hospitals in Southern Californa and (2)
prescribed, directed or authorized by the Attending Physician.
M. Non-Member Rates: The charges set forth in the applicable schedule of charges
maintained by Medical Group or Hospitals for services provided to patients who are
not Members.
N. Service Area: Within Los Angeles, Orange, Riverside, San Bernardino, San Diego
and Ventura Counties the Service Area is that area which is within a radius of thirty
miles of any Hospital or Medical Office.
0. Medicare: The Federal Health Insurance for the Aged and Disabled Act.
P. Skilled Nursing Facility: A licensed institution (or a distinct part of an in-
stitution) which (1) provides 24 hour a day licensed nursing care; (2) has in effect
a transfer agreement with one or more hospitals; (3) is primarily engaged in provid-
ing skilled nursing care and related services to inpatients who require medical or
nursing care as part of an ongoing therapeutic regimen; and (4) has been approved in
writing by Medical Group.
Q. Extended Care Services: Those services necessary to the health of patients
which are generally provided by Skilled Nursing Facilities, including nursing care,
bed and board, physical, occupational or speech therapy, medical social services,
drugs, biologicals, supplies, appliances and equipment, when such services are per-
formed, prescribed or directed by the Attending Physician.
R. Supplemental Charges: Those amounts,if any, which must be paid by Members when
they receive covered services not fully prepaid hereunder.
2. ELIGIBILITY, ENROLLMENT AND COVERAGE
A. Eligibility. Individuals are accepted for enrollment and continuing coverage
only if they meet all applicable requirements set forth below and reside in the Ser-
vice Area when originally enrolled.
Page 2 Group 4329-00
(1) Subscribers. To be a Subscriber, a person on his or her own behalf and not
by virtue of dependency status, must be either:
(a) An employee of Group employed to work a minimum of 20 hours per week; or
(b) Entitled to coverage under a trust agreement or employment contract,
except that no change in Group's eligibility or participation requirements is
effective for purposes of this Agreement unless Health Plan consents.
(2) Family Dependents. To be a Family Dependent a person must be:
(a) The Subscriber's spouse; or
(b) A dependent child of the Subscriber or the Subscriber's spouse and ei-
ther:
(i) Unmarried and either under age 19, or under age 24 and attending an
accredited school on a full-time basis; or
(ii) Over age 19 and incapable of self-sustaining employment by reason of
mental retardation or physical handicap incurred prior to age 19 (or prior
to age 24 if enrolled as a student as in (i) above), and chiefly dependent
upon the Subscriber or the Subscriber's spouse for support and maintenance,
with proof of incapacity and dependency furnished annually if requested by
Health Plan; or
(c) Any other unmarried dependent child under age 19 or under age 24 if
enrolled as a student as in (i) above, entirely supported by the Subscriber or
the Subscriber's spouse and permanently residing in the Subscriber's household.
Ineligible Persons. No person is eligible to enrol1 hereunder if the person or
any other person in his or her Family Unit has had Health Plan coverage terminated
under this or any other Health Plan Medical and Hospital Service Agreement for any
reason specified in Section 9-B.
B. Enrollment. Group will (1) offer coverage under this Agreement to all eligible persons on conditions no less favorable than those for any alternate health care plan
available through Group, and (2) have an open enrollment period at least once a year
during which all eligible persons are offered a choice of enrollment under this
Agreement or any alternate health care plan available through Group.
(1) Newly Eligible Persons. A person who newly attains eligibility to become a
Subscriber may enrol1 by submitting an enrollment application to Group within 30
days. If Group has a probationary period during which a new employee is not
eligible to become a Subscriber, the enrollment application must be submitted to
Group within 30 days after the probationary period ends. If Subscriber desires
to enrol1 the persons then eligible to become the Subscriber's Family Dependents,
they must be enrolled at the same time.
Any person who thereafter newly attains eligibility to become a Family Depen-
dent, such as a new spouse or newborn child, may be enrolled by Subscriber's sub-
mitting a change of enrollment form to Group within 30 days. A newborn child of a
Family Dependent other than the Subscriber's spouse may be enrolled hereunder only if the newborn child is eligible under Section 2-A(2)(c); if not eligible under
Page 3 Group 4329-00
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Section 2-A(2)(c), the newborn may be enrolled under an Individual Service Agree-
ment by submitting an application within 30 days of birth.
(2) Open Enrollment Period. There shall be an Open Enrollment Period between
December 01 - December 15 each year.
Eligible persons not enrolled when newly eligible may only be enrolled as Sub-
cribers and Family Dependents by submitting an enrollment application to Group
during the open enrollment period.
Limitation on Enrollment. If Health Plan determines that it is necessary to limit
enrollment of additional Members in order to maintain a suitable level of Medical or
Hospital Services to Members, Health Plan may limit enrollment (except for newborns
or newly adopted children) as it deems appropriate notwithstanding the eligibility
and enrollment provisions of this Section 2 or any other provision of this Agreement.
C. Effective Date of Coverage.
(1) Newly Eligible Persons. Coverage for every newly eligible and enrolled per-
son except a newborn or adopted child is effective on the first day of the month
following receipt of the enrollment card. An eligible and enrolled newborn child
is covered from birth, and an eligible and enrolled adopted child is covered from
the date placed in the custody of the adoptive parents.
(2) Open Enrollment Period. Coverage for persons enrolled during the open en-
rollment period December 01 - December 15 is effective January 01.
D. Subject to the provisions of Section 9, a person who is a Member hereunder
on the first day of a month is covered for the entire month.
3. RELATIONS AMONG PARTIES AFFECTED BY AGREEMENT
The relationship between Health Plan and Medical Group and between Health Plan and
Hospitals is an independent contractor relationship; Physicians and Hospitals are not
agents or employees of Health Plan, nor is Health Plan or any employee of Health
Plan, an employee or agent of Hospitals or Medical Group or any Physician.
Physicians maintain the physician-patient relationship with Members and are solely
responsible to Members for all Medical Services. Hospitals maintain the hospital-
patient relationship with Members and are solely responsible to Members for all Hos-
pital Services.
Patient-identifying information from the medical records of Members and patient-
identifying information received by Physicians or Hospitals incident to the
physician-patient or hospital-patient relationship is kept confidential and is not
disclosed without the prior consent of the Member, except (i) for internal use by
Health Plan, Hospitals or Medical Group in bona fide medical research or education,
or for use in the administration of this Agreement, and (ii) to comply with govern-
ment requirements established by law.
Neither Group nor any Member is the agent or representative of Health Plan, and
neither is liable for any acts or omissions of Health Plan, its agents or employees,
or of Medical Group, any Physician, or Hospitals, or any other person or organization
with which Health Plan has made or hereafter makes arrangements for performance of
services under this Agreement.
Page 4 Group 4329-00
The contracts between Health Plan and Medical Group and Health Plan and Hospitals
provide that Members shall not be liable for any amounts owed Medical Group or Hospi-
tals by Health Plan. However, should Health Plan fail to pay a non-contracting pro-
vider the Member may be liable for the cost of any such services received by him.
4. RATES AND PAYMENT
A. Periodic Payment Schedule. Group shall remit to Health Plan on behalf of each
Subscriber and his or her Family Dependents for each month on or before the last day
of the preceding month the following amounts:
Basic Rate Structure
Subscriber only
Subscriber with one Family Dependent
Subscriber with two or more Family Dependents
$ 67.09
$ 134.18
$ 191.10
Variables to Basic Rate Structure
For each Member age 65 or older, who is (a) not entitled to
benefits under Part B of Medicare, or (b) entitled to bene-
fits under Part B of Medicare but has not assigned such be-
nefits to Health Plan Add $ 14.58
For each Member (up to 2 per Family Unit) entitled to bene-
fits under both Parts A and B of Medicare, who has assigned
Part B benefits to Health Plan:
Subscriber Subtract $ 32.21
Subscriber's spouse or child Subtract $ 32.21
These amounts are called the "Base Payment". If a state or any other taxing au-
thority imposes upon Health Plan a tax or license fee which is levied upon or meas-
ured by the Base Payment or by Health Plan's gross receipts or any portion of either,
then Health Plan may amend this Agreement with respect to rates to increase the Base
Payment by an amount sufficient to cover all such taxes or license fees rounded to
the nearest cent, effective as of the date stated in the notice, which shall not be
earlier than the date of imposition of such tax or license, by mailing a postage pre-
paid notice of the amendment to Group at its address of record with Health Plan at
least 30 days before the effective date of the amendment.
Only Members for whom the stipulated payment is received by Health Plan are enti-
tled to Medical and Hospital Services hereunder, and then only for the period for
which such payment is received.
B. Other Charges. In addition, Members must pay for or arrange for payment of Sup-
plemental Charges and other amounts they owe Health Plan, Hospitals and Medical
Group.
Limits on Supplemental Charges. After a Member (or Family Unit) demonstrates that
the Member (or Family Unit) has paid Supplemental Charges for Basic Health Services
received during a calendar year which total the Member (or Family Unit) limit on such
Supplemental Charges established by Health Plan for that calendar year, no additional
Supplemental Charges are made to the Member (or Family Unit) for such services during
the remainder of the calendar year. The limit for any calendar year will not exceed
Health Plan's annual charge for fully prepaid Basic Health Services established ef-
fective January 1 of the calendar year. Health Plan will notify Group prior to Janu-
ary 1 of each year of the limit on Supplemental Charges under this paragraph for the
ensuing calendar year.
Page 5 Group 4329-00
For the calendar year 1983 the limit on Supplemental Charges is $750.00 per Member
but not more than an aggregate of $2,100.00 for a Family Unit of 3 or more Members.
"Basic Health Services" for determining this limit on Supplemental Charges are the
benefits covered in Section 11, Parts A,C,D,F(2),L,M,B, except blood; E, except occu-
pational therapy and speech therapy;H, except contraceptive drugs and devices and in-
fertility medications; the first 20 out-patient visits specified in Section 11-N and
Sections 11-Q, 11-R, and 11-S, except for care which is not otherwise a Basic Health
Service under this paragraph.
Payments made by the Member or on his behalf for non-covered services or due as a
result of Section 6-C or 11-S-(2)(a) are not Supplemental Charges for Basic Health
Services.
C. Medicare Payments. Payments required hereunder are established on the assump-
tion that Medicare payments for services provided to Members hereunder will be re-
ceived by Health Plan or the provider of services entitled thereto. Therefore, all
sums payable on behalf of Members pursuant to Medicare for services provided pursuant
to this Agreement are payable to and retained by either Health Plan or the provider
of services entitled thereto, and each Member entitled to any Medicare benefits shall
complete and submit to Health Plan all consents, releases, assignments and other do-
cuments reasonably requested by Health Plan in order to obtain or assure such pay-
ment. Any Member who fails to do so must pay for services received at Non-Member
Rates.
D. Employer Contribution. Employer contribution shall be determined by Group, but
in no case will be less than one-half the rate required for a single Subscriber.
5. SERVICES AND BENEFITS
Subject to all terms and provisions of this Agreement, Members are entitled to
receive services and other benefits as follows:
A. Within the Service Area. Within the Service Area, Members are entitled to re-
ceive the services and other benefits specified in Section 11 when provided, pre-
scribed or directed by Physicians.
Choice of Physician and Hospital. Within the Service Area, covered services are
available only from Medical Group, Hospitals and in Skilled Nursing Facilities, and
neither Health Plan, Hospitals, Medical Group nor any Physician has any liability or
obligation on account of any service or benefit sought or received by any Member from
any other doctor, hospital or skilled nursing facility, or other person, institution,
or organization unless (1) prior special arrangements are made by a Physician and
confirmed by written referral from Medical Group or (2) such services are covered un-
der Section 11-S(l)(a).
B. Outside the Service Area. While outside the Service Area, Members may have be-
nefits under Sections 11-R and 11-S(l)(b).
6. EXCLUSIONS, LIMITATIONS, AND REDUCTIONS
A. Exclusions. The following are excluded from the coverage of this Agreement:
(1) Employer or Governmental Responsibility.
Page 6 Group 4329-00
(a) Financial responsibility for services and other benefits provided or
arranged by Health Plan for any illness, injury or condition for which, or as a result of which, a payment or any other benefit, including amounts received in
settlement of claims therefor ("Financial Benefit") is provided or is required
to be provided either:
(i) Pursuant to any federal, state, county or municipal workers' compen-
sation or employer's liability law or other legislation of similar purpose
or import; or
(ii) From any federal, state, county, municipal or other governmental
agency, excluding Medicaid benefits.
(b) Services for any illness, injury or condition for which, or as a result
of which, a service benefit, including amounts received in settlement of
claims therefore ("Service Benefit") is provided or is required to be pro-
vided by the Veterans Administration for military service-connected disa-
bilities, as defined by the Veterans Administration, when such care is reason-
ably available to the Member.
If there is reasonable doubt whether any Financial Benefit or Service Bene-
fit is available or is required to be provided because of such illness, injury
or condition pursuant to such a law or from such a source, and if the Member
seeks diligently to establish his or her rights to Financial Benefits or Ser-
vice Benefits, then services that otherwise would be provided under this Agree-
ment will be provided, except that the value of such services, at Non-Member
Rates, is recoverable by Health Plan or its nominee from any person, organiza-
tion or agency providing Financial Benefits or Service Benefits or from whom
Financial Benefits or Service Benefits are due, or from the Member, to the ex-
tent that monetary Benefits are provided or payable or would have been required
to be provided if the Member had diligently sought to establish his or her
rights to such Financial Benefits or Service Benefits.
(2) Non-Covered Inpatient Care. Custodial care, domiciliary care, convalescent
care, care in an intermediate care facility and any other inpatient care which is
not medically required and specifically covered by this Service Agreement.
(3) Cosmetic Services. Plastic surgery or other services which are indicated
primarily for cosmetic purposes, except as provided in Section 11-I.
(4) Dental Care. Dental care and dental X-rays, including care for injury to
teeth.
(5) Certain Physical Examinations. Physical examinations and related services
required for obtaining or continuing employment, insurance or governmental licens-
ing.
(6) Experimental Procedures and Procedures Not Generally and Customarily
Available in Southern California. Medical, surgical or other health care proce-
dures which are experimental, and procedures which are not generally and custom-
arily available in Southern California.
(7) Voluntary Infertility. Services to reverse voluntary, surgically induced
infertility.
(8) Podiatry. Podiatric services and services of a podiatrist or chiropodist.
Page 7 Group 4329-00
(9) Chiropractic. Chiropractic services and services of a chiropractor.
(10) Durable Equipment. Durable medical equipment, such as oxygen tents, hos-
pital beds, and wheelchairs used in the Member's home (including an institution
used as his or her home) except that Medicare members have the benefits set
forth in Section 11-L (2).
(11) Corrective Appliances and Artificial Aids. Artificial aids and corrective
appliances, such as braces, prosthetic devices (except as provided in Section ll-
I), hearing aids, corrective lenses and eyeglasses, except that Physicians provide
the services necessary to determine the need therefor and attempt to make arrange-
ments whereby they may be obtained.
(12) Blood. Blood, except as specified in Section 11-B.
(13) Organ Transplants. Organ transplants except that kidney transplants are
provided in accord with Section 11-J.
(14) Sex Change. All services when related to sex changes.
B. Limitations. The rights of Members and obligations of Health Plan, Hospitals
Medical Group and Physicians hereunder are subject to the following limitations:
(1) Major Disaster or Epidemic. If a major disaster or epidemic occurs, Phy-
sicians and Hospitals render Medical and Hospital Services (and arrange Extended
Care Services and Home Health Services) insofar as practical, according to their
best judgment, within limitation of available facilities and personnel, but nei-
ther Health Plan, Hospitals, Medical Group nor any Physician has any liabili-
ty or obligation for delay or failure to provide (or arrange) any such services
to the extent the disaster or epidemic causes unavailability of facilities or
personnel.
(2) Unusual Circumstances. If, due to unusual circumstances, such as (a) com-
plete or partial destruction of facilities; war; riot; civil insurrection; labor
disputes not involving Health Plan, Hospitals or Medical Group; disability of a
significant part of Hospital or Medical Group personnel; or similar causes; or (b)
labor disputes involving Health Plan, Hospitals, or Medical Group, the rendi-
tion or provision of services and other benefits covered hereunder is delayed or
rendered impractical, Hospitals, Medical Group and Physicians will use
their best efforts to provide services covered hereunder; but, with regard to
(a>, neither Health Plan, Hospitals, Medical Group nor any Physician shall have
any liability or obligation on account of such delay or such failure to provide
services or other benefits, and with regard to (b), the provision of non-
emergent care may be deferred until after resolution of the labor dispute.
(3) Refusal to Accept Treatment. Certain Members may, for personal reasons, re-
fuse to accept procedures or treatment recommended by Physician. Physicians may
regard such refusal as incompatible with the continuance of a satisfactory physi-
cian-patient relationship and as obstructing the providing of proper medical care.
Physicians use their best efforts to render all necessary and appropriate profes-
sional services in a manner compatible with a Member's wishes, insofar as this can
be done consistently with the Physicians' judgment regarding proper medical prac-
tice. If a Member refuses to follow a recommended treatment or procedure, and the
Physician believes that no professionally acceptable alternative exists, the Mem-
ber is so advised. If the Member still refuses to follow the recommended treatment
Page 8 Group 4329-00
or procedure, then neither Medical Group, Hospitals, Health Plan nor any Physician
has any further responsibility to provide care for the condition under treatment.
(4) Alcohol and Drug Dependency. Services for alcohol and drug dependency are
provided only in accord with Section 11-M.
(5) Rehabilitation. Rehabilitative treatment is provided only in accord with
Section 11-E.
(6) Psychiatric Conditions. Mental health services including any treatment for
mental illness or disorders, or drug-induced mental condition, are provided only
in accord with Section 11-N.
C. Reductions. The benefits of Members are subject to the following reductions:
(1) Injuries or Illnesses Caused by Third Parties. This reduction does not ap- ply to Medicare Members.
(a) Services Received at Facilities Contracting with Health Plan. If injury
or illness is caused by any act or omission of a third party, services and
other benefits are furnished or arranged by Physicians and Hospitals at Non-
Member Rates; however, the Member is not required to pay any portion of such
charges for services and other benefits which is in excess of the total amount
collected from, or on behalf of, the third party on account of the injury or
illness.
(b) Emergency Services Received at Facilities Not Contracting with Health
Plan. If injury or illness is caused by any act or omission of a third party,
payments under Section 11-S are made for the services of physicians, hospitals,
and other providers not contracting with Health Plan if the Member signs an
agreement (i) to reimburse Health Plan for any amount it pays up to the amount
of any settlement or judgment the Member receives, and (ii) directing his or
her attorney to disburse such amounts directly to Health Plan.
(2) Medicare. Benefits are reduced by any benefits to which a Member is enti-
tled under Medicare.
7. CONVERSION AND TRANSFER
A. Conversion to Non-Group Enrollment. If any person ceases to qualify as a Member
for any reason other than termination of membership rights pursuant to Section 9,
then said person may, within thirty days after termination of said rights, convert to
non-group membership effective as of the date of such termination.
B. Change of Residence. Members who move from the Southern California Region to
any geographical area not served by Health Plan may, if they desire, continue their
Health Plan coverage. However, the only benefits provided outside the Service Area
are those specified in Sections 11-R amd 11-S.
Members who move to another Health Plan Region must promptly apply to a Health
Plan office in such Region to transfer their Membership.
No right to service benefits under Sections 11-R and 11-S exists in another Health Plan Region after a Member has been a resident in such Region more than 90 days, un-
less the Member, by prior application to Health Plan, demonstrates special cir-
cumstances under which a longer period is "temporary" and the Member's continuing
status of temporary residence is confirmed in writing by Health Plan.
Page 9 Group 4329-00
8. ARBITRATION OF CLAIMS
A. Initiating a Claim. Any claim arising from alleged violation of a legal duty
incident to this Agreement shall be submitted to binding arbitration if the claim is
asserted:
(1) by a Member, or by a Member's heir or personal representative (llClaimant")
(2) On account of death, mental disturbance or bodily injury arising from ren-
dition or failure to render services under this Agreement, irrespective of the le-
gal theory upon which the claim is asserted;
(3) For monetary damages exceeding the jurisdictional limit of the Small Claims
Court; and
(4) Against one or more of the following (URespondent"):
(a) Health Plan,
(b) Hospitals,
(c) Medical Group,
(d) Any Physician, or
(e) Any employee of the foregoing.
Claimant shall initiate the claim by serving at least one Respondent with notice
of the nature of the claim and a demand for arbitration. Claimant shall serve all
Respondents reasonably servable, and the arbitrators shall have jurisdiction only
over Respondents actually served. The notice and demand must be served in the fol-
lowing manner: Natural persons must be served as in a California civil action, and
any other Respondent must be served by registered letter, postage prepaid, addressed
to Respondent in care of Health Plan at the address provided in Section 10-J.
B. Initiating Arbitration Proceedings. Within 30 days after initial service on a
Respondent, Claimant and Respondent each shall designate an arbitrator and give writ-
ten notice of such designation to the other, and each shall deposit $150.00 in a spe-
cial account maintained by Bank of America National Trust and Savings Association,
Wilshire-Robertson Branch, 8760 Wilshire Boulevard, Los Angeles, California 90211, to
provide the initial funds to pay the fees of the neutral arbitrator and expenses of
arbitration as approved by him or her, which fees and expenses shall be borne equally
by the parties. "Expenses of arbitration" does not include counsel or witness fees or
other expenses incurred by a party for his or her own benefit. Said account shall be
replenish from time to time as directed by the neutral arbitrator. Within 30 days
after these notices have been given and payments made, the two arbitrators so select-
ed shall select a neutral arbitrator and give notice of the selection to Claimant and
all Respondents served, and the three arbitrators shall hold a hearing within a rea-
sonable time thereafter. Except where otherwise agreed to by the parties, arbitration
shall be held at a time and place designated by the neutral arbitrator in a county
where an alleged wrongful act occured.
C. General Provisions. All claims based upon the same incident, transaction or
related curcumstances shall be arbitrated in one proceeding and all Respondents duly
served in connection therewith shall be parties. A claim shall be waived and forever
barred if (1) on the date notice thereof is received, the claim, if asserted in a
Page 10 Group 4329-00
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civil action, would be barred by the applicable California statute of limitations, or
(2) the Claimant fails to pursue the arbitration claim in accord with the procedures
prescribed herein with reasonable diligence. All notices or other papers required to
be served or convenient in the conduct of arbitration proceedings following the ini-
tial service shall be served by mailing the same, postage prepaid, to such address as
each party gives for this purpose. With respect to any matter not herein expressly
provided for, the arbitration shall be governed by California Code of Civil Procedure
provisions relating to arbitration.
9. TERM AND TERMINATION
A. Term.
This Agreement continues in effect from the effective date stated on the last page
of this Agreement to January 01, 1984, and from year to year thereafter, subject
to Health Plan or Group terminating this Agreement pursuant to Section 9B.
B. Termination.
Except as specifically provided in this paragraph, all rights to services and oth-
er benefits hereunder terminate as of the effective date of termination.
(1) Termination of Agreement. This Agreement may be terminated as follows:
(a) Termination on Notice. Either party may terminate this Agreement
by giving written notice to the other at least 60 days prior to any
January 1 ("Anniversary Date").
(b) Nonpayment. If Group fails to make any past due monthly payment within
15 days after notice to Group of the amount payable, then Health Plan may ter-
minate this Agreement by written notice effective immediately upon written no-
tice.
(c) Discontinuance or Partial Discontinuance of Health Plan Operations and
Services. If Health Plan's governing Board determines that Health Plan would be
unable or it would be impractical to continue providing or arranging any or all
benefits and services being provided or arranged pursuant to this Agreement, then Health Plan may terminate this Agreement upon 30 days written notice to
Group, and neither Health Plan, Hospitals, Medical Group, nor any Physician
shall have any further liability or responsibility, except for benefits refer-
red to in Section 9(B)(l)(d), by reason of or pursuant to this Agreement after
the effective date of such termination.
(d) Continued Coverage for Disabled Members. If this Agreement is termi-
nated, any totally disabled Member who became totally disabled after December
31, 1977, and while enrolled as a Member under this Agreement shall, subject to
all limitations and restrictions of this Agreement, including payment of Sup-
plemental Charges, be covered for the disabling condition for (a) 12 months,
or (b) until no longer totally disabled, or (c) until this Agreement is re-
placed by another group health benefits arrangement providing benefits similar
to those provided hereunder (if such other arrangement is without limitation
as to the disabling condition), whichever occurs first. A person is totally
disabled if he or she (a) has any medically determinable physical or mental im-
pairment that (i) can be expected to result in death, or (ii) has lasted or can
be expected to last for a continuous period of not less than 12 months, and
(iii) renders the individual unable to engage in any substantial gainful acti-
Page 11 Group 4329-00
vity, or (b) is (i) age 55 or older, and (ii) unable, by reason of legal blind-
ness, to engage in substantial gainful activity requiring skills or abilities
comparable to those of any gainful activity in which he or she previously en-
gaged with some regularity over a substantial period of time.
(2) Termination of Specific Members.
(a) Termination for Cause. If Hospitals or Medical Group, after reasonable
efforts to establish and maintain a satisfactory hospital-patient or physician-
patient relationship with any Member, are unable to do so, then the rights of
the Member and all other Members of the Family Unit may be terminated on not
less than 15 days written notice to Subscriber.
(b) Nonpayment. If a Member fails to pay any amount owed by the Member to
Health Plan, Hospitals or Medical Group within 15 days after notice to the Fa-
mily Unit Subscriber of the amount due, then Health Plan may terminate the
rights of the Member and all other Members of the Family Unit effective immedi-
ately upon written notice and their rights may be reinstated only by payment of
the amounts due and by renewed application and re-enrollment in accord with
Section 2-B(2).
(c) Furnishing Incorrect or Incomplete Information. Members warrant that all
information contained in applications, questionnaires, forms or statements sub-
mitted to Health Plan incident to enrollment under this Agreement or the admi-
nistration hereof is true, correct and complete. Members agree to advise Health
Plan of any change in family or Medicare coverage status that affects eligibil-
ity for membership. If a Member knowingly furnishes incorrect or incomplete in-
formation or subsequently fails to inform Health Plan of changes of eligibility
status of dependents, then the rights of the Member and all other Members of
the Family Unit may be terminated effective immediately upon written notice.
(d) Misuse of Identification Card. If any Member permits the use of his or
her or any other Member's Health Plan identification card by any other person,
or uses another person's card, the card may be retained by Health Plan, and all
rights of the Member and all other Members of the Family Unit may be terminated
effective immediately upon written notice.
(3) Return of Prorata Portion of Monthly Payment in Certain Cases. If the
rights of a Member hereunder are terminated under Section 9(B)(2), prepayments re-
ceived on account of the terminated Member or Members applicable to periods after
the effective date of termination, plus amounts due on claims, if any, less any
amounts due to Health Plan, Hospitals or Medical Group, are refunded within thirty
days and neither Health Plan, Hospitals, Medical Group nor any Physician has any
further liability or responsibility under this Agreement.
(4) Opportunity for Review of Certain Terminations by Commissioner of Corpora-
tions. A Member who alleges that his or her rights hereunder were terminated or
not renewed because of a Member's health status or requirements for health care
services, may request a review of the termination by the Commissioner of Corpora-
tions. Section 1365 (b) of the Knox-Keene Act provides as follows:
“(b) An enrollee or subscriber who alleges that an enrollment or subscrip-
tion has been cancelled or not renewed because of the enrollee's or subscri-
ber's health status or requirement for health care services may request a re-
view by the commissioner. If the commissioner determines that a proper com-
plaint exists under the provisions of this section, the commissioner shall no-
Page 12 Group 4329-00
tify the plan. Within 15 days after receipt of such notice, the plan shall ei-
ther request a hearing or reinstate the enrollee or subscriber. If, after
hearing, the commissioner determines that the cancellation or failure to renew
is contrary to subdivision (a), the commissioner shall order the plan to rein-
state the enrollee or subscriber. A reinstatement pursuant to this subdivision
shall be retroactive to the time of cancellation or failure to renew and the
plan shall be liable for the expenses incurred by the subscriber or enrollee
for covered health care services from the date of cancellation or nonrenewal to
and including the date of reinstatement."
C. Amendment
Health Plan may amend this Service Agreement with respect to any matter, including
rates, effective as of any Anniversary Date by mailing a postage prepaid notice of
the amendments to Group at its address of record with Health Plan at least 60 days
before the Anniversary Date. All amendments are deemed accepted by Group unless Group
gives Health Plan written notice of non-acceptance at least 30 days before the Anni-
versary Date, in which event this Service Agreement and all rights to services and
other benefits terminate on the Anniversary Date.
10. MISCELLANEOUS PROVISIONS
A. Acceptance of Agreement. Group may accept this Agreement either by execution
of the acceptance provided on the last page of this Service Agreement or by making
payment to Health Plan pursuant to Section 4-A hereof, and such acceptance renders
all terms and provisions hereof binding on Health Plan and Group.
B. Agreement Binding on Members. By this Agreement, Group makes Health Plan cov-
erage available to persons who are eligible. However, this Agreement is subject to
amendment, modification or termination in accord with any provision hereof or by mu-
tual agreement between Health Plan and Group without the consent or concurrence of
Members. By electing medical and hospital coverage pursuant to this Agreement, or ac-
cepting benefits hereunder, all Members legally capable of contracting, and the legal representatives of all Members incapable of contracting, agree to all terms, condi-
tions and provisions hereof.
C. Applications, Statements, and Questionnaires. Members or applicants for mem-
bership shall complete and submit to Health Plan such applications, medical review
questionnaires, or other forms or statements as Health Plan may reasonably request.
D. Identification Cards. Cards issued by Health Plan to Members pursuant to this
Agreement are for identification only. Possession of a Health Plan identification
card confers no rights to services or other benefits under this Agreement. To be en-
titled to such services or benefits the holder of the card must, in fact, be a Member
on whose behalf all applicable charges under this Agreement have been paid. Any per-
son receiving services or other benefits to which he or she is not then entitled pur-
suant to the provisions of this Agreement is chargeable therefor at Non-Member Rates.
E. Right to Examine Records. Health Plan at reasonable times may examine Group's
pertinent records, with respect to eligibility and monthly payments under this Agree-
ment.
F. Notice of Certain Events. Health Plan shall give Group written notice within a
reasonable time of any termination or breach of contract by, or inability to perform
of, Hospitals or Medical Group or any other person with whom Health Plan has a con-
tract to provide services and benefits hereunder, if Group may be materially and ad-
versely affected thereby.
Page 13 Group 4329-00
In the event that the contract between Health Plan and Hospitals, Medical Group or
any other contracting provider is terminated while a Member is under the care of such
provider, Health Plan will retain financial responsibility for such care, in excess
of any applicable supplemental charges. Such responsibility shall continue until the
services being rendered are completed, or until Health Plan makes provision for the
assumption of such services by another provider and so notifies subscriber, whichever
occurs first.
G. Governing Law. Health Plan is subject to the requirements of Chapter 2.2 of
Division 2 of the California Health and Safety Code and of Subchapter 5.5 of Chapter
3 of Title 10 of the California Administrative Code, and any provision required to be
in this Service Agreement by either of the above shall bind Health Plan whether or
not set forth herein.
H. Administration of Agreement. Health Plan may adopt reasonable policies, pro-
cedures, rules and interpretations to promote orderly and efficient administration of
this Agreement.
I. Member Information. Group shall inform Subscribers (1) of the periodic charges
applicable to their coverage; (2) of conditions of eligibility regarding Subscribers
and Family Dependents; and (3) when coverage becomes effective and terminates.
J. Notices. Any notice under this Agreement may be given by United States mail,
postage prepaid, addressed as follows:
If To Health Plan:
Health Plan Manager
Kaiser Foundation Health Plan, Inc.
4747 Sunset Boulevard
Los Angeles, California 90027
If To A Member:
To the latest address provided for the Member on enrollment or change of ad- dress forms actually delivered to Health Plan.
If to Group:
To the address indicated on the last page of this Agreement.
A person designated as Group Representative on the last page of this Agreement or
otherwise designated by Group by notice to Health Plan, shall disseminate notice to
Subscribers by the next regular communication to them, but in no event later than 30
days after receipt thereof, of all matters (of which Group Representative receives
notice from Health Plan) to which a reasonable person would attach importance in de-
termining the action to be taken upon the matter.
11. BENEFIT SCHEDULE
Subject to all terms, conditions, limitations and exclusions herein, Members are
entitled to the Medical and Hospital Services and other benefits set forth in this
Section, upon payment of specified Supplemental Charges or Non-Member rates. These
services and benefits are available only if and to the extent that they are provided,
prescribed or directed by a Physician, and unless otherwise specifically provided,
received at a Hospital or Medical Office.
Page 14 Group 4329-00
Benefits hereunder include and are not in addition to Medicare Benefits.
A. MEDICAL CARE IN HOSPITAL, OFFICE AND SKILLED NURSING FACILITY
Except for Medical Services specifically described in other parts of this Section
11, Medical Services are provided as follows.
(1) Care While Hospitalized. During prescribed hospitalization specified in
Section 11-B, Medical Services, including surgical procedures, anesthesia and con-
sultation with and treatment by specialists, are provided without charge.
(2) Care in Medical Offices or Emergency Departments.
(a) Diagnosis and Treatment. Medical Services, including surgical pro-
cedures, eye examinations for corrective lenses, ear examinations to determine
the need for hearing correction, and consultation with and treatment by
specialists, are provided without charge.
(b) Preventive Services. Medical Services for health maintenance, including
physical checkups, are provided without charge.
Exclusion. Physical examinations required for obtaining or continuing em-
ployment, insurance or governmental licensing are not covered.
(3) Care in Skilled Nursing Facility. Medical Services, to the extent practica-
ble within the limitations of the equipment and staff of the Skilled Nursing Faci-
lity, are provided without charge while the Member is admitted to the Facility as
a registered bed patient.
B. HOSPITAL CARE
When prescribed, the following Hospital Services are provided without charge: room
and board; general nursing care; services and supplies; use of operating room; pri-
vate room; intensive care room and related hospital services; special diet; special
duty nursing; medications as specified in Section 11-F, and medical supplies.
Diagnostic tests and procedures are provided in accord with Section 11-D, and the-
rapeutic procedures are provided in accord with Section 11-E.
Blood used in blood transfusions is provided without charge, if blood is replaced
at a blood bank designated by Medical Group in accord with the blood bank's require-
ments. Health Plan may charge Non-Member Rates for blood which is not replaced; ex-
cept (i) no charge is made for blood covered under Medicare, and (ii) a Member is not
charged for blood if (a) any Member of the Family Unit donated blood within the pre-
ceding 12 months, or (b) no Member of the Family Unit meets the medical criteria for
blood doners.
C. HOME VISITS
Necessary home visits by Physicians to supervise services provided under Section
11-L, and by visiting nurses when prescribed by a Physician, are provided within the
Service Area without charge.
0. DIAGNOSTIC TESTS AND PROCEDURES
Page 15 Group 4329-00
When prescribed, the following diagnostic tests and procedures are provided with-
out charge: diagnostic laboratory tests including cytology examinations and venereal
disease tests, diagnostic X-rays, diagnostic nuclear medicine procedures including
radioisotopes used therewith, sonograms, pulmonary function studies, cardiovascular
studies, audiologic function studies, electroencephalograms, electrocardiograms,
electromyograms and other diagnostic studies using electrostimulation or electronic
equipment or producing recordings, tracings, images or similar readings.
E. THERAPEUTIC PROCEDURES
(1) Prescribed physical therapy, occupational therapy, and inhalation therapy
are provided without charge while receiving Hospital Services under Section 11-B,
Extended Care Services under Section 11-K, and Home Health Services under Section
11-L and when received in Medical Offices. Physical therapy and occupational the-
rapy treatment are limited to treatment for conditions (including acute phases of
chronic conditions) which in the judgment of the Attending Physician are subject
to significant improvement through relatively short-term therapy.
(2) Prescribed radiotherapy and therapeutic nuclear medicine procedures includ-
ing radioisotopes used therewith are provided without charge while receiving Hos-
pital Services under Section 11-B and in Medical Offices. Radiation therapy is
provided by the specialized Regional Radiation Therapy Service at the Los Angeles
Medical Center.
(3) Prescribed orthoptic treatments and dermatological black light treatments
are provided without charge in Medical Offices.
(4) Speech Therapy. During coverage under this or any other Health Plan Service
Agreement (including renewals), prescribed speech therapy is provided on a group
or individual basis for the first thirty visits per condition at a $5.00 charge
per visit while receiving Hospital Services under Section 11-B, Extended Care
Services under Section 11-K or outpatient services in Medical Offices, and without
charge while receiving Home Health Service under Section 11-L. Additional visits
are provided at Non-Member Rates except that further treatment of articulation
disorders due to congenital abnormalities of the palate are provided upon payment
of a $5.00 charge per visit. Speech therapy covered in whole or in part by Medi- care is provided without charge. The number of visits provided hereunder is re-
duced by each broken appointment unless Medical Group's procedures for cancelling
appointments are complied with.
F. PRESCRIBED MEDICATIONS, IMMUNIZATIONS, AND DRESSINGS AND CASTS
(1) Prescribed Medications and Items.
(a) Administered to Members.
(i) While Hospitalized. During hospitalization specified in Section 11-B,
all prescribed medications, injectables, radioactive materials used for
therapeutic purposes, and allergy test materials and allergy treatment ma-
terials are provided without charge.
(ii) In Medical Offices, Emergency Departments and on Home Visits. All
prescribed injectable medications (including immune serums) which were
developed and in general use for specific diseases on April 1 of the year
immediately preceding the year in which this Agreement was entered into or
last renewed; chemotherapy medications generally available in Southern Cali-
Page 16 Group 4329-00
fornia when prescribed for the treatment of cancer; and allergy test and
treatment materials administered in Medical Offices, at Hospital emergency
rooms and on home visits are provided without charge.
Prescribed injectable medications (including immune serums) which were
not developed or in general use for specific diseases as of April 1 of the
preceding year administered in Medical Offices, at Hospital emergency
departments and on home visits are provided without charge to Medicare
members and upon payment of a reasonable charge to other members.
Intravenous fluids and medications, additives and nutrients administered
therewith are provided without charge when administered and are furnished
without charge at pharmacies in Hospitals and designated Medical Offices
when prescribed by a Physician for self-administration.
(b) Purchased by Members.
Members are provided up to a 100 day supply of covered medications and ac-
cessories at a charge of $2.50 for each prescription (except that if the regu-
lar charge is less than $2.50, members pay the regular charge), and any excess
over a 100 day supply at a reasonable charge. Each prescription refill is pro-
vided on the same basis as the original prescription. If requested and legally
permissible, refills are mailed upon prepayment of applicable charges.
The following medications and accessories are covered only when prescribed
by Physicians and obtained at pharmacies in Hospitals and designated Medical
Offices. The locations and scheduled hours of operation of these pharmacies are
provided to Group on request.
(i) Drugs for which a prescription is required by law.
(ii) Additional drugs and accessories.
(A) Insulin
(B) The following diabetic supplies:
(a) Insulin syringes and needles
(b) Glucose test tablets
(c) Glucose test tape
(d) Acetone test tablets
(C) Compounded dermatological preparations which must be prepared by a
pharmacist in accord with a Physician's prescription.
(D) Antacids
(E) For Members with enterostomies and urinary diversions, the fol-
lowing ostomy supplies and equipment: appliances, adhesives, skin bar-
riers, skin care items, belts and clamps, and internal and appliance deo-
dorants.
(2) Immunizations. Immunizations (including immune serums, human origin) avail-
Page 17 Group 4329-00
able in Southern California which were developed and in general use for specific '
diseases on April 1 of the year immediately preceding the year in which this
Agreement became effective or was last renewed are provided without charge. Unex-
pected mass immunizations are provided at a charge approximating the lesser of
Health Plan's cost for the immunizing material or 50 percent of Non-Member Rates.
(3) Dressings and Casts. During hospitalization specified in Section llB, and
at Medical Offices, Hospital emergency departments, and on home visits, prescribed
dressings and casts are provided without charge.
(4) Amino Acid Modified Products. Amino acid modified products used in the
treatment of inborn errors of amino acid metabolism when prescribed by a Physician
for inborn aminoacidopathy are provided without charge during the child's hospi-
talization, and are furnished without charge at pharmacies in Hospitals and desig-
nated Medical Offices for self-administered use.
G. AMBULANCE SERVICE
Necessary ambulance service is provided without charge within the Service Area if
ordered or approved by a Physician.
H. OBSTETRICAL CARE, FAMILY PLANNING AND INFERTILITY STUDIES
(1) Obstetrical Care. Full obstetrical care, after pregnancy is confirmed, in-
cluding all applicable benefits set forth below, is provided without charge.
Obstetrical care includes the following services for the mother before and dur-
ing confinement, and during the post-partum period: Hospital Services, including
use of delivery room; Medical Services, including operations such as Caesarean
sections; special procedures such as those for prenatal diagnosis of genetic
disorders of the fetus; anesthesia; medications, including injectables; X-ray and
laboratory services. Outpatient medications, including injectables, are provided
in accord with Section 11-F. Care for the newborn child is provided without charge
during the mother's confinement. Thereafter, coverage for the newborn continues
only if the parent applies for enrollment of the newborn (and pays prepayment
fees, if any) within 30 days of birth.
Interrupted Pregnancy. Care for interrupted pregnancy (spontaneous or induced
termination of pregnancy) is provided without charge.
(2) Family Planning and Infertility Studies. Family planning counseling, in-
cluding pre-abortion and post-abortion counseling and information on birth con-
trol, is provided upon payment of the registration charge, if any, specified in
Section 11-A(2). Contraceptive devices are provided at reasonable charges. Contra-
Contraceptive drugs are provided in accord with Section 11-F.
All Medical Services for diagnosis and treatment of involuntary infertility are
provided upon payment of the registration charge, if any, specified in Section
11-A(2), x-ray and laboratory procedures in conjunction with family planning and infertility studies are provided in accord with Section 11-D, and medications are
provided in accord with Section 11-F.
I. RECONSTRUCTIVE SURGERY AND PROSTHETIC DEVICES FOLLOWING MASTECTOMY
If all or part of a breast is sugically removed for medically necessary reasons on
or after July 1, 1980, reconstructive surgery and prosthetic devices incident to the
mastectomy are provided subject to the payment of applicable Supplemental Charges, if
Page 18 Group 4329-00
any. A Physician determines whether reconstructive surgery is medically feasible and
the extent to which further reconstructive surgery is necessary.
Medical Group will designate the source from which external prostheses are to be
obtained. Replacement will be made when prostheses are no longer functional. Custom
made prostheses will be provided when necessary.
J. HEMODIALYSIS AND KIDNEY TRANSPLANTS
All necessary services for hemodialysis for chronic renal disease and for kidney
transplants are provided without charge, subject to the limitations in this Section
11-J.
Care for acute renal conditions, including hemodialysis, is provided as for any
other condition. Whether a Member is suffering from an acute or chronic conditon is
determined by Medical Group. Covered services for chronic conditions include equip-
ment, training and medical supplies required for home dialysis, and the directly re-
lated reasonable medical and hospital expenses of a donor or prospective donor.
Covered services are provided (1) at the Kaiser Foundation Hemodialysis Center in Los
Angeles ("Hemodialysis Center") if the Attending Physician and the Medical Group
Regional Renal Conference ("Renal Conference") are of the opinion that the Member
meets the criteria of the Hemodialysis Center, or (2) upon written referral by
the Renal Conference at hemodialysis facilities or at community transplant facilities
within the Service Area that are approved by Medical Group. Referrals are subject
to all provisions of Section 11-Q of this Schedule, and are made only if the Renal
Conference determines that a service referred to in this Section represents the
preferred method of treatment. If, after the start of treatment at the Hemodi- alysis Center or after referral to another facility, either the Renal Conference
or the medical staff of the hemodialysis facility determines that the Member does
not satisfy its criteria for the service involved, Health Plan's obligation is lim-
ited to paying for covered services provided prior to such determination, plus
covered services subsequently provided that are covered in whole or in part under
Medicare. Neither Health Plan, Medical Group nor Physicians undertakes to furnish a
kidney donor nor to assure the'availability or capacity of referral facilities ap-
proved by Medical Group.
K. EXTENDED CARE SERVICES
During each calendar year, up to 100 days of prescribed Extended Care Services are
provided or arranged at approved Skilled Nursing Facilities, except that the number
of days of care is reduced and offset by all days of Extended Care Services covered
in whole or in part by Medicare that the Member receives which were not prescribed or
directed by a Physician or which were received from facilities not approved in
writing by Medical Group, and by the number of days of Extended Care Services that
the member received under any other Health Plan Service Agreement during the same
calendar year.
Physical therapy, occupational therapy, inhalation therapy and speech therapy are
provided in accord with Section 11-E. Other covered Extended Care Services are pro-
vided without charge.
L. HOME HEALTH SERVICES
Benefits under this Section 11-L are provided within the Service Area and are
available only if the Attending Physician determines that it is feasible to maintain
effective supervision and control of the Member's care.
Page 19 Group 4329-00
(1) Members Not Entitled to Medicare Benefits. Home health services are limited
to services of registered nurses and home health aides on a part-time or intermit-
tent basis, and services of a medical social worker as prescribed or directed by
the Attending Physician, and are provided without charge. Inhalation therapy, phy-
sical therapy, occupational therapy and speech therapy are provided in accord with
Section 11-E.
(2) Members Entitled to Medicare Benefits. All home health services (as defined
in Medicare) that are covered in whole or in part under Medicare and that are
prescribed or directed by the Attending Physician, are provided without charge.
Durable Equipment for Medicare Members. Durable medical equipment used in a
patient's home (including an institution used as his or her home) covered in whole
or in part under Medicare is provided without charge to Medicare Members for the
same period that partial or full reimbursement therefor is available under Medi-
care.
M. TREATMENT FOR ALCOHOL AND DRUG DEPENDENCY
Subject to the exclusions set forth in this Section M, and to the Supplemental
Charges, if any, set forth in Section 11, the care described herein is provided for
alcohol and/or drug dependency:
(1) Inpatient Care for Withdrawal. Prescribed Hospital Services for the medical
management of the signs and symptoms attendant to the withdrawal process.
(2) Outpatient Services. Diagnosis and prescribed treatment and counseling and
services for the medical management of the signs and symptoms attendant to the
withdrawal process are provided in Medical Offices.
(3) Exclusions. The following services are not provided:
(a) Home visits.
(b) Methadone maintenance.
(c) Continuation in a course of therapy for patients who are
disruptive or physically abusive.
N. MENTAL HEALTH SERVICES
Mental Health services specified in this Section 11-N are limited to acute psychi-
atric conditions which in the judgment of the Attending Physician are subject to sig-
nificant improvement through relatively short-term therapy.
Calendar year maximums include the number of outpatient visits, days of inpatient mental health services and sessions of day care or night care services received dur-
ing the same calendar year under any other Health Plan Service Agreement.
(1) Outpatient Mental Health Services. All services of Physicians and mental
health professionals, as performed, prescribed or directed by the Attending Physi-
cian, including diagnostic evaluation and psychiatric treatment, including indivi-
dual therapy and group therapy, are provided at Medical Offices without charge to
Medicare Members for the first 20 visits each calendar year and at a $5.00 charge
thereafter, and to all other Members upon payment of a $10.00 registration charge
Page 20 Group 4329-00
1
per visit for the first twenty visits during each calendar year, and at Non-Member
Rates thereafter. A charge is made for each broken appointment unless Medical
Group's procedures for cancelling appointments are complied with.
(2) Day Care and Night Care Services. If, in the professional judgment of the
Attending Physician, a Member would benefit from day care or night care mental
health services, up to 28 sessions of prescribed care and additional sessions of
day care or night care paid for in whole or in part by Medicare, are provided
without charge each calendar year at facilities designated by Health Plan, and an
additional 62 sessions of care are provided during the calendar year at 25% of
Non-Member Rates, except that this benefit is reduced by two sessions for each day
of hospitalization for psychiatric conditions received by the patient pursuant to
Section 11-N(3) during the calendar year. Each fully prepaid day of hospitaliza-
tion received pursuant to Section 11-N(3) exhausts two fully prepaid sessions of
day or night care under this Section 11-N(2). Day care and night care include all
services of Physicians and mental health professionals and the following services
and supplies prescribed by a Physician: psychiatric nursing care, group therapy,
occupational therapy, drug therapy, shock therapy, medications and supplies.
(3) Inpatient Mental Health Services. If, in the professional judgment of the
Attending Physician, a Member requires short-term inpatient mental health ser-
vices, up to 14 days of Hospital Services, and additional days of Hospital Ser-
vices paid for in whole or in part under Medicare, are provided without charge
each calendar year at facilities designated by Health Plan, and an additional 31
says of care are provided each calendar year at 25% of Non-Member Rates, except
that this benefit is reduced by one day for each two sessions of day care or night
care received by the patient pursuant to Section 11-N(2) during the calendar year.
Each fully prepaid session of day care or night care received pursuant to Section
11-N(2) exhausts one-half fully prepaid day of hospitalization under this Section
11-N(3).
Hospital Services include all services of Physicians and mental health profes-
sionals and the following services as prescribed by a Physician: Board and room,
psychiatric nursing care, group therapy, shock therapy, drug therapy, medications
and supplies while the patient is confined as a registered bed patient in a Hospi-
tal.
(4) Psychological Testing. If, in the professional judgment of the Attending
Physician, a Member requires psychological testing, prescribed tests are provided
without charge. Court-ordered testing, and testing for ability, aptitude, intelli-
gence or interest, are not covered.
(5) Exclusions and Limitations. The following services are not covered:
(a) Mental health services for the following conditions after diagnosis if,
in the professional judgment of the Attending Physician, they would not be
responsive to therapeutic management:
(i) Chronic psychosis, except that acute episodes due to a chronic psy-
chotic condition are covered if the patient has been cooperative and has re-
sponded favorably to an ongoing treatment plan.
(ii) Care for organic psychosis.
(iii) Intractable personality disorders.
Page 21 Group 4329-00
(b) Mental health services for mental retardation after diagnosis.
(c) Psychiatric therapy on court order or as a condition of parole or proba-
tion.
0. MEDICAL SOCIAL SERVICES
Medical social services are provided without charge at Hospitals and Medical Of-
fices. Medical social services include hospital discharge planning, social services
counseling and referrals for services not covered under this Agreement.
P. HEALTH EDUCATION
Health education services for specific conditions, such as diabetic counseling,
post-coronary counseling and nutritional counseling, are provided upon payment of the
registration charge, if any, specified in Section 11-A(2).
When available, general health education services not addressed to a specific con-
dition, such as weight control classes and anti-smoking classes, are provided upon
payment of a reasonable charge.
Education in the appropriate use of Health Plan's services, and printed health ed-
ucation materials published by Health Plan which contain instructions on achieving
and maintaining physical and mental health and on preventing illness and injury, are
provided without charge. Recorded health education programs are provided at cost.
Q. PAYMENT IN LIEU OF SERVICE BENEFITS
If, in the professional judgment of Medical Group, a Member requires Medical or
Hospital Services covered by this Agreement which require skills not available within
Medical Group or facilities not available in Hospitals and Medical Offices, and Medi-
cal Group determines that it would be in the best interests of the Member to obtain
care from another source in the Service Area, then, upon written referral by Medical
Group, payment in lieu of service benefits hereunder, is made for prescribed services
within the coverage of this Agreement.
R. SERVICE BENEFITS IN OTHER HEALTH PLAN REGIONS
If a Member is temporarily in another Health Plan Region the Member may obtain
hospital and medical services from physicians and hospitals that have a contractual
arrangement with Health Plan or a related organization.
Health Plan, either directly or through related organizations, conducts direct-
service medical and hospital care programs in the San Francisco Bay and Sacramento
areas in California, in the Cleveland area in Ohio, in the Denver area in Colorado,
in Portland, Oregon and vicinity, in Washington D.C. and vicinity, on the Islands
of Oahu and Maui, Hawaii, and in the greater Dallas-Fort Worth area in Texas. A
description of such other Regions and a list of their contracting hospitals and medi-
cal office facilities may be obtained at the Health Plan office.
Services and Supplemental Charges are those prevailing in each Region for the
Health Plan coverage generally provided there, that is most nearly compearable to the
Member's coverage in the Southern California Region.
S. EMERGENCY SERVICES RECEIVED FROM PROVIDERS NOT CONTRACTING WITH
HEALTH PLAN
Page 22 Group 4329-00
- . 1
(1) Emergency Services. This Section 11-S defines and limits Health Plan's ob-
ligation to pay for Emergency Services that a Member receives from a physician,
hospital or other provider not contracting with Health Plan. The term llEmergency
Services" means medically necessary health services that are: (a) generally avail-
able and customarily provided in Southern California, (b) covered under this Ser-
vice Agreement, and (c) immediately required because of unforeseen illness or in-
jury.
(2) Reductions for Other Benefits and Copayments. The amount otherwise payable
is reduced by Other Benefits and Copayments.
(a) Other Benefits means all amounts paid or payable, or which in the ab-
sence of this Agreement would be payable, for the Emergency Services in ques-
tion, under any insurance policy or contract, or any other contract, or any governmental program except Medicaid. If the member notifies Health Plan that
Other Benefits equal in amount to the charges for Emergency Services have not
been paid within a reasonable period of time, Health Plan will pay for Emergen-
cy Services in accord with this Section 11-S if the Member (1) assigns all Oth-
er Benefits to Health Plan, (2) agrees to cooperate fully with Health Plan in
obtaining Other Benefits, and (3) allows Health Plan to obtain confirmation
from any person regarding Other Benefits. Any person claiming benefits under
this Section shall furnish Health Plan with such information as may be neces-
sary to implement these provisions.
Reimbursement for Emergency Services required because of an act or omission
of a third party is subject to the conditions stated in Section 6-C(1).
(b) Copayments means the sum of (i) the amount of Supplemental Charges that
would be due if Emergency Services were received from Physicians or Hospitals
or at Medical Offices, (ii) the amount charged for Emergency Services which is
in excess of reasonable charges for such services, and (iii) if Emergency Ser-
vices are obtained within the Service Area or within 30 air miles of the home
of a Member who resides outside the Service Area, 50% of the first $100 after
Other Benefits and the amounts under (b) (i) and (b) (ii) have been deducted.
(3) Payment. Subject to the foregoing limitations:
(a) Within the Service Area. Health Plan will pay for Emergency Services re-
ceived within the Service Area from providers not contracting with Health Plan
if:
(i) Receipt of the Emergency Services from Physicians or Hospitals or at
Medical Offices would have entailed a delay resulting in death, serious di-
sability or significant jeopardy to the Member's condition; or
(ii) Receipt of Emergency Services from a physician, hospital or other
provider not contracting with Health Plan was beyond the control of the
Member and the Member's immediate family.
(b) Outside the Service Area. Health Plan will pay for Emergency Services
received outside the Service Area from providers not contracting with Health
Plan if:
(i) A Member who resides in the Service Area becomes ill or is injured
while outside the Service Area. Covered benefits include Emergency Services
Page 23 Group 4329-00
for unexpected premature delivery, but not for normal delivery (after 8
months gestation), unless Health Plan determines that the Member was outside
the Service Area because of circumstances beyond her control or because of extreme personal emergency.
(ii) A Member who resides outside the Service area:
(A) becomes ill or is injured while more than 30 air miles from the
Member's home and receives Emergency Services more than 30 air miles from
the Member's home; covered benefits include Emergency Services for unex-
pected premature delivery, but not for normal delivery (after 8 months
gestation) unless Health Plan determines that the Member was more than 30
air miles from her home because of circumstances beyond her control or
because of extreme personal emergency, or
(B) receives Emergency Services, other than for delivery, less than 30
miles from the Members's home if:
(a) Emergency Services were needed to prevent death, serious disa-
bility or significant jeopardy to the Member's condition and it would
have been unreasonable to expect the Member to obtain such services
from Physicians or Hospitals or at Medical Offices; or
(b) Receipt of Emergency Services from a physician, hospital, or
other provider not contracting with Health Plan was beyond the control
of the Member and the Member's immediate family.
(4) Continuing or Follow-up Treatment. Continuing or follow-up treatment from
providers not contracting with Health Plan is not covered under this Section 11-S,
except that Health Plan at its option may continue inpatient care coverage in lieu
of transferring the Member. Payment is limited to Emergency Services required be-
fore the Member can, without medically harmful consequences, be transported to a
Hospital or Medical Office in the Service Area, or, if the Member is near another
Health Plan Region, to a contracting hospital or medical office in the other
Health Plan Region. If the member obtains prior approval from Health Plan or a
Physician in the Service Area or in the nearest other Health Plan Region, covered
benefits include necessary ambulance service or other special transportation ar-
rangements when medically required to transport the Member to a Hospital or Med-
ical Office in the Service Area or to a contracting hospital or medical office in
the nearest other Health Plan Region for continuing or follow-up treatment.
(5) Notification and Claims. Any Member receiving hospital Emergency Services
within the scope of this Section 11-S must notify the Health Plan office within 48
hours after care is commenced. No claim pursuant to this Section 11-S is allowed
unless a complete application for payment, on forms provided by Health Plan, is
filed with the Health Plan office within 60 days after the first Emergency Service
for which payment is requested. The 48 hour and 60 day notice requirements are not
applied if notice is given as soon as reasonably possible.
(6) Releases and Assignments. Each Member claiming reimbursement hereunder
shall complete and submit to Health Plan such consents, releases, assignments and
other documents as Health Plan may reasonably request for the purpose of determin-
ing the applicability of and implementing this Section 11-S.
(7) Right of Recovery. Any overpayment hereunder may be recovered by Health
Plan from any person to whom the payment was made, or from any insurance company
Page 24 Group 4329-00
- . -I
or organization which is obligated to pay for the Emergency Services.
Page 25 Group 4329-00
. 7 ’ . .
Executed at Los Angeles, California to take effect as of January 01, 1983
Date: January 18, 1983
KAISER FOUNDATION HEALTH PLAN, INC.
A California nonprofit corporation
BY
Authorized Representative
Southern California Region
Accepted Februarx.?<..., lg.!.?.. . . . . . . . . .
Group: 4329-00
CITY OF CARLSBAD
1200 ELM AVENUE
CARLSBAD, CA
92008
Attn: JEROME N. PIETI, PERS DIRECTOR
BY Grodp Representative
BY Group Representative
Page 27 Group 4329-00
Health Plan Copy
-
1200 ELM AVEpiUE
CARLSBAD, CALIFORN!A 92008
Office of the City Clerk
February 4, 1983
Kaiser Permanente Kaiser Foundation Health Plan, Inc. 4747 Sunset Boulevard Los Angeles, CA 90027
Attention: Michael H. Katcher
Per your request in your letter of January 25, 1983, enclosed for your records is a copy of the signature page-of the Group Medical and Hospi- tal Service Agreement, which has been signed by Mayor Casler on behalf of the City of Carlsbad.
TELEPHONE:
(714) 438-5535
Enc.
KAISER FkLvv4NENTE
Kaiser Foundation Health Plan, inc.
Southern California Region
January 25, 1983
I: * 1, /.: ** < /,- / i i :, I j, ‘l,.. *‘!. . ’ ,:i ;’ ’ , ,x .’
,>.’ . . -kg r’ ., I, I; &J? ( ‘T.? j.. ‘. I> : i t. -.
i ; : / ‘; ‘. ‘I , *.
i.
‘. I” . .’ ,‘.’
. . ,L‘ _/‘.‘_.
City of Carlsbad 1200 Elm Avenue Carlsbad, CA 92008
Attention: Jerome N. Pieti, Personnel Director ,*'
Enclosed is a Group Medical and Hospital Service Agreement between City of Carlsbad and Kaiser Foundation Health Plan.
Following your review, we ask that you sign the second copy of the signature page and return just the signature page for our records.
If you have any questions or require additional information, please contact Mr. James Berry at our San Diego office (714) 563-2300.
Michael H. Katcher
Vice President &
Health Plan Manager
MHK/GE:lc Enclosures
cc: J. Berry
Group No. 4329-00
4747 Sunset Boulevard l Los Angeles l California 90027
1200 ELM AVENUE
CARLSBAD, CALIFORNIA 92008
Office of fhe City Clerk
TELEPHONE:
(714) 438-5535
March 1, 1983
Michael Katcher Vice President Kaiser Permanente Kaiser Foundation Health Plan, Inc. 4747 Sunset Boulevard Los Angeles, CA 90027
Re: Group No. 4329-00 - Amendment- City of Carlsbad
Enclosed per your letter of February 18, 1983, is an executed copy of the amendment changing the effective date of the contract for the above referenced group.
If you have any questions regarding this matter, please do not hesitate to contact this office.
deputy City Clerk
Enc.
KAISER PEklJlANENTE
Kaiser Foundation Health Plan, Inc.
Southern California Region
February 18, 1983
City of Car&bad
1200 Elm Avenue
Carlsbad, CA 92008
Attention: Jerome N. Pieti, Personnel Director
This will confirm the change in your groups effective date and
anniversary date from January 1 to February 1. An amendment
covering this change is enclosed, and should be inserted in your
Group Medical and Hospital Service Agreement.
Following your review of the enclosed documents, we ask that one
copy of the amendment executed on behalf of your group be returned
for our records.
If you have any questions or require additional information,
please contact Mr. James Berry at our San Diego office (619) 280-
2300.
Michael H. Katcher
Vice President &
Health Plan Manager
MHK/GE:lc
Enclosures
cc: J. Berry
Group No. 4329-00
4747 Sunset Boulevard l Los Angeles l California 90027
KAISER FOUNDATION HEALTH PLAN, INC.
A Nonprofit Corporation Southern California Region
GROUP MEDICAL AND HOSPITAL SERVICE AGREEMENT
AMENDMENT
The Group Medical and Hospital Service Agreement between Kaiser Foundation Health’ Plan, Inc. and the
Group named below is amended as set forth below and in the attachment.
Section 9A is hereby amended as follows:
"This Agreement continues in effect from the effective date stated on the last
page of this Agreement to February 1, 1984 and from year to year thereafter, subject
to Health Plan or Group terminating this Agreement pursuant to Section 9B."
The first line of the last page is amended to read:
"Executed at Los Angeles, California to take effect as of February 1, 1983."
MONTHLY PAYMENTS:
The monthly payments per Family Unit required under this Agreement are:
Basic Rate Structure
Subscriber only
Subscriber with one Family Dependent
Subscriber with two or more Family Dependents
Variables to Basic Rate Structure
For each Member age 65 or older who is (a) not entitled to benefits under
Part B of Medicate, or (b) entitled to benefits under Part B of Medicare
but has not assigned such benefits to Health Plan
For each Member (up to 2 per Family Unit) entitled to benefits under
both Parts A and B of Medicare who has assigned Part B benefits to
Health Plan:
Subscriber
Subscriber’s spouse or child
Total
S ...............
$ ...............
S ...............
Add s . . . . . . . . . . . . . . .
Subtract S ...............
Subtract f ...............
Accepted ..................................... , 19.. .......
Group:
CITY OF CARLSBAD
By‘. /fji, d L
Groyp Representative
By
Group Representative
Group No. 4329-00
Executed at Los Angeles, California to take
effect as of February 1, 1983.
Date . . . . . . . . ..Fehruar$..l8.................. 19.83..
KAISER FOUNDATION HEALTH PLAN, INC. A California nonprofit corporation
Authorized Representative
Southern California Region
(Bl Amend)