WASHINGTON, D.C. HEALTHLINK SMALL BUSINESS PLAN SUMMARIES · 2 D.C. HEALTHLINK PLATINUM PLAN...

A better choice for good health.

WASHINGTON, D.C. HEALTHLINK SMALL BUSINESS

PLAN SUMMARIES2015

TABLE OF CONTENTS

Washington D.C. Health PlansD.C. Healthlink Platinum plan summaries ...............................................................................................................2

D.C. Healthlink Gold plan summaries .....................................................................................................................4

D.C. Healthlink Silver plan summaries ................................................................................................................... 8

D.C. Healthlink Bronze plan summaries .............................................................................................................. 10

Definitions, Exclusions, and Limitations ...............................................................................................................12

2

D.C. HEALTHLINK PLATINUM PLAN SUMMARIESThe following is a limited description of benefits offered by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (KFHP-MAS). Not all services and procedures are covered by your benefits contract. This summary of benefits is for comparison purposes only and does not create rights not given through the benefit plan. These plans are “non-grandfathered health plans” under the Patient Protection and Affordable Care Act. Adult and pediatric dental benefits are underwritten by KFHP-MAS and administered by Dominion Dental Services USA, Inc. (Dominion).

PLAN DETAILSRefer to Definitions, Exclusions, and Limitations at back of booklet for more details and information.

KP DC Platinum $0/$20/Dental/PedDental

KP DC Platinum(ia) $500/$20/Dental/PedDental

Individual plan annual deductible (subscriber only) None $500

Family plan annual deductible (individual/family) None/None $500/$1,000

Member coinsurance (plan pays/member pays),except as otherwise indicated

100%/0% 100%/0%

Individual plan annual out-of-pocket maximum (subscriber only) $1,500 $1,500

Family plan annual out-of-pocket maximum (individual/family) $1,500/$3,000 $1,500/$3,000

Network(iii) Signature or Select Signature or Select

BENEFITS

Outpatient Services

Primary care office visit $20 $20

Specialty care office visit $30 $30

Preventive care/screening/immunization No charge No charge

X-rays and laboratory diagnostic services $30 $20

MRI/CT/PET $150 $50 after deductible

Outpatient facility fee (e.g., ambulatory surgery center) $100 $50 after deductible

Outpatient surgery physician/surgical services No charge No charge after deductible

Mental health/chemical dependency outpatient $20 per visit individual therapy/$10 per visit group therapy $20 per visit individual therapy/$10 per visit group therapy

Maternity Services

Routine pre-natal visits (after confirmation of pregnancy) and postpartum visits

No charge No charge

Inpatient Services

All inpatient hospital services (including mental health/chemical dependency)

$150 per admission $100 per admission after deductible

Prescription Drugs (30-day supply)

Rx—Deductible None None

Rx—Generic drugs $5 $5

Rx—Preferred brand drugs $15 $25

Rx—Non-preferred brand drugs $30 $50

3

D.C. HEALTHLINK PLATINUM PLAN SUMMARIESThe following is a limited description of benefits offered by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (KFHP-MAS). Not all services and procedures are covered by your benefits contract. This summary of benefits is for comparison purposes only and does not create rights not given through the benefit plan. These plans are “non-grandfathered health plans” under the Patient Protection and Affordable Care Act. Adult and pediatric dental benefits are underwritten by KFHP-MAS and administered by Dominion Dental Services USA, Inc. (Dominion).


KP DC Platinum $0/$20/Dental/PedDental

KP DC Platinum(ia) $500/$20/Dental/PedDental

Urgent Care and Emergency Services

Urgent care office visits during regular office hours $20 (PCP)/$30 (specialty) $20 (PCP)/$30 (specialty)

Urgent care centers (after hours urgent care) $30 $30

Emergency room $100 (waived if admitted) $100 after deductible (waived if admitted)

Therapy and Rehabilitation Services

Chiropractic services $30 $30

Pediatric Dental Services

Periodic oral evaluation $10 office visit copay* $10 office visit copay*

Prophylaxis (cleaning) $10 office visit copay* $10 office visit copay*

Topical application of fluoride $10 office visit copay* $10 office visit copay*

Bitewing X-rays $10 office visit copay. No additional cost for 1 to 4 films* $10 office visit copay. No additional cost for 1 to 4 films*

Adult Dental Services ($30 Preventive Plan)

Preventive services $30 copay (applicable fee schedule applies) $30 copay (applicable fee schedule applies)

Diagnostic services Applicable fee schedule applies Applicable fee schedule applies

Pediatric Vision Services

Routine eye exam with Optometrist $20 $20

Frames $0 copay† $0 copay†

Lenses $0 copay† $0 copay†

Contacts $0 copay†† $0 copay††

Adult Vision Services

Routine eye exam with Optometrist $20 $20

Frames 25% discount off retail price 25% discount off retail price

Lenses 25% discount off retail price 25% discount off retail price

Contacts 15% discount off retail price 15% discount off retail price

*Charges may apply if other extensive services are required. For more information and to obtain a copy of applicable fee schedule, please visit www.DominionDental.com/kaiserdentists†One pair per year from a selected group of frames and limited to single vision or bifocal lenses (ST28) in polycarbonate or plastic†† Limited to a 3-month supply from a selected list of contacts; medically necessary contacts—$0 copay, limited to 2 pair per eye per year from a selected list of contacts. All listed services except Adult Vision and Adult Dental Services are subject to the out-of-pocket maximum. Please refer to your Evidence of Coverage (EOC) for the complete list of services that are subject to the out-of-pocket maximum.

4

D.C. HEALTHLINK GOLD PLAN SUMMARIESThe following is a limited description of benefits offered by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (KFHP-MAS). Not all services and procedures are covered by your benefits contract. This summary of benefits is for comparison purposes only and does not create rights not given through the benefit plan. These plans are “non-grandfathered health plans” under the Patient Protection and Affordable Care Act. Adult and pediatric dental benefits are underwritten by KFHP-MAS and administered by Dominion Dental Services USA, Inc. (Dominion).


KP DC Gold$0/$20/Dental/

PedDental

KP DC Gold(ia) $500/$20/Dental/

PedDental

KP DC Gold(ia)

$1,000/$30/ Dental/PedDental

KP DC Gold(ic)

$1,250/0%/Dental/PedDental

Individual plan annual deductible (subscriber only) None $500 $1,000 $1,250

Family plan annual deductible (individual/family) None/None $500/$1,000 $2,000/$2,000 $2,500/$2,500

Member coinsurance (plan pays/member pays), except as otherwise indicated

100%/0% 0% 90%/10% 100%/0%

Individual plan annual out-of-pocket maximum (subscriber only)

$5,000 $3,000 $3,500 $2,500

Family plan annual out-of-pocket maximum (individual/family)

$5,000/$10,000 $3,000/$6,000 $3,500/$7,000 $5,000/$5,000

Network(iii) Signature or Select Signature or Select Signature or Select Signature or Select

BENEFITS

Outpatient Services

Primary care office visit $20 $20 $30 No charge after deductible

Specialty care office visit $40 $40 $40 No charge after deductible

Preventive care/screening/immunization No charge No charge No charge No charge

X-rays and laboratory diagnostic services $40 $40 $30 No charge after deductible

MRI/CT/PET $300 $150 after deductible 10% after deductible No charge after deductible

Outpatient facility fee (e.g., ambulatory surgery center)

$150 $50 after deductible 10% after deductible No charge after deductible

Outpatient surgery physician/surgical services No charge $0 after deductible 10% after deductible No charge after deductible

Mental health/chemical dependency outpatient $20 per visit individual therapy/$10 per visit group therapy

$20 per visit individual therapy/$10 per visit group therapy


No charge after deductible

Maternity Services

Routine pre-natal visits (after confirmation ofpregnancy) and postpartum visits

No charge No charge No charge No charge

Inpatient Services

All inpatient hospital services(including mental health/chemical dependency)

$300 per day, up to 3 days $500 per admission after deductible 10% after deductible No charge after deductible


Rx—Deductible None None None Applies to medical deductible

Rx—Generic drugs $15 $15 $15 $15 after deductible

Rx—Preferred brand drugs $50 $45 $45 $35 after deductible

Rx—Non-preferred brand drugs $100 $60 $60 $50 after deductible

5

D.C. HEALTHLINK GOLD PLAN SUMMARIESThe following is a limited description of benefits offered by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (KFHP-MAS). Not all services and procedures are covered by your benefits contract. This summary of benefits is for comparison purposes only and does not create rights not given through the benefit plan. These plans are “non-grandfathered health plans” under the Patient Protection and Affordable Care Act. Adult and pediatric dental benefits are underwritten by KFHP-MAS and administered by Dominion Dental Services USA, Inc. (Dominion).


KP DC Gold$0/$20/Dental/

PedDental

KP DC Gold(ia) $500/$20/Dental/

PedDental

KP DC Gold(ia)


KP DC Gold(ic)

$1,250/0%/Dental/PedDental


Urgent care office visits during regular office hours $20 (PCP)/$40 (specialty) $20 (PCP)/$40 (specialty) $30 (PCP)/$40 (specialty) No charge after deductible

Urgent care centers (after hours urgent care) $40 $40 $40 No charge after deductible

Emergency room $250 (waived if admitted) $250 (waived if admitted) $150 after deductible (waived if admitted)

$200 after deductible (waived if admitted)


Chiropractic services $40 $40 $40 No charge after deductible


Periodic oral evaluation $10 office visit copay* $10 office visit copay* $10 office visit copay* $10 office visit copay*

Prophylaxis (cleaning) $10 office visit copay* $10 office visit copay* $10 office visit copay* $10 office visit copay*

Topical application of fluoride $10 office visit copay* $10 office visit copay* $10 office visit copay* $10 office visit copay*

Bitewing X-rays $10 office visit copayNo additional cost for 1 to 4 films*

$10 office visit copayNo additional cost for 1 to 4 films*




Preventive services $30 copay (applicable fee schedule applies)

$30 copay (applicable fee schedule applies)



Diagnostic services Applicable fee schedule applies

Applicable fee schedule applies




Routine eye exam with Optometrist $20 $20 $30 No charge after deductible

Frames $0 copay† $0 copay $0 copay† $0 copay after deductible†

Lenses $0 copay† $0 copay $0 copay† $0 copay after deductible†

Contacts $0 copay†† $0 copay $0 copay†† $0 copay after deductible††


Routine eye exam with Optometrist $20 $20 $30 No charge after deductible

Frames 25% discount off retail price 25% discount off retail price 25% discount off retail price Not covered

Lenses 25% discount off retail price 25% discount off retail price 25% discount off retail price Not covered

Contacts 15% discount off retail price 15% discount off retail price 15% discount off retail price Not covered

*Charges may apply if other extensive services are required. For more information and to obtain a copy of applicable fee schedule, please visit www.DominionDental.com/kaiserdentists†One pair per year from a selected group of frames and limited to single vision or bifocal lenses (ST28) in polycarbonate or plastic†† Limited to a 3-month supply from a selected list of contacts; medically necessary contacts—$0 copay, limited to 2 pair per eye per year from a selected list of contacts. All listed services except Adult Vision and Adult Dental Services are subject to the out-of-pocket maximum. Please refer to your EOC for the complete list of services that are subject to the out-of-pocket maximum.

6

D.C. HEALTHLINK GOLD PLAN SUMMARIES (CONT.)The following is a limited description of benefits offered by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (KFHP-MAS). Not all services and procedures are covered by your benefits contract. This summary of benefits is for comparison purposes only and does not create rights not given through the benefit plan. These plans are “non-grandfathered health plans” under the Patient Protection and Affordable Care Act. Adult and pediatric dental benefits are underwritten by KFHP-MAS and administered by Dominion Dental Services USA, Inc. (Dominion).


KP DC Gold(ic)


KP DC Gold (ia)

$1,000/$30/POS/Dental/PedDental

IN-PLAN OUT-OF-PLAN

Individual plan annual deductible (subscriber only) $1,250 $1,000 $2,000

Family plan annual deductible (individual/family) $2,500/$2,500 $1,000/$2,000 $2,000/$4,000


100%/10% 90%/10% 70%/30%


$2,500 $3,500 $7,000


$5,000/$5,000 $3,500/$7,000 $7,000/$14,000

Network(iii) Signature Signature Not applicable

BENEFITS

Outpatient Services

Primary care office visit $10 after deductible $30 $50 copay after deductible

Specialty care office visit $10 after deductible $40 $60 copay after deductible

Preventive care/screening/immunization No charge No charge 30% after deductible

X-rays and laboratory diagnostic services No charge after deductible $30 30% after deductible

MRI/CT/PET $50 after deductible 10% after deductible 30% after deductible


$50 after deductible 10% after deductible 30% after deductible

Outpatient surgery physician/surgical services No charge after deductible 10% after deductible 30% after deductible

Mental health/chemical dependency outpatient $10 per visit individual therapy/$5 per visit group therapy (after deductible)



Maternity Services

Routine pre-natal visits (after confirmation ofpregnancy) and postpartum visits

No charge No charge No charge

Inpatient Services

All inpatient hospital services(including mental health/chemical dependency)

$100 per admission after deductible 10% after deductible 30% after deductible


Rx—Deductible None None None

Rx—Generic drugs $5 $15 30%

Rx—Preferred brand drugs $25 $45 30%

Rx—Non-preferred brand drugs $45 $60 30%

7

D.C. HEALTHLINK GOLD PLAN SUMMARIES (CONT.)The following is a limited description of benefits offered by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (KFHP-MAS). Not all services and procedures are covered by your benefits contract. This summary of benefits is for comparison purposes only and does not create rights not given through the benefit plan. These plans are “non-grandfathered health plans” under the Patient Protection and Affordable Care Act. Adult and pediatric dental benefits are underwritten by KFHP-MAS and administered by Dominion Dental Services USA, Inc. (Dominion).


KP DC Gold(ic)


KP DC Gold (ia)


IN-PLAN OUT-OF-PLAN


Urgent care office visits during regular office hours $10 (PCP)/$10 (specialty) (after deductible) $30 (PCP)/$40 (specialty) $50 (PCP)/$60 (specialty) (after deductible)

Urgent care centers (after hours urgent care) $10 after deductible $40 $60 after deductible

Emergency room $100 after deductible (waived if admitted) $150 after deductible (waived if admitted) $150 after deductible (waived if admitted)


Chiropractic services $10 after deductible $40 $60 after deductible


Periodic oral evaluation $10 office visit copay* $10 office visit copay* Not applicable

Prophylaxis (cleaning) $10 office visit copay* $10 office visit copay* Not applicable

Topical application of fluoride $10 office visit copay* $10 office visit copay* Not applicable



Not applicable


Preventive services $30 copay (applicable fee schedule applies) $30 copay (applicable fee schedule applies) Not applicable

Diagnostic services Applicable fee schedule applies Applicable fee schedule applies Not applicable


Routine eye exam with Optometrist $10 after deductible $30 $50 after deductible

Frames $0 copay after deductible† $0 copay† 30% after deductible

Lenses $0 copay after deductible† $0 copay† 30% after deductible

Contacts $0 copay after deductible†† $0 copay†† 30% after deductible


Routine eye exam with Optometrist $10 after deductible $30 $50 after deductible

Frames Not covered 25% discount off retail price 10% discount off retail price

Lenses Not covered 25% discount off retail price 10% discount off retail price

Contacts Not covered 15% discount off retail price 5% discount off retail price


8

D.C. HEALTHLINK SILVER PLAN SUMMARIESThe following is a limited description of benefits offered by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (KFHP-MAS). Not all services and procedures are covered by your benefits contract. This summary of benefits is for comparison purposes only and does not create rights not given through the benefit plan. These plans are “non-grandfathered health plans” under the Patient Protection and Affordable Care Act. Adult and pediatric dental benefits are underwritten by KFHP-MAS and administered by Dominion Dental Services USA, Inc. (Dominion).


KP DC Silver(ia)

$1,250/$35/Dental/PedDental

KP DC Silver(ia)


KP DC Silver(ib)

$1,500/$30/HSA/ Dental/PedDental

KP DC Silver(ib)

$1,500/$30/10%/HSA/Dental/PedDental

KP DC Silver(ia)


IN-PLAN OUT-OF-PLAN

Individual plan annual deductible (subscriber only) $1,250 $2,000 $1,500 $1,500 $2,000 $4,000

Family plan annual deductible (individual/family) $1,250/$2,500 $2,000/$4,000 $3,000/$3,000 $3,000/$3,000 $2,000/$4,000 $4,000/$8,000


80%/20% 80%/20% 80%/20% 90%/10% 80%/20% 60%/40%


$5,000 $5,000 $5,000 $5,000 $5,000 $10,000


$5,000/$10,000 $5,000/$10,000 $10,000/$10,000 $10,000/$10,000 $5,000/$10,000 $10,000/$20,000

Network(iii) Signature Signature Signature Signature Signature Not applicable

BENEFITS

Outpatient Services

Primary care office visit $35 $35 $30 after deductible $30 after deductible $35 $55 after deductible

Specialty care office visit $50 $50 $40 after deductible $40 after deductible $50 $70 after deductible

Preventive care/screening/immunization No charge No charge No charge No charge No charge 40% after deductible

X-rays and laboratory diagnostic services $50 after deductible $50 after deductible 20% after deductible 10% after deductible $50 after deductible 40% after deductible

MRI/CT/PET 20% after deductible 20% after deductible 20% after deductible 10% after deductible 20% after deductible 40% after deductible


20% after deductible 20% after deductible 20% after deductible 10% after deductible 20% after deductible 40% after deductible

Outpatient surgery physician/surgical services 20% after deductible 20% after deductible 20% after deductible 10% after deductible 20% after deductible 40% after deductible



$25 per visit individual therapy/$10 per visit group therapy (after deductible)




Maternity Services


No charge No charge No charge No charge No charge 40% after deductible

Inpatient Services




Rx—Deductible None None Applies to medical deductible

Applies to medical deductible

None None

Rx—Generic drugs $25 $25 $25 after deductible $25 after deductible $25 40% after deductible

Rx—Preferred brand drugs $50 $50 $50 after deductible $50 after deductible $50 40% after deductible

Rx—Non-preferred brand drugs $75 $75 $75 after deductible $75 after deductible $75 40% after deductible

9

D.C. HEALTHLINK SILVER PLAN SUMMARIESThe following is a limited description of benefits offered by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (KFHP-MAS). Not all services and procedures are covered by your benefits contract. This summary of benefits is for comparison purposes only and does not create rights not given through the benefit plan. These plans are “non-grandfathered health plans” under the Patient Protection and Affordable Care Act. Adult and pediatric dental benefits are underwritten by KFHP-MAS and administered by Dominion Dental Services USA, Inc. (Dominion).


KP DC Silver(ia)


KP DC Silver(ia)


KP DC Silver(ib)

$1,500/$30/HSA/ Dental/PedDental

KP DC Silver(ib)

$1,500/$30/10%/HSA/Dental/PedDental

KP DC Silver(ia)


IN-PLAN OUT-OF-PLAN


Urgent care office visits during regular office hours $35 (PCP)/$50 (specialty) $35 (PCP)/$50 (specialty) $30 (PCP)/$40 (specialty) (after deductible)

$30 (PCP)/$40 (specialty) (after deductible)

$35 (PCP)/$50 (specialty) $55 (PCP)/$70 (specialty) (after deductible)

Urgent care centers (after hours urgent care) $50 $50 $40 after deductible $40 after deductible $50 $70 after deductible

Emergency room $250 after deductible (waived if admitted)


20% after deductible 10% after deductible $250 after deductible (waived if admitted)



Chiropractic services $50 $50 $40 after deductible $40 after deductible $50 $70 after deductible


Periodic oral evaluation $10 office visit copay* $10 office visit copay* $10 office visit copay* $10 office visit copay* $10 office visit copay* Not applicable

Prophylaxis (cleaning) $10 office visit copay* $10 office visit copay* $10 office visit copay* $10 office visit copay* $10 office visit copay* Not applicable

Topical application of fluoride $10 office visit copay* $10 office visit copay* $10 office visit copay* $10 office visit copay* $10 office visit copay* Not applicable






Not applicable







Not applicable






Not applicable


Routine eye exam with Optometrist $35 $35 $30 after deductible $30 after deductible $35 $50 after deductible

Frames $0 copay† $0 copay† $0 copay after deductible† $0 copay after deductible† $0 copay† 40% after deductible

Lenses $0 copay† $0 copay† $0 copay after deductible† $0 copay after deductible† $0 copay† 40% after deductible

Contacts $0 copay†† $0 copay†† $0 copay after deductible†† $0 copay after deductible†† $0 copay†† 40% after deductible


Routine eye exam with Optometrist $35 $35 $30 after deductible $30 after deductible $35 $50 after deductible

Frames 25% discount off retail price 25% discount off retail price Not covered Not covered 25% discount off retail price 10% discount off retail price

Lenses 25% discount off retail price 25% discount off retail price Not covered Not covered 25% discount off retail price 10% discount off retail price

Contacts 15% discount off retail price 15% discount off retail price Not covered Not covered 15% discount off retail price 5% discount off retail price


10

D.C. HEALTHLINK BRONZE PLAN SUMMARIESThe following is a limited description of benefits offered by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (KFHP-MAS). Not all services and procedures are covered by your benefits contract. This summary of benefits is for comparison purposes only and does not create rights not given through the benefit plan. These plans are “non-grandfathered health plans” under the Patient Protection and Affordable Care Act. Adult and pediatric dental benefits are underwritten by KFHP-MAS and administered by Dominion Dental Services USA, Inc. (Dominion).


KP DC Bronze(ia)


KP DC Bronze(ib)

$2,750/$40/30%/HSA/ Dental/PedDental

KP DC Bronze(ib)

$3,500/20%/HSA/ Dental/PedDental

KP DC Bronze(ib)

$4,500/$20/HSA/Dental/PedDental

KP DC Bronze(ia)


IN-PLAN OUT-OF-PLAN

Individual plan annual deductible (subscriber only) $4,500 $2,750 $3,500 $4,500 $4,500 $9,000

Family plan annual deductible (individual/family) $4,500/$9,000 $5,500/$5,500 $7,000/$7,000 $9,000/$9,000 $4,500/$9,000 $9,000/$18,000


60%/40% 70%/30% 80%/20% 70%/30% 60%/40% 50%/50%


$6,350 $6,350 $6,350 $6,350 $6,350 $18,000


$6,350/$12,700 $12,700/$12,700 $12,700/$12,700 $12,700/$12,700 $6,350/$12,700 $18,000/$36,000

Network(iii) Signature Signature Signature Signature Signature Not applicable

BENEFITS

Outpatient Services

Primary care office visit $50 $40 after deductible 20% after deductible $20 after deductible $50 50% after deductible

Specialty care office visit $50 after deductible $50 after deductible 20% after deductible $30 after deductible $50 after deductible 50% after deductible

Preventive care/screening/immunization No charge No charge No charge No charge No charge 50% after deductible

X-rays and laboratory diagnostic services 40% after deductible 30% after deductible 20% after deductible 30% after deductible 40% after deductible 50% after deductible

MRI/CT/PET 40% after deductible 30% after deductible 20% after deductible 30% after deductible 40% after deductible 50% after deductible



Outpatient surgery physician/surgical services 40% after deductible 30% after deductible 20% after deductible 30% after deductible 40% after deductible 50% after deductible


$25 individual therapy/ $10 group therapy (after deductible)

20% individual therapy/ 20% group therapy (after deductible)



50% after deductible

Maternity Services


No charge No charge No charge No charge No charge 50% after deductible

Inpatient Services




Rx—Deductible Applies to medical deductible






Rx—Generic drugs $25 after deductible $25 after deductible $25 after deductible $25 after deductible $25 after deductible 50% after deductible

Rx—Preferred brand drugs $60 after deductible $50 after deductible $60 after deductible $60 after deductible $60 after deductible 50% after deductible

Rx—Non-preferred brand drugs 50% after deductible $75 after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible

11

D.C. HEALTHLINK BRONZE PLAN SUMMARIESThe following is a limited description of benefits offered by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (KFHP-MAS). Not all services and procedures are covered by your benefits contract. This summary of benefits is for comparison purposes only and does not create rights not given through the benefit plan. These plans are “non-grandfathered health plans” under the Patient Protection and Affordable Care Act. Adult and pediatric dental benefits are underwritten by KFHP-MAS and administered by Dominion Dental Services USA, Inc. (Dominion).


KP DC Bronze(ia)


KP DC Bronze(ib)

$2,750/$40/30%/HSA/ Dental/PedDental

KP DC Bronze(ib)

$3,500/20%/HSA/ Dental/PedDental

KP DC Bronze(ib)

$4,500/$20/HSA/Dental/PedDental

KP DC Bronze(ia)


IN-PLAN OUT-OF-PLAN


Urgent care office visits during regular office hours $50 (PCP)/$50 (specialty) (after deductible)


20% (PCP)/20% (specialty) (after deductible)



50% (PCP)/50% (specialty) (after deductible)

Urgent care centers (after hours urgent care) $50 after deductible $50 after deductible 20% after deductible $30 after deductible $50 after deductible 50% after deductible

Emergency room 40% after deductible 30% after deductible 20% after deductible 30% after deductible 40% after deductible 40% after deductible


Chiropractic services $50 after deductible $50 after deductible 20% after deductible $30 after deductible $50 after deductible 50% after deductible


Periodic oral evaluation $10 office visit copay* $10 office visit copay* $10 office visit copay* $10 office visit copay* $10 office visit copay* Not applicable

Prophylaxis (cleaning) $10 office visit copay* $10 office visit copay* $10 office visit copay* $10 office visit copay* $10 office visit copay* Not applicable

Topical application of fluoride $10 office visit copay* $10 office visit copay* $10 office visit copay* $10 office visit copay* $10 office visit copay* Not applicable






Not applicable







Not applicable






Not applicable


Routine eye exam with Optometrist $50 $40 after deductible 20% after deductible $20 after deductible $50 50% after deductible

Frames $0 copay† $0 copay after deductible† $0 copay after deductible† $0 copay after deductible† $0 copay† 50% after deductible

Lenses $0 copay† $0 copay after deductible† $0 copay after deductible† $0 copay after deductible† $0 copay† 50% after deductible

Contacts $0 copay†† $0 copay after deductible†† $0 copay after deductible†† $0 copay after deductible†† $0 copay†† 50% after deductible


Routine eye exam with Optometrist $50 $40 after deductible 20% after deductible $20 after deductible $50 50% after deductible

Frames 25% discount off retail price Not covered Not covered Not covered 25% discount off retail price 10% discount off retail price

Lenses 25% discount off retail price Not covered Not covered Not covered 25% discount off retail price 10% discount off retail price

Contacts 15% discount off retail price Not covered Not covered Not covered 15% discount off retail price 5% discount off retail price


12

DEFINITIONS

(ia) Deductible HMO Plans Deductible plans with family coverage have both an individual deductible and a family deductible. That means that one member of the family can meet the lower individual deductible and be eligible for coinsurance or copayments before the higher family deductible is satisfied. Similarly, one family member can meet the individual out-of-pocket maximum before the family out-of-pocket maximum is met.

(ib) HSA-Qualified Deductible HMO Plans Under HSA-Qualified deductible family plans, there is no individual member deductible or out-of-pocket maximum. Instead, all plans are subject to a family deductible or out-of-pocket maximum which can be met by one or more family members contributing to a combined family deductible or out-of-pocket maximum. Once the combined contribution of all covered family members’ has reached the applicable deductible or out-of-pocket maximum, the deductible/out-of-pocket maximum will be satisfied for all family members for the remainder of the contract year.

(ic) High Deductible HMO Plans High Deductible HMO Plans work in the same way the HSA-Qualified Deductible HMO Plans do. However, they are not eligible to be paired with Health Savings Accounts (HSA).

(iii) Kaiser Permanente SignatureSM provider network With the Kaiser Permanente Signature provider network, you receive quality care provided by our physicians – a network of physicians who practice exclusively in our medical centers conveniently located throughout the covered Maryland, Virginia, and Washington, D.C., service areas. You can choose a doctor at any time, for any reason, ensuring that your phyician meets your needs. Our medical centers offer a range of services in one location, including primary care, lab, X-ray, and pharmacy. For inpatient services, you have convenient access to contracted hospitals located throughout the area. When you receive care, tests, and screenings in our medical centers, you can use My Health Manager on kp.org to email your doctor’s office, check most lab results, schedule and cancel appointments, order prescription refills for mail delivery or pickup, and much more.

(iii) Kaiser Permanente SelectSM provider network Building on our Signature physician network, Select adds access to contracted community physicians in private practice. Members may choose a Mid-Atlantic Permanente Medical Group or community physician for primary care and have access to contracted hospitals located throughout the area.

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EXCLUSIONS*

Certain Alternative Medical Services

Acupuncture Services and any Services of an Acupuncturist, Naturopath, and Massage Therapist.

Certain Exams and Services

Physical examinations and other Services (a) required for obtaining or maintaining employment or participation in employee programs; or (b) required for insurance or licensing or disability determinations; or (c) on court-order or required for parole or probation.

Cosmetic Services

Services that are intended primarily to improve your appearance and that are not likely to result in significant improvement in physical function.

Custodial Care

Custodial care means assistance with activities of daily living (for example: walking, getting in and out of bed, bathing, dressing, feeding, toileting, and taking medicine), or care that can be performed safely and effectively by people who, in order to provide the care, do not require medical licenses or certificates or the presence of a supervising licensed nurse.

Dental Care

Dental care and dental X-rays, including dental appliances, dental implants, orthodontia, shortening of the mandible or maxillae for cosmetic purposes, correction of malocclusion, dental Services resulting from medical treatment such as surgery on the jawbone and radiation treatment, and any dental treatment involved in temporal mandibular joint (TMJ) pain dysfunction syndrome.

Disposable Supplies

Disposable supplies for home use such as bandages, gauze, tape, antiseptics, dressings, ace-type bandages, and any other supplies, dressings, appliances, or devices.

Employer or Government Responsibility

Financial responsibility for Services that an employer or government agency is required by law to provide.

Experimental or Investigational Services

Service is experimental or investigational for your condition if any of the following statements apply to it as of the time the Service is or will be provided to you:

• It cannot be legally marketed in the United States without the approval of the Food and Drug Administration (“FDA”) and such approval has not been granted; or

• It is the subject of a current new drug or new device application on file with the FDA and FDA approval has not been granted; or

• It is subject to the approval or review of an Institutional Review Board (“IRB”) of the treating facility that approves or reviews research concerning the safety, toxicity, or efficacy of services; or

• It is the subject of a written protocol used by the treating facility for research, clinical trials, or other tests or studies to evaluate its safety, effectiveness, toxicity or efficacy, as evidenced in the protocol itself or in the written consent form used by the facility.

In making determinations whether a Service is experimental or investigational, the following sources of information will be relied upon exclusively:

• your medical records,

• the written protocols or other documents pursuant to which the Service has been or will be provided,

• any consent documents you or your representative has executed or will be asked to execute, to receive the Service,

• the files and records of the IRB or similar body that approves or reviews research at the institution where the Service has been or will be provided, and other information concerning the authority or actions of the IRB or similar body,

• the published authoritative medical or scientific literature regarding the service, as applied to your illness or injury, and

• regulations, records, applications, and any other documents or actions issued by, filed with, or taken by, the FDA, the Office of Technology Assessment, or other agencies within the United States Department of Health and Human Services, or any state agency performing similar functions.

Health Plan consults Medical Group and then uses the criteria described above to decide if a particular Service is experimental or investigational.

External Prosthetic and Orthotic Devices

Services and supplies for external prosthetic and orthotic devices.

Prohibited Referrals

Payment of any claim, bill, or other demand or request for payment for covered services determined to be furnished as the result of a referral prohibited by law.

Routine Foot Care Services

Routine foot care Services that are not medically necessary. This exclusion does not exclude Services when you are under active treatment for a metabolic or peripheral vascular disease

Services for Members in the Custody of Law Enforcement Officers

Non-Plan Provider Services provided or arranged by criminal justice institutions for Members in the custody of law enforcement officers.

Surrogacy Arrangements

Services related to conception, pregnancy or delivery in connection with a surrogacy arrangement. A surrogacy arrangement is one in which a woman agrees to become pregnant and to surrender the baby to another person or persons who intend to raise the child.

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Travel and Lodging Expenses

Travel and lodging expenses except that in some situations, if a Plan Physician refers you to a non-Plan Provider outside our Service Area. We may pay certain expenses that we pre-authorize in accord with our travel and lodging guidelines.

Vision Services

Any eye surgery solely for the purpose of correcting refractive defects of the eye, such as myopia, hyperopia, or astigmatism (for example, radial keratotomy, photo- refractive keratectomy, and similar procedures.

Workers’ Compensation or Employer’s Liability

Financial responsibility for Services for any illness, injury, or condition, to the extent a payment or any other benefit, including any amount received as a settlement (collectively referred to a “Financial Benefit”), is provided under any workers’ compensation or employer’s liability law. We will provide Services even if it is unclear whether you are entitled to a Financial Benefit; but we may recover the value of Services from the following sources:

• Any source providing a Financial Benefit or from whom a Financial Benefit is due; or

• You, to the extent that a Financial Benefit is provided or payable or would have been required to be provided or payable if you had diligently sought to establish your rights to the Financial Benefit under any workers’ compensation or employers’ liability law.

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LIMITATIONS AND EXCLUSIONS*

Accidental Dental Injury Services

Accidental Dental Injury Services Exclusions:

• Services provided by non-Plan Providers.

• Services provided after 12 months from the date the injury occurred.

• Services for teeth that have been avulsed (knocked out) or that have been so severely damaged that in the opinion of the Plan Provider, restoration is impossible.

Ambulance Services

Ambulance Services Exclusions:

• Transportation by car, taxi, bus, minivan, and any other type of transportation (other than a licensed ambulance), even if it is the only way to travel to a Plan Provider.

• Non-emergent transportation Services that are not medically appropriate and that have not been ordered by a Plan Provider.

Anesthesia for Dental Services

Anesthesia for Dental Services Exclusions:

• The dentist’s or specialist’s professional Services.

• Anesthesia and related facility charges for dental care for temporomandibular joint (TMJ) disorders.

Blood, Blood Products, and their Administration

Blood, Blood Products and their Administration Limitations:

• Member recipients must be designated at the time of procurement of cord blood

Blood, Blood Products and their Administration Exclusions:

• Directed blood donations.

Chemical Dependency and Mental Health Services

Chemical Dependency and Mental Health Services Exclusions:

• Services in a facility whose primary purpose is to provide treatment for alcoholism, drug abuse, or drug addiction, except as described above.

• Services provided in a psychiatric residential treatment facility, except as described above.

• Services for Members who, in the opinion of the Plan Provider, are seeking Services for nontherapeutic purposes.

• Psychological testing for ability, aptitude, intelligence, or interest.

• Services on court order or as a condition of parole or probation, unless determined by the Plan Provider to be necessary and appropriate.

• Evaluations that are primarily for legal or administrative purposes, and are not Medically Necessary.

Clinical Trials

Clinical trials exclusions:

a. The investigational Service.

b. Services provided solely for data collection and analysis and that are not used in your direct clinical management.

Diabetic Equipment, Supplies, and Self-Management

Diabetic Equipment and Supplies Limitation:

Diabetic equipment and supplies are limited to Health Plan preferred equipment and supplies unless the equipment or supply: (1) was prescribed by a Plan Provider; and (2) (a) there is no equivalent preferred equipment or supply available, or (b) an equivalent preferred equipment or supply (i) has been ineffective in treating the disease or condition of the Member; or

(ii) has caused or is likely to cause an adverse reaction or other harm to the Member. “Health Plan preferred equipment and supplies” are those purchased from a Plan preferred vendor.

Drugs, Supplies, and Supplements

Drugs, Supplies and Supplements Exclusions:

• Drugs, supplies, and supplements that can be self-administered or do not require administration or observation by medical personnel.

• Drugs for which a prescription is not required by law.

• Drugs for the treatment of sexual dysfunction disorders.

Durable Medical Equipment

Durable Medical Equipment Exclusions:

• Comfort, convenience, or luxury equipment or features.

• Exercise or hygiene equipment.

• Non-medical items such as sauna baths or elevators.

• Modifications to your home or car.

• Devices for testing blood or other body substances (except as covered under “Diabetes Equipment, Supplies and Self Management”).

• Electronic monitors of the heart or lungs, except infant apnea monitors.

• Services not preauthorized by Health Plan.

Emergency Services

Emergency Services Limitations:

• Notification: If you receive care at a hospital emergency room or are admitted to a non-plan hospital, you, or someone on your behalf, must notify us as soon as possible, but not later than

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48 hours or the next business day, whichever is later, or the emergency room visit or hospital admission unless it was not reasonably possible to notify us. If you are admitted to a hospital, we will decide whether to make arrangements for necessary continued care where you are, or to transfer you to a facility we designate. If you do not notify us as provided herein, we will not cover the emergency room visit, or hospital care you receive after transfer would have been possible.

• Continuing or Follow-up Treatment: Except as provided for under “Continuing Treatment Following Emergency Surgery,” we do not cover continuing or follow-up treatment after Emergency Services unless authorized by Health Plan. We cover only the out-of-Plan emergency Services that are required before you could, without medically harmful results, have been moved to a facility we designate either inside or outside our Service Area or in another Kaiser Foundation Health Plan or allied plan service area.

• Hospital Observation: Transfer to an observation bed or observation status does not qualify as an admission to a hospital and your emergency room visit copayment will not be waived.

Habilitative Services

Habilitative Services Exclusions:

• Assistive technology Services and devices.

• Services provided through federal, state or local early intervention programs, including school programs.


• Services for a Member that has plateaued and is able to demonstrate stability of skills and functioning even when Services are reduced.

• Services not provided by a licensed or certified therapist.

Hearing Tests

Hearing Tests Exclusions:

• Tests to determine an appropriate hearing aid; and

• Hearing aids or tests to determine their efficacy.

Home Health Care

Home Health Care Limitations:

• Home Health Care visits shall be limited to 90 visits per, and up to four (4) hours per visit per episode of care.

Home Health Care Exclusions:

• Custodial care (see definition under “Exclusions” in the Kaiser Foundation Health Plan of the Mid-Atlantic States “Exclusions” section).

• Routine administration of oral medications, eye drops, ointments.

• General maintenance care of colostomy, ileostomy, and ureterostomy.

• Medical supplies or dressings applied by a Member or family caregiver.

• Corrective appliances, artificial aids, and orthopedic devices.

• Homemaker Services.

• Care that a Plan Provider determines may be appropriately provided in a Plan Facility or Skilled Nursing Facility, and we provide or offer to provide that care in one of these facilities.


• Transportation and delivery service costs of Durable Medical Equipment, medications, drugs, medical supplies and supplements to the home.

Hospice Care

Hospice Care Limitation:

Hospice Care Services are limited to a maximum of 180 days per eligibility period.

Medical Foods

Medical Foods Exclusions:

• Medical food for treatment of any conditions other than an inherited metabolic disease.

Morbid Obesity

Morbid Obesity Services Exclusions


Oral Surgery

Oral Surgery Exclusions:

• Oral surgery Services when the functional aspect is minimal and would not in itself warrant surgery.

• Lab fees associated with cysts that are considered dental under our standards.

• Medical and dental Services for treatment of the condition commonly referred to as TMJ (temporomandibular joint syndrome).

• Orthodontic Services.

• Dental appliances.

Prescription Drugs

Prescription Drugs Limitations:

• For drugs prescribed by dentists, coverage is limited to antibiotics and pain relief drugs that are included on our Preferred Drug List and purchased at a Plan Pharmacy or a participating network pharmacy.

• In the event of a civil emergency or the shortage of one or more prescription drugs, we may limit availability in consultation with the Health Plan’s emergency management department and/or our Pharmacy and Therapeutics Committee. If limited, the applicable Cost Share per prescription will apply.

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Prescription Drugs Exclusions:

• Drugs for which a prescription is not required by law, except for non-prescription drugs that are prescribed by a Plan Provider and are listed in our Preferred Drug List.

• Compounded preparations that do not contain at least one ingredient requiring a prescription and are not listed in our Preferred Drug List: 1) Drugs obtained from a non-Plan Pharmacy, except when the drug is prescribed during an emergency or urgent care visit in which covered Services are rendered, or 2) associated with a covered authorized referral outside the Service Area.

• Take home drugs received from a hospital, Skilled Nursing Facility, or other similar facility.

• Drugs that are not listed in our Preferred Drug List.

• Drugs that are considered to be experimental or investigational.

• Except as specifically covered, a drug (a) which can be obtained without a prescription, or (b) for which there is a non-prescription drug that is the identical chemical equivalent (i.e., same active ingredient and dosage) to a prescription drug.

• Drugs for which the Member is not legally obligated to pay, or for which no charge is made, b) Blood or blood products.

• Drugs or dermatological preparations, ointments, lotions, and creams prescribed for cosmetic purposes including but not limited to drugs used to retard or reverse the effects of skin aging or to treat nail fungus or hair loss.

• Medical foods.

• Drugs for the palliation and management of terminal illness if they are provided by a licensed hospice agency to a Member participating in our hospice care program.

• Replacement prescriptions necessitated by theft or loss.

• Prescribed drugs and accessories that are necessary for Services that are excluded.

• Special packaging (e.g., blister pack, unit dose, unit-of-use packaging) that is different from the

Health Plan’s standard packaging for prescription drugs.

• Alternative formulations or delivery methods that are (1) different from the Health Plan’s standard formulation or delivery method for prescription drugs and (2) deemed not Medically Necessary.

• Durable medical equipment, prosthetic or orthotic devices, and their supplies, including: peak flow meters, nebulizers, and spacers; and ostomy and urological supplies.

• Drugs and devices that are provided during a covered stay in a hospital or Skilled Nursing Facility, or that require administration or observation by medical personnel and are provided to you in a medical office or during home visits. This includes the equipment and supplies associated with the administration of a drug.

• Bandages or dressings.

• Diabetic equipment and supplies.

• Growth hormone therapy (GHT) for treatment of adults age 18 or older, except when prescribed by a Plan Physician, pursuant to clinical guidelines for adults.

• Immunizations and vaccinations solely for the purpose of travel.

• Any prescription drug product that is therapeutically equivalent to an over-the-counter drug, upon a review and determination by the Pharmacy and Therapeutics Committee.

• Drugs for weight management.

• Drugs for treatment of sexual dysfunction disorder, such as erectile dysfunction.

• Drugs for the treatment of infertility.

Preventive Health Care Services

Preventive Health Services Limitation:

While treatment may be provided in the following situations, the following Services are not considered Preventive Care Services. Applicable Cost shares will apply.

• Monitoring a chronic disease;

• Follow-up Services after you have been diagnosed with a disease.

• Testing and diagnosis for specific diseases for which you have been determined to be at high risk for contracting based on factors determined by national standards.

• Services provided when you show signs or symptoms of a specific disease or disease process;

• Non-routine gynecological visits;

• Lab, imaging, and other ancillary Services not included in routine prenatal care.

• Non-preventive Services performed in conjunction with a sterilization.

• Lab, imaging, and other ancillary Services associated with sterilizations.

• Complications that arise after a sterilization procedure.

• Treatment of a medical condition or problem identified during the course of a preventive screening exam;

• Over-the-counter contraceptive pills, supplies, and devices.

• Personal and convenience supplies associated with breastfeeding equipment such as pads, bottles, and carrier cases.

• Replacement or upgrades for breastfeeding equipment that is not rented Durable Medical Equipment.

• Prescription contraceptives that do not require clinical administration for certain group health plans that provide outpatient prescription drug coverage that includes FDA-approved contraception that is separate from Health Plan coverage and furnished through another prescription drug provider.

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Prosthetic Devices

Breast Prosthetics Limitation:

• Coverage for mastectomy bras is limited to a maximum of two (2) per calendar year.

Prosthetic Devices Exclusions:


• Internally implanted breast prosthetics for cosmetic purposes.

• External prosthetics, except as provided in this Section under “Cleft-Lip, Cleft Palate, or Both”, or “Hearing Services”, if applicable.

• Repair or replacement of prosthetics due to loss or misuse.

• Hair Prostheses.

• Microprocessor and robotic controlled external prosthetics and orthotics not covered under the Medicare Coverage Database.

• Multifocal intraocular lens implants.

Reconstructive Surgery

Reconstructive Surgery Exclusions:

Cosmetic surgery, plastic surgery, or other Services, supplies, dermatological preparations and ointments, other than those listed above, that are intended primarily to improve your appearance, or are not likely to result in significant improvement in physical function, and are not Medically Necessary. Examples of excluded cosmetic dermatology services are:

• Removal of moles or other benign skin growths for appearance only

• Chemical Peels

• Pierced earlobe repairs, except for the repair of an acute bleeding laceration

Skilled Nursing Facility Care

Skilled Nursing Facility Exclusions:

• Custodial care (see definition under “Exclusions” in the “Exclusions, Limitations, and Reductions” section of the EOC).

• Domiciliary care.

Telemedicine ServicesWe cover Telemedicine Services that would otherwise be covered under this Benefits section when provided on a face-to-face basis.

Telemedicine Services means the delivery of Healthcare Services through the use of interactive audio, video, or other electronic media used for the purpose of diagnosis, consultation, or treatment.

Telemedicine Services Exclusions:

Services delivered through audio-only telephones, electronic mail messages, or facsimile transmissions.


Physical, Occupational, and Speech Therapy Services

We cover Medically Necessary inpatient and outpatient physical, occupational and speech therapy.

Physical, Occupational, and Speech Therapy Services Limitations:

• Physical therapy is limited to treatment to restore physical function that was lost due to injury or illness. It is not covered to develop physical function, except as provided for under “Early Intervention Services” in this section.

• Occupational therapy is limited to treatment to achieve and maintain improved self-care and other customary activities of daily living.

• Speech therapy is limited to treatment for speech impairments due to injury or illness.

Multidisciplinary Rehabilitation Limitations:

• The limitations listed above for physical, occupation and speech therapy also applies to those Services when provided within a multidisciplinary program.

Therapy and Rehabilitation Services Exclusions:

• Long-term rehabilitative therapy.

• Except as provided for cardiac and pulmonary rehabilitation Services, no coverage is provided for any therapy that the Plan Physician determines cannot achieve measurable improvement in function within a 90-day period.

Transplant Services

Transplant Services Exclusions:

• Services related to non-human or artificial organs and their implantation.

Urgent Care

Urgent Care Limitations:

We do not cover Services outside our Service Area for conditions that, before leaving the Service Area, you should have known might require Services while outside our Service Area, such as dialysis for end-stage renal disease, post-operative care following surgery, and treatment for continuing infections, unless we determine that you were temporarily outside our Service Area because of an extreme personal emergency.

Urgent Care Exclusions:

• Urgent Care Services within our Service Area that were not provided by a Plan Provider or Plan Facility.

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Vision Services

Vision Exclusions:

• Industrial and athletic safety frames.

• Eyeglass lenses and contact lenses with no refractive value.

• Sunglasses without corrective lenses unless Medically Necessary.

• Any eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), far-sightedness (hyperopia), and astigmatism (for example, radial keratotomy, photo-refractive keratectomy, and similar procedures).

• Eye exercises.

• Contact lens Services other than the initial fitting and purchase of contact lenses as provided in this section.

• Replacement of lost, broken, or damaged lenses frames and contact lenses.

• Plano lenses.

• Lens adornment, such as engraving, faceting, or jewelling.

• Low-vision devices.

• Non-prescription products, such as eyeglass holders, eyeglass cases, and repair kits.

• Orthoptic (eye training) therapy.

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PEDIATRIC DENTAL EXCLUSIONS AND LIMITATIONS*

Exclusions

1. Services which are covered under worker’s compensation or employer’s liability laws.

2. Services which are not necessary for the patient’s dental health as determined by the Plan.

3. Cosmetic, elective or aesthetic dentistry except as required due to accidental bodily injury to sound natural teeth as determined by the Plan.

4. Oral surgery requiring the setting of fractures or dislocations.

5. Services with respect to malignancies, cysts or neoplasms, hereditary, congenital, mandibular prognathism or development malformations where, in the opinion of the Plan, such services should not be performed in a dental office.

6. Dispensing of drugs.

7. Hospitalization for any dental procedure.

8. Treatment required for conditions resulting from major disaster, epidemic, war, acts of war, whether declared or undeclared, or while on active duty as a member of the armed forces of any nation.

9. Replacement due to loss or theft of prosthetic appliance.

10. Procedures not listed as covered benefits under this Plan.

11. Services obtained outside of the dental office in which enrolled and that are not preauthorized by such office or the Plan (with the exception of out-of-area emergency dental services).

12. Services related to the treatment of TMD (Temporomandibular Disorder) except if TMD is caused by severe, dysfunctional, handicapping malocclusion that requires medically necessary orthodontia services.

13. Services performed by a Dental Specialist without a referral from a General Dentist (with the exception of Orthodontics). Participating Dental Providers should refer to Specialty Care Referral

Guidelines.

14. Elective surgery including, but not limited to, extraction of non-pathologic, asymptomatic impacted teeth as determined by the Plan. The prophylactic removal of these teeth for medically necessary orthodontia services may be covered subject to review.

15. Non-medically necessary orthodontia and Phase I Treatment codes D8010 and D8050 for medically necessary orthodontia are not covered benefits under this policy. Discounts are provided to members through the Plan’s agreements with its participating orthodontists. The provider agreements create no liability for payment by the Dental Administrator. Any payments by the member for services not covered by the plan do not contribute to the out-of-pocket maximum. The Invisalign system and similar specialized braces are not a covered benefit. See limitation #25 concerning medically necessary orthodontia.

Limitations

1. One evaluation (D0120, D0140, D0145, D0150, D0160, D0180) is covered once per six months, per patient. D0150 limited to once in 12 months).

2. One (1) teeth cleaning (D1110 or D1120) per 6 months, per patient.

3. One (1) fluoride application every 6 months, per patient.

4. One (1) set of bitewing x-rays are covered per six (6) months, per patient starting at age two.

5. One (1) set of full mouth x-rays or panoramic film is covered every five (5) years. Panoramic x-rays are limited to ages 6-18. No more than one set of x-rays are covered per visit.

6. One (1) sealant per tooth is covered per 36 months, per patient up to age 18 (limited to occlusal surfaces of posterior permanent teeth without restorations or decay).

7. One (1) space maintainer (D1510, D1520, D1515 or D1525) is covered per 24 months per patient, per arch.

8. Replacement of a filling is covered if it is more than three (3) years from the date of original placement.

9. Replacement of a primary stainless steel crown (under age 15), crown, denture, or other prosthodontic appliance is covered if it is more than five (5) years from the date of original placement.

10. Crown and bridge fees apply to treatment involving five or fewer units when presented in a single treatment plan. Additional crown or bridge units, beginning with the sixth unit, are available at the provider’s Usual, Customary, and Reasonable (UCR) fee, minus 25%.

11. Relining and rebasing of dentures is covered once per 24 months, per patient.

12. Root canal treatment is covered once per lifetime.

13. Periodontal scaling and root planing (D4341 or D4342), limited to one (1) per 24 months, per patient, per quadrant.

14. Osseous surgery (D4260 or D4261), gingival flap procedure (D4240), and gingivectomy or gingivoplasy (D4210 - D4212) are limited to one (1) per 36 months.

15. Full mouth debridement is covered once per lifetime, per patient.

16. Procedure Code D4381 is limited to one (1) benefit per tooth for three teeth per quadrant; or a total of 12 teeth for all four quadrants per twelve (12) months. Must have pocket depths of five (5) millimeters or greater.

17. Periodontal surgery of any type, including any associated material, is covered once every 24 months, per quadrant or surgical site.

18. Periodontal maintenance is covered twice per calendar year in addition to adult prophylaxis, within 24 months after definitive periodontal therapy.

19. Denture rebase and denture reline is limited to 1 in a 36 month period 6 months after initial placement.

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20. Anesthesia requires a narrative of medical necessity be maintained in patient records. A maximum of 60 minutes of services are allowed for general anesthesia and intravenous or non-intravenous conscious sedation. General anesthesia is not covered with procedure codes D9230, D9241 or D9242. Intravenous conscious sedation is not covered with procedure codes D9220, D9221 or D9230. Non-intravenous conscious sedation is not covered with procedure codes D9220, D9221 or D9230. Analgesia (nitrous oxide) is not covered with procedure codes D9220, D9221, D9241 or D9242.

21. Occlusal guards are covered by report for patients 13 years of age or older when the purpose of the occlusal guard is for the treatment of bruxism or diagnoses other than temporomandibular dysfunction (TMD). Occlusal guards are limited to one per 12 consecutive month period.

22. Deep sedation/general anesthesia and intravenous conscious sedation are covered (by report) only when provided in connection with a covered procedure(s) when determined to be medically or dentally necessary for documented handicapped or uncontrollable patients or justifiable medical or dental conditions.

23. Fixed partial dentures, buildups, and posts and cores for members under 16 years of age are only covered if deemed necessary by the Participating Dental Provider.

24. Onlays, crowns, and posts and cores for members 12 years of age or younger are only covered if deemed necessary by the Participating Dental Provider. Cast posts and cores (D2952) are processed as an alternate benefit of a prefabricated post and core. Posts are eligible only when provided as part of a crown buildup or implant and are considered integral to the buildup or implant.

25. Orthodontics is only covered if medically necessary as determined by the Plan. Patient copayments will apply to the routine orthodontic appliance portion of services only. Additional costs incurred will become the patient’s responsibility.

Only current ADA CDT codes are considered valid by the Dental Administrator.

Current Dental Terminology © American Dental Association.

* Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (KFHP-MAS), will not be bound by the exclusions and limitations listed herein, but rather, the benefits, services, exclusions, and limitations listed in your Evidence of Coverage provided in a separate document. Consult the Evidence of Coverage to determine governing contractual provisions including detailed benefits, exclusions and limitations related to the benefit plan. The Evidence of Coverage is the legally binding document between KFHP-MAS and its members. In the event of ambiguity, or a conflict between this summary and the Evidence of Coverage, the Evidence of Coverage shall control.

Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.2101 East Jefferson St., Rockville, MD 20852141283_PlanSummaryDC_BSg_br_FINAL 10/15/14–12/31/15

WASHINGTON, D.C. HEALTHLINK SMALL BUSINESS PLAN SUMMARIES · 2 D.C. HEALTHLINK PLATINUM PLAN...

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