WIXLIB

Kaiser Foundation Health Plan, Inc.Southern California RegionA nonprofit corporationEOC #13 - Kaiser Permanente Traditional HMO PlanEvidence of Coverage forCSEBA/VICTOR VALLEY COMMUNITY COLLEGEGroup ID: 106090 Contract: 1 Version: 73 EOC Number: 13July 1, 2022, through June 30, 2023Member Service Contact Center24 hours a day, seven days a week (except closed holidays)1‑800-464-4000 (TTY users call 711)kp.org

coaccum NGF ACA

TABLE OF CONTENTS FOR EOC #13Cost Share Summary . 1Accumulation Period . 1Deductibles and Out-of-Pocket Maximums . 1Cost Share Summary Tables by Benefit . 1Introduction . 19About Kaiser Permanente . 19Term of this EOC . 19Definitions . 19Premiums, Eligibility, and Enrollment . 24Premiums. 24Who Is Eligible. 24How to Enroll and When Coverage Begins . 27How to Obtain Services . 29Routine Care . 29Urgent Care . 29Not Sure What Kind of Care You Need? . 30Your Personal Plan Physician . 30Getting a Referral . 30Second Opinions. 33Contracts with Plan Providers . 33Receiving Care Outside of Your Home Region . 34Your ID Card . 34Timely Access to Care . 34Getting Assistance . 35Plan Facilities . 35Emergency Services and Urgent Care . 36Emergency Services . 36Urgent Care . 37Payment and Reimbursement . 37Benefits . 37Your Cost Share . 38Administered Drugs and Products . 41Ambulance Services . 41Bariatric Surgery . 42Behavioral Health Treatment for Autism Spectrum Disorder . 42Dental and Orthodontic Services . 43Dialysis Care . 44Durable Medical Equipment (“DME”) for Home Use . 45Emergency and Urgent Care Visits . 46Family Planning Services . 46Fertility Services. 47Fertility Preservation Services for Iatrogenic Infertility . 48Health Education . 48Hearing Services. 48Home Health Care . 48Hospice Care . 49Hospital Inpatient Care . 50

Injury to Teeth . 50Mental Health Services . 50Office Visits . 51Ostomy and Urological Supplies . 51Outpatient Imaging, Laboratory, and Other Diagnostic and Treatment Services . 52Outpatient Prescription Drugs, Supplies, and Supplements . 52Outpatient Surgery and Outpatient Procedures . 55Preventive Services . 56Prosthetic and Orthotic Devices . 56Reconstructive Surgery . 57Rehabilitative and Habilitative Services. 58Services in Connection with a Clinical Trial . 58Skilled Nursing Facility Care . 59Substance Use Disorder Treatment . 60Telehealth Visits . 60Transplant Services . 60Vision Services for Adult Members . 61Vision Services for Pediatric Members . 62Exclusions, Limitations, Coordination of Benefits, and Reductions . 63Exclusions . 63Limitations . 66Coordination of Benefits . 66Reductions . 66Post-Service Claims and Appeals . 68Who May File. 69Supporting Documents . 69Initial Claims . 69Appeals . 70External Review . 71Additional Review. 71Dispute Resolution . 71Grievances . 71Independent Review Organization for Non-Formulary Prescription Drug Requests . 74Department of Managed Health Care Complaints. 75Independent Medical Review (“IMR”) . 75Office of Civil Rights Complaints . 76Additional Review. 76Binding Arbitration . 76Termination of Membership . 78Termination Due to Loss of Eligibility . 79Termination of Agreement. 79Termination for Cause . 79Termination of a Product or all Products. 79Payments after Termination . 79State Review of Membership Termination . 79Continuation of Membership. 79Continuation of Group Coverage . 80Continuation of Coverage under an Individual Plan . 83Miscellaneous Provisions . 83Administration of Agreement . 83Advance Directives . 83

Amendment of Agreement. 83Applications and Statements . 83Assignment . 83Attorney and Advocate Fees and Expenses . 83Claims Review Authority . 84EOC Binding on Members . 84ERISA Notices . 84Governing Law . 84Group and Members Not Our Agents. 84No Waiver . 84Notices Regarding Your Coverage . 84Overpayment Recovery . 84Privacy Practices . 85Public Policy Participation . 85Helpful Information. 85How to Obtain this EOC in Other Formats . 85Provider Directory . 85Online Tools and Resources . 86How to Reach Us . 86Payment Responsibility . 87

Cost Share SummaryThis “Cost Share Summary” is part of your Evidence of Coverage (EOC) and is meant to explain the amount you will pay forcovered Services under this plan. It does not provide a full description of your benefits. For a full description of your benefits,including any limitations and exclusions, please read this entire EOC, including any amendments, carefully.Accumulation PeriodThe Accumulation Period for this plan is January 1 through December 31.Deductibles and Out-of-Pocket MaximumsFor Services that apply to the Plan Out-of-Pocket Maximum, you will not pay any more Cost Share for the rest of theAccumulation Period once you have reached the amounts listed below.Family CoverageFamily CoverageSelf-Only CoverageAmounts Per Accumulation PeriodEach Member in a Family Entire Family of two or(a Family of one Member)of two or more Membersmore MembersPlan DeductibleNoneNoneNoneDrug DeductibleNoneNoneNonePlan Out-of-Pocket Maximum (“OOPM”) 1,500 1,500 3,000Cost Share Summary Tables by BenefitHow to read the Cost Share summary tablesEach table below explains the Cost Share for a category of benefits. Specific Services related to the benefit are described inthe first column of each table. For a detailed description of coverage for a particular benefit, refer to the same benefit headingin the “Benefits” section of this EOC. Copayment / Coinsurance. This column describes the Cost Share you will pay for Services after you have met yourPlan Deductible or Drug Deductible, if applicable. (Please see the “Deductibles and Out-of-Pocket Maximums”section above to determine if your plan includes deductibles.) If the Services are not covered in your plan, thiscolumn will read “Not covered.” If we provide an Allowance that you can use toward the cost of the Services, thiscolumn will include the Allowance. Subject to Deductible. This column explains whether the Cost Share you pay for Services is subject to a PlanDeductible or Drug Deductible. If the Services are subject to a deductible, you will pay Charges for those Servicesuntil you have met your deductible. If the Services are subject to a deductible, there will be a “ ” or “D” in thiscolumn, depending on which deductible applies (“ ” for Plan Deductible, “D” for Drug Deductible). If the Servicesdo not apply to a deductible, or if your plan does not include a deductible, this column will be blank. For a moredetailed explanation of deductibles, refer to “Plan Deductible” and “Drug Deductible” in the “Benefits” section ofthis EOC. Applies to OOPM. This column explains whether the Cost Share you pay for Services counts toward the Plan Outof-Pocket Maximum (“OOPM”) after you have met any applicable deductible. If the Services count toward the PlanOOPM, there will be a “ ” in this column. If the Services do not count toward the Plan OOPM, this column will beblank. For a more detailed explanation of the Plan OOPM, refer to “Plan Out-of-Pocket Maximum” heading in the“Benefits” section of this EOC.Group ID: 106090 Kaiser Permanente Traditional HMO PlanContract: 1 Version: 73 EOC# 13 Effective: 7/1/22 6/30/23Date: April 20, 2022Page 1

Administered drugs and productsDescription of Administered Drugs and Products ServicesCopayment /CoinsuranceSubject toDeductibleApplies toOOPMWhole blood, red blood cells, plasma, and plateletsNo charge Allergy antigens (including administration)No charge Cancer chemotherapy drugs and adjunctsNo charge Drugs and products that are administered via intravenous therapy orNo chargeinjection that are not for cancer chemotherapy, including blood factorproducts and biological products (“biologics”) derived from tissue,cells, or blood All other administered drugs and productsNo charge Drugs and products administered to you during a home visitNo charge Ambulance ServicesDescription of Ambulance ServicesCopayment /CoinsuranceSubject toDeductibleApplies toOOPMEmergency ambulance ServicesNo charge Nonemergency ambulance and psychiatric transport van ServicesNo charge Behavioral health treatment for autism spectrum disorderDescription of Behavioral Health Treatment ServicesCopayment /CoinsuranceCovered Services 10 per daySubject toDeductibleApplies toOOPM Dialysis careDescription of Dialysis Care ServicesCopayment /CoinsuranceSubject toDeductibleApplies toOOPMEquipment and supplies for home hemodialysis and home peritonealdialysisNo charge One routine outpatient visit per month with the multidisciplinarynephrology team for a consultation, evaluation, or treatmentNo charge Group ID: 106090 Kaiser Permanente Traditional HMO PlanContract: 1 Version: 73 EOC# 13 Effective: 7/1/22 6/30/23Date: April 20, 2022Page 2

Description of Dialysis Care ServicesCopayment /CoinsuranceHemodialysis and peritoneal dialysis treatment at a Plan Facility 10 per visitSubject toDeductibleApplies toOOPM Durable Medical Equipment (“DME”) for home useDescription of DME ServicesCopayment /CoinsuranceSubject toDeductibleApplies toOOPMBlood glucose monitors for diabetes blood testing and their suppliesNo charge Peak flow metersNo charge Insulin pumps and supplies to operate the pumpNo charge Other Base DME Items as described in this EOCNo charge Supplemental DME items as described in this EOCNo chargeRetail-grade breast pumpsNo charge Hospital-grade breast pumpsNo charge Emergency and Urgent Care visitsDescription of Emergency and Urgent Care Visit ServicesCopayment /CoinsuranceSubject toDeductibleApplies toOOPMEmergency Department visits 50 per visit Urgent Care visits 10 per visit Note: If you are admitted to the hospital as an inpatient from the Emergency Department, the Emergency Department visitsCost Share above does not apply. Instead, the Services you received in the Emergency Department, including any observationstay, if applicable, will be considered part of your inpatient hospital stay. For the Cost Share for inpatient care, refer to“Hospital inpatient care” in this “Cost Share Summary.” The Emergency Department Cost Share does apply if you areadmitted for observation but are not admitted as an inpatient.Family planning ServicesDescription of Family Planning ServicesCopayment /CoinsuranceFamily planning counselingNo chargeGroup ID: 106090 Kaiser Permanente Traditional HMO PlanContract: 1 Version: 73 EOC# 13 Effective: 7/1/22 6/30/23Date: April 20, 2022Subject toDeductibleApplies toOOPM Page 3