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Kaiser Foundation Health Plan, Inc.Southern California RegionA nonprofit corporationEOC #56 - Kaiser Permanente HSA-Qualified High DeductibleHealth Plan (“HDHP”) HMOEvidence of Coverage forCSEBA-MP/BASSETT UNIFIED SCHOOL DISTRICTGroup ID: 101656 Contract: 1 Version: 65 EOC Number: 56July 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

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TABLE OF CONTENTS FOR EOC #56Cost Share Summary . 1Accumulation Period . 1Deductibles and Out-of-Pocket Maximums . 1Cost Share Summary Tables by Benefit . 1Introduction . 17About Kaiser Permanente . 17Your Plan. 17Term of this EOC . 18Definitions . 18Premiums, Eligibility, and Enrollment . 23Premiums. 23Who Is Eligible. 23How to Enroll and When Coverage Begins. 26How to Obtain Services . 28Routine Care. 28Urgent Care . 28Not Sure What Kind of Care You Need? . 28Your Personal Plan Physician . 28Getting a Referral . 29Second Opinions . 31Contracts with Plan Providers . 32Receiving Care Outside of Your Home Region . 32Your ID Card . 33Timely Access to Care . 33Getting Assistance . 33Plan Facilities . 34Emergency Services and Urgent Care . 34Emergency Services . 34Urgent Care . 35Payment and Reimbursement . 36Benefits . 36Your Cost Share . 37Administered Drugs and Products . 40Ambulance Services . 41Bariatric Surgery . 41Behavioral Health Treatment for Autism Spectrum Disorder . 41Dental and Orthodontic Services . 43Dialysis Care . 44Durable Medical Equipment (“DME”) for Home Use . 44Emergency and Urgent Care Visits . 46Family Planning Services . 46Fertility Services . 46Fertility Preservation Services for Iatrogenic Infertility . 47Health Education . 47Hearing Services . 47Home Health Care . 47Hospice Care . 48

Hospital Inpatient Care . 49Injury to Teeth . 49Mental Health Services . 49Office Visits . 50Ostomy and Urological Supplies . 51Outpatient Imaging, Laboratory, and Other Diagnostic and Treatment Services . 51Outpatient Prescription Drugs, Supplies, and Supplements . 51Outpatient Surgery and Outpatient Procedures . 54Preventive Services . 55Prosthetic and Orthotic Devices . 55Reconstructive Surgery . 56Rehabilitative and Habilitative Services. 57Services in Connection with a Clinical Trial . 57Skilled Nursing Facility Care . 58Substance Use Disorder Treatment . 58Telehealth Visits . 59Transplant Services . 59Vision Services for Adult Members . 60Vision Services for Pediatric Members . 60Exclusions, Limitations, Coordination of Benefits, and Reductions . 61Exclusions . 61Limitations . 64Coordination of Benefits . 64Reductions . 64Post-Service Claims and Appeals . 66Who May File. 66Supporting Documents . 67Initial Claims . 67Appeals . 68External Review . 69Additional Review. 69Dispute Resolution . 69Grievances . 69Independent Review Organization for Non-Formulary Prescription Drug Requests . 72Department of Managed Health Care Complaints. 73Independent Medical Review (“IMR”) . 73Office of Civil Rights Complaints . 74Additional Review. 74Binding Arbitration . 74Termination of Membership . 76Termination Due to Loss of Eligibility. 76Termination of Agreement. 77Termination for Cause . 77Termination of a Product or all Products. 77Payments after Termination . 77State Review of Membership Termination . 77Continuation of Membership. 77Continuation of Group Coverage . 77Continuation of Coverage under an Individual Plan . 81Miscellaneous Provisions . 81Administration of Agreement . 81

Advance Directives . 81Amendment of Agreement. 81Applications and Statements . 81Assignment . 81Attorney and Advocate Fees and Expenses . 81Claims Review Authority . 81EOC Binding on Members . 82ERISA Notices . 82Governing Law . 82Group and Members Not Our Agents. 82No Waiver . 82Notices Regarding Your Coverage . 82Overpayment Recovery . 82Privacy Practices . 83Public Policy Participation . 83Helpful Information. 83How to Obtain this EOC in Other Formats . 83Provider Directory . 83Online Tools and Resources . 83How to Reach Us. 84Payment Responsibility . 85

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.For Services that are subject to the Plan Deductible or the Drug Deductible, you must pay Charges for covered Services youreceive during the Accumulation Period until you reach the deductible amounts listed below. All payments you maketoward your deductibles apply to the Plan Out-of-Pocket Maximum amounts listed below.Note: The Plan Deductible amount is subject to increase if the U.S. Department of the Treasury changes the minimumdeductible required in High Deductible Health Plans.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 Deductible 2,800 2,800 5,600Drug DeductibleNot applicableNot applicableNot applicablePlan Out-of-Pocket Maximum (“OOPM”) 5,600 5,600 11,200Cost 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: 101656 Kaiser Permanente HSA-Qualified High Deductible Health Plan (“HDHP”) HMOContract: 1 Version: 65 EOC# 56 Effective: 7/1/22 6/30/23Date: April 5, 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) 10 per visit 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 Services20% Coinsurance Nonemergency ambulance and psychiatric transport van Services20% Coinsurance Behavioral health treatment for autism spectrum disorderDescription of Behavioral Health Treatment ServicesCovered ServicesCopayment /Coinsurance20% Coinsurance up toa maximum of 10 perdaySubject toDeductible Applies toOOPM Dialysis careDescription of Dialysis Care ServicesEquipment and supplies for home hemodialysis and home peritonealdialysisCopayment /CoinsuranceNo chargeGroup ID: 101656 Kaiser Permanente HSA-Qualified High Deductible Health Plan (“HDHP”) HMOContract: 1 Version: 65 EOC# 56 Effective: 7/1/22 6/30/23Date: April 5, 2022Subject toDeductible Applies toOOPM Page 2

Description of Dialysis Care ServicesCopayment /CoinsuranceSubject toDeductibleApplies toOOPMOne routine outpatient visit per month with the multidisciplinarynephrology team for a consultation, evaluation, or treatmentNo charge Hemodialysis and peritoneal dialysis treatment at a Plan Facility 10 per visit Durable Medical Equipment (“DME”) for home useDescription of DME ServicesCopayment /CoinsuranceSubject toDeductibleApplies toOOPMBlood glucose monitors for diabetes blood testing and their supplies20% Coinsurance Peak flow meters20% Coinsurance Insulin pumps and supplies to operate the pump20% Coinsurance Other Base DME Items as described in this EOC20% Coinsurance Supplemental DME items as described in this EOC20% Coinsurance Retail-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 visits20% Coinsurance 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.Group ID: 101656 Kaiser Permanente HSA-Qualified High Deductible Health Plan (“HDHP”) HMOContract: 1 Version: 65 EOC# 56 Effective: 7/1/22 6/30/23Date: April 5, 2022Page 3