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Summary Plan Description (SPD)
Table of Contents
- Title Page
- General Information
- Assistance
- Governing Benefit Documents
- Keep Your Records Current
- Letter of Introduction
- Eligibility Requirements
- Eligibility Requirements
- Crediting Disability Hours for Retiree Eligibility
- Disability or Partial Disability Retirees
- Retirees Working Maintenance
- Eligibile Spouse
- Termination of Eligibility for Spouse
- Coordination of Benefits - Duplicate Coverage
- Enrollment Requirements
- You Must Enroll and Agree to Make a Monthly Payment
- Application Process for Enrollment in the Retiree Health Plan
- Retirees Working Maintenance
- Deadline for Enrollment in the Retiree Health Plan and When Coverage Begins
- Medicare Enrollment Required
- Medicare Assignments on HMOs
- Third Party Liability
- Annual Open Enrollment Period
- Required Monthly Pension Deduction/Self-Payment
- Plan Benefits Available to You
- Brief Summary Comparison of Retiree Health Plan Benefits
- Easy Reference – Frequently Asked Questions
- General Plan Definitions
- Plan Amendment Procedures
- Termination & Reduction of Coverage
- Termination of Coverage for Retiree
- Return to Covered Employment
- Suspension of Benefits for Other Than Return to Covered Employment
- Termination of Coverage for Spouse
- Federal Laws You Should Know About
- COBRA
- Health Insurance Portability & Accountability Act (HIPAA)
- HIPAA Privacy Statement
- The Newborns’ and Mothers’ Health Protection Act (Newborns’ Act)
- Women’s Health & Cancer Rights Act (WHCRA)
- The Mental Health Parity Act (MHPA)
- Selecting an HMO, Premium Reimbursement or Medicare Supplement Plan
- HMO Medical Plans
- Medicare Supplement Plan for Retirees/Spouses
- Premium Reimbursement Plan
- Questions and Answers About the Premium Reimbursement Plan
- Kaiser Permanente HMO Medical Plan for Early Retirees
- Kaiser Permanente Summary of Benefits for Early Retirees
- Basic Information
- In Case of an Emergency
- Online Internet Website
- Kaiser Permanente Medical Care That Is Not Covered
- Continuation of Group Coverage under Federal or State Law
- Coordination of Benefits
- Extension of Benefits
- Third Party Liability
- PacifiCare HMO Medical Plan for Early Retirees
- Summary of Benefits
- Basic Information
- In Case of An Emergency Situation
- Chiropractic Benefit
- Allergy Serum Benefit
- Women’s Health & Cancer Rights Act
- Online Internet Website
- Exclusions and Limitations
- Converting To An Individual Plan
- COBRA
- Coordination of Benefits
- Extension of Benefits
- Third Party Liability
- Death Benefit for Retirees
- HMO Plans Age 65 and Older or Enrolled in Medicare Parts A & B at Any Age
- Kaiser Permanente - Senior Advantage
- Summary of Benefits
- Medicare Eligibility Requirements
- Exclusions, Limitations, and Reductions
- Medicare as Secondary Payer
- Coordination of Benefits
- PacifiCare – Secure Horizons
- Medicare Supplement Plan
- Participants Enrolled in Medicare Parts A and B
- Becoming Eligible for Medicare
- A Brief Explanation of Medicare
- Retiree Health Plan Medicare Supplement Benefits
- Mandatory Generic Prescription Drug Plan
- For PacifiCare Early Retirees, Medicare Supplement Plan and Premium Reimbursement Plan
- Questions and Answers on Generic Drugs
- Walk-In Pharmacy Plan - Prescription Solutions
- Mail Service Pharmacy Plan - Prescription Solutions
- Prescription Drug Reimbursement Plan – Out-of-Network Pharmacies
- Limitations and Exclusions
- Prescription Solutions California Pharmacy Chains
- Dental Plans Available to Disability Pensioners on Medicare Parts A and B under Age 65
- Vision Service Plan (VSP) Disability Retiree Under Age 65
- Benefits
- Co-payments and Schedule of Benefits
- Using the Plan
- Non-Panel Providers
- Limitations
- Complaints
- Integrated Member Assistance Program (MAP) and Managed Mental Health & Chemical Dependency Benefits Program
- Introduction
- PacifiCare HMO Plan Participants
- Access Your MAP Anytime
- Mental Health & Chemical Dependency Benefits Program
- What is Clinically/Medically Appropriate Treatment?
- How Does the Program Work?
- What Are the Benefits?
- Questions and Answers About the Program
- Submission of Claims
- Exclusions & Limitations
- Medical Necessity – Request for Reconsideration of Denial and Appeals Procedures
- Disclosure Information
- Claims & Appeal Rules
- Introduction
- Pre-Service Claims
- Post-Service Claims
- Retiree Eligibility Issues
- Exhaustion of the Appeal Process
- Questions & Answers Common to Claims and Appeals
- Your Rights Under the Employee Retirement Income Security Act of 1974 (ERISA)
- Receive Information About Your Plan and Benefits
- Continue Group Health Plan Coverage
- The Newborn & Mothers Health Protection Act
- Certificate of Creditable Coverage
- Prudent Actions by Plan Fiduciaries
- Enforce Your Rights
- Assistance With Your Questions
- Notice To Participants
Amendments
- Amendment 1 - Eligible Spouse Provisions
- Amendment 2 - New Dental Schedule of Benefits
- Amendment 3 - Revisions to Dental Schedule of Benefits
- Amendment 4 - New Dental Schedule
- Amendment 5 - Mandatory Generic Prescription Drug Plan Copayments
- Amendment 6 - Mandatory Generic Prescription Pharmacy Chains
- Amendment 7 - Kaiser Early Retiree Prescriptions
- Amendment 8 - COBRA/Legal Spouse Rules
- Amendment 9 - New DeltaCare Schedule of Benefits
- Amendment 10 - HIPAA Exception to Initial Enrollment Deadline
- Amendment 11 - Mandatory Generic Prescription Drug Plan Limitations
- Amendment 12 - HMO Plan Benefits
- Amendment 13 - Medicare Supplement Plan & Premium Reimbursement Plan
- Amendment 14 - Special Rule for Medicare 'Double Coverage' Members