Kaiser Permanente Medical Care That Is Not Covered

Exclusions

The general exclusions set forth in this section apply to services and benefits otherwise covered under the Kaiser Permanente Plan. "Service" in this section means any treatment, therapeutic or diagnostic procedure, drug, equipment, or device. When a service is excluded, all other services that are necessary for the excluded service and that would otherwise be a covered benefit are also excluded.

The following are excluded from your Kaiser Permanente coverage:

1. Financial responsibility for conditions covered by Workers' Compensation;


2. Financial responsibility and services for care that is required to be provided only by a governmental agency;


3. Financial responsibility for services that, by law, an Employer is required to provide;


4. Services for military service-connected conditions, as defined by the Veterans' Administration, for which care is reasonably available to the member from the Veterans' Administration;


5. Physical examinations and related services
   1. required for obtaining or maintaining employment or participation in Employee programs,
   2. required for insurance or governmental licensing, or
   3. ordered by a court;


6. Dental services and dental x-rays including dental services following accidental injury to teeth; dental appliances; orthodontia; and dental services resulting from medical treatment such as surgery on the jawbone and radiation treatment;


7. Services related to conception by artificial means (artificial insemination is covered except for donor semen and donor eggs and services related to their procurement and storage) such as in vitro fertilization, ovum transplant, and gamete and zygote intra-fallopian transfer; the cost of donor semen and donor eggs; prescription drug related to these excluded services;


8. Services to reverse voluntary, surgically induced infertility;


9. Experimental or investigational services and those procedures not generally and customarily provided to patients residing in the Kaiser Permanente service area.


10. Cosmetic services, plastic surgery, or other services that are performed primarily to improve appearance and that will not result in significant improvement in physical functions. This exclusion does not apply to covered services for correction of significant disfigurement resulting from an injury or medically necessary surgery, incident to breast reconstruction following a mastectomy, or are necessary for treatment of port wine stains.


11. Non-human and artificial organs and their implantation;


12. Services related to sexual re-assignment;


13. Routine foot-care services that are not medically necessary;


14. Drugs and medications when used for cosmetic purposes;


15. Custodial care, which is assistance with activities of daily living which include, but are not limited to, activities such as walking, getting in and out of bed, bathing, dressing, feeding, toileting, and taking medication; or care that can be performed safely and effectively by persons who, in order to provide that care, do not require licensure or certification or the presence of a supervising licensed nurse.


16. Care in an intermediate care facility. Care for which, in the judgment of a Kaiser Permanente Plan physician, the facilities and services of an acute general hospital or the extended care services of a skilled nursing facility are not medically necessary.

Limitations

1. In the event of a major disaster, epidemic, war, riot, civil insurrection, disability of significant part of Kaiser Permanente personnel, or complete or partial destruction of facilities, or other circumstances beyond Kaiser Permanente's control, Kaiser Permanente will make a good faith effort to provide or arrange for covered services. However, it will not be responsible for any delay or failure in providing benefits or services due to lack of available facilities or personnel.


2. Coverage is not provided for care for conditions for which a member has refused recommended treatment for personal reasons when Medical Group physicians believe that no professionally acceptable alternative treatment exists.


3. Coverage for physical, respiratory, occupational, and speech therapies is limited to conditions (including acute phases of chronic conditions) that are subject to significant improvement in function within a reasonable and generally predictable period. Inpatient and outpatient rehabilitation, including these therapies, is limited to a two-month period per condition.


4. Coverage is not provided for mental health services for the care of chronic psychosis, organic psychosis, and other conditions that a Kaiser Permanente physician believes would not be responsive to therapeutic management; care for mental retardation; care as a condition of parole or probation, unless determined by a Kaiser Permanente physician to be medically necessary and appropriate; court-ordered testing; testing for intelligence, ability, aptitude, or interest.


5. Coverage is not provided for alcohol and drug dependency services as follows: continuation of counseling and treatment for disruptive or physically abusive patients, court-ordered services or as a condition of parole or probation, and methadone maintenance, except that methadone maintenance treatment for a pregnant member throughout her pregnancy and for two months after delivery is provided without charge at a licensed treatment center approved by the Medical Group when prescribed by a Kaiser Permanente physician.


6. Coverage is not provided for internally implanted time-release drugs and injectable contraceptives.

Reductions

1. Refer to the section below entitled, "Third Party Liability".


2. Kaiser Permanente will seek reimbursement for services they have provided to Medicare members for an injury or illness described in (1), above, under the medical expense payment provisions of any motor vehicle insurance policy covering the member. You must furnish information about the existence of any policy, and complete and submit all claims, releases, and other documents necessary for us to comply with federal law.


3. Coordination of Benefits (COB).