 |
 |
 |
 |
 |
 |
 |
 |
|
|
|
|
|
|
 |
|
|
 |
|
|
 |
 |
|
|
|
 |
Summary Plan Description (SPD)
In Case of an Emergency
Definition of DependentsEmergency care is provided at nearly all Plan Hospitals 24 hours a day, 7 days a week. If you are not sure whether your situation is an emergency, call the Emergency Department at your local Plan Hospital and we will advise you on the appropriate action to take. Refer to The Guidebook to Kaiser Permanente Services or your local telephone directory for telephone numbers. For life-threatening conditions, call 911 immediately.
For urgent care, call one of Kaiser’s telephone advice nurses who are registered nurses (RNs) specially trained to help assess medical problems and provide medical advice. They can help solve a problem over the phone and instruct you on self-care at home if appropriate. If the problem is more severe and you need an appointment, they will help you get one.
Payment will be made for covered emergency care services received from out-of-plan providers even if you were injured through the fault of someone else. If you collect any money from the other person or from his or her insurance company, you will be required to reimburse Kaiser (or its designee) for those payments Kaiser made for medical care provided to you for that injury or illness, up to the amount you received from the settlement or judgment. Kaiser shall have a lien on the settlement or judgment for the purpose of that reimbursement.
At Kaiser's request, you shall execute lien forms directing your attorney or the other person to make payments directly to Kaiser from the proceeds of the settlement or judgment. If Kaiser institutes legal action to enforce its lien, the party that substantially prevails shall be reimbursed for the reasonable costs of collection, including attorney fees, by the other party(s).
This provision applies even if the total settlement or judgment you receive is less than your action damages. It is your responsibility to notify Kaiser of any actual or potential claim or legal action you anticipate bringing or have brought against the other person within 30 days from the date of filing a claim or legal action against the other person.
Services Received At An Out-Of-Plan Facility
To be eligible for this benefit, you must notify Kaiser Permanente within 24 hours after care begins (or as soon as reasonably possible). This benefit is provided only for emergency treatment required before your condition permits transfer to a Plan facility. Medically necessary special transportation is covered with prior approval from a Kaiser physician. Kaiser may arrange for your transfer to a Plan facility as soon as it is medically appropriate to do so. This benefit applies only to care that is a covered service under the Kaiser service agreement.
Your enrollment packet included The Guidebook to Kaiser Permanente Services, which lists Kaiser phone numbers to call in case of an emergency. These phone numbers are also on the back on your Kaiser I.D. card.
Services At Out-Of-Plan Facilities Outside Kaiser Service Area
If you are injured or become unexpectedly ill while you are outside the Kaiser Service Area, they will cover Out-of-Plan Emergency Services that could not reasonably be delayed until you could get to a Plan Facility.
Services At Out-Of-Plan Facilities Within Kaiser Service Area
If you are within the Kaiser Service Area, they will cover Out-of-Plan Emergency Services only if going to a Plan Facility for treatment would have caused a delay resulting in permanent damage to your health.
Limitations on Benefits for Services Received From Out-Of-Plan Physicians or Facilities
- Kaiser will pay only what they determine to be reasonable and customary charges for care received from out-of-plan providers. Any amounts in excess of what Kaiser considers reasonable and customary must be paid by you.
- Any other health care coverage program (Medicare, insurance, government
programs, etc., but not including Medicaid/Medi-Cal or Medicare for members who
have elected, under federal law, to have their group contract benefits primary
and Medicare benefits secondary) is payable first before your Kaiser Permanente
benefit for emergency services at an out-of-plan facility is payable. However,
if payment under the other program is not made within a reasonable amount of
time, Kaiser will pay the physicians and facilities who provided the care if
you:
- Assign all other benefits to Kaiser and agree to fully cooperate with Kaiser in obtaining these benefits;
- Allow Kaiser to obtain confirmation from the source of other benefits that such benefits have not already been paid; and
- Furnish Kaiser with any information necessary to implement these
provisions.
- Payments under this benefit are subject to reduction if you may have been injured through the fault of someone else.
Kaiser may recover any overpayment made to them as a result of items 2 and 3 above from the person who received payment or from the person or organization obligated to pay for the care received.