Bridge Program


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Bridge Program

  1. 1. The Kaiser Permanente Bridge Program A community service of Kaiser Foundation Health Plan of Georgia, Inc.
  2. 2. Across America there are an estimated 45.7 million people who are uninsured. In our state alone, close to two million Georgians fall into this category. Some may work for employers who do not provide coverage for workers’ dependents. Others may not have access to employer-sponsored health coverage at all. In response to this growing problem, Kaiser Permanente, a nonprofit health plan, has created The Kaiser Permanente Bridge Program. This unique program is designed to help individuals and families whose family income is at or below 300 percent of the federal poverty standard. Members of this program obtain health care coverage at a reduced cost for up to two years if all eligibility requirements continue to be met. The Health Plan may periodically confirm members are still meeting the subsidy eligibility requirements. Through The Kaiser Permanente Bridge Program, Kaiser Permanente will offer health benefits for a very low monthly charge. Individuals and families will pay a fraction of the normal cost depending on the number of people in their household. As a community service, Kaiser Permanente will subsidize 95 percent of the cost. To apply, please contact a Kaiser Permanente Bridge Program participating agency. 1
  3. 3. What you’ll find inside The Kaiser Permanente advantage Learn why more than 270,000 people in Atlanta choose Kaiser Permanente 3 to care for their health. How does The Kaiser Permanente Bridge Program work? Learn about important features and how the program is administered. 5 Who is eligible Find out about The Kaiser Permanente Bridge Program eligibility requirements. 5 The Kaiser Permanente Bridge Program highlights Review your plan benefits and our coverage area. 6 Our privacy practices Read a description of how medical information about you may be used 9 and disclosed, and how you can get access to it. Additional information Learn more about The Kaiser Permanente Bridge Program coverage, 15 our pharmacy formulary, preauthorization, exclusions, and more. 2
  4. 4. ■ The Kaiser Great care and service For more than 20 years, Kaiser Convenience We make it easy to get the care Permanente Permanente has been providing metro-Atlanta with quality health you need, when you need it. Whether it’s locations close to advantage care that’s convenient, simple, and affordable. It’s our distinct approach where you live or work, seeing a physician when you need one, or to health care that keeps our mem- multiple services under one roof, bers coming back year after year: we’ve got you covered. And you You’ve probably heard about won’t have to worry about filing ■ Total health claims when you visit our medical our dedication to quality care, centers or any of our affiliated At Kaiser Permanente, we’re doctors and hospitals. committed to your total health— excellent service, and unmatched mind, body, and spirit. You’ll like You’ll also enjoy the convenience how we make it easier for you to convenience. But there are more of many online services. On our take an active role in your own Web site,, you can empower health. We help you live well reasons than ever to make yourself with many 24-hour health through health education classes, resources including: discounts on health-related services, Kaiser Permanente your and much more. And you’re covered ■ Health assessment tools for the preventive care you need, partner in health. like routine physicals, well-child ■ Personalized health improvement care, mammograms, immunizations, plans and more. So you can stay healthy ■ Health encyclopedia and live your life to the fullest. Healthy Solutions. ■ Online prescription refills ■ Personalized care Get your own personal health ■ Routine appointment requests When you choose a Kaiser coach 24 hours a day, 7 days a Nurse advice by e-mail Permanente doctor, you’ll get ■ week by phone—at no cost— quality care from a doctor who through Kaiser Permanente takes the time to get to know you Healthy Solutions. and your health needs. You’ll have ■ Talk about tests or all the things you need to get the procedures, upcoming personalized care you deserve— appointments, medications, compassionate people backed by diet, or exercise. medical excellence, advanced ■ Get information about technology, and leading-edge conditions, general health, research. and wellness. ■ Learn about new techniques to help take control of specific conditions or overall health. ■ Receive personalized check-in calls. ■ Get additional health infor- mation mailed to your home. 3
  5. 5. Kaiser Permanente ■ Great discounts Consumer Choice Medical Centers We even make it more affordable Option to live healthy. Through our When you join Kaiser Permanente, SelfWise program, you can take As part of a state law, you have you’ll have the freedom to choose advantage of a variety of health- another option available to you to get care at one of our 15 modern related discounts** including: through The Kaiser Permanente medical centers, and you’ll see why Bridge Program. The Consumer members keep coming back. ■ Health club membership Choice Option (CCO) allows you ■ ■ Weight Watchers membership to nominate and use providers not Save time by seeing a doctor, normally available through our getting lab tests or X-rays, and ■ Massage therapy, chiropractic, health plan, while still receiving picking up a prescription all in acupressure, and acupuncture benefits comparable to those you the same building.* services would receive when using in- ■ See a doctor at night or on week- ■ Vision care network providers. This option costs ends at our after-hours locations. an additional 17.5 percent and is ■ Get a same-day appointment based on the full monthly premium, when you need one. not on the portion you pay after Stay connected with the subsidy. ■ Receive quality, personalized My health manager† care from a doctor who takes If you would like more information the time to listen. on the CCO—including an election With the My health manager section of, you have form, information on how to secure 24-hour access to your nominate a provider, and rate health record online. Kaiser information—please call our A few things that might Permanente’s electronic patient consumer choice representative at surprise you. health record system enables (404) 364-4900. If you are interest- you to stay connected to your ed in enrolling in the CCO, please Want more reasons to choose Kaiser health, and it allows your doctor wait until after you receive and Permanente? Here are some that may to view your information instantly review the CCO materials to return surprise you: right in the exam room. Below your medical questionnaire. The ■ Wide selection of doctors are just some of the features medical questionnaire and CCO elec- available to you: tion form must be returned to Kaiser In addition to the physicians in our Permanente at the same time. medical centers, you’ll have access ■ E-mail your doctor’s office to more than 1,800 affiliated commu- ■ Review past office visits * Most medical centers. nity doctors. ■ Schedule, request, cancel, ** Available to Kaiser Permanente and view appointments members and their enrolled family ■ Easy access members. Discounts and services You can self-refer to select specialties ■ View most lab test results are provided on a fee-for-service including Ob/Gyn, dermatology, ■ Access the health records of basis, do not replace and cannot be optometry, ophthalmology, and your children combined with any existing benefit, behavioral health. and are not covered benefits. Kaiser ■ View immunization history Permanente assumes no responsibility ■ Emergency care ■ Order prescription refills and for the arrangement, nature, quality, You’ll have peace of mind knowing view current medications or outcome of the services. For more information, call (404) 261-2590. you’re covered for emergency care † Available to members receiving anywhere you travel. care/filling prescriptions at Kaiser Permanente Medical Centers. 4
  6. 6. The Kaiser Membership in the Kaiser Permanente Bridge Program at the subsidized All persons applying to The Kaiser Permanente Bridge Program must Permanente amount is limited to 24 months from the date of initial enrollment. At meet the requirements outlined below to qualify: Bridge Program— the end of 24 months, the reduced premium offered through The Kaiser ■ The subscriber and all applying dependents must live in Kaiser How does it Permanente Bridge Program will end. Members will receive notification Permanente’s Georgia Region Service Area. work? regarding their post termination coverage options. ■ The annual household income must be at or less than 300 Target Audiences percent of the current federal The Kaiser Permanente Bridge poverty guidelines. Program members will receive The Kaiser Permanente Bridge ■ Family members must be ineligible benefits comparable to those Program is intended for individuals for any other health insurance offered to other Kaiser Permanente and families facing short-term program including Medicare, members. Eligible members will be problems. It is for persons who are Medicaid, PeachCare, and billed by Kaiser Permanente and not eligible for Medicaid, Medicare, employer-sponsored health care. pay the designated portion of or PeachCare; and who do not have access to employer–sponsored health ■ At least one family member their premium directly to Kaiser Permanente each month. care insurance. (subscriber, spouse, or dependent) must be actively enrolled with a To be covered, all health care services Enrollment into The Kaiser Perma- participating partner. must be provided, authorized, or nente Bridge Program is limited; ■ An applicant may not have been prescribed by a Kaiser Permanente Kaiser Permanente reserves the right previously enrolled in The Kaiser Plan provider, except in cases of a to stop accepting new enrollments Permanente Bridge Program. medical emergency. If any program at any time without prior notice. ■ Age 64 and under. eligibility requirement changes for the member (or dependent), they Who is Eligible? Upon acceptance into The Kaiser must notify The Kaiser Permanente Permanente Bridge Program, the Before you review the specific Bridge Program in writing. Please Health Plan may periodically confirm plan information, check to make send changes to: members are still meeting the subsidy sure you live within our Service fax: 404-364-4767 eligibility requirements outlined in Area. You’re eligible to apply for e-mail: the Evidence of Coverage. If the The Kaiser Permanente Bridge Health Plan determines that the Program coverage if you live in one Bridge Program member is no longer of the following counties: Barrow, meeting the eligibility requirements, How is The Kaiser Bartow, Butts, Carroll, Cherokee, the Health Plan will terminate Clayton, Cobb, Coweta, Dawson, Permanente Bridge DeKalb, Douglas, Fayette, Forsyth, coverage at the end of the month Program Administered? Fulton, Gwinnett, Hall, Haralson, under The Kaiser Permanente Bridge Program. Persons interested in The Kaiser Heard, Henry, Lamar, Meriwether, Permanente Bridge Program must Newton, Paulding, Pickens, Pike, apply through a participating agency. Rockdale, Spalding, and Walton. 5
  7. 7. The Kaiser Permanente Bridge Program Highlights Deductible - Individual / Family None Coinsurance Out-of-Pocket Max - Individual / Family Not Applicable Maximum Benefit While Covered 1 Unlimited Coinsurance Not Applicable Benefits Office Services ■ Primary Care (Including Laboratory and Radiology Services) $10 copay ■ Specialty Care (Including Laboratory and Radiology Services) $10 copay ■ Preventive Services 2 Plan pays 100% ■ Maternity (obstetrician/midwife) Plan pays 100% ■ High Tech Radiology Services (MRI, CT, PET, others) $10 copay Outpatient Services ■ Rehabilitation Therapies - 20 visits per year (Physical and Occupational Therapies combined) $10 copay ■ Outpatient Hospital and Surgical Facility (Including Laboratory and Radiology Services) $10 copay ■ High Tech Radiology Services (MRI, CT, PET, others) $10 copay Emergency Services ■ Emergency Room Visit (per visit; copay waived if admitted) $50 copay ■ After-Hours Urgent Care (per visit) $10 copay ■ Ambulance (per trip) $50 copay Inpatient Services ■ Hospital (facility charge) Plan pays 100% ■ Maternity (hospital delivery) Plan pays 100% Mental Health Services ■ Outpatient Mental Health 3 - Limited to 48 visits per calendar year $10 copay ■ Inpatient Mental Health Facility - 30 days per calendar year Plan pays 100% Pharmacy Services - 30 day supply Mail Order available ■ Generic Drugs - Kaiser Permanente Medical Centers/Designated community pharmacies $10 copay/$16 copay ■ Brand Preferred Drugs - Kaiser Permanente Medical Centers/Designated community pharmacies $20 copay/$26 copay Other Services ■ Durable Medical Equipment/Prosthetics and Orthotics Plan pays 100% ■ Vision Exams $10 copay 1. Some benefits may have limitations. 2. Office visit copay may apply. Well-Child Visit: No Charge up to age 2. 3. Limited to 48 visits. Outpatient Mental Health and Outpatient Group Therapy combined. This is a summary description and is not intended to replace your Kaiser Permanente Bridge Program Evidence of Coverage, which contains the complete provisions of this coverage. 6 Some services require preauthorization.
  8. 8. The Kaiser Permanente Bridge Program Monthly Rates* Full Monthly Member Monthly rate Premium with 95% Subsidy Subscriber Only $431.52 $21 Subscriber + Child(ren) $776.73 $38 Subscriber + Spouse $863.04 $43 Subscriber + Family $1,294.55 $64 *Rates are effective for 24 months from the date of enrollment. Premium subsidy is based on income. If you are 65 or older, please inquire about our coverage for Medicare-eligible members at 1-888-468-0100. Frequently asked questions 1. Do I have to go to Kaiser 3. How do I find out which Permanente’s Medical Centers doctors are available? to get care? Visit our searchable online Medical No. You can choose to get care at Staff Directory at our medical centers, where you’ll You can also refer to the printed enjoy the convenience of being able Kaiser Permanente HMO Physician to see a doctor and get lab, X-ray, Directory. and pharmacy services all in the same building at most medical centers. Or, you can visit one of our 4. What if I need emergency care 1,800 affiliated community physicians. when I’m traveling? You’re covered for emergency or 2. Can I see the doctor I have now urgent care anywhere you travel. if I choose a Kaiser Permanente Receiving emergency or urgent care HMO plan? outside of our metro-Atlanta Service Area is one of the few times you If your current primary care doctor may need to file a claim. is one of our 1,800 affiliated community physicians, you can continue to see him or her. If you 5. Can I cover just my children? have a specialist, and that person is Yes. You can get coverage for just part of our network, you may be your children, just your spouse, just able to see him or her as well. yourself, or any combination of the (You will need a referral from above who live in our Service Area. your Kaiser Permanente personal You just need to choose the appro- physician for most specialty care.) priate plan. You may also see another provider outside of our network at your own expense. 6. Why is Kaiser Permanente subsidizing the premiums for this program? We believe in supporting healthy communities. One of the ways we are able to accomplish this is by directly offering care through our own health care providers in our own medical centers. 7
  9. 9. Where to get care PICKENS DAWSON For a current provider listing, visit our searchable Medical Staff Directory at Kaiser Permanente Medical Centers (15 locations) ● Affiliated Community Physicians’ Medical Offices (Over 1,800 doctors) HARALSON H 20 Affiliated Hospitals* * The hospital that you will be admitted to will be determined by the primary care physician you select. CARROLL HEARD Our medical centers Alpharetta Medical Center 3550 Preston Ridge Road PIKE LAMAR MERIWETHER Alpharetta, GA 30005 Brookwood at Peachtree Medical Office 1745 Peachtree St., Suite U Atlanta, GA 30309 Cascade Medical Center West Cobb Medical Center Henry Towne Centre Medical Center 1175 Cascade Parkway 3640 Tramore Point Parkway 1125 Towne Centre Village Drive Atlanta, GA 30311 Austell, GA 30106 McDonough, GA 30253 Crescent Medical Center Panola Medical Center * Medical centers designated for 200 Crescent Centre Parkway 5440 Hillandale Drive after-hours urgent care. Tucker, GA 30084 Lithonia, GA 30058 Hours: Cumberland Medical Center* Monday through Friday, 6 to 9:30 p.m.; Southwood Medical Center* 2525 Cumberland Parkway Saturday, 9 a.m. to 8:30 p.m.; 2400 Mt. Zion Parkway Atlanta, GA 30339 Sunday, 10 a.m. to 5:30 p.m. Jonesboro, GA 30236 Forsyth Medical Office Stonecrest Medical Center 1400 Northside Forsyth Drive 8011 Mall Parkway Suite 350 Lithonia, GA 50038 Cumming, GA 30041 Sugar Hill - Buford Medical Center Glenlake Medical Center 1435 Broadmoor Boulevard 20 Glenlake Parkway Sugar Hill, GA 30518 Atlanta, GA 30328 TownPark Medical Center Gwinnett Medical Center* 750 TownPark Lane 3650 Steve Reynolds Boulevard Kennesaw, GA 30144 Duluth, GA 30096 8
  10. 10. Our privacy In the course of providing and administering health care, II. About our responsibility to practices we collect various types of health information from various sources, protect your PHI such as you, other members (for By law, we must example, your spouse or parents), and other health care professionals. 1) protect the privacy of your PHI; Notice of privacy The types of information we collect and maintain about our members 2) tell you about your rights and our practices include among other things, medical legal duties with respect to your This notice describes how medical and hospital records, such as general PHI; and information about you may be used medical, mental health, and sub- and disclosed and how you can get stance abuse patient records, labora- 3) tell you about our privacy access to this information. Please tory results, X-ray results, pharmacy practices and follow our notice review it carefully. records, and appointment records. currently in effect. In this notice we use the terms Kaiser Permanente collects other We take these responsibilities “we,” “us” and “our” to describe the health plan information using a vari- seriously and, as in the past, we will Kaiser Permanente, Georgia Region. ety of techniques. Examples include: continue to take appropriate steps to For more details, please refer to safeguard the privacy of your PHI. section IV. of this notice. ■ Collecting information from you through surveys, applications, related forms, and other written requests and communications; I. What is “Protected III. Your rights regarding ■ Collecting information from your Health Information?” employer, benefits plan sponsor, your PHI Your protected health information or association regarding group This section tells you about your (PHI) is health information that con- coverage that you may have rights regarding your PHI, for tains identifiers, such as your name, through group applications, example, your medical and billing social security number, or other census data, and other written records. It also describes how you information that reveals who you requests and communications; can exercise these rights. are. For example, your medical ■ Collecting information from Your right to see and receive record is PHI because it includes visitors to our Web site such copies of your PHI your name and other identifiers. as online forms, site visit data, and In general, you have a right to see If you are a Kaiser Foundation other online communications; and and receive copies of PHI in Health Plan member and also designated record sets such as your ■ Collecting information from con- an employee of any Kaiser medical record or billing record. sumer or medical reporting agen- If you would like to see or receive a Permanente company, PHI does not cies or other sources such as copy of such a record, please write include the health information in insurance support organizations to us. When you know the Kaiser your employment records. and credit bureaus. Permanente facility or medical center where you received your care, please write to us at that address. If you don’t know where your records that you want to see are located, please write to us at Customer Service Department, 9
  11. 11. Kaiser Foundation Health Plan of Your request should be sent as Your right to request limits Georgia, Inc., Nine Piedmont Center, described above in the section en- on uses and disclosures of 3495 Piedmont Road, NE, Atlanta, titled “Your right to see and receive your PHI Georgia 30305-1736. After we receive copies of your PHI.” If we approve You may request that we limit your written request, we will let you your request, we will make the our uses and disclosures of your PHI know when and how you can see or correction or addition to your PHI. for treatment, payment, and health obtain a copy of your record. If you If we deny your request, we will care operations purposes. However, agree, we will give you a summary or tell you why and explain your by law, we do not have to agree to explanation of your PHI instead of right to file a written statement of your request. Because we strongly providing a copy. We may charge disagreement. believe that this information is you a fee for the copy, summary, or needed to manage care of our mem- explanation. If we don’t have your Your right to an accounting of bers/patients appropriately, it is our record but we know who does, we disclosures of PHI policy not to agree to requests for will tell you who to contact to You may ask us for a list of our restrictions. request it. disclosures of your PHI. If you would like a list of disclosures, please write Your right to receive a paper In limited situations, we may deny to us as described above in the sec- copy of this notice some or all of your request to see or tion entitled “Your right to see and receive a copy of your records, but receive copies of your PHI.” The list You also have a right to receive if we do, we will tell you why in we give you will include disclosures a paper copy of this notice upon writing and explain your right, if any, made in the last six years, unless you request. to have our denial reviewed. request a shorter time period or if fewer than six years have passed Your right to choose how we since April 14, 2003. For example, if send PHI to you you requested a list of disclosures on You may ask us to send your PHI April 14, 2005, the list would cover IV. Kaiser Permanente to you at a different address (for only two years. example, your work address) or by companies subject to different means (for example, fax You are entitled to one disclosure this notice instead of regular mail). When we accounting in any 12-month period This notice applies to the Kaiser can reasonably and lawfully agree to at no charge. If you request any Permanente, Georgia Region which your request, we will. However, we additional accountings fewer than includes: are permitted to charge you for any 12 months later, we may charge a fee. additional cost of sending your PHI ■ The Southeast Permanente Medical to different addresses or by Except as may otherwise be re- Group, Inc. (TSPMG) different means. quired under state law, an accounting does not include certain disclosures, ■ Kaiser Foundation Health Plan of Your right to correct or update for example, disclosures to carry out Georgia, Inc. including its health your PHI treatment, payment and health care plan and provider operations; If you believe there is a mistake in operations; disclosures that occurred prior to April 14, 2003; disclosures for ■ Kaiser Foundation Hospitals your PHI or that important informa- tion is missing, you may request that which Kaiser Permanente, Georgia (KFH), as described below; and we correct, delete, or add to the Region had a signed authorization; disclosures of your PHI to you; dis- ■ Kaiser Foundation Health Plan, record. Please write to us and tell us what you are asking for and why we closures for notifications for disaster Inc. (KFHP, Inc.), as described should make the correction, deletion, relief purposes; or disclosures to below or addition. persons involved in your care and persons acting on your behalf. 10
  12. 12. Our health care delivery sites Sometimes we are allowed by law to 2) for your treatment; 3) for case include Kaiser Permanente medical use and disclose certain PHI without management and care coordination; centers, our member call advice and your written permission. We briefly or 4) to direct or recommend avail- appointment centers, and our mem- describe these uses and disclosures able treatment options, therapies, ber Web site. below and give you some examples. health care providers, or care set- tings. For example, we may tell you To provide you with the health How much PHI is used or about a new drug or procedure or care you expect when treating you, disclosed without your written per- about educational or health manage- paying for your care, and conducting mission will vary depending, for ment activities. our operations, such as quality assur- example, on the intended purpose ance, accreditation, licensing and of the use of disclosure. Sometimes ■ Payment: Your PHI may be need- compliance, these Kaiser Permanente we may only need to use or disclose ed to determine our responsibility companies share your PHI with each a limited amount of PHI, such as to to pay for, or to permit us to bill other. send you an appointment reminder and collect payment for, treatment or to confirm that you are a health and health-related services that Our personnel may have plan member. At other times we may you receive. For example, we access to your PHI as employees, need to use or disclose more PHI may have an obligation to pay for physicians, volunteers, persons such as when we are providing health care you receive from an working with us in other capacities, medical treatment. outside provider. When you or or professional staff members and the provider sends us the bill for others authorized to enter informa- ■ Treatment: This is the most impor- health care services, we use and tion into a medical record of a tant use and disclosure of your disclose your PHI to determine Kaiser Permanente Medical Center. PHI. For example, our physicians, how much, if any, of the bill we Our region may also share your PHI nurses, and other health care are responsible for paying. with KFH and KFHP, Inc. in connec- personnel, including trainees, tion with shared services and other involved in your care use and ■ Health care operations: We may national Kaiser Permanente activities disclose your PHI to diagnose use and disclose your PHI for for treatment, payment, or health your condition and evaluate your certain health care operations, care operations purposes. For exam- health care needs. Our personnel such as: quality assessment and ple, if you are being considered for will use and disclose your PHI in improvement; training and evalua- a transplant, we will share your PHI order to provide and coordinate tion of health care professionals; with our Kaiser Permanente National the care and services you need, licensing; accreditation; activities Transplant Network. for example: prescriptions; X-rays; relating to the creation, renewal and lab work. If you need care or replacement of health insurance from health care providers who or health benefits; conducting are not part of Kaiser Permanente, medical review; legal services; such as community resources to auditing functions, including fraud V. How we may use and assist with your health care needs and abuse detection and compli- disclose your PHI at home, we may disclose your ance programs; customer services; PHI to them. and determining premiums and Your confidentiality is important to other costs of providing health us. Our physicians and employees ■ Treatment alternatives and health- care. We may also disclose your are required to maintain the con- related benefits and services: PHI for certain health care fidentiality of the PHI of our In some instances, the law permits operations of other health plans members/patients and we have us to contact you: 1) to describe and health care providers. policies and procedures and other our network or describe the extent safeguards to help protect your PHI to which we offer and pay for from improper use and disclosure. various products and services; 11
  13. 13. ■ Business associates: We may ■ Communications with family and ■ Research: Kaiser Permanente contract with business associates others when you are not present: engages in extensive and im- to perform certain functions or There may be times when it is portant research. Some of our activities on our behalf, such as necessary to disclose your PHI to research may involve medical payment and health care opera- a family member or other person procedures and some is limited to tions. These business associates involved in your care because collection and analysis of health must agree to safeguard your PHI. there is an emergency, you are not data. Research of all kinds may present, or you lack the decision involve the use or disclosure of ■ Appointment reminders: Your PHI making capacity to agree or object. your PHI. Your PHI can generally allows us to contact you about In those instances, we will use our be used or disclosed for research appointments for treatment or professional judgment to deter- without your permission if an other health care you may need. mine if it’s in your best interest to Institutional Review Board (IRB) disclose your PHI. If so, we will approves such use or disclosure. ■ Specific types of PHI: There are limit the disclosure to the PHI that An IRB is a committee that is stricter requirements for use and is directly relevant to the person’s responsible, under federal law, for disclosure of some types of PHI, involvement with your health care. reviewing and approving human for example, drug and alcohol For example, we may allow some- subjects research to protect the abuse patient information, mental one to pick up a prescription safety of the participants and the health records, and HIV/AIDS for you. confidentiality of PHI. information. However, there are still circumstances in which these ■ Disclosure in case of disaster ■ Organ donation: Except as limited types of information may be used relief: We may disclose your name, by applicable law, we may use or or disclosed without your authori- city of residence, age, gender, and disclose PHI to organ-procurement zation. If you become a patient in general condition to a public or organizations to assist with organ, our chemical dependency pro- private disaster relief organization eye or other tissue donations. gram, we will give you a separate to assist disaster relief efforts, written notice, as required by law, unless you object at the time. ■ Public health activities: Public about your privacy rights for your health activities cover many chemical dependency program ■ Disclosures to parents as personal functions performed or authorized PHI. representatives of minors: In most by government agencies to pro- cases, we may disclose your minor mote and protect the public’s ■ Communications with family and child’s PHI to you. In some situa- health and may require us to others when you are present: tions, however, we are permitted disclose your PHI. Sometimes a family member or or even required by law to deny other person involved in your your access to your minor child’s For example, we may disclose care will be present when we are PHI. Examples of when we must your PHI as part of our obligation discussing your PHI with you. If deny such access include situa- to report to public health authorities you object, please tell us and we tions involving your daughter’s certain diseases, injuries, conditions, won’t discuss your PHI or we will pregnancy, the prevention of her and vital events such as births or ask the person to leave. pregnancy, childbirth, and abortion abortions. Sometimes we may records where a court waives disclose your PHI to someone you parental notification of abortion. may have exposed to a communica- In addition, the law denies access ble disease, or who may otherwise to your child’s PHI if your child be at risk of getting or spreading is married or otherwise the disease. emancipated. 12
  14. 14. The Food and Drug Adminis- ■ Workers’ compensation: In order ■ Lawsuits and other legal disputes: tration (FDA) is responsible for to comply with workers’ com- We may use and disclose PHI in tracking and monitoring certain pensation laws, we may use and responding to a court or adminis- medical products, such as pacemak- disclose your PHI. For example, trative order, a subpoena, or a ers and hip replacements, to identify we may communicate your discovery request. We may also product problems and failures and medical information regarding a use and disclose PHI to the extent injuries they may have caused. If work-related injury or illness to permitted by law without your you have received one of these claims administrators, insurance authorization, for example, to products, we may use and disclose carriers, and others responsible defend a lawsuit or arbitration. your PHI to the FDA or other for evaluating your claim for authorized persons or organizations, workers’ compensation benefits. ■ Law enforcement: We may such as the maker of the product. disclose PHI to authorized ■ Military activity and national officials for law enforcement We may use and disclose your PHI security: We may sometimes use purposes, for example, to as necessary to comply with federal or disclose the PHI of armed respond to a search warrant, and state laws that govern work- forces personnel to the applicable report a crime on our premises, place safety. military authorities when they investigate fraud, or help identify believe it is necessary to properly or locate someone. ■ Health oversight: As health care carry out military missions. We providers and health plans, we are may also disclose your PHI to ■ Serious threat to health or safety: subject to oversight conducted by authorized federal officials as We may use and disclose your federal and state agencies. These necessary for national security PHI if we believe it is necessary agencies may conduct audits of and intelligence activities or for to avoid a serious threat to your our operations and activities and protection of the President and health or safety or to someone in that process, they may review other government officials and else’s. your PHI. dignitaries. ■ Abuse or neglect: By law, ■ Disclosures to your employer ■ Marketing: Kaiser Permanente we may disclose PHI to the or your employee organization: may use and, in some instances, appropriate authority to report If you are enrolled in Kaiser disclose your PHI to contact you suspected child abuse or neglect Foundation Health Plan of Georgia about benefits, services or supplies or to identify suspected victims through your employer or employ- that we can offer you in addition of abuse, neglect, or domestic ee organization, we may share to your KP coverage. violence. certain PHI with them without your authorization but only when ■ Fundraising: We may use or ■ Coroners and funeral directors: allowed by law. For example, we disclose PHI to contact you to We may disclose PHI to a coroner may disclose your PHI for a raise funds for our organization. or medical examiner to permit workers compensation claim or identification of a body, determine to determine whether you are ■ Required by law: In some cause of death, or for other official enrolled in the plan or whether circumstances federal or state duties. We may also disclose PHI premiums have been paid on your law requires that we disclose your to funeral directors. behalf. For other purposes, such as PHI to others. For example, the for inquiries by your employer or Secretary of the Department of employee organization on your Health and Human Services may behalf, we will obtain your author- review our compliance efforts, ization when necessary. which may include seeing your PHI. 13
  15. 15. ■ Inmates: Under the federal law VII. How to contact us VIII. Changes to that requires us to give you this notice, inmates do not have the about this notice or to this notice same rights to control their PHI complain about our We may change this notice and as other individuals. If you are an privacy practices our privacy practices at any time, inmate of a correctional institution as long as the change is consistent or in the custody of a law enforce- If you have any questions about this with state and federal law. Any ment official, we may disclose notice, or want to lodge a complaint revised notice will apply both to the your PHI to the correctional about our privacy practices, please PHI we already have about you at institution or the law enforcement let us know by calling or writing the time of the change, and any PHI official for certain purposes, for to Customer Service Department, created or received after the change example, to protect your health Kaiser Foundation Health Plan of takes effect. If we make an impor- or safety or someone else’s. Georgia, Inc., Nine Piedmont Center, tant change to our privacy practices, 3495 Piedmont Road, NE, we will promptly change this notice Atlanta, Georgia 30305-1736. and provide a new notice on our If you are enrolled in a plan other member Web site at than Senior Advantage, you may call and our member publication, Customer Service at (404) 261-2590. VI. All other uses and Its hours of operation are Monday Partners in Health. Except for changes required by law, we will disclosures of your PHI through Friday from 8:30 a.m. to not implement an important change require your prior 9 p.m. and Saturday through Sunday to our privacy practices before we from 8 a.m. through 2 p.m. If you written authorization are enrolled in Senior Advantage, revise this notice. Except for those uses and disclo- you may call the Senior Advantage sures described above, we will not Customer Service Department use or disclose your PHI without at (404) 233-3700 or toll free your written authorization. When at 1-800-232-4404 (TTY: 1-800- your authorization is required and 255-0056). Its hours of operation IX. Effective date of you authorize us to use or disclose are Monday through Sunday from this notice your PHI for some purpose, you 8 a.m. through 8 p.m. You also may revoke that authorization by This notice is effective on may notify the Secretary of the notifying us in writing at any time. April 14, 2003. Department of Health and Human Please note that the revocation will Services (HHS). not apply to any authorized use or disclosure of your PHI that took We will not take retaliatory action place before we received your against you if you file a complaint revocation. Also, if you gave your about our privacy practices. authorization to secure a policy of insurance, including health care coverage from us, you may not be permitted to revoke it until the insurer can no longer contest the policy issued to you or a claim under the policy. 14
  16. 16. Additional Pharmacy Formulary Emergency care does not require prior authorization; however, you are information Kaiser Permanente uses a formulary which is a list of prescription drugs strongly encouraged to contact Kaiser Permanente after emergency care is that have been approved by our received so Kaiser Permanente can Pharmacy and Therapeutics coordinate follow-up services. Committee for our Members. About your Prescription Our Pharmacy and Therapeutics Drug benefit Committee, which is comprised of Plan Physicians and other Plan Questions? You can purchase prescription drugs Providers, selects prescription drugs from Kaiser Permanente Medical If you have questions, please call for the drug formulary based on a Kaiser Permanente Customer Service Center pharmacies or designated number of factors, including safety community pharmacies. at (404) 261-2590. and effectiveness as determined from a review of medical literature What is covered: Drugs for which and research. The Pharmacy and a prescription is required by law Therapeutics Committee meets and that are listed on the Kaiser monthly to consider adding and Permanente Formulary; Insulin removing prescription drugs on the (including disposable needles drug formulary. If you have any and syringes for injecting insulin); questions about the formulary, call Compounded dermatological (404) 261-2590. preparations; Glucose test strips; and Diaphragms. Unless otherwise specified by a physician, generic drugs may be used to fill a prescription. Utilization Management At Kaiser Permanente, the Utilization Exclusions: Prescribed drugs for Management Program works with excluded services; Replacement participating providers to plan, of lost or damaged drugs and organize and deliver quality health accessories; Drugs used in the care services by ensuring these treatment of involuntary infertility; services are medically appropriate, and Drugs used in the treatment medically necessary and provided of sexual dysfunction disorders; in a cost-effective manner. Some weight loss drugs; and smoking services require prior notification cessation drugs. and/or prior authorization by the Utilization Management Program; examples include, but are not limited to: inpatient admissions; outpatient surgery; specialized services such as home health, medical supplies/equipment, and hospice care; skilled nursing and acute rehabilitation facilities. 15
  17. 17. Services that require infertility or any other infertility This is a summary description and treatment; Nonhuman and artificial is not intended to replace your preauthorization organs and their implantation; Kaiser Permanente Bridge Program Preauthorization is required for Court-ordered services; Mental health Evidence of Coverage, which contains certain services. For preauthorization, services for chronic conditions and the complete provisions of this call 1-800-221-2412. mental retardation after diagnosis; coverage. If you have questions or Testing for ability, aptitude, intelli- need additional information, please gence, or interest; Corrective shoes call Kaiser Permanente Customer General Exclusions and orthotic foot supports and Service at (404) 261-2590. The following services are excluded inserts; More than one device for the from all coverage: Services which same part of the body or same an employer or any government function; Replacement of lost devices; agency is responsible to provide, Dental devices and appliances other including workers’ compensation; than those specified; Electronic Custodial care or care in an inter- monitors of bodily functions (except mediate care facility; Services ordered infant apnea monitors and blood by administrators of criminal justice glucose monitors); Devices to per- or mental health institutions; form medical testing of body fluids, Cosmetic services (including drugs excretions, or substances; Devices and injectables); Dental services not medical in nature; Convenience, other than those specified (including comfort or luxury items; Disposable services and appliances for injuries supplies for home use; Reconstruc- to teeth resulting from chewing or tive surgery following removal of extraction of wisdom teeth); Physical breast implants that were inserted for examinations required for obtaining cosmetic reasons; All services, drugs, or maintaining employment or and supplies related to the treatment participation in employee programs, of obesity; most disposable supplies. or insurance or government licensing; Experimental or investigational services; Refractive surgery; Corrective lenses, eyeglasses and hearing aids; Orthoptics (eye exercises); Routine foot care services; Examinations for the prescription of hearing aids; All services and drugs related to sexual reassignment; Long-term physical, speech and occupational therapy and rehabilitation; Cognitive rehabilitation programs; Vocational rehabilitation; Services that are primarily educational in nature; Cost of semen and eggs; Services for conception by artificial means; Reversal of voluntary 16
  18. 18. The Kaiser Permanente Bridge Program For more information contact: Kaiser Permanente Customer Service: Public Affairs Department (404) 261-2590 locally Nine Piedmont Center 1-800-611-1811 long distance 3495 Piedmont Road, NE Atlanta, GA 30305 CB-090004 1/09 ©2009 Kaiser Foundation Health Plan of Georgia, Inc.