SAMPLE GROUP Evidence of Coverage for - Kaiser Permanente

Kaiser Foundation Health Plan, Inc. Northern California Region

Combined Chiropractic and Acupuncture Services Amendment of the Kaiser Foundation Health Plan, Inc. Evidence of Coverage for

SAMPLE GROUP

Note: This is a sample Evidence of Coverage (EOC) document. EOCs that are issued as part of a specific customer's Group Agreement will differ from this sample. For example, this EOC does not include customer-specific coverage and eligibility information, and the sample EOC may be updated at any time for accuracy, to comply with laws and regulations, or to reflect changes in how coverage is administered. The terms of any contract holder's coverage are governed by the Group Agreement issued to that customer by Kaiser Foundation Health Plan, Inc.

January 1, 2022, through December 31, 2022

ASH Plans Customer Service Department Monday through Friday, 5 a.m. to 6 p.m. 1-800-678-9133 (TTY users call 711) toll free ash/kp

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TABLE OF CONTENTS

Benefit Highlights ..................................................................................................................................................................1 Introduction ............................................................................................................................................................................3 Definitions ..............................................................................................................................................................................3 ASH Participating Providers ..................................................................................................................................................4

How to Obtain Services......................................................................................................................................................4 Covered Services ....................................................................................................................................................................5

Office Visits .......................................................................................................................................................................5 Laboratory Tests and X-rays ..............................................................................................................................................6 Chiropractic Supports and Appliances ...............................................................................................................................6 Second Opinions.................................................................................................................................................................6 Emergency and Urgent Services Covered Under this Amendment ...................................................................................6

Emergency and urgent chiropractic Services .................................................................................................................6 Emergency and urgent acupuncture Services.................................................................................................................6 How to file a claim .........................................................................................................................................................6 Exclusions ..............................................................................................................................................................................7 Customer Service ...................................................................................................................................................................7 Grievances ..............................................................................................................................................................................7

Benefit Highlights

We cover the Services described below, subject to exclusions described in the "Exclusions" section, only if all of the following conditions are satisfied:

You are a Member on the date that you receive the Services

ASH Plans has determined that the Services are Medically Necessary, except as described in this Amendment

You receive the Services from ASH Participating Providers or other licensed providers that ASH contracts to provide covered care, except as described in this Amendment

Professional Services (ASH Participating Provider office visits)

You Pay

Chiropractic and acupuncture office visits (up to a combined total of 30

visits per 12-month period)........................................................................ $10 per visit

Other

You Pay

X-rays and laboratory tests that are covered Chiropractic Services ............ No charge

Chiropractic supports and appliances .......................................................... Amounts in excess of the $50 Allowance

This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Share, out-ofpocket maximums, exclusions, or limitations, nor does it list all benefits and Cost Share amounts. For a complete explanation, refer to the "Covered Services" and "Exclusions" sections.

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