Bridge Program

The Kaiser Permanente

A community service of Kaiser Foundation Health Plan of Georgia, Inc.

Bridge Program

090004 Bridge Brochure:BP 202476A Brochure_v2 2/19/09 12:15 PM Page 2

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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.

Across America


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What you’ll find inside

The Kaiser Permanente advantageLearn why more than 270,000 people in Atlanta choose Kaiser Permanente 3to 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 eligibleFind out about The Kaiser Permanente Bridge Program eligibility requirements. 5

The Kaiser Permanente Bridge Program highlightsReview your plan benefits and our coverage area. 6

Our privacy practicesRead a description of how medical information about you may be used 9and disclosed, and how you can get access to it.

Additional informationLearn more about The Kaiser Permanente Bridge Program coverage, 15our pharmacy formulary, preauthorization, exclusions, and more.


The KaiserPermanenteadvantage

You’ve probably heard about

our dedication to quality care,

excellent service, and unmatched

convenience. But there are more

reasons than ever to make

Kaiser Permanente your

partner in health.

Great care and serviceFor more than 20 years, KaiserPermanente has been providingmetro-Atlanta with quality healthcare that’s convenient, simple, andaffordable. It’s our distinct approachto health care that keeps our mem-bers coming back year after year:

■ Total healthAt Kaiser Permanente, we’re committed to your total health—mind, body, and spirit. You’ll likehow we make it easier for you totake an active role in your ownhealth. We help you live wellthrough health education classes,discounts on health-related services,and much more. And you’re coveredfor the preventive care you need,like routine physicals, well-childcare, mammograms, immunizations,and more. So you can stay healthyand live your life to the fullest.

■ Personalized careWhen you choose a KaiserPermanente doctor, you’ll get quality care from a doctor who takes the time to get to know youand your health needs. You’ll haveall the things you need to get the personalized care you deserve—compassionate people backed bymedical excellence, advanced technology, and leading-edgeresearch.

■ ConvenienceWe make it easy to get the care you need, when you need it.Whether it’s locations close to where you live or work, seeing aphysician when you need one, ormultiple services under one roof,we’ve got you covered. And youwon’t have to worry about filingclaims when you visit our medicalcenters or any of our affiliated doctors and hospitals.

You’ll also enjoy the convenience of many online services. On ourWeb site, kp.org, you can empoweryourself with many 24-hour healthresources including:

■ Health assessment tools

■ Personalized health improvementplans

■ Health encyclopedia

■ Online prescription refills

■ Routine appointment requests

■ Nurse advice by e-mail

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Healthy Solutions.

Get your own personal healthcoach 24 hours a day, 7 days aweek by phone—at no cost—through Kaiser PermanenteHealthy Solutions.

■ Talk about tests or procedures, upcoming appointments, medications,diet, or exercise.

■ Get information about conditions, general health,and wellness.

■ Learn about new techniquesto help take control of specific conditions or overall health.

■ Receive personalized check-in calls.

■ Get additional health infor-mation mailed to your home.


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Kaiser Permanente Medical CentersWhen you join Kaiser Permanente,you’ll have the freedom to choose to get care at one of our 15 modernmedical centers, and you’ll see whymembers keep coming back.

■ Save time by seeing a doctor, getting lab tests or X-rays, andpicking up a prescription all in the same building.*

■ See a doctor at night or on week-ends at our after-hours locations.

■ Get a same-day appointment when you need one.

■ Receive quality, personalized care from a doctor who takes the time to listen.

A few things that mightsurprise you.Want more reasons to choose KaiserPermanente? Here are some that maysurprise you:

■ Wide selection of doctorsIn addition to the physicians in ourmedical centers, you’ll have accessto more than 1,800 affiliated commu-nity doctors.

■ Easy accessYou can self-refer to select specialtiesincluding Ob/Gyn, dermatology,optometry, ophthalmology, and behavioral health.

■ Emergency careYou’ll have peace of mind knowingyou’re covered for emergency careanywhere you travel.

■ Great discountsWe even make it more affordable to live healthy. Through ourSelfWise program, you can takeadvantage of a variety of health-related discounts** including:

■ Health club membership

■ Weight Watchers membership

■ Massage therapy, chiropractic, acupressure, and acupunctureservices

■ Vision care

Consumer Choice OptionAs part of a state law, you haveanother option available to youthrough The Kaiser PermanenteBridge Program. The ConsumerChoice Option (CCO) allows you to nominate and use providers not normally available through ourhealth plan, while still receiving benefits comparable to those youwould receive when using in-network providers. This option costsan additional 17.5 percent and isbased on the full monthly premium,not on the portion you pay after the subsidy.

If you would like more informationon the CCO—including an electionform, information on how to nominate a provider, and rate information—please call our consumer choice representative at(404) 364-4900. If you are interest-ed in enrolling in the CCO, pleasewait until after you receive andreview the CCO materials to returnyour medical questionnaire. Themedical questionnaire and CCO elec-tion form must be returned to KaiserPermanente at the same time.

* Most medical centers.

** Available to Kaiser Permanente members and their enrolled familymembers. Discounts and services are provided on a fee-for-service basis, do not replace and cannot becombined with any existing benefit,and are not covered benefits. KaiserPermanente assumes no responsibilityfor the arrangement, nature, quality, or outcome of the services. For moreinformation, call (404) 261-2590.

Stay connected with My health manager†

With the My health managersection of kp.org, you havesecure 24-hour access to yourhealth record online. KaiserPermanente’s electronic patienthealth record system enablesyou to stay connected to yourhealth, and it allows your doctorto view your information instantlyright in the exam room. Beloware just some of the featuresavailable to you:

■ E-mail your doctor’s office

■ Review past office visits

■ Schedule, request, cancel, and view appointments

■ View most lab test results

■ Access the health records of your children

■ View immunization history

■ Order prescription refills and view current medications

†Available to members receivingcare/filling prescriptions at KaiserPermanente Medical Centers.


The Kaiser Permanente BridgeProgram members will receive benefits comparable to those offered to other Kaiser Permanente members. Eligible members will bebilled by Kaiser Permanente and pay the designated portion of their premium directly to KaiserPermanente each month.

To be covered, all health care servicesmust be provided, authorized, orprescribed by a Kaiser PermanentePlan provider, except in cases of amedical emergency. If any programeligibility requirement changes forthe member (or dependent), theymust notify The Kaiser PermanenteBridge Program in writing. Pleasesend changes to:

fax: 404-364-4767e-mail: [email protected]

How is The KaiserPermanente BridgeProgram Administered?Persons interested in The KaiserPermanente Bridge Program mustapply through a participating agency.

Membership in the Kaiser PermanenteBridge Program at the subsidizedamount is limited to 24 months fromthe date of initial enrollment. At the end of 24 months, the reducedpremium offered through The KaiserPermanente Bridge Program will end.Members will receive notificationregarding their post termination coverage options.

Target AudiencesThe Kaiser Permanente BridgeProgram is intended for individualsand families facing short-term problems. It is for persons who arenot eligible for Medicaid, Medicare,or PeachCare; and who do not haveaccess to employer–sponsored healthcare insurance.

Enrollment into The Kaiser Perma-nente Bridge Program is limited;Kaiser Permanente reserves the right to stop accepting new enrollments at any time without prior notice.

Who is Eligible?Before you review the specific plan information, check to makesure you live within our ServiceArea. You’re eligible to apply forThe Kaiser Permanente BridgeProgram coverage if you live in oneof the following counties: Barrow,Bartow, Butts, Carroll, Cherokee,Clayton, Cobb, Coweta, Dawson,DeKalb, Douglas, Fayette, Forsyth,Fulton, Gwinnett, Hall, Haralson,Heard, Henry, Lamar, Meriwether,Newton, Paulding, Pickens, Pike,Rockdale, Spalding, and Walton.

All persons applying to The KaiserPermanente Bridge Program mustmeet the requirements outlinedbelow to qualify:

■ The subscriber and all applyingdependents must live in KaiserPermanente’s Georgia RegionService Area.

■ The annual household incomemust be at or less than 300 percent of the current federalpoverty guidelines.

■ Family members must be ineligiblefor any other health insurance program including Medicare,Medicaid, PeachCare, and employer-sponsored health care.

■ At least one family member (subscriber, spouse, or dependent)must be actively enrolled with aparticipating partner.

■ An applicant may not have beenpreviously enrolled in The KaiserPermanente Bridge Program.

■ Age 64 and under.

Upon acceptance into The KaiserPermanente Bridge Program, theHealth Plan may periodically confirmmembers are still meeting the subsidyeligibility requirements outlined inthe Evidence of Coverage. If theHealth Plan determines that theBridge Program member is no longermeeting the eligibility requirements,the Health Plan will terminate coverage at the end of the monthunder The Kaiser Permanente Bridge Program.

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The KaiserPermanente Bridge Program—How does itwork?


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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

The Kaiser Permanente Bridge Program Highlights

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.Some services require preauthorization.


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*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.

The Kaiser Permanente Bridge Program Monthly Rates*

Full Monthly Member Monthly ratePremium with 95% Subsidy

Subscriber Only $431.52 $21Subscriber + Child(ren) $776.73 $38

Subscriber + Spouse $863.04 $43Subscriber + Family $1,294.55 $64

1. Do I have to go to KaiserPermanente’s Medical Centers to get care?

No. You can choose to get care atour medical centers, where you’llenjoy the convenience of being ableto see a doctor and get lab, X-ray, and pharmacy services all in thesame building at most medicalcenters. Or, you can visit one of our1,800 affiliated community physicians.

2. Can I see the doctor I have nowif I choose a Kaiser PermanenteHMO plan?

If your current primary care doctor is one of our 1,800 affiliated community physicians, you can continue to see him or her. If you have a specialist, and that person is part of our network, you may be able to see him or her as well. (You will need a referral from your Kaiser Permanente personal physician for most specialty care.)You may also see another provideroutside of our network at your ownexpense.

3. How do I find out which doctors are available?

Visit our searchable online MedicalStaff Directory at kp.org/medicalstaff.You can also refer to the printedKaiser Permanente HMO PhysicianDirectory.

4. What if I need emergency carewhen I’m traveling?

You’re covered for emergency orurgent care anywhere you travel.Receiving emergency or urgent careoutside of our metro-Atlanta ServiceArea is one of the few times youmay need to file a claim.

5. Can I cover just my children?

Yes. You can get coverage for justyour children, just your spouse, justyourself, or any combination of theabove who live in our Service Area.You just need to choose the appro-priate plan.

6. Why is Kaiser Permanente subsidizing the premiums for this program?

We believe in supporting healthycommunities. One of the ways weare able to accomplish this is bydirectly offering care through ourown health care providers in ourown medical centers.

Frequently asked questions


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Where to get care

CARROLL

HEARD

PICKENS

DAWSON

MERIWETHER PIKE LAMAR

HARALSON

Our medical centersAlpharetta Medical Center3550 Preston Ridge RoadAlpharetta, GA 30005

Brookwood at Peachtree Medical Office1745 Peachtree St., Suite UAtlanta, GA 30309

Cascade Medical Center1175 Cascade ParkwayAtlanta, GA 30311

Crescent Medical Center200 Crescent Centre ParkwayTucker, GA 30084

Cumberland Medical Center*2525 Cumberland Parkway Atlanta, GA 30339

Forsyth Medical Office1400 Northside Forsyth Drive Suite 350Cumming, GA 30041

Glenlake Medical Center20 Glenlake ParkwayAtlanta, GA 30328

Gwinnett Medical Center*3650 Steve Reynolds BoulevardDuluth, GA 30096

Henry Towne Centre Medical Center1125 Towne Centre Village DriveMcDonough, GA 30253

Panola Medical Center5440 Hillandale DriveLithonia, GA 30058

Southwood Medical Center*2400 Mt. Zion ParkwayJonesboro, GA 30236

Stonecrest Medical Center8011 Mall ParkwayLithonia, GA 50038

Sugar Hill - Buford Medical Center1435 Broadmoor BoulevardSugar Hill, GA 30518

TownPark Medical Center750 TownPark LaneKennesaw, GA 30144

West Cobb Medical Center3640 Tramore Point ParkwayAustell, GA 30106

* Medical centers designated for after-hours urgent care.

Hours: Monday through Friday, 6 to 9:30 p.m.;Saturday, 9 a.m. to 8:30 p.m.; Sunday, 10 a.m. to 5:30 p.m.

Kaiser Permanente Medical Centers (15 locations)

●● Affiliated Community Physicians’ Medical Offices (Over 1,800 doctors)

H 20 Affiliated Hospitals*

* The hospital that you will be admitted to will be determined by the primary care physician you select.

For a current provider listing,

visit our searchable Medical Staff

Directory at kp.org/medicalstaff


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Our privacypractices

Notice of privacy practicesThis notice describes how medicalinformation about you may be usedand disclosed and how you can getaccess to this information. Pleasereview it carefully.

In this notice we use the terms “we,” “us” and “our” to describe theKaiser Permanente, Georgia Region.For more details, please refer to section IV. of this notice.

I. What is “ProtectedHealth Information?”

Your protected health information(PHI) is health information that con-tains identifiers, such as your name,social security number, or otherinformation that reveals who youare. For example, your medicalrecord is PHI because it includesyour name and other identifiers.

If you are a Kaiser FoundationHealth Plan member and also an employee of any KaiserPermanente company, PHI does notinclude the health information inyour employment records.

In the course of providing and administering health care, we collect various types of healthinformation from various sources,such as you, other members (forexample, your spouse or parents),and other health care professionals.The types of information we collectand maintain about our membersinclude among other things, medicaland hospital records, such as generalmedical, mental health, and sub-stance abuse patient records, labora-tory results, X-ray results, pharmacyrecords, and appointment records.

Kaiser Permanente collects otherhealth plan information using a vari-ety of techniques. Examples include:

■ Collecting information from youthrough surveys, applications,related forms, and other writtenrequests and communications;

■ Collecting information from youremployer, benefits plan sponsor,or association regarding groupcoverage that you may havethrough group applications, census data, and other writtenrequests and communications;

■ Collecting information from visitors to our Web site such as online forms, site visit data, andother online communications; and

■ Collecting information from con-sumer or medical reporting agen-cies or other sources such asinsurance support organizationsand credit bureaus.

II. About ourresponsibility toprotect your PHI

By law, we must

1) protect the privacy of your PHI;

2) tell you about your rights and ourlegal duties with respect to yourPHI; and

3) tell you about our privacypractices and follow our noticecurrently in effect.

We take these responsibilitiesseriously and, as in the past, we willcontinue to take appropriate steps tosafeguard the privacy of your PHI.

III. Your rights regarding your PHI

This section tells you about yourrights regarding your PHI, forexample, your medical and billingrecords. It also describes how youcan exercise these rights.

Your right to see and receivecopies of your PHI In general, you have a right to seeand receive copies of PHI indesignated record sets such as yourmedical record or billing record. If you would like to see or receive acopy of such a record, please writeto us. When you know the KaiserPermanente facility or medical centerwhere you received your care,please write to us at that address. If you don’t know where yourrecords that you want to see arelocated, please write to us atCustomer Service Department,


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Kaiser Foundation Health Plan ofGeorgia, Inc., Nine Piedmont Center,3495 Piedmont Road, NE, Atlanta,Georgia 30305-1736. After we receiveyour written request, we will let youknow when and how you can see orobtain a copy of your record. If youagree, we will give you a summary orexplanation of your PHI instead ofproviding a copy. We may chargeyou a fee for the copy, summary, orexplanation. If we don’t have yourrecord but we know who does, wewill tell you who to contact torequest it.

In limited situations, we may denysome or all of your request to see orreceive a copy of your records, but if we do, we will tell you why inwriting and explain your right, if any,to have our denial reviewed.

Your right to choose how wesend PHI to you You may ask us to send your PHI to you at a different address (forexample, your work address) or bydifferent means (for example, faxinstead of regular mail). When wecan reasonably and lawfully agree toyour request, we will. However, weare permitted to charge you for anyadditional cost of sending your PHIto different addresses or by different means.

Your right to correct or updateyour PHI If you believe there is a mistake inyour PHI or that important informa-tion is missing, you may request thatwe correct, delete, or add to therecord. Please write to us and tell uswhat you are asking for and why weshould make the correction, deletion,or addition.

Your request should be sent asdescribed above in the section en-titled “Your right to see and receivecopies of your PHI.” If we approveyour request, we will make the correction or addition to your PHI. If we deny your request, we will tell you why and explain your right to file a written statement ofdisagreement.

Your right to an accounting ofdisclosures of PHI You may ask us for a list of ourdisclosures of your PHI. If you wouldlike a list of disclosures, please writeto us as described above in the sec-tion entitled “Your right to see andreceive copies of your PHI.” The listwe give you will include disclosuresmade in the last six years, unless yourequest a shorter time period or iffewer than six years have passedsince April 14, 2003. For example, ifyou requested a list of disclosures onApril 14, 2005, the list would coveronly two years.

You are entitled to one disclosureaccounting in any 12-month period at no charge. If you request any additional accountings fewer than 12 months later, we may charge a fee.

Except as may otherwise be re-quired under state law, an accountingdoes not include certain disclosures,for example, disclosures to carry outtreatment, payment and health careoperations; disclosures that occurredprior to April 14, 2003; disclosures forwhich Kaiser Permanente, GeorgiaRegion had a signed authorization;disclosures of your PHI to you; dis-closures for notifications for disasterrelief purposes; or disclosures to persons involved in your care andpersons acting on your behalf.

Your right to request limits on uses and disclosures of your PHI You may request that we limit our uses and disclosures of your PHIfor treatment, payment, and healthcare operations purposes. However,by law, we do not have to agree toyour request. Because we stronglybelieve that this information isneeded to manage care of our mem-bers/patients appropriately, it is ourpolicy not to agree to requests forrestrictions.

Your right to receive a papercopy of this notice

You also have a right to receive a paper copy of this notice uponrequest.

IV. Kaiser Permanente companies subject to this notice

This notice applies to the KaiserPermanente, Georgia Region whichincludes:

■ The Southeast Permanente MedicalGroup, Inc. (TSPMG)

■ Kaiser Foundation Health Plan ofGeorgia, Inc. including its healthplan and provider operations;

■ Kaiser Foundation Hospitals(KFH), as described below; and

■ Kaiser Foundation Health Plan,Inc. (KFHP, Inc.), as describedbelow


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Our health care delivery sitesinclude Kaiser Permanente medicalcenters, our member call advice andappointment centers, and our mem-ber Web site.

To provide you with the healthcare you expect when treating you,paying for your care, and conductingour operations, such as quality assur-ance, accreditation, licensing andcompliance, these Kaiser Permanentecompanies share your PHI with eachother.

Our personnel may have access to your PHI as employees,physicians, volunteers, personsworking with us in other capacities,or professional staff members andothers authorized to enter informa-tion into a medical record of aKaiser Permanente Medical Center.Our region may also share your PHIwith KFH and KFHP, Inc. in connec-tion with shared services and othernational Kaiser Permanente activitiesfor treatment, payment, or healthcare operations purposes. For exam-ple, if you are being considered fora transplant, we will share your PHIwith our Kaiser Permanente NationalTransplant Network.

V. How we may use and disclose your PHI

Your confidentiality is important tous. Our physicians and employeesare required to maintain the con-fidentiality of the PHI of our members/patients and we have policies and procedures and othersafeguards to help protect your PHIfrom improper use and disclosure.

Sometimes we are allowed by law touse and disclose certain PHI withoutyour written permission. We brieflydescribe these uses and disclosuresbelow and give you some examples.

How much PHI is used or disclosed without your written per-mission will vary depending, forexample, on the intended purposeof the use of disclosure. Sometimeswe may only need to use or disclosea limited amount of PHI, such as tosend you an appointment reminderor to confirm that you are a healthplan member. At other times we mayneed to use or disclose more PHIsuch as when we are providingmedical treatment.

■ Treatment: This is the most impor-tant use and disclosure of yourPHI. For example, our physicians,nurses, and other health care personnel, including trainees,involved in your care use and disclose your PHI to diagnose your condition and evaluate yourhealth care needs. Our personnelwill use and disclose your PHI inorder to provide and coordinatethe care and services you need,for example: prescriptions; X-rays;and lab work. If you need carefrom health care providers whoare not part of Kaiser Permanente,such as community resources toassist with your health care needsat home, we may disclose yourPHI to them.

■ Treatment alternatives and health-related benefits and services: In some instances, the law permitsus to contact you: 1) to describeour network or describe the extentto which we offer and pay for various products and services;

2) for your treatment; 3) for casemanagement and care coordination;or 4) to direct or recommend avail-able treatment options, therapies,health care providers, or care set-tings. For example, we may tell youabout a new drug or procedure orabout educational or health manage-ment activities.

■ Payment: Your PHI may be need-ed to determine our responsibilityto pay for, or to permit us to billand collect payment for, treatmentand health-related services thatyou receive. For example, we may have an obligation to pay forhealth care you receive from anoutside provider. When you or the provider sends us the bill forhealth care services, we use anddisclose your PHI to determinehow much, if any, of the bill weare responsible for paying.

■ Health care operations: We mayuse and disclose your PHI for certain health care operations,such as: quality assessment andimprovement; training and evalua-tion of health care professionals;licensing; accreditation; activitiesrelating to the creation, renewal or replacement of health insuranceor health benefits; conductingmedical review; legal services;auditing functions, including fraudand abuse detection and compli-ance programs; customer services;and determining premiums andother costs of providing healthcare. We may also disclose yourPHI for certain health care operations of other health plansand health care providers.


■ Business associates: We maycontract with business associatesto perform certain functions oractivities on our behalf, such aspayment and health care opera-tions. These business associatesmust agree to safeguard your PHI.

■ Appointment reminders: Your PHIallows us to contact you aboutappointments for treatment orother health care you may need.

■ Specific types of PHI: There arestricter requirements for use anddisclosure of some types of PHI,for example, drug and alcoholabuse patient information, mentalhealth records, and HIV/AIDSinformation. However, there arestill circumstances in which thesetypes of information may be usedor disclosed without your authori-zation. If you become a patient inour chemical dependency pro-gram, we will give you a separatewritten notice, as required by law,about your privacy rights for yourchemical dependency programPHI.

■ Communications with family andothers when you are present:Sometimes a family member orother person involved in your care will be present when we arediscussing your PHI with you. Ifyou object, please tell us and wewon’t discuss your PHI or we willask the person to leave.

■ Communications with family andothers when you are not present:There may be times when it isnecessary to disclose your PHI toa family member or other personinvolved in your care becausethere is an emergency, you are notpresent, or you lack the decisionmaking capacity to agree or object.In those instances, we will use ourprofessional judgment to deter-mine if it’s in your best interest todisclose your PHI. If so, we willlimit the disclosure to the PHI thatis directly relevant to the person’sinvolvement with your health care.For example, we may allow some-one to pick up a prescription for you.

■ Disclosure in case of disasterrelief: We may disclose your name,city of residence, age, gender, andgeneral condition to a public orprivate disaster relief organizationto assist disaster relief efforts,unless you object at the time.

■ Disclosures to parents as personalrepresentatives of minors: In mostcases, we may disclose your minorchild’s PHI to you. In some situa-tions, however, we are permittedor even required by law to denyyour access to your minor child’sPHI. Examples of when we mustdeny such access include situa-tions involving your daughter’spregnancy, the prevention of herpregnancy, childbirth, and abortionrecords where a court waivesparental notification of abortion. In addition, the law denies accessto your child’s PHI if your child is married or otherwise emancipated.

■ Research: Kaiser Permanenteengages in extensive and im-portant research. Some of ourresearch may involve medical procedures and some is limited tocollection and analysis of healthdata. Research of all kinds mayinvolve the use or disclosure ofyour PHI. Your PHI can generallybe used or disclosed for researchwithout your permission if anInstitutional Review Board (IRB)approves such use or disclosure.An IRB is a committee that isresponsible, under federal law, forreviewing and approving humansubjects research to protect thesafety of the participants and the confidentiality of PHI.

■ Organ donation: Except as limitedby applicable law, we may use ordisclose PHI to organ-procurementorganizations to assist with organ,eye or other tissue donations.

■ Public health activities: Publichealth activities cover many functions performed or authorizedby government agencies to pro-mote and protect the public’shealth and may require us to disclose your PHI.

For example, we may discloseyour PHI as part of our obligationto report to public health authoritiescertain diseases, injuries, conditions,and vital events such as births orabortions. Sometimes we maydisclose your PHI to someone youmay have exposed to a communica-ble disease, or who may otherwisebe at risk of getting or spreading the disease.

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The Food and Drug Adminis -tration (FDA) is responsible fortracking and monitoring certain medical products, such as pacemak-ers and hip replacements, to identifyproduct problems and failures andinjuries they may have caused. Ifyou have received one of theseproducts, we may use and discloseyour PHI to the FDA or otherauthorized persons or organizations,such as the maker of the product.

We may use and disclose your PHIas necessary to comply with federaland state laws that govern work-place safety.

■ Health oversight: As health careproviders and health plans, we aresubject to oversight conducted byfederal and state agencies. Theseagencies may conduct audits ofour operations and activities andin that process, they may reviewyour PHI.

■ Disclosures to your employer or your employee organization: If you are enrolled in KaiserFoundation Health Plan of Georgiathrough your employer or employ-ee organization, we may sharecertain PHI with them withoutyour authorization but only whenallowed by law. For example, wemay disclose your PHI for aworkers compensation claim orto determine whether you areenrolled in the plan or whetherpremiums have been paid on yourbehalf. For other purposes, such asfor inquiries by your employer oremployee organization on yourbehalf, we will obtain your author-ization when necessary.

■ Workers’ compensation: In orderto comply with workers’ com-pensation laws, we may use anddisclose your PHI. For example,we may communicate your medical information regarding awork-related injury or illness toclaims administrators, insurancecarriers, and others responsible for evaluating your claim for workers’ compensation benefits.

■ Military activity and national security: We may sometimes use or disclose the PHI of armedforces personnel to the applicablemilitary authorities when theybelieve it is necessary to properlycarry out military missions. Wemay also disclose your PHI toauthorized federal officials as necessary for national security and intelligence activities or forprotection of the President andother government officials and dignitaries.

■ Marketing: Kaiser Permanente may use and, in some instances,disclose your PHI to contact youabout benefits, services or suppliesthat we can offer you in additionto your KP coverage.

■ Fundraising: We may use ordisclose PHI to contact you toraise funds for our organization.

■ Required by law: In somecircumstances federal or state law requires that we disclose yourPHI to others. For example, theSecretary of the Department ofHealth and Human Services mayreview our compliance efforts,which may include seeing yourPHI.

■ Lawsuits and other legal disputes:We may use and disclose PHI inresponding to a court or adminis-trative order, a subpoena, or a discovery request. We may alsouse and disclose PHI to the extent permitted by law without yourauthorization, for example, todefend a lawsuit or arbitration.

■ Law enforcement: We may disclose PHI to authorizedofficials for law enforcement purposes, for example, to respond to a search warrant,report a crime on our premises,investigate fraud, or help identifyor locate someone.

■ Serious threat to health or safety:We may use and disclose your PHI if we believe it is necessary to avoid a serious threat to yourhealth or safety or to someoneelse’s.

■ Abuse or neglect: By law, we may disclose PHI to the appropriate authority to report suspected child abuse or neglector to identify suspected victims of abuse, neglect, or domestic violence.

■ Coroners and funeral directors: We may disclose PHI to a coroneror medical examiner to permitidentification of a body, determinecause of death, or for other officialduties. We may also disclose PHIto funeral directors.


■ Inmates: Under the federal lawthat requires us to give you thisnotice, inmates do not have thesame rights to control their PHI as other individuals. If you are aninmate of a correctional institutionor in the custody of a law enforce-ment official, we may discloseyour PHI to the correctional institution or the law enforcement official for certain purposes, forexample, to protect your health or safety or someone else’s.

VI. All other uses and disclosures of your PHI require your priorwritten authorization

Except for those uses and disclo-sures described above, we will notuse or disclose your PHI withoutyour written authorization. Whenyour authorization is required andyou authorize us to use or discloseyour PHI for some purpose, youmay revoke that authorization bynotifying us in writing at any time.Please note that the revocation willnot apply to any authorized use ordisclosure of your PHI that tookplace before we received your revocation. Also, if you gave yourauthorization to secure a policy ofinsurance, including health care coverage from us, you may not bepermitted to revoke it until theinsurer can no longer contest thepolicy issued to you or a claimunder the policy.

VII. How to contact usabout this notice or tocomplain about ourprivacy practices

If you have any questions about thisnotice, or want to lodge a complaintabout our privacy practices, pleaselet us know by calling or writing to Customer Service Department, Kaiser Foundation Health Plan ofGeorgia, Inc., Nine Piedmont Center,3495 Piedmont Road, NE, Atlanta, Georgia 30305-1736. If you are enrolled in a plan otherthan Senior Advantage, you may callCustomer Service at (404) 261-2590.Its hours of operation are Mondaythrough Friday from 8:30 a.m. to 9 p.m. and Saturday through Sundayfrom 8 a.m. through 2 p.m. If youare enrolled in Senior Advantage,you may call the Senior AdvantageCustomer Service Department at (404) 233-3700 or toll free at 1-800-232-4404 (TTY: 1-800-255-0056). Its hours of operation are Monday through Sunday from 8 a.m. through 8 p.m. You also may notify the Secretary of theDepartment of Health and HumanServices (HHS).

We will not take retaliatory actionagainst you if you file a complaintabout our privacy practices.

VIII. Changes tothis notice

We may change this notice and our privacy practices at any time, as long as the change is consistentwith state and federal law. Anyrevised notice will apply both to thePHI we already have about you atthe time of the change, and any PHIcreated or received after the changetakes effect. If we make an impor-tant change to our privacy practices,we will promptly change this noticeand provide a new notice on ourmember Web site at www.kp.organd our member publication,Partners in Health. Except forchanges required by law, we willnot implement an important changeto our privacy practices before werevise this notice.

IX. Effective date ofthis notice

This notice is effective on April 14, 2003.

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Additional information

About your PrescriptionDrug benefitYou can purchase prescription drugsfrom Kaiser Permanente MedicalCenter phar macies or designatedcommunity pharmacies.

What is covered: Drugs for which a prescription is required by law and that are listed on the KaiserPermanente Formulary; Insulin(including disposable needles and syringes for injecting insulin);Compounded dermatological preparations; Glucose test strips; and Diaphragms. Unless otherwisespecified by a physician, genericdrugs may be used to fill a prescription.

Exclusions: Prescribed drugs forexcluded services; Replace ment of lost or damaged drugs and accessories; Drugs used in the treatment of involuntary infertility;and Drugs used in the treatment of sexual dysfunction disorders;weight loss drugs; and smoking cessation drugs.

Pharmacy Formulary

Kaiser Permanente uses a formularywhich is a list of prescription drugsthat have been approved by ourPharmacy and TherapeuticsCommittee for our Members. Our Pharmacy and TherapeuticsCommittee, which is comprised ofPlan Physicians and other PlanProviders, selects prescription drugsfor the drug formulary based on anumber of factors, including safetyand effectiveness as determinedfrom a review of medical literatureand research. The Pharmacy andTherapeutics Committee meetsmonthly to consider adding andremoving prescription drugs on thedrug formulary. If you have anyquestions about the formulary, call(404) 261-2590.

Utilization ManagementAt Kaiser Permanente, the UtilizationManagement Pro gram works withparticipating providers to plan,organize and deliver quality healthcare services by ensuring these services are medically appropriate,medically necessary and provided in a cost-effective manner. Someservices require prior noti ficationand/or prior authorization by theUtilization Management Program;examples include, but are not limited to: in patient admissions; outpatient surgery; specialized services such as home health, medical supplies/equipment, andhospice care; skilled nursing andacute rehabilitation facilities.

Emergency care does not requireprior autho rization; however, you arestrongly encouraged to contact KaiserPermanente after emergency care isreceived so Kaiser Perma nente cancoordinate follow-up services.

Questions?If you have questions, please callKaiser Permanente Customer Serviceat (404) 261-2590.


Services that requirepreauthorizationPreauthorization is required for certain services. For preauthorization,call 1-800-221-2412.

General ExclusionsThe following services are excludedfrom all coverage: Services whichan employer or any governmentagency is responsible to provide,including workers’ com pensation;Custodial care or care in an inter-mediate care facility; Services orderedby administrators of criminal justiceor mental health institutions;Cosmetic services (including drugsand injectables); Dental services other than those specified (including services and appliances for injuries to teeth resulting from chewing or extraction of wisdom teeth); Physicalexaminations required for obtainingor maintaining employ ment or participation in employee programs,or insurance or government licensing;Experi mental or investigational services;Refractive surgery; Corrective lenses,eye glasses and hearing aids;Orthoptics (eye exercises); Routinefoot care services; Examina tions forthe prescription of hearing aids; Allservices and drugs related to sexualreassignment; Long-term physical,speech and occupational therapy andrehabilitation; Cognitive rehabilitation programs; Vocational rehabilitation;Services that are primarily educationalin nature; Cost of semen and eggs;Services for conception by artificialmeans; Reversal of voluntary

infertility or any other infertility treatment; Nonhuman and artificialorgans and their implantation;Court-ordered services; Mental healthservices for chronic conditions andmental retardation after diagnosis;Testing for ability, aptitude, intelli-gence, or interest; Corrective shoesand orthotic foot supports andinserts; More than one device for thesame part of the body or samefunction; Replace ment of lost devices;Dental devices and appliances otherthan those specified; Electronic monitors of bodily functions (exceptinfant apnea monitors and blood glucose monitors); Devices to per-form medical testing of body fluids, excretions, or substances; Devices not medical in nature; Convenience,comfort or luxury items; Disposablesupplies for home use; Reconstruc-tive surgery following removal ofbreast implants that were inserted forcosmetic reasons; All services, drugs,and supplies related to the treatmentof obesity; most disposable supplies.

This is a summary description andis not intended to replace your Kaiser Permanente Bridge ProgramEvidence of Coverage, which containsthe complete provisions of this coverage. If you have questions orneed additional information, pleasecall Kaiser Permanente CustomerService at (404) 261-2590.

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CB-090004 1/09 ©2009 Kaiser Foundation Health Plan of Georgia, Inc.

The Kaiser Permanente Bridge Program

kp.org

Kaiser Permanente Public Affairs DepartmentNine Piedmont Center3495 Piedmont Road, NEAtlanta, GA [email protected]

For more information contact:Customer Service:(404) 261-2590 locally1-800-611-1811 long distance


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