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Provided by American Specialty Health Plans of California, Inc. (ASH Plans)Your Kaiser PermanenteCHIROPRACTIC andACUPUNCTURE benefitsWhen you need chiropractic or acupuncture care,follow these simple steps:1. Find an ASH Plans Participating Provider near you: Go to ashlink.com/ash/kp, or Call 1-800-678-9133 (TTY 711), Monday through Friday,from 5 a.m. to 6 p.m. Pacific time.2. Schedule an appointment.3. Pay for your office visit when you arrive for your appointment.(See the reverse for more details.)
YOUR KAISER PERMANENTE COMBINED CHIROPRACTIC AND ACUPUNCTURE BENEFITServicesChiropractic Services are covered when providedby a Participating Provider and Medically Necessaryto treat or diagnose Neuromusculoskeletal Disorders.Acupuncture Services are covered when aParticipating Provider finds that the Services areMedically Necessary to treat or diagnoseNeuromusculoskeletal Disorders, nausea, or pain.You can obtain Services from any ASH PlansParticipating Providers without a referral from aKaiser Permanente Plan Physician.Cost Sharing and Office Visit MaximumsOffice visit cost share: 10 copay per visitOffice visit limit: Up to a combined total of 30 medically necessary Chiropracticand Acupuncture visits per yearChiropractic appliance benefit: If the amount of the appliance in the ASH Plans feeschedule exceeds 50, you will pay the amount in excess of 50, and that paymentwill not apply toward the Plan Deductible or Plan Out-of-Pocket Maximum. Coveredchiropractic appliances are limited to: elbow supports, back supports, cervical collars,cervical pillows, heel lifts, hot or cold packs, lumbar braces and supports, lumbarcushions, orthotics, wrist supports, rib belts, home traction units, ankles braces,knee braces, rib supports, and wrist braces.Office visits: Covered Services are limited to Medically Necessary Chiropractic and Acupuncture Services authorized and provided by ASHPlans Participating Providers except for the initial examination, emergency and urgent Chiropractic and Acupuncture Services, and Services thatare not available from Participating Providers or other licensed providers with which ASH contracts to provide covered care. Each office visitcounts toward any visit limit, if applicable, even if acupuncture or a chiropractic adjustment is not provided during the visit.X-rays and laboratory tests: Medically Necessary X-rays and laboratory tests are covered at no charge when prescribed as part of coveredchiropractic care and a Participating Provider provides the Services or refers you to another licensed provider with which ASH contracts forthe Services.Participating ProvidersASH Plans contracts with Participating Providers and other licensed providers to provide covered Chiropractic Services (including laboratorytests, X-rays, and chiropractic appliances). ASH Plans contracts with Participating Providers to provide acupuncture care (includingadjunctive therapies, such as acupressure, moxibustion, or breathing techniques, when provided during the same course of treatment andin conjunction with acupuncture). You must receive covered Services from a Participating Provider or another licensed provider with whichASH contracts, except for Emergency Chiropractic Services, Emergency Acupuncture Services, Urgent Chiropractic Services, and UrgentAcupuncture Services, and Services that are not available from Participating Providers or other licensed providers with which ASH contractsto provide covered Services that are authorized in advance by ASH Plans. The list of Participating Providers is available on the ASH Planswebsite at ashlink.com/ash/kp or from the ASH Plans Customer Service Department at 1-800-678-9133. The list of Participating Providers issubject to change at any time without notice.How to Obtain Covered ServicesTo obtain covered Services, call a Participating Provider to schedule an initial examination. If additional Services are required, verificationthat the Services are Medically Necessary may be required. Your Participating Provider will request any medical necessity determinations.An ASH Plan’s clinician in the same or similar specialty as the provider of Services under review will decide whether Services are or wereMedically Necessary. ASH Plans will disclose to you, upon request, the written criteria it uses to make the decision to authorize, modify,delay, or deny a request for authorization. If you have questions or concerns, please contact the ASH Plans Customer Service Department.Second OpinionsYou may request a second opinion in regard to covered Services by contacting another Participating Provider. A Participating Provider may alsorequest a second opinion in regard to covered Services by referring you to another Participating Provider in the same or similar specialty.Your CostsWhen you receive covered Services, you must pay your Cost Share as described in the Combined Chiropractic and Acupuncture ServicesAmendment of your Health Plan Evidence of Coverage. The Cost Share does not apply toward the Plan Out-of-Pocket Maximum described inthe Health Plan Evidence of Coverage (unless you have a plan with an HSA option).Emergency and Urgent Chiropractic and Acupuncture ServicesWe cover Emergency Chiropractic Services, Emergency Acupuncture Services, Urgent Chiropractic Services, and Urgent AcupunctureServices provided by both Participating Providers and Non–Participating Providers. We do not cover follow-up or continuing care from aNon–Participating Provider unless ASH Plans has authorized the services in advance. Also, we do not cover services from a Non–Participating Provider that ASH Plans determines are not Emergency Chiropractic Services, Emergency Acupuncture Services, UrgentChiropractic Services, or Urgent Acupuncture Services.Getting AssistanceIf you have questions about the Services you can get from an ASH Plans Participating Provider or another licensed provider with which ASHcontracts, you may call ASH Plans Customer Service Department at 1-800-678-9133 (TTY users call 711), weekdays from 5 a.m. to 6 p.m.Pacific time.ChiroAcu 3057 NCAL 3058 SCAL (9/16)
YOUR KAISER PERMANENTE COMBINED CHIROPRACTIC AND ACUPUNCTURE BENEFITGrievancesYou can file a grievance with Kaiser Permanente regarding any issue. Your grievance must explain your issue, such as the reasons why youbelieve a decision was in error or why you are dissatisfied with Services you received. You may submit your grievance orally or in writing to KaiserPermanente as described in your Health Plan Evidence of Coverage.Exclusions and Limitations Acupuncture Services for conditions other than Neuromusculoskeletal Disorders, nausea, and painServices for asthma or addiction, such as nicotine addictionHypnotherapy, behavior training, sleep therapy, and weight programsThermographyExperimental or investigational ServicesCT scans, MRIs, PET scans, bone scans, nuclear medicine, and any other types of diagnostic imaging or radiology other than X-rays coveredunder the “Covered Services” section of your Combined Chiropractic and Acupuncture Services Amendment Ambulance and other transportation Education programs, nonmedical self-care or self-help, any self-help physical exercise training, and any related diagnostic testing Services for pre-employment physicals or vocational rehabilitation Acupuncture performed with reusable needles Air conditioners, air purifiers, therapeutic mattresses, chiropractic appliances, durable medical equipment, supplies, devices, appliances,and any other item except those listed as covered in your Combined Chiropractic and Acupuncture Services Amendment Drugs and medicines, including non-legend or proprietary drugs and medicines Services you receive outside the state of California, except for Emergency Chiropractic Services, Emergency Acupuncture Services, UrgentChiropractic Services, or Urgent Acupuncture Services Hospital services, anesthesia, manipulation under anesthesia, and related services For Chiropractic Services, adjunctive therapy not associated with spinal, muscle, or joint manipulations For Acupuncture Services, adjunctive therapies unless provided during the same course of treatment and in conjunction with acupuncture Dietary and nutritional supplements, such as vitamins, minerals, herbs, herbal products, injectable supplements, and similar products Massage therapy Services provided by a chiropractor that are not within the scope of licensure for a chiropractor licensed in California Services provided by an acupuncturist that are not within the scope of licensure for an acupuncturist licensed in California Maintenance care (services provided to Members whose treatment records indicate that they have reached maximum therapeutic benefit)DefinitionsAcupuncture Services: The stimulation of certain points on or near the surface of the body by the insertion of needles to prevent or modify theperception of pain or to normalize physiological functions (including adjunctive therapies, such as acupressure, cupping, moxibustion, orbreathing techniques, when provided during the same course of treatment and in conjunction with acupuncture) when provided by anacupuncturist for the treatment of your Neuromusculoskeletal Disorder, nausea (such as nausea related to chemotherapy, postsurgical pain,or pregnancy), or pain (such as lower back pain, shoulder pain, joint pain, or headaches).ASH Plans: American Specialty Health Plans of California, Inc., a California corporation.Chiropractic Services: Services provided or prescribed by a chiropractor (including laboratory tests, X-rays, and chiropractic appliances) forthe treatment of your Neuromusculoskeletal Disorder.Emergency Acupuncture Services: Covered Acupuncture Services provided for the treatment of a Neuromusculoskeletal Disorder, nausea, orpain, which manifests itself by acute symptoms of sufficient severity (including severe pain) such that a reasonable person could expect theabsence of immediate Acupuncture Services to result in serious jeopardy to your health or body functions or organs.Emergency Chiropractic Services: Covered Chiropractic Services provided for the treatment of a Neuromusculoskeletal Disorder whichmanifests itself by acute symptoms of sufficient severity (including severe pain) such that a reasonable person could expect the absence ofimmediate Chiropractic Services to result in serious jeopardy to your health or body functions or organs.Neuromusculoskeletal Disorders: Conditions with associated signs and symptoms related to the nervous, muscular, or skeletal systems.Neuromusculoskeletal Disorders are conditions typically categorized as structural, degenerative, or inflammatory disorders, or biomechanicaldysfunction of the joints of the body or related components of the motor unit (muscles, tendons, fascia, nerves, ligaments/capsules, discs, andsynovial structures), and related neurological manifestations or conditions.Participating Provider: An acupuncturist who is licensed to provide acupuncture services in California and who has a contract with ASH Plansto provide Medically Necessary Acupuncture Services to you, or a chiropractor who is licensed to provide chiropractic services in California and(continues)who has a contract with ASH Plans to provide Medically Necessary Chiropractic Services to you.ChiroAcu 3057 NCAL 3058 SCAL (9/16)
YOUR KAISER PERMANENTE COMBINED CHIROPRACTIC AND ACUPUNCTURE BENEFITDefinitions (continued)Urgent Acupuncture Services: Acupuncture Services that meet all of the following requirements: They are necessary to prevent serious deterioration of your health resulting from an unforeseen illness, injury, or complication of an existingcondition, including pregnancy. They cannot be delayed until you return to the Service Area.Urgent Chiropractic Services: Chiropractic Services that meet all of the following requirements: They are necessary to prevent serious deterioration of your health, resulting from an unforeseen illness, injury, or complication of an existingcondition, including pregnancy. They cannot be delayed until you return to the Service Area.This is a summary and is intended to highlight only the most frequently asked questions about the chiropractic and acupuncture benefit,including cost shares. Please refer to the Combined Chiropractic and Acupuncture Services Amendment of the Kaiser Foundation Health Plan,Inc., Evidence of Coverage for a detailed description of the chiropractic and acupuncture benefits, including exclusions and limitations,Emergency Chiropractic Services, Emergency Acupuncture Services, Urgent Chiropractic Services, or Urgent Acupuncture Services.Kaiser Foundation Health Plan, Inc. (Health Plan) contracts with American Specialty Health Plans of California, Inc. (ASH Plans) to make the ASHPlans network of Participating Providers available to you. You can obtain covered Services from any Participating Provider without a referral froma Plan Physician. Your Cost Share is due when you receive covered Services. Please see the definitions section of your Combined Chiropracticand Acupuncture Services Amendment of the Kaiser Foundation Health Plan, Inc., Evidence of Coverage for terms you should know.ChiroAcu 3057 NCAL 3058 SCAL (9/16)Please recycle. September 2016
Kaiser Permanente Plan Physician. Office visit cost share: 10 copay per visit Office visit limit: Up to a combined total of 30 medically necessary Chiropractic and Acupuncture visits per year Chiropractic appliance ben
