Reply to Kaiser - Infertility Services DO count toward OOP Max

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Reply to "Kaiser - Infertility Services DO count toward OOP Max"

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[quote=Anonymous]Here's the email I sent, if it helps someone:

Dear Mr. Abarca,

My name is [blank], and I am a federal government employee.  The federal government is currently undergoing open season, and I am considering switching to Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (E32 High Option – Self and Family).  I need your assistance to clarify coverage.

The 2016 High Option plan, according to publication RI 73-047, covers infertility services.  According to Section 5(a), under page 32, many infertility services are covered up to 50% of Kaiser’s allowance.

In addition, the 2016 High Option plan has a catastrophic protection out-of-pocket maximum of $4,500 per family enrollment.  Section 4 of the plan explains that “[a]fter your cost-sharing total $2,250 per person up to $4,500 per family enrollment . . . , you do not have to pay any more certain covered services.”  The plan also states that “copayments and coinsurance for the following services do not count toward [the] catastrophic protection out-of-pocket maximum, and [the member] must continue to pay copayments and coinsurance for these services: (1) Acupuncture services; (2) Dental services, except accidental injury dental benefit services; (3) orthopedic devices; and (4) travel benefit.”  This list of exceptions, however, does not include infertility services.

In addition, the Summary of Benefits answers the question, “What is not included in the out-of-pocket limit?”  In response, it says: “Premiums, balance-billed charges, and health care this plan doesn’t cover.”  It does not exclude infertility services from this list.

My understanding, based on the documents provided and my conversation with member services, is that infertility services do count toward the catastrophic protection out-of-pocket maximum under the 2016 High Option.  I have looked through both the 2016 Mid Atlantic Summary of Benefits and Coverage (available here: http://healthplans.kaiserpermanente.org/federalemployees/wp-content/uploads/sites/2/2015/09/2016-MidAtlantic-Summary-of-Benefits-and-Coverage.pdf) and the 2016 Mid Atlantic Plan Brochure (available here: http://healthplans.kaiserpermanente.org/federalemployees/wp-content/uploads/sites/2/2015/09/2016-MidAtlantic-Plan-Brochure.pdf), and nothing in these documents seems to indicate that infertility services are not counted toward the catastrophic protection out-of-pocket maximum.

If you could please point me to where I can find information showing that infertility services are not counted toward the catastrophic protection out-of-pocket maximum, I would greatly appreciate it.  Otherwise, please confirm both via phone [phone number] and via letter [address] that infertility services indeed count toward the catastrophic protection out-of-pocket maximum under the 2016 Mid Atlantic High Plan.  If they do, I will happily switch from [current provider] over to Kaiser Permanente.
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