Advantage Plus - Enroll now for 2015 - Get extra vision, dental, and …info.kaiserpermanente.org/info_assets/vibrantyou/pdf/... · 2014. 10. 16. · 1 5 BENEFITS AT A GLANCE The

All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest.

500 NE Multnomah St., Suite 100, Portland, OR 97232. ©2014 Kaiser Foundation Health Plan of the Northwest

H9003_ADMEM0115 accepted 539SA-14/9-14

Kaiser Permanente Senior Advantage (HMO) Northwest

Enroll now for 2015

Get extra vision, dental, and hearing benefits

Advantage Plus

539SA-14/9-14 For more information visit kp.org/vibrantyou.

Be healthy. Be vibrant.

Now you have the option to add dental, hearing, extra vision benefits to your Kaiser Permanente Senior Advantage plan. And even better, it’s affordable.

1539SA-14/9-14

For a fast, easy review of this Advantage Plus booklet, just follow steps A, B, and C. See the table of contents on page 3 to learn more about Advantage Plus and everything it provides.

Quick start guide

A Go to page 2 for a quick look at how Advantage Plus makes it easy to expand your health care coverage. For more detailed information about Advantage Plus benefits, go to page 5.

B Turn to “Benefits at a glance” on page 5 for a summary of the dental care, hearing aid, and extra eyewear benefits of Advantage Plus.

C Apply for coverage by filling out the enrollment form. Please see “How to apply for coverage” on page 34.

GET STARTED HERE

If you have questions, please call one of our licensed sales specialists toll free at 1‑877‑451‑3817 (TTY 711), seven days a week, 8 a.m. to 8 p.m., or visit kp.org/vibrantyou.


As a Kaiser Permanente Senior Advantage Basic or Senior Advantage individual plan member, you enjoy the convenience of one plan that combines your Medicare coverage with Kaiser Permanente coverage. Now, with Advantage Plus, you get a bundle of valuable dental care, hearing aid, and extra eyewear benefits added to your plan — so all your health benefits come in one convenient package.

More health coverage. More value.

Advantage Plus works together with your Senior Advantage Basic or Senior Advantage individual plan to give you dental care, hearing aid, and extra eyewear coverage all through a convenient and trusted source — Kaiser Permanente.

• Save time and money by eliminating the need to shop around for dental care, hearing aid, and extra eyewear benefits separately.

• One bill — for both your Senior Advantage Basic or Senior Advantage individual plan and Advantage Plus coverage — makes taking care of your health easier than ever. If you prefer, your entire Senior Advantage Basic or Senior Advantage premium and your Advantage Plus premium can be made through a monthly electronic funds transfer.

You deserve the total health care that’s yours through Senior Advantage Basic or Senior Advantage with Advantage Plus. It’s one more way we can help you live a more vibrant life.

Refer to your Kaiser Permanente Senior Advantage (HMO) or Senior Advantage Basic (HMO) Evidence of Coverage (EOC) for detailed information about dental services provided under your Senior Advantage or Senior Advantage Basic individual plan.

Kaiser Permanente is an HMO plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium and any other applicable Medicare premium(s), if not otherwise paid by Medicaid or another third party. You must reside in the Kaiser Permanente Medicare health plan service area in which you enroll.

ADVANTAGE PLUS

A BENEFITS PACKAGE FOR A HEALTHIER, MORE VIBRANT YOU

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TABLE OF CONTENTSTABLE OF CONTENTS

1 Benefits at a glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

2 Dental coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Q&As

Kaiser Permanente dental providersKaiser Permanente dental offices

3 Hearing aid coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Q&As

4 Eyewear coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Q&As

5 How to apply for coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

6 Information you need to know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Enrollment/disenrollment

Page


1

5

BENEFITS AT A GLANCE

The Advantage Plus package gives you the option of adding more benefits to your Senior Advantage Basic or Senior Advantage individual plan. This chart shows the dental services, hearing aid, and extra eyewear benefits you receive when you purchase Advantage Plus for an additional $41 a month for all three benefits. This $41 monthly premium will be added to your Senior Advantage Basic or Senior Advantage individual plan premium.

The $1,250 annual dental benefit maximum applies for most dental services. The total plan charges for preventive, diagnostic, and most restorative services received apply to the annual dental benefit maximum except where noted.

Senior Advantage Basic or Senior Advantage individual plan coverage only

Advantage Plus coverage combined with Senior Advantage Basic or Senior Advantage individual plan coverage

DENTAL

Preventive dental services are not covered.

Preventive and diagnostic services:

No copayment or coinsurance up to the $1,250 annual dental benefit maximum for:

• Oral examination (maximum of 2 per calendar year).

• Bite wing X-ray (maximum of 2 per calendar year).

• Other X-rays dentally needed.

• One full mouth X-ray every 5 years.

• Cleanings (no more than 2 per consecutive 12-month period).

• Fluoride treatments.

Note: Total plan charges for preventive and diagnostic services received apply to the annual dental benefit maximum. Preventive and diagnostic services are not subject to meeting your dental deductible.




DENTAL (continued)

Comprehensive (basic and major restorative) dental services are not covered.

Basic and major restorative services:

Member pays 20% coinsurance after a $35 dental deductible up to the $1,250 annual dental benefit maximum.

Restorative services include:

• Fillings.

• Periodontal cleaning.

• Simple extractions.

• Oral surgery.

• Endodontic services (e.g., root canal).

• Fixed prosthetics (e.g., bridges and crowns).

• Removable prosthetics (dentures).

Note: Total plan charges for services we cover, less deductible and/or coinsurance you pay, count toward the $1,250 annual dental benefit maximum.

Nightguards: 10% coinsurance (based on full price).*

Nitrous oxide:*

• $15 copayment per occurrence for adults and children 13 years of age and older.

• $0 copayment per occurrence for children under 13.

Emergency or urgent dental care:

• $25 copayment per office visit on the same or next business day.* (This copayment only applies to emergency or urgent dental care received at Kaiser Permanente facilities.)

• All other applicable copayments, coinsurance, and total plan charges apply.

Out-of-area dental emergency care:

• Plan pays up to $100 per episode for emergency dental care provided by non-network providers outside the Northwest Kaiser Permanente Senior Advantage service area.

• You pay all dental charges exceeding $100.

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DENTAL (continued)

• Emergency dental care is covered for relief of pain, acute infection, hemorrhage or necessary treatment (including local anesthesia and pre-medication) due to injury.

*Annual dental benefit maximum does not apply.

NOTE:

• In any calendar year, we will not cover services that are subject to the deductible until you meet the deductible listed in the “Benefit Chart” during that calendar year.

• The only payments that count toward the deductible are those you make for covered services that are subject to the deductible under your EOC.

• The value of preventive and diagnostic services that you receive does not count toward the deductible.

• For services subject to the deductible, you must pay total plan charges until you meet the deductible.

• Once the deductible is satisfied, no further deductible will be due for the remainder of the calendar year.

HEARING AIDS

Hearing aids and fitting services are not covered.

$500 for up to one aid per ear every 3 years.

You must pay all hearing aid charges after the $1,000 hearing aid benefit maximum coverage amount.




EYEWEAR

No charge for Medicare-covered eyewear after each cataract surgery; one pair of eyeglasses or contact lenses from a designated selection of frames/lenses or contact lenses.

Medicare-covered eyewear after cataract surgery is only covered for the cost of basic eyeglass frames and lenses. You must pay charges above the Medicare-covered amount for premium lenses, premium eyeglass frames, anti-reflective coating, tints, polarized, photochromic lenses, or other premium options.

$175 allowance toward prescription eyeglasses or contact lenses every two years.

and

No charge for Medicare-covered eyewear after each cataract surgery; one pair of eyeglasses or contact lenses from a designated selection of frames/lenses or contact lenses.

Once the Advantage Plus $175 eyewear benefit is used toward a purchase, the benefit will not become available for two years from order date.

See your Kaiser Permanente Senior Advantage Basic or Senior Advantage Evidence of Coverage for detailed information about dental, hearing, and vision services provided under your Senior Advantage Basic or Senior Advantage individual plan.

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2 THE POWER OF A HEALTHY SMILE

Personal dental care means seeing a friendly, familiar face when you visit your Kaiser Permanente dental office. It means getting care from dental professionals who understand your needs and history. We’re here to help make it easy.

Your dental health is vital to your overall health. Healthy teeth and gums mean you can eat better and feel better — physically and mentally. And nothing engages the people around you like a smile.

Prevention and treatment of dental problems are important at any stage of life. You may experience more tooth sensitivity or have dental problems as a result of certain medications or health conditions. Regular oral exams not only keep your mouth healthy, but can also help identify medical problems.

Advantage Plus makes it easy to get the dental care you need. Enjoy the power of a healthy smile.

Health tip:

REDUCE YOUR RISK OF INFECTIONBrushing and flossing not only are important for healthy teeth, but also may help reduce the risk of infection. Good oral hygiene is especially important for anyone facing surgery for hip or knee replacement. Bacteria can travel from the mouth to other parts of the body, causing infection — a major cause of failure in joint replacements.


Q&AsDENTAL

Advantage Plus dental benefits are provided through Kaiser Permanente dental providers.

1. Which dentist can I visit?

Your personal care dentist plays an important role in coordinating your dental care needs, including routine dental visits and referrals to specialists. We encourage you to choose a personal care dentist.

Just follow these simple steps:

a. Choose a Kaiser Permanente dental office that’s close to where you live or work as your regular dental office.

b. Choose a personal care dentist and dental hygienist. Ask friends or co-workers about the Kaiser Permanente dentist and dental hygienists they visit. Look on kp.org/dental/nw/directory. Or ask us for help selecting someone who is right for you. You can change your caregivers at any time.

c. Let us get to know you. Make your concerns and needs known to your dentist and hygienist. Always feel free to ask questions by calling Member Services.

2. How do I make a dental appointment?

When you have questions, need dental services, need to make an appointment, or need to ask about eligibility, please call the Dental Appointment Center from 6:30 a.m. to 6 p.m., Monday through Friday, or 7:30 a.m. to 4 p.m., Saturday. Please have your Kaiser Permanente ID card available.

Portland area .................................................503‑286‑6868 (toll free 1‑800‑448‑6118)

Salem area .....................................................503‑370‑4311 (toll free 1‑800‑448‑6118)

Vancouver area ..............................................360‑254‑9158 (toll free 1‑800‑448‑6118)

Longview area ................................................360‑575‑4800 (toll free 1‑800‑448‑6118)

TTY ............................................................................................................... 711 toll free

Outside of office hours, please call our automated system at 1‑800‑448‑6118 toll free, 24 hours a day, to cancel an appointment, schedule a hygiene appointment, or leave a message to get a call back. For dental emergencies outside of the above hours, call our 24-hour advice nurse toll free at 1‑800‑813‑2000 (TTY 711).

3. How do I cancel a dental appointment?

Please give us a 24-hour notice if you can’t keep a dental appointment. This allows us to give your appointment to another member. To cancel, please call one of the Dental Appointment Center numbers listed above.

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4. What happens if I have an urgent dental need?

If you need urgent dental care, call the Dental Appointment Center. A representative will arrange for you to receive care as soon as possible. See your Kaiser Permanente Senior Advantage Basic or Senior Advantage Evidence of Coverage and Benefit Chart for a description of your urgent dental care benefit. Examples of urgent dental care include treatment of toothaches, chipped teeth, broken fillings that cause irritation, and swelling around a tooth.

5. What happens if I have a dental emergency?

In a dental emergency, please call the Dental Appointment Center for assistance or for arrangements to be seen for care. For dental emergencies outside the Dental Appointment Center hours, call our 24-hour advice nurse to arrange for care. Emergency dental care involves treatment of sudden and unexpected conditions in or around the teeth and gums needing immediate attention. Examples include treatment of severe traumatic injury, swelling that interferes with swallowing and/or breathing, or bleeding that does not stop. For additional details on emergency dental care, see your EOC.

6. What denture services are available?

Denture services are available at your Kaiser Permanente dental office. You will need a referral from your Kaiser Permanente dentist. If you have an emergency, such as a broken denture, please call the Dental Appointment Center for a same-day appointment at your dental office.

7. If I am traveling outside the Northwest Senior Advantage service area, do I have any dental coverage?

You have limited coverage for emergency or urgent dental care outside the service area. Kaiser Permanente pays up to $100 per episode for emergency relief of pain, acute infection, or hemorrhage or necessary treatment, including local anesthesia and pre-medication, due to injury.

You will need to fill out the Non Plan Care Information Form within 365 days after first receiving dental care at non–Kaiser Permanente dental facilities or as soon as reasonably possible. You can obtain a claim form from Member Services or on our website at kp.org. Mail your completed claim form and request for payment with any dental bills or dental receipts to:

Claims Administration Kaiser Foundation Health Plan of the Northwest 500 NE Multnomah St., Suite 100 Portland, OR 97232-2099

8. Will I get a separate Kaiser Permanente dental ID card?

No, your Kaiser Permanente medical ID card is all you need at Kaiser Permanente dental offices.

9. Does my dental plan have a deductible?

Yes, there is a $35 annual deductible for basic and major restorative dental services. There is no deductible for preventive and diagnostic dental services.


10. How does the dental deductible work?

A deductible is the amount you must pay before our plan begins to pay its share of your covered dental services. You pay for covered basic and major restorative dental services until you meet the $35 deductible. Once you meet the deductible, you will pay 20 percent coinsurance for basic and major restorative dental services until you meet the annual dental benefit maximum.

11. What is the annual dental benefit maximum?

Your dental benefits have a $1,250 annual dental benefit maximum. The actual cost of the services you receive (the total plan charges), not counting copayment, coinsurance, or deductible amounts, accrue or apply to the $1,250 annual dental benefit maximum. Once you reach the annual dental benefit maximum, you are responsible for the total plan charges for any additional dental services you receive in that calendar year. The actual costs (total plan charges) for most, but not all, covered dental services apply to the dental benefit maximum.

12. What actual costs (total plan charges) apply to the annual dental benefit maximum?

The actual cost for the following services applies to the dental benefit maximum:

Preventive and diagnostic services (such as oral exams, X-rays, and cleanings).

Basic and major restorative services (such as fillings, crowns, and dentures).

13. What are total plan charges?

Total plan charges are the actual cost of the services you receive, not counting a copayment, coinsurance, or deductible amount. For example: If you receive preventive and diagnostic services and the amount of the actual cost is $410, although your copayment amount is $0 prior to reaching your annual dental benefit maximum, the $410 actual cost of the preventive and diagnostic services applies to the annual dental benefit maximum.

14. What does not apply to the annual dental benefit maximum?

Your copayment, coinsurance, deductible amount and emergency office visit fees that you pay for any covered dental service do not apply to the annual dental benefit maximum.

The actual cost for the following covered services does not apply to the dental benefit maximum:

Nightguards.

Nitrous oxide.

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This chart shows an example of how the deductible and the annual dental benefit maximum work. Amounts listed may not reflect your actual services or dental needs.

Annual care

Actual cost of

the dental service

(total plan charges)

Member out‑of‑pocket$0 for preventive and diagnostics services20% coinsurance for

basic and major restorative services after

$35 deductible

Kaiser Permanente

pays

Annual dental benefit

maximum balance

2 cleanings $190.00 $0 $190.00 $1,060.00

2 oral exams $114.00 $0 $114.00 $946.00

1 set of periapical X-rays $53.00 $0 $53.00 $893.00

1 set of X-rays (4 bitewings) $70.00 $0 $70.00 $823.00

1 panoramic X-ray $114.00 $0 $114.00 $709.00

1 surface amalgam (metal) filling $138.00

Annual deductible $35 + 20% coinsurance:

$138-$35 (deductible) = $103$103 at 20% coinsurance =

$20.60$35 + $20.60 = $55.60 member out-of-pocket $82.40 $626.60

4+ surface amalgam (metal) fillings $244.00 $48.80 $195.20 $431.40

Tooth extraction $150.00 $30.00 $120.00 $311.40

1 limited evaluation $87.00 $17.40 $69.60 $241.80

Adjust denture $83.00 $16.60 $66.40 $175.40

Total $1,243.00 $168.40 $1,074.60 $175.40

15. Do I have a share of the cost (deductible, copayment, or coinsurance) for covered preventive and diagnostic services (cleanings, oral exams, fluoride treatments, and X‑rays)?

There is no deductible for preventive and diagnostic services. You also have no share of the cost (no copayment or coinsurance) for these services, as long as you have not reached your annual dental benefit maximum. If you have reached your annual dental benefit maximum, then you will pay the actual cost (total plan charges) for preventive and diagnostic services.

16. When will I be charged a coinsurance or copayment?

You will be charged a $25 office visit copayment for emergency or urgent dental appointments at Kaiser Permanente dental offices. You also have a share of the cost for nightguards (10 percent coinsurance) and nitrous oxide (a $15 copayment for those 13 and older). These cost shares apply regardless of whether you have reached the annual dental benefit maximum.


17. If I have dental X‑rays from my previous dentist, can they be used in place of new X‑rays?

Your dentist will determine whether your outside X-rays can be used or if you’ll need new ones. There are several factors the examining dentist will take into account in order to answer that question. You can ask your former dentist to send the X-rays to the Kaiser Permanente dental office you have chosen for your appointment prior to your examination. Or you may bring them to your initial exam. Your initial examination cannot be completed without dental X-rays.

The dentist will assess the quality of the X-rays supplied. Copies of X-rays are frequently unclear and difficult to read, making them unusable for a new exam. The dentist must feel confident about making an accurate diagnosis from any dental X-ray.

The dentist will also assess the time that has passed since the X-rays were taken, along with the dental health presentation of the patient. If a patient has evidence of dental disease and/or a history of extensive dental treatment, the interval between X-rays is shortened. Patients in good dental health with very few previous dental restorations generally have longer intervals between X-rays.

18. Why am I going to receive a comprehensive examination with X‑rays as a new Kaiser Permanente dental program member?

Our dentists and hygienists follow specific care standards, which include a comprehensive examination of all new members. By providing a comprehensive oral health assessment, we’re better able to diagnose and treat potential problem areas while laying the groundwork for future dental care. The guidelines used for determining the number of X-rays needed at an initial examination are based on the U.S. Food and Drug Administration (FDA) guidelines for prescribing dental radiographs (X-rays).

19. What are the FDA guidelines for dental X‑rays for new adult patients?

The FDA advises dental practices to take individualized posterior bitewings with panoramic examination or posterior bitewings and selected periapical images. A full-mouth intraoral radiographic (X-ray) examination is advised when patients show evidence of generalized dental disease or a history of extensive dental treatment.

20. Who can I contact if I have more questions about my dental benefits?

Please contact Member Services at 1‑877‑221‑8221 (TTY 711) seven days a week, 8 a.m. to 8 p.m. (For language interpretation, call 1‑800‑324‑8010.)

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TYPES OF DENTAL PROFESSIONALS Our Kaiser Permanente dental offices have several types of dental professionals to meet your needs. Each dental office in this brochure lists the names of the people who work there and their professional qualifications. Here are the abbreviations and titles:

DDS Doctor of Dental Surgery DMD Doctor of Medical Dentistry LD Licensed Denturist RDH Registered Dental Hygienist

We have dental professionals practicing in the following specialties:

Denturist A dental technician who specializes in making and fitting dentures.

Endodontist A dentist who specializes in root canals and the treatment of diseases or injuries that affect the pulp of teeth.

Orthodontist A dentist who specializes in preventing and treating misaligned teeth.

Pediatric dentist A dentist who specializes in treating children from birth through adolescence.

Periodontist A specialist who treats the gums and supporting structures of the teeth.

Prosthodontist A dentist who specializes in restoring teeth and/or replacing missing teeth with bridges, dentures, crowns, or implants.


DENTAL OFFICES, CONTACT NUMBERS, AND PROVIDERSThis list is current as of August 2014. This list may include providers who are not currently accepting new patients. For the most up-to-date information on network providers, please visit kp.org/dental/nw/directory or call toll free 1‑800‑813‑2000 (TTY 711).

ALOHA DENTAL OFFICE17675 SW Tualatin Valley Highway, Beaverton, OR 97003

Appointments: 503‑286‑6868

General dentists

Chung, John, DDS

Dave, Nipoon, DDS

Lee, Cyrus, DMD

Popov, Lindsey, DMD

Pediatric dentist

Antony, Susan, DDS

Huber, Piper, DDS

Periodontist

Akiyama, Dennis, DDS

Lowen, Krista, DDS

Registered dental hygienists

Do, Julie, RDH

Jackson, Kathleen, RDH

La, Anna, RDH

Lane, Kandice, RDH

Rapp, Cindi, RDH

Roessler, Luann, RDH

Vahoomani, Lisa, RDH

BEAVERTON DENTAL OFFICE4855 SW Western Ave., Beaverton, OR 97005


General dentists

French, Daniel, DMD

Leoni, Russel, DMD

Opperman, Joshua, DMD

Kincaid, Wendy, DMD

Tsen, T. Eric, DMD


Bazor, Kristin, RDH

Cerbu, Delia, RDH

Cregger, Sami, RDH

Hartley, Martha, RDH

Hockema, Jennifer, RDH

Jacobson, Emily, RDH

Nilsen, Lynn, RDH

Proudfoot, Alisa, RDH

Smythe, Nancy, RDH

Teeny, Summer, RDH

Williams, Teresa, RDH

CASCADE PARK DENTAL OFFICE12711 SE Mill Plain Blvd., Vancouver, WA 98684


General dentists

Callaghan, Jody, DMD

De Ainza, Minah, DDS

Johnson, Aaron, DMD

Lee, Felix, DMD

Omans, Richard, DDS

Rawley, Nikolas, DMD

Straube, David, DMD

Denturist

Fettig, Shawn, LD

Orthodontist

Mumford, Bruce, DMD

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Pediatric dentist

Vo-Cheng, Linh, DMD


Atkinson, Tracy, RDH

Ausmus, Shelley, RDH

Charpentier, Brenda, RDH

Dietel, Toni, RDH

Hancock-Marshall, Karen, RDH

Henegan, Amy, RDH

Jancze, Tamera, RDH

Januik, Dawn, RDH

Knotts, Jamie, RDH

Larson, Bonnie, RDH

Nichols, Kristeen, RDH

Pelosi, Kathryn, RDH

Tamayao, Patricia, RDH

Teegarden, Katarzyna, RDH

Vollstedt, Jennifer, RDH

CLACKAMAS DENTAL OFFICE10209 SE Sunnyside Road, Clackamas, OR 97015


General dentists

Geist, Dean, DMD

Hill, John, DDS

Muraki, Yoshiyuki (Charlie), DMD

Patterson, Mailiki, DDS

Peng, Myron, DMD

Schaumburg, Susan, DMD

Trybom, Misty, DDS

Walker, David, DMD

Yoo, Jimmy, DDS


Amick, Tamara, RDH

Hankins, Janet, RDH

McNeil, Karen, RDH

Morrison, Paula, RDH

Nonamaker, Cindy, RDH

Sasser, Charlotte, RDH

Saxton, Sara, RDH

Stoltenburg, Ronda, RDH

Vaughn, Michelle, RDH

Wilson, Sandra, RDH

EASTMORELAND DENTAL OFFICE5025 SE 28th Ave., Portland, OR 97202


General dentists

Censoni, Paula, DMD

Chang, Lloyd, DDS

McCashew, Robert, DDS

Vanwitzenburg, Marcus, DMD

Villanueva, Mark, DDS

White, Johanna, DDS

Periodontists

Akiyama, Dennis, DDS


Brandon, Sierra, RDH

Farlinger-King, Jacqueline, RDH

Kirkpatrick, Jessicah, RDH

Le, Thu-Ha, RDH

Lynch, Julia, RDH

Marston, Julie, RDH

Martin, Chenoa, RDH

McAdams, Kimberly, RDH

Schmierbach, Angela, RDH

Secrist, Daryn, RDH

Thorburn, Molly, RDH

GLISAN DENTAL OFFICE10102 NE Glisan St., Portland, OR 97220


General dentists

Casper, Carrie, DMD

Devarajan, Deepak, DMD

Nasserziayee, Farooq, DMD

Pak, John, DDS

Paynter, Mitchell, DMD

Scarzella, Clayton, DMD

Smith, James, DMD


Endodontist

Wiltbank, Kenneth, DMD

Oral surgeons

Holland, John, DDS

Rawley, Daniel, DDS

Orthodontist

Teeter, David, DMD

Pediatric dentist

Stafford, Greg, DDS

Periodontist

Watson, Marcy, DDS

Watari, Tetsuji, DDS


Allbritton, Christie, RDH

Brewer, Cindy, RDH

Bulbuk, Rodica, RDH

Geist, Alyson, RDH

Grandi, Berit, RDH

James, Lara, RDH

Kaady, Tyler, RDH

Mitchell, Lori, RDH

Niculcea, Laurice, RDH

Riordan, Mary, RDH

Smith, Cheri, RDH

Wilkie, Andrea, RDH

GRAND AVENUE DENTAL OFFICE1314 NE Grand Ave., Portland, OR 97232


General dentists

Chen, Alan, DMD

Creager, John, DMD

Edwards, Isaac, DMD

Fife-Griffin, Heather, DMD

Gilbert, Jennifer, DMD

Guerrero, Lisa, DDS

Lemrick, Curtis, DMD

Whitt, Jason, DMD

Wolfe, Jeffrey, DDS

Orthodontist

Barrett, Robert, DMD

Pediatric dentist

Hakimeh, Samer, DDS


Barry, Yardena, RDH

Bolds, Ashley, RDH

Brown, Sharon, RDH

Bushue, Bailey, RDH

Denmark, Kyle, RDH

Gerlach, Rachel, RDH

Grinko, Anna, RDH

Luu, Kelly, RDH

MacPherson, Marie, RDH

McVicker, Megan, RDH

Muir, Julianne, RDH

Stumpf, Abby, RDH

Randel, Rebecca, RDH

Wong, Nancy, RDH

GRESHAM DENTAL OFFICE360 NW Burnside Road, Gresham, OR 97030


General dentists

Del Togno Armanasco, Richard, DMD

Ferek, Robert, DDS

Leinassar, Ronald, DMD

Tran, Nhu-Ha, DMD


Burkhart, Jacqueline, RDH

Gwilliam, Sharon, RDH

Propeck, Terese, RDH

Vieru, Fivia, RDH

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LONGVIEW‑KELSO DENTAL OFFICE1230 Seventh Ave., Longview, WA 98632


General dentists

Ghanee, Nadereh “Nadia,” DMD

Kaufman, Ethan, DDS

Kim, John, DMD

Pope, Marcus, DDS

Denturist

Fettig, Shawn, LD


Anderson, Jana, RDH

Balbarais, Candace, RDH

Besco, Anita, RDH

Chadwick, Daphne, RDH

England, Kellee, RDH

Geiger, Shauna, RDH

Ray, Janet, RDH

NORTH INTERSTATE DENTAL OFFICE7201 N. Interstate Ave., Portland, OR 97217

Appointments 503‑286‑6868

Denturist

Miller, Gene, LD

Prosthodontist

Ambard, Alberto, DDS

Broyles, Allison, DMD

NORTH LANCASTER DENTAL OFFICE2300 Lancaster Drive NE, Salem, OR 97305


General dentists

Castilla, Edariz, DDS

Daniels, Allison, DMD

DeLange, Kregg, DMD

Haider, R. Jeremy, DMD

Karam, Aziz, DMD

Povey, Ira, DDS

Santee, Daniel, DMD

Denturist

Cantarero, Oswaldo, LD

Periodontist

Bowman, Jila, DDS


Bielby, Myra, RDH

Coburn, Katherine, RDH

Dyer, Haley, RDH

Fox, Delores, RDH

Geark, Sarah, RDH

Henkel, Ginger, RDH

Jordan, Kelly, RDH

Liermann, Katherine, RDH

Smith, Karla, RDH

Timberlake, Jessica, RDH

Wade, Mary, RDH

OREGON CITY DENTAL OFFICE1900 SE McLoughlin Blvd., Suite 68, Oregon City, OR 97045


General dentists

Allen, John, DMD

Edwards, Douglas, DMD

Francis, Molly, DMD

Pacewic, Jean, DMD


Freeman, Misty, RDH

McCommas, Teresa, RDH

Neumeister, Carleigh, RDH

Payne, Monica, RDH

Regan, Kathy, RDH

Shumskiy, Irina, RDH

Pediatric dentist

Setter, Shelby, DDS


ROCKWOOD DENTAL OFFICE822 NE 181st Ave., Portland, OR 97230


Denturist

Cain, Dennis, LD

Waite, Teresa, LD

General dentists

Amador, Raul, DMD

Browning, Jonathan, DDS

Chang, Michael, DDS

Justice, Steven, DDS


Bettendorf, Julie, RDH

Caldwell, Faren, RDH

Carpenter, Adriana, RDH

Detrick, Katherine, RDH

Dow, Susan, RDH

Fawver, Sarah, RDH

Gwilliam, Sharon, RDH

Kaady, Jane, RDH

Tretyakova, Maria, RDH

SALMON CREEK DENTAL OFFICE14406 NE 20th Ave., Vancouver, WA 98686


General dentists

Chung, Matthew, DDS

Creed, William, DMD

Daly, Marianne, DMD

Geisel, Mark, DDS

Karagianes, Susan, DMD

Kim, John, DMD

Lytle, Reed, DDS

Manalili, Angela, DMD

Monfort, Brandt, DDS

Endodontist

Reese, Randy, DDS

Periodontist

Watson, Marcy, DDS


Bowers, Brook, RDH

Casey, Theresa, RDH

Ching, Leslie, RDH

Hart, Diane, RDH

Janke, Kathryn, RDH

Larson, Bonnie, RDH

Madden, Mi, RDH

McCullough, Rose, RDH

Salari-Miller, Minoo, RDH

Sherbina, Elena, RDH

Siemieniec, Judy, RDH

Waddell, Margaret, RDH

Zamora, Carla, RDH

SKYLINE DENTAL OFFICE5135 Skyline Road S., Salem, OR 97306


General dentists

Allen, Francis, DMD

Chung, Daniel, DDS

Harms, Jennifer, DDS

Khalil, Tara, DDS

Le, Linda, DDS

Olson, Vanessa, DDS

Southworth, James, DMD

White, Robert, DDS

Oral surgeon

Holland, John, DDS

Pediatric dentist

Lane, Katherine, DMD


Abbott, Melissa, RDH

Coste, Adriana, RDH

Dayton, Kimberly, RDH

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Hahn, Carolyn, RDH

Mallorie, Megan, RDH

McQuigg, Jesse, RDH

Morrical, Stacey, RDH

Rollins, Janine, RDH

Smith, Hallie, RDH

Smith, Teresa, RDH

SUNSET DENTAL OFFICE19075 NW Tanasbourne Drive, Suite 300 Hillsboro, OR 97124


General dentists

Antony, Matthew, DDS

Balekjian, Gregory, DDS

Doan, Phuong “Teresa,” DMD

Floor, K. Larson, DMD

Kao, May, DDS

Odell (Boettcher), Juanita, DMD

Row, Charles, DDS

Stringer, Brett, DMD

Wilson, Kelley, DMD

Young, Harold, DMD

Oral surgeon

Dezura, Kelly, DMD

Kleinman, Alexis, DMD

Orthodontist

Ratliff, Tom, DDS

Shimogaki, Sheri, DDS

Pediatric dentist

Huber, Piper, DDS

Laraway, Lester, DDS


Blume, Julie, RDH

Cao, Bichthuy, RDH

Caroline, Wendy, RDH

Dulwick, Deborah, RDH

Fultz, Lubov, RDH

Fun, Kayvandokht, RDH

Gray, Susan, RDH

Haines, Erika, RDH

Ko, Irene, RDH

Mai, Thu-Lan, RDH

Nguyen, Chi, RDH

Richter, Deborah, RDH

Sadiq, Maarof, RDH

Tatum, Maria, RDH

Treanor, Jacob, RDH

Yafai, Anissa, RDH

TIGARD DENTAL OFFICE7105 SW Hampton St., Tigard, OR 97223


General dentists

Bowers, Greg, DMD

Grishman, Michael, DDS

Houtz, Jeff, DMD

Kimura-Opperman, Rie, DMD

Pihlstrom, Dan, DDS

Shih, Matthew, DDS

Towle, Morgan, DDS

White, Danny, DDS

Endodontist

Reams, Gregg, DMD

Wiltbank, Kenneth, DMD


Goodsell, Adele, RDH

Hellums, Donna, RDH

Hughes, Laura, RDH

Kelly, Desiree, RDH

McKenna, Barbara, RDH

Morgan, Alicia, RDH

Neuman, Julie, RDH

Sahebi, Akram, RDH

Steiner, Barbara, RDH

Traweek, Joan, RDH

Treharne, Kayla, RDH


DENTAL BENEFIT DESCRIPTIONSNote: Services are covered up to the annual dental benefit maximum. You are responsible for any total plan charges that exceed the annual maximum.

We provide treatment and services based on dental need and appropriateness. A dentally necessary service is, in the judgment of a licensed dentist, required to prevent, diagnose, or treat a dental condition. A service is dentally necessary and dentally appropriate only if a dentist determines that its omission would adversely affect your dental health and its provision constitutes a dentally appropriate course of treatment for you in accord with generally accepted professional standards of practice that are consistent with a standard of care in the dental community.

Preventive and diagnostic services

• Diagnostic examination. Examination of your mouth, X-rays to check for cavities, and determining the condition of your teeth and gums.

• Preventive services. Preventive care includes such services as routine teeth cleaning (prophylaxis) and fluoride treatments.

• Prophylaxis. Preventive cleaning of the teeth. You are covered for no more than two visits for oral prophylaxis treatments in any consecutive 12-month period, except when you are receiving periodontal treatment.

• Space maintainer. Appliance used to maintain spacing after removal of a tooth or teeth.

Basic restoration services

• Basic restorative services. Your plan covers routine fillings and stainless steel and plastic/acrylic crowns.

• Simple extractions. Your plan covers simple tooth extractions.

Oral surgery services

• Oral surgery. Surgical tooth extractions, including diagnosis and evaluation, are covered.

Periodontics

• Periodontics (gum treatment). Treatment of disease of the gums. Diagnosis, evaluation, and treatment of disease of the gums, including scaling and root planing, are provided.

Endodontics

• Endodontics (root canal therapy). Treatment of the root canal or tooth pulp. Your benefit includes root canal and related therapy, including diagnosis and evaluation.

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Major restorative services

• Major restorative services. Your plan covers gold and porcelain crowns, inlays, bridge abutments and pontics, and other cast metal restorations. If you request a procedure or material not covered, or in excess of what is recommended by your dentist, you will be responsible for the additional total plan charges. Repair or replacement of prosthetic appliances that are less than five years old is not covered.

• Pontic. An artificial tooth on a dental bridge.

• Removable prosthetic services. Covered services include full and partial dentures, relines, and rebases. Your plan covers repair and adjustment of dentures and other prosthetic devices damaged through normal use. If a prosthetic device cannot be repaired, we will cover replacement once every five years.

• Prosthetic device. We cover artificial teeth such as dentures or bridges.

• Rebase. We cover replacement of the entire denture base, except the teeth, to improve the bite and/or fit.

• Reline. We cover adding a new layer of plastic material to the inside of a set of full or partial dentures to improve the fit.

Emergency/urgent care

• Emergency care. Care for a condition requiring immediate treatment for acute infection, hemorrhage, injury to the gums and/or teeth, or relief of extreme pain that would lead a prudent layperson possessing an average knowledge of health and medicine to reasonably expect that immediate dental attention is needed. Coverage includes local anesthesia and pre-medication.

• Urgent condition. A dental problem such as toothaches, chipped teeth, broken/lost fillings causing irritation, swelling around a tooth, or a broken prosthetic that may require something other than a routine appointment.

Other services/benefits

• Nightguard. A removable dental appliance designed to minimize the effects of grinding and other occlusal factors.

• Nitrous oxide. Covered for children when administered by a participating pediatric dentist, oral surgeon, or periodontist and for adults when administered by a participating oral surgeon or periodontist.

Exclusions

• Conditions for which service or reimbursement is required by law to be provided at or by a government agency.

• Cosmetic services, supplies, or prescription drugs that are intended primarily to improve appearance, repair, and/or replace cosmetic dental restorations.


• Dental implants, including bone augmentation and fixed or removable prosthetic devices attached to or covering the implants; all related services, including diagnostic consultations, impressions, oral surgery, placement, removal, and cleaning when provided in conjunction with dental implants; and services associated with postoperative conditions and complications arising from implants.

• Experimental or investigational treatments, procedures, and other services that are not commonly considered standard dental practice or that require governmental approval.

• Full mouth reconstruction and occlusal rehabilitation, including appliances, restorations, and procedures needed to alter vertical dimension, occlusion, or correct attrition or abrasion.

• Genetic testing.

• “Hospital call fees,” “call fees,” or similar charges associated with dentally necessary services that are performed at ambulatory surgery centers or hospitals.

• Medical or hospital services, unless otherwise specified in the EOC.

• Orthodontic services.

• Prescription drugs obtainable with or without a prescription. These may be covered under your medical benefits.

• Prosthetic devices following your decision to have a tooth (or teeth) extracted for nonclinical reasons or when a tooth is restorable.

• Replacement of prefabricated, noncast crowns, including noncast stainless steel crowns not placed by a participating dentist.

• Sedation and general anesthesia (including, but not limited to, intramuscular IV sedation, non-IV sedation and inhalation sedation) are not covered, except when administered by an oral surgeon, periodontist, or pediatric dentist pursuant to the nitrous oxide benefit as described in your EOC.

• Services for conditions that are covered by workers’ compensation or that are the employer’s responsibility.

• Services furnished by a family member.

• Services provided or arranged by criminal justice institutions for members confined therein, unless care would be covered as emergency care.

• Speech aid prosthetic devices and follow-up modifications.

• Surgery to correct malocclusion or temporomandibular joint disorders; treatment for problems of the jaw joint, including temporomandibular joint syndrome and craniomandibular disorders; and treatment of conditions of the joint linking the jawbone and skull and of the complex of muscles, nerves, and other tissues related to that joint.

• Treatment to restore tooth structure lost due to attrition, erosion, or abrasion.

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Limitations

• Dental services in conjunction with medically necessary general anesthesia. We cover the dental services described in your EOC when provided in a hospital or ambulatory surgery center, if these services are performed at that location in order to obtain medically necessary general anesthesia for a member. We do not cover the general anesthesia services.

• Repair or replacement needed due to normal wear and tear of fixed and removable prosthetic devices that are less than five years old.

• Works in progress started prior to your effective date are not covered and are the liability of the member or a prior dental insurance carrier. The only exception is a root canal in which the pulpal debridement has been completed. Dental services to complete the root canal following pulpal debridement will be covered at 50 percent of the usual and customary charges, subject to deductibles and dental benefit maximum as indicated in the EOC on the Benefit Chart.


3 HEAR WELL, LIVE WELL

Good hearing means you can participate in life more fully. You’re more confident, more secure, and more connected to your world.

Millions of Americans experience some degree of hearing loss. Among people over 50, it’s the third most common ailment, behind heart disease and arthritis. But now, more than ever, hearing loss doesn’t mean that your quality of life has to change. Today’s hearing products are smaller, more effective, and more comfortable.

The hearing aid benefit from Advantage Plus can help make sure you’re not missing the sounds and conversations that make life more fulfilling.

See your Kaiser Permanente Senior Advantage (HMO) Directory for the list of Kaiser Permanente medical offices with audiology services.

Health tip:

QUICK HEARING SELF-CHECKBe sure to have your hearing checked by a Kaiser Permanente provider. In the meantime, use these questions for a simple self-check of your hearing health:

• Do you often ask people to speak up or repeat themselves?

• Do you have trouble following conversations in a noisy room or understanding speech on the phone?

• Do you have trouble hearing the sound of your telephone, alarm clock, or doorbell?

• Do others complain that your TV or stereo is too loud?

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Q&AsHEARING SERVICES

Kaiser Permanente or Kaiser Permanente–designated physicians or audiologists provide hearing care products and services for Kaiser Permanente members.

1. Are hearing tests covered?

Kaiser Permanente Senior Advantage Basic and Senior Advantage individual plans cover hearing tests that determine the need for hearing correction. These tests are provided at the specialty office visit copayment. There is no charge for hearing aid evaluations that determine the appropriate hearing aid and for tests to verify that the aid matches the prescription. If you suspect you have a hearing loss, call your Kaiser Permanente primary care physician.

2. If I have a hearing loss, are hearing aids covered?

Yes. As a Kaiser Permanente Senior Advantage Basic or Senior Advantage member with the Advantage Plus benefit package, you have coverage for up to a $1,000 benefit allowance toward the purchase of hearing aids. You are covered for up to $500 per ear per aid every three years (36 months). If your hearing aids cost more than $500 per ear per aid, you will be responsible for 100 percent of the difference. If you do not use all of the $500 at the initial point of sale, you cannot use it later.

3. Where can I obtain my hearing aids?

You may use your hearing aid benefit at a designated Kaiser Permanente Audiology Department.

4. Are referrals or special claim forms required to use my hearing aid benefit?

No, referrals or claim forms are not required for a hearing aid purchased from or authorized by Kaiser Permanente.

5. Are there any limitations to the type of style of hearing aid that is covered?

Kaiser Permanente or Kaiser Permanente–designated audiologists will assist you in selecting a hearing aid that best meets your needs. A range of technologies and styles are available, and you will receive a thorough explanation of your test results and recommended treatment options. Coverage is limited to the types and models of hearing aids furnished by Kaiser Permanente or a Kaiser Permanente–designated audiologist.

6. What if I have a medical problem with my hearing?

If a medical problem is identified during the hearing examination, the audiologist can notify your primary care physician of the results to assist you in obtaining the appropriate medical follow-up.

7. What if I need service or repairs on my hearing aids?

If you purchased your hearing aid at a Kaiser Permanente or Kaiser Permanente–designated network audiology provider, you have a manufacturer’s warranty. You may also purchase an additional optional extended warranty. Talk with your audiologist if you are interested in this extra warranty coverage. If you purchased your hearing aid


at a Kaiser Permanente network provider, you should ask the provider for warranty information on your specific hearing aid. Batteries, accessories, and damaged hearing aid repairs are not part of your hearing aid package and are an out-of-pocket expense. There is a $100 non-refundable fee, per hearing aid, should you decide to return the hearing aid during the trial period.

Hearing aid exclusions

• Bone-anchored hearing aids are not covered under Advantage Plus hearing aid benefit (instead, refer to “Prosthetic or orthotic devices and related supplies” benefit description in the Senior Advantage individual plans’ EOC).

• Cochlear implants and osseointegrated external hearing devices (instead, refer to “Prosthetic or orthotic devices and related supplies” benefit description in the Senior Advantage individual plans’ EOC).

• Hearing aids that were fitted before you were covered under Advantage Plus (for example, a hearing aid that was fitted during the previous contract year will not be covered under Advantage Plus, though it might be covered under your EOC for the previous contract year).

• Internally implanted hearing aids.

• Repair of hearing aids beyond the warranty period.

• Replacement parts and batteries, repair of hearing aids, earmolds, and replacement of lost or broken hearing aids (the manufacturer warranty may cover some of these).

• Services related to the ear or hearing other than those described in this section (instead, refer to the “Hearing services” benefit description in the Senior Advantage individual plans’ EOC).

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4 FOCUS ON A HEALTHIER YOU

Good vision and healthy eyes are your keys to seeing the world around you. At Vision Essentials by Kaiser Permanente, we offer eye care services to help keep your world in focus. Our team of experienced eye care professionals will work closely with you to help keep your vision sharp and your eyes healthy. Plus, your eye health information becomes part of your overall Kaiser Permanente medical record, helping you and your medical team keep a complete picture of your health.

Here is an immediate way to enhance your life: improve your vision. It’s possible that your vision has changed — but you haven’t noticed. An eye exam can show you what you’ve been missing. When you see clearly, your daily activities, such as driving and reading, become noticeably easier.

It’s important to have your eyes checked regularly to identify minor as well as more serious eye problems. Advantage Plus gives you a $175 allowance toward the purchase of eyewear so you’ll have a new benefit option to help you see a brighter, more vibrant world. This is in addition to eye exams and standard eyewear following cataract surgery covered under our Senior Advantage individual plans.

Vision Essentials by Kaiser Permanente. Putting the focus on total health through our unique combination of services. Providing eye exams, prescription updates, eyeglasses, and contact lenses to suit your every need.


Health tip:

SUNSCREEN FOR YOUR EYESNo matter how old you are, protecting your eyes from the sun is important to your overall health. Consider using your Advantage Plus extra eyewear benefit toward a pair of prescription sunglasses. Your sunglass lenses can be manufactured to the optical prescription specifications provided by your doctor.

Ultraviolet (UV) rays contribute to many eye and vision problems, including cataracts, pterygium, corneal sunburn, skin cancer (eyelids), and age-related macular degeneration, a leading cause of vision loss. Not only do our sunglasses screen out 100 percent of UV rays and enhance your visual performance, they also offer a great way to express your own sense of style. Please visit kp2020.org to learn more.

Q&AsEYEWEAR COVERAGE

The extra eyewear benefit covered by Advantage Plus is provided at Vision Essentials by Kaiser Permanente locations, and at participating network providers. For information about vision benefits (including limitations and exclusions) covered under your Senior Advantage Basic or Senior Advantage individual plan, please refer to your EOC Benefit Chart under “Vision Services.”

Your Advantage Plus coverage is in addition to the coverage described in your EOC under “Vision Services” by adding a $175 allowance eyewear benefit coverage amount to the eyewear services covered under Senior Advantage Basic or Senior Advantage individual plan (when you have cataract surgery). You may use this $175 allowance eyewear benefit coverage amount to purchase prescription eyeglass frame/lenses or contacts once every 24 months. If the eyewear you purchase costs more than $175, you pay the difference.

1. What is my coverage for eyeglass frames, lenses, and contact lenses?

As a Kaiser Permanente member with the Advantage Plus benefit package, you will receive a maximum plan benefit allowance amount of $175 every two years to use toward the purchase of eyeglass frames, lenses, and/or contact lenses. This benefit is in addition to standard eyewear following cataract surgery covered at no charge under your Senior Advantage Basic or Senior Advantage individual plan.

2. Where can I obtain my eyeglasses and contact lenses?

You may use your vision benefit at any of our Vision Essentials locations, which are conveniently located in most of our medical offices and carry a large selection of eyeglass frames, lenses, and contact lenses* priced to fit many budgets, or at participating network providers. To find a Vision Essentials location near you, look in your Senior Advantage Directory. Or you may call Kaiser Permanente Member Services toll free at 1‑877‑221‑8221 (TTY 711 for the hearing/speech impaired), seven days a week, 8 a.m. to 8 p.m., or visit kp2020.org for more information.

*Contact lens services are provided at most of our Vision Essentials locations.

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3. How do the prices compare with the competition?

At Vision Essentials, you will find a wide selection of the latest eyeglass and sunglass frames — at the lowest possible cost, guaranteed. If you purchase frames from our regularly stocked inventory and find the same brand and style priced lower elsewhere within 30 days of receiving your eyeglasses, we will match it and refund the difference to you, plus $1. This guarantee excludes Internet pricing.

4. How long will it take to get my glasses?

Each individual’s prescription is special. Our average turnaround time is three to five business days. Every prescription has to be precisely custom-made, and certain types of specialized lenses take longer than others. Members can choose from a wide range of optical products, including different lens materials to fulfill individual needs.

5. Does Vision Essentials by Kaiser Permanente offer a warranty on eyeglasses?

Your new eyeglasses are warranted against breakage and defects in materials or workmanship for a period of one year from the date you receive your glasses. In the event of a defect, Vision Essentials by Kaiser Permanente will repair or replace your eyeglasses as necessary with the same style, size, and color without charge, or a replacement of equal value will be made. This warranty does not cover loss, theft, damage due to ordinary wear and tear, mishandling, or scratched lenses. When you purchase your eyeglasses, you can also buy a Lens Protection Plan. This plan will replace scratched lenses once within one year from the original date you receive your eyeglasses. The Lens Protection Plan replaces lenses with the original prescription using the original lens design.

We also offer a 30-day eyeglass satisfaction guarantee. We want you to be completely satisfied with your prescription eyeglasses. You may exchange or return them for a complete refund within 30 days from the original date you receive your eyeglasses (less your reinstated vision benefit, if applicable).

6. What if my prescription changes shortly after I get my new prescription and eyeglasses?

Doctor-approved prescription changes can be made at no charge within 90 days from the original date you receive your eyeglasses.

7. Will I get a separate ID card for Vision Essentials by Kaiser Permanente?

No, your Kaiser Permanente medical ID card is all you need at Vision Essentials locations.

8. How do I make or cancel an eye care optometry/ophthalmology appointment?

Please call 503‑813‑2000 from 7 a.m. to 6 p.m. (toll free 1‑800‑813‑2000/TTY 711) to make or cancel an appointment. If you need to cancel, please give us 24-hour notice.

9. When will I be eligible to use my Advantage Plus extra eyewear benefit for the first time?

Once you receive confirmation of your enrollment in Advantage Plus, you can begin using your extra eyewear benefit on your effective date.


10. After I use my Advantage Plus extra eyewear $175 benefit, when can I use it again?

You are eligible to use your Advantage Plus eyewear $175 benefit allowance every two years. This is counted from the date you last ordered your eyeglasses or contact lenses while enrolled as a member of Kaiser Permanente Senior Advantage Basic or Senior Advantage individual plan with Advantage Plus.

11. Can I combine my Advantage Plus extra eyewear $175 benefit allowance with other optical discounts or promotions offered by Vision Essentials?

No. Depending on the total price of your eyeglasses (frame and lenses) or contact lenses, you may either use your Advantage Plus $175 vision benefit allowance or take advantage of our current promotions, whichever option provides the best savings for you. Please visit kp2020.org to learn more.

12. Can I combine my Advantage Plus extra eyewear $175 benefit allowance with my Senior Advantage Basic or Senior Advantage individual plan eyewear benefit listed in the EOC?

These are two separate benefits. Under your Senior Advantage Basic or Senior Advantage individual plan post-cataract surgery eyewear benefit, there is no charge for Medicare-covered standard eyeglasses or contact lenses. Any remaining balance resulting from the purchase of premium products/options is calculated as follows:

Premium eyeglass and lens products/options*– Medicare allowable amounts for frame and lens Member obligation

*Premium eyeglass and lens products/options include premium lenses, premium eyeglass frames, anti-reflective coatings, tints, and polarized or photochromic lenses.

You may not combine your Advantage Plus extra eyewear $175 benefit allowance with your Senior Advantage Basic or Senior Advantage individual plan post-cataract surgery eyewear benefit to decrease your out-of-pocket member obligation amount.

Once the Advantage Plus eyewear $175 benefit allowance is used toward a purchase, the allowance will not become available for two years from the order date.

The Advantage Plus extra eyewear allowance may not be used for total plan charges associated with professional services, Protection Plan, cosmetic contact lenses fitting and follow-up care, low-vision aids, or post-cataract surgery eyewear.

Multiple replacement eyeglass and cosmetic lenses are covered if a member’s prescription changes 0.5 diopter or more within 12 months of the initial exam. Replacement lenses are covered up to the following maximum allowances:

• $60 for single vision lenses and contact lenses.

• $90 for multifocal lenses and contact lenses.

• Replacement coverage is for the original product type (eyeglasses or contacts only).

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TYPES OF EYE CARE PROFESSIONALSOur team of experienced eye care professionals will work closely with you to help keep your vision sharp and your eyes healthy.

We have eye care professionals practicing in the following specialties:

Contact lens professionals Specialize in fitting your contact lenses.

Eye care professionals Inclusive term for all the people who provide eye care services at and in conjunction with Vision Essentials, including ophthalmologists, optometrists, and contact lens fitters.

Ophthalmologists (MD) Diagnose and treat eye diseases and disorders and are licensed to perform eye surgery.

Opticians Help you select the right eyewear for your needs. Technicians are trained to fill prescriptions for glasses written by optometrists. They are responsible for the fit and comfort of prescription glasses.

Optometrists (OD) Examine your eyes for general eye health, diagnose and treat eye diseases, and write prescriptions for vision correction.

Vision definitions

Eye care services. The products and services offered by Vision Essentials by Kaiser Permanente.

Eyewear. Prescription glasses, sunglasses, and contact lenses.

Optical center. A Vision Essentials facility where you can receive eye care services and purchase eyewear.

Prescription sunglasses. Glasses that contain a corrective prescription and are primarily used to shield eyes from sun damage.

Sunglasses. Glasses primarily used to shield eyes from sun damage that do not contain a corrective prescription.

Vision/eyewear exclusions

• Low-vision aids.

• Non-prescription products (other than eyeglass frames), such as non-prescription sunglasses, eyeglass holders, eyeglass cases, repair kits, contact lens cases, contact lens cleaning and wetting solution, and lens protection plans.

• Professional services for fitting and follow-up care for contact lenses.

• Replacement of lost, broken, or damaged lenses or frames.

• Vision therapy (orthoptics or eye exercises).


5 HOW TO APPLY FOR COVERAGE

Applying for Advantage Plus is easy

1. If you are currently a Kaiser Permanente Senior Advantage Basic or Senior Advantage individual plan member, please complete the enrollment form. The annual enrollment period for Advantage Plus is October 15 to December 7, 2014, for a January 1, 2015, effective date. You can also enroll any time through March 31, 2015, for coverage effective the first day of the following month. If you would like to receive an enrollment form, please call one of our licensed sales specialists at 1‑877‑451‑3817 (TTY 711 for the hearing/speech impaired), seven days a week, 8 a.m. to 8 p.m.

2. If you are now applying for Kaiser Permanente Senior Advantage Basic or Senior Advantage individual plan membership and you also want the Advantage Plus package, complete the Advantage Plus enrollment form. If you would like to receive an Advantage Plus enrollment form, please call one of our licensed sales specialists at 1‑877‑451‑3817 (TTY 711 for the hearing/speech impaired), seven days a week, 8 a.m. to 8 p.m.

3. Return your Advantage Plus enrollment form in the enclosed business reply envelope to:

Kaiser Permanente Medicare Department P.O. Box 232407 San Diego, CA 92193-9914

4. We’ll notify you when your application has been approved and give you additional details about your coverage and start date.

The premium for your Advantage Plus optional benefit package of dental, hearing aid, and extra eyewear benefits is $41 per month. The $41 monthly premium is in addition to your Senior Advantage Basic or Senior Advantage individual plan premium.

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6 INFORMATION YOU NEED TO KNOW

ENROLLMENT/DISENROLLMENT

Enrollment

Other important information about applying for Advantage Plus:

• You must be a Kaiser Permanente Senior Advantage Basic or Senior Advantage individual plan member to enroll in the Advantage Plus package. (If your Senior Advantage plan is provided to you under a group or trust fund, you are not eligible to enroll in Advantage Plus.)

• If you are currently a Kaiser Permanente Senior Advantage Basic or Senior Advantage individual plan member, you can enroll in the Advantage Plus package during the annual enrollment period from October 15 through December 7, 2014, to begin your Advantage Plus plan year on January 1, 2015. You can also enroll any time through March 31, 2015, for coverage effective the first day of the following month.

• If you are applying for Kaiser Permanente Senior Advantage Basic or Senior Advantage individual plan membership, you can enroll in the Advantage Plus package at the same time by completing the Advantage Plus enrollment form. Your Advantage Plus benefit coverage period will begin on the same date as your Kaiser Permanente Senior Advantage Basic or Senior Advantage.

• If you are a new Kaiser Permanente Senior Advantage Basic or Senior Advantage individual plan member and your Senior Advantage membership effective date is within the past 30 days, you can enroll in the Advantage Plus package by completing an enrollment form. Your Advantage Plus benefit coverage period will begin on the first day of the month after your completed Advantage Plus enrollment form is received by Kaiser Foundation Health Plan of the Northwest. Please note that if you do not enroll in Advantage Plus within the first 30 days of your Kaiser Permanente Senior Advantage Basic or Senior Advantage effective date, then you cannot apply for Advantage Plus until the annual enrollment period for an effective date of January 1.

• If you lose Kaiser Permanente group dental coverage outside of the annual enrollment period and you have Individual Senior Advantage, you may add Advantage Plus within 30 days of your Kaiser Permanente group dental termination date.

Disenrollment

You may terminate your Advantage Plus coverage at any time during the year. Your disenrollment will be effective the first of the month following the date we receive your written disenrollment request or completed Advantage Plus disenrollment form. For more information regarding disenrollment, please call Member Services toll free at 1‑877‑221‑8221 (TTY 711 for the hearing/speech impaired) between 8 a.m. and 8 p.m., seven days per week.

36539SA-14/9-14 For more information visit kp.org/vibrantyou.36

If you disenroll from Advantage Plus, you will not be eligible to re-enroll until the next annual enrollment period October 15 through December 7, 2015, for coverage to be effective January 1. You can keep the Senior Advantage Basic or Senior Advantage plan coverage you are enrolled in as long as you continue to pay your full plan premiums and continue to meet the eligibility requirements.

If you fail to pay your full Advantage Plus premium, you will be disenrolled from your Advantage Plus optional supplemental benefit package. You can keep the Senior Advantage Basic or Senior Advantage plan coverage you are enrolled in as long as you continue to pay your full Senior Advantage Basic or Senior Advantage Plan premiums and continue to meet the eligibility requirements.

If you disenrolled after you used your Advantage Plus extra eyewear benefit, and subsequently re-enrolled in Advantage Plus with the same Senior Advantage individual plan, you won’t be able to get covered eyewear until 24 months after you last used your Advantage Plus eyewear benefit.

If you disenrolled after you used your Advantage Plus hearing aid benefit, and subsequently re-enrolled in Advantage Plus with the same Senior Advantage individual plan, you won’t be able to get covered hearing aids until 36 months after you last used your Advantage Plus hearing aid benefit.

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Enroll in Advantage Plus today.

Get more value from your Kaiser Permanente Medicare health plan by adding Advantage Plus. You can get extra benefits such as dental, vision, and hearing coverage for an affordable monthly fee. More health benefits, great care. Now that’s a healthy addition to your coverage. Enroll today.

Want more info?

Call one of our licensed sales specialists at 1‑877‑451‑3817 (TTY 711 toll free for the hearing/speech impaired) seven days a week, 8 a.m. to 8 p.m., or visit us online at kp.org/vibrantyou.

For a healthier, more vibrant you.

Kaiser Foundation Health Plan of the Northwest500 NE Multnomah St., Suite 100Portland, OR 97232

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©2014 Kaiser Foundation Health Plan of the NorthwestH9003_ADMEM0115 accepted 539SA-14/9-14

Documents

Advantage Plus - Enroll now for 2015 - Get extra vision, dental, and …info.kaiserpermanente.org/info_assets/vibrantyou/pdf/... · 2014. 10. 16. · 1 5 BENEFITS AT A GLANCE The