Validación de la propuesta

We may adopt reasonable policies, procedures, and interpretations to promote orderly and efficient

administration of your Group's Agreement, including this Evidence of Coverage.

Agreement binding on Members

By electing coverage or accepting benefits under this Evidence of Coverage, all Members legally capable of contracting, and the legal representatives of all Members incapable of contracting, agree to all provisions of this Evidence of Coverage.

Amendment of Agreement

Your Group's Agreement with us will change periodically. If these changes affect this Evidence of Coverage, your Group is required to inform you in accord with applicable law and your Group's Agreement.

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Applications and statements

You must complete any applications, forms, or statements that we request in our normal course of business or as specified in this Evidence of Coverage. Assignment

You may not assign this Evidence of Coverage or any of the rights, interests, claims for money due, benefits, or obligations hereunder without our prior written consent. Attorney and advocate fees and expenses In any dispute between a Member and Health Plan, the Medical Group, or Kaiser Foundation Hospitals, each party will bear its own fees and expenses, including attorneys' fees, advocates' fees, and other expenses. Claims review authority

We are responsible for determining whether you are entitled to benefits under this Evidence of Coverage and we have the discretionary authority to review and evaluate claims that arise under this Evidence of Coverage. We conduct this evaluation independently by interpreting the provisions of this Evidence of Coverage. We may use medical experts to help us review claims. If coverage under this Evidence of Coverage is subject to the Employee Retirement Income Security Act (ERISA) claims procedure regulation (29 CFR 2560.503-1), then we are a "named claims fiduciary" to review claims under this Evidence of Coverage.

ERISA notices

This "ERISA notices" section applies only if your Group's health benefit plan is subject to the Employee Retirement Income Security Act (ERISA). We provide these notices to assist ERISA-covered groups in

complying with ERISA. Coverage for Services described in these notices is subject to all provisions of this Evidence of Coverage.

Newborns' and Mother's Health Protection Act.

Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

Women's Health and Cancer Rights Act. If you have

had or are going to have a mastectomy, you may be entitled to certain benefits under the Women's Health and Cancer Rights Act. For individuals receiving

mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for all stages of reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses, and treatment of physical complications of the

mastectomy, including lymphedemas. These benefits will be provided subject to the same Cost Share applicable to other medical and surgical benefits provided under this plan.

Governing law

Except as preempted by federal law, this Evidence of Coverage will be governed in accord with California law and any provision that is required to be in this Evidence of Coverage by state or federal law shall bind Members and Health Plan whether or not set forth in this Evidence of Coverage.

Group and Members not our agents

Neither your Group nor any Member is the agent or representative of Health Plan.

No waiver

Our failure to enforce any provision of this Evidence of Coverage will not constitute a waiver of that or any other provision, or impair our right thereafter to require your strict performance of any provision.

Notices

Our notices to you will be sent to the most recent address we have for the Subscriber. The Subscriber is responsible for notifying us of any change in address. Subscribers who move should call our Member Service Contact Center and Social Security toll free at 1-800-772-1213 (TTY users call 1-800-325-0778) as soon as possible to give us their new address. If a Member does not reside with the Subscriber, he or she should contact our Member Service Contact Center to discuss alternate delivery options.

Note: When we tell your Group about changes to this Evidence of Coverage or provide your Group other information that affects you, your Group is required to notify the Subscriber within 30 days after receiving the information from us.

Notice about Medicare Secondary Payer subrogation rights

We have the right and responsibility to collect for covered Medicare services for which Medicare is not the primary payer. According to CMS regulations at 42 CFR sections 422.108 and 423.462, Kaiser Permanente Senior Advantage, as a Medicare Advantage Organization, will exercise the same rights of recovery that the Secretary exercises under CMS regulations in subparts B through D of part 411 of 42 CFR and the rules established in this section supersede any state laws.

Overpayment recovery

We may recover any overpayment we make for Services from anyone who receives such an overpayment or from any person or organization obligated to pay for the Services.

Public policy participation

The Kaiser Foundation Health Plan, Inc., Board of Directors establishes public policy for Health Plan. A list of the Board of Directors is available on our website at

kp.org or from our Member Service Contact Center.

If you would like to provide input about Health Plan public policy for consideration by the Board, please send written comments to:

Kaiser Foundation Health Plan, Inc. Office of Board and Corporate Governance Services

One Kaiser Plaza, 19th Floor Oakland, CA 94612

Telephone access (TTY)

If you are hearing or speech impaired and use a text telephone device (TTY, also known as TDD) to

communicate by phone, you can use the California Relay Service by calling 711 if a dedicated TTY number is not available for the telephone number that you want to call.

Important Phone Numbers and