Covered Expenses

You're eligible to receive a total of 60 covered alternative care visits/year. This may include any combination of acupuncture, hypnotherapy and/or massage therapy visits.

(For plan benefits, see "KingCare^SM Benefits at a Glance.")

Ambulance Services

KingCare^SM covers medically necessary emergency ground or air ambulance services to a network facility or the nearest facility where appropriate care is covered. (For plan benefits, see "KingCare^SM Benefits at a Glance.")

Chemical Dependency Treatment

Covered inpatient and outpatient chemical dependency treatment includes:

detoxification services;

diagnostic evaluation and education;

organized individual and group counseling; and

prescription drugs.

Aetna network providers obtain preauthorization for chemical dependency treatment as necessary. If you see an out-of-network provider, you must obtain preauthorization from Aetna for inpatient chemical dependency treatment. (For details, see "Preauthorization.") Chemical dependency benefits are covered up to the maximum described in "KingCare^SM Benefits at a Glance."

For additional counseling and referral services, you may also contact the Making Life Easier Program. (For more information, see Contact Information.)

Aetna processes claims for prescription drugs used during inpatient hospitalization. Express Scripts processes claims for outpatient retail pharmacy and mail-order drugs. (For details about prescription drug coverage, see "Using Your Prescription Drug Plan" and "KingCare^SM Benefits at a Glance.")

Chiropractic Care and Manipulative Therapy

IMPORTANT!

Some chiropractic services aren't covered. (For details, see "Expenses Not Covered.")

KingCare^SM covers the services of licensed chiropractors for the diagnosis and treatment of musculoskeletal disorders, including:

diagnostic lab services directly related to the spinal care treatment you're receiving;

full spinal X-rays; and

non-invasive spinal manipulations.

(For plan benefits, see "KingCare^SM Benefits at a Glance.")

Diabetes Care Training

KingCare^SM covers diabetes care training when prescribed by and supervised by your physician as part of a self-care program. The program must consist of services recognized by health care professionals and be designed to educate you about specific conditions and any lifestyle changes necessary as a result of your diabetes condition. Reasonable charges include individual or group educational services, tuition, supplies and appropriate diagnostic services. (For plan benefits, see "KingCare^SM Benefits at a Glance.")

Durable Medical Equipment, Prosthetics and Orthopedic Appliances

Durable medical equipment is covered if it:

is designed for prolonged use;

has a specific therapeutic purpose in treating an illness or injury;

is prescribed by your physician; and

is primarily and customarily used for medical purposes only.

Network providers will obtain preauthorization for your care as necessary. If you see an out-of-network provider, you must obtain preauthorization from Aetna. (For details, see "Preauthorization." For plan benefits, see "KingCare^SM Benefits at a Glance.")

Medical Services. KingCare^SM covers the following durable medical equipment:

artificial limbs or eyes, including implant lenses prescribed by your physician and required as the result of cataract surgery or to replace a missing portion of the eye;

casts, splints, crutches, trusses and braces;

diabetes equipment, excluding batteries, for home testing and insulin administration not covered under the prescription drug benefit (For details about prescription drug coverage, see "Using Your Prescription Drug Plan");

initial external prosthesis and bra necessitated by breast surgery and replacement of these items when required by normal wear, a change in medical condition or additional surgery;

oxygen and rental equipment for its administration;

penile prosthesis, with a lifetime maximum of two prostheses, when impotence is caused by a covered medical condition, a complication directly resulting from a covered surgery, or an injury to the genitalia or spinal cord, and other accepted treatment has been unsuccessful;

rental or purchase, as decided by Aetna, of durable medical equipment such as wheelchairs, hospital beds and respiratory equipment (combined rental fees may not exceed full purchase price); and

wig or hairpiece to replace hair lost due to radiation therapy or chemotherapy for a covered condition, up to a lifetime maximum of $100.

Prescription Drug Services. Some durable medical equipment is covered through Express Scripts. (For more information, see "Using Your Prescription Drug Plan.")

Emergency Room Care

Emergency room treatment is covered only for medical conditions that threaten loss of life or limb or may cause serious harm to the patient's health if not done immediately. Examples of conditions that might require emergency room care include, but are not limited to:

chest pain;

convulsions;

major burns;

severe breathing problems;

unconsciousness or confusion, especially after a head injury; and

uncontrollable bleeding.

If you need emergency room care, follow these steps:

Call 911 or go to the nearest hospital emergency room immediately.

When you arrive, show your medical plan ID card.

If possible, call Aetna within 48 hours using the phone number printed on the front of your ID card; otherwise, you may receive a reduced benefit.

If you're incapable of calling Aetna, ask a friend, relative or hospital staff member to call for you.

If you have a medical emergency as determined by KingCare^SM, you'll receive the network level of benefits whether you receive network or out-of-network care. (For plan benefits, see "KingCare^SM Benefits at a Glance.") If your condition doesn't qualify as a medical emergency but care is urgently needed, see "Urgent Care" for a description of coverage.

Family Planning

IMPORTANT!

Some family planning services aren't covered. (For details, see "Expenses Not Covered.")

Medical Services. KingCare^SM covers the following family planning services:

insertion of intrauterine birth control devices (IUDs);

tubal ligation;

vasectomy; and

voluntary termination of pregnancy (abortion).

(For plan benefits, see "KingCare^SM Benefits at a Glance.")

Prescription Drug Services. Birth control pills and devices requiring a prescription are covered and processed by Express Scripts. (For plan benefits, see "KingCare^SM Benefits at a Glance.")

Growth Hormones

Growth hormones are covered for certain medical conditions and must be preauthorized whether you receive network or out-of-network care. If you receive this drug from your physician, he/she will bill Aetna for the drug and its administration. If you obtain the drug from a retail pharmacy or mail-order service, Express Scripts pays for the drug and Aetna pays for administration by your physician, if needed. (For plan benefits, see "KingCare^SM Benefits at a Glance.")

Hearing Aids

Hearing aids, including fitting, rental and repair, are covered. (For plan benefits, see "KingCare^SM Benefits at a Glance.")

Home Health Care

IMPORTANT!

Some home health care services aren't covered. (For details, see "Expenses Not Covered.")

Home health care services are covered if care:

takes the place of a hospital stay;

is part of a home health care plan; and

is provided and billed by an organization licensed as a home health care agency by the state of Washington.

Network providers obtain preauthorization for your care as necessary. If you see an out-of-network provider for home health care, you must obtain preauthorization from Aetna. (For details, see "Preauthorization.")

Covered services include:

nursing care;

occupational therapy;

physical therapy;

respiratory therapy;

restorative therapy; and

speech therapy (restorative only).

Services and prescription drugs provided and billed by a home infusion therapy company are also covered if the company is licensed by the state as a home health care agency. The prescription drug claims are processed by Express Scripts when they're filled at a retail pharmacy or through the mail-order service. (For details, see "Using Your Prescription Drug Plan.")

(For plan benefits, see "KingCare^SM Benefits at a Glance.")

Hospice Care

IMPORTANT!

Some hospice care services aren't covered. (For details, see "Expenses Not Covered.")

Hospice care is a coordinated program of supportive care for a dying person by a team of professionals and volunteers. The team may include a physician, nurse, medical social worker or physical, speech, occupational or respiratory therapist.

Hospice care services are covered up to six months if care:

takes the place of a hospital stay;

is part of a hospice care treatment plan; and

is provided and billed by an organization licensed as a hospice by the state of Washington.

Network providers obtain preauthorization for your care as necessary. If you see an out-of-network provider for hospice care, you must obtain preauthorization from Aetna. (For details, see "Preauthorization.")

Covered services include:

drugs and medications (Aetna processes claims for prescription drugs provided by the hospice during the course of medical treatment, and Express Scripts processes claims for retail pharmacy and mail-order drugs. For details, see "Using Your Prescription Drug Plan");

emotional support services;

family bereavement services;

home health services;

homemaker services, if appropriate to patient's direct care;

inpatient hospice care;

physician services; and

respite care for dependents providing care for the patient.

An extension of these benefits beyond the six-month lifetime maximum may be granted if Aetna receives a written request from your physician. (For plan benefits, see "KingCare^SM Benefits at a Glance.")

Hospital Care

IMPORTANT!

Some inpatient care services aren't covered. (For details, see "Expenses Not Covered.")

Inpatient Care. Covered inpatient hospital care includes:

hospital services such as:

anesthesia and related supplies administered by hospital staff;

artificial kidney treatment;

blood, blood plasma and blood derivatives;

drugs provided by the hospital in the course of medical treatment;

electrocardiograms;

operating rooms, recovery rooms, isolation rooms and cast rooms;

oxygen and its administration;

physiotherapy and hydrotherapy;

splints, casts and dressings;

X-ray, radium and radioactive isotope therapy; and

X-ray and lab exams;

intensive care or coronary care units;

newborn nursery care after covered childbirth, including circumcision; and

semi-private room, patient meals and general nursing care (private room charges are covered only up to the hospital's semi-private room rate).

Network providers obtain preauthorization for your care as necessary. If you see an out-of-network provider, you must obtain preauthorization from Aetna for inpatient care other than that necessary for up to 48 hours following a vaginal childbirth or 96 hours following a cesarean section. (For details, see "Preauthorization.")

If a hospital stay continues from one calendar year to the next, a second deductible isn't required for further treatment before discharge. Coverage continues at 100% until discharge, if the out-of-pocket maximum is met for the year in which hospitalization began.

(For plan benefits, see "KingCare^SM Benefits at a Glance.")

Outpatient Care. Covered outpatient care includes:

diagnostic and therapeutic nuclear medicine in a hospital setting;

hospital outpatient chemotherapy to treat malignancies;

outpatient surgery; and

surgery in an ambulatory surgical center in place of inpatient hospital care.

(For plan benefits, see "KingCare^SM Benefits at a Glance.")

Infertility

IMPORTANT!

Some infertility-related expenses aren't covered. (For details, see "Expenses Not Covered.")

Covered infertility expenses include:

embryo transfer;

intrauterine and intravaginal artificial insemination; and

in vitro fertilization.

(For plan benefits, see "KingCare^SM Benefits at a Glance.")

Injury to Teeth

The services of a licensed dentist are covered for repair of accidental injury to sound, natural teeth. Injuries caused by biting or chewing are not covered. Treatment must begin within 30 days of the accident, and all services must be provided within 12 months of the date of injury. (For plan benefits, see "KingCare^SM Benefits at a Glance.")

Inpatient Care Alternatives

Your physician may develop a written treatment plan for care in an equally or more cost-effective setting than a hospital or skilled nursing facility. If the alternative setting plan is approved by Aetna, all hospital or skilled nursing facility benefit terms, maximums and limits apply to the inpatient care alternatives, depending on the kind of care the alternative is intended to replace. (For plan benefits, see "KingCare^SM Benefits at a Glance.")

Jaw Abnormalities

Surgical corrections of jaw abnormalities, or malocclusions, are covered when medically necessary. (For plan benefits, see "KingCare^SM Benefits at a Glance.")

Lab, X-ray and Other Diagnostic Testing

Covered services include:

lab or X-ray services such as ultrasound, nuclear medicine and allergy testing;

screening and diagnostic procedures during pregnancy, as well as related genetic counseling when medically necessary for prenatal diagnosis of congenital disorders; and

services provided by a physician or licensed optometrist to diagnose or treat medical conditions of the eye (eyewear and routine vision exams and tests for vision sharpness are covered under your vision plan).

(For routine screenings, such as hearing tests and mammograms, see "Preventive Care." For plan benefits, see "KingCare^SM Benefits at a Glance.")

Maternity Care

IMPORTANT!

Some maternity-related expenses aren't covered. (For details, see "Expenses Not Covered.")

Maternity care is covered if provided by:

a physician or registered nurse whose specialty is midwifery; or

a midwife licensed by the State of Washington.

Covered maternity care includes:

complications of pregnancy or delivery;

hospitalization and delivery, including home births and licensed birthing centers for low-risk pregnancies;

postpartum care;

pregnancy care;

related genetic counseling when medically necessary for prenatal diagnosis of congenital disorders; and

screening and diagnostic procedures during pregnancy.

(For plan benefits, see "KingCare^SM Benefits at a Glance.")

HOSPITAL STAYS AND FEDERAL LAW

Group medical plans and health insurers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section. However, federal law generally doesn't prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother and/or newborn earlier than 48 hours or 96 hours, as applicable. In any case, plans and insurers may not require a provider to obtain authorization for prescribing a stay that doesn't exceed 48 hours or 96 hours, as applicable.

You don't need to preauthorize the length of stay unless it exceeds the 48- or 96-hour rule.

Mental Health Care

IMPORTANT!

Some mental health services aren't covered. (For details, see "Expenses Not Covered.")

Mental heath care services are covered at the same coinsurance rates as other medical care.

Inpatient and outpatient mental health care is covered if provided by a:

licensed psychiatrist (MD);

licensed psychologist (PhD);

licensed master's-level mental health counselor;

licensed nurse practitioner (ARNP);

community mental health agency licensed by the Department of Health; or

licensed state hospital.

For additional counseling and referral services, you may also call the Making Life Easier Program. (See Contact Information.)

Covered services include:

individual and group psychotherapy;

inpatient care or day-treatment care instead of hospitalization (must be in a licensed medical facility);

lab services related to the covered provider's approved treatment plan;

marriage and family therapy;

physical exams and intake history; and

psychological testing.

(For plan benefits, see "KingCare^SM Benefits at a Glance.")

Depending on individual medical needs, other benefit options may be available under the KingCare^SM case management program. (For more information, see "Case Management.")

Network providers obtain preauthorization for your care as necessary. If you see an out-of-network provider, you must obtain preauthorization from Aetna for inpatient mental health care. (For details, see "Preauthorization.")

Naturopathy

KingCare^SM covers the following services:

immunization agents or biological sera, such as allergy serum;

medical care in the provider's office;

nutritional counseling by a licensed nutritionist or dietitian when medically necessary for disease management;

physician services for surgery and anesthesia, and home, office, hospital and skilled nursing facility visits; and

second opinions obtained before treatment (the provider giving the second opinion must be qualified, either through experience or specialist training); a second opinion may be required to confirm the medical necessity of a proposed surgery or treatment plan.

Neurodevelopmental Therapy

KingCare^SM covers inpatient and outpatient neurodevelopmental therapy for covered dependents age six and younger.

Neurodevelopmental therapy services are covered only if the care is:

furnished by providers authorized to deliver occupational therapy, speech therapy and physical therapy;

prescribed by the patient's physician, and

provided because significant deterioration in the child's condition would result without such services, or to restore and improve the child's ability to function.

Network providers obtain preauthorization for your care as necessary. If you see an out-of-network provider you must obtain preauthorization for inpatient neurodevelopmental therapy. (For details, see "Preauthorization." For plan benefits, see "KingCare^SM Benefits at a Glance" on page XX.)

Newborn Care

KingCare^SM covers newborns under the mother's health plan for the first three weeks, as required by Washington State law. (For plan benefits, see "KingCare^SM Benefits at a Glance.") To continue the newborn's coverage after three weeks, the newborn must be eligible and enrolled within 60 days of birth. (For information about enrolling newborns, see "Adding Eligible Dependents.")

Obesity Surgery

IMPORTANT!

You must successfully complete a physician-supervised weight management and exercise program before you can obtain preauthorization for obesity surgery.

Obesity surgery or other procedures, treatment or services such as gastric intestinal bypass surgery are covered only if proven medically necessary per the Aetna Policy Coverage Bulletin. You must obtain preauthorization for this coverage. (For details, see "Preauthorization.") However, successful completion of a physician-supervised weight management and exercise program is required before you can obtain preauthorization. (For plan benefits, see "KingCare^SM Benefits at a Glance.")

Phenylketonuria (PKU) Formula

KingCare^SM covers the medical dietary formula that treats PKU. Claims are processed through Aetna. (For plan benefits, see "KingCare^SM Benefits at a Glance.")

Physician and Other Medical/Surgical Services

KingCare^SM covers the following services:

immunization agents or biological sera, such as allergy serum;

medical care in the provider's office;

nutritional counseling by a licensed nutritionist or dietitian when medically necessary for disease management;

physician services for surgery and anesthesia, and home, office, hospital and skilled nursing facility visits; and

(For plan benefits, see "KingCare^SM Benefits at a Glance.")

Prescription Drugs

Information about your prescription drug coverage is available under "Using Your Prescription Drug Plan."

Preventive Care

KingCare^SM covers the following preventive care services:

breast exams, pelvic exams and Pap tests every year for women;

mammograms every year for women over 40, or as determined by a provider for high-risk patients;

cervical screening every year;

diagnostic screening for prostate cancer as recommended by a physician, registered nurse or physician assistant; annual exams are recommended at age 40 and older;

cholesterol screening every 5 years for men 35 and older, and every 5 years for women 45 and older;

immunizations, including annual flu shots (immunizations for travel are not covered); and

routine physicals and hearing tests.

Immunizations, routine physicals and hearing tests are covered according to the following schedule. The schedule is a guideline; benefits may be available for more frequent care depending on the situation. Before scheduling a routine physical, confirm with Aetna that your physical will be covered.


Age	Preventive Care
Birth to 1 year	Routine newborn care plus 7 well-baby office exams
1-2 years	2 well-child exams
2- 5 years	3 well-child exams, with 1 exam in each of these age groups: 2–3, 3–4, 4–5
6 - 12 years	7 well-child exams, with 1 exam per year
13 - 17 years	5 well-teen exams, with 1 exam per year
18 - 25 years	1 well-adult exam every 2 years
26 - 49 years	1 well-adult exam every 2 years
50 – 64 years	1 well-adult exam every 2 years
65 years and older	1 well-adult exam every year

(For plan benefits, see "KingCare^SM Benefits at a Glance.")

Radiation Therapy, Chemotherapy and Respiratory Therapy

Inpatient and outpatient services are covered for medically necessary radiation, chemotherapy and respiratory therapy when prescribed by your physician. (For plan benefits, see "KingCare^SM Benefits at a Glance.")

Reconstructive Services

Reconstructive surgery to improve or restore bodily function is covered, subject to Aetna's review and approval. KingCare^SM covers cosmetic surgery to improve physical appearance only if it's medically necessary.

KingCare^SM covers the following services if the patient is receiving benefits for a mastectomy and elects breast reconstruction in connection with the mastectomy, as determined in consultation with the attending physician:

prosthesis and treatment of physical complications of all stages of mastectomy, including lymphedemas;

reconstruction of the breast on which the mastectomy has been performed; and

surgery and reconstruction of the healthy breast to produce a symmetrical appearance.

These reconstructive benefits are subject to the same annual deductible and coinsurance provisions as other medical and surgical benefits. (For plan benefits, see "KingCare^SM Benefits at a Glance.")

Rehabilitative Services

IMPORTANT!

Some rehabilitative services aren't covered. (For details, see "Expenses Not Covered.")

KingCare^SM covers medically necessary inpatient and outpatient rehabilitative care designed to restore and improve a physical function lost due to a covered illness or injury. This care is considered medically necessary only if significant improvement in the lost function occurs while the care is provided and the attending physician expects significant improvement to continue. To verify whether coverage for rehabilitative services applies or continues to apply, Aetna has the right to obtain written opinions from the attending physician concerning whether and to what extent the significant improvement is occurring. (For plan benefits, see "KingCare^SM Benefits at a Glance.")

Skilled Nursing Facility

IMPORTANT!

Some skilled nursing facility services aren't covered. (For details, see "Expenses Not Covered.")

Skilled nursing facility services are covered if:

they're provided and billed by an organization licensed as a skilled nursing facility by the state of Washington; and

the care takes the place of a hospital stay.

Let your provider know a written plan of treatment is required for these services to be covered. Network providers obtain preauthorization for your care as necessary. If you see an out-of-network provider for skilled nursing facility care, you must obtain preauthorization from Aetna. (For details, see "Preauthorization.")

Prescription drugs are covered through Aetna when provided by the skilled nursing facility and used by the patient during a period of covered skilled nursing facility care. Outpatient, retail pharmacy and mail-order drugs are covered through Express Scripts. (For details, see "Using Your Prescription Drug Plan.")

(For plan benefits, see "KingCare^SM Benefits at a Glance.")

Smoking Cessation

IMPORTANT!

Some smoking cessation expenses aren't covered. (For details, see "Expenses Not Covered.")

KingCare^SM covers:

acupuncture to ease nicotine withdrawal;

hypnotherapy to ease nicotine withdrawal;

non-prescription nicotine patches, lozenges and gum, which are covered at 100% through Aetna;

prescription drugs to ease nicotine withdrawal, inhalers and sprays, which are covered at 100% through Express Scripts; and

smoking cessation programs, including a Tobacco Quit Line, which are covered at 100% through Harris HealthTrends (other smoking cessation programs are covered at the out-of-network rate, but to receive benefits for out-of-network smoking cessation programs, you must complete the full course of treatment).

(For plan benefits, see "KingCare^SM Benefits at a Glance.")

Temporomandibular Joint (TMJ) Disorders

Diagnosis and treatment of TMJ and myofascial pain, including night guards when prescribed by a medical doctor due to a TMJ diagnosis, are covered as a medical condition. Out-of-network services must be preauthorized and in general use and acceptance by the medical/dental community to relieve symptoms, promote healing, modify behavior and stabilize the condition. (For plan benefits, see "KingCare^SM Benefits at a Glance.")

Additional benefits are available through the Dental Plan.

Transplants

IMPORTANT!

Some transplant-related expenses aren't covered. (For details, see "Expenses Not Covered.")

KingCare^SM covers professional and facility fees for inpatient accommodation, diagnostic tests and exams, surgery and follow-up care, as well as certain donor expenses, related to transplants. Benefits may include travel and accommodations for a recipient's dependent or parent and up to $100 a day for the dependent's food and lodging if the care is provided out of state. These benefits are payable only until the dependent's presence is no longer necessary, as determined by Aetna.

Network providers obtain preauthorization for your care as necessary. If you see an out-of-network provider for transplants, you must obtain preauthorization from Aetna. (For details, see "Preauthorization.")

You're not eligible for organ transplant benefits until the first day of the 13th month of continuous coverage under KingCare^SM before a transplant will be covered.

If your physician recommends a transplant, even if it's not listed in this section, call Aetna immediately to discuss your situation and determine if the transplant is covered. If it is covered, make the necessary arrangements.

The following human transplants are covered:

bone marrow, including peripheral stem cell rescue;

cornea;

heart;

heart-lung;

kidney;

liver;

lung, single or double; and

pancreas with kidney.

(For plan benefits, see "KingCare^SM Benefits at a Glance.")

Transplant Recipients. If you're a transplant recipient, all of your services and supplies, including transportation to and from designated facilities, are covered. Designated facilities are specific facilities identified by Aetna and authorized to perform certain transplant procedures for plan members. You must be accepted into the facility's transplant program and continue to follow that program's protocol.

Transplant Donor. Transplant donor expenses are covered if the recipient is a plan member. Covered services include:

bone marrow testing and typing of the brothers, sisters, parents and children of the patient who needs the transplant (testing and typing of any other potential donor are not covered);

evaluation of the donor organ or bone marrow, its removal and transport of both the surgical/harvesting team and donor organ or bone marrow, if used for a covered transplant; and

locating a donor, such as tissue typing of dependents and other donor procurement costs.

Urgent Care

KingCare^SM covers treatment for conditions that aren't considered a medical emergency but may need immediate medical attention. Examples of urgent conditions include:

ear infections;

high fevers; and

minor burns.

If you need urgent care during office hours, call your physician's office for assistance. After office hours, call your physician's office and contact the on-call physician. Depending on your situation, the physician may provide instructions over the phone, ask you to come into the office or advise you to go to the nearest emergency room.

If you see a network provider for urgent care, you'll receive network-level benefits. If you see an out-of-network provider for urgent care, you'll receive out-of-network benefits. However, if you need emergency care, it will be covered at network levels whether you see a network or out-of-network provider. (For plan benefits, see "KingCare^SM Benefits at a Glance.")

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Updated: August 1, 2007