Washington Alternative Care Benefit (Acupuncture, Naturopathy, Massage)

All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest 500 NE Multnomah St., Suite 100, Portland, OR 97232 ©2019 Kaiser Foundation Health Plan of the Northwest 338172811_LBG_04-19

Washington alternative care benefit (acupuncture, naturopathy, massage)

This benefit covers self-referred acupuncture, naturopathic, and massage therapy services when obtained from participating providers. Benefits are subject to the copays or coinsurance, and visit and/or dollar limits shown below.

Choose your benefit maximum, 3 options: Benefit maximum per year (naturopathy and massage combined) $1,000 / $1,500 / $2,000

Services You Pay* Acupuncture services (12-visit limit) Specialty office visit cost share Naturopathic medicine (benefit max applies) Specialty office visit cost share Massage therapy (12-visit limit and benefit max applies) $25 *If added to an HSA-qualified deductible plan, this benefit is subject to the deductible.

Office visits You do not need a referral to make an appointment. There is no claim form to file. You pay your copay or coinsurance directly to the provider when you receive care. Once your benefit limit has been reached, you pay 100% of the cost of services for the remainder of the calendar year. As a member, you will receive a discount of up to 20%.

Participating providers We contract with the CHP Group, a network of alternative care providers, to provide covered services to members. Visit chpgroup.com for a list of participating providers or contact Member Services.

Acupuncture services Acupuncturists influence the health of the body by the insertion of very fine needles. Acupuncture treatment is primarily used to relieve pain, reduce inflammation, and promote healing. Covered services include: ▪ Evaluation and management. ▪ Acupuncture. ▪ Electro acupuncture.

This is not a contract. This benefit summary does not fully describe your benefit coverage with Kaiser Foundation Health Plan of the Northwest. Please see your Evidence of Coverage (EOC) for complete details of benefits as well as exclusions and limitations. In the event of a conflict between this summary and the EOC, the EOC will control. All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest 500 NE Multnomah St., Suite 100, Portland, OR 97232 ©2019 Kaiser Foundation Health Plan of the Northwest 338172811_LBG_04-19

Naturopathic medicine services Naturopathic medicine is a natural approach to health and healing that emphasizes a holistic approach to the diagnosis, treatment, and prevention of illness. Naturopathic physicians diagnose and treat patients by using natural modalities such as clinical nutrition, herbal medicine, and homeopathy. Covered services include evaluation and management.

When prescribed during a naturopathic medicine visit, certain laboratory tests may be covered, as described in your EOC.

Massage therapy services Therapeutic massage involves the manipulation of soft tissue structures of the body to help alleviate pain, muscle discomfort, and stress by helping to promote health and wellness. Covered services include evaluation and management.

Alternative care exclusions ▪ Acupressure. ▪ Hearing exams. ▪ Nerve conduction studies, electromyography, ▪ Behavioral training and ▪ Infertility services. computerized muscle testing, modification, including but not ▪ The following laboratory or range of motion testing. limited to biofeedback, services: hypnotherapy, play therapy, ▪ Obstetrical services. and sleep therapy. - Comprehensive digestive ▪ Over-the-counter drugs, stool analysis. ▪ Charges incurred as a result medications (prescription or of missed appointment or an - Cytotoxic food allergy nonprescription) including appointment not canceled. test. vitamins, minerals, nutritional - Darkfield examination for or dietary supplements, or ▪ Chiropractic services in toxicity or parasites. any other supply or product, excess of those necessary for whether or not prescribed. maximum chiropractic - EAV and electronic tests improvement. for diagnosis or allergy. ▪ Physical examinations for - Fecal transient and evaluations and reports for ▪ Cosmetics, dietary retention time. licensing, school, sports, supplements, recreation, premarital, or those required health or beauty classes, - Henshaw test. for court proceedings. aids, or equipment. - Intestinal permeability. ▪ Point injection therapy ▪ Costs or charges incurred for - Loomis 24-hour urine (aquapuncture). which the member is not nutrient/enzyme analysis. legally required to pay. - Melatonin biorhythm ▪ Preventive services. challenge. ▪ Cupping. ▪ Proctology services. - Salivary caffeine ▪ Dental services, including clearance. ▪ Public facility care required temporomandibular joint by federal, state, or local law. (TMJ) services. - Sulfate/creatine ratio. - Thermography, hair ▪ Services considered ▪ Dermal friction technique. analysis, heavy metal experimental or investigational. ▪ Disorders connected to screening, and mineral military service. studies. ▪ Services designed to maintain optimal health in the ▪ Durable medical equipment, - Tryptophan load test. absence of symptoms. devices, appliances, - Urinary sodium benzoate. orthotics, or prosthetics. - Urine saliva pH. ▪ Smoking cessation. ▪ Environmental - Zinc tolerance test. ▪ Sonopuncture. enhancements; modifications ▪ Laserpuncture. ▪ Surgery. to dwellings, property, or motor vehicles; adaptive ▪ Mental health services of any ▪ Transportation services. kind. equipment; personal ▪ Vocational rehabilitation. lodgings; travel expenses; ▪ Moxibustion. and meals. ▪ X-ray documentation and/or ▪ MRIs, diagnostic ultrasounds, interpretation when ▪ Fertility services, including CT scans, bone scans, and prescribed by an reversal of sterilizations. other special imaging studies. acupuncturist or naturopath. ▪ Gynecological services. ▪ Nambudripad allergy ▪ Health or exercise classes, eliminated technique (NAET). aids, or equipment.

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