86 2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Section 7 — How to ask us to keep covering certain medical services if you think your coverage is ending too soon Section 7.1 – This section is only about three services: Home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services When you are getting covered home health services, skilled nursing care, or rehabilitation care (Comprehensive Outpatient Rehabilitation Facility), you have the right to keep getting your services for that type of care for as long as the care is needed to diagnose and treat your illness or injury. When we decide it is time to stop covering any of the three types of care for you, we are required to tell you in advance. When your coverage for that care ends, we will stop paying our share of the cost for your care. If you think we are ending the coverage of your care too soon, you can appeal our decision. This section tells you how to ask for an appeal. Section 7.2 – We will tell you in advance when your coverage will be ending Legal Notice of Medicare Non-Coverage. It tells you how you can request a fast-track Term appeal. Requesting a fast-track appeal is a formal, legal way to request a change to our coverage decision about when to stop your care. 1. You receive a notice in writing at least two days before our plan is going to stop covering your care. The notice tells you: • The date when we will stop covering the care for you. • How to request a fast track appeal to request us to keep covering your care for a longer period of time. 2. You, or someone who is acting on your behalf, will be asked to sign the written notice to show that you received it. Signing the notice shows only that you have received the information about when your coverage will stop. Signing it does not mean you agree with the plan's decision to stop care. Section 7.3 – Step-by-step: How to make a Level 1 appeal to have our plan cover your care for a longer time If you want to ask us to cover your care for a longer period of time, you will need to use the appeals process to make this request. Before you start, understand what you need to do and what the deadlines are. • Follow the process. • Meet the deadlines. kp.org