Kern Legacy Health Plan

 
Plan Overview

The Kern Legacy Health Plan is an Exclusive Provider Organization (EPO) option. The plan offers hospital, prescription, and specialist physician care through the County hospital, Kern Medical Center (KMC). The plan features:

  • Lower biweekly employee contributions
  • A large selection of primary care and ob-gyn physicians similar to those on existing County plans
  • Convenient downtown location (County Administrative Building, 1115 Truxtun Avenue, First Floor) for:
    • prescription drop-off and pick-up
    • lab services (e.g., blood tests)
    • member services (e.g., answering questions about plan services)
  • $0 co-pay for generic and preferred name-brand prescriptions at KMC pharmacies, including the downtown pick-up station
  • $0 co-pay for Inpatient Hospitalization and Outpatient Surgery/Procedures at KMC
  • KMC Specialty services provided at 6401 Truxtun Avenue

For information on dental and vision coverage, visit Kern County Health Benefits

Urgent Care

Important Documents
Member Handbook
Provider Handbook
Provider Quick Reference Sheet
Provider Directory
(updated 3/07/14)
Sample ID Card

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Member Services Hotline
and Eligibility Verification
Local: 661-868-3280
Toll-Free: 855-308-KLHP (5547)

(once connected, choose Option 5)
   ...more contact info

Provider Portal
Plan Benefits

General Benefits Information

2014 Summary of Benefits and Coverage  (PDF)

Summary Plan Description  (PDF)

Continuity of Care

Members who are under the care of a physician for a serious medical condition prior to joining the Kern Legacy Health Plan may request to continue receiving care from their current provider. A Continuity of Care request must be submitted prior to receiving any additional services from the current provider. To submit a request:

1. Complete the Continuity of Care Request form and submit it to Kern Legacy Health Plan.

or

2. Call the Member Services Hotline at 661-868-3280 or 1-855-308-KLHP (5547); option 5

Summary/Co-pays

Type of Plan/Benefit Level EPO  (Exclusive Provider Organization)
Who Directs Your Care Contracted Primary Care Physician (PCP)
Who Provides Your Care PCPs contracted with this plan plus specialists in the PCP’s medical group. Specialist visits require a referral or a Prior Authorization. Prior authorization must be obtained for services not available in the network.
Annual Deductible $0
Calendar Year Out-of-Pocket Max (Once this maximum is paid by the member, the plan pays a higher amount - up to 100% coverage) $1,000 per person
$3,000 per family
Primary Physician Visit $10 co-pay
Specialist Physician Visits $15 co-pay
Wellness Visit - up to age 2 Active employees: $0 co-pay
Retirees: $10 co-pay
Wellness Visit - age 2+ Active employees: $0 co-pay
Retirees: $10 co-pay
Outpatient Surgery / Procedure $0 co-pay at KMC or
$150 (hospital setting) co-pay
$50 (surgery center) co-pay
Inpatient Hospitalization $0 copay at KMC
$100/day copay in outlying network hospitals
No coverage at other local hospitals except through emergency room admission
Emergency Room $75 co-pay  (waived if admitted)
Urgent Care $15 co-pay
Mammogram & Pap Smear $0 co-pay
Immunizations  (Office visit co-pay applies) $0 co-pay
Diagnostic Lab/X -Ray $0 co-pay
Physical, speech and occupational therapy $0 co-pay (max 60 visits/year combined)
Durable Medical Equipment $0 co-pay
Allergy Testing & Diagnosis $0 co-pay
Chiropractic $10 per visit – maximum 20 visits per calendar year
Prescription - Retail Active employees: $0 co-pay at KMC network pharmacy/pick-up station (up to a 90-day supply); $30 at non-KMC pharmacy
Retirees: $0 co-pay generic, $20 co-pay brand-name at KMC network pharmacy/pick-up station (up to a 90-day supply); $45 at non-KMC pharmacy
Prescription - Mail order Active employees: $0 co-pay for up to a 90-day supply through KMC Mail Service
Retirees: $0 co-pay generic, $20 co-pay brand-name for up to a 90-day supply through KMC Mail Service

This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, out-of pocket maximums, exclusions or limitations, nor does it list all benefits. For a more complete explanation, please refer to the 2014 Summary of Benefits and Coverage (PDF) for the plan.

Forms and Guidelines

Member Forms

Continuity of Care Request  (PDF)

Request to continue receiving care for a serious medical condition from a current provider

Member ID Card Request  (PDF)

Request to receive a replacement member ID card if a card is lost/stolen/damaged.

Pharmacy Mail Order  (PDF)

Primary-Care Physician (PCP) Change Request  (PDF)

Request for Reimbursement - Medical Services  (PDF)

Request for Reimbursement - Pharmacy  (PDF)

Provider Forms

Lab Requisition Order  (PDF)

Provider Portal Access User Application  (PDF)

Radiology/Imaging Service Referral  (PDF)

Radiology Scheduling - Biopsy  (PDF)

Radiology Scheduling - Nuclear Medicine  (PDF)

Referral/Prior-Authorization  (PDF)

Provider Guidelines

CT Exam Guidelines and Routine Indications for Contrast  (PDF)

MRI Exam Guidelines and Routine Indications for Contrast  (PDF)

MRI Scheduling Codes  (PDF)

Grievance / Appeal Procedure

Appealing a Denied Authorization

Members may appeal a denied authorization by calling the Member Services Hotline at 661-868-3280 or 1-855-308-KLHP (5547); option 5

Timeline for addressing appeals

  • Urgent matter: within 3 business days
  • Non-urgent matter: within 30 days

Other Grievances/Appeals

Members are also encouraged to call the Member Services Hotline to express concerns over customer service or concerns with provider’s services.

Member Services Hotline: 661-868-3280 or 1-855-308-KLHP (5547); option 5

Newsletters

Members will receive a quarterly publication in an easy-to-read and entertaining format. Articles will include information on general health and information specific to issues in the community.

Current Newsletter

A Legacy of Good Health

Past Issues

Fall 2013

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