When a contract is not a contract.

I have spent most of the summer chatting every other day with the
"representatives" of LLNS at Hewitt Management in a so-far futile
attempt to get LLNS to adhere to the Kaiser health benefits as outlined
in 20 years of "Evidence of Coverage" (EOC) documents, including the
present one covering LLNS.

My primary complaint (shared by many at LLNL?) is that UC threw us
bona-fide UC retirees over the wall, linking us to the private
contractor, LLNS, for whom we never worked (or wanted to work!!) a day
in our lives. This was probably a prelude to the accelerating shrinkage
of the UCOP staff (with what change in UCOP budget?) that is now
requiring the campuses to take over many of the formerly system-wide
functions operated by UCOP. I might understand booting campus UC
retirees back to their respective campuses for benefit management (which
are at least UC non-profit institutions), but why must I end up begging
for UC benefits from a management company that is dedicated to profit
for George Schultz and bonuses for Lab ULM?? I note that the UC Regents
have not returned the half million or more of license or royalty income
from my patents, either to me to the private LLNS.

Over the past 3 years, my partner and I have managed to sell our house
in San Jose and to build a great new place in the hills of southern
Mendocino County, moving here in April. My UC pension and the associated
benefits were a very important consideration in all of our decisions. I
have been lucky to have Kaiser's east-bay HIV specialist as my personal
physician since 1989, and I remain extremely healthy and robust due to
his care and my own research. We were assured multiple times by Kaiser
and my physician that we would continue our Kaiser membership, getting
most of our medical services at the Santa Rosa Kaiser center, although
Mendocino County is technically out of the direct service area (see EOC
excerpts below). My physician would remain my continued provider and I
would take the occasional 120 mile trip to see him. He assured me that
he continues having patients that live even farther away and would
arrange for me to see other appropriate specialists in Santa Rosa.
(Recall that Kaiser is a membership organization and not a health
insurance company, per se) This continued Kaiser membership is based on
the eligibility clauses that are part of all the past UC and present
LLNS EOC:


"Service Area eligibility requirements
The Subscriber must live or work in our Service Area at
the time he or she enrolls. The "Definitions" section
describes our Service Area and how it may change. You
cannot enroll or continue enrollment as a Subscriber or
Dependent if you live in or move to a Region outside
California except as described below. If you move
anywhere else outside our Service Area after enrollment,
you can continue your membership as long as you meet
all other eligibility requirements. However, you must
receive covered Services from Plan Providers inside our
Service Area, except as described in the following
sections"

After 2 months of frantic phoning (Hewitt canceled our Kaiser membership
as of June 26), I am today told that the LLNS group "contract" does not
allow out-of-service-area membership. The decision is apparently made
only on zipcode and no other lack of "eligibility" has been stated. The
LLNL on-site health benefit co-ordinator also supports this strange
interpretation of EOC language. I have not (YET) been allowed to see
this so-called REAL group contract, and no one can explain to me how or
why we have received yearly EOC documents that have not (apparently)
truthfully reflected this hidden contract, despite what the first text
in the LLNS Kaiser EOC states:

"Introduction

This Evidence of Coverage (EOC) describes the health
care coverage of "Kaiser Permanente Traditional Plan"
(which is not a federally qualified health benefit plan)
provided under the Group Agreement (Agreement)
between Kaiser Foundation Health Plan, Inc. (Health
Plan) and your Group. For benefits provided under any
other Health Plan program, refer to that plan's evidence
of coverage. "

I will, of course, be obtaining legal assistance and challenging this
decision, because I have found Kaiser to be the only non-profit health
care system (other than the VA) that actually operates moderately
successfully in this country. However, all LLNS employees and
unfortunate UC-LLNL retirees should be aware that LLNS management does
not adhere to the health care coverage that is plainly described in the
published EOC, at least for this provider. What other clauses are
similarly "not relevant"??? I recommend that we all obtain the _TRUE_
group coverage contracts for the health plans, since leaving the plans'
interpretations solely in the hands of for-profit management is likely
to result in arbitrary and unchallangeable "decisions" that cost us
money, health, and potentially, life!

aka 2005-Retiree