Page 128 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Kidney Disease Programs

Comprehensive Kidney Solution (CKS) program

For Participants diagnosed with Kidney Disease, your Plan offers the Comprehensive Kidney Solution
(CKS) program to help you manage the effects of advanced Chronic Kidney Disease (CKD) through End-
stage Renal Disease (ESRD).
Should the disease progress to the point of needing dialysis, CKS provides access to top-performing
dialysis centers. That means you will receive treatment based on a "best practices" approach from health
care professionals with demonstrated expertise.

There are hundreds of contracted dialysis centers across the country, but in situations where you cannot
conveniently access a contracted dialysis center, CKS will work to negotiate patient-specific agreements
on your behalf.

To learn more about Comprehensive Kidney Solutions, visit www.myoptumhealthcomplexmedical.com or
call the number on your ID card.

Coverage for dialysis and kidney-related services are based on your health plan's terms, exclusions,
limitations and conditions, including the plan's eligibility requirements and coverage guidelines.
Participation in this program is voluntary. If you decide to no longer participate in the program, please
contact CKS of your decision.

Kidney Resource Services program (KRS) program
End-Stage Renal Disease (ESRD)
The Kidney Resource Services program provides Covered Persons with access to a registered nurse
advocate who specializes in helping individuals live with kidney disease. As a participant in the KRS
program, you'll work with a nurse who will provide you with support and information. The nurse can help
you manage other conditions, such as diabetes and high blood pressure. He or she can also help you find
doctors, specialists and dialysis centers. This program is available at no extra cost to you.

With KRS, you have access to a registered nurse who specializes in kidney health. This program is
designed to help you be your own best advocate for your health. You may have been referred to the KRS
program by your medical provider or from past claim information. As part of your health insurance
benefits, it's available at no extra cost to you.
KRS nurse advocates are available, Monday through Friday toll-free at 1-866-561-7518 (TTY: 711).

Coverage for dialysis and kidney-related services are based on your health plan's terms, exclusions,
limitations and conditions, including the plan's eligibility requirements and coverage guidelines.
Participation in this program is voluntary.

Spine and Joint Solutions (SJS) Program

The Spine and Joint Solution is a surgical program that provides access to top-performing, regional
surgical centers for individuals who meet the criteria for select elective, inpatient surgeries. When you
contact the specialized nurse team and enroll in the SJS program the Plan pays Benefits for select
elective, inpatient surgeries provided by Designated Providers participating in the SJS program. The
specialized nurse team provides guided access to a network of credentialed SJS providers.
To learn more about SJS, contact the Claims Administrator at the number on your ID card.
If you are considering any of the above surgeries you must contact SJS prior to surgery to enroll in the
program in order for the surgery to be a considered a Covered Health Care Service under the Plan.

125 Clinical Programs and Resources