Kaiser Permanente Plus and Deductible Kaiser Permanente Plus give you more choices. You can continue to see your favorite out-of-network provider while still getting all the benefits of the Kaiser Permanente Signature network.
Kaiser Permanente Signature network:
Fully coordinated, high-quality* care; lowest cost of the two options.
- In this option, choose physicians, specialists, and some affiliated providers.
- Kaiser Permanente providers are connected to your electronic health record, so they’re up to date on your care.
- Lowest out-of-pocket costs compared to the out-of-network provider option.
- Most medical centers across the region offer many services conveniently under one roof, including pharmacy, imaging, lab tests, primary care physicians and specialists, and urgent care services.
- Your primary care physician coordinates your care. When you need specialty care, you and your doctor will find the specialist right for you and coordinate the referral. Specialists can often be seen within a few days, or even sooner.
- No claims paperwork is required.
Keep seeing your favorite out-of-network provider:
- You can receive care from any licensed care provider in the nation, up to 10 visits or covered outpatient medical services each year.
- If you have a provider you love, you don’t have to switch. Your visits will still be covered, as long as you don’t exceed the annual visit limit.
- You will also be assigned an in-network primary care physician for your convenience, but you can change doctors any time.
You can use your visits for these types of items/services under the out-of-network benefit:
- Routine office visits, including primary, preventive and specialty care, as well as mental health and chemical dependency visits.
- Diagnostic lab tests, X-rays, and special procedures (each office visit, test, X-ray, and procedure counts separately toward your limit).
- Physical, occupational, and speech therapy office visits.
- Allergy injections received at an office.
What’s the cost?
- Your cost share (copayment or coinsurance) will be higher if you choose to go out-of-network.
- Your costs under the out-of-network benefit are not subject to your deductible (if applicable), and they do not apply to your out-of-pocket maximum for the year.
What’s not covered out-of-network
- Inpatient services
- Outpatient surgery
- Prenatal and maternity care
- Chiropractic services
- Dental
- Vision
- Genetic testing
- See your Evidence of Coverage (EOC) for details on other excluded benefits.
- Services not covered under your base medical plan will not be covered out-of-network.
- Emergency care is covered at any emergency facility but will always be administered as an in-network covered service with the applicable cost shares applied.
*National Committee for Quality Assurance “NCQA’s Private Health Insurance Plan Ratings 2017–2018.”
- Keep your doctor. The out-of-network benefit allows you to keep your favorite provider, while still getting all the great benefits of Kaiser Permanente.
- Pharmacy services. Prescriptions from out-of-network providers are covered at all Kaiser Permanente and network pharmacies. You also have the option of filling prescriptions at pharmacies outside of the Kaiser Permanente network.
Check here for more about pharmacy services, finding doctors and facilities, and the benefits of Kaiser Permanente Plus and Deductible Kaiser Permanente Plus.
Is Kaiser Permanente Plus or Deductible Kaiser Permanente Plus right for you?
Here are some examples of how people use the out-of-network benefit to get the care they want:
Kaiser Permanente is excited to offer our KP Plus plans in the Individual and Family segment in Maryland and the District of Columbia. As a KP Plus member, you receive comprehensive care from Kaiser Permanente physicians. You can also choose to see any licensed provider outside Kaiser Permanente for certain covered outpatient services (visit limits apply).
Three Ways KP Plus Meets Your Needs
- Members have access to comprehensive care with Mid-Atlantic Permanente Medical Group, P.C. (Permanente) physicians.
- You can also access certain kinds of care outside Kaiser Permanente should you choose:
- Up to 10 out-of-network outpatient medical visits per year, including physician office visits, lab, and radiology.
- In addition, up to 5 out-of-network pharmacy refills.
- Out-of-network payments do not accrue toward in-plan deductibles or out-of-pocket maximums.
- Typically, greater affordability than alternatives with out-of-network coverage, with lower premiums and predictable copays.
Plan Overview
The Individual and Family segment in Maryland and the District of Columbia has one KP Plus plan each. Below is a high-level summary of selected benefits provided by the plans, highlighting the out-of-network feature. Please visit BuyKP.org for further details.
Maryland
KP MD Gold 1700/20/Vision plan (Off-Exchange)
| In-Network | Out-Of-Network (visit limits apply) | |
| Deductible | $1,700 | N/A |
| Coinsurance | 35% | N/A |
| Out-of-Pocket Maximum | $8.300 | N/A |
| Primary Office Visit | $20 | $40 |
| Specialist Office Visit | $50 | $70 |
| Lab | $15 | $35 |
| X-Ray | $65 | $85 |
| Generic Drug | $10 | $30 |
District of Columbia
KP DC Gold 0 Ded/100 RxDed/Vision (On-Exchange)
| In-Network | Out-of-Network (visit limits apply) | |
| Deductible | $0 | N/A |
| Coinsurance | 35% | N/A |
| Out-of-Pocket Maximum | $7,150 | N/A |
| Primary Office Visit | $20
(Copay waived for children under 5) |
$40
(Copay waived for children under 5) |
| Specialist Office Visit | $40 | $60 |
| Lab | $30 | $50 |
| X-Ray | $65 | $85 |
| Generic Drug | $15 | $35 |
Frequently asked questions
Q1: What plans are available?
For 2024 there are two Gold-tier pilot plans available, one each in Maryland and the District of Columbia. Please find the details above under Plan Overview.
Q2: How can I purchase a KP Plus plan?
- Maryland consumers can browse and purchase that plan directly from BuyKP.org. Alternatively, if you are working with a broker, please let them know you are interested in a KP Plus plan.
- Consumers in the District of Columbia must purchase plans on the health insurance exchange at DCHealthLink.com. Please select the “Individual & Family” option and look for the KP Plus plan among the Kaiser Permanente options.
Q3: Is a KP Plus plan right for me?
The KP Plus may be right for you if travel and require care outside the Kaiser Permanente service area from time to time, or if you need to retain some access to an existing provider as you transition your care to Kaiser Permanente. For instance, this might occur because you want to finish in-progress routine care (e.g., physical therapy) that was started with another provider.
Q4: What process can I expect when I go outside Kaiser Permanente for services?
When utilizing out-of-network services, some providers and pharmacies may require payment of the full cost at the point of service. The member must then file a claim for reimbursement from Kaiser Permanente. Some providers may process the claim for the member; it will depend on those providers’ respective offices.
Q5: How will non-Kaiser Permanente providers know that my insurance covers my care with them?
Kaiser Permanente provides a handout that you can give your physician to answer questions that they may have. Because out-of-network providers do not have a contract with Kaiser Permanente, members may need to prepay for services and submit a claim for reimbursement.
Q6: How are the out-of-network visits counted?
An out-of-network “visit” is any encounter or service that is rendered out-of-network. For instance, a member who sees a specialist and has lab work done uses two “visits” from the annual limit. Multiple encounters in the same office setting on the same day may count as multiple visits and will accrue toward the annual visit limits.
Q7: What happens if I go over my visit or Rx limit?
You will either be required to pay out of pocket for any additional out-of-network services or you may obtain all their care in-network for the remainder of the contract year.
Q8: How will I know how many visits I have used?
The visit count will be included in the Explanation of Benefits document (EOB) that you will receive after each episode of care. You may also call the Member Services number on your insurance card to inquire.
Q9: Are the 10 visits and 5 prescriptions for each member, or are those shared within a family?
Each individual member with a KP Plus product will have 10 visits (for certain physicians, lab, and imaging services) and 5 prescription fills/refills per year.
Q10: Will I need a referral or pre-authorization to use the out-of-network benefits?
No. KP Plus members may use their out-of-network benefits without a referral or pre-authorization.
Q11: Where can I get help if I have a question?
Please chat with one of our specialists by selecting that option at BuyKP.org, or call 800-488-3590 (TTY 711). Our operating hours vary based on the season. From November 1st to January 31st, we are open from Monday to Saturday, 6am to 8pm Pacific Standard Time. From February 1st to October 31st, we are open from Monday to Friday, 6am to 8pm Pacific Standard Time.