Why Out-of-Area PPO?

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Out-of-Area PPO offers two options that empower employees to make decisions about how they receive care and who they receive it from.

Employees are free to choose whatever provider they prefer, whenever they receive care.

What does each option offer?

In-Network:

PHCS, MultiPlan and Cigna PPO Networks

A wide network of providers with managed out-of-pocket costs.

Choose from an extensive network nationwide to medical care through Kaiser Permanente Insurance Company’s (KPIC) network access agreements with PHCS, MultiPlan and the Cigna PPO Networks. Members have access within Kaiser Permanente States of CA, CO, GA, HI, MD, OR, VA, WA and DC to PHCS and MultiPlan networks. Members also have access in non-Kaiser Permanente States to the CignaPPONetwork*.

*Disclaimer: The Cigna PPO Network refers to health care providers (doctors, hospitals, specialists) contracted as part of the Cigna PPO for Shared Administration

We’ve contracted with three networks: Private Health Systems (PHCS), MultiPlan and Cigna PPO Networks to manage provider costs.
A physician usually completes and submits claim forms, just as with most traditional health plans.
No referral is needed for office visits to specialists.
Members using Options 1 and 2 do need precertification for all inpatient services and certain outpatient surgeries, services and procedures. The exception is if using the Cigna PPO Network for care in non-Kaiser Permanente States (outside of CA, CO, GA, HI, MD, OR, VA, WA and DC), the Cigna PPO providers are responsible for obtaining precertification on your behalf when precertification is required. You won’t be financially responsible if a Cigna PPO provider fails to obtain precertification for covered services.
Some services are subject to a deductible, then copay or coinsurance. Certain services are covered before the deductible at a copay.
Providers’ fees are subject to negotiated rates and they are not allowed to charge directly for covered services.

Out-of-Network:

Care from any other licensed provider in the U.S., highest out-of-pocket costs.

Employees can receive care from any licensed care provider in the U.S., including physicians, specialists, hospital or laboratory (who are not considered in-network).
Out-of-pocket costs will usually be the highest with this option.
No referral is needed for office visits to specialists.
Inpatient and certain outpatient services are subject to precertification.
Most services are subject to a deductible, then coinsurance.
Out-of-network providers have not agreed to negotiated rates. Providers may require payment of the full cost of each visit. If so, a claim for reimbursement will need to be submitted.
Providers may bill for the difference, if any, between actual billed charges and the maximum allowable charge. Charges that exceed the maximum allowable are not covered, do not satisfy the deductible, and do not accumulate to the out-of-pocket maximum.

KPIC has contracted with PHCS and MultiPlan, national preferred provider organization networks that contract with physicians, hospitals, and other health care providers, to provide access to the PHCS network for KPIC. Not all PHCS™ and MultiPlan™ network providers are included. For a list of network participants, go to PHCS and Multiplan Networks.

Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc. (KFHP), underwrites the In-Network PPO Tier and Out-of-Network Tier.

Employees get the care they need. Out-of-Area PPO empowers employees to choose how and where they get covered care.
Manage care and costs: Employees can choose their provider. They determine how to manage out-of-pocket costs. They decide which provider network option they want to use any time they access care.
Preventive care: It’s covered at no cost to employees when they see an in-network provider.
Pharmacy services: Employees can have prescriptions filled at retail pharmacies across the country.

Check here for more about pharmacy services, finding doctors and facilities and the benefits of Out-of-Area PPO.

Is Out-of-Area PPO right for you?

Here are some examples of how people use Out-of-Area PPO to get the care they want:

Tracey: Gets great family care, keeps her specialist, and manages costs.

Tracey lives in Southern California and is enrolled in the Out-of-Area PPO plan. She has an OB/GYN she has used for years who does not participate in the PHCS or MultiPlan networks. Tracey can continue to see her OB/GYN using the out-of-network option. Tracey can also save money by seeing PHCS network providers for other services. This plan allows Tracey the choice of providers.

Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc. (KFHP), underwrites the In-Network PPO Tier and Out-of-Network Tier.

Offering the Out-of-Area PPO plan at your company

For employers and brokers, the Out-of-Area PPO product is a great solution:

It gives your valuable employees choice in their providers and allow them to determine and manage their health care costs.
Having two provider options to choose from gives your valued employees what they need to be healthier and more productive every day.
The versatility and benefits of Out-of-Area PPO can help attract and retain employees.
Your company has the convenience of one health care provider for all your employee benefits administration.
Offer it side-by-side with HMO, HMO Plus, Deductible HMO, Deductible HMO Plus, HSA-Qualified Deductible plans, or Flexible Choice plans to decrease your company’s overall health care costs, and still offer your employees plan choice when they work and live outside the Kaiser Permanente Mid-Atlantic States coverage area.

How the Out-of-Area PPO plan works for your company and employees.

With each of these plans, you can offer your participating employees two options when they receive care:

In-Network: With the in-network option, members have access to three network for coverage nationwide through Kaiser Insurance Company’s (KPIC) network access agreements with PHCS, MultiPlan and the Cigna PPO Networks. Members have access within Kaiser Permanente States of CA, CO, GA, HI, MD, OR, VA, WA and DC to PHCS and MultiPlan networks. Members also have access in non-Kaiser Permanente States to the CignaPPONetwork*

*Disclaimer: The Cigna PPO Network refers to health care providers (doctors, hospitals, specialists) contracted as part of the Cigna PPO for Shared Administration.

Out-of-Network: Members can receive services from any other licensed provider or facility they choose. Members pay deductibles, coinsurance, and may be balance billed. Out-of-pocket costs are generally the highest with this option.

Learn more about what’s included in-network and out-of-network, and how they work.

*The PHCS^TM and MultiPlan^TM networks include physicians and health care practitioners and facilities that are available to Kaiser Permanente Insurance Company members via a network access agreement. Not all PHCS™ and MultiPlan™ network providers are included. For a list of network participants, go to PHCS and Multiplan Networks.

Employers’ frequently asked questions

What are the pharmacy choices under Out-o-Area PPO?

Members have several choices for having their prescriptions filled.

Kaiser Permanente has contracted with MedImpact to fill outpatient prescriptions at over 70,000 participating retail pharmacies—including Costco, Rite Aid, CVS and many supermarket chains. (Not all pharmacies in a chain may participate.)
Members also can fill prescriptions at any licensed pharmacy outside the MedImpact network.
Learn more about pharmacy services.

What are guidelines regarding precertification?

Members using Options 1 and 2 do need precertification for all inpatient services and certain outpatient surgeries, services and procedures. The exception is if using the Cigna PPO Network for care in non-Kaiser Permanente States (outside of CA, CO, GA, HI, MD, OR, VA, WA and DC), the Cigna PPO providers are responsible for obtaining precertification on your behalf when precertification is required. You won’t be financially responsible if a Cigna PPO provider fails to obtain precertification for covered services.
Our Permanente Advantage office with its extended hours is the administrator for precertification.
Learn more about precertification.

How are new members on-boarded?

Onboarding includes: Comprehensive New Member Reference Guides, an onboarding call from Customer Service agents, and a help line with extended hours for any questions, from accessing care to transferring prescriptions.

Who processes claims?

The plans that underwrite the in-network and out-of-network options processes the claims.

Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc. (KFHP), underwrites the Out-of-Area PPO product.

Who do we contact for product pricing or to purchase Out-of-Area PPO?

Contact Kaiser Permanente at any time through our Business Plans contact page.

Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc. (KFHP), underwrites the In-Network PPO Tier (Option 1) and Out-of-Network Tier (Option 2).