How to Access Covered Care
Choose your doctor and change anytime.
Getting in-depth information on how your plan works and getting connected with a provider who suits your individual needs is the first priority. Choose from a wide range of providers. Remember—you can change at any time. Your plan provides you with that flexibility.
For Information about Kaiser Permanente Insurance Company’s (KPIC’s) Network Adequacy Policy, please review our Frequently Asked Questions Document.
For information about Maryland Appointment Wait Time Standards please review Maryland Maryland Network Adequacy Median Appointment Waiting Time document.
Here’s an overview of getting care with the Out-of-Area PPO plan. There are two options to choose from: PHCS, MultiPlan or Cigna Healthcare PPO networks (in-Network) and out-of-network.
In-Network
Private Healthcare Systems (PHCS), MultiPlan and Cigna Healthcare PPO Networks
Call any participating provider’s office directly
- You can call or make an appointment directly with any provider that participates in the PHCS and/or MultiPlan networks* within Kaiser Permanente States of CA, CO, GA, HI, MD, OR, VA, WA and DC or you can make an appointment directly with any provider that participates in the Cigna Healthcare PPO Network outside of the Kaiser Permanente States.
- You don’t need a referral for appointments with in-network specialists. However, you will need precertification for all inpatient admissions and some services and procedures when in Kaiser Permanente states using PHCS or MultiPlan network providers. 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 Healthcare PPO providers are responsible for obtaining precertification on your behalf when precertification is required. You won’t be financially responsible if a Cigna Healthcare PPO provider fails to obtain precertification for covered services.
- At your appointment, show your member ID card. The first time you visit, you will have to let the office staff know you’re using the PPO option of your plan.
- To find up-to-date participating physicians, facilities or health care practitioners you can search by Location or call Customer Service at 1-888-225-7202 (TTY 711), Monday through Friday 8:00 a.m. to 6 p.m., Eastern time.
Kaiser Permanente States: Within CA, CO, GA, HI, MD, OR, VA, WA and DC you have access to PHCS and Multiplan Networks**
Non-Kaiser Permanente States: The Cigna Healthcare PPO Network* only provides access to care in non-Kaiser Permanente states.
*Disclaimer: The Cigna Healthcare PPO Network refers to the health care providers (doctors, hospitals, specialists) contracted as part of the Cigna Healthcare PPO for Shared Administration
- With in-network providers, you’ll have to pay copays, coinsurance and meet a deductible. Please refer to your employer’s KPIC Group Policy and Certificate of Insurance (COI) for details about your plan and benefits.
You’ll pay less out-of-pocket when you receive services from in-network providers compared to out-of-network providers.
The Cigna Healthcare PPO Network refers to the health care providers (doctors, hospitals, specialists) contracted as part of the Cigna Healthcare PPO for Shared Administration. Cigna HealthcareSM is an independent company and not affiliated with Kaiser Foundation Health Plan, Inc., and its subsidiary health plans. Access to the Cigna Healthcare PPO Network is available through Cigna Healthcare’s contractual relationship with the Kaiser Permanente Health Plans. The Cigna Healthcare PPO Network is provided exclusively by or through operating subsidiaries of The Cigna Group, including Cigna Health and Life Insurance Company. The Cigna Healthcare name, logo, and other marks are owned by Cigna Healthcare Intellectual Property, Inc.
* The PHCSTM and MultiPlanTM 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.
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).
Out-of-Network
Call any participating provider’s office directly.
- You can call any out-of-network licensed provider for care or to make an appointment and you can call their office directly.
- You don’t need a referral for appointments with out-of-network specialists. However, you will need precertification for some services and procedures.
- At your appointment, show your member ID card. The first time you visit, you will have to let the office staff know you’re using the indemnity option of your plan.
- Your doctor may require you to pay the full cost of the visit. And you will need to submit claim forms and itemized bills for reimbursement.
- You’ll have to pay coinsurance and meet a deductible. You’ll also be responsible for any difference between what your provider charges for service and the payment your Out-of-Area PPO provides.
You’ll generally pay the most out-of-pocket when you receive services from out-of-network providers and facilities.
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.
It’s important to keep in mind:
- Your cost-shares will vary in each provider option.
- The amount you pay for a particular service will depend on the provider option you choose and—in some cases—where you choose to receive care.
To find out more:
- Your Out-of-Area PPO Plan Reference Guide has details about accessing covered care using the different options.
- Refer to your employer’s KPIC Group Policy and Certificate of Insurance (COI).
- Refer to your ID card or call Customer Service, Monday through Friday, 8:00 a.m. to 6:00 p.m., Eastern time, at 1-888-225-7202 (TTY 711).
The terms of your employer’s KPIC Group Policy and Certificate of Insurance (COI) govern the scope of covered benefits within the in-network and out-of-network options. Certain exclusions and limitations apply.