How to Access Covered Care
You can choose coordinated care with your Kaiser Permanente physician or call any provider’s office directly. Here’s a quick view of getting care with Flexible Choice’s three options: HMO (Option 1), PHCS & MultiPlan Networks within MAS and other Kaiser Permanente states or Cigna Healthcare PPO Network when travelling outside Kaiser Permanente states (Option 2) and Out-of-Network (Option 3).
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.
HMO
Option 1: Many ways to access care through Kaiser Permanente.
- Your care in the Kaiser Permanente network starts with your own personal doctor—your primary care physician—who will coordinate your care. You choose your own doctor and you can change your doctor at any time.
- You can also see some specialists without a referral such as obstetrics/gynecology, optometry, and some kinds of behavioral health.
- You can manage your care at kp.org. Visit anytime from anywhere to make an appointment, refill most prescriptions, see most lab results, and much more.
- You could also have a video visit with a doctor at no extra cost.
- Urgent care is available 24/7 at six medical centers, and with extended hours at five others.
With Option 1, you’ll usually pay the lowest out-of-pocket costs with no or a lower deductible.
PHCS & MultiPlan Networks or Cigna Healthcare PPO Network
Option 2: Call any participating provider’s office directly.
You can call or make an appointment directly with any Option 2 participating provider. To find up-to-date Participating Providers or confirm if your current provider is part of the Network, you can search for Providers 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 Flexible Choice Provider Directory
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 PPO for Shared Administration.
- You don’t need a referral for appointments with Option 2 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 PPO option of your plan.
- With Option 2 providers, you’ll probably have to pay copays, coinsurance and meet a deductible. Please refer to your Certificate of Insurance for detail about your plan and benefits.
You’ll pay more out of pocket when you receive services from Option 2 providers compared to Option 1.
Out-of-Network
Option 3: Call any licensed provider’s office directly.
- You can call any Option 3 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 Option 3 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 KPIC provides.
You’ll generally pay the most out of pocket when you receive services from Option 3 providers and facilities.
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 member handbook has details about accessing covered care using the different Options.
- Call Member Services at 888-225-7202 or refer to your ID card.
- Download the KP app for iOS or Android
*The terms of your Evidence of Coverage govern the scope of covered benefits in Option 1. The terms of your Certificate of Insurance govern the scope of covered benefits in Options 2 and 3. Certain exclusions and limitations apply.