Understanding Your Plan and Benefits
Your Out-of-Area (OOA) Preferred Provider Organization (PPO)* plan empowers you to make the best health care choice for you—wherever you are, and whenever you need care.
Here’s an overview of getting care with Out-of-Area PPO. There are two options to choose from: participating providers in the PHCS, MultiPlan or Cigna Healthcare PPO networks (in-network) and non-participating or out-of-network providers. This plan allows members to use services outside of the Kaiser Permanente coverage area and is available for mid-size and large group employees who work and live outside the Kaiser Permanente Mid-Atlantic States coverage area.
In-Network
Private Healthcare Systems (PHCS), MultiPlan and Cigna PPO Networks
Features and benefits of covered care from in-network providers.
A wide network of contracted participating providers. 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 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.
Out-of-pocket costs. When you see participating providers, you generally have lower out-of-pocket costs. Provider fees are subject to negotiated rates and providers are not allowed to balance bill you for covered services. Your participating provider also completes and submits claim forms.
No-cost preventive care. Preventive care services are offered at no charge whether or not you have met the deductible.
Specialty care. You don’t need a referral for specialty appointments with participating providers. Please note that all inpatient care and certain outpatient services are subject to precertification.
Behavioral health. You can receive care for mental illness, emotional disorders, and drug or alcohol abuse from a provider in the participating provider networks. Please note that all inpatient care and certain outpatient services are subject to precertification.
Hospital care. You can receive inpatient hospitalization services from participating hospitals and facilities. Please note that all inpatient care and certain outpatient services are subject to precertification.
Emergency care. You are covered for emergency care worldwide. The emergency care copay will be waived if you are directly admitted to a hospital as a result of an emergency.
Urgent care. You can visit any PHCS or MultiPlan urgent care facility within Kaiser Permanente states or use the Cigna Healthcare PPO Network urgent care facilities when in non-Kaiser Permanente states (outside of CA, CO, GA, HI, MD, OR, VA, WA and DC),
Vision Care. You can receive vision care from an Option 2 provider within the participating provider networks.
Maternity care. You can choose any provider for your obstetric care from participating providers within our network. Your copay will be $0 for physician office visits while you are pregnant. Be sure to call for precertification during your first trimester.
Lab tests and X-rays. You can contact facilities directly. Check first to be sure the facilities are part of the PHCS or MultiPlan network when in Kaiser Permanente States or the Cigna PPO Network when in non-Kaiser Permanente States.
Pharmacy services. Learn about your pharmacy benefits.
To find out more about what is covered in-network:
- See your Certificate of Insurance (COI) or your Out-of-Area PPO Plan Reference Guide.
- Contact the benefits officer where you work, if your employer provides your coverage.
- Refer to your ID card or call Customer Service, Monday through Friday,to 8:00 a.m. to 6 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 in-network option.
Inpatient and certain outpatient services are subject to precertification when in Kaiser Permanente states using PHCS or MultiPlan network providers. You must call 1-888-567-6847 (TTY 711) for precertification. Representatives are available from 8 a.m. to 11 p.m., Monday through Friday, Eastern time. If using the Cigna Healthcare 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.
*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).
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 or MultiPlan networks for KPIC. Not all PHCS and MultiPlan network providers are included. For a list of network participants, go to multiplan.com/kpmas.
**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.
Out-of-Network
Any other licensed provider or physician that is not a part of the In-Network provider list.
You have access to any licensed provider, pharmacy, or hospital that is not considered in-network.
Out-of-pocket costs. Using out-of-network providers generally means higher out-of-pocket costs than with in-network providers. Your out-of-pocket costs will generally be the highest when you choose to receive care from an out-of-network provider or facility. Most services are subject to a deductible, then coinsurance. Depending on your out-of-network provider, you may be required to pay the full cost of the service and submit a claim for reimbursement. Only covered charges count toward meeting the deductible and out-of-pocket maximum. In addition, out-of-network providers may also bill you for the difference, if any, between actual billed charges and the maximum allowable charge. Charges that exceed the determined maximum allowable charge are not covered charges, do not satisfy the deductible, and do not accumulate to the out-of-pocket maximum.
Behavioral health. You can receive care from any licensed behavioral health or chemical dependency professional for mental illness, emotional disorders, and drug or alcohol abuse.
Hospital care. You can receive inpatient hospitalization services from licensed or accredited hospitals and facilities that are not in the in-network option.
Emergency care. All emergency care is covered as an in-network benefit.
Urgent care. You can visit any licensed out-of-network urgent care facility.
Vision care. You can visit any licensed optometrist or vision facility.
Maternity care. You can choose any licensed provider for obstetric care.
Lab tests and X-rays. You can receive lab, X-ray, and other imaging services at any licensed facility.
Pharmacy services. Learn about your pharmacy benefits.
To find out more about what is covered out-of-network:
- See your Out-of-Area PPO Plan Reference Guide.
- Contact the benefits officer where you work, if your employer provides your coverage.
- Refer to your ID card or call Customer Service, Monday through Friday, 9:00 a.m. to 9:00 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 in the out-of-network option.
Inpatient and certain outpatient services are subject to precertification. You must call 1-888-567-6847 (TTY 711) for precertification. Representatives are available from 8 a.m. to 11 p.m., Monday through Friday, Eastern time.
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.