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Understanding Your Plan and Benefits

Kaiser Permanente Plus and Deductible Kaiser Permanente Plus plans provide limited nationwide coverage with any licensed provider, balanced by the high-quality* care innate to Kaiser Permanente’s integrated delivery system.

Here’s an overview of getting care with the plan. There are two options to choose from with your plan: Kaiser Permanente Signature (or in-network) and any other licensed provider (or out-of-network).

*National Committee for Quality Assurance “NCQA’s Private Health Insurance Plan Ratings 2017–2018.”

Kaiser Permanente Network
Out-of-Network Benefit

Kaiser Permanente Plus/Deductible Kaiser Permanente Plus

Kaiser Permanente providers and facilities

Benefits inside the Kaiser Permanente Signature network

Lowest out-of-pocket costs. With this option, you’ll usually pay the least out of pocket, with no or a lower deductible.
Coordinated care. Your primary care physician works closely with specialists, pharmacists, lab technicians, therapists, and many other professionals. And because they are all connected through your electronic medical record, everyone in the network gets up-to-the-minute information on your health for a better care experience.
No hassle referrals. Most specialist visits require a referral, but your primary care physician will typically handle this for you.
State-of-the-art medical centers. Kaiser Permanente’s state-of-the-art medical centers are located throughout the region, with doctors, specialists, imaging, and in most locations, pharmacy and lab, all in one place.
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. Urgent care is available 24/7 at six medical centers.
Hospital care. Kaiser Permanente carefully selects hospitals to work with us in taking great care of you.*
Medical advice. When you call for medical advice, you will be connected with a professional who can help advise you and make an appointment with one of our providers. You can get advice by calling the appointment number on the back of your ID card 24/7.
Lab services. Your results from tests done in Kaiser Permanente medical centers can be read (for most results) online soon after the lab completes your tests, sometimes the same day.
No-cost preventive care. With your plan, you pay $0 for preventive care. That includes routine physicals, well-child visits, and certain screenings and tests (such as mammograms).
Choose from telehealth options that fit into your schedule. Chat with a Kaiser Permanente doctor, email, or schedule a phone or video visit. Be aware that costs may apply for some visits. **
Manage your health online. Use the convenient features of kp.org to manage your health.***
- Email your doctor’s office
- View most test results
- Schedule or cancel routine appointments
- Refill most prescriptions
- View past visits
- Find care options and Urgent Care locations near you
- Register at kp.org/registernow
  - Select your region
  - Your user name and password can also be used on our mobile app

To find out more about what is covered under the Kaiser Permanente Network, see your Evidence of Coverage (EOC) or call Customer Service at:

- - Washington Metro Area: 703-359-7878 (TTY 711)
  - Outside Washington Metro Area: 800-777-7904 (TTY 711)
*The premier hospitals are independently owned and operated hospitals, and they contract with Kaiser Foundation Hospitals.
**Video visits are available for members who receive care at Kaiser Permanente medical centers. You must be 18 or older to schedule a video visit. Check with your doctor’s office to find out if video visits are available to you.
***These features are available when you get care at Kaiser Permanente facilities.

Out-of-Network Benefit

Any other licensed provider

You already have access to the best of Kaiser Permanente through your traditional HMO or DHMO coverage—but as a Kaiser Permanente Plus member, you get even more. Choose to see any licensed provider outside of the Kaiser Permanente Signature network, any time, for up to 10 visits or covered outpatient medical services each year. You can also fill 5 prescriptions at out-of-network pharmacies.
You’ll get 10 visits with out-of-network providers for certain covered outpatient services, including lab tests and X-rays. So, if you have a provider you love, you do not 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 do not need a referral or pre-certification to use your out-of-network benefits.
Out-of-network lab tests, X-rays, allergy injections, and physical, occupational, and speech therapy visits all count as separate visits. For example, if you see your out-of-network provider and he/she orders a lab test done in his/her office, this will count as two visits.
Here is a list of key services/items that count as a visit covered 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 and X-rays count separately toward your visit limit
- Physical, occupational, and speech therapy office visits
- Allergy injections received at an office
Your cost share (copayment or coinsurance) will be higher than the cost share for these services if you choose to go out of network.
Your out-of-network benefit is not subject to a deductible, and it does not apply to your out-of-pocket maximum.
Consider having prescriptions, labs and radiology performed at Kaiser Permanente to save on visit limits and out-of-pocket costs.
Emergency care. ER services are covered at any emergency facility but will always be administered as an in-network covered service with the applicable cost shares applied.
Pharmacy services. Learn about your pharmacy benefits in the out-of-network option.

What’s Not Covered with the Out-of-Network Benefit:

Inpatient services
Outpatient surgery
Prenatal and maternity care
Chiropractic services
Dental
Vision
See your Evidence of Coverage (EOC) for details on other excluded benefits.
Services not covered under your base medical plan will not be covered under the out-of-network benefit.

To find out more about what is covered under the out-of-network benefit:

Refer to your Evidence of Coverage (EOC).
Contact the human resources/benefits officer where you work.
Refer to your ID card or call the Customer Service Center, Monday through Friday, 7:30 a.m. to 9 p.m., Eastern time at 888-225-7202 (TTY 711).

This site provides an overview of your benefits and services. If there are any differences between this website and your Evidence of Coverage (EOC), your Evidence of Coverage (EOC) will prevail.