The POS plan empowers your employees to make decisions about how they receive care – and who they receive it from. Your employees can receive care from providers in the HMO Tier, Participating Provider Tier, or from any licensed physician or facility they choose in the Non-Participating Provider Tier.
Your employees are free to choose whatever provider they prefer, whenever they receive care.
What does each Tier offer?
HMO Tier:
Fully coordinated, high-quality care, lowest cost of the three tiers.
- A primary care physician coordinates care. When specialty care is needed, they will find the specialist right for the member and coordinate the referral. Specialists can often be seen within a few days, or even sooner.
- Kaiser Permanente Plan Providers are connected to an electronic health record, so they’re up-to-date on members care.
- Lowest out-of-pocket costs compared to the Participating Provider Tier and Non-Participating Provider Tier.
- Most facilities offer many services conveniently under one roof, including pharmacy, imaging, lab, primary care physicians and specialists, and urgent care services.
- No claims paperwork is required.
Participating Provider Tier:
A wide network of providers with managed out-of-pocket costs.
- A wide network of participating providers nationwide.
- Kaiser Permanente Insurance Company contracts with both the PHCS Network and Cigna PPO Network to manage provider costs.
- Out-of-pocket costs will be higher than in the HMO Tier and usually less than the Non-Participating Provider Tier.
- Physicians will complete claim forms, just as with most traditional health plans.
- A referral is not needed to see specialists.
- Certain services require precertification.
Non-Participating Provider Tier:
Care from any licensed provider in the U.S., highest out-of-pocket costs.
- Receive care from any licensed care provider in the U.S., including physicians, specialists, hospital, or laboratory (outside of the HMO Tier or Participating Provider Tier).
- Out-of-pocket costs will usually be the highest with this tier.
- Payment may be required to the provider directly at the point-of-service.
- A claim form will have to be completed, just as with most traditional health plans. If payment is required at the point of service, a medical claim will need to be submitted.
- A referral is not needed to see specialists. Certain services require precertification.
View Kaiser Permanente’s Sample Coverage Documents:
FOR future members – To view our SAMPLE plan documents, click here and choose the line of business and state from the dropdown menu and review items to assist in your plan choice.
FOR current members – The sample documents may vary from your actual benefits. To receive a copy of your specific plan documents, please contact Customer Service at 1-800-788-0710 (TTY 711), Monday through Friday, 7 a.m. to 7 p.m., Pacific time.
- Get the care you need. POS plans empower you to choose how and where you get covered care.
- Manage your care and costs. Provider choice.
- Preventive care. It’s covered at no cost or a copay with a Kaiser Permanente Plan Provider or Participating Provider.
- Pharmacy services. Most Kaiser Permanente facilities have on-site pharmacies. Prescriptions can also be filled at retail pharmacies across the country.
Check here for more about pharmacy services, finding doctors and facilities, and the benefits of the POS Plan.
Is the POS Plan right for you?
- Here are some examples of how people use POS Plans to get the care they want:
For employers and brokers, POS Plans are a great all-in-one solution:
- Give your valuable employees full choice in their providers and allow them to determine and manage their health care costs.
- Having three tiers of providers to choose from gives your valued employees what they need to be healthier and more productive every day.
- The versatility and benefits of POS plans can help attract and retain employees.
- Your company has the convenience of one health plan for all your employee benefits administration.
- Offer it side-by-side with HMO, DHMO, or HDHP plans to decrease your company’s overall health care costs, and still offer your employees plan choice.
How the POS plan works for your company and employees.
With the POS Plan, you can offer your participating employees three tiers of providers when they receive care:
- HMO Tier. Members can receive in-network care from Kaiser Permanente’s integrated health care delivery system through our Kaiser Permanente Plan Providers. This tier provides the most coordinated care with the lowest out-of-pocket costs, with no deductible. Preventive care is covered at no cost or just a copay. Members can also use kp.org and our mobile app to schedule certain appointments, email their doctors, view lab results, and refill prescriptions online.
- Participating Provider Tier. With the Participating Provider Tier, members can select their providers based on location to manage provider costs. Certain services are subject to deductible, with coinsurance after the deductible has been met. Some services including office visits are offered at a copay.
Kaiser Permanente States: The PHCS Network provides access to care in the Kaiser Permanente states of CA, CO, GA, HI, MD, OR, VA, WA and DC.
Non-Kaiser Permanente States: The CignaPPONetwork* only provides access to care in non-Kaiser Permanente states.
*Disclaimer: The Cigna PPO Network refers to the health care providers (doctors, hospitals, specialists) contracted as part of the Cigna PPO for Shared Administration.
- Non-Participating Provider Tier. Members can receive services from any licensed provider or facility they choose outside the HMO Tier or Participating Provider Tier. Members pay deductibles, coinsurance, and any difference between the cost of the service and payment provided. Out-of-pocket costs are generally the highest under this tier.
- Learn more about what’s included in the HMO Tier, Participating Provider Tier, and Non-Participating Provider Tier, and how they work.
- The POS Plan also includes: preventive care, pharmacy services, worldwide coverage, and customized case management services for serious health conditions.
Employer and broker frequently asked questions
What are the pharmacy choices under the POS Plan?
Members have several choices for having their prescriptions filled.
- Most Kaiser Permanente facilities have on-site pharmacies. Members can fill prescriptions written by providers in the HMO Tier, Participating Provider Tier, and Non-Participating Provider Tier at Kaiser Permanente pharmacies, at the lowest out-of-pocket cost. KPIC has contracted with MedImpact to fill outpatient prescriptions at participating retail pharmacies—including Rite Aid, Walgreens, Kroger and many supermarket chains. (Not all pharmacies in a chain may participate).
- Members can also choose to receive prescriptions by mail at Kaiser Permanente medical offices.*
- Learn more about pharmacy services.
What are guidelines regarding precertification?
- For care with participating providers and non-participating providers, members must obtain precertification for inpatient services, and certain outpatient surgeries, services, and procedures.
- Learn more about precertification.
How are new members on-boarded?
- Onboarding includes: Comprehensive New Member Handbooks, an onboarding call from Customer Service agents, and a help line for any questions, from accessing care to transferring prescriptions.
Who do we contact for product pricing or to purchase a POS plan?
- Please contact your Kaiser Permanente representative.
Who processes claims?
- The plans that underwrite the HMO Tier, Participating Provider Tier, and Non-Participating Provider Tier, process the claims:
- Kaiser Foundation Health Plan of California, Inc. (KFHP CA), underwrites the HMO Tier of the plan.
- Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc., underwrites the Participating Provider Tier and Non-Participating Provider Tier.
*A program operated or arranged by a health plan distributes prescription drugs to members via mail. Some medications are not eligible for the Mail Service Delivery Program. These may include, but are not limited to, drugs that are time or temperature sensitive, drugs that cannot legally be sent by U.S. mail, and drugs that require professional administration or observation.