The PPO 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 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 the PPO Plan offer?
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 less than in 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 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 Insurance Company’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 view a copy of your specific plan documents, 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. The PPO Plan empowers 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 copay with a Participating Provider.
- Pharmacy services. You can have prescriptions filled at participating MedImpact retail pharmacies across the country.
Check here for more about pharmacy services, finding doctors and facilities, and the benefits of the PPO Plan.
Is the PPO Plan right for you?
Here are some examples of how people use their PPO plan to get the care they want:
For employers, the PPO Plan is 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 two 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 the PPO plan 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 PPO Plan works for your company and employees.
With the PPO Plan, you can offer your participating employees two tiers of providers when they receive care:
- 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 Participating Provider Tier. Members pay deductibles, coinsurance, and any difference between the cost of the service and payment provided. Out-of-pocket costs are the highest under this tier.
- Learn more about what’s included in the Participating Provider Tier, and Non-Participating Provider Tier, and how they work.
- The PPO Plan also includes: preventive care, pharmacy services, worldwide coverage, and customized case management services for serious health conditions.
Employers’ frequently asked questions
What are the pharmacy choices under the PPO Plan?
- KPIC has contracted with MedImpact to fill outpatient prescriptions at participating retail pharmacies—including Rite Aid, Safeway, Walgreens, and many supermarket chains. (Not all pharmacies in a chain may participate).
- 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 PPO plan?
- Please contact your Kaiser Permanente representative.
Who processes claims?
- Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc., underwrites and processes claims for the PPO Plan.