Understanding Your Plan & Benefits | Out-of-Area PPO Plan | Kaiser Permanente Georgia (2024)

Participating Providers

Features and benefits of covered care from our participating provider network.

In the Participating Provider Tier, you don’t have to select a personal doctor. You can see participating providers in the PHCS Network for KPIC when in California and other Kaiser Permanente states of Colorado, Georgia, Hawaii, Maryland, Oregon, Virginia, Washington, and the District of Columbia. The Cigna PPO Network is available in all non-Kaiser Permanente states. No referral* is needed for the Participating Provider Tier for either the PHCS Network or Cigna PPO Network.

To find a Participating Provider or confirm if your current provider is part of the Participating Provider Tier, you can search for Providers by Location, or call Customer Service at 1-800-788-0710 (TTY 711), Monday through Friday 7a.m. to 7p.m., Pacific time.

Kaiser Permanente States: The PHCS Networkprovides 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.

• A wide network of contracted providers. The PHCS Network for KPIC consists of doctors, hospitals, specialists, laboratories, and physical therapists nationwide. The Cigna PPO Network refers to doctors, hospitals, specialists contracted as part of the Cigna PPO Network for Shared Administration.
• Out-of-pocket costs. You will probably have lower out-of-pocket costs than in the Non-Participating Tier (such as a deductible, coinsurance, and a copay). Providers are not allowed to bill any balances for covered services.
• Specialty care. You don’t need a referral for specialty appointments with any participating providers. Cigna PPO Network providers are responsible for all precertifications. However, for participating providers in the PHCS Network for KPIC, you must obtain precertification for certain services and treatments* such as:
  • Hospital admissions
  • Outpatient surgeries
  • Inpatient rehabilitation, hospice, or skilled nursing facility services
  • MRI, CT, and PET scans
  • For a complete list of services that require precertification, see your Certificate of Insurance (COI)

• Behavioral health. You can receive care for mental illness, emotional disorders, and drug or alcohol abuse from a participating provider.
• Hospital care. You can receive inpatient hospitalization services from participating providers. Your Participating Provider may make arrangements for your hospital admission. (Important! Not all physicians contracted in the Participating Provider Tier have admitting privileges with participating hospitals). Please confirm the facility is contracted with the network or you may pay higher out-of-pocket costs*. If you are receiving care within California and Kaiser Permanente states, learn more at PHCS Network. If you are receiving care outside of the Kaiser Permanente states, learn more at CignaPPONetwork*
• Emergencycare. You can visit any licensed emergency care facility.
• Urgent care. You can visit any licensed urgent care facility.
• Maternity Care. For your obstetric care* you can choose any participating provider.
• Lab tests, X-rays. You can contact facilities directly. Check first to be sure the facilities are part of the participating provider networks.
• Pharmacy services. Learn aboutyour pharmacy benefitsin the Participating Provider Tier.
• Preventive care. With your plan, most preventive care services are covered at no cost. That includes routine physicals, well-child visits, and certain screenings and tests (such as mammograms).

Non-grandfathered group health plans and health insurance issuers offering non-grandfathered group or individual health insurance coverage are required under Public Health Service Act (PHS Act) section 2713 and California Insurance Code 10112.2 to provide benefits for, and prohibit the imposition of cost-sharing requirements with respect to, the following:

Pre-exposure prophylaxis (PrEP) with effective antiretroviral therapy to persons who are at high risk of HIV acquisition. In addition, the following related services for HIV PrEP initiation and follow-up care are covered:

1. 1. 1. Services for initiation of HIV Prep, including: HIV testing, Kidney function testing, Serologic testing for hepatitis B and C virus, Hepatitis B vaccination, Testing for Sexually Transmitted Infections (STIs), Pregnancy testing (when appropriate).
      2. Follow-up and monitoring services, including: HIV testing every 3 months, office visits to a primary care provider or specialist for prescribing and medication management, Lab testing to monitor effects of medication.

To find out more about what is covered under the Participating Provider Tier.

• For more information on your small group PPO insurance coverage, please refer to the Small Group Transparency in Coverage document.
• See your PPO Member Handbook.
• Refer to your Certificate of Insurance (COI).
• Contact the human resources/benefits officer where you work if your employer provides your coverage.
• Call Customer Service at 1-800-788-0710 (TTY 711), Monday through Friday, 7 a.m. to 7 p.m., Pacific time.

*Inpatient and certain outpatient services are subject to precertification, if using the PHCS Network in California or other Kaiser Permanente states. You are responsible for obtaining precertification. You must call 1-888-251-7052 (TTY 711), Monday through Friday, 6 a.m. to 6 p.m. Pacific time, for precertification. If using the Cigna PPO Network for care in non-Kaiser Permanente states, the Cigna PPO providers are responsible for obtaining precertification on your behalf when precertification is required.

This site provides an overview of your benefits and services. If there are any differences between this document and your COI, your COI will prevail.

For the Participating Provider Network, Kaiser Permanente Insurance Company (KPIC) has contracted with PHCS, Inc., a subsidiary of MultiPlan, Inc. The list of participating PHCS Network for KPIC providers is subject to change without notice.

KPIC has also contracted with the Cigna PPO Network outside of Kaiser Permanente states for health care providers (doctors, hospitals, specialists) contracted as part of the Cigna PPO for Shared Administration.

Cigna is an independent company and not affiliated with Kaiser Foundation Health Plan, Inc., and its subsidiary health plans. Access to the Cigna PPO Network is available through Cigna’s contractual relationship with the Kaiser Permanente health plans. The Cigna PPO Network is provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

Non-Participating Providers

Any licensed provider

Features and benefits of receiving covered care from any licensed provider.

• Provider choice, care anywhere. Your Non-Participating Provider Tier benefits cover care you receive from any licensed provider (who’s not in the Participating Provider Tier).
• Using Non-Participating Providersgenerallymeans higher out-of-pocket costs.Your out-of-pocket costs will generally be the highest when you choose to receive care from aNon-Participating Provider or facility.
• 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 Participating Provider Tier.*
• Emergency care.You can visit any licensed emergency care facility. Emergency care is covered at theParticipating Provider Tier benefit level, and you will be responsible only for the Participating Provider Tier cost share, regardless of where you seek care.
• Urgent care.You can visit any licensed urgent care facility.
• Maternity care.You can choose any licensed provider for obstetric care.*
• Lab tests, X-rays. You can contact facilities directly.

To find out more about what is covered under the Non-Participating Provider Tier:

• For more information on your small group PPO insurance coverage, please refer to the Small Group Transparency in Coverage document.
• See your PPO Member Handbook.
• Refer to your Certificate of Insurance (COI).
• Contact the human resources/benefitsofficerwhere you work if your employer provides your coverage.
• Call Customer Service at 1-800-788-0710 (TTY 711), Monday through Friday, 7 a.m. to 7 p.m., Pacific time.

*Inpatient and certain outpatient services are subject to precertification. Youmust call 1-888-251-7052 (TTY 711), Monday through Friday, 6 a.m. to 6 p.m., Pacific time, for precertification.

This site provides an overview of your benefits and services. If there are any differences between this document and your COI, your COI will prevail.