What are the advantages of an HMO plan? There are several advantages when you belong to an HMO plan. Generally, 1) You do not need to submit claim forms and wait to be reimbursed by the plan; 2) Your HMO provider obtains any needed pre authorization for you; and 3) In most cases, you only pay a copayment (you do not owe any more payments for the covered services).
How do I choose a primary care doctor? When you enroll on Kaiser, you do not need to choose a primary care doctor although it is highly encouraged (you can request appointments with the PCP of your choice when you call Member Services to schedule your appointment). Your primary care doctor will be the first doctor you see for all your health care needs. If you need special kinds of care, this doctor will refer you to other kinds of health care providers.
Do I have to choose a primary care physician? Although you can get care at any Kaiser Permanente facility, it is recommended that you select a personal physician at the medical facility that you’ll go to most often. You can select a personal physician from Kaiser’s Adult or Internal Medicine, Obstetric/Gynecology and Pediatrics departments. Whatever department you choose, you’ll receive preventive care, regular immunizations, health screenings, and diagnosis and treatment of your medical conditions. You can choose your personal physician by phone or through Kaiser’s website. Go to www.kp.org/mydoctor and click on “select a personal physician.”
What is the best way to schedule an appointment? You may schedule appointments by calling Kaiser Member Services (800-464-4000) or online at: members.kp.org. Before scheduling appointments online you’ll need to register and Kaiser will mail a password to your home. Once you have your password you can begin scheduling appointments online
What if I need to see a specialist? Your personal physician will refer you to a Plan specialist when he/she feels that you need specialty care. However, you do not need a referral for Optometry, Psychiatry and Chemical Dependency Services.
What is a copayment? A copayment or copay is a set fee that you must pay for the use of specific medical services covered by the insurance plan. Copayments are generally set for medical office visits, emergency room visits, hospital admissions and prescriptions.
What are standing referrals? If you have a condition or disease that requires continuing care from a specialist or is life-threatening, degenerative, or disabling (including HIV or AIDS), your primary care doctor may give you a standing referral to a specialist or specialty care center. The referral will be made if your primary care doctor, in consultation with you, and a specialist or specialty care center, if any, determines that continuing specialized care is medically necessary for your condition or disease.
What happens in an emergency? In a true emergency, get the care you need as quickly as you can. If you are able, contact Member Services at the number on your identification card, even in an emergency. However, even if you are unable to contact Member Services, get the care you need. Even if you need to go out of network, your plan will cover emergency care at in network benefit levels as long as you follow the plan rules.
Check to see how your plan defines a true emergency. Examples typically include severe bleeding, chest pain, and unconsciousness (life or limb threatening).
How are emergencies handled? If you need emergency services, get the medical care you need right away by calling 911 or going to the nearest hospital. Kaiser covers emergency care from Plan providers and non-Plan providers (emergency care is defined as a medical or psychiatric condition that manifests itself by acute symptoms of sufficient severity such that you could reasonably expect the absence of immediate medical attention to result in serious jeopardy to your health or serious impairment of your bodily functions or organs; or if you are in active labor and there isn’t enough time for safe transfer to a Plan hospital before delivery or if transfer poses a threat to you or your unborn child’s health and safety). If you are admitted to a non-Plan hospital, you must notify Kaiser within 24 hours or as soon as reasonably possible.
How does an HMO work when I obtain care outside the HMO? Generally, HMO plans do not cover services provided outside the HMO except in certain emergency situations.
What if I am unsure whether to visit an Urgent Care Center or the Emergency Room?
You may contact a Kaiser registered nurse for advice 24 hours a day, seven days a week. The nurses can help assess your symptoms and provide advice over the phone when medically appropriate. They can also answer questions about medical problems, help you decide what to do next, or make a same-day or next-day appointment for you. To reach an advice nurse, simply call your physician’s office.
What happens if I need care while I'm traveling?
If you are traveling outside of your Kaiser service area, you should order a Travel Kit. This kit will tell you how to get care, what kind of care is covered, and what to do if you’re admitted to a non-Kaiser facility. To order a Travel Kit, contact Member Services (800-464-4000). Please order this kit at least two weeks before you travel to ensure you receive it in time.
If it's not an emergency and you need care while traveling, call Member Services at the number on your identification card. Member Services can refer you to an in network provider (if available).
In a true emergency, get the care you need as quickly as you can. If you are able, contact Member Services at the number on your identification card, even in an emergency. However, even if you are unable to contact Member Services, get the care you need. Even if you need to go out of network, your plan will cover emergency care at in network benefit levels as long as you follow the plan rules.
Check to see how your plan defines a true emergency. Examples typically include severe bleeding, chest pain, and unconsciousness (life or limb threatening).
More Questions? Contact the Benefits Department or call our insurance broker, PSW Benefit Resources at 877-866-2623.