Choice Products Northwest

For Members

Understanding Your Plan and Benefits

Our PPO Plus® plans provide members living outside the Kaiser Permanente NW service area with access to a contracted network or any licensed provider they choose.

With PPO Plus®, there are 2 tiers, or levels of benefit, to choose from: preferred provider organization (PPO) network, or non-participating provider.

 

 

Preferred Provider Organization (PPO) Network Tier

This tier is served by First Choice Health, First Health Network, and Kaiser Permanente providers and facilities. Your copay, coinsurance, and deductible are at the same level, regardless of which PPO provider or PPO facility you choose. This tier provides care at the lowest out-of-pocket costs.

To find a participating provider or confirm if your current provider is part of the network, please visit our customized network locators.

First Choice Health Network
(Members receive care in OR, WA, ID, MT, WY, ND, SD, and AK.)

First Health Network
(Members receive care in all states EXCEPT OR, WA, ID, MT, WY, ND, SD, and AK.)

Kaiser Permanente

If you have any questions or need help with any of the PPO providers, you may contact their customer support at:

First Choice Health Network
1-800-467-5281

First Health Network
1-888-685-7774

Kaiser Permanente
1-866-616-0047 (TTY 711)

Features and benefits of our plan:

    • Out-of-pocket costs. With this tier, you’ll pay the least out-of-pocket, with a lower or no deductible.
    • Emergency care. You are covered for emergency care anywhere, worldwide.
    • No-cost preventive care. In this tier, you pay $0 for preventive care. That includes routine physicals, well-child visits, and certain screenings and tests (such as mammograms).
    • First Choice Health Network, First Health Network, or Kaiser Permanente Network. You can choose to receive your medical care through a provider contracted within the First Choice Health Network or the First Health Network. Or you can use a Kaiser Permanente provider.
    • A wide network of contracted providers. The PPO Network consist of doctors, hospitals, specialists, laboratories, and physical therapists across the country.
    • Specialty care. Most First Choice Health Network or First Health Network providers do not require a referral for specialty care. However, this is determined by the specialty provider so please inquire with them when scheduling your appointment. Your participating provider must obtain prior authorization for certain services and treatments* such as:
      • Inpatient hospital stay
      • Outpatient surgery
      • Home health, hospice, and skilled nursing facility services
      • Imaging services
      • Please review your Evidence of Coverage (EOC) for plan details
    • Behavioral health. You can receive care for mental health and drug or alcohol dependency from a provider in the Preferred Provider Organization (PPO) Network.*
    • Hospital care. You can receive inpatient hospitalization services from the PPO Network hospitals and facilities. Your participating provider may make arrangements for your hospital admission
      • NOTE: Not all providers contracted in the Preferred Provider Organization (PPO) provider tier have admitting privileges with participating hospitals. Please confirm the facility and providers are contracted with the network or you may pay higher out-of-pocket costs.
    • Maternity care. You can choose a PPO Network provider for your obstetric care.
    • Lab tests and imaging. You can choose a PPO Network provider for lab tests and imaging.
    • Pharmacy services. Learn about your pharmacy benefits on the pharmacy page.

For additional information on what is covered under the Preferred Provider Organization (PPO) provider tier:

  •  Refer to your Evidence of Coverage (EOC).
  • Contact the human resources/benefits representative where you work, if your employer provides your coverage.
  • Call the PPO Plus Contact Center at 1-866-616-0047 (TTY 711).

*Inpatient and certain outpatient services are subject to prior authorization. Your participating provider must call 1-855-281-1840 (TTY 711) for prior authorization. Failure to get prior authorization will result in greater out-of-pocket cost to you.

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

For its PPO Provider Network, Kaiser Permanente has contracted with First Choice Health Network or First Health Network. The list of participating First Choice Health Network or First Health Network providers is subject to change without notice.

Non-Participating Provider Tier

Any other licensed provider or physician

Choose a non-participating provider nationwide. Non-participating providers include any licensed providers who are not PPO providers. This tier has higher out-of-pocket costs.

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 PPO provider tier).
  • Using non-participating providers means higher out-of-pocket costs. Your out-of-pocket costs will be the highest when you choose to receive care from a non-participating provider or facility. When using a non-participating provider or facility, you will be responsible for the amount you are billed above the maximum allowable charge set out in your Evidence of Coverage (EOC) — this is referred to as balance billing. These charges billed directly by your provider do not apply to your deductible or out-of-pocket maximum.
  • Behavioral health. You can receive care from any licensed behavioral health or chemical dependency professional for mental health and drug or alcohol dependency.*
  • Hospital care. You can receive inpatient hospitalization services from licensed or accredited hospitals and facilities that are not in the PPO provider tier.
  • Emergency care. You can visit any licensed non-participating emergency care facility. Emergency care is covered at the PPO Provider Network tier benefit level, and you will be responsible only for the PPO Network tier cost share, regardless of where you seek emergency care.
  • Urgent care. You can visit any licensed non-participating urgent care facility.
  • Maternity care. You can choose any licensed provider for obstetric care.
  • Lab tests and imaging. You can choose any licensed provider for lab tests and imaging.
  • Pharmacy services. Learn about your pharmacy benefits on the pharmacy page.

For additional information on what is covered under the non-participating provider tier:

  • Refer to your Evidence of Coverage (EOC).
  • Contact the human resources/benefits representative where you work, if your employer provides your coverage.

Call the PPO Plus Contact Center at 1-866-616-0047 (TTY 711).

*Inpatient and certain outpatient services are subject to prior authorization. Your non-participating provider must call 1-855-281-1840 (TTY 711) for prior authorization. Failure to get prior authorization will result in greater cost to you.

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

 

Balance Billing

If you use an out-of-network (or non-participating) provider, it is important that you understand balance billing. Balance billing can mean significant out-of-pocket costs for you.

What is balance billing?

Balance billing is the difference between what an out-of-network provider charges for a service and what Medicare will reimburse for that service. What Medicare will reimburse for the service is called an “allowed amount.”

For example, if an out-of-network provider charges $100 and the allowed amount is $70, the provider can balance-bill you directly for the difference — in this case, $30. You will be responsible for paying all amounts above the allowed amount.

This is one reason why it’s generally less expensive to use in-network providers (a Kaiser Permanente provider or a provider in Kaiser Permanente’s First Choice Health or First Health Network). In-network providers cannot bill you above the allowed amount.

Other things to know about balance billing:

  • Your deductible 
    • Balance-billed amounts do not accumulate to your deductible.
  • Your out-of-pocket maximum 
    • Although your plan has an out-of-pocket maximum, it does not apply to balance-billed charges from an out-of-network provider. This means you could end up paying above your annual out-of-pocket maximum to cover the cost of a service.
  • Billing
    • You could receive a bill in the mail at any time after your service.Let’s say you have a $3,500 out-of-pocket maximum for the year. During that year, you have an office visit ($30 in network versus 20% coinsurance out of network) and surgery ($500 copay in network versus 35% coinsurance out of network) with an out-of-network provider:

Example

Let’s say you have a $3,500 out-of-pocket maximum for the year. During that year, you have an office visit ($30 in network versus 20% coinsurance out of network) and surgery ($500 copay in network versus 35% coinsurance out of network) with an out-of-network provider:

In this scenario, you must pay $70,750 out of pocket even though your out-of-pocket maximum is $3,500.

Please contact Member Services at 1-866-616-0047 (TTY 711) for more information.