Identification cards | We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider or fill a prescription at a Plan pharmacy. Providers may request photo identification together with your ID card to verify identity. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation letter (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call our Member Services Department at 800-813-2000 (TTY: 711) or write to us at: Membership Administration, Kaiser Permanente, 500 NE Multnomah St., Suite 100, Portland, OR 97232. After registering on our website at www.kp.org/feds, you may also request replacement cards electronically. |
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Where you get covered care | You get care from “Plan providers” and “Plan facilities”. You will only pay cost-sharing as described in Section 4. Your Cost for Covered Services. |
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Balance Billing Protection | FEHB Carriers must have clauses in their Plan provider agreements. These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the Plan provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount. If a Plan provider bills you for covered services over your normal cost share (deductible, copay, co-insurance), contact your Carrier to enforce the terms of its provider contract. |
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Plan providers | Plan providers are physicians and other healthcare professionals in our service area that we employ or contract with to provide covered services to our members. We contract with Northwest Permanente, P.C. (Medical Group) and community physicians and physician groups to provide or arrange covered services for our members. Medical care is provided through physicians, nurse practitioners, physician assistants, and other skilled medical personnel. Specialists in most major specialties are available as part of the medical teams for consultation and treatment. Services by Plan providers are covered when acting within the scope of their license or certification under applicable state law. We credential Plan providers according to national standards.
Benefits are provided under this Plan for the services of covered providers, in accordance with Section 2706(a) of the Public Health Service Act. Coverage of practitioners is not determined by your state’s designation as a medically underserved area.
We list covered providers in our network provider directory, which we update periodically, and available on our website. Directories are available at the time of enrollment or upon request by calling our Member Services Department at 800-813-2000 (TTY: 711).
Benefits described in this brochure are available to all members meeting medical necessity guidelines, regardless of race, color, national origin, age, disability, religion, sex, pregnancy, or genetic information.
This plan provides Care Coordinators for complex conditions and can be reached at 800-813-2000 (TTY: 711) for assistance. |
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Plan facilities | Members may get covered routine care from any Plan provider at any Kaiser Permanente medical office and from any affiliated Plan provider in our service area.
Plan facilities are hospitals, medical offices, and other facilities in our service area that we own or contract with to provide covered services to our members. Kaiser Permanente offers comprehensive healthcare at Plan facilities conveniently located throughout the Portland and Salem areas in Oregon and the Vancouver and Longview-Kelso areas in Washington.
We list Plan facilities in our Medical Directory, with their locations and phone numbers. Directories are updated on a regular basis and are available at the time of enrollment or upon request by calling our Member Services Department at 800-813-2000 (TTY: 711). The list is also on our website at www.kp.org/feds.
You must receive your health services at Plan facilities, except if you have an emergency, prior authorization, or out-of-area urgent care. If you are visiting another Kaiser Permanente service area or allied plan service area, you may receive healthcare services at those Kaiser Permanente facilities. See Section 5(h), Wellness and Other Special Features, for more details. Under the circumstances specified in this brochure, you may receive follow-up or continuing care while you travel anywhere. |
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What you must do to get covered care | It depends on the type of care you need. First, you and each covered family member choose a primary care provider. This decision is important since your primary care provider provides or arranges for most of your healthcare.
To choose or change your primary care provider, you can either select one from our Medical Directory, from our website, www.kp.org/feds, or you can call our Member Services Department at 800-813-2000 (TTY: 711). |
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Primary care | We encourage you to choose a primary care provider when you enroll. Your primary care provider can be a physician, nurse practitioner, or physician assistant and you may select a primary care provider from any of our available Plan providers who practice in these specialties: internal medicine, family medicine, pediatrics, general practice or obstetrics and gynecology. Your primary care provider will provide most of your healthcare, or give you a referral to see a specialist.
Please notify us of the primary care provider you choose. If you need help choosing a primary care provider, call us. You may change your primary care provider at any time. You are free to see other Plan physicians if your primary care provider is not available, and to receive care at other Kaiser Permanente facilities. |
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Specialty care | Specialty care is care you receive from providers other than a primary care provider. When your primary care provider believes you may need specialty care, they will request authorization from the Plan to refer you to a specialist for an initial consultation and/or for a certain number of visits. If the Plan approves the referral, you may seek the initial consultation from the specialist to whom you were referred. You must then return to your primary care provider after the consultation, unless your referral authorizes a certain number of additional visits without the need to obtain another referral. The primary care provider must provide or obtain authorization for a specialist to provide all follow-up care. Do not go to the specialist for return visits unless your primary care provider gives you a referral. However, you may see Plan obstetrician/gynecologists, optometrists, mental health and substance abuse providers, chiropractors, occupational health providers, social worker services and receive cancer counseling without a referral.
Here are some other things you should know about specialty care:
- If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care provider, in consultation with you and your attending specialist, may develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary care provider will use our criteria when creating your treatment plan (the physician may have to get an authorization or approval beforehand).
- If you are seeing a specialist when you enroll in our Plan, talk to your primary care provider. Your primary care provider will decide what treatment you need. If they decide to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.
- If you are seeing a specialist and your specialist leaves the Plan, call your primary care provider, who will arrange for you to see another specialist. You may be able to receive approved services from your current specialist until we can make arrangements for you to see a Plan specialist.
- You may continue seeing your specialist for up to 90 days if you are undergoing treatment for a chronic or disabling condition and you lose access to your specialist because:
- we drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB plan;
- we terminate our contract with your specialist for other than cause; or
- we reduce our service area and you enroll in another FEHB plan;
Contact us at 800-632-9700, or if we drop out of the FEHB Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.
Note: Under certain circumstances and for a limited period of time, we may continue to pay for covered services provided by your Plan physician or a physician you have been referred to by your Plan physician, after the physician’s contract with us terminates. This extension of coverage is available until the earlier of the following dates: The day following the completion of the active course of treatment giving rise to your exercising your continuity of care right; or the 120th day from the date we notify you of the contracts termination. You may qualify for this continuity of coverage if you satisfy all of the following requirements:
- You are a Member on the date you receive the services.
- You are undergoing an active course of treatment that is medically necessary, and you and your treating physician agree that it is desirable to maintain continuity of care.
- We would have covered the services if you had received them from a Plan provider.
- The physician agrees to adhere to the conditions of the terminated contract between the physician and us.
Additionally, this extension of coverage is available if you are in the second trimester of pregnancy, until the later of the following dates: the 45th day after the baby’s birth; or as long as you are receiving active treatment, but not later than the 120th day from the date we notify you of the termination. To apply for this continuity of care extension, you must submit a written request to us.
Note: If you lose access to your specialist because you changed your carrier or plan option enrollment, contact your new plan.
Sex-Trait Modification: If you are mid-treatment under this Plan, within a surgical or chemical regimen for Sex-Trait Modification for diagnosed gender dysphoria, for services for which you received coverage formerly covered under the 2025 Plan brochure, you may seek an exception to continue care for that treatment. Please call our Member Services Department at 800-813-2000 (TTY: 711) or visit kp.org/feds for our exception process.
If you disagree with our decision on your exception, please see Section 8 of this brochure for the disputed claims process.
Individuals under age 19 are not eligible for exceptions related to services for ongoing surgical or hormonal treatment for diagnosed gender dysphoria. |
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Hospital care | Your Plan primary care provider or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility. |
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If you are hospitalized when your enrollment begins | We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our Member Services Department immediately at 800-813-2000 (TTY: 711). If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:
- you are discharged, not merely moved to an alternative care center;
- the day your benefits from your former plan run out; or
- the 92nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment. |
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You need prior Plan approval for certain services | Your primary care provider arranges most referrals to specialists. For certain services your Plan provider must obtain approval from us. Before we approve a referral, we may consider if the service or item is medically necessary and meets other coverage requirements. We call this review and approval process “prior authorization.” Once the referral is approved, we will notify you that we have authorized your referral.
Your Plan provider must obtain prior authorization for:
- Alternative treatments
- Ambulance transport (non-emergency)
- Applied Behavior Analysis (ABA)
- Bariatric surgery
- Certain prescription medications as identified on our formulary
- Cosmetic, reconstructive, and plastic surgery
- Drug formulary exceptions
- Durable medical equipment (DME) and orthopedic and prosthetic devices
- Home health services and hospice care
- Inpatient hospital care services, surgery, and procedures
- Open MRI
- Organ/tissue transplants
- Outpatient surgery and procedures
- Physical, occupational, speech, massage, and rehabilitative therapy services
- Routine foot care services
- Services or items from a non-plan Provider or at non-plan facilities
- Skilled nursing care
- Temporomandibular joint (TMJ)/TMD treatment services
To confirm if a referral has been approved for a service or item that requires prior authorization, please call our Member Services Department at 800-813-2000 (TTY: 711).
Your Plan provider submits the request for the services above with supporting documentation. You should call your Plan provider’s office if you have not been notified of the outcome of the review within 5 working days. If your request is not approved, you have the right to ask us in writing to reconsider our initial decision (see Section 8, The Disputed Claims Process).
Prior authorization determinations are made based on the information available at the time the service or item is requested. We will not cover the service or item unless you are a Plan member on the date you receive the service or item. |
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Non-urgent care claims | For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. We will make our decision within 15 days of receipt of the pre-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.
If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information. |
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Urgent care claims | If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours. If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.
If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know information we need to complete our review of the claim. You will then have up to 48 hours to provide the required information. We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.
We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.
You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 503-813-4480. You may also call OPM’s FEHB 3 at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us at 503-813-4480. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim). |
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Concurrent Care Claims | A concurrent care claim involves care provided over a period of time or over a number of treatments. We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends. If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect.
If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim. |
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Emergency services/accidents and post-stabilization care | Emergency services do not require prior authorization. However, if you are admitted to a non-plan facility, you or your family member must notify the Plan within 48 hours, or as soon as reasonably possible, or your claims may be denied.
You must obtain prior authorization from us for post-stabilization care you receive from non-plan providers.
If your treatment needs to be extended, see Section 5(d), Emergency Services/Accidents for more information. |
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If your treatment needs to be extended | If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim. |
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Maternity care | You do not need precertification of a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are discharged, your physician or the hospital must contact us for precertification of additional days for your baby.
Note: When a newborn requires definitive treatment during or after the mother’s hospital stay, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits. |
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What happens when you do not follow the precertification rules | You must receive your health services at Plan facilities, except if you have an emergency, authorized referral, or out-of-area urgent care. Your primary care provider will provide most of your healthcare, or give you a referral to see a specialist. If you do not obtain a referral from us for services or items that require a referral, we will not pay any amount for those services or items and you may be liable for the full price of those services or items. This also includes any residual amounts, such as deductibles, copayments or coinsurance that are not covered or not paid by any other insurance plan you use to pay for those services or items. |
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Circumstances beyond our control | Under extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care. |
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If you disagree with our pre-service claim decision | If you have a pre-service claim and you do not agree with our prior approval decision, you may request a review in accord with the procedures detailed below. If your claim is in reference to a contraceptive, call our Member Services Department at 800-813-2000 (TTY: 711).
If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8. |
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To reconsider a non-urgent care claim | Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.
In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to do one of the following:
- Precertify your hospital stay or, if applicable, arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply.
- Ask you or your provider for more information.
You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.
3. Write to you and maintain our denial. |
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To reconsider an urgent care claim | In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.
Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request. We will expedite the review process, which allows oral or written request for appeals and the exchange of information by phone, electronic mail, facsimile, or other expeditious methods. |
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To file an appeal with OPM | After we reconsider your pre-service claim. if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure. |
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