This Plan is a health maintenance organization (HMO). OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards. Kaiser Foundation Health Plan, Mid-Atlantic States, Inc. holds the following accreditations: National Committee for Quality Assurance (NCQA). To learn more about this plan’s accreditation, please visit the following website: www.ncqa.org. We require you to use specific physicians, hospitals, and other providers. Through the Mid-Atlantic Permanente Medical Group, PC (Medical Group), we will coordinate your healthcare services, including among other things, when care is medically necessary and what treatment is appropriate. You have the ability to choose your Primary Care Physician (PCP) within the Medical Group. You will receive most of your care through these providers and at our facilities unless we have issued you a referral to another Plan provider. We are solely responsible for the selection of providers in your area. Contact us for a copy of our most recent provider directory. We give you a choice of enrollment in a High Option, Standard Option or Prosper.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. We follow the procedures for determining whether a service is medically necessary and a covered benefit described in this brochure when reviewing any prescribed course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You pay only the copayments, coinsurance and deductibles described in this brochure. When you receive emergency or other authorized services from non-Plan providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will be available, remain under contract with us, or be appropriate to care for you.
Questions regarding what protections apply may be directed to us at 877-KP4-FEDS (877-574-3337). You can also read additional information from the U.S. Department of Health and Human Services at www.healthcare.gov.
General features of our High Option, Standard Option and Prosper
How we pay providers
For the majority of our services, we contract with the Medical Group, and select hospitals to provide the benefits in this brochure. In addition, we may contract with a limited number of other physicians. These Plan providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (copayments, coinsurance, deductibles, and non-covered services and supplies).
Your rights and responsibilities
OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information about us, our providers, and our facilities. OPM's FEHB website www.opm.gov/healthcare-insurance lists the specific types of information that we must make available to you. Some of the required information is listed below.
- We are a health maintenance organization that has provided healthcare services to the Washington, DC and Baltimore, Maryland metropolitan areas since 1972.
- This medical benefit plan is provided by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. Medical, hospital and administrative services are provided through our integrated healthcare delivery organization known as Kaiser Permanente. Kaiser Permanente is composed of Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (a Maryland-based non-profit/not-for-profit organization) and the Mid-Atlantic Permanente Medical Group, P.C. (a for-profit Maryland-based corporation) which provides services in Plan medical offices throughout the Washington, DC and Baltimore, Maryland metropolitan areas.
You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. You can view the complete list of these rights and responsibilities by visiting our Kaiser Permanente Mid-Atlantic States website at www.kp.org/feds. You can also contact us to request that we mail a copy to you.
If you want more information, please call us at 877-KP4-FEDS (877-574-3337) (TTY: 711), or write to Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., Member Services Department, 2101 East Jefferson Street, Rockville, Maryland, 20852. You may also visit our website at www.kp.org/feds.
By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI, visit our website at www.kp.org/feds to obtain our Notice of Privacy Practices. You can also contact us to request that we mail you a copy of that Notice.
Language interpretation services
Language interpretation services are available to assist non-English speaking members. When you call Kaiser Permanente to make an appointment or talk with a medical advice nurse or member services representative, if you need an interpreter, we will provide language assistance.
Your medical and claims records are confidential
We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies.
To enroll in this Plan, you must live in or work in our service area. This is where our providers practice. Our service area is:
- The District of Columbia
- Virginia - The following cities and counties: Alexandria City, Arlington, Fairfax City, Fairfax, Falls Church City, Fredericksburg City, King George, Loudoun, Manassas City, Manassas Park City, Prince William, Spotsylvania, Stafford
- Portions of the following Virginia counties, as indicated by the ZIP codes below, are also within the service area:
- Caroline - 22408, 22446, 22535, 22538, 22546, 22580 and 23015
- Culpepper - 22407, 22736
- Fauquier - 20115, 20116, 20117, 20119, 20128, 20137, 20138, 20139, 20140, 20144, 20181, 20184, 20185, 20186, 20187, 20188, 20198, 22406, 22556, 22639, 22642, 22643, 22720, 22728 and 22739
- Hanover - 22546, 23015 and 23024
- Louisa - 23015, 23024, 23117 and 23170
- Orange - 22508, 22551, 22567 and 22960
- Westmoreland - 22443 and 22485
- Maryland - The following cities and counties: Anne Arundel, Baltimore City, Baltimore, Carroll, Harford, Howard, Montgomery, Prince Georges
- Portions of the following Maryland counties, as indicated by the ZIP codes below, are also within the service area:
- Calvert - 20610, 20639, 20678, 20689, 20714, 20732, 20736 and 20754
- Charles - 20601, 20602, 20603, 20604, 20607, 20612, 20613, 20616, 20617, 20637, 20640, 20643, 20645, 20646, 20658, 20675, 20677 and 20695
- Frederick - 20842, 20871, 21701, 21702, 21703, 21704, 21705, 21709, 21710, 21714, 21716, 21717, 21718, 21754, 21755, 21757, 21758, 21759, 21762, 21769, 21770, 21771, 21774, 21775, 21776, 21777, 21790, 21791, 21792 and 21793
Ordinarily, you must receive your care from Medical Group and select hospitals. In a limited number of circumstances other physicians and providers may be providing care for you under the direction of the Medical Group. However, we are part of the Kaiser Permanente Medical Care Program, and if you are visiting another Kaiser Permanente service area, you can receive visiting member care from designated providers in that area. See Section 5(h). Wellness and Other Special Features, for more details. We also pay for certain follow-up services or continuing care services while you are traveling outside the service area, as described in Section 5(h); and for emergency care obtained from any non-Plan provider, as described in Section 5(d). Emergency Services/Accidents. We will not pay for any other healthcare services out of our service area unless the services have prior Plan approval.
If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.