Kaiser Permanente’s KP Plus gives employees Kaiser’s integrated care with a limited option to see doctors outside the network, which makes it a real alternative to a PPO for some employers.
Many business owners rule Kaiser out because they worry employees will not accept a closed network. KP Plus changes that conversation. Members keep the coordinated care Kaiser is known for, and they get a safety valve for the times they want to see someone else. Here is how it works, where the limits are, and what to ask before you consider it at renewal.
How KP Plus works
For care from Kaiser Permanente doctors, facilities, and affiliated providers, KP Plus works like a conventional managed plan with predictable costs. Members get:
- Set copays and coinsurance for most covered services
- $0 preventive care, including routine physicals, well-child visits, and certain screenings
- 24/7 phone and video visits with Kaiser Permanente clinicians
- Anytime access to kp.org to view most lab and test results, schedule routine appointments, and manage prescriptions
A deductible may apply depending on the plan the employer chooses.
Out-of-network flexibility, and its limits
The feature that separates KP Plus from a standard HMO is a capped amount of out-of-network care each year:
- Up to 10 out-of-network doctor visits or outpatient medical services per year, including lab and imaging
- Up to five prescription fills per year, with some restrictions
- No referrals or prior authorization needed, and services are available when members travel
The cap is the part employers should explain clearly to employees. Out-of-network charges do not count toward the member’s deductible, if one applies. Members may have to pay in full at the time of service and submit a claim for reimbursement, and they may owe any amount billed above what the plan covers. Not every service is available outside Kaiser and its affiliated providers. Inpatient care, outpatient surgery, maternity, and prenatal care are among the exclusions, so members should check their Evidence of Coverage for details.
Making the most of the benefit
Members stretch the out-of-network allowance furthest when they use Kaiser for routine care and route labs, imaging, and prescriptions back to Kaiser. If an out-of-network provider orders a lab or imaging test, the member can upload the order on kp.org and it is routed to a Kaiser facility. Out-of-network providers can also send prescriptions electronically to any Kaiser pharmacy.
| Service | Use an out-of-network provider | Route it back to Kaiser |
|---|---|---|
| Office visit | Higher copay or coinsurance; counts toward the 10-service limit | Not applicable |
| Lab or imaging | Higher copay or coinsurance; counts toward the 10-service limit | Upload the order on kp.org; lower copay or coinsurance; does not count toward the limit |
| Prescription | Higher copay or coinsurance; counts toward the 5-fill limit | Ask the provider to e-prescribe to a Kaiser pharmacy; lower copay or coinsurance; does not count toward the limit |
A member who sees an outside doctor but sends the lab work and prescription to Kaiser uses one of 10 services and none of the five fills, and pays less overall.
Is KP Plus right for your group?
KP Plus fits best when most of your employees live near Kaiser facilities and would rarely need to go elsewhere, but you want to offer more than a closed network. It is a weaker fit if many employees rely on specific outside specialists, or if your workforce is spread across areas Kaiser does not serve.
Before you consider it at renewal, ask your broker:
- Is KP Plus available to a group of our size, and in our service area?
- How do premiums compare with our current PPO for the same contribution strategy?
- Which deductible and copay options apply to the KP Plus plans offered to us?
- How will we explain the 10-service and five-fill limits, and the exclusions, to employees at open enrollment?
- What share of our employees already use Kaiser or live within its network?
Benefits and availability vary by plan and region, so confirm details in the Evidence of Coverage before you decide. Talk with your Maxwell Agency advisor to see how KP Plus compares with your current options.