Get answers to important questions about Medicare and Kaiser Permanente Medicare health plans

Throughout the year, the Centers for Medicare & Medicaid Services sends out updates about additional covered services or changes to existing covered services. These notifications are called National Coverage Determinations (NCDs). View the NCDs for the current plan year (PDF).

Medicare is a federal program that provides health coverage to people age 65 and older, and to people with certain disabilities, such as end-stage renal disease.

Medicaid (Medi-Cal in California) is a public program that provides health coverage to people with low incomes.

People who have both Medicare and Medicaid/Medi-Cal coverage may be eligible for extra benefits through a Kaiser Permanente Medicare Medicaid Dual Special Needs Plan (D-SNP). A D-SNP lets you keep your Medicaid/Medi-Cal benefits and includes more benefits than Original Medicare. Visit our Dual Special Needs Plan page anytime to learn more and see if you’re eligible to enroll.

No. You won’t lose Part A and Part B coverage. When you become a member, Kaiser Permanente will provide your Medicare benefits to you. Keep in mind that to sign up for a Kaiser Permanente Medicare health plan, you’ll need to be enrolled in Medicare Part B.

You can't be disenrolled because of your health. Your membership can be ended for other reasons, which may include, but are not limited to:

• Failing to pay your Kaiser Permanente premium, if your plan has one
• Living outside a Kaiser Permanente service area for 90 days to 12 months (depending on your plan)
• Moving permanently out of a Kaiser Permanente service area
• Not staying enrolled in Medicare

See your Evidence of Coverage for causes for disenrollment.

If you bought your previous non-Medicare plan yourself, be sure to cancel it as soon as your enrollment in a Kaiser Permanente Medicare health plan is approved. If you don't, you'll need to pay the premiums for both plans until you cancel your previous plan.

You may have to pay late enrollment penalties if you enroll in Medicare Parts B and D (prescription drug coverage) after your 7-month initial enrollment period.

But you may not have to enroll in Parts B or D if you have qualifying coverage during your initial enrollment period. This can include coverage from current or former employer or union, TRICARE, the Indian Health Service, or the Department of Veterans Affairs. They’re also required to send you with an annual notice of creditable coverage to let you know whether your coverage qualifies.

To find out when you can sign up for Medicare without late enrollment penalties, you can answer a few questions on Medicare.gov.

Yes. In most cases, you're covered for emergency or urgent care from any medical provider while traveling outside a Kaiser Permanente service area, including while traveling outside the U.S. Read more about Travel Coverage (PDF) or visit kp.org/travel.

While you’re temporarily outside a Kaiser Permanente area, coverage is limited to medical emergencies and urgent care. For Kaiser Permanente Senior Advantage (HMO) and Medicare Advantage (HMO) members, renal dialysis services are also covered.

If you're outside a Kaiser Permanente area for more than 3 to 12 months (depending on your plan), or you permanently move outside the area, Medicare requires us to disenroll you from our plan. Call us and we can help you with coverage when you travel or move.

If a state of disaster or emergency in your geographic area is declared, Kaiser Permanente will make every effort to keep our facilities open to care for you.

If there’s a disaster, we'll post information about access to our facilities on kp.org. Read more about Kaiser Permanente’s Disaster Planning Policy.

With a Kaiser Permanente Medicare health plan, you have a range of guaranteed rights and protections, including:

• Timely access to covered services and drugs
• Fair and respectful treatment at all times
• The right to file a complaint
• Security and privacy for your health information
• Clearly explained treatment options and participation in making decisions about your treatment options
• The right to get plan information and treatment explanations in a language or format that works for you (including languages other than English, Braille, large print, and audiotapes)

Find more details in your plan’s documents, such as the Evidence of Coverage, or in the Medicare & You handbook available at medicare.gov. You also can call Medicare at 1-800-MEDICARE (1-800-633-4227) (TTY 711), 24 hours a day, 7 days a week.

To request a coverage decision (also called an organization determination) about medical services you’d like but haven’t received, or about payment of a bill, contact Member Services.

A response for a standard request for care or services can take up to 14 calendar days. A response for a request for payment can take up to 30 days. If your health requires a quick response, you should ask us to make a "fast coverage decision." You, your doctor, or your representative can make the request for medical care. We'll respond to a fast coverage decision within 72 hours. If we say no to your request for coverage for medical care or payment, you can ask for an appeal.

If we say no to your request for coverage for medical care or payment of a bill, you have the right to ask us to reconsider by making a Level 1 Appeal. You’ll need to make your appeal request within 60 calendar days from the date on the written notice we send you with our answer to your request for a coverage or payment decision.

You can appoint a representative to help you. Your representative can be a family member, friend, advocate, attorney, doctor, or someone else who will act on your behalf. Fill out an Appointment of Representative form and send it in with your appeal. Also available in Chinese [中文本] (PDF).

• For a standard appeal, write to Member Services.
• If your health requires a quick response, ask for a "fast appeal" by writing or calling Member Services. You, your doctor, or your representative can do this. If your representative is appealing our decision for you, your appeal must include an Appointment of Representative form authorizing this person to represent you.
  • Within 72 hours for a fast appeal
  • Within 30 calendar days for a standard appeal request for medical care
  • Within 60 calendar days for a standard appeal request for payment of a bill
• If we say no to part or all of your appeal, your case will automatically be sent to Level 2 of the appeals process, which is done by an Independent Review Organization. That organization will review your appeal carefully and give you its decision and reasons for it in writing.

For additional details, see Chapter 9 in your Evidence of Coverage.

If you’re unhappy with the medical care or services you’re getting, or if you’re unhappy with our processes, you can make a complaint. This is also known as filing a grievance. Call or write to Member Services within 60 days of the incident.

We’ll look into your complaint and give you our answer within 30 calendar days. For additional details, see Chapter 9 in your Evidence of Coverage.

To get a summary of information about the appeals and grievances that plan members have filed with Kaiser Permanente, please contact Member Services.

You can also use the online Medicare Complaint Form to send a complaint directly to Medicare.

Protect your identity by knowing how to recognize and report fraud. Don't give your Medicare claim number, or other plan information, to anyone other than your health plan representatives and the medical professionals and facilities that give you care.

Look out for signs of fraud or suspicious offers. For example:

• Bills or statements for care you never got
• Bribes to get you to see an unfamiliar doctor or use services you don't need

Visit the Medicare website for more information on preventing fraud. To report suspected fraud, call the toll-free number 1-877-7SAFERX (1-877-772-3379).

You may end your Medicare health plan membership only during certain times of the year, known as enrollment periods. All members can leave our plan during either the Annual Enrollment Period, the Medicare Advantage Open Enrollment Period, or a Special Enrollment Period. The date your membership ends may vary based on when your request is received or the enrollment period used.

For more information on enrollment periods and to learn how to disenroll, review your Evidence of Coverage or contact Member Services.

Note: If you’re on a group Medicare Advantage plan, your disenrollment options may be different. Contact your group administrator or Member Services.