How the KPOS Program Works

Under the KPOS program, you have the choice to use your primary care physician (referred care) or use a provider of your choice (self-referred care), but self referred benefits are paid at lower level.   The KPOS Program uses a network of doctors and hospitals that have satisfied certain participation criteria. Certain referral rules apply in order to obtain the highest level of benefits. When you join the KPOS Program, you select a PCP.Your PCP must provide care or give you a referral in order for you to receive the highest level of benefits. If you do not have a referral from your PCP, a reduced level of benefits applies, some services may not be covered and filing a claim form or forms may be necessary. This is a summary of how the KPOS Program works:   You choose a Primary Care Physician (PCP) from an extensive list of participating physicians. This list will be provided to you automatically without charge.   Services you receive from your PCP, and services referred by your PCP, are considered referred care.   No deductibles or coinsurance will be required for referred care. Your out-of- pocket costs for covered referred services are limited to co-payments. You will be responsible for a $15 co-payment for certain services such as office visits and routine physicals ($25 co-payment for a specialist).   You have the freedom to choose any provider you want, but self-referred benefits are paid at a lower level (generally 80% of the reasonable and customary amount as defined below) after the calendar year deductible is met. Thus, your out-of-pocket costs will be higher with self-referred care. You may also have to file claim forms.   No claim forms are required for referred care in most instances. If you require emergency or urgent care outside the service area and you cannot arrange for the provider to bill Keystone, you may have to pay charges and then seek reimbursement. Note: The KPOS Program only covers services that are determined by Keystone (referred services) or QCC (self-referred services) to be "medically necessary" for the condition for which they are provided. It does not cover procedures or treatments determined by KPOS Program to be experimental. There is no annual deductible to meet if you use referred care.