2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 43 Chapter 3: Using our plan for your medical services What if a specialist or another network provider leaves our plan? We may make changes to the hospitals, doctors, and specialists (providers) that are part of your plan during the year. If your doctor or specialist leaves your plan, you have certain rights and protections that are summarized below: • Even though our network of providers may change during the year, Medicare requires that we furnish you with uninterrupted access to qualified doctors and specialists. • We will notify you that your provider is leaving our plan so that you have time to select a new provider. ♦ If your primary care or behavioral health provider leaves our plan, we will notify you if you have seen that provider within the past three years. ♦ If any of your other providers leave our plan, we will notify you if you are assigned to the provider, currently receive care from them, or have seen them within the past three months. • We will assist you in selecting a new qualified in-network provider that you may access for continued care. • If you are currently undergoing medical treatment or therapies with your current provider, you have the right to request, and we will work with you to ensure, that the medically necessary treatment or therapies you are receiving continue. • We will provide you with information about the different enrollment periods available to you and options you may have for changing plans. • We will arrange for any medically necessary covered benefit outside of our provider network, but at in-network cost-sharing, when an in-network provider or benefit is unavailable or inadequate to meet your medical needs. The appropriate Medical Group designee will authorize the services if they determine that the covered services are medically necessary and are not available from a network provider. Referrals to out-of-network providers will be for a specific treatment plan, which may include a standing referral if ongoing care is prescribed. It specifies the duration of the referral without having to get additional approval from us. Please ask your network provider what services have been authorized if you are not certain. If the out-of-network specialist wants you to come back for more care, be sure to check if the referral covers the additional care. If it doesn't, please contact your network provider. • If you find out your doctor or specialist is leaving your plan, please contact us so we can assist you in finding a new provider to manage your care. • If you believe we have not furnished you with a qualified provider to replace your previous provider or that your care is not being appropriately managed, you have the right to file a quality of care complaint with the QIO, a quality of care grievance to our plan, or both. Please see Chapter 7. 1-877-221-8221 (TTY 711), 7 days a week, 8 a.m. to 8 p.m.