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Kaiser Permanente Dual Complete Plan 1 MD (HMO D-SNP)
The Centers for Medicare & Medicaid Services (CMS) publishes annual Star Ratings that reflect how each Medicare Advantage plan performs across a range of metrics, using a system of one to five stars.
$0.00
Monthly Premium
Kaiser Permanente Dual Complete Plan 1 MD (HMO D-SNP) is a HMO D-SNP plan offered by Kaiser Foundation Health Plan, Inc.
Plan ID: H2172-016
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Medicare beneficiaries may find it helpful to review available Medicare Advantage plans in their area. Medicare Advantage plans are designed to combine the coverage offered from Original Medicare (Medicare Part A and Part B) while also offering additional benefits.
Many Medicare Advantage plans may cover prescription drug coverage as well as additional benefits such as Dental, Vision and Hearing.
Learn more about Medicare Advantage plans such as Kaiser Permanente Dual Complete Plan 1 MD (HMO D-SNP) - H2172-016 by Kaiser Foundation Health Plan, Inc. as well as other Medicare Advantage plans available in your area.
$0.00
Monthly Premium
Maryland Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $210 |
| Out of Pocket Max |
In-Network: $0 Out-of-Network: N/A |
| Initial Coverage Limit | $0 |
| Catastrophic Coverage Limit | $2100 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Coinsurance for Primary Care Office Visit $0% or$ 20% |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Coinsurance for Physician Specialist Office Visit $0% or$ 20% Prior Authorization Required for Doctor Specialty Visit Referral Required for Doctor Specialty Visit |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $0 or $2080 Prior Authorization Required for Acute Hospital Services Referral Required for Acute Hospital Services Members admitted and discharged on the same day pay a copayment for one day. |
| Urgent Care | Urgent Care: Copayment for Urgent Care $0 or $40 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $0 or $40 |
| Emergency Room Visit | Emergency Care: Copayment for Emergency Care $0 or $115 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 0 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $0 or $115 Copayment for Worldwide Emergency Transportation $0 |
| Ambulance Transportation | In-Network: Ground Ambulance: Coinsurance for Ground Ambulance Services $0% or$ 20% Air Ambulance: Coinsurance for Air Ambulance Services $0% or$ 20% Prior Authorization Required for Air Ambulance |
Health Care Services and Medical Supplies
Kaiser Permanente Dual Complete Plan 1 MD (HMO D-SNP) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In-Network: Chiropractic Services: Coinsurance for Medicare-covered Chiropractic Services 0% or 20% Prior Authorization Required for Chiropractic Services Referral Required for Chiropractic Services |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0 Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 0% or 20% |
| Durable Medical Equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20% Prior Authorization Required for Durable Medical Equipment The minimum coinsurance applies to ultraviolet light therapy equipment for psoriasis treatment. The maximum coinsurance applies to all other DME. |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Coinsurance for Medicare-covered Diagnostic Procedures/Tests 0% or 20% Coinsurance for Medicare-covered Lab Services 0% or 20% Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Referral Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Coinsurance for Medicare-covered Diagnostic Radiological Services 0% or 20% Coinsurance for Medicare-covered Therapeutic Radiological Services 0% or 20% Coinsurance for Medicare-covered X-Ray Services 0% or 20% |
| Home Health Care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Referral Required for Home Health Services |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $0 or $2080 Prior Authorization Required for Psychiatric Hospital Services Referral Required for Psychiatric Hospital Services Members admitted and discharged on the same day pay a copayment for one day. |
| Mental Health Outpatient Care | In-Network: Outpatient Mental Health Services: Coinsurance for Medicare-covered Individual Sessions 0% or 20% Coinsurance for Medicare-covered Group Sessions 0% or 20% |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Coinsurance for Medicare Covered Outpatient Hospital Services 0% to 20% Prior Authorization Required for Outpatient Hospital Services Referral Required for Outpatient Hospital Services The minimum coinsurance applies to surgical procedures performed during a screening colonoscopy and diagnostic colonoscopies in response to a positive gFOBT, FIT, or sigmoidoscopy. The maximum coinsurance applies to all other services. Outpatient Observation Services: Coinsurance for Medicare Covered Observation Services 0% to 20% Prior Authorization Required for Outpatient Observation Services The minimum coinsurance applies to observation stays incident to other outpatient hospital services such as an ER visit or outpatient surgery. The maximum coinsurance applies when admitted directly to the hospital for observation. Ambulatory Surgical Center Services: Coinsurance for Ambulatory Surgical Center Services 0% or 20% Prior Authorization Required for Ambulatory Surgical Center Services Referral Required for Ambulatory Surgical Center Services |
| Outpatient Substance Abuse Care | In-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare-covered Individual Sessions 0% or 20% Coinsurance for Medicare-covered Group Sessions 0% or 20% Prior Authorization Required for Outpatient Substance Abuse Services Referral Required for Outpatient Substance Abuse Services |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0
Benefit will be available on the same debit card as the food & produce benefit. |
| Podiatry Services | In-Network: Podiatry Services: Coinsurance for Medicare-Covered Podiatry Services 0% or 20% Prior Authorization Required for Podiatry Services Referral Required for Podiatry Services |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $218 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services Referral Required for Skilled Nursing Facility Services |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network:
Copayment for Oral exams $0
Copayment for Dental x-rays $0
Copayment for Other diagnostic services $0
Copayment for Fluoride treatment $0
Copayment for Other preventive services $0 Copayment for Endodontics $0 Copayment for Periodontics $0 Copayment for Prothodontics, removable $0 Copayment for Prothodontics, fixed $0 Copayment for Maxillofacial surgery $0 Copayment for Adjunctive general services $0 Maximum Plan Benefit of $1,500 every year (combined with Preventive Dental) |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Eye Exams: Coinsurance for Medicare Covered Benefits 0% to 20% Coinsurance for Routine Eye Exams 0% or 20% Prior Authorization Required for Eye Exams Referral Required for Eye Exams The minimum coinsurance applies to diabetic retinopathy services. The maximum coinsurance applies to services rendered by an ophthalmologist. Eyewear: Coinsurance for Medicare-Covered Benefits 0% or 20% Copayment for Contact Lenses $0 Copayment for Eyeglasses (lenses and frames) $0 Copayment for Eyeglass Lenses $0 Copayment for Eyeglass Frames $0 Maximum Plan Benefit of $300 every two years Referral Required for Eyewear |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Coinsurance for Medicare Covered Benefits 0% or 20% Copayment for Fitting/Evaluation for Hearing Aid $0 Prior Authorization Required for Hearing Exams Referral Required for Hearing Exams Hearing Aids: Copayment for Hearing Aids $0
|
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit |
Prescription Drug Costs and Coverage
The Kaiser Permanente Dual Complete Plan 1 MD (HMO D-SNP) plan offers the following prescription drug coverage, with an annual drug deductible of $210 (excludes Tiers 1 and 2) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $210 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $210 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $210 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|