Kaiser Permanente Dual Essential Plan 1 (HMO D-SNP)

4.5 out of 5 stars
$0.00
Monthly Premium

Kaiser Permanente Dual Essential Plan 1 (HMO D-SNP) is a HMO D-SNP plan offered by Kaiser Foundation Health Plan, Inc.

Plan ID: H1170-008

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 Essential Plan 1 (HMO D-SNP) - H1170-008 by Kaiser Foundation Health Plan, Inc. as well as other Medicare Advantage plans available in your area.

$0.00
Monthly Premium

Georgia Counties Served

CherokeeClaytonCobbCowetaDekalbDouglasFayetteForsythFultonGwinnettHenryPauldingRussell

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $615
Out of Pocket Max In-Network: $9250
Out-of-Network: N/A
Initial Coverage Limit $0
Catastrophic Coverage Limit $2100
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0
Referral Required for Doctor Specialty Visit
No referral is required for dermatology, obstetrics, and gynecology.
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $0 or $2000
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 $35

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $0 or $35
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 or $280
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $0 or $280

Air Ambulance:
Copayment for Air Ambulance Services $0 or $280
Prior Authorization Required for Air Ambulance

Health Care Services and Medical Supplies

Kaiser Permanente Dual Essential Plan 1 (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%
In-Network:

Chiropractic Services:
Coinsurance for Medicare-covered Chiropractic Services 0% or 20%
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 canes, crutches, and ultraviolet light therapy 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:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $35
Copayment for Medicare-covered Lab Services $0 to $35
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
Referral Required for Outpatient Diag Procs/Tests/Lab Services
The minimum copayment applies to services provided in a medical office. The maximum copayment applies to services provided in an outpatient hospital setting.

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0 to $290
Coinsurance for Medicare-covered Therapeutic Radiological Services 0% or 20%
Copayment for Medicare-covered X-Ray Services $0 to $35
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 $1880
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:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $300
Prior Authorization Required for Outpatient Hospital Services
The minimum copayment for Medicare-covered Outpatient Hospital Services applies to surgical procedures performed during a screening colonoscopy and diagnostic colonoscopies in response to a positive gFOBT, FIT, or sigmoidoscopy. The maximum copayment for Medicare-covered Outpatient Hospital Services applies to all other services.

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $0 to $300
Prior Authorization Required for Outpatient Observation Services
The minimum copayment for Medicare -covered Observation Services applies to observation stays incident to an ER visit or outpatient surgery. The maximum copayment for Medicare-covered Observation Services applies when admitted directly to the hospital for observation.

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 or $300
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:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0
In-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0
Over-the-counter (OTC) Items
In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0
  • Maximum plan benefit of $100.00 every three months for Over-The-Counter (OTC) Items
Maximum Plan Benefit of $100 every three months
Benefit will be available on the same debit card as the food & produce benefit.
Podiatry Services
In-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $0
Prior Authorization Required for Podiatry Services
Referral Required for Podiatry Services
In-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $0
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:

Medicare Covered Preventive Dental:
Copayment for Office Visit $0

Non-Medicare Covered Preventive Dental:
Copayment for Non-medicare preventive $0
Copayment for Oral exams $0
  • Maximum 2 visits every year
Copayment for Dental x-rays $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Other diagnostic services $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Prophylaxis $0
  • Maximum 2 visits every year
Copayment for Fluoride treatment $0
  • Maximum 2 visits every year
Copayment for Other preventive services $0

Non-Medicare Covered Comprehensive Dental:
Copayment for Non-medicare comprehensive $0
Copayment for Restorative services $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Endodontics $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Periodontics $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Prothodontics, removable $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Prothodontics, fixed $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Maxillofacial surgery $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Adjunctive general services $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0
Copayment for Routine Eye Exams $0
  • Maximum 1 Routine Eye Exams every year

Eyewear:
Copayment for Medicare-Covered Benefits $0
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 $575 every two years

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $0
Copayment for Routine Hearing Exams $0
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0

Hearing Aids:
Copayment for Hearing Aids $0
  • Maximum 2 Hearing Aids every three years
Maximum Plan Benefit of $1,000 every three years

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:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
Tobacco use cessation
Yearly "Wellness" visit

Prescription Drug Costs and Coverage

The Kaiser Permanente Dual Essential Plan 1 (HMO D-SNP) plan offers the following prescription drug coverage, with an annual drug deductible of $615 (excludes Tiers 1 and 2) per year.

Coverage Cost
Coverage & Cost
Annual Drug Deductible $615 (excludes Tiers 1 and 2)
Preferred Generic
  • Standard retail $0.00
  • Standard mail order $0.00
Generic
  • Standard retail $0.00
  • Standard mail order $0.00
Annual Drug Deductible $615 (excludes Tiers 1 and 2)
Preferred Generic
  • Standard retail $0.00
  • Standard mail order $0.00
Generic
  • Standard retail $0.00
  • Standard mail order $0.00
Annual Drug Deductible $615 (excludes Tiers 1 and 2)
Preferred Generic
  • Standard retail $0.00
  • Standard mail order $0.00
Generic
  • Standard retail $0.00
  • Standard mail order $0.00
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