Kaiser Permanente Medicare Advantage Liberty (HMO)
Kaiser Permanente Medicare Advantage Liberty (HMO) H2172-005 Plan Details
Kaiser Permanente Medicare Advantage Liberty (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Kaiser Foundation Health Plan, Inc.
Plan ID: H2172-005
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$0.00
Monthly Premium
Kaiser Permanente Medicare Advantage Liberty (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Kaiser Foundation Health Plan, Inc.
Plan ID: H2172-005
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
District of Columbia Counties Served
Maryland Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $-1 |
| Out of Pocket Max |
In-Network: $6900 Out-of-Network: N/A |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $15.00 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $40.00 Prior Authorization Required for Doctor Specialty Visit Referral Required for Doctor Specialty Visit Prior authorization required |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $300.00 per day for days 1 to 5 $0.00 per day for days 6 to the end of your stay Prior Authorization Required for Acute Hospital Services Referral Required for Acute Hospital Services Prior authorization required |
| Urgent Care | Copayment for Urgent Care $40.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $40.00 |
| Emergency Room Visit | Copayment for Emergency Care $100.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital Worldwide Coverage: Copayment for Worldwide Emergency Coverage $100.00 Copayment for Worldwide Emergency Transportation $250.00 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $250.00 Air Ambulance: Copayment for Air Ambulance Services $250.00 Please see Evidence of Coverage for Prior Authorization rules Prior authorization required |
Health Care Services and Medical Supplies
Kaiser Permanente Medicare Advantage Liberty (HMO) 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: Copayment for Medicare-covered Chiropractic Services $15.00 Prior Authorization Required for Chiropractic Services Referral Required for Chiropractic Services Prior authorization required |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0.00 Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% Prior Authorization Required for Diabetic Supplies and Services Prior authorization required |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20% Prior Authorization Required for Durable Medical Equipment Prior authorization required |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 Copayment for Medicare-covered Lab Services $0.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Referral Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $10.00 to $150.00 Copayment for Medicare-covered Therapeutic Radiological Services $40.00 Copayment for Medicare-covered X-Ray Services $10.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services Referral Required for Outpatient Diag/Therapeutic Rad Services Prior authorization required |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services Referral Required for Home Health Services Prior authorization required |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $300.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Prior Authorization Required for Psychiatric Hospital Services Referral Required for Psychiatric Hospital Services Prior authorization required |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $20.00 Copayment for Medicare-covered Group Sessions $10.00 Prior Authorization Required for Outpatient Mental Health Services Prior authorization required |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $200.00 Prior Authorization Required for Outpatient Hospital Services Referral Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $0.00 to $200.00 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $200.00 Prior Authorization Required for Ambulatory Surgical Center Services Referral Required for Ambulatory Surgical Center Services Prior authorization required |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $20.00 Copayment for Medicare-covered Group Sessions $10.00 Prior Authorization Required for Outpatient Substance Abuse Services Referral Required for Outpatient Substance Abuse Services Prior authorization required |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $30.00 every three months Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $40.00 Prior Authorization Required for Podiatry Services Referral Required for Podiatry Services Prior authorization required |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $203.00 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services Referral Required for Skilled Nursing Facility Services Prior authorization required |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Preventive Dental: Copayment for Office Visit $0.00 to $40.00 Office Vists include:
Comprehensive Dental: Copayment for Medicare-covered Benefits $40.00 Copayment for Diagnostic Services $0.00 Maximum Plan Benefit of $500.00 every year for Non-Medicare Covered Comprehensive Prior Authorization Required for Comprehensive Dental Referral Required for Comprehensive Dental Prior authorization required |
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 $0.00 to $40.00 Copayment for Routine Eye Exams $15.00 to $40.00 Prior Authorization Required for Eye Exams Referral Required for Eye Exams Eyewear: Coinsurance for Medicare-Covered Benefits 20% Prior Authorization Required for Eyewear Referral Required for Eyewear Prior authorization required |
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 $40.00 Copayment for Fitting/Evaluation for Hearing Aid $0.00 Prior Authorization Required for Hearing Exams Referral Required for Hearing Exams Prior authorization required |
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 |
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