Kaiser Permanente Senior Advantage San Diego (HMO)

Kaiser Permanente Senior Advantage San Diego (HMO) H0524-037 Plan Details
5 out of 5 stars

Kaiser Permanente Senior Advantage San Diego (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Kaiser Foundation Health Plan, Inc.
Plan ID: H0524-037

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

$0.00
Monthly Premium

Kaiser Permanente Senior Advantage San Diego (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Kaiser Foundation Health Plan, Inc.
Plan ID: H0524-037

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

Kaiser Permanente Senior Advantage San Diego (HMO) H0524-037 Plan Details
5 out of 5 stars

Kaiser Permanente Senior Advantage San Diego (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Kaiser Foundation Health Plan, Inc.
Plan ID: H0524-037

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

$0.00
Monthly Premium

California Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $1999
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 $0.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0.00
Referral Required for Doctor Specialty Visit
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$0.00 per day for days 1 to 90
Prior Authorization Required for Acute Hospital Services
Referral Required for Acute Hospital Services
Prior authorization required
Urgent Care
Copayment for Urgent Care $0.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $0.00
Emergency Room Visit
Copayment for Emergency Care $135.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $135.00
Copayment for Worldwide Emergency Transportation $200.00
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $200.00

Air Ambulance:
Copayment for Air Ambulance Services $200.00

Health Care Services and Medical Supplies

Kaiser Permanente Senior Advantage San Diego (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 $0.00
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
Referral Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $130.00
Copayment for Medicare-covered Therapeutic Radiological Services $0.00
Copayment for Medicare-covered X-Ray Services $0.00
Referral Required for Outpatient Diag/Therapeutic Rad Services
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Referral Required for Home Health Services
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$0.00 per day for days 1 to 90
Referral Required for Psychiatric Hospital Services
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $0.00
Copayment for Medicare-covered Group Sessions $0.00
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $0.00 to $135.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $0.00
Copayment for Medicare-covered Group Sessions $0.00
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 $50.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $0.00
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$100.00 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
Office Vists include:
    • Maximum 2 visits every year
    Copayment for Oral Exams $0.00
    • Maximum 2 visits every year
    Copayment for Dental X-Rays $0.00
    • Maximum 1 visit (Please see Evidence of Coverage for details)
    Prior Authorization Required for Preventive Dental
    Referral Required for Preventive Dental

    Comprehensive Dental:
    Copayment for Medicare-covered Benefits $0.00
    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
    Copayment for Routine Eye Exams $0.00
    Referral Required for Eye Exams

    Eyewear:
    Copayment for Medicare-Covered Benefits $0.00
    Referral Required for Eyewear

    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 $0.00

    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