Kaiser Permanente Sr Adv Basic Santa Clara (HMO)

Kaiser Permanente Sr Adv Basic Santa Clara (HMO) H0524-062 Plan Details
5 out of 5 stars

Kaiser Permanente Sr Adv Basic Santa Clara (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H0524-062.

$15.00
Monthly Premium

Kaiser Permanente Sr Adv Basic Santa Clara (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H0524-062.

Kaiser Permanente Sr Adv Basic Santa Clara (HMO) H0524-062 Plan Details
5 out of 5 stars

Kaiser Permanente Sr Adv Basic Santa Clara (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H0524-062.

$15.00
Monthly Premium

California Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $6700
Out-of-Network: 0
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
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 $25.00
Referral Required for Doctor Specialty Visit
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 $15.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $15.00
Emergency Room Visit
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $90.00
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 Sr Adv Basic Santa Clara (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 $5.00
Copayment for Medicare-covered Lab Services $0.00 to $5.00
Referral Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $15.00 to $195.00
Copayment for Medicare-covered Therapeutic Radiological Services $0.00
Copayment for Medicare-covered X-Ray Services $15.00
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:
$265.00 per day for days 1 to 5
$0.00 per day for days 6 to the end of your stay
Referral Required for Psychiatric Hospital Services
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $15.00
Copayment for Medicare-covered Group Sessions $7.00
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $290.00

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $0.00 to $90.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $290.00
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $15.00
Copayment for Medicare-covered Group Sessions $5.00
Over-the-counter (OTC) Items
In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $25.00
Referral Required for Podiatry Services
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 to $15.00
Office Vists include:
  • Oral Exams(Max 2 every year)
  • Prophylaxis (Cleaning)(Max 2 every year)
  • Dental X-Rays(Max 1(Please see Evidence of Coverage for details))
  • Maximum 2 visits every year
Prior Authorization Required for Preventive Dental
Referral Required for Preventive Dental

Comprehensive Dental:
Copayment for Medicare-covered Benefits $15.00 to $25.00
Copayment for Diagnostic Services $0.00
  • Maximum 2 visits every year
Copayment for Periodontics $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Extractions $15.00
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 to $25.00
Copayment for Routine Eye Exams $15.00
Referral Required for Eye Exams

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Maximum Plan Allowance of $40.00 every two years for all Non-Medicare covered 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 $25.00
Referral Required for Hearing Exams

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