Senior Advantage Medicare Medi-Cal North P2 (HMO D-SNP)
Senior Advantage Medicare Medi-Cal North P2 (HMO D-SNP) H8794-002 Plan Details
Senior Advantage Medicare Medi-Cal North P2 (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Kaiser Foundation Health Plan, Inc.
Plan ID: H8794-002
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$30.10
Monthly Premium
Senior Advantage Medicare Medi-Cal North P2 (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Kaiser Foundation Health Plan, Inc.
Plan ID: H8794-002
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
California Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $545 |
| Out of Pocket Max |
In-Network: $3400 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 $0.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $0.00 Copayment for Worldwide Emergency Transportation $200.00 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $0.00 Air Ambulance: Copayment for Air Ambulance Services $0.00 |
Health Care Services and Medical Supplies
Senior Advantage Medicare Medi-Cal North P2 (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: Copayment for Medicare-covered Chiropractic Services $0.00 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 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00 Prior Authorization Required for Diabetic Supplies and Services Prior authorization required |
| Durable Medical Eqipment (DME) | In-Network: Copayment for Medicare-covered Durable Medical Equipment $0.00 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 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 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 $140.00 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 Referral Required for Podiatry Services |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 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: Copayment for Prophylaxis (Cleaning) $0.00
Prior Authorization Required for Preventive Dental Referral Required for Preventive Dental Comprehensive Dental: Copayment for Medicare-covered Benefits $0.00 Copayment for Non-routine Services $0.00 Copayment for Diagnostic Services $0.00 Copayment for Restorative Services $0.00 Copayment for Endodontics $0.00 Copayment for Periodontics $0.00 Copayment for Extractions $0.00 Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $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 Maximum Plan Allowance of $350.00 every year for all Non-Medicare covered eyewear 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:
Yearly "Wellness" visit |
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