Plan Basics
Contract Year 2020
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H2172-001-000
Plan Organization Kaiser Permanente
Plan Type Local HMO
Plan Name Kaiser Permanente Medicare Advantage High DC (HMO)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Plan Doctors for Most Services
Benefit Type Enhanced Alternative
Special Needs Plan No
Overall Star Rating 5 Stars
Plan Cost Sharing
Premium $142.00
Total Premium (Includes Part B) $277.50
Monthly Part C Premium $83.70
Monthly Part D Basic Premium $58.30
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $58.30
Monthly Part D Premium Full Assistance $28.60
Monthly Part D Premium 75% Assistance $36.10
Monthly Part D Premium 50% Assistance $43.50
Monthly Part D Premium 25% Assistance $50.90
Part D Drug Deductible $0.00
Part D Initial Coverage Limit $4020.00
Part D Catastrophic Coverage Threshold $6350.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $5500.00
Gap Coverage Yes
Formulary Website Formulary Link

Medicare Advantage Plan Health Benefits


Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Extractions No - Yes Yes $72-429
Diagnostic services No - Yes Yes $11-69
Non-routine services No - Yes Yes $0-55
Periodontics No - Yes Yes $76-836
Prosthodontics, other oral/maxillofacial surgery, other services No - Yes Yes $30-3,658
Endodontics No - Yes Yes $47-1,047
Restorative services No - Yes Yes $40-755
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic tests and procedures - - Yes Yes $0 copay
Lab services - - Yes Yes $0 copay
Diagnostic radiology services (e.g., MRI) - - Yes Yes $40
Outpatient x-rays - - Yes Yes $10
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Specialist - - Yes Yes $30 per visit
Primary - - - - $5 per visit
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Routine foot care - - - - Not covered
Foot exams and treatment - - Yes Yes $30
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Outpatient group therapy visit with a psychiatrist - - Yes Yes $5
Outpatient individual therapy visit - - Yes No $10
Inpatient hospital - psychiatric - - Yes Yes $200 per day for days 1 through 5 $0 per day for days 6 through 90
Outpatient group therapy visit - - Yes No $5
Outpatient individual therapy visit with a psychiatrist - - Yes Yes $10
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes Yes $0 per day for days 1 through 20 $110 per day for days 21 through 100
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes - No No $0 copay
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Eyeglasses (frames and lenses) Yes - Yes Yes $0 copay
Eyeglass frames Yes - Yes Yes $0 copay
Eyeglass lenses Yes - Yes Yes $0 copay
Other No - - - Not covered
Routine eye exam No - Yes Yes $5-30
Upgrades - - - - Not covered
Contact lenses Yes - Yes Yes $0 copay
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered
Additional Benefits And/or Reduced Cost-sharing For Enrollees With Certain Health Conditions?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $200
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes Yes $200 per day for days 1 through 5 $0 per day for days 6 through 90
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Durable medical equipment (e.g., wheelchairs, oxygen) - - Yes - 20% per item
Prosthetics (e.g., braces, artificial limbs) - - Yes - 20% per item
Diabetes supplies - - Yes - $0 copay
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes Yes $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Physical therapy and speech and language therapy visit - - Yes Yes $30
Occupational therapy visit - - Yes Yes $30
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 per visit (always covered)
Urgent care - - - - $30 per visit (always covered)
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation No - - - Not covered
Hearing aids - outer ear No - - - Not covered
Hearing aids - over the ear No - - - Not covered
Hearing exam - - Yes Yes $30
Hearing aids - inner ear No - - - Not covered
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $5,500 In-network
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Other Part B drugs - - Yes - $0-47
Chemotherapy - - Yes - $0-47
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Yes
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes Yes $100 per visit
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes - No No Covered under office visit
Fluoride treatment Yes - No No Covered under office visit
Office visit - - No No $30.00
Oral exam Yes - No No Covered under office visit
Dental x-ray(s) Yes - No No Covered under office visit

Medicare Plan Packages


Package #1
Category Cost Sharing Type Cost Share
Comprehensive dental Monthly Premium
Eyewear Monthly Premium
Hearing aids Monthly Premium
Hearing exam Monthly Premium
Preventive dental Monthly Premium
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048
Plan Available in these Counties
District Of Columbia County, Washington D.C.

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