Plan Basics
Contract Year 2020
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H2172-005-000
Plan Organization Kaiser Permanente
Plan Type Local HMO *
Plan Name Kaiser Permanente Medicare Advantage w/o Part D (HMO)
Drugs Covered No
Doctors Choice Plan Doctors for Most Services
Overall Star Rating 5 Stars
Plan Cost Sharing
Premium $30.00
Total Premium (Includes Part B) $165.50
Monthly Part C Premium $30.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $6700.00
Formulary Website Formulary Link

Medicare Advantage Plan Health Benefits


Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services No - Yes Yes $11-69
Periodontics No - Yes Yes $76-836
Endodontics No - Yes Yes $47-1,047
Non-routine services No - Yes Yes $0-55
Prosthodontics, other oral/maxillofacial surgery, other services No - Yes Yes $30-3,658
Restorative services No - Yes Yes $40-755
Extractions No - Yes Yes $72-429
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - - Yes Yes $100
Diagnostic tests and procedures - - Yes Yes $0 copay
Lab services - - Yes Yes $0 copay
Outpatient x-rays - - Yes Yes $10
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - - - - $10 per visit
Specialist - - Yes Yes $35 per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Urgent care - - - - $35 per visit (always covered)
Emergency - - - - $90 per visit (always covered)
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Hearing aids - inner ear No - - - Not covered
Fitting/evaluation No - - - Not covered
Hearing aids - outer ear No - - - Not covered
Hearing aids - over the ear No - - - Not covered
Hearing exam - - Yes Yes $35
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - - Yes Yes $225 per day for days 1 through 5 $0 per day for days 6 through 90
Outpatient group therapy visit with a psychiatrist - - Yes Yes $10
Outpatient group therapy visit - - Yes No $10
Outpatient individual therapy visit - - Yes No $20
Outpatient individual therapy visit with a psychiatrist - - Yes Yes $20
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Physical therapy and speech and language therapy visit - - Yes Yes $35
Occupational therapy visit - - Yes Yes $35
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Eyeglass frames Yes - Yes Yes $0 copay
Other No - - - Not covered
Contact lenses Yes - Yes Yes $0 copay
Eyeglass lenses Yes - Yes Yes $0 copay
Upgrades - - - - Not covered
Eyeglasses (frames and lenses) Yes - Yes Yes $0 copay
Routine eye exam No - Yes Yes $10-35
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - - Yes Yes $35
Routine foot care - - - - Not covered
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $250
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $6,700 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
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes Yes $200 per visit
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
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 $225 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
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes Yes $0 copay
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Dental x-ray(s) Yes - No No Covered under office visit
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
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Yes
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes Yes $0 per day for days 1 through 20 $150 per day for days 21 through 100
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes - No No $0 copay

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

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