Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H0630-015-000
Plan Organization Kaiser Permanente
Plan Type Local HMO
Plan Name Kaiser Permanente Senior Advantage Silver (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
Plan Cost Sharing
Premium $47.00
Total Premium (Includes Part B) $182.50
Monthly Part C Premium $7.40
Monthly Part D Basic Premium $39.60
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $39.60
Monthly Part D Premium Full Assistance $5.30
Monthly Part D Premium 75% Assistance $13.90
Monthly Part D Premium 50% Assistance $22.40
Monthly Part D Premium 25% Assistance $31.00
Part D Drug Deductible $50.00
Annual Drug Deductible $50.00
Tiers Excluded From Deductible 1
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $3400.00
Gap Coverage No

Medicare Advantage Plan Health Benefits


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
Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services Yes - No No $10 copay
Endodontics Yes - No No 50% coinsurance
Extractions Yes - No No 50% coinsurance
Non-routine services Yes - No No 50% coinsurance
Periodontics Yes - No No 50% coinsurance
Prosthodontics, other oral/maxillofacial surgery, other services Yes - No No 50% coinsurance
Restorative services Yes - No No 50% coinsurance
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - - No Yes $80-115 copay
Diagnostic tests and procedures - - No Yes $0 copay
Lab services - - No Yes $0 copay
Outpatient x-rays - - No Yes $0 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - - - - $0 copay
Specialist - - No No $25 copay per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 copay per visit (always covered)
Urgent care - - - - $25 copay per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - - No Yes $25 copay
Routine foot care Yes - No Yes $0 copay
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $250 copay
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation No - No No $0 copay
Hearing aids - inner ear No - - - Not covered
Hearing aids - outer ear No - - - Not covered
Hearing aids - over the ear No - - - Not covered
Hearing exam - - No No $0 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes Yes $175 per day for days 1 through 5$0 per day for days 6 through 90
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $3,400 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - - No - $0 copay
Durable medical equipment (e.g., wheelchairs, oxygen) - - Yes - 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - - Yes - 20% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - - Yes - $10-47 copay or 20% coinsurance
Other Part B drugs - - Yes - $10-47 copay or 20% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - - Yes Yes $175 per day for days 1 through 5$0 per day for days 6 through 90
Outpatient group therapy visit - - No No $10 copay
Outpatient group therapy visit with a psychiatrist - - No No $10 copay
Outpatient individual therapy visit - - No No $20 copay
Outpatient individual therapy visit with a psychiatrist - - No No $20 copay
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Yes
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes Yes $150 copay per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No $0 copay
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes - No No $10 copay
Dental x-ray(s) Yes - No No $10 copay
Fluoride treatment Yes - No No $10 copay
Oral exam Yes - No No $10 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - - No Yes $20 copay
Physical therapy and speech and language therapy visit - - No Yes $20 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes Yes $0 per day for days 1 through 20$160 per day for days 21 through 42$0 per day for days 43 through 100
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not covered
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes - No No $0 copay
Eyeglass frames Yes - No No $0 copay
Eyeglass lenses Yes - No No $0 copay
Eyeglasses (frames and lenses) Yes - No No $0 copay
Other No - - - Not covered
Routine eye exam No - No No $0 copay
Upgrades - - - - Not covered
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered

Medicare Plan Packages


Package #1
Category Cost Sharing Type Cost Share
Comprehensive dental Monthly Premium $35.00
Eyewear Monthly Premium $35.00
Hearing aids Monthly Premium $35.00
Package #2
Category Cost Sharing Type Cost Share
Acupuncture Monthly Premium $14.00
Hearing aids Monthly Premium $14.00
Transportation Monthly Premium $14.00
Plan Drug Info
Formulary Link Drug Formulary Directory
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048

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