On the KP 0/25/Rx plan, you would pay a separate copayment for each of the covered services you receive. In this case, you would pay a $25 copay for the doctor’s ofice visit, a $25 copay for the X-ray, and either a $15 copay or 50 percent coinsurance (whichever is greater) for the generic drug. Facility fee (e.g., ambulatory surgery center) $15 copayment / procedure(s) Not covered -none Physician/surgeon fees If you need immediate medical attention Emergency room services $50 copayment / visit(s) -none- Emergency medical transportation No charge -none- Urgent care $15 copayment / visit(s). The MFA program covers emergency and medically necessary health care services, pharmacy services and products, and medical supplies provided at Kaiser Permanente facilities (such as hospitals, medical centers, and medical office buildings), at Kaiser Permanente outpatient pharmacies, or by Kaiser Permanente providers. Emergency Visits. Emergency care by a physician, level 1 (low severity) $170 Emergency care by a physician, level 2 $250 Emergency care by a physician, level 3 $375 Emergency care by a physician, level 4 (high severity) $560.Depending on your plan, these services may be preventive and covered at no cost or at a copay. For more information, see.
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Kaiser Permanente Senior Advantage Standard (HMO) H9003-006 is a 2021 Medicare Advantage Plan or Medicare Part-C plan by Kaiser Permanente available to residents in Oregon and Washington. This plan includes additional Medicare prescription drug (Part-D) coverage. The Kaiser Permanente Senior Advantage Standard (HMO) has a monthly premium of $44.00 and has an in-network Maximum Out-of-Pocket limit of $4,900 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $4,900 out of pocket. This can be a extremely nice safety net.
Kaiser Permanente Senior Advantage Standard (HMO) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your PCPs okay, called a referral. Services received from an out-of-network provider are not typically covered by the plan.
Kaiser Permanente works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Kaiser Permanente Senior Advantage Standard (HMO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Kaiser Permanente and not Original Medicare. With Medicare Advantage Plans you are always covered for urgently needed and emergency care. Plus you receive all of the benefits of Original Medicare from Kaiser Permanente except hospice care. Original Medicare still provides you with hospice care even if you sign up for a Medicare Advantage Plan.
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2021 Kaiser Permanente Medicare Advantage Plan Costs
| Name: | Kaiser Permanente Senior Advantage Standard (HMO) |
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| Plan ID: |
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| Provider: | Kaiser Permanente |
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| Year: | 2021 |
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| Type: | Local HMO |
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| Monthly Premium C+D: | $44.00 |
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| Part C Premium: | $3.30 |
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| MOOP: | $4,900 |
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| Part D (Drug) Premium: | $40.70 |
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| Part D Supplemental Premium | $0 |
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| Total Part D Premium: | $40.70 |
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| Drug Deductible: | $0 |
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| Tiers with No Deductible: | 0 |
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| Gap Coverage: | Yes |
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| Benchmark: | not below the regional benchmark |
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| Type of Medicare Health: | Enhanced Alternative |
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| Drug Benefit Type: | Enhanced |
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| Similar Plan: | H9003-007 |
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Kaiser Permanente Senior Advantage Standard (HMO) Part-C Premium
Kaiser Permanente plan charges a $3.30 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.
H9003-006 Part-D Deductible and Premium
Kaiser Permanente Senior Advantage Standard (HMO) has a monthly drug premium of $40.70 and a $0 drug deductible. This Kaiser Permanente plan offers a $40.70 Part D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0 this Premium covers any enhanced plan benefits offered by Kaiser Permanente above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $40.70. The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lower due to negative basic or supplemental premiums.
Kaiser Permanente Gap Coverage
In 2021 once you and your plan provider have spent $4130 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA 'donut hole') You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Kaiser Permanente plan does offer additional coverage through the gap.
Premium Assistance
The Low Income Subsidy (LIS) helps people with Medicare pay for prescription drugs, and lowers the costs of Medicare prescription drug coverage. Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Kaiser Permanente Senior Advantage Standard (HMO) medicare insurance offers a $4.70 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $13.70 for 75% low income subsidy $22.70 for 50% and $31.70 for 25%.
| Full LIS Premium: | $4.70 |
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| 75% LIS Premium: | $13.70 |
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| 50% LIS Premium: | $22.70 |
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| 25% LIS Premium: | $31.70 |
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H9003-006 Formulary or Drug Coverage
Kaiser Permanente Senior Advantage Standard (HMO) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers.By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price.
2021 Kaiser Permanente Senior Advantage Standard (HMO) Summary of Benefits
Kaiser Dialysis Copay
Additional Benefits
Comprehensive Dental
| Diagnostic services | Not covered |
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| Endodontics | Not covered |
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| Extractions | Not covered |
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| Non-routine services | Not covered |
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| Periodontics | Not covered |
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| Prosthodontics, other oral/maxillofacial surgery, other services | Not covered |
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| Restorative services | Not covered |
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Deductible
Diagnostic Tests and Procedures
| Diagnostic radiology services (e.g., MRI) | $10-150 copay |
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| Diagnostic tests and procedures | $10-35 copay |
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| Lab services | $0 copay |
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| Outpatient x-rays | $10 copay |
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Doctor Visits
| Primary | $5 copay per visit |
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| Specialist | $35 copay per visit |
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Emergency care/Urgent Care
| Emergency | $90 copay per visit (always covered) |
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| Urgent care | $35 copay per visit (always covered) |
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Foot Care (podiatry services)
| Foot exams and treatment | $35 copay |
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| Routine foot care | Not covered |
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Ground Ambulance
Hearing
| Fitting/evaluation | $0 copay |
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| Hearing aids - inner ear | Not covered |
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| Hearing aids - outer ear | Not covered |
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| Hearing aids - over the ear | Not covered |
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| Hearing exam | $35 copay |
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Inpatient Hospital Coverage
$265 per day for days 1 through 6
$0 per day for days 7 through 90 |
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Medical Equipment/Supplies
| Diabetes supplies | $0 copay |
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| Durable medical equipment (e.g., wheelchairs, oxygen) | 0-20% coinsurance per item |
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| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item |
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Medicare Part B Drugs
| Chemotherapy | $10-45 copay or 0-15% coinsurance |
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| Other Part B drugs | $0-45 copay or 0-15% coinsurance |
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Mental Health Services
| Inpatient hospital - psychiatric | $245 per day for days 1 through 6
$0 per day for days 7 through 90 |
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| Outpatient group therapy visit | $2 copay |
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| Outpatient group therapy visit with a psychiatrist | $2 copay |
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| Outpatient individual therapy visit | $5 copay |
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| Outpatient individual therapy visit with a psychiatrist | $5 copay |
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MOOP
Option
Optional supplemental benefits
Outpatient Hospital Coverage
Package #1
| Deductible |
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| Monthly Premium | $44.00 |
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Preventive Care
Preventive Dental
| Cleaning | Not covered |
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| Dental x-ray(s) | Not covered |
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| Fluoride treatment | Not covered |
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| Oral exam | Not covered |
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Rehabilitation Services
| Occupational therapy visit | $35 copay |
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| Physical therapy and speech and language therapy visit | $35 copay |
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Skilled Nursing Facility
$0 per day for days 1 through 20
$50 per day for days 21 through 100 |
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Transportation
Kaiser Permanente Emergency Copay
Vision
| Contact lenses | Not covered |
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| Eyeglass frames | Not covered |
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| Eyeglass lenses | Not covered |
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| Eyeglasses (frames and lenses) | Not covered |
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| Other | Not covered |
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| Routine eye exam | $35 copay |
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| Upgrades | Not covered |
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Wellness Programs (e.g. fitness nursing hotline)
Reviews for Kaiser Permanente Senior Advantage Standard (HMO) H9003
| 2019 Overall Rating |
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| Part C Summary Rating |
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| Part D Summary Rating |
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| Staying Healthy: Screenings, Tests, Vaccines |
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| Managing Chronic (Long Term) Conditions |
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| Member Experience with Health Plan |
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| Complaints and Changes in Plans Performance |
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| Health Plan Customer Service |
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| Drug Plan Customer Service |
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| Complaints and Changes in the Drug Plan |
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| Member Experience with the Drug Plan |
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| Drug Safety and Accuracy of Drug Pricing |
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Staying Healthy, Screening, Testing, & Vaccines
| Total Preventative Rating |
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| Breast Cancer Screening |
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| Colorectal Cancer Screening |
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| Annual Flu Vaccine |
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| Improving Physical |
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| Improving Mental Health |
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| Monitoring Physical Activity |
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| Adult BMI Assessment |
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Managing Chronic And Long Term Care for Older Adults
| Total Rating |
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| SNP Care Management |
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| Medication Review |
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| Functional Status Assessment |
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| Pain Screening |
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| Osteoporosis Management |
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| Diabetes Care - Eye Exam |
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| Diabetes Care - Kidney Disease |
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| Diabetes Care - Blood Sugar |
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| Rheumatoid Arthritis |
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| Reducing Risk of Falling |
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| Improving Bladder Control |
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| Medication Reconciliation |
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| Statin Therapy |
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Kaiser Emergency Cost
Member Experience with Health Plan
| Total Experience Rating |
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| Getting Needed Care |
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| Customer Service |
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| Health Care Quality |
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| Rating of Health Plan |
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| Care Coordination |
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Member Complaints and Changes in Kaiser Permanente Senior Advantage Standard (HMO) Plans Performance
| Total Rating |
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| Complaints about Health Plan |
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| Members Leaving the Plan |
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| Health Plan Quality Improvement |
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| Timely Decisions About Appeals |
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Health Plan Customer Service Rating for Kaiser Permanente Senior Advantage Standard (HMO)
| Total Customer Service Rating |
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| Reviewing Appeals Decisions |
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| Call Center, TTY, Foreign Language |
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Kaiser Permanente Senior Advantage Standard (HMO) Drug Plan Customer Service Ratings
| Total Rating |
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| Call Center, TTY, Foreign Language |
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| Appeals Auto |
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| Appeals Upheld |
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Ratings For Member Complaints and Changes in the Drug Plans Performance
| Total Rating |
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| Complaints about the Drug Plan |
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| Members Choosing to Leave the Plan |
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| Drug Plan Quality Improvement |
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Member Experience with the Drug Plan
| Total Rating |
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| Rating of Drug Plan |
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| Getting Needed Prescription Drugs |
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Drug Safety and Accuracy of Drug Pricing
| Total Rating |
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| MPF Price Accuracy |
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| Drug Adherence for Diabetes Medications |
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| Drug Adherence for Hypertension (RAS antagonists) |
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| Drug Adherence for Cholesterol (Statins) |
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| MTM Program Completion Rate for CMR |
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| Statin with Diabetes |
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Kaiser Er Copay
Ready to Enroll?
Or Call
1-855-778-4180
Mon-Sat 8am-11pm EST
Sun 9am-6pm EST
Coverage Area for Kaiser Permanente Senior Advantage Standard (HMO)
(Click county to compare all available Advantage plans)
| State: | Oregon
Washington
|
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| County: | Benton,Clackamas,Clark,Columbia,Cowlitz,
Linn,Marion,Multnomah,Polk,
Wahkiakum,Washington,Yamhill, |
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Kaiser Permanente Emergency Room Copay
Kaiser Permanente Emergency Room Copay
Source: CMS.
Data as of September 9, 2020.
Notes: Data are subject to change as contracts are finalized. For 2021, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part D benefit.Includes 2021 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.