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Kaiser Permanente Senior Advantage Basic Stanis (HMO) - H0524-041-000
$0.00
Monthly Premium
Kaiser Permanente Senior Advantage Basic Stanis (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Kaiser Foundation Health Plan, Inc.
Plan ID: H0524-041-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
California Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.
Learn more about California Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $4,900.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $5 |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $10 Referral Required for Doctor Specialty Visit |
| Inpatient hospital care | In-Network: Acute Hospital Services: $230 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Acute Hospital Services Referral Required for Acute Hospital Services Prior authorization only applies to transplants. Members admitted and discharged on the same day pay a copayment for one day. |
| Urgent care | Urgent Care: Copayment for Urgent Care $5 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $5 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $125 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $125 Copayment for Worldwide Emergency Transportation $300 |
| Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $300 Air Ambulance: Copayment for Air Ambulance Services $300 |
Health Care Services and Medical Supplies
Kaiser Permanente Senior Advantage Basic Stanis (HMO) covers a range of additional benefits. Learn more about Kaiser Permanente Senior Advantage Basic Stanis (HMO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $5 Prior Authorization Required for Chiropractic Services Referral Required for Chiropractic Services |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0 Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% |
| Durable medical equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20% Prior Authorization Required for Durable Medical Equipment The minimum coinsurance applies to peak flow meters and ultraviolet light therapy equipment for psoriasis treatment. The maximum coinsurance applies to all other DME. |
| 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 Copayment for Medicare-covered Lab Services $0 Referral Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0 to $225 Copayment for Medicare-covered Therapeutic Radiological Services $0 Copayment for Medicare-covered X-Ray Services $0 |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Referral Required for Home Health Services |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: $230 per day for days 1 to 5 $0 per day for days 6 to 90 Referral Required for Psychiatric Hospital Services Members admitted and discharged on the same day pay a copayment for one day. |
| Mental health outpatient care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $5 Copayment for Medicare-covered Group Sessions $2 |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $165 The minimum copayment applies to surgical procedures performed during a screening colonoscopy and diagnostic colonoscopies in response to a positive gFOBT, FIT, or sigmoidoscopy. The maximum copayment applies to all other services. Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $0 to $125 The minimum copayment applies to observation stays incident to other outpatient hospital services such as an ER visit or outpatient surgery. The maximum copayment applies when admitted directly to the hospital for observation. Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $165 |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $5 Copayment for Medicare-covered Group Sessions $2 |
| Over-the-counter items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0
OTC items: We cover OTC items listed in our OTC catalog for free home delivery. Each order must be at least $25. NRT: We cover FDA-approved nicotine replacement therapy over-the-counter medications up to two 100-day supplies during the calendar year. |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $10 Referral Required for Podiatry Services |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $100 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services Referral Required for Skilled Nursing Facility Services |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | In-Network: Medicare Covered Dental: Copayment for Office Visit $5 to $10 Prior Authorization Required for Medicare Covered Dental Referral Required for Medicare Covered Dental The minimum copayment applies to services provided by a dentist. The maximum copayment applies to care provided by a specialist. Non-Medicare Covered Dental: Copayment for Non-medicare preventive $0 Copayment for Oral exams $0
Copayment for Prophylaxis $0
We cover the following preventive dental services not covered by Medicare: 1) Medically necessary preventive dental services to ensure the oral cavity is clear of infection prior to being placed on the transplant wait-list. In the case of urgent transplantation, these services may be performed post-transplant. 2) Other preventive dental services not related to transplants. Non-Medicare Covered Comprehensive Dental: Copayment for Periodontics $0
|
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0 to $10 Copayment for Routine Eye Exams $5 Referral Required for Eye Exams |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $10 |
Preventive Services and Health/Wellness Education Programs
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| 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 |
When reviewing California Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of California that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
California Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.