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This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2020 Kaiser Permanente Medicare Advantage w/o Part D (HMO) in Fairfax, Virginia

Medicare Advantage Plan Benefit Details in Plain Text
The following Medicare Advantage plan benefits apply to the Kaiser Permanente Medicare Advantage w/o Part D (HMO) (H2172 - 005) in Fairfax, Virginia .

This plan is administered by .  To switch to a different Medicare Advantage plan or to change your location, click here.
Click here to see the Kaiser Permanente Medicare Advantage w/o Part D (HMO) health benefit details in chart format or email and view benefits chart

Plan Premium
The Kaiser Permanente Medicare Advantage w/o Part D (HMO) has a monthly premium of $30.00. That is $360.00 for 12 months. There are a few factors that can increase or decrease this premium. If you qualify for full or partial extra help, your premium will be lower. If you have a premium penalty, your premium will be higher. Please remember that the $30.00 montly premium is in addition to your Medicare Part B premium. If you have a premium penalty, your premium will be higher. Or if you have a higher income you would be subject to the Income Related Adjustment Amount (IRMAA).

This Medicare Advantage Plan without Prescription Drug Coverage is a Local HMO * plan.

Plan Membership and Plan Ratings
The Kaiser Permanente Medicare Advantage w/o Part D (HMO) (H2172 - 005) currently has 470 members. There are 24 members enrolled in this plan in Fairfax, Virginia, and 16 members in Virginia.

The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 5 stars.   Therefore, this plan qualifies for the 5-star rating Special Enrollment period ( Read more). The detail CMS plan carrier ratings are as follows:
Please be aware that this plan does NOT include Prescription Drug Coverage!
The Kaiser Permanente Medicare Advantage w/o Part D (HMO) offers many Health Coverage Benefits. The following section will describe these benefits in detail.

** Base Plan **
Premium
• Total monthly premium: $30.00
• Health plan premium: $30
• Drug plan premium: $0
• You must continue to pay your Part B premium.
• Part B premium reduction: No
Deductible
• Health plan deductible: $0
• Other health plan deductibles: In-network: No
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $6,700 In-network
Optional supplemental benefits
• Yes
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: No
Doctor visits
• Primary: $10 copay per visit
• Specialist: $35 copay per visit (authorization and referral required)
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures: $0 copay (authorization and referral required)
• Lab services: $0 copay (authorization and referral required)
• Diagnostic radiology services (e.g., MRI): $100 copay (authorization and referral required)
• Outpatient x-rays: $10 copay (authorization and referral required)
Emergency care/Urgent care
• Emergency: $90 copay per visit (always covered)
• Urgent care: $35 copay per visit (always covered)
Inpatient hospital coverage
• $225 per day for days 1 through 5
$0 per day for days 6 through 90 (authorization and referral required)
Outpatient hospital coverage
• $200 copay per visit (authorization and referral required)
Skilled Nursing Facility
• $0 per day for days 1 through 20
$150 per day for days 21 through 100 (authorization and referral required)
Preventive care
• $0 copay (authorization and referral required)
Ground ambulance
• $250 copay
Rehabilitation services
• Occupational therapy visit: $35 copay (authorization and referral required)
• Physical therapy and speech and language therapy visit: $35 copay (authorization and referral required)
Mental health services
• Inpatient hospital - psychiatric: $225 per day for days 1 through 5
$0 per day for days 6 through 90 (authorization and referral required)
• Outpatient group therapy visit with a psychiatrist: $10 copay (authorization and referral required)
• Outpatient individual therapy visit with a psychiatrist: $20 copay (authorization and referral required)
• Outpatient group therapy visit: $10 copay (authorization required)
• Outpatient individual therapy visit: $20 copay (authorization required)
Opioid treatment program services
• In-network: $35.00 copay (authorization and referral required)
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen): 20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs): 20% coinsurance per item (authorization required)
• Diabetes supplies: $0 copay (authorization required)
Dialysis
• 20% coinsurance (authorization and referral required)
Hearing
• Hearing exam: $35 copay (authorization and referral required)
• Fitting/evaluation: Not covered
• Hearing aids - inner ear: Not covered
• Hearing aids - outer ear: Not covered
• Hearing aids - over the ear: Not covered
Preventive dental
• Office visit: $30.00
• Oral exam: Covered under office visit (limits apply)
• Cleaning: Covered under office visit (limits apply)
• Fluoride treatment: Covered under office visit (limits apply)
• Dental x-ray(s): Covered under office visit (limits apply)
Comprehensive dental
• Non-routine services: $0-55 copay (authorization and referral required)
• Diagnostic services: $11-69 copay (authorization and referral required)
• Restorative services: $40-755 copay (authorization and referral required)
• Endodontics: $47-1,047 copay (authorization and referral required)
• Periodontics: $76-836 copay (authorization and referral required)
• Extractions: $72-429 copay (authorization and referral required)
• Prosthodontics, other oral/maxillofacial surgery, other services: $30-3,658 copay (authorization and referral required)
Vision
• Routine eye exam: $10-35 copay (authorization and referral required)
• Other: Not covered
• Contact lenses: $0 copay (limits apply, authorization and referral required)
• Eyeglasses (frames and lenses): $0 copay (limits apply, authorization and referral required)
• Eyeglass frames: $0 copay (limits apply, authorization and referral required)
• Eyeglass lenses: $0 copay (limits apply, authorization and referral required)
• Upgrades: Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Covered
Transportation
• $0 copay (limits apply)
Foot care (podiatry services)
• Foot exams and treatment: $35 copay (authorization and referral required)
• Routine foot care: Not covered
Medicare Part B drugs
• Chemotherapy: $0-47 copay (authorization required)
• Other Part B drugs: $0-47 copay (authorization required)
Package #1
• Monthly Premium: $25.00
• Deductible:
Medically-approved non-opioid pain management services
• Chiropractic services: Not covered
• Acupuncture: Not covered
• Therapeutic Massage: Not covered
• Alternative Therapies: Not covered
More benefits
• Transportation services: Some coverage
• Transportation services for non-emergency care: Plan-approved locations: Not covered
• Over-the-counter drug benefits: Not covered
• Meals for short duration: Not covered
• Annual physical exams: Some coverage
• Telehealth: Some coverage
• WorldWide emergency transportation: Some coverage
• WorldWide emergency coverage: Some coverage
• WorldWide emergency urgent care: Some coverage
• Fitness Benefit: Not covered
• In-Home Support Services: Not covered
• Bathroom Safety Devices: Not covered
• Health Education: Some coverage
• In-Home Safety Assessment: Not covered
• Personal Emergency Response System (PERS): Not covered
• Medical Nutrition Therapy (MNT): Not covered
• Post discharge In-Home Medication Reconciliation: Not covered
• Re-admission Prevention: Not covered
• Wigs for Hair Loss Related to Chemotherapy: Not covered
• Weight Management Programs: Not covered
• Adult Day Health Services: Not covered
• Nutritional/Dietary Benefit: Not covered
• Home-Based Palliative Care: Not covered
• Support for Caregivers of Enrollees: Not covered
• Additional Sessions of Smoking and Tobacco Cessation Counseling: Not covered
• Enhanced Disease Management: Not covered
• Telemonitoring Services: Not covered
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Some coverage
• Counseling Services: Not covered




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