Kaiser Permanente Medicare Advantage Value DC (HMO-POS)

H2172 - 012 - 0
3.5 out of 5 stars (3.5 / 5)

kaiser-permanente medicare provider logo

Kaiser Permanente Medicare Advantage Value DC (HMO-POS) is a Medicare Advantage (Part C) Plan by Kaiser Permanente.

This page features plan details for 2024 Kaiser Permanente Medicare Advantage Value DC (HMO-POS) H2172 – 012 – 0 available in DC.

IMPORTANT: This page has been updated with plan and premium data for 2024.

Locations

Kaiser Permanente Medicare Advantage Value DC (HMO-POS) is offered in the following locations.

Plan Overview

Kaiser Permanente Medicare Advantage Value DC (HMO-POS) offers the following coverage and cost-sharing.

Insurer:Kaiser Permanente
Health Plan Deductible:$0.00
MOOP:$6,900 In-network
Drugs Covered:Yes

Ready to sign up for Kaiser Permanente Medicare Advantage Value DC (HMO-POS) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 TTY 711.

8am – 11pm EST. 7 days a week

Premium Breakdown

Kaiser Permanente Medicare Advantage Value DC (HMO-POS) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$174.70 $0.00 $0.00 $0.00 $174.70
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Kaiser Permanente Medicare Advantage Value DC (HMO-POS) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible:$0.00
Initial Coverage Limit:$5,030.00
Catastrophic Coverage Limit:$8,000.00
Drug Benefit Type:Enhanced Alternative
Additional Gap Coverage:Yes
Formulary Link: Formulary Link

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$0.00$

NOTE:  The Inflation Reduction Act of 2022 has expanded full subsidy eligibility under the LIS program to individuals with incomes up to 150% of the Federal Poverty Level. People who qualify for Extra Help generally will pay no more than $4.50 for each generic drug and $11.20 for each brand-name drug.

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00. Once you reach that amount, you will enter the next coverage phase.

Gap Coverage Phase

After your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00, you will pay no more than the amounts below for any drug tier until you reach $8,000.00.

Tier Cost
All other tiers (Generic)25%
All other tiers (Brand-name)25%

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Kaiser Permanente Medicare Advantage Value DC (HMO-POS) also provides the following benefits.

Health plan deductible

$0

Other health plan deductibles?

In-network No

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

$6,900 In-network

Optional supplemental benefits

Yes

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

In-network No

Outpatient hospital coverage

In-network $0-300 copay per visit (Authorization is required.) (Referral is required.)

Doctor visits

In-network Primary$5 copay per visit (Not applicable.) (Not applicable.)
out-of-network Primary$0-25 copay per visit (Not applicable.) (Not applicable.)
In-network Specialist$0-40 copay per visit (Authorization is required.) (Referral is required.)
out-of-network Specialist$0-50 copay per visit (Authorization is required.) (Referral is required.)

Preventive care

In-network $0 copay (Authorization is required.) (Referral is required.)
out-of-network $0-25 copay (Authorization is required.) (Referral is required.)

Emergency care/Urgent care

Emergency$100 copay per visit (always covered) (Not applicable.) (Not applicable.)
Urgent care$40 copay per visit (always covered) (Not applicable.) (Not applicable.)

Diagnostic procedures/lab services/imaging

In-network Diagnostic tests and procedures$0 copay (Authorization is required.) (Referral is required.)
out-of-network Diagnostic tests and procedures$0-25 copay (Authorization is required.) (Referral is required.)
In-network Lab services$0 copay (Authorization is required.) (Referral is required.)
out-of-network Lab services$0-25 copay (Authorization is required.) (Referral is required.)
In-network Diagnostic radiology services (e.g., MRI)$0-170 copay (Authorization is required.) (Referral is required.)
out-of-network Diagnostic radiology services (e.g., MRI)$0-25 copay (Authorization is required.) (Referral is required.)
In-network Outpatient x-rays$20 copay (Authorization is required.) (Referral is required.)
out-of-network Outpatient x-rays$0-25 copay (Authorization is required.) (Referral is required.)

Hearing

In-network Hearing exam$40 copay (Authorization is required.) (Referral is required.)
out-of-network Hearing exam$0-50 copay (Authorization is required.) (Referral is required.)
In-network Fitting/evaluation$0 copay (There are no limits.) (Authorization is required.) (Referral is required.)
Hearing aids – inner earNot covered (There are no limits.) (Not applicable.) (Not applicable.)
Hearing aids – outer earNot covered (There are no limits.) (Not applicable.) (Not applicable.)
Hearing aids – over the earNot covered (There are no limits.) (Not applicable.) (Not applicable.)

Preventive dental

In-network Office visit$40.00 (Authorization is not required.) (Referral is not required.)
Oral examCovered under office visit (Limits may apply.) (Authorization is not required.) (Referral is not required.)
CleaningCovered under office visit (Limits may apply.) (Authorization is not required.) (Referral is not required.)
Fluoride treatmentCovered under office visit (Limits may apply.) (Authorization is not required.) (Referral is not required.)
Dental x-ray(s)Covered under office visit (Limits may apply.) (Authorization is not required.) (Referral is not required.)

Comprehensive dental

In-network Non-routine services50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is required.)
In-network Diagnostic services0% coinsurance (Limits may apply.) (Authorization is required.) (Referral is required.)
In-network Restorative services50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is required.)
In-network Endodontics50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is required.)
In-network Periodontics50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is required.)
In-network Extractions$40 copay or 50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is required.)
In-network Prosthodontics, other oral/maxillofacial surgery, other services50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is required.)

Vision

In-network Routine eye exam$5-40 copay (There are no limits.) (Authorization is required.) (Referral is required.)
OtherNot covered (There are no limits.) (Not applicable.) (Not applicable.)
In-network Contact lenses$0 copay (Limits may apply.) (Authorization is required.) (Referral is required.)
In-network Eyeglasses (frames and lenses)$0 copay (Limits may apply.) (Authorization is required.) (Referral is required.)
In-network Eyeglass frames$0 copay (Limits may apply.) (Authorization is required.) (Referral is required.)
In-network Eyeglass lenses$0 copay (Limits may apply.) (Authorization is required.) (Referral is required.)
UpgradesNot covered (Not applicable.) (Not applicable.)

Rehabilitation services

In-network Occupational therapy visit$40 copay (Authorization is required.) (Referral is required.)
out-of-network Occupational therapy visit$0-50 copay (Authorization is required.) (Referral is required.)
In-network Physical therapy and speech and language therapy visit$40 copay (Authorization is required.) (Referral is required.)
out-of-network Physical therapy and speech and language therapy visit$0-50 copay (Authorization is required.) (Referral is required.)

Ground ambulance

In-network $275 copay (Not applicable.) (Not applicable.)

Transportation

Not covered (Not applicable.) (Not applicable.)

Foot care (podiatry services)

In-network Foot exams and treatment$40 copay (Authorization is required.) (Referral is required.)
out-of-network Foot exams and treatment$0-50 copay (Authorization is required.) (Referral is required.)
Routine foot careNot covered (Not applicable.) (Not applicable.)

Medical equipment/supplies

In-network Durable medical equipment (e.g., wheelchairs, oxygen)0-20% coinsurance per item (Authorization is required.) (Not applicable.)
In-network Prosthetics (e.g., braces, artificial limbs)20% coinsurance per item (Authorization is required.) (Not applicable.)
In-network Diabetes supplies$0 copay (Authorization is required.) (Not applicable.)

Wellness programs (e.g., fitness, nursing hotline)

Covered (Authorization is required.) (Referral is required.)

Medicare Part B drugs

In-network Chemotherapy$12-47 copay or 0-20% coinsurance (Authorization is required.) (Not applicable.)
out-of-network Chemotherapy20% coinsurance (Authorization is required.) (Not applicable.)
In-network Other Part B drugs$12-47 copay or 0-20% coinsurance (Authorization is required.) (Not applicable.)
out-of-network Other Part B drugs20% coinsurance (Authorization is required.) (Not applicable.)
In-network Part B Insulin drugs$12-35 copay (Authorization is required.) (Not applicable.)
out-of-network Part B Insulin drugs20% coinsurance (Authorization is required.) (Not applicable.)

Inpatient hospital coverage

In-network $300 per day for days 1 through 5
$0 per day for days 6 through 90
$0 per day for days 90 and beyond (Authorization is required.) (Referral is required.)
out-of-network Not Applicable (Authorization is required.) (Referral is required.)

Mental health services

In-network Inpatient hospital – psychiatric$300 per day for days 1 through 5
$0 per day for days 6 through 90 (Authorization is required.) (Referral is required.)
out-of-network Inpatient hospital – psychiatricNot Applicable (Authorization is required.) (Referral is required.)
In-network Outpatient group therapy visit with a psychiatrist$5 copay (Authorization is required.) (Referral is required.)
out-of-network Outpatient group therapy visit with a psychiatrist$15-25 copay (Authorization is required.) (Referral is required.)
In-network Outpatient individual therapy visit with a psychiatrist$10 copay (Authorization is required.) (Referral is required.)
out-of-network Outpatient individual therapy visit with a psychiatrist$15-25 copay (Authorization is required.) (Referral is required.)
In-network Outpatient group therapy visit$5 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient group therapy visit$15-25 copay (Authorization is required.) (Referral is not required.)
In-network Outpatient individual therapy visit$10 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient individual therapy visit$15-25 copay (Authorization is required.) (Referral is not required.)

Skilled Nursing Facility

In-network $0 per day for days 1 through 20
$203 per day for days 21 through 100 (Authorization is required.) (Referral is required.)
out-of-network Not Applicable (Authorization is required.) (Referral is required.)

Package #1

Monthly Premium$18.00
Deductiblenan

Package #2

Monthly Premium$23.00
Deductiblenan

Optional Benefits

Package #1

Comprehensive dental:Monthly Premium:$20.00
Comprehensive dental:Deductible:N/A
Eyewear:Monthly Premium:$20.00
Eyewear:Deductible:N/A
Hearing aids:Monthly Premium:$20.00
Hearing aids:Deductible:N/A

Ready to sign up for Kaiser Permanente Medicare Advantage Value DC (HMO-POS) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 TTY 711.

8am – 11pm EST. 7 days a week

Table of Contents