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Kaiser Permanente Dual Complete Plan 1 MD (HMO D-SNP) - H2172-016-000
$0.00
Monthly Premium
Kaiser Permanente Dual Complete Plan 1 MD (HMO D-SNP) is a HMO D-SNP Medicare Advantage (Medicare Part C) plan offered by Kaiser Foundation Health Plan, Inc.
Plan ID: H2172-016-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Maryland 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 additional benefits Original Medicare doesn’t cover.
Learn more about Maryland 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 | $0.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,100.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0 Prior Authorization Required for Doctor Specialty Visit Referral Required for Doctor Specialty Visit |
| Inpatient hospital care | In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $0 Prior Authorization Required for Acute Hospital Services Referral Required for Acute Hospital Services Members admitted and discharged on the same day pay a copayment for one day. |
| Urgent care | Urgent Care: Copayment for Urgent Care $0 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $0 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $0 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 0 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $0 Copayment for Worldwide Emergency Transportation $0 |
| Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $0 Prior Authorization Required for Ground Ambulance Air Ambulance: Copayment for Air Ambulance Services $0 Prior Authorization Required for Air Ambulance |
Health Care Services and Medical Supplies
Kaiser Permanente Dual Complete Plan 1 MD (HMO D-SNP) covers a range of additional benefits. Learn more about Kaiser Permanente Dual Complete Plan 1 MD (HMO D-SNP) 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 $0 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 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0 Prior Authorization Required for Diabetic Supplies and Services |
| Durable medical equipment (DME) | In-Network: Durable Medical Equipment: Copayment for Medicare-covered Durable Medical Equipment $0 Prior Authorization Required for Durable Medical Equipment The minimum coinsurance applies to 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 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Referral Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0 Copayment for Medicare-covered Therapeutic Radiological Services $0 Copayment for Medicare-covered X-Ray Services $0 Prior Authorization Required for Diagnostic Radiological Services and Therapeutic Radiological Services Referral Required for Diagnostic Radiological Services and Therapeutic Radiological Services |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Referral Required for Home Health Services |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $0 Prior Authorization Required for Psychiatric Hospital Services 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 $0 Copayment for Medicare-covered Group Sessions $0 Prior Authorization Required for Individual Sessions and Group Sessions |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 Prior Authorization Required for Outpatient Hospital Services Referral Required for Outpatient Hospital Services The minimum coinsurance applies to surgical procedures performed during a screening colonoscopy and diagnostic colonoscopies in response to a positive gFOBT, FIT, or sigmoidoscopy. The maximum coinsurance applies to all other services. Outpatient Observation Services: Copayment for Medicare Covered Observation Services $0 Prior Authorization Required for Outpatient Observation Services The minimum coinsurance applies to observation stays incident to other outpatient hospital services such as an ER visit or outpatient surgery. The maximum coinsurance applies when admitted directly to the hospital for observation. Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 Prior Authorization Required for Ambulatory Surgical Center Services Referral Required for Ambulatory Surgical Center Services |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $0 Copayment for Medicare-covered Group Sessions $0 Prior Authorization Required for Outpatient Substance Abuse Services Referral Required for Outpatient Substance Abuse Services |
| Over-the-counter items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0
The item purchase allowance does not cover service, delivery, shipping, or vehicle-loading fees. Service fees are not tips. |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $0 Prior Authorization Required for Podiatry Services Referral Required for Podiatry Services |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $0 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 Preventive Dental: Copayment for Office Visit $0 Prior Authorization Required for Medicare Covered Preventive Dental Referral Required for Medicare Covered Preventive Dental Non-Medicare Covered Preventive Dental: Copayment for Non-medicare preventive $0
Copayment for Prophylaxis $0
Maximum Plan Benefit of $3,000 every year Non-Medicare Covered Comprehensive Dental: Copayment for Non-medicare comprehensive $0 Copayment for Restorative services $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 Copayment for Routine Eye Exams $0 Prior Authorization Required for Eye Exams Referral Required for Eye Exams The minimum coinsurance applies to diabetic retinopathy services. The maximum coinsurance applies to services rendered by an ophthalmologist. Eyewear: Copayment for Medicare-Covered Benefits $0 Copayment for Contact Lenses $0 Copayment for Eyeglasses (lenses and frames) $0 Copayment for Eyeglass Lenses $0 Copayment for Eyeglass Frames $0 Maximum Plan Benefit of $300 every year Referral Required for Eyewear |
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 $0 Copayment for Fitting/Evaluation for Hearing Aid $0 Prior Authorization Required for Hearing Exams Referral Required for Hearing Exams Hearing Aids: Copayment for Hearing Aids $0
|
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 Maryland 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 Maryland 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 |
Maryland Counties Served
We offer plans from Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, HealthspringSM or Kaiser Permanente.