Kaiser Permanente Medicare Advantage High VA (HMO-POS)

3.5 out of 5 stars* for plan year 2024
$134.00 Monthly Premium

Kaiser Permanente Medicare Advantage High VA (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Kaiser Foundation Health Plan, Inc.

Plan ID: H2172-008-000

$134.00 Monthly Premium

Virginia 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 Virginia 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$134.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$0.00
Out-of-pocket maximum$5,700.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$8,000.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $10.00
Specialty doctor visit
POS (Out-of-Network):

Doctor Specialty Visit:
Copayment for Medicare Covered Physician Specialist Office Visit $0.00 to $50.00
Inpatient hospital careIn-Network:

Acute Hospital Services:
$250.00 per day for days 1 to 5
$0.00 per day for days 6 to the end of your stay
Prior Authorization Required for Acute Hospital Services
Referral Required for Acute Hospital Services
Urgent care
Urgent Care:
Copayment for Urgent Care $35.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $35.00
Emergency room visit
Emergency Care:
Copayment for Emergency Care $120.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $120.00
Copayment for Worldwide Emergency Transportation $225.00
Ambulance transportationIn-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $225.00

Air Ambulance:
Copayment for Air Ambulance Services $225.00

Please see Evidence of Coverage for Prior Authorization rules

Health Care Services and Medical Supplies

Kaiser Permanente Medicare Advantage High VA (HMO-POS) covers a range of additional benefits. Learn more about Kaiser Permanente Medicare Advantage High VA (HMO-POS) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage Details
Chiropractic servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $10.00
Prior Authorization Required for Chiropractic Services
Referral Required for Chiropractic Services
Diabetes supplies, training, nutrition therapy and monitoringIn-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0.00
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Prior Authorization Required for Diabetic Supplies and Services
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
Diagnostic tests, lab and radiology services, and X-rays
POS (Out-of-Network):

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests $0.00 to $25.00
Copayment for Medicare Covered Lab Services $0.00 to $25.00
Copayment for Medicare Covered Diagnostic Radiological Services $0.00 to $25.00
Copayment for Medicare Covered Outpatient X-Ray Services $0.00 to $25.00
Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Referral Required for Home Health Services
Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
$250.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services
Referral Required for Psychiatric Hospital Services
Mental health outpatient care
POS (Out-of-Network):

Outpatient Mental Health Services:
Copayment for Medicare Covered Individual Sessions $15.00 to $25.00
Copayment for Medicare Covered Group Sessions $15.00 to $25.00
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $125.00
Prior Authorization Required for Outpatient Hospital Services
Referral Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $0.00 to $125.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $125.00
Prior Authorization Required for Ambulatory Surgical Center Services
Referral Required for Ambulatory Surgical Center Services
Outpatient substance abuse care
POS (Out-of-Network):

Outpatient Substance Abuse Services:
Copayment for Medicare Covered Individual or Group Sessions $15.00 to $25.00
Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $60.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry services
POS (Out-of-Network):

Podiatry Services:
Copayment for Medicare Covered Podiatry Services $0.00 to $50.00
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$160.00 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 careIn-Network:

Preventive Dental:
Copayment for Office Visit $0.00 to $35.00
Office Vists include:
    • Maximum 2 visits every year
    Copayment for Oral Exams $0.00
    • Maximum 2 visits every year
    Copayment for Prophylaxis (Cleaning) $0.00
    • Maximum 2 visits every year
    Copayment for Fluoride Treatment $0.00
    • Maximum 1 visit every year
    Copayment for Dental X-Rays $0.00
    • Maximum 1 visit (Please see Evidence of Coverage for details)

    Comprehensive Dental:
    Copayment for Medicare-covered Benefits $35.00
    Copayment for Diagnostic Services $0.00
    Maximum Plan Benefit of $500.00 every year for Non-Medicare Covered Comprehensive
    Prior Authorization Required for Comprehensive Dental
    Referral Required for Comprehensive Dental

    Vision Benefits

    The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

    Coverage Details
    Vision benefits
    POS (Out-of-Network):

    Medicare Covered Vision Services:
    Copayment for Medicare Covered Eye Exams $0.00 to $50.00

    Hearing Benefits

    The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

    Coverage Details
    Hearing benefits
    POS (Out-of-Network):

    Medicare Covered Hearing Services:
    Copayment for Medicare Covered Hearing Exams $0.00 to $50.00

    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 programsIn-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:
    • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit

    When reviewing Virginia 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 Virginia 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

    Virginia Counties Served

    We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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