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Kaiser Permanente Sr Adv Enhanced Marin San Mateo (HMO) - H0524-031-000

na* for plan year 2025

$67.00

Monthly Premium

Kaiser Permanente Sr Adv Enhanced Marin San Mateo (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Kaiser Foundation Health Plan, Inc.

Plan ID: H0524-031-000

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$67.00

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

CoverageDetails
Monthly plan premium$67.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$0.00
Out-of-pocket maximum$3,900.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$2,000.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $5
Referral Required for Doctor Specialty Visit
Inpatient hospital careIn-Network:

Acute Hospital Services:
$180 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 $0

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $0
Emergency room visit
Emergency Care:
Copayment for Emergency Care $140
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 $140
Copayment for Worldwide Emergency Transportation $200
Ambulance transportationIn-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $200

Air Ambulance:
Copayment for Air Ambulance Services $200

Health Care Services and Medical Supplies

Kaiser Permanente Sr Adv Enhanced Marin San Mateo (HMO) covers a range of additional benefits. Learn more about Kaiser Permanente Sr Adv Enhanced Marin San Mateo (HMO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic servicesIn-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 monitoringIn-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-raysIn-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 $200
Copayment for Medicare-covered Therapeutic Radiological Services $0
Copayment for Medicare-covered X-Ray Services $0
Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Referral Required for Home Health Services
Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
$180 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 careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $140
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 $140
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 $140
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0
Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0
  • Maximum plan benefit of $60.00 every three months for Over-The-Counter (OTC) Items
Maximum Plan Benefit of $60 every three months
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 servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $5
Referral Required for Podiatry Services
Skilled Nursing Facility (SNF) careIn-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.

CoverageDetails
Dental careIn-Network:

Medicare Covered Dental:
Copayment for Office Visit $0 to $5
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
  • Maximum 2 visits every year
Copayment for Dental x-rays $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Other diagnostic services $0
Copayment for Prophylaxis $0
  • Maximum 2 visits every year
Copayment for Flouride treatment $0
  • Maximum 2 visits every year
Copayment for Other preventive services $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
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Maxillofacial surgery $0

Vision Benefits

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

CoverageDetails
Vision careIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0 to $5
Copayment for Routine Eye Exams $0
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.

CoverageDetails
Hearing careIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $5

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.

CoverageDetails
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 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.

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