Senior Advantage Medicare Medicaid Plan 2 (HMO D-SNP)

5 out of 5 stars* for plan year 2023
$0.00 Monthly Premium

Senior Advantage Medicare Medicaid Plan 2 (HMO D-SNP) is a HMO D-SNP Medicare Advantage (Medicare Part C) plan offered by Kaiser Foundation Health Plan, Inc.

Plan ID: H1170-011-000

$0.00 Monthly Premium

Georgia 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 Georgia 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$7,400.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00

Please see Summary of Benefits for details
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0.00
Referral Required for Doctor Specialty Visit

Please see Summary of Benefits for details
Inpatient hospital careIn-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $12 (Theres no limit to the number of medically necessary inpatient hospital days)
  • If you are eligible for Medicare cost-sharing assistance under Medicaid, you pay $0.
Prior Authorization Required for Acute Hospital Services
Referral Required for Acute Hospital Services

Please see Summary of Benefits for details
Urgent care
Urgent Care:
Copayment for Urgent Care $0.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $0.00

Please see Summary of Benefits for details
Emergency room visit
Emergency Care:
Copayment for Emergency Care $20
  • Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $20
Copayment for Worldwide Emergency Transportation $25

Please see Summary of Benefits for details
Ambulance transportationIn-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $25

Air Ambulance:
Copayment for Air Ambulance Services $25

Please see Evidence of Coverage for Prior Authorization rules

Health Care Services and Medical Supplies

Senior Advantage Medicare Medicaid Plan 2 (HMO D-SNP) covers a range of additional benefits. Learn more about Senior Advantage Medicare Medicaid Plan 2 (HMO D-SNP) 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 $0.00

Please see Summary of Benefits for details
Diabetes supplies, training, nutrition therapy and monitoringIn-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0.00
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00

Please see Summary of Benefits for details
Durable medical equipment (DME)In-Network:

Durable Medical Equipment:
Copayment for Medicare-covered Durable Medical Equipment $0.00
Prior Authorization Required for Durable Medical Equipment

Please see Summary of Benefits for details
Diagnostic tests, lab and radiology services, and X-raysIn-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00
Copayment for Medicare-covered Lab Services $0.00
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 $0.00
Copayment for Medicare-covered Therapeutic Radiological Services $0.00
Copayment for Medicare-covered X-Ray Services $0.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Referral Required for Outpatient Diag/Therapeutic Rad Services

Please see Summary of Benefits for details
Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services

Please see Summary of Benefits for details
Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $12
Prior Authorization Required for Psychiatric Hospital Services
Referral Required for Psychiatric Hospital Services

Please see Summary of Benefits for details
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $0.00
Copayment for Medicare-covered Group Sessions $0.00

Please see Summary of Benefits for details
Outpatient services/surgeryIn-Network:

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

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00
Prior Authorization Required for Ambulatory Surgical Center Services

Please see Summary of Benefits for details
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $0.00
Copayment for Medicare-covered Group Sessions $0.00

Please see Summary of Benefits for details
Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $300.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit

Please see Summary of Benefits for details
Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $0.00
Referral Required for Podiatry Services

Please see Summary of Benefits for details
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
Copayment for Skilled Nursing Facility Services per Stay $0.00
  • We cover up to 100 days per benefit period.
Prior Authorization Required for Skilled Nursing Facility Services
Referral Required for Skilled Nursing Facility Services

Please see Summary of Benefits for details

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 Oral Exams $0.00
  • Maximum 2 visits every year
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 2 visits every year
Copayment for Dental X-Rays $0.00
  • Maximum 2 visits every year

Comprehensive Dental:
Copayment for Medicare-covered Benefits $0.00
Copayment for Diagnostic Services $0.00
Copayment for Restorative Services $28.00 to $580.00
Copayment for Periodontics $0.00 to $400.00
Copayment for Extractions $22.00
Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $420.00 to $480.00
Prior Authorization Required for Comprehensive Dental
Referral Required for Comprehensive Dental

Please see Summary of Benefits for details

Vision Benefits

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

Coverage Details
Vision benefitsIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for eyeglasses or contact lenses after cataract surgery $0.00
Maximum Plan Allowance of $575 every two years for all Non-Medicare covered eyewear
  • If your eyewear costs more than $575, you pay the difference.

Please see Summary of Benefits for details

Hearing Benefits

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

Coverage Details
Hearing benefitsIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year

Please see Summary of Benefits for details

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 shotsHepatitis B shotsPneumococcal shots
Tobacco use cessation
Yearly "Wellness" visit

Please see Summary of Benefits for details

When reviewing Georgia 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 Georgia 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

Georgia Counties Served

Barrow Butts Newton Rockdale Spalding Walton
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