2019 Medicare Advantage Plan Services for
Kaiser Permanente Medicare Advantage Standard MD (HMO)
Kaiser Permanente Medicare Advantage Standard MD (HMO) H2172-004 is a 2019 Medicare Advantage or Medicare Part-C plan by Kaiser Permanente available to residents in Maryland. This plan includes additional Medicare prescription drug (Part-D) coverage. The Kaiser Permanente Medicare Advantage Standard MD (HMO) has a monthly premium of $28.00 and has an in-network Maximum Out-of-Pocket limit of $6,700 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $6,700 out of pocket. This can be a extremely nice safety net.
Kaiser Permanente Medicare Advantage Standard MD (HMO) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your PCPs okay, called a referral. Services received from an out-of-network provider are not typically covered by the plan.
Kaiser Permanente works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Kaiser Permanente Medicare Advantage Standard MD (HMO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Kaiser Permanente and not Original Medicare. With Medicare Advantage Plans you are always covered for urgently needed and emergency care. Plus you receive all of the benefits of Original Medicare from Kaiser Permanente except hospice care. Original Medicare still provides you with hospice care even if you sign up for a Medicare Advantage Plan.
2019 Kaiser Permanente Medicare Advantage Plan Details
| Name: | Kaiser Permanente Medicare Advantage Standard MD (HMO) |
|---|---|
| ID: | H2172-004 |
| Provider: | Kaiser Permanente |
| Year: | 2019 |
| Type: | Local HMO |
| Monthly Premium C+D: | $28.00 |
| Part C Premium: | $0.00 |
| MOOP: | $6,700 |
| Part D (Drug) Premium: | $28.00 |
| Part D Supplemental Premium | $0.00 |
| Total Part D Premium: | $28.00 |
| Drug Deductible: | $0.00 |
| Tiers with No Deductible: | 0 |
| Gap Coverage: | Yes |
| Initial Coverage Limit: | $3820 |
| Benchmark: | not below the regional benchmark |
| Type of Medicare Health: | Enhanced Alternative |
| Drug Benefit Type: | Enhanced |
Part-C Premium
Kaiser Permanente plan charges a $0.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.
Part-D Deductible and Premium
Kaiser Permanente Medicare Advantage Standard MD (HMO) has a monthly drug premium of $28.00 and a $0.00 drug deductible. This Kaiser Permanente plan offers a $28.00 Part D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by Kaiser Permanente above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $28.00. The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lower due to negative basic or supplemental premiums.
Premium Assistance
Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Kaiser Permanente Medicare Advantage Standard MD (HMO) medicare insurance offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $7.00 for 75% low income subsidy $14.00 for 50% and $21.00 for 25%.
| Full LIS Premium: | $0.00 |
|---|---|
| 75% LIS Premium: | $7.00 |
| 50% LIS Premium: | $14.00 |
| 25% LIS Premium: | $21.00 |
Gap Coverage
In 2019 once you and your plan provider have spent $3820 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for brand-name drugs and 37% on generic drugs unless your plan offers additional coverage. This Kaiser Permanente plan does offer additional coverage through the gap.
Plan Services
Health plan deductible
| $0 |
|---|
Emergency care/Urgent care
| Emergency | $90 per visit (always covered) | |
|---|---|---|
| Urgent care | $40 per visit (always covered) |
Diagnostic procedures/lab services/imaging
| Diagnostic tests and procedures | $0 copay | |
|---|---|---|
| Lab services | $0 copay | |
| Diagnostic radiology services (e.g., MRI) | $150 | |
| Outpatient x-rays | $10 |
Hearing
| Hearing exam | $40 | |
|---|---|---|
| Fitting/evaluation | Not covered | |
| Hearing aids - inner ear | Not covered | |
| Hearing aids - outer ear | Not covered | |
| Hearing aids - over the ear | Not covered |
Preventive dental
| Office visit | $30.00 | |
|---|---|---|
| Oral exam | Covered under office visit | |
| Cleaning | Covered under office visit | |
| Fluoride treatment | Covered under office visit | |
| Dental x-ray(s) | Covered under office visit |
Comprehensive dental
| Non-routine services | $0-55 | |
|---|---|---|
| Diagnostic services | $11-69 | |
| Restorative services | $40-755 | |
| Endodontics | $47-1,047 | |
| Periodontics | $33-836 | |
| Extractions | $72-429 | |
| Prosthodontics, other oral/maxillofacial surgery, other services | $30-3,658 |
Vision
| Routine eye exam | $10-40 | |
|---|---|---|
| Other | Not covered | |
| Contact lenses | $0 copay | |
| Eyeglasses (frames and lenses) | $0 copay | |
| Eyeglass frames | $0 copay | |
| Eyeglass lenses | $0 copay | |
| Upgrades | Not covered |
Mental health services
| Inpatient hospital - psychiatric | $250 per day for days 1 through 5 $0 per day for days 6 through 90 |
|
|---|---|---|
| Outpatient group therapy visit with a psychiatrist | $10 | |
| Outpatient individual therapy visit with a psychiatrist | $20 | |
| Outpatient group therapy visit | $10 | |
| Outpatient individual therapy visit | $20 |
Skilled Nursing Facility
| $0 per day for days 1 through 20 $160 per day for days 21 through 100 |
|---|
Rehabilitation services
| Occupational therapy visit | $40 | |
|---|---|---|
| Physical therapy and speech and language therapy visit | $40 |
Ground ambulance
| $275 |
|---|
Other health plan deductibles?
| In-Network | No |
|---|
Transportation
| Not covered |
|---|
Foot care (podiatry services)
| Foot exams and treatment | $40 | |
|---|---|---|
| Routine foot care | Not covered |
Medical equipment/supplies
| Durable medical equipment (e.g., wheelchairs, oxygen) | 20% per item | |
|---|---|---|
| Prosthetics (e.g., braces, artificial limbs) | 20% per item | |
| Diabetes supplies | $0 copay |
Wellness programs (e.g., fitness, nursing hotline)
| Covered |
|---|
Medicare Part B drugs
| Chemotherapy | $0-47 | |
|---|---|---|
| Other Part B drugs | $0-47 |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $6,700 In-network |
|---|
Optional supplemental benefits
| Yes |
|---|
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network | No |
|---|
Inpatient hospital coverage
| $250 per day for days 1 through 5 $0 per day for days 6 through 90 |
|---|
Outpatient hospital coverage
| $250 per visit |
|---|
Doctor visits
| Primary | $10 per visit | |
|---|---|---|
| Specialist | $40 per visit |
Preventive care
| $0 copay |
|---|
Ratings for Kaiser Permanente Medicare Advantage Standard MD (HMO) H2172
| 2018 Overall Rating | ||
|---|---|---|
| Part C Summary Rating | ||
| Part D Summary Rating | ||
| Staying Healthy: Screenings, Tests, Vaccines | ||
| Managing Chronic (Long Term) Conditions | ||
| Member Experience with Health Plan | ||
| Complaints and Changes in Plans Performance | ||
| Health Plan Customer Service | ||
| Drug Plan Customer Service | ||
| Complaints and Changes in the Drug Plan | ||
| Member Experience with the Drug Plan | ||
| Drug Safety and Accuracy of Drug Pricing |
Staying Healthy, Screening, Testing, & Vaccines
| Total Preventative Rating | ||
|---|---|---|
| Breast Cancer Screening | ||
| Colorectal Cancer Screening | ||
| Annual Flu Vaccine | ||
| Improving Physical | ||
| Improving Mental Health | ||
| Monitoring Physical Activity | ||
| Adult BMI Assessment |
Managing Chronic And Long Term Care for Older Adults
| Total Rating | ||
|---|---|---|
| SNP Care Management | ||
| Medication Review | ||
| Functional Status Assessment | ||
| Pain Screening | ||
| Osteoporosis Management | ||
| Diabetes Care - Eye Exam | ||
| Diabetes Care - Kidney Disease | ||
| Diabetes Care - Blood Sugar | ||
| Controlling Blood Pressure | ||
| Rheumatoid Arthritis | ||
| Reducing Risk of Falling | ||
| Improving Bladder Control | ||
| Medication Reconciliation | ||
| Plan All-Cause Readmissions | ||
| Statin Therapy |
Member Experience with Health Plan
| Total Experience Rating | ||
|---|---|---|
| Getting Needed Care | ||
| Timely Care and Appointments | ||
| Customer Service | ||
| Health Care Quality | ||
| Rating of Health Plan | ||
| Care Coordination |
Member Complaints and Changes in Kaiser Permanente Medicare Advantage Standard MD (HMO) Plans Performance
| Total Rating | ||
|---|---|---|
| Complaints about Health Plan | ||
| Members Leaving the Plan | ||
| Health Plan Quality Improvement |
Health Plan Customer Service Rating for Kaiser Permanente Medicare Advantage Standard MD (HMO)
| Total Customer Service Rating | ||
|---|---|---|
| Timely Decisions About Appeals | ||
| Reviewing Appeals Decisions | ||
| Call Center, TTY, Foreign Language |
Kaiser Permanente Medicare Advantage Standard MD (HMO) Drug Plan Customer Service ratings
| Total Rating | ||
|---|---|---|
| Call Center, TTY, Foreign Language | ||
| Appeals Auto | ||
| Appeals Upheld |
Ratings For Member Complaints and Changes in the Drug Plans Performance
| Total Rating | ||
|---|---|---|
| Complaints about the Drug Plan | ||
| Members Choosing to Leave the Plan | ||
| Drug Plan Quality Improvement |
Member Experience with the Drug Plan
| Total Rating | ||
|---|---|---|
| Rating of Drug Plan | ||
| Getting Needed Prescription Drugs |
Drug Safety and Accuracy of Drug Pricing
| Total Rating | ||
|---|---|---|
| MPF Price Accuracy | ||
| Drug Adherence for Diabetes Medications | ||
| Drug Adherence for Hypertension (RAS antagonists) | ||
| Drug Adherence for Cholesterol (Statins) | ||
| MTM Program Completion Rate for CMR | ||
| Statin with Diabetes |
Coverage Area for Kaiser Permanente Medicare Advantage Standard MD (HMO)
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Source: CMS.
Data as of September 2, 2018.
Star Rating as of October 10, 2018.
For More Information on Ratings Please See the CMS Tech Notes.
Notes: Data are subject to change as contracts are finalized. For 2019, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part D benefit.
Includes 2019 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.