2023 Kaiser Permanente Senior Advantage Enhanced (HMO-POS)

Kaiser Permanente Senior Advantage Enhanced (HMO-POS) H9003-001 is a 2023 Medicare Advantage Plan or Part-C by Kaiser Permanente available to residents in Oregon and Washington. This plan includes additional prescription drug (Part-D) coverage. Kaiser Permanente Kaiser Permanente Senior Advantage Enhanced (HMO-POS) has a monthly premium of $127.00 and has an in-network maximum out-of-pocket limit of $3,000 (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay $3,000 out-of-pocket. This can be an extremely nice safety net.

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 Senior Advantage Enhanced (HMO-POS) 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 2023 Medicare Advantage Plan you are always covered for urgently needed and emergency care. Plus, you receive all the benefits of Original Medicare from Kaiser Permanente except hospice care. Original Medicare still provides you with hospice care if you sign up for Medicare Advantage in Oregon or Medicare Advantage in Washington.




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2023 Kaiser Permanente Medicare Advantage Plan Overview

Name:Kaiser Permanente Senior Advantage Enhanced (HMO-POS)
Plan ID:H9003 001 0
Provider:Kaiser Permanente
Year:2023
Type:Local HMO
Combined Premium (C+D):$127.00/mo
Part C Premium:$20.10/mo
MOOP:$3,000/yr
Part D (Drug) Premium:$74.10/mo
Part D Supplemental Premium$32.80/mo
Total Part D Premium:$106.9/mo
Drug Deductible:$0/yr
Tiers with No Deductible:0
Gap Coverage:Yes
Benchmark:Not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced
Similar Plan: H9003-006




What type of plan is Kaiser Permanente Senior Advantage Enhanced (HMO-POS)

Kaiser Permanente Senior Advantage Enhanced (HMO-POS) 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 primary care physician 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 primary care physician approval, called a referral. Services received from an out-of-network provider are not typically covered.

With a HMO-POS point-of-service you have the option to go out-of-network or see a specialist without a referral. But, you may pay more for out-of-network care you receive than from an in-network provider.



How much does Kaiser Permanente Senior Advantage Enhanced (HMO-POS) cost?


Monthly Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Kaiser Permanente charges a $127.00 consolidated premium. The Part C premium is $20.10 this charge 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

An annual deductible is the amount you pay out-of-pocket for your prescription drugs before your plan begins to pay. Kaiser Permanente Senior Advantage Enhanced (HMO-POS) has a monthly drug premium of $74.10 and a $0 drug deductible. This Kaiser Permanente plan offers a $74.10 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 $32.80. 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 $106.9. The Part D Total Premium is the addition of supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.


Kaiser Permanente Gap Coverage

In 2023 once you and your plan provider have spent $4660 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 prescription drugs unless your plan offers additional coverage. This Kaiser Permanente plan does offer additional coverage through the gap.


Extra Help Premium Assistance

The Low Income Subsidy (LIS) Extra Helps people with Medicare pay for prescription drugs and lowers the costs of Medicare prescription drug coverage. Income limits are based on the Federal Poverty Level (FPL), which changes every year in February or March. The 2022 income limit is $1,719 ($2,309 for couples) per month. Depending on your income level you may be eligible for a full 75%, 50%, 25% premium assistance. The Kaiser Permanente Senior Advantage Enhanced (HMO-POS) medicare insurance offers a $65.90 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $76.10 for 75% low-income subsidy $86.40 for 50% and $96.60 for 25%.


Full Assistance Premium:$65.90
75% Assistance Premium:$76.10
50% Assistance Premium:$86.40
25% Assistance Premium:$96.60


MOOP

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Kaiser Permanente Senior Advantage Enhanced (HMO-POS) by Kaiser Permanente MOOP is $3,000. Once you spend $3,000 you will pay nothing for Part A or Part B covered services. Copayments and coinsurance for Medicare approved services apply toward your out-of-pocket limit. Remember Original Medicare (Parts A and B) doesn’t have a MOOP.



Formulary and Drug Coverage

Kaiser Permanente Senior Advantage Enhanced (HMO-POS) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price.

Drug Tier Copay
Preferred
Pharmacy
Copay
Nonpreferred
Pharmacy
Tier 1 NA $0
Tier 2 NA $10
Tier 3 NA $45
Tier 4 NA $90
Tier 5 NA 33%
Tier 6 NA $0

The complete Kaiser Permanente Senior Advantage Enhanced (HMO-POS) Formulary.
*Initial Coverage Phase and 30 day supply





Summary of Benefits

*2021 data this will be updated with 2023 data when available.

The benefit information provided is a summary of what Kaiser Permanente Senior Advantage Enhanced (HMO-POS) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Kaiser Permanente helps get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.




Additional Benefits


Yes



Comprehensive Dental


Diagnostic services Not covered
Endodontics Not covered
Extractions Not covered
Non-routine services Not covered
Periodontics Not covered
Prosthodontics, other oral/maxillofacial surgery, other services Not covered
Restorative services Not covered



Deductible


$0



Diagnostic Tests and Procedures


Diagnostic radiology services (e.g., MRI) $10-100 copay
Diagnostic tests and procedures $10-25 copay
Lab services $0 copay
Outpatient x-rays $10 copay



Doctor Visits


Primary $5 copay per visit
Specialist $25 copay per visit



Emergency care/Urgent Care


Emergency $120 copay per visit (always covered)
Urgent care $25 copay per visit (always covered)



Foot Care (podiatry services)


Foot exams and treatment $25 copay
Routine foot care Not covered



Ground Ambulance


$150 copay



Hearing


Fitting/evaluation $0 copay
Hearing aids - inner ear Not covered
Hearing aids - outer ear Not covered
Hearing aids - over the ear Not covered
Hearing exam $25 copay



Inpatient Hospital Coverage


$200 per day for days 1 through 6
$0 per day for days 7 through 90



Medical Equipment/Supplies


Diabetes supplies $0 copay
Durable medical equipment (e.g., wheelchairs, oxygen) 0-20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) 20% coinsurance per item



Medicare Part B Drugs


Chemotherapy $10-45 copay or 0-15% coinsurance
Other Part B drugs $0-45 copay or 0-15% coinsurance



Mental Health Services


Inpatient hospital - psychiatric $200 per day for days 1 through 6
$0 per day for days 7 through 90
Outpatient group therapy visit $2 copay
Outpatient group therapy visit with a psychiatrist $2 copay
Outpatient individual therapy visit $5 copay
Outpatient individual therapy visit with a psychiatrist $5 copay



MOOP


$3,000 In-network



Option


No



Optional supplemental benefits


Yes



Outpatient Hospital Coverage


$0-125 copay per visit



Package #1


Deductible
Monthly Premium $44.00



Preventive Care


$0 copay



Preventive Dental


Cleaning Not covered
Dental x-ray(s) Not covered
Fluoride treatment Not covered
Oral exam Not covered



Rehabilitation Services


Occupational therapy visit $25 copay
Physical therapy and speech and language therapy visit $25 copay



Skilled Nursing Facility


$0 copay



Transportation


Not covered



Vision


Contact lenses Not covered
Eyeglass frames Not covered
Eyeglass lenses Not covered
Eyeglasses (frames and lenses) Not covered
Other Not covered
Routine eye exam $25 copay
Upgrades Not covered



Wellness Programs (e.g. fitness nursing hotline)


Covered




CMS Star Ratings


Is Kaiser Permanente Senior Advantage Enhanced (HMO-POS) a good plan? Kaiser Permanente Senior Advantage Enhanced (HMO-POS) received a 4 overall star rating from the CMS. The CMS uses a Star Rating System to measure how well Medicare Advantage and Part D plans perform. Plans are rated on a one-to-five scale, with one star representing poor performance and five stars representing excellent performance. Medicare Advantage with prescription drug (Part D) coverage (MA-PD) contracts are rated on up to 38 unique quality and performance measures. You can use the CMS star rating to compare Kaiser Permanente Senior Advantage Enhanced (HMO-POS) performance among several different plans.

2022 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
Monitoring Physical Activity


Managing Chronic And Long Term Care for Older Adults

Total Rating
SNP Care Management
Medication Review
Pain Assessment
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Controlling Blood Pressure
Reducing Risk of Falling
Improving Bladder Control
Medication Reconciliation
Statin Therapy


Member Experience with H9003-001 Health Plan

Total Experience Rating
Getting Needed Care
Getting Appointments
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination


Member Complaints and Changes in Plans Performance

Total Rating
Complaints about Health Plan
Members Leaving the Plan
Health Plan Quality Improvement


Health Plan Customer Service Rating for Kaiser Permanente

Total Customer Service Rating
Timely Decisions About Appeals
Reviewing Appeals Decisions
Call Center, TTY, Foreign Language


Drug Plan Customer Service Ratings

Total Rating
Call Center, TTY, Foreign Language


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



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Coverage Area

(Click county or state to compare all available Advantage plans)

The availability of Medicare Advantage Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for Kaiser Permanente Senior Advantage Enhanced (HMO-POS) requires you to live in that plan’s service area. The service area is listed below:



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How much does Kaiser Permanente Senior Advantage Enhanced (HMO-POS) cost?

Kaiser Permanente charges a $127.00 consolidated monthly premium. A monthly premium is the fee you pay to the plan in exchange for coverage of Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

How much is Kaiser Permanente Senior Advantage Enhanced (HMO-POS) MOOP?

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Kaiser Permanente Senior Advantage Enhanced (HMO-POS) by Kaiser Permanente MOOP is $3,000. Once you spend $3,000 you will pay nothing for Part A or Part B covered services.

What type of plan is Kaiser Permanente Senior Advantage Enhanced (HMO-POS)?

Kaiser Permanente Senior Advantage Enhanced (HMO-POS) is a Local HMO. With a health maintenance organization you will be required to receive most of your health care from an in-network provider. HMOs require that you select a primary care physician (PCP).

With a HMO-POS point-of-service you have the option to go out-of-network or see a specialist without a referral. But, you may pay more for out-of-network care you receive than from an in-network provider.

Is Kaiser Permanente Senior Advantage Enhanced (HMO-POS) a good plan?

Kaiser Permanente Senior Advantage Enhanced (HMO-POS) received a 4 overall star rating from the CMS. The CMS uses a Star Rating System to measure how well plans perform. Plans are rated on a one-to-five scale, with one star representing poor performance and five stars representing excellent performance.



Source:CMS. Data as of Oct 1, 2022.

Last updated on

Notes: Data are subject to change as contracts are finalized. For 2023, 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 2023 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

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*Licensed Agent Disclaimer: We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE (TTY users should call 1-877-486-2048) 24 hours a day/7 days a week to get information on all of your options.

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