With your HMO enrollment, you agree that Kaiser Permanente will provide all your medical services, including doctor, specialist, hospital, outpatient, laboratory, home health care, hospice, mental health, emergency, vision exams, hearing exams and hearing aids, speech, occupational, and physical therapy, prescription drugs, well-baby care, and preventive care.
Your vision coverage and chemical dependency services are provided through Kaiser.
Your Dental benefits are provided through Delta Dental.
There are no annual deductibles to pay or claim forms to file.
But it is important to understand that all medical services, except covered emergencies, must be obtained from or with the permission of the HMO. You pay 100% of the charges for medical services and supplies obtained from any source except Kaiser Permanente, except in an emergency.
Kaiser Permanente, not the Health and Welfare Plan Trustees, sets the rules and conducts the appeals process for denied claims. It is the final authority in determining whether any services and supplies you may request, in or out of the HMO, are medically necessary and covered benefits.
The Services described below are covered only if all the following conditions are satisfied:
• The Services are Medically Necessary
• The Services are provided, prescribed, authorized, or directed by a Plan Physician and you receive the Services from Plan Providers inside our Service Area, except where specifically noted to the contrary in the Evidence of Coverage for authorized referrals, Emergency Care, Post-stabilization Care, Out-of-Area Urgent Care, and emergency ambulance services.
Senior Advantage is for Members entitled to Medicare, providing the advantages of combined Medicare and Health Plan benefits. Enrollment in this Senior Advantage with Part D plan means that you are automatically enrolled in Medicare Part D.
| ANNUAL OUT-OF-POCKET MAXIMUMS | |
|---|---|
| For any one Member in the same Family Unit | $1,500 per calendar year |
| For an entire Family Unit of two or more Members | $3,000 per calendar year |
| Copayments and Coinsurance for most Services count toward this maximum as desribed in the Evidence of Coverage | |
| Deductible or Lifetime Maximum | None |
| PROFESSIONAL SERVICES (Plan Provider office visits) | |
| Primary and specialty care visits (includes routine and Urgent Care appoinments) | $10 per visit |
| Routine preventive physical exams | $10 per visit |
| Family planning visits | $10 per visit |
| Scheduled prenatal care and first postpartum visit | $10 per visit |
| Eye exams and glaucoma screening | $10 per visit |
| Hearing tests | $10 per visit |
| Physical, occupational, and speech therapy visits | $10 per visit |
| OUTPATIENT SERVICES | |
| Outpatient surgery | $10 per procedure |
| Allergy injection visits | $3 per visit |
| Allergy testing visits | $10 per visit |
| Vaccines (immunizations) | No charge |
| X-rays, annual mammograms, and lab tests | No charge |
| Manual manipulation of the spine | $10 per visit |
| Health education | $10 per individual visit No charge for group visits |
| HOSPITILIZATION SERVICES | |
| Room and board, surgery, anesthesia, X-rays, lab tests, and drugs | $100 per admission |
| EMERGENCY HEALTH COVERAGE | |
| Emergency Department and Out-of-Area Urgent Care visits | $35 per visit (does not apply if admitted to the hospital as an inpatient within 24 hours for the same condition) |
| AMBULANCE SERVICES | |
| Ambulance Services | $50 per trip |
| PRESCRIPTION DRUG COVERAGE | |
| Most covered outpatient items in accord with our drug formularies | $10 for up to a 100 day supply |
| DURABLE MEDICAL EQUIPMENT | |
| Covered durable medical equipment for home use in accord with our DME formulary | No charge |
| MENTAL HEALTH SERVICES | |
| Inpatient psychiatric care: first 190 days per lifetime as covered by Medicare. Thereafter, up to 45 days per calendar year | $100 per admission |
| Outpatient individual and group therapy visits | $10 per individual therapy visit $5 per group therapy visit |
| CHEMICAL DEPENDENCY SERVICES | |
| Inpatient detoxification | $100 per admission |
| Outpatient individual therapy visits | $10 per visit |
| Outpatient group therapy visits | $5 per visit |
| Transitional residential recovery Services (up to 60 days per calendar year, not to exceed 120 days in any five-year period) | $100 per admission |
| Home Health Services | |
| Home health care (part-time, intermittent) No charge | |
| OTHER | |
| Eyewear purchased from Plan Optical Sales Offices every 24 months | Amount in excess of $175 Allowance |
| Skilled nursing facility care (up to 100 days per benefit period) | No charge |
| This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, exclusions, or limitations, and it does not list all benefits, Copayments, and Coinsurance. For a complete explanation, please refer to the Evidence of Coverage. Please note that we provide all benefits required by law (for example, diabetes testing supplies). | |
The Services described below are covered only if all the following conditions are satisfied:
• The Services are Medically Necessary
• The Services are provided, prescribed, authorized, or directed by a Plan Physician and you receive the Services from Plan Providers inside our Service Area, except where specifically noted to the contrary in the Evidence of Coverage for authorized referrals, Emergency Care, Post-stabilization Care, Out-of-Area Urgent Care, and emergency ambulance services.
Senior Advantage is for Members entitled to Medicare, providing the advantages of combined Medicare and Health Plan benefits. Enrollment in this Senior Advantage with Part D plan means that you are automatically enrolled in Medicare Part D.
| ANNUAL OUT-OF-POCKET MAXIMUMS | |
| For any one Member in the same Family Unit | $1,500 per calendar year |
| For an entire Family Unit of two or more Members | $3,000 per calendar year |
| Copayments and Coinsurance for most Services count toward this maximum as desribed in the Evidence of Coverage | |
| Deductible or Lifetime Maximum | None |
| PROFESSIONAL SERVICES (Plan Provider office visits) | |
| Primary and specialty care visits (includes routine and Urgent Care appointments) | No charge |
| Routine preventive physical exams | No charge |
| Family planning visits | No charge |
| Scheduled prenatal care and first postpartum visit | No charge |
| Eye exams and glaucoma screening | No charge |
| Hearing tests | No charge |
| Physical, occupational, and speech therapy visits | No charge |
| OUTPATIENT SERVICES | |
| Outpatient surgery | No charge |
| Allergy injection visits | No charge |
| Allergy testing visits | No charge |
| Vaccines (immunizations) | No charge |
| X-rays, annual mammograms, and lab tests | No charge |
| Manual manipulation of the spine | No charge |
| Health education | No charge |
| HOSPITILIZATION SERVICES | |
| Room and board, surgery, anesthesia, X-rays, lab tests, and drugs | No charge |
| EMERGENCY HEALTH COVERAGE | |
| Emergency Department and Out-of-Area Urgent Care visits | No charge |
| EMERGENCY HEALTH COVERAGE | |
| Ambulance Services | No charge |
| PRESCRIPTION DRUG COVERAGE | |
| Covered outpatient items in accord with our drug formularies | No charge for up to a 100 day supply |
| DURABLE MEDICAL EQUIPMENT | |
| Covered durable medical equipment for home use in accord with our DME formulary | No charge |
| MENTAL HEALTH SERVICES | |
| Inpatient psychiatric care: first 190 days per lifetime as covered by Medicare. Thereafter, up to 45 days per calendar year. | No charge |
| Outpatient visits (individual and group therapy visits) | No charge |
| CHEMICAL DEPENDENCY SERVICES | |
| Inpatient detoxification | No charge |
| Outpatient individual therapy visits | No charge |
| Outpatient group therapy visits | No charge |
| Transitional residential recovery Services (up to 60 days per calendar year, not to exceed 120 days in any five-year period) | No charge |
| HOME HEALTH SERVICES | |
| Home health care (part-time, intermittent) | No charge |
| OTHER | |
| Eyewear purchased from Plan Optical Sales Offices every 24 months | Amount in excess of $350 Allowance |
| Hearing aid(s) every 36 months | Amount in excess of $2,500 Allowance per aid |
| Skilled nursing facility care | No charge |
| This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, exclusions, or limitations, and it does not list all benefits, Copayments, and Coinsurance. For a complete explanation, please refer to the Evidence of Coverage. Please note that we provide all benefits required by law (for example, diabetes testing supplies). | |
800.464.4000 (ENGLISH)
800.788.0616 (SPANISH)
Senior Advantage Booklet
Senior Advantage (MSP) Booklet
Enroll/Change Form (English Only)