- Learn about the features and benefits of the Kaiser Permanente HMO DHMO Plus under each of the two provider options. Choice Products Colorado. 2 Tier Point-of-Service Plan. 3 Tier Point-of-Service Plan. The emergency care copay will be waived if you are directly admitted to a hospital as a result of an emergency.
- Improving health care access for people with limited incomes and resources is fundamental to Kaiser Permanente’s mission. Our Medical Financial Assistance program helps low-income, uninsured, and underserved patients receive access to care.
All Kaiser Permanente health plans cover the medical benefits you and your family need, with an emphasis on preventive care and your overall wellness. Plus, every plan includes access to high-quality virtual care with Kaiser Permanente doctors and clinicians.
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Kaiser Permanente Senior Advantage Standard (HMO) H9003-006 is a 2021 Medicare Advantage Plan or Medicare Part-C plan by Kaiser Permanente available to residents in Oregon and Washington. This plan includes additional Medicare prescription drug (Part-D) coverage. The Kaiser Permanente Senior Advantage Standard (HMO) has a monthly premium of $44.00 and has an in-network Maximum Out-of-Pocket limit of $4,900 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $4,900 out of pocket. This can be a extremely nice safety net.
Kaiser Permanente Senior Advantage Standard (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 Senior Advantage Standard (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.
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2021 Kaiser Permanente Medicare Advantage Plan Costs
| Name: | Kaiser Permanente Senior Advantage Standard (HMO) |
|---|---|
| Plan ID: | |
| Provider: | Kaiser Permanente |
| Year: | 2021 |
| Type: | Local HMO |
| Monthly Premium C+D: | $44.00 |
| Part C Premium: | $3.30 |
| MOOP: | $4,900 |
| Part D (Drug) Premium: | $40.70 |
| Part D Supplemental Premium | $0 |
| Total Part D Premium: | $40.70 |
| Drug Deductible: | $0 |
| 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: | H9003-007 |
Kaiser Permanente Senior Advantage Standard (HMO) Part-C Premium
Kaiser Permanente plan charges a $3.30 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.
H9003-006 Part-D Deductible and Premium
Kaiser Permanente Senior Advantage Standard (HMO) has a monthly drug premium of $40.70 and a $0 drug deductible. This Kaiser Permanente plan offers a $40.70 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 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 $40.70. 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.
Kaiser Permanente Gap Coverage
In 2021 once you and your plan provider have spent $4130 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.
Premium Assistance
The Low Income Subsidy (LIS) helps people with Medicare pay for prescription drugs, and lowers the costs of Medicare prescription drug coverage. Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Kaiser Permanente Senior Advantage Standard (HMO) medicare insurance offers a $4.70 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $13.70 for 75% low income subsidy $22.70 for 50% and $31.70 for 25%.
| Full LIS Premium: | $4.70 |
|---|---|
| 75% LIS Premium: | $13.70 |
| 50% LIS Premium: | $22.70 |
| 25% LIS Premium: | $31.70 |
H9003-006 Formulary or Drug Coverage
Kaiser Permanente Senior Advantage Standard (HMO) 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.
2021 Kaiser Permanente Senior Advantage Standard (HMO) Summary of Benefits
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) | $10-150 copay |
|---|---|
| Diagnostic tests and procedures | $10-35 copay |
| Lab services | $0 copay |
| Outpatient x-rays | $10 copay |
Doctor Visits
| Primary | $5 copay per visit |
|---|---|
| Specialist | $35 copay per visit |
Emergency care/Urgent Care
| Emergency | $90 copay per visit (always covered) |
|---|---|
| Urgent care | $35 copay per visit (always covered) |
Foot Care (podiatry services)
| Foot exams and treatment | $35 copay |
|---|---|
| Routine foot care | Not covered |
Ground Ambulance
| $200 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 | $35 copay |
Inpatient Hospital Coverage
| $265 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 | $245 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
| $4,900 In-network |
|---|
Option
| No |
|---|
Optional supplemental benefits
| Yes |
|---|
Outpatient Hospital Coverage
| $0-210 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 | $35 copay |
|---|---|
| Physical therapy and speech and language therapy visit | $35 copay |
Skilled Nursing Facility
| $0 per day for days 1 through 20 $50 per day for days 21 through 100 |
|---|
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 | $35 copay |
| Upgrades | Not covered |
Wellness Programs (e.g. fitness nursing hotline)
| Covered |
|---|
Reviews for Kaiser Permanente Senior Advantage Standard (HMO) H9003
| 2019 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 |
| Rheumatoid Arthritis |
| Reducing Risk of Falling |
| Improving Bladder Control |
| Medication Reconciliation |
| Statin Therapy |
Member Experience with Health Plan
| Total Experience Rating |
|---|
| Getting Needed Care |
| Customer Service |
| Health Care Quality |
| Rating of Health Plan |
| Care Coordination |
Member Complaints and Changes in Kaiser Permanente Senior Advantage Standard (HMO) Plans Performance
| Total Rating |
|---|
| Complaints about Health Plan |
| Members Leaving the Plan |
| Health Plan Quality Improvement |
| Timely Decisions About Appeals |
Health Plan Customer Service Rating for Kaiser Permanente Senior Advantage Standard (HMO)
| Total Customer Service Rating |
|---|
| Reviewing Appeals Decisions |
| Call Center, TTY, Foreign Language |
Kaiser Permanente Senior Advantage Standard (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 |
Ready to Enroll?
Or Call
1-855-778-4180
Mon-Sat 8am-11pm EST
Sun 9am-6pm EST
Coverage Area for Kaiser Permanente Senior Advantage Standard (HMO)
(Click county to compare all available Advantage plans)
| State: | Oregon Washington |
|---|---|
| County: | Benton,Clackamas,Clark,Columbia,Cowlitz, Linn,Marion,Multnomah,Polk, Wahkiakum,Washington,Yamhill, |
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Source: CMS.
Data as of September 9, 2020.
Notes: Data are subject to change as contracts are finalized. For 2021, 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 2021 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.
When you are searching for health coverage, You want to make sure there’s a plan available that meets your family’s health needs, allows you to see your preferred doctors or specialists, and works with your budget. The most common choice you’ll have is between a health maintenance organization (HMO) plan and a preferred provider organization (PPO) plan.
In this article, we’ll explain and compare the following aspects of HMO and PPO plans:
- HMO plan advantages and disadvantages
- HMO plan costs
- PPO plan advantages and disadvantages
- PPO plan costs
- HMO plans versus PPO plans
- Other types of health plans (EPO and POS)
- What to consider when choosing a health insurance plan
What’s an HMO plan?
An HMO plan is based on a network of hospitals, doctors, and other health care providers that agree to coordinate care within a network in return for a certain payment rate for their services. Many HMO providers are paid on a per-member basis, regardless of the number of times they see a member. This makes HMO plans a more economical choice than PPOs. An HMO generally only covers care received from the plan’s contracted providers, known as “in-network” providers. When you’re covered through an HMO, you may need to select a primary care doctor to manage your health care and refer you to specialists within the network. While you will typically need to stay within the network for care, HMO plans sometimes refer members to see outside specialists for care that can’t be provided within their HMO system. Members may also seek emergency care from the closest emergency room.
Advantages of HMO plans
The advantages of HMO plans compared with PPO plans make them a popular choice if you’re budget-conscious or if you don’t anticipate many doctor visits.
- Lower monthly premiums and generally lower out-of-pocket costs.
- Generally lower out-of-pocket costs for prescriptions.
- Claims won’t have to be filed as often since medical care you receive is typically in-network.
- Convenience of having a primary care doctor as your advocate to coordinate and manage your care.
Disadvantages of HMO plans
Kaiser Hmo Er Copay
- HMO plans require you to stay within their network for care, unless it’s a medical emergency.
- If your current doctor isn’t part of the HMO’s network, you’ll need to choose a new primary care doctor.
Kaiser Permanente Hmo Copay
What costs are associated with an HMO plan?
Typical costs associated with HMO plans include deductibles (the amount you must pay before insurance begins contributing to your medical bills) and monthly premiums (the amount taken out of your paycheck).
What is a PPO plan?
A PPO plan is designed to give you more flexibility in choosing which health care providers you see. Care is typically more affordable if you stay in-network. But if you have a doctor you prefer to see, it might be easier to visit him or her with a PPO plan.
Advantages of PPO plans
A PPO plan can be a better choice compared with an HMO if you need flexibility in which health care providers you see.
- More flexibility to use providers both in-network and out-of-network.
- You can usually visit specialists without a referral, including out-of-network specialists.
Kaiser Permanente $20 Copayment Hmo Plan
Disadvantages of PPO plans
- Typically higher monthly premiums and out-of-pocket costs than for HMO plans.
- More responsibility for managing and coordinating your own care without a primary care doctor.
What costs are associated with a PPO plan?
The typical costs of a PPO plan can include higher monthly premiums and out-of-pocket costs. You may also need to pay a deductible before your coverage benefits begin. If you see an out-of-network doctor, you’ll typically have to pay in full for your copay during the visit, cover the cost of the medical bill, and then file a claim to be reimbursed by your PPO plan.
What are the differences between HMO and PPO plans?
This chart provides a simple comparison between an HMO and a PPO, based on some of the key components of health insurance plans.