Kaiser Permanente Medicare Advantage Value Balt (HMO)

Kaiser Permanente Medicare Advantage Value Balt (HMO) H2172-006 Plan Details
3.5 out of 5 stars

Kaiser Permanente Medicare Advantage Value Balt (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Kaiser Foundation Health Plan, Inc.
Plan ID: H2172-006

HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

$0.00
Monthly Premium

Kaiser Permanente Medicare Advantage Value Balt (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Kaiser Foundation Health Plan, Inc.
Plan ID: H2172-006

HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

Kaiser Permanente Medicare Advantage Value Balt (HMO) H2172-006 Plan Details
3.5 out of 5 stars

Kaiser Permanente Medicare Advantage Value Balt (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Kaiser Foundation Health Plan, Inc.
Plan ID: H2172-006

HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

$0.00
Monthly Premium

Maryland Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $7200
Out-of-Network: N/A
Initial Coverage Limit $5030
Catastrophic Coverage Limit $8,000
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $10.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0.00 to $40.00
Prior Authorization Required for Doctor Specialty Visit
Referral Required for Doctor Specialty Visit
Prior authorization required
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$300.00 per day for days 1 to 5
$0.00 per day for days 6 to the end of your stay
Prior Authorization Required for Acute Hospital Services
Referral Required for Acute Hospital Services
Prior authorization required
Urgent Care
Copayment for Urgent Care $40.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $40.00
Emergency Room Visit
Copayment for Emergency Care $100.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $100.00
Copayment for Worldwide Emergency Transportation $275.00
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $275.00

Air Ambulance:
Copayment for Air Ambulance Services $275.00

Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required

Health Care Services and Medical Supplies

Kaiser Permanente Medicare Advantage Value Balt (HMO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Copayment for Medicare-covered Chiropractic Services $10.00
Prior Authorization Required for Chiropractic Services
Referral Required for Chiropractic Services
Prior authorization required
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Copayment for Medicare-covered Diabetic Supplies $0.00
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Prior Authorization Required for Diabetic Supplies and Services
Prior authorization required
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-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 $20.00 to $190.00
Copayment for Medicare-covered Therapeutic Radiological Services $40.00
Copayment for Medicare-covered X-Ray Services $20.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Referral Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Referral Required for Home Health Services
Prior authorization required
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$300.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services
Referral Required for Psychiatric Hospital Services
Prior authorization required
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $20.00
Copayment for Medicare-covered Group Sessions $10.00
Prior Authorization Required for Outpatient Mental Health Services
Prior authorization required
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $300.00
Prior Authorization Required for Outpatient Hospital Services
Referral Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $0.00 to $300.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $300.00
Prior Authorization Required for Ambulatory Surgical Center Services
Referral Required for Ambulatory Surgical Center Services
Prior authorization required
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $20.00
Copayment for Medicare-covered Group Sessions $10.00
Prior Authorization Required for Outpatient Substance Abuse Services
Referral Required for Outpatient Substance Abuse Services
Prior authorization required
Over-the-counter (OTC) Items
In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $30.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $40.00
Prior Authorization Required for Podiatry Services
Referral Required for Podiatry Services
Prior authorization required
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$203.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Referral Required for Skilled Nursing Facility Services
Prior authorization required

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Preventive Dental:
Copayment for Office Visit $0.00 to $40.00
Office Vists include:
    • Maximum 2 visits every year
    Copayment for Oral Exams $0.00
    • Maximum 2 visits every year
    Copayment for Prophylaxis (Cleaning) $0.00
    • Maximum 2 visits every year
    Copayment for Fluoride Treatment $0.00
    • Maximum 1 visit every year
    Copayment for Dental X-Rays $0.00
    • Maximum 1 visit (Please see Evidence of Coverage for details)

    Comprehensive Dental:
    Copayment for Medicare-covered Benefits $40.00
    Copayment for Diagnostic Services $0.00
    Maximum Plan Benefit of $1000.00 every year for Non-Medicare Covered Comprehensive
    Prior Authorization Required for Comprehensive Dental
    Referral Required for Comprehensive Dental
    Prior authorization required

    Vision Benefits

    The following vision services are covered from in-network providers.

    Coverage Cost
    Vision Benefits
    In-Network:

    Eye Exams:
    Copayment for Medicare Covered Benefits $0.00 to $40.00
    Copayment for Routine Eye Exams $10.00 to $40.00
    Prior Authorization Required for Eye Exams
    Referral Required for Eye Exams

    Eyewear:
    Coinsurance for Medicare-Covered Benefits 20%
    Prior Authorization Required for Eyewear
    Referral Required for Eyewear
    Prior authorization required

    Hearing Benefits

    The following hearing services are covered from in-network providers.

    Coverage Cost
    Hearing Benefits
    In-Network:

    Hearing Exams:
    Copayment for Medicare Covered Benefits $40.00
    Copayment for Fitting/Evaluation for Hearing Aid $0.00
    Prior Authorization Required for Hearing Exams
    Referral Required for Hearing Exams
    Prior authorization required

    Preventive Services and Health/Wellness Education Programs

    The following services are covered from in-network providers.

    Coverage Cost
    Preventive Services and Health/Wellness Education Programs
    In-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 shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit