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Kaiser Permanente Dual Essential Plan 1 (HMO D-SNP) - H1170-008-000
$0.00
Monthly Premium
Kaiser Permanente Dual Essential Plan 1 (HMO D-SNP) is a HMO D-SNP Medicare Advantage (Medicare Part C) plan offered by Kaiser Foundation Health Plan, Inc.
Plan ID: H1170-008-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Georgia Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.
Learn more about Georgia Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $400.00 |
| Out-of-pocket maximum | $8,850.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0 Referral Required for Doctor Specialty Visit No referral is required for dermatology, obstetrics, and gynecology. |
| Inpatient hospital care | In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $0 or $2000 Prior Authorization Required for Acute Hospital Services Referral Required for Acute Hospital Services Members admitted and discharged on the same day pay a copayment for one day. |
| Urgent care | Urgent Care: Copayment for Urgent Care $0 or $35 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $0 or $35 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $0 or $110 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 0 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $0 or $110 Copayment for Worldwide Emergency Transportation $0 or $280 |
| Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $0 or $280 Air Ambulance: Copayment for Air Ambulance Services $0 or $280 Prior Authorization Required for Air Ambulance |
Health Care Services and Medical Supplies
Kaiser Permanente Dual Essential Plan 1 (HMO D-SNP) covers a range of additional benefits. Learn more about Kaiser Permanente Dual Essential Plan 1 (HMO D-SNP) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Chiropractic Services: Coinsurance for Medicare-covered Chiropractic Services 0% or 35% |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0 Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 0% or 20% |
| Durable medical equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20% Prior Authorization Required for Durable Medical Equipment The minimum coinsurance applies to canes, crutches, and ultraviolet light therapy for psoriasis treatment. The maximum coinsurance applies to all other DME. |
| 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 to $35 Copayment for Medicare-covered Lab Services $0 to $35 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Referral Required for Outpatient Diag Procs/Tests/Lab Services The minimum copayment applies to services provided in a medical office. The maximum copayment applies to services provided in an outpatient hospital setting. Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0 to $290 Coinsurance for Medicare-covered Therapeutic Radiological Services 0% or 20% Copayment for Medicare-covered X-Ray Services $0 to $35 |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $0 or $1880 Prior Authorization Required for Psychiatric Hospital Services Referral Required for Psychiatric Hospital Services Members admitted and discharged on the same day pay a copayment for one day. |
| Mental health outpatient care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $0 Copayment for Medicare-covered Group Sessions $0 |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $300 Prior Authorization Required for Outpatient Hospital Services The minimum copayment for Medicare-covered Outpatient Hospital Services applies to surgical procedures performed during a screening colonoscopy and diagnostic colonoscopies in response to a positive gFOBT, FIT, or sigmoidoscopy. The maximum copayment for Medicare-covered Outpatient Hospital Services applies to all other services. Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $0 to $300 Prior Authorization Required for Outpatient Observation Services The minimum copayment for Medicare -covered Observation Services applies to observation stays incident to an ER visit or outpatient surgery. The maximum copayment for Medicare-covered Observation Services applies when admitted directly to the hospital for observation. Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 or $300 Prior Authorization Required for Ambulatory Surgical Center Services |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $0 Copayment for Medicare-covered Group Sessions $0 |
| Over-the-counter items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0
Minimum order amount: Each order must be at least $20. |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $0 Prior Authorization Required for Podiatry Services Referral Required for Podiatry Services |
| Skilled Nursing Facility (SNF) care | 0 or $In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $214 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services Referral Required for Skilled Nursing Facility Services |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | In-Network: Medicare Covered Preventive Dental: Copayment for Office Visit $0 Non-Medicare Covered Preventive Dental: Copayment for Non-medicare preventive $0 Copayment for Oral exams $0 Coinsurance for Oral exams $0 or 75%
Coinsurance for Dental x-rays 75%
Coinsurance for Other diagnostic services 75% Copayment for Prophylaxis $0 Coinsurance for Prophylaxis 75%
Coinsurance for Flouride treatment 75%
Coinsurance for Other preventative services 75% Non-Medicare Covered Comprehensive Dental: Copayment for Restorative services $28 to $580 Coinsurance for Restorative services 75% Copayment for Periodontics $0 to $400 Coinsurance for Periodontics 75% Copayment for Prothodontics, removable $420 to $480 Copayment for Maxillofacial surgery $22 Coinsurance for Maxillofacial surgery 75% Copayment for Adjunctive general services $0 Coinsurance for Adjunctive general services 75% |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0 Copayment for Routine Eye Exams $0
Eyewear: Copayment for Medicare-Covered Benefits $0 Maximum Plan Allowance of $575 every two years |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $0 Copayment for Routine Hearing Exams $0
Hearing Aids: Maximum Plan Allowance of $500 every three years |
Preventive Services and Health/Wellness Education Programs
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| 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:
Yearly "Wellness" visit |
Prescription Drug Costs and Coverage
The Kaiser Permanente Dual Essential Plan 1 (HMO D-SNP) offers prescription drug coverage, with an annual drug deductible of $400.00 (excludes Tiers 1, 2, and 6)
Coverage & Cost | |
|---|---|
| Coverage | Cost |
| Annual drug deductible | $400.00 (excludes Tiers 1, 2, and 6) |
| Tier 1 |
|
| Tier 2 |
|
| Tier 6 |
|
| Annual drug deductible | $400.00 (excludes Tiers 1, 2, and 6) |
| Tier 1 |
|
| Tier 2 |
|
| Tier 6 |
|
| Annual drug deductible | $400.00 (excludes Tiers 1, 2, and 6) |
| Tier 1 |
|
| Tier 2 |
|
| Tier 6 |
|
When reviewing Georgia Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of Georgia that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Georgia Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.