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Kaiser Permanente Senior Advantage Choice North (PPO) - H3138-003-000
$0.00
Monthly Premium
Kaiser Permanente Senior Advantage Choice North (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Kaiser Foundation Health Plan, Inc.
Plan ID: H3138-003-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Colorado 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 Colorado Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Enrollment may be limited to certain times of the year. See why you may be able to enroll.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $5,100.00 |
| 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 $30 Referral only applies to allergy, dermatology and urology specialists. |
| Inpatient hospital care | Out-of-Network: Acute Hospital Services: $500 per day for days 1 to 18 $0 per day for days 19 to 90 Members admitted and discharged on the same day pay a copayment for one day. |
| Urgent care | Urgent Care: Copayment for Urgent Care $35 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $35 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $125 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 $125 Copayment for Worldwide Emergency Transportation $340 |
| Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $340 Prior Authorization Required for Ground Ambulance Services Air Ambulance: Copayment for Air Ambulance Services $340 Prior Authorization Required for Air Ambulance Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $340 Copayment for Medicare Covered Ambulance Services - Air $340 |
Health Care Services and Medical Supplies
Kaiser Permanente Senior Advantage Choice North (PPO) covers a range of additional benefits. Learn more about Kaiser Permanente Senior Advantage Choice North (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | Out-of-Network: Medicare Covered Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 40% |
| 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 20% Prior Authorization Required for Diabetic Therapeutic Shoes or Inserts Out-of-Network: Medicare Covered Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies 0% to 40% Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 0% to 40% |
| 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 ultraviolet light therapy equipment 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 Copayment for Medicare-covered Lab Services $0 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 $50 to $145 Copayment for Medicare-covered Therapeutic Radiological Services $30 Copayment for Medicare-covered X-Ray Services $15 Prior Authorization Required for Diagnostic Radiological Services and Therapeutic Radiological Services Referral Required for Diagnostic Radiological Services, Therapeutic Radiological Services and X-Ray Services Out-of-Network: Medicare Covered Diagnostic Procedures/Tests Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 40% Coinsurance for Medicare Covered Lab Services 40% Coinsurance for Medicare Covered Diagnostic Radiological Services 40% Coinsurance for Medicare Covered Therapeutic Radiological Services 40% Coinsurance for Medicare Covered Outpatient X-Ray Services 40% |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Referral Required for Home Health Services |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: $295 per day for days 1 to 5 $0 per day for days 6 to 90 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 $25 Copayment for Medicare-covered Group Sessions $15 |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $250 Prior Authorization Required for Outpatient Hospital Services Referral Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $250 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $185 Prior Authorization Required for Ambulatory Surgical Center Services Referral Required for Ambulatory Surgical Center Services |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $25 Copayment for Medicare-covered Group Sessions $15 |
| Over-the-counter items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0
OTC items: Minimum order amount: Each order must be at least $35. Tobacco cessation: We cover FDA-approved tobacco cessation over-the-counter medications for up to two tobacco cessation attempts per year up to two 90-day supplies. |
| Podiatry services | Out-of-Network: Medicare Covered Podiatry Services: Copayment for Medicare Covered Podiatry Services $65 |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $203 per day for days 21 to 46 $0 per day for days 47 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 | Out-of-Network: Medicare Covered Preventive Dental Services: Copayment for Medicare Covered Preventive Dental $65 |
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 | Out-of-Network: Medicare Covered Eye Exams Services: Coinsurance for Medicare Covered Eye Exams 40% Copayment for Medicare Covered Eyewear $0 |
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 | Out-of-Network: Medicare Covered Hearing Exams Services: Coinsurance for Medicare Covered Hearing Exams 40% |
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 | Out-of-Network: Medicare Covered Medicare-covered Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 |
When reviewing Colorado 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 Colorado 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 |
Colorado Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.