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Kaiser Permanente Sr Adv Enhanced Marin San Mateo (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Kaiser Permanente Sr Adv Enhanced Marin San Mateo (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Kaiser Permanente Sr Adv Enhanced Marin San Mateo (HMO) in 2025, please refer to our full plan details page.
Kaiser Permanente Sr Adv Enhanced Marin San Mateo (HMO) is a HMO plan offered by Kaiser Foundation Health Plan, Inc. available for enrollment in 2025 to people living in Marin and San Mateo Counties Plan - Enhanced. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Kaiser Permanente Sr Adv Enhanced Marin San Mateo (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Kaiser Permanente Sr Adv Enhanced Marin San Mateo (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Kaiser Permanente Sr Adv Enhanced Marin San Mateo (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $67.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $3900.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Kaiser Permanente Sr Adv Enhanced Marin San Mateo (HMO) plan has no deductible for prescription drugs. In the initial coverage phase, you'll pay varying copays or coinsurance depending on the drug tier and pharmacy type. For example, generic drugs have a $5 copay at standard pharmacies, while preferred brand drugs have a $100 copay. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for Part D-covered drugs. However, you may still have to pay for excluded drugs covered under an enhanced benefit. This plan may have a reduced premium if you qualify for the low-income subsidy, with a monthly premium of $24.10.
Additional Benefits
The Kaiser Permanente Sr Adv Enhanced Marin San Mateo (HMO) plan offers a variety of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services range from no copay to $140. Emergency services and ambulance services have copays, and primary care, preventive services, and many other services are available with no copay. This plan also includes benefits for vision, dental, and hearing services, with some services having copays. Medical equipment, home health, and skilled nursing facility services are covered with copays or coinsurance. Additionally, the plan covers some other services like acupuncture and over-the-counter items.
Inpatient Hospital See details
The Inpatient Hospital benefit covers Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, including services not usually covered by Medicare plans, with a copay of $180 for days 1-5 and no copay for days 6-90. Additional days for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric have no copay for days 91-999. Non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services include outpatient hospital services and observation services with a copay of $0-$140, outpatient substance abuse services with no copay for individual and group sessions, outpatient blood services with no copay, and ambulatory surgical center (ASC) services with a $140 copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Kaiser Permanente Sr Adv Enhanced Marin San Mateo (HMO) plan with no copay and no coinsurance. A doctor referral is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Kaiser Permanente Sr Adv Enhanced Marin San Mateo (HMO) plan. There is a $200 copay for both Ground Ambulance Services and Air Ambulance Services, with no coinsurance. Transportation Services to health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services have a $140 copay and no coinsurance, Urgently Needed Services have no copay and no coinsurance, and Worldwide Emergency Coverage has a $140 copay, Worldwide Urgent Coverage has no copay, and Worldwide Emergency Transportation has a $200 copay, with no coinsurance for any of these services.
Primary Care See details
The Kaiser Permanente Sr Adv Enhanced Marin San Mateo (HMO) plan covers Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services. Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Individual Sessions for Mental Health Specialty Services, Group Sessions for Mental Health Specialty Services, Individual Sessions for Psychiatric Services, Group Sessions for Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, and Additional Telehealth Benefits have no copay. Physician Specialist Services has a $5 copay.
Preventive Services See details
Preventive Services include annual physical exams with no copay, and additional preventive services that include Health Education, Nutritional/Dietary Benefit, and Remote Access Technologies, all with no copay. Other services like In-Home Safety Assessment, Personal Emergency Response System, and others are not covered.
Hearing Services See details
Hearing services are partially covered by the Kaiser Permanente Sr Adv Enhanced Marin San Mateo (HMO) plan. Hearing exams are covered with a $5 copay, but routine hearing exams are not covered, and prescription hearing aids and OTC hearing aids are also not covered.
Vision Services See details
Vision services include eye exams with a copay of $0-$5. Eyewear benefits are partially covered, but contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Kaiser Permanente Sr Adv Enhanced Marin San Mateo (HMO) plan offers dental services with no copay for Other Dental Services and Oral and Maxillofacial Surgery, while Medicare Dental Services have a copay between $0 and $5. Orthodontics and Maxillofacial Prosthetics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, the copay is $5-$35. For Medicare Part B Chemotherapy/Radiation Drugs, the copay is $0-$47, with a coinsurance between 0-20%. Other Medicare Part B Drugs have a copay of $0-$47, with a coinsurance between 0-20%.
Dialysis Services See details
Dialysis Services are covered under the Kaiser Permanente Sr Adv Enhanced Marin San Mateo (HMO) plan. There is a 20% coinsurance for dialysis services.
Medical Equipment See details
Medical equipment benefits are covered, including durable medical equipment with a coinsurance between 0% and 20% and no copay, prosthetic devices with a 20% coinsurance, and medical supplies with a coinsurance between 0% and 20%. Diabetic supplies have no copay, while diabetic therapeutic shoes/inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including Diagnostic Procedures/Tests, Lab Services, Diagnostic Radiological Services, Therapeutic Radiological Services, and Outpatient X-Ray Services. Diagnostic Procedures/Tests have no copay, Lab Services have no copay, Diagnostic Radiological Services have a copay of up to $200, Therapeutic Radiological Services have no copay, and Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Kaiser Permanente Sr Adv Enhanced Marin San Mateo (HMO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but not in practice. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Kaiser Permanente Sr Adv Enhanced Marin San Mateo (HMO) plan. You will have no copay for days 1-20, and a $100 copay for days 21-100.
Other Services See details
Other Services includes acupuncture with no copay, over-the-counter items with a $60 maximum benefit every three months, and residential substance use disorder and MH treatment with a $100 copay. Other services such as meal benefits, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and Private Duty Nursing Services are not covered.
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