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Kaiser Permanente Senior Advantage San Diego (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Kaiser Permanente Senior Advantage San Diego (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Kaiser Permanente Senior Advantage San Diego (HMO) in 2025, please refer to our full plan details page.
Kaiser Permanente Senior Advantage San Diego (HMO) is a HMO plan offered by Kaiser Foundation Health Plan, Inc. available for enrollment in 2025 to people living in San Diego County Plan. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Kaiser Permanente Senior Advantage San Diego (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 Senior Advantage San Diego (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 Senior Advantage San Diego (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. 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 $1499.00 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 Senior Advantage San Diego (HMO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay varying copays or coinsurance depending on the drug tier and pharmacy used. For example, a standard generic drug has a $5 copay at a standard pharmacy, while a preferred brand drug has a $100 copay. Once your total drug costs reach $2000, 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 any enhanced benefit.
Additional Benefits
The Kaiser Permanente Senior Advantage San Diego (HMO) plan offers a wide range of benefits with varying costs. Many services have no copay, including inpatient hospital stays, outpatient services, primary care, preventive services, hearing exams, vision exams, dental exams, diagnostic and radiological services, and home health services. Other services, such as ambulance and emergency services, have copays, while some services like dialysis, medical equipment, and other 2 benefits have coinsurance. This plan also provides coverage for hearing, vision, and dental services, with some limitations. Additionally, the plan includes coverage for services like partial hospitalization, home infusion, and skilled nursing facilities. There are also additional benefits like acupuncture and over-the-counter items with no copay.
Inpatient Hospital See details
Inpatient Hospital benefits include Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both of which have no copay for days 1-90 and additional days 91-999. Non-Medicare-covered stays are not covered for either Inpatient Hospital-Acute or Inpatient Hospital Psychiatric.
Outpatient Services See details
Outpatient services cover outpatient hospital services, ambulatory surgical center (ASC) services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services, ASC services, and outpatient blood services have no copay, while observation services have a copay between $0.00 and $140.00. Both individual and group sessions for outpatient substance abuse have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Kaiser Permanente Senior Advantage San Diego (HMO) plan, with a doctor referral required. There is no copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Kaiser Permanente Senior Advantage San Diego (HMO) plan. Ground and Air Ambulance Services have a $130 copay, and there is no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Worldwide Emergency Services, are covered. For Emergency Services and Worldwide Emergency Coverage, there is a $140 copay, and for Worldwide Emergency Transportation, the copay is $130. Urgently Needed Services and Worldwide Urgent Coverage have no copay.
Primary Care See details
The Kaiser Permanente Senior Advantage San Diego (HMO) plan offers primary care physician services, chiropractic services, physician specialist services, mental health specialty services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services with no copay. Occupational therapy services, individual and group sessions for mental health specialty services, and individual and group sessions for psychiatric services have a $0 copay. Routine chiropractic care is not covered, and podiatry services are not covered.
Preventive Services See details
Preventive services include an annual physical exam with no copay, and additional services such as health education, nutritional/dietary benefits, fitness benefits, remote access technologies, kidney disease education, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit, all with no copay. In-home safety assessment, personal emergency response system, medical nutrition therapy, post-discharge in-home medication reconciliation, readmission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, home and bathroom safety devices and modifications, and counseling services are not covered.
Hearing Services See details
Hearing services are partially covered by the Kaiser Permanente Senior Advantage San Diego (HMO) plan, with hearing exams covered and no copay. However, routine hearing exams, prescription hearing aids, and OTC hearing aids are not covered.
Vision Services See details
Vision services with Kaiser Permanente Senior Advantage San Diego (HMO) include eye exams with no copay, and routine eye exams with no copay. 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
Dental services are covered, including oral exams, dental x-rays, and other diagnostic services, each with no copay. Restorative services have a copay between $36 and $124, and adjunctive general services have a $58 copay, while periodontics has a copay between $0 and $71. Oral and maxillofacial surgery has a copay between $0 and $229. Maxillofacial prosthetics and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a copay of $5 to $35, while Medicare Part B Chemotherapy/Radiation Drugs have a copay of $0 to $47 with 0% to 20% coinsurance, and Other Medicare Part B Drugs have a copay of $0 to $47 with 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Kaiser Permanente Senior Advantage San Diego (HMO) plan, and a doctor referral is required. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. Durable Medical Equipment has a coinsurance between 0% and 20%, and no copay. Prosthetic Devices have a 20% coinsurance. Medical Supplies have a coinsurance between 0% and 20%. Diabetic Supplies have no copay, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including diagnostic procedures/tests, lab services, diagnostic radiological services, therapeutic radiological services, and outpatient X-ray services, are covered with a doctor's referral. Diagnostic procedures/tests and outpatient X-ray services have no copay, while lab services have a $0 copay. Diagnostic and therapeutic radiological services have a maximum copay of $0.
Home Health Services See details
Home Health Services are covered under the Kaiser Permanente Senior Advantage San Diego (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 the specific services are not covered by the plan. A doctor referral is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered with prior authorization and a doctor's referral. There is no copay for days 1-20, and a $100 copay for days 21-100. Additional days beyond Medicare-covered for SNF and Non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes coverage for acupuncture with no copay, and over-the-counter (OTC) items with a maximum benefit of $90 every three months. Meal benefit, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered. Other 1 benefits are covered with no copay, and Other 2 benefits are covered with 0% - 20% coinsurance.
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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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