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Kaiser Permanente Senior Advantage Enhanced Fresno (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Kaiser Permanente Senior Advantage Enhanced Fresno (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 Enhanced Fresno (HMO) in 2025, please refer to our full plan details page.
Kaiser Permanente Senior Advantage Enhanced Fresno (HMO) is a HMO plan offered by Kaiser Foundation Health Plan, Inc. available for enrollment in 2025 to people living in Greater Fresno Area 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 Senior Advantage Enhanced Fresno (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 Enhanced Fresno (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 Enhanced Fresno (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $65.00. 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 $2500.00 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 Enhanced Fresno (HMO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay varying copays or coinsurance amounts depending on the drug tier and pharmacy type. For example, preferred generic drugs have an $8 copay at standard and mail-order pharmacies, while standard generic drugs have a $47 copay. For preferred brand drugs, the copay is $100, and non-preferred drugs have a 33% coinsurance. The plan also offers a specialty tier with no copay at standard pharmacies. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Kaiser Permanente Senior Advantage Enhanced Fresno (HMO) plan offers a wide range of benefits with varying costs. This plan includes coverage for inpatient hospital stays, outpatient services, and emergency services. Many services have no copay, including primary care, preventive services, and home health services, while others have copays ranging from $5 to $300, such as specialist visits and ambulance services. Additional benefits include coverage for hearing, vision, and dental services with varying copays or coinsurance. Diagnostic and radiological services, skilled nursing facility stays, and home infusion services are also covered, with some services requiring referrals or prior authorization. The plan also covers acupuncture and over-the-counter items, with a limited benefit amount.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, both with a $230 copay for days 1-5 and no copay for days 6-90, as well as Additional Days for both, with no copay for days 91-999. Non-Medicare-covered stay is not covered.
Outpatient Services See details
Outpatient services include coverage for outpatient hospital services with a copay between $0 and $175, observation services with a copay between $0 and $140, and ambulatory surgical center (ASC) services with a $175 copay. This plan also covers outpatient substance abuse services and outpatient blood services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered with a doctor's referral, and there is no copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Kaiser Permanente Senior Advantage Enhanced Fresno (HMO) plan. Ground and Air Ambulance Services have a $300 copay, with no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the Kaiser Permanente Senior Advantage Enhanced Fresno (HMO) plan. For Emergency Services and Worldwide Emergency Coverage, there is a $140 copay, while Worldwide Emergency Transportation has a $300 copay; Urgently Needed Services and Worldwide Urgent Coverage have no copay, and there is no coinsurance for any of these services.
Primary Care See details
The Kaiser Permanente Senior Advantage Enhanced Fresno (HMO) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, other health care professional services, psychiatric services, physical therapy, speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Primary care physician services, chiropractic services, and additional telehealth benefits have no copay, while physician specialist services have a $5 copay.
Preventive Services See details
Preventive services are covered, including an annual physical exam with no copay. Additional preventive services, kidney disease education, and other preventive services are also covered, though some services may have a copay, and a referral may be required. The plan covers Health Education and Nutritional/Dietary Benefits with no copay. Some services such as In-Home Safety Assessment, Personal Emergency Response System, Medical Nutrition Therapy, and others are not covered.
Hearing Services See details
Hearing services include hearing exams and fitting/evaluation for hearing aids. Hearing exams have a $5 copay, while routine hearing exams are not covered. Prescription hearing aids and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a copay of $0-$5, and routine eye exams with no copay. Eyewear benefits are partially covered, and do not include contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, or upgrades.
Dental Services See details
Dental services include coverage for Medicare Dental Services with a copay of $0-$5, and Other Dental Services with no copay. Orthodontic Services, Restorative Services, Adjunctive General Services, Endodontics, Prosthodontics (removable and fixed), and Implant Services are offered as optional supplemental benefits. Maxillofacial Prosthetics and Orthodontics are not covered. Oral and Maxillofacial Surgery is covered with no copay.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, requiring prior authorization. Medicare Part B Insulin Drugs have a copay of $8 to $35, while Medicare Part B Chemotherapy/Radiation Drugs have a copay of $0 to $47, with a coinsurance between 0% and 20%. Other Medicare Part B Drugs have a copay of $0 to $47, with a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Kaiser Permanente Senior Advantage Enhanced Fresno (HMO) plan. You will pay 20% coinsurance.
Medical Equipment See details
Medical equipment is covered, including durable medical equipment, prosthetics, medical supplies, and diabetic equipment. Durable medical equipment has a coinsurance of 0% to 20% with no copay, while durable medical equipment for use outside the home is not covered. Prosthetic devices have a 20% coinsurance, and medical supplies have a 0% to 20% coinsurance. Diabetic supplies have no copay, and diabetic therapeutic shoes/inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including Diagnostic Procedures/Tests with no copay, Lab Services with no copay, Diagnostic Radiological Services with a copay up to $200, Therapeutic Radiological Services with no copay, and Outpatient X-Ray Services with no copay. A doctor referral is required for all services.
Home Health Services See details
Home Health Services are covered by the Kaiser Permanente Senior Advantage Enhanced Fresno (HMO) plan with no copay and no coinsurance. However, additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Kaiser Permanente Senior Advantage Enhanced Fresno (HMO) plan. This includes Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Kaiser Permanente Senior Advantage Enhanced Fresno (HMO) plan, but require prior authorization and a doctor's referral. There is no copay for days 1-20, and a $100 copay for days 21-100, with no coinsurance. Additional days beyond Medicare-covered for SNF, and Non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Kaiser Permanente Senior Advantage Enhanced Fresno (HMO) plan covers acupuncture with no copay, and over-the-counter (OTC) items with a maximum benefit coverage amount of $60 every three months. The plan does not cover meal benefits, and it does not cover 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, or Self-Directed Personal Assistance Services. Other 1 benefits are covered with a $100 copay, and Other 2 benefits are covered with 0% - 20% coinsurance.
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