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Kaiser Permanente Sr Adv Enhanced Santa Clara (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Kaiser Permanente Sr Adv Enhanced Santa Clara (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 Santa Clara (HMO) in 2025, please refer to our full plan details page.
Kaiser Permanente Sr Adv Enhanced Santa Clara (HMO) is a HMO plan offered by Kaiser Foundation Health Plan, Inc. available for enrollment in 2025 to people living in Santa Clara County 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 Santa Clara (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 Santa Clara (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 Santa Clara (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 $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 Santa Clara (HMO) plan has no deductible for prescription drugs. In the initial coverage phase, you will pay different copays or coinsurance amounts depending on the drug tier and pharmacy you use. For example, preferred generic drugs have a $7.00 copay at standard and mail order pharmacies, while non-preferred drugs have 33% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase and pay nothing for covered Part D drugs. This plan's premium may be reduced if you qualify for the low-income subsidy; those who qualify will pay $19.30.
Additional Benefits
The Kaiser Permanente Sr Adv Enhanced Santa Clara (HMO) plan offers a wide range of benefits with varying costs. Inpatient hospital stays have a copay, but many outpatient services, including primary care, mental health, and preventive services, have no copay. The plan also includes coverage for ambulance, emergency, and vision services with copays or coinsurance. Dental, hearing, and home health services are also covered, with some services having no copay.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with a $215 copay 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, and Non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a copay of $0-$160, observation services with a copay of $0-$140, ambulatory surgical center (ASC) services with a copay of $160, outpatient substance abuse services with no copay for both individual and group sessions, and outpatient blood services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered with no copay and requires a doctor referral.
Ambulance and Transportation Services See details
The Kaiser Permanente Sr Adv Enhanced Santa Clara (HMO) plan covers ambulance services with no coinsurance, but a $250 copay for both ground and air ambulance services. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered under the Kaiser Permanente Sr Adv Enhanced Santa Clara (HMO) plan. Emergency Services have a $140 copay and no coinsurance, while Urgently Needed Services have no copay and no coinsurance. Worldwide Emergency Coverage has a $140 copay, Worldwide Urgent Coverage has no copay, and Worldwide Emergency Transportation has a $250 copay, all with no coinsurance.
Primary Care See details
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 are covered under the Kaiser Permanente Sr Adv Enhanced Santa Clara (HMO) plan. Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Mental Health Specialty Services, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services have no copay. Physician Specialist Services have a $5 copay. Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
Preventive services include Medicare-covered services, an annual physical exam with no copay, and additional preventive services. Additional preventive services, kidney disease education services, and other preventive services are covered with no copay. Some services like In-Home Safety Assessment, Medical Nutrition Therapy, and others are not covered.
Hearing Services See details
Hearing services include hearing exams with a $5 copay, and fitting/evaluation for hearing aids. 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 is also 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, with no copay for most services. Medicare Dental Services have a copay of $0-$5, and Periodontics and Oral and Maxillofacial Surgery have no copay.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. Medicare Part B Insulin Drugs have a copay of $7 to $35. Medicare Part B Chemotherapy/Radiation Drugs have a copay of $0 to $47, and a coinsurance between 0% and 20%. Other Medicare Part B Drugs have a copay of $0 to $47, and a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Kaiser Permanente Sr Adv Enhanced Santa Clara (HMO) plan. The coinsurance for these services is 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has no copay, and a coinsurance between 0% and 20%, and Durable Medical Equipment for use outside the home is not covered. Prosthetic devices have a 20% coinsurance, and medical supplies have a coinsurance between 0% and 20%. 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 under the Kaiser Permanente Sr Adv Enhanced Santa Clara (HMO) plan. Diagnostic Procedures/Tests have no copay, while Lab Services have no copay. Diagnostic Radiological Services have a copay of at most $205, 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 Santa Clara (HMO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. A referral is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but 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. A doctor referral is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization and a doctor's referral. For days 1-20, there is no copay, and for days 21-100, the copay is $100. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Under the "Other Services" benefit, acupuncture is covered with no copay, and over-the-counter items are covered with a maximum benefit of $60 every three months. Some services are not covered, including meal benefits, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and more.
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