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Kaiser Permanente Senior Advantage Santa Cruz (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Kaiser Permanente Senior Advantage Santa Cruz (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 Santa Cruz (HMO) in 2025, please refer to our full plan details page.
Kaiser Permanente Senior Advantage Santa Cruz (HMO) is a HMO plan offered by Kaiser Foundation Health Plan, Inc. available for enrollment in 2025 to people living in Santa Cruz 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 Santa Cruz (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 Santa Cruz (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 Santa Cruz (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 $4900.00 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:
Sign up for Kaiser Permanente Senior Advantage Santa Cruz (HMO)
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Drug Coverage
The Kaiser Permanente Senior Advantage Santa Cruz (HMO) plan has an enhanced alternative drug benefit. There is no deductible for prescription drugs. During the initial coverage phase, you will pay varying copays or coinsurance depending on the drug tier and pharmacy. For example, you may pay $5.00 for preferred generic drugs at a standard pharmacy, or 33% coinsurance for non-preferred drugs. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase and pay nothing for covered drugs.
Additional Benefits
The Kaiser Permanente Senior Advantage Santa Cruz (HMO) plan offers comprehensive coverage with varying costs for different services. Inpatient hospital stays have a copay, while outpatient services, including primary care, mental health, and preventive services, often have no copay. The plan also includes coverage for ambulance, emergency, and vision services, as well as dental services. This plan provides additional benefits such as coverage for hearing exams, home health services, and diagnostic services, some with no copay or coinsurance. Prescription hearing aids and OTC hearing aids are not covered. Some services, like skilled nursing facilities, have a copay after the initial days.
Inpatient Hospital See details
Inpatient Hospital coverage includes both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you will pay a $190 copay for days 1-5, and no copay for days 6-90, with no coinsurance. Additional days (91-999) have no copay. For Inpatient Hospital Psychiatric, you will pay a $190 copay for days 1-5, and no copay for days 6-90, with no coinsurance. Additional days (91-999) have no copay. Non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with a copay between $0 and $145, and observation services, with a copay between $0 and $125. The plan also covers ambulatory surgical center services for a $145 copay, outpatient substance abuse services with no copay, and outpatient blood services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Kaiser Permanente Senior Advantage Santa Cruz (HMO) plan with no copay, and a doctor referral is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Kaiser Permanente Senior Advantage Santa Cruz (HMO) plan, including both ground and air ambulance services. Ground and air ambulance services each have a $250 copay, and there is no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered under the Kaiser Permanente Senior Advantage Santa Cruz (HMO) plan, with a $125 copay and no coinsurance, and the copay is waived if admitted to the hospital within 24 hours. Urgently Needed Services have no copay and no coinsurance. Worldwide Emergency Services are covered, with a $125 copay for Worldwide Emergency Coverage, no copay for Worldwide Urgent Coverage, and a $250 copay for Worldwide Emergency Transportation.
Primary Care See details
The Kaiser Permanente Senior Advantage Santa Cruz (HMO) plan covers primary care physician services and chiropractic services with no copay, while occupational therapy services have a copay between $5 and $10. Physician specialist services have a $5 copay, and mental health and psychiatric services have no copay for individual and group sessions. Physical therapy and speech-language pathology services have a copay between $0 and $10, and additional telehealth benefits have no copay. Opioid treatment program services have no copay.
Preventive Services See details
Preventive Services include an annual physical exam with no copay, and additional preventive services are covered with no copay for services such as Health Education, Nutritional/Dietary Benefit, Remote Access Technologies, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. Some services, such as In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission 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 covered, with a $5 copay for hearing exams. 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 for routine eye exams and other eye exams, with no coinsurance. Eyewear is 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 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), Implant Services, and Prosthodontics (fixed) are offered as optional, supplemental benefits. Maxillofacial Prosthetics and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, but require prior authorization. Medicare Part B Insulin Drugs have a copay between $5 and $35, while Medicare Part B Chemotherapy/Radiation Drugs have a copay between $0 and $47 with 0-20% coinsurance, and Other Medicare Part B Drugs have a copay between $0 and $47 with 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Kaiser Permanente Senior Advantage Santa Cruz (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered by the Kaiser Permanente Senior Advantage Santa Cruz (HMO) plan, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has no copay and a coinsurance between 0% and 20%, but Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance, while Medical Supplies have a coinsurance between 0% and 20%. Diabetic Supplies have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for Diagnostic Procedures/Tests with no copay, Lab Services with no copay, Diagnostic Radiological Services with a maximum copay of $190, Therapeutic Radiological Services with no copay, and Outpatient X-Ray Services with no copay.
Home Health Services See details
Home Health Services are covered under the Kaiser Permanente Senior Advantage Santa Cruz (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 plan does not cover any of the sub-services, including 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. 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 are not covered.
Other Services See details
Other Services include acupuncture with no copay, and over-the-counter (OTC) items with a $60 maximum benefit every three months. Residential Substance Use Disorder and MH Treatment has a $100 copay, and DME and Prosthetic/Medical Supplies not covered by Medicare has a coinsurance of 0% - 20%. 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.
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