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Kaiser Permanente Sr Adv Basic Santa Clara (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Kaiser Permanente Sr Adv Basic 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 Basic Santa Clara (HMO) in 2025, please refer to our full plan details page.
Kaiser Permanente Sr Adv Basic 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 - Basic. 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 Basic 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 Basic 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 Basic Santa Clara (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 $6000.00 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 Basic Santa Clara (HMO) plan has no deductible for prescription drugs. In the initial coverage phase, you will pay a copay for each prescription, which varies depending on the drug tier and pharmacy type. For example, preferred generic drugs have a $12 copay at standard and mail order pharmacies. For non-preferred drugs, you pay 33% coinsurance, while specialty tier drugs have no copay. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Kaiser Permanente Sr Adv Basic Santa Clara (HMO) plan offers comprehensive coverage for inpatient and outpatient services. This plan includes coverage for hospital stays, with a copay for the first few days, and a $0 copay after that. Many services, such as primary care visits, mental health sessions, and preventive services, have low copays, making it easy to access care. The plan also covers a wide range of services, including emergency care, hearing exams, vision exams, and dental services. Diagnostic and radiological services, dialysis services, and home health services are covered as well. However, some services, such as cardiac rehabilitation and additional home care, are not included.
Inpatient Hospital See details
Inpatient Hospital services are covered, including acute and psychiatric care. For acute care, you will pay a $245 copay for days 1-5, and no copay for days 6-90, while additional days from 91-999 have no copay. Psychiatric care has the same cost structure as acute care. Non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, ambulatory surgical center (ASC) services, outpatient substance abuse services, and outpatient blood services. Outpatient Hospital Services have a copay between $0 and $180, Observation Services have a copay between $0 and $125, and Ambulatory Surgical Center (ASC) Services have a $180 copay. Individual sessions for Outpatient Substance Abuse have a $5 copay, and Group Sessions for Outpatient Substance Abuse have a $2 copay. Outpatient Blood Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered with a doctor referral and no copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Kaiser Permanente Sr Adv Basic Santa Clara (HMO) plan. Ground and Air Ambulance Services each have a $250 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. Emergency Services have a $125 copay, Urgently Needed Services have a $5 copay, and Worldwide Emergency Services have a $125 copay for Worldwide Emergency Coverage, a $5 copay for Worldwide Urgent Coverage, and a $250 copay for Worldwide Emergency Transportation.
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. Primary care physician visits and chiropractic services have a $5 copay, specialist visits have a $15 copay, and individual mental health sessions have a $5 copay while group sessions have a $2 copay. Other health care professionals have a copay between $3 and $15, and individual psychiatric sessions have a copay between $0 and $5 while group sessions have a copay between $0 and $2. Physical therapy and speech-language pathology services have no copay, and additional telehealth benefits and opioid treatment programs have no copay.
Preventive Services See details
Preventive Services include annual physical exams, with no copay. Additional preventive services are covered, including Health Education with a copay between $0 and $5, and Nutritional/Dietary Benefit with a copay between $0 and $5, but other services like 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, and Telemonitoring Services are not covered. Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit have no copay.
Hearing Services See details
Hearing services include hearing exams with a $15 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 $5 for routine eye exams, and between $0 and $15 for other eye exams; however, contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are not covered. A doctor referral is required for eye exams and eyewear.
Dental Services See details
The Kaiser Permanente Sr Adv Basic Santa Clara (HMO) plan covers dental services, including oral exams, dental x-rays, and other diagnostic dental services with no copay, and oral and maxillofacial surgery with a $5 copay, but does not cover maxillofacial prosthetics or orthodontics. Other services, like restorative services, are offered as an optional supplemental benefit.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. Medicare Part B Insulin Drugs have a copay between $0 and $25, while Medicare Part B Chemotherapy/Radiation Drugs have a copay between $0 and $47, and Other Medicare Part B Drugs have a copay between $0 and $47, and a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Kaiser Permanente Sr Adv Basic Santa Clara (HMO) plan. The coinsurance for these services is 20%.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME) with 0% to 20% coinsurance and Prosthetics/Medical Supplies with 0% to 20% coinsurance. Diabetic Equipment is covered, with Medicare-covered Diabetic Supplies having no copay and Medicare-covered Diabetic Therapeutic Shoes or Inserts with 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures, lab services, and radiological services. Diagnostic Procedures/Tests have no copay, and Lab Services have no copay. Diagnostic Radiological Services have a copay of at most $225, while Therapeutic Radiological Services and Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Kaiser Permanente Sr Adv Basic Santa Clara (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 Sr Adv Basic Santa Clara (HMO) plan. 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 under the Kaiser Permanente Sr Adv Basic Santa Clara (HMO) plan, but require prior authorization and a doctor's referral. You will have no copay for days 1-20, and a $100 copay per day for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include acupuncture with a $5 copay, over-the-counter items with a $60 maximum benefit every three months, and other services such as 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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