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Kaiser Permanente Medicare Advantage High DC (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Kaiser Permanente Medicare Advantage High DC (HMO-POS). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Kaiser Permanente Medicare Advantage High DC (HMO-POS) in 2025, please refer to our full plan details page.
Kaiser Permanente Medicare Advantage High DC (HMO-POS) is a HMO-POS plan offered by Kaiser Foundation Health Plan, Inc. available for enrollment in 2025 to people living in DC. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Kaiser Permanente Medicare Advantage High DC (HMO-POS) 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 Medicare Advantage High DC (HMO-POS).
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 Medicare Advantage High DC (HMO-POS), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $105.00. 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 $5700.00 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 Medicare Advantage High DC (HMO-POS) plan has an enhanced alternative drug benefit. This plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay a copay for your prescriptions depending on the drug tier and the pharmacy you use. For example, preferred generic drugs have a $12 copay at preferred pharmacies. After your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The Kaiser Permanente Medicare Advantage High DC (HMO-POS) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a copay, while outpatient services have copays depending on the service type. Emergency and primary care services come with copays, while preventive services like annual physical exams and additional services like health education have no copay. The plan also provides coverage for hearing and vision services, with copays for exams and coinsurance for eyewear. Dental services have copays, and home infusion, dialysis, and medical equipment are covered with copays or coinsurance. Diagnostic, radiological, and home health services have no copay, and the plan also covers skilled nursing facility stays with copays. Other services, including over-the-counter items, are available with specified cost-sharing.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, there is a $225 copay for days 1-5, and no copay for days 6-90. Inpatient Hospital Psychiatric has the same cost sharing.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, observation services, outpatient substance abuse services, and outpatient blood services, are covered. Outpatient hospital and observation services have a copay between $0 and $125, ambulatory surgical center services have a $125 copay, individual outpatient substance abuse sessions have a $10 copay, group outpatient substance abuse sessions have a $5 copay, and outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Kaiser Permanente Medicare Advantage High DC (HMO-POS) plan, requiring prior authorization and a doctor referral. This service has a $5 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Kaiser Permanente Medicare Advantage High DC (HMO-POS) plan, including both ground and air ambulance services, each with a $225 copay. Transportation Services to a plan-approved health-related location have no copay, and include up to 24 one-way trips per year.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the Kaiser Permanente Medicare Advantage High DC (HMO-POS) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay, Urgently Needed Services has a $30 copay, and Worldwide Emergency Transportation has a $225 copay; all other services have no copay or 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. Primary Care Physician Services and Chiropractic Services have a $5 copay. Occupational Therapy Services have a $30 copay. Physician Specialist Services have a copay between $0 and $30. Mental Health Specialty Services have a $10 copay for individual sessions and a $5 copay for group sessions. Other Health Care Professional services have a copay between $5 and $30. Psychiatric Services have a $10 copay for individual sessions and a $5 copay for group sessions. Physical Therapy and Speech-Language Pathology Services have a $30 copay. Additional Telehealth Benefits have no copay. Opioid Treatment Program Services have a $30 copay. Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
Preventive Services include Medicare-covered services, annual physical exams with no copay, and additional services including Health Education, Home-Based Palliative Care, Remote Access Technologies, and Fitness Benefit, all with no copay. Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit are covered with no copay. In-Home Safety Assessment, Personal Emergency Response System, Medical Nutrition Therapy, Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, In-Home Support Services, Support for Caregivers, 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 exams have a $30 copay, while fitting and evaluation for hearing aids have no copay. Prescription hearing aids are covered, with a plan-specified amount of $1,000 every three years. Routine hearing exams, inner ear prescription hearing aids, outer ear prescription hearing aids, over the ear prescription hearing aids, and OTC hearing aids are not covered.
Vision Services See details
The Kaiser Permanente Medicare Advantage High DC (HMO-POS) plan covers vision services, including eye exams with a copay of $0-$30, and eyewear with a 20% coinsurance and a combined maximum of $250 every two years. Upgrades are not covered.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $30 copay, and Other Dental Services with a copay between $0 and $30. Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Kaiser Permanente Medicare Advantage High DC (HMO-POS) plan. Medicare Part B Insulin Drugs have a copay between $12.00 and $35.00, and Medicare Part B Chemotherapy/Radiation Drugs have a copay between $12.00 and $47.00. Other Medicare Part B Drugs have a copay between $12.00 and $47.00, with a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Kaiser Permanente Medicare Advantage High DC (HMO-POS) plan. You will pay 20% coinsurance.
Medical Equipment See details
Medical equipment, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment, is covered. DME has a coinsurance between 0% and 20%, and no copay. Prosthetic Devices and Medical Supplies have a 20% coinsurance and no copay. Diabetic Supplies have no coinsurance and no copay, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance and no copay. Durable Medical Equipment for use outside the home is not covered.
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 copay of up to $100, Therapeutic Radiological Services with a copay of $30 or more, and Outpatient X-Ray Services with a $10 copay. Prior authorization and a doctor referral are required for all services.
Home Health Services See details
Home Health Services are covered by the Kaiser Permanente Medicare Advantage High DC (HMO-POS) 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 Medicare Advantage High DC (HMO-POS) plan. Prior authorization and a doctor's referral are required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization and a doctor referral. There is no copay for days 1-20, and a $160 copay for days 21-100.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) items with a maximum benefit of $70 every three months, and Other 1 services with coinsurance between 0% and 20%. Acupuncture, 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 2 has a $125 copay.
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