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Kaiser Permanente Medicare Advantage Standard DC (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Kaiser Permanente Medicare Advantage Standard 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 Standard DC (HMO-POS) in 2025, please refer to our full plan details page.
Kaiser Permanente Medicare Advantage Standard 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 Standard 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 Standard 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 Standard DC (HMO-POS), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $30.00. 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 $6900.00 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 Standard DC (HMO-POS) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay a copay for your prescriptions, which varies depending on the drug tier and pharmacy type. For example, preferred generic drugs have a $12 copay at preferred pharmacies and $20 at standard pharmacies. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you'll pay nothing for Part D covered drugs. However, this plan's premium may be reduced if you qualify for the low-income subsidy.
Additional Benefits
The Kaiser Permanente Medicare Advantage Standard DC (HMO-POS) plan offers a range of benefits, including inpatient hospital stays with a copay, outpatient services, and emergency care. The plan also covers primary care visits for a small copay, along with preventive, hearing, vision, and dental services. Additional benefits include home health services with no copay, coverage for medical equipment, and access to diagnostic and radiological services. This plan also provides coverage for ambulance and transportation services, plus offers limited coverage for over-the-counter items, and skilled nursing facilities.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For days 1-5, there is a $245 copay, and for days 6-90, there is no copay. Additional days for Inpatient Hospital-Acute have no copay for days 91-999. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute, as well as additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric, are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay of $0-$130, Observation Services with a copay of $0-$130, Ambulatory Surgical Center (ASC) Services with a $130 copay, Individual Sessions for Outpatient Substance Abuse with a copay of $10, Group Sessions for Outpatient Substance Abuse with a $5 copay, and Outpatient Blood Services with no copay. Prior authorization and a doctor referral may be required for some services.
Partial Hospitalization See details
Partial Hospitalization is covered under this plan, with a $5 copay. Prior authorization and a doctor referral are required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including ground and air ambulance services with a $225 copay. Transportation Services to a plan-approved health-related location has no copay, and covers up to 24 one-way trips per year. Transportation Services to any health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Kaiser Permanente Medicare Advantage Standard DC (HMO-POS) plan. Emergency Services have a $110 copay, Urgently Needed Services have a $35 copay, Worldwide Emergency Coverage has a $110 copay, Worldwide Urgent Coverage has a $35 copay, and Worldwide Emergency Transportation has a $225 copay.
Primary Care See details
The Kaiser Permanente Medicare Advantage Standard DC (HMO-POS) plan covers primary care physician services and chiropractic services for a $5 copay, and occupational therapy with a $35 copay. Specialist services have a copay between $0-$35, while individual and group mental health and psychiatric sessions have a copay between $5-$10. Physical therapy and speech-language pathology services have a $35 copay, and additional telehealth benefits have no copay. Opioid treatment program services have a $35 copay.
Preventive Services See details
Preventive Services include coverage for Medicare-covered preventive services with prior authorization and a doctor's referral, annual physical exams with no copay, and additional preventive services including Health Education, Fitness Benefit, Remote Access Technologies, Home-Based Palliative Care, Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, all with no copay. However, 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, Nutritional/Dietary Benefit, 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 include hearing exams with a $35 copay, and fitting/evaluation for hearing aids with no copay, while routine hearing exams are not covered. Prescription hearing aids are covered, with a maximum benefit of $1,000 every three years, and prescription hearing aids (all types) are covered for two visits every three years, but prescription hearing aids for inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a copay of $0-$35, and eyewear with 20% coinsurance. Contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames are covered. Upgrades are not covered.
Dental Services See details
Dental Services are covered, with Medicare Dental Services requiring a $35 copay. Other Dental Services have a copay between $0 and $35, Oral Exams are covered with a copay of $0, and Dental X-Rays are covered with a copay of $0. Orthodontic Services are covered up to a maximum of $2500 per year, while Restorative, Adjunctive General, Endodontics, Periodontics, Prosthodontics (removable and fixed), and Oral and Maxillofacial Surgery services are covered with a 50% coinsurance and Prosthodontics (removable and fixed) require prior authorization. Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
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. The copay for Medicare Part B Insulin Drugs is $12-$35, and the copay for Medicare Part B Chemotherapy/Radiation Drugs is $12-$47; Other Medicare Part B Drugs have a copay of $12-$47 and a coinsurance between 0-20%.
Dialysis Services See details
Dialysis Services are covered, but require prior authorization and a doctor referral. You will pay 20% coinsurance.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a coinsurance between 0% and 20%, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices, Medical Supplies, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance, and Diabetic Supplies has no coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including Diagnostic Procedures/Tests and Lab Services with no copay, and Diagnostic Radiological Services with a copay of at most $100, Therapeutic Radiological Services with a copay of at least $35, and Outpatient X-Ray Services with a $15 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 Standard DC (HMO-POS) 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 specific services of Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD are not covered. Prior authorization and a doctor's referral are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Kaiser Permanente Medicare Advantage Standard DC (HMO-POS) plan. For days 1-20, there is no copay, and for days 21-100, the copay is $203.
Other Services See details
The "Other Services" benefit covers Over-the-Counter (OTC) Items, with a maximum benefit of $80 every three months. Other services like 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 1 covers DME and medical supplies not covered by Medicare with a coinsurance between 0% and 20%, and Other 2 covers surgical procedures performed in an ASC not covered by Medicare with a $130 copay.
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