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Kaiser Permanente Medicare Advantage High VA (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Kaiser Permanente Medicare Advantage High VA (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 VA (HMO-POS) in 2025, please refer to our full plan details page.
Kaiser Permanente Medicare Advantage High VA (HMO-POS) is a HMO-POS plan offered by Kaiser Foundation Health Plan, Inc. available for enrollment in 2025 to people living in Northern Virginia. 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 VA (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 VA (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 VA (HMO-POS), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $137.00. 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 VA (HMO-POS) plan has an enhanced alternative drug benefit. The plan has a $0 deductible for prescription drugs. In the initial coverage phase, you will pay a copay for your prescriptions depending on the drug tier and the pharmacy you use. For example, preferred generic drugs have a $10 copay at preferred pharmacies and a $20 copay at standard pharmacies. Specialty tier drugs have no copay. After your total drug costs reach $2,000, you enter the catastrophic coverage phase where you will pay nothing for your Part D covered drugs.
Additional Benefits
The Kaiser Permanente Medicare Advantage High VA (HMO-POS) plan offers a range of benefits, including inpatient hospital stays with a $245 copay for the first six days, and outpatient services with copays varying from $0 to $155. This plan also covers ambulance services for a $225 copay, and offers vision and dental benefits, with varying copays or coinsurance. This plan includes coverage for primary care with a $10 copay, and preventive services like annual exams with no copay. Additionally, it covers hearing exams, hearing aids, and home health services with no copay, and offers other benefits like medical equipment and diagnostic services with varying cost-sharing.
Inpatient Hospital See details
Inpatient hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For days 1-6 of Inpatient Hospital-Acute and Inpatient Hospital Psychiatric stays, the copay is $245, and days 7-90 have no copay. Additional days for Inpatient Hospital-Acute have no copay, while non-Medicare covered stays and upgrades for Inpatient Hospital-Acute and 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 between $0 and $155, Observation Services with a copay between $0 and $155, Ambulatory Surgical Center (ASC) Services with a $155 copay, Outpatient Substance Abuse Services, and Outpatient Blood Services with no copay. Individual sessions for Outpatient Substance Abuse have a copay of $10, and group sessions have a $5 copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Kaiser Permanente Medicare Advantage High VA (HMO-POS) plan, requiring prior authorization and a doctor referral. The copay for this benefit is $10.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including ground and air ambulance services, each with a $225 copay. Transportation Services to a plan-approved health-related location are covered with no copay, offering 24 one-way trips per year. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered, with a $125 copay and no coinsurance. Urgently Needed Services have a $35 copay and no coinsurance. Worldwide Emergency Services are also covered, with a $125 copay for Worldwide Emergency Coverage, a $35 copay for Worldwide Urgent Coverage, and a $225 copay for Worldwide Emergency Transportation.
Primary Care See details
The Kaiser Permanente Medicare Advantage High VA (HMO-POS) plan covers primary care physician services and chiropractic services with a $10 copay, physician specialist services and physical therapy with a $35 copay, and additional telehealth benefits with no copay. Individual and group mental health and psychiatric sessions have copays between $5 and $10, and occupational therapy has a $35 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive Services are covered by the Kaiser Permanente Medicare Advantage High VA (HMO-POS) plan, including annual physical exams with no copay. Other preventive services, such as 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 also have no copay. Additional preventive services are covered, but may have a copay. Some services, such as In-Home Safety Assessment, Personal Emergency Response System (PERS), and others, 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. Prescription hearing aids are covered up to $1000 per ear every three years, but inner ear, outer ear, and over the ear hearing aids are not covered. Routine hearing exams and OTC hearing aids are not covered.
Vision Services See details
Vision Services include coverage for eye exams with a copay of $0-$35, and eyewear with a 20% coinsurance for contact lenses, but upgrades are not covered. Eyewear has a combined maximum benefit of $250 every two years.
Dental Services See details
Dental Services are covered, including Medicare Dental Services with a $35 copay, and Other Dental Services with a $0-$35 copay; some services like Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Fluoride Treatment, and Other Preventive Dental Services are also covered with varying limitations. Orthodontic Services are covered up to a $1,000 annual maximum, while Restorative, Adjunctive General, Endodontics, Periodontics, Prosthodontics (removable and fixed), and Oral and Maxillofacial Surgery services are covered with 50% coinsurance. 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 VA (HMO-POS) plan, including Medicare Part B Insulin Drugs with a copay of $10-$35, and Medicare Part B Chemotherapy/Radiation Drugs with a copay of $10-$47 and 0-20% coinsurance. Other Medicare Part B Drugs have a copay of $10-$47 and 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Kaiser Permanente Medicare Advantage High VA (HMO-POS) plan, but require prior authorization and a doctor's referral. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME) with 0-20% coinsurance and no copay, though Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies have a 20% coinsurance and no copay, and Diabetic Equipment is covered, with Diabetic Supplies having no coinsurance and Diabetic Therapeutic Shoes/Inserts having 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Kaiser Permanente Medicare Advantage High VA (HMO-POS) plan. Diagnostic Procedures/Tests have no copay, and Lab Services have no copay. Diagnostic Radiological Services have a copay of at most $150, Therapeutic Radiological Services have a copay of at most $35, and Outpatient X-Ray Services have a $10 copay.
Home Health Services See details
Home Health Services are covered by the Kaiser Permanente Medicare Advantage High VA (HMO-POS) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization and a referral are required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Kaiser Permanente Medicare Advantage High VA (HMO-POS) plan. Although the plan covers Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services, none of these services are covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Kaiser Permanente Medicare Advantage High VA (HMO-POS) plan, with a $0 copay for days 1-20, and a $160 copay for days 21-100. Additional days beyond Medicare-covered for SNF and Non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Kaiser Permanente Medicare Advantage High VA (HMO-POS) plan's other services benefit covers over-the-counter items with a maximum benefit of $60 every three months, and also covers "Other 1" services with 0-20% coinsurance and "Other 2" services with a $155 copay, but acupuncture, meal benefits, and several other services are not covered.
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