A non-government entity
Kaiser Permanente Medicare Advantage Value MD (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Kaiser Permanente Medicare Advantage Value MD (HMO). 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 Value MD (HMO) in 2025, please refer to our full plan details page.
Kaiser Permanente Medicare Advantage Value MD (HMO) is a HMO plan offered by Kaiser Foundation Health Plan, Inc. available for enrollment in 2025 to people living in Counties: AA, CH, CR, CV, FR, HA, HO, PG, MO. 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 Value MD (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 Medicare Advantage Value MD (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 Medicare Advantage Value MD (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 $7200.00 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 Value MD (HMO) plan has a $0 deductible for prescription drugs. During 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 $14 copay, while preferred brand drugs have a $100 copay. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for covered Part D drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
The Kaiser Permanente Medicare Advantage Value MD (HMO) plan offers comprehensive coverage with a variety of benefits. Inpatient hospital stays have a $300 copay for days 1-5, and then no copay for the rest of the stay. Outpatient services have varying copays, and emergency services have a $110 copay. This plan covers primary care with a $10 copay, and also includes preventive services, hearing, vision, and dental coverage. Hearing exams cost $40, and vision exams have no copay. Dental services include a $40 copay for Medicare dental services, and orthodontic services are covered up to $1500 per year.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For days 1-5, there is a $300 copay, and for days 6-90, there is no copay. Additional days for Inpatient Hospital-Acute are covered with no copay. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered, and Additional Days and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services are covered by the Kaiser Permanente Medicare Advantage Value MD (HMO) plan. Outpatient Hospital Services and Observation Services have a copay between $0 and $300, Ambulatory Surgical Center (ASC) Services have a $300 copay, and Outpatient Substance Abuse Services have a $20 copay for individual sessions and a $10 copay for group sessions. Outpatient Blood Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Kaiser Permanente Medicare Advantage Value MD (HMO) plan, and requires prior authorization and a doctor referral. You will have a $10 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services, including ground and air ambulance services, are covered with a $275 copay and no coinsurance; however, transportation services to any health-related location are not covered. Prior authorization is required for all ambulance services.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the Kaiser Permanente Medicare Advantage Value MD (HMO) plan. Emergency Services have a $110 copay, Urgently Needed Services have a $40 copay, Worldwide Emergency Coverage has a $110 copay, Worldwide Urgent Coverage has a $40 copay, and Worldwide Emergency Transportation has a $275 copay.
Primary Care See details
The Kaiser Permanente Medicare Advantage Value MD (HMO) plan covers primary care physician services and chiropractic services with a $10 copay. Occupational therapy services have a $35 copay, while physician specialist services have a copay between $0 and $40. Mental health specialty services, including individual and group sessions, have copays of $20 and $10, respectively, and physical therapy and speech-language pathology services have a $40 copay. Additional telehealth benefits have no copay, and opioid treatment program services have a $40 copay. Chiropractic services, occupational therapy, physician specialist services, mental health specialty services, physical therapy, speech-language pathology services, and opioid treatment program services require prior authorization and a doctor's referral.
Preventive Services See details
Preventive services include annual physical exams with no copay, and other services like Health Education, Home-Based Palliative Care, Fitness Benefit, Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline), Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, all with no copay. Some 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, 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 coverage for hearing exams with a $40 copay, fitting/evaluation for hearing aids with no copay, and prescription hearing aids. Routine hearing exams, prescription hearing aids - inner ear, prescription hearing aids - outer ear, prescription hearing aids - over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a copay of $0-$40, 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 include coverage for Medicare Dental Services with a $40 copay, and other services with a copay between $0 and $40. Orthodontic Services are covered up to a maximum of $1500 per year with no copay or coinsurance, while Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), and Oral and Maxillofacial Surgery are covered with a 50% coinsurance and require prior authorization. Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, the copay is between $14 and $35. For Medicare Part B Chemotherapy/Radiation Drugs, the copay is between $14 and $47, and the coinsurance is between 0% and 20%. For Other Medicare Part B Drugs, the copay is between $14 and $47, and the coinsurance is between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Kaiser Permanente Medicare Advantage Value MD (HMO) plan and require prior authorization and a doctor's referral. You are responsible for 20% coinsurance.
Medical Equipment See details
Medical equipment is covered under the Kaiser Permanente Medicare Advantage Value MD (HMO) plan, including durable medical equipment, prosthetics, medical supplies, and diabetic equipment. Durable medical equipment has a coinsurance between 0% and 20%, while durable medical equipment for use outside the home is not covered. Prosthetic devices and medical supplies have a 20% coinsurance, and diabetic supplies have no coinsurance, while diabetic therapeutic shoes/inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Kaiser Permanente Medicare Advantage Value MD (HMO) plan. Diagnostic Procedures/Tests have no copay, and Lab Services have no copay. Diagnostic Radiological Services have a copay of at least $20 and at most $150, Therapeutic Radiological Services have a copay of $40, and Outpatient X-Ray Services have a $20 copay.
Home Health Services See details
Home Health Services are covered under the Kaiser Permanente Medicare Advantage Value MD (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 Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. A doctor referral and prior authorization are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Kaiser Permanente Medicare Advantage Value MD (HMO) plan, but require prior authorization and a doctor referral. For days 1-20, there is no copay, and for days 21-100, the copay is $214 per day; additional days beyond Medicare-covered SNF stays and non-Medicare-covered SNF stays are not covered.
Other Services See details
The Kaiser Permanente Medicare Advantage Value MD (HMO) plan's Other Services benefit covers Over-the-Counter (OTC) items with a maximum benefit coverage amount of $50 every three months, and other services are not covered. Other services include 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.
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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