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Kaiser Permanente Medicare Advantage Value DC (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Kaiser Permanente Medicare Advantage Value 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 Value DC (HMO-POS) in 2025, please refer to our full plan details page.
Kaiser Permanente Medicare Advantage Value 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 Value 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 Value 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 Value DC (HMO-POS), 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 $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 Value 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 the pharmacy you use. For example, preferred generic drugs have a $7 copay at preferred pharmacies and a $20 copay at standard pharmacies. 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 have to pay for excluded drugs covered under any enhanced benefit. Specialty tier drugs have no copay.
Additional Benefits
The Kaiser Permanente Medicare Advantage Value DC (HMO-POS) plan offers a range of benefits with varying costs. For inpatient hospital stays, you'll pay a $290 copay for the first five days, and then no copay. Outpatient services have copays ranging from $0 to $290, and emergency services have a $110 copay. The plan also includes coverage for primary care visits with a $5 copay, along with preventive services and annual physical exams with no copay. Hearing exams have a $40 copay, and vision services include eye exams with a copay between $0 and $40. Dental services are covered with copays between $0 and $40, 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 Inpatient Hospital-Acute, you pay a $290 copay for days 1-5, and no copay for days 6-90; additional days for Inpatient Hospital-Acute have no copay. Inpatient Hospital Psychiatric services have a $290 copay for days 1-5, and no copay for days 6-90. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Additional Days for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services and observation services with a copay between $0 and $290, ambulatory surgical center services with a $290 copay, outpatient substance abuse services with a $5 to $10 copay, and outpatient blood services with no copay. Prior authorization and a doctor referral are required for all services.
Partial Hospitalization See details
Partial hospitalization is covered by the Kaiser Permanente Medicare Advantage Value DC (HMO-POS) plan, but requires prior authorization and a doctor referral. You will have a $5 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Kaiser Permanente Medicare Advantage Value DC (HMO-POS) plan. Ground and air ambulance services have a $275 copay, and there is no coinsurance; however, 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 by the Kaiser Permanente Medicare Advantage Value DC (HMO-POS) plan. Emergency Services and Worldwide Emergency Coverage have a $110 copay, Urgently Needed Services has a $40 copay, and Worldwide Emergency Transportation has a $275 copay; all other services have no coinsurance.
Primary Care See details
Primary Care Physician services have a $5 copay, while 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, and Opioid Treatment Program Services require a referral and/or prior authorization. Additional Telehealth Benefits have no copay.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services with no copay and Annual Physical Exams with no copay. Additional preventive services, Kidney Disease Education Services, and Other Preventive Services are covered, with the specific copay information available in the plan details.
Hearing Services See details
The Kaiser Permanente Medicare Advantage Value DC (HMO-POS) plan covers Hearing Exams with a $40 copay. Fitting/Evaluation for Hearing Aids is covered with no copay. Prescription Hearing Aids are covered, and the plan covers up to $1,000 every three years. However, 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; however, upgrades are not covered. Routine eye exams have a copay of $5-$40.
Dental Services See details
The Kaiser Permanente Medicare Advantage Value DC (HMO-POS) plan covers dental services, including Medicare Dental Services with a $40 copay, and other dental services with a copay between $0 and $40. Orthodontic services are covered up to a maximum of $1500 per year, and restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with a 50% coinsurance. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs, are covered by the Kaiser Permanente Medicare Advantage Value DC (HMO-POS) plan. For Medicare Part B Insulin Drugs, the copay is between $7.00 and $35.00; for Medicare Part B Chemotherapy/Radiation Drugs, the copay is between $7.00 and $47.00, with a coinsurance between 0% and 20%; and for Other Medicare Part B Drugs, the copay is between $7.00 and $47.00, with a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Kaiser Permanente Medicare Advantage Value DC (HMO-POS) plan, requiring prior authorization and a doctor referral. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits are covered by the Kaiser Permanente Medicare Advantage Value DC (HMO-POS) plan, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. Durable Medical Equipment has no copay, with a 0-20% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies have no copay and a 20% coinsurance for Medicare-covered Prosthetic Devices and Medical Supplies. Diabetic Supplies have no copay and no coinsurance, while Diabetic Therapeutic Shoes/Inserts have a 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, while Lab Services have no copay. Diagnostic Radiological Services have a copay of at most $170, Therapeutic Radiological Services have a copay of at least $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 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 not the specific services listed: Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. Prior authorization and a doctor referral are required for coverage.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Kaiser Permanente Medicare Advantage Value DC (HMO-POS) plan, but require prior authorization and a doctor's referral. There is no copay for days 1-20, and a $214 copay for days 21-100; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) Items with a maximum benefit of $70 every three months, and for Other 1 services, which have a coinsurance of 0% - 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, Self-Directed Personal Assistance Services are not covered. Other 2 services are covered with a $290 copay.
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