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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 2026, 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 2026 to people living in DC. This plan received an overall rating of 4.5 out of 5 stars in 2026.
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 $7500.00 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 features no drug deductible, meaning your prescription coverage begins immediately. For Tier 1 preferred generics, you will pay no copay at preferred pharmacies or through standard mail order, while standard pharmacies charge a $10 copay for a one-month supply. Tier 2 generics cost a $15 copay for a one-month supply at preferred pharmacies and feature no copay for two- or three-month fills ordered through standard mail delivery. Tier 3 preferred brands require a $47 copay for a one-month supply, and Tier 4 non-preferred drugs cost a $100 copay across standard and preferred pharmacies. Tier 5 specialty drugs require a 28% coinsurance, while Tier 6 vaccines are highly accessible with no copay for a one-month supply at both preferred and standard pharmacies.
Additional Benefits
The Kaiser Permanente Medicare Advantage Value DC (HMO-POS) plan offers comprehensive coverage with predictable cost-sharing, featuring no coinsurance for many key medical services. Primary care visits require a $5 copay, telehealth services have no copay, and specialist visits carry a $40 copay. For hospital stays, inpatient acute care requires a $350 daily copay for the first five days and no copay for days 6 through 90, while emergency room visits have a $115 copay. This plan also includes valuable supplemental benefits like dental, vision, and hearing coverage to help lower your out-of-pocket costs. Preventive dental and hearing aid fittings feature no copay, while prescription hearing aids are covered with no copay up to $1,000 per ear every three years. Additionally, members can access home health services with no copay and receive up to $25 quarterly for over-the-counter items.
Inpatient Hospital See details
Kaiser Permanente Medicare Advantage Value DC (HMO-POS) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $350 daily copay for days 1 to 5 and no copay for days 6 to 90. The benefit is partially covered because upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered, though unlimited additional acute care days are included with no copay.
Outpatient Services See details
Outpatient Services under the Kaiser Permanente Medicare Advantage Value DC (HMO-POS) plan feature no coinsurance across all covered benefits, with copays ranging from no copay up to $350. Patients will pay a copay of $0 to $350 for outpatient hospital and observation services, $350 for ambulatory surgical center services, $5 to $10 for outpatient substance abuse sessions, and no copay or deductible for outpatient blood services.
Partial Hospitalization See details
Kaiser Permanente Medicare Advantage Value DC (HMO-POS) covers partial hospitalization services with a $5.00 copay and no coinsurance. Prior authorization and a referral are required to access this covered benefit.
Ambulance and Transportation Services See details
Ambulance services are covered by Kaiser Permanente Medicare Advantage Value DC (HMO-POS) for a $275 copay per trip with no coinsurance, though prior authorization is required. Routine transportation services to health-related locations are not covered under this plan.
Emergency Services See details
Kaiser Permanente Medicare Advantage Value DC (HMO-POS) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital. Urgently needed services are covered with a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services require no coinsurance and copays of $115, $40, and $275 respectively.
Primary Care See details
Kaiser Permanente Medicare Advantage Value DC (HMO-POS) covers primary care visits for a $5 copay and telehealth services with no copay, both with no coinsurance. Specialist visits and physical therapy carry a $40 copay with no coinsurance, while podiatry is not covered, and some chiropractic services are covered but routine and other chiropractic services are not.
Preventive Services See details
Preventive services are partially covered by Kaiser Permanente Medicare Advantage Value DC (HMO-POS) with no copay and no coinsurance for covered benefits like annual physicals, fitness benefits, and health education. Sub-services that are not covered include in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, chemotherapy wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, in-home support, caregiver support, additional smoking cessation counseling, enhanced disease management, telemonitoring, home safety modifications, and counseling.
Hearing Services See details
Kaiser Permanente Medicare Advantage Value DC (HMO-POS) provides partially covered hearing services, including Medicare-covered hearing exams for a $40 copay and no coinsurance, and hearing aid fittings with no copay and no coinsurance. Prescription hearing aids are covered with no copay and no coinsurance up to $1,000 per ear every three years; however, routine hearing exams, OTC hearing aids, and inner, outer, or over-the-ear prescription hearing aids are not covered.
Vision Services See details
Kaiser Permanente Medicare Advantage Value DC (HMO-POS) covers vision services with no deductibles, including routine eye exams with a $5 to $40 copay and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay and a 20% coinsurance for contact lenses up to a $200 limit every two years, but upgrades are excluded.
Dental Services See details
Kaiser Permanente Medicare Advantage Value DC (HMO-POS) offers partially covered dental services, with exclusions for implant services, orthodontics, and maxillofacial prosthetics. Preventive and diagnostic services range from no copay to a $40 copay with no coinsurance, while covered comprehensive services require 50% coinsurance with either no copay or a $40 copay for oral surgery.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Kaiser Permanente Medicare Advantage Value DC (HMO-POS) with prior authorization, featuring a $15.00 to $35.00 copay and no coinsurance for insulin. Other covered Part B drugs, including chemotherapy and radiation, require a copay of $15.00 to $47.00 and 0% to 20% coinsurance.
Dialysis Services See details
Kaiser Permanente Medicare Advantage Value DC (HMO-POS) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization and a referral are required to receive these covered services.
Medical Equipment See details
Medical equipment is covered by Kaiser Permanente Medicare Advantage Value DC (HMO-POS) with no copays, though prior authorization is required for these services. Durable medical equipment features 0% to 20% coinsurance, diabetic supplies have no coinsurance, and prosthetics, medical supplies, and diabetic therapeutic shoes require 20% coinsurance.
Diagnostic and Radiological Services See details
Kaiser Permanente Medicare Advantage Value DC (HMO-POS) covers diagnostic and radiological services with no coinsurance, although prior authorization and referrals are required. Outpatient diagnostic procedures, tests, and lab services have no copay, while diagnostic and therapeutic radiological services and outpatient X-rays require a $40 copay.
Home Health Services See details
Kaiser Permanente Medicare Advantage Value DC (HMO-POS) covers Home Health Services with no copay and no coinsurance. Prior authorization and a referral are required to access this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Kaiser Permanente Medicare Advantage Value DC (HMO-POS) with no coinsurance, although some services are covered while cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered. Copayments for these rehabilitation services range from $20 to $40, and both prior authorization and referrals are required.
Skilled Nursing Facility (SNF) See details
Kaiser Permanente Medicare Advantage Value DC (HMO-POS) covers Skilled Nursing Facility (SNF) services with no coinsurance, though prior authorization and referrals are required. There is no copay for days 1 through 20, a $218 daily copay for days 21 through 100, and no prior three-day hospital stay is required, though additional days beyond the 100-day limit are not covered.
Other Services See details
Other services are partially covered by Kaiser Permanente Medicare Advantage Value DC (HMO-POS), including over-the-counter items with no copay and no coinsurance up to $25 quarterly, and non-Medicare medical supplies with no copay and 0% to 20% coinsurance. Non-Medicare surgical procedures at an ambulatory surgical center are covered with a $350 copay and no coinsurance, but acupuncture and meal benefits are not covered.
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