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Kaiser Permanente Medicare Advantage Optimal (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Kaiser Permanente Medicare Advantage Optimal (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 Optimal (HMO) in 2025, please refer to our full plan details page.
Kaiser Permanente Medicare Advantage Optimal (HMO) is a HMO plan offered by Kaiser Foundation Health Plan, Inc. available for enrollment in 2025 to people living in Counties: KI, PI, KP, SN, GY, LE, MA, TH. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Kaiser Permanente Medicare Advantage Optimal (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 Optimal (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 Optimal (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $353.00. 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 $3150.00 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 Optimal (HMO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For example, preferred generic drugs have a $5 copay at preferred pharmacies, while preferred brand drugs have a $99 copay. In the initial coverage phase, your costs will continue until your total drug costs reach $2,000. Once you reach that amount, you will enter the catastrophic coverage phase where you will pay nothing for your drugs.
Additional Benefits
The Kaiser Permanente Medicare Advantage Optimal (HMO) plan offers a wide range of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services have copays depending on the service. Emergency and urgent care services have copays, and primary care visits have no copay for many services. Preventive, hearing, vision, and dental services are also covered. The plan includes coverage for home health, and medical equipment, with varying copays and coinsurance amounts. The plan also offers additional benefits like ambulance services, and cardiac rehabilitation services, with copays and coinsurance applying in different scenarios.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric care. For acute care, there is a $190 copay for days 1-2, and no copay for days 3-90; additional days have no copay. For inpatient psychiatric care, there is a $190 copay for days 1-2, and no copay for days 3-90. Non-Medicare-covered stays and upgrades for acute and psychiatric care are not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services have a copay between $0 and $165, observation services and ambulatory surgical center services have a $165 copay, individual outpatient substance abuse sessions have a $20 copay, and group outpatient substance abuse sessions have a $10 copay. Outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Kaiser Permanente Medicare Advantage Optimal (HMO) plan, with a $55 copay. Prior authorization and a doctor referral are required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with all ambulance services requiring prior authorization. Ground and air ambulance services have a $150 copay and no coinsurance, while transportation services to health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Kaiser Permanente Medicare Advantage Optimal (HMO) plan. Emergency Services have a $140 copay with no coinsurance. Urgently Needed Services have a $20 copay with no coinsurance. Worldwide Emergency Coverage has a $140 copay, Worldwide Urgent Coverage has a $20 copay, and Worldwide Emergency Transportation has a $150 copay; all have no coinsurance.
Primary Care See details
Primary Care includes coverage for primary care physician services with no copay, chiropractic services with a $10 copay, occupational therapy services with a copay between $0 and $10, physician specialist services with a $20 copay, mental health specialty services with a copay between $10 and $20 depending on the session, other health care professional services with a copay between $0 and $20, psychiatric services with a copay between $10 and $20 depending on the session, physical therapy and speech-language pathology services with a copay between $0 and $10, additional telehealth benefits with no copay, and opioid treatment program services with a $20 copay. Podiatry Services are not covered.
Preventive Services See details
Preventive services are covered, including an annual physical exam with no copay. Additional preventive services, including alternative therapies, are covered, though some services have a copay.
Hearing Services See details
Hearing services include hearing exams with no copay and routine hearing exams and fitting/evaluation for hearing aids with a copay between $0 and $20. Prescription and OTC hearing aids are not covered.
Vision Services See details
The Kaiser Permanente Medicare Advantage Optimal (HMO) plan covers vision services, including routine eye exams with a copay of $0-$20, and eyewear with no copay. Eyewear has a combined maximum plan benefit coverage amount of $350 per year, and upgrades are not covered.
Dental Services See details
Dental Services include oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, and other preventive dental services with no copay, but are limited to 2 visits every year. Orthodontic services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including insulin and other Medicare Part B drugs. For Medicare Part B Insulin Drugs, there is a $35 copay.
Dialysis Services See details
Dialysis Services are covered by the Kaiser Permanente Medicare Advantage Optimal (HMO) plan, but require prior authorization and a doctor's referral. The plan has a coinsurance of 20% for dialysis services.
Medical Equipment See details
The Kaiser Permanente Medicare Advantage Optimal (HMO) plan covers medical equipment, including durable medical equipment, prosthetics, medical supplies, and diabetic equipment. Durable medical equipment has a 20% coinsurance, and durable medical equipment for use outside the home is not covered. Prosthetic devices and medical supplies have a 20% coinsurance. Diabetic supplies and diabetic therapeutic shoes/inserts have no copay, and you may need to pay a copay for other diabetic supplies.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including Diagnostic Procedures/Tests and Lab Services, are covered with no copay. Diagnostic Radiological Services have a copay of at most $50, while Therapeutic Radiological Services have a coinsurance of at most 20%. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Kaiser Permanente Medicare Advantage Optimal (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 not in practice. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
The Kaiser Permanente Medicare Advantage Optimal (HMO) plan covers Skilled Nursing Facility (SNF) services with prior authorization and a doctor's referral. You will have no copay for days 1-20, and a $50 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes coverage for acupuncture with a $10 copay per visit, limited to 25 treatments per year, while over-the-counter items, meal benefits, and other services are not covered. Additional services such as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services are not covered.
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