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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 2026, 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, SN, GY, LE, MA, TH. This plan received an overall rating of 4 out of 5 stars in 2026.
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 $358.00. 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 features prescription drug coverage with no annual drug deductible. You will pay no copay for Tier 1 preferred generic drugs when filled at a preferred pharmacy or through standard mail order. Tier 2 generic medications are also highly affordable, starting at a $5 copay for a one-month supply at preferred pharmacies and featuring no copay for two- or three-month supplies filled via standard mail order. Higher-tier medications, such as Tier 3 preferred brands and Tier 4 non-preferred drugs, carry a $45 and $99 copay respectively for a one-month supply at both preferred and standard pharmacies. Tier 5 specialty drugs require a 32% coinsurance, while Tier 6 vaccines are available with no copay for a one-month supply at both preferred and standard pharmacies.
Additional Benefits
The Kaiser Permanente Medicare Advantage Optimal (HMO) plan offers robust medical coverage with predictable out-of-pocket costs, featuring no copay for primary care, telehealth, preventive services, and covered dental care. For inpatient hospital stays, you will pay a $190 daily copay for the first two days and no copay for days three through 90. Outpatient services and emergency care are also highly accessible, with emergency visits requiring a $140 copay and outpatient procedures ranging from no copay to a $165 copay. Specialist visits, routine eye exams, and routine hearing exams are very affordable, with copays ranging from no copay to $20, alongside a $200 annual eyewear allowance. While home health services and diabetic supplies have no copay, durable medical equipment and dialysis require a 20% coinsurance. It is important to note that this plan does not cover hearing aids, acupuncture, over-the-counter items, or meal benefits.
Inpatient Hospital See details
Kaiser Permanente Medicare Advantage Optimal (HMO) partially covers inpatient hospital services with no coinsurance, requiring a $190 copay per day for days 1 and 2, and no copay for days 3 through 90. Non-Medicare-covered stays, upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
Kaiser Permanente Medicare Advantage Optimal (HMO) covers outpatient services with no coinsurance, featuring a $0 to $165 copay for outpatient hospital services and a $165 copay for ambulatory surgical center and observation services. Outpatient substance abuse services require a $10 copay for group sessions and a $20 copay for individual sessions, while outpatient blood services have no copay or coinsurance.
Partial Hospitalization See details
Kaiser Permanente Medicare Advantage Optimal (HMO) covers partial hospitalization with a $55.00 copay and no coinsurance. Prior authorization and a referral are required for these services.
Ambulance and Transportation Services See details
Kaiser Permanente Medicare Advantage Optimal (HMO) covers ground and air ambulance services with a $150 copay and no coinsurance, though prior authorization is required. Transportation services are partially covered, but trips to plan-approved health-related locations and any health-related locations are not covered.
Emergency Services See details
Kaiser Permanente Medicare Advantage Optimal (HMO) covers emergency services with a $140 copay and no coinsurance, with the copay waived if admitted to the hospital within 24 hours. Urgently needed care is covered with a $20 copay and no coinsurance, while worldwide emergency services are covered with no coinsurance and copays ranging from $20 to $150.
Primary Care See details
Kaiser Permanente Medicare Advantage Optimal (HMO) offers primary care and telehealth services with no copay and no coinsurance. Specialist visits, physical therapy, and mental health services feature copays ranging from $0 to $20 with no coinsurance, while chiropractic services are partially covered (routine care has a $10 copay, but other chiropractic services are not covered) and podiatry is not covered.
Preventive Services See details
Kaiser Permanente Medicare Advantage Optimal (HMO) covers preventive services, including annual physical exams, kidney disease education, and diabetes self-management training, with no copay and no coinsurance. Additional preventive benefits are partially covered with no coinsurance, featuring fitness programs and smoking cessation counseling with no copay, and alternative therapies with a $10 copay, while health education, weight management programs, and in-home safety assessments are not covered.
Hearing Services See details
Kaiser Permanente Medicare Advantage Optimal (HMO) covers hearing exams with no deductible and no coinsurance, featuring no copay for Medicare-covered exams and annual hearing aid fittings, and a $0 to $20 copay for one routine hearing exam per year. Prescription and OTC hearing aids are not covered by this plan.
Vision Services See details
Vision services are partially covered by Kaiser Permanente Medicare Advantage Optimal (HMO), offering routine eye exams with a $0 to $20 copay, no coinsurance, and no deductible, though other eye exam services and eyewear upgrades are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible up to a $200 annual maximum for contact lenses, lenses, and frames.
Dental Services See details
Dental Services are partially covered under the Kaiser Permanente Medicare Advantage Optimal (HMO) plan, featuring no copay and no coinsurance for covered preventive and comprehensive care. Covered treatments include exams, cleanings, and oral surgery, but maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Kaiser Permanente Medicare Advantage Optimal (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Covered Part B insulin drugs have a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs carry a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered under the Kaiser Permanente Medicare Advantage Optimal (HMO) plan with no copay and a 20% coinsurance. Patients will need to obtain both a referral and prior authorization to receive these covered services.
Medical Equipment See details
Kaiser Permanente Medicare Advantage Optimal (HMO) covers durable medical equipment, prosthetics, and medical supplies with no copay and a 20% coinsurance, subject to prior authorization. Diabetic equipment, supplies, and therapeutic shoes are covered with no copay and no coinsurance, though brand limitations and prior authorization requirements apply.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Kaiser Permanente Medicare Advantage Optimal (HMO), with prior authorization and referrals required. Diagnostic tests and lab services have no copay and no coinsurance, while diagnostic radiological services require a $65 copay (no coinsurance), outpatient X-rays have no copay, and therapeutic radiological services carry a 20% coinsurance (no copay).
Home Health Services See details
Home health services are covered by Kaiser Permanente Medicare Advantage Optimal (HMO) with no copay and no coinsurance. Both prior authorization and a referral are required to access this benefit.
Cardiac Rehabilitation Services See details
Kaiser Permanente Medicare Advantage Optimal (HMO) covers Cardiac Rehabilitation Services with no coinsurance, though prior authorization and referrals are required. While some services are covered, specific sub-services—including cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy for symptomatic peripheral artery disease—are not covered and require a $10 copay.
Skilled Nursing Facility (SNF) See details
Kaiser Permanente Medicare Advantage Optimal (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring no copay for days 1 through 20 and a $115 copay for days 21 through 100. The benefit is partially covered, as prior authorization and referrals are required, and additional days beyond the standard 100 days are not covered.
Other Services See details
Other services are not covered under the Kaiser Permanente Medicare Advantage Optimal (HMO), meaning there is no coverage or cost-sharing for acupuncture, over-the-counter (OTC) items, or meal benefits.
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