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Kaiser Permanente Medicare Advantage Essential (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Kaiser Permanente Medicare Advantage Essential (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 Essential (HMO) in 2025, please refer to our full plan details page.
Kaiser Permanente Medicare Advantage Essential (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 Essential (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 Essential (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 Essential (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $99.00. 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 $4000.00 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 Essential (HMO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay a copay for your prescriptions, depending on the drug tier and pharmacy. For example, preferred generic drugs have a $5 copay at preferred pharmacies and $20 at standard pharmacies. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for Part D covered drugs. If you qualify for the low-income subsidy, you will pay $0.60 for Part D drugs.
Additional Benefits
The Kaiser Permanente Medicare Advantage Essential (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services have copays that vary. Emergency services have a copay, as do ambulance services. The plan includes no copay for primary care, preventive services, hearing exams, vision exams, and dental services. Additional benefits include coverage for home health services, skilled nursing facilities, and other services like acupuncture.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric care, with a $240 copay for days 1-4, and no copay for days 5-90. Additional days for inpatient hospital-acute have no copay, while non-Medicare-covered stays and upgrades for inpatient hospital-acute are not covered, along with additional days and non-Medicare-covered stays for inpatient hospital psychiatric.
Outpatient Services See details
Outpatient Services include coverage for hospital services with a copay between $0 and $220, observation services with a $220 copay, and ambulatory surgical center services with a $220 copay. Individual sessions for outpatient substance abuse have a $35 copay, and group sessions have a $25 copay, and outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Kaiser Permanente Medicare Advantage Essential (HMO) plan, requiring prior authorization and a doctor referral, with a $55 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required for all ambulance services. Ground and Air Ambulance Services have a $200 copay, and there is no coinsurance; however, Transportation Services to health-related locations are not covered.
Emergency Services See details
Emergency Services, including urgently needed services, are covered by the Kaiser Permanente Medicare Advantage Essential (HMO) plan. Emergency services have a $140 copay with no coinsurance, while urgently needed services have a $25 copay with no coinsurance. Worldwide Emergency Coverage has a $140 copay, Worldwide Urgent Coverage has a $25 copay, and Worldwide Emergency Transportation has a $200 copay.
Primary Care See details
For Primary Care services, this plan has no copay. Chiropractic services have a $20 copay, with Routine Care and Other services covered. Occupational Therapy Services have a copay between $0 and $35. Physician Specialist Services have a $25 copay, and Mental Health Specialty Services have copays of $25-$35 depending on the type of session. Other Health Care Professional services have a copay between $0 and $25. Psychiatric Services have copays of $25-$35 depending on the type of session. Physical Therapy and Speech-Language Pathology Services have a copay between $0 and $35. Additional Telehealth Benefits have no copay. Opioid Treatment Program Services have a $25 copay.
Preventive Services See details
Preventive services, including annual physical exams, are covered with no copay. Other preventive services, such as additional sessions of smoking and tobacco cessation counseling, fitness benefits, and remote access technologies, are covered with no copay. Services like Health Education, In-Home Safety Assessment, and others are not covered.
Hearing Services See details
Hearing exams and fitting/evaluation for hearing aids are covered with no copay, and routine hearing exams are covered with a copay between $0 and $25. Prescription hearing aids and OTC hearing aids are not covered.
Vision Services See details
Vision Services include coverage for eye exams with a copay of $0-$25, and eyewear with no copay; however, upgrades are not covered. The plan offers a combined maximum of $300 per year for eyewear.
Dental Services See details
Dental Services are covered, including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, and other preventive dental services with no copay. Medicare Dental Services require prior authorization and a doctor referral, with a $25 copay. Orthodontic services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics, maxillofacial prosthetics, implant services, prosthodontics, fixed, oral and maxillofacial surgery, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered, but require prior authorization and a doctor's referral. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical equipment, including durable medical equipment, prosthetics, and diabetic equipment, is covered under the Kaiser Permanente Medicare Advantage Essential (HMO) plan. Durable Medical Equipment (DME) 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, and diabetic supplies and diabetic therapeutic shoes/inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures, lab services, and radiological services. Diagnostic Procedures/Tests and Lab Services have no copay, while Diagnostic Radiological Services have a copay of at least $175, and Therapeutic Radiological Services have a coinsurance of at least 20%. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Kaiser Permanente Medicare Advantage Essential (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 not covered by the Kaiser Permanente Medicare Advantage Essential (HMO) plan. Services require prior authorization and a doctor referral.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Kaiser Permanente Medicare Advantage Essential (HMO) plan, but require prior authorization and a doctor referral. You will have no copay for days 1-20, and a $115 copay for days 21-100. Additional days beyond Medicare-covered for Skilled Nursing Facility (SNF) and Non-Medicare-covered stays for Skilled Nursing Facility (SNF) are not covered.
Other Services See details
Other Services includes acupuncture with a $10 copay, but other services such as over-the-counter items, meal benefits, and others are not covered. Acupuncture is limited to 25 treatments per year.
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