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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 2026, 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: KP, GY, LE, MA. This plan received an overall rating of 4 out of 5 stars in 2026.
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 $104.00. 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 features a $0 drug deductible, meaning your prescription coverage begins immediately. Under this plan, you will pay no copay for Tier 1 preferred generic drugs filled at preferred pharmacies or through standard mail order, as well as no copay for Tier 6 vaccines. Tier 2 generic drugs are also highly affordable, starting at a $5 copay for a one-month supply at preferred pharmacies, with no copay for two- and three-month supplies ordered through standard mail. For Tier 3 preferred brand drugs and Tier 4 non-preferred drugs, copays start at $47 and $99 respectively for a one-month supply at both preferred and standard pharmacies. Standard mail order offers cost savings on these medications, lowering the three-month copay to $117.50 for Tier 3 and $247.50 for Tier 4. Specialty medications in Tier 5 require a 33% coinsurance across all pharmacy options, including mail order.
Additional Benefits
The Kaiser Permanente Medicare Advantage Essential (HMO) plan offers comprehensive coverage for core medical services with many benefits requiring no coinsurance. Members enjoy no copay for primary care visits, preventive care, and home health services, while specialist visits range from no copay up to $35. For hospital care, inpatient stays require a $260 daily copay for days 1 through 4 followed by no copay for days 5 through 90, and emergency services carry a $140 copay. Routine dental and vision services are highly accessible, featuring no copay for preventive dental care and a $200 yearly eyewear allowance with no copay. Diagnostic labs and outpatient X-rays also have no copay, while durable medical equipment and dialysis services require a 20% coinsurance. Please note that some services, such as routine transportation, hearing aids, and over-the-counter items, are not covered by this plan.
Inpatient Hospital See details
Kaiser Permanente Medicare Advantage Essential (HMO) covers inpatient hospital services with no coinsurance, requiring a $260 daily copay for days 1 through 4 and no copay for days 5 through 90. While unlimited additional acute care days are covered at no copay, psychiatric additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient Services under the Kaiser Permanente Medicare Advantage Essential (HMO) plan are covered with no coinsurance, with copays ranging from no copay up to $230 depending on the service. Outpatient hospital services have a $0 to $230 copay, ambulatory surgical and observation services require a $230 copay, outpatient substance abuse sessions cost $25 to $35, and outpatient blood services have no copay.
Partial Hospitalization See details
Partial hospitalization is covered by Kaiser Permanente Medicare Advantage Essential (HMO) with a $55.00 copay and no coinsurance. Prior authorization and a referral are required to receive this benefit.
Ambulance and Transportation Services See details
Kaiser Permanente Medicare Advantage Essential (HMO) covers ground and air ambulance services with a $220 copay and no coinsurance, with prior authorization required. Transportation services, including transit to plan-approved or any health-related locations, are not covered.
Emergency Services See details
Kaiser Permanente Medicare Advantage Essential (HMO) covers emergency services with a $140 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $25 copay with no coinsurance, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays of $140, $25, and $220, respectively.
Primary Care See details
Kaiser Permanente Medicare Advantage Essential (HMO) offers primary care physician visits and telehealth benefits with no copay and no coinsurance, while other covered services like therapy and specialist visits have copays ranging from $0 to $35 and no coinsurance. Routine chiropractic care is covered with a $20 copay, but other chiropractic services and podiatry services are not covered.
Preventive Services See details
Preventive services are partially covered under the Kaiser Permanente Medicare Advantage Essential (HMO) with no copay and no coinsurance for covered benefits like annual physical exams, smoking cessation counseling, and diabetes self-management training. However, several supplemental options are not covered, including health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, weight management programs, and alternative therapies.
Hearing Services See details
Kaiser Permanente Medicare Advantage Essential (HMO) covers hearing exams with no deductible, no coinsurance, and copays ranging from no copay up to $25, while prescription and over-the-counter hearing aids are not covered. Covered services include one routine hearing exam and one fitting evaluation yearly, both of which require prior authorization and a referral.
Vision Services See details
Kaiser Permanente Medicare Advantage Essential (HMO) covers routine eye exams with a $0 to $25 copay and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible up to a $200 yearly limit, but eyewear upgrades are excluded.
Dental Services See details
Kaiser Permanente Medicare Advantage Essential (HMO) provides partially covered dental services, featuring Medicare-covered dental care for a $25 copay and no coinsurance, and preventive services with no copay and no coinsurance. While most comprehensive dental treatments are covered, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Kaiser Permanente Medicare Advantage Essential (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Under this benefit, Medicare Part B chemotherapy and other Part B drugs carry no copay and a 0% to 20% coinsurance, while Medicare Part B insulin is covered with a $35 copay and no coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Kaiser Permanente Medicare Advantage Essential (HMO) plan with no copay and a 20% coinsurance. Prior authorization and a referral are required to receive these covered services.
Medical Equipment See details
Kaiser Permanente Medicare Advantage Essential (HMO) covers durable medical equipment, prosthetics, and medical supplies with no copay and a 20% coinsurance. Diabetic equipment, supplies, and therapeutic shoes are also covered with no copay and no coinsurance, though prior authorization is required for medical equipment benefits.
Diagnostic and Radiological Services See details
Kaiser Permanente Medicare Advantage Essential (HMO) covers diagnostic and radiological services, offering lab services, diagnostic procedures, and outpatient X-rays with no copay and no coinsurance. Diagnostic radiological services require a minimum copay of $195, while therapeutic radiological services incur a minimum 20% coinsurance, with prior authorization and referrals required for all services.
Home Health Services See details
Kaiser Permanente Medicare Advantage Essential (HMO) 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
Kaiser Permanente Medicare Advantage Essential (HMO) covers cardiac rehabilitation services with no coinsurance, though prior authorization and referrals are required. While some services are covered, cardiac rehabilitation ($35 copay), intensive cardiac rehabilitation ($35 copay), pulmonary rehabilitation ($15 copay), and supervised exercise therapy for peripheral artery disease ($25 copay) are not covered.
Skilled Nursing Facility (SNF) See details
Kaiser Permanente Medicare Advantage Essential (HMO) partially covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring no copay for days 1 to 20 and a $218 copayment for days 21 to 100. Prior authorization and referrals are required, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other Services are not covered under the Kaiser Permanente Medicare Advantage Essential (HMO) plan, which does not provide coverage for acupuncture, over-the-counter (OTC) items, or meal benefits.
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