Kaiser Permanente Sr Adv Basic Contra Costa (HMO)

H0524 - 061 - 0
4.5 out of 5 stars (4.5 / 5)

kaiser-permanente medicare provider logo

Kaiser Permanente Sr Adv Basic Contra Costa (HMO) is a Medicare Advantage Plan by Kaiser Permanente.

This page features plan details for 2025 Kaiser Permanente Sr Adv Basic Contra Costa (HMO) H0524 – 061 – 0 available in Contra Costa County Plan – Basic.

Locations

Kaiser Permanente Sr Adv Basic Contra Costa (HMO) is offered in the following locations.

Plan Overview

Kaiser Permanente Sr Adv Basic Contra Costa (HMO) offers the following coverage and cost-sharing.

Insurer:Kaiser Permanente
Health Plan Deductible:$0
MOOP:$5,000 In-network
Drugs Covered:Yes

Ready to sign up for Kaiser Permanente Sr Adv Basic Contra Costa (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

Kaiser Permanente Sr Adv Basic Contra Costa (HMO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$185.00 $0.00 $0.00 $ $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Kaiser Permanente Sr Adv Basic Contra Costa (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $0.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$0.00$0.00

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Kaiser Permanente Sr Adv Basic Contra Costa (HMO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: Yes, contact plan for further details

Comprehensive Dental

  • Oral and Maxillofacial Surgery
    • In-Network: No Coins – 5.00 Copay (Limits Apply, Authorization Required, Referral Required)
  • Periodontics
    • In-Network: No Coins – 0.00 Copay (Authorization Required, Referral Required)

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – – Copay (Authorization Required, Referral Required)
  • Fluoride Treatment
    • In-Network: No Coins – – Copay (Authorization Required, Referral Required)
  • Oral Exams
    • In-Network: No Coins – – Copay (Authorization Required, Referral Required)
  • Other Diagnostic Dental Services
    • In-Network: No Coins – – Copay (Limits Apply, Authorization Required, Referral Required)
  • Other Preventive Dental Services
    • In-Network: No Coins – – Copay (Limits Apply, Authorization Required, Referral Required)
  • Prophylaxis (cleaning)
    • In-Network: No Coins – – Copay (Authorization Required, Referral Required)

Diagnostic procedures/lab services/imaging

  • Diagnostic radiology services (e.g., MRI)
    • $0-190 copay (Referral Required)
  • Lab services
    • $0 copay (Referral Required)
  • Outpatient x-rays
    • $0 copay (Referral Required)
  • Diagnostic tests and procedures
    • $0 copay (Referral Required)

Doctor visits

  • Primary
    • $5 copay per visit
  • Specialist
    • $10 copay per visit (Referral Required)

Emergency care/Urgent care

  • Urgent care
    • $5 copay per visit (always covered)
  • Emergency
    • $125 copay per visit (always covered)

Foot care (podiatry services)

  • Routine foot care
    • Not covered
  • Foot exams and treatment
    • $10 copay (Referral Required)

Ground ambulance

    • $200 copay

Health plan deductible

    • $0

Hearing

  • Hearing aids – outer ear
    • Not covered
  • Medicare-Covered Hearing Exam
    • $10 copay
  • Hearing aids – inner ear
    • Not covered
  • Hearing aids – over the ear
    • Not covered
  • Fitting/evaluation
    • Not covered
  • Hearing aids OTC
    • Not covered

Inpatient hospital coverage

    • $200 per day for days 1 through 5
      $0 per day for days 6 through 90
      $0 per day for days 91 and beyond (Authorization Required, Referral Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $5,000 In-network

Medical equipment/supplies

  • Diabetes supplies
    • $0 copay per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • 0-20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • 20% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • $0-47 copay or 0-20% coinsurance (Authorization Required)
  • Other Part B drugs
    • $0-47 copay or 0-20% coinsurance (Authorization Required)

Mental health services

  • Inpatient hospital – psychiatric
    • $200 per day for days 1 through 5
      $0 per day for days 6 through 90
      $0 per day for days 91 and beyond (Referral Required)
  • Outpatient group therapy visit with a psychiatrist
    • $0-2 copay
  • Outpatient individual therapy visit with a psychiatrist
    • $0-5 copay
  • Outpatient group therapy visit
    • $2 copay
  • Outpatient individual therapy visit
    • $5 copay

Optional supplemental benefits

    • Yes

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • $0-150 copay per visit

Preventive care

    • $0 copay (Referral Required)

Rehabilitation services

  • Occupational therapy visit
    • $0 copay (Referral Required)
  • Physical therapy and speech and language therapy visit
    • $0 copay (Referral Required)

Skilled Nursing Facility

    • $0 per day for days 1 through 20
      $100 per day for days 21 through 100 (Authorization Required, Referral Required)

Transportation

    • Not covered

Vision

  • Eyeglasses (frames and lenses)
    • Not covered
  • Other
    • Not covered
  • Eyeglass lenses
    • Not covered
  • Upgrades
    • Not covered
  • Contact lenses
    • Not covered
  • Eyeglass frames
    • Not covered
  • Routine eye exam
    • $5 copay (Referral Required)

Wellness programs (e.g., fitness, nursing hotline)

    • Covered (Referral Required)

NCAL Advantage Plus

Comprehensive Dental

  • Restorative Services, Endodontics, Periodontics, Prosthodontics, removable, Implant Services, Prosthodontics, fixed, Oral and Maxillofacial Surgery, Adjunctive General Services
    • Monthly Premium: $21.00

Diagnostic and Preventive Dental

  • Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Other Preventive Dental Services
    • Monthly Premium: $21.00

Eyewear

  • Contact Lenses, Eyeglasses (lenses and frames), Eyeglass lenses, Eyeglass frames
    • Monthly Premium: $21.00

Hearing Aids

  • Prescription Hearing Aids (all types)
    • Monthly Premium: $21.00

Hearing Exams

  • Fitting/Evaluation for Hearing Aid
    • Monthly Premium: $21.00

Preventive and Other Defined Supplemental Services

  • Fitness Benefit
    • Monthly Premium: $21.00

Ready to sign up for Kaiser Permanente Sr Adv Basic Contra Costa (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Need more information on Kaiser Permanente Sr Adv Basic Contra Costa (HMO)? See 2025 Kaiser Permanente Sr Adv Basic Contra Costa (HMO) at MedicareAdvantageRX.com.

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