Kaiser Permanente Sr Adv Basic Santa Clara (HMO)

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

• • In-Network: No

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)
  • $0-225 copay (Referral Required)
• Diagnostic tests and procedures
  • $0 copay (Referral Required)
• Lab services
  • $0 copay (Referral Required)
• Outpatient x-rays
  • $0 copay (Referral Required)

Doctor visits

• Primary
  • $5 copay per visit
• Specialist
  • $15 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
  • $15 copay (Referral Required)

Ground ambulance

• • $250 copay

Health plan deductible

• • $0

Hearing

• Hearing aids – over the ear
  • Not covered
• Hearing aids – outer ear
  • Not covered
• Fitting/evaluation
  • Not covered
• Hearing aids – inner ear
  • Not covered
• Hearing aids OTC
  • Not covered
• Medicare-Covered Hearing Exam
  • $15 copay

Inpatient hospital coverage

• • $245 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)

• • $6,000 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
  • $245 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
  • $2 copay
• Outpatient group therapy visit with a psychiatrist
  • $0-2 copay
• Outpatient individual therapy visit
  • $5 copay
• Outpatient individual therapy visit with a psychiatrist
  • $0-5 copay

Optional supplemental benefits

• • Yes

Other health plan deductibles?

• • In-Network: No

Outpatient hospital coverage

• • $0-180 copay per visit

Preventive care

• • $0 copay (Referral Required)

Rehabilitation services

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

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

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