Kaiser Permanente Senior Advantage Choice DM (PPO)
Kaiser Permanente Senior Advantage Choice DM (PPO) H3138-001 Plan Details
Kaiser Permanente Senior Advantage Choice DM (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Kaiser Foundation Health Plan, Inc.
Plan ID: H3138-001
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$0.00
Monthly Premium
Kaiser Permanente Senior Advantage Choice DM (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Kaiser Foundation Health Plan, Inc.
Plan ID: H3138-001
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $5100 Out-of-Network: N/A |
| Initial Coverage Limit | $2000 |
| Catastrophic Coverage Limit | $2,000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 Out-of-Network: Doctor Office Visit Services: Copayment for Medicare Covered Primary Care Office Visit $35 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $30 Referral only applies to allergy, dermatology and urology specialists. Out-of-Network: Doctor Specialty Visit Services: Copayment for Medicare Covered Physician Specialist Office Visit $65 Referral only applies to allergy, dermatology and urology specialists. |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $295 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Acute Hospital Services Referral Required for Acute Hospital Services Members admitted and discharged on the same day pay a copayment for one day. Prior authorization required Out-of-Network: Acute Hospital Services: $500 per day for days 1 to 18 $0 per day for days 19 to 90 Members admitted and discharged on the same day pay a copayment for one day. |
| Urgent Care | Copayment for Urgent Care $35 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $35 |
| Emergency Room Visit | Copayment for Emergency Care $125 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 0 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $125 Copayment for Worldwide Emergency Transportation $340 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $340 Prior Authorization Required for Ground Ambulance Services Air Ambulance: Copayment for Air Ambulance Services $340 Prior Authorization Required for Air Ambulance Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $340 Copayment for Medicare Covered Ambulance Services - Air $340 Prior authorization required |
Health Care Services and Medical Supplies
Kaiser Permanente Senior Advantage Choice DM (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In-Network: Copayment for Medicare-covered Chiropractic Services $20 Out-of-Network: Medicare Covered Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 40% |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0 Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% Prior Authorization Required for Diabetic Therapeutic Shoes or Inserts Out-of-Network: Medicare Covered Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies 0% to 40% Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 0% to 40% Prior authorization required |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20% Prior Authorization Required for Durable Medical Equipment The minimum coinsurance applies to ultraviolet light therapy equipment for psoriasis treatment. The maximum coinsurance applies to all other DME. Prior authorization required Out-of-Network: Medicare Covered Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 40% The minimum coinsurance applies to ultraviolet light therapy equipment for psoriasis treatment. The maximum coinsurance applies to all other DME. |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0 Copayment for Medicare-covered Lab Services $0 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Referral Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $50 to $130 Copayment for Medicare-covered Therapeutic Radiological Services $30 Copayment for Medicare-covered X-Ray Services $15 Prior Authorization Required for Diagnostic Radiological Services and Therapeutic Radiological Services Referral Required for Diagnostic Radiological Services, Therapeutic Radiological Services and X-Ray Services Out-of-Network: Medicare Covered Diagnostic Procedures/Tests Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 40% Coinsurance for Medicare Covered Lab Services 40% Coinsurance for Medicare Covered Diagnostic Radiological Services 40% Coinsurance for Medicare Covered Therapeutic Radiological Services 40% Coinsurance for Medicare Covered Outpatient X-Ray Services 40% Prior authorization required |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Referral Required for Home Health Services Prior authorization required Out-of-Network: Medicare Covered Home Health Services: Coinsurance for Medicare Covered Home Health 40% |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $295 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Psychiatric Hospital Services Referral Required for Psychiatric Hospital Services Members admitted and discharged on the same day pay a copayment for one day. Prior authorization required Out-of-Network: Psychiatric Hospital Services: $500 per day for days 1 to 18 $0 per day for days 19 to 90 Members admitted and discharged on the same day pay a copayment for one day. |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $25 Copayment for Medicare-covered Group Sessions $15 Out-of-Network: Medicare Covered Mental Health Services: Copayment for Medicare Covered Individual Sessions $40 to $50 Copayment for Medicare Covered Group Sessions $40 to $50 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $250 Prior Authorization Required for Outpatient Hospital Services Referral Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $250 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $190 Prior Authorization Required for Ambulatory Surgical Center Services Referral Required for Ambulatory Surgical Center Services Prior authorization required Out-of-Network: Medicare Covered Outpatient Hospital Services: Coinsurance for Medicare Covered Outpatient Hospital Services 40% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40% |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $25 Copayment for Medicare-covered Group Sessions $15 Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual Sessions $40 to $50 Copayment for Medicare Covered Group Sessions $40 to $50 |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0
OTC items: Minimum order amount: Each order must be at least $35. Tobacco cessation: We cover FDA-approved tobacco cessation over-the-counter medications for up to two tobacco cessation attempts per year up to two 90-day supplies. Out-of-Network: Non-Medicare Covered Over-The-Counter (OTC) Items Services: Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0
|
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $30 Referral Required for Podiatry Services Out-of-Network: Medicare Covered Podiatry Services: Copayment for Medicare Covered Podiatry Services $65 |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $203 per day for days 21 to 46 $0 per day for days 47 to 100 Prior Authorization Required for Skilled Nursing Facility Services Referral Required for Skilled Nursing Facility Services Prior authorization required Out-of-Network: Skilled Nursing Facility Services: $225 per day for days 1 to 40 $0 per day for days 41 to 100 |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Medicare Covered Preventive Dental: Copayment for Office Visit $30 Non-Medicare Covered Preventive Dental: Copayment for Non-medicare preventive $0
Copayment for Prophylaxis $0
Non-Medicare Covered Comprehensive Dental: Copayment for Non-medicare comprehensive $0 Coinsurance for Restorative services 30% Coinsurance for Endodontics 50% Coinsurance for Periodontics 50% Coinsurance for Implant services 50% Out-of-Network: Medicare Covered Preventive Dental Services: Copayment for Medicare Covered Preventive Dental $65 |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0 to $30 Copayment for Routine Eye Exams $0 Eyewear: Copayment for Medicare-Covered Benefits $0 Maximum Plan Allowance of $500 every year Benefit will be available on the same debit card as the hearing aid benefit. Out-of-Network: Medicare Covered Eye Exams Services: Coinsurance for Medicare Covered Eye Exams 40% Copayment for Medicare Covered Eyewear $0 |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $10 Copayment for Routine Hearing Exams $0 Copayment for Fitting/Evaluation for Hearing Aid $0 Hearing Aids: Copayment for Hearing Aids $0 Maximum Plan Benefit of $400 every year Benefit will be available on the same debit card as the eyewear benefit. Out-of-Network: Medicare Covered Hearing Exams Services: Coinsurance for Medicare Covered Hearing Exams 40% |
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit Out-of-Network: Medicare Covered Medicare-covered Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 |
