Kaiser Permanente Senior Advantage Liberty (HMO)
Kaiser Permanente Senior Advantage Liberty (HMO) H1170-014 Plan Details
Kaiser Permanente Senior Advantage Liberty (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Kaiser Foundation Health Plan, Inc.
Plan ID: H1170-014
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 Liberty (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Kaiser Foundation Health Plan, Inc.
Plan ID: H1170-014
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 | $-1 |
| Out of Pocket Max |
In-Network: $6000 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 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0 to $40 Referral Required for Doctor Specialty Visit The minimum copayment applies to house calls. The maximum copayment applies to visits with all other specialist visits. No referral is required for dermatology, obstetrics, and gynecology. |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $295 per day for days 1 to 6 $0 per day for days 7 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 |
| Urgent Care | Copayment for Urgent Care $40 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $40 |
| 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 $225 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $225 Air Ambulance: Copayment for Air Ambulance Services $225 Prior Authorization Required for Air Ambulance Prior authorization required |
Health Care Services and Medical Supplies
Kaiser Permanente Senior Advantage Liberty (HMO) 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: Coinsurance for Medicare-covered Chiropractic Services 20% |
| 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% |
| 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 canes, crutches, and ultraviolet light therapy for psoriasis treatment. The maximum coinsurance applies to all other DME. Prior authorization required |
| 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 to $35 Copayment for Medicare-covered Lab Services $0 to $35 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Referral Required for Outpatient Diag Procs/Tests/Lab Services The minimum copayment applies to services provided in a medical office. The maximum copayment applies to services provided in an outpatient hospital setting. Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0 to $245 Copayment for Medicare-covered Therapeutic Radiological Services $40 Copayment for Medicare-covered X-Ray Services $0 to $50 Prior authorization required |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Prior authorization required |
| 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 |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $40 Copayment for Medicare-covered Group Sessions $20 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $275 Prior Authorization Required for Outpatient Hospital Services The minimum copayment for Medicare-covered Outpatient Hospital Services applies to surgical procedures performed during a screening colonoscopy and diagnostic colonoscopies in response to a positive gFOBT, FIT, or sigmoidoscopy. The maximum copayment for Medicare-covered Outpatient Hospital Services applies to all other services. Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $0 to $275 Prior Authorization Required for Outpatient Observation Services The minimum copayment for Medicare -covered Observation Services applies to observation stays incident to an ER visit or outpatient surgery. The maximum copayment for Medicare-covered Observation Services applies when admitted directly to the hospital for observation. Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $275 Prior Authorization Required for Ambulatory Surgical Center Services Prior authorization required |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $40 Copayment for Medicare-covered Group Sessions $20 |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0
Minimum order amount: Each order must be at least $20. |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $40 Prior Authorization Required for Podiatry Services Referral Required for Podiatry Services Prior authorization required |
| 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 100 Prior Authorization Required for Skilled Nursing Facility Services Referral Required for Skilled Nursing Facility Services Prior authorization required |
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 $40 Non-Medicare Covered Preventive Dental: Copayment for Non-medicare preventive $0 Copayment for Oral exams $0 Coinsurance for Oral exams 75%
Coinsurance for Dental x-rays 75%
Coinsurance for Other diagnostic services 75% Copayment for Prophylaxis $0 Coinsurance for Prophylaxis 75%
Coinsurance for Fluoride treatment 75%
Coinsurance for Other preventive services 75% Non-Medicare Covered Comprehensive Dental: Copayment for Non-medicare comprehensive $0 Copayment for Restorative services $28 to $580 Coinsurance for Restorative services 75% Copayment for Periodontics $0 to $400 Coinsurance for Periodontics 75% Copayment for Prothodontics, removable $420 to $480 Copayment for Maxillofacial surgery $22 Coinsurance for Maxillofacial surgery 75% Copayment for Adjunctive general services $0 Coinsurance for Adjunctive general services 75% |
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 $40 Copayment for Routine Eye Exams $0
Eyewear: Coinsurance for Medicare-Covered Benefits 20% Maximum Plan Allowance of $500 every two years |
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 $40 Copayment for Routine Hearing Exams $0
|
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 |
