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Kaiser Permanente Dual Complete (HMO D-SNP) - H1170-015-000

4.5 out of 5 stars* for plan year 2025

$0.00

Monthly Premium

Kaiser Permanente Dual Complete (HMO D-SNP) is a HMO D-SNP Medicare Advantage (Medicare Part C) plan offered by Kaiser Foundation Health Plan, Inc.

Plan ID: H1170-015-000

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$0.00

Monthly Premium

Georgia Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about Georgia Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Basic Costs and Coverage

CoverageDetails
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$385.00
Out-of-pocket maximum$9,350.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$2,000.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0
Referral Required for Doctor Specialty Visit
No referral is required for dermatology, obstetrics, and gynecology.
Inpatient hospital careIn-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $0
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.
Urgent care
Urgent Care:
Copayment for Urgent Care $0

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $0
Emergency room visit
Emergency Care:
Copayment for Emergency Care $0
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 $0
Copayment for Worldwide Emergency Transportation $0
Ambulance transportationIn-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $0

Air Ambulance:
Copayment for Air Ambulance Services $0
Prior Authorization Required for Air Ambulance

Health Care Services and Medical Supplies

Kaiser Permanente Dual Complete (HMO D-SNP) covers a range of additional benefits. Learn more about Kaiser Permanente Dual Complete (HMO D-SNP) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $0
Diabetes supplies, training, nutrition therapy and monitoringIn-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0
Durable medical equipment (DME)In-Network:

Durable Medical Equipment:
Copayment for Medicare-covered Durable Medical Equipment $0
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.
Diagnostic tests, lab and radiology services, and X-raysIn-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 $0
Copayment for Medicare-covered Therapeutic Radiological Services $0
Copayment for Medicare-covered X-Ray Services $0
Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $0
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.
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0
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
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 $0
Prior Authorization Required for Ambulatory Surgical Center Services
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0
Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0
  • Maximum plan benefit of $255.00 every three months for Over-The-Counter (OTC) Items
Maximum Plan Benefit of $255 every three months
Minimum order amount: Each order must be at least $20.
Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $0
Prior Authorization Required for Podiatry Services
Referral Required for Podiatry Services
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$0 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Referral Required for Skilled Nursing Facility Services

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Dental careIn-Network:

Medicare Covered Preventive Dental:
Copayment for Office Visit $0

Non-Medicare Covered Preventive Dental:
Copayment for Non-medicare preventive $0
Copayment for Oral exams $0
Coinsurance for Oral exams 75%
  • Maximum 2 visits every year
Copayment for Dental x-rays $0
Coinsurance for Oral exams 75%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Other diagnostic services $0
Copayment for Prophylaxis $0
Coinsurance for Oral exams 75%
  • Maximum 2 visits every year
Copayment for Flouride treatment $0
Coinsurance for Oral exams 75%
  • Maximum 2 visits every year
Copayment for Other preventative services $0
Non-Medicare Covered Comprehensive Dental:
Copayment for Restorative services $28-$580
Coinsurance for Restorative services 75%
Copayment for Periodontics $0-$400
Coinsurance for Periodontics 75%
Copayment for Prothodontics, removable $420-$480
Coninsurance for Prosthodontics 75%
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, though there may be provider network restrictions. See the plan Evidence of Coverage

CoverageDetails
Vision careIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0
Copayment for Routine Eye Exams $0
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0
Maximum Plan Allowance of $575 every two years

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Hearing careIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $0
Copayment for Routine Hearing Exams $0
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0

Hearing Aids:
Maximum Plan Allowance of $1,000 every three years

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Preventive services and health/wellness education programsIn-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:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit

    Prescription Drug Costs and Coverage

    The Kaiser Permanente Dual Complete (HMO D-SNP) offers prescription drug coverage, with an annual drug deductible of $385.00 (excludes Tiers 1, 2, and 6)

    Coverage & Cost
    Coverage
    Cost
    Annual drug deductible$385.00 (excludes Tiers 1, 2, and 6)
    Tier 1
    • Standard retail $0.00
    • Standard mail order $0.00
    Tier 2
    • Standard retail $0.00
    • Standard mail order $0.00
    Tier 6
    • Standard retail $0.00
    Annual drug deductible$385.00 (excludes Tiers 1, 2, and 6)
    Tier 1
    • Standard retail $0.00
    • Standard mail order $0.00
    Tier 2
    • Standard retail $0.00
    • Standard mail order $0.00
    Tier 6
    • Standard retail N/A
    Annual drug deductible$385.00 (excludes Tiers 1, 2, and 6)
    Tier 1
    • Standard retail $0.00
    • Standard mail order $0.00
    Tier 2
    • Standard retail $0.00
    • Standard mail order $0.00
    Tier 6
    • Standard retail N/A

    When reviewing Georgia Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

    You may be able to find plans in your part of Georgia that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

    Plan Documents

    Links to plan documents

    Georgia Counties Served

    We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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