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Kaiser Permanente Medicare Advantage Value VA (HMO-POS) - H2172-010-000

4.5 out of 5 stars* for plan year 2025

$0.00

Monthly Premium

Kaiser Permanente Medicare Advantage Value VA (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Kaiser Foundation Health Plan, Inc.

Plan ID: H2172-010-000

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

$0.00

Monthly Premium

Virginia 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 Virginia 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$0.00
Out-of-pocket maximum$6,500.00
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 $5
Specialty doctor visit
Out-of-Network:

Doctor Specialty Visit Services:
Copayment for Physician Specialist Office Visit $0 to $50
Inpatient hospital careIn-Network:

Acute Hospital Services:
$270 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.
Urgent care
Urgent Care:
Copayment for Urgent Care $40

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $40
Emergency room visit
Emergency Care:
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 $275
Ambulance transportationIn-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $275

Air Ambulance:
Copayment for Air Ambulance Services $275
Prior Authorization Required for Air Ambulance

Health Care Services and Medical Supplies

Kaiser Permanente Medicare Advantage Value VA (HMO-POS) covers a range of additional benefits. Learn more about Kaiser Permanente Medicare Advantage Value VA (HMO-POS) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic services
Out-of-Network:

Medicare Covered Chiropractic Services:
Copayment for Medicare Covered Chiropractic Services $0 to $50
Diabetes supplies, training, nutrition therapy and monitoringIn-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Durable medical equipment (DME)In-Network:

Durable Medical Equipment:
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.
Diagnostic tests, lab and radiology services, and X-rays
Out-of-Network:

Medicare Covered Diagnostic Procedures/Tests Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests
$0 to $25
Copayment for Medicare Covered Lab Services
$0 to $25
Copayment for Medicare Covered Diagnostic Radiological Services $0 to $25
Copayment for Medicare Covered Outpatient X-Ray Services $0 to $25
Home health careIn-Network:

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

Psychiatric Hospital Services:
$270 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.
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $10
Copayment for Medicare-covered Group Sessions $5
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $270
Prior Authorization Required for Outpatient Hospital Services
Referral 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 $270
Prior Authorization Required for Outpatient Observation Services
The minimum copayment for Medicare-covered Observation Services applies to observation stays incident to other outpatient hospital services such as 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 $270
Prior Authorization Required for Ambulatory Surgical Center Services
Referral Required for Ambulatory Surgical Center Services
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $10
Copayment for Medicare-covered Group Sessions $5
Prior Authorization Required for Outpatient Substance Abuse Services
Referral Required for Outpatient Substance Abuse Services
Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0
  • Maximum plan benefit of $50.00 every three months for Over-The-Counter (OTC) Items
Maximum Plan Benefit of $50 every three months
Minimum order amount: Each order must be at least $20.
Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $40
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
$203 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 $40
Prior Authorization Required for Medicare Covered Preventive Dental
Referral Required for Medicare Covered Preventive Dental

Non-Medicare Covered Preventive Dental:
Copayment for Non-medicare preventive $0
Copayment for Oral exams $0
  • Maximum 2 visits every year
Copayment for Dental x-rays $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Other diagnostic services $0
Copayment for Prophylaxis $0
  • Maximum 2 visits every year
Copayment for Flouride treatment $0
  • Maximum 1 visit every year
Copayment for Other preventative services $0


Non-Medicare Covered Comprehensive Dental:
Prior Authorization Required for Comprehensive Dental
Coinsurance for Restorative services 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Endodontics 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Periodontics 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Prothodontics, removable 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Prothodontics, fixed 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Maxillofacial surgery 50%
Coinsurance for Maxillofacial surgery 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Adjunctive general services 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $1,500 every year

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 to $40
Copayment for Routine Eye Exams $5 to $40
Referral Required for Eye Exams

Eyewear:
Coinsurance for Medicare-Covered Benefits 20%
Maximum Plan Allowance of $200 every two years
Referral Required for Eyewear

Hearing Benefits

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

CoverageDetails
Hearing care
Out-of-Network:

Medicare Covered Hearing Exams Services:
Copayment for Medicare Covered Hearing Exams $0 to $50

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 programs
Out-of-Network:

Medicare Covered Medicare-covered Preventive Services:
Copayment for Medicare Covered Medicare-covered Preventive Services $0 to $25

When reviewing Virginia 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 Virginia 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

Virginia 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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