Kaiser Permanente Senior Advantage Choice South (PPO)
Kaiser Permanente Senior Advantage Choice South (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Kaiser Foundation Health Plan, Inc.
Plan ID: H3138-002-000
Colorado 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 Colorado 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
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $5,100.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $8,000.00 |
| Primary care doctor visit | Out-of-Network: Doctor Office Visit: Copayment for Medicare Covered Primary Care Office Visit $30.00 |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $30.00 |
| Inpatient hospital care | In-Network: Acute Hospital Services: $295.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Prior Authorization Required for Acute Hospital Services Referral Required for Acute Hospital Services |
| Urgent care | Urgent Care: Copayment for Urgent Care $35.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $35.00 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $120.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital Worldwide Coverage: Copayment for Worldwide Emergency Coverage $120.00 Copayment for Worldwide Emergency Transportation $250.00 |
| Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $250.00 Air Ambulance: Copayment for Air Ambulance Services $250.00 Please see Evidence of Coverage for Prior Authorization rules |
Health Care Services and Medical Supplies
Kaiser Permanente Senior Advantage Choice South (PPO) covers a range of additional benefits. Learn more about Kaiser Permanente Senior Advantage Choice South (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $20.00 |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0.00 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 |
| Diagnostic tests, lab and radiology services, and X-rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 Copayment for Medicare-covered Lab Services $0.00 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 $50.00 to $150.00 Copayment for Medicare-covered Therapeutic Radiological Services $30.00 Copayment for Medicare-covered X-Ray Services $15.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services Referral Required for Outpatient Diag/Therapeutic Rad Services |
| Home health care | Out-of-Network: Home Health Services: Coinsurance for Medicare Covered Home Health 40% |
| Mental health inpatient care | Out-of-Network: $500.00 per day for days 1 to 18 $0.00 per day for days 19 to 90 |
| Mental health outpatient care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $25.00 Copayment for Medicare-covered Group Sessions $15.00 |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $250.00 Prior Authorization Required for Outpatient Hospital Services Referral Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $250.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $200.00 Prior Authorization Required for Ambulatory Surgical Center Services Referral Required for Ambulatory Surgical Center Services |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $25.00 Copayment for Medicare-covered Group Sessions $15.00 |
| Over-the-counter items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $75.00 every three months Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $30.00 |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $203.00 per day for days 21 to 46 $0.00 per day for days 47 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.
| Coverage | Details |
|---|---|
| Dental care | Out-of-Network: Medicare Covered Dental Services: Copayment for Medicare Covered Comprehensive Dental $50.00 Non-Medicare Covered Dental Services: Copayment for Non-Medicare Covered Preventive Dental $0.00 Coinsurance for Non-Medicare Covered Comprehensive Dental 30% to 50% |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Vision benefits | Out-of-Network: Medicare Covered Vision Services: Coinsurance for Medicare Covered Eye Exams 40% Copayment for Medicare Covered Eyewear $0.00 Non-Medicare Covered Vision Services: Coinsurance for Non-Medicare Covered Eye Exams 40% Copayment for Non-Medicare Covered Eyewear $0.00 |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $10.00 Copayment for Routine Hearing Exams $0.00 Copayment for Fitting/Evaluation for Hearing Aid $0.00 Hearing Aids: Copayment for Hearing Aids $0.00 Maximum Plan Benefit of $300.00 every year both ears combined for in and out of network services combined Referral Required for Hearing Aids Benefit will be available on the same debit card as the eyewear benefit. |
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.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | Out-of-Network: Medicare-covered Zero Dollar Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0.00 |
When reviewing Colorado 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 Colorado 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 |
Colorado Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.
