Senior Advantage Medicare Medicaid (HMO D-SNP)

5 out of 5 stars* for plan year 2023
$0.00 Monthly Premium

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

Plan ID: H0630-014-000

$0.00 Monthly Premium

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$0.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$7,400.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00

Please see Summary of Benefits for details
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0.00

Please see Summary of Benefits for details
Inpatient hospital careIn-Network:

Acute Hospital Services:
$195 per day for days 1 to 5, and $0 per day for days 6 to the end of your stay
Prior Authorization Required for Acute Hospital Services
Referral Required for Acute Hospital Services

Please see Evidence of Coverage for details
Urgent care
Urgent Care:
Copayment for Urgent Care $0.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $0.00

Please see Evidence of Coverage for details
Emergency room visit
Emergency Care:
Copayment for Emergency Care $110
  • Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $110.00
Coinsurance for Worldwide Emergency Transportation 20%

Please see Evidence of Coverage for details
Ambulance transportationIn-Network:

Ground Ambulance:
Coinsurance for Ground Ambulance Services 20%
  • If you are eligible for Medicare cost-sharing assistance under Medicaid, you pay $0.

Air Ambulance:
Coinsurance for Air Ambulance Services 20%
  • If you are eligible for Medicare cost-sharing assistance under Medicaid, you pay $0.

Please see Evidence of Coverage for Prior Authorization rules

Health Care Services and Medical Supplies

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

Coverage Details
Chiropractic servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $0.00

Please see Evidence of Coverage for details
Diabetes supplies, training, nutrition therapy and monitoringIn-Network:

Diabetic Supplies and Services:
Coinsurance for Medicare-covered Diabetic Supplies 0%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%

Please see Evidence of Coverage for details
Durable medical equipment (DME)In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
  • If you are eligible for Medicare cost-sharing assistance under Medicaid, you pay $0.
Prior Authorization Required

Please see Evidence of Coverage for details
Diagnostic tests, lab and radiology services, and X-raysIn-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

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00
Copayment for Medicare-covered Therapeutic Radiological Services $0.00
Copayment for Medicare-covered X-Ray Services $0.00
Prior Authorization Required

Please see Evidence of Coverage for details
Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required

Please see Evidence of Coverage for details
Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
$195 per day for days 1 to 5, and $0 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services
Referral Required for Psychiatric Hospital Services

Please see Evidence of Coverage for details
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $0.00
Copayment for Medicare-covered Group Sessions $0.00

Please see Evidence of Coverage for details
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $200
  • If you are eligible for Medicare cost-sharing assistance under Medicaid, you pay $0.
Prior Authorization Required for Outpatient Hospital Services
Referral Required for Outpatient Hospital Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $125
Referral Required for Ambulatory Surgical Center Services

Please see Evidence of Coverage for details
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $0.00
Copayment for Medicare-covered Group Sessions $0.00

Please see Evidence of Coverage for details
Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $100.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit

Please see Evidence of Coverage for details
Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $0.00
Copayment for Routine Foot Care $0.00
  • Maximum 4 visits every year
Referral Required for Podiatry Services

Please see Evidence of Coverage for details
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$196 per day for days 21 to 42
$0 per day for days 43 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Referral Required for Skilled Nursing Facility Services

Please see Evidence of Coverage for details

Dental Benefits

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

Coverage Details
Dental careIn-Network:

Preventive Dental:
Copayment for Oral Exams $0.00
  • Maximum 2 visits every year
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 2 visits every year
Copayment for Fluoride Treatment $0.00
  • Maximum 1 visit every year
Copayment for Dental X-Rays $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)

Comprehensive Dental:
Copayment for Medicare-covered Benefits $0.00
Prosthodontics, and other oral/maxillofacial surgery $0.00
Non-routine services $0.00
Diagnostic services $0.00
Restorative services $0.00
Endodontics $0.00
Periodontics $0.00
Extractions $0.00
Maximum Plan Allowance of $1000.00 every year for Non-Medicare Covered Comprehensive

Please see Evidence of Coverage for details

Vision Benefits

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

Coverage Details
Vision benefitsIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Eye Exams $0.00

Eyewear:
Allowance for eyeglasses or contact lenses $300 every year
  • You pay any amounts that exceed $300 every year.
Eyeglasses or contact lenses after cataract surgery: $0 copay up to Medicare's limit.

Please see Evidence of Coverage for details

Hearing Benefits

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

Coverage Details
Hearing benefitsIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Hearing Exams $0.00
Copayment for Fitting/Evaluation for Hearing Aid $0.00

Hearing Aids:
Maximum Plan Allowance of $1500.00 every two years per ear
Referral Required for Hearing Aids

Please see Evidence of Coverage for details

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 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 shotsHepatitis B shotsPneumococcal shots
Tobacco use cessation
Yearly "Wellness" visit

Please see Evidence of Coverage for details

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

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