Kaiser Senior Advantage — Northern and Southern California
(Medicare Advantage HMO)
The information in this chart is intended as a high-level summary only. The information about the HMOs or the insured products contained in an applicable Evidence of Coverage (EOC) or service provider agreement between Pacific Gas and Electric Company and the HMO or service provider shall govern in case of conflict between this chart and the EOC or service provider agreement.
If you enroll in Kaiser Senior Advantage, you can request an EOC from Kaiser Senior Advantage, free of charge. It describes Kaiser Senior Advantage's benefit provisions, claims procedures, provider and facility information, and other rules in detail. If you need additional information, including a list of participating network providers, you can contact Kaiser Senior Advantage directly.
The information contained in this summary is informational only. No right shall accrue to you and/or your dependents because of any statement of error, or in omission from, this summary. Kaiser Senior Advantage's EOC is the binding document between the health plan and its members.
Summary Chart
This summary chart describes benefits as of January 1, 2013.
Provisions
Kaiser Permanente Senior Advantage North and South (Medicare Advantage HMO)
General
  • Must use services provided at Kaiser Permanente hospitals and offices by Kaiser Permanente providers
  • No annual deductible
  • Annual out-of-pocket maximum:
    • $1,500/person; no more than $3,000/family (excludes prescription drugs and infertility services)
  • No lifetime benefit maximum
  • No pre-existing condition exclusions
Hospital Stay
No charge
Skilled Nursing Facility
No charge to members in service area for up to 100 days per benefit period when prescribed by a plan physician; no prior hospital stay required; not covered for members living outside of service area; excludes custodial care
Emergency Room Care
$25 copay/visit for emergencies (waived if admitted directly to the hospital within 24 hours for the same condition)
Outpatient Hospital Care
$10 copay/procedure for outpatient surgery; $10 copay/visit for all other outpatient services
Office Visits
  • $10 copay/office visit
  • No charge/home visit
Urgent Care Visits
  • $10 copay/visit at a Kaiser facility in area;
  • $25 copay/visit at non-Kaiser facility
Routine Physical Examinations
No charge
Immunizations and Injections
  • Immunizations — no charge
  • $10 copay/visit for allergy testing if no office visit
  • $3 copay/visit for allergy injections if no office visit; allergy serum not sold separately
Eye Examinations
$10 copay/exam; $150 eyewear allowance for medically necessary eyewear every 24 months
X-rays and Lab Tests
No charge
Pre-Admission Testing
No charge
Home Health Care
No charge to members in service area when prescribed by a plan physician; not covered for members living outside of service area. See plan EOC for limitations and exclusions
Hospice Care
Covered under Medicare for members with Medicare Parts A and B when prescribed by a plan physician; not covered for members living outside of service area
Outpatient Physical Therapy
$10 copay/visit; provided as long as, in the judgment of a plan physician, significant improvement is achievable
Durable Medical Equipment
No charge to members in service area when prescribed by a plan physician; not covered for members living outside of service area; see plan EOC for limitations and exclusions
Chiropractic Care
$10 copay/visit; preauthorization required; self-referral not allowed
Hearing Aids and related expenses
Covered effective January 1, 2014
100% up to a flat dollar allowance of $1,000 or 80% of the total cost—whichever is greater—for Medically Necessary only; one per ear every three years
Acupuncture
$10 copay/visit; preauthorization required; self-referral not allowed
Other Benefits
Hearing exams — $10 copay/visit
Prescription Drug Benefits
When you and your dependents are enrolled in Kaiser Permanente Senior Advantage, the plan's Part D Prescription Drug Plan provides your retail and mail-order prescription drug coverage, not Express Scripts. For specific information about drug coverage through Kaiser Senior Advantage's Part D Prescription Drug Plan, contact Kaiser Permanente Senior Advantage directly.
Provisions
Kaiser Permanente Senior Advantage North and South (Medicare Advantage HMO)
General
Retail and mail-order Medicare Part D prescription drug plans are administered by Kaiser Senior Advantage HMO.
Annual Prescription Drug Deductible (Separate from medical plan deductible)
None
Annual Prescription Drug Out-of-Pocket Maximum
None
Annual or Lifetime Prescription Drug Maximum Benefit Limit
None
Retail Purchases
Medicare Part D plan
You pay $10/up to 100-day supply
Closed formulary
Mail-Order Purchases
Medicare Part D plan
You pay $10/up to 100-day supply
Closed formulary
Infertility, Sexual Dysfunction, Memory Enhancement and Contraceptive Drugs
Call Kaiser Permanente for details
Mental Health and Substance Abuse (MHSA) Benefits
The following chart provides an overview of Mental Health and Substance Abuse (MHSA) benefits for Kaiser Permanente Senior Advantage plan members. These benefits are administered both by Kaiser Permanente Senior Advantage and by ValueOptions, depending on the type of care you receive.
When care is provided by ValueOptions:
  • Pre-authorization is required for inpatient and hospital stays; you must obtain it within 48 hours of the start of treatment. Care that is not medically necessary will not be covered.
For more information on benefits provided by ValueOptions, refer to the Mental Health and Substance Abuse Coverage section.
Provisions
Kaiser Permanente Senior Advantage North and South (Medicare Advantage HMO)
General
Kaiser Permanente Senior Advantage's general medical plan provisions also apply to Mental Health and Substance Abuse benefits.
Outpatient Mental Health
  • $10 copay/visit (individual)
  • $5 copay/visit (group)
  • No visit limit
Inpatient Mental Health
No charge; no day limit
Outpatient Substance Abuse
Coverage through Kaiser
  • $10 copay/visit (individual)
  • $5 copay/visit (group)
  • No visit limit
Inpatient Substance Abuse
  • Only Medical Detoxification covered by Kaiser — no charge. May use ValueOptions for detoxification.
Coverage for Eligible Expenses* through ValueOptions, not HMO, requires referral by ValueOptions:
  • No charge for other inpatient and residential services when pre-authorized by ValueOptions
  • No limit on number of stays
* Coverage for Eligible Expenses. "Eligible Expenses" are: (1) expenses for Covered Health Services that are covered by the plan; (2) those that ValueOptions considers "Medically Necessary" for diagnosis or treatment; and (3) those that do not exceed the "Usual and Customary" rate as determined by ValueOptions. Any costs not meeting this definition are the responsibility of the member. For additional information or questions, call ValueOptions.
Other Information
Eligible Dependents and Member Rights
Refer to the complete description of eligibility, COBRA rights, Qualified Medical Child Support Order procedures and rights, ERISA rights and information, plan funding and plan continuation provisions provided elsewhere in this Summary of Benefits Handbook.
Choice of Providers
Members must use Kaiser Permanente HMO facilities and physicians, except for emergencies or as noted in the Evidence of Coverage. A Kaiser Permanente HMO physician must determine that the services and supplies are medically necessary to prevent, diagnose, or treat a member's medical condition. The services and supplies must be provided, prescribed, authorized or directed by a Kaiser Permanente HMO physician. Members may choose a primary care physician.
Plan Telephone Number
800-443-0815
Website