Kaiser Permanente Senior Advantage Enhanced Fresno (HMO) 2024 Benefit Details for Plan H0524-038-0 by Kaiser Permanente
Kaiser Permanente Senior Advantage Enhanced Fresno is a HMO Medicare Advantage plan, {with_without_pdp} Part D prescription drug benefits, available in 2024.
This health plan, from Kaiser Permanente, includes all Original Medicare benefits, and may offer extra services, but out-of-pocket costs are different.
Plan Basics | |
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Plan ID: | H0524 038 0 |
Plan Type: | Local HMO |
Plan Year: | 2024 |
Premium: | $70.00/mo Plus your Medicare Part B premium. |
Health Plan Deductible: | $0.00 |
Out-of-Pocket Maximum: | $2,500/yr |
Part B Reduction: | $0.00/mo |
Drug Plan Benefit: | Enhanced, $0.00 deductible |
Rx Gap Coverage: | Yes |
Supplemental Benefits: | Dental, Vision |
Availability: | See List |
Insured By: | Kaiser Permanente |
Summary of Benefits |
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Health Plan Cost Sharing
This Kaiser Permanente Medicare Advantage plan has cost-sharing. These are costs you must pay out-of-pocket when you use approved health services.
NOTE: Most preventive services are covered 100% by the plan as a Part B benefit.
The following table summarizes the most common out-of-pocket costs you will incur if you join this plan unless you go out-of-network:
Healthcare Service | Member Cost |
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Doctor Visits (In-Network) | |
Primary: | $5 Copay |
Specialist: | $10 Copay Referral Required |
Wellness programs (e.g., fitness, nursing hotline): | None |
Preventive care: | $0 Copay |
Foot Care (In-Network) | |
Foot exams and treatment (Medicare-covered): | $10 Copay Referral Required |
Routine foot care: | Not Covered |
Chiropractic Care (In-Network) | |
Medicare-covered chiropractic care: | $5 Copay Authorization Required, Referral Required |
Routine chiropractic care: | Not Covered |
Emergency Care / Urgent Care | |
Emergency room care: | $135 Copay |
Urgent care: | $5 Copay |
Ground ambulance: | $250 Copay |
Inpatient hospital coverage: | $230.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
Outpatient hospital coverage: | $175 Copay |
Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $100.00 per day for days 21 and beyond |
Optional supplemental benefits: | |
Mental Health Services (In-Network) | |
Outpatient individual therapy visit with a psychiatrist: | $5 Copay |
Outpatient group therapy visit with a psychiatrist: | $2 Copay |
Inpatient hospital - psychiatric: | $230.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
Outpatient group therapy visit: | $2 Copay |
Outpatient individual therapy visit: | $0 |
Rehabilitation Services (In-Network) | |
Physical therapy and speech and language therapy visit: | $15 Copay Referral Required |
Occupational therapy visit: | $15 Copay Referral Required |
Medical Equipment / Supplies (In-Network) | |
Diabetes supplies: | $0 Copay Authorization Required |
Durable medical equipment (e.g., wheelchairs, oxygen): | 20% Coinsurance Authorization Required |
Prosthetics (e.g., braces, artificial limbs): | 20% Coinsurance |
Diagnostic Procedures / Lab Services / Imaging (In-Network) | |
Diagnostic radiology services (e.g., MRI): | $200 Copay Referral Required |
Lab services: | $0 Copay Referral Required |
Outpatient x-rays: | $10 Copay Referral Required |
Diagnostic tests and procedures: | $0 Copay Referral Required |
Medicare Part B Drugs (In-Network) | |
Chemotherapy: | 20% Coinsurance |
Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Feel free to download our Kaiser Permanente Senior Advantage Enhanced Fresno Summary of Benefits information.
Supplemental Benefits
The following is a summary of the supplemental benefits Kaiser Permanente includes with this plan:
Supplemental Healthcare Service | Member Cost |
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Preventive Dental | Maximum dental benefit: | Non Specified |
Oral exam (In-Network) | Covered |
Fluoride treatment (In-Network) | Not Covered |
Dental x-ray(s) (In-Network) | Covered |
Cleaning (In-Network) | Covered |
Comprehensive Dental | |
Periodontics (In-Network) | Covered |
Non-routine services (In-Network) | Not Covered |
Diagnostic services (In-Network) | Covered |
Extractions (In-Network) | Covered |
Endodontics (In-Network) | Not Covered |
Restorative services (In-Network) | Not Covered |
Prosthodontics, other oral/maxillofacial surgery, other services (In-Network) | Not Covered |
Hearing Aids | |
Fitting/evaluation (In-Network) | Not Covered |
Hearing aids (In-Network) | Not Covered |
Hearing exam (In-Network) | Not Covered |
Vision | Maximum vision benefit: | Non Specified |
Eyeglasses (frames and lenses) (In-Network) | Not Covered |
Routine eye exam (In-Network) | $5 Copay Referral Required, Limitations Apply |
Contact lenses (In-Network) | Not Covered |
Additional Benefits
None specified.
Prescription Drug Plan Costs & Benefits
Kaiser Permanente Senior Advantage Enhanced Fresno includes an enhanced benefit Medicare Part D plan (PDP). Enhanced plans have a higher actuarial value than basic plans. Actuarial value simply refers to the percentage of cost that's covered by the plan.
Prescription Drug Plan Premium
Although the prescription drug plan (Part D) premium is bundled with the total plan cost, some plans have supplemental costs and/or offer low-income subsidy (LIS) assistance. LIS, also known as Extra Help, is a Social Security program that helps people with limited income and resources lower or cut Part D costs.
The following table outlines the prescription drug plan premium details of this plan.
Basic Part D Premium: | $50.60 |
Supplemental Part D Premium: | $0.00 |
Total Part D Premium: | $50.60 |
Part D Premium with Full LIS Assistance: | $9.60 |
If you would like more information about the Extra Help program, you can refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $0.00. This is the amount you must pay at the pharmacy before Kaiser Permanente begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Kaiser Permanente Senior Advantage Enhanced Fresno has out-of-pocket costs that you must pay when you pick up your prescriptions.
Drug Tier | Preferred | Standard |
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1 (Preferred Generic) | N/A | $0.00 copay |
2 (Generic) | N/A | $8.00 copay |
3 (Preferred Brand) | N/A | $47.00 copay |
4 (Non-Preferred Drug) | N/A | $100.00 copay |
5 (Specialty Tier) | N/A | 33% |
6 (Vaccines ($0 cost sharing)) | N/A | $0.00 copay |
2024 CMS Rating Marks
Each year the Centers for Medicare & Medicaid Services (CMS) rates health plans (Part C) in five broad categories and drug plans (Part D) in four broad categories based on a 5-star rating system. Here are the most recent CMS ratings for Kaiser Permanente Senior Advantage Enhanced Fresno.
CMS Measure | Star Rating |
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2024 Overall Rating | |
Staying Healthy: Screenings, Tests, Vaccines | |
Managing Chronic (Long Term) Conditions | |
Member Experience with Health Plan | |
Complaints and Changes in Plans Performance | |
Health Plan Customer Service | |
Drug Plan Customer Service | |
Complaints and Changes in the Drug Plan | |
Member Experience with the Drug Plan | |
Drug Safety and Accuracy of Drug Pricing |
In terms of quality care, this Medicare Advantage HMO plan is much better than the average plan in the areas it serves. Kaiser Permanente Senior Advantage Enhanced Fresno does an excellent job keeping its members healthy through its preventive care program with proactive screenings, tests, and vaccines. This plan is good at managing its member's chronic (long-term) health conditions.
Members report that their experience with this HMO plan is below average. When it comes to complaints and changes in performance, this plan is below average. Not the best or the worst when it comes to customer service, this health plan's customer service is average.
Kaiser Permanente Senior Advantage Enhanced Fresno offers some dental and vision benefits, but not hearing.
With an added premium of $70.00 dollars per month, prospective members are advised to carefully weigh the value of the plan's additional benefits. We love it when we see a plan with a maximum out-of-pocket (MOOP) limit less than $3,000, and this plan brings it in at $2,500 per year. The MOOP does not include prescriptions, but the good news is that a 5-day stay in the hospital with Kaiser Permanente Senior Advantage Enhanced Fresno will probably cost less than Original Medicare. This health plan does not have an annual deductible, making health care a little easier to budget.
Plan Availability
Kaiser Permanente Senior Advantage Enhanced Fresno (H0524-038-0) is available in the following locations (click to open):
Additional Medicare Advantage Plan Options
The Medicare Advantage program offers a myriad of options, including these plans:
- H0524-054-0: Kaiser Permanente Senior Advantage Santa Cruz (HMO)
- H0524-033-0: Kaiser Permanente Sr Adv Enhanced Contra Costa (HMO)
- H0524-003-0: Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
- H0524-082-0: Kaiser Permanente Senior Advantage San Diego Value (HMO)
- H0524-063-0: Kaiser Permanente Senior Advantage Basic Solano (HMO)
Contact Kaiser Permanente
Plan Website: | http://kp.org/medicare |
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Formulary Information: | http://kp.org/directory |
Pharmacy Information: | Kaiser Permanente Pharmacy Page |
Prospective Members: | (800)777-1238 |
TTY Users: | 711 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Advantage program on www.medicare.gov.
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, GlobalHealth, Health Care Service Corporation, Cigna Healthcare, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Scott and White Health Plan now part of Baylor Scott & White Health, UnitedHealthcare(R), and Wellcare.
Citations & References
- Kaiser Permanente, http://kp.org/medicare, Last Accessed February 20, 2024
- Medicare.gov, "Medicare Advantage Plans cover all Medicare services", Last Accessed February 20, 2024
- Medicare.gov, "How Original Medicare Works", Last Accessed February 19, 2024
- Medicare.gov, "Medicare & You", Last Accessed February 19, 2024
- Medicare.gov, "What Medicare Covers", Last Accessed February 7, 2023
- CMS.gov, Landscape Source Files, Last Accessed February 21, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed February 21, 2024
- CMS.gov, Plan Benefits Package, Last Accessed February 21, 2024
About This H0524-038-0 Plan Detail Page
The data on this Kaiser Permanente Senior Advantage Enhanced Fresno plan detail page is derived from the 2024 Landscape Source Files, Plan Benefit Package, and Medicare Part C and Part D Performance Data published by CMS.
The author interprets these files, and their associated data dictionary, with great care, making every attempt to communicate the data submitted by Kaiser Permanente to CMS as clearly and accurately as possible. Given the complexity of the data, the author recommends that all potential enrollees request an official Summary of Benefits from Kaiser Permanente, at (800)777-1238, prior to enrollment.