Kaiser Permanente Dual Essential (D-SNP) Plan Details for Gilpin County, CO
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*CMS rated this Kaiser Permanente plan (H0630-014-0) 4 (Good) out of 5 stars.
Kaiser Permanente Dual Essential (D-SNP) is a Dual-Eligible Medicare Special Needs Plan. The 2025 Annual Enrollment period starts October 15. Plan benefits begin January 1.
This plan is required to provide all of the same benefits as Original Medicare, but out-of-pocket costs are different. This private health insurance option may include extra benefits not covered by Medicare Part A or Part B.
Eligible individuals must meet all Dual-Eligible SNP qualification requirements to join this Kaiser Permanente D-SNP plan.
| Plan Basics | |
|---|---|
| Plan ID: | H0630-014-0 |
| Plan Type: | HMO D-SNP |
| Plan Year: | 2025 |
| Premium: | $0.00/mo Plus your Part B premium. |
| Health Plan Deductible: | $0.00 |
| Out-of-Pocket Maximum: | 4,900.00 /yr |
| Part B Reduction: | $0.00/mo |
| Drug Plan Benefit: | Enhanced $530.00 deductible |
| Supplemental Benefits: | Vision, Hearing |
| Availability: | Gilpin County, CO |
| Insured By: | Kaiser Permanente |
| Summary of Benefits |
|---|
Health Plan Cost Sharing & Benefits
The following table is a summary of the most common out-of-pocket costs you will incur if you join this Kaiser Permanente plan:
Doctor's Office Visits
| Service | Enrollee Cost (in-network) |
|---|---|
| Primary: | $0 Copay |
| Specialist: | $5 Copay Referral Required |
Emergency, Urgent, and Inpatient Hospital Coverage
| Service | Enrollee Cost |
|---|---|
| Emergency room care: | $125 Copay |
| Urgent care: | $0 Copay |
| Ground ambulance: | 20% Coinsurance |
| Inpatient hospital care: | $225.00 per day for days 1 through 6 $0.00 per day for days 7 and beyond |
| Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $203.00 per day for days 21 through 45 $0.00 per day for days 46 and beyond |
Foot Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Foot Exams and Treatments (Medicare-covered): | $5 Copay Referral Required |
| Routine Foot Care: | $0 Copay Referral Required |
Chiropractic Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Medicare-covered chiropractic: | $20 Copay |
| Routine chiropractic: | $20 Copay |
Mental Health Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Outpatient individual therapy: | $0 Copay |
| Outpatient group therapy: | $0 Copay |
| Inpatient psychiatric hospital care: | $225.00 per day for days 1 through 6 $0.00 per day for days 7 and beyond |
Rehabilitation Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Physical therapy and speech and language therapy: | $0 Copay Referral Required |
| Occupational therapy: | $0 Copay Referral Required |
Medical Equipment and Supplies
| Service | Enrollee Cost (in-network) |
|---|---|
| Diabetes supplies: | $0 Copay Prior Authorization Required |
| Durable medical equipment: | 20% Coinsurance Prior Authorization Required |
| Prosthetics: | 20% Coinsurance |
Diagnostics, Lab Services, and Imaging
| Service | Enrollee Cost (in-network) |
|---|---|
| Diagnostic radiology services: | $125 Copay Prior Authorization Required, Referral Required |
| Lab services: | $0 Copay Prior Authorization Required, Referral Required |
| Outpatient x-rays: | $0 Copay Prior Authorization Required, Referral Required |
| Diagnostic tests and procedures: | $0 Copay Prior Authorization Required, Referral Required |
Medicare Part B Drugs
| Service | Enrollee Cost (in-network) |
|---|---|
| Chemotherapy: | 20% Coinsurance |
| Other Part B drugs (Medicare-covered): | 20% Coinsurance |
Dental Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare Covered Preventive Dental | $5 Copay |
| Oral exam | $0 Copay |
| Dental x-rays | $0 Copay |
| Cleaning | $0 Copay |
| Periodontics | Not Covered |
| Endodontics | Not Covered |
| Restorative Services | Not Covered |
| Maximum dental benefit: | $3,000.00 (Every year) |
Hearing Aids and Services
| Service | Member Cost (in-network) |
|---|---|
| Fitting/evaluation | Covered Limits may apply |
| Hearing aids | Not Covered |
| Hearing exam | Covered Limits may apply |
Vision Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare-covered eye exam (in-network) | $0 Copay |
| Routine eye exam (in-network) | $0 Copay |
| Eyewear benefits | None |
Feel free to download our Kaiser Permanente Dual Essential Summary of Benefits information.
Prescription Drug Plan Costs & Benefits
Kaiser Permanente Dual Essential 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 premium details of this prescription drug plan.
| Basic Part D Premium: | $(3.20) |
| Supplemental Part D Premium: | $3.20 |
| Total Part D Premium: | $0.00 |
| Low Income Premium Subsidy: | $37.02 |
| Low Income Premium Subsidy CMS Pays: | $0.00 |
| Low Income Subsidy Premium: | $0.00 |
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 $530.00. You must pay this amount 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 Dual Essential has out-of-pocket costs you must pay when you pick up your prescriptions.
| Drug Tier | Retail | Mail Order | |
|---|---|---|---|
| Preferred Generic | 22.00% | 22.00% | |
| Generic | 23.00% | 23.00% | |
| Preferred Brand | 24.00% | 24.00% | |
| Non-Preferred Drug | 25.00% | 25.00% | |
| Specialty Tier | 25.00% | 25.00% | |
| Vaccines* | $0.00 | $0.00 | |
| *The Part D deductible does not apply. | |||
CMS Rating Marks
Each year Medicare rates D-SNP plans, using a 5-star rating system, in nine major categories. These ratings are designed to help you understand the quality of care and service you can expect if you qualify and choose to join Kaiser Permanente Dual Essential .
| CMS Measure | Star Rating |
|---|---|
| 2025 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 |
Additional D-SNP Plan Options
Here are some additional Medicare SNP plans that might be worth reviewing:
- Kaiser Permanente Dual Essential
- Kaiser Permanente Dual Complete
- Kaiser Permanente Dual Complete Pueblo
Contact Kaiser Permanente
| Website: | Kaiser Permanente Plan Page |
|---|---|
| Providers: | Kaiser Permanente Providers Page |
| Formulary: | Kaiser Permanente Formulary Page |
| Pharmacy: | Kaiser Permanente Pharmacy Page |
| New Member Health Plan Help: | (877)408-3492 |
| New Member Health Plan TTY: | 711 |
| New Member Part D Help: | (877)408-3492 |
| New Member Part D 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.
Health Plan Compatibility
Special Needs Plans (SNPs) under Medicare Advantage typically do not work with other types of health insurance. If you have Medicare Part A or Part B and decide to join an SNP plan, you will be removed from Original Medicare. Furthermore, you cannot be enrolled in an SNP plan and hold a Medigap Insurance policy at the same time.
With a D-SNP, members retain their existing Medicaid plan and benefits. Veterans who have VA Health Benefits may also be able to receive care at their local VA hospital.
Citations & References
- Kaiser Permanente, http://kp.org/medicare, Last Accessed October 13, 2024
- Medicaid.gov, "Medicaid & CHIP in Colorado", Last Accessed October 1, 2024
- CMS.gov, Landscape Source Files, Last Accessed October 2, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed October 2, 2024
- CMS.gov, Plan Benefits Package, Last Accessed October 5, 2024
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Baylor Scott & White Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, GlobalHealth, Health Care Service Corporation, Healthy Blue, HealthSun, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.