Since 2006, Medicare has paid plans under a bidding process. Plans submit “bids” based on estimated costs per enrollee for services covered under Medicare Parts A and B; all bids that meet the necessary requirements are accepted. The bids are compared to benchmark amounts that are set by a formula established in statute and vary by county (or region in the case of regional PPOs). The benchmarks are the maximum amount Medicare will pay a plan in a given area. If a plan’s bid is higher than the benchmark, enrollees pay the difference between the benchmark and the bid in the form of a monthly premium, in addition to the Medicare Part B premium. If the bid is lower than the benchmark, the plan and Medicare split the difference between the bid and the benchmark; the plan’s share is known as a “rebate,” which must be used to provide supplemental benefits to enrollees. Medicare payments to plans are then adjusted based on enrollees’ risk profiles.
Kaiser Permanente Medicare Advantage Plans with Part D (Prescription Drug) Coverage
The following Kaiser Permanente plans offer Medicare Advantage and Part D coverage to California residents. Medicare Advantage plans, also known as Medicare Part C, are alternatives to original Medicare. These plans help cover the costs of services provided by hospitals, doctors, lab tests and some preventive screenings. These plans’ Part D component helps cover prescription drugs. Even if a plan’s monthly premium is $0, you would still pay the equivalent of the original Medicare premium. Not all plans shown here will be available to you; enter your zip code to see plans in your area. You can read about whether Medicare Advantage is right for you. If you only want plans with drug coverage, browse Prescription Drug (Part D) Plans.
Kaiser Permanente Advantage Plus
Kaiser Permanente is an HMO plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal. Benefits, formulary, pharmacy network, provider network, premium and/or copayments/coinsurance may change on January 1 of each year. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. You must reside in the Kaiser Permanente Medicare health plan service area in which you enroll. You must be a Kaiser Permanente Senior Advantage individual plan member to apply, and you must continue to pay applicable Senior Advantage and Medicare Part B premiums and any other applicable Medicare premium(s), if not otherwise paid by Medicaid or another third party. The Silver&Fit Program is provided by American Specialty Health Fitness, Inc., a subsidiary of American Specialty Health Incorporated (ASH). All programs and services are not available in all areas. Silver&Fit, The Silver Slate, and the Silver&Fit Signature Series Classes are federally registered trademarks of ASH. Other names and logos may be trademarks of their respective owners.
Affordable Health Coverage
Rating and national average are based on Controlling High Blood Pressure 2013 ratings from the Healthcare Effectiveness Data and Information Set (HEDIS) for commercial plans published by the National Committee for Quality Assurance. HEDIS is a tool used by more than 90 percent of America’s health plans to measure performance on important dimensions of care and service. HEDIS is a registered trademark of the National Committee of Quality Assurance (NCQA). For more information, visit ncqa.org.
Kaiser Permanente Senior Advantage Basic (HMO) 2014
Your in-network prescription coverage may be limited to the plan’s service area. This means that if you travel outside the service area, you may have to pay the full cost of your prescription. In certain emergencies, your drugs will be covered if you get them at an out-of-network-pharmacy although you may have to pay additional charges. Contact the plan for details. Total yearly drug costs are the total drug costs paid by both you and a Part D plan. Your provider must get prior authorization from Kaiser Permanente Senior Advantage Basic (HMO) for certain drugs. You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan’s website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount. If you request a formulary exception for a drug and Kaiser Permanente Senior Advantage Basic (HMO) approves the exception, you will pay Tier 3: Preferred Brand cost sharing for that drug. In-Network $0 deductible. Initial Coverage You pay the following until total yearly drug costs reach $2,850: Retail Pharmacy Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. You can get drugs the following way(s): Tier 1: Preferred Generic
in Plan Benefits Details
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Kaiser Permanente Advantage Plus
• If you are already a Senior Advantage member, you may add Advantage Plus during the annual election period October 15 – December 7 for coverage to become effective on January 1, 2015. If you don’t enroll during the annual election period, you have until March 31, 2015 to enroll. Coverage is effective the first day of the month following the date we receive your completed enrollment form.
Medicare Advantage 2015 Data Spotlight: Overview of Plan Changes
When SNPs were authorized, there were few requirements beyond those otherwise required of other Medicare Advantage plans. The Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 established additional requirements for SNPs, including requiring all SNPs to provide a care management plan to document how care would be provided for enrollees and requiring C-SNPs to limit enrollment to beneficiaries with specific diagnoses or conditions. As a result of the new MIPPA requirements, the number of SNPs declined in 2010. The ACA required D-SNPs to have a contract with the Medicaid agency for every state in which the plan operates, beginning in 2013. Additionally, in 2013, joint federal-state financial alignment demonstrations to improve the coordination of Medicare and Medicaid for dually eligible beneficiaries began to enroll beneficiaries. Today, financial alignment demonstrations are underway in 12 states: California, Colorado, Illinois, Massachusetts, Michigan, Minnesota, New York, Ohio, South Carolina, Texas, Virginia, and Washington. The financial alignment demonstrations could influence the availability of D-SNPs in these states, either increasing or decreasing the availability of SNPs, depending on the design of the demonstration.