Kaiser Fndn Hp Of The Mid-Atlantic Sts
2101 East Jefferson Street
Rockville, MD 20852
Phone: 1-888-777-5536
Toll free: 1-888-777-5536
Website
http://kp.org/medicare
Pharmacy
http://www.kp.org/seniorrx
Plan Rating | 4.5 out of 5 stars |
Premium and Other Important Information | $0.00 monthly plan premium in addition to your monthly Medicare Part B premium. |
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. | |
$3 400 out-of-pocket limit for select Medicare-covered services. Contact plan for details regarding Medicare-covered services under this limit. | |
Doctor and Hospital Choice | Referral required for network hospitals and specialists (for certain benefits). |
You can use any network doctor. If you go to out-of-network doctors the plan may not cover the services but Medicare will pay its share for Medicare-covered services When Medicare pays its share you pay the Medicare Part B deductible and coinsurance. | |
Inpatient Hospital Care | Plan covers 90 days each benefit period. |
$1 000 copay for each Medicare-covered hospital stay | |
Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day. | |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |
Inpatient Mental Health Care | You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. |
$1 000 copay for each Medicare-covered hospital stay. | |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |
Skilled Nursing Facility (SNF) | Authorization rules may apply. |
Plan covers up to 100 days each benefit period | |
For Medicare-covered SNF stays: | |
Days 1 - 10: $0 copay per day | |
Days 11 - 100: $63 copay per day | |
Home Health Care | Authorization rules may apply. |
$0 copay for Medicare-covered home health visits | |
Hospice | You must get care from a Medicare-certified hospice. Your plan will pay for a consultative visit before you select hospice. |
Doctor Office Visits | Authorization rules may apply. |
$30 copay for each primary care doctor visit for Medicare-covered benefits. | |
$40 copay for each in-area network urgent care Medicare-covered visit | |
$40 copay for each specialist visit for Medicare-covered benefits. | |
Chiropractic Services | Authorization rules may apply. |
$20 copay for each Medicare-covered visit | |
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers. | |
Podiatry Services | Authorization rules may apply. |
$40 copay for each Medicare-covered visit | |
Medicare-covered podiatry benefits are for medically-necessary foot care. | |
Outpatient Mental Health Care | Authorization rules may apply. |
$30 copay for each Medicare-covered individual therapy visit | |
$30 copay for each Medicare-covered group therapy visit | |
$30 copay for each Medicare-covered individual therapy visit with a psychiatrist | |
$30 copay for each Medicare-covered group therapy visit with a psychiatrist | |
$30 copay for Medicare-covered partial hospitalization program services | |
Outpatient Substance Abuse Care | Authorization rules may apply. |
$30 copay for Medicare-covered individual visits | |
$30 copay for Medicare-covered group visits | |
Outpatient Services/Surgery | Authorization rules may apply. |
$250 copay for each Medicare-covered ambulatory surgical center visit | |
$250 copay for each Medicare-covered outpatient hospital facility visit | |
Ambulance Services | Authorization rules may apply. |
$200 copay for Medicare-covered ambulance benefits. | |
Emergency Care | $65 copay for Medicare-covered emergency room visits |
Not covered outside the U.S. except under limited circumstances. Contact the plan for more details. | |
If you are admitted to the hospital within 48-hour(s) for the same condition you pay $0 for the emergency room visit. | |
Urgently Needed Care | $40 copay for Medicare-covered urgently-needed-care visits |
Outpatient Rehabilitation Services | Authorization rules may apply. |
$40 copay for Medicare-covered Occupational Therapy visits | |
$40 copay for Medicare-covered Physical and/or Speech and Language Therapy visits | |
Durable Medical Equipment | Authorization rules may apply. |
20% of the cost for Medicare-covered items | |
Prosthetic Devices | Authorization rules may apply. |
20% of the cost for Medicare-covered items | |
Diabetes Programs and Supplies | Authorization rules may apply. |
$0 copay for Diabetes self-management training | |
0% of the cost for Diabetes monitoring supplies | |
20% of the cost for Therapeutic shoes or inserts | |
Diagnostic Tests X-Rays Lab Services and Radiology Services | Authorization rules may apply. |
$0 copay for Medicare-covered lab services | |
$0 to $100 copay for Medicare-covered diagnostic procedures and tests | |
$0 copay for Medicare-covered X-rays | |
$0 to $100 copay for Medicare-covered diagnostic radiology services (not including X-rays) | |
$40 copay for Medicare-covered therapeutic radiology services | |
Cardiac and Pulmonary Rehabilitation Services | Authorization rules may apply. |
$40 copay for Medicare-covered Cardiac Rehabilitation Services | |
$40 copay for Medicare-covered Intensive Cardiac Rehabilitation Services | |
$40 copay for Medicare-covered Pulmonary Rehabilitation Services | |
Preventive Services and Wellness/Education Programs | $0 copay for all preventive services covered under Original Medicare at zero cost sharing: |
HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. Please contact plan for details. | |
The plan covers the following supplemental education/wellness programs: | |
Kidney Disease and Conditions | Authorization rules may apply. |
Cost plan members pay Fee-for-Service cost sharing for out-of-area dialysis. | |
$30 copay for renal dialysis | |
$0 copay for kidney disease education services | |
Outpatient Prescription Drugs | Most drugs not covered. |
$0 to $50 copay for Part B-covered chemotherapy drugs and other Part B-covered drugs. | |
This plan does not offer prescription drug coverage. | |
Dental Services | Authorization rules may apply. |
In general preventive dental benefits (such as cleaning) not covered. | |
$40 copay for Medicare-covered dental benefits | |
Hearing Services | Authorization rules may apply. |
In general supplemental routine hearing exams and hearing aids not covered. | |
Vision Services | Authorization rules may apply. |
Non-Medicare Supplemental eye exams and glasses not covered. | |
If the doctor provides you services in addition to eye exams separate cost sharing of $30 to $40 may apply | |
Over-the-Counter Items | The plan does not cover Over-the-Counter items. |
Transportation | This plan does not cover supplemental routine transportation. |
Acupuncture | This plan does not cover Acupuncture. |
Premium and Other Important Information | In 2012 the monthly Part B Standard Premium is $99.90 and the annual Part B deductible amount is $140. |
If a doctor or supplier does not accept assignment their costs are often higher which means you pay more. | |
Most people will pay the standard monthly Part B premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. | |
Doctor and Hospital Choice | You may go to any doctor specialist or hospital that accepts Medicare. |
Inpatient Hospital Care | In 2012 the amounts for each benefit period are: Days 1 - 60: $1 156 deductible Days 61 - 90: $289 per day Days 91 - 150: $578 per lifetime reserve day |
Call 1-800-MEDICARE (1-800-633-4227) for information about lifetime reserve days. | |
Lifetime reserve days can only be used once. | |
"A ""benefit period"" starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have." | |
Inpatient Mental Health Care | In 2012 the amounts for each benefit period are: Days 1 - 60: $1 156 deductible Days 61 - 90: $289 per day Days 91 - 150: $578 per lifetime reserve day |
You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. | |
Skilled Nursing Facility (SNF) | In 2012 the amounts for each benefit period after at least a 3-day covered hospital stay are: Days 1 - 20: $0 per day Days 21 - 100: $144.50 per day |
100 days for each benefit period. | |
"A ""benefit period"" starts the day you go into a hospital or SNF. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have." | |
Home Health Care | $0 copay. |
Hospice | You pay part of the cost for outpatient drugs and inpatient respite care. |
You must get care from a Medicare-certified hospice. | |
Doctor Office Visits | 20% coinsurance |
Chiropractic Services | Supplemental routine care not covered |
20% coinsurance for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers. | |
Podiatry Services | Supplemental routine care not covered. |
20% coinsurance for medically necessary foot care including care for medical conditions affecting the lower limbs. | |
Outpatient Mental Health Care | 40% coinsurance for most outpatient mental health services |
Specified copayment for outpatient partial hospitalization program services furnished by a hospital or community mental health center (CMHC). Copay cannot exceed the Part A inpatient hospital deductible. | |
"""Partial hospitalization program"" is a structured program of active outpatient psychiatric treatment that is more intense than the care received in your doctor's or therapist's office and is an alternative to inpatient hospitalization." | |
Outpatient Substance Abuse Care | 20% coinsurance |
Outpatient Services/Surgery | 20% coinsurance for the doctor's services |
Specified copayment for outpatient hospital facility services Copay cannot exceed the Part A inpatient hospital deductible. | |
20% coinsurance for ambulatory surgical center facility services | |
Ambulance Services | 20% coinsurance |
Emergency Care | 20% coinsurance for the doctor's services |
Specified copayment for outpatient hospital facility emergency services. | |
Emergency services copay cannot exceed Part A inpatient hospital deductible for each service provided by the hospital. | |
You don't have to pay the emergency room copay if you are admitted to the hospital as an inpatient for the same condition within 3 days of the emergency room visit. | |
Not covered outside the U.S. except under limited circumstances. | |
Urgently Needed Care | 20% coinsurance or a set copay |
NOT covered outside the U.S. except under limited circumstances. | |
Outpatient Rehabilitation Services | 20% coinsurance |
Durable Medical Equipment | 20% coinsurance |
Prosthetic Devices | 20% coinsurance |
Diabetes Programs and Supplies | 20% coinsurance for diabetes self-management training |
20% coinsurance for diabetes supplies | |
20% coinsurance for diabetic therapeutic shoes or inserts | |
Diagnostic Tests X-Rays Lab Services and Radiology Services | 20% coinsurance for diagnostic tests and x-rays |
$0 copay for Medicare-covered lab services | |
Lab Services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare does not cover most supplemental routine screening tests like checking your cholesterol. | |
Cardiac and Pulmonary Rehabilitation Services | 20% coinsurance Cardiac Rehabilitation services 20% coinsurance for Pulmonary Rehabilitation services 20% coinsurance for Intensive Cardiac Rehabilitation services |
This applies to program services provided in a doctor+s office. Specified cost sharing for program services provided by hospital outpatient departments. | |
Preventive Services and Wellness/Education Programs | No coinsurance copayment or deductible for the following: |
Kidney Disease and Conditions | 20% coinsurance for renal dialysis |
20% coinsurance for kidney disease education services | |
Outpatient Prescription Drugs | Most drugs are not covered under Original Medicare. You can add prescription drug coverage to Original Medicare by joining a Medicare Prescription Drug Plan or you can get all your Medicare coverage including prescription drug coverage by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage. |
Dental Services | Preventive dental services (such as cleaning) not covered. |
Hearing Services | Supplemental routine hearing exams and hearing aids not covered. |
20% coinsurance for diagnostic hearing exams. | |
Vision Services | 20% coinsurance for diagnosis and treatment of diseases and conditions of the eye. |
Supplemental routine eye exams and glasses not covered. | |
Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery. | |
Annual glaucoma screenings covered for people at risk. | |
Over-the-Counter Items | Not covered. |
Transportation | Not covered. |
Acupuncture | Not covered. |
Point of Service | You may go to any doctor specialist or hospital that accepts Medicare. |
Help is available. If you have limited income and resources, you may qualify for help paying your Medicare health care and/or prescription drug coverage costs. For more information, visit socialsecurity.gov, call Social Security at 1-800-772-1213, or apply for help at your State Medical Assistance (Medicaid) office.
If you have questions about Medicare, visit medicare.gov or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.