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How Kaiser Medicare Advantage Works

Reviewed by Russell Noga, Licensed Medicare Insurance Broker (all 50 states) — Last updated October 8, 2026

Kaiser Permanente Medicare Advantage works as an integrated HMO: your plan, doctors, hospitals and pharmacies are usually part of one system, and you generally must use Kaiser facilities except for emergencies and urgent care away from home.

Kaiser serves Medicare members in 9 states and DC. For 2027 it leaves 2 Nevada and 3 Washington counties and drops its last 3 PPO plans, so Kaiser becomes an HMO-focused offering.

✔ Licensed in all 50 states
✔ Based on CMS 2027 data
✔ Free plan comparison

Key Highlights

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Integrated plan, doctors and hospitals.

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Mostly HMO for 2027.

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Last 3 PPOs dropped.

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The national average 2027 Medicare Advantage premium is $12 a month, down from $14.37 (CMS).

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Annual Enrollment runs October 15 to December 7, 2026.

Compare plans and enroll online

The Integrated Model, Step by Step

How Care Flows

1

You choose a Kaiser primary care doctor. They coordinate most of your care.

2

Specialists are usually inside Kaiser. Referrals often move through the same system.

3

Records are shared. Your doctors, labs and pharmacy can see the same chart.

4

Pharmacy is in the system. Most prescriptions are filled at Kaiser pharmacies or by mail.

5

Emergencies are covered anywhere. Emergency and urgent care away from home are covered.

Why People Choose Kaiser

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Doctors, hospitals and pharmacy in one system

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Shared records across your care team

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Simple copays on many plans

What to Weigh

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Generally must use Kaiser facilities

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Limited coverage outside service areas except emergencies

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Only in certain counties

Benefits Kaiser Permanente Plans May Offer

Kaiser Permanente Plans May Include

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Hospital and medical coverage, the same as Original Medicare Part A and B

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Part D prescription drug coverage on most plans

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Routine dental, vision and hearing benefits

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Fitness programs and over-the-counter allowances

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Telehealth visits and care coordination programs

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A yearly out-of-pocket maximum on every plan

Not all plans offer all benefits. Benefits vary by plan and county and can change for 2027. Check each plan’s Evidence of Coverage before you enroll.

Understanding Medicare Coverage Basics

What Changed at Kaiser for 2027

9 States + DC

Kaiser Permanente’s Medicare footprint.

2 NV, 3 WA

Counties Kaiser is leaving for 2027.

Last 3 PPOs

Being dropped for 2027.

Watch for: if your plan is ending, you will get a non-renewal letter. Your coverage continues through December 31, 2026. If you do nothing, you return to Original Medicare without drug coverage.

Guaranteed issue: if your Medicare Advantage plan leaves your area, you generally can buy certain Medicare Supplement plans without health questions, until 63 days after your coverage ends.

Find & Compare Plans Online

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Kaiser 2027 at a Glance

Kaiser’s 2027 changes are smaller than those at several large national insurers, but members in the affected Nevada and Washington counties and anyone in a Kaiser PPO should expect a non-renewal notice and must choose new coverage.

Kaiser Versus a Typical Network HMO

Feature Kaiser Permanente Typical Network HMO
Who runs the doctors Largely Kaiser’s own medical groups Independent doctors contracted with the plan
Records One shared system Varies by practice
Pharmacy Mainly Kaiser pharmacies Retail pharmacy network
Out-of-area care Emergencies and urgent care Emergencies and urgent care

Understanding Monthly Premiums and Costs

How Medicare Advantage Works

Medicare Advantage, also called Part C, is a way to get your Medicare benefits through a private insurance company approved by Medicare. The plan covers everything Original Medicare Part A and Part B cover, except hospice care, which Original Medicare still pays. Most plans also include Part D drug coverage, and many may add extras such as routine dental, vision and hearing benefits.

The trade-off is that Kaiser Permanente plans typically rely on provider networks of doctors and hospitals, and some services may need a referral or prior authorization. Unlike Original Medicare, every Medicare Advantage plan caps what you spend out of pocket each year on covered medical care. Your Part B premium still applies, along with any premium your plan charges.

Feature HMO PPO
Out-of-network care Not covered except emergencies and urgent care Covered at a higher cost
Referrals for specialists Usually required Usually not required
Premiums Usually lower Usually higher
Out-of-pocket maximum In-network limit In-network limit plus a higher combined limit
Best for Lower costs, local care Flexibility, travel, keeping specific doctors

Pros and Cons of Medicare Advantage

Advantages

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Often a low or $0 premium

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A yearly out-of-pocket maximum

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Drug coverage usually included

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Many plans may include dental, vision and hearing benefits

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One card and one plan

Tradeoffs

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Networks; HMOs require in-network care except emergencies

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Prior authorization and referrals are common

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Copays add up if you use a lot of care

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Plans and networks can change every year

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Switching to Medigap later may require health questions

Kaiser Permanente Drug Coverage for 2027

Drug coverage under Part D comes built into most Kaiser Permanente Medicare Advantage plans. Every plan sets its own formulary, drug tiers and pharmacy network, and costs are often lower at preferred pharmacies or by mail order. In 2027, a plan’s Part D deductible may be as high as $700, and spending on covered drugs is capped at $2,400 out of pocket.

Tier Typical Drugs Typical Cost
Tier 1 Preferred generics Lowest copay
Tier 2 Generics Low copay
Tier 3 Preferred brand-name drugs Moderate copay
Tier 4 Non-preferred drugs Higher copay or coinsurance
Tier 5 Specialty drugs Highest coinsurance

Tier structures vary by plan. Check each plan’s formulary.

Sometimes a drug you take is not on a plan’s 2027 formulary, or it carries a rule like prior authorization. You still have options:

If Your Drug Is Not Covered

1

Ask for a transition fill. In the first 90 days of a new plan year or a new plan, plans generally must give you a temporary supply of a drug you were already taking, so you have time to switch or request an exception.

2

Ask your doctor about alternatives. A covered drug in the same class may work as well and cost less.

3

Request a formulary or tiering exception. Your doctor submits a statement explaining why you need the drug or a lower copay. Plans must decide within set time limits.

4

Appeal a denial. If the plan says no, you can appeal, and there are several levels of review.

See steps to appeal a Medicare Part D denial.

If Your Plan Is Ending

A Kaiser Permanente member whose plan is leaving their county for 2027 should have gotten a non-renewal notice in early October. You are not cut off immediately: coverage runs through December 31, 2026, which leaves time to pick a new plan.

If Your Plan Is Ending

1

Read the non-renewal letter. It confirms your plan is ending and explains your options.

2

List your doctors and drugs. You will need them to compare replacement plans.

3

Compare plans for 2027. Check networks, drug coverage and the out-of-pocket maximum, not just the premium.

4

Choose by December 31 for no gap. Enrolling during Annual Enrollment by December 7 gives you coverage on January 1, 2027.

5

Use your Special Enrollment Period if needed. People whose plans end generally can still make a choice through the end of February 2027.

If you do nothing: you return to Original Medicare on January 1, 2027, without drug coverage unless you choose a Part D plan. Going without drug coverage can lead to a late enrollment penalty.

Medigap rights: when your Medicare Advantage plan leaves your area, you generally have a guaranteed issue right to buy certain Medicare Supplement plans without health questions, up to 63 days after your coverage ends.

How to Compare Kaiser Permanente Plans for 2027

How to Compare

1

Read your Annual Notice of Change. It lists every change to your current plan for 2027.

2

Check your doctors and hospitals. Confirm each provider is in the 2027 network, not just the 2026 one.

3

Check your prescriptions. Confirm each drug, its tier and any prior authorization or step therapy rules.

4

Compare total yearly cost. Add the premium, typical copays and drug costs, and look at the out-of-pocket maximum.

5

Check star ratings. Medicare rates plans from 1 to 5 stars on quality and service.

6

Enroll by December 7. Your new coverage starts January 1, 2027.

2027 Enrollment Dates

Enrollment Period Dates What You Can Do
Annual Enrollment Period October 15 to December 7, 2026 Join, switch or drop a Medicare Advantage or Part D plan for January 1, 2027
Medicare Advantage Open Enrollment January 1 to March 31, 2027 If you are in Medicare Advantage, switch to another plan or return to Original Medicare once
Initial Enrollment Period 7 months around your 65th birthday month Sign up for Medicare and choose your first plan
Special Enrollment Periods Varies Change plans after events like moving, losing other coverage or your plan leaving your area

Most people make changes during Annual Enrollment. If you are happy with your current plan, you do not have to do anything; it renews automatically. Still, read your Annual Notice of Change, because premiums, copays, networks and drug lists can all change on January 1.

Special Needs Plans

Special Needs Plans (SNPs) are Medicare Advantage plans built for specific groups. Benefits, networks and drug lists are designed around the members they serve, and many include care coordinators. For 2027, Special Needs Plans are one of the few areas where large insurers are adding plans, even as they cut PPOs.

Type Who Qualifies What Is Different
Dual Special Needs Plan (D-SNP) People with both Medicare and Medicaid Coordinates both programs; often very low costs and added benefits
Chronic Condition SNP (C-SNP) People with qualifying conditions such as diabetes, heart failure or chronic lung disease Doctors, drugs and programs built around the condition
Institutional SNP (I-SNP) People living in a nursing home or who need that level of care at home Care delivered where the member lives

Turning 65 in 2027

If you turn 65 in 2027, your Initial Enrollment Period lasts seven months: the three months before your birthday month, your birthday month and the three months after. Signing up during the first three months means your coverage starts on the first day of your birthday month.

Turning 65 Checklist

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Sign up for Part A and Part B, unless you have qualifying employer coverage and choose to delay Part B

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Decide between Medicare Advantage and Original Medicare with Medigap

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Join a drug plan, or a Medicare Advantage plan with drugs, to avoid a Part D late penalty

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If you choose Medigap, buy during your six-month Medigap Open Enrollment Period

Star Ratings

Medicare rates every Medicare Advantage and Part D plan from 1 to 5 stars each fall, based on things like preventive care, how well the plan manages chronic conditions, member complaints, customer service and drug pricing accuracy. The ratings are shown in Medicare Plan Finder.

Using Star Ratings

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A rating of 4 stars or higher is generally a good sign of quality and service

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Five-star plans have a special enrollment period, so you can switch into one once during the year

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New plans may not have a rating yet, which is not a bad sign by itself

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Ratings measure the plan overall, not how well it covers your specific doctors and drugs

Medicare Advantage or Medigap?

Medicare Advantage Original Medicare + Medigap
Monthly premium Often low or $0 (2027 average $12, CMS) Higher; varies by plan letter, age and ZIP
Doctors Usually a network Any provider in the U.S. that accepts Medicare
Costs when you get care Copays and coinsurance up to a yearly maximum Low and predictable; little or nothing on Plan G after the Part B deductible
Drug coverage Usually included Add a separate Part D plan
Dental, vision, hearing Many plans may include some coverage Not included
Changing later Every year during Annual Enrollment Health questions in most states after your Medigap Open Enrollment Period

Help Paying Medicare Costs

If your income and savings are limited, two programs can cut your Medicare costs sharply:

Medicare Savings Programs

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Run by your state Medicaid office

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Can pay your Part B premium, and sometimes deductibles and coinsurance

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Income and asset limits vary by state

Extra Help (Part D)

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Run by Social Security

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Lowers Part D premiums, deductibles and copays

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People in a Medicare Savings Program qualify automatically

Those who are eligible for Medicare along with full Medicaid might also have the option of enrolling in a Dual Special Needs Plan. Learn more about help for low-income Part D beneficiaries.

Reading Your Annual Notice of Change

Check Every Line

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Your 2027 premium and deductible

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Copays for doctors, specialists and hospital stays

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The out-of-pocket maximum

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Updates to your formulary, drug tiers and coverage requirements

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Whether your doctors, hospitals and pharmacy are still in network

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Changes to dental, vision, hearing and other extras

Plans must send the Annual Notice of Change by September 30. It is the single most useful document you get each fall, because it tells you exactly how your plan changes on January 1.

Special Enrollment Periods

Outside the fall and early-year windows, you generally need a Special Enrollment Period to change plans. Common reasons include:

You May Qualify If

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Your plan is leaving your area or ending

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You move outside your plan’s service area

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You lose employer or union coverage

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You qualify for Extra Help or a Medicare Savings Program, or your Medicaid status changes

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You want to join a 5-star plan, once a year

Each Special Enrollment Period has its own time limit, so act as soon as the event happens.

Prior Authorization and Referrals

Most Medicare Advantage plans require prior authorization for some services, such as certain surgeries, advanced imaging, skilled nursing stays and some drugs. Your doctor usually requests it, but ask whether a planned service needs approval so a denial does not surprise you.

If a request is denied, you or your doctor can appeal. Medicare rules set deadlines for plans to decide, with faster deadlines when waiting could seriously harm your health.

Getting Help

You do not have to compare plans alone, and you should not have to pay for help. These are the free options:

Free Help Comparing Plans

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Medicare Plan Finder on Medicare.gov, available any time

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1-800-MEDICARE (1-800-633-4227), available 24 hours a day, seven days a week

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Your State Health Insurance Assistance Program (SHIP), which offers free, unbiased counseling

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A licensed insurance agent or broker, who can compare plans from several insurers at no cost to you

Before any call, have your Medicare card, your list of drugs and doses, your doctors and your preferred pharmacies ready. It turns a long conversation into a short one.

Bottom Line

The Bottom Line

Kaiser works best for people who live in a Kaiser service area and are happy to get nearly all care inside its system.

Compare plans and enroll online

Frequently Asked Questions

➤ How does Kaiser Medicare Advantage work?

Kaiser Permanente runs an integrated system in which the health plan, doctors, hospitals and pharmacies work together. You pick a Kaiser primary care doctor, get most care in Kaiser facilities and fill most prescriptions at Kaiser pharmacies, with emergencies covered anywhere.

➤ Is Kaiser Medicare Advantage an HMO?

Mostly, yes. Kaiser is dropping its last 3 PPO plans for 2027, so its Medicare Advantage lineup is HMO-based. That generally means you must use Kaiser providers for non-emergency care, so confirm your doctors are part of the system.

➤ Can I see doctors outside Kaiser?

Generally only for emergencies, urgent care when you are away from your service area, or when Kaiser approves a referral outside its system. Routine care outside Kaiser is usually not covered, which is the main tradeoff of its integrated model.

➤ Where is Kaiser Medicare Advantage available?

Kaiser Permanente serves Medicare members in 9 states and Washington, D.C., but only in certain counties within them. For 2027 it is leaving 2 Nevada and 3 Washington counties. Enter your ZIP code in Medicare Plan Finder to confirm availability.

➤ Is Kaiser leaving Medicare Advantage in 2027?

No. Kaiser Permanente continues in Medicare Advantage for 2027, but it is leaving 2 Nevada and 3 Washington counties and ending its last 3 PPO plans. Affected members will receive a non-renewal notice and a Special Enrollment Period.

➤ Do Kaiser plans include drug coverage?

Most Kaiser Medicare Advantage plans include Part D drug coverage filled through Kaiser pharmacies and mail order. For 2027 the out-of-pocket cap on covered drugs is $2,400 and the maximum Part D deductible is $700.

➤ What extra benefits may Kaiser plans include?

Kaiser plans may include benefits such as dental, vision, hearing or fitness programs, depending on the plan and region. Not all plans offer all benefits, and benefits can change for 2027, so check the Evidence of Coverage for your plan.

➤ Who is Kaiser Medicare Advantage a good fit for?

Kaiser tends to suit people who live in a Kaiser service area, like coordinated care in one system and do not need to keep doctors outside Kaiser. People who travel often or want any-doctor freedom may prefer Original Medicare with Medigap.

➤ How do I compare Kaiser with other plans?

Compare networks, drug coverage, copays and the out-of-pocket maximum in Medicare Plan Finder. Look at Kaiser’s star rating too. Free help is available from your State Health Insurance Assistance Program (SHIP) or a licensed agent at no cost.

➤ When can I join a Kaiser plan for 2027?

Annual Enrollment runs October 15 to December 7, 2026, with coverage starting January 1, 2027. New Medicare enrollees can join during their Initial Enrollment Period, and Medicare Advantage members can make one change from January 1 to March 31, 2027.

Have Questions?

Speak with a licensed insurance agent

1-855-398-0716

TTY users 711

Mon-Fri: 8am-9pm ET

Find & Compare Plans Online

Speak with a licensed insurance agent

1-855-398-0716TTY 711

Mon-Fri: 8am-9pm ET

ZRN Health & Financial Services, LLC, a Texas limited liability company

MedicarePlansGuide.org
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Austin, TX 78734

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