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Gold Advantage (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Gold Advantage (HMO-POS). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Gold Advantage (HMO-POS) in 2025, please refer to our full plan details page.
Gold Advantage (HMO-POS) is a HMO-POS plan offered by Gold Kidney Health Plan available for enrollment in 2025 to people living in Jacksonville, West Fl, Treasure Coast, & South Fl. The overall rating for this plan is not yet available for 2025.
It's important to know that Gold Advantage (HMO-POS) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Gold Advantage (HMO-POS).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Gold Advantage (HMO-POS), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $135.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $2900.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Gold Advantage (HMO-POS) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay varying copays depending on the drug tier and pharmacy type, ranging from $5 to $100 or 33% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
The Gold Advantage (HMO-POS) plan offers a range of benefits with varying costs. Inpatient hospital stays have a $175 copay for days 1-5, and no copay for days 6-90. Outpatient services and primary care visits have copays ranging from $0 to $125, with specialized services like chiropractic and podiatry at a $20 copay. The plan also includes coverage for emergency services with a $110 copay, hearing and vision services, and dental services with a $500 maximum benefit every three months. Other covered benefits include home health services with no copay, skilled nursing facilities with a copay, and home infusion services with a copay or coinsurance, depending on the type of drug.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, with a copay of $175 for days 1-5 and no copay for days 6-90 for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. Additional days, non-Medicare covered stays, and upgrades for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with a copay between $0 and $125, observation services with a $175 copay, and ambulatory surgical center services with no copay. Outpatient substance abuse services have a $25 copay for individual sessions and a $15 copay for group sessions, and outpatient blood services have a 20% coinsurance.
Partial Hospitalization See details
Partial Hospitalization is covered by the Gold Advantage (HMO-POS) plan, but requires prior authorization. The copay for this benefit is $80.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Gold Advantage (HMO-POS) plan, including both ground and air ambulance services, but transportation services to health-related locations are not covered. Ground ambulance services have a $275 copay, while air ambulance services have a 20% coinsurance.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Gold Advantage (HMO-POS) plan. Emergency Services has a $110 copay, while Urgently Needed Services has a $20 copay, and Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $120 copay.
Primary Care See details
The Gold Advantage (HMO-POS) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services with a $35 copay, physician specialist services with a $20 copay, mental health specialty services, podiatry services with a $20 copay, other health care professional services with a $20 copay, psychiatric services, physical therapy and speech-language pathology services with a $35 copay, additional telehealth benefits with a $20 copay, and opioid treatment program services with a $25 copay. Routine chiropractic care is covered with a $20 copay for 6 visits per year. Individual and group sessions for mental health specialty services have minimum and maximum copays of $25 and $10, respectively. Individual and group sessions for psychiatric services have minimum and maximum copays of $25 and $10, respectively.
Preventive Services See details
Preventive Services are covered, including Medicare-covered preventive services, annual physical exams, and additional preventive services. This plan also covers Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Therapeutic Massage, In-Home Support Services, Fitness Benefit, Remote Access Technologies, Home and Bathroom Safety Devices and Modifications, Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. Medical Nutrition Therapy, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, and Counseling Services are not covered. Therapeutic Massage and Home and Bathroom Safety Devices and Modifications have a maximum plan benefit coverage amount of $25.00 every month, and the Fitness Benefit has a maximum plan benefit coverage amount of $25.00 every month.
Hearing Services See details
Hearing Services are covered under the Gold Advantage (HMO-POS) plan, including routine hearing exams and fitting/evaluation for hearing aids. The plan also covers prescription hearing aids, but not prescription hearing aids for the inner ear, outer ear, or over the ear, nor OTC hearing aids.
Vision Services See details
Vision services, including eye exams and eyewear, are covered under the Gold Advantage (HMO-POS) plan. Routine eye exams have no copay, and there is a maximum plan benefit coverage of $500.
Dental Services See details
The Gold Advantage (HMO-POS) plan covers dental services with a $500 maximum benefit every three months, including oral exams, dental X-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics. Orthodontic services are covered under diagnostic and preventive dental (16b).
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Gold Advantage (HMO-POS) plan with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment coverage includes Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, and Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies have a 20% coinsurance for Medicare-covered devices and supplies, and Diabetic Equipment has a 20% coinsurance for Medicare-covered supplies and therapeutic shoes/inserts.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered under the Gold Advantage (HMO-POS) plan. Diagnostic Procedures/Tests, Lab Services, and Outpatient X-Ray Services are not covered, while Diagnostic Radiological Services have a copay of up to $95.00, and Therapeutic Radiological Services have a coinsurance of at most 20%.
Home Health Services See details
Home Health Services are covered by the Gold Advantage (HMO-POS) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Gold Advantage (HMO-POS) plan. The plan does not cover any services related to cardiac rehabilitation, including intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Gold Advantage (HMO-POS) plan, with prior authorization required. For days 1-20, there is no copay, and for days 21-100, the copay is $214.
Other Services See details
The Gold Advantage (HMO-POS) plan covers acupuncture with a 20% coinsurance up to 12 treatments per year and also covers over-the-counter items, with a maximum benefit of $25.00 every month. Other services such as meal benefits, and specific services such as Early and Periodic Screening, Diagnostic, and Treatment services are not covered.
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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