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Gold Heart & Diabetes (HMO-POS C-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Gold Heart & Diabetes (HMO-POS C-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Gold Heart & Diabetes (HMO-POS C-SNP) in 2026, please refer to our full plan details page.
Gold Heart & Diabetes (HMO-POS C-SNP) is a HMO-POS C-SNP plan offered by Gold Kidney Health Plan available for enrollment in 2025 to people living in Counties: GA, MA, PA, PL. This plan received an overall rating of 3 out of 5 stars in 2026.
It's important to know that Gold Heart & Diabetes (HMO-POS C-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
Gold Heart & Diabetes (HMO-POS C-SNP)is a Special Needs Type (SNP) plan. This means you can only enroll in this plan if you meet specific criteria. See our full plan details page for more information.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Gold Heart & Diabetes (HMO-POS C-SNP).
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 Heart & Diabetes (HMO-POS C-SNP), 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.
This plan does not come with a Part B Premium reduction. You must continue to pay your 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 $2500.00 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 Heart & Diabetes (HMO-POS C-SNP) plan offers an Enhanced Alternative drug benefit with no prescription drug deductible. During the initial coverage phase, you will pay no copay for Tier 1 preferred generic and Tier 5 specialty drugs at standard pharmacies and through standard mail. Other costs include a $40 copay for Tier 2 standard generics, a $100 copay for Tier 3 preferred brands, and a 33% coinsurance for Tier 4 non-preferred drugs. These initial coverage rates apply until your yearly out-of-pocket drug costs reach $2,100.00, at which point you enter the catastrophic coverage phase and pay nothing for covered Part D drugs. Additionally, individuals who qualify for the low-income subsidy can reduce their Part D premium to $0.00.
Additional Benefits
The Gold Heart & Diabetes (HMO-POS C-SNP) plan offers robust medical coverage with predictable out-of-pocket costs, featuring low to no copays for primary care and specialist visits. Inpatient hospital stays require a $125 daily copay for the first five days, followed by no copay for days 6 through 90. Additionally, emergency room visits carry a $90 copay, and skilled nursing facility stays require no copay for the first 20 days. This plan also provides extensive supplemental benefits, including routine vision and hearing exams for a $20 copay, alongside dental coverage up to a $4,000 annual maximum with no copays for comprehensive procedures. Members can take advantage of up to 24 one-way transportation trips per year and annual physicals with no copay. Essential medical needs are also supported with a $35 copay for Part B insulin and a 20% coinsurance for durable medical equipment.
Inpatient Hospital See details
Gold Heart & Diabetes (HMO-POS C-SNP) partially covers inpatient hospital services, requiring a copay of $125 per day for days 1 through 5, no copay for days 6 through 90, and no coinsurance for Medicare-covered acute and psychiatric stays. Prior authorization is required, and non-Medicare-covered stays, upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by Gold Heart & Diabetes (HMO-POS C-SNP), featuring no copay or coinsurance for ambulatory surgical center visits, and copays ranging from $0 to $125 with no coinsurance for outpatient hospital and daily observation services. Outpatient substance abuse sessions require a $15 to $25 copay with no coinsurance, while outpatient blood services are subject to a 20% coinsurance with no copay.
Partial Hospitalization See details
Gold Heart & Diabetes (HMO-POS C-SNP) covers partial hospitalization benefits with an $80 copay and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Gold Heart & Diabetes (HMO-POS C-SNP) covers ground ambulance services with a $150 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay. Transportation services are partially covered, offering up to 24 one-way trips per year to plan-approved locations with no copay and no coinsurance, while trips to any health-related location are not covered.
Emergency Services See details
Gold Heart & Diabetes (HMO-POS C-SNP) covers emergency services with a $90 copay and no coinsurance, and urgently needed services with a $10 copay and no coinsurance. Worldwide emergency, urgent, and transportation services are also covered up to a $75,000 maximum limit with a $120 copay and no coinsurance per service.
Primary Care See details
Gold Heart & Diabetes (HMO-POS C-SNP) covers primary care, specialist visits, and telehealth services with copays ranging from no copay to $20 and no coinsurance. Additional services like chiropractic care, podiatry, physical therapy, psychiatric services, and opioid treatment are also covered with copays between $10 and $25 and no coinsurance.
Preventive Services See details
Preventive Services are partially covered by Gold Heart & Diabetes (HMO-POS C-SNP) with no copay or coinsurance for covered options like annual physicals, fitness benefits, and glaucoma screenings. However, several sub-services are not covered, including health education, medical nutrition therapy, wigs for chemotherapy-related hair loss, weight management programs, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, additional smoking cessation counseling, telemonitoring, home and bathroom safety modifications, and counseling services.
Hearing Services See details
Hearing services are partially covered by the Gold Heart & Diabetes (HMO-POS C-SNP) plan, which offers one routine hearing exam annually for a $20 copay and no coinsurance, alongside fitting evaluations with no copay and no coinsurance. Up to two prescription hearing aids (all types) are covered per year with a copay ranging from $195 to $1,395 and no coinsurance, but OTC hearing aids and inner ear, outer ear, and over-the-ear prescription hearing aids are not covered.
Vision Services See details
Vision services are covered by Gold Heart & Diabetes (HMO-POS C-SNP), including one routine eye exam per year for a $20 copay and no coinsurance. Eyewear is partially covered with no copay or coinsurance, providing an annual allowance of up to $200 for eyeglasses and $115 for contact lenses, though upgrades are not covered.
Dental Services See details
Dental services are partially covered by Gold Heart & Diabetes (HMO-POS C-SNP) up to a $4,000 annual maximum, excluding implants, orthodontics, maxillofacial prosthetics, and fixed or removable prosthodontics. Medicare-covered dental services require a $20 copay and no coinsurance, while other covered comprehensive procedures require either a 20% coinsurance or no coinsurance, with no copays.
Home Infusion bundled Services See details
Gold Heart & Diabetes (HMO-POS C-SNP) partially covers home infusion bundled services with prior authorization, though Part D home infusion drugs are not covered. Covered Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have no copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis Services are covered by the Gold Heart & Diabetes (HMO-POS C-SNP) plan with a 20% coinsurance and no copay.
Medical Equipment See details
Medical equipment is partially covered by Gold Heart & Diabetes (HMO-POS C-SNP), featuring a 20% coinsurance and no copay for durable medical equipment, prosthetic devices, and medical supplies. Diabetic supplies and diabetic therapeutic shoes or inserts are not covered under this plan.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered under Gold Heart & Diabetes (HMO-POS C-SNP), with outpatient X-ray services not covered. Covered lab services require no copay or coinsurance, diagnostic procedures and diagnostic radiological services have copays up to $30 and $75 with no coinsurance, and therapeutic radiological services require a 20% coinsurance and a copay.
Home Health Services See details
Home Health Services are covered under the Gold Heart & Diabetes (HMO-POS C-SNP) plan, although prior authorization is required to access these benefits. Specific copay and coinsurance costs are not specified in the plan details.
Cardiac Rehabilitation Services See details
Gold Heart & Diabetes (HMO-POS C-SNP) indicates that some services are covered for Cardiac Rehabilitation, but Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. Prior authorization is required, and no copay or coinsurance is specified since these sub-services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are partially covered by Gold Heart & Diabetes (HMO-POS C-SNP) with no copay for days 1 to 20, a $214 daily copay for days 21 to 100, and no coinsurance. Prior authorization is required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other Services are partially covered by Gold Heart & Diabetes (HMO-POS C-SNP), which offers acupuncture for a $10 copay and no coinsurance for up to 12 treatments per year, as well as referral-based meal benefits for chronic illnesses with no copay or coinsurance. Over-the-counter (OTC) items and Dual Eligible SNP services are not covered under this plan.
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* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
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